COLLEGE OF OSTEOPATHIC PHYSICIANS AND SURGEONS LOS ANGELES, CALIFORNIA THE SURGICAL DISEASES OF CHILDREN THE^XjnB [SURGICAL DISEASES OF CHILDREN 7 WILLIAM FRANCIS CAMPBELL, A.B., M.D. PBOFESSOB OF ANATOMY, LONG ISLAND COLLEGE HOSPITAL; SURGEON-IN-CHIEF TRINITY HOSPITAL; ATTENDING SURGEON, METHODIST EPISCOPAL HOSPITAL; CONSULTING SURGEON, CONEY ISLAND, SWEDISH AND JAMAICA HOSPITALS, AND LE GRAND KERR, M.D. ATTENDING PEDIATHIST TO THE METHODIST EPISCOPAL, WILLIAMSBURGH, BUSHWICK AND SWEDISH HOSPITALS; CONSULTING PEDIATRIST TO THE INDUSTRIAL HOME FOR CHILDREN AND THE ROCKAWAY BEACH HOSPITAL. NEW YORK AND LONDON D. APPLETON AND COMPANY 1912 ^ COPYRIGHT, 1912, BY D. APPLETON AND COMPANY Printed in New York, U. S. A. UPON WHOSE CONSCIENTIOUS CARE AND DEVOTION TO HUMAN WELFARE DEPENDS THE EFFICIENCY OF FUTURE MEN AND WOMEN THIS BOOK IS DEDICATED PREFACE The child is an unfinished product. Childhood is the period when Nature, through physiological processes peculiarly active, en- deavors to bring the individual to completeness, and thus preserve the species. This phenomenon of growth implies more active, more rapid, more constant cellular changes. It necessitates greater nutritional demands, and leaves little vital capital in reserve for contingencies. Thus, while the child's organism is more plastic, it is less stable ; while it heals rapidly, it devitalizes easily. With constructive sur- gery it is a walling ally, to destructive procedures it is intolerant. The surgery of childhood therefore imposes a problem peculiarly difficult, not merely because of the smaller anatomical relationships, but because the surgeon is dealing with an organism singularly com- plex in which the surgical disease is ever interwoven with problems of nutrition, development, and future efficiency. Modern surgery, with its perfection of technique, is adequate only as it can adapt itself to the peculiar demands of the child's or- ganism. The surgeon is efficient only as he possesses a correct appreciation of surgical diseases as they affect the child. The authors therefore feel that a distinct advance in this field is possible only as the surgical diseases of childhood are viewed from both the standpoints of the Surgeon and the Pecliatrist. Again, the surgery of childhood imposes a heavy responsibility upon the family physician it is always his problem first, before it is shifted to the shoulders of the specialist; upon his prompt recognition of the sur- gical disorder, and his adequate appreciation of the proper treatment, the future welfare of the child depends. A deformity can often be corrected in early life which later is accompanied by secondary changes which can never be corrected. A crippled child is often a neglected child. There will be fewer cripples in the world when the physician is more alert to the importance of the early recognition of disease and its timely treatment. In those congenital deformities and chronic diseases connected with the locomotor apparatus the authors have endeavored to em- PREFACE phasize the importance of early diagnosis, the treatment is merely suggestive; and it is urged that the advantages of the orthopedic clinic be sought, and the experience and skill of the orthopedic surgeon be secured. It is not the profound knowledge of the specialist that is needed so much as a sound practical knowledge of surgery and the child, and a deep sense of the responsible part which the physician plays in the welfare of the future men and women. The authors present this volume as a practical guide to the family physician that he may render a better service to his patient. The interests of the patient are best conserved when there is a practical appreciation of the fact that in the treatment of surgical diseases the physician and surgeon each play an important role the role of cooperation ; each bears an equal responsibility, and each con- tributes his share to the favorable or unfavorable result. The works of many authors who have contributed their expe- rience have been consulted and freely quoted, due acknowledgment of which has been noted in the text. We desire to express our appreciation of the work of Mr. F. A. Deck, whose efficient cooperation in making the illustrations has materially enhanced the value of the text. WILLIAM FRANCIS CAMPBELL, LEGRAND KERR. BROOKLYN, NEW YORK. CONTENTS PART I GENERAL SURGERY SECTION I GENERAL CONSIDERATIONS CHAPTER PAGE I. QUALIFICATIONS OP THE PEDIATBTC SURGEON . . 3-4 II. THE EXPRESSION OF DISEASE IN THE YOUNG CHILD . 4-9 SECTION II EXAMINATION III. THE EXAMINATION 10-21 General considerations What is the age? General history taking Securing child's confidence. IV. GENERAL POSTURE 21-24 Side position Dorsal position On the abdomen Forced positions Upright position Constantly changed position. V. THE GAIT 24-26 Limping Waddling Stumbling gait. VI. PAIN 26-46 General considerations : Tenderness ; Mode of Onset ; Time of occurrence; Character of pain; Site of pain The surgical significance of pain : Abdominal pain; Headache; Earache; Painful defecation; Painful urination. VII. THE EXAMINATION OF THE BLOOD .... 46-55 General considerations : Method of obtaining the specimen; Examination of the fresh specimen; The blood count; The color index Abnormal conditions of the blood: Leukocytosis ; Leukopenia; Eosino- philia ; Lymphocytosis. VIII. THE DIAGNOSTIC VALUE OF THE X-RAY . . 55-56 ix CONTENTS SECTION III ANESTHETIZATION [AFTER PAGE IX. ANKSTIIKMA . . . 57-66 General considerations: Preparation of the child; Conditions to be watched by the anesthetist; Selec- tion of the anesthetic Varieties of anesthetics: Ether; Chloroform; Nitrous oxid; Nitrous-oxygen- ether; Nitrous-ether; Ethyl chlorid. X. POST-ANESTHETIC CARE 66-69 Nausea and vomiting Hematemesis Undue rest- lessness Sweating Thirst. XL SEQUELAE OF ANESTHESIA 69-71 Conjunctivitis Soreness of the jaw Soreness of the tongue Paralysis Burns Pneumonia. XII. LOCAL ANESTHESIA 71-73 Cold, freezing Infiltration. SECTION IV THE OPERATION XIII. PREPARATION FOR THE OPERATION .... 74-84 Preparation of the patient : Physical condition ; Urine; Blood; Laxative; Digestive disturbances; Water drinking; Bathing; Toilet of mouth Prepa- ration of the field of operation Examination of pa- tient: Examination of the heart; Examination of the chest; Examination of the urine. XIV. THE CONTROL OF HEMORRHAGE 84-88 Primary hemorrhage; Delayed hemorrhage Sec- ondary hemorrhage; Constitutional treatment of hemorrhage. XV. POST-OPERATIVE CARE 88-95 The room Diet after operation The bowel func- tion Vomiting Care of the wound. CONTENTS xi CHAPTER PAGE XVI. THIRST: ITS SIGNIFICANCE AND RELIEF . . . 95-97 XVII. PAIN AND SLEEP . ; 97-99 XVIII. THE GENERAL MANAGEMENT OF POST-OPERATIVE CON- VALESCENCE 99-101 Fresh air and sunshine. XIX. GAVAGE, LAVAGE, AND RECTAL FEEDING . . . 101-106 Gavage Nasal feeding Lavage Rectal feeding. XX. SHOCK 106-111 Diagnosis Etiology Treatment of shock. SECTION V CONSTITUTIONAL AFFECTIONS WITH A SURGICAL ASPECT XXI. HEMOPHILIA . 112-115 Etiology Pathology Symptomatology Diag- nosis Prognosis Treatment. XXII. RACHITIS 115-130 Etiology Age incidence Symptoms Diagnosis Treatment. XXIII. SCORBUTUS 130-138 Age incidence Etiology Pathology Symptoma- tology Diagnosis Prognosis Prophylaxis and treatment. XXIV. SYPHILIS 138-155 Acquired syphilis Congenital syphilis : Types of disease; Pathology; Symptoms; Diagnosis; Prog- nosis; Treatment. XXV. STATUS LYMPHATICUS 155-158 Pathology Symptoms Diagnosis. SECTION VI INFECTIOUS DISEASES XXVI. ADENITIS 159-174 Simple acute adenitis: Etiology; The lesions; Symptomatology ; Diagnosis ; Treatment Simple Jii CONTENTS chronic adenitis: Symptoms; Diagnosis; Treatment Syphilitic adenitis Tuberculous adenitis: Etiol- ogy; Lesions; Symptoms; Diagnosis; Prognosis; Treatment. XXVII. OSTEOMYELITIS Infective osteomyelitis: Etiology and pathology; Symptoms; Diagnosis; Prognosis; Treatment Rarer forms of osteomyelitis; Periostitis albumi- nosa; Primary chronic osteomyelitis. XXVIII. TUBERCULOSIS XXIX. XXX. Surgical tuberculosis: Etiology; Clinical manifesta- tions in children and adults; Clinical diagnosis of tuberculosis; General principles of surgical treat- ment; Treatment of surgical tuberculosis Tuber- culosis of bones and joints; Tuberculosis of bones; Tuberculosis of joints. ERYSIPELAS Etiology Incubation Symptoms Diagnosis Prognosis Treatment. TETANUS Etiology : Bacillus tetani Clinical forms Symp- tomatology and diagnosis Prognosis Treatment. 174-183 184-208 208-214 214-226 XXXI. SEPTIC DISEASES 226-235 Septic diseases in general septic intoxication : Symptoms Septicemia : Symptoms ; Prognosis ; Treatment Pyemia: Etiology; Symptoms; Com- plications; Diagnosis; Treatment Sapremia: Eti- ology; Treatment Purulent infections of the skin and subcutaneous tissues. XXXII. BACTERIAL VACCINES . 235-236 SECTION VII INJURIES XXXIII. BURNS AND SCALDS Results Diagnosis Prognosis Treatment. . 237-246 CONTENTS Xlll CHAPTER XXXIV. FRACTURES IN CHILDREN Peculiarities of fracture in children ; Fractures of the newly born ; Incomplete or greenstick fractures ; Separation of the epiphyses; Exuberant callus; . Fracture fever Intrapartum fractures : Fracture of the humerus ; Fracture of the clavicle ; Fracture of the femur Traumatic separation of the epi- physes : Separation of the upper epiphysis of the humerus; Separation of the lower epiphysis of the humerus; Separation of the lower epiphysis of the tibia; Separation of the upper epiphysis of the tibia. PAGE 246-258 SECTION VIII SURGICAL DISEASES OF THE CENTRAL NERVOUS SYSTEM XXXV. INJURY AND DISEASE OF THE SPINAL CORD AS EVI- DENCED BY SYMPTOMS ...... 259-267 Paralysis: Corticospinal paralysis; Spinomuscular paralysis; General character of paralysis following injury or disease of the spinal cord Disturbances of anal and vesical sphincter control Ataxia : Babinski's sign ; Sensory disturbances Disturbances of sensation Pain Vasomotor and trophic dis- turbances. XXXVI. NATURE OP INJURIES OF THE SPINAL CORD . . . 268-270 Spinal concussion Contusion and laceration of the cord Mode of production of injuries to the spinal cord. XXXVII. LUMBAR PUNCTURE . . . . 270-277 XXXVIII. INJURIES OF THE BRAIN AND ITS MEMBRANES . . 277-284 Symptoms: Cerebral vomiting; Headache; Convul- sions; Paralysis; Muscular contraction Concussion of the brain: Symptoms; Prognosis; Diagnosis; Treatment Compression of the brain: Symptoms; Prognosis Contusion, laceration, and wounds of the brain : Symptoms ; Diagnosis. XXXIX. THROMBOSIS OF THE SINUSES OF THE DURA MATER . 284-287 Etiology Site Symptoms Course and prognosis Treatment. xiv CONTENTS CHAPTER PAGE XL. CEREBRAL ABSCESS 287-292 Etiology Symptoms Diagnosis Prognosis Treatment. XLI. XLIL INTRACRANIAL TUMORS Etiology Symptoms Diagnosis. . 292-297 THE PARALYSIS OF CHILDHOOD . , ^ . Acute poliomyelitis: The age incidence; The sea- sonal incidence; Symptoms; Diagnosis; Mechanical and operative treatment Erb's paralysis : Etiology ; Pathology; Diagnosis; Prognosis; Treatment In- fantile cerebral paralysis: The prenatal group; The natal group; The postnatal group Pressure paral- ysis Musculospiral nerve paralysis Facial paral- ysis Sympathetic nerve paralysis. 298-319 SECTION IX NEOPLASMS XLIIL TUMORS IN CHILDREN General consideration of tumors The transforma- tion of benign into malignant tumors Varieties of tumors : Fibromata ; Myxomata ; Lipoma ; Bone tumors; Chondromata; Osteomata; Myomata; Neu- romata; Lymphoma; Sarcoma; Carcinoma; Terato- mata; Angioma; Lymphangioma; Cystoma; Reten- tion cysts; Dermoids; Keloid. 320-350 THE HEAD AND NECK XLIV. AFFECTIONS or THE HEAD ...... Congenital affections: Encephalocele; Microcepha- lus; Congenital hydrocephalus ; Cephalhematoma Fractures of the skull ; Dermoid cysts of the head. 353-362 CONTENTS CHAPTEB XLV. AFFECTIONS OF THE EAR Malformation of the external ear- in the ear Middle ear disease. XV PAGE 302-364 -Foreign bodies XLVI. FACE AFFECTIONS 364-370 Vascular nevus : Varieties ; Diagnosis ; Prognosis ; Treatment Lymphangiomas of the face : Lyinph- angioma of the eyelids; Lymphangioma of the lips Dermoid cysts of the face: Diagnosis; Treatment. XLVII. ORAL AFFECTIONS 370-387 Foreign bodies in the nose Harelip: Clinical pic- ture; Prognosis; Operation; After-treatment Cleft palate : Etiology and pathology ; Treatment ; Af ter- - treatment Ranula : Varieties; Treatment Hyper- trophied tonsils Adenoid vegetations Retrophar- yngeal abscess: Etiology; Symptoms; Diagnosis; Prognosis ; Treatment. XL VIII. THE AIR PASSAGES 387-395 Foreign bodies in the air passages: Symptoms; Diagnosis ; Prognosis ; Treatment - - Intubation : Preparation of the operator; Preparation of the patient; The Operation; After-treatment; Re- moval of the tube Tracheotomy: Anatomical points; Operation; After-treatment. XLIX. THE NECK 396-409 Congenital torticollis: Etiology; Pathology; Symp- toms; Diagnosis; Treatment Tuberculous glands of the neck : Anatomical considerations ; Method of invasion; Symptoms; Diagnosis; Treatment Bronchial fistula?: Clinical characteristics; Treat- ment Bronchial fibro-chondromata : Treatment Congenital cysts of the neck: Lymphatic cysts; Bronchial cysts Dermoid cysts of the neck Lipo- mas, of the face and neck. L. THE ESOPHAGUS . . 409-414 Malformation of the esophagus : Varieties ; Symp- toms; Treatment Congenital stenosis of the esoph- agus Foreign bodies in the pharynx and esopha- gus: Anatomical peculiarities; Symptoms; Treat- ment Cicatricial stenosis of the esophagus : Clinical course; Diagnosis; Treatment. XVI CONTENTS CHAPTER LI. PAGE 415-426 SECTION XI THORAX AND SPINE CONGENITAL AFFECTIONS OF THE THORAX AND SPINE . Malformation of the thorax: Absence of the ster- num; Cleft sternum; Pigeon breast; "Funnel chest Supernumerary cervical ribs Spinal Bifida : Loca- tion ; Anatomical classification ; 'Symptoms ; Diag- nosis; Prognosis; Treatment Congenital sacrococ- cygeal tumors; Etiology and pathology; Situation; Symptoms; Diagnosis; Treatment Paracoccygeal fistulas Congenital diaphragmatic hernia : Loca- tion ; Symptoms ; Treatment Congenital hernia of the lung. LII. EMPYEMA . . . . ... . . 426-429 Special features of symptoms Diagnosis Prog- nosis Treatment After-treatment Bilateral em- pyema. LIIL CURVATURE OF THE SPINE 429-446 The normal evolution of the spinal column Ab- normal positions of spinal column : Kyphosis ; Lordosis; Scoliosis. LIV. TUBERCULOSIS OF THE SPINE 446-465 Clinical picture Symptoms Diagnosis Differen- tial diagnosis Prognosis Treatment Tubercu- losis of the sacroiliac joint. SECTION XII ABDOMEN AND PELVIS LV. CONGENITAL AFFECTIONS OF THE ABDOMEN . . . 466-470 Meckel's diverticulum : Clinical anatomy ; Diagnosis ; Treatment Malformations of the urachus : Uri- nary fistula? of the umbilicus ; Cysts of the urachus. LVI. HERNIA 470-489 rmbilical hernia: Pathology; Symptoms; Treat- ment Inguinal hernia: Normal and pathological CONTENTS xvii anatomy; Frequency; Etiology; Site; Pathology; Symptoms; Differential diagnosis; Complications; Treatment Femoral or crural hernia. LVII. EXSTROPHY OF THE BLADDER 489-492 LVIII. CONGENITAL HYPERTROPHIC STENOSIS OF THE PYLORUS 492-494 Normal and pathological anatomy Occurrence Symptoms Treatment. LIX. PERITONITIS Tuberculous peritonitis: Clinical forms; Symptoms; Diagnosis ; Treatment Pnemnococcus peritonitis : Clinical forms; Symptoms; Diagnosis; Treatment. "LX. APPENDICITIS Anatomy Etiology and Pathology Symptoms Diagnosis Prognosis Treatment. 499-512 LXI. INTESTINAL DISORDERS Intussusception : Symptoms ; Diagnosis ; Prognosis ; Treatment Congenital idiopathic dilatation of the colon : Symptoms ; Treatment. 512-517 LXII. DISEASES OF THE ANUS AND RECTUM .... Imperf orate anus and rectum : Clinical picture ; Treatment Prolapse of the rectum: Symptoms; Diagnosis; Prognosis; Treatment Polypus of rectum; Etiology; Symptoms; Diagnosis; Treat- ment Fissure of the anus: Symptoms; Treatment Perianal abscess: Symptoms; Treatment. 517-528 LXIIL SARCOMA OF THE KIDNEY Diagnosis Prognosis Treatment. 528-529 LXIV. BLADDER DISEASES Enuresis, incontinence of urine: Symptoms; Diag- nosis; Treatment Vesical calculi: Etiology; Symp- toms; Diagnosis; Treatment Tremors of the blad- der: Symptoms; Treatment. 529-534 LXV. PHIMOSIS AND PARAPHIMOSIS . ..... Phimosis : Clinical course ; Treatment Paraphi- mosis: Treatment. 535-538 xvm CONTENTS LXVI. DISEASES OP THE TESTIS 539-549 Hydrocele: Normal and pathological anatomy; va- rieties; Symptoms; Diagnosis; Treatment Unde- scended and misplaced testicle: Undeseended tes- ticle; Misplaced testicle; Complications; Prognosis; Symptoms ; Treatment Tuberculosis of the testicle : Clinical picture; Diagnosis; Treatment Sarcoma of the testicle: Treatment. LXVIL EPISPADIAS AND HYPOSPADIAS '. 549-559 Epispadias: Pathology; Symptoms; Treatment Hypospadias : Pathology ; Clinical varieties ; Func- tional disturbances; Treatment. LXVIII. MALFORMATIONS OF THE FEMALE GENITALS.. 559-560 SECTION XIII THE UPPER EXTREMITY LXIX. CONGENITAL MALFORMATIONS OF THE EXTREMITIES . 561-562 Absence of extremities: Ectromely; Phocomely; Etiology; Treatment Congenital grooves. LXX. THE SHOULDER 562-567 Congenital elevation of the scapula : Clinical pic- ture; Etiology; Treatment Fracture of the clavicle: Symptoms; Treatment Congenital dislocation of the shoulder Tuberculosis of the shoulder: Symp- toms; Diagnosis; Prognosis; Treatment. LXXI. THE ELBOW 567-590 Congenital dislocation of the elbow Tuberculosis of the elbow: Symptoms; Diagnosis; Treatment Fracture at the elbow : Anatomy of the elbow ; Diagnosis; Prognosis; Typical forms of fracture of the elbow in children; Treatment. LXXII. THE FOREARM AND HAND 590-603 Greenstick fracture of the forearm Volkmann's ischemic contracture Subluxation of the head of the radius: Symptoms; Treatment Madelung's deform- ity Fracture of the lower end of the radius Tu- berculosis of the wrist: Symptoms; Prognosis; XIX Treatment Tuberculosis of the phalanges Con- genital deviations of the hand: Varieties; Eti- ology; Treatment Injuries of the hand in child- hood Malformation of the fingers; Polydactyly; Syndactyly; Ectrodactyly ; Clubbed thumb. SECTION XIV THE LOWER EXTREMITY LXXIII. CONGENITAL DISLOCATION OF THE HIP . Etiology and pathology Symptoms Diagnosis- Prognosis Treatment. 604-611 LXXIV. COXA VARA AND COXA VALGA 612-615 Coxa vara : Etiology and pathology ; Symptoms ; Diagnosis; Prognosis; Treatment Coxa Valga : Etiology; Symptoms; Diagnosis; Treatment. LXXV. HIP JOINT DISEASE 615-628 Pathology Symptoms -- Diagnosis Differen- tial Diagnosis Prognosis Treatment. LXXVI. FRACTURE OP THE FEMUR 628-632 Fracture of the neck of the femur: Diagnosis; Treatment; Fracture of the Shaft of the femur: Pathology; Diagnosis; Treatment. LXXVII. AFFECTIONS OF THE KNEE 632-646 Congenital absence of the knee Congenital dislo- cation of the patella Injury of the tubercle of the tibia Genu valgum: Age of occurrence; Symp- toms; Prognosis; Treatment Genu varum Eti- ology; Symptoms; Prognosis; Treatment Genu re- curvatum Tuberculosis of the knee: Pathology; Symptoms; Diagnosis; Prognosis; Treatment. LXXVIII. TIBIA AND FIBULA 646-650 Rachitic curvatures of the leg: Pathology; Treat- ment Congenital absence of the fibula : Pathology ; Diagnosis; Treatment Congenital absence of the tibia : Pathology ; Prognosis ; Treatment. xx CONTENTS CHAPTER PAGE LXXIX. DEFORMITIES OF THE FOOT 650-669 Club foot: Etiology; Pathological anatomy; Symp- toms; Prognosis; Treatment Acquired club foot Paralytic club foot Talipes equinus: Pathology; Symptoms ; Treatment Pes cavus Pathology ; Treatment Talipes calcaneus Flat-foot; Anatom- ical considerations; Varieties; Symptoms; Diag- nosis; Prognosis; Treatment. LXXX. AFFECTIONS OF THE ANKLE AND TOES . . . 669-674 Tuberculosis of the ankle: Pathology; Symptoms; Prognosis; Treatment Deformities of the toes: Claw foot; Hallux valgus; Hallux varus; Ham- mer-toe. INDEX 677 LIST OF ILLUSTRATIONS FIG. PAGE 1. The marked differences between the child and the adult 7 2. Comparative size of lower jaw in infant and adult, showing- changes during development 8 3. A composite chart of the respirations of twenty infants of four months of age 11 4. History card 13 5. Rachitic type of skull 16 6. Tlie teeth between six and eight months 17 7. The teeth two months after the appearance of the two lower central incisors 17 8. The teeth between twelfth and fourteenth months 18 9. The teeth between sixteenth and twenty-second months 18 10. The teeth between the twenty-second and twenty-eighth months . . 19 11. Side posture characteristically assumed in painful conditions of chest and sometimes when one side of abdomen is affected .... 22 12. Dorsal posture, which is posture assumed by child most often in peritonitis, perinephritis, appendicitis 22 13. Posture "on the abdomen" 23 14. Pain in the lateral wall of the chest 29 15. Pain in the epigastrium 30 16. General abdominal pain 33 17. Diagnostic significance of headache in children 41 18. Mastoid abscess showing characteristic swelling behind ear and pushing auricle forward 43 19. Puncturing the lobe of the ear with a needle with cutting edge to obtain specimen of blood without injury to the corpuscles. . 47 20. Transferring blood from lobe of ear to the cover glass 48 21. Placing cover glass with specimen of blood upon glass slide 49 22. Method of spreading specimen of blood upon slide for dry smear. 52 23. Puncture of a vein to secure blood for examination 53 24. Throwing the jaw forward during anesthesia 60 25. Gwathney anesthesia apparatus 62 26. Convenient container for small quantities of chloroform 63 27. Apparatus and method used in intubation anesthesia 65 28. First step in infiltration anesthesia 71 29. Second step in infiltration anesthesia 72 30. Relative cardiac dullness and absolute cardiac dullness in an in- fant of one year 81 xxi xxii LIST OF ILLUSTRATIONS FIG. PAGE 31. Area of relative cardiac dullness and absolute cardiac dullness in child of six years 81 32. Area of relative cardiac dullness and absolute cardiac dullness in child of twelve years 81 33. Condom tied over penis to collect specimen of urine for ex- amination 82 34. Chapin urinal 82 35. Chapin urinal in position 83 36. Mosquito forceps 85 37. Child properly attended after operation, body being adequately protected and vomitus taken care of 90 38. Child neglected after operation 92 39. Apparatus for stomach washing 102 40. Lavage in older child 103 41. Apparatus for rectal washing or rectal feeding 105 42. Side view of rachitic boy 116 43. Rachitic deformity 117 44. Rachitic deformity 117 45. Rachitic deformity in child of fifteen months 119 46. Comparative contours of normal and rachitic stomach 120 47. Typical case of rickets 122 48. Comparative chest contours 123 49. Typical bowing of the legs in a rachitic child 124 50. Leg of rachitic child 126 51. Cranial contours : anteroposterior circumference transverse . . . 127 52. Marked raehitic deformity 129 53. Head of syphilitic infant showing characteristic fissures at cor- ners of mouth and generally shriveled appearance 142 54. Head of syphilitic infant, showing the destruction of the hair. . 143 55. Congenital syphilis 144 56. Gumma of the leg in syphilitic infant 146 57. Gumma of the eyelid 147 58. Saber-like appearance of leg sometimes observed in congenital syphilis 148 59. Hutchinson's teeth 149 60. Salivary calculi remotely simulating adenitis 161 61. Front view of same case as Figure 60 161 62. Location of the principal lymphatic glands of neck 163 63. Location of the principal lymphatic glands of trunk 164 64. Tuberculous adenitis 168 65. Tuberculous adenitis, showing marked enlargement which may sometimes take place without glands breaking down 168 66. Abscess pointing in front of upper part of the sternomastoid 169 67. Abscess pointing in front of lower part of sternomastoid 170 68. Abscess pointing behind upper part of sternomastoid 171 LIST OF ILLUSTRATIONS xxiii FIG. PAGE 69. Abscess pointing in front of sternomastoid 172 70. Showing it is unsafe to expect disease to be self-limited 173 71. Illustrative of the same proposition as Figure 70 173 72. Suppurative osteomyelitis of the tibia 177 73. Diagram to show removal of portion of tibia and relation of infolded periosteum 181 74. Von Pirquet test for tuberculosis 189 75. Morro test for tuberculosis 190 76. Tuberculous infection of bones of face 196 77. Sites for injection of sera or vaccines in children 236 78. Proper position for treatment of burns involving neck 237 79. Incorrect position in burns of the arm or axilla 238 80. Correct position for child with extensive burns of the arm or axilla 239 81. An incorrect and particularly bad position for burns of palm of -hand 240 82. Incorrect position for hand in burns of even moderate degree. . . . 241 83. Correct position in burns of the palm of the hand 242 84. An incorrect posture for the leg when it is site of extensive burns 243 85. Correct position of the leg in extensive burns 243 86. The results of incorrect position and delayed skin grafting in ex- tensive burn of the neck 87. Side view of same case as Figure 86 88. Greenstick fracture of the" forearm 89. Double rectangular splint and position of arms when applied in fracture of the humerus 249 90. The inverted T-shaped splint and position of arms when applied in fracture of clavicle 250 91. Splints in position in fracture of femur 251 92. Dressing completed in fracture of femur 251 93. Line of upper epiphysis of humerus and how end of diaphysis fits into it 253 94. Traumatic separation at upper epiphysis of humerus 254 95. Arrest of development of right arm due to early traumatic sepa- ration of the epiphyseal cartilage 255 96. Showing epiphysis of femur 255 97. Separation lower epiphysis of the femur 256 98. Lower epiphysis of humerus centers of ossification of capitellum and internal condyle 257 99. The normal epiphyseal line at upper end of tibia and fibula 257 100. Testing the knee reflexes 265 101. Correct posture for performance of lumbar puncture 271 102. Locating the right point of entrance in lumbar puncture 272 103. Needle in position and fluid being collected in sterile tube 273 104. Upright position for lumbar puncture 274 XXIV no. PAGE 105. Upright position in lumbar puncture needle in place and fluid flowing 275 106. Age incidence in poliomyelitis as observed in 1909 epidemic in Brooklyn, N. Y., by authors 299 107. Seasonal incidence of poliomyelitis as observed by authors in 1909 300 108. Atrophy of the musculature of leg following poliomyelitis 304 109. Hernia of abdominal wall due to paralysis of abdominal muscles in poliomyelitis 305 110. Flail-like limb, the result of paralysis and atrophy of poliomye- litis 307 111. Sarcoma of the kidneys 332 112. Sarcoma of the kidnej r s 333 113. Sarcoma of kidneys removed from child of two years 335 114. Angioma 342 115. Anterior meningocele springing from root of nose 354 116. Large occipital encephalocele 354 117. Microcephalus with encephalocele 356 118. Hydrocephalic child 357 119. Bat ears 362 120. Macroglassia 368 121. A. Unilateral hare-lip. B. Bilateral hare-lip 371 122. Steps in operation for simple notch in border of the lip 373 123. Steps in operation for complete fissure of the lip 373 124. V-shaped interval filled by the intermaxillary bone 376 125. Complete cleft involving hard and soft palate 376 126. Mouth-gag with sharp teeth that bite into the gum 378 127. Convenient forms of small-bladed knives 378 128. Lane needle, holder and needles 379 129. Lines of incision for repair of a median cleft in infancy 380 130. Method of fixation of the reflected flap beneath the elevated flap by a double row of sutures 381 131. Flaps sutured in position for repair of median cleft 381 132. Incomplete cleft palate without hare-lip operated at fourth week. 382 133. Hare-lip and cleft palate operated at the third week 382 134. The cricothyroid membrane through which rapid tracheotomy may be performed 388 135. Position of the child for intubation 390 136. Instruments used in intubation 391 137. A. Method of drawing the epiglottis forward. B. Introducing tube alongside of finger. C. Pushing tube into position with index finger 392 138. Outer tube of tracheal cannula. B. Inner tube of tracheal cannula 394 139. Improvised tracheal cannula made from rubber tubing 395 140. Torticollis 397 141. Lines of incision for plastic operation on the sternomastoid muscle 398 LIST OF ILLUSTRATIONS xxv yiQ - PAGE 142. Bilateral tuberculous glands of the neck 400 143. Line of incision for the radical removal of tuberculous glands of the neck 403 144. Location of the orifices of persistent bronchial fistula? 404 145. Congenital lymphatic cyst of the neck 400 146. The esophageal tube, showing the three points of construction. . . 411 147. Spina bifida 417 148. Ulcerating spina bifida 419 149. Spina bifida occulta 420 150. Sacral tumor before operation 422 151. Showing result after removal of sacral tumor 423 152. Drainage tubes in wound after resection of rib 428 153. The normal contour of the spinal column 430 154. Rachitic kyphosis 432 155. The"faulty posture resulting in the "pot-belly" of abdominal ptosis 433 156. Faulty and correct posture 434 157. Bending exercises with hands behind the back for the correction of round shoulders 435 158. Breathing exercise for the correction of round shoulders 435 159. Faulty sitting position 436 160. Scoliosis 437 161. Distortion of the ribs in lateral curvature 440 162. Method of applying adhesive strip to back on which the line of spinous processes is traced for future reference 442 163. Kyphosis of Pott's disease 448 164. Characteristic attitude of patient in picking up an object from the ground 451 165. Method of demonstrating normal flexibility of the spine 453 166. Method of demonstrating rigidity of the spine 453 167. The Whitman-Bradford frame 457 168. The Taylor brace for supporting the spine 458 169. Support for the head attached to the upper part of the Taylor brace 459 170. The "hammock frame" of Bradford and Lovett 460 171. Method of applying plaster jacket in the Bradford-Lovett frame. 460 172. The Calot jacket with opening over kyphos for the intersection of cotton-pads to diminish deformity 461 173. Lateral view of the transposed spinous processes 463 174. Method of applying adhesive strips for maintaining reduction in infantile umbilical hernia 473 175. Migration of testicle and tube-like process of peritoneum pro- jected into the scrotum 475 176. Relation of testicle to vaginal process of peritoneum just before birth 476 177. The final and normal disposition of the vaginal process 476 xxvi LIST OF ILLUSTRATIONS no. PAGE 178. Congenital inguinal hernia 477 179. Method of shaking the hernial contents back into the abdominal cavity 480 180. Cross-body trees applied to left inguinal hernia 483 181. Showing method of taking diagi-am with lead tape 484 182. Diagram of two persons whose measurements are identical 485 183. Operative technique for the simple reducible hernias of childhood . 488 184. Exstrophy of the bladder and bilateral undescended testicle 490 185. Diagram of stomach showing that its two-fold function is plainly marked in its structure 493 186. The vermiform appendix 500 187. Infantile cecum 500 188. Rectal-bimanual examination 504 189. Operative technique for appendectomy 509 190. Intussusception in vertical section 512 191. Congenital idiopathic dilatation of the colon 510 192. Absence of anus, rectum terminating in blind pouch 518 193. Normal anus with anorectal septum 518 194. Rectum terminating in the vagina 519 195. Protrusion of the anal mucosa through the anal orifice 521 196. Prolapse of the rectum 52:2 197. Sarcoma of the kidney 52S 198. The prepuce held taut and slit made along the dorsum of the prepuce 537 199. The excess prepuce removed, leaving small collar of skin and mucosa at base of corona 537 200. The skin and mucosa sutured and the ends of catgut left long to hold dressing in place 537 201. Gauze dressing tied in place 538 202. Tapping a hydrocele 541 203. Bilateral-inguinal nndescended testicle 542 204. Incision through skin, superficial fascia, aponeurosis of the ex- ternal oblique, and the peritoneal pouch opened 545 205. Upper end of vaginal process ligated 54(5 206. Cord lengthened, testicle freed and ready for replacement 54(5 207. Making pocket in the scrotum for reception of testicle ")47 208. Duplay's operation for epispadias 551 209. Hypospadias of the glands 552 210. Penile hypospadias 553 211. Penoscrotal hypospadias 553 212. Beck's operation 556 213. Rochet's operation 557 214. Bucknall's operation for penoscrotal hypospadias 558 215. Congenital elevation of the scapula 563 216. Ankylosis of the shoulder joint 565 LIST OF ILLUSTBATIONS xxvii PAGE 217. Radiograph of normal elbow at ten years 570 218. Radiograph of normal elbow at two years 571 219. The four centers of ossification forming the lower epiphysis of the humerus 571 220. Relation of the three bony points of the elbow 574 221. The "carrying angle" which the supinated forearm forms with the arm ; 574 222. Surface and profile radiograph of a supracondylar fracture 576 223. Supracondylar fracture 579 224. Fracture of the external condyie 580 225. Fracture of the internal epiconclyle 581 226. Internal angular splint 585 227. Gunstock deformity caused by obliteration of the carrying angle. 585 228. Application of the internal angular splint for fracture of the elbow 587 229. First position arm is held in position of forced flexion by adhe- sive strap. Second position dressing is completed by plaster bandage enswathing arm and chest 588 230. Greenstick fracture of the bones of the forearm 591 231. Fracture of the forearm immobilized in position of supination. . 591 232. Madelung's deformity 593 233. Spina ventosa 596 234. Clubbed hand with malformation of the bones of the forearm. . 597 235. Syndactyly Webbed fingers 601 236. Didot's operation for webbed fingers 601 237. Agnew's operation for webbed fingers 602 238. Diagram showing displaced femoral head on the dorsum ilii 605 239. Bilateral congenital dislocation of the hip in a boy of fifteen .... 607 240. Plaster fixation after reduction of a congenitally dislocated hip . . 610 241. Coxa vara 613 242. Obliteration of the gluteal fold in disease of the right hip 618 243. The results of malpositions and their effect on the pelvis 619 244. Diagram demonstrating the effects of malpositions of the limbs on the pelvis 620 245. Patient on his back, the knee of affected side flexed 620 246. Diseased limb extended back arched 621 247. Diseased hip flexed until lordosis of spine is obliterated, showing amount of fixed flexion deformity 623 248. Extension applied on wheeled litter 626 249. Taylor hip-splint 627 250. A. Fracture of neck of femur. B. Restoration of notarial angle by forcible abduction 629 251. Long spica as applied for treatment of fracture of neck of femur 630 252. Vertical suspension in fracture of shaft of femur 631 253. Genu valgum, or "knock-knee" 634 xxviii LIST OF ILLUSTRATIONS FIQ. PAGE 254. "Knock-knee" brace of Bradford and Lovett 637 255. MacEwen's supracondyloid osteotomy 638 256. Bilateral genu varum 640 257. Bow-leg brace of Bradford and Lovett 641 258. Rachitic curvatures of the bones of the leg 647 259. Congenital absence of the tibia 649 260. Club-foot 651 261. Congenital club-foot 652 262. Relation of the tendons in front of the ankle 656 263. Relations of the structures behind internal malleolus 657 264. Taylor's club-foot retention shoe applied 658 265. Varieties of deformities of the foot 661 266. Pes cavus 662 267. Flat-foot 664 268. Print of soles of a normal foot and flat-foot 666 269. Supernumerary toe 671 270. Hallux valgus 672 271. Hammer toes 674 PART I GENERAL SECTION I GENERAL CONSIDERATIONS CHAPTER I QUALIFICATIONS OF THE PEDIATRIC SUEGEON The first requirement of the surgeon who hopes to deal effectively with the surgicaj affections of childhood is a broad clinical experience with surgical conditions and a perfection of operative technique which has been acquired through actual contact with many cases. Such clinical experience will teach him that an operative procedure in the young requires more preliminary planning, more rapid operat- ing, and infinitely more gentle manipulation of tissues than a similar procedure in older persons. There are to-day very many conditions which are forcing the public and the medical profession to recognize the fact that the care of children is a more or less complex problem. We must recognize the fact that there are surgical conditions which are unknown to childhood ; that there are those also that are peculiar to that period of life, and that a particular disease is varied in its manifestations as it is observed in the different periods of childhood. To that knowledge which he already possesses of the details of scientific medicine and surgery, the pediatric surgeon must also bring a knowledge of and love for children. And it is not sufficient to know how disease or injury affects children; he must also know how children react to disease. The ability to correctly diagnose and to treat the surgical condi- tions of childhood can be met in two ways. The surgeon may per- fect himself as far as possible in the diseases of children, and, if this knowledge is augmented by large powers of close observation and a discerning and discriminating judgment, he is well equipped for his task. However, if, lacking the time or opportunity to be- 3 4 THE EXPRESSION OE DISEASE come unusually proficient in the medical as well as the surgical diseases of childhood, he may make use of the skill of the trained pediatrician. In fact, if the operative technique and courage of the skilled surgeon were more often coupled with the knowledge and judgment of the pediatrist, the surgical results to the child would be much better. And no small part of the surgeon's success with children will be due to his tact, his sympathy, his gentle firmness, and ability to inspire confidence in the particular child under examina- tion. The statement that the pediatric surgeon must be more than a skilled operator is not Utopian; there are very definite reasons for the statement. Disease in the infant or young child does not express itself as in the adult, therefore the pediatric surgeon must understand much of this difference and be able to interpret it correctly. A brief resume of some of these differences must be instructive. CHAPTER II THE EXPEESSION OF DISEASE IN THE YOUNG CHILD The clinical manifestations of disease in infancy and in ma- turity are vastly different ; it is this difference that makes the appre- ciation of disease in the infant difficult. The familiar things which are used as the foundation for building up the superstructure of diagnosis in the adult are in infants entirely absent, or are so totally different that they are misleading. In approaching the infant the inexperienced are at once confronted with a sense of loneliness sim- ilar to that which overcomes the stranger in a strange land ; a land in which there are few familiar scenes and none to guide. While there are many diseases which are peculiar to the period of life known as infancy, it is the peculiarity of the patient as much as the disease which must interest us, for it is this that leads to the varied expression of disease. Of prime importance in the study of any disease is the accuracy with which a diagnosis may be made. In infancy this entails that we must be acquainted witb THE EXPRESSION OF DISEASE 5 facts about the infant which have no direct bearing upon the disease or injury present, but which must often modify or entirely change our usual interpretation of symptoms. For instance, we are always conscious of the insignificant influence of the mind upon disease in infancy, for the diagnostic possibility is appreciably limited by the fact that psychic neurotic influences are almost excluded. The various tissues may also be incapable of exhibiting phe- nomena which are the result of certain etiological factors, or in their immaturity they may respond more easily and certainly to other factors. And, again, even in the presence of a definite symptoma- tology, the reasoning and deduction as to its cause must be entirely distinct from the same processes as they apply in adult life. For in- stance, the very"young infant is comparatively free from convulsive seizures, because, during the first three months of life, the acute sys- temic bacterial toxemias, which are potent factors in the etiology of convulsions, are infrequent. Then, again, stimulation of the cortical motor centers and of the convulsive centers at the base of the brain does not excite convulsive movement easily, because the nerve force discharged from these centers is hindered in its dissemination by the under-development of the myelin sheaths of the fibers of the pyram- idal tracts. These sheaths are gradually developed so that about the third or fourth month of life the pyramidal tracts have their functions sufficiently developed to bring the spinal cells and the cerebral convulsive centers into close touch. But after the third month and until the end of the second year all of the nerve centers are most irritable, so that convulsive seizures are common. The clinical import of this is that convul- sions in the very young infant are of serious import and that not infrequently after their subsidence there is some weakness of the affected musculature. That convulsions occurring at the onset of some disease in an infant between the ages of three months and two years are of but little import and may be due to the most trivial cause, while in adult life any such event at any time would be sufficient cause for great alarm. The necessity of recognizing these differences must be appar- ent, because it is by a correct analysis of them that we are enabled 6 THE EXPRESSION OF DISEASE to determine the import of symptoms. Not infrequently apparently mild symptoms are interpreted as indicative of mild disease, while seemingly more grave ones arouse unnecessary alarm and foster the drawing of wrong conclusions. Take, for example, the symptomatology of an acute illness in the infant or the results of an injury; we find that there is not the limitation of symptoms referable to the particular organ or re- gion which is primarily involved as in adult life, but the infant becomes the subject of more general or constitutional symptoms. Thus the expression of the disease or injury is more constitutional than focal and the younger the child the more striking the con- trast. This is largely due to the fact that there is an inability in in- fancy to focalization of nervous function because immaturity leads to an interference with the complete mechanism of inhibitory con- trol. Then again, the reflexes are not restrained, but become general- ized, leading to the appreciation of constitutional symptoms. And so we observe that nervous phenomena which would be of grave import in later life lose much of their gravity because they occur in the immature. For instance, the onset of most of the acute diseases of infancy gives rise to one or more convulsions, an event which is practically unheard of in adult life. Such convulsions are almost always mild in their effect upon the infant and cause little or no alarm to the one who is experienced enough to determine their significance and give them their proper value. And again, the digestive system bears considerable of the brunt of the invasion of any disease in infancy, so that it is our common experience to observe the symptoms of vomiting, diarrhea, or consti- pation at the onset of most of the diseases of infancy. Even making allowance for the ease with which disease of the digestive apparatus is produced in infants, the fact remains that a considerable propor- tion of disturbance which is laid to digestive disease is due only to the onset of some acute infection. The inarticulate expression of disease in infants has several THE EXPBESSION OF DISEASE 7 qualities which adults do not possess. And first among these is absolute honesty of such expressions. An infant's philosophy (if we may call it such) is contained in this statement: "All that is painful is evil; all that is pleasurable is good." To the infant the mere act of living in contentment is sufficient and this sufficiency takes no recognition whatever of the future, but is limited to the comfort of the moment. Neither is there any liv- FIG. 1. THE MARKED DIFFERENCES BETWEEN THE CHILD AND THE ADULT. At birth; the head repre- At six years; the head In adult life; the head sents one-fourth of the whole length of the body. six years; represents one-sixth of the body length. represents one-eighth of the body length. ing in the past, and this is aptly illustrated by the experiences of an infant in pain either from disease or injury. With the quick sub- sidence of the pain there is an immediate return to the usual play- fulness and no recollection of the past. Health and Disease are terms that have for the infant no con- tent. This fact of living for the moment is one of the chief factors in the discomfort attendant upon enforced restraint. The infant dis- 8 THE EXPRESSION OF DISEASE likes illness and by nature his rebellion against the restraint which an illness enforces is absolutely honest. This should lead one to appreciate the fact that if an infant shows any tendency to lose interest, to lag in its play, to become fretful, or act as if in discomfort, the cause should be sought in the bodily health. Therefore, muscular activity, which is an important factor in the growth and development of infants, is responsible for some of the peculiarities which are noted in illness. In fact, the disinclination to continue the usual muscular activ- ity should be interpreted as an early sign of ill health, and this is often expressed by the infant in the desire to be left undisturbed. The common accompaniment of diminished muscular activity is a diminution of mental activity, and the infant loses interest in its surroundings because the exertion demanded by the attentive attitude is unpleasant. And so when illness or injury has marked one of these little ones as its victim, this same antagonism to illness, this rebellion FIG. 2. COMPARATIVE SIZE OF LOWER JAW IN INFANT AND ADULT, SHOWING ALSO THE VERY MARKED CHANGES WHICH TAKE PLACE DURING DEVELOPMENT. against the consequent restraint, keeps the infant from the magnifi- cation or multiplication of its symptoms. Further than this the infant is entirely uninfluenced by the habit of morbid introspection and is therefore incapable of exaggerat- ing its ills for the sake of attracting attention to itself. Whatever exaggeration takes place is due to the parent who gives the history, and, through innocence or design, distorts the facts ; or to the surgeon who allows the given history to influence his judgment more effect- ively than what he finds by observation and examination. THE EXPRESSION OF DISEASE 9 We have more than once heard it stated that even infants would exaggerate their ailments, and that the quality of introspection in them was not entirely wanting. But this has always been based upon the demands which some children make upon their attendants during an illness. Much of this is the result of habit which has been formed during periods of health and is not a part of the ill- ness. There is no doubt that children need and demand more sympathy than any other class of patients, but the demand for it rarely exceeds the need. The infant crying in his apprehension may be labeled by the inexperienced as a disturber of the peace, but not so to the mother who understands the meaning of the cry and who is moved by its eloquence. "To the infant her arms are as a narcotic and when the mental need is fully supplied there is no further demand. Therefore the mental attitude of the infant, at least, may be taken as a safe guide and index to his bodily state. Of course, in the case of older children who have been indulged and spoiled, some considera- tion must be given by the surgeon to these factors. From these general facts, which are not always appreciated and may even be unknown, we can readily see that the more definite ex- pression of disease in children is often misinterpreted or unrecog- nized. SECTION II EXAMINATION CHAPTER III THE EXAMINATION General Considerations. The examination of infants and chil- dren offers many difficulties and peculiarities which do not obtain in adult life. Naturally the greatest contrast to adult life is ex- hibited by the infant (the child under the age of two years). After the end of the second year this contrast becomes progressively less, so that with the arrival at the age of puberty and the completion of the physiological upheaval which takes place at that period, the child becomes the adult. During all of this period from birth to puberty there are very marked differences in the surgical conditions which may occur and these refer particularly to the etiology, the pathology, the symptomatology, diagnosis, and treatment. The commonly accepted idea that as soon as the child is able to express its wants and its feelings with a considerable degree of in- telligence it becomes an adult in miniature is wrong. The child bears to the adult a relation of potentiality; nothing more. A com- plete description- of all the changes which take place and mark the child as being distinctively different from the adult would include each element of mental and physical growth and even the most general recognition of these differences emphasizes the error of applying exactly the same methods of examination as in the adult. The proper surgical examination of the child requires a previous in- timate knowledge of the normal child at the various periods of its growth and development. And without an intimate acquaintance with the morbid tendencies which are peculiar to each of these periods, and a clear understanding of the fact that from slightly active causes the child, with its unstable equilibrium, will exhibit 10 WHAT IS THE AGE? 11 the most varied and irregular disturbances, one is certain to bo led into serious error. It is essential that the surgeon have a clear understanding of the various congenital conditions and affections and also know intimately the usual surgical diseases and conditions which occur at the several periods of childhood. The tendency among surgeons has been to somewhat disregard the general condition and nutrition of the child and to divert all of the attention to a consideration of the disease or injury present and to look upon that simply as a mechanical proposition or a field for operative procedure. Such an attitude does not give to the child the best chance, for, in considering the problems connected with a possible surgical intervention, the surgeon gains much and gives much, if he takes cognizance of the child's organism as a whole. RAPID PAUSE IRREGULAR PAUSE IRREGULAR PAUSE RAPID PAUSE IRREGULAR PAUSE RAPID FIG. 3. A COMPOSITE CHART OF THE RESPIRATIONS OF 20 INFANTS OF FOUR MONTHS OF AGE. This represents the respirations for a full minute while the infants were at rest. This broader view of his sphere of work will aid in the discovery and relief of underlying conditions or in the avoidance of unpleasant (and at times fatal) complications during convalescence from an op- erative procedure. What Is the Age? This is a question the answer to which will largely influence the diagnosis. There are many diseases which are subject to the influence of factors which are active at one period of life but which are inactive at other times. Diseases of the new-born give immediate evidence of their existence or at most the event is de- layed for but a few days. This is particularly true of the injuries which may occur as the result of labor, and for illustration we need only mention caput succedaneum, cephalhematoma, hematoma of the 1-2 THE EXAMINATION sternocleidomastoid, visceral hemorrhages, obstetric palsies, tetanus neonatorum, atelectasis, ophthalmia neonatorum, etc. Congenital surgical conditions are at once evident. We might take for illus- tration the two conditions of hemophilia and hemorrhagic disease of the newly born. These two are commonly confused, though they are totally dissimilar. For instance in hemophilia the bleeding takes place as the result of some trivial injury or accident, and may begin or continue at any time during life. Usually the symptoms do not appear until after the first year of life, and predominate in the case of males as high as 13 to 1. But in hemorrhagic disease of the newly born the symptoms almost invariably are present before the twelfth day of life, and are rapidly fatal or may continue for a few weeks, but whatever the course the occurrence of hemorrhage is self-limited. Hemorrhages occur spontaneously, and entirely irre- spective of injury. Therefore, we can readily see that the question of age sometimes becomes a very important factor in diagnosis. General History Taking. Naturally there arise conditions of in- jury or disease in children which at once place the matter as an emergency, and the surgeon in such instances may feel impelled by the circumstances to proceed at once to apply the measures which experience shows offer the greatest relief. These are the few in- stances in which full history taking may be delayed until an oppor- tune time, but even though delayed it should not be neglected. It is not an uncommon experience to act in an emergency so as to satis- factorily meet the demands of the time, and while doing so to form an opinion quickly as to the conditions present, only later to have these conclusions completely upset by the history as revealed later. A careful record should be made sooner or later in every instance and the details of such a record do not materially differ from a simi- lar record of an adult case, except as it refers to certain events in the child's life and development. But whether kept by book or card matters little as long as the record is complete enough to act as such. Incomplete records may be harmful as well as being unsatisfactory. The card system will prove of most service, as the cases can bo classed not alone as individual ones, but at the time when the diag- nosis is positively made the cards may be classified according to the GENERAL HISTORY TAKING 13 disease or injury present. The card which we have found of most service is the one here shown (see Figure 4), and as it is of con- venient size (5x8 inches), and blank upon the reverse side, it allows of the free use of rubber stamps which outline the various portions of the body. The use of such stamps is a great time saver and tends to develop accuracy. For convenience of use while in the patient's home similar data is printed upon very thin but good paper stock and, when conveni- ent, this is pasted upon one of the cards. Birth Httlory Feeding Hi; Referred by Dr. FIG. 4 HISTORY CARD. W. C. on first line means white or colored. Nat. on second line means nationality. F. M. on fourth and fifth lines refers to paternal or maternal grandparents. The feeding history, the weight, and the history of the teeth are placed so that a ready comparison can be made of these as associated factors. The reverse side is blank for further data or the use of outline stamps indicating the affected portion of the body. THE HISTORY OF THE PRESENT ILLNESS is naturally the first thing to be elicited, and this is best done by a single leading question put to the parent, as, "Of what does the child complain ?" Only under exceptional circumstances should there be any interruption as this history is given. Full scope should be allowed the parent to tell all about the child's condition and the events that led up to it, 14 THE EXAMINATION and meanwhile the surgeon should be studying two things., the his- tory as given, and the temperament of the one who is giving it. This latter is quite important, as there is a tendency in some to en- large upon the illness or injury or to exaggerate particular symp- toms: and, upon the other hand, certain important ones may be underestimated or overlooked. The larger number of parents deceive the surgeon unintention- ally through the common habit of the loose use of words and inac- curacy of observation. In order to excite the greater interest of the surgeon or from some morbid tendency some will knowingly exaggerate all of the symptoms. All of these matters must be given consideration. Lead- ing questions must be absolutely avoided. The statement as regards the time of the onset will immediately place the disease in one of two categories acute or chronic. Never- theless, even if acute, it is important to determine beyond any reas- onable doubt whether it is dependent upon some underlying chronic condition. From this an endeavor should be made to arrange the subsequent symptoms in the order of their occurrence up to the time of examination, and, if the child has been previously the subject of surgical intervention, completeness demands that the procedure pre- viously undertaken be fully known. Upon fixing the date of onset there will arise the difficulties at- tending upon inaccurate observation of the parent. For instance, a spinal curvature which has existed for months may not have been observed, and when discovered the parent, not wishing to appear neglectful or unobserving, , states that it is of recent origin. This inaccuracy is always more in evidence when we are dealing with swellings, new growths, muscular incoordinations, and gradually de- veloped conditions. In older children who show a normal degree of intelligence a few pointed questions put to the child will prove a valuable supple- ment to the history, provided that the parent has been warned against interrupting the child, even though its answers do not completely coincide with the parent's history. The history thus obtained through parent and child will be in every instance incomplete. Dif- GENERAL HISTORY TAKING 15 fereiit methods of elucidation will suggest themselves, according to the temperament and intelligence of the history-giver. The exam- iner must recognize the fact that much of the history as given by the child is influenced by its own chief characteristics, and that this is also true of the parent's history giving. Of course, in cases of accident involving possible legal complications, another undesirable element is added which greatly affects the history as given. The time spent in obtaining a full and complete account of the child's present and previous condition is never wasted. It is not necessary that the history be given in strict accordance with the occurrence of the events ; the main thing is that the surgeon have in his own mind an orderly arrangement of the events, in order to arrive at the fight conclusions as to what events require further investigation. It may be necessary, in order to do this, to ask a few pointed but not leading questions. THE HISTORY OF THE PREVIOUS CONDITION of the child is an important one in surgery, in fact more so than in medical practice, because the operations of surgery are more exact and there is less chance for error. For instance, it might be positively stated that a child had suffered from scarlet fever when the true condition was simply erythema scarletiform, and this is always misleading, but if there was a history of appendicitis with surgical relief the matter becomes one of certainty. A knowledge of all of the diseases from which the child may have suffered is essential in history taking in surgery, provided that a fairly accurate account of the nature, the date, and the severity of the disease can be obtained. Previous attacks of certain diseases predispose the child to subsequent attacks, while, on the other hand, one attack offers a certain amount of immunity against future at- tacks. And, again, many conditions arise simply as sequelae, so that a history of the primary affection throws some light upon the immedi- ate condition. But here again the surgeon shares with the internist the trials of inaccurate statements. For the purpose of obtaining an estimate of the child's power of resistance to certain diseases and its ability to withstand the or- 16 THE EXAMINATION deal of a possible surgical procedure the history of the previous con- dition must take cognizance of the following: Was the child born at full term or abortive ? If the latter, then there is sufficient reason for the little one remaining weak and anemic for a long time. An abortive infant is always more susceptible to all of the infections and shows a decided tendency to become rachitic. The vital resist- ance of such children is always much lower and more easily disturbed than the normal. However, if there is a tardy development without a recognized cause or occurring as the result of a recognized etiology, but out of all proportion to that cause, it should at least suggest the possibility of syphilis. The same is true of a rachitic type of skull developed in a child without the other evidences of rachitis (as beaded ribs, baldness of occiput, head sweating, flabby musculature, anemia, etc.) being present or proportionately marked. A history of the abor- tive habit in the mother would always suggest the probability of syphilis. FIG. 5. RACHITIC TYPE OF SKULL. Was the delivery of the in- (Note especially the flattened vertex) < i i i ' fant attended with difficulty or the labor protracted ? If so, this might account for a subsequent epi- lepsy or mental deficiency or, if very difficult but not necessarily protracted, for spastic hemiplegia and other nervous diseases. How was the child fed? This question is important as an indi- cator of the probable power of resistance which the child may h;m> and, combined with the next question, "When and how were the teeth erupted ?" gives a good clew to the discovery of a rachitic condition. The average order and time of appearance of the teeth is as fol- lows: Between six and eight months, the two lower central incisors. Two months later, the four upper incisors. SECURING CHILD'S CONFIDENCE IT Four months later, two lower lateral incisors and four anterior molars. Six months later, the four canines. In another six months, the four posterior molars. Speaking generally, the deviation from the average in teethinc; is an indication of the general nutrition of the child. There may be normally some variation in the time of the appearance of the first teeth (the two lower central incisors), but after their appearance there should be a quite constant regularity in the order of the erup- tion of the other teeth. If the child is one of several in a family it is necessary to know something of the general condition and history of the brothers and FIG. 6. THE TEETH BETWEEN Six AND EIGHT MONTHS. FIG. 7. THE TEETH Two MONTHS AFTER THE APPEARANCE OF THE Two LOWER CENTRAL INCISORS. sisters and, in case any have died, to learn the cause of death. Where the family is large inquiry must be made as to the intervals between births, as rapidly recurring pregnancies exhaust the mother and have a decided influence upon the physical condition of each succeeding child. Any history of the tendency of the children of a family to suffer from unaccountable anemias and malnutrition during the earlier periods of life, despite the fact that the hygienic surroundings and the dietetic care are both excellent, or the occurrence of anomalous types of disease in two or more children of a family should arouse a suspicion of syphilis. Securing Child's Confidence. The securing of the cooperation and 18 THE EXAMINATION confidence of the child depends almost entirely upon the tact and firmness of the surgeon with a knowledge of the child's chief char- acteristics and an appeal to these latter. Activity is one of the most prominent characteristics in early life. The child is naturally restless and rebels against restraint which extends over long periods. Added to this, is an inability to concentrate the thoughts for more than a short time. This restless- ness is Nature's method of preventing a one-sided development. The child, being incapable of lengthy concentration or repose, makes a demand for variety and frequent change. The examiner must take cognizance of this characteristic and plan his examination so that FIG. 8. THE TEETH BETWEEN THE TWELFTH AND FOURTEENTH MONTHS. FIG. 9. THE TEETH BETWEEN THE SIXTEENTH AND TWENTY-SECOND . MONTHS. change of posture and of the details may be frequent enough to secure the child's interest and cooperation. While incapable of prolonged concentration the characteristic of attention is so strong in childhood that there is often an inability to avoid interest in things which are presented to the child's atten- tion. This is true in part chiefly because curiosity is so prominent at this period in life. The child usually gives its attention instinc- tively and without any effort of the will. A knowledge of this char- acteristic will prove most helpful in securing relaxation of muscles or helping in a proper estimate of the degree of tenderness present in a tender or painful part. Imagination is most vivid in early childhood, and advantage can be taken of this to secure a considerable degree of cooperation. It is this same characteristic of imagination that becomes a large factor in SECURING CHILD'S CONFIDENCE 19 making examinations in children difficult. Often the characteristic has been misguided and advantage has been taken of it to frighten children into a semblance of obedience. Commonly, the physician has been held up as one to be feared, and the child comes to the ex- amination table with a long-established dread of the examiner, who- ever he may be. But the characteristic is so strong that for the moment the sur- geon is commonly able with tact to so strongly excite it that the usual fear and dread is overcome and for the time the child is sub- missive. A few simple lines upon a piece of paper will readily be transformed by the imagination of the child into real persons or things when the suggestion comes from the one who draws the lines. There are some^very practical points that it is well for all exam- iners of children to remember. (1) KTo child's confidence is ever gained by deception. If the procedure about to be undertaken is one that will be painful it is best to state that fact, coincident with the beginning of the proced- ure. In some children it is advis- able to withhold any statement as to the possibility of causing discom- fort, as their dread of pain is more than their actual experience of it. In such cases we must proceed immediately with the examination. But saying to a child of ordinary intelligence "It will not hurt," when we are assured that the procedure about to be undertaken will or may cause discomfort, is at once destructive of the child's confi- dence and must be avoided. It is the child's confidence and coopera- tion that we seek, and these are never gained except by frankness and firmness. (2) Begin with the simplest procedure and delay the more pain- ful or terrifying ones until the last. (3) Do not expect relaxation of muscles by request; divert the child's attention and secure it in that way. (4) Every child must know that the examiner is master of the FIG. 10. THE TEETH BETWEEN THE TWENTY-SECOND AND THE TWENTY- EIGHTH MONTHS. 20 . THE EXAMINATION situation. We may have to use very different methods in our ap- proach to the child, according to their age, temperament, present condition, and past training and environment, but these do not in- fluence the necessity of having every child feel instinctively that for the time he or she is under the domination of a higher will. (5) Do not add to your office armamentarium expensive toy.s or articles which cannot be carried away by the child. Children have an easily aroused sense of injustice, and if a toy is given to secure cooperation and then when the examination is over the toy is taken away, the child justly rebels and the confidence thus once destroyed is hard to secure at subsequent examinations. And there is another danger of the expensive toy. Any child may be the subject of an infectious or contagious disease, and the retention of the handled toy in the office of the surgeon invites dis- aster to the following patients. Sanitation and good sense demand the use of the inexpensive attention holder. THE APPROACH TO THE CHILD may have to be in many instances very gradual, and the examiner must remember that he is dealing with an irrational, easily frightened being, whose disease has un- doubtedly irritated or exhausted it to such an extent that it lacks entire self-control. It is hardly necessary, therefore, to state that before a successful examination can be made the examiner and the child must under- stand each other. There can be no hard and fast rules by which we may hope to win the confidence of the child ; one will require to be absolutely ignored for the time being while a history of the condi- tion is being obtained; another must be approached at once. AViili a child of this latter class it is best for the surgeon to retire from the room at the first sign of rebellion at his presence, and obtain the full history of the case, after which the approach must be firm to conVince the child that the surgeon is the master of the situation. In dealing with older children the object may be obtained by drawing the child into a conversation, and this is best done by im- personal questioning. But no replies must be expected from such questioning, for a child that is timid usually does not talk, and if pressed for a reply the shyness is increased. The real object of the SIDE POSITION" 21 remarks to the child is to impel him to join in and through this opening to gain his confidence. If the conversation is about the things in which he is vitally interested it will be but a few moments before he is compelled by his own interest to join in with the ex- aminer, who is then well on the road to the securing of the little one's confidence. Of course, in the instance of the "spoiled child," there is no possibility of gaining its confidence or cooperation, except after a very long season of contact. Such a child's confidence and trust in any one have been almost completely destroyed. These unfortunates have never been brought under the influence of authority, and are always the product of bad training. They must of necessity be dealt with firmly and forcibly, and not in the presence of their parents. CHAPTER IV GENERAL POSTURE The position which a child assumes while in bed is often sug- gestive. The attitude of the child may, on the one hand, be reassur- ing, as we note that he lies quietly and rests easily and sits up or turns to greet the surgeon. It assures one that the disease or injury is probably slight, or that convalescence is already established. When the child becomes muscularly and mentally inactive we may be sure that the illness or injury is severe. In fact, the disinclination to continue muscular activity should always be interpreted as an early sign of ill health, and this is often expressed by the child in the de- sire to be left undisturbed. The common accompaniment of dimin- ished muscular activity is a diminution of mental activity, and the child loses interest in its surroundings and playmates because the exertion demanded by the attentive attitude is unpleasant. Side Position. The side position is assumed characteristically in acute pleurisy until the time of effusion, and then there is often a change to the dorsal. If a child is pale and thin, indicating that the illness has been a long one, and the breathing is much interfered 22 GENERAL POSTURE with, we may be almost certain that there is a large exudate. A light percussion would be sufficient to exclude pneumothorax. FIQ. 11. SIDE POSTURE CHARACTERISTICALLY ASSUMED IN PAINFUL CONDITIONS OF THE CHEST AND SOMETIMES WHEN ONE SIDE OF THE ABDOMEN is AFFECTED. Dorsal Position. The dorsal position (a) with slightly flexed legs, is the position of election in cases of acute peritonitis and tuberculous peritonitis. Motion is carefully avoided, and in acute FIG. 12. DORSAL POSTURE, WHICH is THE POSTURE ASSUMED BT THE CHILD MOST OFTEN IN PERITONITIS, PERINEPHRITIS, APPENDICITIS. peritonitis there is usually an expressed fear as the child is ap- proached. (b) With a curve of the body slightly toward the right side, and ON THE ABDOMEN with the right knee more or less flexed, the dorsal position is as- sumed in appendicitis if pain or tenderness are prominent features. Sometimes the child will hold the knee, but this should not distract the surgeon's attention from the real site of trouble, which is within the abdomen. (c) With the thighs and also the knees flexed and more or less rigidity of the leg of the affected side the dorsal posture is assumed in perinephritis, but is a rather late occurrence. Preceding this there is the assumption of the position of slight flexion of the body toward the affected side and some flexion of the knee and hip. In standing the child may place the hand upon the knee of the affected side or slightly above it. This posture is assumed in lumbar disease of the spine, also, and these must be differentiated. FIG. 13. POSTURK "ON THE ABDOMEN." The child usually does not lie flat on the abdomen for any length of time, but re- mains partly in that posture for protracted periods. (d) With the affected limb held more or less rigid and flexed to relieve the tension in acute infective tenosynovitis and in scurvy when epiphyseal separation has occurred or is threatening. But it must not be forgotten by the surgeon that in children a full bladder or the occurrence of a hernia (even of a mild degree) will compel the child not infrequently to assume the dorsal posture. (e) If a child suffering from pleurisy and assuming the char- acteristic side position changes that posture to a prolonged dorsal one it is suggestive of effusion. On the Abdomen. On the abdomen is the position taken in: (a) 24 THE GAIT some cases of Pott's disease, but in this it is by no means character- istic. (b) In phlegmons of the back (to relieve the pain from undue pressure). (c) To secure the relief which is occasioned by pressure in non- inflammatory conditions of the abdomen. Forced Positions. Forced positions are those which are assumed in certain diseases as tetanus, meningitis, etc., and which are ex- hibited as opisthotonos and emprosthotonos. Upright Position. The upright position may be assumed as the result of accumulations of fluid within the abdomen interfering with respiration, from large effusions in the pericardial or pleural cav- ities, or from hypcrthyroidism. Constantly Changed Position. Constant changing of position is indicative of pain and irritation, and if the legs are alternately drawn up and down and the arms thrown about the probability is that inflammation is not present in any marked degree. CHAPTER V THE GAIT Limping. If the child limps even slightly the cause should be determined at once, and it must never be dismissed as a trivial symptom. The examination to determine the cause should be made with the child nude. It is an easy matter to attribute most of the instances of limp to rheumatism as the cause, and without the most careful questioning the surgeon can be readily led into error by the history as given by the parent. But we must be ever mindful of the fact that countless errors have been made in attributing most limps to rheumatism, and the attitude of the surgeon must con- stantly be that the diagnosis of rheumatism in children should not be made until every other possible cause for the symptoms has been excluded. In a large number of the instances the true cause of the limp will be found in muscular rigidity consequent upon inflamma- WADDLING 25 tory bone disease. This is true, irrespective of the presence or ab- sence of pain as expressed by the child. In the large majority of instances the cause of the limp will be found in an incipient tubercu- lous or inflammatory bone disease of the spine, the hip, the knee, or other joint. The first condition is usually one of muscular rigidity, and this in itself may create the limp, and yet the child may not be conscious of pain. Limping from rheumatism is not long con- tinued. That is, rheumatism has as one of its characteristics in childhood the marked tendency to be non-arthritic in its manifesta- tions, but cardiovascular. When arthritic symptoms are present it is very unusual for a particular joint to be affected for more than two or three days. Then other joints may become affected in suc- cession. From this it will be observed that a persistent limp would not be at all suggestive of rheumatism, unless in those rarer in- stances in which deformity has taken place. The characteristic limp- ing in tuberculous hip disease is a decided prolongation of the nor- mal time in which the affected leg is made to bear the weight of the body. This by observation gives a gait which is quite uneven and with some slight dragging of the affected member. However, if the . disease has already caused deformity, there will be a very decided limp, because the leg is then held in abnormal relation to the pelvis. Intermittent limping is often observed in the earlier stages of joint disease, but its most characteristic appearance is in those cases in which there is an obstructive interference with the circulation of the lower limbs. This interference comes from thickened arteries; in other words, there is a true arterial sclerosis of the legs. While not common, yet it occasionally appears during childhood and may result in gangrene. The pain is most commonly complained of at the hip or in the calf, and is aggravated by exercise. Pulsation of the arteries of the foot is diminished and the whole foot may assume a white or bluish hue and become cold. The etiology is uncertain, but syphilis has been associated in most instances which have been studied. Rest in bed or by crutches is the treatment plus the treat- ment of the exciting cause (as syphilis) if that can be reasonably determined. Waddling. While the first thing that is forcibly brought to the 26 PAIN attention in children who suffer from congenital dislocation is that they walk late, still it is evident that from the time the first steps are taken the gait is uncertain and staggering. In cases of double dislocation there appears the very characteristic "waddling" walk. However, this type of walking is closely approximated by some cases of rachitis. If the surgeon finds that there exist the usual de- formities of the limbs as observed in rachitis, such as the curved tibiae, the epiphyseal swellings, etc., this is not sufficient evidence to establish the diagnosis of rachitis. Cases of congenital dislocation frequently exhibit just such deformity, and a most searching ex- amination is necessary to establish the diagnosis definitely. Stumbling Gait. In flat-foot the inability to dorsiflex the ankle beyond the right angle results in a stumbling or awkward gait which is especially noticeable when the child runs, because there occurs a spastic contraction of the calf muscles. The child generally walks with much shortened steps, bent knees, and the feet everted. Sooner or later to every surgeon who deals largely with children will come patients with a history of injury of the knee followed ap- parently weeks or months later by swelling, effusion, and disability. While all evidences of the traumatism have usually disappeared, still the immediate pathological condition at the time of examina- tion may be anything from a sensitive joint to a tuberculous process or a sarcoma. This always results in some interference with the free use of the limb, and there is a consequent limp which is persistent and usually progressive. CHAPTEK VI PAIN GENERAL CONSIDERATIONS Pain is very difficult of recognition in infancy because many of the notable features which usually accompany it are present in con- ditions in which no pain is appreciated. (Some of these features GENERAL CONSIDERATIONS 27 are the tense pulse, hurried respirations, drawn features, restless- ness, etc.) Being a purely subjective symptom, its intensity as well as its presence must often be determined by observation, by the nature and extent of the probable cause, and the statements of the child or its parent. Even in children of considerable age and intelligence the recog- nition of pain and its intensity must be substantiated by other evi- dences than the statements of child or parent. When the child is too taciturn, exaggerates, or is in any way incapable of accurately describing the sensation of pain, we must rely more upon the objective evidences. By far the largest factor in the proper estimation of pain in children, and an appreciation of its intensity and character, comes from the inability of the examiner to correctly gage individual susceptibility, and this can never be learned from books. There are marked differences among children in the susceptibility to pain perception, and this is further modified by nutritional conditions existent at the time or shortly antedating it. Long-continued pain leaves the child less resistant and therefore actual pain at the time of examination seems much exaggerated. Tenderness should not be confounded with pain. It is the product of painful sensations through the agency of pressure, and pain is usually associated with tenderness. In diagnosis it is well to recall that pressure over the part complained of by the child as being the actual site of pain may reveal no tenderness, while pressure over a more distant and uncomplained of part may show the real point of invasion. Mode of Onset. The mode of onset is indicative of the acuteness of the causative factor ; sudden onset or short duration indicating an acute condition and gradually developed or prolonged pain indicat- ing chronicity and no solution of continuity. Time of Occurrence. The time of occurrence has some value. For instance, headaches occurring in the late afternoon are almost always due to anemia or a weakened heart action. Pain at night is always suggestive of periosteal inflammation. Pain immediately 28 PAIN following a meal would be suggestive of a digestive fault and, if occurring somewhat later and referred to the abdomen, then of an intestinal one. Then, again, we may have the pain referred to some functional act, and its increase or occurrence persistently with the acts of respiration, urination, deglutition, defecation, and so forth, would indicate the true cause. Character of the Pain. If the child be intelligent enough to dis- tinguish the character of the pain there may be some value in de- termining this point, for it is often indicative of the cause. (a) An acute, stabbing pain is usually observed in the acute inflammations. If radiating it is suggestive of neuralgia or neu- ritis. (b) Dull pain occurs mostly as the result of inflammations in the mucous membranes, the parenchymatous viscera, or when inflamma- tion has been of long standing. It is also observed in visceral af- fections and injuries. (c) Constant and boring pain is observed in affections of the bones and in periosteal disease. The pain of hip joint disease is an early but by no means a constant symptom, and in most instances the pain is much worse at night. It may be referred to the knee of the affected side. (d) Aching pain or soreness indicates that the affection is in the musculature, although the underlying cause may be constitutional. (e) Burning and itching pain is most commonly observed in the various skin affections. (f) Remitting pain is suggestive and characteristic of colic, of some cases of neuralgia, and cramps of all kinds. (g) Pain increased by motion is observed in all inflammatory processes, in diseases of the bones and joints (in which it is usually dependent upon muscular spasm), and particularly and character- istically in scurvy and rachitis. In fact, in scurvy, it is a very com- mon experience to find that the very first symptom which calls at- tention to the fact that the child is not well is the history of evident pain upon handling, and this may have persisted for a considerable time before other symptoms are noted. Site of the Pain. In children the site of the pain does not al- GENERAL CONSIDERATIONS ways correspond with the situation of the causative factor. It is always well for the surgeon to remember that pain in children cor- responds only to nerve distribution, so that when an organ or part is affected with disease the pain is sometimes referred to that situa- tion, but is more commonly referred to points somewhat distant but in line with the nerve distribution from the diseased part. For instance, the referred pain due to Pott's disease has been the occasion for a considerable amount of error. I Deferred to the abdomen, it has often given rise to the suspicion of digest- ive trouble; to the chest, it has occa- sioned a diagnosis of pleurisy. GENERALLY DIFFUSED PAIN occurs quite constantly in children in all the febrile processes, and particularly those with an infectious etiology, so that its diagnostic import is quite small. PAIN IN THE LATERAL WALL OF THE CHEST. This has as its most common causes pleurisy, intercostal neuralgia, enlarged bronchial glands, vertebral disease, pneumonia, and dis- eases and injuries of the chest wall. PA IX IN THE PRECORDIAL REGION is usually due to gastralgia, pericar- ditis (rare in children). PAIN ABOUT THE DIAPHRAGM may persist for several hours after severe vomiting or prolonged coughing, and is commonly observed in pl( urisy. EPIGASTRIC PAIN generally depends for its cause upon some one of the gastric neuroses, gastric inflammation, vertebral disease, or pneumonia, or may be due to acute gastric dilatation. PAIN IN THE UPPER EXTREMITY is most commonly due to neu- FIG. 14. PAIN IN THE LATERAL WALL OF THE CHEST. Most commonly present in pleurisy, enlarged bronchial glands, inter- costal neuralgia, vertebral dis- ease, pneumonia and chest in- juries. 30 PAIN ritis, enlarged axillary glands, and to bone disease. Confined strictly to the left arm, it is observed frequently with enlarged spleen. BILATERAL PAIN IN THE AKMS is usually of central origin, or may be due to vertebral disease. SPINAL PAIN is complained of most often in spinal curvature, vertebral disease, diseases of the meninges (associated with muscular spasm), and in many cases of rachitis and scurvy (in which it closely simulates the pain due to organic disease). PAIN IN THE LOWER EXTREMITY is usually due to hip joint disease (usually referred to the knee), psoas abscess, peri- nephritis, sciatica, or, less commonly than is usually supposed, to rheumatism. In fact, every other pos- sible cause for pain should be eliminated be- fore a diagnosis of rheu- matism is made in a child. Pain is not one of the prominent features of rheumatism in children. Pain referred to a joint may be due to synovitis, osteomyelitis, tuberculous bone disease, scurvy, or rheumatism. In some rare instances rachitis may cause such pain. PAIN IN THE EAR is almost always due to acute otitis or to mas- toiditis. PAIN IN THE ABDOMEN, the HEAD, and in the EAR are very im- portant symptoms during infancy and childhood, and therefore they have been considered somewhat fully in separate sections. (See Abdominal Pain, page 31; Headache, page 40; Earache, page 42.) FIG. 15. PAIN IN THE EPIGASTRIUM. Most often present in pneumonia, the gastric neu- roses, gastric inflammation and acute gastric dil- atation. THE SURGICAL SIGNIFICANCE OF PA IX 31 It is almost impossible and quite unnecessary to refer in detail to all of the conditions which in childhood will cause pain, therefore all that we have considered as essential was a reference to some of the more important causes of pain, and particularly those with which the surgeon will commonly come in contact in children. THE* SURGICAL SIGNIFICANCE OF PAIN Abdominal Pain. It requires considerable judgment to give ab- dominal pain in the child its proper interpretation. In the exam- ination of the older child it is necessary to determine at the outset whether or not the pain is limited to the abdominal wall, or if it is associated with one of the underlying viscera. While it is not very common, at the same time it is not infre- quent that we find the wall of the abdomen hyperesthetic. The result is that in the examination to determine the site of any ab- dominal pain the inner aspect of the thighs should be first exam- ined. In doing this we gain two things : first, we do not directly approach the site of expressed pain, and we thereby gain the child's confidence somewhat ; and, second, hyperesthesia of the abdominal wall is almost invariably associated with a similar condition of the inner aspect of the thighs, and absence in this situation would lead one to suspect its absence in the abdomen. When such hyperesthesia is present it is spread over a somewhat considerable area, extending well up over the chest. If a fold of the skin is grasped and firm pressure is made upon it the pain is in- creased in proportion to the degree of pressure. Hyperesthesia of the skin of the abdomen is fairly constantly associated with typhoid fever and meningitis ; less frequently with malaria, the other acute infectious diseases, and anemia. Sometimes we find that the pain is simply muscular, and the causes of such a condition are usually exposure to cold, straining from violent coughing, unusual exercises involving the abdominal musculature, and in rare instances rheumatism. In all such cases the pain is localized quite strictly to the rccti muscles if the active cause is a mild one. 32 PAIN However, if the condition is of the unusual severe type, there may be vomiting, some fever, and rather widespread abdominal pain, which compels the child to assume one position and remain in it. The whole course of the severest attacks is not over forty-eight hours. In nearly every instance exercise is the cause of the severe attacks. If the pain is due to inflammation of the peritoneum it is by far the most acute abdominal pain which is observed. It is continuous, although this fact may be overlooked, owing to the acute exacerba- tions which occur, and which are due to peristalsis. Associated with the pain there is tension of the abdominal wall, the slightest pressure increases the pain markedly and makes the tension more prominent, and there are the other evidences of inflammation of the peritoneum, as tympanites, constipation, etc. INTESTINAL, COLIC is one of the most frequent causes of pain and crying in infants. They not only cry, but usually there is a succession of shrieks, which is associated with throwing about of the legs, until relief comes with the expulsion of flatus. Generally such attacks are associated with constipation, but this is not always the case; they are not infrequently associated with diarrhea. An im- portant aid in the rapid recognition of this condition is the fact of .the quick relief which is afforded by the use of a warm enema and the absence of other symptoms than colic. By far the chief seat of conditions which result in attacks of in- testinal colic is the stomach, and failure of perfect digestion in that organ is almost certain to be followed by colic. Intestinal parasites are a less frequent cause, as is also loss of tone of the muscular walls of the intestines. The abdomen is generally much distended with gas, and if there is an absence of this feature the search for the cause should be most thorough, and it ought not to be accepted as a simple intestinal colic until every other possible cause is excluded. It is characteristic of the condition that after the subsidence of the attack there is an en- tire absence of all ill effects. Intestinal colic is most frequent during the first six months of life, and irrespective of the fact as to whether the infant is breast- THE SURGICAL SIGNIFICANCE OF PAIN 33 fed or bottle-fed. Perhaps it would be no exaggeration to say that fully three-quarters of all the cases are due to the proteid element in the food. In the diagnosis of the condition one must be certain that the attacks are acute, for a chronic state of flatulence in an infant may be associated with more or less wasting and slight fever, and would suggest the probability of a beginning tuberculous peritonitis. If there are elevation of the evening temperature and a well-defined tenderness of the abdomen, with various points at which there is evident thickening, then the diag- nosis of tuberculous peri- tonitis is almost certain. It is in older children, in those beyond infancy, that abdominal pain is most common and perplex- ing, and we might well ask what is to be our attitude toward this class of cases ; what shall we do with them ? We might be justi- fied in making a somewhat arbitrary division into the acute, the chronic, and the borderline cases, for this is practically what we do when we approach a case for the first time. We may now disregard those instances in which this symptom is due to violence, for the etiology in such cases is so evident. APPENDICITIS. Under the acute cases we naturally think of appendicitis first. And why ? Certainly it is not because abdominal pain is necessarily an early or characteristic symptom in appendicitis in children, for that is not so. But the subject of appendicitis is so FIG. 16. GENERAL ABDOMINAL PAIN. Usually restricted to the area indicated but may extend well up over the lower portion of the chest. 34 PAIN constantly forced upon our attention that we are often led to give it undue prominence in our efforts to make a diagnosis. Why not give a similar consideration to those conditions which are much less common than appendicitis, but which are just as im- portant of recognition, if any adequate treatment is to be instituted ? The recognition of appendicitis is made so comparatively easy that it is often diagnosed when it does not really exist. On the other hand, there are borderline cases that, on account of their indefinite symptomatology and the absence of a clean-cut, well-defined clinical picture, are not adequately treated, the mild chronicity of the symp- toms or their appearance at long intervals not being sufficient to emphasize the real seriousness of the condition until it is too late. These cases are usually classed under the popular lay, but unscien- tific, misnomer, "bilious attacks." Appendicitis exhibits three cardinal symptoms : localized ab- dominal pain, localized abdominal tenderness, and rigidity of the right recti muscles. Of these three the first is the least important in diagnosis, for it may be slight. Usually, however, pain is severe and intermittent, so that the child complains as of colic. The child (unless of much intelligence and over six or seven years of age) exhibits its usual inability to definitely locate the pain, and in most instances when it is somewhat definitely located it is referred to the umbilicus. Tenderness is a much more constant feature, and is seldom, if ever, absent. By palpation it is located in the right inguinal region, but the whole abdomen may be hyperesthetic. Even in this case there is more acute tenderness in the right inguinal region. Muscular rigidity is the last mentioned and yet the most valu- able sign of the three, for it is never wanting in some degree. It is particularly marked in the lower quadrant on the right side, but unless the child is unusually quiet it is most difficult to demonstrate. Rise of temperature may be absent or moderate, or there may be considerable pyrexia, the usual ranges being between 100 and 104 F. It must be remembered, however, that the height of the fever is no indication of the severity of the disease. Associated with the fever there is generally more or less vomiting, which is usually THE SURGICAL SIGNIFICANCE OF PAIN 35 repeated, and may persist until it becomes first bilious, then fecal (the latter being very rare). In contrast to the usually low temperature the pulse is charac- teristically rapid and is thin and thready. Thirst, which is marked, and constipation, which is obstinate, are the rule, although the at- tack may at times be preceded by diarrhea. The child often as- sumes a dorsal position with the right limb flexed at the hip and knee. The termination of the disease is by resolution, the develop- ment of general peritonitis, or the formation of an abscess. An attack of appendicitis is usually sudden, and the acute catar- rhal type may subside within forty-eight hours and fail to be recog- nized. However, if all cases of supposed acute attacks of indiges- tion were examined after a subsidence of all symptoms, in many instances a careful palpation would reveal a slight thickening and induration about the region of the appendix, and the true nature of the attacks would thus be discovered. It is not unusual for several such attacks to occur within a few months or years, and in every instance be attributed to some error in diet. The value in recognizing such attacks is in advising ap- propriate measures for the prevention of a severe suppurative form of the disease, which is liable to appear at any time, either during the course of one of j:he mild attacks or directly after it. If an abscess is formed then this is recognized by the boggy feel of the tumor and exploration by the fingers through the rectum. Symptoms which are strongly suggestive of an abscess are fluc- tuating fever (with the history of chills in older children or con- vulsions in infants), a persistently coated and furred tongue, and increasing prostration. The value of a blood count is doubtful in children. , Such a count requires the most careful technique, and to avoid error there must be several counts daily, and if the pus becomes encysted the count is of lessened value. For practical general work it is useless. When an abscess has developed the course of such is very in- definite, sometimes persisting with symptoms of a mild septicemia for weeks. It is very rare that severe symptoms are persistent for a considerable period. Peritonitis sometimes will develop upon the 36 PAIN third or fourth day, and usually collapse and death quickly follow in such cases. The symptoms which are the most suggestive of such an ex- tension are an otherwise unexplained rise in the temperature, ab- dominal distention, rather sudden subsidence of the localized pain, to be followed shortly by generalized abdominal pain, tympanites, and collapse. The diagnosis must be made first from acute indigestion, which usually exhibits a higher temperature and much more rapid sub- sidence of the acute symptoms, and which exhibits no thickening in the region of the appendix when palpation is later practiced. Late palpation should always be performed. From volvulus and intussusception the diagnosis is usually read- ily made, for in these conditions there is absence of the temperature rise, and there is present the passage of bloody stools or mucus dis- charges from the rectum which are accompanied with tenesmus and the development of a left-sided tumor, as a rule. The tympanites may be so early in appearance and so marked in degree that the tumor cannot be made out. Nephritic colic may simulate appendicitis for a time, br.t the pain is limited to the lumbar region, and instead of increasing is decreased by pressure. The pain generally radiates along the course of the ureter and is relieved to an extent by urination. There is no muscular rigidity of the abdomen. Slight fever may be present, but this is unusual. Hepatic colic sometimes has a most acute onset, with severe pain and vomiting, and may simulate appendicitis, but the pain is more severe and persistent in character and confined mostly to the lower portion of the right side of the chest. Typhoid fever is sometimes hard to differentiate, particularly when the history is vague and the symptoms are not pronounced. It is then necessary to delay judg- ment or apply the Widal test. Pneumonia of the lower lobe may have an onset much like ap- pendicitis, and with a similar abdominal pain, which is due to in- volvement of the lower dorsal nerves, so that it is necessary to carefully examine the chest to distinguish the real disease. The THE SURGICAL SIGNIFICANCE OF PA IX 37 symptoms which would suggest a lung condition are : sudden rise of temperature to 103 F. or over, and its maintenance above that point, increased respirations (out of proportion to pulse), relaxed abdominal muscles, and cough. ACUTE PERITONITIS is usually easy to recognize 011 account of the well-defined symptoms, chief of which is severe and diffused abdominal pain. This pain is increased by the slightest degree of pressure, so that the motion of the child, coughing, sneezing, or jar- ring the bed will increase the suffering greatly. The result is that the child remains immobile upon the back, with the legs drawn up to relieve the tension on the abdominal muscles. The onset is nearly always quite abrupt, with vomiting and rise of temperature, the vomiting being usually present only at the onset and the temperature reaching 103 or 105 F. The most constant feature of the disease is the swollen and tympanitic abdomen. The distention is diffuse in nearly every instance, but rarely it may not be so regular. Constipation is the rule. Outside of the local symptoms there is evidence, from the gen- eral ones, of the seriousness of the disease. From the start pros- tration is marked and the pulse is weak and small. The pain is evidenced by the drawn and pinched features, and the extremities are in some cases cold and clammy. The mind is generally clear. When the vomiting persists it is usually an indication that collapse will quickly supervene. In childhood the course of the disease is usually rapid (three or four days), but, if of a moderate severity, the course may be ten days, and after that time there is generally a localization of the process with good chances for recovery. If peritoneal abscess de- velops, then we have the added symptoms of hectic temperature, chills, sweating, and local signs of tumor. In young infants the disease is not so well defined, and therefore is harder to distinguish. In them it usually proves fatal within the first seventy-two hours, and with symptoms so obscure that often the diagnosis is not made. The pain is evidenced by the restless- ness, the constant crying, and fretfulness. In most cases the diag- nosis is not made unless there has been a clear history of some eti- 38 PAIN ologic factor. In the newly-born this might be by direct infection through the umbilical vessels ; in older infants by traumatism, severe burns, or as a secondary condition to appendicitis, hepatic abscess, acute intestinal obstruction, pleuritis, gonorrheal vulvovaginitis, pneumonia, or scarlet fever. LOBAR PNEUMONIA is a very common cause of acute abdominal pain in children, and one that is readily overlooked. It is a safe guide that no matter what the acuteness of the abdominal pain, or even its location, if there is a marked disproportion between the pulse and the respirations, that pneumonia should at once be suspected as its cause. It has been our rather common experience to have chil- dren sent to our hospital ^services for operation for appendicitis, and upon examination to find that the appendix was apparently normal, but that the pain in the abdomen was entirely dependent upon a right-sided lobar pneumonia. So frequently has this occurred that it should be prominent in the mind of every surgeon who deals with children. CATARRH OF THE J.ARGE INTESTINE is accompanied by frequent colicky pains which are associated with tenesmus and stools that are composed mostly of mucus. It must be differentiated from in- tussusception. INTUSSUSCEPTION exhibits a most intense abdominal pain, and the onset is sudden, with repeated, violent vomiting. While the pain may be apparently paroxysmal, yet by careful examination we find it to be continuous with distinct paroxysmal increases and accom- panied by much straining and screaming. Prostration is always extreme. At first there is usually the passage of small quantities of blood and mucus, or at times these may be passed with small quan- tities of feces. Other cases show an entire absence of any discharge from the rectum from the beginning. The most characteristic feature is the formation of a smooth, slightly movable, very tender, cylindrical tumor, palpable through the abdominal wall and usually felt above the umbilicus, extending toward the right flank. INTESTINAL, PARASITES may be suspected as the cause of colic if the pain occurs in the day upon an empty stomach, but the only THE SUKGICAL SIGNIFICANCE OF PAIN 39 positive diagnosis is made by their removal resulting in an entire subsidence of all the symptoms. The pain in SPINAL CARIES is usually worse at night, and is re- ferred to those parts of the abdomen which are the site of the dis- tribution of the nerves that are nearest the site of the spinal lesion. In NEPHRITIC COLIC there is usually a distinct family history or history of previous attacks, and it follows exercise as a rule. STRANGULATED HERNIA is not difficult of detection, for the local signs are usually well marked, leaving little chance of error. The pain is similar to that of other intestinal obstructive conditions. OVERDISTENDED BLADDER may occur during the course of sev- eral diseases and be directly the cause of most severe abdominal pain, and it must be taken into account as a possible cause of acute ab- dominal pain and differentiated. LEAD COLIC would hardly be considered as a cause of abdominal pain, and yet we have observed an instance in which it was the only reasonable cause, and removal' of the susceptible child from the home that was being decorated resulted in immediate relief. ACUTE RHEUMATIC FEVER may have as its first and chief mani- festation painful involvement of the abdominal musculature. One of us has reported several such cases.* In differentiation the sur- geon must consider the two types of influenza which are commonly associated with abdominal pain the gastroenteric and the nervous types. ACUTE GASTRIC DILATATION, which is not as rare as supposed, but which is often overlooked, may cause great abdominal pain. In the stomach tube we have a perfect means of diagnosis, and if it was more often applied as a diagnostic and therapeutic measure under the circumstances of the two chief etiological factors operation and infections in general fewer cases would be overlooked, MOVABLE KIDNEY is another condition that is supposed to be rare in childhood, and yet when looked for is frequently found to exist. It may be the cause of most misleading pain, and when right- sided has been known by us to be mistaken for appendicitis. * Am. J. of Obstets., 1911. 40 PAIN" CHRONIC GASTRIC DILATATION is commonly a cause of long-con- tinued abdominal pain in children, and is apt to be mistaken for the chronic indigestion with which it is so commonly associated. The stomach tube is the best means that we have of clearing up the diag- nosis. CASSATION OF THE MESENTERIC GLANDS causes chronic abdom- inal pain with acute exacerbations, which are frequent, but the as- sociated symptoms should make detection easy, although repeated examinations may have to be made before any glands can be palpated. Headache. Until the child reaches the age of five years it is not always easy to distinguish headache, although the two conditions under which it occurs in childhood which are of interest to the surgeon are those in which the pain is of such a character and in- tensity that it can hardly be overlooked even in the youngest child. These conditions are intracranial tumor and meningitis. In fact, headache in children under the age of five is unusual except as it occurs in connection with disease or injury of the brain or its meninges. Occurring in children, its significance is much more than in adult life, and it must therefore be considered as an important symptom needing a definite explanation. In the presence of an acute headache with fever the first consid- eration is to determine whether or not the headache is due to the rise of temperature, and therefore we must decide it by the intensity of the fever and the character of the headache. In regard to the former, headache is rare with the temperature under 103 F., unless brain or meningeal disease or injury are pres- ent. In regard to the character of the headache, when due to a rise in temperature, it is relieved by pressure over the temples, by cold applications, and massage of the veins of the neck, but is increased by active motion. The headache of tuberculous meningitis is usually very severe and continuous, bearing absolutely no relation to the temperature, which may be low. Generally speaking, the more disproportion there is between the intensity of a fever and the intensity of the headache the greater the probability of meningeal or cerebral dis- ease. THE SURGICAL SIGNIFICANCE OF PAIN 41 The headache of purulent meningitis, of simple meningitis, and of the epidemic form of cerebrospinal meningitis occurs early during the onset and is usually intense. Not uncommonly it. is the one symp- tom that overshadows all the others for a time. Because of the circumstances preceding its occurrence, an acute intense headache in children does not usually mislead the surgeon for any length of time. Following certain injuries or operative procedures, or when injury is added to or associated with certain Anemia Epilepsy Meningitis Anemia Autointoxication Eye-strain Syphilitic nodes Disease and foreign bodies in the nasopharynx f Caries of the teeth - Otitis media Foreign body Meningitis Epilepsy Spinal caries of cervical region Middle-ear disease FIG. 17. DIAGNOSTIC SIGNIFICANCE OP HEADACHE IN CHILDREN. diseases, the occurrence of inflammatory conditions of the brain or its coverings is often looked upon as a possibility, and thei'efore the occurrence of this one symptom is not apt to be misinterpreted if it persist for any time. Most of the surgeon's consideration of headache will be given to those of a chronic nature. And chronic, persistent headache in children should always excite the suspicion of possible tumor of the brain. It is by far the most prominent feature, being persistent and severe, but not so intense as in adults. It often shows its greatest 42 PAIN intensity during the night or in the early morning. It is most severe when the tumor is in the posterior cranial fossa. Closely as- sociated with the headache are vertigo and vomiting and optic neu- ritis, so that the association of such symptoms would at once exclude most other conditions. Only one thing seems to affect the severity and persistency of the headache, and that is the occurrence of hydro- cephalus, for when this develops the pain may entirely disappear. Only a complete examination will satisfactorily exclude the chronic headaches which are due to disease of the organs of special sense, and in all instances of chronic headache, particularly those which show more or less tendency to exacerbation, possible local causes in these organs should be sought. In the ears there may be an impacted body or the existence of a chronic otitis. The eyes may be the site of muscular weaknesses, strabismus, errors of refraction, keratitis or iritis, and these will in time be the cause of more or less persistent headache. In the nasal passages there may be an impacted body (young children are so fond of placing foreign bodies in the nostrils and the ears) polypi, hypertrophic rhinitis, or adenoid vegetations which are the cause. Migraine is too paroxysmal in its occurrence to cause any con- fusion with the chronic headaches due to brain injury or disease. Earache. Pain in the ear is most characteristically present in tWo conditions that may have a surgical aspect, otitis and mastoid- itis. Acute otitis is usually secondary to some infective process in the nasopharynx, with extension through the Eustachian tube. Pain in such instances is a more or less prominent feature associated with moderate fever. In infants otitis is not readily diagnosed, and com- monly the problem presented by the symptomatology is the detection of the cause of an indefinite and persistent elevation of the tem- perature with restlessness. The absence of definite otoscopic signs is the rule rather than the exception, although the pain which can- not be definitely located by so young a patient is the cause of the restlessness. In older children the pain is located more definitely, and is usu- THE SURGICAL SIGNIFICANCE OF PAIN 43 ally early and severe. It must be recalled, however, that every far- ache does not mean otitis, for sometimes the pain is reflex from dental caries, etc. In every case of doubtful origin a careful examination of the ear is absolutely essential. Mastoiditis may be primary or secondary. Primary mastoiditis is a slow and usually painless process, without much fever, but with extensive bone destruction and no intracranial symptoms of any extent. There is no historv of otitis, and the membrane is normal. Secondary mastoiditis usually occurs in from two to eight weeks after tympanic suppuration, and usually with an acute on- set. The signs of mastoiditis are increase in the temperature, cessation of otorrhea, edema or swelling back of the auricle, with heat, redness and pain, and constitutional symptoms due to the local inflammation. In some instances pus may con- tinue to ooze through the open- ing in the membrane, or occa- sionally there may be increased discharge with lessened pain, although the other symptoms be- come exaggerated. While it is in some instances a difficult matter to demonstrate a slight mastoid tenderness, persistent tender- ness over one side should always arouse suspicion. The point of greatest tenderness is close behind the auricle just over the antrum, and tenderness in this area, particularly if associated with a cessation or diminution in the discharge which has occurred rapidly, should always be regarded as significant. The characteristic otoscopic ap- pearances are bulging of Shrapnell's membrane and drooping of the upper posterior wall of the external meatus (Bacon). Several complications and sequelae may follow otitis or mastoid- itis, the chief of which are meningitis, which frequently results in FIG. 18. MASTOID ABSCESS, SHOWING THE CHARACTERISTIC SWELLING BEHIND THE EAR AND PUSHING THE AURICLE FOR- WARD. 44 death, cerebral abscess which, if it occurs, is usually situated in the temperospheuoidal lobe, thrombosis of the lateral sinus, which may be simple or septic, and facial paralysis due to extension of the in- flammatory process to the seventh nerve. Painful Defecation. Painful defecation is usually associated with rectal tenesmus, but must not be confused with the latter. The com- monest cause of painful defecation in children is anal fissure, and this may require surgical treatment. It is of common occurrence and arises from several causes, and the fear of pain which accom- panies an evacuation brings about a chronic constipation which may for a long time be the chief symptom. The pain is very severe at the time of defecation; and persists for a considerable period after the evacuation. Hemorrhoids may be the cause of painful defecation, but hem- orrhoids are very rare in children, and when present are usually very small and externally located so that their detection is simple. Proctitis is a cause of very painful defecation, but this is in most instances overshadowed by the extreme rectal tenesmus which is a prominent part of this disease. Rectal tenesmus is differentiated from painful defecation in that rectal tenesmus is evidenced by a constant desire to empty the rec- tum, and while this is associated with more or less pain, the effort to defecate is partly or wholly ineffective. Rectal tenesmus with hemorrhages of any considerable degree would suggest ulcerative proctitis or rectal polypi. Painful Urination. Painful urination is closely associated with retention of urine, and in some particulars it is quite impossible to clinically separate the two. When there is painful urination in a child there is almost invariably retention also, which is enforced. This symptom always points to a local cause, and the most fre- quent are as follows : In the newly-born it may be due to sandy excretions which per- sist for a week or two (rarely longer), or to an adherent prepuce which offers a mechanical and reflex resistance to the free passage of the urine. Overacidity and a too concentrated urine also cause painful urination in the young. THE SUKGICAL SIGNIFICANCE OF PAIN 45 Dysuria is most severe and persistent, however, in vesical cal- culus, which may be surgical in itself or its complications. Calculi may be formed in the kidney, and when not too large may be passed into the bladder. They may be single or multiple, rounded or irregular in shape. That there is a hereditary tendency has been demonstrated. The symptoms are similar to those of adult life, and the only positive means of diagnosis is by the use of the sound, the X-ray, or the cystoscope. When the stone is in the ureter there is usually marked paroxysmal pain beginning in the lumbar region and radi- ating toward the pubis, and this may suddenly cease when the passage is accomplished. In place of these symptoms there may be a dull, persistent pain in the loins, radiating to various parts of the lower abdomen and thighs, and especially noticeable after exercise. With this there are alternating but irregular scantiness and excess of urine, some nausea and perhaps vomiting. In all instances of suspected calculi the possibility of the symp- toms being dependent upon cystitis must be remembered and con- sidered, so that the examination must be planned with this differ- entiation in view. It is easy to see how a balanitis could result in marked dysuria when the parts are swollen and edematous and covered with pus, as they sometimes are. When it is impossible to withdraw the foreskin and expose the glans the disease is evidenced by the marginal red- ness with the appearance of pus at the opening. It is important to be sure that the pus does not come from the urethra, for in that case we would be dealing with an entirely dif- ferent proposition. In such cases the dorsum of the prepuce should be split up sufficiently to thoroughly expose the glans. Urethritis and vulvovaginitis both are prolific causes of dysuria, but microscopical examination of the discharge is sufficient to differ- entiate these and determine their type. Erosions of the glans or of the labia frequently excite a degree of dysuria which is out of all proportion to the extent of the lesion. The suffering may be extreme in nervous children. 46 EXAMINATION OF THE BLOOD Herpes of the vulva also causes marked dysuria. Vesical spasm is accompanied with frequent urination more than with pain. CHAPTER VII THE EXAMINATION OF THE BLOOD GENERAL CONSIDERATIONS In the examination of the blood in children the most skilled assistance possible should be obtained for the laboratory work. Coupled with this there must be considerable judgment shown by the surgeon in his adaptation of the laboratory findings. The practice is far too common of accepting the laboratory find- ings as final and conclusive, and this attitude continues to lead many into error, and has done more than any other one thing to bring blood examinations into partial disrepute. There must always be a sane and reasonable interpretation of the laboratory findings as they are associated with (and not discon- nected from) the clinical manifestations. These findings should be used merely as one of several aids which help to guide the surgeon to a correct appreciation of the clinical manifestations. To be of any real service to the surgeon the blood findings must fit more or less accurately with the other data of which he is already pos- sessed. Or, in other words, if the preponderance of evidence is given to the blood findings in all cases, and the clinical manifesta- tions are made subservient to the laboratory methods of examination, constant error will be the result. The surgeon must correlate his blood findings with the clinical evidences in all instances. It must always be remembered that the study of the blood in children has not been as satisfactory as in adult life, and that in a way it is still in the experimental stage, for conclusions are neither as definite nor the examination as free from possible error as in later life. In the further consideration of the methods of blood examination GENERAL CONSIDERATIONS we will disregard the many details except in so far as they are of service to the surgeon and are applicable to children. For the de- tails of complete blood examinations the reader is referred to the many excellent books upon this special subject. Method of Obtaining the Specimen. This should not be done in the usual manner with a sharp-pointed needle, but with some instru- ment that has a cutting edge. A Hagedon needle is always within reach of the surgeon, and is therefore a serviceable and practical instrument to use. If a large quantity of blood is required, an event FIG. 19. PUNCTURING THE LOBE OF THE EAR WITH A NEEDLE WITH A CUTTING EDGE, TO OBTAIN A SPECIMEN OF THE BLOOD WITHOUT INJURY TO THE CORPUSCLES. which is most unusual, then a hypodermic syringe may be used to puncture a vein after the part has been thoroughly prepared. The constant selection of one part (as the lobe of the ear or the finger tip) is unnecessary, since, in many instances, it will serve the pur- pose better if the specimen be drawn from other parts. The one necessary precaution is that cyanosed or edematous parts be strictly avoided. The site of puncture in children should be one in which the patient cannot watch the proceeding, so that the lobe of the ear may be used. The objection to this is that the child will rebel when 48 EXAMINATION OF THE BLOOD it feels the prick, and the head is hard to control. The large toe or the heel offer excellent situations for puncture. The stab must be made quickly and firmly so as to limit the amount of pain, and if the stab is deep enough manipulation, which destroys the integrity of the specimen, will be unnecessary. Before any such procedure is undertaken the history of a pos- sible hemophilia should be gone into carefully. Whenever practical the specimen should be obtained before a FIG. 20. TRANSFERRING THE BLOOD FROM THE LOBE OF THE EAR TO THE COVER GLASS. meal, to avoid possible errors from the leukocytosis which is normal in children after a meal. Examination of the Fresh Specimen. While this is not always practical, it should be carried out whenever possible, because the advantages of the stained specimen are secondary and, all things being equal, the fresh specimen will give the best information. The principle points which can be obtained from the fresh speci- men are the study and detection of the plasmodium malarise, the several abnormal changes in shape and size of the blood cells and the presence of excessive numbers of white cells. GENERAL CONSIDERATIONS The Blood Count.- This is one feature in the blood examination of children that should receive more careful consideration from the surgeon, and particularly if operative procedures are being consid- ered. It is in the detection of anemia and the accurate estimation of its progress that this procedure becomes a necessary one for the surgeon. The study of hematology is quite as important as a con- sideration of the clinical features in the anemias of childhood. There- fore a decrease in the red cells would occur to some extent in all diseases and severe injuries, but has its most common existence in the anemias. FIG. 21. PLACING THE COVER GLASS WITH THE SPECIMEN OF BLOOD UPON A GLASS SLIDE. The Color Index. While the blood count is of considerable value in estimating the anemias, for the purposes of diagnosis of anemias in children it is only necessary to demonstrate one change, and that is a deficiency in the hemoglobin. This may exist because too little is formed or because too much has been destroyed. In childhood the blood cells are unstable, parting with their hemoglobin readily, and upon slight provocation exhibiting nucleated forms. The blood- forming organs are also worked to their limit because of the demands of the growing organism. We can readily understand that the pathology of the blood is very closely associated with that of every individual organ, for the blood gives and receives material from them 50 EXAMINATION OF THE BLOOD all, therefore the composition of the blood depends somewhat upon the general condition of all of the organs of the body, and by a study of this fluid a more or less exact index is given of the general con- dition of the child. Such data may prove of immense value in aiding the surgeon to decide between immediate and delayed operation, or in changing his usual methods to suit the requirements of a special condition. It may be well to mention that the hemoglobin percentage in infants is comparatively high, and that while there is a rapid fall during the first few days of life, it is still high for a considerable period. After the first month there occurs another fall, which covers a period of from ore to two months, and the percentage reached at the end of this second fall is the average for the first two years of life. The low limit at this period may be placed at 60. After the end of the second year, and until the time of puberty, there occurs a slow but gradual increase, so that, at the age of thirteen or fourteen, the percentage is close to 85. ABNORMAL CONDITIONS OF THE BLOOD Leukocytosis. At the time of birth the leukocytes number 12,000 to 24,000 per cubic millimeter, but within a very few days they reach the lower average of 10,000 to 15,000. During the period between two years and puberty the average is 6,000 to 12,000. A leukocytosis may be physiological or pathological, and this has especial importance during childhood because physiological leukocy- tosis is exaggerated during the earlier periods of life. It is due largely to the concentration of the blood and to peripheral stasis. But irrespective of the marked physiological leukocytosis of the newly-born, other factors also influence the numbers of leukocytes and these must be considered. Fasting decreases the number of leukocytes to a very considerable degree. This is true, also, when the nutrition is chronically inter- fered with, so that any malnutrition becomes a more or less im- ABNORMAL CONDITIONS OF THE BLOOD 51 portant factor to be taken into consideration when making deduc- tions from the blood examination. When food is taken there is a rapid increase in the number, and this commonly occurs within one hour after the ingestion of the meal and persists for several hours. Any active exercise (and less certainly passive exercises) causes an increase, and cool bathing or sponging will do the same. What has been called an agonal leukocytosis is observed in children shortly before death takes place. Pathological leukocytosis occurs in many of the conditions of childhood which are associated with disease or injury. But the tendency is to place too much importance upon this method of ex- amination, which, in children much more than in adults, is uncer- tain and often unsatisfactory. In the infections which are minor the leukocytosis is of a mild grade, while in moderate infections it is marked if the resistance be good. In the very severe infections, or in instances in which the resistance to the infection is low, there may be no leukocytosis at all because the toxemia is so intense. It has its chief importance in those diseases in which there occurs pus formation, as in abscess (except cerebral abscess), peritonitis, osteomyelitis, septicemia, pyemia, etc. For instance, following a pneumonia, a sudden increase in the leukocytes would indicate empyema, if the clinical manifestations suggested such a possibility. It is useful also in differentiating be- tween those diseases that are catarrhal or purulent, as for example, in a doubtful appendicitis. Septic meningitis exhibits a leukocytosis; cerebrospinal meningitis shows it in some degree in fully two-thirds of the cases, and in tuberculous meningitis there is ordinarily no leukocytosis. Pathological leukocytosis is preceded by a very brief period, during which there is decided diminution in the number of leu- kocytes, and this is due to the initial shock caused by the irritant. It might be well to accept the generally recognized division of leukocytosis into: (a) Inflammatory leukocytosis, or that which is dependent upon 52 EXAMINATION OF THE BLOOD inflammation or infection; examples of which are abscess, sepsis, pneumonia, scarlet fever, etc. (b) Post-hemorrhagic leukocytosis, or that which is evident within a few hours after an acute hemorrhage, and which persists for from three to five days (gradual hemorrhage does not seem to produce it). (c) Leukocytosis of the malignant growths. (d) Toxic leukocytosis, as is observed in the non-bacterial poi- sonings, such as alcohol, mercury, ammonia, etc., and in poisonings of the system such as occur in uremia and snake-bite. Generally speaking, it may be said that the presence of a leu- kocytosis is good evidence that there is sufficient resistance to an in- FIG. 22. METHOD OF SPREADING A SPECIMEN OF THE BLOOD UPON A SLIDE FOR A DRY SMEAR. The blood gathered on one slide is gently and evenly spread by the edge of the other slide. flammation or infection. Thus, it may prove serviceable at times to search for its existence in any child who is the subject of an in- flammation of pyogenic genesis. The value of such examination is, however, lessened in children because the absence of a leukocytosis does not in them always mean that there is no inflammation or in- fection. The little patient's system may be so overpowered by the virulence of the infection, or the resistance of the child may be so low that leukocytosis may be absent. ABNORMAL CONDITIONS OF THE BLOOD In other instances, as when the products of the inflammation or infection are walled off and become encysted, no further absorption taking place, the leukocytes approximate the normal. A progressively increasing leukocytosis is indicative of an ensu- ing suppurative process, and therefore it may at times become the indicator for treatment, for if some condition be present that might give rise to pus formation the progressive leukocytosis would indi- cate that suppuration was impending and therefore the wisdom of undertaking some surgical procedure to forestall it may have to be considered. FIG. 23. PUNCTURE OF A VEIN TO SECURE THE BLOOD FOR EXAMINATION. A towel or bandage wrapped snugly about the part makes the veins more prominent and the needle of the syringe is so placed that the natural course of the blood in the vein is not interfered with. Many of the infections are not associated with a leukocytosis, as, for instance, typhoid fever, measles, parotiditis, intermittent fever, uncomplicated tuberculosis, etc. This absence therefore might in some instances have a diagnostic value in that it adds to the value of the deductions made from other observations. The value of a leukocytosis as a diagnostic and prognostic aid in surgery depends not merely upon the actual number of leukocytes present, but more upon the maintenance of the relative proportions of the polymorpho- nuclears to the total number of leukocytes. It cannot, however, be too definitely stated that the value of 54 EXAMINATION OF THE BLOOD leukocytosis as a diagnostic and prognostic aid is of greatly less value during the period of childhood than in later life. The subject certainly needs much more study and observation before the surgeon can rely with comfortable certainty upon the findings. It is not alone that the findings are often unsatisfactory and inaccurate, but the application of them to the clinical needs requires much systematic and careful study. Leukopenia. Leukopenia, or a diminution in the white blood cells, indicates some serious nutritional fault, and is present in the severe anemias or in leukemia, which is complicated with infection, as well as being present in many of the minor affections of childhood. If infection be present it indicates that there is no resistance to the infection. In any event, its surgical significance is that surgical procedure along the line of operative relief of any extent is only justifiable under the most urgent circumstances. Eosinophilia. An increase in the eosinophiles is common to many conditions of childhood, but still in some instances may have some diagnostic or prognostic value. It is present more or less promi- nently in the malignant tumors, in the infections by animal parasites, purpura and hemorrhagic exudate; in diseases in which the bone marrow becomes diseased, in urticaria, phemphigus, scarlet fever, after most of the fevers, and frequently in rheumatism. As it is in- dicative of an active degeneration of the blood, it becomes an un- favorable prognostic indicator, although in scarlet fever and chloro- sis its presence may be viewed with some favor. Lymphocytosis. The lymphocytes are normally more numerous than in adult life, and this needs to be remembered by the examiner, for many instances of supposed lymphocytosis are not so, but merely exhibit the normal condition for the earlier periods of life, and in this particular may prove misleading. Even when a lymphocytosis is accepted as a fact there must !>; evidences of both a relative and an absolute increase, because, if the polynuclear neutrophiles are decreased in number, there may be an apparent but not an actual increase in the lymphocytes. There occurs a lymphocytosis in many of the severe types of disease, as, for instance, in gastroenteritis, pertussis, rachitis, scor- DIAGNOSTIC VALUE OF THE X-RAY 55 butus, and congenital syphilis, but the greatest increase occurs in lymphatic leukemia. CHAPTEK VIII THE DIAGNOSTIC VALUE OF THE X-RAY When we consider fractures the diagnostic value of the X-ray can hardly be overestimated if we are positive that the technique is perfect and the operator has had sufficient experience. There is this danger, however, in X-ray work, that the results are modified to a large extent by the ability of the operator and his equipment. It, however, is scarcely possible for a fracture to be overlooked with the use of ordinary care, although the greatest dif- ficulty will be experienced in the detection of fractures of the skull, or the bones of the face. The limitations of accuracy are due to the inability to bring certain parts into close proximity with the plate. Two exposures are necessary for satisfactory results, because a single picture of a fracture in which the displacement is in one plane, and that the one of the rays as they fall upon the plate, may fail to show the lesion. The pictures should be taken at right angles to each other. Stereo- scopic radiographs overcome this. In the diagnosis of dislocations the X-ray is of considerably less value than in fracture because our other methods of examination are usually satisfactory and quite exact, but in those instances in which there is a reasonable doubt as to the co-existence of fracture the X-ray is of decided value. In the diagnosis of bone deformity and bone disease this method of examination is of large value and gives data which is of consider- able value in the planning of possible operative relief. For example, we might take one instance; in tuberculous cavities in the bones or tuberculous sequestra in the articular portions of the bones, it is pos- sible by the use of the X-ray to determine whether or not the sur- rounding tissues have been invaded, and if so, to what extent, and 56 DIAGNOSTIC VALUE OF THE X-RAY therefore it gives a valuable clew to the surgeon as to the opportune time for operative interference. In the detection of foreign bodies in the tissues the X-ray has a distinct value, but two pictures should be taken in planes at right angles to each other, for in no other way (except by stereoscopic radiographs) can the body be satisfactorily located. This is so be- cause the shadow will not show the depth. For absolutely accurate work one of the several localizers may be necessary, but in most instances the pictures from two planes fully answer the purpose of the surgeon. Cysts, abscesses, aneurysms, and various other pathological con- ditions are not always satisfactorily followed in their course by the ordinary clinical methods of examination, and in such instances the X-ray becomes of considerable aid in placing a somewhat exact de- termination of their progress and extent. Calculi of the various kinds are usually detected by the X-ray, but there may be some difficulty experienced according to the char- acter of the stone. Most of the dissatisfaction has come from un- avoidable imperfect technique, for the problems of the radiographist are most difficult in this particular field. However, the problems are less perplexing in children than in adults, and the ease with which pictures of the proper quality may be obtained in young subjects makes this method of examination most satisfactory. SECTION III ANESTHETIZA TION CHAPTER IX ANESTHESIA GENERAL CONSIDERATIONS The surgeon must not expect the child to cooperate in the under- taking of a surgical procedure, whether it be an operation, a pain- ful dressing, painful examination, or adjustment of injured parts. Therefore the administration of an anesthetic is more frequently necessary than in adults. Children bear pain badly, and therefore surgical procedures of even the most ordinary kind are frequently cruel unless the child is protected by an anesthetic. For instance, in the case of fractures, an accurate adjustment is often impossible without an anesthetic, and in the matter of diagnosis alone the com- bined examination under anesthesia and X-ray is desirable and often absolutely necessary. Even in what are commonly considered the minor surgical conditions, we are convinced that the shock offered to the child by the knowledge of what is taking place more than counterbalances the possible slightly depressing effect of the primary stage of ether anesthesia. Therefore the field of local anesthesia in children is very much smaller than in later life. Before taking up the various anesthetics it is well to consider some points which apply with equal force to all, and which must be worked out as the circumstances permit. Preparation of the Child. It is not always possible to make the preparation of the patient that is desirable, but, barring those cases which come under the head of "emergencies," there should be a well- 57 58 ANESTHESIA defined course. It must be remembered by the anesthetist that the same consideration must be given to the age, the weight, and the general condition of the child in the administration of an anesthetic as is given to the administration of any powerful drug. Particular attention must be paid to the condition of the heart, the lungs, the kidneys, and the blood. To avoid repetition the reader is referred to the section on "Preparation of the Patient" on page 75. With this examination complete, it remains to clear out the child's mouth and nose just before the administration of the anes- thetic. Children are very prone to have foreign bodies in their mouths, and it is surprising to find how often our search reveals the presence of candy, chewing gum, buttons, etc. The clearing of the mouth and nose of plugs of mucus or nasal discharge adds much to the comfort and safety of administering the anesthetic, besides helping to reduce the danger of post-anesthetic pneumonia. The use of a weak solution of cocain with adrenalin has proved most satisfactory in diminishing secretion and favoring free respira- tion. In older children the administration of a very small dose of morphia and atropin hypodermically, just before the anesthetic, may serve in prolonging the effect of the latter and diminishing post- operative pain. However, its favorable action is so uncertain that its use is questionable, and in very young children it should not be ** given at all. The danger to children from an anesthetic is not the asphyxial element but the toxic element ; therefore the conservation of the child's normal functioning as regards its secretions (with the ex- ception of the mouth) is very important. Morphin and atropin are both apt to interfere with these, and while all children are more or less susceptible to the action of opiates and unfavorably acted upon by them, there are many who exhibit this susceptibility in very marked degree. The intestinal tract should always be freely cleared out before the administration of the anesthetic. If time permits, some prepara- tion of castor oil should be given and the food regulated after that so that nothing is placed in the digestive tract which can cause GENEKAL COXSIDEBATIONS 59 future trouble. When time does not permit the use of a laxative or cathartic, a high rectal enema may be given consisting of two ounces of sulphate of magnesia (to quickly dissolve the intestinal mucus), four ounces of glycerin, and a quart of warm water. This is much more effectual than the ordinary and irritating softsoap enema. The operating room should have a maintained temperature of from 72 to 75 F. The ventilation of the room should be sufficient to prevent the usual stuffiness with its consequent depression. Our experience has been that most operating rooms are not properly supplied with fresh air during the time of operation, and this de- privation of oxygen markedly influences the dangers from the ad- ministration of the anesthetic. There must be adequate protection of the cutaneous surface, therefore as small a part as possible should be exposed and the rest of the body should be well covered. In infants or very young children, or those who give any appreciable evidences of a low resistant power, further protection should be given by wrapping unexposed parts in absorbent wool secured with light bandages. This conservation of heat is very important in long operations, no matter what the age or nutritional condition of the child. Children tolerate hunger poorly, therefore it is necessai-y to administer some form of nutriment within two or three hours of the anesthetic. This should be of such a nature as to cause no future accident, and we find the best form is diluted cream. For instance, the top ten ounces may be removed from a quart bottle of milk in which the cream has risen and this diluted with twenty or thirty ounces of plain sweetened water, or, in older children, a weak solution of a cereal water or coffee. This leaves no residue in the stomach which will give rise to difficulty later. Of course, in infants a much weaker strength may be necessary. If the child has inadvertently partaken of a meal shortly before the administration of the anesthetic, lavage must be practiced. Conditions to Be Watched by the Anesthetist. It is a foolish pol- rcy, for which we must eventually pay the penalty, to allow an in- experienced anesthetist to administer the anesthetic. It is not so much a question of tact and the ability to secure the child's confidence 60 ANESTHESIA that is necessary, although that is most desirable, but the dangers from the anesthetic are all so magnified in childhood that we must be certain of securing the best possible anesthetist for each individual case. Inaccuracies of administration which would be rather trifling in the adult, or at least would only lead to annoying delay or conse- quences, in the child become at once serious and often very grave situations. The closest attention must be given to the pupil and lid reflexes, FIG. 24. THROWING THE JAW FORWARD DURING ANESTHESIA. This manipulation is not often necessary in children and when it is, it should not be accomplished in the usual manner, but the jaw should be gently but firmly held forward rather than forced forward. as these are the most important guides to the depth of the anesthesia. A gradually dilating pupil with increased corneal lid reflex is an in- dication for more of the anesthetic. A dilating pupil with absence of the corneal lid reflex is a warning to reduce the anesthesia. Dila- tation commonly takes place when there is much handling of the tissues and indicates a certain degree of shock which should result o in a somewhat lessened degree of anesthesia. A suddenly dilating pupil with increased corneal lid reflex GENEKAL CONS1DEKAT10NS (51 usually indicates an impending attack of vomiting. The same is true of a pin point pupil with shallow respirations, and both may be met with an increase in the anesthetic. In the administration of the anesthetics there must be provision for the constant and very free admixture with air. Children never tolerate a concentrated anesthetic, and so the apparatus and gauze must be so arranged that this perfect and maintained admixture is possible. Lymphatisn or status lymphaticus introduces an element of great danger into anesthesia, in that many of the deaths which take place with more or less suddenness during and immediately after anesthesia are directly attributable to this condition. This makes it of great interest to the surgeon. What part the anesthetic plays in this condition is very uncer- tain, but clinically we know that they bear any anesthetic badly, although there are several instances in which these children have been subjected to anesthesia on previous occasions without any alarming result and have finally succumbed to a later administra- tion. We are convinced that the administration of the anesthetic is only one of many factors and by no means the chief one, because many of these children die without undergoing any serious injury or surgical procedure. To avoid repetition the reader is referred to page 155. Selection of the Anesthetic. This will depend upon the physical examination of the child and the part to be subjected to operation. In short, quick procedures, such as rapidly breaking up adhesions about a joint, the adjustment of a fracture, etc., chloroform or nitrous oxid may be selected. The objection to the latter is its uncertainty in overcoming muscular spasm. Chloroform is of service when the large amount of mucus produced by ether would interfere with the operative field. Ether may be dangerous to use even in the presence of a very slight bronchitis (converting such into pneu- monia) and in the presence of marked disease of the heart or kidneys, or tuberculosis of the lung, the contraindications to its use are strong. ANESTHESIA VARIETY OF ANESTHETICS Ether. In England chloroform is used much more extensively than any other general anesthetic, but in the United States ether easily holds first place as the anesthetic of choice, both for adults and for children. Unless it interferes with a strong personal preference which is backed by a long experience, it is well for the surgeon to select the anesthetic which, in the consensus of opinion of his colleagues, is in most favor. Such a stand does not in any way vitiate personal thought, which should be fostered, but acts as a protection to the oper- ator. The disadvantages of ether as they apply par- ticularly to childhood are its unpleasant odor, its rather slow action, its proneness to excite nausea and vomiting, and its tendency to produce such an irritation of the upper respiratory tract as to result in the excitation FIG. 25.-GWATHNEY ANESTHESIA APPARATUS. of trou blesome COUgh and This apparatus represents one of the best methods of producing a safe and comfortable anesthesia and lllUC'h mUCUS. Besides is of particular service in children. , i ,1 ,1 IIA ? this there is the ability ot the vapor to immediately reduce the temperature in its immediate vicinity between 25 and 30 F. These few facts are the main ones that must be considered in the administration of ether in children, otherwise the technique does not differ materially from the administration in adult cases. The unpleasant odor cannot be overcome, although it may be made less objectionable by a few whiffs of cologne given just previous to the anesthetic. Its slow action depends in some measure upon the method of administration, therefore the personal element (both VARIETY OF ANESTHETICS 63 patient and anesthetist) enters largely. The same may be said in regard to nausea, vomiting, or cough: they are reduced to a mini- mum when the anesthetic is in skilled hands and the preparation of the child has been possible and sufficient. When we consider the comparative immensity of the surface to which the ether penetrates and recall its ability to lower temperature, we have a strong clew to the frequent occurrence of post-anesthesia catarrhs in children. The avoidance of such is largely a matter of securing a warm vapor (if possible) with adequate protection of the cutaneous surfaces. Chloroform. Despite the fact that chloroform is often wrongly used, the remains of a previously opened package being commonly FIG. 26. CONVENIENT CONTAINER FOR SMALL QUANTITIES OF CHLOROFORM. With the breaking off of the ends of the two glass tips, the rate of administration is entirely within the control of the anesthetist. saved for succeeding anesthesias, the evidence proves that it is an un- certain agent in childhood. There is a very rapid deterioration which occurs after the container is once opened, so that, if used, the surgeon should be provided with several containers holding rather small amounts, in order that the anesthetist may use one or more as the occasion demands. The danger from the toxic element is so strong in children that, in the administration of chloroform, the gauze upon which it is cautiously dropped should not come within i several inches of the face. Near to the gauze the vapor is always dense, and to insure even reasonable safety there must occur a proper 64 ANESTHESIA and adequate diminution of the density of the vapor by admixture with air. Before administration the face must be smeared with some pro- tective oil, as the vapor is irritating to the skin. The dangers are similar to those of adult life; the only difference is one of degree, for the child is, in every particular, vastly more susceptible to the toxic effect of this agent and succumbs much more surely and rapidly. During the chloroform anesthesia there is not uncommonly a period of pseudo-anesthesia, which precedes the true anesthetic state, and is evidenced by shallow breathing,- insensitive cornea, and small pupil. Its occurrence has been most common when the anesthetic has been given irregularly, or there has been no marked stimulus to the patient. If it is not recognized, there may be some embarrassment to the operator who commences his procedure and is soon handi- capped by reflex movement or a depressed heart. Chloroform should not be administered without a small plug being placed between the teeth. Not infrequently there occurs a spasm of the muscles of the jaw and, while valuable time is being lost in attempting to overcome this so as to introduce a mouth gag, the child becomes dangerously depressed from the retained vapor. The plug usually prevents a spasm, but if it occurs then the introduction of the mouth gag is simple and immediate. Delayed chloroform poisoning is very rare in children, but when- ever it occurs it is almost uniformly fatal. Its onset is within forty-eight hours or less after the administration of the anesthetic. The symptoms are severe and persistent vomiting, delirium al- ternating with coma or apathy, periods of unaccountable screaming, a rapid pulse, and a slight jaundice. Acetone may be detected in the urine. Whether the fatty changes which are noticed post mortem are the result of the anesthetic or have been present before its administration is undetermined. The treatment is one of judicious but efficient stimulation and the ad- ministration of large doses of alkalies so as to completely overcome the acidity of the urine. Nitrous Oxid. For short operations or procedures in children this VARIETY OF ANESTHETICS 65 is an ideal anesthetic. The disadvantage of the bulk of the appara- tus is much more than compensated for by the speedy and safe production of anesthesia and the rapid recovery from its effects. The one disadvantage is the great uncertainty with which this anesthetic relaxes muscles. This, however, only limits its field in a small degree. However, we must recall that there is some danger in its use in the presence of any well-defined cardiac disease. Nitrous-Oxygen-Ether. This combination is a very expensive one to use for prolonged effects, but has the advantage of making the primary stage of anesthesia very brief, diminishing the discomfort FIG. 27. APPARATUS AND METHOD USED IN INTUBATION ANESTHESIA. One tube is introduced through each nostril. Gauze is packed in the pharynx (A) to prevent the aspiration of blood or mucus. This is Crile's method and is useful in operations about the mouth. After full anesthesia is accomplished in the usual manner, the tubes are introduced and the anesthetist and inhaler are thus both removed from the field of operation. to the child, and somewhat lessening the subsequent nausea and vomiting. Nitrous-Ether.- If nitrous oxide is given just before the adminis- tration of ether, the struggling of the child during the first stage of ether anesthesia is reduced considerably, although the effect of the nitrous oxid is so transient that, commonly, there is some slight struggling before the ether has been given in sufficient amount. In the hands of an expert, even this slight struggling may be overcome. Ethyl Chlorid. While not without danger, this is a very rapid 66 POST-ANESTHETIC CARE method of producing a very brief anesthesia and may be used for short operations (30 to 60 seconds). The danger comes mostly from the attempt at prolonged administration. There is frequently a decided rigidity of the jaw muscles under the anesthesia and this limits its usefulness in procedures about the mouth. As a preliminary anesthetic to ether, ethyl chlorid holds a valuable place. CHAPTEK X POST-ANESTHETIC CAEE Just as soon as the operative procedure is completed and the dressings applied, the child must be thoroughly dried, and if any of the garments are wet or soiled they must be cha'nged at once. The room in which the child is taken to recover from the anesthetic should have an easily sustained temperature of TO F., and must be so isolated from the rest of the house that complete quiet and rest may be obtained. The child recovering from an anesthetic requires the undivided attention of the nurse so that such accidents as falling out of bed,. tongue swallowing, disturbances of dressings, etc., may. be avoided. While recovery in children depends largely upon the amount of anesthetic used and also the length of administration, yet these fac- tors are not so important as in adults. In children there is a per- sonal susceptibility which must always be taken into account, and more depends upon the skill with which the anesthetic was given than upon the amount or the time. It is the duty of the anesthetist to remain with his patient until the child shows by its ability to dispose of its vomitus that a con- siderable degree of consciousness has been regained. After the child has responded to questioning or has cried lustily, it is safe to leave its further care to the nurse. It is often advisable to allow the mother to be with the child and act in cooperation with the nurse in securing mental and physical rest. The accidents which are apt to occur are similar to those in NAUSEA AND VOMITING 67 adults, except that the child is more susceptible to the anesthetic and is less capable of taking care of itself during recovery. This means that the watching must be more careful and the preparations for emergencies adequate. The administration of oxygen aids very much in the speedy and comfortable return of consciousness. Nausea and Vomiting. Vomiting after the administration of ether should be expected. It occurs suddenly, is usually of short duration and mild, but may be so violent as to quite exhaust the child. There are several factors which favor vomiting and these should be mentioned so that they may be avoided when possible: (a) The presence of a large amount of liquid in the stomach, or of a small amount of solids, at the beginning of the administra- tion of the anesthetic. (b) The use of an anesthetic of poor quality or one that has been exposed for some time to atmospheric influences. (c) The swallowing of considerable quantities of blood, mucus, or saliva during the administration of the anesthetic. (d) The uneven administration of the anesthetic. There is another element that we must remember in chloroform anesthesia; while the above factors apply, they do so in a lesser degree than when ether is administered, but the usual production of thick mucus over the pharyngeal wall tends to excite and prolong vomiting until it is removed by vomiting or a swab. However, the anesthetist must be ever mindful that there some- times occurs vomiting which has no connection in any way with the administration of the anesthetic, but which has a significance which is all its own. This type of vomiting is serious and is men- tioned in detail in the section "Postoperative Care" on page 93. We have found that cracked ice has been used commonly to allay the nausea and vomiting, but in children it rather tends to increase it, so that its use should be restricted. The best procedure is to allow, within two hours, frequent sips of hot, sweetened water (about one dram every five minutes) for an hour or two and then a full glassful, for about this time the child will crave it. This is 68 POST-ANESTHETIC CARE almost immediately followed by vomiting and the subsidence of all nausea and vomiting. After this, water given in small quantities and at frequent intervals will usually be retained. Vomiting per- sisting for over six or eight hours after the withdrawal of the anesthetic may only yield to lavage. When the vomiting seems to be of real distress to the child, we believe that the administration of very minute doses of cocain hydrochlorid in hot water is justified so that the child may secure its rest. Persistent vomiting requires the same vigorous treatment and management as are used in adult cases. Hematemesis. This is exceedingly rare in childhood and the mode of its production has never been clearly understood. The prognosis is unfavorable and the treatment usually ineffectual. Undue Restlessness. There is always a certain degree of rest- lessness following the administration of an anesthetic in children and this is peculiarly true of ether. But this restlessness soon passes over. Any degree of undue restlessness which is prolonged should be the cause of a most thorough investigation of all connected with the operation, for at times the cause will be found in some easily rectified condition which, if neglected, may seriously influence the final results. The causes of restlessness, exclusive of the influence of the anes- thetic, are considered on page 97. Sweating. This should always be regarded as significant in children to whom an anesthetic has been given. It does not occur in children simply as the result of the anesthetic, as we see sometimes in vigorous adults, but is always indicative of some weakness and shock and hemorrhage should be suspected. In no instance should it be lightly regarded. Thirst. There is a well-defined post-anesthetic inhibitory action upon the secretions of the mouth and throat which general anesthetics occasion and this results in such a sense of dryness that it often becomes a most troublesome feature. Much of the discomfort is overcome if the mouth is very frequently rinsed out with a mild antiseptic, alkaline solution, used cool. If the giving of water, as SORENESS OF THE TOXGUE 69 advised on page 95, is carried out, thirst, as well as the nausea and vomiting, is relieved. If excessive, the relief of thirst may require the use of rectal saline injections or subcutaneous saline infusion. However, in chil- dren this is rarely necessary. CHAPTEE XI What we call the sequelae of the anesthetic are those conditions which so commonly occur as the result not alone of the anesthetic, but of the associated influences of the handling necessary to the proper performance of the procedure. They are not due to the anesthetic but rather to the circumstances of its administration. Conjunctivitis. This does not occur with the experienced anes- thetist except as the result of accident, as it is caused by the ether or its vapor coming into contact with the eye. Just as soon as the contact is noticed, if the circumstances permit, the eye should be thoroughly cleansed with sterile water or a boric acid solution. However, if, in spite of all care, the irritation shows after a day or two, a drop or two of cocain (one grain to the ounce) may be in- stilled into the eye every four to six hours, and during the intervals frequent irrigations of boric acid solution may be used. Soreness of the Jaw. This condition we have not seen occur in children, although it is common enough among adults when the anes- thetist has been compelled to force the jaw forward. Soreness of the Tongue. This depends almost entirely upon the mechanical injury which takes place, no matter how carefully re- traction of the tongue may be done during the administration of an anesthetic. Usually the most ordinary measures of cleanliness and rest will result in immediate relief, but, if sloughing occurs, it may be neces- sary to resort to such measures as the use of a 10 to 15 per cent, solution of nitrate of silver, or some other local treatment of the sloughing surface. 70 Paralysis. Paralysis may occur as the direct result of prolonged or firm pressure over the limbs or may even be partial from a strained posture of a limb while under the anesthetic. The prognosis of such pressure paralysis is always good and in a few days, or, at most, a few weeks, it entirely disappears. The treatment consists of per- sistent massage, the use of electricity, or the application of the Bier constriction once daily. While very uncommon, there seems to be good evidence to sup- port the statement that, despite the most careful handling of the child while under the anesthetic, paralysis of a central origin may occur as the direct result of the administration of the anesthetic. This latter can in no way be avoided. Burns. Burns of a very slight degree may occur as a direct result of contact of the anesthetic (especially chloroform) with the tissues about the mouth. To avoid these burns means to avoid the contact. Burns of a more serious nature are liable to occur if hot-water bags or bottles are used and careful watching is neglected. The post-anesthetic state of the child is such that no complaint will be immediately made of excessive heat, and before such complaint is made the damage is frequently serious. Pneumonia. There are several factors which contribute very largely to the occurrence of post-anesthetic pneumonia. (a) First and foremost in their production is the presence of even a slight bronchitis in the child subjected to the anesthetic or to any surgical procedure. (b) Insufficient protection to the surface of the body during and immediately following a surgical procedure. (c) Prolonged lying in one position after operation. (d) Imperfect or careless anesthesia. (e) Neglect of the toilet of the mouth before the administration of the anesthetic. We have never seen any but a bronchopneumonia occurring in children after anesthesia which could be directly attributed to the anesthetic. The instances in which a lobar pneumonia has occurred have been somewhat rare and a careful resume of the historv indi- COLD, FREEZING 71 cates that the lobar pneumonia was merely a coincidence and not directly related to the anesthesia. Not uncommonly, the supposed post-anesthetic pneumonias are the result of mistaken diagnoses. For instance, it has occurred sev- eral times in our hospital service that children have been sent in for an immediate appendectomy when the real disease was not appen- dicitis but a lobar pneumonia with masked physical signs. If such cases are operated upon and the appendix found normal, the subse- quent rapid appearance of more definite signs of pneumonia is blamed to the anesthetic, when such is not actually the case. CHAPTEE XII LOCAL ANESTHESIA Cold; Freezing. The influence of even slight degrees of cold in producing a local and short anesthesia is somewhat marked in chil- dren. If the object of the surgeon is only to secure a slight effect, FIG. 28. FIBST STEP IN INFILTRATION ANESTHESIA. As the part is steadied with one hand, the injection is made until a considerable area is infiltrated. 72 LOCAL ANESTHESIA the application of ice alone or a mixture of ice and salt will rapidly benumb the skin so that but little pain will be felt during a short, quick operation. The local spray of ethyl chlorid or of ether will accomplish similar results. However, the pain which is experienced when the part is long subjected to the influence of cold and the benumbing effect is passing away is sometimes so severe as to cause real suffering. In prolonged application of cold or FIG. 29. SKCOND STEP IN INFILTRATION ANESTHESIA. The second and subsequent injections are made so that the edges of each infiltrated area slightly overlap. actual freezing there is always the danger of devitalization of the tissues with possible serious after-results. With the use of ice or the ice and salt mixture it is, of course, impossible to secure a sterile field for operation, therefore this method is limited in its use. Infiltration. The use of cocain upon the mucous surface has a wide range of usefulness in children. Foreign bodies may thus be removed with certainty and without pain and in the simpler manipu- lations or operations about the nose, throat, eyes, rectum, and urethra its use is invaluable. INFILTRATION 73 Novocain, which is far less toxic than cocain, may be used in its stead. Eucain is also less toxic than cocain and may be substituted for it. Local infiltration anesthesia has a wider range of usefulness than is commonly supposed. Its chief objection is the time required to properly produce it. Connective tissue may thus be benumbed suc- cessively by the injection of normal salt solution or of cocain and adrenalin. Many of the strictly localized and minor operations may be undertaken under its use. The local use of cocain subcutaneously may, in some instances, be of much value, but the dangers consequent upon the lack of perfect control of the child must always be borne in mind. In a few instances, when combined with nerve blocking by the injections of the cocain about the nerve, as well as subcutaneously, it has proved effective. The use of quinin and urea is too uncertain for extended use in childhood. SECTION IV THE OPERATION CHAPTER XIII PKEPARATION FOB THE OPERATION Barring those instances which can be safely considered as emerg- ency surgery, there should be a very careful preparation for the opera- tive procedure, and this must be planned according to some definite scheme, so that no detail may be overlooked. The importance of thorough preparation will not be fully appreciated by the surgeon un- til the results of a well-planned operative procedure are compared with the results of one of similar magnitude performed as an emerg- ency. We are not unmindful of the fact that most surgeons working in institutions in which there is a considerable amount of accident or emergency surgery have the experience that the unprepared cases submitted to operation seem to do almost equally well with the pre- pared ones. This is notably true in the case of children. But the fault has always been with the kind and degree of preparation. We are convinced that a child may be too thoroughly dosed and coddled in anticipation of some operative procedure and this may parade under the name of preparation. Now, preparation does not neces- sarily mean the institution of starvation methods and prolonged or severe catharsis, both of which are the usual methods. The idea of preparation is not to dose the child or to rapidly compel a decided change in its habits or even to immediately restrict its usual activity, but it is to so safeguard the operative procedure that without too much alteration of the child's life the very best results are secured with the least possible interference with the normal life of the child. Naturally, there is a wide range of factors 74 PREPARATION OF THE PATIENT 75 which will operate differently in different cases, so that, considering; environment and all allied factors and the personal experience of the individual operator, nothing but the most general rules can rea- sonably apply. Each surgical case is a case by itself and this point is emphasized when we recall the teachings of all skilled podiatrists : that every child must be individualized. PREPARATION OP THE PATIENT Physical Condition. Many of the things which have been noted by the history and examination of the child will have offered consider- able information in regard to its general condition. But in addition to this there must be an intimacy with the physical condition of the child which will allow of advantage being taken of every factor which influences the prognosis. Children are especially liable to infection and therefore much caution is necessary to exclude the possibility of the child being in the incubation stage of one of the acute infectious exanthemata. The development of diphtheria, measles, scarlet fever, or smallpox, coin- cident with or closely following an operation, will often determine the result. Thus, in an operation in which the time of the procedure is elective, if there has been the possibility of exposure, the opera- tion should be delayed until the incubation period is past. The time that has been taken to bring out clearly the history of possible exposure is never wasted. To act intelligently means that one must have a clear idea of the various incubation periods. These periods are as follows : Measles : from the time of exposure until the catarrhal symptoms first appear there is usually an interval of eleven days ; then follows the stage of invasion, which lasts for about three days. Kubella : from fourteen to eighteen days. Scarlet fever: from six hours to five or six days; the shorter periods being much more common than the longer ones. Variola '. the average is twelve days. Varicella : fourteen days. 76 PREPARATION FOR THE OPERATION Diphtheria: There are present in the mouths and throats of many children who still remain healthy the Klebs-Loefflcr bacilli. Just as long as such a child is protected from any shock or injury these fail to cause any lesion. But coincident with anything which depresses the child's system there is usually a rapid increase in the bacilli. It will thus be readily seen that the only safe procedure in an elective case is to take a culture from the throat and demon- strate either the presence or the absence of the bacilli. Cerebrospinal meningitis (epidemic) : two to four days. Erysipelas : twelve hours to three days. 'If vaccination has been performed, three weeks should elapse before the operation is undertaken, except in emergency. There are many other factors which must be considered also in elective cases. The attempt to correct a deformity, remove a slow- growing tumor, or subject the ill-nourished, anemic child to other surgical procedure may prove disastrous, or in any event will not be as successful as the operation done under more favoring cir- cumstances. The surgeon should refer the child to some one skilled in the details which are so essential in bringing such a child into the best possible physical condition to withstand the strain of an operative procedure and do it successfully. Disease which has no direct bearing upon the surgical condition must receive attention, as it may seriously influence the outcome of an otherwise successful mechanical result. We recall very dis- tinctly an abdominal operation undertaken against our advice in a child suffering from a mild form of pertussis. Immediately fol- lowing the operation the depression of the child's nervous system was so marked that the spasms of coughing became more frequent and severe and the abdominal wound was torn open. The child hovered between life and death for days and, although the technique of the operation was perfect, the results were nearly fatal. Thus we see that any constitutional disease enters very largely into the problem as to when to operate. We must, however, speak particularly of hemophilia, as it has such an important bearing upon the outcome of even the most PREPARATION OF THE PATIENT 77 simple surgical procedure which may result in hemorrhage. (See page 112.) We do not think it is necessary to do more than emphasize the fact that the examination of the various organs, and particularly the heart, the lungs, kidneys, and blood, should proceed along somewhat similar lines as in adult cases. But, . if anything, there must be more care given to this examination, and unless the surgeon is particularly skilled in this work the best interests of the child call- for other assistance. Urine. The difficulty which sometimes attends the securing of a specimen of the urine should be no deterrent of this procedure in every case. In the male the urine may be collected by the use of a condom fastened over the penis, and in females it may be collected in a small cup or vessel made for that purpose. When only a small quantity is required (as to determine the presence of albumin) a small piece of absorbent cotton may be used. It happens at times that catheterization becomes necessary, and in such instances only the small instrument should be used (as No. 6, American scale). Blood. The presence or absence of anemia in the child cannot be determined simply by observation but is only proved by the de- termination of some blood change. Pallor of the skin and the mucous surfaces, if gradually developed, is usually a very suggestive sign of a reduction in the number of blood cells and of hemoglobin, but it is safer to confirm this by other means. When it is decided that anemia is present, it is necessary to go 1 icy ond this and determine whether it is primary or secondary. Most of the anemias occurring during childhood are secondary and therefore we must find out whether the blood condition is not depend- ent upon nephritis, tuberculosis, rachitis, malnutrition, some suppura- tive process, or other condition. The influence of chronic poisonings, as by arsenic, mercury, etc., must be remembered. If the hemoglobin is low, the giving of the anesthetic becomes a greater danger, collapse is much more liable to occur, and con- valescence and repair are hindered. If the hemoglobin percentage is below sixty, any operative pro- 78 PREPARATION FOR THE OPERATION cedure should be only undertaken under unusual precautions to safe- guard the child against shock and hemorrhage. Jaundice. If there are any evidences of jaundice present in the child, there is apt to be an unusual loss of blood even under the ordinary procedures, and it may be wise in such instances to test its coagulability. Laxative. It is not always possible to thoroughly clear out the intestinal tract with the administration of a single dose of a laxa- tive. Thorough cleansing may require a careful regulation of- the diet for two or three days and, with that, the intelligent use of a laxative or cathartic. However, it is always advisable to admin- ister a few hours before the operation a soapsuds enema, or one consisting of magnesia sulphate, one ounce, glycerin, two ounces, and warm water, one pint. This latter is particularly . serviceable in surgery about the rectum, as practically all of the mucus is dis- solved and removed by it. In cases in which much abdominal dis- tention is present turpentine may be added to the enema (one dram to each pint). In abdominal operations an enema of milk and molasses is serviceable in older children. Digestive Disturbances. The great liability of infants and young children to suffer from frequent disturbances of the digestive organs should excite the interest and attention of the surgeon because the perfect performance of the nutritive functions is essential to suc- cessful surgery. It is readily observed that a gas-distended stomach or intestine will interfere, perhaps seriously, with the perfect per- formance of an operation upon the abdomen. But this is a mat- ter of interference with technique; there is a more serious aspect, and that relates to the anesthetic. Many of the failures to control the anesthesia are directly attributable to this factor. Irrespective of technique or the anesthetic, the convalescence of the young child or infant may be seriously complicated by an acute digestive dis- turbance of either stomach or intestine. If removal from the home becomes necessary, it may entail some change in the diet, and this removal and change should be sufficiently long to demonstrate its safety, whenever practical. Water Drinking. Kather free water drinking should be encour- PREPARATION OF THE FIELD OF OPERATION 79 aged, for it seems to act favorably upon elimination through the kidneys and the skin. Bathing. Bathing contributes not a little to the final result, for frequently the necessary dressings applied after an operation cover so much of the child's body that free bathing or sponging subse- quent to the operation is impractical. Toilet of Mouth.- The toilet of the mouth should be most rigor- ous, and yet there must be extreme care in the case of infants that the delicate mucous membrane is not injured in any way. It is not uncommon to find in infants minute patches of commencing stoma- titis, and whenever possible these should receive adequate attention before the infant is subjected to operation. Neglect in this particu- lar may lead to serious complications, for in any uncared-for mouth there may exist organisms which will develop rapidly under the favoring irritation caused by ether particularly. Practically all the diseases of the mouth are the result of trauma or of infection. The cavity is certainly an ideal breeding place for all kinds of organisms, and" it is only by the action of the secretions and the constant cleansing which normally goes on that disease is not more common. Probably the secretions act more emphatically in preventing disease than we are aware of, for clinically it is a fact that with diminished secretion, or in the presence of conditions which disturb the composition of that secretion, diseases of the mouth are more prevalent. PREPARATION OF THE FIELD OF OPERATION Until the child is about to be operated upon, the field of opera- tion should not receive any more attention than the warm cleansing bath, which not alone considers the field of operation but is a general one. There are good reasons for restricting undue preparation. The child's skin is tender and very easily injured and becomes easily the site of an infection. Shaving or vigorous rubbing done many hours before the operation may cause almost imperceptible injuries which favor bacterial growth, arid the heat and the moisture of a 80 PREPARATION FOR THE OPERATION dressing left on the surface for many hours need no elaboration of ours to emphasize their possibilities for harm. Such preparations should be left until shortly before the operation. All scrubbing of the skin should be done thoroughly, but withal gently. Not uncommonly we find in the field of operation or closely approximating it a patch of eczema, and the question arises as to how to dispose of it as a factor. If eczema is moderate or severe in a child, the operation should be postponed, if possible, until the effect of direct treatment of this troublesome condition can be se- cured. However, if the operative procedure must be accomplished, then there are two ways of attacking it. If the eczematous patch is directly in the field of operation, it should be curetted and painted with tincture of iodin just previous to the operation. If simply close to the operative field, the patch should be isolated by gauze and collodion. We recall one instance in Avhich the operative field was so thickly studded with these patches that the whole of the surface was covered with three layers of gauze soaked in collodin (after removal of all scabs and debris) and the incision carried through the gauze and skin. This offered us a protected field which we felt that we could not secure in any other way. It more certainly than any other method reduced the probability of foreign material being carried into the wound. What we have advised in regard to eczema- tous patches would apply in a measure to those with broken skin. The stronger antiseptics cannot be used on a child's skin, there- fore we are very much restricted in our choice of these agents. The foregoing observations, of course, apply only in a general way; there must be special preparation for special areas and even for unusual or special operations. EXAMINATION OF PATIENT Examination of the Heart. This should be made by the surgeon or his assistant in every case and must be independent of the similar examination which must be a routine (routine as regards its occur- rence and not as regards its preciseness) method of the anesthetist, EXAMINATION OF PATIENT 81 although the two examinations should be compared. The examina- tion differs only in some details from that of the adult heart, and FIG. 30. RELATIVE CARDIAC DULLNESS (OUTLINED) AND ABSOLUTE CARDIAC DULLNESS (SHADED) IN AN INFANT OF ONE YEAH. FIG. 31. AREA OF RELATIVE CARDIAC DULLNESS (OUTLINED) AND ABSOLUTE CARDIAC DULLNESS (SHADED) IN CHILD OF Six YEARS. while there exist anatomic and physiologic differences, the difficul- ties which attend the examination of the child's heart are not those of method but those of deduc- tion. These differences are thoroughly discussed in the works upon this special sub- ject. Provided that compensation is established, valvular disease of the heart is no contraindi- cation to the administration of a general anesthetic or the performance of a major sur- gical operation. Examination of the Chest. Inspection will frequently give a clew as to the nutritional state of the patient, an insufficient subcutaneous covering of the bony framework indicating some general weakness or malnutrition. FIG. 32. AREA OF RELATIVE CARDIAC DULLNESS (OUTLINED) AND ABSOLUTE CARDIAC DULLNESS (SHADED) IN CHILD OF TWELVE YEARS. PREPARATION FOR THE OPERATION A flat chest is commonly associated with a tuberculous history. Pigeon breast chest indicates that there is some persistent interfer- ence with free respiration, or it may occur in rachitis. In the rachitic chest there is a shortened chest with prominence of the sternum and beading of the ribs and the costal angle is usually quite acute. The funnel chest has no special significance. In the emphysematous chest the aiiteroposterior diameter is increased, the sternum perceptibly arched, the ribs thickened and running horizontally outward, making a wide subcostal angle. An error that is frequently made is in mistaking a similar condi- tion which occurs in kyphosis, but in the latter there is no evidence of chest disease and the ribs are not thickened. Unilateral enlargement is most noticeable at the base and is generally the result of an accumulation of gas or fluid in one plcural cavity, but may be due to compensation on account of disease of the other lung. When compensatory, the affected lung is smaller than normal. When not due to compen- sation, the ribs are elevated, the side more rounded and the inter- spaces usually obliterated. Unilateral contraction is due usually to pleuritic adhesions or may be due to a collapsed lung. If abscess is formed, the shoulder droops and there may be more or less spinal curvature. FIG. 33. CONDOM TIED OVEH PENIS TO COLLECT SPECIMEN OF THE URINE FOR EXAMINATION. FIG. 34. CHAPIN URINAL, FOR THE COL- LECTION OF SPECIMENS FOR EXAMI- NATION. EXAMINATION OF PATIENT 83 It requires care under this condition to differentiate scoliosis from primary vertebral disease. Precordial bulging is usually dependent upon an enlarged heart, but less commonly occurs with large pericardial effusions (rare in children), aneurysm, and tumor. Hypochondrium bulging occurs with large effusions into the pleura and in hepatic and subphrenic abscess, but if right sided may be due to liver enlargement. In each instance a very careful examination must be made of the chest, for, in children, diseases of the bronchi and lungs are very FIG. 35. CHAPIN URINAL IN POSITION. common and easily made worse, and at best are liable to lead to serious consequences, particularly when complicated by injury, the administration of an anesthetic, or the shock of even the minor surgi- cal procedures. Examination of the TJrine. For the purposes of smooth surgery the examination of the urine in young subjects should be even more painstaking than in adults, because of the fact that, in the former, disease often has its beginnings insidiously. Hematuria must not be confounded with hemoglobinuria, which latter is due simply to the presence of blood-pigment in the urine, 84 THE CONTROL OF HEMORRHAGE while hematuria is evidenced by the actual presence of blood. The common local causes of hematuria in children are trauma of the various kinds, calculi,- jnew growths, congestion or inflammations anywhere in the genitourinary tract, and ruptured veins. The gen- eral causes are chiefly hemorrhagic diseases of the new-born, purpura, scorbutus, malaria, syphilis, tuberculosis, nephritis, and hemophilia. The use of certain drugs may also cause it. Pyuria may be due to the pus coming from any portion of the genitourinary tract, but the most frequent source in children is the pelvis of the kidney. Next in frequency we find that the pus comes from an outside source, as when an abscess opens into the tract. An acute pyuria suggests more often than anything else a pyelitis, while chronic pyuria is strongly indicative of tuberculosis of the kidney. The details of the urinary examination are similar to those of adults ; the thing to be emphasized is the relatively greater import- ance of such examination in childhood. CHAPTEK XIV THE CONTROL OF HEMORRHAGE Without going into a lengthy and unnecessary discussion of prob- lems in regard to the circulatory apparatus in children, it is only needful that the surgeon clearly and constantly appreciate one fact : that children stand hemorrhage badly. In a survey of the varied theories and possibilities which are advanced by various writers in regard to the subject, we find that the anatomic and physiologic peculiarities which are recognized all point to three very definite clinical facts and these are what are of interest. (1) There is a diminished blood pressure in childhood. (2) The circulation of the blood stream is very rapid. (3) The pulse is rapid and easily disturbed. These clinical facts emphasize the operative need. It must be clearly understood that the surgeon who deals with DELAYED HEMOBRHAGE 85 the child must make every provision against the loss of even the smallest quantities of blood. This entails considerable care in the preparation for any operative procedure that may be necessary. The Esmarch bandage should be used whenever practical. It is a grave mistake not to have an abundant supply of hemostatic forceps and these should be of such size that they will not involve in their grasp too much of the tissues. The mosquito forceps are particularly serviceable for this work. It is an excellent plan to have each vessel grasped between forceps before its division. As pressure alone acts favorably upon the con- tractility of the vessels, the use of ligatures is not as essential as in adults. For surfaces that ooze there is nothing better than gentle pressure with hot gauze sponges, or, if this fail to give prompt results, a hot normal salt solution may be used. Provision should be made before the operation for the possible necessity of pack- ing cavities with suitable gauze, the use of the cautery, or any other known method to conserve the loss of blood. Primary Hemorrhage. The recognition and treatment of this condition do not differ in any material way from a similar con- dition in adults; however, there is ever present the danger arising from an unsuspected case of hemophilia. Delayed Hemorrhage. This is the type of hemorrhage that oc- curs after recovery from the anesthesia and may occur within a few hours or be delayed for nearly a week. The symptoms vary with the rapidity with which blood is lost and also its amount. Delayed hemorrhage is always a vastly more FIG. 36 MOSQUITO FORCEPS. 86 THE CONTROL OF HEMORRHAGE serious matter in children than in adults. Very quickly there is added the full symptomatology of shock and it only requires a small amount of blood (in some instances we have noted it after a loss of one or two ounces) to bring this about. It is rare in these days of careful technique to observe the quickly fatal cases in which the child will bleed to death within a few minutes. Generally the picture is somewhat like this: the child several hours or days after operation shows an undue restless- ness with a small, weak pulse. With increasing restlessness there is some dyspnea, but neither of these may be very pronounced. The pulse, however, continues to increase and out of all proportion to other symptoms. This symptomatology may be all that is present and should always be considered by the surgeon as sufficient cause for a most searching examination of the child for hemorrhage. There is a marked difference between the symptoms of delayed hemorrhage in adults and in children ; in the former the symptoma- tology expresses itself as clearly due to loss of blood, but in the latter it is not so expressed but occurs as the result of very early shock. Therefore, while in adults we usually encounter pallor, extreme nervousness, thirst, air hunger, and great anxiety, these may be entirely absent in children and the symptomatology of shock alone be present (see page 106). The diagnosis from delayed shock is exceedingly difficult and we have observed several instances in which this diagnosis has been made and the autopsy subsequently revealed the fact of delayed hemorrhage, which was unsuspected. The causes are somewhat similar to those of later life. The principal ones to remember are: (a) The more or less perfect closure of small bleeding points by clot and its subsequent dislodgment after the wound has been dressed. (b) Hernatoma subsequent to injury of a vessel during closure of the wound. (c) Much increased blood pressure after an operative procedure, causing what was an apparently well-dried and bloodless surface to begin oozing. CONSTITUTIONAL TREATMENT OF HEMORRHAGE 87 (d) Poorly applied or poorly made sutures. (e) Friable tissues. The treatment is based upon exactly the same principles as govern the care of similar cases in adults. Secondary Hemorrhage. This is hemorrhage which is due to erosion of a vessel through the agency of a septic process and there- fore is observed several days after the operation. It is largely a relic of the days in which aseptic surgery was not possible and is exceedingly rare at the present day. Constitutional Treatment of Hemorrhage. The constitutional treat- ment of hemorrhage must always be added to those measures which are instituted to control the bleeding. Under the existing circum- stances, care must be exercised to avoid increasing the arterial ten- sion too much, either through the use of vasoconstrictors or by the introduction into the body (through the mouth, rectum, subcutan- eously, or by transfusion) of an excessive amount of fluid. In children, the treatment after the control of the hemorrhage is mainly the treatment of shock (see page 109). There are several features of the treatment which should receive the consideration of the surgeon and these might be summarizd as follows: ' THE IMMEDIATE DEMANDS (a) Elevate the foot of the bed. (b) Eliminate all unnecessary persons, noise, light, and excite- ment from the room. (c) Supply oxygen by open windows (continuous method). (d) Maintain body heat by blankets and hot bottles. (e) Stimulate cautiously. THE REMOTER DEMANDS (a) Intravenous, subcutaneous, or rectal injections of normal salt solution (with or without adrenalin) as occasion demands. 88 POST-OPERATIVE CARE (b) Stimulate more boldly than at first, after most carefully noting the effect of the stimulation, not alone upon the circulation but also upon the digestion. (c) Add as rapidly as possible to the diet, considering nutritive value of each article of food, and digestive capacity of prime im- portance. (d) Administer well-selected tonics to correct the acute anemia. And, lastly, in rare instances it may become necessary to con- sider the advisability of blood transfusion. CHAPTER XV POST-OPERATIVE CAEE Not uncommonly a considerable part of the success of a surgical procedure depends upon the post-operative care that the child receives and the responsibility of the surgeon cannot reasonably end with the completion of that procedure. It is needless to discuss what the common custom has been in regard to this matter, for it is suf- ficient to say that the surgeon should have a general supervision of the convalescence of the child, or should be allowed to transfer this responsibility to one equipped to study and safeguard the child's best physical interests. The purpose of post-operative care is not primarily to nurse back to health a child that has been sick, for that is not commonly the case. The child has been wounded, or, at least, that is the best attitude to assume toward the patient and his friends ; the child has been wounded and the real object of the post-operative care and treatment is to avoid any complications or to limit their ravages and to hasten the healing of the injured parts. Of course, the general condition of the child may demand attention quite apart from the injury, or there may exist or arise disease or disturbed function in special parts which will require treatment, but, in the main, the problem is one of wound treatment and complication prophylaxis. This is the surgical viewpoint, but the public demand more than DIET AFTER OPERATION" 89 this ; parents rightly expect the child to be restored as nearly as pos- sible to efficient childhood. The problem of post-operative care is not always a surgical one, and if the courage and skill of the surgeon was more often coupled with the judgment and training of the skilled physician or pediatrist, the results would be better and confidence in surgical procedures be restored. The Room.- The room prepared for the reception of the child after an operative or surgical procedure should be the best ventilated and sunniest one that the house affords. It must be capable of proper ventilation and heating and reasonably near to water and toilet conveniences. The furnishings should be as simple as possible and always selected with the idea of the easy maintenance of proper and adequate surgical cleanliness and without the entailing of the extra work required by a selection of more elaborate furnishings. The bed should be one that can be easily moved and which allows of the proper attendance upon the child from both sides and without disturbing the little patient. Whenever possible, it is well to supply the bed with a pillow stuffed with oakum, which has been previously exposed to the air to eliminate the tarry odor, because this filling can be readily removed and destroyed. It is no uncommon experi- ence to encounter vomiting, and when this occurs the mere chang- ing of the -outside slip of the pillow does not get rid of the materials which are soaked with the vomitus and are therefore surgically un- clean. Oakum is cheap, easily obtained, and readily destroyed. Diet after Operation. The diet of the child must, of course, be modified by the circumstances of age, the previous dietary, the na- ture of the injury, the site of the injury, and the nutritional needs of the particular child. But there are certain general principles which must have the surgeon's consideration. We need not discuss the question of the diet immediately after the operation because this has been considered under post-anesthetic care. The diet should always be one that is nourishing with the least amount of bulk and suited to the needs of the particular child, for some consideration must be given to the previous dietary, no mat- 90 POST-OPERATIVE CAEE ter how wrong it may have been. Children, like adults, do not easily fit themselves to standards of diet and certainly have individual likes and dislikes which must be considered. In addition, although the diet may have been wrong, children are easily the victims of habit and the attempt to radically change or adjust their diet to what it should be without giving any considera- tion at all to what it has been, will result in rebellion against the innovation and the willful refusal to partake of sufficient nourish- ment. Some few children fall readily enough into our dietary FIG. 37. CHILD PROPERLY ATTENDED AFTER THE OPERATION, THE BODY BEING ADE- QUATELY PROTECTED AND THE VOMITUS TAKEN CARE or. schemes, but when they do not, it is much better to allow a dietary which is nourishing and readily taken rather than arbitrarily to insist upon one that is nearer the ideal but which will be refused by the patient. If the child has suffered much from shock or hemorrhage, fluids should be administered early and freely. In abdominal operations or injuries it is wise to rest the gastrointestinal tract for several hours and the withholding of all food may be necessary. Operations upon or injury of the mouth or stomach may make rectal feeding necessary for some time. 91 There is one article of diet which is taken readily by practically every child, irrespective of the age or the other circumstances men- tioned, and that article is milk. However, under the conditions in which the surgical child of any age finds itself, the milk must be modified so as to supply the required nutrition without undue disturbance to the digestive appara- tus. Until the surgeon has had an opportunity to learn the needs of the child or until the child has had the opportunity to adjust itself to the new conditions, we have found that top-milk modified with a sugar and a diluent, and perhaps with the addition of a fresh egg, supplies for a long period all of the nutrition and energy that is actually needed, although variety is lacking. It, however, may be used as the foundation of the diet for several days with excellent results. For instance, in a child of five or six years of age and of average weight and nutrition, the following is given: The top sixteen ounces from a quart of milk. Sixteen ounces of a diluent (water, or a cereal water, with or without the addition of lime water). Sugar of milk, one to one and one-half ounces (to add energy and not merely as a sweetener). The above to be given in quantities suited to the particular needs at the time. Raw egg is added to this when the circumstances allow and either the white or the whole egg is used, according to the digestive capacity of the child. Such a diet meets all the demands of the child confined to bed, and its advantages are, that it can be further modified at a moment's notice, the proteid is high enough for the inactive child and low enough not to overtax the digestive capacity of the intestine, water is supplied in considerable amount and helps the eliminative action of the skin, bowel, and kidneys ; in short, it supplies the necessary energy with the minimum tax upon the digestive and eliminative forces. 92 POST-OPERATIVE CARE Other articles of diet are added as soon as indicated, but always with the digestive capacity in mind. The Bowel Function. There is scarcely any need of emphasizing the great importance of regular and adequate bowel evacuations in surgical convalescence. We must, however, speak particularly of adequate evacuations. Time and time again we have proved that, with the occurrence of one or more evacuations from the bowel and even after the administration of a cathartic, the evacuations are not adequate. This has been proven by the X-ray, through which method of examination we have observed that a portion of the bowel is full. This has suggested to us the desirability of having the food FIG. 38. CHILD NEGLECTED AFTER OPERATION. When left even for a few moments there is danger of injury from falling, from exposure and from the vomitus which may be aspired. that is given to the convalescent child weighed and the probable residue which will appear in the intestines estimated and this result checked off subsequently by having the stools weighed. While this is in no manner brought forward as being absolutely accurate, yet it does not allow of the intestines 'becoming clogged and massed with a large amount of feces without detection. The instances in which this method has been followed have proven its very practical value. It is necessary, therefore, that the surgeon assure himself that there are not alone regular evacuations from the bowel but that such evacuation is adequate. Distention occurs in moderate degree after practically every opera- tive procedure, because the general shock, even though almost undis- CAKE OF THE WOUND 93 coverable temporarily, involves the digestive tract. Fermentation is the result and may be only sufficient to add discomfort to the patient or may become extreme enough to demand active interfer- ence. Carminatives, change of posture, massage of the abdomen, or enemas, or a combination of two or more of these usually give the desired relief quickly. But in paralytic distention we have a serious condition and reliance cannot be placed upon the ordinary methods of relief. As purgation by the mouth is usually ineffectual, no time should be lost in dependence upon that method, but immediate recourse must be taken to irritative enemas, as turpentine and soapsuds, milk and molasses, or hot glycerin. These empty the lower bowel and en- courage the passage of gas from the upper. The tube through which these are given may be left in place, so that the further passage of gases may be facilitated. If repeated enemas are required, they may be given through the same tube while peristalsis is favored by external applications. But great caution must be exercised that the skin of the abdomen is not burned, because in this condition the abdominal wall becomes more or less insensitive. Vomiting. It should be remembered that vomiting following an operation may be due to other causes than the anesthetic, and therefore the surgeon as well as the anesthetist should be watchful for such vomiting as evidence of intestinal obstruction or peritonitis, or as an early symptom of some acute systemic infection, particularly uremia or pneumonia. Care of the Wound. In children, all tissues tend to heal more rapidly than in adults. Irrespective of this, there are certain factors which favor rapid healing, as asepsis, a rich blood and lymphatic supply, the absence of tension, and individual tendencies. Two to four days is the average for the healing of skin wounds in children, while the deeper structures require somewhat longer periods, as from five to ten days. However, it is much longer than this before any strain can be safely placed upon the parts. Time for Dressing. If a wound is clean, the tendency is toward healing by first intention and therefore the usual dressing does not 94 POST-OPERATIVE CARE need removal until it is time for the removal of the stitches. Still, suppuration may take place when least expected and should be de- tected at the earliest possible moment. It is not necessary to remove the dressing to determine this, but the temperature chart, which is a valuable guide, should be closely watched, and if it fails to reach the normal after the first seventy-two hours (during which time there has usually occurred a slight reaction rise of temperature) or, hav- ing been normal, begins to rise, the wound must be examined. In children, the redressing and the removal of stitches is usually done on the fifth day. The next dressing is removed on the eighth day and the deeper sutures, if any, may be removed at this time also. Care against Infection. In dressing the wounds, 110 irrigation should be used and just as much care must be used in the preparation of the hands, the instruments, and dressings as in the original procedure. Of course, infection of the wound may exist without fever, but when that occurs, there is the presence of pain in the part which is due to slight swelling and which is in no way associated with the initial pain, which is present for about twenty-four hours after the infliction of the wound. Thus, pain delayed until the second or third day should arouse the suspicion of possible infection, and when associated with fever the suspicion becomes practically a cer- tainty. Clinically infection is designated as early or late, although there does not seem to be any good reason for this distinction, for the so-called early infection, occurring between the third and sixth days, is a superficial infection, while the so-called late infection, occurring during the second week, is a deep-seated affair. Treatment of either type should not be delayed, but free drainage must be estab- lished at once; it is absolutely useless to wait and depend upon Nature. Whenever infection occurs, there is always the danger of its spread, and if the secretions of the wound are allowed free exit this danger is minimized. But despite this, the virulence of the germs may be such that the surrounding tissues are involved or adjacent THIRST: ITS SIGNIFICANCE AND RELIEF 95 parts infected. The infection spreads along the lines of least re- sistance, so that, while it is following a particular course, anatomic barriers may send it along new channels. Early and adequate inci- sions are absolutely necessary for control. Clean wounds in infected areas are treated by drainage and the hastening of the separation of any sloughing tissues with incisions that are sufficiently deep and long to accomplish their purpose of reaching all parts. Sluggish granulation may require stimulating applications or curetting, while exuberant granulations will need removal. The more serious of the wound complications are discussed in other sections of this work, and to these the reader is referred. CHAPTER XVI THIEST: ITS SIGNIFICANCE AND BELIEF Thirst is present to some degree in every instance in which a child is subjected to operation. As its manifestations are not as pronounced as in adults, its existence may be overlooked. No doubt part of the sensation is directly due to the dryness of the mouth and fauces which invariably follows the administration of a general anesthetic. And added to this may be the influence of the abstrac- tion of fluids from the body by the administration of active cathartics preparatory to the operation or by vomiting, sweating, or hemor- rhage during or immediately after the operative procedure. But irrespective of these, we have commonly observed that op- erations performed under local anesthesia are just as surely followed by thirst as when the general anesthesia is used, although it is some- times of a slightly lesser degree. The chief element in its causation is undoubtedly the shock which the child experiences from any surgi- cal interference. The relief of this troublesome condition may be secured in sev- eral ways: (1) by drinks, (2) washing of the mouth, (3) adminis- tration cf water subcutaneously, or (4) by leaving fluids somewhere in the body where absorption may take place readily. 96 THIKST: ITS SIGNIFICANCE AND RELIEF It is rarely that the administration of very small quantities of water for the first hour or two after an anesthetic and the giving of much larger quantities later are contraindicated in children. Even when the water is expelled by vomiting once or twice it is serving a useful purpose in washing out the stomach, and, if retained even for a few minutes in the child's stomach, some of the water is absorbed. We should not wait until the child complains of the sensation of thirst, because if we do an indefinite period may elapse. Children do not readily complain of such discomfort and it is not uncommon to find them almost parched from thirst without any request being made for a drink. The surgeon must leave definite instructions, both as to the amount of fluid to be given and as to the time of the administration. These instructions will depend naturally upon the age and size of the child, the nature of the operative procedure, the duration of the anesthesia, and the degree of hemorrhage and shock present. Washing of the mouth is most effective in the relief of thirst, and if used early and often there is rarely any later suffering from thirst, but the child commonly gives evidence of its comfort from the procedure. Any mild alkaline antiseptic fluid may be used (if it contains no poison) and there is a decided advantage in using it cool but not cold. Saline infusion may be necessary in some few instances and for this procedure the same methods are used as in adult cases, except that a smaller needle than usual should be used. This method, however, rarely becomes necessary, if the surgeon takes advantage of the less dangerous and equally effective one of early proctoclysis. Proctoclysis has failed in many instances to bring relief, not be- cause the method itself is at fault but because the time of its admin- istration has been unduly delayed. Early proctoclysis is the only effectual proctoclysis in children. The positive need of the child should be anticipated and a rectal enema of eight to sixteen ounces of a normal salt solution (approximately one dram to the pint) should be administered at the close of the operation, or just as soon as the child is returned to its bed. When it is appreciated that the need will be great, this may PAIN AND SLEEP !>7 well be repeated within one or two hours. Naturally, all of this will not be retained but usually there is enough tJiat is retained to be very efficient in the relief of subsequent thirst. In cases of urgent demand, where retention by ordinary procto- clysis is not sufficient, we may have recourse to the "drop" or "Mur- phy" method. Several forms of apparatus have been devised to ac- complish the purpose, each one having features which are of apparent advantage. In hospital practice it is usually possible to secure some such apparatus, but in private work advantage has to be taken of what the home affords. Therefore the simplest method is to use a fountain syringe with a tube which is just long enough to reach the patient's buttocks and still allow of some little play, and have attached to the tube a small glass catheter. Our own custom has been to use the smallest catheter obtainable, so that local irritation may be minimized. A hemostat is then clamped upon the tubing so that the water escapes at about the rate of one drop a second. If the catheter is introduced from three to five inches within the sphincter and secured there so that there is little or no motion of it, it may be retained indefinitely. We have demonstrated that wrapping the rubber tubing of the fountain syringe with strips of newspaper cut one to one and one- half inches wide and the ends of each strip fastened with paste, has assured us of having the fluid delivered within the rectum at prac- tically the same temperature as it is within the bag. This simple procedure overcomes one of the chief causes of non-retention of the saline, namely, chilling of the water in its slow passage through the tubing. Leaving a considerable amount of fluid in the body is possible in some operative procedures, and whenever practical this should be done. It goes a long way toward securing freedom from subsequent thirst and discomfort. f CHAPTER XVII PAIN AND SLEEP There is such a close relationship between post-operative pain and sleeplessness that the two might well be considered together. It 98 PAIN AND SLEEP must be clearly appreciated by the surgeon that in children the degree of post-operative pain -bears no relation to the extent or seriousness of the procedure itself. There are very marked differences in in- dividual children in regard to the perception of pain and in addition to this there are nutritional factors which determine very largely the degree of pain. We can reasonably say that there is no one factor that has a more marked influence over the existence or modification of pain than the state of the child's nutrition. We need not expect much complaint in regard to post-operative pain in children but must look for its evidences. As a rule, chil- dren do not make complaint of pain, but quickly show evidences of its effect upon their general condition. Lacking the habit of morbid introspection, these little ones are incapable of exaggerating their ills for the sake of attracting attention to themselves, but, on the other hand, they stand pain so badly that the evidences of its in- roads are quickly observed and it is for these that the surgeon must watch. There is one thing certain that discomfort in the child is never exaggerated into the semblance of pain, as is so commonly the case with adults. To avoid unnecessary repetition the reader is referred to the section on Pain (see page 26). As rest and sleep are not possible with pain and yet the two former are absolutely essential in the securing of a speedy and safe convalescence, the element of pain should be eliminated as much as possible and the inducing of rest and sleep secured. In the elimination of pain, foresight is much better than hind- sight. There are many details in regard to the handling of the patient, the dressing of the wound, the application of possible splints, the change of posture, and so forth, that, if neglected, are certain to be productive of post-operative distress. But irrespective of these details there are instances in which we are reasonably .certain that considerable pain will be present and in such instances it is our duty to anticipate it by the use of some agent to minimize it. Thus, for instance, a very small dose of a sedative, or particularly of an opiate hypodermically just at the close of the operation, is most effective in the relief of pain and the securing of rest and sleep. POST-OPERATIVE CONVALESCENCE 99 Whether to use morphia in operations upon the abdomen or not is a question which has strong advocates upon both sides. Some claim that its effect is to exaggerate intestinal paresis and allow further abdominal distention, thus favoring the occurrence of peri- tonitis, while others are certain that the relief given more than war- rants its use. We have settled this discussion for ourselves by its administration in very small doses and combined with atropin. Whenever possible it is advisable to use anodynes locally. CHAPTEE XVIII THE GENEEAL MANAGEMENT OF POST-OPERATIVE CONVALESCENCE There are three classes of children that come to the surgeon. First, there are those who have a surgical condition which has more or less seriously interfered with their general health. Second, there are those who present a surgical condition which has had little or no effect upon their general constitutional condition and who, if it was not for the surgical condition, might be considered normal children. Thirdly, there are those who, irrespective of the influence (or lack of it) which the surgical condition has had upon their general condition, still show unmistakable signs of a nutritional fault, which may or may not have been exaggerated by their inter- current disease or condition, but which becomes an important factor when surgical interference is considered. We may well dismiss any consideration of the second class be- cause the surgical procedure for their relief is not interwoven with any problems which deal with a constitutional depression. Surgical relief is all that they require to restore them to a normal state. Therefore in them the problems of convalescence are merely those of ordinary hygienic surroundings, diet, and care. In the first class there is also a similar proposition because we are aware that as the surgical condition is in large measure or wholly responsible for the constitutional symptoms, its relief will bring about the relief of the latter. However, we must not be con- 100 POST-OPERATIVE CONVALESCENCE tent to restore this balance of health by merely eliminating the surgical cause, but should hasten convalescence by all suitable meas- ures. Here, then, is the opportunity for the administration of well- selected stimulants or tonics. Of these, the best are cod liver oil, iron, arsenic, strychnin, and alcohol. Cod liver oil stands clearly at the head of the list of tonics for young children, and this is em- phasized more particularly during a period of convalescence. If the precautions are observed of withholding its administration during the time that the tongue is coated, the digestion is disturbed or the inclination to vomiting or nausea exists, its value will be soon evidenced. Most children are the subjects either of anemia or a faulty nutri- tion, and this is one reason why the oil is indicated and proves so markedly beneficial. Iron is not nearly so satisfactory in most cases of anemia because the preparations are far from satisfactory, and even though the condition of the blood is improved, the nutrition is usually not markedly improved. Arsenic is second to iron in its effect upon anemic conditions and in many instances is much preferable to iron on account of having no constipating effect. Alcohol has a distinct use as a tonic, particularly during and after an infection, although its administration must be in small doses and in combination with other tonics, whose properties it en- hances. Fresh Air and Sunshine. Every child needs fresh air and sun- shine just as much as it needs fresh, pure food, and it should be given to them just as regularly and persistently as their meals. Every surgical convalescence is influenced to some degree by the amount of fresh air and sunshine supplied to the patient, and in many instances it is of prime importance. The matter of fresh air and sunshine in the treatment of the surgical aspects of tuberculous bone disease has been amply empha- sized and it has become a most important part of the management. This is as it should be, but, in the emphasis which has been placed upon it, we have often overlooked the fact that similar care is equally GAVAGE 101 beneficial in all surgical conditions in children, although not always as insistently essential. Of course, we must be cautious in our application of these meas- ures and safeguard the child against any possible dangers from exposure in kidney disease. With care and forethought, it is prac- tically always possible to secure for the convalescent surgical child an abundance of fresh air and sunshine without exposure that ma\ prove harmful, and therefore it is always indicated. CHAPTEE XIX GAVAGE, LAVAGE, AND KECTAL FEEDING Gavage, lavage, and rectal feeding are procedures which are noi always familiar to the surgeon. Under some surgical circumstances, however, their importance becomes so great that a brief considera- tion of their application and uses may be useful. Gavage. This consists of the forced introduction of food into the stomach through a tube introduced through the mouth. The appara- tus employed is not complicated. To the neck of a glass funnel which has a capacity of from four to eight ounces is attached a piece of rubber tubing two feet in length. To the end of this tubing is attached a piece of glass tubing three to six inches long and to the other end of the glass tube is attached a soft rubber catheter with a large eye. The size of the catheter should be about No. 16, Ameri- can scale. When ready for introduction the child should be placed upon the back and its head held firmly by an assistant. In children over two or three years of age it is often necessary to first introduce a mouth gag. The tongue is then depressed by the forefinger and the catheter, which has been previously moistened (or lubricated with glycerin), is passed rapidly back into the pharynx and then down the esophagus. The rapidity with which the tube is passed over the pharyngeal wall will determine the amount of gagging and struggling of the child, for, after having once reached the esophagus, it is rare L i U l\ .-s l\ \ . C 102 GAVAGE, LAVAGE, AND RECTAL FEEDING to encounter any resistance. Usually about ten inches of the catheter are passed within the lips and when that much has been accomplished the funnel should be raised to allow the escape of gas. We believe it is always advisable to then lower the funnel so that any fluid con- tent of the stomach may be siphoned off before the food is introduced. The nourishment selected is then poured into the funnel and this is raised slightly above the level of the child so that the inflow is steady but not forcible. Just as soon as the food has disappeared, the tubing is pinched and held firmly while it is quickly withdrawn FIG. 3Q. APPARATUS FOR STOMACH WASHING. (Description in the text.) and by this method we prevent any of the food from getting into the pharynx and exciting vomiting or coughing. It is just as well to be in no haste in removing the gag if one has been used, and, if not, then it is advisable to keep the jaws of the child separated by the finger for a few moments to prevent further gagging. If any regurgitation of the food is to occur it will usually do so at once and under such circumstances it is advisable to imme- diately repeat the procedure. For several minutes after the feeding the child should be kept quiet upon its back. GAVAGE 103 The food given should be at least partly predigested. The whole procedure is entirely free from danger and may readily be taught to a competent attendant. The advisability or necessity of this procedure may arise in cases of prolonged vomiting after an anesthetic, when the child does not retain any food taken in the ordinary way. Its usefulness is at once apparent in conditions in which the child cannot or will not FIG. 40. LAVAGE IN THE OLDER CHILD. In younger children (infants) there is no need of the gag and the dorsal position may be used. partake of sufficient food and this applies particularly to fracture of the jaw or injuries or operative procedures about the mouth and following tracheotomy, intubation, and so forth. The method is one that is much less distressing and much more productive of good in those occasional instances in which it becomes necessary to force the child to partake of food sufficient for its needs. Its usefulness, however, is not strictly limited to the giving of food, because medica- ation and stimulation may be administered in a similar manner. 104 GAVAGE, LAVAGE, AND RECTAL FEEDING Nasal feeding is similar to gavage except that the tube is intro- duced through the nose instead of the mouth. A much smaller -tube is therefore necessary and the best size is the No. 10, American scale. Its use is chiefly in those conditions in which passage through the mouth is inadvisable and when the use of a gag in older children would excite too much fear and struggling. Lavage. Lavage, or stomach washing, is accomplished with the same apparatus as has been described under gavage. However, instead of having the child lying upon the back as in gavage, it should be held in the sitting position and well protected with an apron. A large basin should be provided to receive the washings from the stomach. After the contents of the stomach have been allowed to escape as described under gavage, the funnel is again raised and from two to six ounces of water, containing from 20 to 60 grains of bicarbonate of soda, are introduced and immediately allowed to siphon out. The procedure is then continued with plain boiled water until one of the washings returns clear, and this is usually accomplished after about one quart of fluid has been used. The temperature of the introduced fluid should be close to 105 F., but if gastric irritation is very great, then this may be raised to 110 or 112 F. Under eighteen months this procedure is a most simple one, but as the child gets older there is more and more fear and rebellion against the procedure, so that it is often a very discomforting pro- cedure in children over the age of three years. In cases of poisoning washing is very valuable. In the persistent vomiting occasionally seen after anesthesia, lavage alone, or in combination with gavage, is most valuable in controlling the vomiting and supplying the needed amount of water or nutrition. As a post-operative measure it is' advisable to always leave an ounce or two of the water in the stomach to relieve excessive thirst. Rectal Feeding. This method of feeding occupies in older chil- dren about the same field as it does in adults. But in infants or very young children its application is very limited. After a very few attempts at such feedings, the rectum becomes intolerant and it has been our experience that no more than two or three such at- RECTAL FEEDING 105 tempts can be made without causing trouble. The quantity of the injected nourishment must of necessity be small, usually not more than two or two and one-half ounces, and the interval must be from four to six hours or even longer. Peptonized milk, peptonoids (especially the dry form in peptonized milk), or other forms of beef peptones may be used. In older children four to six ounces may be given at a time, and the selection of the nutrient to be given has a wider range. Egg- albumen, raw beef juice, emulsi- fied fats, a 10 to 20 per cent, solution of raw glucose, or any of the things mentioned as useful in infants may be used. The ab- sorption of all of these is hast- ened and made more certain by the addition of 1 per cent, of salt. The commercially prepared nutrient suppositories may be ser- viceable. The technique of ad- ministration is simple. If possi- ble the child is placed upon his side in an exaggerated Sim's po- sition (left sided), or if this is impractical he may lie upon his back. The buttocks are then slightly elevated. A long, soft FIG. 41. APPARATUS FOR RECTAL WASH- , , , ING OR RECTAL FEEDING. rubber rectal tube is then intro- duced (or a large-sized catheter), after lubrication with oil (glycerin is too irritating). A funnel which has been attached to the other end of the tube or catheter is then filled with the nutrient, and this is allowed to pass very slowly through the tube, which should be about six to eight inches within the sphincter. The elevation of the fun- nel should not be more than just sufficient to force the fluid into the rectum slowly. As the tube is withdrawn the buttocks should be held somewhat firmly together and the child constrained to lie 106 SHOCK quietly for from twenty to thirty minutes or more. This is an im- portant part of the procedure. If this form of feeding is to be continued over a long period, daily washings of the rectum with some mild cleansing fluid will become necessary. Excessive irritability is usually noticed at first, and may often be controlled by the addition of a few drops of laud- anum to the first enemas. Rectal feeding should never be continued indefinitely ; as soon as it is possible to do so it should be stopped. CHAPTER XX SHOCK There are four things which all children bear badly : pain, hemor- rhage, starvation, and cold. Therefore the injured child is already subjected to the influences of shock, the child to be operated upon is very liable to it. While we possess an accumulated knowledge of this condition, a knowledge which has come through the untiring efforts and studies of various clinicians and laboratory workers, yet no one has correlated this knowledge in such a form as to make it readily available and understandable: we are still without a clear understanding of the physiology of its production, and therefore of its classification. But we have in shock clinical manifestations which are well marked, and which go to prove that it is a complete clinical entity, made up of lowered functions, which make up the picture of par- tially suspended animation. This condition varies in its several de- grees just as in adult life. Diagnosis. The diagnosis of shock in childhood is not always easy, for it may be slight in degree, and, as there is a difficulty in clearly describing the condition, personal experience is a large fac- tor in its early recognition. Eor instance, the child may be dazed and yet quite conscious, with mental faculties which act clearly but somewhat sluggishly. The whole nervous system seems to be de- pressed, and yet the child exhibits much restlessness. The cutaneous ETIOLOGY 107 and the other reflexes may be absent or markedly diminished. The pupils react slowly, and may be dilated. There is a peculiar pale- ness of the skin and mucous membranes, and the face of the child may look pinched. The skin is covered with a cold perspiration. The respirations are shallow, the pulse weak and rapid, the blood pressure lowered, and the temperature often subnormal. Now, all of these may or may not be present. Certain it is that if but one or two are present we are hardly justified in calling the condition shock. It is the composite picture, the blending of several of these, that the experienced observer recognizes as the symptoms of shock in the child. Etiology. The causes of shock are several, and in a consideration of the subject it is necessary to take up some of these in detail. Injury as the cause of shock is influenced in its importance by several factors: (a) The greater the injury or irritation of the sensory nerves the greater the liability to and the degree of shock. This is true because of the delicacy of the child's tissues and the fact that injuries in- volving similar areas are proportionately more severe in children than in adults. , (b) For quite similar reasons as stated above the site of the in- jury becomes an important factor, and if the injury be small but involving an area well supplied by sensory nerves it is of much more consequence in the production of an unfavorable effect upon the vaso- motor centers than an injury of larger extent in a less sensitive part. Therefore, in the production of shock such injuries are more im- portant. (c) The kind of injury is an important factor also. It has been demonstrated time and time again, experimentally and clinically, that dragging injuries (particularly if directly or indirectly affecting an organ) are most disastrous in their effects. Thus it will be seen that O / blunt dissection, tearing, or any rough manipulation of the tissues will invite shock. If we were to place these in the order of their importance drag- ging injuries would be placed at the top of the list and far beyond any other in point of importance. Even if involving the most sensi- 108 SHOCK live parts, if the injury be extensive but not of a crushing, rolling, or dragging nature, it is much less liable to produce shock in children than the dragging of an organ or of its attachments even if the organ itself escape serious injury. Hemorrhage has always been recognized as an important factor in the production of shock, and this is of special force in children. Irrespective of the fact whether the blood pressure is reduced to any considerable degree or not, the mere loss of blood will prove sufficient in young children to bring about shock. And this is further influenced by the rapidity with which the blood is lost, for if an ounce of blood is extracted rapidly shock is much more intense than if a similar amount escape slowly. Exposure to cold is not always recognized as an important factor in the production of shock, and yet in childhood its influence is large, it being a close second to hemorrhage. Such exposure may take place in the operating room from an unequal temperature, or may follow removal to the recovery room, which may have a tem- perature which is very diiferent in degree from that of the operating room. Not infrequently exposure takes place while the patient is being removed from table to bed, and the adjustment is not made efficiently. Exposure to heat becomes a factor in the production of shock through the influence of burns which are more or less extensive, or by exhaustion due to summer heat. The duration of the anesthesia often becomes a factor in the pro- duction of shock, for prolonged anesthesia is never well borne by children. The present fact that the child is "taking the anesthetic well" is never a good reason why its administration should be need- lessly prolonged, for the present in anesthesia does not foreshadow the future. It is not an uncommon experience to find that a child taking the anesthetic well suddenly gives evidence of shock. Tnis may prove mild or become alarming. The duration of the operation is somewhat closely allied to the duration of the anesthesia, but not essentially so. If it became a question of choice as to whether to prolong the anesthetic or hasten the operation with its consequent rapid and therefore necessarily less TREATMENT OF SHOCK 109 gentle handling of the tissues, we would emphatically advise the prolongation of the anesthesia. Fear and dread of either the operation or its consequences are of course entirely absent in infancy, and many believe that this ex- tends well into the period of later childhood. It is not so. Older children have intense and lively imaginations, and these have com- monly been unguided, so that even with but little to work upon the child can conjure up situations which are purely imaginary, but which are so real to the child as to result in shock. Of course this factor is under more perfect control of the surgeon than in adults, because, with sufficient tact and judgment the child can often be kept in entire ignorance of what may be impending. However, to belittle this factor in children is to lose sight of something which it is well to keep in view. Anemia most certainly conduces to the production of shock, and this undoubtedly comes largely through the fact that the anemic child is always muscularly weak and lacks nerve tone. It is a factor which demands consideration, and a blood examination would al- ways give to the surgeon an estimate of its probable influence. Treatment of Shock. The treatment of shock resolves itself very largely into an avoidance of those factors which are known to pro- duce it, or, at least, the institution of measures to limit their in- fluence. To some extent the nature and extent of an injury are beyond the control of the surgeon, but, on the other hand, when an operative procedure is necessary much may be done to limit or prevent serious injury. Even in the apposition of injured or torn parts the surgeon can be very delicate in his manipulation, and it is his duty to be so whether the child is under an anesthetic or not. Unnecessary or rough handling of any tissues should be avoided. And especially should dragging or pulling manipulations be forbidden; we say "for- bidden" because the active offender is usually the surgeon's as- sistant, who is entrusted with retractors and forceps. It is necessary then that the instruments used be those of a suitable size, and the handling done in such a manner as to limit as much as possible injury to tissue, and especially all such injury as results from pull- 110 SHOCK ing. Almost ranking with the injury in importance as a factor in shock is hemorrhage, and the control or limitation of this becomes a very important element in the treatment of shock. To avoid repetition the reader is referred to the chapter on "Control of Hem- orrhage" (see page 84). To limit the dangers from exposure to cold there must be ade- quate protection of the child during and after the operation. Only the field of operation should be exposed, and the rest of the body must be amply covered to prevent any possibility of chilling of the surface. When the operation is to be one of considerable severity or length the child should be further protected by hot water bottles, or, in some instances, a warm water mattress may be desirable. Everything must be done to avoid having the surface remain wet, and, therefore, there must be provision made for the liberal use of hot, dry, sterile towels. The bed of the recovery room must also be suitably warmed and the child protected from dampness. To limit the duration of the period of anesthesia it is necessary to make provision for every possible emergency in addition to plan- ning the arrangement of the room, the instruments, and the instruc- tion of the assistants and nurses in their respective duties. To limit the consequences of undue fear or dread all planning in regard to the operative procedure should be done without the knowl- edge of the child. If any considerable degree of anemia is present (as evidenced by the blood examination) the operation should be delayed, if it be one of election, until the percentage of hemoglobin can be raised to a safe and satisfactory standard. There is no need of our advising that extra precautions be taken against exposure to cold and to hemorrhage, for we are strongly convinced that it is the clear duty of the surgeon to always give the strictest attention to these details, and this should be done irrespective of whether anemia is present or not. The further treatment of shock in children involves those meas- ures which are generally recognized as efficient in restoring a normal equilibrium when, through the influence of one or more of the causa- tive factors of shock, this has once been disturbed. The dorsal TEEATMENT OF SHOCK 111 posture, with the head low and the feet elevated, should be main- tained, but in doing so the most gentle measures must be adopted in restraint. For a short time the child's body may be placed at an angle of about 45 degrees. Artificial heat is usually necessary to maintain the normal temperature. The administration of oxygen may be necessary, and is always desirable when an anesthetic has been used. Small doses of morphia subcutaneously act remarkably well as a sedative and heart tonic, and allay restlessness and pain after the child has become conscious. If the degree of shock is great the limbs may be bandaged to- ward the heart with cotton underneath the roller bandage. The value of normal salt solution is very great in some instances, and its subcutaneous administration at a temperature of from 105 to 110 F. should be tried, and particularly if much hemorrhage has taken place. In urgent cases the solution may be given intravenously. SECTION V CONSTITUTIONAL AFFECTIONS WITH A SURGICAL ASPECT CHAPTER XXI HEMOPHILIA Hemophilia is a disease in which there is a marked tendency to excessive bleeding from the slightest wound, or, in its more exag- gerated form, the hemorrhage may be spontaneous. Such children are known as "bleeders." Etiology. The hereditary factor in the disease is very marked, and it has been reported as traced through six or seven generations. The disease is most frequently transmitted through the mother, and, although transmitting it, she may remain free from its influence. This is important to remember in taking the history. More males are affected than females, the proportion being 12 to 1. The exact nature of the disease is still uncertain, and patients affected with it show no other abnormality which can be connected with the disease. Isolated instances have been reported where there was a complete failure to trace a hereditary factor. It is a peculiar fact in the transmission of the disease that a woman herself free from the dis- ease, but with family taint, may marry a perfectly healthy man and her daughters remain free from the disease, while all of the sons are affected. The disease is more prevalent in cold than in warm climates, and in certain communities it seems to be particularly more common (probably on account of intermarriage). Usually the first symptoms are noticed during the first two years of life, and if the child shows no tendency to it during the first eight or ten years he may be .considered exempt. 113 DIAGNOSIS 113 Pathology. It has been contended that there exist an unusual thinness of the walls of the arteries and some degenerative changes, but this is far from, proven. The most that can be said is that the pathology is unknown. Symptomatology. The symptomatology is simple. The child receives a scratch, abrasion, or slight injury, and this is immedi- ately followed by excessive and sometimes uncontrollable hemorrhage. There is usually no marked hemorrhage, but a profuse and steady oozing ; and this may last for several days. Sometimes the oozing may subside completely for a few hours or it may markedly diminish, only to be continued after a short time. In some instances spontaneous hemorrhages take place, and in these cases, in which direct injury is not a factor, there are very apt to be prodromes, such as a full feeling in the head, dizziness, dis- turbances of hearing and of vision, and similar indefinite symptoms which all subside as the hemorrhage takes place. In these cases petechia, hematoma, and ecchymoses are common, and bleeding from the mucous surfaces is very apt to occur. There are at times cases in which large effusions of blood are detected into the joints, and this occurrence may be accompanied with or without fever. The symptoms present after the bleeding has stopped are those which would be present in the same child under other conditions of severe hemorrhage. Diagnosis. The history of the case, the uncontrollable hemor- rhage, the character of the hemorrhage, and the slight injury which causes it are usually sufficient factors to establish the diagnosis. Hemophilia must not be confounded with hemorrhagic disease of the new-born, which shows but slight tendency to predominate in boys, and which is evidenced within the first days after birth in the form of multiple hemorrhages. If the infant lives, within a few days any operative procedure (such as circumcision) may be undertaken without unusual hemorrhage. Bleeding from the umbilicus is common in hemorrhagic disease, but is very rare in hemophilia. When there is a joint involvement the case might be mistaken for one of scurvy, when hemophilia is the real cause of the lesion. 114 HEMOPHILIA The dietetic treatment would have a rapid effect in scurvy, but absolutely none in hemophilia. Prognosis. This is worse in males than in females. The longer the child lives the better the prognosis, as the liability to the occur- rence of hemorrhage decreases with age. Treatment. The marriage of bleeders should be prevented when- ever possible, and this is especially true of the daughters. In the case of a child known to be a hemophiliac every precaution should be taken against the occurrence of injury. At the first appearance of hemorrhage, or the appearance of prodromes, the child should be placed in bed and guarded against all physical and mental excite- ment. If the hemorrhagic part is accessible gentle pressure should be applied. Practically every known styptic has been used, but all with about the same results : ineffectual. Adrenalin, 1 : 1,000, applied directly to the hemorrhagic point has claimed the most advocates recently. Ergot, iron, and cocain all have their sponsors. Gelatin solutions may be tried by mouth, but the subcutaneous use of it must be avoided, as, even with the greatest caution, tetanus may result, and the injury caused by the needle opens another avenue for profuse hemorrhage. The application of ligatures and sutures has proven a failure because of the subsequent slough which is almost inevitable and the renewal of the hemorrhage thereby. It has long been recognized that the serum which separates from clotted blood contains something which favors coagulation of blood. This has led many investigators to experiment with various sera, and with somewhat widely varying results. There are so many questions that still remain unsettled, and there are so many factors of which we know little, that we may say that the experimental stage is not yet over. If it can be freshly obtained ; that is, within a month of its with- drawal from the animal, diphtheria antitoxin may be used. What- ever serum is used, there should be injected about 10 to 20 c. c., and this may be repeated several times if necessary. The fresher the serum, however, the more certain the result. Fresh rabbit serum is particularly serviceable because quite easy to obtain. Leary's method EACHITIS 115 is to shave the chest of the rabbit over the sternum and left side, and with an ordinary antitoxin needle puncture to the left of the sterum about 1 cm. above a line drawn transversely at the junction of the sternum and ensiform, thrusting the needle toward the middle line and slightly upward. This punctures the left ventricle and about 30 c. c. of blood is withdrawn slowly and collected in sterile centrifuge tubes. After a short period in the thermostat the clot is separated by a platinum needle, and the material shaken in an electric centri- fuge and the serum withdrawn. Subcutaneous injection is the pre- ferable method. More recently there have been many experiments carried on with fresh blood withdrawn from some blood relation, and this directly injected into the patient, and the results have seemed to warrant a much more extended trial. When blood serum is needed for any hemorrhagic condition oc- curring during childhood the most rational procedure to us seems to be to withdraw the needed blood from some healthy member of the immediate family, and to obtain the serum from this. The procedure is simple, the fresh blood is always obtainable, and the chances of failure are materially reduced by such a procedure. We have had splendid results by this method in purpura of the various degrees. Direct blood transfusion is indicated in the severer cases using vein to vein anastomosis if practical. CHAPTER XXII KACHITIS (Rickets) This is one of the commonest diseases of childhood, and one which must have a large interest for the surgeon. Popularly it is supposed to exist chiefly among the poorer classes in large cities, and if we simply gave attention to the more marked manifestations of the disease as evidenced by deformity this would seem, to be true. 116 EACHITIS But if the earlier and less prominent symptoms of the disease are known and recognized it will be found to exist commonly, even in the children of the well-to-do. This is all the more surprising when we recall that few diseases are so easy of prevention. This efficacy of preventive measures exists despite the fact that there are many problems in the etiology of the disease which we do not understand. The effect of the disease upon the manner in which the affected child responds to in- jury, infection, or dis- ease is such that no one who is treating chil- dren can overlook. This influence is so great that one should be so perfectly familiar with the earliest mani- festations of the disease and the causes which lead up to it that he will not be misled by symp- toms of other diseases and injuries as they are exaggerated or marked- ly modified by the pres- ence of rachitis. Etiology. W h i 1 e , for practical purposes, it may be assumed that rickets is a dietetic dis- ease, there are many contributing factors which must be given recog- nition. These contributing factors are : (a) RACIAL. The disease is. much more prevalent among the Italians and negroes and, irrespective of the activity of the cause in these races, there is always a more marked type of the disease. This racial susceptibility may, however, be due to another factor, namely, poor hygienic surroundings. FIG. 42. SIDE VIEW OF RACHITIC BOY. The enlarged wrist and elbow are well shown and the flabbiness of the muscles is evidenced by the marked flattening of the buttocks. This flabbiness is one reason why the bones are so easily distorted as they lack muscular protection and support. ETIOLOGY 117 (b) POOR HYGIENIC SURROUNDINGS. The varied manifestations of the disease are seen most commonly among children who are poorly housed and with hygienic surroundings which are not the best. (c) DIGESTIVE DISTURBANCES. It is quite evident that if a chronic state of indigestion is allowed to continue, or if acute attacks of the same are frequent, no matter what may be the manner of feeding the infant, rachitis is almost certain to be evidenced later on. FIG. 43. RACHITIC DEFORMITY. '"| FIG. 44. RACHITIC DEFORMITY. Of course we must not lose sight of the fact that digestive disturb- ance is commonly the accompaniment of rachitis. (d) DIET. The influence of heredity and of syphilis as etiologi- cal factors is doubtful. Of most importance, however, is the dietetic cause. The question at once arises as to what definite fault in the diet causes the disease. This, we believe, can be answered in the follow- ing way : It is caused by a deficiency in the assimilation of the fats. Of all the diets which have been assigned as active causes of 118 EACHITIS rachitis condensed milk easily takes the lead, with cow's milk diluted too much a close second, and patent foods, starch-containing foods, breast milk combined with starch-containing foods, and breast milk alone following in the order named. Let us consider these more in detail. Condensed milk diluted, as is ordinarily suggested, is rich in sugar but very deficient in fat. The excess of sugar has repeatedly been blamed as the element at fault, but this is disproven by two facts ; in those instances in which fat is added to the mixture in the form of cream (the sugar percentage remaining the same) rachitis is not apt to develop, and if the dilution of condensed milk is greater than that ordinarily recommended (thus causing reduction in the sugar percentage also) rachitis will quickly develop. In this instance, then, it is not an excess of sugar, but a deficiency in fats. Cow's milk may be diluted too much, and this will result in a reduction of the fats, proteids, and sugar. But even with a dilution with equal quantities of water the fats and the sugar suffer while the proteid still remains near to what is normal in breast milk. This would indicate that the proteid is not the element at fault, and, as we have already mentioned the facts in regard to sugar, it would seem, that here,'too, the fault is a fat deficiency. The patent foods are rarely used correctly. The usual method is to make the infant's digestive power accommodate itself to some par- ticular formula for a given age, and if it seems to agree no further effort is made to determine how well it agrees. Thus, in nearly every instance, we find that where a patent food is given it is diluted too much for the individual needs of the infant, and, even if suited to the case in question, the food is deficient in fat. It will be found that those patent foods which are followed in the smallest number of instances by rachitis are those in which the attempt has been made to bring the fat element up to a higher standard. Starch-containing foods become factors in the causation of ra- chitis in this manner: they are given to the exclusion of the proper amounts of fat in other food. For instance, when an infant is given bread, potato, or other starchy food freely, foods which contain fat are not taken in sufficient quantity to meet the demands of the sys- ETIOLOGY 119 tern. In such cases starch excess means fat deficiency. Further than this, an infant given an amount of starch which is not easily digested soon loses its power of assimilating food in general, and thus its diminished intake of the fats is exaggerated by the inability to digest and assimilate them. Breast milk combined with starch-containing foods must come under the same analysis as the fore- going (starch-containing foods), and the fault is similar: starch excess caus- ing failure of assimilation. Breast milk alone as the diet may result in rachitis if the milk is poor in quality or if breast feeding is persisted in until it becomes so. In practically every in- stance an examination of the breast milk will prove decided departures from the normal. Many times the mother will be found to be poorly nourished or pregnant. We have sometimes met cases in which it was impossible to explain satis- factorily the occurrence of rachitis, either upon the theory of fat deficiency or any other basis. However, thess few instances need not detract from the value of the fat deficiency theory, nor need they make us lose sight of the F 45 practical application of such a theory in treatment : the giving of fats. Of all the methods used in con- trolling this disease authors are practically a unit in the adminis- tration of cod liver oil, although some use other oil as being mere easily digested. However, the principle is the same: the administra- tion of fats. As was stated earlier in this chapter, long-continued or frequently repeated disturbances of digestion lead to the development of ra- RACHITIC DEFORMITY IN CHILD OF FIFTEEN MONTHS, WHOSE PARENTS NOTICED NOTH- ING WRONG EXCEPT THAT INFANT COULD NOT WALK. 120 RACHITIS chitis. The fault which underlies may be any one of the various fac- tors, and through its influence in disturbing the digestion may result in fat deficiency through imperfect assimilation. Not as uncommonly as supposed the real cause of the deficiency may be the excess of fat in the food. A very high fat percentage in a food may cause a considerable gain in weight for a time, but this cannot continue, for the disturbances of digestion become frequent. Assimila- tion then suffers and there is fat deficiency. Rachitis may therefore occur because of this excess of fat. To sum up, then, the dietetic cause and the practical application of treatment which is immediately beneficial in its re- sults are best explained upon the theory of deficiency of fat, whether that deficiency is due directly to a percentage reduction of the fat or the inability to assimilate it. Age Incidence. This is very difficult to determine because the disease begins so insidiously, but it is a fact that has been noted repeatedly that evidences of the dis- ease are more apt to appear during the second year than the first. The usual time for the appearance of the first symptoms is between the sixth month and the fif- teenth, and the later periods show the most cases. This suggests the value of diet in its prevention, and will be taken up under the treatment. Symptoms. Of slow development and insidiously appearing, it must be evident that the first symptoms of rachitis are difficult of detection. But, on the other hand, the failure of detection is fre- quently due to neglect in paying heed to the less prominent symp- toms. EARLY SYMPTOMS. Anemia is the most constant early symptom FIG. 46. COMPARATIVE CON- TOURS OF THE NORMAL (UPPER FIGURE) AND THE RACHITIC (LOWER FIGURE) STOMACH. These figures were drawn after the stomach had. been out- lined and are a composite outline of the stomachs of twenty normal and twenty rachitic infants of practi- cally the same ages. SYMPTOMS 121 of rachitis, and if it is evidenced in an infant who is apparently otherwise well nourished it should excite our attention. There is nothing which may be considered as characteristic about this anemia, for there is the usual symptomatology, and examination of the blood shows the usual findings of an anemia. Associated with the anemia there is a muscular flabbiness which is usually marked. The infant may appear to be well nourished and fat, but there is no effort made to make a good healthy use of muscles which are apparently well developed. The head will not be held up firmly, the musculature of the back is weak, the little one may not attempt to sit up, or it may do so unsteadily and exhibit all the signs of muscular weakness. Constipation is the rule because of muscular atony associated with a faulty diet. The general muscular flabbiness may also be demonstrated by palpation. The poorly nourished skin becomes soft and easily irritated. Sweating about the head, particularly when the infant makes the effort of nursing and during sleep, is an early accompaniment of anemia. This sweating may be the first symptom to indicate that there is something wrong. As the head is held un- steady and allowed to roll from side to side the hairs are broken off at the occiput, and results in baldness in this region. With any of these symptoms present a carefully taken history will reveal that the infant has been for some weeks or months previously restless at night, has suffered frequently from rhinitis (owing to the frequently moist head), and has been constipated. An unusual fretfulness is evidenced in most infants, but there is no evidence of tenderness or pain, the fretting continuing under varying circumstances and ir- respective of handling or pressure. Dentition is usually delayed, and the first tooth may not appear during the first year. If there is delay in the eruption of the teeth it should excite our suspicion of rachitis as the possible cause, and this is especially true if there is a deviation from the normal in the order of the appearance of the teeth after they have once started to erupt (see page 16), or if there is evidence of early decay or irregu- lar alignment. LATER SYMPTOMS. As the disease continues all of the foregoing KACHITIS symptoms are intensified and others are added. These later symp- toms are the most characteristic ones, and show the severity of the disease; they are the ones of most interest to the surgeon. Usually the first detectable change in the bony structure is a beading of the ribs, or, as it is commonly called, the "rachitic rosary." The bead- ing is most marked in the fifth, sixth, and seventh ribs, and consists of the formation of nodules at the junction of the costal cartilages and the ribs. Sometimes this beading is very slight and remains so even though the disease be severe and the other symptoms marked. Most of the slightly developed ro- saries are explained at autopsy, when it is found that the nodules are chiefly upon the internal sur- face. In average cases autopsy does not show that there is much difference in development betwoen the anterior and the posterior sur- faces. Beading is first detected by palpation, and as it develops it may be readily seen. Thickening of the epipliyseal junctions of some of the long bones, particularly at the wrists, ankles, and knees, soon follows the changes in the ribs. It is due to a similar condition: excessive and irregular proliferation of cartilage cells and ossification. At first there is a knob-like enlargement, which is noted by palpation, and later on is visible. This enlargement lies exactly in the line where epiphysis and diaphysis join. The stature of the infant is but little affected by this bony change, and this is re- markable, considering that this is the point at which the growth in tho length of the bone chiefly occurs. Children are stunted in their growth through the influence of rachitis, but in nearly every instance FIG. 47. TYPICAL CASE OF RICKETS. Note the enlarged wrist, ankle and knee joints, the pendulous abdomen, um- bilical hernia, deformed chest and evident flabbiness of the musculature. SYMPTOMS 1-33 this stunting can be directly traced to bending or distortion of the bone itself. The nodules are never painful or tender. The head of the rachitic child is quite characteristic. It appears to be out of proportion to the size of the body, and an actual enlarge- ment may occur as the result of thickening of the frontal and parietal protuberance. The head assumes a somewhat square shape, being much flattened at the occiput and the vertex. Not uncommonly the bones are so deeply grooved that it is an easy matter to trace the whole course of a vessel over the skull with the finger. This change in the shape and size of the head does not seem to influence in any degree the mentality of the child. Rachitic children are unusually old-fashioned and apt to be precocious, but this is due to the close association with adults and the limitation of their activities among chil- dren of normal physical development. There is usually a marked delay in the closure of the sutures and the fontanelles. From what has been said it will be ob- served that there is a widespread deficiency in FlG 48 ._ CO MPARATivE the nutrition of the bones. The results of this CHEST CONTOURS. , f, . . 1-11 Solid line represents the deficiency are various mechanical changes m normal chest and the the shape of the yielding bony structures, and therefore a change in the body contour. Some of the changes are due to muscular action, some to superin- cumbent weight affecting the bone, and others to atmospheric pres- sure and gastric and intestinal fermentation. Changes in the shape of the chest are very common, the usual one being that the chest is shortened and the sternum forced downward. The portion of the chest near the junction of the ribs and the cartilage is depressed, and this tends to force the lower portion of the sternum forward to a more or less marked degree. The costal angle is commonly quite acute. The vertebrce are not as hard as usual, and the laxity of the mus- culature makes adequate support to the trunk impossible. This results in bending of the spine and, following the law of gravity, the 124 RACHITIS body is bent so that the spinal column is arched with the convexity backward. A rachitic curvature is general and not localized as in Pott's disease. Rotary curvature is very uncommon. If the infant be under the age of six months craniotabes may be present. These are soft spots in the cranium, which are generally situated over the occipital or posterior portions of the parietal bones, are from one- quarter to three-quarters of an inch in diameter, and upon pressure give to the examining hand a sensation like the crackling of parch- ment under the fingers. After six months crani- otabes are very unusual. The secondary changes in the lonij bones are mainly no- ticeable in the legs. There may occur an outward bowing of the tibia and femora, re- sulting in bowleg, or the opposite condition may occur and knock- knee be the result. Bow- leg is mainly due to the mechanical conditions Fio. 49. TYPICAL BOWING OF THE LEGS IN A RACHITIC CHILD. Note also the enlarged ankle joints. affecting a weakened bony and muscular structure, while knock- knee is dependent upon hypertrophic growth causing the tibia to form an obtuse angle with the femur. Very distressing and deforming changes may occur in any of the long bones, and while the arms are not so markedly affected as the legs, yet they do not escape. In the pelvis the commonest deformity is a shortening of the anteroposterior diameter. The abdomen is a prominent feature of rachitis. It is enlarged and tympanitic. There are several causes for this condition ; the dim- SYMPTOMS 125 inislied thoracic cavity causes a downward pressure of the diaphragm, while the eversion of the lower ribs forces the liver and spleen downward. The laxity of the abdominal wall makes resistance to this pressure but slight. There is also almost constant fermentation going on in the intestines, and the abdomen is thus distended until finally all portions are involved. The result of this distention, com- bined with the deformity of the chest, forms a groove which divides the upper and narrow part of the chest from the lower and dis- tended portion (that below the diaphragm), forming what is known as the rachitic girdle. This girdle is usually not present in the early stages of the disease, however. The rachitic child is notably one who is the subject of an easily deranged digestive system. The gastrointestinal tract fails to per- form its functions properly, so that there is a strong inclination to chronic meteorism. Diarrhea is not of necessity associated with chronic intestinal catarrh, which is the common accompaniment of this disease, although such is commonly the case. The lack of tone of the abdominal musculature seems to be a predominant factor, and therefore there is usually a history of constipation, except during the heated term, when the rachitic child is particularly prone to serious diarrhea. The respiratory organs also exhibit a marked tendency toward oft-repeated or chronic catarrhs, so that the child is constantly in danger from the occurrence of serious disease. The nervous symptoms are many and varied. Restlessness at night is one of the earliest. Attacks of laryngismus stridulus, tetany, or convulsions are not uncommon, and of the first two of these we may say that they occur most often in rachitic children. The susceptibility of the rachitic child to convulsive seizures is so marked that the slightest cause will sometimes bring about an at- tack. In each case, of course, all of the associated symptoms will dif- fer ; in one infant it may be the mucous surfaces which suffer most, in others the respiratory tract, the nervous system, or the digestive tract, and the manifestations of the disease will depend largely upon this factor and the age of the child. Active symptoms usually per- 126 KACH1TIS sist for from two to fifteen months, but may continue for longer periods. Diagnosis. It is only during the earlier periods of the disease that the diagnosis is difficult, and even then, after taking a full his- tory of the previous conditions surrounding the child, particularly in regard to the nutrition, there is little chance for an error in diag- nosis. An apparent difficulty has arisen through the fact that several observers have given widely divergent figures in reporting the fre- quency of the disease, but we must recall that it is only recently that FIG. 50. LEG OF RACHITIC CHILD. we have had any clear idea of just what the disease is, and in some places even this knowledge does not appear to be wisely circulated. All of the earlier symptoms (anemia, restlessness at night, head sweating, occipital baldness, craniotabes, delayed closure of the fon- tanelles, delayed dentition, muscular flabbiness), taken singly, may mean something entirely different from rachitis, but, with several such symptoms present and a history of faulty feeding, they can mean nothing else than this disease. It is the undue prominence of some one symptom that is misleading. There may, for instance, be a most profound anemia with all of the other symptoms slight and such bony changes as are hardly noticeable. Associated with a large spleen such symptoms might readily lead to an erroneous diagnosis. It is this special incidence of the disease against certain tissues DIAGNOSIS 127 that delays or complicates the diagnosis. One child is brought to the surgeon because of the large abdomen, another for the change in the shape and size of the head, and these particular symptoms are emphasized above all else. The examination may show but little bony change, but the symptoms are none the less directly due to rachitis. The head enlargement may for a time simulate that of a slight hydrocephalus, but in the latter the forehead is more overhanging and prominent and the whole breadth of the cranium is increased. Any interference with the mentality should suggest the possibility of hydrocephalus. FIG. 51. CRANIAL CONTOURS (COMPARATIVE): ANTEROPOS- TERIOR-ClRCUMFERENCE-TRANSVERSE. The upper figure represents the hydrocephalic head and the lower figure represents the rachitic head. If bony changes are slight and the musculature is markedly af- fected (which is not unusual) there may be a marked similarity to paralysis. This is determined by a study of the electrical reactions and the presence or absence of the various superficial reflexes. The possibility of mistaking syphilis is rather remote, for in the beginning the lesions of syphilis are more like soft infiltrations over the bones, and the part affected is not the end of the bone,' but the junction of the shaft and the epiphysis, or, later in the disease, the shaft itself. The history of the two diseases is entirely different, and the bony changes are much earlier in rachitis than in syphilis. 128 RACHITIS A rachitic type of skull occurring without any of the other evidences of rachitis should at once suggest the probability of syphilis as the cause. Treatment. The prevention of rachitis rarely comes within the province of the surgeon, and yet its main principles must be under- stood if he is to successfully attack the disease as it is exhibited in the form of deformity in the neglected cases. These will be very briefly considered. The surest way to pre- vent rachitis is to give the infant breast milk. If this is impractical because of conditions affecting the mother or her milk, a wet-nurse may be secured, but if this latter also be impossible the infant should be fed upon fresh cow's milk, modified but not pasteurized or ster- ilized. The latter methods of treatment of the milk are entirely un- necessary if the milk is clean to start with, and such treatment of the food can occasionally be "traced as the direct cause of those cases that formerly were classed under the term ''scurvy rickets." These borderline cases do not do well on anything but the fresh cow's milk. But fresh milk must be properly modified, so that the fat content is sufficient for the infant's needs. To avoid unnecessary repetition the reader is referred to page 120 for elucidation upon this point. The hygiene of the infant must be the best obtainable. When the first symptoms appear, no matter how slight, every precaution must be taken to secure the proper hygienic care and food for the needs of the particular infant under observation. Fresh air and sunshine in abundance are absolutely necessary ; the latter all day and the former day and night. These are of great importance, because they have such a marked influence upon the general nutrition of the child. If breast fed, the mother's milk should be examined and the deficiency corrected if possible. If lactation has been unduly pro- longed, or there is a barrier to the correction of the deficiency, ac- cessory feeding must be considered. With the breast milk as the basis for working it out a formula of modified fresh cow's milk should be given suited to the particular child's needs, and as rapidly as is consistent with safety the breast may be withdrawn in favor of the artificial feeding. TREATMENT 129 If the infant is artificially fed an inquiry must determine the deficiency or fault in the feeding, and this must be corrected. This will require that all of the well-known principles of scientific infant feeding be followed with clearness, precision, and system in each individual instance. In this the surgeon will often require the aid of the pediatrist. No care or attention to detail in this matter of hygiene and food can be too exacting, for even an occasional relaxa- tion of persistent effort may result in some complication which will prove disastrous to the infant. While there are instances where the detec- tion of the fault in the diet is very difficult, they are few; in nearly every case the dietetic fault is one that is so evident that it cannot be overlooked. The general principle is to give the fats up to their maximum limit, with great caution that they are not disturbing the digestion and are being properly assimilated. The proteids may also be given up to the standard for the aver- age healthy infant of the same age, but the carbohydrates are to be kept somewhat below what would be normal and are never allowed to interfere with the ingestion and assimilation of the fat, which is the all-important element. Much can be gained by the administration of cod-liver oil or, in fact, any oil that is well tolerated by the diges- tive system. In the giving of the oil the minimum dose should al- ways be given, and as it is observed that it is well tolerated (causing no nausea or digestive disturbance), it may be cautiously increased. Five or ten minims well tolerated is far superior to a dram or more poorly digested. Phosphorus has many advocates, and, while there seems to be much to be desired in the explanation of its effect as well as in its clinical results, it may be used judiciously in conjunction with other treatment (1-100 to 1-200 grain three or four times daily). As the drug is usually prescribed in oil we are often left in doubt as to just FIG. 52. M A R K E D RACHITIC DEFORMITY. 130 SCORBUTUS what credit should be given to the vehicle in the apparently good results in some cases. On purely theoretical grounds calcium may be given (calcium phosphate precipitated or calcium hypophosphite) mixed with the food. There is absolutely no value in giving lime water in the food to obtain the effect attributed to calcium. The anemia is combated with fresh beef -juice and the adminis- tration of iron. Realizing the ease with which deformity occurs through undue muscular effort or mechanical factors affecting the bony structures, it is absolutely necessary to control the activities of the child while there exists the danger of deformity. For this purpose it may even be necessary at times to use splints combined with other enforced rest, but restricted activity usually suffices. But if deformity has already occurred, what should be done ? If effectual means are taken to prevent mechanical factors from further action it is sometimes remarkable what marked improvement takes place in the part. Rest combined with massage and gentle pressure often accomplishes much in the limitation of deformity. The regional treatment of deformity due to rachitis is fully con- sidered under the several regional headings. CHAPTER XXIII SCOEBUTUS While the occurrence of this disease was noted occasionally as far back as the seventeenth century, yet it is only within quite recent years that it has been thoroughly understood and recognized gener- ally. It is the same as the old-time scurvy of sailors, and is brought about by the conditions of modern life. The disease is a constitu- tional malnutrition, and is evidenced chiefly by anemia and a gen- eral hemorrhagic tendency, all of which are definitely connected with a dietetic fault. Its close association with rachitis in infancy has led to much misunderstanding of both diseases, but especially of scorbutus. Age Incidence. The knowledge of the age incidence of the dis- ease may be of considerable aid in the recognition of scorbutus. Its ETIOLOGY 131 onset is practically limited to the last half of the first year of life, and in the great majority of instances its first symptoms arc noted between the sixth and the ninth months. So constant and pro- nounced is this age incidence that if an infant between the ages of six months and one year exhibits any tenderness of the limbs or re- fuses to use them as actively as usual, it should suggest the possi- bility of this disease. However, this fact must not vitiate the further fact that more uncommonly scorbutus may attack the infant of four or five months, or may be delayed in its appearance until well into the second year of life. Etiology. Unlike rachitis, which is most frequent among the poorer classes and certain races, scorbutus shows special preference for the middle and richer classes. There is some explanation for this in the fact that it is unusual to find that the infant among the poorer classes is exclusively fed upon one article of diet, and this immediately brings us to a consideration of the most important etiological factor of all : the diet. As a matter of fact, the diet may be stated as being the sole cause of the disease. From time to time every element of the food has been assigned as the probable cause, and mother's milk, which is the ideal infant food, has several cases of scorbutus charged against it. There is probably no single food that has not been blamed for the occurrence of the disease, and so we find that raw cow's milk has infrequently been assigned as the cause. Peptonized, sterilized, and pasteurized milks all have shown many cases of scorbutus to follow their use. But the large majority of histories of the feeding will show that the infant has been fed exclusively upon one of the patent foods or con- densed milk, and this has suggested the theory that an infant food that is treated so as to preserve it in the operation, loses something which is essential to the perfect performance of nutrition. In other words, the lack of a fresh food seems to be the common factor in the cause of scorbutus. The theory is that the antiscorbutic agent in a food is something which is vital and is destroyed by the proc- esses (prolonged or excessive heat) which are sometimes necessary to its preservation. At the present time, however, irrespective of theory, we must 132 SCORBUTUS accept what thorough investigation has seemed to prove: that scor- butus follows the prolonged use of any food that is unsuited to the infant's needs ; that there are therefore certain kinds of food which must result eventually in the disease, and that the further removed the food is from the natural nutriment of the infant the more cer- tain is the disease to occur. Pathology. Fatal cases are rare because of the striking results of treatment, but in the few instances in which autopsy has been performed the changes that have been found are almost all due to hemorrhage. Under the periosteum of the long bones are found hematomas which have stripped the covering from the bone. There may be separation of the epiphysis in aggravated cases. The sub- periosteal hemorrhages are most commonly found about the shaft and the lower end of the femur, but may occasionally be found over the tibia and other long bones. The bone structure about the epiphy- sis is always congested and hemorrhagic. Hemorrhagic spots are common in the skin, the pleura, pericardium, the liver, spleen, and other viscera, and subcutaneous hematomas are frequent. The gums are swollen, hemorrhagic, and edematous, and the teeth are loosely attached. Symptomatology. Swellings of the gums, with or without a ten- dency to bleed, pain in the joints, and swellings about the limbs are the most prominent symptoms of a well-advanced case of scorbutus. But the classic symptoms must not. mislead the surgeon, for long before these appear it is possible to recognize the disease. Many of the cases begin most insidiously, so that weeks may go by before there is any marked manifestation of the disease. If an infant has been for a prolonged period fed upon a proprietary or other food, and begins to exhibit stationary weight or a failure to keep up the usual steady and consistent gain, is fretful and uneasy, and the food does not seem to agree as well as formerly, that infant should be sus- pected of having scorbutus. Such symptoms strongly indicate that conclusion, and two or three days' treatment with an antiscorbutic diet (see page 137) would absolutely prove it. As the same diet that causes scorbutus may be so deficient in fat as to favor the develop- ment of rachitis, we not uncommonly find the two diseases in com- SYMPTOMATOLOGY 133 bination. However, this must not be assumed as an evidence that the two diseases have any relation between them; they are entirely distinct, but the same dietetic faults may bring about the occurrence of such disease. After some weeks of indefinite symptoms, but such as should arouse suspicion because of the history of the faulty feed- ing, the most striking feature of scorbutus is apt to show itself. This is the tenderness of the limbs, which is more in evidence in the lower than in the upper ones. Coincident with the tenderness or closely following it, there is often palpable or visible swelling of the affected limb, but it must be remembered that this swelling is oc- casionally so slight that it may be overlooked. It is the result of subperiosteal hemorrhage, and therefore it is readily observed that only the most gentle palpation will reveal it. The swelling extends for some distance along the shaft of the bone, and is never limited to the epiphyseal region alone. As has been stated in the pathology, the swellings are mostly found about the lower end of the femur, but may be over any of the long bones, even the ribs. In neglected cases the whole or any part of the bone may be surrounded by these subperiosteal hemorrhages. Rarely such hemorrhages may occur over the bones of the skull and produce large bluish swellings which look like sarcoma. Quickly following the evidences of tenderness, or, in fact, even preceding any such evidence, there may occur a loss of motion of the limb. And just here is where error is made; such cases are commonly not diagnosed as scorbutus, but rheumatism, infantile spinal paralysis, and a host of other conditions are blamed for the inability to move the limb freely. These mistakes should hardly occur, because the tenderness is always acute, and the very severe pain on passive motion, with the swellings and local thickenings, coupled with the history of faulty feeding and the associated symptoms, should make the diagnosis cer- tain. The loss of motion in the limb is due at first probably to fear of pain, but there is soon a mechanical disability in an untreated case. The periosteum is stripped off of the bone by the hemorrhage, and the muscles in the immediate neighborhood may be infiltrated with blood and serum. In less frequent instances epiphyseal separation 134 SCORBTJTUS occurs as the result of extensive hemorrhage, and the disability is complete. The most careful handling of such a limb is the only safeguard against further separation of the parts and the occurrence of fracture. When edema occurs over the affected parts of the limb, as is oc- casionally the case, the subperiosteal swellings cannot be mapped out. The gums also show characteristic changes ; they become swollen and somewhat brighter in color than is usual, with a dark reddish or purple line close to the teeth. When the disease becomes well ad- vanced hemorrhages take place and the gums are very friable, allow- ing the teeth to become much loosened. The condition of the gums is always worse about the site of a tooth. However, this swelling and redness of the gums are not always present, even in cases of moderate severity, and it may require somewhat close examination to detect anything abnormal. The occasional development of this character- istic appearance of the gum behind the tooth, and but slightly in front of it, should lead to an examination of this area in all sus- pected cases of scorbutus. If no teeth have erupted the appearance of the gums is quite different, for hemorrhage is not so likely to take place, and the only evidence may be a few petechial spots over the gum, and particularly over the point where the teeth will first appear. On the other hand, the gums may be markedly affected, and the other symptoms of the disease be but slight in comparison, but such instances are not common. An ecchymosis developed without the clear history of a traumatism in an infant should always excite the suspicion of scorbutus as the cause. Or if an injury is shown, and the local signs due to hemorrhage subcutaneously are out of all pro- portion to the traumatism, it should suggest the same thing. An il- lustrative instance may be of value. We were called to see an infant girl of eight months on account of a fall which she had out of bed, and found that, while the infant had fallen upon her back and did not seem to be harmed, yet there quickly developed an extensive discoloration of the eye, and there was later some bleeding from the mouth. Examination showed that the gums were badly swollen and bleeding, and that there was tenderness in the limbs. The history showed that the infant had been unusually fretful and rebelled against PROGNOSIS 135 any handling for a few days, and the diet had never been anything but one of the proprietary foods. The treatment soon confirmed the diagnosis of scorbntns. Hemorrhages from the mucous surfaces may occur, but these are by no means as constant or noticeable as the more characteristic symptoms. Hematuria is probably present in a large number of the cases, but the difficulty of the microscopic examination and the prompt response to treatment have made this detail one that has been neglected. There is no general rise in the temperature in scorbutus, in fact, pyrexia is decidedly the exception rather than the rule. The occa- sional rises of temperature to 101, 102, or 103 F. are often diffi- cult of explanation, for they are present under so many varying con- ditions and are so short in duration. We must, however, be on our guard in this matter, so that we may rightly give fever its proper value in the matter of diagnosis. It would be an easy matter if associated with edema and fever to attribute the symptoms of scorbutus to an infection, like suppurative periostitis. But subsequent examinations would eliminate this, and if the possibility of scorbutus was carefully considered there could hardly exist any doubt as to the true condition. Diagnosis. Rheumatism may often be considered when scorbutus is the real cause of the symptoms. But the swelling of scorbutus is seldom in the joint itself, but extends up the shaft of the bone. Rheumatism is exceedingly rare in infants, and one need never be long in doubt. There is a real difficulty, however, if a hasty ex- amination is made of mistaking the scorbutus for a paralysis. This will be cleared up quickly by the histories, which are entirely dif- ferent, and the demonstration of the fact that a true paralysis does not exist. Osteosarcoma has in some cases simulated scorbutus when the local signs were alone considered, but the accompanying symptoms of each should make this error impossible. Prognosis. In this disease the effect of treatment is so prompt and so remarkable that there are few diseases which equal it in this respect. Under the proper measures the pain, the tenderness, the 136 SCORBUTUS possible immobility of the limb, and the other associated symptoms clear up to a considerable extent within the first one or two days. After this first striking improvement there is a less marked and yet a steady and rapid improvement in all of the symptoms, so that within one week the infant should be practically well. If there has been thickening about the bone it may take months to entirely disap- pear. Large hematomas may persist for a week or two. Unfavorable factors are the occurrence of a persistent diarrhea and the evidences of a renal involvement (as shown by an examination of the urine), and particularly if there is evidence of pus in the urine. It must be recalled that scorbutus is not a disease which will run a more or less definite course, but is one which will be progressive and chronic in its course, until the appropriate measures are insti- tuted to control it. So unrecognized cases may become so bad that the change in diet causes but a transitory improvement, and the in- fant dies of sheer exhaustion. If already weakened by previous dis- ease then the occurrence of scorbutus in an infant is a very serious matter. Many cases are complicated with pneumonia, and are nearly always fatal. Prophylaxis and Treatment. These two are so closely allied to one another that there is a distinct advantage in considering them together. Prevention of such a serious disease is of prime impor- tance, and prophylaxis demands an intimate knowledge of the eti- ology, which has already been discussed, and careful attention to the details of infant feeding, which would prevent the dietetic fault which causes the disease. We believe it to be excellent practice, and therefore have insisted upon it in our own work, and have recom- mended also in another volume that every infant, whether breast-fed or artificially fed, be given orange juice daily beginning with the end of the third month of life. There is no more certain or simple way in which we can prevent the occurrence of scorbutus than by this method. However, the great value of this measure must not detract from the endeavor which must be made to gradually correct the fault in the diet. Occasionally it may be found that an infant does not tolerate orange juice well, and in such instances fresh grape juice may be substituted. The juice from perfectly fresh beef an- PROPHYLAXIS AND TREATMENT 137 swers a similar purpose, but owing to its stimulating effect its use in infancy is much more restricted than the fruit juices. Given a case in which the symptoms of scorbutus are present, the first procedure must be to change the food. Many different foods have been recognized as the causative factor in scorbutus, and therefore it is not necessary for the handling of an individual case to know all of these. The fact that must be recognized, how- ever, is that the diet that the individual infant is taking is at fault and must be changed. The error in the diet is usually so glaring that, once the surgeon's attention is called to it, it is detected, for the correction of the dietetic faults which bring about this disease re- quires but little exact knowledge of infant feeding. All "dead food" must be discontinued, including condensed milk, sterilized or pasteurized milk, and proprietary foods. The most serviceable substitute for the "dead food" is raw cow's milk prop- erly modified for the age of the infant. Such a food in itself would contain sufficient of the antiscorbutic element to cure the infant, but there are other articles of diet which contain it in greater abundance. Thus we make use of these and give the infant beef juice, orange juice, and potato. The potato, of course, is not used if the infant is very young, but its use is reserved for older infants. The failure of the fruit juices can only be attributed to insuffi- cient dose; the scorbutic infant should have the juice of a moderate sized orange daily, and if beef juice is used it may be given in tablespoon doses night and morning. We might emphasize that the commercially prepared beef juices are absolutely worthless in this disease; the juice must be from fresh (and better uncooked) beef. The potato is prepared by boiling or steaming and forcing through a fine sieve, after which a tablespoonful is given dry or rubbed up with cream or milk, and this dose is administered twice or three times daily. This constitutes the dietetic treatment of scor- butus. The further treatment consists in restricting the activities of the infant so as to protect it from pain and also from possible in- jury. If the limbs are swollen they should be wrapped in cotton and kept in position by a splint if necessary. An excellent plan in 138 SYPHILIS some instances is to place the infant upon a pillow and fasten the limbs with broad tapes; then the infant may be carried from place to place without danger of any injury. The toilet of the mouth should be rigid so as to limit and pos- sibly prevent bacterial decomposition about the gums. After the complete subsidence of active symptoms the nutrition of the infant should be brought up to the highest possible point by a careful and detailed attention to the influence of fresh air, sunshine, hygienic surroundings, a proper diet, and a well-selected tonic suited to the individual need. There is no other disease in which the clinical picture may appear so discouraging and still have such a remarkable response to appropriate treatment by diet and without the use of drugs. Neither is there one in which the application of the proper measures for its relief so completely and immediately confirms the diagnosis. CHAPTER XXIV SYPHILIS This disease, as it occurs during childhood, may be acquired or inherited. ACQUIRED SYPHILIS Acquired syphilis is by far the least common and, in fact, is quite rare, but the possibility of its occurrence in this manner must not be overlooked. The means of its acquisition are many; it may be ac- quired from the mother during the act of birth, it may be that later inoculation from the same source is the cause. Through the contact, accidental or otherwise, with an infected nurse, relative, or friend, through the medium of infected articles, as bottles, toys, and so forth, or by any of the constant means the disease may be acquired by children. In the large majority of the acquired forms the ac- quisition has become possible through innocence or through igno- CONGENITAL SYPHILIS 13!) ranee. However, there are enough instances recorded of precocious children acquiring the disease through the channels of sexual contact with the opposite sex, that this factor must be considered. The oc- casional instance of a primary lesion situated about the anus occur- ring as the result of sexual contact of an infected man gives us food for thought. The possibility of vaccination as the mode of inoculation must be thought of, because in a few instances the humanized virus is still used. Criminal assault is not an unusual means of infection, and in just such cases the utmost skill and precaution must be exercised to differentiate between the congenital and acquired forms. ISTo matter how young the child may be, a somewhat typical course of the phenomena of syphilis, following the appearance of a chancre, or primary adenopathy, is the only substantial proof which we possess that the case is one of acquired syphilis. Snuffles, pem- phigus, and pseudoparalysis are not a part of the clinical picture in the acquired form, while the occurrence of a chancre, no matter what its situation, settles all uncertainty as to the disease being acquired. By whatever means acquired this form of the disease runs a course which is practically similar to that of adult life, with the one exception that it is always a more acute and severe disease, and not uncommonly results in a fatal issue as far as life is concerned. The inability to accurately make the distinction between the two forms may result disastrously to the reputation of some innocent person. CONGENITAL SYPHILIS That inoculation with the disease is possible at the time of con- ception is admitted generally, or the disease may be transmitted at some later period of intrauterine life. These facts have brought about a discussion among writers as to the proper word to use in distinguishing these cases. Many claim that those cases coming under the former heading should be called "inherited syphilis," while the latter class of cases must be termed "congenital syphilis." It is 140 SYPHILIS possible to make this distinction, but is it of practical value to do so ? The manifestations of the disease, whether "inherited" or "con- genital," show no clinical differences, therefore we may with reason make a choice of either term, and personally we will select the term congenital syphilis. Etiology. Congenital syphilis may arise as the result of infec- tion through the spermatozoon, from the ovum, or from both. And this infection may be coincidental with conception, or may be delayed for a short period and occur through the influence of the maternal tissues. If the father be syphilitic the spermatozoon may convey the disease to the offspring. However, after union between the spermatozoon and the ovum has taken place, if the father is subse- quently a victim to the disease he can only infect the embryo in- directly through the medium of the mother. The mother's possibilities of transmitting the disease are great. She may begin by infecting the unimpregnated ovum itself, and continue her activity along this line until the time of birth, so that she is a factor that must be considered. If the mother is already pregnant, and during this pregnancy acquires the disease, the strong probabilities are that she will not infect her offspring. Of course, it may be readily observed that the later in the pregnancy such inoculation occurs the better the chances for the offspring's escape. If the ovum of the woman be perfectly healthy and not syphilized the spermatozoon from a syphilitic father is capable of inoculating it, and the result of such conception will be a syphilitic infant. Clinically it cannot be determined that such a woman acquires the disease, although that she has some modified form of syphilis as the result of having carried a syphilitic infant seems to be proven by the fact that she may nurse the syphilitic infant without acquiring the disease. This another uninfected woman could not do. Of course with such a proposition we must assume that the infant has a syph- ilitic stomatitis or lesion in the mouth, making infection easy. The dangers of transmission are greatest during the active and secondary stages of the disease, while, if impregnation takes place during the tertiary stage, or when the infected parent has been under adequate COXGEXITAL SYPHILIS 141 treatment for a long period, the chances of infection of the infant are slight. Types of Disease. Ordinarily we think of congenital syphilis only as it shows in a more or less virulent infection in the offspring. But, on the other hand, there may be the hereditary transmission of constitutional changes which are the result of the specific poison in the parent. The manifestations of these changes in the offspring are in more or less marked general disturbances which are not traceable to other sources. If we consider only the first type of cases we are taking a very narrow view of the disease. In this type we study changes which are brought about through the influence of the direct hereditary transmission of germs. In the other type we are not of necessity dealing with that situation, but with a constitutional trans- mission which is resulting in the various anomalies as stated. These are dependent upon and connected with the destructive effect of the disease upon the general health and condition of the parents. In other words, we frequently see infants exhibiting tissue changes which are attributable to syphilitic infection, but without any evidences of the usual syphilitic lesions. Pathology. There are not always characteristic lesions, but there are evidences in the viscera, the bones, and the skin of hyperplasias of the connective tissue elements, and these are suggestive. The most common visceral change is in the liver, which is usually enlarged, and may be the site of round cell infiltration and a gen- eral proliferation of the interlobular connective tissue. This change follows quite closely the course of the smaller arteries. Generally there is an associated degeneration of the parenchymatous cells. The gross appearance of such a liver is a speckled viscus, covered with small pin-head-sized yellowish white spots. The spleen is enlarged with an excess of connective tissue. The organ feels much harder than the normal. The lungs show fibroid changes which are quite similar to those which occur in the liver. The gross appearance is a lung of whitish color, and to the feel exhibiting a marked loss of elasticity. The kidney changes are similar, but are less characteristic, be- cause the same changes are noted in kidneys that are the result of 142 SYPHILIS other conditions. The lymph nodes may or may not be involved in a moderate degree of small cell proliferation. The skin does not show marked lesions; in most fatal cases the eruption has disappeared. On the other hand, there may be evi- dences of superficial erosions or even a marked ulceration. This is especially common about the anus and the mouth. Bony changes are the most typical, and are most commonly pres- ent. There are usually the ordinary evidences of inflammatory changes where the shaft and epiphysis approximate, and these changes are commonest in the long bones. They may, however, occur FIG. 53. HEAD OF SYPHILITIC INFANT, SHOWING THE CHARACTER- ISTIC FISSURES AT THE CORNERS OF THE MOUTH AND THE GENERALLY SHRIVELED APPEARANCE. in other bones. If marked inflammation has taken place there are some enlargement and swelling of the epiphyseal junction, or there may be separation. Late cases show osteophytic growths on the shafts of the long bones. Gummata are common and may be broken down and ulcerated. Symptoms. THE APPEAEAXCE OF THE IXFANT AT BIRTH. The appearance of the infant at birth will depend upon several factors virulence of the infection and the stage at which the infant is born. The infant may be born without giving any evidences of the discnsr. and it is only after a period of careful watching that we are enabled to detect evidence of the infection. If there is a premature birth CONGENITAL SYPHILIS 143 the usual evidences of such immaturity are more or less marked. The dusky color which many of these infants have is due to the general vascular tone being defective. Rarely we see the birth of a pre- mature infant with well-marked evidences of the disease in the skin and mucous membranes. If symptoms are present at birth it indicates the severity of the infection, and such infants usually live but a few days. The shriv- eled appearance of such an infant is due to the lack of fatty tissue in the body. The skin lesions are more or less tense bullie set upon FIG. 54. HEAD OF SYPHILITIC INFANT, SHOWING THE DESTRUCTION OF THE HAIR. a deep red base or surrounded with a dark or brownish red ring. These bullae contain serum, blood, or pus. In much smaller numbers are seen less tense bulls?, which dry rapidly into areas of a dusky red hue, and upon which the epidermis lies in a brown crust. Fre- quently the epidermis slips from these areas, leaving moist and de- nuded surfaces. The soles and palms are the parts most affected, although there may be an affection of other parts. In the severe cases there is usually a general distribution. There is, however, one marked characteristic: if they appear at all they are always present upon the palms and soles. 144 SYPHILIS SYMPTOMS SOME TIME AFTER BIRTH. It must be recalled, however, that it is the appearance of symptoms, some time after birth that particularly interests the surgeon, because this constitutes the great majority of cases. There is in congenital syphilis no initial lesion which corresponds with the chancre of the acquired form, and the period of incubation is subject to considerable latitude. The most prominent is a persistent rhinitis. It occurs as an early symp- tom, and for a long time may remain the single prominent evidence of the disease. It varies in degree from a slight stuffiness of the nose, without visible discharge, to a condition in which there is a profuse blood-stained discharge continually discharging from the FIG. 55. CONGENITAL SYPHILIS. This illustration shows a well marked eruption and the general emaciation. nostrils and interfering seriously with respiration and the act of nursing. But whatever its degree it is persistent. We recall no in- stance in which this symptom was absent, although its evidences in some few instances have been but slight. During the first few days of life we can commonly demonstrate a swelling of the nasal mucous membrane, particularly that of the inferior turbinate bone, and this occurs without any definite etiology. When the nose is markedly involved there may be later depression over the bridge, but this is not common. When it does occur it is usually very rapid in its course. Apart from this involvement of the nasal mucous membranes there is usually no other involvement of the mucous surfaces, except CONGENITAL SYPHILIS 145 at the regions about the openings of the body, and at these situations fissures may appear. These fissures radiate outward from the mucous surface, and are often deep enough to cause permanent scars. The peculiar eruptions on the skin usually appear soon after the rhinitis, and remain a prominent feature of the disease. The most common type of skin lesion is an eruption in the form of the flat, disclike, reddened areas, which later change to a brownish tinge, and the eruption situated about the thighs, the lower abdomen, and but- tocks. These may also appear on the face or upon the soles and palms. These may be described variously as erythematous, papular, vesicular, macular, or pustular, but this division is confusing and unnecessary, because the essential feature of the eruption is the flat, disclike, circumscribed character with its peculiar color. A differ- ence in the intensity of the inflammation is really what accounts for the difference in the descriptions of the character of the lesion. The tendency of coalescence is not a marked feature of congenital syph- ilis. On the soles and the palms, which are favorite sites for the eruption, the lesions are seen as smooth, shiny, dark red or brown areas, and perhaps an occasional bulla. It is only necessary to re- member the main features of the eruption to avoid being led into error. There is a variation in intensity and in distribution, and this variation has led to the description of almost innumerable forms of eruption. The main point is to have a clear idea of the main fea- tures of the eruption of congenital syphilis, and this is of value only as it is associated with other clinical features or a history which will warrant us in making a diagnosis. After several months it is not unusual to find that the hair be- comes very much thinned out, and this may occur to such an extent that but little hair is left. However, there is never the baldness which is noticeable in alopecia areata. The falling out begins gen- erally over the vertex, and this gives the child the weird appearance of still retaining a thicker fringe of hair about the sides of the head. The nails are usually involved, and ordinarily show suppuration about the matrix, with subsequent nail destruction. But preceding this there may be a simple arching of the dorsum of the nail. 146 SYPHILIS Splenic enlargement is quite common. However, as this is a common accompaniment of many conditions in infancy, its value as evidence is lessened. Not commonly there may be hoarseness or aphonia, which indi- cates some involvement of the mucous membrane about the larynx. In its influence upon the nervous system the disease frequently shows very early and marked effects. It may so affect the nervous FlG. 56. GUMMA OF THE LEG IN SYPHILITIC INFANT. system of the fetus as to markedly affect its normal development. This is usually evidenced by an arrest of brain development, which is the cause of the many cases of idiocy which occur. The secondary symptoms which are dependent upon this involvement of the in- fant's nervous system are of course varied and innumerable. Orchitis may occur, and the enlargement of the testes may be considerable (two or three times the normal size), without tender- ness. Occurring in early infancy this symptom is almost pathog- nomonic. The eye frequently shows changes, and there may be a choroiditis, keratitis, or corneal opacity as the result. A choroidorctinitis is not uncommon. Most characteristic of all of the eye conditions is an in- terstitial keratitis, which is commonly associated with Hutchinsoman CONGENITAL SYPHILIS 117 type of the permanent teeth. Usually one eye is affected for several weeks before the second one, and the sight may be very much dimin- ished for many weeks or even months. Anemia is always present, and may be very profound, but it is a common experience to find this symptom persistent but moderate in degree until many of the other manifestations of the disease have cleared up, and then it is not unusual for the anemia to be evidenced in its most acute form. With the anemia there is generally a pallor to the skin, which has a brownish-yellow tinge. The affections of the bones which occur dur- ing the course of con- genital syphilis may well be divided into two groups: those which ac- company the early mani- festations and those which accompany the later ones. Acute epiphysitis is the most common ac- companiment of the early manifestations. The onset is almost al- ways very acute, so that usually the first thing noted is that the infant is unable to move the limb. As a consequence two types of motor disturbance may be no- ticed the paralytic and the spastic. There may be inability to move a limb because of the acute epiphysis present, and it is not uncommon to find that this disability is the first prominent feature. Usually it is one or both arms that are affected, and the infant cries with pain if the arms are handled. It is of interest to recall that in specific bone disease of the arms there is flaccidity, while in the lower limbs there is contracture or spasticity. The explanation of this difference is found in the anatomical relations of the mus- culature to the joints. FlG. 57. GUMMA OF THE EYELID (BROKEN DOWN). 148 SYPHILIS With widespread involvement we may have crepitation. The danger of mistaking such an occurrence for sudden paralysis is great. The slightest motion causes intense pain to the infant. This symptom, when it occurs, is almost invariably present during the first six weeks of the infant's life. It is not long before some swell- ing is noticed at about the epiphyseal line, being very prominent in superficially placed bone, but less so in a deeper situated one. Usu- ally there is a decided limitation to the swelling to the end of the bone, but in rare and extreme cases it may involve much more of the limb. Neglected, this may go on to suppuration. Chronic osteoperiostitis is usu- ally evidenced in the tibia. There is a forward curve to the anterior surface of the bone, and the ap- pearance of the tibia is then saber- like; it appears as though the bone was compressed at the sides, result- ing in the forward curve or arch- ing. This arching is only apparent, however, for there is no actual FIG. 58.-SABER-LIKE APPEARANCE OF cllrye Q f ^ ghaft Q f ^ ^ th(J THE LEG WHICH is SOMETIMES OB- SERVED IN CONGENITAL SYPHILIS, appearance being entirely due to new-formed tissue on the anterior surface. The new bone deposit is the result of a specific periostitis, and therefore in the early stages it is accompanied by pain which is worse at night. With the occurrence of visible thickening the pain becomes less and less of a factor. Atypical cases may give no evidences of pain except upon handling of the infant. The changes in the skull may be manifested in several ways: there may be changes which are not distinguishable from those due to rachitis ; there may be abnormal protuberance of the frontal and parietal eminences, with early ossification of the sutures, or hydro- cephalus. The usual form is that of a gummatous periostitis. These gummata are half-spherical, limited swellings, which are more or CONGENITAL SYPHILIS 149 less painful. At first they appear to be solid, hut later there is a somewhat distinct fluctuation felt, and at the same time they become more or less adherent to the skin. Dactylitis is not so common as epiphysitis, but when it occurs it resembles somewhat closely that due to tuberculosis. The fingers are more often affected than the toes. Fusiform swell ins: of the O proximal phalanx is the usual lesion. The teeth are erupted late, and show early decay. The changes are many; all of the teeth, or only the middle incisors, may be ab- normally small, with resultant slits between the teeth. In other in- FIG. 59. HUTCHINSON'S TEETH. (Beers.) stances they are covered with a false enamel, which rapidly crumbles, allowing the teeth to decay or rot. On the surfaces there are fre- quently calciform and fusiform striated erosions, which are some- times single, forming a groove. Such teeth occur most often in the congenital type of the disease, but are not limited to this form, or even to syphilis, 'so that they are to be considered only as corrobora- tive evidence. Particularly characteristic of syphilis is the presence of Hutchinson's teeth; these are characterized by the semilunar notching of the free edge of the two upper middle incisors. Besides this, the teeth are short, narrow, and with rounded corners. 150 SYPHILIS Hemorrhagic effusions in all situations are common in the young infant, so that it is not uncommon to find that, under the influence of prolonged or difficult labor, even intracranial or subpericranial effusions occur. The evidences of the interference with nutrition may become very marked, so that the infant may die of wasting, or remain so emaciated and weakened that some slight intercurrent dis- ease is sufficient to cause death. An irregular type of temperature is common to congenital syph- ilis. Often the superficial lymphatic glands are enlarged so that they are palpable, but the enlargements show no distinctive features, being similar to gland involvement in other conditions. However, this adenitis is more apt to occur as a late manifestation rather than an early one. One of the latest symptoms to appear is an affection of the ears, which is quite characteristic of congenital syphilis and which is de- pendent upon mild but persistent inflammation of the middle ear. This symptom is deafness, which is rapid in its course, and, in fact, so rapid that complete deafness is common after a few weeks of the onset. Diagnosis. There are several factors which must be considered in this particular : The family history, the type of the disease, the appearance of the infant at birth, and the appearance of symptoms some time after birth. FAMILY HISTORY. This is most important and yet difficult to obtain, unless the examiner has a clearcut idea of what he should elicit and has the ability to do it skilfully. Because of the attitude which the laity assume in regard to the matter, the question "Have any of the family ever had syphilis?" should never be asked. A denial means nothing, and by placing the questioned one upon guard it detracts from the honesty and value of subsequent answers to other questions. It is far better and much more certain to obtain a history of events which will establish a strong presumptive evidence as to the existence of the disease. The several events to be considered are these: (a) The tendency of the children of a given family to suffer from unaccountable anemias and malnutrition during the earlier CONGENITAL SYPHILIS 151 periods of life, despite the fact that the hygienic surroundings and the dietetic care are both excellent. (b) The occurrence of anomalous types of disease in two or more children of the same family, or the unusual course of a disease under similar circumstances. (c) Tardy development without a recognized cause, or occurring as the result of a recognized etiology, but out of all proportion to that cause and occurring in two or more children of the same family. (d) The occurrence of a rachitic type of skull without the other evidences of rachitis being proportionately marked. (e) History of the disease, direct or presumptive, in one or both parents. (f ) A history of the abortive habit in the mother without definite cause. The death of the fetus may occur at any period of intrauterine life. But the most common occurrence of the event is between the fourth and the seventh month. In those pregnancies which are terminated early (first five months) the fetus may show no evidences of the disease which are clearly demonstrable. Histological sections may be compared with those of the normal fetus, but this is not always feasible. During the last four months of pregnancy, if the fetus is expelled the evidences of disease are usually unmistakable. This is particularly true of changes in the placenta. Not infrequently the placental changes cause a phlebitis of the cord (veins), and the premature expulsion and death of the fetus are found in hydramnios. The gross appearance of the specific placenta is usually as fol- lows: It is larger and heavier than normal and its lobes are de- formed. It is pale and often yellowish in hue, with much thickened and hardened cord. The types of the disease (see page 141) and the appearance of the infant at birth (see page 142) have already been referred to and need not be repeated at this point. It is now very generally believed that the Spirochaeta pallid a is the cause of syphilis. Of course, most of the work along this line has been among adults and in the acquired form of the disease. But there is enough evidence to warrant us in conceding that the cause of syphilis has been discovered, although the technique necessary to COLLlietE OF I I !- .-* I 152 SYPHILIS demonstrate this readily is undergoing rapid change and advance- ment. WASSERMANN REACTION. There is every reason to believe that in congenital syphilis the Wassermann reaction will prove and is proving as reliable and valuable as it does in the acquired form. It is freely admitted by the investigators that its value is as propor- tionately great in the diagnosis of the late hereditary type as in the acquired. So far as we have had any experience with its value in early congenital cases it has been confirmatory, but the experience along this line has been too limited to give it much value. With the marked improvements which II. Noguchi, of the Rockefeller In- stitute, has made in the technique there is a stimulus to a wider use of the reaction. It involves but little effort upon the part of the attending physician. Ten or fifteen good sized drops of blood from the ear passed into a sterile tube (similar to that used for the swabs in diphtheria cultures) and tightly sealed are the material necessary. If this is kept cool, the pathologist has a workable material, and it will keep for forty-eight hours. Personally we feel that this method of examination is on the same plane as many of our other methods (as, for instance, diphtheria cultures), a positive reaction from a case accompanied by suspicious symptoms means the presence of syphilis; a negative reaction means nothing. Prognosis. It must be remembered that congenital syphilis is a much more fatal disease than the acquired form of adults. Malnu- trition is the common cause of death, the vitality of the child being so markedly affected that the occurrence of some slight intercurrent disease often determines the issue. The earlier the symptoms appear, the worse the prognosis. Even allowing that the infection is mild and the treatment adequate, syphilitic infants usually do not develop normally, and, therefore, even at its best, the prognosis must be guarded as to the future physical and mental vigor of the child. Treatment. If a woman should become pregnant by a man known to be suffering from syphilis, or if she herself be a syphilitic and be- come pregnant, an antisyphilitic treatment should be rigorously in- stituted as early in the pregnancy as possible, and must be con- tinued throughout the whole period. The treatment should be that CONGENITAL SYPHILIS 153 which has been found adequate in adult cases. The infant horn of such a mother should have every advantage of breast feeding and, during the lactation period, the treatment of the mother should be continued. The best means of treating the affected infant is by the use of mercury, internally, hypodermatically, or by inunction. The hypo- dermatic method has serious objections which are at once obvious, and therefore its use is limited. In institutional work the inunctions are the preferable method because of the certainty with which they act. But in our private practice the benefits of this method are diminished by the inability to hide the fact that the mercury is being used and the staining of the skin, which attracts unfavorable attention to the infant. Inunctions advertise the disease. The inunction is employed by the thorough rubbing into the skin of mercurial ointment. The rubbing must be done once daily and continued for ten minutes. Different areas are selected for each day's application, and the best places are the inner aspect of the thighs, the abdomen, the axilla, or the chest. We have found no advantage in the use of inunctions over the internal administration of the drug. Secrecy, cleanliness, and comfort are all conserved by the latter method. As the symptoms usually appear some time during the first two months of life, the infant may be given either of the following, night and morning, after a feeding: Bichlorid of mercury, 1-200 grain. Gray powder, 1-2 grain. Calomel, 1-8 grain. After the selection is made, the drug is continued for one week, and then on every alternate day an extra dose (the drug administered three times daily in place of twice) is given, until a decided improve- ment has been noted. After the establishment of a steady improve- ment the administration may be reduced again to twice daily, dis- regarding the increased dose on the alternate days. However, if improvement is not rapid enough or continued, the dose may be increased for a time to four or five times daily, but with this increase there will be a tendencv to looseness of the bowels with green stools, 154 SYPHILIS so that a combination with some controlling drug may be necessary. Usually the first indication of improvement is the fading of the cutaneous rash, which as it clears leaves the characteristic stain- ing which persists often for weeks. Almost coincident with the dis- appearance of the rash, the other symptoms begin to subside, although the splenic and liver enlargement may persist for several weeks. Soon there are gains in weight and other evidences that the nutri- tion of the infant is undergoing a decided change for the better. Not infrequently cases are seen in which the vital forces of the infant and its recuperative powers are so low that treatment is of little avail, because before its influence is adequately brought to bear upon the disease the infant is exhausted. Still more rarely treatment fails to act as promptly and efficiently as is usual and the infant slowly dies from inanition. Not infrequently a "cured" case of congenital syphilis has a return of symptoms after several months or years, and therefore it is necessary, in considering the treatment of the disease, to consider what constitutes safety in the cessation of treatment. Abundant clinical experience would seem to strongly indicate that the "cured" case should receive treatment at least one month out of every four, and that, in the presence of any disease affecting nutrition, the usual remedies should be combined with antisyphilitic treatment. lodids are not usually necessary in these cases, and it has been taught that, as the earlier symptoms are "secondaries," their use is never neces- sary. This has explained the failure to get results in some of the cases I have seen in consultation. There are times, even during infancy, when the administration of the iodids is just as necessary and as beneficial as in later childhood, when "tertiary" symptoms are more common. Gummata, the various bone lesions, and particularly acute epi- physitis are much more amenable to treatment by the iodids com- bined with the mercury than by the mercury alone. The inherent tendency to frequent gastrointestinal disturbances, to failures of assimilation, and to nutritional faults must be remem- bered and everything done to surround the syphilitic infant with the best that scientific feeding and hygiene can afford. STATUS LYMPHATICUS 155 The use of salvarsan promises good results in many cases, but at the present time the splendid results reported by some observers in congenital syphilis and the failures reported by others leave the matter somewhat in doubt. It is one of those methods of treat- ment which will have to be tried in several thousand cases and the remoter effects carefully observed before we can accept it as a routine treatment, such as is done with mercury or the iodids to-day. In the meantime it may be administered in selected instances with the promise of good results. CHAPTEE XXV STATUS LYMPHATICUS This term should only be applied to that very definite pathological condition which is associated with a clinical picture that is far from constant or in any manner characteristic, but which is definite enough to distinguish it from "lymphatism," with which it is con- stantly confused. "Lymphatism," or the tendency to hyperplasia of the lymph nodes which exists in all children but which is so characteristic in some children as to be reasonably considered as a diathesis, is entirely distinct from status lymphaticus. There are instances when the one seems to approximate very closely the other, but, on the whole, there is usually enough about the several features of both conditions to clinically separate them. Status lymphaticus may occur at any age, but is most often ob- served between the sixth and the twelfth months. Pathology. Undoubtedly the condition is much more common than we have been led to suppose, because not all cases end fatally. Pathological enlargement of the thymus is not infrequent. As re- gards the normal size and condition of the thymus, the observations of Bovaird and Kicoll are instructive. These observers took the weight of the thymus in nearly 500 consecutive autopsies of children under the age of five years and found that the weight was greatest 156 STATUS LYMPHATICUS at birth, and that thereafter, until the end of the fifth year, the weight did not materially increase or diminish. The birth weight was averaged at 7.7 grams. When glands weighing over 10 grams were excluded this average of 7.7 grams was reduced to 6.5 grams. The very rapid decrease in weight which occurred immediately after birth made the average weight of the gland for the period of childhood up to five years between 3 and 4 grams. Anything over 10 grams was considered by them as abnormal. In the status lymphaticus the thymus may be many times larger than normal, and its increase in weight in proportion. Examined under the microscope, such an enlarged gland does not exhibit any characteristic changes except those due to the hyperplasia. There is associated with this thymus enlargement hyperplasia of the lymphoid tissue throughout the body, so that we observe enlargement of the lymph nodes of the tracheobronchial region, of Peyer's patches and the solitary follicles of the intestine, of the lymphoid tissues of the pharnyx, and, in fact, of all portions of the body. Even the spleen may be enlarged and all other causes of splenic enlargement can be excluded. Symptoms. The condition is of special interest because in early infancy it may be the explanation of the cause of death which takes place under the most trivial circumstances, or occurs without any appreciable cause. Such infants are frequently found dead in their cribs. The cases which are of greatest interest and concern to the surgeon, however, are those in which the child lives to a considerable age and throughout that period gives little or no clew to the condi- tion present. Then, as the result of some slight accident or a minor surgical procedure, or even the administration of an anesthetic in anticipation of one, the symptoms are brought prominently forward. The occurrence of the symptoms is usually so suddenly followed by death that there is no chance for treatment. There is nothing about the child during life that is very suggestive, and most often the history is that a child who has been previously considered in perfect health is suddenly seized with convulsions and a high tern- DIAGNOSIS 157 perature and some indefinite asphyxial feature which does not cor- respond to anything that may be found in the chest. The temperature and convulsions are usually persistent, with death occurring within one to thirty-six hours. In other instances the asphyxial element is the predominant one and may be quite spasmodic but without association with general convulsions. In this type the measures of relief usually bring the child out of the first attack, but this is followed in a few hours by a more severe one, and, after .several such increasing ones, death occurs. In this form the temperature is not usually so high as in the other. Symptoms similar to these, but in many degrees of lessened severity, may sug- gest the true condition and result in recovery. There are many theories in regard to the cause of the symptoms, but we are very uncertain as to their real cause. Pressure of the enlarged thymus upon the lungs, the trachea, the pneumogastric nerves, and upon the heart would seem to be a plausible explanation of the asphyxial features of certain cases, but it fails to explain most cases. The largest number of cases would come under that group in which there is nothing in the condition of the child or about the symptomatology of the attack which would associate it with the status lymphaticus, and yet when the child becomes the victim of an apparently very trivial inflammation or injury there is a very great and disproportionate resistance to injuries and inflammations in particular and to all disease in general. When autopsies have been performed upon children showing this characteristic during life, it has very commonly been found that the status lymphaticus was the only plausible cause. Diagnosis.- It will be observed from this that the diagnosis is always very uncertain and that we cannot be anything more than suspicious of the condition during the life of the child. However, this suspicion may be very strong and rest upon the history of the child suffering severe shock which is out of all pro- portion to any particular injury received. It is common to observe children who, from slight falls or injuries, suffer so severely and remain prostrated so long that we know that something unusual 158 STATUS LYMPHAT1CUS exists about that particular child. A carefully taken surgical his- tory always reveals this point and the surgeon is thus amply warned that under even the slighter surgical procedures that child will give evidences of most serious shock. We have for a long time been suspicious that some degree of status lymphaticus underlies this, although it cannot be definitely proved. For practical purposes, at least, the history is sufficient to make the surgeon cautious in undertaking any surgical procedure. SECTION VI INFECTIOUS DISEASES CHAPTER XXVI ADENITIS SIMPLE ACUTE ADENITIS Acute enlargement of the lymphatic glands is the usual accom- paniment of the various acute infectious diseases, and, in this particu- lar, the enlargement is not an accidental one, for there exists a well- established connection between the location and the extent of the adenitis and the disease with which it is associated. Such enlargements are practically certain to occur when the infectious process causing them is a severe one, or is long in duration. It is not uncommon to find that the primary cause of an adenitis is so apparently minor or has occurred at such a remote period that its influence has been overlooked or forgotten, and under such cir- cumstances the adenitis itself assumes the appearance of a primary condition. During the period of early life, and particularly during the first two years, adenitis is most common and there is good reason for this. The fetus in utero is protected to a very considerable degree by the natural and the acquired immunities of the mother, but immediately after birth it is suddenly exposed to many and varied pathogenic influences. Thus the infant is early forced to depend largely upon its own powers of immunity, which are transmitted to him by his mother, and when these fail him he must necessarily fall back upon the protection offered largely by his own lymphoid tissue and glands. Etiology. Acute adenitis occurs in children of all ages, but par- ticularly in those of tender years in the course of any one of the 139 160 ADENITIS acute infections. Suppuration is not a common occurrence, except during the course of scarlet fever or unless the child is very young or is suffering from some severe nutritional fault. This rather ex- treme susceptibility of infants has already been explained. Given a child with a severe or a prolonged fault of nutrition and the slight- est acute infectious process is practically certain to result in an acute adenitis. One very prolific cause of suppuration is overtreatment of the swellings, particularly by local applications that prove in time more or less irritating to the tender skin of the child. Such measures invite rather than limit pathogenic infection. Any gland in the body may become the site of an adenitis and this depends upon the location and extent of the primary factor. A reference to the chart on pages 163-164: will help to elucidate this point. The Lesions. The changes which take place in the glands are an acute congestion with subsequent swelling, edema, and an active hyperplasia of the lymphoid elements. Resolution is the rule in older children, unless the infection is unusually severe or the child's system is rendered lower in resistance by other factors. During infancy there is a marked tendency toward suppurative changes even when the primary infection is a mild one. If suppuration occurs, inflammation of the surrounding cellular tissue is added to the previous lesions. The lesions are usually unilateral, or if bilateral then one side is almost invariably much worse than the other. Suppuration is practically always unilateral and starts in a single gland, but may extend subsequently to others. Symptomatology. The most typical cases are those which occur during the first two years of life. In them there are present the symptoms of the primary causative factor (which may be a nasal or nasopharyngeal catarrh, or inflammation somewhere about the mouth or the ear) plus an enlargement occurring as a group of nodules which are freely movable and definitely outlined. The swelling is neither rapid in its onset nor great in its extent, and, as a rule, persists only for a short period after the primary dis- ease or causative factor has subsided. The glands most commonly SIMPLE ACUTE ADENITIS affected are the deep cervical. However, in those few instances in which there is an early and marked inflammation, of the peri- glandular cellular tissue, there is a much more rapid swelling and the glands cannot be made out so definitely. With this latter type there are added considerable pain, heat, and tenderness about the parts. When suppuration supervenes it is usually during the latter part of the second week of the swelling, although the instances in which it occurs much later than this are by no means uncommon. There FIG. 60. SALIVARY CALCULI REMOTELY SIMULATING ADENITIS. FIG. 61. FRONT VIEW OF SAME CASE AS FIGURE 60. is a slight elevation of the temperature in most instances, and this fluctuates during the whole course of the adenitis. Any consid- erable rise in the temperature, or a prolongation of its course, should arouse the suspicion of suppuration. In those children who are rachitic, or who exhibit the evidences of some marked nutritional fault, the general symptoms are all apt to be emphasized and may be quite severe, with early prostration. When this occurs it may, for a time, leave one in doubt as to the possibility of the adenitis being entirely responsible. Suppuration is usually not difficult of management because there is a marked tendency toward rapid resolution after a prompt and 162 ADENITIS adequate incision. Most of the cases that do not quickly respond are those in which the incision has been inadequate to the require- ments of the case, or has been too long delayed. The formation of a sinus is very rare. It is uncommon that the infection extends from one gland to another and that multiple abscesses are encountered. It is a peculiar fact that the non-suppurative cases exhibit much more swelling than do the suppurative, but, upon the other hand, they are also more clearly defined. The usual course extends over a period of from four to eight weeks, and not infrequently some of the enlargement persists for several months without causing any appreciable discomfort or in- convenience. Many children exhibit an apparent susceptibility to adenitis and in these chronic enlargement is the rule. Diagnosis. Excepting the acute infectious diseases and the occa- sional local causes of adenitis (as caries of the teeth, stomatitis, ec- zema of the scalp, pediculosis capitis, etc.) acute simple adenitis is a disease largely of infancy. This fact renders the diagnosis much more certain. One of the most common errors is in mistaking an ordinary attack of "mumps" for an acute simple adenitis. This is particularly perplexing in those instances in which the parotiditis begins (that is, as far as the swellings are concerned) as an enlarge- ment of the submaxillary or sublingual glands. In all such instances it is necessary to search for the various causative factors for, with any considerable degree of enlargement dependent upon an acute adenitis, these would be evident. The danger of mistaking tuberculous glands is not great, because in acute adenitis we are dealing with an entirely acute process which has" practically nothing in its symptomatology which is in common with the slow and progressive suppuration which is observed in later childhood. In addition the glands do not adhere to each other or to the skin or the surrounding tissues as they do in tuberculous adenitis. Treatment. Recalling the common occurrence of an acute simple adenitis during childhood, and particularly during the period of in- fancy, the prophylactic demands are that the greatest amount of care SIMPLE ACUTE ADENITIS must be given to the toilet of the mucous membranes whenever there is an existing catarrh, and that care should not be relaxed until a considerable period after the subsidence of all acute symp- toms. During the course of the infectious diseases the authors have found that the usual mouth washes are not entirely efficient in children, no matter how care- fully they are applied, and, in such instances, the regular use of chewing-gum has a most salutary action upon the cleanliness of the mouth. When acute inflammation has occurred relief may be ob- tained most surely by the appli- cation of an ice-bag. There is often a very vigorous objection to this procedure by the child and, in such instances, very hot FlG . 62. LOCATION OF THE PRINCIPAL applications may have to be Sub- LYMPHATIC GLANDS OF THE NECK. Stituted. Pain is markedly re- (For explanation of the diagnostic signifi- -,. i ,1 , , cance of their acute enlargement, see lieved in this manner, but it is very doubtful whether either of these measures have any influ- ence in preventing or limiting suppuration. Local applications of the va- rious ointments and pastes of various strength iodin, and so forth have failed signally in our hands. Such cases go on to suppuration in spite of anything which is applied externally; in fact, it has been our experience numerals below.) 1. Diseases of the ear (especially eruptions) ; eruptions about the face; and occasionally during parotiditis. 2. Mastoiditis and infec- tions and eruptions affecting the scalp. 3. Infections of the chin, the tongue, and the lower lip. 4. Infections of the mouth and teeth, stomatitis, rubeola, and rubella. 5. Infections of the tonsils in the mild attacks of scarlet fever and at first in variola. In severe scarlet fever 5, 6, 7 and 8 may be much affected. 6. Pharyngeal infections and inflam- mations, therefore in retropharyngeal lymphadenitis. Also in severe scarlet fever and in rubeola. 7. Infections of the scalp and severe scarlet fever. 8. Infections of the scalp and severe scarlet fever. (During the course of diph- theria, 4, 5, 6, 7 and 8 may become prominently enlarged, so that the whole neck appears badly swollen and tender.) 164 ADENITIS that many of the recommended local applications tend to bring about, rather than to limit, suppuration. Certain it is that, if they cause even minute breaks in the skin, they favor the introduction of path- ogenic organisms. We are convinced that a careful toilet of the affected and the sur- rounding parts and the prevention of injury to the glands (injury through continued pressure, con- stricture, rubbing, etc.) will accom- plish all that is possible in the lim- itation and prevention . of suppura- tion. When suppuration takes place incision may be deferred until pointing of the abscess has occurred, for then we are reasonably certain that the refilling of the cavity can be prevented. A simple but adequate incision is all that is required in most cases, but, if there is an abundance of broken down tissue, the cavity may require curetting. Such a pro- cedure practically insures prompt healing. In those instances in which healing is delayed the cause may almost always be found in an inadequate incision, which has not allowed of a complete emptying of the cavity. The removal of the primary cause is of necessity indicated in every instance. If the primary cause is eliminated early in an acute simple adenitis it is unusual for suppuration to take place. FIG. 63. LOCATION OF THE PRIN- CIPAL LYMPHATIC GLANDS OF THE TRUNK. (For explanation of the diagnostic significance of their enlargement, see numerals below.) 9. Infections of the neck and occasionally during the course of diphtheria. 10. Infections affecting the arm, the axilla, and the upper por- tions of the chest, anteriorly and posteriorly. 11. Infections of the hand, and especially of the three inner fingers. Quite frequently this is enlarged during the course of a syphilitic eruption. 12. Infections affecting the lower limbs, and particularly the thighs and sometimes during the course of syphilis. In rare in- stances these glands are af- fected in rubella. SIMPLE CHRONIC ADENITIS 165 We are convinced that, despite all that is done to remove the local causes and give the child relief, there still remains an oppor- tunity to still further protect the patient by the judicious adminis- tration of such tonics as iron, arsenic, and cod-liver oil. The best preparation of iron to use is the syrup of the iodid, and this may be given in three- to five-drop doses to an infant of six months, five to ten drops to one of a year, and ten to twenty drops to the older children. It is easily taken when mixed with sufficient water. Fowler's solution of arsenic is a valuable adjunct to the iron or may be used alone, but not in infants under one jear of age. One drop may be given to the infant of a year and, although there are idiosyncrasies to the drug, most children take it well, and one drop may be given for each year of the child's age, up to the fifth year. It must always be well diluted. In cod-liver oil we have one of the very best tonics in this con- dition. There is often a nutritional fault and the child needs the fats. In commencing the administration of the oil the dose should be a very small one, no matter what the particular preparation used, and it should be cautiously increased as the child will tolerate it. A small quantity taken and retained without any evidences of diges- tive disturbance will do more good than a larger quantity borne less comfortably. In regulating the dietary of the child the fats should be given rather freely. SIMPLE CHRONIC ADENITIS Simple chronic adenitis is not nearly so common as the simple acute form and after the fifth year of life it is quite rare. It consists of a simple hyperplasia of the lymph nodes and may follow an acute adenitis or result from subacute or chronic inflam- mations of the various mucous membranes or of the skin. It is more common for an acute adenitis to follow a chronic than for the chronic to be subsequent to the acute, because the acute form is usually added through the agency of some infection. 166 ADENITIS Symptoms. The symptoms are quite constant. The glands upon one or both (commonly upon both) sides of the neck become swollen and, as a rule, a group of glands instead of a solitary gland is in- volved. This swelling usually increases very slowly over a period of from one to two months and then remains stationary for about a similar period, after which there is a very slow subsidence which may persist over several months. The degree of swelling is not nearly so great as in the acute form, and constitutional symptoms are usually entirely absent. There is no tendency to either suppura- tion or caseation of the glands involved. Diagnosis. The diagnosis is rendered very easy if the usual course of the disease is recalled. The chief difficulty in differentia- tion comes from tuberculous adenitis. The age incidence of chronic adenitis is much earlier than in the tuberculous form, occurring, as it does, usually before the third year of life and very rarely after the fifth year, while the tubercu- lous form is observed most commonly after the fifth year. Neither is the course of the disease toward suppuration and caseation, which is not always true of the tuberculous form. Dur- ing the course of tuberculous adenitis the glands become adherent to the skin, to each other, and to the surrounding tissues. They enlarge much more slowly than in chronic adenitis, but to a greater degree, as a rule, than in even the simple acute form. In the simple chronic variety there is practically always an ob- tainable history of some definite etiological factor, which is absent in the tuberculous form. The family history is also a very important factor in the latter variety of adenitis. Constitutional treatment does not yield prompt or entirely satisfactory results in tuberculous adenitis. Treatment. The treatment does not call for surgical interference in the simple cases, but in those which are persistent or which have about them such features and history as make it practically impos- sible to make a positive diagnosis from the tuberculous form opera- tion may be advisable, as giving the child the benefit of the doubt. However, before surgical intervention there should be instituted a persistent trial, over a period of at least a month, of such measures SYPHILITIC ADENITIS 1(57 as are known to influence and benefit a simple chronic adenitis, so that the adequately tried therapeutic test may substantiate the diag- nostic tests. Local applications are of very doubtful value and, for the same reasons as were mentioned in the discussion of simple acute adenitis (see page 163), they may prove harmful. The greatest amount of benefit will be obtained by such measures as insure the highest nutritional efficiency for the child and having this augmented by the administration of suitable tonics. The best of these are iron, arsenic, and cod-liver oil. To avoid repetition the reader is referred to the preceding section (page 105) for the details of their administration. Surgery should be added to this treatment to the extent that it can relieve the child by the removal of any of the various local causes that are most commonly found in the nose or the nasopharynx and the mouth. Change of climate may be necessary in some instances until the child can be brought to a state of physical efficiency which will withstand the strain of its usual surroundings. In every instance out-of-door life must be insisted upon with a moderate amount of exercise. SYPHILITIC ADENITIS It is only rarely that the infant suffering from a congenital syphilis shows any considerable degree of glandular enlargement as a direct result of the disease. As all infants are liable to simple acute adenitis, and especially those who are rendered less resistant by intercurrent disease or nutritional fault, it is common to find the syphilitic infant the subject of a simple acute adenitis, but this must not be mistaken for a syphilitic adenitis. As a late manifesta- tion of syphilis, glandular enlargements frequently occur, however. Their recognition is rendered easy by the fact of their late appear- ance, because, long before such an event occurs, the diagnosis of syphilis has been positively made. The affected glands are very hard and insensitive and also freely movable. The effect of treatment 168 FIG. 64. TUBERCULOUS ADENITIS FIG. 65. TUBERCULOUS ADENITIS SHOW- ING THE MARKED ENLARGEMENT WHICH MAY SOMETIMES TAKE PLACE WITHOUT THE GLANDS BREAKING DOWN. The redness on the edges of these swellings was not due to caseation but was the direct result of irritation from a stiff collar. rapidly removes any doubt as to the underly- ing cause. In their local appearance they very much resemble tubercu- lous glands. The diagnosis of syphilis is considered fully on page 150. TUBERCULOUS ADENITIS Tuberculous adenitis pre- sents some rather striking fea- tures; as, for instance, its rarity during infancy, its com- mon occurrence in later child- hood, and its common occur- rence as the only tuberculous le- sion iri the body in many in- stances. Etiology. The usual occur- rence is between the ages of four to ten years, and the cer- vical glands are those which are most often affected. The con- dition is rather favored by the occurrence of the other forms of adenitis, because by their in- fluence the vitality of the gland is considerably lowered and the part rendered more liable to the successful invasion of the tu- bercle bacillus. Local condi- TUBEKCULOUS ADENITIS 169 tions which favor infection, such as adenoids, enlarged tonsils, chronic pharyngitis, otitis, facial eczema, stomatitis, caries of the teeth, etc., .are prolific causes. Children who are susceptible to glandular enlargements and those with a decided tuberculous family history are the ones most often affected. We might say, then, that tuberculous adenitis is due to a primary infection in those who are especially susceptible to tuberculous dis- ease; to a secondary infection of an al- ready devitalized part, or to both. Lesions. The process is essentially a chronic one, al- though there are two more or less distinct classes of cases ; one in which the process is rapid with early caseation or sup- puration ; -the other much more chronic and with much-de- layed or absent case- ation and softening. The first effect of the tuberculous infection is hyperemia and swelling, the glands be- ing pale pink in color and homogeneous. Next there occurs a pro- liferation of the adenoid reticulum, the glands becoming more firm and finally softening with destruction or conversion of lymphoid cells and caseation. Softening usually starts in the center of the gland. The inflammation in the gland is not confined to that part, but involves the surrounding tissues also, so that adhesions are quickly formed. Fio. 66. ABSCESS POINTING IN FRONT OF UPPER PART OF THE STERNOMASTOID. (Dowd.) 170 ADEXITTS When an abscess forms the content of the cavity is largely de- rived from the tissue of the broken down node, and therefore there is very little pus but a mass of curdy material. This material often does not show the presence of tubercle bacilli, for they are numerous only in the early stages of gland involvement. Several glands may fuse together and the adhesions become attached to all surrounding tissue, whether it be blood vessel, fascia, nerve, skin, or muscle. We must not be unmindful, however, that considerable pus may be evacuated from a tuberculous abscess, because there has been added a mixed infection. It is unusual not to find several glands or a chain of them affected. The course of the local condition will depend upon the virulence of the in- fection and the re- sisting powers of the child ; therefore we may see either reso- lution, encapsulation, calcification, or sup- puration. Thus ab- sorption may occur before caseation ; caseation may be fol- lowed by encapsula- tion and contraction ; calcification may occur, but is rare, or lique- faction may result in the external abscess. Symptoms. The glandular swellings are the only evidences of the disease at first. This swelling comes on gradually and usually in- volves both sides, and it is only later in the course that one side seems to progress more rapidly than the other. One feature of the enlargement is that it is inconsistent ; at one time advancing rapidly, then subsiding somewhat or being arrested FIG. 67. ABSCESS POINTING IN FRONT OF LOWER PART OF STERNOMASTOID. (Dowd.) TUBERCULOUS ADENITIS 171 for a time. At times it seems as though it required some active local condition to start it up again, such as an infectious disease, a stomati- tis, or a lowering of the child's general health, and during these acute exacerbations the parts may become quite painful with the ordinary signs of acute inflammation. The chronicity of the process is marked, so that several years may elapse before suppuration actuallv takes place. The most common site of first appearance is just in front of the sternocleidomastoid muscle. In the rapidly developing cases the glands are of a con- siderable size within two months, although much longer periods are the rule. The outline of the gland can be readily made out at first, and they are freely movable, but later they become adherent, and this tendency to adhesion persistently contin- ues, even the individ- ual glands becoming like one firm mass. The skin becomes discolored as the process becomes more superficial, and areas of softening may be detected with fluctuation until the skin gives way and there occurs the discharge of thick, curdy material with little pus. This may continue until the whole mass is discharged, and even be repeated as other tissues break down. This spontaneous rupture usually results in large, intractable ulcers, the skin having been de- vitalized over a considerable area and having an unhealthy appear- FIG. 68. ABSCESS POINTING BEHIND UPPER PART STERNOMASTOID. (Dowd.) 172 ADENITIS ance. They may resist all treatment and the subsequent scars are large, if not actually deforming. They are more or less tender and adherent to the deep tissues. The general health of the affected child may remain reasonably good, much more so than we would expect with such a process active in the glands. Diagnosis. The diagnosis is not difficult when we recall the dis- tinguishing features, which are : the age of the child (four to ten years), the tri- fling or apparently absent primary cause, the irregular course of the swell- ings, the chronicity of the disease, the tuberculous family history, and the marked tendency to- ward caseation, sof- tening, and abscess. Simple acute ad- enitis occurs in in- fancy m o s 1 1 y, is much more rapid in its course, and- has a short course. Simple adenitis, whether acute or chronic, can be traced to some very definite cause, and the course is not toward caseation or suppuration when uncomplicated. Constitutional treatment gives quick results in the simple forms, while it is not efficient in the tuberculous. If sup- puration takes place in the simple forms it is early (usually within the first four to five weeks). The effects of treatment would at once differentiate syphilitic adenitis. Hodgkin's disease and malignant disease could offer no FIG. 69. ABSCESS POINTING IN FRONT MASTOID. (Dowd.) OF STEKNO- TUBERCULOUS ADENITIS 173 difficulty, as the course of each is so entirely different. Prognosis. Fi- nal recovery can be predicted even though the course is very chronic, for, in itself, tuberculous adenitis is not de- structive to life. But the danger is always present of mixed in- fection, and the child is never entirely safe with that possibility in view. The possi- bility of a general infection must also be borne in mind. Treatment. The general treatment de- mands that the child's surroundings be changed sufficient- ly to give it the best possible chance to build up. It is most important that any nutritional fault be corrected at once. Here, again, as in the simple forms of the disease, iron, ar- senic, and cod-liver oil are of great bene- fit (see page 165). FIG. 70. SHOWING THAT IT is UNSAFE TO EXPECT THE DISEASE TO BE SELF-LIMITED, EVEN WHEN THE CHILD is AT THE MOST FAVORABLE AGE. (Dowd.) FIG. 71. ILLUSTRATIVE OF THE SAME PROPOSITION AS FIGURE 70. (Dowd.) 174 OSTEOMYELITIS Local treatment of the affected parts is not only useless, but is positively harmful, in that the glands are subjected to unnecessary injury. It is very important, however, to remove all possible sources of irritation, such as hypertrophied tonsils, adenoids, pathological con- ditions in the nose, chronic otitis, conjunctivitis, caries, ulcerations about the nose and mouth, etc. Operative measures are indicated if the above means have been tried for two or perhaps three months without success, as is shown by the glands continuing to increase in size or in number, and par- ticularly if softening occurs. Under the above conditions it is unwise to leave the cure to Mature, because there always remains the danger of a general in- fection or an added one of a different type and the scarring and chronicity of the non-operative cure are a disadvantage and always remain an uncertainty. And when the operative procedure is decided upon it must be radical enough so that all of the diseased tissues are removed through a free incision. OSTEOMYELITIS In considering the surgical diseases of bone, the fact should be recalled that bone is not merely the framework on which the tissues are arranged, but that it is itself a tissue a tissue, though dense, well supplied with blood conveyed by periosteal and medullary ves- sels. Thus, when bone is divided or injured, it bleeds like other tissue, and hence shows the same inflammatory reactions to irrita- tion. Furthermore, the ends of the long bones (epiphyses) are at- tached to the shaft (diaphysis) by means of its epipliyseal cartilage, from which the bone continues to grow in length until it has reached maturity, when the cartilaginous junction disappears and the epi- physis is solidly joined to the shaft. Hence bones increase in length by continued ossification in the epiphyseal cartilage. Bones increase INFECTIVE OSTEOMYELITIS 175 in circumference by the deposition of new bone from the deeper layer of the periosteum. Anything which interferes with growth at the epiphyseal line will lead to diminution in the length which the adult bone should attain. Anything which interferes with growth from the deeper layer of periosteum will result in a disproportionate thickness of bone. Again, the marrow inside the shaft of the long bones is important ; for we note that in children and up to the age of fifteen this mar- row is red, extremely vascular, and that it forms one of the blood factories of the body. With adult life the marrow becomes yellow, owing to the deposition of fat cells, and its blood-forming function ceases. INFECTIVE OSTEOMYELITIS Infective osteomyelitis is an acute suppuration of the bone due to the lodgment and growth in the b6ne marrow of pyogenic organ- isms. This suppurative process assumes distinct characteristics 'because of the anatomical peculiarities of the tissue involved. Its virulence and extensive ravages are evident when we consider the kind of tissue affected, and the dense bony walls which imprison the products of inflammation. It is preeminently a disease of childhood and adolescence, and, while it prefers the diaphysis of the long bones near the fertile epiphyses, no bone of the body is exempt. Etiology and Pathology. PREDISPOSING CAUSES. It is evident that osteomyelitic infection is favored by suitable soil. Thus we note its preference for growing bones one-half the cases appear be- tween the ages of thirteen and seventeen. Again, an injury or blow which lowers the vital resistance of the tissue often precedes the appearance of the disease thus, for example, the disease occurs three times as frequently in boys as in girls, which emphasizes the influence of trauma, to which boys are more exposed. Faulty nutri- tion, exposure to cold, and extreme fatigue must also be reckoned as factors in preparing the soil, while previous infectious diseases (the exanthemata, typhoid, pneumonia) often provide the invading microorganisms. 176 OSTEOMYELITIS The DIRECT CAUSE is a pyogenic infection from a near-by wound (compound fracture, etc.), or, in the great majority of cases, carried by way of the blood vessels (hematogenous). The infecting mechanism is most commonly the Staphylococcus pyogenes aureus, more rarely the albus and citreus. In a few cases it is the streptococcus. In some cases the pneumococcus. In chil- dren under two years we may get a pneumococcus osteomyelitis with- out an antecedent pneumonia. The bacteria are deposited by the blood vessels in the bone marrow, which, because of its own dimin- ished power of resistance or the great virulence of the germ, finally perishes in the struggle and there is inaugurated a suppurative inflammation which rapidly spreads through the Haversian canals, reaches the periosteum, leads to suppurative periostitis, lifts the periosteum from the bone, denudes the bone of its nutrient membrane, and leaves a necrotic mass of bone involving either a part or the entire shaft. The rarer cases are those caused by inflammation through the periosteum. As the process proceeds the necrotic area is gradually separated from the healthy bone by a layer of granulation tissue, the periosteum forms new masses of bone which walls off and en- capsulates the sequestra, through this wall are found openings for the drainage of pus, which makes its way through the overlying soft parts and leads to fistula formation. The granulation tissue surrounding the sequestra has a digestive action which, in the course of years, is capable of dissolving large sequestra and thus bringing about a spontaneous cure, providing the gravity of the disease and the long-continued suppuration do not lead to a fatal termination. Remember that it is impossible to judge of the extent of an osseous inflammation by its intensity and the extent of the periosteal lesion. Sometimes a limited osteomyelitis is associated with considerable periosteal detachment, and again the periosteum is often little af- fected, while the bone may be infiltrated from its surface to the depth of its medullary canal. The favorite place for the disease is the long bones, and the parts most frequently affected are in the order named : the lower extremity INFECTIVE OSTEOMYELITIS 177 of the femur, the upper end of the tibia and fibula, the upper end of the humerus, the inferior extremity of the radius and ulna. Symptoms, A previously healthy child is suddenly attacked with intense pain localized near the ends of one of the long bones accom- panied by chills and high fever. The pain of osteomyelitis has two characteristics: (a) Its sudden onset. As Estor suggests, ask the patient with osteomyelitis to tell you what day the disease appeared and his response will be precise, not only as to the day, but the hour of the first chill. (b) Its intensity. The excruciating sever- ity of the pain, aggravated by the slightest mo- tion or pressure, is comparable to no other pain symptom. It may be referred to the entire bone or to a neighboring joint. One of the most characteristic symptoms is loss of function in the affected limb. The pa- tient is absolutely unable to move the limb in the slightest manner. There is tenderness, sometimes involving the entire bone, but the greatest tenderness is over the inflammatory focus. It is obvious that, since the products of suppuration are confined within an impermeable bony wall, the amount of septic absorption and the symptoms of tox- emia are extreme. Hence the pulse is rapid, THE TIBIA. (Lexer.) , , . , . j.i a - Purulent forces in the temperature high, the tongue dry, the eyes metaphysis which sunken. Delirium, stupor, and coma succeed each other so rapidly that the characteristic local symptoms often entirely escape notice. The leukocyte count is high 25,000 to 30,000, with a relative increase of the polymorphonu- clear leukocytes. Locally there is swelling of the soft parts over the infected bone. [G " epiphysis; b. Peri- osteum raised by pus; c. Phlegmon of the medulla; d. Separation of the epiphysis ; e. Rup- ture into joint. 178 OSTEOMYELITIS The skin becomes red and edematous, and the neighboring lymph glands are swollen and painful. Fluctuation of the soft parts indi- cates abscess, which may open spontaneously and be followed by fistula formation. Escape of the pus externally is followed by cessa- tion of pain and fever. Nor is the process always confined to the bone first attacked. It may extend to the epiphysis, lead to its de- tachment and final destruction, enter the joint and cause a suppura- tive arthritis (see Fig. 72). Likewise the infection may be carried by the circulation to other bones and there may result multiple suppurative foci. All these complications add to the gravity of the situation and may lead to death. Diagnosis. With a disease presenting such striking characteris- tics it may be difficult to explain why so many cases of acute osteo- myelitis are compromised by a procrastinating medical treatment when the indications for surgical intervention are immediate. As a matter of experience osteomyelitis is often confounded with typhoid fever, acute articular rheumatism, and meningitis. This is true especially of rheumatism. The explanation is not difficult when we consider that when the doctor first sees the case it is usually after the severe initial symptoms. The clinical picture has changed to one of profound prostration with cerebral symptoms. In other words, the delirium, stupor., and coma have succeeded one another in such rapid succession that the severe initial and localizing symptoms are masked by the profound septic intoxication. The picture is now one of septic fever not unlike typhoid, and, if a careful history of the onset is not obtained and a careful examination, especially of the long bones, is neglected, confusion is inevitable. Rule: Every child suddenly attacked with high fever and de- lirium, of the origin of which there is the slightest doubt, should be carefully examined for osteomyelitic foci. Typhoid Differential. The leukocyte count is characteristic. In osteomyelitis the leukocytosis is marked ; in typhoid it is absent. Compare the onset of 'the two diseases, the difference is clearly de- fined; typhoid is not sudden, it is preceded by well-known prodro- INFECTIVE OSTEOMYELITIS 179 mata, with diarrhea and abdominal tenderness. None of these are present in osteomyelitis, besides typhoid presents no acute bone symptoms. Widal reaction is of little use as an early means of diagnosis; its value as a diagnostic aid is in the second week of typhoid. In painful bone and joint affections rheumatism is the last thing to think of. Acute Articular Rheumatism Differential. Rheumatism affects more than one joint and the pain is circumscribed, not the diffused and reflected pain of osteomyelitis. The maximum of pain is inter- articular, not epiphyseal or diaphyseal. Joint symptoms in osteomy- elitis are late symptoms. The general symptoms in rheumatism are much less severe than in osteomyelitis. In all cases of doubt the X-ray is an important aid in clarifying the diagnosis. Prognosis is grave, not only in the acute forms, which often have a fatal termination, but in those less severe forms where the disease becomes chronic and there is established a constant evolution of new sequestra, new abscesses, new fistulae, extending over a number of years and bringing about chronic visceral lesions, amyloid degenera- tion of the liver and kidneys. Treatment. There is only one treatment for osteomyelitis: radi- cal surgical intervention without delay, since there is no contraindi- cation to operation when once the diagnosis of acute osteomyelitis has been made. Furthermore, superficial incisions down to the soft parts are futile. The surgical relief of osteomyelitis contem- plates nothing less than an opening in the bone down to the marrow the focus of infection. Remember that the pus is in the medullary canal as well as under the periosteum. Hence, periosteal incisions are insufficient. Method. Make a free incision the full length of the affected part down to the bone, being careful to avoid the tendons, vessels, and nerves, and to secure perfect hemostasis. Be sure to lay the periosteum open the full extent of the pathological process; then open up the bone either by trephine at three or four points, or by chiseling a groove out of the bone as far as the pus infiltration of 180 OSTEOMYELITIS the marrow extends. Be careful not to lift up or injure the perios- teum unnecessarily. The pus is to be carefully wiped out and the bone cavity drained. A specimen of the pus should be examined to discover the infecting organism and the appropriate vaccine prepared for injection. Curet- ting, irrigating with antiseptic solutions, and otherwise disturbing the infected marrow are to be avoided. For it will be recalled that the internal surface is lined with endosteum the bone-forming membrane of the internal surface of the cortex. Curetting only destroys the integrity of the endosteum and leads to necrosis of the inside of the cortex. The treatment of osteomyelitis is compromised as much by super- ficial incisions as by late incisions. Trephining the bone adds noth- ing to the risk of operation it may not only save the bone, it may save life. Interfere as little as possible with the epiphyseal line, especially at the knee. In the lower extremity the increase in length of the bones is greatest at the knee. In the upper extremity the increase is greatest at the shoulder and wrist. In cases operated upon very early (which is exceptional) before the endosteum is destroyed, there will be no formation of a seques- trum, and the wound will heal by granulation. In the majority of cases (late operation, spontaneous opening, inadequate drainage, etc.) the endosteum has been destroyed, a portion of the bone ne- croses, there remains a sequestrum, and the disease passes into the subacute or chronic stage, in which is seen the process of sequestra- tion by which the necrotic bone separates and forms a sequestrum a foreign body surrounded by a shell of new bony formation, which is perforated by fistulae and continues to discharge pus so long as the sequestrum remains. It is evident that the sequestrum must be removed, either spon- taneously or by operation, and the management of this stage of the disease demands surgical discrimination. Formerly it was thought wise to wait until the sequestrum was freely movable and surrounded by a dense shell of bone. No one rule of procedure is broad enough to cover all cases and the surgeon must discreetly select the operation INFECTIVE OSTEOMYELITIS 181 which best fulfills the anatomical and pathological requirements. Nichols has ably classified these cases and their treatment as follows : (1) Removal of the necrotic sequestrum before the hard bony shell is formed, and while the periosteum is still plas- tic. This operation is applicable where "an accessory bone is present which may act as a splint and main- tain the length of the limb during the process of bone regeneration." For example, the fibula may act as a splint while the tibia is undergoing regeneration. Again, it is indicated "in those cases in which there has been an extensive destruction of the entire diam- eter of the diaphysis over a greater or lesser length." The usual time for this operation is at the end of the eighth week. The operation contemplates the removal of the dis- eased portion of the shaft subperiosteally, the excision being made through healthy bone. The periosteum is carefully stripped off and preserved in its integrity so that it forms a bridge between the two remaining O o ends of bone over which a new shaft of bone is formed (Fig. 73). The results in properly selected cases are excel- lent. The newly regenerated bone is functionally sat- isfactory and may be used with safety in from six to eight months. FIG. 73 DIA- GRAM TO SHOW REMOVAL OF A PORTION OF THE TIBIA, AND RELATION OF INFOLDED PERIOSTEUM WHICH FORMS A BRIDGE BE- TWEEN THE Two REMAIN- ING ENDS OF BONE. (After Nichols -Keen's Surgery.) (2) Removal of the necrotic sequestrum as soon as the involucrum is sufficiently strong to guarantee the integrity of the shaft. This procedure is indicated where there is no ac- cessory bone to act as a splint, such as the humerus, where it is evident that a removal of any portion of the shaft before a periosteal shell is formed must result in deform- ing muscular contractures. Furthermore, the operation must be done before the involucrum becomes too dense and while it still has reparative power to fill up the central defect left by removal of the sequestrum. 182 OSTEOMYELITIS It is often a difficult question to decide when the conditions are ripe for this operation. Nichols believes that the operation can be undertaken when the total diameter of the involucrum is equal to one-half of the diameter of the normal shaft, and that the time is approximately twelve weeks after the acute infection. (3) Removal of sequestrum with dense involucrum. The diffi- culty with these cases is not in the removal of the sequestrum, but after the sequestrum is removed there is still a discharging bony cavity which refuses to heal, the inner surface of the dense bony shell has lost its power of regeneration, and there remains a suppurating cavity with all its secondary dangers. The problem, then, is how to obliterate the defect after the se- questrum is removed. The number of procedures suggested is an evidence of the difficulties which present. Prominent among these suggestions are: Filling the cavity with pieces of sponge; Utilizing a blood clot, hoping for its subsequent organization; Filling the cavity with Mosetig's iodoform plug, which consists of iodoform sixty parts, spermaceti forty parts, and oil of Sesame forty parts. This mixture remains solid at body temperature ; when used it is heated until it is fluid, poured into the bone cavity, where it is expected to form a framework for bone deposition. It must be evident that the filling of bone cavities either with blood clot or foreign substances is, as a rule, a disappointing pro- cedure, since success depends upon asepsis a condition which, in these bone cavities, it is well-nigh impossible to obtain. A far better procedure is to remove the dense cortical shell ex- tensively until the bone surface is flattened and then fasten to the bone surface inverted flaps of skin taken from either side of the cavity. In many cases these skin flaps will adhere to the bone and obliterate the cavity. Living Bone Grafts. A few successes have been reported by this ingenious method; even entire joints have been transplanted. The whole question of transplanting the living tissue of animals to supply human defects is in the experimental stage and its employ- ment is suggested, not advised. RAEER FORMS OF OSTEOMYELITIS 183 RARER FORMS OF OSTEOMYELITIS Periostitis Albuminosa. Periostitis albuminosa, first identified by Oilier, is really a superficial osteomyelitis, due to an attenuated form of one of the pyogenic organisms, in which the exudate is serous in- stead of purulent. It is characterized by an accumulation of mucoid or gelatinous fluid like synovia, situated between the bone and the periosteum. It is found especially in the young and near the epiphyses of the long bones. The bone is very slightly affected, though in some cases there is a superficial necrosis. It usually begins with sharp pain in the bone with rise of tem- perature and considerable localized swelling, which fluctuates on palpation. On incising the swelling we find the periosteum thick- ened and an albuminous fluid between the periosteum and bone. The prognosis is favorable and simple evacuation of the fluid is sufficient to bring about a cure. Primary Chronic Osteomyelitis. Primary chronic osteomyelitis is that form of osteomyelitis in which the patient presents sequestra and an hyperostoses without any of the previous characteristic phenomena of acute osteomyelitis. It is to this form of osteomyelitis that Paget gave the name of "quiet necrosis." The patient presents the symp- toms of pain and swelling of the bone, but the general state is not affected the bony changes take place without suppuration. This silent change may go on for months or years and finally become an acute process. To differentiate it from syphilitic osteomyelitis and osteosarcoma is very difficult. The X-ray may be of service. The obvious treatment is removal of the necrotic bone. In ex- ceptional cases the necrosis has been so extensive that amputation was necessary. 184 TUBERCULOSIS CHAPTER XXVIII TUBERCULOSIS SURGICAL TUBERCULOSIS By this term we include those varied lesions affecting different structures, which are directly attributable to infection by the tubercle bacilli, and which require surgical intervention. More or less strict localization is the rule, so that often drainage, removal, or sterilization is possible. This infectious, communicable disease was at one time, and not long since, considered somewhat uncom- mon during infancy and early childhood and although many con- ditions of the child's system were described as predisposing to tuberculosis they were not always recognized as the early features of the disease itself. But now the disease occupies an important place in pediatrics and surgery and contributes largely to infant mortality and childhood suffering. Scrofulosis was a term that was freely used a few years ago to define what was then thought to be a definite clinical entity but which is now held to be synonymous with tuberculosis. It implied that the affected child was one possessing a very low resisting power which was generally hereditary and particularly prone to enlarge- ment of the lymphatic glands. Generally these indications were present after the third and before the tenth year of life. As there was always present a general malnutrition, almost innumerable symptoms would be dependent upon this and upon the fact that the child showed a marked inclination to the occurrence of chronic in- flammation of various tissues and organs under the influence of the slightest irritation. Whether the term should be retained to still define a condition is still a question among many writers. Status lympliaticus or lymphatism is often confounded with tuberculosis, but as it is fully considered in another section (see page 155) it need not be elaborated here. Etiology. TUBERCLE BACILLI. The tubercle bacillus appears in SURGICAL TUBERCULOSIS 185 the tissues as a short, slender rod and is classed by many with the streptothrices because of the inclination to produce branching form in culture media. Its main characteristics are its slow growth on culture media and its difficult development under the influence of either high or low temperatures. Thus we see that the bacilli are parasitic and that they cannot multiply except in the body of an animal. It is a well-known fact that dried sputum retains its virulence for from two to four months but that exposure to sun- light or even the milder antiseptics reduce or destroy that virulence. Action of the Bacilli in the Tissues. Unless destroyed soon after entering the body, the bacilli multiply rapidly and establish an area of chronic inflammation, the result of which is the forma- tion of granulation tissue. The cells of this focus may take on a characteristic arrangement, so that the result is the formation of tubercles. These are recognized as small nodules, produced by pro- liferation of the connective tissue and in the course of their develop- ment their centers undergo caseation. Microscopically, a fully de- veloped tubercle appears with its center necrotic and at its periphery there are numerous giant cells, each of which consists of a mass of degenerated protoplasm with five to twenty nuclei at its border. The necrotic center is usually surrounded with a wall of epithelioid cells and round cells again surround these. Then comes a more or less complete surrounding with mature connective tissues, and if this be completed the tubercle is said to be encapsulated. But occasionally the tubercle appears as a more diffuse affair so that we encounter cell proliferation over a considerable area. CONDITIONS PREDISPOSING TO INFECTION. Of first importance, we must mention any condition of lowered vitality irrespective of its cause and independent of the fact as to whether it is hereditary or acquired. Such a condition renders the tissues of the child more easy of invasion and makes the multiplication of the bacilli more certain. The Influence of Heredity. Instances of congenital tuberculosis have been reported but they are rare. However, it is a well-estab- lished fact that tuberculosis is very apt to occur in very young children and in them shows its most varied forms, but this does not 186 TUBERCULOSIS mean that the disease is necessarily congenital. With the clearer understanding of the disease, the influence of heredity has been minimized, so that at the present time it is not considered as an important factor. But not so with what is called the tuberculous diathesis. The tuberculous diathesis plays as important a part in the etiology of tuberculosis as does the exciting cause itself. Inde- pendent of direct infection there can be no development of the disease. In the presence of the diathesis it requires but a slight exposure to start the process. Under exactly similar conditions, the diathetic child will succumb, while the non-diathetic one will escape. Those who ignore the influence of a constitutional taint that renders the child peculiarly vulnerable to tuberculosis ignore the evidences which have come through the careful compilation of life insurance tables which cover thousands of cases and extend over a long period of years. The family history then becomes an impor- tant factor in the recognition of the disease and its probable occur- rence. Environment is an important factor because, while lowered re- sistance and chronic states of malnutrition predispose to the develop- ment of tuberculosis, environment certainly influences nutrition and resistance. Poverty with its consequent evils of overcrowding, poor ventilation, insufficient food, and absence of recreating influences becomes an important predisposing cause. The geographic dif- ferences in the disease can be explained mostly upon the basis of differing environment. Age has a very distinct influence, for tuberculosis is rare during the first few months of life, but, as the infant grows older, the pre- disposition becomes relatively stronger. Probably 80 per cent, of the cases occur between the second and fifth year. During the first two years the disease occurs almost exclusively as an affec- tion of the bronchial lymph nodes or of secondary pulmonary in- volvement. After two years, tuberculous meningitis is more common than before, and affections of the bones, of the mesen- teric lymph nodes, the peritoneum, and the intestines are not un- common. SURGICAL TUBERCULOSIS 187 The predisposition of sex is doubtful, infants and children of both being affected apparently in equal numbers. Racial predisposition is noticeable in that the colored race is particularly prone to the disease. Predisposition of Previous Disease. This we consider a most important factor. Naturally we are aware that any exhausting disease may predispose to tuberculous infection, but, irrespective of this, we are convinced that more cases of tuberculosis follow measles and pertussis than under any other conditions. Given a child who by a favoring constitution or association with the disease has been liable to infection, the probabilities of such infection are great if measles or pertussis occur. And this appears to be entirely independent of the severity of these two diseases. Personally, we never consider a child safe after an attack of either disease until it has been thoroughly examined several times after convalescence and for a period covering at least three months in measles and one year in pertussis. Traumatic predisposition seems to determine the localization of the disease rather than its occurrence and we have been impressed with the fact that the occurrence of an injury often gave the sur- geon the first opportunity to discover the presence of the disease. Bone and joint injuries are particularly liable to be followed by localization of the disease and this is especially true if the injury be a slight one. But in most instances examination of the child shows that there is a tuberculous affection of some other tissue present and that the injury has simply aroused localized infection through the influences of lessened resistance. A more severe injury calls for more active participation by the system in the processes of immediate repair and therefore seems to render strict localiza- tion less liable. Clinical Manifestations in Children and Adults. While the tissue results are practically the same in adults and children when infec- tion has occurred, still there are some marked differences of invasion that need to be borne in mind. In dealing with adults, the mind naturally turns to pulmonary involvement when tuberculosis is men- tioned. But to the pediatrist or the pediatric surgeon, tuberculosis 188 TUBEKCTJLOSIS means first some glandular, meningeal, miliary, bone, joint, perito- neal, or diffused lesion, while pulmonary involvement is the least prominent. If the disease occurs as an acute infection in the child it is much more liable to become generalized than in adult life. The same is true if the lesion be strictly localized; generalization is the rule in children. Clinical Diagnosis of Tuberculosis. The clinical diagnosis of tu- berculosis is almost always possible without actual demonstration of the presence of the tubercle bacilli, but on the other hand there are so many conditions which in their onset so closely approximate the onset of tuberculosis that recognition of the bacilli becomes almost indispensable. It is true that while the tubercle bacilli are always present if the lesion is due to tuberculosis, yet their demon- stration may be attended with so much difficulty that microscopic examination is unsatisfactory and uncertain. Under such conditions resort must be made to inoculation of the suspected material into the organisms of susceptible animals. In fact, in an examination for the bacilli in the skeletal structures it should not be expected that they will appear in anything like as large numbers as in other situations, as, for instance, the viscera. In fact, a considerable search may have to be made before they are demonstrated. We have repeatedly observed instances in which the most thorough and per- sistent search failed to reveal them at all. This fact has made the inoculation of animals a necessary procedure in many cases. It must, of course, be recognized that nothing approaches in importance the actual demonstration of the presence of the tubercle bacillus as a direct means of diagnosis and this needs to be empha- sized when the indirect methods are in such common use to-day. There is always the danger that the indirect methods will be given an undue importance. Tuberculin is used in the indirect methods of diagnosis. There are three ways of using it. (1) SUBCUTANEOUS TUBEBCULIN TEST. The usual method is to administer 1-10 milligram for the initial dose and double that quantity in forty-eight hours if no reaction occurs. If there is slight reaction from the initial dose, the second one is of the same quantity as the first and, if the second reaction is more marked SURGICAL TUBERCULOSIS 189 than the initial one, this constitutes a positive reaction. If there is no reaction from the first two doses, a third and still larger dose is given and if no reaction occurs the result may be considered as negative. The child should be under observation for two days preceding the test and four-hourly temperatures recorded. After the adminis- tration, two-hourly temperatures are recorded. The site chosen is not very important but the usual aseptic precautions are necessary. Reaction is of two kinds : general and local. General reaction includes a rise in temperature, increased pulse rate, general malaise, and, possibly, some headache. The really valu- FIG. 74. VON PIRQUET TEST FOR TUBERCULOSIS. In making the three scarifications, the control should be left at the top, so that rubbing will not inoculate it from the other two scarifications. able sign is the elevated temperature and it occurs between the sixth and twelfth hour as a rule, a rise of more than one half degree being regarded as positive or, at least, as an indication for other injections. The local reaction cannot always be observed, but if present is of greater value than the general signs. It varies with the site of the disease, so that in pulmonary tuberculosis there may be in- creased pain or cough, while in tuberculous glands there occurs an increase in tenderness and swelling. In peritonitis a more or less active diarrhea may be set up. (2) CUTANEOUS TEST (Von Pirquet). The site chosen should be cleansed carefully and dried. Water and alcohol must be avoided 190 TUBERCULOSIS as they cause the tuberculin to flow. Three scarifications should be made (preferably upon the inner surface of the arm), sufficient to partly denude the surface but not draw blood. These scarifi- cations are best placed three to four inches apart. Into two of these the tuberculin is placed and protected from flowing by cotton, but care must be used not to use enough cotton to completely absorb the tuberculin. (For Lincoln's method see page 201.) A positive reaction may occur after a few hours or may be latent Fio. 75. Mono TEST FOR TUBERCULOSIS. for several days, but the usual appearance is within twenty-four hours. The specific reaction begins as a slightly raised red spot spreading from the scarification with the diameter of the papule usually about two-fifths of an inch. Exceptionally the center is soft but never pustular. The Moro Reaction. In this test the skin of the abdomen or chest is rubbed over a surface of four square inches, with a pea- sized piece of the tuberculin ointment. Usually on the second day, 191 if positive reaction is present, small papules appear over the treated area. These disappear within a week. (3) OPHTHALMO-REACTION (Calmette). In this test one drop of a one per cent, solution of tuberculin is instilled into one eye of the patient and if positive there occurs redness of the caruncle spreading to the conjunctiva with the production of tears and some discomfort. In some instances the severity of this reaction becomes alarming. Three to twelve hours is the usual time for the reaction to appear after the application. Its use is of too much uncertainty and fraught with too great danger to be of practical service in children. The clinical diagnosis of surgical tuberculosis is based in general upon the formation of tuberculous tissue in the form of tubercles or of larger areas of tuberculous infiltration, with a tendency to caseation (and finally softening and liquefaction), absence of the usual signs of acute inflammation, marked tendency to the invasion of surrounding tissues, and chronicity. General Principles of Surgical Treatment. These are directly in- fluenced by the marked tendency of the disease to become general- ized in childhood, no matter what or where the primary focus may be. The results are two: (1) there are considerably more care and thought given to the advisability of operative interference, and (2) when once the operation is determined upon, the most radical pro- cedure seems to promise the best protection to the child. All this procedure requires a nicety of judgment and a thorough- ness of examination such as are rarely necessary under other con- ditions. The disease as it affects the bony structures shows a decided pre- dilection for the epiphysis and, in this particular, we observe that it is quite the opposite to osteomyelitis, which usually invades the diaphyses. Of course, we must not be unmindful of that peculiar localization which is almost exclusively confined to the period of infancy, in which the diaphyses of the smaller long bones of the hand and foot are affected. It is the spongy portion of the bone that bears the brunt of the primary invasion, as a rule. The interior of the bone is not un- 192 TUBERCULOSIS commonly the site of the original infection, and in that case we observe a tuberculous osteomyelitis. A cold abscess may result, but more often we encounter a caseous focus in the thickness of which there may be a sequestrum which differs materially from that of an osteomyelitis, in that it is not so hard but is much more friable and has all of the characteristics of a caries. When occurring in the superficial structure of the bone, there is commonly a quite strictly localized lesion of the bone, with subse- quent extension through and finally over the periosteum of pus, and, when such an abscess is incised, we frequently observe that the periosteum is intact for a considerable area. It is a common experience that the tuberculosis beginning in bone may heal spontaneously, and this is particularly so if a joint is not involved. And even in the latter case resolution sometimes takes place. But the tendency is toward extension and progression and therefore every case must be treated as radically as the cir- cumstances demand. And no matter how careful the surgeon may be in his removal of all seeming diseased tissue, it is often impossible to be sure that some small area has not been left un- touched. In infancy and childhood the onset is usually not that of an acute arthritis, but it occurs as a slow and painless condition. Despite the marked tendency toward progression and extension, we cannot too strongly state that tuberculosis of the bones and joints is amenable to treatment, and the results are remarkably good, con- sidering the destruction present. Treatment of Surgical Tuberculosis. GENERAL TREATMENT. - The treatment of surgical tuberculosis involves at the outset the protection of others, so that it becomes the immediate duty of the surgeon to destroy any infected material or discharge or to render it incapable of infection. Fire is the best means of protection and all materials that can possibly be so destroyed should be. Climate is of considerable importance in tuberculosis affecting the lungs, but in the disease as it affects the bones, the glands, and the joints it has little if any influence. And so, surgical tubercu- losis does not demand change of climate. However, the influence SURGICAL TUBERCULOSIS 193 of sunshine and fresh air is nothing short of remarkable. It can be readily placed in the very front ranks of surgical treatment of tuberculosis, constituting considerably more than one-half of the beneficial influence upon the lesions. It is therefore imperative that the child spend most if not all of its time in the open air, and, when conditions permit, all the hours possible should be spent in the direct rays of the sun. It is of course desirable that the air be clean as well as fresh and free from dust and odor. If there is a preference to be given the location, the seashore should be selected as best adapted to meet all of the necessary conditions. The influence of direct sunshine is of very large importance in the treatment and when feasible the portion of the child's body affected with the disease should be exposed to the sun's rays oc- casionally during the day. The rays have a considerable pene- tration power, retard the growth of the bacilli, and favorably affect the nutritive processes. The influence of the clean fresh air is largely dependent upon its oxygen, which, when inhaled continuously, stimulates oxidation and favors reparative processes. Rest of the affected part is im- portant in the treatment. This very fact will often try the re- sources of the surgeon because its enforcement may mean confine- ment to bed, which latter may be undesirable. Here is the place for a display of judgment and the child should be given the benefit of confinement to bed, but not in a close room but in the open air. And while the necessary rest which is entailed helps to bring about a condition characterized by the temporary retention of waste products and muscular atony, this may be overcome to some extent by passive exercises. Gentle massage administered at regular intervals, with or with- out oil, and passive motion of all parts not affected will usually suffice. The eliminative forces of the skin, bowel, and kidneys must be encouraged, because the diet must be necessarily forced. By forcing the diet we imply that all the nourishment possible should be given, but with the most careful attention to the digestive capacity. At no time should the desire to increase the nutrition jeopardize the diges- 194 TUBERCULOSIS tion. However, we must aim to give a diet which is beyond the needs consequent upon waste; in a word, the child should be fully- fed rather than underfed. We have found that in many instances plain milk is distasteful and it is the rule to use the top pint (after the cream has risen) from a quart bottle and dilute it with eight ounces of plain water, any cereal water, or a carbonated water (suiting it to the child's changing tastes), and adding one- half to one dram of sugar of milk to each two ounces of the mixture to increase the carbohydrates. This plan works remarkably well. There is no one plan of diet that will favorably affect all cases ; the mixed dietary is best suited to the indications. Most of the digestive disturbances are directly traceable to one large meal, and therefore the effort should be made to control this, so that small meals are given at rather shorter intervals. Eggs are very valuable, but there is a mistaken notion that the whites represent all of the nourish- ment; this is not so, the whole egg should be given and preferably raw or very lightly cooked. Cod liver oil is also used as a food and its judicious administra- tion certainly accomplishes marked results in many instances. Milk, eggs, and cod liver oil have been specially mentioned simply because they are preeminently valuable and we wish to speak briefly of the methods of administration. It is unnecessary to elab- orate upon the values of the various other articles of diet, for their values are fully considered in books devoted exclusively to that pur- pose. All that is necessary now is to reiterate that the great bulk of the treatment consists in rest, fresh, clean air constantly supplied, and a dietary which more than meets the immediate needs without in any manner disturbing the child's digestive apparatus. Drug administration may safely occupy a very minor field. This type of treatment is quite restricted to the control of unde- sirable symptoms and to influencing the nutritive and reparative processes. There is often the indication for a well-selected tonic or even a stimulant, and the inevitable anemia always demands the administration of arsenic or iron. Then we have recourse to such remedies as relieve individual accompaniments, as constipation, insomnia, excessive perspiration, etc. SUEGICAL TUBERCULOSIS 195 LOCAL TREATMENT demands rest, as has been stated, and this may in turn require some restraining apparatus. During the acute and painful period the best restraining apparatus is undoubtedly plaster, as it is efficient and cannot be disturbed by the child. But as quickly as the circumstances will allow, substitution should be made by using leather or a less harsh restraining apparatus than the p]aster cast. There is also another element in the rest treatment that we must always consider, and that is that the limb is not only placed at absolute rest, but also in a good position. This position must always approximate as closely as possible the position of the particular limb in repose, and therefore we have a different posture for each joint. But irrespective of rest and posture there are several drugs that pos- sess antituberculous properties, and advantage may sometimes be taken of these in the local treatment of the lesion. lodoform or formalin are the best of these (see page 197), particularly if acting in a part from which air is excluded. Guaiacol has been used freely as an application over an affected part, but its service as such is doubtful. Zinc chlorid, balsam of Peru, oil of cinnamon, ichthyol, and mercury ointment have all won advocates, but after all their use is very limited. The Finsen light and the X-ray have a place in the local treat- ment of the disease, being particularly useful in areas of localized tuberculosis, and especially in lupus, in which they effect such a decided influence that they should be used. Lupus, however, is ex- ceedingly rare, but when encountered it is usually between the ages of eight or nine and puberty. The adult cases are generally exacer- bations of old areas which were present in childhood but which break down again later. OPERATIVE TREATMENT. In the operative treatment the prin- ciples involved are to thoroughly empty and remove all tuberculous foci and to complete the destruction of any bacteria present. Unless the operative procedure can be radical and complete, it should be deferred, for partial operations or those which are not sufficiently radical nearly always result in a widespread diffusion of the process with its attendant dangers to the life of the patient. 196 TUBERCULOSIS There are times when it may be advisable to simply open and drain, but these are so few that the decision to do so must only come after the most careful consideration of all the factors involved. The incomplete operation, that is, with the removal of some of the tissue, is much more dangerous than incision and drainage, be- cause partial removal opens up avenues for infection which were closed previously by white blood corpuscles or fibrous tissue. In considering any operative procedure upon foci of tuberculous infection we must be mind- ful of the fact that, just as long as the foci are circum- scribed in the depths of the tissue without contact with external air, the tubercle bacillus is the one that is present in pure culture. Once exposed to the air, and the staphylococci and the streptococci added, they bring another danger to the patient, favoring degenera- tion of the tuberculosis and devitalizing of the child. It is necessary to men- tion the claim of Bier that under certain circumstances the production of active or passive hyperemia will favorably influence an inflamed area. Just why hyperemia so produced should influence tuberculosis is still dis- puted. The method of passive hyperemia is of undoubted value in some instances, and in some of these cases its value is great, the re- sults being quick and marked. There is no question but that in most instances it lessens the pain, and if the applications of the cups or the bandages are of short duration and but slight hyperemia pro- duced, the results in joint tuberculosis warrant its extended trial. At one time it was presumed that a radical operation meant only FIG. 76. TUBERCULOUS INFECTION OF THE BONES OF THE FACE. On the right is seen the swelling which has per- sisted for two months, while on the left the tissues have broken down and there is well marked, just in front of the ear, a point at which the skin is ready to break. This swelling has persisted for four months. SURGICAL TUBERCULOSIS 197 amputation or resection. Amputation fortunately is practically a relic of past treatment. Eesections of the joints are open to the serious objection that they are usually followed hy persistent sinuses and continuous suppuration and destruction of the joint does not bring about any certainty of a cure because of the involvement of the neighboring structures. There are also always a very consider- able shortening and the ever present danger of a resulting flail-like limb. Resections should be avoided whenever possible in infancy and young childhood because of their mentioned dangers and the fact that simpler operations are just as certain in their ultimate results. In the operative treatment of cold abscesses no satisfactory re- sults are obtained from puncture and subsequent injection (of iodo- form and ether) unless the proper time is chosen for the procedure. If the skin is already reddened above the abscess we are certain to find that a fistulous tract has already been formed and puncture is apt to bring about just what we are trying to avoid septic compli- cations. But, on the other hand, if opened by puncture too early, that is, before fluctuation, the procedure is not successful. In performing puncture the very strictest attention must be paid to every detail as far as the most rigid asepsis is concerned. In performing puncture as much of the content of the abscess as pos- sible should be removed and then the cavity washed out with a sat- urated solution of boric acid until the return is quite clear, after which the iodoform and ether may be injecteol. The amount of iodoform used is that which is within safe limits for the particular child under treatment. As ordinarily used iodoform should be mixed with ether in the strength of 1 to 10, and with such a mix- ture the penetration to the deeper structures is great, the expansion of the ether as it evaporizes carrying the iodoform with it. We might add the precaution that in withdrawing the cannula from the trocar sufficient time should elapse to allow the ether to vaporize sufficiently to distend the cavity of the abscess, and then its escape should be slow. After such a procedure it is very impor- tant that the part subjected to the operation be immobilized, and preferably with a plaster apparatus. Usually it is necessary to re- 198 TUBERCULOSIS peat the procedure two, three, or even four times, but not infre- quently one operation is all that is needed. The interval between punctures should be close to three or four weeks. Even when unsuccessful as far as a cure is concerned puncture, when repeated, gives one a strong clew as to the course that the dis- ease is taking through the character of the liquid which is with- drawn. Occasionally, despite all precautions, a sinus will form and the contents of the sac be forced out through the opening made by the trocar, but the protective influence of the iodoform seems to prevent any septic complications. When puncture fails it is usually because the sac is filled with a caseous material which cannot be removed entirely by this method. In such cases free incision and cleansing with subsequent phenol swabbing are efficient. The phenol is liquefied with glycerin, and the whole cavity swabbed so that the solution is in contact with the sur- faces for one to three minutes, and then the excess washed off with alcohol. Simple aspiration may at times be the proper method. Cutting operations should not be undertaken as primary meas- ures, but should be reserved for such cases as offer little or no chance for improving under the less radical methods. We must never lose sight of the fact that the child's constitution is such that it aids in a very large measure all conservative measures for cure in the early stages of this disease. The child's tissues tend to heal unless the process is an old one, and although the simpler methods may take a much longer time to ultimately cure, there is but little, if any, danger of the process spreading while the original focus is under treatment. TUBERCULIN TREATMENT. The use of tuberculin has proven of marked success in many instances, and its use should be more general. It is easy of application, and in children, if the one pre- caution is taken of commencing with the very small doses so as to gage the susceptibility of the individual child, no harm can be done. The chief difficulty has been that every child's individual sus- ceptibility differs, and there is no way of telling beforehand just what this amounts to until an injection is given. This makes ex- TTJBEBCULOSIS OF BONES AND JOINTS 199 perimentation with vary small initial closes absolutely necessary for success, and with this precaution established we have in tuberculin a most potent and valuable adjunct to our other methods of treatment. Etiology and Pathology. Tuberculous lesions are essentially the same whether they occur in hard or soft tissue. The active irri- tant is the tubercle bacillus carried by the blood stream and lodged at some point of lowered vital resistance. The tissue reaction to this irritant is similar throughout the body, modified only by the density of the tissues. Hence, when once the tubercle bacilli have found a suitable soil we note in bone as in other tissues the same orderly pathological events which in an uninterrupted march present successively a typical picture, viz. : the formation of typical tubercle, typical granulation tissue, typical caseation, suppuration, and fistulization. It is well to remember that it is extremely difficult to find the specific bacilli in bone and joint lesions, since they are present in ex- tremely small numbers, and even the most expert may not be able to discover them. The inoculation of guinea pigs is a better method of demonstrating the specificity of the lesion. We note that in acute osteomyelitis the diaphyses of the long bones are usually affected; in tuberculosis the epiphyses are pre- ferred. It is only very exceptionally that tuberculosis starts in the diaphysis. The one exception to be noted is tuberculosis of the smaller long bones of the hand and foot, which is known as "spina, ventosa" and frequently seen in childhood. Again, tuberculosis has a predilection for the spongy tissue of bone, the epiphyses of the long bones, the small bones of the carpus and tarsus, the bodies of the vertebras, bones of the cranium, face, sternum, etc. Tuberculosis of bone is always a secondary character, the bacillus 200 TUBERCULOSIS often being carried from a distant site (bronchial glands, mucous membrane of nasopharynx, intestinal tract, etc.). The influence of trauma plays an important role, for there must be in the body innumerable potential bacterial factors which the resisting power of the organism overcomes and thus prevents perma- nent lodgment. If the resisting power of the tissues is modified by traumatism there are prepared a suitable soil and a fertile tuberculous focus. Similarly the tissues may be prepared by some predisposition like the strumous diathesis, or by the exhausting effects of disease such as measles, scarlet fever, pertussis, etc. There are two characteristics of tuberculoiis infection : (a) Gradual destruction of the tissue first attacked. (b) Gradual invasion of the surrounding tissues always in the line of least resistance. (a) The destruction of the tissue first attacked may go on to caseation, then by a process of fibrosis or calcification its progress may be checked and healing ensue. (b) The usual course is gradual invasion of the surrounding tissue; the granulation masses dissolve the bone, and cavities are formed filled with cheesy material and bone sand (caries). In other cases the granulation tissue cuts off the vascular supply of certain portions of the bone so that the bone dies from starvation and a sequestrum is formed (necrosis). It is obvious that a tuberculous process in the epiphysis is a menace to the neighboring joint gradual dissolution of the bone tissue, destruction of the cartilage and synovial membrane are the forerunners of joint invasion, and the joint becomes filled with typical granulation tissue. With the liquefaction of the cascating masses and the increased pressure of the exudate, the pus spreads always in the line of least resistance until it reaches the surface by perforating the skin, often at a remote site from the original focus (fistulization). Thus is formed a discharging sinus. Symptoms. Tuberculosis of bone is distinguished by its chronic course and its torpid character. It begins without pain, grows TUBERCULOSIS OF BONES AND JOINTS 201 slowly, and is accompanied by few local or constitutional disturb- ances. Tbe chronicity of the process and the reflex disturbance are characteristic. It is the reflex disturbance whch gives a varying picture as the disease manifests itself in different bones. The essentials of this reflex disturbance are the referred pain, the muscular atrophy, and muscular spasm. The referred pain is noted in hip disease, where the pain is felt at the knee; likewise a lesion at one end of a long bone may cause pain at the other. Muscular spasm must be regarded as an effort to maintain the part in a state of physiological rest. This tendency is specially noticeable about the joints where muscular spasm gradually leads to fixation and deformity. In the small pipe bones of the hand and foot there is a charac- teristic bulging in the shaft known as spina ventosa (characteristic in children). In the flat bones there are carious areas eaten out, leaving a thin bony wall. Finally, the opening of the abscess, the persistence of fistulous tracts, fever, emaciation, and diarrhea are evidence of general in- fection. It is also well to note the special predisposition in children to meningeal complications. However, as Piechand and Denuce have observed, the generaliza- tion of osseous tuberculosis in children is not frequent, and in spite of extensive osseous lesions we find the viscera intact, and that sec- ondary infections are more to be feared than general tubercular infections. Diagnosis. Laboratory demonstration of the tubercle bacilli is not practical. Their presence is proven by the death of a guinea pig after intraperitoneal injection of the products of inflammation. Great assistance will be afforded by a properly interpreted X-ray picture showing the slight reaction of the tissues and the lack of the periosteal wall. Finally the v. Pirquet skin reaction is an excellent means of diagnosis in small children. In larger children who have already had some form of tuberculosis the findings are not so positive. The technique used, is that recommended by Lincoln as de- :TlOl-. 202 TUBERCULOSIS scribed by Johnson in his Surgical Diagnosis : "A small area of skin on the inner side of the forearm or other convenient situation is sponged off with ether. A tube containing twenty-five per cent, tuberculin and a tube containing blank solution are broken off at either end. Two drops of the tuberculin are blown on the arm about one and one-half inches apart, and one drop of the blank solution between the two drops of tuberculin. The scarifier is rubbed off with ether and the edge of its tip is revolved about four times in the drop of tuberculin, holding the scarifier at right angles to the skin, and using enough pressure to slightly dent the skin. The operation is repeated in the second drop of tuberculin; the scarifier is again cleaned with ether, and the spot covered with blank solution is then scarified. The only immediate result will be three tiny depressions in the skin in the center of the three drops of liquid." The scarified points are covered with a vaccination shield until dry. The reaction, if any, usually appears at the end of twenty-four hours, and consists of a red, indurated swelling with a central de- pression. It subsides in from one to four weeks, depending upon its severity. There are no constitutional symptoms, and only slight local itching and tenderness. As Lincoln observes, the more ad- vanced the disease, that is, the lower the reacting power of the in- dividual, the smaller the percentage of positive results to the tuber- culin test. The positive reactions are much higher in cases of sur- gical tuberculosis than in advanced cases of pulmonary tuberculosis. Other means of diagnosis by similar methods are considered on page 188. It will be necessary to differentiate syphilitic bone infections. The diagnosis of bone syphilis is usually not difficult. Its predilec- tion for certain bones (crest of tibia, inner border of ulna, and the clavicle), the tender swellings on the surface of the bone, the osteo- copic pains occurring at night, the periosteal exudation forming exotoses on the surface of the bones, specially the tibia, produce characteristic deformities, and as Kirmisson remarks the frequency of this deformity about the tibia has made it true that the tibia is the bone par excellence for the diagnosis of hereditary syphilis. TUBERCULOSIS OF BONES AND JOINTS 203 Other evidences of the disease may confirm the diagnosis, such as notched teeth and interstitial keratitis, and the occurrence of abor- tions or premature births and other incidents in the family history. (See page 150.) Finally we have the laboratory diagnosis by Wassermann reac- tion, demonstration of the spirochete; and the results of anti-syphi- litic treatment. Prognosis. The outlook for tuberculous bony lesions in children is generally favorable. All depends on the child's general condition. Even extensive lesions heal if the general condition is improved. If the tissues cannot master the disease then the local lesions multiply and the disease is generalized. Treatment. In the treatment of local tuberculosis too much em- phasis cannot be placed upon the fundamental principle that we are treating the local expression of a general condition. The local lesions, whether in bone or joint, are only the local evidence of a debilitated body. It is not merely a diseased bone or joint that needs treatment, it is a sick child hence the folly of that surgical attitude which extols the knife and neglects the soil in which the disease is thriving. Operation may remove an infected area, but if the body continues sick the disease will appear in another place. As well attempt to improve the garden soil by eradicating a single weed. Bone tuberculosis is always a secondary process; even with the most radical operation the primary focus still remains; hence, the treatment of all local tuberculous lesions, especially those of bone and joint in children, is : General treatment of the child to so improve the tissues that the tubercle bacilli will cease to thrive, and this gen- eral treatment must be assisted by such local surgical treatment as will prevent local extension, secondary infection, and diminished function. The whole problem in surgical tuberculosis is to increase the vital resistance of the organism with the least amount of local dam- age. In children the knife is the last resort, and extensive openings of tuberculous foci, curettings, and all radical procedures are to be avoided. 204 TUBERCULOSIS GENERAL, TREATMENT. The tissues of the patient are improved by proper nutrition, unlimited sunshine, and fresh air. TUBERCULIN has given excellent results in bone tuberculosis and should be given in small doses gradually increased. LOCAL TREATMENT should consist in the application of those measures which are constructive. Destructive measures (knife, curette) should be used only as a last resort. First : Place the dis- eased part in a condition of physiological rest, in such a position as will permanently result in the least amount of functional disabil- ity. Second: Increase the blood supply to the diseased area by making an artificial chronic congestion after the method of Bier. The congestion is produced by the application of an elastic bandage above the point involved which shuts off the venous circulation with- out interfering with the arterial flow. This treatment may be ap- plied from fifteen minutes to one hour at a time toleration of the elastic bandage increases with use, and later it can be borne for longer periods. This method has produced marked improvement in many cases. It should be the routine treatment in cases where it can be effectually applied. Closed tuberculous abscesses, whether they are far removed from the bone focus or not, are not to be opened; they should always be aspirated and the contents removed by suction. Aspiration should be repeated until the discharge becomes serous in character, then inject a few drops of a five per cent, emulsion of iodoform and glycerin or a 20 per cent, solution of formalin in glycerin and apply sterile compresses over the abscess area. INDICATIONS FOR OPERATIVE TREATMENT. When the X-ray demonstrates the presence of a sequestrum it should be carefully re- moved to avoid chronic suppuration. Nothing but the dead bone should be removed, curetting should be avoided, and the remaining cavity filled with a five per cent emulsion of iodoform and glycerin. Any further treatment should be on conservative lines. This offers the best chance of relief. When the tuberculous foci threaten a joint an extracapsular opening should be considered. Secondary infections and extensive suppurations require radical operative relief. 205 TUBERCULOSIS OF JOINTS Pathology. Joint tuberculosis is one of the most frequent dis- eases of childhood, and is responsible for a large number of defor- mities. All visceral cavities are really joint cavities, and tuber- culosis of the articulations presents much the same pathological anat- omy as is found in pulmonary tuberculosis. The spongy extremity of the bone may be compared to the lung, the synovial sac to the pleura. Thus the joint may be infected: (a) By a spread of the disease from the neighboring epiphysis; (b) by infection of the synovia through the blood stream. In either event the onset is slow and insidious and the subsequent progress exceedingly chronic. Irri- tation of the synovial membrane gives rise to serous exudate (tuber- culous hydrops), or the joint is invaded with the typical granula- tion tissue which caseates, suppurates, and slowly disintegrates the joint structures. Finally a joint abscess may form, the pus finds its way through the thickened capsule and fistulization ensues. A late feature of the disease may be a pathological dislocation due to muscular spasm. The dry form of joint tuberculosis (arthritis tuberculosa sicca), which is characterized by the absence of fluid, is rarely seen in chil- dren ; it occurs most frequently in persons of advanced years. In children there is usually a primary exudate, and the joint is slowly filled with typical granulation tissue. The external appearance of the joint is characterized by the obliteration of its contour, which is replaced by a local swelling cov- ered by the white, tense, shiny skin (white swelling). The struggle of the tissues to master the infection is shown in their eifort to wall off the focus either by the formation of a fibrous capsule or a sclerotic bone capsule. Not only is the joint itself in- volved in the tuberculous process, but most conspicuous are the alterations which occur in the muscles which move the joint and the vicious positions which are ultimately established. The surrounding muscles may be directly invaded by the tuber- culous process, a conspicuous example of which is the psoas abscess often seen in Pott's disease. Associated with these joint lesions is 206 TUBEKCULOSIS an invariable muscular atrophy, not merely the atrophy of disuse, but a distinct degeneration of the muscle directly attributable to the disease. Finally, the effort of nature to fix the joint in the position of greatest physiological rest gives rise to muscular spasm, muscular contraction, which in time becomes fixed; the muscles shorten, undergo fibrous degeneration, and the joint assumes a definite vicious position. Prognosis. The prognosis in children is more favorable than in adults. In only a small percentage of cases does the process become generalized or are the viscera involved (meningitis, amyloid degenera- tion). As to the integrity of the joint it is extremely rare that treat- ment is begun sufficiently early to restore normal function. The very process by which the disease is conquered (formation of fibrous tissue) is the price of the cure which must be paid in an ankylosis, either complete or incomplete. It should be well understood by the parents that the best they can expect in the treatment of a tuber- culous joint is ankylosis in a position most favorable to function. Symptoms. Early diagnosis lessens subsequent disability and shortens the course of the disease. Among the early symptoms is pain, exaggerated by fatigue and movement, sometimes localized, at other times reflected. Note the reflected pain at the knee in early hip disease one of the charac- teristics of early pain is the fact that it disappears when the patient lies down. Tenderness may be elicited by direct pressure on the affected epiphysis or by percussion. Next follows loss of function the pa- tient limps in his effort to protect the joint from the impact in walk- ing. The joint is fixed by muscular spasm an early sign of great diagnostic value. Then follow muscular contraction with definite vicious attitude, muscular atrophy, enlargement of the joint, glandu- lar involvement, abscess formation, fistulization, pathological di~- location, etc. The later stages of the disease show their effects upon the general health in the secondary anemias and the general toxemia. Errors in diagnosis will be avoided by examining the child TUBEECULOS1S OF BONES AND JOINTS 207 stripped of its clothing, paying careful attention to all the joints and comparing the diseased with the corresponding healthy joint. The diagnosis of joint tuberculosis must be considered in the special consideration of the separate joints since the clinical picture changes as the disease manifests itself in the different joints. Treatment. What has been said of bone tuberculosis applies equally to tuberculous joints too much emphasis cannot be placed upon the fundamental principle that we, are treating the local ex- pression of a general condition. As we have stated, the local lesions, whether in bone or joint, are only the local evidence of a debilitated body. It is not merely a diseased bone or joint that needs treatment, it is a sick child hence the folly of that surgical attitude which extols the knife and neglects the soil in which the disease is thriving. Operation may remove an infected area, but if the body continues sick the disease will appear in another place. As well attempt to improve the garden soil by eradicating a single weed. The treatment of all tuberculous lesions of the joints in children is : General treatment of the child to so improve the tissues that the tubercle bacilli will cease to thrive, assisted by such local surgical treatment as will prevent local extension, secondary infection, and diminished function. GENERAL TREATMENT. The tissues of the patient are improved by proper nutrition, unlimited sunshine, and fresh air. The use of tuberculin has been followed by excellent results (see technique, p. 198). LOCAL. First and most foremost it is essential to secure physiological rest in a good position which will necessitate correc- tion of the 'vicious attitude, immobilization of the articulation, and the application of extension to keep the diseased joint surfaces apart. Second: The blood supply to the diseased area should be in- creased by producing an artificial chronic congestion after the method of Bier. The congestion is produced by the application of an elastic bandage above the part involved which shuts off the venous circulation without interfering with the arterial flow. This treat- ment may be applied from fifteen minutes to one hour at a time - 208 EEYS1PELAS toleration of the elastic bandage increases with use, and later it can be borne for longer periods. This method has given excellent results. It is obvious that this method is applicable to joints below the hip and shoulder. Joint abscesses are not to be opened, they should always be aspirated and their contents removed by suction, followed by the injection of five per cent, emulsion of iodoform and glycerin, or a two per cent, solution of formalin and glycerin. The indications for OPERATIVE TREATMENT will be discussed under treatment of special joints. CHAPTER XXIX ERYSIPELAS Etiology. This disease is a wound infection which results in a rapidly spreading inflammation of the skin and the mucous mem- branes. The size of the wound has no bearing upon the extent or virulence of the disease for with the slightest abrasion there may be as severe a type of the disease as with a more extended injury to the tissues. While with our present knowledge it is possible to lay much stress upon climatic influence in the prevalence of the disease, still we must acknowledge that during the severer seasons, particularly the cold and damp periods, or when there are sudden and rapid variations of temperature, the disease is far more apt to occur. The direct cause is the entrance of streptococci into the skin and this streptococcus does not differ from the streptococcus pyogenes. Therefore we must accept the facts established repeatedly by animal experimentation and confirmed by clinical experience, that there is no specific agent of erysipelas but that the disease may be typically produced in man by cocci that are not obtained from a case of erysipelas and that one and the same agent may produce erysipelas or suppuration. This knowledge is of vast clinical value and explains readily SYMPTOMS 209 many of the perplexing problems of infection which were unknown before. The organism enters the lymph spaces and then migrates further into the tissues. Regarding the direct mode of transmission, we know that there must be the most careful isolation of the child affected with the disease, as he is a constant source of danger to those with whom he comes in contact. The room in which the child is confined, the articles contained therein, the attendants, all may become active agents in the dissemination of the disease, unless the most thorough care and disinfection are carried out. Incubation. The period of incubation is still unknown in man because we have only the date obtained from artificial transmission experiments to aid us. But from these it would seem that there is a period during which there are no appreciable symptoms present, and this period is between one and three days. However, there are instances in which everything indicates as long a period as seven or eight days. Symptoms. The symptomatology is influenced by the age of the child and whether it occurs as a primary or secondary affection. In the new-born the umbilical region shows a slight redness which spreads rapidly downward over the abdomen or even down the legs. The parts affected are edematous and feel warm. Within a few hours the redness and edema may have spread over a large surface, but it is rare that it ever spreads up over the upper por- tion of the abdomen or the chest. There is no chill and rarely any marked constitutional dis- turbance to indicate the onset of the disease. Fever is not always present and when it occurs the rise of the temperature is usually very gradual although in some instances it may eventually become very high. In the new-born the edema is always more marked than in later life, but the sharply defined borders of the eruption are less. In older children the disease follows quite closely the symptomatology of adult life, but of course with the modifications which come with the immaturity of the affected child. Occurring as a primary affection there is usually a chill or something which closely approximates the chill and this is accompa- 210 ERYSIPELAS nied by a decided rise in the temperature and some digestive de- rangement (usually vomiting). In general, when present, the temperature is of a remittent or intermittent type and while the height of the temperature seems to be independent of the severity of the disease (low temperatures being observed in the severe cases as well as in the mildest ones), yet the influence which such a temperature is having upon the general condition of the particular child will be of value in prognosis. Occurring as a secondary affection (as during the course of scarlet fever), there are usually no chill and no decided rise of temperature, so that erysipelas in such instances may readily be overlooked for a time. For example, if a child suffering from scarlet fever or sepsis become affected with erysipelas, the tempera- ture will be elevated only one or perhaps two degrees by the second- ary affection and this will occur without a chill or chilly sensations or any other marked constitutional disturbance which would indicate its presence. Therefore it is only by the most watchful care and observation that the surgeon will make the early diagnosis of this disease in the presence of other infections and even then only by an appreciation of the local symptoms and minor constitutional symptoms which are suggestive. Some children (those of more than the average intelligence) may complain of indefinite pains in the muscles or a new sense of weariness which is not accounted for by anything connected with the primary disease. In nearly every instance there is increased restlessness or fretfulness and these are very apt to be attributed to other causes than the onset of erysipelas. However, it is the local signs that are of most value and in general the disease is evidenced by the appearance of one or more closely associated reddened spots, distinctly elevated above the level of the skin. These may have the sensations of burning or itching. But as the disease develops this sensation is replaced by one of tension. The characteristic appearance is a markedly reddened surface, with sharply defined borders, the skin being swollen and hot and often with a peculiar luster. From this principal focus many smaller processes may advance until a large area is covered. According to the situation of the eruption and also its intensity, SYMPTOMS 211 there are modifications in its appearance, so that on the skin of the head, for example, there is uniform and marked infiltration, while in other situations and notably those in which the bony structures come close to the surface there are apparent islands of inflammatory edema. This cutaneous inflammation usually reaches its height within two or three days, after which there are a gradual decline and disap- pearance which depend somewhat upon the virulence and the loca- tion of the affection. If attacking the face and head and uncompli- cated, the whole process subsides in about seven or eight days, while on the other hand if the disease has shown a tendency to advance from one point to another it may be several weeks before all signs of it subside. There are forms of the disease which follow a very acute course, but these are the unusual cases. In such instances, there are all the symptoms of a marked sepsis, or early in the course of the disease there may be severe headache with clouding of the sensorium or marked delirium. Other cases merely exhibit an early and pro- found state of coma which resists all the usual efforts to combat it. Erysipelas of the mucous membranes deserves special mention because it leads so often to the severest symptoms and complica- tions. It is not uncommon to find that erysipelas of the throat or nose has preceded the evidences of cutaneous inflammation. But it is not this common experience that is most important, but that rarer condition in which the larynx becomes affected secondarily and produces very rapidly such dyspnea and stenosis as are danger- ous to the life of the child. In such conditions early death is often only averted by early tracheotomy. And, further than this, the wide extension of the inflammation may result in severe bronchitis or pneumonia, which latter is accom- panied by very slow hepatization and a marked splenic tumor and is extremely dangerous to life. There is in erysipelas a marked tendency to relapses, for no immunity is acquired by once having the disease. On the other hand, there seems to be a decided tendency in some children, after once having the disease, to continue to be- come affected during successive years. 212 ERYSIPELAS But, irrespective of this tendency to remote relapses, there is also a tendency to immediate relapse, so that a few hours after subsidence of all symptoms the affection may again appear, and this may be repeated several times. Diagnosis. The diagnosis does not offer much difficulty after the inflammation has appeared upon the skin. The painful area is hot, of a rose-red color, and exhibits an edematous swelling which is quite sharply defined from the rest of the healthy tissue, so that the demarcation is marked. But evdn with the usually well- developed symptomatology which is encountered the disease may readily be confounded with other conditions. One of the most per- plexing problems at times is to differentiate between a simple erythema and erysipelas. The former depends upon a transitory hyperemia of the skin and the chief points of difference are that it runs its course without a marked elevation of the temperature or without any decided pain or swelling. Erythema exudativa multiforme may exhibit lesions of limited extent, and the same be associated with more or less severe general symptoms, simulating erysipelas, but the etiologic factors are en- tirely dissimilar and this is also a rather rare condition in child- hood, while erysipelas is common. A diffuse phlegmonous inflammation simulates erysipelas closely as it is characterized by redness and swelling with inflammation, but in these diffuse inflammations the redness is much darker than in erysipelas, is not limited in any direction, and the skin has a hard, board-like feel. If erysipelas attacks the mucous surfaces, its diagnosis remains very uncertain until the time of its spread to the skin, for it is readily seen that the associated symptoms of glandular swelling, rapid rise in temperature, splenic enlargement, and dysphagia are common to other inflammations of the throat. Prognosis. The prognosis in the newly born is always unfavor- able ; cases under one year almost invariably die. Even during the first year of life any form of the* disease must be considered danger- ous. After the period of infancy, in simple uncomplicated cases, the prognosis is favorable, although it must always be recalled that the toxic action of the organism, acting upon the heart in the iinnia- TREATMENT 213 ture, adds a considerable element of danger which is not easy to overcome. Occurring in an ill-nourished child, even as a primary affection, there is great danger to life. As a secondary affection, occurring in a child already weakened by the primary disease, the prognosis is unfavorable. Laryngeal involvement is always a grave matter, usually demanding operative interference, which the child cannot always stand. Treatment. The treatment is mainly prophylactic, for we know that the child affected or convalescent from the disease is a great source of danger. Further than this, we know that the streptococcus producing the disease is long lived and that this microorganism remains for a great length of time about the room in which the child was confined and retains most of its virulence. It is necessary then to isolate all affected individuals and insti- tute such a scheme of isolation and disinfection as will adequately meet the requirements. It is unnecessary to enumerate these pre- cautions, which are similar to those used in other infectious diseases of a high virulence, but in addition for adequate prophylaxis there must be the most careful toilet of the eyes, the ears, and the nose and mouth. LOCAL TREATMENT involves the use of such applications as will limit the activity of the cocci and therefore excellent results are ob- tained from such local applications as 25 per cent, to 50 per cent, ichthyol with collodium. To be of service, the antiseptics in com- mon use must be applied in strong solutions and therefore their use is very much restricted in children because of the unfavorable action on the skin. A 1 or (in older children) a 2 per cent, solution of carbolic acid (Phenol), with exclusion of air, may be of service, particularly if glycerin be added (about 10 per cent.), or 1 per cent, corrosive sublimate with glycerin may be used. The GENERAL TREATMENT aims chiefly to prevent diminished heart action with subsequent collapse. To combat this there should be the early institution of forced feeding with small, frequent, and concentrated meals and the administration of a cardiac stimulant and an iron tonic. As a cardiac stimulant, the tincture of strophanthus meets every requirement without the danger of up- 214 TETANUS setting the digestion. As an iron tonic, nothing compares with the wine of the citrate of iron in this disease, the small amount of alcohol present being of distinct value. Absolute rest in bed is of course essential. Persistent or severe headache is best treated by an ice cap. However, some children are so restless that this is an almost impossible method and, in such instances, the administration of small doses of acetphenetidin will bring relief and without danger to the heart unless its use is continued over a long period. For the restlessness and possible delirium, tepid baths of from five to ten minutes' duration are of value and may be repeated every three or four hours if required. Free water drinking, regulation of the bowel function, and strict attention to the digestion are essentials in the general treatment. General principles are applicable to the complications which occur. CHAPTER XXX TETANUS Etiology: Bacillus Tetani. There have been but few more spec- tacular advances made in the study and the understanding of a disease within the last two decades than have obtained in tetanus, or, as it is commonly called, lockjaw. While in remote times the symptomatology was recognized and the relation of the disease to wounds was clearly noted, yet it was not until quite recent years that the bacteriologic, chemical, etio- logical, and anatomico-physiological features were given proper interpretation. It was in 1884 that the true cause of tetanus was discovered by Nicolaier and through the influences of that discovery we came rapidly to have a clear appreciation of this dread disease. Following Nicolaier, other investigators soon proved that this specific bacillus was present in large numbers in garden earth, dust, and wherever these were carried, but that its occurrence in nature was far from being uniform. Although much more abundant in CLINICAL FORMS 215 some soils than in others, the tetanus bacilli are very common. Yet, in spite of this fact and the opportunity which is offered by the body for its entrance (because the minutest wound is sufficient for infection), the total number of cases is quite small. The reason for this may be found in the biologico-chemical properties of the bacillus. The bacillus only grows anaerobically ; but it is capable when introduced into a wound of producing certain powerful poisons which when absorbed into the system produce characteristic and usually fatal spasms. The bacillus has this peculiarity: it remains quite strictly con- fined to the site of its introduction and has a rather short life in the wound or point of entrance. But we have learned that the bacillus alone does not produce the severe phenomena which are so commonly fatal to life, but that these manifestations are due to products of metabolism which are traceable to the influence of the bacillus. These toxins are developed at the point of entrance of the bacillus and by way of the nerves advance toward the cord and medulla. And it has been proven that, although, the tetanus bacillus only lives at the point of entrance, the toxins produced exhibit an entirely different characteristic and are taken into the system with extraordinary rapidity. Thus we find that it is these toxins which are responsible for the clinical phenomena. And although there were many theories advanced in the past to explain the occurrence of the clinical manifestations, these were rather un- satisfactory until after much labor it has been shown that the tetanus toxin has a special affinity for the substance of the central nervous system. It is not necessary to delay for the final settle- ment of all of the problems which are still unsettled in regard to the nature and extent of this toxin affinity, but the surgeon may safely accept it as a fact that this affinity of the central nervous system and the toxin is not only present but is very marked. Clinical Forms. Although there is but one recognizable cause of this disease, yet it is advisable for clinical purposes to recognize the two forms of the disease in childhood. Tetanus neonatorum is the result of infection through the umbilical cord; tetanus trau- 216 TETANUS matica occurs as in the adult through the influence of a general injury of more or less severity, or through any loss of continuity of the skin. The symptom-complex of the two forms is so similar that one description will answer for both. The only differences are those which are attributable to the influence which the age of the patient has upon any disease. Facial tetanus is a form of the disease which is so pronounced in certain particulars that it needs special mention. Its main characteristic is that we are not dealing with spasms of distinct groups of muscles only, but along with them, or preceding their occurrence, there is a paralysis of the facial nerve. This type most frequently follows injuries to the head. Chronic tetanus is simply a modified type of the disease with a longer period of incubation, a much lessened severity of all the symptoms, and a longer course, so that the child may be afflicted for one or two months and eventually recover, or, as is more often the case, die of the exhaustion caused by the disease. Symptomatology and Diagnosis. The most prominent symptoms are those relating to the motor sphere; there is hardly a large muscle group in the body which escapes, although primarily and most severely the musculature of the head and neck is affected. The usual history is that some days after an injury (which may not have been noticed at the time or thought of since its infliction) there occurs an indefinite stiffness of the musculature of the neck and jaw. In the infant the result of this stiffness is an inability to nurse, with its consequent train of other symptoms. This inabil- ity to nurse is almost invariably the first thing noted by the mother, but it is usually reported as an effort upon^the part of the infant to take the nipple and accompanied by severe crying at the attempt. This is due to the spasm of the masseters. The stiffness which was first noted rapidly increases until the jaws are set and there is great difficulty in even partially opening them. The musculature of the neck becomes board-like in its tension, and the head may be drawn forcibly backward. The face is set and the eyes are usually motion- less, the ala3 nasi widely dilated, and the mouth increased in breadth and drawn downward. There may be added to this a SYMPTOMATOLOGY AND DIAGNOSIS 217 peculiar facial grimace which is not unlike a painful attempt to smile. This latter is often present very early and may be the first symptom noted. So severe may these spasms' become that the muscle may be ruptured. The musculature of the back and the abdomen is next involved, and, when this occurs, the position of the whole body may be either one of three opisthotonos, emprothotonos, or pleurothotonos. As a rule the upper extremity is not involved. When the disease pro- gresses, the legs, especially at the knee joint, become affected, but the feet and the toes are usually spared. When the spasm becomes so general that it affects the musculature of the internal organs, the termination is usually and fortunately rapid. The dia- phragm is generally markedly involved in the spasm. The rapidity with which this diaphragmatic spasm occurs at any stage of the disease adds an early and grave danger of suffocation. When well developed, the slightest movement is sufficient to bring on an exaggeration of the spasm of the already tense and board-like muscles. The nerves of sight and of hearing are exceed- ingly and painfully sensitive. Even the entrance of some person into the room, the sudden admission of sunlight, noise, or even sud- den draft, may bring on spasm and so make the suffering of the child most excruciating. Almost without variation the spasms are tonic, only in rare instances being clonic. This recurrence of spasmodic seizures leads one to believe that there are periods of complete relaxation, but this is not so. There are definite periods during which there are partial relaxation and apparent rest, but it is characteristic of the disease that, once a muscle group is affected, there is continuance of the spasm without complete relaxation at any time. Cerebral symptoms are not very apt to develop until near to the time of death, when one may encounter delirium, but .unfortunately in most of the cases the mind remains unusually clear. Perspira- tion is usually excessive and the tears flow freely and in great abundance. The temperature is generally very high during the height of the attack and just before a fatal termination may rise still higher, 218 TETANUS reaching in some instances 110 to 114 F. For one or two hours after death occurs the temperature may still remain high. With the symptoms well developed there is but little chance of an error in the recognition of the disease. But not all cases are typical in their onset and development, and under such circum- stances an error in diagnosis is not uncommon during the develop- mental stage. A contracture of the musculature of the jaw may be present in a more or less marked degree in several conditions affecting the jaw itself or the oral cavity. Some of these conditions might make the diagnosis difficult at first and they must be differentiated. The most common sources of error are an abscess situated close to the masseter, facial neuralgia of a severe type (particularly such as may follow the infectious disease), hysteria, meningitis, and more rarely complications of dentition and follicular tonsillitis. It is not difficult in the child to determine whether or not local conditions are directly responsible for a seeming trismus, and with such a distinction there is usually a clearing up of all doubt as to the occurrence of tetanus. An examination of the oral cavity under any of the above-named conditions might meet with considerable resistance, but this would never be so marked that it could not be overcome by a little patience. One distinctive feature would be that, with a true trismus due to tetanus, the attempt to overcome it would result in an exaggeration of the spasm. Of the general conditions which might lead to an error in diag- nosis, we have three meningitis, hydrophobia and strychnin poisoning. In the first two of these trismus is not a prominent feature and may be entirely absent. The cerebral symptoms of meningitis ought to serve clearly to distinguish it from tetanus, for in meningitis the mind is not clear as it is in tetanus, the cerebral symptoms are progressive and persist throughout the course of the disease, while in tetanus, if present at all, it is not until the end is near. The history and the characteristic features of hydrophobia are always sufficiently marked, so that none but the most superficial examination would fail to reveal them. PROGNOSIS 219 In poisoning by strychnin there may or may not be a history of the ingestion of the drug, so that reliance must more often be placed upon other factors. It is particularly true of strychnin poisoning .spasms that they are most prominent in the extremities, and this characteristic occurs early. When trismus occurs at all it does so late. The reverse is true of tetanus; trismus is the earliest symptom noted in nearly every case, and spasms of the extremities are late in occurrence (the arms being rarely affected). The contracture of the muscle in tetanus never completely sub- sides; it does have periods in which there is partial relaxation, but this is never complete. In poisoning by strychnin there are definite periods of complete relaxation. There is a real difficulty offered when we attempt to determine just how many days elapse between the infection and the first appearance of symptoms. Children are so commonly the subjects of injury that many times the occurrence of such is quickly forgotten, so that as an aid this fact is often valueless. It can be readily seen that animal experimentation does not help us in this difficulty to any considerable extent because each species has a different susceptibility to the infection and in the ex- periments the toxins are used. Rose has carefully observed many cases in human beings, and his opinion in this particular should be given considerable weight. He believes that symptoms arise during the second week after the injury in about one-half of the cases and that in a third of the cases they show during the third week. There are still others who claim a much longer period of latency. Prognosis. The prognosis is quite intimately connected with the period of incubation, for it is a well-recognized fact that the more rapidly the symptoms develop after the injury the more unfavor- able the prognosis. But even eliminating those cases in which the period of incubation is short and the chances of recovery almost nil, the prognosis is far from hopeful, for about one-half of the cases which are developed late terminate unfavorably. Before it was possible to use the antitoxin for this disease these figures were higher. Naturally the age of the patient markedly influences the 220 TETANUS prognosis ; the younger the child the less favorable the results. There are individual features of the disease which are guides to the prognosis: (a) A temperature of 103 F. or over (except in a rachitic child) at the height of the disease is unfavorable. (b) Complete trismus, by its interference with the nutrition, is an unfavoring factor. (c) Involvement of the musculature of the respiratory tract or of the muscles of deglutition is an ill omen. (d) Frequent or continued tetanic attacks are indicative of a fatal ending. While it is readily seen that any one of these symptoms may prove to be the fatal one if they be intense enough, yet a combina- tion of a lessened degree or two or more of them should be regarded with great alarm. Tetanus may be regarded as the most uniformly fatal disease with which the surgeon deals, death occurring usually within a very few days after the onset. And even after the disease seems to have done its worst and the symptoms are all improving, it is no uncom- mon experience to have a sudden onset of some one of the pre- viously mentioned symptoms with early death. Therefore a most guarded prognosis must be made up until the time of complete recovery. Treatment. The treatment involves four main propositions: (1) The treatment of the injury or wound. (2) The specific serum therapy. (3) General medical treatment. (4) Dietetic care and general nursing. TREATMENT OF THE WOUND. The treatment of the wound de- mands a clear appreciation of what is to be accomplished and the most energetic measures to bring about the result. The toxin developed by the bacillus does not act in the wound itself but is carried with great rapidity by the lymph channels and the blood to the central nervous system. Thus the treatment of the wound depends somewhat upon the time at which the child is seen and resolves itself into two methods: prophylactic and direct. TREATMENT 221 The prophylactic method need not be enlarged upon because the surgeon of to-day, recognizing the absolute necessity of asepsis, cleanses every wound no matter how slight before he feels secure in any further surgical procedure. But when the wound is con- taminated with earth, it is necessary to use the most powerful anti- septics or the cautery to destroy the bacillus. Nothing short of the most- energetic measures will suffice, because the bacillus is exceedingly resistant to external influences, and, on the other hand, may remain in the wound, constantly producing fresh toxins. The direct treatment is that which is taken after the patient has exhibited the earliest signs of the disease and involves a most thorough search for all possible points of entrance. It is not suffi- cient to give attention to one wound, no matter how serious it may seem, but every wound (the slightest as well as the severest) should receive examination and care. While it is impossible to foretell by the first symptoms just what amount of toxemia is present, yet the complete direct treat- ment of all wounds offers a considerable amount of protection to the child. The treatment involves the thorough use of such methods as have been advised in the prophylactic treatment of the wound, and, in addition to these, deep incisions into the wound, or in some instances complete excision of the wound. Extirpation" is as far as the surgeon need go; amputation of a limb is never necessary. TETANUS ANTITOXIN. The value of this agent and its capabil- ities as a protective are settled beyond any reasonable doubt. But to get the best obtainable results from its use, the surgeon must appreciate some of the peculiarities of the agent. And, first, it has been experimentally proven that absorption is very slow, so that the maximum amount is not found in the circulation until twenty- four hours or more have elapsed since its injection. Secondly: Examinations of the secretions and excretions show that most of the antitoxin is eliminated unchanged. Thirdly: The antitoxin does not destroy the toxin, but simply through some unaccountable chemical influence renders it inert. Fourth (and most significant of all) : The nervous system, as 222 TETANUS represented by the nerve tissue, does not in any manner take up the antitoxin. To return to the tetanus bacillus, it generates its toxins so rapidly, the toxin is so virulent (the minutest quantity being suf- ficient to bring about fatal results), that no time can be lost in administering the antitoxin. The behavior of the antitoxin experi- mentally indicates the best methods of its use. This must be im- mediate because of the slow absorption of the agent and the rapid action of the tetanus bacillus and therefore it may be administered intravenously and about the tissues in the affected areas. However, for the most prompt and certain action, there is no method which is superior to the intraspinal injection. In this operation, spinal puncture is performed as usual and from five to ten c. c. of the spinal fluid allowed to escape. Then an equal amount of the antitoxin is injected directly but slowly into the canal. When later injections are required, the intravenous method or the much slower subcutaneous method may be serviceable. Rogers advocates a plan somewhat like this : 10 to 20 c. c. are injected into the tissues about the affected area; 10 to 20 c. c. intra- venously; 5 to 20 minims into the nerves of the axillary plexus if the wound is of the upper extremity; in the crural, sciatic, and obturator nerves if in the lower. Of course, such dosage is his method for adults. For children the dose must be modified according to the stage of the disease, the lateness of the appearance of symptoms after the injury, and the age of the child. But for an average case and an average child the dosage would be: for one year, 1,000 to 3,000 units; for five years, 3,000 to 5,000 units; ten years, 8,000 to 12,000 units, and the frequency of these doses should be every four, six, or eight hours (never longer than eight hours). For immunization, an average dose of from 400 to 800 units should be given. GENERAL MEDICAL TREATMENT. The general medical treat- ment brings up at once the consideration of the use of opium or its derivatives. Its use is at once attended with good results, for it diminishes the intensity of the spasms and even seems to have TREATMENT 223 some influence in prolonging the intervals between them. Its action is favorable on the insomnia which is so characteristic of tetanus. Preference naturally should be given to morphin because of its known reliability and more constant uniformity of action. Per- sonally, we are adverse to the use of morphin by the mouth or by suppository, for more certain results are secured by the hypo- dermic administration. Chloral holds place as a close second to morphin, but its lis- agreeable taste easily excites spasm of the muscles of deglutition in children and therefore it is best given per rectum in milk. A combination of these two drugs, carefully adjusted to the individual need, practically meets every indication for drug treat- ment. But to secure the proper results the individual need must be studied and the dosage of the drugs made large enough to meet it. Subcutaneous injections of sulphate of magnesia have not proved satisfactory in our hands, on account of the sudden respira- tory paralysis. Many other drugs have been recommended from time to time, notably large doses of the bromids and the salicylates, but their action is weak and therefore doubtful. Before leaving this subject we must mention the advantage gained by narcosis. The adminis- tration of an anesthetic by a skilled hand will accomplish a com- plete subsidence of the trismus and thereby allow the introduction of a stomach tube and the administration of nourishment, or may render it safe for the surgeon to undertake some surgical pro- cedure which would be impossible without narcosis. But the dangers of such a procedure as anesthesia must be recognized, and therefore the administration must be in the most skilled hands to prevent the rapid termination of the life of the child by suffoca- tion. The choice of the anesthetic is determined in the same man- ner as in any child who is to be the subject of surgical intervention (see page 61), and in addition is influenced by the object sought. If this is merely the control of the spasms, chloroform is the choice on account of its rapid action. DIET AND GENERAL NURSING. The dietetic care and general nursing are at once very difficult because the general standard of 224 TETANUS what constitutes good nursing and feeding cannot be carried on in this disease. The nutrition of the child is particularly difficult to maintain, so that it is our common experience that children die from sheer exhaustion long before the disease has advanced to the danger point. The trismus may be so marked that it is impossible to force the jaws open sufficiently to give even the minutest quan- tity of food. There are three methods by which we may feed the child : by rectum, subcutaneously, and by the stomach tube after narcosis. Rectal feeding is accomplished as. in any other condition (see page 104), and is the least desirable of the three methods because the manipulation necessary usually brings about spasms, which are exhausting and at once interfere with the continuance of the method. The subcutaneous method is more serviceable than the rectal, but there are certain precautions that must be observed. While the preparation of the nutriment is done with the careful attention to detail which is advisable under all other conditions (consideration of these points would unnecessarily enlarge this section, therefore the reader is referred to the books upon Dietetics), in addition to this the preparation must be done away from the room of the patient and the disinfection of the skin be most thorough. Two hun- dred c. c. of olive oil given in this manner represents nearly 2,000 calories and the disturbance to the child in its administration is slight. After the withdrawal of the needle, which must be small, the puncture should be covered with collodion. Whenever the trismus allows it, food should be given by the mouth and a selection made of such nourishment as contains in the least bulk the greatest food value. Every precaution should be taken to have the vessels containing the food of such a substance as will not be broken if a spasm comes on while the child is being fed. One of the most satisfactory methods is to allow the child to use a common nursing nipple, for in this way the food is taken at the rate required and there is no danger of breakage. In giving liquid nourishment the attention of the child should bs attracted to the fact that he is taking such, because without this there is TREATMENT 225 danger of regurgitation and through that of an aspiration pneu- monia. The most serviceable foods are the dry beef peptonoids, strong beef tea with raw egg, cream, cocoa or chocolate, beef juice, and dextrinized cereals which have been concentrated by further heating. Sugar of milk should be used freely in the food, not because of its sweetening effect but as a carbohydrate. Just as soon as the condition of the child warrants it, the food should be increased in variety but with the precaution that the dangers from aspiration be avoided. Briefly stated, the nutrition should conform to the stage of the disease but at all times should be as concentrated and as highly nutritious as possible. Feeding by the stomach tube after narcosis is not without danger as has already been suggested (see page 223), but it may become neces- sary or even expedient to undertake this method once in twenty- four or forty-eight hours in conjunction with one of the other methods of feeding. The disadvantages are that the amount of nutrient given this way must be limited by the capacity of the stomach and there is constantly the danger of an aspiration pneu- monia when the tube is removed. Actual nursing as it is practiced in other conditions is an im- possibility in the case of tetanus because motion, noise, and excite- ment of any kind must be limited in the sick-room. The failure to control these features will result in the occurrence of repeated spasm. The room selected to confine the child should be one as far removed from the street and from the necessary noise of the house- hold as possible. Further protection is offered by the hanging of heavy curtains at the doors and the wearing of soft slippers by the attendants. The room should be somewhat darkened but well ventilated, and if a change is necessary in either of these, that is, if more light is to be admitted or thorough airing done, the process should be gradual because even these slight sudden changes often bring about a spasm. The bed should be broad enough to prevent falling out during a spasm and if possible the mattress should be of water or feathers to limit injury. The upper board of the bed must be protected so as to prevent injury during an extensor spasm, Conservatism in 226 SEPTIC DISEASES the nursing is wisdom and the whole attitude of the nurse should be one of watchful care rather than strict attention to the niceties of the sick-room. The best interests of the child demand not only that the absolutely necessary attentions be given but that he be pro- tected from possible injury during the spasms. There can be little question but that full baths have a decided and favorable influence upon the spasms of tetanus, but whatever good is accomplished by them is probably more than counterbal- anced by the necessary manipulations of the child in the accomplish- ment. It is only under the most favorable circumstances that bath- ing can be safely indulged in, and then the bath should be a warm one no matter whether fever is present or not. The reaction from a cool bath or even cool sponging, which is so favorable in other conditions in children, is decidedly unfavorable in tetanus and tends to increase spasms. CHAPTEK XXXI SEPTIC DISEASES SEPTIC DISEASES IN GENERAL Septic intoxication indicates that the symptomatology is de- pendent upon absorption of the toxic products of pus-producing organisms from a focus of suppuration and in this it is quite dif- ferent from septicemia, which is a form of infection in which the living pus organisms are existent in the blood and multiply there. And, further, it is distinguished from pyemia, which is that form of poisoning in which the organisms, having entered the blood, are carried to distant parts and by lodgment there form new foci of suppuration. This division is not simply arbitrary but is based upon clinical characteristics and helps materially in the understanding of the correct surgical interference to establish. Blood cultures are of value in the severer forms of infection because it is practically always possible to isolate one or the other SEPTIC INTOXICATION 227 of the various forms of pyogenic cocci in the blood and this having been established it may be feasible to institute appropriate sera or vaccine treatment. Not only this, but the recognition of the particular organism adds considerable value to the statements as to prognosis. And the most definite data that can be obtained upon which to base the prognosis is of considerable value in aiding the surgeon in his determination as to just what surgical measures to pursue. SEPTIC INTOXICATION Septic intoxication may exist in almost any degree, as for instance in those cases in which there are only the almost unappre- ciated symptoms of mild malaise and an elevation of the tempera- ture of considerably less than one degree to those fulminating cases which may be fatal within a few hours after their onset. This is so because the condition is present to some extent whenever an acute infection by the pus-producing organisms exists in the body. Symptoms. While it might be stated generally that the sympto- matology is influenced directly by the virulence of the bacteria and the amount of the toxins absorbed plus certain local conditions, yet there are many other modifying factors which will be mentioned later. Chief among the local modifying conditions is that of tension, for if pus is confined in unyielding tissues it is more certain to cause important constitutional symptoms than when not under pressure. And it is a well-established fact that certain tissues are much more absorbent than are others, and this has a decided influence. The constitutional symptoms are fever, a rapid pulse, prostra- tion, thirst, malaise, more or less profuse sweating, possibly chills, convulsions, or other symptoms. The fever is usually remittent or may be intermittent and when improvement is not taking place the tendency is upward until death takes place. The pulse is rapid in all cases, but is full in 228 SEPTIC DISEASES the moderate infections, while it is rapid and weak in the severer ones. There is usually a well-marked preservation of the tempera- ture rise as related to the pulse rate. If, on the other hand, there is low temperature with rapid pulse it indicates that there is a grave form of poisoning. While a high temperature and a cor- responding rapid pulse indicate considerable severity of the infec- tion, their continuous correspondence is of itself a rather favorable sign. The removal of tension or the evacuation of the offending mate- rial by removing the inflammatory focus results in immediate re- duction in the height of the temperature, although if the surgical procedure undertaken to accomplish this has involved the lymph spaces, there may be a temporary fall in the temperature followed by an immediate rise and again followed by a more or less rapid fall to normal or nearly so. If, after appropriate surgical interference, the symptoms do not show an immediate improvement and recovery become established, septicemia is to be suspected, although we must also remember that it is not always possible to immediately establish adequate surgical relief either as regards the relief of tension or of evacuation, and in such instances an immediate subsidence of the symptoms cannot be looked for. It is, therefore, not always possible, even with surgical intervention, to definitely establish the diagnosis between septic intoxication and septicemia. Septic intoxication may result from unavoidable or unconscious errors in operative work. This is generally evidenced within forty- eight hours by restlessness and, if the child be old enough to com- plain intelligently, by a sense of pain or discomfort in the wound. However, it must be remembered that children, even of a consider- able age, do not complain because of the fear of further interference and, in fact, many are led to deceive in this matter. The constitutional symptoms are of more value than any state- ment of the child, and slight but progressive rise of temperature, associated with thirst, restlessness, coated tongue, a flushed face, and bright eye, should always arouse suspicion and lead to an im- mediate inspection of the wound, SEPTICEMIA 229 Headache and a general sense of discomfort with scanty urine and constipated bowels are later symptoms. It is easy to attribute the early symptoms to some digestive disturbance, or to accept them as due to constipation if it exists, and this is particularly so if the statements of the child are ac- cepted, but the only line of safety is in not accepting this lazy solution of a symptomatology which may mean much to the child. An examination of the wound shows it to be red, swollen, and tender and there may be minute areas of necrotic tissue; or the wound may appear free from inflammation and it is only by deep pressure that tenderness is elicited. Upon opening the wound pus is evacuated usually along the lines of the sutures, and this evacua- tion and relief of tension are followed by prompt subsidence of all symptoms and rapid healing. SEPTICEMIA Septicemia is that form of blood poisoning in which the living pus organisms exist in the blood and multiply there. It is, there- fore, not to be expected that the removal of the local lesion will result in an arrested progress of the disease and in this particular it is characteristically different from septic intoxication. Symptoms. The symptoms are not always characteristic but usually beffin with some malaise and fever and the child shows L *> o decided disinclination for its usual activities. In other instance? there is a more acute onset with a decided chill or convulsion and followed quickly by marked prostration, headache, a typhoidal state, and a fluctuating temperature. The pulse is rapid and weak, no matter what the type of onset. Septic rashes are common and may be erythematous, petechial, pustular, or hemorrhagic. Diarrhea and splenic enlargement are common. Septic endo- carditis, pericarditis, bronchitis, or pneumonia may occur. Increasing prostration, profuse sweating, uncontrollable diar- rhea, progressively failing pulse, excessive thirst, and exhausting restlessness are added as the disease progresses. 230 SEPTIC DISEASES The blood examination shows a marked leukocytosis and by cul- ture the invading organism may be isolated. Prognosis. The prognosis is always grave, although, happily, we seldom encounter the disease during childhood. Treatment. The treatment always involves the adequate surgical treatment of the local lesion whenever that is practical, and this may require incision, drainage, curetting, cauterization, continu- ous immersion or irrigation, or the Bier hyperemic method. The general treatment is most important and should be sup- portive and stimulating plus all measures which favor elimination through the bowels, kidneys, and skin. Maintenance of the nutri- tion is exceedingly important and the efforts which are spent upon this one factor alone often decide the final outcome of the disease. Vaccine therapy is considered in another section, to which the reader is referred. PYEMIA Etiology. Pyemia is not at all common in children, and this is probably due to two factors: the modern method of dealing with wounds, and the liability of the child to the more extreme results of infection. Pyemia is that form of infection in which the organisms, having entered the blood, are carried to distant parts and there find lodgment and form new foci of suppuration. The emboli have their genesis in infected thrombi formed in the veins, the vessel being infected from without by extension of an infectious inflammation or the adherence to its walls of bacteria circulating in the blood. Any pus-producing organism may cause pyemia. Symptoms. The symptoms are variable, on account of the degree of accompanying septicemia, the location and number of metastatic foci, and whether the disease assumes the acute or chronic course. If a child is suffering from an infected wound or acute septic inflammation, and develops a chill or convulsion with a sudden high temperature, followed by as rapid a fall and profuse sweating, it should lead at once to the suspicion of embolic metastasis. SAPREMIA 231 Subsequent chills or convulsions and elevations of the tempera- ture follow an irregular type and simulate malarial fever. Diarrhea, foul breath, anorexia, coated tongue, jaundice, and headache are of common occurrence. The spleen may be enlarged. The mental condition may remain unchanged, although irritability and undue restlessness are the rule. Each new chill and elevation of temperature leave the child much worse. Anemia and pros- tration are early and marked. The local changes are also marked: if the wound is actively suppurating, with the onset of pyemia, the discharge is much lessened and the surface becomes drier and pale, the existing granu- lations appearing anemic and possibly softening and disappearing. Any tissue may be invaded and new abscesses form from time to time and this may occur insidiously and rapidly. Each new chill or convulsion indicates fresh involvement and these should be sought and subjected to surgical interference if possible. Complications. Complications are of course common, as the infection is very liable to be carried into important organs inac- cessible to surgical relief. Thus the prognosis is always very grave. Diagnosis. In the diagnosis, malaria may be excluded by blood examination, which would show no presence of the plasmodium and absence also of leukocytosis. Acute miliary tuberculosis and typhoid fever and that rarer disease, malignant endocarditis, must be excluded. Treatment. The treatment is upon the same principles as that of septicemia plus the opening, the cleansing, or the extirpation of the infected vessels in the neighborhood of the wound, or it may be advisable to ligate a vessel. The metastatic abscesses must be surgically treated whenever they are found and can be reached. SAPREMIA Etiology. Sapremia, or putrid intoxication, is the condition which is caused by the absorption into the system of the products of the bacteria of putrefaction. A pure sapremia rarely, if ever, SEPTIC DISEASES exists alone, there being in practically every instance the toxemia of other pus-producing organisms. In children the consequences of the disease are of far more importance than in adults, because with them there are usually the most extreme results as far as the ravages of the infection are concerned. Symptoms and Diagnosis. The symptoms are those of a sudden intoxication and usually are ushered in with a chill or a convulsion and a rapid rise in the temperature. In some instances the rise in the temperature is the first thing noted and for several hours may remain the only symptom. It is only in rare instances that there are pro- dromal symptoms of malaise, anorexia, headache, and prostration. The temperature usually rises rapidly to 103 or even 106 F. and is associated with a rapid pulse. After these initial symptoms the child may be overwhelmed by the poison and rapidly become delirious or comatose, with a quickly and persistently failing circulation, so that the body is bathed in a profuse, cold perspiration. Thus it may be that the symptoms in their severity resemble those of shock. A more common occurrence, however, is for the initial symptoms to be added to by those of marked prostration, headache, vomiting, and extreme restlessness. The failing circulation is always a char- acteristic, even in the milder cases. The diagnosis is established as a rule by surgical interference, for the very nature of the disease makes any unnecessary delay dangerous. Thus, if there be a pure sapremia, the removal of the offending ma- terial will be followed by immediate improvement in all of the symp- toms and there is no return of these symptoms. Having a focus of dead material within the body and these symptoms added, we are practically certain of the diagnosis of this form of infection. The wound itself may be tender and painful and excrete a thin but foul-smelling discharge. Naturally the constitutional symptoms will be influenced by the size and character of the absorbing surface, the amount of the putrid material present, the degree of pressure present, and the age and general nutritional state of the child. PURULENT INFECTIONS OP THE SKIN 233 Continuance of the symptoms, or their failure to promptly respond to surgical interference, indicates a mixed infection. Combinations of sapremia with septic infection, saprophytic, and pyogenic infection are very common, and the resultant local lesion and constitutional symptomatology may be of any possible severity. Thus we may encounter moist gangrene and like lesions as examples of the severer types. The less severe ones are rather common as the result of injury with extensive laceration or con- tusion. Treatment.' The general treatment demands the judicious assist- ance of all of the eliminative forces in their work, the regulation of the diet, and appropriate symptomatic treatment. With the prompt and adequate establishment of surgical inter- ference, the prognosis is favorable if the wound is easily accessible, all symptoms usually subsiding within forty-eight hours. PURULENT INFECTIONS OF THE SKIN AND SUB- CUTANEOUS TISSUES The two factors of enfeebled resistance to infection and a tender skin make serious affections of young children possible through in- fection. Abscess, furuncle, or phlegmon may result as the invasion of bacteria (usually the staphylococcus pyogenes aureus), which cause, by the action of their virus or their interference with the nutrition of the parts, a necrosis of the tissues with the signs of inflammation and the formation of pus. When the tissue breaks down it is usually eliminated by breaking through the skin. Naturally we find that in those infants or children in whom the nutritive processes are disturbed, or are not up to normal, such processes are much more active and add to the already debilitated state. These infections may remain single or may run together and undermine a considerable area of the skin. Furuncles run prac- tically the same course as in adults, except that they appear in large numbers and over a long period in malnourished infants, par- 234 SEPTIC DISEASES ticularly over the buttocks, scalp, thighs, and shoulders. Any one or more of these may become gangrenous and cause a general in- fection and to that extent they are serious. In evacuating the pus in furunculosis, the surrounding skin should be adequately protected by ointment or collodion, otherwise the infection may be spread. Squeezing or pressing is dangerous because of its liability to injure the protective wall of the cavity and thus change a localized into a generalized infection. Every procedure, no matter how apparently slight it may seem, should take recognition of the possibility of considerable loss of blood or the opening up of new avenues of in- fection, both of which children bear badly. Spontaneous rupture seems to leave the least scarring, and, therefore, it is advisable in most instances to avoid incision or punc- ture in prominent places. With protection of the skin against injury (which is possible also through excessive sweating, poorly adjusted clothing, etc.), and reasonable warmth, many of these chil- dren do well without surgical interference. It must be distinctly remembered that this type of local infec- tion is a different proposition from a similar condition in adults, and while in the latter free incisions would be the proper procedure, the opposite is true in childhood. Klapp's method of drawing out the pus by puncture and suction by cups is a splendid one and can be done without harm to the child. Abscesses are treated very much in the same manner as furunculosis, in that the skin is protected and as soon as fluctuation is detected an incision is made and the pus evacuated (preferably by aspiration). Packing may result in necrosis and is unnecessary as the use of a probe is sufficient to open the incision again. Drain- age tubes are only necessary when pus is deep seated and the mouth of the wound persistently closes. Phlegmons require similar treatment with such modifications as the individual case suggests. The general symptoms of all types of these infections are de- pendent upon the extent, the location, and the duration of the pro- cess. With an increase of the size of the affected area there is an increase of general symptoms. BACTEKIAL VACCINES 235 Bier's method of producing hyperemia is of large service in some instances in which the focus is situated upon a limb. Many of the failures attributed to this method have undoubtedly come from a lack of appreciation of its general principles and a consequent mis- application of the method. A correct understanding of these is so indispensable that it is not within the scope of this work to go into details which are essential for the successful use of this method, and therefore the reader is referred to Bier's own writings, or the translations made by Meyer. Bier's method should be used in conjunction with and not apart from other well-recognized surgical procedures. CHAPTER XXXII BACTERIAL VACCINES The theory of a bacterial vaccine is that when it is injected it has a similar effect to that produced in the horse by the injection of toxins or attenuated cultures; that is, it stimulates the patient to produce a large supply of antibodies and enables him to resist disease. This action differs from the use of serums, for in the latter the antibodies are supplied directly and there is a passive immunity, while in the use of vaccines antibodies are manafactured in the body and there is an active immunity. The literature upon the subject is large and the expressed opinions differ widely, so that the practical working out of the theories has not reached that stage yet when we can place much reliance upon it. On general principles, the use of serum is indicated, if at all, when the infection is generalized and vaccines when the infection is localized strictly or when the general infection is not acute. From a broad survey of the literature, we gather clearly that the vaccines are far from infallible and that they have decided limitations. They are at best in children auxiliary means of attempting to combat infections and should never be allowed to 236 entirely supplant the other well-recognized and proved methods of medical or surgical relief. Autogenous vaccines seem to be no more efficient than stock vaccines competently prepared and which are certainly much easier to obtain and cause no delay in applying the method of treatment. The greatest care should be observed to have the syringe per- fectly sterile and the skin about the part to be subjected to injec- tion properly prepared according to the rules of adequate antisepsis. There is no set guide by which we may determine the exact dose needed in a given case or by which we can clearly indicate the need of subsequent injections. However, the clinical manifestations are the chief guides both as to the size of the dose and the necessity for its repe- tition. Each vaccine is selected accord- ing to the particular type of infec- tion, and this must be determined beforehand. But there are instances in which the exact nature of the in- fection cannot be definitely deter- mined, or in which the necessity for immediate action does not allow of much investigation, and in such in- stances we have a valuable adjunct in the Combined Bacterial Vaccine of Van Cott. We must emphasize again that the use of a vaccine, no matter how clearly indicated, or how carefully selected, should not take the place of the usual and well-recognized methods of treatment, nor should its use deter in any way from the activity of such means of combating the infection. Bacterial vaccines are adjuncts to, but never substitutes for, the medical or surgical treatment of infections in childhood. FIG. 77. SITES FOR INJECTION OF SERA OR VACCINES IN CHILDREN. SECTION VII INJURIES CHAPTER XXXIII BURNS AND SCALDS The frequency with which the surgeon is called upon to treat burns and scalds in young children gives the subject an importance that cannot be overlooked. FIG. 78. PROPER POSITION FOR THE TREATMENT OF BURNS INVOLVING THE NECK. The head should not be thrown forward by a pillow, but a roll or small pillow must support the shoulders. It is not alone the ignorance of the child or the carelessness of its attendants that contribute to this, but, irrespective of these, the skin of the young child, being so much more delicate than that of the adult and its proportionate surface being so much more ex- tensive, adds a further element of easy destruction. Thus we find that the prognosis of burns and scalds in the immature is much more serious than in later life. 237 238 BUKNS AND SCALDS Clinically there does not seem to be any apparent difference in the effect which different kinds of heat have upon the child's tissues and the effect from a flame, a heated surface in direct contact with the body, or radiated heat is practically the same, provided the degree of heat be the same. Scalding is apt to be more extensive than burning and also more superficial, but this is determined by the fact of the more widespread distribution of the scalding material and its more rapid cooling, while in burns the heat is gen- erally applied to a smaller surface and for a longer time. There is no practical advantage in attempting to classify burns or scalds according to their degrees or the depth of the lesion. Practically, the burns and scalds which are observed at the bedside by the surgeon are of a mixed form, being a combination of the char- acteristics of the superficial and deeper injuries. In most instances the injury is to the skin and to the tissues just beneath. Restoration of the surface to its normal condition is the rule if infec- tion can be prevented. But in most in- stances infection has taken place early and the results are not then so good, as scarring is apt to occur with its subse- quent unpleasant and disfiguring results. Results. The pain and shock which accompany even limited burns are a serious matter in children and are productive of grave results, and the toxins produced in the tissues affected by extensive burns lead to rapidly fatal issues. There is always one inevitable result of burns or scalds in child- hood shock. This may be so slight as to be scarcely appreciable, or may cause death within a few minutes. Shock depends more FIG. 79. INCORRECT POSITION IN BURNS OF THE ARM OR AXILLA. In this position contractures are sure to occur and markedly limit motion. RESULTS 239 upon the extent of the burned area than upon its depth, and this is so because of the importance of the cutaneous surface as a neces- sity to perfect functioning of organs in childhood, and the fact that a cutaneous nerve injured and exposed by superficial burning causes more pain than a nerve destroyed. And so it is the common ex- perience in children to find that burns of the so-called second degree (because of the reasons stated) show the highest mortality. The symptoms are the usual ones of shock (see page 106), and death may occur by collapse or coma. If the shock is not severe, or if severe FIG. 80. CORRECT POSITION FOR CHILD WITH EXTENSIVE BURNS OF THE ARM OR AXILLA and the child recovers, there are apt to be several days of fever, irre- spective of infection or complications. The dangers from burns or scalds are many, even when shock is but moderate. Putrefactive toxemia may early add to the danger to life and, in addition to this, there is the ever-present danger of a mixed infection either with tetanus or erysipelas. Congestion of the internal organs often takes place in some unexplained manner (some claim that mere destruction of the skin is responsible; others that peripheral irritation is the cause, and still others, blood destruction, capillary thrombosis, etc.), and adds to the symptomatology and the unfavorable prognosis. Thus we find that suppression of urine is common at all stages of the burn, BURNS AND SCALDS and that nephritic congestion is most common; that congestion of the brain often adds its unpleasant symptomatology, that intestinal congestion results in diarrhea of a persistent nature, intestinal ulceration or hemorrhage, or that any one or all of the organs of the body suffer. All of these factors render the outcome more doubtful. Then we are not unmindful of the disfiguring scars which often result. And as a consequence of extensive scarring there may be FIG. 81. AN INCORRECT AND PARTICULARLY BAD POSITION FOR BURNS (EVEN MODERATE) OF THE PALM OF THE HAND. A useless member is practically certain to be the result when contracture takes place. actual deformity or partial loss of function through cicatricial con- traction. More remote dangers are those of subsequent chronic ulceration or keloid growth. Diagnosis. The diagnosis may involve close observation because the history may be absent or wilfully withheld or denied on account of possible medico-legal issues. It may then become necessary to make a distinction between a burn and a scald and in the latter the hairs are not destroyed and the appearance of the affected sur- face is quite uniform. Wires which are charged with electricity make the burn quite black at the point of contact and this point is surrounded by a DIAGNOSIS 241 paler and very dry-appearing area. A peculiarity about the electric burn is that, although from the appearances on the surface the burn may not seem to be extensive, the involvement of the deeper struc- tures may be so. Thus considerable caution must be exercised in making a prognosis. X-ray burns command separate comment. The deleterious effects upon the skin and the subcutaneous tissues and even of the deeper structures are an established fact. It is not infrequent that the first indications do not show for several days after an exposure, and the mildest type of such a burn is evidenced by a peculiar blush or redness of the skin which resembles a sunburn. This continues FIG. 82. INCORRECT POSITION FOR HAND IN BURNS OF EVEN MODERATE DEGREE. This position is better than that in Fig. 81 but is far from correct. for several days, with gradual disappearance, or may persist for weeks. Repeated exposures will result in the appearance of a num- ber of small brown or blackish freckles and a slight general pig- mentation of the skin. This more rarely occurs, even after a single exposure. Accidental exposure of a hair-covered surface may cause temporary falling of the hair. In the more severe types of X-ray burn, the erythema is succeeded by a superficial and ill-defined vesication and associated with this there may be slight swelling of the skin. Usually in such burns the general symptoms of irritation are added. It is not uncommon to observe a dry, brawny exfoliation follow the erythema. 242 BURNS AND SCALDS The more serious burn is that in which, for some unknown reason, the erythema is rapidly succeeded by deep ulceratiori and sloughing. The ulcer is usually covered with an adherent, grayish, leathery-looking membrane and has a slightly hyperemic border. Pain of a severe character is the rule and the ulcer shows no tendency to spontaneous healing. Prognosis. The prognosis is affected directly by the age, for in the very young it is much more unfavorable than in the older child, and in all children is less hopeful than in adults. There are many factors which must receive careful consideration in making the prognosis, and chief among these are the extent of the surface involved, the age of the patient, the gen- eral nutrition of the child, the site of the burn, and the possibility of avoiding complications. In extensive burns, even after recovery from the primary shock, life is still menaced by nephritis, uremia, coma, thrombus, and duodenal ulcer. In burns involving over one-half of the surface of the body death usually occurs within the first twenty-four hours from toxic absorption. If the chest or abdomen is involved to any considerable extent, the prognosis is grave, because even relatively small burns over these areas are rapidly destructive to life. If infection occurs or a complication is added, the outlook be- comes less hopeful. Treatment. The treatment comprises local, general, and sympto- matic care. The GENERAL TREATMENT should be directed at once toward combating shock (see page 109), and for this purpose there is no FIQ. 83. CORRECT POSITION IN BURNS OP THE PALM OF THE HAND. Fingers should be extended and separated from one another and held so by proper splints. TEEATMBNT 243 single drug so valuable as opium. Immediate small doses of mor- phin administered hypodermically relieve the pain, steady the nervous system, and limit or prevent vital depression. Heart stimulants are used as indicated by the need. Next in importance FIG. 84. AN INCOHBECT POSTURE FOB THE LEG WHEN IT is THE SITE OF EXTENSIVE BUBNS. is a supply of fluids to compensate for the great loss which takes place in extensive burned surfaces and to aid in the elimination of the toxins. This is best accomplished by saline injections per rectum, small amounts being given at frequent intervals. The LOCAL TREATMENT demands the same scrupulous care as is FIG. 85. COBBECT POSITION OF THE LEG IN EXTENSIVE BUBNS. given to other wounds and the farther the local treatment of burns is removed from the accepted principles of wound treatment the less satisfactory will be the results. Since septic absorption is so large a factor in producing fatal results, the thorough disinfection of the wound and the application of such dressings as will facilitate and not hinder or retain the discharges are essential. It is usually 244 BURNS AND SCALDS impossible to secure thorough cleansing of the burn without an anesthetic. Therefore an anesthetic should be given at once (this helps also to limit shock), the clothing completely removed, and the wound surface methodically disinfected with a boric acid solution. .j^er^ * Blisters should be opened and the raised epithelium removed. The wounded surface must be then cleansed of all devitalized tissue. In the choice of a dressing it is at once obvious that any appli- cation which retains the dis- charges and thus promotes septic absorption is irrational and dan- gerous, hence ointments and pow- ders have no place in the treat- ment of burns. It is time that they were abandoned and rational measures adopted. The ideal dressing for a burn is one which allays the pain, pre- vents sepsis, and promotes heal- ing : these characteristics are admirably exhibited in picric acid. Make a solution containing picric acid, one and one-half drams, alcohol, three ounces, and distilled water, forty ounces. Moisten gauze compresses with this solution and apply to the injured surface and retain them there by light bandages. In applying the dressings considerable care must be taken to overlap the edges of the wounded surface so that ample protection is assured against marginal infection which so frequently occurs. In extensive burns the whole body may be immersed in a bath of boric acid solution, which must be kept at the body temperature. The prevention of deforming cicatrices is no minor part of the FIG. 86. THE RESULTS OF INCORRECT POSITION AND DELAYED SKIN GRAFTING IN EXTENSIVE BURN OF THE NECK. Note the deforming as well as the dis- abling effects of inadequate surgical treatment. TREATMENT treatment. Even after the patient is well on the road to recovery he is still menaced by the possibility of contracting cicatrices, which not only deform but compromise function. However, if the surgeon is vigilant many deplorable results may be prevented by the early ap- plication of adequate prophylactic measures. The following sugges- tions are important: (a) In the arm or the leg the use of splints is indicated to hold the limb in the opposite direction to which it is likely to be drawn by a contracting cicatrix. (b) In burns of adjacent fin- gers the dressing should embrace each finger separately and the fin- gers be held in extension by a splint to prevent cicatricial syndac- tyly and deforming flexures. (c) Skin grafting is the best means of rapidly healing a granu- lating surface and of preventing cicatricial contraction. This valuable adjuvant is too frequently used as a last resort to cover in granulating surfaces which refuse to heal and when a ci- catricial base is already established. Skin grafting should be used early: just as soon as a healthy granulating surface is established. Small Thiersch grafts should be implanted at several sittings. Do not attempt too much at one operation. Several short ether narcoses are less harmful than one long one, and the small graft frequently applied is usually the short- est route to satisfactory results. Even with the greatest care burns in certain regions are followed by cicatricial deformities. This is notably true in burns about the face and neck. Ectropion often follows burns of the eyelid. Burns of the lip, of the chin, and the neck draw the lip downward, depress the chin FIG. 87. SIDE VIEW OF SAME CASE AS FIGURE 86. 246 and fix it on the sternum (Fig. 87), or cause various deviations of the neck to one side. These ultimate cicatricial deformities must be treated on the general principles which govern plastic operations: excision of the cicatricial bands, followed by grafting, or transplantation of skin flaps. This usually ameliorates the deplorable deformities. It must, however, be remembered that extensive skin plastics should be attempted only after granulation areas are covered by scar tissue. The SYMPTOMATIC TREATMENT includes the management of such complications as diarrhea, suppression of urine, delirium, etc. The further treatment of the burned area is that of any crushed or macerated surface and the principles of antisepsis, asepsis, and frequent dressings are the same. To prevent or limit contraction and impairment of function, all large granulating surfaces should be covered with skin grafts and, in addition to this, the healing surface should be placed in a position which will insure the greatest usefulness in case such con- traction takes place. Usually extreme extension will be found the most serviceable position. It is always advisable in children to dress a small portion of the area at one time, leaving the rest unexposed. And it may be well to reiterate that, in the subsequent dressings as well as in the first one, the use of an anesthetic is advisable if thorough attention to all details of the dressing cannot be secured without it. CHAPTEE XXXIV FRACTUKES IN CHILDREN The child is an unfinished product. Its tissues are in a state of plasticity. The bones are soft and elastic; they bend without breaking, just as the young sapling will bend under a force which would break the mature tree. Furthermore, the ends of the bones, PECULIARITIES 247 the epiphyses, act as elastic buffers, which break up the effects of a fall, and accommodate themselves to considerable pressure with- out displacement. Hence dislocations in children are rare, and the force that in an adult would cause a dislocation, in a child is liable to result in fracture. The great majority of fractures in children are due to falls, yet it is remarkable how extensive the fall may be (down a flight of stairs) without resulting in injury to the bones. PECULIARITIES OP FRACTURE IN CHILDREN A. Fractures of the Newly Born. While it is possible for intra- uterine fractures to occur, they are extremely rare: Fracture is more liable to occur during deliv- ery while the limbs are being dis- engaged (fracture of femur or humerus), or as a result of the application of forceps (depres- sions of the cranial bones). B. Fractures Without Dis- placement (Subperiosteal Frac- tures). Owing to the thickness of the periosteum a complete f rac- t u r e without displacement is quite frequent in the first years of life. These fractures fre- quently pass unrecognized and it is only after the callus has formed an obvious swelling that the pa- rents bring the child to the doc- tor for consultation. This is notably the case in Sllbperiosteal FIG. 88. GREENS-TICK FRACTURE OF THE , , . , T,. FOREARM. fractures of the clavicle. Diag- nosis is often difficult, specially as all other signs of recognition of the fracture may be absent (deformity, displacement, crepitus). 248 FRACTURES IN CHILDREN Only by means of the X-ray can we prove a lesion heretofore only suspected through swelling and pain. Always suspect fracture when children refuse to use their extremities, especially where their atten- tion is purposely drawn away from the injury. C. Incomplete or Greenstick Fractures. Here the break is only partial like a green stick when bent, so the young pliable bone bends, and breaks only on the convex side, while the bony tissue on the concave side remains intact (Fig. 88). This variety of frac- ture is frequently found in the forearm and clavicle. D. Separation of the Epiphyses. It will be recalled that the long bones have a large epiphysis at each end and that during child- hood, and prior to about the twentieth year, consolidation of the epiphysis with the shaft is not complete; hence, in certain injuries, the epiphysis is separated, or becomes "unglued" from the shaft. It is obvious that this lesion can take place only during the period prior to the time of ossification. E. Exuberant Callus. While the production of callus is effected by the same process as in adults, the repair is more rapid (one- third the time required in adults), and in young children may be so exuberant that the bony swelling simulates an actual neoplasm. It is obvious that these callous swellings may easily be mistaken for tumors of serious import. F. Fracture Fever. There is frequently an elevation of tempera- ture in the fractures of children, especially where there is consider- able ecchymosis. This is undoubtedly due to the absorption of fibrin ferment. Its practical import is in the fact that it is often difficult to differentiate between fracture and osteomyelitis, especially in the presence of a subperiosteal fracture where the only symptoms are pain and fever. INTRAPARTUM FRACTURES Fractures occurring during delivery are of sufficient importance to merit special consideration, since the soft plastic body, the tender skin, the adipose tissue which surrounds the bones, the problem of keeping the dressing clean, all present formidable difficulties in INTRAPARTUM FRACTURES 249 applying and retaining splints that are practically efficient. The usual sites of fractures occurring during delivery are : the humerus, the clavicle, and the femur. Fracture of the Humerus. Fracture of the humerus is usually oblique and at the middle of the diaphysis. When the shortness of the arm and its plasticity are considered, it is obvious that the usual methods of treatment applicable to older children and adults are not only inefficient but impractical. FIG. 89. DOUBLE RECTANGULAR SPLINT AND POSITION OF ARMS WHEN APPLIED, IN FRACTURE OF THE HUMERUS. (After Spitzy.) To fix the arm in a right-angle splint is almost impossible, since the arm is only a few centimeters in length; to splint the arm in permanent extension is difficult, since a bandage tight enough to secure the arm to the splint will in practically every instance cause edema of the hand. The only satisfactory solution of the problem has been sug- gested by Spitzy, who fixes the elbow at right angles in a horizontal elevated position upon a long double rectangular splint, using the 250 FRACTURES IN CHILDREN uninjured arm as a means of fixation. The splint passes across the back from one arm to the other, holding the arms in an ele- vated horizontal position, the forearm being flexed at a right angle (Fig. 89). It is obvious that in this position neither the move- ments of the child nor the handling which its care necessitates com- promise the fixation of the fragments. Fracture of the Clavicle. The aim in the treatment of fractured clavicle is to prevent the shoulder from falling forward and thereby obviate overlapping of the fragments and angu- lar deformity. The same principle is used in ap- plying the splint here as in fractured hu- inerus. An inverted _L shaped splint is used, passing across the back and em- bracing the forearms, which are flexed at a right angle and held in a hori- zontal position (Fig. 90). In this position the arm is rotated outward, the an- terior portion of the cap- sule of the ioint is held FIG. 90. THE INVERTED J.- SHAPED SPLINT, AND POSITION OF ARMS WHEN APPLIED IN FRACTURE taut, pulling the fragment OF THE CLAVICLE. (After Spitzy). outward and backward, and thus preventing overlapping and angular deformity. Fracture of the Femur. Fracture of the femur in infants pre- sents all the difficulties presented in fracture of the upper extremity plus the serious problem of keeping the dressings unsoiled. The choice of two methods may be made: (a) The thigh may be placed in maximum flexion so that the knee is in contact with the body, the foot over the shoulder. Tin 1 extremity in this position is fixed by bandages to the abdomen. INTRAPARTUM FRACTURES 251 While this postural treatment has the maximum advantage of cleanliness the results are not always satisfactory. (b) The authors prefer the suggestion of Spitzy, who appre- FIG. 91. SPLINTS IN POSITION IN FRACTURE OF THE FEMUR. (After Spitzy.) FIG. 92. DRESSING COMPLETED IN FRACTURE OF FEMUR. Note the obvious advantages of cleanliness, comfort, and efficient fixation. (After Spitzy.) JLLIESIZ OF OSTlOl= 252 FRACTURES IN CHILDREN ciates the advantage of the natural biological position of flexed hip and knee joints as the most comfortable for the child and the most convenient for handling it in caring for its needs. This position is maintained by an anterior splint embracing both extremities, and extending from a point corresponding to the lower end of the sternum to and including the foot. The apparatus consists of two strips of iron one inch wide, united at one end by a rivet. The splints are bent to correspond to the curve of the abdomen and the anterior aspect of the lower extremity in its natural position of comfortable flexion, and pro- longed at right angles over the dorsum of the foot (Fig. 91). To tjm this splint both extremities are fixed. The advantages are obvious: cleanliness, comfort, and efficient fixation (Fig. 92). TRAUMATIC SEPARATION OF THE EPIPHYSES Notwithstanding the fact fyat consolidation of the epiphysis with the shaft is not complete, yet it must be remembered that it takes a tremendous amount of force to separate any epiphysis from its adjoining shaft ; for the cartilaginous connection with the shaft is reinforced by a cuff of extremely thick periosteum, and a greater force is necessary to cause a separation of the epiphysis than is re- quired to fracture the bone. It is rare that the epiphysis separates without tearing off a piece of bone belonging to the shaft. The X-ray has shown that many so-called epiphyseal separations are actually fractures in the neighborhood of the epiphyseal line. Con- trary, therefore, to popular belief, true epiphyseal separation is extremely rare. It is always the result of great violence and torsion, and is usually produced by indirect force. The lesion is most fre- quent between the ages of ten and fifteen. A point of great practical interest is the effect which epiphyseal separation has upon the growth of the limb. As Poland has shown, arrest of growth is comparatively rare; yet the prognosis of these injuries must always be given with caution, and the possibility of shortening, even in cases with slight displacement, must not be minimized. G3T2G ^0 SfjBJJO : TEAUMATIC SEPAKATION OF THE EPIPHYSES While it is possible for any epiphysis to be separated, it is prac- tical to consider only those that occur most frequently. According to Poland the order of frequency of the principal varieties may be classed as follows: 1. The upper epiphysis of the humerus. 2. The lower epiphysis of the femur. 3. The lower epiphysis of the radius. 4. The lower epiphysis of the humerus. 5. The lower epiphysis of the tibia. 6. The upper epiphysis of the tibia. Separation of the Tipper Epiphysis of the Humerus. The upper epi- physis includes the head and tuberosities, and is represented by a line which follows the lower half of the anatomical neck, and then diverges outward to a point represented by the insertion of the teres minor muscle. (Fig. 93.) It will thus be seen that the end of the diaphysis .fits into its epiphysis like a wedge. It unites with the shaft, at from the twenti- eth to the twenty-fourth year. Epiphyseal separa- tion of the upper end of the humerus is extremely rare in children, except in those constitutional affec- tions, such as rickets, ma- r a s m u s , syphilis, and scurvy, where slight violence may cause separation without displace- ment. Traumatic separation is caused by some severe indirect vio- lence such as a fall from a height, the force being transmitted through the hand ; or catching the limb in a revolving wheel. The displacement is characteristic. The head of the bone is in B FIG. 93. A. SHOWS LINE OF UPPER EPIPHYSIS OF HUMERUS. B. SHOWS HOW THE END OF THE DIAPHYSIS FITS INTO ITS EPIPHYSIS LIKE A WEDGE. 254 FRACTURES IN CHILDREN place, but rotated outward by the action of the muscles attracted to the greater tuberosity. (Fig. 94.) The shaft is drawn forward and inward by the muscles attached to the bicipital groove. The upper end of the shaft can be felt at the front of the shoulders and is sometimes seen beneath the skin. This gives rise to an abrupt pro- jection at the front of the joint a short distance below the coracoid process (Gray). When the arm is rotated crepitus is felt but it is of a soft cartilaginous character. The periosteum is not entirely torn across; portions of it may fall between the fragments and prevent complete reduction. This injury sometimes brings about prema- FIG. 94. TRAUMATIC SEPARATION AT THE UPPER EPIPHYSIS OF HTJMERUS. ture ossification, and, as the growth of the humerus in length i-s chiefly through the upper epipliysis, arrest of growth may follow. (Fig. 95.) Caution. This injury is liable to be mistaken for a dislocation of the shoulder. To avoid this error remember the general rule that dislocations in children are extremely rare and that injuries about the joint are either epiphyseal separations or fractures near the joint. Besides this general rule the evidence in favor of frac- ture is found in the preternatural mobility and crepitus. The value of the X-ray is evident. TRAUMATIC SEPARATION OF THE EPIPHYSES 255 Treatment. When the displace- ment is slight abduction and traction under anesthesia are sufficient to bring the separated parts in line. After reduction the shoulder and arm should be immobilized in a Velpeau bandage of plaster of paris. There are, however, certain displacements which cannot be reduced without operative assistance. The torn peri- osteum falls between the fragments, the end of the diaphysis is buried in the muscle mass, and manipula- tion reduction is futile. It will be necessary in such cases to make an inci- sion and clear . 95. ARREST OF DEVELOP- MENT OF RIGHT ARM DUE TO EARLY TRAUMATIC SEPARATION OF THE EPIPHYSEAL CARTILAGE. (Helferich.) FIG. 96. SHOWING EPIPHYSES OF FEMUR. away the intervening soft parts that prevent reduction ; in some instances it may be neces- sary to resect the head of the bone. Separation of the Lower Epiphysis of the Femur. Recall the fact that the lower epi- physis of the femur includes all of the articu- lar surface of the lower end of the femur with the attachments of the gastrocnemius muscle. The line of the epiphysis passes transversely across just above the edge of the articular surface. (Fig- 96.) It joins the shaft of the bone at about the twenty-first year. It is evident that the knee joint depends for its support upon its ligaments and surround- 256 FRACTURES IN CHILDREN ing fascia, thus, any strain upon the knee joint is transmitted to the ligaments attached to the lower femoral epiphysis and, if suffi- cient force is applied, the epiphyseal cartilage is detached. This accident is due to great violence and twisting of the joint. In a large number of instances it has followed the vicious practice of catching on behind a moving vehicle, and getting the leg caught in the spokes of the revolving wheel. The displacement of the epiphysis is usually forward. (Fig. 97.) Some- times the injury is compounded by the end of the diaphysis protruding back- ward through the skin. Injury to the popliteal vessels has resulted in aneurysm and gangrene of the leg. Diagnosis. This injury may be mis-/ taken for a dislocation of the knee or a supracondyloid fracture of the femur. Remember that dislocation in children is rare. The character of the crepitus in supracondyloid fracture is hard and bony, in epiphyseal separation it is soft and cartilaginous. Careful attention to the history of the injury is important. Epiphyseal separation is always followed by considerable shock and great swelling. The value of X-ray examination is obvi- FIG. 97. SEPARATION OF LOWER OUS. EPIPHYSIS OF THE FEMUR THE EPIPHYSIS DISPLACED Treatment. If the separation is 1111- FORWARD, THE END OF THE DIAPHYSIS PROTRUDING BACK- complicated reduction should be at- tempted by flexing the leg to a right angle and making traction and countertraction on leg and thigh. After reduction is complete the limb should be kept in a position of flexion to assist in retaining the epiphysis in position, and im- mobilized in a plaster-of-paris splint. After three or four weeks the leg may be gradually extended. The plaster is removed after six TEAUMATIC SEPARATION OF THE EPIPHYSES 257 weeks; after ten weeks the patient may be allowed to walk. If attempts at reduc- tion are unsuccessful it will be necessary to clear the fragments of obstructing bands and reduce through an open incision. In extreme cases it may be necessary to resect the end of the diaphy- sis. If the separation is com- plicated by an open wound or the vessels are torn such sur- gical measures must be insti- tuted as the case demands. Shortening is to be expected ; the amount depends upon the severity of the injury. Separation of the lower epi- physis of the radius is a very infrequent lesion. The epiphy- sis unites with the shaft of the bone at the twentieth year and prior to this time the separated epiphysis simulates Colles' frac- ture. While the lesion is pro- duced like a Colles' fracture by falling on the extended hand, the break is nearer the line of the joint, there is no impaction, and the relative position of the sty- loid process is not disturbed. Reduction of a separation of the epiphysis is simple, the frag- ments are easily held in posi- tion, and the healing is prompt. FIG. 98. LOWER EPIPHYSIS OF THE HUMERUS ; CENTERS OF OSSIFICATION OF CAPITELLUM ; AND INTERNAL CONDYLE. FIG. 99. THE NORMAL EPIPHYSEAL LINE AT UPPER END OF TIBIA AND FIBULA 258 FRACTURES IN CHILDREN Separation of the Lower Epiphysis of the Humerus. The lower epiphysis of the humerus is composed of the external epicondyle, the capitellum, and the trochlear. (Fig. 98.) These separate centers of ossification unite about the thirteenth year, and about the seven- teenth year they join the shaft of the bone (Scudder). It is rare to find a true epiphyseal separation from injuries of the elbow since traumatism generally produces a fracture and not an epiphyseal sepa- ration. When such separation occurs it is usually in very young children (see fracture of the elbow). Separation of the Lower Epiphysis of the Tibia. This is very rare. It is usually accompanied by a fracture of the fibula, simu- lates Pott's fracture, and the treatment is the same. Separation of the Upper Epiphysis of the Tibia. It will be re- called that the upper epiphysis of the tibia runs transversely across the tibia about one-half inch below the articular surface and passes down anteriorly in a tongue-shaped process to include the tubercle. (Fig. 99.) Scudder demonstrates "that many apparent trivial in- juries such as violent contraction of the quadriceps extensor muscle a blow to the region of the tubercle of the tibia, result in partial separation, with or without some displacement of the tongue-shaped portion of the upper epiphysis of the tibia." This lesion is not un- usual in young athletic adults, and when there is no displacement it is of the nature of an epiphyseal sprain. Protective immobilization of the knee is usually sufficient to effect a cure. SECTION VIII SURGICAL DISEASES OF THE CENTRAL NERVOUS SYSTEM CHAPTER XXXV INJURY AND DISEASE OF THE SPINAL CORD AS EVIDENCED BY SYMPTOMS While there is usually a more or less complicated admixture of prominent and characteristic symptoms in either injury or disease of the spinal cord, it is still most practical to consider these indi- vidually in so far as they are connected with conditions that may be amenable to surgical relief. These symptoms are paralysis, changes of gait and of posture, disturbances of the anal and vesical sphincters, ataxia, disturbances of motor or sensory reflexes, disturbances of sensation, pain, vaso- motor and trophic disturbances. PARALYSIS As the result of either an injury or disease, paralysis may ex- hibit itself in the form of weakness or a total loss of power in one muscle, a group of muscles, or an entire limb. What is sometimes called "false paralysis" must not be mis- taken for paralysis, for inhibition of the muscular function pro- duced by disease which causes pain upon motion is by no means a paralysis, although it so often simulates it. According to the type of the paralysis, we have spastic paralysis (evidenced by an increase in the muscular tone, an exaggeration of the reflexes, etc.) and flaccid paralysis (in which the muscular 259 260 INJUKY AND DISEASE OF THE SPINAL CORD tone is diminished, the reflexes decreased or abolished, and no re- sistance offered to passive motion). In considering the injuries or surgical diseases of the spinal cord, it is quite essential that we clearly distinguish between these two prominent types of paralysis, as this often gives us a valuable clew as to the probable cause. For instance, paralysis may occur as the result of some injury or disease of the cerebral cortex, or of lesions in the motor paths at any point between the cortical motor center and the motor cells of the anterior horns of the gray matter of the spinal cord. Paralysis dependent upon injury or disease affecting the lateral pyramidal and anterior median column motor paths is known as corticospinal (or central neuron) paralysis, while that due to lesions on the motor cells of the cord itself is designated as spino- muscular (or peripheral neuron) paralysis. It is the clinical manifestations, however, with which we are most concerned, and these vary according as the lesion acts as an inhibitory or as a destructive force upon the central or upon the peripheral neuron. The clinical manifestations which distinguish these are as follows : Central Neuron Lesion Peripheral Neuron Lesion Paralysis with rigidity. Paralysis with flaccidity. Increased tendon reflexes. Loss of all reflexes. Loss of peripheral reflexes. Atrophy slight or absent. Atrophy early or marked. Trophic changes slight. Trophic changes marked. Electrical reaction preserved. Electrical reaction degenerated. It must be recalled, however, that this rather distinctive char- acter of the paralysis is not always evident immediately after an injury or a rapidly acquired lesion, but that occasionally a period of several hours, or more rarely of two or three days, must elapse before the really distinctive features are evident. Monoplegia may be closely simulated by immobility of the limit, which is entirely dependent upon the fear of pain which is caused by motion, or on an immobility from epiphyseal separation. PARALYSIS 201 In an older child pain would be complained of, but in the case of an infant the parent might easily make misstatements. Irrespec- tive of the history, an examination including passive motion would determine the difference. With epiphyseal separation there are more or less crepitation and an enlargement at the ends of the long bones. The estimation of muscular tone has been fully considered in another chapter. On account of its importance to the surgeon, we might consider these a little more in detail. Corticospinal Paralysis.- In this type there is not always an ab- solute paralysis, although- the- musculature is more or less rigid and the joints are moved with some resistance. Percussion of the tendon of the muscle and sometimes of the muscle itself will promptly result in contraction. The general appearance of the limb is not one of atrophy, although there is commonly more or less impaired circulation with consequent blueness and coldness and occasionally a marked edema. Sensation remains normal when allowances have been made for the influence of a defective circulation and the pos- sible edema, both of which in part destroy the normal sensitiveness of the cutaneous surface. As has been stated, the electrical reaction remains normal. Such a paralysis is common as the result of cerebral injury or disease and is evidenced as a hemiplegia, but if it originates in the cord and is due to some transverse lesion the paralysis will affect both lower limbs, or, in a cervical lesion, both arms. Thus it is encountered in some cases of Pott's disease, pressure (tumor or other lesion), after hemorrhage, and in the soft- ening following thrombosis. Spinonmscular Paralysis. In this type there is an absolute paralysis and if recovery takes place at all it is only after a very long period. In contradistinction to the corticospinal type of paralysis, which affects quite uniformly all the muscles of a limb or part, the spino- muscular type affects distinct groups of muscles, and, if all of the musculature of a limb be affected at first, there is great probability that rapid recovery will be quickly evidenced in most of the muscles. The flaccidity of the musculature allows of free passive motion of 262 INJURY AND DISEASE OF THE SPINAL CORD the limb and the looseness of the joints allows of over-motion. Per- cussion fails to bring about any contractions. The general appearance of the limb is one of atrophy, which occurs early and is persistent. This is accompanied by more or less marked blueness and coldness. Sensation may or may not be impaired. The reaction of degeneration is evidenced by the use of the electrical current. This type of paralysis may be observed in tumors, hemorrhages, or softening of the cord, and in some forms of myelitis. While its common occurrence is in disease which is not amenable to surgical intervention, its characteristics are important to remember, so that differentiation may be possible from paralysis dependent upon lesions of the peripheral nerves. General Character of Paralysis Following Injury or Disease of the Spinal Cord. Generally speaking, there are two forms of paralysis which follow injury of the spinal cord and these depend upon the extent of the injury; that is, whether there has occurred complete or incomplete destruction. As the latter is the only one amenable to successful surgical treatment, it is most important that the dis- tinction between the two forms be clearly made. A complete destruction of the spinal cord at any level results at once in complete paralysis of the musculature below that level. There is flaccidity (peripheral neuron type) and not rigidity. The loss of tendon and muscle reflex is complete and persistent and there is no appreciable difference between the two sides of the body, either as regards this feature or the paralysis. Loss of sensibility to pain, to changes of temperature, and generally to touch is evi- denced over a very definite surface. Vasomotor paralysis is also prominent. There is also retention of urine. Upon the other hand, in an incomplete destruction, the one that may be helped by surgery (as when the cord is compressed or con-' tused), there is also a complete paralysis below the level of the lesion, but this is accompanied by muscular rigidity and an in- crease in the tendon and muscle reflexes. It is not uncommon also to note evidences of partial involvement of the wall of the bowel. There is loss of bladder control. DISTURBANCES OF SPHINCTER CONTROL 203 We can see from this how very important it is that the two types be kept clearly in mind and the differentiation made at the time of the injury, so that the possibility of surgical relief may be considered. DISTURBANCES OF ANAL AND VESICAL SPHINCTER CONTROL Disturbances of the sphincter control of the anal and vesical regions are the very common accompaniments of all injuries and diseases which affect the spinal cord. They are also one of the most distressing features, both to the patient and his attendants. The reflex mechanism controlling these parts is situated in the fourth and fifth sacral segments of the cord. The function is two- fold. Sensory impulses received by the cord from distention of the bladder or the rectum cause an inhibitory influence to be exerted upon the contractions of the vesical and anal sphincters, so that they relax and, in addition to this, there are stimulation and contrac- tion of the detrusor muscles. This dual action causes the contents of the bladder or the rectum to escape. This mechanism may be so disturbed by injury or disease of the cord that these centers may be cut off from the controlling influence of the brain and act auto- matically, or the bladder and rectum may empty themselves involun- tarily, but at intervals; this latter being known as "active incon- tinence." But if there is a destruction of the centers in the sacral segments, there is complete incontinence. These disturbances of bladder and rectum activity are very com- mon to all injuries and diseases of the spinal cord and by their existence add a real danger of subsequent infection through the necessity for instrumental relief. Of course, the rectum may be mechanically emptied over a long period without any serious consequences, but it not uncommonly happens that this method of relief is not always successful without the danger of injury to the parts. 264 INJURY AND DISEASE OF THE SPINAL COED ATAXIA Disturbances of the muscular sense and loss of muscular co- ordination are observed in nonsurgical lesions of the cord quite com- monly, but the surgical conditions under which they are most fre- quently encountered are tumors of the cord, or growths in the meninges, which press upon the posterior columns of the cord. The characteristic ataxic gait is evidenced by: (1) An uncertain placing of the feet with steps of very irregu- lar length. (2) The tendency to lose the balance. (3) In the more advanced stages the step may resemble a kick forward with the feet widespread. Closure of the eyes renders the ataxia more marked, so that the consequent swaying of the body compels the child to open the eyes to maintain its balance. Very young children become so easily discouraged with an ataxic gait that they are very prone to make no further attempts to walk, so that the surgeon must remember that an apparent paralysis following ataxia may be dependent not upon inability but upon disinclination. Habit is unusually strong during the earlier periods of life, and it is not uncommon after a real physical disability has been en- tirely cleared up to find that the child has acquired a habit from his previous disability, and, in neurotic individuals, this may be persistent. The peculiar gait which is the result of the ataxia seems to deeply interest some children when they are convalescent, and this leads to persistent imitation of the real physical disability, with the consequent formation of habit disability. DISTURBANCES OF MOTOR AND SENSORY REFLEXES If lesions of the peripheral nerves can be positively eliminated as the cause, a loss of tendon reflexes indicates a lesion situated in MOTOR AND SENSORY REFLEXES s>G5 that segment of the cord which presides over the particular reflex in question. This gives peculiar value to this means of diagnosis, as it aids materially in the determination of the definite level at which we will find the lesion. Exaggeration of the tendon reflexes indicates that the inhibitory control of the brain over the cord has been disturbed, and, as a result, the cord reacts more readily to sensory impulses and to clonus results. Without going into a consideration of all reflex actions, most of which are in common usage, certain special signs of nervous irritability must be mentioned. FIG. 100. TESTING THE KNEE REFLEXES. Whenever possible this should be done with a percussion hammer. Babinski's Sign. Babinski found that in disease of the motor tract dorsal flexion, i. e., extension of the great toe, resulted from reflex irritation on the sole of the foot. Normally, two reflexes may be obtained by irritation of the sole: (a) plantar flexion, and (b) dorsal flexion of the toes and combined movements of the leg, due to a strong stimulus. In Babinski's sign dorsal flexion results from a slight stimulus and therefore the spinal reflex is exaggerated. It may be due to increased excitability of the cord from the administration of strychnin, or diminished excitability of the cortex from depressing drugs, or conditions of the system which result in more or less stupor. The sign does not necessarily mean that there 266 INJURY AND DISEASE OF THE SPINAL CORD is disease of the motor tract. It is constantly present in the newly born and persists with more or less certainty up to two years, and, occasionally, beyond that period, so that the sign has practically no value before the third year of life is ended. In children over the age of three the sign may have some value as it is absent in hysteria, while other tendon reflexes are apt to be much exaggerated. Sensory disturbances are difficult to estimate in children. The skin reflexes are, however, commonly lost or disturbed in those instances in which the tendon reflexes are increased, but taken as a whole, on account of the difficulty of accurate determination in childhood, they are of greatly less value than the tendon reflexes. DISTURBANCES OF SENSATION These are quite difficult of recognition in the very young and, even in those children who are older and of average intelligence, there is an uncertainty because of their inability to accurately de- scribe or locate sensations. Sensations, such as heat or cold, numbness, tingling, fulness, pressure or weight, may be produced in the skin by irritation of the sensory areas of the cord and such sensations may affect the whole or a part of the limb.. A destruction of the sensory areas in the cord leads to anesthesia, which will be complete if the sensory areas are entirely destroyed at the level, or if the posterior nerve roots are cut or destroyed. With an incomplete injury to the sensory areas in the cord, there result a loss of some kinds of sensation and the retention of tlie others. Loss of tactile sensation (the sense of touch) always suggests a widespread degeneration in the anterolateral and posterior columns of the cord. Analgesia (loss of the sense of pain) and thermoanalgesia (loss of the sense of temperature) indicate a lesion of the central gray matter and of the ascending anterolateral fibers. VASOMOTOE AND TROPHIC DISTURBANCES 267 Ataxia (loss of the muscular sense) is indicative of a lesion of the posterior columns of the cord. In unilateral lesions, the side opposite to the site of the lesion is generally the site of a disturbed tactile sense (tactile anesthesia), with slight hyperesthesia on the side with the lesion. Total anesthesia indicates a total destruction of the segment of the cord at that level. In estimating the extent of these disturbances it must always be remembered that the areas of skin supplied by the several seg- ments of the cord overlap. PAIN The sensation of pain may be referred to the spine itself or to any situation to which the nerve supply goes. Pain referred di- rectly to the spine rather more indicates irritation of the posterior nerve roots or the meninges than of the cord itself. Pain due to lesions in the cord is almost invariably referred to the periphery below the level of the lesion. Thus if the lesion be one that is situated high in the cord, generalized pain may be the result over nearly the whole of the body. VASOMOTOR AND TROPHIC DISTURBANCES These are very common after an injury of the cord and also in certain diseases. Impaired circulation, with a consequent blueness and coldness, is commonly encountered. There is a markedly dimin- ished nutrition of the tissues and therefore they are rendered much less resistant to both internal and external influences. Not only do the muscles suffer in their nutrition and finally atrophy, but the bones may also become fragile. When it is recalled that this faulty nutrition of the tissues is accompanied by more or less insensibility to pressure and to pain, it is readily observed why so many of these cases suffer from gan- grenous lesions and bed-sores. 268 NATURE OF INJURIES OF THE SPINAL CORD CHAPTER XXXVI NATURE OF INJURIES OF THE SPINAL COED SPINAL CONCUSSION Such an injury to the cord is conceivable when the force which has been exerted stops short of real contusion and experimentation shows that zonal edema of the ganglionic cells may be produced with temporary interference with normal functioning. The symp- toms are those of mental shock rather than those of any definite pathological condition. At one time this supposed injury was responsible for extravagant claims for damages. The protection which is naturally afforded by the body to the spinal cord removes it from the possibility of the same injury as might more easily occur in the brain. But there are no characteristic symptoms and in human beings it has not yet been definitely demonstrated, so that we may dismiss the subject from further consideration. CONTUSION AND LACERATION OF THE CORD An injury of this character will usually produce a partial de- struction of the substance of the cord or may be so severe as to result in complete destruction. But contusion must not be con- fused with that temporary disability from a possible zonal edema. Zonal edema acts by partial separation of the cells by effusion and by pressure ; or, in other words, it is a very mild degree of contusion without any destruction. Contusion of the cord does not usually occur without a very considerable injury to the tissues which surround the cord ; in fact, the cord suffers less proportionately. There may be a total absence of symptoms in the beginning and several days or weeks may elapse before the usual symptoms of gradual complete zonal paralysis are in evidence. At best, the whole symptomatology is uncertain and in no way characteristic. MODE OF PRODUCTION 269 On the other hand, there may be immediate loss of motion with a much blunted or lost sensation. We are compelled to base our diagnosis of contusion alone upon a marked increase in the sensitiveness to pressure over the spine at the .level of the injury and with a coincident disturbance of the nerves below that level, after we have excluded any disturbance of the bony parts. To be successful in the latter, we must depend upon a most painstaking examination and radiography. This is an important differentiation to make, because, by excluding any bony injury, we have a clear contraindication for an operative pro- cedure, with the possible exception of lumbar puncture, if intradural hemorrhage occurs. Hemorrhage into the cord is a regular accompaniment of con- tusions of much severity and may occur even without discoverable injury to the bony parts. The blood may find its way through several segments of the cord and more commonly extends upward than downward. The symptoms are focal. The destruction of the cord varies with the extent of the hemorrhage and in some instances a very con- siderable portion may be distended with clot. Later on when this absorbs a cavity may be left. Intradural hemorrhage is not an indi- cation for operative interference unless it is of such an extent that pressure symptoms occur and in such instances relief may com- monly be obtained by lumbar puncture. This may be repeated as occasion demands. The situation is different however when the hemorrhage is into the cord itself (hematomyelia), for then an early operation is always indicated. The demand is for early and immediate control before extensive separation of the ganglionic cells. Late operative interference does not offer much relief as the destructive element is soon established. MODE OF PRODUCTION OF INJURIES TO THE SPINAL CORD In fractures and in dislocations it is not unusual for the bones to become displaced in such a manner that the canal is suddenly 270 LUMBAR PUNCTURE narrowed, so that the cord is either compressed, torn or cut across. The tendency is then for the bones to spring immediately back to place after the force causing the injury is removed. The cord may entirely escape injury or only suffer a slight contusion even when the bone injury is extensive. CHAPTER XXXVII LUMBAE PUNCTURE Lumbar puncture is a minor surgical procedure and, because it is so, its value has been very much underestimated. When first introduced by Quincke it was accepted as a procedure which was replete with hidden dangers, because, by it, there was an invasion of parts which were heretofore considered impossible of such attack. Now, a far different view obtains and because of its widespread application within the few years following its introduction it has been looked upon as a minor operation and is not used as fre- quently or as efficiently as it might well be. Lumbar puncture in surgical pediatric practice is minor only in its technique. It is ab- solutely necessary that the surgeon working among children have a clear knowledge of its technique and of the possibilities of diagnosis and treatment which result from its judicious application. It is not strange that there should at first have been a hesitancy about invading the subarachnoid space, and that the anatomical relationships of the cerebrospinal axis and its membranes, coupled with the many changes which the cerebrospinal fluid might undergo pathologically, made the procedure one of doubtful utility. But experience has proven that the procedure has a very definite value and that this is true in such a large sense that its use should be much more common than at the present time, for commonly by its aid uncertainty gives way to certainty, and apparently correct con- clusions arrived at clinically are changed entirely or modified through the pathological findings made possible by lumbar puncture. We will first consider the technique of the operation. LUMBAR PUNCTURE 271 The instruments necessary for the proper performance of this procedure are a small scalpel, a stylet needle, a sterilized graduated tube hydrometer, and culture tubes. It is so rarely necessary to estimate the pressure of the fluid in children that a manometer is not needed. The most satisfactory needle is one that is fitted with a stylet and is specially devised for its purpose. However, an ordinary hypodermic needle has been used successfully many times, but its danger is in the long point with which it is equipped. When one is not fully prepared with the proper needle it is much better to file off the point of the ordinary hypodermic needle so that it is FIG. 101. CORRECT POSTURE FOR PERFORMANCE OF LUMBAR PUNCTURE. The child should be held firmly on a hard surface, so that there is no marked lateral curve to the body but so that the spine is arched well by steady pressure of the hands of the assistant. almost square across, rather than to hesitate about performing the procedure. The scalpel is used to divide the skin at the chosen site, so that infection shall not be carried into the canal with the introduction of the needle. The skin of small children is so thin that we do not feel that the use of the scalpel is necessary in them, but only in those who have unusually thickened skins or are closely approach- ing adult life. The location of the puncture should be between either the third and fourth or between the fourth and fifth lumbar vertebrae. We have found that the sitting position in children is imprac- 272 LUMBAR PUNCTURE tical, for we fail to secure their perfect cooperation, and the danger of breaking the needle is always present. The recumbent posture upon the side is the best possible one, as it allows of the most per- fect control of the possible struggles of the child. In this position the child's knees should be drawn well up and the shoulders brought forward, thus bending the body forward in an arch. The necessity of having the child lying upon a firm surface will be readily seen, so that there can be no marked lateral bending of the back. To locate definitely the correct lumbar space for the puncture FIG. 102. LOCATING THE RIGHT POINT OF ENTRANCE IN LUMBAR PUNCTURE. A tape passed taut between the crests of the ilium crosses the space between the fourth and fifth lumbar vertebra?, which is usual point of entrance. an imaginary line is drawn across from the crest of one ilium to the crest of the other, or a sterilized tape or cord may be stretched across and either of these will be the guide for the point of puncture. The needle should be inserted in the interspinous space just below this level. The preparation of the skin should be most carefully attended to, and, although the procedure is so simple in its performance, every precaution should be taken as regards strict asepsis. The skin should be gently cleansed with green soap and finally with alcohol, and after this is done the exact site of the puncture should 273 be painted lightly with tincture of iodin. This procedure insures against infection in children even without the use of the scalpel to divide the skin. Anesthesia is usually unnecessary and the individuality of each child and the nature and stage of the disease present will determine whether any anesthesia is necessary, and will also indicate whether it be a local or a general one. We are constantly performing puncture without any anesthetic and always without untoward results. The technique is simple in children. The point of the needle FIG. 103. THE NEEDLE IN POSITION AND THE FLUID BEING COLLECTED IN A STERILE TUBE. should be inserted very slightly to the side of the median line and also well toward the lower part of the intervertebral space. While the needle is held firmly its point should be directed very slightly toward the median line and slightly upward. A fair degree of force may be necessary to puncture the skin and underlying tissues, i)ut after this first resistance is overcome there should be no display of force by the operator. A sudden cessation of all resistance is usually the first indication that the point of the needle has entered the canal, and this is immediately followed by the escape of the fluid; usually drop by drop. While each child differs somewhat anatomically from its brother, it is well to recall that the canal is 274 LUMBAR PUNCTURE in most instances reached when the needle has penetrated to the depth of one inch. The withdrawal of the stylet allows of the ready escape of the fluid. "Dry taps" are in almost every instance due to a failure to enter the canal. It is sometimes stated that some tissue may occlude the needle, or that the fluid is too thick to flow. In regard to the former, the use of the stylet overcomes that difficulty. The latter claim for a dry tap seems at first most reasonable, but we have encountered several such instances in which, without disturbing the needle at all, an exag- geration of the flexure of the spine, .coupled with forcible bending of the head upon the chest, has immediately started the flow of the fluid. In sev- eral hundreds of punctures we have never had a so- called dry tap. With the opportunity to immedi- ately puncture the canal following unsuccessful at- tempts to do so, we feel more and more convinced that dry taps are evidence of a failure to enter the canal. In fact, the only absolute assur- ance that one has that he has entered the canal is the withdrawal of some of its contents. Even when the pressure of the fluid is practically negative, as may occur when the cerebral portion of the subarachnoid space is blocked by inflammatory products or a new growth, at least suffi- cient will escape to show that the canal has been entered. It is possible that the point of the needle may wound the rich FIQ. 104. THE UPRIGHT POSITION FOB LUMBAR PUNCTURE. This position may be used in older children but the patient is never under as complete con- trol as in the posture illustrated in Fig. 101. 275 plexus of veins beneath the dura and when this occurs a few drops of blood will escape and this must be differentiated from a real hemorrhagic condition of the fluid itself. The fact that the first few drops of blood are immediately followed by the appearance of a clear fluid will distinguish this. For examination this blood-stained fluid may be discarded but the amount measured. The amount of fluid withdrawn will, of course, be determined FIG. 105. UPEIGHT POSTURE IN LUMBAR PUNCTURE; NEEDLE IN PLACE AND FLUID FLOWING. by the purposes for which it is taken. For diagnostic purposes, from five to ten c. c. is sufficient. When, however, the fluid is withdrawn to relieve intracranial pressure, the amount withdrawn must be the smallest quantity which will actually accomplish the desired result. The wound should be closed with adhesive plaster or covered with collodion. Normal cerebrospinal fluid is colorless and like water in its clearness, of an alkaline reaction and with a specific gravity of be- tween 1.003 and 1.007. While the amount has never been 276 LUMBAR PUNCTURE accurately determined, it has been closely estimated as being be- tween three and five drams in infants and from four to twelve drams in older children. While these figures are a variable quan- tity, yet they give us a little idea of the amounts usually present. Amounts much in excess of these should be considered as suspicious. The fluid is continuously under a double pressure, elastic and hydrostatic, and these two are so adjusted that, under normal con- ditions, the fluid escapes rather slowly, drop by drop (about 40 drops per minute). It contains but little albumin (0.02 to 0.05 per cent.), some chlorids (0.7 per cent.), glucose and another copper-reducing sub- stance, and traces of urea. The other substances contained do not interest us surgically. Increased pressure is brought about by anything which increases the volume of the fluid, so that it is commonly observed under such conditions as the various inflammatory diseases of the cerebrospinal axis or the membranes, new growths within the brain or cord, hemorrhages or fractures that interfere with the normal drainage and absorption of the fluid, hydrocephalus, in some hydremic states of the blood and the various general toxemias which cause meningeal irritation. It is only possible to isolate or determine the specific form of infection in the fluid by a thorough bacteriological examination. Such an examination adds precision to the differential diagnosis. For instance, it is not uncommon for meningitis to clinically pur- sue its entire course with a symptomatology that is so uncertain, or is so obscured by the symptoms of an intercurrent disease, that a more certain means of diagnosis must be sought. We have this means in lumbar puncture. It is not alone that positive findings are conclusive, but there is a certain value in negative findings when they persist over a period of several days. As a means of accurate diagnosis there is no one procedure which offers so much satisfaction in the affections of the cerebrospinal axis or its mem- branes. Lumbar puncture as a means of treatment has a much less important office to perform than in diagnosis. Its use in this field is quite limited in childhood. There are, however, some in- SYMPTOMS 277 stances in which distressing symptoms due to pressure may be im- mediately relieved, and, under those conditions in which we know that the fluid must be laden with microorganisms or toxins, the pro- cedure is justified upon the ground of surgical expediency, if for no other reason. Lumbar puncture as a means of administering antitoxin sera requires the use of a somewhat larger needle than for puncture alone, and one to which the syringe may be attached. The sera for tetanus and for cerebrospinal meningitis are the ones used in this manner. The puncture is made in the usual site and manner and as much of the cerebrospinal fluid as possible is withdrawn to be immediately followed by the injection of tho warmed serum, slowly introduced through the same needle. CHAPTEE XXXVIII INJURIES OF THE BRAIN AND ITS MEMBRANES SYMPTOMS The various injuries and diseases of the brain are responsible for certain symptoms which may be local or general, or an ad- mixture of both. This symptomatology may be dependent upon some interference with the functions of the brain as a whole or be confined to some limited portion of the brain tissue. Occurring in portions of the brain in which the function has been definitely located, we are able to apply the appropriate surgical interference for relief because we are furnished with a more or less definite clew as to the extent and location of the lesion. But such definiteness is unusual in childhood, for, at this period of life, the very unstable nervous system and the relatively poor inhibitory control render the symptomatology consequent upon in- jury to the central nervous system much more complicated than in adults. The symptoms due to cerebral shock are commonly so marked 278 INJURIES OF THE BRAIN AND ITS MEMBRANES that for the time they mask those which are due to compression, laceration, or contusion. In addition, children are especially prone to the various infections and, as there is a tendency toward infec- tion in brain injuries, there is often added a new chain of symptoms which are merged with the preceding ones and either complicate or dominate those of the original lesion. It is only under those few instances in which we have the most definite and exact knowledge of cerebral localization that we may reasonably hope to correctly interpret the symptoms. And even under these conditions we are often surprised to find that our ability to localize the lesion quite definitely is rendered less certain by the fact that certain large areas of the brain may be injured with- out anything more being present than the most uncertain and unin- telligible symptomatology. It is unnecessary for us to consider cerebral localization in this section, as this is a study by itself. Without going into unnecessary detail, the general signs of brain lesions are : unaccountable vomiting without preceding nausea, headache, vertigo, optic neuritis, convulsions, stupor, and coma. The focal motor symptoms are in part irritative and, in part, de- structive, so that we may have various muscular contractions, or paralysis, and these may assist in more or less definitely locating the lesion. Even in the face of a history of a definite injury, the surgeon must not be unmindful of the fact that there may commonly be in children associated lesions, and that the act of vomiting may be centric, toxemic, or reflex. Cerebral Vomiting. Cerebral vomiting is always sudden and more or less projectile in character and occurs without any of the evidences of preceding nausea. The act occurs as though it were the contents of the mouth that were being expelled instead of those of the stomach. This may occur while the stomach is empty and is usually aggravated by sudden changes of position, especially from the horizontal to the vertical. Persistency is its chief characteristic ; it yields to no treatment or diet and each act leaves the child more and more prostrated and without the evident sense of relief that SYMPTOMS 279 comes by expulsion of the stomach content in other types of vomiting. Headache. It is true in a measure of all pains, but particularly of headache, in children, that it is not definitely located but com- plaint is made in a general way. Headache in children under the age of five years is uncommon except in connection with disease or injury of the brain or its membranes. If there be an associated ele- vation of temperature the first thing that must be determined is to what extent the headache is dependent upon the rise of tempera- ture. This is decided by considering the intensity of the fever and the character of the headache. In regard to the intensity of the fever, headache is rare in children with a temperature under 103 F., unless there is disease or injury of the brain or meninges, and then it may be intense even with a low or normal temperature. The character of the headache is such when due to rise in temperature that it is readily relieved by pressure over the temples, by the appli- cation of cold locally, or by massage of the veins of the neck, and is increased for a time by active motion. Persistent headaches should always arouse the suspicion of cerebral tumor or abscess. Convulsions. It must be remembered that the very young infant is comparatively free from convulsive seizures even from extensive lesions, because of the immaturity of its nervous system. But from the third month of life to the end of the second year all of the nerve centers of the infant are most irritable, so that convulsions are common. Along with this irritability, there exists an enfeebled inhibition, so that there is only a mild restraining influence exer- cised. Very many errors have been made in ascribing a convulsion to a cerebral cause simply because it happened to be unilateral. Such an event has no bearing unless the unilateral convulsions are con- tinued over a protracted period. It cannot be too emphatically stated that unilateral convulsions occur without the slightest evi- dences of cerebral disease. It is necessary to remember in the diagnosis of convulsions of a cerebral origin that : (a) Convulsions are not commonly the beginning of brain 280 IN JUKIES OF THE BRAIN AND ITS MEMBRANES lesions, but are of later occurrence. For instance in an acnte brain disease, or an injury, there are in practically every instance head- ache, somnolence, retarded and irregular pulse, mental dulness, etc., existing before the onset of convulsions, although it may re- quire a carefully taken history to bring this out, as the convulsion seems to overshadow every other event. (b) Persistent recurrences are the rule. It is easy to see how shock, fright, or any one of the many influences to which an injured child is liable might act reflexly to excite a single convulsion, but these would be practically coincident with the infliction of the in- jury and would not persist. Paralysis. Paralysis due to a cerebral origin is chiefly char- acterized by a spastic condition of the musculature affected by hemiplegia, exaggerated reflexes, and no change in electrical re- actions. As a remote feature there is little or no atrophy of the muscles affected by the paralysis. Muscular Contraction. It is important to differentiate between a true spasticity of a muscle and the contracture which is observed after degeneration of a muscle, as is frequently seen during child- hood. In the latter condition there is a permanent flexion, and the resistance to passive motion is not because of an increased mus- cular tone, but is dependent upon actual change in the structure of the muscle itself. As the observance of the condition of the musculature is so very important, it may be well to define briefly what is meant by mus- cular tone. Muscular tone means that condition of the voluntary muscles by which there is always maintained a sufficient degree of tension to enable the muscle promptly to respond to nerve stimula- tion. Naturally this tone varies under normal conditions, but only to a slight degree. Under the influence of fatigue, ane- mia, malnutrition, or any condition which tends to permanently or temporarily exhaust the system (and therefore during shock) there is a lessened tone. The most satisfactory test of muscular tone is the resistance offered to passive motion. The limb is grasped firmly and suddenly flexed, and, if the normal tone exists, there is a very transient involuntary resistance, which rapidly disappears, COXCUSSIOtf OF THE BRAIN 281 so that the limb may be freely moved with but slight effort. The child must be off its guard when this procedure is undertaken. By assuming to make the desired motion, as if in play, so as to gain the child's confidence, and then suddenly diverting its atten- tion, the test can be satisfactorily made, even in rebellious patients. CONCUSSION OF THE BRAIN Concussion of the brain has little in common with that doubt- ful condition of spinal concussion, nor can the arguments against the production of the latter be reasonably used against concussion of the brain as a more or less distinct entity. By cerebral concussion we mean the condition of the child which follows generalized injury to the head in which there is no lesion of the brain that can be recognized, but in which there are exhibited the symptoms of temporary impairment or loss of function of the brain as a whole. Symptoms. The symptomatology is of course immediate. Al- most coincident with the infliction of the injury the child becomes unconscious. This unconsciousness may be partial or complete, momentary or prolonged. In the mild cases recovery commences almost immediately and, with the possible exception of a sense of weakness, slight vertigo, or headache, normal consciousness is not further disturbed. However, even in these milder instances of dis- turbance it is a fact that the child is incapable of accurately de- scribing the events that immediately preceded or followed the in- fliction of the injury. In the more severe instances the unconscious- ness may last for several hours and have the added symptoms of shock. The skin is pale, the pulse slow and feeble, the respirations superficial or stertorous, the conjunctiva insensitive, and, in addi- tion, vomiting and muscular twitchings are common. There is a gradual return to the normal after several hours, as a rule, but in a few instances such symptoms persist for a day with- out much improvement. The child generally rebels against any attempts at interference and assumes the flexed posture on the side. 282 Prognosis. An increased irritability is usually a favorable sign, indicating that recovery is taking place, and this is particularly so if accompanied by flushing of the face and a pulse of high tension and rapid. Diagnosis. It is the quite rapid and steady return to full con- sciousness that makes the diagnosis possible. Even if the return to consciousness is apparently rapid in an injured child, but is un- steady and interrupted with periods during which there occurs an undoubted relapse, we must be suspicious of more severe injury than concussion. Or, when the unconsciousness is prolonged over a period of twelve hours, it is then more than probable that either contusion or laceration is present in some degree. Treatment. The treatment is the securing of absolute mental and physical quiet and rest until consciousness is fully restored. COMPRESSION OF THE BRAIN Compression of the brain may be caused by any condition that creates a sudden continuous increase of intracranial pressure and therefore may be dependent upon depressed fragments of bone, foreign bodies, effused blood, or inflammatory exudates. Symptoms. It is almost impossible during the first few hours after an injury to distinguish between the symptoms due to con- cussion and those due to compression. This is true, in part, be- cause the two are usually associated and it is only when the symp- toms of concussion have had an opportunity to clear up that we are able to clearly distinguish those which are dependent upon the com- pression. There are really two types of symptoms: those due to irritation and those due to direct or indirect pressure. The first (the irritative) are immediate and are generally evi- denced as an undue excitability, accompanied by marked flushing of the face and a slow but high-tension pulse. Nausea and vomit- ing are common and the fact that nausea accompanies this type of cerebral vomiting should at once suggest the existence of irritation. The sensorium is disturbed; the mentality is dulled and, while the COMPRESSION OF THE BRAIN 283 child continues to be excessively irritable, the mental dulness in- creases progressively until coma supervenes. The second type (the pressure) of symptoms set in with tho onset of the coma and this event really marks the onset of the true symptoms of compression. The change in the pulse is marked, the force being greatly reduced at the same time that the rate is pro- gressively diminished. The respirations are slow and may become stertorous, but are always irregular. Perhaps the most characteristic symptoms are those which are observed in the pupils. The pupil upon the side corresponding with the injury is at first contracted and very shortly after becomes more or less persistently dilated, so that there is always a consider- able difference between the two pupils. Strabismus is not uncom- mon and may be associated with nystagmus, which latter is prac- tically always present. Paralysis, limited to groups of muscles, is not infrequent or there may exist a hemiplegia or paraplegia. The paralyses when present are upon the side opposite to the compression. The severity of the compression is indicated by the extent of the paralysis and the degree of inequality or insensitiveness of the pupils. Paralysis confined to groups of muscles, which do not cover a large area, indicates that pressure (probably from hemorrhage) is situated between the dura and the skull and is small in its extent. Widespread paralysis, particularly hemiplegia or paraplegia, indi- cates a very considerable injury with hemorrhage beneath the dura. Prognosis. There is one very constant indicator of the prognosis in any given case and that is the respiration. Without paying too much attention to the nature or extent of the injury, the surgeon has this clear indication that the farther the respirations get from the normal, both as regards their type and rhythm, the graver the prognosis. A rapidly fatal issue can be reasonably expected by a type of respiration which exhibits more or less prolonged cessation with subsequent irregular resumption. The pulse is no indicator in children of either the severity of the compression or its probable outcome. 284 THROMBOSIS OF THE SINUSES CONTUSION, LACERATION, AND WOUNDS OF THE BRAIN The substance of the brain may be contused or lacerated as the result of direct or indirect violence acting upon the skull or the brain itself. We may therefore have lesions which vary greatly; from minute punctate hemorrhages up to more or less complete disorganization of a large or even a greater part of the brain. The injury to the brain does not depend upon the situation of the violence, for it is not uncommon to find that immediately about the point of greatest violence the brain is practically or wholly uninjured, while distant portions on the same or even the opposite side of the brain may exhibit most serious disorganization. Symptoms. The symptoms depend very largely upon the por- tion of the brain that is injured, therefore will vary greatly in any given case. However, there are at first always present the symp- toms of cerebral concussion and these are generally associated with those due to intracranial hemorrhage and compression. Such symp- toms may be very severe, but, upon the other hand, there may be a most serious injury to the brain without any immediate definite symptoms. Or symptoms may not be in evidence at all until sev- eral days, weeks, or even months after the injury. Diagnosis. The only way in which a diagnosis can be reason- ably made is by the exclusion of concussion and compression symp- toms and this may require the assistance of the X-ray or even of operative procedure. As a remote effect, epilepsy is not uncommon. CHAPTER XXXIX THEOMBOSIS OF THE SINUSES OF THE DURA MATER While there are two types of sinus thrombosis which occur in children, there is but one that interests the surgeon, and that is the inflammatory. The other type, the cachectic, is practically impos- SYMPTOMS 285 Bible of diagnosis during life and has no relation to the surgical conditions of childhood and therefore will not be considered here. Inflammatory sinus thrombosis, which is also commonly known as septic thrombosis and sinus phlebitis, occurs most commonly in connection with meningitis, but, as a surgical complication, its most common occurrence is with the infectious processes affecting the middle ear. While this is true in a general way, it ought to be emphasized that its association in this particular is less common during childhood than in adult life. Etiology. It may have as its etiology traumatism about the head, necrosis of the cranial bones, or infectious processes affecting any of the soft parts of the face or head, or similar processes of the mouth, nasal fossa, or pharynx. The acute infectious diseases, such as scarlet fever and diphtheria in particular, make infection easy through the mouth and the pharynx. Site. The site of the original disease determines the site of the thrombosis. Thus, if the primary infection is of the cranial bone, or of the scalp, extension is to the longitudinal sinus; if of the ear, then the lateral sinus; if the base of the skull, the mouth, the jaw, or the nose, then the cavernous sinus. Symptoms. The GENERAL SYMPTOMS are those of pyemia (un- less occurring in the course of meningitis, when practically no new symptoms are added). The symptomatology, therefore, is usually that of recurring chills (or convulsions in the very young), asso- ciated with a widely fluctuating but usually very high temperature and considerable sweating. It is just such symptoms associated with some primary infectious process about the head or face that suggest the diagnosis and if in an infant we observe the symp- toms and local signs of an infection, followed by convulsions and somnolence, it should at once excite the suspicion of sinus throm- bosis. Headache may be present in a minor degree and if it is persistent or severe, or becomes associated with marked vomiting, it indicates a complicating meningitis. In fact, the cerebral symp- toms are far from being characteristic, consisting usually of mild headache, crying out during the sleep, somnolence, and possibly coma. Or added to these there may be strabismus, nystagmus, and 286 THROMBOSIS OF THE SINUSES dilatation of the pupils. Very rarely we may observe paralysis. Metastasis is not uncommon and in some instances there are evi- dences of abscesses of the brain or other organs, and, more rarely, an extension into the internal jugular vein, so that that vessel may be easily felt as a hard cord just along the anterior border of the sternomastoid muscle. The LOCAL SYMPTOMS are dependent largely upon the particular sinus affected. Cyanosis of the face, with dilatation of the temporal and frontal veins, with or without epistaxis, indicates an infection of the superior longitudinal sinus. Dilatation of the veins of the neck, or the hardening of the in- ternal jugular vein, as already referred to, with or without edema behind the mastoid process and possible extension to the neck, sug- gests an invasion of the lateral sinus. Not uncommonly attention is first directed to the infection by the objective evidences of pain whenever the head is moved. The child therefore attempts to limit such motion and there consequently often exists a persistent lateral inclination of the head and this is accompanied with more or less dysphagia. Protrusion of the eyeball of the affected side, or localized edema about the orbit, indicates the cavernous sinus as the site of the in- fection. One or both sides may be affected. It must be readily observed that these local signs are all very uncertain and that but little reliance can be placed upon them alone as a means of diagnosis. It is only by their close association with a more definite general symptomatology that they have any value and they must be considered in that relationship. Course and Prognosis. The course of the infection is very irregu- lar and uncertain and may cover a period of a very few days or persist for three weeks or more. The prognosis is always grave, death usually taking place from meningitis, cerebral abscess, pyemia, or a rapid exhaustion. Of course, there always remains the pos- sibility of a collateral circulation being established, or of an oblitera- tion of the sinus by fibrous tissue and a secondary hydrocephalus, but even this means temporary relief only. ETIOLOGY 287 Treatment. The treatment is purely surgical and the results depend almost entirely upon the accessibility of the infection. Operations upon the lateral sinus offer the most promising results and, whenever the diagnosis is clear, operative procedure should be immediate. CHAPTER XL Abscess of the brain is a much more frequent disease during childhood than is ordinarily supposed. The difficulty surrounding its diagnosis has often resulted in its being overlooked. Its most common occurrence during childhood is between the ages of five and ten years, it being a rarity either before or after that period, until well into adult life. Before the beginning of the fifth year of life the marked tendency is toward suppurative meningitis rather than abscess. Etiology. The etiology is two-fold in the main : otitis and trauma. By far the most frequent cause is a chronic otitis. And chronicity seems to be a most important factor, for it is rarely the case that an acute otitis is followed by brain abscess, so that, while we remain uncertain as to the exact manner in which a chronic otitis results in abscess, we must always bear in mind its relatively great influence as the etiological factor. It is not necessary that the pus be retained for the production of cerebral abscess; as many cases occur when the discharge is free as when it is not. Trauma is another important eiological factor and the degree or extent of the injury need not be great. Even in the instances in which cerebral concussion has been diagnosed abscess may follow, but in such instances there was probably some undiscoverable con- tusion or laceration present also. In some cases it is impossible to reasonably assign the cause. The abscess is the result of an acute inflammation of the brain. The center of the diseased focus breaks down and suppurates rapidly 288 CEREBRAL ABSCESS and the resulting cavity is filled with the necrotic material, a yellow- ish green, fetid pus, fluid, and bacteria. In addition to the pus- producing organisms there may be present also other pathogenic bacteria, as the pneumococcus or tubercle bacillus. Within a few weeks the cavity may become encapsulated and assume a more regular spherical shape. But encapsulation does not in any way indicate a cure although it may cause the abscess to remain latent for a long period (perhaps years). Traumatic abscess is practically always solitary and its most common situation is the cerebrum. Otitic brain abscess follows a morbid process which begins in the bone and only involves the dura secondarily. The usual situa- tion is in the temporal lobe or in the cerebellum. Symptoms. The symptomatology is influenced by many factors, chief of which are the site of the abscess and the stage of the disease. In regard to the latter, we can more or less clearly distinguish four rather well-defined stages: (1) The initial stage, which may be ushered in by a train of symptoms which are so slight as to pass unnoticed or be assigned to some slight indisposition. In other instances these symptoms may be masked by those of the primary disease or the injury. But when present so as to be appreciated, they are headache, vomiting, chills, and a general prostration. Such symptoms are common to many other conditions in childhood, so that it is rather their asso- ciation with possible causative factors of cerebral abscess that gives them value. The initial stage lasts for from one to five or six days and is merged into the next stage. (2) The latent stage. This may be entirely absent or be so short that it is practically impossible to distinguish it. However, the usual course is for this latent stage to persist over a long period so that for months there may be an almost entire absence of symp- toms. With the possible exceptions of an occasional headache, vertigo, or nausea, and, more rarely, chilliness and drowsiness, there may be nothing to interrupt the latent stage. A few reported cases have shown that this stage may persist for several years. If SYMPTOMS 289 focal symptoms have been present during the initial stage they still persist in the latent stage but they do not progress. It is easy to see how a prolonged latent stage would cause one to forget the symptoms of the initial stage, or to assign them to some other cause, and, therefore, in the taking of the history this point should be recalled. (3) The stage of full development. This in a few instances seems to immediately follow the initial stage, but, as has been sug- gested, the latent stage may intervene. The general symptoms of the initial stage are still present, but there are added to these those symptoms which depend upon the situation of the lesion and its size. The usual course is for the headache to become less intense but more definitely located, and its intensity is influenced greatly by anything which raises the blood pressure. Percussion may, at times, reveal localized pain in the skull. When vomiting is present, a sudden change of posture usually provokes it. Convulsions are not common. The pulse rate is markedly reduced, so that it is not uncommon to note a fall to 40 or 50 beats a minute, and the rate is out of all proportion to the respirations, which remain unchanged, with one exception: in cerebellar abscess they are also reduced. The tem- perature remains normal or subnormal, as a rule, but there may occur slight rises. When such a rise occurs, it is always slight and characteristically persistent. A high temperature or a fluctuating one should arouse suspicions of suppurative meningitis or sinus thrombosis, for it is not suggestive of an uncomplicated cerebral abscess. Psychic changes are merely suggestive and, while they have a cer- tain interest, they are not real aids to diagnosis. They consist in the main of lapses of memory, periods of excitability, facial flush- ings, etc. Occasionally this stage of full development is apparently ab- sent because the terminal stage is ushered in with great rapidity, so that, like lightning out of a clear sky, acute symptoms develop and prove rapidly fatal. (4) The terminal stage. This is usually merged with the pre- 290 CEREBRAL ABSCESS ceding stage, so that there is no clear line of demarcation between the two, but merely the increased evidences of progression. It has already been mentioned that the intervening stages may be so short that the terminal stage seems to immediately follow the initial stage, or, more often, the latent stage. The symptomatology of this stage is dependent upon a rapid ex- tension of the inflammatory process associated with an edema and softening of the tissues about the abscess, to the rupture of the abscess, or a. supervening meningitis. Thus, we may observe a great variety of symptoms but it is always a more intense symptoma- tology than has immediately preceded. There is, however, one ex- ception to this, and that is when the symptoms preceding the terminal stage are not intensified but modified and even made less active by the onset of the marked symptoms of pyemia and rapid and extreme exhaustion without any well-defined cerebral symptoms. The focal symptoms are generally very indefinite, for an abscess of a considerable size may be present in the temperosphenoidal lobe for instance, in the central portion of the frontal lobe, or in the cerebellum without appreciable focal signs. It is only in a few favored instances that we are able to locate the abscess definitely from the focal signs. Word deafness (hearing but not understanding the spoken word), deafness upon the opposite side, and oculomotor paralysis would suggest an affection of the temporal lobe. Cortical convulsions and opposite-sided hemiplegia would suggest the parietal lobe. Rigidity of the neck musculature, interference with the gait, violent headache, and vomiting suggest the cerebellum as the site. Persistently indefinite focal signs are the rule, particularly if the frontal lobe be affected. Occipital lobe abscess is rare. Difficult as it may be to satisfactorily establish it, it should constantly be our effort to determine the exciting cause, whenever we are suspicious of cerebral abscess. We must also be cognizant of the fact that, in children, disease of the nose or ear may remain apparently latent for a very long period, and that injury to the head may not immediately be followed by symptoms due to conse- quent disease. The very indefiniteness of the symptomatology should be remembered, despite the fact that a considerable amount of suppuration may be present in the brain. And even in those instances in which we are quite positive of intracranial suppuration we must differentiate suppurative meningitis and sinus thrombosis from brain abscess. Suppurative meningitis has a much more acute onset than has abscess, and the symptomatology is always more acute and progressive from the very beginning. However, with all this common acuteness and rapid progression, the local symptoms are more unreliable and transitory. Lumbar puncture reveals the presence of pus. Sinus thrombosis exhibits a rather typical pus temperature, with possible chills, and sweating and local edemas are common occur- rences. In both instances, the history of the onset and the considera- tion of the events which immediately and remotely preceded it will serve to distinguish each disease in a much more certain manner than will the particular attention to individual or special symptoms. A study of the previous history of the child is therefore of much more importance than the mere study of the symptomatology. Diagnosis. The diagnosis of chronic abscess from tumor is not always simple. In tuberculous children particularly, the association of brain tubercle with a chronic and persistent discharge from one or from both ears is not uncommon and this may easily prove mis- leading if the discharge from the ear is considered as the primary disease. The main points to consider are these: tumor may occur at any age and without a definite etiology (with the one exception of tubercle), and is also characterized by its slow but very persistent course, with the constant addition of newer symptoms as the older ones progress. Violent and persistent headache is a prominent feature, mental disturbances are marked, focal symptoms are quite definite, and fever is absent. In contradistinction to this, cerebral abscess is rare before five years or after ten years in children, it presents a definite history or etiology if this be carefully sought, it exhibits a most irregular course both as regards the symptoms and the various stages of the disease and their relationship to each 292 INTEACRAN1AL TUMORS other, headache is not one of the characteristic symptoms, and focal symptoms are indefinite. However, despite all these differences, it is not always possible to avoid a reasonable error in the diagnosis, or, at best, we may be compelled to remain for a time in doubt as to the real nature of the lesion. In such instances it is good judgment to consider the case as one of abscess and, if possible, to give the child the benefit of operative interference. Prognosis. The prognosis is very unfavorable. Not infre- quently rupture supervenes before the symptoms have given suffi- cient warning of the progress of the disease. Treatment. Medical treatment of cerebral abscess offers nothing more than the temporary relief which might come from the usual measures used in the acute stage of acute intracranial inflammation. The utter hopelessness of any permanent relief coming from any- thing else but surgical interference should lead to the earliest pos- sible operative relief. INTRACEANIAL TUMORS In a study of the neoplasms which affect the central nervous sys- tem, we are at once confronted with the fact that the nature of the neoplasm has much less to do with the symptomatology than has the site of the tumor. Thus it would seem to us reasonable to consider intracranial tumors in a somewhat different manner from other growths and give little attention to the exact nature of the lesion. Intracranial tumors are not uncommon during childhood, al- though they may be considered as rare under the age of two years, with the one exception of tubercle. Of all tumors, at least one-half are tuberculous, and one-quarter either glioma or sarcoma. The frequency with which cerebellar tumors occur is noticeable. Etiology. The etiology is obscure when we leave out the two factors of injury and tubercle. The tuberculous tumors are often SYMPTOMS ;><>:> multiple, sharply defined, and surrounded by softening, lint they rarely break down. Gliomata are epithelial in origin, infiltrating in character, and prone to degeneration, softening and cystic forma- tion, and sometimes hemorrhage.' They are slow in growth but do not involve the bones or cause secondary deposits. Sarcoma is most commonly situated in the cerebellum. The influence of injury is probably what accounts for the greater prevalence among boys. Symptoms. GEXERAL SYMPTOMS. Of all the symptoms, head- ache is the most prominent, being persistent, generally severe (but not so severe as in adults), and occasionally intense. Xot uncom- monly it occurs with most marked intensity during the night and in the early morning. Mental effort or anything which increases intracranial pressure exaggerates the headache. Occasionally it is localized over the site of the tumor and is most intense when the tumor is in the posterior cranial fossa, the pain then being occipital and radiating into the neck. Tenderness of the scalp is not uncommon in cortical tumors. Closely associated with the headache there is the occurrence of vomiting and vertigo. The result is that, for a short time, the case may simulate headache from some digestive disturbance. The vomiting, however, is of the projectile type and has no relation to the meals. Like the headache the vomiting and vertigo are per- sistent, making in all three very suggestive symptoms. Vertigo may occur even while the child is reclining and may be described as a sense of falling or turning (subjective sign), or it may be stated that the room is moving (objective). In about four-fifths of all the cases optic neuritis accompanies cerebral tumors. It is not uniform in both eyes and has no relation to the size of the tumor. In the early stage of the disease general convulsions are com- mon, but the rule is that there are long periods between the con- vulsive seizures in the beginning. This may lead to the conclusion that the attacks are dependent upon other causes. All degrees of convulsions are observed from simple twitchings to severe and typical epileptiform seizures. 294 INTBACRAXIAL TUMORS The mental symptoms show the greatest variety and complexity, and such symptoms are so frequent in childhood during the course of disease that they are not apt to excite suspicion as to the true condition for a long time. At first there is very apt to be an irritability which is unnatural to the child, followed by depression and a disinclination to play or to be amused. Somnolence may be added to this, although it may not be noticeable until late in the disease. Any child who suffers from headache, associated with vomiting and vertigo, all of which are persistent (although not necessarily severe), and who is at the same time persistently and increasingly somnolent, must be regarded with suspicion. Even without the somnolence, which may be of later occurrence, we still have three characteristic symptoms: persistent headache, vomiting, and optic neuritis. If vomiting be absent, as is the occurrence in rare cases. then optic neuritis is also apt to be absent, so that the one constant feature of intracranial tumors is headache (persistent). Xow if headache alone is present there may be considerable difficulty in the diagnosis at first. The only thing which appears to affect the severity and persistency of the headache is the occurrence of hydro- cephalus and when this is well developed the pain may entirely disappear. Nystagmus is usually of late occurrence and is irrespec- tive of the situation of the tumor. Hydrocephalus also may occur with a tumor in any situation, but if appearing early or being ex- treme in degree, it indicates that the lesion is obstructing the sylvian aqueduct or the fourth ventricle. The pulse alters with change of posture and is infrequent, slow, and irregular. LOCAL SYMPTOMS. These may be absent or few at first and are practically always slight in the earlier stages and increasing with the size of the tumor, a very sudden increase indicating that hemor- rhage has taken place. It is not uncommon to observe a lesion of the frontal lobe with- out obvious signs. Usually, however, there is evidence of mental impairment which may be observed as dulness or apathy, or may amount practically to imbecility. Fainting attacks, petit mal. SYMPTOMS 295 enurcsis, and coma are also common to this lesion. Extending back- ward, the tumor may involve by pressure the motor area and cause convulsions on the opposite side of the body. An inability to write indicates involvement of the left frontal convolution and motor aphasia of the third frontal gyms. Sudden loss of consciousness or an impairment of it, associated with automatism, is characteristic, but may also occur in temporal and occipital lesions. From pressure there may occur brachial, facial, or crural monoplegia, or even hemiplegia, which occurs grad- ually. There may be either unilateral or bilateral anosmia. Blind- ness is not uncommon. In the event of lesions existing which are destructive to the cen- tral convolutions, there may be observed paralysis of voluntary motion in the corresponding parts of the body, or there may simply exist an impairment which shows as a weakness. Inability to localize touch or irritative phenomena is quite common. Localized epilepsy is among one of the earliest symptoms, but usually is rapid in its spread, so that Jacksonian convulsions may involve the whole side of the body within a short time. Of the occipital lobe, the most characteristic local sign is bi- lateral homonymous hemianopia. If on the left side, there may be word-blindness and an inability to recognize those persons or things which are familiar (physical blindness). There may also be sensory epilepsy, visual hallucinations, and visual aura. Of the temporal lobe, there may be an alteration of the mental- ity without other signs. However, when the other signs occur they are deafness, word-blindness, word-deafness, or a total loss of speech. Hallucinations of smell and of taste are common, but their loss is infrequent. Involvement of the internal capsule has as its chief characteris- tics hemiplegia, hemianesthesia, which is never absolute, and hemianopia. Tumor of the pons presents the unusual combination of hemiplegia with crossed facial anesthesia. Ataxia is common, as is also intention tremor. Spastic paralysis of the face may be present, also deafness and hemianesthesia. Tumor of the medulla causes atrophic changes, as paralysis of the 296 INTRACEANIAL TUMORS lips, palate, pharynx, and larynx, but in this situation a tumor usually proves rapidly fatal, so that symptoms are not observed for any considerable period. The signs of cerebellar involvement are mostly dynamic, and to be well demonstrated the general mental and physical condition of the affected child must be reasonably good. Hemiataxia (on the side with the lesion) is frequent, but is more pronounced in the upper than in the lower limb. Movement is unsteady and uncertain when an attempt is made at the finer adjustments. In most of the cases, the head is inclined to the shoulder of the same side as the lesion, the face being slightly turned to the opposite side. This is most noticeable in the sitting position. When the child stands, the body is bent toward the side with the lesion and there may a tendency to fall in that direction, for the child is very unsteady. While walking, the child does so with a sort of lunge and progresses in a curved line. Sometimes there is bilateral ataxia with forward bending of the body or re- traction of the head with backward inclination of the body. Nys- tagmus is usually marked and irritative phenomena are sometimes prominent. There has been no attempt in considering these local symptoms to do more than suggest some of the more prominent ones, and the finer details of localization must be studied from the works upon this special subject. Diagnosis. The diagnosis is at times difficult and for a period may be impossible. It depends largely upon the general symptoms which have been mentioned as characteristic, but, in addition, the local signs have to be considered secondarily. In the matter of localization, Taylor bases a. table upon the presence of hemiplegia and this may prove useful. (1) Pure hemiplegia the tumor is above the tentorium. (2) With palsy of the opposite third nerve in the crus cerebri. (3) With hemiataxy and nuclear ocular palsy in the mesen- cephalon. (4) With hemiataxy on either side and palsy of the fifth, seventh, and eight nerves on the same side in the pons varolii. DIAGNOSIS 297 (5) Without facial palsy, with hemiataxy on the opposite side. and with alternate palsy of the ninth to twelfth nerves in the medulla. When optic neuritis exists alone or in association with headache and vomiting, it at once leads to a suspicion of organic disease of the brain, of kidney disease, lead poisoning or grave anemia. The two latter can usually be easily eliminated, for there is the history of lead colic in the one and the impoverishment of the blood must be extreme in the other to cause such symptoms. Uncertainty could not exist long. Also, in anemia, the neuritis is of rapid development as com- pared with tumor and the influence of treatment is quickly ap- parent. Kidney lesions would be revealed by urinalysis and headache is not extreme or persistent. It is with other brain diseases that tumor is apt to be confused. If basilar meningitis be slowly developed, it may for a time simulate intracranial tumor but in the latter there is an entire absence of fever, of the slow and retarded pulse, of the constipation, of the re- tracted abdomen, and of the pupillary changes. The onset of tuberculous meningitis is more rapid than tumor, and the prodromes, the wasting, the history, the tuberculin tests, and lumbar puncture are sufficient to make the distinction soon clear. In some instances the symptoms of a slow onset of local signs with a progressive course are not due to tumor (although they simu- late it), but are occasioned by an enlarging focus of disseminated sclerosis involving one of the peduncles of the cerebellum. In those instances the optic discs are pale and other symptoms finally appear, although they may be long delayed. Hemorrhage could hardly offer a difficulty, as its onset is sud- den, in marked contrast to that of tumor, and the symptoms show periods of progressive improvement instead of progressively growing worse. The differential diagnosis between intracranial tumor and cere- bral abscess has already been fully considered (see page 291). 298 THE PARALYSES OF CHILDHOOD CHAPTER XLII THE PAKALYSES OF CHILDHOOD To the surgeon working among children there will be presented from time to time instances in which one or more limbs are partly or completely paralyzed. Or, as is more commonly the case, the child is presented because of the persistence of some contracture or some more or less marked deformity which is dependent upon the paralysis or the contracture. In some few instances there may exist a combination of all of these. We must admit that the treatment of the results of the several forms of paralysis has much in common as regards the advisability of the repair and transference of nerves, the performance of tenot- omy, or of tendon shortening, lengthening, or transplantation and also as regards the technique when these are performed, but it is quite necessary that the surgeon be able to make the direct and differential diagnosis clear. In this section it is necessary for us to consider the following: Poliomyelitis, an acute disease, due to an inflammation of the anterior portion of the cord principally, but with possible further extension; Erb's paralysis, or paralysis of the arm in the new-born; infantile cerebral paralysis, from a lesion within the cranium ; pressure paralysis; paralysis of the musculospinal nerve, and facial paralysis. ACUTE POLIOMYELITIS We should not allow the confusion of many names to lead us astray in regard to the definite facts which are known of this disease because of its close study and investigation within very recent times, especially by Flexner in this country. Acute anterior poliomyelitis, infantile spinal paralysis, acute atrophic spinal paralysis, myelitis of the anterior horns, infantile atrophic paralysis, infantile paralysis, essential paralysis of chil- ACUTE POLIOMYELITIS 299 YEAR OF LIFE \2 dren these are some of the many names by which the disease is variously known. Of all the forms of paralysis occurring in childhood, this is the most frequent and yet, with this common occurrence, there are still constantly arising facts in regard to the disease which are difficult for the diagnostician in particular. The age incidence is of considerable interest because it is mainly a disease of early childhood and it might be noted that the central nervous system seems especially susceptible to infection at this period of life, as is no- ticed by the more com- mon occurrences of sup- purative, cerebrospinal, and tuberculous meningi- tis before the end of the third year. The most common de- velopment is during the second year of life and this should receive spe- cial mention because it contrasts with the first- y e a r age-incidence o f FIG. 106. AGE INCIDENCE IN POLIOMYELITIS AS OBSERVED IN THE 1909 EPIDEMIC IN BROOKLYN, N.Y., BY THE AUTHORS. cerebral hemiplegia. It will be noted by reference to the accompanying chart that, while seventy-two cases occurred during the first three years of life, there was a decided maximum incidence during the second year. The earliest onset was at four months. The seasonal incidence is even more interesting than the age- incidence and this can be best studied from the accompanying chart. The earliest case occurred in the authors' series in the month of May, and the latest during November, and of all the cases the sea- sonal incidence reached its maximum in September. It must be remembered, however, that it is true of all the infec- tions of childhood that the symptomatology occurs distinctly seasonal 300 THE PARALYSES OF CHILDHOOD and varies with each particular epidemic and especially with the type of child affected. For instance, we do not expect the rachitic or malnourished child to respond in the same manner as his normal brother and, besides this, there is the important influence of age or immaturity. In the presence then of a disease which has been long recognized, but only recently carefully studied, we find abundant cause for the conflicting statements as to the manifestations of the acute stage. Symptoms. ONSET. We might reasonably divide these mani- festations into three somewhat distinct periods: the period of onset, of paralysis, and, finally, of retrogression. The symptoms of the period of onset are by no means constant and may exhibit such a variability that there are three rather distinct types of onset. The commonest type of onset is that of an acute illness of an indefi- nite nature, lasting from two to three days, with symptoms of fever, diar- rhea, vomiting, and some malaise prominent, and followed by paralysis. There may be other symptoms present, as dysphagia, constipation, cough, and an undue restlessness, but these usually do not excite any particular attention or comment. On the other hand, there may be a prolongation of this symptomatology over a period of several days. In a small proportion of the cases the nervous phenomena are so prominent that they make one suspicious of a cerebral rather than a spinal affection. A less common onset than the preceding is that in which there is very apparent suddenness, which is probably more apparent, how- ever, than real. It is more than likely that most of the cases with OSES! JAN I FEB I HCH I APR I MAY | MH \ JUl | AUG I SEP I OCT I NOV I DEC FIG. 107. SEASONAL INCIDENCE or POLIOMYELITIS AS OBSEKVED BY THE AUTHORS IN 1909. ACUTE POLIOMYELITIS 301 such an onset terminate fatally before an accurate diagnosis can be made and are often reported as instances of meningitis, when the real condition present is an involvement of the cervical portion of the cord. An insidious onset, without any serious general manifestations, the disease going through the successive stages without some promi- nent symptom to give the clew, is the rarest type of onset in chil- dren. Or, in other words, a true subacute or chronic course through- out all of the stages of the disease is at best rare. In these cases the paralysis is not marked as such, but is exhibited as a muscular weakness followed by wasting. It is extremely doubtful if the disease ever occurs in fetal life; and, of the early cases which have been reported as occurring dur- ing the first few days or weeks of life, the more probable diagnosis is hemorrhage rather than poliomyelitis. There does not seem to be any difference in the affection of the sexes and a close study of many epidemics will show that this is a very variable factor. In regard to the individual symptoms: Fever is present in about eighty per cent, of the cases and when confirmed by the thermometer shows a range from 100 F. to 102 F. as the rule, and the higher temperatures as the exception. The rise in temperature usually persists until the occurrence of the paralysis, at which time it is either much lowered or disappears. Exceptional cases exhibit a persistency of the temperature rise after the onset of the paralysis and this is usually accompanied by con- stitutional disturbances also. Diarrhea is present in over one-half of the cases, but there is nothing about the number or the character of the stools which is in any way suggestive. Vomiting is rarely a prominent feature, but occurs in some de- gree in about one-third of the cases, and its most common occurrence is at the onset of the fever and, therefore, there is always some doubt as to whether it is due to the onset of the disease or is the result of a digestive fault at the onset of an elevation of the body temperature. It is always transient and never projectile. LlBl\Uv\ OF COLLEGE OF OSTlOl=.0 H;N ilv'S- N J^l'Kl-.lE 1 302 Cough is very common and occurs without any detectable physical signs to account for it. It is present in one-third of the cases. Constipation occurs in a small proportion of the cases. Difficulty in deglutition is not uncommon and this is irrespective of any condition in the throat to account for it. Occurring in about 30 per cent, of the cases, it is one of the earliest symptoms. Rigidity of the neck musculature is infrequent and, when it does occur, its onset is sudden and there are distinct periods during which complete relaxation takes place and it therefore has no more significance than the similar rigidity of a temporary nature which occurs in practically all of the infections in children. Transitory loss of sensibility may at times be noted in the cases that are seen early. Pain is present in more or less degree in practically every case and can be easily elicited by gentle squeezing of the muscles. This sensitiveness of the musculature is irrespective of the muscles which are affected, being quite general. After the first few days the pain is more strictly localized in the affected muscles and is apt to be more marked than previously. While there is nothing suggestive about these symptoms when taken individually, there are combinations of them that are of great value in the presence of a known epidemic. The commonest com- binations are fever, diarrhea, and cough, with or without dysphagia and fever, vomiting, cough, and diarrhea. Other combinations are much less common. PARALYSIS. Such combinations of symptoms may continue for three or four days and subside without paralysis following. How often this occurs during an epidemic it is impossible to determine, but there are probably a large proportion of such instances. In other cases there is muscular weakness persisting for several days and out of all proportion to the severity of the initial symptoms, but no paralysis. Typical cases are, however, not of this abortive type, but the symptoms of the onset are followed by paralysis. The interval be- tween the symptoms of the onset and the occurrence of the paralysis A'lO'STgO ~,Cj H0HJJG5 303 varies greatly.' The onset of the paralysis may be apparently so sudden that no symptoms have been noted as preceding it, so that it is not uncommon to get a history of the child retiring at night in health and arising paralyzed in the morning. However, care- ful history taking eliminates practically all of these instances, for it is shown that mild but unnoted symptoms were present, the calamity of the paralysis overshadowing them. The paralysis may occur, however, as early as within twenty-four hours (or in rare instances less), or may be delayed until the second week. The average, however, is for its occurrence upon the second or third day. The typical paralysis is that w r hich shows a loss of power in some muscles with flaccidity. It seems clear that the portions of the cord remote from the brain are most commonly affected, as is shown by the lower limbs being most often affected. The first onset of the paralysis is never an indicator of what the ultimate result will be. In a few instances the progressive nature of the paralysis is very marked, muscle after muscle being affected in succession. But the commoner occurrence is to observe a more or less widespread paralysis at the onset with subsequent clearing up to a decided degree. Within a few days the preserva- tion of the normal electrical irritability will enable the examiner to pick out the muscles which are capable of more or less regenera- tion. In no other condition is there such an early loss of response to the faradic current. The tendon-jerks are rapidly lost in the affected limbs, but this loss depends upon the distribution of the paralysis ; there may be extensive paralysis of the legs with no loss of knee-jerk, so long as part of the quadriceps extensor, particularly the vastus internus, is intact. Atrophy of the musculature may be present as early as the end of the first week, although its later occurrence is the rule. The usual course is for the paralysis to progressively improve for a period of three months and atrophy to occur not earlier than within four to eight weeks. The growth of the limb is arrested and it becomes shorter and smaller than the unaffected one. There is another type of the disease which is rarely seen except 304 THE PAKALYSES OF CHILDHOOD in epidemics and which shows an involvement of the cranial nerves, indicating a bulbar lesion. In this type, more or less severe or con- tinued convulsions may be added to the usual symptomatology, or a single convulsion may be followed by stupor or delirium. Paraly- ses involving the face, trunk, and neck are common and there may be difficulty in swallowing. Diagnosis. It is impossible to make the diagnosis before the occurrence of paralysis with- out the aid of lumbar punc- ture. If lumbar puncture is performed early the fluid is found to be opalescent or slightly turbid, on account of the many mononuclear cells and not uncommonly such a fluid will coagulate spontaneously. Xoguchi's globulin test shows positive reaction. With the occur- rence of the paralysis there is a gradual clearing up of the fluid, and within a very few days there is nothing left by which we can distinguish the disease. Differential diagnosis is difficult at first because there is nothing in the prodromal symptoms to arouse a suspicion of the disease, except in the presence of an epidemic, so that many errors are made either through a too hasty diagnosis or through too much regard for one symptom. The onset of one of the acute infectious diseases, diseases of the joint, rheumatism, and many other conditions will be diagnosed as a result of the prodromal symptoms, and it is only with the occurrence of the paralysis that the diagnosis is made definite. The appearance of early cerebral symptoms makes the differ- Fio. 108. ATROPHY OP THE MUSCTTLATUBB OF THE LEG FOLLOWING POLIOMYELITIS. ACUTE POLIOMYELITIS 305 entiation between this disease and cerebrospinal meningitis, or even tuberculous meningitis, quite impossible without the aid offered by an accurate bacteriological examination of the fluid obtained by lum- bar puncture. When the disease is observed in its later stages there may be some difficulty offered by cerebral palsies, multiple neuritis, or a pseudoparalysis. In regard to infantile cerebral paralysis and poliomyelitis, they both affect children of quite similar ages (as before the third year of life), but the maximum age-incidence of the former is during the first year of life. The mode of onset is quite similar in both diseases in that paralysis quickly follows some indefi- nite symptomatology. The paralysis in both may be lo- calized in an entire limb, or affect certain muscles of a limb. Now, while these sim- ilarities are marked, the dif- ferences are also clear. Cere- bral paralysis is unilateral and the usual form is hemi- plegia and if but one member be affected it is, by a prepon- derating preference, the arm, and if two limbs are affected then the arm and the leg of the same side. In the cerebral paralysis there is an absence of any electrical change in the affected muscles, but this is difficult to determine in children. In cerebral paralysis the reflexes are exaggerated, while in the spinal type they are diminished or lost. After a case of poliomyelitis has persisted for a long time, that is, until such time as the paralyzed musculature begins to show FIG. 109. HERNIA OF THE ABDOMINAL WALL DUE TO PARALYSIS OF THE ABDOMINAL MUS- CLES IN POLIOMYELITIS. The authors observed several such cases during the 1909 epidemic. 306 THE PARALYSES OF CHILDHOOD atrophic changes, it may readily be mistaken for one of the follow- ing conditions: muscular dystrophy, multiple neuritis, acute trans- verse myelitis, pseudoparalysis of scurvy or rickets, and paralysis following acute meningitis. As it is at this stage of the disease, or later, that the child is brought to the surgeon's attention, it is most important that these be differentiated. The distinction from muscular dystrophy is usually easy, for the history is entirely different, but, in the instances in which a definite and clear history is impossible to obtain, the facts then to be considered carefully are that, in muscular dystrophy, all the limbs are usually affected and if it is of the pseudohypertrophic type certain muscles are enlarged. There is an absence of the cold- ness and cyanosis of the affected limb, as is common in poliomyelitis. Multiple neuritis is generally distinguished by its gradual onset and by the presence, more or less prominently, of sensory symptoms, as pain (which is usually along the course of the affected nerve) and alterations in the sense of touch, temperature, and the muscular sense. Besides this there are the history and possibility (if enough time has elapsed) of spontaneous recovery. But at times the onset of multiple neuritis is sudden, with febrile symptoms and an early paralysis, and the sensory symptoms are not marked, and under these circumstances it is almost impos- sible to make an early diagnosis. The course of the disease is the main point upon which the surgeon must rely. Acute transverse myelitis at the onset may simulate poliomye- litis, but in the former there are decided anesthesia, exaggerated knee-jerks, ankle-clonus, and, what is quite distinct from poliomye- litis, there is usually an involvement of the sphincters. The reflexes at the level of the lesion are usually lost. But the chief character- istic is that, besides acute transverse myelitis being rare in children, there is more or less anesthesia developed simultaneously with para- plegia. Pseudoparalysis of scurvy or rickets is a condition which must be considered on account of former errors. The pain in the limbs, the extreme wasting of the muscles, and the general indefiniteness of many of the symptoms make the differentiation sometimes difficult. ACUTE POLIOMYELITIS sor There should always be a search made for the associated symptoms of scurvy, and the gums will give valuable evidence, particularly if any teeth are present. The spongy gums, which bleed readily, the pain upon motion of any kind, and the general tenderness and hyperesthesia all tend to the exclusion of spinal disease. The muscular weakness due to rickets is sometimes mistaken for a flaccid paralysis, but the electrical reactions are normal, the condition is always bilateral, and other evidences of rickets are present. Acute meningitis may be followed by paralysis with flaccidity and atro- phy, and, if observed at this stage, may simulate poliomyelitis. The paraly- sis, however, is always pre- ceded by signs of irritation and the sensory symptoms are usually marked. Pain is severe and increased by motion or pressure. The history would aid in ex- cluding the possibility of anything but meningitis. Prognosis. It is pos- sible for complete recovery to take place without paralysis or even after there has been an extensive loss of power, but unfortunately this is the uncommon rather than the usual occurrence. In most instances there is some residual paralysis. The symptoms upon which is based the opinion as to the extent of permanent paralysis are the amount of wasting and the electrical reactions. Loss of faradic contractility within ten days is good evidence that atrophy will occur early and be marked. The most favorable indication of improvement is the return of faradic contractility, and if this is lost for several months FIG. 110. FLAIL-LIKE LIMB, THE RESULT OF PARALYSIS AND ATROPHY OF POLIOMYELITIS. Note the atrophy of the arm and evident laxity of the ligaments of the shoulder. 308 THE PAEALYSES OF CHILDHOOD (4 to 6) recovery is very doubtful, and if delayed longer than six months the chances of recovery are practically nil. Persistence of faradic contractility is a most hopeful sign. The danger to life is greater than has previously been supposed, because many of the very acute cases which have proved fatal have been variously diagnosed. Of course, the mortality varies with the particular epidemic, as is true of all infections in children, and the figures are influenced by the skill of the particular observer, but may be placed reasonably as about ten per cent. It is the bulbar cases particularly which cause the confusion, because the acute symptomatology leads readily into erroneous diagnoses. Mechanical and Operative Treatment. These procedures are the only ones that interest the surgeon, for he rarely, if ever, sees the casein its early acute stages. The object of all mechanical devices is to prevent or to limit the deformity, and, further than that, they are used to assist the child in maintaining its equilibrium, so that, with such devices, the child may get along quite comfortably. Mechanical devices should not be used however to overcome deformity, although, used in conjunction with operative treatment which has relieved deform- ity, they are valuable in preventing a return to the original con- dition. Just , as soon as paralysis is discovered, the affected part should be placed and restrained more or less in. the natural position, not allowing normal muscles to act against unopposing ones. In the large majority of cases the child is brought to the surgeon because of deformity, and when this is corrected it is still neces- sary that the surgeon preserve the results of his operative procedure by the institution of subsequent mechanical treatment. ERB'S PARALYSIS The more common term used to designate this form of paralysis is birth palsy. Tt consists of a paralysis of one or both upper ex- tremities from an injury to the brachial plexus during labor. ERB'S PARALYSIS 309 Etiology. The etiology is not entirely clear, although most observers are agreed that the injury is inflicted, in breech cases, at the time that the shoulder is pulled upon so as to make easy the delivery of the head, or when the arm is pulled down if it lies above the head, or elevation of the arm upward and backward caus- ing compression of the nerves. In vertex presentations it may be due to the pressure of the forceps, depression of the shoulder with the head bent to the op- posite side and rotated, lack of flexion in face presentations, or to excessive or prolonged traction on the head. It has also been ascribed to constriction by the cord and has more rarely followed apparently normal labors in which traction has not been a factor. Pathology. Whatever the direct method of production, the lesion is located in the fifth cervical nerve and the sixth cervical in prac- tically every instance. There may be several degrees of injury, as complete rupture, rupture of a few of the nerve fibers, or stretching or rupture of the sheath of the nerve, and involvement of the nerve fibers, possibly with an associated hemorrhage, or there may occur a bruising of the nerve from direct compression. The cicatricial changes and neuritis, which are sometimes found, are secondary. The axis cylinders are destroyed and between their ends there occurs the formation of new connective tissue. The disability of the musculature is dependent upon the extent of the injury plus the anatomical variations which may exist in the plexus formation. If the fifth nerve is involved alone and there are no complications, the deltoid, biceps, spinati, brachialis anticus, supinators, and radial extensors of the wrist are involved. If the sixth nerve be_ involved also, then there is further involvement of the musculature and the pectorals, latissimus dorsi, and triceps suffer. With complicating involvement of the seventh nerve, the extensors of the fingers are affected. If the whole plexus be involved in the injury, there occurs a complete paralysis of the whole of the lirnb. Occasionally there may be observed a "lower arm" form of paralysis and, while it is possible for such to exist as a primary 310 THE PARALYSES OF CHILDHOOD condition, yet in nearly every instance it will be found that it is the persistence of some of the paralysis which has previously in- volved the whole of the limb. In practically every instance the deltoid suffers the most and may be the only muscle affected. Diagnosis. The diagnosis is not always easy, for the condition may be overlooked for weeks if the paralysis is not extensive. It may simply be noted that the infant does not use the arm as freely as it should, and such an occurrence usually does not attract any particular attention. The more common situation is that the arm is held loosely at the side of the body and is not moved. The limb is rotated inward, the forearm extended, pronated, and incapable of flexion or supination, and the hand turned back and slightly flexed. It is very difficult to estimate in the infant just what degree of loss of sensation has taken place, but as far as we are able to demonstrate it its degree and extent are slight, except in the occa- sional severe injury. Muscular atrophy is noticeable within a few weeks and this, like the paralysis, may be overlooked for a long time. This is so because the muscle is so small in infants and is so well covered with fat. The reaction of degeneration may be present. Contraction of the affected musculature or the unopposed action of the normal musculature may result in early rigidity. The paralysis may be further complicated by partial involve- ment of the sympathetic, or by fracture of the humerus or clavicle, or a separation of the head of the humerus, facial paralysis, or wry-neck. The diagnosis is not difficult if the case is typical and is seen early. However, if observed late, there is the possibility of mis- taking it for poliomyelitis; a mistake which is rather easy to make unless the history is carefully taken. It must be recalled as sug- gested previously that the paralysis may be unnoticed for several weeks and, therefore, in the history taking, its existence from birth will be .denied. When there is a complicating injury, as fracture, the inability ERB'S PAEALYSIS 311 to use the arm may be attributed to that, and the paralysis may easily be overlooked. It is necessary therefore to exclude fracture or dislocation, epiphysitis, and separation of an cpiphysis, or if they exist as complications to estimate their relation to the amount of disability present. In eliminating these we make use of the fact that there is no electrical change and no true paralysis is present. Paralysis with a very similar distribution may occur as the result of other injury, pressure from enlarged glands or tumors, or from neuritis or spinal caries. These are easily excluded however. In Erb's paralysis the particular muscle group which is affected is quite characteristic. Cerebral palsy is rarely monoplegic and still more rarely limited in its distribution to a particular group of muscles. Prognosis. The prognosis is made by carefully watching the progress of the disease toward spontaneous recovery, coupled with a consideration of the extent of the injury. This may also be further influenced by the amenability to surgical interference. The milder cases show little or no discomfort and improvement is early and progressive and usually complete. Even in the moder- ately severe instances if recovery starts it is usually progressive. In these instances, however, recovery is not always complete and some disability may be permanent. Cases that will eventually recover should show some improve- ment in from one to three months and be fully recovered within a year. In other instances, the prognosis is not good unless through surgical intervention; therefore this latter should be undertaken in all cases that show no improvement within the first three months, or which, having exhibited that improvement, show an arrest of improvement within the first year. A ready response to faradic irritation is a favorable sign, but if the muscles fail in their response to faradism and yet react to galvanism, surgical intervention should be instituted. Flexion of the elbow is usually the first sign of recovery and further progress may be arrested at that point. 312 THE PARALYSES OF CHILDHOOD The unpleasant and disabling sequels of atrophy, contractures, and maldevelopment of the arm, possibly with deformity from over- acting muscles, may be the remote results. Treatment. The indications for treatment are clear. At first the parts must be kept at absolute rest to allow sufficient time for the damaged tissue to undergo repair. As the parts are rendered less resistant to external influence, warmth and protection should be afforded by wrapping the arm in cotton wool. The arm should be so fastened that the overstretched muscles are mechanically re- laxed for weeks or months if necessary. After the first month, the nutrition of the parts may be main- tained by cutaneous friction, or massage, and passive motion. If there is response to faradism, the current should be used regularly, making each muscle contract twenty to thirty times with the mildest current possible. In the case of no response to faradism, galvanism may be used for a time and replaced by faradism as soon as pos- sible. Daily use of electricity gives the best results. The operative treatment is considered in detail elsewhere and must be supplemented by electricity and massage. INFANTILE CEREBRAL PARALYSIS Under this term there are included several groups of cases which have certain common clinical features, although the etiology is very different. A reasonable division would be into three groups: the prenatal, the natal, and the postnatal. The prenatal group, or paralysis of intrauterine origin, is the least frequent, and the paralysis is due to defective development or possibly to intracranial hemorrhages, occurring late in gestation. There may be porencephalus or cysts extending into the brain substance. At birth such an infant will usually show some loss of power, but as a rule this is not the prominent feature. What is much more noticeable is that there exist spastic flexures or rigidity of one or more of the extremities. The type of the paralysis is INFANTILE CEREBRAL PARALYSIS 313 generally diplegic or paraplegic. If due to cortical underdevelop- ment there may be general flaccidity in place of the more character- istic spasticity. Later there are marked evidences of mental im- pairment, which may even amount to idiocy if the infant lives. The natal group, or the cerebral birth-paralysis, is due in prac- tically every instance to meningeal hemorrhage. The instances in which prolonged or difficult labor and the use of the forceps are blamed as the cause may exist, but such an origin is doubtful and, at best, rare. The primary symptoms as a rule clearly indicate the extent of the lesion. If widespread, convulsions ensue. Diplegia and para- plegia develop early and are in themselves indicative of the extent of the lesion ; a diffuse lesion resulting in diplegia ; a less extensive one in paraplegia. Hemiplegia and monoplegia are rare. With the survival of the infant through the first stage, the secondary symptoms will depend upon the extent and distribution of the lesion. Usually there is more or less rigidity or spastic involvement of the extremities, but at times this is so slight that the infant is brought for examination because of a supposed general weakness, or a mental backwardness. In some instances the condition of the limbs is duplicated in the neck. This spastic condition of the ex- tremities may be well marked and also may be either constant or intermittent. Head retraction and opisthotonos are not uncommon. The general condition of the infant is always poor and it re- mains small and delicate. This renders the infant less resistant to other influences and many of them die in early infancy from rather slight acute causes. We have observed rarely a fairly good physical condition with marked mental impairment. It is very difficult to demonstrate the degree of mental impairment until the infant reaches its second year of life. Speech and hearing are both affected to some extent, but the sight is rarely involved. The infant may not be able to sit up or to walk until it reaches the age of three or four years, and then the gait is usually a crossed-leg one, due to spasms of. the adductors. There is exaggeration of all the reflexes and the crossed-leg posture may persist even when the 314 THE PARALYSES OF CHILDHOOD child is at rest. Muscular atrophy is marked in the affected parts as a rule. The arms are not involved as commonly as the legs and in about 50 per cent, of the cases are not involved at all. In the milder cases the diagnosis may be delayed because there is nothing that readily excites suspicion until the infant is six to eight months old and then, as the infant does not sit up or advance normally, the muscular weakness is noted and possibly also the tendency to spasm of the musculature. The symptoms may then be attributed to rachitis or looked upon simply as an evidence of general backwardness, but a careful ex- amination reveals the spasticity and the exaggeration of the reflexes. Of course, as the infant advances in age, the true condition becomes more and more emphasized and the recognition of it is rendered less and less difficult. Epilepsy develops in fully one-half of the cases, usually begin- ning as the Jacksonian type in the limb which was most affected and then becoming general. The postnatal group, or acute acquired paralysis, has a somewhat obscure etiology and in most instances it is impossible to determine whether the infant exhibited any appreciable disability at birth or not. Heredity seems to play no part. The frequent occurrence of convulsions at the onset has been assigned as the common cause, but there is good reason to believe that it is the lesion that precipi- tates the convulsion rather than that the convulsion causes the lesion. The lesions are those of the blood vessels, the membranes, and the brain substance. Of the blood vessel lesions we have hemor- rhage as the most important and usually meningeal (rarely cere- bral) ; embolism, and thrombosis. Thrombosis is very rare, but embolism may occur in older children as a result of acute rheumatic endocarditis. The lesions in the membranes are generally the re- sult of a preceding meningitis or may be due to syphilis. The brain substance may be involved by atrophy and sclerosis, although these indicate the terminal conditions rather than the earlier ones. The large majority of cases are seen during the first year of life. Diplegia and paraplegia are observed occasionally, but the char- INFANTILE CEREBRAL PARALYSIS 315 acteristic form is hemiplegia. The onset is sudden and convul- sions are present in over one-half of the cases and these may be repeated and followed by a state of unconsciousness. After thirty- six hours the convulsions are not apt to continue. There are an associated high temperature and usually more or less vomiting, delirium, and other symptoms which suggest some inflammatory condition in the brain and these may persist for two to three days before the discovery of any paralysis. The tempera- ture rise rarely precedes the occurrence of the convulsions. The onset of the paralysis is sudden. If the lesion is extensive, all that may be noticed with the acute onset are diplegia, coma, and death, but this termination is infre- quent. The usual course is that there is observed a typical hemi- plegia, with only a slight involvement of the face, or with entire exemption of the latter. The paralysis is at first complete, reaching its maximum of in- tensity before the end of the first week or the first part of the second week, when there occurs a gradual improvement. With left-sided lesions the speech may be affected. During the height of the paralysis sensation may be abolished, while the deep reflexes are exaggerated on the paralyzed side. Spasticity gradually asserts itself and may always be detected when a careful examination is made. Laughing and crying bring out more clearly any affection of the face, as they intensify the stiffening of the features and emphasize the loss of expression upon one side of the face. There may be sluggish movement and over- action during volitional motion. Sometimes both sides of the face are affected by spastic paresis, but this does not indicate that the lesion involves more than the one cerebral hemisphere ; it is probably the result of muscle innervation, so that the muscles subserving the bilaterally associated movements of the face are not as active as usual. After several weeks the child may be able to walk and drag the affected leg, and the usual course is for some interference with the gait to persist, complete recovery being rare. The arm recovers more slowly than the leg and contractures are usual after two or three years. sic THE PARALYSES OF CHILDHOOD The gait in walking is peculiar, .because the limb is swung at the hip and brought across the body (generally too far), and because of the shortening of the whole limb. This results in the walking being almost entirely done upon the toes, resulting in compensatory tilting of the pelvis and possibly some lateral spinal curvature. When the child is prone the limb may assume the hemiplegic posi- tion and to all appearances is a useless member, but with the child active the difference is marked. Disorders of motion are common as a sequel. They are chiefly of two classes: (a) defects accompanying voluntary motion, and (b) spontaneous movements. Defects of the first class usually do not appear unless there is considerable voluntary motion possible. All the voluntary movements are executed with more or less evident effort, the motion being slow and stiff, and this is most marked after periods of rest. Choreic movements are common when muscular precision is attempted. Spontaneous movements are of three classes : (a) choreic when the spastic contracture is not marked ; (b) athetosis which is not marked except in the parts which have suf- fered most, therefore in the periphery; (c) tremor which usually accompanies motion and which may persist during the periods of rest. As regards the deformities that may occur, it is needless to enumerate them ; all that is essential is to remember their mode of production and then their nature is understood. There is an arrested development which affects the bones, the joints, and the soft tissues. The result is that the measurements of all parts are below the normal with two exceptions: First, when there is a fat hypertrophy of the part and, second, when athetosis and localized choreic movements are present in such degree as to produce hyper- trophy. The atrophies are not from disuse of the members, but are due to cerebral innervation. The mental condition may remain almost normal, but the earlier that paralysis occurs the more certain is mental insufficiency. The diagnosis between the congenital, and the acquired forms may not always be possible, for frequently the symptoms of the 317 congenital type are so mild that no attention is paid to them until the time arrives for the infant to sit up or walk. Upon the other hand, this differentiation is not really important. Considerable difficulty may be encountered in making the diag- nosis from poliomyelitis. A history of an acute onset, absence of sensory symptoms, the atrophied limbs, and deformities may be observed in both, but, on the other hand, the spasticity, the presence of perverse or spontaneous movements, preservation of electrical reactions in the paralyzed muscles, and the retention of the deep reflexes are distinguishing signs of cerebral paralysis. The onset with acute symptoms usually leads to a suspicion of the onset of one of the acute infectious diseases or of meningitis. The differ- entiation is made by lumbar puncture, which gives positive results if the symptoms are due to meningitis, and, in regard to the acute infections, close observation for a few hours and the occurrence of hemiplegia clear up any doubt. The treatment is unsatisfactory because the conditions asso- ciated with the occurrence of the disease make interference prac- tically impossible. There is, therefore, practically nothing left to do but to treat symptomatically and to limit or prevent deformities or complications. PRESSURE PARALYSIS Edematous swelling is the result when the blood supply of a part is interfered with, as, for example, the result of a too tightly applied bandage or splint. While the whole limb may be painful, the extremity becomes swollen and may be discolored or blue. The muscles are apparently paralyzed and, as the flexor muscles are stronger normally than the extensors, within a few days there occurs some flexion. There are, however, no true paralysis and no sensory changes. Such a condition may come on very rapidly after fracture and finally the musculature may undergo interstitial fibrosis, becom- ing therefore smaller, harder, and contracted. The real condition present in many instances is a myositis com- plicating a neuritis. 318 THE PARALYSES OF CHILDHOOD Rest and warmth are usually sufficient to effect a cure, but if fibrosis has occurred no treatment is of any avail. Surgical inter- vention may become necessary on account of a subsequent de- formity. MUSCULOSPIRAL NERVE PARALYSIS Musculospiral nerve paralysis, or radial paralysis as it is some- times called, may occur congenitally on account of an amniotic band or intrapartum pressure on the nerve, or be acquired through press- ure, fracture, or systemic poisoning (lead). The results are paralysis of the extensors of the wrist, flexion of the fingers, and wrist-drop. Peroneal paralysis and crural nerve paralysis may be due to similar causes. FACIAL PARALYSIS Facial paralysis may result from the pressure exerted upon the parts at the time of birth, particularly when a difficult forceps opera- tion has been performed, or there is a faulty pelvis or one in which there is a tumor resulting in prolonged labor and undue pressure on the head. Subsequent to this it may be caused by meningitis, tumors, or a lesion affecting the nerve after its exit from the stylomastoid foramen. Bell's paralysis is the acquired variety, affecting the frontal and inferior branches of the nerve. It is due to any one of the several causes of neuritis (pressure, injury, etc.), or may occur in conse- quence of middle ear disease, in which instance it is of serious im- port, indicating an extensive involvement of the temporal bone. The prognosis is closely associated with the cause, motor paraly- sis from injury, but with no complications, usually clearing up rapidly (weeks), and aural cases making more or less complete recoveries unless there is necrosis of the canal, in which case re- covery is rare. SYMPATHETIC NERVE PARALYSIS 319 The treatment is by persistent galvanism and in the permanent cases by nerve anastomosis. SYMPATHETIC NERVE PARALYSIS There may be several conditions in and about the neck that act upon the sympathetic nerve and thereby cause paralysis. Some of these conditions are undue pressure from enlarged glands, injury (operative or other), disease of the spinal cord, injury to the brachial plexus, etc. In consequence of the paralysis there may be pupillary contrac- tion, and associated with this there is commonly a contracture of the eyelids, so that the whole palpebral aperture seems much smaller. At times there are retraction of the eyeball and an ab- normal deficiency in the production of perspiration on the affected side of the face. However, if the acting cause is less severe, so that in place of paralysis there is irritation, it is common to observe pupillary dilatation with enlargement of the palpebral aperture, and, not in- frequently, protrusion of the eyeball and an abnormal production of perspiration upon the affected side of the face. CHAPTER XLIII TUMORS IN CHILDREN GENERAL CONSIDERATION OF TUMORS It was customary for a long time to call all swellings tumors, and so we have had grouped together a conglomerate mass of morbid conditions which has resulted in the utmost confusion. Even with the aid of recent microscopic work and differential staining the chaos is not entirely cleared up and we are still compelled to retain the term "tumor" for clinical reasons, although the pathologist has bared it of much of its former importance and significance. Every advance in the pathological study of tumors has been the means of reducing the list of morbid conditions classed formerly as tumors, and, further than that, has usually been the instrument of classing under one term a number of conditions which previously were considered as very diverse. Being ignorant of the patho- genesis of tumors we have been compelled to study and classify them histologically. There is no need of our entering a discussion as to the value of the theory of infectious or parasitic etiology, or of the part that local irritation possibly plays either in the production of a tumor or the change from innocence into malignancy. With our present knowledge, it is sufficient to say that patholo- gists have clearly demonstrated that a tumor is composed of tissues which exist normally in the body and that the minuter structure of every tumor corresponds with that of the tissue from which it grew, as far as the tissue itself is concerned; so that a fatty tumor 320 THE TRANSFORMATION OF TUMORS 321 always arises from fat, etc., etc. Thus, knowing the minuter struc- ture of an organ or part, the pathologist is enabled to predict just what tumors can affect any given organ of the body. The division into benign (or innocent) and malignant tumors is the result of the previous observations that some tumors showed no destructive features, while others (the malignant) exhibited the more or less early characteristic of being very destructive to the life of the affected individual. However, we must be mindful of the fact that even benign tumors may destroy the life of a child, depending upon the situation of such a tumor and its ability to interfere with the perfect func- tioning of an important organ. In this manner the benign tumors differ materially from the malignant tumors, for the latter destroy life no matter what their situation. There are in addition some anatomic conditions which differen- tiate innocent from malignant tumors. The benign or innocent form usually has about it an investing envelope which is known as its capsule and through the agency of this capsule it is quite definitely isolated from neighboring structures and even from the tissue in which they grow. Benign tumors do not infect the lymphatic glands and rarely cause death, except as they are in close relation to vital structures. The removal of the growth is not fol- lowed by a recurrence, provided such removal has been complete. On the other hand, malignant tumors are rarely encapsulated and show a very marked tendency to infiltrate the adjacent tissues. They infect the lymph glands and also have the property of dis- semination by blood vessels or lymphatics. Their removal does not secure protection against recurrence, no matter how complete the procedure may be. THE TRANSFORMATION OF BENIGN INTO MALIGNANT TUMORS There are almost innumerable theories which might be advanced in regard to this question, many of which are very plausible but incapable of direct proof, and, in a work of this character, where 322 TUMORS IN CHILDREN the practical is made to predominate over the purely theoretical, we may well dismiss these without discussion. Of this we are certain : that the more the histology of all tumors is carefully studied and advanced, the less the line of demarcation between the benign and the malignant tumors becomes. With our present knowledge upon this question, we are no doubt justified in making the distinc- tion of benign and malignant tumors, but when it comes to a ques- tion of real practical value, the question of prognosis or of treat- ment, our division is much less significant. Face to face with the great uncertainty which enshrouds the whole question, the position of the pathologist is made very strong by the attitude of the practice of the surgeon, who, in his dealing with them, takes the stand that all tumors, whether benign or malig- nant, or occupying an indeterminable middle ground, should be re- moved at the earliest possible moment if the circumstances permit. Such a position and stand is good practice in the face of all the facts and theories which we possess upon the subject. VARIETIES OF TUMORS Fibromata. It was formerly supposed that fibromata were very common, but pathology has proven that tumors that are composed entirely of fibrous tissues are comparatively rare. However, there are mixed varieties which are common enough in childhood. Such tumors may occur in any situation in which connective tissue is abundant. For instance, pigmental moles are fibromata. Fibromata may be single or occur as numerous, small, painless nodules in the connective tissue and lying directly beneath the skin. Less com- monly they occur as small enlargements along some nerve trunk. There is one variety that is very painful. Occasionally they are found growing in the nasopharynx. Fibro- angioma and fibrosarcoma are not uncommonly observed in the naso- pharynx of children over the age of eight to ten years and especially in males. The so-called fibrous epulis, a small, dense, smooth tumor, which grows from the periosteum of the alveolar process, is an VARIETIES OF TUMORS 323 example of a misnomer, for the name has no significance in fact, except as it relates to the situation of the tumor. These tumors must be distinguished from the fibroma, which comes from the con- nective tissue of the alveolar process, and which latter requires the use of chisel or saw for its removal. Keloid is one variety of fibroma, The ETIOLOGY of this class of tumors seems to be irritation or trauma. The instances in which they occur congenitally are com- paratively rare. This etiology probably explains in a large measure why they are less common in children than in adnlt life. The diag- nosis is made from the situation and character of the tumor. It is smooth in outline and easily movable on account of being encap- sulated. The growth of the tumor is very slow and is accompanied by no pain unless directly connected with a nerve or pressing upon one. Outside of this pain is only present if the tumor is markedly inflamed. The skin covering a fibroma is usually thinned out and smooth, and this characteristic helps to distinguish it from papil- loma, which is covered by adherent skin. The PROGNOSIS depends materially upon the situation of the tumor, for it is harmless unless pressing upon some important organ or nerve trunk or occluding a passage. Irritation and injury add another danger : that of transformation into a sarcoma, although it may do this irrespective of either of these elements. The TREATMENT should always be removal, if the tumor is ac- cessible. This is necessary because of the great and constant danger of injury or irritation and final transformation into a sarcoma. Naturally the situation of the tumor becomes a factor in the sim- plicity of its removal, and, if deep seated, the operative procedure may be a somewhat extended one. Being encapsulated, the pro- cedure is one of enucleation unless there is present some inflamma- tion which requires the more radical step of excision. Myxomata. These tumors have a composition which is identical with the jelly-like substance of the umbilical cord. The so-called "auditory or aural polypi" must not be considered as tumors, for they merely consist of myxomatous tissue. The commonest variety is that which occurs at the umbilicus of the infant ; the so-called fungus 324 TUMOKS IN CH1LDKBN umbilici or umbilical polypus, and which usually appears as a much reddened pea or cherry-sized growth. While it would be strictly within our province to rule out myxoma entirely from our classification of tumors, it is probably better to retain the same for a time to avoid confusion. Therefore we will describe some of the variety of tumors which have been con- sidered as myxoma. For instance, polypus of the rectum is really a soft vascular myxofibroma attached to the wall of the rectum by a pedicle. Such a growth may appear outside of the sphincter dur- ing defecation or may only be detected high in the rectum by digital examination. It usually causes symptoms of pain upon defecation or tenesmus; blood-stained stools or an oozing of bloody mucus and perhaps reflex bladder symptoms from pulling of the growth. Ker- vous symptoms are common on account of the local irritation. When multiple, rectal polypi are always invariably adenomata. Myxolipoma, teratoma, and myxosarcoma are considered under their appropriate headings. There is a great tendency in so-called myomata to transforma- tion into sarcoma, although in itself it is very benign. The growth is slow and any rapid development should at once arouse the suspi- cion of malignancy. It is soft, fluctuating, and translucent. TREATMENT. Removal is the only treatment and the stump should be carefully cauterized. It is the part of wisdom, in every instance in which the tumor takes on a sudden growth, to remove it immediately and take liberal sections of it to determine microscop- ically whether or not the transition is taking place. In rectal polypi, avulsion has been tried by many and by a few with apparent success, but we cannot recommend such a procedure, for the dangers of hemorrhage are great, and incomplete removal is the final result except in the most skillful hands. Ligature close to the base and incision close to the ligature is tho most desirable procedure. When situated in the nares or the aural canal, the forceps, the snare, or the sharp spoon curette are to be used, but always with the precaution that the removal is complete so as to avoid any recurrence. Whenever possible the basal attachment should be re- VAKIETIES OF TUMOES 325 moved and the work of the instrument supplemented by the use of the cautery. Lipoma. This is the most innocent of all the tumors and also one of the rarest of childhood. Its only danger comes from its size and, at times, from its position. When it is stated that it is a rare tumor in children it must be remembered that reference is made to pure lipoma and not to the more common mixed types, as when associated with muscular, fibrous, cartilaginous, and bone struc- tures. Occasionally we will observe, as in cretins, a more or less general fat hypertrophy or fatty enlargements about the neck, and these de- posits have been called lipomas, and pseudolipomas, as well as dif- fuse lipomata. They can in no sense be considered as tumors. The TREATMENT of lipoma is by excision. The treatment of combination tumors in which lipoma is a part is a different mat- ter, and this is considered under the appropriate headings. The general hypertrophy of fat or "lipomatosis" and the fatty enlargements which occur in cretins are always treated medically, for there is no appropriate surgical treatment. Bone Tumors. The clinical history of a child suffering from some form of bone tumor is in most instances as follows : ( 1 ) There has been some pain or tenderness over the affected area for several weeks or perhaps months, or an occasional limping accompanied by or alternating with periods of pain; (2) a distinct tumor is felt when the physical examination is made; (3) a very slight trauma has been the direct cause of a fracture. Either one of these should make the surgeon suspicious of tumor in the bone. But in the examination we must determine whether the enlargement, which is palpable, is actually a neoplasm of the bone or merely the result of some inflammatory process. Having determined this differential point, it is necessary to definitely de- termine whether the tumor is benign or malignant. If the child is brought for examination on account of a fracture from slight trauma, we must eliminate carefully the possible existence of the several causes of such. Therefore it is necessary to exclude spon- taneous fracture (or that due to slight trauma) due to scurvy, 32fi TUMORS IN CHILDREN rachitis, and exhausting nutritional diseases, also infectious osteo- myelitis, tuberculosis of bone, and syphilis. With these excluded, if the fracture has been due to rarefaction of the bone by the tumor, then, added to the suggestive history and the palpable enlargement, will be the more or less characteristic history and symptoms of bone neoplasms. If the child exhibits palpable enlargement of the bone, palpation usually shows many soft spots and the enlargement is seldom uni- formly firm. Chondromata. Chondromata are tumors formed of hyalin cartil- age and the outgrowths of preexisting cartilage. Of the innocent growths of childhood these are by far the most common. The ETIOLOGY is not quite clear, although the influences of heredity are very marked in some instances. Trauma plays an im- portant part in the etiology, but whether it does so independent of heredity is uncertain. Rachitis certainly predisposes the child to chondromata, and it would seem from the history of some cases a& though this disease was not alone a predisposing but an actual factor. OCCURRENCE. The phalanges seem to be a favorite situation for chondromata, and several fingers of one or of both hands may be badly distorted by the growths. Chondromata of bone make their appearance practically always before puberty. Being strongly encapsulated they very often create deep furrows in the bones affected. PATHOLOGY. Chondromata are hard and painless as a rule, but these factors may be modified to the extent that occasionally the tumor will become cystic upon its surface and may cause pain by direct pressure upon a nerve. As a rule they grow slowly and steadily. It is this slow but steady growth and the fact that chon- dromata are multiple that distinguish them from osteosarcoma. The growth is encapsulated unless mixed. In cases of doubt, if a needle is plunged into an osteoma it will not enter the unyielding mass, but with chondromata the needle enters quite freely. Malignant chondromata is the term applied to sarcomata in which there is an abundance of hyalin cartilage and which latter has become calcified, and the differences between this and the benign variety of chondromata must be remembered. The prognosis is only un- favorable as the liability of the growth to become a sarcoma is evidenced. The TREATMENT is removal whenever possible. But the situa- tion and extent of the growth may make this a difficult matter. It is necessary to remember, in deciding npon an operative procedure or making the prognosis, that chondromata of bone generally stop increasing in size as the skeleton reaches its full growth. When operative procedure becomes necessary the best surgical relief is obtained by incision of the shell and capsule and shelling out of the cartilage. The fact that the tumor is encapsulated has been responsible for the more conservative surgical work upon these tumors during the past few years. If sufficient time is given to careful surgical work it is remarkable how much bone can be spared in the removal of the tumor, even when of considerable size. But, despite this, there are times when the more radical procedures are forced upon us. The most trying cases to relieve by operation are those in which a joint is involved, for, no matter how carefully planned, excision results almost invariably in a badly stumped joint- When there is considerable involvement of joint, amputation may have to be considered as the best means of relief. When the interior of a bone is involved the operative procedure must involve com- plete excision of the infected parts. It is in the cases in which the whole thickness of the shaft of a bone is involved that amputa- tion becomes most necessary. Chondromata affecting the parotid gland usually cease increas- ing after attaining a considerable size. The treatment of this variety is complete enucleation, which may be done at any period of its growth. Great care must be exercised to avoid injury to the facial nerve, the blood vessels, or the duct of the gland. Osteomata. VARIETIES. Osteomata are tumors composed of bone and are of two varieties : compact and cancellous. The com- pact or hard osteoma is identical in its structure with the tissue forming the hard portion of the shafts of the long bones. The cancellous or soft varietv resembles in its structure the cancellous 328 TUMORS IN CHILDREN portions of the bones and possesses a thick covering of hyaliu cartilage. OCCURRENCE. These tumors occur with quite some frequency during childhood, and this is not difficult to understand when we recall the rapid changes which are taking place in the skeleton dur- ing this period of development and growth. And the fact that all bony growth is most active at or near to the epiphyseal line makes their occurrence at this point most common. DIAGNOSIS. Chondromata and osteomata have much between them that is common and the resemblance is so striking at times that a clear demarcation is impossible. This resemblance is much more marked when there occurs a mixture of varieties, or a transition is taking place, as not uncommonly occurs. As in chondromata, the influence of heredity is marked, especially when favored by the active factors of injury or irritation. The growths are mostly multiple and very slow of growth. When the child's skeleton has attained its maximum growth the tumor usually ceases increasing in size also. The hereditary influence is also shown in the rather common instances in which more than one member of a family will be affected. Cartilage-clad osteomata are occasionally observed in large num- bers on the long bones of the arms and legs and may be congenital, frequently exhibiting bilateral symmetry. Their recognition is usually very easy on account of the extreme hardness and the fact that the growth is situated about the bone. The X-ray also helps materially in outlining their situation and attachments. In their development the tumors are painless unless they involve some nerve structure. If unmixed, osteomata are innocent. Care must be exercised not to mistake osteomata for exostosis. This latter term has recently been restricted to include only such enlargements as occur in bone at the point of the insertion of a muscle. For instance, if the long bones of a very young child are examined it will be found that they are smooth in outline and the shape almost cylindrical. The attachment of the powerful muscles is to periosteum, which is relatively thick. On the other hand, in the adult the shafts of the long bones are irregular and at the i tion of the more powerful muscles there is an enlargement, and this ossified insertion of the muscle may be easily felt through the soft parts. TREATMENT. Surgical interference is usually unnecessary and is only indicated when the tumor occasions pressure over some im- portant part, or interferes with the perfect functioning of an organ or joint. Deformity of the face from involvement of its bones, or deafness, which was occasioned by interference with the auditory canal, would be added indications for operation. The sessile osteomata are sometimes very difficult to remove on account of their firmness, while the pedunculated variety may often be readily removed with stout forceps. When situated near a joint, the operative procedure must take cognizance of the fact of the danger involved in opening into the synovial membrane. A radical removal of the growth prevents any recurrence. Myomata. Tumors composed of striated muscular fibers (rhab- domyoma) are rare enough to be considered as pathological curios- ities, and when it does occur it is always congenital. There can be little question but that many of the tumors which were formerly reported as myoma were in reality some other type of growth, most likely sarcoma, and this was made possible by the great difficulty in recognition. In the reported cases, the occurrence of the tumor has been usually in connection with the kidney or testicle. Myoma and myo- fibroma have been reported in the cardiac musculature. In vesical polypus, and in tumors of the parotid and testicle and ovary, striated muscular fibers have been found by different observers. Leiomyoma, composed of the unstriated muscular fibers, rarely occurs during childhood. Neuromata. There has not been until recently a very clear understanding of what constituted neuromata, for with former classifications all tumors of nerves were called neuromata by the surgeons, but not by the pathologists. This uncertainty has been particularly true of children, and Ashby and Wright report the instance of an eleven-year-old female who was operated upon for neuroma. The tumor and the nerve 330 TUMORS IN CHILDREN could not be separated and about five inches of the latter was re- moved, but the result was a good one, with sensation retained in the foot. The pathologist's report showed this growth to be a myxofibroma with nerves which could be traced through it for a distance, and which then became lost as they showed signs of de- generation. This is merely an illustration of what has formerly taken place, and such a tumor, not carefully examined, would be put down as a neuroma. If we could carefully eliminate from the reported cases all those of fibromas or myxomas, connected with nerves very closely, and all instances of bulbous tumor which are traversed by nerves or nerve filaments, we would at once eliminate many so-called neuromas. The somewhat familiar swelling to which the name neuroma is applied is an oval encapsulated tumor composed of tissue which is exactly similar to that which composes the nerve sheath. Such tumors may be single or multiple. Pain is not a necessary feature, although when one of these tumors is situated upon the terminal filaments of a cutaneous nerve it gives rise to considerable pain. Xeuromas may be situated upon any portion of a nerve and may vary in size from a pin-head to a good-sized lemon. Most commonly the side of the face is the site of neuroma, and in these parts they are easily felt beneath the skin. While they rarely recur or disseminate, they may, in exceptional cases, cause death. In itself an innocent tumor, neuroma may be transformed into sarcoma. Irrespective of this danger it may seriously inter- fere with the child's activity and therefore its health and develop- ment. The TREATMENT of a solitary neuroma which lies in a part easily accessible is by removal if it is giving any marked inconvenience. On general principles if the neuroma is causing but little or no distress or interfering with no function, it may be left alone. There is always a danger in removal that the tumor will be found to be situated on an important nerve trunk containing motor fibers, and destruction of these may prove more serious than the mere presence of the tumor itself. The most satisfactory procedure is to disregard the growth until VARIETIES OF TUMORS 331 the symptoms produced by it become insistent for relief, and then the operative procedure should be planned to enucleate the tumor if possible, so as to avoid all injury to the nerve. Lymphoma. Enlargement of the lymphatic glands is probably the most common of all varieties of tumefaction, and yet there exists considerable confusion in regard to lymphoma. Very common causes of the enlargement are acute and chronic simple adenitis, tuberculous adenitis. For a detailed consideration of these, the reader is referred to the section on Adenitis. The association of enlargement with leukemia and pseudo- leukemia, although somewhat obscure in its nature, is less common and yet a frequent occurrence. Carcinoma might in more rare in- stances be a cause of enlargement (secondary). More remote still would be glanders acting as a cause of enlargement. The true lymphoma is a benign encapsulated tumor composed of new lymphatic tissue. The enlargement is due to this new tissue and does not in any manner depend upon blood infection. The sur- rounding tissues and glands are not involved. The tumor is mov- able and smooth in its outline and usually single, but when several appear at the same time they show a remarkable uniformity of growth and development. The tumor grows very slowly and does not at any period of its development exhibit any signs of heat, pain, redness, or tenderness. There is but one line of TREATMENT and that is : early and com- plete enucleation. Sarcoma. When sarcoma occurs in childhood, it is much more malignant than in adult life, growing much more rapidly and pro- ducing a more destructive effect upon the general health. On the other hand, it is not so common in children as in adults. Sarcoma is practically the only malignant tumor of childhood. The tumor may arise from any situation in which connective tissue exists, and in studying the pathology of these growths it is important to re- member that when they involve any organ the original site of the growth was in the connective tissue about or connected with the organ and from there the encroachment took place. VARIETIES. There are several varieties of sarcoma and these 332 TUMORS IN CHILDREN derive their names from the prevailing type of cell which is in their composition. Therefore we find that the "round-cell sarcoma" con- sists almost entirely of round cells, each with a central round nucleus. A very delicate intercellular substance separates the cells of the tumor and it is rich in blood vessels and devoid of lymph- atics. This richness in blood supply is sometimes so marked that the tumor will pulsate and the movement in the tumor may be detected by observation as well as by palpation. Occasionally a distinct hum or murmur may be heard through the tumor. These points are some- times valuable ones for differentiation. This type may occur in bone, nerve, muscle, gland, or any organ at any time of life, either intrauterine or ex- trauterine. A rather common type of this round-cell variety is one that occurs with the lymph gland tissue in abun- dance and from this feature derives the name of "lymphosarcoma." The round-cell sarcoma is the most malig- nant of all types. "The spindle-cell sarcoma" has cells which resemble spindles, which are usually of a uni- form size. In different tumors the size and shape of the cells will differ very materially, although each indi- vidual tumor shows marked uniformity of cells. If the tumor contains much hyalin cartilage, as it may when situ- ated on the shafts of the long bones, it is often referred to as a "chondrifying sarcoma." Sometimes the hyalin cartilage may com- pose most of the tumor. If this cartilage is calcified it is often re- ferred to as "malignant chondroma," and the differences between this and the benign chondromata must be appreciated. The spindle- FIG. 111. SARCOMA OF THE KID- NEYS. Tumors are outlined to show size. (Napier.) VARIETIES OF TUMORS 333 celled sarcoma is second in its malignancy in childhood and usually springs from bone, periosteum, or fascia. The "giant-celled sarcoma" is the least malignant of the three varieties. It occurs most commonly upon the articular ends of the long bones and upon the jaw. While the recognition of these three varieties is necessary, still there are characteristics which are quite common to all that may well be considered. PATHOLOGY. Sarcomata rarely are encapsulated and when such a condition is present it is really only apparent and is consequent upon the location of the tumor. Lacking the capsule the tumor in- filtrates the adjoining structures. This becomes a very serious mat- ter when the situation is one in which important organs or tissues FIG. 112. SARCOMA OF THE KIDNEYS. (Napier.) Tumors outlined. are involved. In this invasion infiltration no structure is spared and, when dangerously situated, even a very small growth may be destructive to the child's life. This characteristic also has a very important bearing upon the treatment because anything short of the most radical operative procedure and excision wide of the growth will result in recurrence. Most important, too, is the ease with which cells from the original tumor are carried by the blood vessels to distant parts, where they become arrested in their progress in the smaller vessels or find a suitable grafting place and set up secondary processes. Tie number of such may be unlimited. This widespread dissemina- tion is one of the most serious and dangerous features of sarcomata. 334 TUMORS IN CHILDREN OCCURRENCE. While sarcoma is entirely unlimited in its situa- tion and respects no age, yet there are some -interesting facts in regard to its distribution and the age incidence. For instance, in infancy, the kidneys, the ovaries, and the adrenals are very liable to become the site of sarcoma and in a large number of instances this occurrence is bilateral. On the other hand, if the tumor occurs in these situations in adults, it is unilateral. And again, during infancy, retinal sarcomata are not uncommon and these possess the ability to disseminate through the optic nerve, but restricted to it entirely and most commonly occur bilaterally. However, if occurring in an adult in this situation, the tumor is unilateral and has a very widespread dissemination, sometimes throughout the body. Sarcomata rarely attack either the radius or the ulna and even the fibula usually escapes. It is a curious fact that when the tibia is the point of attack the growth is not so malignant and recur- rence after amputation is always longer delayed than when the femur, for instance, is the site of the growth. By far the most common sarcoma in children is that of the kid- ney, while sarcoma of the testicle holds second place in point of frequency. CHARACTER AND GROWTH. Sarcomata are almost always regu- lar in their outlines, although the shape of the tumor may be globular, circular, oblong, or flattened, according to the situation of the tumor and its adjustment to adjoining structures. The tumor is smooth and if located in the soft parts it is movable. If covered by skin this is not adherent, but the veins of the surface may be much enlarged. The consistence of the tumor varies very widely, so that it may be firm or cystic and the softer tumor may give rise to apparent fluctuation. Sometimes the tumor itself is the first thing noted, but usually before such an occurrence there are present the symptoms which are dependent upon pressure of the growth. These symptoms, of course, are as varied as the situation of the tumor itself. The growth of a sarcoma is very rapid. For instance, in sarcoma of the kidney, the growth may be so rapid that within three or four months from the time of its first discovery it may fill the abdomen of the child. Such a tumor may at first be mis- VAEIETIES OF TUMORS 335 taken for hydronephrosis and exploratory puncture may be neces- sary to determine this. The needle is best inserted half-way be- tween the last rib and the crest of the ilium ; three inches from the spine. Hydronephrosis would yield a urinous fluid, either with or without blood. DIAGNOSIS. From carcinoma sarcoma is distinguished by the latter's more rapid growth, its later ulceration (unless skin or mucous membrane is involved), its more rapid dissemination along FlG. 113.-SARCOMATA OF THE KlDNEYS, REMOVED FROM A CHILD OF TWO YEARS. the blood vessels instead of by the lymphatics, and its later con- stitutional symptoms, as cachexia, etc. TREATMENT. The treatment of sarcoma is early and radical removal, therefore amputation is almost invariably indicated if the tumor be situated upon a limb. The growth of the tumor is so very rapid and its dissemination through the blood vessels so very wide- spread and rapid that operative procedure must rapidly follow the diagnosis of the growth. In view of the fact that dissemination is so prominent a characteristic of these growths, the incising of the tis- sues well beyond the limits of the tumor becomes absolutely neces- 336 TUMORS IN CHILDREN sary and is an important factor in the prognosis. The neighboring lymphatics must also be removed and if skin covers the tumor it must be excised also freely. The instances in which an apparently radical operation has been done upon a limb and the tumor has recurred are common enough to warrant the surgeon performing an immediate amputation in such cases without temporizing and being finally forced to a later amputation. Of course, if numerous metastases have occurred, any operative procedure may become useless as far as the prolongation of life is concerned. At the present time, anything short of radical surgical inter- ference is worse than useless. Carcinoma. Carcinoma is not nearly so common in childhood as is sarcoma, and when it does occur the usual form is that of an encephaloma. Such a tumor is usually soft and rapidly growing on account of the excessive number of cells which are enmeshed in a rather sparse lattice stroma. The malignancy is very marked. The disease is one of prime importance, despite its relative infre- quency in children, because of its insidious onset, its rapid destruc- tion of life, and the helpless and hopeless condition in which it leaves its victim when the disease is once firmly established. CHARACTERISTICS AND PATHOLOGY. One of the features which makes this disease so dangerous is the frequency with which its diagnosis is delayed or not made until the invasion has been such as to give the victim no chance for life. The dissemination of the tumor by the formation of secondary nodules and its rapid exten- sion to the lymph glands add much to its malignancy. A striking characteristic of carcinoma is that it is never strictly limited as a lesion, so that it is impossible to map it out with any degree of accuracy. The surgeon comes squarely upon this prob- lem when he undertakes an operative procedure and cuts into the tissues; there is nothing that in any way clearly defines the limits of the growth. Even when examined by the pathologist it is impos- sible to tell with any degree of accuracy the limitations of the growth. This characteristic has a direct bearing upon the surgical procedure, for, if the microscope fails to reveal the limits of the VARIETIES OF TUMORS 337 tumor, how difficult is the position of the operator who must depend largely upon his unaided sense of sight and touch. Thus it is that the removal of the whole of a cancerous organ or part is the usual procedure and the only one that promises much result. For instance, if a child is observed with a gland affected with carcinoma, it is impossible to say that that gland alone is the site of the disease ; carcinoma very rapidly invades surrounding structures and it makes no difference what the nature of the surrounding tissue. This im- plication of adjacent parts is such a grave matter that we must always consider it in planning any operative procedure. Carcinoma is poorly supplied with blood and, therefore, degenerative changes are early and common. This feature helps us in distinguishing it from sarcoma. The infection of the lymph glands by carcinoma is, as has been stated, an early, a characteristic, and an important feature of the disease. Lymphatics involved in the site of original disease readily convey the cancerous material to neighboring glands and these may become so filled with the infected material that they burst their capsules. It is a curious fact that dissemination through the lymphatics varies very greatly in different individuals and also in different situations of the same individual, so that we cannot with any certainty predict just what amount of dissemination will take place in any given case. It is even true that occasionally the lymphatics will become so clogged with the cancerous material that in a measure they disconnect themselves from the rest of the system and, for a time, the disease seems to remain localized. But this we do know, that the proportion of instances in which rapid dissemina- tion will certainly occur is so large that there is grave danger in the delay that allows such a progression of the disease. When secondary infection has taken place through dissemination, the secondary foci usually exhibit a remarkable vitality and power to exist independently and to in time become the starting point of other foci. These secondary deposits may occur -in any organ or in fact in any tissue of the body. The question of the influence of heredity in relation to carcinoma is most unsettled; there is so much to be 338 TUMORS IN CHILDREN said upon both sides, based only upon theory, that we may, for practical purposes, await more definite information. DIAGNOSIS. The diagnosis is rendered somewhat more easy by the fact that carcinoma is somewhat rare in children. Yet we must not be unmindful of the fact that it may occur congenitally as well as in any period of childhood or infancy. Its rarity should not make us unmindful of its possible existence. One of its most con- stant features in children is its very rapid growth. This rapidity of growth often makes it simulate an inflammatory swelling, but in the latter the increase of size is more rapid and with this there is always much more pain, tenderness, and heat. Redness of the surface of the swelling alone is of no value, for it may be present in inflammation or in carcinoma, so but little importance can be attached to it, except as it is associated with other symptoms. To this there might be one exception and that is in the case of a cold abscess, which would not have the characteristics of the inflamma- tory swelling, but which could be readily diagnosed by exploratory puncture and aspiration. Gummata might for a time offer some difficulty, but these occur rather late in childhood and there would be the other signs of a well-developed syphilis. The presence or absence of either hard- ness of the part or of fluctuation would be of doubtful value in differential diagnosis because either condition may be present in carcinoma in children. It is possible to mistake carcinoma of the skin for a tuberculous lesion. However, cutaneous carcinoma is almost unknown in childhood. Actinomycosis has features which are characteristic enough to easily distinguish it. Sarcoma exhibits a more rapid growth than carcinoma and has a later ulceration (unless the skin or mucous membrane is in- volved). Its dissemination is along the blood vessels rather than through the channel of the lymphatics and the constitutional symp- toms are always of later appearance. To state it more definitely: if we observe a tumor with well- defined margins, which has grown without much early pain and is VAEIETIES OF TUMORS 339 not very tender at the time of the examination, but has associated with it a demonstrable enlargement of the adjacent lymph glands, while unassociated lymph glands remain normal, and there is no ulceration of the skin or any well-defined cause for the lymph- adenitis, we are justified in considering the case one of carcinoma. This should be immediately followed by an examination of a sec- tion of the growth, so that the clinical diagnosis may be backed up by the laboratory. PROGNOSIS. The prognosis is always unfavorable in children and this is largely influenced by the fact that they do not exhibit the varieties of carcinoma which are found in the adult to be amenable to surgical interference. Instead of the accessible epithelioma or the slow-growing scirrhus, which are observed com- monly in the adult, in children the disease is most often a very rapidly increasing and malignant encephaloma. TREATMENT. The only treatment that promises anything in the way of relief or possible cure is an early and adequate re- moval of the part affected with all of its associated lymphatics and lymph nodes, and this can only be done when the diagnosis has been made at a very early stage of the disease. Therefore we may state, as a general proposition, that the prognosis and the treat- ment depend almost entirely upon the accuracy of the diagnosis and upon how early it has been made. And, even with such advantages, the prognosis is still very grave because surgical ingenuity has covered every detail of the work and with our present knowledge of the disease nothing has been left undone to offer all possible relief. And yet, with it all, we are face to face with the fact that the disease, by its insidious growth, its early painless onset, its characteristic illimitation, and its power of dissemination, finally baffles the best skill of the best surgeons. But even though it has been decided that the case is one that offers no hope, and although it come under the heading of inoperable carcinoma, there is much that can be done to afford relief to the individual affected. Local cleanliness goes a great ways in pre- venting unnecessary suffering and, therefore, very frequent dress- ings with absorbent powders to check or limit the discharges and 340 TUMORS IX CHILDREN reduce the fetor are indicated in every case. The judicious adminis- tration of an opiate is not alone helpful, but is very much indicated. By a careful and painstaking regulation of the diet and activities of the child as well as its hygienic surroundings, much is done to rid the disease of many of its most horrible features. The use of the X-ray promised well for a time, but its ultimate result has been disappointing, and, after thorough testing by many observers, its use has become limited to its local effect. The toxin and serum therapy methods of treating carcinoma are still unsatisfactory and uncertain and not free from risk. At the present time, the method has no place in the treatment of carcinoma in children. Teratomata. Teratomata of all varieties may occur in infancy and in childhood. There are two forms: the external and the in- ternal. Keen's definition is: "a teratoma is an irregular conglom- erate mass containing the tissues and fragments of viscera belong- ing to a suppressed fetus attached to an otherwise normal indi- vidual." PATHOLOGY. The EXTERNAL, FORM is almost exclusively limited to the skull and vertebral column. To make the matter more clear it may be necessary to refer briefly to the subject of conjoined twins. Conjoined twins, of course, may exhibit many different forms, the result largely of circumstances, because in their produc- tion one goes on to more or less complete development, while the other has only a minor portion of its parts developed. This latter is called the parasitic fetus, while the stronger and developed fetus is called the autosite. In the instances in which the development of the parasitic fetus is so poor that it resembles merely a tumor, which, upon dissection, may contain a few vertebrae or almost undis- tinguishable fragments of viscera or skin, it is called a teratoma. The relation between parasitic fetuses and teratomata has been established and its discussion is unnecessary here. The INTERNAL TERATOMATA occur in like manner to the external and have the similar varieties of development and form. They differ from the external in that they are inclosed in a cyst and that they are dangerous to the life of the autosite from mechanical inter- VARIETIES OF TUMORS 341 fereiice with function and from their occasional tendency to malig- nancy. In this particular they differ materially from the external variety, which merely causes inconvenience by its presence and attachments. TREATMENT. The treatment of teratomata is one that must be decided individually for each case. There are many factors which enter into a consideration of operative relief and not the least of these is the opposition which the surgeon may meet from the relatives of the afflicted child, who may see a possible source of gain in the little one's affliction being exhibited. In the external form we merely have the question of inconvenience to the child to consider plus the danger of any operative procedure. In the internal form there is real danger to the child, which obtains as long as the growth is left undisturbed. Serious results may result mechan- ically at any time and may be sufficient to destroy life. And, again, the operative procedure is much less simple and much more fraught with danger than in the external form. These considerations alone make it necessary to determine the course to pursue in any given case by the individual factors present at the time. Angiomata. Angiomata are tumors which consist of an abnormal formation of blood vessels. These tumors occur in three VARIETIES : the simple nevus, the cavernous nevus, and the plexiform angioma. This latter variety is most apt to appear about the temples and, less frequently, on the arms, legs, or fingers. However, it may occur in any situation in which there is connective tissue. The commonest form of all is the simple nevus, which usually appears upon the skin or occasionally upon the mucous membranes as a patch of discoloration. The varying color between blue and pink depends upon the character of the abnormal vessels, so that when the venules predominate the color will be bluish, and if the arterioles are abundant then the color will be pinkish. Occasionally the ordinary nevus, which is embedded in fat and surrounded by a network of lymphatics will exhibit a remarkable richness in these lymphatics, and, as these predominate over venules and arterioles, it is called a lymphangioma. It is possible for the simple nevus to become cavernous or even 342 TUMORS IN CHILDREN plexiform. When this occurs there is usually not alone a trans- formation of type, but this is accompanied by an extension both on the surface and deeper in. A cavernous nevus is usually situated upon the skin, but they have been reported as occurring in many other situations. It is generally of rather slow growth and may, because of its size and situation, become very annoying. CHARACTERISTICS. Nevi differ greatly in size. Some are so small as to be almost imperceptible, while others may extend over the whole limb or act mechanically in displacing some important organ. They may be multiple. The smaller ones tend to disap- pear. Irrespective of the type, they may remain stationary for an indefi- nite period, or may be- come at any time the site of an acute inflam- mation, with all of the dangers which are at- tendant upon such a con- dition in a situation rich in blood vessels and lym- phatics and poor in the power of resistance. All angiomata are congenital or occur during the first few weeks after birth. PROGNOSIS. Degenerative processes sometimes occur in children, so that, after some slight injury, there may follow necrosis or gan- grene. The dangers from hemorrhage have been much exaggerated. The prognosis is always good as regards life and health, for the growths interfere with neither. The TREATMENT is by excision when the area affected is not too large for such a procedure. Caustics, curetting, and electrolysis all have their advocates, but for clean, satisfactory work in children excision is by far the best method whenever practical or liquid car- bon dioxid may be serviceable. FIG. 114. ANGIOMA. (Beers). VARIETIES OF TUMORS 343 Lymphangioma. As has already been stated, when there are an abnormal formation of the lymphatics and a preponderance of these over the blood vessels in the part and a tumor is formed, it is called lymphangioma. Or, in other words, lymphangioma bears the same relationship to the lymphatics as angioma does to the blood vessels. As in angiomata, there are three VARIETIES : the lymphatic nevus, the cavernous lymphangioma, and the lymphatic cyst. The lymphatic nevus is practically colorless, although at times it may be of a slight pinkish hue, or, if situated upon one of the mucous surfaces, it may be slightly yellowish. A cavernous lymphangioma may become cystic in its center, but this change is not common. The most typical appearance is as it occurs in the neck as a congenital swelling, appearing as a trans- lucent cyst filled with lymph. One of their peculiarities is their tendency to disappear after a period in which they have become quite inflamed. It is this combination of inflammation and subse- quent disappearance which makes them so rare after childhood. These tumors have no limiting capsule and are almost invariably congenital. Innocent of itself, such a tumor may cause considerable danger because of its mechanical interference with perfect function- ing of an organ or part. The tumor may remain stationary in- definitely or increase rapidly in size, or even become the site of infection. It is liable to all of the degenerative changes which occur in other tumors. There is no limit to the situation in which it may occur, although the favorite sites are the neck, the shoulder, or axilla or upper part of the arm, and the tongue, the lips and the cheek. DIAGNOSIS. The diagnosis is made easier if the tumor is present at birth, but this is not always the case and, therefore, some confusion might occur if this fact was not recalled. The appear- ance of the skin immediately over the tumor is normal or nearly so (there may be a slight paleness) if inflammation is absent. The tumor is not compressible unless the number of blood vessels in it is large and if the latter condition obtained then the color would be changed. This incompressibility helps to distinguish it from an angioma. But in cases of doubt the aspirating needle may be used 344 TUMORS IN CHILDREN and if clear lymph is withdrawn through the needle the tumor is lymphangioma. But, on the other hand, if there is a perfect ad- mixture of blood and lymph, then it is an angioma. There is -c/he precaution, however, that must be taken into account in aspiration: the withdrawn fluid must represent the content of the tumor and not be the content of the tumor plus blood from an outside source as the result of injury by the needle. PROGNOSIS. There is but little danger from a lymphangioma unless so situated that by its mechanical interference it causes symp- toms. Any rapid growth of the tumor should at once excite the suspicion of implication with sarcoma. This should be determined immediately by the microscope. The accidental rupture of the tumor often results in a most troublesome lymphorrhea, which is disastrous to the child's general health. TREATMENT. The treatment is by excision. This is modified to some extent by the situation of the tumor. In the planning of the operation the surgeon must recall that these tumors may extend very deeply below the surface and involve many important organs or vessels. The absence of any limiting capsule makes the matter of the dissection of the tumor one of great nicety, skill, and patience. It is very annoying to the surgeon to commence an operation upon what may seem by examination to be rather a superficial lesion and to find that an unusual amount of skill and time is demanded for the removal of the growth. And what is more annoying still is to find that, after this period of most trying work, the tumor which is finally removed appears very shrunken and insignificant, indicating in no way the difficulty of its removal. If the tumor is so situated that it is impracticable to do a complete excision, partial excision may be the operation of selection. After partial excision, injections of iodin, phenol, or bichlorid of mercury may be used to produce fibrosis in the remaining portions and favor their shrinkage. In some situations it is possible to apply pressure and this method in combination with injections ought to produce some favorable results. In every instance the parents of the child should be made ac- quainted with the fact that what appears as a vetfy superficial affair VARIETIES OF TUMORS 345 may be in reality a very deep-seated one and that nothing but the operation will clearly determine the fact. Tapping has never been markedly successful, except in excep- tional instances of a single cyst with thinned-out walls. Cystomata. Representative of cystomata in childhood there are the cystic growths which occur in connection with the jaws. In one form there occurs an epithelial infolding upon the alveolar mar- gin and this results in cystic enlargement. Such growths are mul- tilocular. The cysts arising from the tooth follicles, or which have their genesis in misplaced teeth, are called dentary cysts. When arising from a misplaced tooth, it may be either one of the temporary or the permanent sets. Such cysts contain, in addition to the misplaced tooth, a fluid of a varying character, which may even be purulent. Any enlargement of the jaw about where a tooth should have appeared should at once arouse the suspicion of cystoma, and this becomes practically positive when we arc able to demonstrate more or less distinct crackling of the jaw at that point. The diagnosis, however, can be definitely cleared up by free incision, in which event the fluid and tooth are removed if it be a cystoma of that type. Retention Cysts. It would be unwise to leave the subject of tumors in childhood without giving some consideration to a form of tumefaction which bears no direct relationship to the tumors which we have already considered, but which must be taken into account when we consider the diagnosis and treatment. We refer to retention cysts. ETIOLOGY. These are swellings that are caused by some ob- struction of the outlet of a gland, or the retention of its excretions or secretions in a previously existing space and in sufficient amount to cause symptoms or become palpable. The obstruction itself may be occasioned by many factors, so that, irrespective of the retention cyst itself, we have to differentiate and place in their proper rela- tionships to the cyst the following: (a) Pressure from tumors. (b) Inflammation and its consequent swelling. 346 TUMORS IN CHILDREN (c) Cicatricial constriction. (d) Flexion or twisting of the duct of the gland. (e) Valvular insufficiency or closure. (f) Mechanical obstruction within the lumen of the duct, as by concretions, parasites, or foreign body. (g) Alteration in the excretion or secretion of the gland. It will be readily observed that many of the conditions which would result in retention cysts in adults are absent in childhood and, therefore, the occurrence of this form of tumefaction is much rarer in children than in adult life. Congenital cystic kidney is not uncommon in infancy. In fact, this condition is frequently the cause of death of the fetus. Infants who are born with double cystic kidneys usually die very early from uremia and it is almost a certainty that such infants cannot live but one, two, or three days. Most of them are dead-born, but if they survive it is only for a few hours, as a rule. However, if but one kidney is involved, the infant may live indefinitely and allow of an operation being performed later if the size and situation of the cyst do not prohibit the procedure. If easily accessible and of small size and its mechanical pressure has not interfered too seriously with the functioning of other organs, the procedure gives the infant a good chance for life. A nephritis occurring in an infant from any cause may be the direct agent in bringing about an obstruction or plugging of the uriniferous tubules, just as sometimes happens in adults. The ob- struction may be from a hyperplasia of the connective tissues of the part or may be due to clots or foreign material. The tubules then dilate and form" cysts. In other instances there may occur a developmental failure of perfect continuity between the renal and the collecting tubules and this may be the obstructing cause. Or one or both kidneys may be small at birth and composed largely of connective tissue and mul- tiple small cysts. . DIAGNOSIS. Before taking up separately the treatment and prognosis of hydronephrosis and ranula, we wish to speak of reten- tion cysts in general. In the diagnosis we must always recall that 347 the cyst is . always located at or near an excreting or a secreting organ or has some connection, either direct or indirect, with the duct of such an organ. Thus we expect some interference with excretion or secretion from the affected gland. Pain would depend largely upon the size of the obstructing cause and the situation of the affected part and also whether or not inflammation was present. Inflammation is so commonly the cause of the obstruction, however, that pain is usually an early and more or less prominent feature. Exploratory puncture should always be done if the situation of the tumor warrants its performance. Only in this way can we be positive of its nature. PROGNOSIS. The prognosis depends very largely upon the im- portance of the gland affected and whether it is located superficially or deep. Of course infection adds another element with which we have to deal. TREATMENT. The treatment is purely surgical and if the ob- structing cause is one that can be removed it must be done. If the cause cannot be removed then the indications are to withdraw the fluid in the cyst and establish drainage. It may occur that the obstructing cause is one which totally destroys the outlet and in such instances, the cyst should be removed if possible. But if adhesions are so abundant that this procedure is inadvisable because of possible injury to adjacent parts or because of the length of time required for the operation, then exposure of the cyst walls and cauterization and packing with gauze may be done to establish granulation and final closure. HYDRONEPHROSIS. Hydronephrosis occurs as a dilatation of the pelvis of the kidney with subsequent atrophy of the organic parenchyma. This condition may occur congenitally or be acquired and may be either unilateral or bilateral. The congenital cases are the commoner ones. It is not necessary in its production that the retention of urine be complete, for the amount and degree of reten- tion depend largely upon the obstructing cause. The symptoms, other than the demonstration of the tumor, are very variable or may be entirely absent. The diagnosis is most often made from the presence of an abdominal tumor. This tumor is spherical, 348 TUMORS IX CHILDREN smooth, and fluctuating and very intimately connected with the kidney. In the instances in which the tumor is unilateral the diagnosis is rendered somewhat easy, for there are the unilateral bulging and flatness upon percussion and the connection with the kidney can be readily mapped out. But, when occurring bilaterally, the diag- nosis is much complicated. Exploratory puncture yields a trans- parent fluid which contains urea or uric acid. Echinococcus of the kidney, while very rare in children, may closely simulate hydro- nephrosis. Aspiration of the tumor in echinococcus would yield a fluid which would show the absence of the ordinary urinary con- stituents and the presence of the "booklets" which are peculiar to echinococcus. Very large ovarian tumors are niore likely to be mistaken for hydronephrosis, although they are rare. Such tumors are spherical, smooth, and fluctuating, but they arise in the false pelvis and occupy the region of the umbilicus and the hypogastrium, while the lateral portions of the back are free from the presence of the tumor. The position of the tumor and the absence of demon- strable connection with the kidney serve to distinguish it even with- out exploratory punctures. Dermoids. These are tumors which are furnished with skin, but which grow in situations in which skin is not found under normal conditions. The simplest condition of a dermoid is a more or less globular sac or cyst, the inner wall of which is lined with striated epithelium furnished with hair, sebaceous glands, and sweat glands, the shed hair, epithelium, and glandular excretions forming a mass within the sac and distending it. Sequestration dermoids are those which occur strictly in the regions of embryonic fissures; thus they are common about the face and upon the trunk, below the occipital protuberance, and along the center of the back to the coccyx and upward after passing through the perineum through the center of the abdomen, thorax, and neck. In the scalp the commonest situation is over the anterior fontanelle, but with the occipital protuberance as a close second. VARIETIES OF TUMORS 341) The rarer form of dermoid is the tubulodermoid, which arises in what are known as obsolete canals. Dermoids usually remain quiescent, or at least this is true of them as a class, until the time of puberty, when they may take on decided changes. As they are so commonly pedunculated, their ex- tirpation is generally an easy procedure. Keloid. Keloids may arise spontaneously, but their usual appear- ance is after an injury. However, there is always some doubt as to the spontaneous origin because even with great care we cannot always be certain that some slight injury has not existed but been 1 overlooked. Keloids are connective tissue growths in the corium. Their ETIOLOGY is unknown, although there is much to suggest a microbic genesis when clinically we observe that their common association is with suppurative processes. CHARACTER. They may appear at any time during life but are most common after the period of childhood. When they occur they are usually single. The keloid is sharply defined, raised above the surface of the skin, freely movable, and of variable shapes. Not uncommonly there are projections which run into neighboring parts and these have frequently been likened to claws. In rare instances the growth may be pedunculated. The surface is usually smooth and white, but may have a pinkish hue if it is very vascular. Occasionally we find instances in which the number of such growths may reach a hundred or more, but in these cases it is generally pos- sible to trace a decided hereditary influence or a constitutional taint. SYMPTOMS. At times there may be some tenderness about the growth, or pain may actually exist, but these symptoms are uncom- mon. Outside of these, and a possible itching or burning sensation, the only subjective symptoms are those which are due to the in- convenience caused by the situation of the growth. PROGNOSIS. Growth is slow but persistent and resists all forms of treatment, although there are cases in which spontaneous im- provement occurs. The fact that the growth may follow any slight injury (as, for example, vaccination, ear-piercing, burns, etc.) and is not influenced by any treatment, and is apt to recur after removal, 350 TUMORS IN CHILDREN renders the prognosis rather uncertain and unfavorable. But, upon the other hand, it is very unusual for keloids to ulcerate or acquire malignancy. The TREATMENT remains uncertain because of the tendency to recurrence. The only method which at present seems to offer a reasonable chance of relief is the application of the X-ray or a com- bination of excision immediately followed by the X-ray treatments or radium. Some operators have experienced success with excision coupled with a very wide margin of incision about the growth, so as to include all of the affected vessels. Still others advise mutilation by numerous linear incisions dividing the vessels. With such uncertainty existing, it is advisable to let the growth alone unless there occur sufficient grounds of surgical interference on account of the subjective symptoms. PART II REGIONAL SURGERY 5fJ H ff H J J ;. :. P. [/ L \ r \ I P vr-TG- SECTION X THE HEAD AND NECK CHAPTEK XLIV AFFECTIONS OF THE HEAD f CONGENITAL AFFECTIONS ENCEPHALOCELE Encephalocele is a congenital tumor composed of a sac contain- ing fluid or nervous elements in its interior, and held by a pedicle of dura mater which traverses a bony defect in the skull. Varieties. We distinguish three varieties according to the con- tents of the sac: (a) Meningoceie the tumor is composed of a sac containing only fluid, like cerebrospinal fluid. (b) Encephalocele the tumor is composed of a sac containing nervous elements (but no structure peculiar to any portion of the brain). (c) Hydrencephalocele the tumor is composed of a sac con- taining nervous elements and fluid. Situation. There are two points of election for the site of these tumors : (a) The occipital region in the median line above the external protuberance where hydrencephaloceles and meningoceles are usually found. (b) The frontal region, at the glabella, the usual situation of encephaloceles. (Fig. 115.) Tumors situated in the occipital region are usually more volu- minous, usually pedunculated, and may attain a great size owing to 353 354 AFFECTIONS OF THE HEAD FIG. 115. ANTERIOR MENINGOCELE SPRINGING FROM ROOT OF NOSE. (Kirmisson.) their ever-increasing fluid contents. Thus the con- stantly distended sac and friction of the everlying skin subject them to ulcera- tion, rupture, and conse- q u e n t fatal meningitis. Those in the frontal region are usually small, remain stationary, and are not a menace to life. It is well to remember that these tumors when large may form an ob- stacle to normal labor, and present obvious difficulties of antepartum diagnosis. Pathology. T h e s e tu- mors are due to arrest of development, and it is not unusual to find in the same subject the coincidence of spina bifida and cleft palate. They are really "cranial spina bifida." It must be remem- bered that these tumors are in no sense a hernia cerebri, first : because the sac does not correspond to the membranes of the brain; and secondly: the contents of the sac, or nervous elements, are typical of no part of the brain. Symptoms. T he tu- mor is of varying size and consistency, accord- ing to its contents; usu- FlG. 116. LARGE OCCIPITAL ENCEPHALOCELE. (After Spitzy.) CONGENITAL AFFECTIONS 355 ally pedunculated when situated posteriorly. The overlying skin is thin, devoid of hair, and often the site of angiomatous patches. On palpation there is a sense of fluctuation, and, while in some cases the tumor may be reduced by pressure, it must be remembered that convulsions and coma may thereby be the result of cerebral compression. These tumors become tense when the child cries or makes an unusual effort, and sometimes expansile movements can be felt synchronous with the heart beat. Diagnosis. These tumors may be confounded with cephalhema- tomata, dermoid cysts, and angiomata. Keep in mind the char- acteristic features of these tumors as to location, fluctuation, reduci- bility, and the discomfort occasioned by pressure. Note that cephalhematomata are situated laterally, usually on the right, are not reducible, pressure gives rise to no cerebral dis- turbance, and their margin is formed by a periosteal ridge. Dermoid cysts are found near the anterior fontanelle, are not reducible, and have a doughy consistency. Angiomata will rarely be mistaken since they are not well de- fined or of significant volume. Though rare, it is well to remem- ber that a meningocele has been mistaken for a nasal polypus. Owen reports a case of meningocele that presented through the suture between the orbital plate of the frontal bone and the cribri- form plate of the ethmoid, "where its appearance so closely re- sembled that of a nasal polypus that its removal was attempted with a pair of forceps a proceeding which entailed a fatal attack of meningitis." Treatment. The success obtained by extirpation is well estab- lished and it is the method of choice. Neither puncture nor injection is satisfactory nor safe. The operation is indicated except where there is a coincident hydrocephalus or extreme debility of the patient. OPERATION consists in making skin flaps to cover in the wound of excision; freeing the sac to its pedicle; ligation of the pedicle without opening the sac, and excision of the mass. The opening in the bone may be closed by an osteoplastic flap chiseled 356 AFFECTIONS OF THE HEAD from the adjacent bone and the wound accurately approximated by several layers of sutures. The dangers of this operation are: first, the operative shock; second, leakage of the eerebrospinal fluid. MICROCEPHALUS Microcephalus is a condition in which the cranium is abnormally small, due to an arrest of development of the brain. It is often associated with other deformities, such as encephalocele, malforma- tions of the extremities, and arrested development of the genitals. FIG. 117. MICROCEPHALUS WITH ENCEPHALOCELE. (Dr. Zacharie's case.) \ (Fig. 117.) These children are feeble-minded, the intelligence being diminished in variable degrees; their physiognomy is that of the idiot. Treatment. Lannelongue has proposed to relieve this condition by excising strips of bone on each side of the vertex of the skull (craniectomy) for the purpose of permitting the brain to expand. The results, however, do not justify this procedure, nor is it founded on scientific facts, since the undeveloped brain is the cause and not the result of the microcephalic skull. The treatment of this condition is not surgical but pedagogic. These children should be placed in special institutions, where their physical, mental, and moral education can be properly supervised. CONGENITAL AFFECTIONS ,357 CONGENITAL, HYDROCEPHALUS Congenital hydrocephalus is an accumulation of cerebrospinal fluid in the ventricles of the brain. As Gushing observes : "Hydro- cephalus is a symptom of a disease, not a disease itself." Hence the abnormal accumulation of fluid in the ventricles indicates the presence of a diseased secretory function (hypersecretion) or a mechanical obstruction preventing the fluid's escape. It may be that congenital syphilis plays an important role in causing an ab- normal increase in the amount of fluid secreted, or there may be some ob- struction which prevents its exit through the fora- m e n o f Magendie, o r a degeneration of the arachnoid which blocks its outlet from the sub- arachnoid space. Pathology. Whatever the cause the results pre- sent a striking clinical picture. The accumulat- ing fluid gradually dis- tends the ventricles and thins out the surround- ing cerebral tissue until the brain forms only a thin covering for the enlarged ventricles. To make room for its increasing contents the cranial vault is correspondingly extended. The cranial bones are thinned and atrophied, the fontanelles are widened and tense, the sutures distended, and the head attains enormous proportion's. The disproportion between the large head and the small triangular face is weird. (Fig. 118.) These chil- dren are feeble and badly nourished, locomotion is retarded, the intelligence is altered in varying proportions ; some hydrocephalics FIG. 118. HYDROCEPHALIC CHILD. (After Willard.) 358 AFFECTIONS OF THE HEAD are idiots or imbeciles, others are simply backward. These patients rarely live to adult life. Treatment. The treatment up to the present time is entirely ex- perimental and the results disappointing. In the presence, however, of what seems a hopeless problem, experimental surgery should not be discouraged, since the end justifies the means. To eliminate the syphilitic element every case should receive antisyphilitic treat- ment (mercury, "606" injection, etc.). The SURGICAL solution of the hydrocephalic problem contem- plates the evacuation of the fluid: (a) by intermittent evacuation; (b) by permanent evacuation. (a) Intermittent evacuation may be done by tapping the ven- tricle with a fine aspirating needle through the fontanelle a little external to the median line to avoid the superior longitudinal sinus ; or the fluid may be evacuated through a lumbar puncture. Simple puncture, however, has given disappointing results, since there is a rapid reaccumulation of fluid within a few hours after its withdrawal. In spite of the discouraging results, v. Bokay is enthusiastic in advising frequent Tepeated lumbar puncture, and reports nine cases in which surprisingly good results were obtained. The author regards a chronic or congenital hydrocephalus as cured only when the functional disturbance has wholly disappeared and the circumference of the head approaches that of the normal child. The age of the nine cases at the beginning of his treatment varied between three and nine months. The treatment lasted from four months to four and one-half years. Puncture was undertaken every four to eight weeks. The amount of cerebrospinal fluid removed at each seance varied between 20 and 40 c. c. The num- ber of punctures were from 9 to 32 (average of 17). Five cases were completely cured. Three cases showed marked improvement, and one case no result whatever. No untoward results were noted in these systematic lumbar punctures carried on for a long period. The results are better the sooner the treatment is begun. (b) Permanent evacuation contemplates the establishment of continued drainage to relieve the accumulating fluid. The measures CONGENITAL AFFECTIONS 359 proposed are numerous and ingenious. Among these may be men- tioned : (1) Subcutaneous drainage between the arachnoid spaces and the subaponeurotic layer of the scalp. (2) Uniting the lateral ventricle with the longitudinal sinus by transplanting a portion of the saphenous vein. (3) Cushing's method of retroperitoneal drainage by a com- bined laparotomy and laminectomy. It is evident that all these procedures are complicated, that they necessarily give a high mor- tality and as yet belong to the domain of experimental surgery. CEPHALHEMATOMA Cephalhematoma is an effusion of blood between the bone of the cranium and its pericranium. It occurs in the new-born, is usually limited to one of the parietal bones, and is the result of traumatism during delivery. Pathology. The vessels beneath the pericranium are torn and blood is slowly effused, lifting the pericranium from the bone, and forming a tumor which is localized on the parietal bone. It will be recalled that the pericranium dips down between the sutures forming the intersutural membrane, thus the effusion is confined to one bone, and the resulting tumor is conformed to the outline of the bone. As a rule the cephalhematoma appears a day or two after birth. The tumor is soft, increases in size for several days, and finally develops a bony ridge along the edge of the bone, which throws into sharp contrast the soft fluctuating center, and thus simulates a frac- ture of the skull. The tumor subsides very slowly, leaving behind the bony rim which, after a time, likewise disappears. The only complication is their possible transformation into a phlegmon. Diagnosis. The diagnosis ought not to be difficult, and it should not be mistaken for a congenital tumor (encephalocele) if its well- marked characteristics are kept in mind: (a) its lateral situation; (b) absence of pulsation or reducibility ; (c) its soft center and sur- rounding bony rim. 360 AFFECTIOXS OF THE HEAD Treatment. The treatment is that of all hematomata, viz., pro- tection of the skin from infection while the effusion is being al>- sorbed. There are no topical remedies which hasten absorption. The skin over the lesion may be protected by an antiseptic compress held in place by a cap. If suppuration occurs, incision and drain- age as in abscess. FRACTURES OF THE SKULL Fractures of the skull in young children have a symptomatology and prognosis the peculiarities of which merit special attention. Injuries to' the skull are caused by accidents which play an important role in the life of the child, such as falling down stairs, roller skating, the sports and games of childhood, all offer endless possibilities for injury. Recall the fact that anatomically the skull of the child differs from that of the adult in the fact that it is more elastic, ossification is incomplete. Treves has compared the skull of an infant to that of an old man as a cranium of tin would be to a cranium of earthenware. A blow that would dent the one would crack the other. As long as the fontanelles are open the soft bones of the skull are protected from injury by their great elasticity. Hence, (a) fractures of the skull in young children are relatively less serious than in adults, (b) They are less extensive than in adults, as they do not have the same tendency to extend downward and involve the base, (c) The prognosis is better in children than in adults. Mortality from fracture of the skull in children is low: hence, (d) the attitude of the surgeon toward fractures of the skull in young children should be one of conservatism, and no operative interference should be contemplated unless the indications are pro- nounced. If in doubt do not operate. Although injuries to the head of the child are relatively not of serious consequence, it must be remembered that such injuries may be followed by traumatic meningocele, meningitis, and at a later period epilepsy. The secondary results of a blow on the head of a child are always indefinite. DERMOID CYSTS OF THE HEAD 3G1 In older children fractures of the skull are accompanied by typical concussion ; in basal fractures by bleeding from the ear, nose, and mouth, and they do not differ from similar injuries in adults in their development or symptomatology. Treatment. Although the prognosis is usually benign, these injuries demand vigilant attention and careful study. Avoid opera- tion if there is no cerebral compression, and beware of converting a subcutaneous fracture into an open one. The dangers of infec- tion are grave. When no operative interference is called for, the treatment should be directed toward allaying all irritation and the restoration of the injured brain structures to the normal. This may be accomplished by rest in bed, an ice-bag to the head, light diet, and the administration of calomel. Illoway believes that calomel has an antiphlogistic action on the brain and its coverings, and is effective in allaying cortical irritation. When there are present cerebral symptoms of intracranial hemorrhage and compression, the usual operations of decompression, trephining, and removal of depressed fragments of bone are indi- cated as in the adult. DERMOID CYSTS OF THE HEAD These cysts are due to an ectodermal inclusion during the pro- cess of closure of the embryonal clefts. They are lined by true epithelium presenting all the characteristics of true skin; hence the varied contents of these cysts: Sebaceous material, hairs, some- times teeth, and more rarely cartilage or bone. Dermoid cysts of the head are found in three typical situations the root of the nose, the anterior fontanelle, and the external occipital protuberance. Characteristics. (a) These cysts often lie quiescent until puberty before they disclose their presence, (b) They have no connection with the overlying skin, (c) They are deep seated, often lie in saucer-shaped depressions of bone by a pedicle, (d) They have a doughy consistency, (e) They are not reducible. 362 AFFECTIONS OF THE EAK Diagnosis. The diagnosis of these tumors is rarely difficult when their location, consistency, and noii-reducibility are kept in mind. (See Meningocele, p. 355.) Treatment. Complete extirpation. There is no class of tumors that demand more careful dissection of the cyst wall intact, in- cluding the pedicle down to the bone. If the smallest portion is left the tumor may be reproduced or an intractable fistula may be established. In cysts of the anterior fontanelle the cyst wall may be adherent to the dura and require the most careful dissection in separating the two structures. Cysts of the external occipital protuberance may be actually situated within the cranial cavity and may require opening of the cerebellar fossa for their successful removal. CHAPTER XLV AFFECTIONS OF THE EAR MALFORMATIONS OF THE EXTERNAL EAR Various deformities of the ear are observed either as the result of accident or, as is most frequent in children, due to congenital malforma- tion. Among these deformities we note complete or partial absence of the auricle ; bifid lobule ; "bat-ears" ; su- pernumerary auricles; displaced au- ricle ; atresia of the auditory canal. It is obvious that many of these defects can be corrected by surgical intervention. Supernumerary auri- cles may be excised. "Bat-ears" (Fig. 119), when particularly unsightly, mav be drawn in toward the head FIG. 119. "BAT-EARS." FOREIGN BODIES IN THE EAR 303 by dissecting off a flap of skin at the junction of the auricle with the mastoid and suturing the raw^ surfaces together. Bifid lobule is easily corrected by freshening the edges of the defect and applying sutures. Atresia of the canal, when membranous, is easily cor- rected; but when the obstruction is osseous it may or may not be possible to remedy the defect. FOREIGN BODIES IN THE EAR In very young children where instinct dominates there is a natural fondness for introducing foreign bodies into the natural passages. Hence, the extraction of foreign bodies from the ear, nose, esophagus, and trachea constitutes an important chapter in the surgery of children. A great variety of small objects may be introduced into the ear, such as buttons, beads, pins, etc. Again, insects, flies, bugs may crawl into the meatus and become caught in the cerumen. It is evident that the presence of these foreign bodies may be the cause of intense pain, swelling, inflammation, suppuration; and even fatal results are possible from perforation of the membrana tympani, infection of the inner ear, and subse- quent meningitis. In all cases of earache examine the auditory canal with an ear speculum, a good light, and head mirror. If the patient is very young and intractable employ light ether anesthesia. In compli- cated cases or cases of long standing secure if possible the services of an otologist. Treatment. First fill the canal with glycerin or oil to destroy insects and lubricate the passageway; then use warm water, syring- ing the ear with moderate force. Foreign bodies recently intro- duced will be dislodged by this method. If not successful employ light anesthesia and extract by means of a pin bent like a fish-hook or a very fine forceps. All instruments should be cautiously intro- duced in order not to wound the drum or canal. In extreme cases it will be necessary to make an incision behind the ear in the retro- auricular groove and open the cartilaginous part of the meatus in order to expose the inner part of the canal. 364 FACE AFFECTIONS MIDDLE EAR DISEASE The tympanic chamber or middle ear is a region of great clinical importance in children because of the frequent infections to which it is subjected. It will be recalled that the tympanum is in direct communication with the nasopharynx through the Eustach- ian tube; hence, in inflammatory conditions of the throat and nose diphtheria, scarlet fever, measles, tonsillitis, postnasal adenoids, etc. the infection may extend into the middle ear and produce changes in the structures which seriously impair the hearing, or a suppurative condition may be inaugurated (suppurative otifis media), which will lead to grave consequences. In abscess of the tympanum, if not evacuated by surgical inter- vention, the membrane may rupture spontaneously and the pus be discharged through the external meatus; or the infection may travel through the roof of the tympanum, causing meningitis and intracranial abscess. It may travel through the tympanic floor, involving the internal jugular vein and causing septic thrombo- phlebitis; caries of the anterior walls has been followed by ulcera- tion into the carotid artery and fatal hemorrhage. Caries of the Fallopian canal is often followed by permanent facial paralysis. Disorganization of the internal ear leads to permanent deafness ; while infection of the mastoid antrum and cells is followed by mas- toiditis. These complications so serious in their results should be thoroughly appreciated, and it should be further understood that their treatment is not within the province of the general prac- titioner, but belongs to the skilled otologist. CHAPTER XLVI FACE AFFECTIONS VASCULAR NEVUS Vascular nevus ("birth-mark," "port-wine" mark) is a vascular tumor (angioma) composed of capillary vessels of abnormal arrange- VASCULAR NEVUS 365 ment, which may grow and develop by proliferation and new forma- tion of the vessels. These nevi are due to developmental disturb- ances and are found near the embryonic fissures mouth, eyebrows, cheek, etc., and are not infrequently associated with other congenital defects. The face seems to be a site of predilection for these con- genital tumors; two-thirds of all angiomata are found here and predominate in about the same proportion in the female sex (V. Bergmann). Varieties. The simple or superficial nevi lie in the skin and consist of a convolution of capillaries. They are flat, with the skin slightly elevated, and present a red or bluish red patch on the skin or mucous membrane and are usually noticed at birth as a cosmetic defect. They may remain stationary or grow with great rapidity and involve the entire half of the face in a few months. Occasionally they disappear spontaneously. Compression of the affected area causes the blood to disappear, but it promptly returns when the pressure is removed. Variations in blood pressure caused by efforts of crying or the reclining position modify the volume of the tumor. The venous nevi (cavernous angiomata) are true vascular neo- plasms which are composed of cavernous spaces bound together by delicate connective tissue and filled with blood. They are usually subcutaneous, but the skin may also be involved. When they are confined to the subcutaneous tissue they appear as bluish, trans- lucent, soft, depressible tumors, which are emptied by compression, but refill when released. Coughing or straining increases their volume. When there is communication with an artery distinct pulsation is observed. Diagnosis. There is little difficulty in recognizing the nevi by their characteristic appearance and the fact that they disappear on pressure. Prognosis. Every nevus may on occasion grow and extend with great rapidity; hence the necessity for very early treatment to pre- vent extension and consequent deformity. Spontaneous cure occurs only through injuries to the surface, which produce inflammatory reaction with subsequent scar formation, yet even then there 366 FACE AFFECTIONS may remain some focus from which an angioma may develop anew. Treatment. When the nevus is situated in parts of the body where excision can be performed, it is unquestionably the most rapid and effective method. The incision is made wide of the growth, and hemorrhage is avoided by well-planned digital com- pression. The larger vessels are ligated, sutures are so placed that they include the depth of the wound and thus prevent the formation of hematoma and subsequent bleeding. Where the shorter radical operation is not expedient (angioma of the face) and in superficial nevi it is better to adopt those me'asures which produce inflamma- tory reaction and subsequent scar formation and which are applied at repeated sittings. Pacquelin Cautery. Multiple scarifications are done by this means at repeated sittings. While the treatment is slow, the scars are flat and not unsightly. Liquid Carbon Dioxid. The treatment with liquid carbon dioxid is most satisfactory in superficial nevi. It is sprayed on the surface for ten or twenty seconds, and after several repetitions of the treatment at weekly intervals the nevus disappears with a scar that is scarcely visible. Magnesium Needles. In nevus of the face that cannot be operated or that grows into the deeper tissues and cannot be reached by extirpation, Spitzy advocates the introduction of magnesium needles into the tumor. The needles are introduced through small skin incisions and are distributed throughout the tumor. The absorption of the magnesium results in scar formation and the destruction of the angiomatous tissues. X-Ray and Radium. It must be remembered that the use of the X-ray and radium has given excellent results in nevi that did not permit operation. Spitzy has cured an angioma of the upper lip without great scar formation after a few treatments with radium in the mouth. Injection of Irritating Fluids. Lastly, it must be emphasized that the injection of irritating fluids such as alcohol, carbolic acid, iodin, etc., is not a safe procedure and should be regarded as an obsolete method of the preantiseptic era. LYMPHANGIOMAS OF THE FACE 3G7 LYMPHANGIOMAS OF THE FACE We occasionally find on the face of infants a diffuse hyper- trophy of the soft parts, notably the eyelid, check, and lips. They may be circumscribed or diffused. They are soft tumors, intimately connected with the skin, which is normal in appearance, grow slowly, and are painless. These tumors are similar in structure to the hemangiomas only the lymphatic vessels are involved and pre- sent either a cavernous arrangement, in which the cavities communi- cate with one another, or a grape-like structure formed of one or more cysts. Lymphangioma of the Eyelids. Lymphangioma of the eyelids is a rare condition and may involve the eyelids of both eyes or be con- fined to one eye. The lesion most frequently affects the two upper eyelids. In Froelich's case the upper lids were greatly increased in volume and well circumscribed; the color of the skin over the tumor was more pigmented than the skin of the face. The tumor was brawny, neither compressible nor reducible, and, with the ex- ception of the deformity, gave no disturbance. It is evident that when the lesion is in the lower lid and well developed it may cause an ectropion which may necessitate operative interven- tion. TREATMENT. When intervention is necessary partial excision and electrolysis must be employed. Lymphangioma of the Lips (Macrochcilia). The lesion is more frequently seen in the lips than in the eyelids. It may entirely sur- round the lips and produce an ectropion of the mucosa. In marked cases of macrocheilia the development of the upper and lower jaw may be interfered with (V. Bergmann). The special site of predilection is the upper lip, which it usually involves in toto. The upper lip projects forward and, in extreme cases, it may overhang and extend in front of the lower lip as far as the chin. This tumor must be differentiated from angioma of the Up by the unchanged condition of the skin. Discoloration of 3G8 FACE AFFECTIONS the skin indicates the presence of blood vessels. Besides angiomas are compressible and reducible. TREATMENT. When the size of the tumor produces a marked de- formity it i,s necessary to resort to excision. It is obvious that operative interference here is difficult, owing to the small size of the parts and the improbability of removing all the tumor-tissue. The most satisfactory results are obtained by wedge-shaped ex- cisions from the diseased lip. Lymphangioma of the Tongue ( Macroglossia ) . Lymphangioma of the tongue is a congenital condition which affects the anterior three-fourths of the tongue and may attain enormous proportions. (Fig. 120.) The affection at birth may be noted only by the difficulty which the infant has in nurs- ing, and it is necessary to nourish these children by a spoon or nursing bottle. As the tongue increases in size it finally protrudes from the mouth and cannot be reduced without causing suffocation. Marked changes are now produced in the tongue and the lower jaw. The tongue is now exposed to various irritations, the papillae hypertrophy, and it becomes dry and black and cracked. The pressure of the teeth causes ulcerations. Froelich has described a case in which the incisor teeth finally cut the pro- truding portion so deeply that it became gangrenous. More fre- quently the pressure of the tumor upon the incisors and canine teeth may cause them to project forward. The lower jaw is likewise modified by pressure, so that it is everted and a median depression is formed from which the saliva FIG. 120. MACROGLOSSIA. (After Owen.) DEKMOID CYSTS OF THE FACE ;$<><) is constantly dribbling. It is obvious that mastication is quite impossible, and the child must be nourished by introducing fluids behind the projecting mass. Phonation is likewise defective, and in Froelich's case was reduced to incomprehensible guttural sounds. TREATMENT. Early incision before later complications and de- formity of the jaw take place. Remove a V-shaped piece from the anterior part of the tongue and suture the sides of the wound together. DERMOID CYSTS OF THE FACE While these cysts are most frequently found about the upper margin of the orbit, they are also found at the root of the nose, in the periauricular region, and on the neck. These cysts are small when first observed, because their superficial situation exposes them to early observation. Sometimes these cysts are present at birth, others do not develop till later. Cysts near the orbit are most frequently situated over the ex- ternal angular process of the frontal at the level of the fronto- maxillary fissure. Occasionally they penetrate into the cavity of the orbit. Their extirpation is easily accomplished by an incision over the line of the eyebrow to avoid a visible scar. It may be necessary to chisel out its bony implantation when the cyst is firmly adherent. Cysts at the inner angle of the orbit are less frequent. Cysts at the root of the nose may be easily mistaken for menin- gocele; the latter, however, is present at birth, while the cysts ap- pear later ; the cyst is not reducible and does not become tense when the child cries. Periauricular cysts arc situated either in front of the external auditory meatus or over the mastoid region. The latter are not un- common. Cysts of the cheek correspond in position to the intermaxillary cleft. They are usually situated at the anterior border of the masseter. 370 OEAL AFFECTIONS Diagnosis. The typical situation of these cysts as described above is of itself significant. The skin is freely movable over the tumor, the surface is smooth without lobulation, their consistency is doughy. They are usually small, though they may acquire large dimensions. They grow very slowly. The tumor is usually ad- herent and fixed by a pedicle to the underlying bone. It will be necessary to differentiate dermoid cysts from sebaceous cysts. The latter are adherent to the overlying skin and freely movable on the underlying structures. The lipomata are more rare, and are dis- tinguished by their greater volume, flabbiness, and lobulation. Treatment.- Complete extirpation which includes the pedicle; otherwise the cyst may return. CHAPTER XLVII ORAL AFFECTIONS FOREIGN BODIES IN THE NOSE The same variety of small objects are introduced into the nose as in the ear beans, beads, buttons, etc. Insects may also make their way into the nasal fossae. When foreign l)ody is suspected, confirm the suspicion by direct examination with speculum and head mirror. Treatment. Induce the child to sneeze by tickling the opposite nostril. If this is not successful try vigorous syringing with warm water. In complicated cases secure if possible the services of a rhinologist. It may be necessary to anesthetize the child and re- move the foreign body by instrumentation. Foreign bodies per- manently lodged in the nasal fossa? cause ulceration and chronic suppuration. \ HARELIP Clinical Picture. Hare-lip is a congenital fissure or cleft of the lip due to arrest of development. The lower lip develops from two HAEELIP 371 centers which fuse in the median line and a congenital fissure of the lower lip rarely occurs. The upper lip develops from three centers: a median, represented by the frontonasal process, and two lateral, corresponding to the superior maxillary processes. When these processes fail to unite on one or both sides of the frontonasal process there results a unilateral or bilateral (single or double) harelip (Fig. 121). The failure of these fissures to close may be due to some mechanical or pathological obstruction ; they are de- velopmental defects in which rachitis or increased intracranial pressure may play an important role. Note that hare-lip is a lateral cleft, not a median one. The deformity may consist only of a notch in the upper lip, or it may FIG. 121. A. UNILATERAL HAKE-LIP. B. BILATERAL HARE-LIP. extend up into the nostril and be associated with a cleft palate. It is more common on the left side. In double hare-lip the median portion of the lip may be at- tached with the intermaxillary bone to the projecting nasal septum (persistent fetal type), since the intermaxillary bone, the nasal septum, and the median portion of the lip are developed from the same center. The intermaxillary bone contains the germs of the incisor teeth. The fissure in hare-lip, therefore, corresponds to the interval be- tween the lateral incisors and the canine teeth. When the fissure extends into the nasal cavity the ala of the nose loses its normal arch and is flattened out. The red border of the lip is not inter- rupted but is drawn up into the fissure (see Fig. 121). When the fissure is complete it extends to the mucous lining of the nose. 372 ORAL AFFECTIONS Prognosis differs according to the degree of the fissure. Hare- lip is not only a most unsightly deformity, but the function of the lip is compromised so that nutrition is imperfect, the child is unable to suckle the breast and must be fed with a spoon, and deglutition is only partially performed, as a portion of the milk is regurgitated by the nares. The absence of the nasal filters exposes the child to infection and respiratory troubles, and later phonation is seriously embarrassed. Early closure of the lip guarantees the normal direction in growth of the intermaxillary bone; an open lip encourages an ex- cessive growth of the intermaxillary bone in the direction of the opening. Luckily hare-lip is such an ugly deformity that parents are im- pelled by feelings of pride to have the defect promptly repaired. The operation, as a rule, is well borne by children and the mortality is extremely low. With modern surgical technique and a rapid operator the dangers of operation are almost nil. Operation. At what age should the operation be performed ? The best time to operate is as soon after birth as possible. Nothing is gained by delay except the consequences of faulty nutrition. The earlier the operation the more plastic the tissues and the more rapid the repair. The vessels in the newly-born are small, hence the loss of blood is slight, the risk to life trivial. Xo preparation for operation is necessary. The mucosa is only devitalized by the use of antiseptic fluids. It is necessary only to have the face clean. The aim of the surgeon in this operation is to restore the lip to its natural form. A simple freshening of the edges and closure of the fissure will not give a satisfactory cosmetic result, since the sequel of such a procedure is invariably a notch in the free border of the lip, which remains as evidence of the original deformity. To avoid this a plastic operation is essential, planned to meet the different conditions which each case presents. For example, in dealing with a simple notch in the border of the lip a transverse incision is made above the notch, the lip drawn down so as to convert the transverse into a vertical-shaped opening, and the sutures applied in this direction. Thus the deplh <>f the lip is increased and the lahial border remains intact. (Fiji;. \-2~2.) When the fissure involves the entire lip, incisions arc made on each side of the cleft from the nose down to the line of the lip, leav- ing the bases of the flaps attached. The two flaps are drawn down, B D FIG. 122. STEPS IN OPERATION FOR SIMPLE NOTCH IN BORDER OF THE LIP. A. Dotted line of incision. B. Transverse incision completed. C. Transverse con- verted into a vertical opening. D. Line of sutures completes the operation. the freshened edges united by suture so that there will result a normal eminence at the free border of the lip. (Fig. 123.) What- ever operation be devised to meet the needs of the individual case the following points should be noted: FIG. 123. STEPS IN OPERATION FOB COMPLETE FISSURE OF THE LIP. A. Line of incision on each side of the cleft. B. The two flaps drawn down. C. Union of freshened edges by a vertical suture line. (a) Anesthesia is not only unnecessary but it is attended with a certain amount of danger. It is quite satisfactory to have the patient's arms covered with a sheet and held by an assistant in the upright position. This 374 ORAL AFFECTIONS position lessens the bleeding and gives the operator an opportunity to observe the lines of the face and plan for the best cosmetic results. Bleeding may be controlled by the fingers of an assistant com- pressing the coronary arteries if -necessary. The use of artery clamps is not advised since the vitality of the tissue is thus impaired by pressure necrosis. The loss of blood will not be serious if the incisions are exact and executed with rapidity. (b) The first essential step in the operation is to free the soft parts from the bone. This should be done thoroughly so as to permit normal coaptation without any pulling. (c) The incisions should be exact, well defined, and present as broad a surface as possible for coaptation. (d) The sutures should be of silk or linen thread and embrace the entire thickness of the lip down to but not including the mucosa. These sutures must not be tied so tight as to cut through or compress the tissues. Be sure that the suture line is so exact that it presents no pockets for the collection and decomposition of food. (e) Dress the wound with collodion painted over gauze. After-treatment. For the first twenty-four hours give only sterile water. It is not a good plan to feed milk until the injured mucosa is sealed up by the products of repair, since milk is a good medium for bacteria and the mouth is difficult to cleanse. Milk diet may be given on the second day, always following the feeding by sterile water to wash away the milk remnants. The dressing should remain in place for seven days, when the sutures may be removed. It is well to protect the wound from the child's fingers by splintering the arms. The habit of sucking the fingers is a menace to perfect results. In BILATERAL HAKE-LIP the greatest difficulty in closing the fissure is sometimes caused by the protrusion of the intermaxillary bone. In early operation this difficulty is rarely encountered, the pressure of the lip after closure causes the bone to assume its normal direction. In neglected cases it may be necessary to force the pro- truding bone back into the fissure. The projecting intermaxillary CLEFT PALATE 375 bone must be gotten into line so as to be on the same level as the adjacent alveolar borders of the maxillary bones. It must be remembered that the intermaxillary bone carries the incisor teeth and that it should be removed only under great provo- cation. In its absence the upper lip is depressed and the deformity is only overcome by a bridge of teeth. Besides, the removal of this process seriously compromises the development of the nasopharynx, arrests the normal growth of the upper jaw and thus impairs the function of normal respiration and the vital capacity of the indi- vidual. CLEFT PALATE Etiology and Pathology. Cleft palate is a congenital gap in the palate due to arrest of development and can be understood only by an intelligent appreciation of the changes which take place in the formation of the nasal and buccal cavities during fetal life. Recall the fact that in early fetal life the nasal and buccal cavities are one; the formation of a partition between these two cavities is only accomplished by the development of the palate, which is formed by the palatal plates of the superior maxillary bones, and the palate bones growing horizontally inward on each side, meeting in the median line and thus closing the fetal gap between the two cavities. Again, note that the fusing of'lHe. palatal plates does not form a complete partition; there still remains a V-shaped interval in front, the apex of which is at the anterior palatine canal, the sides extending to the interval between the lateral incisor and canine teeth. (Fig. 124.) This interval is filled by the intermaxillary bones which are developed from the frontonasal process forming the septum of the nose. With these facts in mind it is readily seen that an arrest of development may produce a median gap or cleft which varies in degree from a notch in the soft palate to a complete gap involving both the soft and hard palates as far as the anterior palatine canal. If the cleft extends beyond this point and involves the alveolar margin it leaves the median line and follows the suture line of the 376 OEAL AFFECTIONS FIG. 124. NOTE THE V-SHAPED INTERVAL FILLED BY THE INTERMAXILLARY BONE. A. Median articulation. B. Intermaxillary bone. intermaxillary bone, the an- terior extremity of the cleft appearing between the lat- eral incisor and canine teeth. (Fig. 125.) If the cleft involves only one side of the intermaxillary bones single hare-lip is usually present, if it involves both sides of the intermaxillary bones double hare-lip is pro- duced and the intermaxil- lary bones are attached to the tip of the nose. Every form of cleft pal- ate can exist alone or in conjunction with hare-lip. It is obvious that this condition is a serious menace to the nutrition of the infant, since it is impossible for the child to suckle or satis- factorily swallow the food introduced into the mouth. The food often regurgitates through the nose and endangers respiration. Chil- dren with cleft palate should be fed in the upright position so that the fluid will gravitate directly into the pharynx. Later, articulation and phonation are seriously compromised the defec- tive nasopharyngeal wall permits the air current to escape through the nose and makes the distinct articulation of consonants impossible. The tools of speech must be normal in order to have correct FIG. 125. COMPLETE CLEFT INVOLVING HARD Speech. JNot only this, AND SOFT PALATES. CLEFT PALATE 377 but unless the mouth and nasal cavities are separated early in life normal physiological function is impossible: hence, normal develop- ment is seriously compromised, vital capacity is impaired, the physiognomy is altered, and the individual is physically and intel- lectually a defective. Treatment. As Lane observes, "the treatment of cleft palate has been a matter of creed and tradition and has not been arrived at in any reasonable manner." Fortunately surgeons are beginning to appreciate that the old dictum of delay has nothing to commend it. It is fallacious in premise and conclusion. If the normal de- velopment of the nasopharynx and the surrounding structures de- pends upon its normal physiology it is obvious that the nose and mouth cavities should be separated as early as possible. The child cannot develop so long as its supply of air and food is de- ficient. The proper time to operate for cleft palate is as soon after birth as possible. The plasticity of the new-born tissues, their capacity for repair, the trifling hemorrhage, the slight risk to life, the possibility of obtaining a broad well vascularized flap before the teeth have begun to encroach upon the mucous membrane combine to make early infancy an opportune time for repairing this defect. The opera- tion devised by Lane is ingenious, rational, and satisfactory, and far superior to the usual method of freshening the edges of the cleft and bringing them together, or the complicated method of Brophy, who approximates the two superior maxillary bones by means of silver wire and adjusts the vivified edges of the cleft with sutures. THE "LANE OPERATION." The principle of this operation is "to close in the interval between the edges of the cleft by muco- periosteum in the case of the hard palate, and by mucous membrane and submucous tissue in case of the soft palate." The features of the operation are the breadth of the flaps, and the ingenious method of overlapping them so that the fissure is closed in by a curtain of tissue on which there is no tension and in which the play of the muscles is unimpaired. 378 FIG. 126. MOUTH-GAG WITH SHARP TEETH THAT BITE INTO THE GUM. If hare-lip exists the defect is repaired at the same time as the cleft in the palate. Lane under no circumstances ever removes the intermaxillary bone or performs any operation upon it with a view of displacing it backward. "The pressure which is exerted upon it by the lip after its continuity has been effected is quite sufficient to bring about its backward dis- placement." Instruments. Since the op- eration is one of great delicacy it is impossible to employ the ordi- nary surgical instruments with any degree of satisfaction. The operator must work in a small cavity upon tissues that are easily torn and devitalized; the essentials are a good light, complete ex- posure, and special instruments of precision. These should consist of a suitable mouth gag with sharp teeth which bite into the gum and will not slip as shown in Fig. 126 ; a knife with a small blade (Fig. 127) ; small curved elevator for detaching flaps; small round in- testinal needles, a needleholder with small jaws and opposing surfaces that are serrated so as to grip the needle (Fig. 128) ; mouse-toothed thumb forcep, and artery clamps for controlling the palatine vessels. Very fine silk is used for the sutures. The anesthetic employed is ether the drop method with Ferguson cone. Operation. It is obvious that in the clos- ure of any particular cleft the surgeon must be largely guided by his experience, and that FIG. 127. CONVENIENT only the principles and a general description of BLADED KNJVXS. CLEFT PALATE 379 methods can be given, which must be modified to suit the individual needs. The operation as described by Lane is as follows: ''The mouth gags are placed in position and the tongue drawn forward by a ligature so as to give free access to the cleft in its entire length. If the soft parts overlying the edges of the cleft are thick and vascular a flap is cut from the mucous membrane, submucous tissue, and periosteum of one side, having its attachment or base along the free margin of the cleft. The palatine vascular supply is divided while the flap is being reflected inward, and it depends for its blood supply on vessels entering its attached margin. "The mucous membrane, submucous tissue, and periosteum are raised from the opposing margin of the cleft by an elevator, an incision being made along the length of the edge of the cleft. "The reflected flap with its scanty supply of blood derived from small vessels in its attached mar- gin is then placed beneath the elevated flap, whose blood supply is ample, and it is fixed in position by a double row of sutures. In this manner two ex- tensive raw surfaces well supplied with bleod and uninfluenced by any tension whatever are retained in accurate apposition. "If, on the other hand, the cleft is too broad to admit of its safe and perfect closure in this manner, one flap, comprising all the mucous membrane, sub- mucous tissue, and periosteum on one side, is raised except at the point of entry of the posterior palatine vessels, while the soft parts on the opposite side are raised in a flap from which the posterior palatine has been excluded, and which pivots on a base formed by the margin of the cleft. Here we have a mobile, well-vascularized flap, which can be thrown as a bridge in any direction and can be superimposed on the flap of the opposite side, the closure being necessarily rendered complete by flaps from the edges of a hare-lip." FIG. 128. LANE NEEDLE -HOLD- ER AND NEE- DLES. 380 ORAL AFFECTIONS This method may be best illustrated diagrammatically as indi- cated in Fig. 129, which represents the roof of the mouth with a cleft extending through the hard and soft palates. The alveolus is indicated by A A A. The operation consists in introducing a reflected flap on one side beneath a raised flap of the opposite side as follows: The reflected flap is made by the incision ab, which extends from the anterior limit of the cleft forward and outward through the mucoperiosteum to beyond the outer surface of the alveolus; FIG. 129. LINES OF INCISION FOR REPAIR OF A MEDIAN CLEFT IN INFANCY. (Lane.) be runs along the outer surface of the gums at the junction of the cheek and alveolus; cd extends along the free posterior margin of the palate to the uvula. This flap is carefully raised from the underlying structures, the posterior palatine vessels and nerves being clamped and divided. Its attached border is the edge of the cleft on one side, and as it is reflected over the cleft its mucous surface- looks upward. The raised flap is made by an incision ae extending on to tlio alveolus; the incision af courses along the free margin of the cleft and is continued as fg, obliquely outward and backward along the upper surface of the soft palate. The incision gh extends along the posterior free margin of the palate to the tip of the uvula. CLEFT PALATE 381 The mucoperiosteal flap afg is now raised from the bone, the soft palate freed from the posterior margin of the hard palate, and the mucous membrane on its upper surface turned outward. The completion of the operation consists in introducing the re- flected flap of one side beneath the raised flap of the opposite side FIG. 130. METHOD OF FIXATION OF THE REFLECTED FLAP BENEATH THE ELEVATED FLAP BY A DOUBLE Row OF SUTURES. (Lane.) and the two fixed in position by a double line of sutures as shown in Fig. 130. The completed operation with dotted suture lines is shown in Fig. 131. If the septum presents a free margin which extends to the level of the cleft (see Fig. 129), an additional incision (1-2) is made along Fio. 131. FLAPS SUTURED IN POSITION FOR REPAIR OF MEDIAN CLEFT. the middle line of the septum through the mucous membrane and periosteum with two transverse incisions (3-4 and 5-6). These two narrow flaps are turned down laterally and the re- flected flap denuded of its mucous membrane along the area of contact is sutured to the superimposed flaps and the margin of the septum (Figs. 129 and 131) (Lane). A natural objection to this operation is the large area of raw surface which is left. It is surprising how rapidly this surface is 382 OEAL AFFECTIONS covered over by new tissue and the normal appearance of the mucosa restored. This general principle of superimposed flaps is applicable to every variety of cleft palate, it is modified as the individual needs and ingenuity of the surgeon suggests (Figs. 132 and 133) PIG. 132. INCOMPLETE CLEFT PALATE WITHOUT HAKE-LIP OPERATED AT FOURTH WEEK.. After-treatment. For the first twenty-four hours give only sterile water. Do not give milk until the injured mucosa is sealed up by the products of repair, since milk is a good medium for bacteria and the mouth is difficult to cleanse. Keep the child quiet and try to prevent crying. Milk diet may be given on the second day. Always follow the feed- ing with sterile water to wash away the milk remnants. No mechanical cleansing of the mouth is practical in small children. On the seventh day the Sutures should be FIG. 133. HARE-LIP AND CLEFT PALATE OPERATED AT THE THIRD WEEK. removed. Result at nine months. HYPERTEOPHIED TONSILS 383 RANULA Ranula is a term used to designate those cysts in the sublingual region which are due to an obstruction of a mucous or salivary gland. This condition may be congenital or acquired. It is most frequently observed between the seventh and tenth years. It is usually discovered by accident as a small, ovoid, bluish-white swell- ing, situated on one side of the tongue and usually elevating the floor of the mouth. Varieties. It is obvious that the cyst may vary somewhat accord- ing to the structure involved. Thus we have sublingual ranula due to blocking of the ducts of Rivini, a very common form, which may occasionally be large enough to interfere with speech and deglutition. Submaxillary ranula, caused by an obstruction of Wharton's duct. If the obstruction is at the orifice a cylindrical swelling is produced in the floor of the mouth; if at the origin of the duct, the gland itself may be distended and present a swelling beneath the jaw. Incisive ranula is a dilatation of a small gland adjacent to the frenum at its junction with the lower jaw (near the incisor tooth). Blandins ranula is due to an obstruction of the ducts of the glands of Blandin or Nuhn, situated on the inferior surface near the tip of the tongue. Weber's ranula is a dilatation of the glands situated posteriorly on the lateral border of the tongue. Wherever situated ranula is characterized by its indolent symp- tomatology and the diagnosis is extremely easy. Treatment. Total extirpation wherever possible. This is easier said than done, and as a rule it will be possible to dissect out only a portion of the cyst wall, the remainder is painted with tincture of iodin and the wound packed with gauze for twenty-four hours. HYPERTROPHIED TONSILS The etiology and symptomatology of enlarged tonsils are too well known and also ably described in special literature to need eluci- 384 ORAL AFFECTIONS elation here. But there are certain rather well-defined indications for their removal that must be appreciated. Not every livpcv- trophied tonsil is evidenced by an enlargement that can be. plainly seen. In fact, many of the worst cases are those in which the tonsil is buried and, to superficial examinations, does not seem to be enlarged. Their removal is advisable: (a) When the child suffers repeated attacks of tonsillitis. (b) When there is a nasal or deficient articulation. (c) When deafness or repeated attacks of earache are present and other causes can be reasonably eliminated. (d) When there is obstruction to free breathing, with or with- out the consequent deforming effects upon the chest. In every instance the examination must include the determina- tion of whether adenoids exist also. Adenoid vegetations are found in nearly every instance in which the tonsils are chronically hyper- trophied. Complete removal is always preferable. The danger from the operation is practically limited to that of hemorrhage, which has been excessive in a few instances. ADENOID VEGETATIONS There is but one method by which these growths may be detected, and that is by digital examination. While there are many symp- toms (as deafness, mouth breathing, snoring, restless sleeping, the facial expression, etc.) which are suggestive, the digital examina- tion is the only positive means of determination. The finger should completely explore the rhinopharynx. In infants, when digital examination is impractical, more de- pendence has to be placed upon the inability to properly nurse and the evidences of obstructive breathing. However, in determining this as due to adenoids, the surgeon must eliminate the possibility of occlusion of the nostril, deformity of the palate, acute rhinitis, retropharyngeal abscess, pharyngeal paralysis, nasal diphtheria, en- larged cervical glands, enlarged thyroid gland, and the local effects (in the nose and pharynx) of tuberculosis and syphilis. EETEOPHARYNGEAL ABSCESS 385 When detected their removal is advisable if they are the cause of symptoms and, in many instances, the removal of the accompany- ing hypertrophied tonsils is indicated also to make the relief com- plete. The after-care of children who have been operated upon for the removal of either adenoids or hypertrophied tonsils is no small part of the treatment, and its neglect tends to bring the procedure into disrepute. When these enlargements have caused symptoms they are usually marked ones before an operation is consented to, and the child is far below its normal efficiency. This must be corrected by the ad- ministration of suitable tonics and the regulation of the diet and general hygiene of the child before and after the operation. Cer- tain definite exercises are in nearly every instance necessary to over- come the deformities which have been the result of the obstructed breathing. RETROPHARYNGEAL ABSCESS The formation of an abscess behind the posterior pharyngeal wall is a special affection of childhood. More than one-half the cases occur during the first year (V. Bergmann). It is an extremely grave affection and may prove fatal unless there is timely inter- vention. Etiology. Besides the chronic tuberculous abscess in the retro- pharyngeal space, which may result from disease of the cervical vertebra}, we encounter the acute abscess, due to suppuration of the lymph glands, situated behind the pharynx and along the cervical vertebra. The infection is carried from the mucous membrane of the nasal fossa?, the nasopharynx, or the middle ear during the course of measles, scarlet fever, whooping cough, bronchopneu- monia, and tonsillitis. Symptoms. The symptoms are at first those due to inflammatory reaction and septic absorption, and second those due to functional disturbance. Besides the pain, fever, and swelling there are diffi- 386 ORAL AFFECTIONS culty in swallowing, disturbance of respiration, and changes in the voice. Dysphagia is caused by the painful movements of deglutition and by the actual obstacle which the phlegmon presents to the passage of food. As soon as the child attempts to swallow the fluid is im- mediately regurgitated through the nose or mouth. Dyspnea. Respiration is labored, inspiration is accompanied by a wheezing sound indicating an obstruction to the air passages. The voice is altered, the mouth is filled with mucus; movements of the neck are painful, and there is marked rigidity of the muscles of the neck. Diagnosis. It is not rare to find this condition overlooked simply from neglect to palpate the pharynx. Never fail to palpate the pharynx of a child suffering from dysphagia or dyspnea. By introducing the finger into the mouth and directing it toward the posterior pharyngeal wall tumefaction and fluctuation are readily recognized. Prognosis. Retropharyngeal abscesses left to themselves usually result in death from asphyxia, due to spasm of the glottis or spon- taneous opening of the abscess and the sudden precipitation of a quantity of pus into the air passages. Treatment. Prompt evacuation of the abscess. The operation should be performed without delay and without anesthesia. The child is held by the nurse so that the head and hands are im- mobilized. A straight bistoury is prepared by protecting the blade with adhesive plaster to within a quarter of an inch of its point. The left index finger is introduced to the point of fluctuation and along this finger the knife is guided to the posterior pharyngeal wall, in which an incision of about one-half inch is made. As soon as the pus escapes the child's head is turned directly downward to prevent the pus from entering the larynx. It is not rare after the incision for the child to stop breathing, but artificial respiration with the head low usually results in prompt restoration. The operation is usually curative and it is rarely necessary to reopen the wound because of its too early closure. FOKEIGX BODIES IX THE AIll PASSAGES 387 Retropharyngeal abscess may be opened externally by a cuta- neous incision in front of the sternomastoid, but it is obvious that such intervention implies a careful dissection under anesthesia, and is not to be considered where time is the essential factor in saving life. CHAPTER XLVIII THE AIR PASSAGES FOREIGN BODIES IN THE AIR PASSAGES Various foreign bodies find their way into the air passages, such as peas, beans, beads, buttons, pins, nails, tacks, toy whistles, etc. The object is introduced into the mouth, and aspirated into the air tube under the influence of sudden inspiration induced by laugh- ing or coughing. The ultimate destination of the object depends upon its size and shape. Hough, angular bodies are usually arrested in the larynx, if the object is large enough to completely obstruct the laryngotrachea. According to Lenox Browne twenty per cent, of foreign bodies are arrested in the larynx, about fifty per cent, pass into the trachea, and about twenty-five per cent, lodge in the bronchi. Symptoms. Whatever the foreign body may be it produces first an initial crisis at the time of the accident, a crisis marked by con- vulsive cough, suffocation, cyanosis, and violent vomiting. During the spasm the foreign body is expelled, or death may supervene from sudden cardiac or respiratory failure, or it passes the glottis and becomes lodged in the trachea or bronchus, to remain for a variable time quiescent, interrupted at irregular intervals by re- peated crises of cough and suffocation as the foreign body is moved about by the changing position of the child. Crises of suffocation may occur during sleep. Auscultation often reveals curious vibratory sounds. When a large bronchus is plugged there is absence of vesicular murmur in the corresponding part of the lung. 388 THE AIR PASSAGES The expectoration is at first mucous, sometimes tinged with blood, later it becomes purulent. Pain is rarely produced by a foreign body, sometimes, however, it may be localized at the sternum or in the back. Diagnosis is based on the history and the initial crisis. The X-ray is a valuable agent in accurately locating metallic substances when the symptoms are not urgent. If the body is lodged in the larynx it may be detected by the laryngoscope; if below the larynx, bronchoscopy should be employed. Prognosis. While it is rare for the initial crisis to terminate in death, and while foreign bodies may be tolerated for a long time after the accident, pulmonary complications always threaten a fatal termination. The prognosis is therefore grave. Treatment. This depends upon where the foreign body is located. // the symptoms are urgent an at- tempt may be made to remove the body by introducing the finger into the mouth, or the body is sometimes forcibly expelled by inverting the FIG. 134. A. THE CRICOTHYROID MEM- patient and striking him on the BRANE THROUGH WHICH RAPID "TRACHEOTOMY" MAY BE PER- FORMED. back. If not immediately success- ful do a laryngotomy at once. Lar- yngotomy consists in opening the larynx through the cricothyroid membrane by a transverse incision made close to the upper border of the cricoid cartilage. (Fig. 134.) It is the simplest and quickest method of relieving dyspnea when prompt intervention is demanded. Where the symptoms are less urgent extraction may be possible through the natural passages by means of the laryngoscope and forceps, but preparations for an instant tracheotomy should always precede these manipulations should sudden spasm of the glottis demand intervention. INTUBATION 38!) When the body is situated below the larynx a tracheotomy may be performed. It is not unusual to see a foreign body expelled through the tracheotomy wound as soon as the trachea is opened and before the tube is introduced. When the symptoms are not urgent the child should be placed under the care of one who is skilled in laryngoscopy and bron- choscopy. The obsolete method of blindly groping after foreign bodies is not justified when it is possible to obtain the services of one who is skilled in the use of modern instruments of precision. INTUBATION The advantages of intubation over tracheotomy are its simplicity and the rapidity with which it may be accomplished without any anesthetic, and for these reasons chiefly, it has practically super- seded the latter operation for the relief of laryngeal diphtheria. It is an operation that any surgeon may be called upon to perform at any time, and as the symptoms which demand its performance are usually very urgent, familiarity with the technique is necessary. The procedure may be necessary not alone in diphtheria but in a retropharyngeal abscess, which is situated low on the posterior pharyngeal wall, in edema of the larynx, or acute laryngitis. While there is considerable dispute as to the actual need or value of the procedure in any given case, it may be stated as a fact borne out by repeated clinical experiences that the operation is usually undertaken too late rather than too early to give all the relief that can be obtained. It is a safe rule to give precedence to the general state of the child as regards exhaustion and fatigue in its struggles for air, rather than to the more commonly accepted one of the estimated degree of stenosis as evidenced by recession in the suprasternal and infrasternal regions. Especially in diphtheria it is absolutely essential to conserve every bit of strength, and thus, if any error is made, it should be upon the side of early intubation and safety. Preparation of the Operator. The nose and mouth should be pro- 390 THE AIE PASSAGES tected with gauze and the clothing by a sheet or gown so that if the child coughs the operator is not endangered. Preparation of the Patient. The child's body should be firmly wrapped in a strong sheet or blanket so that the arms and legs are secured sufficiently to make the inevitable struggling ineffectual. Thus secured the patient is held upon the lap of the nurse with the head on the nurse's right shoulder, who, with her left hand, securely holds the head in position and with her right encircles the child's body. If the child struggles greatly a third person may be necessary to hold the head in posi- tion, for this is a very im- portant part of the pro- cedure. (Fig. 135.) Preparation of the In- struments (Fig. 136). A well-oiled silk thread is loosely looped through the eye of the tube so that withdrawal of the tube can be readily accom- plished if it is misplaced or is coughed into the pharynx, or the thread can be easily withdrawn when the tube is properly placed. The rest of the instruments should be conveniently placed for rapid work and all previously sterilized. The introducer must be fitted with a proper sized tube. The Operation. The first step is to introduce the gag, and suffi- cient time should be taken to have it properly placed so that it will remain in position and not obstruct the field of operation by slipping or turning, as is often the case. After the gag is placed the assistant throws the child's head slightly backward while at the same time making slight but persistent traction and supporting the FIG. 135. POSITION OF CHILD FOR INTUBATION. INTUBATION 391 gag. The introducer having been previously armed with tho proper tube is held in the right hand of the operator, while the glottis is located with the forefinger of his left, and using that as his guide, he passes the tip of the tube directly into the larynx. This is done by keeping strictly to the median line and keeping the handle paral- lel with the chest until the tip of the tube is well back toward the pharynx, when a curved motion through the elevation of the handle FIG. 136. INSTRUMENTS USED IN INTUBATION. (Fowler.) carries the tip of the tube to the larynx. When certain that the tube is in place the thumb of the right hand releases the tube from the obturator and the finger of the left hand adjusts it more per- fectly in place. Both fingers should aid in accomplishing this ad- justment, because when reliance is placed alone upon the finger that holds the introducer the tube may stick and be dislodged. (Fig. 137.) After the withdrawal of the introducer if the breathing shows improvement the gag is removed. After from fifteen to 392 THE AIR PASSAGES twenty minutes, if everything is all right, the thread may be cut and withdrawn. However, if a very competent nurse is not avail- able, this should be left in place and fastened to the cheek with tape while the child's arms are restrained so that it cannot interfere with the thread. In this way instant removal of the tube is easily accomplished. Every step of the procedure should be carried on with the greatest gentleness compatible with rapidity and certainty. After-treatment. An experienced attendant is necessary at all times to guard against accidental clogging of the tube or its dis- lodgment. By lowering the head, liquid nourishment may be freely given without fear of interfering with the tube. In some instances we have found it more desirable to introduce a stomach A B FIG. 137. A. METHOD OF DRAWING THE EPIGLOTTIS FORWARD. B. INTRODUCING TUBE ALONG SIDE OF FINGER. C. PUSHING THE TUBE INTO POSITION WITH INDEX FINGER. (Morrow.) tube and administer nourishment in that way or by a catheter through the nose. Removal of the Tube. This demands the same amount of prep- aration as the introduction and is accomplished as soon as the symptoms allow, which is usually on the third, fourth, or the fifth day. With the child in the same position as at introduction the gag is placed as before and the extractor passed down into the lumen, where its blades are separated and the tube withdrawn. It is neces- sary to perform this rapidly also. TRACHEOTOMY Since the introduction of antitoxin in the treatment of diphtheria and the use of O'Duryer's method of intubation for laryngeal ob- struction tracheotomy has a much more limited field. It is still TRACHEOTOMY 393 indicated however, when intubation fails to relieve, as an emergency measure when foreign bodies obstruct the air passages, and as a preliminary procedure to other operations. Anatomical Points. (a) Tracheotomy is high or low as it is performed above or below the isthmus of the thyroid. In children the high operation is always chosen. (b) The difficulties of tracheotomy increase the nearer the in- cision is made to the sternal notch, just as the depth of the trachea increases, and the number and importance of the overlying struc- tures. (e) The patient's shoulders should be raised by a sand bag and the head thrown back and steadied. This position draws the trachea up and throws it forward, thereby increasing the operative field and bringing the trachea nearer the surface. (d) The incision should be made exactly in the median line. This line corresponds to the point where the layers of fascia meet and to the median raphe between the muscles, and incurs the least amount of hemorrhage by avoiding the greatest number of vessels. The exact median incision is also the best preliminary precaution against losing the trachea by getting off to one side. (e) The trachea has a considerable range of mobility; it rises and falls with each respiration. It should therefore be steadied by transfixing it with a sharp hook and drawing it forward before opening it. (f ) The trachea should be opened by a short thrust of the knife in order to penetrate the lining mucous membrane. The mistake has been made of pushing the mucosa in front of the knife and introducing the tube between the mucous membrane and the fibro- cartilaginous portion of the trachea. (g) In children the difficulties of tracheotomy are increased by its smaller size and greater depth. The presence of the thymus gland and the higher level of the vessels at the root of the neck must be taken into consideration. (h) The greatest danger in tracheotomy is hemorrhage getting into trachea and causing asphyxiation by obstructing the bronchi: therefore, hemostasis should be complete before opening the trachea. 394 THE AIE PASSAGES Operation. The operation consists in incising the trachea and introducing through the opening a cannula, through which air reaches the lungs. Instruments. When instant operation is necessary a knife and a rubber tube may be the means of saving life. When deliberation is possible provide a knife, scissors, thumb-forceps, hemostatic for- ceps, retractors, tenacula, and a tracheotomy tube. Anesthesia. While in extreme cases a rapid operation may be done without anesthesia, it is better when practical to give light FIG. 138. A. OUTER TUBE OF TRACHEAL CANNULA. B. INNER TUBE OF TRACHEAL CANNULA. chloroform anesthesia to children, since their struggles embarrass the operator. Envelop the patient's body in a blanket with the arms extended and held close to the body. Place the patient on a table in a good light, the shoulders elevated, and the head thrown back, so that the neck is extended and the trachea thrown forward. An assistant steadies the patient's head, while another at the foot of the table keeps the extremities in full extension. Steady the trachea by grasping the larynx with the thumb and middle finger of the left hand, the index finger being placed on the cricoid cartilage. Make an incision of about an inch from the cricoid TRACHEOTOMY 395 cartilage downward, and exactly in the median line. Divide the soft parts down to the trachea, ligate all bleeding points, and retract the wound edges so as to expose the trachea. Firmly fix the trachea with tenacula, draw it forward, and open the trachea by a short thrust of the knife so that the mucous lining is penetrated as well as the fibrocartilaginous tube. Introduce two silk retraction sutures in the edges of the tra- cheal wound so that the slit may be held apart (the silk retraction sutures should be perma- nently retained in case the tube needs to be re- inserted), with the tracheal wound held apart by the retraction sutures pass the outer tube (Fig. 138 A) backward and downward into the trachea and then immediately insert the inner cannula. (Fig. 138 B.) Secure the tube in place by the attached tapes tied behind the neck. In emergency cases, when a metallic tube is not at hand, an improvised rubber tube may be employed as shown in Fig. 139. After-treatment. Protect the opening of the tube with a few layers of moist gauze. A trained nurse should be in constant attendance to remove and cleanse the inner tube if obstruc- tion occurs, otherwise the inner tube should be removed, cleansed and boiled morning and night. The tube should be worn only as long as normal respiration is impeded. Normal respiration may be tested by closing the tracheal opening with the finger. At first the tube may be removed for a few hours at a time; after the child has gradually become accustomed to normal respiration the tube is dis- pensed with. FIG. 139. IMPROVISED TRACHEAL CANNULA MADE FROM RUBBER TUBING. (Brewer.) 396 THE NECK CHAPTER XLIX THE NECK CONGENITAL TORTICOLLIS Congenital torticollis (wry-neck) refers to the special attitude which the head and neck assume due to unilateral myogenic con- tractures usually affecting the sternomastoid and scalenus anticus muscles. Etiology. The etiology of this affection may be found as in other developmental defects (such as hare-lip, etc.) to be the result of intrauterine forces, which manifest themselves either in incom- plete or in abnormal development; or it may be the result of ob- structive traumatism in which is inaugurated a chronic interstitial myositis with subsequent contractures. Congenital wry-neck must not be confounded with postural wry-neck secondary to other pathological conditions, such as cervical spinal caries, suppurative cervical adenitis about the sternomastoid, otitis with glandular swelling, ocular defects, etc. Pathology. Certain pathological changes occur which have an important bearing on the treatment. While the sternomastoid muscle is most prominently affected, it must not be forgotten that the scalenus anticus is also involved. Thus the muscles undergoing fibrous degeneration contract, shorten, and pull the head toward the corresponding shoulder. The position of the sternomastoid muscle is such that it forms a prominent cord which is increased when the head is forced into normal position. It is also to be recalled that the two heads of the sternomastoid the sternal and clavicular confer upon this muscle a double function they pull the head toward the shoulder, and rotate it toward the opposite side. Hence the deformity will vary somewhat according to which head is affected. If the contraction is chiefly in the sternal head, rotation will predominate; if in the clavicular head, inclination will be most marked. As a result of this disturbed muscular balance there are pro- CONGENITAL TORTICOLLIS 397 nounced secondary changes shown in an asymmetry of the head and face. The changed static conditions of the affected side interfere with nutrition, retard development, and result in craniofacial atrophy. Again, this facial scoliosis changes the horizontal plane of the eyes, ears, nose, and mouth, into one of obliquity. The shoul- der girdle of the affected side is drawn up, and there follows a cervical scoliosis with the curvature directed toward the sound side, with secondary compensatory curves in the dorsal and lumbar regions as the structure and function of the spinal column demand. Symptoms. The typical deformity due to the two-fold function of the sternomastoid muscle is easily recognized. The head is inclined toward the affected side and rotated toward the sound side (Fig. 140). The malposi- tion of the head is so fixed that it may be increased but not di- minished. All other changes are caused secondarily, and are adaptation changes of growth. The two cardinal symptoms inclination and rotation will vary in severity according as the sternal or clavicular heads of the muscle are most affected. Asymmetry of the face and curvatures of the spine have already been noted in the pathology. Diagnosis. There should be little difficulty in recognizing true wry-neck by the hard and tense contracture of the degenerated and shortened muscle. We must differentiate postural wry-neck result- ing from other pathological conditions which is temporarily a posi- tion of greatest comfort. Thus cervical caries, subluxations, adenitis, etc., must be eliminated by careful examinations of the vertebras in the neck and through the mouth cavity; by the use of the X-ray ; by the von Pirquet test ; by the absence of acute in- flammatory symptoms, FIG. 140. TORTICOLLIS. NOTE THE INCLINA- TION AND ROTATION OF THE HEAD. (Estor.) 398 THE NECK Treatment. The operative treatment of congenital wry-neck is always to be preferred since it removes at once the obstacle to re- duction. The operation should consist of an open resection of the muscle with adequate exposure of the parts. Subcutaneous tenot- omies in the presence of asepsis are no longer admissible; in this region, with its important vessels, surgery in the dark is inex- cusable. An adequate horizontal incision should be made a finger's breadth above the clavicle; avoid if possible the external jugular vein, which lies close to the pos- terior margin of the muscle; isolate the muscle and divide both heads on a grooved di- rector. Be sure that the muscle fibers are completely divided as well as the fascia. If necessary the scalenus anticus may be re- sected and an extirpation of scar tissue be done in addition. When the contraction is extreme a plastic operation will increase the length of the muscle by di- viding the clavicular portion near the clavicle and the sternal portion near the bifurcation and uniting the two heads (Fig. 141): After the resection is com- pleted the wound is closed without drainage and the head and neck dressed with plaster bandages in an over-corrected position and retained in this position for several weeks. The results of opera- tion are always more favorable in the early cases secondary cur- vatures of the spine form an unpleasant complication. The parents should be informed that while operation will correct the position of the head the facial asymmetry will remain unaltered. If these cases are seen very early, in the first weeks, treatment FIG. 141. LINES OF INCISION FOR PLASTIC OPERATION ON THE STERNOMASTOID MUSCLE. AB and CD are united by suture. TUBERCULOUS GLANDS OF THE NECK 300 should begin by correcting the position with pillows placed under the affected side. If there is hematoma of the muscle it should be massaged and the surface painted with iodin (half strength). When the symptoms become more pronounced after the first few months, in spite of positional treatment, operation should be advised at once before secondary changes appear. Spasmodic wry-neck is very rare in children. It may be relieved by over-correction with plaster collar, or by division of the spinal accessory nerve. TUBEECULOUS GLANDS OF THE NECK Tuberculous glands of the neck is one of the most common affections of childhood. It will be recalled that the neck is one of the most important lymph stations of the body. Not only is it rich in lymphatic glands, but these glands stand guard over more gate- ways of infection than those in any other region of the body. The cervical lymph glands drain not only the regions in which they are situated, but also the head, face, nose, mouth, and throat. Again, the importance of the lymphatic system in the child and the predilection of the tubercle bacilli for lymphatic tissue explain the frequency of this affection. Anatomical Considerations. Anatomically the glands are ar- ranged in a glandular collar which encircles the neck at its junc- tion with the head. From this passes on either side a vertical chain underneath the sternomastoid, accompanying the vessels and nerves as far as the junction of the neck and thorax. Method of Invasion. The infecting organism emigrates from the mucous linings of the mouth, nose, pharynx, etc., to the neighbor- ing lymph spaces and are finally lodged in the filter stations of the lymph apparatus the glands, which become the centers of in- flammatory reaction. Hence, the gland enlarges, there is the forma- tion of typical tubercle, the inner structures break down, and the gland is converted into an abscess inclosed in the denser gland capsule, which in turn breaks down and the pus slowly pushes its 400 THE NECK way to the surface, discharges, and leaves fistulous tracts. In some cases the cheesy glands remain encapsulated, become calcined, but harbor for a long time the infectious material. Thus it will be noted that the tuberculous process in the lymph glands present the same typical picture in the formation of granu- lation tissue, followed by caseation, suppuration, and fistulization, as in other tissues. Symptoms. While tuberculous adenitis is extremely common in childhood it is most frequently observed after the fifth year. The child is usually in fair health and is brought to the physician because the parents have noticed a painless "lump" in the neck. This "lump" may be a simple enlarged gland, which rolls freely under the skin, or it may be formed of several glands mak- ing a considerable mass. These enlarged glands are found in typical locations corresponding to the typical "arrangement of the lymph glands such as in the submaxillary space, along the in- ner border of the sternomastoid, in the carotid region, etc. (Fig- 142.) It is obvious that the character of the infected gland differs according to the grade of the disease. Thus, the gland may be simply Jiypertrophied. The child then presents a fair condition of health. One or more enlarged glands are observed in front of the sternomastoid, varying in size from a pea to an egg. The glands are painless, hard, distinctly separated. They increase or diminish in volume, but never completely disap- pear. They are accompanied by no functional symptoms and the parents are concerned only about the deformity they present. At a later stage the glands may soften, become adherent to each other FIG. 142. BILATERAL TUBERCULOUS GLANDS OF THE NECK. TUBERCULOUS GLANDS OF THE NECK 401 and surrounding structures as the result of a periadenitis, and pre- sent symptoms of fluctuation. Finally, the overlying skin becomes adherent, ulcerates, and permits the escape of the caseous pus, which leaves a fistulous tract communicating with the indurated mass. The clinical evolution from a simple hypertrophy to fistuliza- tion may be present in its various stages in the same subject. Thus it is not uncommon to note in certain patients evidences of simple hypertrophy associated with glands in the process of softening, and those that have already discharged their caseous contents. The clin- ical picture presents the different aspects of the same disease. Again, a simple glandular hypertrophy may be absorbed and disappear, or it may become sclerosed and persist indefinitely with the same volume and consistency, presenting no symptoms save that of deformity. Occasionally, a superadded pyogenic infection may change the chronic character of the disease into an acute process characterized by pain, fever, and the formation of an acute adenophlegmon. Diagnosis. The diagnosis of tuberculous glands of the neck is generally extremely easy. Remember that tuberculous glands are by far the most common tumor of the neck, and the most frequent cause of abscess. Again, note their chronic course and their tend- ency to softening and pus formation. Fortify the diagnosis by correlating the primary focus usually found in a pharyngeal tonsil (adenoids), enlarged tonsils, chronic otitis media, dental earies, etc. These are the most frequent gateways of infection. Tuberculous glands of the neck must be differentiated from lymphosarcoma by their chronic course and the mobility and larger range of motion of the glandular masses. Sarcoma spreads through the capsule, infiltrates the surrounding tissues, and forms a com- pact mass. From true leukemia the disease must be differentiated by the blood examination. In the former there is a marked leukocytosis. From pseudoleukemia, or HodgJcins disease, by the less marked enlargement of the lymph nodes. A steady increase in the size of the tumors, the sudden successive involvement of group after group LlliK.-^ E Cl r CSTEO ol 1 1: 402 THE NECK of glands, and the appearance of similar enlargements in other regions speak for pseudoleukemia (Johnson). From branchial cyst the disease is differentiated by the fact that the cyst presents a solitary tumor, rather elongated in form, and not accompanied by other small nodules. A small puncture will eliminate all doubt. As a last resort the diagnosis may be settled by excising a gland and examining a section macroscopically and microscopically, or guinea pigs may be inoculated with the gland detritus. Treatment. As in all tuberculous lesions the treatment should be directed toward improving the tissues so that the tubercle bacilli will cease to thrive. This will be accomplished by proper nutrition, unlimited sunshine, and fresh air. Local disinfection of the mouth, teeth, nose, and pharynx should not be neglected. Under proper hygienic treatment many cases of early tubercu- lous adenitis will recede and operation may be avoided. The local application of iodin or other medicaments is the merest folly, since it in no way influences the course of the disease. If the gland is softening and suppuration is present, a small incision should be made under strict antiseptic precautions, the contents evacuated, and a small rubber tissue drain inserted. No curetting should be done, since it only opens the way for new infection, and the less the inter- ference the more rapid the healing. When persistent and large glandular masses are present OPERA- TIVE TREATMENT is indicated. Experience has shown that the radical removal of tuberculous glands of the neck is one of the most satisfactory operations in surgery. Not only does it prevent suppurating sinuses and unsightly scars, but it relieves the region at once of the diseased tissues. The operation for the extirpation of tuberculous glands is formidable: it requires an exact anatomic dissection, and is a procedure of major importance. Remember that if the operation is attempted the removal of the glands must be radical ; a partial removal of the larger lymph nodes is useless and is followed by immediate recurrence. Again, the palpable enlargement is no index of the extent of involvement: one or two enlarged glands on the surface usually indicate a nest of BEANCHIAL FISTULA 403 tuberculous glands extending along the internal jugular vein even as far as the clavicle. Therefore, extensive incisions, thorough exposure of the parts, extirpation of the entire glandular chain whether enlarged or not are the prime requisites of this operative procedure. No description of the details of the operation is possible. Only a resourceful and experienced surgeon should attempt it. It is sug- gested that the lines of incision be so planned as to give the greatest exposure with the least resulting scar. (Fig. 143.) Horizontal inci- sions in the natural folds of the neck; the only vertical incision be- ing placed behind the sternomastoid ; skin su- tures of horse-hair with fine needle give the best cosmetic results. Though the operative technique is difficult and the procedure is a long one, it is remarkable how speedy the recovery and how satis- factory the results. These patients are usually out of bed the day after the operation and healing is cogj^iete in a week. FIG. 143. LINE OF INCISION FOB THE RADICAL REMOVAL OF TUBERCULOUS GLANDS OF THE NECK. II BRANCHIAL FISTULJE Branchial fistula are either primary, due to the imperfect obliteration of one of the branchial clefts and exist at birth, or are secondary to the opening of a branchial cyst. The median fistulse are quite rare and are concerned with the imperfect obliteration of the thyroglossal duct. The lateral fistulas are more frequent; 404 THE NECK sometimes unilateral, sometimes bilateral and symmetrical. The external orifices of these fistulse are usually indicated by a nodule of skin and are situated along the line of the anterior border of the sternomastoid muscle opposite the angle of the jaw, the thyrohyoid space, and the sternoclavicular articulation (Fig. 144). The in- ternal orifices are either in the region of the tonsil or the sinus pyriformis. Clinical Characteristics. There is a more or less constant flow of secretion from the fistula which is increased by the movements of mastication and deglutition. The fistula may temporarily close, become inflamed, and give rise to an abscess, which subsequently dis- charges. When a probe is intro- duced into the canal it cannot penetrate for more than two or three centimeters without incit- ing a spasmodic cough or a pain- ful irritation of the pharynx. The fistula is complete when it has a pharyngeal orifice, which is usually situated in the vicinity of the tonsils. The course of these fistula? is fairly uniform: along the anterior or inferior surface of the sternomastoid to the greater cornu of the hyoid bone, it then curves in and passes under the posterior belly of the digastric muscle to its orifice in the pharynx. The fistula is incomplete if it has only an external opening in the skin, or only an internal opening near the tonsil ; the latter are rarely recognized, but their presence may be suspected if by pressure on the side of the neck there is a gush of serous fluid from a peri- tonsillar orifice. It is difficult to demonstrate the course of one of these fistulse since palpation gives no clew, because of the thickness of the over- FIG. 144. LOCATION OF THE ORIFICES OF PERSISTENT BRANCHIAL FISTULA. BRANCHIAL FIBRO-CHONDROMATA 405 lying structures. An injection of bismuth emulsion into the fistu- lous track will appear on a radiograph and be of some assistance in the subsequent treatment. Treatment. Total extirpation is the treatment of choice. Unless the tract is completely removed, a return of the fistula is to be ex- pected. It is obvious that this operation involves a careful dissec- tion and exact anatomical knowledge especially in dealing with that part of the tract that penetrates deeply into the pharyngeal region and is in close proximity to the carotid vessels. Hence each case should be carefully considered. If the fistula is not very apparent and is secreting only a few drops at infrequent intervals it may be well to try injections of tincture of iodin, especially in a girl where a scar is to be avoided. The injection treatment is sometimes successful. If, however, the fistula is quite apparent, with a tendency to become inflamed and suppurate, we should not hesitate to propose total extirpation. BRANCHIAL FIBRO-CHONDROMATA There are small, hard appendages sometimes found on the face or neck of the new-born, which are the result of the proliferation of histological elements along the course of the branchial clefts. They form small, hard tumors, more or less pedunculated, and covered by adherent skin. They are found along the line of the intermaxillary cleft, especially in the neighborhood of the ear, or along the anterior border of the sternomastoid. As a rule they are quite small, painless, and composed of fibro- cartilaginous tissue. Their removal is demanded only because of the deformity which they occasion. Treatment. When the pedicle is very narrow a simple ligation and excision are sufficient; when the pedicle is broad, a curved in- cision at the base, with suture of the skin opening, is necessary. In certain cases the cartilaginous elements extend deeply into the at- tached base of the tumor and unless completely extirpated the tumor may return. 406 THE NECK CONGENITAL CYSTS OF THE NECK Lymphatic Cysts (Hydrocele of the Neck}. The lymphatic cysts are large congenital tumors which may attain enormous proportions, situated in the lateral surface of the neck, and often extending from the lower jaw to the clavicle. (Sometimes under the clavicle into the axilla.) The pathology of these cysts is obscure; the present theory places their origin in the lymphatic system. They are generally multilocular and consist of a number of cysts of varying size. The content of the cysts varies; at times it is a clear transparent serum, again it may be mixed with blood or even seropurulent. SYMPTOMS. Clinically these cysts present a tumor of variable volume, usually quite large, situ- ated on the side of the neck, which it markedly deforms. The tumor is either round or lobulated. The overlying skin presents a normal appearance and is independent of the tumor. (Fig. 145.) When the cyst is multilocular, its con- sistency is soft and flabby, like that of a varicocele ; or, when a cyst cavity predominates, it may be fluctuating. The functional symptoms are ordinarily of little importance. In spite of their volume they rarely give any trouble beyond the inconvenience and deformity. Exceptionally, when these cysts in- vade the pharynx and trachea, they may interfere with respiration or deglutition. The method of progression of these cysts is characteristic. They extend like neoplasms, gradually invading the muscular planes, and even infiltrate the muscles themselves. They pass under the clavicle into the axilla ; or behind the sternum and invade the mediastinum. They form adhesions to the great vessels. FIG. 145. CONGENITAL LYMPHATIC CYST OF THE NECK. (Spitzy.) CONGENITAL CYSTS OF THE NECK 407 DIAGNOSIS. There is no congenital tumor which presents the clinical picture of a lymphatic cyst. Tuberculous glands and bran- chial cysts are small and develop later. A lipoma may be equally voluminous but it is less localized, develops toward the posterior surface of the neck, and presents no point of fluctuation. An angioma may cause some confusion but the absence of dis- coloration of the skin, the absence of turgescence of the tumor when the child cries, the lack of complete reductibility enable us to recog- nize the lymphatic cyst. TREATMENT. Total extirpation may be called ideal, but it is possible only when the cyst is small, well defined, and non-' infiltrating. The long and difficult dissection which some of these tumors impose renders total extirpation inexpedient. If the tumor is increasing rapidly we may puncture and drain, or it may be wise to be content with partial extirpation, and marsupialize the remain- ing portion by suturing the sac to the edges of the skin incision. A complete cure is then obtained on condition that all the partitions which separate the cystic cavities are destroyed. Branchial cysts are due to imperfect obliteration of oner of the branchial clefts, which may result in a branchial fistula when the entire tract remains open, there being an internal and external orifice ; or a cystic fistula when one end of the tract is closed ; or a branchial cyst when both ends of the tract are closed, the inter- mediate portion remaining open. It is obvious that these cysts are situated laterally. But there are also median cysts due to the im- perfect obliteration of the thyroglossal duct, these cysts occupy a median position in front of the trachea from the foramen cecum to the thyroid gland. SYMPTOMS. Clinically these cysts are either median or lateral. They are rarely seen at birth, but usually appear during the early years of life or toward puberty. They give so little trouble that the physician is rarely consulted until at a more advanced age and then because of the deformity. The tumor is small, about the size of a walnut, rather elongated, and of hard consistency. The skin is not adherent, and the tumor is movable in a transverse direction, riot vertically. 408 THE NECK The cyst may undergo a rapid increase in size, followed by in- flammation and suppuration, and open externally, the consequence of which is a fistula which will continue to discharge until it is destroyed. These fistulas may close temporarily, but in a few weeks suppuration is reproduced and the fistula opens anew. This same succession of phenomena is repeated until the fistulous tract is extirpated. TREATMENT. Complete extirpation is the only treatment which will prevent their return. If the cyst is completely walled off the extirpation is simple, but usually the cyst is connected with a very small canal which is directed toward the pharynx in the lateral cysts, and toward the base of the tongue in the median cysts. To follow this canal to its termination is extremely difficult, and yet if the extirpation is not complete the fistula will later return. DERMOID CYSTS OF THE NECK The suprahyoid median cysts develop in the floor of the mouth between the geniohyoglossus and hyoglossus muscles, and are easily mistaken for ranula. When they attain considerable size they project in the floor of the mouth, elevate the tongue, and form a prominence below the chin. They are doughy in consistence and are adherent either to the symphysis menti or to the body of the hyoid. They are painless and develop slowly. They may be extir- pated either by the mouth or by a submental incision. The suprahyoid lateral cysts are situated at the angle of the jaw and form a prominence, when of considerable size, both in the pharynx and on the side of the neck. They form adhesions with the vessels of the neck and for this reason are difficult to extirpate. LIPOMAS OF THE FACE AND NECK Lipomas must be reckoned among the more frequent congenital tumors. They are either superficial or deep, and the latter are MALFORMATIONS OF THE ESOPHAGUS 409 often attached to the periosteum and underlying bone. Sometimes the lipomas are associated with angiomas (angiolipomas) which is recognized on excision by their vascular arrangement and the char- acteristic convoluted capillaries between the fatty lobules. Congenital lipomas of the neck are characterized by their great volume and tendency to diffuse. They extend between the muscles, toward the supraclavicular fossa, the thorax, and axillary region. The overlying skin is normal, they are of soft consistency, and indefinitely lobulated. They are neither well defined, reducible, nor fluctuating, which distinguishes them from cystic lymphangiomas. When these tumors extend toward the pharynx and trachea they may interfere with deglutition and respiration. Their chief characteristic is their tendency to diffuse. They are not well defined and their extirpation is consequently difficult. The only treatment is excision. If the tumor is very large it may be expedient to perform the extirpation in several stages. CHAPTER L THE ESOPHAGUS MALFORMATIONS OF THE ESOPHAGUS Varieties. Malformations of the esophagus are extremely rare. COMPLETE ABSENCE of the esophagus has been reported, but there are only a few cases on record. In these cases both the upper and cardiac openings were closed and between the two there was no trace of an esophageal tube. PARTIAL ABSENCE is not quite so rare. The anomaly is variable. Sometimes the upper end extends for a variable length only to dis- appear in adhesions to the trachea ; the lower end is missing. ABNORMAL COMMUNICATIONS. Abno'rmal communications are always into the trachea. The esophagus may be present in its en- tirety and communicate to a greater or less extent with the trachea. 410 THE ESOPHAGUS Usually a communication with the trachea is accompanied by par- tial absence of the esophagus (Froelich). Symptoms. The symptoms depend upon the character of the deformity. It is obvious that in absence of the esophagus every swallow of food is rejected. When there is a communication with the- trachea every swallow of food is followed by a spasm of suffo- cation and coughing. If all the milk is not regurgitated we may conclude that there is a simple communication between the esoph- agus and trachea, and alimentation may be provided by means of a stomach tube. Treatment. The only treatment of these conditions is to do a gastrostomy ; and this operation on children offers little hope of success. Attempts to restore the missing portion of the esophagus by means of intestinal grafts are purely experimental. CONGENITAL STENOSIS OF THE ESOPHAGUS Congenital stenosis of the esophagus is never diagnosed in the infant. It is only later when the character of the food is coarser that difficulty in swallowing is noticed. The passage of an esopha- geal sound will indicate the location of the stricture, and esophagos- copy will indicate its character. The treatment consists in progressive dilatation, and persistent treatment assures a cure. FOREIGN BODIES IN THE PHARYNX AND ESOPHAGUS The arrest of foreign bodies in the pharynx and esophagus is a frequent accident of childhood. Buttons, marbles, coins, jack stones, fish bones, etc., are caught at certain points in the pharyngo- esophageal tube and produce a train of symptoms always distress- ing and sometimes fatal. Anatomical Peculiarities. There are certain anatomical peculiar- ities in the caliber of the esophagus which have an important bear- FOREIGN BODIES IN THE ESOPHAGUS 411 S- ing upon the impaction of foreign bodies. It must be remembered that there are three normal points of constriction (Fig. 140) : A. At its beginning opposite the cricoid cartilage. The pharynx, like a funnel, leads down to the narrow opening of the esophagus; hence foreign bodies are very apt to become impacted at this point. B. At the point where the left bronchus and the arch of the aorta cross at the level of the fourth dorsal vertebra. C. At the point where the esophagus passes through the diaphragm. At these points the caliber is a quarter of an inch narrower than elsewhere. As a general rule in children foreign bodies lodge in the cervical portion of the esophagus and it is only exceptionally that they are impacted fur- ther down. The point of election is just above the cricoid cartilage wedged in between the spine and the larynx. Symptoms. While the symptoms are quite vari- able, depending upon the character of the im- pacted object, there are in most instances an im- mediate spasmodic contracture and a secondary in- flammatory swelling which fixes the object at its point of arrest. Where the foreign body is caught at the junction of the pharynx and esophagus there are at first dyspnea and asphyxia resembling an obstruction of the air passage. Afterwards as the object settles in the esopha- gus there are well localized pain and dysphagia with or without regurgitation. These symptoms may be mild at first, but as inflam- mation sets in they become more intense. If relief is not obtained or if the patient is subjected to ill-advised and obsolete methods of removal, death may supervene from traumatic esophagitis. Fish bones usually cause only the symptom of pain, while coins may lodge in the walls of the esophagus for weeks without causing any dis- FIG. 146. THE ESOPHAGEAL TUBE SHOW- ING THE THREE POINTS OF CON- STRICTION. A. Opposite the cricoid cartilage. B. Where it is crossed by the left bronchus. C. Where it pass- es through the diaphragm. 412 THE ESOPHAGUS comfort in swallowing. It is well to note that the localized pain may persist even after the foreign body reaches the stomach, so that patients frequently affirm that they feel the presence of the object though it is no longer lodged in the esophageal wall. Treatment The use of the radiograph for purposes of diagnosis and the esophagoscope for removing the foreign body has relegated the various extractors to the medical museum. No longer is it necessary to grope blindly after foreign bodies in the esophagus. With the use of modern instruments of precision the removal is generally successful, and operation (esophagotomy) is seldom re- quired. The instruments, technique, and skill necessary for esoph- agoscopy limit its practice to those who are qualified by ex- perience for this special line of work. CICATRICIAL STENOSIS OF THE ESOPHAGUS Cicatricial stenosis of the esophagus is quite frequent in chil- dren and is produced by swallowing caustic fluids. Clinical Course. The clinical course of these burns of the esoph- agus is quite characteristic. It is worthy of note that immedi- ately after swallowing the caustic the burns of the lips, mouth, and pharynx may be quite insignificant, and yet the middle and lower portion of the esophagus may be profoundly affected. The longer contact with the esophageal tube has produced more tissue damage; hence the superficial damage to the tissues of the mouth is no guarantee of a benign prognosis. After the accident the child at first refuses to swallow liquids, but when compelled to do so 'by thirst the fluid is immediately re- gurgitated owing to spasm of the esophagus as the fluid comes in contact with the injured area. This spasm of the esophagus may increase and form a complete obstruction and the patient pass into a state of profound shock ; or the spasm of the esophagus may abate, the child gradually be able to swallow fluids, and in a few days the function of deglutition return to the normal. This happy outcome often gives the parents a false sense of security only to CICATHICIAL STENOSIS OF THE ESOPHAGUS 413 be followed later by a stricture due to cicatricial contraction. Then it will be found that after a few months symptoms of obstruction again appear. At first badly masticated food, then semi-solid food is rejected, and finally only fluids reach the stomach. If the con- dition is untreated the stenosis becomes progressively worse and the child dies from inanition. Diagnosis. The diagnosis is simple when the history is taken into consideration with the actual regurgitation of food. The loca- tion of the stricture is determined by passing an esophageal sound as large a sound as possible the smaller sounds are apt to catch in the folds of the mucous membrane. It must not be forgotten that in esophagoscopy we have an excellent means of determining the extent and shape of the constriction and the subsequent progress of the treatment. Exploration of the esophagus must be conducted with the greatest prudence. We are dealing with an injured tube whose walls are rendered inelastic and friable over the stenosed area, and ill-conducted instrumentation may result in death. Treatment. In recent burns of the esophagus the injured part must be put at rest for a few days. The spasm of the esophagus, which occurs when attempts are made to swallow fluids, is the best indication that nature resents forced deglutition. In the mean- time the child should be given saline injections per rectum at fre- quent intervals. After two or three days try small quantities of albumin water and milk by mouth. If spasm is still present it may be allayed by the administration of a small dose of morphin hypodermically. Sometimes a catheter may be passed into the stomach and nourishment introduced by this means. If these measures prove futile it will be necessary to do a gastrostomy. This operation in children is neither more difficult nor more dangerous than in the adult (Froelich). Through this opening milk or egg albumin water may be introduced by means of a catheter three or four times a day. After the nutrition of the child is assured, it will be necessary to consider dilatation of the esophagus. Three or four weeks after the initial accident esophagoscopy should be done to determine the exact nature of the lesion and the cautious passage of esophageal 414 THE ESOPHAGUS bougies should be commenced to prevent contractile stricture. If stenosis is already present progressive dilatation with esophageal bougies should be employed. Beginning with the smallest bulb that will pass, the size is increased every three or four days until a diameter of one centimeter is reached. The dilatation should never be forced, and the safest plan may be to practise dilatation under control of the esophagoscope or to cautiously nick the stricture with an esophagotome when it is particularly dense. In permanent stricture retrograde dilatation may be employed. "The stomach is opened and a strong linen string is passed through the stricture, one end of the string is brought out through the open- ing in the. stomach and the other through the mouth. The stricture is made tense by a conical bougie and is then divided by rapidly drawing the string up and down with a sawing movement. The string is withdrawn and the external wound closed. Recurrence is prevented by the frequent introduction of esophageal bougies." (Gottstein.) It must be remembered that a child affected with cicatricial stricture of the esophagus is never definitely cured by dilatation ; even when sufficient caliber has been obtained it is necessary from time to time to pass a bougie to prevent recurrence. SECTION XI THORAX AND SPINE CHAPTER LI CONGENITAL AFFECTIONS OF THE THORAX AND SPINE MALFORMATIONS OF THE THORAX Absence of the Sternum. Cases are reported of total or partial absence of the sternum, compatible with life. In such instances the anterior thoracic wall is incomplete and in the median line we note a simple membrane covered with integument. On each side, the ribs terminate by a free extremity or are connected with the ribs of the opposite side by a fibrous membrane which acts as a substitute for the sternum. Cleft-Sternum. It will be recalled that the sternum is developed in lateral halves. When, because of lack of development, the two halves fail to fuse in the median line we have a condition of cleft- sternum which may give rise to displacements of the viscera behind. Again, at the lower part of the sternum near the ensiform appendix in the median line, there sometimes exists a round orifice the sternal foramen sometimes large enough to admit the little finger. This orifice may establish communication between a mediastinal abscess and the exterior, or subcutaneous abscess may invade the cellular tissue behind the sternum. Pigeon Breast. Pigeon breast is an abnormal projection of the sternum beyond the level of the ribs. It presents an appearance as if the thorax had been pressed together from both sides, i. e., the transverse diameter is diminished and the anteroposterior diameter increased. On both sides of the sternum from the second to the eighth rib we find a depression or groove. 415 416 AFFECTIONS OF THE THORAX AND SPINE Many theories have been advanced to explain this deformity, but the real cause is not well understood. It is to be noted that this deformity is associated with the stigmata of rachitis such as beading of the ribs, bow legs, etc., and an abnormal softness of the bones is undoubtedly a necessary condition for its development, yet the special deformity remains unexplained. Pigeon breast as a rule is only a cosmetic defect and there is no increase of deformity in the process of growth. TREATMENT. This deformity may be considerably modified if treatment is begun early while the ribs and sternum are still soft. Deep breathing with manual compression of the thorax, anti- rachitic remedies, light gymnastics for developing the chest walls will assist in obliterating the deformity. Funnel Chest. Funnel chest is a sinking in of the anterior chest wall in the median line. It may vary from a slight groove to a de- pression deep enough to hold a man's fist. It is really a kyphosis of the sternum and in extreme cases markedly decreases the antero- posterior diameter so that the viscera are displaced. The cause of this deformity is probably intrauterine pressure. The chin, elbow, or foot pressing against the sternum in utero would be the plausible explanation of such a malformation. Yet it may be a developmental defect since its hereditary tendency is well authenticated. TREATMENT. The treatment of this defect is very limited. Deep breathing and light gymnastics for developing the chest may bring about improvement, but no perfect result has been reported. SUPERNUMERARY CERVICAL RIBS The most frequent appearance of this phenomenon and the most interesting from a surgical standpoint is that of the seventh cervical rib. It springs from the transverse process of the seventh cervical vertebra and may be found on one or both sides but unequally developed. Surgically, it presents an exostosis occupying the subclavian SPINA BIFIDA 417 fossa and independent of the clavicle. It may compress the vessels and nerves beneath the clavicle, causing pain and weakness of the upper extremity. It may produce distortion of the neck and spine, torticollis, and lateral curvature. On examination there is found a bony prominence above the clavicle, in association with which may be felt the pulsations of the subclavian artery. All doubt as to diagnosis will be cleared away by a radiograph. Treatment. If serious symptoms are present complete extirpa- tion of the rib should be performed. It is well worth noting that this anomalous rib is frequently adherent to the pleural cul-de-sac, and delicate dissection will be necessary to free it. SPINA BIFIDA Spina bifida is a hernia-like protrusion of the contents of the spinal canal through a congenital defect of one or more of the vertebral arches. The her- nia is formed by some of the spinal membranes and contains cerebrospinal fluid with or without the cord or nerve-roots. (Fig. 147.) Location. It is essen- tially a congenital bony defect of the spinal canal and is frequently associ- ated with other deformi- ties, such as club-foot, cleft palate, etc. While this FIG. 147. SPINA BIFIDA. congenital defect may oc- cupy any portion of the spinal canal, it is most frequently situated in the lumbosacral region, rarely in the cervical, exceptionally in the dorsal region. In very 418 AFFECTIONS OF THE THORAX AND SPINE rare instances the bony defect is situated anteriorly and there is a forward intrapelvic protrusion of the contents of the spinal canal. These cases are rarely diagnosed except during abdominal operations. The tumor-like mass is sessile or slightly pedunculated, present- ing a variable volume, usually not exceeding the size of an orange or tomato. The skin covering is thin, whitish, of a cicatricial aspect, and often umbilicated. It may be the site of nevoid stains or of an ul- cerated area through which oozes cerebrospinal fluid. The skin at the periphery of the tumor becomes thicker and is often encircled by a "collarette of hair." The sac of the hernial protrusion is formed from the arachnoid membrane since the dura mater participates in the bony defect. The content of the sac consists of cerebrospinal fluid with or without the cord or nerve roots. Spina bifida is frequently associated with hydrocephalus, which suggests a fundamental disturb- ance of the cerebrospinal circulation as the causative factor in these developmental defects. Anatomical Classification. Spina bifida may rationally be di- vided according to its anatomical characteristics. (a) Spinal meningocele contains only cerebrospinal fluid. It forms a globular tumor, usually pedunculated, and as the sac con- tains no nervous elements it is not associated with motor or sensory disturbances. (b) Myelomeningocele contains fluid with flattened cord and nerve roots spread out over the dorsal aspect of the sac. The tumor is flattened and umbilicated at the center. This form of spina bifida is associated with extensive defects of innervation caused by tension on the nerve roots (paralysis of lower extremities, bladder, and rectum). (c) Myelocystocele is a hernial protrusion due to fluid accumu- lating in the central canal (intramedullary), so that the hernia is formed by the distended cord itself lining the sac. The skin cover- ing is often strongly pigmented and covered with a growth of hair. This variety is frequently associated with other malformations; notably defects of the anterior abdominal wall, bladder, etc. Symptoms. The presence of a congenital tumor over the spinal canal, associated with nervous disturbances, should give us the key SPINA BIFIDA 419 to the character of the tumor. Note that the tension of the tumor varies with posture, and that its volume increases when the child coughs or cries. Pressure over the tumor causes swelling of the fontanelles, and sometimes a partial reduction of the tumor is fol- lowed by convulsions. In soft compressible sacs the bony defect may be palpated or it may be revealed by the X-ray. Functional disturbances vary according to the character of the tumor. In severe cases there are paraplegia and incontinence of urine and feces. Remember that all spina bifida have not the same structure, hence the diverse symptoms. FIG. 148. ULCERATING SPINA BIFIDA. Diagnosis. The diagnostic points are its congenital origin, its position, and its variable tension. A diagnosis of the variety of spina bifida is not very certain except by exploratory incision. Prognosis is grave. Life is constantly threatened through infec- tion of the meninges, rupture of the sac, and urinary sepsis. (Fig. 148.) The majority of cases die early. Those that survive are the meningoceles. Treatment. (a) Protect the tumor from injury by a suitable shield of leather or celluloid held by adhesive straps, (b) Advise operation unless it is contraindicated by extensive paralysis or hydrocephalus operation does not relieve paralysis. Explain to 420 AFFECTIONS OF THE THOKAX AND SPINE the parents that the gravity of the condition warrants the risk of operation and that the result may be fatal. Operation for meningo- cele has given the most favorable results; in other forms the results are deplorable. The success of the operation depends upon the char- acter of the tumor, the vitality of the child, and the simplicity of procedure. OPERATION. Have the patient's head low so as to anticipate sudden loss of cerebrospinal fluid. Make elliptical incision through the skin so as to excise the central portion. Separate the sac down to the pedicle. Open the sac, isolate nerve-roots if present, and replace them in the vertebral groove. Li- gate the base of sac with catgut, or, if too broad, su- ture and excise it. Close the defect by fascial flaps and suture the skin. Spina bifida occulta is a condition in which a bony defect is present without a protrusion of the contents of the spinal canal. There is a vertebral defect with- FIG. 149.-SPINA BIFIDA OCCULTA. (Phillips.) out the presence o f a tumor. The situation of the defect is in the lumbosacral region and is in- dicated only by pigmentation of the skin and a patch of hair, which often grows to such a length as to resemble a tail. (Fig. 149.) While many of these cases present no symptoms except tho cutaneous stigmata, there are others in which there is partial paraly- sis of the lower extremity bladder and rectum caused by a rudi- mentary development of the spinal canal, as shown by the presence of fibrous bands, which pass through the defect, connecting the lower end of the cord with the skin. As the child grows those bands pull upon the cord and cause the paralytic symptoms. This defect is often complicated by such neoplasms as lipomata, angio- CONGENITAL SACEOCOCCYGEAL TOIOIJS 4il mata, dermoids, etc., and when they develop inside the canal they produce pressure on the cord. TREATMENT. Unless symptoms of paralysis are present no surgical intervention is required. In the presence of a complicat- ing tumor, or of fibrous bands causing compression, their extirpa- tion is clearly indicated. CONGENITAL SACROCOCCYGEAL TUMORS Etiology and Pathology. Congenital sacrococcygeal tumors be- long to the group of teratomata. They may or may not be asso- ciated with meningocele. Their mode of origin is still under dis- cussion. One school claims that they are the result of misplace- ment of germinal fragments, while others contend that it is of bi- germinal origin, i. e., that such a tumor represents an incomplete monstrosity of twins. The data obtained from both the gross and microscopic examina- tion of these tumors gives evidence in support of either of these claims. Those who believe in the monogerminal origin hold that cell inclusions occur when the dorsal surface of the early embryonic mass folds itself to form what in the future is to be the spinal canal. The fact that the skin attaches itself very early in the sacrum, and may thus become inclosed below the cutaneous surface, is thought to be a strong reason for the occurrence of these dermoid-like tumors. On the other hand, the finding in these tumors of such forma- tions as a complete limb, portions of a skull, eyes, trachea, etc., is argued by the bigerminal advocates as proof that the existent fetus had in its early career included the products of another fecundated ovum. However it be, these growths are polycystic, have a fibrous basic structure, and contain various secretions, chiefly the fatty, grumous material so characteristic of dermoids. Because they sometimes contain neuroglia and ganglionic cells they have also been called 422 AFFECTIONS OF THE THORAX AND SPIXE neuroepitheliomata. In size they may vary from a pea to that of a child's head. (Fig. 150.) Situation. They are usually situated in the mid-dorsal line of the sacrum (which bone may at times be reduced to a mere shell of horseshoe shape) at its junction with the coccyx. If the tumor be at all large the coccyx is absent. Sometimes these tumors are situated in front of the sacrum or coccyx, and then give symptoms of intrapelvic pressure. Cases are on record where the latter growths have discharged their con- tents into the rectum. Steinthal quotes Kroner and Marchand FIG. 150. SACRAL TUMOR BEFORE OPERATION. (v. Bergmann, "System of the Practice of Surgery") in a very interesting report of a girl, 20 years of age, who had an anterior sacral meningocele, closely resembling a cyst of the broad ligament. This tumor was first aspirated, then opened and drained; death followed with symptoms indicating meningitis. Of considerable interest are those cases where a congenital fistula has existed in the sacral region, proving refractory to the ordinary surgical methods, but upon radical operation is found to communicate with a teratoma, either in the sacrum itself or in the presacral tissues. In one such instance, recently reported by Keen and Coplin, the X-ray demonstrated the presence of extra segments of lumbar vertebra besides fetal parts of the original teratoma. CONGENITAL SACEOCOCCYGEAL TUMOIJS 423 From the data of their case the existence of a triple monstrosity may well be assumed. Symptoms. These tumors are most frequently found in girls. They are sessile or pedunculated, grow to a considerable volume, and are prone to ulcerate. It must be remembered that these tumors not only grow externally, but also grow internally, encroaching on the pelvis, and often compromising both the rectum and bladder. Diagnosis. In diagnosing these tumors we must eliminate spina bifida by the absence of its car- dinal symptomatic features re- ducibility, compression, tension in fontanelles, and paralyses. Always make a rectal examina- tion in these cases to recognize any intrapelvic prolongation of the growth. Treatment. The only treat- ment of any avail is operative ; and in uncomplicated cases the results are excellent (Fig. 151). Make the skin incisions ample to get at the large pedicle and placed as far as possible from, the anal orifice. Observe care- fully hemostasis of the pedicle, which is large and receives ves- sels from the median sacral ar- tery. Dissection of the intrapelvic lobe must be conducted with prudence. Dress the wound with aristol and collodion, and, over this, gauze and oil silk. Change the dressings frequently in order to keep the wound scrupulously clean, as an infection of the wound may be fatal. FIG. 151. SHOWING KESULT AFTER RE- MOVAL OF SACRAL TUMOR. '424 AFFECTIONS OF THE THORAX AND SPINE PARACOCCYGEAL FISTULJE In many subjects there exists a slight cutaneous depression in the sacrococcygeal region, which never gives rise to unpleasant symptoms, but remains simply a harmless malformation. When, however, the depression is deeper, the hair and sebaceous glands may be the site of irritation, inflammation, suppuration, and the formation of a fistulous tract. If the pus is abundant it dissects up the neighboring tissues, produces secondary fistulous tracts, and presents a picture which may simulate osteopathic fistulse. These fistulse are to be differentiated from those of bony origin by the his- tory and the evidence of cutaneous invagination. Treatment. The application of caustics is of little value. Care- ful dissection of the fistulous tract and the walls of the primary focus is the only guarantee of a cure. CONGENITAL DIAPHRAGMATIC HERNIA Congenital diaphragmatic hernia is rare. To appreciate this condition it must be recalled that the diaphragm is developed in two segments: the anterior portion is formed by the primary dia- phragm, or septum transversum; the posterior portion develops much later, and in the process of occlusion it is the space at the costovertebral angle that is the last to be covered in. Thus develop- mental defects in the anterior portion of the diaphragm are rare ; they are also rare on the right side because of the presence of the liver. Location. The principal positions in which these defects are found are: (a) At the costovertebral angle, (b) At the normal orifice between the sternal and costal portions of the diaphragm which transmits the internal mammary artery. Hernias in this position pass into the anterior mediastinum, (c) At the esophageal opening, (d) At the opening for the sympathetic cord. Hernias never occur at the opening for the inferior vena cava. CONGENITAL HERXTA OF THE LUX({ 4->r> Two conditions may be present according as the hernia has a sac or not. If the pleura and peritoneum are fused at the edge of the orifice the contents of the abdomen can pass into the thorax without a sac (false hernia). When the defect in the diaphragm is closed by a union of the pleura and peritoneum the hernia possesses a sac formed by the united layers of pleura and peritoneum (true hernias). The true diaphragmatic hernias are comparatively rare. It is well to remember that these congenital hernias are usually on the 'left side and that they may contain all the abdominal organs with the exception of the bladder and kidneys rarely the liver. Symptoms. Most .of the children affected with this form of hernia die soon after birth. In the cases that survive the true anatomical condition is not suspected until later, when symptoms of intestinal obstruction present, usually attributed to causes other than that of developmental defect of the diaphragm. However, such a possible defect should be kept in mind when there is retraction of the abdomen ; when the left half of the thorax gives a tympanic note on percussion and intestinal gurgling on auscultation, when the heart is markedly displaced to the right, and the patient presents symptoms of dyspnea, cyanosis, digestive disturbance, .pain, vomiting, and constipation. Treatment. Theoretically surgical intervention is indicated if the diagnosis is possible. Since reduction has been found impossible through a laparotomy wound the operation should contemplate a resection of the ribs, using the sternocostal articulation as a hinge for the flap, so that the hernia may be approached from the thoracic side. After a reduction of the hernia, an attempt should be made to close the diaphragmatic defect. This is not always possible by means of sutures, and some authors advise sewing the stomach in the hernial orifice. CONGENITAL HERNIA OF THE LUNG In certain congenital defects of the chest wall there may be present such hernial protrusions of the lung as to constitute a monstrosity and be incompatible with life. 426 EMPYEMA As a rule, however, the child is born with a defect of the thoracic wall and the hernia is developed some days later. Us presence is marked by a small elastic tumor, which increases on expiration and decreases on inspiration. The tumor is reducible and when compressed between the fingers gives the sensation of gaseous crepitation. Treatment consists in reducing the mass and retaining it by means of a compress and bandage. OHAPTEE LIT EMPYEMA Empyema (purulent pleurisy) is very frequent in children and presents special points of interest which merit careful consideration. Empyema is usually met with in very young children (before the age of five). It is even frequent in the new-born where it is rarely diagnosticated and is revealed only by autopsy. Empyema in the child is usually the result of a pneumococcus infection. It is true that it may be the result of a tuberculous, a staphylococcus, or streptococcus invasion, but the pneumococc'iis variety, following a lobar or bronchopneumonia, is typical of child- hood. Empyema in the child is usually an acute process. We rarely encounter the chronic type. The thorax of the child is supple and elastic, there is a tendency for the parietal and visceral pleura to approximate, which opposes the formation of a suppurating cavity with rigid walls. Hence, the thoracoplastics of Estlander, etc., or the decortication of the lung is rarely if ever needed. Special Features of Symptoms. Where there is a considerable collection of pus absolute dulness is the natural consequence; not- withstanding this, vesicular breathing is persistent. Again the elasticity of the child's thorax renders the swelling and deformity marked in comparing the two sides. Aside from the above exceptions the local and constitutional TREATMENT 427 symptoms do not differ from the manifestations of the same disease in the adult. Diagnosis. The use of the antiseptic puncture will eliminate diagnostic errors. Prognosis. The prognosis of pneumococcus empyema is most favorable. Spontaneous cures have occurred: (a) by absorption of the pus; (b) by discharge into the bronchi, when it is vomited and coughed up; (c) by discharge through an external opening after perforation of the thoracic wall (empyema necessitatus). While this spontaneous evolution of empyema in the child is not at all exceptional, it should not deter the surgeon from prompt evacuation of the pus by operative measures. A high mortality is the penalty of procrastination, or at best a crippled lung, or con- traction of the chest, which results in a pronounced scoliosis. Treatment. Early operative intervention is the only rational procedure in order to prevent septic poisoning and secondary de- formities. In the management of these cases there are two distinct methods to be employed, each method having its special indications. The choice of procedure requires surgical discrimination, together with a proper estimate of the patient's vital index and therapeutic pos- sibilities. A. RESECTION OF RIB. Resection of rib is indicated in strong children above two years of age. Operation. A general anesthesia is not only superfluous but dangerous. A local anesthesia (novocain or stovain) is sufficient for the operation, which requires only a few minutes. The opening into the chest should be made at the lowest point. A safe guide is to make the incision in the posterior axillary line on a level with the angle of the scapula. Always make a pre- liminary aspiration over the point selected for incision to demon- strate the presence of pus. A short incision should be made down on to the rib, the perios- teum separated, a periosteal elevator inserted under. the rib, and about a half to three-quarters of an inch of rib removed by the costotome. 428 EMPYEMA After removal of the rib the pleura is opened by a sharp-nosed artery clamp and en larked to admit the index finger. The inserted finger regulates the flow of pus so that it is removed slowly. Irrigation is not only superfluous, it is useless and often harmful. Two rubber drainage tubes should be placed in the wound and securely fastened to prevent them being sucked into the pleural cavity an accident not infrequent and always disagreeable. (Fig. 152.) The duration of the discharge varies in the most favorable cases it ceases after a few weeks, in unfavorable cases it may ex- ist for a long time. The earlier the resection is made the quicker the lung expands and suppura- tion ceases. The drain should be removed when the discharge is so trivial that it probably comes from the drainage tract. B. INTERMITTENT A s P i K A- TION. In very young children with lowered vitality the safest procedure is to employ repeated aspirations with the injection of a two per cent, solution of forma- lin in glycerin. Method. Insert an aspirat- ing needle about two fingers' breadth below the upper border of pus and withdraw about two ounces of fluid. Kepeat the aspiration daily, going down one intercostal space as the pus recedes until no more pus is found. Every third day inject an ounce of a two per cent. solution of formalin in glycerin. This method gives excellent results in small children since it removes only a small portion of pus at a seance and thus allows the lung to slowly expand and fill the space. On the other hand a total removal is followed by rapid exudation and 152. DRAINAGE TUBES IN WOUND AFTER RESECTION OF RIB. BILATEKAL EMPYEMA 429 an enormous loss of serum into the empty cavity, which is a serious drain on the vital resources. After-treatment is a very important adjunct to prevent thoracic deformities and subsequent scoliosis. Breathing and gymnastic exercises should be begun early and even some thoracic brace may be necessary to hold the trunk in a normal erect position. Bilateral Empyema. Bilateral empyema is found almost ex- clusively in children. The two sides may be affected simultaneously or a few days apart. The rule of treatment is the same as in uni- lateral empyema, except operation should never be done on the two sides at one seance. Double empyema is a grave condition, the operative risk is great, and its management requires surgical discrimination. CHAPTEK LIII CUEVATUEE OF THE SPINE In considering the curvatures of the spine due to disturbances of growth, one must not lose sight of the important role which the biological facts assume in explaining certain abnormal deviations. In the process of evolving a biped from a quadruped certain skeletal changes and adaptations were imposed by the erect posture. It is obvious that this posture makes special demands upon the spinal column in carrying weight and preserving equilibrium. It is always a critical time in the life of the child when it begins to walk and its skeletal tissues assume the weight-bearing functions of the erect posture. If, in addition to this, the build- ing material of the skeleton has undergone pathological changes, as in rachitis, it is obvious that the bones are deprived of that hard- ness and power of resistance needed to carry weight and act as levers. Hence it is that this abnormal plasticity under the pressure of weight and the active pulling of the muscles results in curvatures of the bones. The important role which rachitis plays in altering the building 430 CURVATURE OF THE SPINE material of the skeleton and thus threatening growth and further development is not confined to the first years of childhood; it casts its shadow into the period of puberty and acts as a latent stigma when increased activity is demanded by the profound evolutionary changes to which the body is subjected. THE NORMAL EVOLUTION OF THE SPINAL COLUMN In the quadruped the spinal column is straight, but as the erect posture is assumed certain compensatory curves are produced, which, result in the permanent physiological curves of the spine. At birth the spinal column is straight, but when the child begins to sit up the weight of the head causes the back to bend, and a primitive spinal curve with the convexity backward is produced ; when, how- ever, the child begins to stand and walk, the effort to maintain equilibrium brings into play the muscles which act to produce compensatory curves, and thus is produced the normal contour, which consists of a long curve in the dorsal region with its convexity backward, and the two compensatory curves in the cervical and lumbar regions with the convexity forward (Fig. 153). These curves vary greatly within physiological limits and are modified by habit, occupation, and sex. Again, it is evident that the normal position of the spinal column is maintained by the continuous coopera- tion of the muscles thus the posterior muscles (erector spinaa) endeavor to increase the lordosis, while the anterior muscles of the abdomen (rectus abdominis, etc.) endeavor to increase the kyphosis of the column. Note also the influence of the position of the pelvis upon the form of the spinal column. The pelvis is rigidly fixed to the spinal column through the sacro- FiG.153. THE iliac articulation; movement of the pelvis is accom- TOTTB or THE plished through the hip joint. The flexor muscles of SPINAL COL- UMN. the hip lower the anterior part of the pelvis and the ABNOKMAL POSITIONS OF SPINAL COLUMN 431 pelvic plane approaches the vertical; the extensors of the hip lower the posterior part of the pelvis and the pelvic plane becomes more or less horizontal. In forward bending of the pelvis, equilibrium is maintained by a strong lumbar lordosis, which bends backward the whole spinal column. (Note the marked lordosis in the ultra-femi- nine figure where there is a congenital forward tilt of the pelvis.) When the pelvis is tilted backward equilibrium is maintained by a lumbar kyphosis. Hence the inclination of the pelvis has an impor- tant influence upon the form of the spinal column, and its importance will be observed later in the treatment of abnormal positions of the spinal column. ABNORMAL POSITIONS OF THE SPINAL COLUMN A. Kyphosis (Deviation with a Posterior Convexity). By this is meant an habitual attitude characterized by curvature of the spine with the convexity backward, which is either an increase in the physiological curve, or a curve due to some pathological state. We note in this connection: (a) Rachitic kyphosis, most marked in the lower segment under the form of a dorsolumbar kyphosis, found in early childhood, (b) Postural kyphosis "round shoul- ders" most marked in the upper dorsal region, seen in later child- hood and adolescence. RACHITIC KYPHOSIS. Rachitic kyphosis is mainly caused by permitting rachitic children to assume the sitting posture too early. The inclination toward kyphosis is seen when the child is carried on the arm; a too high pillow or a too soft bed will cause an in- creased kyphosis of the soft rachitic spinal column. (Fig. 154.) While the kyphosis of early childhood is usually not fixed and disappears when the child lies down, yet it may become rigid and result in an habitual kyphotic curve. When we consider that fre- quently a later scoliosis is developed from a rachitic kyphosis, the importance of early treatment is obvious. 432 When a disposition toward kyphosis is observed the child should be placed on the abdomen; when the legs are lifted a pronounced lordosis will be observed in the normal spine; in rigid kyphosis we note a pronounced convexity. Prophylaxis. When a child exhibits a tendency toward rachitis special care should be exercised in regard to posture. These chil- dren should lie on an even, hard mattress. They should not be carried on the arm; nor should they sit in the baby carriage with the knees extended. Treatment. After the kyphosis has been developed the con- dition can be best coun- teracted b y postural treatment which encour- ages lordosis. Place the child on the belly with a pillow under the chest and thighs, and compel him to reach up for playthings. The over- stretched and weakened muscles of the back should be strengthened by daily massage. In older children the use of a rocking chair or other appropriate gymnastics Fro. 154.-RACHmc KYPHOBIS. (Spitzy.) ^^ ^ prescribed> POSTURAL KYPHOSIS. "BOUND SHOULDERS" OF SCHOOL CHIL- DREN is a form of kyphosis which appears during the school years and is most marked in the upper dorsal vertebrae. The origin of this deformity is muscular weakness. It will be recalled that the spine is held in its proper physiological curve by a proper inn sen! ar balance; there must be continuous action of the erector spiime and the flexors and extensors of the hip. In children with a weakened muscular system the steady pull of the muscles is tiresome, hence they relax and allow the spinal column to assume a position in ABNORMAL POSITIONS OF SPINAL COLUMN 433 which the muscles are passive hence the kyphotic position of the dorsal and lumbar vertebrae. Again this muscular relaxation overstretches the posterior part of the spinal column and with it the attached ligaments, the inter- vertebral cartilages thin out in front, the vertebrae are pressed to- gether anteriorly, and the way is paved for diminished movability of the column and ultimate stiff- ness and fixation. It is also to be noted that the flexors and extensors of the hip play an important role, since re- laxation of these muscles causes the pelvis to drop backward until the inclination of the pelvis is so diminished that the lumbar lordo- sis is obliterated. These children also allow the shoulders to sink downward and forward to relieve the tiring action of the shoulder muscles. The ab- dominal muscles are lengthened and thinned, resulting in the "pot belly" of abdominal ptosis. They are the thin, frail, weakly chil- dren, with round shoulders, con- tracted chests, protuberant abdomens, who later become the neuras- thenic men and women. (Fig. 155.) Therefore, it" is obvious that the muscles are the important factors in "round shoulders" and it is the recognition of this fact that forms the basis of rational treat- ment. Treatment. The rational treatment of this deformity must contemplate improvement in the general nutrition combined with some system of gymnastic exercises which will straighten the muscles of the back, shoulders, and hips. A list of such exercises can merely be suggestive; they must FIG. 155. THE FAULTY POSTURE RE- SULTING IN THE "POT-BELLY" OP ABDOMINAL PTOSIS. (Reynolds.) 434 CURVATURE OF THE SPINE be modified or extended to suit the individual needs. First, the child should be taught proper posture. The relation of posture to human efficiency is not sufficiently appreciated, as is well illustrated in the faulty posture of the majority of men and women. The relaxed posture with the forward head, round shoulders, hollow chest, protuberant abdomen, with the viscera crowded down in front of the pelvis, is the prevalent posture. This chronically bad posture brings about mechanical disturbance in the thoracic and abdominal viscera, which in time leads to me- chanical and bacterial changes and finally to chronic disease. This faulty posture is corrected neither by braces nor belts, but by a regen- e r a t e d muscular system. Proper posture is therefore the first essential in the treatment of these cases. The child must first be taught to have a proper mental conception of the military position (head erect, chin drawn in, shoul- ders thrown back, abdomen retracted) the reverse of the "round shoulder" posture. (Fig. 156.) After this mental picture is fixed by precept and example it should be crystallized into habitual mus- cular expression by proper gymnastic exercise and such sports as contribute to its permanency. Some modification of the "setting-up" exercises of the military school is an admirable drill to follow. Such exercises as stretch and bend the trunk, performed while the hands are behind the back, are admirable. (Fig. 157.) Breathing exercises develop the chest and increase muscular nutrition. (Fig. 158.) Such sports as swim- FIG. 156. FAULTY AND CORRECT POSTURE. ABNOKMAL POSITIONS OF SPINAL COLUMN 435 FIG. 157. BENDING EXERCISE WITH HANDS BEHIND THE BACK FOR THE CORRECTION OF ROUND SHOULDERS. FIG. 158. BREATHING EXERCISE FOR THE CORRECTION OF ROUND SHOULDERS. The arms are drawn back in inspiration, and forward in expiration. 436 CUKVATUKE OF THE SPINE ming, rowing, and skating are of special advantage. If there is a tendency to fixation of the spine special exercises must be prescribed to stretch the anterior part of the column, such as hanging 011 rings or bars. Whatever exercise is prescribed its efficacy will be in proportion to its regularity and the demands which it makes upon sunshine. and fresh air. Parents and teachers should give special attention to the correct sitting posture of the child and this attention should begin by providing a proper kind of chair, and a desk of suitable height. The ma- jority of chairs in the home are made for ornament rather than utility. Few are hygienic even for the adult, none are provided for the child. He must either stand or conform in a pro- crustean fashion t o the choice of his elders. (Fig. 159.) The disproportion be- tween the chair and the child, the lack of proper back rest, the use of unsuitable desks all contribute to foster the kyphotic position. The use of braces should be discouraged. All braces have some objectionable points, the most serious of which is that they prevent the action of the muscles involved and as a result fa- vor atrophy of disuse. The best brace is a well-developed muscle. B. Lordosis (Deviation with a Posterior Concavity}. Lordosis is a much less important deviation than kyphosis and is usually symptomatic of some disease or deformity either of the spine or FIG. 159. FAULTY SITTING POSITION. ABNOEMAL POSITIONS OF SPINAL COLUMN 437 its adncxa. Lordosis is observed as a result of hip-joint disease, congenital dislocation of the hip, spondylitis, etc. The TREATMENT of these lordoses is the treatment of the pri- mary cause if this is curable then the lordosis will disappear in those cases in which there is no ankylosis. The lordosis of young rachitic children and scoliotic children is simply an expression of the general bony, muscular, and ligamentous weakness, which must be corrected by appro- priate therapeutic and hygienic measures. C. Scoliosis (Contin- u o u s Laterial Devia- tion). By the term scoliosis is meant an habitual lateral devia- tion of the spinal col- umn accompanied by a rotation of the vertebral bodies. Thus it will be noted that scoliosis is a double lesion it is really a distortion, the elements of which are a lateral deviation of the spine and a rotation of its segments. The spine FlG i 60 ._scoLiosi8. is not only bent, it is Note ,he ain twisted. These two facts are basic in appreciating the nature of scoliosis. As Bradford and Lovett observe, scoliosis is not a disease in any true sense, but a distortion of growth. The deformity, appears and is developed during the growing years, the largest number of cases occurring between the 7th and 10th years. It is a very common affection statistics show that about 25 per cent, of school children are scoliotic. It seems to be more frequent in girls than in boys. As a rule, the main curvature involves only 438 CURVATURE OF THE SPINE one part of the column, while above or below we observe compen- satory curves which are directed to the opposite side and are due to an attempt to reestablish spinal equilibrium (Fig. 160). These curvatures in the spine are followed by changes in the contour of the trunk; on the convex side the trunk is arched out, on the concave side the trunk is arched in ; thus the hip of the concave side is more prominent and is spoken of as "high hip" while in curvatures of the upper segment we note that the shoulder of the convex side is more prominent "high shoulder." ETIOLOGY AND PATHOLOGY. It is obvious that the erect posture makes special demands upon the spinal column in carrying weight and preserving equilibrium "lateral curvature of the spine is one of the penalties of the erect posture." It is essentially a deformity of growth, due to pressure abnormally distributed upon a plastic spine. It is not easy, however, to always recognize the direct cause of this deformity. Those commonly found are: (a) Congenital Scoliosis. Not so infrequent as previously sup- posed. It is undoubtedly due to the fetus being held in a faulty intrauterine position, caused by a deficiency of liquor amnii. (b) Rachitic Scoliosis. Many pronounced forms of scoliosis are to be traced back to rachitis. (c) Static Scoliosis. Inequality in the length of the limbs causes obliquity of the pelvis, and in order to keep the trunk in a state of equilibrium, the spinal column must develop a compen- satory curve. This condition is observed in congenital dislocation of the hip, hip disease, paralysis, and pronounced deformities affect- ing one leg. (d) Empyema, scoliosis occasionally follows a chronic empyema in which the function of the lung is obliterated by adhesions and -the side of the chest retracted. As a result, the function of the unaffected lung is increased and the convexity of the curve is directed toward the healthy side. (e) Paralytic scoliosis the result of anterior poliomyelitis. The most pronounced cases are the result of unilateral paralysis of the muscles of the trunk. Here the convexity of the curve is again directed toward the healthy side since the function of the disabled ABNORMAL POSITIONS OF SPINAL COLUMN 439 side of the thorax is compensated by increased activity on the sound side. (f) Occupation Scoliosis. A large number of all scolioses are to be traced back to certain occupations that require habitual inclina- tion of the trunk. This is observed in stone cutters and carpenters, where the activity of the muscles is exercised in one-sided move- ments in violinists, draftsmen, school children carrying books on one side, false position in writing, etc. PATHOLOGICAL ANATOM Y. Although the pathological anatomy has been carefully investigated there is still much that is unknown in this interesting affection. It must be remembered that we are dealing with a deformity, not a disease; and that the pathological factors are the results of the deformity in the vertebrae and its secondary effects upon the trunk and its contents. In scoliosis existing for a short time there is slight deviation from the normal the scoliosis is functional, there is "lateral curva- ture without rotation." In long existing scoliosis there are struc- tural changes which modify the form and function of the spinal column. Lateral inclination is not the only factor, there is also vertebral torsion. The intervertebral cartilages become wedge- shaped, and the bodies of the vertebras rotate so that they look toward the side of the convexity while the spinous processes point toward the concavity. A consideration of these changes is practical only in so far as the clinical conditions are concerned. Among the most striking secondary deformities of lateral curvature is that of the thorax. The attached ribs must necessarily follow the direction given by the distorted vertebra; and it must be recalled that these verte- brae are not only bent but twisted; thus it is that on the convex side the ribs are drawn backward and their angles project beyond the spinous processes, "sometimes covering and concealing them," while on the concave side the ribs are turned forward, brought closer together, and the intercostal spaces diminished so that the ribs may be in actual contact (Fig. 161). The result of this rota- tion is to considerably diminish the capacity of the chest on the con- vex side, so that the greater part of the breathing must be done 440 CURVATURE OF THE SPINE with the lung of the concave side. These various changes in the form of the thorax correspondingly modify its capacity, dis- place and compress its contents, and compromise their vital func- tion. This compromised pulmonary function is evidently the cause of the frequently observed tuberculous infiltration of the apices of the lung. Musser found in 100 cases of scoliotic children 53 affections of the apices of the lung. In pronounced scoliosis there is dis- placement of the heart, while the great vessels and esophagus following the course of scoliotic curve are more or less displaced. Intercostal neuralgia is of special practical interest. It is usually found on the concave side and is the result of pressure on the nerves from the im- pinging ribs. SYMPTOMS. The onset of scoliosis is usually slow and insidious. The earliest intimation that these patients give is the characteristic slouching pos- ture which they assume. They seem to sit or stand without any muscular grip on themselves. The shoulders are re- laxed, they always lean to one side or the other, one shoulder is higher than the other. Usually it is when this faulty position becomes permanent that these patients are first seen by the surgeon. Examination. These cases should be examined with great care and with complete exposure of the posterior aspect of the trunk. The clothes should be removed to the iliac crests in girls the skirt may be fastened by a belt around the trochanters, or a skirt with an elastic top band should be provided. The patient should stand with the back to the light, the hair lifted from the neck and the FIG. 161. DISTORTION OF THE RIBS IN LATERAL CURVATURE. (Bradford and Lovett.) ABNORMAL POSITIONS OF SPINAL COLUMN 4-11 arms hanging naturally. First, inspect the posture of the patient and note any deviations from the normal even slight lateral in- clinations will produce some asymmetry of the trunk. !Mark with a soft pencil or ink the spinous processes, the iliac crests, and the angles of the scapula. Note : Any differences in the height of the shoulders ; any pro- jection of the scapulae; the relation of the arms to the sides, and the form and size of the two "brachio-thoracic triangles" ; any dif- ference in the height of the hips; any fullness on one side with a corresponding concavity on the other. Compare the line of the spinous processes with a plumb-line suspended behind in the line of the cleft of the buttocks ; any lateral deviation is evidence of scoliosis. The flexibility of the spine should be tested. Kirmisson insists on the importance of not neglecting the examination of the feet since scoliosis is often connected with flat foot ; also the lower extremities should be measured "in order to make sure that there is not any difference in length between them which cannot be ex- plained by any other pathological condition." Careful records of the deformity should be kept for purposes of comparison in the future history of the case. Whenever pos- sible, photographs of the back should be made with the patient stand- ing behind a thread screen. Elmer's method of recording is simple and convenient. "A strip of adhesive plaster three inches wide is laid along the spine from the vertebral prominences to the sacrum. The spinous processes are marked and outlined (Fig. 162). The plaster is then removed, backed with brown paper, labeled with name and date, and filed for future comparison." (Willard.) DIFFEEENTIAL DIAGNOSIS. There is a possibility of confound- ing lateral curvature with early Pott's disease, especially those atypical cases of spinal caries with a lateral tilt. But they should not be difficult to differentiate since one presents a clinical picture of disease, the other of deformity only. In Pott's disease the spine is rigid, the patient cannot stoop or bend, there is not a lateral curve but an angular tilt to one side, and pressure over the spinous '442 CURVATURE OF THE SPINE processes produces pain. A correct diagnosis is of the highest im- portance, since the gymnastic exercises so important in scoliosis would give disastrous results in Pott's disease. PROGNOSIS. It must be remembered that scoliosis is a de- formity of growth, hence the earlier the deformity appears the worse the prognosis. Those cases which appear at an early age are more serious than those which develop in adolescence. It should be well understood that scoliosis can never be corrected without treatment. It is a grave error to treat these cases lightly and assure the parents that the child will outgrow the deformity. Spontaneous cure of a true scoliosis does not occur. The fate of a scoliotic child de- pends upon early and long-con- tinued treatment. PROPHYLAXIS. In the pre- vention of scoliosis the family physician plays an important role. The discovery of the de- formity when well advanced may be left to parents or nurse, but the discovery of the tend- FIG. 162.- METHOD OF APPLYING AD- HESIVE STRIP TO BACK ON WHICH THE LINE OF SPINOUS PROCESSES Is TRACED WITH PENCIL FOR FUTURE REFERENCE. (Willard.) ency to deformity should be an- ticipated by the supervising care of the family physician. He should be on the lookout for faulty posture and examine from time to time those children com- mitted to his care in whom a tendency to deformity is suspected. Special vigilance should be exercised regarding the proper posture of the child. The relaxed posture with the forward head, round shoulders, hollow chest, protuberant abdomen is the forerunner of spinal deformity. ABNORMAL POSITIONS OF SPINAL COLUMN 443 Good nutrition, strong muscles, correct position while standing and sitting, proper seats and desks for school children, open-air games which do not require one-sided muscle work are the best pro- tection against the formation of scoliosis. TREATMENT. As soon as the diagnosis of scoliosis is made there is presented a definite and difficult problem, for the solution of which the family physician is usually responsible. The ques- tion arises whether all these cases require such treatment as can be obtained only in an orthopedic clinic or even under the super- vision of an orthopedic surgeon. Is there any portion of these cases that can be properly treated by the physician without special orthopedic training? When so large a proportion as .25 per cent of all school girls have scoliosis there is need of some treatment adapted to at least a portion of these cases which can be effectively carried out under the supervision of the family physician. If we adopt Lovett's classification of: (a) Functional or postural scoliosis cases without marked or- ganic change, and (b) Structural or habitual scoliosis cases in which a perma- nent change has taken place in the spine and soft parts. We have a rational pathological classification and one which naturally divides the cases into those which may be treated under the supervision of the family physician and those that require the facilities of the orthopedic clinic and the skill of the orthopedic surgeon. Thus the treatment of postural or functional scoliosis may be properly instituted by the physician without special ortho- pedic training, providing he possesses what is called the "orthopedic temperament," which combines perseverance and patience. The treatment of postural scoliosis is essentially hygienic and gymnastic. The first consideration is to eliminate all contributory causes, such as errors of vision, which compel children to incline the head ; differences in length of legs, which should be corrected by building up the short leg with a high sole; flat foot, etc. Next, carefully avoid excessive bodily or mental fatigue. Ar- 444 CURVATURE OF THE SPINE ; range the day so that the periods of activity arc shortened, the periods of rest increased. The hours of study should be so arranged that they are frequently interrupted by periods of relaxation. The chief aim should be to teach the child proper posture, and to give it permanent muscular expression, through persistent development, by means of proper gymnastic exercises. These exercises are neither complicated nor costly. They are within the means of all patients and the scope of every physician and gymnasium teacher. Remember that braces and corsets have no place in the treatment of postural scoliosis. The best brace is a well-developed muscle. The scheme of gymnastics here outlined is merely suggestive, it must be modified to meet the needs of the individual case. Dur- ing the first month the daily drill should be no longer than a half hour. Afterwards it may gradually be increased to one hour. Whatever exercise is prescribed, its efficacy will be in proportion to its regularity and the demands which it makes upon sunshine and fresh air. Suggestive Exercises. (a) Proper posture, best inculcated by teaching the military position, and by using some modification of the "setting-up" drill in the military school. (b) Deep breathing develops the chest, promotes flexibility, and increases muscular nutrition. (c) Stretching exercises, such as are obtained by hanging on rings or bars, will have an excellent effect in stretching and straight- ening the column. (d) Dumb-bell exercises are highly recommended, not merely for developing the muscles of the trunk, but to cultivate all the muscles of the body and thus attain a condition of perfect muscular coordination. Techner's system of exercises with light dumb-bells, as described in the Annals of Surgery, August, 1895, is an excellent guide. (e) Swimming is an excellent exercise for straightening the vertebral column and at the same time develops the chest by the enforced deep breathing. These exercises should be continued for ABNORMAL POSITIONS OF SPINAL COLUMN 415 several months and the condition of the spine regularly inspected and recorded. Treatment of Structural Scoliosis. It must be remembered that in these cases a permanent change has taken place in the spine and its soft parts, and to restore flexibility and an improved position is a problem which requires the resources of an orthopedic clinic and the supervision of an orthopedic surgeon. The methods employed have for their aim reduction of the de- formity and retention of the corrected position until permanent re- covery is obtained by building a "muscular splint" through proper gymnastic exercises. Reduction of the deformity is accomplished by means of: (a) Gymnastic exercises which bend back the scoliotic part of the spinal column, stretching the shortened soft parts of the concave side and strengthening the overstretched erector spinse of the con- vex side. For this purpose the side-bending exercises are useful. (b) Corrective apparatus. Numerous appliances for correct- ing scoliosis have been devised, some of which are very complicated and expensive. Such apparatus is intended to reduce the deformity and strengthen the muscles on which the improved position relies for support. This apparatus is available only in the orthopedic clinic and under the direction of the orthopedic surgeon. (c) Passive stretching. Suspension by means of Sayre's ap- paratus straightens the spine and reduces both the curvature and the rotation. The results, however, are futile unless the advantage gained is secured by proper muscular support. (d) Plaster jackets and corsets. It must be remembered that the corrective action of the corset is slight; its function is solely to retain the improved position; hence, it is a temporary expedient to be used only while an efficient musculature is being developed, i. e., between the exercise periods when the muscular power is not sufficient to prevent a further sagging of the trunk toward the con- vex side. It is also indicated when intercostal neuralgia is present. The fitting and prescribing of these corsets should be left to the ortho- pedic surgeon. The important point to remember is that there is 446 TUBERCULOSIS OF THE SPINE nothing curative about a corset, it is simply a temporary splint, and that the corset without exercise is futile. Rachitic Scoliosis. In rachitic scoliosis, occurring most fre- quently from the fifth to the tenth year, the importance of general treatment to improve the body's building material is quite evident. Again, in very young children, we cannot count on the efficacy of gymnastics, hence the most efficient means is prolonged rest on a Bradford and Lovett frame. CHAPTEE LIV TUBERCULOSIS OF THE SPINE (Pott's Disease) Clinical Picture. Tuberculosis of the spine presents the same pathological process as tuberculosis of bone in other regions. We see here the same orderly pathological events which in an uninter- rupted march present successively a typical picture, viz. : the forma- tion of typical tubercle, typical granulation tissue, typical caseation, suppuration, and fistulization. The clinical picture varies because of the peculiar anatomical structure and relations of the spine. It is therefore necessary to grasp certain fundamental structural facts concerning the spine to clearly comprehend the details of the phenomena which the tubercu- lous process here presents. Clinically the spine is a flexible bony tube which lodges the spinal cord. Furthermore, this flexible bony tube is composed of a number of superimposed vertebral segments, each articulating with the other through a distinct joint and all bound firmly together by strong ligaments. Though little movement is permitted be- tween any two vertebra (the atlas and axis excepted), yet the col- lective motion between them all is considerable. Finally, the spine supports and connects the three important cavities of the body: the cranial, the thoracic, and the abdominopelvic. CLINICAL PICTURE 447 It must be also noted that the structure of the individual verte- brae plays an important part in tuberculous pathology. A vertebra consists of a body composed of spongy bone, and an arch consisting of several processes which are largely composed of compact tissue, and connected with each vertebra are four joints with synovial cavities. It is evident that the spongy vertebral body is the fertile fi~ld for tubercular proliferation, and the multiple joints are gate- ways for its dissemination. In speaking of Pott's disease, there- fore, we refer to tuberculosis of the bodies of the vertebrae. Pott's disease is frequently found in childhood, specially from the second to. the fifth years just the time when the vertebrae are assuming their weight-bearing function. Furthermore, Spitzy shows that the vertebra? most used are the vertebras most frequently affected in small children, the lower thoracic vertebrae are chiefly affected because in the kyphosis of sitting they are most depressed and pushed out; in adults, the lumbar vertebras, because they carry the most weight. Rarely are the cervical vertebrae attacked in children. The tuberculous process spreads through the body of the verte- bra in a characteristic manner, the granulation tissue going on to caseation and often suppuration. The intervertebral fibrocartilag- inous discs are destroyed and the next vertebra invaded. Thus, while the weight-bearing bodies are destroyed, the articular pro- cesses behind remain intact, but the solidity of the spinal column is undermined, finally yields to the superimposed weight, and col- lapses, forming a posterior angulation known as kyphosis (Fig. 163). When a single vertebra is affected the kyphosis is angular; when several vertebrae are involved the protrusion is more or less curved. When the lateral portion of a body is affected and gives way there will occur a lateral tilt (scoliosis). Hence the first characteristic of Pott's disease is deformity of the spine (hump-back). But the primary deformity is followed by secondary compen- satory curves which may entirely change the normal contour. Thus an angular deformity in the lumbar spine will be followed by a lordosis of the dorsal vertebrae; a deformity of the cervical column 448 TUBERCULOSIS OF THE SPINE will modify the normal kyphosis of the dorsal column. Thus the deformity of Pott's disease may so modify the normal curves of the spine that they are reversed. Note again that the spine sup- ports and connects the three important cavities of the body: the cranial, the thoracic, and the abdominopelvic. It must be evident that a deformity in the dorsal column will seriously affect the thorax and its viscera. Thus the chest is shortened and its depth in- creased (pigeon-breast). Some- times the lower border of the ribs is pressed against the iliac crests. It is evident that compression of the thoracic contents interferes with proper oxygenation of the blood and seriously compromises proper nutrition. Besides this it is evident that the abdominal vis- cera are also compressed and dis- placed by the deformed thorax. The further progress of the dis- ease is marked by the appear- ance of abscesses, the character- istic of which is to point in a region far removed from their origin. The progress of the abscess depends upon gravity, and the disposition of the aponeurosis, since it burrows along the fascial planes in the path of least re- sistance. In the cervical region the pus may burrow backward and appear under the skin, but as a rule it pushes forward and forms a retro- pharyngeal abscess; sometimes it burrows beneath the dee]) fascia, compressing the trachea and esophagus, and invades the medi- astinum; or it may pass into the posterior mediastinum along the great vessels and into the thigh. In the dorsal region the pus may break through the pleura into FIG. 163. KYPHOSIS OF POTT'S DISEASE. SYMPTOMS the lung; or it may burrow along the intercostal spaces and appear on the anterior surface of the chest ; or it may travel down in front of the bodies of the vertebrae and, passing beneath the internal arcuate ligament, enter the sheath of the psoas muscle, thence to the iliac fossae, and pass beneath Poupart's ligament; or it may descend into the pelvis, pass through the great sacrosciatic foramen, and point on the back of the thigh. In the lumbar region the pus usually follows the course of the psoas muscle, descends to the iliac fossa, passes beneath Poupart's ligament, and reaches the thigh just below the groin, to the outer side of the femoral vessels; or it may make its way into the ischio- rectal fossa and form a perirectal abscess. Paralysis. Since the spine is a flexible bony tube which lodges the spinal cord, it is evident that the cord may sometimes become involved by extension of the inflammatory process or by direct pressure of diseased bone. The causes of the compression vary. It may be an inflammatory thickening of the dura; or the granula- tion masses may invade the spinal canal. Sometimes the canal is narrowed by ,an encroaching abscess or sequestrum. Rarely is the compression due to the angular deformity. Whatever the cause of the compression there results a lesion of that part of the cord distal to the pressure and often there remains a sclerosis with secondary ascending and descending degenerations. Symptoms. It is evident from the foregoing pathology that the. three conspicuous symptoms of Pott's disease are: deformity of the spine, abscess of spinal origin, and paralysis ; yet none of these are early symptoms and the latter is inconstant or absent; hence they cannot be considered in the early diagnosis which is so essential in arresting the progress of the disease and obtaining a cure without deformity. The disease must be recognized not by the major, but by the minor symptoms. The early symptoms are the result of disturb- ance of the function of the spine. The normal mobility of the spine is arrested and the spine is immobilized by tension of the muscles, hence the: Symptoms of Attitude. These are the result of nature's effort 450 TUBERCULOSIS OF THE SPINE to form a muscular splint by which the spine is put at rest. Hence muscular spasm causing rigidity of the spine is one of the earliest and most characteristic symptoms. !Note, therefore, that these patients make every effort to limit movement in the spine; there is no desire for activity; the whole attitude is one of spinal rigidity and anxious care to protect the diseased part. This is observed in the peculiar gait which is characterized by the guarded manner in which the patient walks, the feet touching the ground with great care, the weight being borne upon the toes. In sitting the patient makes an effort to support the trunk by grasping the seat or the arm of the chair. In standing the nearest objects are seized for support; and if the child is asked to pick up something from the floor the back is held rigid while the hip and knee joints are bent; when the pelvis is sufficiently lowered for the child to seize the object the erect posture is carefully resumed by placing the hands on the anterior surface of the thigh. (Fig. 164.) In cervical disease there may be rigidity resembling torticollis, and the head is often supported by the hands while the elbows rest upon something. In dorsal disease there is an appearance of abnormally square shoulders. These children do not want to be handled or seized by others they avoid everything that can cause movement in the distressed vertebral joints. Pain. The pain of Pott's disease is due to irritation of the roots of the spinal nerves and is usually referred to the peripheral ends of the nerves in their area of distribution. Thus occipital neuralgia, pain in the chest and abdomen, the "belly-ache" of dorsal caries are frequent sources of diagnostic errors. There may also be pain over the affected vertebrae, provoked by direct pressure or by percussion. As Kirmisson observes, "Method- ical pressure on the spinal processes sometimes gives no results, while a percussion exercised on the same processes gives pain. This is quite easy to understand, for it is not the spinal process itself which is affected, but rather the corresponding vertebral body. Thus a sharp percussion may be sufficient to give a shock to the SYMPTOMS 451 focus of the disease, while pressure alone is not enough to cause it The use of both these means of examination must therefore never be omitted." Finally it may be said that early pain of Pott's disease is a referred pain. This pain is lessened in repose, exaggerated by FIG. 164. CHARACTERISTIC ATTITUDE OF THE PATIENT IN PICKING UP AN OBJECT FROM THE GROUND SHOWING THE RIGIDITY OF THE SPINE IN POTT' DISEASE. (Spitzy.) fatigue, and augmented by pressure or percussion over the spinal processes. Deformity. In advanced Pott's disease the most characteristic symptom is the deformity or angulation of the vertebral column (humpback) caused by the collapse of the affected vertebral bodies. The hump is most accentuated in the dorsal region, where there is a normal backward convexity, and less pronounced in the cervical and lumbar regions. In some cases the destruction of the vertebral bodies is so irregular that a lateral deviation is produced when \z \.' \ ki-i r i iv 1 <- 452 TUBERCULOSIS OF THE SPINE this occurs in the early stage of the disease, before the angular de- formity appears, it may easily be mistaken for a scoliosis. Abscesses. The tendency of these abscesses to gravitate to a region far removed from their origin has been noted in the pathol- ogy. It is obvious that the symptoms of these abscesses vary with the region in which they localize. Thus cervical abscesses will give symptoms of difficult respiration and deglutition ; others will present pressure symptoms in the mediastinum, causing dyspnea and cyanosis ; pressure on nerves, causing pain in the lower extremities ; psoas contraction, causing flexion, abduction, and external rotation of the thigh, which simulate hip disease. The rupture of these abscesses is followed by discharging fistulas which, in the course of years, find a fatal termination in amyloid degeneration of the viscera. Pott's paralysis is usually a paralysis of the lower limbs, due to compression of the cord as described in the pathology. It is well to note that this nervous phenomenon may be one of the earliest symptoms before the appearance of the deformity. The motor nerves are affected long before the sensory nerve paths are damaged. The patella reflex is increased, ankle clonus is present. Long after motor paresis is established there follows paralysis of the bladder and rectum, causing incontinence of urine and feces. Examination of patient is extremely important since a diag- nosis cannot be made without an observation of the objective symp- toms. For this purpose the child should be stripped naked and the symptoms of attitude carefully noted. Observe the patient's atti- tude in walking, standing, sitting down, and getting up. Ask the child to pick up some object from the floor. These movements will bring out the evidence of spinal rigidity. Have the child lie on his belly on a table and try to hyper- extend the spine by lifting the legs from the table. Normally the spine will be flexed by this movement (Fig. 165) ; in Pott's disease the spine is held rigid and the contracted muscles cause it to be lifted in one piece. (Fig. 166.) Carefully note the movements of the head ; any limitation of them should cause suspicion. If deformity is present a permanent ft 3 J J r , DIAGNOSIS 453 FIG. 165. METHOD OF DEMONSTRATING NORMAL FLEXIBILITY OF THE SPINE. record should be made for future reference by placing the child on his abdomen and molding a lead strip to the spine. The outline is traced on cardboard, cut out, and refitted to the spine. Diagnosis. E a r 1 y diagnosis is essential for the prevention of defor- mity and the serious se- quela which mark its later stages. There is no disease whose mim- icry of visceral, disor- ders covers so wide a range or offers so fertile a field for diagnostic errors. As Willard observes, "The infection is frequently treated for rheumatism until the kyphosis appears; for pharyngitis, bronchitis, pneumonia, pleurisy, gastritis, appendicitis, nephritis and cystitis." The early diagnosis must be made by mus- cular spasm and reflex pain. The X-ray will be serviceable only in diag- nosing disease of the cervical vertebrae. The tuberculin test may be a valuable diagnostic ad- junct. An excellent rule to follow is: when in doubt give the patient the benefit of the doubt b y immobilizing the spine. Such a procedure FIG. 166. METHOD OF DEMONSTRATING RIGIDITY OF THE SPINE. will cause no regret. 454 TUBERCULOSIS OF THE SPINE Differential Diagnosis. It is evident that when the disease is well advanced there is no difficulty in diagnosis. But at the onset, with the multiplicity of referred pains, and the wide range of their activity, there seems to be offered an extensive field for differential diagnosis. Yet if the chronicity of the tuberculous process and its accompanying malaise be given due weight; if its expression in the spine, invariably manifest by muscular spasm and spinal rigidity, be properly considered, many of the disorders which it simulates will be promptly eliminated, and the number of pathological con- ditions with which it is likely to be confounded will be greatly reduced. (a) Lateral Curvature. If the Pott's deformity is not median but lateral a scoliosis may be suggested. But scoliosis has none of the characteristics of a disease. It is a deformity characterized not only by a lateral curve but by a certain amount of rotation of the vertebrae which gives prominence to the ribs on one side and makes the shoulder of one side higher ; but there are no muscular rigidity, no pain, no abscess, no paralyses. (b) Rachitic Jcyphosis never presents the angular deformity of Pott's disease. There is a long posterior curve which can be re- duced by manipulation; there is no muscular rigidity, and other signs of rachitis are usually present. (c) Wry-neck. When cervical disease is present there may exist a sideward rotation of the head that causes a torticollis posi- tion. Yet in wry-neck complete painful fixation is absent, only the opposite movement is hindered. In cervical Pott's disease every movement is hindered. (See Congenital Torticollis or Wry-neck, pp. 396-397.) (d) Hip Disease. In the psoas contraction of Pott's disease the movements of extension, adduction, and inward rotation are limited; in hip disease the hip is fixed and motion is limited in all directions. Besides, absence of pain in the hip joint and muscular rigidity of the spine will clear up the diagnosis. (e) Sarcoma presents symptoms that closely resemble tubercu- losis of the spine. Sarcoma is extremely rare, rapidly progressive, is marked by a more diffused and irregular deformity, and is TKEATMENT 455 accompanied by agonizing pain due to pressure upon the posterior nerve roots, which is not relieved by rest. (f) Traumatic spondylitis may be followed by an angular de- formity which closely resembles Pott's disease. The characteristics of this disease have been described by Kiimmel. It is a post- traumatic condition in which the symptoms appear long after the original injury, and is marked by pain along the peripheral nerves, sometimes paralyses, and the gradual development of an angular deformity which simulates the deformity of tuberculous spine. It is evident that such a train of symptoms may make diagnosis ex- tremely difficult. The history of the case, the absence of muscular spasm and abscess formation, and the greater amount of tender- ness will exclude Pott's disease. Prognosis. Pott's disease runs an extremely chronic course. Prognosis depends not only upon the promptness and efficacy of the treatment but upon the vital asset of the patient's tissues. When deformity is present, it remains permanent and the ultimate cure of the disease is at the price of a hump-back. The presence of paralysis does not necessarily affect the prognosis unfavorably. With the subsidence of the disease the pressure effects may abate and the cord be restored to its normal function. It is well to remember that of all the tuberculous affections of bones or joints Pott's disease takes the longest to cure. It is im- possible to definitely state the length of time over which the treat- ment must extend. In cervical disease not less than two years, in dorsal and lumbar affections four or five years, or more. Treatment. Here, as in all tuberculous processes, we are treat- ing the local expression of a general condition; hence it is of para- mount importance to so improve the tissues by general hygienic measures that the tubercle bacilli will cease to thrive. GENERAL TREATMENT consists in proper nutrition, unlimited sunshine and fresh air. LOCALLY, the indications in Pott's disease call for rest, which implies the removal of all weight and as complete immobilization of the spine as possible. This simple principle of rest persisted in for many years offers the only hope for a favorable result. Com- 45G TUBERCULOSIS OF THE SPINE plete rest for the spine can best be secured by recumbency in bed, which relieves the superimposed weight, and by some fixation ap- paratus which completely immobilizes the spine. It is evident that this treatment cannot be satisfactorily carried on in an out-patient clinic. Unless the social position of the patient permits this treatment being satisfactorily carried out at home, the patient should be treated in a suitable institution, otherwise the end results cannot be the best for life and deformity. GENERAL RULES (1) Absolute recumbency when the lesion is in an acute stage; or in the presence of abscess or paraplegia ; and continued until all inflammatory phenomena have subsided. In general the time required is from twelve to eighteen months. (2) Ambulatory treatment when on careful examination the patient is free from pain and all inflammatory phenomena, and the formation of ankylosis at the seat of the lesion is well advanced. The patient may then be allowed to assume the upright position after the application of some fixation splint for spinal support. (1) Treatment by recumbency is most satisfactorily accom- plished by the use of the Whitman-Bradford canvas-covered gas-pipe frame (Fig. 167), which is described by Whitman as follows: "It is made of ordinary galvanized gas-pipe or steel tubing of a small di- ameter. It should be about four inches longer than the child, and about four-fifths as wide, the lateral bars corresponding to the articu- lar surfaces of the four extremities with the trunk. * ' The cover should be of strong canvas suitably protected in the center by rubber cloth. This is applied and drawn tight by means of corset lacings and straps. Upon this two thick pads of felt are sewed; these should be about seven inches in length and about an inch in thick- ness, placed on either side of the spinous processes at the seat of the disease, thus protecting them from pressure, fixing the parts more firmly and increasing the leverage of the apparatus. TREATMENT 457 "The child, wearing only an undershirt, stockings, and diaper, is placed upon the frame and is fixed there usually by a front piece or apron similar to that used with the spinal brace. As soon as the patient has become accustomed to the restraint one begins to over-extend the spine by bending the bars from time to time, with the aim of actually separating the diseased vertebral bodies and obliterating all the physiological curves of the spine, so that the body shall be finally bent backward to form the segment of a circle. The greatest convexity is at the seat of the disease, and as the head and lower extremities are on a much lower level an element of gravity traction is present in some instances, while the support of the spine, as a whole, is much more comprehensive than when FIG. 167. THE WHITMAN-BRADFORD FRAME. (After Whitman.) the body lies upon a plane surface." (Whitman's Orthopedic Surgery. ) The patient is kept continuously recumbent. The skin of the back is kept scrupulously clean by turning the child and bathing the back daily with dilute alcohol, and dusting with powder. The urine and feces are received in a bed-pan. The use of the canvas-covered frame overcomes the principal objection to the recumbent treatment, since it offers an easy method of transportation, and the patient can thus receive the benefits of being kept almost continuously out-of-doors. To this bed frame can be easily attached traction for the head when the disease is in the cervical region, and in cases of paralysis traction on both legs may be added. The deformity is reduced gradually and without pain by the use of the felt pads on each side of the diseased vertebral spines, 458 TUBERCULOSIS OF THE SPINE and the spine is gradually suporextended backward and the pressure on the diseased vertebral bodies relieved by the progressive arching of the gas-pipe frame (Willard). (2) Ambulatory treatment may be safely begun three months after the cessation of all acute symptoms. The upright position, however, must not be assumed without some form of mechanical support to the spine. This sup- port to the weakened spine may be furnished by plaster jackets or steel braces. Spitzy's suggestion to permit the patient to gradually resume the upright position is worthy of commendation. After a plaster jacket is applied he allows the pa- tient out of bed, but not to walk. The child is permitted only to crawl, so that the vertebral column may still be free from weight. After this form of locomotion has been practised for a few months the child is allowed to walk. For after-treatment a steel brace similar to the Taylor appa- ratus is highly efficient. (Fig. 168). By this means the spine is splinted from pelvis to shoulders by two steel uprights on either side of the vertebral spines, joined above and below by cross-pieces and held in position by shoulder straps and by a canvas apron extending from the top of the sternum to the pubis. Perineal straps may be added if there is a tendency for the brace to slip upward. The brace should be worn day and night. Great care must be observed to prevent excoriation of the skin by, first, having the brace accurately fitted and properly padded; and, second, by removing the splint daily while the child is lying down so that the skin may be carefully HI f . 168. THE TAYLOR BRACE FOB SUPPORTING THE SPINE. TREATMENT 459 bathed and powdered. When the disease is in the cervical or upper dorsal region a head support should be used either a Sayre's jury- mast attached to the plaster jacket, or the addition of an oval ring supported on a post attached to the upper part of the Taylor brace (Fig. 169). The Application of Plaster Jackets. The application of an efficient plaster jacket is an art. Hence, the efficiency of a plaster jacket depends upon the skill with which it is applied. An ill-fitting plaster jacket is worse than useless, for it only adds in- sult to injury. It hides without helping the defect, and thus de- ceives both physician and pa- tient. However clearly defined the principles of the plaster jacket, or the details of its ap- plication, what give it worth are the judgment and skill of the surgeon who applies it. The aim of the plaster jacket is to act not only as a splint to the spine but to secure fixation in an improved position. The old method of applying the plas- FIG. 169. SUPPORT FOR THE HEAD AT- TACHED TO THE UPPER PABT OF THE TAYLOR BRACE. ter jacket with vertical suspen- sion has fostered the erroneous idea that suspension pulled the vertebra apart, and the support of the jacket prevented the vertebrae from coming in contact. The whole effect of vertical suspension is to reduce the physiological curves without affecting the kyphos. Hence the improved position is more readily attained by applying the jacket while the patient is in a position of horizontal suspension or recumbency. For this purpose the "hammock frame" of Brad- ford and Lovett has been found to be admirably adapted (Fig. 170). 460 TUBERCULOSIS OF THE SPINE Upon this the patient rests face downward, the arms are ex- tended, and the hands grasp the frame above. The roller bandage is passed through the slits in the canvas on each side and includes the canvas, which is cut away after the bandage is completed. FIG. 170. THE "HAMMOCK FRAME" OF BRADFORD AND LOVETT. (Fig. 171.) The principle of this simple apparatus must be well understood to be appreciated. It is well summarized by Lovett in "Keen's Surgery": "The FIG. 171. METHOD OF APPLYING PLASTER JACKET IN THE BRADFORD-LOVETT FRAME. (Ware.) cloth is fastened to a rectangular frame of gas-pipe, at one end firmly, and at the other by means of a rod attached to the other side of the frame fastened to a screw and chain, by which means TEEATMENT 4G1 the hammock can be made either tight or loose. * * The jacket is then applied as far as the level of the apex of the deformity and allowed to harden. The hammock is then loosened, hyper- extending the patient and straightening the upper part of the spine. This is carried to the point of slight discomfort and the jacket completed. In this way a hyperextension is obtained directly at the seat of disease." The Calot jacket is one of the most effective forms of ambu- latory support, but, contrary to the author's teaching, it is difficult to apply. As shown in Fig. 172, it is essentially a plaster jacket which combines fixation of the neck and shoulders with that of the pelvis. The front is cut away and a window is cut in the back FIG. 172. THE CALOT JACKET WITH OPENING OVER KYPHOS FOR THE INSEBTION OF COTTON-PADS TO DIMINISH THE DEFORMITY. (Ware.) over the kyphosis, as illustrated, through which pads of cotton wadding are forced and held in place by adhesive plaster. The trunk is in this way forced forward and the deformity dimin- ished. This treatment of the kyphosis is repeated at intervals of two months. The Application of Braces. While the plaster jacket is cheap and readily applied, it has many disadvantages which render it inferior to the brace. After a time the plaster jacket becomes loose and ceases to be an accurate or adequate support to the diseased spine. Besides this, it is hot and dirty and does not readily permit inspection of the back or adjustment to the modified shape of the spinal column. It is evident that these objections do not apply to the adjustable brace, which in many cases will be found the pref- 462 TUBERCULOSIS OF THE SPINE erable form of support. The efficiency of the brace depends upon the accuracy of its construction and the skill with which it is ad- justed. It is evident, therefore, that the construction and applica- tion of the brace should be under the direction of an orthopedic surgeon specially fitted by training and experience. In ordering a brace an outline of the spine should be made with the patient lying prone. This is done with a pliable metal strip laid upon the spine and accurately fitted to its curves from the neck to the sacrum. The molded metal strip is carefully transferred and laid on its side upon card-board and the outline traced to serve as a guide in the construction of the brace. After the brace is completed its accurate adjustment and proper fitting require the skill that is acquired only by experience. OPERATIVE TREATMENT. Dr. Russell A. Hibbs has recently proposed an operation for Pott's disease which aims to produce "a fusion of the posterior aspects of the vertebrae, to obliterate motion of the vertebral articulations over the diseased area, and to relieve pressure on the involved bodies, thereby hastening the cure and preventing deformity." The author proposes to accomplish by operation what nature attempts to do, viz., to eliminate motion of the diseased joints by an extraordinary bony growth. The author describes the operation as follows: "A longitudinal incision is made directly over the spinous processes through the skin, supraspinous ligament, and periosteum, to the tips of the spinous processes. The periosteum is split over both the upper and lower borders of the spinous processes and the laminae, and stripped from them to the base of the transverse processes." The spinous processes are partially fractured and used for bridging the gap between the vertebne (Fig. 173). "The lateral walls of periosteum and of the split supraspinous ligament are brought together over these processes by interrupted chromic cat-gut sutures. The skin wound is closed by silk, and a steel brace applied, with the space between the uprights increased somewhat at the site of the wound so as not to make pressure upon it" (Annals of Surgery, May, 1912). The author reports a num- ber of cases with excellent results. TREATMENT 4(53 TREATMENT OF COMPLICATIONS Abscess. It has already been observed that the characteristic of these abscesses is to point in a region far removed from their origin. It is obvious that the super- ficial collection of pus is but the terminus of a long suppurating tract, which no operation, however thorough, can cleanse, and which in opening becomes the gateway of secondary infection and possible death. The treatment here, as in all tuberculous abscesses, is strictly conservative. Under the expectant treatment many of these abscesses disappear spontaneously. When the abscess approaches the surface it should be aspirated under aseptic precautions, its contents re- moved by suction, and injected with a five per cent*, emulsion of iodoform and glycerin. This is repeated as often as the pus accumu- lates and discontinued when the fluid with- drawn becomes serous in character. When the abscess becomes acute prompt incision is indicated. Retropharyngeal abscess demands prompt evacuation since it interferes with respira- tion and deglutition, and if it discharges spontaneously into the pharynx it may give rise to asphyxia and septic pneumonia. These abscesses may be evacuated by an in- cision through the pharynx (with the head hanging low to prevent the pus getting into the larynx), or, better still, by an incision along the posterior border of the sternomastoid muscle below the level of the mastoid process. The incision is deepened by blunt dissection until the cavity of the abscess is reached. Pott's Paraplegia. The treatment of the paralysis is recumb- ency with traction. Internal remedies, electricity, and counter- irritation are of little value. In paralyses resisting all conservative treatment, where the indications are vital, the operation of laminec- FIG. 173. LATERAL VIEW OF THE TRANSPOSED S P i N o u s PROCESSES. (Hibbs.) 464 TUBERCULOSIS OF THE SPINE tomy may be contemplated. The operation, however, is grave and the results are not encouraging. Suboccipital Pott's Disease. Under this term is included tuber- culous inflammation of the articulation between the occipital bone and the atlas and the atlas and axis. It is not a special disease of childhood, but is frequently observed during this period. It is evident that the gravity of this disease is due to its proximity to the medulla and the tendency to spontaneous dislocation, causing sudden death. The pain is intense, radiating along the neck and toward the shoulder; it is increased on moving the head; hence these patients hold the head in a state of fixation, support the head with the hands, and rather than rotate the head they turn the eyes or the whole body, while the head is immobilized by the muscles. Should abscess form it may point at the back of the pharynx, the posterior border of the sternomastoid muscle, or the subclavian triangle. The treatment is recumbency with extension during the acute stage. Later immobilization by an efficient head brace or a Calot support. In summing up the treatment of Pott's disease the judicious remarks of Bradford and Lovett are well worth accentuating: "The proper treatment of Pott's disease is not the application of any method, the use of any corset or brace, but the employment of such means as are efficient for carrying out the object aimed at." ' * * "In the treatment of these cases the sur- geon should be familiar with the advantages to be gained by all methods, and should employ each as the case demands, and for such a length of time as the circumstances of the case may require, or combine the different methods as may be advisable." TUBERCULOSIS OF THE SACROILIAC JOINT Tuberculosis of the sacroiliac joint is rarely observed in chil- dren ; it may be secondary to Pott's disease. The usual tuberculous process goes on to abscess formation, which is often the first symp- tom which calls attention to the disease. The location of the joint TREATMENT 465 is such that the pus may find its way to remote parts; along the psoas muscle to the iliac fossa, or groin ; through the sciatic foramen to the buttock ; or along the sacrum and coccyx to the rectum, where it may appear as a periproctitic abscess. Symptoms. Pain, due to weight-bearing, or pressure on the sciatic nerve. Pain may be provoked by deep abdominal pressure toward the sacroiliac synchondrosis, or by rectal palpation; or by flexion of the thigh while the leg is extended. Spitzy regards pain on pressing the pelvic bones together as a pathognomonic sign and in conjunction with abscess the diagnosis is positive. There is discomfort in walking, freedom of gait is lost, short steps are taken to avoid pelvic motion, and the patient stands with the weight thrown toward the sound side, producing a lateral curvature. Diagnosis. The diagnosis is not always easy, it may be con- founded with Pott's disease of the lumbar spine and hip disease. Attention is called to the pathognomonic sign of Spitzy pain on pressing the pelvic bones together. An X-ray plate will be the best protection against mistakes. Prognosis is bad. The anatomical conditions are such that ab- scess may go on for years, invading the pelvis and consuming the vital resistance of the child. Treatment is not satisfactory. The most that can be done is to aspirate the abscess formation and inject with iodoform emulsion. Immobilize the pelvis and leg of affected side in a plaster cast. Put a thick-sole shoe on the sound side and let the patient walk with crutches. Operation in children is scarcely to be considered. SECTION XII ABDOMEN AND PELVIS CHAPTER LV CONGENITAL AFFECTIONS OF THE ABDOMEN Imperfect development of the anterior abdominal wall may re- sult in the absence of a portion of the wall, so that the viscera are exposed and unprotected; or a lack of union in the median line may be evidenced by a congenital hernia, which may vary from one of small size to a protrusion containing all the movable viscera. The highest grade of malformation presents a fissure involving abdomen, bladder, and intestine. These cases, however, are not viable or operable and have no practical interest for the surgeon. Since the umbilicus is the entrance for the embryo's nutrition and the means of communication between mother and child, it is the part that is closed last, and is a special center for congenital defects. MECKEL'S DIVERTICULUM Clinical Anatomy. Meckel's diverticulum represents a portion of the omphalomesenteric duct which has not closed. As a result there remains a diverticulum or tube similar to the appendix, which is attached to the ileum in the vicinity of the ileocecal valve (the distance varies from several inches to two or three feet). This diverticulum may give rise to certain conditions of great practical interest to the surgeon. 1. It may remain attached to the intestine and hang freely in the abdominal cavity as a blind diverticulum. This is the form of diverticulum described by Meckel, attached to the convex free bor- 466 MECKEL'S DIVERTICULUM 467 der of the intestine in the vicinity of the ileocecal valve. (It is rarely attached near the mesenteric border.) Its length varies from one to three inches and it communicates with the cavity of the in- testine. It is evident that this form of diverticulum may give rise to internal strangulation either by the adhesion of its tip to other loops of intestine or by forming adhesions to the abdominal wall. The authors have successfully operated on a case of intestinal obstruc- tion caused by a diverticulum adherent to the abdominal wall about which the intestines rotated, forming a complete volvulus. Even when the diverticulum hangs free in the abdominal cavity it may become the site of an acute inflammation (diverticulitis) from foreign bodies or intestinal infection, and resemble appendi- citis in its symptomatology. 2. It may remain patent wholly or in part and attached to the umbilicus, giving rise to several important pathological conditions.. If the canal is open throughout its entire extent there results a fistula which discharges mucus or feces. After the cord has dropped off a small cherry-red mass is found at the umbilicus with a dimp- ling at the center through which a probe can be passed for several inches and from which is discharged at first mucus and later on fecal material. The velvet-like mucous membrane leads to an easy recognition of the nature of this condition. This eversion of the mucosa may precede a very troublesome condition ; for as the child cries and strains a hernia of the mucous membrane forms, and as the fistulous opening enlarges the intestinal wall itself is dragged out, and a prolapsus of the small bowel results in acute strangulation. If the diverticulum persists as a cord inside the abdomen, it may remain so during life without causing trouble; or, on the other hand, it may be the cause of intestinal strangulation. Umbilical Cysts. If the canal adjoining the umbilicus only remains open, and the secretion within the unobl iterated portion accumulates, a cyst is formed which lies between the skin and aponeurosis; or if the deeper portion of the duct is involved an intraperitoneal cyst may be formed. Umbilical adenoma is caused by the adenoid tissue of the 468 AFFECTIONS OF THE ABDOMEN diverticulum or its remains, which forms a small, red, mulberry- shaped tumor at the umbilicus. These tumors are pedunculated arid have no lumen, by which they are distinguished from diverticu- lous fistula complicated with prolapse of the mucosa. Diagnosis. The diagnosis of pathological lesions in infants in the region of the umbilicus is not only important, but often very complicated. When the diverticulum is patent and a fecal fistula exists the diagnosis is simple, but this condition is extremely rare. It is usual to find only a slight mucopurulent discharge through a small opening. Under such circumstances it will be necessary to know whether the discharge comes from a fistula of the diverticuium or from a fistula of the urachus. When it is possible to pass a probe through the fistula valuable information may be gleaned from the direction which the probe takes. In fistula of the urachus the direction is toward the bladder. Note the reaction of the discharge. Acid reaction suggests urinary components and fistula of the urachus ; alkaline reaction makes a Meckel's diverticulum more probable. Methylene blue (subcutaneous injections) may be used as a diagnostic measure. When a fistula of the urachus is present blue urine will be observed coming from the opening. It is well to note that umbilical cysts are rare and that their diagnosis presents no difficulty. Umbilical adenomata must be differentiated from a patent diverticulum with an eversion of the intestinal mucosa, and also from an umbilical granuloma. Note that adenomata have no orifice at the center, while a diverticulum with a prolapsed mucosa has a central orifice which is recognized on its surface. And if the in- testinal wall itself is herniated there is either a furrow surrounding the central mass or two orifices. While the granuloma and adenoma have no orifice or lumen, yet the granulomata are flatter, softer, more of a pink color, and secrete pus ; while the adenoma is more prominent, bright red in color, and secretes mucus. It is well to be sure about the diagnosis before excising such growths, as there is always danger of cutting a loop of intestine. MALFOKMATIONS OF THE URACHIJS 469 Furthermore, in all cases of intestinal obstructions in children with other deformities, such as hare-lip, cleft palate, etc., always recall the possibility of an existing Meckel's diverticulum. Treatment. In cases of patent diverticnlum or cyst of the diverticulum, the canal should be extirpated through a small incision through the median edge of the rectus muscle. The entire canal to its junction with the intestine should be removed, the stump in- verted and covered over with Lembert sutures. Granulomata and adenomata should be simply excised according to the usual surgical technique. As Cullen observes it is important to ligate the pedicle of an adenoma as it usually contains vessels of goodly size; and further, in all such cases the parents should be cautioned to watch the child carefully, because in a certain percentage of these children a Meckel's diverticulum exists and is firmly attached to the umbili- cus. If at any time signs of intestinal obstruction develop an exploratory section should at once be performed. MALFORMATIONS OF THE URACHUS The urachus is normally obliterated about the middle of intra- uterine life, but in certain cases it remains wholly or partly open and gives rise to urinary fistula? of the umbilicus or to cysts of the urachus. Urinary Fistulae of the Umbilicus. Urinary fistula? of the um- bilicus although quite rare are found more frequently in boys than girls. As soon as the cord is cut the permeable urachus is opened and a congenital urinary fistula is established. When the natural urinary outlet is unobstructed there are only a few drops of urine which ooze through the fistula. If, on the contrary, the normal outlet is obstructed by a phimosis or a mem- branous diaphragm of the urethra, all the urine passes through the fistulous opening. It is obvious that this canal may easily become infected and the discharge become purulent, and that eventually the bladder itself may participate in this infection. The DIAGNOSIS is made by the character of the discharge. The 470 HEENIA urinary components are recognized by the acid reaction, by the appearance of blue discharge after the subcutaneous injection of methyl blue, and by the passage of the probe in the direction of the bladder. The TREATMENT consists in removing any obstructions if they exist to the normal urinary outlet. Do not waste time by employ- ing such futile methods as compression or the actual cautery, but plan to excise the fistulous tract to its connection with the blad- der, where it usually broadens out like a cone. Suture the bladder and close the abdominal wound with drainage. Cysts of the Urachus. If a portion only of the urachus is per- meable, cysts may be produced occupying the median line below the umbilicus. These cysts may attain considerable volume and some- times contain calculi. The TREATMENT of cysts that do not communicate with the bladder is extirpation. CHAPTER LVI HERNIA In the surgery of children hernia plays an important role, first, because of its frequency; second, because of its etiology; and third, because it is more amenable to treatment and ultimate cure, either by supports or operation, than in the adult. Etiology. Hernia in children is congenital (the exception to this rule is rare). It is -a developmental defect just as hare-lip, and the causes which produce either are practically the same. Defective development, due to a low vital index, explains the frequency with which hernia is associated with other congenital de- formities. Note its special frequency among the weak, premature, and degenerate; also its hereditary nature, occurring in families where there are other stigmata of degeneration. . Either failure to close the openings during fetal life or weak- ness at these points due to late closure is the rational explanation UMBILICAL HERNIA 471 of the hernias of childhood; it will also be found that acquired hernias, even in adults, are very rare. UMBILICAL HERNIA Umbilical hernia is very frequent in childhood because it will be recalled that the umbilicus is a potential center of congenital defects. The umbilicus is an abdominal cicatrix which marks the site of the umbilical ring through which the placental vessels pass in intrauterine life. Hence, defective development of the abdominal wall may leave a median gap which persists after birth, or imper- fect closure of the cicatrix may leave a weak spot through which a hernia appears a few days or weeks after birth. Umbilical hernia must not be confused with exomphalocele, which is not a true hernia at all. Exomphalocele is a developmental defect of the wall of the abdomen in which portions of the viscera remain external to and are not inclosed within the abdominal cavity. (See p. 466.) The true umbilical hernia of childhood, whether present at birth or occurring a few days or weeks after birth, may be properly con- sidered under the term infantile umbilical hernia. Pathology. Infantile umbilical hernia may present under two aspects. First: It may present at birth and occupy the cord at its site of implantation. These hernias are frequently so small that they pass unrecognized and may be compromised in ligating the cord. Hence, in tying off the umbilical cord the presence of gut should first be excluded or it may be caught in the ligature. Second: The hernia may occur a few days or a few weeks after birth, before the cicatrix has firmly closed the ring. Excessive coughing, crying, straining imposed by constipation, or phimosis, in conjunction with a weakened ring is sufficient to bring about this condition. The coverings of the hernia consist of skin and peritoneum, and at the apex of the protrusion the skin and peritoneum are usually 472 HERNIA adherent. The contents of the sac in large hernias consist of small intestine; in small hernias a portion of the omentum is usually found adherent to the sac, which prevents the complete closure of the ring. It may be said in general that these small umbilical hernias are extremely frequent, usually benign, and have a tendency to spontaneous cure. Symptoms. Usually there is present at the umbilical ring a small globular tumor about the size of a pea which becomes tense on crying or straining. It is easily reducible and contents of sac disap- pear with a gurgle. There is little serious general disturbance, nothing more than colic and digestive disorders. There is no tendency to strangulation. Umbilical hernia must not be con- founded with congenital tumors of the umbilicus (see p. 467). Its reducibility and accompanying gurgle will suggest the nature of the tumor. Treatment. The first indication in the treatment of infantile umbilical hernia is the elimination of all factors which are found to be causing increased intra-abdominal pressure, such as disturb- ance of digestion, difficult micturition, constipation, phimosis, and coughing. In the management of infantile umbilical hernia keep in mind the fact that the tendency of these hernias is toward spontaneous cure, provided reduction is maintained continuously. Reduction is of little value unless retention is complete and continuous. "A single .protrusion may destroy the work of several weeks of re- tention." Hence the fundamental principle of treatment is reduction and retention. The reduction should be complete, and the retention continuous. To accomplish this either palliative or operative meas- ures may be employed. Since the tendency of these hernias is toward spontaneous cure, palliative measures should be our first recourse. Rule : Use palliative measures for six months if without re- sults, consider radical operation. PALLIATIVE TREATMENT. The object of this treatment is to assist nature in her efforts toward a spontaneous cure. All that is UMBILICAL HERNIA 473 necessary is to continuously maintain reduction without interfering with the closure of the ring. The simplest and most effective method is to approximate the edges of the ring by the proper appli- cation of adhesive straps to the abdomen. The application of padded buttons and coins over the ring is usually unnecessary and ofttimes does more harm than good. Method. Prepare two strips of zinc oxid adhesive plaster two and one-half inches wide and long enough to reach well around to- ward the back of the patient. After careful cleansing of the umbil- icus, reduce the contents of the hernia, and place over the ring a small piece of absorbent cotton which has been well powdered the purpose of this cotton is simply to prevent excoriation of the folds of the skin. While the umbilicus is pushed in, the adhesive strips are ap- plied obliquely over the abdomen so that they cross at the umbilicus ; as the straps are brought across, the skin along the median line is folded inward so as to overlap the ring and thus form an excellent support for maintaining reduction. (Fig. 174.) To be success- ful this treatment must be continuous. It must be worn day and night. The failures are usually in children deprived of vigilant and intelligent nursing. Ex- coriations of the skin are to be avoided by frequent bathing and sponging with alcohol, special care being given to the folds of the skin which . , , FIG. 174. METHOD OF APPLYING overlap the ring. A well-powdered ADHESIVE STRIPS FOR MAIN- ,11 TAINING REDUCTION IN INFAN- piece of absorbent cotton frequently TILE UMBILICAL HEKNIA . changed will usually prevent irritation. If the tender skin will not tolerate adhesive strips, then use a carefully applied binder or a rubber bandage. Caution. Whenever the adhesive straps are removed, or the binder changed for purposes of cleanliness, always maintain the hernia reduced ly pressure with the fingers until new retention 474 HERNIA straps are applied. A single protrusion will destroy what it has taken weeks to accomplish. OPERATIVE TREATMENT. -Indications. First, in irreducible and strangulated umbilical hernia it is necessary to operate promptly ; these conditions, however, are very rare. Second, in large hernias of the umbilical cord operation should be done preferably the second or third day. Third, if after six months' palliative treatment no results are obtained, radical operation should be con- sidered. If the nutritional index is sufficiently high there is no reason to delay until the hernia is larger, adhesions firmer, and operation more difficult. An early operation can be done by a skilled surgeon with little danger, since only a few drops of ether are necessary, the time con- sumed is not more than ten minutes, healing is rapid, and the re- sults satisfactory. Technique of Operation. Prepare the field of operation by lightly painting the skin with tincture of iodin (half strength). Keep in mind the fact that the thickness of tissue which protects the hernial contents is very slight ; the sac is very thin and partly adherent to the skin. Make a small curved incision below the umbilicus about one-half inch from the edge of the hernia. Find the line of cleavage and separate the sac as far as pos- sible. Open the sac, leaving that portion which is adherent to the skin undisturbed. Reduce the herniai contents. Ligate the sac close to its base, bring the edges of the ring to- gether by cross sutures, and suture the skin flap in position. The umbilicus should not be extirpated, since it has a cosmetic value which warrants its preservation. The wound should be dressed with a small pad of sterile gauze held in position by cross strips of adhesive plaster. Healing is usually complete by the fifth day, when sutures may be removed. The adhesive strips may be dispensed with on the tenth day. INGUINAL HEENIA 475 INGUINAL HERNIA transv. Fascia Normal and Pathological Anatomy. Inguinal hernia in children is congenital; it is a developmental defect due either to imperfect or delayed closure of a fetal process. No adequate conception of inguinal hernia is possible without recalling the various steps in the evolution and migration of the testicle. Note, first, that in the early part of intrauterine life the testicle lies in the abdominal cavity behind the peritoneum. From this position it migrates through the abdominal wall, and eventually reaches the scrotum dur- ing the ninth month. Second, the pathway which the testicle takes through the abdominal wall is the future in- g u i n a 1 canal. Third, while the testicle retains its retroperitoneal posi- t i o n throughout this process of evolution, it F IG . 175. MIGRATION OF TESTICLE AND TUBE-LIKE ... . PROCESS OF PERITONEUM PROJECTED INTO THE maintains a very impor- SCROTUM. tant peritoneal relation- ship which must be well understood, viz. : while the testicle is migrat- ing toward the scrotum, a titbelike process of peritoneum is projected into the scrotum (Fig. 175) the processus vaginalis which just before birth assumes a relationship as shown in Fig. 176. The final normal disposition of the processus vaginalis, which is usually complete at birth, is as follows: Its upper end is closed; the lower portion in relation with the testicle becomes the tunica vaginalis of the testicle ; the intermediate portion atrophies. (Fig. 177.) Supposing this normal obliteration of the processus vaginalis is 476 HERNIA transy. Fascia five, vagin: perform. Tunica vagin propria ' FIG. 176. RELATION OF TESTICLE TO VAGINAL PROCESS OF PERITONEUM JUST BEFORE BIRTH. not complete at birth, or it remains imper- fectly closed, as in Fig. 176, it is obvi- ous that it needs but a slight excess of intra-abdominal pres- sure to force an in- testinal loop into the preformed sac. Fur- thermore, it is esti- mated that in one- h a 1 f the new-born there is an open processus vaginalis which usually obliterates during the first weeks. It is possible, however, for this process to remain open without causing the pal lent any trouble during life. Such a condition is made possible when the canal is guarded by good muscular rings. Frequency. Inguinal hernia is much more frequent in the male because of the inguinal canal the weak spot made by the pathway of the migrating testicle. In the female the canal of Nuck is the analogue of the inguinal canal. It transmits the round ligament accompanied by a prolongation of peritoneum correspond- ing to the processus va- ginalis. Hence, in the female inguinal hernia presents in the canal of FIG. 177 - THE FINAL AND NORMAL DISPOSITION OF THE VAGINAL PROCESS USUALLY COMPLETE AT BIRTH. transv. Fascia Tunica vaginal^ propria. INGUINAL HERNIA 477 It will also be observed that inguinal hernia is more frequent in boys than in girls (40-1) because of the developmental difference in the inguinal canal. Etiology. It is evident that the unobliterated processus vayinalis is the preformed sac which is the potential cause of a congenital inguinal hernia whenever intra-abdominal pressure exceeds inter- muscular abdominal support. Hence, a congenital inguinal hernia has no reference to the time of its appearance, but to the congenital defect which invites it. It may be present at birth, it may appear before puberty or after puberty. Site. -^Inguinal her- nia is more frequent on the right side, not be- cause of any marked difference in intra-ab- dominal pressure in the two sides, but because the unobliterated pro- cessus vaginalis is more frequent on the right side. Pathology. The her- n i a 1 contents usually consist of loops of small intestine; omentum is found less frequently, because in children the omentum is not well developed, and still more rarely we find the cecum, the appendix, and the ovary. The presence of the ovary in the sac may be a coincident congenital defect the ovary approxi- mating the male type in migrating to the inguinal canal and labia major a. The hernial contents are almost always reducible a notable exception to this rule is the frequency with which adhesions are found with the sac when the cecum and appendix form its con- tents. If in a child a right-sided hernia cannot be reduced it is probable that the cecum or appendix is in the sac. FIG. 178. CONGENITAL INGUINAL HERNIA. 478 HERNIA Symptoms. Functional symptoms are of little value. In the mind of the parent certain intestinal colics are attributed to the hernia, but the only reliable evidence is the demonstration of the presence of an inguinoscrotal tumor (Fig. 178) which gives an im- pulse when the child cries or makes any effort that increases intra- abdominal pressure, and on lying down recedes; or by gentle pres- sure is reduced with a gurgle. Furthermore, after reduction, in- crease in the size of the ring may be determined by invaginating the scrotum with the index finger to ascertain if it will admit the finger tip. Gurgling occurring coincident with reduction is patliognomonic. However, in young children the picture is not always well defined there are other conditions engrafted on the same congenital defect, such as undescended testicle, hydrocele, and cysts of the cord, which must be carefully differentiated, since they have an important prac- tical relation to hernia. Hence, when an inguinal hernia is sus- pected in a child the first duty of a surgeon is to eliminate possible errors of diagnosis. Do not be satisfied with one examination. Several examinations are often advantageous, especially in very young children. Differential Diagnosis. First: Eliminate undescended testicle. Examine the scrotum and ascertain if the testicle is in its normal position. If the testicle is permanently absent (not due to cremas- teric reflex) the hernia is probably complicated by an undescended testicle (see p. 542). Careful examination of the inguinal mass in reference to consistency and tenderness will disclose its nature. In hernia the tumor is elastic and painless on pressure. In un- descended testicle the tumor is firm and painful on pressure. Second: Eliminate congenital hydrocele. Hydrocele is very frequently mistaken for hernia, Note the following differentials : Hernia Congenital Hydrocele Reduction sudden and with Reduction slow and silent. gurgling. Not translucent. Translucent. Reappears rapidly on coughing. Reappears slowly. INGUINAL HERNIA 479 The light test in infants cannot be always used as a differential, since light is often freely transmitted through the gut in infants. Third : Encysted hydrocele of the cord presents a tense, rounded tumor, the content of which is not reducible, but its extreme mobility permits it to be forced en masse toward the internal ring and thus mislead by an apparent reduction. There is no impulse on coughing or straining. Complications. In addition to the complications of undescended testicle and hydrocele already noted, we may mention tuberculosis of the sac, which resembles an adherent omental hernia by present- ing a dull, irreducible tumor. In the presence of a swollen testicle this condition may be suspected. It is well to keep in mind the inflammatory symptoms resembling the "acute abdomen" which may present in undescended testicle, torsion of the cord, and in- flamed hydrocele of the cord. Strangulated hernia is rare in childhood. It occurs most fre- quently during the first two years. It is not only a rarer compli- cation, but it is less grave than in adults and gangrene of the gut is unusual. This is easily explained by the elasticity and the little resistance of the young tissues forming the inguinal canal. The symptoms of strangulation are those of acute intestinal obstruction, and are similar to a like condition in the adult; but they are more acute than in the adult. The child cries with pain and draws the legs up, there is sudden irreducibility of a hernia which becomes tense and painful, this is followed by vomiting and stoppage of gas and feces : The indication for immediate relief is imperative. Treatment. Two widely different and distinct indications pre- sent themselves in dealing with inguinal hernia in children: (a) the treatment of strangulated hernia; (b) the treatment of reducible hernia. TREATMENT OF STRANGULATED HERNIA. The treatment of strangulated hernia is immediate and resolves itself into two pro- cedures: first, taxis reduction by manipulation; second, operation radical cure. Taxis. Reduction by manipulation is more successful in chil- dren than in adults, and if done early and according to well-defined 480 HEKNIA rules it is often efficacious in giving relief until an opportune time can be selected for a radical cure. Rule: Try taxis if the strangulation has not existed for more than twelve hours. The strangulation is less tense in children than in adults, hence the period during which taxis may be tried is more prolonged. Method of Taxis. Place the patient in a warm bath. Produce a light narcosis by a few drops of ether. Lift the pa- tient straight up by the legs, letting the body hang down; then pull the scrotum up and shake the contents back into the abdominal cavity (Spitzy). (Fig. 179.) This position favors the coopera- tion of all the natural forces the relief of congestion, the influence of gravity, the pull of the mesentery in re- ducing the strangulated loop, and renders dangerous man- ual pressure unnecessary. Operation. A radical op- eration for strangulated her- nia should be done at once if taxis fails. The operation for strangulated hernia does not differ in a general way from the same procedure in the adult, but there are special indica- tions in children which require special emphasis and they will have their proportional weight in these cases which require surgical dis- crimination. Special indications : (1) When there is doubt as to the viability of the gut, remember that young children do not bear well resection of the intestine; FIG. 179. METHOD OF SHAKING THE HERNIAL CONTENTS BACK INTO THE ABDOMINAL CAVITY. (Spitzy.) INGUINAL HEKXIA 481 yet their tissues have a great power of recuperation. Hence: Reduce a doubtful loop of gut rather than take the risk of resection (apt to be fatal in young children). (2) When the gut is not viable and not reducible. Here it is a question of resection or artificial anus ; a choice between a possible immediate fatality through shock, and an ultimate fatality through malnutrition. Spitzy believes that resection is the procedure of choice because larger children will stand resection fairly well, and small children are not benefited by an artificial anus. Malnutrition and the presence of a fecal fistula ultimately necessitate resection. TREATMENT OF REDUCIBLE HERNIA. The fundamental prin- ciple in the treatment of simple inguinal hernia is reduction and retention. Remove all causes of increased intra-abdominal pressure, such as tight belly bands, indigestion, constipation, phimosis, stone in the bladder, etc., which cause crying and straining. Keep the hernia continuously reduced by closing the hernial opening: (a) by mechanical appliances truss; (b) by radical cure operation. In infants it is possible to obtain a spontaneous cure by maintaining continuous reduction. After the second year the chances of cure by this method are doubtful. Surgical treatment of hernia in childhood is eminently satisfactory and restores normal conditions at once. Rule : In infants apply truss continuously as soon as the hernia is diagnosed. After the second year consider radical operation if the nutri- tional index is favorable. (a) Treatment by Truss. As soon as a hernia is diagnosed in an infant apply a truss continuously night and day. Treatment by truss can be efficient only when the principles of the treatment are intelligently understood and its application is in the hands of a vigilant and careful nurse. It must be well understood that the object of the truss is two-fold to obtain if possible a spontaneous cure, and, failing in this, to carry the child safely over the first few years till a proper time can be selected for operation. First: A truss to be efficacious must be worn continuously. 482 HEKNIA The object of the truss is to keep the hernia reduced to prevent its escape into the sac to bring about obliteration of the sac. Hence the support must be continuous day and night, during the bath, when the truss is changed. From the time the truss is ap- plied there must not be a moment when the hernial opening is left without support. In case the child should cry or cough or strain during a moment when the opening is unsupported the hernia may again protrude and spoil the results obtained by months of treat- ment. The Management of the Truss in Infants. This should be under the supervision of the physician, not the truss maker. The physician should measure, select, fit, and make the first application of the truss. The nurse should receive specific instructions in reference to the purpose of the truss; the location of the hernial opening; the proper placing of the pad; the hygiene of the truss and the inguinal region; the proper support of the hernial open- ing by the fingers of the nurse when the truss is removed for cleans- ing the parts. This instruction is as important as the ordering of the truss, for without it the truss will accomplish nothing but irritation to the infant. Furthermore, it should be imderstood that when the physi- cian prescribes a truss he does not dismiss a patient, he accepts a patient who is to receive his professional care so long as the truss is worn. It cannot be made too emphatic that the cure of a hernia never results from the mere application of a truss; it is truss plus intelli- gent supervision. The Truss. The mechanical treatment of hernia does not imply that the treatment is to be left to a mechanic. It is more than the mere prescribing of the truss. It implies accurate measurement for i the size of the truss; definite instructions as to the type of the truss; careful shaping of the truss so that the truss conforms to the patient, not the patient to the truss. Type of Truss. Eliminate from consideration such unreliable relics as "hanks of worsted" and "folded skeins of Berlin wool" ; their inefficacy is only equaled by their uncleanliness. INGUINAL HEENIA 483 In selecting a truss be sure that it is, first, efficacious; second, cleanly. To be efficacious it must possess a metallic spring which can be so adjusted to the child that it conforms to the shape of the pelvis; and maintains a pressure that holds the hernia without irritating the skin. To be cleanly it must be simple in design, waterproof through- out, so that it may be unaffected by urine and frequently cleansed. The type of truss which most completely fulfills these require- ments is the "Cross- body" truss, which es- sentially consists of a pad with a metallic spring surrounding two- thirds of the pelvis and supplied with a strap which completes the cir- cumference by being but- toned to the pad. This is also known as the "Hood" truss. (Fig. 180.) De Garmo has modi- fied and improved this truss by substituting for the steel spring one of German silver cov- ered with hard rubber, which is easily shaped and maintains a light but efficient pressure. The "De Garmo Hood" truss meets all the indications of sim- plicity, efficiency, and cleanliness, and is the type of truss to be recommended in the mechanical treatment of hernia in young chil- dren. Measuring for the Truss. Have the child lying on his back. Take the circumference of the pelvis by holding the end of the tape at the hernial protrusion, which should be marked with ink, FIG. 180. CROSS-BODY TRUSS APPLIED TO LEFT INGUINAL HERNIA. (De Garmo.) 484 HERNIA and passing it around the hip midway between the crest of the ilium and the great trochanter the resulting number of inches is the size required. Should there be a double hernia note the distance between the points of the protrusions (marked with ink) so that the pads may be properly located. Shaping the Truss. After the proper sized truss has been pro- cured, it is next to be shaped so as to conform to the pelvis of the patient who is to wear it. No truss can be said to fit until it is properly shaped. To hold the hernia without irritating the skin it must be properly shaped, and it must be shaped by the physician. For re- producing an accurate tracing of the conforma- tion of the pelvis the sim- p 1 e and efficient "lead tape" method of De Gar- mo is recommended. This author uses a strip of sheet lead one inch wide, 1-16 inch thick, and about 15 inches long. "The end of the tape is placed over the hernia and extends from this point across the front of the ab- domen and around the hip of the opposite side and thence across the back. (Fig. 181.) The lead is gently pressed to the form of the body, care- fully removed, and placed edgewise upon a sheet of paper or case book of suitable size. "A tracing is now made of its inner surface with a lead pencil. This will represent about two-thirds of the circumference of the pelvis and when transferred to paper the diagram may be com- pleted by turning the lead over and completing the tracing. This FIG. 181. SHOWING METHOD OF TAKING DIAGRAM WITH LEAD TAPE. (De Garmo.) INGUINAL HERNIA 485 diagram gives the shape of a section of the hip taken on a line covered by the truss spring." (Fig. 182.) In shaping a truss covered with hard rubber it must be first warmed by passing the spring through an alcohol name, otherwise the rubber will crack. Hygiene of the Truss. Since continu- ous pressure is the price of cure, it is evident that the skin will tolerate this treatment only with the most scrupulous cleanliness and persist- ent vigilance. The problem is to pre- vent excoriations of the skin constantly subject- ed to pressure and soiled with urine. To this end the skin and truss must be kept clean and dry. The ^ . FIG. 182. DIAGRAM OF Two PERSONS \\HOSE MEAS- best results are ob- UREMENTS ARE IDENTICAL. (De Garmo.) tained by having two trusses. The truss is kept on while the child is being bathed ; when removed for cleansing the underlying skin, the nurse is instructed to maintain pressure with the fingers over the hernial opening. The skin is then cleansed and sponged with alcohol and witch hazel, dusted with talcum powder, and the clean and dry truss adjusted in place. This is to be repeated as often as necessary to keep the skin clean and dry. Should excoriations of the skin occur apply zinc oxid ointment. The Physicians Supervision. After the truss is prescribed, fitted and shaped, and full directions given for the after care, the physician's supervision is still essential. For the child that wears a truss is a patient until the hernia is cured. One important fact 486 HERNIA must be kept in mind the child is growing and the truss must be changed and adjusted to meet the demands of growth. Hence the patient should be seen at regular intervals, for the mechanical treat- ment of hernia in children will be successful only in proportion to the careful supervision of the family physician. (&) The Radical Cure. There is only one good reason for de- laying the radical cure of hernia, and that is to have the nutritional index high enough to insure safety. Operation is neither safe nor satisfactory before the age of two years. The extreme thinness of the sac, the diminutive structures, and the sensitiveness to shock all combine to make the operation in infants difficult and delicate. After the age of two years, however, if the nutritional index is sufficiently high, there is no reason for continuing the truss if a spontaneous cure has not already been obtained. Operation is then indicated. The truss should be abandoned after the age of two because: (a) The chances of cure steadily diminish up to the age of puberty. (b) Truss pressure causes atrophy of the underlying muscles, diminishes the protection afforded by the muscles, and lessens the chances of radical cure. (c) The wearing of a truss interferes with proper exercise and thus interferes with bodily development. The child who wears a truss is handicapped in the struggle for existence. (d) The cures by truss are often apparent, not permanent. There are many recurrences. (e) Radical operation removes at once the serious handicap men- tioned above with all its disagreeable sequelae, by establishing normal conditions. (f) With the age limitation mentioned above it is the author's experience that the younger the child the more satisfactory the re- sults of operation. Preparations for operation should be of the simplest kind. A dose of castor oil the preceding day; light ether anesthesia; the field of operation lightly painted with tincture of iodin (half strength) . INGUINAL HEKNIA 487 Operation. There is enough difference in the hernias of adults and children to warrant a difference in technique. In children the sac is extremely thin and difficult to isolate, the inguinal canal is short, the structures are diminutive, and what is required most of all is a simple, delicate, and rapid technique. The Bassini operation the standard operation in adults can he replaced by a much simpler procedure giving equally good results. The author reserves the Bassini operation for strangulated hernias ; for hernias with adherent contents (cecal hernia) ; for large hernias in adolescents; for hernias complicated with undescended testicle. For these conditions Bassini's method possesses the advantages of exposing the entire length of the inguinal canal by splitting the aponeurosis of the external oblique and thus revealing at once the relations of the sac. In the simple reducible hernias of childhood it is neither neces- sary to split the aponeurosis nor to transplant the cord. The one essential feature in obtaining a permanent cure is careful isolation and obliteration of the sac. The author, therefore, prefers the technique of Kocher in the management of simple reducible her- nias. Technique of Operation. Incision over the inguinal canal, and as high above the scrotum as possible to avoid contamination of urine dividing skin and superficial fascia. Careful hemostasis at every step. Identify the aponeurosis of the external oblique and the pillars of the external ring. (Fig. 183.) Note the elements of the cord emerging from the ring. Identify the sac and proceed to separate it from the cord by careful dissection ; open sac and reduce contents. If the sac is connected with the tunica vaginalis of the testicle, divide the sac transversely, leaving the lower part in connection with the tunica vaginalis of the testicle. The upper part of the sac is grasped by forceps, pulled forcibly downward, a ligature applied as high as possible, and the superfluous sac removed. Or, in older children, the sac may be transposed a la Kocher by grasping the apex of the sac with curved forceps and pushing it along the inguinal canal as far as the internal abdominal ring, where it is protruded through 488 HERNIA a small opening in the aponeurosis and forcibly pulled through. The neck of the sac is ligated close to the slit in the aponeurosis, the sac is cut off, and the stump is allowed to retract inside the ab- domen. Finally the small opening in the aponeurosis is closed. (Kocher.) Whichever disposition of the sac is made, the canal is closed by suturing the pillars of the ring, the operator being careful not to compress the cord. The operation is completed by suturing the skin, painting the wound with collodion-aristol and securing a small compress in place by cross strips of adhesive plaster. This operation in skilled hands should be completed in ten FIG. 183. OPERATIVE TECHNIQUE FOR THE SIMPLE REDUCIBLE HERNIAS OF CHILDHOOD; A. Exposure of aponeurosis of the external oblique, and sac separated from the cord; B. Sac opened, contents reduced, and sac ligated. C. Sutures in place for strengthen- ing anterior wall of canal, and closing pillars of ring. minutes or less, and requires but a few drops of ether. Observe strict asepsis and use absorbable sutures. After-treatment. The dressings are removed at the end of ten days, after the second day the bowels are moved daily; otherwise the child is regarded as normal. In older children active physical exercise should be prohibited for six months after operation, espe- cially those exercises which increase intra-abdominal pressure. The operation in females does not differ essentially from that in males. It must be remembered that the canal of Nuck is the ana- logue of the inguinal canal, and that it lodges the round ligament. Hence absence of the cord renders closure of the external ring much easier, but it is much more difficult to find the sac. If the ovary is FEMORAL OR CRURAL HERNIA 489 present in the hernial contents the aponeurosis should be split and the ovary reduced in the abdominal cavity. The round ligament should be preserved. FEMORAL OR CRURAL HERNIA Femoral or crural hernia is rare in children, though it is found both in boys and girls (1-2). It is much more difficult to apply an efficient truss in this region and operation should be considered when the nutritional index warrants it. The operation differs in no respect from the operation in adults. CHAPTER LVII EXSTROPHY OF THE BLADDER Exstrophy of the bladder is a developmental defect in which there is a failure of union between the two lateral halves of the bladder. This malformation affects not only the anterior wall of the bladder, but involves the abdominal wall, the pubic symphysis, and the roof of the urethra. In other words, the fissure extends through the abdominal wall and into the bladder and urethra (Fig. 184). Hence, the aperture is filled by the posterior wall of the bladder and the floor of the urethra. This deplorable condition is quite rare and is most frequently observed in boys, often associated with other malformations, such as imperforate anus, spina bifida, hare-lip, club foot, etc. As a rule the cleft is a complete one, though rarely the fissure involves only the upper or lower portion of the bladder. In some cases the fissure involves only the abdominal wall, the bladder wall being complete forms a hernia through the abdominal fissure ectopic bladder. Symptoms. Below the umbilicus is found a cleft in the abdominal wall, through which extrudes a moist, red shining mucous membrane with many folds and corrugations, which is recognized as the mucous 490 EXSTROPHY OF THE BLADDER lining of the posterior wall of the bladder pushed forward by the pressure of the intestines. The irritated mucous membrane is very vulnerable, easily bleeds, and is painful to the touch. The protruding bladder wall is not reduced spontaneously. In small children it may be forced back by means of a tampon, but bulges out as soon as the pressure is removed. In the region of the trigone are recognized the two ureteral orifices from which urine is discharging in rhythmical ejaculations. In addi- tion the pelvic ring is incomplete, the symphysis pubis is open, and the fissure continues to the urethra. In boys we find a rudimentary penis with total epispadias and undescended testicle on one or both sides. The changes in the fe- rn a 1 e are similar the urethra deprived of its roof is represented by a groove. The labia majora and minora are entirely separated, and hence the anterior commissure of the vulva is absent. The va- gina and uterus are some- times double. The uterus may be so incorporated with the posterior bladder wall that they are very difficult to separate. CLINICAL COURSE. As a result of this malformation there is a constant dribbling of urine which soils the clothes, excoriates the skin, and envelops the patient with a disgusting odor. Besides this, inflammation of the vesical mucosa renders the patient liable to an ascending pyelonephritis from infection through the orifices of the ureters. Thus the patient is impossible as a member of society; the mortality is very great from the constant irritation and infection of the urinary tract; and they. are sexually impotent. Treatment.- It is obvious that the first indication is to allay the irritating symptoms by protecting the exposed vesical mucosa from FIG. 184. EXSTROPHY OF THE BLADDER, AND BILATERAL UNDESCENDED TESTICLE. (Broca.) TREATMENT 491 injury, by providing sanitary dressings for the incontinence, and by assuaging the painful excoriations of the adjacent skin with suit- able ointments. OPERATIVE RELIEF. It must be stated at the onset that the treatment of this condition by operative measures is discouraging. The multiplicity of the operative procedures suggested is sufficient proof of their inadequacy. Not as yet has surgical ingenuity de- vised a satisfactory reconstruction of the bladder and urethra, with a functionating sphincter to prevent incontinence. Methods. The methods suggested may be divided into two groups : (1) Autoplastic Method. This method has for its object the reconstruction of a urinary reservoir by restoring the anterior wall of the bladder with flaps of skin taken from the neighboring parts. The results of this method are uncertain and unsatisfactory, because the newly constructed receptacle is too small for the purpose of a urinary reservoir; it favors the decomposition of urine and the formation of extensive phosphatic deposits, which are irritating and the frequent source of infection; and lastly, as there is no sphinteric control, the patient is doomed to incontinence. (2) Diversion of the Urinary Channel into the Lower Bowel. Among the many operative procedures the suggestion of Maydl is the most practical. It consists in excising from the bladder wall its trigone with ureters and their openings, and implanting the whole into the wall of the sigmoid flexure. The remainder of the bladder is dissected out and the abdominal defect is permanent]} closed. It is obvious that this operative procedure fulfills in a large measure the requirements which permanent relief demands. The urine drains into the rectum, where tolerance of its presence is acquired, and it may be retained for three or four hours under con- trol of the anal sphincter. Thus by the same operation the vesical hernia is repaired and the incontinence cured. The objections to the operation are: its complicated technique which renders it too serious to be undertaken in young infants; the danger of hydronephrosis from kinking the ureters as the trigone 492 HYPERTROPHIC STENOSIS OF THE PYLORUS is turned on an axis of 180 in implanting it into the bowel wall ; the danger of pyelonephritis by infection from the bowel extending into the ureters and renal pelves. In the management of these cases it is better to abstain from operative relief during the early years of life until the child has acquired sufficient resistance to safely bear an operation so ex- tensive as the implantation of the ureters into the bowel. The horrible character of the deformity warrants the risk of any opera- tion which promises relief. In the meantime instruct the parents to keep the child as clean as possible by the use of ointments to prevent excoriations of the skin; by protecting the bladder mucosa with sterile gauze com- presses to prevent contact with the clothes; and to create the most favorable conditions possible for subsequent operation. CHAPTEK LVIII CONGENITAL HYPEETKOPHIC STENOSIS OF THE PYLORUS While formerly this condition was considered quite rare, an awakened interest in the subject and a closer study of the symptoma- tology have shown that it is by no means a rarity, but that hereto- fore the condition was simply overlooked. Normal and Pathological Anatomy. It will be recalled that the stomach is structurally and functionally an organ with a two-fold purpose. First, it is to receive the food as a reservoir ; second, it is to triturate the food and prepare it for intestinal digestion. This two-fold function is plainly marked in its structure; for about the middle of the body of the stomach there is a distinct line of demarcation observed in the thickness of the stomach wall ; above this line the wall is comparatively thin and forms the cardiac pouch; below this line and extending to the pylorus the wall is thickened and forms the pyloric canal (Fig. 185). This division of the stomach into a passive cardiac pouch for storage and an active pyloric canal for trituration exactly corresponds to the two-fold SYMPTOMS -193 gastric function and is of considerable significance in the pathology of hypertrophic stenosis of the pylorus. Postmortem findings demonstrate that there is an enormous thickening of the pyloric canal, due to a hypertrophy of the circular muscular fibers. The clinical facts are most rationally explained by presupposing spasm, with hypertrophy of the pyloric canal, and the production of a pyloric swelling that obstructs the outlet of the stomach. Occurrence. Hutchinson makes the important observation that it occurs more frequently in males (80 per cent.) and in the first- born, but offers no explanation of these suggestive facts. Symptoms. The symptoms are so characteristic that the condi- tion can scarcely be overlooked by a careful observer. It should first be noted that the symptoms rarely date from birth, but usu- ally make their appearance from two to three weeks later. Vomiting is the most promi- nent and persistent feature. It is apt to be projectile in character, appears soon after feeding, and consists of the stomach contents only ; it never contains bile. Marked constipation is usually present. Since the food does not find its way into the intestine the stools are rare and small. Emaciation is marked. The child rapidly loses weight and pre- sents a condition of starvation. The physical signs are no less characteristic. Dilatation of the stomach can be demonstrated by percussion, and it will be found to greatly exceed its normal limits. Visible peristalsis is observed shortly after taking food. These peristaltic waves travel across the abdomen from left to right and are so vigorous that they do not escape the notice of the mother or nurse. This vigorous peristalsis is pathognomonic of obstruction. FIG. 185. DIAGRAM OF STOMACH SHOWING THAT ITS TWO-FOLD FUNCTION is PLAINLY MARKED IN ITS STRUCTURE. 494 PERITONITIS Pyloric tumor is found on palpation, usually quite hard, situated in the pyloric area just to the right of the median line. With this sequence of symptoms and physical signs the diagnosis is unmis- takable. Treatment. While the evidence of mechanical obstruction is in- dubitable, yet it is a clinical fact that a number of children present- ing these symptoms have been cured by medical treatment. It may be that modified function has some favorable action upon the factors that determine obstruction; and thus medical treatment may so modify the "acid control of the pylorus" and the muscular spasm, that in a number of cases it is an efficacious means of cure. In all cases it is, therefore, wise to try MEDICAL TREATMENT first. Hutchinson recommends the following regime: (1) Regulate the diet so that the child is fed small quantities at frequent intervals. (2) Lavage of the stomach once or twice daily. (3) Small saline enemata (two ounces) twice daily to make up for the loss of fluids. If there is no improvement in three or four weeks, surgical treatment offers the only probability of cure. The operation of choice is gastroenterostomy ; but it must be remembered that very young children do not bear long intra- abdominal operations well; hence, the gravity of the operation must always be prognosticated. CHAPTER LIX PERITONITIS TUBERCULOUS PERITONITIS Tuberculous peritonitis is more frequent in the child than in the adult. It is rare before the age of six, and most frequently found between the sixth and twelfth years. It is a matter of com- TUBERCULOSIS PERITONITIS 495 mon observation that tuberculous peritonitis generally affects chil- dren who are apparently in good health and who are free from all taint of tuberculosis, either personal or hereditary. In most cases tuberculous peritonitis is secondary, the infection being carried by the blood stream, by the lymphatics, or by direct continuity of tissues (tuberculous ulcer). Clinically the surgeon is concerned only with those chronic manifestations of tuberculous peritonitis which appear in three forms corresponding to the three stages of tuberculous evolution. It is obvious that the dividing line between these different forms is not sharply defined, but that they merge one into the other, or the different lesions may coexist Clinical Forms. -(a) The ascitic form is characterized by the presence of serous fluid often in large quantities ; the peritoneal sur- face is studded with minute tuberculous nodules. It is rare to find the bacilli in the fluid even after centrifugation, but the inoculation of guinea pigs with the fluid usually transmits the disease. This form of ascites may persist for a long time; or it may be cured spontaneously. (b) The fibrous form presents the process of a curative sclerosis and is so accentuated that it forms very large cicatricial masses. The viscera are fixed one to the other and to the abdominal wall by thick fibrous adhesions. These fibrous bands may contract and con- strict the neighboring organs, producing atrophy, compression, or obstruction. Intestinal obstruction is more frequent in the fibrous form than in other varieties of tuberculous peritonitis. These fibrous masses especially about the cecum and in the great omeutum may resemble irregular tumors and be mistaken for neoplasms. (c) The caseous form is but another stage of the tuberculous process. Caseous foci are found among the fibrous adhesions. Sometimes there are calcareous foci and little pockets of pus. The great omentum is infiltrated and adherent. The intestinal loops, inflamed and agglutinated, become friable and rupture under slight provocation. The intestines may even rupture spontaneously and give rise to a fecal phlegmon. Symptoms. It is obvious that the symptoms vary with the form of the disease. It runs a chronic course and presents a progressive 496 PERITONITIS cachexia. There are emaciation, slight fever, diarrhea, abdominal pains, and slight tenderness. In the ascitic form the symptoms are due to a gradually increasing quantity of fluid in the peritoneal cavity. The abdomen is distended, the skin tense and shiny, and the veins prominent. Sometimes the fluid is encapsulated by adhesions and simulates a cystic tumor which is difficult to diagnose. In the fibrous form the abdomen is slightly distended and palpa- tion reveals hard, nodular masses. Rectal examination will also disclose matting of the intestines and scattered nodules. In the caseous form, or cold abscess of the belly, the progress is more acute and the temperature more irregular. Vomiting, diarrhea, and abdominal pains are more pronounced. Examination of the abdomen discloses irregular zones of flatness and tympany. Sometimes the abscess opens in the neighborhood of the umbilicus or perforates some part of the abdominal wall or opens into the bladder. Diagnosis as a rule is not difficult after carefully observing the history and general findings, with the assistance of the v. Pirquet skin reaction, and injection of guinea pigs with the exudate. Treatment. Although it has been shown that about one-third of all cases of tuberculous peritonitis recover spontaneously, or with- out operative treatment (Borchgrevink and Rose), the improvement which follows laparotomy is often remarkable, due to some reactive changes which have not been explained. It is wiser, however, in these cases to follow a conservative course and at the onset of the disease try the open-air treatment, aspiration, and X-ray before re- sorting to laparotomy. If improvement is not steady after a trial of these measures for three months, resort to operation. The operation is simple. The abdomen is opened in the median line below the umbilicus, and the straw-colored fluid allowed to drain away. If on inspection the Fallopian tube is found to be the primary focus, it should be removed. The wound should be closed throughout. No drainage tube is employed as it favors the forma- tion of a sinus and in some cases a fecal fistula. Judd advises evisceration as far as possible and washing the intestines with a fifty per cent, solution of commercial hydrogen PNEUMOCOCCUS PEE1TONIT1S 4U7 peroxid. The abdominal cavity is also thoroughly flushed with the same solution and washed out with normal saline solution. Chil- dren, however, do not bear evisceration well and milder measures are advised. The success of operation is more frequent in the ascitic form than in the fibroadhesive form. It is rare in the caseous form. Advanced tuberculosis or amyloid changes in the lungs, in- testines, or kidney contraindicate operation. PNEUMOCOCCUS PERITONITIS Pneumococcus peritonitis is an exceedingly rare affection with a special predilection for children. It is usually observed in children between the second and twelfth years, and is much more frequent in girls. It is a specific infection of the peritoneum, secondary to some preexisting pneumococcic lesion, such as a pleuropneumonia or an otitis media. The so-called "primary" form is simply the use of an illogical term to indicate that the mode of infection is obscure. The action of the pneumococcus on serous membranes presents two peculiarities. It produces abundant suppuration and a precipi- tation of considerable fibrin, so that the suppuration tends to become encysted. We note, therefore, that the cases fall into two distinct groups the encysted and the diffuse forms. Clinical Forms. (a) The encysted form is the clinical type most frequently found in young children. The encapsulated pus is generally found beneath the anterior abdominal wall, in the median line, below the umbilicus. This pus pocket may increase so as to form an enormous cavity, pushing the intestines aside and walling itself off with a whitish-gray membrane. The character of the exudate is usually thick, creamy, greenish- yellow, and odorless, and presents numerous fibrin flakes. (b) The diffuse form is rarer, more difficult to recognize, and the prognosis is much more grave. Here there is no limiting mem- brane, the pus is scattered throughout the abdomen. It is well to 498 PERITONITIS keep in mind, however, that pneumococcus peritonitis is the least grave form of acute peritonitis. Symptoms. In the encapsulated form the onset is sudden in- tense abdominal pain, at first diffuse, and later centering about the umbilicus; vomiting, fever, and diarrhea characterized by its fetid odor. The general train of symptoms are those of the acute abdomen. After a few days the pain, vomiting, and fever abate, but the local abdominal conditions become more pronounced; the abdomen is distended and there is distinct swelling in the umbilical region ; the child appears cachectic. It is well to note, however, that there is no muscular rigidity. After ten or twelve days the pain be- gins again, there are pronounced swelling, fluctuation, and occasion- ally edema of the abdominal wall in the region of the umbilicus, and if the process is not interrupted the skin is finally perforated and a quantity of pus is discharged. Thus the progress of the disease is in cycles, recognized by peritoneal invasion, accumulation of pus, and spontaneous rupture. In the diffuse form the onset is likewise sudden abdominal pain, vomiting, diarrhea, and fever; but the symptoms are all accentuated, the prostration is intense, and death may occur in forty- eight hours. As Stone observes, "the picture of peritonitis develops with interesting qualifications, rigidity as a rule being far less marked than the other symptoms would seem to justify, and there is diarrhea instead of constipation." The prognosis is grave, and the results fatal unless the tide is stemmed by early operation. Diagnosis. It is evident that the encysted form presents a clinical picture which simulates appendicitis and with which it may be easily confused. Note, however, that, while the onset is the same in the two affec- tions, in pneumococcus peritonitis the pain is more diffused, there is diarrhea rather than constipation, and the muscular rigidity of appendicitis is absent. In tuberculous peritonitis the fetid diar- rhea is rare, the swelling evolutes more slowly, the lesion is less circumscribed, the masses are isolated, and there is evidence of ascitic fluid. In the diffused form the diagnosis is always difficult, but the PNEUMOCOCCUS PERITONITIS 499 indications are never obscure and no time need be spent upon the etiology when the indications for surgical intervention are so apparent. Treatment. The treatment of either form is laparotomy and drainage. The incision should be made in the median line below the umbilicus. The pus is gently evacuated, no irrigation, drainage tubes are placed so as to reach the deepest possible point. In the encysted form the prognosis is good ; in the diffuse form the prognosis is always grave. CHAPTER LX APPENDICITIS Appendicitis merits special consideration in the surgery of child- hood because of its frequency, its obscure symptomatology, its peculiar clinical course, and its special rules of treatment. Appendicitis in the child differs in many details from the adult type, because the child is more than a miniature adult. The child presents special characteristics in his anatomical relationships. There is a difference in the plasticity of the tissues, the inflammatory reaction, the operative risk, and the after-treatment. Appendicitis in children is specially frequent in the period be- tween the fifth and fifteenth years. It is uncommon before the fifth year and rare in children under two years of age. Boys are more frequently affected than girls. Anatomy.' The vermiform appendix is the undeveloped distal portion of the primitive cecum. In the fetus the distal portion of the cecum ceases to grow while the upper portion increases in size; hence, at birth there results a narrow tube, the appendix, hanging from the end of the cecum (Fig. 186). Thus it is obvious that the position of the appendix depends upon the position of the cecum. But it must be recalled that the cecum in migrating from the left side of the abdominal cavity to the right iliac fossa may be arrested in any part of its course, under the liver, behind the umbilicus, or 500 FIG. 186. THE VERMIFORM APPENDIX. A. Cecum; B. Vermiform appendix; C. Meso- appendix; D. Appendicular artery. in front of the right kid- ney, and thus the appen- dix may occupy any po- sition in the abdominal cavity. Again, the relatively shorter lumbar region of the child causes the cecum to lie at a com- paratively higher level, and thus the appendix is situated higher than Mc- Burney's point. The infantile appen- dix is relatively larger as compared with the rest of the alimentary canal than in adults, while the walls are much more delicate, especially the submucous coat. The junction of the appendix with the cecum is sometimes funnel-shaped, the apex of the funnel being continued into the appendix (Fig. 187). It is evident that foreign bodies in this type of appendix readily make their entrance as well as their escape. Drainage is superior in the infantile appendix since in the smoother mucosa and greater lu- men there is less tendency to the formation of valves which close its cecal opening. Finally, it must be remem- bered that in the infant there is no line of demarcation between the abdomen and the pelvis. The pelvis is but the cone-shaped terminus of the abdominal cavity. At this period the bladder is in greater part an abdominal organ, the uterus does not occupy the true pelvic cavity, while the ova- FIG. 187. INFANTILE CECUM THE CONE-SHAPED CECUM CONTINUED INTO THE APPENDIX. ETIOLOGY AND PATHOLOGY 501 ries and Fallopian tubes rest in the iliac fossae. It is not until the child begins to walk that there is any striking change which differen- tiates the abdominal and pelvic cavities. Etiology and Pathology. As already stated, appendicitis is rare in children under two years of age. The reason for this is evident ; the smoother mucosa and relatively larger lumen of the appendix- give better drainage there is less tendency to retention of secre- tions ; the prone position of the infant prevents congestion ; while the simple diet and fluidity of the stools render the intestinal tube free from stagnation and fecal concretions. In older children the etiology is the same as in adults. Ap- pendicitis is largely a matter of defective drainage and defective structure. When we consider the excessive length compared with the lumen of the appendix; the fact that this long, narrow tube is blind at one extremity, while at the other it communicates with the cecum a center of infectious material ; and that it is guarded by a valve at its cecal orifice (the valve of Gerlach), it is evident that if the appendix is joined to the cecum at an acute angle, or if the mucosa in the neighborhood of the valve be swollen, there results a tube with both extremities sealed, and all possibility of drainage eliminated. Again, the appendix contains a relatively large amount of lymphoid tissue (the "abdominal tonsil"). This tissue is of low vital resistance, specially prone to bacterial invasion. All these facts suggest that the appendix is histologically prone to inflammatory processes since here we have a particularly susceptible tissue con- tiguous to a particularly infectious center. Intestinal worms are also important factors in the etiology of appendicitis. It is obvious that in their activities they may cause an erosion of the delicate mucosa, which opens the way for bacterial invasion. General infections play an important role in the causation of ap- pendicitis. It is not infrequent to find appendicitis following in the wake of measles, otitis media, influenza, tonsillitis, and typhoid fever. This coincidence is specially marked in influenza and gives it special etiological significance. Gastrointestinal Disorders. Apart from structural defects and Lllil\;Ux\ OF .COLLEGE O'r OSTEOL= 502 APPENDICITIS the special infections mentioned above, gastrointestinal disorders probably play the largest part in causing appendicitis in children. Disorders of digestion affect all parts of the digestive tube, and it may well be that appendicitis is but a localized enteritis, for it is significant that appendicitis in the child is often preceded by re- peated attacks of gastrointestinal disorder. Points of Difference in the Pathological Process. The evolution of appendicitis in the child presents several points of difference from that of the adult type. Appendicitis in children is not so fatal an affection as in adults because the infant's appendix is less prone to perforation and gangrene. The tendency of the disease in the child is toward the formation of a localized abscess. At the first onset of inflammation the omentum promptly offers its protection by wrapping itself about the diseased organ, thus walling it off from the general peritoneal cavity. Hence, unless the abscess rup- tures, general peritonitis is rare. Not only is there found the pri- mary abscess surrounding the appendix, but, as the disease evolutes, secondary abscesses are formed which may communicate with the primary focus by a narrow canal, or be completely separated. This condition is notably illustrated in the secondary pelvic abscesses. The two foci may develop simultaneously or the pelvic suppuration appear after the iliac. Again, abscess may appear in the left iliac fossa or in both fossae at the same time. The so-called left-sided appendicitis in children is usually a secondary iliac abscess situated on the left side. It is also to be remembered that multiple purulent foci, independent of each other, may become encysted, and, if the surrounding adhesions are inadequate for defense, they may at any time rupture into the general peritoneal cavity and set up a diffuse peritonitis. Secondary Complications of Other Organs. Not only is there a tendency to localized suppuration of neighboring parts, but to the involvement of organs at a distance, such as subphrenic abscess, abscess of the lung, liver, brain, and parotid. Not infrequently does a pleural empyema follow in the wake of appendicitis, and as Kelly observes : "It has happened in several instances that a pleural empyema has been discovered and operated upon, while the pri- SYMPTOMS 503 mary cause, a suppurating appendix, has not been discovered until the postmortem." Finally, let it be emphasized that the pathological picture, there- fore, in the appendicitis of childhood is the picture of localized suppuration. It is this fact that explains why the disease is less fatal in childhood than in adults and why so many untreated or badly treated cases survive in spite of procrastinating measures, which in the adult would prove fatal. Mother Nature never leaves her children wholly unprotected ; for every defect there is some com- pensatory provision ; and if the child cannot intelligently articulate its abdominal distress, yet it is not without a sign ; for the hand- writing is on the abdominal wall so that he who will may read. Symptoms. In considering the symptomatology of appendicitis in children the physician must appreciate that he is not dealing with a miniature adult ; the child can neither analyze its sensations nor intelligently articulate its distress. There is no reliable evidence except the previous history as obtained from the parents and the objective symptoms. It is obvious that the skilled observer must understand the child nature and be able to properly estimate the value of the symptoms under disadvantages which do not obtain in the adult. When called to treat a child with bellyache, vomiting, and fever proceed at once to prove that it is not appendicitis before attempting to prescribe. Much damage has been done by the routine practice of prescribing for abdominal pain without making a care- ful examination of the abdomen. Get a careful history from the parents and note if gastrointestinal disorders have preceded the attack. They play an important role in the etiology of appendicitis in children. Find out if there has been any undue desire to empty the bladder or painful micturition. This is a significant prodromal symptom. Next examine the thoracic viscera an acute abdomen and right iliac pain are often the first signs of a pneumonia or pleurisy. If the child is old enough it may be able to localize its pain in the region of the appendix and the physician may elicit tenderness on pressure over McBurney's point. With these two facts the at- tention is immediately directed toward appendicitis. 504 APPENDICITIS Muscular rigidity that most valuable sign in adults cannot be depended upon in children, since the young child resists any attempt to examine the abdomen and obscures its local and compara- tive significance by straining and putting up a general muscular defense. Cutaneous hyperesthesia is often significant of appendicular in- flammation. A sharp pain is elicited when the skin is lightly touched. Never fail to make a rectal examination in every case of sus- pected appendicitis. In a child, the palpating finger can easily ex- plore the cecal region and obtain valuable information (Fig. 188). Besides, this method is more gentle and less dangerous than deep pal- Fio. 188. RECTAL-BIMANUAL EXAMINATION. pation from the outside. // the child is intractable these examina- tions should be made under light ether anesthesia. Always remember in palpating a child's abdomen, even if under anesthesia, that gentle- ness is essential, and that more than ordinary care should be used in order not to rupture the extremely delicate adhesions. When with pain, tenderness, and rigidity there is associated a palpable mass in the right iliac fossa, the diagnosis is no longer doubtful. The general symptoms of fever, acceleration of pulse, vomiting, constipation, or diarrhea, are evidences of toxic absorption and must be given due consideration in connection with the local symptoms described above. Due regard should be given to postural symptoms, such as stooping or limping, and their association with appendicial abscess must not be forgotten. Diagnosis. The diagnosis of appendicitis in children is either DIAGNOSIS 505 simple or very difficult, depending upon whether there is or is not a palpable mass in the appendicular region. Cases presenting pain without palpable mass may ~be mis- taken for: (a) Acute Indigestion. Here the pain is general in character; there is no localized tenderness in the right iliac fossa or right- sided rigidity. There is no progressive leukocytosis and the acute symptoms rapidly subside. (b) Typhoid Fever. The onset of typhoid is slow; the localized symptoms are not well denned. The increase in the size of the spleen and the Widal reaction will establish the diagnosis. (c) Pneumonia. If the thoracic viscera be examined in every case of suspected appendicitis, the results of auscultation will leave no doubt as to the correct diagnosis. Cases presenting pain with palpable mass may be mistaken for: (d) Intussusception. Ileocecal intussusception presents symp- toms that closely mimic appendicitis and is often difficult to dif- ferentiate. The fact that it occurs in children with the greatest frequency next to appendicitis should entitle it to the most careful consideration. The onset of intussusception is marked by pain, but not by fever as in appendicitis. There is a discharge of blood and mucus from the rectum. The tumor is circumscribed, sausage- shaped, and movable transversely, in contradistinction to the diffused and immovable mass of appendicitis. (See Intussusception, p. 512.) (e) Tuberculous Peritonitis. Here the symptoms are more diffuse. Palpation reveals other masses than that in the iliac fossa. These masses vary in size from small nodules to large irregular tumors. Abnormal areas of flatness and dulness caused by masses of adhesions and the presence of free fluid ought to sufficiently differentiate the two affections. In doubtful cases the v. Pirquet skin reaction will be helpful. Intestinal obstruction may or may not present a palpable mass. Remember that the onset of intestinal obstruction is not accompa- nied by fever. The mechanical phenomena of obstruction alone mark the first stage. It is only later in the disease that there are pain, fever, vomiting, and abdominal distention. A leukocyte count 506 APPENDICITIS will be useful in making an early differentiation of the two con- ditions. It is well to keep in mind the many possibilities which may simulate appendicitis. Hip disease, urinary calculi, hernia, and undescended testicle, ovarian neuralgia, gonorrheal salpingitis all these should receive consideration in doubtful cases. The prevalence of appendicitis has directed the popular mind toward a state of ex- pectancy whenever there is abdominal pain, and this in turn uncon- sciously prejudices the judgment of the family physician. Every case of suspected appendicitis is a problem which requires the surgeon's calm judgment before he employs the Jcnife. Prognosis. Since prognosis depends upon prompt surgical inter- vention, it is evident that the prognosis in very young children is handicapped by their inability to describe their symptoms, the parents' ignorant interpretation of the attack as that of indigestion, and the physician's difficulty in arriving at an early diagnosis. Prognosis is always more serious in children under the age of five, and it is increasingly better from five to fifteen. In all cases the early removal of the appendix insures a favorable prognosis. Treatment. The treatment of acute appendicitis should begin as soon as appendicitis is suspected. It is the merest folly to teach that there are two methods of treating appendicitis, that the family physician is to carry the case along as far as he can and when his medication proves futile call in a surgeon to inaugurate an entirely different method of treatment. There is only one treatment of appendicitis ; in this treatment the physician and surgeon each play an important role a role of cooperation each bears an equal responsibility, and each contributes his share to the favorable or unfavorable result. The results of the modern treatment of appendicitis, favorable as they are, can never be what they should be until the physician and surgeon are recon- ciled in a unity of purpose and uniformity of procedure. There is no medical and surgical treatment of appendicitis. The treatment is preoperative and operative. This definitely fixes the status of the physician and surgeon ; the one prepares the patient for operation, the other performs the operation. PREOPEKATIVE TREATMENT. The preparation is just as impor. TREATMENT 507 tant as the operation, and the operative results will not improve until the surgeon receives the patient rationally prepared. When the physician, therefore, suspects appendicitis his further treatment should be directed toward preparing the patient for opera- tion. That is putting the patient in the best possible condition to receive the benefits of operation. He must understand that the aim in all acute abdominal conditions is to put the gastrointestinal tube in a state of quiescence; that the great disturbing factor is peri- stalsis, and that everything that stimulates peristalsis is to be elimi- nated. The introduction of food and the use of cathartics are the two disturbing elements; the use of either increases peristalsis and hence helps to distribute rather than localize the infection. In the preoperative treatment, therefore, the indications are: First: Keep the patient in bed and as quiet as possible. Secojid : Since children do not bear well the deprivation of nourishment by mouth, give them that which creates the least in- testinal disturbance water and egg-albumin. The child's nutri- tion will not be seriously impaired by this diet, at least for twenty- four hours. Third : Never prescribe a cathartic. A purge is the most deadly medication that can be employed in any acute abdominal condition. Fourth: Apply an ice-bag to the abdomen. The sedative effect of the ice-bag and its inhibiting effect upon localized inflammations are well established. Fifth : The employment of small doses of opium after the diag- nosis has been established quiets the patient and exerts a beneficent influence upon the local process. The foregoing preliminary treatment gives the child its best chance in combating a subtle foe, for it is the employment of nature's method of local rest wherever there is local inflammation. Furthermore, it gives the surgeon an assurance that his problem has not been complicated by a preliminary skirmish that has only weakened the lines of defense; but that the physician's viewpoint has been distinctly surgical from the very beginning, and that each is contributing his share to the solution of the same problem. Let it be understood then that the treatment of appendicitis is distinctly 508 APPENDICITIS surgical and that he who treats it assumes the role of surgeon. He who practises the expectant treatment shoulders a large respon- sibility, for the results of early operation in children are just as good as in adults and the threatening phantom of general perito- nitis casts its shadow upon every case unrelieved by operation. OPERATIVE TREATMENT. The rule, then, is to operate upon every case of appendicitis early while the disease is confined to the appendix. There is danger only when the disease gets beyond the confines of the appendix. This is the ideal treatment and the mor- tality is practically nil. An important consideration for the general practitioner, situated as he often is far from those skilled in abdominal surgery, is not when to operate, but when it is safe to wait. It is obvious that no hard or fast rules can be formulated for a disease so conspicuously treacherous. While patients do recover from mild attacks of appendicitis without operation, no physician can prophesy at the beginning of an attack what the outcome is going to be, and it must be remem- bered that a conservative observing treatment cannot be inaugurated without great responsibility. If the case comes under the observa- tion of the physician three or four days after the initial attack, with local and general symptoms abating, and the exudate is being ab- sorbed as shown by repeated palpations per rectum, operation is not indicated. If, however, the exudate does not diminish after six or seven days, operation is indicated to remove the suppurating, focus and thus prevent a general diffusion of the infection from possible rupture of the abscess. Deaver advises deferring operation "in cases where there is a localizing abscess, with diffuse peritonitis, general abdominal tender- ness, with more or less distention and bilateral rigidity, moderately high temperature and rapid pulse, with a low leukocyte count and a large percentage of polymorphonuclears." Such cases, however, must be placed in the Fowler position and an ice-bag applied to the abdomen, saline is to be given by rectum, and they are to receive no nourishment by mouth, and no cathartics. After the acute symp- toms have abated and the abscess is well localized, it is evacuated. TREATMENT 509 It is evident that these cases belong in the hospital, where the details of the treatment can be under the direct supervision of the surgeon. In the chronic forms of appendicitis associated with gastro- intestinal disturbance operation should be done in the interval be- FIG. 189. OPERATIVE TECHNIQUE FOB APPENDECTOMY. A, Incision exposing cecum; B, Cecum delivered, and meso-appendix ligated; C, Ap- pendix ligated; D, Appendix excised. tween the acute attacks. This procedure is practically free from danger and relieves the patient of the chronic gastric distress. THE OPERATION (Fig. 189). In early and interval operations the skin incision is made over McBurney's point and parallel to Pou- part's ligament. The skin, fat and fascia, and aponeurosis of the external oblique are incised; the fibers of the internal oblique 510 APPENDICITIS are separated by blunt dissection, and the peritoneum exposed and opened. To locate the appendix it is well to remember that the anterior longitudinal band, which is plainly seen on the anterior surface of the colon, leads to the inferior extremity of the cecum, at which point the base of the appendix is attached. Hence, to find the ap- pendix, don't search for it,- but locate the cecum and the appendix will be found in the neighborhood of the ileocecal junction. With two fingers introduced into the abdominal cavity search for the cecum and draw it through the incision so that it lies on the abdominal wall, where it is held in position by the released muscles. The remainder of the operation is extraperitoneal. The mesoappendix is clamped and ligated ; the appendix is detached from the mesoappendix and its coats crushed with a clamp near its origin. It is then ligated and removed. The stump is cauterized with car- bolic and alcohol or sterilized with iodin. The operation is com- pleted by suturing the peritoneum and muscular layers with cat- gut. The skin and fascia are closed by a figure of eight suture. The child may be allowed out of bed on the fifth day and the sutures are removed on the seventh day and the patient discharged. In appendicial abscess make the incision over the most prominent part. It is well to remember that in children it is often necessary to drain a secondary abscess on the left side, so that two incisions are necessary, one on the right and another on the left side. Remove the pus as gently as possible and be careful not to tear away the protective barriers. The appendix is removed if it can be easily reached, but it should not be removed if it endangers the patient's chances of recovery. As a rule it is wiser to do nothing but evacuate the abscess. The appendix may be removed at a subsequent operation. Place a rubber drain so that it reaches the deepest possible point and suture all the abdominal layers, leaving only an exit for the drainage tube. Gauze packing should not be used ; as a drain it is useless and is often the cause of fecal fistula. Fecal fistulas are rare since gauze drains have been abandoned. If the cecal wall is infiltrated, TREATMENT 511 or there is a suspicious looking area, it is well to pull down the omentum and make an omental graft over the dangerous spot. In Diffused Peritonitis. Remove the appendix, the source of the infection. Remove as much of the pus as can be reached through the wound with sponges ; the remainder is removed by rub- ber drainage tube. Avoid irritation of the abdominal cavity ; it is not only a futile but harmful procedure since it destroys the pro- tective action of the peritoneum. It is only pus under tension that is harmful; as soon as the tension is relieved its toxic action ceases. Close the abdominal cavity with the exception of the exit for the drainage tube. By complete closure of the abdominal cavity the normal pressure and intra-abdominal tension conditions are restored. Thus the pressure of the abdominal muscles and the diaphragm not only helps to force the pus through the open drain, but the perito- neum is prepared to resume its protective function under normal functional and nutritive conditions. AFTER-TREATMENT. However carefully the operation has been performed, a successful issue of the case cannot be expected without rational after-treatment. Two procedures are of the utmost im- portance : (a) The "Fowler Position." The posture of the patient is of the utmost importance in securing proper drainage. As soon as the patient is returned to his bed he should be placed in the "Fowler position" (half sitting) to direct the drainage toward the pelvis and prevent further toxic absorption through the diaphragm. (b) Prevention of a dangerous lowering of the blood pressure by the introduction of normal saline solution. By the reaction of the inflammation, the vessels of the abdomen are dilated ; the child bleeds into his abdominal vessels ; and, further- more, the suppuration makes a great demand upon the body fluids, all of which contributes to a dangerous lowering of the blood pressure and weakening of the heart action. Restoration of the blood pressure is admirably accomplished by the introduction of normal saline solution by means of the "Murphy drip" (introduction of saline solution into the rectum by the "drop method"). The "Murphy drip," however, is not well borne by chil- 512 INTESTIXAL DISORDERS dren because of their restlessness, and it is better to use small enemas of normal saline every half to one hour. In administering these enemas bear in mind that they must be small enough to be retained not more than two or three ounces. When vomiting ceases fluid may be supplied by mouth. Diffused peritonitis operated upon early by conservative measures gives a good prognosis in children. CHAPTER LXI INTESTINAL DISORDERS INTUSSUSCEPTION All forms of intestinal obstruction are found in children, but by far the most common form in infancy is intussusception or in- testinal invagination. Intussusception is essentially a disease of infancy, three-fourths of the cases being under two years of age. Boys are more frequently affected than girls. Intussusception is the telescoping or invagi- nation of one segment of bowel into the lower adjoining segment (Fig. 190). There are a few instances in which the invagination occurs in the opposite direction from below upward it is very exceptional. Intussusception may occur in any part of the intestine, but in children the ileocecal re- gion is the most frequent site. The anatomical reason for this is evident when it is recalled that the normal ileocecal junction is really in the form of an invagination. The usual form of intussusception is that in which the ileuin with the cecum is prolapsed into the colon, the ileocecal valve form- ing the apex of the protrusion. This form of intussusception may be so extensive that the ileocecal valve may reach the rectum and pro- FIG. 190. INTUSSUS- CEPTION IN VERTI- CAL SECTION. a. Intussuscipiens; b, Intussusceptum. INTUSSUSCEPTION 513 trude through the anus. Note the mechanics of an intussusception in a vertical section. (Fig. 190.) It consists of three layers of bowel. The two inner layers the intussusceptum belong to the prolapsed portion; the outer layer the intussuscipiens the receiving portion. Again, the two prolapsed layers have their peritoneal surfaces in contact; hence the probability of them becoming adherent. The receiving portion and the prolapsed portion have their mucous sur- faces in contact. It must be obvious that mechanical intussusception of itself does not produce intestinal obstruction ; the obstruction is due to the subsequent swelling of the parts and the accumulation of feces. Again, the prolapsed bowel carries along its vascular pedicle the mesentery hence, circulatory disturbances arise venous con- gestion, giving rise to bleeding within the bowel ; and arterial con- striction, producing gangrene of the prolapsed bowel, which may slough off and spontaneous cure result, provided adhesions have previously been formed at the neck of the intussusception. Symptoms. The onset is usually sudden. A previously healthy infant expresses his agony by screaming and moving the legs about at intervals of a few minutes. Between the pain crises the child remains quiet, but not for long; the spasms of pain increase in fre- quency and duration. Vomiting is an early symptom and recurs frequently.- The pale face, drawn features, low temperature, and thready pulse plainly indicate that the vital centers ar^ profoundly affected. Note carefully that obstruction is not an early symptom of intussusception obstruction is secondary. Hence, the child at first expels gas and fecal material but note the special character of the material that is passed by the bowel it is fecal matter in small quantities mixed with mucus and blood. Bloody stools are characteristic of intussusception. The blood passed by rectum is usually in small quantities, but cases are reported in which the hemorrhage was so profuse that death ensued. As time goes on the patient passes into a state of collapse ; con- stipation becomes absolute, and the abdomen is tympanitic. 514 INTESTINAL DISORDERS EXAMINATION OF ABDOMEN. If the abdomen be palpated early and gently it is usually possible to detect at some point of the abdomen most frequently in the right iliac fossa a round or sausage-shaped tumor, which can be moved transversely. As the invagination progresses the tumor increases in volume. It is evident that in ileocecal invagination the tumor follows the course of the large intestine and may finally reach the left iliac fossa and the rectum. EXAMINATION OF RECTUM. In all cases of intestinal obstruc- tion in children never fail to make a rectal examination. This is of special value in intussusception. The bloody mucus which soils the examining finger is in itself significant, while if the invaginated intestine reaches the rectum the finger will come in contact with a soft rounded tumor, which is distinguished from a rectal polypus by its greater volume and the fact that it has no point of attachment to the rectal wall. If the invaginated mass protrudes through the rectum it is dis- tinguished from a prolapsus ani by its dark color and absence of pedicle. Where spontaneous cure occurs, which is rare, a fetid diarrhea marks the expulsion of the sloughing intussusceptum. Diagnosis should not be difficult if we keep in mind the cardinal symptoms sudden onset, violent intermittent pain, bloody stools, and tumor; and the additional fact that invagination is the most frequent cause of intestinal obstruction in very young children (under age of two). In infants it is differentiated from enterocolitis by the presence of a tumor, the profound collapse, and bloody stools. It is differentiated from appendicitis by the absence of fever, the more circumscribed tumor, mobility of the tumor transversely, and bloody stools. The fate of the patient depends upon early diagnosis. Prognosis. After diagnosis has been made only radical removal of the pathological condition can give relief. It must be remembered that results are good only when the opera- tion is done in the first twelve hours. Furthermore, it is not pos- sible from the symptom-complex to get an adequate idea of the INTUSSUSCEPTION 515 severity of the anatomical changes, and the only rational remedy is immediate exposure of the invaginated part. Treatment. Never prescribe a cathartic in any acute abdominal condition only damage is done in intestinal obstruction by pre- scribing cathartics. A purge is a deadly measure in intussusception. Never prescribe opium until the diagnosis has been made and prep- arations for operation begun. METHOD OF PROCEDURE. After complete preparation for opera- tion is made: First: Try bloodless reduction as follows: Give the patient light ether narcosis to relax the abdominal wall. Make a careful bimanual examination per rectum. Endeavor to reduce the invaginated intestine by distention with water. Introduce saline at body temperature per rectum by means of a soft rubber catheter and a funnel held about three feet above the patient. The patient's pelvis is elevated and the glutei pressed closely together to prevent the return of the liquid. With the abdomen relaxed by narcosis any changes in the tumor are easily recognized by means of palpation. If the surgeon is successful the patient should be put to bed and given a dose of opium to prevent the invagination from returning. This method of reduction has the same relation to intussusception as taxis has to strangulated hernia. It also has the same limitations. Second: If irrigation leads to no disinvagination, immediate opening of the abdomen should follow. The tumor-mass should be brought forward and all eventration and chilling of the intestines avoided, as the shock is fatal to chil- dren. The invaginated part is wrapped in hot towels and kept extraperitoneal. The other loops of bowel are replaced. The method of loosening the invaginated gut is very important. Never pull out the invaginated part because of the danger of tear- ing the gut. Try and push out the invaginated part slowly and gently. If manual reduction of the invagination is impossible then resection must be considered. But remember that manual reduction should be done if possible, for it is easier to save a child even with 516 INTESTINAL DISOEDEES a slight laceration of the serosa, which can be patched with omentum, than to subject it to resection. . The technique of resection varies with the location of the lesion and the general rules of abdominal surgery apply. CONGENITAL IDIOPATHIC DILATATION OF THE COLON (Hirschsprung's Disease) This condition has been termed "giant colon" and is character- ized by an enormous dilatation of the colon for which no mechanical or specific cause can be found. The disease is usually observed in young children, who are brought to the physician on account of obstipation. Symptoms. The symptoms are observed soon after birth, and the history given by the parent shows that the child's bowels have never moved normally ; that a movement of the bowel is not possible without the use of an enema. These cases go for weeks without a bowel movement, then for a day or two there will be many large move- ments of foul feces, to be followed again by weeks of constipation (Judd). The disease is more com- mon in boys than in girls, and is characterized by a condition of extreme de- bility and emaciation. The development of the body is retarded by mal- FIG. 191. CONGENITAL IDIOPATHIC DILATATION OF THE COLON. (Escherich's. Case.) IMPERFORATE ANUS AND RECTUM 517 nutrition and autointoxication, while in striking contrast is the greatly distended abdomen. (Fig. 191.) It is evident that the greatly distended colon presses the dia- phragm upward, encroaches upon the thoracic cavity and its viscera, so that respiration is embarrassed and the heart function impaired by displacement. Treatment. Surgery offers the only permanent relief for these cases, since nutritional equilibrium cannot be established so long as the dilated colon acts as a fecal reservoir that cannot be normally emptied. Operation necessitates the elimination of the diseased colon and an anastomosis of the ileum and rectum. The technique of the resection and anastomosis is the same as in the adult. It must be remembered, however, that the long duration of the operation and the narcosis is dangerous to the child. It is essential therefore that the operation be as simple and speedy as possible. All eventration and chilling of the intestines should be avoided; all manipulations should be done extraperitoneally, and the vitality of the peritoneum should be carefully conserved. CHAPTEK LXII DISEASES OF THE ANUS AND EECTUM IMPERFORATE ANUS AND RECTUM There are many curious developmental defects of the rectum and anus, such as absence of the rectum or anus, or both, and again, the opening of the rectum at some unusual point, such as the blad- der, deep urethra, and vagina. The most common congenital defect of the rectum is imperf 'orate anus, occurring most frequently at the anorectal junction. The reason for this defect is apparent. The rectum and anal canal are developed independently of each other. The rectum is developed from the terminal extremity of the hind-gut, the anal canal by an 518 DISEASES OF THE ANUS AND RECTUM invagination at the site of the anus, the septum between the two being normally absorbed and a continuous canal formed. Fail- ure of this partition to absorb re- sults in imperforate anus. The occlusion may consist of a thin membrane, which is readily in- cised, or it may attain consider- able thickness, requiring more ex- tensive operation to obtain relief and establish a permanent canal. Absence of the anus is very FIG. 192. ABSENCE OF ANUS; RECTUM rare (Fig. 192). There is USU- JSch.'T IN A BLIND P UCH ' a11 ? a closed but well-formed anus. If the anus is not devel- oped the sphincter ani does not exist, and therefore when the rectum is brought out through the perineum incontinence follows. If the anus is closed but normally formed it is usual to get continence after operation. Clinical Picture. It is obvious that the clinical picture of im- perforate anus is that of intes- tinal obstruction. It is observed shortly after birth that there is no escape of meconium, the child does not soil the diaper. There are restlessness and vomiting, the child refuses the breast, the urine is scanty, and the skin jaundiced ; the abdomen distends, and unless there is successful in- tervention there are general tox- emia and death. The fact that the child does not soil the diaper is the first FIG. 193. NORMAL ANUS WITH ANO- intimation that there is an OC- RECTAL SEPTUM. (Froelicb.) IMPERFORATE ANUS AND RECTUM 519 elusion of the rectum, and an examination should be immediately made to establish a diagnosis. The child should be placed on its back and the parts thoroughly exposed so that the anus may be examined with the greatest care. If the anus is occluded by a thin membrane, the greenish color of the meconium can be seen through the transparent membrane, which also balloons out when the child cries. Again the anus may be normal, but there may be an anorectal septum occluding the passage (Fig. 193). No examination is com- plete without passing a sound to prove the condition of the anorectal tube. Finally the anus may be absent and there be no bulging of the perineum when the child cries, so that there is no intimation of the depth at which the bowel is oc- cluded. It is obvious that in these cases the prognosis is extremely unfavorable. Examine the urogenital re- gion for external fistulse that communicate with the bowel. These openings are apt to be situated on the under surface of the penis or skin of scrotum; in the female, examine the pos- terior wall of the vagina and the vulva. (Fig. 194.) It is obvious that those cases where there is a total or partial communication with the bladder give the worse prognosis, since in- fection of the urinary tract is inevitable. If the urine is sometimes clear, and at other times mixed with feces, there is a communication with the urethra. If the urine is always mixed with feces the com- munication is probably with the bladder. Treatment. Operation is necessary to restore the normal ana- tomical conditions. The time of operation depends upon the gravity of the malformation. Fistulous communications can wait, but the removal of a total obstruction is an urgent operation and must be relieved as speedily as possible. FIG. 194. RECTUM TERMINATING IN THE VAGINA. 520 DISEASES OF THE ANUS AND EECTUM (1) If the obliteration of the rectum is due to a thin bulging membrane, do not be content with a simple puncture. Place the infant in the lithotomy position, so that the perineum is well ex- posed. Make a crucial incision in the membrane. After the in- testine is completely emptied, wash out the rectum, excise the tags of membrane, and suture the mucosa to the skin. (2) If the rectum is more or less distant from the perineum and does not bulge when the infant cries, it is necessary to search for the rectum by way of the perineum. Give light ether anesthesia and place the infant in the lithotomy position. Make a median incision through the anal dimple (when the anus is present cut the sphincter only once posteriorly) and dissect carefully toward the anterior surface of the sacrum. Take care not to wound the blad- der in front. It can be easily identified by previously inserting a catheter. Proceed carefully along the anterior surface of the sacrum, where the rectum must be found. After the ampulla of the rectum is identified by its bluish appearance, do a blunt dissection with the finger to separate it from the neighboring organs and mobilize it so as to bring it down and forward to the surface of the skin. Be careful to avoid any violent traction which might burst the distended bowel. Carefully tampon the wound with gauze, then incise and evacuate the contents of the bowel. After the wound has been thor- oughly irrigated suture the lips of the incised rectum to the skin with sutures that traverse the entire thickness of the rectal wall and close the deep wound with figure-of-eight sutures. An anus thus formed has a tendency to contract, so that it is necessary to dilate with a sound every day. (3) If the rectum cannot be found as far as the promontory of the sacrum, do a left-sided laparotomy and through this opening endeavor to push the rectum toward the perineal wound. If this procedure fails make an artificial anus (inguinal colostomy). The mortality of operations for anorectal occlusions is very high. They are satisfactory only when the sphincter is present. (4) Operative intervention for abnormal openings of the bowel is less urgent. These cases are bad surgical risks and operation should be avoided until the vital index is sufficiently high. No PROLAPSE OF THE RECTUM 521 formal operations are applicable to these cases. They tax the ingenuity of the surgeon, and each case is a law unto itself. PROLAPSE OF THE RECTUM Prolapse of the rectum is a protrusion of the mucous membrane of the rectum or of the entire rectal wall through the anus. Thus there may be a "partial" or "total" prolapse, and the distinction between the two is not the length but the thickness of the prolapse. "Partial" prolapse is a protrusion of the anal mu- cosa through the anal orifice. (Fig. 195.) It may return spontaneously after the effort of defecation which caused its expulsion. It is due to a relaxation of the cellular tis- sue which holds the mucosa to the muscular coat of the anus. "Total" prolapse is a protrusion of the entire rec- tal wall, caused by a relaxa- tion of the tissues which hold the rectum in place and by an increase in the intrapelvic pressure to which the rectum is exposed. It is a significant anatomical fact that the great majority of cases of rectal prolapse occur between the first and third years, when the erect posture is in the developmental stage, while physio- logical lordosis is as yet incomplete and the sacral curve is still shallow. The rectum not sufficiently adapted to the upright position; the pelvic floor relaxed by the atrophy of malnutrition and lack of muscular tone; the increased intra-abdominal pressure caused by FIG. 195. PROTRUSION OF THE ANAL MUCOSA THROUGH THE ANAL ORIFICE. (Spitzy.) 522 DISEASES OF THE ANUS AND RECTUM straining at stool in the sitting posture are factors which contribute to the descent of the bowel through the anal outlet. Furthermore, such affections as chronic diarrhea, whooping cough, phimosis, vesical calculus, polypus of the rectum, all of which increase intra- abdominal pressure by causing undue and prolonged straining, play an important pathogenic role in the production of rectal prolapse. For rectal prolapse finally represents the unequal struggle between the rectal tissues and the propulsive force which is necessary to expel the rectal contents. Symptoms. Inspection reveals a rosette of mucous membrane covered with glairy mucus sur- rounding the anus, with an orifice at its summit. Usually it can be easily reduced after defecation. If the entire rectum is pro- lapsed we observe an elongated flabby tube curved backward. The orifice at its summit the lumen of the intestine is elliptical and flat transversely. The color of the pro- lapse is a violet red. If it remains for a long time exposed, it swells, bleeds, and presents areas of ul- ceration with a grayish base. It is evident that the protruding rectal mass is composed of two portions of the rectal tube with their serous coats in contact (Fig. 196), and that between the internal and external cylinders there is a potential pouch in which loops of intes- tine may occasionally engage. This form of hernia is known as hedrocele. If the prolapse is continuous there are pain, constant loss of blood, ulceration, and infection, which seriously imperil the child's existence. Diagnosis. There are few lesions that can be confounded with rectal prolapse only two are liable to confuse: (a) Rectal polypus, which is a small tumor and permits the introduction of the finger between its pedicle and the rectal wall. FIQ. 196. PROLAPSE OF THE RECTUM. PROLAPSE OF THE RECTUM 523 (b) Intestinal imagination, which presents the general symp- toms of intestinal obstruction, and permits the examining finger to sweep around between the tnmor and the rectal wall. Prognosis. If the child is properly watched and treated up to the fifth year the prolapse may disappear spontaneously unless pre- vented by congenital causes or by tumors. If the prolapse is not kept reduced the sphincter and muscular floor may be so weakened and stretched that permanent reduction is impossible. Treatment. The tendency of this disturbance is toward spon- taneous cure and a cure can be obtained in a large number of cases by removing the etiological factors and keeping the prolapse reduced. When all digestive disturbance is stopped, and the child is placed under proper hygienic conditions, when all conditions causing abdominal pressure are suppressed and straining at stool is avoided, the tendency to prolapse will soon vanish. PREVENTING THE EXTRUSION BY MECHANICAL MEANS. The cure consists in preventing the extrusion. The indications, then, are first to remove all contributory causes and then to reduce the prolapse and keep it reduced. Persistent care will obviate the necessity of operative procedures. Method. If the sphincter has not entirely lost its tonicity the following procedure will result in curing a large majority of cases. Place the child on the lap face down, and raise the legs so as to get the assistance of gravity. Anoint the prolapse with vaselin and grasp it by the four fingers. Gently compress the prolapse so as to reduce its volume and push it in the anal orifice. Further extrusion of the prolapse is now prevented by placing two adhesive straps across the buttocks so as to hold them firmly together and thus support the anal muscle. After each defecation the parts are cleansed, and protrusion reduced, and the straps renewed. It is evident that this treatment must be repeated several times a day, and the mother or nurse must be instructed accordingly. REDUCTION OF PROLAPSE BY OPERATION. If the prolapse has continued for a long time, so that the sphincter has lost its tonicity, and reduction cannot be maintained, operation is indicated. Many operations have been devised which undoubtedly give excellent re- 524 DISEASES OF THE AXUS AXD RECTUM suits in the adult, but these operations are too severe for children, and the simpler procedures should always be chosen. (a) Cauterization. Light ether anesthesia; preparatory purga- tive and cleansing enema. The paquelin cautery is drawn along the mucous membrane lengthwise of the bowel. The whole thickness of the mucosa is seared (not the muscularis) at four points, in front, behind, and on each side. The operation is completed by inserting into the rectum a rubber tube wound with iodoform gauze and smeared with vaselin. The after-pain is controlled by small doses of opium and the bowels are kept constipated for a week. As the scars heal the resulting cicatricial bands contract and hold the mucosa in good position. (b) Spitzy's Method of Paraffin Injection. The prolapse is re- duced and treated until the mucosa is free from excoriations. Under light ether narcosis, and with careful disinfection of the anal region, the author introduces into the pararectal tissue by means of a syringe holding 5 c. c. two pencil-like splints of paraffin. The point of the filled syringe is inserted one centimeter above the anal orifice and pushed into the pararectal tissue about two and a half inches under control of the finger inserted into the rectum and without encroaching upon the mucous membrane. The injec- tion is made as the syringe is slowly withdrawn and stops just be- fore the point of entrance is reached. In this manner a rapidly hardening pencil-like splint is formed and repeated on the opposite side. After the injection the buttocks are firmly strapped with adhesive plaster for two days. After the first normal defecation the children are discharged. Thirty-two cases with only one failure are reported by Spitzy. The writers have had no personal experience with this method but the excellent results reported are worthy of consideration. (c) Formal Operations. Such as are designed to fix the rectum at a higher level (rectopexy, colopexy, etc.) have no place in the surgery of childhood. If, however, the prolapse is of long duration and its dimensions are such that reduction cannot be considered, amputation of the prolapse is demanded. After careful disinfection, grasp .the prolapsed mass with a wet POLYPUS OF KECTUM 525 bichlorid towel, and cautiously make an incision transversely across the mass a finger's breadth below the anal margin. Look out for intestinal coils in the peritoneal pouch between the two coats of the prolapsed gut. Close off the peritoneal cavity by suturing together the serous surfaces as the incision is extended. After the external tube is entirely divided, the internal tube is excised just in front of the line of sutures already applied and the cut edge clamped with forceps to prevent retraction. The second row of sutures is now applied, including all the coats of the gut. The stump is cleansed and returned and the bowel is kept constipated for a week. POLYPUS OF RECTUM Rectal polypi are benign tumors with a pedicle, implanted on the posterior rectal wall. The character of the polypi found in children are true adenomata ; they are soft, usually single, about the size of a cherry, and of a dark red color. These tumors are at first sessile, but little by little as the tumor drags on the mucous membrane a pedicle is formed. This pedicle may rupture and the tumors be expelled spontaneously. The pedicle is rarely implanted higher than one and a half to two inches above the anus. Etiology. The etiology of polypus of the rectum is a matter of conjecture; we only know that it is an affection specially frequent in children between the second and fourth years and that it is a factor in causing prolapsus of the rectal wall. Symptoms. Painful defecation, frequent desire to go to stool, straining efforts at stool, the frequent presence of blood or of bloody mucus in the stools, vesical tenesmus, and anemia. The staining of the napkin with blood gives the parents the impression that the child is suffering from hemorrhoids. Diagnosis.- The passing of blood with the stools should immedi- ately suggest polypus of the rectum, and a rectal examination should be made. The rectal touch permits us to recognize the pedunculated tumor, which may often be drawn out of the anus. But the 526 DISEASES OF THE ANUS AND- RECTUM pedicle should not be ruptured, as it may cause considerable hemor- rhage. If a satisfactory examination cannot be made with the finger a speculum may be of service. Treatment. Extirpation of the polypus is easily effected by passing a ligature around the pedicle and excising the tumor with scissors. If the pedicle is short it may be necessary to anesthetize and practise forcible dilatation of the anus preliminary to ligation and excision. FISSURE OF THE ANUS Fissure of the anus consists of a small crack or loss of substance in the mucosa of the anal margin. It is really an intrasphincteric erosion hidden in the folds of the anus usually lying on the posterior wall. It is originally due to a superficial tear in the mucosa, caused by the passage of a too large or too hard fecal bolus. Rarely it is caused by the mechanical obstruction of a polypus or the irritation of an enterocolitis. As a rule the child suffering from anal fissure is a constipated child. Symptoms. Sharp pain at time of defecation, slight loss of blood, and spasmodic contraction of the sphincter. Constipation may be the initial cause, or it may be voluntary on the part of the child because of the fear of pain. Whenever a child has a constipated movement with pain and some loss of blood our attention should be directed toward anal fissure, and an examination should be made with this condition in view. Hilton has called attention to the fact that the same nerves which supply the mucous membrane supply the muscular apparatus acting upon that membrane. Observe how this law is corroborated in fissure of the anus. The exposure of the sensory nerve filaments on the ulcer surface causes reflex spasmodic contraction of the sphincter. As the sphincter contracts, it squeezes the sensitive edges of the ulcer; in course of time the sphincter hypertrophies and the symptoms which at first appeared for a short time after stool are later prolonged from one stool to another. Again, the anal canal and the neck of the bladder are intimately PEEIANAL ABSCESS 527 associated through their nerve supply, hence, fissure of the anus is often accompanied by retention of urine. Not only this but the pelvic viscera and the thigh and leg are intimately associated in their nerve supply through the sacral plexus, hence anal fissure is sometimes associated with muscular contrac- tures of the thigh accompanied by pain in the hip and knee a picture simulating coxalgia. In very young children fissure of the anus is rarely recognized; whenever, therefore, there is painful defecation, a rectal examination should be made. To do this satisfactorily light ether anesthesia should be employed. Treatment.- The prime indication is to remove the constipation by mild laxatives. Locally, good results may be obtained by applying directly to the fissure a ten per cent, solution of nitrate of silver or cocain oint- ment. If these measures fail the sovereign remedy is forcible dila- tation of the sphincter under light ether narcosis. The operator inserts both thumbs and gently dilates the anal ring until the muscle is thoroughly relaxed. After operation the patient should be kept in bed for two or three days and given a light diet for easy defecation. PERIANAL ABSCESS Abscesses pf the perianal region are rare in children. The entrance of the infection is through a preexisting fissure or through a recent wound of the anorectal mucosa, sometimes due to the use of the rectal thermometer or to foreign bodies from the intestine. In certain cases they are secondary to an osteomyelitis of the pubis. Symptoms. Whatever the cause, these abscesses have a common symptomatology at the onset there are high fever and pain at the time of defecation. Later there is a hard diffuse swelling about the anus, which later softens and opens spontaneously, discharging a quantity of pus and blood. 528 SARCOMA OF THE KIDNEY In rare instances there may be urinary disturbances due to compression of the urethra. Treatment. Early incision as soon as the abscess is recognized to prevent spreading. The incision should extend into the anal opening to secure a rapid cure and prevent the formation of fistulse. I CHAPTER LXIII SAECOMA OP THE KIDNEY As cancer is the malignant disease of old age, so sarcoma is the malignant disease of infancy. Its relation with the embryonal building material has some probable bearing upon its relative fre- quency in the child's organism. Sarcoma of the kidney is found quite frequently in children during the first decade. It merits special men- tion because of its insidious onset and the enormous proportions that the tumor may attain. As a rule, when the surgeon sees these cases the tumor has ac- quired a volume that makes intervention impossible. While the tumor grows with great rapidity, the general health is not at first affected, the urine is nearly normal, heinaturia is rare, and there are no marked symptoms of pain. It is only later, when the size of the tumor attracts the pa- rents' attention, that sur- Fio. 197. SARCOMA OF THE KIDNEY. (Spitzy.) gical intervention is SOUght. ENURESIS INCONTINENCE OF URINE 529 These tumors grow to such an extent that they fill the entire abdomen (Fig. 197). It is then that symptoms of compression ap- pear : ascites, edema of the lower extremities, suppression of urine, and pressure on the intercostal, lumbar, and sacral nerves. Emacia- tion is rapid and death occurs in a few months. Diagnosis. Rarely is there an opportunity to make a diagnosis before the appearance of a large tumor, and "of all the large abdominal tumors in infancy, a renal tumor is the most frequent." Prognosis. The prognosis is extremely grave. Even after surgical intervention recurrence is the rule if the patient survives the operation. Treatment can consist only of nephrectomy. The size of the tumor compels removal by the abdominal route. In the presence of cachexia operation is contraindicated. CHAPTER LXIV BLADDER DISEASES ENURESIS INCONTINENCE OF URINE The incontinence of urine peculiar to children is the nocturnal incontinence which is manifest by involuntary and unconscious micturition which occurs during the hours of sleep and is not ac- companied by any lesion of the urinary apparatus which rationally explains the infirmity (Bazy). It is an affection often rebellious, and in certain cases resists the most varied treatment. It is noted most frequently in boys, especially in children of a neuropathic diathesis many are epileptics. Symptoms. The incontinence either occurs every night or at certain irregular periods. In nearly every case there is frequent urination during the day. The incontinence is favored by heavy sleep, unusual fatigue, and the ingestion of large quantities of fluid. 530 BLADDER DISEASES Frequently incontinence disappears at the time of adolescence after a grave disease or after a violent emotion (Broca). Diagnosis. In diagnosing true nocturnal incontinence it must not be confused with symptomatic incontinence which occurs so fre- quently as the result of phimosis, preputial adhesions, anal fissures, polypus of the rectum, stone of the bladder, etc. All these varieties of incontinence must be eliminated before a diagnosis of true nocturnal incontinence is established. Treatment. Reprimand and punishment are not only useless but harmful, since they only increase the nervousness which we seek to allay. Begin treatment by establishing proper hygienic measures. Diminish the quantity of fluids, especially at night, avoid coffee, tea, and spiced foods. Do not let the patient become -fatigued, and encourage him to live out of doors. The only internal medication that is worth trying is thyroid extract, which has given some excellent results. If the milder measures are not effective, two operative pro- cedures are suggested which have given remarkable results : (1) Epidural injection of a weak solution of cocain or artificial serum in the sacral canal as suggested by Cathelin. (2) Retrorectal injection of artificial serum as suggested by Jaboulay. Spitzy reports this method as being superior to the epidural injections. It is based on the assumption that nocturnal incontinence results from some functional trouble of the sym- pathetic nervous system which is produced in the hypogastric plexus. By injecting a certain quantity of artificial serum in the retrorectal space, an energetic action is thereby exercised on the sympathetic fibers or the nerve ganglia, either by stretching or by excitation (Spitzy). The needle is inserted vertically at the point of the coccyx; the index finger in the rectum prevents penetration and perforation of the rectal wall. About six to eight drams of serum is injected at one seance. The effect is usually immediate. If necessary the injection may be repeated. VESICAL CALCULI 531 VESICAL CALCULI Etiology. Stone of the bladder is by no means rare in early life, and is most frequently found in poorly nourished children in whom the oxidation of tissues is imperfectly accomplished. Boys are more frequently affected than girls, and the greater number of cases occur between the second and seventh years. Spitzy observes that the urine of the new-born contains an excess of uric acid, which frequently gives rise to a renal calculus. This renal concretion then descends into the bladder. In other words, vesical stone in chil- dren usually has its origin in the kidney. It is an incontestable fact that in the child the central focus of vesical stone is always of uric origin and is not due to vesical infection. The composition of the stone may vary, but the important clinical fact is that the calculi of children are for the most part oxalate of lime stones, more or less voluminous, very hard, of irregular sur- face the typical mulberry calculus. Symptoms. The symptoms in children are more obscure than in the adult. This is due not merely to the child's inability to intelli- gently interpret its sensations, but to certain misleading reflex phenomena and a real difference in the pathological picture. For a long time the symptoms may be so vague that stone of the blad- der is not suspected. Carefully interrogate the parents about the onset of the affection, the character of the pain, the peculiarities of micturition, etc. Pain. The intensity of the pain is very variable. It may be absent, or it may appear in the form of crises, in the course of which the child cries out, stamps his feet, puts his hands on his genitals, and drags at the penis and the prepuce. Rectal prolapse often results from the continued straining. Sometimes there is violent abdominal pain with vomiting, which simulates an intestinal disorder. Later the pain is localized in the bladder, the perineum, and the penis, and we note that it is associated with disorders of micturi- tion (dysuria). 532 BLADDER DISEASES Disorders of Micturition. There is a frequent desire to urinate, due to special irritability of the bladder, which in time may become a veritable incontinence. 'Where there is a history of incontinence, especially an inconti- nence which occurs not only during the night, but likewise during the day, suspect stone of the bladder. Micturition is painful at the beginning, contrary to cystitis, where the pain is terminal. Another characteristic symptom is sudden interruption of the stream of urine, due to the displacement of the stone by the con- tracting bladder and sudden plugging of the neck, which is facili- tated by the absence of the prostate at this time of life. Again, if the stone is small and elongated, it may become en- gaged in the urethral orifice and be the cause of retention of the urine. Hematuria, so frequent in the adult, is extremely rare in chil- dren. Cystitis may appear after a time, accompanied by pain, fre- quent micturition, and purulent urine. Since other causes of cystitis in children are very exceptional the presence of cystitis is strong evidence in favor of stone of the bladder. EXAMINATION. When suspicion is directed toward stone of the bladder by any of the above symptoms, a local examination is next in order; externally, by means of the rectal touch; internally by exploration with the sound. As a rule light ether anesthesia should be employed. A rectal examination is specially valuable in this condition, since the rudi- mentary prostate and seminal vesicles permit us to easily reach the base of the bladder, and when combined with abdominal palpation a hard body like a stone is easily felt; and when the stone is large' enough it may even be grasped between the rectal and abdominal fingers. In exploration of the bladder by means of the sound it is essen- tial that asepsis be observed, that the bladder be moderately dis- tended with sterile water, and that the sound be passed with all gentleness. Once in the bladder the cavity should be thoroughly VESICAL CALCULI 533 explored at all points. The thoroughness of the search may be aided by introducing the finger in the rectum at the same time. If convenient the radiograph may be used, and if the result is positive intravesical exploration with an instrument is thus avoided. Diagnosis. There need be no mistake made if direct rectal ex- amination and exploration of the bladder be employed. Errors arise because of the insidious onset of vesical calculus. Incontinence of urine, when not exclusively nocturnal, should always suggest the possibility of stone of the bladder. The bladder symptoms must not be attributed to phimosis and balanitis without confirmatory evidence. Treatment. Surgical intervention is the only means of remov- ing the cause of the trouble. Suprapubic cystotomy is the operation of choice. This opera- tion is easily performed, since in children the bladder is more of an abdominal than pelvic organ, and an entrance is easily effected just above the pubes without opening the peritoneum. The field of operation is disinfected by tincture of iodin (half strength). The bladder may be inflated with air to increase the anterior surface of the bladder uncovered by peritoneum. A longitudinal incision is made just above the symphysis; the recti are separated and the wound retracted; the prevesical fat is dissected away with the finger; the distended bladder is recognized and seized with two Kocher clamps placed as near the top as pos- sible and on each side of the median line, and the bladder is opened between the clamps in the median line. After separating the blad- der opening the stone is removed by means of a tenaculum. If there is no serious infection or intravesical hemorrhage the bladder should be closed by two rows of superimposed sutures of cat-gut. (It is important to use cat-gut; if silk falls into the bladder it may form the nucleus of a new stone.) The first line of sutures includes all the thickness of the blad- der wall except the mucosa. The second line enfolds the edges by interrupted Lembert sutures. The greatest attention should be paid to the closure of the bladder wound at its lower part, as leakage generally occurs at this point. 534 BLADDER DISEASES When the suture line is complete its effectiveness may be proved by injecting water. Suture the recti muscles, place a drain in the lower angle of the wound, close the skin incision, and leave a self- retaining catheter in the bladder. Watch carefully the bladder drainage and prevent the catheter from being blocked with incrustations by injecting every day a small quantity of boric acid solution. Remove the prevesical drain on the second day and the catheter on the fourth day. This operation is simple, benign, and efficacious, and the results are excellent. TUMORS OF THE BLADDER Tumors of the bladder are rare in children and are of the con- nective tissue types such as sarcoma, fibrosarcoma, myosarcoma, lymphosarcoma, fibromyoma, etc. These tumors appear in the form of polypi usually attached by pedicles to the base of the bladder. Symptoms. The first symptoms noticed are disorders of micturi- tion dysuria, incontinence of urine, pains in the belly, which sug- gest the presence of calculus; but rectal and bladder exploration eliminates all doubt. Cystitis accompanied by hematuria is always suggestive of either bladder tumor or bladder tuberculosis. The hematuria of neoplasm, however, is abundant, spontaneous, and re- bellious to ordinary therapeutic measures. Tumors of the bladder develop rapidly. Their local extension is a grave obstacle to the excretion of urine, hence hydronephrosis and pyelonephritis are possible complications, and death is frequently caused by uremia. These tumors extend and invade the neighbor- ing regions uterus, vagina, prostate, and abdominal wall. Treatment. The outlook for tumors of the bladder in children is extremely grave. Death is the usual termination. In certain rare cases, where the tumor is benign, extirpation may be attempted. In the majority of cases the treatment is symptomatic. PHIMOSIS 535 CHAPTER LXV PHIMOSIS AND PARAPHIMOSIS PHIMOSIS Phimosis is a very frequent anomaly and refers to an abnormal narrowing of the preputial orifice, which prevents the prepuce from being drawn back over the glans. In certain very accentuated cases it may be an obstacle to urination. The degree of phimosis varies considerably, but rarely is there complete preputial occlusion. In connection with this malformation the length of the prepuce is a matter of real importance. In the long prepuce with a narrow opening the pressure of the urine dilates the preputial sac and stag- nates, causing the deposition of phosphatic salts, which, with the smegma, is a source of constant irritation. Phimosis is very frequently accompanied by adhesions between the glans and the inner surface of the prepuce, which are easily broken down. The products of retained secretion are also to be noted in the accumulation of little white cheesy masses (smegma) which collect around the corona of the glans. Phimosis is usually associated with a short frenum. Clinical Course. It is quite evident if the preputial orifice be abnormally small considerable effort is necessary to expel the urine, and that the violent straining, which causes increased abdominal pressure, will predispose the sufferer to such secondary dis- orders as hernia and prolapsus of the rectum. Besides, the stag- nation of urine within the preputial sac predisposes the sufferer to the formation of preputial calculi, analogous to those formed in the bladder. Again, the narrow preputial orifice affords no adequate outlet to the normal secretion and prevents a proper cleansing of the glans ; hence, smegma collects within the cavity, infection follows, and inflammation results, giving rise to balanitis. Not only this, but many reflex nervous phenomena, convulsions, nocturnal incontinence, 536 PHIMOSIS AND PARAPHIMOSIS retention of urine, masturbation, incomplete development of the glans, and liability to venereal infection may be charged to phimoeis. Treatment. The presence of phimosis is an indication for opera- tion. BLOODLESS STKETCHINQ of the orifice by the introduction of a pair of forceps between the glans and the prepuce and gradually opening their blades is very painful to the patient and necessitates subsequent operation. It should not be practised. In very young children, where relief is needed and an anesthetic is to be avoided, the authors simply make a dorsal slit of the prepuce (with or without grooved director) from apex to corona with a single cut of the scissors. This is quickly done and causes only momentary pain. The adhesions are broken up, the glans cleansed, and the wound without suture is dressed with sterile zinc oxid ointment. This is a rapid and satisfactory procedure when anesthesia is not to be employed. In cases where anesthesia is permissible circum- cision is the procedure of choice. CIBCUMCISIOX. This small operation is easily performed, frees the patient at once from his suffering, and disposes for all time of preputial irritation. While this operation is comparatively simple, yet results far from esthetic are often seen. The tendency is to re more too much skin, the operator forgetting that while the skin of the prepuce can be freely drawn forward, owing to its great mobility, the mucous membrane is definitely held in position by its attachment to the corona; hence the skin is frequently excised at a much higher level than the niucosa. Again, the use of phimosis forceps is unnecessary and misli ad- ing and should be abandoned. Operative Procedure. All the disinfection that is practical ran be accomplished by thorough cleansing with soap and water. The instruments required are four hemostatic forceps, a thumb- forceps, a straight scissors and a scissors curved on the flat, two small curved needles threaded with fine catgut, a needle-holder and four fine catgut ligatures, some aseptic gauze and sterile zinc oxid ointment. PHIMOSIS 537 The child is given light ether anesthesia. On each side of the preputial orifice apply a hemostatic forceps and, with the prepuce 10S. Tin; I'IIKIM CK IH HELD TAUT AND A SLIT u MADE ALONG THE DOHHUM OF THE PRE- PUCE WITH SCIHSOHH. FIG. 199. THE EXCESS PREPUCE is REMOVED WITH CUHVEU SCISSORS LEAVING A SMALL COLLAR OF SKIN AND MUCOHA AT BAHE OF CORONA. held taut, make a slit, alonir (he dot-sum of I lie prepuce willi scissors (Fig. 198). Gently break up the adhesions, freeing the prepuce down to the corona, and d'-aiise the glans of all secretion. With the curved scissors remove the -i prepuce, leaving a small collar of skin and iiinco.-a. at the base of the ci.rona ( \'"iii. !!>!)). Li^ate. all bleeding points and be sure that hemostasis is perfect before proceeding further. Large hemato- mata inay form in the loose cellular tissue be- l'' I(J - 200.- -Tun SKIN AND MI;CJHA AUK SI-K iti,i> AND THE ENDB OF CAT-GUT LEFT LONG TO HOLD neath the skin if hemo- THE GAUZE-STRIP DRESSING IN PLACE. 538 PHIMOS1S AND PARAPHIMOSIS stasis is not exact. Suture the skin and mucosa at four or five equi- distant points, tying and leaving the ends of the catgut long, for use in holding the dressing in position. (Fig. 200.) Fold a piece of sterile gauze several thicknesses and three- eighths o^ an inch wide. Tie this strip of gauze in position next to the wound margin by util- izing the long ends of the catgut sutures (Fig. 201), and smear the dressing freely with sterile zinc oxid ointment. This ambulatory dressing tied in with the sutures affords sufficient protec- tion, and at the end of a week, when healing is complete, falls off with the absorption of the catgut. The dressing should be kept well smeared Fio. 201. GATJZB w ith zinc oxid ointment or carbolized vaselin to DRESSING TIED IN ... PLACE. prevent the urine soaking into the dressings. PARAPHIMOSIS Paraphimosis is a sequela of phimosis. The child out of simple curiosity or during masturbation slips the exuberant foreskin back of the glans into the coronal groove, and the retracted prepuce thus forms a constricting ring at the base of the glans. The prepuce becomes edematous, swells to enormous propor- tions, and finally necroses. In extreme cases a constriction that is allowed to go unrelieved may cause gangrene, but usually ulceration of the constricting ring results in spontaneous cure. Treatment. In most cases reduction is accomplished by holding the glans between the middle and index fingers and pushing in the glans with the thumb. It is better to use light anesthesia. If efforts at reduction fail, or if gangrene threatens, taxis should be abandoned and the constricting ring of prepuce should be incised on a grooved director and then do whatever plastic operation the condition requires. HYDEOCELE 539 CHAPTER LXVI DISEASES OF THE TESTIS HYDROCELE Hydrocele ordinarily refers to an accumulation of serous fluid in the tunica vaginalis. It is frequently found in the new-born and during the first months of life. Normal and Pathological Anatomy. To appreciate the varieties of hydrocele and rationally account for the same, it is only neces- sary to recall the fact that the testicle in its descent from the abdomen into the scrotum is preceded by a pouch of peritoneum the processus vaginalis. At birth the portion of the pouch extend- ing from the internal ring to the upper part of the testicle is normally closed and obliterated, the lower portion of the pouch re- mains as the tunica vaginalis testis. Suppose that normal obliteration of this process is defective, then it is obvious that the hydrocele may occupy the whole or any part of the peritoneal pouch (processus vaginalis). Hence the variety of hydrocele depends upon the variety of defect in the obliteration of the peritoneal pouch. Varieties. In congenital hydrocele the whole peritoneal pouch remains open and is filled with serous fluid. It may communicate with the peritoneal cavity by a very narrow opening, in which case it is characterized by being reducible under pressure. Furthermore, there is a noticeable variation in size. It fills up during the day and empties during the night, or may disappear for a time, a fact often noted by the parents. In a badly nourished child a communi- cating hydrocele may be symptomatic of tuberculous peritonitis. In infantile hydrocele the upper part of the peritoneal pouch is closed, the lower portion communicates with the tunica, and when distended with fluid is liable to be mistaken for an inguinal hernia. In encysted hydrocele of the cord the peritoneal pouch is closed above and below, the intervening portion being distended with fluid. 540 DISEASES OF THE TESTIS Infantile hydrocele is frequently found in the new-born and is often accompanied by edema of the scrotum. It lasts but a few days and is probably due to some injury received by the scrotum at birth. Symptoms will depend upon the variety of hydrocele. In congenital hydrocele there is a smooth, tense, elastic, ovoid tumor of the scrotum; flat on percussion, and usually reducible under gentle pressure. The volume of the tumor varies, gradually emptying during the night when the child is recumbent and refill- ing during the day when the child is about. There is more or loss impulse on crying or straining. The tumor is translucent when a light (candle or electric bulb) is placed behind it, and the examiner looks through a cylinder of rnetal, rubber, or partially closed hand pressed against the opposite side. In infantile hydrocele the symptoms are similar to those of con- genital hydrocele, but the tumor is not reducible. In encysted hydrocele of the cord there is felt one or more small, rounded cystic tumors, about the size of an almond, connected with the cord, and distinct from the testicle. They are very mobile in all directions and may be forced en masse into the inguinal canal and thus mislead by an apparent reduction. Diagnosis. The practical point in hydrocele is the fact that it simulates hernia, from which it is to be differentiated. It is not infrequent to find a truss applied to a hydrocele of the cord, mis- taken for a hernia. The character of the tumor depends upon its contents. Is it a loop of gut or free fluid ? Get a careful history from the parents ; if the swelling extends over a long period without general disturb- ance it points to hydrocele. Note if reduction is difficult. If the volume of the tumor is larger during the night than during the day, it points to congenital hydrocele. The reduction of a hernia by taxis is sudden and accompanied by gurgling, in a congenital hydrocele it is slow and silent. A hernial tumor reappears suddenly on coughing or straining, a hydro- cele reappears slowly. Intestine is resonant on percussion, hydrocele is flat. A hydrocele is translucent ; but it must be remembered that the HYDROCELE 541 light test in infants is not reliable as a differential, since hernia in a child may also be translucent. Treatment. It must be remembered that congenital hydrocele has a tendency to spontaneous cure during the first months of life by physiological obliteration of the sac. The expectant treatment is worth trying in all hydroceles of childhood. If the hydrocele persists or increases, in size a radical cure is indicated. In the RATIONAL TREATMENT of hydrocele it must be evident, first, that no external application of any medicament can be of therapeutic value ; second, the possible communication of the sac with the peritoneal cavity em- phasizes the dangers of inject- ing such substances as carbolic acid and iodin to obliterate the sac. Such procedures are un- safe and cause unnecessary com- plications (sloughing of scro- tum, suppurative orchitis, etc.). A certain number of cases will be cured by simple aseptic as- piration. Operation. The skin is prepared by painting with tinc- ture of iodin (half strength). The sac is made tense and the aspirating needle inserted so as to avoid the testicle, which lies at the lower posterior portion of the scrotum. The puncture should be made in front and above, the needle pointing upward and backward. (Fig. 202.) After with- drawal of the fluid the puncture is closed with collodion-aristol. If after several tappings there is recurrence, a radical cure is indicated. RADICAL CURE is the least dangerous and the most efficient remedy. The procedure is practically the same as for the radical cure of hernia, viz. : isolation and excision of the sac. HYDROCELE COMPLICATED BY HERNIA should be treated by aspi- ration and truss. If not cured after two years do a radical cure. FIG. 202. TAPPFNG A HYDKOCELE. (Keen's Surgery.) 542 DISEASES OF THE TESTIS HYDKOCELE OF THE CANAL OF NUCK in girls is treated on the same principles as stated above. UNDESCENDED AND MISPLACED TESTICLE It will be recalled that in normal development the testicles migrate during fetal life from the abdomen, through the inguinal canal, to their permanent position in the scrotum. It is evident that in faulty development either the testicle may permanently lodge at any point between its original site and the scrotum un- descended testicle- or it may descend, but finally lodge in some abnormal position mis- placed testicle. Undescended Testicle (Cry pt or chid is w.) Here the testicle in its migration has failed to reach the scrotum and may be retained (a) in the abdomen; (b) in the inguinal canal (most fre- quent) ; (c) just exter- nal to the external ring. This malformation may be either unilateral or bi- lateral. (Fig. 203.) Misplaced testicle (ectopia testis) may take a position (a) in front of the thigh near the saphenous opening; (b) in the perineum in front of the anus. These abnormal positions of the testicle have not only an important physical and psychical influence on the growth of the individual, but they are associated with grave pathological possibilities. It must be remembered that the testicle is not only a gland with a procreative function, but it is a gland with an internal secretion essential to the development of the distinctly masculine type. FIG. 203. BILATERAL-INGUINAL UNDESCENDED TESTICLE. UXDESCEKDED AXD MISPLACED TESTICLE 543 Unilateral ectopia may be compensated by an increase of the other testicle and a vigorous masculine type be developed, but in bilateral ectopia degeneration is manifest in rudimentary organs and a reversion to the feminine type. Hence these sufferers should receive the most careful consideration since their fate largely de- pends upon their management before puberty. Complications. (a) An undescended testicle is usuany an im- perfectly developed organ, and if not corrected before puberty its ability to secrete spermatozoids is probably lost; hence, in bilateral displacement, the individual is probably sterile. (b) These children have an open vaginal process, which sub- jects them to the danger of a present or potential hernia. (c) These misplaced testicles are predisposed to torsion of the cord from the action of the inguinal muscles, which gives rise to severe disturbances, such as pain, nausea, and vomiting, frequently simulating appendicitis or strangulated hernia. (d) Imperfect development, constant irritation, and pressure of surrounding structures predispose the retained testicle to malig- nant disease (sarcomatous degeneration). (e) The deformity itself is important enough to warrant every possible means being used for its correction. Prognosis. Remember that the majority of undescended testicles are cases of delayed descent, and a large number will make their way to the scrotum before the age of puberty; hence early inter- ference is contraindicated except for complications ; and castration in a child is under all circumstances to be avoided. Symptoms. Do not mistake retracted testicle for undescended testicle. It will be recalled that in childhood the inguinal canal is patent and the cremasteric reflex strong; it is not unusual for one or both testicles to be drawn up temporarily by the cremaster muscle into the inguinal canal and thus simulate undescended testicle. It has happened that a surgeon prepared to operate for undescended testicle finds, after anesthesia is established, both testicles in the scrotum. Retracted testicle is temporary, retained testicle is permanent. Hence absence of testicle in the scrotum is to be considered sympto- 544 DISEASES OF THE TESTIS matic of undescended testicle only with the above reservation. An unusually small and undeveloped scrotum is found in all these chil- dren, the result, not the cause, of the condition. Careful examination of the inguinal canal and its surroundings will usually disclose the position of the testicle (unless within the abdomen), and the discovery of a small tumor in the canal, pain- ful on pressure, taken in connection with the empty scrotum, may be regarded as a reliable symptom of non-descent. Failing to find the testicle in the inguinal region, the region over the saphenous opening and the perineum should be searched for misplaced testicle. Treatment. Remember that a large number of undescended testicles will make their way into the scrotum before the age of puberty. Hence uncomplicated undescended testicle needs no treatment before the tenth year. Operation should be done between the tenth and twelfth year. In very early childhood massage may help to bring the testicle down, but after this period it is a useless pro- cedure. COMPLICATIONS. In nearly all cases of undescended testicle situated in the inguinal canal a congenital hernial sac is present. Hence hernia and undescended testicle are usually coincident. It will be readily appreciated how difficult it is to keep the hernia in place without injuring the testicle; not only this, but there is always danger of strangulation. It is sometimes possible to keep the hernia in place by means of a "forked truss" a truss with a "forked" pad to avoid pressure on the testicle. However, all forms of truss cripple the child and cannot be worn without danger. Hernia complicating undescended testicle is a positive indication for opera- tive interference. In the early months no truss, no treatment, is necessary, since the dangers of strangulation at this period are very small. But when the child reaches from the second to the third year (depend- ing upon its nutritional coefficient) an operation for the radical cure of the hernia and retained testicle should be performed. Hence, the following rules of treatment should be observed: UNDESCENDED AND MISPLACED TESTICLE 545 (a) Uncomplicated undescended testicle operation between the tenth and twelfth years. (b) Undescended testicle complicated with hernia operation between the second and third years. (c) Massage in very early childhood is permissible, but it is difficult, sometimes dangerous, and seldom successful. Operation. The operation of Bevan has been so perfected that its author claims that testicles which lie entirely within the abdomen can in almost all cases be brought down and retained permanently in the scrotum. FIG. 204. INCISION THROUGH SKIN, SUPERFICIAL FASCIA, APONEUHOSIS OF THE EXTERNAL OBLIQUE, AND THE PERITONEAL POUCH OPENED. (Bevan.) The technique of the operation, as given by its author, is as follows ("Keen's Surgery," Vol. IV, p. 594) : "An incision is made about three inches long over the inguinal canal. This cut should divide skin, superficial fascia, and the aponeurosis of the external oblique. "Under the external oblique will be found a pouch of peritoneum extending from the abdominal peritoneum through the canal and down to the scrotum. Sometimes the pouch extends to the bottom of the scrotum, even in cases in which the testicle has never been out of the abdominal cavity. This pouch of peritoneum is covered 546 DISEASES OF THE TESTIS by the cremasteric muscle and fascia, and the transversalis fascia. These thin layers should be divided and the peri- toneal pouch opened. (Fig. 204.) The vaginal process of peritoneum should be divided transversely well above the tes- ticle. Care should be taken not to injure the cord, and in chil- _, dren, where the peritoneal proc- FIG. 205. UPPER END OF VAGINAL PROCESS LIGATED. PDRSE-STRING SUTURE CLOS- ess IS as delicate as tissue pa- ING LOWER END OF VAGINAL PROCESS AND FORMING A TUNICA VAGINALIS FOR per, the dissection must be THE TESTICLE. (Bevan.) .,, i -,T made with great care and with small instruments. After complete transverse division of the vaginal process the upper end is closed with a catgut ligature, as is the sac in a hernial operation, and the lower end is closed with a purse- string suture, making a tunica vaginalis for the testis. (Fig. 205.) Then with a gauze sponge the peritoneum is carefully wiped off from the cord. As the wiping proceeds the cord will gradually lengthen until the testicle can be brought well down upon the thigh. // "Tense fibrous strands in the cord are to be torn either with the fingers or blunt dissecting forceps, and the cord is to be freed of everything except the vas and th^ vessels. (Fig. 206.) "When, as in the excep- tional case, a large peri- toneal pouch extends to the bottom of the scrotum, FIG. 206. CORD LENGTHENED, TESTICLE IREED the testicle can now be AND READY FOR REPLACEMENT. (Bevan.) TUBEKCULOSIS OF THE TESTICLE 547 pushed into this and retained by a purse-string suture within the neck of the scrotum. As a rule, however, it is necessary to make a cavity by blunt dissection with the finger. (Fig. 207.) "In a few cases but these will be quite the exception it is found, even after the free exposure of the cord, that it is not long enough to permit of the reduction well into the scrotum. In such cases it will be seen that the shortened structures are the spermatic artery and veins. These can be divided between two ligatures, care being taken to avoid injury to the vas and the vessels of the vas. "It will then be found that the testicle can by gentle trac- tion be brought down sufficiently to replace it in the scrotum without tension. "The wound is now closed as in an ordinary hernia operation, not transplanting the cord as is done in the Bussini operation, but allowing it to remain in its normal position. The success of the operation depends upon free- ing the testicle so completely that it can be placed in a roomy FIG. 207. MAKING POCKET IN THE SCRO- pocket Well down in the SCro- TUM FOR RECEPTION OF THE TESTICLE. . , (Bevan.) turn without tension. TUBERCULOSIS OF THE TESTICLE Tuberculosis of the testicle, although not frequent in childhood, is by no means rare. Statistics show that it is a disease of early childhood, usually before the age of seven years. It is an interest- ing observation that undescended testicle, which is frequently the site of malignant growths, is rarely affected by tuberculosis (Broca). Clinical Picture. In children the lesion first appears in the testicle itself, whereas in the adult the epididymis is where we ex- pect to find it. 548 DISEASES OF THE TESTIS While we observe the same general characteristics of the disease in children as in adults, there is one clinical feature which merits special attention the frequency of the acute form of tuberculous orchitis in very young children. Without any previous warning of local disease the testicle suddenly becomes the site of acute inflam- matory reaction, which subsides in a few days, leaving only some nodulated areas; or it may go on to the formation of a tuberculous abscess, which opens and leaves in its wake a fistulous tract. As a rule the process is subacute or chronic, marked by swelling of the testicle, which feels hard and nodular. At times the testicle and epididymis form a tumor mass, in which the two cannot be distinguished. The involvement of the cord is evidenced by thick- ening, induration, and nodular areas along its course. The blad- der, prostate, and seminal vesicles are much more rarely invaded in children than in adults. The clinic form may follow an acute attack, or it may be chronic from the start. Diagnosis. As a rule the diagnosis is not difficult. The tume- faction, nodulation, involvement of the cord, suppuration, and fistulization are all characteristic. In the chronic form it will be necessary to differentiate syphilitic testicle and malignant disease. Remember that syphilitic testicle is observed very early, especially in the new-born, associated with other signs of hereditary syphilis ; that its progress is very indolent, and that the affection is usually bilateral. It is not characterized by suppuration and is amenable only to antisyphilitic treatment. Malignant disease is recognized by the rapidity of the growth and the size it attains. Treatment. The treatment of tuberculous testicle in childhood should be hygienically radical, but locally conservative. Unlimited fresh air and sunshine, with substantial alimentation. Rest in bed if the process is acute, and suspension of the testicle in all cases. Here, as in other parts of the body, the local infection is often con- quered by raising the vital resistance of the body tissues through improved hygienic measures. A high vital index is more efficacious than the knife. The acute abscess requires simple incision. The chronic abscess EPISPADIAS 549 should be aspirated and injected with iodoform and glycerin emul- sion. Fistulous tracts require curetting and cauterization. Castration is rarely called for. SARCOMA OF THE TESTICLE The testicle is a frequent site of malignant growths in child- hood. It is possible that traumatism plays a part in the causation of these tumors and explains the relative frequency of sarcomatous degeneration in undescended testicle. The starting point is usually in the testicle itself, but soon the epididymis is involved and the process rapidly extends along the spermatic cord to the abdominal cavity. If untreated, the scrotal tissues become involved and present a fungous mass of ulcerating tissue. Deep palpation of the abdomen will reveal enlarged glands in the iliac and lumbar region. The later stages exhibit the usual evi- dences of cachexia and malignant toxemia. The rapidity of the growth and futility of specific treatment distinguish it from tuberculous or syphilitic testicle. Treatment. Removal of the testicle and the cord as high up as possible as soon as the disease is recognized. Results, however, are not promising; recurrence is the rule. Bevan's suggestion to supplement castration by an extended treatment with Coley's mixed toxins is worth trying. CHAPTER LXVII EPISPADIAS AND HYPOSPADIAS EPISPADIAS Pathology. -Epispadias is a congenital malformation character- ized by an abnormal opening of the urethra on the dorsum of the 550 EPISPADIAS AND HYPOSPADIAS penis. It is a rare deformity and is often associated with congenital vesical fissures. The developmental explanation of this defect is somewhat ambiguous. According to Taylor, the erectile bodies have become reversed, so that the corpus spongiosum occupies the dorsal position, and hence urethral defects present on the dorsal surface. The deformity varies according as the defect involves the entire length of the penile urethra or only a part. We distinguish two varieties of epispadias according to the position of the cleft : peno- pubic epispadias and balanic epispadias. In penopubic epispadias the defect involves the entire length of the urethra, and there are often associated malformations, such as exstrophy of the bladder, hernia of the bladder, and undescended testicle. In balanic epispadias (much more rare than the complete) the urethral opening is on the dorsal surface at the base of the glans, the urethral segment of the glans being represented by a dorsal groove. The penis is atrophied and drawn up toward the pubis; the prepuce is redundant and lies like an apron over the ventral side of the glans, so that it is necessary to draw the penis down by seizing the redundant foreskin of the inferior surface, to perceive the median groove. Symptoms. The symptoms vary according to the variety of epispadias. This deformity causes grave trouble in micturition, and later it compromises the sexual function. In partial epispadias the urine can be retained, but the abnormal stream of urine spreads out laterally and soils the neighboring parts. In complete epispa- dias incontinence of urine is the result. The sexual function is compromised by atrophy of the penis, which is a future obstacle to coitus, and the seminal fluid escapes in a dribble and cannot be projected into the vaginal canal. It is well to note that epispadias in the female is very rare, and the changes in the conformation of the external genitals will hardly be recognized by the parents. The incontinence which accompanies the deformity in the female is the only symptom which suggests its presence. The sexual function is normal. Treatment. In cases of epispadias with incontinence of urine EPISPADIAS 551 no local plastic operations will restore the bladder sphincter; it is necessary, whether there is a coexisting exstrophy of the bladder or not, to treat the epispadias in the same manner by implanting the ureters into the bowel. In the milder forms of epispadias an endeavor is made to create normal conditions by changing the groove into a tube by the use of plastic flaps. It is obvious that, in order to create proper conditions for heal- ing, the urine must be temporarily diverted from the newly con- structed urethra. Hence: As a necessary preliminary step, perineal FIG. 208. DUPLAY'S OPERATION FOR EPISPADIAS. A. The denuded surfaces on each side the corpora cavernosaj B. The denuded surfaces brought together over a glass rod, and fixed with quill and button sutures. drainage should be instituted (external urethrotomy) and main- tained until healing of the new canal is complete. In constructing the new canal the operation of Duplay is by far the most satisfactory. The roof of the urethra is formed by denuding "a rectangular strip of tissue about one-fourth of an inch in width from each side of the corpora cavernosa, and three-fourths of an inch from the middle line of the dorsum of the penis, extending from the apex of the glans penis down to the epispadiac opening." (Horwitz.) The denuded surfaces are brought together by quill and button sutures, over a glass rod or catheter (Fig. 208). After healing is Or OSTEQl^ PI /i 10 ^ \ 01 Mr ,M: 552 EPISPADIAS AND HYPOSPADIAS complete it will be necessary to form a junction between the new urethra and the epispadiac opening by freshening and firmly ap- proximating the edges. It may be necessary to do several minor plastic operations before the closure is complete. HYPOSPADIAS Pathology. Hypospadias is characterized by an abnormal open- ing of the urethra on the under surface of the penis, and may vary from a small opening to a complete defect of the penoscrotal urethra. This malformation is quite frequent, especially the variety in which the abnormal orifice is situated on the under surface of the glans. Heredity undoubtedly plays an important role in the appearance of this defect, since there are certain hypospadiac families. Broca FIG. 209. HYPOSPADIAS OF THE GLANS (diagram). A. The urethral opening is at the base of the glans with a groove on the under surface of the glans extending from the abnormal orifice to the normal position of the meatus; B. Abnormal orifice, and a normal meatus, but its canal ends blindly. and Mouchet observe that it is a frequent malformation among the Bourbons. Clinical Varieties. There are three varieties of hypospadias, di- vided according to the position in which the termination of the urethra is found. (1) Hypospadias of the Glans. The urethral opening is at the base of the glans, sometimes so small that it can scarcely be dis- covered. As a rule there is a more or less pronounced groove on the under surface of the glans, extending from the abnormal orifice to the normal position of the meatus (Fig. 209A) ; or there may be an abnormal orifice and a normal meatus, but its canal ends blindly (Fig. 209B). The glans is small and curves downward ; the frenum is absent ; the prepuce though exuberant covers only the superior and lateral 1. rj 3 J J HYPOSPADIAS 553 surfaces of the glans, and is wanting on the inferior aspect of the glans. This appearance of the prepuce alone is sufficient to permit a diagnosis of hypospadias. (2) Penile and Penoscrotal Hypospadias. In penile hypospa- dias the urethral open- ing occupies a point somewhere on the in- ferior surface of the penis. (Fig. 210.) In the penoscrotal variety the urethral orifice is further back, at the penoscrotal angle. There may be a ure- thral canal in front of the abnormal orifice (Fig. 21 IB), or simply a more or less devel- oped groove (Fig. 211 A) ; or in place of the groove there may be a fibrous band extending between scrotum and the inferior surface of the penis by which the penis is held curved downward. FIG. 210. PENILE HYPOSPADIAS. (Broca.) FIG. 211. PENOSCROTAL HYPOSPADIAS (diagram). A. Penoscrotal orifice with a groove in front; B. Penoscrotal orifice with a blind urethral canal in front of the abnormal orifice. (3) Scrotal or Perineoscrotal Hypospadias. In this more ex- tensive fissure of the genital organs the formation approaches the female type. The scrotum is divided into two independent pockets, 554 EPISPADIAS AXV HYPOSPADIAS the urethral orifice opening between them or at the perineoscrotal angle. The testicles are generally atrophied and ectopic. It is evi- dent that as the meatus lies between two cutaneous folds resembling the vulva, and the atrophied penis is not unlike the clitoris, this variety presents an appearance which closely resembles the external genitals of the female (hypospadias vulviforme), and that errors in sex may be easily made at birth from a superficial examination. In cases of doubt a rectal examination should be made to establish the presence or absence of a uterus and its adnexa. Even with a rectal examination the findings are often vague, and in extreme cases it is impossible to determine the sex. Hermaphrodites are in the majority of cases really pseudohermaphrodites of the male sex affected with perineoscrotal hypospadias. Functional Disturbances.- Functional disturbances vary accord- ing to the position of the abnormal opening, and affect the functions of micturition and generation. In hypospadias of the glans func- tional disturbances are less serious, although the orifice may be so small as to cause retention and its attending complications. The stream of urine is usually projected forward and is not scattered over the scrotum. Coitus and fecundation are possible. In other varieties penile, penoscrotal, and scrotal the urine is scattered over the neighboring parts, soiling the clothes, and pro- ducing a disagreeable erythema. In order to pass the urine to the best advantage these patients assume the squatting position like women. Coitus is usually impossible, and even when possible fecundation is improbable. It is obvious that subjects affected with perineoscrotal hypospadias are capable of alternately playing the role of either male or female. Treatment. The object to be attained is the restitution of normal anatomical conditions by freeing the penis, reconstructing the urethra and imbedding it below the skin surface. This is ac- complished by a series of plastic operations. INDICATIONS FOE OPERATION. If the opening is so small that retention is imminent it should be freely incised to avoid the conse- quences of stricture, otherwise hypospadias requires no immediate operative treatment. In the milder cases where the orifice is of HYPOSPADIAS 555 normal dimensions and is situated near the normal tneatus no opera- tion is required. In cases of balanitic hypospadias where the orifice is at the base of the glans, or a short distance away, operation should be considered, but not before the child is four years of age. This variety of hypospadias is best corrected by the operation of Beck. In restoring the penile urethra various plastic methods may be used, and the ultimate result is attained only by operating in dif- ferent stages. In the scrotal variety of hypospadias surgical treatment can ac- complish nothing. In all operations for hypospadias the prognosis can never be assured. Time, patience, and surgical ingenuity will often accomplish satisfactory results, but under the most favorable circumstances the prognosis is conjectural. OPERATIONS. Beck's Operation for Balanitic Hypospadias. This procedure is described by Beck as "a forward dislocation of the urethra. In place of forming a new urethra the existing one is utilized by dissecting it free and dislocating it forward, so that a new canal does not need to be created, the existing urethra perform- ing its function." This operation utilizes the elasticity of the urethra, which can be stretched to a considerable degree without injury. The operation is conducted as follows: The urethra is first exposed by two lateral skin flaps. (Fig. 212 A.) The urethra is dissected out and isolated from the surrounding parts for about an inch so that it can be drawn to the extremity of the glans without difficulty. The glans is transfixed with a iiarrow-bladed knife from base to tip. (Fig. 212B.) The loosened urethra is pulled through the new canal (Fig. 212C) and fixed to the edges of the opening by four silk sutures. The skin flaps are sutured in position. (Fig. 212D.) In penile or penoscrotal hypospadias, whatever plastic procedure is chosen, the first step consists in freeing the penis from any exist- ing adhesions, and correcting curvatures. For until the penis is straight and able to lie on the anterior abdominal wall no opera- tion for forming a new urethral canal should be attempted. After straightening the penis the new canal may be formed by various plastic procedures. The authors consider Rochet's opera- 556 EPISPADIAS AND HYPOSPADIAS tion for penile hypospadias and Bucknall's operation for penoscrotal hypospadias as the easiest and most rational procedures. FIG. 212. BECK'S OPERATION. (After Beck.) A. Incisions for exposing urethra; B. Tunneling of glans penis; C. The loosened urethra drawn through the new canal; D. Flaps sutured in position. Rochet's Operation. A transverse incision is made in front of the hypospadiac opening and a subcutaneous channel is tunneled by HYPOSPADIAS 557 means of a blunt instrument to the base of the glans. A meatus is formed by making a transverse slit in the glans and the blunt instrument is passed on to the opening in the glans (Fig. 213A). The channel thus tunneled is prepared to receive the newly formed urethra, which is made by taking a flap from the scrotum with its base at the hypospadiac orifice. This flap with the skin surface turned in is sutured about a ^To. 21 French catheter (Fig. 213B). The catheter thus covered with the skin flap is drawn through the previously prepared channel and the edges of the newly formed urethra are sutured to the new meatus (Fig. 213C). The catheter FIG. 213. ROCHET'S OPERATION. A. Tunneling of penis and glans; B. Skin flap sutured around catheter; C. Newurethral canal reversed and drawn through tunnel to tip of penis. (Rochet.) is pushed into the bladder and retained. The raw surface is covered by approximating the skin edges with sutures. (Fowler's Surgery.) BucJcnall's operation, as described by J. K. Murphy, is as follows (Fig. 214) : "First Stage: The penis is first drawn up over the abdomen and kept in position while the scrotum is stretched downward. Two vertical incisions are now made on either side of the middle line of the penis and scrotum ; these should be about a quarter of an inch apart, and are so arranged that the position of the urethral orifice is in the mid part of the median strip of skin thus defined (Fig. 214A). This median strip will form the new urethra; its penile portion, 558 EPISPADIAS AND HYPOSPADIAS or that in front of the meatus, part, or that behind the meatus, FIG. 214. BUCKNALL'S OPERATION FOR PENOSCROTAL HYPOSPADIAS. (Burchard.) A. The vertical and horizontal inci- sions for the flaps; B. Flaps dis- sected up and turned back ; C. The penis secured to the scrotum; D. Flaps sutured together and sutures tied over small piece of drainage tube; E. New urethra closed in by flaps dissected from the scrotum ; F. Raw area closed by suturing edges of skin. is to form the roof; and its scrota! the floor. At either ends of the two longitudinal incisions, lateral in- cisions are now made outward for about a quarter of an inch, and two lateral flaps are now dissected up from end to end of the lateral in- cisions. These should be of the same thickness throughout. They are now turned back, and we have now the stage reached in Fig. 21-4B, which shows the central line of skin to form the new urethra, and the new surfaces on either side formed by the lateral flaps turned back. "A soft rubber catheter is now passed into the meatus for about half an inch, and then laid along the lower half of the median strip of skin. "All is now ready for the next stage. In this the upper half of the strip of skin is brought down over the catheter with the penis to form the roof of the urethra. Thus the penis is brought down into con- tact with the scrotum as in Fig. 214C; each lateral flap is bent on itself at the middle to form a broad edge on each side. The flaps must be carefully sutured together in such a way that each suture takes in not only the outer skin edges, but approximates the skin edges which are to form the urethra round the catheter. The method IMPERFORATE HYMEX 559 is shown in Fig. 214D. Five or six fine sutures are put in on each side and tied over a small piece of drainage tube. The catheter is now secured by a suture and made to drain into a bottle. The catheter is left in for a week and the sutures removed about the same time. "Second Stage: It now only remains to free the penis from its position fixed to the front of the scrotum, and to provide a skin covering for its under surface. This final result is obtained by making an incision on the scrotum as in Fig. 214E. These incisions should be some way distant from the penis on either side, so as to provide a flap wide enough to cover its under surface without ten- sion. These flaps are now dissected up from the scrotum, care being taken not to injure the new urethra at the root of the penis. The flaps are now sutured together on the under surface of the penis, as in Fig. 214E, and the raw surface on the scrotum obliter- ated by bringing the edges together as in Fig. 214F. This operation is ingenious and most effectively meets the anatomical requirements; it is therefore freely quoted. CHAPTEE LXYIII MALFOEMATIONS OF THE FEMALE GENITALS There are various minor malformations of the female genitals, such as hypertrophy of the labia minora, hypertrophy of the clitoris, which may demand amputation. We also find that hypospadias and epispadias occur in the female, though they are much more rare than in the male. The treatment requires suitable plastic opera- tions similar to those described for the male genitals. Imperforate Hymen. The malformations of real clinical im- portance, however, are the imperf 'orations of the hymen, vagina, and uterine canal. The important fact is that there are usually no ex- ternal evidences of these defects and they remain unrecognized until puberty and the establishment of the menstrual flow. At this time there appear sharp colicky pains, the exact cause 500 MALFORMATIONS OF THE FEMALE GENITALS of which is at first not recognized. These painful crises show a periodic character corresponding to the menstrual epoch. They become more and more intense, with some peritoneal re- action, and finally a fluctuating tumor may appear above the pubis and menace life by its possible rupture. The gradual collection of menstrual fluid distends vagina, uterus, and tubes, and unless re- lieved may rupture into the peritoneal cavity and be followed by peritonitis. A history of periodic pain beginning at puberty without men- strual flow should suggest an examination of the genitals. If the hymen is imperforate it should be incised and dilated under anesthesia. If the vagina is imperforate an effort should be made to incise the septum and to establish a permeable canal by the passage of bougies. In extreme cases hysterectomy may be required. SECTION XIII THE UPPER EXTREMITY CHAPTER LXIX CONGENITAL MALFOKMATIONS OF THE EXTREMITIES ABSENCE OF EXTREMITIES There may be a more or less complete absence of one or more of the extremities or of their segments. These malformations may be grouped in three divisions. Ectromely. Ectromely refers to the complete absence of one or more extremities. Sometimes all four extremities are missing. More frequently it affects either the two upper extremities or the two lower extremities. Rarely is the malformation confined to a single limb. Curious anomalies are observed, such as the formation of a stump terminating in one or more digits, or a stump without any appendage. Hemimely. Here the distal segment of one or more extremities is missing or exists in a rudimentary state the limb terminates in a stump, at the extremity of which are sometimes appended im- perfectly developed fingers or foes. Hemimely sometimes affects all the limbs, or again only a single limb is involved. Phocomely. In this malformation the upper segments of the limb are absent and the distal segments hands or feet are directly attached to the trunk. It usually affects the entire two upper or two lower limbs. It is rarely found in a single extremity. Etiology. The etiology of these malformations is explained by a more or less complete arrest of development of the various seg- ments which form the limb, perhaps by intrauterine amputations. 561 562 THE SHOULDER A biological as well as traumatic origin combines to bring about these defects. Treatment. Amputation of useless appendages that interfere with the application of some prosthetic apparatus, and some form of artificial extremity to improve function. CONGENITAL GROOVES Congenital grooves are transverse or oblique circular grooves found on the fingers, toes, forearm, or leg; rarely on the superior segment of the limbs. These grooves affect more or less profoundly the soft tissues and may compromise the continuity of the limb. It is not irrational to consider them the first stage of a congenital amputation. CHAPTER LXX THE SHOULDER CONGENITAL ELEVATION OF THE SCAPULA Clinical Picture. This congenital high position of the scapula is recognized by the evident asymmetry of the two scapulae. One of them is displaced upward, and at the same time it appears to rotate around a sagittal axis (Fig. 215). Not only is there a dis- placement, but the scapula is deformed by the abnormal traction of the muscles acting under conditions which modify their function. Thus the superior border is curved forward like a hook, giving the impression of an exostosis. The head is turned toward the affected side with marked scoliosis of the neck and a compensatory dorsal curve of the spinal column. These secondary changes in the position of the head and spinal column vary in different cases, but are always associated with diffi- culty in raising the arm to a horizontal position because of the dis- FRACTURE OF THE CLAVICLE 563 turbed balance of those muscles which move the shoulder girdle on the plane of the thorax. Etiology. The etiology of this deformity is obscure. It must be regarded as a development defect. It is often accom- panied by other malforma- tions. Some authors have at- tributed the high position of the scapula to a bony bridge which connects it with one of the vertebra?. Its removal has been attended with good results. Treatment. Examine the case with X-ray to detect any bony connection between the scapula and the spine. The existence of such a bony bridge indicates operative interference. The secondary symptoms wry-neck and scoliosis must be relieved by appropriate mechanical treatment. FIG. 215. CONGENITAL ELEVATION OF THE SCAPULA. (Kirmisson.) FRACTURE OF THE CLAVICLE Fracture of the clavicle is very frequent in children under ten years of age. The mechanism which in an adult would result in dislocation of the shoulder produces a fracture of the clavicle in children a fall upon the shoulder or extended hand ; or it may be produced during labor. (See Intrapartum Fracture, p. 248.) The point of fracture is usually at the weakest part of the clavicle the junction of the outer and middle thirds. As a rule it is either incomplete (green-stick) or complete but subperiosteal. Symptoms are often obscure since we do not get the characteristic attitude or the displacement presented in the adult. The character 564 THE SHOULDEK of the fracture is such that there is no crepitation or abnormal mobility. We note only that there is pain when the arm is moved and that the child is disposed to keep the arm at rest. Rule. When following a fall upon the shoulder a child ex- hibits pain on movement of the arm, or refuses to move it volun- tarily, suspect fracture of the clavicle. Many of these cases are brought to the surgeon some time after the injury because the parents have noticed a circumscribed swell- ing over the seat of fracture, which indicates the formation of callus. Treatment. There being no displacement, reduction is unneces- sary and it is only essential to keep the parts at rest by placing the arm in a sling and fixing the arm to the trunk by a few turns of a plaster bandage. At the end of two weeks the arm may be placed in a sling outside the clothes for an additional week. CONGENITAL DISLOCATION OF THE SHOULDER Congenital dislocation of the shoulder is extremely rare. When it occurs it is probably due to injury contracted during delivery, and is often associated with injury to the brachial plexus. Treatment* Endeavor to reduce, and maintain the head in its proper position by some fixation apparatus; otherwise operative treatment will be necessary to avoid functional impairment. TUBERCULOSIS OF THE SHOULDER Tuberculosis of the shoulder is rare. The pathology is that of tuberculous joint disease in general (see Tuberculosis of the Joints, p. 205). Though the fungus form is more usual, there is a tendency in the shoulder for the disease to assume the dry or atrophic form. Caries sicca is a dry osteoarthritis of the head of the humerus in which there is destruction of bone and synovial membrane terminat- ing in ankylosis. TTTBEKCTJLOSIS OF THE SHOULDER 565 Symptoms. In the fungus form the joint capsule is filled with granulations and the overlying deltoid appears swollen, giving an undue prominence to the shoulder. In the dry form the deltoid is atrophied from disuse and the shoulder is flattened. There is pain on pressure over the humeral head or on motion, and function is thereby compromised. The arm is held in a position of adduction and slight inward rotation. Limitation of movement in the shoulder joint must be carefully considered with a due regard to a possible source of error, for it will be recalled that limitation of movement in the joint itself is often masked by compensatory rotation of the scapula. FIG. 216. ANKYLOSIS OF THE SHOULDER-JOINT. Note that when the arm is in a horizontal position a right angle is formed with the scapula in the normal joint; an acute angle in the ankylosed joint. Note in Fig. 216 that when the arm is in a horizontal position a right angle is formed with the scapula, but when the joint is ankylosed it forms an acute angle due to the compensatory rotation of the scapula. Hence, in judging defective mobility of the shoulder joint, the surgeon should observe these movements from be- hind, and, after immobilizing the scapula with one hand, note whether normal movements of the joint cause the scapula to rotate. When the caseating mass suppurates the pus breaks through the capsule, finds its way along the bicipital groove, where it may present be- neath the anterior or posterior border of the deltoid, or in the axilla, or beneath the scapula ; and at these various points subsequent fistulse may be established. The axillary glands are always involved. 566 THE SHOULDER Diagnosis. Chronic swelling in 'the shoulder joint of a child should always arouse suspicion. The von Pirquet reaction and use of the X-ray will materially aid in reaching a conclusion. Sul>- deltoid hursitis may present a clinical picture which simulates the dry form of tubercular arthritis, but in bursitis joint movements are not essentially obliterated and an examination under ether will remove any doubt. Osteosarcoma may superficially simulate the fungus form, but the difference in the clinical picture and the X-ray will settle this question. Prognosis, The outcome of this disease in its most favorable aspect presents two important considerations: (a) Healing of the joint is followed by loss of function except in those rare cases where there is a hydrops of short duration. (b) There is usually considerable shortening of the extremity due to destruction of the epiphyseal cartilage. It is well to remember that proximity of the lung adds the grave danger of its involvement in the process. Treatment. GENERAL, TREATMENT is that of joint tuberculosis (see p. 207). LOCALLY the treatment should be along conservative lines with special reference to immobilization of the joint in a position most favorable to function. Abscess formation demands aspiration, the contents removed by suction, and the injection of a five per cent, emulsion of iodoform and glycerin, or a two per cent, emulsion of formalin and glycerin. Immobilization of the shoulder joint cannot be obtained by simply placing the shoulder in a plaster cast. Kirmisson's rule should be followed, viz. : "We should include to a very large extent the cervical region, for we can fix the joint properly only by making our plaster apparatus reach up even to the occiput and mastoid region of the affected side, or by taking it over to the cervical region of the opposite side." Resection of the shoulder joint is rarely to be considered in chil- dren since removal of the epiphysis results in permanent shortening, and even ankylosis of the shoulder joint is not attended by serious functional impairment since there are ample compensatory move- TUBERCULOSIS OF THE ELBOW 5(57 ments of the shoulder girdle. The forcible breaking up of a shoul- der ankylosis under anesthesia is a dangerous procedure, since it invites a recurrence of the disease in a latent focus. CHAPTER LXXI CONGENITAL DISLOCATION OF THE ELBOW Congenital dislocation of the elbow occasionally occurs, al- though the lesion most frequently observed is an isolated dislocation of the head of the radius. There is frequently observed in these de- formities a bony bridge connecting the radius and ulna, the radius remains in pronation as in the quadrupeds, showing that we are dealing with a developmental defect. The function of the elbow is seriously compromised by the deformity. The hand is per- manently pronated and cannot be completely flexed at the elbow. Treatment. Removal of the obstructions to motion. An X-ray will determine the character of the deformity and the existence of abnormal bony connections. Resection of the head of the radius is obviously indicated when it obstructs free movements of the forearm. TUBERCULOSIS OF THE ELBOW The elbow is the joint of the upper extremity in which the tuber- culous process is most frequently manifest. It appears mostly in the osseous form, the foci appearing usually in the external condyle of the humerus, often in the olecranon, and rarely in the head of the radius. The disease spreads from its primary focus, filling the joint with granulation tissue which follows the typical process of caseation, suppuration, and fistulization. Symptoms. Pain, swelling, gradual fixation, and muscular 568 THE ELBOW atrophy. The joint loses its normal contour and acquires a spindle- shaped form. The joint being most superficial posteriorly, we note an oblitera- tion of the normal grooves on each side of the olecranon, and later, when abscess discharges, fistulous openings are formed on either side the triceps tendon. As the disease progresses the joint assumes a characteristic vicious attitude it is fixed in a position of slight flexion combined with marked pronation. It is evident that this position incapaci- tates the arm for ordinary service, since the hand can neither reach the mouth nor head. There is usually involvement of the epitroch- lear and axillary glands. Diagnosis offers little difficulty. The history and X-ray will dif- ferentiate similar clinical pictures. Osteosarcoma is rarely found in the elbow joint. Treatment. General treatment is that of joint tuberculosis (see p. 207). Sometimes the X-ray will demonstrate that the disease is extraarticular, and it may then be possible to open the bone abscess outward and thus prevent it from breaking through into the joint. When the joint is involved, immobilize in plaster cast in the position of greatest functional value, which is a position of such pro- nounced flexion and supination that the palmar surface of the hand can easily reach the mouth. Immobilization should continue until three months after all inflammatory phenomena have disappeared. The blood supply to the diseased area should be increased by producing an artificial chronic congestion after the method of Bier. Abscess formation demands aspiration, removal of contents by suction, and the injection of a five per cent, emulsion of iodoform and glycerin, or a two per cent, emulsion of formalin and glycerin. Otherwise the treatment is conservative. Healing of the tubercular process usually results in ankylosis, or untreated the disease pro- gresses to suppuration and fistulization. In both of these conditions operative measures must be considered. Do not resort to resection of the elbow in young children unless there are pronounced vital or functional indications. Resection of FRACTURES AT THE ELBOW 569 the elbow in children is attended with arrest of growth in the limb and often flail joint. If, therefore, there is ankylosis in good func- tional position it is the part of wisdom to be satisfied with a fairly useful though deformed arm. If, on the other hand, there is anky- losis in such faulty position that function is seriously impaired, resection of the joint is indicated. Resection and arthrectomy must be resorted to in those extreme cases where continued suppuration and fistulization make the indi- cations vital. FRACTURES AT THE ELBOW As Kirmisson has remarked, "Fractures of the elbow are par excellence the fractures of childhood." Not only their frequency but their gravity lays a heavy burden of responsibility upon every practitioner. For these fractures imperil the function of the joint, and the usefulness of the limb is at stake. In childhood the elbow is a center of traumatism because it is a point of diminished re- sistance. The lower extremity of the humerus, with which the bones of the forearm are in intimate relation, is in process of de- velopment and ossification it is an unfinished product, and as yet unprepared to offer resistance to an unusual strain. But the unusual strain is frequent in childhood as an instinctive means of defense and protection; when the child falls the arms are naturally pro- jected in front and interposed between the body and the ground; the shock transmitted from the ground to the shoulder is centered at the elbow, in great part upon the lower extremity of the humerus, and the articular surface is not only broken but the fragments usually dislocated, so that consequences singularly complex are the result. Hero, then, is a joint of great functional importance presenting a lesion of great complexity. The problem is not a simple one, since it involves a reduction that not only restores continuity of the fragments, but functional activity of the joint. It is obvious that in the fracture of a long bone a slight discrepancy of the frag- 570 THE ELBOW ments is compatible with perfect functional result. But in frac- ture of the elbow even slight abnormal prominence in the interior of the joint will be an obstacle to the normal joint movements, and may be the cause of a permanent infirmity. Again, it must be emphasized that, under the most favorable con- ditions of treatment, perfect results cannot be guaranteed; the prognosis must always be guarded, and the possibility of functional impairment emphasized. However, the best results can be obtained only when treatment is based upon exact knowledge of the mech- anism of the joint and of the dam- age caused by the trauinatism; these facts are the only safe guides in reducing the fragments and maintaining them in permanent position. Exact information can be obtained only by means of the X-ray. A fracture of the elbow should not be subjected to treat- ment until the X-ray has demon- strated the exact lesion. Proper reduction of the fragments is only possible when the patient is anes- thetized. No other course is per- missible except this is rendered impossible by circumstances. A fractured elbow requires an X-ray to define the lesion, an anesthetic to facilitate reduction, and a sec- ond X-ray to verify the accuracy of reduction. Anatomy of the Elbow. The child's elbow is not a miniature adult elbow, it is a joint formed by epiphyses in the process of de- velopment. An exact knowledge of the development of the elbow is necessary to properly interpret the radiograph and reduce the fragments. The surgeon must know the normal before he can inter- pret the pathological ; he must be familiar with the precise situation of the centers of ossification in the epiphyses, their form and value, FIG. 217. RADIOGRAPH OF NORMAL ELBOW AT TEN YEARS. Note the epiphyseal centers appear- ing as detached fragments. FKACTUKES AT THE ELBOW 571 FIG. 218. RADIOGRAPH OF NORMAL ELBOW AT Two YEARS. and how they look in the picture. It is easy to mis- take a conjoined cartilage for a fracture line, or a cen- ter of ossification for a de- t a c h e d fragment (Fig. 217). It must be recalled that until the end of the second year the lower end of the humerus is cartilagi- nous, no centers of ossifi- cation have as yet appeared (Fig. 218). At the third year the diaphysis pushes out a median wedge-like prolongation toward the middle of the epiphysis, which gives solidity to the inferior extremity; about this diaphyseal prolongation are grouped the four centers of ossification (Fig. 219). The first center of ossi- fication to appear is that for the capitellum at the third year; it extends inward and forms the outer half of the trochlear surface. The centers for the inner portion of the trochlear and for the external condyle appear at the twelfth year. These three centers coalesce and form an epiphy- sis, which unites with the shaft at about the sixteenth year. The fourth center for FIG. 219.-THE FOUR CENTERS OF OSSIFICA- the i nterna l epicondyle ap- TION FORMING THE LOWER 'EPIPHYSISOF THE HUMERUS. pears at about the fifth a, the capitellum; b, the inner epicondyle; c, the trochlea; d, the outer epicondyle. year. It forms a Separate 572 THE ELBOW epiphysis, and unites with the shaft at about the eighteenth year. It will be noted that these four ossific centers may be naturally divided into two distinct groups : (a) The inferior and external group, consisting of the external condyle, capitellum, and trochlear, which coalesce and form one mass which joins the shaft about the sixteenth year, and (b) The internal epicondyle, which joins the shaft late, rarely before the eighteenth year, and sometimes as late as the twenty-fifth year. This anatomical division of the centers has an important bear- ing on the character and frequency of elbow fractures. At the superior extremity of the ulna the olecranon process is car- tilaginous. A center of ossification appears about the ninth year, and this epiphysis unites with the shaft about the twentieth. The upper extremity of the radius is capped with cartilage, the center appears at the sixth year and fuses with the neck about the age of eighteen. Etiology. The etiology of these fractures is important to keep in mind because of the clew which it gives to diagnosis. These fractures are rare in the first two years, since at this period the epiphyses are entirely cartilaginous and act as elastic buffers, which transmit blows without breaking; besides the child is less exposed to traumatism. They are most frequent during the developmental period of the elbow, which is between the third and fourteenth years. Boys are naturally more exposed than girls because of their activity. The cause of these fractures is significant. They are rarely caused by sudden traction (sudden traction usually causes dislo- cation of the radial head) or by direct violence. Almost uniformly there is the history of an indirect blow transmitted to the articular extremities. For example, the child falls (rarely from an elevated position), it instinctively protects itself by projecting the forearm in front, the hand conies in contact with the ground, and the shock is transmitted to the inferior extremity of the humerus, which frac- tures in various directions according to the position of the arm. The two forces then are the weight of the body, transmitted by the FRACTUEES AT THE ELBOW 573 humerus, and the resistance of the ground, transmitted by the radius. Diagnosis. When a child presents itself after injury to the elbow there may be a contusion or a dislocation, but always suspect fracture. Remember that supracondyloid fracture, without displacement or fracture of the internal condyle, may simulate contusion by the absence of swelling and ecchymosis, and the slight interference with function. Even when careful examination points to contusion, radio- graph the elbow lest a fracture escape unrecognized. Whenever the apparent symptoms point to dislocation remember that a simple dis- location in a child unaccompanied by fracture is rare. Apparent dislocation should always suggest a search for the accompanying fracture. The X-ray will usually reveal an osseous lesion of which the dislocation is but a symptom. METHOD OF EXAMINATION. The obstacles in the way of a thor- ough examination are many : The child cannot be interrogated ; the history of the injury cannot be obtained at first hand; the surgeon must rely solely on his own ingenuity in interpreting the facts. These facts are gleaned principally by inspection and palpation ; but the child resists a local examination, the muscles are contracted, and the condition thus obscured; hence the necessity of anesthesia, not deep, but just sufficient to relax the muscles and permit free palpation. Never hesitate to give an anesthetic of short duration for the examination of every elbow injury. First, inspect the elbow and note the localization of the ecchy- mosis; if it surrounds the elbow supracondyloid fracture may be sus- pected; if it is localized at the sides, look for fracture of the condyles. Second, palpate the parts: Note the normal anatomical relations of the uninjured elbow: (a) The Relation of the Three Bony Points. Place the thumb and middle fingers on the internal and external condyles and the index finger on the tip of the olecranon. When the forearm is fully extended the three bony points lie on the same transverse line 574 THE ELBOW (Fig. 220). Any modification of the normal relations of the three bony points is due to fracture or dislocation. (b) The head of the radius can be felt in the dimple behind the elbow. Its rotation is manifest when the forearm is pronated and supinated. In injuries about the elbow the . determination of the position of the radial head is of prime importance. FIG. 220. RELATION OF THE THREE BONY POINTS OF THE ELBOW. FIG. 221. THE " CARRYING ANGLE" WHICH THE SUPINATED FORE- ARM FORMS WITH THE ARM. (c) Compare the "carrying angle" of the two arms the obtuse angle which the extended forearm forms with the arm (Fig. 221). This angle is modified in certain fractures of the elbow. (d) Note the movement of the elbow joint, both flexion and ex- tension. Remember there is normally no lateral motion in the ex- tended elbow joint. With these standards of comparison the injured elbow should FRACTURES AT THE ELBOW 575 be carefully palpated and the presence of crepitus and other abnor- malities determined. These palpations should be conducted in a gentle, delicate manner, nor should force ever be used sufficient to exaggerate the lesion and destroy the valuable periostea! connections. The aim of every examination is precision of diagnosis. This can be obtained only by a careful methodical clinical examination con- trolled by the X-ray. THE VALUE OF X-RAY EXAMINATION. The final word of diag- nosis belongs to the X-ray, nor should it ever be omitted even when the injury appears trivial. It is impossible by palpation alone to discover all the details of a fractured elbow. In the X-ray we have a valuable aid in making a precise diagnosis. We do not believe the X-ray is sufficient of itself, nor is it to supplant the clinical examination, or relegate it to a second place; but the clinical and radiographic examination taken in conjunction each interprets the other. After thorough palpation the X-ray enables us to correct errors; to confirm a diagnosis already made, and to give mathe- matical precision to our conclusions; and finally when the reduction is made and the retention splint applied it checks the final error of imperfect reduction and retention. The X-ray picture should be taken and interpreted by those who possess special knowledge and experience. An amateur X-ray pic- ture of an injured elbow is of little value. However good the picture it is valueless unless properly interpreted. As already stated the child's elbow is not a miniature adult elbow, it is a joint in the pro- cess of development it consists of osseous regions, cartilaginous regions, and centers in process of ossification; its parts are of dif- ferent density and offer a different resistance to the penetration of the X-rays. The essential factor in the picture is detail, hence the necessity of using soft tubes. In radiographing an injured elbow there should always be two pictures of the same fracture, a surface radiograph and a profile radiograph (Fig. 222). (a) The surface radiograph should be taken with the arm in complete extension, the arm resting on the plate on its posterior surface. (b) The profile radiograph should be taken with the elbow in 576 THE ELBOW median flexion, the hand pronated with its internal surface resting on the plate. It is obvious that the child should be anesthetised in order that the proper attitude may be assumed without provoking pain. After the diagnosis is confirmed, the reduction made, and the splint applied, a second X-raj should confirm the accuracy of the results. Prognosis. The prognosis of fracture of the elbow in children FIG. 222. SURFACE AND PROFILE RADIOGRAPH OF A STJPRACONDYLAR FRACTURE. Note the value of the profile radiograph in showing the nature of the injury. must always be guarded ; even under the most favorable conditions of treatment perfect results cannot be guaranteed. The possibility of some functional impairment should always be emphasized. While the process of ossification in the child is very rapid because of the extreme fertility of the young periosteum, yet consolidation of the fragments, however perfect, is compatible with a very imperfect functional result. The prognosis of these fractures depends upon: (a) Reduction It is obvious that perfect reduction is the prime requisite of perfect functional results; yet it is well to keep 577 in mind the difficulties of perfect reduction and thus be guarded in our prognosis; for no surgeon, however skilful, can guarantee a per- fect result in a fracture of the elbow, however simple. There are some fractures of the elbow primarily irreducible, such as those rare cases of impaction where surgical intervention may be necessary; or there may be interposition of the fragment in the joint where the interarticular obstacle opposes reposition, and all attempts at reduc- tion are fruitless. These cases left to themselves inevitably produce bad results. Immobilization and massage can have but one result, viz., to increase articular inflammation and forestall complete ankylosis. These cases must be relieved by surgical intervention. Again, we find a certain proportion of cases where the fragment rotates on itself. In supracondyloid fracture the fragment may so tilt on itself that reduction is impossible and surgical intervention necessary to complete a cure. Finally, there are cases which present certain difficulties in re- duction even after the clinical diagnosis and the X-ray have con- firmed the findings and reduction seems simple. Such cases are those with very small fragments and great swelling (interarticular fracture of the condyle or fracture of the neck of the radius). The fragments are so small that the fingers can secure little hold, espe- cially in the presence of much swelling. Reduction by direct pressure is often impossible, and reduction must be made indirectly by means of the ligaments in exercising traction on the forearm. Many of these cases escape unreduced and result in defective con- solidation. (b) Retention. Even after reduction is satisfactorily accom- plished it is necessary to retain the fragments in proper position. It must be remembered that many fractures after reduction have a remarkable tendency to secondary displacement. When the frag- ment is reduced it may be easily held in position by direct pressure of the fingers, but when we substitute for the pressure thus made immobilization by the splint, there is often produced a displacement of the fractured surfaces, which results in vicious position. Again, after the splint has been on for a few days the swelling disappears and the splint no longer accurately supports the frag- 578 THE ELBOW ments, which then become displaced. Thus, imperfect retention of the fragments may result in abnormal prominence or deviation of the forearm (gun-stock deformity) or in impaired function (Destot, Vignard, Barlatier). (c) Exuberant Callus. This is specially observed in fractures incompletely reduced or badly immobilized and may be a grave com- plication. The prognosis, of course, is variable, depending upon the situation and the volume of callus. It is obvious that in supracon- dyloid fracture the callus may be excessive and even produce de- formity without interfering with articular movements. If, however, it is situated anteriorly it may form an osteoma of considerable volume and thus interfere with flexion. If the fracture is inter- articular the prognosis is graver, since exuberant callus may fill the olecranon and coronoid fossae and thus interfere with flexion and extension. Again, in some fractures there is extensive laceration of the periosteum and capsule, as well as detachment of the ligaments. Exuberant callus is usually absorbed if the fracture is recent and immobilization is sufficiently long. In old fractures the prog- nosis is bad and the result is usually complete ankylosis. (d) Arthritis. In all fractures involving the joint traumatic arthritis with more or less swelling is to be expected. In these cases the prognosis depends upon the articular reaction. In such fractures as the high supracondyloid, fracture of the internal epi- condyle, the joint is not involved and the prognosis depends entirely upon accurate reduction. In intra-articular fracture, however (frac- ture of one of the condyles), there is usually a hemarthrosis, which either absorbs slowly or organizes and forms fibrous bands which result in ankylosis. These cases require nice surgical judgment since too early mobilization excites inflammatory reaction and mechanically irri- tates the periosteum, while too long immobilization favors organiza- tion of the exudate. Typical Forms of Fracture of the Elbow in Children. The chil- dren's types of fracture at the elbow, in the order of their frequency, are: A. SUPRACONDYLAR FRACTURE (Fig. 223). The mechanism of FKACTUKES AT THE ELBOW 579 this lesion differs in no essential from the corresponding lesion in the adult. It is more frequently found in older children who are exposed to severer traumatism and in whom the different parts of the humeral end are better consolidated. The fracture is usually the result of a fall upon the outstretched hand, the hyperextended elbow prying off the lower end of the humerus. (In an adult this same force usually produces backward dislocation of the elbow.) The line of fracture is just above the epiphyseal line, as a rule directed obliquely upward and backward. The lower fragment is displaced upward and backward and held in this position by the strong action of the triceps. The overriding fragments cause a full- FlG. 223. SUPBACONDYLAR FRACTURE. ness at the elbow in front, producing a deformity which simulates a backward dislocation of the elbow. (Rarely there may be a supracondyloid fracture without dis- placement, simulating contusion by absence of swelling and the slight interference with function.) Examination of this lesion is difficult because of the swelling and ecchymosis, hence anesthesia is essential. Determine the position of the three bony points. It will be found that the tip of the olecranon, though pulled backward and upward, maintains its rela- tive position in a straight transverse line with the epicondyles. In backward dislocation the tip of the olecranon is above the trans- verse line connecting the three bony points. The sharp edge of the 580 THE ELBOW upper fragment may be felt in the fold of the elbow pressing against the soft parts, and the general symptoms of fracture are present (deformity, abnormal mobility, crepitus, ecchymosis, and loss of function). Movements of flexion and extension are easily made (in sharp contrast to dislocation). Traction upon the forearm while the humerus is fixed reduces the deformity; as soon as the traction is relaxed the deformity recurs. The value of the X-ray is obvious. (For treat- ment, see p. 584.) B. SEPARATION OF TILE LOWER EPIPHYSIS OF THE HUMERUS. Separation of the lower epiphysis of the humerus is a very rare lesion and does not occur after the third year. The usual cause is a fall on the elbow or "jamming" the el- bow in a door. The symptoms are sim- ilar to those of supracon- dylar fracture. If there is slight swelling it may be possible to palpate the wedge-shaped lower end of the diaphysis and the cor- responding excavation on the upper surface of the epiphysis. It may also be possible to determine the "muffled crepitus" characteristic of epiphyseal separa- tions. It is well to note that the X-ray will show no displacement before the second year, since the epiphysis at this period is carti- laginous and permeable to the rays. C. FRACTURE OF THE EXTERNAL CONDYLE (Fig. 224). Frac- ture of the external condyle is almost as frequent as supracoudylar fracture. It is obvious that in a fall on the palm of the hand the force is transmitted directly through the radius to the outer side of FIG. 224. FRACTURE or THE EXTERNAL CONDYLE. 581 the humerus ; besides the process of ossification is much slower in the external than the internal condyle. These factors contribute to its frequency. While the fracture line follows the general course of the epiphyseal line, yet it is usual to find either a portion of the shaft or the external edge of the trochlear included in the fragment. The functional symptoms are those of fractures at the elbow- pain on movement and complete impotence. On examination, swelling and ecchymosis are noted in the region of the outer condyle, if the examination is made sev- eral hours after the in- jury. The fragment is usually displaced upward .and outward, producing a well-marked deformity, and the normal relation of the three bony parts is disturbed. In exploring the elbow the superficial situation of the fragment permits satisfactory pal- pation of the fragment, the abnormal mobility, and crepitus. In comparing the two forearms placed in extension it will be noted that there is often a deviation of the injured side, pro- ducing the deformity known as cubitus varus. Pronation and supi- nation are always possible under anesthesia, and forced supination will frequently elicit crepitus. There should be little difficulty in diagnosing this lesion under anesthesia. Confirmation by the X-ray is important. D. FRACTURE OF THE INTERN AL EPICONDYLE (Fig. 225). Fracture of the internal epicondyle is quite commonly observed and is usually caused by a direct blow or fall upon the inner surface of FIG. 225. FKACTUBE OF THE INTERNAL EPICON- DTLE. (Destot.) THE ELBOW the elbow. The fragment is small, the displacement downward, and the joint rarely involved. There are pain, swelling, and ecchymosis over the fractured region, but the joint movements are not seriously impaired. The close relation of the ulnar nerve to this bony process exposes it to injury as a complication of fracture. In some cases the fractured fragment had to be removed to relieve pressure on the nerve (Poland). The symptoms of this lesion are in general benign, and unless careful examination is made it may be mistaken for contusion. It must be remembered that fracture of the internal condyle is sometimes a complication of elbow dislocation and one of great im- portance. Simple dislocation in the child is exceptional ; it is usually associated with fracture of the internal epicondyle. When such a lesion is present it may assume a grave aspect by the fragment being caught between the joint surfaces, so that the osseous fragment can- not be recognized by palpation, nor can movements of the joint be obtained even under anesthesia. Fractures of the internal condyle, as well as of the olecranon and the radial neck, are rare in children and differ in no essential from the corresponding lesions in the adult. Treatment. The prime consideration in the treatment of frac- tures of th'e elbow is not simply a reduction that restores continuity of the fragments, but one that restores functional activity of the joint. In-lthe fracture of a long bone a slight discrepancy of the fragments is compatible with perfect functional result. But in frac- ture of the elbow even slight abnormal prominence in the interior of the joint will be an obstacle to normal joint movements, and may be the cause of permanent disability. It is obvious that reduction here is something more than the reposition of fragments ; it implies a coaptation so accurate and a retention so complete that the result- ing joint surfaces will permit of normal joint movements. If the fragments be accurately reduced and held in this position, the questions of duration of immobilization and the special position in which the limb should be placed are secondary considerations. The fundamental fact must be appreciated that it is not the duration of the immobilization that produces ankylosis, it is faulty reduction causing periosteal proliferation that locks the joint ; and, FEACTURES AT THE ELBOW 583 further, no special position of the arm will obviate the disastrous results of an incomplete reduction. The general rule to be followed in all cases of fractured dhow is accurate reduction maintained by that splint and that position of the arm which is best suited to the special indications of the indi- vidual case. It is futile and misleading to presume to indicate precise methods of treatment invariably applicable to each variety of fractured elbow. Even in the same type of fracture there are anatomical dif- ferences which must be appreciated. Some displacements are cor- rected by traction, others by direct pressure on the fragment. Each fracture is a special problem, with its individual needs and its peculiar indications. While, therefore, no precise rules can be formulated, certain precepts may be followed which will be a safe guide in all cases. First Step : Find out exactly just what is fractured and be satis- fied with nothing but anatomical accuracy. A clinical examination under anesthesia is the first requisite; but it is never sufficient; it must be supplemented by an X-ray examination. Two radiographs should be made, one profile, and one surface view. The radiographs should be made and interpreted by a radiographer of experience. The X-ray picture without proper interpretation is futile. Second Step : Reduce the fracture by such maneuvers as are efficient in accurately coapting the fragments (flexion, extension, traction, direct pressure, etc.). A maneuver is selected for its effir ciency and not according to precedent. Whatever the maneuvers, care should be taken to avoid any rough manipulation, which only exaggerates periosteal lesions, and consequent impairment of func- tion. Firmness and gentleness are always more effective; they ac- complish more and damage less. Third Step: Immobilize permanently only when certain that re- duction has been obtained, and that the position of the arm and the splint selected are adequate to maintain reduction. This will be evidenced by (a) normal conformation of the parts ; (b) a normal range of flexion and extension. But best of all is the confirmation 584 THE ELBOW furnished by a second radiograph. The procedure should be as follows : After reduction has been obtained, and the arm placed in that position which seemingly is most efficient in maintaining reduction, a temporary splint should be applied and a radiograph taken; if the picture confirms the accuracy of reduction and efficiency of immobilization, then the temporary splint should be made perma- nent. And no permanent immobilization should be attempted until satisfactory evidence has been obtained that the reduction, position of arm, and splint are as perfect as the character of the injury per- mits. Lastly: In the choice of splints preference should always be given to plaster of paris. No other form of splint can be molded so accurately or held so securely an important consideration where the child's restlessness predisposes to secondary displacement. SPECIAL INDICATIONS IN THE TREATMENT OF FRACTURES OF THE ELBOW. I. Fractures Without Displacement. These frac- tures are quite rare. The prognosis is good providing the proper method of treatment is pursued. There being no reduction neces- sary and the function of the joint being unimpaired the necessity of careful immobilization is not always appreciated. To put such a fracture simply in a sling is an error, and to begin mobilization of the joint too early is fraught with grave danger. The fracture should be immobilized with great care, and early movement of the joint avoided lest exuberant periosteal proliferation be stimulated and secondary displacements induced. A well fitting plaster splint should be applied and the arm immobilized for three weeks. II. Fractures with Displacement. A. Supracondylar Fracture. If the fracture is seen a few hours after the traumatism the swell- ing is at its height and it is better to wait two or three days until the swelling subsides before attempting to reduce and permanently immobilize. In the meantime place the arm in a temporary internal angular splint (Fig. 226). After the swelling has subsided (at end of 48 to 72 hours) anesthetize the patient (in the presence of an X-ray if possible) 585 FIG. 226. INTERNAL ANGULAR SPLINT PADDED WITH SHEET WADDING AND FASTENED WITH ADHESIVE STRIPS. (After Cotton.) and make accurate reduction by such manipulations as are most efficient. Usually reduc- tion is best accomplished by having an assistant make countertraction and backward pressure upon the upper fragment. The surgeon meanwhile by a steady pull downward upon the forearm reduces the upward displace- ment of the lower fragment, and then by a movement of forced flexion brings the fragment forward into its normal rela- tion with the diaphysis. In making this reduction two errors should be carefully avoided: First: In the movement of forced flexion of the forearm care should be taken not to over- reduce, that is, transform the original posterior displacement into an anterior displacement, and thus compromise restoration of function. Second : There is nearly always some lateral displacement, especially some inward deviation, which if not corrected results in "gun-stock" de- formity (loss of the "carrying-angle"). (Fig. 227.) This deviation, while not interfering with the function of the joint, results in a deformity sometimes inconvenient. Reduction, therefore, to be complete must cor- rect not only the backward displacement of the fragment but its lateral deviation. The difficulty, FIG 227 " GUN- however, i g i n the fact that the movement of STOCK" DEFOB- f orce d flexion which brings the displaced fragment MITY CAUSED BY OBLITERATION forward into position does not correct the lateral OF THE "CARRY- ... . ,. ING ANGLE." deviation, it only obscures it. Lateral displace- 586 THE ELBOW ment is corrected only with the forearm in complete extension. Hence, when making the first movement traction downward on the extended forearm be sure that any lateral deviation is cor- rected and maintained before forcibly flexing the forearm. Repeat the movements of reduction as often as necessary to be assured that the reduction is complete. Retention. After reduction nas been obtained the fragment must be permanently held in position by some retentive splint. The tendency to secondary displacement in these fractures must be prevented not only by a well-fitting splint, but by that special posi- tion of the forearm in which the reduction is best protected. The best position is the position which holds the fragments in place. While the general rule holds good, viz. : to immobilize in that posi- tion and by that splint -which maintains the best reduction, experi- ence has shown that the fragments are best coapted with the fore- arm flexed either at -a right angle or an acute angle (hyperflexion the "Jones position"). Both positions should be tried; select the position which maintains the best reduction, put on a temporary splint, and verify the selection by the radiograph. In right angle flexion the fragments are best retained by the application of an internal angular splint molded of plaster of paris extending from the line of the axilla to the wrist (leaving the fingers of the child at liberty). The splint is padded with sheet wadding and crowded well into the bend of the elbow (Fig. 228). The splint is held in position by adhesive strips around the arm and wrist, the limb enswathed in cotton, and a bandage applied from the wrist to the upper border of the splint. The arm must not be supported by a sling since pressure of a sling has a tendency to invite displacement of the fragments. In acute flexion ("Jones position") the fragment is reduced and maintained in position by forced flexion, so that the forearm is in contact with the anterior surface of the arm. The coronoid process in front, the hook-like process of the olecranon behind, and the strap-like tendon of the triceps, all these elements conspire to keep the fragment reduced and pressed firmly against the shaft of the humerus. FRACTURES AT THE ELBOW 587 Method of Applying the Acutely Flexed Position. The degree of flexion possible will depend upon the amount of swelling- present. Place a piece of well-powdered gauze in the bend of the elbow, and with the forearm acutely flexed retain the position by an adhesive strip three inches wide passing about the arm arid forearm. (Fig. 229.) Place a gauze compress to protect the skin where the hand and forearm come in contact with the chest, and support the arm FIG. 228. APPLICATION OF THE INTERNAL ANGULAR SPLINT FOR FRACTURE OF THE ELBOW. Note in the first position that the splint is applied to the arm, and the forearm flexed up- on the splint. In the second position the angle of the splint is crowded into the bend of the elbow while the adhesive straps are applied. by a plaster bandage enswathing the arm and chest, leaving the fingers of the child at liberty. A vigilant supervision should be kept of the acutely flexed arm for the first week. Watch the radial pulse the vessels at the bend of the elbow are readily compressed by acute flexion, especially if swelling be present. Adjust the amount of flexion according to the amount of swelling; the degree of the patient's comfort will indicate the need for readjustment of the dressings. 588 Duration of Immobilization. As a rule the fracture should be immobilized for three weeks. It is well at the end of the first weeki to remove the dressings and readjust them since there is a tendency for them to become loose as the swelling subsides. It is a wise pre- caution at this time to verify the efficiency of the position again by a radiograph. At the end of the third week the dressing should be removed and the efforts of the surgeon directed toward the establishment of FIG. 229. NOTE IN FIRST POSITION THE ARM is HELD IN A POSITION OF FORCED FLEXION BY ADHESIVE STRAP. IN SECOND POSITION THE DRESSING IB COMPLETED BY A PLASTER BANDAGE ENSWATHING THE ARM AND CHEST. normal joint movement. These efforts, however, should not be in the line of passive movements which force flexion and extension; nothing is gained by this practice. Forced movements are not only unnecessary, they are harmful., and often cause the ankylosis they seek to avert. The efforts of the surgeon should be directed toward encouraging the child to make the movements himself. Spontaneous movements are slower, but they are much surer, and in the end will achieve the best results. Be patient and remember that restoration FKACTUKES AT THE ELBOW 589 of joint function is slow. Be satisfied if normal joint movement is reestablished in three or four months. B. Separation of the Lower Epiphysis of the Humcrus. The treatment is the same as in supracondylar fracture of the humerus (see p. 584). C. Fracture of the External Condyle. Reduction of this frac- ture is not always easy, since the fragment is small and obscured by swelling of the overlying tissues. It will be found serviceable here to combine traction with direct pressure on the fragment. With the patient anesthetized have an assistant make traction on the forearm and apply direct pressure to the displaced fragment until reduction is obtained. Place the forearm in that position which best holds the fragment in place, put on a temporary splint, and verify the results by a radiograph. The final position may be one of complete extension, right angle flexion, or acute flexion. The surgeon need not hesitate to adopt the position which maintains re- duction, even though this be complete extension, since it is some- times necessary to resort to this position to avoid an ultimate cubitus valgus or varus. D. Fracture of the Internal Epicondyle. It should be remem- bered that the attached muscles tend to draw the fragment forward and downward, hence the elbow should be immobilized in the acutely flexed position (see p. 587) to relax the muscles that arise from the epitrochlear. Even when the fragment is not reduced the de- formity is slight and in no way compromises function. Consolida- tion is sufficiently advanced at the end of ten days to place the arm in a sling. The arm may be used at the end of three weeks. OPERATIVE TREATMENT ix FRACTURES AT THE ELBOW. It is evident that even under the most favorable circumstances there are a few fractures at the elbow which cannot be satisfactorily reduced. To immobilize an unreduced fracture is to invite at least an imperfect functional result, sometimes a disastrous re- sult. There are certain fractures which cannot be reduced by the ordinary means of traction and direct pressure because of an impaction or interposition of fragments. In such cases operation is indicated, either to restore the fragment to its normal position, 590 THE FOKEAKM AND HAND or failing in this to remove it. Intervention in these cases should be done early, not later than the third or fourth day ; where opera- tion is delayed until the period of full periosteal activity the addi- tional irritation favors exuberant periosteal proliferation and subse- quent functional impairment. In cases of vicious union operation is indicated only when the movements of the joint are sufficiently limited to warrant interven- tion. It is obvious that these cases may entail the removal of a bony prominence; or, when complete ankylosis exists, a total resec- tion. It is important to remember that operation in these cases should never be done early in the active stage of periosteal pro- liferation. Wait until six months after the injury. In nerve injuries the irritation is usually due either to exuberant callus or compression by a displaced fragment. In case of ex- uberant callus the chances are that the symptoms will disappear as the callus is absorbed. When the nerve is compressed by a frag- ment of bone it is necessary to free the nerve, otherwise the paraly- sis will become permanent. CHAPTER LXXII THE FOKEAKM AND HAND GREEN-STICK FRACTURE OF THE FOREARM Incomplete or green-stick fracture of the bones of the forearm occurs in children as a result of a fall upon the outstretched hand or a blow upon the forearm. The deformity is characteristic ; there is an exaggeration of the normal curve a bowing backward at the seat of fracture (Fig. 230). Pain and tenderness are present, but crepitus is absent ; hence this injury is often diagnosed as a "sprained arm." A radiograph will assist in confirming the diagnosis. Treatment. The reduction should be made under anesthesia, and when possible confirmed by a radiograph. Reduction should be made by traction and careful pressure upon the bones at the seat VOLKMANN'S ISCHEMIC CONTRACTUEE 591 of fracture. It should be re- membered that reduction must be done cautiously, and if pos- sible the bones should ba molded back to their original form without completing the fracture. O v e r-correction, however, may result in displacement which impairs the special func- tion of rotation of the forearm (pronation and supination). While making the reduction the hand should be supinated, since in this position the bones are parallel and separated by the greatest interval. The forearm should be im- mobilized in a position of FIG. 230. GREEN-STICK FRACTURE OF THE BONES OF THE FOREARM. supination with the elbow at a right angle. Molded plaster-of-paris splints (internal and external angular) extending above the elbow, and held in position by adhesive strips, are especially suitable in children. Traction on the forearm should be made while the plaster hardens. (Fig. 231.) VOLKMANN'S ISCHE- MIC CONTRACTURE Volkmann's ischemic contracture is a contrac- tion of the muscles of the forearm from muscle ischemia due to the appli- cation of too tight ban- dages. The flexed posi- FIG. 231. FRACTURE OF THE FOREARM IMMOBIL- IZED IN A POSITION OF SUPINATION. 592 THE FOREARM AND HAND tion of the forearm with the end of a splint jammed against the bend of the elbow is a prevalent cause. The diminution of the blood supply causes muscular atrophy, increase and contraction of con- nective 'tissue, and shortening of the muscles. As a result of this contracture the hand assumes a typical position, the wrist and fingers being permanently flexed. This condition may be improved by forcible stretching, massage, active and passive movements. In exceptional cases lengthening of all the flexor tendons has given excellent results. (J. K. Murphy.) SUBLUXATION OF THE HEAD OF THE RADIUS Subluxation of the head of the radius is frequently observed in children under four years of age. It is caused by sudden traction on the arm at the hand such as is produced by a sudden pull on the arm in assisting a child up a step, or supporting it when it stumbles. (Two cases in drawing the arm through the sleeve of the dress. Stimson.) The lesion is produced by traction on the extended elbow, caus- ing an escape of the front portion of the head of the radius below the orbicular ligament. (Duverney.) Symptoms. The attitude is typical slight flexion at the elbow with the hand held in complete pronation. The child refuses to use the arm, and cries out when the surgeon attempts to examine it. There is no noticeable swelling or deformity; the elbow can be moved in every direction except supination : supination is distinctly limited. This symptom is pathognomonic. The typical history and characteristic attitude are sufficient to establish a diagnosis. Treatment. The reduction is made without difficulty by traction on the forearm with direct pressure on the head of the radius. The reduction is complete when all motions at the elbow are normal. It is usually sufficient to support the arm in right angle flexion with a sling for forty-eight hours, after which the child may be permitted to use the arm. FRACTURE OF THE LOWEE END OF RADIUS 593 MADELUNG'S DEFORMITY (Spontaneous Subluxation of the Wrist) This deformity (Fig. 232) consists of a forward subluxation of the wrist with a dorsal prominence of the head of the ulna. The condition is rare and found mostly in girls. The affec- tion is essentially a develop- mental defect of the lower epiphysis of the radius, the articular surface of which no longer maintains a right angle with the plane of the forearm, but bends for- ward toward the palmar sur- face, carrying with it the at- tached carpus, thus produc- ing displacement of the wrist, and, as a sequence, accentu- ating the prominence of the head of the ulna. It begins after the twelfth year and usually takes some years to fully develop. It is found both single and double. It is accompanied by pain and disturbance of function, especially rotation and hyperextension. Treatment. Reduction is impossible. Little can be accomplished by surgical or orthopedic means. In severe cases osteotomy of the radius may be considered after the disease has run its course. FIG. 232. MADELUNG'S DEFORMITY. (Stetten's Case.) FRACTURE OF THE LOWER END OF THE RADIUS Fracture of the lower end of the radius, while frequent in adults, rarely occurs in children. The force which produces a frac- ture of the lower end of the radius in adults in young children results in a green-stick fracture of both bones of the forearm. 594 THE FOEEARM AND HAND In older children, however, we often find a fracture of the lower end of the radius near the epiphyseal line pure epiphyseal separa- tion is very rare and only in young children. The deformity re- sembles that of Colles' fracture ("silver-fork" deformity), but is less extreme. The fragment is displaced backward, causing a promi- nence at the back of the wrist, which might suggest a dislocation. Diagnosis should be confirmed by a radiogaph. Treatment. Accurate reduction is essential. Imperfect reduc- tion may seriously interfere with the growth of the bone. Immobil- ize with plaster splint. TUBERCULOSIS OF THE WRIST Tuberculosis of the wrist is rare. Beginning in a single bone it spreads throughout the carpus. Its existence is facilitated by the numerous synovial cavities which surround the carpal bones, and the proximity of the tendon sheaths renders them liable to invasion. It will be noted that the palmar side of the wrist is protected by a mass of tendons, the dorsal surface being more superficial ; hence the objective symptoms are found on the dorsal surface of the wrist. Symptoms are similar to those of tubercular joints elsewhere pain, swelling, fixation in vicious attitude, loss of function, and muscular atrophy. The later stages of the disease are marked by fistulse, which open on the back of the wrist. It will be recalled that the radius is the handle of the hand and that it is the radius which enters into the formation of the wrist joint, not the ulna, hence articular activity is in the radial side of the wrist and it is on the radial side that the tubercular process first appears. The swelling causes the bony prominences to disappear and the fur- rows between the hand and the arm are lost. Furthermore, the de- formity is increased by the vicious attitude shown in extension of the fingers and flexion and pronation of the hand. Movements of flexion and extension are gradually diminished and finally disap- TUBERCULOSIS OF THE PHALANGES 595 pear as the tendon sheaths are invaded. Finally, the hand becomes an inert mass deprived of all function. Any difficulties in diag- nosis will be cleared away by the X-ray. Prognosis. The anatomical conditions favor extension of the process, and cure of the disease is always attended with great loss of function. Treatment. The GENERAL, TREATMENT is that of surgical tuber- culosis (see Joint Tuberculosis, p. 20T). LOCALLY the wrist should be immobilized in plaster (the hand in extension, midway between pronation and supination) as soon as the diagnosis is made. The cast should extend to the upper third of the forearm, the fingers being left free so that they may be exer- cised by active and passive movements. The cast should not be dis- pensed with until all pain and inflammatory reaction have disap- peared for three months. The blood supply to the diseased part should be increased by artificial chronic congestion according to the method of Bier. Abscesses should be aspirated and their contents removed by suction, and five per cent, emulsion of iodoform and glycerin or a two per cent, emulsion of formalin and glycerin injected. Other- wise the treatment is conservative, even in advanced cases, for, as Kirmisson observes, "in dealing with bony and articular tubercle in children there are no limits to the possibilities of conservative treatment." Finally, the outlook in resection of the wrist is not encouraging. The numerous tendons which cover both the anterior and posterior surfaces of the articulation : the invasion of synovial pockets, the difficulty of removing all the diseased tissue without sacrificing important organs, the dissemination of the disease in the efforts to remove it render resection of the wrist a procedure of more doubt- ful value than that of the shoulder or elbow. TUBERCULOSIS OF THE PHALANGES Tuberculosis of the phalanges is quite frequent in childhood, especially during the second and third years, and presents a char- 596 THE FOREARM AXD HAND acteristic clinical picture which appears under the form of spina ventosa (Fig. 233). The disease attacks the small pipe bones of the hand and foot, the tubercle localizing primarily either in the periosteum or the central spongy tissue. Here we note the effect of the invading tubercle and the irritative hyperplasia of surrounding tissue in the characteristic swelling of the bone, which presents a spindle '-sh aped enlargement. Later the skin ulcerates, the bone becomes perforated, a fistula is formed, and the tendon sheaths become infected. As a rule this form of tuberculosis is exclu- sively diaphyseal, the articula- tions being nearly always exempt. Spina ventosa is relatively benign and prior to ulceration spontaneous cure by resolution is possible. Even after fistuliza- tion small sequestra may be ex- pelled, the sinus close, and a good result be obtained, though often at the cost of more or less de- formity. Treatment. The general treat- ment of bone tuberculosis (see p. 207) ; Locally, avoid much interference and remember the fre- quency of spontaneous cure. Immobilize the part, apply Bier's hyperemia treatment, relieve abscess by aspiration and suction, remove sequestra, inject the fistu- lous tract with five per cent, iodoform and glycerin emulsion. Avoid the knife since spontaneous cure gives better functional results than operative cure. In cases of complete destruction of the bone the function of the finger may be preserved by transplanting between the remaining epiphyseal surfaces a spicula of bone taken from the tibia, or one may resort to Bardenheuer's method of replacing the diseased phalanx by taking a bony flap from the adjoining phalanx and turning it around FIG. 233. SPINA VENTOSA. CONGENITAL DEVIATIONS OF THE HAND 597 its articular surface so that the new fragment of bone bridges the gap- Amputation of a tuberculous finger should only be resorted to as a last extremity when there is complete destruction, infection of neighboring structures, or painful deformity. CONGENITAL DEVIATIONS OF THE HAND Varieties. Permanent deviations of the hand or the wrist are associated with absence as well as complete or partial defects of the bones of the forearm. Clubbed hand is that condition in which the hand does not form a normal angle with the forearm. Only in rare cases is there a clubbed hand without defective formation of the skeleton of the forearm. (Fig. 234.) Usually it is associated with absence of radius or ulna, com- monly the radius: The hand is then inclined toward the radial side and forms a right angle with the ulna. The end of the ulna is easily palpated beneath the skin. With this deformity the thumb and its metacarpal bone are usu- ally missing. The ulna is rarely absent: Here the hand is deviated toward the ulnar side, but movement at the wrist is free. The elbow on the contrary is often completely ankylosed. Etiology. The etiology of FIG. 234. CLUBBED HAND WITH MAL- ,i IP . ,. n , i FORMATION OF THE BONES OF THE these delects IS found in the proc- FOREARM. (Goodrich's case.) 598 THE FOREAEM AND HAND ess of development, but the explanations of it are entirely specula- tive. Treatment consists in the use of various orthopedic apparatus appropriate to the condition. By operation we may lengthen or shorten the tendons according as the deformity demands. In absence of the radius Bardenheuer has ingeniously split the ulna and inserted the carpus into the fork with good results. INJURIES OF THE HAND IN CHILDHOOD The accidents of childhood are largely those which occur to the child in the process of becoming acquainted with his environment. Incised and lacerated wounds of the hand from implements used in the family life, burns and scalds from playing with matches or proximity to the stove, injuries to the bones by falling down stairs, and the countless injuries which are the result of the games and sports of childhood. Incisee},, and lacerated wounds should be treated according to the accepted rules of aseptic and antiseptic surgery, with the following precautions : Avoid the use of those disinfecting agents to which the child's tissues are very sensitive, especially avoid carbolic acid. This anti- septic agent should find no place in the surgery of childhood. The danger of carbolic gangrene when carbolic solutions are applied to the digits must not be forgotten. Do not attempt to disinfect wounds by scrubbing with green soap. Such methods do more harm to the tissues than to the bac- teria which lie hidden in the lymph spaces. After splinters and debris have been removed the wounded 1 is- sues should be painted with half-strength iodin solution. It is the most satisfactory antiseptic for wounds that we possess. When the wound has come in contact with soil or gunpowder ^firecracker wounds) the patient should be guarded against tetanus by prophylactic injections of antitetanic serum. Such injections INJUEIES OF THE HAND IN CHILDHOOD 599 can do no harm their omission and subsequent development of tetanus should rightfully subject the physician to severe censure. Treatment. Wounds of the hand are among the most important lesions which claim the attention of the surgeon. The hand is naturally predisposed to wounds of all kinds, specially those result- ing from machinery accidents, and the explosion of fire-arms, where the resultant condition is not merely a wound but a multiplicity of wounds, involving to a greater or less extent vessels, nerves, tendons, muscles, and bone. In the presence of such injuries it is impos- sible to be guided by hard and fast rules of procedure only the general principles of treatment can be suggested. Experience and judgment must modify them to suit the individual case. It is urged that these injuries be approached in a spirit of conservatism with the determination to sacrifice nothing that can be saved. The inestimable value of a hand, even a partial hand, is the strongest appeal to conservative surgery. Primary amputations of the hand should be classed among the rarest operations in the domain of surgery. Nature is a better adjunct than the knife in the treatment of these conditions. See what the recuperative forces of nature will do to preserve and restore the wounded parts. Remember that the thumb opposes all the other fingers, hence its value in the role of prehension is vital. // the thumb be removed the hand is reduced to a mere hook. A single finger and a thumb are worth more than any artificial substitute. IMMEDIATE TREATMENT. After explaining the gravity of the injury and obtaining permission to do whatever is necessary, anesthetize the patient. Do not cleanse the wound by scrubbing with green soap simply saturate the wound with iodin solution half strength ; then remove with thumb forceps the debris, splinters, and loose bone. Ligate all bleeding vessels, then study the anatomy of the wound. What tendons and nerves are involved ? What dis- position of the parts will give the most useful hand ? Surgery should be constructive as well as conservative. Make an immediate suture of the severed tendons and nerves. Don't do too much cut- ting; cut nothing away that can be saved; leave too much, rather than too little; arrive at no hasty conclusions in reference to amputation ; 600 THE FOREARM AND HAND irhcii in doubt don't amputate; see what nature will do first, let amputation be a secondary consideration. It is wonderful how youthful tissues recuperate under conservative treatment and useful function is restored. Do not attempt any extensive primary plastics, because of the dangers of infection. After attention to vessels, tendons, and nerves, again soak the wound with iodin half strength and make such closure of the wound as is expedient with safety, but don't make the mistake of closing the wound too tightly, be sure and leave ample room for drainage these wounds poten- tially are infected wounds closing them invites disaster. In ex- tensive lacerated wounds of the hand the authors regard the con- tinuous hand bath of saline solution at a temperature of 110 as the most effective after-treatment. The continuous heat and ad- mirable drainage which the continuous bath affords make it an ideal therapeutic measure for the preservation and restoration of lacerated tissues. After all dangers of infection have passed the efforts of the sur- geon should be directed toward the restoration of the largest degree of function. Where amputation is imperative no formal method must be con- sidered. The extent of the injury determines the choice of method. Take the flap whenever you can find it with the least possible short- ening of the hand. The surgeon will select that method which sacri- fices the least amount of tissue. If the above suggestions are observed it will be found that nature works some agreeable surprises even in injuries that are seemingly irreparable. .MALFORMATION OF THE FINGERS The different disturbances of development result in curious anomalies of the fingers, such as polydactyly (redundant number of fingers), ectrodadyly (insufficient number of fingers), and syndac- tyly (a fusing of the fingers). Polydactyly is the most frequent malformation and calls for surgical intervention, since the removal of these unsightly super- MALFORMATION OF THE FIXGERS 601 fluous fingers is desirable, because they are rarely of any functional value. The operative removal should be done according to cosmetic principles, and no operation should be done if there is any doubt as to the metacarpal con- nections until this important point is demonstrated by the X-ray. A radiograph shows which of the fingers is superfluous. Syndactyly (Fig. -235) is an urgent indication for surgical intervention. Here the condition demands not merely a cosmetic consideration but the connected fingers are retarded in their growth. The tissue connecting the fingers varies from a thin web of skin to a broad bony fusion between the phalanges. In the most FIG. 235. SYNDACTYLY WEBBED FINGERS. FIG. 236. DIDOT'S OPERATION FOR WEBBED FINGERS. severe cases the skin passes over the fingers without any interdigital furrows and the fingernails are then unseparated. TREATMENT. Permanent separation of the adherent parts. LelZ 01- OSTLOt- k. SUKl: 602 The greatest difficulty in this operation lies in covering in the separated surfaces with skin. Unless this is done with some care the parts grow together again. Hence any operation to be success- ful must contemplate the use of plastic skin flaps. The deformity should be corrected by a plastic operation in early childhood the second or third year. Didot's Operation (Fig. 236). "Two narrow longitudinal flaps are dissected up as thick as possible from the palmar and dorsal aspects of the affected fingers, and each flap is folded around to cover in the raw surface of the finger to which it is attached." The flaps are secured by interrupted horse-hair sutures. (Jacobson.) U FIG. 237. AGNEW'S OPERATION FOB WEBBED FINGERS. This operation is ingenious but not always satisfactory in chil- dren, since the necessary dissection is liable to injure the digital vessels and nerves. A simple and more satisfactory procedure is Agnew's Operation (Fig. 237). A triangular flap is raised from the dorsal surface of the web with the base at the root of the fingers. The remainder of the web is divided and the flap carried through the cleft at the base of the fingers and sutured in position. The fingers should be separated and immobilized until healing is com- plete. Ectrodactyly. In this deformity any or all of the fingers may be absent. It is often associated with other deformities of the fingers, such as abnormal development of individual digits, fusion of some jfjH MALFORMATION OF THE FINGERS 003 of the fingers, absence of the middle finger with its metacarpal, pro- ducing "forked hand." It is obvious that operative interference is indicated according to requirements. There are other deformities observed, especially in the thumb. Among these may be noted "bifid thumb" & double thumb, each with its own metacarpal bone and tendons. It is obvious that "bifid thumb" should be conserved and the defect modified by a plastic operation. Occasionally we find a thumb with three phalanges, often asso- ciated with "bifid thumb." Clubbed Thumb. This malformation is sometimes noted, and consists of a lateral deviation in the axis of the thumb the second phalanx forms a right angle with the first. The indications are to restore the thumb to its normal axis by division of the fibrous reten- tion bands and to maintain the thumb in normal position by a splint that corrects the deformity. SECTION XIV THE LOWER EXTREMITY CHAPTEK LXXIII CONGENITAL DISLOCATION OF THE HIP While this is the most frequent of congenital dislocations, it is not a common affection. It occurs more frequently in girls than in boys and is usually unilateral. Etiology and Pathology. A number of causes have been ad- vanced to explain this condition, but the theory of congenital mal- formation arrested development, resulting in an unusually small head of the femur and a shallow acetabulum rationally accounts for the phenomena. There are three significant facts which shed some light on the etiology of this affection : First: The hereditary factor. It appears in certain families and is often associated with other defects. Second: It is more frequent in females than males (7-1). Third: It is more frequent in the higher races (5 to 10 times rarer in the black and yellow races. Spitzy). These facts suggest that in the evolution of a biped certain structural weaknesses resulted not present in the quadruped. This is notably true of the hip- joint a joint not as well adapted for the erect posture of man as it is for the bent posture of the quadruped. Furthermore, the female pelvis has broadened out to adapt itself to the larger brain and consequent larger size of the fetal head. As the pelvis broadens the acetabulum becomes shallow hence the greater frequency of congenital dislocation in the female. A clear understanding of the anatomical defects present in this affection is essential to appreciate its symptomatology and treatment. 604 ETIOLOGY AND PATHOLOGY 605 Let it be understood that in congenital dislocation we are not dealing with a ruptured capsular ligament through which the femoral head has torn its way. We are dealing with a displace- ment of the joint within the capsular space; hence we find primary defects in the structure of the joint, and secondary changes de- veloped by the use of the defective joint. PKIMAEY DEFECTS. (a) Shallow Acetabulum. Instead of a cup-like cavity to receive the head of the femur there is a malforma- tion which varies from a shallow saucer to a mere indentation. The empty cotyloid cavity is filled with connective tissue, loses its depth and spherical form, and often assumes a triangular shape. (b) Changes in upper end of femur are variable and due to lack of develop- ment. The head is small and flattened. Changes are noted in the angle of the neck, usually a certain degree of coxa vara, the length of the neck is di- minished and sometimes wanting altogether, so that the head rests on the great FIG. 238. DIAGRAM SHOWING DISPLACED FEMORAL HEAD ON THE DORSUM ILII. trochanter. It is obvious that the condition does not manifest itself at birth, but passes un- noticed until the child begins to walk, then occur SECONDARY CHANGES due to use of the defective joint. It is apparent that when the child begins to walk and no support is offered the femoral head by the acetabulum, it becomes permanently displaced on the dorsum ilii (Fig. 238), and the weight of the body is borne by the capsule, which becomes greatly thickened, stretched out like an hour-glass-shaped tube, the constriction of the hour-glass separating the head from the acetabulum, which forms a serious ob- stacle to reduction. It is evident that the muscles surrounding the hip-joint must undergo adaptive changes in length and direction consequent upon 606 CONGENITAL DISLOCATION OF THE HIP loss of bony function. These changes consist of shortening and hypertrophy. Other secondary effects, such as asymmetry of the pelvis, curvatures of the spine, and loss of normal muscular balance, are the natural sequence. Symptoms. The history which the parents give shows that noth- ing abnormal was observed until the child began to walk; that the child learned to walk late; that he walks badly, falls easily, and tries to sustain himself by grasping objects. In addition to this they have noticed the deformity of the hip. The most prominent symptom is the "limping" gait of the patient, present both in uni- lateral and bilateral dislocations. The "limping" of unilateral dislo- cation is the "waddling" of bilateral dislocation. The characteristic "limping" is due not only to the shortening, but because the femoral head is not held in a fixed position on the bone above it it glides up and down; at every step the patient takes the body gives way, and on inspection the up-and-down movements of the trochanter can be distinctly seen. In unilateral congenital dislocation note the characteristic "limp- ing" gait, the shortening, the trochanter above Nelaton's line, flat- tening of the buttock, and prominence of the trochanter on the affected side. There are also tilting of the pelvis to correct the short- ening and lateral curvature of the spine. On examination the head is found out of its normal position and may be felt displaced upward under the soft parts when rolled about by manipulation. It will also be found that there are normal flexion, extension, adduction, rotation, and circumduction. Abduc- tion only is found to be limited and the movement is suddenly ar- rested. Bilateral congenital dislocation of the hip presents the same local conditions on both sides (Fig. 239). The pelvis seems to have penetrated like a wedge between the extremities, which appear too short when compared with the well-developed trunk. Two promi- nent symptoms confirm the diagnosis: (a) The patient's gait. The patient in walking "waddles" like a duck ; with each step the body sways from side to side a feature plainly discernible through the clothes. TEEATMENT 607 (b) The patient's attitude. There is a well-marked lordosis of the lumbar spine producing a condition of "saddle back." The affected limbs undergo muscular atrophy and the deformity increases with age. An important observation is the fact that, while these patients walk incorrectly, they walk without more fatigue than others. Diagnosis.' With a suggestive history and the characteristic gait of the deformity the diagnosis usually presents no difficulties. The X-ray is the most direct means of dispelling all doubt. It will be necessary to differentiate coxa vara which gives "limping" gait, trochanter above Ne- laton's line, and shortening of the extremity. The gait, however, is firmer and the femoral head is in its normal position. In paralytic dislocation of the hip (extremely rare) there are displacement of the head and ascension of the great trochanter, seen in the his- tory of infantile paralysis; but the least traction on the extremity is sufficient to bring the head into normal position. In hip-joint disease it is hardly possible to make a mistake when the fixation of the head is considered, the painful passive movements, and the dragging of the limb. Besides congenital dis- location is ruled out by the presence of fever, swelling, abscess, and fistulization. The history, careful examination, and finally the X-ray will insure a correct diagnosis. Prognosis. When untreated the dislocation becomes more and more aggravated by the growing weight of the body hence walk- ing is more difficult and lordosis and scoliosis more accentuated. Under proper treatment the deformity can be completely cured. Treatment. The earlier the treatment the better. If it is pos- sible to make a diagnosis before the patient walks, treatment may be begun by preventing further development of the deformity and :G. 239. BILAT- ERAL CONGENITAL DISLOCATION OF THE HlP IN A BOY OF FIFTEEN. (Kir- misson.) 608 CONGENITAL DISLOCATION OF THE HIP not allowing the child to bear its weight for the first two years. These patients are usually brought to the physician after the second year when there is pronounced disturbance in walking. Three methods of treatment may be used. (a) MECHANICAL,. In patients too old to permit of reduction a corset made of felt with silicate of soda and shellac or leather will improve the patient's gait by pressing against the trochanter and thus prevent the head from slipping upward when walking. (b) BLOODLESS REDUCTION. Lorenz employs a method of manipulation by which all the resisting structures are over-stretched, the head of the femur brought to the level of the acetabulum and implanted in this position, where it is held by a plaster splint so arranged that as the limb is used the head will be pressed into the cavity, which it will gradually dilate, deepen, and convert into a staple joint. The age of election for this procedure is from three to six years, though in unilateral cases it may be tried up to the twelfth year. Method. The object of this method is to obtain a complete ana- tomical reduction and to retain the reduction sufficiently long to establish a normal and permanent articulation. First, the patient is deeply anesthetized to the point of complete relaxation. Second, manipulation of the thigh by flexion, extension, rotation, abduction, and massage to overcome the resistance in the shortened muscles and fascia and thus by over-stretching these tissues eliminate the obstacle to reduction. The steps of the procedure vary with different operators the result is the same. The method of Kirmisson has been followed by the authors with excellent results and is essentially as follows: An assistant holds the pelvis firmly fixed while the surgeon proceeds to flex the thigh on the pelvis, repeating the movement until the head of the femur is brought down as low as possible and in relation with the posterior and inferior portion of the acetabulum. Next the limb is slowly abducted, and in this position it will be found that the shortened tendons of the adductors stand out prominently beneath the skin. This tension of the adductors must be made to yield by firm and increasing abduction together with massage until the thigh in forced TEEATMENT 609 abduction lies on its external surface, even though some of the muscular fibers are ruptured (in some cases it is necessary to divide the tendon of the adductor longus). After complete abduction is obtained the limb is circumducted until the head is freely movable. Thus with the head brought as low as possible and freely mov- able, the fascial and muscular obstacles having been removed by over-stretching, we proceed to Reduction. To understand the movements of reduction it must be remembered that the Y-ligament of Bigelow is the chief aid to the surgeon in accomplishing reduction, since it acts as a fulcrum to the shaft of the bone, the diaphysis being the long arm, and the femoral head the short arm of the lever. Thus every movement of the knee produces an opposite movement of the femoral head. The thigh is flexed to lower the head then abducted and strongly rotated outward by this movement the head is forced over the rim of the acetabulum and a sudden "jump" indicates that the head has reached the socket. It must not be expected that a reduc- tion can be accomplished in the first attempt. Repeated trials are often necessary, combined with direct pressure on the great tro- chanter. When the head is finally in place there is the noticeable fulness in Scarpa's triangle and the head can be felt beneath the crural arch. After reduction it is necessary that the head be maintained in position by Fixation. To extend the limb in normal position after reduc- tion is only to invite a return of the dislocation. To make the re- duction permanent it is necessary to fix the limb in a position of flexion, abduction, and external rotation for a period sufficiently long to mold the muscles and joint into a state of equilibrium and stability. To attain this the pelvis and thigh must be fixed in a plaster cast extending from the arch of the ribs to the knee. The duration of fixation in this position is variable (from three to six months) and depends upon the ease with which the reduction is maintained. During this period the child is permitted to walk with a high 610 CONGENITAL DISLOCATION OF THE HIP sole on the affected leg (Fig. 240). If the retention is satisfactory the bandage should be removed at the end of the third month; the joint examined and radiographed, and if the position is satisfactory a second plaster bandage is applied in a position of less flexion and abduction. At the end of two or three months the cast is again re- moved, the joint examined, and the cast reapplied with the limb in normal position. The duration of fixation varies from six months to a year. It is well to remember that empirical treatment in these cases is impossible the frequency with which the cast should be changed and the modification of the position of the limb must depend upon the case and the dictates of ex- perience. After the cast is finally re- moved the child is permitted to walk with crutches so as to use the limb without weight. The joint should be gently mobilized and the limb mas- saged. Later,- an active gymnastic ex- ercise to improve the adductors may be of great advantage. Complications. The most frequent accidents occurring in bloodless reduc- tion are : (a) Fracture, which is not grave and has no bad influence on the result. It is well to remember that this may be avoided by abstaining from violent movements. (b) Ecchymosis from the ruptured fibers of the over-stretched adductors, which is absorbed in a few days. (c) Vicious Attitude. Even after successful reduction it is sometimes found that a twist in the nock of the femur causes a corresponding vicious attitude in the axis of the femur. To correct this it may be necessary to do a subtrochanteric osteotomy. FIG. 240. PLASTKR FIXATION AFTER REDUCTION OF A CON- GENITALLY DISLOCATED HlP. (Bradford and Lovett.) TREATMENT 611 In bilateral dislocation the treatment remains the same as for unilateral dislocation. Both hips are reduced at one seance. It is well to remember, however, that an equally good result on both sides is rarely obtained. (c) REDUCTION BY INCISION AND MANIPULATION. The patient is anesthetized and an incision made from the anterior superior spine downward and passing below the tip of the great trochanter (Lorenz). The fascia lata is incised, the muscles retracted, and the capsule of the joint exposed. The capsule is now split and the opening enlarged so as to expose freely the bony structures. If the head is held by the liga- menturn teres it should be excised and removed. A thorough exami- nation of the parts is made to ascertain the conditions which pre- vent retention of the head in the acetabulum and these obstructions removed. It may be necessary to deepen the acetabulum by scooping out the dense fibrous tissue which sometimes fills it, or it may be neces- sary to round out the flattened head. When the obstacles to reduc- tion have been removed the head is pried into the acetabulum and the capsule sutured about the head and neck so as to act as a means of retention. The limb should be retained in a position of strong abduction by a plaster bandage reaching from the axilla to the toes (Lovett). The abduction is reduced with each dressing and later massage and passive movements are instituted. The operation is extensive and severe and even in a case of normal healing requires a high vital resistance on the part of the patient. The results of open operation cannot approach bloodless reduc- tion. Besides its severe strain on the vital forces, it is often fol- lowed by disturbance of function and ankylosis. 612 COXA VARA AND COXA VALGA CHAPTER LXXIV COXA VAKA AND COXA VALGA COXA VARA Coxa vara is a deformity of the femoral neck manifested by a deficiency in the normal angle which is formed by the head and neck of the femur with the shaft. It will be noted that normally the neck of the femur forms an "angle of inclination" with the shaft of about 125. In coxa vara the angle of inclination is de- creased to a right angle, or may even form an acute angle of 60-70 (Fig. 241). There is also some deviation in the normal angle which the head forms with the neck. This is usually an angle of about 12 pointing backward. In coxa vara this angle is increased. Etiology and Pathology. In considering the etiology of coxa vara it must be noted that the normal angle of inclination of the femoral neck is a product of the upright position. In quadrupeds and the anthropoid apes the neck remains at a right angle; hence we see in congenital coxa vara a reversion to a lower type. We may also have a traumatic coxa vara due to vicious union in frac- tures of the neck of the femur. The two forms of coxa vara which concern us here are the rachitic coxa vara of small children and the coxa vara of adolescents. It is evident that any pathogenic factor that modifies the nutri- tion of the bone or compromises its resistance can cause coxa vara. If the neck of the femur loses its resistance it bends under the body weight, hence rachitis plays an important role in the etiology of this affection. In the coxa vara of adolescents there is developed at the age of puberty a similar deviation due either to defective nutrition late rickets or a deviation in the epiphyseal line between the neck and the head. Coxa vara may be either unilateral or bilateral. COXA VARA 613 Symptoms. (a) Pain, which is often reflected to the knee and foot. It disappears in repose and appears when the patient walks. This pain is due to abnormal tension upon the muscles and liga- ments. (b) Impairment of function. There is a disturbance of gait. The patient "limps," and in bilateral affections "wabbles" like con- genital hip-joint dislocation. The affected leg tires easily, and there are manifest the defects due to shortening and to the disturbance in the muscle mechanism caused by the displacement of the trochanter above Nelaton's line. ON EXAMINATION we find that the limb is shortened, adducted, and rotated outward. The greater trochanter is above Nelaton's line and the head of the femur is in its normal place. There are limitation of the movements of abduction and internal rotation. Abduction is prevented by the shortened ad- ductors and the bony interference caused by the high position of the trochanter. Diagnosis. When the history is carefully con- sidered the diagnosis is not difficult. The prin- cipal diagnostic signs are shortening of the ex- tremity and displacement of the trochanter above Nekton's line without displacement of the femoral head. When the trouble exists from birth it must be differentiated from congenital dislocation of the hip by the more secure gait, the recognition of the head in its normal position; and finally, the X-ray will determine the exact diagnosis and should never be omitted. When the affection occurs during early adolescence it must be differentiated from hip-joint disease by its rapid onset, absence of constitutional symptoms or muscular rigidity, and early occurrence of shortening. Prognosis. While the progress of the disease may be checked under proper treatment it must be understood that such resulting FIG. 241. COXA VAKA. 614 COXA VARA AND COXA VALGA deformity as changes in the bone have established is permanent, and that function is modified according to the degree of deformity. Treatment. Rest in bed with continuous traction of the limb in a position of abduction, using such drugs as favorably influence the formation of bone, and out-of-door life. When the symptoms have disappeared the use of the limb should be resumed gradually and with the use of crutches. When there are marked deformity and impairment of function it will be necessary to resort to operative measures, as subtrochaiiteric osteotomy. COXA VALGA Coxa valga is a deformity of the femoral neck in which the angle of inclination is increased and the normal obliquity of the neck exaggerated. In some cases of coxa valga the X-ray shows that the angle of inclination is so exaggerated that the shaft and the neck of the femur appear to be in a continuous line. Etiology. Coxa valga may be congenital or acquired. The con- genital type may occur in conjunction with or without congenital dislocation of the hip. Acquired coxa valga is usually the result of continuous traction by "dead weight" from below and is found frequently in infantile paralysis, or in the pendent stump of a thigh amputated in early childhood. It is seen on the opposite side of a genu valgum, after fracture of the neck of the femur with impaction and vicious union, and after injuries and separation of the epiphysis (Tubby). Symptoms. When it is remembered that the absence of weight- bearing is an important etiological factor, it is obvious that the de- formity is most frequently found in an unused extremity and hence the symptoms are obscure. The limb is in a position of abduction and external rotation with corresponding limited adduction and in- ward rotation. There is lengthening with pain and lameness. Diagnosis. The X-ray is necessary in making an exact diagnosis. Treatment. Osteotomy of the neck of the femur with fixation in adduction is indicated for the purpose of restoring the normal angle between the femoral neck and shaft. PATHOLOGY 615 CHAPTER LXXV HIP-JOINT DISEASE Hip-joint disease (tuberculosis of the hip, coxalgia) is essen- tially a disease of childhood and one of the most common forms of joint tuberculosis. It most frequently attacks children between the ages of five and ten years and is generally unilateral. It be- gins either as a tuberculosis of the synovial membrane, or as a tuberculous osteomyelitis of the head of the bone or the acetabulum. Whatever the initial focus, a destructive process is inaugurated in the joint, in which the onset is insidious, the development slow, and the symptoms pronounced only when the disease is well ad- vanced. It is a disease that presents a problem of great difficulty and responsibility, it demands the closest attention of the medical adviser since successful treatment depends upon early diagnosis. Pathology. The tuberculous process in the hip is similar to that in other joints. The disease spreads from its primary focus and invades the joint, filling it with granulations and destroying the joint mechanism. The whole head and neck undergo slow disin- tegration and under the superimposed weight sometimes fracture and leave the head lying in the acetabulum like a sequestra. Though more resistant, the acetabulum is affected likewise, and, as the bony tissue softens, the head, by the action of the weight, is pushed more and more upward into the softened acetabulum, which enlarges, and later the head is dislocated. After caseation and suppuration the abscess perforates the cap- sule and appears superficially in the region of the trochanter, at the lower border of the glutei, or into the pelvic cavity if it perforates the acetabulum. Cure of the disease is accomplished by scar forma- tion, resulting in fibrous and sclerotic changes in the elements of the joint. It is evident that complete restitution of function can be expected only in the early stages of hydrops articuli ; in all other cases the cure implies varying degrees of functional disability. 616 HIP-JOINT DISEASE Both the bone and the muscles show marked nutritional dis- turbances, the muscles of the thigh undergoing marked atrophy. It is evident that arrest of development of the extremity and vitiation of the pelvis, of grave import to the female, are among the remote consequences. Symptoms. As the disease begins insidiously every effort should be made to anticipate its progress by a correct interpretation of its earliest indications. Note the important fact that the onset of the disease is rarely acute, and that it frequently makes its appearance in children apparently in vigorous health. Again, the earliest symptoms are not the direct symptoms of a diseased joint, they are the reflex symptoms of disease in the neigh- borhood of the joint. (a) Lameness. The earliest appreciable symptom of hip disease is a slight limp, and for months this is sometimes the only symptom. Note that the lameness at first is indefinite and intermittent. The child makes every effort to favor the affected limb, he drags rather than moves the leg along, and the mother's observations are invalu- able to the surgeon in correlating this data. She observes that the child does not use one limb with the same freedom as the other. That when the child stands at rest he invari- ably stands on the healthy limb a fact confirmed by examination and associated with this it is noted that the knee of the affected side is slightly flexed and the thigh slightly abducted. This position of abduction is the inevitable position assumed to avoid painful weight-bearing, by shifting the leg from the axis of weight. The mother has noticed that the rhythm of the gait is broken there is an inequality in duration and intensity of the gait, the patient remains longer on the healthy limb and puts the foot to the ground with more force ; hence the ear alone can detect the arhythmic gait. Furthermore, it is observed that there is a certain amount of stiffness of gait in the morning immediately after getting out of bed, which gradually wears off as the joint "limbers up" and be- comes pronounced again toward night when the child is fatigued. The manifestation of early lameness is therefore often a vary- SYMPTOMS 617 ing expression of rest or fatigue a limitation of motion for the purpose of resting and protecting the joint. (b) Pain. While pain is among Hie early symptoms, it is not a constant symptom and may be absent at any stage of the disease. The pain may be constant or intermittent and usually appears after the fatigue of a long walk, or is manifest in night cries. The peculiarity of the pain of early hip disease is the fact that the pain is at first referred to the knee. This phenomenon is ex- plained by the distribution of the obturator nerve which supplies both the hip and the knee joints. Irritation of the nerve at the hip is expressed in pain at the knee. Hence when a child complains of pain at the knee (especially if accompanied by slight limp) do not consider it insignificant. It may be the initial symptom of a grave malady of the hip joint. Again, if upon examination of the knee there is found no lesion which explains the pain, suspect that it is a sympathetic phenomenon connected with tuberculous hip. The pain may be increased by any movement which causes pressure on the joint surfaces, demonstrated by exercising pressure on the trochanter, the knee, or sole of the foot. Sudden pain at night, sufficient to wake the child with a cry, is characteristic, and due to sudden muscular spasm, for during the day the muscles are on guard and immobilize the joint, but when the child is asleep the joint is unprotected and slight movement affects the unguarded joint. Note that pain and limp are not necessarily simultaneous. Some- times there is no pain but slight limp, or there may be no limp but slight pain. (c) Muscular spasm is the most important early symptom of hip disease, and when combined with pain and limp the diagnosis is unmistakable; for muscular spasm to some degree is never absent even at the beginning of the disease. All attempts at movement are followed by muscular spasm an effort to fix the affected joint by reflex contraction of the muscles. Finally all movements are restricted and the hip is fixed in an abnormal typical position. In the early stage, however, the limi- tations of motion are entirely the result of muscular spasm, since 618 HIP-JOIXT DISEASE under anesthesia all the movements are restored to the normal. Muscular spasm is not only the most important symptom in diag- nosis, but, as Bradford and Lovett observe, it furnishes the most accurate index of the progress of the case and improves or becomes worse as the affected joint improves or deteriorates. As the disease progresses the child avoids walking as much as possible, prefers to sit or lie in bed. (d) Muscular Atrophy. The muscles of the af- fected limb early show a diminution in size, easily detected by measuring the circumference of the two thighs and calfs. A dif- ference of one-half to one and one-half inches may be demonstrated. Early atro- phy of the muscles con- trolling a joint is pathog- nomonic of joint disease. (e) Flattening of the buttock and loss of the glu- teal fold (Fig. 242) is due to flexion of the hip combined with atrophy of the gluteal muscles. A comparison of the two sides shows a striking contrast in the obliteration of the fold on the affected side. (f) Malpositions. As a result of an effort on the part of the patient to assume an attitude of greatest comfort, and the subsequent muscular contractions in the faulty positions, there is ultimately produced fixation of the limb in an abnormal position, i. e., the limb is fixed in various positions of flexion, abduction, adduction, and eversion ; or in various combinations of one with the other, there FIG. 242. OBLITERATION OF THE GLUTEAL FOLD IN DISEASE OF THE RIGHT HIP. SYMPTOMS 619 being no regular order in which these faulty positions make their appearance. The results of malpositions and their effect on the pelvis: It is important to understand that the fixation of the limb in a distorted position is always followed by tilting of the pelvis a compensation necessary to make the limbs parallel and thus permit the patient to walk or stand on both feet (Fig. 243). This can be demonstrated easily by means of a simple diagram. Normally both limbs are at right angles to the pel- vis as shown in diagram (Fig. 244A). Assume now that the right leg repre- sented by the line a c is fixed in a faulty position of adduction a e, it is evident that the two limbs represented by the lines a e and b d cannot be brought into a parallel relation without tilting the pelvis represented by the line a b, with the resultant position as shown in Fig. 244B. For it must be re- membered that the adjustment is not done in the diseased joint, but in the healthy joint which adapts itself by as- suming a position of abduction in order to be brought into a parallel position with the permanently adducted leg. Again, assume the right leg repre- sented by the line a c, as shown in Fig. 244C, is fixed in a faulty position of abduction a e it is evident that the lines a e and ~b d cannot be brought into a parallel relation without tilting the pelvis a ~b, with the resultant position as shown in Fig. 244D. ISTow note the second important fact: namely, that the adducted leg a c with the tilting of the pelvis was carried upward with that side of the pelvis and appears to be shorter than the leg b d; but it must be noted that this is only apparent, since the legs a c and b d really measure the same length. FIG. 243. THE RESULTS OF MAL- POSITIONS AND THEIR EFFECT ON THE PELVIS. 620 HIP-JOINT DISEASE b Again, the abducted leg a c with the tilting of the pelvis is car- ried downward with that side of the pelvis and appears to be longer .. than the leg I) d, but it is only | apparent since the lines represent- ed ing the legs really measure the same length. Hence, apparent shortening is an inequality of the legs caused by tilting of the pelvis, and de- pendent upon the amount of ad- duction or abduction. It is best demonstrated by measuring from the umbilicus to each internal mal- leolus. Meal shortening is not a po- sitional condition, but an actual affection of the limb, the result of retarded growth or disease of the / joint. It is always demonstrated by measuring from the anterior superior iliac spine to the internal malleolus. Flexion of the thigh is very characteristic of early hip disease. It is observed in the attitude of the patient as he lies with the knee of the affected side flexed (Fig. 245). Fio. 244. DIAGRAM DEMONSTRATING THE EFFECTS OF MALPOSITIONS OF THE LlMBS ON THE PELVIS. FIG. 245. WHEN THE PATIENT LIES ON His BACK THE KNEE OF THE AFFECTED SIDE is FLEXED. Fixation of the thigh in the position of flexion is demonstrated by placing the patient upon a table flat on his back and extending the diseased limb until it is in contact with the table (Fig. 246). DIAGNOSIS 621 Observe that in order to maintain the fixed flexion the pelvis must tilt forward with a resultant arching upward of the lurnbosacral vertebrae. This is the compensation lordosis of the lumbar spine which invariably accompanies fixed flexion in hip disease. (g) Swelling. Thickening of the tissues about the hip-joint is corroborative evidence of disease. There are often dense infiltration, marked swelling and fluctuation when abscess presents. The inguinal glands are often enlarged and after a time suppurate and discharge. (h) Abscess. During the course of the disease the granulation tissue caseates, then suppurates: The pus perforates the capsule, burrows along the line of least resistance, and leaves discharging sinuses opening on the front and side of the thigh, the buttock or perineum. Occasionally perforation of the acetabulum occurs and PIG. 246. WHEN THE DISEASED LIMB is EXTENDED THE BACK is ARCHED AS THE PELVIS TILTS FORWARD TO MAINTAIN THE FIXED FLEXION. an abscess is formed within the pelvis which may point above Poupart's ligament, about the rectum or ischiorectal fossa. Early and efficient treatment precludes the possibility of abscess formation. Diagnosis. Remember that early diagnosis is essential to favor- able prognosis and successful treatment. The most important early symptom of hip disease is muscular spasm and when combined with pain and limp the diagnosis is unmistakable. As Valette asserts, there can be no hip disease if the movements at the hip are perfect, any difference in the range of motion of the two hips suggests disease. After the disease is well established the train of symp- toms as described above present a vivid picture. EXAMINATION OF PATIENT. First get a detailed history of the case from the parents. Note specially what they have observed. These patients present a typical history of a gradual onset of lame- 622 HIP-JOINT DISEASE ness, stiffness of the hip, a disposition to favor one side, pain at the knee. The temperature should be taken. The clothes should then be removed and the attitude of the patient observed in stand- ing, walking, lying down, and getting up. Ask the patient to stand on one leg, it will be difficult for the patient to stand on the affected leg. Mark the position of the two anterior superior iliac spines upon the skin with ink and note the compensatory tilting of the pelvis. Remember that adduction causes apparent shortening, abduction apparent lengthening. Place the patient in the dorsal position upon a hard table (not bed) and direct the examination so as to ascertain if there is any diminution in the physiological movements of the joint. Before touching the patient make a note of the facts that can be observed by a preliminary inspection. If there is fixed flexion the patient lies with the knee of the affected side flexed. When the child is asked to extend the limbs in a parallel posi- tion the back will be arched (lordosis of the lumbar spine) if a fixed flexion position exists; when the leg returns to the flexed position the arched back disappears evidence that the normal arc of motion of the joint is limited. After the preliminary inspection grasp the lower part of the leg with one hand and the pelvis with the other and by gentle manipulation test all the movements of the joint, first in the normal, then in the suspected limb to detect muscular spasm. During each movement it is important to dis- tinguish between normal motion in the joint and movement of the pelvis. Note that these manipulations are for the purpose of appreciat- ing the slightest amount of muscular spasm; hence they should bo gentle and steady. Gentle manipulation will not only cause the patient the least discomfort but it will give the most accurate in- formation concerning muscular spasm. First test the normal range of motion in the healthy joint try successively flexion, extension, abduction, internal and external rotation. In this preliminary ex- amination the child becomes accustomed to the manipulations. Then examine the suspected joint. It will be found that the range of movement on the diseased side is diminished, and when an DIAGNOSIS 623 attempt is made to go beyond certain limits it causes pain or com- pensatory movement of the pelvis. Now note how the diminished movement affects the pelvis. It will be observed that when the leg of the affected side is brought in full extension there is produced a lordosis of the lumbar spine. ( See Fig. 246.) Now flex the affected leg, and when the angle of flexion reaches a certain degree it will be noted that the lordosis is elimi- nated (Fig. 247). The angle of flexion at which this occurs measures the amount of fixed flexion deformity. Next abduct the leg and note the point at which the pelvis be- FIG. 247. DISEASED HIP FLEXED UNTIL LORDOSIS OF THE SPINE is OBLITERATED SHOWING THE AMOUNT OF FIXED FLEXION DEFORMITY. gins to move. Try internal and external rotation and observe the limitation of motion. Note the presence or absence of pain when pressure is made over the trochanter or upon the sole of the extended leg. Look for swelling over the trochanter, Scarpa's space, the inguinal glands. Measure the length of the limbs (being sure that the limbs are placed in absolutely symmetrical position) for shortening. Measure the circumference of both limbs at the middle of the thighs and calfs for atrophy. Having recognized the early stages of hip disease, the later posi- tion changes offer no difficulties. 624 HIP-JOINT DISEASE It must not be forgotten that in the X-ray we have a valuable aid in diagnosis. At the beginning of the disease it will show an enlargement of the joint; later, changes in contour of the joint bodies, destruction of bone, and eventual changes in the normal position of the head and acetabulum which form the basis of real shortening. Differential Diagnosis. Tubercular disease of the hip should be differentiated from: (a) Acute osteomyelitis of the hip by the latter's acute onset the clinical picture of an acute infection as seen in the pain, swell- ing, temperature, leukocytosis, and general sepsis. (b) Pott's disease of the lumbar spine is often difficult to dif- ferentiate and the diagnosis must sometimes be postponed until characteristic symptoms of one or the other disease present. (See p. 454.) The confusing factor is the contraction of the psoas muscle which may cause lameness by limiting motion. The limita- tion of motion, however, is confined to hyperextension : Abduction, adduction, and rotation are not restricted. Again, in Pott's disease there is rigidity of the lumbar spine and extension of the limb causes no compensatory lordosis. Every movement of the patient demonstrates the effort being made to keep the inflamed spine absolutely rigid. The formation of a psoas abscess may present a picture of flexion contracture in the hip-joint, but the other hip movements except extension are free. Examination of the lumbar vertebrae will reveal some tenderness and usually some deformity. (c) Trochanteric Bursitis. The bursa situated between the trochanter and tendon of the gluteus maximus may when inflamed give rise to symptoms simulating hip disease, since the pain causes the thigh to be fixed in the flexed and adducted position. It should be differentiated by the absence of pain in the joint itself and the ability to rotate the head of the femur without limitation or pain. (d) Traumatic affections are differentiated by the history, course, and aid of the X-ray. (e) Rarely will it be necessary to differentiate arthritis de- formans, coxa vara, appendicitis, perinephritis, and malignant TEEATMENT 625 disease of the hip. Their symptoms are discussed under the ap- propriate headings. Prognosis. Untreated, the end results of hip disease present striking deformities, changes in the bony conformation of the joint which lead to dislocation, usually backward, with actual shortening; while the patient may finally succumb to progressive emaciation from the discharging sinuses, amyloid changes in the viscera, or tuberculous meningitis. A favorable termination is by resolution or by ankylosis. Early recognition and early treatment will shorten the course of the disease and offer a better functional prognosis. The duration of the disease is rarely less than two years, and often the diseased can be regarded as cured only after four to six years. Before beginning the treatment of a case of hip disease state s clearly that the disease is noted for its chronicity, that treatment is a matter of years, and that recovery without some lameness is impossible. Treatment. Too much emphasis cannot be placed upon the fundamental principle that we are treating the local expression of a general condition. The local lesions whether in bone or joint are only the local evidence of a debilitated body. Of paramount impor- tance then is the general treatment of the child to so improve the tissues that the tubercle bacilli will cease to thrive. General treat- ment consists in proper nutrition, unlimited sunshine and fresh air. Locally the indications in hip disease call for rest, traction, fixation, and protection. This treatment must cover a long and trying period, testing the patience of surgeon and parents ; effective cooperation can only be obtained when parents have an intelligent conception of the course of the disease and the value of early im- mobilization in effecting a cure with the least amount of functional impairment. It is evident that the social position of the child plays a great part in the efficiency of all local treatment, since the best treat- ment in bad surroundings must be followed by disappointing results. The treatment of these cases should be under the direction of those specially fitted by training and experience. The indications for treatment involve nice questions of judgment which can be 626 HIP-JOINT DISEASE acquired only by experience. The treatment can be merely out- lined in a general way: It is evident that the first indication is rest to the inflamed joint, such rest as can be obtained by preventing the inflamed sur- faces from coming in contact and thus diminishing reflex muscular spasm ; rest that is uninterrupted and as nearly absolute as possible. The patient, therefore, should be placed in a recumbent position, not in a bed, which permits tossing about, but on an apparatus such as the gas-pipe frame of Bradford and Lovett, which per- Fio. 248. EXTENSION APPLIED ON WHEELED LITTER. (Merrill.) mits the child to be carried into the open air (an oblong frame made of gas pipe across which is stretched canvas tightly laced to the side bars and made in two sections with a separation of several inches opposite the arms), or upon a wheeled litter which permits the patient to be placed out of doors and kept there night and day if possible (Fig. 248). In this position the patient should be kept day and night and traction of from five to fifteen pounds applied by means of Buck's extension. The traction should pull in the line of deformity, and the amount TEEATMENT 627 of weight be increased until the pain ceases. The aim of traction is to pull and keep the inflamed joint surfaces apart until the inflam- matory process has subsided, the muscular spasm abated, and the deformity is reduced. When this condition has been attained (in from three to six months), and attested by gradually taking off the weight without recurrence of symptoms for at least three months, the recumbent treatment should be followed by the ambulatory method, which combines traction and fixa- tion and also permits the patient to get about on crutches: thus combining the benefits of fresh air and that of rest to the joint. The requirements of this treatment are amply fulfilled by the Taylor traction splint (Fig. 249), which consists of a pel- vic band attached to which is an adjustable metal upright with a rectangular foot piece. The pelvic band passes around the pelvis below the anterior superior spines and the two attached perineal straps furnish coun- ter-traction. Extension is secured by means of ad- hesive straps applied from the middle of the thigh to the maireoli and fastened to the straps on the foot piece of the splint. The patient should wear a high shoe three inches thick on the sound side and use crutches so that the splint swings clear of the ground. The splint should be worn day and night and changed only when required for purposes of cleanli- ness (Lovett). As to the length of time for which splints are indi- cated, Von Bergmann's rule is of general application: "Splints are worn until the joint is not sensitive to the body weight or to a blow on the head of the trochanter." Upon the recurrence of pain or acute symptoms the patient should at once be returned to the recumbent position with traction ; and it must be remembered that in an apparently healed process the FIG. 249. THE TAYLOR HIP-SPLINT. (Keen's Sur- gery.) 628 FRACTURES OF THE FEMUR infection may still be latent and threaten a renewal of the process. Hence in keeping the joint immobilized it is better to err on the side of conservatism, for while you may regret taking the splint off too soon you will never regret leaving it on too long. The adjust- ment of braces and immobilizing apparatus and the period of time in which they should be worn should be left to the judgment of surgeons with special orthopedic experience. TREATMENT OF COMPLICATIONS. (a) Abscess should be treated ' i: '1 conservatively. '" Ifcis well to remember that these abscesses under the influence of rest alone are sometimes absorbed. Hence, when abscess formation threatens, the patient should be placed in .the recumbent position. If absorption does not take place, aspirate, remove the con- tents by suction, and inject a five per cent, emulsion of iodoform and glycerin. Any further operative procedures can only be justified by vital necessity. (b) Resection of the Hip. When we consider the excellent re- sults obtained by conservative treatment it is doubtful whether a child should be subjected to this procedure, especially when we con- sider that the mortality is high and the functional results unsatis- factory the interference with growth causes great shortening and deformity. Besides the price paid does not insure the removal of the disease. As a rule it may be stated that resection may be considered after conservative treatment has failed and where conditions of necrosis, extensive caries, prolonged suppuration, and intrapelvic abscess make recovery impossible without operative interference. (c) Amputation is done only to save the child's life after con- servative treatment to save the limb has failed. CHAPTER LXXVI FRACTURES OF THE FEMUR FRACTURE OF THE NECK OF THE FEMUR Fracture of the neck of the femur was formerly thought to be extremely rare in children. The investigations of Whitman, how- ever, have shown that it is by no means uncommon and until quite FRACTURE OF THE NECK OF THE FEMUR 629 recently has passed unrecognized. The reason for this is quite evi- dent when we consider the distinct difference in the clinical picture presented by a fracture of the neck of the femur in children and that of a similar injury in old age. In old age a slight injury is followed by immediate disability. In childhood a severe injury is followed by slight disability. It is only later that the maximum disability occurs. It is obvious that such an injury may be mistaken for a sprain or contusion of the hip. This deceptive symptomatology is explained by the fact that fracture of the neck of the femur in childhood is usually of the "green-stick" variety; hence there is no complete and immediate disability, on the contrary after a few days the patient is able to walk with slight limp and discomfort. After several months or FIG. 250. SHOWING A. FRACTURE OF THE NECK OF THE FEMUR; AND B. RESTORATION OF THE NORMAL ANGLE BY FORCIBLE ABDUCTION. (Whitman.) years, however, there may be pronounced disability due to a gradual bending of the femoral neck "coxa vara traumatica/' Diagnosis. When a child has received a severe injury to the hip careful examination should be made in order that a fracture of the neck of the femur may not pass unrecognized and untreated. In case of a "green-stick" fracture there are shortening of the thigh one-half to three-quarters of an inch slight outward rota- tion, limitation of motion, and some discomfort. The clinical evi- dence should be confirmed by the radiograph. Treatment. As soon as the diagnosis is made the treatment 630 FRACTURES OF THE FEMUR should be after the method of Whitman "The patient having been anesthetized, the limb, under manual traction, should by gentle force be placed in the attitude of full abduction and extension, thus utiliz- ing the fulcrum of the upper border of the acetabulum to restore the normal angle of the neck (Fig. 250). In this position a plaster bandage reaching from the axilla to the toes should be applied." (Fig. 251.) After six weeks a traction hip splint should be worn FIG. 251. THE LONG SPICA AS APPLIED FOR THE TREATMENT OF FRACTURE OF THE NECK OF THE FEMUR. (Whitman.) for several months until union is sufficiently firm to eliminate the dangers of a subsequent coxa vara. FRACTURE OF THE SHAFT OF THE FEMUR Pathology. Fracture of the shaft of the femur is very frequent in children. The majority are oblique fractures of the shaft. They are caused by direct or indirect violence incurred through gym- nastics or through a fall from a great height. It is to be noted that in small children with rickets the fracture is more often trans- verse than spiral, especially as the fracture approaches the lower end of the femur (Spitzy). Subperiosteal fracture here is rarely found since the pull of the strong muscle masses soon causes com- plete displacement. In fracture of the upper third there are apt to be abduction of the upper and adduction of the lower fragment. In FRACTURE OF THE SHAFT OF THE FEMUR G31 the lower third displacement is usually very slight except in the supracondylar fractures, where the action of the gastrocnemius pulls the peripheral fragment back into the popliteal space and may com- press the artery which lies close to the bone. Diagnosis. The diagnosis is not difficult; the evident deformity, shortening, displacement, and crepitus confirm the suspicion. Treatment. The use of the Bradford frame with vertical sus- pension of the injured limb is by far the most satisfactory method of treatment. The child lies upon the Bradford frame, to which the shoulders FIG. 252. VERTICAL SUSPENSION IN FRACTURE OF THE SHAFT OF THE FEMUR. (Spitzy.) and trunk are fixed by straps. Adhesive strips are applied to the legs as in Buck's extension, the limb is flexed at a right angle to the body, and extension secured by weight and pulley attached to some improvised support immediately above the patient. (The support may easily be constructed of barrel hoops secured to bed or peram- bulator [Fig. 252].) The extension weight should be heavy enough to just lift the buttock of the injured side off the mattress and allow the opposite buttock to come in full contact with the mattress. In case of much displacement coaptation splints may be applied to the thigh in addition. This seemingly awkward position is well 632 AFFECTIONS OF THE KNEE borne by children and has the advantage of keeping the child dry and clean. Frequent inspection is necessary to avoid decubitus on account of the tender skin. After firm union is secured apply a plaster spica, allow the patient up, put a high shoe upon the well foot, and let him get about with crutches. CHAPTER LXXVII AFFECTIONS OF THE KNEE CONGENITAL ABSENCE OF THE PATELLA Congenital absence of the patella is usually associated with other malformations of the skeleton, such as congenital dislocation of the hip, absence of the fibula, etc. Absence of the patella without other lesions is rare. The knee presents a flattened appearance. The examining fingers penetrate into the depression between the femur and tibia and the conformation of the articular elements is easily outlined. In some cases there is no great functional disturbance, in others there is a certain amount of articular instability shown by the lateral movements. Treatment. The treatment will depend upon the amount of functional disability. Orthopedic apparatus is of real service in appropriate cases. In "flail knee" an arthrodesis at the knee joint is indicated. CONGENITAL DISLOCATION OF THE PATELLA Like congenital dislocation of the hip the lesion is not recog- nized until the child begins to walk. The patella is usually displaced outward and may be de- scribed as: (a) Incomplete dislocation; the patella in flexion rests in front INJURY OF THE TUBERCLE OF THE TIBIA G33 of the external condyle, but in extension it returns to its normal position. (b) Intermittent dislocation; the patella is displaced while bend- ing the knee and returns to its normal position in extension. (c) Permanent dislocation; the patella remains permanently displaced on the outer surface of the external condyle. It has been found that in many of these cases there is a diminution in the size of the trochlear surface of the external condyle. In inveterate cases it is often a secondary phenomenon of genu valgum. Treatment depends upon the amount of functional disability. In the majority of cases it will be sufficient to prescribe an elastic knee cap. In cases with notable impairment of function (instability, synovitis, etc.) operative intervention is indicated. Operative inter- ference in these cases is extremely difficult and delicate since it contemplates entering the joint, freeing the patella, deepening the intercondyloid groove, which is completely filled up, and plication of the capsule. Or the line of traction can be changed by detach- ing the tuberosity of the tibia with its attached ligamentum patella? and anchoring it by sutures further inward. INJURY OF THE TUBERCLE OF THE TIBIA During childhood and adolescence, before the tubercle is united to the shaft, a sudden, violent action of the quadriceps extensor muscle may result in separation of the tibial tubercle. Poland records ten cases, all occurring in athletic boys between the ages of sixteen and eighteen. In all injuries about the knee resulting from sudden strain of the quadriceps extensor, separation of the tibial tubercle and frac- ture of the patella should be carefully distinguished. It should be remembered that fracture of the patella is not a lesion of childhood and is very rare in adolescence. In separation of the tibial tubercle there are swelling, pain, tenderness, apparent enlargement of the tubercle, and loss of func- 634 AFFECTIONS OF THE KNEE tion. Crepitus may be obtained by pulling the fragment downward (White). In doubtful cases the X-ray will furnish conclusive evidence. Treatment. The fragment should be drawn down to its normal position and the leg fixed in an extended position by means of a plaster bandage. Complete recovery is the usual result. GENU VALGUM It must be remembered that normally the axis of the femur and the axis of the tibia do not form a straight line, but a line broken at the level of the knee by an ob- tuse angle open externally. The knee therefore naturally inclines inward; and genu valgnm or "knock-knee" is only an exaggera- tion of this physiological disposi- tion to the extent of a deformity. (Fig. 253.) Age of Occurrence. Genu val- gum is found at two distinct peri- ods in young children and in adolescents and between these two there is an important differ- ence. In the genu valgum of young children the underlying cause is rickets and it is most frequently manifest between the first and fifth years. It is usually a bilateral affection, though knock-knee may be present on one side and bow legs on the other. It is often associated with other char- acteristic rachitic deformities. It is obvious that when the child assumes the erect posture and endeavors to maintain its equi- librium there must be an increased demand on the bony tissue not as yet completely solidified. Furthermore, the weakness FIG. 253. GENU VALGUM OR "KNOCK- KNEE". (Estor.) GENU VALGUM 635 in the knee is associated with a relaxation of the muscles and ligaments of the foot; hence knock-knee and flat foot are gener- ally associated. As a result these children try to compensate for the weakness of structure by strength of attitude; hence they stand with the knees braced against each other and the feet far apart ; finally the bone yields at those points which are specially subjected to weight and where there is a natural tendency to curvature. The lesion is found in the abnormal obliquity of the epiphyseal lines or marked curvatures in the lower end of the femur or upper end of the tibia. There is also associated with it a relaxation of the liga- mentous structures of the joint which permits of abnormal joint movements. In the genu valgum of adolescence the lesion is usually uni- lateral and well defined. Some observers believe that it is a mani- festation of late rickets, others attribute it to a disproportionate de- velopment of the two condyles ; physiological activity being greater in the internal condyle than in the external condyle. However, the lesion is almost constantly found in the internal condyle of the femur. It is only in very pronounced cases that there is a curva- ture in the lower end of the diaphysis. Symptoms. While the deformity is self-evident, the parents are concerned at first only with the awkward gait, which may vary from a slight limp to a "waddling" gait, depending on the extent of the deformity, and complaints of pain in the knees and legs after exercise. EXAMINATION. The preliminary symptoms will suggest a thor- ough examination of the naked child, both standing and lying down. Inspection of the child while standing reveals the deformity at the knee by the fact that the child stands with the knees in con- tact and the feet some distance apart. In establishing the degree of knock-knee the patient should be lying down with the limbs fully extended and the two knees in contact. The amount of separation between the two internal malleoli measures the amount of deformity. The deviation is corrected when the two internal malleoli can be put together and the knees touch. A record of the deformity should be made on a sheet of paper 636 AFFECTIONS OF THE KNEE placed beneath, reaching from the ankle to above the knees, the limbs traced with pencil and the distance between the malleoli noted in inches. A comparison of these records gives an exact idea of the progress of the case. Passive movements of the knee cause no pain. It will be found, however, that when the leg is flexed on the thigh the deformity disappears due to the simple anatomical fact that when the thigh is flexed the femur rotates outward on its own axis, hence the ap- parent correction of the deformity and the importance of applying all mechanical treatment with the leg fully extended. As nature always tries to cure a curvature by a counter curva- ture, so we often find compensatory deformities such as flat foot, an equinovarus position of the foot, lumbar scoliosis, etc. Prognosis. Every case can be improved by treatment. In mild cases hygienic and mechanical treatment will be efficacious; in severe cases operation will improve. Treatment in young children should embrace: 1. PROPHYLAXIS. The habit of carrying the child about on the arm of the nurse should be discouraged. In children with soft bones it is a competent cause of curvatures. Infants should lie on their back or belly and be wheeled about. The habit of encouraging children to walk by offering artificial support is to be condemned. Children pass spontaneously from the crawling to the walking period when the apparatus of locomotion is prepared for its additional burden. Precocious walking is responsible for much precocious deformity. 2. EXPECTANT TREATMENT. By this is not meant the expecta- tion of a spontaneous cure by ignoring the condition. It implies rest, constitutional treatment, massage, and passive movements. In rachitic knock-knee the patient should be kept off the feet; sea air, sun baths, proper diet, and antirachitic treatment are the fundamentals. The legs should be massaged daily and the de- formity gently corrected by grasping firmly the inner condyle and the lower part of the extended leg. Only such force should be used as is borne with comfort by the child. This manipulation should be repeated several times a day. GENU VALGUM 637 It is obvious that this treatment is applicable only in mild cases and under conditions where the social status permits constant super- vision. 3. MECHANICAL TREATMENT. The principle of this treatment is to establish a continuous pull on the knee with the ultimate aim of changing the relations of the femoral condyle by causing atrophy of the internal condyle and enlargement of the external condyle. Thus an anatomical cure is produced. Various apparatus have been devised for the correction of knock- knee. The simplest and most effective is the "knock-knee" brace of Bradford and Lovett. (Fig. 254.) It consists of "a light steel rod attached below to a steel sole plate and joined at the ankle. It runs up the outside of the leg as far as the trochanter and then the rod is bent backward and upward, to lie against the upper part of the but- tock and serve as an arm by which the leg can be everted or inverted if the child toes in or out in walking. "The knee is drawn upon by a square leather pad pulling from the shaft opposite the knee. The upper ends of the apparatus should be buckled posteriorly together by two straps, one connecting the tips of the posterior arms and sometimes another may be needed, running across the lower abdomen, connecting the shafts ; by length- ening and shortening these straps it is evident that any desired de- gree of inversion or eversion of the feet may be produced." (Bradford and Lovett.) It is obvious that mechanical treatment is efficacious only when the bones are soft and yielding, otherwise such treatment only leads to derangement of the joint. Hence, mechanical treatment is indicated before the fourth or fifth year. Little is to be expected from it after this age. If no improvement FlQ. 254. "K N O C K -K N E E" BRACE OF BRADFORD AND LOVETT. (Keen's Surgery.) 638 AFFECTIONS OF THE KNEE is secured from mechanical treatment after a trial of six months operation should be considered. 4. OPERATIVE TREATMENT. (a) Forcible Correction Under Ether and Application of Plaster Cast. This method of treatment is specially applicable to young children whose social position is such that mechanical treatment can- not be effectively applied. Some au- thors believe that, whatever the social position, it is better to do one pro- cedure for correcting, rather than months of splints. Forcible correction of the defor- mity may be accomplished by osteo- clasis forcible fracture by manual or instrumental means; or epiphy- seolysis loosening and displacing the lower epiphysis of the femur by manual pressure. It is obvious that in both these procedures in addition to the inac- curacy there is considerable derange- ment of the soft parts about the knee not to mention ankylosis, and paralysis of the peroneal nerve which in some cases have remained perma- nent. (b) Osteotomy (Partial Division of the Bone by Chisel, Completed Di- vision by Fracturing the Partly Di- vided Bone). MacEwen's supra- condyloid osteotomy has given excellent results. It consists of a par- tial division of the shaft of the femur just above the internal condyle, the operation being completed by forcible fracture. (Fig. 255.) Method. With careful antiseptic preparation of field of opera- tion and light ether anesthesia the patient should lie on his side so that the outer surface of the knee rests on a sand-bag. FIG. 255. MACEWBN'S SUPRACONDT- LOID OSTEOTOMY. (After Jacobson.) GENU VARUM 639 "Point of election" at inner side of thigh one-half inch above the adductor tubercle of the internal condyle. At this point the skin is divided just enough to permit the osteotome to enter. By gently tapping with a mallet the osteotome divides the bone from within out until three-fourths of the bone has thus been cut through. The remaining portion is fractured by gentle pressure. The leg is now placed in a corrected position, the skin incision dressed with aseptic gauze, and the limb immobilized in a plaster cast. At the end of four weeks the cast is removed, and in six weeks the patient is permitted to stand on the leg. GENU VARUM Genu varum (bow legs) is the opposite deformity to genu valgum. The leg and thigh form an angle or curve internally, the apex of the angle or curve being at the knee. The deformity is characterized by the knees being more or less separated and the malleoli in contact. It is usually bilateral, sometimes accompanied by genu valgum of the opposite side, and is an affection of early childhood (Fig. 256). Etiology. The habit of carrying a child on the arm of a nurse always on the same side is a frequent cause of curvature of the lower extremities. Some children are born with an exaggeration of the natural curve of the tibia and exhibit bow legs before they attempt to walk. The principal cause of genu varum, however, is nearly always rickets and hence it usually appears when the child begins to walk. The soft bones are unequal to the superimposed weight and yield in the line of least resistance. The deformity is usually bilateral. The site of the lesion varies. As a rule there is bowing of both femur and tibia ; in other cases the femur is normal and the bow- ing is in the upper or lower third of the tibia. The fibula follows the lead of the tibia and bows with it. It is not rare to find asso- ciated with genu varum other stigmata of rickets. Symptoms. First: General symptoms of rickets. Second: The 640 AFFECTIONS OF THE KNEE deformity is apparent. When the feet are brought together the knees are separated, and the Germans have aptly called it "0-leg." The gait is modified so that the child walks with a waddle, and in severe cases resembles that of congenital dislocation. EXAMINATION. Thorough examination of the naked child, both standing and lying down. Determine the exact site of the deformity, whether in femur or tibia. Bring the insides of the knees together by crossing the legs and note whether the thighs are parallel or not. For pur- poses of record make trac- ings of the deformity by placing the child on the back upon a sheet of paper and outline the legs with pencil. Prognosis. Every case can be improved by treat- ment. In mild cases hy- gienic and mechanical treat- ment will be efficacious; in severe cases operation will improve. Treatment. The treat- ment is similar to that of knoek-knee. All the meas- ures recommended for rick- ets are applicable here (see p. 128). 1. PROPHYLAXIS. Many curvatures of the lower extremities can be avoided by: (a) Forbidding the child to be carried about on the arm of a nurse. Soft bones yield to continued pressure. (b) Avoid using very thick diapers. (c) Do not encourage the child to walk too soon. Precocious walkijig is responsible for much precocious deformity. FIG. 256. BILATERAL GENTJVARUM. (Spitzy.) GENU VAEUM 641 2. EXPECTANT TREATMENT. For children under three years old no mechanical treatment is necessary. When any tendency to this deformity is noted use massage and manual pressure. Several times a day the child can sit with the ankles together and gentle pressure be exerted upon the legs at the point of greatest curvature. Much benefit may be obtained from the expectant treatment since bow legs show a greater tendency toward spontaneous cure than knock-knee 3. MECHANICAL TREATMENT. The principle of this treatment is to establish a continuous in- ward pressure by the application of braces to the inner side of the leg. Various apparatus have been devised, but the simplest and most effective is the bow-leg brace of Bradford and Lovett (Fig. 25 T), which consists of "a light steel upright which is at- tached below to the sole plate of the shoe. It runs up nearly to the origin of the adductor mus- cles, but it must fall a little short of them or it will excori- ate the skin in walking. The upright is then bent forward and upward, and curved to fit into the groin and come up as far as the posterior part of the dorsum of the ilium. In this way a lever is provided in which to evert the feet to any extent by alter- ing the curve of their arms and strapping them together behind. Pads for the outsides of the legs are made of leather and buckled by two or three straps to the upright, opposite the greatest con- vexity of the curve. Where the curve is wholly in the tibia and the child does not 'toe-in' it is sufficient to carry the upright just above the knee, and to end it in the semi-circular pad plate which FIG. 257. BOW-LEG BRACE OF BRADFORD AND LOVETT. (Keen's Surgery.) 642 is applied against the inner part of the thigh." (Bradford and Lovett.) It is obvious that mechanical treatment is efficacious only when the bones are soft and yielding, hence it is indicated before the fourth or fifth year. If no improvement is secured from mechanical treatment after a trial of six months, or the child's social position precludes proper care and attention, operation should be considered. 4. OPERATIVE TREATMENT. (a) Forcible Correction Under Ether and Application of Plaster Cast. This method involves frac- ture of the deformed bone either manually or by the aid of mechanical appliances (osteoclast). By placing the limb over a sand-bag and exerting sudden manual pressure a green-stick fracture is produced which at once permits the deformity to be corrected; or a more precise method is to pro- duce the fracture by means of an osteoclast. After a corrected position has been secured a plaster cast should be applied, extending from the toes to the hip. At the end of four weeks the cast is removed and in six weeks the patient is permitted to stand on the leg. (b) Osteotomy is the procedure of choice in sharp curves near the ankle or knee, and in all cases of anterior curvature of the tibia. The bone is divided at the point of greatest deformity and a linear osteotomy is to be preferred to the removal of a wedge which shortens the leg (Lovett). The technique of this operation is de- scribed on p. 638. GENU RECURVATUM This is a deformity characterized by a hyperextension of the knees, so that the leg forms with the thigh a curve with an anterior concavity. Sometimes the deformity is so accentuated that the lower extremity of the femur forms a prominence in the popliteal space ; or the leg may form an acute angle with the anterior surface of the thigh. This deformity may be congenital or acquired. It is usually secondary to: (a) Infantile paralysis where the loss of muscular control TUBEKCULOSIS OF THE KNEE 643 places the knee in hyperextension and overstretches the posterior ligaments. (b) Tuberculous disease of the joint where the ligaments are destroyed. (c) Hip-joint disease treated by traction. (d) Traumatism. Treatment by means of a brace with a stop- joint to prevent hyperextension. TUBERCULOSIS OF THE KNEE (Tumor Albus, White Swelling) Tuberculous disease of the knee-joint is quite frequent, follow- ing in the order of frequency after Pott's disease and hip-disease. Pathology. The pathology is that of tuberculous joint disease in general (see Tuberculosis of the Joints, p. 205). The exciting cause is often attributed to slight traumatism, contusions, or wrenching of the joint. It appears mostly in the osseous form, the foci being located in the condyles of the femur, the head of the tibia, or in the patella ; probably the head of the tibia is most frequently affected. The usual course of the tuberculous process is observed in the swollen joint distended by synovial fluid or by tuberculous granula- tions. The knee assumes its biological position midflexion; "pain position"; swelling accentuated by the action of the muscles gives the joint a peculiar spindle-shaped appearance, covered with tense, shiny, waxy skin, from which it derives the name "white swelling." Later the process goes on to caseation, suppuration, and fistulization. As the knee is held in slight flexion the action of the strong flexors overcomes the extensor, and there result a backward sub- luxation and outward rotation of the tibia. It is evident that the end results of treatment depend upon the amount of destruction in the joint elements. A hydrops may permit of healing without changes in the joint function, but the granulating and abscess forms leave in their wake a stiff knee due to fibrous or bony ankylosis. 644 AFFECTIONS OF THE KNEE Symptoms. The symptoms vary according to the clinical evo- lution of the disease, and as in all tuberculous processes they appear slowly, insidiously, but persistently. When a child exhibits after slight injury to the knee persistent stiffness or limp with slight flexion and muscular rigidity of the joint, tuberculous disease should be suspected. The pain at first may be only a feeling of discomfort, worse in the morning and wearing off during the day. Its reflex ex- pression is shown in the limp, the muscular rigidity, and the effort of the child to protect the joint from motion. Not infrequently are these early symptoms misinterpreted and valuable time lost by mistaking a tuberculous joint for rheumatism. As the disease advances the knee assumes a position of flexion, the position of greatest comfort. With the knee in fixed flexion the child walks only on the toes and avoids as much as possible the dis- comfort of weight-bearing. The swelling about the knee increases, the muscles of the thigh and calf atrophy, and the joint becomes spindle-shaped. As time goes on the fixation becomes more perma- nent and results in a vicious attitude, which invites backward sub- luxation; the pain increases in severity and is expressed in night cries. Disorganization of the elements of the joint follows with abscess and fistulization. Shortening is not a conspicuous feature, on the contrary it is not uncommon to find lengthening of the affected limb due to congestion of the epiphyses. Diagnosis. Early diagnosis lessens subsequent disability and shortens the course of the disease. The frequency of tuberculous joint disease in children should lead us to look with suspicion upon every case of swelling of the knee joint with intermittent lameness. As Willard tersely observes, "The great producer of cripples is the practitioner or surgeon who carelessly passes over a limp or a pain as a 'habit' or as rheumatism the burden of proof in chronic diseases of the knee in a child should always rest upon the non- tuberculous side of the question, since infinite risks are involved by delaying proper treatment." The X-ray is a valuable aid in differentiating the chronic types of joint disease from tuberculosis. TUBEECULOSIS OF THE KNEE G45 The von Pirquet tuberculin test is specially serviceable in small children. Prognosis. As in all joint tuberculosis the prognosis depends upon early diagnosis and efficient treatment. In children the prog- nosis is exceptionally good when treatment is begun early. The duration of the disease is from one to three years and recovery is attended with varying functional disability. Treatment. It must be ever kept in mind that it is not merely a diseased joint that needs treatment, it is a sick child. The diseased joint is but the local expression of a general condition. Hence, GENERAL TREATMENT of the child to so improve the tissues that the tubercle bacilli will cease to thrive. The tissues of the patient are improved by proper nutrition, unlimited sunshine, and fresh air. The use of tuberculin has been followed by excellent results (see Technique, p. 201). LOCALLY the treatment is limited to the most conservative measures, for we are dealing here with an epiphyseal center that largely contributes to the growth of the extremity. The whole aim of local treatment is to secure physiological rest in a good position; correction of the vicious attitude, and immobilization of the articu- lation. The blood supply to the diseased joint should be increased by producing artificial chronic congestion after the method of Bier (see Joint Tuberculosis, p. 207). In the acutely painful stage the patient should be treated in the recumbent position with the joint immobilized and with traction in the line of deformity. Forcible correction of the deformity should never be attempted, since damage to the popliteal vessels may result in gangrene. After the deformity has been corrected the joint is immobilized by a plaster cast reaching from the malleoli to the adductor tendons, a high shoe is placed on the sound leg, and the patient goes about on crutches, or the Thomas knee splint may be used. It consists of a leather-covered perineal ring, two steel uprights attached to the ring above and joined below by a rubber-shod steel shoe piece which extends two inches below the sole of the foot. Broad leather straps 646 THE TIBIA AND FIBULA above and below the knee hold the appliance in place. The sole of the shoe of the opposite side is built up to equalize the length of the limbs, and crutches may be used, though they are not necessary. When symptoms of pain and muscular spasm have subsided the fixation apparatus may be gradually withdrawn. Any return of symptoms is an indication to reapply the apparatus. Abscess formation should be treated by aspiration, removal of contents by suction, and injection of a five per cent, emulsion of iodoform and glycerin. Operative treatment in children, except for abscess or deformity (angular ankylosis), is not to be considered. The only rational procedure is persevering conservative treatment to save the limb, amputation to save life. CHAPTER LXXVIII THE TIBIA AND FIBULA RACHITIC CURVATURES OF THE LEG These are among the most frequent manifestations of rickets during the first three years, and require most frequently among allied deformities surgical interference. These curvatures are always more prominent in the tibia be- cause it is the weight carrier. They are generally bilateral ; when unilateral the left leg is usually affected. Pathology. There are a great variety of these deformities, yet it will be noted they all follow a certain type. They are all the expression of an exaggeration of the normal physiological curves, plus the greater pull of the biologically older groups of muscles muscular balance depends upon normal bone softened bone yields to the stronger muscular pull. Note in one of the most common types anterior curvature of the leg the deformity is at the weakest point at the junction of the lower and middle thirds (Fig. 258). The bony tissue adapts itself CONGENITAL ABSENCE OF THE FIBULA 647 to the changed conditions on the weighted, concave side it becomes stronger and more compact, on the opposite side it is less dense. The bone is further modified from the triangular to the flattened form ("saber shin"). The role of the muscles is shown by the tense condition of the tendo achilles, which bridges the curvature like the tightened string of a bow. The deformity is accompanied by functional troubles due to relaxation of the neighboring joints, and deviations of the foot, hence the gait is uncertain and the child frequently falls. Treatment. PROPHYLAXIS (see p. 128). Em- ploy antirachitic measures sunshine, sea air, and proper diet are the essentials. No weight bearing on the leg. If the deformity still increases it may be neces- sary to use orthopedic apparatus to remove weight from the leg. No operative interference until the fifth year until the rachitis is cured. OPERATION. At the proper time operation is always to be preferred to the use of apparatus, for its use always implies an atrophic influence on the limb. A linear osteotomy should be done at the point of greatest curvature, and the corrected posi- tion maintained by a plaster cast for six weeks. The role of the tendo achilles must not be over- looked in correcting curvatures of the leg. It plays an important part in their production and should be divided subcutaneously to facilitate correction and avoid recur- rence. FIG. 258. RA- CHITIC CURVA- TURES OF THE BONES OF THE LEG. (Estor.) CONGENITAL ABSENCE OF THE FIBULA Congenital absence of the fibula is much more frequent than that of the tibia. The fibula may be entirely absent, or there may 648 THE TIBIA A>O) FIBULA be a remaining fragment of the upper* or lower part of the bone it is usually the lower part that is wanting. Pathology. The extremity on the side of the absent fibula is atrophied and shortened, but it is specially accentuated in the leg. The shortening is the result of an angular deformity of the tibia at the junction of the middle and lower thirds which usually curves forward and inward. Quite frequently on the skin over the angular prominence is found a cicatrix more or less depressed. In most of the cases there is an absence of one or more of the toes on the fibular side of the foot, while there are often other mal- formations in other parts of the body associated with this deformity. The curvature in the tibia and the absence of the external mal- leolus cause the foot to be thrown into a valgus position, while the contraction of the tendo achilles draws the heel up and causes the foot to assume a position of equinovalgus. Volkman's deformity, which has been described as a congenital deformity of the tibiotarsal joint, in which the whole foot is thrown outward, is probably the result of a congenital absence of the lower portion of the fibula. The cause of this arrest of development can only be conjectured. It may be due to amniotic compression, or to obscure lesions in early embryological development. Diagnosis. The diagnosis of this lesion is not difficult and is promptly confirmed by the X-ray. ^ Treatment. There are two evident indications for treatment: (a) the curvature of the tibia; (b) the equinovalgus deviation of the foot. It is well to delay treatment until the age of two, and at that time proceed to straighten the tibia by a cuneiform osteotomy. It is well to note that the position of the foot cannot be corrected by the usual tenotomy and over-correction for equinovalgus devia- tion since the absence of the external malleolus only invites a recurrence. In these cases it will be necessary to divide the structures which mold the foot in its vicious position and permanently unite the foot and leg by means of an arthrodesis of the tibiotarsal joint. Kirmis- son remarks that in some cases the atrophy is so great that we are justified in amputating the limb. CONGENITAL ABSENCE OF THE TIBIA 64i> CONGENITAL ABSENCE OF THE TIBIA Pathology. Congenital absence of the tibia is much rarer than congenital absence of the fibula. It may be partial or complete, uni- lateral or bilateral (Fig. 259). Complete absence is usually accom- panied by a malformation of the condyles of the femur which appear to be bifurcated and the head of the fibula ar- ticulates with the external bi- furcation. The crucial ligaments are absent and most observers re- port absence of the patella, though Kirmisson believes that it is usually present but not recognized because it is concealed in the abnormally deep hollow between the con- dyles. The fibula, which is considerably hypertrophied, presents a decided curvature directed backward and out- ward. In partial absence of the tibia the upper extremity forms a normal articulation FIG. 259. CONGENITAL ABSENCE^ THE TIBIA. with the femur, but the rem- (Hoffa.) nant of bone becomes attenuated and terminates in a sharp point more or less prominent beneath the skin; over this point is usually found a cicatricial depression similar to that found in congenital ab- sence of other bones. The whole extremity is markedly atrophied and shortened, and there are usually evidences of malformation in other parts of the body, absence of one or more toes, etc. As a result of this malformation we find two characteristic de- 650 DEFORMITIES OF THE FOOT formities: (a) the leg is permanently flexed on the thigh; (b) the foot is in a position of extreme varus or equinovarus. Prognosis. The prognosis of these cases is not encouraging. The atrophy, shortening, and vicious position only increase as time goes on. Treatment. Many of these cases are beyond constructive surgery and require amputation. If the limb is sufficiently developed and the fibula hypertrophied enough to support the weight of the body constructive surgery promises surprising results. The fibula supplies the place of the missing tibia by transplant- ing the head of the fibula into the intercondylar notch of the femur. The foot is straightened and fixed in good position by an arthrodesis at the ankle joint. With the aid of prosthetic apparatus this pro- cedure has given some excellent results. In a case operated by Meyer for congenital absence of the tibia by transplanting the head of the fibula and doing an arthrodesis at the ankle joint the shortening from the anterior superior spine to the ball of the foot where the weight is borne measures two inches, of which three-quarters is in the femur. The right affected calf is three-quarters of an inch smaller than the left. The foot is fixed at 135. There are no hyperextension and no rotation possible at the knee. The boy can extend his leg to 165 strongly, and flex it to 90. The ankylosis at the ankle is firm. These cases should be operated upon from the second to the fourth year. CHAPTER LXXIX DEFORMITIES OF THE FOOT CLUB FOOT Club foot is a term popularly applied to a vicious attitude of the foot in relation to the leg. More specifically it is a deformity of the foot in which the sole is inverted, the heel elevated, and the toe turned inward (talipes equinovarus). The foot is rolled inward CLUB FOOT 651 so that the inner surface of the foot looks up, the outer surface is in contact with the ground, so that the patient walks on the outer side and, in severe cases, on the dorsum of the foot (Fig. 2 GO). It is one of the commonest of congenital deformities, occurs more frequently in boys, and usually affects both sides. Club foot may be either congenital or acquired as the result of infantile paralysis, cicatrices, or injury. FIG. 260. CLUB FOOT. Note that the foot is rolled inward so that the inner surface of the foot is directed upward. (Estor.) CONGENITAL CLUB FOOT Etiology. The etiology of this deformity is variously explained as the result of vicious attitudes during intrauterine life; as the result of faulty development of the foot, etc. We know that in utero the feet are placed against each other by their soles and in this supinated position most children are born. The extreme of this position would give club foot (Fig. 261). Fur- thermore, heredity seems to play some part as a predisposing factor, since the deformity has been noted in the parents and several chil- dren of the same family, while some authors have found club foot E Ol r V l> I I"* I (i U V- 652 DEFORMITIES OF THE FOOT much more frequent in children born of consanguineous marriages than among others. . We know that the deformity occurs in company with other de- fects, such as hydrocephalus and spina bifida, and that the specific cause of these malformations is as yet unknown. Pathological Anatomy. Fixation of the foot causes a correspond- ing change in the bony framework and the fascia, while the muscles adapt themselves to the changed function. Monod's classification is excellent since it rationally explains the three distinct pathological changes in the progress of club foot in the order of their develop- ment. This author divides the subject into: FIG. 261. CONGENITAL CLUB FOOT. (1) MUSCULAR CLUB FOOT. Here the vicious attitude is main- tained by the retraction, shortening, and tonic action of the muscles in adapting themselves to the abnormal direction and the altered function. This shortening is most marked in the tibialis anticus, the tibialis posticus, and the gastrocnemius as shown in the tension of the tendo achilles. The course of the tendons is more or less modi- fied by being carried further inward, as for example the common extensor of the toes and the extensor proprius hallucis. This is the variety of club foot most frequently found at birth. (2) LIGAMENTOUS CLUB FOOT. This is more complicated than the former, since to muscular contraction is added ligamentous con- 5 . J5 3 J , CLUB FOOT 653 traction. The contraction is specially observed in the plantar liga- ments and fascia and the internal lateral ligament. The ligaments on the inner, concave side are all shortened, on the outer, convex side they are lengthened. (3) OSSEOUS CLUB FOOT. To muscular and ligamentous con- traction are added bony deformities. Hence osseous club foot does not usually appear until a certain time after birth. It will be seen that bony changes are brought about by continued pressure in an abnormal direction. Hence the tendency of the deformity is obvious ; on the inner or concave side the bones are pressed together, their volume diminished, and their tissues condensed. On^he outer or convex side the bones appear enlarged and rare- fied. !Not only are the bones distorted, but they are dislocated, the normal articular surfaces are gradually obliterated, and new joint relations formed. In a structure like the foot, combining unusual strength and mobility, such a deformity as club foot must modify all the bones of the tarsus, yet a glance at the normal anatomical relations will demonstrate that the astragulus the bony link that connects leg and foot must be the center of the deforming influences. In this connection we note that the astragulus is sublaxated for- ward, its posterior part articulates with the tibia, its anterior part is enlarged, cannot be embraced by the tibiofibular arch, and pro- jects beneath the skin. The head of the astragulus is atrophied and falls inward, the neck is lengthened, and the head bent inward so that the articular surface looks inward instead of forward. The os calcis is pulled upward by the tendo achilles so that it approaches a vertical position. It undergoes an in-curving so that the concavity of its internal surface is exaggerated and there is produced a correspond- ing convexity of its external surface. Where the deformity exists for some time the cartilaginous coverings disappear from non-use and obstructions are formed which make return to the normal position impossible. The other bones of the tarsus undergo some modifications, but they are not such as to present important obstacles to reduction. 654 DEFORMITIES OF THE FOOT Thus it will be seen that to a primary positional defect are added complicated pathological changes involving muscles, ligaments, fascia, and bone, a proper appreciation of which is essential before any line of treatment can be rationally instituted. Symptoms. In addition to the obvious deformity there &re great awkwardness and unsteadiness in walking as the child walks on the outer edge of the foot and the "toeing in" is pronounced, one foot must be lifted over the other as the step is taken. As the weight is borne on the outer edge of the foot pressure bursse and callosities are soon developed. There can be no difficulty in diagnosing congenital club foot. Prognosis.- A club foot untreated never tends toward spon- taneous cure, but toward obstinate malformation. Under modern treatment a cure may be expected in children, and an improvement promised in adult cases. Treatment. Whatever procedure is chosen it must be clearly understood that there are two distinct deformities to be corrected : (a) correction of the varus position; (b) correction of the equinus position, and the deformity should receive attention in the order given. While the methods of correction vary, the purpose is the same: reduction of the deformity and retention in the corrected position until the cure is permanent. MECHANICAL TREATMENT. (1) The treatment of congenital club foot of the new-born should be begun as early as possible. Just as soon as the child's nutritional status is established at the end of the second or third week begin manipulation and massage. It must be remembered that the foot grows rapidly during the first months of life and if the growth can be directed in a normal direc- tion during this period much can be accomplished in the way of correction. As Willard observes, every case of club foot could be cured with good functional motion if the member could be held in the corrected position by a human hand for six months. This treatment can be carried out by an intelligent nurse under the direction of the physician. She should be instructed to gently manipulate the foot several times a day by unrolling it and hold- ing it in a corrected position as far as the comfort of the child will CLUB FOOT 655 permit; with this should be combined massage of the weakened muscles. When the contracted muscles and ligaments have been suffi- ciently stretched so that the foot is easily held in the corrected posi- tion it may be retained by a light plaster-of-paris cast reaching above the knee and renewed every two or three weeks. This treatment persistently followed will succeed in many cases in so reducing the deformity that the child will be able to place the sole squarely on the floor when it begins to walk. Walking on a deformed foot must not be permitted, since by this means a moderate deformity will be converted into an in- veterate one. (2) If persistent massage gives no results at the end of five months, or if the case is a child of five months who has not been previously treated forcible straightening under ether is indicated to place the foot at once in a normal position so that as the child walks he becomes an active agent in the corrective process. OPERATIVE MEASURES. To mold the foot into a corrected posi- tion and make it perfectly flexible it will be necessary to divide the tendons and fascia, which form a barrier to reduction. The opera- tions most frequently required are the following: (1) Subcutaneous Tenotomy of Tendo Achilles. While this is a simple procedure, two precautions should be observed: (a) strict aseptic methods; (b) care should be exercised not to wound the posterior tibial vessels and nerve which lie on the inner side of the tendon and are separated by a sufficient interval to insure their safety. The subcutaneous method is employed to avoid a cicatrix at the posterior part of the leg, which Kirmisson has seen become the seat of keloid degeneration and contraction. The knife is introduced on the internal side, passing flatwise be- tween the skin and tendon, the sharp edge of the blade is then turned toward the tendon, the foot flexed to put the tendon on tension, and the tendon carefully divided from without in. The tendon can be felt to give way as the ends separate. The wound is dressed with aseptic gauze, 656 DEFORMITIES OF THE FOOT After section of the tendo achilles not only flexion of the foot is possible and the equinus position relieved, but ofttimes the inversion also disappears. (2) Division of the Plantar Fascia. When the plantar fascia opposes reduction it can be felt as a broad tense ligament beneath the skin, extending from the os calcis to the base of the great toe. It should be divided at its most prominent point midway between the heel and the ball of the foot. The fascia is made prominent by placing the great toe in forced extension. The knife is inserted on the inner side of the sole between the skin and the fascia; the sharp edge is then turned inward and the fascia divided transversely until all resisting bands yield. The only structure to be avoided is the internal plantar artery, which is deeply placed and need cause no concern if the operator uses ordinary care. (3) Division of the Tendons of the Tibialis Anticus and Posticus. To correct inversion of the foot it is sometimes necessary to divide the ten- dons of the tibial muscles. The tendon of the tibialis anticus is easily found, since it presents a subcutaneous prominence on the dorsum of the foot where the tendon is made tense by abducting the foot. It is the first tendon in front of the ankle external to the inner malleolus (Fig. 262). The artery and nerve lie to the outer side. The knife is introduced to the outer side of the tendon beneath the skin and the tendon divided toward the bone. The tendon of the tibialis posticus is the tendon immediately be- hind the internal malleolus. The position of this tendon is such that safety is insured only by open division (Fig. 263). An incision is made along the posterior border of the tibia just above the malleolus, the tendon next the bone is lifted on a grooved director, and after its insertion has been demonstrated it is divided, FIG. 262. RELA- TION OF THE TENDONS IN FRONT OF THE ANKLE. (Davis.) CLUB FOOT 657 (4) If the deformity does not yield to tenotomy it may be neces- sary to resort to the open operation of Phelps, which consists of complete open section of the contracted tissues on the concave side of the foot by an incision extending from the tip of the internal malleolus obliquely across the inner border to the base of the first metatarsal. This inci- sion divides tendons, muscles, fascia, liga- ments, and all resisting structures. Hemorrhage should be provided for by use of Esmarch's bandage, the incision packed with gauze, and sterile dress- ings applied. The foot is held in an over-cor- rected position while plaster bandages are ap- plied. After tenotomy the wounds are protected by sterile dressings, the foot is held in an over- corrected position by a light plaster-of-paris ban- dage extending from toes to thigh. After-treatment. At the end of the third week the patient is permitted to walk, at the end of the fourth week the cast is removed, the foot thor- oughly stretched, and a second cast applied for four weeks. When the cast is finally removed some form of walking shoe is employed until the bony structures are molded into permanent relationships. FIG. 263. RELATIONS OF THE STRUCTURES BEHIND THE INTERNAL MALLEOLUS. A. Tendon of tibialis posticus; B. tendon of flexor longus digitorum ; C. posterior tibial artery ; D. posterior tibial nerve; E. tendon of flexor longus hallucis. 658 DEFORMITIES OF THE FOOT The Taylor club-foot shoe is one of the most efficient of these appliances and is concealed in the shoe (Fig. 264). Failures and imperfect results are caused more by incomplete after-treatment than by imperfect operation. After-treatment in these cases extends over months and years; it involves not only the constant wearing of a retentive apparatus, but at the same time development of the musculature by massage and by active and passive gymnastics. TREATMENT OF CASES THAT HAVE NEVER BEEN TREATED AND BEGIN TO WALK, OR RELAPSING AND ADULT CASES. It is evident that in these cases the bones have become permanently deformed and new relationships established, hence nothing short of a bony resection which diminishes the mass of bone at the outer border of the foot will be an efficacious means of correc- tion. To reduce the equinus position partial or total removal of the astragulus. To reduce the varus position removal of an osseous wedge from the external base of the tarsus (cuneiform tarsectomy). Tarsectomy is a valuable pro- cedure in those inveterate and r?- lapsing cases which have failed t > be benefited by lesser operations, but Kirmisson's rule should be re- membered, that "all these operations are to be considered as excep- tional and should have no place in the treatment of club foot in the first period pf infancy and childhood." Tarsectomy may contemplate an osteotomy of the neck of the astragulus, removal of the head and neck, or, in extreme cases, enucleation of the astragulus ; or a wedge of bone may be .removed from the outer side of the foot at the junction of the os calcis and cuboid. These operations should be done under strict aseptic con- FIG. 264. TAYLOR'S CLUB-FOOT RE- TENTION SHOE APPLIED. (Bradford and Lovett.) CLUB FOOT 659 ditions and by surgeons of experience. The after-treatment is the same as in tenotomies. ACQUIRED CLUB FOOT Acquired club foot may be the result of infantile paralysis, cerebral spastic paralysis, cicatrices, fractures, or joint disease. Club foot following traumatism is due to fractures, sprains, or burns. The deformity following fractures and sprains is treated by forcible reduction and tenotomy and osteotomy as indicated. In case of burns the scar tissue should be removed and skin grafting done. In deformities following tuberculous disease of the ankle cor- rective measures may be applied only after the tuberculous process has remained cured for a year. PARALYTIC CLUB FOOT Among the diseases of the nervous system in children anterior poliomyelitis is observed most frequently. As a result of this disease the lower extremities are frequently paralyzed either partially or totally. As a rule, however, the results of infantile paralysis are finally localized in certain groups of muscles, or sometimes a single muscle, especially those of the leg; hence deformities of the feet are a frequent sequelss and call for surgical intervention. The paralyzed muscles atrophy and undergo fibrous changes; there is consequently a loss of equilibrium among the muscle groups, and, the action of the antagonists being unopposed, there result vicious attitudes. It is obvious that if all the muscles of the leg are paralyzed the result will be a flail-like foot, which can be made to assume any posi- tion, but in paralytic club foot the lesion is usually partial and it is the loss of function in certain groups of muscles which causes the deformity. To cite a common example if the flexors of the foot 660 DEFORMITIES OF THE FOOT are paralyzed the powerful extensors will gradually pull the foot into a position of equinus or equinovarus, or, if the conditions are reversed, the foot will assume a position of calcaneus or calcaneo- valgus. These deformities usually appear from two to six months after the primary infection. Club foot of paralytic origin is to be differentiated from congen- ital club foot in that it is very much less severe and the foot is less fixed in its vicious position by the retraction of muscles and liga- ments (Kirmisson). Treatment. The treatment of the primary lesion belongs to medicine. Surgery is concerned only with the treatment of the deformity. The indications for treatment in these cases are: (a) The application of electricity and massage to prevent de- generation of the affected muscles. The galvanic current should be applied as soon as possible as soon as the diagnosis is made and the febrile period has terminated. If the case is seen early, before the deformity is fixed, electricity and massage alone are indicated. If the case is seen later, when the deformity is fixed, it is proper to correct the deformity before applying electric treatment. (b) Correction of the Deformity. If the case is seen early it will be easy to prevent fixation of the foot in a vicious position by means of massage and passive movements. Even slight contractures of the muscles may be overcome ; but when the muscular contractions are more pronounced, with a tendency to fixation of the foot in a vicious position, further deformity may be prevented by the use of some apparatus like the Taylor varus shoe (see p. 658). In severe cases, however, and in adults it will be necessary to resort to tenot- omies (see p. 656). In suitable cases active muscular traction may be accomplished by activating the paralyzed muscles by means of nerve-plastics, or by transplantation of tendons. Tendon anastomosis is a complex and delicate operation. Ana- tomical knowledge and surgical skill should be possessed by those who attempt this procedure. The aim of tendon transplantation is to substitute the action of TALIPES EQUINUS 661 a sound muscle for that of a muscle which is paralyzed. A thor- ough study of the active movements by electric examination and an estimate of the value of the various muscles are necessary prelimi- naries to a rational and efficient operation. TALIPES EQUINUS Pathology. Talipes equinus or pes equinus is that condition of the foot in which it is held in a position of plantar flexion, the heel is raised from the ground and the patient walks on the ball of the foot (Fig. 265). The foot may be extended to a straight line with the leg, so that the weight is borne on the heads of the metatarsals and the toes are in dorsiflexion. The deformity is either congenital or acquired. As a congenital FIG. 265. VARIETIES OF DEFORMITIES OF THE FOOT. A. Talipes calcaneus; B. Talipes varus; C. Talipes valgus; D. Talipes equinus. deformity it is extremely rare, and is treated by manipulation and retention in an over-corrected position by plaster cast. To accom- plish this it may be necessary to tenotomize the tendo achilles. Acquired pes equinus may be the result of anterior poliomyelitis with partial paralysis affecting the anterior tibial muscles and con- traction of the gastrocnemius and soleus ; or it may be due to spastic paralysis, neuritis, shortening of the leg by fracture or hip disease, malposition from long confinement to bed, and posterior cicatrices. Symptoms. Pain, limp, and deformity. Corns and callosities develop where the weight is borne and the toes are dorsiflexed. 662 DEFORMITIES OF THE FOOT Fixation of the deformed position and inability to dorsally flex the foot are diagnostic. Treatment. Slight cases may be treated by manipulation, but the majority of cases will require division of the tendo achilles and forcible reduction under ether with retention in plaster bandages for three or four weeks. Some cases may be so severe as to require re- moval of a wedge of bone from the front of the joint. PES CAVUS Pathology. Pes cavus (hollow foot) is that condition of the foot in which the hollow or arch of the foot is exaggerated (Fig. 266). The typical deformity is shown in the foot of the high-bred Chinese woman. It is a rare congenital deformity. The acquired form may be the result of infantile paralysis (paralysis of the interossei and lumbricales and the muscles inserted into the sesamoid bones of the great toe), Duchenne ; or the wearing of shoes that are too short. The sole is abnormally arched, the dorsum is abnormally promi- nent, and the plantar fascia forms a thick band from the heel to ball of great toe. The toes also have a characteristic de- formity "claw toe" caused by extension at the metatarso-phalangeal joints, and flexion at the first interphalangeal joints. It is obvious that this deformity after a time becomes very painful, since the weight is thrown on the forward part of the foot, callosities form on the sole over FIG. 266. PES CAVUS. the heads of the metatarsals and on the dorsal surface of the contracted toes. Treatment. The treatment consists in restoration of the muscu- lar balance, reduction of the deformity, and immobilization in good position. To reduce the deformity it may be necessary to divide the plantar fascia (see p. 657) or contracted tendons. FLAT-FOOT 663 After reduction the foot is held in the corrected position by a plaster bandage. Lovett recommends that when the patient begins to walk he should have a stiff flat steel plate run the length of the shoe be- tween the leather soles, running from which over the dorsum of the foot is a stout leather strap. The object of this is that at each step downward pressure is exerted on the dorsum of the foot. TALIPES CALCANEUS Talipes calcaneus is that condition of the foot in which it is held in dorsal flexion. The patient walks on the heel (see Fig. 265). It is rarely congenital; usually the result of infantile paralysis. The congenital form is usually amenable to manipulative correction and retention in plaster bandages. In the acquired form there is usually paralysis of the muscles of the calf, the relaxed tendo achilles permits the os calcis to drop until it is in a straight line with the leg. This deformity is also seen in caries of the ankle joint and after rupture of the calf muscles. Treatment. The treatment consists in manipulative correction and fixation; in extreme cases tenotomy of the dorsal flexors, short- ening of the tendo achilles. In paralysis of the gastrocnemius tendon transplantation may be considered. After reduction is obtained a retention shoe may be applied. FLAT-FOOT Talipes valgus is a deformity in which the foot is pronated and abducted, the plantar arch obliterated, so that the inner border of the foot comes in contact with the ground (Fig. 267). Willard esti- mates that one-fifth of the deformities of the body presenting them- selves to the surgeon are from weakened tarsal arches. Anatomical Considerations. A normal foot is the product of DEFORMITIES OF THE FOOT normal development, and normal development is often checked by ambitious parents who encase the foot in a shoe that retards growth and then encourage precocious walking by all sorts of inducements, even to the use of apparatus such as walking chairs. Bare-footed children who are permitted to exercise their walking instinct when and how nature intended are rarely the victims of flat foot. Parents should be instructed by the physician in the physiology of locomotion and in this should be accentuated two important points : First : The feet of small children should not be encased in shoes. There should be nothing to compress the foot nothing to impede the free movements of the toes since the muscles of the toes are the sup- porting tendons of the foot. Children should be encouraged to walk barefooted when possible, and when foot covering is required the use of the sandal is recommended, since it allows unhin- dered movements of the toes. Second: Walking should always be preceded by crawling to attempt to eliminate the "crawling period" is to prepare the way for deformities. The process by which the child establishes locomotion in the upright position is only a repetition of its biological development. In the developmental history of the race crawling preceded walking, and if the child is left to his own instincts he will naturally be- gin moving about by crawling, thus developing the bones, mus- cles, and ligaments for the later weight; and when the prepara- tion of these structures is sufficient, the crawling period is spon- taneously carried over into the walking period. Only when the child stands up alone and of his own volition tries to balance him- FLAT-FOOT. PLAT-FOOT GG5 self by objects and thus move about should he be allowed to walk (Spitzy). Varieties. Flat foot is either congenital or acquired. Con- genital flat foot is rare occurs only in a small percentage of new- borns as a result of embryological position. Here it must be ob- served that the generous layer of fat makes the foot of the new-born appear flat, but is not the apparent absence of the arch of the new- born that constitutes the deformity, but the rolling out of the sole and the outward displacement of the foot in relation to the leg so that the internal malleolus is abnormally prominent. The treatment of this congenital deformity is by manipulative correction and retention in plaster bandages. Do not allow the child to begin walking without proper support to the plantar arch. Acquired Flat Foot. It is evident that this deformity may be the result of rachitis, and it is often associated with other rachitic deformities (note the frequency of knock-knee with flat foot). It may also occur as the result of infantile paralysis, diseases of the ankle joint, and Pott's fracture. Typical flat foot is the static variety and, as Lovett has tersely put it, "it is an expression of a disproportion between the body weight and the sustaining power of the muscles and ligaments." Precocious walking means that weight is superimposed on struc- tures not yet prepared for the weight-bearing function the use of unsuitable shoes, occupations requiring prolonged standing on hard floors, excess of body weight, all infer a disproportion between the burden and the burden bearer the result is over-stretched liga- ments, relaxed ligaments, falling of the arch till the entire plantar surface comes in contact with the ground, bringing pressure upon points that are not adapted to withstand it, throwing the joint sur- faces out of line, and giving rise to a condition which produces pain and fatigue when the patient walks. Symptoms. A child is brought to the surgeon because the parents have noticed that the walk is heavy, the foot is pointed outward, the shoes are worn out on the inner side: The child tires out easily and always wants to be carried. EXAMINATION. The patient should be stripped so that the feet, 666 DEFORMITIES OP THE FOOT leg, hips, and back can be observed. The child is stood upon a flat table and the observation recorded. It will be noted that the foot appears elongated and broader. It is pointed out, and the internal malleolus is more prominent. The plantar arch is much diminished or flat on the ground, while the instep is flat and often concave. Observe the foot from behind, where the valgus deformity is well marked. Note that the axis of the leg, instead of falling through the middle of the heel, falls to the inner side. There are certain pain- FIG. 268. PKINT OF SOLES OF A FLAT-FOOT AND A NORMAL FOOT. ful points in flat foot, viz. : At the inner border of the foot in front of the internal malleolus and at the base of the first and fifth metatarsal bones. Make an imprint of the tread for purposes of record by wetting the sole with water and have the patient stand for an instant upon a piece of brown wrapping paper smoothly spread on a hard table or floor. Lift the foot and trace the outline of the wet imprint with pencil. Note the difference in the normal and flat foot (Fig. 268). Flat foot is often associated with hallux valgus and hammertoe. Diagnosis. The diagnosis in pronounced cases is not difficult; FLAT-FOOT 667 the lighter cases, however, where changes in the arch are slight, are often puzzling. Every painful foot should receive a thorough ex- amination and all "growing" pains in knee, hip, and back should suggest inspection of the foot. The lazy diagnosis of rheumatism in painful foot often means overlooked flat foot. One precaution needs to be mentioned remember that a painful pronated foot sometimes signifies tuberculous disease of the tarsus. A careful con- sideration of the position, the anatomical changes, and the character- istic painful points and X-ray will clear up the diagnosis. Prognosis. If the deformity remains untreated the deforming factors cooperate to make the deformity permanent. Early cases are cured by proper treatment. Severe cases are greatly benefited. Treatment should be, first, prophylactic, and, second, curative measures. The PROPHYLAXIS of flat foot should consist principally in the proper development of the foot of the child by observing the physi- ology of locomotion, which emphasizes two important points : First: Avoid the compression effects of shoes as much as pos- sible and permit the foot to grow in a normal way. Second : Discourage the pernicious practice of precocious walk- ing, and make it plain to parents that in the development of loco- motion crawling is an essential preliminary to walking (see p. 664). CURATIVE MEASURES in children contemplate the restoration of the foot to the normal position, in which it is held by proper support until by securing normal anatomical relations and normal muscular equilibrium the temporary artificial support can be abandoned. The simple wearing of a support may prevent further sinking and diminish pain, but it will not remold the foot to the normal type. Hence, proper support to the arch must be supplemented by general treatment sunshine, sea air, massage, gymnastics for secur- ing muscular control. Supports. Wherever there is a tendency to pronated foot the tread may be altered by raising the inner side of the sole of the shoe from one-sixteenth to one-quarter inch and thus throwing the weight away from the plantar arch to the outer side of the foot. It is highly important that the shoe should be of proper width, 668 DEFORMITIES OF THE FOOT so that the toes are not squeezed together. It should be as wide as the weight-bearing foot in front (Lovett). It is also important to instruct the patient not to toe out in walking but to walk with feet straight in front. There are a great variety of sole plates of dif- ferent materials, their aim being to form a splint for the inner plan- tar aspect of the foot. A reliable support is made of tempered spring steel shaped to fit the arch of a normal sole, and worn inside the shoe. The most accurate method is to have the steel support forged to fit the indi- vidual plaster model. Gymnastics for the Deficient Muscles. The use of supports is to be regarded as temporary while the muscles and ligaments are being developed, so that at the proper time the supports can be gradually withdrawn. For small children Willard recommends that a large rubber ball, eight or ten inches in diameter, be attached to the shoe by an elastic cord, and that forcible and repeated striking of this ball with the big toe by the action of the adductors of the foot will develop the deficient muscles and keep up the interest by affording amusement as a return ball. For older children they should be instructed to walk on tip toes as a daily systematic exercise, or to raise them- selves gradually on their toes and while in this position separate the heels as widely as possible, then slowly lowered to the ground (Bradford and Lovett). When the flat foot is of a severe form where there is permanent contracture it is obvious that the methods heretofore described will be of little use. It will be necessary to forcibly correct the de- formity under ether and retain the foot by 'plaster bandages in a position of extreme adduction and inversion for three weeks. After the cast is taken off the previous methods of treatment will be applicable. Operative Treatment. Various operations have been proposed for the relief of those severe cases which are intractable to forcible corrective measures. The most efficient procedure contemplates the removal of a wedge-shaped piece of bone from the tarsus with the base downward at the point of greatest inward convexity. The foot TUBEECULOSIS OF THE ANKLE 66