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 THE LIBRARY 
 
 OF 
 
 THE UNIVERSITY 
 
 OF CALIFORNIA 
 
 LOS ANGELES 
 
 GIFT OF 
 
 SAN FRANCISCO 
 COUNTY MEDICAL SOdETT

 
 THE NEW SYDENHAM 
 
 SOCIETY. 
 
 INSTITUTED MDCCCLVIII. 
 
 VOLUME XCIV.
 
 CLINICAL SUEGEEY 
 
 EXTEACTS FEOM THE 
 
 EEPOETS OE SUEGICAL PEACTICE 
 BETWEEN THE YEAES 1860-1876. 
 
 Dr. TH. BILLEOTH, 
 
 PEOFESSOE OE SUEGEEY IN VIENNA. 
 
 TKANSLATED FEOM THE ORIGINAL, AND EDITED, WITH 
 ANNOTATIONS, 
 
 C. T. DENT, F.R.C.S., 
 
 ASSISTANT SUEGEON TO ST. GEOEGE'S HOSPITAL; SUEGEON TO THE BELGEAVE 
 HOSPITAL FOE CHILDBEN. 
 
 WITH NINE LITHOGRAPHS AND TWENTY-NINE WOODCUTS. 
 
 THE NEW SYDENHAM SOCIETY, 
 LONDON. 
 
 MDCCCLXXXI.
 
 ;7^7 
 
 PHIIiTED BY J. E. ADLAED, BABTHOLOIIEW CLOSE.
 
 biomedical 
 Library 
 
 WO 
 
 lb 
 
 EDITOR'S PEEFACE. 
 
 The work, of which an abridged translation is contained in 
 the following pages, consists of four volumes of Hospital Keports, 
 and relates to Professor Billroth's surgical experiences between 
 the years j86o and 1876. The work in its entirety com- 
 prises some eighteen hundred pages. To reduce this within 
 the prescribed limits of the present volume has been the chief 
 diiSbulty of my task, and it has not been accomplished without 
 sacrifice. I am conscious, indeed, that the original Reports have 
 been strangely altered in shape, not only by a sort of literary 
 foreshortening, but further by the necessary process of collating the 
 several ^volumes. A considerable amount of rearrangement was 
 inevitable, but the general plan of the work has been adhered to. 
 In the text I have usually indicated the volume from which the 
 matter is translated. Thus, " Z. B." signifies the Eeports from 
 the Ziirich Hospital, and relates to experience between i860 and 
 1867 ; " W. B." stands for the Reports from the General Hospital 
 in Vienna between 1868 and 1876. 
 
 The Introductions and Prefaces to the various volumes, though 
 well werthy of perusal, have been uniformly omitted, for they 
 would have been out of harmony with the work as altered. I felt 
 less compunction in leaving out this portion of the work, for the 
 greater part of these Introductions is occupied with the discussion 
 of statistics. Now, the Statistical Tables, and with them many 
 incidental remarks bearing on the subject, save those containe.d in 
 Chapters XVIII and XIX have all been cut out. At first sight it 
 might seem irrational to omit almost wholly a portion of the work to 
 which the most prominent place is assigned by its author, and to 
 
 59817-? *
 
 VI EDITOE S PREFACE. 
 
 discard a subject which forms really the backbone of the volumes. 
 But I did so on two grounds. One is, that the statistical tables in 
 question are readily accessible and intelligible in- the original work ; 
 another, that without any expression of opinion on my own part, I 
 feel fully the force of a sententious remark made by Prof. Billroth 
 himself — " So ist die Statistik wie ein Weib, ein Spiegel reinster 
 Tugend und Wahrheit, oder cine Metze fiir Jeden, zu AUem zu 
 brauchen.^' 
 
 For the assistance of those who may wish to avail themselves of 
 these admirably compiled statistics, a special chapter (XX) has been 
 inserted containing full references. 
 
 In a few instances I have added cases or remarks of especial 
 interest which were published separately in various journals and 
 archives, and which are only referred to in the main work. From 
 the same sources I have endeavoured to bring the volume as far as 
 possible up to date by means of short notes describing any recent 
 modifications adopted in operating, etc. Additions have thus been 
 made on the subjects of ovariotomy, litholapaxy, carbolic-acid 
 poisoning, extroversion of the bladder, talipes, and others, all of 
 which will be found in their proper places in the text. 
 
 The present mode of conducting antiseptic operations in Prof. 
 Billroth's clinic is, briefly, as follows : — No spray is used. Carbolic 
 acid is the antiseptic agent employed, in solutions of i, 3, or 5 per 
 cent. The instruments and sponges (especial care being taken with 
 the latter) are rendered thoroughly aseptic. Silk ligatures are found 
 to answer best ; the threads are boiled for one liour in 5 per cent, 
 solution of carbolic acid before use. The ends of the ligatures are 
 cut off close to the knot. Unless suppuration takes place, which 
 is of rare occurrence, the ligature knots do not come away. No 
 protective is laid on the %vound ; the first layer of gauze is damp. 
 Before use, the gauze is soaked in the following mixture : — Spirit 
 3^ pints; colofonium 14 oz. ; glycerine 3^ oz. ; carbolic acid 
 3^ oz. It is then wrung out and is ready for use almost directly. 
 The entire preparation of the dressings occupies about fifteen 
 minutes. The Lister's mackintosh is replaced by a special soft, 
 impermeable material of a less expensive nature. The dressings are, 
 as a rule, changed for the first time on the fifth day. The drainage 
 tubes are then removed and the second dressings allowed to remain 
 on for five or six days, at the end of which period the special 
 antiseptic precautious are usually discontinued.
 
 EDITOE S PEEFACE. Vll 
 
 For the above information I am indebted chiefly to the courtesy 
 of Dr. Johann Mikulicz, of Vienna, assistant in Prof. Billroth's 
 clinic. 
 
 An attempt to weave together materials collected from these 
 various sources may possibly have produced something worse than 
 mere patchwork, and have yielded a fabric unfit to stand the wear 
 and tear of critical perusal. Of the scant justice that the present 
 rather disjointed version does to the original volumes no one can 
 be more conscious than myself. The task of editing the work 
 would have been far harder had not the admirable arrangement and 
 compilation materially lightened the labour. To the best of my 
 power I have sought to remedy the defects arising from a rearrange- 
 ment of the work by a copious index, by subdividing the chapters 
 into sections, and by supplying full summaries at the head of each 
 section and chapter. In this part of my task it is my pleasant 
 duty to acknowledge material assistance from my friend Dr. C. de 
 Lacy Lacy. 
 
 I have not scrupled to make the translation in parts rather free. 
 Where the differences in idiom and construction between two lan- 
 guages are considerable, an attempt to reproduce too faithfully the 
 original is apt to miss its mark. Sentences, which to those un- 
 familiar with the original language might appear merely involved, 
 are likely to become altogether incomprehensible if done too 
 Uterally into another tongue. I have aimed solely at making 
 the translation intelligible, and constantly borne in mind Voltaire's 
 warning : " Malheur aux faiseurs de traductions litterales ! C'est la 
 qu'on peut dire que la lettre tue ! " 
 
 C. T. D. 
 
 London ; July, i88i.
 
 CONTENTS. 
 
 CHAPTER I. 
 
 FAes 
 AKHSEPTIC TREATMENT OF WOUNDS, AND ANAESTHE- 
 TICS . . . . . .1 
 
 CHAPTER II. 
 CAEBOLIC ACID POISONING 
 
 CHAPTER III. 
 
 HOSPITAL GANGRENE (DIPHTHERITIC INFLAMMATION 
 
 OF WOUNDS) AND PYEMIA . . . .17 
 
 CHAPTER IV. 
 TRAUMATIC ERYSIPELAS . . . .21 
 
 CHAPTER V. 
 
 INJURIES AND DISEASES OF THE HEAD. 
 
 SamoK A. — Scalp wounds without brain symptoms — Case. Injury to 
 skull without brain symptoms— Cases. Fatal case of punctured 
 wound. Case of concussion with pulpy discharge from the ear. 
 Cases of severe concussion. Cases — Depressed fracture of the skull ; 
 fractured base ; encephalitis. Two cases of head injury with late 
 cerebral symptoms. Case of trephining. Case of cerebral abscess 
 without fractured skull. General remarks on head injuries . 31
 
 CONTENTS. 
 
 FAGB 
 
 Section B. — Chronic Inflammations and Tumoues. — Chronic ostitis. 
 Syphilitic necrosis. Warty hyxiertrophy of scalp. Congenital cyst. 
 Periosteal fibro-sarcoma. Melanotic sarcoma. Osteo-sarcoma. 
 Epithelioma . . . . • .42 
 
 CHAPTER VI. 
 
 DISEASES OF THE EAR AND THE FRONTAL SINUS. 
 
 Caries of petrous bone. Epithelioma of inner ear ; of external ear. 
 Congenital atresia. Distension of frontal sinus — Cases. Case of 
 hsematoma of frontal sinus . . . -47 
 
 CHAPTER VII. 
 
 INJURIES AND DISEASES OF THE FACE, MOUTH, AND NASAL 
 
 CAVITIES. 
 
 Section A. — Miscellaneous. — Case of luxation of the eyeball. Cases 
 of epistaxis ; malignant carbuncle. Remarks on i^eriostitis of jaw. 
 Case of suppuration of .antrum. Liipus — recurring after rhino- 
 plastic operation. Chronic infiltration of cheek — Case treated by 
 arsenic. Case of hypertrophy of tongue and cavernous lymphec- 
 tasis. Case of spontaneous gangrene. Case of atresia of nasal 
 cavities. Hypertrophy of nose. Remarks on removal of tonsils. 
 Two cases of syphiloma. Cases of tubercular disease of tongue. 
 Case of paresis after ligature of the carotid. Case of parasitic 
 sycosis . . . . . .50 
 
 Section B. — Neueotomy and Neueectomt. — Case of neuralgia of 
 the infra-orbital nerve ; neurotomy. Case of neuralgia of the fifth 
 nerve, treated by repeated operations ; death. Cases of neuralgia 
 of the fifth nerve, treated by neurectomy and neui'otomy. Case 
 of neuralgia of third division of fifth nerve ; haemorrhage 
 after operations ; ligature of carotid ; optic-nerve atrophy. Re- 
 marks on neuralgia of the fifth nerve. Etiology. Treatment. 
 Neurotomy. Neurectomy . . , .58 
 
 Section C. — Phosphoeus Peeiostitis and Neceosis . -71 
 
 Section D. — Plastic Suegeey of the Face, Nose, and Mouth. — 
 Remarks on deviation of the septum narium. Case of salivary 
 fistula. Treatment of hare-lip. Treatment of cleft palate. De- 
 formities treated by plastic operations. Cicatricial contractions of 
 mouth — Cases. Case of ectropium and comeitis. Rhinoplastic 
 operations. Case of repeated operations . . '77
 
 CONTENTS. XI 
 
 PAGE 
 
 Section E.^Nok-malignant Tumours. — Cases : — Pigmentation of 
 face. Horny cutaneous growths. Arterio- venous angioma of nose. 
 Ditto of forehead and eyelids, treated by acupuncture. Pulsating 
 tumour of head. Treatment of angioma cavernosum. Case of 
 moUuscum lipomatosum ; repeated operations. Large neuroma 
 plexifonne. Case of neuro-fibroma of temporal region and orbit. 
 Non-malignant cylindroma of orbit ; removal ; recovery. Echino- 
 coccus of orbit. Fibroma of the cheek. Fibroma of parotid — Cases. 
 Distension of the antrum ; remarks. Note on tumours of the jaw. 
 Case of huge fibroma of lower jaw. Note on polypus nasi. Naso- 
 pharyngeal polypus — Cases. Note on ranula. Congenital papil- 
 loma of tongue. Sebaceous cyst of tongue . . .86 
 
 Section F. — Malignant Tumoues. — Cancer of face — Cases. Cancerous 
 ulceration of cheek leading to necrosis of jaw. Case of rodent 
 ulcer (?) ; remarks. Notes on epithelioma of the face ; of lip. 
 Cases of sarcoma of cheek. Cancer of salivaiy glands, tongue, etc. ; 
 remarks. Sarcoma of salivaiy glands ; remarks. Case of medullary 
 lymphoma of tonsils ; death. Case of alveolar cancer of tongue. 
 Ligature of lingual artery for cancer. Eemarks on cancer of tongue 
 — Cases. Sarcoma of orbit; mixed celled; "psammon;" periosteal. 
 Exploratory puncture of orbital tumours — Case. Cylindro-sarcoma. 
 Cancer of orbit ; removal ; hernia cerebri, etc. ; recovery. Sar- 
 coma of lower jaw ; central ; periosteal. Note on maxillary 
 tumours. Sarcoma of nose. Malignant polypi of nose . . 103 
 
 CHAPTEE VIII. 
 
 DISEASES AND INJURIES OF THE NECK. 
 
 Section A. — Miscellaneous. — Acute cellulitis. Case of cut-throat. 
 Case of clonic spasm of sterno-mastoid muscle. Tumours : — Case 
 of cavernoiis blood tumour ; case of cavernous lymph tumour and 
 varix lymphaticus. Case of congenital cyst. Case of serous cyst. 
 Case of superficial ulcerated sai-coma. Cases of stricture of the 
 cesojjhagus — malignant, syphilitic, traumatic. Case of congenital 
 diverticulum of the ojsophagus. Case of branchial fistula. Case of 
 syphilitic stricture of pharynx. Foreign bodies in the oesophagus 
 — Cases. Foreigh bodies in larynx — Cases. Cases of tubercular 
 disease of larynx. Case of extirpation of larynx and bronchocele. 
 Case of papillaiy cancer of the trachea ; removal. Case of stricture 
 of trachea. Case of cancer of thyroid and trachea ; removal. 
 Laiyngotomy and tracheotomy in croup and in other diseased con- 
 ditions . . . . . .124 
 
 Section B. — Diseases oe the Lymphatic Glands. — Simple enlarge- 
 ments — Operative treatment. Chronic lymj)hadenitis and lym-
 
 xii CONTENTS. 
 
 PAGE 
 
 phoma. Medullary lymphoma and lympho-sarcoma. Case of 
 primary (?) epithelial cancer of glands . . .142 
 
 SEcnon C. — Diseases of the Thyeoid Body. — Various forms of 
 bronchocele — Clinical and pathological characteristics. Cases of 
 bronchocele treated by puncture — by injection of iodine (remarks 
 on 20 cases) — by chloride of zinc past« — by subcutaneous laceration 
 — by tenotomy of stemo-mastoid — by extirpation (remarks on 18 
 cases). Three oases of extirpation of bronchoceles. Case of cyst 
 bui-sting into pharynx. Cases of cyst treated by injection and 
 incision. Cases of malignant bronchocele. Cases of abscess in 
 thyroid. Case of bronchocele during pregnancy ; tracheotomy. 
 General remarks on treatment of bronchocele by iodine injections. 
 Cases of softening of bronchocele . . . • i.'i6 
 
 CHAPTER IX. 
 
 DISEASES OF THE VERTEBRAL COLUMN. 
 
 Case of dislocation of third cervical vertebra. Case of subluxation of 
 cervical vei-tebiiB. Angular curvature — Case. Case of necrosis of 
 lumbar vertebrae. Remai-ks on treatment of vertebral caries. 
 Treatment of abscess. Case of mistaken diagnosis in retro-pha- 
 ryngeal abscess. Remarks on tumours of vertebral column. 
 Lateral curvature — treatment of. Cases of spina bifida . 177 
 
 CHAPTEK X. 
 
 LX JURIES AXD DISEASES OF THE BACK AND BREAST. 
 
 SeCTIOJ.- a. — IXJUEIES AXD DISEASES OF THE ThoBAX, BaCK, ETC. — 
 
 Cases of penetrating wound of back. Gunshot wound. Case of 
 fractured ribs with pneumothorax. Chronic periostitis and caries 
 of the ribs — Cases and remarks. Case of encysted empyema. 
 Resection of ribs for empyema. Case of partial pneumothorax 
 after paracentesis. Aneurism of thyroid axis. Case of, aortic 
 aneurism bursting into oesophagus. Paralysis of serrati muscles. 
 Case of ossification of the fascias of the back. Case of cyst of back 
 treated by injection. Case of multiple soft fibromata. Case of 
 racemose angioma ; removal. Cavernous blood tumour and lipoma ; 
 removal. Cases of sarcoma of the back — recurrent spindle-celled — 
 melanotic. Case of sarcoma of thorax of long standing . .190 
 
 Section B. — Diseases of the Beeast. — Case of neuralgia of the 
 breast. Cases of hypertrophy. Sub-mammary lipoma, simulating 
 hypertrophy. Involution cyst of mamma. Remaiks on adeno-
 
 CONTENTS. Xlll 
 
 PAGE 
 
 fibroma of the breast. Case of cysto-sarcoma of very slow growth. 
 Sarcoma developing in both breasts during pregnancy. Kemarks 
 on adeno-cysto-sarcoma. Case of melanotic carcinoma combined 
 with alveolar sarcoma. Double carcinoma developing during preg- 
 nancy. Remarks on cases of cancer occurring at Ziirich — at Vienna. 
 Operative treatment of mammary cancer. Diseases of the male 
 breaat. Case of chronic induration — of carcinoma . . 206 
 
 CHAPTER XI. 
 
 INJURIES AND DISEASES OF THE ABDOMEN AND RECTUM. 
 
 Section A. — Injtjeies and Diseases of the Abdomen. — Cases of 
 penetrating abdominal wounds. Case of rupture of abdominal 
 muscle. Case of injury to stomach. Case of ruptured spleen — 
 Death from other causes. Retro-peritoneal inflammation and 
 abscess — Cases. Cases of villous cancer of pyloras, ulcerating 
 through the abdominal walls. Encysted peritoneal effusion — 
 Cases and remarks : Three doubtful cases of same affection. Case 
 of volvulus. Cases of fibrous tumour of the abdominal walls. 
 Cases of cancer of the omentum and pelvic viscera — attempted 
 removal ...... 227 
 
 Section B. — Heenia. — Hernia of the umbilical cord — Cases. Urn- 
 bilical hernia and congenital fgecal fistula. Ventral hernia. 
 Phrenic hernia. Case of incarcerated ventral hernia ; death. 
 Case of internal strangulation ; abdominal section ; death ; 
 Remarks. Cases with symptoms of strangulation — inflamed 
 empty hernial sac ; hernia purulenta ; peritonitis from typhus (?) 
 ulcer ; strangulated testis. Case of umbilical hernia ; gangrene 
 of gut. Remarks on strangulated hernia ; treatment. Case of 
 faecal and vesical fistula after femoral hernia. Case of fascal 
 fistula after hernia; ditto, treated by plastic operation. Case of 
 artificial anus cured by enterotome. Case of strangulated vermi- 
 form appendix. Case of femoral Littre's hernia. General 
 remarks on strangulated hernia .... 288 
 
 Section C. — Diseases of the Rectum. — Case of perforating ulcer of 
 rectum. Atresia ani. Case of fistula in ano. Operations for 
 fistula in ano. Case of prolapsus recti. Treatment of hismorr- 
 hoids. Removal of rectum for cancer. Case of malignant stricture 
 of rectum. Case of permanent recovery after removal of rectum. 
 Cancer of rectum — Treatment .... 250
 
 XIV CONTENTS. 
 
 CHAPTER XII. 
 DISEASES OF THE URINARY ORGANS. 
 
 PAGE 
 
 Case of abscess perforating the bladder. Cases of renal tumour; hydro- 
 nephrosis. Case of foreign body in bladder. Remarks on chronic 
 cystitis and, pyelitis. Alkaline fermentation of urine — Treatment. 
 Case of laceration of urethra — urethrotomy. Remarks on traumatic 
 stricture of urethra. Herpes after catheterisation. Treatment of 
 stricture — Rapid dilatation — External urethrotomy — Internal ditto. 
 Cases of lithotrity. Remarks on operations for stone. Lithotrity. 
 Lithotomy. Possibility of dissolving calculus. Litholapaxy. 
 Hypertrophy of prostate. Case of prostatic abscess. Vesico- 
 vaginal fistula. Extroversion of bladder and epispadias — Operative 
 treatment ...... 257 
 
 CHAPTER XIII. 
 
 DISEASES OF THE MALE GENERATIVE ORGANS. 
 
 Cases of serpiginous syphilitic ulceration. Case of cancer of the prostate — 
 Removal. Case of hydrocele with thickened calcareous sac. Radical 
 treatment of hydrocele. Remarks on chronic inflammation of testis. 
 " Tubercular testis " — Treatment. Chronic orchitis leading to sup- 
 puration. Castration. Cases of malignant sarcocele. Remarks . 288 
 
 CHAPTER XIV. 
 
 DISEASES OF THE FEMALE GENERATIVE ORGANS. 
 
 Case of prematurity. Case of polypoid growths of the vagina and 
 urinary bladder in a child. Case of ovarian cyst. Large uterine 
 fibroma containing central cyst. Doubtful ovarian tumour treated 
 by iodine injection. Ovariotomy — Remarks on 140 cases. Laparo- 
 hysterotomy. Recent modifications in method of operating (1881) 296 
 
 CHAPTER XY. 
 
 INJURIES AND DISEASES OF THE PELVIS AND LUMBAR 
 
 REGIONS. 
 
 Case of gunshot wound. Case of diastasis of bones of pehds. Fracture 
 of pelvis — Case and remarks. Case of chronic pelvic abscess uncon-
 
 CONTENTS. XV 
 
 PAGE 
 
 nected witli bone. Ditto opening into gluteal ai-teiy. Eemarks 
 on pelvic abscess. Cases of retro-peritoneal abscess. Case of 
 caries of pelvis with retention of urine. Chronic periostitis and 
 caries of pelvis— Cases and remarks. Inflammation of inguinal 
 lymphatic glands. Case of inguinal abscess bursting into the 
 bladder. Case of cystic enchondroma. Case of large osteo- 
 chondroma; removal, transfusion, death. Large enchondroma of 
 the pelvis ; removal ; death on seventh day. Cases of pulsating 
 sarcoma of pelvis. Sarcoma of the pelvic cavity pressing on the 
 bladder; operation to relieve retention. Case of spindle-celled 
 sarcoma of nates. Case of cancerous degeneration of a congenital 
 coccygeal tumour ..... 320- 
 
 CHAPTER XYL 
 
 INJURIES AND DISEASES OF THE UPPER EXTREMITY, 
 
 Section A. — Injtteies. — Cases of frost-bite. Case of paralysis and 
 atrophy of arm after injury. Cases of paralysis of the muscnlo- 
 spii'al nerve after contusion. Case of contusion of the elbow — 
 death. Contusion of wrist — excision. Contusion of arm — deatii. 
 Injuries of the hand and fingers — Cases. Wounds of the hand. 
 Fracture of the clavicle — treatment. Fracture of neck of fhc 
 humerus — treatment. Fractures of lower end of humerus — treat- 
 ment. Badly united fractures — Cases. Case of paresis after 
 oblique fracture of radius and ulna. Case of ankylosis after frac- 
 ture. Fracture of lower end of radius. Cases of pseudarthrosis. 
 Paralysis of musculo-spiral nerve after fracture of humerus — Cases 
 and remarks. Paralysis from the use of crutches. Dislocation . 
 of humerus — death. Paralysis and atrophy after dislocation ol" 
 humerus. Cases of irreducible dislocation ; paralysis after disloca- 
 tion. Dislocations of ulna ; of thumb. Penetrating wound of 
 shoulder- joint — excision. Case of multiple pyaemia — recovery. 
 Case of penetrating wound of elbow- joint. Seven cases of com- 
 pound fracture of elbow — remarks .... 339 
 
 Section B. — ^Acute and Cheonic Inflammations.^ — Acute non- 
 traumatic inflammations — general remarks. Case of acute rheu- 
 matic disease of wrist. Case of acute osteomyelitis. Necrosis of 
 the bones of the upper extremity. Ganglion. Cases of tenosyno- 
 vitis — treatment. Case of onychogryphosis. Chronic malignant 
 onychia. Case of elephantiasis. Case of syphilitic ulceration. 
 Doubtful case of gangrene of fingers. Gangrene of puerperal 
 origin. Case of chronic periostitis. Chronic disea.se of shoulder 
 and elbow-joints. Remarks on excision. Arthritis deformans. 
 Disease of shoulder-joint — excision. Subperiosteal axiision of
 
 XYl CONTENTS. 
 
 PAoe 
 
 elbow. Case of reproduction of elbow-joint after excision. Anlry- 
 losi^ of elbow — treatment. Case of hydrops of the elbow-joint. 
 Chronic disease of the wrist-joint. Case of excision of wrist . 359 
 
 Section C. — jMalfoemations, Tumoces, etc. — Contracted cicatrix 
 from burn — Operation. Case of contracted palmar fascia. Syn- 
 dactylia. Ca.ses of subclavian aneurism ; Compression ; Ergotin 
 injections. Traximatic aneurisms of radial artery ; Ligature of 
 brachial ; Antyllus's operation. Case of clonic spasm of muscles of 
 shoulder. Case of neuralgia. Simple tumours — Enlarged deltoid 
 bursa ; Atheroma of finger ; Cavernous lymphangioma ; Enchon- 
 droma ; Cicatricial fibroma of palm of hand ; Neuro-fibroma of 
 the musculo-spiral nerve ; Osteoma. Malignant tumours — Sar- 
 coma (small-celled) of deltoid ; Alveolar sarcoma of humerus ; 
 Sarcoma of hand ; Lympho-sarcoma treated by injection of albumi- 
 nate of mercury ; Granulation sarcoma ; Spindle-celled sarcoma ; 
 Osteo-sarcoma of clavicle — Removal ; Osteo-sarcoma of humerus ; 
 Central osteo-sarcoma of ulna ; Epithelial carcinoma originating 
 in the wound of an issue ..... 373 
 
 CHAPTER XYII. 
 INJURIES AXD DISEASES OF THE LOUVER EXTREMITY. 
 
 Section A. — Ixjueies. — Frost-bite. Contusions of the hip. Fracture 
 of neck of femur. Case of gangrene after fracture of femur. 
 Treatment of simple fi-actures of femur ; of leg ; of fibula ; of 
 patella. Case of pyaemia after simple fi-actui'e. Case of fracture 
 of necrosed femur. Case of softening callus a year after union. 
 Cases of faulty union. Cases of pseudarthrosis. Treatment of 
 pseudarthrosis. Cases of ununited fracture ; repeated operations. 
 Remarkable case of compound fracture of thigh. Compound 
 fracture of leg — Case. Cases of compound dislocation of ankle. 
 Cases of dislocated hip. Case of dislocation of astragalus. Wound 
 of both tibial arteries . . . . -387 
 
 Section B. — Acute .vnd Chbonic Inflammations.— Cases of acut« 
 phlegmonous inflammation. Spontaneous gangi'ene from embolism. 
 Gangrene from disease of the smaller arteries — Cage. Case of 
 gangrene from anaemia ; from some unknown cause. Amputation 
 in gangrene. Cases of gangrene ; spontaneous ; from embolism of 
 subclavian ; senile. Varieties of gangrene. Case of ulceration of 
 leg with lengthening of the limb. Cases of gangrenous ulceration. 
 Periai-ticular abscess. Acute gonitis — Case. 
 
 Cases of acute periostitis and osteomyelitis ; of femur ; of tibia ; 
 remarks. Cases of osteomyelitis with separation of epiphyses. 
 Case of acute ostitis. Cases of subacute osteomyelitis. Ditto
 
 CONTENTS. XVll 
 
 PAGE 
 
 affecting numerous bones. General remarks on acute periostitis 
 and osteomyelitis. Other cases of the same disease. Case of ditto 
 with lengthening of the limb. Very chronic ostitis . . 402 
 
 Section C. — Acute and Cheonic Inflammations of Joints. — 
 Acute hip-joint disease in adults — Cases and remarks. Eemarks on 
 chronic hip-joint disease. Case in which forcible extension was 
 applied. Tumor albus of the hip. Cases of ankylosed hip ; 
 treatment by osteotomy and fracturing neck of femur. Disloca- 
 tion of hip after typhus — Case. Case of pathological luxation of 
 hip. Chronic inflammation of knee. Cases of ankylosed knee ; ' 
 treated by forcible extension ; by osteotomy. Tumor albus of 
 knee. Case of acute meningitis after excision. Hydrops genu. 
 Cases of loose cartilage. Chronic disease of ankle and tarsus . 426- 
 
 Section D. — Tumoues, Anetteisms, Defoemities, etc. — Cases of 
 lipoma ; enchondroma ; ecchondrosis ossificans bursata ; multiple 
 oeteomata ; neuro-fibroma ; recurrent ditto ; cavernous lymphatic 
 tumour (2) ; melanoma ; pulsating sarcoma ; central sarcoma of 
 femur — removal ; epithelioma. 
 
 Cages of femoral aneurism treated by ligature ; ditto by compres- 
 sion and ligature ; traumatic aneurism — Antyllus's operation ; ditto 
 cured by compression ; spontaneous aneurism — double ligature of 
 femoral ; traumatic aneurism ; arterio- venous aneurism ; femoral 
 aneurism treated by arterial clamp ; popliteal aneurism treated by 
 ergotine injections. General remarks on treatment of aneurism. 
 Genu Valgum ; osteotomy. Case of spastic talipes. Remarks on 
 talipes ; treatment ; case. Osteotomy for ricketty deformities. 
 Case of congenital dislocation of toes. Case of pes gigas. Case of 
 congenital absence of femur . . . •445- 
 
 CHAPTEE XYIII. 
 
 (M STATISTICS OF AMPUTATIONS, EESECTIONS, AND 
 OSTEOTOMIES . . . . .469 
 
 CHAPTER XIX. 
 ON STATISTICS OF TUMOURS . . . .477 
 
 CHAPTER XX. 
 REFERENCES TO STATISTICS, TABLES, ETC. . '.487
 
 xviu 
 
 CONTENTS. 
 
 APPENDIX I — Caebolic Acid Poisoning . . 
 
 „ II — Acute Peeiostitis and Osteomtelitis . 
 
 „ III — On the Removal of the Pyloetjs fob Canceb 
 
 PAGB 
 . 489 
 
 • 493 
 
 INDEX 
 
 . Sii 
 
 Eeeata.— P. 8, line 7, and p. 12, line 12, /or "Koster" read "Kiistcr.'
 
 LIST OF ILLUSTEATIONS. 
 
 Fig. page 
 
 1. Chart illustrating Cases of Erysipelas . . .29 
 
 2. Chart illustrating Cases of Fatal Septo-pya?mia . . 29 
 
 3. Congenital Serous Cyst . . . . '43 
 
 4. Multiple Soft Fibro-fatty Tumours . . . .92 
 
 5. The same as in Fig. 4, after twenty Operations . '93 
 
 6. Soft Fibroma, probably originating in the Spheno-maxillary Fossa 96 
 
 7. Osteo-chondro-fibroma of the Lower Jaw . . .98 
 
 8. Carcinomatous Ulceration of the Face and Jaws . . 106 
 
 9. Central Sarcoma of the Lower Jaw . . . .120 
 
 10. Periosteal Sarcoma of the Lower Jaw . . .121 
 
 11. Bronchocele, extending into and narrowing the Trachea . .161 
 
 12. Cystic Bronchocele, which burst Into the Pharynx . .166 
 
 13. Ossification of the Fascia of the Back . . . 198 
 
 14. Multiple Soft Fibromata ..... 203 
 
 15. Hypeiirophy of the Breasts .... 208 
 
 16. Congenital Faecal Fistula connected with an Intestinal Diverticulum 240 
 
 17. Abscess, connected with the Ischium, presenting in the Popliteal 
 
 Space ...... 325 
 
 18. (a) Deformity of Hand, the result of Contracted Cicatrix ; (h) the 
 
 same, after Resection of a portion of the Radius . . 374 
 
 19. Faulty Union of Intra-uterine Fracture . . . 394 
 
 20. Ununited Fracture of the Leg. .... 397 
 
 21. Lower Half of the Femur, affected with very Chronic Ostitis and 
 
 Osteomyelitis . . . . . 425 
 
 22. Pathological Luxation of the Femur . . 435 
 
 23. Bones of Stump four and a half years after Plrogoff's Amputation . 
 
 24. Pes gigas ...... 468 
 
 25. Chart showing relative frequency of Sarcoma of the Cutis, Cellular 
 
 Tissue, Fascia, and Bones, and Carcinoma of the Cutis and 
 Mucous Membrane . . . . '484
 
 XX LIST OF ILLUSTRATIONS. 
 
 Fig. page 
 
 26. Chart showing relative frequency of Sarcoma of the Breast and 
 
 Adeno-fihroma and Adeno-cysto-sarcoma of the Breast . 485 
 
 27. Diagram showing Incisions for Removal of Pylorus . . 497 
 
 28. Gusaenbauer's Intestinal Suture .... 500 
 
 29. Czerny's Intestinal Suture ..... 500 
 
 LiTHOGEAPHED Plates, with descriptions, will be found at end of 
 work.
 
 CHAPTER 1. 
 
 ANTISEPTIC TREATMENT OF WOUNDS, AND ANiBSTHETICS. 
 
 In 1875, I first began to employ the antiseptic method regu- 
 larly. In 1877, my assistant, Dr. Wolfler journeyed to England, 
 Prance, and Germany, and brought back with him the most recent 
 modifications of the method ; whereupon we began afresh with our 
 antiseptic treatment. The utmost precautions were taken to ensure 
 asepticity, and to diminish the sources of infection. The time 
 of making post-mortem examinations was altered ; none of the 
 servants employed about the dead-house were allowed to come 
 near the clinic or operating theatre ; all my assistaais were 
 provided with special coats, which were washed daily; special 
 receptacles were set apart for the antiseptic dressings, and all the 
 sponges were most carefully and thoroughly disinfected with carbolic 
 acid and then soaked in thymol before use. I had long had an 
 idea that some of the misfortunes met with after ovariotomy might 
 be traced to imperfect disinfection of sponges. Professor Frisch 
 has shown that sponges, even after they have been soaked for 
 twenty-four hours in 5 per cent, carbolic solution, are still 
 capable of developing organic germs. In short, in every detail^ to 
 the best of my power, I carried out Lister^s and Volkmann's in- 
 junctions. Unfortunately, to some extent, this system is based on 
 imperfect scientific knowledge, and thus a certain amount of faith 
 is demanded of those who obediently carry out every detail. 
 
 In the beginning of 1878, the following form of antiseptic 
 dressing was introduced into our clinic : — Two per cent, carbolic 
 steam spray ; all instruments, drainage-tubes, and silk soaked in 
 
 1
 
 2 ANTISEPTIC TREATMENT OF WOUNDS. 
 
 5 per cent, carbolic acid ; silk protective on the wound ; over 
 this crumpled carbolic gauze, then a large fold of carbolic gauze 
 and mackintosh; next gauze roller bandages to keep all in 
 place, the edges of the dressiugs filled with salicylated wool, and 
 over this, a layer of cotton-wadding. With recent wounds, all 
 vent on well at first, but then two patients — one with caries of the 
 hip, another of the elbow-joint — were attacked with septic phlegmo- 
 nous inflammation of the most severe character. The secretion of 
 the wound was free from odour ; both patients died.^ For a time, 
 matters went on better, but then cases of carbolic poisoning, and of 
 carboHc eczema became so common, that I gave up this antiseptic, 
 replacing it by thymol. Then I employed dressings containing no 
 carbolic, but saturated with spermaceti and colophony.- The pro- 
 tective thus became unnecessary, for its principal use is to prevent 
 the direct contact of the wound and carbolic gauze. 
 
 On the whole, I was well pleased with this method, and was able 
 to demonstrate to those who watched our practice, that the results 
 are just as satisfactory as could be shown in the wards of the 
 most zealous and practised "antiseptist." Further, I have con- 
 
 ' I have long tried to make clear to myself and others the difference between 
 septic and phlogistic, or zymoid ferment on the one hand, and the product of 
 fermentation — the putrid and phlogistic poison — on the other. Evidence that 
 both elements coexist in the tissues and fluids, but are not identical, only 
 gradually came to light. I have often maintained that the materials producing 
 septic infection and phlogogeuous inflammation could neither be gaseous nor 
 fluid, but must be looked upon as minute atomic molecular bodies. The 
 view that these ferments always exist in very minute organisms has been 
 widely diffused by Lister and Pasteur, but I have shown reasons to doubt the 
 absolutely convincing nature of their experiments (see my work on the ' Cocco- 
 Bacteria Septica '). Now, the putrid poison — the product of fermentation — 
 there can be no doubt, is a non-orgauised body, possessing certain properties 
 which have been described by Pauum and Bergmann. During the process of 
 decomposition odorous products are often set free ; such products may possess 
 certain poisonous properties, but they are not identical with the poison, nor do 
 they constitute it ; the putrid poison is inodorous. Moreover, the part whence 
 it arises need not have any ill smell ; yet further, it may be formed from 
 tissues to which air has not access. If a wound be free from smell there is a 
 tolerably strong probability that no decomposition is going on in it. At the 
 same time products may develop at the edges of the wound or in retained 
 blood, by whose absorption pyrogenous effects may be set up. Inodorous 
 phlogistic poisonous material is formed, for example, in connection with those 
 acute inflammations with which we are familiar, aud which originate in the 
 subcutaneous tissues, 
 
 2 I.e. black resin or turpentine boiled in water and dried.
 
 ANTISEPTIC TREATMENT OF WOUNDS. 3 
 
 vinced myself that the enthusiastic expressions of some members 
 of our profession, on the subject of the new method of dressing 
 wounds, are not to be taken too literally ; " not a single drop 
 of pus forms under these dressings/' "no surgical fever — only 
 slight aseptic rise of temperature/' or again, "every resection 
 wound heals by first intention • " or, " pyaemia in future will be 
 relegated to the records of history/' Such assurances — especially 
 by word of mouth — may often be heard. Por my part, I neither 
 allow myself to endorse such sentiments, nor to use such expres- 
 sions ; nor am I unduly depressed if these wonders fail to occur. 
 In expressions such 'as these, there is rather more imagination 
 mixed up with the truth, than is altogether good. Experience Avill 
 gradually show what is due to fancy, and what to actual observation. 
 Without venturing to assert that I have come to any final con- 
 clusion on the subject of the advantages of antiseptic dressings 
 over other methods of treating wounds, I think I may say that 
 practically it is an admirable method, and I shall always recommend 
 it as safe and reliable, until some better mode of treatment has 
 been devised. It is especially suitable for recent wounds, and for 
 operations on tissues which are not suppurating. Cases where a 
 septic condition exists before the operation, must be again dis- 
 tinguished. Thus, I amputated the thigh, for gangrene of the leg 
 following a gun-shot wound of the popliteal artery ; no part of the 
 wound healed by first intention, and death followed a fortnight 
 later, from sepsis. Here, the antiseptic method cannot be held 
 answerable, nor does it exert any material influence on such cases. 
 
 Farther, cases of cold abscess or caries must be considered from 
 a different point of view. The advice sounds very beautiful and 
 simple to extirpate all suppurating parts, as if they were particles 
 of cancer, then to disinfect the wound with suitable applications, 
 and treat them as if they were recent. Every surgeon who has 
 attempted to follow such directions, knows the difficulty, nay the 
 impossibility^ of carrying them out in many instances. As far as I 
 can gather from Volkmann's ' Bericht,' and from those who liave 
 frequented his clinic, he amputates far more often for caries of the 
 joints than I do ; he has probably less opportunity, therefore, than 
 I have had of seeing the results of resections and evidements. There 
 are special reasons for this ; among others, the people here are very 
 loth to submit to amputation. During the last ten years, I have 
 felt less disposed towards conservative operations for caries, and
 
 4 ANTISEPTIC TREATMENT OF WOUNDS. 
 
 should have amputated far more frequently if the patients or their 
 friends had not objected. I never held myself justified in perform- 
 ing excision of the hip in cases where no suppuration existed, and 
 where there was only fungous synovitis, or slight ostitis of the 
 upper end of the femur. Nor do I often feel it right to undertake 
 the task of removhig every suppurating part from some anaemic^ 
 miserable child, the subject of knee- or hip-joint disease with 
 extensive suppuration. In such operations, however, I freely 
 admit that the antiseptic method often has one advantage, viz. 
 that the immediate results after operation are much better than 
 they used to be under our old systems. Nowadays, there is 
 good prospect of temporary benefit when the patients are weakly, 
 or even decidedly tuberculous. Formerly, we should not have 
 thought of operating, for fear of the severe suppuration that would 
 inevitably follow. Still, treat these wounds as you will, sinuses 
 will be left, and the ultimate results will be almost as unsatisfactory 
 as they used to be. The same applies to evidemeut of carious 
 bone about the hand or foot ; two or three weeks after the 
 operation, the wounds will be in just the same condition as they 
 were with our old-fashioned dressings. 
 
 In a few instances I have opened and treated antiseptically, cold, 
 congestive abscesses connected with diseased spine ; I have not 
 seen any of these abscesses close up very rapidly, and the patients 
 ultimately left in much the same cotidition as if the abscess had 
 been allowed to open spontaneously. Again, in chronic supra- 
 fascial abscesses about the back or thigh, in one or two cases I laid 
 the cavity freely open, scraped the walls, united the wound by 
 sutures, inserted a di-ainage-tube, and employed antiseptics. One 
 case only healed up soundly, and remained so; in all the others 
 the cicatrices broke down, and fresh suppuration followed from 
 the sinuses ; nor did I perceive any advantage over simple puncture 
 and drainage. Eeluctantly, therefore, I have come to the con- 
 clusion that the antiseptic method is of no material advantage in 
 assisting our endeavours to convert these chronic ulcerative pro- 
 cesses into simple traumatic lesions. A large proportion of the 
 patients who come under my care are affected with such com- 
 plaints : this fact must excuse my inability to manifest any true 
 enthusiasm for a method of treatment which is best adapted to 
 cases I am seldom called upon to treat, viz. severe injuries.' 
 
 ' In the year 1877, among 20,105 patients admitted into the hospital at
 
 ANTISEPTIC TREATMENT OF WOUNDS. 5 
 
 On one point I wish particularly to insist, viz. the absolute im- 
 portance of carefully watching patients treated antiseptically. I 
 have never felt so much anxiety in any other operation cases, for if 
 they do not go on perfectly well they generally go utterly to the bad. 
 When, in " aseptic " cases, septic phlegmonous inflammation is set 
 up under an occlusion-dressing, the same thing happens as when 
 the abdominal wound is completely closed after laparotomy, that is 
 to say, so much toxic inflammatory and infective material is gene- 
 rated that the patient will die in spite of all incisions. It is of the 
 greatest importance, though a matter of some difficulty, to recog- 
 nise this state of things in the early stage. As often happens 
 in septic poisoning, the temperature may be either at, or even 
 below, the normal ; but if the patient's expression be altered, his 
 tongue clammy, the condition drowsy, the pulse rapid, the sym- 
 ptoms ought never to pass unnoticed, for they betoken a most 
 dangerous condition. The wound may be opened at this stage; 
 there will often be no ill smell. If the phlegmonous inflammation 
 has commenced in the subcutaneous cellular tissue, it will be 
 recognised by a slight brownish discoloration of the cutis near the 
 wound. If the deeper parts be attacked, there will be no positive 
 evidence. Formerly I thought that under the antiseptic .treat- 
 ment such phlegmonous inflammations might subside, and so per- 
 severed in the treatment ; thus I lost many patients. It is of the 
 utmost importance to recognise the moment when the antiseptics 
 should be discarded. In former times the surgeon felt that he 
 could do something himself for operation cases by careful watching 
 and supervision ; but nowadays, so much depends upon the hands 
 and clothes of assistants and nurses, and on the intelligence of the 
 workmen who manufacture the dressings, that the surgeon, though 
 
 Vienna (the K. K. Allg. Krankenhaus), there were but 17 with complicated 
 fractures of the leg. Again, at the Rudolf-Spital, in Vienna, 17 cases of 
 fractured leg simple or otherwise were recorded during the year 1874, out of a 
 total of 5775 admissions. The small number of these and other severe 
 injuries is accounted for, according to Prof. Billroth, by several reasons. 
 Thus, in Vienna there are no large iron manufactories. The railway companies 
 have their own special hospitals. Again, the Viennese working man is as a 
 rule careful, and rarely drinks to excess during the working hours. In 
 Northern Germany dram drinking (schnaps) is far more common. There the 
 men are seldom actually intoxicated while at work, but they have strong liquor 
 constantly by them. Severe injuries are much more common in Northern 
 Germany. It is to be feared that the experience in our English hospitals 
 fully bears out Prof. Billroth's suggested explanations.
 
 ANESTHETICS. 
 
 answerable for the fate of his patients, often has not the circum- 
 stances wholly under his control. The proper management of 
 cases under the antiseptic system is the most difficult task I have 
 ever attempted ; still, this shall not deter me from doing my very 
 best to perfect the system. 
 
 Anesthetics. 
 
 At the end of the year 1878, I had had a quarter of a century's 
 experience in operations ; more than six years as assistant, and the 
 rest of the time in the charge of my own clinic. During this 
 period I had seen chloroform administered some 6000 times, 
 with two cases of death.i Up to the end of 1870, I always 
 employed chloroform alone as an anaesthetic : since then I have 
 used a mixture, consisting of three parts of chloroform, one of 
 sulphuric ether, and one of alcohol. With this anaesthetic I am 
 perfectly well satisfied, and have not seen any asphyxia or syncope 
 result from its use ; the mixture seems to me merely of service in 
 diluting the chloroform. My two assistant surgeons and my eight 
 assistants undertake the post of chloroformist for a month at a 
 lime, in regular rotation. On this account, again, I think it 
 more prudent to use diluted chloroform. No doubt the pure 
 chloroform produces anaesthesia more rapidly than this mixture, 
 but, on the other hand, the latter is less apt to excite vomiting. 
 
 * Reported the ' Wien. Med. Woch.,' 1868, p. 762 ; and 1870, No. 16.
 
 CHAPTER II. 
 
 CARBOLIC ACID POISONING. 
 
 Many men are in the habit of denying rare, but unpleasant 
 occurrences until they themselves have experienced them; the 
 peculiarity is not uncommon. There are many surgeons sceptical 
 on the subject of death from chloroform; may it be their good 
 fortune never to be undeceived. So^ again, the number of those 
 who disbelieve in death from carbolic-acid poisoning is by no 
 means small, and yet death from carbolic acid is far more frequent 
 than from chloroform. 
 
 During the time that I employed solutions of chloride of lime 
 and acetate of alum as antiseptic agents, I had reason to be grati- 
 fied with the success to which I could fairly lay claim. Cases, 
 however, occurred at times when I was less satisfied with the 
 efficacy of these materials, especially when used in concentrated 
 solutions. I found then that superficial eschars were formed, 
 and the discharge of the secretion from the deeper parts was hin- 
 dered. Eor a long time past I have devoted my attention to the 
 subject, and, at my request, Dr. Gersuny^ and Dr. Steiner^ tried 
 some experiments with solutions of carbolic acid and chloride of 
 zinc. The results of their investigations were, briefly, as follows : 
 — " Both agents were found, unfortunately, to be thoroughly 
 efficacious antiseptics only when employed in highly concentrated 
 solutions. When so used the cellular tissue and the coats of the 
 vessels were corroded ; such effects in large hollow wounds, espe- 
 cially in the axilla, might entail very serious consequences. 
 Weaker solutions were found powerless to check decomposition of 
 the secretions in recent hollow wounds, still less where the^suppura- 
 tion had already lost its healthy character." These investigations 
 were published at the end of 1871 and the commencement of 1872. 
 
 ^ 'Areli. fiir Kl. Chirurg.,' Ed. xii, p. 814. 
 " ' Wien. Med. W0CI1./1S72, No. 28.
 
 8 CAEBOLIC ACID POISONING. 
 
 Clinical observation subsequently confirmed them in every par- 
 ticular. At this time it was not known that the absorption of 
 carbolic acid by a wounded surface might produce fatal results. 
 At my request some of my pupils prosecuted researches on the 
 subject, but they were discouraged by the uncertain results with 
 regard to the toxic symptoms, and also by their failure to de- 
 monstrate any distinctive pathological appearances. Koster, in a 
 very laborious essay ,^ has treated the subject at great length, but 
 I see from his experiments that he got no further than we did. 
 The subcutaneous injection of concentrated solutions led to rapid 
 and extensive sloughing of the skin and cellular tissue, and most 
 of the animals died from these causes, some with high, some with 
 low temperatures. No decided results were obtained by injecting 
 weak solutions of carbolic acid. The injections, if repeated fre- 
 quently, caused suppuration and rapid emaciation, and led to such 
 complicated conditions that it was found impossible to estimate 
 accurately, or discriminate with precision, the appearances mani- 
 fested. The animals experimented upon were carefully examined 
 after death, but no evidence could be gathered to settle with cer- 
 tainty whether in man death was due to absorption of the carbolic 
 acid by the skin or the cellular tissue. 
 
 The poisonous properties of carbolic acid would scarcely have 
 been so soon recognised had not the olive-green discoloration of 
 the urine constituted a symptom too obvious to be overlooked. 
 If all substances which are excreted by the urine caused alteration 
 of colour iu that fluid — if, for instance, the urine or saliva were 
 always black when they contained iodine — the appearance would 
 not lead to apprehensions of poisoning. The symptom is one on 
 which I must dwell for a short time. 
 
 According to my experience, there can exist no doubt that 
 the discoloration of the urine aff"ords no reliable test of the 
 amount of carbolic acid absorbed, but may depend on the idio- 
 syncrasies of the individual. The fact that the olive-green colour 
 of the urine proves that carbolic acid has been absorbed is 
 almost beyond question. Let us imagine, however, two indi- 
 viduals subjected, under precisely similar conditions, to the action 
 (external) of equal quantities of carbolic acid; in one the urine 
 might be normal in colour, in the other green; yet it would 
 hardly be correct to assume that in the first case no carbolic acid 
 ' 'Arch, fiir Kl. Chir.,' Bd. xxiii, p. 117.
 
 CARBOLUEIA. 9 
 
 had been absorbed. We should more properly conclude that, in 
 such a case the carbolic acid was not excreted at all, or, at any 
 rate, in quantities too small to colour the urine green. Again, in 
 such an individual the substance might not be excreted through 
 the kidneys, but through the intestines, skin, or lungs. People 
 are in the habit of looking upon all such matters as being far 
 simpler than they really are. Undue stress is laid upon the 
 amount of the poison absorbed. I grant that here, also, idiosyn- 
 crasies should be taken into account, but it must not be forgotten 
 that these may be the very causes that explain the diverse capa- 
 bility of excretion. One case was under my observation (a case of 
 empyema, in which i per cent, carbolic solution was allowed to run 
 through the pleural cavity for twenty-four hours), in which the 
 urine was still green fourteen days after the carbolic had been dis- 
 continued. In this patient not only had the carbolic acid been 
 entirely abandoned, but thymol had been substituted with the best 
 results. This case also showed that carbolic acid may sometimes 
 be retained in the body for a long period ; it might, therefore, not 
 unreasonably be supposed that this substance acts as a cumulative 
 poison on the organism. True, the most eminent toxicologists 
 hold that it has no such effects, yet such would have been the case 
 in the above instance had I persevered in the use of the acid. No 
 doubt the experience of other surgeons coincides with my own, in 
 the observation that the green colour of the urine (and the other 
 toxic symptoms also) occurs at varying periods of time after opera- 
 tions performed under carbolic spray and the use of Lister's gauze 
 dressings. Sometimes forty-eight hours elapse before these sym- 
 ptoms are observed, sometimes they arc evident after a few hours. 
 Slow absorption and slow excretion are naturally associated. If 
 the green colour of the urine depends upon the amount of sul- 
 phuric acid contained in the organism, as we are assured by the 
 chemists it does, then a further important point must be taken 
 into account, viz. the quality of the food. Now, this is very 
 different in different countries. I was greatly struck by the fol- 
 lowing extract from the journal of my assistant, Dr. Wolfler : — 
 *' It is very remarkable that although Lister, in dressing wounds, 
 lays gauze soaked in 2^ per cent, carbolic solution over the pro- 
 tective, he has never seen any ill eflfects from the carbolic acid. In 
 a case of chronic abscess opened and treated antiseptically (the 
 first case so treated by him in London) the urine, to Lister's great
 
 10 CASES OF CARBOLIC ACID POISONING. 
 
 surprise, became of a dark reddish-brown (bierbraun) colour. He 
 at once replaced the carbolic acid in this case by other disinfecting 
 substances." 
 
 As I have stated above, it happens once in a way with us that 
 the urine does not become green in cases treated with carbolic 
 acid ; such an exception is exceedingly rare ; almost every patient 
 treated on this plan has green urine. At first we paid but little 
 attention to the symptom unless it lasted a long time, or was 
 strongly marked. Unfortunately, several cases of severe poison- 
 ing — some of them fatal — forced upon our notice the danger 
 arising from absorption of carbolic acid. Nor is it only in washing 
 out the wound or using the spray, that the risk is incurred. In 
 many persons the dry carbolic gauze dressings are sufficient to turn 
 the urine a very deep olive green ; one of my assistants had dark 
 green urine merely from repeatedly dipping his finger (the skin of 
 which was unbroken) in carbolic solution. True he was exposed to 
 the spray also for some time. Dr. Wcilfler, on his return from 
 England, thought that all this might depend on the impurity of our 
 carbolic acid, so we obtained chemically pure acid, but the results 
 were the same. Then I procured the carbolic acid from the English 
 manufactory which supplies Lister ; the only difference seemed to 
 be that the absorption effects were rather more severe. How are 
 we to account for these facts ? Must not the explanation be that 
 the conditions of absorption and excretion among our hetero- 
 geneous population difi'er from those of the English race ? As a 
 rule, I am rather sceptical about such hypotheses, but here I can 
 see no other solution. 
 
 In illustration of my remarks, let me here narrate three cases 
 of severe carbolic poisoning, which, fortunately ended in recovery. 
 
 Case. — I opened a chronic abscess in the thigh of a child three years old, 
 under i per cent, carbolic spray and introduced a drainage tnbe. Antiseptic 
 dressings, consisting of eight layers of gauze wrung out of 5 per cent, carbolic 
 acid, a double layer of absorbent paper, and then a thick layer of jute, were 
 applied, and the whole was kept in position by a gauze bandage. Two 
 hours later it was found necessary to renew the dressing. Three hours 
 afterwards the child began to vomit, and became very restless. The sickness 
 persisted and collapse set in. The abscess had been opened at ten a.m. and 
 at five p.m. the temperature was 97*6°. Wine and acetic ether were ordered, 
 and the carbolised bandage taken off. The symptoms continued through the 
 night, and the next morming the child was completely unconscious (temp. 96°). 
 By means of stimulants and artificial nourishment the child at length revived.
 
 CASES OP CARBOLIC ACID POISONING. 11 
 
 so that by 9.30 a.m. iu the morning (twenty-four hours after the opening of 
 the abscess) the temperature had risen to 99"6°, and answers could be elicited. 
 The pulse again was perceptible (132). Collapse again occurred, however; 
 urine and thin dark motions were passed unconsciously. By midday the 
 temperature again sank to 9) '5° and did not rise towards evening. The urine 
 passed was now of a dark olive-green colour ; towards evening the vomiting 
 ceased. The child, though much exhausted, recovered completely by the 
 second day, and the temperature again became normal ; by the fourth day the 
 urine was of natural colour. The abscess healed up rapidly. 
 
 Case. — In a little girl, set. 6^, excision of the head of the femur, below the 
 trochanter, was performed for caries, under 2 per cent, carbolic steam spray. 
 The notes do not say whether the wound was washed out with 5 per cent, 
 carbolic solution at the conclusion of the operation. Lister's dressings were 
 applied and renewed after a few hours. The day after the operation the urine 
 was of a dark olive-green colour ; the patient suffered from nausea and 
 vomited dark olive-green fluid; the temperature stood at 101*4°. Sulphuric 
 acid was prescribed. On the third day she was lethargic and vomited black 
 fluid. The morning temperature on this third day was 103-8°, and the evening 
 99"6°. Consciousness returned, and sickness ceased on the fifth day. On the 
 eighth day the urine was of natural colour; slow convalescence followed. 
 Immediately on the occurrence of the carbolisra the Lister's dressings were 
 replaced by thymol dressings. 
 
 Case. — A girl, set. 6, was admitted with hip-joint disease, with abscess and 
 sinuses. She had no albuminuria, but her general condition was very feeble. 
 The sinuses were dilated and syringed out every fourth day with 5 per 
 cent, carbolic-acid solution, which was allowed to escape immediately. The 
 urine turned olive green. The upper end of the femur was resected under 
 thymol spray, and the wound washed out with thymol solution, as carbolism 
 existed. Lister's dressings were applied. The day after the operation the child, 
 who was in a very reduced and anoemic condition, vomited several times ; the 
 green colour of the urine persisted. Two days after the operation the wound was 
 dressed as before, but without the use of the spray. The patient now began 
 to lose consciousness ; the urine was passed involuntarily ; the stools were 
 very dark. Sodae Sulph. was prescribed. Two days later the wound was 
 again dressed in the same way as before (I thought it hardly possible that a 
 dangerous amount of carbolic acid could be taken up from the gauze dressings 
 when the wound was covered with protective. In former cases I had always 
 laid the blame on the spray, the syringing of the wound, or soaking the gauze 
 in carbolic acid). The stools were black and loose, and the patient vomited on 
 several occasions black fluid. It was found necessary to discontinue the 
 Sodai Sulph. on account of the diarrhoea. During the next two days the 
 dressings were changed daily ; tlie motions and urine continued black. On 
 the eighth day after the operation simple spermaceti gauze was substituted for 
 the thymol and carbolic dressings. Erom this time no further symptoms 
 of carbolism occurred. The wound meanwhile had almost healed, but
 
 12 CEREBRAL EFFECTS OF CARBOLIC POISONING. 
 
 subsequently gave way again. By the tenth day the urine was natural in 
 colour, but contained albumin. Symptoms indicative of meningitis and 
 localised cerebral affection now arose. Clonic spasms affected the right sterno- 
 mastoid muscle, and both the upper extremities were paralysed. Then com- 
 plete sopor came on. All these symptoms, however, gradually subsided, and 
 the albumin disappeared from the urine. The stools continued dark for about 
 three weeks. The patient was eventually carried off by an attack of erysipelas 
 eight weeks after the operation. Post-mortem examination showed suppura- 
 tion in both thighs and thrombosis of tlie crural veins, and chronic encephalitis 
 affecting the cortex and grey matter of the frontal convolutions. 
 
 I am far from ascribing death in this last case to the carbolic 
 acid ; still, I think the term proposed by Koster, " carbolic 
 marasmus " might be applicable. All three cases above recorded 
 were in children j intensely dark urine, black stools, vomiting of 
 black fluid, restlessness, collapse, lethargy, were in all the cases the 
 principal symptoms to a greater or less extent. 
 
 I have already drawn attention to the occurrence of acute serous 
 meningitis in children after operations.^ In these cases, however, 
 the symptoms are different, and death takes place early. Menin- 
 gitis — usually basal — is met with rather frequently in children 
 afi'ected with caries, but I have seldom found in such cases caseous 
 areas in the brain substance. In the last of the three cases above 
 given, the disease was of a most complicated form. Unquestionably, 
 acute nephritis had something to do with it, and I have already 
 shown the connection of this with carbolism. A recent contribution 
 by Sonnenburg to the ' Centralblatt fiir Chirurgie ' (1878, No. 45) 
 sets this beyond doubt ; the brain symptoms also may be due to 
 nephritis. I do not unreservedly agree with the view that these 
 caseous areas in the brains of children are due to " old chronic 
 caseation." Any one who has experimented on rabbits knows that 
 these areas may form in animals in a few days, and may be found 
 in all the organs ; the existence of a capsule will determine the age 
 of such areas. In children they may remain latent for a long 
 period, especially when situated in the frontal convolutions. These 
 areas are undoubtedly the starting-point of localised convulsive 
 movements in certain parts of the body; whether they then 
 originate, or whether they only betray themselves more owing to 
 oedema of the brain depending on nephritis, or whether in enlarg- 
 ing they give rise to symptoms of irritation, are all questions 
 which could hardly be answered precisely. We do not know the 
 > «Wien. Med. Woch.,' 1868, Xo. i.
 
 FATAL CARBOLIC POISONING. 15 
 
 anatomical changes wrought in the brain by carbolic acid ; if the 
 latter gives rise to coagulation in the cerebral vessels, it may well 
 give rise to these caseous areas, but at present the whole matter is 
 veiled in obscurity. I pass on now to a case of fatal carbolic 
 poisoning. 
 
 Case. — A. S — , set, i8, was operated ou for necrosis of the upper end of 
 the tibia. She had at the time swelling of the knee. Lister's dressings were 
 employed. The operation was followed by rapid effusion into the knee-joint 
 and high fever. I thought that I might cut short the suppuration by washing 
 out the knee-joint with 5 per cent, carbolic solution, adopting the method 
 so successfully employed by Volkmann and Schede. Accordingly three weeks 
 after the first operation the joint was punctured, and a considerable amount of 
 flocculent pus let out. A solution containing 5 per cent, of carbolic acid 
 and 2 of glycerine was thrown into the joint, and allowed to run out again. 
 This process was repeated some ten or twelve times till the fluid, on escaping, 
 was clear. All the injection appeared to return. The canula was then re- 
 moved, and Lister's dressings applied. The patient recovered consciousness 
 after tlie anaesthetic, but was very cold. She soon again became completely 
 unconscious, with very small pulse. An hour and a half after the operation 
 she was in a state of deep sopor ; the pulse was scarcely perceptible ; tempe- 
 rature 978°. She could not be induced to swallow anything. During the 
 next two hours the sopor continued; the pulse disappeared, but the action of 
 the heart was perceptible and regular; respirations frequent, rather shallow ; 
 pupils equal, moderately dilated ; eyelids open, constantly moving. Slight 
 convulsive movements were noticed in the muscles of the extremities, espe- 
 cially in the forearms. These increased until the hand and forearm were 
 drawn up into a spasmodically flexed position. The temperature sank in the 
 course of three hours to 95°. The extremities were cold and dry, while on 
 the face and chest a cold sweat broke out. Absolutely no reflex movement 
 ou pricking the surface with the needle point. Every kind of stimulant was 
 employed : wine and ether were forced between the closed teeth, and a little 
 was eventually swallowed. By means of friction and artificial warmth the 
 patient revived in a slight degree, and was able to mutter a few words, and to 
 swallow some wine and strong colfce. The pulse again could be felt and the 
 tonic spasms of the arras yielded, although the muscular contractions per- 
 sisted. The fluids that had been taken were now vomited, but the general 
 condition did not improve in consequence (as happens also in narcotism from 
 chloroform). On the contrary, the collapse set iu anew, the pulse again 
 disappeared, the action of the heart became weaker and weaker, the respira- 
 tions more shallow, the convulsive movements of the muscles ceased, and she 
 died six hours after the operation. 
 
 The post-mortem examination was most carefully performed by 
 Dr. Chiari, and the various parts of the body analysed chemically 
 by Prof. Ludwig. My best thanks are due to these gentlemen for
 
 14 FATAL CARBOLIC POISONING. 
 
 the care they bestowed on a case which may be taken as a typical 
 one of acute carbolic poisoning. The report was as follows : 
 
 "The right lower extremity somewhat enlarged iu the neighbourhood of the 
 knee-joint, partly from infiltration of the soft parts, partly from bony thicken- 
 ing of the tibia. In the cavity of the knee-joint some reddish fluid containing 
 flakes of pus ; the muscles of the right thigh infiltrated throughout with 
 reddish-brown fluid smelling decidedly of carbolic. Tliis condition is espe- 
 cially observed near the space between the capsule of the knee-joint and the 
 quadriceps extensor cruris. At the upper eud of this recess is a perforation, 
 admitting the little finger, bordered by suppurating, broken-down tissue, and 
 forming a communication between the interior of the joint and a cavity the 
 size of an egg in the lower part of the muscle. This cavity is invested by 
 muscular tissue of greyish-white colour. The synovial membrane of the knee 
 is of a broMmish-red colour and feels like leather. The cartilage on the femur 
 and tibia is wanting at some points. 
 
 " The meninges and brain very pale, the latter rather wet ; serous frothy 
 fluid in the air tubes ; lungs free from adhesions, (Edematous, and rather 
 congested. 
 
 The bronchial mucous membrane slightly reddened. Heart contracted, 
 above normal size : recent clot in the cavities, muscular substance pale. 
 Liver slightly fatty, of a pale grey colour. Spleen (240 grm.) pale, firm. 
 Kidneys pale grey. No htemorrhage in any of the internal organs. 
 
 Microscopic examination of the muscular substance of the thigh shows the 
 contractile tissue partly broken up into fibrilli, partly into discs, iu some 
 parts degenerated into a finely granular detritus. In the other muscles, in 
 the heart and parenchyma of the kidneys, the so-called "cloudy sweUing" 
 (triibe schwellung). 
 
 Chemical exar,ii>iaiion. — Prof. Ludwig, who examined portions of the liver, 
 spleen, kidneys, heart, muscles, and some of the urine drawn off during the 
 height of the symptoms, reports, — " In the specimens submitted to me, 
 abundant carbolic acid was found. I estimated the amount of carbolic acid in 
 the 74 c.c. of urine analysed at o"297, giving 4"Oi grm. in 1000 c.c." 
 
 Gladly would we eliminate all element of " luck " from successful 
 operations. In truth a noble aim, and one for which I have always 
 striven with all my might. But " ill-luck "" we cannot get rid of; 
 or must I regard it as a fatality that I lost my patient in this ter- 
 rible manner ? After hesitating for years, I had minutely followed 
 the advice of other colleagues, and, in order to check a severe dis- 
 ease, adopted a method, the efficacy of which seemed already estab- 
 lished, and from which brilliant results were guaranteed. Can it 
 be that some of my colleagues have had similar experiences, and 
 refrained from making them known ? At the least, I trust that the 
 death of my patient may have been the means of preserving others 
 from such calamities.
 
 FATAL CAEBOLIC POISONING. 15 
 
 Case. — From a patient, E. W., set. 43, 1 removed a simple ovarian cyst of 
 moderate size, under 2 per cent, carbolic hand spray. The adhesions were few 
 and easily separated : the pedicle, which was thin, was secured with a catgut 
 ligature and allowed to fall back into the abdomen. A drainage tube was 
 passed through Douglas's pouch, and brought out through the vagina. Lister's 
 dressings were used. Some blood-stained serum flowed away through the tube 
 the next day, and 2 per cent, carbolic acid solution was syringed in through 
 the tube. The records of the case do not accurately state the number of 
 times that the carbolic was injected nor whether the fluid escaped again freely. 
 The patient felt unduly weak and restless, considering the comparatively 
 simple nature of the operation. The urine was of the usual dark carbolic 
 colour. Pour days later vomiting commenced and the urine was of a very 
 dark green colour : the stools, too, were black. Of course, the carbolic injec- 
 tions and dressings were at once left off; the symptoms however persisted, and 
 the urine, later on, became tinged with blood. Death took place on the tenth 
 day. 
 
 Post-mortem. — Adhesions of an extensive character were discovered. No 
 absorption of the catgut ligature placed around the pedicle had taken place, 
 nor had the tied portion of the pedicle necrosed. The mucous membrane of 
 the stomach and intestines was pale. Microscopically, nothing abnormal was 
 revealed. 
 
 In two other instances the same somewhat negative results were 
 yielded by the post-mortem examination. One was the case of a 
 man whose thigh was amputated for a cysto-sarcoma of the tibia, 
 and who died on the third day after the operation ; the other (a 
 man, aged 74, who was extensively burnt about the body) died the 
 day after the employment of the carbolic and Lister's dressings, five 
 days subsequently to the primary injury. In this latter case the 
 state of the urine is not recorded ; rapid collapse and a temperature 
 of 95° preceded death. 
 
 The pEithological appearances after carbolic-acid poisoning are so 
 equivocal, seeing that we know nothing of the conditions which 
 conduce to death, that we can no more frame a purely anatomical 
 description of carbolic poisoning than we can of chloroform poison- 
 ing. We are limited, therefore, to combining the initial effects of 
 the carbohc acid with the symptoms ushering in death, and in this 
 way to form, from a clinical point of view, a conception of the 
 disease. 
 
 Those who have perused what I have written above, will not be 
 surprised at my inability to develop any great enthusiasm for the 
 antiseptic method, from which hitherto the employment of carbolic 
 acid could not be dissociated. We have an old saying, that men 
 are wiser on leaving the council, and no doubt many will shrug
 
 16 CARBOLIC ACID POISONING. 
 
 their shoulders when I state the conclusions that I have arrived at 
 after an experience extending over several years. 
 
 jN^ow the danger arising from carbolic-acid poisoning has only 
 been properly appreciated during the last few years. At first, 
 every one was carried away with enthusiasm at the wonderful suc- 
 cess of the Listerian system ; for my own part, I hesitated to 
 ascribe the effects in many of the above-recorded cases to carbolic 
 poisoning, fearing lest, in weighing these cases, I might be preju- 
 diced by a mistrust of the antiseptic system, founded on theoretical 
 grounds. I do not doubt that anaemia, childhood, old age, and 
 weakly constitution are to be taken into consideration in forming 
 a judgment. Although my mistrust of the antiseptic system begins 
 to melt away in the face of successive favourable results, and I can 
 now (from having seen more cases) take a wider view ; yet there is 
 no question in my mind that in all the instances given above, car- 
 bolic poisoning decidedly caused death, though perhaps in some of 
 the more weakly patients it merely sufficed to turn the scale. 
 
 Xot long ago, at a banquet in Vienna, Marion Sims spoke in 
 highly flattering terms of our clinics and hospitals ; in particular 
 he found the mortality in the lying-in department so small that he 
 said, " It is no more mortality, it is accident " — a graceful, well- 
 meant, and consolatory remark, tiria irTwotvra for the antiseptic 
 enthusiasts ! It is to be regretted, liowever, that " accident " is 
 so frequently fatal, that the term is almost convertible into " mor- 
 talitv.^' 
 
 See Appendix 1, infra.
 
 CHAPTER III. 
 
 HOSPITAL GANGRENE (DIPHTHEllITIC INFLAMMATION OF 
 WOUNDS) AND PYJ^IMIA. 
 
 I MET with no cases of this nature while at Ziirich. Ten came 
 under my care while I was at Vienna, between 1867 and 1H76, but 
 five of these did not originate in the hospital ; all recovered. 
 
 Hosjjital gangrene differs so essentially from erysipelas and 
 phlegmonous inflammation, and is so widely dissimilar in its course, 
 that we are justified in the supposition that it has a separate and 
 and special cause of origin. 
 
 With regard to its etiology, probably the majority of surgeons 
 hold the same opinion as they do of erysipelas and diphtheritis, that 
 is to say, they suppose it may either originate spontaneously, or by 
 contagion. I have not seen much of the disease, but my observa- 
 tions have led me decidedly to the conclusion that, in hospitals, the 
 disease almost invariably spreads by contagion ; and, secondly, that 
 the contagious material — whatever it be — is of short life, tolerably 
 definite action, and is easily destroyed. 
 
 With regard to the first point, there is, according to my exjjeri- 
 ence, among the ordinary forms of septic conditions of wounds and 
 ulcers, none which can set up the rapidly progressing phagedienic 
 disease known as hospital gangrene. As yet it has not been found 
 possible to produce hospital gangrene experimentally. I still hesi- 
 tate to accept unconditionally the assurance of our best observers, 
 that zymotic germs have much to do with the causation of erysipe- 
 las, diphtheritis, septicaemia, and pyaemia ; but in hospital gan- 
 grene there appears to be no doubt that the disease is so caused. 
 Not only is this shown by microscopical examination of the pulpy 
 tissue and the edges of the ulceration, but also by the manner in 
 which the process begins and spreads in the wound. 
 
 The manner in which the tissue is destroyed is so peculiar that 
 I cannot but believe that this disease is due to some special kind of 
 
 2
 
 IS ETIOLOGY OP HOSPITAL GANGRENE. 
 
 zymotic germs, and that these germs, once fully formed and trans- 
 ferred to a wound, readily increase and develope in the same way. 
 At one time or another, however, this fungus, however specific its 
 nature, must have originated de novo, though how the genesis took 
 place we can scarcely even guess. Pleating everywhere in the 
 atmosphere are germs which may develop various properties, 
 according as the conditions in which they are placed prove favour- 
 able to such development, such, for instance, as the degree of 
 moisture and the like. We can conceive that these germs may 
 develop in the acid fermentation of pus, or in the alkaline deposits 
 on the edges of vessels containing urine ; then they become dried 
 up again, placed under congenial conditions they germinate, and 
 undergo certain metamorphoses ; thus, the process goes on until 
 finally, having passed through a complicated and probably an ever 
 slightly-varying cycle of changes, they acquire those properties by 
 virtue of which their activity reaches a maximum, and by which 
 the tissues are so rapidly eaten away and destroyed. This view is 
 in accordance with those theories which would refer all these germ 
 diseases as far as possible to one original source — perhaps the peni- 
 ciUium micrococcus. The infrequency of hospital gangrene renders 
 another explanation possible, viz. that this is a rare form of micro- 
 coccus, and is only introduced into hospitals now and again in the 
 linen or cotton fibre of the bed coverings or horse-hair mattresses, 
 or in straw palliasses. No doubt these views will, before long, be 
 modified; the investigation of the problem is unquestionably of 
 great interest, and I should have applied myself more closely to the 
 subject, or persuaded my pupils to do so, had it not been dangerous 
 to our patients. Being confident that hospital gangrene was readily 
 amenable to treatment, I requested on one occasion that I might 
 be entrusted with the care of the patients so affected. The conse- 
 quence was that the disease attacked a patient in one of my own 
 wards. It does not do to play with fire even though one should be 
 a member of the fire brigade. 
 
 As to my second statement, viz. that the contagious material is 
 definite in its action, I support this assertion on the observation, 
 that the infective power is comparatively weak, forasmuch as the 
 contagious material is not so much transferred through the atmos- 
 phere or by a third person, as directly from one case to another. 
 Many may dissent from this opinion, but they will probably agree 
 with me that the contagious material has but a short life, and is
 
 PYJIMIA. 19 
 
 easily destroyed. We know it can readily originate, and if, like the 
 contagious material of erysipelas, it were hard to destroy, I should 
 have found it impossible to prevent the spread of hospital gangrene 
 in my wards. 
 
 Seven cases came under my care in Vienna during 1868 ; one of 
 the patient was admitted with a wound in the forearm, which had 
 been attacked with the disease in a typical form. Probably from 
 this case two others became affected; in one instance the diphtheria 
 originated, to all appearance, spontaneously, but fortunately did 
 not sjiread. In another the diphtheritic inflammation of the wound 
 was associated with septicsemia, and in two others with pyaemia, 
 while in one patient in whom the lower jaw had been partly resected, 
 the wound was attacked with diphtheritic inflammation, the affection 
 subsequently spreading over the throat. 
 
 The toxic material which sets up diphtheritic inflammation of 
 wounds is, as I have said, very peculiar in its nature ; it is allied to 
 the toxic material causing diphtheritic inflammation of the mucous 
 membrane, and to septic phlegmonous inflammation, but whether it 
 be identical cannot yet be answered. To my thinking, the number of 
 these cases in our hospitals is far too large, for if perfect cleanliness 
 and purity be insisted upon in the atmosphere, in the bandages, and 
 the hands of the dressers and operators, the disease may be entirely 
 eradicated and does not readily reappear when once banished. One 
 cannot say the same of erysipelas, phlegmonous inflammation, lym- 
 phangitis and their consequences. The conditions favourable to 
 the production of these last-named diseases are far more numerous 
 and common than is the case with diphtheritic inflammation of a 
 wound, but yet if all surgeons would but recognise the comp^irative 
 facility with which hospital gangrene may be eradicated, we should 
 very soon only hear of this disease as a tradition handed down from 
 the former dark ages of superstition. 
 
 Pyjsmia. 
 
 With regard to pycemia, I adopt the nomenclature proposed by 
 Hueter, and designate as pysemic, those cases where there is 
 general severe purulent infection, although no rigid line can be 
 traced between pysemia on the one hand, and hectic and secondary 
 fever on the other. It does not seem proper to consider all cases
 
 20 PYiEMIA AND SEPTO-PY^MIA. 
 
 of severe secondary fever as pyeemic. Witli Hueter, also, I dis- 
 tinguish between pytemia simplex where there are no metastases, 
 and pyaemia multiplex, where metastatic purulent deposits occur, 
 and where numerous areas of infection are kept up and increased. 
 Nor in tabulating my cases have 1 made a special class for septo- 
 pyaemia, although I do not deny that this combination may exist ; 
 on the contrary, I think that the latter has a distinctive symptoma- 
 tology, but it must be admitted that it would be arbitrary to decide, 
 from the notes of cases, whether the secretions of the wounds were 
 ichorous or purulent, or a combination of the two.^ 
 
 With regard to the pathological and anatomical aspect of pyaemia, 
 erysipelas, and diphtheria, I feel that I can now add but little to 
 what I have already written in the ' Archiv fiir Klin. Chirurg.,' Bd. 
 ix. I may observe, however, that in Vienna, metastatic disease of 
 the brain and brain membranes were of remarkably frequent occur- 
 rence, especially after operations about the head, the tongue, or the 
 lower jaw. In some cases we were able distinctly to demonstrate 
 that the diphtheritic process extended up the nerve sheaths. Venous 
 tlirombosis became more and more rare, whilst pure septicaemia and 
 pyaemia simplex gradually came more and more into the foreground. 
 
 Tables of cases of septo-pyaemia (including some of diphtheritic 
 inflammation of wounds) and erysipelas will be found in the 
 ' Wiener Bericht,' 187 1-6, p. 54 et seq. 
 
 ^ The above sentence may serve to explain the significance attached in 
 Germany to the term "jauche" (ichor). There appears to be no true English 
 equivalent ; the word " ichor " is used rather vaguely in surgical literature. 
 It would be desirable to adopt some such definition of the two terms — ichor 
 and pus — as suggested by Sir J. Paget in his ' Lectures on Surg. Path.,' 
 3rd edition, p. 316. "A constant difference between pus and ichor will be, 
 that the latter contains disintegrated or dissolved material of the ulcerating 
 tissue — the former does not." — [Ed.]
 
 CHAPTEE IV. 
 TRAUMATIC ERYSIPELAS.' 
 
 During the whole course of a tolerably long hospital experience, 
 I never met with so little erysipelas as in Vienna, during the year 
 1868 (I'l per cent, of the cases admitted), while in the years 
 1869-70, the number rose to 6 per cent. There was no great 
 difference between the annual number of the patients uud^r treat- 
 ment, so there remains this remarkable fact, that the number of 
 erysipelas cases was six times greater in one year than it had been 
 in the previous twelve months, and this without the deterioration 
 of any of the sanitary conditions of the hospital; nay, the rise 
 coincided with the most extensive use of carbolic acid, and the 
 systematic isolation of cases in separate wards. 
 
 Such an experience is discouraging, but it would be wrong in 
 the highest degree to infer that we need despair of banishing this 
 formidable foe from our surgical wards. We must study all the 
 more incessantly to learn the nature and method of its action, and 
 must hunt it out from every possible hiding-place. 
 
 We know that true (wandering) erysipelas sometimes starts from 
 quite recent wounds, sometimes from those which have existed for 
 a long time ; I have tried to distinguish between these two kinds 
 by designating the former "septic''' erysipelas, and the latter 
 erysipelas " originating from infection from without.^' My idea is, 
 that in the former class of cases, the cause of the erysipelas must 
 be attributed to the decomposition of retained blood or secretion 
 from the wound ; whereas, in the second class, the infection comes 
 from without. This view as to the double nature of the etiology of 
 erysipelas appears to me to be adopted by most surgeons, though 
 with numerous modifications. It corresponds also with the opinions 
 
 ' In counexion with this Chapter, Prof. Billroth's remarks on the subject m 
 his ' Surg. Patli.' (Hacklej's Trausl.) may be studied with advantage. His 
 views are there clearly and briefly expressed. Sec also the author's writings 
 in the ' Arch, fiir Kl. Chirurg.,' Bd. iv and Bd. ix. — (Ed.)
 
 22 ETIOLOGY OP TRAUMATIC ERYSIPELAS. 
 
 ■whicli generally obtain on the method of spreading of other in- 
 fectious diseases, such as typhus, scarlatina, diphtheritis, &c. 
 There is a tendency among the younger generation to defend more 
 and more energetically the view that these morbid processes solely 
 spread by infection from without. In the case of many other 
 diseases which we now hold only to spread by contagion, there has 
 been a similar alteration of opinion ; not so very long since, it was 
 thought that syphilis sometimes was caused by want of cleanliness, 
 sometimes by ' contagion. The spontaneous origin of measles, 
 scarlet fever, and smallpox is still believed in by many, while 
 absolutely denied by others. Griesinger, who has won such undying 
 fame by his doctrine on the specific nature of the poison of typhus, 
 could account for well known matters of fact, in no other way than 
 by supposing that true typhus might also originate through the 
 absorption of septic matter. Liebermeister denied this, and we 
 now acknowledge that typhus can only spread by specific infection. 
 It was just the same formerly with regard to Asiatic cholera, which 
 was thouglit to be at times produced in summer by the eating of 
 unripe fruit. 
 
 I mention these facts, in order to remind my readers that our 
 views on erysipelas are very much the same as those which obtain 
 among physicians generally, with regard to the majority of in- 
 fectious diseases ; and amongst surgeons, as also - amongst the 
 physicians, the number of those constantly increases, who hold that 
 these maladies in the vast majority of cases — perhaps always — are 
 spread by some specific cause of disease. 
 
 Long and careful study of those questions has led me to the con- 
 clusion that the severe general diseases, which we call septicaemia 
 and pyemia, are not specific according to our modern interpretation 
 of the terms infection and contagion. With erysipelas and hospital 
 gangrene, the reverse is certainly the case. I was only gradually 
 convinced of the truth of this view ; the proofs seem to me simple 
 enough, and I have given them at length elsewhere. Virtually it 
 comes to this : — That the origin of septicemia and pyaemia depends 
 on the situation and nature of the lesion, and is closely connected 
 with certain definite stages of its progress, while any wound, in 
 any part of the body and at any stage whatsoever, may be attacked 
 by erysipelas, or hospital gangrene. 
 
 Supposing that for some twelve months, without known cause, all 
 the erysipelas that occurred was found to attack healthily granu-
 
 EXTENSION OF EEYSIPELAS. 23 
 
 lating wounds in all kinds of different stages ; or old sinuses of 
 various kinds. If sucli had been our observation, the opinion that 
 the infection was from without, would gain more and more point ; 
 we should naturally tend more to the supposition that there was 
 but one etiological cause for erysipelas, for such a view would be 
 more simple and satisfactory. Where the erysipelas attacked a 
 wound beneath which decomposing blood and secretion had 
 been pent up, we should not be able to ascribe the causation 
 of the disease to these retained fluids. We should be forced 
 to conclude that in such cases the specific poison of erysi- 
 pelas had been introduced into the wound by the instruments 
 or sponges, or inoculated by the hands of the surgeon himself. 
 Such a hypothesis may be accepted even by those who hold, in all 
 other respects, that the rule is for eirysipelas to spread by con- 
 tagion and infection. W^e may add that it is an exceedingly rare 
 thing for true erysipelas to arise from the retention of decomposed 
 blood and secretion ; usually under such conditions phlegmonous 
 dermatitis is set up. If by true erysipelas we mean lymphangitis, 
 something still further may be added ; the phlogogenous^ poison 
 can be pressed further and further in all directions where the tension 
 of the tissues and fascia offers no resistance, but it would not easily 
 find its way into the lymph vessels (as is shown by artificial injection 
 into the subcutaneous cellular tissue), for the cellular tissue has no 
 lymph capillaries. If the poisonous material finds its way into the 
 branches of the subcutaneous lymphatics, it must flow on in a centri- 
 petal direction, for the valves will prevent any back flow into the 
 lymphatic network of the cutis. Lymphangitis can therefore very 
 well be associated with phlegmonous inflammation, but erysipelas not 
 so readily. If, on the other hand, the inflammation of the cutis is 
 the primary affection, the phlogogenous poison will very readily 
 flow off through the lymphatic vessels, explaining the frequent 
 association of subcutaneous lymphangitis with erysipelas, Prom 
 the lymphatics it penetrates into the cellular tissue, and thus 
 becomes combined with phlegmonous inflammation. This appears to 
 be the most common process of extension. If the excessive swelling 
 of the subcutaneous cellular tissue compresses the branches of the 
 lymphatics and veins, and obstructs the flow, the irritating material 
 spreads in the superficial vascular network along the surface of the 
 
 ^ See Billi-oth's ' Surg. Path.,' op. jam. cit,, pp. 89, 90, for explanation of 
 this term.
 
 24 SPECIFIC NATUEE OF ERYSIPELAS. 
 
 cutis. Fluids external to the lymph capillaries may diffuse them- 
 selves through the meshes of the connective tissue of the cutis 
 — the common form of acute dermatitis. This is proved also by 
 the results of attempts to inject the lymphatic vessels of the cutis. 
 Let us follow out this train of thought a little further. 
 
 If we look upon erysipelas as lymphangitis of the cutis, and 
 distinguish it thus anatomically from ordinary acute dermatitis, the 
 question arises, in what degree are we justified in saying that the 
 cause of erysipelas is a " specific " one ? Is it really necessary, ac- 
 cording to the views above stated, to assume that there is some- 
 thing special and peculiar ? If we imagine a phlogogenous sub- 
 stance, which is either soluble in the fluids of the body or else 
 suspended in the form of fine molecules, we are met by a further 
 inquiry ; may not this same substance, since it can penetrate into 
 the lymphatic vessels and the meshes of the cutis, into the loose 
 subcutaneous cellular tissue, into the fine subcutaneous lymphatics, 
 or into the veins, set up erysipelas, dermatitis, phlegmon, lym- 
 phangitis or phlebitis ? May it not therefore depend merely 
 on accidental circumstances whether one form or another of in- 
 flammation is developed ? I cannot unconditionally answer all 
 these knotty questions in the negative ; that is to say, I admit that 
 there is no evidence against the supposition that all these forms of 
 inflammation are capable of being set up by this same irritating^ 
 phlogogenous material. But I shall at once be told " there is, 
 then, nothing that speaks in favour of there being a specific 
 erysipelas poison." I answer as follows : — The theory that 
 erysipelas is set up by some material which diffuses itself through 
 the superficial lymphatic networks of the cutis, presupposes several 
 conditions. 
 
 (i.) That this material gets into these lymphatic vessels. 
 
 (2.) That in these vessels it either keeps or receives its irri- 
 tating properties ; in no case can it well part with them. 
 
 (3.) That the passage of the Ijmph along the surface meets 
 with no obstacles, such, for instance, as would be oflered by coagu- 
 lation. 
 
 (4.) That it is not carried ofi" too rapidly. 
 
 If it be admitted that a substance possesses these definite pro- 
 perties, and can only act under these definite conditions, we may 
 call it " specific." Nothing at all is alleged against the assertion 
 that there may be many such specific agents.
 
 SPECIFIC NATURE OP ERYSIPELAS. 25- 
 
 Possibly, also, tlie same agents may produce ordinary dermatitis, 
 phlegmon, lymphangitis, or phlebitis, but unless altered, the mate- 
 rial which sets up these forms of inflammation cannot also cause 
 erysipelas, not even if it penetrates into the lymph capillaries, for, 
 as stated above, the mere getting in is not of itself sufficient to set 
 up the disease. 
 
 The " specific " properties of whatever it is that causes the dis- 
 ease must in this, as in many other cases, be of a purely physical 
 and chemical nature. To my mind this does not interfere in any 
 degree with the view that these phlogogenous bodies may be germs 
 of a vegetable or animal nature ; nay, rather, if we assume that the 
 toxic material possesses infective power so prodigious as to exceed 
 a milliqnfold the most potent inorganic poison, we are reduced to 
 conclude that this poison spreads by some process akin to fermen- 
 tation. To some such view we are every day more and more 
 impelled. 
 
 The phlogogenous substance which, from somewhere or another, 
 without any fresh injury, finds its way into the granulation tissue, 
 thence into the lymphatic network of the cutis, therein diffuses and 
 occasions constantly spreading inflammation, sets up, according to 
 my view, erysipelas. Its '' specific" properties just depend upon 
 the nature of its activity. That it does not penetrate into the 
 deeper parts, and so set up lymphangitis, phlegmon, or phlebitis, 
 may be explained by several hypotheses ; perhaps it cannot pene- 
 trate, or if it does, it may part with its phlogogenous properties 
 during its passage from the superficial to the deep parts. These 
 negative characteristics constitute, in part, the specific attributes of 
 the poison. 
 
 No doubt many surgeons will be little satisfied with this defini- 
 tion of the term " specific." All I mean is that such an explana- 
 tion is possible, and does not run counter to facts ; I freely admit 
 my inability to prove that it must be so. There are those who 
 stand rigidly by the orthodox doctrine, that there is one miasma 
 for phlebitis, another for pyaemia, a third for erysipelas, a fourth 
 for lymphangitis, etc., and that they must be inhaled or swallowed 
 like other miasmata, all of which have certain common properties. 
 Once introduced into the system, each, according to its own sepa- 
 rate nature, selects a particular tissue or organ in which it carries 
 on its mysterious work. (The so-called " specific " drugs are 
 undoubtedly analogous in this respect.) To the disciples of this
 
 26 CAUSATION OF ERYSIPELAS. 
 
 theory it must be answered, that, when we take into account the 
 results of careful observations, their views as regards accidental 
 diseases of wounds can no longer be sustained. 
 
 For reasons already given, it will be admitted that the cause or 
 causes of erysipelas are always brought from without into the 
 organism ; they may be introduced during operations, by dressings, 
 or by the air of the ward. 
 
 I by no means conceal the fact that a view such as this of the 
 etiology of erysipelas would to me be very acceptable ; but obser- 
 vations have, to my mind, unquestionably shown that, under cer- 
 tain rare conditions, the poison of erysipelas, with all its " specific " 
 characteristics, as above explained, may develop in the body itself 
 from substances which have no relation with the atmosphere or 
 external influences. Thus it comes about that true erysipelas will 
 develop in the skin over a joint affected with metastatic inflamma- 
 tion. I noticed such an occurrence no long time since in a man 
 who was attacked with pyremic inflammation of the elbow-joint 
 after external urethrotomy. I satisfied myself, by the most careful 
 examination, that there was not the slightest excoriation of the 
 skin from which erysipelas could have originated. I can only 
 explain the occurrence of this undoubted erysipelas on the supposi- 
 tion that the products of inflammation penetrated, in some excep- 
 tional way, through the lymphatic vessels from the synovial mem- 
 brane to the cutis (that is to say, the current in the lymphatics was 
 reversed), and thus set up the capillary lymphangitis. Closely related 
 to, in fact, at times hardly to be distinguished from, true erysi- 
 pelas, is the reddening of the skin over the joints in gout. Again, 
 there is a form of dermatitis very similar to erysipelas which occa- 
 sionally accompanies diphtheritic inflammation of the bladder or 
 mucous membranes, and hospital gangrene ; but in all these cases 
 one prominent characteristic of traumatic erysipelas is wanting, 
 viz. its power of spreading and wandering over the surface. 
 
 In connection with pysemic exudations, and in diphtheritis, 
 arthritis, &c., phlogogenous material may be generated and pass 
 into the lymph capillaries of the cutis, but it will not acquire the 
 property of diffusing the process widely over the cutaneous sur- 
 face. These are abortive varieties, as it were, when compared with 
 the forms of erysipelas set up by infection. They possess a few, 
 but not all, of the properties necessary to set up real erysipelas ; they 
 are not thoroughly " specific,^^ but, so to speak, only half caste.
 
 CONTAGION OP ERYSIPELAS. 27 
 
 It is difficult in the face of what has been said to hold by the 
 etiological unity of erysipelas ; for the present we must admit that 
 it has a twofold mode of origin. It may commence by the trans- 
 mission of some substance coming from without, ready to set 
 up, and fully capable of itself of setting up, the disease, or by the 
 development of a similar material in connection with certain morbid 
 products. In this respect I hold the same views with regard to 
 the origin of erysipelas as I do to that of diphtheritic inflamma- 
 tions.^ It is decidedly far more common for the latter to spread 
 by contagion, but, under the influence of septic blood poisoning, 
 they may originate independently of contagion. 
 
 AYe must confess our position, and acknowledge that our in- 
 formation on the etiology of disease increases very gradually, but 
 it would be wrong did wc fail to recognise how much has been 
 achieved by careful work during the course of the last ten years," 
 or did we ignore how these questions, as time goes on, are assuming 
 more precise and definite shapes. 
 
 Statistics showed that the period of the year had no influ- 
 ence on the origin and extension of erysipelas in our hospitals. 
 The disease lasted usually but a very short time, owing probably to 
 the early isolation of the patients. The percentage of women 
 attacked was twice as great as that of the male patients. This fact, 
 however, I do not ascribe to the greater receptivity of the female sex 
 to erysipelas, but rather to the arrangements of my wards in the 
 hospital at Zurich; there, the female wards, and the separation 
 room to which the erysipelas patients were transferred, were all on 
 the ground floor. It is quite possible — notwithstanding that the 
 utmost precautions were taken against such an occurrence — that 
 the contagion was carried on the clothes of the assistants or nurses 
 from one room to the other. Moreover, the walls of ground floor 
 rooms are more inclined to be damp ; not that this of itself can 
 produce erysipelas, but if the contagion is in the form of minute, 
 dust-like particles — whether of animal or vegetable nature — it 
 would more readily get attached where the walls are damp. 
 
 In certain patients, erysipelas occurred immediately after opera- 
 tion. If the infection were set up at the time of operation, such 
 cases show that erysipelas has no stage of incubation, but that the 
 
 1 ' Wien. Med. Wocb.,' 1870, Nos. 7 and 8. 
 
 - This essay on erysipelas is contained in the 'Wien, Ber.' for 1S69 — 70, 
 published in Berlin, 1872. — [Ed.]
 
 28 PRECAUTIONS AGAINST ERYSIPELAS. 
 
 disease begins as soon as the patients are exposed to the infection. 
 In a few cases the onset of erysipelas followed so directly on some 
 slight surgical proceeding — such, for instance, as the probing of a 
 wound — that the probability of infection from the instrument could 
 not be ignored. One of the worst cases of erysipelas I met with, 
 and which ended fatally, developed in a young woman, immediately 
 after the cauterisation of an old sinus of the breast with the galvanic 
 wire. Even supposing that the sinus was infected by the probe 
 which was used to introduce the wire, it is most remarkable that 
 the contagium was not immediately destroyed by the intense heat. 
 There is a terrible mystery about such cases. 
 
 I was unable to prove that age, occupation, or the constitu- 
 tion of the patients had anything to do with the causation of 
 erysipelas. As to the duration and course of the fever, I have 
 very little new information to give, but I have frequently been 
 able to confirm observations previously made, that many cases are 
 attended by continuous fever, while others run their course 
 with interrupted attacks, eacli lasting several days (erysipelas 
 recurrens). 
 
 The only prophylactic treatment that is of any avail against the 
 spreading of erysipelas in hospitals, consists in thoroughly cleaning 
 and disinfecting the wards in which a case of erysipelas has broken 
 out, whether it were introduced or whether it originated in the 
 wards. The entire wards, and all the beds, bedding, and furniture 
 must be most carefully disinfected. Isolation when the patient is 
 once attacked is but a poor substitute when one cannot employ 
 these radical measures. Erysipelas diminished to a minimum in 
 my wards at Zurich, from the time that extra rooms were placed at 
 my disposal, and I was able every five weeks to completely empty 
 and thoroughly cleanse the wards. It has been urged against the 
 efficacy of such precautions, that cases are recorded where the very 
 first surgical patients admitted into newly-built hospitals were 
 attacked with erysipelas. Is it not jjossible in these cases that old 
 sources of infection were introduced into the new house, in the 
 bedding, bandages, etc. ? Again, were the surgeons and nurses 
 changed? The '^ specific^'' contagium of erysipelas, once started, 
 is exceedingly difficult to destroy, and exceedingly difficult to 
 banish from the wards. Still, if our nurses would give as much 
 trouble to hunting out and clearing away every particle of dust 
 from the wards as a careful housewife does to keep her house in
 
 STATISTICS OF ERYSIPELAS. 
 
 29 
 
 proper order, we should gradually see erysipelas disappear from 
 our hospitals. 
 
 The chart (Fig. i) illustrates in a remarkable manner, the number 
 Fig. I. — Erysipelas. 
 
 The dotted line shows the number of cases in liospital 
 
 and private jiracticc together. The lowermost liue marks tlie 
 number ol' i'atal cases. 
 
 Fir. 2. — Fatal Septo-?y.?:mta. 
 
 of cases of erysipelas met with between 1860-76. The dotted line 
 includes cases occurring in my private practice. "With regard to
 
 30 ERYSIPELAS AND SEPTO-PYiEMIA. 
 
 this chart, I think that the fall observed between 1863-66 may be 
 ascribed to the open treatment of wounds. The remarkable rise 
 in 1869 was principally due to an improper sanitary condition of 
 the female wards. 
 
 If the erysipelas chart be compared with that showing the 
 number of cases of septo-pyaemia (Fig. 3) it will be observed that 
 there is no great amount of correspondence between the two. In 
 1863, it will be noticed that the line begins to fall; now, this 
 period again corresponds to the date when I first employed the 
 open treatment of wounds. I did not adopt the antiseptic method 
 till 1875. 0^^ the whole, the tables suggest that the mere treat- 
 ment of wounds has not such an all-powerful influence as we are 
 disposed to ascribe to it, but that other agencies are concerned — 
 agencies which we do not know, though we can guess what their 
 nature is.
 
 CHAPTER V. 
 
 HEAD INJURIES. 
 
 Section A. — Scalp wounds wWiout brain symptoms — Case. Injury 
 to slcull without hrain symptoms — Cases. Fatal case of punc- 
 tured wound. Case of concussion toith pulpy discharge from 
 the ear. . Cases of severe concussion. Cases' — Depressed frac- 
 titre of the shdl, fractured hase, encephalitis. Two cases of 
 head injury toith late cerebral symptoms. Case of trephining. 
 Case of cerebral abscess toithout fractured shdl. General 
 remarks on head injuries. 
 
 The following cases are separated according to the custom wliicli 
 usually obtains in surgical text-books, into injuries of — (i) the soft 
 parts ; (2) the bones ; (3) scalp ; and (4) brain. For practical 
 purposes this seems the best arrangement. 
 
 Cases of scalp wound without any brain symptoms. — An injury of 
 this nature occurred in a man who came into the hospital with sym- 
 ptoms of septic poisoning. JPost mortem. — Neither meningitis, 
 thrombosis of the sinuses, nor metastatic abscesses were found. 
 The other tvTO were children of five and eleven years old respec- 
 tively, in whom the scalp was extensively torn. In both, suppura- 
 tive meningitis with thrombosis of the sinuses was discovered after 
 death ; the younger child died on the twenty-eighth, the elder on the 
 twenty -fifth, day after the injury. In the latter case a few days before 
 death the right cornea sloughed, owing to compression of the oph- 
 thalmic division of the fifth nerve by pus in the cavernous sinuses.^ 
 
 My constant practice is to sew up scalp wounds when they gape 
 widely, but I remove the sutures if any considerable swelling and 
 pain appears in the neighbourhood of the wound. If this be not 
 promptly done, I generally found much pain, tension, and sharp 
 fever result. 
 
 1 This case is fully reported in the 'Wieu. Wochens.,' 1S67,
 
 32 HEAD INJURIES ^YITHOUT CEEEBEAL SYMPTOMS. 
 
 Pour cases of bone injury of some importance, but without any 
 brain symptoms, did well. 
 
 Case. — W. H — , £et. 23, a strong miner, was injured in blasting a rock. 
 He came up to the hospital at once with a lacerated wound, two inches long, 
 over the left frontal eminence. Fifteen small fragments of bone were 
 extracted, leaving a gap in the skull the size of a shilling. Dura mater 
 uninjured ; uninterrupted recovery in forty-three days. 
 
 Case. — D. S — , a labourer, aet. 50, was injured in the same way as the 
 preceding case. Here, however, a fragment of stone, the size of a sixpence, 
 was firmly embedded in the bone in the middle of the forehead. Several 
 medical men liad attempted to extract it without success, and the patient was 
 sent up to the hospital twelve hoixrs after the injury to be trephined. By 
 gouging away a portion of the external table near the impacted body I was 
 able to remove it with the elevator. A few small fragments were taken away 
 with the forceps. The dura mater was uninjured. Recovery iu twenty-flve 
 days. 
 
 Case. — R. F — , a smith, set. 30, was injured by a heavy blow on the forehead 
 from a stone. Six weeks after the injury the wound was still suppurating ; 
 some small fragments of the stone were then extracted, but the wound did not 
 completely close, and the patient came up to the hospital, eight weeks after 
 the injury. A sinus in the middle of the scar, close to the hairy scalp, led 
 down to exposed bone. I slit up the sinus, and removed a number of frag- 
 ments of bone and of the stone. The gap left extended through the whole 
 thickness of the frontal bone, and the dura mater was seen, but not pulsating. 
 The wound healed in fifteen days after the slitting up of the sinus. 
 
 Case. — J. M — , tet. 22, an artisan, attempted to commit suicide. He 
 placed the barrel of a pistol, loaded with two bullets, against the middle of his 
 Yorehcad and fired it off. Blood flowed from a wound, but lie did not lose 
 consciousness, and made a second unsuccessful attempt, this time placing the 
 muzzle against his right temple. After this he desisted, and went to a doctor, 
 who removed a piece of lead from the wound in the temporal region, and sent 
 him up to the hospital. ^Ve found two lacerated wounds, their edges 
 blackened with powder, in the situations mentioned. No injury of the 
 skull could be made out, although the bone was exposed iu the neigh- 
 bourhood of the wounds. Superficial necrosis followed and he recovered 
 in seventy-eight days. 
 
 The absence of even transitory concussion in this case is to be 
 ■explained by the fact that the injury was confined to a small por- 
 tion of the skull. In military practice similar cases have been met 
 with, though not often ; the favourable progress of the first three 
 cases is accounted for by the circumstance that the dura mater was 
 uninjured.
 
 CASES OF CONCUSSION. 33 
 
 In one case we had to deal with a punctured wound in tlie right temporal 
 region, the result of a stab with a peul^nife. At first there were no brain 
 symptoms, and the injury was considered trivial. On the fourth day con- 
 siderable headache came on, followed shortly by great restlessness, delirium, 
 and finally coma. Death on the sixth day after the injury. Post mortem : a 
 small punctured wound was found passing through the temporal bone into the 
 brain ; in the anterior lobe the brain substance was broken down at one part 
 into a soft, red, pulpy mass, the size of a walnut. 
 
 The condition found agreed with the diagnosis ; attempts had been 
 made to find the opening in the bone during life, with the object of 
 letting out the pus. The opening, however, was not discovered, 
 inasmuch as the wound ran very obliquely through the temporal 
 muscle. Even if the opening had been enlarged no good would 
 have come of it, as no pus had formed that could have been 
 evacuated. 
 
 Concussion, with symptoms varying from those of a transitory 
 nature up to twenty-four hours' duration, without any further 
 brain symptoms following. 
 
 Vomiting was but seldom observed. 
 
 In one of these cases, where there was no scalp wound, erysipelas occurred, 
 commencing at the right ear, from which bleeding had taken place. 
 
 Bleeding from the nose and ear, and ecchymosis of the ocular 
 conjunctiva is not uncommon. Jn many of these cases there might 
 have been fissures of the skull which could not be diagnosed. 
 
 In one patient there was a discharge from the ear, of a pulpy 
 white nature, mixed with blood, which had exactly the appearance 
 of brain matter. Still, the case could hardly have been mistaken 
 for fissure of the base, with discharge of brain matter, in the face of 
 complete recovery, even had not microscopical examination proved 
 that the discharged pulp consisted of epithelial elements coming 
 from the external auditory canal. The tympanic membrane was 
 uninjured. 
 
 Concussion^ with more or less persistent disturbance of the mental 
 
 faciolties. 
 
 A young student fell, in the dark, from a terrace unguarded by railings. He 
 lay unconscious, and was brought up to the hospital soon after the accident, 
 with symptoms of severe concussion ; no mark of injury could be discovered 
 about the head. The unconsciousness continued, and a few days after he 
 became very restless. He would try to avoid examination by curling himself 
 
 3
 
 34 CASES OF CONCUSSION ENCEPHALITIS. 
 
 up ill a corner of tlie betl, and rolling his blanket round bim. This condition 
 lasted five days. He then began to answer questions, but unintelligibly. For 
 three weeks he was off his head. He ate, drank, and slept, but answered 
 irrationally, did not know where he was, or recognise his relations. He was 
 during this period free from fever, clean, and easily managed. Gradually his 
 intelligence began to return. Five weeks after the injury his intellectual 
 faculties were completely restored. The treatment consisted in frequent 
 douching. 
 
 Since this I have observed a similar ca.'^e of less severity, where 
 the intellectual derangement lasted only eight days after the con- 
 cussion. 
 
 A woman, ait. 22, was beaten about the head with an axe. Unconsciousness 
 for four hours. Vomited twice. At the back of the head were several wounds 
 down to the bone ; at the bottom of one the bone was exposed to the extent 
 of a floriu and depressed to the depth of six to nine lines for an extent of one 
 inch. Ecchymosis of both eyelids, subconjunctival in the right eye. Pupils 
 equal, much dilated, sensitive. Treatment consisted of ice and aperients. 
 For the first week after the injury there was severe headache. The depressed 
 portion was left as it was. Traumatic fever, lasting twenty-four hours ; then 
 secondary febrile disturbance on the ninth day, lasting five days. No direct 
 cause to be assigned for this latter attack which was followed by rapid 
 convalescence. 
 
 Degression of the skull with loss of consciousness quichly passing off. 
 Death from encephalitis. 
 
 C. W — , set. 18, a labourer, was struck on the head, just to the left of the 
 sagittal suture, by a brick ; insensible for ten minutes ; vomited four times 
 before admission ; a V-sbaped clean cut wound 6 cm. long, at the middle of 
 which was a depression from 6 to 8 mm. deep ; no gaping of the bone ; no 
 paralysis ; conscious, memory clear. On the morning of the second day he 
 passed his urine under him. In the afternoon of the same day right motor 
 paralysis; sensation partial. At times only the patient could be got to 
 answer questions slowly. Calomel was given, ice applied, and vensesection 
 performed. On the third day complete right anaisthesia, with total loss of 
 consciousness. The depressed fragment was elevated, and a small wound of 
 the dura mater seen. The operation was unsuccessful. Deep coma, and death 
 four days after the injury. Post-mortem : a fissure an inch and a half in 
 length was discovered, which commenced at the back part of the left side of 
 the frontal bone and ran over the left parietal towards the medial line. At 
 the posterior extremity of this a second fissure three quarters of an inch 
 long was seen in the left parietal bone. Immediately in front of the coronal 
 suture a third, half an inch in length, extending through the thickness of the
 
 CASES OF FRACTURED BASE. 35 
 
 left half of the froutal bone. On the border of this last fissure a fragment of 
 bone about the size of a hazel nut was driven in to a depth of a line and a half. 
 This depressed portion formed an irregular boundary to a gap the size of a 
 sixpence, limited on the other side by the teeth of the sagittal edge of the 
 right parietal. 
 
 The dura mater corresponding to the extent of injury to the bone, and the 
 ■whole convex surface of the large hemisphere was of a dark green colour, 
 infiltrated with purulent fluid, and perforated in two places, each the diameter 
 of a pea ; these rents extended through tJie pia mater and were close to the 
 longitudinal sinus, which contained fluid blood. A reddish, pulpy area, the size 
 of a walnut, was found in the cortex of the brain, the capillary blood-vessels in 
 the neighbourhood of this area being much injected. The rest of the brain 
 was anaemic, and moderately firm. A i'ew drachms of clear serum in the 
 ventricles. 
 
 Fracfttred base. Insensibility from tlie time of injury up till death. 
 
 F. S — , get. 44, fell from a scaffold, a distance of about six feet. When 
 admitted he was in a heavy, drowsy condition, but moved the arms and legs 
 about in a restless manner, and had strong convulsive movements of the whole 
 body. Death took place forty-eight hours after the injury. Post mortem : 
 Extensive fracture of the right and left orbital plates, extending through the 
 sella turcica as far as the clivus. A triangular portion of the frontal bone 
 corresponding to the glabella lay loose in the cavity of the skull. The dura 
 mater was somewhat stretched, the pia mater infiltrated with puriform fluid, 
 particularly at the base of the anterior and middle lobes. Pulpy breaking 
 down of the braiu cortex over the extent of a sixpence at the anterior 
 extremity of the right anterior lobe of the cerebrum. 
 
 Severe hrain symptoms after an injury to the head and scalp wound. 
 Pycemia thirty -three days after the injury. Thrombosis of the 
 sinuses. 
 
 J. M — , a^t. 33, fell down some steps on to the back of his head, and sus- 
 tained a slight wound in the occipital region, which was not thought of much 
 importance ; no cerebral symptoms. A few days later, suppuration began 
 beneath the scalp, and several incisions were made ; the local symptoms 
 improved, but some giddiness remained ; the face was flushed and the pulse 
 small ; leeches were on several occasions applied to the back of the neck, 
 and ice-bags were kept continually on the head ; he had no paralysis, but 
 became more and more emaciated. The original wound and the incisions 
 healed up. Tiiirty-three days after the injury he had a rigor, which was 
 repeated during the next few days. Death occurred fortj-one days after the 
 injury. Post mortem : a fissure three inches long was found, extending for- 
 wards from the foramen magnum. Pus in the subcutaneous veins of the
 
 36 CASES OF HEAD INJCKT WITH LATE CEEEBEAL SYMPTOMS. 
 
 scalp and in the right transverse sinus ; the other sinuses were free from 
 thrombus. At the apex of the left anterior lobe of the brain, a cavity the size 
 of a walnut, filled with rust-coloured pulpy matter ; on the under surface of 
 the right hemisphere of the cerebellum, a superficial softened patch the size of 
 a shilling. Some softening on the lower surface of the right posterior cerebral 
 lobe. 
 
 In none of the cases which came under my care in the Zurich 
 Hospital was there discharge of cerehro-spinal fluid from the nose 
 or ears, or hernia cerebri. 
 
 Three cases of head injury with late cerebral symyton^. 
 
 K. R — , set. 32, was so beaten about the head with a hatchet and a knife, 
 that tue scalp was regularly cut to pieces. In many places the periosteum 
 was torn from the bone. No cerebral symptoms after the slight temporary 
 loss of consciousness had passed of. Profuse suppuration followed, but, with 
 the exception of a spot the size of a florin where the left parietal bone was 
 exposed, the scalp united over the skull. The patient had severe fever for 
 sixteen days; the temperature being seldom below 39°. From the sixteenth 
 to the twenty-fifth day some secondary fever. Convalescence was unsatis- 
 factory though no special symptoms could be noticed. The patient continued 
 in an apathetic state. On the twenty-fifth day she became again very feverish 
 with severe headache. This was followed a few days later by partial loss of 
 consciousness, so that she would hardly respond to questions. The faeces and 
 urine passed involuntarily. As the exposed boue was seen at one spot to be 
 infiltrated with pus, I suspected the presence of pus beneath. I therefore 
 removed some bone with the chisel, but finding only fluid blood in the deeper 
 part of the skull, I abstained from opening the cranial cavity. Death took 
 place on the thirty-fifth day after the injury. No symptoms of paralysis 
 throughout. Post mortem : a portion of the upper part of the frontal bone the 
 size of a florin, dull white, partly necrosed. The dura mater on the upper 
 part of the left hemisphere studded with greyish-red granulations, the size of 
 hemp-seeds. The brain — especially the anterior half of the left hemisphere — 
 swollen and fluctuating ; in this hemisphere an abscess, containing several 
 ounces of very foul pus, which had opened into the left ventricle ; the abscess 
 cavity surrounded by a layer of greenish-coloured granulations half a line in- 
 thickness. 
 
 If I had adopted bolder measures in this case, and trephined 
 through the bone, I must have come down on the abscess, the 
 existence of which I suspected. It is doubtful, however, consider- 
 ing the large collection of pus, whether such a proceeding would 
 have saved the patient's life. 
 
 31. D — , fct. 71, fell down stairs while drunk. A large flap of the scalp-
 
 CASE OF OEREBEAL ABSCESS. 37 
 
 over tlie left parietal bone was torn up, together with the periosteum, so that 
 the bone was exposed over an extent the size of the palm of the hand. Con- 
 sidering his advanced age, the patient went on better at first than might have 
 been expected. Two months after the injury a fragment of bone, an inch 
 square, was removed, which included the whole thickness of the skull. The 
 brain pulsations were visible after the removal of the sequestrum. Two weeks 
 after this he was attacked with erysipelas of the head and face, and abscesses 
 formed at several spots. He rallied a little from this attack, but was reduced 
 to a very low condition, and died on the loist day after the injury with sym- 
 ptoms of purulent meningitis. Post mortem : " A number of perforations were 
 found in the parietal bone, some the size of a bean, some of a sixpence; in 
 other parts the outer lamella only was left, rough and of a faint yellow colour. 
 The dura mater thickened, the outer surface of the membrane corresponding 
 to the perforations in the vault, covered with yellow breaking-down granula- 
 tions. Brain anaemic and wet. In the right iliac vein a thrombus, which had 
 caused some oedema of the lower extremity of the same side." 
 
 A. B — , set. 31, a labourer, fell backwards from a waggon. For half an 
 hour he was insensible, then quickly recovered consciousness. A wound an 
 inch long over the left parietal eminence healed up rapidly, with the exception 
 of a small suppurating opening. The patient was about to return to his work 
 when — twelve days after the injury — he was seized with violent headache, and, 
 two days later, when brought back to the hospital he was unconscious. All 
 the symptoms pointed to severe meningitis ; fluctuation was felt beneath the 
 cicatrix. An incision let out some thin pus, and the bone below was found to 
 be exposed. We diagnosed a contusion of the brain, with meningitis and 
 suppuration beneath the site of injury. He was trephined on the fifteenth 
 day. The moment the cranial cavity was opened a stream of pus gushed out. 
 No improvement or consciousness followed, and he died on the following 
 evening— five days after the onset of the acute secondary meningitis. Post 
 mortem: "Purulent infiltration of the diploe in the neighbourhood of the 
 injury ; diffuse purulent meningitis on the left side, with pus in the veins of 
 the dura mater. Convolutions flattened. A large number of abscesses in both, 
 lungs." 
 
 Abscess of the hr am following head injury without fractured sTcull, 
 
 A strong carman, set. 30, was admitted, having been run over three days pre- 
 Tiously, with a wound over the right parietal eminence. The patient picked him- 
 self up immediately after the injury, went home, and applied cold compresses to 
 the wound. On the third day the wound began to suppurate, and he applied 
 to a doctor, who advised him to go to the hospital. On admission we found 
 a semicircular flap, three inches long, torn up from the skull. The bone was 
 exposed, but no fissure could be seen. Six days after the injury slight right 
 facial paralysis appeared, which soon became complete. This was succeeded by 
 stiffness of the muscles at the back of the neck, the head being constantly bent
 
 38 REMARKS ON INJURIES OF THE HEAD. 
 
 over to the right. In the course of the next week the whole body became 
 stiff and hard as a board, so that he could be lifted up as if he were made of 
 wood. He became greatly emaciated. The mind was clear up to his death, 
 which occurred on the twenty-eighth day after the injury. The edges of the 
 wound had l)ecome firmly united, and superficial exfoliation of the exposed 
 bone had takcu place. Throughout there was absence of fever. Post mortem : 
 Notwithstanding the most diligent search, no fissure of the skull could be 
 found ; the dura mater immediately beneath the wound was adherent to the 
 bone, and beneath this an abscess of the brain, one inch in diameter, was 
 found ; nothing else abnormal in the brain or other organs. 
 
 I conclude that in this case the parietal bone had been driven in 
 without fracture, and that a contusion of the brain led to the 
 formation of abscess. 
 
 Head Injuries with severe Brain Symptoms. 
 
 These may be classified as follows, according to their progress 
 and symptoms : 
 
 I. Cases in which brain symptoms occurred simultaneously with 
 the injury. 
 
 Under this head may be noted a case of commotio cerebri which 
 terminated fatally on the fifth day; symptoms of compression 
 appeared on the third. We found diffuse suppurative meningitis 
 without extravasation or fracture of the skull. 
 
 Among the patients with symptoms of compression dating from 
 the time of injury, but who survived, the injury was followed in 
 one case by paralysis of the portio dura, in a second of the oculo- 
 motor nerve ; a third had complete paralysis of the right arm, while 
 in a fourth persistent deafness of both ears resulted. In two of the 
 fatal cases there was crossed hemiplegia. One patient who had 
 sustained a slight depression of the occipital bone, was nearly com- 
 pletely paralysed in both legs for two months. He then began to 
 improve without any special treatment, and subsequently recovered 
 the complete use of the lower limbs. In one instance, as the result 
 of a small circular fracture of the left parietal bone without injury 
 to the dura mater, weakness and numbness of the left forearm and 
 hand followed. The paresis disappeared completely after eight 
 days and the patient got well. 
 
 In two cases of gun-shot wound a revolver bullet passed through
 
 KEMAEKS ON INJURIES OF THE HEAD. 39 
 
 the head from front to back, carrying splinters of bone through the 
 brain; in both, the bullets were afterwards found on the inner sur- 
 face of the occipital bone, against which they had impinged with- 
 out perforating. One of these unfortunate suicides survived the 
 injury twenty-four, the other thirty-eight hours. The other cases 
 terminated fatally, for the most part, about the third/day. Contu- 
 sion of the brain substance and suppurative meningitis were almost 
 invariably found ; in one case only was death brought about by 
 compression from extravasated blood, 
 
 2,. Cases in which the brain symptoms first began some time 
 after the injury, that is to say, from twelve to twenty-four hours up 
 to from three to twenty-eight days. 
 
 All the cases met with at Zurich which came under this head 
 terminated fatally, the greater number from suppurative meningitis 
 following limited depression. Metastatic abscesses in the lungs 
 were found in one case where the brain symptoms began after a 
 rigor occurring on the twelfth day. In another case brain sym- 
 ptoms showed first on the twenty-eighth day. Here there was a 
 depression at the back of the head with the fragments firmly 
 wedged in (the injury had been caused by a falling brick), and 
 some portions of the internal table were necrosed ; this latter was 
 doubtless the cause of the extensive suppurative meningitis which 
 was set up so late. 
 
 General Remarks. 
 
 It is easy enough, in cases of head injury, where the sensorium is 
 unaffected and the general condition normal, to note the commence- 
 ment of congestion or inflammation of the brain. In cases, how- 
 ever, of compression or of severe commotio cerebri (which con- 
 ditions are often not easily to be separated, and which are very 
 frequently combined), dating from the reception of the injury, the 
 onset of meningitis is often very difficult to determine; in such 
 cases inflammatory symptoms are mostly wanting, and the patient 
 not uncommonly passes directly from a semi-conscious, or highly 
 restless condition, into a state of profound coma. Under such 
 circumstances, the rigors, which not infrequently clearly indicate 
 the onset of meningitis, are wanting. According to my experience, 
 dilatation of the pupils and slowing of the pulse first appear, when.
 
 40 REMARKS ON INJURIES OF THE HEAD. 
 
 the patient lies in a condition of heavy drowsiness, and when there 
 is but little hope of recovery. Higli temperatures, together with 
 complete loss of consciousness and slow pulse, may sometimes 
 ■indicate meningitis. When a head injury is followed by increasing 
 symptoms of compression, but without fever, and death takes place 
 after two or three days, probably no meningitis will be found post 
 mortem. In such cases death must be ascribed to compression 
 caused by extravasation and serous effusions. 
 
 Do the cases of acute suppurative meningitis really only die from 
 compression and oedema of the brain, the result of the pressure 
 exercised on the return flow of the venous blood ? This question 
 1 have often put to myself at the autopsies of these cases, particu- 
 larly when the purulent and serous effusions were small in amount, 
 and totally out of proportion to the severe symptoms observed 
 during life. Por my own part, I am convinced that blood- 
 poisoning, which is nearly always associated with traumatic 
 meningitis and manifests itself by high fever, is perhaps quite as 
 often the cause of death as the compression of the brain. I have 
 no doubt in ray own mind that " foudroyante " traumatic perito- 
 nitis, and acute traumatic pleurisy,^ are fatal from the extensive 
 absorption of highly poisonous inflammatory products ; this is 
 easily explained on anatomical grounds, for we know through 
 v. Eecklinghausen that these serous membranes are immensely rich 
 in lymphatics, and that these same lymphatics have openings on their 
 free surface, into which molecular bodies can pass. The researches 
 of this observer have shown further that the membranes of the 
 brain and the brain itself are both richly supplied with lymph 
 channels (perivascular canals). Now, by these — so soon as trau- 
 matic inflammation is set up — the highly poisonous products can be 
 readily taken up, so that anatomical grounds exist for the assertion 
 I have just made. Septicaemia, as we observe it come on in 
 injuries of the extremities, without any head lesion, is often marked 
 in its course by partial loss of consciousness or maniacal delirium, 
 and evidenced by the hot, flushed forehead, a full, hard pulse, in 
 short, by symptoms which in a case of head injury we should refer 
 positively to the participation of the brain, while really such brain 
 symptoms are only the result of blood-poisoning. It is exceediugly 
 difficult to assign in every case the right cause, from sj'mptoms such 
 
 1 i.e. Secondary, pjsemic pleurisy. Ed.
 
 EEMAEKS OX INJURIES OP THE HEAD. 41 
 
 as these. I have met with cases where I was very doubtful whether 
 I had to deal with dehrium arising from drink, or from septicaemia. 
 
 In all the cases of severe injuries of the skull which I examined 
 post mortem at Ziirich_, I found only coagulated blood diffused over 
 the dura mater ; where there was deep circumscribed depression, the 
 dura mater was invariably torn. In most of the cases of fissure 
 and fracture of the skull, contusion of the brain substance existed 
 at the same time, so that I never regretted that I did not trephine. 
 With regard to the removal of splinters of bone, the same rules are 
 to be followed as in compound fractures generally. 
 
 Ecchymosis of the eyelids and bleeding from the ear and nose, 
 combined with a drowsy, heavy condition, are the surest signs of 
 fractured base that I know. Contusion of the brain is so frequently 
 associated with depressed fracture of the skull that the diagnosis 
 of the one condition mostly coincides with that of the other. We 
 are only justified in diagnosing fracture of the petrous bone from 
 paralysis of the facial nerve, when deafness of the affected side is 
 present at the same time. Paralysis of the portio dura, as I have 
 observed, may be manifested when the upper or lower part of the 
 hemispheres is contused. 
 
 I employ ice-bladders to the head in all severe cases of injury to 
 that part. Yensesection I find of service only at the commencement 
 of meningitis. In the later stages of meningitis and encephalitis it 
 appears to me to be injurious and to expedite collapse, as it does 
 also in septicaemia. The same applies to the exhibition of 
 aperients. 
 
 Of fifty-nine cases of severe head injury met with in Yienna, in 
 ■which brain symptoms began at the time of the injury and continued 
 up to death, or lasted for days and weeks after general recovery, 
 twenty-three were discharged from hospital. But some paresis, as 
 I have said, remained in many of these. In one of these cases, 
 epileptiform convulsions came on four years after the injuries, without 
 any intermediate illness, and proved rapidly fatal. Post mortem : 
 superficial softening of the base of the brain was discovered, corre- 
 sponding to the spot where the original extravasation must have 
 been. Looking at this case^ I much regret that I am unable to 
 give any particulars of the subsequent history of the others who 
 recovered ; I greatly fear that the same thing has taken place in 
 other cases also. At present nothing can be positively stated as 
 to how Jong this sword of Damocles — viz. disease of the brain
 
 42 CASES OF OSTITIS AND NECEOSIS OF SKULL. 
 
 occurring long after an injury to the head — hangs over those in 
 whom there has been extensive extravasation and loss of con- 
 sciousness for a considerable period, followed by slow absorption 
 of the effused blood. 
 
 Section B. — Chronic Inflamjiations and Tumouks. 
 
 Cases of: — Chronic ostitis. S^pJiilitic necrosis. Warty hypertrophy 
 of scalp. Congenital cyst. Periosteal fihro-sarcoma. Mela- 
 notic sarcoma. Osteosarcoma. Epithelioma. 
 
 Periostitis of the shdl and caries, possibly of syphilitic origin. 
 
 A weakly -developed girl of i8, bad periostitis and ostitis with ulceration 
 and necrosis of the frontal bone, together with periostitis of the tuber ischii. 
 She was higlily anaemic, marasmic, and the subject of lardaceous disease. 
 Death from acute purulent meningitis. The whole of her family were very 
 subject to bone diseases. Her sister died of caries of the hand and spine. 
 No congenital syphilis could be proved. 
 
 Syphilitic necrosis of the skull. 
 
 A — , set. 44. Syphilitic infection twenty-four years previously. Since then 
 his wife had borne three healthy children, one of whom died of typhus when 
 fifteen years old. The others were still alive when he was under my care. The 
 frontal bone bad been affected with syphilitic disease for nine months. Almost 
 the entire left half of the bone was removed as a sequestrum. The dura mater 
 beneath was covered with granulations, and the pulsations of the brain were 
 very plain. The patient did not wait for the part to cicatrise over, but left 
 with a shield over the gap. Six years afterward he was in good health, and 
 had had no further syphilitic manifestations. 
 
 Warty hypertrophy of the scalp. 
 
 The drawing (PI. \, fig. 1) was taken from a young man, 
 aet. 20, with a warty hypertrophy of the scalp, which had existed 
 from infancy. It was excised with complete success; an elastic
 
 CONGENITAL CYST OF THE HEAD. 
 
 43 
 
 bandage was placed round the head, so that there was scarcely any 
 loss of blood. 
 
 The following case of a congenital cyst at the back of the head 
 with serous contents, its cavity unconnected with that of the interior 
 of the skull, is so rare as to be well worthy of record. 
 
 K,. W — , a female child, 3 days old, was admitted for a congenital tumour 
 at the back of the head. The birth had been accomplislied by natural means. 
 The tumour gave the child a two-headed appearance. (The shape and size of 
 the swelling may be gathered from the illustration Fig. 3). The tumour was 
 
 Fi«3. 3. — Congenital Serous Cyst. 
 
 soft, fluctuating, and moderately full of fluid, so that wc were able easily to 
 satisfy ourselves that there was no ^opening in the skull, and that the tumour
 
 44 PERIOSTEAL SAECOMA OF THE HEAD. 
 
 ■was neither an encephalocele nor meningocele. The right ulna was unnaturally 
 short, so that the hand of that side was strongly adducted. No other deformity 
 was noticeable. As soon as the child had become a little accustomed to resi- 
 dence in hospital, and took its food well, I punctured the cyst and drew off 
 five ounces of clear, light-coloured fluid. 
 
 Prof. Wislicenus, of Ziirich, who examined the fluid, reported its composi- 
 tion to be, briefly as follows : 
 
 Serum albumin . . . 4*29 per cent. 
 
 Myosin and fibrin-forming ingredients . Very small quantities. 
 
 Paralbumin . . . .A trace, 
 
 Mucin . . • .0. 
 
 Urea .... The slightest trace. 
 
 Sugar .... Doubtful. 
 
 Sulphuric, phosphoric, and muriatic acids,") . i-,,. 
 Sodium chloride . . J ' 
 
 This analysis showed that the cyst did not contain cerebro-spinal fluid, 
 ■which has remarkably little albumin. Xo opening could be found in the bone 
 after the puncture. The sac begau to fill again slowly, but diarrhoea came on 
 the day after operation. This was followed by pneumonia, and the child died, 
 a week after the puncture. Post-mortem : the cyst was found to consist of a 
 thin-walled sac with a very smooth lining. It lay in the cellular tissue 
 beneath the scalp, and was easUy removable from the bone. No opening in 
 the skull, or defect where some previously existing communication might have 
 been shut ofl", could be found. 
 
 The following interesting case of periosteal fibro-sarcoma of the 
 back of head, occurred in private practice. 
 
 H — , a merchant, set. 40, of moderately strong build, first noticed, when he 
 was twenty years of age, a hard lump in the occipital region. Its growth was 
 very gradual and painless. The tumour was removed when it had attained the 
 size of a walnut. Ten years after, some thickening appeared about the 
 cicatrix of the operation wound. For a time it remained stationary, then 
 after a few years began again to grow slowly and without pain. It was 
 removed a second time, fifteen years after the first operation. Shortly after 
 the wound had healed some fresh nodules appeared in the cicatrix. These 
 grew rather more rapidly than before, and were not movable on the bone. 
 Eighteen years after the first operation, a growth the size of a florin was 
 removed, and the exposed bone cauterised; superficial exfoliation followed. 
 Two years after this I first saw the patient. The growth had recurred locally, 
 very shortly after the last operation wound had healed. I found all the back 
 of the head, down to the muscles of the neck, covered with hard, painless 
 nodules, varying in size from a bean to a cherry. Some were isolated, some 
 had coalesced. I diagnosed periosteal fibroma with implication of the cervical 
 lymphatic glands. The disease was so extensive that I consented rather 
 reluctantly to operate. On the 6th December, 1861, 1 removed the whole of 
 the diseased parts, including all the occipital scalp, very freely, and scraped 
 away the periosteum with the raspatory. The patient did remarkably well
 
 SAKGOMA OP THE HEAD. 45 
 
 after this. The bone surface granulated without exfoliation. In twelve 
 weeks the wound healed, but then a new growth appeared in the neck and 
 soon after in the cicatrix. In the spring of 1862 the recurrent growth was 
 again operated on, this time by caustic arrow-heads. He grew weaker, and 
 finally died of marasmus, after intense suffering. There was a perforation of 
 the skull the size of a florin. 
 
 The entire duration of the disease from the commencement was 
 twenty-four years. 
 
 Microscopically the tumour was found to be a highly granular 
 fibro-sarcoma.^ 
 
 Melanotic alveolar sarcoma of the head. 
 
 S. S — , aet. 53. When 43 years old a tumour developed in the left parietal 
 region after an attack of erysipelas of the head. Three years later the growth 
 was removed, when it had attained the size of a chestnut. The patient was 
 unable to inform us whether it was then at all black. For four years after this 
 there was no recurrence, but then a nodule developed in the cicatrix, which 
 was removed seven years after the first operation. It was then the size of a 
 hen's egg and superficially ulcerated. It proved to be an alveolar melanotic 
 sarcoma.- He was seen two years after, and was then in good health, free 
 from any recurrence of the growth. 
 
 J. M — , aet. 37. Fifteen years before admission a nodule appeared over the 
 left parietal region, which increased so slowly that after three years it was no 
 larger than a hazel nut ; at the least irritation the growth became iuflamed, so 
 that her medical attendant mistook it for an abscess and made an incision into 
 the swelling. No pus came, but the opening ulcerated, and the growth 
 increased rapidly, and became adherent to the bone. Owing to an attack of 
 erysipelas, operation was postponed. The patient was lost sight of. 
 
 Osteosarcoma. 
 
 M — , ffit. 22, had a tumour the size of an apple behind the left ear, wliicl; 
 could not be moved on the bone beneath. Its connection with the temporal 
 bone was sawn through and the growth removed. The tumour consisted, for 
 the most part, of bone as hard as ivory, interspersed with fibro-sarcomatous 
 tissue. She was seen again three years later, and there was then no recurrence. 
 
 ' I.e. a spindle-celled sarcoma where the fibrous intercellular substance pre- 
 ponderates. Cf. Billroth, ' Surg. Path.' Hackley's Trans., 1877, p. 613. 
 
 ^ Op. sup. cit., p. 616. The absence of recurrence is remarkable. See a 
 case infra, in Chap. X, Section A.
 
 46 EPITHELIOMvV OF SCALP. 
 
 Epithelioma originating in a cicatrix ; removal. Meningitis on the 
 sixth day. Death. 
 
 r. — , set. 33, a maid-servant, when a year old was severely burnt over the 
 left temporal region. The cicatrix, which was about the size of the palm of 
 the hand, did not heal up completely for two years. No bone came avray. 
 Three years and a half before her admission, the cicatrix began to ulcerate 
 without obvious reason, at several isolated spots, and scabs formed. Very 
 soon the ulceration spread over the entire cicatrix, and when the patient was 
 first seen, the whole surface presented the appearance of a superficial epithelioma, 
 which on removal it proved to be. The skull was not implicated. The 
 ulcerated surface was removed, the incisions being carried wide of its limits, 
 and separated from the bones with the raspatory. The surface was covered 
 with dry charpie. After six days, most of the dressing was loosened by the 
 suppuration and was removed with the forceps, fresh charpie being applied. 
 The patient, who up till then had been entirely free from feverish symptoms, 
 had a severe rigor on the following evening. The next day symptoms of 
 meningitis developed ; paralysis of the right half of the body ensued with 
 convulsions. She died sixteen days after the operation. Post mortem : " puru- 
 lent meningitis over the entire left hemisphere ; pus in the veins of the dura 
 mater ; the diploii corresponding to the seat of operation free from pus ; the 
 brain superficially infiltrated with purulent matter. A small abscess in the left 
 lung. No secondary cancerous deposits." 
 
 I have no doubt that in this case the infection was due to the 
 changing of the charpie dressing.
 
 CHAPTEfi VI. 
 
 DISEASES OF THE EAK AND THE FRONTAL SINUS. 
 
 Cases of : — Caries of petrous bone. Epithelioma of inner ear. Of 
 external ear. Congenital atresia. Distension of frontal 
 sinus — Cases. Case of Hematoma of frontal sinus. 
 
 Ear. 
 
 Under this heading may be mentioned the case of a man who was admitted 
 with purulent discharge from the ear, caries of the right mastoid process 
 with abscess, and great pain. Some days after admission be had an apoplecti- 
 form attack. I enlarged the fistulous opening in the mastoid process with 
 the chisel, but let out no pus. Extending my opening down to the dura 
 mater subsequently, I thrust a very small, slender knife into the brain, in the 
 hope of evacuating the contents of an abscess of the brain ; no pus came. The 
 symptoms remained unaltered, and the patient died shortly after. Caries of 
 the petrous bone with purulent meningitis of moderate extent, and thrombosis 
 of the right transverse sinus were found post mortem. 
 
 The following case of epithelioma of the inner ear I saw as a 
 private patient, in consultation with Dr. Brunner of Zurich. 
 
 Frau M — , set. 56, first consulted me in April, 1867. Her prevfous health 
 had been good. For two years she had been troubled with frequent itching 
 and tickling sensations in the right ear, and had been in the habit of constantly 
 scratching the irritating surface in the auditory canal with the end of a hair 
 pin. In the spring of 1866 there was some thin puriform discharge from the 
 ear, with swelling of the walls of the canal, and impairment of hearing. For 
 a time she employed hot water douches to the ear at a bathing establishment. 
 The result of this was that she caught a violent cold, and came back to 
 Ziirich with further impairment of hearing, and pain in the ear. At the 
 beginning of 1867 she noticed that her face was drawn to the left, and she 
 therefore consulted a medical man, who found her suffering from right facial 
 paralysis and purulent otorrhcea. He removed a granulating mass from the 
 deep part of the ear with a vulsellum. The bleeding, which was considerable, 
 was arrested by a plug of charpie, soaked in Liq. Ferri Sesquichlor. Intense 
 pain and severe inflammation followed this proceeding, but yielded, after a few
 
 48 EPITHELIOMA OF THE EAE. 
 
 days, to leeching, &e. She then consulted Dr. Brunner, who found her in the 
 condition described, and removed a polypus-like mass of granulations which 
 blocked up the external auditory passage. Examined microscopically, the 
 growth was found to be undoubted epithelioma. When I first saw the 
 patient the appearance was so exactly like that of caries of the internal ear 
 that I could not be convinced till I had myself examined the growth, a portion 
 of which was again removed. I could only confirm my colleague's dictum 
 after examination. The growth was a perfect specimen of epithelioma. 
 We came then to the conclusion that in all probability the growth had 
 extended through the petrous bone and given rise to the facial paralysis. 
 Keither the cervical nor the submaxillary glands were enlarged. Interference 
 under the circumstances would obviously have been futile. As the disease 
 extended, the parts about the tragus and the mastoid process became involved. 
 The growth never protruded beyond the external auditory meatus. The pain 
 increased so much that constant hypodermic injections of morphia were neces- 
 sary, and she died of exhaustion a year after the commencement of the disease. 
 Unfortunately no post mortem was permitted. 
 
 epithelioma of the ear. 
 
 A. S — , set. 50, male. Two years before admission some warty prominences 
 formed on the left concha ; these grew rapidly, and for three quarters of a 
 year had been ulcerated. When first seen the entire ear was converted into a 
 cancerous mass. The neighbouring lymphatic glands were not affected. The 
 ear was removed, but the patient died of multiple pyaemia nine days after the 
 operation. 
 
 A. B — , set. 58. Ten years previously a small nodule had made its appear- 
 ance on the left concha, which in the course of three years only attained the 
 dimensions of a pea. The patient then received a blow on the tumour, which 
 caused the growth to become very painful, and to ulcerate. When seen the 
 cancer was the size of a bean, at the upper part of the coucha. It was excised, 
 and there was no recurrence eleven months later. 
 
 In the case of a child, set. 3I years, with congenital atresia and 
 imperfect development of both ears, I endeavoured to make an 
 auditory canal, but the attempt failed ; the wounds healed without 
 any trouble and the condition remained unaltered. 
 
 Miscellaneous. 
 
 Disiension of the frontal sinus. 
 
 -^l — J get. 49, very subject to obstinate colds. Three years before admission 
 he had suffered from attacks of severe pain over the right side of the forehead, 
 which lasted, as a rule, from about ten in the morning until the evening. A year
 
 DISTENSION OF THE FRONTAL SINUS. 49 
 
 previously be had observed swelling over the right inner canthus, followed a 
 iew months later by considerable discharge of pus through the right nostril. 
 Tliis lasted for a time, and then the swelling was opened from the outside by 
 V. Arlt, a quantity of pus being let out. A fistula was left, which was usually 
 kept closed by a plug of charpie. On the removal of this, free discharge 
 always followed. I cut away the anterior wall of the distended sinus, united 
 the scalp wound over it, and left in a small drainage tube. The pain and 
 swelling completely disappeared after this proceeding, but five years and a half 
 later there was still some discharge through the fistula. 
 
 M. A — , a weekly child, set. ii, was brought to me with distension of the 
 right frontal sinus, and some exophthalmus, which had existed for six. months. 
 On making an opening the sinus was found to be filled with exuberant granu- 
 lations. These I removed with a raspatory. He recovered slowly, and after 
 some months the fistula closed. Five years later I heard that the sinus had 
 not reopened, but the exophthalmus was unaltered. 
 
 In the case of M — , set. 38, distension of the left frontal sinus, accompanied 
 by severe headache, had commenced sixteen mouths previously, without known 
 cause. Some weeks after its formation the swelling broke under the left 
 supraorbital notch, and pus was discharged. The resulting fistula closed at 
 times, but then swelling and pain came on, which were relieved when the dis- 
 charge again took place. With the probe I detected a sequestrum lying loose 
 in the cavity ; I dilated the fistula and extracted the loose piece. The suppu- 
 ration then decreased considerably, but a fortnight later the fistula had not 
 ■closed. She then left, and further particulars of the case are wanting. 
 
 A male, set. 56, had received, three months previously, a wound at the root of 
 the nose, from a bull's horn. The wound was sewn up and soon healed, but a 
 knob of granulations formed at the right inner canthus, which became moist 
 and prominent from time to time. After removal of the little outgrowth, we 
 found an opening leading into the right frontal cavity. Tlie fistula was 
 dilated, and a small drainage tube inserted. Although the tube was worn for 
 a long time, and only finally taken out when the secretion had ceased, the 
 fistula was still discharging, about eighteen months after. 
 
 A male, set. 78, had been troubled for six months with a swelling at the inner 
 part of the upper right lid, which at first was hard and painful. After a short 
 time it broke spontaneously, and discharged pus. As the purulent discharge from 
 the fistula persisted, I cut away the anterior wall of the right frontal sinus, 
 and stuffed the cavity with charpie, soaked in acetate of alum. The discharge, 
 thereupon, gradually ceased, and the fistula completely closed up after some 
 months. Two years after he was well and free from pain. 
 
 Hcematoma of the frontal sinus. 
 
 K. S — , at. 7, was operated on December, 1870. Healing followed after 
 excision of the anterior wall. The eye was lost. 
 
 4
 
 CHAPTER VII. 
 
 INJURIES AKD DISEASES OF THE PACE, MOUTH, AND NASAL 
 
 CAVITIES. 
 
 Section A. — Miscellaneous. 
 
 Case of luxation of the eyeball. Cases — epistaxis, malignant car- 
 buncle. Remarks on periostitis of jaw. Case of suppuration 
 of antrum. Lupus — recurring after rhinoplastic operation. 
 Chronic infiltration of cheek — Case treated by arsenic. Case of 
 hypertrophy of tongue and cavernous lymphectasis. Case of 
 spontaneous gangrene. Case of atresia of nasal cavities. Hy- 
 pertrophy of nose. Remarhs on removal of tonsils. Two cases 
 of syphiloma. Cases of tubercular disease of tongue. Case of 
 paresis after ligature of the carotid. Case of parasitic sycosis. 
 
 Luxation of the eyeball. 
 
 E. M — , aet. 23, was struck in the eye by a stick during a drunken brawl, 
 and thrown backwards against a tree, whereby he suffered an abrasion and a 
 contusion over the left temporal region. The patient slept off the effect of 
 bis debauch, and came up on the following day to the hospital. We then 
 found that the left eyeball protruded to such an extent that it was entirely 
 uncovered by the eyelid. Both eyelids were curled up inwardly, and lay 
 behind the eyeball, which projected and was twisted downwards to some 
 extent. Much blood was extravasated beneath the conjunctiva. A trace of 
 movement in a vertical direction remained. All lateral movement was lost; 
 vision was completely destroyed. No examination was made with the ophthal- 
 moscope, or, at any rate, none is recorded. The condition clearly answered to 
 that which has been termed luxatio bulbi. An attempt to replace the eyeball 
 into the orbit failed, for the outer and inner commissures were torn. Sup- 
 puration and shrinking of the eye followed, in consequence of which it was 
 slowly retracted into the orbital cavity. 
 
 Severe epistaxis was seen in a' man sixty-two years old, coming on after 
 violent sneezing, and proceeding to faintness and loss of pulse. No disease of 
 the bone could be made out. The posterior nares were plugged by means
 
 PEEIOSTITIS OF JAW SUPPURATION OF ANTRUM. 51 
 
 of Bellocq's tube. No return of the haemorrhage after removal of the plugs- 
 five days later. 
 
 A case of malignant carbuncular infiltration of the nose and forehead, was- 
 met with in a young man, who had probably had typhus recently. He had 
 severe cerebral symptoms. The disease terminated fatally on the sixteenth day 
 after the redness and pain was first observed. Three weeks before this 
 disease was noticed he had been laid up with much abdominal pain. Post 
 mortem : we found purulent meningitis on the under surface of the anterior 
 lobe of the brain, superficial softening of the grey matter, and metastatic 
 abscesses in the lungs. Some cicatrising ulcers were found in the intestine, 
 close above the ilio-caecal valve. 
 
 Feriosiitis. 
 
 Twenty-three cases of subacute periostisis were under observa- 
 tion, all of which originated from carious teeth ; most of these led 
 to the formation of large abscesses which, in spite of incisions made 
 internally, frequently broke also externally. None of these were 
 followed by necrosis. The bone is seldom found exposed after 
 such abscesses have been opened. I think that they originate in 
 most cases in the loose cellular tissue of the outer layer of the 
 periosteum,^ starting from the local infection caused by the carious 
 teeth ; the ichorous discharge extends outwards from the sockets of 
 the teeth, first in the alveoli, then through the bone (by means of 
 the lymphatics ?) to the periosteum of the jaw ; here then inflam- 
 mation is set up ; the extensive oedema and the pain, the latter being 
 frequently severe, give rise to much distress. 
 
 8ibppuration in the antrum. 
 
 In a man set. 40. The purulent discharge had existed for three years. The 
 antrum was freely laid open through the alveolar process, and a piece of 
 larainaria was discovered in its cavity. Repeated attempts had been made a 
 year before to dilate the sinus with laminaria tents; no doubt the frag- 
 ment was broken off at the time, and remained unnoticed ever since. A 
 drainage-tube was kept for a long time in the opening. In spite of careful 
 washing out of the cavity the suppuration, two years later, had not completely 
 ceased, although no sequestrum or caries could be discovered in the antrum ; 
 the swelling and pain, however, subsided. 
 
 The other case was that of a man set. 30, who for some months, had had dull 
 pain in the right upper jaw. Eight months previously pus came through an 
 opening which formed in the canine fossa. ' The opening into the antrum 
 
 ^ See Appendix II, infra.
 
 52 LUPUS — CHRONIC INFILTRATION OF CHEEK. 
 
 •was enlarged and a drainage tube inserted. The pain and swelling had com- 
 pletely disappeared when he was discharged and the suppuration was very 
 slight in amount. 
 
 Lttpus, 
 
 While at ZLirich I met with fifteen cases, all females — one a child. 
 My usual treatment for this affection consists in destroying the 
 diseased surface with caustic potash^ taking care that the action 
 extends well into the sound tissues. In one instance I removed 
 with the knife a tubercular, hypertrophic lupoid growth from the 
 corner of the mouth of a woman aged 45. Although the whole of 
 the diseased tissue was removed, it recurred locally a few months 
 after. I then destroyed it with caustic. The patient died six 
 months after of tuberculosis. 
 
 Lupus recurring in a newly-formed nose. 
 
 C. J — , set. 45, had suffered from lupus of the nose from her youth, which 
 had completely destroyed the organ. Fourteen years previously a complete 
 rhinoplastic operation had been performed from the forehead, with a very good 
 result as far as the appearance was concerned. When admitted there were 
 numerous scattered nodules about the nose and in the neighbourhood of the 
 check. The patient was transferred to Professor Hebra's wards. 
 
 Cases of chronic infiltration of the cheek with granulation 
 material (granulations infiltration) were not uncommon at Zurich. 
 They occurred chiefly in children, and were characterised chiefly by 
 the breaking down and suppuration of the central parts, leading to 
 the formation of an ulcerous cavity. By clearing off the skin, 
 scraping away the spongy granulations, and applying caustic potash, 
 rapid healing was induced and good cicatrices were left. A few 
 years ago an enthusiast on the subject of tumours described these 
 infiltrations as a new kind of myxoma. 
 
 Tlie following case is worthy of record as an illustration of the 
 remakable effect of arsenic. The etiology of the disease could not 
 be positively made out. 
 
 E. B — , at. 37. Her father was confiued in a lunatic asylum; her mother 
 died in the hospital of some disease of the stomach. She herself had enjoyed 
 good health up to the ^e of 21. The catamenia then came for the first time, 
 but did not occur subsequently. She was subject to frequent acute abdominal
 
 HYPERTROPHY OF FACE AND CAVERNOUS LYMPHECTASI-S. 53 
 
 paia. Pour years before her admission^ from no assignable cause, an abscess, 
 the size of an egg, formed over the left side of the vault of the skull and opened 
 spontaneously a year after its first appearance ; a large quantity of thick pus 
 was discharged and the abscess then rapidly healed. During the following 
 years similar swellings appeared, at one time in the right, at another in the left 
 infraorbital region, then deep in the neck ; none of these went on to the 
 formation of abscesses ; they came and went slowly, and without pain. For 
 four months there had been swelling and redness of the nose ; for three weeks 
 the nose had been stopped up and had discharged a good deal of thin pus. She 
 denied any syphilitic taint, and there were no appearances of this disease. 
 
 The patient was of weak frame, pale, indolent, and of dull intellect. The 
 nose was red and swollen ; on the right side of the cheek, close to the nose, was 
 seen a circular ulcer, the size of a shilling, with sharp edges, covered with 
 breaking down diphtheritic granulations, on which was some serous secretion. 
 The mucous membrane of the nose was swollen. 
 
 Prompted by the appearance of the ulcer and the recollection of other cases, 
 we tried antisyphilitic treatment (Decoct. Zittmanni) for a time. Then as the 
 ulceration spread caustics were employed and iodide given internally. This 
 treatment was continued for nearly five months ; meanwhile the disease extended. 
 As a purely empirical experiment, I now gave ten drops of Tr. Eowleri thrice 
 daily. Improvement at once commenced and the parts began to cicatrise. She 
 left in six weclis' time with the ulceration healed, though, it is true, with con- 
 siderable deforn)ity of the nose. 
 
 To my mind the marvellous improvement that followed the exhi- 
 bition of the arsenic was a lamentable defeat for rational thera- 
 peutics. Was the morbid process of a syphilitic, a scrofulous, or a 
 lupous nature ? "Who could decide ? The disease was the result 
 of a dyscrasia, which was destroyed by the arsenic. As a matter of 
 fact, we can as yet offer no explanation for the frequently remark- 
 able effects of arsenic in chronic affections of the skin. 
 
 Unilateral congenital hypertroplty of the mucous m,emhrane of the 
 cheek and the upper surface of the tongue, combined with caver- 
 nous lymiihectasis. 
 
 B. H — , a;t. lo, was born with the following deformity which had not 
 materially altered since his birth. Tiie right cheek was considerably thicker 
 than the left, the thickening being chiefly limited to the mucous membrane and 
 the submucous tissue. The right half of the tongue was covered with papilla;, 
 from one to two lines in height, arranged in groups and covered by a thick 
 layer of epithelium. All these parts had increased proportionately with the 
 growth of the body, but without having any special growth in themselves. 
 From time to time the cheek and tongue swelled, and occasioned difficulty in 
 swallowing. These attacks usually lasted two or three days, and then gradually
 
 54 GANGEENE FROM ANEMIA ATEESIA NASI. 
 
 disappeared. The last attack was of so severe a nature and was associated 
 with so muck difficulty of breathing that the parents sought for advice. I 
 diagnosed hypertrophy of the cellular tissue and fat, united with cavernous 
 lymphectasis. My experience of these kinds of congenital tumours led me to 
 conclude, from the periodical sweDing, that the latter condition existed. All 
 material symptoms indicative of a cavernous blood tumour were wanting. I 
 employed punctiform cauterisation with the gal vano- cautery, and took the 
 opportunity to destroy the papillary formations of the tongue at the same time ; 
 similar applications were made at intervals of from two to three weeks, and by 
 this means the whole tumour of the cheek was diminished in size, and the 
 growth on the tongue destroyed. The reaction following the first cauterisation 
 was slight in character. After the third operation, where the cautery was 
 applied rather more energetically, great swelling of the cheek and parotid 
 gland ensued. The parotitis was tolerably severe, lasting about three weeks, 
 and finally ended in resolution under treatment with iodide ; meanwhile the 
 tumour of the cheek had become somewhat smaller. Later reports stated that 
 his condition some time after he had left the hospital, remained the same. He 
 was free from the painful swelling which formerly occurred. Five years later 
 he came back, in order to have the rest of the excrescence removed ; excepting 
 a slight thickening of the cheek his condition was perfectly normal. 
 
 Gangrene of the nose. 
 
 In the winter of 1862 a young man was admitted into the hospital for 
 gangrene of the end of the nose, said to have been caused hj frost-bite. 
 After a time spontaneous gangrene of the feet set in ; the cause could not be 
 completely made out. 
 
 I think that these cases of spontaneous gangrene can only be 
 explained by great anaemia and feebleness of the heart. Further 
 remarks on this subject will be found in the chapter on " Diseases 
 and Injuries of the Lower Extremity." 
 
 Atresia of both nasal cavities. 
 
 This condition was seen in a girl, 3 years old, the result of cicatricial con- 
 traction after variola. The cicatrices were cut out and the openings dilated 
 by laminaria tents. India-rubber tubes were passed in, and ultimately the 
 normal width of the nasal cavities was completely restored. I do not know 
 whether recovery was permanent ; I rather fear that it was not, for the mother, 
 who was a poor woman, probably had no time to attend to the directions 
 which were given to her, of keeping the parts clean and introducing the tubes 
 every day, for some months.
 
 EEMOVAL OF HTPERTROPHIED TONSILS. 55 
 
 Hypertrophy of the Nose. 
 
 The drawing (Plate I, fig. 4«) was taken from a highly intempe- 
 rate man, aged 54, who for fifteen years had suffered from gradu- 
 ally increasing redness and swelling of the nose. Fig. \h shows 
 the same patient after operation, which was not followed by ery- 
 sipelas ; the cartilages were carefully preserved. The growth con- 
 sisted of soft, elastic integument, with numerous dilated sebaceous 
 follicles. 
 
 Plate I, fig. 3, illustrates the same condition ; the patient would 
 not submit to any operation. 
 
 Eemoval of Hypertrophied Tonsils. 
 
 I always remove tonsils with a sharp double hook and a straight 
 or curved probe-pointed knife, as I vt^as taught by von Langenbeck. 
 In one case very formidable haemorrhage occurred during this ope- 
 ration, which I have performed I know not how often. On re- 
 moving the left tonsil in a young hysterical lady, an immense gush 
 of blood occurred and partly descended into the larynx. I 
 attempted in vain to introduce my finger into the mouth so as to 
 exert pressure on the bleeding spot ; the patient would not allow 
 this proceeding. I instantly, therefore, made pressure on the 
 carotid artery and kept it up for some time, while the patient 
 retched fearfully. After a while the bleeding stopped ; the scene 
 was, however, so unpleasant for the patient, as well as for myself, 
 that I should wish to preserve everybody from a similar mishap. 
 Being desirous of removing the tonsil thoroughly, I had drawn it 
 rather too far forward, and had in this way drawn out also and cut 
 off a fold of mucous membrane from the side and back of the 
 pharynx. The blood appeared to come from this wound, evidently 
 from some large branch of the pharyngeal artery. Care should, 
 therefore, be taken to avoid drawing forward the tonsils too much. 
 
 Two very ciiriotis cases of syphiloma. 
 
 A. B — , set. 9, had suffered, according to his own account, for two months 
 from a flat, firm infiltration of the left upper eyelid. The skin covering it was
 
 56 SYPHILOMA — TUBERCULAR ULCERATION OF TONGUE. 
 
 of a reddish-blue colour ; a lymphatic gland, the size of a hazel-nut, could b& 
 felt iu front of the left ear. Over the whole body, was seen a distinct, well- 
 marked roseola ; no fever. The infiltration in the eyelid was considered by 
 some of my colleagues to be cancerous. 1 did not share this opinion, but at 
 first could not form any diagnosis. From the skin disease, and later on from 
 other conditions which assisted our diagnosis, we concluded that the swelling 
 of the eyelid was of syphilitic origin, although no syphilitic infection could be 
 proved. In the sequel, the case became very complicated. At the outset, 
 iodide of potassium was given internally. In three weeks the infiltration of 
 the eyelid had nearly disappeared. A few days later, the child was attacked 
 with severe symptoms of meningitis, with vomitings, cramps, and finally com- 
 plete coma. The case seemed desperate ; ice was applied, and large doses of 
 calomel given. About the fifth day of the disease consciousness returned, and 
 gradual recovery ensued. When the patient was discharged, a fortnight later, 
 at the wish of his parents, the exanthem had disappeared, and only a slight 
 swelling of the eyelid was perceptible. I am unable to say whether further 
 symptoms of syphilis followed later on. 
 
 S, C — , aet. 26, was received as an out-patient with a tumour, con- 
 nected to the septum narium. The growth was of soft, elastic consistence, 
 almost fluctuating, and had the circumfereuce of a small walnut. Under the 
 impression that it might be a cyst, I punctured it with a flue knife, but only 
 blood was let out. I concluded then that it was a sarcoma, and the patient 
 was admitted for operation. On further examination an extensive brownish 
 exanthem was found over the whole body, and enlargement of the cervical 
 glands. In answer to inquiries, he stated that some years previously he had 
 had a chancre. Antisyphilitic remedies were now employed, since it seemed 
 in the highest degree probable that the tumour on the nose might be a 
 syphiloma. The patient, however, was attacked with erysipelas starting from 
 the little puncture on the nose, and died of pyaemia. Post mortem : the. 
 tumour of the nose was scarcely perceptible, as it had disappeared during the 
 erysipelas. Nothing further was found to clear up the diagnosis. 
 
 Tubercular nodules and ulceration of the tongue. 
 Both the following cases presented great difficulties in diagnosis. 
 
 J. M — , 8et. 53, had suffered for six months from dry cough and nocturnal 
 sweats, with occasional slight hsemoptysis. Six weeks previous to admission 
 he had noticed, in the middle line of the upper surface of the tongue, a nodule, 
 the size of a pea. This sometimes was very painful, and had gradually in- 
 creased up to admission. It was then the size of a hazel nut and the mucous 
 membrane covering it was fissured. 
 
 The majority of those who saw the case considered it to be a syphiloma. The 
 administration of iodide of potassium in moderate doses for three weeks had 
 absolutely no effect on the growth. I then concluded it might be a carcinoma, 
 and removed it. The wound healed rapidly, but the patient died three weeks
 
 PARESIS AFTER LIGATURE 01*^ TlIK (JAROTID ARTERY. 57 
 
 later ol' iuberculosis of the lungs and intestines. The base of the ulcer of the 
 tongue proved to be a fatty small-celled infiltration between the bundles of 
 muscle, around which lay a ring of breaking down miliary tubercle. 
 
 P. A — , set. 38, a strong, well-built man, was admitted with a history of 
 numerous attacks of hsemoptysis two years previously, followed, by severe 
 bronchial catarrh lasting nearly nine months. He had been relieved by long- 
 continued " curd treatment." The appearance, the formation of the thorax, 
 and the well-nourished condition of the man, were such that his statements 
 seemed scarcely credible. Nothing abnormal could be found after careful 
 percussion and auscultation of the thorax. Five months previously he had 
 first remarked a small fissure on the upper surface of the tongue, which gradually 
 increased, and on admission was nearly three quarters of an inch long and about 
 a line and a half in depth. The patient denied any syphilitic infection. The 
 fissure-like ulcer had nearly healed after repeated energetic cauterisation with 
 argent, nit., when the patient left for private reasons. Subsequently the 
 small ulcer completely closed up, leaving only a slight trace. For a time 
 it remained unaltered, but six months later, it again began to increase and 
 became wider, more rounded, and extended in all directions. On the second 
 admission of the patient, the anterior and right half of the tongue were 
 occupied by an ulcer witli hard sinuous edges and irregular base. The 
 appearance of the ulcer led me to suspect that it was most probably syphilitic, 
 and accordingly iodide of potassium was given. The use of this remedy for 
 two weeks exercised no effect on the ulcer. Microscopical examination of a 
 piece cut away from the edge proved decidedly that it was not cancer. The 
 application of caustic potash on two occasions had a better effect, and bi'ought 
 about partial healing, but soon afterwards the ulceration resumed its former 
 aspect. He suffered now from nocturnal fever and bronchial catarrh. The 
 patient left unimproved, became terribly emaciated, and died a few months 
 later of tuberculosis of the lunss. 
 
 Paresis after ligature of the common carotid arterij. 
 
 M. M — , ffit. 24, was brought to the hospital, when 17 years of age, for 
 a naso-pharyngeal polypus. This was removed with the galvanic wire loop. 
 Two years later it returned. The tumour, which was situated also in the ptery- 
 goid fossa, was then again removed with the knife. Ten days after the operation 
 severe haemorrhage occurred, probably from the internal maxillary artery. Tor 
 this the left common carotid was ligatured. Almost immediately after the 
 operation the patient had pain about the forehead, and dilatation of both 
 pupils, principally of the left, with partial loss of power in the right hand. A 
 few hours after the operation speech was lost. On the second day right 
 paraplegia was noticed ; bed-sores followed in several parts. Five weeks later 
 the condition was as follows : — On tlie riglit side paralysis of motion, sensation 
 normal ; no facial paralysis ; the pupils contracted slowly to light ; the tongue 
 could be well protruded ; speech imperfect, and articulation defective. Urins 
 and faeces passed involuntarily.
 
 58 NEUEALGIA OF INFRAORBITAL NERVE. 
 
 Fourteen months later, he came back ; he could then -walk, but with a 
 dragfjing gait ; the sphincters were now under control, and the paralysis of 
 the upper extremity was improved ; in other parts it was unaltered. 
 
 Six years after the ligature of the artery I saw him again. There was then a 
 good deal of wasting of the right side, especially of the arm ; he could not 
 prouate nor supinate the hand, and the fingers were flexed ; the sensation of 
 the skin and muscles was greater on the affected than on the sound side, and 
 the reaction to an electro-motor stimulus was also greater on this side. 
 Paradisation was employed to the arm, and a constant current along the 
 course of the left sympathetic in the neck. Distinct, though sliglit improve- 
 ment, followed this treatment.^ 
 
 Parasitic sycosis of the chin. 
 
 This disease was met with in the person of a small house proprietor in a 
 Hungarian village, who tended his cows himself. The disease was new to me. 
 There was an ulcer, the size of a florin, somewhat resembling epithelioma, but 
 with soft edges ; pus, not unlike the matter in comedones, could be pressed 
 out, especially from the root sheaths of the hairs of the beard, over the 
 diseased parts. The hairs came out very easily ; on their sheaths were many 
 fungi, somewhat larger than the spores of herpes tonsurans. Recovery soon 
 followed on the removal of the hairs and the application of a mixture of 
 sulphur and glycerine. 
 
 Section B. — Neurotomy and Neurectomy. 
 
 Case of neuralgia of the infra-orbital nerve ; neurotomy. Case 
 of neuralgia of the fifth nerve, treated hy repeated operations ; 
 death. Cases of neuralgia of the fifth nerve, treated by 
 neurectomy and neurotomy. Case of neuralgia of third division 
 of fifth nerve ; hmnorrhage after operations ; ligature of 
 carotid ; optic-nerve atrophy. Remarks on neuralgia of the 
 fifth nerve. Etiology. Treatment. Neurotomy. Neurectomy. 
 
 Herr B — , set. 46, had for twelve years suffered from neuralgia of the right 
 infraorbital nerve ; the attacks of pain, which were accurately limited to the 
 distribution of this nerve, were excited by touching the cheek with the tongue 
 by^eating, plucking the beard, &c. Owing to the complaint the patient was 
 only able with great difficulty to gain his livelihood as a clerk and writing 
 master. No cause could be assigned for the affection ; in other respects he 
 was^perfectly well. The teeth were unusually perfect and good. He had 
 
 ' The case will be found fully recorded in Prof. Schuh's collected works, 
 p. 906. In the ' Archiv fiir klin. Chir.,' Bd. xiii, p. 379, is recorded an interest- 
 ing case of epileptic attacks following injury of the right sciatic nerve.
 
 EEMARKABLE CASE OF NEURALGIA OF FIFTH NERVE. 59 
 
 consulted numerous medical men, and the bundles of prescriptions exhibited 
 were evidence that all the usual remedies had been tried. In July, 1863, T 
 divided, subcutaneously, the infraorbital nerve at its exit from the canal at 
 several points (Zerschneiduug). From this time forth he was free from his 
 attacks, his cheerfulness returned, and he was able to resume his avocations. 
 This lasted for a year and a half. Then, slight momentary darting pain in the 
 nose began ; these slight paroxysms were accompanied from time to time by 
 swelling of the mucous membrane of the right side, but without causing much 
 discomfort. 
 
 In February, 1866, my patient came back, stating that his com- 
 plaint was more an inconvenience than a disease, but he desired 
 that the section should be again performed that he might be rid of 
 the trifling attacks. In February, 1867, I divided the nasal 
 branch of the infraorbital subcutaneously. When I saw him 
 again in July, 1867, he was, and had been, completely free from 
 the attacks. Any one who had seen this man then, and also 
 at the first, would have called the result a brilliant one, even if the 
 neuralgia were subsequently to return. 
 
 From a surgical point of view the following case of neuralgia is 
 probably unique : 
 
 Herr E — , set. 60, was admitted in March, 1864. Considering his age, 
 he was robust, muscular, and energetic, and had previously enjoyed good 
 health. Two years previously he had first experienced pains of a sharp 
 nature in the left cheek and the teeth. These occurred at such long intervals 
 that they were thought to be rheumatic. This view was further strengthened, 
 as each attack was accompanied by flushing of the face, especially on the left 
 side ; this likewise was thought to be due to his having caught cold. Soon, 
 however, the attacks became more frequent, first every week, then every second 
 day, finally daily ; for four mouths the paroxysms came on several times daily, 
 being excited often by speaking, masticating, stroking the beard, or pressure 
 on the part. The spasms of pain never occurred unless the patient excited 
 them by some movement or touch. So long as he had sufficient control over 
 himself to be perfectly still in bed, he was able to sleep soundly through the 
 night ; the spasms never occurred during sleep. When admitted he was unable 
 to eat or drink without bringing on an attack. The pain during the spasms 
 extended over the left cheek and upper lip, the upper jaw and the teeth, and 
 varied in intensity and duration. He distinguished slight and severe attacks. 
 
 When the disease began he had some diseased molar teeth in the left 
 superior maxilla. Thinking that the pain might originate from these teeth, he 
 had them extracted on different occasions, as well as some other teeth on the 
 left side. However, the removal of the teeth did not improve matters. All 
 kinds of remedies, internal and external, such as quinine, steel, arsenic, iodides, 
 veratrum, &c., were tried without success. Subcutaneous injections of 
 morphia alone gave benefit ; gradually the amount of morphia thus administered
 
 60 NEURALGIA OF TIFTH NEEVE — REPEATED OPEKATIONS. 
 
 had to be increased, until not less that two scruj)les daily were necessary to 
 keep him free from pain. As a result, he had repeatedly symptoms of morphia- 
 intoxication such as Nussbaum has described, and which that authority 
 attributes to the direct passage of the morphia into the blood. 
 
 The patient earnestly begged for an operation. On the advice of Professor 
 Griesinger, however, we first tried local bloodletting, which had not previously 
 been employed ; four leeches were applied. Not the slightest improvement 
 followed; on the contrary, the parts in the neighbourhood of the leech- bites 
 became inflamed, and more morphia than ever had to be administered. No 
 particularly painful spots could be discovered, except that in certain points in 
 the toothless left upper jaw pressure caused rather more pain than elsewhere. 
 Pressure, however, did not produce an attack. Under the circumstances 1 
 should have preferred subcutaneous section of the infraorbital nerve at 
 its exit from the jaw; the patient, however, so urgently entreated that 
 the most radical operation possible might be performed, that I extirpated 
 the portion of nerve lying in the infraorbital canal, in the usual way. The 
 portion removed measured three quarters of an inch ; neither with the naked 
 eye nor with the microscope could anything morbid be discovered in it. Por 
 a few days only after this operation did the patient remain free from pain ; the 
 old troubles then recommenced, though it is true that they were less frequent 
 and less severe. Touching, or stretching of the angle of the mouth, touching 
 or pressure on the ramus of the upper jaw now excited the spasmodic attacks ; 
 the drairging pains extended backwards to the palate, thence into the 
 pterygo-palatine fossa and the temporal region ; curiously enough, the distri- 
 bution of the infraorbital nerve remained free from pain. The attacks shortly 
 became more severe, and it was found necessary to revert to the anodyne 
 injections ; these had a magical effect, but had to be repeated often during the 
 day. 
 
 Further minute examination convinced me (i) that the affection was only 
 in the course of the second division of the fifth nerve ; and (2) that the 
 pain was always reflex and originated in peripheral excitation. The remark- 
 ably prompt effect of the local narcotic injections on the peripheral branches 
 seemed to me to confirm the hypothesis of some peripheral affection. With 
 this idea, I conceived that I might benefit the patient by severing the 
 second division of the fifth nerve at the foramen rotundum, and dissecting 
 away such adjoining branches as could be reached. Such a proceeding 
 appeared to me possible enough with the aid of v. Langenbeck's osteoplastic 
 resection of the superior maxilla. At the time I thought that I was the 
 first to develop this bold idea in a methodical manner, but found that 
 Caruoclian and Nussbaum had already performed such operations with 
 fcuccess. 
 
 Following Professor Grlesinger's advice, however, I removed (on the 
 12th May, 1864) with bone forceps and gouge, the alveolar portion of the 
 upper jaw which was painful on pressure. I could not well anaesthetise the 
 patient, as it was necessary for me to know what portions of the jaw were 
 painful. In two places I came upon uiiobiiterated alveoli filled up with 
 granulation tissue, the touching of which straightway occasioned the paroxysms 
 of pain; these granulations and the parts in their neighbourhood were
 
 NBCJEALGIA OP FIFTH NEEVE REPEATED OPERATIONS. Gl 
 
 removed. The patient bore this terribly severe procedure with firmness, but he 
 vras rewarded, for after this operation the attacks ceased. He was restored, 
 as it were, to a new life, left on the 27th of May, and resumed his work as a 
 ranger. 
 
 Por three quarters of a year (up to February, 1865) he continued perfectly 
 well ; then, though at long intervals, slight symptoms began, recalling the 
 former attacks. As before they were attributed to external causes. His condi- 
 tion was tolerable, and he was able to pursue his avocations. In the autumn of 
 1865 the attacks of pain began to increase in frequency and severity (about one 
 and a half years after the last operation) and in February, 1866, his condition 
 became so unendurable that he was unable to continue his work any longer. 
 In the meantime he had tried every sort of remedy but had lost confidence in 
 everything except a fresh operation, and with this object he came back to the 
 hospital. During the paroxysms the cheek was now free from pain, but all 
 the other parts supplied by the second division of the fifth nerve were affected- 
 Rest could only be procured by very strong morphia injections. In February, 
 1866, I performed v. Langenbeck's osteoplastic resection of the superior 
 maxilla, and broke away the posterior wall of the antrum and the back part of 
 the floor of the orbit. Next, the second division of the fifth was traced up, 
 and the orbital dental branches sought for ; the trunk of the nerve was cut 
 close to the foramen rotuudum. I then drew the nerve forward, separated the 
 branches for some distance and completely removed the infraorbital nerve. 
 The operation entailed but little hsemorrhage. The portion -of bone was 
 replaced and united well, as did also the wound. Reaction was moderate. 
 After this the attacks of pain ceased. 
 
 On examination, the entire trunk with its principal branches was 
 found to have been removed, but unfortunately the spheno-palatine 
 ganglion was left. In similar cases I should consider the removal 
 of this ganglion of importance. Microscopically no pathological 
 appearances could be detected. 
 
 Towards the end of March, 1S66, the neuralgic symptoms unfortunately 
 returned again, on any touching or stretching of the left angle of the mouth ; 
 soon the attacks became more frequent. I then determined to resect the buc- 
 cinator nerve, which, though a branch of the third division, is partly a nerve of 
 sensation, and supplies the angle of the mouth and the mucous membrane. 
 Although the trunk of this nerve was readily found in the dead subject, yet, in 
 the cicatricial tissues of the patient's cheek, it cost me a long search to discover 
 and excise a portion of the nerve. I was unfortunate enough, in searching for 
 the nerve, to divide Stenon's duct close to its exit from the gland. This was in 
 April, 1866; the neuralgic pains completely disappeared, but the patient had 
 an attack of erysipelas ambulans ; this latter he got over well, but was left with 
 a salivary fistula. In May, 1866, a mouth later, the neuralgic pains again 
 appeared about the upper jaw and in tlie neighbourhood of the chin. I then 
 made an incision from the mouth towards the lateral wall of the antrum, carry-
 
 62 NEURALGIA OF FIFTH NEEYE — EEPEATED OPEEATIONS. 
 
 ing it pretty far back, so as to meet with the posterior dental nerves ; the 
 mental nerve was also cut through at its exit from the infra-maxillary canal. 
 The first incision was followed by sharp heemorrhage, which could not be checked 
 until the patient was much exhausted. At the end of May, iS66, I attempted 
 to close the salivary fistula by drawing the stump of the duct into the mouth, 
 and uniting the skin over the opening, but without success. It then occurred 
 to me to place a ligature round the duct and allow the gland to atrophy, but as 
 •we know that wounds of the gland substance heal readily after excision of the 
 jaw or removal of tumours, I decided to remove the anterior portion of the 
 gland ; the skin wound was united over the gap. About five days subsequently 
 the gland began to swell and, as it increased in size, became highly painful. 
 Pressure was tried without good result ; suppuration took place, and the entire 
 gland became converted into a multitude of little abscesses, the last of which 
 did not Ileal for two mouths. The patient then left the hospital free from his 
 neuralgia. 
 
 For five months he continued well ; then the old troubles began again in 
 December, 1866. In January, 1867, he suffered from severe attacks. In April 
 and May of the same year a remarkable improvement took place, but in June 
 the pain returned with its full severity. The attacks of pain now ramified for 
 the most part from the alveolar process of the left superior maxilla over to the 
 nose, the lower eyelid, the ear, and the temple ; thence the pain penetrated 
 deep down into the head. The paroxysms occurred during eating, talking, &c., 
 but never when he kept absolutely quiet. In July, 1867, he returned and be- 
 sought a further operation. The constant current was suggested, but the 
 patient would not hear of any proposal short of operation. Life had become a 
 burden to him. I therefore, in July, 1867j tied the left common carotid artery 
 above the omohyoid. My patient was at tliat time in his sixty-fourth year ; in 
 spite of all his sufferings he was vigorous for his age, cheery, and of indo- 
 mitable bodily and mental energy. A few days after the operation he had 
 slight attacks of pain, which then diminished, and entirely ceased at the end of 
 the first week after the operation. The patient became a new man ; he would 
 not remain in bed, and left seventeen days after the operation, although the 
 ligature had not come away. 
 
 The further history of this ease was communicated to me. I 
 learnt that recurrence took place, and the constant current was 
 tried with success. The paroxysms then came back again, and up 
 to his death were of agonizing pain. Enormous doses of morphia 
 were given. The small subcutaneous syringes were useless, and he 
 procured one that held two drachms. He was accustomed to in- 
 ject 18 grs. of morphium twelve times daily. By means of this 
 he had intervals when the pain was endurable, and could get sleep 
 for an hour or two. Finally he became reduced to a skeleton, and 
 died of exhaustion. Post mortem : absolutely no morbid change 
 could be detected in the nerves, the brain,, or the bony canals.
 
 OPEEATIVE TREATMENT OF NEUEALGIA. 63 
 
 It appears to me beyond question that the operations were the 
 means of prolonging this man's life, or, at any rate, of making it 
 tolerable for some periods. Prom the scientific point of view the 
 negative results of the post-mortem examination are very dis- 
 heartening. 
 
 The duration of the disease, dating from the commencement of 
 the neuralgia to his death, was seven years. 
 
 Do these two cases encourage us to undertake operations for 
 neuralgia or not ? The first, as it seems to me, speaks strongly in 
 favour of neurotomy ; in the second, a radical cure seemed scarcely 
 possible, since no drugs — the subcutaneous injections excepted — had 
 any power of alleviating, still less of curing the disease. By the 
 operations the patient was repeatedly benefited, so that he passed 
 many months free from pain. I am convinced that, had it not been 
 for the operations, he would long before have put a bullet into his 
 brain, for he was quite the man to do so. For mine own part, 
 when the neuralgia is produced chiefly in a reflex manner, I should 
 not hesitate to proceed as I did in the cases described. If fresh 
 recurrences took place and electricity failed, I would again excise 
 the painful portions of the jaw, render the affected half of the face 
 insensitive by cutting through the supplying nerve trunks, perhaps 
 again ligature the carotid artery, and so forth. Mechanical treat- 
 ment, such as this, and directed purely against symptoms, may be 
 called irrational. Let us not deceive ourselves. Are we not per- 
 petually in the same position with regard to internal diseases, where 
 we can only alleviate the painful symptoms ? Our patients will 
 thank us more for alleviating their suff'erings, even by an irrational 
 mode of treatment, than for a ' rational ' therapeutic nihilism. 
 
 Neuralgia of the fifth nerve. 
 
 The two following cases are instances where the pain started 
 from some manifest lasting irritation, but where there were no 
 decided paroxysms. 
 
 P. H — , a woman, set. 19. The left eyeball bad been enucleated a year 
 previously, aud a right iridectomy had been performed for glaucoma. For 
 seven weeks she had had intense, but not continual, pain in the tract of the 
 right frontal nerve. This nerve was divided and the pain in the forehead 
 ceased, but became subsequently much more intense in the right eyeball, aud 
 then in the track of the right supra-raaxillary nerve. The constant current
 
 64 OPEEATION FOK .NEU1{AI,GIA FOLLOWED BY OPTIC ATROPHY. 
 
 was tried without success. Gradual alleviation of the paroxysms was 
 obtained by the repeated use of morphia injections, and four years later her 
 condition was tolerable. Tiie condition of the right eyeball did not alter. 
 
 Iv, W — , set. 25. After an attack of typhus, a dull pain persisted over the 
 riglit half of the forehead. There were no typical paroxysms, and the man 
 probably had catarrh of the frontal sinuses. The patient had, the year 
 previously, suffered from epileptiform attacks. No operation seemed to me to 
 be indicated in this case, and the patient was discharged unimproved. 
 
 A. B — , set. 53. Pain had existed for twelve years over the distribution of the 
 second division of the fifth nerve. In May, 1872, subcutaneous discission was 
 performed on the nerve at its exit from the infraorbital canal. Four mouths later 
 the pain recurred. In November, 1 873, the operation was repeated. He recovered, 
 but recurrence again took place in three months. In March, 1874, the whole 
 nerve was cut out of the canal. The patient wrote, three years later, to the 
 effect that his pain had not altogether disappeared, as he always felt some 
 slight twinges iu cold weather; however, his condition was materially 
 improved in comparison to what it had formerly been. 
 
 In two other cases the same nerve was completely extirpated out 
 of the canal. Eecovery followed, but nothing could be heard of 
 the patients on inquiry three years later. In one of these cases sub- 
 cutaneous discission of the nerve at its exit from the canal had 
 been quite unsuccessful in relieving the pain, 
 
 M. H — , ffit. 43. Neuralgia had existed on the right side for ten years. 
 A portion of the inferior dental nerve just above the canal was cut out. A 
 few days later severe arterial hsemorrhage took place from the wound, which 
 was so formidable, in spite of a tampon, as to necessitate ligature of the 
 right common carotid artery. Three days later the hsemorrhage again 
 occurred ; a firm tampon of penghawar finally controlled the bleeding. The 
 patient was much exhausted by loss of blood, and recovered but slowly. An 
 abscess subsequently formed behind the angle of the jaw ; it was opened, and 
 the bone was found exposed. Three weeks after the operation he had a rigor, 
 and five days later he became completely blind in the right eye. Tlie retinal 
 veins were found to be enormously distended, the arteries were very small, and 
 extravasation was seen in the neighbourhood of the macula. Atrophy of the 
 optic nerve followed later on. Eventually he recovered after the removal of a 
 sequestrum from the bottom of the abscess. Six months later we heard that 
 he was perfectly strong and had had no further neuralgic attack, but the eye, 
 of course, remained blind.
 
 ETIOLOGY OF NEURALGIA OF FIFTH NERVE. 65 
 
 Neuralgia of the Fifth Neuve. 
 
 Between the years i860 and 1876, thirty-two cases of neuralgia 
 of the fifth nerve, came under my care. 
 
 Strange as it may seem, these typical neuralgias usually arise 
 without any known cause. A cold was several times given as the 
 origin, but in two-thirds of the cases the patients could assign no 
 cause whatever. The first, " tearing," '' twinging," " darting," and 
 the slight and great " burning " sensations, came on quite unex- 
 pectedly. Patients with tic douleureux are very sensitive to cold, 
 especially to cold draughts playing on the face. Usually they 
 muffle up their faces in wool, and move about as little as possible. 
 Once I succeeded in inducing a patient to apply an ice-bladder on 
 the affected part of the face for some few days, and to rub the skin 
 of the face once daily with ice. The pains increased to such a 
 degree, in spite of the administration of morphia injections at the 
 same time, that the treatment had to be discontinued. In no single 
 instance have I seen any benefit derived from blood-letting. Sex 
 appears to have a great influence on this disease, for it is so 
 infinitely more common in men, that any chance of coincidence can 
 be excluded from the compiled statistics. Among thirty cases, the 
 neuralgia commenced in thirteen, between the ages of 30 and 40, 
 and in eight others between 41 and 50. The nerve most commonly 
 affected is the second division. At first we invariably examined the 
 nerves when cut out, but as we could neither discover anything 
 wrong with the naked eye, nor with the aid of the microscope, the 
 examination was afterwards discontinued. 
 
 The disease, like many other spasmodic complaints, appears 
 always to be purely functional. No case has occurred to me 
 hitherto, in which tumours, exudations, etc., caused symptoms of 
 tic douleureux by pressing upon or stretching the branches of the 
 nerve itself, or any portion of the central nerve system. The nerves, 
 at their exit from the spinal canal, might be compressed by 
 diffused tubercular or cancerous disease of the vertebral column ; 
 but this will not cause neuralgic attacks as in tic, though of course, 
 the pain in these cases is really very intense. True neuromata are 
 usually only painful when touched. The few examinations of the 
 brain, which have been made on persons who died with neuralgia 
 of the fifth nerve, showed nothing, so far as I know, to elucidate the 
 
 6
 
 66 PEOGNOSIS OF NEPRALGIA. 
 
 disease. In these examinations there is perhaps a tendency to find 
 something pathological a tout prix, which otherwise would scarcely 
 have been thought deserving of mention. My own impression is, 
 that the pains are commonly excited in a reflex manner, and that 
 the apparatus for stopping such excitation has, as it were got 
 out of order, from some unknown cause. 
 
 It would be very desirable to know whether the constant current or 
 neurotomy could, at any rate, in some few cases, effect a radical cure. 
 What, again, is the percentage of tlie cases under treatment, where 
 permanent benefit is derived from neurectomy or from neurotomy ? 
 Is the result more decided and more lasting when the patients are 
 operated on early or late ? Should our prognosis vary, according 
 as the first, second, or third division of the nerve is affected ? An 
 enormous array of statistics would be necessary, in order to give a 
 general answer to these questions. What do we mean when we 
 say that a neuralgia has been radically and permanently cured by 
 operation ? Ought it to signify " as long as the individual lives 
 after the operation ?" When patients operated on die, say from 
 typhus, some months after the operation, during which period they 
 have been free from pain, nothing is proven as to the radical cure 
 effected by the treatment, although the good effect lasted up to the 
 death of the patient. In a disease, where sometimes for periods of 
 years, no symptoms occur, and which sometimes disappears alto- 
 gether just as it originated, from no known reason, or again, perhaps 
 five years after a successful operation, suddenly comes back with 
 intense severity, it is difficult to form any opinion as to the radical 
 effect of any form of therapeutical treatment. 
 
 In the majority of cases, it is true, the attacks of pain ceased to 
 occur after operation. But the question arises, for how long? It 
 would be of great importance to find this out. I have given the 
 point my utmost attention, but at the very outset one is met by 
 serious difficulties ; about many patients no subsequent history is 
 obtainable, and when they do communicate, their descriptions are 
 usually of little value. Generally speaking, the attacks return, but 
 with less severity ; it is very difficult, however, to learn the amount 
 of improvement by means of correspondence with the patients. For 
 the present, therefore, I prefer not to attempt to lay down any rules 
 on the matter. Subjoined is a resume — imperfect, as I am well 
 aware — of the results of special forms of treatment and operations.
 
 TREATMENT OF NEURALGIA CONSTANT CURRENT, 67 
 
 Spontaneous c%(,re. 
 
 In the case of a man who had suffered for eight years from neuralgia of the 
 secoud division of the fifth nerve, the pain gradually ceased without any treat- 
 ment. Wlien I saw him last he had been for four months completely free 
 from attacks. 
 
 Another man, who had suffered for eleven years from neuralgia of the second 
 division of the fifth nerve, broke tiirough some ice and fell into the water ; thence- 
 forward, for a period of eight mouths, his attacks ceased. At the end of that 
 time the neuralgia returned. He was then attacked with typhus, after which 
 the pains ceased again, but returned once more, though with somewhat weak- 
 ened intensity, six months later. He improved remarkably then under morphia 
 injections. 
 
 Constant Current. 
 
 In eleven cases the constant current was employed, chiefly on the 
 neck — the so-called galvanisation of the sympathetic nerve. The 
 application of the direct current through the affected side of the 
 head was seldom employed^ and this treatment is scarcely ever of any 
 use.^ If the sufferers had sufficient patience the constant current 
 was employed for at least three weeks before I gave up the hope of 
 its being of any use, for I have seen one case in which no effect was 
 observed during the first two weeks, but in which subsequent 
 benefit was derived. Usually a few sittings are sufficient to show 
 whether the attacks become milder, shorter, or less frequent. In 
 two cases no benefit whatever was derived ; in two other instances 
 the patients obtained complete relief for a year. One of these was 
 in the habit of coming back for treatment from time to time, directly 
 the first warning symptoms of the disease occurred. In the other 
 case the neuralgia returned, but in a slighter degree. In one 
 patient the good effects lasted for four months ; in another for only 
 four weeks, and then the attacks returned with all their former 
 severity. In five instances the improvement, after from three to 
 four weeks of treatment, was so decided, and the attacks were so 
 much diminished in severity and frequency, that the patients 
 dechned any operation. Unfortunately, I have not been able to 
 obtain any subsequent information about these patients. 
 
 * I leave it to the electrotherapeutists to continue the discussion as to w-liafe 
 it is that is excited or allayed by the application of the constant current.
 
 68 MODE OF FEEFOEMING NEUKOTOMY AND NEURECTOMY. 
 
 Neurotomy. 
 
 In performing subcutaneous neurotomy I never limit myself to a 
 simple division, but I carry the knife through the nerve in several 
 places close to each other. In this way the nerve is cut into pieces 
 over an extent of about half a centimetre, and rapid regeneration is 
 obviated. I usually perform the operation subcutaneously, but 
 sometimes make an incision about two centimetres long exactly 
 over the portion of the nerve I wish to cut through. In three 
 cases I divided the supraorbital close to the upper margin of the 
 orbit before the nerve enters the notch. In none of these cases did 
 any benefit result, although the division of the nerve was proved 
 beyond a doubt, by the anaesthesia of the portion of the skin that it 
 supplied. 
 
 In dividing the infraorbital nerve, I usually insert a fine neuro- 
 tome into the canal and turn it round, so that the nerve is de- 
 stroyed for at least the length of a centimetre. Care should be 
 taken not to break the knife, as happened to me once in a subcuta- 
 neous operation of this nature. I had to make an iacision through 
 the skin in order to extract the broken piece. I have performed 
 this operation on seven occasions, three times entirely without suc- 
 cess, although the side of the lip supplied by the nerve was deprived 
 of sensation. In three cases the cure lasted only four months, 
 and in one other for three months. In two instances the pains 
 recurred with less severity, and in two were as bad as before. 
 
 Neurectomy. 
 
 In performing neurectomy of the infraorbital nerve I make a 
 horizontal incision, about three and a half centimetres long, along 
 the lower edge of the orbit ; then with a raspatory I push back the 
 periosteum as far back as the entrance of the nerve into the canal ; 
 then with a strong resection knife I cut through the nerve in this 
 situation together with the upper wall of the antrum. Next, with 
 two pairs of dissecting forceps, I separate the nerve from the lower 
 border of the orbit, beginning at the back part. The nerve is then 
 drawn out of the canal, and is cut through where it forms its fan- 
 like expansion. A small drainage-tube is left in for a couple of
 
 RESULTS OBTAINED BY NEURECTOMY. 69 
 
 days ; the wound usually heals rapidly by first intention, and the 
 mark of the operation is scarcely visible after a short time. This 
 proceeding I have adopted in six cases. Two were entirely suc- 
 cessful; in two others the attacks had completely ceased when 
 the patients were discharged, and no subsequent information 
 could be obtained about them. In one instance the attacks were 
 entirely absent for six months, and then returned with their former 
 severity. In one case, after complete relief for three months, the 
 attacks recurred with diminished intensity. 
 
 In one patient, after a futile resection of the infraorbital nerve, 
 I cut away the painful parts of the alveolar process. The attacks 
 ceased completely for seven months, and then came back as before. 
 Much the same result followed extirpation of the stump of the 
 second nerve at the foramen rotundum and neurectomy of the 
 mental nerve. 
 
 In five cases I performed neurectomy of the mandibular nerve, 
 i. e. a portion of the nerve, about one centimetre in length, was 
 resected above the dental canal. This method has been described 
 by Dr. Menzel in the 'Arch. f. kl. Chirurgie,' Bd. xiii, p. 668. 
 The operation is not without risk, but it seems to be beneficial. 
 In one case the patient was completely free from his attacks for a 
 year; then mild recurrence took place, which, however, did not 
 seriously inconvenience him. 
 
 One of the patients operated on died from diphtheritic inflamma- 
 tion of the wound and ostitis of the lower jaw, with septic poison- 
 ing. This seems to have been caused by the retained secretions in 
 the wound, which became closed by swelling of the periosteum of 
 the gum. Profiting by the experience of tliis case, I always subse- 
 quently left a small drainage tube in the wound. 
 
 After this operation there is at times some difficulty in opening 
 the mouth for the first two or three months, but later on this com- 
 pletely disappears, I must not forget to mention that I saw a 
 patient in whom the attacks had ceased for five years after a neu- 
 rectomy of the mandibular nerve, performed by Schuh. Severe 
 recurrence then followed, on which the constant current had only 
 for a short time any beneficial effect. 
 
 To sum up, I have performed neuro-discission in seven cases, 
 neurectomy in fifteen ; in two I have partially resected the upper jaw, 
 and in one instance the carotid artery was ligatured. Taking all 
 the results together they seem certainly unfavourable. It may be
 
 70 RATIONALE OF OPERATIVE TREATMENT. 
 
 thought irrational to undertake any operation in order to relieve a 
 disease of which we do not understand the cause, yet, further, 
 where we cannot predict with any certainty whether any benefit will 
 follow from the operation, and how long, if improvement does so 
 follow, it is likely to last. Nevertheless I am convinced that these 
 operations, which are seldom dangerous, cannot be avoided in the 
 case of these tortured patients. Often the effect of such operation 
 is like that of tracheotomy on those who are in a state of suffoca- 
 tation. Free these unfortunate creatures from the anxious strain of 
 expecting at any moment this terrible pain, and their delight will 
 soon show itself. They are full of gratitude for the operation, and 
 even if recurrence does take place they do not reproach the surgeon, 
 as so many patients do when tumours recur ; on the contrary, they 
 almost invariably beg for further operation. I have often had occa- 
 sion to insist with gentle earnestness on tentative treatment with 
 the constant current. Many of the patients lost patience only too 
 soon when it was tried ; they come back to the surgeon after all 
 remedies have been exhausted, with the rooted conviction that from 
 division of the nerve alone can they obtain relief from their agonising 
 pain. 
 
 As a rule, T am much more opposed to operation than the patients 
 are, for I recognise in operation only a last resource, and if this 
 remedy can give no help there is nothing further to be done. Once, 
 and once only, have I met with a patient who was so terrified at the 
 thought of an operation that he could not persuade himself to have 
 anything done. This was a man fifty years of age, but he looked 
 as if he were seventy ; for fifteen years he had suffered from neural- 
 gia of the mandibular nerve. I can sec him now before me, ema- 
 ciated to a skeleton, with a rigid, staring expression, with the saliva 
 constantly dribbling from his open mouth, with white, neglected beard, 
 and long unkempt hair. Morphia injections alone gave him brief 
 intervals of relief, and these to be of any use had to be given in ever- 
 increasing doses. Such was the end of a case described above; towards 
 the end he was taking eighteen times a day twelve grains of morphia, 
 until at last even the herculean frame of this man succumbed. Only 
 those who have had no experience of the torments suffered by these 
 unfortunates could condemn these patients to what is little better than 
 a long-protracted suicide. Are we, by discarding operations for the 
 division of nerves, to throw on one side a remedy which is not in 
 itself attended by any serious risk ? Are we to renounce a remedy
 
 PHOSPHOEUS PEEIOSTITIS. 71 
 
 which can give these most unfortunate of all sufferers a prospect of 
 recovering; if only to some slight extent, some general feeling of 
 health for the time which they have still to live ? Let us as sur- 
 geons imagine ourselves confronted by a patient for whom this 
 treatment is absolutely the only resource. Can we avert our eyes 
 from the sufferer's glance when he begs, if only for " some relief, 
 some easement, some hope ?" There can be no doubt as to the 
 answer we should return to such an entreaty. There can be no 
 doubt as to our course of action. 
 
 Section C. — Phosphorus Periostitis and Necrosis. 
 
 In the year i860 there were no less than twenty lucifer-match 
 factories in Ziirich, and we had therefore abundant opportunity for 
 studying the disease of the jaws arising from phosphorus. During 
 i860 and 1 861 the frequency of the disease struck me very much. 
 Out of twenty-three cases which came under my notice sixteen oc- 
 curred during these two years. Between 1861-66 I only met with 
 seven, and three of these patients did not come from the Canton 
 Zurich. This diminution of the disease was so striking that there 
 could be no doubt that it depended upon the improved sanitary 
 regulations enforced by the police. Improvements were effected in 
 the internal arrangements of the manufactories, and the district 
 medical officer was ordered to inspect all the operatives at least once 
 a month. His duty was to enforce their absence from the manu- 
 factory on the first occurrence of pain about the jaws, or if they 
 showed any symptoms of illness. As to the exact nature of the 
 process by which the fumes of phosphorus affect the periosteum of 
 the jaws, no positive opinion can be given. The supposition that 
 the phosphorus in some form or other is taken up into the blood, 
 and then exerts a specific irritating influence on the jaws, has 
 hitherto neither been proved nor refuted ; the same is true of the 
 hypothesis that the phosphoric fumes exert a directly injurious 
 influence on the gums, particularly when the teeth are carious or 
 the alveoli diseased. It is evident that phosphorus periostitis may 
 occur when the teeth are not diseased, for in some of my patients 
 all the teeth were perfectly sound ; this I have myself observed, 
 though only in a few instances. A single case, however, would be
 
 72 CLASS OF CASES SEEN IN ZUEICK. 
 
 sufficient to refute the assertion that disease of the teeth is always 
 found in connection with this malady. 
 
 My tables show that of twsnty-six cases the upper jaw was 
 affected m eight instances, and the lower jaw in eighteen, and that 
 the ages of the patients varied from i8 to 33.^ There was no 
 material difference between the frequency of the malady in the two 
 sexes. Most of these persons begin work in the manufactories as 
 children; the length of time for which they had been employed 
 bore no proportion to the severity of the disease, nor did it influ- 
 ence its occurrence. 
 
 It is well known that a person previously healthy may work for 
 many years in a lucifer manufactory without becoming affected, pro- 
 vided the rooms be well ventilated and proper precautions taken ; 
 on the other hand, a short period of the work in a badly-ventilated 
 apartment, is sufficient to induce the disease ; many accidental cir- 
 cumstances have, however, to be taken into account. With regard 
 to the progress of the complaint, I find it noted that only subacute 
 or chronic cases came before me ; I saw none of the very acute forms 
 with foul suppuration and infective fever. The pain varies very 
 much ; it is never completely absent, but instances occurred where 
 it was sufficient to cause insomnia during many weeks. The dis- 
 ease was usually associated with slow remittent fever, great emacia- 
 tion, and weakness. 
 
 In January, 1866, a strong peasant girl came under my care, 
 from the Canton Unterwald, in whom the disease was in such an 
 early stage that the periostitis could be treated as such. In this 
 patient the teeth were all perfectly sound up to the first left 
 molar ; this had been healthy too, but the patient had allowed a 
 country practitioner to extract it as she fancied that the pain was 
 especially severe at this spot. At the bottom of the socket the bone 
 was bare and suppurating. Over the whole of the lower jaw, the 
 gum and periosteum were considerably swollen and painful ; at the 
 right border of the jaw lay a small abscess in the subcutaneous cel- 
 lular tissue. (I may here remark that abscesses forming externally,, 
 in connection with the jaw, are by no means always directly set up 
 
 ^ The history of tweuty-three cases of this disease, arranged in a tabular 
 form, will be found iu Billrotli's ' Chir. Klinik,' 1860-67, P- ^3 ^^ ^^1- Three 
 other cases are recorded iu the 'Chir. Klinik,' for 1S68. Most of these are 
 referred to iu an essay by Dr. G. Haltcnhof, entitled ' De la periostite et de !a. 
 Necrose Phosphorique,' Zurich, 1865.
 
 XATURE OF PHOSPHOEUS " NECROSIS. 73 
 
 by diseased bone or periosteum ; frequently they originate iu the 
 loose layer of cellular tissue lying on the newly- formed layers of bone, 
 without exposing the latter ; cloacas and sinuses may form, as in 
 necrosis, but they are less frequent about the jaws than elsewhere, 
 inasmuch as the pus originating between the old and the new bone 
 breaks into the mouth.) I treated this patient for two months with 
 iodine inunctions, and iodide of potassium internally. The swelling 
 of the periosteum and gums completely disappeared under this 
 treatment. I expected some slight exfoliation from the exposed 
 alveoli, a process that I should like to have seen completed, but 
 which did not occur while the patient was under my care. She felt 
 herself so well and free from pain that she would no longer stay in 
 the hospital. I heard, three months after her discharge, that she 
 continued perfectly well. 
 
 In cases where the periostitis ran a chronic course, and was 
 attended by slight pain, the patients always came far too late to 
 the hospital. At the outset they paid but little attention to their 
 condition, and felt bound to earn their livelihood by working on in 
 the manufactory. I have known these patients, when for a time, 
 want of room prevented their admission into the hospital, go back 
 again, in s])ite of all advice to the contrary, to the manufactory with sup- 
 puration of the jaws. The truth of the saying that " necessity knows 
 no laws " is the simple explanation of this lack of common sense. 
 
 The lower jaw is far more frequently affected than the upper ; 
 this is shown in my small number of cases. As regards the dura- 
 tion of the disease, many circumstances have to be taken into 
 account. Among my cases the shortest period was six months, the 
 longest two and a half years. 
 
 In the matter of treatment I am sure that, if the patient be 
 removed from the factory immediately on the occurrence of pain in 
 the lower jaw, the mouth well washed out, and favourable dietetic 
 conditions secured, the process will stop of itself. Perhaps in. 
 chronic cases, and in those which are subacute at the outset, iodides 
 or mercury may assist in arresting the disease. The loss of many 
 jaws, nay, of many lives, may certainly be obviated by timely treat- 
 ment. Before going further into the treatment, I must say a word 
 upon the anatomical conditions, for the expression phosphorus 
 '' necrosis " has led to much misunderstanding. It must not be 
 supposed that from the first a circumscribed portion of the jaw 
 becomes rapidly necrosed, as in noma or gangrene of the mouth
 
 7-1. PATHOLOGY OP PHOSPHOIIUS PERIOSTITIS. 
 
 after typhus. The disease at the commencement comparatively 
 seldom takes the form of suppurative periostitis and osteo-myelitis. 
 At the outset the periosteum and gum thicken ; young bone is, in 
 consequence, very rapidly produced from the germ tissue, partly 
 developing on the surface of the bone, partly from the layer of 
 periosteum immediately in connection with it. In the great 
 majority of cases phosphorus periostitis is, like other forms of 
 chronic periostitis, primarily an osteo-plastic process. Ulceration 
 and suppuration occur at a later stage of the disease. The sub- 
 stance poured out to form the cast of new bone on the superficial 
 surface of the diseased jaw, begins to melt away ; in part it forms 
 granulation tissue, in part it breaks down into pus ; thus, the shell 
 of bone becomes entirely detached from the jaw, and new formation 
 and thickening only take place on its outer surface. The steps of 
 the process are similar to those observed in normal growth of bone, 
 viz. apposition of the periosteum, and breaking down of the first- 
 formed inner layers into the marrow (in this instance into granulation 
 material and eventually into pus). If the process went on with per- 
 fect regularity, the newly-formed invagiuating bone would become 
 continually thicker and thicker, and eventually separate itself entirely 
 from the jaw. Further, by suppuration of the vessels passing from 
 the periosteum into the bone, the jaw would be cut off from the 
 circulation, and thrown off ifi ioto as a sequestrum. Naturally the 
 bony investment would be incomplete, as none would be formed 
 where tjie teeth are implanted. But the changes by no means go 
 on with such uniformity ; the ulcerative process of the superficial 
 surface of the jaw progresses with great irregularity. The invagi- 
 nating bone is broken through by caries and ulceration from within. 
 As long as circulation goes on in the medulla of the jaw central 
 softening changes take place -, granulation masses, forming bone and 
 then breaking down, originate in the alveoli and around the sockets 
 of the teeth ; the flow of blood to the jaw from without is checked 
 here and there. By collateral circulation the medulla is supplied, 
 so that the outer part of the jaw dies, while the inner part is kept 
 alive; the investing layers of bone are often destroyed in their 
 growth ; here and there the new bone substance melts away by ulce- 
 ration, or partial necrosis takes place ; abscesses form around the 
 jaw, and at times acute inflammation of the mucous membrane of 
 the mouth or tongue is added, thus further interfering with the cir- 
 culation. The process fluctuates between osteo-plastic or ulcerative
 
 RESULTS OP PHOSPHOEUS PERIOSTITIS. 75 
 
 ostitis and necrosis. Such changes are by no means confined to 
 this disease alone ; many affections of the periosteum, of the bones 
 and of the joints run their course, oscillating in the same way 
 between new formation and degeneration, between plastic pro- 
 duction and ulcerative and necrotic breaking down. 
 
 If the local process be allowed to progress without interference, 
 the results will vary exceedingly. If all goes on favourably, from 
 time to time single necrosed portions may be removed, and an 
 invaginating layer of bone will be left to serve instead of the 
 original bone. In my judgment a purely expectant treatment does 
 not yield the best results. I saw one case where, under such treat- 
 ment, half the jaw came away through the cheek as a sequestrum, 
 and the new formation was ultimately very inconsiderable, being in 
 great part destroyed by ulceration and suppuration; moreover, very 
 ugly scars were left on the cheek. It will usually be observed that 
 the disease commences on one side, cither on the lower or upper 
 jaw. If the patients remain under observation long enough, the 
 process may be seen to gradually extend over half the jaw, or may 
 even affect the entire bone. The extension either progresses by 
 occasional acute attacks, or spreads gradually; no antiphlogistic 
 treatment will either hinder or check it. Cases like these lead one 
 naturally to supjjose that if the part first affected had been promptly 
 removed the entire half of the jaw need not have been lost. Acting 
 on this idea in three cases, I resected the diseased portion of the 
 jaw in its continuity ; I made my incision externally, broke away 
 the osteophytic layers, and preserved the periosteum. In one case 
 only, however, was the wished-for success obtained, that is to say, 
 the process stopped, and the continuity of the jaw was completely 
 restored by abundant bone formation. In other cases I forcibly 
 extracted the sequestrum through the mouth, which may often be 
 done without breaking the newly-formed bojie ; on the whole, the 
 results were not bad. The proper opportunity for forcible extrac- 
 tion of the diseased and half necrosed jaw is when the separation 
 of the invaginated bone is sufficiently far advanced and as thick as 
 possible. If the pain, however, be very severe, and the patient 
 much reduced, I remove the bone at an earlier period. It is very 
 interesting to see how rapidly, at times, the shell of bone left be- 
 comes a solid mass. In two very successful cases of recovery after 
 total necrosis of the lower jaw, a new bone was formed resembhng 
 that of old edentulous persons.
 
 76 PEOGNOSIS IN PHOSPHORUS PERIOSTITIS. 
 
 In phosphorus necrosis of the upper jaw it has been asserted 
 that no replacement of the bone takes place. This is onlj^ partly 
 correct; naturally the alveolar process of the upper is less capable 
 of restoration than that of the lower jaw. It must be remembered 
 that after loss of the body of the upper jaw, no proper antrum will 
 be re-formed, and the walls of the upper jaw will collapse. The 
 palatine process is completed from above and below, but the bone 
 will be greatly retracted ; nothing is gained after extraction of the 
 palatine process, by uniting the muco-periosteal investment of the 
 hard palate to the upper lip. The zygomatic, nasal and orbital pro- 
 cesses, may be completely regenerated. In one of my patients, who 
 was supplied with an artificial alveolar process fitted with teeth, 
 scarcely anything wrong would have been noticed, nor would any- 
 body have supposed from seeing or speaking with the man, that 
 both the upper jaws and both the zygomatic bones had been entirely 
 lost. 
 
 With regard to the danger to life of phosphorus periostitis, it is 
 known that a few, especially among the young, die from its results, 
 either from tuberculosis of the lungs, abscess of the brain, or 
 marasmus. Two of my patients died of tuberculosis of the lungs 
 during the inflammatory stage of the disease of the jaw. The two 
 diseases are so far connected, that individuals predisposed to tuber- 
 culosis of the lungs, are liable to this disease at an earlier period 
 and in a more severe form, if their strength is exhausted by a com- 
 plaint involving suppuration, ulceration and fever. 
 
 A word as to the durability of the new periosteal bone. That a 
 certain amount of atrophy and superficial destruction of the newly- 
 formed bone takes place, cannot be denied, but neither in thi« case, 
 nor in necroses elsewhere, does it proceed to such an extent as 
 materially to interfere with the appearance. I may mention in sup- 
 port of this statement, that I saw one of my patients who had 
 suffered from total necrosis of the jaw, six years after his recovery. 
 The new bone was smooth on the outer and inner surface but felt 
 compact ; it was slightly lower and smaller, however, than when he 
 left the hospital. It is very interesting to observe, though the fact 
 is unexplained, how the callus about a fracture, like invaginating 
 bone, disappears only to a certain extent, and as nearly as possible 
 reproduces the original shape of the bone.^ 
 
 ' Some highly suggestive remarks on this point will be found in Paget's 
 ' Lectures on Surgical Pathology,' Lecture vii. — [Ed.]
 
 DEVIATION OF THE SEPTUM NAEIUM. 77 
 
 (Section D. — Plastic Surgeey of the Face, Nose, and 
 Mouth. 
 
 Remarks on deviatmi of the septum narium. Case of salivary 
 fistula. Treatment of liare-lip. Treatment of cleft palate. 
 Deformities treated hy plastic ojjerations. Cicatricial contrac- 
 tions of mouth — Cases. Case of ectr opium and corneitis. 
 Rhinoplastic operations. Case of repeated operations. 
 
 Deviation of the septum narium. 
 
 This condition is usually congenital, and is accompanied by a 
 peculiar typical obliquity of the nose. Sometimes^ however, a 
 similar condition results from blows on the nose, causing fracture 
 or bending of the septum. Only three of these cases were treated 
 inside the hospital, but many came under notice as out-patients and 
 in private practice. Formerly, I used to endeavour to correct the 
 deviation of the septum and to keep it straight by the insertion of 
 small wooden or ivory wedges into the nasal cavities, after separat- 
 ing the cartilaginous and bony part of the septum. This process 
 is long and tedious, and, moreover, it completely failed in a patient 
 of mine in Ziirich ; nothing material was gained after six weeks of 
 torment. Since then, therefore, I have abandoned this treatment. 
 If the blocking of the nasal cavity, owing to the bent septum, is 
 very troublesome, I make a hole large enough to admit a pea 
 through the bent part, so that the patients at least have the sub- 
 jective sensation of breathing through both nostrils ; with this con- 
 dition of things they were always very well satisfied. This little 
 operation requires some delicacy. Were not the cases so rare, it 
 ■would be worth while to have a kind of nippers constructed, some- 
 thing like those used by railway guards to clip the tickets. I have 
 usually managed with the aid of a two-edged knife and a pair of 
 curved scissors, but the effect is not always quite satisfactory. 
 The opening should be made rather high up, so that it cannot be 
 seen. At the upper part, however, the septum is so strong that it 
 is not easily cut through. In young persons the opening ought to 
 be at least large enough to admit a pea, otherwise it is apt to be-
 
 78 CASE OF SALIVARY FISTULA — ^H ARE-LI P. 
 
 come smaller and the operation may require to be repeated. The 
 deviation of the septum and its effect in impeding respiration through 
 the nose, is imperfectly understood by many surgeons, like the par- 
 tial enlargements of the inferior turbinated bone. These patients 
 were nearly always sent to me with the diagnosis of nasal polypus. 
 
 Salwary fistula. 
 
 One case came under my care in which, five months previously, an abscess 
 had originated in the neighbourhood of Stenon's duct without known cause. 
 A fortnight after its first appearance the abscess was opened. A fine fistulous 
 opening was left, from which a considerable amount of saliva continually escaped, 
 especially after eating. The probe passed through the opening into the duct 
 close to its exit from the gland. Inasmuch as the proximal end was too short 
 to allow of its being detached and turned into the mouth, I dissected out the 
 duct together with the fistula, and placed close above it a strong silk ligature hi 
 such a way that I was able to tie the ends of the thread firmly iu the mouth. 
 Then I refreshed the two edges of the skin wound and brought them together 
 over the ligature. My hope was, that the ligature would soon cut its way 
 through, that the skin would heal by first intention, and that the saliva would 
 pass into the mouth through the fistula, which was now turned in that direc- 
 tion. This did not succeed, however, so directly as I wished ; the parotid 
 swelled up considerably for the first few days. The loop of the ligature was 
 removed from the mouth after a week. In the meantime the skin sutures had 
 been removed ; some suppuration took place at their situation ; pus could also 
 be pressed out from the parotid at the wound, and some saliva also flowed 
 externally. The part was cauterised and pressure applied. Finally the wound 
 in the check closed, four weeks after the operation, and no more saliva escaped 
 externally. I cannot say positively whether this result was due to partial sup- 
 puration and atrophy of the gland, or owing to the altered situation of the 
 fistula, which had been directed inwards. 
 
 Haiie-hp. 
 
 Unless the parents urgently demand an operation as early as 
 possible, I generally prefer to operate on children when they are 
 more than one year old. I always advise this in strong children 
 with complicated hare-lips, especially when the inter-maxillary bones 
 are displaced and the hare-lip is double. In a few cases that I have 
 kept under observation for some time after operation, the fissure of 
 the alveolar process closed after a few months, when tlie operation 
 was performed at the second year.
 
 OPEEATION FOR HARE-LIP. 79 
 
 I liave been particularly satisfied with tlie results of operation, as 
 far as appearance is concerned, on children at rather later periods 
 of life and in adults. Operations on little children do not always 
 succeed as well as could be wished, on account of the diminutive 
 size and softness of the parts. The flaps of the lips cannot always 
 be adapted exactly as desired, and even if this be satisfactorily 
 accomplished, the result does not in every case quite come up to 
 expectation, so that some few years after further slight proceedings 
 become desirable in order to improve the appearance. At later 
 periods of life the thick edges of the lip can be much better 
 refreshed, trimmed, apposed, and united, just as seems at the time 
 to be desirable, and there need be no fear as to the result. In 
 order to obtain the best possible result, when there is no fissure of 
 the alveolar process, the operation should be deferred till the patients 
 are from three to six years old, but the friends and relations of the 
 child will seldom agree to this delay. Operations on quite little chil- 
 dren sometimes succeeded so completely that I was not able to im- 
 prove matters later on. Still, I decline to give any absolute guarantee 
 with regard to the result in such cases. Here, in Vienna, children 
 of considerable age and adults very frequently come to the clinic 
 with hare-lip which has not been operated upon. This, doubtless 
 is explained by the fact that these individuals, for the most part, come 
 from the outlying districts where there are but few surgeons. 
 
 Staphyloraphy and Urano-plastic Operations for Con- 
 genital Malformations. 
 
 Although, according to the experience of Eose, better results can 
 be obtained when the children are operated on under the influence 
 of an anesthetic, and with the head hanging down, yet the func- 
 tional results have hitherto not encouraged me to perform these 
 operations on children to any great extent. However, the matter 
 is by no manner of means yet settled.^ I had two fatal cases, in 
 children of two weeks and two months old respectively. The ope- 
 ration should, therefore, be delayed until the children are a year 
 old and in good health. With regard to the functional success of 
 
 ^ Vide a paper by Mr. ThoiUcis Smilh in the ' Med.-Chir. Trans.,' vol. li. To 
 Mr. Smith is due the credit, at any rate in this country, of showing that the 
 operation coukl be performed at an early age. — [Ed.]
 
 so SPEECH AFTER STAPHYLORAPHY. 
 
 operations undertaken at an early age, I may mention the case of a 
 child who was treated successfully when one year old. Four years 
 afterwards he still spoke with rather a guttural tone ; but an instance 
 such as this by no means settles this point, for we do not know 
 whether later, say when this child was fifteen years of age, his speech 
 would not have been better than if he had been operated on at the 
 age of fourteen. Careful comparisons require to be made on the 
 subject. The further question also arises, whether after successful 
 operations for hare-lij) and staphyloraphy during the first year of 
 life, the fissure in the hard palate may not close spontaneously later 
 on. Now, in my patient, the fissure had in no degree diminished 
 after the lapse of a year, so that this case proves nothing ; further- 
 more, if this child had been provided with an obturator early, and 
 had from the first practised and exercised the palatal muscles after 
 the velum had been united by operation, his speech might have been 
 better than in a patient operated on later in life. Although I value 
 very highly the conspicuous success which Siiersen^ has obtained 
 by the invention of his obturator, yet what I mean is, that we should 
 not desist from attempts to obtain an equally good result by opera- 
 tion. The new methods of operating devised by Passavant and 
 Schonborn deserve to have every attention paid to them, and require 
 still further development. 
 
 In the case of a woman in whom staphyloraphy had previously 
 been performed by another surgeon, I did an urano-plastic opera- 
 tion. The patient was exceedingly troublesome and restless. On 
 the third day violent vomiting occurred after a surfeit of milk and 
 cherries, and all the sutures gave way. The operation was, of 
 course, unsuccessful. 
 
 In six patients who were cured by operation, and in one who was 
 provided with an obturator after union of the velum, speech was 
 improved, but it was still not so good as in the case of patients 
 operated on for simple fissure of the arch of the palate. The 
 patients were well pleased that they required no longer to wear an 
 obturator, and that their food and drink did not so readily pass up 
 into the nose, but were disappointed with regard to the improve- 
 ment of articulation. I cannot say whether ossification of the 
 newly-formed palate followed later on. 
 
 It appears to me, from what I have learned after minute obser- 
 vation on these cases, that the soft palate is united to the posterior 
 ' 'Lclirbucli d. Zahiibeilkunde,' Leipzig, 1877.
 
 CICATEICIAL CONTRACTION OF MOUTH. 81 
 
 wall of the pharynx by a kind of sphincter apparatus, which lies 
 above the union of the soft to the hard palate, and may be regarded 
 as the uppermost portion of the constrictor pharyngis. 
 
 This sphincter is always defective anteriorly in total fissure of the 
 velum,, and in those cases where the fissure involves the hard as 
 well as the soft palate. The union of the velum palati and the 
 muco-periosteal lining of the palate does not lead to the functional 
 development of this muscle. This appears to me to explain why, 
 after operations on adults, speech is not improved. I noticed this 
 fact after my first operation for cleft of the hard palate, and Simon, 
 Passavant, Siiersen, and others have arrived at the same conclusions. 
 Siiersen describes the benefits of using an obturator in such glow- 
 ing terms that, according to him, we ought almost to discard ope- 
 rations for congenital fissures of the palate. 
 
 Deformities Treated by Plastic Operations. 
 
 I met with a few cases of cicatricial contraction of the mouth, 
 resulting from periosteal abscess in the neighbourhood of the back 
 part of the lower jaw. 
 
 In most of these the cicatricial bands were only on one side, and 
 situated far back, so that the mouth could either not be opened 
 at all, or at the best, only to a slight extent. Under the influence 
 of an ansesthetic, the jaws were forced apart by Heister's speculum 
 and then the bands being cut through, the blades of the speculum 
 were separated to the widest possible extent. After treatment for 
 several weeks with the introduction of wooden wedges, the function 
 of the jaw was so far restored that in some of the cases the mouth 
 could be opened 5 centimetres. I cannot say how long this good 
 efPect lasted : at any rate none of the patients came back to me. 
 
 In another case the contraction was the result of destruction of 
 the lip by noma ; another followed after the excision of a cancer. 
 In both of these I replaced the lower lip and the angles of the 
 mouth on both sides, by flaps taken from the cheeks and chin. The 
 mouth subsequently became contracted, partly owing to the con- 
 traction of the cicatrices, and partly from the adhesions of the 
 lip to the lower surface of the jaw. In a third case the opening of 
 the mouth was so narrowed by a rhinoscleroma,^ which extended 
 over the lips, that it would only just admit the end of a pencil. In 
 
 ^ See Mikulicz, " Ueber das Rhinosclerom," ' Arch. f. Klin. Cliir.,' Bd, xx, 
 p. 485. 
 
 6
 
 82 CICATEICIAL CONTRACTION OF MOUTH. 
 
 all three cases incisions were made on either side, so as to widen 
 the mouth; the mucous membrane was then united with the cheek, 
 so as to cover over the raw edges, and the patients eventually were 
 able to open their mouths to a fair extent. 
 
 F. S — , set. 43, had had for four years disease of the mouth, in consequence 
 of which tlie inner surface of the left cheek had become firmly united to the 
 upper and lower jaws. The patient was scarcely able to separate his teeth, and 
 could only take fluid food. He had previously been treated by the introduc- 
 tion of wooden wedges and incisions through the cicatrices; neither of these 
 proceedings had, however, done him auy good. As it was found impossible to 
 open the mouth any wider by Heister's speculum, a portion of the jaw, a third 
 of an inch in breadth, corresponding to the left lower canine tooth, was cut out, 
 in order to form a pseudarthrosis. The parts healed up well, but the resulting 
 cicatrix was so firm that when the patient was discharged after two months' 
 treatment, the incisor teeth could only be separated apart to the extent of a 
 quarter of an inch. The patient was a semi-idiotic individual, and could not 
 be induced to use for himself any mechanical devices for dilating the mouth ; 
 still less would he submit to a more extensive resection, which was thought 
 necessary in order to enable him to open his mouth wider. The con- 
 dition, therefore, of the patient on his discharge was highly unsatisfactory. 
 Two years later he came back to the hospital on account of a whitlow. The 
 final result of the operation above described w^as then seen to be very satisfac- 
 tory. The patient could open his mouth wide enough to admit the thumb. 
 The right side of the jaw, in front of the resected part, was displaced rather to 
 the left, while the left half of the jaw had somewhat atrophied. The move- 
 ment in the pseudarthrosis was not extensive, but was sufficient to allow him 
 to masticate solid food, 
 
 A. S — , set. 5. For about a year the extent to which she could open her 
 mouth had been constantly diminishing. When admitted she could not sepa- 
 rate the teeth from each other more than two lines. The parents were unable 
 to give any reason for this condition. On examination, the anterior border of 
 the right masseter muscle was felt to be very tense. This was cut through, 
 and she was then treated by the introduction of wooden wedges. Rapid and 
 complete recovery followed. 
 
 Ectropium. 
 
 J. H — , set. 14, was admitted with complete ectropium of the upper lid, 
 which had resulted from ulceration of the eyelids, and caries of the lower sur- 
 face of the nasal bones. A sound could be passed right under the nasal bones 
 from one side to the other. The conjunctiva of the lids was turned upwards 
 and much swollen and red. Both cornese were almost entirely devoid of cover- 
 ing and somewhat infiltrated, and tlie ocular conjunctiva highly vascular. 
 When admitted, ulceration of the right cornea existed, which, in spite of Pro- 
 fessor Arlt's careful treatment, could not be checked, and prolapse of the iris 
 followed. Finally, the inflammation ceased, but the vision of the right eye
 
 EHINOPLASTIC OPEEATIONS. 88 
 
 was reduced to quantitative perception of light. When tlie patient was admitted, 
 I doubted whetiier I ought not to have at once performed a blepliaroplastic 
 operation ; this seemed, however, risky, considering the inflamed condition 
 of the eye. On the left eye, 1 performed a blepharoplastic operation, bor- 
 rowing the flaps from the temporal region. The result was most unexpectedly 
 favourable not only with regard to the covering of the cornea, but in appear- 
 ance. Tiic infiltration of the cornea, together with the conjunctivitis, dis- 
 appeared very shortly after the operation. The vision of the left eye was not 
 only preserved by the blepharoplastic proceeding, but improved by the gradual 
 and complete clearing of the cornea. An attack of erysipelas, which reduced 
 the patient very much, prevented me from performing a similar operation on 
 the right eye. 
 
 Rhinoplastic Operations. . 
 
 Three patients came under my care at the Zurich Hospital, in 
 whom tliere was complete or nearly complete destruction of the 
 nose, the result either of caries of the bony framework of the nose, 
 or of syphilitic ulceration. In all three cases, rhinoplastic 
 operations from the forehead were performed with successful 
 results. One of these patients died of albuminuria a few months 
 after operation. My attempts to utilise, as much as possible, the 
 remnants of the nose, convince me, as it has also other experienced 
 operators, that such endeavours are not advisable. The remnants 
 of the shrunken cartilages of the nose, in spite of all possible pndding 
 with the other soft parts, invariably contract again during cicatriza- 
 tion. The alse of the nose, and the process of the septum alone, 
 cannot be too carefully preserved. In three rhinoplastic cases I 
 utihsed the periosteum of the frontal bone for the new nose, but in 
 none was there any new osseous formation. The wounds on the 
 forehead healed more slowly and remained longer adherent to the 
 bone than in the older and more usual procedure. Two of the 
 cases where I performed total rhinoplastic operations were asso- 
 ciated with partial defect of the upper lip. I first performed a 
 cheiloplastic, and then immediately proceeded to the rhinoplastic 
 operation. I cannot, however, recommend this proceeding ; healing 
 by first intention is endangered by the numerous sutures which meet 
 together at the upper lip. In both the cases the septum healed but 
 partially, and had to be completed by a later operation. It is 
 always better first to form the upper hp ; when this has completely 
 healed, the rhinoplastic part of the operation may be undertaken. 
 
 Of fourteen complete and nearly complete rhinoplastic operations 
 (cases of cancer not included) performed between the years 1 860
 
 84 MODE OF PERFORMING RHINOPLA.STIC OPEEATIONS. 
 
 and 1876, the lesion was, in twelve cases, of syphilitic origin ; in 
 one it was due to lupus, and in one to a gunshot wound. 
 
 In all these cases I formed the nose from the forehead ; gangrene 
 never followed, not even partial destruction of the septum or alae of 
 the nose. So far as I can remember this was also the case after 
 rhinoplastic operations performed after the removal of cancer. In 
 one case only the flaps, which had been formed from very thin skin 
 taken from the forehead, shrank up so rapidly that I had subse- 
 quently to perform a new rhinoplastic operation, borrowing two 
 flaps from the cheek. One patient died of pyaemia, which com- 
 menced with suppuration in the frontal bone, and ran on to 
 meningitis, thrombosis, and abscesses on the lungs. In another 
 case diphtheritic inflammation attacked the wound in the forehead, 
 but it did not last long. Undoubtedly, the disease arose from some 
 transplanted skin, which had been taken from a leg amputated on 
 account of caries. My experience of transplantation has not been 
 favourable, and I have completely given up the method in wounds 
 of the face. The pieces of skin transplanted do not usually last, 
 and when they do, they give a sort of mosaic appearance to the 
 scar, and a red cicatricial edge forms around the white transplanted 
 portion of skin. Whether this edge disappears in the course of 
 years I cannot say. I once saw a cicatrix where the skin had been 
 taken from the hand, in which such a mark was very evident several 
 months after the operation. The question not infrequently arises 
 after the removal of cancers extending from the nose over the 
 cheeks, as to whether the gap in the cheek should be covered in by 
 flaps taken from the forehead. The gap might also be closed, by 
 a sliding plastic operation or by flaps, so that only the natural 
 shape of the apertura pyriformis is left. My experience leads me 
 to a decided preference for the latter method, for this gives the best 
 appearance. Directly after the operation I introduce a thick gutta- 
 percha tube into the nasal cavity, as far up as the infundibulum, 
 and insert some charpie, so as to keep the apex of the nose and the 
 alae in good position from the first. This is better than the old 
 plan of plugging up the nose with charpie, for the patients are able 
 at once to breathe through the newly-formed nose. For the first 
 few days the tubes are syringed out several times in the twenty- 
 four hours ; after the fourth day they are changed ; after this they 
 are changed daily. I usually employ the gutta-percha tubes 
 throughout, and do not introduce any lead or other rigid tubes. If
 
 KHINOPLASTIG FOR RESULTS OF SYPHILITIC DISEASE. 85 
 
 V. Langenbeck^s method be adopted, of folding in the septum and 
 both alae of the nose, and preserving the mucous membrane of the 
 lower part of the nasal passage, there is no danger of the nasal 
 cavities closing up at a later period. The amount of subsequent 
 narrowing depends materially on the patients. The tubes ought 
 to be introduced every night, for at least a year. By doubling 
 in the septum and alpe, the lower part of the nose is certainly made 
 rather thick, and will remain so for about a year, but as the newly- 
 formed organs always become rather soft, thin, and smaller, after 
 some time, the prominence of the nose will be so materially 
 diminished that its appearance will be very ugly, unless the whole 
 of the lower part be made as thick as possible at first. I have no 
 experience of rhinoplastic operations on children ; I have never 
 ventured to perform complete rhinoplastic in such cases, for fear 
 that the newly-formed noses might not grow and keep pace with 
 the development of the face. Possibly I am prejudiced; any 
 positive information on this point would be very desirable. We 
 are often implored by the parents of such unfortunate children to 
 do something in order to improve the deformity. 
 
 Repeated rhinojilastic operations from the arm, forehead and cheek. 
 
 J. R — , set. 30. The nose in this patient bad been destroyed by syphilitic 
 disease. In March, 1870, a complete rhinoplastic was performed by Dr. 
 Salzer from the left upper arm. The result, which was at first very successful 
 was marred by sloughing of the septum and a portion of botli alse of the nose ; 
 subsequently the remainder shrivelled up completely. In November, 1870, I 
 performed a complete rhinoplastic from the forehead. The result at the out- 
 set was again satisfactory, but the flap from the forehead and the septum 
 shrank up to such an extent that the apex of the nose projected very much 
 upwards and the prominence of the organ was insuflBcient. On the 2nd 
 December, therefore, I performed a fresh operation, with a view to renew the 
 end of the nose. Unfortunately, the nourishment of the upper part of the 
 septum, when separated from its bridge and the alse of the nose, was inadequate, 
 and the greater part of the end of the nose and a portion of the ala sloughed. 
 The defects which now existed on both sides were filled up by two small flaps 
 from the cheeks. The eventual result was tolerably satisfactory, though not so 
 good as in a well-formed rhinoplastic from the forehead. The cicatrices on the 
 cheeks were less disfiguring than I had expected ; I had never previously per- 
 formed or seen a rhinoplastic operation where the flap was taken from the 
 cheek. In the course of some months, the flaps which I had transplanted 
 became so shortened that the projection of the nose, which at first was very 
 good, became ultimately as bad as before. Having had previous experience on 
 this patient, I did not venture at once to proceed to any further plastic opera-*
 
 86 ^■ON-MALIGXAXT TUMOUES OF FACE, ETC. 
 
 tioii. By transplanting fresli flaps and causing the end of the nose to sink 
 back into better position, the sliape of the organ could have been materially 
 improved, but I counselled the man, in case he wished for any further operative 
 proceedings, to come back in a year's time. Ko further record of the case can 
 be found. 
 
 Section E. — Xox-maligxaut Tumours. 
 
 Cases : — Pigmentation of face. Horny cutaneous growths. Arterio- 
 venous angioma of nose. Ditto of forehead and eyelids, treated 
 ly acnpimcture . Pulsating tumour of head. Treatment of 
 angioma cavernosum. Case of molluscum lipomatosum ; 
 repeated operations. Large neuroma plexiforme. Case of 
 neuro-fbroma of temporal region and orbit. Non-malignant 
 cylindroma of orbit i removal; recovery. Echinococcus of orbit. 
 Fibroma of the cheek. Fibroma of parotid — Cases. Distension 
 of the antrum ; remarks. Note on tumours of the jaw. Case 
 of huge fibroma of loioer jaio. Note on polypus nasi. Naso- 
 pharyngeal polypus — Cases. Note on ranula. Congenital 
 papilloma of tongue. Sebaceous cyst of tongue. 
 
 Pigmentation of face. 
 
 A gill, set. S, came under treatment with the following history : — Six yeai's 
 previously some pigmentation, brownish yellow in some places, black in others, 
 first appeared on the skiu, near the eyes. It occurred in the form of little spots, 
 varying iu size from a piu's head to a lentil. Between the spots the skin was 
 tolerably pale, so that she presented a completely piebald appearance. The 
 pigmentation extended over the whole body. For some months she had suf- 
 fered from intolerance of light. In the substance of the cutis of the cheek 
 and the aire of the nose were several soft, prominent, roundish nodules, varying 
 iu size from a lentil to a pigeon's egg. The patient was transferred to the 
 department for skin diseases. 
 
 Horny cutaneous growths. 
 
 One of these, situated on the left upper eyelid, was half an inch long and 
 about two lines thick. The patient was a woman fifty-three years of age, and 
 the projection had been growing for many months. The other was on the left 
 lower eyelid in a man set. 33. It had beeu growing for three mouths and was 
 2 centimetres long, i a centimetre thick, and somewhat spiral in form. Both 
 were removed. 
 
 Arierio-venous angioma. 
 
 Casi:. — E. J — , at. 35. Twenty years previously she had had a fall and 
 struck iier nose. Some little time after a pulsating swelling formed, which
 
 ANGIOMA TREATED BY ACUPUNCTURE. 87 
 
 gradually increased to the size and appearance shown in PI. I, fig. 2. The 
 tumour, which was very compressible, was composed of strongly pulsating 
 arteries and highly dilated veins. The patient would not allow any operative 
 treatment. 
 
 Racemose arterio -venous angioma. 
 
 J. S — , xt. 17. At birth a violet coloured mole, the size of a pea was 
 observed near the glabella ; when he was twelve years old it began gradually to 
 increase. On admission, an angioma was seen, formed of small arteries and 
 veins, which extended over the central portion of the forehead, from the edge 
 of the hairy scalp down as far as the middle of the nose. On the left side, it 
 had spread on to the cheek below the eyelid. Remembering the successful 
 effect of acupuncture which I had previously employed in a similar case 
 (Wien. Med. Woch. 1871, No. 42), I adopted the following method: — 
 I first performed acupuncture with fifteen long, fine, gilt needles, which 
 I inserted right through the base of the vascular growth. No reaction 
 followed. A fortnight later, ten more needles were carried in a longitudinal 
 direction beneath the base of the tumour. Twelve days after the last operation 
 the needles, most of which were loose, were removed ; very little suppuration 
 took place from the punctures. 
 
 Several very tortuous branches of the temporal artery were then secured 
 subcutaneously by acupressure as near as possible to the growth. Two days 
 later distinct pulsation could still be felt in an artery which ran upwards 
 in the left cheek. Nine days later the needles were removed. The tumour 
 had collapsed considerably, but still pulsated strongly at the lower part. Seven 
 more acupuncture needles were then inserted, which were removed three weeks 
 later, as they were quite loose. The diminution in size and pulsation of the 
 angioma did not last ; in some places it remained stationary, whilst at other 
 parts the pulsation increased. Firm pressure was then tried with sheets of 
 gutta percha, which were laid on soft, and then hardened. No success followed 
 this proceeding. I next excised a central portion over the forehead in such a 
 way that the edges of skin could be united together. Healing did not follow 
 by first intention, and when he was discharged the wound was still suppurating. 
 Meanwhile, I had thoroughly applied the galvano-cautery to the portion of the 
 angioma where pulsation still continued. The slight bleeding which occurred 
 from the punctures and the wounds from time to time was always easily con- 
 trolled. The patient was now discharged temporarily, that we might see the 
 effect of the cicatricial contraction. The skin, corresponding to the extensive 
 region that had been operated on, though no longer raised, was very red in 
 colour ; distinct pulsation was still perceptible at the borders. A year later 
 the patient returned to the hospital ; the cicatrix was but slightly raised, and 
 was in some parts of a light blue colour, at others of an arterial red. At many 
 points pulsation was perceptible. I employed galvano-caustic puncture ex- 
 tensively on two occasions, and the patient was discharged with the wound 
 still granulating. A year later he again returned; the pulsation was then still 
 distinct at many points, but in all other respects he was in good health. 
 
 The case is still under treatment (1876).
 
 88 ANGIOMA CAVERNOSUM. 
 
 H. K — , a strong man, set. 27, consulted me in November, 1871. Ten years 
 before he had noticed a pulsating swelling at the back of his head. He could 
 assign no cause for it, but was certain that the disease was not congenital, at 
 any rate, in the form of a pulsating growth. He had never been told whether 
 a naevus had existed at this spot at the time of birth. Two years after the new 
 formation had been first noticed it was injected by Nelaton with sesqui- 
 cldoride of iron. Slight diminution followed. This process was repeated a 
 year later by the same surgeon, and again two years before he came to me by 
 Pean, with much the same result. On each occasion the tumour became some- 
 what smaller and the pulsation diminished, but it soon reverted to the former 
 condition. When I saw him the tumour was the size of a goose's egg, soft 
 and elastic. Pulsation was everywhere distinct, and tolerably strong. I tried 
 electro-puncture with the constant stream (10 cells) for eight minutes, passing 
 the needles into the tumour. Considerable bleeding occurred from the punc- 
 tures, and was controlled by pressure. The reaction was slight, and no success 
 followed the operation. The man had not sufficient patience to wait for any 
 further operative proceedings. 
 
 Angioma Cavernosum. 
 
 In eleven cases of angioma cavernosum, which came under 
 observation at Yienna, the eyelids, nose, cheeks, lips, raucous 
 membrane of the mouth, and the tongue were the parts affected. 
 In some of the cases, one of these parts alone was the seat of the 
 vascular growth, in others several of them were involved together ; 
 phleboliths were frequently noticed. In eight instances we learned 
 that a small blue spot had existed from birth; these congenital 
 cavernous angiomata increased more slowly than those of the plexi- 
 form variety. The patients operated on ranged from two years old 
 up to twenty-nine. The increase in the size of the tumour from 
 the time at which it was first noticed, was, in the majority of cases 
 very gradual. In one instance, the vascular growth originated in 
 the skin of the nose at nineteen years of age, without any known 
 cause, and in the course of ten years had only attained moderate 
 dimensions. Two other patients ascribed the origin very positively 
 to a blow on the cheek. The preponderance of the female sex in 
 all these cases of angioma is striking. 
 
 In five instances total or partial excision seemed to me the most 
 suitable proceeding. Occasionally I employed galvano-caustic punc- 
 ture, and in three cases I passed repeatedly through the tumour 
 threads soaked in perchloride of iron. I saw lately a child, twelve
 
 TREATMENT OF ANGIOMA CAVERNOSUM. 89 
 
 years of age^ in whom v. Pitlia had, six years previously, curecl a 
 cavernous angioma by repeated injections with Liquor Perri. It 
 was evident from the cicatrix that the growth must have extended 
 over the left half of the nose up to the internal canthus. Unfortu* 
 nately the eye had become completely amaurotic. An English surgeon 
 informed me that a child, in whom he was treating an angioma of 
 the cheek by the injection of Liquor Ferri, had died suddenly under 
 his hands. Experiences such as these are sufficient to induce me to 
 refrain from this plan of treatment in the neighbourhood of the 
 face, head, and neck. Simple cauterisation with fuming sulphuric 
 acid, can rarely be employed about the face to any great extent, 
 on account of the great superficial contraction that follows. In 
 one case, where I had destroyed a small 'teleangiectasis of the 
 temporal region in this manner with complete success, the cicatrix 
 preserved a deep, reddish-brown colour. Although the part was 
 completely movable and the wrinkles in the skin were not inter- 
 rupted on any slight movement, as for instance, in laughing, yet the 
 red colour of the scar, which could not be completely removed by 
 pressure, caused an unpleasant effect. Evidently there was some 
 yellowish red pigment deposited in the cicatrix. The scar, vv'hich 
 was only three-fourths of a centimetre in diameter, might easily have 
 been cut out, but it disturbed the vanity of the youth too little to 
 induce him to submit to its removal. 
 
 I have never seen a similar result follow after cauterisation ; the 
 cicatrix, after the application of fuming nitric acid, often remains 
 thick and rather painful for a long time, but this disappears after 
 some months, and the cicatrices eventually become as white as in 
 other cases. 
 
 Time has strengthened the favourable impression which I formerly 
 held with regard to the treatment by galvano-caustic puncture of 
 diffused angiomata for which excision was unsuitable. It is very 
 important to watch these cases closely while the sloughs are 
 separating. At this time hsemorrhage often occurs ; care must be 
 exercised, therefore, in treating out-patients by this method. One 
 unfortunate child died from hsemorrhage of this nature, for his 
 neglectful parents did not send for a surgeon until the child had 
 bled to death. In children who are carefully dressed every day in 
 the clinic no bleeding of importance ever occurred. I think, there- 
 fore, that there is no danger in sending the little patients home 
 after cauterisation, provided they be enjoined to come up daily to
 
 90 TREATMENT OF ANGIOMA BY GALVANO-CAUTEUY. 
 
 have the part dressed. In the case of parents who do not look 
 very closely after the lives of their children — which, among poor 
 people, is common enough — we should always take into account a 
 possible want of care, for the consequences of which the surgeon 
 would be held responsible. Recently I have adapted to Paquelin's 
 apparatus a sharp-pointed platinum cautery, which answers very 
 well in cases of angioma. By means of this instrument we are able 
 to dispense with the galvano-caustic apparatus, which in private 
 practice is a great advantage. I have repeatedly employed threads 
 soaked in perchloride of iron. As far as one can judge of the effect 
 a few weeks after the application, the results were good. Of course 
 the cicatrices are no better than after galvano-puncture. Suppura- 
 tion usually follows on the use of the threads, thus bringing about 
 a more decided effect. 
 
 In the treatment of these angiomata, we often find that in cases 
 which are not completely cured at the time when treatment ceases, 
 the remainder of the growth undergoes spontaneous cure. In other 
 cases, again, which are supposed to be completely cured, further 
 growth takes place contrary to expectation. I should not presume 
 to give any decided prognosis as to the permanence of a cure in any 
 particular case. 
 
 Of six cases of plexiform angioma met with at Vienna during 
 1869 — 1870, two were cured by excision of the growth, while four 
 were treated partly by repeated puncture with the galvano-cautery, 
 partly by the galvanic wire. In all these cases the growth was con- 
 genital, and began shortly after birth to grow more or less quickly, 
 in two of the cases reaching such an extent that with other methods 
 of treatment but little could have been accomplished. The treat- 
 ment with the galvano-cautery and the galvanic wire has exceeded 
 my most sanguine expectations. A priori I did not promise myself 
 much from its use, for in order to obtain a cure it seemed to me 
 that the whole of the new vascular formation must be destroyed, and 
 that, therefore, cicatricial contraction would be the same as after ex- 
 tirpation of the growth. The injection of Liquor Terri, in cases of 
 plexiform angioma had not impressed me favourably. I therefore 
 adopted again the plan of destroying these superficial angiomata 
 with fuming sulphuric acid, while moderate-sized tumours of this 
 kind I removed with the knife. In one of my cases, however,! doubt 
 whether any surgeon would have ventured to excise the growth ; 
 the skin of half the nose, the glabella, the whole of the lower eye-
 
 TfiEATMENT OP ANGIOMA BY GALVANO-CAUTERY. 91 
 
 lid, the entire cheek, and half the upper lip were affected. To remove 
 with the knife a growth of this extent in a child is rather too formi- 
 dable an idea ; even if by repeated partial excisions the hsemorrhage 
 could have been obviated, terrible disfigurement must have been 
 left. In Ziirich_, I had already adopted, with success, Nussbaum's 
 recommendation to puncture these angiomata with bundles of red- 
 hot needles ; this process, however, is very tedious, for the needles 
 cool so rapidly that they perpetually require heating again. In 
 cases of large angioma, therefore, the success of each individual 
 operation is but slight, and the parents of the little patients soon 
 lose patience. By thoroughly puncturing the tumour with the red- 
 hot pointed galvano-cautery, taking care, however, to leave small 
 islands untouched, not only are the vessels which are met with 
 destroyed, but, after the loosening of the eschars, the vessels in the 
 immediate neighbourhood also harden. The galvano-cautery should 
 not be raised to a white heat, or bleeding will occur. From the islands 
 of epidermis remaining between the punctures, cicatrisation proceeds 
 rapidly after the swelling has subsided^ i.e. eight or ten days after the 
 operation. Suppuration is often tolerably severe, but I have never 
 seen hsemorrhage occur later on — a matter of some importance. 
 Lately I iiave repeatedly treated children in this way, and sent them 
 home at once. I advise the parents always to apply cold compresses 
 for the first few days, then oiled lint, and direct that the children be 
 brought back to me when the wounds are healed. In treating large 
 teleangiectases of the face, I generally commence by galvano-punc- 
 ture all round the growth, in order to stop any peripheral extension. 
 Especial caution is necessary in the use of the galvano-cautery in 
 the orbital region. I make one of my assistants cover up the closed 
 eye with a wet sponge, so as to leave exposed only tlie part to be 
 operated upon ; the head of the child must be kept absolutely still 
 by another assistant. The operator must learn to manipulate the 
 somewhat long and heavy instrument with great precision. The 
 point should be carried in with a quick touch, as deeply as necessary 
 at the right spot, and must then rapidly be lifted out again, lest the 
 heat emanating from the cautery damage the eye. In carrying out 
 this somewhat difficult treatment I take care to have a firm rest for 
 my arm and hand, and I enjoin my assistants to concentrate their 
 entire attention on what they are doing. A single slip might 
 damage the eye irretrievably. For large angiomata I find the appli- 
 cation of the galvanic wire very practical ; it may be employed in
 
 92 
 
 TREATMENT OF ANGIOMA BY GALVANIC WIRE. 
 
 difiFereut ways. The platinum wire mav be sl)arpened to a needle 
 point, and then carried round the base of the tumour. For the first 
 time this does very well, but later on the wire softens from the heat 
 and the point becomes blunt. Should the tumour offer resistance 
 at any point the wire cannot be got through it. On the whole it 
 is safer to carry the wire round by means of a long, stout, straight 
 needle, passing it through the base of the tumour, or else to thrust 
 a fine trocar beneath the growth, and then pass the wire through the 
 canula. Some bleeding certainly follows, but soon stops when the 
 wire is heated again. In adopting this method the wire should only 
 be raised to a red heat ; if it be made white hot, it cuts too quickly 
 and severe hsemorrhage will be the result. 
 
 Fig. 4.— Mttltiplb Soft Pibko-fattt Tumoubs.
 
 CASE OF MULTIPLE FIBEO-FATTY TUMOURS. 
 
 93 
 
 Multiple soft fihro -fatty tumours. {Leoiitiasis, moUuscum 
 lipomatosicm, elej^ltantiasis arahum)} 
 
 Case. — The patient was 33 years of age, and had suffered from the above 
 affection for thirty-one years. The condition will be best understood by the 
 illustration (Fio;. 4) ; the rii^ht eye was found to be destroyed — probably from 
 panophthalmitis. A few similar tumours, varying in size from a pea to a bean, 
 were found on the back and chest. The vision of the left eye was normal, but 
 the patient was unable to see unless he raised up the folds of the eyelid with 
 his fingers, or arranged iiis hat so to keep the pendulous massesoutof the way. 
 I operated on him on twenty different occasions. The ultimate result is shown 
 in Fig. g. When he left there was a slight ectropium, and he had not 
 recovered any power in his left eyelid. I did not, however, dare to diminish the 
 size of the lid any more, for fear of endangering the cornea. A strip of plaster 
 was applied, so as to keep the fold raised and enable him to see. 
 
 Fig. 5. — The same as in Fig. 4, after Twenty Opebations. 
 
 ' S^e also a cat,t; described, infra. Chap. X, Section A.
 
 94 CASE OF " NEUEOMA PLEXIFOEME " OF OEBIT. 
 
 Xeuro-Jibroma. (" Neuroma plexiforme," Firclwv:.) 
 
 lu 1866 a student, set. 18, of sturdy build, was sent to me. In the left 
 temporal region he had a diffused swelling, which did not project in a globular 
 form, but gave an appearance of widening to the temple, and caused the face to 
 look awry. The swelling extended into the upper eyelid, perhaps also into the 
 orbit, and was uniformly soft, save where some hard cords and nodules could 
 be felt. Probably the tumour was of congenital origin ; it had increased during 
 the last few years so much that the left eye was concealed, and he could not 
 obtain a situation by reason of the disfigurement. 
 
 A more minute investigation of the face and head showed as follows : — The 
 zygomatic arch on the left side was considerably broader and thicker than on 
 the right ; the outer part of the left orbit and the anterior half of the left side 
 of the skull were also widened. lu the left parietal bone, close to the sagittal 
 suture, an opening the size of a bean could be felf, in which the pulsation of the 
 arteries of the brain was distinct. Taking all things together into consideration, 
 I diagnosed a congenital diffused growth of cellular tissue and fat, permeated,by 
 obliterated and dilated blood-vessels. The opening in the skull, most probably 
 congenital, made the extirpation of the tumour from the skull inadvisable, since 
 it was not impossible to tell whether beneath the tumour similar defects in the 
 skull might not exist in the temporal fossa, or further, wliether the veins, which 
 seemed to be obliterated, did not continue into the skull, either connected with 
 the diploic veins or with the sinuses of the dura mater. I was loth, therefore 
 to attempt the removal of the tumour, but yielded to the earnest request of the 
 patient. The skin overlying the tumour was unaltered and was carefully pre- 
 served ; the incisions were made in such a way that no deformity remained 
 after the parts healed. The removal of tlie mass of the tumour was very diffi- 
 cult, partly owing to its situation, and partly from its ill-defiued extent ; 
 however, finally it succeeded completely. Our cliief difficulty lay in removing 
 the portion of the tumour which projected into the orbit without injuring 
 important structures ; unfortunately the greater part of the levator palpebrse 
 had to be sacrificed. I then found that I was dealing with that rare form of 
 morbid growth, a neuroma plexiforme, one case only of which I had previously 
 met with, and that a small growth in the upper eyelid. The parts healed 
 kindly, and the patient was discharged in good condition but with the move- 
 ment of the upper eyelid rather impaired; some ectropium came on later, for 
 which he was operated upon by Professor Horner. 
 
 The examination of the tumour showed that it consisted of tor- 
 tuous bands of a white colour, marked like intestine. The diameter 
 of these fibres, which were with difficulty disentangled, varied from 
 a half to two lines. In section the}' were seen to be of a pale grey 
 colour, and arranged in distinct layers. ^lost of the bands were marked 
 with a central faint yellow dot. Under the microscope these bands 
 were seen to consist of cellular tissue, rich in cells. The centre 
 showed here and there fat detritus ; in the finer bands double con-
 
 CASE OF NEURO-FIBEOMA " CYLINDROMA." 95 
 
 toured nerve fibres could distinctly be recognised. The cords were 
 embedded in, and loosely connected to, cellular tissue containing a 
 quantity of fat. I would have specially remarked that the 
 tumour at the time of the operation was not painful, and had not 
 previously caused any pain, had not this fact been frequently noticed 
 in cases of neuroma. 
 
 Neuro-fibroma. 
 
 The patient was a girl, set. 15. From an early age it had been observed that 
 the right temporal region was rather thicker than the left. The swelling had 
 increased very slowly since its commencement. When admitted, the right 
 temporal region, the outer part of the right upper eyelid, and the upper part of 
 the right cheek were somewhat swollen. The skin of the part was normal in 
 appearance, and the swelling painless. The right eyeball was natural and its 
 movements were not interfered with. The swollen part felt somewhat like a 
 fibroma moUuscum, and several hard nodules existed, which were tender ou 
 pressure. We diagnosed a plexiform neuro-fibroma, probably of congenital 
 origin, as in most of the cases where this part of the body is aifected. The 
 growth was removed by two operations at an interval of sixteen days. 
 Recovery followed, and the disfigurement was completely remedied. The 
 neuro-fibro)nata were embedded in a soft, lobulated fatty tissue. 
 
 The following case, in which a cylindroma,! the nature of which 
 was clearly established by microscopical examination, had not 
 recurred three years after removal, is of such rarity that it deserves 
 to be recorded. 
 
 A. V — , set. 45, had suffered for two years from severe neuralgic pains in the 
 right temporal and supra-orbital regions. Four months previously the exist- 
 ence of a tumour in the right orbit had been established. Vision was not 
 interfered with ; the eyeball was not markedly displaced, nor was the upper lid 
 pushed forward. An incision was made through the upper lid, parallel with 
 the supra.orbital edge. The connections of the tumour to the other contents 
 of the orbit were severed with the scissors, and the growth was then separated 
 away from the orbital roof by means of the raspatory. On the removal of the 
 anterior part of the hard, nodulated tumour, the growth M'as found to extend 
 back behind the eyeball. This was then removed and the rest of the 
 growth extirpated. Three years later we heard that the woman was in good 
 health and free from recurrence, but that still, from time to time, slight sup- 
 puration occurred from the back of the orbit. This might very probably have 
 arisen from some small sequestrum. 
 
 ^ Cf. the author ' Surg. Path.,' Hackley's Trans., p. 635. He there states 
 that no special class can be made of the " Cylindromata " (see another case, 
 infra, p. 118).
 
 9G 
 
 ECHrNOCOCCUS OF ORBIT. 
 
 Echinococcus. 
 
 A child, set. lo, ^vas brought to me with left exophthalmus, which had 
 been gradually formiBg for two years. On admission, I found moderate 
 congestion of the retina, vision much impaired, and diplopia. Fluctuation 
 was perceptible in the tumour. The diagnosis, at first rather doubtful, 
 was cleared up by puncture and the evacuation of some clear, non-albu- 
 minous watery fluid. Rapid swelling followed with chemosis. An incision 
 was made into the swelling, and a large white ecchinococcus sac extracted. 
 The eyeball gradually resumed its natural position ; the suppuration was very 
 slight. When the patient was discharged the diplopia still existed as before 
 the operation. 
 
 Fibroma of the cheek. 
 
 Case. — A strong man, set. 41, was admitted with a tumour, the size of a large 
 
 Fig. 6. — Soft Fibroma, probably originating in the Spheng-maxillary 
 
 Fossa.
 
 CYST OF THE UPPEE JAW. 97 
 
 fist, in the right cheek. The growth had first been noticed nine years pre- 
 viously, probably originating in the spheuo-maxillary fossa. In four years it 
 had reached the size of an apple, and was then removed, but soon recurred, and 
 had continually increased up to admission. The tumour occasioned no pain and 
 had caused no atrophy of the bones. It was removed, and six years later no 
 recurrence had taken place. The growth proved to be a highly cedematous 
 soft fibroma. (See illustration, Fig. 7.) 
 
 Fibroma of t/te paroiid. 
 
 T. S — , set. 4, had a tumour, the size of an orange, which had been growing 
 for one year ; it was removed successfully. The age of the patient and the 
 rapid growth of the tumour render the case a rare one. It proved to be 
 a simple firm fibroma. 
 
 Two cases of cy&t of the upper jaw [hydrops of the antrum ?) 
 
 A woman, ret. 36, with very bad teeth and numerous stumps had a tumour, 
 which had been forming for four years, without pain, and had attained the size 
 of an apple. Distinct fluctuation could be felt. Six weeks previously to 
 admission a tooth had been extracted over the inner half of the cyst, and a 
 quantity of brown, viscid fluid escaped. The swelling soon after again resumed 
 its former dimensions. The bone was not expanded over the tumour, the hard 
 palate was not displaced, nor the eyeball prominent. The swelling was punc- 
 tured from the mouth, above the alveolar process, the fluid evacuated, and 
 tincture of iodine injected. Considerable swelling followed, which lasted for a 
 few days ; the tumour then collapsed. Six months later the cheek was rather 
 drawn in, but there ,was no further accumulation of fluid. The cure was 
 permanent. 
 
 A robust man, ect. 25, had, six months previously, suffered from toothache of 
 a right molar, accompanied by acute swelling : this yielded after a few days, 
 but some enlargement in the alveolar process, close above the first right molar, 
 was left. No pain in the swelling ; the hard palate was arched over the part 
 corresponding to the swelling. When admitted, he had a cyst, the size of a 
 walnut, with thin, bony walls. The outer wall was cut away, and some brown, 
 viscid, ropy matter evacuated. Complete recovery followed. Eight months 
 later the slight depression of the alveolar process, corresponding to the seat of 
 the growth, could scarcely be recognised. 
 
 These two cases fall into the class of those which were formerly 
 spoken of generally as hydrops of the antrum. I do not think 
 that these flat-walled cavities full of brown viscid matter are. 
 dilatations of the antrum. More probably they are formed in the 
 alveolar process, and originate close above the sockets of the 
 teeth. Opportunities of investigating the anatomical condition of 
 
 7
 
 98 
 
 EPULIS. 
 
 such cysts in the upper jaw are rare, and the correctness of the 
 different views is therefore not easily ascertained. 
 
 "While at Zyiirich I met with nine cases of osteo-fibro-sarcoma 
 (epulis) growing from the alveolar process, all of which were in 
 women : six were on the lower and three on the upper jaw. Since 
 
 Fig 
 
 OsTEO-CrrONDKO-T'lBKOMA OF THE LoWER JaW. 
 
 these tumours usually project forwards from one of the alveoli, it 
 is often a simple matter to remove them from the bone, but this is 
 not always sufficient ; it is necessary to bring about the exfolia- 
 tion of the small bony surface on which the tumour lies, with the 
 actual cautery, or else to remove a portion of the bone. This need
 
 POLYPUS NASI. NASO-PHAEYNGEAL POLYPUS. 99 
 
 not be done, perhaps, always on the first occasion, but should in- 
 variably be practised after the first recurrence. In two cases in 
 which repeated recurrence took place, the bone tissue of the maxillae 
 became gradually atrophied. An extensive resection of the superior 
 maxilla was found necessary, after which no fresh recurrence took 
 place. In one other case, at the third removal of the tumour by 
 means of bone forceps, the inferior maxilla was fractured. Osseous 
 union followed. 
 
 Osteo-cJiondro-fihroma oftlie lower jaw. 
 
 The tumour shown in the ilhislration (Fig. 7) was met with in a woman, 
 thirty-five years of age, in whom it had existed for thirty-five years. She was 
 operated upon by Dr. Menzel, but died of erysipelas. A full record of the case 
 will be found iu the ' Archiv. f. kL Chirurg./ I Heftj Bd. siii. 
 
 Polypus nasi. 
 
 In large polypi my practice is invariably to break off the lower 
 turbinated bone, as by this means recurrence is best obviated. 
 Naturally, reaction is greater than after simple extraction of the 
 polypus. In one case erysipelas followed the operation. The other 
 patients recovered rapidly and completely. After two or three com- 
 plete removals recurrence does not usually take place. 
 
 Naso-pharyngeal Polypus. 
 
 It is remarkable to observe how frequently polypus-nasi occurs 
 in men, especially those between ten and thirty years of age. In 
 this respect, these new formations resemble sarcoma of the jaw. 
 
 In eight cases osteoplastic resection of the jaw was performed, 
 and the tumour was then removed with the ecraseur or the galvano- 
 caustic loop. The stumps of these polypi can often be felt some 
 weeks after operation, but new polypi do not always develop and 
 many of them atrophy. In small polypi rhinoscopic examination 
 is of importance.
 
 100 CASES OF NASO-PHARTNGEA.L POLYPI. 
 
 Fibro-cavernous naso-pTiaryngeal polypi, 
 
 E. K — , set. 23, of strong constitution, was admitted in Januaiy, 1861. 
 For two veai-s he had noticed a gradually increasing obstruction of the right 
 nasal cavity. Six weeks previously a surgeon had attempted to remove a 
 tumom- from this cavity ; profuse haemoiThage followed the attempt, but 
 nothing was brought away. On examination, I found a fibrous polypus 
 attached to the base of the skull, and extending into the right nasal cavity 
 and antrum ; the right side of the palate was thinned and pushed forward. 
 Von Langenbeck's osteoplastic resection of the right nasal process of the upper 
 jaw was performed, and the tumour was removed with the knife and scissors. 
 The skull was seen to be somewhat thinned. On the third day symptoms 
 of meningitis set in, with repeated rigors. Death took place on the eighth 
 day after operation. Post moi-tem : a gap in the basilar process of the 
 sphenoid bone was found. Purulent meningitis and abscesses in the lungs. 
 
 E. Y — , set. 22, a small, weakly man, had for two years noticed difiBculty 
 of breathing through the nose, which for the last twelve months had been 
 completely stopped up. A large naso-pharyngeal fibroid polypus was made 
 out, extending from the right nasal cavity, behind the velum and up to 
 the cheek. The anterior and posterior walls of the antrum had been absorbed 
 by pressure ; the right half of the nose was much swollen. I operated as 
 follows : — An incision was made, which commenced at the glabella, extended 
 down by the side of the nose, and was then continued below, close to the 
 septum nasi ; another from the glabella, along the lower edge of the right 
 orbit ; a thii'd fi'om the right ala of the nose, parallel with the mouth, extend- 
 ing outwards for an inch and a half. These incisions were carried through 
 the nasal bone and the upper jaw by the key-hole saw ; the sawn portion of 
 bone was then lifted up like a lid ; the polypus thus plainly rendered visible 
 was carefully removed with knife and scissoi*s fi"om its attachments, and the 
 detached bone pressed back and kept in position by skin sutures and a com- 
 press. The wound healed by first intention, and the patient was discharged 
 in seventeen days. Nine months later he was in good health and free from 
 any recurrence. 
 
 J. D — , set. 27. Previous health good. In 1866, at the battle of Konigs- 
 gratz, he fell off his horse and bled at the nose and mouth. Towards the 
 end of the year he observed some difficulty of breathing, and his comrades 
 complained of his loud snoring at night. Gradually the symptoms increased, 
 and at times he had severe hsemon-hage. He had been often advised to sub- 
 mit to operation, but could not bring himself to agree to it. At last the 
 difficulty of breathing became so great that he could only sleep in a sitting 
 position, and was much weakened by loss of blood. The jwlypus was attached 
 at the upper part and on the right side of the phaiynx by a tolerably broad 
 base. It extended into and completely filled up the pharynx, so that it was 
 visible below the soft palate. Since the nasal cavity was too naiTow to admit 
 of the use of the ecraseiu- with any certainty, I performed osteoplastic resec- 
 tion of the nasal process of the upper jaw, and removed the polypus by means 
 of the galvanic wire.
 
 CASES OP NASO-PHARTNGEAL POLYPI. RANULA. 101 
 
 He recovered, and a year later I saw him again. There was no 
 recurrence ; both nasal cavities were perfectly free, no deformity 
 existed, and the cicatrix was scarcely visible. There was, however, 
 slight epiphora. 
 
 F. M — , set. 41, noticed first in January, 1869, some obstruction of the left 
 nasal cavity, and pain in the forehead ; by July, 1869, the left side of the 
 nose was completely choked up. A polypus was then removed by Professor 
 von Dumreicher by the forceps, and the patient was discharged a few days 
 later. Shortly after the operation the obstruction returned, and now extended 
 into the right nasal cavity. On the admission of the patient a tumour, 
 having the circumference of a small apple, with a gangrenous surface, was 
 seen lying behind the velum. Superiorly the growth was attached to the 
 upper part of the pharynx on the right side. The growth was removed 
 ■through the right nasal cavity by means of the ecraseur. On further exa- 
 mination after the operation a second small tumour, with a similar attach- 
 ment, was found on the left side, and this was removed in the same way 
 through the left nasal cavity. Discharged recovered. Fifteen months later 
 lie wrote and informed us that he was free from all recun^ence and able to 
 breathe without hindrance through either side of the nose. 
 
 F. H — , set. 19, had suffered for three years from difficulty of breathing 
 through the nose, swelling of the right half of the face, and frequent 
 severe epistaxis from both nostrils. For the last few weeks deglutition had 
 been interfered with. "When admitted the whole of the right upper jaw was 
 prominent ; the anterior wall of the antrum reduced to a thin lamella ; the 
 right eyeball pushed forward, and on a higher level than the left. The hard 
 palate on the right side was thinned and yielded to pressure ; the velum wa« 
 pushed forward as far as the middle of the tongue ; the tumour entirely 
 filled the pharynx, as well as the right nasal cavity. He was able only to 
 count fingers with the right eye. The growth was removed with complete 
 success by Dr. Menzel. An incision was carried down the side of the nose • 
 and through the upper lip. The remnants of the right superior maxilla were 
 removed, and a tumour, the size of the fist, laid bare. This had a tolerably 
 broad connection to the lower surface of the body of the sphenoid, a portion 
 of which was removed, together with the tumour, but the cavity of the skull 
 was not opened ; the eyeball was preserved. No improvement of vision is 
 recorded. Nine months later he was well, and free from recurrence. 
 
 Eanula. 
 
 "While at Ziirich I met with two cases in which sebaceous 
 contents were found ia the ranulae : one was in a child of four 
 years old, possibly a cyst in connection with the branchial fissure ; 
 the other in a young man. In both the cysts were slit up, and 
 .their walls united bv sutures to the mucous membrane of the
 
 102 TEEATMENT OF EANULA. 
 
 mouth ; considerable swelling of the parts beneath the tongue fol- 
 lowed. The sutures were removed after four days, and recovery 
 was permanent in both patients. 
 
 Formerly, my practice was to lay open the cysts from the 
 mouth, as extensively as possible, and then to unite the wall of the 
 cyst to the mucous membrane of the mouth ; where the ranula 
 consists of a sebaceous cyst, I should still do this, having pre- 
 viously washed out the sac thoroughly. Lately, however, I have 
 preferred to pass a thick silk thread from the mouth through the 
 upper wall of the ranula, and then to knot it in the mouth, without 
 drawing the string very tight. If the wall of the cyst is not too 
 thin the threads are allowed to remain three or four weeks ; they 
 then fall out, and the cysts shrink up and are cured. Most of 
 these cases were treated as out-patients. They did not usually 
 come before us unless the swelling was very considerable ; some- 
 times they did not return for many months after the threads had 
 been inserted, when the latter were found sometimes crusted over, 
 but still in position. If the cyst wall be very thin, and the thread 
 tied very tightly, the latter cuts its way through in a few days, 
 and then the growth is sure to refill. If the operation is con- 
 ducted in the way I have described it is of so trifling a nature 
 that it does not matter if it requires to be repeated, in case the 
 opening in the cyst happens to close up prematurely. The remark- 
 able preponderance of ranula in the female sex is very striking . 
 
 Congenital papilloma of the tongue. 
 
 A youth, set. 13, was admitted for a remarkable kind of degeneration of 
 the upper surface of the tongue. The organ was rough, uneven, and covered 
 with growtlis of various sizes, from one to two lines in height, composed of 
 soft hypertrophied papillae. This condition had been observed in a slight 
 degree from the time of birth. From time to time little ulcers had fonned 
 and slight bleeding had taken place. Kecovery followed after repeated 
 removal with the scissors and galvano-caustic pimcture. 
 
 Sebaceous cyst. 
 
 A cyst, the size of a bean, which had commenced four months previously, 
 was removed from the upper part of a tongue of a child set. 1 2 ; the whiteness 
 of the sac gave the tumour the appearance of a cysticercus, but it proved on 
 microscopic examination to be sebaceous, probably of congenital origin.
 
 CANCER OF THE FACE. 103 
 
 Sectio]s p. — Malignant Tumours. 
 
 Cancer of face — Cases. Cancerous ulceration of cJieeJc leading to 
 necrosis of jaw. Case of rodent nicer {?) ; remarhs. Notes on 
 epithelioma of the face ; of Up. Cotses of sarcoma of cheek. 
 Cancer of salivary gland, tongue, etc. ; remarhs. Sarcoma of 
 salivary glands ; remarhs. Case of medullar]/ lymphoma of 
 tonsils; death. Case of alveolar cancer of tongne. Ligature 
 of lingual artery for cancer. Remarks on cancer of tongue — 
 Cases. Sarcoma of orbit ; mixed celled ; " psamtnon ;" 
 periosteal. Exploratory puncture of orbital tumours — Case. 
 Cylindro- sarcoma. Cancer of orbit ; removal. Hernia cerebri, 
 etc ; recovery. Sarcoma of lower jaw ; central ; periosteal. 
 Note on maxillary tumours. Sarcoma of nose. Malignant 
 polypi of nose. 
 
 Cancer of the face. 
 
 K. S — , set. 50, had had for eight years a wart on the left ala of the 
 nose, followed by ulceration and the formation of crusts. On admission, the 
 left ala of the nose was completely destroyed, and the superficial cancerous 
 ulceration of the skin spread over the cheek to some extent. The defect in 
 the cheek was supplied by a flap transplanted by a sliding movement, and 
 the left ala replaced by skin borrowed from the right side of the nose. The 
 parts healed by first intention. 
 
 As far as the appearance of the patient was concerned the result 
 was not good ; the flap made by the sliding movement became 
 oedematous and thickened— a condition however, which would tend 
 to improve. The thin skin over the left ala of the nose shrivelled 
 up, and the nostril in consequence was much narrowed; this latter 
 imperfection might probably have been improved by the introduction 
 of laminaria tents and lead tubes. No further record of the patient 
 was obtainable. 
 
 P. B— , ajt. 61. The nose had been excoriated by a fall two years pre- 
 viously ; following this a small knot developed slowly at the end of the 
 nose, which by degrees spread over the ala and invaded the left cheek. 
 
 This was a case of infiltrated cancer, growing rather rapidly. The defect 
 in the cheek was made good, as in the previous case, by skin borrowed from 
 the cheek, and then complete rhinoplastic from the forehead was performed ; 
 six weeks later the bridaie was cut through. Although healing did not
 
 104 EHINOPLASTIC OPEEATIONS. 
 
 follow by first intention, the ultimate result was good. Two years later she 
 had no recun-ence, and was able to breathe well through the nose. 
 
 These two cases were so far peculiar that in both a considerable 
 portion of the cheek was destroyed as well as the nose. In such 
 instances the surgeon may proceed in different ways. Formerly, it 
 was the rule to make the flaps from the forehead of such shape and 
 size that they covered the whole of the defect. The result of this 
 usually was that the new nose did not fit well where the flap from 
 the forehead passes over to the cheek. I have preferred therefore, 
 in such cases, after complete excision of the diseased part, to 
 commence by closing the defect in the cheek, leaving then only a 
 raw surface, suitable for the appHcation of the new nose. This is 
 covered from the forehead in the ordinary way. In order to close 
 the defect in the cheek, the skin must be drawn over after that 
 horizontal incisions have been made, either above, below, or on both 
 of these places. In this way a flap, with a broad base externally, can 
 be obtained, or else, according to the form and situation of the gap, a 
 flap from the cheek must be made with its base either directed 
 upwards or downwards. If made in the latter way the parts are 
 apt to remain cedematous for a long time ; in all cases the defect in 
 the cheek should be closed in such a way that there is no tension 
 or lateral traction on the edges of the wound to which the skin 
 forming the nose is applied. 
 
 B. U — , tet. 58. Six years before admission a knot, the size of a lentil, 
 appeared on the left ala of the nose, which during the next five years grew 
 but slowly ; it scabbed over, and at times bled. The year following, the 
 ulcer began to increase more rapidly. On admission, almost the entire nose, 
 and a portion of the upper lip below the septum was destroyed by the 
 superficial cancer of the skin. The whole ulcerated surface was cut away, 
 and a rhinoplastic operation from the forehead performed. The skin of the 
 forehead was rather thin. The pedicle was formed at the upper part of the 
 inner palpebral angle. As far as appearance went, the result was not good, 
 for, from the thinness of the skin and subsequent shrinking, the nose was 
 not sufiiciently prominent. The condition was but little improved by sub- 
 sequent operation. 
 
 In rhinoplastic from the forehead, I prefer to make the pedicle 
 as deep as possible, and find it best to use the skin in the neigh- 
 bourhood of the glabella. By this method the cicatrix of the fore- 
 head is smaller and shorter than when the pedicle of the flap is 
 taken from above the eyebrow ; if the pedicle be cut thick, the 
 greatest care must be exercised not to miscalculate the length of the
 
 EPITHELIOMA OF CHEEK AND LOWER JAW. 105 
 
 flap. In the last-mentioned case I made this mistake. I tried then 
 to obviate it by freeing as much as possible the pedicle of the flap 
 towards the orbit, and the new nose was certainly united successfully 
 in this way. Its direction was, however, at first somewhat crooked, 
 and had to be corrected subsequently. Nor was this the only 
 mishap. In order to make the pedicle of the flap as thick as possible 
 I had removed the periosteum from the glabella as far as the internal 
 palpebral ligament. Two days later a prodigious exophthalmus came 
 on, evidently from oedema of the tissues around the bulb. For a week 
 the condition was very critical, and I feared lest suppuration should 
 occur in the orbit. Fortunately, then the swelling disappeared 
 spontaneously, and no damage to the eye resulted. 
 
 M. S — , set. 52, was admitted with an ulceration of the left cheek, which 
 had extended far into the mouth and gradually attacked the lower jaw. The 
 disease had existed one year. When I first saw the patient I doubted 
 whether it was a case of necrosis of the jaw, or a carcinoma with foul 
 discharge. The mouth could only be opened to a very small extent. On a 
 more minute examination I found the lower jaw in the neighbourhood o£ 
 the first molar tooth completely destroyed (spontaneous fracture) ; the entire 
 posterior half was bare and necrosed. I removed the portion of bone some- 
 what forcibly, and was able to twist it away at the joint without using any 
 cutting insti-ument. I thought now for certain that the case was one of 
 simple necrosis of the jaw, but in order to make sure I examined some 
 shreds of gi-anulations which were attached to the extracted bone ; on these 
 were found undoubted elements of epithelial cancer. The patient died a few 
 days later of septica3mia. 
 
 I have examined many cases of carcinoma of the jaw, but I never 
 previously saw the disease lead to complete necrosis of the bone. 
 Such a result can evidently only be caused by a complete breaking 
 down of the new formation. 
 
 M. D — , set. 33. Syphilis or cancer? The nose was swollen and stopped 
 up, the hard palate completely ulcerated and softened, the soft palate gone, 
 and superficial ulceration was evident in the pharynx. Some of the sub- 
 maxillary glands were hard and enlarged. The disease, which had existed 
 for three years, and commenced with dysphagia, infiltration, and pain in the 
 «oft palate, had been considered by everybody who saw it to be of a syphilitic 
 nature. Antisyiihilitic remedies of various kinds had been employed, but 
 without any success. I myself was forced to conclude that I had before me 
 a rare form of syphilis. The patient was so strong, and the course of the 
 disease so gradual that the other alternative, viz. epithelial cancer, could not 
 be entertained. Professor Hebra, whom I consulted about the case, held 
 that it was an epithelial cancer ; in order to make sure, I removed a small 
 portion and examined it microscopically. It proved to be a cancer. We
 
 IOC EPITHELIOMA OF THE FACE AND JAW. 
 
 ceased to torment him any longer with remedies, and he was discharged. 
 Fourteen months later we heard that the unfortunate man was still alive, 
 but in a deplorable condition. Finally the ulceration spread to a most 
 tenible extent (see Fig. 8), and he died six yeai-s and a half after the first 
 commencement of the disease. 
 
 Fig. 8. — Cabcikomatous Ulcekatiox of the Face and Jaws. 
 
 This case is one of extreme rarity, since it forms an exception to 
 the rule, that cancers originating in the mouth develop rapidly. 
 It is a form of carcinoma which seems somewhat analogous to the 
 superficial cancer (ulcus-rodens) of the skin. It certainly gradually 
 destroys the bones, but very slowly, and is especially characterised 
 by very late infection of the lymphatic glands. I remember to have 
 seen five or six cases where superdcial epithelial cancer of the nose, 
 the cheek, or the eyelids, lasted from ten to fifteen years, and finally
 
 CANCER OF THE FACE AND LIPS. 107 
 
 destroyed the whole of the upper jaw or the bones of the skull, 
 without infiltrating the lymphatic glands. That such a form of 
 cancer ever began in the mouth was to me a new fact. 
 
 All the cases observed at Ziirich were — with one exception — 
 superficial ulcerated epithelial cancer. With regard to recurrence in 
 these cases, I should mention that this mostly occurred after 
 removal of portions of the skin overlying bone. I could not always 
 persuade myself to entirely remove a bone to all appearance per- 
 fectly healthy, or even to remove much of it. In some cases, as, for 
 instance, when the frontal or ethmoid bone were affected, this was 
 not possible. What I have learnt from these cases, however, would 
 induce me to cut more boldly hereafter than I have in the past. 
 According to my experience, it may be laid down almost as a 
 principle that, when a patient who has been operated on for 
 cancer of the face or lip has no recurrence either continuous or 
 infective in the lymphatic glands from six to eight months later, 
 there is the greatest probability that, at the least for many years, 
 often for the rest of his life, he will have been cured by operation. 
 Local recurrences coming on after the lapse of some years, com- 
 paratively frequent in the case of sarcomata, are very rare in cancer 
 of the face. It becomes still more urgently important, therefore, 
 to operate as early as possible and to operate freely. 
 
 From a list of 252 cases it was shown that the lips were more 
 frequently attacked with cancer than any other part of the skin of 
 the face. The lower lip and the angle of the mouth are especially 
 hable to this disease. Primary cancerous diseases of the upper lip 
 are exceedingly rare. The great preponderance of the male sex is 
 shown markedly by the list of patients (196 male^ 56 female), and 
 the same difference between the relative frequency with which the 
 sexes are attacked shows itself also, though to a less extent, in 
 cancer of the upper parts of the face. Operations for cancer of the 
 skin of the eyelids, and also of that of the face generally, show a 
 much larger mortality than when the lip or the skin of the nose was 
 afi'ected. I am unable quite to account for this. In all these 
 groups of operations, some part or other of the bones was at 
 times laid bare or resected, but not more in one group than in 
 another. In some of these cases plastic operations were performed 
 subsequently, but this will not account for the difference of the 
 mortality, which was twice as great in the two groups of cases first 
 mentioned.
 
 108 EPITHELIOMA OF THE LIP. 
 
 Cancer of the Face, Nasal and Obal Cavities.^ 
 
 Epithelioma of the lip. 
 
 Of thirty cases occurring in my practice at Zurich, twenty-nine 
 were on the lower and one only on the upper lip. The duration of 
 time which the patients allowed to elapse from the commencement 
 of the disease up to the first operation varied exceedingly. Any 
 attempts to make use of records with regard to recurrence, exten- 
 sion of degeneration, and especially of the infection of the lymphatic 
 glands, meets with insuperable obstacles. The greatest variations 
 are found in respect of the rapidity of growth, and the time at which 
 the glands become infected. The impression that I have formed is 
 that, speaking generally, the progress of the disease is slower in 
 proportion to the lateness of the age at which it first occurs. 
 Further, when the disease commences with the formation of epithe- 
 lial scabs and fissures on the edge of the lip (i.e. superficial 
 epithehal cancer, starting from the rete Malpighii) the progress is 
 more slow, and the lymphatic glands are afi'ected later, than when 
 the cancer commences in tlie form of small nodules in the substance 
 of the lip, or as ulceration on its inner surface {i.e. infiltrated 
 glandular follicular epithehal cancer) . This last form attacks the 
 glands remarkably early. 
 
 All the thirty cases mentioned were operated upon. In some of 
 them the operation extended beyond the lip, when infiltrated glands 
 in the neck required removal. In cancer of the hp I never 
 employed drugs, and have been no case hitherto in which any im- 
 provement followed local remedies. On the other hand, I have seen 
 numerous cases where the patients have been tormented with the 
 repeated application of caustics, which have done no good. Some 
 highly satisfactory results are shown in my tables. Nine of the 
 patients were so far improved by operation that they were in the 
 best of health from two to seven and a half years afterwards. In 
 five others recurrence followed so rapidly after operation that we 
 could only suppose that some of the growth had been left behind. 
 Most operators are very sensitive to any suggestion that any rem- 
 nants of cancer have been left behind in the patients who have been 
 
 ^ Elaborate statistical tables will be found in the ' Ziiricher Bericht,' pp. 
 120-144.
 
 INFECTION OF LYMPHATIC GLANDS IN EPITHELIOMA OF LIP . 
 
 under their care ; it is certainly a reproach, but not always the 
 operator's fault. I have occupied myself a great deal in the inves- 
 tigation of tumours, and fancy that I am able to recognise all the 
 different forms on section when fresh. I must, however, admit that 
 under some circumstances it may be exceedingly difficult to know 
 exactly whether all the disease has been removed, especially in 
 operations that are conducted in deeply lying parts, as the neck, 
 uterus, or rectum. Not infrequently the conviction is forced upon 
 you too late that it is impossible to remove all the disease without 
 running a fatal risk. When patients comeback early to the surgeon 
 with " continuous^ recurrence " in the lip, a thorough new opera- 
 tion should be performed. This can be done with good prospect of 
 success, as in the case of a young man who had some cancerous 
 nodules in his lower lip, which had been growing for a year and a 
 half; these were removed. The disease soon recurred and grew 
 rapidly. The prognosis seemed very bad. The growth was freely 
 removed, and five years later he was quite well. We must acknow- 
 ledge how powerless we are against cancerous infections of the 
 lymphatic glands. At the time of operation the affection may be so 
 slight as to escape detection by touch. When removed the number 
 of glands, especially in the neck, is often so great and the region is 
 so difficult for the operator, that some, which though very small are 
 already aflected, may very easily be overlooked. My advice is to 
 operate on cancer of the lip as on other carcinomatous growths as 
 soon as ever the diagnosis is established, and before the lymphatic 
 glands become affected. If surgeons would act on this principle the 
 cure of these cases by operation would not only be more frequent, 
 but, I trust, might even become the rule. 
 
 Sarcoma. 
 
 A man, set. 63, had five years previously observed the development of a 
 nodule in his right cheek. In the course of two years it had attained the size 
 of a hen's egg, and broke into the cavity of the mouth, discharging pus and 
 some small lumps of fleshy appearance ; the opening closed. A year later a 
 new formed tumour, which had reached the size of a fist, broke again into the 
 cavity of the mouth ; the wound again closed up and healed and the swelling 
 markedly diminished. Since that time the tumour had again gi-own to the size 
 of a man's fist, and when the patient came under treatment was scarcely 
 
 * " Continuirlich."
 
 110 CANCER OF MUCOUS MEMBRANE, ETC. 
 
 movable on the upper jaw. The tumour, which proved to be an encapsuled 
 fjstic myxo-sarcoma, was shelled out without the removal of any part of the 
 bone. Eecoveiy followed. Four years later the patient was in good health, 
 though the tumour recurred shortly after the operation and became ulcerated, 
 without, however, augmenting to any great extent. 
 
 Infiltrated sarcoma. 
 
 F. S — , set. 40, fell, when twenty yeai-s of age, on to the right side of his 
 face. Considerable swelling occurred, which never entirely disappeared but 
 gradually went on to the formation of a slow gi-owing tumour. Four years 
 after its origin v. Pitha removed the growth, resecting at the same time the 
 whole thickness of the jaw. The patient then remained well for sixteen 
 yeare ; then a new tumour occun-ed in the portion of the right side of the 
 jaw which had been left, and in six weeks had attained the size of the fist, 
 causing very severe pain. The growth was removed, and the portion of the 
 jaw exarticulated. Convalescence was rapid, but recuiTence soon took place 
 again. Tlie growth was again removed, but once more the tumour recuiTed 
 and earned oft" the patient, a year and two months after the commencement of 
 the second srrowth. 
 
 Cancer, of the Mucous Membrane and adjoining Organs — 
 Salivary Glands, Tongue, and Cavity of the Nose. 
 
 Anatomical investigations have led me to the conclusion, that 
 cancer of the upper jaw and the cavity of the nose mostly 
 originates in the follicles of the mucous membrane of the antrum, 
 nasal cavities, palate, or gums. In the lower jaw it is easy by 
 observations on patients to show that the disease starts from the 
 lip, the mucous membrane of the mouth, the tongue, or the parotid 
 gland, and spreads over on to the bone. I have never seen, 
 hitherto, a genuine primary cancer of the lower jaw. It is a remark- 
 able fact that the soft medullary cancers of the upper jaw and the 
 cavity of the nose very rarely affect the lymphatic glands of the 
 neck. Even when the glands are attacked it occurs very late; 
 this may partly be explained by the anatomical conditions. Perhaps 
 the mucous membrane of the nose and antrum is poorly supplied 
 with lymphatics. As yet we do not know much about this. 
 
 With respect to the etiology, I have already stated that I entirely 
 acknowledge the influence of local irritations on the origin of cancer; 
 still I am of opinion that such irritation only then leads to the 
 formation of a tumour, or to the direct development of cancer, if
 
 CANCER OF MTTCOUS MEMBRANE, ETC. PAROTID TUMOUES. Ill 
 
 the affected individual be predisposed to it by hereditary causes, age, 
 etc., whether such predisposition be considered chiefly local or 
 general. Incidental causes are always inquired into, but compara- 
 tively seldom can anything definite be discovered ; thus, in my list 
 of cases repeated attacks of erysipelas, injuries, blows, burns, irri- 
 tation from stumps of teeth, cicatrix of an abscess, and the like, are 
 given as the causes of origin. Of eighty-nine cases, I have myself 
 examined post mortem eighteen, and have never found any cancer in 
 the internal organs. This, as contrasted with my former experiences 
 at Berlin, appears to me worthy of remark. In one case, besides a 
 superficial epithelial cancer, I found a contracted carcinoma of the 
 breast. Investigations as to the hereditary tendency to cancer or 
 a " tumour diathesis " were exceedingly difficult, inasmuch as in 
 Zurich, among the common people, the term " tumour '' is used 
 indiscriminately to signify furuncle, abscess, swelling of the joints, 
 etc., so that I can give no reliable information on this point. 
 
 Very peculiar forms ofsarcomaaremet with in the salivary glands, 
 and the diagnosis often presents great difficulties, which can only be 
 cleared up by very careful examination under the microscope. 
 
 Even with this aid pathologists do not always agree. Difficult 
 questions often arise, such as a differential diagnosis between alveo- 
 lar plexiform sarcoma, and carcinoma. I will only consider for the 
 moment the parotid gland. In these cases, many clinical symptoms 
 have to be taken into account to assist our diagnosis. I never hesi- 
 tate to pronounce a parotid tumour to be carcinomatous when it is 
 absolutely immovable, hard and ulcerated, and when the cervical 
 lymphatic glands are affected. In small tumours of the parotid 
 region (say up to the size of a hen^s egg), occurring in persons on 
 the wrong side of forty, tlie immobility, pain, cicatricial contraction in 
 the growth, facial paralysis, etc., would lead me to judge that the 
 case is one of carcinoma. 
 
 Most of these tumours of the parotid gland^ are myxo-sarcomata, 
 or enchondromata, the latter being sometimes cystic. In the great 
 majority of cases facial paralysis follows after the operation. In 
 only one case (that of a rapidly growing granulation sarcoma) , which 
 was not operated upon, was it due to the pressure of the tumour. 
 When the trunk of the nerves was cut through in the parotid the 
 paralysis was permanent. In those cases where single branches only 
 
 ^ These remarks refer to the cases under observation and treatment 
 between i860 — 1876.
 
 112 CANCER OP THE TONGUE. 
 
 were divided, improvement followed in the course of a year or so 
 and in some instances the paralysis completely disappeared. The 
 majority of the tumours originated between the ages of ten and 
 thirty. 
 
 Medullary lymphoma of tlie tonsils and the sulmaxillary lymphatic 
 
 glands. 
 
 J. T — , set. 62. The tumour, whicli was of moderate size, had been 
 noticed four weeks previously, first externally, later internally. The velum 
 on the right side was pushed forward to a gi'eat extent, and the tumour 
 bulged out from beneath it ; breathing and swallowing were difficult. 
 Osteoplastic resection of the lower jaw was performed and the tumour com- 
 pletely extirpated. The operation was long and very extensive, and death 
 took place fi'om exhaustion two days later. 
 
 Alveolar cancer of the tongue. 
 
 J. F — , set. 57. Five months previously a small lump had appeared in the 
 left half of the tongue, which grew rapidly, and caused pain. The tumour, 
 which was the size of a walnut, was removed by the ecraseur. The growth 
 was of a veiy peculiar character, showing a combination of a branching chon- 
 droma with alveolar cancer (Driisenkrebs). 
 
 Eighteen months later he was seen again. There was then no 
 recurrence in the tongue or swelling of the lymphatic glands. He 
 died a few months later of lung disease. 
 
 W. K — , set. 57j had first noticed pain and hardness of the right half of 
 the tongue six weeks before admission ; a cancerous ulcer, which extended far 
 back, was seen on the right side of the tongue ; no enlarged glands could be 
 felt ; he could only open the mouth to a small extent. In order to avoid 
 hfemon-hage as much as possible, I commenced by ligaturing the right lingual 
 artery. I perfoimed the operation lege artis, but had most extraordinary diffi- 
 culty in discovering the artery. Finally, I thought I saw it pulsating, and placed 
 a ligature round it. The mouth was then forced open, and it was found that 
 the disease involved the inner surface of the lower jaw on the right side. I 
 completely resected the diseased portion of the maxilla, and was then able, 
 very conveniently, to remove the whole diseased portion of the tongue as far 
 back as the larynx ; this was done with great care. 
 
 Had I knovrn previously that it would have been necessary to 
 extirpate the lower half of the jaw, I should naturally not have 
 ligatured the Ungual artery. In removing the lower and under
 
 LIGATUEE OF LINGUAL ARTERY FOE CANCER OF TONGUE. 113 
 
 portion of the tongue, tolerably free hsemorrhage occurred from the 
 lingual artery, and I had my doubts as to whether this vessel had 
 actually been tied. The patient died two days later of septicaemia. 
 Post mortem, we discovered that the lingual vein had been ligatured 
 instead of the artery. Every surgeon knows the difficulty of tying 
 the lingual artery in old people ; the vessel lies so deep that it is 
 very difficult to distinguish it from thick-walled distended veins, 
 especially when owing to heart disease — as in this case — the veins 
 pulsate. Never previously had I met with a lingual vein of such 
 thickness. In the dead subject the veins are usually empty, and 
 the conditions are so different that no opportunity is afforded for 
 practising properly these delicate, but — under some conditions — very 
 valuable operations. 
 
 Cancer of the tongue and the mouth. 
 
 Of forty-eight cases met with between i860 — 1876, forty-two 
 were operated on ; fifteen died after operation, three died from 
 other accidental circumstances. The disease commonly begins 
 between 50 and 60 years of age, but one of my patients was 70 
 years old, and two others between the ages of 27 and 29. A man, 
 in whom the disease had extended far back into the pharynx, died 
 from pericEsophagitis, mediastinitis and septic pleuritis, which were set 
 up by the passage of a probang through the walls of the oesophagus. 
 In one man the lingual artery was ligatured on both sides, in the 
 liope that the infiltration of the tongue in the cavity of the mouth 
 might diminish. However, the ligature led to no good results, nor 
 did any rapid breaking down of the already ulcerated new formation 
 occur. 
 
 In thirteen cases I operated from the neck ; eight of these patients 
 died after the operation. In one instance the lower jaw was sawn 
 through at the side, and an ivory plug was introduced into the medul- 
 lary cavity. Death followed from osteomyelitis of the lower jaw. In 
 thirty-two cases I removed the cancer from the mouth, in twenty- 
 one instances I ligatured the artery on one side, and in two on both 
 sides. Altogether, including the case mentioned above, the lingual 
 artery was ligatured twenty-seven times ; no secondary hsemorrhage 
 ever followed. The wounds always healed satisfactorily, and since 
 I took to inserting a small drain, usually closed by first intention.
 
 114 KEMOVAL OF TONGUE FOR CANCER. 
 
 ficrasement I have of late discarded, but on five occasions I 
 removed the growth with the galvano-caustic loop. However, I 
 have quite given up both these methods, for the following reasons : — 
 ist. In separating the tongue longitudinally, haemorrhage cannot 
 be completely guarded against : even if the platinum wire be only 
 moderately heated the loop cuts its way too easily and quickly, as 
 the bundles of muscle are arranged parallel to its track. 2nd. 
 Bleeding does not occur from the fore part of the tongue to 
 any great extent, and by means of the knife the removal of 
 the cancerous disease can be more accurately effected. 3rd. In 
 cases where the degeneration of the tongue extends far back and 
 reaches low down, it is not easy to be sure of removing all the 
 diseased portion with the loop, by reason of the irregular depth to 
 which the disease extends. Small fragments remaining on the 
 cauterised surface cannot be readily recognised, and even if they are 
 detected, their subsequent removal is usually attended with con- 
 siderable bleeding. Finally, excision with the galvano-caustic loop 
 gives no security against diphtheritic disease of the wound, and one 
 of my patients died from this affection. 
 
 Latterly I have given up uniting the operation wounds by 
 sutures. I cannot assert that the sutures bring about any evil 
 results, but I find that patients have much less pain after the opera- 
 tion if no sutures are inserted, for the tongue does not swell so much 
 and the secretion of saliva is much less in amount and does not last 
 so long. When portions of the floor of the mouth were excised, an 
 opening was always made towards the neck, in order to facilitate the 
 discharge of the secretions. This arrangement is very comfortable 
 for the patients. 
 
 As regards removal of the tongue from the neck, different opera- 
 tions have been proposed and practised by Regnoli, Czerny, and 
 myself, but I regret to say that the hopes which I formerly enter- 
 tained have, unfortunately, not been confirmed. "Wider experience 
 of the operation seems to show that it is of a more dangerous 
 character than from the first few cases it appeared to be. In a list 
 of thirteen such operations, eight deaths were recorded ; diphtheritic 
 inflammation of the surface of the wound, followed sooner or later by 
 metastatic affections, was in all the cause of death. We took the 
 utmost precautious in order to obviate, if possible, this diphtheritic 
 inflammation of the mouth; the mouth and the teeth were always 
 carefully cleansed for several days beforehand. Solutions of per-
 
 DIPHTHEEITIO INFLAMMATION OF MOUTH. 115 
 
 manganate of potash were repeatedly tried. I applied sometimes 
 strong chloride of zinc solution to the fresh wounds. In many cases 
 I united the mucous membrane with sutures in such a way as to 
 establish, for the first few days, a sinus through which the secretions 
 might drain away ; but even all these precautions are not sufficient 
 to guarantee against the occurrence of diphtheritic inflammation of 
 the mouth. A remarkable and interesting fact was often noticed at 
 the post-mortem examinations of these cases, namely, the existence 
 of numerous abscesses in the brain. Diffuse meningitis is often found. 
 In two cases, indeed, this latter affection was diagnosed during 
 life from the hemiplegia, which in one instance came on suddenly, as 
 in apoplexy. It seems that in many cases at least the inflammatory 
 process does not extend by thrombosis and embolism, but rather 
 spreads along the sheaths of nerves, such as the lingual nerve. In 
 one instance it was possible to prove this by a preparation. Lobular 
 embolic pneumonia,^ manifested by small lobular inflammatory areas, 
 seems to be the most common direct cause of death in these patients 
 after operation, as also in cases of resection of the lower jaw ; it is 
 much less often associated with pleuritic eflfusion than the small 
 secondary embolic abscesses of the lung. The mere fact that the 
 small bronchi are full of mucus, purulent catarrhal secretion, or blood, 
 does not of itself entail any great danger, so long as the power of 
 expectoration is good. But the minute diphtheritic particles find 
 their way into the bronchi from the wound surface in the mouth 
 (especially when the power of swallowing is impaired), and affect not 
 only the bronchial mucous membrane, but the very substance of the 
 lung. This variety of broncho-pneumonia (capillary bronchial 
 diphtheria) is so much the more injurious, for often for many days 
 there is scarcely any power of expectoration. 
 
 In 1877 (at Vienna) I gave up the operation for removal of the 
 tongue from the neck, and adopted the plan of cutting through the 
 jaw at the side, and thus obtaining access to the deeper parts, 
 following in this v. Langenbeck^s example, the advantages of which 
 over my own method I fully recognise. I cannot for the present 
 say whether there is any difference in the mortality after the two 
 operations. The results of removal of cancers in this region are, 
 on the whole, very unfavourable as regards recurrence; even very 
 extensive operations give no better results. Only by operating 
 at an earlier period can this state of things be improved. In 
 ^ " Fremdkoi'per Pneumonie."
 
 116 CASES OF SARCOMA OF THE ORBIT. 
 
 very few cases were the patients free from recurrence for any 
 number of years. Somewhat larger is the number of those in 
 whom after operation on the tongue, recurrence does not take 
 place locally, but in the lymphatic glands. This happened in 
 about one third of my cases ; in two-thirds of the cases recurrence 
 took place in the neighbourhood of the cicatrix and in the lymphatic 
 glands a few months after recovery from the operation. 
 
 Cancer of the tongue is a remarkably common affection in 
 Vienna. 
 
 Small-celled granulation sarcoma and mt/xo-sareoma of the orbit. 
 
 J. F — , ffit. 55, a stout, strong man, had noticed six years preTiously that his 
 right eye was becoming prominent. On admission, the eiophthalmus wa« 
 excessive. The tumour moved uniformly and equally with the eye, but the 
 movements to the right side were much more limited than to the left. The 
 right comea was softened and completely destroyed ; the left eyeball intact. 
 From the nature of the movement an intraocular tumour was diagnosed ; the 
 whole contents of the right orbit were removed, including the periosteum. 
 Close to the foramen opticum the bone was so thin and soft that we had to 
 proceed with the greatest caution ; it was doubtful, therefore, whether the 
 extirpation was complete. The tumour lay between the eyeball and the 
 muscles, completely surrounding the former but without growing into it. 
 Recovery followed. At the bottom of the orbit granulations could be seen, 
 but so far as could be made out there was no recurrence when he was dis- 
 charged. Eight months later we heard that the tumour had recun-ed in the 
 oi-bit, but it seems probable that this was only a little hypertrophy of the 
 cicatrix, for a year and a half after he wrote that he was in good health, and 
 able to follow his profession as a teacher and an organist. 
 
 The case shows that, notwithstanding the apparently unfavourable 
 conditions of tumours of this nature, they can be extirpated success- 
 fully; without operation death must soon undoubtedly have 
 occurred. Unfortunately successes like these are only too rare. 
 
 Psammon- sarcoma ( Virchotv) of the orbit. 
 
 S. B — , set. 16. Eight years previously exophthalmus had been first noticed, 
 and the Aosion shortly afterwards became impaired. The tumour, which deve- 
 loped gradually, gave no pain. On admission a gi-owth of the size of the fist 
 projected from the right orbit, and the eyelids were increased to nearly 
 double their natui'al size ; still, they could be completely shut and opened. 
 An immovable atrophied bulb was seen on separating the eyelids. The orbit«
 
 EXAMINATION WITH NEEDLE IN ORBITAL TUMOURS. 117 
 
 were distinctly widened, especially externally. The tumour was not sensitive 
 on pressure. Pricking sensations were felt in the tumour on touching or 
 combing the right side of his head ; no pain in the head ; general condition 
 good. The tumour was removed from the orbit ; this was followed by such 
 bleeding and collapse that the patient's life was with difficulty saved at the 
 time. A few hours after the operation vomiting occurred, followed by un- 
 consciousness, and he died six days after the operation. Post mortem : 
 extensive suppurative meningitis was found, especially on the right side. The 
 tumour had broken into the orbit above, and on the inner side extended 
 somewhat into the cavity of the skull and suiTounded the atrophied optic 
 nerve. The tumour proved to be a psammon-sarcoma (brain-sand tumour)j 
 possibly commencing from the sheath of the optic nerve. 
 
 Ossifying periosteal sarcoma on the upper edge of the orbit. 
 
 T>. D — , set. 32. A year previously he noticed a tumour situated on the 
 upper border of the orbit. It grew rapidly, pushed the eyeball forward to 
 some extent, extended upwards on to the frontal bone, and was immovably 
 connected to the skull. No headache or pain in the growth, which was of 
 the size of a small apple. The operation which was undertaken for its 
 removal was not completed ; the tumour, which had penetrated into the 
 cranial cavity, could not be separated away from the bone, and was only partly 
 removed. Death followed after twenty -four hours, with the same symptoms 
 as in the previous case. Post mortem : we found projecting into the ante- 
 rior fossa of the skull a tumour the same size as that which was visible 
 externally. 
 
 These two cases afford a further illustration of the importance of 
 puncturing with a grooved needle in cases of orbital tumours, so as 
 to be to some extent sure that the bony walls of the orbit still exist. 
 It may certainly be urged against this proceeding that if the bones 
 were destroyed serious consequences would ensue if the needle 
 were passed into the brain substance. But no great danger results 
 from such an injury — at least, I know that in tumours of the bones 
 of the skull I have often been sure that I have punctured the brain 
 substance with the needle, but no harm has followed. I can only 
 remember one case in my experience, in which an abscess of the brain 
 was found after examination with the grooved needle ; here, however, 
 there was no proof that the two were related as cause and effect. 
 The case was that of an old woman, who had a large carcinoma on 
 the forehead. The ulcerated surface was punctured on several occa- 
 sions, and a gap in the frontal bone, the size of a five-shilling piece, 
 detected. On discovering this von Langenbeck declined to operate. 
 Cerebral symptoms occurred and the patient died some time later.
 
 118 CASE OF ORBITAL SAECOMA : NEEDLE EXAMINATION. 
 
 The dura mater was found cancerous and thickened ; at the apex of the 
 left anterior lobe of the brain was an abscess, the size of a hen's egg, 
 whose anterior wall was soldered to, and in part formed by, the dura 
 mater. The abscess, therefore, might possibly have been caused by 
 inflammation extending from the cancerous ulcer ; at the same time^ 
 it must be admitted that it might have originated from the repeated 
 needle punctures. Considering that this doubtful case is the only 
 one which I can recall contra-indicating examination by the needle, 
 it seems to me scarcely sufficient to cancel the great advantages of 
 this method of examination. Cases do certainly occur in which 
 recovery follows the removal of tumours, notwithstanding the 
 opening of the cranial cavity, and in spite of the removal of the 
 diseased degenerated dura mater. When such cases do occur, they 
 may afford some consolation, but my experience does not encourage 
 me to push operative surgery much further in this direction. 
 
 In the following case the result of examination with the needle 
 induced me to undertake an operation which, from all other condi- 
 tions, seemed to be almost hopeless. 
 
 CylindrO'iarcoma. 
 
 Frau C. S — , set. 28, came under my treatment in December, 1870 ; she 
 was a pallid brunette, of moderate stature, rather emaciated. In October^ 
 iS62,she first noticed a hard knot, the size of a pin's head, situated in the skin 
 of the eyelid, near the middle of the right upper orbital edge. It increased 
 gradually with pain, and in the course of a year had become the size of a 
 pigeon's qs^^. The eyeball was displaced downwards and forwards, and the- 
 power of vision was somewhat impaired. When in this condition she was 
 operated upon by Professor Balassa in Pesth. From the report of this 
 surgeon, it appears that the tumour lay deep down in the orbit over the upper 
 half of the bone, and was drawn forward and removed, together with the 
 periosteum ; the eyeball was preserved, although the power of vision and 
 movement remaining in it was but little. A year later recurrence took place 
 in and about the cicatrix ; the gi-owth of the tumour was this time slower, so 
 that, up to the time when I saw her, it had taken six years to reach the size 
 of a hen's egg. Severe pain occasionally occurred, extending over the whole 
 forehead ; the right eyeball was much displaced forwards and downwards ;, 
 lateral movements were somewhat, vertical movements much, impaired. Sh& 
 could only count fingei-s at a distance of three feet. Some separate promi- 
 nent nodules of the hardish in-egular tumour were very painful. Examina- 
 tion with the needle showed that the tumour was everywhere finnly connected 
 with the skull, and the bone offered resistance. It was found impossible- 
 during the operation to preserve the eyeball. A portion of bone had to be 
 removed with the gouge from the upper border of the orbit, and a part of the;
 
 HERNIA CEREBRI AFTER OPERATION RECOVERY. 119 
 
 tumour was lifted out from the right frontal sinus, into which it had extended 
 by pressure. The tumour, as had been diagnosed, proved to be a typical 
 cylindroma. The patient recovered. 
 
 The following case is one of extraordinary interest in the follow- 
 ing particulars : — (i) that after the operation, prolapsus cerebri took 
 place into the orbit ; (2) that this was complicated with aphasia and 
 paresis of the opposite half of the body; and {3), most remarkable 
 of all, that these conditions after a time disappeared, and the 
 patient again recovered complete health. 
 
 B. T — , set. 47, had a superficial destructive ulceration of the left half of 
 the nose and eyelids, extending into the orbit. This had commenced as a 
 nodule, close to the inner angle of the left eye, eight years previously. 
 During the operation, the entu-e orbit had to be scraped out with a raspatory, 
 for everywhere suspicious nodules could be felt. The cancer for the most 
 part was superficial, and the bones on exposal seemed to be free of disease. 
 At one point, however, just above the lachrymal bone, a gap the size of a 
 bean was seen. The diseased part was removed with great care and caution ; 
 after this was done the pulsations of the brain were distinctly seen at this 
 spot. The brain seemed to be covered by roughened dura mater. The 
 patient, who was much distressed by the long operation and the plastic pro- 
 cedure following it, had moderate fever during the next few days. He 
 vomited repeatedly, complained of headache, and was not always quite clear 
 in his mind. An ice-bladder was kept continually applied to his head after 
 the operation. We expected suppurative meningitis ; however, the vomiting 
 ceased on the third day, and the pain diminished. From the third to the 
 Seventh day the fever diminished in the most satisfactoiy way. The 
 sequel of the case was most remarkable. Hernia of the brain sub- 
 stance, the size of a small walnut, took place through the gap into the 
 orbit. On the fifth day the tongue could not be protruded, but if it were 
 pulled out he could draw it back again. The cornea of the right eye, which 
 alone existed, possessed scarcely any sensation, and could be touched without 
 making the patient blink. The patient could see and hear, and gave signs 
 that he could understand whatever was said to him, but he could not speak. 
 Phonation, however, was not completely lost, for when in pain he uttered 
 cries. If he were spoken to he waited a moment, then shrugged his 
 shoulders, to intimate that he could not express his thoughts. He made the 
 same movement if he were asked to write. He could swallow without diflS- 
 culty, and refused any kind of food or drink which was forbidden by his 
 Jewish co-religionists. He was dumb, but not without power of thought and 
 reason. Thus, he made signs when he required the bed-pan or porringer to 
 void his urine. He could stand up, and with support walk a few steps, but the 
 right half of the body was weaker than the left. This condition continued, and 
 we feared, therefore, that a fatal issue could not be far off. On the eigbt day 
 he had an epileptiform attack, which lasted for half an hour. During this 
 the convulsive movements in all his limbs were so severe that in spite of the
 
 120 
 
 CENTRAL SABCOMA OF THE LOWER JAW. 
 
 nurse's support he fell out of bed. On the fifteenth day after the operation 
 undoubted symptoms of improvement first showed themselves, and quickly 
 followed one after the other. The tongue could again be protruded, but for 
 some day always was directed rather to the left. The first word which the 
 patient was able to utter was " heiss ; " then he commenced to write, and 
 stated that he could not speak. On being asked why not, he only shrugged 
 his shoulders. Gradually, however, speech returned, the weakness of the right 
 side disappeared, and the cornea again became normally sensitive. By the 
 twentieth day after operation the disturbance of the activity of the nerve 
 system had disappeared. On the seventh day after operation febrile sym- 
 ptoms had disappeared, but he had a f ebricula remittens, with somewhat severe 
 exacerbations, on the ninth, fifteenth, and sixteenth days. The prolapsed 
 brain in great measure returned, though not completely. Later on, the orbit 
 was covered in by a flap taken fi-om the forehead, in order to prevent, as far 
 as possible, any injury to the exposed part of the bi-ain. Four months 
 after admission he was discharged. The cancer recurred, and he died two 
 years after the operation, twelve yeai-s after the commencement of the 
 disease. 
 
 Central sarcoma of the lower Jaw. 
 
 The tumour represented in the illustration occurred in a vexy anaemic girl, 
 set. 14, and had existed for four- years. I sawed through the jaw near the right 
 
 Fig. 9. — Cexthal Sabcoma of the Lowru Jaw.
 
 PERIOSTEAL SARCOMA OF THE LOWER JAW. 
 
 121 
 
 canine tooth, and disarticulated the bone on the left side. Death took place 
 a few hours after the operation from exhaustion. This case ig also 
 described in v. Pitha and Billroth 's * Chirurg.,' Bd. ii, 2 Abth., p. 459. 
 
 Periosteal sarcoma of the lower jaw. 
 
 K. T — , set. 26, had noticed for nine months a swelling near the left tem- 
 poro-maxillaiy articulation. In the course of three months it had reached 
 the size of a hen's egg. The tumour then began to increase with great 
 rapidity, and spread over the whole of the lower jaw, reaching the size shown 
 
 Fig. 10. — Periosteal Saecoma of the Lower Jaw. 
 
 in the illustration. The patient could not completely close her mouth, and 
 was only able to swallow fluids ; the respiration was quite free. After con- 
 sultation with my colleague, v. Dumreicher, I decided against operation, as 
 we felt sure the patient would have died from the hsemorrhage. The dis- 
 articulation must be rapidly accomplished in such cases or the haemorrhage 
 may prove fatal.
 
 122 COMPARISON OP TUMOUKS OF UPPER AND LOWER JAW. 
 
 Tumours of the Lower and Upper Jaw. 
 
 It is interesting to compare the relative frequency of diseases 
 occurring in the upper and lower jaw. In the upper jaw, cystie 
 tumours are more common. Epulis-sarcoma occurs equally in both. 
 The encapsuled form of central osteo-sarcoma is pecuhar to the lower 
 jaw. On the whole, the development of sarcoma is somewhat more 
 common in the lower jaw, though not markedly so. My numbers 
 are too small to allow me to make any positive statements on this 
 point. 
 
 Cases of infiltrated and periosteal sarcoma of the jaws are very 
 unfavourable, for the patients usually die early of recurrence of the 
 growth. The duration of life in these cases varies from nine months 
 to two years. Operations for sarcoma of the lower jaw are more 
 dangerous than in the upper. 
 
 Spindle-celled sarcoma of the nose. 
 
 A. S — , set. 63, came under treatment in November, 1870. His previous. 
 health had been good, but nine months before admission the left nasal cavity- 
 became blocked up, as if he had a bad cold. For six months bleeding had at 
 times occurred from the nose, and the left half of the organ was pushed to- 
 one side by a tumour developing within the cavity. Caustics had been 
 applied unsuccessfully. From time to time small portions of the tumour 
 came away. When I saw him the left nasal cavity was completely filled up 
 by a tumour, which had a pedunculated attachment to the mucous membrane 
 of the septum. The nose was slit up and the tumour removed, together 
 with a portion of the septum. In April, 1871, he came back to me with 
 a recurrence of the growth, which filled up the left nasal cavity and infil- 
 trated the skin of the nose. The submaxillary lymphatic glands were enlarged 
 and soft. The tumour was removed, but it recurred, and a few months later 
 had again filled up the cavity, while the neck was extensively invaded by 
 malignant deposit. The disease lasted altogether a year and a half. The 
 growth proved to be a soft spindle-celled sarcoma. 
 
 K. S — , set 9. In July, 1877, 1 removed with the galvano-caustic ^craseur 
 some fibro-sarcomatous polypi from the nose. Some polypi remained behind, 
 which were extracted a month later, after the nose had been previously slit 
 up. Two months later osteoplastic resection of the upper jaw was found 
 necessary, in order to remove some fresh growths. These were excised and 
 the surface cauterised. Numerous tumoure were found attached by broad/ 
 bases, so that it was not possible to be certain at the operation whether all 
 the small i-emnants adheiing to the bone were removed. A few Aveeks aftet
 
 MALIGNANT TUMOURS OP NOSE. 123 
 
 the child was discharged new symptoms of recurrence took place, and the 
 patient was readmitted in a state of dyspnoea, with the left side of the face 
 enormously swollen and the eyeballs prominent. Resection of the upper 
 jaw was performed, and the base of the tumour scared with the actual cautery. 
 Eighteen months later he came back to me again, free from recurrence and 
 in perfectly good health ; inasmuch as the former recui'rences had always 
 taken place immediately after the operations, there seemed to be some hope 
 that he might now be freed from these troubles. At any rate, there was 
 manifestly no tendency to continuous recurrence. 
 
 Considering the fibro- sarcomatous character of these tumours, it 
 was of course impossible to predict whether local recurrence might 
 not take place.
 
 CHAPTER YIII. 
 
 DISEASES AND INJUEIES OF THE NECK. 
 
 Section A. — Miscellaneous. 
 
 Acute cellulitis. Case of cut-throat. Case of clonic spasm of 
 sttrno-mastoid muscle. Tumours : — Case of cavernous blood 
 tumour; case of cavernous lymph tumour and varix lym- 
 phatictis. Case of congenital cyst. Case of serous cyst. Case of 
 superficial ulcerated sarcoma. Case of stricture of the oesopha- 
 gus — malignant, syphilitic, traumatic. Case of congenital 
 diverticulum of the oesophagus. Case of branchial fistula. 
 Case of syphilitic stricture of pharynx. Foreign bodies in the 
 oesophagus — Cases. Foreign bodies in larynx — Cases. Cases 
 of tubercular disease of larynx. Case of extirpation of larynx 
 and bronchocele. Case of papillary cancer of the trachea y 
 removal. Case of stricture of trachea. Case of cancer of 
 thyroid and trachea ; removal. Laryngotomy and tracheotomy 
 in croup and in other diseased conditions. 
 
 A FEW cases of deep suppuration in the cellular tissue, occurring 
 without known cause, came under treatment. The symptoms were 
 very severe, and a long time elapsed before the abscess presented 
 externally. In all the cases, as early as possible, careful dissecting 
 incisions were carried down to the abscess. One man, thirty-three 
 years old, died of septic fever with mediastinitis and pleuritis. A 
 man, fifty-two years of age, died from sudden profuse haemorrhage 
 causing suffocation. The left superior thyroid artery, which lay 
 on the wall of the abscess, was found to be ulcerated through. An 
 opening also had formed in the left wall of the pharynx. 
 
 The cause and origin of these phlegmonous inflammations, most 
 of which go on to suppuration, is by no means always clear. In 
 one of my cases it was due to perichondritis of the larynx; in 
 another I think acute parostitis about the angle of the lower jaw set
 
 CUT THEOAT — CLONIC SPASM OF STBRNO-MASTOID. 125 
 
 up by carious teeth, was the source of disease,, which was un- 
 accompanied by any suppuration of the periosteum proper. 
 
 These inflammations at times assume a diphtheritic character. 
 It is with the diphtheritic nature of the process that I connect the 
 almost stony hardness of the infiltrated tissues and the severity of 
 the general symptoms; this view is further evidenced by the 
 rapid collapse, great quickness of the pulse, complete suppuration 
 and sloughing of the extensively infiltrated tissue, the slow healing, 
 and tedious convalescence. In many cases these iiiflammations are 
 parossal, originating in the neighbourhood of the vertebrae, and 
 sometimes, also, they may be set up by acute infection of the deep 
 lymphatic glands. 
 
 Cut-throat. 
 
 In one case, where a man had attempted suicide, the wound extended through 
 the thyroid cartilage in such a way that the vocal cords were cut through. 
 Partial necrosis of the cut edges of the cartilage followed, and the Tocal 
 cords shrank up completely. Although stenosis was prevented by the early 
 introduction of large tubes, yet no power of speech was recovered. Dr. Gus- 
 senbauer, who gave the utmost attention to this patient, constructed an arti- 
 ficial larynx, which the patient, who was a man of some intelligence, learned 
 to use to such good purpose that he could be distinctly understood at a 
 distance of two rooms. 
 
 Clonic spasm of the sterno-mastoid muscle after a gunshot wound. 
 
 A. H — , fet. 42, had received a gunshot wound fourteen years previously ; 
 the bullet, which had entered close to the right ala of the nose, had broken 
 off all the back teeth in the upper jaw, and had then been spat out in a 
 flattened-out shape. Numerous necrosed fragments of bone separated subse- 
 quently, and recovery was very tedious. Seven years after the injury spas- 
 modic twitchings commenced in the right sterno-mastoid. At first they 
 occurred but occasionally, then became more frequent, and gradually extended 
 over the whole right half of the face. When I saw the patient the spasms 
 were almost incessant, and affected also, at times, the muscles of the throat 
 During sleep they ceased. The patient had been treated by subcutaneous 
 injections, and every kind of drug supposed to be of use in such cases, but 
 without any benefit. 
 
 I examined repeatedly to see if I could find any deeply situated 
 foreign body, such as a portion of the bullet, but never succeeded 
 in doing so. At the request of the patient on two occasions I 
 divided the right sterno-mastoid muscle subcutaneously, but no 
 improvement resulted.
 
 126 OASES OF SIMPLE TUMOUES OP NECK. 
 
 Cavernous hlood tumour. 
 
 A tumour of this natai'e, the size of a large chestnut, was found in the 
 subcutaneous cellular tissue of the inner edge of the stemo-mastoid muscle. 
 The patient was fourteen years old, and the tumour had existed for four 
 years. The growth was removed and recovery followed. Four large veins 
 required ligature. 
 
 Cavemoica lymph tumour. 
 
 J. P — , aet. 23, had noticed three years previously a swelling beneath the 
 chin ; this gradually increased without giving any pain, and on admission was 
 the size of a hen's egg. A cystic growth was diagnosed. On cutting down, 
 I came upon a thin-walled cyst ; this was opened, and a little clear yellow serum 
 escaped. Behind this lay another small cyst, which was readily emptied by 
 pressure. I now came down upon some cavernous tissue, from which all the 
 fluid soon ran out. The growth then so collapsed that much difficulty was 
 experienced in removing it. The tissue, on the most careful examination, 
 seemed in no way to differ from that of a cavernous blood cyst. 
 
 Varix lymphaticus. 
 
 A man, aet. 36, had had for many years a distinctly fluctxiating tumour, 
 the size of a hen's egg, in the posterior triangle of the neck. Some serous 
 fluid was drawn off, containing only a few colourless blood-cells. Some 
 iodine and water was injected, and the cyst shortly after shrank up com- 
 pletely. 
 
 Congenital cyst. 
 
 F. M — , aet. seven months, was stated by the surgeon who had attended him 
 to have been bom with a tumour, the size of an ostrich's eg^, on the left side 
 of his neck. Distmct fluctuation was evident in the swelling, which was very 
 translucent. When two days old the cyst had been punctured, and a thin, 
 yellow, serous fluid was let out. The skin over the tumour collapsed, together 
 with the sac of the cyst, so as to form a Aviinkled mass. Two months after- 
 wards the cyst had again filled up to the size of an apple ; it then shrank 
 up again to the size of a walnut, although nothing was done to it. Six days 
 before admission the tumour had again begun to grow, and the skin over- 
 lying it had become swollen and red. The patient was feverish. Suppura- 
 tion was suspected, and some pus was let out through a puncture. As this 
 treatment obviously could not have effected a cure, I laid open the anterior 
 wall of the cyst. On introducing the finger I found several septa in the 
 cavity ; I broke through these without causing any bleeding, and could then 
 pass my finger right back to tlie anterior surface of the vertebral column. 
 Eemarkably slight reaction followed this operation, and in a month the 
 cavity had completely closed up.
 
 9EE0US cyst: malignant STEICTURE op (ESOPHAGUS. 127 
 
 Probably this was a case of congenital cystic hygroma. The 
 child went on well, and when he came back to me, some time after, 
 was well developed. The skin of the neck on the right side was 
 rather wrinkled, but in other respects there was nothing abnormal 
 to be seen. Behind the posterior edge of the sterno-mastoid the 
 finger could be pushed in quite up to the vertebral column. 
 
 Serous cyst of the neck. 
 
 G. H — , aet. 30, was admitted in June, 1870. In March, 1869, lie had 
 suffered from pleurisy of the left side, which had confined him to bed for 
 three months. Immediately after this he first noticed a soft painless tumour, 
 the size of a hazel nut, above the left clavicle, which increased slowly but 
 constantly. When he was admitted the cyst was of the circumference of a 
 good sized apple, and fluctuated distinctly. The cyst was punctured, some pure 
 serum escaped, and the sac then completely collapsed. I immediately injected 
 some tincture of iodine, with an equal amount of water, and let the injection 
 out again after ten minutes. Moderate reaction followed ; absorption was 
 very gradual ; a year later we heard that the tumour had gradually dis- 
 appeared entirely. 
 
 The case may have been one of lymphangioma or a lympb varix, 
 possibly originating from compression of the thoracic duct by the 
 pleuritic exudation. 
 
 Superficial ulcerated sarcoma, 
 
 A woman, £et. 53, found, when she was sixteen years old, a wood tick 
 (Jxodjes ricinus) in the skin over the subclavian triangle. This she drew out. 
 A small nodule remained at the spot, which increased slowly but continually 
 for thirty-seven years. The lymphatic glands in the neighbourhood were not 
 enlarged. The tumour was removed, and three years later the patient was 
 free from recuiTence, and perfectly well. 
 
 Cancerous Stricture op the CEsophagus. 
 
 Most of these cases were treated by the introduction of 
 bougies. In one case the cancer of the oesophagus was com- 
 bined with an aneurism of the arch of the aorta. No internal 
 cancerous deposits were found post mortem. Under some cir- 
 cumstances it may be just as difficult to introduce a sound 
 through a stricture of the oesophagus as through a stricture 
 of the urethra. In the former case, the patient may still be
 
 128 MALIGNANT STEICTUKE OF (ESOPHAGUS. 
 
 able to swallow pulpy food just as in the latter he may still be 
 able to pass the water in a tolerably large stream. Both strictures, 
 therefore, may be permeable, and yet will not admit an instrument. 
 In strictures of the cesophagus the difficulty may be due to the fact 
 that the dilatation above the stricture is so considerable that the 
 point of the bougie becomes lost in the sacculation, and so fails to 
 hit on the point of constriction. If the stricture be caused by a 
 tumour in the wall of the oesophagus, and this wall is felt to be 
 hard and irregular, it is sometimes impossible to work through it 
 by ordinary elastic sounds, or even the best made English instru- 
 ments. In the case of an elderly gentleman who was only able to 
 swallow pulpy food, but who could swallow this with tolerable ease, 
 I was unable, like some other surgeons who had made attempts, to 
 pass the ordinary instruments through the narrow part of the 
 oesophagus, even after much trouble. I then had a long conical 
 sound of lead made ; with this I was easily able to pass through 
 the stricture, merely allowing the instrument to find a way through 
 by its own weight. The daily dilatation with the bougie for car- 
 cinomatous strictures is the only thing that we can do to preserve 
 the unfortunate patient from death by starvation. I am certain, 
 however, that this daily stretching and irritation of the carcinoma 
 hastens its softening. I saw a case once, in Berhn, where a carci- 
 noma of the oesophagus had made its way through into the left 
 lower lobe of the lung, so that the patient, who was accustomed to 
 pass an instrument every day for himself, thrust it into one of the 
 bronchi. I know of another case where the bougie perforated the 
 aorta. " Also vorsicht.'^ 
 
 Cicatricial stricture of the cssopliagus of st/philitic origin. 
 
 A man, set. 55, had suffered for some months from cataiThal inflammation 
 of the back of the throat, accompanied by much slimy discharge. Just 
 behind the cricoid cartilage a small annular conti-acted area could be felt. 
 Broad condylomata were seen about the angles of the mouth and the tongue. 
 Deglutition was much interfered with. Under treatment for six weeks 
 with the Decoctum Zittmanni and the use of bougies during six months, he 
 completely recovered. I saw him two years after this, and he was then 
 perfectly well. 
 
 The following case of traumatic stricture of the oesophagus is 
 remarkable : 
 
 A man, ajt. 25, of slight build, had a veiy tight stricture of the oesophagus,
 
 TRAUMAUTIC STRICTURE OF THE (ESOPHAGUS. 129 
 
 the result o£ swallowing some caustic soda. It was only just possible to pass 
 a small instrument through it. The instrument had been passed several 
 times, and one morning went through so easily that I passed immediately 
 after a tliicker conical sound. This was introduced slowly, but not without 
 some little pressure and difficulty : the patient suddenly complained of intense 
 pain, whereupon the instrument was immediately withdrawn. The same day 
 he became very feverish, and complained of piercing pains in his right side ; 
 the breathing too became veiy laborious, and pleurisy, with some effusion on ' 
 the right side, was discovered. In the course of the next few days, the pleu- 
 ritic effusion increased, the patient became collapsed, and died. Post mortem : 
 pleurisy was found on the right side, as we had expected, and some mediasti- 
 nitis at the back, but there was no injury to any part of the oesophagus. 
 
 The dilatation, although gradual, had evidently set up inflammation 
 of the cellular tissue around the stricture, which by continuity of 
 structure had extended to the pleura. This process was new to me 
 in the case of the oesophagus, though I had occasionally seen it in 
 the treatment of urethral strictures. My colleague, Rokitansky, 
 who had the kindness to examine the preparation, and was able to 
 convince himself that there was no laceration of the oesophagus, not 
 even an abrasion of the mucous membrane, informed me that he 
 had already seen similar cases ; he suspected that, in consequence of 
 the stretching of the cicatricial tissue of the stricture, some injurious 
 matter had filtered through from the oesophagus into the mediastinal 
 cellular tissue, and had there set up inflammation. 
 
 Traumatic stricture of the (xsophagus. 
 
 M. L — , aet. 4, had a stricture of the oesophagus, resulting from swallowing 
 some caustic soda five months previously. This was dilated by means of 
 bougies, and the child became able to swallow its food with tolerable ease. 
 She came to us with the history that she had been unable to swallow any- 
 thing for twenty-four hours. A medical man had repeatedly endeavoured to 
 introduce a bougie, but had been unable to get through the stricture. 
 
 The attempts had given the child much pain, and caused some bleeding. 
 When admitted the patient was much collapsed, the temperature low, pulse 
 scarcely perceptible, and the face cyanosed ; the tissues of the neck emphy- 
 sematous, and dyspnoea marked. We diagnosed perforation of the oesophagus 
 and consequent inflammation of the deep cellular tissue of the neck. 
 Tracheotomy was immediately performed, but the child died the same 
 evening. The stricture was found aftei-wards to lie on a level with the cricoid 
 cartilage . At this point there was a perforation of the oesophagus, leading 
 into the posterior mediastinum, in which a cavity full of blood was found.
 
 130 CONGENITAL DIVERTICULUM OF OESOPHAGUS. 
 
 (hngeniial diverticulum on the left side of tTie oesopJiagtis. 
 
 This case did not occur in my practice, and the only specimen 
 that I know of which illustrates this very rare condition is a pre- 
 paration presented to the Ziirich Museum by Dr. Biihler, whose 
 description I here append. 
 
 " The preparation was taken from a woman £et. ^6, and shows a diverti- 
 culum of the CESophagus, about the size of a duck's egg. The history was not 
 clear, but it seems that she had had a tumour on the left side of the neck for 
 many yeai"s, which was subject to occasional enlargement. Some of the food 
 used to enter tliis quasi-stomach, and would remain there for a considerable 
 time. In order to render swallowing easier, and in pai-t also to empty the sac, 
 she was accustomed to make pressure externally. When she did this the 
 food, altered by acid fermentation, regurgitated with a kind of retching and 
 produced a most disagreeable taste. In this way she could make the tumour 
 disai^pear. When full the sac caused some neuralgic pains by pressing on the 
 brachial plexus : this she could relieve by squeezing out the contents." 
 
 The patient died of tubercular peritonitis. Dr. Biihler looked 
 upon the affection as one of congenital origin. 
 
 With this view I must concur. The inlet of the diverticulum 
 was about the size of a florin ; the sac itself was formed of the 
 mucous membrane and muscular coats of the oesophagus. The 
 mucous membrane showed no trace of cicatrix. I could not clearly 
 make out from the preparation the level at which the diverticulum 
 opened into the cesophagus, but it must have about corresponded to 
 that of the cricoid cartilage. Examination of the preparation led 
 me to the conclusion that the diverticulum had been formed by the 
 partial closing of one of the branchial fissures externally, while the 
 internal opening had remained patent. I thought that this view 
 had not been previously suggested, but I find a similar explanation 
 in V. Bardeleben's surgery. 
 
 Branchial fistula. 
 
 Karl L — , set. i8, had from his birth a small sinus connected with the 
 pharynx on the right side of the hyoid bone. The opening was covered by 
 membrane. If milk were injected into the sinus it passed down into the 
 thvoat.l 
 
 ' Full references to the literature of this subject will be found in a paper 
 by Sir. J. Paget, in 'Med.-Chir. Trans.,' 1878, vol. Ixi, p. 41. [Ed.]
 
 rOEEIGN BODIES IN (ESOPHAGXIS. 131 
 
 Extensive cicatricial stricture of the pharynx of syphilltie origin. 
 
 A man, set. 40, came to tlie hospital with respiration and deglutition much 
 impeded. On opening the mouth a singular spectacle presented itself. The 
 cavity behind the base of the tongue was shut off by a smooth diaphragm, in 
 the centre of which was situated an opening of the diameter of a penholder ; 
 through this opening he breathed and took his food. The nares also appeared 
 to be completely closed up at the back ; evidently this remarkable condition 
 had resulted from cicatrisation following ulceration of the inner edges of the 
 velum and the doi^sum of the tongue, which had become united together. It 
 appeared that he had sufEered for some three years from ulceration about the 
 neck, and had been treated partly with Zittmann's decoction and partly with 
 inunction and iodine. He left before any treatment could be adopted. 
 
 I had intended to dilate the opening by means of tubes, and 
 subsequently to excise a portion of the cicatrix. 
 
 Foreign hody in the esophagus. 
 
 A man, a^t. 56, had noticed for some time a tumour on the left side of his 
 neck, accompanied by scratching sensations in swallowing. He was constantly 
 clearing his throat, and spat up at times a little blood. Externally the growth 
 seemed to be an abscess and was incised. A pointed, sharp, angular piece of 
 bone, which had evidently been broken off, escaped. The abscess soon closed 
 
 The piece of bone had doubtless been swallowed and stuck fast 
 in the oesophagus^ which it had then perforated, and so made its 
 way externally. From the shape of the bone it was evidently not 
 :i sequestrum from the vertebral column. 
 
 A child, set. i, accidentally swallowed a button three days before admission. 
 It appeared that he had a stricture of the 03S0phagns, caused by eating some 
 lye a year previously, which had been almost completely cured by dilatation. 
 Not an atom of food could pass into the stomach after he swallowed the 
 button, and even water, though slowly swallowed, regurgitated. The button 
 was extracted by oesophagotomy, and the child soon recovered. (The case is- 
 reported in the ' Arch. f. Klin. Chirm'g.,' Bd. xii, p. 678.) 
 
 A girl, set. 7, had swallowed some sulphuric acid when she was eighteen 
 months old. Since that time she had suffered fi-om dysphagia, and the 
 ffisophagus had been frequently dilated with bougies. When admitted the 
 child was veiy emaciated ; she suffered from cough and occasionally spat up 
 pus. She was very sensitive to the introduction of instniments, which some - 
 times passed quite easily, on other occasions met with much difficulty. The 
 bougies passed very readily into the sacculations of the mucous membrane.
 
 132 FOEEIGN BODY IN LARYNX LARYNGOTOMY. 
 
 Although the child was able to swallow milk and soup in tolerably large 
 quantities, she became more and more mai-asmic, and died two months after 
 admission. Post mortem : extensive suppuration was found in the oesophagus 
 which was much pouched and sacculated ; in one of the pouches was fixed a 
 glass bead the size of a small bean. 
 
 The child liad never told us that she had swallowed a bead. It is 
 remarkable that the sound never struck on the foreign body, and 
 that the bead had not become loosened by the suppuration, and 
 fallen into the stomach; in all probability the bead had always 
 remained fixed in the stricture, and the sounds had found a way 
 through by its side. 
 
 One remarkable case is recorded by Dr. C. Gussenbauer in the 
 'Med. "Wochen.' for 1876, p. 20, in which a highly tuberculous 
 man, thirty-four years of age, swallowed the half of a large bent 
 table-knife, probably with suicidal intentions. The knife was ex- 
 tracted by oesophagotomy, but the patient died ten days after the 
 operation of profuse suppuration from the cavity. 
 
 Foreign body in the larynx. 
 
 G. S. — , aet. 7, broke by accident a pane of glass ; he had a metal trouser 
 button in his mouth at the time ; he was so startled by the crash that he 
 swallowed the button. A short time after this he had gi'eat dyspnoea ; this 
 was somewhat diminished by vigorous slapping on the back. Emetics were 
 given without benefit, and the respiration continued laborious and whistling. 
 Four days after the accident he was brought to me. Under chloroform the 
 trachea was opened through the conoid ligament ; nothing escaped, nor could 
 anything be felt below in the trachea. Above, caught in the left side of the 
 larynx, a metallic body was felt. I bent a loop of wire into the shape of a 
 hook, so as to draw down the substance. At my fii-st attempt I touched it 
 with this, but on trying again was unable to feel the button. Meanwhile the 
 breathing had again become perfectly free. As soon as the child had recovered 
 from the anaesthetic, he made repeated, apparently pui"poseless, swallowing 
 movements, and then said " now it has gone down." I supposed now that 
 the button had descended into the stomach, and, as a matter of fact, it was 
 passed three days later. Doubtless, I had pushed it back from the laiynx 
 and the child had swallowed it. The wound of the larynx soon healed up 
 and the child recovered perfectly. There was no impairment of function in 
 the larynx. 
 
 Tuberculous infiltration of the upper part of the larynx. 
 
 A woman, aet. 36, tolerably well nourished, had suffered for some time from 
 hoareeness, cough, and latterly from difficulty of breathing. A nodulated
 
 TUEEECULOUS DISEASE OF LARYNX. EXTIRPATION. 133 
 
 infiltration existed about the upper opening o£ the larynx and above the false 
 vocal cords. Opinions differed as to the nature of the growth, which was, 
 however, proved to be of a tuberculous nature by the removal and microscopic 
 examination of a small piece. I performed tracheotomy and left the canula 
 in the trachea ; then I laid open the pharynx completely from just above the 
 edge of the thyroid cartilage, and removed the gi-eater part of the infiltrated 
 mass. The patient died, ten days after, of double pneumonia. Post mortem : 
 some firm, partially calcified nodules were found to have been left in the 
 larynx. 
 
 Tuberculous disease of larynx. 
 
 J. S. — , ast. 56, an ill-nourished man of slender frame, had suffered from 
 hoarseness and a feeling of suffocation for four months. A laryngoscopic 
 examination showed some red papillary growths on the vocal cords, extending 
 down to the larynx. There seemed every probability that it was a case of 
 carcinoma of the larynx. However, a poiiion of the growth, removed by 
 Dr. Schrotter, seemed under the microscope to be a granulation papilloma, 
 covered by a thick layer of epithelium. On account of increasing danger of 
 suffocation, I split open the larynx and cleared out the whole of the diseased 
 part. The reaction that followed was trifling. The dyspnoea ceased, and 
 remai'kable improvement followed for a time. Soon, however, wasting and 
 diaiThoea set in, and the patient died. Post mortem : caseous infiltration of 
 the apices of both lungs was discovered, with tubercular disease of the intestinal 
 mucous membrane. Further examination of the growth removed had already 
 proved the incorrectness of our diagnosis, and showed that the disease of the 
 larynx was of a tubercular nature. 
 
 One case of laryngeal stenosis resulting from tuberculous ulceration was 
 brought to me in a girl twenty-eight years of age ; the dyspnoea, which was 
 veiy great, was so relieved by the inhalation of lime water sprayed upon the 
 part that no operatioir was found necessary. 
 
 Complete extirpation of the larynx, with removal of a small 
 bronchocele. 
 
 A. R — , set. 54, had suffered for about twelve months from constantly 
 increasing hoarseness and cough, and for four months from dyspnaa. When 
 admitted he was in an emaciated condition, somewhat cyanosed, and breathing 
 with difficulty. Considerable cataiTrhal inflammation of both lungs, with 
 dulness over the apices, and a considerable amount of muco-puinilent sputa. 
 Over the centre of a rather long and slender neck was a movable bronchocele, 
 the size of a hen's e^g. The larynx felt very hard, and the anterior angle 
 of the thyi-oid cartilage was filled up and rounded. From Prof. Schrotter's 
 laryngoscopic report I extract the following : — 
 
 " (Edematous swelling over both arytenoids ; the cavity of the larynx 
 between the false vocal cords is completely filled with a faintly red 
 uneven growth of triangular shape, covering up both true vocal cords and 
 the glottis. If the mirror be much depressed a narrow slit can, on deep
 
 134 PAPILLAEY CANCER OF TRACHEA — REMOVAL. 
 
 inspiration, be seen between the masses, through which air can pass." In 
 Nov. 1874, total removal of the larynx was performed. The bronchocele was 
 easily shelled out and removed. Tracheotomy had not been previously per- 
 formed and the trachea sank down rather deeply. The haemorrhage was very 
 slight. Although the wound did well and there was but little febrile reaction, 
 yet the patient's dyspncea increased, as he was unable to raise the sputa, and he 
 died four days after the operation. Examination of the larynx after removal 
 showed an extensively diffused cancerous growth spreading over the larynx, 
 which had partially invaded the cartilages. Extensive broncho-pneumonia 
 was found post mortem. 
 
 If I had to deal with another case of this nature, I should cer- 
 tainly commence by performing tracheotomy, then try by all means 
 to improve the bronchitis before extirpating the larynx. In the 
 above case there can be no question that, owing to the defective 
 power of expiration after the removal of the larynx, the bronchitis 
 ran on to broncho-pneumonia.^ 
 
 Papillari/ cancer (<') of the trachea. — The following case is of 
 special interest and importance, not only from its rarity, but also 
 from the difficulty of diagnosis and the repeated operations per- 
 formed for its relief. 
 
 HeiT M. F — , set. 42, came to me in September, 1876. He stated that since 
 October, 1875, he had at times difficulty of breathing during exertion. In 
 Februaiy, 1876, these troubles increased, and he had attacks almost of suffo- 
 cation, together with some haemoptysis. The patient was a short sturdy man 
 of healthy appearance. Eespiration was accompanied with a noise audible at 
 some distance. He was quite unable to walk upstaii-s, owing to his shortness of 
 breath ; occasionally he had terrible distress from a feeling of impending 
 suffocation. With the laryngoscope, deep down in the trachea, close above 
 the bifurcation, a reddish floating gi-owth was seen connected to the right 
 wall of the trachea, and leaving only a small fissure free for respiration. 
 After consultation with Professor Stork, I perfonned the following operation : 
 — The anterior wall of the trachea, from the cricoid cartilage down to a little 
 below the edge of the sternum, was exposed, the isthmus of the thyroid 
 divided, and the vessels immediately ligatured. The entire trachea was then 
 laid open longitudinally, and the edges held apart by shai-p hooks. 
 
 It is always necessary in the trachea, as in the larjnx, to lay 
 open the tube freely. If the manipulation of instruments is to be 
 conducted with certainty, or a small mirror introduced so as to 
 obtain a view of the deeper parts, the whole region should be 
 thoroughly exposed before the trachea is cut into. 
 
 ' Another case of complete removal of the laiynx is described by Dr. 
 Gussenbauer in the ' Arch f . kl. Chii-.,' Bd. xvii, p. 343.
 
 PAPILLAET CANCEB, OF TEACHEA REMOVAL. 135 
 
 I inti'oduced my little finger rapidly down the trachea and could just reach 
 a small tumour with the tip of it. With a long-handled, curved, sharp-edged 
 spoon I was lucky enough to detach and di-aw out the tumour at the fii'st 
 attempt. The haemon-hage fi-om the trachea was not great and ceased spon- 
 taneously. 
 
 In case severe haemorrhage had arisen T was provided with a 
 thick elastic catheter, which I intended to introduce into the 
 right bronchus, so as, at any rate, to enable the patient to breathe 
 with the right lung until the haemorrhage ceased. 
 
 On recovering from the anaesthetic, the patient was able to breathe perfectly 
 freely, and there was no need to introduce a canula. The tracheal wound 
 healed up in twelve days. Microscopical examination of the tumom-, which 
 was about the size of a bean, showed it be a highly vascular papilloma, formed 
 of granulation tissue covered by a thick layer of epithelium. It was con- 
 nected by a narrow pedicle to a part of one of the tracheal cartilages. I was 
 inclined to fear that recun^ence would take place, although experience does 
 not show that papUlomata deep down in the trachea are often the starting- 
 points of carcinomata. 
 
 Three months later the dijBBculty of respiration agaia occun-ed, followed by 
 tracheal catan-h and hoai-seness. When he came back to me in June, 1877, 
 paralysis of the right vocal cord was found, and some small reddish growths 
 deep down in the trachea. We could only suppose that the paralysis was 
 caused by some tumour, possibly an infiltrated lymphatic gland, which we 
 ■oould not feel, pressing upon the right recurrent nerve. 
 
 In July, 1877, I performed the same operation as on the previous occasion. 
 Some difficulty was experienced in exposing the trachea, for the cicatrix was 
 not easily separated. On introducing my finger I found that there was a 
 considerable gi'owth on the original site, but besides this the right side of 
 the trachea at the level of the manubrium stemi was much compressed by a 
 firm mass. A very long cauula was left in the trachea ; I felt certain now 
 that the stenosis of the trachea and the dyspnoea were caused by cancerous 
 infiltration of the deep glands ; the prognosis, therefore, seemed to me devoid 
 of hope. However, during the next few weeks the patient improved in a 
 remarkably satisfactoiy way. We tried for a long time to find a form of 
 tube through which the patient might breathe freely, and at the same time 
 be able to raise the sputa. Finally, at Professor Stork's suggestion, a valvular 
 apparatus was made, which was attached to the canula anteriorly, so that the 
 patient could breathe freely and speak through the tube, without being per- 
 petually compelled to keep his finger on the opening. A still further 
 unlooked-for improvement took place, for the voice became perfectly clear 
 and the paralysis of the vocal cords disappeared. After a time the voice 
 became as strong and resonant as ever it was, so that as an orator he could 
 have filled the largest room. 
 
 This result is diflBcult of explanation. The tumour, which had 
 appeared at the right side of the neck, and was somewhat painful on
 
 136 STEICTUEE Of TRACHEA FROM BLENNORRHCEA. 
 
 pressure, had vanished again two weeks later. Was it pushed on 
 one side by the pressure of the tube, or did it really subside when 
 the paralysis of the vocal cord began to disappear ? I conceived it 
 possible that the disease might be a rare form of syphilis, and with 
 that idea applied mercurial ointment and gave iodides. How much 
 this had to do with the improvement I am unable to say. In 
 October, 1878, I heard with great pleasure that the patient was 
 still perfectly well. 
 
 Slriciure of trachea. 
 
 A very rare form of stiicture of the ti-achea was met with in a strong 
 and well-built woman, set. 25, who ascribed the origin of her disease 
 to catching severe cold three yeare previously while engaged in bleach- 
 ing linen. Since that time she had been hoarse, constantly felt irri- 
 tating sensations in the neck, and had much troublesome cough. The 
 sputa had never been very copious, but in the summer time often contained 
 blood. For the four months preceding admission the troubles had increased 
 very considerably, especially since she had been compelled to work near a 
 manufactory, the smoke of which frequently occasioned her severe attacks of 
 sulfocation. The patient was sent up to the hospital to have tracheotomy 
 performed. When admitted the respii-ations were forty to the minute and 
 there was much straining of the umscles of the neck. A loud hareh sound 
 was heard in the trachea at each inspiration, somewhat sharper on expii'ation,. 
 as if the air then were forced through a narrow tunnel ; this noise, which was 
 sometimes of a faint hissing nature and sometimes more like a sigh, was 
 uniformly audible over the entire lung. On percussion a normal note was 
 yielded over all the chest. Frequently, the inspiration would be easy for a 
 time, and would then be interrupted by a hoai-se little cough ; this occun-ed 
 especially after exerfion or moving about much, but did not entirely cease 
 even when she lay quiet in bed ; the heart sounds were natural, the second 
 sound j>erhaps a little intensified ; all other functions normal. The patient 
 had had no children and denied any gonorrhceal or syphilitic infection. 
 
 Prof. Stork reported to me as follows about the case : 
 
 " Profuse secretion of pus is found in the naso-pharyngeal region ; the 
 entire roof of the pharynx is covered with pus ; the mucous membrane about 
 the infundibula pale, and covered also with pus. Examined from in front, 
 swelling of the mucous membrane is found in the nasal cavity ; no ulcere or 
 cicatrices are anywhere \'isible. In the interior of the larynx, with the ex- 
 ception of catan-h, evidenced by a moderate amount of swelling, and here 
 and there some pumlent secretion, nothing abnormal is to be seen. Veiy deep 
 down in the trachea is seen a stenosis, diaphragmatic in form, the clear space 
 having about the diameter of a goose-quill. The dyspnoea is in nowise- 
 proportionate to the stenosis, for in strictures of the ti*achea of the diameter 
 seen in this case it is not usual to find the breathing so materially obstructed.- 
 
 ::^-
 
 STEICTURE OF TllACHEA FllOM BLENNOEEHCEA. 137 
 
 I can only suppose, therefore, that below the visible contraction is another 
 stenosis, and this deeper funnel-shaped stenosis may at a guess correspond 
 to about the sixth or seventh ring of the trachea." 
 
 Prof. Stork considered the disease to be due to a kind of blennor- 
 rhoea, with induration, contraction, and thickening of the mucous 
 membrane of the kind first minutely described by himself. Prom 
 his experience he was of opinion that no material or lasting benefit 
 would be derived from any operative proceeding. I determined, 
 however, to undertake something in order to preserve the patient 
 from death by suffocation. 
 
 With the assistance and sanction of Professor Stork, I proceeded as 
 follows : — The patient was narcotised, and then the entire anterior surface 
 of the trachea was exposed from the cricoid cartilage down to the sternal 
 notch. This was then cut open longitudinally, and the edges were widely 
 separated; the rings of the trachea were much calcified. I now introduced 
 my little finger, and found a strictui-e at the exact spot described by 
 Professor Stork. Through this, with some difficulty, I was able to introduce 
 an elastic No. 12 catheter. I then discovered that it was not a ring-shaped 
 stricture or a membranous diaphragm which caused the obstruction, but a 
 uniform constriction which extended down for at least 2 centimetres, probably 
 as far as the bifurcation. The opening of the constricted tube was too 
 small to admit any of the tracheal canulse we had at hand. Even if I had 
 introduced such a one, the patient could not have stood it for any length of 
 time, for any little plug of mucus would have sufficed to choke it up. 
 Forcible stretching appeared to me a more dangerous proceeding than 
 incision — the more so, that I could not be certain whether the contraction 
 was only formed by thickening of the mucous membrane and the submucous 
 tissue, or whether the cartilaginous part of the trachea did not participate in 
 the stricture. I preferred, thex'efore, to introduce a probe-pointed knife with 
 its cutting edge forwards, and carried it down for about an inch, so as to 
 incise the tissues for about 2 millimetres. The htemorrhage was trifling. 
 I was able now to increase the dilatation by introducing my little finger, 
 which I can'ied down as far as the bifurcation ; I was thus able to con- 
 vince myself that the constriction was only due to a considerable hypertrophy 
 of the submucous tissue, for on the division of this and the mucous mem- 
 brane, the edges gaped widely, and allowed dilatation. The tracheal rings, 
 although very hai'd, were not constricted. 
 
 The patient was able to breathe much more freely after she recovered from 
 the ansesthetic, but in the course of the next few days it was evident that 
 there was some hindrance to respiration through the tube. This was 
 evidently due to the fact that the tube did not reach down low enough to 
 keep apart the lower portions of the trachea, which soon contracted again. I 
 introduced, therefore, a somewhat longer tube, but the breathing was not . 
 entirely free until I had passed down to the right bronchus a conical-shaped 
 tube, which at the upper part was equal in diameter to the normal trachea. .
 
 138 CANCER OF THYROID AND TRACHEA REMOVAL. 
 
 I hoped, however, to improve matters still more. During all this time (two 
 months) all kinds of local and internal remedies had been employed which 
 are supposed to be beneficial in blennorrhoea of the mucous membrane, such as 
 inhalations, topical application of astringent solutions, the internal adminis- 
 tration of copaiba, balsam of Peru, tannin, etc. No appreciable benefit, 
 beyond, perhaps, a slight diminution in the] secretion of pus, took place. 
 Every time that attempts were made to shorten the tube, or to discontinue 
 its use for a time, such formidable dyspnoea occurred that the long tracheal 
 tube had again to be introduced at once ; we gave up all idea of being able 
 eventually to remove the tube entirely. Wishing, however, to enable the 
 patient at least to speak, we introduced a tube with an opening at the bend, 
 through which we supposed that the air would readily pass when the 
 anterior opening of the tube was closed. To our surprise this was not found 
 to be the case ; the lower part of the larynx had, after the tracheotomy, 
 become so much naiTOwed and filled up with prominent granulations that it 
 was no longer permeable to the air ; notwithstanding all our efEorts we were 
 tinable to dilate this part of the larynx ; ultimately the patient became 
 wearied with the attempts and left the hospital wearing the tube, through 
 which she could breathe well enough. By closing the opening for a moment 
 or two with her finger, she was able to speak a few words intelligibly in a 
 hoarse voice. I was unable to learn anything further about the case. 
 
 Extensive ulcerated carcinoma of the right half of the thyroid and 
 
 trachea. 
 
 A Russian merchant, set. 53, had suffered for three years from laryngeal 
 catan-h, with constant hoarseness and dyspnoea. At an early stage of the disease 
 paralysis of the vocal cord was found, probably from the tumour, which was 
 deeply situated, pressing upon the right recurrent nerve. Laryngotomy had 
 been performed, and a canula left in, through which the patient was able to 
 breathe very well. The patient asserted that he noticed the development of 
 a tumour in the light side of his neck a few weeks after the laryngotomy. 
 For a time his condition remained tolerable, although the tumour increased 
 to the size of a fist. Shortly before I saw him the dyspnoea again recurred, as 
 the tumour had pushed to the left side and nan-owed the trachea close to its 
 entrance into the thorax, and the canula could not be kept in situ. The case 
 seemed to me to be hopeless, and I could only advise morphia injections to 
 relieve the pain and dyspnoea. Apart from the local trouble, the patient was 
 in good condition, and begged that something might be done to give relief ; 
 he was willing to face any risk. The fii-st idea which occun-ed to me, of 
 introducing a long thin canula into the laryngotomy wound so as to pass it 
 below the impediment, was not found pi-acticable. The tube at once caused 
 severe cough and haemorrhage from the trachea, and the patient soon refused 
 any further treatment of that sort. By the introduction of the tube, however, 
 I had made out that the tumour went further down into the ti-achea. The 
 patient insisted that there must be some means or other of giving him relief, 
 for he felt himself otherwise in such good health. I have seldom met any one
 
 LARYNGOTOMY AND TRACHEOTOMY. 139 
 
 with such implicit faith in the power of surgical ai't. I decided on the 
 following operation : — An incision was made over the right side of the tumour, 
 the capsule was split, and the whole mass of the tumour scooped out. As 
 each separate part was exposed penghawar was immediately applied. The 
 right wall of the trachea was completely destroyed, but we were now able to 
 introduce a canula deeply down and leave it there. The hsemon'hage was 
 considerable, but easily controlled. The patient was much relieved by this 
 proceeding ; the secretion from the wound was but slight ; the penghawar 
 came away in about three weeks' time, but even at that date some fresh for- 
 mations were apparent in the deeper parts, and the relief could only have been 
 of a very transitory nature. 
 
 I am under the impression that some such treatment might be 
 of use in many bronchoceles where the capsule is too jfirmly con- 
 nected to the surrounding parts to admit of complete extirpation. 
 It seems that Kocher has adopted this plan for some time, and had 
 satisfactory results from it. 
 
 Thirteen cases of laryngotomy and tracheotomy for laryngeal croup. 
 
 All these patients at the time of operation were almost in a 
 state of asphyxia. Only one recovered. One case occurred in 
 a woman between twenty and thirty years of age, the others in 
 children from two to ten years old. Laryngotomy through the 
 conoid ligament was always performed in the latter. In one case I 
 was unfortunate enough to see the patient die of suffocation under 
 my hands. 
 
 The patient was a strong child, set. 6, on whom laryngotomy was performed 
 for severe croup. The operation was of considerable difficulty, for the child 
 had a short fat neck and a veiy large thyi-oid gland. The incision into the 
 larynx was in consequence made partly through the thyroid cartilage, and the 
 canula had a great tendency to fall out. Three hours after the operation I 
 was called to the child again by the parents, as he was breathing veiy badly. 
 Finding the canula half out, I deteiToined to enlarge the wound down- 
 wards. With this object I placed the child on a table, close to the window of 
 a very dark little room, and then carried a probe-pointed knife into the wound 
 of the larynx. I had scarcely extended the incision for more than a line 
 when a gush of blood welled up, which very quickly got into the trachea. I 
 immediately introduced the canula, blew thi-ough it, and then attempted to 
 secure the bleeding vessel with the forceps, but could not re-establish 
 respiration. 
 
 This is the only case in which a patient has ever died immediately 
 under the knife at my hands. It made a great and permanent
 
 140 TRACHEOTOMY IN CHILDEEN. 
 
 impression on my mind, and has been to me a most decided warning 
 against ever attempting tracheotomy again when single-handed. If 
 anybody had been with me to hold the child I could have cut down on 
 the trachea below dehberately, and so avoided the bleeding. Nobody, 
 however, except the parents, who were in a great state of perturba- 
 tion, was present : the child had so much dyspnoea that I thought 
 myself bound to act at once and alone, and thus met with this 
 disaster. 
 
 A successful case occurred in a child four years of age. 
 
 I perfoiined tracheotomy when the child was almost in extremis. The 
 canula was first removed twenty days after the operation. The granulations 
 of the wound in the neck were so prominent that they extended into the 
 trachea and prevented me from removing the tube earlier, inasmuch as they 
 half filled up the trachea and caused gi-eat dyspnoea. After repeatedly removing 
 the gi-anulations and applying caustics, I was able to dispense permanently 
 with the canula ; the opening then rapidly closed. 
 
 I think that the tracheotomies on children are the most difficult 
 operations I have ever performed. The cases which I had at 
 Ziirich were commonly in small children with very short fat necks 
 and enlarged thyroid glands. Not infrequently I found lying on 
 the larynx such extensive and dense plexuses of veins that 
 numerous vessels had to be secured before I could reach the conoid 
 ligament ; moreover, the children were, as a rule, only brought up 
 to the hospital in the last stage of dyspncea. In five or six cases 
 the children were completely asphyxiated under the operation, but 
 were brought round by artificial respiration. Judging from my 
 experience I am unable to understand how many surgeons 'talk of 
 laryngotomy for croup as a very simple affair. I should blame no 
 surgeon who declined to perform this operation. It is often one of 
 great difficulty, and we are the more bound to acknowledge the 
 highly creditable fact there is no inconsiderable number of surgeons 
 who practise it. But yet it may be the means of directly saving 
 life. Thus, Dr. KeifFer, of Frauenfeld, records that in his country 
 practice he has performed tracheotomy in eighteen cases of croup, 
 and that eight children have recovered ; truly a brilliant result. 
 Such figures as these we should bear in mind, so as not to be 
 dissuaded from this operation, even should we for periods of years 
 meet only with unsuccessful cases. The patient is much better off 
 in tracheotomy, as in herniotomy, when the surgeon, under whose 
 treatment he is, selects the right moment for operation ; far better
 
 LARYNGOTOMT AND TRACHEOTOMY CAUSE OF DEATH. 141 
 
 that he should do this than that after long resistance the patient 
 should, at a late — often too late — a stage be brought up to the 
 hospital. To us professors in the surgical clinics these cases come 
 usually too late. 
 
 Laryngotomy and Tracheotomy. 
 
 In twenty-two cases one or other of these operations was per- 
 formed for high degrees of asphyxia of some duration. In six only 
 did the operation preserve life, yet all the patients were able to 
 breathe with perfect freedom directly after the introduction of the 
 tube, and there seemed no reason why they should not have recovered. 
 Death occurred from a few hours at the earliest to three days at 
 the latest after the operation, and started apparently from the 
 respiratory organs; the patients breathed with more and more 
 difficulty, became cyanosed, and then rapidly collapsed and died. 
 
 In no instance were any direct material obstructions to the 
 breathing found in the lungs. The autopsies revealed little more 
 than insignificant globular infiltration or slight atelectasis, from 
 choking of the small bronchi by the tough mucus, with perhaps 
 some old emphysema (especially in strumous subjects) or chronic 
 bronchial catarrh. The post-mortem appearances did not explain 
 the rapidly fatal issue of many cases. When, however, symptoms 
 of asphyxia rapidly supervene on a laryngeal or tracheal stenosis 
 which has existed for some days, and especially in those who have 
 suffered perhaps for years from difficult respiration and imperfect 
 oxygenation of the blood, it can be readily understood tliat a 
 restitutio ad integrum of the respiratory chemical changes can no 
 more be accomplished by the enfeebled apparatus. Eor in such 
 cases the blood is overloaded with carbonic acid and other waste 
 products. From the therapeutical point of view, these sad cases 
 have given me much concern ; possibly the same unknown causes 
 are fatal also in diphtheritic inflammation of the air passages ; 
 yet in the latter we find — sometimes at any rate — that the 
 morbid processes extend deeper down into the lungs. Moreover, 
 we have learned that the diphtheritic process which primarily 
 affects the air passages has some special injurious effect on the 
 nerve system, and induces also rapid breaking down of the muscular 
 tissue of the heart. Cases, therefore, having a sudden fatal termination
 
 142 SUPPTJEATION AND CASEATION OP LYMPHATIC GLANDS. 
 
 from failure of the heart can be to some extent explained on ana- 
 tomical and physiological grounds. 
 
 Of the twenty-two cases mentioned above, in thirteen tracheotomy 
 was performed for osdema of the glottis, originating from various 
 causes ; one was a case of fracture of the laryngeal cartilages, and 
 in eight laryngotomy was performed for great dyspnoea, the result 
 of bronchocele. 
 
 Tracheotomy was performed also in eighteen cases of croup, with 
 two recoveries ; one of these patients died of inanition a few weeks 
 after the canula was removed. These cases were met with between 
 i860 and 1876. 
 
 Section B. — Diseases of the Lymphatic Glands. 
 
 Simple enlargements — Operative treatment. Chronic lymphadenitis 
 and lymphoma. Medullary lymphoma and lymphosarcoma. 
 Case of primary (?) epithelial cancer of glands. 
 
 Of 145 cases of simple hyperplastic suppurating and caseating 
 glands, 87 occurred between the ages of eleven and twenty. The 
 preponderating frequency with which the disease occurs at this 
 period of life is very striking. Formerly I thought that the so- 
 called strumous enlarged glands were especially common in 
 children, and were connected with the second dentition. This, 
 however, can have no great influence, for the permanent teeth 
 have mostly made their appearance when the patients have entered 
 their second decennium. The prognosis in this complaint is, for 
 many reasons, an unfavourable one ; in the first place, we must con- 
 fess that we possess no specific to bring about resorption of the 
 simplest, purely hyperplastic, glandular enlargements. Still less do 
 we know of any remedy which can obviate caseation or suppuration. 
 Many of these swellings come and go without its being possible to 
 assign any reason, either for the one or the other process. In one 
 case, cold douches; in another, iodides; in a third, the use of 
 mineral or salt-water baths ; in yet others, strapping is said to have 
 caused improvement or recovery. At times startling cures result 
 from these remedies. Yet the surgeon should not be blamed 
 if he frequently fails to achieve anything of the sort. 1 do not
 
 SUPPUEATION IN CASEOUS LYMPHATIC GLANDS. 143 
 
 say that the regulation remedies are absolutely worthless, but no 
 one of them can be counted on with any degree of certainty. 
 Nothing whatever can be expected from internal remedies. As 
 consulting surgeons, we, as a rule, have no knowledge as to whether 
 the dietetic rules recommended by us to be observed for periods of 
 months or years are carried out. 
 
 Who would venture to guarantee with any certainty that he could 
 prevent the occurrence of suppuration in a swollen gland ? Speaking 
 generally, it is true that diseases of the lymphatic glands mostly 
 occur deuteropathically and reflect the primary disease. From 
 acute suppurative or diphtheritic inflammations of the skin and 
 cellular tissue result acute suppurative or diphtheritic perilymphan- 
 gitis, perilymphadenitis, and lymphadenitis. Chronic hyperplastic 
 inflammations of the nature of elephantiasis are the precursors of 
 similar changes in the lymphatic glands. Chronic suppurating, 
 ulcerative, and caseating changes in the superficial membranes cause 
 suppurative and caseating lymphadenitis. If, for example, the pri- 
 marily affected areas in the lungs go on to degeneration and calcifi- 
 cation, the same process occurs in a deutero])athically infiltrated 
 lymphatic gland ; inasmuch, however, as the primary diseases occur- 
 ring on the head and face which lead to swelling of the lymphatic 
 glands are of a transient nature, they do not usually come under 
 our observation, and we have then to deal with the enlargements of 
 the lymphatic glands as producers, in themselves, of further disease. 
 Their prodncts are the means of infecting other glands, and so the 
 process goes on. There is a peculiarity in the suppuration which 
 so frequently occurs in the glands ; the change is seldom brought 
 about by the softening and suppuration of the first hyperplastic 
 formations : more commonly these products first caseate, pus forms 
 around these caseous areas, and then enters into them, so that these 
 same caseous deposits appear to go on to suppuration. Probably a 
 chronic condition of irritation around the capsule of the gland is 
 excited and kept up by the caseating matter, which is with difiiculty 
 got rid of; this condition, which at the outset leads to plastic 
 changes and defective growth, eventually brings about ulcerative 
 softening in the vicinity of the glands. 
 
 I have never seen calcification of the cervical lymphatic glands. 
 They either remain in a dry, so-called tubercular condition, or else 
 su])purate and slough, sometimes after months or years of quiescence. 
 I cannot say whether from these caseous glands general tubercu-
 
 144 CASEATING LYMPHATIC GLANDS. 
 
 losis may be set up. No satisfactory instance of it has occurred 
 under my observation. lu all the cases in which I saw tubercular 
 disease of the lungs or intestines in connection with these suppura- 
 ting glands, my impression was that the condition was due as 
 much to hereditary predisposition as to the lymphatic glands ; the 
 latter, indeed, seemed to me to occur half accidentally as the first 
 symptom of the tubercular diathesis. From my experience, which 
 I freely confess is but small, I would venture to assert that amongst 
 the numerous cases of tubercular disease of the intestines or lungs 
 there were but few who had at the same time any sinuses about the 
 neck or cicatrices ; far more frequently are these sinuses or cica- 
 trices found in those affected with caries. 
 
 If these caseating areas are once formed in enlarged cervical 
 glands, my opinion is that they will not be absorbed. Such glands 
 can be recognised by their hardness, fixity, and by their gradual 
 coalescence. At such a stage, no doubt, some contraction of the 
 hyperplastic tissue surrounding the caseous area may take place, 
 diminution in size may follow, but no complete disappearance can 
 be looked for. Again, it is true that the glands may remain for 
 vears unaltered when in this condition ; further infection then but 
 seldom ensues. Any severe congestion about the glands, caused per- 
 haps by a blow or a fall, or originating without any known cause, 
 can again awake into activity the irritating material stored up in the 
 glands. Then the surrounding parts become inflamed, soften, and 
 suppurate, an ulcerated cavity forms after they break, and the 
 caseous masses are discharged. Even then a long time may elapse 
 before the hard capsules of the glands shrink up completely and the 
 sinuses close. It is no uncommon thing to see such changes, 
 going on slowly for ten years or more, eventually leaving numerous 
 unsightly cicatrices. Not infrequently the patients, especially when 
 young girls, pine away both physically and mentally. The process 
 wears them out, and even if they do not die early, all their enjoy- 
 ment of life is embittered, and at times permanently destroyed. 
 
 It is more disagreeable for the surgeon to give a highly un- 
 certain prognosis than to find his treatment powerless ; the one alter- 
 native affects his reputation with the public far more than the other. 
 On the whole, mistakes in prognosis wiU be less infrequently 
 made if the disease be predicted as likely to last many years. 
 
 In the therapeutical treatment, the progress of time has found us 
 -all much more active ; no one who has removed many such glands.
 
 TEEATMENT OF CASEOUS LYMPHATIC GLANDS. 145 
 
 and has convinced himself, as he probably will do, that more than 
 75 per cent, of them contain caseous deposits, is likely to be 
 deceived as to the possibility of such glands becoming absorbed, nor 
 will he imagine that they can disappear without leaving cicatrices. 
 Bearing this in mind, the surgeon will more readily counsel opera- 
 tion to these patients. Of course, cases where other tubercular 
 processes of the internal organs have been already diagnosed must 
 be excluded. A further reason for advising operation is that such 
 a proceeding is very rarely attended with any risk, and that the 
 resulting cicatrices are, as a rule, less disfiguring than when the 
 process is allowed to run its own course. 
 
 Two different forms of operative measures may be adopted. 
 
 1. The sinuses may be enlarged superficially with the knife, and 
 the deeper parts with sponge or laminaria tents ; then the thinned 
 ulcerated edges of the skin can be cut away, and the cavities scraped 
 out with a sharp spoon, or else the surface of the wound may be 
 destroyed with nitric acid, caustic potash, or liquor ferri, and the 
 part left to heal up. I have adopted methods of this nature, 
 modifying them according to circumstances, in many cases, and have 
 had good reason to be satisfied with the results. One patient alone 
 died of pysemia after this treatment. The thickened capsules of the 
 glands which are connected to the surrounding parts are commonly 
 left behind ; on their capacity for shrinking up, and on the yielding 
 of the surrounding parte, the rapidity of recovery depends. It need 
 hardly be said that these operations, which are often rather formid- 
 able, are contra-indicated if the patients be in a low state. Cases 
 will be met with in which the capsules of the glands and the parts 
 immediately around them are so indurated that months may elapse 
 before the sinus will close ; sometimes remnants of the gland tissue 
 remain behind, which then caseate, and materially delay recovery. 
 The operation then has to be partially repeated. I must further 
 remark that the surgeon should proceed boldly in scraping out and 
 cutting away the ulcerated edges of the skin ; the more the latter 
 are spared the more ugly is the scar ; thinned skin, ulcerated on its 
 inner surface and overlying caseous and softened deposits, should 
 always be removed. I have always regretted it, when I have only 
 scraped out the ulcerated surface below and have allowed such tissue 
 to remain. If by good luck suppuration did not occur, yet the 
 deeper part of the cicatrix became so prominent that the subsequent 
 scar had a very unsightly appearance. 
 
 10
 
 146 EXTIRPATION OF CASEOUS GLANDS. 
 
 2. All the glands that can be got at may be removed, together 
 with their capsules. It need hardly be pointed out that caution is 
 necessary in such operations; they are simple and easy of per- 
 formance when the capsules are not too firmly united to the sur- 
 rounding parts, and can be detached without cutting. Such 
 operations, however, may cause anxiety to the most experienced 
 surgeon, as he proceeds step by step with his knife, the more so if he 
 is working in close proximity to the large vessels of the neck; 
 moreover, they may become very formidable by their long duration 
 and loss of blood. I have never lost a patient from collapse, but I 
 have often had occasion, owing to the weakness of the patient, to 
 break off and complete the operation on a subsequent occasion. 
 If the glands were enlarged on both sides, I always removed 
 each set separately. I almost invariably make my incision along 
 the anterior or posterior edge of the sterno- mastoid muscle. By 
 extending this incision longitudinally sufficient space can always be 
 obtained. In removing glands in this way, the operator will often 
 find himself in close proximity to the internal jugular vein; this 
 vessel is much more easily displaced by the glands than the carotid 
 artery or the vagus nerve; its wall, too, more readily becomes 
 connected to the capsules of the glands than the sheaths of the 
 arteries and nerves. In four cases I divided the internal jugular 
 vein between a double ligature, and no untoward results followed. 
 Secondary haemorrhage, however, often followed in cases where 
 a small puncture had been made through the wall of the vein 
 and the side of the vessel secured, or where branches of the 
 veins less than a centimetre in length were tied. I consider myself 
 very fortunate only to have lost one patient from secondary 
 haemorrhage of this nature. In operations about the cervical glands, 
 as well as in dealing with those in the axilla, I make it a rule, if 
 any small puncture be made in tlie wall of a vein or if short branches 
 be wounded, always to expose the vessels thorouglily and divide them 
 between a double ligature. I consider such a proceeding far less 
 dangerous than the apparently less severe plan of ligaturing the side 
 of the vein. The latter method sometimes succeeds, but often the 
 adhesion gives way, and the short thrombus becomes detached; 
 hsemorrhage then occurs, tampons have to be applied, and extensive 
 thrombosis — with possibly serious consequences — is the result. I 
 have never seen any injurious disturbance to the circulation result 
 from ligature of the jugular vein.
 
 EXTIEPATION OF CASEOUS GLANDS. 147 
 
 I may further remark, that in extirpating glands, together with 
 the parts immediately around them, behind the border of the lower 
 jaw, a branch of the facial nerve, lying deep in front of the internal 
 maxillary artery, may be met with and divided. This branch 
 supplies the muscles of the lower lip up to the red edge ; if the 
 nerve be cut through the lip curls inwards, and cannot be turned 
 out, as for instance, in laughing or smiling. At first this state of 
 things occasions a good deal of disfigurement, but after a time the 
 condition improves : in some cases it entirely disappears. I am 
 unable to say whether this latter result always takes place, but 
 from my experience of the results after division of other small 
 branches of the facial nerve, I think it is highly probable. If 
 these operations be performed carefully and without much injury to 
 the surrounding parts, if the haemorrhage be completely controlled, 
 the wound drained, and well- applied pressure made, the whole part 
 may heal up by first intention. If the glands have been completely 
 removed the patients are, in many instances, entirely relieved of 
 their trouble in a week or two. Good results like this are not so 
 very uncommon, and are highly satisfactory when contrasted with 
 the ordinary methods of treatment. It may of course happen that 
 portions of the capsules of the glands or of the caseous deposits may 
 escape notice or be purposely left behind, for fear of going too far ; 
 under such circumstances certainly sinuses will be left, which may 
 suppurate for a long time, and require subsequently to be treated 
 by the ordinary means. Unfortunately, too, many cases occur in 
 which other glands subsequently become affected, and fresh operation 
 may be necessary, if the patient be not in a hectic state. Finally, 
 there are cases in which on one or both sides hard caseous glands 
 extend from the ear to the clavicle; unless such patients are of very 
 strong constitution, which is very seldom the case, the magnitude 
 of the operation may preclude the idea of any surgical interference. 
 In spite of all this I can only — speaking generally — advise extirpation 
 of the cervical lymphatic glands, inasmuch as our other means of 
 treating these diseases are, as has been already said, far too in- 
 effective. 
 
 Of ninety-four cases operated on, I lost three ; one from secondary 
 haemorrhage, one from erysipelas, and one from pyaemia. Of nine 
 patients, in whom parenchymatous injections had been employed 
 with different kinds of fluid during considerable periods, two died 
 of erysipelas. In dealing with small statistics, accidental causes
 
 148 PEIMAET LYMPHATIC GLANDULAR TUMOURS. 
 
 have a very important influence, and I think it hardly worth while 
 to estimate the percentage of mortality from the figures at my 
 command. 
 
 Chronic Lymphadenitis and Lymphoma. (Z. B.) 
 
 In no other organs is there so much difficulty in distinguishing 
 minutely between chronic inflammation and tumour formations as 
 in the lymphatic glands. In the earlier stages, swellings of the 
 lymphatic glands all resemble each other. Histologically, the 
 swelling is invariably found to be due to simple hyperplasia. At a 
 later stage, in the great majority of cases, this hyperplasia leads to 
 caseation and suppuration, which changes may either start from 
 infection originating in the areas of inflammation, or else may be 
 idiopathic. In either case there is more or less tendency to 
 ulceration and perforation of the skin, and the formation of the so- 
 called " strumous '' glandular ulcers. 
 
 Forms consequently occur where the hyperplasia, remaining as 
 such, and without any retrograde metamorphoses, continually and 
 slowly progresses, until the whole tissue of the gland becomes and 
 remains uniform in structure (simple lymphoma or scrofulous 
 glandular sarcoma). Now, if this process should be arrested in its 
 progress, caseation will sometimes occur in the later stages of these 
 tumours. Next come the quickly growing softening lymphomata, 
 which, on dissection, seems to have the appearance of the medullary 
 formation. Among these we may still find pure hyperplastic forms, 
 which, although on minute investigation, may prove to be spindle- 
 celled sarcoma, yet often to the naked eye occur under the guise 
 of the so-called " tumor-fasciculatus," i. e. a growth where the 
 fibrous material can be torn into bundles like muscle. Finally, we 
 come to tumours of the lymphatic glands originating secondarily — 
 secondary sarcoma, chondroma, carcinoma, etc. 
 
 The primary lymphatic glandular tumours come first under con- 
 sideration. 
 
 In a lymphatic gland caseous metamorphosis following chronic 
 inflammation can only be distinguished from simple hyperplasia, 
 if the gland be softened, and fluctuation evident, or if pus has 
 already made its way out externally. Multiple glandular swellings 
 of slow and continuous growth, which coalesce without altering in
 
 ETIOLOGY OP LYMPHOMA. 149 
 
 consistence, may usually be looked upon as simple hyperplasia. 
 Such cases, however progress so slowly that they are seldom kept 
 under observation in hospital to the end of the disease. One of the 
 most marked features of the scrofulous diathesis lies in the great 
 proneness to inflammation of the lymphatic system. I entirely agree 
 with Virchow in his views on this matter, when he states that in 
 nearly aU cases some peripheral irritation gives rise to these lym- 
 phatic swellings (I would ratlier say some infection coming from 
 without to a lymphatic gland) . He argues that the peculiarity of 
 the scrofulous diathesis consists in this : that these formative irrita- 
 tions do not cease when the source of irritation is removed — i.e. 
 when the peripheral area from which the irritation originates recovers 
 itself — but that the hyperplasia which has been once started 
 in the lymphatic glands is then able by itself to extend more and 
 more. I wish only to add to this that there are some individuals 
 in whom such irritation leads to a continuous uniformly extending 
 new formation (simple lymphoma) and that there are others in 
 whom the hyperplastic formation soon becomes caseous, or breaks 
 down and suppurates. This is tantamount to saying that etiologi- 
 cally the simple lymphoma and the caseous suppurative and ulcerated 
 lymphadenitis have essentially the same causes of origin. 
 
 In these lymphatic swellings, then, which are recorded in my 
 tables, cases only were entered which could be looked upon as 
 idiopathic, and in which, at the time that the patients were under 
 treatment, there was no disease in the neighbourhood of the face 
 -or head. In a few cases investigations were made as to whether 
 the affection of the lymphatic glands had been preceded by some 
 other disease, which might possibly have given rise to the lym- 
 phoma. I find noted that the lymphatic swellings were preceded 
 in two cases by periostitis and caries of the upper jaw, in two by 
 impetigo capitis, in several cases by inflammation of the eye, once 
 by pneumonia, two by erysipelas of the face, once by angina, once 
 by acute rheumatism, and in one instance the lymphatic glands 
 were swollen, together with the thyroid gland. With regard to 
 this last case it should be observed that lymphatic gland swellings 
 do not accompany the ordinary common form of bronchocele, which 
 I may mention in passing is somewhat remarkable. 
 
 Since attempts have gained ground to refer lymphatic swellings, 
 which formerly were classified as idiopathic, as little as possible 
 •;to accidental causes, we have repeatedly heard that there are
 
 150 INFLUENCE OF JJENTITION ON LYMPHOMA. 
 
 two dentition periods which produce glandular swellings. Thee 
 enlargements, attract little notice in the majority of cases ; in scro- 
 fulous children they are marked and become permanent, owing, as 
 it is supposed, to some local qualitative want of power to^resist irri- 
 tative disturbances. It is certainly worth while for the profession 
 to continue their etiological investigations in this direction, but for 
 the hospital surgeon the difficulties are in this, as in other etio- 
 logical investigations, very great; for the most part we have to 
 depend on the unreliable statements of patients who are usually 
 uneducated. As to the age at which, among our patients, lym- 
 phatic swellings originate, I have some tolerably clear data. The 
 small glandular swellings which come under observation in children 
 from one to five years old mostly prove to be acute or subacute 
 abscesses. It would be, however, premature did we attempt to infer 
 from this that the first period of dentition may not give rise to 
 chronic lymphoma, for our observations did not extend to the out- 
 patients, and no children were admitted simply for swollen cervical 
 glands. Lymphatic swellings in children of rather more advanced 
 age were not usually referred back by the parents to the period of 
 the first dentition : this I may point out is due to the fact that the 
 lymphatic swellings at that age more commonly disappear or else 
 terminate in acute abscess ; in general, all the symptoms accompany- 
 ing the first period of dentition have a more acute character than 
 those of the second period. 
 
 Out of fifty-seven cases fifteen occurred during the second period 
 of dentition. The influence of the wisdom teeth on the disease is 
 an open question. In none of the cases was there syphilis; in one 
 case only was the hypertrophy of the lymphatic glands in the neck, 
 accompanied by enlargement of the spleen without any increase of 
 the white corpuscles of the blood. The patient died of marasmus 
 and anaemia. Post mortem, we found an enormously hypertrophied 
 spleen, and commencing cirrhosis of the liver ; in the blood of the 
 splenic veins were many spindle cells (endothelium of the vein) ; the 
 other organs were normal. The whole process had lasted one year. 
 
 Whatever ideas be entertained as to the etiology of lymphoma, 
 two general conclusions are beyond dispute — (i) the lymphatic 
 glands are almost invariably affected secondarily; {2) excepting the 
 mesentery, there is no region of the body where the lymphatic glands 
 are so often swollen as in the neck. Now, for this there must be 
 reasons, and these reasons ought to be discovered. Perhaps we do
 
 OPERATIVE TEEATMENT. 151' 
 
 not always inquire carefully enough whether exanthemata^ especially 
 measles and scarlet fever, immediately preceded the commencement 
 of the glandular swellings ; both are accompanied very often with 
 such intense catarrh in the neighbourhood of the face and head that 
 a very evident source of lymphatic swelling is thereby occasioned. 
 Further, caries of the teeth with the alveolar periostitis which so 
 frequently accompanies it, is certainly in many cases the original 
 cause of the lymphatic swellings. I have tried repeatedly to learn what 
 happened to these patients later on, and whether they were affected 
 with new diseases of the lymphatic system, such as leukaemia, 
 anaemia, diseases of the spleen, etc., or whether they died of tuber- 
 culosis of the lungs. It would be very important to gain knowledge 
 on such points, but it was so difficult, often impossible, to get any 
 reliable information, that I soon got wearied at the unproductive 
 results of my inquiries about the subsequent diseases of these 
 patients. 
 
 In the treatment of these diseases I have scarcely seen any good 
 result from iodine, cod-liver oil or iron; external application of 
 iodine, too, seems to have absolutely no effect, in whatever form it 
 be applied. However, I prescribe it frequently, for I know nothing 
 better to prescribe. Compression, as advocated by my esteemed 
 teacher Baum, sometimes brought about slight diminution of the 
 glandular tumours, at other times led to softening and suppuration. 
 Oji the whole, I have come round to the opinion that the simplest 
 plan of treatment is either to destroy or to extirpate the glands. 
 This method of treatment would seem to be still more worthy of 
 recommendation if the modern views as to the origin of tuberculosis 
 should prove true — viz. that every caseous area, especially if it exist 
 in the lymphatic gland, may prove to be a source of danger. 
 Extirpation of the cervical lymphatic glands may be very easy, or it 
 may be very difficult. It is always practicable when the capsules of 
 the glands are not too much adherent together or united to the sur- 
 rounding parts, and when the glands are not too much softened. If 
 in the latter condition, they cannot be completely removed, and sinuses 
 are left, which take a long time to heal. In removing lymphatic glands 
 the knife should only be employed till the capsule of the gland is ex- 
 posed, and then the tumour should be turned out with the finger or 
 with blunt instruments. The large vessels passing in at the hilus 
 should be ligatured before they are cut through. These operations 
 may extend down to the sheaths of the deep vessels and nerves of the
 
 152 OPERATIVE TREATMENT. 
 
 neck, but the reaction is, as a rule, moderate and recovery rapid ; 
 certainly in most cases the patients are youthful. Of twenty-seven 
 cases in which I extirpated the glands in this way I did not lose 
 a single patient. One of my cases was a simple multiple lymphoma 
 on both sides of the neck, in a girl eighteen years of age. If the 
 removal of the glands is not possible, we are then limited to the 
 application of caustics, or incision and scraping out of the caseous 
 matter, methods which will usually prove ultimately successful, if 
 other conditions be favourable, though often not for months or years. 
 These manipulations are often rendered very troublesome by the 
 situation of the swellings, as, for instance, when the sinuses run deep 
 under the sterno-mastoid muscle. Cauterisation with caustic potash 
 or chloride of zinc arrowheads are the most potent remedies. If it 
 is necessary to penetrate very deeply these remedies should not be 
 employed too boldly, for fear of damaging the carotid artery or jugu- 
 lar vein. Stick caustic is less dangerous. Caseous lymphatic 
 swellings and sinuses may form in old people,^ but it is not advisable 
 to be too bold in laying these open or removing the swelling. I 
 saw one old man die after this operation, although he seemed to be 
 by no means particularly feeble. No operation should be risked 
 which will entail febrile reaction in those who have tuberculosis of 
 the lungs, or a predisposition thereunto. In such cases local inter- 
 ference must be avoided as much as possible, for it would not only 
 be futile, but dangerous. Those who object to the extirpation of 
 lymphomata assert that these operations are fruitless, inasmuch as 
 fresh glands always become affected subsequently ; this view is not, 
 however, in all cases accurate. In my tables a list of cases will be 
 found where the patients were known to be in good health some 
 years after the operation, and that, too, in cases in which several 
 glands had been extirpated. 
 
 In six cases of rapidly growing soft lymphomata the exhibition of 
 arsenic was employed, on three occasions with remarkable success. 
 In one of these patients the lymphoma had affected the cervical, 
 axillary, cubital, and inguinal glands on both sides, as well as those 
 of the mesentery. The arsenical treatment was attended with great 
 success for the time, but I have no later information about the 
 patient. Of the other two cases, one occurred in a man with lym- 
 phomata in both sides of the neck, both axillae, and who had at the 
 same time a large mediastinal tumour ; the other was a unilateral 
 
 » Cf. Sir. J. Paget on "Senile Scrofula," 'Clin. Essays' 1st, Ed. p. 344.
 
 PAEENCHYMATOUS INJECTIONS IN LYMPHOMA. 153 
 
 tumour of the neck in a child; in three instances the arsenical 
 treatment led to no good results. These were all cases where soft 
 rapidly growing tumours occurred separately in different parts of the 
 body, and did not coalesce with one another (malignant lymphoma). 
 Such cases are usually associated with pallor, but not commonly 
 with leucocythemia ; there is simple hyperplasia of the gland. 
 Death commonly follows from hydrsemia, marasmus, and dropsy. 
 In all the cases (seven) the disease commenced below thirty years of 
 age. 
 
 Simple ordinary lymphoma (W. B., 1870). — In three patients I 
 tried parenchymatous injections of the tumours. Solutions of chlo- 
 ride of gold, carbolic acid, quinine, iodine, etc., were the drugs em- 
 ployed. In all the cases the effects so far resembled each other 
 that no direct shrinking of the growth nor absorption was caused 
 by the employment of these drugs, but repeated injections were in- 
 variably followed by small abscesses. The tumour then shrank up 
 to some extent, whether the pus was let out or escaped spontaneously. 
 No material diminution, however, was brought about. After we had 
 employed injections made in different ways and of various strengths, 
 we finally abandoned the method of treatment. Other surgeons 
 have met with rather better success. But I may remark that among 
 the many cases in which I have extirpated lymphoma in Vienna, I 
 have very seldom met with simple hyperplastic, unaltered forms of 
 the growth. The glands are nearly always completely caseous, and 
 frequently softened; even the smallest glands are found in this 
 condition. Now, even in simple hyperplasia of the glands, there is 
 but little hope of resorption ; and such a result can scarcely be ex- 
 pected when the glands are completely caseous. The mesenteric and 
 bronchial glands have a far greater tendency to shrink up, calcify, 
 and degenerate than the cervical, axillary, or inguinal glands. The 
 latter groups are much more prone, generally speaking, to softening. 
 The early occurrence of caseation in lymphomata, explains to my 
 mind why compression is so ineffective.^ 
 
 Medullary Lymphoma and Lympho-sarcoma. 
 
 Histologically we are justified in distinguishing between these 
 ^ Remarks on these tumours will be found in ' Ai-cli. f . Kl. Chii-.,' Bel. 
 
 xviii, p. 98, ' Wien. Med. Jahrbuch,' 1877, Heft iii, p. 153, and ' Wien. 
 
 Med. Wocli.,' 1877, No. 1.
 
 154 MEDULLAEY LYMPHOMA AND LTMPHO-SARCOMA. 
 
 two forms of morbid growth, though it is by no means ea«y to do 
 so. From a clinical point of view such a separation, so far as my 
 acquaintance with the two forms of disease extends, would be of 
 little value. In early stages, and when they first originate, no dis- 
 tinction can be made between the two forms of glandular enlarge- 
 ment. After they have grown for some time unnoticed, they begin 
 rapidly to increase; the separate nodules coalesce, the whole mass of 
 the tumour becomes adherent to the deeper parts surrounding the 
 lower jaw, extending back to the vertebral column, and displacing or 
 even becoming united to the larynx. In the meantime the skin 
 over the tumour has turned red and thin ; the tumour is in parts 80 
 soft, as to yield a sense of fluctuation, though it contains no fluid. 
 In this state it may remain for a few weeks. If the growth be 
 extirpated at this period the tumour on section will resemble in 
 consistence the white matter of the brain. In some parts it will be 
 semi-solid, in other parts separable into bundles, like those of muscle 
 or the fasciculi of coagulated fibrin (carcinoma fasciculatum of 
 Eokitansky^) ; the individual glands can scarcely be difi"erentiated one 
 from another in the uniform mass. The tumour is certainly sur- 
 rounded completely by a capsule of cellular tissue, but the separate 
 capsules investing the glands will have disappeared and become lost 
 in the mass of the growth. Microscopically, no structure can be 
 found, while in freshly-cut portions of the tumour only lymph-cells^ 
 with here and there a few spindle-cells and fine bundles of cellular 
 tissue will be recognised. If thin sections of preparations, 
 hardened in chromic acid or alcohol, be pencilled over or shaken up, 
 a fine network of fibres bearing a rich capillary plexus, similar to 
 that found in the alveoli of the lymphatic glands, may be recognised, 
 in the meshes of which the lymph- cells are contained. The mor 
 narrow the meshes of the net are, the more does the structure of the 
 lymphoma approach to that of the granulation sarcoma (glioma of 
 Yirchow) ; not infrequently, indeed, two forms may be united together 
 in the lymphoma. The thicker the fibrous reticulation, the larger the 
 spaces, the more does the network resemble the stroma of a cancer. 
 This means of distinction led me to characterise the foUowing case 
 as one of medullary lymphoma : 
 
 H. K — , vet. 30, had noticed for thirteen months glandular swelling on the 
 right side of his neck. In the course of a year the tumours had increased, 
 without pain, to the size of a f cetal head. In removing the growth the pneumo- 
 
 1 ' Billr. Path.,' Hackley's Trans., p. 618.
 
 CASE OF MEDULLARY LYMPHOMA. 155 
 
 gastric nerve was found to pass right through the middle of the tumour, and 
 a portion of the nerve, one inch in length, was inadvertently cut away. The 
 internal jugular vein was wounded and the carotid artery laid hare for a 
 considerable distance. The patient was discharged in six weeks with the 
 wound almost healed. By means of the laryngoscope paralysis of the right 
 vocal cord was detected. Two months later the patient came back to the 
 hospital with a recun-ence of the growth, which had again reached the size of 
 a foetal head, and become ulcerated. No operation was possible and the 
 patient died shortly afterwards of haemon'hage. The disease had lasted alto- 
 gether seventeen months. The patient had in early youth suffered from 
 glandular swellings, which had in great measure disappeared before the new 
 growth originated. 
 
 Medullary lymphoma may occur at any age, and seems to be 
 rather more common in men than women. I have seen a morbid 
 growth of this nature in a child one year old, and quite recently a case 
 where a man, sixty years of age, had a similar tumour in the axillary 
 glands. Whether permanent cure may follow from early and com- 
 plete removal of these tumours must for the present be undecided. 
 Prom the examinations I have made it is clear to me that not 
 only the capsules of the glands, but the adjacent cellular tissue 
 also, become infiltrated by a small-celled growth and converted 
 into lymphoma. According to this view, complete extirpation 
 would only be possible if a portion of the apparently healthy tissue 
 immediately around was removed together with the tumour, which 
 in the neck is not practicable. Many of the recurrences are cer- 
 tainly local, i.e. glands which at the time of operation had not 
 become affected and are left, become subsequently the seats of fresh 
 morbid growth. 
 
 Medullary lymphoma. 
 
 Frau P — , set. 36, was a well-nourished, healthy-looking woman, whose 
 previous health had been good. About two years before I saw her she 
 suffered from a painful carious tooth on the right side of the lower jaw. 
 In consequence of this, swelling of the lymphatic glands below the edge of 
 the jaw occuiTed. At first the swelling increased very slowly, but after a 
 few months more rapidly, occasionally causing some pain. When she came 
 to me, the tumour was the size of a goose-egg, immovably connected to the 
 bone, and extending but little into the mouth ; the tonsils were not affected. 
 The whole of the right half of the lower jaw was removed ; the condyle and 
 the coronoid process were left. The tumour Avas veiy carefully extirpated, 
 so that no visible trace of it remained. Unfortunately veiy rapid recurrence 
 took place, and she died two months after the operation. 
 
 J. G — , set. 37, a brewer, had noticed, for six months, some swelling partly
 
 156 DISEASES OF THE THYROID BODY. 
 
 in the neck and partly behind the right angle of the jaw. This had been 
 preceded for some time by singing noises in the ear. For two montlis the 
 growth had been increasing veiy rapidly in the neck, and caused difficulty of 
 swallowing and breathing. The tumour filled up the right side of the cavity 
 of the pharynx up to the velum, and extended from that point to the lower 
 and back part of the angle of the jaw, at 'which latter point it bulged foi-ward 
 prominently. Operation appeared to me to be unadvisable. With a view 
 to cause some shrinking of the growth a solution of carbolic acid (two 
 grains to six drachms of water) was injected into the tumour at six different 
 points ; moderate reaction followed. Thi-ee days later the injection was 
 repeated. The growth constantly enlarged, and four days after the last 
 operation the difficulty of respiration was so gi'eat that laiyngotomy was per- 
 formed. Fluctuation was then distinct, both externally and internally. 
 Severally incisions were made and some foul sanious pus evacuated. The 
 growth shrank up so much subsequently that in three weeks the canula was 
 removed and the patient could breathe fi-eely through his laiynx. He died 
 four months later. The disease had lasted about a year. 
 
 Primary epithelial cancer of glands. 
 
 A man, set. 58, had a deep-seated epithelial cancer of the lymphatic glands 
 on both sides of the neck. No peripheral disease could be clearly proved. 
 The tumour was removed six months after it was first noticed. The internal 
 jugular vein had to be ligatured. He died five days after the operation of 
 aeptic fever (infections fieber). 
 
 Section C. — Diseases of the Thyroid Body. 
 
 Various forms of hronchocele — Clinical and pathological charac- 
 teristics. Cases of hronchocele treated by puncture — by injec- 
 tion of iodine — {remarks on 20 cases) — by chloride of zinc 
 paste — by subcutaneous laceration — by tenotomy of sterno-mas- 
 toid — by extirpation {remarks o» 18 cases). Three cases of 
 extirpation of bronchocele. Case of cyst bursting into pharynx. 
 Cases of cyst treated by injection and incision. Cases of malig- 
 nant bronchocele. Cases of abscess in thyroid. Case of 
 hronchocele during pregnancy ; tracheotomy. General remarks 
 on treatment of bronchocele by iodine injections. Cases of 
 softening of bronchocele. 
 
 In connection with these cases, which will only be considered 
 at present from an operative point of view, I must premise the
 
 VAEIETIES OP BEONCHOOBLE. CYSTIC BRONCHOCELE. 157 
 
 following observations : — We have to distinguish — (i)The diffused, 
 commonly bilateral hypertrophies which are vulgarly termed " thick 
 neck '' (Dicke Hals). This affection is infinitely common, without 
 giving rise to any serious trouble. Such cases require no operative 
 treatment. In young persons they can be improved at their 
 commencement by energetic treatment by iodine, but can seldom 
 be dispersed entirely. (2) Bronchoceles which are circumscribed 
 glandular hypertrophies, tuberous adenoma or cysto-adenoma ; 
 these may occur singly, but are often multiple. The rest of the 
 thyroid gland may be perfectly normal, though it is usually rather 
 hypertrophied. (3) Pure cystic bronchocele. (4) Carcinoma of 
 the thyroid — " struma carcinomatosa." There is no need to 
 employ a special term for the so-called " struma aneurismatica."^ 
 In nearly all the multiple tumours of the thyroid which have 
 existed for some time, the supplying arteries are much dilated. 
 
 Oystic bronchocele. — There is usually little difficulty in recog- 
 nising a pure primary cystic bronchocele if the tumour is of any 
 size and pushes forward prominently. By primary cystic broncho- 
 celes I mean those which are composed of a single smooth-lined 
 sac, secreting usually a dull yellow or brownish fluid of viscid 
 consistence. They are developed by hyper-secretion in the separate 
 vesicles of the thyroid gland, which then coalesce: sometimes they 
 form in a single vesicle. They may attain the size of a man's head, 
 and though not infrequently on one side, usually lie in the middle 
 line of the neck. There are other kinds of cystic bronchoceles with 
 contents similar to the foregoing, which have a rough lining, and 
 originate in the parenchymatous gland tissue. These cysts develop 
 by mucoid softening in the swollen parenchymatous tissue ; in 
 addition to this softening a central process of contraction is common 
 enough in bronchoceles. The walls of the cysts may calcify. It 
 is often a matter of great difficulty to diagnose cysts formed by 
 softening. A puncture with an exploring trocar is often needed in 
 order to clear up the diagnosis, for when the bronchocele is very 
 soft and the capsule tense, the feeling of fluctuation cannot be dis- 
 tinguished from that of a cyst containing fluid. The puncture in 
 such cases does not always let out much fluid, for these cyst walls 
 have frequently but little elasticity. More rarely in parenchy- 
 matous bronchoceles it happens that the whole substance becomes 
 ^ ' Billr. Patli.,' Hackley's Trans., p. G^g.
 
 158 TREATMENT OF CYSTIC BEONCHOCELES BY PUNCTURE. 
 
 converted into a greyish, granular, thick pulp. If these tumours 
 be examined after death, on cutting into the mass a firm sac with 
 pulpy contents will be found, which during life, would have 
 given the impression of being a solid growth. The pulpy matter is 
 usually calcified in part ; this form of bronchocele may, perhaps, be 
 diagnosed when neither blood nor fluid escapes, after the explora- 
 tory puncture. These are by no means the only metamorphoses 
 of tumours of the thyroid, which originate in the parenchyma; 
 for purposes of diagnosis, however, and with regard to operative 
 interference, they seem to be the most important changes. 
 
 That the simple evacuation of the fluid by puncture is nearly 
 always but a palliative measure might be inferred by analogy from 
 the puncture of cysts in other regions. This method is, however, 
 not very advisable in cystic bronchoceles for severe inflammation 
 may follow, as in the following case : 
 
 C. K — , set. 25, had a large hypertrophied thyi-oid. In the middle line of 
 his neck was a distinctly fluctuating tumour, the size of a hen's egg. 
 Considerable dyspnoea had gradually developed. The central tumour was 
 punct\xred, and some brownish fluid and blood let out. The tumour did not 
 properly collapse. A cyst with central softening was diagnosed. Severe 
 inflammation followed ; a sinus formed In connection with the cyst ; gradually 
 the enlargement disappeared under the application of ice ; the breathing 
 again was free, and he left Avith the sinus still discharging. Six weeks 
 later he came back with enlargement of the gi'owth, and much dyspnoea. 
 The central portion of the tumour was removed and proved to be a cysto- 
 adenoma. 
 
 J. S — , set. 30, had, on the right side, a hard bronchocele, the size of 
 a goose-egg. He had considerable dyspnoea, aggravated by some tracheal 
 catan-h. The tumour was punctiu-ed, some chocolate-coloured fluid evacu- 
 ated, and the dyspnoea immediately improved. The bronchocele, however, 
 did not collapse, and at the posterior part was hard. During the next 
 few days the dyspnoea again increased ; the pvmcture was repeated, and a 
 canula left in, however without benefit, as the dyspnoea increased, until 
 asphyxia threatened. A large incision was then made, and the edges of the 
 cyst were united by sutures to the skin. The cyst contained some puriform 
 fluid, and at the posterior part the wall was calcified. Improvement soon 
 took place, and the patient completely recovered. The calcified masses pro- 
 bably dissolved ; at any rate, notliing of them was found in the secretion. 
 The patient's neck became again quite slender. 
 
 After these two cases I ceased to employ puncture as a palliative 
 measure, and have always laid open or removed these softening
 
 IODINE INJECTIONS IN CYSTIC BRONCHOCELE. 159 
 
 cysts. Puncture with an exploring trocar so as to let out a few 
 drops of the fluid is not a dangerous proceeding. The puncture of 
 parenchymatous bronchoceles if carefully conducted, does not, as a 
 rule, lead to any inflammation of the thyroid. In one case of a 
 single large cyst in a man, aet. 32, the cyst was punctured and a 
 drainage tube left in. Moderate reaction followed. When the 
 patient came under my care he had a fistulous opening which, by 
 repeated injections of iodine, we succeeded at last in closing, six 
 months after the original operation. 
 
 Another patient, an old man, in whom ten years previously a 
 small incision had been made into a thyroid cyst by my predecessor, 
 came back to the hospital on account of some slight injury. He 
 still had a fistulous opening leading into the cyst ; but little secre- 
 tion, however, came from it, and he would not allow of any treat- 
 ment. In ten cases the method of v. Bruns and v. Chelius Jun 
 was adopted, i.e. the cyst was laid open and its edges united to the 
 skin. On three occasions this was performed as a secondary mea- 
 sure, on patients in a feverish condition (case of J. S — ,supra). 
 Two other cases died, one of pyaemia twenty-nine days after the 
 operation, while the other, who had been nearly asphyxiated by the 
 growth, died of septiceemia. 
 
 Puncture and injection of iodine. — After puncture half an ounce 
 of Tinct. lodi. Fort, (one dram of iodine dissolved in ether to one 
 ounce of absolute alcohol), was injected and left in, and then a 
 collodion bandage^ was placed on the anterior half of the neck. 
 While at Zurich I had twenty such cases. Fifteen of these were in 
 women and girls, from twelve to twenty-nine years of age, and five 
 in men and boys, from twelve to thirty-two. In all instances the 
 thyroid cyst, which so far as could be judged was simple, was per- 
 manently cured. In many of these patients diffused hypertrophy 
 of the thyroid, or parenchymatous bronchoceles existed at the same 
 time. In many instances the bronchoceles were completely covered 
 by the cysts, which at times were as large as a man's head. I 
 mention this, because it is interesting and important to know that 
 the coexistence of hypertrophied thyroid and solid bronchoceles 
 does not contra-indicate the puncture of the cyst and the injection 
 of iodine. Unfortunately, however, the treatment of the cyst has 
 
 ' I.e. strips of gauze of a finger's breadth soaked in collodion, a form of 
 bandage much employed in some parts of Germany — [Ed.]
 
 160 SUBCUTANEOUS LACERATION OF BEONOHOCELE. 
 
 no influence on the disappearance of the remaining portion of the 
 tumour. It sometimes happens that after the operation haemorrhage 
 occurs into the cyst, evidenced by rapid swelling. In one instance 
 the cyst became so swollen that it was larger than before the puncture 
 I put on a collodion bandage thicker than usual, and applied ice. 
 Recovery was somewhat delayed but no other harm happened. 
 With regard to the after-treatment, when iodine has been iujected, 
 it should be observed that sharp fever usually follows the operation, 
 lodism may occur, so that the patients have to lay up for a few days. 
 The collodion bandage is most effective against the swelling, and I 
 have seldom had occasion to apply ice. Gas often develops in 
 these cysts after operation ; no harm comes of it and it is best not 
 to let it out; some months may elapse before the effusion, and 
 the gaseous contents of the sac are absorbed. Matters will not be 
 expedited by making any fresh punctures, as I experienced. In 
 two cases where I punctured under these conditions, severe inflam- 
 mation set in with dyspnoea and fever, and I had to lay open the 
 cyst and unite the walls by sutures to the skin, and though both 
 patients recovered, they had been exposed needlessly to a second 
 operation and a new source of danger.^ 
 
 In a case of parenchymatous bronchocele, associated with smaller cysts, 
 occurring in a decrepid woman, fifty-nine yeare of age, I applied chloride 
 o£ zinc paste. On both sides were large thp-oid tumours, causing dyspnoea. 
 The skin was incised on the right side where the larger tumour lay, and strips 
 of lint soaked in chloride of zinc paste applied. On the following day 
 the cauterised part was scraped away, and the paste reapplied. The dyspnoea 
 gi-adually increased, until the patient become asphyxiated. Post mortem : 
 the trachea was found narrowed, and the bronchocele had in part extended 
 into it. (See Fig. ii). 
 
 Three cases of subcutaneous laceration of parenchymatous Iron- 
 choceles. — I have repeatedly observed, that in cases where at difi'erent 
 times several punctures had been made into parenchymatous bron- 
 choceles, in order to determine the consistence of the mass, dyspnoea 
 was relieved and sometimes, as it appeared to me, the tumour 
 diminished in size. Examinations of a considerable number of 
 bronchoceles of this nature showed me further that not infrequently, 
 a central cicatricial contraction took place. This gave me the idea 
 
 1 For fui-ther remarks on the treatment by iodine injections, vide infra 
 pp. 170—175.
 
 SUBCUTANEOUS LACERATION OE BEONCHOCELE. 161 
 Fig. II, — Beonchocele, exteijding into, and naeeowing the Trachea. 
 
 that it migM be possible, in cases where extirpation would have 
 been out of the question, to procure a process of shrinking, bj 
 repeated subcutaneous punctures; at any rate, I thought that I 
 could make the tumour soften, and so change a solid into a cystic 
 growth. I carried this idea into effect in the case of a phlegmatic 
 young woman, set. 32, who had a lateral, deep-seated, firm bron- 
 chocele, causing some dyspnoea. I thrust into it a moderate sized 
 trocar, drew out the stilet and moved the canula about in different 
 directions in the tumour ; this brought about no reaction, so that I 
 
 11
 
 162 TENOTOMY OF THE STEENO-MASTOID EXTIRPATION. 
 
 repeated the proceeding several times, at intervals of a few days. 
 Eventually the tumour became hot and painful, and fluctuated; 
 then I made an incision, and let out the pus and pulpy matter. 
 Complete recovery followed. In another case, however, the result 
 was very different. 
 
 A. B — , £et. 37, Lad a fluctuating soft bronchocele the size of an apple, 
 close above tlie sternum, and extending a little beneath it. Great dyspnoea 
 and ti-acheal catarrh, with attacks of asphyxia. Subcutaneous dilaceration 
 was performed. Veiy severe swelling of the tumour followed ; the skin of 
 the neck became discoloured and brown ; the dyspnoea increased, and she 
 was attacked with septic fever and delirium. I extirpated the tumour, but 
 death followed from septicjemia. 
 
 This last case has rather deterred me from this method, which 
 at first, seemed to me to promise good results. I have long had an 
 idea of injecting very small quantities of much diluted tincture of 
 iodine, or other substances, into parenchymatous bronchoceles ; 
 hitherto, however, I have never tried this plan ; chiefly because the 
 results of completely removing bronchoceles have in my hands 
 become better and better. 
 
 Tenotomy of the gterno -mastoid. 
 
 Frau S — , jet. 26, had a bronchocele of the right side, with tracheal stenosis. 
 The muscle was divided subcutaneously and marked improvement of the 
 breathing followed. 
 
 HeiT V—, set. 17, had a considerable substernal cyst on the left side. The 
 whole muscle was cut thi-ough completely, and the left stemo-hyoid muscle, 
 as well as the fascia of the neck, partially divided, until the capsule of the 
 tumoiur was exposed, a large skin wound being thus made ; no material 
 improvement followed, and death occurred some days after the operation, 
 from septicaemia with duodenal ulceration and intestinal hiemorrhage. (' Ziir. 
 Ber.,' i860— 1867.) 
 
 t Extirpation of bronchoceles. 
 
 In eighteen cases, while I was at Zurich, primary extirpation was 
 undertaken for tumours of greater or less size, which may be 
 arranged as follows : — {a) Bronchoceles causing little or no dyspnoea, 
 and exclusively lying in the middle line of the neck, over the upper 
 border of the sternum, (h) Bronchoceles, mostly unilateral, partly 
 substernal, in which the symptoms of dyspncea threatened to produce 
 asphyxiation. Of ten such cases, four recovered and six died.
 
 EXTIRPATION OP BEONCHOCELES. 163 
 
 F. B— , ret. 23, had severe dyspnoea. Laiyngoscopic examinations showed 
 that the trachea was considerably pressed to the left, and the cavity of the 
 tube naiTOwed intei-nally. The tumour was scarcely noticeable. By making 
 an incision on the left side of the trachea, I was able to draw forward a bron- 
 chocele the size of a hen's egg with immediate relief to the respiration. The 
 day after the operation, rales were heard in the trachea, and the dyspnoea 
 again increased markedly. Tracheotomy was performed and the breathing 
 again became free. Everything went on well for a week after the operation, 
 when rapid collapse occuiTed and he died rather suddenly. The canula was 
 not stopped up. Post-mortem examination showed only extensive capillary 
 bronchitis. The neighbourhood of the wound and the mediastinal cellular 
 tissue were not infiltrated, nor was there any thrombosis of the vein. 
 
 U. B — , set. 29, had a sub-stemal tumour in the middle line, the size of an 
 apple, causing formidable dyspnoea, attacks of suffocation at night, loss of 
 sleep, and great distress. The growth was removed ; haemorrhage occurred 
 again after he recovered from the anaesthetic, and a tampon soaked in sesqui- 
 chloride of iron was applied. As this brought on the difficulty of breath- 
 ing again, the tampon had to be removed on the day following. The bleeding 
 recurred, and the liquor fen-i was again applied. Gangrene of the trachea 
 followed, and he died of septicaemia, and mediastinitis, four days after the 
 operation. 
 
 On carefully reviewing the results of my experience, I have come 
 to the following conclusions with regard to the operative treatment 
 of bronchocele. Simple primary thyroid cysts may be radically cured 
 by puncture and injection of iodine ; this is the most sure, and the 
 least dangerous method. Cysts of this description may be recognised 
 by their distinct fluctuation, and the cholesterine contained in the 
 evacuated fluid. In secondary or softening cysts, the fluctuation is 
 seldom very distinct. The fluid escapes slowly ; that which flows last 
 is mixed with blood, and the walls do not collapse much. Such 
 cysts were treated by incision, but the operation is scarcely less 
 dangerous than extirpation. 
 
 Bronchoceles, even of large size, situated in the middle line of 
 the neck, and causing little or no dyspnoea, can usually be removed 
 successfully, especially in women and girls. Much less favourable 
 in its results is the operation for completely removing deep-seated 
 substernal or unilateral bronchoceles, accompanied by a high degree 
 of dyspncEa; even in cases in which the operation is immediately 
 successful in saving life, the ultimate result is frequently un- 
 favourable. 
 
 I have occupied myself a great deal with the question as to why 
 some bronchoceles cause so much dyspnoea, while others, perhaps of
 
 164 MODE OF EXTIEPATING BKONCHOCELES. 
 
 much larger size, entail none. This materially depends on the 
 situation of the tumour; if the enlargement occurs in the lower 
 part of the lobes of the thyroid and pushes forward against the 
 unyieldiug sternum and first rib, compression of the trachea follows 
 and dyspnoea is produced. Bronchoceles seated laterally at a 
 somewliat higher level, frequently cause dyspnoea at" their commence- 
 ment ; later, however, when they bulge forwards between the fibres 
 of the fascia and the anterior (seldom the posterior) edge of the 
 sterno-mastoid, the dyspncea again disappears. Cysts, as well as 
 parenchymatous bronchoceles may — according to their situation — 
 cause dyspncEa. In such cases the division of the sterno-mastoid 
 has but little efl'ect. The deep-seated substernal bronchcoceles, which 
 are the most dangerous of all, are not interfered with by the sterno- 
 mastoid muscle but by the sternum. In deep-seated bronchoceles 
 the dyspncea is more marked in the male sex ; probably owing to 
 the fact that the fascia and muscles of the neck are more rigid, and 
 that the tumour is therefore prevented from extending anteriorly. 
 
 The complete removal of a broncliocele is a simple matter, but 
 requires a good deal of care and attention in its performance. 
 Every bronchocele is encapsuled ; the capsule is merely connected 
 to the parenchyma of the gland and the surrounding parts by very 
 loose cellular tissue and blood-vessels. The incision has to be 
 carried through this capsule, and sometimes extended into the gland 
 substance. If the surgeon has not had a good deal of experience 
 of this operation, he may easily detach the whole mass of the thy- 
 roid, instead of merely the bronchocele, thus rendering the opera- 
 tion far more complicated and dangerous. The tumour must be 
 separated cautiously with the fingers, care being taken not to 
 lacerate the parts or to tear the growth away too forcibly, as the 
 veins and arteries passing into the bronchocele are very thin and 
 readily ruptured. It is a matter of no little difficulty and danger 
 to secure these vessels when they extend far back into the paren- 
 chyma of the gland or deep under the sternum. No vessel ought 
 to be cut through until it has been previously ligatured or 
 secured on the proximal side. As soon as the capsule of the 
 tumour is distinctly exposed, the knife and scissors must be laid 
 aside. If the growth be ligatured en masse the threads should be 
 drawn together as tightly as possible, otherwise the ends of the 
 vessels will escape from the knots. Liquor ferri should not be 
 employed to check bleeding in these cases, as it attacks the car-
 
 CASE OF THYROID CYST. 165 
 
 tilages of the trachea. If more thau ligature and acupressure be 
 required, ice or pressure will control the bleeding. Subcutaneous 
 laceration of bronchoceles, which are firm and solid in consistence, 
 may be with caution employed further, but in soft parenchymatous 
 goitres, which bleed freely on puncture, this method should be 
 entirely rejected. 
 
 Large prominent bronchoceles in people above forty years of age, 
 with slight or no dyspnea, should not be operated on just for the 
 sake of appearance. I think that small bronchoceles connected to 
 the lower part of the thyroid in children and young people should 
 be more often removed, especially when their situation is such that 
 the tumour might, with the increased growth, possibly entail some 
 danger. (' Ziir. Ber.,' i860— 1867.) 
 
 J. K — , fet. 45. The bvoncliocele had originated six years previously on the 
 ■right side of tlie neck ; the tumour which was the size of the fist had jiushed 
 the trachea and carotid artery very much on one side ; the breathing was diffi- 
 cult, and he suffered constantly from tracheal catarrh. The entire right half 
 • of the thyroid gland was removed. Death three days later from septicaemia. 
 
 In two other cases tumours in the middle line of the neck — one 
 the size of a walnut, the other of a goose-egg — w^re successfully 
 -removed. ('Wien. Ber.,' 1869-70.) 
 
 Cijst of the thyroid body. 
 
 M — , £et. 40, had noticed the slow and painless development of a tumour on 
 the left side of his neck for fifteen years. The growth had attained the size 
 of a child's head, without materially interfering with breathing or swallow- 
 ing. 
 
 Ten days before admission, he was thrown out of a waggon, and struck the 
 tumour a severe blow against the ground ; immediately he felt a quantity of 
 fluid pass into the throat, and spat it out. The fluid was of a brown colour. 
 Thereupon, the tumour in the neck disappeared ; evidently a cyst had burst 
 into the pharynx. The patient was at first exceedingly rejoiced at the result 
 of the accident which had apparently cured a long-existing and disfiguring 
 complaint. Shortly afterwards, however, he discovered to his great distress, 
 that anything he swallowed passed into tlie sac, and but little made its way into 
 the stomach. He was unable, however, to press anything back from the sac 
 into the throat. The tumour in consequence soon became as large as before, 
 and as the respiration was impeded, a medical man punctured the tumour with 
 a trochar and let out the fluid. The fluid, according to the patient's account, 
 principally collected in the cyst after drinking. He was able to swallow sop 
 iind broth, but could not say whether the food passed into the stomach. When 
 •.admitted he was in a very weak state ; to restore his strength in some measure
 
 166 
 
 CASE OF THYEOID CYST. 
 
 injections of wine and eggs were passed down through a stomach tube. The 
 tumour increased in circumference and at the time of operation it was the 
 same size as before the accident. At the upper half it was resonant on per- 
 cussion. Neither air nor fluid could be emptied out of the sac into the 
 pharynx. A kind of valve had evidently been formed when the cyst was 
 ruptured, the result of which was that substances could enter the sac from 
 
 Fig. 12. — Cystic Beonchocele, which buest into the Phaetnx. 
 
 ¥' \ 
 
 the pharynx but would not return. The only thing to do tlierefore wasjto 
 lay open the whole sac and the skin overlying it, and to urute the wall of the 
 cyst to the skin. The contents of the sac were found to be thin and of a 
 brownish coloui* ; the gas had no ill smell. The inner surface of the cyst was 
 rough ; at the upper part an opening just admitting the index finger led into
 
 THYEOID CYST TKEATED BY IODINE INJECTION. 167 
 
 the pharynx. We were now prepared to find it necessary to feed the patient 
 through the tube, but to our no little astonishment, the patient was able to 
 swallow fluid, without the escape of a single drop through the cyst. It 
 appeared that the edges of the opening into the pharynx had become so dis- 
 placed on the collapse of the cyst, that the action of the valve was completely 
 reversed. Extensive breaking down of the inner surface of the cyst wall 
 took place, followed by hasmorrhage from the deep parts, and he died of 
 pytemia. Post mortem, the diagnosis was confirmed ; the opening into the 
 pharynx was about the level of the cricoid cartilage, but it was so contracted 
 that it would scarcely admit the point of the little finger. The opening in 
 the cyst wall, and that in the mucous membrane of the pharynx, formed the 
 orifices of a canal about three lines in length, which ran obliquely upwards. 
 Probaljly the walls of this canal were so pressed together, when the muscles 
 of deglutition contracted, that no fluid was able to get through. 
 
 Herr X — , a man about 60 years of age, had on the right side, a cyst of 
 the thyroid, about the size of a foetal head, which had existed for a great 
 many years. I was hastily summoned one day and found him com- 
 pletely cyanosed, with a small pulse, and rattling respiration. The cyst had 
 always occasioned him some difficulty in breathing, but the immediate con- 
 dition had been brought on by acute catarrh, resulting from a recent cold. 
 His medical attendant had employed divers remedies for the catarrh, but the 
 difficulty of breathing kept on increasing, and threatened to terminate fatally 
 by oedema of the lungs. I felt bound to do something to ward oft" the immi- 
 nent danger, although I did not expect much chance of saving his life, either 
 by puncture, injection with iodine, or incision. I hesitated to lay open the 
 cyst, on account of its size, and partly also, from fear that the operation 
 might lead to extension of sloughing, and suppuration of the inner surface. 
 Moreover I thought that the inflammation always following any operative 
 treatment of bronchoceles, would probably prove fatal. As I had formerly 
 seen more violent reaction follow after simple puncture than after puncture 
 combined with iodine injection, I selected the latter method. The evacuation 
 of the contents of the cyst only partly succeeded, for though I employed a 
 trocar of moderate calibre, the fluid, which was of a brownish-red colour, only 
 escaped in small quantities. The canula constantly became choked, and then 
 had to be cleared again ; the cyst required to be pressed repeatedly and apart 
 of the fluid could only be drawn off with a syringe. Maniptilations of this 
 nature, where there is no dyspnoea leads often to such bad results, that in this 
 case I feared so much the more that violent inflammation of the sac would 
 ensue. At last I succeeded in emptying the cyst, and then injected half an 
 ounce of strong tincture of iodine, and applied a collodion bandage. Although 
 the patient was much relieved from his dyspnoea by the operation yet he did 
 not rally properly, owing to his very weak state. In spite of strong morphia 
 injections, he had passed many sleepless nights in succession before I saw him. 
 From the comparatively slight effect on the dyspnoea, it seemed possible that 
 his condition was due to swelling of the tracheal mucous membrane at the con- 
 stricted part, as well as from emphysema and bronchial catarrh ; however, his 
 condition for twenty-four hours after the operation improved. The cyst then
 
 ]6S CYSTIC BKONCHOCELE — MALIGNANT BEONCHOCELE. 
 
 again increased in size and during the nest evening a quantity of fluid 
 escaped from the scarcely closed opening and air got in. The next morning 
 I was obliged, on account of the great tension of the cyst, to lay it open, and 
 tlie afternoon of the same day he rapidly sank and died. No post mortem 
 was permitted. 
 
 Cystic hronchocele. 
 
 M. W — , set. i8, had a tumour, the size of a large apple, in the middle line 
 of the neck, which had existed for eight yeai-s. This was punctured and some 
 chocolate-coloured fluid evacuated. Five weeks later the gi-owth had made 
 so little progress towards resorption, that I punctured again. On tliis occasion 
 only some thick gi-anular pulp was let out. The cyst walls then swelled up 
 considerably and the patient became feverish, so that I determined to make 
 a small incision. The cavity of the cyst was found completely contracted, 
 and the swelling was only caused by the thickening of the wall. 
 
 Carcinoma of the tliyroid. 
 
 P. S — , set. 28, a slightly built, ill-nourished, anaemic woman had observed, 
 two years previously, swelling of the left half of the thyroid, which had 
 increased very slowly and without pain. When I saw her the tumour was 
 the size of a hen's egg, very hard, and immovably connected to the trachea ; 
 it caused intense dyspno3a, quite dispropoi-tionate to the size of the tumour. 
 I supposed that the gi'owth was an ordinary "struma" partly calcified, 
 and suspected that a process extended down beneath the sternum, and there 
 pressed on the trachea. I extii-pated the tumour, and found the operation 
 one of the most difiicult which I have ever performed. There was great 
 difficulty in separating the tumour from the ti*achea and the deeper parts ; 
 the haemorrhage was very severe, and attacks of sufiocation occuiTed and she 
 seemed several times during the operation on the point of death fi-om 
 asphyxia. The left inferior thyroid artery had to be ligatured. The 
 patient recovered from this very formidable operation and her breathing 
 became again gi-adually fi'ee. Almost immediately' after the operation, 
 however, the following remarkable condition was manifested ; the patient 
 almost always choked on swallowing the least fluid, and she could only 
 avoid this by swallowing, with the greatest caution, minute quantities 
 at a time. This troublesome condition existed for several weeks ; the 
 voice, which before the operation was rather hoarse, became after the 
 operation still more hoai"sc and bass. Remembering previous similar cases, I 
 concluded from these symptoms that the left recurrent nerve had been included 
 in the ligature placed around the thyroid artciy and in truth, Dr. Schiotter, 
 on examination, discovered complete paralysis of the left vocal cord. The 
 tumour proved to be very difEerent from an ordinary hronchocele. Numerous 
 amorphous calcareous deposits were indeed seen, but microscopically cylindrical 
 and spherical cells were- found in the soft mass of the tumour such as exist 
 onl^' in typical alveolar cancer. Four months later the patient came back ; 
 on the whole she had somewhat improved and the tendency to choke only
 
 MALIGNANT BEONCHOCELE ABSCESS OP THYEOID. 169 
 
 occurred, if she drank fast : the breathing, however, had again become 
 impeded, and the breath was very foul. With the aid of the laryngoscope 
 the tube of the trachea was found to be much naiTowed by a nodulated 
 growth which had invaded the left wall of the laiynx and trachea. The 
 patient was anxious for a second operation, but under the circumstances, I 
 could not advise it. She died two or three months later from suffocation. 
 
 Carcinoma of the thyroid [strunia-carcinomaiosa) . 
 
 A. G — , iBt. 35, an emaciated, weakly woman, had from her childhood, a 
 thick neck. For two years the tumoui- had increased more rapidly, so that 
 on admission, the entire right side of the neck, down as far as the clavicle 
 was occupied by an immovable growth. Operation was out of the question. 
 The jugular vein was found post mortem to be crammed full of the cancerous 
 mass. Metastatic tumoure were also discovered in the lungs and liver. The 
 disease had lasted about two years. 
 
 Malignant bronchocele. 
 
 A remarkable case of this nature was met with in a man, set. 61. The 
 bronchocele extended deeply beneath the sternum, and compressed the right 
 innominate vein. As a result, all the subcutaneous veins of the neck, and 
 the front of the trunk, became converted into an enormously dilated convoluted 
 mass. The patient died shortly after his admission of marasmus. 
 
 The case is recorded at great length in the 'Wiener Med. 
 Wochenschrift/ 1877, No. i, by Dr. Kretschy. The drawings on 
 Plates II and III will sufficiently illustrate the case here. The 
 tumour was found after death to be a medullary cancer of the 
 thyroid, partly cystic ; during life it occupied the position shown by 
 the dotted line in PI. iii, fig. 6 c. 
 
 Two cases of alscess of the thyroid gland. 
 
 The first was that of a man, a3t. 30, who had from his childhood a thick neck. 
 Without any known cause, the left half of the thyroid gland became painful 
 and swollen. Ten days later the skin was much reddened, and fluctuation was 
 distinct. Onchotomy was perfonned. The patient was in a high state of 
 fever at the time, but in three weeks he was able to leave. For a fortnight 
 after the incision, he had relapses of fever, with continual discharge of pus 
 at the lower part. 
 
 The second case was that of a woman, set. 26, who, after a natural confine- 
 ment, had severe feverish symptoms and much pain in the head and neck. 
 An extremely tender swelling then formed on the left side of the neck, and 
 soon ran on to acute inflammation of the left side of the thyroid, which
 
 170 IODINE INJECTIONS IN BRONOHOCELES. 
 
 was moderately enlarged. Rapid recovery followed the opening of the 
 abscess. 
 
 Bronchocele during pregnancy. 
 
 A woman, a)t. 33, was admitted to the lying-in ward with a large, diffuse, 
 bilateral bronchocele. As her dyspnoea was excessive, premature labour was 
 induced at the seventh month of pregnancy. After delivery, the dyspnoea 
 constantly increased and the patient was transferred to the surgical ward almost 
 in a state of asphyxia. She recovered in some measui'e after tracheotomy. 
 Pneumonia of the right side followed and canied her off. Post mortem, 
 only hyperplastic enlargement of both lateml lobes of the thyroid was found. 
 
 An almost exactly analogous case also terminated fatally after 
 tracheotomy. 
 
 TuiIOURS OF THE ThYROID. 
 
 Parenchymatous injections of tincture of iodine} 
 
 The following observations are founded on the cases which came 
 under my care between i860 and 1876. 
 
 I have never employed parenchymatous injections of iodine in 
 undoubted cases of cystic bronchocele, although my colleague, Stork, 
 has seen cystic bronchoceles shrink up after repeated injections of 
 small quantities of this drug. In old, partially calcified bron- 
 choceles, which are usually permeated by very large blood-vessels, 
 I have likewise abstained from the use of iodine. In doubted 
 carcinoma the remedy is always useless. I always use the pure 
 iodine tincture of our Pharmacopoeia for injection. As regards the 
 risk, I think it less dangerous to inject the pure alcoholic solution 
 of iodine, than mixtures of water and tincture of iodine. If the 
 alcohol be much diluted, swelling of the tissue, and subsequent 
 decomposition, may be brought about; the pure alcoholic solution 
 of iodine, produces immediate coagulation and contraction of the 
 tissues with which it comes into contact. On the first occasion I 
 inject about half an ordinary subcutaneous morphia syringe-full. 
 The syringe should be filled with the tincture of iodine before the 
 point is screwed on, the piston pressed down so as to exclude all 
 air, and the point must then be plunged deeply into the bronchocele, 
 
 * See also above, p. 159.
 
 IODINE INJECTIONS IN BRONOHOCELES. 171 
 
 wliich is steadied by the left hand^ and the contents of the syringe 
 rapidly injected. There is no need to put any plaster over the 
 little puncture. I describe this proceeding minutely, since I 
 should like to see this method more extensively adopted by 
 practical surgeons, and perceive that many avoid it from fear of 
 some ill consequences resulting from not carrying out the details 
 accurately. 
 
 There may be some trouble and delicacy required in puncturing 
 bronchoceles smaller than a hen's egg ; of course, nothing should 
 be injected unless the operator is certain that the point has entered 
 the bronchocele, for to inject tincture of iodine into the cellular 
 tissue would probably cause suppuration. It does not matter in 
 what direction the puncture is made. It is better to vary the situa- 
 tion of the punctures and the directions in which the fluid is 
 injected. If the diameter of a bronchocele can be approximately 
 estimated, there is no danger of penetrating it and injuring the 
 trachea, oesophogus, or the large vessels of the neck. This method 
 of treatment can only present any difficulties when the bronchoceles 
 are small and very movable. 
 
 The immediate effect of the injection varies greatly in different 
 patients ; most of those so treated experience just a slight burning 
 sensation after the injection : others describe an unpleasant feeling 
 of tension, while many complain of severe pain extending over 
 the whole face and jaws, which lasts for several minutes and is at 
 times associated with a sensation of great distress and faintness. 
 The presence of iodine can be proved after a short time — say half 
 an hour — in the urine and saliva. Slight swelling and pain, lasting 
 from three to eight days, is nearly always experienced about the 
 injected part. If, as usually happens during the subsequent week, 
 distinct, though only slight diminution in size takes place, the 
 treatment may be pursued with confidence. The patients are able 
 to estimate with tolerable accuracy the diminution in the size of the 
 growth by the fit of their clothes or cravats. If a rapid cure be 
 required, we should not wait until all trace of tenderness resulting 
 from the previous injection has passed away; a syringe-full should 
 be injected twice or three times a week, at different parts of the 
 bronchocele ; more than this, according to my experience, is not to 
 be recommended. Many patients are anxious to get well with the 
 utmost possible speed ; they may experience little or no pain from 
 frequent injections, or, if they do, they keep it to themselves. If
 
 172 EFFECTS OF IODINE INJECTIONS ON BRONCHOCELES. 
 
 tlie bronchocele be injected every other day, or daily, no ill effect 
 in the general condition will probably be noticed for the first week, 
 but then, after repeated injections, rapid emaciation sets in even in 
 strong individuals; the patients become languid, exhausted and 
 feverish at night ; the eyes are bright and sunken, the urine con- 
 tains albumin, and sometimes the sputa show traces of blood, while 
 the patients are troubled with cough and catarrhal inflammation, 
 'formerly I did not quite believe in these subacute and chronic 
 states of iodism, for I never saw it after the use of iodide of potas- 
 •sium in large doses ; I no longer now, however, have any doubt 
 that the condition above described is the direct result of the iodine. 
 Many pathologists take quite a different view, and hold that when 
 a bronchocele, from any reason whatever, disappears rapidly, the 
 ■organism becomes aff<icted owing to the taking up of the products 
 of the broken-down tissue, which had been absorbed from the 
 bronchocele. The emaciation is then, according to their view, not 
 caused by the iodine, but by the absorption of the brpken-down 
 -tissue of the bronchocele. It is exceedingly difficult to say which 
 view is the correct one. I can only recall one case where the 
 patient was not taking iodine in which the rapid disappearance of a 
 bronchocele was attended by emaciation. 
 
 A man, aet. 50, had sufEered for many years from bronchocele of the left 
 side, of the dimensions of a large fist ; tabes gradually developed, which 
 seemed to have its starting-point in the brain, and was associated with ptosis 
 of the right eye. In the course of a year he became reduced to a skeleton ; 
 he had sufEered from severe neuralgic pains, allayed by frequent morphia 
 injections. Simultaneously with this general emaciation the bronchocele 
 entirely disappeared. 
 
 Now, could it be said in this case that tabes was secondary to 
 the disappearance of the struma? Hardly, I think; rather the 
 relations of the two processes must have been reversed. I only 
 adduce the case as an example of the disappearance of a long- 
 existing bronchocele accompanied by rapid emaciation, without 
 iodine injections. 
 
 Although this only occasionally happens, yet I have observed 
 emaciation accompany the injection of iodine in a good number of 
 cases. I think that I am justified in entering a warning against 
 ^ny too rapid and bold attempts at cures of this description, especi- 
 .ally in weakly individuals. E-^necially careful ought we to be with
 
 EFFECTS OP IODINE INJECTIONS ON BRONCHOCELES. 173 
 
 young girls coming of tubercular families ; in children under the 
 age of six years, I should hardly care to employ the method at all 
 and at a later age after each injection great care and close watching 
 are necessary. 
 
 I have seen bronchoceles the size of a fist so decrease in the 
 course of four weeks after the iodine injection, that they were 
 scarcely the size of a hen's egg. True, at the same time there 
 was considerable emaciation. Whether these bronchoceles soon 
 recurred again, or remained permanently contracted, I cannot 
 say. 
 
 In a f6w cases I saw remarkably good results in bronchoceles 
 situated in the middle line, partly substernal, and causing dyspnoea. 
 
 A cliild, set. lo, who had a bronchocele of this sort, causing gi-eat dyspnoea,, 
 was sent to the hospital to have tracheotomy performed ; he was kept under 
 constant observation, and we were ready to do tracheotomy at any moment. I 
 thought tliat I would try the effect of iodine injections, although I had some 
 fear that they might at first increase tlie dyspnoea ; however, this was not the 
 case, for after forty-eight hours the chikl breathed much more freely. The 
 injections were repeated at short intervals, and in fourteen days the 
 respirations were perfectly free. Certainly, he became rather emaciated, but 
 soon recovered from this vnih. the assistance of good food and fresh air. 
 
 Undoubtedly the effect of the iodine treatment here was very- 
 striking, and this success is by no means diminished in my eyes by 
 the fact that six months later the dyspnoea gradually came back 
 again; repetition of the former treatment again brought about 
 equally good results. The parents were sensible enough to bring 
 the child up twice weekly for a long time, in order that we might 
 inject the bronchocele. The treatment was pursued till the bron- 
 chocele became so small that we could hardly inject it with any 
 safety. 
 
 Dr. Gersuny, my assistant, met with equally good success in the 
 case of a woman with a large bronchocele, which surrounded the 
 entire trachea, and produced severe dyspnoea, and occasionally almost 
 suffocated the patient. 
 
 No one who has examined the anatomical structure of many 
 bronchoceles can be astonished that the injections of iodine act 
 upon bronchoceles with such varying effects. It is only in the 
 diffused, hypertrophic glands, in which the development of the 
 vessels keeps pace with the new formation of gland tissue, that the 
 structure of the bronchocele is unaltered. Sooner or later, changes.
 
 174 EFFECTS OF IODINE INJECTIONS ON BRONCHOCELES. 
 
 the result of irregular circulation, occur in most encapsuled goitrous 
 growths. Extravasations of blood are frequent, portions may break 
 down into a softened, colloid tissue, or become necrosed (yellow 
 infarcts), while central cicatricial contraction is very common. 
 Sometimes the growth calcifies ; at other times all the blood-vessels 
 passing into the bronchocele through the capsule become oblite- 
 rated, and so the entire contents of the capsule degenerate into a 
 pulpy, sebaceous-hke matter ; the original tissue of the bronchocele 
 and the colloid substance of the gland vesicles cannot be absorbed 
 by themselves. When united with iodine, however, they are 
 absorbable. With our present knowledge of chemistry it ought 
 not to be impossible to analyse these processes. After the absorp- 
 tion of the colloid substance, the tissue shrinks up into a cicatricial- 
 like mass ; the tissue of the bronchocele does not entirely disappear, 
 like that of a lymphoma after the use of Fowler's solution, but 
 a hard cicatrix remains where the substance of the bronchocele 
 formerly existed. Even after the most successful cures of goitre by 
 injection, these cicatrices do not entirely disappear. If a bron- 
 chocele consists of cicatricial tissue ill supplied with blood, non- 
 vascular infarcts and pulpy substance, the iodine will have a 
 very slight and very slow effect in causing its absorption and may 
 have none. The most brilliant results were invariably observed in 
 bronchoceles that had either recently originated or were rapidly 
 growing. It would be very desirable for those who have oppor- 
 tunities, to watch these individuals for a long period of time after 
 the employment of this plan of treatment ; we might then learn 
 whether recovery is permanent, or how often the injections must be 
 repeated in order to destroy the tendency to goitre. I cannot too 
 highly recommend the works of Liicke, Kocher, Eose and others, 
 for those who wish to study the subject of bronchoceles. Notwith- 
 standing all the labour that has been expended on the etiology of 
 this disease, much remains unexplained; next to the undoubted 
 endemic influences, a purely individual disposition plays some 
 undetermined part in its causation. Thus, I know of a family, 
 living in a district where goitre is common, and in whom two 
 children out of four had no trace of goitre ; one of these was a boy, 
 the other a girl, both of whom died when about ten years old. In 
 both the other children, who were girls, goitre developed at the 
 age of four. In the younger of the two, the bronchocele dis- 
 appeared completely, after the employment of iodine, internally and
 
 TREATMENT OF BRONCHOCELE. 175 
 
 externally, when she was six years old, and at the age of twelve, had 
 not grown again ; in the other older child, the goitre, of tolerable 
 size, was still existing at the age of sixteen, and had to be from 
 time to time treated by the injection of iodine ; usually one injection 
 every six months was sufficient. All four children were through- 
 out placed under the same condition of life. 
 
 I have been repeatedly assured by mothers here, in Vienna, that 
 their girls who, when children, had very thick necks, lost this con- 
 dition on reaching puberty, whilst in other girls bronchoceles first 
 developed at this very time. 
 
 The following case, which I observed in private practice, is of an 
 interesting nature : 
 
 A strong young fellow, about sixteen years of age, came to me with a 
 diffused bilateral broucliocele, o£ considerable size, which had commenced 
 fourteen days previously. The skin overlying the bronchocele was so much 
 stretched, as to seem almost transparent. In all parts there was distinct 
 pulsation in the bronchocele. The heart sounds were natural, and as there 
 was no exophthalmus, my impression fii'st was, that the case was one of 
 commencing morbus Basedowii. One of my colleagues, whom I consulted, 
 was of the same opinion. Notwithstanding that some of my colleagues were 
 opposed to the treatment, I ordered inunction with iodine applications and 
 the internal administration of iodide of potassium in ordinary doses, without 
 however, expecting much from the treatment. I did not employ injections 
 of iodine, for in strongly pulsating tumours these appear to me to be 
 dangerous. Recovery was remarkably rapid ; in six weeks the bronchocele 
 had entirely disappeared. I was interested to find that Liicke has observed 
 several similar cases. 
 
 I have elsewhere mentioned the unfortunate results of injecting 
 alcohol into a bronchocele.i Possibly decomposition would occur 
 less readily if rectified or absolute alcohol were injected, but still 
 the entire injection might, by ill luck, be thrown into a vein, and 
 fatal intoxication be the result. It certainly would be desirable in 
 parenchymatous injections for bronchocele to replace the iodine by 
 some other less dangerous substance. The few attempts that I 
 have made with T^owler's tincture, a remedy certainly quite free 
 from danger, were unsuccessful. 
 
 Between i860 and 1876, of 93 cases of bronchocele operated on 
 by myself only 18 died, and of 36 cases in which I extirpated a goitre 
 13 only were fatal. In opposition to the pessimist views handed 
 
 ^ In my work on ' Cocco-bacteria Septica,' p. 86.
 
 176 SPONTANEOUS SOFTENING OE BKONCHOCELES. 
 
 down to me by my teachers^ I look upon these results as not un- 
 favourable. 
 
 Spontaneous soft,ening of a large hronchocele in an old man. 
 
 E. H — , set. 65, had sufEered for thirty-five years from a struma of the 
 right side, which had slowly increased to the size of two fists. In the course 
 of two months, it had become soft and increased in size, and was i-ather 
 painful at the upper part, but without producing any difficulty of breathing. 
 A puncture showed that the gi-eater part of the hronchocele consisted of a 
 cyst, filled with chocolate-coloured fluid mixed with small solid masses ; 
 the base was firm. An incision an inch long was made under the spray, a 
 di'ainage tube left in, and the wound dressed daily with careful antiseptic 
 precautions. Absolutely no inflammatory reaction followed. Three weeks 
 later there was no discharge through the drainage tube. The tumour had 
 collapsed to the size of a small fist, and the opening healed up veiy shortly 
 afterwards. Six months later the patient was perfectly well. 
 
 A man, jst. 66, who had had from his youth a hronchocele on both sides, 
 noticed, fom* weeks before admission, a stiiking increase in size of the left 
 half of the tumoui-. The gi'owth was so soft that the existence of fluid was 
 suspected ; however, a puncture with a small fine scalpel let out only some 
 blood. The swelling now increased though kept down as much as possible by 
 the continuous application of ice. A few days later some pus escaped from 
 the puncture, and he was attacked with erysipelas, which commenced at the 
 wound. Later on, pumlent discharge again occun-ed, and the tumour 
 diminished to a considerable extent ; the opening healed up completely. 
 
 Softening of sarcomatous thyroid tumour. 
 
 A man, set. 21, had had for some time a " thick neck," but no enlargements 
 of the lymphatic glands. The year previously he was attacked with some 
 inflammation about the neck, lasting but a short time. A growth was then 
 noticed on the right side of the neck, which had since giown rapidly and 
 given a good deal of pain. "When admitted, the patient was in a very low 
 state, with extensive bronchial cataixh, anasarca, and dyspnoea. On the 
 upper part of the right side of the neck was a large soft tumour. An 
 incision was made into the ma.ss, and some softening portions of the growth 
 escaped ; these had the striicture of a spindle-celled sarcoma. Slight relief 
 followed. He died a few day later from oedema of the lungs. I supposed 
 that the case was one of softening lympho-sarcoma, but the post mortem 
 showed that the tumour had probably originated in the left half of the 
 gland ; at any rate, no part of this was to be discovered.
 
 CHAPTEE IX. 
 
 DISEASES OF THE VERTEBRAL COLUMN. 
 
 Case of dislocation of third cervical vertebra. Case of sub- 
 luxation of cervical vertebra'. Angular curvature — Case. Case 
 of necrosis of lumbar vertebrcB. Remarks on treatment of ver- 
 tebral caries. Treatment of abscess. Cases of mistaken dia- 
 gnosis in retro- pharyngeal abscess. Remarks on tumours of ver- 
 tebral column. Lateral curvature — treatment of. Cases of 
 spina bifida. 
 
 Dislocation of the third cervical vertebra forwards mthoui fracture. 
 
 This injuiy was the result of a fall from the second storey of a house. 
 The patient had also a depressed fracture of the skull, and a fractured sternum. 
 When admitted into the hospital, he was not completely comatose, but in 
 such a condition that it was not possible to estimate the degree of anajsthesia;; 
 he lay motionless, but could at will move the fingers on both sides. Deatk 
 resulted on the second day, from oedema of the lungs. 
 
 Among my cases of caries of the vertebral column is a remarkable 
 instance of a girl^ jet. 8^ in whom an abscess developed at the back 
 of the neck, in consequence of which the head was always cranedi 
 obliquely forward. An extraordinary amount of mobility was evi- 
 dent between the third and fourth cervical vertebrae. If the head 
 were not fixed it fell forwards, as a sub-luxation had made its 
 appearance between the vertebrae named ; the condition was not 
 painful, and by raising the head reduction was easily effected. I have 
 never yet met with, or read of, any other similar case ; yet I can 
 only explain the condition on the supposition that it was the result 
 of disease of the vertebral column, possibly a case of rapid destruc- 
 tion of the intervertebral discs, with relaxation of the vertebral 
 ligaments. As long as the head was fixed by a fillet, like the instru- 
 ment for torticollis, her condition was tolerable. No alteration 
 
 12
 
 17S KYPHOSIS. NECROSIS AlsD CARIES OF LUMBAR VERTEBRA. 
 
 was observed during the whole time that the child was under 
 observation. 
 
 Kyphosis. Miliary tubercle of lungs and kidneys. 
 
 H. H — , set. II, had been suffering for many years, but for one year only 
 previous to admission, was confined to bed. The pains first occurred 
 in the neighbourhood of the left hip, and then along the spines 
 of the vertebrae. The child was extremely emaciated, and in a 
 miserable condition, with mai-ked angular curvature of the lower dorsal 
 vei-tebrae ; the left lower extremity was much flexed at the hip and knee- 
 joints ; the right in the same condition, but to a less extent. About the left 
 thigh were cicatrices, and beneath Poupart's ligament was a sinus which, 
 together with another behind the trochanter, discharged thin, stinking pus. 
 Baths were ordered and a liberal diet prescribed. Dian-hcea set in, and the 
 child became marasmic. One day — three months after admission — he was 
 attacked with severe headache and vomiting, which for a long time could 
 not be controlled. Death followed three days after. During the last two 
 hours of his life only, he was unconscious. Post mortem : some purulent 
 exudation was found at the base of the brain, but no miliary tubercle ; in the 
 centre of the right middle lobe of the brain was a caseous nodule, surrounded 
 by softened brain tissue, with many punctifoim extravasations. Some 
 miliary tubercles in the apices of both lungs and miliary nodules in the 
 lining membrane of the pelvis of the kidney. 
 
 Necrosis of spinous process rf lumbar vertebree. Caries. 
 
 A. W — , set, 1 6, a strong girl, fell off a stool, and caused herself gi'eat pain 
 in the lumbar region. The pain persisted, but diminished in intensity. 
 Gradually an abscess formed over the lowest lumbar vertebra. Six weeks 
 after the fall it broke ; since that time the opening never closed ; it lay two 
 fingers' breadth on the right side of the middle line, and two inches above 
 the sacrum. The probe detected the presence of a loose piece of bone, which 
 about corresponded to the spinous process of the fifth lumbar vertebi-a. This 
 was removed some months after. After the removal of the sequestrum, 
 softened rotten bone could still be felt. Subsequently another chronic 
 abscess formed over the os sacrum, below the sinus. We heard subsequently 
 that she died a year and ten months after the commencement of the disease. 
 
 Kyphosis. 
 
 T. D — , aet. 9, had ten months previously first noticed pain in the lumbar 
 region. Eight months previously some of the lumbar vertebrae became 
 prominent, causing a moderate amount of kyphosis ; pressure on the affected 
 pai-t of the vertebral column caused no pain. The patient was kept on his
 
 TREATMENT OF ABSCESS IN SPINAL CAEIES. 179 
 
 back, extension was kept up by means of a weight, and the pelvis was encased 
 in a plaster jacket ; the weight was increased up to 8 lbs. without giving any 
 pain, but no noticeable improvement of the curvature resulted. 
 
 Treatment of Yertebral Caries. 
 
 The treatment of this terrible affection consists principally in 
 keeping the patient in the recumbent position. If there was much 
 kyphosis the back was supported by jackets made of plaster, gutta 
 percha, or pasteboard, and the ordinary " anti-scrofulous " 
 strengthening remedies were given. Sometimes, in well-nourished 
 individuals, an issue was made in the neighbourhood of the vertebral 
 column. In acute inflammation of the cervical vertebrae the good 
 effects of a seton are sometimes remarkable. Treatment with ice 
 would here also undoubtedly be of benefit if it were possible to 
 apply the remedy more conveniently. If an ice-bladder be laid at 
 the back of the neck the air collects at the upper part and the direct 
 effect of the cold is lost ; the patients have therefore to be kept in 
 a half sitting-up position. 
 
 In Zurich, at an earlier period of my clinical career, I was in the 
 habit sometimes of opening abscesses connected with diseased ver- 
 tebrae, sometimes with the trocar, or by subcutaneous incision, 
 with caustic, etc. ; no benefit was ever derived from this proceeding. 
 I was induced at one time, though not very often, to inject iodine 
 into these abscesses ; I invariably regretted it. The chronic sup- 
 puration becomes acute much too readily, and leads then to break- 
 ing down of the abscess walls and most severe general symptoms. 
 The beneficial effects of injections of tepid water, air, or water with 
 a very slight trace of tincture of iodine, seem to me doubtful. If 
 the opening of the abscess is too small the best plan is to dilate it 
 with laminaria. I lost one patient from pyaemia after extending 
 the opening by incision. Now I no longer open these abscesses, 
 for I have come to the conclusion that matters are never improved 
 by such treatment, and the best that can be hoped for, in the most 
 favourable cases, is that they are not made any worse. After these 
 abscesses have opened spontaneously they usually contract, and a 
 sinus is left; they are then much more likely to heal. It is 
 extremely difficult to convince oneself of the truth of these prin- 
 ciples, much more to persuade the laity to accept them, for the
 
 180 PROGNOSIS OF SPINAL CAEIES. 
 
 latter judge by what they see in cases of acute abscess^ and have an- 
 idea that letting out the matter cures the disease- Eecovery depends 
 materially on the constitution and the position in life of the patient^ 
 influences on which medical art can have but little effect. To attack 
 the disease directly usually does more harm than good. Probably 
 more of these cases would recover if the patients were placed under 
 proper dietetic treatment, and could be induced to rest at an earlier 
 period. From the nature of the disease, the children of the poor 
 are not brought to the surgeon until curvature is manifest and one 
 or more of the bodies of the vertebrse is already destroyed. Most 
 alult patients, too, go on for many months without heeding the 
 warning of the surgeon, and it only first occurs to them that they 
 are ill when they have pain and difficulty in doing their work ; then 
 usually it is too late. It is often said that this is only true of the 
 uneducated classes, but this is by no means the case; it is so with 
 all people who have to gain their livelihood by work. 
 
 From tables it appears that patients affected with spinal caries 
 not unfrequently die in the first year of the disease, but much more 
 commonly in the second. The third year of the disease is also 
 dangerous ; if the patients survive this period, their chance of life is 
 much better, but still the disease may have a fatal issue even after 
 thirteen years' duration. In a case which was under my treatment 
 at Ziirich, some dormant infiltration of the vertebral column deve- 
 loped very rapidly and acutely, after resection of the head of the 
 humerus for caries, in a girl fourteen years of age. For eighteen 
 days after the resection, all went on well ; then very acute ostitis,^ 
 and periostitis of the cervical vertebrse began simultaneously with 
 suppuration of the right metacarpus and the left metatarsus. Un- 
 fortunately, no post mortem was allowed. In Vienna, I saw 
 caries of the cervical vertebrse develop with great rapidity, in a 
 woman, ajt. 74, who died of marasmus, three months after the first 
 symptoms of the disease appeared. Hitherto, I have never seen 
 any cases such as have been described by other authors as general 
 tuberculosis of the vertebral column, combined with general 
 neuralgia, though unfortunately I have only too often had oppor- 
 tunities of observing the latter symptoms in cancerous affections of 
 the vertebral column. Besides the symptoms of phthisis and 
 marasmus, which these patients manifest, amyloid degenerations of 
 the internal organs and caseous deposits can often enough be 
 
 * I.e. Osteomyelitis. See ' Billr. Path.,' p, 296, and Appendix 11, infra.
 
 STATISTICS OF VERTEBRAL CARIES. 181 
 
 ■diagnosed during life. In children, acute basal meningitis not 
 unfrequently finally caries off the patients. If the disease commences 
 in adult life, general tuberculosis, in many cases, soon becomes 
 evident, even if it were not already in existence when the vertebral 
 column became affected. I have not observed hitherto that the 
 paralysis (usually connected with contraction of the muscles) which 
 sometimes folbws Pott's disease, can of itself prove fatal. I have 
 often been astonished to observe how long patients paralysed in 
 this way are able to exist when placed under favourable conditions. 
 The paralysis, even when it has reached a high degree, may dis- 
 appear in part, sometimes almost entirely. 
 
 I see now, from time to time, a girl, £et. i8, in whom paralysis of the lower 
 extremities has existed for four years, as the result of caries of the spine and 
 angular curvature of many years' standing. A year after the commencement 
 of the paralysis, there was entire absence of movement in the extremities. 
 Since then some slight movements have gradually returned. When I last saw 
 her the legs were somewhat flexed at the knees, and attempts to straighten 
 them gave severe pain and general cramp. The patient has to be kept con- 
 stantly lying. Attempts to straighten the legs gradually, so as to enable her 
 to get about, by means of some artificial support, proved fruitless ; the appli- 
 cation of the constant current did not diminish the great reflex irritability. 
 I ca,nnot say for certain whether faradisation of the muscles had any influence 
 in bringing about the slight movements which she now possesses in the lower 
 extremities. The sensibility of the skin seems quite unimpaired. 
 
 From Menzel's highly interesting statistics on the subject of 
 caries ('Arch. f. Klin. Chir.,' Bd. xii, p. 340) we may gather that 
 the vertebrae are more frequently affected with caries than any 
 other bones. Of 11 96 cases of caries, the vertebral column was 
 affected in 702 ; the different sections of the spine were affected in 
 the following proportions : — Cervical vertebrae 185; dorsal vertebrae 
 310; lumbar vertebrae 199; in 8 cases the part affected was not 
 stated. I was very much interested in observing that the small 
 number of cases (90) in my clinic proved also that the dorsal 
 vertebrae were more frequently affected, from which we may fairly 
 deduce that a collection of 100 cases is sufficient to show the true 
 proportion. Unfortunately in my records, the actual vertebrae 
 involved in the kyphosis are not precisely noted, so I cannot 
 say whether my small number of cases confirms the observations 
 of Menzel, that the second cervical, the sixth dorsal, and the fourth 
 lumbar vertebrae are most frequently, and the fifth cervical and the 
 iirst lumbar are most rarely diseased. V. MenzePs chart (loc. cit.
 
 182 PEOGNOSIS OF SPINAL CARIES. 
 
 p. 356), deduced from the record of 694 cases, shows in an interest- 
 ing way the most commoD form of kyphosis. 
 
 As regards the chance of recovery from spinal caries, what can I 
 say ? I have adopted a position of complete resignation, the more 
 that I have come to the conclusion that my records are too 
 favourable ; it was not often possible to keep little children, from 
 one to three years old, under continual observation, and it is just 
 at this period of life that the mortality among children is most 
 considerable. I may add, that from my experience of caries, a con- 
 genital predisposition seems to be by far the most common source 
 of the disease. In patients thus predisposed, some accidental 
 cause of irritation sets up active disease, although the latter may 
 often occur without any possibility of proving any such cause of 
 origin. Children with spinal caries require to be most carefully 
 kept from all other sources of injury, and placed under generally 
 favourable hygienic and dietetic conditions ; such conditions demand 
 the constant attention of some grown person and favourable social 
 circumstances. Even when the opportunity offers of treating these 
 children for a long period of time, and when all these conditions 
 were fulfilled in the best possible way by the constant and watchful 
 care of a mother, how seldom are the efforts of the surgeon crowned 
 with success. As an example of many similar cases, I adduce the 
 following : 
 
 A girl, set. 8, who had previously heen in good health and well nourished 
 had a small, cold abscess over the left sixth rib. My advice was, to wait for 
 the spontaneous opening of the abscess, which took place about six months 
 afterwards ; in two months the abscess had healed without any medical treat- 
 ment, and the general condition of the child was unaffected. A year later 
 all the symptoms of disease of the cervical vertebrae made their appearance. 
 The child was most carefully tended ; for about a year she was kept com- 
 pletely at rest, then an apparatus to fix the head was provided, which was 
 worn for about three years. During this time the patient lived during the 
 summer at Hall and Ischl, during the winter at Mentone and Meran. A 
 retro-pharyngeal abscess formed and was allowed to open spontaneously, as 
 also another abscess at the back of the neck. A small sequestnim came away 
 from the opening in the neck, and the sinus eventually healed completely. 
 All the pain disappeared ; the cervical curvature was scarcely noticeable, but 
 there was no movement in the upper cervical vertebrae. The child seemed in 
 excellent health ; she became fat and strong, spent all the summer in the 
 mountains, and was always tended with the greatest care. Any surgeon 
 would have set down the case as one that had completely recovered, but 
 this lasted scai'cely three years ; then the mother noticed that the child held
 
 TREATMENT OP SPINAL CARIES. 183 
 
 herself more stiffly than before, was less inclined to move about, and could 
 not speak well. I examined her most carefully, but could find nothing 
 wrong ; a few months later, a prominence was noticed on the left side, close 
 to the spine, which proved to be a chronic abscess, and soon after curvature 
 began to develop in the lower dorsal vertebrae ; the patient was taken ofE to a 
 southern climate, but a few months later numerous abscesses broke, and the 
 excessive suppuration so exhausted her that she died, about fifteen months 
 after the commencement of the second attack of the disease. The parents 
 and relations were healthy, with the exception of the mother, who was 
 delicate and of weakly frame, and who had a slight attack of haemoptysis, 
 about a year before the death of the child. Such cases show how powerless 
 we are against constitutional predisposition. 
 
 I need hardly say that I always assign the first place to such 
 hygienic and dietetic conditions as may seem most important for 
 the case under treatment, but how seldom is it found possible to 
 carry out these regulations. 
 
 As for local remedies, I used to employ setons, issues, and tinct. 
 of iodine, as was recommended by my teachers. The inefficacy of 
 these remedies led me later to give them up completely ; constant 
 application of ice, for three or four months (especially in cases of 
 commencing disease in girls), is of some benefit, though unfortu- 
 nately, the effect of the remedy on the pain and inability to move 
 was only of a transitory character in my patients. 
 
 Formerly, I used to keep these children always lying, generally 
 in the prone position, as I had been taught to do ; in some cases, 
 I employed extension by weights, and more recently have sometimes 
 used Thomas's splints. It is often difficult or well nigh impracticable 
 for poor people, and even for those of the middle class (the bour- 
 geoisie), to keep their children constantly at rest ; if the children be of 
 a lively disposition, they require the constant attention of some one 
 at their bedside, or else they are more frequently sitting up than 
 lying down in bed. I have never seen any remarkable advantage 
 arise from this constant lying or a more rapidly favourable issue; 
 at times the curvature seems to be somewhat improved, but 
 this becomes as bad as before as soon as the child stands up. 
 Latterly, if patients have no pain with curvature of the dorsal or 
 lumbar vertebrae, I have always allowed them to get about as much 
 as they pleased, wearing a stiff jacket. These jackets should be 
 made of the lightest possible material and surround the pelvis, so 
 that the upper half of the vertebral column above the curvature is 
 supported in a sort of funnel, which takes off all the weight from
 
 18-1 MECHANICAL TEEATMEXT OF ANGCLAR CURVATURE. 
 
 the diseased parts. This can only be properly applied when the 
 curvature is on a level with, or lower than the fifth dorsal vertebrse ; 
 if the curvature be higher, the upper part of the vertebral column 
 must be supported by a suitable apparatus, either on the plan of 
 the old apparatus for torticollis, or on the plan advocated by Taylor, 
 in which the head is supported from below at the occiput. 
 
 By the use of appliances of these kinds (which I have especially 
 employed of late years in private practice), I have seen just as good 
 results as when the children were condemned to be constantly lying 
 down. Usually the parents are much more easily persuaded to 
 purchase such apparatus, and to apply them regularly, than to keep 
 the children for periods of years lying on their backs or faces. I 
 do not say that it is better for these children to wear supports of 
 this nature than to be kept constantly lying down, but it is much 
 more advisable for them than that they should sit up in bed, as 
 they do, without any support for the greater part of the day.^ 
 
 I need hardly say that in spite of my somewhat pessimist opinions 
 as to the prognosis of spinal caries, I always recommend the parents 
 of these children to tend them with the utmost care. Writing, as 
 I do, for my colleagues, I consider it my duty to describe by 
 observations unreservedly as I have done. I should be glad to 
 learn that I have drawn too dark a picture, and would only ask 
 my colleagues to withold any definite opinion until they have kept 
 their patients under observation for ten years or more, and can then 
 give their experience of the ultimate results in figures. 
 
 With regard to the treatment of congestive abscesses my advice 
 is never to open them. I never saw abscesses of this nature 
 descend beyond the middle of the thigh ; usually they open spon- 
 taneously when they are still in the upper third of the thigh. I 
 have not met with a case where the abscess burst into the abdominal 
 cavity. I usually regretted it when I opened these abscesses. In 
 one case lately, led away by the eulogistic terms in which the result 
 of opening, draining, and antiseptic treatment of these abscesses had 
 been described, I was induced to open a congestive abscess in a 
 case where fluctuation was just perceptible beneath Poupart's liga- 
 ment. The third day after the opening arterial bleeding took place 
 
 1 A simple and effective contrivance to obviate tliis is in use at the Hospital 
 for Hip Disease in Queen's Square, London, and elsewhere. It is described 
 by Mr. Edmund Owen in his "Harveian Lectures," 1880, published in 
 'Louisville Med. News,' vol. is., No. 222, p. 151. (Ed.)
 
 TREATMENT OF CONGESTIVE ABSCESS. 185 
 
 from the abscess. This was controlled by pressure after it had 
 recurred three times, but some days later it carried off the little 
 patient. A small perforation was found in the iliac artery, which 
 lay completely exposed on the floor of the abscess. If the skin is 
 thin and reddened over any part of an abscess in the thigh puncture 
 will do no harm. Possibly, also, the abscesses may in some cases 
 be opened at an earlier period without any directly injurious efi'ects. 
 But I can perceive no advantage from early opening, save that the 
 rainds of the parents seem to be set at rest. Such cases as these 
 can be but rarely taken into hospital, and even when admitted only 
 kept in for a short time ; few families have the means to provide 
 for the daily or even weekly antiseptic dressings. Nearly always 
 a kind of valvuhir closure of the sinus follows after spontaneous 
 opening; the discharge flows away slowly, usually being little more 
 than serum or very thin pus (curiously enough, this has been 
 ascribed to the antiseptic dressings), and nothing gets in from 
 without. In abscesses that have been allowed to open sponta- 
 neously I have never seen decomposition of the pus occur, even 
 when, as often happened, they were dressed with the dirtiest, rags. 
 "While in Ziirich, I saw a case of pyaemia follow the probing and 
 dilatation of a sinus. As a rule, nothing of therapeutical import- 
 ance is learned by probing such abscesses, and the practice is there- 
 fore not one to be advocated. 
 
 Undoubtedly, cases of caries necrotica of the vertebral column 
 occur where the closure of the sinus is prevented by a sequestrum. 
 Hitherto, however, it has been found impracticable to extract large 
 sequestra from the vertebral column; small sequestra mostly come 
 away of themselves without endangering the life of the patient. It 
 might seem possible to make an incision on one side of the curva- 
 ture, and in this way to extract the sequestrum and gouge away the 
 carious parts, but the haemorrhage cannot be readily controlled, and 
 the spinal cord will be exposed to injury ; hitherto I have not ven- 
 tured on the attempt. In children already in a low state, on whom 
 such an operation might be performed as a last resource, there is 
 no prospect of the parts healing up. I have never felt inclined 
 to undertake such a proceeding in children who were tolerably 
 well-nourished, though such an operation, in cases of commencing 
 caries in other bones, yields capital results. Yet with our advanced 
 knowledge of the treatment of wounds, and in the face of the un- 
 favourable prognosis, I should not blame any surgeon for making
 
 186 CASES SIMULATING KETEO-PHARYNGEAL ABSCESS. 
 
 the attempt. I remember some years ago to have read something 
 about an operation of this kind which was performed in America, 
 but I do not recollect what became of the patient. 
 
 It need scarcely be stated that abscesses connected with caries 
 of the cervical vertebrje must be opened if they cause any difficulty of 
 respiration. One would hardly think that the diagnosis of these 
 retro -pharyngeal abscesses could be a matter of doubt, and yet I 
 have twice been mistaken in such cases. 
 
 In one of the patients, the apparent abscess was found to be a difEused, very 
 soft, medullaiy lympho-sarcoma, -w-ith a rounded surface and distinct fluctua- 
 tion; the cervical lymphatic glands firet became afEected some weeks later, 
 and the patient died of the tumour a few months afterwards. 
 
 The second case was that of a healthy man, aet. i8, who, in addition to a 
 bronchocele, had a fluctuating retro-pharyngeal tumour. All that the patient 
 could tell us was that for some weeks he had found some difficulty in swallow- 
 ing and breathing, and his voice had been nasal. The appearance of the man 
 hardly led us to suspect disease of the spine. After consultation with Pro- 
 fessor Stork, we came to the conclusion.that the swelling was due to a retro- 
 pharyngeal abscess. An incision was made into it, and we were not a little 
 taken aback when a tremendous stream of dark blood gushed forth. The 
 situation was a most distressing one. Direct pressure was scarcely practicable ; 
 the blood was partly swallowed, and then vomited up again, in part it 
 descended into the larynx and was coughed up. Finally, while I made pres- 
 sure on the carotids. Professor Stork quickly prepared a solution of alum, 
 which the patient took into his mouth, and the bleeding was eventually con- 
 trolled, but not before it had caused us the greatest anxiety. The patient 
 became veiT faint ; we kept him lying on his back for some time, and made 
 him keep small pieces of ice in the mouth. The hsemorrhage did not return, 
 and in a few days the opening of the incision closed. This was a case of a 
 hsematoma in the posterior wall of the pharynx, resembling a retro-pharyn- 
 geal abscess. 
 
 I cannot understand how it could have been in any way connected 
 with the bronchocele, which was of small size, for these small thy- 
 roid tumours do not exert any pressure on the viens ; even in large 
 bronchoceles, into which blood-vessels almost the thickness of the 
 finger pass, I never saw a hsematoma of the pharynx. Professor 
 Stork was kind enough to give me the following information about 
 the patient some six months later : — " On the left side of the 
 pharynx in the same situation is a uniform, soft, non-pulsating 
 tumour, with broad base, of moderate circumference, and but slightly 
 prominent. The cicatrix of incision is still visible ; the hsematoma 
 is now, as before, invested by a tough wall ; the bronchocele has
 
 TUMOURS OF SPINE. LATERAL CURVATURE. 187 
 
 not altered. The patient can now breathe and swallow without 
 difficulty ; in other respects his general condition is unaltered ; the 
 guttural tone of voice exists as before." Eemembering my former 
 experience, I did not venture to make a fresh incision, or to employ 
 galvano-puncture. The haemorrhage was so formidable that even 
 the most intrepid surgeon would not readily have forgotten it. 
 
 TUMOUKS. 
 
 I have met with no cases of primary tumours in the vertebral 
 column, and my only acquaintance with them is derived from 
 museums and atlases. Metastatic cancer of the spine, following cancer 
 of the breast, I have seen tolerably often. I hardly know any more 
 terrible disease than this. The last cases which I had occasion to 
 see very often, occurred in young, well-nourished women about 
 thirty years of age. These patients suffered for five or six months 
 most unspeakable agony before death came to their relief. In the 
 face of such diseases one is compelled to look almost leniently on 
 suicide. I remember once, after a consultation with one of my 
 colleagues on one of these unfortunate cases, he remarked to me as 
 we were going down stairs, " Should we not be almost justified in 
 prescribing cyanide of potassium in such a case ? " But a saying 
 of Griesinger's rose before my mind, " The surgeon should not give 
 up his patient until he has drawn his last breath," 
 
 Lateral Curvature. 
 
 My experience does not enable me to say much about the treat- 
 ment of lateral curvature. I generally advise the remedies recom- 
 mended by the best authors. These patients were never admitted 
 into the hospital ; the slighter cases would not remain in, and in 
 the severe cases so little could be promised that we did not feel 
 justified in burdening the parish with the expense of keeping them 
 for some years in the hospital. The out-patient department sufficed 
 for purposes of clinical demonstration. It is an unfortunate thing, 
 from an educational point of view, that so few opportunities could 
 be afforded of studying the treatment of these cases, or of seeing the 
 ultimate results of this very common affection. This want is often
 
 188 LATEllAL CURVATURE. 
 
 felt and embarrassment experienced when such cases are afterwards 
 met with in private practice. I tried to obviate this clinical defect, 
 as far as possible, by constantly talking about the causes and treat- 
 ment of commencing lateral curvature. 
 
 As for the numerous cases which I have met with in private 
 practice, they were commonly lost sight of after they had consulted 
 me once or twice. If tlie complaint does not improve in the course 
 of a few months, or if I am compelled to say that the necessary 
 treatment may last perhaps a year or more, they go on from one 
 surgeon to another, until they discover one who takes a more hopeful 
 view of their case. Advice and prescriptions are far more agreeable 
 to the patients and their parents than innumerable rules and 
 regulations as to diet and gymnastics. Such treatment becomes 
 costly and troublesome, and swallows up, perhaps, all the means of 
 the family to comparatively little purpose. In Vienna, it is not 
 possible to keep these children in orthopaedic establishments under 
 .1200 or 1500 florins a year (from £115 to £140), and if the 
 necessary orthopaedic treatment has to be kept up for two or three 
 years, most families would hesitate before they laid out so large a 
 sum for the benefit of one of their children, when perhaps the 
 entire family live in some little town and have no more than an 
 annual income of 800 florins. 
 
 In m}' private practice, I see annually a great many girls affected 
 with lateral curvature, but I fear that all my powers of persuasion 
 are unable to induce perhaps more than one annually to enter one 
 of these gymnastic institutions. Seldom can a positive answer be 
 returned in the affirmative, to the question, " After all this trouble, 
 can you promise complete recovery within two years?" In the 
 majority of cases we can only promise that, at any rate, matters 
 will not be made worse ; the laity are little able to understand how 
 much worse the condition might become, for the disease can be but 
 seldom attended with any danger to life. These questions and 
 arguments one way and another are interminable. Should a case 
 remain stationary and the curvature grow no worse, as frequently 
 happens, then we hear said, " We see these surgeons exaggerate the 
 whole matter — the fact is, they know but little about it, etc." We 
 ■can only then, advise what we consider to be best on physiological 
 — and empirical — grounds.
 
 SPINA BIFIDA. 189- 
 
 Spina bifida. 
 
 In the case of a child a few months old, the sac of the spina bifida had 
 previously been tolerably tough and thick ; the child had talipes equino- 
 varus of the left and calcaneo- valgus of the right foot. Subsequently, large' 
 hydrocephalus formed ; the skin over the spina bifida became very tense, 
 translucent, and inflamed. Under antiseptics I laid open the sac, evacuated 
 the fluid, and united the edges with sutures. Death followed five hours 
 after the operation. 
 
 I remember another case, where I encircled with a drainage tube a slender 
 pedunculated spina bifida over the sacrum, then punctured the cyst, and 
 injected diluted tincture of iodine. The child died of myelitis a few days 
 later.
 
 CHAPTER X. 
 INJURIES AND DISEASES OF THE BACK AND BREAST. 
 
 Section A. — Injuries and Diseases of the Thorax, Back, etc. 
 
 Cases of penetrating wound of back. Gunshot wound. Case of 
 fractured ribs with pneumothorax. Chronic periostitis and 
 caries of the ribs — Cases and remarks. Case of encysted 
 empyema. Besection of ribs for empyema. Case of partial 
 pneumothorax after paracentesis. Aneurism of thyroid axis. 
 Case of aortic aneurism bursting into mophagus. Paralysis 
 of serrati muscles. Case of ossification of the fascia of the 
 back. Case of cyst of hack treated by injection. Case of multiple 
 soft fibromata. Case of racemose angioma ; removal. Cavernous 
 blood tumour and lipoma ; removal. Cases of sarcoma of the 
 back — recurrent spindle-celled ; melanotic. Case of sarcoma 
 of thorax of long standing. 
 
 Penetrating wounds of the back. 
 
 A. M — , set. 20, received a stab in the back, on the left side, between the 
 scapula and the vertebral column. Moderate amount of hjemorrhage, no 
 dyspnoea or pneumothorax. The •wound was closed by strapping ; three 
 days after the injury the wound was probed by a medical man, thereupon 
 severe pleurisy occurred, which lasted three days. From the symptoms in 
 this case, it seems possible that the wound had perforated an adhesion. 
 
 F. E — , set. 29, was stabbed twice with a knife over the breast ; one of 
 the wounds, evidently a penetrating one, passed through the left third rib 
 external to the heart. On the right side, an extensive stab wound passed 
 into the third costal cartilage, but did not penetrate the pleural cavity. 
 Both wounds were closed ; severe dyspnoea followed, treated by venesection 
 and morphia. The dyspnoea became woi*se, owing to increased left pneumo- 
 thorax. On the eighth day after the injury, the patient felt as if he were
 
 PBNETEATING WOUNDS OP THOEAX. 191 
 
 on the point of suffocation. Water was injected, after Griesinger's method,^ 
 so as to convert the pneumothorax into hydrothorax. The patient rallied 
 a little and the dysj)noea somewhat diminished. Fifteen days after the 
 injury, severe hsemorrhage took place from the wound on the right side ; this 
 was controlled, but collapse set in, and he died from increasing weakness and 
 dyspnoea, thirty days after the injury. Post mortem : pyo-pneumothorax 
 on the left side, and a wound of the right internal mammary artery. 
 
 U. M — , set. 30, a strong man, was stabbed in the breast by a drunken 
 comrade armed with a poignard. Blood flowed freely from a wound in the 
 right first intercostal space, close to the sternum. A medical man was called 
 in and the wound most carefully closed with three button sutures. The 
 next day the patient was brought up to the hospital ; there was then dul- 
 ness on the right side from the middle of the scapula downwards ; air 
 and blood passed out by the side of the sutures. In order to determine 
 whether the haemorrhage came from the thoracic wall, the wound was reopened 
 and was found to extend deep down into the thorax. Dark blood welled from 
 the cavity. The wound was again closed firmly with sutures. The patient 
 had much difficulty in breathing, and complained of great pain in the right 
 side of the thorax. There was some cough, but the sputa, which were 
 brought up with some difficulty, were unmixed with blood. Two days after 
 the injury the dyspnoea increased and was not relieved in any degree by 
 venesection ; collapse and death followed the next day. Post mortem : in 
 the innominate vein, opposite the opening of the vena cava superior, 
 was a wound about a ctm. in length, with somewhat irregular edges ; firm 
 adhesions of the right upper part of the lung, the pleura extensively covered 
 with dry, fibrous lymph ; in the right pleural cavity about 30 oz. of blood, 
 partly fluid, but containing also much clot ; the apices and the anterior 
 halves of the lower lobes of the lungs alone contained air. Extensive sugilla- 
 tion of the cellular tissue around the heart. 
 
 Penetrating gunshot wound. 
 
 K. T., set. 25, was shot in the back by a saloon gun at two paces distance. 
 A medical man was called in, who drew a large paper wad from the 
 bottom of the wound. There was but little haemorrhage ; some blood was 
 coughed up. The patient was brought up the next day to the hospital ; 
 he then had some pain in breathing, and the respirations were shallow. 
 Close under the left scapula was a gap in the skin, the size of the palm of 
 the hand, with lacerated and blackened edges. On examination with the 
 finger the wound was found to extend deep down as far as the ribs. No 
 fracture could be detected, and there seemed to be no foreign bodies in the 
 wound. On the left side there was dulness, in front and behind. Por 
 four or five days all went on well, but then he had increased fever and dysp- 
 noea and rather abundant discharge of serum from the wound. During the 
 
 ^ ' V. Pitha and Billroth's Chir.,' Bd. iii, AbtLl. ii, p. 101.
 
 192 PENETEATING GUNSHOT WOUND. PRACTUBED RIBS. 
 
 next fortnight he improved ; then the dyspnoea again set in, and there were 
 symptoms of left pneumothorax. Thin pus was discharged from the wound, 
 and two or three days later air also escaped. He became collapsed, and died. 
 Two days before death he had copious vomiting of bilious matter, with 
 distension and abdominal pain. Post mortem : a small poi-tion of the seventh 
 rib, con-esponding to the wound, was denuded of periosteum ; the probe 
 passed below the lower edge of the rib, and ran obliquely upwards for about 
 eight inches into the cavity of the thorax ; downwards, the opening extended 
 for about four inches. The heart was found pushed towards the middle line. 
 In the left pleura, three or four pints of thin, dark, foul pus. About the 
 centre of the lower lobe of the left lung, was a ragged gap on the sui-face, 
 the size of a shilling. The entire lung was compressed and contained no air. 
 A square-shaped opening was found in the posterior wall of the oesophagus, 
 just above the diaphragm, and the tissue between the oesophagus and aorta 
 in the lower part of the thoracic cavity was converted into a dirty, stinking 
 pulpy mass.' 
 
 Penetrating gunshot wound of the chest. 
 
 W — , £et. 23, attempted to shoot himself with a revolver. A very small 
 aperture entrance lay imder the left nipple, just external to the area of pi'se- 
 cordial dulness. He had considerable hsemothorax and infiltration of the 
 lobe of lower lung. Subsequently pleurisy with exudation followed, and at a 
 later stage circumscribed pneumothorax (Hohlen-phiinomene), with a good 
 deal of purulent vomit, accompanied by febrile symptoms and emaciation. 
 Eventually the patient recovered. The symptoms of the pneumothorax, and 
 the purulent vomit disappeared entirely, but some dulness at the lower part 
 of the left lung persisted. I suppose that the bullet was fixed in the left 
 lower lobe of the lung, an abscess formed around it, which healed up, 
 and so the bullet was encapsuled. We were unable to gain any further in- 
 formation about the case. 
 
 Fracture of the ribs. 
 
 In one case that came under notice, the fouxih, fifth, and sixth ribs, were 
 fractured anteriorly on the right side. The skin was raised up prominently 
 over a broken off fragment of the fifth rib. The patient had a slight attack 
 of pleurisy, which he got over. Gradually a small portion of the prominent 
 skin became gangrenous. On the seventeenth day after the injury, without 
 any further symptoms, the fragment perforated, but the projection was closely 
 invested by the skin. Thinking that the internal opening into the pleura 
 must have been firmly closed by exudation, I tried to extract the piece of bone. 
 
 ' I think that in this case there is no doubt that the softening of the 
 oesophagus took place during life. With regard to this point see an 
 interesting essay by Prof. HofEman, of Basel. (' Virchow's Arch.,' 18G8).
 
 CASES OF CHRONIC ABSCESS AND CARIES. 193 
 
 As I was moving the fragments air entered the thorax with a hissing 
 noise ; the protruding portion of hone was then cut off, and the wound closed 
 by a suture. Pneumothorax was immediately evident ; the dyspnoea in- 
 creased, and was soon followed by pleuritic effusion. The patient became 
 very feverish, and was threatened with symptoms of suffocation. Paracentesis 
 was pei-formed with a trocar, without allowing any air to enter, but no 
 improvement followed ; the sutures gave way, and from the opened up wound 
 an eiysipelas ambulans started. Repeated rigors followed, and he died of 
 pyremia thirty-nine days after the injury, and twenty-two after the operation ; 
 the latter undoubtedly was premature. 
 
 Chronic periostitis and caries of the rihs. 
 
 J. B — , set. 29, was admitted with commencing tubercular disease of the 
 kings ; for eleven weeks he had had chronic abscesses in the neighbourhood 
 of the right nipple, in front of the third right rib, and in the neelc. In addi- 
 tion to this there was a spontaneous fracture of the sixth right rib. 
 
 C. F — , set. 53. In the course of three years a large chronic abscess had, 
 without known cause of origin, developed on the right side of the back. He 
 was admitted ■with a high degree of emphysema with bronchiectasis and pleii- 
 ritic effusion on the left side ; the breathing became gradually worse until lie 
 died of suffocation. Post mortem : bronchiectasis was found on both sides, 
 empyema on the left side, communicating with the chronic abscess at the 
 back part ; a carious cavity in the sixth rib, and numerous osteophytes on 
 the neighbouring ribs. 
 
 Chronic ahscess and caries of the thorax. 
 
 J. G — , set. 37, had suffered for many years from pains in the back ; two 
 years previously he had had a sharp attack of pleurisy. After he had 
 recovered from this, a small tumour developed a little to the inner side of tlie 
 left nipple. A few months later he had some severe pulmonary affection, 
 followed by general dropsy ; from this he gradually recovered, and regained a 
 tolerable amount of strength. When admitted, there was a swelling, the size 
 of a hen's Qg^, over the junction of the fourth rib with its cartilage. Distinct 
 crepitus was perceptible between the cartilage and the bone. Tlie swelling 
 was tympanitic on percussion, and could be pressed back to some extent. 
 Probably the case was one of circumscribed pneumothorax, i. e. an abscess 
 cavity, which had burst into a bronchus. Posteriorly there was extensive 
 dulness. I did not think it advisable to make an incision into the swelling 
 and the patient was transferred to the physician. 
 
 13
 
 194 CARIES OP EIBS AND STEEXUM. 
 
 Caeies of the Eibs. 
 
 Spontaneous fracture of the ribs, as a sequel of carious destruction, 
 Wiis noticed in several instances (Case of J. B — , supra). In the 
 r:!)s caseous ostitis and caries necrotica is not infrequent; small 
 sequestra are often spontaneously extruded. In one case I resected 
 ]) )rtions of the diseased ribs comprising the whole thickness of 
 the bone; three years later the sinuses were still discharging. 
 
 I can see no advantage in the early opening of abscesses depen- 
 i'''nt on carious ribs ; I commonly allow them to break spontaneously. 
 1 II tolerably healthy people incision does not accelerate the closure 
 oi the sinus, while in the tuberculous it is injurious. 
 
 Caries ksh i^ecrosis of the Sternum. 
 
 Although in only two of these cases could syphilis be positively 
 established, yet here in Yienna I have seen an immense number of 
 cases of chronic disease of the sternum, evidently of a syphilitic 
 origin; some as out-patients, some in private practice. The disease 
 appears commonly to occur when all syphilitic symptoms have ceased 
 for many — perhaps ten or twenty years. It does not appear to me 
 that disease of the sternum is often associated with tuberculosis, a 
 connection which undoubtedly exists in caries of the ribs. 
 
 Chronic Abscesses without any perceptible Caries of the 
 Ribs or Sternum. 
 
 These abscesses either remained unopened as long as the patients 
 were under observation, or after they were incised no disease of the 
 bone could be discovered, notwithstanding repeated examination. 
 Twelve such cases came under observation, the ages ranging from 
 fourteen to sixty-five. In two instances an attack of pleurisy had 
 preceded the commencement of the affection, but at the time of 
 admission no effusion could be detected in the pleural cavity. 
 
 The unfavourable prognosis that must be given in caries and caries 
 necrotica of the ribs, is evidenced by eight cases which were under 
 observation at Yienna ; of these, recovery took place in one only 
 and that at the end of five years. Even this man was of a wretchedj 
 weakly constitution, and obviously could not have long to live. 
 
 1
 
 EMPYEMA (?). EESECTION OP EIBS FOR EMPYEMA. 195 
 
 Ijncysted empyema {large peripleural abscess ?). 
 
 A man, set. 22, had some glandular abscesses in the right axilla, after an 
 attack of smallpox ; and at the same time, pain in the upper part of the right 
 breast, and severe rigoi-s. The breathing was but little embarrassed. The 
 abscesses had been opened five months before his admission. On admission 
 there was bvit a moderate amount of suppuration, with dulness over the right 
 upper half of the thorax. An extensive incision was made, and the broken 
 down and suppu^rating gland tissue scraped out ; four days later the opening 
 in the intercostal space was found, and a drainage tube passed in. Tlie suppu- 
 ration then gradually diminished and the patient was discharged three months 
 later at his own wish, with only slight discharge from the sinus. 
 
 Resection of vihsfor empyema. 
 
 A child, ait. 1 2, had an attack of pleurisy seven years before admission, 
 which ran on to empyema, and broke spontaneously. Three years later the 
 child came under my care. I resected portions of two of tlie ribs with some 
 benefit, but considerable discharge took place through the opening, and the 
 patient's condition was only moderately satisfactory. Further resection of 
 the ribs was performed four years later ; seven years after the original open- 
 ing the sinus still discharged, though only to a slight degree. Tliroughout, 
 the patient was very carefully looked after. The child was rather small and 
 weakly, but very intelligent, and had attended school for the last five years. 
 
 A child, aet. 8. Seven months after the commencement of pleurisy of the 
 left side, spontaneous opening took place ; a year later he was brought to the 
 hospital. Portions of two of the ribs were resected, in order to allow the pus 
 to escape more freely ; injections were made into the cavity. Seven months 
 after operation there was still considerable discharge from the sinus, 
 
 A woman, ret. 28. Six months after the commencement of pleurisy of the 
 left side, spontaneous evacuation occurred. Ten months later she came up in 
 a very reduced condition to the hospital. The fistula was dilated, and the 
 cavity injected ; she then went into the coimtry for a time, and improved 
 considerably, but eleven months later, there was still free discharge through 
 the sinus. A portion of one of the ribs was then resected, and the contents 
 of a cavity, the size of two fists, evacuated. The discharge had not ceased six 
 months afterwards. 
 
 Partial pneumothorax, occurring after paracentesis. 
 
 A man, tet. 28. Eight weeks after the commencement of a pleurisy^of the 
 left side, paracentesis was performed with Dieulafoy's aspirator, and 300 c.c. 
 of thick, greenish pus let out. When he came under my care, some little'time
 
 196 ANEURISM OF THYROID AXIS — OF AORTA. 
 
 later, I let out 2700 c.c. of thick pus, by means of my paracentesis trocar, 
 without allowing any air to enter. The next day it was noticed that each 
 systole of the heart was accompanied by a distinct, metallic sound. There 
 was no proof of the existence of any air in the iiericardial region, but slight 
 pneumothorax was evident, close to the heart ; the respirations had a distinct 
 metallic sound, and at times rales were heard. For four weeks he went on 
 well, and was completely free fi'om feveiish symptoms. While recovering 
 from an attack of facial eiTsipelas, the dyspnoea increased so much that I had 
 to tap the thorax again. 
 
 Aneurism of the rigid thyroid axis, originating without Jcnown cause 
 in an otherwise strong man. 
 
 A year and a half after the commencement of the disease, the patient 
 neceived a kick fi-om a hoi-se on the aneurism ; great swelling resulted, and 
 when he came up two months later to the hospital, the tumour was the size 
 of a foetal head. The exact part implicated could not then be made out. I 
 suspected at the time that the tumour was connected with the subclavian 
 artery originally, and that the aneurism had become diffused, owing to the 
 blow. Compression, by means of bags of shot, and the application of ice did 
 no good ; the swelling rapidly assumed such formidable pi'oportions, and the 
 patient became so anaemic, that I was unwilling to attempt to ligature the 
 innominate artery. The aneurism did not actually bui-st, but increased to 
 such a size that it appeared as if all the blood in his body must have been 
 contained in the sac, and he gradually died of hsemoiTh^e into the aneurism. 
 Post mortem : the subclavian artery was found intact, but an opening existed 
 in the thyroid axis, just where it branches off from the main vessel. 
 
 The case was therefore one of false aneurism from the very com- 
 mencement. I rather suspected that the patient deliberately gave 
 a false account of his symptoms, in order to conceal the fact that 
 he had received an injury from some one. 
 
 Aneurism of the descending aorta, lursting into the cesophagus. 
 
 H. E — , ajt. 50. The patient, who was of a small and weakly frame, had 
 fallen from a tree a month previously, and from that time felt occasionally 
 pain in the left side. For nine months he had suffered from bronchitis, but 
 with this exception had had no previous illness. A few days after the fall, 
 severe burning pains were felt in the neighbourhood of the lower ribs, accom- 
 panied by constipation, loss of appetite, and irritating cough. On examina- 
 tion, the lungs were found to be healthy. Two days before admission, the 
 patient fell into a deep fainting fit, from which he but slowly recovered. 
 The physician who was called to attend him, discovered a soft, prominent, 
 strongly pulsating tumour between the left scapula and the spinous processes,
 
 PARALYSIS OF SEERATI MUSCLES. 197 
 
 extending from the fourth to the eighth dorsal vertebrae. The heart sounds 
 were natiiral ; no abnoi-mal sound could be detected on auscultation over the 
 tumour. There was no particular pain in pressing the growth, but the patient 
 complained of pain radiating away from it, in a downward direction. Two 
 days after admission, he complained to his next neighbour of a dimness of 
 vision ; immediately after he had an attack of dyspncea and became com- 
 pletely unconscious. The assistant who was called to him found the pulse 
 much quickened, the respirations rapid, the face blanched and sunken, the 
 lips and gums white. He died a quarter of an hour after. 
 
 Post-mortem. — ^A quantity of partly coagulated, partly fluid blood poured 
 out of the cavity of the mouth. The left lung, was highly emphysematous. 
 Close below the bifurcation of the trachea and connected to the posterior 
 walls of both bronchi, was a tumour, the size of a hen's egg, which was 
 attached also to the anterior wall of the oesophagus. The commencement of 
 the thoracic aorta was dilated into a sac, firmly connected to the chest walls 
 and the vertebral column. An opening in the wall of the oesophagus, was 
 found to be connected with a second small aneurism filled with blood clot. 
 The principal aneurism was full of old firmly adherent coagulum. There was 
 considerable destruction of the ribs and vertebral column ; the spinal canal 
 was exposed for three or four centimetres. The stomach contained an enor- 
 mous mass of coagulated blood. 
 
 Paralysis of both serrati muscles. 
 
 This affection was observed in a baker, jet. 25, in whom the paralysis 
 probably originated from over-exertion. The paresis had gradually become 
 complete, and affected also other of the scapular muscles. 
 
 ' Ossification of the fascia of the back} 
 
 U. E— , of Zell, Ct. Ziirich, about twenty-four years old, had, so far as his 
 parents could remember, been perfectly healthy up to three years old. No 
 hereditary tendency to this or any similar affection existed ; the patient 
 himself ascribed the origin of his condition to a fall when he was three years 
 old, in which he alighted heavily on his outstretched hands, and for a long 
 time after had severe pain in both shoulders. No dislocation seems to have 
 taken place at any rate at the time ; the surgeon who attended him only 
 prescribed cold water applications to the painful parts. 
 
 Very shortly after the fall, accoi'ding to the patient's account, the move- 
 ments of the arms began to be more and more restricted, and in the course of 
 some years the condition which existed on admission gradually developed 
 (see Fig. 13). At first he was able to work in a manufactory, but eventually 
 the limited movements of his arms prevented him from doing any work, so 
 that for many years before admission he had been without any calling. It 
 
 * Trom a dissertation by Dr Zollinger, Zurich, 1867.
 
 198 
 
 OSSIFICATION OF THE FASCIA OF THE BACK. 
 
 seemed possible that his condition was due to a previously existing diathesis, 
 and tliat the injury, wliich apparently was not of a very serious nature, was 
 but the exciting cause. If so, the case was analogous to those recorded by 
 V. Testelin and Danbressi. The statements of the patient in such a 
 matter, of coui-se could not be unreservedly accepted, inasmuch as the disease 
 
 Fig. 13. — Ossification of the Fascia of the Back. 
 
 originated at such an early period of life that one could hardly expect the 
 man to remember the minute symptoms of his complaint very distinctly. Up 
 to three yeai-s before admission his health had been good ; he then, however, 
 was attacked by some severe illness, which confined him to bed for four 
 weeks. The disease was marked by symptoms of severe fever, great pain on
 
 OSSIFICATION OP THE FASCIA OP THE BACK. 199 
 
 both sides of the thorax, cough, dyspnoea and delirium. His medical 
 attendant pronounced the affection to be inflammation of the lungs and of 
 the brain. Probably, however, it was a case of severe pneumonia, with the 
 so-called nervous symi^toms. Complete recovery gradually followed, with 
 the single exception that during convalescence the vision of his left eye 
 became affected, and in a few days was completely lost, a most remarkable 
 symptom to which we shall return later on. 
 
 During the two or three years previous to admission, the man stated that 
 his condition had not appreciably altered ; the process of ossification seemed 
 to have become stationary, or at any rate, went on very slowly. 
 
 When admitted the patient was seen to be of stunted frame, ill-nourished, 
 and of rather dull intelligence. When standing or walking, the body was 
 flexed at the lumbar vei-tebrse. The head was craned forwards, and buried 
 between the shoulders ; the arms did not hang straight down from the 
 shoulder- joints, but were somewhat abducted, and a little flexed at the elbows. 
 On looking at the patient, the point that struck the eye most prominently 
 was the number of abnormal inequalities and prominences of the back 
 (see Fig. 13). Immediately beneath the skin, and taking, as it were, the lower 
 pai-t of the lumbar spine as a central point, numerous in-egularly an-anged 
 flat surfaces, humps, and ridges of bony hardness could be felt, from which 
 other similar flat ridges and spurs branched off in every direction. From this 
 same central point, one especially hard, strong ridge extended outwards and 
 downwards into the mass of the glutajus maximus muscle ; at the end it 
 broke up into numerous small processes, which branched off laterally in 
 different directions, and — like the parent ridges — ended in three tolerably 
 sharp-pointed extremities, lying free in the muscle. By introducing the 
 point of the finger under these processes, and moving them about, they were 
 found to be elastic, and could be bent from the points of attachment. 
 Manipulation gave the patient no particular discomfort. On both sides of 
 the vertebral column, over the sacro-spinalis muscle, were numerous perfectly 
 immovable excrescences and bosses of bony hardness most irregular in 
 arrangement. These latter ridges did not correspond to any particular 
 muscular bundles, and were perfectly unsymmetrical on the two sides. On 
 the whole, there was rather more disease on the left side than on the right. 
 In the neighbourhood of the latissimus dorsi muscle, on either side, lay 
 another bony mass, immediately below the skin ; on the left side, the muscle 
 felt as if its entire circumference were thickened and converted into bone. 
 The inferior angle of the scapula could neither be seen nor felt, and appeared 
 to have coalesced with the ossified muscle into a single mass. The lower 
 edge of the latissimus dorsi was especially sharp where it forms the i^osterior 
 boundary of the axilla. At this point the ossification abruptly ceased with a 
 rounded off extremity, just before the muscle reached its point of insertion 
 into the humerus. 
 
 In the deltoid — usually a favourite spot for pathological ossification — there 
 was no eipecial bony hardness, but the insertion of the muscle into the 
 humenis could be felt as an abnormally tense band ; the more so that the 
 panniculuB adiposus was at this point but ill developed, and the rest of the
 
 200 OSSIFICATION OF THE FASCIA OF THE BACK. 
 
 muscle was wasted. The same was the case with the pectoral muscles. No 
 abnormal inequality or hardness existed at the sides and anterior surface of 
 the thorax. From what has been said, it may be gathered that the movements 
 of the arms at the shoulder-joints, although very limited, were not wholly 
 absent. The humenis which was slightly abducted when in a position of 
 repose, could be adducted to a certain extent though not completely crossed 
 over on to the abdomen. Eotation of the humerus at the shoulder-joint was 
 free, but gave rise to a curious phenomenon. As it was moved, the head of the 
 humerus slipped hither and thither with trembling movements, as if there 
 were some irregularities on its surface, and a sound resembling soft crepitus 
 was distinctly audible at some distance. The explanation probably was that 
 the separate muscular bundles of the deltoid were atrophied and the interetitial 
 connective tissue increased. Thus the whole mass had become stiff, and 
 perhaps adherent more or less to the capsule of the joint, and the iiTcgularities 
 of the diy cellular tissue, gave rise, on rotation of the head of the bone, to 
 the quivering movements and grating sounds. The ami could not be 
 completely extended at the elbow-joint, evidently owing to the tough and 
 stiff condition of the biceps tendon. Xo material difference existed between 
 the shoulder- and elbow-joints of the two sides. With the exception of a 
 small, rounded exostosis on the second phalanx of the index finger, no other 
 pathological ossification existed elsewhere in the upper extremities. The fii-st 
 phalangeal articulation of the left middle finger was restricted in its movement, 
 owing to unifonn tluckening of the ends of the phalanges from bony or 
 cartilaginous thickening. The movements of all the other joints of the hands 
 and feet were perfectly normal. 
 
 With the exception of a small exostosis on the inner side of the left tibia, 
 and a similar growth on the outer side of the condyle of the right femur 
 there was nothing abnonnal to be noted in the lower extremities, and the- 
 patient could, without inconvenience, walk for several hours. But the list 
 of ossifications is not yet exhausted, for the movements of the lower jaw were 
 much impaii-ed, and it, could only be depressed sufficiently to admit the 
 little finger between the teeth. No hai'dness or irregularity could be felt 
 from without in the muscles of mastication ; probably, therefore, the 
 defective movement was due to the tough and stiff condition of the articular 
 ligaments. The affection of this articulation, as far as could be gathered 
 from the patient, was of late occurrence. 
 
 The movements of the vertebral column were veiy partial ; the patient was 
 completely unable to straighten himself from his bent position. Lateral 
 movements and rotation between the doi-sal vertebrae were only possible to a 
 very limited extent. Those of the cervical vertebrae were more free, but even 
 here the movements were far below the normal ; thus the power of bending 
 back was almost completely absent, owing to the loss of extensibility in both 
 stenio-mastoid muscles which stood out as prominent, rigid bands. Extending 
 from the angle of the chin to the sterao-clavicular region were numerous- 
 tough, cord-like bands, obviously due to partial thickening of the interstitial 
 cellular tissue in the platysma myoides. 
 
 Inspiration was kept up by means of the so-called auxiliary muscles o£
 
 CYST OV 1!ACK. 201 
 
 respiration acting on the upper part o£ tlie thorax. At each deep inspiration, the 
 thorax was distinctly raised ; the action of the diaphragm, though not absent, 
 was comparatively slight. This condition was explained by the immobility 
 and rigidity of the false ribs, which prevented the displacement of the 
 abdominal viscera. In this respect the case presented difBered materially 
 from that recorded by Skinner, in which the thorax was perfectly tranquil 
 during respiration, all movement being prevented by the bony union of the 
 ribs and thoracic muscles. 
 
 The cardiac sounds did not suggest any ossification of the muscular 
 substance of the heart. 
 
 In other respects the patient had nothing to complain of, his appetite was 
 excellent, and all the functions of the body were properly discharged ; neither 
 in the quantity nor constituents of the urine could anything abnormal be 
 found. 
 
 AVith respect to the amaurosis of the left eye, the question arose — and it 
 was a question very difficult to decide — -whether the loss of vision had any 
 connection with his attack of pneumonia. Prof. Horner, who saw the 
 patient directly after the eye became affected, kindly sent to us the following 
 information — " I found complete amaurosis of the left eye, so that he could 
 only distinguish the movements of the hand when quite close ; the ophthal- 
 moscope eliowed complete optic atrophy, small vessels, and a very transparent 
 lamina cribrosa. In the neighbourhood of the macula; were small htemor- 
 rhagic spots. Traces of absorbed extravasation were seen about the veins 
 at the upper parts, and on or in the vessels were fine, white, glistening 
 discrete dots, which seemed to be connected with some alteration of the 
 walls of the vessels ; below, about in the equator of the eye, was a round, chalky, 
 glistening spot, over which passed a blood-vessel. In the right eye the outer 
 half of the papilla was much flattened, and the lamina cribrosa remarkably 
 defined. The inner part of the optic disc red in colour ; field of vision 
 normal." The connection of the complete atrophy of the left, and the partial 
 atrophy of the right optic nerve, with the extensive processes of ossification 
 about the body, it is not easy to explain : still, the supposition seems by 
 no means improbable that the white spot seen in the left fundus was due to 
 a calcareous deposit in the choroid. The unusually strong reflection of the- 
 brilliant white colour of this spot rather negatived the idea that it could 
 have been due to pigmentary atrophy alone. 
 
 Cj/si of the bade. 
 
 A youth, set. i6, came up to the Clinic with a fluctuating tumour, the size 
 of a goose &gg, close under the left scapula. This had been accidentally 
 noticed some weeks before by a comrade, while he was bathing. I punctured 
 the cyst, and let out a few ounces of clear, highly albuminous serum ; 
 microscopically, no structural elements could be observed. In three weeks, 
 the growth had filled up again as large as before. I then punctured it again,, 
 and injected with equal parts of iodine and water. A good deal of effusion 
 followed which was rapidly absorbed. Unfortunately I lost sight of the- 
 youth, and cannot say whether the cure was permanent.
 
 202 LIP03IA. MULTIPLE FIBROMATA. ANGIOMA. 
 
 Lipoma. 
 
 With regard to fatty tumours of the trunk, it may be worth 
 notice that these, in most instances, were found on the back ; their 
 frequency in the female slx is evidenced by the fact that among 
 twenty-seven cases, only four occurred in men. 
 
 Multiple soft fib romatu. {Fig. 14). 
 
 G. A — , a3t. 53. About thii-ty years previously a tumour weighing between 
 four or five ounces had been removed from the chin. About the same date 
 numerous soft small tumoure developed in the skin, principally about the 
 trunk. Most of the growths were no lai'ger than a linseed, or a pea, but a 
 few were of somewhat lai'ger size. The long, pendulous tumour of the 
 breast, with which he was admitted, developed on one of the small tumours. 
 Six years previously it began to increase in size markedly and for a year or 
 two had been gi-owing with gieat i-apidity. The growth was removed with 
 the knife ; the haemorrhage was but slight, and recovery followed.^ 
 
 Angioma. 
 
 A man, aet. 43, had a racemose, pulsating, arterio- venous angioma the size 
 of the hand on the right side. He had had since birth a vascular mole in 
 this spot, which had gi^adually increased. For the last few jears he liad been 
 troubled with repeated vomitings, and haemoiThage from the niuvus, and was 
 greatly reduced, and anaemic. An elastic bandage was placed on the thorax 
 above and below the growth. I was thus able to excise the growth, without 
 any loss of blood. The wound was united by sutures, but a considerable 
 collection of blood took place under them, and they had to be loosened, on 
 account of commencing septic inflammation and suppui-ation in the neigh- 
 bourhood. Repeated haemon'hage followed with septic pleurisy, and he died 
 six days after the operation. 
 
 Cavernous blood tumour, combined with a small lobulated lipoma. 
 
 I could not say in this case nor in another, which I once saw on 
 the thigh, whether tlie fat formation (Rindfleisch), or the develop- 
 
 ' The case is analogous to those described by Mr. G. D. Pollock in the 
 ' Med.-Chir. Transactions,' vol. Ivi, p. 255, and the ' Path. Soc. Transactions,' 
 vol. xxvi, p. 219, as 'Fibroma molluscum.' Other references to the literature 
 of the subject will be found at the end of a paper by Dr. Sangster in the 
 ' Clin. Soc. Trans.,' vol. xiii, p. 166. The Museum of St. George's Hospital 
 contains numerous drawings and photographs of patients with this affection 
 and in the Catalogue of the Museum will be found further information. See 
 ako a case supra pp. 92, 93, Fig. 4. — [Ed.]
 
 MULTIPLE SOFT FIBROMATA, 
 
 203 
 
 Fig 14. — Multiple Soft Fibeomata.
 
 20 A CAYEKXOUS BLOOD TUMOUR AND LIPOMA. SARCOMA. 
 
 ment of cavernous tissue (Liicke) was primary. Both new formations 
 were in equal proportions throughout the entire tumour. 
 
 H. B — , tct. 26, a remarkably strong man, stated that five or six months 
 previously one of his fellow-labourers had remarked a swelling below his right 
 scapula which caused the bone to project from the thorax in a remarkable 
 manner. The tumour seemed to be lobulated, and at some parts fluctuation 
 could be detected. It was painless, and reached from the upper border to 
 below the inferior angle of the scapula, so that it lay partly below the shoulder- 
 blade and partly between that bone and the vertebral column. A large wound 
 had to be made in order to remove the gi'owth, and the operation was accom- 
 panied by severe hsemonhage. Unhealth}- suppuration of the cellular tissue 
 followed, and septic symptoms. Constant wet packing was employed so as to 
 promote profuse sweating. The patient recovered and more than a year later 
 was free from recun-ence. I should not have been surprL«;ed if the growth had 
 recuiTed, for, on account of the severe bleeding and the collapse of the tumour, 
 it was very diflScult to distinguish the morbid gi-owth from the normal fat, 
 seeing that the lobes of the tumour extended far around into the suri'ounding 
 adipose tissue. 
 
 Small-celled medullary sarcoma, in part spindle-celled, originatir^g 
 in the S2ibcutaneous cellular tissue of the fascia of the back. 
 
 M. W — , a strong man, set. 67, had previously enjoyed good health. Some 
 nine months previously he had noticed a small tumour in the skin of the back, 
 on the right side of the vertebral column ; the growth became painful and the 
 skin over it reddened, so that it gave the appearance of a slowly forming 
 abscess. However, the growth constantly increased, and in the coui-se of two 
 months had reached the size of a foetal head. The tumour was then com- 
 pletely removed, but soon after the wound had healed recun-ence took place, 
 whereupon it was removed a second time, five months after the first operation. 
 Two months later, the man came under my care. The tumour had then again 
 recurred in the form of numerous detached nodules lying close to each other 
 and extending into the muscular, fatty and cellular tissues of the back. I extir- 
 pated the tumour thoroughly, removing a large portion of skin, together with 
 the muscles and fascia in the neighbourhood of the growth. Scarcely had the 
 wound healed when fresh recurrence took place in the cicatrix. I made a 
 final attempt to save the patient by further extensive excision of the nodules 
 and the pai-ts around them, but I had to give up the attempt, for although 
 the dissections extended down to the arches of the vertebi-se, there still 
 appeared suspicious spots deeper down still. The patient died of exhaustion 
 a few months later. After death it was found that neither the axillary nor 
 the bronchial glands, nor any of the organs were diseased. The duration of 
 the diseaie was a little over fifteen months.
 
 MELANOTIC SAKCOMA. 205 
 
 Melanotic small-celled and spindle- celled sarcoma. 
 
 E. G — , £et. 42. Two years previously she had noticed an excoriation on 
 the left side of the back. Startin^:^ from this a tumour of a brownish 
 colour developed, growing at first slowly, then more rapidly. The patient 
 could not state whether there had been any previously existing pigmentation 
 at this spot ; on no other part of the body were there any such discolourations. 
 When the growth had reached the size of a hen's egg, it was removed (four- 
 teen months before she came under my care). The wound healed naturally 
 enough, but when she came under observation, the cicatrix was of a brownish 
 colour. Six months before admission, some tumours formed in the left 
 axilla ; some months later she had pains in the neighbourhood of the liver, 
 and when admitted pain in the bladder, and pigment in the urine. She 
 died of exhaiistion a month after admission. The disease had lasted two 
 years and two months. Post mortem : spindle-celled sarcoma was found in 
 the left axilla, both lungs and pleura, the heart, liver, spleen, kidneys, intes- 
 tine, omentum, urinary bladder, and on the outer surface of the uterus and 
 ovaries. The peritoneum was covered with dark brown pigment but free from 
 the gi'owths. All the fat of the omentum and mesentery of a dark brown 
 colour ; six ounces of brown fluid in the abdominal cavity ; pigmentary 
 granules in the blood. Dr. Lehmann examined the pigment, and found in 
 it ulmine (perhaps identical with or an altered form of Stadler's " bili- 
 humin").' 
 
 Sarcoma of the thoracic walls. 
 
 In a man, get. 60, thirty-five years previously, a nodule appeared in the 
 skin, close to the left nipple. In the course of ten years it had attained to 
 
 * A somewhat similar case, which is of interest as showing the extraordi- 
 nary tendency to multiplication in some forms of melanotic sarcoma, came 
 lately under the translator's observation. The patient, a woman, jet. 60, 
 was admitted in June 1879, into St. George's Hospital for a mushroom- 
 shaped growth on the back. This had developed on a scaly patch which she 
 had had all her life. The growth was removed three months after its com- 
 mencement, and proved, on microscopic examination, to be a melanotic 
 alveolar sarcoma rich in pigment. Three months after removal a tumour 
 appeared in the left axilla, and there was evidence of malignant disease of 
 the pleura. Subsequently numerous other malignant nodules made their 
 appearance, and she died of exhaustion, a little over a year after the first 
 tumour was noticed. Post mortem : innumerable small, malignant growtl:s 
 were found in almost every part of the body ; some fifty or more were scat- 
 tered about the brain ; about the pleura and peritoneum they were absolutely 
 innumerable. Growths were found about the pericardium, the endocardium, 
 the pancreas, utems, liver, and many hundred in the subcutaneous tissue of 
 the trunk, the neck, the groins, and arms. In the axillae and the groins thcv 
 occupied, oljviously, the position of the lymphatic glands. The morbid 
 growth had also recurred in the cicatrix of operation. [Ed.]
 
 206 EECURRENT SARCOMA OF LONG DUEATIOX. 
 
 the size of a hen's egg, and was then removed. For twelve years he was free 
 from recuiTence, then a fr-esh growth appeared close to the scar, which after 
 four years was again removed. For many years after this his health was 
 excellent. Then however, several nodules appeared close to the scar and 
 began to ulcerate. Caustics were applied, and he got quite well. Soon, 
 however, the growth again recmred, and was allowed to attain the size of a 
 man's head. It was then extirpated by Schuh, fifteen years before I saw 
 him ; the mass removed weighed six pounds. Before the extensive wound 
 had completely healed, small nodules again made theii- appearance, which were 
 removed three months after the last opei-ation. For fourteen yeai-s after 
 this he was perfectly free from any recun-ence ; the disease then returned in 
 the cicatrix. He came under my care with a gi'owth about the size of a 
 hen's egg, from which severe hsemoiThage at times took place ; at his earnest 
 request I removed it. Fresh giowth and ulceration took place in and about 
 the cicatiix, which extended from the sternum, up over the shoulder, and at 
 last proved fatal. From fii-st to last, the disease had existed for thirty-six 
 and a half years. 
 
 (The exact histological nature of the growth is not stated. [Ed.]) 
 
 Section B. — Diseases of the Breast. 
 
 Case of neuralgia of ike breast. Case of hypertrophy. Sub -mammary 
 lipoma, siinulating hypertrophy. Involution cyst of mamma. 
 Remarks on adeno-fibroma of the breast. Case of cysto-sar coma 
 of very sloio growth. Sarcoma developing in both breasts during 
 ^Jregnancy. Remarks on adeno-cysto-sarcoma . Case of melanotic 
 carcinoma combined with alveolar sarcoma. Double carcinoma 
 developing during pregnancy. Remarks on cases of cancer 
 occurring at Zurich — at Vienna. Ojierative treatment of 
 mammary cancer. Diseases of the male breast. Case of 
 chronic induration — of carcinoma. 
 
 Neuralgia of the left breast. 
 
 Frau S. C — , set. 58, had suffered from no previous disease of any severity. 
 The menses commenced when she was seventeen, never gave any trouble, 
 and had ceased four years before admission. She had been mamed thirty 
 yeai-s, borne fifteen children, and had nursed four of them herself. "NVlien 
 forty-eight years of age, without any knowTi reason, pains of a shooting, 
 gnawing character, commenced in the left mammary gland. The menses, 
 which at that time had not ceased, had no influence on the pain. Six years 
 previously she had consulted Schuh, who gave as his opinion that the pain 
 was of a neuralgic character, and only at the urgent request of the patient 
 consented to remove a great part of the left breast. The pain persisted in
 
 NEURALGIA OF BEEAST. HTPEETROPHT. 207 
 
 the parts left as before. Two years later v. Pitha removed the painful por- 
 tion of the gland, but again without benefit. When I saw her, there was 
 only a small portion of the upper part of the gland remaining, chiefly con- 
 sisting of fat, but in this, on minute examination, painful spots could be 
 detected. On the supposition that these possibly might be small neuromata 
 I removed the painful portion, but found in it no trace of anything abnor- 
 mal. At first her sufferings were relieved, but the pain then returned in 
 and about the cicatrix with all its former intensity. 
 
 This is the first case of neuralgia of the mamma, which I have 
 had an opportunity of observing. As in the other cases which I 
 have met with in surgical literature the patient was a highly 
 hysterical woman, dark and stout. As long as she was compelled 
 to busy herself in household affairs, and in attending to her husband, 
 she seemed to be perfectly well; directly she was idle, or was 
 reminded of her state of health, the pains occurred with severity. 
 Gradually, her condition became intolerable to those round about 
 her. She absolutely declined injections of morphia, stating that 
 some time previously, as the result of an injection, she was brought 
 into a state of great excitement followed by depression. She fre- 
 quently consulted me, and I tried all kinds of remedies, none of 
 which unfortunately gave her any benefit. I often had an 
 impression that there was some insanity mixed up with her con- 
 dition. Possibly these and similar conditions are only a form of 
 intercostal neuralgia, usually depending on some central nervous 
 affection ; of course, cases where small painful tumours exist in 
 the gland must be excepted. 
 
 Hypertrophy of the mammce. 
 
 M. S — , a?t. i6, was admitted under Professor Carl Brann, who was kind 
 enough to supply the following information with regard to the case : 
 
 " The patient was a virgin. The catamenia commenced in November 1867, 
 when she was fourteen years of age. Up to the end of April 1868, the 
 breasts were quite small. In the course of the next two months, they 
 attained the size shown in Fig. 15, then for some months became much 
 smaller, but in October of the same year, they again rapidly increased to their 
 former dimensions. The base of the left breast measured 23 inches in cir- 
 cumference. The measurement from the lower edge of the third rib, at 
 the attachment of the breast to the nipple was \o% inches ; the transverse 
 measurement 9 incites. The circumference of the base of the right breast 
 was 19], inclies. From the third rib to the nipple 9f inches, the transverse 
 diameter 8i. The measurements were taken when the breasts were hanging- 
 down. Two yeare later we heard that the breasts diminished considerably in
 
 208 
 
 HYPERTROPHY OF THE BREASTS. 
 
 «ize dui-ing the winter and the spring, and the patient was able to do light 
 work without difficulty. In the course of the summer, however, they again 
 reached the size which they had on her previous admission. She refused to 
 stay in hospital. 
 
 Fig. 15. — Htpeeteopht of the Bbeasts. 
 
 (It is noticeable that in this case, if we may judge by the illustration 
 Ihe nipples are situated at the lower part of the hypertrophied breasts, and 
 not, as it usually found in this afEection, directed upwards towards the 
 •clavicle. Cf. Birkett, in ' Holmes' System of Surg.,' vol. v, p. 238, 2nd. ed. 
 -[Ed.])
 
 HTPERTEOPHY OF MAMM^. 209 
 
 Enormous hypertrophy of both mammcs. 
 
 A. R — , a servant girl, set. 22, strongly built, and well-nourislied, had 
 •always had good health as a child. The menses began when she was fifteen 
 and had always been regular. When nineteen years old, she noticed a marked 
 enlargement of both breasts ; these gradually increased in size, without occa- 
 sioning her any pain or material inconvenience. When admitted, she was 
 found to be in about the fifth month of pregnancy, and the breasts had 
 inci'eased to such a prodigious size that she was quite unable to do any work. 
 The mammae reached down to the umbilicus, and were of immense thickness ; 
 the circumference of the left breast, at the base, measured sixty-five centi- 
 metres, and that of the right, sixty-eight ; from the upper border to the lower, 
 in a line with the nipple, the left measured sixty-three centimetres and the 
 right sixty-seven ; the greatest circumference of the left breast was eighty- 
 two, and of the right eighty-four. The skin over the breasts was thickened, 
 but not very intimately united with the glandular tissue. The subcutaneous 
 "venous plexuses showed extensively through the skin. The mass of the gland 
 felt tough ; in both breasts there were bosses of greater or less size not very 
 distinctly difEerentiated. The breasts occasioned her no pain, but their weight 
 was so great that she was forced constantly to keep her bed. 
 
 The idea of operation could hardly be entertained, when the enormous 
 extent of the growth was considered, especially in the woman's condition. A 
 compressive bandage was therefore applied daily ; after a few days the right 
 breast appeared to become somewhat softer. The pressure of the bandage 
 had caused a slight excoriation of the skin, and she was attacked with severe 
 erysipelas, commencing at that spot. The next day she aborted, became 
 rapidly collapsed, and died in twenty-four hours. 
 
 On examin&tion of the glands it was found that the hypertrophy 
 did not consist of a pure hyperplasia, such as is commonly supposed 
 to exist in these cases ; but the enlargement was due to a number 
 of fibromata of different sizes, some hard, some soft, enclosing 
 glandular acini, the ducts of which — as usual in these tumours — 
 were widened out into branching spaces. The cross section of the 
 mamma resembled that of a uterus, studded with numerous 
 fibromata, but the tumours were softer and contained more juice 
 than ordinary uterine fibrous growths. 
 
 I may refer to my work on diseases of the breast (' von Pitha 
 and Billroth's Chirurg.,^ Band 3, Abth. ii, p. 85) for a case of 
 immense lipoma, situated behind the right mamma. The case was 
 diagnosed as hypertrophy of the breast, for the tumour had pushed 
 forward the gland to such an extent that the nipple was situated 
 at the lowest part of the tumour, into which the entire gland seemed 
 to have disappeared. 
 
 14
 
 210 INVOLUTION CYSTS. ADENO-FIBROMA. 
 
 Involution Cysts of the Mamma. 
 
 These tumours are exceedingly difficult to diagnose when occurring 
 in large, fat women. As a rule, the surgeon expects to meet with 
 carcinoma, and is extremely delighted to find that he has only to 
 deal with the smooth-walled cysts. These cysts are certainly at 
 times found in or near undoubted cancer. I saw three such cases, 
 in all of which the cysts were rather larger than a hen's egg. Two 
 I removed, on the supposition that they were carcinomatous. The 
 third case is recorded below. 
 
 A woman, set. 60, whose daucrliter I had operated on several times for cystic 
 sarcoma of the breast, came under treatment for a slowly-growing cyst of the 
 left breast. When I saw her, the growth wa.s the size of a hen's egg, and 
 had existed for many years. The old woman was blind and would not con- 
 sent to an operation, so I punctured the cyst ; it refilled, and I repeated the 
 puncture, and injected equal parts of iodine and water. No resorption fol- 
 lowed, but the opening of the puncture gave way after a few weeks, and some 
 years later there was stiU purulent discharge fi-om the sinus. 
 
 ADENO-riBROMATA. 
 
 I include under this heading the firm rounded or oval lobulated 
 and encapsuled tumours, which on section are of a very pale 
 reddish — almost white — colour. They nearly always include 
 glandular tissue, but this has a very unimportant share in the new 
 formation. As a rule the acini are scarcely enlarged, but the 
 branching ducts are greatly elongated, and dilated into irregular 
 slit-shaped spaces,^ containing a little thin mucoid secretion. The 
 slit-like spaces in these tumours are never converted into large 
 CTsts. The tissue itself consists of tough — usually fasciculated — 
 granular connective-like tissue.- From the cut surface of these 
 tumours, a little muco-serous fluid may be expressed ; the tissue 
 itself is for the most part dry. 
 
 » ' Billroth's Path.,' 624 et seq. 
 
 ^ " The tissue of the neoplasia itself is usually composed of small, round, 
 spindle-shaped — rarely of branched cells — with considerably developed 
 fibrous, sometimes gelatinous, intercellular subBtance." Op. cit., 625.
 
 ADENO-FIBROMA. CTSTO-SAECOMA. 211 
 
 There can be no doubt^ tliat from a purely anatomical point of 
 view, the difference between these tumours and cysto-sarcomata is 
 very slight, and we should be perfectly justified in considering 
 the&e tumours as representing the initial stage of cysto-sarcoma. 
 Practical observation^ however, allows us to form these new growths 
 into a well-defined group from a clinical point of view. They are 
 characterised by their very slow growth ; their frequent occurrence 
 in young women and girls ; their painlessness, and not infrequent 
 multiplicity, as well as by the fact that they do not appear to recur 
 after operation. 
 
 It is a curious fact that I never once saw a case of this nature 
 in Zurich. While in Berlin — during a period of seven years — I 
 only observed five or six cases; all the observations that I have 
 collected are drawn from Yienna, and the number would have been 
 very much larger, if I had kept the record of cases that came under 
 my notice in private. I commonly advised removal, if treatment 
 with iodine for some months did no good; but I did not always 
 advise operation very earnestly. 
 
 We cannot positively affirm, in answer to the usual question, 
 that the tumour, if left untouched, will be directly dangerous to 
 life. In two cases I have observed large cysto-sarcoma develop 
 on some nodules of this description, which had remained for a long 
 time indolent, and scarcely altered in size. It is far more common 
 for carcinoma to make its appearance in connection with these 
 tumours, when the women arrive at the age at which carcinoma 
 occurs. In such cases I always advise removal, as also when stabbing 
 pains occurred, or any rapid increase of growth was noticed. 
 
 Altogether nineteen cases of adeno-fibroma came under observa- 
 tion. Nine of the women were married ; most of them had children, 
 and had nursed one or more themselves ; but, unfortunately, the 
 records on this point are incomplete. 
 
 The age at which the tumours developed was as follows : — From 
 12 to 20, six cases; from 21 to 30, nine cases; from 38 to 40, 
 four cases. 
 
 Cysto-sarcoma 
 
 E. S — , aet.43, unmarried, noticed first when she was nine years old 
 a small, painless lump in the left breast; this increased slowly and in 
 twenty-seven years had attained the size of a fist. It was then removed 
 successfully by Schuh. A year later a fresh tumour appearea in the neigh-
 
 212 DOUBLE SARCOMA DURING PREGNANCY. 
 
 bourhood of the cicatrix, and was again removed by Schuh, a year after the 
 fii-st operation, when it was the size of a hen's egg. According to the patient's 
 account, both the tumoui-s were called cysto-sarcoma. The gi-owth again 
 recuned in the cicatrix, and was removed two yeai-s later by Weinlechner ; 
 the wound again healed up, as is usually the case with cysto-sarcoma. In 
 a year and eight months recurrence again took place in the cicatrix, and at 
 the same time a tumour appeared in the right breast, which felt more nodulated 
 and harder than that in the left. Both were painful and tender on pi-essure. 
 I found a tumour the size of an apple in each breast ; on the I'ight side, a 
 typical infiltrated alveolar carcinoma, with infiltration of the axillary glands ; 
 on the left side a typical cysto-sarcoma, without any enlargement of the 
 axillary glands. I removed the whole of the right breast, together with the 
 axillary glands, and extii-pated the tumour on the left side (the fourth 
 operation on the cysto-sarcoma). Examination of the growths proved the 
 absolute accuracy of the diagnosis. She recovered very quickly, and was 
 discharged thirteen days after the operation. We heard subsequently that 
 she died rather suddenly after one day's illness ; unfortunately, no post 
 mortem was pennitted, and the circumstances of her death were not detailed. 
 
 jSarcoma developing in both mammary glands during pregnancy. 
 
 Fi-au L — , came to me in May, 1869. She was then thirty-one years of 
 age. She had had two children and became pregnant for the third time in 
 November, 1868. In January, 1869, she noticed a swelling in the left 
 breast, which was rather hard. From time to time slight serous discharge 
 escaped from the nipple. She suffered no pain. She did not trouble about 
 her condition, until the enlargement of the breast became considerable, and 
 she felt hei-self weak and began to lose flesh, yet her general condition was 
 not materially affected, and there was no disease of any internal organs. 
 
 In May, 1869, she consulted several surgeons in Vienna about 
 her case. Different opinions were given — some counselled immediate 
 amputation of the breast, while others were opposed to this. When 
 she consulted me I found the left breast the size of a man's head, 
 firm, and elastic ; the skin over it was cedematous, the tumour 
 freely movable on the thorax, and the axillary glands not enlarged. 
 In the right breast also indurated nodules could be felt. The 
 patient was of slight build and emaciated. 1 was against operation, 
 as I did not think it probable that the patient would recover from 
 the amputation of both breasts. Professor Carl v. Braun, whom we 
 consulted, was of opinion that the induction of premature labour 
 might perhaps be of benefit, for he thought that, as assuredly the 
 tumour had developed during pregnancy, it might be the result of
 
 ADENO-CTSTO-SARCOMA. 213 
 
 some excessive physiological process, and there might possibly be 
 some hope of its disappearing when lactation occurred. 
 
 Prof. V. Braun accordingly induced premature labour and delivered a seven 
 months' child, which died soon after birth. The lying-in progressed normally, 
 but no proper secretion of milk made its appearance. The patient had 
 constant febrile symptoms ; cough set in, with much viscid sputa ; the 
 appetite failed, and she died in a month of marasmus. Unfortunately, no 
 post mortem was allowed, but I was able to remove some portions of both 
 breasts for examination. The tissue was of a faint rose colour, soft and 
 tough. Some milky-looldng fluid could be pressed out from it. Microscopi- 
 cally the growths proved to be granulation sarcoma (glio-sarcoma, small 
 round-celled sarcoma of Virchow). 
 
 Adeno- cysto- sarcoma . 
 
 In contrast to adeno-fibroma of the breast, where the tumours 
 show such a striking similarity that, except for the size, and 
 lobulation, one can scarcely be distinguished from another, the 
 varieties of cysto-sarcoma are remarkably numerous. At one time 
 the intercellular tissue resembles that of an cedematous fibroma, at 
 another of a myxoma, at another of a giant and spindle-celled 
 sarcoma, while occasionally the growths are of a small, round- celled 
 — almost lymphoma-like — nature. Sometimes the cysts are large, 
 sometimes small, and of the most diverse shapes ; but nearly always 
 contain mucoid fluid. Sometimes the cysts occur singly, while 
 sometimes they occupy the greater part of the new formation ; the 
 cysts may be crammed full of growth or with perfectly smooth walls. 
 Cases also have occurred to me though but rarely, where the 
 growth contained newly-formed racemose and tubular gland 
 structure. 
 
 These growths do not, as a rule, recur ; at times, however, they 
 do return after removal, sometimes as mere cysts, sometimes more 
 in the form of sarcoma, and not only locally, for in two instances the 
 axillary glands were affected. 
 
 The age at which the tumours developed was as follows : — At 1 9, 
 one case; between 24 and 30, two cases; between 34 and 40, eight 
 cases ; between 41 and 50, five cases ; at the age of 52, one case. 
 Total nineteen cases. 
 
 In twelve of the patients on whom I operated, I learned that
 
 214 MELANOTIC CARCIXOMA. 
 
 from periods from two up to nine and a half years after tlie operation 
 they were free from recurrence. Sarcoma, as is well known, is apt 
 to recur locally, after long intervals of time. In this special class of 
 cases, however, according to my present experience, if the growth 
 does return, the recurrences follow one after the other at very short 
 intervals. On one patient I operated five times for a purely local 
 recurrence ; the lymphatic glands were not implicated. Since then 
 she has remained perfectly well. I thought, at the last operation, 
 that I had removed the last remnants of the gland which in this 
 case was not very extensive. A severe attack of erysipelas occurred 
 after the operation, which she got over. At the time of writing, a 
 year has passed since the operation, and no fresh recurrence has 
 taken place ; formerly her intervals of health seldom lasted longer 
 than three months. In two other patients the axillary glands were 
 also affected, and in one of these the lymphatic glands contained 
 numerous cysts with muco-sanious contents. Such cysts in the 
 axillary glands can only have originated by mucoid softening of 
 new tissue, which tissue is the result of infection, and consists of 
 giant, spindle, and star-shaped cells arranged in an alveolar form. 
 Unfortunately, in this case the mammary tumour was not examined 
 with sufficient minuteness to enable us to say whether the cystic 
 formation in the mamma had itself originated in this manner, or 
 whether it was the result of dilatation of the acini. In one case 
 secondary growths took place in the ribs, pleura, and pericardium, 
 and proved fatal. I was enabled to assure myself in this instance 
 that the growth had not been mistaken for cancer, nor did carcinoma 
 supervene. 
 
 Melanotic Cakcinoma, combined with Alveolae Sarcoma. 
 
 While engaged in examination of these mammary tumours, the 
 progress of which is very much like that of carcinoma, I was for a 
 long time in doubt how to classify them. The dark pigmentation, 
 and the arrangement of the large celled elements, partly in finely 
 reticulated structure,^ with the cells here and there firmly embedded 
 in the alveoli, seemed to make it probable that they were of a sar- 
 comatous nature. But the manner of extension of the growth, the 
 
 1 'Billroth'sPath./p. 6i6.
 
 DOUBLE CARCINOMA DURING PREGNANCY. 215 
 
 rapid affection of the lymphatic glands, and the typical glandular 
 form of the large cylindrical cells and cell-globules in other parts of 
 the tumours/ seem to put it beyond question that the growths 
 were true, rapidly growing mammary cancers. I can only suppose 
 that these tumours represent a very intimate combination of carci- 
 noma and sarcoma, with abundant epithelial proliferation, and 
 metamorphosis of the stroma into the tissue of richly pigmented 
 alveolar sarcoma. 
 
 Frau M — . set. 68, had observed a tumour of the right breast for two 
 years, which originated just below and external to the nipple. She had 
 ten children, but had nursed none of them herself ; menses regular from 
 fourteen to fifty -three years of age. Beneath the right eye there was a dark 
 blue nodule, the size of a lentil, which was stated to be congenital ; her 
 brother had a similar mark in the same situation ; in the neighbourhood of 
 the supra-spinous fossa she had another of these little dark nodules, also 
 congenital. The patient was a spare, pale woman. On admission, the 
 right mamma was the size of a child's head, hard, and united to the skin. 
 A bunch of glands could be felt in the axilla ; the entire tumour was 
 removed, the operation being a very extensive one. Three months later the 
 patient was discharged with the wound healed, but a small, bluish nodule 
 infiltrating the skin had appeared on the right side of the back. Notwith- 
 standing repeated pei-suasion, she declined to have this removed. The 
 nodule developed into a tumour, and others originated in. its neighbourhood ; 
 the immediate vicinity of the scar and the cicatrix remained free from disease, 
 and the patient died of marasmus about a year after the operation. Un- 
 fortunately no post mortem was made. The disease altogether lasted four 
 yeai*s. 
 
 Acute double carcinoma of the breast, developing during pregnancy. 
 
 Frau J — , set. 36, the mother of seven children, gave the following history : 
 — About five weeks previous to admission, she experienced sudden pain and 
 tension in the breasts (very positively ascribed to eating some ice). At the 
 time the breasts were about the normal size, corresponding to the eighth 
 month of pregnancy. Prom this time both mammary glands increased 
 rapidly in size and hardness. Seven days before she came ainder me, 
 premature labour had been induced by Prof. Carl v. Braun, and she was 
 delivered of a healthy child. Parturition was not attended by any serious 
 haemorrhage. The patient was of a spare frame and veiy pale ; both breasts 
 were rather larger than a child's head, semi-spherical, rigid, and covered 
 over by tense, glistening skin, which was discoloured, and allowed the 
 superficial vessels to show through clearly. The skin was so tense that the 
 
 ' Op. cit., p. 615.
 
 216 CANCER OF THE FEMALE BREAST. 
 
 breasts were but little movable on the deeper parts. The tumours were o£ 
 tough consistence and elastic in pai-ts. No colostrum could be expressed from 
 the nipples, and the axillary glands could not be felt. Pressure was applied 
 to the breasts, but the patient became weaker every day, vomiting all food, 
 and died a week after admission ; the whole process, therefore, had only lasted 
 six weeks. Post mortem : both mammary glands were found to be converted 
 into lobulated, soft, reddish, degenerated masses, exuding on section a white 
 milky fluid. The gi-owths were firmly connected to the fascia over the great 
 pectoral muscle by thickened, infiltrated, cellular material. Medullary 
 nodules were found also in the thyroid gland, the pericardium, substance o£ 
 the liver, large omentum, and the cortex of the kidney. This, in contrast to 
 the previous case,^ was distinctly of a carcinomatous nature. 
 
 Cancer of the Female Breast (Z. B.). 
 
 The number of my cases (49) " is naturally too small for me to be 
 able to draw any statistical deductions of value with regard to the 
 causes of origin of the disease. I may mention, however, that in 
 six cases it was noted that after confinement a nodule had re- 
 mained in the breast, which soon after became painful, and later 
 on, developed into cancer. Nodules of this description often 
 remain indolent for a long time (in three of my cases for four, 
 eighteen, or thirty years respectively), and then, often with- 
 out any known immediately exciting cause, rapidly increase and 
 become painful. In one instance, a blow was given as the origin of 
 the disease ; in no other could any history of injury be traced. I 
 am unable to say, from the somewhat scanty records of the cases, 
 what relation the physiological function of the mammary glands 
 bears to the development of cancer. In the Canton Zurich the 
 women commonly have very ill-developed breasts. On this and 
 many other social grounds, the mothers seldom nurse their children, 
 but usually bring them up by hand. This is one of the principal 
 reasons for the enormous mortality among children in the Canton 
 Zurich. My records do not enable me to state positively in how 
 many instances the patients have borne children, but from Avhat has 
 been said, it may be gathered that nearly all the women who had 
 borne children and were affected with cancer of the breast had not 
 nursed their offspring. These women work very hard in the fields, 
 vineyards, and manufactories, so that they become prematurely oldj^ 
 
 ^ Supra p. 212. 
 
 ^ This number refers to his practice at Ziirlch. [Ed.]
 
 CANCEE OP THE FEMALE BREAST. 217 
 
 the more so that they are but ill fed. About Zurich it is the rarest 
 thing to find stout strong women in the middle and lower labouring 
 class. By the time they are forty-five^ they are always grey -haired ;^ 
 the menses usually commence late, and cease at an early age ; chlo- 
 rosis is very common among the girls working in the country and in 
 the manufactories. The fact that the patients were usually described 
 as thin, ill-nourished^ and anaemic, does not bear any direct relation 
 to the formation of cancer, but is a characteristic of the whole 
 population. 
 
 The frequency with which cancer develops appears to me to bear 
 neither a direct nor an indirect relation to the general nourishment 
 of the body. I should not, from what I have observed hitherto, be 
 prepared to make any positive statement on the subject; I have seen 
 old, withered-up women with immense, rapidly-growing carcino- 
 mata; and other stout individuals with shrunken, long-existing 
 scirrhous growths. Just as frequently, too, I have observed these 
 conditions inverted. 
 
 Anatomically, a parallel may be drawn between the nodulated 
 forms of cancer of the breast, and the tuberous rapidly growing 
 forms of epithelial cancer ; so likewise, the superficial, partly cica- 
 trising epithelial cancers correspond to the contracted scirrhus of 
 mammary glands. In cancer of the skin there is a decided differ- 
 ence in respect of the commencement of the two forms, according 
 to the period of life, which is not the case in cancer of the breast. 
 
 Rodent ulcer is rarely seen in individuals under forty-five years of 
 age ; the hard shrunken breast cancer occurs by no means infre- 
 quently before this period. Purely individual idiosyncrasies seem 
 to have some influence here, which has hitherto escaped observation. 
 As for the age, at which cancers of the breast most commonly occur, 
 an analysis of my small number of cases confirms what is already 
 known. It has often occurred to me that cancer of the breast 
 originating in young women grows more rapidly than when it is 
 developed first at a later period of life. This is, however, not always 
 the rule. 
 
 It may be gathered from my Ziirich tables, that the disease most 
 commonly occurs between the ages of thirty-five and sixty ; at an 
 earlier period, therefore, than cancer of the lip or skin, which 
 
 ' In nearly every single case of scirrhus of the breast admitted into St. 
 George's Hospital for a period of some sixteen months the hair had begun to 
 turn grey about the time the tumour was first noticed. [Ed.]
 
 218 AFFECTION OF THE LYMPHATIC GLANDS IN CANCER. 
 
 most commonly attacks people between the ages of fifty and 
 seventy. The development of cancer appears to be on the 
 whole of earlier occurrence in women than in men. The majority 
 of women affected with cancer of the breast died in about three years 
 after the commencement of the disease. If the disease appeared 
 between the ages of thirty and forty, it ran, as a rule, a more rapid 
 course. Of the women between sixty and seventy, who were attacked 
 two were carried off by the disease in less than a year. I have 
 abeady stated my inability to give any information on the subject 
 of hereditary tendency to the development of tumours. 
 
 With regard to the course of the disease and duration of life in 
 those who died of cancer of the breast, any statements concerning 
 the rapidity with which the axillary glands became affected would 
 be of great value. But here observation is left altogether in the 
 lurch. As a rule, the patients know nothing about the first com- 
 mencement of the axillary swelling, or give very unreliable infor- 
 mation. Most surgeons, too, deceive themselves on this point. 
 The normal axillary glands are so soft that in general they cannot 
 be felt even in very thin persons. If large glands can be felt, they 
 are already diseased and, indeed, usually very extensively diseased. 
 We often hear sympathetic, irritative glandular swellings spoken of 
 in cases of cancer, by which is meant that the glands though enlarged 
 are not yet cancerous. I grant that inflammatory, non-specific 
 glandular enlargements may occur in cancer, especially in connection 
 with the ulcerated forms. But it would be erroneous to suppose 
 that they can be recognised by the external examination of the 
 patient ; more than this, they cannot always be distinguished on 
 microscopical examination. 
 
 On this point I must refer to what I have said on the subject of 
 cancer of the lip and face. The surgeon should regard any enlarged 
 lymphatic gland in the neighbourhood of a cancer with the utmost 
 suspicion and treat it accordingly. The lymphatic glands generally 
 become affected very rapidly in diseases of the breast, and as early 
 in the hard as in the soft cancers. To this rule, the highly- 
 shrunken, scirrhous tumours of very old women form an excep- 
 tion. Anomalous cases, too, occur, such, for instance, as rapidly 
 ulcerating mammary cancer, unaccompanied by disease of the 
 lymphatics. It is possible that the position of the tumour in the 
 breast influences the rapidity with which the axillary glands 
 become affected ; for instance, the growth may be situated close to
 
 AFFECTION OF THE LYMPHATIC GLANDS IN CANCER. 219 
 
 the gland, or in parts where the circulation of lymph is free, or the 
 reverse. In the rare cases where nodules occur to the inner side 
 of the nipple, enlargement of the lymphatic glands certainly takes 
 place later. On the other hand, the glands are attacked with great 
 rapidity — indeed, almost directly — when the nodules are situated 
 oji the outer side of and above the nipple. 
 
 The lymphatic glands of Mohrenheim's fossa, and those in the 
 subclavian triangle, become affected secondarily, subsequent to the 
 infection of the axillary glands. This is obviously connected with 
 the course of the lymph and depends on purely mechanical con- 
 ditions. 
 
 Among my forty-nine patients, the condition of the axillary glands 
 was distinctly noticed in thirty-six cases; in twenty-four they were 
 perceptibly diseased before the patients came for operation. In 
 twelve no glands could be felt at the time of operation. In five of 
 these patients, recurrence took place in the glands soon after the 
 operation ; undoubtedly germs of the disease existed at the time 
 of operation . Some few patients presented themselves with numerous 
 detached nodules in the skin and muscles about the tumour of the 
 breast. These are the worst class of cases, and the most hopeless 
 from an operative point of view. I was fortunate enough to meet 
 with them but rarely at Ziirich. 
 
 No estimate whatever can be formed of the period of time at 
 which internal cancer is likely to occur after the development of 
 primary tumours of the mamma and the axillary glands. Visceral 
 disease was found in one case, in which the breast was affected 
 eight months previously, and was absent in another, where the 
 afi"ection had existed at least twenty-two months. Carcinoma of 
 the ribs, the substance of the heart, the pleura or the lungs, un- 
 questionably originates from the direct passage of cancerous 
 elements through the lymphatic vessels. It is remarkable that 
 the development of nodules in the pleura comparatively seldom 
 causes pain or effusion. 
 
 In fourteen cases I had an opportunity of examining, post mortem, 
 women whom I had had under observation for cancer of the breast. 
 In many cases where there was no autopsy it was possible to make 
 a positive diagnosis during life. My experience with regard to in- 
 ternal cancer may be summarised as follows: — Twice no internal 
 cancer whatever was found. In six cases nodules were found in 
 both pleurae and lung? ; the ribs and the external surface of the
 
 220 VISCERAL AFFECTIONS IN MAMMARY CANCER. 
 
 heart were each affected in one instance. In fifteen cases, nodules 
 were found in the liver; twice in the vertebral column, twice in the 
 brain, and twice in the upper part of the humerus.^ The frequent 
 association of cancer of the liver with a similar affection of the breast 
 is striking. My idea is, that the cancerous material is directly 
 transported through the lymphatic vessels of the mediastinum, dia- 
 phragm, and suspensory ligament of the liver. If this be so, we 
 should expect to find cancer of the liver occurring more often when 
 the right breast is affected. In a series of fifteen cases the right 
 breast was affected in nine, and the left in six instances ; the number 
 of cases, however, is too small to enable me to speak positively on 
 the point. Purther, the lymphatic vessels surrounding the inferior 
 vena cava, aorta, and oesophagus, where these pass through the dia- 
 phragm, may convey lymph containing cancerous elements to the 
 liver. Or are we to look upon these growths in the liver as an 
 expression of multiple cancer formation? Here is a field for much 
 inquiry. 
 
 At Vienna my experience of the disease was much extended, and 
 the following remarks relate to my practice there. 
 
 Of 238 cases of this disease, the affection began at the following 
 ages: — Erom 26 to 30, twelve cases; 31 to 40, forty -three ; 
 41 to 50, ninety-three; 51 to 60, fifty-eight; 61 to 70, 
 thirty; 71 to 77, two. Total 238. 
 
 I may note, in connection with the above table, that in the rather 
 numerous cases, where the cancer developed on nodules remaining 
 in young women after confinement, the commencement of the disease 
 is dated from the period when these indolent nodules began to be 
 painful and increase. 
 
 In 236 cases it is recorded whether the patients were married, 
 unmarried, or widows ; the latter, whose number is small, I have 
 included under the married, while some unmarried patients, who had 
 
 1 In the ' Lancet' for June 12, 1880, p. 912, Mr. Snow has called attention 
 to a thickening and tenderness o£ the upper part of the humerus, on the 
 same side as the diseased gland, which, he states, is frequently seen in scir- 
 rhus of the breast. Mr. Snow ascribes the condition of the bone to a low 
 form of periostitis ; and has found the medulla affected in such cases. Since 
 reading Mr. Snow's paper I have, among perhaps a dozen cases, observed the 
 symptom twice. [Ed.]
 
 INFLUENCE OF LACTATION ON CANCER. 221 
 
 had children, are also put down under the same head. From this 
 table it results that cancer of the breast was seen in twenty-three 
 unmarried, and 213 married. But even these figures do not show 
 really that the unmarried have any security against the development 
 of cancer, or again, that the married are especially predisposed 
 thereto, for the proportion of the unmarried to the married, in the 
 table of cases, corresponds pretty closely to the proportion of un- 
 married to the married generally. Again, of 309 married women 
 who had cancer, 186 had borne children, while twentry-three were 
 barren. Now, these figures again correspond generally to the pro- 
 portion of fruitful to unfruitful women. Even from the best ke})t 
 records, it cannot be made out how many of these women nursed 
 their children themselves, or for how long; I must therefore leave 
 the question undecided, whether the nursing or non-nursing of the 
 children, or whether a long-continued or brief period of lactation 
 predisposes to cancer formation ; nor am I able to make any positive 
 statement on the frequency with which mastitis has previously 
 occurred in breasts that later become the seats of cancer.^ It 
 is far better to confess that we do not know anything for certain 
 about these matters than to make mixed statements. That the 
 disease is sometimes hereditary is beyond question, but even if 
 minute statistics could be got out on this point, they would be 
 incomplete, unless we were able also to discover whether the 
 ancestors and blood relations had new formations in other parts of 
 their organism, and especially whether any suffered from carcinoma. 
 Even amongst the educated classes, such investigations meet with 
 insuperable obstacles. 
 
 Of the further characteristics, and the histological nature of the 
 cancers operated upon, I have seldom been able to find in the 
 records accounts sufficiently precise to justify any general statement, 
 beyond the fact that I am able to guarantee the accuracy of the 
 diagnosis, " carcinoma.'' This much I can say with certainty, that 
 of the above-mentioned 245 cases I only met with a single case of 
 melanotic cancer, already described. In three instances the cancer 
 developed simultaneously in both breasts, two being cases of cancer 
 " en cuirasse." We often see that when carcinoma exists in one 
 breast, towards the end it develops in both mammae. I have 
 already mentioned the frequency with which metastasis takes place 
 
 1 C£. Birkett, article in 'Holmes's Syst. Surg.,' 2nd ed., vol. v, p. 275, and 
 Paget, ' Surg. Path.' 3rd ed., pp. 635 et seq.
 
 222 OPERATIVE TREATMENT. 
 
 in the vertebral column, while on the subject of diseases of that 
 region. 
 
 Operations on the Bkeast and Diseased Axillary Glands.^ 
 
 Of II 8 operations on the breast alone, eight were fatal ; the cause 
 of death in all instances was erysipelas. Of 187 operations on the 
 breast and the axillary glands, or (where recurrence took place) on 
 the latter alone, forty patients died from various causes ; three deaths 
 occurred from severe secondary haemorrhage, but many of the other 
 cases, who were attacked with septicaemia, pyaemia, or erysipelas had 
 also haemorrhage from the axillae. As regards this haemorrhage, I 
 may remark here, that I inherited from my teachers a great dread 
 of hgaturing veins, especially large venous trunks. Formerly, 
 therefore, whenever it was possible, I used to control the venous 
 haemorrhage with tampons, while in the worst cases I tied the 
 branches close to the trunk, or else eecured the wall of the vein 
 and so partially tied the vessel. For a year I gave up this practice, 
 and was in the habit of washing out the wounds with solution of 
 cliloride of zinc and concentrated solutions of carbolic acid in oil. 
 Now, however, we know that all this is injurious, and that it is far 
 less dangerous to place a double ligature on the axillary vein, and 
 then divide the vessel between the ligatures. This plan is rarely 
 followed by any oedrma of the arm, a result which formerly was of 
 very common occurrence. During the last few years, therefore, we 
 have found much less risk in treating these cases. I cannot ignore 
 the fact, that by our more modern methods of operating, where the 
 skin is preserved as far as possible, so as to induce the wounds to 
 unite quickly by first intention, recurrence seems to me to take 
 place far more rapidly. Formerly, I used to remove all the skin of 
 the breast in my cases. It is true the wound often took two or 
 three months to heal, but the subsequent results — as far as recurrence 
 is concerned — were far more favourable. In five cases I operated with 
 chloride of zinc paste, or caustic arrowheads ; one of these patients 
 died of erysipelas. In five instances, also, I removed the entire 
 mamma together with the tumour by means of the galvano-caustic 
 loop. The immediate results of the operation are apt to mislead. 
 No inflammation of the pleura ever followed the operation, but the 
 * ' Wiener Bericht,' 1876. 
 
 I
 
 OPERATIVE TREATMENT. 223 
 
 wounds, though at first they seemed small, were found to be very 
 extensive after the separation of the eschar, and were frequently 
 highly sensitive to the pressure of the bandage ; moreover, they 
 took a long time to heal. In one woman the cicatrix was thickened 
 and sensitive three years after operation. On the whole, I cannot 
 recommend these methods. 
 
 Operation, and Recukrence at the Seat of Operation.^ 
 
 Amputation of the breast is, in general, not so very dangerous an 
 operation, even when all the axillary glands that can be got at are 
 removed. Of forty-six operations at Ziirich, performed on thirty- 
 eight individuals, seven died of erysipelas and pyaemia. This average 
 is unfavourable, but would probably improve with a larger number 
 of cases. In many instances, I was forced to expose the axillary vein 
 or to ligature that vessel. Several times I have removed supra- 
 clavicular glands, formerly in some instances where there were small 
 nodules, I used to practice partial excision of the gland, but lately 
 I have given this up for the following reasons : — Whenever recur- 
 rence took place about the cicatrix, it started from the part of the 
 gland which had been left ; lately, therefore, I have always removed 
 the entire mamma — or at least thought I did so ; one is easily de- 
 ceived on this point. It is exceedingly difficult to remove the entire 
 mamma, since one cannot always know where it ceases. The 
 glandular connective tissue generally loses itself in the fatty tissue, 
 passing from the periphery of the gland to the centre, as it does 
 also in every separate lobule. In an ordinary, not very extensive, 
 operation for removal of the breast, a circle of glandular lobules 
 nearly always remains behind in the fat. At the time of operation 
 the structures can be neither seen nor felt ; it is only by microsco- 
 pical examination, and in properly prepared specimens that little acini 
 can be detected embedded in the fat. Although, therefore, it may 
 be our intention to extirpate the breast, we seldom remove it entirely 
 and thus local recurrence frequently takes place. No surgeon of 
 experience would gainsay the assertion that it is but seldom possible 
 to completely extirpate all the lymphatic glands. Naturally we do 
 not remove that which does not appear diseased to the sight or 
 touch. Often and often a gland is left behind, in which some germ 
 
 1 ' Ziiricli. Bericht,' i860— 1867.
 
 224 OPERATIVE TREATMENT. 
 
 of cancer is already deposited ; this is sufficient to cause further in- 
 fection. Operation would effect far more in mammary cancers if 
 surgeons would but determine to excise unhesitatingly every sus- 
 picious nodule in the breast. On the slightest appearance of local 
 recurrence the whole breast should be at once removed, and removed 
 freely, together with every enlarged axillary gland; it would be 
 better perhaps, when the nodules are growing rapidly, to remove the 
 entire gland at the first operation. So long as surgeons are not 
 convinced of the absolute necessity of his proceeding, and do not 
 impress it on the laity, so long will the results of treatment fail to 
 improve. Away with ointments and caustics ; the one thing that can 
 be of use in this disease is the knife in tlie hand of a skilful surgeon. 
 No doubt cases will always occur where the growth is so rapid and 
 the infection of the lymphatic glands and the blood so swift, that 
 nothing avails, but in very many cases, if the treatment were dif- 
 ferent, benefit might be far more enduring, lasting perhaps some- 
 times for the rest of the patient's life. As the matter now stands 
 between the profession and the public, the majority of women come 
 up for operation far, far too late. This is proved especially by the many 
 instances in which, after operation for mammary cancer, recurrence 
 takes place both locally and in the lymphatic glands. Indeed, it is 
 seldom possible to perform a complete operation, i.e. to remove the 
 whole of the diseased part. Ceienim censeo : we can benefit these 
 patients alone by operating on them far earlier than we are accus- 
 tomed to do at present. Granted that even this is not possible in all 
 instances, yet it is the case with many of these unfortunate women. 
 A search through my records with a view to determine the duration 
 of life after operation, shows that some died in from two to eight 
 months ; others lived from one and a quarter up to three and a 
 quarter years after operation. Seven of the forty-nine cases were 
 living when this was written, but with recurrence of the disease. 
 One was still alive with recurrence three years after the operation ; 
 while six were alive without recurrence at periods varying from 
 fifteen months to six years. I am sure that the experience of 
 other surgeons must be very much the same; still, I am firmly 
 convinced that the results would be better if the operations had 
 been performed earlier. 
 
 It appears to me that we are on most points in the dark, with 
 regard to cancer of the breast — this frequently- occurring disease. 
 It matters not whether the patients be married or single, fruitful or
 
 DISEASES OF THE MALE BREAST. 22-> 
 
 unfruitful, rich or poor, of full or slender habit, workers or idlers — 
 neither the origin nor the course of the disease appears to be aifected 
 by any of these influences. What does influence the disease? Let 
 us seek further, and we may discover. 
 
 Diseases of the Male Breast. 
 
 Chronic infiamMatory induration of ilie male breast. 
 
 A youth, set. i6, whose breasts were rather large on both sides, noticed 
 three months before admission, without any known cause, some swelling and 
 redness about the left nipple. The inflammatory symptoms lasted for about 
 six weeks and then disappeared, but the swelling remained. The left breast 
 was the size of a goose e^^, hard, nodulated, perfectly moveable, intimately 
 united to the nipple, but not implicating the skin ; very slight tenderness on 
 pressure. As the infiltration seemed to be the result of a previous inflamma- 
 tion, iodine ointment merely was applied. He came back again eight months 
 later ; there was then no distinct tumour to be seen, but the lobes of the left 
 mammary gland were somewhat harder and more easily felt than on the right 
 side ; in both axillae were some swollen, but not indurated glands. The 
 general health was very good. 
 
 Carcinoma of the male breast. {The nature, microscopical orother' 
 wise, is not stated.) 
 
 G. K — , ajt. 62, had noticed for three months induration of the right 
 nipple ; the mammary gland on that side contained several tumours, the size 
 of hazel-nuts. No enlargement of the axillary glands. The right mamma 
 was removed, and eighteen months later he was well, and free from recur- 
 rence. 
 
 S. S — , set. 68, stated that at least forty years previously, he noticed 
 that the left nipple was much indrawn ; the parts around swelled, and 
 remained painful for some weeks ; the pain and swelling then disappeared, 
 but a hard nodule the size of a pea was left, close to the nipple. Three years 
 before he was admitted, the nodule, which up till then had never occasioned 
 bim any annoyance, began to increase in size. In the left breast, the skin 
 was glazed and tense over a convoluted mass of carcinoma the size of an 
 orange ; axillaiy glands free. The breast was removed, and he recovei-ed. 
 
 In the case of A. B — , a small nodule made its appearance close to the left 
 nipple, two years before I saw him, when he was seventy-one years of age. 
 Gradually the entire mammary gland degenerated into a hard growth, the 
 
 15
 
 226 CANCER OP MALE BEEAST. 
 
 size of an egg. He died of erysipelas, following operation for the removal 
 of the tumour. 
 
 Carcinoma of the leH hreast and the axillary glands. 
 
 A. S — , £et. 42, had lived from 1848 to 1859 in Siberia, during most of 
 which time he had suffered from scurvy. In 1859 he succeeded in making 
 his escape and he then lived in his native Poland, in comfort. In the Polisli 
 revolutionaiy wars of 1867 he received several wounds. As the result of a 
 wound of the chest, he suffered for a long time from empyema. (The wound 
 was close to the left nipple and the bullet was only extracted after several 
 months.) He then lived in Berlin, subsequently in Paris, in which latter place 
 he was operated upon by Goslin for a partial empyema. 
 
 At the beginning of 1869 he noticed in the cicatrix in the left breast, and 
 also in the left axilla, some small nodules, attended by occasional severe, 
 radiating pains. The small tumoui-s increased slowly but steadily, up to the 
 time of admission ; at that time the growth in the breast was about the 
 circumference of half-a-crown, and that in the axilla about the size of a 
 small apple. The breast and the axillary tumour were removed at the end of 
 1870, and a month later he was discharged. 
 
 The man came back to me three years later with some enlarged 
 and indurated glands in the left axilla and severe pain down the left 
 arm. The glands were removed. This was in 1873. I have not 
 been able to learn the further sequel of the case. 
 
 i
 
 CHAPTEE XI. 
 
 INJURIES AND DISEASES OF THE ABDOMEN AND RECTUM. 
 
 Section A. — Injuries and Diseases of the Abdomen. 
 
 Cases of penetrating aidominal wounds. Case of rupture of abdo- 
 minal muscle. Case of injury to stomach. Case of ruptured 
 spleen — Death from other causes. Retro-i^eritoneal inflamma- 
 tion and abscess — Cases. Cases of villous cancer of pylorus, 
 ulcerating through the abdominal loalls. Encysted peritoneal 
 effusion — Cases and Remarks : three doubtful cases of same 
 affection. Case of volvulus. Cases of fibrous tumour of the 
 abdominal walls. Cases of cancer of the omentum and pelvic 
 viscera — Attempted removal. 
 
 Penetrating wounds of the abdomen. 
 
 In two cases of tolerably extensive abdominal wound, with escape of the 
 intestine, which was uninjured, the gut was replaced, the wound united, and 
 the patients recovered in a few days, without a trace of peritonitis. In a 
 third case, a woman, ajt. 27, had received a stab in the abdomen an inch and 
 a half above the left superior spine of the ilium ; here there was considerable 
 protrusion of the omentum, which could not be reduced through the wound. 
 This was enlarged, and the omentum replaced. Considerable hsemorrhage 
 came from an artery in the abdominal wall. The patient died of peritonitis 
 three days after the injury. 
 
 J. G — , ajt. 31, a convict, attempted suicide in the following manner : — To 
 the lower edge of the foot-board of his bed, he fastened a knife in such a 
 way that the point was directed downwards. Then he placed blocks of 
 wood beneath the feet, at the lower end ; he then laid down under the bed, so 
 that the point of the knife was immediately over the umbilicus, and knocked 
 away the blocks, so that the knife was plunged into the abdomen. In this 
 position he was found in the morning. The wound was united by sutures, 
 and he was sent up to the hospital. He had vomited blood once. Acute 
 peritonitis set in on the morning of the third day, and he died shortly after.
 
 228 CASES OP ABDOMINAL INJUEIES. 
 
 Poet mortem : two very small perforating wounds were found on the larger 
 curvature in the stomach ; peritoneum very hyperaemic ; very slight efEusion. 
 
 H. W — , set. 32, a very unintellectual man, was admitted with the following 
 history : — About two years previously he fell on a stake, and received a wound 
 three fingers' breadth, below the navel. He stated that some fat protnided, 
 which he cut o£E himself with a pair of scissors. The wound soon healed up. 
 The cicatrix bulged forwards to some extent, but gave him no pain. Four 
 days before admission he fell from a hay loft and struck himself on 
 the abdomen. When he had recovered, he noticed some blood on his 
 trousers. The cicatrix had been raptured, and the omentum protraded. 
 When I saw him the protrusion was granulating, he was quite free from 
 fever, and there was no trace of peritonitis. The protrusion was covered 
 with an oiled pad of lint ; gradually it shi-ank up, and was retracted into 
 the abdomen in thirty days after the injury. 
 
 This last case speaks strongly against the reposition of prolapsed 
 omentum^ while the case mentioned above shows the bad result 
 following dilation of the wound and reduction of omental protrusion. 
 
 Subcutaneous interstitial rupture of an abdominal muscle. 
 
 A strong young man, set. 22, in attempting to save himself from falling^ 
 backwards as he sprang from a cart, felt intense pain in the abdominal wall. 
 The pain persisted for some days with such severity that the patient was 
 unable to draw himself upright. In the course of a week it gradually 
 disappeared. 
 
 In the following case I diagnosed an injury of the stomach;, 
 complete recovery followed. 
 
 J. B — , a labourer, set. 38, was at work in a narrow trench about twelve 
 feet deep, the side of which fell in. The patient, who was found in a stooping 
 position, was promptly dug out, and brought up in an unconscious condition 
 to the hospital. When admitted, he was collapsed, cold, and pulseless, with 
 extensive superficial excoriations over many parts of the body, and subcu- 
 taneous extravasations on the back and the left upper arm ; the abdomen was 
 a little distended, and rather painful. Consciousness shortly returned. 
 Towards evening the patient vomited sevei-al times blood and remnants of 
 food ; this repeatedly occurred on the next day also. The vomit always 
 contained recent blood. The region of the stomach was painful on pressure. 
 Great distension for the first two days ; the hsematemesis then diminished^ 
 finally ceasing on the thud day ; the pain disappeared at the same time and 
 the distension gradually subsided entirely. 
 
 The following case of head injury may be here mentioned.
 
 EETEO-PERITONEAL CELLULITIS. 229 
 
 although the rupture of the spleen found post mortem was only of 
 secondary importance. 
 
 G. B— , aat. 43, lost his balance and fell down two flights of stairs on to 
 the pavement. He died five days after the injury, evidently from com- 
 mencing suppurative encephalitis, the result of a separation of the lamboid 
 suture, and cerebral injuries. The spleen was found enlarged to thrice its 
 normal size, and partly adherent to the diaphragm. On the upper surface 
 the capsule was torn, and the parenchyma of the organ traversed in its whole 
 thickness by a rent, full of loose blood-clot. 
 
 Erom the appearance of the rent, and the small quantity of blood 
 effused, we concluded that this injury might have healed up com- 
 j)letely. 
 
 Eetro-peeitoneal Inflammation with the Formation of 
 
 Abscess. 
 
 These are commonly called psoas abscesses (congestive abscesses 
 arising in connection with disease of the vertebral column are here 
 excluded), but the substance of the psoas muscle is seldom the 
 starting point of these inflammations. In the majority of cases, the 
 pus is formed in the retro-peritoneal cellular tissue in the neigh- 
 bourhood of the pelvis ; seldom above this level. (The disease is 
 known in England as retro-peritoneal cellulitis.) 
 
 The substance of the psoas muscle may become involved in the 
 suppuration, and the periosteum of the pelvis, with the processes or 
 bodies of the vertebrae, be partially eroded ; these changes, however, 
 are so slight in cases where the cellular tissue is primarily inflamed 
 that they can readily be distinguished after death from primary 
 periostitis and ostitis of the spinal column and pelvis. In such 
 inflammations a tolerably good prognosis can be given only when 
 they originate in connection with the puerperal state. The 
 abscesses which arise in this situation from other causes are always 
 serious, and in weakly individuals highly dangerous to life. 
 
 In the case of a child, who was in a very low condition from multiple 
 periostitis of the extremities, an attack of severe abdominal pain, accompanied 
 by flatulent distension, occurred. The umbilicus then began to bulge 
 forward, and finally an enormous amount of pus escaped through it. The 
 patient was taken away, so that I was unable to find out the source of the 
 suppuration.
 
 230 EETEO-PERITONEAL CELLULITIS AND ABSCESS. 
 
 Elizabeth K — , aet. 43, had sufEered previously from suppuration of the 
 cervical lymphatic glands, and erysipelas ; subsequently she had abscesses in 
 the sole of the right foot, below the right clavicle, and over the seventh and 
 eighth ribs. Six weeks before she was admitted, she complained of pain in 
 the right thigh, contraction of the lower limb, and abdominal swelling. On 
 examination, a retro-peritoneal tumour, the size of a man's head, was 
 discovered in the abdomen. We observed the swelling gradually descend 
 from day to day to the inner side of the right thigh. She had no disease of 
 the vertebral column. At her own request she left the hospital in this 
 condition ; then for five weeks she was compelled to keep her bed at home, 
 and sufEered for a long time from severe diarrhoea. Gradually the tumour 
 became less and less, the movements of the leg became mora free, the strength 
 returned, and she recovered completely. 
 
 It was doubtful in this case whether the collection of pus, which 
 certainly existed, made its way through the intestines and so 
 escaped during her attack of diarrhoea, or whether it was absorbed. 
 Considering the large size of the collection, the latter supposition 
 seems highly improbable. 
 
 Caspar F., aet. 33, had snfEeredfrom chronic suppuration, and periostitis of 
 one of the metacarpal bones, seven years previously. Two years later he had 
 severe pain in the pelvis, rapidly increasing to such an extent, that it 
 prevented hiTn from getting about ; both thighs were flexed. He gradually 
 recovered, and began to move about a little on crutches, and in the course of two 
 years, was able again to walk quite uprightly. For some time then he remained 
 perfectly well. A month before admission he was attacked with a severe 
 rigor, and the next day felt lancinating pains in the region of the left hip. 
 The leg again became drawn up, and he was forced to adopt a stooping mode 
 of progression ; for some few days before admission he had pains also in the 
 right hip. Eetro-peritoneal abscesses could be felt on both sides, just above 
 Poupart's ligament. These broke, and he died in consequence of the extensive 
 suppuration. Post mortem : retro-peritoneal abscesses were found on both 
 Bides, extending along the psoas up to the twelfth dorsal veiiebi-se. The 
 abscesses did not communicate with each other nor with the vertebrae, nor 
 were the bones of the pelvis diseased. 
 
 The following case, which was at one time supposed to be an 
 abscess in the abdominal wall, may here be recorded : 
 
 M. S — , tet. 68, had noticed about a month before admission, a painful 
 swelling a little to the left of the umbilicus. No cause could be assigned for 
 its commencement. At the outset it was not painful on pressure, but 
 occasioned merely some shooting pain in walking. The patient was a 
 well-nourished spare woman, and with the exception of this local trouble, 
 was in tolerable health. The tumour lay in the abdominal walls, like 
 a disc, and had almost exactly the appearance of a moderate sized boil.
 
 CANCEE OF PYLOKUS. ENCYSTED PERITONITIS. 231 
 
 I supposed that it was a case of abscess of the abdominal walls, and as 
 fluctuation was distinct at the upper part, I attempted to confirm my 
 diagnosis by making an incision. About a couple of ounces of bi'oken 
 down substance, mixed with pus and blood, escaped. The abscess refused 
 to close. Instead of pus, a thin, ill-smelling secretion escaped, and 
 the infiltration of the surrounding parts increased. The patient lost appetite, 
 and wasted. I then rather inclined to the view that it was a case of central 
 softening sarcoma of the abdominal walls. On examining microscopically 
 some of the granidations, I found undoubted elements of alveolar cancer 
 (Driisen Carcinoma). I now thought that the case must be one of gastric 
 cancer which had broken thi-ough the abdominal wall. But this view was 
 given up, inasmuch as no food ever came out through the opening. During 
 the whole course of the disease she never had any vomiting. Death took 
 place finally from exhaustion, no fresh symptoms having occun-ed to assist the 
 diagnosis. Post mortem : we found a medullary villous carcinoma of the 
 pylorus, which had made its way externally. A probe could be passed from 
 without into the stomach, yet none of the contents of the stomach had ever 
 escaped. 
 
 Uncysted peritoneal effusion. 
 
 Graf von M — , a stout, well-nourished man, set. 32, consulted me and some 
 of my colleagues in April, 1870. Unfortunately, I have no minute record 
 of the history of the case, beyond the fact that the patient had been perfectly 
 well up to three months j)reviously, and that the first symptom of the disease 
 was some fulness of the upper part of the abdomen. On examination, a 
 fluctuating tumour rather larger than a child's head was found, intimately 
 connected to the right lobe of the liver. 
 
 Two of my colleagues were of opinion that the case was one of 
 hydatid tumour^ a view which seemed to be confirmed by the pain- 
 less, though constant growth of the swelling. The circumference 
 of the liver, however, appeared to have increased with remarkable 
 rapidity for a hydatid. The distension of the abdomen, when we 
 saw him, was so great that the patient's breathing and sleep were 
 much interfered with. The functions of the bowels, too, were 
 impaired ; the patient was emaciated, and lost strength from day to 
 day, so that he was no longer able to stand. He urgently requested 
 that some decided treatment might be adopted, as, in the condition 
 that he was, he felt that he could not last long. At a consultation 
 with my colleagues, von Dumreicher and von Pitha, we decided unani- 
 mously that the case was undoubtedly one of hydatid tumour of the 
 liver. AVe agreed, also, that the patient must shortly die, unless some
 
 232 ENCYSTED PERITONEAL EFFUSION. 
 
 operation was undertaken ; at the same time we did not conceal 
 from him the risk of such a proceeding. So convinced were we 
 of the correctness of our diagnosis, that we considered an explora- 
 tory puncture to be only waste of time. To attempt a radical cure 
 with injection of iodine, seemed to us inadvisable on account of the 
 immense size of the tumour. The absorption of iodine from so 
 large a surface might have led to fatal poisoning, and the injec- 
 tion of a weak solution would have been of no avail. Simon's 
 method of double puncture with subsequent incision appeared to 
 us the best method of opening the cyst ; at the same time we were 
 gravely anxious about the large suppurating surface that would 
 thus be caused in the interior of the abdomen, fearing that febrile 
 marasmus might bring about the same result which sometimes 
 follows this method of treating ovarian cysts. The patient caught 
 eagerly at the suggestion of an operation which might probably 
 save his life. We operated on him a few days later, when his 
 condition was as follows : 
 
 The abdomen was enormously distended, especially at tlie upper part, and 
 bulged forward in a spherical form over the pit of the stomach and left lobe 
 of the liver. Fluctuation was distinct over the whole abdomen, the wave 
 being communicated upwards and downwards as well as from side to side. 
 Dulness on percussion commenced anteiiorly, laterally and posteriorly at the 
 level of the nipple, and extended over the whole abdomen. A small part 
 only below the heart, which was in its normal situation, was resonant 
 (owing to the distended stomach), and below on the left side (owing to the 
 distended intestines) : the position of the diaphragm was scarcely altered. 
 The respiratory movements did not perceptibly affect the position of the tumour ; 
 the extent of the dulness was the same, whether he lay down or stood up. I 
 made a punctm-e in a vertical line with the nipple, just below the edge of 
 the ribs, employing a highly curved trochar, which was plunged in at the 
 spot mentioned, and brought oiit again at about two inches distance. On 
 the summit of the curve in the cauula there was an opening. After the 
 stilet was removed, one of the terminal openings of the trocar was closed with 
 a plug : to the other end a long caoutchouc tube was attached, through which 
 the fluid was allowed to flow off. Thirty-eight pints were drawn off in this 
 manner. I abstained from applying any pressm-e to the abdomen, and closed 
 the opening in the canula as soon as the flow began to slacken. The next 
 day I evacuated about eight pints, and the day after that again four- pints of 
 fluid of the same nature as at the first tapping. 
 
 The fluid was found to be of a greenish-yellow colour, not trans- 
 lucent, and highly viscid. The sediment was very small in amount, 
 of a yellowish colour, and contained a few conglomerate, highly-
 
 ENCYSTED PEKITONEAL EFFUSION. 233 
 
 refracting, minute lobules, which were seen also floating about 
 singly; these were evidently the remnants of completely shrunken 
 coloured blood-cells. The fluid was faintly alkaline, and on boiling 
 was converted into a white flocculent mass. 
 
 The fluid was so markedly unhke that of a hydatid, and it was 
 so entirely different to any that I had previously met with, that to 
 my mind, the accuracy of our diagnosis seemed already to be a 
 matter of doubt. A further analysis at the chemico-pathological 
 department of the hospital yielded little more than negative results. 
 The fluid proved to be rich in albumin, and contained a consider- 
 able quantity of sugar, a little urea, and a trace of succinic acid and 
 indican. In order to make the result of our puncture agree with 
 the diagnosis of a hydatid of the liver it was necessary to suppose 
 that the animal had died, and that a secondary effusion had there- 
 upon taken place into the cyst. From the nature of the fluid we 
 might indeed have concluded that it was some exceptionally thick, 
 dropsical effusion, but there was no ascites. The manner in 
 which the growth had originated, pointed to a tumour distinctly 
 localised in the liver at the outset, or at any rate to some well- 
 defined growth. Could it be a circumscribed peritoneal effusion, 
 without a trace of pus, and where not the slightest symptom of 
 peritonitis had ever existed ? Could it be due to tubercular peri- 
 tonitis ? Such suppositions seemed in the highest degree improbable 
 in the case of a cavalry officer whose previous health had always 
 been good. 
 
 On percussing the abdomen three days later, a further puzzle 
 presented itself. All the intestines had, speaking generally, 
 returned to their normal positions. In the left hypochondrium, 
 however, was an area of dulness, the extent of the hand; close 
 above the trochar, which was still in situ, and just where the liver 
 must have been situated, was a small space, where the percussion 
 note was markedly resonant. I forbear from recording aU the 
 conjectural diagnoses and the views that were expressed. I need 
 only say that eventually we adopted our first opinion that the case 
 was one of hydatid with, however, the above-mentioned modifica- 
 tion. Accordingly, the treatment was carried further ; our idea was, 
 to leave the canula in situ for about a week ; we supposed that by that 
 time the sac of the hydatid would become united to the abdominal 
 wall; an india-rubber tube was then to be passed through the 
 canula, and after the latter had been removed, was to be fastened on
 
 234 ENCYSTED PERITONEAL EFFUSION. 
 
 the abdominal wall, and gradually tightened until it cut its way 
 through the portion of the abdominal wall which lay between the two 
 openings. The cavity during the meanwhile was to be washed out 
 daily. Our only dread, besides acute peritonitis, was lest exhaus- 
 tion should supervene from the suppuration of so large a cavity. 
 
 Of local reaction after tlie operation there was practically none ; on the second 
 day, moderate fever set in, which entirely disappeared by the sixth day, and 
 the patient then was free from fever up till the end of the fourth week. 
 On the sixth day after the operation, I removed the canula, and 
 left in a drainage tube. The opening had to be repeatedly dilated with 
 sponge tents, in order to allow the constant discharge of the secretion. The 
 nature of the fluid was different to what we had expected. It was thin, 
 seldom had any ill smell, did not become really pximlent, and ceased to be 
 discharged at the beginning of the fourth week. The tube was then removed 
 and both openings closed up shortly after. 
 
 While all this was going on, the patient was attacked with rather severe 
 bronchial cataiTh. For a while I conceived it to be possible that tuberculosis 
 of the lungs had been developing and that the abdominal affection might be 
 connected with peritoneal disease. However, the bronchial catarrh dis- 
 appeared, and after repeated examination of the thoi^ax, I gave up this idea. 
 The progress of the case after the operation, and the healing of this immense 
 cyst, wliich had evidently occupied the right side of the abdomen, gave us 
 gi'eat satisfaction : but the feeling was short lived. The abdomen again 
 began to enlarge, and repeated examinations showed clearly that the area of 
 dulness already mentioned was daily increasing in size. Shortly afterwards 
 it assumed the appearance of a rounded swelling ; at the commencement of 
 the fifth week, feverish symptoms again came on rapidly, and the general con- 
 dition deteriorated. 
 
 This new formed tumour yielded distinct fluctuation; it was 
 painless and fixed j what was it ? At a further consultation we 
 came to the conclusion that a second hydatid cyst, which must have 
 been masked by the previous one, had rapidly developed. 
 
 The swelling was punctured and ten pints of thin fluid, of the same nature 
 as on the former occasion, were evacuated. It was evidently impossible to 
 evacuate the sac entirely, as the fluid appeared to be enclosed in numerous 
 deeply situated cysts. Slight relief followed, but the patient from this time 
 forth was never entirely free from febrile symptoms. 
 
 I now abandoned entirely the idea that the case was one of 
 hydatid tumour; however, I was unable to form any other 
 diagnosis.
 
 ENCYSTED PERITONEAL EFFUSION. 235 
 
 The patient now rapidly lost strength, although he was placed under the 
 most favourahle conditions. The abdomen rapidly increased in size again, 
 especially at the lower part on the left side. I punctured again at tliis spot, 
 but did not succeed in evacuating much fluid. The fever increased, and he 
 died thi-ee months after I first saw him. 
 
 The post-mortem examination revealed chronic peritonitis, with 
 encysted serous effusions. The intestines were adherent together, 
 partly by cellular tissue, partly by fibrous bands. We were 
 unable to find any cause for the condition. My supposition that 
 the process might have been due to miliary tuberculosis, was 
 negatived by the fact that no trace of tubercle could be found 
 anywhere in the body. 
 
 The case was an obscure one, in its origin as well as in its 
 progress. Oppolzer, who has perhaps the largest experience of any 
 living physician of abdominal diseases, told me that he had never 
 seen a similar case. 
 
 With regard to the operative proceedings, it may be remarked 
 that the double puncture was unnecessary; one would have 
 been quite sufficient. It is noteworthy that the canula re- 
 mained in the abdominal cavity for a week without exciting any 
 appreciable local irritation. The punctures relieved the patient, 
 and prolonged his life, or, at any rate, did no harm. The collection 
 of fluid caused the patient so much discomfort that the two first 
 punctures must have been made, even if we had diagnosed the case 
 aright. 
 
 Rare cases seldom occur singly. Not long after I met with a 
 similar case to the above, which I was enabled to diagnose correctly, 
 and where I punctured only once. The patient, however, died of 
 exhaustion. 
 
 The four following cases were probably of the same nature, 
 though we had no opportunity of positively verifying the diagnosis : 
 
 T. M — , set. 21, a powerful man, was admitted with a prominent bulging 
 of the lower part of the abdomen, just above the symphysis pubis. On 
 palpation, a tolerably resistant tumour, the size o£ a foetal head and firmly 
 connected to the symphysis, could be felt. The swelling was painless, and 
 lay immediately behind the abdominal wall with which it was connected. 
 The bladder and the bowels acted normally, and a catheter passed easily. 
 Nothing of the tumour could be made out through the rectum. The patient 
 could state nothing positively about the origin of the tumour, which caused 
 him no trouble ; he had noticed it for about eight days, but could not say 
 whether it had developed slowly or quickly.
 
 236 ENCYSTED PERITONEAL EFFUSION. 
 
 The tumour was so markedly consistent, and its shape so 
 rounded and sharply defined, that at the first glance it was impos- 
 sible to avoid the conclusion that it was a fibroma or chondroma. 
 Taking into consideration the highly unreliable character of the 
 patient^s account, the unfavourable prospects of any operation, and 
 the absence of any discomfort, expectant treatment seemed desirable. 
 As it was thought possible that the swelling might be an extrava- 
 sation of blood between the peritoneum and abdominal wall, or 
 might be merely due to effusion, mercurial inunction was employed, 
 and warm fomentations applied. Under this treatment the tumour 
 rapidly diminished, and in a fortnight was so small that it could 
 scarcely be felt, 
 
 J. J — , a chaplain, set. 35, stated that he had sufEered for about 
 nine months from symptoms of indigestion ; occasional vomiting, and 
 attacks of heartburn were the principal symptoms. Eight months 
 before admission he had a severe attack of colic, which, according to the 
 report of his medical attendant, was complicated with peritonitis. He was 
 confined to bed for six weeks, and recovered slowly, but completely. Some 
 months before his admission he remarked a sensation of fulness in the 
 abdomen, and for a few weeks he had noticed an abnormal swelling in the 
 lower part of the belly. I found an encysted, fluctuating tumour, fully the 
 size of a man's head, in the umbilical region. Two litres of thin, dark brown 
 fluid were evacuated by means of the aspirator. jMicroscopical examination 
 of this fluid showed large numbers of granular cells, coloured blood-corpuscles, 
 crystals of cholesteiine, and gi-anular debiis. The patient was discharged 
 four days later, much relieved. Deeper down, however, a swelling was 
 perceptible, which had somewhat increased in cii'cumf erence since the puncture. 
 This swelling extended foiTvards so rapidly that the patient returned to the 
 hospital within three weeks, with the tumoui- as large as it was before the 
 operation. Puncture was repeated, and 1600 cc. of the same fluid as before 
 withdrawn. I heard a year later that the rest of the swelling had completely 
 disappeared spontaneously, and that the patient was in perfect health. 
 
 B. H — , set. 30, had noticed an increase in the size of her abdomen for 
 about a year. She had no pain, and was able, though with some difficulty, 
 to do her work. As she began to lose flesh, and some swelling of the feet 
 occuiTcd, she came under ti'eatment. The case had been diagnosed as one of 
 ovarian tumour. The abdomen was much enlarged, the circumference at the 
 level of the umbilicus being 125 ctm., and from the xiphoid appendix to the 
 symphysis pubis, 95 ctm. Examination by percussion made the diagnosis of 
 encysted peritoneal effusion highly probable ; no reason could be assigned, 
 however, for its origin. 
 
 The abdomen was punctured at several points, and altogther 2500 cc. of 
 highly albuminous, yellow, viscid fluid were evacuated. The patient was 
 then transferred to another part of the hospital, and I was unable to obtain 
 any further record of her case.
 
 VOLVULUS. FIBROMA OF ABDOMINAL WALL. 237' 
 
 Elizabeth A — , ajt. lo, was stated by her parents to have suffered from 
 typhus five weeks before her admission. Eight days before she came under 
 my care a painful swelling was remarked, extending from the umbilicus deep 
 down into the abdomen. The skin about the umbilicus was reddened, very 
 thin, and bulged prominently forward. The abscess was opened by a small' 
 incision, and about two and a half pints of thin, greenish pus escaped. 
 Convalescence was delayed by an attack of diari'hoea, but the abscess healed 
 up in about six weeks. There was still slight dulness in the neighbourhood 
 of the cicatrix when she was discharged. 
 
 Volvulus. 
 
 A woman, £et. ^g, was admitted with symptoms of severe ileus, which had' 
 existed for twenty-four hours ; she had also an inguinal hernia, which, 
 however, was found to be perfectly moveable and flaccid. The condition of 
 collapse precluded any operation, and the patient died in a few hours. Post. 
 moiiem : volvulus of the greater part of the ileum was found. 
 
 Fibrous tumour of the abdominal walls. 
 
 Josephine W — , mother of several children, was admitted with a fibroma, 
 the size of a man's head, situated in the middle line just beneath the 
 umbilicus ; the tumour had commenced nine months previously, when she 
 was thirty-four years old. The patient had been confined five months 
 before admission. The growth of the tumour had been particularly rapid 
 during the pregnancy. I removed the tumour, separating the thin layer of 
 the peritoneum over a space the size of the palm of the hand, from its under 
 surface. lifo recun-ence had taken place nearly four years after. 
 
 Emilie E — , set. 24, the mother of several children, had a fibroma which 
 had commenced two years previously. The tumour was the size of a fcetal 
 head and situated just to the right of the umbilicus. A small portion of the 
 peritoneum was cut away in removing the growth. Four and a half yeai"s 
 later, she had no recurrence. 
 
 Etiologically it is worthy of note that these fascial tumours were 
 nearly always observed in women who had been several times 
 pregnant. 
 
 Carcinoma of the omentum and the pelvic viscera. 
 
 Two cases of this nature came under observation, in women aged 
 respectively twenty-eight and forty-one. In one case, the tumour
 
 238 CANCER OF OMENTUM AND PELVIC VISCEEA. 
 
 was correctly diagnosed to be situated in the omentum ; in the other, 
 no precise diagnosis could be formed. In both there was marked 
 ascites. Both cases were operated on, the operation in each 
 instance lasting about two hours. One of the patients died of 
 anDemia in eighteen hours, the other was carried off by peritonitis 
 in six days. The entire peritoneum, the superficial surface of the 
 intestines, ovaries and uterus, were studded with small nodules, 
 whose existence was of course only revealed on the removal of the 
 large omental tumour, which was universally adherent. The peri- 
 toneum becomes involved so rapidly in such cases, that there is no 
 hope of removing all the diseased parts completely, by operation; 
 even if this were possible, there would be no prospect of any lasting 
 benefit. In fact, these cases are so utterly hopeless, that were I, as 
 the result of a mistaken diagnosis, to meet with another, I should 
 at once close the wound. 
 
 Section B. — Hernia. 
 
 Hernia of the umbilical cord — Cases. Umbilical hernia and con- 
 genital /cecal JisUtla. Ventral hernia. Phrenic hernia. Case 
 of incarcerated ventral hernia; death. Case of internal 
 strangulation; abdominal section; death — RemarJcs. Cases 
 with symptoms of strangulation ; inflamed empty hernial sac ; 
 hernia pnrulenta ; peritonitis from typhus (.?) ulcer; strangulated 
 testis. Case of umbilical hernia ; gangrene of gut. Remarks 
 on strangulated hernia : treatment. Case of f cecal and vesical 
 ■fistula after femoral hernia. Case of facal fistula after hernia : 
 ditto, treated by plastic operation. Case of artificial anus 
 cured by enterotome. Case of strangulated vermiform appendix. 
 Case of femoral Littre's hernia. General remarks on strangu- 
 lated hernia. 
 
 Hernia OF THE Umbilical Cord. (Nabelschwurhernia). 
 
 Two cases of this nature occurring in new born children came 
 under treatment ; one child recovered perfectly, the other died of
 
 UMBILICAL HERNIA. 239 
 
 incarceration. These are the first two cases in which I had the 
 opportunity of observing the natural process of healing of this 
 malformation, as described at length by Eose. In neither case was 
 anything done, beyond applying a pad of oiled linen and a compress 
 so as to protect the hernia from external injury. In the first case 
 the hernia was as large as a good-sized apple ; the portion of the 
 umbilical cord (vagina funiculi umbilicalis) overlying the intestine 
 dried up in the course of ten days. By this time the protruding 
 intestine was covered by fibrinous adhesions, which gradually 
 changed to a granulating surface. The subsequent shrinking and 
 cicatrisation brought about the gradual reduction of the intestine. 
 Eventually, a cicatrix about the size of a florin was left at the 
 umbilicus, over which a flat pad and compress were fitted. 
 
 The second case was that of a very weakly child, in whom the 
 hernia was of a pyriform shape. On the thirteenth day the patient 
 was attacked by severe vomiting and died shortly after. Rokitansky, 
 who was present at the post mortem, gave as his opinion that death 
 was caused by incarceration of the hernial tumour, and that this 
 incarceration was due partly to the contraction of the cicatricial 
 granulating tissue, partly to the contraction of the umbilical 
 ring. 
 
 Umbilical heenia. 
 
 These cases were treated by the application of a pad, kept in 
 position by plaster. 
 
 A child fourteen weeks old was brought to us with a congenital 
 fpecal fistula, connected with the intestine at the umbilicus. At this 
 point an invaginated loop of intestine, half an inch in length pro- 
 truded. Faeces rarely or never passed through the fistula, and the 
 bowels acted naturally every day. The child was very much 
 emaciated. I fancy that this was a case where an intestinal diver- 
 ticulum remained open at the umbilicus. I ligatured the protruding 
 portion and removed it; no peritonitis followed. The bowels con- 
 tinued quite regular. My idea was, as soon as the ligature came 
 away, to attempt the closure of the fistula, but as the child was 
 very weakly, the parents took it away from the hospital, and it died 
 soon after; unfortunately no post mortem could be obtained. 
 (See next page, Pig. i6).
 
 240 CONGENITAL FMCAL FISTULA. VENTRAL HERNIA. 
 
 Fig. i6. — Congenital fxcax fistula connected with an Intestinal 
 
 DivEKTicuLnr. 
 
 Ventral hernia. 
 
 In the case of a child, aet. 8, a ventral heniia formed, just above Poupart's 
 ligament, pnsHng through the cicatrix of a previously existing deep 
 ulceration of spontaneous origin. 
 
 Fhrenic hernia. 
 
 A diaphragmatic hernia was met with accidentally in making a post mortem 
 on a man, set. 55. Through a round, smooth-edged aperture, the size of 
 the hand, on the right half of the diaphragm, part of the liver and several 
 loops of the small intestine, projected into the right pleural cavity. There 
 were no Bymptoms during life.
 
 VENTEAL HERNIA. INTERNAL STRANGULATION. 241 
 
 Ventral hernia with sym/pioms of sir angulation and ckronie 
 peritonitis. 
 
 Friderike C — , set. 43. Twenty years previously she gave birth to her first 
 and only child. Shortly after the confinement she noticed a soft, reducible 
 tumour, the size of a hen's egg, close to the umbilicus on the left side. During 
 the succeeding twelve months the tumour became constantly larger. Ten 
 years later, symptoms of incarceration occun-ed ; the abdominal hernia became 
 in-educible, and the patient was operated on by Pi-of . von Bruns in Tiibingen. 
 The hernia came back after the operation, but for a long time was reducible. 
 The patient neglected to wear her bandage, and went back to a rather 
 laborious occupation : the tumour then became gradually larger and larger. 
 During the last few months, before she came under our care, it had been 
 painful and iiTeducible. Four days before she was taken into the hospital, 
 she had severe abdominal pain, vomiting, and constipation. The patient was 
 a veiy spare, thin woman ; when admitted the pulse was very small, and the 
 temperature low. A ventral hernia, larger than a man's head, existed close 
 below and a little to the left side of the umbilicus. The swelling was in 
 part resonant on percussion. Opium was given and attempts made to replace 
 the tumour without success ; the vomiting continued. I therefore made an 
 Incision thi'ough the abdominal walls, into the upper border of the tumour. 
 Immediately on making this incision, an enormous amount of the fluid 
 contents of the small intestine escaped from a long loop of gut, which was 
 adherent to the edge of the opening. None of the fluid, however, escaped 
 into the abdominal cavity, as the portion of intestine opened was universally 
 adherent to the abdominal wall. It was found impossible to examine further 
 the state of the parts, for the intestines were everywhere inseparably matted 
 to each other or to the hernial sac. The intestinal fistula, which I had unin- 
 tentionally formed, I left open. Slight improvement followed the operation 
 for a while, but then collapse ensued, and she died five days later. Post 
 mortem : no exact explanation of the incarceration could be made out, but 
 all the intestines were united into a convoluteci mass, adherent everywhere 
 to the omentum and the abdominal walls. 
 
 Internal strangulation. Ahdoininal Section. 
 
 J. H, set. 24, a vigorous, strong man, was seized suddenly, without any 
 known cause, with severe abdominal pain, followed shortly by vomiting. 
 These symptoms kept on increasing, and no action of the bowels took place. 
 Six days after the commencement of the illness, the patient was brought 
 up to the hospital with all the symptoms of ileus. He stated that as a child 
 he had an inguinal hernia on the right side, but that of late years he had 
 never noticed it. No trace of hernia could be found in the right inguinal 
 region. Inasmuch as opium, clysters, poultices to the abdomen, etc., had 
 already been employed and the patient's condition was evidently beyond cure 
 
 16
 
 242 ABDOMINAL SECTION FOR INTERNAL STRANGULATION. 
 
 by internal medicine, I proposed an operation, to whicli the patient gladly 
 assented. As there was a chance that the formerly existing hernia might he 
 strangulated in the right inguinal canal, an incision was made through the 
 skin in this region. On dissecting down, a hernia sac indeed was found, but 
 it was empty. The abdominal wall was next slit up as far as the internal 
 opening, but no strang\ilation was there found. I introduced my finger 
 deeply, but could feel nothing abnormal. I then carried up the incision 
 through the abdominal wall, fii-st two, then four inches above the internal 
 ring, and, exposed some very red and distended intestine. The gut was 
 pressed to one side, and after some search, it was found that a tolerably long 
 loop of intestine had slipped through a hole in the mesenteiy, and had thereby 
 become strangulated. In attempting carefully to di-aw back the loop of 
 intestine, I tore it at the strangulated spot. The faeces escaped through an 
 opening about the size of a shilling, but we managed to prevent aU but a 
 reiy small portion fi'om escaping into the abdomen. I then enlarged the 
 opening into the mesentery, and carefully di-ew back the entire loop. Except 
 at the ruptm-ed spot, this coil of intestine was not materially injured. The 
 abdominal cavity was washed out, and the portion of intestine in which the 
 opening lay was united to the abdominal wall in such a way as to allow the 
 contents to escape externally. Although the patient was reduced to an 
 extremely weak state, the vomiting ceased, and the distension subsided 
 entirely. The faeces passed out through the fistula. Unfortunately, two or 
 three days after the operation, phlegmonous inflammation commenced about 
 the wound, the result, as was afterwards discovered, of the sloughing of the 
 abdominal fascia. Partial gangrene followed with collapse, and he died nine 
 days after the operation. Post mortem : extensive fibrous adhesions were 
 found, chiefly in the right side, which connected the folds of intestine together. 
 The open part of the intestine was united to the abdominal wall. 
 
 Although this case ended fatally, yet it has more encouraged than 
 deterred me from similar operations. I think now that I committed 
 a great error at the outset, in making my incision for the laparo- 
 tomy in the side, and still more, of continuing it in that region. 
 Such an incision would have been quite proper, on the supposition 
 that the strangulation was situated at the internal abdomiDal riug. 
 But as soon as this idea was shown to be incorrect, it would have 
 been better to have made a new incision in the linea alba. The 
 lateral wound throughout the muscular abdominal wall, the conse- 
 quent haemorrhage, and especially the difficulty of uniting the incision 
 by sutures, together with the pressure which had necessarily to 
 be exerted on the wound, were all conditions very unfavourable to 
 rapid healing. Cases occur from time to time where all the sym- 
 ptoms point to severe ileus, and yet spontaneous recovery takes 
 place. In such the diagnosis may be very difficult. Bearing in
 
 CASES SIMULATING STEANGULATED HEENIA. 243 
 
 mind the striking results of ovariotomy, I think we ought undoubt- 
 edly to decide on laparotomy more frequently in these eases. 
 Enterotomy above the strangulated point is a very unsatisfactory 
 operation, and has not fulfilled the expectations that were enter- 
 tained of it. 
 
 Cases in which symptoms of strangulation were present though no 
 strangulation existed. 
 
 S. W — , set. 43, had noticed a small tumour in the riglit gi'oin for about 
 twenty years. Fifteen years previously the tumour became very painful on 
 one occasion and she had severe abdominal pain and vomiting. The tumour 
 was reduced by a medical man and the pain and vomiting ceased ; however, 
 she did not take to wearing a truss. The day before her admission into the 
 hospital she was seized with violent pain in the tumour, vomiting and con- 
 stipation. Unsuccessful attempts were made before and on her admission to 
 reduce the tumour by taxis. The swelling was about the size of a walnut, 
 very hard and painful, and situated in the right f emoi-al region. Herniotomy 
 was perfonned ; the hernial sac was so fibrous and thickened that at first I 
 thought it was the uteras. At length I succeeded in opening up a small 
 cavity lined by a smooth, serous membrane, containing nothing. It proved 
 to be an empty hernial sac, the walls of which were fully half an inch in 
 thickness. A ligature was placed around the sac, and it was removed. The 
 symptoms of incarceration disappeared and the patient recovered. 
 
 Another case of the same sort is the following : 
 
 A. H — , set. 24, had suffered from lancinating pain on the left side of the 
 abdomen ever since her first pregnancy, which happened when she was twenty 
 years of age. Six days before her admi«sion to the hospital, she was seized 
 with severe pain in the abdomen, which, however, diminished during the 
 next two days, so that she was able, though with some effort, to continue her 
 work. Three days after the commencement of the symptoms, she was forced 
 to take to her bed. She had a constant inclination to vomit. Two days before 
 admission, the bowels acted after an enema. On her admission we diagnosed 
 a small, strangulated femoral hernia on the left side, with much flatulent 
 distension. .Taxis was attempted unsuccessfully. Herniotomy was performed, 
 but we found that the tumom- consisted only of a thickened and inflamed 
 empty hernial sac with a very narrow cavity. Kecovery followed its ligature 
 and removal. 
 
 The third case, almost exactly similar, occurring in the person of 
 a woman set. 68, illustrates well the fact that inflammation of an old
 
 2U CASES SIMULATING STRANGULATED HERNIA. 
 
 hernial sac may present symptoms indistinguishable from those of 
 strangulated intestine.^ 
 
 J. M — , set. 50, had had a small femoral hernia on the left side as long as 
 she could remember ; the rupture had always been easily reducible, and she 
 had never worn a truss. Four days before her admission the hernial tumour 
 became painful, and she had symptoms of incarceration of moderate severity. 
 Herniotomy was performed, and the hernial sac, on being laid open, was 
 found to contain nothing but a tablespoonful of thin pus (hernia purulenta). 
 
 Caspar G — , set. 32, had sufEered for along time from a reducible inguinal 
 hernia of the left side. For many years he had sufEered from constitutional 
 svphilis, and two years previously had some ulceration of the rectum, which 
 led to the formation of fistula. Fifteen days before his admission he was 
 attacked with violent pain in the abdomen, which rapidly ran on to peri- 
 tonitis and was attended by severe vomiting. The hernia was perfectly 
 movable ; the lower part of the abdomen was especially painful, and it was 
 fi-om this part that the pain originated. As the vomiting and all the other 
 symptoms increased, I thought that I had better attempt to discover, as there 
 seemed but little hope otherwise, whether there might be some strangula- 
 tion in the intestine at the internal abdominal ring, or in its neighbourhood. 
 I therefore performed herniotomy, and gradually extended the incision 
 upwards through the abdominal wall, but could feel nothing on exploration 
 with my finger. A large quantity of peritoneal efEusion escaped. Death 
 occuiTed the day after the operation, the fourth after the commencement of 
 the peritonitis. Post mortem : an ulcer the size of a thaler was found on 
 the ileo-colic valve, close to which was a perforation ; it was at this point 
 that the peritonitis had originated. Professor Griesinger pronounced the 
 lesion to be a slowly progressing typhus ulcer. Subsequent inquiries proved 
 that a few weeks before his admission he had suffered for some time from 
 weakness and diarrhoea, accompanied by slight malaise. 
 
 Probably this was a case of typhus ambulans levissimus. It is 
 conceivable, however, that it may have been a very rare instance of 
 a syphilitic ulcer in the cnecum. Some nodules of fatty, degenerated, 
 and dry broken-down tissue were found in the spleen, which may 
 possibly also have been of the nature of syphilomata. 
 
 Jacob W — , aet. 30, had suffered for fifteen years from an inguinal hernia, 
 on account of which he had always worn a truss. About five months before 
 admission he had broken his trass, and since that time it had kept the hernia 
 
 ^ It seems as if all the symptoms of strangulation as we commonly know 
 them, may occur when any of the abdominal contents pa.ss into the hernial 
 sac, i.e. all these symptoms, vomiting, constipation, abdominal pain, etc., 
 arise when the lesion affects any part supplied by the abdominal sympathetic 
 nerves. [Ed.]
 
 STRANGULATED UMBILICAL HEENIA. 245 
 
 up but imperfectly. He had noticed also for half a year that the right testis, 
 which was always rather higher than the left, had gi'adually increased in size-, 
 though without giving any pain. However, he had never submitted to any 
 treatment for this complaint. About eighteen hours before admission he 
 was attacked with violent pain in the lower part of the abdomen ; he sent for 
 a medical man, who gave him a mixture. The griping pains diminished after 
 this, but still persisted in the right side in the neighbourhood of the hernia. 
 The patient lost appetite, and on the morning of admission he had severe 
 vomiting. When admitted he had an inclination to vomit. All the symptouis 
 seemed to point to strangulated hernia, although it was noticeable that the 
 right testis could not be properly separated from the hernial tumour. Taxis 
 was tried ineffectually. Herniotomy was performed and the hernial sac was 
 found to contain only the strangulated testis, degenerated to a soft pulp. 
 This was removed and recovery followed. 
 
 Umbilical hernia. 
 
 A stout, strong woman, set. 54, was admitted with a moderate-sized hernia, 
 which had been strangulated for twenty-six hours. She had no pai'ticular 
 pain, and the case was not at first regarded as serious. Taxis was tried in- 
 effectually after she had been in a bath for an hour, and then, under an anas- 
 sthetic, herniotomy was performed. The hernia consisted of a loop of 
 intestine completely gangrenous, and a portion of the omentum of a reddish 
 grey colour. I did not replace the omentum, but merely laid open the intes- 
 tine. For the first two days all went on well, but then vomiting and disten- 
 sion began ; very little escaped from the artificial opening in the intestine, 
 and nothing at all passed by the rectum. Death followed four days after the 
 operation. At the post-mortem examination, the coils of intestine lying in 
 the umbilical region were found extensively matted together, as well as to 
 the omentum and the abdominal wall. The strangulated portion of intestine- 
 was so much bent upon itself that the escape of f seces at the artificial open- 
 ing was materially interfered with, even after the operation. 
 
 Strangulated Heriqia. (Z. B.) 
 
 The number of herniotomies has diminished from year to year^ 
 since the more extended employment of chloroform has allowed 
 increased facilities for taxis. 
 
 In sixteen cases of herniotomy^ for strangulated inguinal hernia, 
 attempts were made to replace the gut in every instance without 
 opening the sac; in one instance only, that of a woman, did the 
 endeavour succeed. In one case it was found impossible to reduce 
 
 ' At Ziii-ich.
 
 246 STRANGULATED HERNIA. CASE OF F^CAL FISTULA. 
 
 the intestine after division of the abdominal ring and the neck of 
 the sac ; the intestine was then punctured, but still reduction could 
 not be effected. On extending the incision upwards, the loop of 
 intestine (caecum) was found twisted on its axis; death followed. 
 One well marked case of a so-called Littre's hernia was met with, 
 and in one instance the hernia consisted of the bladder. We know 
 only too well that, as a rule, people with strangulated hernia come 
 too late to the hospital, even when they have had proper advice from 
 their medical attendants. The usual practice at Ziirich, in cases of 
 strangulated hernia, is to place the patients at once in a warm bath, 
 and keep them there for an hour ; then they were placed under 
 chloroform, and if taxis was unsuccessful, herniotomy was at once 
 performed. 
 
 In three cases only, out of seventeen operations for strangulated 
 femoral hernia, was it found possible to reduce the hernia without 
 opening the sac. Among the cases of recovery, an interesting 
 instance is noted, where the Fallopian tube was found in the hernial 
 sac on the right side. 
 
 F(Rcal fistula after operation for strangulated hernia. 
 
 In tlie case o£ a man, jst. 40, a faecal fistula formed, after operation for 
 strangulated femoral hernia ; the gut was found to be gangrenous, and a por- 
 tion of the intestinal wall afterwards sloughed. In the course of the next 
 three months the fistula diminished in size, but would not close. The faeces 
 all passed thi-ough the fistula. Attempts to completely close the opening with 
 a pad could not be borne for any length of time, and the bandage became 
 detached by the forcible discharge at the end of twenty-four hours. On exa- 
 mination, a valvular formation was found on the posterior wall of the intes- 
 tine, and above this, marked stenosis where the gut had been partly destroyed. 
 My assistant. Dr. Eis, devised a most ingenious apparatus, whereby the 
 protruding fold was so pushed back that the fseces, in part, were able to pass 
 through the rectum. Further than this I could not get by the employment 
 of this appai-atus. I dilated the fistula with laminaria and divided Poupart's 
 ligament in order to be able to ascertain the condition of the parts as clearly 
 as possible, but I could not succeed sufficiently to be able to apply the 
 ent^rotome with proper certainty. I had a suspicion that the fistula was con- 
 nected with the sigmoid flexure, since the fajces were not of the consistence 
 which might be expected if they came from the small intestine. In order to 
 ascertain the time that it would take for some injected milk to pass, we threw 
 in some with a catheter into what we supposed was the lower portion of the 
 intestine. An hour afterwards the whole of the milk was passed by the ure- 
 thra. Xow, on examining the bladder, we found that there was a vesical,
 
 CASES OF ¥MCAL FISTULA. 247 
 
 as well as an intestinal fistula, althougli during a period of tlirce months not 
 a drop of urine had passed through the fistula. This, therefore, had been a 
 case where the hernia was vesical as well as intestinal, and where a portion 
 of the bladder and intestine had become gangrenous from the strangulation. 
 The patient became gradually weaker and died five months after the opera- 
 tion. Post mortem : a well-marked stricture was found in the small intes- 
 tine, at the point where the fistula existed. The process of the bladder 
 protmding from the side, like a diverticulum, opened close to the intestinal 
 fistula. This process was closed by a valvular fold of mucous membrane. 
 
 Fcecal fistula. 
 
 Martin W — , set. 65. Two years before he came under my care, the patient 
 had allowed a ' rupture cutter ' (Bruchschneider), whose name he would not 
 reveal, and who was not a qualified man, to perform a radical operation for a 
 large scrotal hernia of the left side. According to the patient's account, the 
 entire hernial sac, together with the scrotum and testis (the left testis was 
 absent), was encircled by a ligature, cauterised, and allowed to slough off. 
 The patient survived this proceeding, but afterwards a tumour bulged for- 
 wai'd in the wound ; this the operator pronounced to be an abscess, and 
 opened it ; however, no pus came, but gas and thin faecal fluid escaped. The 
 wound healed, but the fistula persisted, though there was but slight discharge 
 from it. When he came under me two years later I found an enormous 
 hernia on the left side, partly inguinal and partly ventral. The bowels acted 
 regularly, and very little discharge took place from the fistula. A suitable 
 bandage was applied, and the fistula healed up in five weeks. 
 
 Carl W — , set. 28, stated that fourteen years before admission a swelling 
 formed in the right iliac region ; it broke spontaneously, and pus and faeces 
 escaped. The opening thus left contracted at times, and then again enlarged. 
 For two years it had closed up altogether but broke open again ten years 
 before his admission, as he was lifting a heavy weight. Suppuration about 
 the abdominal walls followed, leaving numerous sinuses ; these latter had 
 been laid open, but no operation had been undertaken, or attempt made to 
 cure the faecal fistula. For five years the patient had worn a linen plug and 
 a firm compress on the opening, which had closed it veiy effectually. I found 
 an opening in the abdominal walls close to the caecum, about an inch and a 
 half in length and three quarters of an inch in breath. This I closed by 
 turning down a flap from above, applying the epidermal surface to the mucous 
 membrane of the intestine. The central portion of the flap healed, so that 
 the fistula was bridged over. Unluckily the patient would not submit to 
 any further operative proceeding, and left incompletely cured. I have no 
 doubt that I should have succeeded ultimately in closing the fistula. 
 
 Katherine W — , set. 39. In this case an unbilical hernia had formed at the 
 patient's first confinement, sixteen years previously ; during subsequent preg- 
 nancies it increased in size, and became irreducible. Dm-ing her eleventh
 
 248 STRANGULATED APPENDIX GMGl. FEMORAL HERNIA. 
 
 pregnancy, the hernia became incarcerated, and she had symptoms of ileus 
 and severe peritonitis. Gangrene of the gut followed, leading to the forma- 
 tion of a fsecal abscess at the umbilicus, through which subsequently all the 
 f seces passed. In spite of this terrible mishap, she was delivered at the proper 
 time of a healthy child. The faecal fistula remained, however, after the 
 confinement, in the same condition as before. Dr. Menzel succeeded, after 
 repeated careful examinations, in discovering the upper and lower openings in 
 the intestine and determining the position of the intermediate portion with 
 such accuracy that we were able to apply the enterotome. After four houi-Sj 
 however, the instrument had to be removed, owing to the severity of the pain. 
 A week later the enterotome was again applied ; it came away in twenty-four 
 hours and a few shreds of tissue were found between the blades ; five days 
 later it was again applied ; in the evening severe abdominal pain occurred, 
 which, however, was completely relieved by moi-phia injections. During the 
 next three days, the instrument was applied more firmly, again giving 
 much p&in, which did not last long. Five days after the last application 
 the enterotome came away, enclosing a portion of mucous membrane. The 
 fistula was then carefully closed by a pad and compress, and three days later 
 the first natural motion passed which she had had for eleven years. When 
 she was discharged a few days later, the fistula was very small and nothing 
 escaped from it. A few months later it had completely closed. 
 
 One remarkable case, where the processus vermiformis degene- 
 rated into a cyst, was strangulated, is described by Dr. Wolfler in., 
 the *Arch. f. kl. Chir./ Bd. xxi, p. 432.^ 
 
 Temoral Hernia. 
 
 In two cases, where simple taxis was successful in reducing the 
 hernia, a fatal result ensued. In one of the patients, rapid collapse 
 and cyanosis came on four hours after the taxis. Post mortem : 
 it was found that the intestine had been torn at the strangulated 
 part. The hernia had been strangulated for five days ; the symptoms 
 were not particularly severe, there was no peritonitis and the hernia 
 gave scarcely any pain. Very moderate taxis was sufficient, without 
 the use of any aneesthetic. Death was due to fsecal extravasation 
 into the abdominal cavity. In the other case, the patient was 
 admitted with severe peritonitis. The hernia was very easily 
 replaced, but the vomiting persisted, and the patient died of col- 
 lapse fourteen hours after the taxis. Post mortem : the case was 
 
 ^ Mr. Pick has recorded a similar case which occurred in his practice at St; 
 George's Hospital, in the ' Lancet,' No. xxi, vol. i, 1880, p. 801. [Ed.]
 
 STRANGULATED HERNIA. HERNIOTOMY. 249^ 
 
 found to be one of Littre's hernia, with the gut in a gangrenous 
 state. 
 
 Strangulated Hernia. (W. B.) 
 
 Between i860 and 1876, 164 cases of strangulated hernia came 
 under observation (89 males, 75 females). In 89 instances the 
 hernia was reduced by taxis, without operation. Two patients died 
 after taxis. In 73 cases herniotomy was performed, with 35 recove- 
 ries and 38 deaths. The number of cases successfully treated by 
 taxis ought to be rather larger than the above figures show ; a 
 number of persons who came up to the clinic immediately on noti- 
 eing symptoms of strangulation were not kept in the hospital, but 
 were furnished with trusses and sent back home again after the 
 reduction of the hernia. In the majority of these patients ineffec- 
 tive attempts at taxis had been made before they came to us. Often 
 enough the symptoms had existed for several days. This explains 
 the unfavourable result in some cases : thus in five of the patients 
 operated on, the hernia was found completely gangrenous, and in 
 two cases, where taxis was employed, gangrene had set in. 
 
 Formerly I always followed the advice given to me by my 
 teachers, and in performing herniotomy avoided, if possible, opening 
 the sac. I have often succeeded in so doing, but I never found that 
 it had any material influence on the subsequent result. As regards 
 injuries to the peritoneum, our ideas have become materially modi- 
 fied ; we no longer apprehend any direct danger to life from injury or 
 wound, but rather from septic infection of the peritoneum, a mem- 
 brane from which the poisonous material is readily absorbed into 
 the blood. Now I have repeatedly satisfied myself that the sero- 
 sanguineous faintly-smelling fluid, such as is commonly found in 
 the sac in herniotomies, frequently contains bacteria. I have been 
 able to convince myself of the septic properties of this secretion, by 
 the infection of a small wound on my own finger, and by the inocu- 
 lation of a rabbit's cornea. Every surgeon will admit the extreme 
 difficulty of judging accurately of the condition of a hernial loop of 
 intestine, or a protruding portion of omentum, by the colour. We- 
 know now that during the intermediate stages of an inflammation of 
 a tissue, going on to gangrene, septic products are formed ; these 
 products have infective properties. We can scarcely wonder, there- 
 fore, if, after replacing a semi-gangrenous coil of intestine, the peri-
 
 250 PERFORATING ULCER OP RECTUM. 
 
 toneum becomes infected and septic peritonitis is set up, wliich, 
 previously, in all probability could not have taken place. Much of 
 course depends on the firmness and extent of the fibrinous adhesions 
 shutting off the herniated part from the rest of the intestine. On 
 this account I consider it, therefore, far better to open the sac on all 
 occasions, to let out the fluid, and then to disinfect the protruding 
 strangulated intestine by careful washing with carbolic acid. This 
 should be done before the constriction is divided. The intestine 
 should then be allowed to slip in, care being taken to avoid, as far 
 as possible, cramming it back, or pushing it too far into the 
 abdominal cavity with the fingers. 
 
 Section C. — Diseases of the Eectum. 
 
 Case of perforating ulcer of rectum. Atresia ani. Case of fistula 
 in ano. Operations for fistida in ano. Case of prolapsus 
 recti. Treatment of hcBmorrhoids. Removal of rectum for 
 cancer. Case of malignant stricture of rectum. Case of 
 permanent recovery after removal of rectum. Cancer of 
 rectum — Treatment. 
 
 Perforating rilcer (?) of the rectum ; death from septicemia. 
 
 Fmn^ois J — , set. 43. As far as could be made out from this man's account^ 
 he had suffered for ten days fi'om pain in the peiinseum. He had never had 
 any difficulty in mictuidtion, but had been troubled at times with hasmor- 
 rhoids. Though a strongly built man, he was in a weak, apathetic state 
 when admitted, with sunken features, rapid, small pulse, and low tempera- 
 ture. The parts in the neighbourhood of the rectum and perinceum, and the 
 posterior part of the scrotum were gangrenous. The urethra and the bladder 
 were normal, and nothing wrong could be felt in the rectum, though this 
 examination gave him a good deal of pain. Incisions were made into the 
 gangrenous part, and difEused purulent infiltration of the cellular tissue 
 found everywhere. He died on the fourteenth day of septicaemia. The post- 
 mortem report was as follows : — " On the right side, in the neighbourhood of 
 the rectum, an irregular suppurating area, the size of the fist, extending back 
 to the base of the bladder. The skin of the penis highly oedematous, and 
 infiltrated with pus ; the urethra perfectly normal. Two centimetres in 
 front of the gangrenous portion of the urethra an abscess in the coi-pus caver- 
 nosum, about the size of a walnut, containing dark foul pus. Urinary 
 bladder normal. In the rectum some hsemorrhoidal tumours of moderate size ;
 
 ATRESIA ANI. FISTULA IN ANO. 251 
 
 at one point a round opening, two millimetres in diameter, ending in a stel- 
 late-shaped cicatrix, leading to the above-mentioned suppurating area. A 
 little above this, another opening, leading to the same point." 
 
 Atresia ani. 
 
 A child three days old was admitted with enormous distension and icterus. 
 The lower end of the rectum could not be found ; an artificial anus was made 
 in the sigmoid flexure. The child died nine days after the operation. 
 
 Fistula in ano, treated hy g alvano- cautery . 
 
 This was the case of a very wi-etched, ansemic woman, about thirty years of 
 age, who had suffered from haemoptysis, and had at the time of operation, a 
 considerable amount of bronchial cataiTh. She had also had repeated attacks 
 of peritonitis. I had twice declined to operate, on account of her weakly con- 
 dition. She had three moderately long fistulse, which occasioned her such 
 intensely severe pain (a symptom which hitherto I had very rarely seen) that 
 she was constantly seeking advice. The pain was only partially relieved by 
 morphia suppositories, and the administration of this drug caused headache and 
 vomiting. At last I decided to divide the fistula carefully with the galvano- 
 cauteiy. I succeeded in doing this without the loss of a single drop of blood. 
 It was some time, however, before the wound healed and the patient then 
 returned home free from pain. 
 
 The frequency of affections of the rectum, especially of fistula in 
 ano, in Vienna, was to me a matter of some surprise. I was 
 struck, also, with the number of cases in which this disease was 
 combined with tuberculosis of the lungs. I had not met with this 
 previously either in Berlin or at Zurich, and it was only in Vienna 
 that I was first able to appreciate the advice of the older surgeons 
 to abstain from operating on fistulse in tubercular cases. Judging 
 from the small, short fistulse, which I had previously met with 
 once in a way, such counsel had seemed to me excessive pedantry. 
 The geographical distribution of surgical diseases is far more 
 irregular than any one who had always practised in one locality 
 would suppose. 
 
 Fistula Eecti et Ani. 
 
 Of fifty-eight cases met with at Vienna, nine were operated on 
 with the galvano-caustic wire loop. In two the fistulas were com- 
 plicated by moderately tight stricture. These were divided, and
 
 252 PROLAPSUS EECTI. TEEATMENT OF HEMORRHOIDS. 
 
 dilated by bougies. One woman died of erysipelas after this 
 operation. 
 
 All my cases of fissure (seven) recovered after cauterisation with 
 nitrate of silver and application of zinc ointment, except one, 
 where the condition returned as before. 
 
 Prolapsus recti. 
 
 A woman, set. 33, had a prolapse of the rectum, which descended sometimes 
 when the bowels acted, to the extent of three inches ; she had some difficulty 
 in reducing it. I applied fuming nitric acid to the prolapse over four strips 
 of the mucous membrane, in a longitudinal direction, each a finger's breadth. 
 The patient was discharged in three weeks ; the prolapse then no longer 
 descended when the bowels acted. Fifteen months later the patient wrote 
 that the prolapse had unfortunately returned to some extent, though it was 
 not so bad aa before. On the whole she felt much better. 
 
 From this it may be seen that in such cases the effect of the 
 fuming acid is not sufficient. In two cases treated by the actual 
 cautery, I learned four years after the operation that the cure had 
 been effectual. 
 
 H^MOERHOIDS. (W. B.) 
 
 The frequency of this affection is very unequally distributed 
 throughout the world. It is very common among the Slav popu- 
 lation, especially the Gallician Jews ; even youths often suffer, and 
 are so reduced by the loss of blood that at times operation is 
 imperatively necessary to save life. In ten cases which came under 
 my treatment in 1869-70, 1 adopted the method of cauterisation 
 with the wire loop, which has been so successfully employed by 
 von Langenbeck. One of these patients I saw after the lapse of a 
 year, and was able to satisfy myself of the permanency of the cure. 
 It can be easily understood than when a tendency to obstruction is 
 associated with these hsemorrhoidal protrusions (which is more 
 rarely the case than one might think) it cannot be removed by the 
 operation. I usually removed the haemorrhoids by means of the 
 galvano-cautery. The patients were narcotised and placed in the 
 same position as for the other methods of operating. The tumour 
 was then drawn forward by forceps, and cut through as slowly as 
 possible with the galvano-caustic loop, which ought scarcely to be
 
 TREATMENT OF HJIMOEEHOIDS. 253 
 
 raised to a red heat; it will be found better to abstain from 
 touching the cauterised surface with sponges. In this way the 
 entire operation may be performed without any loss of blood. I 
 am careful not to remove the entire tumour, in order to prevent 
 the formation of a cicatricial stricture. If three or four tumours 
 require removal, care should be taken to leave strips of mucous 
 membrane between each- of them. Some narrowing of the tube is 
 apt to follow, five or six weeks after the operation, causing the 
 patient some trouble in defsecation. In a month or six weeks, 
 however, the cicatrix yields again, and the annoyance disappears. 
 In order to save the patient this discomfort I have been in the 
 habit lately of removing not more than two of the larger tumours, 
 above and below or on either side. The bowels should be properly 
 cleared out for several days beforehand by castor oil and injections. 
 On the day of operation I give some opium, in order to prevent 
 any action of the bowels following shortly after operation. On the 
 third day I give a dose of castor oil. Care should be taken not to 
 cauterise the anal folds, as this causes unnecessary discomfort to 
 the patient. The pain, which is usually tolerably severe during 
 the first few days, can be controlled by cold. Cloths wrung out of 
 iced water should be laid between the nates, and frequently 
 changed. No local after treatment is necessary. I find that by 
 this plan of treatment all danger can be avoided, and a cure most 
 quickly effected. 
 
 HEMORRHOIDAL PrOLAPSE. 
 
 In one case of this nature spontaneous recovery took place. The 
 patient was admitted with the prolapse strangulated and gangrenous. 
 In due course it dropped ofi", and recovery took place without any 
 general constitutional disturbance. 
 
 In a few cases a cure was eflfected by taking away two or three 
 small folds by means of the galvano- caustic loop ; in nine cases the 
 application of fuming sulphuric acid was very successful. On the 
 value of this latter method I have already made some remarks in 
 the ' Wien. Med. Wochens.,' 1871, No. 35. 
 
 All the patients (eighty-one) who came under my treatment for 
 this affection were cured. In a few instances I know that the con- 
 dition returned in a slight degree, but in most of the cases the
 
 254 CANCEE OP EECTUM. 
 
 recovery was permanent. I have already in the 'Wien. Med. 
 Wochens./ 1871, No. ^^, pointed out the great advantage of 
 employing fuming sulphuric acid. I have not been able to discover 
 that the acid nitrate of mercury has any special qualities to recom- 
 mend it. Both caustics are disadvantageous in one respect, viz. 
 that their action is materially interfered with when haemorrhage 
 takes place from the application ; these are the very cases where 
 the hsemorrhoidal condition is apt to return owing to imperfect 
 cauterisation. 
 
 In such cases the actual cautery takes its old place, as it does 
 also wherever the protrusion is very large, or requires to be drawn 
 forwards with the vulsellum, a proceeding which always occasions 
 some bleeding. 
 
 In singly occurring protrusions personal convenience will guide 
 the operator in choosing between the actual cautery and the 
 galvauo-caustic loop. Quite recently I have, for convenience sake, 
 employed von Langenbeck's clamp, and then destroyed the haemor- 
 rhoids by Paquelin's cautery. This method of operating is the 
 most convenient for the surgeon, and the most radical for the 
 patient when an anaesthetic is desired. I have only employed the 
 ligature and ecraseur once, in order to show it to my audience, as I 
 had no previous experience of its efficacy. 
 
 Cancek op the Kectum. 
 
 While at Ziirich I extirpated the rectum in twelve cases, on 
 account of malignant disease. Except in two, they were all cases 
 of ulcerated alveolar cancer (Driisen Krebs); six recovered and 
 six died of peritonitis after the operation. 
 
 Cancerous stricture of the rectum. Removal. 
 
 2err S — , about fifty years of age, had Buffered for many years from 
 obstruction, whicb, however, he had always been able to overcome successfully 
 without taking any medicine, by carefully regulating his diet. Three months 
 before he consulted me, very severe pain attacked him, and he lost some 
 blood whenever the bowels acted. The motions were veiy hard and painful. 
 Examination occasioned much distress, but I was able to find, about half 
 an inch above the rectum, a stricture, caused by a projecting cancerous growth. 
 The stricture was about an inch and a half in length, and the finger could
 
 EEMOVAL OP CANCER OF RECTUM. 255 
 
 just be passed through it ; the hard masses of new growth were tolerably 
 movable. In October, 1870, I removed the lower end of the rectum. As 
 the patient was rather anaemic, the operation was performed as far as possible 
 with the galvanic loop. After the diseased portion had been extirpated, I felt 
 high up, on the left side of the wound, a rather hard nodule, the size of a 
 hen's egg, which I removed partly with the finger, partly with the scissors. 
 Furious haemorrhage followed, and we had the greatest trouble in controlling 
 the bleeding by protracted digital compression and ice. During the next twenty- 
 four hours, the patient's life hung in the balance, and it was only by long-con- 
 tinued stimulation and artificial heat that we were able to keep him alive. 
 Convalescence was slow, but stiU the wound eventually healed. The patient 
 was again able to retain the faeces, and for some months was restored to very 
 good health. About five months later, the sacrum became tender on pressure 
 and he was frequently attacked with severe pain in this region. The left 
 inguinal glands began to enlarge, and the patient lost strength. No recurrence 
 took place locally. When I saw him eight months after the operation the 
 anal opening was veiy wide. The mucous membrane of the rectum, which was 
 normal in appearance, projected downwards, like a small ectropion ; the patient 
 could retain the faces, when they were not of too thin consistence. 
 
 Although such cases are more deterrent than encouraging, when 
 we look to the danger of the operation and the rapidity of recurrence, 
 yet I have met with one which dissuades me from giving up extir- 
 pation of the rectum for carcinoma. 
 
 I was consulted by a lady, tet. 58, for a prolapse of the rectum, of moderate 
 size. I learned from her medical man, who was present at the operation, 
 that, three or four years previously, Schuh had removed with the galvano- 
 caustic loop, a ring-shaped cancer of the rectum, which extended high up the 
 bowel. She had been operated upon also with the knife, by Dr. Low, two 
 years before she consulted Schuh. 
 
 When I saw her no trace of recurrence had taken place. Except 
 for the local trouble resulting from the removal of the rectum, the 
 lady was perfectly well. As there was no possibility in this instance 
 of any error of diagnosis, the case may be noted as one of permanent 
 cure. 
 
 While at Vienna I removed the lower end of the rectum in thirty- 
 three cases ; once for melano-sarcoma, in all the other instances for 
 carcinoma. Twenty of the patients survived the operation, though 
 most of these died within two years of recurrence : thirteen died of 
 the operation. The severe haemorrhage attending this operation did
 
 256 REMOVAL OP RECTUM FOR CANCER. 
 
 not seem to be diminislied by employing the galvano-caustic 
 apparatus; none of the patients died actually from this cause, 
 though great loss of blood more than once gave cause for anxiety. 
 Death invariably took place from retro-peritoneal suppuration which 
 as a rule was characterised by acutely septic symptoms, so that the 
 patients generally died in from four to eight days ; two cases only 
 lasted rather longer. At times it seemed as if the suppuration were 
 inclined to decrease, after the separation of large sloughs of cellular 
 tissue, but the patients died nevertheless of pysemia and exhaustion. 
 On the whole I have come to the conclusion that cases where the 
 whole of the sphincter, together with a portion of the skin was 
 removed, do better than those in which as much as possible of these 
 parts is preserved. By trying to save too much the discharge of 
 secretion is impeded, even when almost the entire cavity of the 
 wound is filled with drainage tubes. Uniting the edge of the 
 rectum to the skin wound hinders the escape of secretion, even 
 though only two or three sutures be employed ; I do not now advise 
 this plan, by which at the best but little is gained. Healing by 
 first intention can rarely be looked for ; as a rule, the sutures cut 
 their way through within two or three days, and the rectum then 
 becomes drawn up again. One case which was remarkably suc- 
 cessful, in respect of the length of time that elapsed without any 
 recurrence of the disease, has already been mentioned (p. 2^^). The 
 majority of these cases are unsatisfactory. The number of patients 
 that I have seen in private, on whom I declined to operate, is 
 tolerably large; the despair of these unfortunates, like that of 
 many others who have been sent up for operation, is often heart- 
 rending when they hear that no operation is advisable, and that 
 they must abandon themselves to the prospect of a speedy end to 
 their lives. So it has come about that in spite of the unfavourable 
 prospects I have from time to time taken up this operation again, 
 yet I can well understand that these operations are wholly dis- 
 countenanced by surgeons who seldom meet with such cases, and 
 who are spared the distressing scenes which are inflicted on us, 
 owing to the vivacious and sensitive nature of the Austrian tem- 
 perament.
 
 CHAPTER XII. 
 
 DISEASES OF THE URINARY ORGANS. 
 
 Case of alscess perforating the bladder. Cases of renal tumour ; 
 Hydronephrosis. Caae of foreign lody in lladder. Remarks 
 on chronic cystitis and 'pyelitis. Alkaline fermentation of urine 
 — Treatment. Case of laceration of urethra — urethrotomy. 
 Remarks on traximatic stricture of urethra. Herpes after 
 catheterisation. Treatment of stricture — Rajnd dilatation — 
 External urethrotomy — Internal ditto. Cases of lithotrity. 
 Remarks on operations for stone. Lithotrity. Lithotomy. 
 Possiiility of dissolving calculus. Litholapaxy. Hypertrophy 
 of prostate. Case of prostatic alscess. Vesico-vaginal fistula. 
 Mxtroversion of bladder and epispadias — Operative treatment. 
 
 Abscess perforating the bladder. 
 
 J. M — , set. 54. A fortnight previously he was in perfectly good health ; he 
 was then attacked with obstinate constipation, frequent desire to pass water, 
 and pain in micturition. He was treated before he came to us, by laxatives, 
 and catheterisation. When admitted, the catheter passed easily, but deviated 
 to the left as it entered the bladder. Deep down in the pelvis could be felt a 
 soft, elastic tumour, the size of a foetal head, which was also perceptibl© 
 fi-om the rectum. I supposed that it was a retroperitoneal malignant growth 
 of the pelvis. I ordered the water, which was turbid, alkaline, and contained 
 pus, to be drawn off regularly, and the bladder to be washed out. The man 
 died a week after admission. Post mortem : A retro-peritoneal abscess was 
 found, which had perforated the bladder in two places. 
 
 Abscesses in this situation are very rare in men^ though they are 
 not of infrequent occurrence in the female sex. If a correct 
 diagnosis had been made, puncture by the rectum might have saved 
 the patient's life. 
 
 17
 
 258 RENAL TUMOUR. HYDRONEPHROSIS. 
 
 Renal tumour. 
 
 Barbara F — , a delicate, anaBmic woman, tet. 40, was sent np to the hospital 
 for a supposed ovarian tumour. The abdomen was enlarged as in the last 
 month of pregnancy. The tumour was hard, had been noticed for six years, 
 and proved to be connected with the right kidney. On puncturing it, a little 
 yellowish, flocculent matter was withdrawn, which proved to be broken down 
 tissue. No operation was practicable. 
 
 Hydronephrosis. 
 
 Therese B — , set. 24. When eight years old, she suffered from abdo- 
 minal pain, and for a long time was unable to get about. Swelling of 
 the abdomen, especially of the left side followed. Twelve years before 
 admission the abdomen was as large as when I first saw her. The swelling 
 was then punctured, and twenty-four pints of serous fluid drawn off. Five 
 years later the fluid had re-collected and the same quantity was again let out, 
 it being now of a brownish-red colour. Two years before admission, the 
 tumour was again tapped, a clear yellow fluid escaping. Since this last 
 occasion the abdomen had slowly increased in size, without giving any pain. 
 When I saw her, she was a well-formed, stout, girl ; the abdomen was 
 distended unequally, the upper half on the left, and the lower half on the 
 right side, being especially prominent. Fluctuation was everywhere distinct. 
 The tumour was dull on percussion, but not apparently solid anywhere. I 
 tapj)ed the swelling, and di-ew off thirteen pints of ^faintly acid, turbid, 
 albuminous fluid, containing a few lymph cells. 
 
 Taking all tilings into consideration, I have no doubt that this 
 was a case of left hydronephrosis. I hoped that analysis of the 
 fluid would have established the diagnosis^ but such was not the 
 case. No uric or hippuric acid could be found ; a considerable 
 amount of succinic acid was detected. This last ingredient would 
 have pointed rather to hydatid cyst, had there not been many 
 things against such a view. 
 
 Foreign body in the bladder. 
 
 A man, aet. 34, who suffered fi-om stricture, while passing for himself an 
 old, much-used bougie, allowed it accidentally to slip into the bladder. A 
 few days later he came under treatment. A catheter was passed, but nothing 
 abnoiTual could be felt. Six days after the accident, the patient was unable 
 to pass any water. On attempting to introduce an instrument, an obstacle was 
 met with, about half an inch from the meatus. With a pair of forceps, the 
 bougie, perfectly soft, and with the varnish worn off, was di-awn out. By
 
 VESICAL IRRITABILITY. 259 
 
 tlie contractions of the bladder, therefore, the instrament must have been so 
 placed that it was extinided through the urethra — an exceptional piece of 
 good fortune for the patient. 
 
 Chronic Cystitis and Pyelitis. 
 
 I have only met with diphtheritic inflammation of the bladder as 
 a secondary affection, and as such consequent on fracture of the 
 spine, ruptured urethra, stricture, or hypertrophy of the prostate. 
 The so-called irritable bladder is, by many authors, thought to be 
 of a neuralgic nature. It is possible that there is such an affection 
 as pure neuralgia of the bladder, but the cases which I have seen, 
 and which correspond accurately to the "irritable bladder ^^ of 
 English authors, were not neuralgic at all; they were due to 
 catarrhal inflammation of the bladder or the pelvis of the kidney, 
 and were characterised usually by strongly acid, highly coloured 
 urine containing a little cloudy mucus, and marked reflex con- 
 traction of the bladder, even when the organ was only moderately 
 full. Spasmodic contraction of the sphincter vesicae was also 
 usually present. In patients thus affected it is often a matter of 
 great difficulty to pass a catheter, for the urethra, near the neck of 
 the bladder, is so sensitive that the contact of the instrument sets 
 up a powerful reflex contraction ; steady and moderate pressure with 
 a large sized instrument will alone enable the surgeon to enter the 
 bladder; nor is the spasm always removed by chloroform. It often 
 happens that the catheter will pass quite easily one day, and on 
 another cannot be got in. I have found opium suppositories and 
 warm baths, the best remedies against this irritable condition, 
 which, at any rate, sometimes may thus be alleviated. It appears 
 to me that this irritability of the bladder is analogous to the spas- 
 modic condition met with in superficial lesions of other mucous 
 membranes, such as blepharo-spasm in kerato-conjunctivitis, or the 
 colicky pains associated with gastric or intestinal catarrh ; again, 
 the tenesmus in fissures or excoriations of the rectum, and the spas- 
 modic cough in many forms of laryngeal and pulmonary catarrh are 
 of the same nature. In all such conditions considerable hypersemia 
 of the mucous membrane is associated with the superficial abrasion 
 of the epithelial surface, or perhaps with some slight excoriation. 
 I cannot say whether a similar condition of the neck or mucous lining
 
 260 TKEATMENT OF VESICAL CATAEEH. 
 
 of the bladder, the ureters, or the pelvis of the kidney ever occurs and 
 gives rise to the complex symptoms of irritable bladder, lor I have 
 never had an opportunity in any of these patients, of making a post- 
 mortem examination; I consider it, however, very probable that 
 such is the explanation. Cases of idiopathic catarrh of the bladder 
 (from which category I exclude gonorrhoeal cystitis) are, so far as 
 my limited experience extends, of exceeding rarity. I agree with 
 Coulson that the symptoms which strike the eye most are rather 
 those of catarrh of the pelvis of the kidney, with or without tuber- 
 cular disease of that organ (chronic caseating nephritis). As the 
 disease progresses, it will usually betray itself by the familiar 
 symptoms, especially when the pyelitis is completely established, 
 with abundant purulent sediment in acid urine. 
 
 Alkaline urine occurs only in the secondary stage of vesical 
 catarrh, though undoubtedly, it is very soon manifest. It is most 
 commonly due to long retention, fermentation of the urine set up 
 by materials introduced on catheters, foreign bodies, or tumours of 
 the bladder. Perhaps also, in simple idiopathic catarrh of the bladder 
 with acid urine, the introduction of fermentative matter, such as 
 infusoria or fungi, may alter the secretion of the mucous membrane 
 and lead to purulent alkaUne catarrh. This cannot be so common 
 as some suppose, for we see that pyelitis and vesical catarrh will go 
 on for many years unchanged, and without the uriue becoming 
 alkaline. Ordinary pus of itself does not set up alkaline fermen- 
 tation of the urine in the bladder; this change is due to some 
 special variety of pus, or perhaps to some special animal or vege- 
 table ferment. 
 
 The treatment of catarrh of the urinary passages like the treat- 
 ment of chronic catarrh generally, is highly unsatisfactory. The 
 affection appears to me as incurable as cancer or tubercle, and is 
 only less dangerous in that it is not so rapidly fatal. Idiopathic 
 catarrh of the urinary mucous membranes is connected with con- 
 stitutional disturbances of which we know little. I have occupied 
 myself a good deal with this subject. The classical works of 
 Coulson, Thompson and others, mention a great number of remedies 
 which I have tried over and over again. Purulent catarrh of the 
 bladder with alkaline urine, will be greatly improved by washing 
 out the bladder daily through a double catheter. Xot infrequently 
 the alkalinity of the urine can be completely remedied. A drop or 
 two of sulphuric acid should be added to each ounce of water
 
 IDIOPATHIC CYSTITIS AND CYSTO-PTELITIS. 261 
 
 injected. In cases of idiopathic catarrh of the bladder or the 
 pelvis of the kidney, or in irritable bladder, I have never been able 
 yet to find a sure and speedy remedy. Most patients grow weary 
 of treatment which lasts for months. I will not mention here all 
 the internal remedies which I have systematically employed in turn, 
 but I may say emphatically that when the catarrh is associated with 
 acid urine and irritability of the neck of the bladder, injections are, 
 at best, but of temporary benefit; usually they are perfectly useless, 
 and sometimes they increase the irritability of the bladder. 
 
 Between i860 and 1876, I met with fourteen cases of chronic 
 gonorrheal cystitis. The disease often went on for months, but 
 usually subsided by means of careful diet and rest, and the per- 
 sistent administration of copaiba. No severe symptoms were met 
 with in any of these cases. 
 
 Pure idiopathic cystitis and cysto-pyelitis, by which I mean 
 cases in which the disease was not due to infection, stricture, 
 syphilis, or hypertrophy of the prostate, I met with in thirty-eight 
 instances. Thirty-three of the patients were men, and five women. 
 
 Thave devoted my best attention to the treatment of this dis- 
 tressing affection, but it seems to me an almost hopeless one. I 
 do not hesitate to say at once to these patients that I can give them 
 advice by which their sufferings may be somewhat alleviated, but 
 that I cannot cure them. My experience at Ziirich led me to the 
 same conclusion. In Vienna, where the disease was very common, 
 I tried again all kinds of new and old remedies, but without any 
 success, save that I was able in some instances to stall off fatal 
 consequences ; still, the results of my experience may be of use to 
 others. 
 
 These patients usually came to the hospital on account of acute 
 exacerbation of their symptoms caused by alkaline fermentation of the 
 urine in the bladder. For this condition treatment could effect a good 
 deal ; in such cases I formerly used to wash out the bladder with a 
 mixture containing one drop of strong muriatic acid to thirty 
 grammes of water; but this very often gives much pain, and I was 
 glad to find that there were other remedies which were equally 
 efficacious, though slower in their action. Such are phosphoric, 
 nitric, or benzoic acids administered internally (I have not had any
 
 262 TKEATifENT OF ALKALINE UEINE. 
 
 experience of salicylic acid, which has lately been recommended).^ 
 I give five grammes of these acids with a httle fruit syrup daily, in 
 a large quantity of water. Phosphoric and nitric acids are of less 
 unpleasant taste than benzoic acid : the latter again is not so readily 
 soluble in water, and more, therefore, has to be taken. On the 
 other hand, the benzoic acid is tolerated better by the stomach, 
 indeed, I have seen cases where the appetite improved under its 
 administration. It is well known that benzoic acid is in part excreted 
 in the urine as hippuric acid, and partly passes out unaltered; it 
 does not irritate the most sensitive or the loosest mucous membrane, 
 while the phosphoric acid turns the urine acid so quickly and 
 strongly at times that it has to be left off ; if continued the vesical 
 pains are much increased. According to the degree of alkaline 
 fermentation in the bladder, it took, as a rule, from four to eight 
 days in moderately severe cases before the urine became acid. 
 Previous to this there comes a period during which the urine, when 
 allowed to stand, is at one time alkaline again, at another preserves 
 its acidity. Sometimes the urine was exceedingly pale, with 
 scarcely a trace of colouring matter in it; this may perhaps depend 
 on the amount that the patients drink. In opposition to this view 
 we may note that the amount of urine excreted is in many cases by 
 no means excessive; and, again, that the paleness is far more 
 marked than can be accounted for by the drinking of large quan- 
 tities of water. One other factor should be taken into account, 
 viz. that often in these patients there is very little secreting power 
 left in the kidneys, and proportionately little colouring matter is 
 formed. The absence of colour is masked by the blood and pus, 
 as long as the mucous membrane of the urinary tract is kept in an 
 inflamed condition by the ammouiacal urine. I have seen a few 
 cases where the patient could not stand the acidulation of the urine 
 even with very small doses of phosphoric acid. In a few other 
 cases, too, it was not found possible to keep the urine acid, not- 
 withstanding that various acids were administered for periods of 
 several weeks. Certainly, these were complicated with rough calculi 
 in the bladder. I suspect that the ferment was contained in the 
 irregularities and depressions of the stone. 
 
 ' Recently I have frequently recommended a 5 percent, solution of chlorate 
 of potash for the treatment of ammouiacal fennentation of the urine, with 
 advantage. I have employed the same remedy also in cases where the urine 
 was neutral or feebly acid, and cloudy, with bacteria.
 
 BACTERIA IN URINE. 26S 
 
 When the ammouiacal fermentation of the urine is got rid of we 
 are able to see the true state of things. With it will disappear the 
 ammonisemia (evidenced by constant pain in the head, dryness 
 of the tongue, nausea for food, especially for meat), constant 
 tendency to micturate, hsematuria, diarrhoea, etc., all of which 
 conditions I look upon as accidental complications in diseases of 
 the urinary tract. 
 
 The patients, as regards the urine, may be separated into two 
 classes ; in one set the urine will be almost perfectly clear, and a 
 sharply -defined, viscid, clear yellow layer of pus will separate at 
 the bottom of the urine glass. In another set of cases the urine 
 does not become clear, but is more or less cloudy, even after it has 
 stood for some days. Boiling seems at first to have no influence 
 on it, but it usually becomes clear after a time if allowed to stand in 
 the test tube after boiling. Treated with Liquor Potassse and boil- 
 ing it clears at once. In turbid urine of this description, even when 
 fresh, I invariably found bacteria, and can only ascribe the constant 
 cloudiness to this cause. The sediment forms when the bacteria 
 die, or when their vegetative power is exhausted. Por many years 
 I had two such cases under almost constant treatment, and always 
 found bacteria and turbidity, even when the urine was strongly acid. 
 I employ the term " bacteria " here in the true sense of the word. 
 If these organisms are examined under a strong objective (Hartnak, 
 No. lo) they are seen as very pale, small, short, staff-shaped 
 bodies ; they are usually at rest and seldom attached in groups of 
 three or four. They do not set up any ammoniacal fermentation. I 
 almost doubt whether they are particularly injurious, for patients 
 with cysto-pyelitis, whose urine is turbid and contains bacteria, 
 have no more and no further troubles than patients similarly 
 affected whose urine is clear. I cannot say for certain whether 
 these bacteria become small streptococci from some accidental 
 ammoniacal fermentation of the urine. The streptococci are 
 always found in ammoniacal urine, but it has not, to my mind, 
 been proved that they bring about the fermentation. For the 
 present we must be content with our knowledge of the fact that in 
 constantly acid urine true bacteria may be seen together with pus 
 corpuscles. It appears very difficult to destroy these bacteria in 
 the urine. In none of the cases which I had under observation 
 did they altogether disappear, though in some their numbers 
 distinctly diminished under the administration of copaiba, benzoic
 
 264 TREATMENT OF CYSTITIS AXD CYSTO-PTELITIS. 
 
 acid, silicate of soda, curds, etc. These patients are very intolerant 
 of injections into the bladder ; the urethra and bladder are highly 
 sensitive, and, as a rule, they tire of the multiplicity of remedies, and 
 object to any new treatment, for fear lest their condition, which, at the 
 least, is endurable, should be rendered worse. One would suppose 
 that if these bacteria are really formed in the urine, they would be 
 washed away by the free use of water, and the passing of large 
 quantities of urine. If ammoniacal urine be injected into the 
 bladder of a dog, the alkalescence lasts but a short time; the 
 l)acteria, together with the ferment, are soon got rid of, and in a 
 few days the urine is again normal. I suspect that perhaps the 
 place where the bacteria are formed is situated in some angle of the 
 pelvis of the kidney, or in some pouch of the mucous membrane of 
 the bladder. Hitherto, I have had no opportunity of confirming 
 this idea by post-mortem examination. 
 
 The ex-centric pains and irritability are very troublesome, and in 
 manv cases exceedingly severe. Such are the constant desire to 
 pass urine, severe paiu in the perineum after micturition, painful 
 erections especially towards morning, and a constant, moderately 
 severe, burning sensation in the urethra, of nervous origin. I 
 have never yet succeeded in completely relieving these symptoms, 
 or in guarding effectually against their return. Suppositories of 
 morphia and belladonna, frequent warm baths, chloral, lupulin, 
 bromide of potassium, quinine, and the like, all give but temporary 
 rehef. The patients will soon abandon these remedies after they 
 have given them a trial. It is a matter of surprise to me that none 
 of the patients whom I had under observation employed morphia 
 injections on themselves; most of them had a great horror of the 
 drug, even when they had tested its efficacy more than once. I 
 conclude from this fact that the pain cannot be so very intense. 
 As a rule, these patients are in a highly nervous, often very hypo- 
 chondriacal, state. They are tormented by the persistence, more 
 than the intensity of the pain. After a few years they make up their 
 minds that they have no chance of ever recovering. Often they 
 experience a sensation of relief amounting almost to convalescence, 
 when after a severe exacerbation they return to what they call their 
 '•'proper state of disease." At least, they have the impression for 
 the time that they are doing better, and feel, therefore, more 
 comfortable than if they remained always in the same condition. 
 Of the pareses which may succeed this malady, I have only
 
 TEEATMEiNT OF CYSTITIS AND CTSTO-PYELITIS. 265 
 
 observed two, viz. paralysis of the detrusor uriuse muscle, and of the 
 sphincter vesicae. Hitherto I have not met with any cases in which 
 diseases of the spinal cord were set up in a reflex manner, although 
 many of these patients seem to be, or to become, tabetic. In one 
 case which I had under constant observation a year ago, the 
 urine could sometimes be expelled without pain, but now it has to be 
 drawn off ; yet no change can be detected in the bladder with the 
 catheter. In others the sphincter failed in its functions only when 
 the bladder was very distended, especially in the night, as so often 
 happens in hypertrophy of the prostate. Under such conditions 
 the only thing that can be done is to teach the patient how to use 
 the catheter for himself. If the bladder is able to contract to its 
 smallest dimensions several times daily, its innervation will recover 
 though it will not regain its normal power. 
 
 The most difficult task that the surgeon has to accomplish, after 
 he has combated all these accidental complications is to cure the 
 actual disease. Here it must be admitted our art chiefly fails. I 
 think I have tried every kind of remedy that has been recommended; 
 all kinds of astringents, drugs highly recommended by English 
 writers such as Buchu, Pareira Brava, etc. Liq. Per. Sesquichlor,, 
 (as used by Thompson for ^' irritable bladder "), inhalations of tur- 
 pentine (advised by Dittel), have been tried in turn. In private, 
 a few patients obtained slight relief from some of these drugs, espe- 
 cially when they first took to a new one, but the improvement did 
 not last. Baths and mineral waters can do little more; if the 
 patients drink much, their troubles increase. The waters of Carls- 
 bad, Marienbad, and Heinrichsquelle, I found useless. On the 
 other hand the baths of Teplitz, Gastein, and Baden-Baden are often 
 remarkably beneficial. Mountain climates are seldom borne well ; 
 these patients easily catch cold, and have an instinctive dread of low 
 temperatures. In winter, when possible, I advise these patients to seek 
 a southern climate, but the effect of the Riviera and similar places 
 does not come up to expectations. The more quietly these patients 
 live, the longer do they resist their complaint. I know of cases 
 where decided symptoms of pyelitis have existed for ten years or 
 more and yet the affection, as determined by the quantity of pus, 
 has not increased. With these patients I did not find it possible 
 to make repeated examinations of the urine, at regular intervals. 
 I cannot say positively whether the amount of urea diminishes in 
 proportion to the gradual disappearance of the secreting substance
 
 266 NATURE OF PYELITIS. CASE OF LACERATED URETHRA. 
 
 of the kidneys, or whether albuminuria finally occurs; the first 
 mentioned effect is highly probable. 
 
 Pyelitis, it seems to me, belongs to that large group of diseases 
 which we are in the habit of ascribing to the tuberculo-scrofulous 
 diathesis. It occupies a distinct position between amyloid degene- 
 ration on the one hand, and Bright^s disease on the other. The 
 two latter processes rarely lead to suppuration of the substance or 
 the pelvis of the kidney. From the group of tuberculo-scrofulous 
 diseases, purulent catarrh may be dissociated. This affection does 
 not always lead to miliary tubercle or to caseation, although both 
 these conditions may occur. Caseous nephritis or peri-nephritis is 
 certainly often associated with pyelitis. The catarrh of the pelvis 
 of the kidney may either precede or follow the affection of the paren- 
 chyma ; bronchial catarrh, blenorrhcea and their results are diseases 
 parallel, though not so very often associated with cysto-pyelitis. 
 General marasmus may occur at a late stage of renal disease, and 
 then some sHght accidental cause will prove fatal. The more in- 
 efficiently the functions of the kidneys are performed, the more 
 danger will there be from any febrile disturbance, for the kidneys 
 manifestly play an important part in repairing such disturbances. 
 Ammoniacal fermentation of the urine in the bladder, with ammo- 
 niaemia, often rapidly disappears when the kidneys are doing their 
 work tolerably well. When the cortical substance is much atro- 
 phied, such a condition may prove fatal. 
 
 Calculous pyelitis, like the cysto-pyelitis set up by chronic reten- 
 tion of urine, has nothing whatever to do with a tuberculo-scro- 
 fulous diathesis. Lithiasis is more connected with arthritis, 
 rheumatism, arterial sclerosis and cardiac disease. Large calculi in 
 the pelvis of the kidney can of course, set up suppuration mechani- 
 cally, and may cause also purulent cystitis. But the reason does 
 not seem to me quite clear why sometimes even in cases where the 
 stones are large and rough, these changes are altogether absent, or 
 very slight. Further investigation is necessary to determine whether 
 the suppuration depends more on constitutional tendencies, or on 
 the chemical and physical qualities of the stone. 
 
 Laceration of urethra. Urethrotomy. 
 
 A man, set. 22, who three weeks previotisly had sustained a comminuted 
 fracture of the pelvis, was admitted with an abscess around the urethra, and
 
 STRIGTUEE OF UEETHEA. UEETHRAL FEVER. 267 
 
 urinary infiltration of the perinseum. The uretha had been lacerated at the 
 time o£ injury by a splinter of bone. External nrethrotomy was performed, 
 
 and a pointed fragment of bone found loose in the abscess cavity. Death 
 followed four days after the operation. 
 
 Further details of the case will be found in the ' Arch, fiir Klin. Chir./ 
 Bd. i, p. 447. 
 
 Stricture of the Urethra. 
 
 As long as a single drop of urine can find its way down the 
 urethra to the meatus, the expression " impermeable stricture " is 
 only relative, and signifies merely that the surgeon is not able to 
 pass an instrument. The more skill and practice the surgeon has 
 in passing bougies, the more rarely will he meet with impassable 
 strictures. As a result it follows that urethrotomy will be less 
 often required, unless the sensitiveness of the stricture, or the 
 irritability of the urethra indicate this operation. 
 
 Rigors after the passage of instruments I have often seen ; I have 
 met with them occasionally in persons with normal urethra;, who 
 required the water to be drawn ofi" for paralysis of the bladder 
 resulting from fractured spine. These rigors usually occur from an 
 hour and a half up to three hours after the passage of the instru- 
 ment. In most of these cases it will be found that some, though 
 possibly a very slight injury has been inflicted on the mucous mem- 
 brane of the urethra. The evidence of such lesion may consist in a 
 little blood on the instrument, or a few blood clots in the urine ; 
 still this is not always the case : 
 
 A man, ajt. 46, had a stricture, which just admitted the finest instrument. 
 After the first two occasions on which it was passed, rigors followed, although 
 no drop of blood escaped. On the third occasion a metallic instrument was 
 passed ; this was followed by a severe ursemic attack which ended in a copious 
 emption of herpes in the lip.' External urethrotomy was performed, and the 
 patient soon recovered. 
 
 Sometimes the patients allow the instruments to remain much 
 longer in the urethra than they were ordered to. I generally leave 
 the instruments in for five minutes. No doubt this irritability of 
 
 ^ Cf . Verneuil on " Herpes as a Complication of Cutting Wounds," ' Lancet,* 
 1878, vol. ii, p. 873. [Ed.]
 
 2Q8 GONORRHGEAL STRICTURE. 
 
 the urethra depends largely on nervous causes. I have no doubt 
 that the feverish attacks, which are real and immediately dependent 
 on the instrumentation, are due to swelling and transient inflamma- 
 tion of the urethra. 
 
 Thirteen cases of traumatic stricture in the perineal part of the 
 urethra came under my care at Ziirich and Vienna. Seven were 
 cured by dilatation ; five died after external urethrotomy which was 
 rendered necessary by the almost complete impermeability of the 
 stricture, and the existence of numerous fistulous openings. Tn all 
 these cases a high degree of cystitis was found, greatly dilated and 
 tortuous ureters, pyo-nephrosis and atrophy of the substance of the 
 kidney. All these patients were operated on at Zurich, at a period 
 when I had not learned to recognise sufficiently the injurious 
 influence that ammoniacal fermentation of the urine in the bladder 
 exerts on operation cases. 
 
 Ordinary Gonorrhceal Stricture. 
 
 The majority of these patients were treated by gradual dilatation 
 and discharged as soon as the strictures were sufficiently enlarged. 
 The patients were always advised to continue the use of instru- 
 msnts. 
 
 In six cases I performed rapid dilatation of the stricture with 
 Thompson's instrument. The cure was speedily effected iu all. In 
 none of these patients was the stricture very tight nor were there 
 any fistulse. The reaction after the operation was usually very 
 trifling. I am unable to say whether the cure was permanent in 
 any of these cases.^ In three instances internal urethrotomy was 
 performed with Linhart's instrument. The immediate result was 
 good. On one patient I operated twice, the second time after an 
 interval of a year. Evidently on the first occasion the instrument 
 had not penetrated deeply enough. Recovery seems to have been 
 permanent after the second operation. 
 
 There is no doubt that a large number of moderately severe stric- 
 tures can be permanently cured with comparative rapidity and 
 without any great amount of pain, by the use of bougies; patience 
 
 ^ Two are recorded in the ' Wien. Med. "Wocli./ 1S69, p. 790.
 
 TKEATMENT OP GONOERHCEAL STEICTUEE. 269 
 
 however, and a certain amount of skill is demanded of the patients 
 by whom the regular use of instruments has to be carried out per- 
 severinglyfor periods of years. On the other hand it is unquestionable 
 that strictures through which at first only the finest bougies or catgut 
 instruments can be passed, will prove very troublesome, painful, and 
 tedious to cure by dilatation. The pain, the intercurrent swelling 
 and the periurethritis by no means diminish in proportion to the 
 increase of the dilatation. On the contrary, whenever a change is 
 made to a larger instrument, much care must be exercised, lest 
 the cure be interrupted again for a long time by the swelling of 
 the parts. Many of these sufferers lose patience ; many again die 
 from the inflammation which the constant instrumentation sets up 
 about the urinary passages. My statistics furnish fresh evidence of 
 this. In seventy-five cases of urethral stricture (without reference 
 to the cause or situation of the disease) treated by gradual dilata- 
 tion, the mortality was 9*9 per cent. No doubt it should be noted, 
 that these statistics were compiled almost exclusively from hospital 
 cases, that is to say from the labouring classes; such patients 
 do not usually seek for advice until their sufi'erings become so 
 troublesome that they are unable any longer to follow their employ- 
 ment. As a rule these people came to the hospital complaining of 
 vesical pain and catarrh ; most of them were unaware that they had 
 a stricture. But gonorrhoeal stricture is very common in the higher 
 and more educated classes, where the people take more care of them- 
 selves and are more ready to consult the surgeon for slight distur- 
 bances of health. By excepting this class of cases we should exclude 
 a considerable number of the sb'ghter cases of stricture, for which 
 dilatation is the most suitable treatment. The mortality given 
 above, therefore, can only be held true as regards hospital practice. 
 I am quite convinced that in moderately severe as well as bad cases 
 of stricture, internal urethrotomy and rapid dilatation as a means of 
 accelerating the cure, will soon be as extensively adopted in Ger- 
 many as these operations are in England and Prance. Hitherto the 
 fear of the treatment has been very considerable, not only amongst 
 German surgeons, but also amongst German patients. The latter, 
 as a rule, consider that dilatation with bougies is unattended by any 
 serious risk, while they dread any cutting operation. Of late years, 
 unfortunately, I have had few opportunities of practising more widely 
 these operative measures. From what I have seen, the progress of 
 these cases after operation is almost free from any reaction;
 
 270 NATURE OP GONOEEHCEAL STEICTUEE. 
 
 although my teachers had very little good to say for it, I have been 
 most favourably impressed with the method of treatment. I must 
 repeat that, in my opinion, internal urethrotomy and rapid dilata- 
 tion are only means of accelerating the cure; I mean that the 
 operation will not do away with the necessity of subsequent instru- 
 mentation for a long period of time, nor after external urethrotomy 
 can the cure be properly termed " radical," that is to say, requiring 
 no further treatment. All gonorrhoeal strictures are the results 
 of peri-urethritis and interstitial contraction of the infiltrated 
 tissue. This infiltration, like a cicatrix of the skin which keeps red 
 and thickened for a long time, may remain unaltered without there 
 being any apparent cause for the persistence of the keloid con- 
 dition. As is well known, the condition is most persistent in cica- 
 trices of the skin after burns. The majority of the simplest 
 cicatrices do not reach a condition of histological stability under 
 twelve months. In scars after burns, many years elapse before the 
 cicatrix becomes white, level, and assumes permanently a condition 
 tending to atrophy. So also, there are strictures which we call 
 callous, and which may remain for years in a keloid condition, 
 frequently this is due to some purely individual peculiarity, but it 
 is often kept up by a very chronic gleet ; perhaps also the retention 
 of some of the gonorrhoeal virus in the tissue constitutes a permanent 
 source of irritation. It takes a very long time to get rid of this 
 tissue by passing instruments. If incisions be made deeply on either 
 side through the stricture, the nutrition of the cicatricial tissue will 
 be so far interfered with, that it will more readily atrophy ; but a 
 further effect is brought about. A simple cicatrix replaces the 
 former tissue. Xow this new material is much more easily dilated ; 
 again its daily stretching does not lead, as a rule, to fresh infiltra- 
 tion, but rather to simple superficial ulcers which heal slowly. The 
 conditions are the same as after tenotomy. The advantage of this 
 operation consists in the substitution of a readily extensile cicatri- 
 cial tissue for an inextensile tendon. 
 
 To suppose that club foot can be cured simply by tenotomy, is 
 an error ; an error, unfortunately, not recognised as it should be by 
 surgeons. 
 
 Strictures occurring after chancre are troublesome on account 
 of their inextensibility. As a rule they result from indurated chan- 
 cres which are cicatrised over, and probably contain some syphilitic 
 virus. A constant, though mildly irritable condition, is thus kept
 
 DILATATION OF STEICTUEE. UEETHEOTOMY. 271 
 
 up. The cicatrices, like those of hard chancres on the glans, take 
 a long time to atrophy. 
 
 If the gonorrhoeal infiltration around the urethra is allowed to 
 remain quiescent for a long time, it contracts and takes on the 
 character of atrophied cicatricial tissue. At the same time the 
 tissue, as it becomes drawn together and closes up, forms an 
 annular stricture. In such cases we may sometimes be lucky 
 enough to succeed the first time a bougie is passed, in rupturing the 
 stricture if thin and annular. The disease will then be as good as 
 cured, and will require no long after-treatment. If the ring of the 
 stricture be thick, it is very difficult to dilate, even when there is no 
 keloid tissue about it ; in such cases, internal urethrotomy is far 
 more applicable than in keloid strictures, and ought to be employed 
 far more frequently. It is always very difficult to estimate the 
 thickness of the ring of stricture. On this point even the most ex- 
 perienced authorities may be at fault. I know of one case in which 
 first Civiale and then, a few years later, Thompson had performed 
 internal urethrotomy. In spite of the most careful after-treatment, 
 the stricture, which probably had not been completely divided, con- 
 tracted to such an extent that I was forced to begin the dilatation 
 with the smallest instrument. This treatment, the patient with 
 most constant fortitude allowed to be continued for two years, so as 
 if possible to restore the normal dimensions of the urethra (the case 
 is still under treatment). I have no doubt that even in such a case, 
 atrophy of the cicatricial tissue will eventually occur, so that no 
 further contraction may be feared. No doubt the same result might 
 have been obtained more quickly by performing another urethro- 
 tomy of a more extensive nature, but the patient had rather lost 
 faith in this proceeding since he had been operated on twice unsuc- 
 cessfully. I do not consider it of any material importance whether 
 the stricture is divided from behind forwards, or in the reverse 
 direction on a staff; nor does it matter what instrument is used. 
 Each surgeon will accustom himself to some one mode of operating, 
 especially as he is not likely to meet with many cases. Therein 
 consists really and essentially the art of the so-called "speciaHsts" 
 arid it must not be disparaged. Generally speaking in this respect 
 it is opposed to the character of us German professors ; we consider 
 it of more importance to test the practical value of all rational 
 methods. A man must live to the age of Methuselah if he is to 
 thoroughly carry out practically all the methods of operating for
 
 272 EESULTS OF EXTERNAL URETHROTOMY. 
 
 calculus and stricture, even were he to adopt only tliose recom- 
 mended by the most competent authorities. For German surgeons 
 it requires a good deal of resignation only to operate according to 
 one method ; the French, Italians, and Enghsh do not feel this, 
 partly because they learn and know only one method, and partly 
 because with them the desire for stability of knowledge and its 
 application is stronger, and is considered by them a source of 
 strength, by us Germans one of weakness. 
 
 With regard to the results that I have obtained with external 
 urethrotomy, I should remark that I usually determined on this 
 operation when no other seemed admissible; I adopted it also in the 
 worst class of cases where, though exercising my best skill, the 
 strictures were impermeable to instruments. The results of this 
 operation for traumatic strictures in the perineal urethra were very 
 unfavourable. For gonorrhoeal strictures they were more successful, 
 especially when it is taken into account that of nine cases, erysipelas 
 was the cause of death in the only patient whom I lost after this 
 operation. External urethrotomy is especially adapted for severe 
 cases, particularly when complicated with numerous fistulse. It is 
 not a radical operation according to the definition given above. 
 When I was assistant in v. LangenbecFs clinic, I saw patients in 
 whom the strictures had returned after operation, when they had 
 entirely neglected the use of the catheter. External urethrotomy 
 can only be rendered more effectual by bearing in mind the extent 
 of the stricture, and so dividing it thoroughly with more certainty 
 than is possible in internal urethrotomy. External urethrotomy can 
 only be placed on a level with other methods of operating when we 
 succeed in rendering it free from risk by aseptic treatment of the 
 wound, but this is very difficult to carry out in these cases, on account 
 of the great tendency of the urine to ammoniacal fermentation. 
 
 Between 1860-76, I performed external urethrotomy sixteen 
 times; fourteen times for stricture, twice for injuries of the urethra. 
 Eight patients recovered and eight died. Six of the deaths occur- 
 red in patients with traumatic, one from erysipelas in gonorrhoeal 
 stricture. The other death was in a case of fractured pelvis (p. 266), 
 where the urethra had been injured by a fragment of bone.
 
 CALCULUS VESICA. LITHOTEITY. 273 
 
 Calculus vesicce. 
 
 A man, ajt. 6^, was admitted in a condition of marasmus, with great 
 htematuria. He died from perforation of the bladder, and cystitii?. The 
 bladder contained a calculus, in the centre of which was found a piece of 
 roUed-up newspaper. 
 
 .Death after lithotrity. 
 
 L. M — , aet. 24, had a rather hard stone in the bladder, measuring two and 
 a half by three and a half centimetres. After the first sitting, numerous 
 sharp-edged fragments were passed. The bladder contracted spasmodically 
 on the instrument, and occasioned so much pain that an anaesthetic was given. 
 Even when he was completely narcotised, the spasms still occurred. The 
 evening after the second sitting, the patient sufBered most intense pain ; 
 symptoms of cystitis and peritonitis developed, and he died two days later. 
 
 At the post mortem the wall of the bladder was found obliquely perforated, 
 close to the neck. The shape of the opening showed clearly that it had noli 
 been caused by the lithotrite ; I thinh it could only have been due to a sharp 
 fragment of the calculus, pressed against the wall during a spasmodic con- 
 traction of the bladder, 
 
 A calamity of this nature — one that may arise whenever the ston® 
 is hard — should remind us that lithotrity is not perfectly free from 
 risk, even when the utmost caution is exercised. Still, such occiar- 
 rences are not of sufficient frequency to interfere with the favourable 
 prognosis which can be given in lithotrity as against lithotomy. 
 The case showed further, that even deep ansesthesia is not always 
 sufficient to obviate spasmodic action of the bladder. In this patient 
 the contraction was so strong, that I found it impossible to move the 
 instrument. 
 
 All my cases (eleven) of lithotrity at Vienna, during 1868, reco- 
 vered with one exception. This vras a man, in whom a fragment 
 of stone became impacted at the neck of the bladder, and led to 
 inflammation around the organ and peritonitis. In a child six 
 years old, lithotrity had to be abandoned, on account of the im- 
 paction of the calculus in the urethra. The patient recovered after 
 lateral lithotomy. 
 
 Some farther statistics of lithotrity and lithotomy are to be found 
 in the ' Wien. Bericht/ 1869-70, p. 198. 
 
 18
 
 274 ALKALIifB UEINE AND CALCULUS. 
 
 Opeeatio-ns for Stone. 
 
 It is a well known fact that lithiasis is very unequally distributed 
 througliout the world. Thus, in Ziirich, between i860 and 1867, 
 I met with only five cases. In Vienna, between 1868 and 1876, 
 seventy-four cases came under observation, not including cases 
 which I saw occasionally in consultation, but which did not come 
 under my treatment .^ Most of my cases came from Hungary and 
 lower Austria. There may be reasons for this, but it does not ex- 
 actly prove that the disease is most common in those countries. 
 The operation of lithotomy is frequently practised in Austro- 
 Hungary, as well as in Eoumania and Servia. 
 
 In the few remarks that I have to make on operations for stone, I 
 am well aware that I have no new information to give, and that my 
 slight experience can have but little weight. Little, however, has been 
 written about the affection in Germany, for calculus is not often 
 met with. My colleagues, therefore, may desire to learn the results 
 of my experience. 
 
 In patients with stone, whose urine is alkaline and contains blood, 
 a certain amount of preparation is always necessary, whether litho- 
 tomy or lithotrity be proposed. With pure oxalic calculi, blood 
 often occurs in the urine after much moving about, riding, etc., 
 without any great amount of disease of the bladder. The symptom 
 will disappear if the patient be simply kept at rest in bed. If the 
 urine be alkaline and turbid, containing muco-pus, and occasionally 
 blood, a long course of treatment is necessary before operation is 
 undertaken. We ought not to operate as long as the urine is 
 strongly alkaline. The interesting experiments of Simon and Men- 
 zel have shown in the most decisive way that normal acid urine has 
 no phlogistic properties, even when it is forced into the tissues. 
 Alkaline urine becomes exceedingly phlogogenous, and at times 
 will cause downright gangrene. Simon thinks that this latter effect 
 is only produced when the urine is extravasated in such quantity 
 that it forcibly stretches the tissues. But the same thing happens 
 when only a small amount escapes ; the phlegmonous inflammation 
 is in part set up by the ammouiacal ingredients, and in part extends 
 by the ferment. I have already (p. 361) pointed out the remedies 
 
 1 In thelGeneral Hospital at Yienna there is a distinct depaiiment, under 
 the charge of a special professor, for diseases of the minary organs. [Ei>-]
 
 ALKALINE UEINE. LITHOTEITY. 275 
 
 which are most effective against ammoniacal fermentation of the 
 urine. I must add here, that the object in view is very difficult to 
 obtain in many cases of calculus, and is not always possible when 
 the surface of the stone is porous and rough, for the reason above 
 given. 
 
 Perhaps the best method consists in constantly washing out the 
 bladder with faintly acid solutions. But the pain of this treatment 
 is often more than the patients will stand. 
 
 There is another condition which would render it impossible to 
 keep the urine acid. It may be that the area where the fermen- 
 tation is set up and the bacteria are generated, is situated in the 
 substance of the kidney. The urine will then be alkaline almost 
 as soon as it is secreted. Sometimes, too, the mucous membrane 
 if much diseased will not stand a great amount of acid, yet before 
 any operation is undertaken, the urine not only ought to be acid, 
 but ought to remain so for at least twenty-four hours at the 
 ordinary temperature of a room. If it becomes rapidly alkaline as 
 it passes from the bladder into the tissues, nothing will be gained. 
 As I have already said, it is not always possible to succeed even 
 after weeks of treatment, and I have often had to be satisfied if I 
 could get the urine neutral or faintly acid for a short time. 
 
 As to the contra-indications for lithotrity, I can only agree with 
 English authors. Lately, I have preferred to administer an anaes- 
 thetic when the patients are sensitive, and extend the sittings to 
 twenty or twenty-five minutes. In many patients the bladder is so 
 little sensitive that no anaesthetic is required. If the urine escapes 
 during the operation I inject warm water into the bladder, other- 
 wise, as a rule, I do not. When possible I cause the patient to 
 avoid passing the urine for two hours before each sitting; the 
 bladder will then be found sufficiently full to admit of operation. 
 The interval between the sittings should not be more than three or 
 four days. If sharp cystitis occurs, the interval between the 
 sittings must be made shorter ; the operation then requires to be 
 performed with especial tenderness. The increase of the cystitis is 
 nearly always the result of the irritation set up by pointed fragments 
 of stone. I continue the internal administration of the acid up to 
 the end of the cure. I know only of one patient among my cases of 
 lithotrity in whom the disease recurred. 
 
 Unfortunately, we shall not be justified in the hope that severe 
 cysto-pyelitis due to calculus, will disappear quickly after the
 
 276 LITHOTOMY. SUPEA-PUBIC LITHOTOMY. 
 
 removal of the stone. An annual visit to Carlsbad is of advantage 
 in such cases .^ 
 
 Lithotomy. 
 
 On anatomical grounds I have a distinct preference for median 
 lithotomy, and this is the operation for stone with which I have 
 had most success. Lateral lithotomy gives rather more room, and 
 is especially adapted for children with large calculi. It is always a 
 good plan to measure the stone beforehand. There are few more 
 unpleasant surprises than to cut down upon a stone, and find that 
 it cannot be removed on account of its size. In two cases I adopted 
 with advantage the high operation, which has been recommended 
 for stones whose various diameters are not less than one inch and a 
 half. It is quite true that in the high operation, the incision can 
 be carried so far down on either side of the bladder, as almost to 
 bisect the viscus ; still it is always difficult to grasp and extract 
 the stone; the wound through the superficial parts must be very 
 large, so that the injury inflicted is very considerable. This opera- 
 tion finds no great favour with me, although formerly, when I was 
 fortunate enough to be v. Langenbeck's clinical assistant, I was 
 very much taken with it, and it appeared to me to be the ideal of 
 an operation for stone. The cases of supra-pubic operation in 
 children, performed by v. Langenbeck's masterly hand, did well 
 eventually, but there was much sloughing of the cellular tissue in 
 the neighbourhood of the wound. After the slough separated the 
 wound granulated up well and closed rapidly, but, the children were 
 always very ill after the operation, and suffered far more than when 
 subjected to median or lateral lithotomy. After these latter opera- 
 tions the parts healed up, in the majority of cases very rapidly, 
 sometimes, indeed, by first intention. Children are scarcely upset 
 at all, but are well almost from the moment of operation. As may 
 be supposed the cases do not always run such a favourable course ; 
 indeed, this is shown in the records of my own cHnic. 
 
 To enable the urine to flow away easily through the wound, all 
 kinds of methods have been adopted. In unfavourable cases the 
 
 1 This essay is contained in the ' Wien. Bericht'for 1871 — 1876, pub- 
 lished at Berlin in 1879, and relates to practice before litholapaxv was intro- 
 duced. See infra, p. 279, for remarks on Litholapaxy. [Ed.]
 
 EETRO-PERITONITIS AFTEK LITHOTOMY. 277 
 
 miscliief is always attributed to urinary infiltration. I rather doubt 
 the accuracy of this view. In those who have died after lithotomy, 
 low (jauchig-eitrig) phlegmonous inflammation will be found extend- 
 ing from the wound along the retro-peritoneal tissues. The same 
 form of retro- peritonitis is seen after removal of the rectum, where, 
 at any rate, the urine is not concerned. The real explanation of 
 the condition in this as in nearly all other forms of phlegmonous 
 inflammation, is to be found in the retention and decomposition of 
 the secretions of the wound. If the cellular tissue be loose, as in 
 old people, the inflammation will spread all the more rapidly. The 
 tough, fatty tissue in children is most capable of resisting the pro- 
 cess. Experiments prove beyond doubt that very little ammoniacal 
 urine is sufficient to set up rapid decomposition of the secretions of 
 the wound ; the most dangerous condition therefore, is when such 
 urine cannot be kept from contact with the wound. When the 
 urine has its normal acidity, it is first rendered alkaline by the 
 decomposed secretions of the wound. Experiments show again that 
 this change can rapidly be brought about (see the section in my 
 work ' Coccobacteria Septica ' on Experiments on Infection and 
 Transplantation) . The disinfection of the urine, by which expression 
 I here mean the cessation of its ammoniacal fermentation, cannot 
 always be effected, as I have already mentioned. In such cases 
 therefore, it might be right to apply an occlusion dressing. A 
 catheter passed in through the urethra, and tied into the bladder, 
 together with drainage tubes in the wound may also be desir- 
 able. The bladder, as also the wound, can then be washed out 
 frequently through the drainage tubes. When the urine is of 
 normal acidity, there seems to me to be no objection to passing 
 several drainage tubes deeply into the wound, and then applying a 
 Lister's occlusion dressing. A Nekton's catheter should be kept in 
 the bladder so that the urine may flow ofl^ constantly for the first 
 three or four days, until the edges of the wound are covered with 
 plastic eflfusion and there is no more danger of their being infiltrated 
 with the secretion. 
 
 The period of healing will thus be much shortened, even though 
 it should not always take place by first intention. I have not lately 
 had an opportunity of trying this method, I should have the 
 more confidence in it since watching the progress of a case in which 
 I had removed a myoma of the bladder^ by incisions made as for 
 ■^ This case will be found in the 'Arch, fiir Klin. Chir.,' Bd. xviii, p. 411.
 
 278 POSSIBILITY OP DISSOLVING CALCULUS. 
 
 high and lateral lithotomy. In this case, I had an opportunity of 
 seeing how readily wounds of the bladder wUl heal, when by the 
 continual free escape of urine the viscus is practically converted for 
 the time into an empty tube. 
 
 Although it may seem highly heretical to many of my colleagues 
 yet I cannot forbear from saying a word or two on the possibility of 
 dissolving vesical calculus. I once saw in consultation with v. Pitha 
 an old gentleman, who produced a large box containing a collection 
 of angular fragments of calculus. V. Pitha, who had had the 
 patient under his treatment for a long time, handed the box to me 
 without any remark. I naturally supposed that the fragments were 
 the result of numerous successful crushings, and I was not a little sur- 
 prised therefore, to hear that the patient had never been operated 
 on, but that the fragments of stone had been spontaneously evacu- 
 ated while he was undergoing treatment at Carlsbad. Y. Pitha had 
 declined to operate on the patient, on account of the amount of 
 vesical catarrh. Examination of the debris showed it to consist of 
 broken shell -like fragments : the surfaces of fracture were laminated 
 and it was evident that the calculi were not a collection of small 
 stones, but portions of a large one. The stone had broken up into 
 such minute pieces, that most of them were passed with the urine, 
 although the expulsive power of the bladder was feeble. 
 
 In the atlas of ''^ micro-geology ^' by H. Meckel v. Hemsbach, — 
 unfortunately not published — and in the very rich collection in my 
 clinic, which consists principally of stones collected by Dr. Reyher of 
 Cairo, I find numerous calculi, some of which show very distinctly 
 a tendency to break up in a radiating, some in a concentric manner. 
 Others show both forms of disruption. I should, under other 
 conditions, scarcely have believed that this disruption could have 
 led to so extensive a breaking down as occurred in the above 
 case. 
 
 I think that I have sometimes seen fragments of stone left after 
 lithotrity, especially when consisting of triple phosphates, disappear 
 under the constant administration of acids. In several instances, 
 where a week previously there had been numerous small fragments, 
 repeated examination failed to detect anything in the bladder. It 
 is possible that one is deceived in such cases, and that the urine was 
 not aU filtered with sufficient care, but in some instances, the cir- 
 cumstance was too striking to escape notice. 
 
 There is nothing so very curious in the fact that substances.
 
 LITHOLAPAXY. 279 
 
 occurring in the fluids of the body^ may become combined together 
 and be insoluble, but may return again to a soluble state as the 
 secretions and fluids alter. Physiological and pathological forma- 
 tion and absorption of bone shows us that this can happen. 
 
 LlTHOLAPAXY.^ 
 
 With the general introduction of anaesthetics attempts to prolong 
 the sittings in lithotrity went on hand in hand. Every one who 
 has performed lithotrity knows that the operation has something 
 exciting in it — almost like a hunt. The operator feels the stone 
 and thinks he can seize it ; it slips away, is again sought for, and 
 so the process goes on. Under an anaesthetic the surgeon is able to 
 work more quietly, and thus naturally was led to prolong the 
 sittings. Another circumstance whicb tended to the same 
 end was that, in recent times, attempts to remove the fragments 
 directly after lithotrity had met with more and more success. This 
 was accomplished by means of the so-called evacuation catheter 
 which had large openings on the concavity, the convexity or the 
 sides of the instrument ; narcotism again, favoured this endeavour. 
 Subsequently, special apparatus was made use of in order to suck 
 out the fragments and the grit. 
 
 With the help of technical improvements, it was no long stride 
 from this stage to the present method of crushing the stone and 
 removing it when possible, at a single sitting. Two years ago, an 
 American surgeon, Bigelow, made known the method which he 
 termed htholapaxy. Bigelow^s description must astonish every- 
 body ; he speaks of successful lithotrities, in which the patients had 
 been kept under a narcotic for three hours. The illustrious 
 Thompson has lately developed this principle still further. - 
 
 With regard to my own experience of lithotrity at a single sit- 
 ting, I have as yet only six cases to record; for a critical judgment 
 of the method, the respective values of these cases difi'ered, inasmuch 
 as the stones varied much in size and hardness. The first crushing 
 
 1 From the ' Wien. Med. Woch.,' No. 44, Oct., 1880, being an extract 
 from a paper by Prof. Billroth, read before the K. Iv. Gesellschaft der 
 Aerzte, in Vienna, on Oct. 22nd, 1880. 
 
 2 ' Practical Lithotomy and Lithotrity,' 3rd Ed., 1880, p. 182.
 
 280 LITHOLAPAXY. 
 
 operation I performedj -with the distinct intention of completing it at 
 one sitting was on the 8th June, 1879, on a man, 59 years of age. 
 Tiie stone measured three centimetres in diameter, and was com- 
 posed of uric acid and urates; the operation lasted forty-five 
 minutes. The second case was that of a man, set. 45, who was 
 operated on on the loth May, 1880; the stone was phosphatic and 
 ttneasured two centimetres in diameter. The operation lasted 
 tw^enty-three minutes. In the next two operations the stones were 
 the largest I have dealt with by this method ; one of them was a hard, 
 uric acid calculus, measuring three and a half, the other four centi- 
 metres in diameter. The first operation lasted fifty-five minutes 
 and the second two hours. In the fifth case the stone was phos- 
 phatic, and measured two and a half centimetres; the operation 
 lasted thirty minutes. In my last case, the stone measured one 
 and a half centimetres and lasted fifteen minutes. 
 
 The estimate of the diameters of the stones was taken from the 
 scale on the lithotrite. It is not easy to judge of the size of the cal- 
 culus from the expelled fragments. The size of the stone, which as 
 a rule one is apt to under-estimate considerably, may be determined 
 in the following way ; the debris is filtered through calico into a urine 
 glass ; the fragments that remain on the filter are then collected in 
 the cloth and firmly pressed together. By taking into account also 
 the measures of the different diameters, the shape may be deter- 
 mined more or less accurately. Of course this gives only an 
 approximate measurement, but I may state that by the use of this 
 method, I have observed that very often I had under-estimated 
 the] size of the stone from the fragments. I have often thought 
 that the whole stone could not have been removed, for the 
 fragments did not seem in proportion to the measurements. 
 
 In all the cases mentioned, the febrile reaction was trifling. The 
 patient in whom the operation lasted for two hours had a rigor 
 subsequently, but this was of a pui'ely nervous character, and with- 
 out]any increase of fever. Such rigors are common enough after 
 operations on the bladder. Some of the patients were well enough 
 to be discharged in from ten to twelve days. In order to determine 
 whether any fragments had been left, I make an examination after 
 four or five days, and repeat it on three separate occasions at intervals 
 of two days, sometimes with a full, sometimes with an empty bladder. 
 If I find no fragments at the third examination, I feel pretty well at 
 ease, but it is even then by no means absolutely certain that there
 
 LITHOLAPAXY. 281 
 
 is nothing left. I have heard by letter from patients in whom 
 four weeks after the operation small fragments have come away. In 
 any case we are able to learn by the repeated examinations whether 
 there is anything in the bladder that requires crushing, for stones 
 which cannot be felt, even after repeated sounding, could scarcely 
 be seized with the lithotrite. The operation obviously must be 
 looked upon as completed, when no more fragments can be felt, but 
 still there is always a possibility that we may be deceived, and that 
 the fragments cannot be felt, because they are enclosed in clots of 
 blood, so that there is no ring when they are struck. However, 
 nothing of the sort occurred in any of my cases. 
 
 I must further state that this method is distinctly deserving of 
 very earnest attention. It is a decided step in advance, and very 
 convenient for the patient, that one sitting only should be necessary 
 instead of three or more ; the more so, that the results, as given by 
 Thompson and Bigelow are, on the whole, better than those shown 
 by the earlier methods. 
 
 In my opinion, if we exclude all severe cases of cystitis and cysto- 
 pyelitis, in which no operation for stone is admissible, the danger 
 does not lie in the formation of pus, nor in the loosening of the 
 mucous membrane and consequently easily excited haimorrhage, 
 but in the strongly ammoniacal contents of the urine which may be 
 free or united with carbonic acid, and secondly, in tlie septo- 
 diphtheritic character which such cases generally assume. In a 
 bladder with strongly ammoniacal urine, as is known to pathological 
 anatomists, the lining membrane is much reddened, while on its 
 projections are often seen small shreds of dead tissue, to which 
 fibrinous clots are connected. This makes it appear as though the 
 process were of a diphtheritic nature, and it has also the same 
 character in another respect, viz. that it is highly dangerous for the 
 urine and secretion of the bladder to penetrate into the substance 
 of the mucous membrane, or into the surrounding tissue. It does 
 not matter how this is brought about ; it may be due to the in- 
 flammation alone, or the mucous membrane may be defective 
 between the pouches of the rugae, thus allowing some urine to ooze 
 through, or small excoriations may have been caused by the Htho- 
 trity ; in any case the condition will assume a diphtheritic type, 
 which spreads about the neighbouring cellular tissue. Unhealthy 
 suppuration with a tendency to rapid progress, pericystitis and peri- 
 urethritis may be set up, and these processes assume a virulent
 
 282 HYPERTEOPHY OF THE PROSTATE. 
 
 character from the commencernent. The point of the whole ques- 
 tion amounts then to this ; how can we get rid of amraoniacal 
 fermentation in the bladder ? That is the preliminary condition 
 required for success in a long lithotrity. Until the ammoniacal 
 urine is got rid of^ lithotrity generally, and especially that in one 
 sitting, is, according to my views, contraindicated, for it is in the 
 highest degree dangerous. 
 
 Hypertrophy of the Prostate. 
 
 Among forty-six cases I only met with one in which I was unable 
 to pass the largest sized catheter into the bladder. The patient had 
 complete retention. I was induced at length to try forcible cathe- 
 terisation with a straight instrument — an operation which has been 
 recommended by excellent surgeons, especially by Dupuytren. My 
 attempt was unsuccessful ; the instrument bent and did not pene- 
 trate the prostate gland. Eetro-peritoneal infiltration of urine fol- 
 lowed and the patient died. I do not advise any one to follow my 
 example. In such a case puncture of the bladder by the rectum 
 would have been the proper proceeding. In addition to this case, 
 seven of these patients died in the hospital of uraemia, marasmus, and 
 diphtheritic inflammation of the bladder. The others were sent out 
 after they had been taught to pass an instrument for themselves, 
 and earnestly advised to evacuate the bladder completely by means 
 of it every day. formerly, I used to advise these old men to 
 procure metallic catheters. Lately, I have made them practise 
 passing soft caoutchouc instruments (the so-called Nekton cathe- 
 ters). These instruments can often be introduced into the bladder 
 in cases of hypertrophied prostate with astonishing ease, while the 
 metallic catheters sometimes give trouble. The solidity of the 
 metal catheter is an advantage. 
 
 Inability to pass the water and great catarrh of the bladder with 
 alkaline urine, were the most frequent causes for which the patients 
 came to the hospital. The treatment of this vesical catarrh has 
 already been discussed. (Supra, p. 361 et seq.) 
 
 Twice I found the bladder full of half coagulated blood. By 
 injecting a good sized stream down a catheter, I managed to pump it 
 out ; in both cases there was inability to pass the urine for some
 
 VESICO-VAGINAL FISTULA. 283 
 
 weeks. It seems remarkable to me that Thompson advises blood 
 in the bladder to be left undisturbed. He states it will become fluid 
 by degrees without decomposing, and can then be easily evacuated 
 by the catheter. 
 
 In the case of a gentleman living at Pesth, to whom I was called 
 in consultation, I was unable to pass a catheter. In addition to the 
 enlarged prostate, there were false passages, and the patient was in 
 a very low and weak state. We punctured above the symphysis. 
 I never saw this operation done by my teachers, and this is the only 
 occasion on which I have performed it myself. I heard subse- 
 quently that the patient died two days later. 
 
 A rare case of prostatic abscess came into the hospital at Vienna. 
 The patient was sixty-five years of age. The abscess perforated the 
 peritoneal cavity and the man died of peritonitis. 
 
 Vesico- Vaginal Fistula. 
 
 While at Zurich I met with fifteen cases of this nature. Two 
 were cured by the application of caustic potash. On twelve others 
 I operated successfully; one left at her own request, before the 
 treatment was completed. In the old days these results would have 
 been considered remarkably brilliant. Since we have learned more 
 about the operation, and understand better how to refresh the parts 
 and insert the sutures, success is far more common than failure. It 
 is a curious fact that the cure of vesico-vaginal fistula has not been 
 brought about by any new methods of treatment, but only by 
 increased care in the simple matter of inserting the sutures, a 
 valuable hint for many other operations. I commonly employ silk 
 sutures, for I find that they answer just as well as wire, and are 
 more easily removed.^ 
 
 1 Some furtlier remarks on my method of operating, which may j)ossibly 
 differ in small particulars from that of others, will he found in Dr. deMont- 
 molin's essay " De la Fistule Vesico-vaginale." Neuchatel, 1864.
 
 284 EXTROVERSION OF THE BLADDER AND EriSPADIAS. 
 
 Extroversion of the Bladder and Epispadias. 
 
 Previous to 187 1 I had had no opportunity of treating any of 
 these cases. It seemed to me — as it has also to many others — that 
 the sacrifice of time, and the pain incurred by the patients were wholly 
 out of proportion to the results obtained. Since that date however, 
 I have been successful in a few cases, and there is now no doubt that 
 as time has gone on the principles and method of operation have 
 greatly improved. The length of treatment, too, is less than it was. 
 It is true that we cannot restore the functions of the malformed parts 
 completely, but we can materially improve the condition of these 
 unfortunate individuals. We are not able always to render male 
 patients with this malformation capable of coitus. I do not well see 
 how we can do so ; still it is by no means certain that a future genera- 
 tion of surgeons will not achieve this result. After the bladder is 
 covered in and the urethra formed, the patient may be considered 
 cured, so far as the plastic operation is concerned, but the further 
 difficulty arises of providing by artificial means for the retention of the 
 urine. Herein the prothesis has to fit in with the operative result, or 
 vice versa. These are purely technical difficulties, which can and must 
 be solved. 
 
 The cases are so rare that one cannot arrive early at any definite 
 conclusion. Up to the end of 1876 I had operated on nine persons 
 with extroversion of the bladder, and epispadias ; three died ; 
 one was sent away unimproved ; four were cured ; one is still under 
 treatment. One of the fatal cases was of considerable interest ; the 
 cause of death was pyelitis, an aflPection which seems to be distinctly 
 connected with extroversion of the bladder. 
 
 The case was that of a man, tet. 28, who had frequently passed 
 pure pus from the right ureter before the operation. Whenever this 
 symptom occurred, the patient felt ill and had pains in the neigh- 
 bourhood of the kidney. The urine coming through the other 
 ureter was normal and contained no pus. I had several times 
 operated on the patient after my own method, and the only thing 
 that remained to be done was, to close the so-called " funnel '' at 
 the symphysis. An attack of erysipelas followed the operation ; 
 the wound became diphtheritic, and the urine strongly ammoniacal. 
 The patient withstood the disease three weeks before he finally suc- 
 -cumbed. The post mortem revealed extensive pyelitis on the right
 
 EXTROVERSION OF THE BLADDER AND EPISPADIAS. 285 
 
 side^ and a slight degree of the same condition on the left. The 
 right ureter and the pelvis of the kidney were immensely dilated ; 
 the former especially was dilated and convoluted to a degree that 
 one would expect only to find when the passage of the urine had 
 been materially obstructed by stone or stricture, for years. I was 
 surprised on finding this, when I remembered how well my patient 
 had gone on after the previous operations. The most minute exa- 
 mination failed to detect any contraction in the course of the ureter, 
 or at its orifice. There is no doubt that the source of the mischief 
 lay in a sharp bend of the ureter just before it opened through the 
 posterior wall of the bladder which bulged forwards owing to the- 
 malformation. The effects that may be induced by such twists and 
 bends have been described by Wolfler.^ 
 
 The degree of bending must vary much in different cases, others 
 wise every adult with extroversion of the bladder w^ould be the sub- 
 ject of pyelitis. Now that attention has been called to this compli- 
 cation, it will probably be more frequently observed. At the time 
 of writing (1878) I have under treatment, a child twelve years old, 
 with extroversion of the bladder, who suffers from pyelitis of the 
 right side. After every operation there is an exacerbation, espe- 
 cially when the urine becomes alkaline. In another case, too, in 
 which I had successfully covered over the defective bladder with 
 flaps, the whole improvement was lost after an operation to close a 
 fistula that was left. The urine became ammoniacal and it was 
 evident that diphtheritic inflammation had attacked the posterior sur- 
 face of the new formed covering to the bladder. The inflammation 
 took on a destructive character ; first the cicatrices gave way and 
 then the flaps themselves were destroyed. 
 
 At first I used to cover over the extroversion by paring and 
 uniting the abdominal walls after previously detaching the bladder 
 from them. Then, for a while, I tried making two lateral 
 pedunculated flaps from the abdominal wall. Now I have come to 
 the conclusion that the best method is to dissect up two broad, 
 lateral, doubly-pedunculated flaps, whose narrow parts lie above and 
 below. After ten or fourteen days, when the under surface is gra- 
 nulating well, I unite the two in the middle line without cutting 
 through the peduncles. If the flaps be sufficiently broad, there is 
 no need to unite them by their outer edges ; these lateral openings 
 close spontaneously in from five to six weeks. The bladder is thus 
 ' 'Wien. Med. Wocli.,' 1876, ^i. 295.
 
 286 EXTEOVEKSION OP THE BLADDEE AND EPISPADIAS. 
 
 completely covered in, but an opening should be left at the umbili- 
 cus through -which the urine may escape until the urethra below is 
 completely formed ; then the umbilical opening is closed, and it heals 
 up as the urine escapes below by the newly-formed passage. I intend 
 to describe this method more minutely and with the aid of illustrations 
 hereafter, when the number of my cases is somewhat larger. 
 
 The flaps must be made very broad, that is to say in an a dult 
 they should be at least six centimetres broad in the middle and 
 about five at the upper and lower parts. In a child of course they 
 should be somewhat, but still not so very much, smaller. The 
 flaps should be so completely detached as to overlap each other for 
 about half their width; a sheet of tinfoil is then laid underneath 
 them in their whole length. In a few days they approximate so 
 much that their curved shape becomes straight ; later on, notwith- 
 standing a certain amount of rigidity, they will readily unite in the 
 middle line. A broad surface must be made by scraping away the 
 granulations and the superficial developing epidermis from the 
 edges. At first I suspected that this median cicatrix might possibly 
 give way as the bladder was pressed forward, so that a sort of vesi- 
 cal hernia might form, as happens occasionally under similar condi- 
 tions after laparotomy ; I have, however, a case under observation 
 which was cured five years ago, and which satisfactorily proves that 
 such a fear is groundless. 
 
 The wounds of the abdominal wall, after the formation of flaps 
 on both sides, are of rather formidable size ; the haemorrhage can 
 easily be controlled. If the flaps be made too small, a strip of the 
 tissues, either about the centre or above it, is apt to slough. Such 
 an occurrence will seriously depreciate the result. A further dis- 
 advantage of making the flaps too small is that lateral openings will 
 be left which are very difficult to close. 
 
 We are constantly trying to improve the apparatus to provide 
 for the retention of the urine. A form of apparatus adapted to one 
 of my cases (a child six years old) will be best understood from the 
 illustration (Plate IV, figs. 7 a and 7 h). 
 
 I do not think that these operations should be undertaken before 
 the age of about four, for, in my method of operating, the first pro- 
 ceeding is of a very formidable nature. The only object in operating 
 earlier lay in the hope that the symphysis might spontaneously 
 close after the operation, just as the fissure in the alveolar process 
 closes up after operation for hare-lip. It was thought too that pos-
 
 EXTEOVEESION OF THE BLADDER AND EPISP^DIAS. 287 
 
 sibly the union of the symphysis might bring about also the closure 
 of the sphincter vesicae. I do not think that this expectation will be 
 fulfilled as long as the penis is not detached from the ends of the sym- 
 physis and allowed to sink back. The completion of the operation 
 when children are about four years old, will always have the advan- 
 tage that as the prolapsed bladder is covered up, the little patients 
 avoid a part of the distressing effects of this malformation ; but it 
 requires an intelligent person to apply and constantly wear with 
 due care the required apparatus. Such intelligence can hardly be 
 looked for before the patients are ten or twelve years of age. 
 Further experience is necessary in order to prove whether the pyelitis 
 with which extroversion of the bladder is in so many cases asso- 
 ciated, can be improved or cured by the operation. I do not myself 
 feel very hopeful on this point. I hope there are many of my col- 
 leagues like myself, who take a special interest in gradually over- 
 coming difficulties which at first seem invincible. The records of 
 what I have been able to achieve are to me as so many sign-posts 
 pointing out what still remains to be striven for and attained. 
 
 I learn, through the kindness of Dr. J. Mikulicz, that Prof. 
 Billroth's experience of these operations since writing the above has 
 not been of a very encouraging nature. Some of the patients 
 operated on died of cysto-pyelitis, and this complication seems on 
 the whole to have justified the rather gloomy forebodings expressed 
 in the above pages. Tor the past two years Prof. Billroth has not 
 operated on any of these cases. — [Ed.]
 
 CHAPTER XIII. 
 
 t 
 
 DISEASES OF THE MALE GENERATIVE ORGANS. 
 
 Case of serpiginous sypJiilitic ulceration. Cases of cancer of the 
 prostate — Bemoval. Case of hydrocele with thickened calcareous 
 sac. Radical treatment of hydrocele. Remarks on chronic in- 
 fiammation of testis. " Tubercular testis" — Treatment. Chronic 
 orchitis leading to suppuration. Castration. Cases of malignant 
 sarcocele. Remarks, 
 
 Serpiginous syphilitic ulceration. 
 
 E. W — , set. 33, had contracted twenty-seven months previously a chancrfr 
 at the orifice of the urethra. This was followed, after three weeks, by enlarged 
 inguinal glands which rapidly ran on to suppuration. Ulcers formed about 
 the scrotum. The ulceration and suppuration extended until almost the 
 entire scrotum and the skin of the lower part of the abdominal wall were 
 destroyed. Whilst infiltration appeared at one part, the ulceration healed 
 at another ; at the margins of the cicatrices fresh infiltration constantly 
 appeared, and broke down. Inociilation of the secretion on the arm gave 
 rise to the same infiltration and ulceration. The greater part of the ulceration 
 healed up after the application of caustic potash. 
 
 Carcinoma of the prostate, 
 
 I met with one case of this nature at Ziirich in a man, ajt. 30. In the 
 course of five years the tumour had reached the size of a duck's egg. It was 
 very soft and could be felt in the perinreum and the rectum. I extii-patcd 
 the growth, but found that the tumour had partly extended into the bladder, 
 and wa.s forced to make a lateral opening the size of a shilling, in order to 
 get it all away. The wound healed up completely, but unfortunately 
 recurrence began in the cicatrix after two months, and the patient died 
 about a year later. The growth proved to be a soft, alveolar cancer, ulcerated 
 and breaking down on the vesical surface.
 
 HYDROCELE WITH THICKENED SAC. 289 
 
 Another case whicli came under my care in Vienna in 1873 did not 
 nufoiinuately meet with such good success. The man was 56 years of age. 
 He died four days after the operation from septic phlegmonous inflammation 
 of the retro-peritoneal cellular tissue. 
 
 Hydrocele. 
 
 In one case of this nature we found a number of spermatozoa 
 which were precipitated in the glass, and showed active movements 
 after a long period of time. An iodine injection was thrown in and 
 the patient recovered. 
 
 Hydrocele with a nmch thickened tunica vaginalis. 
 
 A man, set. 51, stated that after a blow received when he was veiy young, 
 the right testis became harder and larger than the left. The swelling had 
 slowly increased for ten years previous to admission ; three months previously 
 it broke spontaneously. Since that time some thin, purulent fluid had 
 escaped. The tumour was the size of the fist and of almost bony hardness . 
 I made an incision through the skin and with the bone jiliers laid open the 
 tunica vaginalis, which was covered on the inner surface with layers of cal- 
 careous deposit ; most of these were removed and the rest were thrown ofE 
 by the subsequent suppuration. 
 
 Radical Treatment of Hydrocele. (W. B.) 
 
 Although I have performed the radical operation for hydrocele on 
 138 patients, my records are so far insufficient that I can only state 
 the exact details in sixty-seven. Of these, the hydrocele was on the 
 right side in thirty-three, on the left in twenty-four, while in ten 
 it was double. It is well known that hydrocele is met with in new- 
 born children, and as the oldest of the patients on whom I operated 
 was seventy-seven, we may fairly say that no age is exempt. My 
 impression is that individuals between the ages of thirty and fifty 
 are most liable to the affection, but formerly I kept no notes on this 
 point, and must leave it to others to confirm or refute my state- 
 ment. Nor can I furnish much information on the etiology of the 
 disease. In the majority of cases the patients are unable to give 
 any minute account of the period of origin. By dint of cross-exa- 
 mination we can sometimes make out that there was a blow or 
 
 19
 
 290 EADICAL TEEATilEXT OF HYDROCELE. 
 
 pressure ; sometimes that gonorrheal orchitis preceded the hydro- 
 cele by a few years ; but this is not of such common occurrence 
 that we should be justified in assuming that because gonorrhoea and 
 hydrocele are common affections, there is any etiological connection 
 between the two. In fact we must admit that in the majority of 
 cases the causes of origin of hydrocele are perfectly unknown. 
 
 I have never operated in hydroceles in children, for the affection 
 almost invariably disappears spontaneously. The youngest patient 
 on whom I operated was fourteen years of age. He had a hydro- 
 cele of the spermatic cord. 
 
 My teachers, Baum and v. Langenbeck, instructed me that any 
 ordinary form of hydrocele could be cured by puncture and 
 injection of iodine. V. Langenbeck saw the affection return in a 
 few cases, and thereupon employed chloroform injections for a time, 
 but recurrence followed also after the use of this remedy. Baum 
 told me in conversation once, that when recurrence took place after 
 the iodine injection it was either due to some defect in the method 
 of operation, or to the fact that the iodine solution was badly pre- 
 pared. 
 
 The process of cure is, that the iodine forms a precipitate in the 
 tunica vaginalis ; there it remains for a long time undissolved, and 
 leads to shrinking of the membrane. No further effusion can 
 therefore occur. It is erroneous to suppose that injection of iodine 
 always causes complete adhesion of the inner surfaces; partial 
 adhesions may at times form, but this is not the main thing. The 
 shrinking of the tunica vaginalis, is the reason for the cessation of 
 the secretion. The results of iodine injections for hydrops articuli, 
 hydro-nephrosis, or into ovarian cysts, show that the opposing 
 surfaces do not become united together ; if this were the case the 
 result of this treatment for hydrops of the knee would always lead 
 to ankylosis of the joint; it is obvious that complete adhesion of 
 the synovial surfaces would produce perfect immobility. 
 
 When I was younger, curiosity led me at times to try other 
 methods of treatment; thus, in two cases of hydrocele I employed 
 electrolysis ; in one of the cases the condition returned as before. 
 
 In 125 instances I used iodine injections and none of the patients 
 came back to me with recurrence of their complaint ; it was of course 
 possible, that in one or two the aff'ection returned, and that they 
 sought other advice. I doubt it, for people with recurrence of 
 tumours or chronic inflammations nearlv alwavs came back to me.
 
 " CIECUMSCRIBED CHEONIO ORCHITIS." 291 
 
 I may add that during my whole surgical experience no patient has 
 ever come before me with a hydrocele recurring after it had been 
 tapped and injected with iodine by another surgeon. 
 
 A few surgeons lately have revived the treatment of hydrocele 
 by incision, and speak well of the results obtained under antiseptic 
 treatment. When I was a student this method of treating hydrocele 
 was considered antiquated and uncertain ; the few cases where the 
 affection returned after operation were those in which incision had 
 been adopted. 
 
 My method of treating hydrocele now is as follows : — I evacuate 
 all the fluid, and then inject two ounces of a mixture containing 
 equal parts of our officinal tincture of iodine and water; the tincture 
 of iodine is always freshly prepared. This mixture I allowed to 
 remain in the tunica vaginahs for five minutes ; meanwhile I 
 manipulate the sac in such a way as to bring the fluid in contact 
 with every part of the lining membrane. If there is any pain I allow 
 all the injected fluid to escape ; if there is no pain I leave a quarter 
 or a third of the fluid in the sac. 
 
 It not infrequently happens that the day after the operation the 
 tunica vaginalis is found to contain some gas. This may have got in 
 at the time of operationj and become expanded by the temperature 
 of the body, or it may be the vapour of the alcohol and iodine. 
 There is never any occasion to evacuate this gas, for it will always 
 be absorbed without trouble. 
 
 Inflammation of the Testis. 
 
 Cases of epididymitis and orchitis which were neither of gonor- 
 rhoeal nor syphilitic origin were usually designated as " tubercular 
 testis." I have endeavoured to substitute for this name the general 
 term of " circumscribed chronic (caseous) orchitis," for the expres- 
 sion " tubercular " compels us too much to assume that this disease 
 is etiologically connected with the tubercular diathesis. This is by 
 no means always tlie case. By reason of the anatomical arrangement 
 of the separate lobules of the testis, disease of one division of this 
 gland does not readily extend into another. The formation of 
 nodules in the testis is scarcely ever due to the coalescence of 
 numerous small miliary nodules into one large mass ; the limitation 
 results from the strong septa which partition off the gland into
 
 292 CHRONIC ORCHITIS AND IMPOTENCE. 
 
 t^eparate divisions. The lymphatics pass separately out of each 
 division to the spermatic cord, through the corpus highmori, so 
 that the lymph of the venous blood and the secretion of the gland 
 all flow out in the same direction. It is more difficult to explain 
 the formation of nodules in the epididymis. I think that the 
 irritating effusions are stored up here and there with the lymph in 
 the lym])hatics ; these latter are — like the veins — much convoluted, 
 being often bent on themselves and forming loops, and from them the 
 irritation spreads to the surrounding parts. So far as I know, it 
 has not yet been proved that these nodules in the epididymis are 
 composed of miliary tubercle. Traumatic, functional, or infective 
 irritation may give rise to the formation of such nodules : of this 
 I have no doubt. In tuberculous subjects the condition very 
 rarely gets weU of itself. On the other hand, we can hardly 
 presume that the tuberculous diathesis exists in cases where such 
 nodules are found in a strong healthy man without any family 
 history of tubercular disease. If there has not been any previous 
 gonorrhoeal or syphilitic infection, or any traumatic cause, we 
 ^shall be left completely at a loss to determine the etiology. 
 
 The patients are rarely able to give any minute information 
 about the origin and gradual increase of this affection. The nodules 
 pass unnoticed at the outset, and often remain for years without 
 any alteration after they first attracted attention. Softening and 
 enlargement is nearly always a sure sign that the growth is about 
 to suppurate and break through, but the process may take months 
 to accomplish. Very frequently two or three of these nodules, 
 varying in size from a bean to a walnut, form close to each other; 
 not infrequently the disease attacks both glands. 
 
 If I meet with indolent nodules of this description in subjects 
 otherwise healthy, I adopt no treatment and advise the patients 
 not to trouble about the matter. If some remedy be thought 
 necessary I prescribe iodine inunctions or compresses soaked in 
 Lotio Plumbi. I have never seen these nodules disappear spon- 
 taneously and consider them incurable. Once only, at the urgent 
 request of a patient, I removed a growth of this description, 
 although it was neither softened nor ulcerated. The patient — a 
 strong man — had become impotent ; he was informed by his 
 medical attendants that the condition was due to the pressure of 
 the nodules on the vas deferens. In such cases, simple pressure on 
 the vas is but rarely met with : far more frequently the larger
 
 CHEONIO OECHITIS AND IMPOTENCE. 293- 
 
 spermatic ducts and epididymis are involved in the degeneration, 
 and so rendered impermeable. Generally, however, even when 
 the disease affects both sides, a number of the spermatic ducts, 
 sufficient to effectually prevent impotence, remain pervious. In the 
 case above mentioned, I acceded ultimately to the wish of the patient, 
 although I openly expressed my doubt whether the operation 
 would have any effect on the impotence ; I laid open the scrotum 
 on both sides, drew out the testes, carefully removed the nodules^ 
 replaced the organs, and then sewed up the wound in the scrotum. 
 All the parts healed up by first intention ; the operation and the 
 rapid healing had an additional interest for me in that it was the 
 first that I performed under the antiseptic system. This was in 
 the spring of 1875. Notwithstanding repeated attempts, I was 
 unfortunately unable to learn whether the operation had the desired 
 functional effect. Where no impoterce existed, I should not advise 
 an operation of this nature; we might be unlucky enough to 
 injure the few spermatic ducts still remaining pervious. The 
 affection is so indolent, and the nodules remain stationary for so 
 long in many of these cases that the patients are seldom induced 
 to demand operation. No doubt there are individuals who 
 become deeply hypochondriacal from the idea that these nodules 
 may cause impotence, and so are very anxious to get rid of them. 
 
 The conditions are different when the nodules are softened and 
 fluctuating, or when they have already broken externally and it 
 becomes necessary to cure the sinus. Such cases are most pro- 
 bably associated with a tubercular diathesis. If bronchial catarrh 
 is present or the apices of the lungs are already infiltrated, it is 
 better not to resort to any operative means. The suppuration in 
 any case is usually but slight after spontaneous opening, and may 
 be still further limited by repeated energetic cauterisation of the 
 sinuses at intervals of fourteen days or so. Under this treatment 
 the sinuses occasionally close, but such a result cannot as a rule be 
 looked for. If there is no distinct proof of any tubercular disease 
 in other organs, I enlarge the sinuses with laminaria or the knife^ 
 scrape out the abscess walls with a sharp spoon, and then introduce 
 charpie soaked in Liquor Ferri and dried, and wait until it iS' 
 thrown off by suppuration. Not infrequently a cure is obtained in 
 this manner. Castration is only suitable for cases where the testis 
 is studded with numerous softened nodules, and where after some 
 months the thickened walls of the cavity have shown no tendency
 
 294 CHRONIC ORCHITIS LEADING TO SUPPURATION. 
 
 to retract. Even in such, perhaps, the condition may be just as 
 well left as it is. 
 
 Cheonic Orchitis going on to Suppukatiox. 
 
 I saw no instance of this disease in Northern Germany ; T cannot 
 say whether this was a coincidence or whether it is of rare occur- 
 rence there. At Ziirich I met with nine cases, occurring in men 
 between the ages of twenty-one and sixty. The disease usually 
 occurred in healthy subjects and generally without known cause, 
 though in one instance it followed a blow. Abscesses slowly formed 
 in different parts of the parenchyma which became filled with cheesy 
 pus and lined with spongy granulations. The process may go on 
 for years without giving any pain. It usually leads to complete 
 destruction of the testis without materially affecting the general 
 condition. In two cases the disease had existed for twelve and fif- 
 teen years respectively. Twice I opened up the largest of the 
 abscesses, scraped away the spongy granulations, and applied com- 
 pression by means of strap])iug. The sinuses healed up, but 
 whether fresh suppuration occurred later I do not know. In none 
 of these cases had the patients any pulmonary disease, nor was 
 there any history of gonorrhoea or syphilis. This form of chronic 
 orchitis can often only be diagnosed by the history of the case ; 
 sometimes even by anatomical exami7iation it cannot be distin- 
 guished from tubercular or syphilitic orchitis. It always seems to 
 me as if in Switzerland the aflection occupied the place of tumours 
 of the testis. It is remarkable that, during a period of seven years 
 and a half at Zurich, I met with no case of cystic or enchondroma- 
 tous disease of the testis, and only three cases of malignant affection 
 of the organ. At Berlin no semester passed without many coming 
 under observation. 
 
 With regard to the operation of castration, I may remark that in 
 two cases I divided the cord with the ecraseur. The division was 
 performed very slowly, yet haemorrhage came on in a few hours in 
 both cases. This shows, at any rate, that the method is unsuited 
 for private practice. I usually tie the vessels singly after cutting 
 through the cord, but I think that they may just as well be liga- 
 tured en masse, provided that a sufficiently strong thread be 
 employed.
 
 MALIGNANT (?) TUMOUR OF THE TESTIS. 295 
 
 Malignant (J) tumour of the testis. 
 
 J. B — , set. 53) tad received a blow on the right testis a year previously. 
 Since then the organ had slowly enlarged, and when admitted it was the size 
 of two fists. The growth was removed. It consisted of a tough fibrous 
 capsule the thickness of the finger, containing blood-stained seram. On the 
 inner surface of the cavity were shreds of tissue ; traces only of the parenchyma 
 of the testis were found in the capsule. The histological report left it 
 uncertain whether the tumour was a softened carcinoma, an altered extravasa- 
 tion of blood, or both together. A year later the patient was quite well. 
 
 The following case is remarkable on account of the age of the 
 patient : 
 
 F. D— , ret. 1 1 months, was admitted for a tumoui- of the left testis which 
 had commenced two months previously without known cause. Fluctuation 
 was distinct in parts ; an incision was made and let out a little pus, but the 
 tumour only partly collapsed. Fungating granulations sprang out of the 
 incision and the inguinal glands became enlarged. The mass was removed 
 and proved to be a medullary cancer. 
 
 Between i860 and 1876 I met with twenty-six cases of tumours 
 of the testis. No instance of cystic or enchondromatous tumour 
 came under my notice. In examining these growth with the micro- 
 scope I was often in doubt as to whether they were sarcoma or car- 
 cinoma. The peculiar structure of the gland causes most of the 
 growths which originate in it to assume a lobulated, cancer-like 
 alveolar nature. The tissue of these new formations is usually soft. 
 It is often impossible to say whether the new formation originates in 
 the soft, delicate cellular tissue of the organ, from the endothelium 
 of the lymph sinuses contained therein, or from the epithelial cells of 
 the seminal ducts. The rapid fatty degeneration and softening and 
 the hsemorrhagic infarcts occurring in these new formations render 
 the examination still more difficult. It is most desirable that this 
 subject should be thoroughly worked out.
 
 CHAPTER XIV. 
 DISEASES OF THE FEMALE GEXEBATIVE ORGANS. 
 
 Case of j)rematunti/. Case of polypoid growths of tTie vagina and 
 urinary bladder ifi a child. Case of ovarian cyst. Large 
 uterine jihroma containing central cyst. Boiiltful ovarian 
 tumour treated by iodine injection. Ovariotomy — Remarks on 
 140 cases. Laparo-hysterotomy. Recent modifications in 
 method of operating ( 1 8 8 1 ) , 
 
 Trernaturity. 
 
 E. A — , set. 4. From birth the breasts were noticed to be i-ather largely 
 developed. When first seen they were of a size corresponding to that nsuaUy 
 seen in our climate, in girls of sixteen or eighteen. When three and a half 
 yeare old there was some muco-sanious discharge from the vagina lasting 
 several days. This was distinctly not due to any injury. Menstruation had 
 not occurred again since that time. On the mons veneris and the labia 
 majora light haii-s half an inch in length were seen. Per rectum a movable body, 
 about the size of a walnut, could be felt which probably was an enlarged 
 uterus. In other respects the child physically as well as mentally was nor- 
 mally developed for its age. 
 
 Rapillary jjolypoid vegetations of the vagina and urinary bladder in 
 a child eighteen months of age. 
 
 The case was one of a very peculiar nature. According to the parents the 
 child's health had been perfectly good up to two months previously. It then 
 had pain during micturition, and mucus, pus and blood were often seen about 
 the genitals. When admitted the vagina was found to be full of vegetations. 
 Some were soft and wart-like, others pedunculated and polypoid ; from all of 
 them a quantity of pus was secreted. The orifice of the urethra was choked 
 up with similar vegetations, and when a catheter was introduced pus escaped 
 thi'ough it before the urine flowed. The vagina was washed out constantly 
 with astringent injections, and subsequently I removed the growths at several
 
 H^MATOMETEA. 297 
 
 sittings. The cliild wlio at the outset had very little appetite, gradually sank 
 and died twenty-four days after admission. 
 
 At the post-mortem examination, growths, similar in natui'e to those 
 descrihed above, were found in the lower paii of the bladder, the portio 
 vaginalis and the canal of the cervix uteri. In addition there was pus in the 
 peritoneum and an abscess of considerable size in the left kidney. It could 
 not be determined whether the condition had originated from gonorrheal 
 infection. 
 
 Hamatometra, 
 
 S. W — , set. 27. Twelve months previously she had a child which was 
 delivered with forceps. The lying-in was attended by serious illness lasting 
 four weeks. The menses did not reappear as her health improved. For five 
 months at stated times she had suffered from severe pain about the sacrum 
 and in the uterus. For a few weeks immediately preceding admission, the 
 pain in the lower part of the abdomen had been tolerably constant. The 
 application of some leeches over the painful part gave no relief. The patient 
 was a tolerably strong woman. The uterus was enlarged to the size of a 
 large fist, and lay rather to the left of the middle line. On examining per 
 vaginam no portio vaginalis uteri could be found. Its place was occupied by 
 some tough cicatricial tissue having a small opening on the left side, from 
 which some sanious pus escaped ; a catheter passed into this, ran upwards 
 towards the left for an inch and a half. The canal, which was possibly the 
 remnant of a former abscess, terminated in a csecal extremity. A fortnight 
 after her admission, I made an incision, strictly in the middle line, into 
 the cicatricial tissue, through which fluctuation was distinct. Some tarry 
 blood escaped, which by moderate pressure on the uterus through the abdomen 
 could be made to flow in large quantity. The operation seemed exceptionally 
 successful. During the next two days the patient went on well, but on the 
 fourth day she complained of severe pain suddenly occurring in the lower 
 part of the abdomen. The pain increased and extended, and within five hours 
 she had all the symptoms of " foudroyante " peritonitis. No remedies wero 
 of any avail, and she died the following day. 
 
 Post mortem. — Six ounces of ill-smelling, turbid, purulent fluid in the 
 abdominal cavity. The intestines distended. The peritoneum covered with 
 a viscid, sticky layer, which in the cavity of the pelvis was more fibrinous in 
 character. Hsematometra was found in accordance with the diagnosis ; 
 both Fallopian tubes were tortuous, with pouch-like dilatations, and full of 
 taiTy blood. In one of the pouches in the right Fallopian tube was a small 
 opening, from whicli a little blood only escaped. Probably this part had 
 been adherent to the intestines. The ostia abdominalia of both Fallopian 
 tubes were closed ; the uterine openings were so naiTowed that the very 
 finest sound could not be readily passed in. 
 
 The above case closely resembles one described by E. Rose in his 
 work entitled " Die Operation der Hgematometra/' {' Monatschr. fiir 
 Geburtskunde u. Frauenkrankh./ Band 29 and 30).
 
 298 OVARIAN CYST. UTERINE FIBROMA. 
 
 Ovarian cyst. 
 
 E. K — , aet. 21, strong and healthy-looking, stated that three and a half 
 years previously the lower part of her ahdomen hegan to increase in size 
 rapidly. The catamenia commenced when she was seventeen. Two yeai"s 
 previously, her medical attendant had punctured the swelling, and let out 
 twenty pints of fluid. Within twelve months the distension had returned to 
 its former size, and the same amount of fluid was again evacuated Five 
 months before admission, the swelling had been punctured a third time, and 
 the usual amount of fluid withdrawn. "Wlien the patient was admitted, the 
 abdomen was distended as in the last month of pregnancy. Fluctuation was 
 everywhere distinct. I made a puncture in the left side, but drew off only 
 two pints of brownish-red viscid fluid. Another puncture in the middle line 
 allowed one pint only of fluid of the same nature to escape. It seemed scarcely 
 conceivable that the tumour, which had formerly been a simple cyst, had now 
 become multilocular. A few days later, thinking that the cyst-contents 
 might be particulai-ly thick, I punctured with a large trocar in the right 
 side. Death followed in thi*ee days from peritonitis. Post mortem : the 
 cyst was found to be united to the abdominal wall so firmly that it could not 
 be separated without tearing the peritoneum ; adhesions had taken place also 
 to the intestines and omentum. The opening of the puncture gaped, and a 
 large quantity of the cyst-contents were found in the abdominal cavity. The 
 walls of the cyst were rigid, a quarter of an inch thick, and rough on the 
 inner side. Deep down in the large sac was a finn tumour, containing 
 numerous smaller cysts. 
 
 Large fibroma of the litems, containing a central cyst. 
 
 B. K — , a?t. 39, stated that when about eighteen she suffered from chlo- 
 rosis. When twenty-eight yeai-s old she had a child. Seven yeare before 
 admission she experienced a good deal of pain in the abdomen, and a prolapse 
 of the vagina and uteinis formed, which, however, gradually disappeared 
 without any special treatment. Three yeai-s later, she noticed swelling of 
 the abdomen, and deep down in it, a spherical, hard tumour-. This constantly 
 increased up to the time of her admission. During all this time the menses 
 had been very abundant, lasting from ten to fourteen days, so that at times 
 there was no interval between the periods. This had much reduced her 
 strength. The patient was of a weakly frame. The abdomen was distended 
 as in the eightli month of pregnancy. The tumour fluctuated distinctly, but 
 the history, and the fact that the cavity of the uterus measured seven inches, 
 showed that the case was one of uterine tumour. I punctured the swelling 
 and let out two quarts of clear serum. The tumour collapsed to some extent 
 after this proceeding. No reaction followed. As extirpations in such cases 
 are usually unfavourable, I did not advise operation. 
 
 The following case may be given rather more fully.
 
 OVAEIAN TUMODK TREATED BY IODINE INJECTION. 299 
 
 Ovarian tumour (?) treated hy puncture and injection of iodine. 
 
 Marie K — , set. i8, had noticed for four years the development of an 
 abdominal tumour, which had occasioned her no pain. The menses com- 
 menced when she was 17 and were regular. She could assign no cause 
 for the origin of the disease. A year previously the tumour had disappeared 
 of itself in the coui'se of two days, and at this time the patient stated that 
 she passed enormous quantities of urine (rupture of the cyst into the bladder). 
 Gradually the swelling returned. Six months before admission a large quan- 
 tity of clear, watery fluid was evacuated by puncture. When admitted the 
 abdomen was distended as in the eighth month of pregnancy, and all the 
 symptoms pointed to a unilocular ovarian cyst. The tumour was punctured 
 a few days after admission, and a large quantity of perfectly watery fluid 
 escaped. A mixture of tincture of iodine and water aa i| oz. was injected and 
 left in the cyst. The patient had rather severe pain for a few hours after 
 the operation. On the following day the abdomen was tender on pressure ; 
 the urine contained some blood. In both urine and saliva a large amount of 
 iodine was found. The fever diminished gradually and subsided altogether on 
 the fourth day ; there was then still a considerable quantity of iodine in the 
 urine. After about a week the fluid began to collect again to some extent 
 in the sac. She was then discharged at her own request. The evacuated 
 fluid was analysed, in the chemico-pathological laboratory of the hospital, 
 and the report was as follows : — " Pale, opalescent fluid, sp. gr. 1009, alkaline ; 
 100 parts of the fluid contained 98*90 of water, I'lo of solid residue. 
 
 (i) Organic substances 0*30. Small quantities of serum albumin, traces 
 of fat, and free fatty acids. No sugar. 
 
 (2) Inorganic materials o'So. Traces of sulphuric and phosphoric acid, 
 and a considerable amount of carbonic and hydrochloric acid. Some calcium, 
 sodium, potash, and traces of magnesia. 
 
 The possibility that the case was one of hydatid cyst cannot be 
 denied. Neither from the history of the case, nor from the analysis, 
 could an absolute diagnosis be arrived at. 
 
 I heard of this patient nine years after the operation. No trace 
 of the tumour could then be felt. She had married, and had borne 
 two children. 
 
 Eecurrence would hardly be expected in such a case as this, but 
 yet it would be desirable to have information, some years after the 
 operation, in other similar cases. Not long ago a patient came to 
 me, in whom one of my colleagues had, two years previously, treated 
 a unilocular cyst by iodine injection. Whether the cyst shrank up 
 completely at the time I cannot say, but when I saw the patient, 
 there was an ovarian tumour about the size of a hen's egg. I did 
 not advise, in this instance, any immediate operation. It is of
 
 300 
 
 STATISTICS OF OVARIOTOMY. 
 
 course very hard to decide in such cases whether the tumour be 
 due to the refilling of the former cyst, or whether it is a fresh 
 growth. It might be asserted that my diagnosis in the case above 
 quoted was possibly incorrect^ and that the cyst had not originated 
 in the ovary but in the broad ligament. I freely admit the possi- 
 bility ; my power of differential diagnosis does not reach so far. 
 
 Injection of iodine into ovarian cysts will always be a com- 
 paratively rare operation, for the treatment is only properly appli- 
 cable to unilocular cysts, with serous contents. Such cysts — 
 according to my experience — are very rarely met with. Excepting 
 the case described above, I have only met with one other, where 
 the method might have been adopted. 
 
 Ovariotomy. (W. B. 1876). 
 
 Between 1865 and 1880, I performed one hundred and forty 
 ovariotomies, with the results shown in the following table : — 
 
 
 
 
 Cases. 
 
 Recovered. 
 
 Died 
 
 In Zurich, 
 
 1865 
 
 
 I 
 
 I 
 
 
 
 In Vienna 
 
 1868 
 
 
 3 
 
 3 
 
 
 
 „ 
 
 1869 
 
 
 2 
 
 
 
 2 
 
 )> 
 
 1871 
 
 
 3 
 
 3 
 
 
 
 „ 
 
 1872 
 
 
 6 
 
 4 
 
 2 
 
 „ 
 
 1873 
 
 
 II 
 
 3 
 
 8 
 
 5> 
 
 1874 
 
 
 12 
 
 5 
 
 7 
 
 „ 
 
 1875 
 
 
 13 
 
 6 
 
 7 
 
 J> 
 
 1876 
 
 
 25 
 
 20 
 
 5 
 
 „ 
 
 1877 
 
 
 29 
 
 16 
 
 13 
 
 „ 
 
 I87S 
 
 
 31 
 
 20 
 
 II 
 
 >» 
 
 Jan. 
 
 and 
 
 
 
 
 
 Feb., 
 
 1879... 
 
 4 
 
 2 
 
 2 
 
 
 
 
 140 
 
 83 
 
 57 
 
 We often hear it urged in opposition to the constantly increasing 
 number of ovariotomies, that many ovarian cysts get well by spon- 
 taneous intra-abdominal bursting, while others are cured by tapping; 
 again, it is said that cysts, which are tapped every six or twelve months, 
 may go on for years without any great detriment to the patient. 
 I am far from doubting the occurrence of such cases, though in the 
 first two classes mentioned we may reasonably doubt whether the
 
 OVARIOTOMY. 30 1 
 
 diagnosis was always correct. Of one thing, however, I am quite 
 sure, viz. that fortunate cases of this description are rare indeed 
 as compared with the frequency of ovarian cysts. Simple cysts, 
 independent of any colloid tumours, are in themselves not of 
 common occurrence ; the number of cases too, where nothing can be 
 drawn off by tapping, and where, to all appearance, firm, or solid 
 tumours exist, is, according to my experience, just as large as the 
 number of cysts that admit of tapping. These firm tumours may 
 either consist of numerous small colloid growths, with tense walls, 
 or may be sarcomata, or dermoid cysts. The number of ovarian 
 cysts met with is quite astonishing to me, and when I reflect that 
 during the last five years my colleagues v. Dumreicher, Dittel, 
 Salzer, Weinlechner, Kumar, Mosetig v. Moorhof, v. Eokitansky, 
 and others, have performed ovariotomy more and more frequently, 
 it almost seems as if more and more ovarian tumours actually 
 arose for the operation. 
 
 Ovariotomy is one of the few operations about which I received 
 no instruction from my teachers ; I have only seen the operation 
 performed once, by any one but myself, viz., by Spencer Wells, 
 in the year 1865, at Ziirich; and in that case I saw nothing of the 
 after treatment. This case I took as my model, and Spencer Wells's 
 remarks on the most important points connected with the operation, 
 I adopted as the fundamental principles for my own guidance, when 
 I began to operate. My first case at Ziirich, and the first few in 
 Vienna, did remarkably well ; then came unsuccessful cases. I 
 followed the recommendations of other operators, and for a time, 
 improvement followed; notably in some of the very worst cases, I 
 succeeded beyond expectation. At that time I used to operate on 
 almost every case, on the principle anceps remedium melius quam 
 nullum. As a consequence my experience widened, but in many 
 cases the results were discouraging. Long before this I had felt 
 that ovariotomy as an operation was more than justified. I became 
 ambitious to extend the operation of laparotomy as far as possible 
 to cases deemed hopeless, and no complication deterred me. 
 Utilising all the recommendations of my colleagues, and often 
 varying my method in details, I have extirpated carcinomatous 
 tumours, sarcomata, omental tumours, the kidney, spleen, etc. 
 This practice had its good as well as its bad consequences. The 
 good results were, that I was able to save the lives of a number of 
 women on whom many of my colleagues would hardly have thought
 
 302 COMPLICATIONS OF OVARIAN CYSTS. 
 
 of operating; gradually also, as I became practised in the details 
 of the operation, I acquired a calmness when confronted with 
 difficulties, which has been of great advantage to my later patients- 
 On the other hand, I lost many of these bad cases, and, becoming 
 sceptical as to the value now of this now of that point of detail, 
 on the vital importance of which stress had been laid, I was con- 
 stantly wavering between one method and another. I may say 
 that it was not till I had performed the operation nearly a hundred 
 times that I was led to the conviction, that in few other operations 
 does so much depend on the operator's individual experience, seeing 
 that the number of complications is so multitudinous. 
 
 After a series of severe cases, which progressed favourably I hardly 
 selected my cases any longer ; still, I declined to operate on solid 
 sarcomatous or cancerous tumours with extensive connections to 
 the pelvis. In two such cases in which I operated, recurrence 
 quickly followed, and the patients only survived for a few months. 
 Irregular nodulated cancerous growths associated with much ascites, 
 at times appear to be very moveable, but they are usually united to 
 the omentum and small intestine by adhesions. Xot only is the 
 actual operation on such cases very dangerous (five patients on 
 whom I operated all died of peritonitis), but so many nodules will 
 often be found on the intestines, and on the inner surface of the 
 abdominal walls, that we are hardly justified in attempting removal. 
 Even if the operation be successful, there is but little prospect of 
 prolonging life. 
 
 Tabes dorsalis when associated with ovarian cysts is a dangerous 
 complication. One case of this nature died of gangrenous bed- 
 sores. Of two patients who suflFered from Bright^'s disease at the 
 time of operation one recovered and one died three years later of 
 general dropsy. Pleuritic effusion, which not uncommonly exists 
 in connection with large ovarian tumours, does not contraindicate 
 oj^eration ; the effusion seems sometimes to be caused by the pressure 
 of the tumour, and is rapidly absorbed after operation. Chronic 
 bronchial catarrh is a fatal complication, since the cough may lead 
 to abdominal pain and secondary haemorrhage from vessels in the 
 adhesions which did not bleed at the time of operation. I have 
 hitherto met with no cases where ovarian cysts were associated with 
 tubercular disease of the lungs. When symptoms of suppuration 
 in the cyst occur, the surgeon is placed in a serious dilemma. Such 
 an untoward occurrence when arising spontaneously is met with
 
 OVAEIOTOMY. 303 
 
 most frequently in dermoid cysts, but may take place also in colloid 
 growths, as the result, perhaps, of twisting of the pedicle. The 
 same result may follow frequently repeated puncture, tapping, or 
 draining. Those who look only to good statistical results, might 
 leave such patients to die without operating ; yet ovariotomy (perhaps 
 sometimes free incision) is the sole means by which these lives can 
 be saved. Out of three such cases I was successful in one instance. 
 The operation was followed by numerous abscesses and convalescence 
 was very tedious. The cysts will usually be almost universally 
 adherent ; at times, too, foul pus will be found in the meshes of the 
 loose adhesions, so that matters can hardly be expected to progress 
 smoothly. 
 
 The temperature of the operating-room was always kept at about 
 80° Eahr. This is a point of importance for cases in which numerous 
 adhesions or free hsemorrhage prolong the operation, and where there 
 is fear of anaemia and collapse. 
 
 It was formerly thought of great importance to make the incision 
 as small as possible. True, it is always desirable, if possible, to draw 
 out the entire cyst and its pedicle through an incision some three 
 inches in length, but this very rarely happens. I find that an 
 incision extending perhaps a couple of inches above the umbilicus, 
 does not in itself materially increase the risk, and it may be of the 
 greatest importance with regard to the further steps of the opera- 
 tion. 
 
 Undoubtedly, if a large incision be made, skilful assistance is 
 necessary to prevent the prolapse of the intestines. These should 
 be kept back by gentle pressure with large sponges, formerly, 
 when I thought it of importance to make the incision as small as 
 possible, I was accustomed to introduce my hand and separate 
 the adhesions as far as possible, before puncturing the cyst, so that 
 the vessels in the torn adhesions might contract with the abdominal 
 walls after the evacuation of the cyst. In most of the cases this 
 plan succeeded very well, but at times, a large amount of blood 
 escaped into the abdominal cavity, and it then became very difficult 
 to find the bleeding spots and to ligature them through the small 
 opening. 
 
 The development of large colloid tumours or cystomata massed 
 together may entail most serious difficulties ; sometimes puncture at 
 numerous points is of service, but if nothing flows out through the 
 cannula, either the incision must be extended far above the umbilicus.
 
 504 OVARIOTOMY. 
 
 or else a bold plunge must be made into the tumour, the septa of 
 the colloid cysts torn through, and the contents scooped out. This 
 answers well enough when the septa are thin and not too numerous. 
 If they are tough and vascular severe haemorrhage may come from 
 the deep parts. The tumour may be adherent, and it may not be 
 possible to expose it and the pedicle rapidly. Under such condi- 
 tions, the situation is grave ; the patients may lose much blood and 
 the operator be in a serious perplexity. If I were to find myself in 
 this dilemma, I should prefer to extend the incision, and draw out 
 the tumour deliberately, leaving my assistants to press back the 
 intestines by means of broad sponges. As soon as the tumour is 
 exposed down to the pedicle, an assistant should hook up the upper 
 end of the wound with his forefinger, and press together the 
 abdominal walls with the other hand. This is the best way of pre- 
 venting prolapse of the intestines. 
 
 Another condition may be met with which may embarrass the most 
 skilful operator, though careful examination will not usually fail to 
 detect it beforehand. I mean when the tumour (simple cysts I have 
 rarely met with) cannot be lifted up out of the true pelvis, but has 
 to be detached. In such cases a portion of the tumour is usually 
 enclosed between the folds of the broad ligament as if it were in a 
 hernial sac. If this portion of the tumour is firmly adherent, the 
 uterus may be so pushed up as to lie in front of the ovarian tumour. 
 
 In one such case where I operated, the uterus, which was pressed 
 out flat and studded with small fibromata, lay so high that on 
 opening the abdomen for a moment I thought my diagnosis was 
 wrong, and that the case was one of cystoma of the uterus. Under 
 such circumstances it is necessary quickly to discover the neck of 
 the sac, where the lower portion of the tumour is invaginated into 
 the ligament, and the tumour must then be carefully separated by 
 the hand. Tolerably severe parenchymatous hsemorrhage may 
 occur, and long-continued pressure with sponges be found necessary. 
 A pedicle proper can scarcely exist in such cases. The vessels, 
 which are often large and resemble cord-like adhesions, should be 
 ligatured before they are cut through. 
 
 Another complication that I have always found dangerous, con- 
 sists in adhesions to the uterus or bladder ; in separating them 
 great care is required. The only method of controlling the haemor- 
 rhage is to apply pressure. In two cases of this description, urine 
 escaped through the wound four or five days after the operation.
 
 CYS'flO PAPILLOMA. CATGUT LIGATURES. 305 
 
 the vesical fistula healed up spontaneously in the course of a few 
 weeks. In another case vesical catarrh and pain persisted for a 
 long time. 
 
 I have frequently found it necessary to ligature short adhesions 
 close to the intestine. I have twice seen fsecal fistula form a week 
 after operation, but in both instances the opening healed spon- 
 taneously in a few weeks. 
 
 On three occasions I met with cystic papilloma ; in all there was 
 much ascites ; the greater part of the growth had to be scooped out 
 with the hands. What astonished me was, that two of the patients 
 recovered and only one died of peritonitis. One of the successful 
 cases I heard of six months after the operation, and she was. then 
 well. The other was a woman some fifty years of age, who was 
 reduced to a skeleton and could scarcely breathe by reason of her 
 ascites. Both ovaries were found degenerated into cystic papil- 
 loma.^ I did not feel certain at the time that all the diseased tissue 
 was removed ; however the patient recovered, and when I saw her 
 two years later she had become stout and was in capital health. 
 There was no trace of recurrence. 
 
 Before passing on to the treatment of the pedicle, I must say a 
 word about the material employed for ligature. Tor some years I 
 used hemp, and when the adhesions were very thick I doubled or 
 trebled the threads, or substituted strong silk. I found it very diffi- 
 cult to acquire familiarity with the use of the catgut ligature. I had 
 been always accustomed when using hemp or silk to tie the knots 
 with the full strength of my hands, and thus, when I came to use 
 catgut I always broke it. Even when by practice I could apply 
 the ligatures properly, I found that the threads often became 
 detached by the sponging or by slight manipulation. I became 
 suspicious, too, of the material ; the carbolic oil in which it was 
 always kept till use was, as a rule, so rancid, that I could not 
 believe that it had any particularly antiseptic properties. I there- 
 fore put this material on one side and adopted silk again, taking 
 care always to soak the threads for half an hour in 5 per cent, 
 carbolic acid solution. 
 
 Tor a time I employed Paquelin's cautery in the case of small 
 adhesions, but found no particular advantage from its use. 
 
 1 The " cauliflower " growth of Dr. Wilson Fox. See ' Med.-Chir. Trans.,' 
 vol. xlvii, p. 246, A resume of Dr. Fox's views will be found in Spencer 
 Wells's ' Diseases of the Ovaries,' pp. 45 et seq. — [Ed.] 
 
 20
 
 306 TEEATMENT OF PEDICLE. CARBOLIC SPEAT. 
 
 Ever since ovariotomy was first introduced, the greatest import- 
 ance has been attached to the treatment of the pedicle. I have 
 employed only two methods, either using Wells's clamp or allowing 
 the pedicle to sink back into the abdomen after it had been ligatured 
 with silk, hemp, or catgut. After numerous trials I came back 
 to Spencer Wells's plan of applying a clamp whenever it was 
 possible, and bringing the stump up externally.^ No doubt the 
 other method has the apparent advantage that the operation is com- 
 pleted at once, but I did not find that convalescence was more 
 rapid from its adoption, and I fail, therefore, to perceive its advan- 
 tage. It is more convenient to apply a clamp than numerous liga- 
 tures ; again it seems more reasonable to allow the sloughing layer 
 of cellular tissue to separate externally than trust to its becoming 
 encapsuled in the abdomen. On the other hand, we cannot deny 
 that the stretching of the pedicle occasionally leads to mischief. It 
 is dangerous to judge of these questions from mere figures, when 
 we bear in mind the numerous other complications of the operation, 
 but we have no means, other than statistics, of setthng particular 
 points of importance. I find that of 34 patients in whom I 
 employed the clamp 1 1 died ; of 42 where the pedicle was returned 
 21 died. Acting on the advice of others, in 27 successive cases I 
 returned the pedicle, but of these 15 died. This discouraged me 
 considerably, the more that I did not meet with any better success 
 when I employed catgut ligature and operated under the spray. 
 
 This leads me to say a word or two on the use of the spray in 
 ovariotomy. My first three operations did well ; then came a very 
 simple case in which the adhesions were few and slight, but which 
 was followed by severe carbolism.- 
 
 One of my colleagues met with a similar misfortune with one of 
 his patients. Death in this case occurred in the second week. In 
 all these cases the hand spray had been employed with 2 per cent, 
 solution of carboHc acid. I was so alarmed at the untoward 
 results that, for a time, I gave up its use while operating, and 
 merely allowed the spray to work in the room some little time 
 before operation. This was in 1874. In 1877 I again resorted to 
 
 ^ I am informed that Messrs Spencer Wells and Knowsley Thornton now 
 
 (1881) make it their practice to ligatiu-e the pedicle with silk and return it. 
 They find that (under antiseptics) convalescence is considerably hastened 
 when the ligature is used. See note at end of chapter. — [Ed.] 
 ' Supra, p. 15.
 
 ANTISEPTIC SPRAY. DRAINAGE. 307 
 
 the antiseptic method, this time employing the steam spray with a 
 I per cent, solution. I had no further deaths from carbolism, but 
 even in simple cases, where I returned the pedicle, the results were 
 so unsuccessful that I again abandoned this method. It is difficult 
 when the spray has been employed, and vomiting and collapse 
 follow, to tell whether the symptoms should be ascribed to the 
 chloroform, the carbolic acid, or to septic peritonitis. Apart from 
 this, even among some of my successful cases, the suppuration was 
 so extensive and severe that I was kept in a constant state of 
 anxiety. In my earlier experience I had never seen suppuration 
 prove fatal at the end of the second week and later. At the time 
 that I am speaking of, I saw it happen in the fourth w^eek after the 
 clamp had separated, and the wound healed. In some cases I 
 made incisions in the abdominal waUs wherever dulness led me to 
 expect suppuration, and in this way was able, though with great 
 difficulty, to save a few of the patients. I can see no harm in 
 using the spray during the dressing of the wound ; I can hardly 
 say whether the spray is really necessary if great attention be paid 
 to cleanliness. 
 
 On three occasions I performed ovariotomy under the thymol 
 spray (I'looo) having seen good results in other operations. Two 
 of the patients died of septic peritonitis ; one recovered, but her life 
 was endangered by numerous abscesses ; one large abscess extended 
 back up as far as the kidney, and was opened in that region. 
 
 I have now therefore, entirely discarded the spray in ovariotomy 
 while the abdominal cavity is open ; it will require a strong induce- 
 ment to persuade me to revert to its use.^ 
 
 With regard to the drainage of the wound, I usually employ the 
 ordinary india-rubber drainage tubes. Primary drainage appears 
 to me unnecessary, if there is no ascitic fluid, and when no adhesions 
 from which hsemorrhage might be expected have been torn through. 
 Out of fifty-one successive cases, I met with but one in which these 
 conditions existed. Comparing the statistics of cases where drainage 
 was employed with those in which it was not, I find a slight difference 
 only in favour of the former method, but I can recall many severe 
 cases in which, in my opinion, the drainage was the means of saving 
 
 ' The above remarks refer to his practice up to the year 1877. In the 
 early part of 1879 the translator had the pleasure of seeing Prof. Billroth 
 perform ovariotomy under the constant use of the thymol spray. See note 
 at end of this chapter. — [Ed.]
 
 308 DRAINAGE AFTER OVARIOTOMY. 
 
 the patient's life. I must add, that it was a long time before I 
 learned to employ free drainage, and could bring myself without 
 hesitation, to insert six or eight drainage tubes in a single case. 
 Ten years ago a surgeon would have been thought crazy for stuffing 
 so much india-rubber into the abdomen. The first case in which I 
 employed drainage through the vagina I shall not readily forget for 
 it gave me very great anxiety. I had unluckily wounded one of 
 the large vessels with my trocar. The haemorrhage was controlled, 
 for a time, by pressure with sponges, but it recurred, and I was 
 compelled the next day to reopen the wound, and clear out the 
 cavity of the pelvis, which was full of blood-clot. The patient was 
 fortunate enough to recover — a result which is not too common 
 under such circumstances. It will be readily understood that after 
 this I preferred to introduce the drainage-tubes only into the 
 wound. Some two years after the above case, I again tried drainage 
 through the vagina, at a time when I attributed much importance 
 to washing out the lower part of the peritoneal cavity with carbolic 
 acid. I inserted two drainage-tubes through Douglas's fold, but 
 the injection did not return, although the tubes were not choked. 
 The carbolic acid solution (5 per cent.) remained in the abdominal 
 cavity, with the result that the patients who, it must be allowed, 
 were already in a septic condition, were seized with rapid collapse. 
 The wounds were opened and the pelvis sponged out, but without 
 avail. I next adopted a long drainage tube, which was brought 
 out above at the symphysis, and below through the vagina, so that 
 the tube could be drawn backwards and forwards, and the openings 
 readily cleared of clots. This method of drainage also I gave up, 
 for I found that constant syringing or even almost continual irrigation 
 were powerless in one case to prevent encysted collections of septic 
 sanious fluid from forming in other parts. I came to the conclusion 
 that Douglas's space could only be perfectly drained by keeping the 
 patients constantly in a sitting position. This is not always possible ; 
 if the patients lie on their backs some fluid will always collect in the 
 cavity of the sacrum, as I have proved by dissection, and this fluid 
 will not escape through the vaginal drain, unless the opening be 
 dilated. After this experience, I entirely abandoned vaginal 
 drainage, a method with which others have been more fortunate. 
 In the more simple cases I insert only one drainage tube and pass 
 the end deeply into Douglas's pouch ; if more be required, I put in 
 two or three in the same place, and pass one down between the
 
 SECONDARY FEVER AFTER OVARIOTOMY. 309 
 
 uterus and the bladder. In the very worst cases, I often insert 
 additional drainage tubes on both sides, deep into the renal regions. 
 Post-mortem, we often find fluid at this part. I pass also tubes 
 beneath the abdominal wall to any part where adhesions were met 
 with, and where, therefore, much effusion may be expected. My 
 impression is, that one cannot well insert too maty drainage tubes, 
 and further, that the non-insertion, at one necessary spot, of a single 
 drainage tube may endanger the life of the patient.^ I prevent the 
 tubes from slipping back into the wound by securing them with 
 safety-pins, which may either be attached to the dressings or left free. 
 
 In sewing up the abdominal wound I pass the sutures through 
 the peritoneum, inserting also a few superficial sutures, in order 
 to provide for more exact apposition. 
 
 On the cut surface of the pedicle I apply little bags of gypstheer 
 which I think is better and safer than crystals of ferri perchlor. 
 The application can be renewed the day after the operation, and 
 permanently discontinued after the subsequent dressing. 
 
 Of late, I have avoided, as much as possible injecting any thing- 
 through the drainage tubes ; nor do I attempt to draw off the 
 fluid and efi'usions, unless serious symptoms arise and no escape 
 takes place through the tubes. In ordinary cases, the drains may 
 be removed after two or three days, but no harm will arise if they 
 are left longer. High temperatures for the first day or two are 
 not altogether favourable, but yet, in the absence of other severe 
 symptoms, need have no particular influence on the prognosis. It 
 is of course most favourable, when we find the general condition 
 good, the temperature low, the pulse moderate, the abdomen 
 flaccid and free from pain, and when the patient has a sense of 
 hunger. Still, all these favourable circumstances by no means 
 exclude the possibility of severe secondary fever during the second 
 week or later. This secondary fever is a sure sign of suppuration, the 
 situation of which must be carefully searched for, especially when 
 flatulent distension and vomiting supervene. The abscess should 
 then, if possible, be opened, either externally or through the 
 vagina, and a drainage tube immediately introduced. If, however, 
 these symptoms do not make their appearance, we may wait 
 quietly for the spontaneous escape of the pus. The abscess may 
 
 ' Prof. Bilh'oth has now (1881) entirely discarded drainage, and tlie 
 above remarks have been inserted chiefly from their historical interest. Seo 
 note at end of chapter. — [Ed.]
 
 310 SEPTIC PEEITONITIS AFTER OPERATION. 
 
 open through the wound, or it may break into the bladder, the 
 large intestine, or the vagina. Cases which are thus left to them- 
 selves, as a rule do well, and the discharge of the pus is accom- 
 panied by a rapid decrease of the fever. Moreover, this may 
 happen several times without harm. If distension, vomiting, 
 restlessness, and rapid pulse supervene, there is but little hope for 
 the patient, even though the temperature keeps low. The severest 
 cases of septic peritonitis constantly run their course with a per- 
 fectly normal temperature. Here we are met by a problem which 
 has not yet been solved. As a liigh temperature would naturally 
 be expected, can it be counterbalanced by other conditions, such as 
 impairment of the renal functions and uraemia, or is it that the bulk 
 of the absorbed septic products at once produces the low temperature 
 of collapse ? It is not easy to believe that the quality of the 
 septic products can vary so much as to cause high temperature in 
 one case, while another can run its course not only without 
 increase, but even with an active depression of the temperature. 
 If in such cases the lower part of the abdominal wound is opened 
 up, with the idea of letting out some sanious matter, little or 
 nothing will be found. The severe symptoms above mentioned, 
 are for the most part signs of diffused peritonitis, where all the 
 intestines are covered by turbid, glutinous purulent effusion, which 
 does not go on to the proper formation of fibrine. 
 
 Before I habitually employed primary drainage, I had often 
 occasion to reopen the wound, in order to let out the effusions, and 
 in this way I have certainly saved patients who, otherwise, must 
 assuredly have died. I then inserted drainage tubes and injected into 
 the cavity weak solutions of carbolic acid and glycerine ; in doing 
 this, it is often remarkably difficult to hit on the entrance into Dou- 
 glas's pouch. When large quantities of sero-sanguineous septic fluid 
 are encysted (which cases are usually characterised by high tem- 
 peratures during the first few days) the fibrinous adhesions are some- 
 times so tough that one scarcely dares to employ the force requisite 
 to separate them, for fear of tearing the intestine ; moreover, the 
 uterus may be displaced backwards, and be so fixed that it is with 
 difficulty detached. Separating the adhesions in this manner is best 
 done within the first forty-eight hours ; on the third or fourth day 
 it is of but little use, for the general septic infection has commonly, 
 by that time, proceeded too far. 
 
 Vomiting during the first twenty-four hours is of slight import-
 
 VOMITINa AFTER OPERATION; DIARRHOEA. 311 
 
 ance as regards prognosis ; if it stops on the second day, or begins 
 as it so often does after the first thirty-six hours, it is then always 
 a sign of peritonitis. The explanation of vomiting in peritonitis is 
 not very clear ; my idea is, that it may in great measure be 
 accounted for on mechanical grounds, and is especially caused by 
 the intestines becoming fixed in an unnatural position through firm, 
 fibrinous adhesions. Prolapse of the intestines, and much moving 
 and pressing back of the same during the operation is very 
 undesirable, for the intestines are thus brought into positions which 
 hinder the peristaltic action. The formation of fibrine takes place 
 so rapidly that in a long operation, the process can almost be seen ; 
 at any rate, the increasing adhesiveness of the intestinal surface is 
 very noticeable. If a loop of intestine is too much handled or 
 twisted about, it may readily become fixed in a position unfavour- 
 able to the passage of its gaseous contents. At times, too, effusions 
 collect in the true pelvis and press on the rectum, or coils of 
 intestine may become so adherent to the pelvis, that the peristaltic 
 action becomes reversed. When colicky pains persist for weeks 
 after the operation, they generally depend upon such abnormal 
 fixation of some part of the intestines. By introducing a short 
 tube into the rectum flatus will often escape, with great relief to 
 the patient ; large quantities of flatus too may be got rid of with the 
 vomit. In troublesome vomiting I have often employed repeated 
 small subcutaneous injections of morphia with great benefit. It may 
 be taken as a good sign, when the vomiting is in this way checked 
 for a few hours, but a bad symptom when it is of no avail. If there 
 be no distension it is perfectly unnecessary to administer enemata. 
 I have often seen everything go on perfectly well, although the 
 bowels did not act till the second week after the operation. 
 Diarrhoea sometimes, though rarely, occurs in septic peritonitis. If 
 the distension be very distressing, I generally give an enema con- 
 taining sixty grammes of infus. sennse comp. with an equal bulk of 
 warm water, and repeat it, if in two hours it has produced no 
 effect. If the enema acts, the patient will be greatly relieved ; if 
 no effect is produced it is a very bad sign. If all has gone on well 
 up to the third or fourth day, but then steadily increasing distension 
 begins accompanied by stercoraceous vomiting, it is sure to be due 
 to incarceration, generally the result of volvulus. In such cases, I 
 have twice performed enterotomy, and opened an immensely dis- 
 tended, small intestine. One was a case of ovariotomy, the other
 
 312 LAPARO-HYSTEKOTOMY. 
 
 of extirpation of the uterus ; the volvulus was found, but both 
 patients died. Post-mortem, we discovered that the enterotomy 
 was above the twisted portion of the gut in one case, and below it 
 in the other. 
 
 "With regard to the cause of death, I may say that I lost no case 
 during the first twenty-four hours. Eight of my cases, however, 
 died within forty-eight hours. I ascribe death in these cases to 
 septic peritonitis, even if secondary haemorrhage took place. Eng- 
 lish surgeons would have attributed the result to " shock." 
 Eighteen patients died of peritonitis between the third and the 
 seventh day, and the others from various causes. 
 
 Laparo-Hysterotomy. (W. B., 1876.) 
 
 Up to the end of 1876, I had performed laparo-hysterotomy in 
 seven cases of uterine fibroma.' Remarks on the first three opera- 
 tions will be found in the 'Wien. Med. Woch.' for 1876, No. i. 
 I have there explained how I have modified my former method 
 of operating. Cases occur, especially in young girls and women, in 
 which the fibroma grows no slower than an ovarian tumour ; the 
 patients may become very helpless merely from the weight of the 
 growth, but their life, supposing that no haemorrhage occurs, is 
 much less directly endangered. The sufferers often remain for many 
 years fairly nourished, and up to a certain stage in the tumour, their 
 pains do not increase markedly. These fibromata are new forma- 
 tions, of a more firm and solid tissue than most colloid tumours of 
 the ovaries. The latter entail danger, not only from their enormous 
 size, sometimes reaching that ordinarily attained by cysts, but espe- 
 cially from the breaking down and death of the tissue, and the 
 softening. When such changes take place in these tumours, chemical 
 products are generated, whose absorption renders the sufferer 
 cachectic and much reduced. Until the size and the weight of an 
 uterine fibroma of itself becomes fatal to the organism, the patients 
 can very well go on for ten years or more, especially if the condi- 
 tions of life are favourable, and they are not compelled to under- 
 take any heavy work. In the case of such women, a rapidly fatal 
 issue cannot be foretold with such positive certainty as in women 
 
 ^ Some fui-tlier cases are recorded by Dr. J. IMikulicz in the ' Wien. Medt 
 Woch,,' March, 1879.
 
 INDICATIONS FOR OPERATION. 313 
 
 who have large colloid ovarian tumours ; operation therefore cannot 
 be so urgently counselled. A second point of danger lies in 
 the haemorrhage ; now this, as it seems to me, does not depend so 
 materially on the mere size of the tumour, as on the thickness of 
 the layers of the uterus between the fibroma and the mucous mem- 
 brane. Fibromata, which lie close under the mucous membrane, lead 
 to ulceration of this lining and consequent hsemorrhage; such 
 hsemorrhage seldom comes directly from the fibroma, but since it 
 proceeds from the mucous membrane of the uterus, appears often 
 under the guise of protracted monorrhagia. There can be no doubt 
 that women with haemorrhage of this nature can be preserved for 
 a long time in very tolerable condition, provided that they are able 
 to rest and take proper precautions; ergotine injections too are 
 especially serviceable in such cases, but apart from the patients 
 to whom such a life would be intolerable, the complete arrest of the 
 hsemorrhage becomes an absolute question of existence for women 
 of the working class. Either they must spend the greater part of 
 their life in the hospital, or, if they work, die from the hemorrhage. 
 Thus I find that two of the cases on whom I operated, had wandered 
 from one department to another in the hospital for nearly two years. 
 Directly they were discharged, and began to work again, hsemor- 
 rhage recurred, and the unfortunate women lost again in a few days 
 all the strength which they had gained by months of residence in 
 the hospital. 
 
 I admit theoretically, that in the rules we lay down with regard 
 to the indication for operation, we ought to free ourselves as much 
 as possible from social conditions. Practically, however, we are very 
 often forced to yield to such influences. Tailing health and 
 inability to work, combined with want of means of existence drives 
 every one to come to a decision ; now this decision is in such cases 
 materially influenced by the fact that it is not with this disease, as 
 with cancer, where operation might be immediately fatal, and can 
 only yield some prolongation of life ; on the contrary, from the 
 nature of uterine fibroma, there is a prospect that a successful opera- 
 tion will restore permanent good health, and that the strength 
 which has been lost will be regained, without the dismal prospect 
 in the back-ground of any recurrence of the disease. Up to the 
 present time (1877) I have only operated on patients with fibromata 
 whose existence had become insupportable, either from the immense 
 size of the tumour, or from the hsemorrhage, and have for the most
 
 814 METHOD OP OPERATING. 
 
 part dissuaded those women who are able to rest and take care of 
 themselves, from any operation, even though they most earnestly 
 desired it. 
 
 My experience has convinced me that technical difficulties alone 
 stand in the way of making these operations more extensively prac- 
 tised. Such difficulties it is fully in our power to overcome. 
 
 Of the laparo-hysterotomies which I performed up to 1876, 
 two recovered ; one of these is described by Dr. Wolfler in the 
 ' Arch. f. Klin. Chirurg.,' Bd. xi. 
 
 In the first case (a girl, 19 years of age), the immense size of 
 the tumour, — in the second, the uncontrollable haemorrhage, decided 
 me to operate. 
 
 Of the five fatal cases, two died of haemorrhage : the first, two 
 hours, the second, twenty-eight hours after the completion of the 
 operation. One patient died on the third day of septic peritonitis, 
 another on the sixth day from volvulus of the ileum; in this 
 case, enterotomy was performed without success. A third died on 
 the seventeenth day of pyaemia, with suppurating thrombosis of the 
 pelvic veins, and emboli in the lungs. 
 
 Although my list of cases is far from numerous, and my experi- 
 ence consequently limited, still, I may be allowed to make some 
 observations on certain points which seem to me to be worthy of 
 remark. I take for granted that nobody would venture on these 
 operations who had not already, from ovariotomy, obtained some 
 experience of those principles whose observance is indispensable in 
 laparotomy. A point that distinguishes these operations from ova- 
 riotomies at the outset is, that in large tumours, an extensive inci- 
 sion has to be made, often right up to the xiphoid appendix. 
 When so large an opening is made into the abdominal cavity, great 
 attention is necessary on the part of the assistants in order to pre- 
 vent the escape of the intestines. I must, from my experience, 
 protest against removing the tumour piecemeal (Pean's " morceile- 
 ment") or attempting to remove small portions of the tumour by 
 enucleation ; such a method prolongs the operation very much, and 
 can scarcely be performed without serious loss of blood. I con- 
 sider the danger of a large incision ^er se, to be less than that of 
 the so-called manipulation. 
 
 In these operations no adhesions should be torn ; they should 
 invariably be ligatured with a double thread or clamped peripherally 
 and then tied on the proximal side. The haemorrhage from the
 
 METHOD OF OPERATING. 315 
 
 torn surface of the layers of the uterus, covering a fibroma, is 
 usually very severe, and will not readily cease spontaneously. 
 Such rents can seldom be ligatured ; it is not possible to say how 
 long the operation may last, and the patients may lose much 
 blood before the uterus can be encircled by a ligature. In one 
 case, before I had learned this by experience, I proceeded to deal 
 with some very extensive soft adhesions on the posterior surface 
 just as I should have in an ovarian tumour, that is to say, I 
 scooped the tumour out with my hand. The haemorrhage was most 
 formidable ; in order at least to stop the bleeding from this huge 
 tumour, I made two of my assistants lift it up, and then placed an 
 ecraseur chain round it below. This was done with the more 
 rapidity inasmuch as the mesentery from which I had separated the 
 tumour was also bleeding furiously. As I removed the tumour 
 above the ecraseur chain, I inadvertently cut off a portion of the 
 bladder which was closely united to the fibroma at the upper part. 
 Having controlled the haemorrhage, a second ecraseur chain was 
 applied over the bladder close to the edge of the cut surface, and 
 then the upper portion of the bladder was separated from the 
 tumour. In doing this, troublesome haemorrhage again occurred. 
 The tumour was then removed at the level of the first ecraseur 
 chain. The patient left the operation table alive, but died two 
 hours after. As in ovarian tumours, so also in fibroma of the 
 uterus, broad adhesions in the true pelvis are most to be dreaded. 
 Such a case occurred to me in 1877. The bleeding was almost 
 beyond control, but still the patient survived it, though she died a 
 day later of septic peritonitis. It is of paramount importance to 
 exercise the greatest possible caution, therefore, in dealing with 
 adhesions in these cases. . 
 
 If the uterus together with the fibroma be free, I ligature the 
 broad ligaments on either side with two strong threads, and if pos- 
 sible, do this in such a way that the ovaries and Fallopian tubes 
 remain connected with the tumour. I use these ligatures double, 
 and tie them with all my might, and then cut through between 
 them ; sometimes these are the only parts ligatured in the whole 
 operation. The large vessels, which are secured in this way seem 
 formidable, but rapidly collapse after the dehgation. Now, the 
 tumour, together with the uterus, being slightly raised by an 
 assistant, and the upper part of the abdominal wound being firmly 
 closed, how are we to proceed ? I am, like Pean, in favour of
 
 316 TREATMENT OF STUMP. 
 
 always placing a ligature round the uterus, close above the portio 
 vaginalis, and then removing the mass of the tumour, together with 
 its hypertrophied capsule of uterine tissue, close above the ligature. 
 If no adhesions be met with, the operation can be performed as 
 cleanly as in a simple ovariotomy, nor need a single drop of blood 
 escape into the abdominal cavity. Now comes the question of how 
 and with what we are to encircle the uterus below, and how we are 
 to deal with the stump. These seem to me most important technical 
 questions, on whose final decision the future fate of the operation 
 will materially depend. 
 
 Hitherto I have abstained from allowing the stump to sink back 
 into the peritoneal cavity. Under some conditions we might, 
 perhaps, succeed in controlling the haemorrhage by securing the 
 numerous vessels, and the stump might then be dropped back 
 without any danger of haemorrhage following. One or more 
 drainage tubes might be passed through the vagina, behind the 
 cut surface, which ordinarily is turned upwards towards the 
 promontory, so as to allow the secretions, which in all these cases 
 are tolerably abundant, to drain off. Many things have hitherto 
 prevented me from adopting this method, especially the thought of 
 the danger that might arise from unchecked bleeding from the 
 stump. One could hardly prevent this, without ligaturing the 
 stump en masse, which in such a case could scarcely be done 
 without causing sloughing, and possibly putrescence. Again, there 
 is a source of danger in that, the vessels behind the uterus at the 
 lower part might be so dilated that there would be a risk of punc- 
 turing them in passing the drainage tubes through the vagina. 
 Finally, I must declare my preference for the extra-peritoneal treat- 
 ment of the pedicle, a preference which I have derived from my 
 ovariotomies. Although, therefore, I discountenance the other 
 method, I would not deny its possible advantages. Pean's loop for 
 encircling the uterus, I do not like; I could never succeed in 
 obtaining any wire which did not break on being drawn tight 
 and twisted. After many attempts to modify the apparatus, I 
 discarded it altogether. I then employed a special kind of clamp, 
 something like that used for the treatment of very thick pedicles in 
 ovariotomy. This instrument, however, drew up the stump of the 
 uterus so much, and pressed at the same time to such an extent on 
 the abdominal walls, that I soon gave it up. I next had an 
 ecraseur made, with a particularly long and strong chain. The
 
 TREATMENT OF STUMP. 31 ^ 
 
 fore part of the instrument was removable. As soon as the chain 
 had been drawn sufficiently tight, it was fixed by means of a screw 
 in the removable part, and it could then be left on after the 
 manner of a clamp and the surface of the stump cauterised. A 
 strong silk thread was then placed on the pedicle below the loop 
 of the ecraseur, so that the knot came on the right side. After 
 the knot had been firmly secured on the pedicle, the two ends of 
 the silk were threaded on a needle, which was then passed through 
 the abdominal wall from within outwards, brought out an inch from 
 the cut edge of the skin and there secured. A similar thread was 
 secured on the left side in the same way. The threads being tied 
 above the skin on both sides, the peritoneal surface of the wound 
 in the abdominal wall lay in firm apposition with the stump : 
 drainage tubes could then be placed between the uniting sutures^ 
 in the ordinary way, passing close up to the stump. By this 
 method the portion of the stump, which has been encircled, is kept 
 well out of the abdominal cavity, and if it sinks back, draws down 
 also the part of the abdominal wall to which it has been apposed^ 
 so that the pedicle cannot be forcibly torn away. By the time that 
 the chain of the ecraseur comes away the threads also separate^ 
 and require merely to be cut through on the surface of the skin, in 
 order to be withdrawn. Some inconvenience in dressing is 
 occasioned by the rusting of the chain of the ecraseur, which is 
 allowed to remain and sinks back deeply, but this is of no moment. 
 When I tried this method for the first time, I did not leave the 
 chain in situ, but I passed strong, double ligatures threaded on a 
 very long straight needle through the pedicle. The latter was 
 raised up vertically and the threads were passed horizontally, from 
 before backwards, and were then knotted at the sides. After this 
 had been done, the chain of the ecraseur was released. In spite, 
 however, of the firm way in which the pedicle was secured, bleeding 
 occurred from it, necessitating the securing of several vessels. 
 
 In my next case I shall try this method again, but after each 
 separate thread has been knotted at the side, I shall carry it once 
 more round the whole pedicle, and draw on it firmly for some time 
 before I tie the knot. The stump of the uterus is so elastic that 
 it requires to be compressed for some time, in order that all serum 
 may be squeezed out, before the knots are secured. 
 
 In applying the ecraseur, great care must be taken ; it must be 
 drawn tight very slowly. After a few minutes the chain will be
 
 318 EECENT MODIFICATIONS IN OPERATING. 
 
 found again quite loose, either because much of the serum has been 
 pressed out of the stump, or because some fragments of the fibroma 
 which may possibly lie in the stump are drawn forward to the cut 
 surface. The chain must then be reapplied, but this should not be 
 done with such force as to separate the peritoneal covering, or severe 
 venous haemorrhage might ensue, which it would be very troublesome 
 to control. The safest plan would probably be to apply two ecra- 
 seur chains one above the other, and then remove the lower one 
 replacing it by a ligature. The ligatures would more easily be 
 drawn sufficiently tight on the parts which had already been encir- 
 cled, and then the upper chain might safely be removed. My only 
 fear is, that by this method, the peritoneum might be torn in taking 
 away the ecraseur chain, and fatal haemorrhage thus be caused. 
 For the first trial of this method a case ought to be selected, in 
 which, up to the point of applying the ecraseur chain, there had 
 been no haemorrhage. 
 
 In a case which recovered after operation (in May, 1877), ^ 
 fistula between the abdominal wall and the vagina persisted for a 
 long time, and mucous discharge flowed through the lower end of 
 the healed cicatrix from the short open canal of the cervix. The 
 fistula in this instance was closed by the energetic application of 
 caustics, but in two similar cases, closure only took place after a 
 long period. 
 
 I am firmly convinced that when we have had wider experience 
 of the practical details of the operation, and especially when we per- 
 form laparo-hysterotomy in cases where the tumours have not been 
 allowed to attain such enormous dimensions, the danger of the 
 operation will be reduced and the results, as in ovariotomy, cannot 
 fail to be better and better. 
 
 Recent Modifications in Operating.^ 
 (April, 1 88 1.) 
 
 Formerly, for laparotomies, thymol spray was used, but this was 
 discontinued early in 1880. Professor Billroth now habitually 
 operates without the spray. His present views on the subject of 
 the spray will be found expressed in a contribution to v. Langen- 
 
 * I am indebted to the kindness of Dr J. Mikulicz, assistant in Prof. 
 Billroth 's clinic, for the infomianion here given. — [Ed.]
 
 RECENT MODIFICATIONS IN OPERATING. 319 
 
 beck's 'Archives/ No. 25, by Dr. J. Mikulicz, entitled " Zur 
 Sprayfrage." The temperature in the room is kept uniformly at 
 20° R. Great care is exercised with the sponges, and the utmost 
 precautions are taken to ensure their proper cleanliness and asepti- 
 city. The separate sponges are kept at least a week in a 5 per 
 cent, solution of carbolic acid. A little time before use they are 
 removed from this and soaked in i per cent, solution. In ovariotomies 
 intraperitoneal treatment of the pedicle is now invariably employed. 
 For the pedicle and for large adhesions the following method is in 
 use. A special clamp is applied firmly for about one minute, so as to 
 press out all the fluids. The clamp itself somewhat resembles a pair 
 of long sequestrum forceps, one only of the two surfaces which come 
 into contact being serrated. By means of a catch at the extremity 
 of the handle the surfaces can be pressed together as tightly as 
 required. The clamp is then removed, and a silk ligature tied 
 round the pedicle or the adhesion, in the groove made by the 
 clamp ; but little force is found necessary in tying the strings. 
 For small adhesions Pean's pince hemostatique is used in the same 
 way as the clamp, the ligature being subsequently applied. No 
 peritoneal drainage is now employed. In uniting the abdominal 
 wound button sutures like those employed by Professor Lister, are 
 found very convenient. 
 
 With regard to the antiseptic modifications recently adopted see 
 introduction. It need only be stated here that antiseptics are 
 rigidly carried out, save that the spray is not used. It has not 
 been found that its discontinuance has in any way interfered with 
 the successful results of these operations. — [Ed.]
 
 CHAPTER XV. 
 
 INJURIES AND DISEASES OF THE PELVIS AND LUMBAR 
 REGIONS. 
 
 Case of gunshot wound. Case of diastasis of bo7ies of pelvis. 
 Fracture of pelvis— Case and remarks. Case of chronic pelvic 
 abscess unconnected with bone. Ditto opening into gluteal 
 artery — Remarks on pelvic abscess. Cases of retro-peritoneal 
 abscess. Case of caries of pelvis with retention of urine. 
 Chronic periostitis and caries of pelvis — Cases and remarks. 
 Inflammation of inguinal lymphatic glands. Case of inguinal 
 abscess bursting into the bladder. Case of cystic enchondroma. 
 Case of large osteo-chondroma ; removal, transfusion, death. 
 Large enchondroma of the pelvis ; removal, death on seventh 
 day. Cases of pulsating sarcoma of pelvis. Sarcoma of the 
 pelvic cavity pressing on the bladder; operation to relieve 
 retention. Case of spindle-celled sarcoma of nates. Case of 
 cancerous degeneration of a congenital coccygeal tumour. 
 
 Gunshot wound. 
 
 A Polish refugee was wounded in a duel with pistols, the ball entering 
 close behind the right trochanter ; no aperture of exit. On exploring the 
 track of the bullet with a catheter, it was found to lead by a de\-ious track 
 to the right edge of the sacrum ; the bullet itself could not be felt. At first 
 all went on well, but at the end of three weeks a deep abscess formed close 
 to the left side of the sacrum. An incision was made, and a piece of cloth — 
 part of the man's trousere — extracted. A cavity could then be felt in the 
 sacrum, but neither through the opening of the abscess, nor through the 
 rectum, could the bullet be felt. Profuse suppuration ensued, rigors, and 
 death in the sixth week. Post-mortem : the bullet was found in front of 
 the OS sacrum, and the bones in the neighbourhood were carious ; no metas- 
 tatic abscesses.
 
 PRAOTURE OF THE PELVIS. 321 
 
 Diastasis of the hones of the pelvis. 
 
 A man, set. 52, was struck down by a falling tree, and died a few hours 
 after the injury. Post-mortem : The bones at the symphysis pubis and 
 the right sacro-iliac joint were found to be widely separated. There was 
 also a complicated fracture in the lower third of the right femur. 
 
 Fracture of the pelvis. 
 
 Among the cases of fractured pelvis may be mentioned that of a child, six 
 years old, over whose pelvis an entire railway train passed, so that the lower 
 part of the body remaiued attached only by the skin, which was but slightly 
 lacerated. No haemorrhage from the large vessels. The child died an hour 
 after the injury. 
 
 The diagnosis of fractured pelvis is, in many cases, easy enough. 
 By forcible rocking of the pelvis, pressure on the symphysis, or 
 exploration by the rectum, the fracture may, in the majority of 
 instances, be recognised through the severe pain and the percep- 
 tible displacement of the bones. No doubt fissures of the venter 
 ilii, and of the acetabulum, cannot be always positively diagnosed, 
 but when, after some considerable injury about the pelvic region — 
 where fracture or dislocation of the vertebral column, thigh, etc., 
 can be excluded — the patient is only able to stand upright or walk 
 with much difficulty, or where these symptoms disappear after some 
 weeks' rest in bed, it may be pretty confidently assumed that frac- 
 ture of the pelvis existed. In a very large number of cases which 
 came under my observation, the patients were unable at first to pass 
 the urine and required the use of the catheter. It must not be 
 supposed, from the presence of this symptom, that any lesion 
 of the bladder necessarily exists, or that the spinal cord has 
 been injured, as such symptoms frequently disappear after a few 
 days or weeks; it is possible that sometimes the jarring of the 
 vesical nerves may account for the paralysis of the detrusor 
 urines; but I suspect that in many cases the functions of the 
 muscular coats of the bladder are paralysed for a time by the 
 extravasated blood, which so frequently, in fractured pelvis, almost 
 entirely surrounds the organ. Usually in simple fracture of the 
 pelvis, the extravasation is soon absorbed, and the functions of 
 the bladder are thereupon restored. In other cases, I believe par- 
 
 21
 
 322 ABSCESS INVOLVING GLUTEAL AETERY. 
 
 tial suppuration takes place, and gives rise to the rigors, which T 
 have frequently observed in cases of fractured pelvis, where recovery 
 followed without any serious results. TThen there is a wound of 
 the skin and injury to the urethra, the breaking down and suppura- 
 tion of the extravasated blood which usually ensues will inevitably 
 prove fatal ; even if no external wound be present, the suppuration- 
 may lead to thrombosis, metastatic abscesses in the lungs, and 
 pyaemia, as some of my cases prove. 
 
 Chronic abscess of the hack of the pelvis, unconnected with lone. 
 
 Louise W — , aet. 26, manied, mother of two children, stated that she had 
 suffered, up to the age of 20, from chronic abscesses in the cervical glands, 
 and also about the elbow and trochanter. About a year and a half before 
 her admission she had severe pain in the right gluteal region, extending 
 down into the lower limbs. Six weeks before we saw her an abscess had 
 been opened in the gluteal region, and a gi-eat quantity of pus let out. 
 Although the cavity of the abscess was most minutely examined, no bone 
 could be detected, and it appeared to be confined to the cellular tissue. The 
 sinuses would not heal, and a year later the patient's chance of recovery 
 seemed hopeless. 
 
 A. L — , £et. 20, a weaver, had suffered, fifteen months before his admission., 
 into the hospital, from pain in the right gluteal region ; he found gradually 
 increasing trouble in getting about. An abscess formed behind the right 
 trochanter, which enlarged steadily, and about a year after the commence- 
 ment of the disease, opened spontaneously at several points. The patient, 
 who up to that time had been able, though with some difficulty, to get about, 
 was now confined to bed ; the suppuration was very considerable. Injections 
 and baths were employed, but the sinuses could not be induced to close. One 
 day, without any apparent cause, sudden hasmon-hage took place from one of 
 the sinuses ; it was controlled by a tampon, but soon after occun-ed again, 
 and he was brought up to the hospital. Shortly after his admission fresh 
 arterial bleeding took place. I laid the sinuses open down deeply into the 
 gluteal muscle and secured the gluteal artery from which the haemon-hagfr 
 came. There was no further return of the bleeding ; the large wounds of 
 incision healed up slowly and the patient gradually recovered, but in spite of 
 careful treatment the sinuses were still discharging, four and a half years 
 after the commencement of the disease. The man was sent home so pale 
 and wasted, and was altogether in so miserable a condition, that he could not 
 be expected to live long. I could not make out that there was any disea.se- 
 of the internal organs ; no exposed bone could be felt through any of the 
 numerous sinuses.
 
 EETEO-PEEITONEAL ABSCESS. 323 
 
 Pelvic Abscess without any appakent Disease op the Ver- 
 tebral Column oe Bones of the PelvisJ 
 
 Altogether I have seen twenty cases of this description — fourteen 
 of which occurred in men and six in women ; in three of the latter 
 the abscesses were of puerperal origin ; in the remaining seventeen 
 no origin could be assigned for the disease. They commonly 
 occurred in individuals between twenty and forty years of age. 
 They nearly all answered to the so-called psoas abscesses, with the 
 characteristic flexion of the leg. In three of the patients absorption 
 took place and recovery followed. In two cases the action of the 
 contracted limb was completely restored ; in one the contraction 
 was permanent ; in those in which the abscesses opened, this took 
 place close above or below Poupart's ligament. Seven of these 
 patients died from the suppuration — partly with symptoms of 
 pyaemia, and partly from the exhaustion. In one instance the 
 abscess broke into the urinary bladder, and in another a fistula 
 formed between the intestine and the abdominal wall. One patient 
 with a large, congestive abscess, which broke into the intestine, 
 recovered completely in a few weeks. 
 
 Retro-peritoneal abscess. {Acute psoitis.} 
 
 In the case of a young lady whom I saw in private, a large abscess had 
 formed and occasioned teixible pain ; the patient did not remain under my 
 treatment, hut I heard subsequently that the abscess did not break, but 
 became absorbed. However, a great deal of contraction was left. The 
 disease lasted seven months. 
 
 In another case, that of a man about 40, an acute abscess formed deep 
 down in the right side of the pelvis. After a month it broke spontaneously, 
 close under Poupart's ligament. In course of time the discharge of pus 
 ceased, and the opening closed up ; convalescence, however, did not set in, 
 aiid the patient had constant pain about the right kidney. Under these 
 circumstances, and on account of his great sulfering, and very severe 
 intermittent febrile attacks, he was brought over from Belgrade to Vienna 
 to see me. I found him in a deplorably reduced condition, and unable to 
 extend his left leg completely. I detected fluctuation deep down in the 
 region of the right kidney, and on making an incision let out a large 
 
 ' See, also, supra, p. 229, for further remarks on abscesses of this nature.
 
 324 CHRONIC PEEIOSTITIS I EETENTION OF UEINE. 
 
 quantity of thick pus. Convalescence was very slow, but eventually it was 
 complete, and the contraction of the leg disappeared ; the patient — who was 
 at one time emaciated to skin and bone, with flushed, hectic cheeks, Hollow 
 voice, and looking as if he had only a few days to live — is now one of the 
 finest and strongest officers in the army. 
 
 Chronic periostitis and caries of the pelvis, with retention of urine. 
 
 A peasant, ast. i8, sufEered from a large abscess on tbe left' side of the os 
 sacrum ; this was accompanied by retention of the urine requiring the daily 
 use of the catheter. After three weeks the abscess, which had reached the 
 size of the fist, was opened ; the edges of the sciatic notch, and the inner 
 surface of the sacrum, were felt exposed and roughened. After the opening 
 of the abscess the patient recovered the power of micturition, and the cavity 
 completely closed up in about four months. 
 
 J. S — , set. 24, a baker, was admitted into the hospital for a pain in the 
 sacral region, from which he had suffered for some time, and the nature of 
 which could not be positively ascertained. After resting for a time the 
 patient was again able to get about his business, but the pains had not 
 entirely deserted him. Two of his brothers and a sister had been affected 
 with glandular abscesses and caries. Some affection of the vertebral column 
 was suspected. Two years before his admission, as he was lifting a heavy 
 weight, he felt an intense pain behind the right trochanter, " as if something 
 had given way ;" shortly after this the right lower limb began to swell and 
 became painful. After a few weeks' rest in bed the diffused swelling and the 
 pain subsided, but a circumscribed, soft, painless tumour was observed at the 
 upper part of the thigh. The patient went back to his work, and in the 
 course of the next two yeai-s the tumour gradually sank lower and lower on 
 the back of the thigh. When admitted we found a sac full of fluid, 
 almost the size of a man's head, in the right ham. By exercising pressure 
 on it a wave could be felt, conducted along a canal of about the dimensions 
 of the thumb, leading right up to the tuberosity of the ischium. (See 
 Fig. 17.) 
 
 The swelling gave the patient no real trouble, but he wished to get rid of 
 it, as he intended to many. I came to the conclusion that the swelling was 
 due to a very large congestive abscess, which had commenced in the pelvis. I 
 acceded to the patient's wish, and let out an immense quantity of thin pug 
 by means of a trocar, taking care not to admit the air. At first all went 
 on well, but then, probably from the patient's disobeying the injunctions to 
 keep quiet, severe inflammation ensued ; the suppurating track had to be 
 laid open in several places and drainage tubes inserted. The patient's con- 
 dition became highly febrile, rigors ensued, and the amount of suppuration 
 was prodigious. I gave him up as beyond recovery, and allowed him, at his 
 own desire, to be removed home. A year later I heard that he had com- 
 pletely recovered health and strength, and was pursuing his avocation.
 
 Fig. 17. — Abscess, connected with the Ischium, peesenting in the 
 Popliteal Space.
 
 326 ABSCESS PEEFOEATING EECTUM: NECEOSIS OF OS SACEUM. 
 
 In the following case also my prognosis, fortunately for the 
 patient, was falsified. 
 
 Alfred S — , set. 13, had been perfectly well up to seven years of age, then 
 an abscess fonned over the sacnim, which after three weeks bi'oke sponta- 
 neously. A sinus was left at the site of the opening, and fresh abscesses 
 formed in the neighbourhood, leading subsequently to the formation of other 
 sinuses. The child became pale, though he did not lose flesh. He was but 
 seldom feverish, and had not often to keep his bed. Six yeare after the 
 commencement of the disease I dUated the sinuses, and removed a seques- 
 tram from the lower part of the os sacnim. The reaction after the opera- 
 tion was comparatively slight. Shortly aftenvards the patient had slight 
 diarrhoea, and faecal fluid escaped through the sinuses. Perforation of the 
 rectum must therefore have taken place ; anasai'ca of the legs followed, then 
 ascites and great weakness, with casts and an immense amount of albumin 
 in the urine. No remedy whatever gave any benefit. The debility 
 increased so much that when, at his parents' wish, he left the hospital, I gave 
 the most unfavoui-able prognosis. Eight or nine months later the child came 
 back perfectly recovered ; the sinuses had closed, the boy was strong, stout, 
 and seemed in the best of health. 
 
 The diagnosis of periostitis and caries of the pelvis may, at the 
 outset of the disease, be very difficult, or even impossible. The con- 
 gestive abscesses in this disease often correspond in the direction 
 they take to those connected with the vertebral column or the hip- 
 joint. It is not always possible, even with the aid of a catheter or 
 probe, to discover the part actually affected. The absence of pain 
 in the vertebral column or the hip-joint assists the diagnosis ; chronic 
 suppuration in the retro-peritoneal cellular tissue, or deeply situated 
 beneath and between the gluteal muscles, closely simulates chronic 
 suppurative periostitis of the pelvis, and not least in its tedious 
 progress. It is easier to recognise caries of the os sacrum, the 
 symphysis pubis, or the sacro-iliac joint. jYo age seems to be 
 especially predisposed to chronic inflammations about the pelvis. 
 My tables shew that the disease was met with in patients whose 
 ages varied from one year up to seventy. In two cases the conges- 
 tive abscesses penetrated from the interior of the pelvis into the hip- 
 joint, and in three instances burst into the rectum. I think that 
 chronic abscesses about the pelvis should be allowed to open spon- 
 taneously ; surgically we can do little more than occasionally dilate 
 the sinuses, keep the parts clean, and promote the free escape of 
 pus. If the disease has existed for many months or years there is 
 scarcely any prospect of cure.
 
 ENOHONDROMA OP PELVIS. 327 
 
 Inflammation of the Inguinal Lymphatic Glands. (W. B.) 
 
 In one case where there was an immense bunch of hypertrophied 
 glands, in which partial suppuration had taken place, I extirpated 
 the mass ; the operation was followed by recovery. 
 
 Eight cases of acute and subacute enlargement of the lymphatic 
 glands came under treatment, for which no peripheral cause of 
 origin could be discovered. If the existence of pus could not be 
 made out, attempts were always made to procure resolution by 
 means of compression with shot-bags. I have succeeded in com- 
 pletely curing a few cases in private practice by this means, and the 
 infiltrated glands often disappear with remarkable rapidity. Single 
 glands, however, in which probably pus had already formed, ran on 
 to suppuration. The treatment by compression was continued after 
 the opening of the abscesses, which closed up with remarkable 
 rapidity. 
 
 The following case, where a deeply-seated inguinal abscess burst 
 
 into the bladder, is of some interest. 
 
 / 
 
 The patient, a man, ast. 32, had noticed nine months before his admission 
 an inguinal swelling on the right side. An abscess formed in this spot, which 
 was opened, and soon healed up. Two months later a fresh abscess formed, 
 close to the cicatrix of the former one. After a fortnight it broke spon- 
 taneously, and urine was discharged, together with pus, from the opening. 
 A very small urinary fistula was left which closed up completely and per- 
 juanently after cauterisation. 
 
 Cystic enchondroma, 
 
 I was consulted by a gentleman about 50 years of age, for a tumour of 
 this nature in the sacro-iliac region. On puncturing the growth, which was 
 ^bout the size of a foetal head, and in which fluctuation was very perceptible, 
 a large quantity of brownish-red, viscid fluid escaped. Numerous sago-like 
 "bodies floated about in the fluid. On microscopical examination these proved 
 io consist of hyaline cartilage. Of the further history of the patient, I know 
 nothing. The tumour had originated thirteen years previously, after an 
 injury. 
 
 OUeo-ckondroma of the pelvis; removal, transfusion, death} 
 
 From an operative point of view the following case is of great 
 
 1 From the 'Wien. Med. Woch.,' Jan. 9, 1875, ^0. ii, p. 26, being au 
 .^ztract from a paper by Dr. Billroth entitled " Zur Bluttranfusion."
 
 328 ENOHONDROMA OF PELVIS. 
 
 interest. With regard to the transfusion, it may be stated that the 
 possibihty of some previously existing infection could not be entirely 
 excluded, although death undoubtedly was not due to the infection. 
 
 Theresa E, — , a cook, set. 29, was admitted for an enormous osteo-chondroma, 
 wMch had originated in the left side of the pelvis and had been first 
 noticed two yeai-s previously. When admitted we found a hard tumour, 
 rather larger than a man's head, springing from the horizontal ramus on the 
 left side. A similar hard growth so completely filled up the pelvis, that 
 def secation and micturition for a long time past had been materially interfered 
 with. The patient had been confined to bed for many months for the left 
 leg was forced into a position of permanent abduction, although the move- 
 ments of the hip-joint were free. She suffered severe neuralgic pain in the 
 left leg, especially along the course of the obturator nerve. 
 
 My first impression on examining the case was that nothing 
 could be done for it. I would have sent the patient back to her 
 own home that she might die quietly among her relations, but as 
 from her condition she required constant catheterisation, subcuta- 
 neous injections, and so forth, which could only be properly admi- 
 nistered in a hospital, I was precluded from so doing. Thus it 
 came about that we saw her constantly growing worse, and we 
 could not avoid the reflection that here was a person dying of a 
 tumour, in itself of an innocent nature, which was attached to one 
 portion of bone only, and whose removal was neither necessarily 
 fatal, nor in all probability absolutely destractive to the functions 
 of the parts. Reflections such as these we neither can nor ought 
 to put on one side, for it is from the like that operations most rich 
 in blessings have been devised, as also it must be admitted the most 
 bitter feelings of resignation with regard to the limitation of our art. 
 
 From the experience derived from a former case,^ I felt that the 
 possibility of successfully removing the mass, with or without a 
 portion of the pelvis, depended on whether the tumour had the 
 same connections to the inner as it had to the outer surface of 
 the pelvis. In the case cited below this was the condition, and 
 the operation succeeded beyond all expectation, although the 
 p^atient died on the seventh day of septic infection. But in 
 this woman the condition of things was worse, the tumour was 
 more extensive and the general condition less favourable. It 
 
 * Case of A. S — , described below, p. 331.
 
 ENOHONDEOMA OF PELVIS : REMOVAL. 329' 
 
 was not possible to define the connection of ike tumour 
 within the pelvis, and we could only make out that the ramus 
 ascendens and the tuber ischii were free from the growth. The 
 horizontal ramus was unaltered. The vagina, the uterus, the 
 bladder, and the intestines lay on the right side of the pelvic cavity 
 and were not completely compressed. Within the pelvis the 
 tumour occupied the left side to an extent which it was impossible 
 to determine, and this fact still rather deterred me from operating 
 although I had pondered the matter well in all its details. 
 
 Again, the extent of the tumour was such that I seriously feared 
 the haemorrhage, although in the case already referred to the bleeding 
 was not formidable ; still I trusted that compression of the aorta, 
 which at the time of writing had recently been employed with good 
 success, might enable me to overcome the difficulty. In order to 
 allow the secretions to escape readily, I determined to cut away a 
 portion of the ascending ramus and to employ free drainage. 
 
 Ultimately, though with anxious misgivings, I decided to attempt the 
 removal of the growth. I forbear to give in detail an account of the oi^era- 
 tion, for it would occupy too much space, and merely premise that my assis- 
 tants as well as myself devoted to it the utmost possible care and attention, 
 feeling that our object was to save the life of a fellow-creature who was in 
 the utmost jeopardy. At first all went on well enough ; the connection of 
 the huge tumour to the outer side of the pelvis was much smaller than we 
 expected ; its diameter was not greater than the forearm of an adult. I 
 resected the greater pai-t of the horizontal ramus, hoping that when I had 
 cut away also a portion of the ascending ramus, I should he able to turn out 
 the tumour without any great difficulty, but on this occasion we found our- 
 selves disappointed as to the connections of the tumour on the inner surface 
 of the pelvis. The growth had no attachments to either of the portions of 
 resected bone, but, as appeared on further examination, to the inner surface 
 on the left side, and that too, by a very broad base of attachment. The 
 space which I had gained by the resection enabled me to introduce my hand 
 into the cavity of the pelvis, and to remove the tumour in layers. In this I at 
 length succeeded, though it occupied an hour or more, and was attended by 
 severe venous haemorrhage from within the pelvis. From time to time the 
 aortic tourniquet had to be relaxed. 
 
 My courage sank at the long duration of the operation and the gi-adual 
 failure of my strength. At length the removal was completed. All the 
 bleeding vessels were ligatured, and the entire wound firmly plugged with 
 tampons, but in the meanwhile the patient, though^ she was only partially 
 narcotised, had become very aneemic and collapsed. We administered some 
 hot coffee and wine which she vomited up at once. While dressing the wound 
 we had enveloped all the extremities with elastic bandages. Immediately
 
 330 ENCHONDEOMA OF PELVIS : REMOVAL : TRANSFUSION. 
 
 on the remaval of the aortic compressor the patient was seized with 
 deep syncope, complete loss o£ pulse, irregular respiration and total insensi- 
 bility. Evidently after the removal of the compressor, the diminished quan- 
 tity of blood proved unequal to the supply of a larger area, and the amount 
 which reached the heart, brain, and lungs was insufficient to keep up the 
 functions of those organs. Still the heart was working. It was of para- 
 mount importance to supply the brain with blood. Instead of the horizontal 
 position adopted for those who have fainted, in view of the imminent risk 
 we placed the head hanging deeply down. Some strong assistants supported 
 the patient with her legs raised, and after some time the respirations became 
 more regular, the widely dilated pupils contracted, and the blanched lips 
 regained some colour. She vomited up some coffee and spoke a few woi'ds. 
 The effect of the position of the head was extraordinary. I had really given 
 up all hope. After she had been almost vertically suspended head down- 
 wards for three or four minutes, the colour of the lips became livid, and we 
 thought that the action of the circulation would be sufficient to continue when 
 she was laid horizontally, but complete collapse ensued after she had been a 
 few minutes in this position. Vertical suspension was again resorted to, and 
 again with success. Five separate times was this repeated. Fearing lest my 
 assitants shoiild become exhausted, I placed the patient on an inclined j)lane 
 in such a way that it did not require so much exertion to support her head 
 downwards. 
 
 At length it became evident, beyond a doubt, that the absolute 
 quantity of the blood was insufficient to support life until new blood 
 formed, for without causing artificial determination of the blood 
 to the brain, the necessary physiological functions could not be kept 
 up. What was there now left but to perform transfusion ? 
 
 I dismissed my dislike of this operation, for I felt that now, if ever, the 
 indications for transfusion were present. Herr Dr. Klotz, of the Tyrol, at 
 -once offered to give some of his blood for the patient. Everything was 
 ready to hand, and I performed the transfusion at once. The venous blood 
 filtered, stirred up, and warmed to 37° C. was injected into the brachial artery 
 of the patient's left arm. The patient struggled so much while I sought for 
 the vessel, that the arm had to be held by two assistants, and it was only 
 after considerable search, and doubt as to whether I had exposed the artery 
 or the vein, that I was able to insert the cannula and inject the blood in a 
 peripheral direction. As I began the transfusion, and slowly injected about 
 three ounces, the patient evidently experienced considerable pain, and called 
 out " herr professor ! " The arm was of an arterial red colour, and some of 
 the subcutaneous veins were visible, when, in a moment, the respiration and 
 beats of the heart ceased — life was suddenly extinguished. 
 
 I am far from thinking that this patient would have lived if 
 transfusion had not been adopted, but any one who had been pre-
 
 TEANSFUSION : ENCHONDROMA OF PELVIS. 331 
 
 sent and seen the occurrence would have had the impression that in 
 this case death was directly caused by the transfusion. The opera- 
 tion had lasted about two hours, and death took place one hour 
 after its termination. 
 
 The post mortem did not reveal anything further at the seat of 
 operation. With regard to the hanging down of the head, it is 
 interesting to observe that the brain was not particularly ansemic. 
 A point of interest also in connection with the transfusion was 
 that the right side of the heart and the lungs contained a moderate 
 amount of blood, while the left side of the heart was absolutely 
 empty and moderately contracted. It seemed as if the organ had 
 refused the blood which poured into it, and had suddenly become 
 rigid. The organs of the abdominal cavity were all highly anaemic. 
 
 Panum says that in cases such as these the failure of transfusion 
 and the beneficial effects which, on physiological grounds, might 
 have been expected from it, must be attributed to the antecedent 
 disturbance (erschiitterung) of the nervous system by the operation 
 and the loss of blood. Others are of opinion that the filling of the 
 right side of the heart, which, relatively, always takes place too 
 quickly, accounts for the sudden paralysis of the organ. My im- 
 pression in the above case was that spasm of the heart had some- 
 thing to do with the matter, partly from the suddenness of death, 
 and partly from the post-mortem appearances. Perhaps also the 
 difference in temperature between the injected blood and the tissues 
 of the exsanguine body, had some share in causing death. 
 
 But let all this be as it may, one fact is clear — that transfusion 
 often fails just when, from all physiological reasonings, we should 
 expect it to have a conspicuous effect.^ 
 
 Enchondroma of the pelvis. Removal. 
 
 A. S — , set. 34, consulted me in December, 1868, for a large encliondroma 
 on the anterior pai-t of the right side of the pelvis. It appeared that up to 
 the commencement of 1865 he had always heen healthy and strong, but 
 that then he had frequent pains in the right hip, resembling lumbago. The 
 pains soon became very severe, extending to below the knee, and were then 
 
 ^ Some further highly interesting remarks on the subject of transfusion 
 (an operation not much in favour with Prof. Billroth) will be found in the 
 • Wien. Med. Woch.,' Nos. i, 2 and 3, Jan. 1875. [Ed.]
 
 332 ENCHONDROMA OF PELVIS. 
 
 supposed to be due to sciatica. Sitting down caused him great sufEering. 
 He was sent to Wiesbaden for the afEection, which was supposed to be of a 
 rheumatic nature. At the end of 1865, he first noticed a hard tumour on the 
 right side of the perineum. For some time the sufEering varied much in 
 degi'ee, and he was not compelled to absent himself from his military duties. 
 He then consulted Professor Eoser, who discovered a pelvic tumour, and on 
 the supposition that it might be a syphilitic exostosis, treated him with 
 iodine, but without any benefit. Subsequently other antisyphilitic treatment 
 was employed with equal want of success. 
 
 In November, 1868, the pain from the tumour increased to such an extent, 
 that frequent subcutaneous injections were necessary, and the patient was 
 forced to keep to his bed. There was great difficulty in defsecation ; enemata 
 could hardly be given, and purgatives caused very great distress ; in fact, 
 his condition was such that we agreed he could not last many months. He 
 was fully aware that his case was hopeless, but was very resigned, and 
 more than hinted his detei-mination to commit suicide, if his sufferings 
 became unbearable. He asked me whether operation was absolutely out of 
 the question. I told him that it was not possible to speak from experience 
 on the matter, but that, acting on certain suppositions — the accuracy of 
 which could not be predetermined — it would be possible to remove the 
 tumour without any direct danger to life ; further, that though, of course, 
 recovery was problematical, his power of walking might be restored. 
 
 The patient caught eagerly at this last ray of hope. I warned 
 him that I would not undertake the operation unless symptoms 
 arose pointing directly to a fatal issue ; on the other hand, I did 
 not conceal from him that a certain amount of strength and 
 vitality were necessary if we were to expect the operation to suc- 
 ceed. I promised to see the patient from time to time. The regi- 
 mental surgeon who saw him with me supposed that I only meant 
 to console the patientj and, though himself an able surgeon, did not 
 fancy that operation was possible. I, however, was seriously in 
 earnest ; the hopeless condition of this amiable young man, who 
 had, so to speak, already done with life, his calm, resolute manner, 
 and his absolute confidence in me, inspired me with courage to 
 attempt something exceptional ; moreover, anatomically, as well as 
 physiologically, the operation was practicable, and did not directly 
 endanger life. 
 
 The patient lost ground more rapidly than I had anticipated ; failure of 
 appetite, increase of pain, almost complete obstruction, difficulty in micturi- 
 tion, insomnia, and ever-increasing doses of morphia — each and alL con- 
 tributed to reduce his strength. 
 
 In Januaiy, 1869, the occurrence of distension and vomiting urged me to 
 decisive action. On mentioning to him the alternative resort of forming an
 
 ENOHONDROMA OF PELVIS: REMOVAL. 333 
 
 artificial anus, he begged most earnestly to be spared from tbis, and 
 reminded me of my promise to operate, before it was too late. On tbe 3rd 
 February, 1869, I performed tbe operation — tbe boldest and most extensive 
 tbat I have ever undertaken. Tbe anatomical conditions were as follows : — 
 On tbe anterior surface of tbe ascending ramus of tbe iscbium, and 
 reacbing from tbis point to tbe obturator foramen, was situated a tumour of 
 bony bardness, equal in size to tbe skull of a cbild five years old. Tbe 
 base of tbe tumoui", wbere it was connected to the pelvis, I estimated to be 
 about tbe breadth and shape of the section of a strong man's forearm just 
 above tbe wrist. Tbe tumour was covered by tbe adductor and the 
 pectineus muscles. The movements of tbe right leg were more or less 
 limited in every direction. The whole of the true pelvis was filled up by an 
 exceedingly hard growth, which however did not project above a line drawn 
 from tbe last lumbar vertebra to the pelvis. By palpation through tbe 
 abdominal wall, tbe tumour was felt to be spherical in form. Tbe rectum 
 was pushed quite over to tbe left side and was impervious three or four 
 inches above the anus. I was unable to make out positively whether the 
 pelvic tumour had developed from tbe right side, but judging from the 
 position of the rectum and bladder, it seemed pi'obable ; indeed, in planning 
 the operation, I started from tbe idea (subsequently confirmed) that the 
 tumour within the pelvis possessed an attachment corresponding to that of 
 the extra-pelvic growth. If tbe growth proved to be a chondroma (the 
 most usual fonn of these tumours) it would be possible to remove the inner 
 tumour with a blunt-pointed resection knife ; in any case, a portion of the 
 ascending ramus of the ischium could be removed without interfering with 
 the power of walking. If tbe growth tui-ned out to be an osteoma, it could 
 certainly be cut away by means of tbe chain saw and chisel. If the extra- 
 coiTesponded to ,the intra-pelvic tumour in its [attachments, the obturator 
 artery, I judged, must be displaced upwards and outwards. 
 
 The more I considered the whole matter the more I felt encou- 
 raged to operate. The extensive suppuration in the pelvic cavity 
 that was bound to follow the operation gave me cause for great 
 anxiety^ for even were our best anticipations realised as far as the 
 operation was concerned, yet the unfavourable conditions, due to the 
 situation of the wound, were such that the risk of pysemia or 
 septicaemia proving fatal was inevitably great. And so it came to 
 pass. 
 
 The patient being placed in the lithotomy position, tbe external tumour 
 was easily exposed by an incision made parallel with tbe adductors. Tbe 
 growth proved to be a chondroma and was easily removed from tbe pelvis 
 with tbe resection knife. I then made an incision on the inner edge of the 
 ascending ramus of the pubes and was easily able to separate the capsule 
 from tbe intra-pelvic tumour; then, passing my band into tbe pelvis, I 
 severed the tumour from its peripheral attachments, and was able to convince
 
 334 PULSATING SAECOMA OF PELVIS. 
 
 myself that the intra-pelvic tumour had the same connections as the cor- 
 responding growth on the outer side. The external tumour, however, seemed 
 to consist entirely of bluish white cartilage, while the inner growth was 
 cystic in nature and broke up in my hand ; the remnants of the cyst were 
 removed by cutting-forcepe and the knife, the loose fi-agments being easily 
 withdi-awn from the pelvis. The haemon-hage was moderate in amount, and 
 no collapse followed after the operation, which had succeeded beyond all 
 expectation, but after the fii-st forty-eight houi-s, the amount of foul sup- 
 puration from the pelvis became enormous ; no antiseptics were of any avail ; 
 the youth and strength of the patient alone enabled him to resist the septic 
 infection up to the seventh day, when he sank and died. Duration of the 
 disease from fii-st to last, about four yeai^s. 
 
 Pulsating sarcoma of the pelvis. 
 
 H — , set. 47, stated that she was the mother of five children. She had had 
 two miscamages, but her last confinement — about four years before her admis- 
 sion had been natural and easy. Three years previously, she noticed occa- 
 sional pain in the right hip, and some twelve months later a tumour appeared 
 in this region ; the pain increased, and she had more and more discomfort in 
 walking. For some little time previous to admission she had lost flesh and 
 strength. I found a tumour, larger than a man's head, more or less spherical 
 and of smooth surface, occupying the position of the right innominate bone. 
 The tumour was of elastic consistence in most parts, and a distinct thrill 
 could be felt and a harsh bruit heard, synchronous with the heart sounds. 
 Xo operation was admissible, and the patient died four years after the com- 
 mencement of the disease.* 
 
 Frau H — , aet. 46, stated that about a year before her admission, in 
 attempting to save herself from a fall, she strained herself severely in the 
 neighbom-hood of the right hip. She always had pain in walking after this, and 
 about four months later, noticed a gradually increasing swelling of the right 
 iliac crest. The difficulty in walking and the pain increased. Fourteen days 
 before I saw her she had had a fall on the affected side, and since that time 
 had no longer been able to support hei-self on her right leg. The patient 
 was a slight, spare, pale woman. The entire right half of the pelvis was 
 pushed forward ; parchment crackling could be felt over the thinned bony 
 plates. The tumour could be traced deeply down into the pelvis ; the whole 
 tumour pulsated, and an aneurismal bruit was audible in it. The size and 
 extent of the growth were such that there seemed to be no hope of success- 
 fully removing it ; the patient died about twenty months after the com- 
 mencement of the disease. 
 
 Guiseppe L — , aet. 43, an Italian miner, of small weakly frame, stated 
 
 * On the occasional difficulty of diagnosis in these cases see a valuable 
 paper by Holmes " On the Diagnosis of Aneurism" ('St. George's Hospital 
 Eeports,' vol. vii, p. 173). [Ed.] 
 
 I
 
 PULSATING SAECOMA OF PELVIS. 335- 
 
 that he had suffered for twenty years from an intermittent fever, which was 
 constantly recurring. About four years before admission, as he was lifting 
 a heavy stone, he experienced a sudden sharp pain in the sacral region, which 
 lasted for about a week, but was not sufficiently severe to prevent his working. 
 The pain, though only slight, persisted at the seat of injury, and two years 
 later, when engaged in some rather heavy work, it recun-ed with greater 
 violence. He then noticed a painful swelling in the neighbourhood of the 
 sacrum. For ten weeks he was laid up ; the swelling did not materially 
 increase, and at the expiration of that period he resumed work. About 
 eighteen months later, when engaged in some tunnelling work, the pain in 
 the pelvic tumour increased to such a degree that he was forced to seek 
 medical aid. For some time, he had noticed distinct pulsation in the growth. 
 He then came under the care of the late Professor 0. Weber who attempted 
 compression of the tumour ; this treatment however, the- patient would not 
 bear, and left the hospital. While journeying to Italy, the pain increased 
 with such severity that he was forced to stop short at Ziirich. When I saw 
 him, I found an ill-defined tumour, the size of the palm of the hand, over 
 the right sacro-iliac joint. The gi'owth was raised up about an inch from the 
 surface of the surrounding parts, and the skin over it altered in appearance. 
 The tumour was hard at the edges, of soft consistence in the centre. Pulsa- 
 tion was everywhere distinctly perceptible, and the whole mass was slightly 
 compressible. No aneurisraal bruit was audible. The tumour projected to 
 some extent into the rectum, and was estimated to be of the size of a foetal 
 head. Subcutaneous injections of moi-phia and the application of cold 
 gave him some relief ; the injection of a few drops of perchloride of 
 iron, had no effect, good or bad. Professor Weber had diagnosed pulsating 
 sarcoma, with which opinion I concurred. Two months later the tumour 
 had increased to such an extent that it reached from the right sacro-iliac 
 articulation, over the right venter ilii, and from the crest of the ilium 
 down to the sciatic notch ; the growth was firm, resistant, and pulsated 
 but slightly. The skin over the upper part was of a dull blue colour ; the 
 lower extremities were slightly oedematous. Pulsation could be distinctly 
 felt on examination by the rectum, and the tumour had extended further 
 into the pelvis than it did two months before ; it gave, however less pain. 
 The tumour was injected on a few occasions with Liq. Ferri Perchlor. with- 
 out any material benefit. Finally, he was attacked with repeated rigors, 
 the tumour began to increase rapidly, erysipelas followed, and he died of 
 marasmus, four years and eight months after the commencement of the 
 disease. Post mortem, we found a sarcoma telangiectodes cysticum of the 
 right ilium, metatastic sarcomata in both lungs and on both pleurae, tumor 
 lienis, sarcoma in the thyroid gland, and metatastic myxo-sarcomatous 
 deposit in the medullary cavity of the third rib. Microscopically the tumour 
 was found to be a very vascular alveolar sarcoma.
 
 336 SARCOMA OF THE PELVIC CAVITY. 
 
 Sarcoma of the 'pelvic cavity. 
 
 An instance of this oocnrred in a man, set. 20. For five weeks the patient 
 had suffered from darting and throbbing pains, radiating from the sacrum 
 down the right leg, and followed after a time by obstinate constipation. 
 The right leg then began to swell so much that the patient became unable to 
 do his work. He was admitted into the hospital, and a tumour was discovered 
 in the pelvis. Troubles in micturition ensued, and catheterisation became 
 more and more difficult, so that the patient was transferred to my care. I 
 found a soft, elastic tumour, the size of a large foetal head, which lay behi*i 
 the bladder and the upper part of the symphysis, and could be felt also from 
 the rectum. A thick elastic catheter alone could be introduced into the 
 bladder ; the patient passed but little urine, and but a small quantity was 
 drawn off. On puncturing the tumour through the abdominal wall only 
 blood was withdrawn ; finally, it became impossible to introduce even the 
 elastic catheter into the bladder, and the patient passed no urine for twenty- 
 four houre. I thereitpon made an incision, sis centimetres long, through 
 the abdominal wall on to the upper border of the capsule of the tumour. 
 The abdominal walls were so closely applied to the surface of the tumour 
 that I had no fear of prolapse of the intestine, and merely applied an anti- 
 septic bandage. Diu-ing the following evening about an ounce of urine was 
 voided. The next day I found that the capsule of the tumour was so firmly 
 united by adhesions to the abdominal walls that I was forced to cut into the 
 mass. The next night again only about one ounce of urine was passed ; 
 nothing of the tumour could be felt thi'ough the bladder ; the third day I 
 set to work carefully and scooped out the medullaiy mass fi'om its capsule 
 with my fingere, which I easily succeeded in doing. The haemon-hage was 
 controlled by plugging the cavity with two carbolised sponges which were 
 removed the same evening. Now that the capsule of the tumour had 
 collapsed the distended bladder could be distinctly felt, and by means of an 
 ordinary elastic catheter I drew ofE 500 gi-ammes of turbid alkaline urine. 
 The catheter was ordered to be kept in the bladder, but the patient, who was 
 somewhat troublesome, let it slip out after a few hours. During the next 
 few days large quantities of urine were voided, some being passed naturally 
 and some drawn oS by the catheter ; the capsule of the tumour collapsed 
 more and more. I did not think there would be any danger of the intestines 
 protruding, as the fibrinous adhesions were so firm. The seventh day after 
 the incision, however, the patient was exceedingly restless, the result of 
 which was that the bandage became loose and a long loop of intestine pro- 
 lapsed. This was replaced and the capsule of the tumour was united by 
 sutures to the abdominal wall, but rapid collapse set in, and he died the next 
 day. 
 
 The sole object of the operation, viz. to allow the escape of the 
 urine, was attained ; more than this was not possible, for we found
 
 MEDULLARY SAECOMA OF NATES. 337 
 
 ■subsequently that total removal of the tumour would have been 
 quite impracticable; moreover, numerous metastatic tumours 
 existed in the liver and the lungs. If I met with another case of 
 this nature, I should unite the capsule firmly with sutures to the 
 abdominal wall before proceeding to evidement of the tumour. 
 
 Medullary spindle-celled sarcoma. 
 
 B. H — , 38t. 29, a joiner, a short, strong man, noticed in January, 1865, a 
 "hard lump the size of a pea, between the nates two inches above the anus. 
 The nodule was situated in the skin, and at the outset gave him little discom- 
 fort beyond a burning sensation if it were touched. After a time, however, 
 it grew more rapidly and became painful. A medical man, who was called 
 m, took the tumour to be a boil, and ordered poultices. A few days later 
 an incision was made but blood only escaped : the wound would not heal, 
 and a fungus-like mass protruded through the opening. In May, 1865 
 (four months after the commencement of the disease), the growth was 
 cauterised with a hot iron ; this did, however, but little good, for directly 
 after the eschar separated, fresh growths protnided ; the surface became 
 gangrenous, haemorrhage took place from it at times, and the patient lost 
 strength. When he was admitted at the end of November, 1865, though 
 rather pale, he was a well-nourished man. An ulcerated f ungating tumour, 
 the size of the palm of the hand extended upwards from the anus for about 
 four inches. I completely extirpated the growth, taking care to cut 
 through skin that to all appearance was healthy, a full inch wide of the base 
 of the tumour. In a month the patient was discharged with the wound 
 nearly healed. Tour months later he returned ; the wound had completely 
 cicatrised, but veiy shortly after this had happened, a fresh nodule became 
 perceptible at the old spot. I found on examination, an ulcerated mass, the 
 size of an Q^g, situated in the cicatrix ; immediately ai'ound were several 
 isolated movable tumours of the same size. I advised immediate operation, 
 but to this the patient would not consent, and he died a month later of 
 trismus and tetanus. From first to last, the disease had existed for sixteen 
 months. 
 
 Cancerous disease, developing in a congenital coccygeal tumour. 
 
 Therese L — , jet. 55, an ana3mic, weakly woman was admitted with a 
 tumour over the sacrum, of tolerably firm consistence. Her mother had 
 told her that the growth was of congenital origin, and at birth was the 
 size of a hazel-nut. The tumour gave no pain, and increased slowly for 
 the first few years, but scarcely any growth had taken place since she 
 was nine years old. As the result of a fall at that time, the tumour 
 became inflamed and swollen. An opening was made into it by a medical 
 man and pus and blood were let out ; the opening had never closed 
 
 22
 
 338 CANCER DEVELOPING IN A CONGENITAL TUMOUR. 
 
 since. Some years later, two fresh openings formed, from which at 
 times severe haemorrhage took place. I found a tumour the size of a 
 man's head dependent fi'om the sacral region, ulcerated in parts. The 
 gi'owth was removed, and proved to be a cjsto-sarcoma, in the centre of 
 which was a curiously formed mass of cartilage. At the lower end of the 
 sacrum, the growth was not very sharply defined ; a few cysts extended 
 down into the depth of the bone which were not followed up. The cysts 
 were found to be lined with ciliated epithelium. The epithelium of the 
 ulcerating cysts was an-anged in thick multiple layers, in which two distinct 
 forms of cells were found, closely resembling those seen in epithelial cancer. 
 No projections or gland-like ingi'owths of the epithelial masses could be 
 traced into the interstitial connective tissue. The wound did not completely 
 heal, and the remnants of the cyst epithelium projected fungus-like, extend- 
 ing also into the suiTounding tissue. The surface of the wound resembled 
 in appearance that of a carcinomatous ulcer ; the right inguinal glands 
 became enlarged and broke, and fungating masses which microscopically 
 were identical with epithelial carcinoma, projected from the openings. 
 
 This case is of the highest interest as showing that a con- 
 genital cystic tumour may, at a late period of life, acquire cancerous 
 characteristics and become infective. We heard subsequently that 
 the patient died a few months after leaving the hospital. The post 
 mortem revealed nothing that had not been already discovered.
 
 CHAPTER XVI. 
 
 INJURIES AND DISEASES OF THE UPPER EXTREMITY. 
 
 Section A. Injuries. — Cases of frost-bite. Case of paralysis and 
 atrojiliy of arm after injiiry. Cases of paralysis of the mus- 
 culo-spiral nerve after contusion. Case of contusion of the 
 elbow — death. Contusion of wrist — excision. Contusion of 
 arm — death. Injuries of the hand and fingers — Cases. Wounds 
 of the hand. Fracture of the clavicle — treatment. Fracture 
 of necJc of the humerus — treatment. Fractures of lower end of 
 humerus — treatment. Badly united fractures — Cases. Case 
 of paresis after oblique fracture of radius and ulna. Case of 
 ankylosis after fracture. Fracture of lower end of radius. 
 Cases of pseudarthrosis. Paralysis of mitsculo-spiral nerve 
 after fracture of humerus — Cases and remarks. Paralysis 
 
 from the use of crutches. Dislocation of humerus — death. 
 Paralysis and atrophy after dislocation of humerus. Cases of 
 irreducible dislocation ; paralysis after dislocation. Disloca- 
 tions of ulna; of thumb. Penetrating wound of shoulder -joint 
 — excision. Case of multiple pycemia — recovery. Case of 
 penetrating wound of elboio-joint. Seven cases of compound 
 
 fracture of elbow — remarks. 
 
 Frost-bite. 
 
 A man, aet. 52, was admitted with frost-bite of the hands and feet ; he was 
 attacked with tetanus, from which, however, he recovered. Unfortunately 
 a complete record of the case is wanting. 
 
 A man, set. 36, was admitted with both hands frozen through driving for 
 seven hours in very severe cold. The demarcation first showed itself in one 
 hand six days after admission. The soft parts were pushed back with a blunt 
 elevator, and some of the phalanges removed. In the other hand, isolated
 
 340 PAEALYSIS APTEE CONTUSION. 
 
 patches of skin only were gangrenous. Some stifEness of bott hands per- 
 sisted for a long time, but eventually disappeared. 
 
 In this instance, tlie effect of the cold gradually diminished from 
 the little finger to the thumb, so that the index finger was least 
 affected, while the thumb had entirely escaped. 
 
 In other cases it was found that much the same parts were 
 affected, i. e. the third, fourth, and little fingers were most com- 
 monly involved, the index finger less frequently, while the thumb 
 was most rarely affected. In one case, however, where all the 
 fingers were completely gangrenous, one half of the thumb was in 
 the same state. In the foot, too, the great toe seems less subject 
 to frost-bite than any others. When the gangrene extends over 
 the hand from the fingers, it usually extends further on the dorsal 
 than on the palmar aspect. 
 
 Paralysis and atrophy of the arm ^ following injury. 
 
 Peter P — , set. 47, was admitted in 1876. Five months previously he had 
 received a blow on the left shoulder from a falling branch. The blow 
 knocked him down, and occasioned severe pain. A medical man who was 
 called in could find no fracture or dislocation, but only a contusion. 
 The nervous symptoms did not appear to have altered from the first ; the 
 muscles of the left shoulder and ai-m were markedly atrophied ; the flexors 
 of the left handjwere contracted. All movement was completely lost in the 
 left hand ; sensation, though very much impaired, was not totally absent. 
 The pain which he had at fii-st experienced had ceased when I saw him. 
 Faradisation caused veiy feeble contraction of a few of the muscles, but no 
 improvement followed the persevering use of this treatment, and the atrophy 
 of the arm steadily progressed.' 
 
 Paralysis of the musculo- spiral nerve after contusion. 
 
 J. A — , set. 31, a railway guard, had his upper arm severely contused as 
 his train was entering a tunnel. Swelling of the limb soon followed. When 
 he was brought to the hospital shoitly after the accident, the musculo- 
 spiral nei-ve was found to be paralysed. Extensive inflammation of the arm 
 followed, but^disappeared without any suppuration. The extensors of the 
 
 ■^ An interesting case of progressive paralysis after injuiy of the shoulder 
 is' recoi-ded Iby Dr. F. Steiner, in the ' Wien. Med. "Woch.,' 1873, p. 592, 
 where will also be found a collection of other cases of the same nature.
 
 CONTUSIONS. 341 
 
 arms were regularly galvanised, and after four months he regained some 
 power, BO that he could move his fingers and hand to some extent, but the 
 function of the hand was permanently impaired. Of the ultimate result of 
 the case I have no record. 
 
 Johannes B — , set. 30, was injured fourteen days before admission in the 
 following manner : while driving a heavily laden three-horse waggon he was 
 thrown out, his left arm became entangled in the reins, and his clothes were 
 caught by the wheel. When he succeeded in stopping the horses he found 
 that his arm was caught under the wheel, and he could not release himself. 
 In this situation he remained for four hours, until another waggoner, who 
 happened to be passing by, extricated him. Great swelling of the injured 
 limb followed, and after four days the blood, extravasated in the cellular 
 tissue of the upper arm, broke down, and suppurated. After a time the 
 swelling subsided, but complete paralysis of the musculo-spiral nerve 
 became evident. Doubtless this had existed from the commencement, but 
 was masked by the swelling and immobility of the limb. When he was 
 discharged after a month the wound had healed, but the paralysis was un- 
 altered ; subsequently the latter affection disappeared spontaneously, and 
 when I saw him a year later he was perfectly well. 
 
 Contusion of elhoio. Death. 
 
 In the case of a man, set. 48, permanent swelling remained after a con- 
 tusion of the elbow-joint ; the patient had not sought for any treatment, but 
 had gone on with his work as a mason, in spite of the pain in the part. Two 
 months after the injury an acute abscess formed, and for a long time it was 
 doubtful whether it would penetrate the joint ; eventually it became evident 
 that it had done so, and resection of the elbow-joint was proposed ; to this, 
 however, the patient would not submit, and he died of pysemia. 
 
 Contusion of wrist. Excision. 
 
 Jacob Pf — , set. 33, a strong man, fell from a height of about eleven feet 
 on to a heap of loose stones, and injured his hand and foreann. In spite of 
 severe pain he went on with his work for a few hours. When admitted into 
 the hospital a week later no fracture could be positively made out. The 
 arm was put up on a splint, and iodine and ice applied. After a time the 
 pain became localised in the wi-ist, and he had all the symptoms of sub- 
 acute inflammation of the joint, which progressed in spite of rest in plaster 
 splints and treatment with ice. Eventually suppuration took place in the 
 joint. I trusted that ankylosis might eventually take place without surgical 
 interference, but the patient became much reduced, and as the extension of 
 the disease showed no tendency to stop, I determined on excision of the 
 wrist. Two lateral incisions were made, and all the carpal bones, together 
 with the articular ends of the radius and ulna were resected. The bones
 
 342 INJURIES OF THE HAND AND FINGERS. 
 
 removed were softened, and their cartilaginous covering almost completely 
 destroyed, -while the ligaments of the joints had degenerated into spongy 
 granulation tissue. The operation at once exerted a most beneficial efEect 
 on his general condition. The febrile symptoms subsided, and the patient 
 rapidly recovered. In about six months the sinuses closed, and he was able 
 to use his hand for light work. When discharged he could flex and extend 
 the hand and the first two phalangeal joints to some extent, and passive 
 pro- and supination were permitted. The metacarpo-phalangeal joints were 
 as before stiff, and allowed of very little movement. 
 
 Contusion . 
 
 Karl G — , set. 36, an ostler, received a kick from a horse on the right 
 side of the breast and axilla. He was knocked down by the blow, but did 
 not lose consciousness, and was able to do light work for the next two days. 
 He then applied for admission at the hospital, as the swelling began to 
 increase. Over the right upper half of the chest, axilla, shoulder, and upper 
 arm, the soft parts were indurated by phlegmonous infiltration, and in the 
 deltoid region were numerous ecchymoses of the skin. No fracture could 
 be made out ; iodine was painted over the swelling, and ice applied. The 
 same evening the patient sank into a semi-unconscious state, with nocturnal 
 delirium and picking at the bed clothes. Collapse set in, and he died seven 
 days after the injury. At the autopsy sero-sanguineous infiltration of the 
 subcutaneous and iuter-cellular muscular tissue found over the right side of 
 the thorax. In the cellular tissue of the axilla, and ai'ound the blood-vessels, 
 were localised abscesses containing gi-eenish-yellow pus ; the vessels themselves 
 contained fluid blood. The brain, the cerebral membranes, and the lungs were 
 congested ; the liver fatty. 
 
 Injuries of the Hand and Fingers. 
 
 The various industries in the Canton Ziirich brought a great 
 number of these cases under observation, especially injuries from 
 machinery. In almost all, treatment with the continuous water 
 bath was adopted, the constant application of ice being sometimes 
 substituted ; amputation of the fingers was very rarely performed. I 
 always allowed the gangrenous portions to separate of tliemselves, 
 and the results of this conservative treatment were very satisfactory. 
 At times fingers were thus preserved of which at first there seemed 
 but little hope. 
 
 A girl, aet. 7, caught her left hand between the rollers of a machine. The 
 skin was completely torn off the hand up to a little above the wrist- joint.
 
 PEACTUEE OF CLAVICLE. 343 
 
 No bone was broken or joint opened, and the hand was exactly like an 
 anatomical preparation. 
 
 A boy, set. i8, caught his arm in a moving windmill; the humerus was 
 fractured about an inch and a half below the joint and the skin torn ofE 
 from the shoulder, the axUla, and in part fi'om the back ; below the point 
 of fi'acture the arm was completely torn away. I left the stump of bone as 
 it was, partly because without taking flaps from the chest I could not have 
 got soft parts to cover it, and partly because I did not think the patient 
 could long survive the injury. There was no haemorrhage. The case did 
 surprisingly well, and the huge wound granulated up slowly after the 
 removal of the stump of bone four months subsequent to the injury. 
 
 Fkactuee of the Clavicle. 
 
 In hospital practice, as is well known, but little is usually done 
 to correct the displacement of these fractures. The moment the 
 patients are free of pain and can use their arm a little they are 
 sent out. Something can be done towards diminishing the dis- 
 placement by careful and repeated application of Dessault's or 
 Briinninghausen^'s apparatus, or Sayre^s plaster bandage. Many 
 of these fractures, it is true, are attended with only a small amount 
 of displacement. In children slight bendings often occur, which 
 remain unnoticed by the parents until callus begins to form. In 
 adults I never succeeded in adjusting and preserving the fragments 
 in perfect position if the dislocation were of any great extent. I 
 never saw any loss of function in the affected extremity, even when 
 the fracture united with a considerable amount of displacement. 
 When opportunities occurred of seeing these cases some years after 
 the injury, I was often astonished to see how far the projecting 
 ends of the fragments had become absorbed, and the thick mass of 
 callus levelled down. Numerous preparations in our museums show 
 how greatly these deformities improve by the lapse of time. 
 
 Patients with this injury, when there was little or no displace- 
 ment of the fragments, were treated from the first with a Mitella. 
 When displacement existed the different forms of bandage that 
 have been recommended were employed, but no great improve- 
 ment to the deformity was ever gained by their use. I had 
 previously, when at Berlin, convinced myself of the uselessness 
 of these bandages for fractures of the clavicle attended with dis- 
 placement, so that now I employ merely the axillary pad and 
 bandage in all cases. To my pupils I recommend the axillary
 
 344 TEACTUEE OF HUMEEUS. 
 
 pad with Dessault's bandage, Briinninghausen's strap, and otlier 
 apparatus, and show them these forms of bandage in order that 
 they may employ them in their private practice and avoid the 
 charge of neglect. At the same time I always take the oppor- 
 tunity of pointing out to them that these bandages are practically 
 ineffective. If they are to be of any use the patients must be kept 
 lying for at least a fortnight, and the bandage must be reapplied 
 very often. It is not very often possible to induce these patients 
 to lie still in bed, and in the case of restless children it is least 
 of all practicable. As to the success of the treatment we may 
 easily deceive ourselves. The amount of callus appears to be 
 very large, when it surrounds the displaced ends of a fractured 
 clavicle. Ultimately it completely disappears, and then there is but 
 little to be seen or felt. This, however, is not due to the surgeon 
 or the bandage, but is brought about spontaneously. It is well 
 known that fracture of the clavicle, though united in a faulty posir- 
 tion, does not lead to any loss of function. 
 
 Practuee of the Surgical Neck of the Humerus. 
 
 In treating this injury, I have employed divers apparatus and 
 appliances which have been recommended in order to correct the 
 displacement. My best results were obtained by constant exten- 
 sion by weights and Gussenbauer's apparatus (described in the 
 'Wien. Med. Woch.,^ 1874, No. 41). By means of this appa- 
 ratus constant extension is kept up, and the patient is able to be 
 up and about. If any displacement results the form of the shoulder 
 is very much disfigured. I have never seen any functional loss 
 from the oblique union of these fractures. 
 
 Fractures about the Lower End of the Humerus. 
 
 All these cases were treated (at Zurich) by plaster bandages, 
 applied as early as possible. The arm was kept in an extended or 
 flexed position as seemed best for the dislocation. Speaking gene- 
 rally, the shape of the elbow-joint and the position of the fractured 
 articular ends can be better preserved when the arm is put up in 
 the extended position, but this rule is not without exception ;, if
 
 BADLY UNITED FEACTUEES. 345 
 
 this position be adopted the patients are forced to keep their beds. 
 It is of the greatest importance to renew the bandage at the latest 
 after ten or fourteen days. Slight dislocations may then be cor- 
 rected by pressure with the fingers or by movement of the joint, 
 which at a later stage will not be so easily done. After four or 
 five weeks passive movement of the joint may be cautiously com- 
 menced under chloroform. It is a great drawback that we are 
 unable to make out the exact nature of all these fractures, on 
 account of the extravasation in the joint, and are thus debarred 
 from giving a clear prognosis as to the ultimate utility of the limb. 
 I think I may state from my experience that' the cases did better, 
 and that the joint was ultimately more useful, where a plaster band-* 
 age was at once applied than where no apparatus except a Mitella 
 was employed. 
 
 Badly united Fractuiies. 
 
 Six cases of fracture into the elbow-joint were admitted, in 
 which fragments of the external or internal condyle had united 
 with the lower end of the humerus in such a way that the function 
 of the joint was impaired. In many of these cases subluxation o? 
 luxation of the radius had taken place. As a rule the results of 
 treatment are unsatisfactory ; in one instance only was complete 
 mobility obtained. 
 
 In some of these patients the power of flexion and extension, and 
 in others pronation and supination were destroyed. 
 
 In a boy, set. 14, who was admitted with a fractiire of the condyle of three 
 weeks' date, the limb was forcibly extended, and put up in plaster. A fort- 
 night later passive movement was again employed. Within two weeks he 
 had some movement in the part, and he ultimately recovered the full use of 
 the limb. 
 
 In the case of a child, who had fractured her external condyle, and dislo- 
 cated the radius four months previously, and who was admitted with the arm 
 ankylosed at an obtuse angle, resection was performed. She recovered, but 
 the arm became ankylosed at a right angle and remained so in spite of many 
 attempts to obtain some movement. 
 
 Prom these cases it may be gathered that the movement of the 
 elbow-joint, after fracture of the ends of the bones forming the
 
 346 BADLY UNITED I'RACTUEES. 
 
 joint, is less capable of restoration when the patients come 
 late under treatment, than when a plaster bandage is applied im- 
 mediately after the injury. In most of these cases the exact 
 nature of the injury is not recognised ; in these fractures, as also 
 in those of the lower epiphysis of the radius, surgeons are often 
 more on the look out for sprains, dislocation or contusions than 
 fractures ; much time is lost in applying leeches, douches, etc., 
 while in the meantime the small displaced fragments of bone are 
 allowed to remain in a position unfavourable to the movement of 
 the joint, and thus the numerous ankyloses are caused. More 
 extensive use of anaesthetics is advisable in examining such 
 fractures. 
 
 If the limb be strong, and the patients are able to use it in their 
 work, I do not think we are justified in recommending excision of 
 the joint very strongly ; it cannot be said that the operation is 
 absolutely without risk (who would lose his life on account of a 
 stiff elbow-joint ?), and, again, movement cannot be positively 
 guaranteed after operation, even though the entire joint be freely 
 excised. That this is so I have seen in three cases, one of which 
 I operated on myself. If the joint be ankylosed in an extended 
 position or at a very inconvenient angle, of course we may advise 
 excision. 
 
 FerTj ohliqiie fracUire of the radius and ulna. 
 
 A boy, set. 6, had fi-actured toth bones of the forearm about tbe centre, 
 six weeks previous to admission. Union had taken place with the aim 
 strongly bent over to the volar side. The joints between the first and second 
 phalanges were contracted, giving the hand a claw-like appearance. The 
 radial ulnar and median nerves were partially paralysed ; it seemed probable 
 that one of the nerves was included in the callus. Under an anaesthetic, the 
 deformity was rectified and the paresis and contraction disappeared completely 
 after a few months under the use of galvanism. 
 
 Partial ankylosis after fracture into the elbow-joint. 
 
 Jacob B — , set. i6, fell heavily five months before his admission on to 
 his left hand ; ever since that time the movement of the elbow -joint had 
 been impaired ; he had never had any bandage applied, but merely a plaster. 
 I found his arm bent at the elbow at an angle of 100°, and very slight 
 mobility of the joint on passive movement only. A mass of callus could be 
 felt about the internal condyle and olecranon ; forcible passive movement
 
 FEACTURE OF EADIUS. 347 
 
 "was daily employed and after two weeks the mobility of the elbow-joint was 
 decidedly increased. 
 
 Fractdre of the Kadius only. 
 
 Among 103 cases of this injury the majority were fractures of the 
 lower epiphysis.^ I usually put up the arm in a plaster bandage. 
 Such fractures are often complicated by fissures extending into the 
 wrist-joint or extravasation of blood, and lead to stiffness of the joint 
 "which often lasts for weeks or months ; the tendons, too, become 
 united by adhesions to the inner surface of the sheaths. Passive 
 movement, rupture of the adhesions (which is frequently exceedingly 
 painful), and soaking the hand in water in all cases effected a cure. 
 
 Among six of these patients who died of other injuries, we found 
 usually on examining the fractures after death that in addition to 
 the transverse fracture of the lower epiphysis fissures extended into 
 the wrist-joint. There is little doubt that this accounts for the 
 stiffness of the wrist-joint, which in many patients, especially in 
 the elderly, persists for so long a time after fractures of this nature. 
 
 Pseudartkrosis. 
 
 A man, set. 39, was admitted who, two years previously had sustained a 
 compound fracture about the centre of the right upper arm ; no pieces of 
 bone had come away. The fracture was treated originally with splints, and 
 then put up in a paste banda,ge. As after sixteen weeks no union had taken 
 place, the treatment was given up. When admitted the arm was much 
 wasted and could be moved in any direction at the seat of fracture. I 
 cut down on the pseudarthrosis, bored through the two fragments, and 
 united the bones with a stout leaden wire. The limb was put up in a 
 plaster bandage with a window. A considerable amount of reaction and 
 suppuration followed. The suture was removed three months after the 
 operation; there was then abundant callus, and the fracture was well 
 consolidated. 
 
 Elizabeth M — , set. 38, was admitted with a compound comminuted 
 fracture about the middle of the right humerus, and other severe in- 
 juries. The fracture was put up at once in a plaster bandage. Subse- 
 quently some fragments of bone became necrosed and were removed, and 
 the wound healed up, but the callus did not consolidate. I saw her a year 
 
 ^ Colles' fracture. [Ed.]
 
 348 PAEALTSIS AFTEE FEACTUEE. 
 
 after the injury, and tried unsuccessfully to induce union by repeatedly 
 rubbing tbe fragments together, and applying iodine. I then operated on 
 the fracture after DiefEenbach's manner, by inserting ivory pegs ; in the 
 course of eighteen months, the imion was sufficiently firm for the patient ta 
 discontinue her bandage. Three months later, however, the fragments again 
 separated ; and the patient was discharged as unimproved.' 
 
 A healthy, strong man, set. 35, was admitted with an ununited fracture, 
 about the centre of the humerus. The injury, which had been sustained 
 six months previously, had at first been treated with splints and afterwards 
 with plaster of Paris ; the fiagments were very movable. I cut off the ends 
 obliquely, united the bones by two platinum wires, and applied a plaster 
 bandage. The patient went back to his native place — Alexandria — eighteen 
 days after the operation ; the wires were removed there, two months later. 
 The patient came back to me a year or two subsequently, and his arm was 
 then perfectly strong and well. 
 
 A strong man, aet, 41, came under treatment for a condition similar to the 
 above : in this case, however, the mobility between the fragments was very 
 extensive ; the lower portion of bone was knobbed at the extremity, and 
 directed inwards, while the upper was atrophied, thin, and displaced outwards. 
 The muscles of the arm were much wasted. On cutting down on the ends of 
 the bones, I found them covered with cartilage and softened ; the extremities 
 were removed, and the fragments wired together by platinum sutures. 
 Osteo-myelitis followed, and the upper fragment necrosed up to the shoulder- 
 joint. After this he had a severe attack of erysipelas. Three months after 
 the operation I removed the sequestrum. There was still some movement at 
 the pseudarthrosis when he was discharged four months after the first 
 operation, but the arm was much thickened by new periosteal bone. I was 
 unable to learn the ultimate result. 
 
 Taralyiu of muscvJo-spiral nerve after fracture. 
 
 A child, set. 6, sustained a fracture of the arm, about two inches above the 
 elbow-joint. Fourteen days after the injuiy he came up to the hospital 
 with the limb put up in a paste-board splint. The fragments, which were 
 but little displaced, were invested with a moderate amount of callus. The 
 second, third, and fourth fingers were flexed, and contracted at the phalan- 
 geal joints and also at the wrist, and the patient was unable to extend the 
 hand and the fingers. We diagnosed paralysis of the musculo-spiral nerve, 
 resulting from the pressure of the callus. Neither the father nor the medical 
 attendant of the child could state whether this paralysis occurred at the time 
 
 1 It does not appear that in either of the above cases the urine was 
 examined. The frequent association of alkaline urine with ununited frac- 
 ture has been commented on by numerous writers though no very satisfactory 
 explanation has as yet been given of their connection. [Ed.]
 
 PARALYSIS AFTER FRACTURE. 349 
 
 of the injury or came on at a later period. The fracture united well, but 
 the deformity of the hand remained. Galvanisation of the muscles gave no 
 benefit. Five years afterwards the paralysis was in statu quo. 
 
 It is possible, from the seat of fracture in this case, that the nerve 
 was also lacerated. If the anatomical arrangement of the parts 
 be considered, it seems curious that this injury does not occur far 
 more frequently. 
 
 Paralysis of musculo-spiral nerve after fractured humerus. 
 
 A man, set. 36, fell from a waggon and was dragged along some little dis- 
 tance, with his arm under the front wheel. On extricating himself, he found 
 that he was unable to use the limb. A medical man applied a splint, which 
 was kept on for eight days, and then cold compresses were employed. He 
 came up to us twelve days after the injury. The humerus was fractured at the 
 jimction of the upper and middle thirds. Corresponding to the upper level 
 of the fracture, a portion of the skin, about two inches in length was gan- 
 grenous. The fracture consolidated in about sis weeks, by which time the 
 wound was almost healed. Paralysis of the musculo spiral was found to 
 exist when he attempted to move his arm. The hand and forearm were so 
 swollen on his admission, that the impaired mobility was not at the time 
 suspected to be due to nerve injury. In addition to the total paralysis of 
 the musculo-spiral, paresis of the parts supplied by the median nerve and 
 some of the cutaneous branches was found to exist. No extension whatever 
 could be effected at the wrist or fingers. 
 
 By means of continued galvanism, the condition was so far improved 
 within a few months that sensation returned in all parts. Flexion of the 
 fingers was not qiiite perfect. Extension of the hand and fingers could then 
 be slowly effected. 
 
 This case is, further, one of special interest from the fact that, 
 though the fracture was simple, necrosis of some fragments took 
 place. It would be, perhaps, better to say that the fracture was 
 subfascial instead of subcutaneous, for, as mentioned above, a small 
 portion of the skin was gangrenous though the fascia was unin- 
 jured. 
 
 The patient was twice attacked by erysipelas after the fracture 
 had united, and abscesses formed about the site of injury; the 
 latter healed up, leaving only a small sinus; on the opposite 
 side of the limb beneath the skin, which was perfectly normal, 
 could be felt some thickening due to invaginating bone ; subse- . 
 quently, two small sequestra were removed at this spot.
 
 350 PAEALYSIS AFTER FEACTUEE. 
 
 E. r — , set. 6, fell down some stabs and sustained a fracture of the 
 humerus which was treated by splints. Union took place, but the hand 
 could not be moved. No improvement followed, as the result of his taking 
 sixty mud baths and a great many soap baths (Seifenbader). He came up 
 to the hospital about five months after the injuiy ; the forearm was com- 
 pletely pronated, and the hand flexed. The fingers were extended at the 
 metacarpo-phalangeal joints, and strongly flexed at the distal phalangeal 
 joints, the thumb alone being extended ; the fingers and hand were cold 
 and of a bluish colour. Veiy slight active movement took place at the 
 wrist ; sensation nowhere lost. Half an inch above the elbow-joint, a small, 
 hard prominence of the humerus was perceptible, and just below this, on the 
 flexor aspect, a cicatrix an inch in length. The child was placed under Pro- 
 fessor Benedict's treatment, and the constant current was employed for 
 three weeks. The thenar muscles alone answered to the galvanism, and this 
 treatment led to no improvement. 
 
 The analogy of the above with the other cases already described 
 gives room for the supposition that the musculo-spiral and median 
 nerves were, in all probability, involved in the callus. By par- 
 tially gouging away this callus and freeing the nerve, it appeared 
 to me that the functions might be restored ; accordingly I dissected 
 out the musculo-spiral nerve from the groove between the supinator 
 longus and the biceps, exposing it for four and a half inches, up to 
 its dorsal branch. The nerve was normal in appearance, neither 
 thickened nor atrophied, and perfectly free from the slightest adhe- 
 sion ; but it did not answer to irritation by the point of a needle, 
 nor did any action take place when the pole of a rotatory electric 
 apparatus was applied directly to it. When the nerve was 
 touched quite at the upper part contraction of the triceps followed. 
 
 As no alteration could be detected in the nerve, and particularly 
 as no adhesion was discovered, the wound was closed; after the 
 effect of the ansesthetic had passed off the patient complained of 
 some pain in the right arm which yielded to a morphia injection. 
 The wound healed rapidly, the greater part by first intention. For 
 the next three weeks the condition remained unaltered. Galvanism 
 was then resorted to again for a month, at the end of which time 
 Professor Benedict noticed the following singular phenomenon : — 
 When both poles were applied to the affected arm no effect was 
 manifested, but if the second electrode were laid on the sound arm, 
 the muscles of the forearm and fingers on the affected side con- 
 tracted, and this contraction was the more forcible according to
 
 PAEALTSIS AFTER TEAOTUEE. 351 
 
 the length of muscle lying above the point of application of the 
 electrode ; if, for instance, the electrode were applied to the dorsum 
 of the affected hand, the extensors contracted more powerfully than 
 when the application was made to the extensor aspect of the fore- 
 arm. This latter phenomenon cannot be readily explained. The 
 fact that contraction only took place on the application of the 
 electrodes to both arms must be taken as a proof of the great dimi- 
 nution of muscular irritability. No benefit was derived from this 
 second course of galvanism. 
 
 As in this case, the distribution of the median nerve was affected 
 as well as that of the musculo-spiral, it was decided to investigate 
 the condition of the former nerve. To all appearance, however, it was 
 found to be perfectly unaltered. A thin plate of glass was then 
 laid under the nerve after it had been exposed in order to ensure 
 its more complete isolation. The pole of a rotatory electrical appa- 
 ratus, and subsequently the constant current, was applied directly 
 to the trunk of the nerve ; one of the flexors of the thumb con- 
 tracted faintly. On employing the nerve-muscle current the mus- 
 cles contracted rather more. A little piece of muscular tissue was 
 taken from the pronator teres and examined microscopically ; the 
 fibrillae were found to be rather thinner than usual, but the stria- 
 tion was perfectly distinct. The wound was then closed and healed 
 up rapidly ; the child left the hospital unimproved in the matter of 
 the paralysis. 
 
 Inasmuch as in this case there was no direct injury to the nerve 
 the symptoms must be ascribed to reflex paralysis — a condition of 
 rare occurrence. 
 
 O. K — , a boj, set. 8, -was brought to me witli an obliquely united fracture 
 of the humerus of six weeks' standing, and paralysis of the musculo-spiral nerve. 
 The latter had been noticed when the bandages were removed. I broke 
 down the callus, which was tolerably soft, put the ai-m straight and applied 
 a fresh bandage which was removed a month later. By means of faradisation, 
 the function of the hand began to improve and in the course of three months, 
 the paralysis had almost disappeared. 
 
 J. G — , set. 41, came up to the hospital with paralysis of the musculo- 
 spiral nerve, which had been noticed soon after a fracture of the forearm, sus- 
 tained four months previously. Faradisation was pursued regularly for two 
 months and the functions of the hand were somewhat improved. 
 
 It would appear that the prospect of recovery in paralysis of the
 
 •352 DISLOCATION OF THE HUMERUS. 
 
 musculo-spiral after injury, whether with or without fracture, is 
 very small if improvement does not show itself within from three to 
 six months. Whether electricity conduces to recovery is to my 
 mind doubtful, for probably in most cases the lesion consists in direct 
 contusion or stretching of the nerve trunk at the time of the frac- 
 ture. It depends on the degree of severity of these injuries, and 
 on the consequent anatomical changes, whether the regeneration 
 (the capability for which, unfortunately, in man is limited) of the 
 damaged nerve-bundles suffices to restore function or not. The 
 results of paralysis of the peroneal nerve following immediately 
 after sudden straightening of genu valgum, fuUy confirm these 
 statements. 
 
 In three cases of paralysis of the musculo-spiral nerve resulting 
 from long-continued use of crutches, the patients — aged respectively 
 twelve, eighteen, and forty-five — recovered completely in about two 
 months under the employment of faradisation, after the use of the 
 crutches had been forbidden. 
 
 Dislocation of the humerus. Death. 
 
 Johann G — , ist. 59, a decrepid old man, who had suffered repeatedly from 
 rheumatic inflammation o£ the joints, while walking carelessly fell into a 
 pit and struck himself on the left shoulder. The joint swelled up and 
 became painful ; soon after the injury he had a severe rigor. Six days later, 
 when he came to the hospital, I found the right humerus dislocated f oi-wards 
 and marked swelling ahout the shoulder, over which the skin was brownish 
 red and emphysematous. The patient was very weak, the pulse small, and 
 temperature low ; no fracture of the ribs could be detected. The dislocation 
 was reduced without difficulty. During the next few days, the collection of 
 gas about the joint constantly increased. The swelling lay close under the 
 clavicle and reached up to the axilla ; although it was undoubtedly filled with 
 gas and blood I hesitated to make an incision into it for fear that I might 
 open the shoulder- joint. In the man's condition he could not have survived 
 suppuration of the joint, resection, or exarticulation. The tumour rapidly 
 increased in size, till the skin became as thin as paper ; meanwhile, the 
 patient became more and more collapsed. Fourteen days after the injury, 
 I decided on opening the cavity, which I found full of gas and foul 
 pus ; collapse followed and death took place fifteen days later — about a 
 mouth after the dislocation. Post mortem : no fracture of the rib could be 
 discovered, so that the case appeai-s to have been one of those rare instances 
 where the blood extravasated at the time of the dislocation decomposed with 
 generation of gas.
 
 DISLOCATION OF HUMEEUS. 353 
 
 Paralysis and atropJiy after dislocation of humerus. 
 
 A man, set. 40, who had dislocated his right humenas nine months pre- 
 viously, came to the hospital with complete paralysis of the forearm and 
 commencing atrophy. By means of Schneider-Mennel's apparatus reduction 
 was effected, hut the arm remained as before, completely paralysed as regards 
 sensation and motion. 
 
 Probably the brachial plexus had become adherent to the dis- 
 located head of the humerus, and was torn in effecting reduction. 
 It is, I think, better in such cases not to attempt reduction, but 
 to excise the head of the humerus, as has been done successfully 
 by von Langenbeck, in cases of paralysis from pressure. 
 
 H. H — , set. 51. The previous histoiy of this highly exceptional case is 
 unfortunately very incomplete. The patient was attacked with a rigor, and 
 at the same time with swelling and redness of the whole right arm, so that 
 it was not possible to examine the shoulder minutely. I suspected acute 
 cellulitis, perhaps accompanied with thrombosis of the axillary vein, since 
 the subcutaneous veins of the shoulder were much distended. Under the 
 application of mercurial ointment and ice, the tumefaction of the arm sub- 
 sided, except about the shoulder, where fluctuation soon after became evident. 
 The skin remained red, the febrile symptoms increased, and the pain in the 
 swelling persisted. There seemed, then, no dol^bt that a large abscess had 
 formed, and I waited for it to open spontaneously ; this, however, did not 
 take place, and eventually (about forty days after the commencement of the 
 symptoms) I made an incision close under the acromion. No pus came, but 
 about a pint of turbid, serous fluid escaped, containing flakes of fibrine. On 
 introducing my finger, I found a large cavity lined by smooth membrane, 
 at the bottom of which the head of the humerus could be felt, dislocated 
 forwards and inwards. As suppuration in the cavity seemed now inevitable, 
 I made a second incision, near the pectoral muscle, and passed in a drainage 
 tube, bringing it out at the first opening. Severe febrile symptoms ensued 
 with rigors, and he died of pyaemia three weeks later. Post mortem : the 
 dislocated head of the humerus was found completely atrophied and covered 
 by papillary osteophytes. It articulated with a false socket, formed between 
 the glenoid fossa of the scapula and the ribs. 
 
 I am at a loss for an explanation of a case such as this ; at any 
 rate, an immense synovial cyst, which perhaps had extended through 
 the capsule of the joint, lay around the luxated head of the humerus. 
 But how had the dislocation taken place ? The patient had given no 
 
 23
 
 854 IREEDUCIBLE DISLOCATIONS OF HTJMEEUS. 
 
 account of any injury, yet he must have sustained one a long time 
 previously ; or was the condition the effect of an arthritis deformans ? 
 Such a result must he very rare. Unfortunately, the records of this 
 case give no information as to whether there had been any previous 
 disease or injury about the shoulder. 
 
 Irreducible dislocation of the shoulder of five weeks' standing. 
 
 Cecilie H — , set. 53, was admitted for a sub-coracoid dislocation of the 
 humerus, the result of an injury five weeks previously. A medical man 
 who saw the case at the time supposed that he had effected reduction under 
 an anaesthetic. Every new — and old — method was tried in turn without 
 success. Finally, we were forced to desist owing to considerable swelling of 
 the arm. "Within a couple of weeks the extravasation and swelling had 
 disappeared, and the movement of the ann was then more free than on 
 admission, which was probably due to our having broken down some 
 adhesions. 
 
 Irreducible dislocation of the shoulder of six weeh? standing. 
 
 Dominic F — , £et. 53, was admitted with the following history : — Six 
 weeks previously he fell from a cart on to his right shoulder. He went to 
 a medical man, who diagnosed a fracture of the humems, and applied splints. 
 Five weeks after the injuiy a surgeon discovered that the arm was dislocated, 
 and endeavoured in vain, with the aid of tkree strong men, to reduce it. On 
 admission the head of the humerus could be felt in the axilla ; the move- 
 ments of the arm were tolerably free. It was found impossible to reduce 
 the dislocation although the methods of von Pitha, Schinzinger, Heine, etc., 
 were tried in turn. Twelve days later a further attempt was made with the 
 Schneider-Mennel's apparatus, and still more force employed. Even this 
 was in vain, and the man left with the dislocation unreduced. 
 
 The following case, in which reduction was effected, is worthy 
 of mention, on account of the complete paralysis of the upper 
 extremity : 
 
 Antoine M — , set. 50, fell from a height of about twelve feet on to his 
 outstretched left arm. Two days later he came to the hospital ; the head of 
 the bumei-us could be felt in the axilla, and was reduced with the greatest 
 ease. The arm was put up in the ordinary way in a miteUa. The pain 
 soon subsided, but as the patient was unable to move the arm he came back 
 twelve days after the injuiy. Sensation and motion were lost in the arm
 
 DISLOCATION OF ULNA: OP THUMB. 355 
 
 and forearm. Witliin four weeks of tlie injury sensation was restored, but 
 mobility did not return ; tbe patient was then transferred to the electro- 
 therapeutic department. 
 
 Eeduction was so easy in this case that most probably the nerves 
 were either bruised or partly lacerated at the time of the injury. 
 
 Dislocation of the ulna hacJcwards at the elbow-joint. 
 
 This injury was observed in the case of a man, aet. 28, who came up to the 
 hospital a fortnight after the injury. Reduction was easily accomplished, 
 but the bone would not stay in position ; probably the coronoid process was 
 also broken off at the same time. He recovered with complete mobility of 
 the joint. 
 
 Dislocation of the thumb. 
 
 An intemperate man dislocated the first phalanx of his thumb on to the 
 dorsal surface of the metacai-pal bone. He came up to the hospital four weeks 
 after the injury. All attempts to reduce the dislocation were unsuccessful 
 until I made an incision through the capsule of the joint. A plaster of 
 Paris bandage was applied. Slight gangrene of the skin took place under 
 the bandage. In due course the slough separated, but the patient was 
 attacked with erysipelas, starting from a slight graze on the nose, which 
 extended over the whole body, and canied him ofE after thi'ee weeks. The 
 fatal result in this case could not, therefore, be directly attributed to the 
 injury of the thumb. 
 
 In another case the patient, a man, came to me two weeks after the injury 
 with a dislocation of the second phalanx on to the dorsum of the fii'st. I 
 was unable to effect reduction until I had resected the head of the first 
 phalanx. 
 
 Suppwation of the shoulder-joint. Excision. 
 
 In a child, set. 13, who had suppuration of the shoulder-joint, resulting 
 from a penetrating wound, I excised the head of the humerus, sawing 
 through the anatomical neck of the bone. Recovery followed in two and a 
 half months, but when the child left the hospital I found that the great 
 tuberosity of the humerus, which had been left behind, was drawn up under 
 the acromion, so that I fear the power of raising the arm may have been 
 mateiially impaired. 
 
 If this were the case it would be proper always to resect at the 
 surgical neck. Still, the cicatrices after the resection of joints are
 
 356 MULTIPLE PYEMIA: EECOVERY. 
 
 always capable of great extension in moving the limb, and it is 
 therefore possible that the mechanical condition of the joint 
 materially improved. Unfortunately, the patient did not come up 
 to see me again. 
 
 Secondari/ amputation of the forearm — multiple pycBmia — recovery. 
 
 Joseph Z — , set. 29, a house-poiier, was wounded, during a quaiTel, by a 
 •cook's knife on the forehead and forearm. The wound on the forehead was 
 about an inch long, and had sliced off a thin layer of bone. On the dorsal 
 .side of the right forearm was a wound a quarter of an inch in length, 
 extending down to the cellular tissue, and over the wrist another small wound ; 
 these were all united by sutures, and healed for the most part by first intention. 
 Subsequently, however, swelling began in the neighbourhood of the wounds, 
 the union gave way, and suppuration followed. Under wet compresses, the 
 swelling and redness of the forehead disappeared, but that of the forearm 
 increased, in spite of constant applications of ice. Ten days after the injury, 
 ■a splinter of glass, an inch in length, was removed from the wound in the 
 forehead, and two days later, a second fragment. The patient supposed that 
 these had got into the wound while he was being dragged along the ground. 
 On the eleventh day a severe rigor occun-ed ; during the next six days he 
 had six more (temp, up to 104°). In the meanwhile the swelling in the 
 forearm increased, and extended up above the elbow. Incisions were made, and 
 •some ill-smelling, diity pus let out. After the sixth rigor, the patient sub- 
 emitted to operation, which previously he had obstinately refused, and circular 
 amputation was accordingly performed at the middle of the upper arm. The 
 tissues cut were apparently healthy ; the haemorrhage was restrained by six 
 •acupressure needles, one suture only was applied, and open treatment 
 adopted. From this time the rigors ceased. Five days after the amputation 
 iae coughed up some spherical lumps of puioilent matter, and had stabbing 
 pains in the left side of the thorax ; ten days later, there was marked 
 pleuritic effusion on the right side, followed after five days by hamoiThagic 
 diarrhoea which lasted for several days. The purulent sputa continued for 
 about a month ; the wound then gradually healed, and in about ten weeks 
 the patient left the hospital recovered. 
 
 This remarkable case shows that recovery may follow after severe 
 -multiple pysemic poisonhig. 
 
 The patient had had six very severe rigors, and the copious, 
 purulent sputa, occurring in the form mentioned, made the existence 
 of abscess in the lungs highly probable, although no elastic tissue 
 •could be found in the expectorated matter. Unquestionably he had 
 |)leurigy of the left side which was probably set up by the abscesses
 
 COMPOUND FRACTUEE IJSITO THE ELBOW-JOINT. 357 
 
 in the lungs. Finally, diarrhcea attended by hsemorrhage persisted 
 for ten days, yet when all further source of infection was removed? 
 by amputation, the patient recovered from the effects. Such cases, 
 unfortunately, are only too rare. 
 
 Compound fracture into the elbow-joint. (Z. B.) 
 The following seven cases came under observation in Zurich : 
 
 J. W — , aet. 50. This man's right olecranon was cut through by the 
 knife of a straw-cutting machine, and a wound an inch and a half long 
 made in the sldn. Two days after the injury complete resection of the 
 elbow-joint was performed. The wound did not heal perfectly for six 
 months. When the patient was discharged he was able to flex and extendi 
 his arm and had some power of pronation and supination. 
 
 I saw him four years later and was astonished to find how mucb 
 the arm had altered for the worse. The forearm was displaced 
 upwards and backwards for three inches, but it could be brought 
 down to its normal position. The amount of lateral mobility was. 
 excessive. Active movements were very limited, but the utility of 
 the hand certainly was quite unimpaired. 
 
 C. S — , set. 70, a wasted, weakly man, had his arm run over. The? 
 olecranon was fractured, and there was a large lacerated wound of the skin, 
 but at first we could not make out that there was any opening into the 
 joint. I did not think that the patient was likely to survive his injury long, 
 for he had a considerable contused wound of the leg also. However he 
 rallied well. Suppuration of the elbow-joint ensued, and on the thirtietli 
 day after the injui-y I excised the joint. He died eighteen days later of 
 febrile marasmus. 
 
 Herr B — , set. 39. This patient while in a state of delirium from typhus 
 fever, sprang out of the third floor of a hospital on to the pavement. He 
 sustained simple fracture of Ijoth calcanea, in addition to a compound 
 fracture of the lower end of the left humerus extending into the joint. The 
 patient was in such a weak state that I did not venture at once upon primary 
 resection. Twelve days after the injury I performed excision, for there was 
 suppuration in the joint and from the contused wounds : the operation was 
 followed by rigors and extensive suppuration about the elbow. Six days, 
 after the excision I amputated the humerus. The patient died two days 
 later — twenty days after the injury — of pysemia.
 
 358 COMPOUND FEACTUEE INTO THE ELBOW-JOINT. 
 
 H. B — , aet. 48, fell from a ladder and fractured both condyles of the 
 humenis. There was extensive extravasation of blood and a very small 
 wound close to the olecranon. His limb was put iu a plaster-of-Paiis 
 splint in which a window was cut, and ice applied. Suppuration of the joint 
 followed, and he died of septiciemia, nine days after the injury. 
 
 Herr E — , aet. 60, a very fat, big man, not exactly a dmnkard, but still, 
 a regular frequenter of the beerhouse, fell fi-om a step-ladder, pitching 
 backwards with the whole weight of his body on to the flexed elbow-joint. 
 The condyles and the olecranon were comminuted. Excision of the joint 
 was performed the day after the injiuy. Death from septicaemia seven days 
 later. 
 
 E. G — , set. 25, received a wound of the elbow-joint from a circular saw, 
 which penetrated into the internal condyle. The joint was excLsed a few 
 houi-s after the accident. Death took place from pyaemia twenty-six days 
 later. 
 
 E. B — , set. 28, received a wound of the right elbow-joint and an injury 
 to the olecranon from a chaff -cutting machine. Primary resection of the 
 joint was performed. The patient was dischai'ged in four months with the 
 wouud healed ; passive movement was almost normal, but the active move- 
 ment was only slight. I could not find out the ultimate result of the case 
 as regards movement. 
 
 The results of conservative and operative treatment for wound 
 of the elbow-joint appeared to me almost equally unfavourable. 
 Including three cases of simple penetrating wound of the joint, 
 one of which was treated by excision the fourteenth day after 
 the injury and recovered, two by expectant means (one recovered 
 and one died of pyaemia), and two cases of compound dislocation, 
 both of whom died of pyaemia (one after amputation), we have 
 altogether eleven cases, of whom three only recovered after resection. 
 Still, we must take into consideration that the fatal cases included 
 a number of old people in whom the prognosis is always bad.
 
 ACUTE NON-TEAUMATIC INFLAMMATIONS. 359 
 
 Section B. Acute and Chronic Inflammations. — Acute non- 
 traumatic inflammations — general remarks. Case of acute 
 rheumatic disease of wrist. Case of acute osteomyelitis. liecrosis 
 of the hones of the upper extremity. Ganglion. Cases of teno- 
 synovitis — treatment. Case of onychogryphosis. Chronic 
 malignant onychia. Case of elephantiasis. Case of syphilitic 
 ulceration. Doubtful case of gangrene of fingers. Gangrene 
 of puerperal origin. Case of chronic periostitis. Chronic 
 disease of shoulder and elbow-joints. UemarJcs on excision. 
 Arthritis deformans. Disease of shoulder -joint — excision. 
 Subperiosteal excision of elbow. Case of reproduction of elbow- 
 joint after excision. Ankylosis of elbow ; treatment. Case of 
 hydrops of the elbow-joint. Chronic disease of the wrist-joint. 
 Case of excision of wrist. 
 
 Acute non-traumatic Inflammations. 
 
 In tabulating my cases for sixteen years, between 1860-76, I 
 entered a great many under the above heading. To all appearance 
 they originated spontaneously, but I have not the shghtest doubt 
 that injuries — though possibly very insignificant — give rise to the 
 infection and inflammation. Most of the " spontaneously arising ■" 
 whitlows start from some slight, neglected graze or puncture or 
 crack on the finger ; as a rule, they lead only to purely local inflam- 
 mation of the part, but sometimes to extensive inflammation of the 
 lymphatics. In the majority of cases resolution follows ; but 
 occasionally the infective material remains stored up in the cubital 
 or axillary glands, and abscesses form later on (see a case quoted 
 in 'Billroth's Path.,' Hackleys' Transl., p. 330). At the com- 
 mencement of the disease, patients do not take care of themselves, 
 and constantly, notwithstanding the pain, go on with their work 
 while there is considerable swelling of the limb. Thus, the 
 extension of inflammation is favoured, and the infectious phlogo- 
 genous material extends up the lymphatics, especially the large 
 supra-fascial lymph- sinuses. Inflammation in the hollow of the 
 hand is especially prone to cause great swelling, and often without
 
 360 ACUTE DISEASE OF WEIST. OSTEOMYELITIS. 
 
 any irritation leads to acute inflammation. Acute spontaneous 
 osteomyelitis is rarely seen in the upper extremity, except in the 
 terminal phalanges (panaritium periostale)"; monarticular rheumatic 
 inflammation too, is of rare occurrence in the upper extremity. In 
 metastatic inflammations of the joints, I have not infrequently 
 seen the lymphatics inflamed, and distinct, localised, erysipelatous 
 redness of the skin over the affected parts. From this I conclude 
 that these periarticular inflammations of the cellular tissue are due 
 to infective material passing out from the synovial membrane, inta 
 the lymphatic vessels. In the same way, I explain the peri- 
 articular inflammation which is met with in acute rheumatic inflam- 
 mations of the joints, and in acute gout. In the latter disease, 
 everybody considers now that there is for the time being, a deposit 
 of urates in the joint, and we may not unreasonably suppose, there- 
 fore, that acute rheumatic inflammation of a joint, and acute 
 spontaneous osteomyelitis are due to the deposit of some infectious 
 material. It seems to me somewhat premature to attempt invari- 
 ably to refer all acute inflammations to the same causes of origin. 
 Much more collateral proof is required than hitherto it has been 
 possible to adduce, and after all, we ought not too blindly to be 
 carried away by this hypothesis of infection. 
 
 Acute injlammaiwn of the wrist-joint. 
 
 A woman, set. 59, stated that her right hand had swollen, and that all the 
 movements had been verr painful for eight days before admission. When I 
 saw her, I fancied that the case was simply one of phlegmonous inflammation, 
 possibly accompanied by inflammation of the sheath of the tendons. The 
 part was painted with strong tincture of iodine, and ice applied. The disease, 
 however, increased rapidly in severity ; the right shoulder and the right 
 elbow became affected, and finally, owing to suppuration and disorganisation 
 of the wi-ist, amputation was resorted to ; the patient died of pyaemia 
 thirty-six days after the commencement of the disease. 
 
 I think in this case the disease was most probably very acute 
 polyarticular rheumatism. 
 
 Necrosis of humerus, acjite osteomyelitis. 
 
 Carl K — , set. 16, was admitted in December, 1869 ; he had suffered from 
 hip disease for four yeai-s, which had gone on to suppuration and ankylosis.
 
 NECROSIS. GANGLION. 361 
 
 Thi-ee years previously, a swelling the size of a fist, formed in the left axilla 
 and opened spontaneously. Over the insertion of the deltoid, was a sinus, at 
 the bottom of which the probe came down upon hard, exposed bone. Passive 
 movement of the shoulder was free enough, but the active movements were 
 impaired. The sinus was laid open, and the cloaca enlarged with the chisel. 
 Instead of the usual sequestrum in the humerus, it was found that the 
 internal layer of bone turned towards the medullary cavity was exposed to 
 the extent of about 8 centimetres. A counter-opening was made in the 
 axilla, and a loose sequestrum, 3 centimetres in length, removed. For 
 ten days he went on well, but then rigors occurred, the precursors of 
 acute osteomyelitis of the humerus. A fortnight later I resected the 
 upper half of the humerus ; the shoulder-joint was uninvolved, but the 
 section of the humerus showed unhealthy suppuration. Evidement of the 
 suppurating medullary cavity was performed with the raspatory. The 
 patient never rallied, and died five days later. At the post mortem we found 
 abscesses in the lungs and double pleurisy. 
 
 Necrosis of the Bones of the Upper Extremity. 
 
 Suppuration and the formation of sequestra in the upper ex- 
 tremity is far more rarely followed by albuminuria than in the 
 lower limb, and the disease is, on that account, far less dangerous 
 to life — even though a long time should elapse before the seques- 
 trum should be removed. Osteomyelitis, in many cases was the 
 result of typhus, or was attributed to that disease ; in other 
 instances some injury was the primary cause. 
 
 Ganglion. (Z. B.) 
 
 Six cases of ordinary ganglion on the dorsal aspect of the wrist 
 came under treatment. In none of them did a forcible blow 
 effect cure ; in five of the cases I employed puncture and sub- 
 cutaneous discission, and obtained permanent cure in all instances 
 without any serious inflammatory symptoms. In one I used 
 forcible compression, that is to say, a padded wooden splint was 
 placed under the wrist, and strips of plaster were drawn tightly 
 over the ganglion and the splint. The hand swelled up, and the 
 ganglion became painful, but disappeared completely after the 
 strapping had been applied a few times. After eight days it again 
 became perceptible and was then again got rid of by compression. 
 The patient then left the hospital and I could not find out any-
 
 362 TENOSYNOVITIS. COMPOUND I'ALMAE GANGLION. 
 
 thing further about her. In another case compression failed com- 
 pletely. 
 
 At Vienna the cases of this disease met with were seen only 
 among the out-patients and in my private practice. I either 
 ruptured the ganglia by pressure, or employed subcutaneous 
 discission. No doubt the condition often returns if the former 
 method be employed, even when pressure is kept up for a long 
 time by a plate of lead and strict rest of the part is enjoined, but 
 the patients, as a rule, prefer the slighter proceeding to puncture 
 or incision. I never saw recurrence of the disease after sub- 
 cutaneous discission. 
 
 Curiously enough, no case of compound palmar ganglion has 
 ever come under my care in Vienna, and I can only remember to 
 have seen two such cases since I have been here. 
 
 Tenosynovitis. 
 
 A gentleman came to me who had had for many years a fluctuating swelling 
 the size of a goose-egg an inch and a half above the wrist-joiint on the 
 dorsal aspect of the forearm. He experienced some inconvenience from the 
 swelling in writing. I first tried to cure it by forcible pressure, but without 
 success ; I then punctured the tumour with a trochar. Some perfectly clear, 
 jelly-like matter was pressed out ; I threw in some iodine diluted with an 
 equal amount of water and allowed the mixture to remain a short time before 
 withdrawing it again. The arm was put up on a splint, with wet bandages. 
 Tolerably severe swelling of the arm, accompanied by fever took place during 
 the next few days ; under the application of ice, the swelling subsided in 
 eight days, and in the course of the next three weeks it had entirely dis- 
 appeared. The opening of puncture healed by first intention. 
 
 Compound palmar ganglion. (Z. B.) 
 
 E. A — , £Et. 26, a turner, stated that he had noticed five years previously 
 a painful swelling in the palm of the hand, which gradually increased until 
 the functions of the fingers became so interfered with, that complete exten- 
 sion (except of the thumb) was no longer possible. The patient was in a 
 great state of alann lest the trouble should get still worse, and was very 
 anxious to have something done. A fiuctuating swelling could be felt in the 
 hollow part of the hand, close above the annular ligament. The fluid could 
 be pressed from one j)art to the other. I punctured the swelling with a 
 medium-sized trochar in the hand, and with difliculty evacuated some colloid, 
 sago-like pulp. Finding, however, that the contents of the swelling were too
 
 ONTCHOGRTPHOSIS. 363 
 
 thick to escape readily, I substituted a large cannula and let out a tumbler 
 full of colloidal matter and numerous melon seed bodies. The cyst was then 
 washed out with lukewarm water, iodine injected, and a bandage applied as 
 in the first case. The puncture during the first few days seemed as though 
 it would heal by first intention, but twelve days after the operation great 
 swelling came on, and as the application of ice did not prevent suppuration, 
 I was forced to make some counter openings. The suppuration was, however, 
 never very great, and after a couple of months the man got well. He came 
 back to me four years later with a report that he could use the hand well in 
 his occupation, and had no pain. On moving the hand it could be seen that 
 the tendons were in part united to their sheaths. The third finger could not 
 be more than semi-flexed, but this movement was perfect in all the others. 
 He could also extend the fingers almost completely. 
 
 In the case of a young woman in whom very much the same 
 condition of things existed I was forced to make an incision into 
 the swelling before the contents could be evacuated ; no iodine was 
 injected. The suppuration lasted over five months, but the 
 ultimate result was much the same as in the previous case. So far 
 as I know recovery was permanent. 
 
 Although the ultimate result in these cases was not bad, yet I 
 must admit that I am rather loth to adopt any operative measures 
 in these large palmar ganglia. The extent and severity of the 
 inflammation of the tendon-sheath can neither be gauged with 
 accuracy beforehand, nor controlled with certainty after it has been 
 excited artificially. My advice is, therefore, to operate only on 
 cases in which the loss of function is so great that it outweighs the 
 possible danger of operation. 
 
 Onycliogryplio&is. 
 
 A woman, set. 20, of strong constitution, was admitted on account of an 
 affection of all the nails of both hands and feet from which she had suffered 
 for three years. The lamella} of the nails were thickened, opaque and 
 looser than natural, and projected over the finger tips like claws. A younger 
 brother of the j)atient had suffered also from the same affection since his 
 seventeenth year. Nothing of the sort existed in the parents. Minute 
 examination showed that the nail was healthy up to the so-called nail furrow, 
 but half a line beyond this was diseased. The cause of the affection there- 
 fore must have existed in that pai-t of the matrix which lay below the sur- 
 face of the nail. Kepeated attempts were made to discover some fungus but 
 invariably without success. All kinds of applications were tried : the nails 
 were cut away in great part, or scraped down from the upper surface ; 
 nothing, however, seemed to do any good, and after three months the patient
 
 364 CHRONIC MALIGNANT ONYCHIA. 
 
 was discharged unimproved. I saw lier three years afterwards and no 
 alteration had taken place in her condition. 
 
 Chronic Malignant Onychia. 
 
 This disease as we see it, almost invariably occurs in children ^ 
 and commences with slight inflammation about the matrix of the 
 nail. Instead of healing, it gradually goes on to slowly pro- 
 gressing ulceration, either beneath or in the neighbourhood of the 
 nail, and is accompanied by great swelling, redness, and pain. It 
 appears probable that the malignant character of the affection is 
 due essentially to neglect of the small wound at the outset. The 
 slow progress of the disease results from the difficulty in getting 
 rid of the poisonous agent (perhaps very minute organisms which 
 have become charged with infective material). The chronic course 
 of the disease, and sometimes its very appearance, cause it to 
 resemble strongly syphilitic ulceration of the finger. Onychia 
 maligna, too, has many points of similarity to diphtheritic ulceration, 
 and I am not entirely averse to considering the affection as a 
 peculiar kind of diphtheritic ulceration; it should be, however, 
 remarked, that onychia maligna is never phagedaenic and that 
 hardly any of the diseased parts are lost. In this respect, there- 
 fore, it has no relationship with other forms of diphtheritic inflam- 
 mations of wounds, least of all with hospital gangrene, notwith- 
 standing that externally the processes seem to be so similar. 
 
 The disease frequently originates spontaneously, perhaps from 
 some unnoticed excoriation or little fissure about the nail. In one 
 of my cases, the disease was supposed to have originated from a 
 blow on the finger with a schoolmaster^s cane a year previously. 
 
 Vanzetti, in his classical work on this disease, has pointed out to 
 us an excellent remedy; this consists of powdered nitrate of lead, 
 which should be dusted over the finger, and kept in position with 
 a dry bandage and strapping. In from five to ten days the 
 dressing should be removed, and a crust will then probably 
 separate, exposing a healthy, granulating surface, which will 
 usually heal under some simple dressing. The newly-formed nail 
 is commonly irregular at first, but in course of time resumes its 
 natural shape.
 
 ELEPHANTIASIS. SYPHILITIC ULCEEATION. 365 
 
 Elephantiasis of the arm. {Chronic indurated cedema.') 
 
 A strong young man, aet. 23, was admitted with tliis affection. When 
 about 12 years old he suffered from chronic ophthalmia and suppurating 
 glands in the neck. Then he had some suppuration about the right forearm, 
 which was a long time in healing. Some swelling and thickening was left 
 about the forearm, which never completely disappeared. It did not occasion 
 him any serious inconvenience or hinder him from working. From time to 
 time, however, without any obvious cause, he had attacks of erysipelas, 
 which usually extended up to the shoulder. He got well in a few days, but 
 after eveiy such attack the arm increased in size. He was suffering from 
 one of these erysipelatous attacks on admission. By suspending the limb 
 and careful bandaging, the size of the arm was materially diminished, but 
 the improvement did not last long, and after a time the patient left the 
 hospital unimproved. 
 
 Such a condition is rare in the arm ; probably the subcutaneous 
 lymphatic channels had been destroyed by the old suppuration, 
 and as no new channels could be formed, and the old ones were 
 insufficient to supply their loss by collateral dilatation, the chronic, 
 indurated oedema was set up. The veins in the affected arm were 
 not dilated. 
 
 Si/philitic ulceration of the arm. 
 
 A woman, jet. 40, came under my care who had suffered from syphilitic 
 symptoms for about twelve years. About twelve years previously ulceration 
 began on the forehead, scalp, integuments of the breast, and over the right 
 hand and arm. She had been frequently under treatment with iodide of 
 potassium, but I could not discover whether she had had a mercurial course. 
 When admitted the ulceration — save on the arm and the dorsal surface 
 of the hand — was for the most part healed, but in these parts it ajjpeared to 
 have progressed uncliecked. On the dorsum of the hand the tissues were so 
 deeply destroyed that the fouiih and fifth metacai-pal bones and their articu- 
 lations were completely exposed. From the depth of the ulceration around it 
 was evident that total gangrene of the fingers must inevitably eusuo. Above 
 the middle of the forearm there was no actual ulceration. At the patient's 
 express wish amputation was performed here, but she died of pyeemia. 
 Excepting a cicatrix of the liver the internal organs were found to be free 
 from syphilitic disease. 
 
 Gangrene of the fingers. 
 
 J. M — , ffit. 56, a labourer, strongly built, but very unintellectual.
 
 366 GANGRENE OF FOREAEM. 
 
 came under my care at Zurich. He stated that up to eight days before 
 admission he had been perfectly well, but that then the tips of aU his fingers 
 became simultaneously swollen and painful, and scabs formed on them. On 
 the tips of all the fingers we found very fii-mly-attached scabs and crasts, 
 which on minute investigation proved to be small mummified portions of skin. 
 In addition to this, on several of the fingers, close to the mummified parts, 
 dark blue patches, like extravasations of blood, were seen beneath the 
 epidennis. Wet compresses were applied to the hand. Twelve days later 
 he was attacked with trismus and subsequently with tetanus, of which he 
 died. Nothing abnonnal was found in the brain or the membranes of the 
 brain at the post mortem. The aorta was highly atheromatous, and the 
 radial and ulnar arteries considerably thickened. The rest of the body was 
 perfectly natural. 
 
 Could this have been a case of ergotism? No history of the 
 sort could be made out. Was it a case of senile gangrene of the 
 fingers, or one in which tetanus accidentally supervened? I am 
 unable to decide the point ; the less so that the digital arteries were 
 not examinedJ 
 
 Sjpontaneoiis gangrene of tJie forearm of puerperal origin. 
 
 I have, unfortunately, only a brief record of this remarkable 
 case. 
 
 Frau V — , set. 35, who had previously been a strong, healthy woman, was 
 in the ninth month of pregnancy when the disease commenced. Seventeen 
 days before her admission, she felt pain in the left hand, for which no cause 
 could be assigned. Two days later the entire upper extremity was greatly 
 swollen up to the axilla. Four days after the commencement of the pain, she 
 had a normal and easy confinement. Three days later, the fingers turned blue 
 and then black. The gangrene then spread rapidly up the forearm. 
 
 The patient had a long journey up to the hospital, and when admitted, I 
 found the left hand, and two thirds of the foreann black and dry ; the skin 
 was leathery and emphysematous. A distinct line of demarcation was seen, 
 which ran round the dorsal aspect in a circular form, and on the volar side a 
 pointed tongue of healthy tissue ran downwards for about half the length of the 
 forearm (like the flap seen on the calf in gangrene from embolism of the 
 popliteal artery.) On the inner side of the upper arai, the tissues of the 
 lower part were infiltrated and reddened, and fluctuation was distinct. The 
 lungs were healthy. There was some sanious discharge fi-om the vagina ; 
 the uteras was contracted, the os externum patent, and the portio vaginalis 
 
 1 Compare Mr. Thomas Smith's case of gangrene of the hand in a child, 
 published in the ' Clin. Soc. Trans.,' vol. xiii, p. 196. [Ed.]
 
 CHEONIO PERIOSTITIS OF FOEEAKM. 367 
 
 relaxed and tender. Amputation was performed about the middle of the ai-m, 
 and an abscess which reached up almost to the axilla laid open. Complete 
 recovery followed in a month. 
 
 With regard to the examination of the arm, I find it only 
 recorded " no thrombosis of the brachial artery or veins, either in 
 the stump or at the amputated portion." This I can hardly 
 believe, for thrombi must undoubtedly have been found at the line 
 of demarcation. I regret that I did not see the case myself, for it 
 occurred during my vacation. From the description of the com- 
 mencement of the disease, and from the position of the line of 
 demarcation, I suspect — reasoning by analogy from similar cases of 
 spontaneous gangrene occurring in the lower extremities — that 
 there was an embolism of the cubital artery, probably originating 
 from endocarditis with vegetation growths on the aortic valves. 
 
 An analogous case also originating during pregnancy, of spon- 
 taneous gangrene of the leg, came under my observation at Ziirich 
 [vide infra in the chapter on the lower extremity). 
 
 CAronic periostitis of ilie hones of the forearm. 
 
 A child, set. 8, was admitted with a swelling of both forearms and patho- 
 logical dislocation of the right hip. It was not possible to find out much 
 beyond the fact that though rather neglected he had been fairly healthy up 
 to two years previously ; the right hip- joint then became affected and painful. 
 The thigh could be freely moved without causing pain. Both forearms we 
 found much swollen, owing to marked deposits of new bone, especially on the 
 ulna, so that these bones, particularly at the upper parts, were twice their 
 normal thickness. This osteoplastic periostitis was suggestive of congenital 
 syphilis. Iodine was applied to the forearm, and iodide of iron was given 
 internally. A fortnight after admission the child became very ill, with pain 
 in the abdomen, and violent vomiting ; during the next few days the 
 abdomen became distended, and the sickness continued. Eighteen days later 
 fifty ounces of thick yellow pus escaped at the umbilicus. The next day 
 the child was taken away by his mother — a rather obstinate woman — against 
 advice. The child was in such a wretched plight that I thought he would 
 soon die ; I heard, however, twelve months later that he was still alive, 
 though in a very deplorable condition. 
 
 Cheonic Inflammation of the Shouldee and Elbow Joints. 
 A table of nine cases — in three of which excision was performed
 
 368 CHRONIC DISEASE OF SHOULDEK AND ELBOW JOINTS. 
 
 — will be found in the ' Bericht ' for 1860-67, P- 4^^^ and a table of 
 thirty cases of chronic inflammation of the elbow, on pp. 430 et 
 seq. 
 
 Excision was practised in fourteen cases and amputation in one, 
 (op, cit., p, 430). While I was at Ziirich none of the patients on 
 whom excision of the elbow -joint was performed for disease died. 
 I operated always according to von. Langenbeck's method. The 
 ultimate utility of the arm in the great majority of cases left 
 nothing to be desired. True, the parts sometimes did not alto- 
 gether heal up for a year or more, but after complete excision, 
 small, slightly discharging sinuses interfere but little with the 
 utility of the limb. The time that these sinuses take to close, 
 depends materially upon the condition of the soft parts at the time 
 of excision ; sometimes chronic periostitis of the joint ends ensues, 
 giving rise to fresh sinuses. Such a condition is, however, rare, 
 and will only occur in persons of very weak constitution. 
 
 The utiHty of the false joint after excision depends very much 
 upon the condition of the muscular system of the patient, especially 
 the muscles of the diseased arm. I have always practised total 
 excision, and have never seen a useless flaU-like Hmb result. 
 However, the laxity of the joint will be found far greater in from 
 two to three years after tl^ excision than might be expected when 
 the patients are discharged from six to eight months after operation. 
 The latter is just the period when the results of operation seem to 
 be most favourable ; it is, therefore, important to avoid removing 
 more of the articular ends than is absolutely necessary, nor should 
 passive movement be commenced too early. In cases where the 
 movements at an early period — say eight or ten weeks — are very 
 free, it will be better to hmit them by means of a hinged sphnt. 
 
 • (W. B.) 
 
 Between 1860-76, fourteen cases of chronic fungous inflammation 
 of the shoulder-joint, most of which were associated with external 
 caries and suppuration, came under treatment. Eight of these were 
 in women and six in men. The joint was excised in four instances ; 
 one only recovered with an exceedingly good and useful arm. 
 Septicaemia proved fatal in one instance, and two of the patients
 
 CHEONIC DISEASES OF JOINTS. 369 
 
 died of phthisis sixteen months and four years respectively after 
 the operation. 
 
 Chronic Diseases of the Joints of the Upper Extremity. 
 
 In tabulating these cases I excepted superficial ulcerations, chronic 
 hydrops of the joints, chronic rheumatic diseases, slight cases of 
 synovitis, and cases of necrosis, as well as those in which ankylosis 
 resulted. I find thus, that between 1860-76, 231 cases came under 
 treatment, 134 of whom were men and 97 women. These figures 
 may be partly explained by the fact that in Vienna, as also in 
 Zurich, more beds were set apart for males ; but on the whole the 
 numbers give a good general idea of the proportionate prevalence of 
 these diseases in the two sexes. These figures are the more 
 striking when we consider that my statistics show that caries of the 
 shoulder and of the elbow-joint more frequently occurs in females. 
 I can hardly account for this, unless on the supposition that severe 
 arm work is more injurious in the female than in the male sex. 
 
 The different parts of the upper extremity are diseased in very 
 different numerical proportions ; thus, out of my whole list of cases 
 (231) the scapula was affected only in four cases, and the clavicle 
 but once ; while the arm, and the elbow downwards inclusive, were 
 affected in no less than 199 instances. The elbow-joint is the part 
 most frequently diseased, probably because it is more exposed to 
 injury, and perhaps also in part because the growth of bone here is 
 greatest, and the disease — as my tables show — generally attacks 
 individuals in whom bony growth is going on actively. 
 
 Poly-articular Chronic Rheumatic Affection of the Joints 
 (Arthritis deformans) . 
 
 Of six cases of this disease, the shoulder-joint was principally 
 affected in two, the wrist in two, the elbow-joint in one, while in 
 one the finger -joints were chiefly involved. All these patients were 
 recommended thermal baths. 
 
 Inflammation of the shoulder-joint. 
 
 The following case is worthy of mention on account of the 
 
 24
 
 370 CASES OF EXCISION OF ELBOW. 
 
 duration of pysemia and the fact that I was compelled to resort to 
 resection : 
 
 A man, aet. 56, but very strong, was admitted on account of a lacerated 
 wound of the hand. At first all went on well, the gangi-enous parts 
 separated, and the wound began to granulate. Sixteen days after the 
 injury, however, the patient was attacked with diarrhoea ; this was controlled 
 by opium, but he lost strength, and had remittent attacks of fever. A 
 month later a painful infiltration was noticed on the inner side of the 
 injiu-ed extremity, at which spot an abscess subsequently formed ; then the 
 shoulder- joint became affected and painful. The patient had no rigors, but 
 was weak, with marked fever in the evenings ; fi'ee sui^puration occurred 
 from the abscess, which was found to be connected with the shoulder- joint ; 
 meanwhile the wound of the hand healed up perfectly. As the suppura- 
 tion seemed to be draining the man's sti-ength, and all the internal organs 
 were healthy, I determined on resection of the humerus. The removal of the 
 carious bone exercised no check on the disease, and he died of marasmus. 
 
 The commencement of the pyaemia here dated in all probability 
 from the attack of diarrhoea — at all events, gradual decline set in 
 from that time. This was four months before he died_, so that 
 we may look on the case as one of chronic pya:;mia, although 
 many surgeons are unwilling to admit the occurrence of such a 
 disease. 
 
 Resection of the elbow. 
 
 In a well-nourished child, set. 14, who had had disease of the elbow for 
 six yeare, originating without known cause, I partially excised the joint, i.e. 
 I removed with the knife only the carious portions of the trochlea and the 
 olecranon, together with a small part of the condyle of the humenis. The 
 parts healed up, but complete ankylosis followed. This was forcibly broken 
 down under anesthetics, but considei-able reaction invariably followed, and 
 the ankylosis returned as before. I then resected the joint again, removing 
 the end of the humerus subperiosteally, with a satisfactory result. 
 
 Beproduction of elbow-joint after excision. 
 
 Leopoldine — , set. 13, an ill-nourished child, was admitted with caries of 
 the right elbow-joint, of three years standing. When admitted, she had but 
 recently recovered from an attack of variola, followed by one of typhus. The 
 joint was completely excised ; the wound did exceedingly well, and her 
 general condition rapidly improved at first; subicquently, however, cold
 
 ANKYLOSIS OP ELBOW. 371 
 
 abacesaes formed in the subcutaneous cellular tissue in various parts of tbe 
 body, wbich much reduced her strength, and she was brought still lower by 
 inflammation of the right knee-joint and periostitis of the left external mal- 
 leolus. The latter did not proceed beyond the stage of infiltration, but au 
 immense abscess formed about the right knee-joint, which was allowed to 
 open spontaneously and then drained ; six months afterwards the abscess was 
 still open, and the joint itself was swollen, and tender on pressure. The 
 excised elbow had completely healed, but active movement, both of flexion 
 and extension, was very slight ; the muscles were much atrophied. Even- 
 tually the knee-joint recovered without any impairment of mobility and the 
 patient was able to walk without limping. Some simises were still open 
 about the calf, but did not communicate with the joint. The excised elbow 
 two yeai-s later, as far as utility was concerned, was in no way inferior to 
 a normal joint, save only that pro- and supination were limited. Three 
 years after the excision, the patient was attacked rather suddenly with 
 suppuration of the knee-joint, and died shortly after of caseous pneumonia. 
 Post mortem : the liver, spleen and kidneys were found to be lardaceous. 
 On examining the resected elbow, a perfect ginglymus was found and a 
 very complete joint had been reproduced.^ 
 
 Ankylosis of the Elbow-Joint following Chronic 
 Eheumatism. 
 
 In two cases that came under my care, the ankylosis was partial, 
 and a slight amount of flexion and extension was permitted. Under 
 an anaesthetic the movements were rendered perfectly free by forcibly 
 breaking down some adhesions, but in neither case was any increased 
 power of movement eventually obtained, nor was the utility of the 
 limb improved. Daily passive movement in such cases is so painful, 
 and followed so constantly by swelling of the part, that the sufferers 
 soon lose patience. Where there is still a certain amount of move- 
 ment matters can be somewhat improved by orthopcedic and 
 gymnastic treatment, if persevered in for some years. When the 
 inflammatory process has lasted for some years, and is followed by 
 complete immobility of the joint, we may consider ourselves — and 
 the patients — fortunate, if the disease terminates in ankylosis ; 
 nothing better can be hoped for in such cases. Sometimes, it is 
 true, caries takes place with partial bony ankylosis ; in such cases I 
 
 ^ This case is more fully described by Dr. von Czemy in the ' Arch, fiir 
 Klin. Chir.,' Bd. xiii, i. Compare Mr. Syme's case recorded and figured in 
 the ' Lancet ' vol. i, 1855, and described in Holmes's ' Principles and Practice 
 of Surgery,' p. 896, ist edition. [Ed.]
 
 372 TEEATMENT OP ANKTLOSED ELBOW-JOINT. 
 
 usually content myself with correcting the deformed position under 
 an anaesthetic. Most of the patients came up with the arm ankylosed 
 at a very obtuse angle ; by bending it to a right angle the limb is 
 rendered far more useful. The limb was always put up in a plaster 
 bandage. I never found it necessary to repeat the process more 
 than once. If any severe pain followed the redressement an ice- 
 bladder was kept on the part, but it was rarely found necessary to 
 continue this application for any length of time. In one instance 
 only (a young girl) a rather acute abscess developed beneath the 
 bandage, over the external condyle ; the plaster case was removed, 
 and a quantity of foul pus let out by an incision. The pus was 
 found to contain a great number of strepto-cocci. Uninterrupted 
 recovery followed. 
 
 In another case I found myself unable to flex the limb to a 
 proper position under chloroform. Suspecting that the difficulty 
 was due to bony union of the olecranon and the trochlea, I cut 
 down on the olecranon and separated it. I was then able to flex 
 the limb, but suppuration followed and the ankylosis was not 
 complete for ten weeks. 
 
 Hydrops of the elbow-joint. {Hydroj^s hernice synovialis) . 
 
 A man, set. 21, came under my care with the history that his previous 
 health had always been good, but that for about three months he had been 
 unable to extend his left arm completely, and found that this limb soon 
 became tired when he was at work : at the same time he noticed a slightly 
 painful swelling beneath the skin, on the outer side of the elbow-joint. 
 When admitted, we found" a subcutaneous swelling, the size of a walnut, 
 firmly attached close above the external condyle of the left humerus. I sus- 
 pected that the tumour was a ganglion connected with the joint, and 
 accordingly discountenanced operation. The patient however, was anxious to 
 have something done, as the condition of the arm interfered with his work. 
 I punctured the swelling, and let out some oolloid matter, containing fibrinous 
 melon-seed bodies. The puncture soon closed, and the fluid collected again, 
 so that a month or two later I performed subcutaneous discission with a teno- 
 tomy knife. The fluid again collected, but unfortunately the whole joint 
 became painful. Subacute inflammation of the entire articulation followed ; 
 the puncture again gave way, and the joint suppurated. I then performed 
 complete excision. He left the hospital with a useful arm, but I was un- 
 able to learn the subsequent result.
 
 CHRONIC DISEASE OF WEIST. 373 
 
 Chronic Inflammation of the Wrist- joint. 
 
 A table of twenty cases — in five of which excision was per- 
 formed — will be found in the 'Bericht' for 1860-67, P* 44°* 
 
 All my excisions of the wrist were performed by means of two 
 lateral incisions ; none of the patients died from the operation. Out 
 of the five cases, two only recovered completely with a tolerably useful 
 hand ; in one other the sinuses were still open, though the patient's 
 general condition was good, four years after operation. One died 
 four years after the operation of phthisis, and a girl, who had at the 
 same time caries of the foot, died of marasmus two or three mouths 
 after the operation. In two instances the disease of the wrist was 
 limited to a few of the carpal bones. One of these patients 
 recovered with ankylosis after the removal of two of the bones, and 
 the other after the extraction of one. 
 
 Excision of the wrisL 
 
 Vincenz N — , jet. 20, was admitted witli necrosis of the outer half of the 
 second metacarpal bone, which had existed for about a year. Tliis bone was 
 removed, but swelling about the wrist, and eventually suppuration of the 
 carpal joints followed. The entire carpus was then excised, and the patient 
 left some months later with very slight swelling of the part ; three sinuses 
 still remained open, but no diseased bone could be felt. 
 
 Notwithstanding repeated inquiry, we were unable to learn any- 
 thing further of this patient ; this is matter for greater regret, as so 
 few minute records are obtainable of the ultimate results of excision 
 of the wrist. 
 
 Section C. Malformations, Tumours, etc. — Contracted cicatrix 
 from burn — Operation. Case of contracted palmar fascia. 
 Si/ndactylia. Cases of subclavian aneurism ; Compression ; Er- 
 gotin injections. Traumatic aneurisms of radial artery / 
 Ligature of brachial ; Antyllus's operation. Case of clonic 
 spasm of muscles of shoulder. Case of neuralgia. Simple 
 Tumours — Enlarged deltoid bursa ; Atheroma of finger ; Caver-
 
 374 
 
 CONTRACTED CICATRIX. 
 
 nous lymphangioma ; Enchondroma ; Cicatricial fibroma of palm 
 of hand ; Neii^ro-fihroma of the musculo-spiral nerve ; Osteoma. 
 Malignant Tumours — Sarcoma {small-celled) of deltoid ; Alve- 
 olar sarcoma of humerus ; Sarcoma of hand ; Lymphosarcoma 
 treated by injection of albuminate of mercury ; Granulation 
 sarcoma ; Spindle-celled sarcoma ; Osteosarcoma of clavicle — 
 Hemoval; Osteosarcoma of humerus ; Central osteosarcoma 
 of ulna ; Epithelial carcinoma originating in the wound of an 
 isstie. 
 
 Contracted cicatrix after burn. 
 
 Fio 1 8. — (a) Defoemitt of Hand the besult of Conteacted Cicatbix ; 
 (&) The same aftee Resection of a poetion of the Radixts. 
 
 a h
 
 MALFORMATIONS. SYNDAOTYLIA. 375 
 
 Kaspar L — , set. 17, was severely burned about tbe rigbt wrist when two 
 yeare of age ; the wound, whicb. was deep and extensive, took two montbs to 
 cicatrise. As tbe contraction of tbe cicatrix was strongest on tbe dorsum of 
 the wrist-joint tbe band became strongly abducted and bent over to tbe 
 ulnar side. (Sec Fig. 18 a.) The patient, whose health was good, was 
 seriously inconvenienced in bis work through this deformity, so that it became 
 highly important to correct it if possible. It appeared that the ulna, pressed 
 upon by tbe cicatrix, had not kept pace in growth with tbe radius ; tbe latter 
 bone was markedly curved ; flexion and extension at tbe wrist- joint were 
 normal ; adduction and abduction somewhat interfered with, while scarcely 
 any pro- and supination was permitted. Tbe deformed position of tbe band 
 was his chief trouble. 
 
 ^^ It would have been of no use in this case to stretch the cicatrix, on account 
 of the oblique position of tbe radial articular surface at the wrist ; it appeared 
 to me better to shorten tbe radius, which was relatively too long. Accordingly 
 I removed with the saw a piece of this bone 4*5 centimetres in length, 
 taking it from tbe lower curved part of bone, and preserving tbe periosteum. 
 The limb was put in a plaster-of- Paris bandage with a window. When tbe 
 patient was discharged three months later, the position of tbe band was as 
 shown in the illustration Fig. 18 &. He could write and do light work, but 
 there was still a certain amount of stiffness in the movements of the hand ; 
 the union of the radius was perfectly solid. 
 
 Contraction of the palmar fascia. 
 
 A dyer, ait. 58, came under my care, for constantly increasing contraction 
 of tbe palmar fascia, fi'om which he had been suffering for two years. The 
 tense bands were divided as far as possible, subcutaneously. After the 
 operation, the fingers could be completely extended ; the hand was bound to 
 a splint, but considerable suppuration followed, whicb lasted three months, 
 and when it ceased the condition of tbe band was no better than before. No 
 fui-tber attempts were made to effect a cure. 
 
 Maleormations. Syndactylia. 
 
 A child, set. 6, was admitted with a curious deformity of the 
 hand. On the right hand there were only four metacarpal bones. 
 At the end of the fourth the pulp of the finger was well developed 
 on the volar side, but below, the bone was somewhat broader than 
 normal. Attached to its head were the two first phalanges, which 
 were connected to each other by bone ; at their bases they diverged 
 from each other at about an angle of 80°. AU the first phalanges 
 were connected by a web of skin, and on each of the two first was 
 a well-developed middle and distal phalanx which were very little
 
 376 CASES OF ANEUEISM. 
 
 separated from each other and resembled somewhat the claws of a 
 crab. The fourth finger was removed, after the attachment at the 
 base had been cut through with the bone forceps. 
 
 Aneurism of the suhclavian artery, treated hy compression. 
 
 K. F — , £et. 34, three weeks previously had struck his right shoulder in a 
 fall ; a week later, he noticed a swelling about the left clavicle, which 
 increased gradually. On admission he had pain in the left arm, and numbness 
 of the fingers. The swelling was of the size of a hen's egg. Digital com- 
 pression was tried, and also pressure, with a specially constructed apparatus, 
 but in five weeks' time, there was no appreciable improvement, and the 
 patient left the hospital uncured. 
 
 Subclavian aneurism. Ergotin injections. 
 
 A man, get. 56, came under my cai'e, who, three years previously, without 
 known cause, had noticed darting pains in the right arm, with formication 
 and numbness of the fingers, but the symptoms were not sufficiently severe 
 to prevent him from following his employment. Sis months before I saw 
 him, the symptoms became more marked, and a medical man detected a pul- 
 sating tumour above the clavicle. Eight days before admission he had a 
 severe attack of dyspnoea. When admitted, I found an aneurism of the right 
 subclavian ai'tery, the size of the fist. As operative proceedings seemed 
 inadvisable, I employed subcutaneous injection of ergotin over the aneurism, 
 as recommended by von Langenbeck. No improvement took place under 
 this treatment ; the growth increased, the attacks of dyspnoea became 
 more frequent, the voice hoarse, and he died of marasmus, a month after 
 admission. 
 
 Traumatic aneurism of the radial artery. Ligature of the brachial. 
 
 A smith, set. 40, was admitted with the following histoiy : — Fifteen days 
 previously, a large splinter flew ofE from a heavy iron hammer, and struck 
 him on the flexor side of the right forearm. Immediately, a jet of blood 
 spurted from the wound, according to the patient's rather hyperbolical 
 account, to a height of six feet. He pressed a coin upon the wound, and 
 placed the arm in cold water. A surgeon applied a bandage and sent him 
 home. The bleeding soon recurred, and during the next fortnight occurred 
 »n an average twice daily. The quantity of blood lost was estimated by the 
 patient at several pints, and must undoubtedly have been very considerable ; 
 the slightest movement — an attack of coughing for instance — was sufiicient 
 to bring on the hajmorrhage again, and the man had fainted several times 
 from loss of blood. The forearm became considerably swollen on the day of
 
 CASES OF ANEURISM. 377 
 
 the injuiy, and during the next twenty -four hours the swelling extended to 
 the hand and upper arm. 
 
 On his admission, the entire upper extremity was much swollen, from the 
 fingers to the axilla ; the upper arm was rigid, oedematous and of a yellowish 
 colour. The hand and the flexor aspect of the forearm were exceedingly 
 swollen and tense ; sensation was partly lost in the hand, and completely 
 absent in the thumb. About the middle of the forearm, on the flexor 
 aspect, was an in-egular gaping wound an inch in length, from which coagula 
 protruded. The haemorrhage occurred again during examination. While an 
 assistant compressed the brachial artery, I passed my finger through the wound 
 into the aneurismal sac, and laid open, with a probe-pointed bistoury, all the 
 soft parts, up to the end of the sac, i.e. to a little above the elbow-joint. 
 The superficial wall of the cavity was composed of the skin and the fascia. 
 At the bend of the elbow, the median vein was cut through, and required 
 ligature at both ends. On turning out all the coagula, the radial artery was 
 seen completely torn through about its centre, and lying bare, as if it had 
 been dissected out. Considering that this vessel had been torn fifteen days 
 previously, and was so extensively exposed, I was unwilling to trust to a 
 double ligature, and therefore secured the brachial artery at the upper angle 
 of the wound, about half an inch above its bifurcation ; hsemorrhage, however, 
 still occuiTcd from the radial artery, and I was compelled therefore to tie it 
 at the point of injury. No further bleeding took place ; within a few hours, 
 the swelling of the hand and forearm materially diminished, and a day or 
 two later movement and sensation returned in the fingers. The man 
 recovered in fifteen days. 
 
 Aneurism of the radial artery. 
 
 A woman, aet. 29, was admitted, who six weeks previously had received a 
 wound on the flexor aspect of the forearm, close to the wrist. The wound 
 soon healed up, but a few days before admission, swelling occurred about the 
 cicatrix, which eventually gave way, and severe hsemorrhage occurred. 
 Antyllus's operation was performed, and the patient recovered. 
 
 All exactly similar case occurred in a boy, set. 16, in whom a 
 pulsating tumour formed in the cicatrix, four weeks after the 
 injury. 1 
 
 Clonic spasm of the muscles of the sho^dder -joint. 
 
 Heinrich K — , set. 8 ; four weeks previously, without any known reason, 
 he had noticed a kind of throbbing and beating sensation in the right 
 shoulder. The outer border and articular portion of the scapida, were spas- 
 
 1 Some remarks on the treatment, etc., of aneurism will be found below in 
 the chapter on the lower extremity. [Ed.]
 
 378 NEUEALGIA. ENLAECtED BUKSA. ATHEROMA. 
 
 modically drawn back about fifty times per minute, the movement being 
 accompanied by a faintly audible cracking noise. The seiratus magnns 
 muscle appeared chiefly affected, but no reason could be discovered for 
 the spasm. We had not an opportunity of studying this choraic-like 
 movement for very long, for the spasms suddenly disappeared one day 
 after the arm had been forcibly raised for some time, for the purpose of 
 examination. The spasms did not return during the next three days, and the 
 patient was then discharged. 
 
 Neuralgia. 
 
 Herr H — , a Eussian, at. 30, came tmder my treatment in 1875. He 
 informed me that, about six years previously, from no known cause, he had 
 severe pain from time to time at a certain point on the right little finger ; 
 the spot was very sensitive when touched, and the pain extended up the arm 
 from it. Two years before, Pirogoff had excised the painful part of skin 
 together with a portion of the matrix of the nail. The wound healed up, 
 but the symptoms were unrelieved except that the shooting sensations did 
 not extend up the arm when the cicatrix was touched. By means of an 
 incision over the first phalanx, I excised a portion of the volar branches of 
 the ulnar and radial norve a centimeti-e and a half in length. The effect of 
 this was to limit the loss of sensation to the affected part. When he left, 
 ten days after the operation, he was free from the attacks, and pressure on 
 the cicatrix did not occasion any pain. Unfortunately, I could not succeed 
 in learning whether the cure was a permanent one. 
 
 Enlarged deltoid bursa. 
 
 A man, aet. 17, came under treatment with a tumour, the size of a goose- 
 egg, situated on the upper part of the left shoulder, in the deltoid muscle. 
 Fluctuation was very distinct. Xo communication could be made out between 
 the swelling and the shoulder-joint ; the cyst was punctured, and some clear, 
 highly albuminous, yellow fluid escaped, which contained a few small pale 
 round cells. Probably this was a case of enlarged subcutaneous bursa. 
 
 Atheroma of the finger. 
 
 Hen- G — , set. 40, came to me with a small hard nodule which he had 
 noticed for some years on the tip of his right middle finger. He attributed 
 its origin to a wound received a long time previously from a flying splinter 
 of a percussion cap. The tumour was about the size of a large pea, tolerably 
 finn, and rather tender. No positive diagnosis could be made, but it was 
 thought to be probably due to a foreign body. On laying it open sebaceous 
 matter immediately escaped, and the walls of the growth collapsed, so that 
 there was some difficulty in removing the whole of the adherent cyst. The
 
 CAVERNOUS LYMPHANGIOMA. ENCHONDROMA. 379 
 
 wound was stuffed with charpie for a while and then allowed to heal, but the 
 cicatrix remained painful and a fresh tumour formed shortly afterwards and 
 broke open the scar of the former operation. Dr. Seybert was able, some 
 months afterwards, to draw out two small sebaceous cysts by means of a 
 pair of forceps, without enlarging the wound. 
 
 Cavernous lymphangioma. 
 
 K. F — , set. 17, a journeyman tailor, came under my care in 1870, for a 
 soft, elastic growth, about the size of the fist, situated under the right deltoid 
 muscle ; the skin overlying the tumour was natural, but the growth was 
 rather bound down by the structures over it. It had existed from his 
 earliest childhood, and had increased gradually. The tumour was taken to 
 be a lipoma. A few days after his admission into the hospital the growth 
 increased in size and became tense ; the skin became red, and the patient 
 feverish. Cold was applied, and the symptoms soon subsided. I removed 
 the tumour by two elliptical incisions. It was not invested by a capsule, but 
 gradually became lost in the surrounding tissue, and in dissetting it out, 
 some thin, serous fluid spurted out at several points. The morbid growth 
 consisted of small communicating caviBrnous spaces, enclosing the fluid men- 
 tioned. It was found necessary to remove the fascia over the deltoid muscle. 
 The wound was filled up with charpie soaked in tincture of iron. Eecovery 
 was complete, though somewhat retarded by an abscess which formed in the 
 axilla. 
 
 On comparing the above case with one recorded below in the 
 section on tumours of the lower extremity, it will be seen that in 
 these tumours the transitory redness and inflammation, the tension 
 of the growth, and the fever occurring without evident cause, 
 all form valuable guides to the diagnosis. Such tumours are 
 most easily mistaken for soft, diffused lipomata. In this case 
 the signs, which in most blood tumours are so characteristic, were 
 absent, viz : the compressibility and erectile properties of the 
 growth. The respiratory movements, too, exerted no appreciable 
 effect upon the swelling. 
 
 Enchondroma. 
 
 A. B — , jBt. 44, was admitted with a tumour in the palm of the hand, 
 which had been growing for ten years and had reached the size of a walnut. 
 The patient was an iron turner, and the origin of the growth was attributed 
 to pressure. The tumour was removed, and found to be situated on the 
 sheath of one of the tendons.
 
 380 ENCHONDEOMA. CICATEICIAL FIBROMA. 
 
 A tumour, the size of alien's egg, which had been growing for eleven years, 
 in a man, sut. 54, was removed from the first phalanx of the right thumb. 
 The cause of origin was the samo as that of the previous case ; here, also, the 
 turaoui- was situated on the sheath of the tendon, and had no connection with 
 the bone. 
 
 Enchondroma of the phalanx. 
 
 Fraulein P — , set. 18, came to me on account of a hard nodule, which had 
 been growing for twelve years in the first phalanx of the little finger. The 
 growth was the size of a large hazel nut, painless, and had originated without 
 any known cause. 
 
 I removed the tumour in the following way : — Having exposed the 
 excrescence I separated it from the bone ; the rest of the growth 
 was then scraped away from the medullary cavity of the shaft to 
 one side of which it was connected. About two thirds of 
 the circumference of the phalanx were thus preserved and a 
 hollowed -out cavity left in the bone ; the sheaths of the tendons 
 were not injured. The patient rapidly recovered. Two years later 
 I heard that no recurrence had taken place. I adopted similar 
 treatment in a case, some years ago, where the enchondroma also 
 sprang from the first phalanx, and was the size of a large bean ; in 
 this case considerable suppuration followed the operation, with 
 inflammation of the sheath of the tendons. The patient recovered 
 with a perfectly normal finger, and no recurrence had taken place 
 four years afterwards. These two cases illustrate, therefore, a rather 
 important point, viz : that, under certain conditions these enchon- 
 dromata are removable without amputation. 
 
 Deep-seated cicatricial fibroma of the palm of the hand, 
 
 F. G — , jet. 43, a teacher, had had some suppuration of the palm of 
 the hand eleven years previously, which healed up without impairing the 
 function of the part. Gradually the cicatrix became hard, thick, and rather 
 sensitive. I removed a very dense fibroma the size of a pigeon's egg. It 
 was of spherical shape and readily lifted out of the deep parts, as soon as the 
 incision had been made. The hiemorrhage was very trifling. The tumour 
 apparently was not connected with any of the nerves. The man soon 
 recovered, and wi'ote a few months later to say that the hand was perfectly 
 normal, but the sensibility of the middle finger was impaiied.
 
 NEURO-FIBROMA. OSTEOMA. SARCOMA. 381 
 
 Neuro-fibroma of the museulo-spiral nerve. 
 
 A tumour of this nature, the size of a bean, was removed from the arm of 
 a man, set. 33 ; he had in addition a neuro-fibroma, the size of a pea, on the 
 internal cutaneous nerve, and two in the lower extremity ; on the right side 
 of the chest also there was a nodule, the size of a pin's head. The growths 
 had been noticed for two years, and were all acutely sensitive. I removed 
 the four nodules, all of which were found to be central neuro-fibromata • 
 one of those on the leg, attached to the peroneal nerve, was the size of 
 a bantam's egg ; paralysis of this latter nerve, and of the museulo-spiral 
 resulted from the operation. I had no opportunity subsequently of learning 
 whether he recovered from this condition. 
 
 Osteoma. {Exostosis hursata olecrani.) 
 
 A man, set. 25, was admitted with a small hard tumour of the olecranon, 
 which he stated had existed as long as he could remember. Some time pre- 
 viously a second softer tumour had formed on the first ; in due course it 
 broke, and some thin yellow fluid escaped. On examining the patient, I 
 found an exostosis, the size of a large bean, at the junction of the' olecranon 
 with the shaft of the ulna. Seated on this was a small thickened bursal sac, 
 from which serum dripped away through a small opening. Movement in 
 the elbow-joint caused some pain. I felt sure that the bui-sal sac mentioned 
 was connected with the articulation. I laid open the bursa and removed the 
 exostosis ; suppuration of the joint followed as I had anticipated. The 
 patient would not allow resection, and left with an ankylosed elbow. 
 
 Sarcoma of the arm,. 
 
 Frau H — , ajt. 55? consulted me on account of a painful swelling of the 
 right deltoid, which had existed for eight weeks. It proved on removal to 
 be a large-celled alveolar sarcoma.^ The growth recurred again and again, 
 always in the cicatrix ; the axillary glands were unaffected throughout. 
 Five years after the first operation the arm was removed at the shoulder- 
 joint : she died a few months later, and at the post-mortem examination 
 some fifteen or twenty soft medullary tumours were found in the lungs. 
 
 The tumour in this case was altered in microscopical character 
 even at its first recurrence, though the change became more apparent 
 in the succeeding growths ; it then partook more of the nature of a 
 small-celled gliomatous growth, parts only showing traces of the 
 original appearance. 
 
 '' Compare Billroth's ' Pathology,' Hackley's Trans., Fig. 138, p. 617. The 
 preparation shown in the illustration was taken from this case. [Ed.]
 
 382 CASES OF SARCOMA. 
 
 M. F — , set. 9, was admitted for a rapidly growing tumour which occupied 
 the upper half of the humerus, and was the size of a child's head. The 
 skin over the growth was thin, and the veins dilated and prominent. I 
 supposed that it was a case of osteo-sarcoma, and amputated at the shoulder- 
 joint. Professor Rindfleisch, however, on examination found that the 
 growth was not such as I had imagined, and following the old nomenclature, 
 he designated it a typical osteoid cancer (Knochen Carcinome) ; according 
 to our present views I should have tenned it an alveolar sarcoma. The 
 mass of the tumour was of a pale greyish-red colour and was partly situated 
 in the medulla of the bone, and partly on the outer surface of the partly 
 destroyed compact tissue, of which only a layer was left. 
 
 I heard subsequently that shortly after her dismissal, recurrence 
 took place in various parts of the body, but not at the site of 
 operation. Towards the end of her life, severe nasal catarrh, 
 complete obstruction of the nose, and total blindness occurred. 
 After death tumours were found connected with the skull and 
 brain, which on examination were seen to be beautiful specimens 
 of small-celled sarcoma — some of the cells being round, and others 
 spindle-shaped. I have no doubt, therefore, that the primary 
 tumour of the humerus was a sarcoma. Unfortunately, the 
 original specimen was lost, so that I was unable to compare the 
 two. The disease lasted altogether twenty-two months. 
 
 Sarcoma of the hand. 
 
 F. H — , set. ig, was admitted for a tumour in the palm of the hand, just 
 above the wrist. The growth onginated after a blow, received three years 
 previously ; it had increased very slowly, and without pain. The parents were 
 much opposed to amputation, and accordingly I ertirpated]^the [growth. I 
 found the tumour connected with the sheaths of the tendons and extending 
 some little distance along them. The operation was performed antiseptically 
 and rapid recovery followed. The movements of the hand were considerably 
 impaired subsequently, but by persevering friction, and faradisation, the stifp- 
 ness gi-adually improved. Recurrence took place seven months later in the 
 cicatrix, and as amputation again was refused, I proceeded once more to dissect 
 out the tumour. The anatomical condition was of some interest ; the morbid 
 growth extended along the sheaths of the tendons to the finger-joints, and I 
 was forced to lay open the sheaths for a considerable extent. Under antiseptic 
 treatment, the wound, which was extensive and complicated, did veiy well 
 at the outset, but secondary hBemoiThage came on, then rigors, and inflam- 
 mation of the pleura, so that amputation became necessary. He recovered 
 from this, but died some months later. Numerous sarcomatous nodules 
 wore found in both lungs and the lymphatic glands of the right axilla were
 
 CASES OF SARCOMA. 383 
 
 degenerated to sarcomatous nodules. The disease altogether lasted four years 
 and five months. 
 
 Lymphosarcoma treated hy injection of albuminate of mercury. 
 
 A boy, set. 13, with a lympho-sarcoma, the eize of an orange, in his axilla, 
 was treated by paryenchymatous injection of albuminate of mercury. 
 Abscesses formed, and in the course of a month the tumour was distinctly 
 smaller, though it had not altogether disappeared. 
 
 Granulatio7i sarcoma of the upper arm. 
 
 Jacob G — , set. 48, was admitted in November, 1869. A year previously 
 he had accidentally noticed a painless nodule about the size of a large pea, 
 which gradually increased, and was ramoved after two months by Professor 
 von Dumreicher. Within two weeks the tumour recurred, and gradually 
 attained the size of a hen's egg ; it was then again removed. Six weeks after 
 this last operation -he came under my care. The growth was then the size of 
 a large foetal head, firm, nodulated, painful, ulcerated at several points and 
 bleeding veiy readily when touched. It encircled the whole upper half of 
 the left arm, and was immovably connected with the bone ; the glands were 
 not afEected. The patient's general condition was so bad that amputation at 
 the shoulder- joint was out of the question, and the patient was discharged as 
 incurable. He died about a year after, so that the disease altogether lasted 
 about fifteen months. 
 
 According to the report of Dr. Albert, assistant in von 
 Dumreicher's Clinic, the original tumour was situated in the sub- 
 cutaneous cellular tissue, and recurrence took place in the cicatrix 
 of operation. No difficulty was found in removing the growth on 
 either occasion, and as far as could be felt and seen, the whole of it 
 was extirpated. 
 
 The case well illustrates the extraordinary rapidity vfith which 
 many sarcomatous tumours recur after operation. It is of rare 
 occurrence for a recurrent tumour within six weeks to attain 
 double the size of a fostal head. During the ten months preceding 
 operation, the growth had only reached the size of a goose-egg, 
 while after an operation — to all appearance radical — it grew within 
 two weeks to the size of a hen's egg, and after a second similar 
 operation, to twice the size of a foetal head.
 
 584 CASES OF SARCOMA. 
 
 Spindle- celled sarcoma, originating in the sheaths of the tendons. 
 
 This case is remarkable not only on account of the tumour, but 
 also for the symptoms following the administration of chloroform. 
 
 Joliann A — , tet. 38, stated tliat from early childhodd his left forearm had 
 been thicker than the right. Nine months before admission, he received a 
 blow on that arm, which caused him severe pain. A small lump formed at 
 the site of injury, which remained stationary for a time, and then began to 
 increase rapidly. I amputated the arm through the lower third. The 
 hajmorrhage was controlled by acupressure. Immediately on the con- 
 elusion of the operation, while the patient was still under the influence of 
 chloi'oform, a sixth of a grain of moi"phia was injected. The operation was 
 pei-f ormed at 1 1 o'clock in the morning, and from that time until six in the 
 evening the patient was in a state of wild delirium ; he did not recognise 
 those standing about him, stated that he had been poisoned, attempted to 
 escape, etc. Towards night the mania passed off. Five days later, he had 
 a rigor, and fifteen days after the amputation he died of pyjemia. Post 
 mortem : the cellular tissue of the posterior wall of the phaiynx opposite 
 the third and fourth cervical vertebrae was infiltrated with punilent matter ; 
 purulent thrombi were found in the femoral and iliac veins and in those of 
 the stump as well as puralent infiltration of the connective tissue about the 
 right elbow-joint. 
 
 Osteosarcoma of the clavicle. 
 
 Therese E — , set. 15, was admitted in 1870. She related that a year pre- 
 viously, as she was lifting a heavy weight, she experienced a sudden pain in 
 the left shoulder, and was unable to work for some days. About a month 
 before admission, she had noticed a tumour the size of a walnut on the left 
 clavicle. I found the outer half of this bone occupied by a firm, elastic 
 tumour of the size of a hen's e^^, reaching nearly up to the acromial end. I 
 removed the growth by sawing through the clavicle at the junction of the 
 internal and middle thirds, and enucleating the bone at the acromial ai"ticu- 
 lation. The patient was discharged a month later, with a small sinus, leading 
 down to a piece of necrosed bone on the sawn extremity of the clavicle. She 
 had full use in the arm ; the growth proved to be a small-celled osteo-sarcoma, 
 in the centre of which the bone was completely destroyed. 
 
 About a year and a half later, the patient was again operated on 
 for a local recurrence of the growth, of about the same size as the 
 former tumour. Notwithstanding the extensive resection of the 
 clavicle, the utility of the arm was not in the least impaired.
 
 OSTEO-SAJRCOMA. EPITHELIAL CANCER. 385 
 
 Osteosarcoma of the Immerus. 
 
 This tumour, which appeared in a man, a^t. 27, was attributed to aninjviry 
 received a year previously, and had attained the size of a child's head. The 
 arm was amputated at the shoulder-joint. The tumour was found to be a 
 periosteal large-celled sarcoma. The wound healed, but the man died two 
 months later of pleurisy and pericarditis. After death, numerous sarco- 
 matous nodules were found in the pulmonary and costal pleura. 
 
 Central osteo-sarcoma of ulna. Resection of the affected hone on 
 iioo occasions. 
 
 A girl, set. 16, was admitted who, nine months previously had sprained hex* 
 right wrist. Some pain persisted in the lower end of the ulna after the 
 injury, and four months later some swelling was noticed. The surgeon who 
 was attending her, thinking that the symptoms were due to periostitis, cut 
 down on the swelling ; no pus escaped, but new growth protruded from the 
 incision, and foul, sanious discharge followed. The girl had become so 
 reduced that her condition seemed most critical when I first saw her. On 
 minute examination, I made out a central osteo-sarcoma in the lower part 
 of the ulna ; the growth was in great part encapsuled by the periosteum. I 
 therefore proposed resection of the lower part of the ulna, instead of 
 amputation, as had been suggested. The wrist-joint was unavoidably opened 
 in the operation, but I succeeded in preserving all the tendons and nerves ; 
 a portion however, of the ulnar artery was excised. The skin of the soft 
 parts, after removal of all suspicious tissue just sufficed to cover the wound. 
 Under antiseptic treatment with boracic acid, the patient recovered perfectly, 
 and a few months after the ojieration, the functions of the hand were so 
 perfectly restored, that she was able to play the harpsichord and do any fine 
 work. Such a result exceeded my most sanguine expectations. For nearly 
 two years all went on well, but then pain and swelling commenced about 
 the cicatrix, and gi-adually the growth began to recur. "When the tumour 
 had attained the size of a hen's Q^^, I removed it again. It was then con- 
 nected to the lower end of the ulna, but did not appear to have sprung from 
 it. She again recovered, with perfect use of the part. 
 
 Epithelial carcinoma of the upper arm, originating in the loound 
 of an isstie. 
 
 The following case is of particular interest, for it shows that 
 under certain unknown conditions, constant irritation, w4iich usually 
 causes merely simple ulceration, maj' give rise to the development 
 of true carcinoma.^ 
 
 ' Compare the caee of coccygeal tumour related above, p. 337. 
 
 26
 
 886 EPITHELIOMA DEVELOPING IN AN ISSUE WOUND. 
 
 Samuel C — , set. 54, a Jewish merchant from Belgrade, had been very sub- 
 ject to inflammation of the eyes. Twenty-eight yeai's before I saw him, two 
 issues had been made on the back of the neck and on the upper arm from 
 which considerable suppuration was kept up : six months before he came to 
 me, the granulations of the issue wound in the arm became more sensitive 
 and the edges harder, while the ulcer increased in size. I found an ulcer the 
 size of a florin, in appearance highly suggestive of epithelioma, over the 
 insertion of the deltoid muscle. Induration could be felt extending deeply 
 down, probably to the surface of the bone. The patient was so weak and 
 anaemic that I merely destroyed the growth with paste. 
 
 He died of febrile marasmus and erysipelas some three months 
 later. The eschar was examined microscopically, and proved to be 
 a well-marked epithelioma, particularly rich in epidermic cells.
 
 CHAPTER XVII. 
 INJURIES AND DISEASES OF THE LOWER EXTREMITY. 
 
 Section A. — Injuries. — Frost-hite. Contusions of the hij). Frac- 
 ture of neck of femur. Case of gangrene after fracture of 
 femur. Treatment of simple fractures of femur ; of leg ; of 
 fibula ; of patella. Case of pycemia after simple fracture. 
 Case of fracture of necrosed femur. Case of softening callus 
 a year after union. Cases of faulty union. Cases of pseud- 
 arthrosis. T^reatmeni of pseudarthrosis. Cases of ununited 
 fracture ; repeated operations. Bemarkahle case of com- 
 pound fracture of thigh. Compound fracture of leg — case. 
 Cases of compound dislocation of anJcle. Cases of dislocated 
 hip. Case of dislocation of astragalus. Wound of both 
 tibial arteries — case. 
 
 Frost Bite. (W. B.) 
 
 When the greater part of the foot is frost-bitten, my rule is to 
 wait for a complete line of demarcation to form, before resorting to 
 amputation. Judging from more recent experience, I think I 
 should now, in such cases, operate at an earlier date. It rarely 
 happens that parts, which, after thawing, are blue in colour and 
 covered with blebs, again come to life, even when arterial blood 
 follows a deep puncture with a needle. Owing to the decomposition 
 of the tissues, there is always risk of phlegmonous inflammation 
 starting in the deeper parts and leading to general septic infection, 
 for the process of absorption, still — though feebly — goes on. The 
 danger arising from this cause certainly overbalances the advan- 
 tage gained by waiting for the line of demarcation to form in the 
 skin ; we might possibly, by waiting, be able to amputate an inch 
 or two lower down, but the patients not infrequently die before
 
 388 CONTUSIONS. FRACTURE OF NECK OF FEMUR. 
 
 the stage of demarcation is reached. My opinion therefore is, 
 that we should amputate through healthy parts as soon as the 
 gangrene has declared itself up to the middle of the foot or to the 
 leg. In the case of frost-bitten toes alone, we may wait for spon- 
 taneous separation. 
 
 Contusions of the Hip. 
 
 Contusions about i\\e trochanter were common enough; the 
 patients came under treatment at very varying periods after the 
 injury. When no distinct fracture or luxation is evident, the 
 diagnosis may be very difficult ; fissure of the acetabulum, 
 extravasation of blood into the joint, with circumscribed periostitis 
 about the trochanter, may be suspected where the function of the 
 part is impaired for any great length of time. Such cases are 
 best treated by simple rest in bed ; in many instances the pain and 
 tenderness do not altogether disappear for two or three months. 
 In no case which has come under my observation have I seen 
 chronic coxitis develop, but the patients were usually strong, 
 healthy men. 
 
 Practure of the Neck of the Femitr. 
 
 Of nineteen cases which came under me at Zurich, eight were 
 extracapsular and eleven intracapsular fractures. When possible 
 I always apply a plaster- of- Paris bandage in these cases, but it is 
 undesirable to adopt this mode of treatment when the patients are 
 very much reduced, and likely to get bed-sores. Tor such I found 
 the best plan was to keep them quietly in bed, with the hip and 
 knee flexed, the legs being bent over a pillow at the knees. One 
 man, set. 73, died of pyaemia forty-three days after the injury. 
 
 Fracture of the femur, followed hy gangrene. 
 
 Conrad G — , ret. 23, was struck by a heavy rolling-stone on the right 
 thigh. He was unable to stand upright after the injury, and was brought a 
 few hours later to tlie hospital with a fracture of the femur four or five 
 inches above the knee, and much contusion of the soft parts. A temporary
 
 TEEATMENT OP FRACTURED FEMUR. 389 
 
 aiTangement o£ splints was applied at first, and the following day a plaster 
 bandage over an ample layer of wadding. Two days after the injury, I was 
 stmckby the white appearance of the projecting part of the foot, and had the 
 bandage cut off. The blood in the subcutaneous veins of the leg was, however, 
 completely stationary, and the skin up to the knee was devoid of all sensa- 
 tion. I supposed that the femoral artery had been injured by the fracture, 
 and had become extensively thrombosed ; gangrene of the leg followed, and 
 it was some time before the line of demarcation was distinct. The patient 
 was already suffering from septic poisoning when I amputated the thigh 
 high up, and he died a few days later of pyaemia. The femoral artery was 
 found to be completely torn through three inches above the hollow of the 
 knee ; the edges of the rent were ragged and rough. A long thrombus 
 extended upwards and downwards. In all probability this had formed very 
 rapidly and prevented the development of a traumatic aneurism. 
 
 It is well known to every surgeon that in bad fractures of the 
 femur the displacement cannot be completely corrected by any plan 
 of treatment. Careful attention and frequent changing of the 
 plaster bandage will do much to diminish the shortening. The 
 best method of applying plaster bandages in fractures of the thigh 
 and in coxitis has been so excellently described by Roser, Volkmann, 
 C. Weber, Liicke, and others, that I can add nothing to what they 
 have said. 
 
 During 1 869-1 870 some fractures of the femur in my clinic 
 were treated by plaster-of-Paris bandages, others by extension. 
 The number of my cases (14) was too small to enable me to give 
 any decided opinion as to the advantages of one method over the 
 other ; stiU, I may say that extension alone is sufficient in most cases 
 of fractured femur, but that if the displacement be very considerable, 
 it is but little more effective than the plaster bandage. Plaster 
 bandages were applied over the knee, and beneath the calf of the 
 leg from about the commencement of the tendo-Achillis. Whether 
 the plaster was applied over wadding or flannel, or nest to the skin 
 made no difference in one respect ; within eight days the bandage 
 invariably became so loose that it was drawn down by the weight to 
 the heel, and if care were not taken, it was liable to cause ulceration 
 about the malleoli. A very slight weight can be used with the plaster 
 bandage, five pounds at the outside ; the bandage should be changed 
 about every eighth day. On the whole, I far prefer extension by means 
 of ordinary strapping ; this I apply generally on Volkmann's plan, as 
 follows : — An ordinary Petit's boot is applied, reaching up to the 
 ham : on to this a square plate of wood is screwed, and extension
 
 390 TEEATMENT OF FRACTURED FEMUR. 
 
 made by means of strips of plaster laid along the sides of the 
 limb. The boot forms, as it were, part of the leg, and can be 
 taken off — plaster, weight, and all — very readily. The advantages 
 of this method of treatment have been so clearly shown by Volk- 
 manu, and more recently by Schede, that any further encomiums 
 from me would be superfluous. Every method of extension has 
 one disadvantage, viz. that in the unavoidable movements of the 
 patient, the upper fragment is more disturbed than it would be if 
 encased in a firm bandage : even if the patient is laid on a sacking 
 stretched over a frame which can be removed and replaced 
 when necessary, this drawback cannot entirely be obviated. Although 
 the pain is diminished by traction on the fractured ends, yet in 
 some very sensitive patients the plan does not answer. If only small 
 weights be employed, sufficient counter-extension will be secured 
 by raising up the foot end of the bed; when a heavy weight 
 was necessary, I employed a perineal strap ; one end passed 
 beneath the sacrum and was secured to the head of the bed, the 
 other passed vertically upwards, and was fastened to a sort of 
 gallows apparatus, immediately above the patient. Counter -exten- 
 sion in this way is less annoying, and more freedom is allowed for 
 the movements of the body. 
 
 Two patients came under treatment, in whom the thigh was in 
 an osteo-porotic condition, after old arthritic disease. In one case 
 the knee, in the other the hip was afi'ected. The fracture was due 
 to very slight injury. Consolidation of the fracture took place in 
 twenty-seven and thirty-two days respectively. 
 
 (W. B.) 
 
 lu fractures of the lower epiphysis of the femur or of the condyles, 
 and for fractures extending into the knee-joint, I have now (1876) 
 altogether abandoned the plaster bandages in favour of treatment 
 by extension j I find that the latter method is more convenient for 
 the patient as well as for the surgeon, that union takes place more 
 rapidly, and that the tendency to shortening can be better controlled 
 than by the plaster treatment. The extension treatment is admir- 
 ably adapted for hospital practice ; still, I by no means wish to 
 deny the excellent results gained by treatment with firm bandages.
 
 TREATMENT OP SIMPLE FEACTUEES OP LEG. 391 
 
 Fractures of the Leg. 
 
 In these cases a plaster- of-Par is bandage was invariably applied 
 at the earliest opportunity. It is sometimes said that plaster 
 bandages materially interfere with the formation of callus^ and 
 render the patient liable to pseudarthrosis. With regard to this 
 statement, I can only say that in healthy subjects, out of eighty-six 
 cases, I only met with six where the amount of union after six 
 weeks was insufficient to allow the patients to stand on the limb. 
 The patients are able as a rule, to get about on crutches within this 
 period ; in the six cases mentioned (in four of which the fracture 
 was in the upper third of the leg^) no pseudarthrosis formed. At the 
 same time, it is undoubtedly true, that if an unyielding bandage be 
 applied early, and much pressure exerted, the formation of the 
 external callus is interfered with, and union is thereby delayed. But 
 this method appears to exercise no injurious effect on the formation 
 of the definitive callus ; still, the early application of the plaster 
 bandage has innumerable advantages, both to the patient and to 
 the surgeon. In fact, my statistics show that the causes of pseud- 
 arthrosis are not to be found in the early treatment by rigid 
 apparatus, as has been unreasonably asserted ; the cause lies deeper, 
 and depends upon the conditions of nutrition of the patients. 
 
 Fracture of the Lower end of the Fibula. 
 
 Fractures of the lower part of the fibula, with the luxation-like 
 dislocation which is often very considerable in these cases, used 
 formerly to occasion a great deal of trouble in treatment. Even now, 
 oblique union is more common after this fracture than after any 
 other which I have met with. By means of an anaesthetic and a well- 
 apphed plaster bandage, the difficulty in treating these cases can 
 be completely overcome, that is, with competent assistance. For 
 the consolation of my colleagues, to whom this latter requisite is 
 not always forthcoming, and who have seen such fractures unite 
 obliquely under their splints and bandages, I may add, that these 
 
 1 And in whicli the nutrient artery of tlie bone may have been injured, 
 thus causing, as Mr. Curling has shown, delayed union of the fracture.— [Ed.J
 
 392 FEACTUKED PATELLA. PYJilMLA AFTER SIMPLE FRACTUEE. 
 
 patients, after a year or so, become astonishingly clever in getting 
 about, and after a couple of years will scarcely be aware that they 
 have any deformity. Of course, however, it is more to the interest 
 of iLe patient that such should not be the case. Massage will be 
 found the most useful means of improving the movements of the 
 ankle-joint, which are often much impaired. 
 
 Fricture of the Patella. (W. B.) 
 
 In treating this injury, I have found no inducement to depart 
 from the old methods of treatment, such as putting the limb up in 
 sphnts or a plaster bandage, frequently drawing the fragments 
 together by strapping and the like. Those who have had plenty of 
 opportunities of seeing how well people are able to get about with 
 the fragments of their patellse an inch or more apart, will hardly 
 be tempted in ordinary cases to proceed to any cutting operation. If 
 a case should be met with where the patellar fragments are much 
 separated, and the limb useless, an operation like that for pseud- 
 arthrosis, such as resecting and uniting the fragments, might pro- 
 perly, under antiseptic precautions, be undertaken. 
 
 Simple fracture of the leg, followed hy pyam^ia. 
 
 A man, set. 84, was run over, and sustained a fractui-e of the upper third 
 of the left leg. There was scarcely any discoloration of the skin. Consider, 
 ing his age he was fairly strong and well, and, as we subsequently found, 
 the arteries were nowhei'e atheromatous except in the brain. A plaster 
 bandage was applied over the knee. On the f oui-th day the temperature shot 
 up to 103"6°, and on the foui-teenth day to 104°, varying between this level and 
 the normal. The patient lost strength daily and complained of difficulty of 
 breathing ; finally, oedema of the lungs set in, and he died fifteen days after 
 the injury. Post mortem : " Commencing formation of callus at the situa- 
 tion of fracture, the parts around, as is usual at this period of fracture, being 
 somewhat infiltrated and of a dark brownish-red colour. Thrombosis of the 
 left femoral vein, and embolism of some of the branches of the left pulmo- 
 naiy arteiy. In both lungs infarcts and abscesses ; the cerebral aiteiies 
 atheromatous, and in the brain numerous small breaking-down deposits," ' 
 
 1 Fat embolism (?).— [Ed.]
 
 FIIACTCTRE OP NECROSED FEMUR. SOFTENING OF CALLUS. 393 
 
 Fracture of necrosed femur. 
 
 A boy, aet. ii, had suffered from necrosis of the femur for nine years; 
 numerous sinuses had formed over the lower end of the bone. Ten days 
 before admission he had a fall on the affected limb, which was followed by 
 much pain and swelling ; the invaginating sheath of bone was found, on 
 admission, to have been fractured. I performed sequestrotomy in the usual 
 way, and applied extension. The operation was, however, followed by exten- 
 sive suppuration, which finally attacked the knee-joint, so that I was forced 
 to amputate the femur high up. He recovered, but the wound did not 
 perfectly heal. The stump of bone was found to be so extensively diseased 
 that I disarticulated it. The patient ultimately did well.^ 
 
 Softening of callus twelve months after union of fracture. 
 
 Eugenie H — , set. 13, a well-developed but highly-nervous child, had, 
 according to her mother's account, fractured her leg when three years old. 
 The limb united in good position, but she had pain whenever she bore on 
 the foot. A year after the injury the leg commenced to bend at the seat of 
 fracture. Iodine was applied but did not check the pain, and in spite of an 
 apparatus the curve became worse. Eventually the pain increased to such 
 an extent that the patient was for a long time confined to her bed. When 
 she came under my care the lower half of the left leg was bent backwards at 
 an angle of about 110°. At the back of the limb the muscles of the calf 
 were very prominent, and just at the angle of the bend the tibia was much 
 thickened. By means of Rizzoli's apparatus the bone was easily fractured, 
 and the limb was then put up in good position in a plaster bandage. The ^ 
 reaction after the operation was extraordinarily severe. I never met with a 
 case where so much pain was experienced at the seat of fracture ; the amount 
 of swelling was very moderate. The plaster bandage was repeatedly changed ; 
 ice and leeches were applied, but the pain could only be controlled by sub- 
 cutaneous injections. I expected an abscess in the bone. At the end of a 
 month we found reason to believe that the pain was not all genuine, and 
 this view was confirmed by the fact that injections of distilled water com- 
 pletely controlled her sufferings. Two months after the fracture the bone 
 was firmly consolidated, but there was still some cedema of the leg. Com- 
 plete recovery followed, though it was slow. Two years later I heard that 
 she could walk freely without limping, and was able to dance. 
 
 This is the only case which I have met with, in which softening 
 
 ' A case somewhat of tliis nature is reported in ' St. George's Hospital 
 Eeports,' vol. viii, p. 533. Recovery followed, with good union.— [Ed.]
 
 39-1. 
 
 FAULTY UNION OP FRACTURED LEG. 
 
 Fig. 19. — Faulty Union of Intea-uteeine Feactuee. 
 
 of callus^ followed subsequently by sclerosis, commenced a year after 
 the consolidation of a fracture. Probably at the time that I frac- 
 tured the Kmb I splintered the bone, and the slow absorption led to 
 some ostitis, which thus hindered the patient for a long time from 
 using the limb. 
 
 Faulty union after fracture of the leg. 
 
 A man, jet. 40, fourteen months previous to his admission to the hospital 
 had sustained a fracture of the cxtei'nal malleohis, and sub-luxation of the 
 astragalus. Considerable deformity resulted from the injuiy. An inch and 
 a half above the malleolus there was a sharp bend in the leg, and the heel 
 was displaced outwards so that the position of the foot was like that seen in 
 a high degree of valgus. Good union had taken place, but he was not able 
 to walk well. With great difficulty I managed to improve the position of 
 the foot, by breaking through the new formed bone, and eventually was so 
 far successful that the patient was able to walk fairly well with the help of 
 a specially constructed boot. It was found impossible, however, to connect 
 the deformity of the foot completely.
 
 PSEDDARTHEOSIS. 395 
 
 Faulty Union of the Leg after Intua-Uterine Fracture. 
 
 The child, whose leg is shown in the illustration (Fig. 19) was 
 born with the deformity, but died before any treatment was adopted. 
 I met with another similar case, in an infant four months old, in 
 whom I was able easily to fracture the bone and straighten the limb. 
 
 Pseudart/irosis of the femur. 
 
 A man, set. d^, strong for his age, came under treatment with a pseud- 
 arthrosis about six inches above the Ivuee-joint. Four months previously he 
 had sustained a very oblique fracture at this spot, which had been treated by 
 plaster bandages. The fragments were only moderately displaced, but could 
 not be induced to consolidate. When he came under my care I first put up 
 his leg in a hollow splint without any bandage, and painted tinct. of iodine 
 over the seat of the fracture. Then I applied forcible extension by Schneider- 
 Mennel's apparatus till the displacement of the f ragr&ents was corrected ; the 
 ends were then forcibly rubbed together, and the limb immediately put up 
 in a plaster-of-Paris bandage. Distinct callus was thrown out after this, and 
 within two months he had recovered sufficiently to be able to walk on the 
 afEected limb. 
 
 A man, a3t. 50, was admitted with an ununited fracture of the left femu.r 
 of fourteen weeks' standing. The fragments were forcibly rubbed together, 
 and a plaster bandage applied. At the end of two months the bandage was 
 removed, but no union had taken place ; accordingly five ivory pegs were 
 driven into the fragments and a firm bandage at once applied. The reaction 
 that followed was but slight ; suppuration took place around some of the 
 pegs, which were then removed and some new pins were driven in. Here- 
 upon great reaction followed ; some of the pegs kept firm, but around others 
 phlegmonous inflammation started, which gradually extended down the whole 
 leg and led to the formation of many abscesses. Consolidation, howevei', 
 of the fi'acture slowly took place, and abundant callus was thrown out. In 
 eight months the patient was discharged cured. 
 
 Ferdinand — , a;t. 50, sustained a fracture of both bones of the leg about 
 the centre. A plaster bandage was applied. Some two months later, on 
 removing the bandage, it was found that there was no union. The fragments 
 were rubbed together and plaster again applied. On the removal of this 
 latter bandage, however, it was discovered that a regular pseudarthrosis had 
 formed. The fragments were again rubbed together, tinct. of iodine was 
 painted on the leg, and phosphorus pills given, but without any improve- 
 ment. I then applied electro-puncture, both poles being sunk down on to 
 the pseudarthrosis ; at first no reaction followed, but subsequently swelling 
 began, which increased more and more ; extensive suppuration set in with 
 rigors and the thigh was amputated, but the patient was already in a pyiemic 
 state, and he died soon after.
 
 ^96 PSETTDAKTHEOSIS. 
 
 I have already recorded a case of pseudarthrosis, treated by 
 electro-puncture^ followed by pyaemia and death. I recollect a case 
 also, under my care at Zurich, which illustrates well the evil results 
 that may arise from still milder treatment. A simple fracture of 
 the bones of the leg was found ununited after the ordinary period 
 of rest in bandages. I then placed the leg upon a splint, and 
 ordered strong tincture of iodine to be painted daily over the frac- 
 ture. Considerable dermatitis resulted, and blebs formed, as I 
 expected, but there followed also results which I had by no means 
 looked for ; the dermatitis ran on to phlegmonous inflammation, 
 suppuration, and gangrene of the skin, and the patient died of 
 pysemia. The case is of considerable importance, for it shows that 
 even six or eight weeks after fracture, we must be careful in the 
 application of iodine, and furthermore, that the EngUsh preparation 
 (Tinctura lodi Fortior) has a far more potent effect than we are accus- 
 tomed to observe when our officinal tincture is employed. 
 
 In treating ununited fracture by the insertion of ivory pegs, I 
 find that it is of the greatest importance to use pegs of at least two 
 lines diameter; from four to eight should be driven in deeply and 
 firmly ; no suppuration ought to follow, if the osteo-plastic pro- 
 cess is to succeed. As soon as the pegs become loose they 
 should be removed and replaced by larger ones. 
 
 Pseudarthrosis, 
 
 Alois W — , set. 24. When four yeai-s of age he fractured the lower third 
 of his right leg, for which he was treated at a children's hospital. When 
 discharged, an apparatus was supplied by the aid of which he was enabled to 
 walk. This, however, was not renewed, and the fragments gradually 
 assumed an exceedingly faulty position. The lower third of the tibia was 
 3esed backwards at a right angle with the rest of the shaft (see Fig 20). 
 Attempts were made to straighten the limb, but the tendo-Achillis offered 
 an insuperable obstacle ; the growth of the whole limb had been arrested, and 
 the muscles were ill developed, although the child generally was fairly 
 strong. The tendo-Achillis was divided, and I was able, though not with- 
 out exerting considerable force, to straighten the leg. It was then found 
 that there was shortening to the extent of three inches ; the fi'agments lay 
 one above the other. In order to improve the position a weight and pulley 
 were applied, and subsequently the two fragments were united together by 
 means of a thick platinum wire ; the ends of the bone were atrophied and 
 denuded of periosteum. The wires were allowed to remain from the 28th 
 June to the 20th October but no union took place, nor did any follow the
 
 PSEUDARTHEOSIS OF LEG. 
 
 397 
 
 employment of ivory pegs. I then cut down upon the ends and split up the 
 fragments longitudinally with a chisel — again without any success. A month 
 later I tried to obtain union by means of a platinum wire again ; this opera- 
 tion was followed by an attack of erysipelas. Then for two months I trieiJ 
 
 Fig. 20. — Ununited Fbacttjee of the Leg. 
 
 the constant current, the needle connected with the zinc plate being deeply 
 sunk into the cicatrix. Finally, at the patient's request, the limb was ampu- 
 tated at the seat of fracture, for it was evident from the amount of shorten- 
 ing that, even if union took place, he would scarcely be able to walk well.
 
 398 COMPOUND PBACTDEE OP THIGH. 
 
 Ununited fractttre of the leg : operation : death. 
 
 J. H. — , jct. 31, a turner, a tolerably strong man, fell from a waggon and 
 sustained a simple fracture of the right leg about the centre. The limb was 
 put up at first in splints and then in plaster. When he came up to the 
 hospital fifteen weeks after the injury, the fragments were still perfectly 
 movable on each other and the limb was rather cedematous. The patient was 
 pale and wasted. Movement of the fragments gave no pain ; the lower 
 fragment was drawn up to the inner side of the upper one. I cut down by 
 a small incision on the lower end of the upper fragment, and passed a plated 
 screw through both fragments so as to fix them together. The limb was 
 then put up in well-padded hollow splints and ice applied. On the fourth 
 day after the operation severe inflammation commenced around the screw, 
 and a large, deep, foul abscess developed. The patient died of pyaemia on 
 the thirtieth day. 
 
 Compound Fractuhe of the Thigh. 
 
 The following case of recovery is perhaps unique, when the 
 extensive nature of the injuries is taken into consideration. 
 
 A woman, fet. 23, in the third month of pregnancy, was admitted with a 
 compound fracture of the thigh, one of the fragments of which penetrated 
 the sldn on the inner side. The injury was caused by the fall of a mass of 
 earth from a railway embankment, beneath which she was bui'ied. Her 
 husband, who was working close to her, was dead when dug out. The 
 patient had sustained the following injuries : compound fracture of the right 
 thigh, extensive contused wounds of the thigh, dorsum of the foot and the 
 face, compound fracture of the right gi-eat toe, simple fracture of the left 
 leg and some of the phalanges of the left foot, contused wound of the left 
 thigh. All the wounds and fractures healed completely in six months, 
 and she then — at the full time — gave birth to a strong, healthy child. 
 
 Compound fracture of the thigh. 
 
 A man, ajt. 47, was ran over by a cart, and brought up to the hospital four 
 hours after the accident. The femur was obliquely fractured and splintered 
 two and a half inches above the lower end ; the fragment protruded through 
 a wound in the skin. Tlie wound communicated also with the knee-joint. 
 He had also a scalp wound three quarters of an inch long over the parietal 
 bone ; the left pupil was dilated to twice the size of the right. Circular 
 amputation was performed through the lower third of the thigh ; the arteries 
 were found to he atheromatous. On removing the acupressure needles after 
 thirty-eight hours, hajmoiThage took place from the femoral arteiy, and this 
 
 I
 
 COMPOUND FRACTURE OP LEG. 399 
 
 vessel was then ligatured. Ichorous suppuration took place in the wound, 
 and the skin wounds partially sloughed. On the tenth day erysipelas attacked 
 the stump, and on the twelfth the wound on the head. He became comatose, 
 and died thirteen days after the injury. 
 
 The temperature was observed to rise after death. Post mortem : 
 pleurisy of the right side ; meningitis and extravasation over the 
 left hemisphere. 
 
 Compound Fracture op the Leg. (Z. B.) 
 
 Ninety-three cases of this injury came under my care at Zurich ; 
 fifty-seven recovered, and forty-six died. These cases natually vary 
 very much with respect to the extent of injury. We know that it 
 is not always the size of the wound, nor the number of comminuted 
 fragments of the bone, which has to be taken into account in our 
 prognosis. The result materially depends on the extent and severity 
 of the contusion, the age of the patients, and the conditions under 
 which they are placed and kept directly after the injury. 
 
 In complicated cases, we are only able to estimate approximately 
 the amount of injury. We sometimes find out more about them 
 during their progress, but then it is often too late. In my table 
 cases only are recorded where the wounds were undoubtedly con- 
 nected with the fracture ; these alone should be counted as com- 
 pound fractures. It is not possible to make any classification of 
 the cases according to the severity and importance of the injury. 
 
 Compound fracture of the leg. 
 
 Joseph S — , mt. 42, was admitted with a fracture of the right leg an inch 
 above the ankle, the result of a fall. The integuments were torn away 
 from the upper fragment an inch and a half. A plaster bandage was ajiplied 
 and open treatment adopted. For eighteen days he went on well, but then 
 swelling and pain occurred, and he became feverish. Incisions were made, a 
 large quantity of foul pus let out, and some fragments of the fibula removed. 
 Two days later hajmon-hage occurred from the incisions, and again the day 
 after. The femoral artery was then tied in the middle of the thigh ; gan- 
 grene of the foot ensued, and eventually amputation was performed tlirough 
 the lower third of the thigh. He died a week after the operation. Post 
 mortem : Abscesses were found in the lungs and liver ; on both sides of tlic 
 ligature on the femoral artery were found firm clots.
 
 400 COMPOUND DISLOCATION OP ANKLE. 
 
 Compound Dislocation of the A^klk-Joint. 
 
 Tour of these cases came under my care at Zurich; in two 
 attempts were made to save the part, but amputation was found 
 necessary on account of diffuse cellulitis, which commenced on the 
 fifth day in one case and on the thirteenth in the other. One 
 patient died of pyaemia, the other of septicsemia; in a third, ampu- 
 tation was performed at the knee-joint on the thirty-sixth day, on 
 account of suppuration of the ankle-joint and diffuse phlegmonous 
 cellulitis. The patient died six days after the operation. 
 
 A man, a-t. 69, came under my care, who had been treated elsewhere for a 
 compound fracture of the ankle, and fractiire of tlie external malleolus. 
 Suppuration of the ankle-joint followed, and as the sinuses could not be got 
 to close the patient came up to the hospital four and a half months after the 
 injury. On examination the astragalus was found to be completely necrosed 
 and loose ; the sinuses were dilated, and the bone extracted. Fifteen 
 months later I saw him ; ankylosis had taken place between the tibia and the 
 OS calcis ; the shortening was very slight, and the jiatient could walk without 
 a stick. 
 
 (The above cases are described as " fracture of the malleolus with wound 
 of the ankle-joint ; " they seem to resemble those usually described in this 
 country as compound dislocation of the ankle, though it is true that there is 
 usually only subluxation of the foot. — Ed.) 
 
 Compound fracture at the ankle-joint. 
 
 Three cases of this nature came under my observation between 
 i869-7o, at Vienna. 
 
 The first was that of a man, set. 52, who fell from a height on to his feet, 
 and sustained a splintered fracture of the external malleolus, and a simple 
 fracture of the internal malleolus. Below the latter was an 'opening the size 
 of a pin's head. A probe was passed in, but did not touch exposed bone ; it 
 must, however, have been due to injuiy from within, as there wa.s no hole 
 either in the stocking or the boot. For the first few days there was some 
 sanious discharge which ceased on the sixth day. Open treatment was 
 adopted, and he recovered with a perfectly moveable ankle-joint. 
 
 A man, set. 20, was admitted with complete dislocation of the foot ; the 
 lower extremities of both the bones of the leg protruded through an opening 
 at the inner side of the ankle. It was found necessary to remove an inch of
 
 DISLOCATION OF HIP: OP ASTRAGALUS. 401 
 
 the bones before the displacement could be con-ected. Open treatment was 
 adopted, and he recovered in five months with a limited amount of active and 
 passive movement in the joint. 
 
 A somewhat similar injury was observed in a boy, who had been run over 
 by a waggon. A plaster bandage with a window was applied. On the third 
 and fourth days after the injury he had rigors, followed eight days later by 
 thrombosis of the saphena vein and gangrene of the toes. Death from 
 pyaemia on the twelfth day. Abscesses were found in the lungs, and 
 breaking-down coagulations in the veins. 
 
 Compound fracture at the ankle-joint. Antiseptic treatment. 
 
 A man, jet. 44, was admitted with this injury ; resection was found neces- 
 saiy before the tibia could be reduced. Under antiseptic treatment he 
 recovered rapidly. 
 
 A man, aet. 60, with the same sort of injury, but who had made a long 
 journey from Hungary, and was only admitted three days after the accident, 
 was treated in the same way. Septic phlegmonous infiltration followed. 
 On the eleventh day after the injury the thigh was amputated, but the 
 patient, who was already in a pysemic state, died three days afterwards. 
 
 Old dislocation of the hip-joint. 
 
 A man, aet. 43, was admitted with a dislocation of the hip on to the dorsum 
 of the ilium, of 134 days' standing. The injury was not recognised at the 
 time of the accident. Two days after his admission (the 136th day) reduc- 
 tion was with some difficult effected, under an anaesthetic, by manipulation. 
 A month later the patient went home, and was able to walk fairly well, 
 though not without a stick. 
 
 Dislocation of hip, 
 
 A man, aet. 27, fell from a ladder and dislocated the head of the femur 
 over the foramen ovale. Reduction was effected by manipulation. The 
 first movements seemed to shift the head of the femur on to the dorsum ilii. 
 Under an anaesthetic flexion and outward rotation effected reduction. 
 
 In a child, aet. 11, with a dislocation of the femur upwards and backwards 
 of three months' date, reduction was found impossible. 
 
 Dislocation of the astragalus. Reduction. Necrosis. 
 
 A man, aet. 29, was admitted with complete dislocation of the astragalus. 
 The bone was displaced outwards and forwards, and the skin over it stretched 
 
 26
 
 402 WOUND OF TIBIAL ARTERIES. 
 
 and discoloured, but not wounded ; the foot lay in a position of marked 
 Tarns. After numerous unsuccessful attempts, reduction was at last efBected 
 easily on exerting powerful traction on the heel. A fortnight later the skin 
 was found gangrenous on the outside of the ankle ; the astragalus became 
 completely necrosed, and was removed three months after the injury. 
 
 Wound of both tibial arteries. 
 
 A strong labourer, set. 31, received two stabs £rom a knife in the left leg. 
 Judging from the appearance of the high boot, whish he brought with him, 
 both the stabs had been inflicted from the outer side. One was close to the 
 erest of the tibia, the other a little higher up and more posterior. Two 
 hours after the injury, when the boot was taken ofE it was found to be full 
 of clotted blood. The leg was perfectly cold and insensitive, not at all 
 swollen, but of a bluish colour from the sugillation. No haemorrhage could 
 be seeu ; cold compresses were applied. The leg became dai'ker and darker 
 in colour and lost power of movement, and when he was brought up to the 
 hospital a month after the injury, the limb was already in a state of mummi- 
 fication up to the head of the tibia. Not only had a complete line of demar- 
 cation formed, but the mummified parts were detached and retracted from 
 the bones, so that at the bottom of the line of demarcation the bones were 
 exposed for about an inch. As in gangi-ene from thrombosis of the popliteal 
 arteiy, the line of demarcation was at a lower level behind than in front. 
 The bones were sawn through, and the flap brought up from behind. Slow 
 convalescence followed. 
 
 Section B. Acute and Chronic Inflammations. — Cases of 
 acute phlegmonous injlar/imation. S2iontaneous gangrene from 
 embolism. Gangrene from disease of the smaller arteries — 
 Case. Case of gangrene from ancemia ; from some iinhiown 
 cause. Amputation in gangrene. Cases of gangrene ; spon- 
 taneous ; from, embolism of subclavian ; senile. Varieties of 
 gangrene. Case of ulceration of leg with lengthening of the 
 limb. Cases of gangrenous ulceration. Periarticular abscess. 
 Acute gonitis — Case. 
 
 Cases of acute periostitis and osteomyelitis ; of femur ; of 
 tibia ; remarJcs. Cases of osteomyelitis with separation of 
 epiphyses. Case of acute ostitis. Cases of subacute osteo- 
 myelitis. Ditto affecting numerous bones. General remarks 
 on acute periostitis and osteomyelitis. Other cases of the
 
 ACUTE PHLEGMON, GANGKENE. 403 
 
 same disease. Case of ditto vnth lengthening of the liml. 
 TerTj chronic ostitis. 
 
 Acute phlegmonous hif animation of the leg. 
 
 A mau, ret. 46, received a slight contusion on the shin, not sufficient to 
 first to prevent him from doing his work. A week after the injury he was 
 admitted witli all the symptoms of pyaemia, and on the following day he 
 died. Post mortem : evidence of chronic alcoholismus was discovered in the 
 cirrhosed liver, and the condition of chronic intestinal catarrh ; in addition 
 abscesses were found in the lungs. 
 
 A man, set. 54> of intemperate hahits, came up to the hospital fifteen days 
 after receiving a slight contusion on the right leg, with an extensive phleg- 
 monous inflammation of the integuments, a portion of which, the size of a 
 florin, was gangrenous. Incisions were made, and the whole of the subcuta- 
 neous cellular tissue of the leg was found to be destroyed and sloughing. 
 Death followed from pyaemia. Suppurative phlebitis was afterwards found 
 in the bones of the leg. In the lungs were recent infarcts and evidence of 
 chronic inflammatory disease. 
 
 When abscesses form in highly acute cases like the above, it might 
 be well to boldly cauterise the incisions, as well as the surface of the 
 wound. As a rule, the milder cases only run on to suppuration ; 
 the worst class prove fatal before abscesses form. We can 
 hardly imagine that the internal exhibition of Liquor Ammoniae, 
 tlie efficacy of which is so much vaunted in snake-bite, could here 
 be of any avail. In cases like these, amputation is nearly always 
 futile. 
 
 Spontaneous gangrene from embolism of the popliteal artery. 
 
 Anna S — , set. 22. Three weeks before admission the patient had been 
 confined of a stillborn child. Some days previous to this she had experienced 
 sudden weakness and pain in the left leg ; the limb swelled and became cold 
 and blue, and when admitted into the hospital the whole of the leg was in a 
 state of moist gangrene. She died of septicaemia about a week afterwards. 
 Endocarditis was found, and the embolism was evidently due to a clot which 
 had originated from the mitral valve. The case resembles one already men- 
 tioned, sw^ra, on p. 366. 
 
 Gangrene from disease of the smaller arteries. 
 A woman, aet. 55, was sent in with the diagnosis "tvpluis." Nothing
 
 404 GANGBENE FROM ARTERIAL DISEASE : FROM ANJSMIA. 
 
 much could be learned from her history. When admitted gangrene was 
 commencing in her left leg. She improved and recovered her strength, but 
 we could form no positive diagnosis. The arteries were rigid. The gangrene, 
 which was perfectly dry, was limited by a line of demarcation formed just 
 below the knee, from which a tongue of skin extended downwards. At the 
 proper time I sawed through the bones below the line of demarcation and 
 turned up a flap of skin to cover the wound. The wound slowly healed, but 
 was not soundly united for eight months. Six years later I heard that she 
 was in excellent health. 
 
 The following case I only saw from time to time in consultation, 
 and am unable, therefore, to give very minute information. 
 
 Lord G — , a man set. 53, of highly aristocratic English descent, had 
 sufEered severely for many years from gout. While he was at Aix-la-Chapelle 
 for this disease, slight paronychia commenced on the gi'eat toe of the left 
 foot ; gradually gangrene developed over the anterior part of this toe. The 
 gangrenous portion separated very slowly. The patient frequently complained 
 of sudden loss of sensation in certain parts of the body, especially in the left 
 leg and in the face. Nothing abnormal could be detected in the arteries or 
 the heart. I saw the patient in 1862, and heai'd afterwards that he died in 
 1863. The diagnosis of the English surgeons was " arterial disease." 
 
 Gangrene from anamia. 
 
 I can give no other cause than the above for the disease in the 
 following case. 
 
 J. H — , a cobbler, set. 35, had suffered two yeare (?) previously from frost- 
 bite of the right foot. During the month of October he was constantly at 
 work in a cold workshop, and his feet and legs were always icy cold and 
 almost without sensation. When he was able to warm them again, some of 
 the toes turned to a blue colour, and this was accompanied by itching of the 
 part. While crossing the Briinig (a tolerably high Swiss pass) in the month 
 of November, the nose and the toes became partially frost-bitten. Soon after 
 this he began to lose strength, and was forced to lie up in a hospital at 
 Lucerne on account of swelling of the leg. The patient was of slight build, 
 rather emaciated, and of very pale, sallow aspect. The end of the nose was 
 of a brownish-blue colour and dry. The gangrenous portions of the skin were 
 defined, but the line of demarcation showed no trace of discolouration, either 
 reddish or bluish. A portion of skin between the second and third toes was 
 dry and gangrenous, and the parts around them sensitive. Under good 
 dietetic and other conditions the gangrenous part of the nose separated, but the 
 process went on in the foot, and the right foot also became affected. No 
 arterial disease could be found, nor anything wrong with the heart. The 
 patient became gradually marasmic as the gangrene of the feet became
 
 GANGRENE FBOM UNKNOWN CAUSE. 405 
 
 moist, and extended moi'e and more rapidly, involving all the parts up to the 
 heel. In spite o£ all kinds o£ tonics, locally and internally, the patient 
 died of intense marasmus two months after admission. The post mortem 
 was most carefully made by Professor Rindfleisch. No disease could be found 
 in any organ, but there was the most marked general ansemia. The spleen 
 was not enlarged ; the blood was thin and watery, but not containing an 
 excess of leucocytes. The muscular substance of the heart was flabby, but 
 not fatty.' 
 
 Gangrene from some imTcnowv, cause. 
 
 Frau G — , ret. 37, came under my care in 1865. She had been married, 
 and had bom three children, but had been a widow for some years. Two 
 years before her admission she sufEered from occasional pain in the legs, 
 sometimes lasting for a few days, sometimes for weeks. A year previously 
 the left little toe had become inflamed ; suppuration occun-ed, but the parts 
 all healed up. Seven months previously she had suffered from severe dart- 
 ing pains in the leg, which sometimes confined her to her bed for days 
 together. This was followed by suppuration between] the fourth and 
 fifth toes, which again healed up. Four months before admission (in the 
 month of June) suppuration again occurred at the former seat of disease, and 
 was followed by gangrene of both the toes. These were removed by a sm*- 
 geon. The wound would not heal, and the gangrenous process gradually 
 extended over the toes and foot. Her strength began to fail, and when she 
 was admitted into the hospital she was in a very reduced state — greatly ema- 
 ciated and with sloughing bed-sores over the sacrum. By the greatest care 
 and attention she was brought round. The left foot separated at the ankle- 
 joint, and subsequently the articular surfaces of the tibia and fibula were 
 sawn off ; the tissues left were insufficient to cover the end of the stump. 
 She suffered more from the bed-sores, however, than from the gangrene of 
 the foot. There were sores on the sacrum, over both trochanters, the sca- 
 pulae, patella}, elbows — in short, everywhere. For weeks she lay on her face, 
 till bed-sores formed over the anterior superior spine. I never before saw 
 anybody reduced to so fearful a state through decubitus. Had it not been 
 for a good English water-pillow she must have died. Eight months after 
 her admission she was discharged strong and well. A year later I saw the 
 patient, stout, active, and in good health. 
 
 I exerted myself to the utmost to discover some reason for the 
 gangrene in this patient ; there were no abnormal symptoms about 
 the heart ; the arteries were of normal dimensions and the pulse 
 strong. Both the femoral arteries were pervious down to the ham. 
 Her neighbours said of her, that she drank a good deal. It is true 
 she was in the habit of drinking from two to three " schoppen '^ o£ 
 
 ' Cf. a case recorded by Nedopil in the ' Wiener Med. Woch.,' 1878.
 
 406 AMPUTATION IN GANGRENE. 
 
 Swiss wine daily, but this is nothing out of the way for the country- 
 women, and even if she had been an habitual drunkard, this would 
 not have accounted directly for the occurrence of the gangrene in so 
 many different parts ; in short, the etiology of the case is still inex- 
 plicable to me. 
 
 In spontaneous gangrene the questions whether amputation 
 should be performed, and what is the right time for the operation, 
 cannot be answered in any general way. The cases must be treated 
 according to circumstances. This much, however, may be said — if 
 the gangrene be due to embolism of the popliteal artery, the best 
 chance for the patient will be to amputate the thigh, close above 
 the knee, as soon as the diagnosis is established, for gangrene of 
 the foot and leg will invariably follow.^ When the gangrene is 
 limited to the toes, it is better not to operate. If the mummification 
 be limited, amputation can be performed through the line of 
 demarcation successfully, if the patient has still strength enough 
 to live for some months or years. A very unfavourable prognosis 
 must be given in moist senile gangrene when the disease extends 
 beyond the toes. Amputation, a little above the line of demarca- 
 tion in the skin, need not be altogether condemned, but it holds 
 out little prospect of success. In symmetrical gangrene — the result 
 of anaemia — the prognosis is so bad that it is better not to operate. 
 
 Spontaneous gangrene. 
 
 A man, set. 55, was admitted with the following history : — For ten years 
 he had sufiered from shortness of breath and palpitation of the heart. Five 
 months previously he had experienced a sudden, severe pain in his right leg. 
 On taking off his boot he found the limb white and almost devoid of sen- 
 sation. Three weeks later, according to his account, " the leg was bluish- 
 black, and the flesh fell away from his bones." The leg was then ampu- 
 tated just beneath the line of demarcation in order to get rid of the stench 
 of the gangrenous parts. From the appearance of the stump and the history 
 of the case, I have no doubt that the gangrene was due to sudden blocking 
 d the popliteal artery, either from embolus or from thrombosis of sponta- 
 neous origin. The bones of the leg projected an inch and a half beyond 
 the stump. In order to improve this I separated a portion of the skin from 
 
 ^ It may be useful to bear in mind in amputation for this condition, a 
 point that has already been remarked, viz. that if the line of demarcation be 
 allowed to form, it does so at a much lower level over the calf of the leg than 
 over the lateral and anterior aspects of the limb. The posterior flap, there- 
 fore, should be the longer. — [Ed.]
 
 SPONTANEOUS GANGRENE. 407 
 
 the anterior surface, and removed aufRcient bone to enable the soft tissues to 
 cover the stump. Unfoi-tunately fresh gangrene followed this operation, 
 collapse set in, and the patient died. Post mortem : the heart was found to 
 be half as large again as natural, the wall of the right ventricle being much 
 thickened ; the valves very extensively diseased ; the bicuspid valve, to- 
 gether with its chordaB tendinese, thickened and contracted. On the. inner 
 surface of the valves spots of calcification, and in one place an ulcer, the size 
 of a bean, to which loose, fibrinous, vegetation-like coagula adhered. The 
 posterior aortic flap adherent to the left. Both cusps of the mitral valve so 
 adherent that the opening would only admit the little finger. 
 
 Meyer W — , set. 37. Four yeai-s previously the patient experienced con- 
 stant formication, accompanied by some pain and swelling of the left 
 foot. He went on with his work, but four months later a small wound 
 formed and gradually increased, starting from a scratch on the little toe. A 
 year later a similar ulcer fonned on the great toe ; caustics were applied, and 
 after the separation of the eschar the ulcer resumed its former appearance. 
 The ulceration now spread slowly over the whole foot, destroying first the 
 little and then the great toe. Under long continued resli the ulceration 
 almost healed up ; he then began to get about, whereupon the cicatrices 
 again began to break down, and again healed up with rest ; so the process 
 went on until the other toes separated, and the soft parts became detached 
 from the metatarsal bones, which, on his admission, were bare and partly 
 covered by osteophytes. The parts about the ulcerated wound were strikingly 
 white and insensitive ; the whole appearance of the disease suggested some 
 slow phagedaenic process ; the thoracic and abdominal viscera were normal, 
 nor could anything be found amiss with the heart or the large vessels. Von 
 Hebra was of opinion that the disease was syphilitic in its nature, although 
 the patient absolutely denied any infection, and no other symptoms of 
 syphilis could be discovered beyond slight swelling of the cervical and cubital 
 glands. Some thought the infection was due to congenital syphilis. Cho- 
 part's amputation was performed and inunction employed. The patient 
 improved decidedly, and the wound got well. In six weeks' time he was able 
 to walk well on the stump, and was then discharged. To my regret I could 
 gain no subsequent information about his case. 
 
 Anton H — , set. 33, was stated to have suffered six weeks before his 
 admission from pneumonia of the left lung and pleurisy of the right side. 
 Fourteen days after the commencement of the disease he felt a sudden pain 
 in the great toe of the left foot, and foimication in the sole of the 
 foot. Soon after, the entire left lower and the right upper extremity 
 became cold and devoid of sensation. After two days the gi'eat toe was 
 noticed to be of a blue colour, and the discolouration gradually spread over 
 the foot and leg. The anaesthesia of the upper extremity disappeared 
 after some days. When admitted the patient was in a very feeble state; the 
 area of precordial dulness was not increased ; a distinct systolic friction 
 murmur was audible. No pulse could be felt in the brachial arteries of the 
 right side nor in the left crural artery ; the left leg was gangrenous up to
 
 408 SPONTANEOUS GANGRENE. 
 
 the knee. The line of demarcation extended lower down over the calf than- 
 on the anterior surface. Amputation was performed, but the patient died a 
 month after the operation. 
 
 Taking into account all the symptoms I had diagnosed endo- 
 myo- pericarditis, with embolism of the left popliteal and the right 
 subclavian arteries. 
 
 From the report of the post-mortem examination I cull the following : — 
 " In the lower lobe of the left lung an infarct, the size of a chestnut, from 
 which a fiim clot extended into a large bi^anch of the pulmonary artery ; a 
 similar thrombus of the right lower lobe. Hepatisation around the infarcts.^ 
 The heart presented the results of acute disease and was covered by a reddish 
 fibrinous layer, with here and there some recent connective tissue. The left 
 ventricle was enlarged, and the walls of the septum covered every^vhere by 
 irregular thickenings, between which the muscular substance presented a 
 singular appearance. In the trabecular tissue were numerous globular vege- 
 tation growths, varying in size from a pea to an almond, some tough, others 
 soft, and of greyish-red colour. The whole length of the right subclavian artery 
 was completely plugged by a thrombus, and the perivascular tissue thickened ; 
 the right subclavian and innominate veins were blocked by firm thrombi. 
 It is possible that the emboli in the arteries of the lungs started from the 
 vegetations of the right side of the heart, but it is just as probable that they 
 came from the thrombi in the subclavian or femoral veins. The femoral 
 artery was obliterated by a tough, fibroid clot extending from Poupart's liga- 
 ment to the amputated surface. The femoral vein was obliterated to some 
 extent." 
 
 Embolism of the subclavian artery is not of common occurrence 
 in such cases. I have recorded above (p. 366) a case of embolism 
 of the brachial artery. 
 
 A case of senile gangrene in an intemperate old man aged sixty- 
 was of some interest, inasmuch as the fingers were affected. 
 
 Six months before admission he had suffered from onychia of the right 
 great toe, accompanied by slight sloughing of the skin ; the gangi-ene of the 
 fingers had commenced with onychia of the left index finger six weeks before 
 admission. A fortnight previously the same process began in the right 
 index finger ; nothing abnormal could be detecited in the arteries, nor was. 
 there any symptom of ergotism. He died two days after admission. The 
 post mortem showed evidence of chronic embolism ; the arteries of the 
 upper extremity were not abnormal as far as they were examined, but unfor- 
 tunately the vessels were not investigated minutely up to the fingers. 
 
 ''Spontaneous gangrene/' or, as the older surgeons used^
 
 VARIETIES OF GANGRENE. 409' 
 
 to call it, "gangrene from internal causes/' may arise, as we 
 now know, in many different ways. Owing to the researches of 
 Dupuytren, Eaynaud, Virchow and others, it is possible to do 
 more than merely distinguish between dry and moist gangrene, 
 and we are now enabled, at the bedside, to make a diagnosis that 
 is accurate anatomically as well as etiologically. The varieties may^ 
 be classified as follows : 
 
 (a) Gangrene from Anemia. (Asphyxie Locale.^) 
 
 In severe and extensive cases of this nature no good results can' 
 be expected from amputation, and if the process be not limited to- 
 small parts of the skin, and the gangrenous parts do not come 
 away of themselves, the disease is necessarily fatal. There is 
 probably some affinity between this disease and the affection 
 recently described as ansemia perniciosa. 
 
 (b) Gangrene due to Embolism. 
 
 In all the cases I met with, the embolism was situated at the 
 bifurcation of the popliteal artery, and arose from endo-myocarditis 
 and valvular disease or some other severe and acute general 
 affection. This form is characterised by (i) its sudden onset; (2) 
 by pain, usually severe and frequently noticed from the second to 
 about the sixth day ; the limb at first becomes white, and devoid 
 of sensation but with formication, then livid and painful ; (3) by 
 the gangrene occurring simultaneously over the whole foot and leg,. 
 the foot as a rule, being mummified, while at the limit of the circu- 
 lation the gangrene is more moist in character ; (4) by the shape of 
 the line of demarcation, which appears anteriorly as a transverse 
 line close under the tuberosities of the tibia, and at the back marks 
 out a flap three or four inches long over the calf. 
 
 In such cases, amputation of the thigh is the best treatment, and 
 should be performed as soon as the diagnosis is established. 
 
 ^ ' De VAsphyxk Locale et cTe la Gangrene Symetrique des Extremites/' 
 Eaynaud, 1862.
 
 410 VAEIETIES OF GANGRENE. 
 
 (c) Gangrene from Hyperplastic Endarteritis. 
 
 I lirst became minutely acquainted with this disease through the 
 writings of Felix v. Winiwarter {' Archiv fiir KHn. Chirurg./ Bd. 23, 
 p. 202), who points out that hyperplastic endarteritis (endarteritis 
 and endophlebitis proliferans) may occur in apparently healthy 
 individuals, and leads to the formation of thrombi, which become 
 organised and vascular ; the variety cannot be diagnosed without the 
 aid of the microscope. Syphilis or alcoholism may give rise to this 
 form of endarteritis. It is doubtful whether the gangrene arising in 
 cases of diabetes mellitus belongs to the same category. The affection 
 requires further investigation ; usually there are prodromal symptoms 
 extending over periods of some years, such as weakness of the circu- 
 lation, mottling of the skin over the joints, sensations of cold, 
 formication, inability to stand long, or to walk far ; some accidental 
 contusion or cut leads first to atonic, and then to sloughing ulcera- 
 tion. The gangrene progresses very slowly, and is usually moist ; 
 it is generally accompanied by severe pain and chronic septic sym- 
 ptoms. There is some risk in waiting for the line of demarcation, 
 for the gangrene is apt to commence anew after the demarcation 
 has apparently been established. It is best to amputate at some 
 distance above the gangrene, as soon as the diagnosis is made. 
 
 (d) Gangrene erom Atheromatous Arteritis; Senile 
 Gangrene. 
 
 This form occurs principally in males; slight injuries, such as 
 pressure from a boot, or inflammation about the nails, are 
 frequently assigned as the starting-points ; the disease commonly 
 begins with a circumscribed stasis, and formation of blebs containing 
 sanious fluid, on eitlier side of the toes. Evidence of chronic 
 alcoholism is frequently discovered post mortem. Anatomically as 
 well as clinically, these cases may be divided into two groups. 
 
 (i) Thrombosis arising from aneurism of the femoral or popliteal 
 artery, which commences gradually and finally becomes complete. 
 
 (2) Gradual thrombosis of tjie smaller digital arteries, with pro- 
 gressive gangrene ; this form may begin over the distribution of the 
 dorsalis pedis or the posterior tibial artery. The ages of the
 
 SENILE GANGRENE. GANGRENE AFTER TYPHUS. 411 
 
 patients who came under my observation, varied between fifty-two 
 and eighty-two. Many of the patients were of dull intellect; 
 atrophy of the brain and atheroma of the cerebral arteries were 
 often found, though not in all instances. A dry form of gangrene 
 — mummification — is the common form; this is due to the fact 
 that the circulation is not suddenly arrested, nor the fluids in the 
 tissues completely imprisoned ; the obstruction takes place gradually, 
 and the fluids are carried away by the veins and lymphatics ; for 
 this to take place, some, however slight, arterial circulation is 
 necessary. When mummification of the leg follows embolism of 
 the popliteal artery, either the plug cannot have been complete at 
 the outset, or else feeble collateral circulation must have gone on. 
 If the circulation be suddenly and totally arrested, decomposition 
 and moist gangrene must follow, as observed in gangrene due to 
 traumatic causes, or to frost-bite. This kind of moist gangrene 
 (sphacelus) differs materially in its origin from the moist gangrene 
 which is due to intense inflammation of the part. This latter form 
 is well described by the old name of warm gangrene (heisser 
 Brand). 
 
 We are never able to predicate the duration of senile gangrene, 
 or the probable limit of demarcation with any degree of certainty. 
 In the cases that I have met with, the duration of the process up 
 to the spontaneous separation of the gangrenous parts, or till death, 
 varied between a month and two years. This is as distressing for 
 the surgeon, as for the patient. In senile gangrene no general rule 
 can be laid down as to when or where we should amputate. In 
 general, so far as I have seen, the results of the regulation ex- 
 pectant treatment are so unfavourable, that I have determined in 
 future, to amputate at an earlier date at the foot, or above the 
 malleoli, unless the patients be too much reduced. Possibly our 
 new methods of treating wounds may bring about more favourable 
 results than our predecessors were able to achieve. 
 
 Gangrene after typhus. 
 
 Wolf B — , aat. 26, liad au attack of typhus nine weeks before admission ; 
 during the third weelv of the disease, according to his statement, dark dis- 
 colouration began in the leg and gradually spread over the toes, commencing 
 at the great toe. In the seventh week, the limits of the gangrene first became 
 defined ; the pain and fever then ceased, and when the patient was admitted
 
 412 GANGRENOUS ULCERATION. PERIARTICULAR ABSCESS. 
 
 he was fairly strong. The line of demarcation was situated in the upper half 
 of the leg, sound skin extending to a lower level on the posterior than on the 
 anterior part. The leg and foot were in a state of mummification, and at 
 the line of demarcation the bones were completely denuded to the extent of 
 an inch. The bones were sawn through subperiosteally an inch and a half 
 above the line of demarcation, and flaps fashioned from the living soft parts. 
 With the exception of a slight attack of lymphangitis, he made an uninter- 
 rupted recovery, and had a good very stump. 
 
 This was a typical case of gangrene — the result of thrombosis- 
 after typhus — of the kind described by Estlander in the 'Archiv 
 fiir Klin. Chir./ Bd. xii. Heft 3. 
 
 Ulceration of the leg. Lengthening of the limb. 
 
 Josepha R — , set. 13, a very neglected child, suffered from gangi-enous 
 ulceration of the leg, which was treated by the application of fuming sul- 
 phuric acid. Exfoliation of the tibia followed and the patient recovered. The 
 affected limb was about a centimetre and a half longer than the sound one. 
 
 Ulceration of the leg. 
 
 A man, set. 56, came under treatment, who twenty-six years previously had 
 been struck on the right leg by a falling tree ; the injuiy was followed by 
 considerable cellulitis, and some destiniction of the skin. The resulting cica- 
 trix had ever since been weak and imperfect. After a time, all the integu- 
 ments of the leg and the foot became thickened, and assumed a condition of 
 elephantiasis. From the knee to the foot, all the tissues were extensively 
 degenerated and ulcerated, and had been so for many years ; the fcetor of the 
 ulceration was abominable. Fomentations, compresses, digital compression 
 of the femoral artery, and many other remedies were tried in vain. Finally 
 the limb was amputated, close above the knee, by means of an anterior flap. 
 The parts healed up remarkably favourably, but twenty-three days after the 
 operation the man was suddenly seized with a rigor, and the stump became 
 blue, swollen and painful ; three days later complete gangi'ene followed, 
 collapse set in and the patient died two days after the rigor. As we had been 
 led to expect, the heart was found to be fatty and the femoral aiiery 
 thrombosed. 
 
 Periarticular Abscess of the Knee. 
 
 In the early stages of this disease, the diagnosis is not always 
 perfectly easy, though it soon becomes established by the absence 
 of any loss of function in the joint. In none of my cases was the
 
 ACUTE PERIOSTITIS AND OSTEOMYELITIS. 413 
 
 knee-joint affected at the same time, a point of interest, inasmuch 
 as disease of the joint (whether acute or chronic synovitis) so 
 frequently causes periarticular abscesses of the cellular tissue. I 
 suspect, from the mode of extension of the inflammation, that the 
 phlogogenous materials pass along the lymphatic channels into the 
 tissue. 
 
 Acute inflammation of the knee. 
 
 A youth, set. i6, received a blow on the knee three days before admission. 
 For two days he followed his employment, but then, on account of the great 
 pain in moving about, sought advice. The patella was distinctly raised by 
 the efEusion ; the swelling of the part readily diminished under treatment, 
 so that in eight days the patella had subsided to its normal place, and the 
 abscess which existed seemed to be solely periarticular. The pus was let out 
 by means of a trocar ; although no air was allowed to enter, the puncture was 
 followed by a high degree of fever. Eventually a free incision was made, a 
 quantity of foul pus evacuated, and the feverish symptoms subsided. 
 Recovery followed in thirteen weeks. 
 
 Probably in this case the acute inflammation of the joint set up 
 the periarticular abscess, and it is possible that there was no per- 
 foration of the capsule. 
 
 Acute Periostitis and Osteomyelitis.^ 
 
 Acute periostitis and osteomyelitis of the femur. 
 
 A boy, set. 8, was admitted with subacute osteomyelitis and osteoplastic 
 periostitis of both femora, which had originated without any known cause. 
 On the right side the upper epiphysis had become softened and detached with- 
 out any suppuration and led to the spontaneous dislocation which was 
 evident. This was reduced, and the limb put up in a plaster bandage. He 
 was under treatment in the hospital for seven months, and subsequently 
 recovered so far that he could jump and run without pain or limping. 
 
 Acute periostitis and osteomyelitis of the tihia, 
 
 A girl, set. 14, had a very acute attack of periostitis of the tibia, together 
 with acute inflammation of the ankle-joint. The anterior surface of the 
 tibia was completely exposed. In the course of a few weeks she had 
 altogether sixteen rigors. I diagnosed osteomyelitis with periostitis ; 
 
 1 See Appendix II.
 
 414 ACUTE OSTEOMYELITIS. 
 
 recovery however, eventually took place, and only a few small portions of 
 bone became detached from the anterior surface of the tibia. 
 
 I suppose, judgiDg from the result, that the case was one merely 
 (rf periostitis, or at any rate, that the medulla of the bone, though 
 it may have been inflamed, was not suppurating — otherwise, 
 complete necrosis of the shaft must have followed. The sinuses 
 did not completely close for two years. The girl recovered 
 perfectly, and there was no shortening of the limb. 
 
 A boy, set. i^, came under my care who, from the accounts given, had been 
 attacked with acute osteomyelitis accomjianied by extensive sloughing of the 
 skin, a year previously. The bone became spontaneously detached at the 
 upper and lower epiphyses. The suppuration was so great that the whole 
 shaft was removed, although there was but little new formed periosteal bone. 
 Pseudarthrosis, in consequence formed ; this was cured by uniting the ends 
 of bones with sutures, and driving in ivoiy pegs. The tibia recovered its 
 normal size, and the growth of the limb was not interfered with. The 
 patient was in perfect health and strength. 
 
 Attention has been repeatedly called, of late, to acute osteo- 
 mvelitis, occurring where there has been no breach of surface. 
 Formerly, the disease was not universally recognised, partly 
 because in making post-mortem examinations in such cases the 
 affected bones were not sufficiently examined, and the anatomical 
 features of the disease, therefore, imperfectly understood, and partly 
 because, in many parts of Germany the disease is of comparatively 
 rase occurrence. For instance, in Vienna, this affection is seldom 
 met with, and during the seven years that I was assistant, I can 
 recall but few cases ; they were more numerous in Ziirich, and I 
 heard of many which were met with in Berne ; von Langenbeck has 
 remarked on the frequency of such cases at Kiel. The comparative 
 rarity of the disease in some places, and its frequency at others, is 
 onlv apparent ; the necroses of the femur and end of the tibia, which 
 are common enough at every hospital, and of which niunerous pre- 
 parations are to be found in every pathological museum, are mostly 
 the result of acute or subacute osteomyelitis. We must take into 
 consideration the fact that patients sufi"ering from acute osteo- 
 myelitis cannot be easily moved, and content themselves in con- 
 sequence with such treatment as they can obtain at home, in pre- 
 ference to undertaking a long journey to a hospital. The frequency 
 of cases of necrosis proves, moreover, that the disease often
 
 ACUTE OSTEOMYELITIS. 415 
 
 terminates spontaneously in recovery, or that the patients very 
 frequently survive the acute stage. The great mortality in hospitals 
 among this class of cases may depend upon special conditions,, such 
 as, possibly, septic infection supervening after incisions have been 
 made. 
 
 From what I know now of the disease, I see that many of the 
 cases which were entered as acute inflammations of the joint should 
 have been classified with those now under consideration. Of such 
 a nature was the following : 
 
 S — , set. 19, had an attack of acute articular rheumatism, which she got 
 over without any ill effects. Eight days hefore admission, the right elbow 
 became painful and moderately swollen ; ice was applied. A peri-articular 
 abscess formed, which was opened four weeks after admission, and it was 
 soon evident that the abscess communicated with the joint. A month later 
 there was grating of the articular extremities, and I excised the joint. The 
 suppuration was profuse and the pus ichorous. Further incisions were found 
 necessary and the patient died of pyaemia, after amputation of the arm, three 
 months after her admission. 
 
 No cause was assigned for the commencement of the disease. I 
 think it very probable that there was acute osteomyelitis of the 
 lower end of the humerus. 
 
 The femur was afi'ected in twenty-four cases (males 17, females 7). 
 Eighteen of these patients died. In this category can be included 
 nine undoubted cases occurring in males — aged respectively 8, 16, 
 17, 18, 22, 29 (2), and in females of 12 and 26. In the following 
 case the lower epiphysis was detached. 
 
 T. H — , ait. 1 8, a locksmith, was attacked with severe rigors, vomitin"-, and 
 pain in the right knee of so intense a nature that he could not stand. When 
 admitted, two days later, the presence of acute osteomyelitis was already 
 unquestionable, and it soon became still more marked. The general con- 
 dition was so typically typhus-like that for the first time on seeing this 
 case, I understood why this disease has been designated "bone typhus" 
 (Knochentyphus). The pains, which were especially severe at night, were 
 relie"ved by morphia injections. Eight days after the commencement of the 
 disease, fluid was detected deeply situated about a hand's breadth above the 
 knee-joint. I made an incision with a long, fine knife, and let out some 
 pus mixed with dark blood ; the pus was inodorous and free from bacteria ; 
 at the same time I felt the bone denuded of periosteum. I did not enlaro-e 
 tlic opening, but ordered wet compresses to be constantly applied and allowed 
 the secretion to drain away spontaneously. The puncture soon closed, but 
 three days later I was forced to extend it for about three inches, and a lar"-e
 
 416 ACUTE AND SUBACUTE PERIOSTITIS. 
 
 drainage tube was inserted. The pus had now an acid smell. Nine days after 
 admission he had repeated attacks]o£ severe dyspnoea and cough. Neither in 
 the heart nor in the lungs could anything abnormal be detected : probably 
 the symptoms were due to fat embolism of the lungs. During the tenth and 
 eleventh days the swelling of the edges of the wound diminished and the 
 patient was relieved ; the tongue became more moist, and the appetite 
 improved, although the evening temperature still kept high, and the pus had 
 a foul smell. A slight bed-sore formed over the sacrum. By the sixteenth 
 day the attacks of dyspnoea had left him, but swelling of the knee-joint was 
 observed. On the nineteenth day the lower epiphysis of the femur was 
 found loose. From this time the patient began to improve ; the bed-sore 
 healed and the fluid in the joint became absorbed. By the twenty-seventh 
 day the fever had ceased. On the fifty-seventh day — the thirty-fifth after the 
 detachment had been noticed — the epiphysis was found to have consolidated 
 a^ain. About five months after the commencement of the disease, a seques- 
 trum was removed, and when the patient was discharged a short time after, 
 the sinus had not completely closed. He had some movement in the knee- 
 joint. It is much to be regretted that the subsequent accounts of this 
 characteristic case are imperfect. 
 
 In the following case also the lower epiphysis of the femur 
 became separated. 
 
 Elise W — , set. 12, had intensely acute suppurative osteomyelitis and 
 periostitis of the femur, followed by abscess of the knee-joint and sepa- 
 ration of the lower epiphysis of the femur. Subsequently osteomyelitis 
 developed in the tibia on the same side ; the femoral vein was blocked up to 
 the vena cava. She had phlegmasia on both sides ; no metastatic abscesses. 
 Death on the sixty -third day. The cause of origin of the disease could not 
 "he made out. 
 
 Subacute periostitis of the femur. 
 
 H. B — , set. 24. Five weeks after the pain had first commenced an abscess 
 was opened. The bone was not necrosed. A sinus persisted at the site of 
 the abscess. When discharged two or three mouths later he could walk well, 
 and the suppuration was very slight. 
 
 Acute ostitis. 
 
 Moritz S — , aet. 22. Eight yeare previously (when fourteen years of age) he 
 was attacked with acute ostitis of both femora, after a severe chill ; both 
 humeri were attacked also as well as the right tibia. Abscesses and sinuses 
 formed over all four extremities. The sinuses in the upper extremities 
 <;losed spontaneously without any exfoliation of the bone, and those over
 
 SUBACUTE OSTEOMYELITIS AND OSTITIS. 417 
 
 tlie tibia healed after tbe seimration o£ a jjortion of bone. AVhen be was 
 admitted tbe only sinuses open were in tbe thighs. On the right sjde a 
 sequestrum and an old drainage tube was removed ; on tbe left side only a 
 drainage tube. The sinuses closed up soundly and the patient was discharged 
 in a month. 
 
 In the next case, the osteomyelitis was of a subacute character. 
 It was found necessary to amputate at the hip-joint, and the patient 
 did not survive the operation. 
 
 Franz T — , a2t. 17, had a fall from a horse three years before I saw him, 
 and his left knee became swollen and painful. He kept his bed for a month, 
 and all the pain ceased. He then was put to a locksmith's trade, and had to 
 work the bellows with his left leg. Eight days before admission he was 
 seized with rather sudden, severe pain in tbe left leg, and symptoms of sub- 
 acute osteomyelitis, principally in the lower half of the left femur, soon 
 after manifested themselves. At tbe end of three weeks fluctuation was 
 suflBciently distinct for me to make a puncture with a fine knife. A large 
 quantity of pus escaped which was free from smell. The patient was much 
 relieved. Subsequently the suppuration extended into the deeper parts, and 
 numerous fresh incisions were found necessary. A large extent of the bone 
 lay bare ; the amount of suppuration became prodigious, and although the 
 patient bad but little fever, his strength sank so rapidly that on the ninety- 
 eighth day of the disease, I decided to amputate at the hip-joint. Shortly 
 before the operation be was ordered a beef steak and some wine. Every pre- 
 caution was taken to guard against loss of blood. Tbe patient was only 
 slightly anaesthetised ; the pulse could only be felt in the carotid artery. I 
 began by ligaturing the femoral ariery ; then encircling the thigh close below 
 the trochanter with the galvano-caustic loop, I cut through the soft parts 
 down to the bone. Absolutely no blood was lost. I had made a longi- 
 tudinal incision obove the trochanter, and was preparing to separate the bone 
 when the patient became suddenly collapsed and died. 
 
 The following case may be distinguished from the two preceding 
 examples of osteomyelitis, inasmuch as the bones were already 
 altered by chronic disease. 
 
 L. M — , xi. 22. "Wlien a child, he suffered from inflammation in the right 
 knee which left the joint contracted. The deformity was gradually cured by 
 repeated forcible extension. Fourteen days before admission he had pains ire 
 the right femur which rapidly grew worse. Subacute ostitis developed, and 
 an abscess formed over the left side, which was opened and drained. A 
 tolerably large extent of bone including almost the entire circumference lay 
 exposed. The suppuration lasted a long time, but no necrosis followed ; the 
 soft parts again sank back on the bone, and the abscess closed completely. 
 In about three months tbe patient had recovered with a perfectly useful 
 limb. 
 
 27
 
 418 OSTEOMYELITIS ATTACKING NUMEROUS BONES. 
 
 The next case is of special interest, inasmuch as the disease 
 extended from the tibia to the femur and pelvis, and affected also 
 other parts. 
 
 Anthon G — , set. 12, was attacked suddenly one day with severe pain in 
 the left leg, so that he was unahle to stand. He was feverish, but the disease 
 did not begin with rigors. Swelling of the left leg and knee-joint was soon 
 observed. The application of some iodine caused extensive vesication, but 
 the patient's condition became worse and worae. On the twelfth day an inci- 
 sion was made just below the knee-joint on the anterior surface of the tibia 
 and some sanious pus let out. During the next few days, swelling was 
 noticed over the lower end of the femur. A foi-tnight after admission bespat 
 up some clotted blood. This symptom did not occur again and nothing 
 abnormal could be detected in the chest. The incision over the tibia was 
 enlarged, but although the discharge was fi-ee, neither the swelling of the 
 knee nor that of the thigh decreased. Between the twenty-second and 
 twenty-fifth days the kneo-joint was washed out thi'ee times. On the first 
 occasion the pus was serous, inodorous, and contained numerous stropto-cooci ; 
 on the second occasion there were fewer cocci, while on the third puncture 
 the pus was thick, and quite free from cocci. It was evident that the lower 
 end of the femur was attacked with osteomyelitis, and on the twenty-sixth 
 day amputation was performed through the middle of the thigh. The child 
 was in a high state of fever at the time of operation. On examining the 
 amputated leg, the upper end of the tibia and the lower end of the femur 
 were found infiltrated with pus, but the ai-ticular cartilages were to all appear- 
 ance intact. The sawn surface of bone was healthy. Undoubted symptoms 
 of osteomyelitis now made their appearance in the stump, and the pain and 
 swelling extended up to the pelvis. Amputation at the hip-joint was out o£ 
 the question for there were signs of suppuration in the opposite thigh as well 
 as in the hip-joint. He died on the forty-eighth day of the disease. At the 
 post-mortem we found osteomyelitis in the stump of the femur, the anterior 
 part of the pelvis, and the upper portion of the right femur. The process 
 had extended up from the left thigh, and the affection of the joints must be 
 accounted for by extension through the lymphatics of the capsule and the 
 periosteum. 
 
 A few infiltrated spots were found in the lungs, but they were evidently so 
 recent that they could scarcely have had any connection with the hsmoptysis 
 which had occurred a month previously. In all probability this symptom was 
 accounted for, as in the preceding case (T. H. stfpj-a, p. 415), by fat embolism 
 of the pulmonaiy capillaries. 
 
 Among thirty cases a definite cause was assigned in two only ; in 
 one instance, chronic disease of the thigh had existed previously. 
 The patients, as a rule, were young, from eight to twenty-nine 
 years old, as my tables show. I have met with acute osteomyelitis.
 
 COCCO-BACTERIA AND ACUTE INFLAMMATIONS. 419 
 
 both at Berlin and Vienna in children a year old ; the mortality is 
 very high when the disease occurs at more advanced periods in life. 
 The acute infection in this disease, seems to have struck the old 
 observers, when they named the infection, " bone-typhus " (Knochen- 
 typhus).^ Rose has already pointed out its possible etiological 
 relation to acute articular rheumatism ; his proposed term '' pseudo- 
 rheumatic" inflammation found, however, but little favour. I 
 wiU not now speculate on the locality of the nidus of infection ; I 
 will only now say, that it is still premature to imagine that the 
 infecting matter is always associated with cocco-bacteria. 
 
 It is extremely difficult to decide the point, for these vegetations 
 — although they may be truly the causes of the inflammation, and 
 although they may be invariably found in the tissues at a time 
 when there is no communication between the air and the seat of 
 inflammation — perish as soon as the secretion of pus is considerable, 
 as I have already pointed out. The cases are still few in number 
 in which undoubted cocco-bacteria vegetations have beeli shown to 
 exist in quite recent acute subcutaneous inflammation. It is by no 
 means proved that these vegetations do not only occasionally 
 develop in such vegetations ; for we must remember that fungi — 
 directly capable of development — which are taken into the circula- 
 tion through the lungs, might be present at the seat of inflamma- 
 tion and as the products of inflammation take up a great quantity 
 of oxygen, there is, as it were, a soil particularly well adapted for 
 the development of any kind of vegetation. If such an area of 
 inflammation is brought, though only for a moment, into contact 
 with the air, let the opening be spontaneous or artificial, then the 
 fact that cocco-bacteria are found in the exudation, ceases to be a 
 proof of any etiological relation between these vegetations and an 
 acute inflammation. 
 
 On the whole, I am inclined to the belief that most of the spon- 
 taneously arising inflammations originate in peculiar fermentative 
 processes in the tissues, but my observations at the bedside have 
 not led me to conclude that the ferment must of necessity be of a 
 vegetable or an animal character ; it is established beyond doubt, 
 that acute progressive septic inflammations can only be produced 
 by inoculation, when the inoculated matter contains cocco-bacteria ; 
 further, that inoculation with septic matters not containing cocco- 
 bacteria produces only symptoms of a more or less tfaMsient 
 ■* Using the term " typhus " in its Hippocratic sense.
 
 420 SYMPTOMS AND TREATMENT OF OSTEOMYELITIS. 
 
 character.^ So far as I know, no systematic observations have 
 hitherto been made at the bedside in other hospitals, of the same 
 nature as mine. Neither on theoretical, nor on practical grounds, 
 can any advantage be derived from promulgating hypotheses, 
 founded on our present information. These matters must be 
 attacked by new methods, and new lines of thought, and from new 
 points of new; the work that has hitherto been done on this 
 subject, is, in my eyes, simply little more than a feeble commence- 
 ment. 
 
 To return to the subject of osteomyelitis ; with regard to the 
 symptoms, I may add that lethargy, profuse diarrhcea, and the 
 early occurrence of bed-sores seem tolerably regular in their occur- 
 rence. A slight degree of icterus is frequently met with and in 
 many cases temporary attacks of dyspncea associated with consider- 
 able hfemoptysis, probably due to fat embohsm in the capillaries of 
 the lungs and liver. This latter lesion occurs, as is known, after 
 compound fractures, but it may also take place where the bones are 
 deliberately fractured, as will be shown hereafter. The process is 
 due to rapid breaking down of the fat cells of the medulla, while 
 the increased intra-ossal pressure favours the passage of the fat 
 cells into the medullary veins. 
 
 In the matter of treatment, I have come to the conclusion, that 
 it is best to wait till fluctuation is distinct, and then to make a fine 
 puncture down to the bone : by thus letting out some of the 
 effused fluid, the tension and the severe pain are relieved. The 
 puncture has little influence in limiting the necrosis that follows, 
 for, although the blood circulates more readily after the efi'used fluid 
 is withdrawn, yet the delimitation of the necrosis is commonly laid 
 down by the time abscess forms. Formerly, much difficulty was 
 experienced in allowing any further effusions to escape readily 
 after puncture, and in guarding against decomposition in re- 
 tained fluid. Xow-a-days, however, with drainage tubes, and 
 modern antiseptic dressings, we may hope to obviate these sources 
 of danger to some extent ; it is of the utmost importance to the 
 patient that we should do so. The drainage tubes have to be 
 carried through the thick muscular coverings of the thigh ; unless 
 numerous drains be kept in, the muscles will close up, or so 
 bulge forward through the splits in the fascia, that the decomposing 
 
 ^ Cf Mikulicz in the ' Arcliiv f iir Klin. Chir.,' Bd. 22, p. 253.
 
 EESTTLTS OF OSTEOMYELITIS. 421 
 
 effusion will be unable to escape ; many, many cases of necrosis of 
 the leg and thigh, came before us, which were treated without the 
 hospital by small incisions usually made when the abscess was 
 almost breaking on the surface. The medical attendant probably 
 feared the haemorrhage which must inevitably result from long and 
 deep incisions in the thigh. This only shows, as already remarked, 
 that osteomyelitis frequently runs its course to a favourable 
 termination with little or no help from the surgeon. Bearing this 
 fact in mind, I only counsel amputation in the most extreme cases ; 
 but little hope of recovery can be entertained from amputation, for 
 the disease has a tendency to progress, and the operation has little 
 power to check this tendency. I have recorded a case above (p. 
 413) where a girl, set. 14, recovered after having fourteen rigors. 
 The patient had to thank my colleague Thiersch for the preserva- 
 tion of her limb; amputation, to my mind, offered her the only 
 chance of life. 
 
 I have never observed relaxation of the ligaments after osteo- 
 myelitis, often as I have seen the joints affected in such cases. 
 Slight lengthening of the limb, owing to excessive growth of the 
 affected bone, was common enough. 
 
 Reckoning the total number of cases which came under treatment 
 between 1870 and 1876, and including those entered as "necrosis,^' 
 as cases of osteomyelitis in which recovery had taken place, I find 
 there were twenty-three in the upper and sixty-six in the lower 
 extremity. Unfortunately, in the earlier cases the records do not 
 show minutely that acute osteomyelitis was always the cause of the 
 necrosis ; but I do not think that I go too far, if of the eighty-nine 
 cases I take fifty and reckon them as acute and subacute osteo- 
 myelitis; excluding acute osteomyelitis of the articular ends of flie 
 bones, which probably were classified as acute inflammations of the 
 joints, I have a sum total of sixty-six cases of acute and subacute 
 osteomyelitis ending in recovery. Although I cannot from my 
 figures, estimate the exact rate of mortality in this disease, I may 
 say this much — that the number of cases of acute osteomyeKtis 
 which recover, is by no means so small as would appear from 
 clinical observations alone. The disease is far more common in the 
 male sex ; of the eighty-nine cases of necrosis, only seventeen 
 occurred in women. It is difficult to say to what cause this 
 enormous difference should be attributed. 
 
 The patients often stated that the disease followed typhus fever.
 
 422 AOUTE OSTEOMYELITIS OF TIBIA. 
 
 Such accounts should be received with caution when we remember 
 that acute osteomyelitis, as already remarked , often exactly resembles 
 typhus in its symptoms. I may repeat here a remark which I hare 
 already made, viz. that the occurrence of dislocation of the hip after 
 typhus, may well be doubted. It is not unlikely that the condition 
 may be really due to osteomyelitis of the upper end of the femur 
 without suppuration, followed by separation of the epiphysis, and 
 displacement of the shaft of the femur backwards ; the lateral 
 decubitus of these patients, and their habit of lying with their hmbs 
 flexed, favour the displacement, for bed-sores often form so early 
 that they avoid lying on their backs. 
 
 In the following case the whole length but not the whole thickness 
 of the tibia was affected. 
 
 C. P — , aet. 14, had recovered from an attack of typhus some months before 
 admission. Three months before I saw him acute osteomyelitis with suppu- 
 ration developed in the right tibia. Most probably, therefore, the osteo- 
 myelitis developed spontaneously with typhoid symptoms. When I saw the 
 boy, there was complete necrosis of the right tibia with separation of the 
 upper epiphysis. He had also suppuration of the knee-joint, a large abscess 
 on the outer side of the thigh, which was on the point of bursting, and was 
 in a high state of fever with commencing septic symptoms. The abscess of 
 the thigh was opened, the knee-joint drained, and a sequestrum removed from 
 liie tibia. He died about a fortnight later. No metastatic disease was found 
 post-mortem nor was there any purulent osteomyelitis of the femur, so 
 that the origin of the large supra-fascial abscess mentioned was not quite 
 clear. 
 
 Osteomyelitis of the tibia. 
 
 A. man, aet. 59, over whose leg the wheel of a waggon had passed, was 
 admitted with an incised wound, two inches long, over the middle of the shin. 
 The inner surface of the tibia was slightly depressed, but the bone was not 
 broken. For the first few days the fever and swelling were considerable, but 
 for twenty-four days he went on well ; some swelling then began on the inner 
 side of the calf, which suppurated, and rendered an incision necessary. The 
 inner surface of the tibia was then foxmd to be completely denuded of peri- 
 osteum; thi-ombosis of the saphena vein followed, and repeated rigors. 
 Death from pyaemia. Osteomyelitis of the tibia, suppurating thrombosis of 
 the femoral veins and suppuration of the knee-joint were found post-mortem, 
 together with abscesses in the lung. 
 
 The age of the patient is a point of some interest in this case.
 
 ACUTE OSTITIS AND OSTEOMYELITIS OF PEMUE 4.23 
 
 Osteomyelitis and periostitis of the femur, 
 
 A boy, itit. 17, was admitted, who could give no accurate Mstoiy of his 
 complaint, but some old, deep cicatrices were found on the left thigh. On 
 admission, the whole of the external aspect of the left thigh was enormously 
 swollen, and the muscles raised up by fluid. The patient was feverish^ 
 The swelling was punctured with Dieulafoy's aspirator, and the febrile sym- 
 ptoms decreased. Subsequently two incisions were made, and an immense 
 amount of foul pus, containing gas, evacuated. A great part of the femur 
 was bathed in ichorous matter, hut nowhere exposed. This condition did 
 not improve, though the wound was washed out many times daily with 
 carbolic lotion. The weak condition of the patient, and the doubtful exis- 
 tence of osteomyelitis, indicated amputation of the hip. Death from 
 septicaemia. Post mortem : the femur was found denuded of periosteum at 
 one point ; the medulla was discoloured, and studded with purulent deposit ; 
 pus was foimd in the knee-joints. 
 
 Ostitis of the femur. 
 
 D. F — , iet. 55. Li this man the disease had commenced five months pre- 
 viously, without known cause, with pain in the knee. An abscess formed over 
 the lower end of the femur, which broke after six weeks and healed up. 
 Seven weeks before admission, a similar abscess formed over the upper end 
 of the femur which also healed up. When I saw the patient there was a 
 large cold abscess over the trochanter major, and the whole extent of the bone 
 was markedly thickened. The abscess which was supra-fascial but ran down 
 deeply, was opened, and the cavity stufEed with charpie. Symptoms of 
 acute osteomyelitis followed with effusion into the knee-joint, and the 
 patient died of erysipelas and pysemia. Post mortem : the upper part of 
 the femur was bathed in pus ; pus also in the hip and knee-joints ; the 
 entii'e femur thickened. 
 
 This, therefore, was a case of chronic ostitis affecting the upper 
 end of the bone, which took on a very acutely infecting character 
 after the incision. 
 
 Anton D — , set. 17, was stated to have suffered from acute articular rheu- 
 matism, seven months before admission ; the affection of the right hip- joint 
 proved especially obstinate. The youth was strong and well-nourished. 
 Over the right trochanter was a large abscess, on the point of bui-sting, which 
 was opened under antiseptic precautions. The discharge shortly aftei-wards 
 became foul and high fever was manifest. The abscess was then freely laid 
 open, and its walls scraped ; the surface of the trochanter was denuded of 
 periosteum. Notwithstanding a free use of carbolic lotion, decomposition
 
 424 CHRONIC PERIOSTITIS AND LENGTHENING OF LIMB. 
 
 went on in th« wound, and the patient died of pyaemia. Poet mortem : 
 metastatic abscesses in the brain and lungs, and purulent thrombosis of the 
 right femoral vein. A small cavity was found in the upper end of the shaft 
 of the femur filled with pug and broken down granulations, and containing 
 a sequestrum. A narrow track connected the cavity to the larger abscess. 
 
 Evidentlj in this case, the symptoms which were supposed to be 
 due to acute articular rheumatism, were the result of subacute, 
 circumscribed osteomyeUtis, which ran on to central necrosis. 
 
 Michael W — , set. 22. Eleven yeare previously without known cause, he 
 was attacked with severe pain in the right leg (proba])ly due to acute osteo- 
 myelitis). A year later, an abscess formed over the inner side of the thigh 
 and was followed by others on the anterior surface of the leg. Some ulcera- 
 tion about the parts was thought to be possibly due to congenital syphilis. 
 The sinuses had never closed since their formation but no bone had come 
 away. The sinuses were laid open, and found to lead down to a' cavity filled 
 with granulations which were scraped away ; the walls of the cavity were of 
 ivory hardness. The sinuses closed in five months. 
 
 The most interesting point in this case was the marked lengthen- 
 ing of the affected extremity ; the lower two thirds of the femur, 
 and the upper two thirds of the tibia, were considerably thickened. 
 The lengthening of the femur amounted to four centimetres and 
 that of the leg was the same.^ (See Plate IX). 
 
 Very chronic periostitis and osteomyelitis. 
 
 A man, aet. 54, was admitted with the following history : — Forty-two years 
 previously he feU heavily on to his right knee. Great swelling of the right 
 knee and thigh followed, and he had to keep his bed for three months. He 
 recovered sufiiciently to walk about, but the knee never became quite straight 
 and remained painful and swollen. Eight yeai-s after the injury an abscess 
 fonned at the lower part of thigh ; the sinuses which resulted were still open 
 when he came under my treatment. In spite of ths fact that the suppui-a- 
 tion was very considerable from no less than four sinuses, the patient's 
 strength had not materially sufEered, His lungs and kidneys wer« sound, 
 although the disease of the bone had existed for forty-two years, and sup- 
 puration had gone on for thirty-four. The external appearance of the 
 limb most strongly suggested necrosis about the popliteal space ; the sinus 
 on the inner side of the femur led down to hard, smooth bone, which how- 
 ever was not loose. I cut down on the inner side of the thigh, but found that 
 
 * Cf . a case recorded by Mr. Day, in the ' Chir. Soc. Trans.,' vol. ii, p. 104 ; 
 and in vol. xi, p. 214. [Ed.]
 
 CHRONIC PERIOSTITIS AND OSTEOMYELITIS. 
 
 425 
 
 there was no sequestrum ; the probe struck against a sclerosed layer of osteo- 
 phytes ; I amputated about the middle o£ the thigh, but found on sawing 
 thpough the bone, that the medullary cavity contained pus ; this, how- 
 ever, only extended for a quarter of an inch above the section, and I there- 
 fore washed it out. The flaps united by first intention, but two sinuses 
 were left, one on the outer and one on the inner side of the wound, which 
 led down to the medullary cavity, from which cavity no proper granulations 
 sprang up. Eventually, after removing subperiosteally an inch and a half 
 of the stump of bone, the parts were induced to heal. 
 
 The preparation — a most interesting one — show that the sym- 
 ptoms had been due to an exceptionally chronic process of osteo- 
 plastic periostitis, with chronic suppurative osteomyelitis. The 
 osteomyelitis showed no tendency to heal, although numerous 
 openings connected with the medullary cavity had formed externally. 
 The medullary cavity itself, was invested by a tolerably tough 
 pyogenic membrane. (See Fig. 21). 
 
 Fig. 21. — Lower Half of the Femur, affected with veby Chronic 
 Ostitis and Osteomtelitis. 
 
 Very chronic ostitis after fracture. 
 
 A man, set. 44, had sustained a compound fracture of the right tibia thirty- 
 five years previously ; numerous small sequestra came away during the year
 
 426 ACUTE HIP-JOINT DISEASE IN ADULTS. 
 
 subsequent to the injury. Many years aftei-wards, other small abscesses and 
 sinuses formed about the seat of f lucture, wbicb were still suppurating when 
 he was admitted. Most careful examination failed to detect any sequestmm. 
 Some improvement followed cauterisation of the sinuses. 
 
 Section C. Acute and Chronic Inflammations of Joints. — 
 Acute hip-joint disease in adults — Cases and remarks. Re- 
 marl'S on chronic hip-joint disease. Case in which forcible 
 extension was applied. Tumor alhus of the hip. Cases of 
 anhylosed hip ; treatment hy osteotomy and fracturing neck of 
 femur. Dislocation of hip after typhus — Case. Case of 
 pathological luxation of hip. Chronic inflammation of knee. 
 Cases of ankylosed knee ; treated hy forcible extension ; by 
 osteotomy. Tumor albus of knee. Case of acute meningitis 
 after excision. Hydrops genu. Cases of loose cartilage. 
 Chronic disease of ankle and tarsus. 
 
 Acute hip-joint disease in adults. 
 
 A girl, let. 20, had acute inflammation of the left hip-joint, which com- 
 menced thi'ee weeks after a fall. Bed sores formed, and the patient died in 
 eighty-seven days. She had pre\-iously suffered fi'om haemoptysis ; her 
 mother and two brothers were phthisical. 
 
 Eosine L — , set. 22. Origin o£ the disease unknown. Death in forty-nine 
 days. 
 
 Agatha B — , set. 39. Oi-igin of the disease unknown. Death in fifty -two 
 days. Bed sorei, septic fever. 
 
 Gottlieb S — , a;t. 21. A chill, while on military service was given as the 
 origin of the disease. Death in ninety-three days from decubitus and 
 pyaemia. 
 
 This acute and rapidly fatal form of coxitis in adults, was new to 
 me. The post-mortem appearances were in all cases the same, viz. 
 the articular cartilage was always completely gone, sometimes 
 hanging in shreds to the bones. The disease consisted essentially 
 of subchondral ostitis with softening and necrosis of the cartilage, 
 and was almost entirely unaccompanied by suppuration. Scarcely 
 a drop of pus escaped from the joint in these cases ; there was
 
 CHEONIO HIP-JOINT DISEASE. 427 
 
 very little destruction of the bones, though the medulla was very 
 red. The capsule of the joint was slightly thickened and the synovial 
 membrane very oedematous and swollen. This formidable disease 
 is characterised by intense pain on attempting any movement, but 
 without any tendency to flexion of the limb, which indeed, is kept 
 in the extended position, rapid emaciation of the whole frame, and 
 a great tendency to decubitus. 
 
 The diagnosis of this severe form of ostitis aft'ecting the head of 
 the femur is always difficult, and it requires indeed great sagacity 
 at times to distinguish the condition from acute synovitis. It is on 
 this account that I have never attempted resection in these cases, 
 though the operation is clearly indicated. By the time that I had 
 ascertained beyond doubt that severe disease of the joint existed it 
 was usually too late for excision, for collapse set in very quickly in 
 these patients. 
 
 I am unable to explain precisely why death took place ; it was 
 not from cachexia or exhausting discharges (Siifteverlust), nor was 
 the pain sufficient to account for the result. Rest by means of a 
 plaster bandage, or opium would have controlled this. The post- 
 mortem examination showed nothing; although rigors sometimes 
 occurred, yet no signs of metastatic inflammation could be dis- 
 covered. I cannot but think, therefore, that the rapidly fatal issue 
 is due to phlogistic infection, starting from the affected joint. 
 
 Chronic Hip- joint Disease. (Z. B). 
 
 A table of sixty-two cases of this affection will be found in the 
 Zurich ' Bericht,' pp. 500, et seq. 34 were males, 28 females ; excision 
 was practised in six cases. No fewer than twenty of these patients 
 died from one cause or another, such as lardaceous disease, 
 marasmus, meningitis, pyaemia or measles. These results are, to 
 my mind, very unfavourable, but there is only one way in which 
 they can be improved, viz. by the patients coming under treatment 
 directly the disease originates. In private practice, among the 
 more educated classes we shall be able gradually to effect this, but 
 not among the children of the labouring population. In a working 
 man's family a sickly child is a terrible burden, and as long as a 
 child suffering from hip-joint disease is able to get about, he is 
 allowed to do so ; it is only when the pain becomes so great that
 
 428 HIP-JOIXT DISEASE IN CHILDREN. 
 
 he has to lie up, or when, from the flexed position of the limb he 
 is unable to get about, that the surgeon is consulted. Complete 
 jest may be enjoined, but even with the best intentions we find it 
 in many families impossible to ensure this condition, for a sick 
 child kept in bed requires the constant supervision of an adult. 
 Finally the parents make up their minds to bring the child up to 
 the hospital. Now, if the hospital be wholly, or in part, arranged 
 for the reception of children treatment may be very efficient ; but if 
 the child be placed in a ward with many other patients, the effect 
 on him may be highly injurious. Young children bear a trans- 
 plantation of this nature but ill, and are less able to stand a pro- 
 longed residence in hospital than adults. How often has it been 
 my lot in Ziirich to see patients, who, by means of good food and 
 uursinginthe well-arranged and airy Ziirich hospital, became certainly 
 somewhat fatter, but yet contumed pale and sickly. If discharged 
 and sent back for a time to a wretched home and poverty, where 
 the conditions seemed far less favourable than in hospital, they 
 nevertheless frequently came back to me after but a short time with 
 healthy colour and in good spirits. Although the causes cannot be 
 traced, this ill effect of hving in hospitals, which is not absent from 
 even the best arranged institutions, shows its influence especially 
 on children. To keep little ones suffering from joint disease in 
 hospital for months at a stretch must always be of doubtful benefit 
 to them. 
 
 The usual well-known remedies should be employed which tend 
 to improve the strength and the general condition, but the main 
 treatment resolves itself into rest, and keeping the leg extended. 
 V^ hen the limb is in good position and shows no tendency to 
 alter for the worse, no special apparatus is required, beyond one 
 or two sand bags laid along the leg and foot so as to prevent 
 movement. If in (florid) coxitis the thigh is flexed in an abnormal 
 position, it may either be forcibly restored by traction, or slowly 
 remedied by extension. Both methods have advantages and dis- 
 advantages and are applicable to diflerent cases. If under an 
 anaesthetic, the thigh falls of itself into a tolerably natural position, 
 and offers no resistance, the contraction of the muscles is only 
 due to the pain. In such cases it will usually be found best, while 
 the patient is stiU under the anaesthetic, to put the hmb in a wire 
 splint and plaster bandage. For the latter to be really effectual, it 
 should reach from close above the ankle to the perineum, and
 
 TREATMENT OF HIP-JOINT DISEASE. 429' 
 
 should encircle also the pelvis ; even then, when the parts about the 
 joint, especially at the back, are very painful, the patients manage to 
 move in the apparatus and raise up the affected half of the pelvis, 
 drawing it over to the sound side. This can only be prevented by 
 including the sound hip also in the bandage, so that the patient 
 cannot move the part at all and is unable to raise himself up, if 
 the bandage reaches up to the crest of the ilium, as it should do. If 
 in florid coxitis the flexion and adduction cannot be corrected by 
 gentle pressure, and traction with the hand under an ansesthetic, it 
 is a sign that ligamentous shortening has already taken place. In 
 such cases it is unadvisable to employ much force; some of the 
 fascia lata, or the adductor muscle may be divided subcutaneously 
 and the deformity thus controlled to some extent, but the contracted 
 ligaments cannot be divided. If much forc6 be employed the 
 articular ends may be forcibly separated and the condition of the 
 part made much worse. In this class of cases permanent extension 
 with weights of from one to three pounds, according to the age of 
 the child, answers best. Not unfrequently the most surprising 
 improvement will take place in the extension of the limb in a very 
 short time — perhaps within a week. Extension can then be kept 
 up, or if it be thought better a plaster bandage applied. I abstain 
 always from opening any abscesses that form unless I intend to 
 proceed at once to excision ; otherwise, I let them alone until they 
 either become absorbed, as I have often seen happen, or break 
 spontaneously. 
 
 I usually only employ the mildest external remedies, such as 
 unguentum argent, nitric, or diluted tinct. of iodine. In early hip- 
 joint disease in very fat children, I have at times made issues just 
 behind the trochanter and kept them open for four weeks or so. 
 Striking improvement sometimes takes place in the condition of the 
 hip under this treatment. The actual cautery — the panacea of the 
 older surgeons for hip-joint disease since the time of Hippocrates — 
 I have never employed, and have seen trouble follow where it was 
 used by others. While at Ziirich I excised the hip-joint in six 
 cases, and in four removed part of the acetabulum at the same time. 
 In two of the patients the operation was directly fatal from pyaemia ; 
 three died of phthisis some time after excision, one of whom had 
 sufficiently recovered to get about well with the aid of a stick. One 
 case only was alive and well eight years after the operation. As a 
 rule, I am not an enthusiastic supporter of excision of the hip- joint
 
 430 EXCISION OF THE HIP. 
 
 for caries. I have had no opportunity myself, of seeing good 
 permanent results in the patients on whom I operated myself, or in 
 those who have been under the treatment of others. Again, it 
 must be acknowledged of excision, that it is very seldom capable of 
 accomplishing what an operation for caries ought to accomphsb, 
 i.e. the removal of all the diseased bone. Removal of the 
 acetabulum has its limits. I do not see that we are justified 
 in performing excision early in children with hip disease, for by 
 timely treatment many more recoveries must follow, and a straight 
 ankylosed hip is better for the patient than an excised joint. Even 
 as regards the functions of the part excision can efi'ect but little, 
 and the power of walking will always be defective. Moreover, the 
 results of excision of the hip are not remarkably favourable quoad 
 vitam, and as it does not hold out any great prospect of saving 
 patients from death when they are much reduced, the operation 
 appears, on the whole, to me, to have no great future before it. A 
 minute statistical inquiry as to the course of hip-joint disease, where 
 excision is not practised, and the efficiency of the ordinary remedies 
 in curing it will alone be able to prove decisively the value or 
 worthlessness of the operation. I do not pretend to give any 
 positive opinion on the subject, although I have long and earnestly 
 interested myself in this question. 
 
 Chronic inflammation of tlie hip-joint. Forcible extension. 
 
 A child, set. 12, came under my care, who five years previously had fallen 
 and struck his left knee. Swelling of the pai-t immediately followed, and 
 there was so much pain at the outset that the patient for six months was 
 kept on his back. Gradually disease of the left hip-joint developed, and 
 abscesses formed. The child was sometimes kept at rest, sometimes allowed 
 to get about with crutches ; during the summer he was sent to different 
 baths, and was altogether well looked after. To this circumstance may be 
 attributed the fact that his general condition was good when he was admitted. 
 The left leg was then strongly adducted at the hip-joint, flexed, and rotated 
 inwai'ds. He could not completely extend the limb at the knee-joint. On 
 both sides of the limb over the hip-joint were sinuses, from which a moderate 
 amount of dischai-ge escaped. The probe passed deeply into these openings, 
 but no bone could be felt. Treatment was commenced by sti-aightening the 
 knee- joint, which was effected without difficulty under chlorof onn ; a plaster 
 bandage was then applied. A few weeks later I broke down the ankylosis 
 of the hip, and by applying extension materially improved the position. 
 Unfortunately the weight and pulley had soon to be given up, for the
 
 TEEATMENT OP ANKYLOSED HIP. 431 
 
 breaking down of the ankylosis was followed by a marked increase in the 
 amount of suppuration ; unluckily, too, an attack of erysipelas further 
 reduced the patient. (Edema about the ankle was observed and the urine 
 was found to contain albumin which was not present when he was admitted, 
 but I cannot be sure whether it was the result of the increased suppuration, 
 or a sequel of the erysipelas. On my advice the patient was sent away 
 home, as there seemed to be but little prospect of doing him any good — «, 
 result which was to me rather unexpected, for the child, on admission, seemed 
 fat and strong. 
 
 This case has convinced me that it is inadvisable to attempt rapid 
 extension of an ankylosed hip-joint in cases where, although the 
 articular surfaces may be healed, there is still suppuration of the 
 soft part. Former experience has brought me reluctantly to the 
 conclusion that straightening of tlie limb ought not to be attempted 
 in such cases. The subsequent extension by means of weights can 
 only achieve a perfect result, when the rigid cicatricial adhesions 
 between the articulating surfaces have been separated. Still, I am 
 always in hopes that something more than this may be gained by 
 treatment. In ankylosis of the hip, when the thigh is flexed at a 
 very acute angle, and sinuses exist in connection with the soft 
 parts, excision of the head of the ankylosed femur can have but 
 the effect of an osteotomy, and when we consider that contractions 
 of the fasciae, muscles, and cicatrices about the joint, have existed 
 perhaps for years, the beneficial efi'ects of excision must be 
 doubtful, and the operation may do harm. In the knee-joint 
 the conditions are more favourable, for the malposition of this joint 
 is almost always in one direction, viz. that of flexion, and the shght 
 inflammatory reaction that may possibly follow the breaking down 
 of an ankylosis where sinuses exist is far less dangerous a pro- 
 ceeding and much more easily controlled, than it is in the hip- 
 joint. 
 
 Tumour Albus op the Hip-joint. 
 
 In tabulating my cases of this disease I met with two consider- 
 able diJBSculties. In the first place, disease of the hip-joint in many 
 cases runs such a chronic course, that it was often difficult to say 
 whether the active disease had ceased, and the case ought to be 
 inserted under the head " ankylosis," or whether the morbid action 
 was still going on. Secondly, there is a form of synovitis which 
 frequently attacks the hip-joint in apparently healthy people between
 
 482 TDMOE ALBUS OF THE HIP. 
 
 twenty and twenty-five years of age, and runs its course without 
 suppuration, but frequently entails stiffness and ankylosis. In the 
 clinic such cases were commonly recorded as "rheumatic coxitis." 
 The bones seldom become affected, but the protracted inactivity of 
 the joint, leads to the so-called " cartilaginous ankylosis,^' in which 
 adhesions form between the folds of synovial membrane, and the cap- 
 sule of the joint becomes contracted.' Such cases, of course, in no 
 way resemble the form of hip-joint disease occurring in children who 
 suffer from dyscrasia. In Ziirich I met with this form of rheumatic 
 coxitis, as it is called, in young adults, far more frequently than in 
 Vienna. 
 
 I find, from my statistics, that of 82 cases in which suppu- 
 ration took place, 46 died; while in 60 cases where there was 
 no suppuration, only 7 died. We may perhaps be justified in 
 deducing from this, that the formation of abscess raises the per- 
 centage of mortality in hip-joint disease from 11 to 56. Now, 
 this result appears to me to be of importance for it shows that 
 we are scarcely justified in performing excision of the hip, un- 
 less suppuration exists, or caries as evidenced by crepitus. To 
 this rule I have hitherto rigidly adhered. An extended series of 
 figures will be required to prove that the ultimate results after 
 excision, are better, as regards function, than those of cases not 
 submitted to operation. Till this is proved, early excision cannot 
 be re«ommended as the ordinary method of treatment. So far as I 
 know Eose and Volkmann have practised excision very early in hip- 
 joint disease, and the results of their operations at the end of a few 
 years, quoad vitam and quoad funciionem may possibly yield us 
 conclusive evidence on the question. 
 
 Suhcutaneous osUoiomy for hip-johit anl-ylos\s. Death from 
 suppuration. 
 
 A child, £et. 8, came i;ndei" my care with its right thigh flexed at a right 
 angle, the result of old suppurative coxitis. I endeavoured, unsuccessfully, 
 to straighten the limb, but the femur was perfectly immovable, nor could 
 the position be improved after dividing the fascia and muscles. Urged by 
 
 ^ Similar changes not infrequently take place in the shoulder- joint after 
 dislocation, but they mostly occur in old people, and are characterised by 
 i-apid wasting of the muscles — a symptom that is not so readily recognised 
 in the hip.
 
 TREATMENT OP ANKYLOSIS : FOECIBLE EXTENSION. 433 
 
 tlie repeated request of the parents, and prompted by the very favourable 
 results of some osteotomies which I had a short time previously performed, 
 I divided the bone subcutaneously just below the trochanter, after Langen- 
 beck's method. The deformity was successfully con-ected, though of course 
 the original length of the limb was not completely restored. Extension by 
 weights was employed after the osteotomy. Two weeks after the operation, 
 extensive suppuration set in, all the old cicatrices gave way, suppuration 
 took place about the ankylosed parts, and finally I had to remove the head of 
 the bone and the trochanter, which had become necrosed from suppuration. 
 The patient died of marasmus nine weeks later. 
 
 Contraction after chronic hip-joint disease, treated hy fracturing the 
 neck of thefermir. 
 
 Emanuel Z — , tet. 13. In this case the right lower extremity was flexed 
 at a right angle, and somewhat wasted, and the hip-joint slightly abducted. 
 Under an anaesthetic, by means of forcible extension and abduction, the neck 
 of the femur was fractured with an audible crack, A slight rent was made 
 through the skin, at the fold of the groin. The patient was discharged six 
 weeks later, with a straight limb, and but slight shortening. No mobility 
 in the hip-joint. 
 
 Franz W — , set. 12. The hip was flexed at an angle of 35° and strongly 
 abducted. The same treatment was adopted, and the limb brought down 
 perfectly straight. Extension was applied, and after ten weeks the patient 
 was able to walk perfectly well. The joint was ankylosed, but he had slight 
 power of abduction. I beard three years later that this patient was able to 
 walk perfectly well and was anxious to many. 
 
 Marie L — , set. 30, had coxitis of four year's standing ; an abscess had 
 fonned over the trochanter, but had closed up six months previously. The 
 right femur was flexed at an obtuse angle, and strongly abducted. In 
 attempting to correct the abduction under an anaesthetic, the femur was 
 ■fractured ; a plaster bandage was applied and the patient was discharged four 
 months later, with about two inches shortening of the limb. I saw her two 
 years after, and she was then able to walk well with the aid of a stick and a 
 high heel. The hip-joint was ankylosed. 
 
 In the two following cases I performed osteotomy of the neck of 
 the femur ; both patients died. 
 
 M. B — , set. 21, had been ill for three years, from what appeared to have 
 been general subacute osteomyelitis of the left femur and tibia ; the knee 
 and the hip-joint both became fixed in consequence. On admission, the knee- 
 joint was flexed at about an angle of 100°. The limb was wasted and strongly 
 jotated outwards and the tibia considerably thickened. An attempt was made 
 
 28
 
 434 OSTEOTOMY OF FEMUR. DISLOCATION OF HIP. 
 
 to break down the ankylosis, but without success ; thereupon, I performed 
 subcutaneous osteotomy with the chisel through the trochanter and neck of 
 the femur. The limb was put up in a plaster bandage, and open treatment 
 adopted. Owing to the deformity of the knee, very great difficulty was ex- 
 perienced in arranging the bandages and keeping the limb in good position. 
 Profuse suppuration ensued, bed-sores formed, the urine became albuminous, 
 and the patient died of exhaustion.^ 
 
 Constantine W — , set. i8. For six years the patient had sufEered from 
 chronic inflammation of the right hip- and elbow-joints, together with ostitis 
 of the right humerus and left ulna. Twelve months before admission, all the 
 active symptoms had subsided. When admitted he was fairly nourished and 
 seemed well in health ; the right hip- joint was ankylosed at an angle of 90°, 
 and strongly abducted. I attempted to break down the ankylosis, without 
 success, and then divided the bone subcutaneously with the chisel just below 
 the trochanter. Lister's dressings were applied. An hour after the patient 
 recovered from the anaesthetic he became cyanosed and had an epileptiform 
 fit, which was followed by others at short intervals during the succeeding two 
 or three hours, and he died of pytemia a week later. 
 
 Dislocation of the femur after typTius. 
 
 This condition was noticed in a child, set. 10. The femur was displaced 
 on to the Uium and could not be reduced, though the limb was moved in all 
 kinds of directions ; during the manipulation I felt a fine kind of crepitus, 
 as i£ the bone were bending. I therefore abstained from further proceedings. 
 The typhus had originated twelve weeks before the patient came up to the 
 hospital. I examined this case repeatedly, and satisfied myself beyond a 
 doubt that dislocation really existed. It is possible, however, that the 
 epiphysis of the head of the femur was only softened and partially detached, so 
 that the greater part of the neck of the femur remained attached to the 
 shaft. Considerable pain was experienced if deep pressure were exerted over 
 the femur. Gradually an abscess formed on the anterior surface of the 
 thigh which broke, and soon closed up again. The patient eventually was 
 able to walk fairly well, though with a slight limp. 
 
 With regard to the origin of the condition I can give no explana- 
 tion. Unfortunately, no satisfactory history of the case could be 
 obtained. Probably, when admitted into the hospital some osteo- 
 myehtis was going on in the upper part of the bone. 
 
 ^ This case has been minutely described by Gussenbauer in the ' Archiv 
 fiir Klin. Chirurg.,' Bd. xviii, p. "404.
 
 PATHOLOGICAL DISLOCATION OF THE HIP. 
 
 435 
 
 Pathological luxation of the hip into the foramen ovale. 
 
 The case was that of a boy, set. 8, in whom from no known cause severe 
 pain had commenced some months previously in the right hip-joint. He 
 was kept at rest, and various local applications were made ; abscess gradually 
 formed, and broke in the groin. The thigh was much flexed, abducted, and 
 outwardly rotated at this period of the disease. Gradually the abscess healed 
 up, and all pain in the part ceased, but the position of the thigh remained 
 unaltered. On careful examination, there seemed to be no doubt that the 
 head of the femur was displaced downwards and inwards, just above the lower 
 rim of the foramen ovale (see Fig. 22). There was a fair amount of move, 
 ment. 
 
 Fig. 22. — Pathological Luxation of the Femue. 
 
 I came to the conclusion that the case was one of those rare 
 instances where the capsule had become perforated after acute
 
 436 CHKONIC INFLAMMATION OF KNEE-JOINT, 
 
 suppuration, and true dislocation had taken place though no caries 
 existed. 
 
 In order to facilitate extension by means of weights, I divided some tense 
 bands of the fascia lata subcutaneously. Unluckily this was followed by 
 rather tedious suppuration, and when the wound had healed up, an eight- 
 pound weight had no effect, although good counter-extension was kept up on 
 the pelvis. The patient was then placed thoroughly under the influence of 
 chlorofonn, and I tried to effect reduction by divers manipulations ; however, 
 my efforts met with no success ; no improvement followed the use of 
 Schneider-Mennel's apparatus. The head of the bone appeai'ed the chief 
 obstacle to reduction, and I therefore excised it, by an incision made in the 
 perineum ; I found no difficulty in the operation. The cartilaginous covering 
 of the bone was almost entire, and over the head of the femur was a distinct 
 capsule. Even after sawing through the neck of the femur the displacement 
 could not be completely reduced. My only hope was, that the cicatricial 
 tissues around might possibly become softer and more yielding from the 
 suppuration, and that the position would then improve ; this hope, however, 
 was not fulfilled, for osteomyelitis of the femur followed, and the patient 
 died of septo-pysemia twelve days after the operation. 
 
 Examination of the part showed that extensive contraction of the fascia 
 lata had formed the obstacle to reduction. 
 
 Chronic Inflammation of the Knee-joint. 
 
 A table of seventy-seven cases will be found in the *Ziirich. 
 Bericht/ pp. 516 et. seq^. Excision was practised twice only; in 
 one of these the patient died of marasmus a long time after the 
 operation ; in this case it was found necessary to amputate the leg, 
 six months after the excision, as the suppuration continued, and the 
 fungous softening ostitis went on in the excised bone. The other 
 patient died of meningitis two months after the operation. I am 
 inclined to think that the indications for this operation should be 
 limited ; it seems to me that almost all the cases of tumor albus of 
 the knee which do not recover by the other methods of treatment, 
 are incurable from constitutional causes. If it could be proved by 
 a large collection of cases that more patients with tumor albus 
 recover after excision of the knee than when the operation is not 
 performed, I should excise more frequently. The question is an 
 exceedingly hard one to answer, and it appears to me that on this 
 subject we are still on the threshold of inquiry.
 
 ANKYLOSIS OP THE KNEE-JOINT. 437 
 
 Ankylosis of the Knee-joint. 
 
 In many cases where the limb was ankylosed at a bad angle, I 
 employed forcible extension under an anaesthetic. Sixteen cases 
 thus treated at Ziirich recovered without any unfavourable sym- 
 ptoms whatever, and the patients were able afterwards to walk with 
 a straight limb. My custom is to abstain from passive movements 
 after straightening the limb in cases where the condition is due ta 
 disease which has existed for more than a year, or where suppuration 
 of the joint has followed after injury. It was found necessary in 
 many cases to repeat the process several times before the limb could 
 be straightened, and I did not always succeed in obtaining a 
 perfectly good result. Prom three to five months, or even more, 
 often elapse before the joint is healed in its new position. The 
 bandages must be kept on as long as there is any pain, but as soon 
 as the patients are able to walk without discomfort, I allow them to 
 get about as much as they please. On the question whether some 
 amount of movement may gradually return after the extension, a 
 reserved opinion must be given. In rheumatic disease affecting 
 only one joint, better results may be expected than in the destructive 
 tumor albus. We must not expect to regain any movement when 
 the leg is rotated outwardly, adducted and flexed, and united 
 obliquely by adhesions to the condyles of the femur. Ankylosis, 
 the result of traumatic suppuration of the joint, is the firmest of all, 
 being usually completely osseous. 
 
 Jobann M — , set. 32. Six years previously he had suffered very acute 
 pain in both knees, but the joints were not much swollen, nor was the skin 
 reddened. The pain lasted for five months ; he then was able to get about 
 with the aid of crutches and a stick, but in the course of a few months, both 
 knees became ankylosed, the right in an extended, the left in a flexed posi- 
 tion. Attempts were made to extend the left leg by means of an apparatus, 
 but without success. The patient then spent some summers at Teplitz, but 
 the mobility of his knee-joints did not materially improve. When admitted 
 I found him a strong man, and in good general health. The left knee was 
 ankylosed at an angle of 120°, and the right completely ankylosed in a. 
 straight position. 
 
 Although the disease in the joints had ceased five years previously, 
 yet taking into consideration the relatively short duration of the 
 disease and its undoubtedly rheumatic origin, I thought it would
 
 438 ANKYLOSIS OF KNEE : EOROIBLE EXTENSION. 
 
 be possible to restore some slight degree of mobility by breaking 
 down the ankylosis. It appeared to me, that the ankylosis was 
 essentially due to adhesions of the synovial folds. 
 
 Accordingly the patient was placed under chloroform, and I thoroughly 
 broke down the ankylosis on both sides. The right leg, previously straight, 
 I was able to flex to a right angle, while the left limb could be brought per- 
 fectly straight ; the left leg was then put up in plaster, and the right in a 
 splint, and ice applied. AU pain soon subsided, and after ten days I com- 
 menced gentle passive movements in the right knee. At first the pain was 
 very severe, but it became less every day. Fourteen days after the extension, 
 I removed the plaster bandage, and commenced passive movements on the 
 left leg. Four weeks after the operation, slight active movement com- 
 menced ; I then sent the patient to Ragatz. A few months later I saw him 
 again ; he could then walk without the aid of a stick, could extend the knees 
 completely and flex them nearly to a right angle. When the patient left 
 the hospital the first time, loud friction sounds could be heard in the joint, 
 but when he made his second visit, these had almost entirely disappeared. 
 
 Success like this can only be attained when little or no alteration 
 bas taken place in the cartilages. The case strikingly illustrates the 
 brilliant results obtainable by forcible extension under an anaesthetic. 
 Had it not been for this treatment^ the knees, most undoubtedly, 
 would have continued stiff. 
 
 Ankylosis of the hiee ; forcible extension ; gangrene of the leg* 
 
 F. A — , set. 29, a weakly, anaemic woman, was admitted with the knee- 
 joint flexed at so acute an angle that the heel was almost in contact with the 
 nates ;'|the leg was rotated inwards, and the patella displaced somewhat out- 
 wards ; the condition was probably due to metastatic inflammation of the 
 joint of puerperal origin. Under an ansesthetic, the limb was forcibly 
 extended. The Ihin skin over the popliteal space was lacerated during the 
 extension and leit a gap three inches wide. No further attempt at exten- 
 sion was made, and the liml) still flexed at an acute angle, was put up in 
 plaster ; the foot was cold and devoid of sensation. On the following day 
 the plaster bandage was removed ; the patient had much pain in the leg, and 
 gradually well marked gangrene became evident. The thigh was ampu- 
 tated, and the patient died. On examining the amputated limb, both the 
 popliteal arteiy and vein were found to be lacerated. 
 
 Cicatricial contraction of the knee-joint. 
 
 L. R — , set. 21, had suffered from syphilis eight years previoiLsly. He 
 had ulceration about the back, the upper arm, and the forehead. Under
 
 ANKYLOSIS OF KNEE : OSTEOTOMY. 439 
 
 iodide of potassium tlie sores healed up in nine months, and the patient's 
 health remained good for six years ; fresh gummata then formed in the right 
 popliteal space, and elsewhere, which broke after a time and led to deep 
 ulceration and extensive destruction of the integuments. Further breaking 
 down was at length arrested, but as the pai-t healed up, the knee became 
 contracted to a right angle, beyond which it could not be extended, though 
 it admitted of some flexion. Paralysis of the peroneal nerve was also 
 evident. On more minute examination, it was found that the cicatrix was 
 very tough, and connected to the capsule of the joint and the deep vessels 
 and nerves. I tried to flex the leg under an anaesthetic, but without success. 
 Seeing that incision into the cicatrix and the popliteal space would have been 
 not only dangerous but useless, I made incisions through the skin, just above 
 the cicatrix, and also on the posterior surface of the thigh. By extending the 
 incision, I cut right round the cicatrix from above, and dissected up the skin 
 and partly also the fascia. I was then able to extend the leg to an obtuse 
 angle. Extension was effected by means of a weight ; the cicatrix softened 
 and yielded gradually, so that within three weeks the leg was straight. 
 The man was supplied with a light splint to keep the limb in good position. 
 After a short time he was able to walk well, without the aid of a stick. 
 
 Ankylosis of the hnee-joint ; osteotomy. 
 
 W. K — , when three years of age, had swelling of both knee-joints with 
 <!ontraction, after an attack of measles. Abscesses, which seemed, however, 
 only to be situated in the subcutaneous cellular tissue, formed above both 
 knees. The i)ain in the joints gradually disappeared, but the contraction of 
 the limbs persisted. The patient hopped about on his hands and legs like a 
 frog. When admitted, both knees were flexed at an acute angle but by 
 passive movement could be extended to a right angle. Both tibiae were 
 displaced backwards to some extent, and the knee-joints covered by deep 
 ulcerations. The child was ill-nouiished and pale, and the case was not very 
 promising for treatment. Still, as the parents of the child were very anxioug 
 that he should be treated in hospital, I first tried to cure the scrofulous 
 ulceration about the joints by means of various remedies, and at the end of 
 five months, I had so far succeeded that \ was able to think of attempting to 
 straighten the legs under chloroform. I was unable, however, to completely 
 straighten either of the limbs. When extended a little beyond a right angle, 
 the contracted posterior ligament and the tension on the scarcely healed cica- 
 trices were the principal obstacles. In addition the flexor muscles were 
 shortened, and I felt that neither brisement force, nor gradual mechanical 
 extension could be of any use. 
 
 The question now arose as to whether extension of the limb 
 could be effected by any other means. Two operations suggested 
 themselves ; one, to resect so much of the condyle of the femur as 
 would permit the long axis of the tibia to drop into a line with that
 
 440 RESECTION OF FEMUR ON RHEA BARTON S PLAN. 
 
 of the femur, and the other to cut out a wedge-shaped piece out 
 of the femur, close above the lower epiphysis (resection or osteo- 
 tomy of Ehea Barton). Eventually I selected the latter opera- 
 tion, for by the other method the mobility which existed would 
 have been sacrificed, and again, by the injury that probably would 
 have been inflicted upon the lower epiphysis, the leg would have 
 become very much shortened ; by means of Ehea Barton's opera- 
 tion the epiphysis could be preserved. I proceeded to perform the 
 following operation on the left thigh. 
 
 I cut down on the femur, a little above the spot where the upper border 
 of the large bursa connected with the knee-joint lies beneath the quadriceps. 
 The periosteum was then divided, and detached from the posterior surface 
 of the bone. I then passed the chain saw beneath the bone and sawed 
 obliquely through it upwards and forwards. As soon as I had cut through 
 the femur, I was able immediately to straighten the leg. It seemed to me 
 quite unnecessary, therefore, to saw off a con-esponding piece from the lower 
 end, but still I did so in order to carry out the operation as advised. The 
 limb was now placed in a plaster bandage in a position of complete extension. 
 The reaction that followed was remarkably slight, and the operation wound 
 had completely closed up within six weeks. Two months after it had 
 healed, I performed a similar osteotomy on the right thigh, but on this occa- 
 sion I did not remove any portion of bone, and merely divided the femur 
 obliquely ; although at the time of operation this was suflScient to allow the 
 limb to be completely straightened, yet later on we found that the result was 
 not so good as in the other leg. In three months the patient was able to gei 
 about the ward, supporting himself by the beds and walls, or with the help 
 of crutches. Both femora were firmly united and almost straight. 
 
 Some eight months later I heard again of the boy, and from a 
 plaster cast which was sent me, saw that the knees had again 
 become somewhat bowed. The right knee could be extended to 
 an angle of 163° and flexed to 100° — the left from 144° to 90.° 
 The boy was able to walk fairly well without using stick or crutches, 
 though his gait was awkward. The feet spread outwards, and the 
 upper part of the body craned forwards. 
 
 On the whole the success of the operations, especially as regards 
 the slight reaction which followed on both occasions, exceeded my 
 most sanguine expectations. 
 
 Andreas R — , set. 38, a strong, well nourished man, suffered from chroniC' 
 inflammation of the left knee-joint when he was sixteen yeai-s of age-^ 
 According to the description of the patient, the disease seemed to have coqia-
 
 TUMOE ALBUS OF THE KNEE. 441 
 
 menced as periostitis on the posterior surface of the lower end of the femuiv 
 Small portions of bone came away from time to time, and the sinuses closed 
 up ultimately after six years. The result was that the knee was somewhat 
 stiff, but his walking was not interfered with. The year before his admission 
 he was attacked with acute inflammation of the same knee-joint, which ran 
 on to suppuration, and terminated in ankylosis. When admitted, the left 
 leg was completely ankylosed at a right angle. As extension under an 
 anaesthetic did not succeed, I removed a wedge-shaped piece from the con- 
 dyle, and was then able to put the leg perfectly straight. The limb was put 
 up in a plaster splint. Spasmodic movements of the leg were very trouble- 
 some for about a fortnight, but yielded to opium and morphia injections. 
 The febrile reaction was remarkably slight. 
 
 Six months later the following report was sent to me : — " The 
 sinuses completely closed three months after the operation; the 
 patient will soon be able to get about without any support ; the 
 knee-joint can be flexed through about io°; the shortening amounts 
 to about two inches." 
 
 TuMoii Albus of the Knee. 
 
 Tables showing the age at which, in 231 patients, this disease 
 commenced, will be found in the 'Wiener Bericht/ 1876, p. 559. 
 Ninety-eight cases commenced between the ages of one and ten, and 
 three are recorded as occurring between the ages of sixty-one and, 
 seventy-one.^ 
 
 I find that the percentage of mortality rises from 6 to 57 per 
 cent, if suppuration occurs. On the whole, suppuration is rather 
 less dangerous in the knee- than in the hip-joint; the prospect of 
 recovery in disease of the knee is slightly greater than in hip-joint 
 disease. 
 
 The following case of excision, where the operation was followed 
 by acute meningitis, deserves notice. 
 
 George W — , set. 5, had suffered from swelling and pain in the left knee 
 for nine months ; the disease was of traumatic origin. Under an anses« 
 thetic, the knee-joint was extended, and a plaster bandage applied. This 
 
 1 Probably under the category of tumor albus is included more than one 
 affection of the joint, and not solely the disease now commonly known ia 
 England as "pulpy degeneration." [Er.]
 
 442 HYDEOPS GENU. LOOSE CARTILAGE. 
 
 had to be removed a few days later, owing to great pain in the part, and the 
 formation of a periarticular abscess. In spite of keeping the joint at perfect 
 rest, the application of ice, etc., he gi-ew worse, and I eventually excised the 
 knee. Two days after the operation, the patient died of acute meningitis 
 and oedema of the brain.' 
 
 Hydrops Genu. 
 
 In one case of this nature I tapped the joint and injected a 
 mixture containing equal parts of iodine and water; after five 
 minutes the injection was allowed to escape again. Recovery 
 followed, though I was unable to learn whether it was permanent. 
 Puncture and forcible pressure by bandages effected a cure in 
 one case. Lately I have adopted Yolkmann's plan of forcible 
 compression, and Heine's method of compression with sponges. 
 The fluid was usually absorbed, but the treatment gave great pain 
 and the fluid re-collected, directly the pressure was relaxed. Many 
 cases proved very obstinate, while on the other hand, many subsided 
 with simple rest. I know no method of treatment which is at once 
 quick in its action and efiicacious in preventing recurrence in this 
 troublesome complaint. 
 
 Loose cartilage in the knee-joint. 
 
 A man, aet. 29, was admitted, who had sufEered for ten years from charac- 
 teristic symptoms of loose cartilage in the knee-joint. The patient was 
 able to press the loose body towards the patella, and there fix it. In this 
 situation I cut down and removed a body, the size of a plum stone, composed 
 of bone, with a caiiilaginous investment. The parts healed up by first in- 
 tention, without any antiseptic precautions. It was now discovered that a 
 second small loose cartilage was still in the joint, which was not so eaaily 
 brought to the surface. I cut down upon it as before, a month after the 
 first operation. Unfortunately, a good deal of blood escaped into the joint, 
 suppiu'ation of the knee followed, and the patient died of pyaemia. 
 
 Eosalie H — , aet. 46. In this case the characteristic pain had first drawn 
 her attention to the loose caiiilage two months before admission. Swelling 
 of the knee and rigore followed, with subacute synovitis lasting for three 
 months. The patient had been able to distinctly feel the cartilage before 
 
 ' Further details of this case will be found in the * Wien. Med. Woch.,* 
 1869, No. I. Cf. also ' Wien. Med. Woch.,' 1868, No. i, andswjM-a, Chapter 
 II, p. 12.
 
 CHRONIC DISEASE OE ANKLE, AND OF FOOT. 443 
 
 admission, but was unable to do so during the fourteen days she remained in 
 hospital ; she was then discharged with a knee-cap. I heard a year later 
 that the knee was perfectly well, and she had had no fresh pain in the part. 
 The diagnosis in this case was somewhat doubtful. 
 
 A man, set. 23, was admitted, who three months previously had fallen 
 down in the street on his right knee. Acute synovitis followed, and he was 
 confined to bed for a fortnight. He then resumed his occupation as a tailor. 
 Shortly afterwards, he felt one day, while walking, a sudden stabbing pain 
 in the knee, and was forced to sit down. Placing his hand on his knee, he 
 felt beneath the skin on the inner side of the patella, an elongated, round, 
 elastic body, which he was able to push about from one part to another, but 
 which slipped away from under the fingers. On the second or third day the 
 same thing happened again, and caused the man to come up to the hospital. 
 The patient would not submit to any operation, and was discharged again 
 after a while. I saw him again two years later. The loose cartilage gave 
 him no particular trouble ; it made its appearance perhaps two or three times 
 in the course of a year, but went away again at once. At times he had some 
 swelling of the knee-joint (a slight degree of hydroj)s genu). Crackling 
 could be felt when the joint was moved (arthritis deformans). 
 
 Chronic Inflammation of the Ankle. (Z. B). 
 
 A table of thirty-nine cases will be found in the ' Zurich. Bericht/ 
 pp. ^^'i et seq^. In six cases partial excision was performed ; thus 
 in four the astragalus was removed, and in one the lower end of the 
 tibia was excised at the same time. Pirogoff's amputation was per- 
 formed in nine cases ; recovery followed in the successful cases, at 
 periods varying from seven and nine weeks up to four months. 
 Those who recovered had excellent stumps (see Fig. 23) . Syme^s 
 amputation was performed in one case ; recovery followed in fifty- 
 one days. 
 
 Chronic Disease of the Bones and Articulations of the 
 Toot. (Z. B).^ 
 
 The first metatarsal bone is comparatively frequently diseased. 
 Becovery in many cases is very tedious after its excision, and the 
 regeneration of bone after superiosteal removal is either very small 
 or entirely wanting. I make it my practice, therefore, among the 
 
 * Tables of thirty-six cases will be found in the ' Ziii-. Ber.,' pp. 542 et seq., 
 and 546 et seq.
 
 4U 
 
 DISEASE OF FIEST METATARSAL BONE. 
 
 Fig. 23. — Boxes of Stump foue axd a half teabs afteb Pibogoff'i 
 
 AMPrTATIOX. 
 
 working classes, to remove the hallux, together with tae metatarsal 
 bone^ when operation is foond necessary. The parts usually heal 
 rapidly, and the gait is not appreciably interfered with. It has also 
 been urged against the practice of removing the first metatarsal 
 bone and leaving the great toe, that the latter becomes displaced by 
 the contraction of the cicatrix, and that its presence is rather detri- 
 mental than otherwise when the patient begins to wear a boot. It- 
 may be so, but one of my cases showed that such is not always the 
 case.
 
 CHEONIC DISEASE OF TAESUS. 445 
 
 Disease of the Tarsus. 
 
 A point of interest that occurred to me in studying my tables of 
 this disease, lay in the fact that the os calcis was, in numerous 
 instances, alone affected ; among fifty-three cases of diseased tarsus, 
 the calcaneus alone was aflpected in twelve, and in every instance 
 suppuration occurred. In all my cases, I practised evidement with 
 subsequent removal of the sequestrum. One of my patients died 
 of pyaemia; unfortunately, in many of the cases I was unable to 
 l«arn how far the treatment was ultimately successful. I regret 
 this, for it would be important to know whether, in such cases, 
 the operation of evidement is a judicious one; at the best, a long 
 time elapses before the cavity becomes filled with bone ; the walls 
 are so rigid owing to the formation of osteophytes (invagiuating 
 bone) that they cannot contract. I trust that others will be able 
 to give us further evidence on this point. 
 
 In the '"Wiener Bericht,' for 1876, p, 572, will be found parallel 
 tables, showing the relative frequency of bone and joint affections 
 in the upper and lower extremities. One point my tables seem to 
 make out tolerably clearly is that in individuals of scrofulous and 
 tubercular habit the upper extremity is, after the lungs, the part 
 most commonly affected. When the two conditions are combined 
 the prognosis is decidedly unfavourable. 
 
 Section D. — Tumours, Aneurisms, Deformities, etc. — Cases 
 of lipoma ; enchondroma ; ecchondrosis ossificans bursata ; 
 multiple osteomata ; neuro-fibroma ; recurrent ditto ; caver- 
 nous lymphatic tumour (2); melanoma ; pulsating sarcoma; 
 central sarcoma of femur — removal; epitheliotna. 
 
 Cases of femoral aneurism treated by ligature ; ditto com- 
 pression and ligature ; traumatic aneurism — Antyllus' opera- 
 tion; ditto cured by compression ; spontaneous aneurism — 
 double ligature of femoral; traumatic aneurism; arterio- 
 venous aneurism ; femoral aneurism treated by arterial clamp ; 
 popliteal aneurism treated by ergotine injection. General re- 
 marks on treatment of aneurism. Genu valgum ; osteotomy. 
 Case cf spastic talipes. Remarks oji talipes : treatment; case.
 
 446 LIPOMA. ENCHONDEOMA. 
 
 Osteotomy for ricketty deformities. Case of congenital disloca- 
 tion of toe. Case of pes gigas. Case of congenital absence of 
 femur. 
 
 Fatty tumour of the thigh. 
 
 A man, set. 55, came under my care with a tumour tlie size of liis head, 
 at the back of the thigh. On removal it proved to be situated beneath the 
 fascia. The growth had existed for four yeare, and had increased slowly, 
 without giving any pain. I suspected from the symptoms that it was a case 
 of myxo-sarcoma. An almost exactly similar case was met with in a woman 
 set. 46. The fact that the growth had existed for only one year, led me to 
 the conclusion that it was a sarcoma, for I could scarcely believe that a fatty- 
 tumour could reach the size of a man's head in twelve months only. The 
 tumour was removed, but the patient died of septicaemia. 
 
 Enchondroma in the sheath of a tendon. Result of Chopart's 
 amputation. 
 
 HeiT X — , set. 35, a stout, strongly built man, had suffered for many years 
 from a slowly growing, moderately firm tumour, which was situated over the 
 second tai-sal bone. Over the upper part of the swelling was an opening 
 from which ill-smeUing, pumlent secretion escaped. I removed the tumour, 
 together with the toe, leaving the base of the metatarsal bone. Unhealthy 
 suppmation and septic fever followed the operation. The anterior part of 
 the foot became involved, and I therefore performed Chopart's amputation. 
 Anatomical examination of the tumour showed that it was composed of cai"ti- 
 lage, and was situated in the sheath of the long extensor tendon of the 
 second toe ; in the centre of the mass was a cavity the size of a walnut, full 
 of ichorous fluid ; a piece of necrosed bone (a partly ossified portion of the 
 chondroma) lay in the ca\'it3'. 
 
 I saw this patient two years later. The foot was then in good 
 position, without any tendency to eqninus, but still the patient 
 only used his foot as if he had a wooden leg, and did not utilise 
 the mobility of the ankle-joint. The stump was often painful and 
 in a constant state of perspiration. I was not particularly pleased 
 with the power of walking on this stump, and am of opinion that 
 it is no better than that obtained by Pirogoff's operation. 
 
 Ecchondrosis ossificans hursata on the lower end of the femur. 
 
 B — , set. 27, had fallen nine years previously on his right thigh ; since that 
 time he had often felt slight pain in the part, though he never walked lame.
 
 BURSAL TUMOUR. OSTEOMATA. NEURO-FIBROMA. 447 
 
 About a year after the fall lie discovered a gi'owtli al)out the size of a hazel 
 nut on the painful spot, close above and on the outer side of the knee-joint. 
 The tumour grew slowly but constantly, and gave no pain. The patient 
 was a perfectly healthy, athletic man. Just above the right knee-joint could 
 be felt a nodulated, bony hard tumour, covered over by a soft, almost fluc- 
 tuating mass ; the entire new formation was the size of a foetal head. It 
 interfered somewhat with the movements of the knee-joint, but did not 
 occasion any great discomfort. The patient had consulted Balassa, and also 
 Schuh, who had wisely dissuaded him from operation. I took the growth 
 to be an exostosis of the epiphysal cai'tilage, over which a bursa bad formed 
 secondarily. The bursa did not seem to communicate with the joint, as the 
 fluid could not be pressed from one cavity to the other. I acceded to the 
 patient's earnest request and removed the tumour, extirpating the bursa and 
 sawing through the exostosis ; the latter was invested with cartilage, and 
 had a broad base of attachment. 
 
 Professor Eindfleisch, wlio took a great interest in the case, had 
 no doubt that the bursa over the tumour of the bone was a process 
 of the synovial membrane of the joint. During the operation I 
 was unable to trace any connection between the sac and the bursa 
 beneath the joint. Unfortunately the result was calamitous, as the 
 patient died in five days of septicaemia. We were unable to obtain 
 a post mortem. 
 
 Multiple osteomata. 
 
 A. D — , set. 8, had, on both femora, tibite, and one of the bones of each 
 foreann, numerous fixed tumours of the size of a hazel nut, and of bony 
 hardness. No impairment of function. 
 
 Neuro-fibroma of the sciatic nerve. 
 
 Leopold S — , a3t. 32. Thirteen years previously he had received a kick in 
 the left gluteal region, which gave him such intense pain that he fell to the 
 ground. After a few days the pain became less severe, but some tenderness 
 persisted. Two years and a half before admission the pain again became 
 worse, and extended down to the left leg as far as the toes. For twelve 
 months the patient had noticed a deeply situated hard tumour, near the 
 tuberosity of the left ischium ; pressure on the growth caused intense pain 
 down the leg. The tumour had been increasing rapidly up till the time of 
 admission, and was then the size of a large fcetal head. The soft pax"ts over 
 it were stretched, and severe pain was experienced on pressure over any part 
 of the leg. Tor a long time he had been confined to his bed, lying usually 
 with the knee flexed. I found considerable difficulty in dissecting out the 
 tumour. The nerve bundles were pressed cut and flatteiied into strips ;
 
 448 RECDKRENT NEURO-FIBROMA. 
 
 fortunately I was able to dissect them away from the growth, so that there 
 was no loss of function after the operation. For the first few Aveeks he had 
 intense pain in the part, nor did this entirely disappear until the nerve was 
 completely covered in by granulations. When discharged there was no trace 
 of recurrence ; he could walk fairly well, and had but little pain in the cica- 
 trix. He died, three months after leaving the hospital, of dropsy and 
 marasmus. 
 
 A point of remarkable interest in this case is that, although the 
 bundles of nerves, after" they had been separated by the finger from 
 the tumour, lay perfectly free, like telegraph wires, across the wound, 
 still their conducting power was perfect. In extirpating large 
 vmasses of glands from the axilla I have observed the same thing. 
 
 Neuro-fibroma ; repeated recurrence. 
 
 M. W — , a tailoress, ait. 25, came under my care for a tumour, the size of a 
 walnut, situated in the calf of the leg. The growth was exceedingly painful, 
 the slightest touch being sufficient to cause intolerable suffering ; the pain also 
 frequently occurred spontaneously. Subcutaneous injections alone gave her 
 temporary relief. I removed the tumour, together with a portion of the 
 N. suralis magnus which enveloped it. The growth recurred in connection 
 with the ends of the cut nerve and was removed on four separate occasions, 
 on the last of which I was only able with great difficulty to avoid opening 
 the knee-joint. The growth again recun-ed ; it became united to the cica- 
 trices of the former operations and to the skin, the parts ulcerated, and the 
 pain was so sevei'e that the thigh was amputated through the lower third. 
 •She recovered from this, and a year later there had been no recurrence of 
 the pain. 
 
 I repeatedly examined the growth fresh, as well as the specimens 
 prepared in spirit ; it appeared to me to be a simple fibroma, 
 which probably had originated in the neurilemma of the sural 
 •nerve, and recurred in connection with the nerve stumps and the 
 surrounding cellular tissue. I have nowhere found any drawings 
 which would justify us histologically iu considering these tumours 
 as true neuromata, with perhaps the new formation of non-medul- 
 lated fibres, in the sense in which Yirchow has extended the 
 signification of neuroma. I cannot ignore the fact that in similar 
 tumours I have been ujiable to make such a positive distinction 
 between bundles of non-meduUated nerve fibres and bundles of fine 
 connective-tissue fibres, that I was thereby enabled to diagnose an 
 *' amyelinic neuroma.'^
 
 CAVERNOUS LYMPHATIC TUMOUR. MELANOMA. 449 
 
 Cavernous lymphatic tumour?- 
 
 A girl, ast. 19, whose previous health had been good, was seized suddenly 
 with pain in the left groin ; she had also vomitings and slight rigors from 
 time to time ; these attacks, which were accompanied by an erysipelatous blush 
 starting in the groin, lasted often for eight days or so, and persisted for a 
 few months, at the end of which time they ceased ; for four years she had 
 had a discharge of lymph, coming from clear, transparent vesicles on the 
 inner aspect of the thigh. The tumour, which was about the size of a fist, 
 was thought at first to be a chronic abscess with an open sinus, and accord- 
 ingly an incision was made ; the cavernous network of the gi-owth was, 
 however, distinctly recognised and a quantity of lymph escaped. As the 
 wound subsequently assumed a rather unhealthy appearance, and the patient 
 became feverish, the part was cauterised with fuming sulphuric acid. On 
 two occasions pressure was made, after the galvano-cautery had been applied 
 to the tumour, but without any benefit. The discharge of fluid continued as 
 before, and the eysipelatous attacks recurred again. The discharge amounted 
 to about forty grms. in the hour. I then removed the tumour, dissecting it 
 all out except a small process which ran down between the large vessels of 
 the thigh ; these vessels were exposed during the operation. For a time 
 after the operation there was a slight discharge of lymph, but this gradually 
 ceased, and in six mouths the patient left perfectly well. 
 
 The tumour consisted of a reticulate stroma enclosing cavernous spaces 
 lined by a beautiful lymph epithelium. 
 
 A child, set. \\, was brought to me with a soft tumour as large as the fist 
 on the dorsum of the foot, of congenital origin. At the time of birth, it was 
 about the size of a date. After removal it was found to consist of fibrous 
 tissue, enclosing numerous cavernous spaces filled with lymph. 
 
 Melanoma (Melanotic Sarcoma?) of the Skin of the Leg. 
 
 I scarcely know whether to classify as sarcomata or carcinomata, 
 tlie tumours, of which the following case is an instance, which occur 
 in the form of small, dark, nodules, and fungus-like growths in the 
 skin of the leg. The form, nature of origin, and mode of onset 
 resemble sarcoma ; the anatomical structure, too, of many of them 
 favours this view ; but in the larger nodules, growths connected 
 
 1 For a description of this rare form of tumour see 'Billroth's Path.,' 
 Hackley's transl., p. 610; Cf . also Virchow, ' Krank. Geschwiilste,' vol. iii, 
 p. 490 ; Liicke, ' Geschwiilste ' p. 267 ; and Dr. Gjorgjevic, in ' Arch. f. 
 Klin. Chirurgie,' Bd. xiii, Heft. 2, p. 646, who described the case of the girl, 
 quoted above, more fully. Compare also a case recorded above, p. 379. 
 
 29
 
 450 MELANOMA. PULSATING SAECOMA. 
 
 with the rete Malpighii are met with of such typically adenoid form 
 that they seem to be a combination of epithelial cancer and 
 sarcoma. In the case given below there would have been na 
 doubt, had the cells of the invading epithelial growths possessed the 
 ordinary flat shape or that of the cells of the rete Malpighii. This, 
 however, was not the case; some of the epithelial cells were 
 cylindrical, others of irregular shape. I am doubtful, therefore, as 
 to the proper position of these growths, but am inclined to consider 
 them as sarcomata, since the new formation invariably arises in the 
 papillary layer of the cutis. 
 
 J. S — , set. 56. From childhood he had had a wart about the size of a 
 pea on the left leg ; the growth was situated on a dark pigmented patch, 
 the size of a farthing. When he was fifty- five years of age, this wart 
 hegan, from no obvious cause, to grow, and within two months had attained 
 the size of a walnut. Then numerous bluish and dark spots and little 
 nodules developed in the primaiy tumour. The original growth was re- 
 moved by means of a ligature, but this had no effect on the progress of the 
 secondary growths. The patient's health was always good, though he was 
 not a [remarkably strong man. The integument of the anterior part of the 
 leg was diseased over an extent of the size of a man's hand. The man 
 suffered much pain, and was veiy anxious for an opei'ation ; the inguinal 
 glands were not enlarged. I removed the whole of the diseased integument ; 
 the patient left in a few months, before the wound had completely healed. 
 Even then, however, some fresh nodules were visible in the immediate 
 neighbour-hood of the cicatrix ; their number increased, severe pain occurred 
 in the breast and back, and he died twelve months later. Duration of the 
 disease two years. 
 
 Pulsating sarcoma of the tibia. 
 
 H. R — , set. 26, a cobbler. For some months a tumour had been developing 
 at the lower end of the tibia. The bone was considei-ably widened in appear- 
 ance. I resected a portion of the tibia, about three inches in length, including 
 the articular cai-tilage of the ankle. Gangrene of the foot followed, and he 
 died of pyaemia in six weeks. The growth proved to be a vascular, central 
 osteo-sarcoma. 
 
 Hen- B — , aet. 29. For two years he had noticed a painful swelling of the 
 tibia, especially at the lower part, and had been unable to get about. He 
 had never had syphilis. I found in the medullary cavity of the tibia a 
 diffused growth expanding the cortical substance of the bone to some extent. 
 At the lower part the tibia was enormously expanded, yielding parchment 
 crackling as the thinned plates of bone gave on pressure. At this 
 part too there was distinct pukation and an aneurismal friction bruit. The 
 leg was amputated just below the knee. Death in six days from septicaemia.
 
 CENTRAL PULSATING SAECOMA. EPITHELIOMA. 451 
 
 No secondary growth was found at the post-mortem examination. The apices 
 of both lungs were full of tubercle. The tumoui- proved to be an enormously 
 vascular alveolar sarcoma, studded with numerous extravasations. 
 
 Central sarcoma of the femur. Removal. 
 
 Katharina F — , set. 17, came under my care in January, 1870. In 
 February, 1869, she had a fall while dancing, followed hy some swelling 
 about the left knee, and had never since been able to walk without crutches ; 
 the knees were flexed at an angle of 104°, and admitted of very slight active 
 and passive movement. About four fingers' breadth over the patella and 
 extending down to the joint the thigh was enlarged, its diameter being 
 about 3 centimetres greater than that of the opposite side. On the inner 
 side "parchment crackling" could be felt; in this situation, too, slight 
 pulsation was perceptible, and a bniit resembling the placental murmur could 
 be heard. The tibial pulse was unaltered. 
 
 The patient absolutely declined amputation ; accordingly I excised the 
 diseased portion of the bone, sawing off about six inches. The medullary 
 cavity was found full of sarcoma. The patient, who was greatly reduced at 
 the time of operation, was much exhausted by the subsequent suppui'ation, 
 diarrhoea, and bed-sores, and died ultimately of pyaemia two months aftei' 
 the operation. Osteomyelitis of the femur was found post mortem with 
 necrosis of the greater part of the shaft. The iliac veins contained purulent 
 thrombi ; the sarcoma was richly studded with myeloplaxes. 
 
 EpitJielioma of tlce leg. 
 
 Joseph B — , pet. 41. Sixteen years before admission, as the result of a 
 blow, a portion of the integument over the shin, the size of a florin, sloughed, 
 and a scale of bone separated at the seat of injury. The wound healed up, 
 but ever since had been covered with a scab. Two years before admission 
 "proud flesh" began to grow from the ulcer, which bled at times, and gave 
 pain. When admitted the case was one of undoubted epithelioma. The 
 inguinal glands were somewhat enlarged, but not more than on the opposite 
 side. Amputation was advised, but the patient declined it ; thereupon I 
 extirpated the growth, scraping it off the tibia with a raspatory. A paste, 
 compofied of chloride of zinc and starch, in equal pai-ts, was applied, and led 
 to the separation of a large scale of bone. The part then rapidly healed up, 
 cicatrisation being accelerated b}'' skin grafting. Five years and three 
 months after the operation, 1 heard of my patient ; no recurrence had taken 
 place ; he was perfectly well in health. The cicatrix now and again became 
 perhaps cxcoiiated, but always healed up again readily. 
 
 Aneurism of the femoral artery. 
 Caspar W — , set. 50. Fifteen years previously he had suffered from
 
 452 FEMOEAL ANEURISM : LIGATUEE. 
 
 remittent fever and some severe illness, which lasted for "nine months. He 
 had been at his work as a bricklayer up to four weeks before his admission. 
 At that time, without any known cause, he was attacked with severe pain 
 in the thigh, which at first became markedly swollen, and then cold, as if 
 lifeless. A swelling the size of a child's head appeared about the centre of 
 the right thigh, on the inner aspect of the limb ; this was thought to be 
 a spurious aneurism, resulting from the rupture of an artery. Digital com- 
 pression was employed at fii-st, but without success, as the patient could not 
 stand the pressure. I then ligatured the femoral artery immediately above 
 the aneurism. For two weeks all went on well, but then symptoms of 
 disturbance in the circulation of the leg became manifest, and eventually 
 gangrene set in. The thigh was amputated high up, and recovery followed. 
 The diagnosis was verified by the examination of the limb. " An immense 
 sac, partly gangrenous ; femoral artery in part calcified; and in it a longi- 
 tudinal rent five lines in length." 
 
 Johann B — , xt. 57. This patient had sufEered for two years from vague 
 rheumatic pains. Fourteen days before admission Into the hospital he expe- 
 rienced sudden pain in the thigh, and shortly afterwards, a small, hard 
 swelling was noticed in the part. When admitted the swelling was the size 
 of a goose egg, and presented all the characteristics of aneurism. Digital 
 compi-ession was employed, and ice applied ; the tumour, however, increased 
 and the patient began to lose strength. I then ligatured the artery close 
 beneath Poupart's ligament. The ligature came away, in thirteen days; 
 secondary haemorrhage took place for which it was found necessary to secure 
 the artery above and below the seat of ligature. Death followed from ex- 
 haustion. The post-mortem appearances exactly resembled tlie case above 
 mentioned. 
 
 Traumatic aneurism of the femoral artery. Anti/lliis's operation. 
 
 Franz L — , a^t. 19. Six weeks previously he had received a wound in the 
 left thigh from a sharp butcher's knife. Severe bleeding occurred at the 
 time, which ceased only when the patient fainted. He placed himself under 
 the treatment of a barber. The haemorrhage recuiTed on tliree occasions up 
 to the date of admission ; the patient was then much reduced and pale, with 
 a small weak pulse ; the lower extremity was swollen, especially on the lower 
 and anterior aspect of the thigh, where was situated a tense, highly elastic 
 swelling, soft and "boggy" at several points. In the line of the sartorius 
 was seen a partially united incised wound over the lower half of the thigh. 
 The patient was anaesthetised, and the artery being compressed just under 
 Poupart's ligament, I made an extensive incision through the soft parts, over 
 the sartorius. A coagulum, the size of a child's head, was turned out and 
 the artery exposed at the bottom of the wound. An incised vT^ound, three 
 lines in length, longitudinal in direction, was seen on the vessel. The vessel 
 was ligatured half an inch above and below the wound. In spite of firm 
 pressure some bleeding still took place, which was not finally controlled till
 
 FEMORAL ANEURISM : COMPRESSION. 453 
 
 a third ligature had been applied. The wound was dressed with carbolic 
 oil ; the same evening the oedema of the extremity had considerably 
 diminished. Slight oozing of dark blood still persisted, which was found 
 to be dxie to the fact that the vein had been wounded at the same time as 
 the artery. A double ligature was placed around the vessel, and the hfemor- 
 rhage stopped ; the oedema after this again increased. On the tenth day two 
 ligatures came away ; the artery — yellow in colour, and tomentose in appear- 
 ance — lay free in the wound. On the twelfth day sudden severe haemorrhage 
 occun-ed. I ligatured the femoral artery close under Poupart's ligament, 
 and the haemorrhage ceased, but this last loss of blood was too much for the 
 patient, and he died from gangrene of the foot two days later. No post 
 mortem was permitted. 
 
 Aneurism cured hy comjoression. 
 
 A man, a^t. 23, was wounded in the thigh by a conical bullet owing to the 
 accidental discharge of a revolver which he let fall from his hand. During 
 the first few hours considerable swelling took place, which partly subsided 
 under cold compresses and rest. Twenty-two days later an aneurism was 
 detected by his medical attendant, for which digital compression was 
 applied and employed daily for two or three hours. When admitted, the 
 shot wound, situated at the junction of the lower and middle thirds of the 
 right thigh, was found to be cicatrised over ; no aperture of exit existed, nor 
 could the bullet be discovered. Just above the cicatrix was a markedly pul- 
 sating aneurism, an inch and a half in length and an inch in breadth ; a loud 
 blowing murmur was distinctly audible. The integument was movable over 
 the swelling, and there was no pain on pressure. Tor the first three days 
 digital compression was employed for seven, nine and ten hours respectively, 
 and then compression by means of a horse-shoe tourniquet and pad. The 
 patient, who was very tractable, applied the compressor himself whenever 
 the pulsation became distinct, and the treatment was continued with but few 
 houre' intermission for twenty-three days. By the ninth day the tumour had 
 become distinctly harder, and the pulsation diminished. On the twenty- 
 eighth day, when the tourniquet was removed no pulsation could be detected, 
 but after eight hours it was faintly perceptible. Compression was resumed 
 and the patient discharged nine days later. The pulsation of the artery could 
 still be felt indistinctly at the situation of the aneurism ; it seemed to be 
 separated from the sac. Eighteen months later I heard that the patient was 
 able to do his work, and was in the habit of applying the tourniquet for a 
 day or two when any pulsation could be felt. No further increase of the 
 aneurism followed. 
 
 PopUieal aneurism ; compression ; doulle ligature of femoral. 
 Ignatz G — , aet. 36, a labourer. Eight months previously, from no knowtt
 
 454 POPLITEAL ANEUEISM : ERGOT INJECTIONS : LIGATURE. 
 
 cause, he had experienced pain in the calf of the leg ; after a few weeks this 
 disappeared. A month before admission the pain recniTed, and after a fort- 
 night he noticed a swelling in the right popliteal space, which had not mate- 
 rially increased up to the time of admission. The Icnee-joint was flexed at 
 an ohtuse angle. Situated in the popliteal space was a sharply-defined pul- 
 sating tumoui', the size of the fist, in which a rasping murmur was audible. 
 The overlying integuments were stretched, but freely movable. The patient 
 in other respects appeared healthy, and there was no rigidity of the arteries. 
 By forcible flexion the pulsation could be diminished, but not entirely con- 
 trolled. Compression, partly instrumental, partly digital, was employed 
 during seventeen days, but the patient complained so much that the treat- 
 ment had frequently to be discontinued for several hours. At first the aneu- 
 rism seemed to become more solid, but eventually we were obliged to give up 
 the compression. I then adopted the plan recommended by von Langenbeck, 
 and injected two grms. of the extract of ergot between the skin and the sac 
 of the aneurism. Slight inflammatoiy swelling about the seat of puncture 
 was the only result. As the anemism then commenced to increase rather 
 rapidly and became more diffused, I ligatured the artery in Hunter's canal ; 
 the pulsation then ceased, the aneurism diminished in size and became hardei', 
 and the cedema of the leg subsided. Twenty-three days after the ligature, 
 haemorrhage occun-ed, which was conti'olled for the time by pressure, but 
 was repeated the next day. Dr. Czerny then tied the aiiery in Scarpa's 
 triangle and the hsemoirhage cea-sed. Two days later bleeding again took 
 place from the proximal end of the site of the firet ligature, but not so 
 severely as on the first occasion. After an unsuccessful attempt to secure 
 the artery at the seat of haemon-hage, a tampon soaked in perchloride of iron 
 was applied, and no further bleeding took place. The second ligature 
 came away on the twenty-fom-th day. By means of extension with a 
 weight and pulley, the limb was completely straightened. When he was 
 discharged, four months after admission, the aneurism was still soft and pul- 
 sated feebly at one point. A year later I heard that he was in good health 
 and able to walk well with a stick and a high heel ; all pulsation had disap- 
 peared. 
 
 Traumatic aneurism. 
 
 Franz M — , set. 42. Three weeks before admission he was wounded acci- 
 dentally in the right thigh by a swoi"d, which passed fi'om the upper and 
 outer to the lower and inner part. The haemorrhage soon ceased on the 
 application of a bandage and the wound healed rapidly, but a pulsating 
 tumour developed at the time, and increased in size up to admission. When 
 I saw him there was a flat pulsating tumour at the junction of the middle 
 and lower thirds of the right tliigh. Signoroni's compressor was applied, 
 and the patient very soon learat to manage the instrument well for himself. 
 From time to time, also, the entire extremity was bandaged. After sixteen 
 days the aneurism had distinctly diminished and the pulsation ceased. The 
 compressor was apptied. dnring another month, by which time the aneurism
 
 TRAUMATIC ANEURISM. ANTERIO-VENOUS ANEURISM. 455 
 
 tad so contracted tliat it could scarcely be felt. Four years later the patient 
 came back again. He told us tbat soon after he went back to his work 
 the aneurism returned, but it gave no trouble and did not increase in size 
 until two years and a half later. In spite of earnest warnings of the ulti- 
 mate danger, the patient could not be induced to submit to the compression 
 again. 
 
 W. L — , a butcher, set. 34, sixteen years previously had accidentally stabbed 
 himself on the inner side of the left thigh. Blood spurted out of the wound 
 and he fainted ; the hsemon-hage was controlled by a tampon saturated with 
 collodion. A year later a distinctly pulsating nodule, which rapidly gi-ew to 
 the size of a hen's egg, developed in the cicatrix. For ten years the aneurism 
 did not increase in size, and occasioned the man scarcely any inconvenience ; 
 but seven weeks before admission he was seized with severe pain about the 
 part. When admitted, nearly the whole of the left thigh on the inner and 
 anterior aspect was occupied by a pulsating tumour, over which the skin was 
 discoloured and at several points very much thinned. Esmarch's bandage 
 was applied, and Antyllus's operation performed under antiseptic precautions. 
 Septic symptoms followed and on the third day I was forced to open up 
 the sac, which had been united by sutures. Diphtheritic inflammation of 
 the wound ensued, and secondary hsemon-hage from the distal end of the 
 arteiy. He died a month after the operation. Post moiiem : all the organs 
 were found veiy anaemic. At the seat of the upper ligature only the conical 
 upper part of the clot was firm, the rest of the thrombus being converted into 
 a cheesy pulp. 
 
 Anterio-venous aneurism. 
 
 Julie P — , set. 32. Pour years previously she had received a deep stab in 
 the right buttock ; severe haemorrhage followed, arrested by pressui-e. The 
 outer part of the leg was devoid of sensation. A whining sound could be 
 heard in the femoral artery close under Poupart's ligament, and for a long 
 time thei'e was extravasation about the thigh. Then on the inner side of 
 the thigh a pulsating tumour formed, in which a distinct whirring bruit 
 could be heard. Blebs had frequently formed on the sole of the foot, and 
 after a time a callous ulcer developed on the heel ; the latter trouble induced 
 the patient to come up to the clinic. An arterio-venous anettrism was found 
 in the upper third of the femoral arteiy. The veins of the limb were not 
 dilated. Compression was applied. Under continuous water baths the ulcer 
 of the heel cicatrised, but the aneurism was not affected by the treatment. 
 I heard a year later that no fresh ulceration had taken place, and that the 
 aneurism had not altered. 
 
 Carl P — , aet. 46. Two years previously he had strained his leg, and felt at 
 the time severe pain in the left popliteal space ; shortly after he noticed a 
 pulsating tumour in the ham. For ten days the pain was so severe that he 
 was forced to keep his bed ; the swelling then almost disappeared, and he 
 was able to resume his occupation. Two months before admission, while
 
 456 FOPLITEAL AXEUEISM *. AETEKIAL CLAMP : LIGATURE. 
 
 going upstairs, be felt the same pain as before. A pulsating tumour tbe 
 size of a goose egg again appeared iu tbe popliteal space, and increased witb 
 rapidity up to admission, being especially aggravated by a long journey to 
 Vienna. The patient, on admission, was strong and well nourished ; the 
 heart healthy ; tbe radial ai-teries a little toi-tuous ; the left leg flexed at the 
 knee, and cedematous at the lower part. The entire popliteal space was occu- 
 pied by a pulsating tumour tbe size of a foetal bead. By means of digital 
 compression all pulsation in the aneurism was stopped, but the leg became livid 
 and cold. The part wbei'e the pressure was applied became so tender that 
 the patient would not submit to the treatment any longer, and the pulsation 
 returned as before. I then exposed the femoral arteiy at the inner border of 
 the sartorius and applied my arterial clamp (described in the author's 
 * Kriegschirargischen Briefe,' p. i6o). As the instrument was well borne, I 
 tightened it until the pulsation in tbe aneurism ceased. Three days later I 
 relaxed the clamp a little, but the pulsation immediately returned, and I 
 found that no clot had fonned either at the seat of pressure or below the 
 clamp. After the clamp had been applied for five days I introduced a fine 
 acupuncture needle into the aneurism, in order to satisfy myself whether any 
 cii'culation was going on deep down. That this was the case was proved by 
 the distinct pulsation of the needle. Suspecting that the pressure of my 
 instniments bad not completely controlled the circulation through the aneu- 
 rism — probably owing to a too free collateral circulation — and fearing lest 
 too long-continued pressure should lead to sloughing of the artery, I removed 
 tbe clamp. The instrument was hardly taken off when the artery recovered 
 its cylindiical shape, proAring that no thrombus bad formed at this spot. The 
 pulsation and the pain recun-ed again at once. A day or two later severe 
 htemoiTbage took place* from tbe wound ; tbe nurse compressed tbe artery 
 effectively beneath Poupart's ligament, and tbe vessel was secured by two 
 ligatures. On tying the upper thread the btemorrhage ceased ; the lower 
 thread was not drawn tight, but left in the wound for precaution. The next 
 morning tbe aneurism no longer pulsated but was tense and tbe skin dis- 
 coloured. As I feared that the clamp might have caused the arteiy to 
 slough, I exposed the vessel freely, passed a double ligature under it, and 
 removed a portion of the vessel an inch in length. This piece was of a 
 greyish colour, and perforated by a small aperture coiTesponding to the lower 
 claw of the clamp. Pyaemia developed after the operation, and he died a. 
 fortnight later. Post mortem : suppurating thrombosis was found in the 
 femoral vein, and metastatic abscesses in the lungs and brain. An opening 
 of the diameter of a bean formed tbe communication between the popliteal 
 arteiy and tbe aneurism ; tbe rest of the vessel was healthy. 
 
 Popliteal aneurism ; compression ; ergotine injection. 
 
 Joseph B — , set. 40, a labourer. Two years previously be had noticed pairu 
 in the right popliteal space occun-ing fi-om no known cause. Wlien admitted 
 he had an aneurism the size of a fa?tal bead ; the knee was flexed, and the 
 leg (Edematous. Compression was at once commenced. In the couree of a
 
 ERGOTINE INJECTION. ANTYLLUS's OPERATION. 457 
 
 month tlie aneurism ■was distinctly smaller and softer, though there was still 
 decided pulsation. Compression was continued, and in addition an ice-bladder 
 was kept to the part. A daily subcutaneous injection of ergotine was ordered ; 
 the injections were persevered with for thirteen days, but were then discon- 
 tinued owing to redness about the leg. The aneurism cei-tainly did not 
 diminish during this period ; the pulsation, indeed, appeared to be rather 
 more marked. A week later the injections were resumed and continued for 
 twenty-two days, but again without improvement. After an interval of a 
 month the injections were again resoi-ted to and continued for three weeks, 
 again without leading to any material improvement. By means of the pres- 
 sure the pulsation had so diminished as to be scarcely perceptible. Once 
 more the ergotine treatment was employed as on the previous occasions, but 
 the treatment was discontinued, as small abscesses formed. After seven 
 months' treatment the patient was discharged at his own earnest request. 
 The aneurism had diminished to one half of its original size, and the pul- 
 sation was very slight. Of his further histoiy I only know that three months 
 after his discharge he was in good health. 
 
 Antyllus's Operation for Aneurism. Treatment of Aneurism. 
 
 Antyllus's operation is a kind of treatment more easily adopted 
 now that we can employ local anseinia. I do not deny that it may be 
 suitable for aneurisms of small arteries/ and for traumatic aneurisms 
 where the sac has given way, more especially in these days when the 
 antiseptic method prevents any undue amount of suppuration : at 
 the same time my experience of the operation up to the present 
 does not lead me to estimate it very highly, for the -following 
 reasons : — The inner surface of these large aneurisms mostly 
 consists of breaking down or sloughing tissue, which can never be 
 wholly removed without causing serious ligemorrhage from the 
 dilated collaterals. The prospect of any rapid healing is therefore 
 very slight. Again, a considerable extent of the artery is often so 
 rotten and soft that secondary haemorrhage is almost the rule, and 
 this is really favoured by the use of catgut ligatures, for the tissues 
 over these ligatures do not become adherent together. I fear that 
 in cases of large traumatic aneurisms of the thigh, associated with 
 inflammatory symptoms and fever, amputation is the surest 
 method of saving life, and should be adopted more frequently than 
 has hitherto, perhaps, been the case. 
 
 The hopes that I formerly entertained of the treatment of 
 * See two cases of aneurism of the radial artery treated by this method 
 recorded above, p. 377.
 
 458 TEEATMENT OF ANEUKISM. MODE OP CUEE. 
 
 aneurism by ligature and arterial closure (arterienklausur) I am 
 bound to say have been rather disappointed. The cases have been 
 ^0 few that each one has been more of the nature of an experiment. 
 Eecent experience has added still more to my satisfaction with the 
 success of instrumental compression. No doubt perseverance is 
 required both of surgeon and patient, and the latter ought to 
 understood and co-operate in the treatment. The frequent employ- 
 ment of the elastic bandage so as to envelop the entire extremity, 
 is of material assistance in this method of treatment. At first, the 
 bandage can only be kept on for a few minutes, but subsequently 
 it can be tolerated for half an hour at a time and several times 
 daily, if the patients have determination. I was surprised on 
 observing that by this method the aneurism does not at first 
 become solid from the formation and collection of blood clot, but 
 that long before this change takes place the sac becomes softer 
 and smaller. The solidification of the tumour and the cessation of 
 pulsation are of course the most favourable signs to be looked for, 
 • and are brought about, not by the organisation of the clot, but by 
 the shrinkage of the sac to its smallest possible dimensions. The 
 diminution of the intra-aneurismatic pressure leads to the shrinkage 
 and the cure is completed by the filKng up of the sac. The clot must 
 be absorbed, and this can only be accomplished by means of the 
 vessels supplying the aneurismal walls. The shrinkage of the sac 
 must progress simultaneously with the resorption, and to such an 
 extent that the cavity entirely disappears. In one case, the sac 
 appeared to have become entirely shut off from the opening in the 
 artery, without any coagulation of its contents ; after the removal 
 of the bandage the aneurismal sac was still of its former size, soft 
 and fluctuating ; absolutely no pulsation could be felt in it, nor 
 was any bruit audible. The explanation of the fact that the fluid 
 blood was not absorbed could evidently be only due to the slight 
 vascularity of the sac, a condition which had perhaps been caused 
 by the firm bandaging of the limb. Kemembering this case, where 
 the blood remained fluid in a sac wliich, to all appearances, was no 
 longer connected with the tube of the artery, and also my unsuccess- 
 ful attempt to close the artery by means of instruments, I have been 
 led to doubt whether we are correct in supposing that the blood 
 can only be preserved in a fluid state if the walls of the vessels are 
 normal. 
 
 These observations and reflections led me to the conclusion that
 
 ELEOTEO-PUNCTUEE: COAGULATING AGENTS. GENU VALGUM. 459 
 
 an aneurism is not completely cured until the sac has entirely 
 shrunk up ; the formation of coagulum is but a means to gain this 
 end ; I do not, therefore, consider a treatment rational which 
 seeks to bring about the formation of coagulum by direct chemical 
 means. By electro-puncture and injection of Liq. Eerri, coagu- 
 lum can be formed artificially, or indirectly by acupuncture, but 
 the complete coagulation of the aneurismal contents cannot be 
 produced without risk to the patient. These methods of treatment, 
 partly from mechanical, partly from chemical causes, set up 
 irritation of the sac walls and may thus induce cicatricial shrinking ; 
 we cannot, however, predict whether the inflammatory process will 
 stop short at the proper time. In this fact lies the uncertainty 
 and danger of such treatment ; without, therefore, denying the 
 possible efficacy of this method, I find no inducement to continue 
 its experimental adoption. 
 
 The number of my cases is too small to enable me to state 
 the time required for cure by compression ; in my patients this 
 period varied between a few days and many months. Undoubtedly 
 digital compression has many advantages, but there are so many 
 practical difficulties in the way of applying it that I prefer 
 instrumental compression. 
 
 Genu Valgum. 
 
 Most of the cases of this nature which I met with at Ziirich 
 were treated by mechanical apparatus of various kinds. In the case 
 of a man set. 25, with a very high degree of knock-knee (Baker's 
 leg),^ I divided the external ligaments of the knee subcutaneously 
 on both sides. The results, with respect to subsequent treatment, 
 were very gratifying. 
 
 A child set. 7, with genu valgum, came under me, who had been 
 treated as an out-patient for some time without success; the 
 limb had been kept in a flexed position by means of a plaster 
 bandage. For this case I devised a special kind of apparatus. 
 The thigh and the leg, including the foot, were enveloped in a 
 plaster bandage over a layer of flannel ; the knee was left uncovered. 
 On the inner side of the thigh piece a stout strip of wood was 
 placed, a little shorter than the limb ; this was kept in position by 
 ^ Billroth's ' Path.,' Hackley's Trans., p. 529.
 
 460 TREATMENT OF GENU VALGUM. 
 
 another plaster bandage, and eonuected to the leg by means of 
 elastic bands. After two months, during which period the apparatus 
 was renewed but once, the deformity of the foot was found to be 
 corrected. On account of the laxity of the ligaments, the whole 
 limb was then encased in a plaster bandage, in which the child was 
 able to walk about fairly well. This method of treatment is of 
 value in certain cases and has the advantage that the patient is not 
 altogether confined to bed. In the out-patient department we 
 frequently employed methods such as this, or plaster bandages 
 frequently renewed, bringing the foot into as good position as 
 possible when applying the bandage. Considerable benefit was 
 derived, but the patients generally left before they were completely 
 cured. 
 
 Genu Valgum and Yarum.^ 
 
 In twenty-six cases of genu valgum, I employed " redressement 
 force/^ With a little practice, it is usually possible to straighten 
 the limbs easily without any apparatus. Before experience had 
 taught me the right amount of force to exert, in order to rupture 
 the ligaments with certainty yet without undue violence, I 
 resorted to subcutaneous division of the external lateral ligament 
 in one case and the biceps tendon in others. Although the imme- 
 diate results of " redressement " are satisfactory, yet convalescence is 
 so slow and the liability to complications so great that I doubt 
 whether I shall ever adopt the plan again extensively. I may 
 refer to Mikulicz's work on the subject. 
 
 Unless the ligaments are completely torn through with a wrench, 
 very little good will be done. If the thigh is padded and put up 
 in a plaster case after the operation, bed-sores are apt to form, and 
 sometimes the pain is very severe. If, on the other hand, the 
 hgaments are completely torn through, and the leg brought into a 
 position of genu varum, which it is easily possible to do, the 
 peroneal nerve may be so stretched that it will lose its functions, 
 and the paralysis thus caused does not always disappear, but may 
 possibly cripple the patients permanently. A very long time 
 elapses before the torn ligaments unite again ; the knees for 
 
 ^ With regard to my treatment of these deformities, I may refer to essays 
 , by Drs. Gussenbauer and Mikulicz published in the ' Archiv fiir Klin. Chir.,* 
 Bd. xviii, pp. I and ,->75, and Bd. xxiii, pp. 561 and 671.
 
 OSTEOTOMY. SPASTIC TALIPES. 461 
 
 months are loose and weak and the patients are sometimes unable 
 ever to walk again without some apparatus. 
 
 In thirteen cases I performed subcutaneous osteotomy of the 
 bones of the leg with the chisel. Unfortunately two of these 
 patients (one after double osteotomy, and another after osteo- 
 tomy of the right leg only) died of sepsis and pyaemia. In the 
 first case the pressure of the bandage set up septic phlegmo- 
 nous inflammation of the leg, and in the other instance suppuration 
 of the bone. With regard to the details of the operation, I may 
 state that the osteotomy of the tibia must be made as complete as 
 possible, so that the infraction may be easy. 
 
 If too many attempts at infraction be made before the osteotomy 
 is completed, the external lateral ligament becomes loosened, and 
 eventually ruptured. The patients then lose all the advantage in 
 the saving of time which the osteotomy might have granted them. 
 The leg should not be padded after the osteotomy, but placed 
 and kept in its new position without too much strain. If there 
 is much difficulty in straightening the limb, one may easily be 
 led to apply the bandages so tightly as to exercise considerable 
 pressure on the soft parts, and thus set up phlegmonous inflam- 
 mation as in the fatal case already mentioned. In all these cases 
 of osteotomy the bandage was either not removed till the cure 
 was completed (provided there were no pain or fever), or else 
 a window was cut in it and open treatment adopted. 
 
 The following case of spastic talipes (hysterical reflex contraction) 
 presents some unusual features. 
 
 Emma F — , a Jewess, set. 19, stated that nineteen days previously to 
 admission she had fallen and sprained her right foot ; immediately after the 
 accident she noticed that the position of the foot was unnatural, and it had 
 remained so since. I found that there was no dislocation, hut that the varas 
 was due to spastic muscular contraction. There was a little swelling on the 
 dorsum of the foot, which disappeared under simple treatment, but the defor- 
 mity became rather worse ; the extensor longus pollicis became contracted to 
 sucli an extent that the great toe was hyper- extended at a right angle to the 
 metatarsus. Galvanism was tried for a time without any benefit. Under 
 chloroform and also during sleep it was found that the foot resumed its 
 normal position ; the moment the patient awoke the varus again became 
 evident. She complained of intense pain when forcible attempts were made 
 to straighten the foot. The foot was then straightened under an anaesthetic 
 and put up in plaster, but the bandage had to be removed after a day or two. 
 On using the actual cautery the deformit}^ would disappear for a few 
 moments. She went under Professor Benedict, who tried an orthopa3dic
 
 462 CONGENITAL TALIPES. TENOTOMY. 
 
 apparatus with india-rubber bands, but without any benefit. She then came 
 under the care of Professor Dumreicher, who divided the tendo-Achillis and, 
 subsequently, numerous other tendons, but without any benefit except for a 
 veiy short time. If the patient were kept quiet in bed, the displacement was 
 very slight. 
 
 Congenital Talipes. 
 
 It is now well known that in congenital talipes the shape of the 
 tarsal bones is abnormal, and that the abnormality increases if the 
 individuals walk about on their club feet. All that we, as surgeons, 
 usually do, in order to cure club foot, is to enable the foot easily 
 to be brought into a natural position and kept so by means of a 
 proper shoe. It is the business of the resident surgeon to see the 
 treatment properly carried out, tliat is, that the shoe fits well, and 
 that the foot cannot shift about in it. Curiously enough, there seem 
 to be many members of our profession who so little appreciate the 
 anatomical conditions that they suppose the treatment to be com- 
 prised in tenotomy. Not infrequently in private I see cases in 
 which years previously tenotomy — and tenotomy alone — had been 
 performed. The parents suppose that the ill success was due to 
 incomplete operation. As far as lies in my power, I urge again 
 and again upon my pupils that tenotomy is only a means to 
 accelerate cure. The treatment of talipes according to our present 
 principles and methods is so eminently satisfactory that I trust 
 practical surgeons will no longer abstain from carrying it out 
 thoroughly. 
 
 While at Zurich thirty-seven cases of congenital talipes came 
 under treatment. This number appears to me comparatively large. 
 The list included only one adult — a girl 31 years of age. After 
 long treatment with Scarpa's shoes,^ she was sent out, able to 
 walk with her feet flat on the ground. The children usually came 
 under treatment when from one to twelve years old. I used some- 
 times to treat them with plaster- of-Paris splints — rarely with 
 mechanical appliances. The tendo-Achillis was divided in about 
 one half of the cases. If the parents of these children lacked the 
 patience or money necessary for the completion of the cure the 
 patients were provided with a Scarpa's shoe and discharged. "We 
 were usually forced to discharge the patients rather early on account 
 
 ^ ' Schienenstiefel.'
 
 MECHANICAL TEEATMENT OP TALIPES. 463- 
 
 of the want of room — too early at least for the children of poor 
 people who are not always in a position to get the shoes repaired, 
 for if the best possible result is to be obtained well-made shoes 
 must be worn for years. It is in this respect that in ordinary- 
 practice the cure is most commonly thwarted ; in most cases we 
 have to be content if we can enable the children to walk on the 
 flat of their feet. If the shoes are left off too early or the treatment 
 is not completed, and the children learn to walk either in large shoes 
 or without any, the entire treatment is thrown away. Orthopa3dic 
 surgery among the poor is only possible in institutions -which are 
 richly endowed or in wealthy children's hospitals, where the patients 
 can be kept under treatment for a number of years. As far as I 
 could learn about the subsequent conditions of the patients the 
 results were not very satisfactory. Thus, in thirteen children with 
 double talipes, I received the following reports in eight instances : — 
 Of four, " can walk fairly though the foot is turned inwards ; " of 
 three, "can walk alone," "can walk freely," of another, "cannot 
 put his foot to the ground properly ; " of seven children with talipes 
 only on one side, the report was, in two cases, " walks fairly well ; " 
 in three, " has trouble and difficulty in walking ; " in two, " the 
 foot is again completely deformed." It would be distinctly unfair 
 to judge of what can be done in the treatment of talipes from these 
 results, for the reports merely show the result of hospital practice 
 among the poor, while they prove that longer mechanical treatment 
 is necessary in children's hospitals to ensure more certain cure. 
 
 My figures showed — (i) that double talipes is about twice as 
 common as single ; (3) that unilateral talipes is not more common 
 on one side than the other ; (3) that male children are far more 
 frequently afflicted than female. I do not think that there is any 
 particular advantage in commencing treatment before the children 
 are a year old; the feet ought to be properly fixed in suitable 
 apparatus before the first attempts to walk are made. I often used 
 to bandage the feet to hollow tin splints with wooden foot-pieces» 
 With these the patients are able to stand and walk. 
 
 A larger number of cases, seen at Yienna, confirmed the general 
 inferences drawn from my Ziirich list. I have often practised sub- 
 cutaneous division of the plantar fascia as well as that of the Achilles 
 tendon. I have never yet found it necessary to divide any other
 
 •i64 TKEATMEXT OF TALIPES. 
 
 teudons or fascise. In a case that came under my care at Zurich 
 (described in the ' Aichiv fiir Klin./ Bd. i, p. 488), and in which I 
 applied a plaster bandage directly after tenotomy and redressement 
 force, deep gangrene of the foot took place. Now, I always allow 
 the wound of the tenotomy to heal before I apply the bandage. 
 After the tenotomy I always now treat talipes in the following 
 manner, with the ultimate results of which, as well as with the 
 rapidity of cure I am well satisfied.^ 
 
 " Tour or five days after the division of the Achilles tendon, when 
 the little wound has healed up, the foot is seized in the hand and 
 brought as straight as possible, care of course being taken not to 
 employ too much force. At the same time, while the leg is held 
 firmlv below the knee by a second person, a plaster-of-Paris bandage 
 is quickly applied over a moderate amount of wadding. This 
 bandage reaches from the toes up to the middle of the leg. The 
 padding must not be too thin at the bend of the foot, or else as it 
 is forced into position the bandage might press the part. While 
 the plaster is still soft the knee of the affected side is bent to a right 
 angle and the flat of one hand is then placed over the sole, and the 
 other on the lower end of the thigh, so that the palms of the two 
 hands face each other. If now the sole of the deformed foot is 
 pressed upwards and outwards with one hand, and at the same time 
 pressure is exerted on the knee with the other in the line of the 
 long axis of the leg, the foot may be brought as near to the normal 
 position as it was before the application of the bandage ; the resistance 
 is limited to the muscular action of the affected Umb. The foot is 
 then kept in its new position by steady pressure of the hands for 
 a few minutes, till the increasing warmth of the bandage proves the 
 plaster to be sufficiently hard. 
 
 This method of treatment can be employed on children under two 
 years of age without the use of any ansesthetic, and without more 
 assistance than that of the person who holds the child. 
 
 The pressure ought only to be applied to the sole as the foot is 
 forced into position. If the whole foot be seized in the hand and 
 the " redressement " effected while the bandages are on, the pres- 
 sure of the fingers will cause the inner surface of the plaster to 
 project and may lead to injurious pressure on the dorsum of the 
 
 1 The following section on the treatment o£ club foot in adults is trans- 
 lated from a paper by Dr, Gersuny, of Vienna, in the ' Wien. Med. "NVoch.,' 
 1878, Bd. xxs, p. S22, and refei-s to Professor Billroth's pi-actice. — [Ed.]
 
 TEEATMENT OP TALIPES BY * EEDEESSEMENT.' 465 
 
 foot. In older persons an anaesthetic is necessary, and more force 
 is required. The redressement can be effected by pressure with the 
 flat of the hand under the sole, while an assistant fixes the leg firmly 
 iu the extended position. 
 
 The apparatus is always renewed in from two to three weeks. In 
 children of a year old the entire treatment lasts from two to three 
 months, and from three to five plaster bandages will suffice. Imme- 
 diately after the removal of the last bandage, a simple apparatus 
 to support the part, consisting of a shoe with two lateral splints, is 
 applied. A catch in the hinge corresponding to the ankle-joint 
 prevents counter-flexion of the foot to more than a right angle, 
 while a strap presses on the part where the foot is most curved. 
 
 When the splints only reach up to the knee, the foot readily turns 
 inwards — a circumstance which may interfere with a successful 
 result. It is better, therefore, that the splints should extend higher 
 up, and they should be first fixed above with a pelvic girdle, as by 
 this means the leg can be completely prevented from rolling 
 inwards. 
 
 After this, as after other modes of treatment, the condition will 
 return if grossly neglected, but it should not if a moderate degree 
 of intelligence on the part of the relations be exercised ; if they will 
 but learn how to apply the simple apparatus properly, they may by 
 means of it effect a permanent cure. The following case will serve 
 as an illustration of the treatment. 
 
 The patient was a girl, ^et. 20, who was born with talipes of the left foot. 
 When a yeai* old she was taken to a well-known oi-thopajdic institution, where 
 she remained under treatment for eighteen months. I was unable to find 
 out the condition of the foot on her discharge, but very soon after she left 
 further medical treatment was necessary ; still, no complete cure was effected. 
 When seen the patient was stout and strong ; she had a slight lateral curva- 
 tui'e as the result of her limping walk and a tolerably high degree of 
 talipes vai'us in the left foot. At the transverse articulation the foot was so 
 sharply bent inwards that there was a deep sulcus on the inner border, the 
 anterior and posterior parts of the foot forming something under a right 
 angle. In addition, her foot was strongly supinated, so that in walking only 
 the outer part of the metatarsal bone touched the ground. On both extre- 
 mities of this bone were callosities. The ankle-joint was so twisted that the 
 external malleolus was markedly more posterior than the internal. On the 
 cuter side of the dorsum of the foot the astragalus formed a decided projec- 
 tion. To complete the description, the great toe was flexed on the dorsum at 
 nearly a right angle with its metatarsal bone, and the extensors would not 
 yield so as to allow of its being straightened. 
 
 30
 
 466 OSTEOTOMY IN EICKETTY DEFOEMITIES. 
 
 The condition of the foot when first seen seemed to demand either excision 
 of a wedge of bone, as practised by Davy and v. Mensen, or evidement of the 
 astragalus, as performed by Verebelyi. As the patient was unwilling to have 
 an operation of any magnitude performed, and stated that she would be satis- 
 fied with a partial cure, I decided on orthopaedic treatment. The plantar 
 fascia was first divided subcutaneously beneath the shai-pest bend of the foot, 
 and sis days later under an anaesthetic the first plaster bandage was applied in 
 the manner described. The improvement at fii-st was so slight that my pre- 
 vious eri)ectations were much moderated, but when after three weeks I tried 
 redressement, I found that the bands were more yielding. Altogether five 
 plaster bandages were applied, and when I removed the fifth bandage after 
 four months of treatment, the shape of the foot was almost nonnal. This 
 seems a strong statement, but on comparing the plaster casts taken before and 
 after treatment it was seen that it was no exaggeration ; the foot was straight, 
 the cleft of the inner border had disappeared, the astragalus had sunk back 
 into its place, and the great toe was in its proper position. In walking, the 
 sole of the foot was perfectly normal as it touched the ground, and the only 
 remnant of the fonner deformity was the excessive curve on the inner edge 
 of the foot. Of coui-se, the right foot was not the same as the left, inasmuch 
 as its growth had been much restricted and it was distinctly shorter than the 
 right. 
 
 Bv the help of a supporting apparatus and a pelvic girdle, the patient soon 
 learned to walk perfectly well, and was sent home highly delighted with the 
 improvement. 
 
 Possibly in this case a cure miglit have been effected in a shorter 
 time than four months by excising a wedge of bone, but the result 
 could hardly have been better. Indeed, it could not have been so 
 good, for the foot, which was already too short, would have been still 
 more curtailed by such an operation." 
 
 Osteotomy foe Ricketty DEFOEiiiTiEs. 
 
 "While at Ziirich I performed subcutaneous osteotomy on four 
 children, whose ages varied from two and a half to three years, for 
 ricketty deformities of the legs. The operation was performed after 
 the rachitic process had ceased. The result was highly satisfactory 
 in all, and very slight reaction followed the operation. In every 
 case the limb was straightened immediately after the osteotomy, 
 and then put up in plaster bandages, a small window being cut 
 over the wound. 
 
 The following case of softening of the bones is of some rarity ; I
 
 CONGENITAL DISLOCATION. PES GIGAS. 467 
 
 know not whether to classify it as one of osteoporosis, rachitis, or 
 halisteresisJ 
 
 A lad, cet. 12, strong and stout for his age, was admitted with some 
 shortening of the left leg, which caused him to limp very considerably. The 
 lower half of the limb had a most typical ricketty curve. He walked on 
 the outer edge of his foot, and had some pain in so doing. It was stated 
 that he had suffered from scarlet fever when three years old, that the leg 
 had then become bent, and that the curve had gone on increasing ever since. 
 The bone was bent at an angle of forty-five degrees. Under an anaesthetic I 
 was able to straighten the limb without applying any great amount of force ; 
 the leg was put up in a splint, and a few days later in a plaster bandage. 
 Large quantities of lime water and milk were given internally. The patient 
 was discharged soon after, as he was able to walk with crutches. I heard a 
 few weeks later that the bandage had been taken off soon after he got home, 
 and the condition had thereupon returned as before. 
 
 (Congenital lateral dislocation of the toes. 
 
 A strong man, jet. 61, was admitted with the following congenital defor- 
 mity of the toes. In the right foot the head of the first metatarsal bone was 
 displaced laterally, and lay beneath the skin on the inner edge of the foot ; 
 the great toe was displaced outwards ; the fifth toe was displaced in a similar 
 manner. In the left foot the deformity was the same, except that the 
 second toe was completely dislocated. 
 
 I am only acquainted with two other cases of a similar nature : 
 a man with congenital lateral displacement in both hands of some 
 of the fingers at the metacarpo-phalangeal joints, and a girl who 
 came under my treatment with a similar malformation of the hands. 
 
 Tes gig as. 
 
 The illustration (Fig. 24, next page) represents a congenital pes gigas in a 
 boy," set. 9. The second and third toes were abnormally developed, together 
 with the central portion of the foot and the panniculus adiposus. 
 
 Congenital absence of the femur. 
 Plate XII illustrates a case of this nature. The patient was admitted 
 
 ' ' Halisterischcr Knochenatrophie ' of E. Volkmann.
 
 468 
 
 PES GIGAS. 
 
 for severe cystitis and pyelitis, and died two days after admission. The 
 drawing was taken immediately after death. Unfortunately no post morteni 
 was allowed. 
 
 Fig. 24. — Pes gigas.
 
 CHAPTER XVIII. 
 
 ON STATISTICS OF AMPUTATIONS, RESECTIONS, AND OSTEO- 
 
 TOMIES.i 
 
 We have long been accustomed to set great value on the results 
 of amputations and resections, and not only to form an opinion of 
 the different methods of operating and of after-treatment from such 
 statistics, but also to look upon them as a test of operative surgery 
 generally, as well as of sanitary and hygienic administration. Much 
 may be said against and much in favour of such a view. In favour 
 of it may be said, that it is easier to tabulate these operations cate- 
 gorically than any others, and that, in this branch of operative sur- 
 gery, cases resembling each other can be taken as a basis for 
 statistics, further, these operations are particularly liable to com- 
 plications, owing to the injuries inflicted on the skin, cellular tissue, 
 muscles, large vessels or bones, and as they demand careful circum- 
 spection on various points are thus best adapted to enlighten us. 
 On the other hand, it may be said that the similarity of the cases 
 is not so great as it w^ould seem at first sight, and it is only by the 
 necessary grouping together of the several cases at the discretion of 
 the operator that a practical basis for statistics can be made. It 
 might be said that the treatment of large cavernous wounds after 
 the removal of tumours, especially the more critical operations, such 
 as laparotomies, give us a far widSr field of view than do amputa- 
 tions, and constitute a much better criterion of the state of our 
 knowledge. No doubt it is possible that as the operation of 
 laparotomy becomes more extensively and more frequently prac- 
 tised, this point of view may assume a more prominent position 
 hereafter. For the present, laparotomies are not of sufficiently 
 frequent occurrence in the surgical wards of our hospitals, to form 
 a basis for general statistics. Again, operations for the removal of 
 tumours, with the single exception perhaps of simple cases of 
 
 * Some additional statistics by Dr. A. Wolfler will be found in tbe ' Wien. 
 Med. Wocli.,' April, 1881, No. 17 et se^.— [Ed.]
 
 470 'method of amputation.' 
 
 amputation of the breast, are not so generally and equally distributed 
 that they would fulfil the required conditions ; at present, there- 
 fore, we practically adopt the amputations and resections performed 
 in the different hospitals which have surgical departments as the 
 principal test and indication of the results of operations for given 
 periods of time. 
 
 It soon became clear that the cases must be grouped according 
 to stated principles, if any practical information were to be gained 
 from the statistics. Some thirty years ago the '' method of ampu- 
 tation " was thought so much of that the results were usually 
 estimated accordingly. The first question was, whether circular, 
 oval, single or double flap amputation had been performed. These 
 considerations are almost disregarded now ; the principles on which 
 an amputation stump ought to be covered in are generally accepted ; 
 we know that to form large muscular flaps is not only unfavourable 
 for healing, but that these masses of muscle in the stump at a later 
 stage disappear here and there, according to recognised anatomical 
 and physiological conditions. I do not think I am wrong in 
 assuming that the principles of forming the stump in an amputa- 
 tion, as represented by two or three circular cuts (with the exception 
 of special methods of exarticulation), are now decided as far as the 
 majority of surgeons are concerned, and that no great importance 
 is attached any longer as to whether that result is obtained by a 
 circular, simple, or a double-flap incision through the skin. 
 
 Contemporaneously with this discussion on the " method of 
 amputation ^' the question as to whether the stump healed by first 
 or second intention was held to be of great importance. When I 
 was a student, a large number of surgeons still encouraged suppu- 
 ration as much as possible by stuffing the flaps with charpie, and 
 applying poultices early to the stump. Contention ran high, too, 
 on the subject of the after treatment, whether the patients should be 
 freely purged and bled (as a student I have seen many amputation 
 stumps covered with leeches), or whether a liberal diet such as beef- 
 steaks and port wine should be depended on for recovery. 
 
 These views obtained during a period when no statistical results 
 of value could be hoped for, for no surgeon considered it his duty 
 to publish openly the truth as to the results of his operations ; 
 practically he was unacquainted with them and could only furnish 
 some very general observations on the subject according to the 
 impressions made on his memory.
 
 PRIMARY AND SECONDARY AMPUTATIONS. HOSPITALISM. 471 
 
 The first comprehensive statistics of amputations were published 
 by Malgaigne, who took them from the journals of the Parisian 
 hospitals. Individual surgeons were thus exempted from being 
 personally answerable for the results shown, which reflected the 
 state of the surgical art as such. Unfortunately, they were so 
 unfavourable that it was made on that account easier for individual 
 surgeons to publish their results themselves, for with the advancing 
 improvement of our art they became gradually better. 
 
 It had long been clear on purely empirical grounds that after the 
 " method of amputation " and "the early union or non-union of 
 amputation wounds '^ there were other circumstances, such as the 
 conditions demanding amputation and the period of the wound and 
 of the illness during which operation was performed, which had the 
 most important bearing on the result. Military surgeons had long 
 been discussing whether amputation ought to be performed imme- 
 diately after the injury (primary) or at a later period, when the 
 gunshot wound had begun to suppurate (secondary). The Paris 
 Academy, in 1745, offered a prize for an answer to this question. 
 Subsequently it was found that, speaking generally, amputations for 
 injuries yielded more unfavourable results than amputations for 
 chronic suppurations, tumours, etc., and thus arose the system of 
 grouping amputation cases which is now fundamentally adopted in 
 most statistical tables ; indeed, this point till a few years ago was 
 held of such paramount importance that the method of operation 
 and the after-treatment were scarcely mentioned. 
 
 The popularisation of pycemia, especially the fact that this disease 
 was looked upon as one almost entirely due to hospital miasmatic 
 influences, for a while diverted attention entirely from the wound 
 and the patient, and made the fate of the case depend almost 
 entirely on the surrounding atmosphere. The favourable results 
 obtained in the hastily-constructed hospital huts during the American 
 war, added to Simpson's crusade against hospitalism, together con- 
 verted surgeons into buildew, »nd builders into surgeons ; it seemed 
 for the time, almost as if it were a matter of perfect indifference 
 how and when amputations and resections were performed, and how 
 the after-treatment of the wound was conducted, provided only the 
 patient were kept in the opai air, or in a well- ventilated locality. 
 The great object now was to group together amputation cases which 
 had been treated in private practice, next those in small hospitals 
 (which by a priori reasoning were held to be, after private
 
 472 ' A^'TISEPTICS ' AND STATISTICS. 
 
 dwelling-houses, most suitable for these cases), and finally in the 
 large city hospitals (the so-called " Mordhohlen " for wounds and 
 ■operation cases). 
 
 Simpson himself contributed not a little towards directing the 
 attention of surgeons again to the importance of the treatment of 
 the wound, when he introduced acupressure as a material aid to 
 healing by first intention. Since acupressure was best adapted to tlie 
 open treatment of wounds, both methods came into vogue together. 
 Then followed the occlusion dressings, originating from the theories 
 of the favourable healing of subcutaneous wounds. My readers 
 will have seen how rivalry has sprung up between these older 
 methods and that now so extensively adopted through to Guerin, 
 Lister, and Volkmann. Xow we are at another extreme, and it is 
 the fashion simply to deny that the hospital or locality in which 
 the amputation case is placed, exercises any efl"ect, and to repudiate 
 any subjective influence of the sick or injured person on the healing, 
 provided only the wound be protected with a good Lister's dressing. 
 Consequently statistics of amputation are produced, in which the 
 open treatment of wounds or the antiseptic occlusion dressing serve 
 as the basis for the tables, and the other circumstances are only 
 incidentally referred to. 
 
 Since, in the comparative short period of about twenty-five years, 
 I have experienced myself all these metamorphoses of amputation 
 statistics which I have by no means over-coloured or exaggerated, 
 the reader will readly understand that I can scarcely persuade 
 myself that we are in a condition now from which we shall not 
 alter. Hitherto, we have always progressed, notwithstanding our 
 temporary partialities, and now that we find ourselves again with 
 this one partiality, we may hope that it will not be the last. It 
 would not astonish me if we were to obtain better results by simpler 
 methods, or perhaps adopt principles entirely opposed to those of 
 l^e present day. 
 
 There are many advantages in the new mode of tabulating 
 amputations, which Yolkmann brought before the Surgical Congress 
 in 1877 ; it is especially adapted to show the excellent working of 
 the antiseptic method — a method practised by Volkmann himself 
 in so admirable a manner — and appears also to mc, not only to 
 give a good idea at a glance, but also to be very practical in 
 general. 
 
 The principal features of Yolkmann's arrangement I have adopted
 
 UNCOMPLICATED CASES OF AMPUTATION. 473 
 
 in tabulating my cases, although I met with many difficulties, 
 which could not be overcome by any system of classification. 
 
 My cases of amputation (between i860 and 1876) were divided 
 into the followino; classes :^ 
 
 (A.) Uncomplicated Cases. 
 
 I. Cases in wJiich the patients eiilier recovered and tvere dis- 
 charged, or died of exhaustion or accidental diseases of wounds. — 
 Under this heading we have 214 cases. In y^ amputation was 
 performed for injury, and in the others for various causes, such as 
 chronic caries, syphilitic gangrene, malignant tumours, frost-bite, 
 pseudarthrosis, etc: 150 recovered; 64 died. Of the deaths 
 9 were from exhaustion (collapse and marasmus), 3 from erysipelas 
 ambulans, 2 from delirium potatorum, 15 from septo-pysemia. 
 In this group, therefore, the mortality amounts to 29 9 per 
 cent. 
 
 (The amputations tabulated in the pages referred to are of every variety. 
 In the upper extremity twelve of the amputations were at the shoulder-joint ; 
 «ight recovered and four died. Two were amputated through the elbow- 
 joint, while in nine the hand was disarticulated ; all the latter patients 
 recovered. In the lower extremity Symes' amputation was performed only 
 twice, Chopart's six times, Lisfranc's once. The opei-ation generally adopted 
 was PirogoS'e, which was performed in thirty-two cases, twenty-six being 
 ■caries of the foot. This latter operation appears to find far more favour 
 on the Continent generally than it does in this country.— Ed.) 
 
 With regard to the two columns in the tables of ^'recovered" 
 and " died,'^ a good many points have to be taken into consideration. 
 A patient was entered as " recovered " if he left the hospital with 
 his stump healed, or nearly healed, although perhaps he may have 
 died of tubgrculosis a week later. We must not quite adopt the 
 •charming notion that the patients who are entered as having 
 recovered from amputation recovered also from any severe general 
 diseases they may have had. Again, the expression "recovered'' 
 
 1 Owing to want of space the tables — though the results shown by them 
 are highly interesting — could not be reprinted entire. They will be found 
 in the ' Wiener Bericht,' 1876, pp. 613 — 626. In what follows I have merely 
 picked out a few of the salient points. — [Ed.]
 
 474 COMPARISON OF ZURICH AND VIENNA STATISTICS. 
 
 does not bear that full significance in many of the cases of 
 caries, which are a very numerous class. If, for example, a 
 patient with tuberculosis of the lungs were discharged with his 
 stump healed, or nearly so, he was put down in the tables as " re- 
 covered," but if, for some reason or other, he remained in the 
 hospital till the time of his death, his case was entered in another 
 table. In large hospitals it is impossible to obviate entirely such 
 sources of error. ,The class of " amputations on account of 
 injuries" corresponds, genially speaking, to that formerly em- 
 ployed of " primary amputations," but in order to avoid multiply- 
 ing the number of groups, I have included a few cases in which 
 amputation was performed at a later period, as, for example, where 
 by gradual necrosis or suppuration (the patient not being pysemic) 
 the skin was so far destroyed that the wound could not be expected 
 to heal up. I agree altogether with Volkmann in rejecting the 
 groups of "intermediary" and '^ secondary" amputations, and 
 substituting for them a class " where septo-pysemia has already 
 developed at the time of amputation.^' The surgeon must often 
 be in grave doubt as to the class in which he is to enter this or 
 that case, and the- lists of "intermediary" and "secondary" 
 amputations not infrequently included very diverse cases. 
 
 With respect to the rather numerous deaths from tuberculosis, it 
 must be noted that I often performed amputations of the foot, the 
 leg, or the arm, in order to relieve patients from the pain of carious 
 joints. 
 
 Volkmann enters delirium potatorum as one of the " intercurrent 
 diseases having no direct connection with the wound," This con- 
 ception of the condition I do not share. Acute fatal cases of 
 delirium potatorum, are, according to my view, set up in drunkards 
 by intense inflammation of the absorption of phlogogenous matter 
 from the wounds or the parts around. I consider the delirium there- 
 fore as an accidental disease of wounds, and classify it as such in my 
 tables. 
 
 Comparing the statistics of amputations in my practice at Ziirich 
 with those at Vienna, I find an improvement in the latter of lo 
 per cent. I think there are two reasons for this: — (i) that in 
 Vienna there were not nearly so many amputations for injuries, 
 and far more from caries, (2) that in Vienna I adopted systemati- 
 cally the open treatment of wounds,^ while in Ziirich I practised 
 ^ See the remarks on p. 30, relating to Figs, i and 2, p. 29.
 
 COMPLICATED CASES OF AMPUTATION. 475 
 
 the older metliod which I had learned from my teachers, of sewing 
 up the wound closely without draining it. 
 
 II. In this second class are tabulated cases (15 in number) in 
 which the patients died in the hospital from diseases which were not 
 directly connected toith the operation wound. 
 
 Nearly all these deaths were due to tuberculosis of the lungs. 
 
 (B.) Complicated Cases. 
 
 I. Operations on patients already the subjects of septic infection. 
 — Under this head are tabulated 69 cases, of whom ^^ died and 14 
 recovered, showing a mortality of 797 per cent. It is important 
 to separate these cases from the principal tables of amputation. 
 For example, cases are included in this class where resection had 
 been performed, and then pytemia having occurred, amputation 
 was resorted to, or where at the earnest entreaty of patients 
 large tumours had been removed from the extremities, and then 
 amputation was performed on account of gangrene and sepsis ; 
 others also in which patients with caries became pysemic after 
 examination of their wounds, and amputation was performed as a last 
 resource. The majority of cases in this group, however, are those 
 of injuries or phlegmonous inflammation, in which amputation 
 was performed too late. I am aware that in many cases I did not 
 recognise the danger sufficiently early, but a large proportion came 
 under my treatment too late, and in many instances my hands 
 were already tied. I never performed operations without the 
 express consent of the patients, or in the case of children, of their 
 parents or guardians. While in Switzerland I could not' converse 
 with the patients in their own dialect, and in Vienna I very often was 
 unable to understand their language, except through the medium of 
 an interpreter. It will be understood, then, that my power of 
 over-persuading the patients was not very great, even when the 
 operation was most urgent. Added to this, individuals of the 
 W'orking classes to whom amputation is proposed, not infrequently, 
 after calm and rational reflection, prefer rather to die than to live 
 ci'ippled and unable to work — a point of view which, as a surgeon 
 one cannot take, but which I cannot but hold is amply justified. 
 These folk have often so little pleasure in life that they do not 
 find it hard to part with it. This is especially the case in Yienna, 
 where suicides are exceedingly common. Often, too, the sufferer
 
 476 AMPUTATIONS IN SEPTIC PATIENTS. EXCISIONS. 
 
 will reason thus : " When I can no longer work, I must beg ; if I 
 die my wife may support my children for a time and then marry 
 again, but she cannot support me and the children for the rest 
 of my life." But with many, as they feel themselves getting worse 
 daily, the desire to live and the dread of death overcome their 
 deliberate reasoning, and they eagerly clutch at the suggestion of 
 amputation, which before they would not hear of. What should 
 the surgeon do in such a case ? His scientijac knowledge says to 
 him, " Too late ; " but can he say the same to the patient ? He 
 may think so, write so, but he will not often do it. W^ho could 
 say to himself, unless the patient was already in articulo mortis, 
 " It is impossible for this man to recover ? '^ Not I ; for I have 
 seen pysemic patients pull through with abscesses in the lungs and 
 cellular tissue, suppuration of the joints, and marked icterus. Not 
 often it is true, but it happens so once in a way. We cannot 
 estimate with any certainty the degree of septic poisoning which 
 any individual person can get over. Thus I have often amputated 
 in such cases where I felt that it would be a marvel if the patient 
 recovered. Those who wish for good statistics of amputations 
 would not operate on septic patients. 
 
 II. Double amputations. — Five cases, 3 recoveries and 2 deaths. 
 
 III. Amputations on patients with other severe injuries. — Two 
 •cases, both died. The separation made by Volkmann between the 
 
 above two groups is as important as their distinction from Group I. 
 Summarising the list for sixteen years, I find that 315 amputa- 
 tions were performed on 305 patients. The mortality amounted 
 to 45 per cent. 
 
 Excisions of Joints. 
 
 These cases are tabulated as follows : 
 
 (A.) Uncomplicated Cases. — I. Cases in wJiich the patients when 
 discharged had recovered, or had only small sinuses, or in which deatft 
 took place after the operation, owing to some accidental diseases of 
 wounds. — Statistics of this class wall be found in the 'Wien. Bericht,' 
 1876, p. 637, where 90 cases are tabulated : — 37 are excisions of the 
 «lbow, 8 of the wrist, 9 of the shoulder. In the lower extremity, 12 
 of the hip, 12 of the knee, and 12 of the ankle. 
 
 The other classes and groups are identical with those adopted in 
 the tables of amputations. 46 osteotomies are recorded, 6 of which 
 .€nded fatallv.
 
 CHAPTER XIX. 
 
 STATISTICS OP TUMOURS.^ 
 
 I HAVE before now had occasion to remark, when reviewing the 
 statistics of tumours in my Zurich records, that a summary taken 
 entirely from the in-patient department can give no accurate idea 
 of what a complete statistical return of tumours would show. In 
 such a summary many cases of carcinoma of the stomach, the 
 intestinal canal, and the liver, sarcoma of the brain and lungs (whicli 
 it must be admitted are of rarer occurrence), carcinoma of the 
 kidney, etc., would not be included, for such were treated in 
 the department for internal diseases. Since surgical gynsecology 
 has become a separate branch, most of the cases of cancer of the 
 rectum, vulva and uterus, have been separated, and, in many 
 university clinics, ovarian tumours also. Of fibroma of the uterus, 
 only the rare cases have been included which came under operation. 
 Many minor operations, such as removal of nasal mucous polypi, 
 sebaceous cysts, hypertrophied tonsils, and angiomata, were treated 
 in the out-patient department. 
 
 In the following tables primary tumours only are taken into 
 account. Tumours set up by infection and metastatic growths are, 
 of course, entirely excluded. 
 
 Comparing the proportionate frequency of tumours and of spon- 
 taneously arising acute or chronic inflammatory processes, I find 
 that, taking the figures from i860 to 1876, 2058 are classified 
 under the former head (tumours), and 3061 under the latter (in- 
 flammations). The Ziirich tables show that the number of acute 
 and chronic inflammations far exceeded that of the tumours 
 (1203 : 526) in Vienna the numbers were 1858 : 1532. It would, 
 however, be rash to conclude that the population of Vienna is more 
 
 ' See also on this subject, A. v. Winiwarter's work, ' Beitrjige zur Statistik 
 cler Carcinome ' (Stuttgart, 1878, F. Ecke), the materials for which were drawn 
 from the clinic at Vienna.
 
 478 
 
 FEEQUENCY OF VAEIOUS TUMOUES. 
 
 disposed to tumour formations than that of Zurich. I think rather 
 that the explanation lies in the fact that patients who had tumours 
 were far less seldom sent away from the hospital in Vienna than 
 those suffering from chronic inflammations. Of the latter class 
 only a limited number could he admitted, owing to the long dura- 
 tion of the diseases. 
 
 The following table shows the frequency of the various forms of 
 tumours : — 
 
 Carcinoma 
 
 
 
 
 862 
 
 Lymphoma 
 Cystoma 
 Sarcoma 
 Fibroma 
 
 
 
 
 261 
 253 
 245 
 163 
 
 Angioma 
 
 
 
 
 101 
 
 Lijwma 
 Adenoma 
 
 
 
 
 66 
 64 
 
 Chondi'oma 
 
 
 
 
 17 
 
 Nenroma 
 
 
 
 
 10 
 
 Osteoma 
 
 
 
 
 9 
 
 Papilloma 
 Echinococciis 
 
 
 
 
 5 
 
 2 
 
 2058 
 
 The order of frequency differs from that in my Zurich tables 
 (Z. B., p. 587 ei seq.), because the classes of cystomata (which 
 includes colloid cysts of the ovaries) and sarcomata were materially 
 larger in Yienna. 
 
 The total number of epithelial new formations (carcinoma, 
 cystoma, adenoma)=ii79, or rather more than half of the total 
 number of tumours (2058). It is interesting to note that these 
 numbers almost exactly correspond with those of my Zlirich tables. 
 In a general statistical table of tumours, the preponderance of epi- 
 thelial new formations would be far more marked, for a large number 
 of uterine and gastric cancers would have to be added, while the 
 number of connective-tissue new formations (fibroma, sarcoma, 
 myoma, chondroma, osteoma) in the internal organs is certainly 
 much smaller. 
 
 "With regard to the distribution of tumours between the sexes, I 
 find that in Zlirich there were more male (299) than female 
 (259) patients. In the above table, the number of females (1037) 
 is slightly larger than that of the males, a fact which is pro-
 
 FREQUENCY OF TUMOURS IN THE SEXES. 
 
 479 
 
 bably accounted for by the ovariotomies. The difference is all 
 the more striking in that the number of women admitted into the 
 hospital was far smaller than that of the men, for I have three male 
 and only two female wards. The number of tumours, therefore, occur- 
 ring in women might be thought much larger, but a correction has 
 to be made; men are so much more subject to injuries than women 
 that the numbers will deceive at first sight ; subtracting the cases 
 of injury, I find that the distribution of surgical diseases is about 
 equal in the two sexes. Still, after making this correction, I find 
 that females are actually more liable to tumours. In men tumours 
 of the face, principally cancers, constitute the only class which occurs 
 with preponderating frequency; this is compensated for by the 
 larger number of cancers of the breast in women. The larger 
 number of cases occurring in the female sex is accounted for by the 
 fact that the organs of generation are far more affected with 
 tumours (cancers of the external organs of the uterus, fibroma of 
 the uterus, ovarian tumours) than is the case with the male sex 
 (cancers of the penis, testicle, fibroma of the prostate). 
 
 The marked preponderance of lipoma in the female sex is striking, 
 and is probable accounted for by the greater development of the 
 panniculus adiposus. Again, in angioma, the female sex (63) is 
 far more often affected than the male sex (38), the difference being 
 so material that all chance of accident may be excluded. This is 
 all the more interesting, as in most of these cases we have to deal 
 with congenital anomalies. 
 
 The following table shows the distribution of tumours in the 
 various regions of the body : 
 
 Pace, nasal, and oral cavities 
 
 712 
 
 The neck 
 
 395 
 
 Breast and back 
 
 349 
 
 Female organs of generation 
 
 147 
 
 Male organs of generation 
 
 114 
 
 Upper extremity 
 
 96 
 
 Abdomen and rectum 
 
 82 
 
 Lower extremity 
 
 73 
 
 Head and ear 
 
 54 
 
 Pelvis and lumbar regions 
 
 21 
 
 Urinary organs 
 
 15 
 
 Veiiebral column 
 
 . • 
 
 2058
 
 480 DISTRIBUTION OF TUMOUES. 
 
 Tlie different distribution of the various forms of tumours in the 
 different regions of the body (and organs) is of acknowledged 
 clinical importance and diagnostic interest, as has lately been very 
 properly pointed out by Liicke. The practising clinical surgeon 
 diagnoses with still more promptness and certainty from the situa- 
 tion of the tumour, for he knows what he is likely to meet with in 
 this or that part. For one who has examined histologically many 
 tumours whose seat of election is known, it is usually possible, 
 by taking into account the situation, the consistence, and the rapidity 
 of growth, to describe rightly the histological character of the 
 tumour even in minute details, before making a section of the 
 growth after removal. Of course it is true that in rare cases there 
 is no guarantee against error, but experience can only be founded 
 on the rule, not on the exception. Trom the tables given I select 
 below for remark only those cases in which the numbers are rela- 
 tively so large as to be of obvious import in the sense I have pointed 
 out. 
 
 I'ibroma was noticed most frequently in the male organs of 
 generation (59 out of a total number of 163). The myo-fibromata 
 of the prostate explain this prevalence. Its equivalent — myo- 
 fibroma of the uterus — is only represented by twenty cases, a number 
 which for reasons already mentioned is far too small. 
 
 The next largest number occurs in the division of the face, nose, 
 and mouth, where fifty fibromata are tabulated, most of them being 
 nasal and naso-pharyngeal polypi. Among the 23 fibromata 
 of the breast, the largest number were adeno-fibromata of the 
 mamma. 
 
 Lipoma (66) was most frequently situated in the breast and back 
 (27), then in the upper extremity (18), especially on the upper arm 
 and shoulder, and finally about the throat and back of the neck 
 (10). The distribution of lipoma is peculiar in being especially 
 restricted to the trunk. 
 
 Sarcoma (245) was most common about the face ; the sarcomata of 
 the jaws and gums (epulis-sarcoma) principally swell the total. 
 Next comes the lower extremity (47), then the breast, {^^, most of 
 them being sarcoma and cysto-sarcoma of the mamma, also sarcoma 
 of the skin, especially on the back) and the upper extremity (26). 
 
 The preponderating frequency of lymphoma (261) about the neck 
 (219) is known to every surgeon, even of small experience. 
 
 Of 101 cases of angioma, most of which were congenital, 74
 
 DISTEIBTJTION OP TUMOURS. 481 
 
 occurred in the face. This may be due to the fact that in the most 
 common position of the -head in utero^ the venous circulation of the 
 part is most liable to be interfered with ; the resulting congestions 
 may perhaps be the primary cause of these vascular growths. 
 
 Fifty-one cases of adenoma (out of a total of 64) were broncho - 
 celes. (The other 13 cases are entered as occurring in the abdomen 
 and rectum.) 
 
 Cystomata (253) were most common (95) in the female organs of 
 generation, which is accounted for by the ovarian cystomata. Of 7 1 
 cases of cystoma in the neck, the majority were cystic bronchoceles. 
 The 42 cystomata of the face include atheromata, cysts of the jaws 
 and ranula. The 25 cystomata of the head were almost exclusively 
 sebaceous. 
 
 Of the 826 carciQomata, 406, or nearly one half, occurred in the 
 face and the nasal or oral cavities; 252 were in the breast, 52 in 
 the rectum, and ^6 in the male organs of generation. 
 
 The following table shows roughly the distribution of the tumours 
 in the various tissues : 
 
 In the cutis . . 499 ") 
 J, mucous membranes 372 j 
 „ glands . . . 
 „ cellular tissue, fascia, fat . 
 „ lymphatic glands 
 „ muscular substance of the uterus 
 
 871' 
 
 642 ■> 
 
 191^ 
 
 249 
 
 17 
 
 ■ ^5i3=73'5i pel- cent. 
 
 ■ 545=26-45 per cent. 
 
 „ nerves 
 
 „ periosteum and bone 
 
 10 
 
 78J 
 
 
 3058 
 
 This table shows that tissues composed of epithelium and con- 
 nective tissue together are most prone to the formation of tumours. 
 The large number of growths starting from the integuments (the 
 cutis and mucous membranes) together (871), as opposed to the 
 glands (642), finds an explanation in the fact that the integuments 
 are far more exposed to such external irritations as are likely to 
 set up abnormal growth. 
 
 In the cutis (499) the carcinomata are especially numerous ; 
 next in order of frequency come the angiomata (69), sarcomata 
 (59), cystomata (54, most of them being sebaceous). Of much 
 rarer occurrence are fibromata (21). 
 
 Tumours attacking the mucous membranes (372, among which 
 
 31
 
 482 TUMOURS OF LYMPHATIC GLANDS. 
 
 are 171 cases of carcinoma) most frequently affected (257) the 
 upper part of the respiratory and digestive tract. The number 
 attacking the lower portion of the digestive tract (65 of the large 
 intestine, among which are 52 cases of carcinoma) is far smaller. 
 
 Under the heading " glands " (643 tumours) the mamma stands 
 at the head of the list (296 cases, of which 252 were cancer) ;. 
 next come the thyroid with iii, the ovary with 100, the prostate 
 with 60 (58 being myo-fibromata) , and the testis with 27. 
 
 Among the tumours of tissues composed only of adenoid sub- 
 stance (545), tumours of the lymphatic glands (lymphoma and 
 lympho-sarcoma) amount to nearly one half (249). The pro- 
 priety of including this group at all may be objected to iu ioto on 
 two grounds — (i) because many of these lymphomata had suppu- 
 rated or become caseous, and should be therefore entered as chronic 
 inflammatory processes, and (2) because, undoubtedly, many of 
 these growths originated deuteropathically by infection from proto- 
 pathic sources of inflammation, and therefore no more belong to 
 this category than do cancers and sarcomata originating in a 
 similar manner. I myself cannot invalidate these objections, but 
 only state in defence that it was not possible to make a strict 
 separation- of lymphomata in this sense. I am decidedly of opinion 
 that primary affections of the lymphatic glands are of very rare 
 occurrence, but as they are the parts which give passage to the 
 fluids of the tissues as they pass on in their centripetal course, a 
 strict separation would only be possible where heteroplastic new 
 formations are found in the lymphatic glands. 
 
 In 191 cases the loose cellular tissue, the fasciae and the fat 
 were the starting-points of new formations. Lipoma and sarcoma 
 occurred in equal numbers, 66 cases of each being noted. 
 
 Seventy-eight cases occurred in the periosteum and bones, includ- 
 ing 46 cases of sarcoma, 1 3 of chondroma, i o of cystoma (of the 
 jaws), and 9 of osteoma. Cancers of the bones always originate, 
 according to my view, in one of two ways, either by extension of 
 the disease from without, or by metastasis. The latter class is not 
 included here, and the former is tabulated under the heading of the 
 tissue from which it originally started. 
 
 I have only noticed one case (a peculiar tumour of the muscles, 
 myoma cysticum, ' Yirchow's Archiv,^ ix), in which I could make 
 out from the histological character of the new formation that it had 
 originated directly from striped muscular tissue. I have observed
 
 CONNECTIVE-TISSUE TUMOURS. 483 
 
 new-formed striped muscular fibre in tumours of the testis,^ and 
 once in a sarcoma of the mamma.^ Neither in Ziirich nor in 
 Vienna have I met with tumours whose origin from muscular 
 bundles I could establish histologically ; in all the cases it was 
 just as possible that the growth originated in the connective tissue 
 of the muscles. 
 
 The my 0- fibromata of the uterus start undoubtedly in the smooth 
 muscular fibre and investing connective tissue of this organ. 
 The uterine glands are not included in these growths, and have no 
 connection with them. Myo-fibromata of the prostate gland, 
 although related histogeneticaUy to the corresponding tumours of 
 the uterus, nearly always include, so far as my investigations hare 
 reached, some portion of the epithelial glandular elements. How- 
 ever slightly we value the alteration of these epithelial elements 
 (dilatation, enlargement, and increase of the epithelium and for- 
 mation of retention cysts) and their influence on the histological 
 character of the general mass of the tumours, these glandular 
 elements still belong as essentially to the tumours as the included 
 glandular elements do to fibroma and sarcoma of the mamma. 
 
 On histogenetic grounds we should be justified perhaps in dis- 
 sociating these tumours which originate in connective tissue from 
 any further relationship with the glands, and allowing the expres- 
 sions " adeno-fibroma" and "adeno-sarcoma" to drop ; on clinical 
 grounds this change is not, at present, generally adopted. By 
 changing over into other groups tumours which have not started 
 from the epithelium, but which lie in the integuments and glands, 
 we should simply augment the class of connective-tissue growths, 
 and diminish that of the glandular tumours. 
 
 In the case of sarcomata, which in some measure agree with 
 carcinomata, I have always kept as minute records as possible, for 
 these tumours have been of special interest to me on account of the 
 difficulty usually experienced with respect to their prognosis. I am 
 able to make some statements as to their origin at the different 
 periods of life. 
 
 A. von Winiwarter has shown the proportions very clearly by 
 means of charts, and has adjusted the inequalities of the sum total 
 by always taking a hundred as the whole number, and calculating 
 
 » ' Deutsche Klin./ 1855, No. 7 ; and Virchow's ' Archiv,' Bd. viii. 
 2 ' Untersuchungen iiber Brustdriisengescliwulste ;' ' Virchow's Archiv/ 
 Bd. iviii.
 
 484 MALIGNA2fT AND SIMPLE TUMOURS OF BKEAST. 
 
 the numbers for the different periods of time marked off in the 
 tables, in their proportion to one hundred. The curves in the chart 
 (Fig. 2j) illustrate the frequency of adeno-fibroma and adeno-cysto- 
 
 FlG. 2.:^. 
 
 15 1-10 11-20 21-30 31-40 41-50 5J-eO 61-70 7|-af| 
 
 The dotted line ilbastiates the cases of cancer of tlie skin and mucous 
 
 membranes. The plain line the cases of sarcoma of the skin, 
 
 cellular tissue and bones. 
 
 sarcoma of the mamma by the side of sarcoma of this organ in an 
 interesting way. We see from this chart that the non-malignant 
 tumours of the mamma begin in the second decennium and that 
 too, in tolerably large numbers. During the third and fourth 
 decennia the numbers keep much the same, and then very rapidly 
 fall. On the other hand, carcinomata are first seen in the third 
 decennium, at which period the number is small; in the fourth and 
 fifth they keep about the same, and then also rapidly fall. The 
 first class of tumours more often developed between the ages of 
 twenty-one and forty, and the second betwesn forty-one and sixty. 
 This proportion is naturally only relative, for it is shown by the 
 other tables that of 296 mammary tumours, 44 were non-malignant 
 and 252 malignant, giving a proportion of 15 : 85. So great a 
 difference might lead one to question the accuracy of the chart.
 
 SAIICOMA AND CAECINOMA. 
 
 485 
 
 but I scarcely think that there is any source of error, for the occur- 
 rence of these tumours is so characteristic that the proportion 
 would scarcely be found to alter in a larger number of cases. 
 
 roUowing A. von Winiwarter's plan, I have contrasted in the 
 same way (Fig. 36) sarcoma of the cutis, cellular tissue, fascia. 
 
 Fig. 26. 
 
 The dotted line illustrates tlie cases of cancer of the hreast. 
 
 plain line the cases of sarcoma of the breast. 
 
 The 
 
 and bones, with carcinoma of the cutis and mucous membrane. In 
 this class of cases the sarcomata commence in the first decennium 
 at a tolerably high figure. Between the second and third they fall 
 to some extent, rising again in the fourth to the level of the first, 
 and then slowly falling. Carcinoma commences at a very low level 
 in the second decennium, and rises slowly in the third and fourth, 
 ascends rapidly to a considerable height during the fifth and sixth, 
 does not remain long at this level, but falls almost as quickly during 
 the next two decennia as it previously rose. The rapid fall in the 
 carcinoma curve after the age of sixty does not, as von Winiwarter 
 has pointed out, show that the disposition to cancerous diseases 
 disappears at a later period of life, for it must be remembered that 
 the number of persons living above the age of sixty is comparatively
 
 486 SARCOMA A^D CARCINOMA. 
 
 Small. With respect to the etiology of carcinoma, the ascent of the 
 curve alone can possess any accurate signification ; it is otherwise 
 with sarcoma. The mortality among the human race by no means 
 increases after the age of forty so rapidly as the curve of the 
 carcinoma sinks. We may well assume, therefore, that the dis- 
 position to the formation of sarcoma absolutely decreases after the 
 fortieth year of life. The result of this investigation may be 
 formulated thus : 
 
 Irritations, which in individuals previously disposed thereunto, lead 
 to the formation of tumours, tend, during the first three and up to 
 the fourth decenuium, principally to tlie formation of sarcoma, at a 
 later period to that of carcinoma.
 
 CHAPTER XX. 
 
 REFERENCES TO STATISTICS, TABLES, ETC. 
 
 The references given below relate to the different volumes of the 
 the ' Chir. Klin. ' Z. B. stands for the ' Ziiricher Bericht/ i860 to 
 1867. W. B., I, signifies ' Wiener Bericht ' for 1868. W. B., 
 II, ' Wiener Bericht ' for 1869-70. W. B., Ill, ' Wiener Bericht ' 
 1871-76. It should be noted that this last volume contains a 
 general statistical survey of the results of sixteen years, from i860 
 to 1876. 
 
 Chapter III. Septicaemia and Pyaemia. — W. B., II, p. 30 -, W. B., 
 Ill, p. 54. 
 IV. Erysipelas.— W. B., II, p. 6; W. B. Ill, p. 58. 
 „ VII. Section C, Phosphorus Necrosis. — Z. B., p. 83 ; 
 
 W. B., I, p. 29. 
 J, „ Section E, Cancer of Pace, Nose, and Mouth. — Z. B., 
 
 pp. 120 — 142; W. B., I, pp. 78 — 108. 
 „ VIII. Section B, Glandular Swellings. — Z. B., p. 183. 
 -jy „ Section C, Treatment of Bronchoceles. — W. B., Ill, 
 
 P- 213- 
 .„ IX. Periostitis and Caries of the Vertebral Column. — Z. B., 
 
 pp. 212, 227, 228; W. B., Ill, p. 224. 
 .J, X. Section B, Mammary Cancer. — Z. B., p. 256 — 272, 
 
 276; W. B., II, p. 146—176. 
 -,, XVI. Section B, Chronic Disease of Shoulder-joint (12 
 
 cases). Excision in 3 cases. — Z. B., p. 426; 
 
 W. B., II, p. 244. (See also p. 368 supra.) 
 .J, „ Section B, Chronic Disease of Elbow-joint (40 cases). 
 
 Excision in 18 cases. — Z. B., p. 430; W. B., II, 
 
 p. 246 ; W. B., Ill, p. 448. 
 ^ 3t Section B, Chronic Disease of Wrist-joint (24 cases). 
 
 ^Excision in 5 cases. — Z. B., p. 440 ; W. B., II,
 
 488 EEFERENCES TO STATISTICAL TABLES. 
 
 p. 254 ; W. B., Ill, p. 459. (See also p. 375 
 
 supra.) 
 Chapter XVII. Section A, Fracture of Femur (14 cases). — W. B., 
 
 II, p. 273. 
 „ „ Section A, Chronic Disease of Hip-joint (88 cases). 
 
 Excison in 7 cases.^ — Z. B., p. 500 ; W. B., II, 
 
 p. 300 ; W. B., Ill, pp. 525, 527. 
 „ „ Section A, Chronic Disease of Knee-joint (124 cases). 
 
 Excision in 8 cases.^ — Z. B., p. 516; W. B., II, 
 
 P-3M. 
 „ „ Section A, Chronic Disease of Ankle-joint and of 
 Bones of Foot (100 cases). — Z. B., pp. 532, 542, 
 546; W. B., II, p. 346. 
 
 It should be noted that in the above references the numbers given 
 only relate to the cases actually tabulated, and do not show the 
 whole number of cases which came under treatment between i860 
 and 1876. 
 
 Table showing the distribution of tumours in the different regions 
 of the body and the relative frequency of tumours in the two sexes. — 
 W. B., Ill, p. 634. 
 
 Table showing the distribution of tumours in the various tissues 
 of the body.— W. B., Ill, p. 641. 
 
 1 Operations for excision of the knee- and hip-joints appeal" to find but 
 little favour in Germany. Professor Billroth himself speaks very disparag- 
 ingly of the former operation (' Surg. Path, and Therapeut.,' Hackley's ti-ans- 
 lation, p. 488). The different views that obtain in this country may be esti- 
 mated from an admirable address on " Surgery," by Mr. T. Holmes, delivered 
 before the British Medical Association at Cambridge in 1880, and published 
 in the ' Brit. Med. Journ.' for August of that year. — [Ed.]
 
 APPENDIX I. 
 CARBOLIC-ACID POISONING. 
 
 The following case o£ carbolic-acid poisoning after ovariotomy may be 
 added to those already given.^ 
 
 From a woman, ait. 41, 1 removed a very large fibro-sarcoma of tlie ovary. 
 She got over the operation well, but a portion of the growth which had been 
 left behind in Douglas's pouch began to increase. Ichorous discharge came 
 from the cut surfaces. All the secretion escaped through an abdominal sinus, 
 which I prevented from closing up by introducing laminaria tents from time 
 to time. So it went on for months. Of the actual ovariotomy the patient 
 could be said to have recovered. I could not make up my mind to operate 
 again on the recurrent growth ; all my efforts were directed to prevent 
 decomposition of the surface of the abdominal tumour ; I intended then to 
 let the sinus close and discharge the patient as incurable. All the remedies 
 ordinarily employed failed ; after repeated dilatation of the sinus I intro- 
 duced deeply two large drains close to one another, and then injected a con- 
 siderable quantity of 3 per cent, carbolic acid solution through one of the tubes. 
 The fluid did not completely escape through the other tube, and a quantity, 
 the amount of which it was difficult to estimate exactly, remained in the 
 abdominal cavity. As there was no ill effect from this during the next 
 twenty-four hours, the injection was repeated on the two succeeding days. 
 The urine became of a veiy dark olive green, but this was such a common 
 occurrence that scarcely any notice was taken of it. On the evening of the 
 thii'd day she was attacked with severe headache, vomiting, and sleeplessness. 
 The carbolic acid was discontinued and replaced by injections of acetate of 
 alum solutions ; the headache, restlessness, and vomiting continued. On the 
 seventh day the patient was semi-comatose ; the pupils were dilated, but 
 answered tolerably quickly to light ; the urine was now normal again, but 
 the cerebral symptoms did not diminish and the drowsiness persisted. On 
 the ninth day she was attacked with repeated epileptiform seizures (unfortu- 
 nately not detailed in the records of the case) of short duration. Death on 
 the tenth day. Post moiiem : " The dura mater, like the cerebral membranes 
 generally and the brain itself, very pale ; the convolutions much flattened, 
 and the brain substance wet and softer than natural ; the ventricles dilated 
 
 ^ The case is given in the ' Wien. Ber.,' for 1860-76, in the chapter on 
 " Carbolic Acid Poisoning."
 
 490 CAEBOLIC-ACID POISONIXG. 
 
 and full of clear seram ; the brain tissue in the neiglibomhoocl of the right 
 lenticulai" ganglion and the parts immediately around tinged with a yellow 
 pigment, the nature of which could not be determined. In the bronchial 
 tubes abundant frothy mucus. Both lungs highly (Edematous and anaemic. 
 Heart natural size, slightly contracted ; in its cavity some purulent exudation. 
 The visceral and parietal pericardium injected and covered with a tough layer 
 of fibrinous exudation. The abdominal organs adherent to each other in great 
 part by stringy and membranous connective tissue. Both kidneys pale. The 
 liver, spleen, and intestinal canal anaemic."* 
 
 Such information as I have been able to gather on the subject of carbolic- 
 acid poisoning strengthens the suggestion made by Professor Billroth that 
 the simple difference of nationality may account for the greater frequency 
 of severe cases observed by him. At the same time I suspect that the sus- 
 ceptibility to the toxic action of carbolic acid does not vary so much as might 
 appear at fii-st sight. There seems to be a general consensus of opinion that 
 children and weakly women are more liable to the effects of the drug than 
 others. Through the kindness of my friend, Mr. J. A. Kempe, late house- 
 surgeon at the Hospital for Sick Children in Great Oi-mond Street, I learn that 
 among the patients there mild cases were moderately frequent, but the 
 symptoms rarely went beyond dark urine, vomiting, and elevation of tem- 
 perature. Mr. Kempe ascribed this at one time to the crade quality of the 
 carbolic acid employed, and found that with a pm*er description the cases were 
 at any rate far less frequent. The symptoms subsided always readily on the 
 discontinuance 'of the carbolic acid. It was noticed in several cases that 
 urine which at first showed no trace of the characteristic tinge became dai'k 
 after standing for some hours.^ Again, Llr. Spencer Wells, in a paper read 
 before the Royal Medical and Chirurgical Society,' stated that he had never 
 known injurious effects from carbolic acid in any of his cases of ovariotomy. 
 I have seen dark urine, associated perhaps, with slight nausea and some 
 elevation of temperature, after ovariotomy, but not proportionately more 
 frequently than after other operations. Here, again, the symptoms always 
 readily subsided after the carbolic acid had been replaced by other sub- 
 stances. Carbolic eczema is more common and, so far as I have been able 
 to leam, the carbolic antiseptic dressings are abandoned or changed for 
 
 ' Another case of carbolic poisoning after ovariotomy will be found supra, 
 p. 15. 
 
 ' See a paper by Mr. Thomas Smith in the ' St. Bart. Hosp. Rep.,' vol. xiv, 
 1878, p. 137. ]\Ir. Smith notes also (p. 144) the great susceptibility of 
 ■ cliildren to the toxic influence of the acid, but do«3 not mention any fatal 
 case. 
 
 ^ A very brief abstract of the paper will be found in the * Med. Chir. 
 
 Proc.,' vol. ir. No. i, p. 31. Bee also on the same subject the reports of two 
 
 •Tery animated discnssionB at the Royal Medical and Chirurgical Society in the 
 
 • * Lancet,' Decembor iSth, 1880, vol. ii. No 35, p. 976, and January i5th,'i88l, 
 
 vol. i. No. 3, p. ici.
 
 CARBOLIC-ACID POISONING : SHOCK. 491 
 
 others far more often on this ground than for carboluria or vomiting. 
 Phenol may produce carboluria or eczema as well as the ordinary carbolic acid, 
 but it is less apt to do so. 
 
 One other circumstance may partly account for the severity of the cases 
 reported from the Continent. Gennan surgeons believe little in " shock," 
 and after antiseptic amputations, for instance, are disposed to ascribe to the 
 effects of the carbolic acid deaths which surgeons in this country would set 
 down usually to the former cause.' Without entering into any discussion 
 on the point, it may be noted, if this view be accurate and " shock " a condi- 
 tion which should not be recognised, then we should expect to find fewex 
 deaths recorded after grave operations previous to the introduction of car- 
 bolic acid. Such, however, judging from the tables of amputations, etc., 
 given above, I do not find to be the case. The term " shock " as a cause of 
 death may be vague and general, but it affords at least as good an explana- 
 tion as one which, though definite, is of doubtful accuracy in all the cases for 
 which it is held accountable. 
 
 At a recent meeting of the Clinical Society,^ Mr. Lister adverted to the 
 great susceptibility of some patients to carbolic acid, and stated that the oil 
 of Eucalyptus glol)ulus, if used properly, was a powerful, reliable,'and unirri- 
 tating antiseptic. 
 
 Neither in Kiister's excellent essay, already referred, to, nor in other works 
 on the subject, can any very satisfactory explanation be found of the chemical 
 . action of carbolic acid on the urine. 
 
 Through the kindness of Dr. Johann Mikulicz, I learn that in Professor 
 Billroth's clinic cases of carbolic-acid poisoning and eczema are now of rare 
 occurrence, nor have any further deaths taken place from the former cause. 
 Carboluria still not uncommonly follows ovariotomy where carbolic acid has 
 been used, but has not interfered with the success of the operations.^ [E^.] 
 
 ' Some remarks on this point will be found in Langenbeck's ' Arch.,' xxiii, 
 p. 149, in the course of a paper by Dr. Ernst Kiister, entitled " Die giftigen 
 Eigenschaften der Carbolsaiire bei Chirurgischer Verwendung." The essay 
 contains numerous references to the literature of the subject. See also Mr. 
 Savory's article " Collapse," ' Holmes's Syst. of Surg.,' vol. i, p. 768, 2nd. 
 <d., which affords an interesting comparison. 
 
 2 Repoi-ted in the ' Lancet,' May 21st, 1881, No. 21, vol. i. 
 
 ' See note at end of Chapter XIV, p. 318, and also Preface.
 
 APPENDIX II. 
 
 ACUTE PERIOSTITIS AND OSTEOMYELITIS. 
 
 Peofessoe Billeoth's views on the pathology of acute periostitis and 
 osteomyelitis can hest be gathered from his ' Surgical Pathology,'^ and differ 
 in some respects from those held by writers in this country : the morbid 
 anatomy of the former affection is, for instance, very differently described by 
 Billroth* and Holmes.* Again, it would seem that osteomyelitis, as an idio- 
 pathic affection, is not uncommon in Germany and Austria. A comparisou 
 of the views of other writers, such as Chassaignac, Verneuil, Crampton, 
 Gerdy, Rognetta, Sir A. Cooper, and others, show that opinions are toler- 
 ably divided on the questions. Cornil and Ranvier,'' in a very brief essay on 
 the subject, probably hit the truth when they describe the affection as liable 
 to commence above or beneath the periosteum or in the bone itself, from 
 which description it is easy to see that these inflammations are at the outset 
 hard to distinguish apart, and are apt to run one into the other. To those 
 who are interested in these questions, I may venture to refer to a paper on 
 the subject, an abstract of which will be found in the ' Lancet,' No. 25, vol. 
 i, i88i5. [Ed.] 
 
 ' ' Surgical Path, and Therapeutics,' Hackley's trans., pp. 289, 448. 
 - Op. cit., p. 293. 
 
 ' ' Syst. of Surgery,' vol. iii, p. 741, 2nd ed. 
 
 ^ ' Manuel d'Histologie Pathologique,' 2nd ed., vol. i, p. 399 (Paris, 1881). 
 5 See also ' Proc. Med, Chir. Soc.,' vol. ix. No. 2, and/ Trans. Med. Chir. 
 Soc.,' vol. Ixiv, rSSi.
 
 APPENDIX III. 
 
 ON THE REMOVAL OF THE PYLORUS FOR CANCER. 
 
 [The essay, of which the following is a condensed translation, is the work 
 of Dr. Anton Wolfler. It describes and relates four cases of removal of part 
 of the stomach and pylorus, three of which were performed by Professor 
 Billroth and one by Dr. Wolfler himself. From want of space, the essay has 
 been necessarily very much abridged, nearly all the historical introduction 
 and numerous references being omitted. The full title of the pamphlet is 
 *Ueber die von HeiTu Professor Billroth Ausgefiihrten Resectionen des 
 Carcinomatosen Pylorus,' Vienna, 1881. — Ec] 
 
 In August, 1877, Billroth concluded a paper on a successful 
 case of gasteroraphy, with a remark to the effect that it would now 
 be but a short step to an operation for removal of cancer of the 
 stomach. Again, two years later, in speaking of a case of entero- 
 raphy, he pointed out that there was no insuperable obstacle to 
 partial resection of the stomach either on anatomical, physiological, 
 or operative grounds ; " it must succeed." 
 
 Gussenbauer and v. Winiwarter were the first to show by ex- 
 periments on animals that the physiological objections were not 
 insuperable. In the case of a dog experimented on by Czerny and 
 Kaiser,^ the animal not only lived a long time after removal of the 
 entire stomach, but the weight of the body increased one half in 
 the course of eight months. It is an interesting fact that gastero- 
 raphy was performed by a Bavarian surgeon, in 152 1.2 The first 
 surgeon actually to perform resection of the pylorus was Pean, who 
 operated on April 5th, 1879. The patient died in five days.^ 
 
 ^ Kaiser : ' Beitrage zu den Operationen am Magen.' Czerny 's ' Beitragen 
 zur Operativen Chirurgie.' Stuttgart, 1878. 
 
 ^ As learned from a rare pamphlet, entitled ' Wunderberliche czaychen 
 vergangen Jars beschehen in Regenspurg tzw der schonen Maria der mueter 
 gottes bye in begriffen.' Regenspurg, 1522. 
 
 ^ ' Gazette des Hopitaux,' No. 60, 1879.
 
 494 ANATOMY OF STOMACH AND GASTRIC CANCEE. 
 
 The second operation was performed by Eydygier/ who, on the 
 1 6th November, 1880, removed a cancer of the pylorus from a mac- 
 set. 64. The patient died twelve hours after the operation.^ 
 
 The anatomy of the stomach and gastric cancer. 
 
 The position of the stomach will be found to vary so much iit 
 different subjects that no decided rule can be laid down as to the 
 incision which will lead down most directly to the pylorus. This 
 part, when cancerous, constantly shifts its position. Rokitansky 
 knew of cases in which the pylorus had sunk down by its weight 
 as far as the symphysis pubis, and Billroth remembered a case 
 where a cancerous pylorus was found close above Poupart's 
 ligament, on the right side. To find it beneath^ or to the right or 
 left of the umbilicus, is by no means uncommon. Not only the 
 weight of the diseased part, but the adhesions also which it con- 
 tracts with the neighbouring organs, conduce to alter its position. 
 The vessels with which the operator is chiefly concerned are, the 
 pyloric branch of the hepatic artery, and the gastro-epiploica 
 dextra ; the latter vessel is easily separable from its loose connec- 
 tions with the greater curvature. The veins run parallel with their 
 arteries. 
 
 From three to five lymphatic glands are usually found in the 
 lesser omentum, and from four to seven on the greater curvature. 
 
 Gussenbauer and v. Winiwarter have shown that the pylorus is 
 a favourite seat of cancer, and that the afi'ection attacks the 
 neighbouring organs comparatively late. Among 903 cases of 
 gastric cancer, the disease started in 542 in the pylorus. Among 
 these, it was found at the post-mortem examination that in 223 
 there were no cancerous nodules. Still more important is the fact 
 that in 172 instances there were no adhesions to the neighbouring 
 organs. Of especial interest, with regard to resection of the 
 pylorus, is the fact observed by Eokitansky that cancer of the 
 pylorus scarcely ever extends down the duodenum. 
 
 1 ' Przeglad Lekarski,' No. 50, 1880. 
 
 ' It appears that about two years ago Guido Cavazzani, of Castelfranco, 
 while extirpating a tumour of the abdominal walls, successfully excised a 
 portion of the anterior wall of the stomach. Fuither details will be found 
 in the ' Gazetta Medica Italiana, Provincie Venete,' 22nd IMarch, 1879, No. 
 12, p. 99.
 
 ICTERUS : DILATATION OF STOMACH. 495^ 
 
 Treparatory treatment before operation. 
 
 It is easy enough to decide that a case is suitable for operation 
 when the cancer of the pylorus is freely movable, but it is very 
 difficult to give an opinion when the carcinoma is partly fixed. 
 The fact that only a part of the stomach is accessible to palpation, 
 and that the organ is held in place by numerous peritoneal con- 
 nections, often make it difficult to say whether the mobility is that 
 of the entire viscus or of the tumour alone. Again, the cancer may 
 be movable to some extent, owing to its being adherent to neighbour- 
 ing organs, such as the colon, or even the liver, which themselves 
 are not firmly fixed. Indeed, one of our cases showed that a 
 certain amount of mobility may be present when the cancer is 
 connected to the pancreas. Icterus, when the cancer is movable, 
 might be due to accidental catarrhal afiection, but when this sym- 
 ptom is present we should generally suspect hepatic cancer, or pres- 
 sure on the gall-duct by extension of the cancer on to the pancreas 
 or into the neighbouring lymphatic glands. 
 
 Judging from our second case, adhesions of the cancer to th& 
 abdominal walls do not seem to absolutely contraindicate operation, 
 unless of course the patient be highly marasmic, or the tumour 
 very large. We need not be deterred from operating even by 
 very marked emaciation, for gastric cancer unfortunately con- 
 sumes the strength with great rapidity, and thus the patients are 
 rarely strong when they come under observation. In order to 
 estimate the extent of the cancer and the degree of mobility, it is 
 always better to examine under an anaesthetic. Considerable diffi- 
 culty will be experienced when the pyloric cancer is associated with 
 dilatation of the stomach. Dilatation in our second case was the 
 principal reason for the fatal issue. It will always be well, there- 
 fore, to estimate the dimensions of the stomach when it is 
 distended artificially with carbonic acid gas by the administration 
 of bitartrate of potash and carbonate of soda. One of the cases 
 (No. i) shows well that the pyloric sphincter is not absolutely 
 necessary for the function of the stomach after resection ; but it may 
 be otherwise when the resection has been performed upon a dilated 
 stomach. When the stomach is able to contract well, the office of 
 the sphincter pylori can be replaced in great measure by the muscular 
 coats of the stomach, which may be able to prevent regurgitation of
 
 496 PEEPARATOEY TREATMENT 
 
 the intestinal contents or, at the least, to empty the gastric contents 
 quickly and completely into the duodenum. 
 
 Our second case showed distinctly that nutrition is gravely 
 interfered with when the stomach is greatly dilated, from the 
 insufficiency of its muscular power. We may hope that further 
 observations will show that when proper precautions are taken, 
 dilatation of the stomach does not absolutely contra-indicate 
 removal of the pylorus, for the condition will seldom be absent in 
 pyloric stenosis. If examination under an anaesthetic, etc., have 
 not enabled us to make out with certainty the extent of the cancer, 
 we can always resort to an exploratory incision as a simple and 
 usually safe help to the diagnosis. If it be decided to operate, 
 particular attention should be paid beforehand to the kind of food 
 that the patient tolerates best. Our first patient took nothing but 
 sour milk before the operation, and for two weeks after it the same 
 food was found best and most agreeable for her. Further, for 
 several days previously, and again two hours before the operation, 
 the stomach must be thoroughly washed out with tepid water. 
 This process is perhaps the most disagreeable part of all the 
 prsparatory treatment for the patients, but they soon become 
 accustomed to it if only the oesophagus tube is introduced often 
 enough. Finally, the precautions necessary for laparotomies 
 generally must be observed, such as emptying the bowels, clothing 
 the extremities with warm flannel, raising the temperature of the 
 room to 20° C, etc. 
 
 Details of the operation. — (1.) An incision should be made 
 through the abdominal waUs over the situation of the tumour. If 
 the cancerous pylorus has sunk down particularly low, it should be 
 raised up before the incision is made. The lines a, h, Fig. 27 show 
 the incisions adopted in our cases. They were from four to five 
 inches in extent. A transverse incision was, on many grounds, found 
 more convenient than a vertical one, as practised by Pean and 
 Rydygier. AH bleeding having been stopped, the peritoneum should 
 be opened and the extent and nature of the adhesions to the surround- 
 ing parts (transverse colon and pancreas, etc.) made out. If the 
 cancer should be adherent to the pancreas, Billroth advises, at present, 
 that the operation should not be further proceeded with. Complete 
 removal would render it necessary to place a ligature on some part 
 of the pancreas. This appears undesirable on two grounds ; first, we 
 know that after ligature of the parotid great swelhng and numerous
 
 ISOLATION OF PYLOEUS. TEEATMENT OP ADHESIONS. 497 
 
 small abscesses not infrequently form, leading to necrosis of 
 portions of the gland ; secondly, there is some fear that the secre- 
 tion escaping from the pancreas may dissolve the cicatrix of the 
 stomach by its peptonising properties. 
 
 Fig. 27. 
 
 If the cancer is so united to the transverse colon that there 
 would be risk of recurrence if the two were merely separated, we 
 inight think of resecting the transverse colon also, but this would 
 be a fatal complication, and greatly protract the operation. If the 
 cancer has extended over the horizontal part of the duodenum, or 
 up to the ductus choledochus — which is very rarely the case — the 
 operation must be discontinued. 
 
 (2.) Isolation of the pylorus. — As soon as the condition of the 
 parts has been made out, the stomach is drawn up to the wound , 
 and examined to see the point at which it must be cut through ; we 
 then know how far we must proceed in detaching the normal and 
 pathological adhesions. Now follows under some circumstances the 
 most difficult part of the operation, viz. the complete isolation of the 
 pylorus and the portion of the stomach and duodenum immediately 
 adjoining. To begin with, the large omentum is detached from the 
 greater curvature, and the gastro-colic ligament cut through. The 
 layers of the omentum are taken up in small portions between two clip 
 forceps, which form grooves just suitable for the application of silk 
 ligatures. The tissue is cut through in the middle between the 
 ligatures or, still better, burnt through with the thermo-cautery. 
 
 32
 
 498 RESECTION OF THE DISEASED PYLORUS. 
 
 This is not, however, always necessary, for by means of blunt 
 forceps the great omentum may be detached without any haemor- 
 rhage ; the lesser omentum is then separated in the same way. In 
 detaching the omentum enlarged lymphatic glands may be met with 
 requiring removal. During the entire operation the portion of the 
 stomach which it is intended to replace must be covered by cloths 
 which have been soaked for fourteen days in 5 per cent, carbolic 
 solution, and wrung out of warm water or warm thymol solution 
 before the operation. When the part to be resected is completely 
 exposed the most difficult and disagreeable steps are over. After 
 the stomach has been isolated, a large, flat, disinfected sponge or 
 cloth should be laid beneath the viscus, so that the further mani- 
 pulations may be carried out with ease and care. By gently 
 lifting out the stomach as far as is necessary all further proceedings 
 may be conducted outside the peritoneal cavity. The sponge and 
 cloth will prove a valuable protection if any contents left in the 
 stomach escape when it is cut into. 
 
 (3.) Resection of the diseased portion. — If it is intended to 
 attach the duodenum to the lesser curvature of the stomach, as in 
 our first two cases (see Plate III, figs. 2 and 5), the incisions 
 are best made as sliown in Plate III, figs, i and 3, The tumour 
 being seized with the vulsellum, the walls of the stomach are cut 
 through with scissors, commencing at the greater curvature. 
 After each stroke of the scissors any bleeding points are secured ; 
 about two thirds must be divided. If it be found that the stomach 
 is not completely empty, the contents should be soaked up with a 
 sponge specially reserved for this purpose. All vessels are now 
 ligatured with fine antiseptic silk, and the cut edges of the stomach 
 so united together that the serous coats are applied to each other. 
 Billroth applies superficial sutures where necessary, in addition to 
 intestinal sutures. The knotted threads are left hanging for the 
 time (Plate III, fig. 3, and fig. 4 n), so as to hold the stomach. 
 The cancerous pylorus is now connected to the intestine alone. 
 Pig. 4 shows the manner in which the division is commenced iu 
 order to separate it from the horizontal part of the duodenum. If 
 there is any fear lest the portion of duodenum should slip away 
 when the division is completed, a few silk threads may be passed, 
 as shown in fig. 4 l. If they are required it will be found better to 
 pass them through the anterior wall of the gut. A small sponge 
 may be inserted temporarily into the duodenum.
 
 METHOD OP UNITING DUODENUM TO STOMACH. 499 
 
 (4.) The insertion of the duodenum into the stomach. — As with the 
 intestine, so here also, we must begin at the posterior walls of the 
 stomach and duodenum. A very good plan of uniting them is to insert 
 the posterior sutures before the duodenum is completely separated. In 
 our first case the entire stomach was cut through, and then the upper 
 half of the duodenum. Several threads were then carried through 
 the walls of the stomach and duodenum to form the posterior 
 " ring suture,^' and were then given to an assistant to hold while 
 the occlusion sutures were being inserted j it was found, however, 
 that the sutures cut their way a little through the thin wall of the 
 duodenum, and that the punctures made by the needle enlarged. 
 In the second case the gut was partly divided, enough being left 
 to hold up the duodenum while the sutures were applied at the back. 
 The disadvantage of this method is that the posterior wall of the 
 duodenum has to be twisted if the operator wishes to make sure of 
 applying these very important sutures with precision. It is far 
 more convenient to apply the posterior "ring sutures" from 
 within, as shown in Plate III, figs. 10 and 11, which were drawn 
 from a preparation made from the dead subject. The needle should 
 be inserted between the mucous and muscular coats, carried through 
 between the muscular and the serous, then through the same layers 
 of the duodenum, and finally brought out between these layers and 
 the mucous membrane at the cut edges. These " inner intestinal 
 sutures " resemble Czerny's modification of Lembert's suture. At 
 my own suggestion first, they were inserted from within outwards, 
 in order to bring a considerable breath of the serous coats into 
 apposition ; the needle should pierce these layers about a centimetre 
 from the cut edges. The edges of the mucous membrane fall 
 naturally into apposition, for, owing to the strong retraction of the 
 muscular coat, the mucous lining always projects a little. If 
 at any point this is not the case, a very fine suture can be 
 carried through the mucous membrane, and the threads cut off 
 quite short (Plate III, fig. 11). The knots of the inner intestinal 
 sutures will thus obviously fall inwards. In this way the posterior 
 walls of the stomach and duodenum are united ; the sutures are 
 now inserted on the anterior surfaces in the ordinary way. It is 
 well to put in a few additional superficial sutures at the point 
 marked " m " in fig. 5. As we know that the ordinary Lembert's 
 knot, such as has been described, brings the inner surfaces into 
 good apposition, it might seem superfluous to put in additional
 
 500 
 
 INTESTINAL * KING SUTURES. 
 
 sutures to unite the cut surfaces of the mucous membrane ; still, I 
 think it is as well to insert at least two or three, and thus to make 
 sure that every part of the cut surface is covered over. This is of 
 importance, for the gastric juice might attack the wounded surface 
 if it were exposed. If it be desired to unite the mucous membrane 
 on the anterior wall, the threads must be inserted from the outside 
 before the Lembert's sutures are passed through the serous coat. 
 Gussenbauer and Czerny have already insisted on the importance 
 of uniting, not only the serous surfaces, but also the edges of the 
 wound. 
 
 Fig. 28. — GrssENBAUEB's Ls'tes- 
 
 TtNAL SniTEE. 
 
 Fig. 29. — Czebxt's Intestixal 
 
 SUTUBE. 
 
 y Mucosa. 
 
 — Muscul. 
 ■'•Serosa. 
 
 When all the sutures have been inserted and finally inspected, a 
 sponge soaked in weak carbolic lotion is laid on the anterior surface of 
 the stomach, and the abdominal walls are united in the ordinary way 
 with lead button sutures, with a few ordinary sutures between them. 
 When all the sutures had been inserted in the first case, we were 
 not a little astonished at the excellent shape of the new-formed 
 stomach (see Plate III, fig. 2), which was almost normal in appear- 
 ance. The greater and lesser curvatures alone were somewhat flat- 
 tened. In our second case, therefore, we saw no reason to alter 
 the plan of attaching the duodenum to the lesser curvature. In 
 consequence, however, of the immense dilatation of the stomach in 
 this case, and the greater extent of the cancer, which rendered it 
 necessary to modify the direction in which the duodenum was 
 divided, a diverticulum formed (Plate III, fig. 5 d), as wiU be 
 described presently. Profiting by this experience the following plan 
 was adopted in the third case : — The duodenum was attached to the
 
 UNION OP DUODENUM TO GREATER CURVATUEE. 501 
 
 greater curvature of the stomach, in order to guard against the- 
 formatioH of a diverticulum, and to provide for the more ready 
 passage of the gastric contents. Unfortunately, the patient, who 
 was in a very reduced state, died twelve hours after the operation. 
 This was the most complete of all Professor Billroth's three resec- 
 tions. Figs. 6 and 7, Plate III, show the direction of the inci- 
 sions, and the resulting form of the resected stomach. 
 
 The only modifications necessary if the duodenum be united to 
 the greater curvature of the stomach are, that the separation should be 
 commenced at the lesser curvature; the occlusion sutures (n, Plate 
 III, fig. 4) should be inserted at once as before, and the rest of the 
 operation conducted as shown in Plate III, fig. 4. If there is any 
 fear lest a diverticulum should be formed at the lesser curvature, it 
 would be as well to carry the incision obliquely through the walls 
 of the stomach, as shown in fig. 6, provided the extent of the cancer 
 permitted it. Under some circumstances, we might find ourselves 
 comj)elled to insert the duodenum midway between the greater and 
 lesser curvature, as shown in figs. 8 and 9, which illustrate the 
 necessary incisions, and the resulting shape of the stomach. 
 
 Under all conditions it is desirable to divide the stomach obliquely, 
 in order to prevent the formation of diverticula. In future cases 
 Professor Billroth intends, whenever possible, to attach the duo- 
 denum to the greater curvature. In none of our cases did a single 
 drop of the contents of the stomach or duodenum escape into the 
 peritoneal cavity, although we used no special contrivance to occlude 
 temporarily either end of the canal. The elastic compressorium 
 employed by Rydygier seems to me not only superfluous, but 
 injurious.^ 
 
 With regard to the method of sewing up the stomach, I think 
 the main point is to avoid any folds ; this will be accomplished by 
 carrying the incision obliquely through the viscus, so that more is 
 cut away from the part where the occlusion Sutures are to be 
 inserted than from the other side. Secondly, the lumen of the 
 stomach should be so far closed by means of Lembert's sutures that 
 the opening left is no larger than that of the duodenum. 
 
 The after-treatment is simple enough when matters progress 
 favourably. In Case i the dressings were first changed and the 
 sutures in the abdominal wall removed on the sixth day. 
 
 Although the second and third cases ended fatally, no general 
 
 ^ On this point see Gussenbauer, ' Arch, f . Kl. Chirarg.,' Bel. xix, p. 350.
 
 502 DIET AETEE OPEEATION. 
 
 peritonitis was set up in these or any of the patients. The second 
 patient died of inanition the result of the mechanical obstruction, and 
 the third of collapse. The diet after the operation is a point of great 
 importance in the after-treatment. Sometimes, nay usually, the 
 patients are in great need of nourishment and will not long tolerate 
 the simple administration of ice. To the first patient, a feeble 
 woman. Professor Billroth did not hesitate to give a tablespoonful 
 of cold sour milk every hour the day after operation ; this was ex- 
 ceptionally well borne. During the following days, larger quantities 
 were given, so that by the eighth day the patient took a litre or more 
 of milk in the twenty-four hours ; subsequently up to the fourteenth 
 day she had some tea and cocoa boiled in milk, wine, and wine- 
 soup, and at the end of a fortnight she was able to take meat. At 
 the outset we had great hopes that we should be able to carry the 
 patients through the first few days by means of nutrient enemata, 
 but neither peptone or pancreatic injections were tolerated ; they 
 generally set up diarrhoea, which reduced the patients very much. 
 We were thus limited to injections containing wine, which at first 
 were given every third hour, directly after the operation and during 
 the next few days, and answered well. Further details will be 
 given in the descriptions of the cases. 
 
 Cas£ I. — Therese Heller, aet. 43, was admitted on the 25th Januaiy, 1881. 
 The patient had suffered for three months from symptoms of indigestion. 
 Every day, about half an hour or an hour after her meals, she brought up 
 the greater part of what she had taken. There was no blood in the vomit 
 but the stools were usually tarry. For some time previous to admission she had 
 been able to take nothing but sour milk. She had wasted much and lost 
 strength, was very anemic, and for the last six weeks had been forced to 
 keep her bed. The skin and mucous membranes generally were pale, the 
 tongue furred, the pulse thready, the abdominal walls flaccid. In the 
 umbilical region could be felt a hard, easily movable tumour, painful on 
 pressui'e, and about the size of a small fist. It was unconnected with the 
 abdominal walls. On the left side of the gi'owth the limits of the stomixch 
 could be distinctly made out by percussion. Other organs normal. Taking 
 into account the weak state of the patient, operation could not long be post- 
 poned. 
 
 The evening before the oi)eration enemata were administered, and an hour 
 before the stomach was washed out. We introduced into the stomach a 
 moderately large drainage tube, to the upper end of which a glass funnel was 
 connected. Through this about a litre or a litre and a half of lukewann 
 water was poured in ; as the funnel was depi'cssed the fluid escaped again, 
 the tube acting as a syphon. This proceeding was repeated several times, 
 until the water escaping from the stomach was perfectly clear. About fom*.
 
 FIKST CASE OP EEMOVAL OF PYLOKUS. 503 
 
 teeu litres of water were employed to wash out tlie organ. The temperature 
 of the operatiug room was kept at 20° C. The operation was performed on 
 the 29th January, 1881. An incision, eleven centimetres long, was carried 
 from right to left over the tumour, above the umbilicus (p. 497, fig. 27, a). On 
 dividing the peritoneum the tumour was found to occupy the pyloric region 
 and the adjoining part of the anterior and posterior walls of the stomach. It 
 proved to be larger than the examination had led us to suspect. The growth 
 was now drawn somewhat forward through the abdominal incision. By 
 means of a cloth, prolapse of the intestines was readily prevented. Double 
 ligatures were carried through separate small portions of the lesser omen- 
 tum, which was then divided between the ligatures, above its connection 
 with the tumour. Five fine silk ligatures were left on the small, and six on 
 the great omentum, which was divided in the same way. The great omentum 
 and the transverse colon were adherent to the gi-eater curvature and thickened. 
 A lymphatic gland, the size of a hazel nut, and two small nodules, which felt 
 hard, were removed, together with the altered gastro-colic ligament. Any 
 parts which to the eye or the touch gave suspicion of cancerous changes were 
 removed, but it was quite possible that in the poiiion of the omentum which 
 was connected to the transverse colon some microscopic nodules were left 
 behind. The jiyloric end of the stomach was in this way completely isolated ; 
 cloths were laid behind the stomach, and the wound in the abdominal walls 
 was protected by sponges from any escape of the gastric contents. The duo- 
 denum was now cut into from above, and the stomach obliquely divided, as 
 shown in Plate III, fig. i. Nothing escaped from the stomach, which was 
 completely empty. The temporary sutures were now inserted in the lesser 
 curvature and the corresponding pai't of the duodenum, as shown in fig. i, l. 
 Next, the stomach and the duodenum were completely cut through and the 
 pyloric tumoiir removed. Four vessels on the stomach required ligature. 
 The lumen of the stomach was partly closed from below upwards 
 with twenty-one sutures, some deep, some superficial. The union of the 
 opening left at the lesser curvature of the stomach with the duodenum was 
 completed by means of thirty-three silk sutures. All the sutures were cut 
 short and left in the cavity of the abdomen. As already mentioned, the wall 
 of the diiodenum could not stand the strain exercised on it by the temporary 
 sutures, and the punctures became enlarged to the size of a lentil, rendering 
 more superficial sutures necessaiy. The stomach was now returned into the 
 abdominal cavity, its surface having been sponged over with a 2 per cent. 
 solution of carbolic acid. Finally the abdominal wound was closed. 
 
 No drainage tubes were inserted, nor was the spray employed 
 during the operation. Carbohc dressings were applied. The opera- 
 tion lasted one hour and a half. The size and shape of the tumour 
 can be gathered from Plates I and II. The part removed mear 
 sured 14 centimetres (5^ inches) along the lower, and 10 centi- 
 metres (4 inches) along the upper border. The incisions had 
 -been carried 2 centimetres beyond the limits of the disease on 
 either side. The pyloric opening was so narrowed that a probe
 
 504 PROGRESS OF FIRST CASE. 
 
 could with difficulty be passed through. Microscopical examination 
 showed the tumour to be an alveolar colloid cancer, and a similar 
 morbid growth was found in the lymphatic glands. 
 
 The progress of the case was favourable. On the second, tenth, 
 and twelfth days the temperature rose to 39° C, and during the 
 intervals it varied between 37° and 38-4° C. On the fifteenth day it 
 ■was normal. With the exception of a feeling of weight during the 
 first twenty-four hours, the patient had no particular subjective 
 sensations. The abdomen kept flaccid, there was no vomiting, and 
 from the very first flatus passed abundantly. During the first day 
 the patient had nothing but ice, on the second day acid milk (a 
 coffee-spoonful every hour), subsequently sweetened milk, and then 
 gradually cofi'ee, cocoa, tea, port w^ine, eggs, biscuits, and 
 " schinken." On the twentieth day after the operation, our patient 
 was able to eat a cutlet with the best of appetite, and on the 
 following day a beef-steak. 
 
 As I have already mentioned, neither the peptone nor the 
 pancreatic injections were tolerated. It was found that they 
 caused flatulence and colic. Wine enemata were persevered in 
 with advantage up to the thirteenth day. 
 
 During the first twelve days the state of the bowels gave rise to 
 some anxiety. Although the patient ate comparatively little, still 
 large quantities of faeces were passed, but so hard were they that 
 the nurse had sometimes to scoop them out with her fingers.' The 
 motions were so white and chalk-like that we feared that the 
 functions of the bile were not properly discharged. As soon, 
 however, as the patient began to take solid food, the stools (at the 
 end of the second week) again became of a brown colour and the 
 faecal masses diminished in size, a proof that the peptonising 
 functions of the stomach had recommenced. 
 
 The abdominal incision was completely healed by the eighth day. 
 
 A few days later an infiltration, which scarcely gave any pain, 
 could be felt beneath the cicatrix, but this had almost disappeared 
 when the patient was discharged at her special request on the 20th 
 February. The further treatment of the case was carried on by 
 Drs. Mikulicz and Ehrendorfer. On the loth April (seven weeks 
 after her discharge) I heard that her condition was very satisfactory ; 
 her nutrition was distinctly improved, she could take any kind of 
 food, the bowels acted normally, and she was able to be about all 
 day.
 
 SECOND CASE OP EEMOVAL OF PYLOEUS. 505 
 
 (Through the kindness of Dr. Wolfler I learnt that this patient died of 
 exhaustion on the 24th May, 1881, nearly four months after the operation. 
 To within a fortnight of her death scarcely any symptoms of indigestion 
 were noticed. The post-mortem exanunation revealed cancerous degeneration 
 of the i:)eritoneum and infiltration of the retro-peritoneal lymphatic glands. 
 The form of the stomach was similar to that of the normal organ. Further 
 information about the case will be found in the ' Wien. Med. Woch.' for 
 28th May, 188 1, No. 22, p. 634.— Ed.) 
 
 Case 2. — Johanna Schonstein, ajt. 39, was admitted on the 24th February, 
 1 88 1. For some months she had suffered from indigestion, loss of appetite, 
 sense of weight in the gastric region after taking solid food, and heartburn. 
 Two months before admission she had some circumscribed peritonitis about 
 the gastric region and some induration was noticed under the ribs on the left 
 side. For some weeks she had only been able to take soup, milk, and coffee. 
 The bowels acted once only in six or eight days, and the stools were tarry. 
 The patient had never vomited. 
 
 When first seen she was very much emaciated and anaemic, having lost 
 ground very much for some time immediately preceding admission. She 
 readily agreed to any operation which gave her a chance of relief from her 
 sufferings. The carcinoma of the stomach seemed to be about the breadth of 
 the palm of the hand, hard, painful on pressure, and tolerably movable. It 
 was situated on the left side, between the umbilicus and the arch of the ribs. 
 The growth evidently had no connection with the liver, but it seemed to be 
 adherent to the abdominal wall. The tongue was rather coated, the pulse 
 small, the temperature normal. The favourable experience of the first case, 
 the youth of the patient, and the fact that the tumour was movable, decided 
 Professor Billroth to operate, or at the least to make a diagnostic incision. 
 The preparatory treatment was the same as in the former case. [The operation 
 was modified in the following particulars : — The stomach and the duodenum 
 were not cut through until the occlusion (Plate III, fig. 4 n) as well as the 
 fixation sutures had been inserted. The operation was performed on the 
 28th Febraary, 1 88 1 . A transverse incision, twelve centimetres (four and three 
 quarter inches) in length, was made over the tumour. The growth appeared 
 to be united to the transversalis fascia, a portion of which and of the adherent 
 abdominal wall were left attached to the tumour. The growth was found to 
 invade the pyloric region of the stomach ; as this was drawn forwards the 
 patient vomited up about half a litre of fluid which had been employed to 
 wash out the stomach. The great and small omenta were then secured with 
 seven and four ligatures respectively. In ligaturing the former, the right 
 gastro-epiploic artery had to be tied. The stomach was now half cut through 
 with the scissors, beginning at the greater curvature. The pylorus was iso- 
 lated, and sponges and cloths laid behind it. The stomach contained 
 also some undigested remnants of food. The cavity was washed out 
 with lukewarm water and its walls cleansed with disinfected sponges. It 
 was then found that the viscus vras exceptionally dilated towards the diaphragm 
 and the left ribs, so that with the longest sponge forcei^s I could not reach 
 the end. Before the complete division of the stomach twenty-eight deep and
 
 506 PKOGRESS OF SECOND CASE. 
 
 superficial occlusion sutures were applied (Plate UI, fig. 3 n) ; then the 
 organ being completely divided through its lesser curvature, the lumen ' a ' 
 (Plate III, fig. 4), was left ; the duodenum was next partly cut through, and 
 the Lembert's sutures (l, l, l) inserted ; the duodenum was now completely 
 severed, and the tumour removed. The other " ling sutures " were inserted 
 and the threads (l) tied ; no difficulty was found in drawing the stomach over 
 to the duodenum. The total number of sutures inserted was fifty -eight. 
 
 As shown in Plate III, fig. 5, a diverticulum (d) formed at the 
 greater curvature. There was no doubt that it was principally due 
 to the fact that the stomach and the duodenum had been cut 
 through in a vertical direction. The abdominal wound was closed 
 and antiseptic dressings applied. No drainage tubes; no spray 
 during the operation, which lasted two hours and three quarters. 
 The excised portion measured ten centimetres along the greater, five 
 centimetres along the smaller curvature, and six centimetres in 
 breadth. The pylorus was filled up by a cancerous mass, its 
 opening just admitting the tip of the finger. The growth was 
 ulcerated on its surface, and proved to be an epithelial cancer. 
 
 The patient died of inanition, with symptoms of great anaemia, on the 
 eighth day after the operation. The morning after the operation she vomited 
 300 grammes of brownish fluid. In the evening, after taking a little milk, 
 retching set in at once. The third day she was better and Ixad taken some 
 m.ilk, etc., but on the fourth day, after taking a little milk, bilious vomiting 
 began. Dui'ing all this time there was no distension ; flatus passed, the 
 wound looked well, and the temx)erature was normal, but the pulse varied 
 between 112 and 120. It was clear that the dilatation of tlie stomach was 
 the essential cause of the vomiting. Evidently the gastric contents did not 
 flow into the duodenum, and evidently also there was no complete stenosis 
 where the '• ring sutures " were applied, for bile was present in the vomit. 
 Suspecting that a quantity of fluid might have collected in the flaccid sac of 
 the stomach, we drew ofE the contents and evacuated about 200 grammes of 
 yellowish, sour fluid. Attempts were made to restore the functions by the 
 administration of good wine and meat, but all in vain ; the greater part was 
 thrown up again in a few houi-s. By the next day we were restricted to 
 giving nutrient euemata. Thinking that a diverticulum might have been 
 left in the stomach, and that some obstruction must exist which had not 
 been present before the operation, for the patient had never previously 
 vomited and had always been able to take fluid food, Professor Billroth 
 adopted the last resource which the circumstances seemed to indicate. The 
 wound was reopened and the occlusion sutiu'es cut. The index finger passed 
 into the stomach could only with difficulty be introdiiced into the duodenum. 
 The anterior " ring sutmes " were also divided and the wall of the duodenum 
 attached to the abdominal walls, a drainage tube being passed into the gut
 
 CAUSE OF DEATH IN SECOND CASE. 507 
 
 for the administration of food. The patient was very pale and collapsed 
 after this operation, which lasted an hour. She died on the following day. 
 
 The post mortem, as we expected, showed no general peritonitis, but only 
 general anasmia and marasmus. 
 
 On reviewing the case of Frau Schoustein we may note that the 
 post mortem proved that the cancer had been completely removed, 
 and that no trace of peritonitis existed. The cause of death was 
 chiefly due to the great dilatation of the stomach ; numerous other 
 unfavourable circumstances were added which rendered the point of 
 junction of the stomach and duodenum impermeable. The hori- 
 zontal part of the duodenum near the lesser curvature was attached 
 to the cicatrix, while the large sac of the stomach was situated at the 
 lower and back part. Thus a sharp bend must have undoubtedly 
 been caused similar to those which Kussmaul has shown to be 
 present in cases of dilatation of the stomach. In addition to this, 
 the duodenum in our case was attached to the thickened edge on 
 the lesser curvature, and thus the lumen, where the " ring sutures " 
 were inserted, was converted into a slit, through which the atonic 
 muscular coats of the stomach were unable to drive the gastric 
 contents. The peristaltic movements of the stomach became 
 reversed and vomiting set in. The importance of dilatation of the 
 stomach as a complication was well shown by this case. 
 
 Case 3. — Prauziska Heininger, single, was admitted 8th March, i88x. 
 She had suffered from gastric troubles and daily vomiting for about a year. 
 Since October, 1880, she had only been able to take fluid food, and since the 
 same date a tumour had been noticed and she had suffered marked pain in the 
 gastric region. When admitted she did, however, take solid food without vomit- 
 ing, but complained of heartburn. She frequently went eight days without 
 any action of the bowels. The patient had become greatly emaciated during 
 the few months previous to admission. When first seen she was very anaemic 
 and wasted ; the mucous membranes were pale, the skin dry, the pulse 88, 
 tlie abdomen soft ; above and to the right of the umbilicus was situated a 
 slightly nodulated tumour, rather larger than a hen's egg, and somewhat 
 movable : its limits could not be exactly defined ; it was free from the abdo- 
 minal walls, gave pain on pressixre, and shifted its position with the respira- 
 tory movements. No dilatation of the stomach could be made out. If she 
 took meat she vomited up the contents of the stomach, with some blood. 
 Milk, coffee, and broth she could take well. The preparatory treatment for 
 the operation consisted in washing out the stomach, nutrient wine enemata, 
 and the usual antiseptic measures. The operation was performed on the 1 2th 
 March, 1881. No spray. An incision was made, four and three quarter 
 inches long, as shown in Fig. i a. The right rectus was cut through, the
 
 508 THIRD AND FOUETH CASES OF REMOVAL OF PYLORUS. 
 
 peritoneum opened, and the cancerous pylorus drawn forward as far as pos- 
 sible. The large omentum was ligatured with eight and the small ^vith six 
 silk threads ; both were then cut through. The cancer was now found to be 
 attached to the pancreas ; the separation was exceedingly difficult, for Pro- 
 fessor Billroth, in \'iew of the subsequent danger to the digestive functions, 
 was unwilling to ligatui-e the pancreas. The gastro-duodenal artery and 
 several other vessels in the neighbourhood were secured. The isolation of 
 the pancreas alone occupied about an hour. The stomach was divided 
 obliquely as far as the centre, as shown in Plate III, fig. 6. The organ con- 
 tained no fluid. Ten occlusion sutures were now put in, and the rest of the 
 stomach divided down to the greater curvature. The duodenum was now 
 cut obliquely from above downwards. On this occasion no provisional sutures 
 were inserted. The back wall of the duodenum was united to that of the 
 stomach by five "inner intestinal" sutures, and the mucous membranes also 
 brought together by three fine tlireads. The rest of the " ring sutures " were 
 completed from the outside. The total number required was thirty -six. The 
 operation lasted two hours and a half ; very little blood was lost ; none of 
 the contents of the stomach or duodenum escaped into the peritoneal cavity. 
 The shape of the stomach was veiy satisfactory, as shown in Plate HI, fig. 7. 
 The patient, who was very anajmic, was much collapsed during the operation. 
 She retched fi-equently during the afternoon, in the evening became suddenly 
 restless, and died the. same night. 
 
 The excised portion measured twelve centimetres along the greater curva- 
 ture, and five along the lesser. The opening of the pylorus just admitted the 
 finger. The gi'owth proved to be medullary cancer. At the post mortem it 
 was found that the cut edge of the duodeimm was about five centimetres from 
 the opening of the ductus choledochus, but this, as well as the pancreatic 
 duct, was well away from the region of operation. Cancerous glands were 
 found neai' the head of the pancreas and in the lesser omentum. In addition 
 there was gi-eat general anaemia, old tuberculosis of the apices of the lungs, 
 and miliary tubercle on and about the plem-a. 
 
 In future, the operation should not be undertaken in cases such as 
 the above ; the great anaemia and the union of the cancer to the 
 pancreas make it a matter of no surprise that the patient died so 
 rapidly. Another time we should abstain from excising the 
 pylorus if an exploratory incision revealed a similar state of affairs. 
 
 Case 4. — On the 8th of April, 1881, Dr. Wolfler had an opportunity of 
 resecting a cancerous pylonis in a patient, set. 52. The tumour was about 
 the size of an apple, and freely movable in every direction. A transveree 
 incision was made above the umbilicus ; the pylorus was readily isolated, as 
 there were no pathological adhesions. The stomach, which was greatly 
 dilated, was cut through obliquely from left to right, beginning at the lesser 
 curvature. Ten occlusion sutures were inserted, and the stomach then com- 
 pletely divided. Three threads were inserted provisionally through the duo- 
 denum in cfi'der to fix the gut, which was then cut thi'ough in the direction
 
 PROGNOSIS. TREATMENT WHEN STOMACH IS DILATED. 509 
 
 shown in Plate III, fig. 6. Thirty " ring sutures " (fourteen internal, sixteen 
 external) were put in and the stomach replaced. The excised mass measured 
 twelve centimetres along the greater curvature. The patient was perfectly 
 free from reaction after the operation. She had no fever, vomiting, or sym- 
 ptoms of peritonitis. For the firet four days she had retching and Ivearthurn 
 several times during the day. On the fifth day her condition was perfectly 
 satisfactory. For. the first nine days she was given fluid food (milk, wine, 
 eggs), which was well borne. By the tenth day she was ahle to take meat. 
 The abdominal wound healed by first intention, and the gastric region was 
 perfectly painless on pressure thirteen days after the operation. 
 
 (Dr. Wolfler writes, under date 28th June, that this patient was then per- 
 fectly well, and was able to take all kinds of nourishment without harm. 
 She was kept under close observation, but no trace of recurrence had, up to 
 date, been discovered.) 
 
 The question might be asked, whether the cicatrix of the stomach 
 after this operation would be able permanently to resist the action 
 of the gastric juice. This may be answered in the affirmative, for 
 we know that many gastric ulcers heal up, and the cicatrix left is not 
 affected by the gastric juice. Further, the permanency of recovery 
 in the cases of gasteroraphy performed by Billroth and Esmarch 
 affords additional evidence of the fact. A patient, on whom more 
 than three years previously Billroth had operated for a large 
 gastric fistula, wrote to us that he continued perfectly well, could 
 take any kind of food, and had not the least pain in the part. 
 
 Is it possible that a cicatricial stricture might originate, perhaps 
 after some years, at the part where the " ring sutures " are inserted ? 
 Our experience of other cases enables us to dismiss this fear. 
 Billroth performed enteroraphy on three patients in the years 1878 
 1879, and 1880, and he heard from them in 1881 that they were 
 going on excellently, that they had no trouble from indigestion, and 
 that the bowels acted normally. We may conclude, then, that no 
 narrowing will take place at the junction of the stomach and 
 duodenum if the serous surfaces unite by first intention. A more 
 important question is the course to be pursued when the stomach 
 is much dilated. Under such circumstances the best plan appears 
 to be to attach the duodenum to the greater curvature. A com- 
 parison of the third and fourth cases illustrates this point. If in 
 excising the pylorus much difficulty is found in drawing the 
 duodenum over to the stomach, it would be proper to leave a 
 fistula into the duodenum for the purposes of nutrition. 
 
 The diseases for which resection of the pylorus should be 
 Deserved are cancer and other rarely occurring tumours, ulcers of
 
 610 CASES SUITABLE FOR EXCISION OF PYLOEUS. 
 
 the stomach, and cicatricial stenosis. In ulcer of the stomach, the 
 operation will be especially indicated if the patient is unable to 
 take any nourishment, or when the anaemia from the haemorrhage 
 gives cause for much anxiety. It is known that ulcers of the 
 stomach are generally situated on the lesser curvature and the pylorus. 
 If on the pylorus, the operation will be like those already described ; 
 if on the lesser curvature the wound of the stomach must be united 
 longitudinally after the ulcer has been excised. This operation 
 would only be difficult when the ulcer lies on the posterior wall 
 of the stomach and is adherent — as it would be — to the pancreas. 
 
 Can a cancer of the pylorus be radically and permanently extir- 
 pated ? The same questions arise here as with regard to the radical 
 cure of cancer in general. As with other carcinomata, recurrence 
 will certainly occur less often when the operation is performed 
 early, the incisions carried wide of the cancer, and when every part 
 that looks the least suspicious during the detachment of the omenta 
 is removed.
 
 INDEX. 
 
 .Abdomen, injuries of, 227 
 
 — penetrating wounds of, 227 
 Abscess, congestive, treatment of, 184 
 
 — perforating gluteal artery, 322 
 iliac artery, 185 
 
 ' — periarticular, 412 
 
 — retro-peritoneal, 229 
 
 — — perforating bladder, 257 
 
 — spinal, treatment of, 179 
 Adenoma, 481, 484 
 Adeno-cysto-saecoma, 213 
 Adeno-fibeoma, 210 
 
 AliKALXJRIA AND CALCULUS, 274 
 
 — in cystitis, 260, 262 
 Alveolae abscess, 51 
 
 — SAECOMA, 381, 382 
 Ammoniacal ueine, 263 
 Amputation, bloodless, at liip-ioint, 
 
 417 
 Amputations, general survey of, 469 
 An^emia, gangi'ene from, 404 
 Anjssthexics, 6 
 Aneueism of aorta, 196 
 
 — arterio-vcuous, 455 
 
 — compression in, 452 — 457 
 
 — cure of, 458 
 
 — femoral, 451—455 
 
 — radial, 376 
 
 — subclavian, 376 
 
 — of thyroid axis, 196 
 
 — traumatic, 376, 377, 454 
 Angioma, chronic diseases of, 480, 488 
 
 — arterio-veuous, 86, 87 
 
 — caveruosum, treatment of, 88 — 92 
 
 — of side, 202 
 
 Ankle-joint, chronic diseases of, 443, 
 
 488 
 Ankle, compound dislocation of, 400 
 Ankylosis, cartilaginous, 432 
 
 — of elbow, 371 
 
 — of hip, 431 
 
 — of knee, 431, 437—441 
 
 Ankylosis of wrist, 373 
 Antiseptic deessings, 1 , 2 
 
 — treatment, 1, vi 
 
 — — of amputations, 47.2 
 Anteum, suppuration of, 51 
 Antyllus's operation, 452, 455, 457 
 Aesenic, in lymphoma, 152 
 
 — in skin diseases, 53 
 Aeteeial clamp, 45 
 Aeteries, wound of tibial, 402 
 Aeteeio-venous angioma, 86, 87 
 Aeteeitis, 404, 410 
 Aetheitis defoemans, 369 
 AsPHYxiE locale, 409 
 Atheeoma of finger, 378 
 Ateesia ani, 251 
 
 — aurium, 48 
 
 — narium, 54 
 Ateophy from injury, 340 
 
 B. 
 
 Back, injuries of, 190 
 Bacteeia in urine, 263 
 Bladdee, catarrh of, 260 
 
 — extroversion of, 284 
 — ■ foreign body in, 258 
 
 — neuralgia of, 259 
 Bone, cancers of, 482 
 
 — softening of, 466 
 Beachial, ligature of, 877 
 
 — ple.Kus, laceration of, 353, 355 
 Branchial fistula, 130 
 Breast, cancer of, 216, 225 
 
 — diseases of, 206 
 
 — double cancer of, during preg- 
 
 nancy, 215 
 
 — hypertrophy of, 207, 209 
 
 — involution cyst of, 210 
 
 — male, diseases of, 225 
 
 — malignant and non-malignant 
 
 tumours of, 484 
 
 — neuralgia of, 206 
 
 — removal of, for cancer, 222
 
 512 
 
 IKDEX. 
 
 Bbostchoceles, 487 
 
 — cjstic, 157, 168 
 
 bursting into pharynx, 165 
 
 treated by puncture, 158 
 
 — degeneration of, 174 
 
 — during pregnancy, 170 
 
 — dyspnoea in, 163 
 
 — effects of puberty on, 175 
 
 — extirpation of, 162 
 
 — iodine injections in, 159, 162, 167, 
 
 170, 173 
 
 — laceration of, 160, 162 
 
 — malignant, 168, 169 
 
 — pulsating, 175 
 
 — sarcomatous, 176 
 
 — spontaneous softening of, 176 
 
 — substernal, 164, 168 
 
 — tenotomy of sterno-mastoid for, 
 
 162 
 
 — varieties of, 157 
 BfBSAIi TTJirOTJB, 378 
 
 CAicrxtrs, case of, 273 
 
 — internal treatment of, 278 
 
 — operations for, 274 
 
 — spontaneous disruption of, 278 
 Cancee, 481, 484 
 
 — alveolar, of tongue, 112 
 
 — double, of breasts during preg- 
 
 nancy, 215 
 
 — metastatic of spine, 186 
 
 — of breast, 216 
 
 — — operati^-e treatment of, 222, 
 
 223 
 
 — of face, 103 
 
 rhinoplastic operation for, 104 
 
 treatment of, 104 
 
 — of jaw, 106, 107 
 
 — of moutb, 110, 116 
 
 — of orbit, 119, 120 
 
 — of pylorus, 230, 494, 510 
 
 — of rectum, 254 
 
 — of tongue, treatment of, IIS, 114 
 
 — of tonsils, 112 
 
 — of tracbca, 138 
 
 — papillary, of tracbea, 134 
 
 — visceral, after mammary, 219 
 Caebolic-acid poisoning, 7, 4S9 
 
 — eczema, 490 
 
 — marasmus, 12 
 
 — poisoning, pathology of, 14, 15 
 
 — spray, 306, 318 
 CAr.EOLiSM, 306 
 Caebolttbia, 8, 9, 490, 491 
 Caeci>"OMA (see also Cancer), 481, 484 
 
 — fasciculatum, 154 
 
 Cabotid, paresis after ligature of, 57 
 CASEors GLA>"DS, removal of, 146 
 
 — treatment of, 145 
 
 Casteation, 294 
 Cataeeh of urinary tract, 260 
 Catgut ligattiee,'305, 457 
 Cauliflowee growth, 305 
 Caustics in lymphoma, 152 
 
 — in mammary cancer, 222, 224 
 CaTEBXOUS blood TUilOUE, 126, 204 
 
 — lymph tumour, 126 
 Cellulitis, acute, of neck, 124 
 Ceeeekal abscess, 36,37 
 Cebtical glands, removal of, 151, 
 
 152 
 
 — vertebra, dislocation of, 177 
 subluxation of, 178 
 
 Chopaet's amputation, 446, 473 
 
 CiCACTEICIAL COSTBACTIOy of niOUth, 
 
 81,82 
 
 — treatment of, 81 
 Clavicle, fracture of, 343 
 
 — resection of, 3&i 
 
 Cleft palate, anatomy of, 80, 81 
 
 — speech in, SO 
 
 — treatment of, 80, 81 
 COCCOBACTEBIA and ACUTE INFLAM- 
 
 MATio^r, 419 
 Coccygeal tumoue, 337 
 
 COLLES'S PEACXrEE, 347 
 
 Collodion bandage, 159 
 Colloid crsis of ovaet, 303 
 Commotio cekebbi, 39 
 Compound feactuee of elbow, 357 
 
 — of leg, 399 
 
 COMPOUN-D PALMAB GANGLION, 362 
 COMPEESSIO cerebei, 38 
 CoMPEESsiON in aneurism, 452, 457 
 
 — of inflamed glands, 327 
 Concussion, 33 
 
 Congenital absence of femur, 467 
 Congenital seeous cyst, 43 
 Constant curbent in neuralgia, 67 
 conteacted cicatrix, 374 
 Contusions, 341, 342 
 
 — of hip. 388 
 
 Choup, tracheotomy in, 139 
 Cut theoat, 125 
 CxsT of back, 201 
 
 — congenital, 126 
 
 — of iippcr jaw, 97 
 
 — serous, of neck, 127 
 Cystic bbonchocele, 157 
 
 — papilloma, 305 
 Cystic hygbomi, 127 
 Cystitis, 259 
 
 — calculous, 275 
 
 — gonorrhceal, 261 
 
 — paresis after, 265 
 
 — ■ treatment of, by mineral waters, 
 265 
 Cystoma, 481 
 
 CxsTO-SAECOMA of breast, 211 
 CzEENY, intestinal suture, 500
 
 INDEX. 
 
 513 
 
 D. 
 
 Deiieium in head injuries, 40 
 
 — potatorum, 474 
 Dentition and lymphoma, 150 
 Deviation of septum narium, 77 
 Diastasis of pelvis, 321 
 Dilaceration of bronchocele, 162 
 Dilatation, rapid, in stricture, 268 
 Diphtheritic inflammation of wounds, 
 
 18 
 Dislocation of astragalus, 401 
 
 — compound, of ankle, 400 
 
 — congenital, of toes, 467 
 
 — irreducible, 354 
 
 — of cervical vertebra, 177 
 
 — of hip, 401 
 
 — of humerus, 352, 353, 354 
 
 — of thumb, 355 
 
 — of ulna, 355 
 
 — pathological, of hip, 434, 435 
 Diverticulum of cesophngus, 130 
 Drainage after ovariotomy, 307 
 Dyspnoea in bronchocele, 163 
 
 E. 
 Ear, diseases of, 47 
 EccHONDROSis of femur, 446 
 EcHiNOCOccus of orbit, 96 
 eceaseur, 316 
 Ectropion, 82 
 Elbow, ankylosis of, 346 
 
 — excision of, 370 
 
 — joint, chronic disease of, 487 
 reproduction of, 370 
 
 Elephantiasis, 365 
 
 Embolism and gangrene, 366, 403, 
 
 409, 412 
 Empyema, encysted, 195 
 
 — resection of ribs for, 195 
 Encephalitis, 34, 41 
 Enchondeoma of foot, 446 
 
 — of hand, 379, 380 
 
 — of pelvis, 327, 331 
 
 Encysted peritoneal efEusion, 231, 235 
 
 Endarteritis, 410 
 
 Enteeoeaphy, 509 
 
 Epiphyses, separation of, 413, 414, 416 
 
 Epispadias, 284 
 
 Epistaxis, 50 
 
 Epithelioma, 451 
 
 — developing on an issue, 385 
 
 — of ear, 47, 48 
 
 — of lip, 108 
 
 — of scalp, 46 
 
 — primary, of glands, 156 
 Ergotine injections in aneurism, 376, 
 
 454, 456 
 Erysipelas, 21, 487 
 
 — statistics of, 28 
 Eucalyptus oil, Lister on, 491 
 
 Evidement of tarsus, 445 
 Excision of elbow, 368 
 
 — of hip, 429, 432, 488 
 
 — of knee, 436, 441, 488 
 
 — of shoulder-joint, 368 
 
 — of wrist, 341 
 
 Excisions, general survey of, 476 
 ExTiEPATiON of caseous glands, 147 
 
 — of larynx, 133 
 
 EXTEA-CAPSULAB FRACTURE, 388 
 
 Extroversion of bladder, 284 
 
 — operation for, 285 
 Eyeball, luxation of, 50 
 
 F. 
 Face, cancer of, 103 
 
 — sarcoma of, 109, 116 
 F^cal fistula, 239 
 
 — congenital, 246, 247 
 
 Fat embolism, 392, 416, 418, 420 
 
 Faulty union, 393 
 
 Femoral heenia, 248 
 
 Femue, compound fracture of, 398 
 
 — congenital absence of, 467 
 
 — fracture of, 488 
 neck of, 388 
 
 — lengthening of, 424 
 
 FiBEO-CAVEENOUS NASO-PHAEYNGEAL 
 POLYPUS, 100 
 
 FiBEO-FATTY TUMOUES, multiple, 93 
 FiBEOMA, 480, 483 
 
 — cicatricial, 380 
 
 — molluscum, 202 
 
 — of abdominal wall, 237 
 
 — of cheek, 96 
 
 — of parotid, 97 
 FiBRO-SARCOMA of head, 44 
 Fistula in ano, 251 
 Foot, chronic disease of, 443 
 Forcible extension in hip-joint dis- 
 ease, 433 
 
 FoEEiGN BODY in oesophagus, 131 
 
 — in larynx, 132 
 Fracture of base of skull, 35, 41 
 
 — of clavicle, 343 
 
 — of femur, 388 
 
 — of fibula, 391 
 
 — of humerus, 344 
 
 — of leg, 391 
 
 — of neck of femur, 388 
 
 — of pateUa, 392 
 
 — of pelvis, 321 
 
 — of radius, 347 
 
 — of ribs, 192 
 
 Frontal sinus, distension of, 48 
 
 — hsematoma of, 49 
 Frost-bite, 339, 387 
 
 G. 
 
 Galvano-cautery for haenaorrhoids, 
 252 
 
 33
 
 514 
 
 INDEX. 
 
 Ganglion, 361 
 
 — compound palmar, 362 
 Gan&hexe, 403 
 
 — amputation in, 406, 410, 411 
 
 — after forcible extension, 43S, 464 
 
 — from wound of tibial arteries, 402 
 
 — hospital, 17 
 
 — of fingers, 365 
 
 — puerperal, 366 
 
 — senile, 410 
 
 — spontaneous, 54 
 
 — varieties of, 409 
 Gasteeoeaphy, 493, 509 
 Geneeative oegans, diseases of fe- 
 male, 296 
 
 — of male, 288 
 Genu taigum, 459 
 Geestjny on talipes, 464 
 Glands, epithelioma of, 156 
 Glandulae bnlabgbments, causation 
 
 of, 149 
 
 — swellings, 487 
 
 Gluteal aeteet, ligature of, 322 
 
 GONOEBHCEAL STEICTUEE, 268 
 
 — pathology of, 270 
 Geanttlation saecoma of arm, 383 
 
 GCNSHOT WOUND, 320 
 
 — of back, 191 
 Gussexbauee on pyloric cancer, 494 
 
 — intestinal suture, 500 
 
 H. 
 
 HEMATOMA of pharynx, 186 
 H^MATOiiETEA, Case of, 297 
 H^iiOEEHAGE after removal of glands, 
 146 
 
 H^lIOEBHOIDAL PEOLAPSE, 253 
 HiEilOEEHOIDS, 252 
 
 Hand, injuries of, 342 
 
 Haeelip, 78 
 
 Head injueies, 31 
 
 Hectic fetee, 19 
 
 Heenia ceeebei into orbit, 119 
 
 Heenia, 238 
 
 — femoral, 248 
 
 — Littre's, 248 
 
 — of vermiform appendix, 248 
 
 — phrenic, 240 
 
 — purulenta, 244 
 
 — simulating strangulated, 243 
 
 — strangulated, 245 
 treatment of, 249 
 
 — taxis in, 249, 250 
 
 — umbilical, 239, 245 
 cord, 239 
 
 — ventral, 240, 241 
 Heenial sac, inflamed, 243 
 
 — opening in herniotomy, 246, 250 
 Heeniotomt, 245 
 
 Heepes after catheterisation, 267 
 
 Hip-joint disease, acute, in adults 
 426, 432 
 
 — chronic, 427, 488 
 
 Hip, excision of, 429, 432, 476, 488 
 Histology of lymphoma, 148 
 Holmes, Mr. T., on excisions, 488 
 
 — ou periostitis, 492 
 
 hoeny cutaneous. geowths, 86 
 Hospital gangeene, 17 
 Hospitalism, 428, 471 
 HuETEE on pyaemia, 19 
 HuMEEUS, affection of, in mammary 
 cancer, 220 
 
 — dislocation of, 352, 354 
 
 — fracture of, 344 
 
 — resection of, 370 
 Htdeocele, 289 
 
 — in children, 290 
 
 — radical treatment of, 289 
 Hydbonepheosis, 258 
 Hydeops of antrum, 97 
 
 — of elbow, 372 
 
 — genu, 442 
 Hypeeplasia of glands, 149 
 Hypeeteophy of cheek and tongue, 
 
 53 
 
 — of nose, 55 
 Hysteeotomy, 312 
 
 ICHOE, 20 
 
 ICTEEUS in pyloric cancer, 495 
 Impotence in orchitis, 292 
 Infea-oebital neeve, division of, 63 
 
 — neuralgia of, 59, 64 
 
 — neurectomy of, 68 
 
 — removal of, 61, 64 
 Injections in lymphoma, 153 
 Inteenal steanguiation, 242 
 Intestinal sutuees, 500 
 Intea-capsulae peactuee, 388 
 Involution cysts, 210 
 
 Iodine injections inbronchocele, 159, 
 
 170, 175 
 Iodism, 172 
 Ieeitable bladdbe, 259 
 
 J. 
 Jaw, osteo-chondro-fihroma of, 98 
 
 — phosphorus disease of, 73, 75 
 
 — resection of, for phosphorus dis- 
 
 ease, 75 
 
 — sarcoma of, 120, 121 
 Joints, diseases of, 369, 426 
 
 •K. 
 
 Kempb, Mr. J. A., on carboluria, 490 
 Knee, ankylosis of, 437 — 441 
 
 — chronic diseases of, 436, 488 
 
 — excision of, 436, 488
 
 INDEX. 
 
 515 
 
 Knee, tumor albus of, 441 
 
 KiJSTEa on carbolic poisoning, 8, 12, 
 
 491 
 Kyphosis, 178 
 
 Lapaeo-htsteeotomy, 312 
 Laparotomy for internal strangula- 
 tion, 242 
 Larynx, extirpation of, 133 
 
 — foreign body in, 132 
 
 — tuberculous disease of, 133 
 Lateeal cuevature, 187 
 Leg, compound fracture of, 399 
 
 — fracture of, 391 
 Lengtheking of limb after ostitis, 424 
 
 LiGATCEB, 305 
 
 LiNQiTAL AETEEY, ligature of, 112, 113 
 Lip, epithelioma of, 108 
 Lipoma, 202, 480 
 
 — subfascial, of tbigh, 446 
 
 — submammary, 209 
 Listee's method, 1, 2, 9 
 Litholapaiy, 279 
 Lithotomy, 276 
 
 — supra-pubic, 276 
 LiTHOTEITY, 275 
 
 — death after, 273 
 Loose caetilage, 442 
 LuMBAE REGIONS, diseases of, 320 
 
 — vertebra, necrosis of, 178 
 Lupus, 52 
 
 Lymphadenitis, 148 
 Lymphangioma caveenosum, 379, 449 
 Lymphangitis, 23 
 
 Lymphatic glands, chronic diseases of, 
 142, 145 
 
 — secondary cancerous afi'ectioas of, 
 
 219 
 Lymphectasis, 54 
 Lymphoma, 148, 480, 482 
 
 — arsenic in, 152 
 
 — caustics in, 152 
 
 — compression for, 152, 153 
 
 — influence of dentition on, 150 
 
 — injections in, 153 
 
 — operative treatment of, 151 
 
 — medullary, 155, 156 
 Lympho-saecoma, 153, 383 
 
 — histology of, 154 
 
 M. 
 
 Malignant carbuncle, 51 
 Mamma, diseases of, see Beeast, 206 
 Manndibulae neeve, neurectomy of, 
 
 69 
 Mastitis and cancee, 221 
 Medullaey lymphoma, 153 
 
 — cases of, 155, 156 
 Melanoma, 449 
 
 Melanotic sarcoma, 45, 205 
 
 — cancer and sarcoma, 214 
 Meningitis, 36, 39 
 
 — after operations, 12, 441 
 Menzel on statistics of spinal disease, 
 
 181 
 Method of amputation, 470 
 Mikulicz on genu valgum, 460 
 Moecellement, 314 
 Muscle, rupture of abdominal, 228 
 Musculo-spieal, paralysis of, 340, 
 
 348, 350 
 Myoma, 482 
 
 N. 
 
 Nasophaeyngeal polypus, 99 
 Neck, acute cellulitis of, 124 
 
 — serous cyst of, 127 
 Neceosis, phosphorus, 71 
 
 — of skull, 42 
 
 Needle examination in orbital tu- 
 mours, 117, 118 
 Neuealgia, causes of, 65 
 
 — effects of operation on, 66 
 
 — of fifth nerve, 58, 65 
 
 — of finger, 378 
 
 — pathology of, QQ 
 
 — spontaneous cure of, 67 
 
 — treatment by constant current, 67 
 Neueectomy, results of, 68, 69 
 Neueo-fibeoma, 94, 95, 381 
 
 — recurrent, 448 
 
 — of sciatic nerve, 447 
 Neurotomy, 63, 68 
 Nose, angioma of, 86 
 
 — hypertrophy of, 55 
 
 — malignant tumours of, 122, 123 
 
 0. 
 
 CEsophagus, diverticulum of, 130 
 
 — foreign body in, 131 
 
 — stricture of, 127, 128 
 traumatic, 129 
 
 — syphilitic strictures of, 128 
 Omentum, cancer of, removed, 238 
 Onychia maligna, 364 
 Onychogryphosis, 363 
 
 Open treatment of wounds, 30, 472, 
 
 474 
 Operative teeatment of cancerous 
 
 glands, 145 
 
 — of harelip, 79 
 
 — of lymphoma, 151 
 
 — of neuralgia, 70 
 Optic ateophy, 64 
 Oebit, cancer of, 119, 120 
 
 — sarcoma of, 116, 120 
 Oechitis, chronic, 291 
 
 — suppurating, 294 
 Ossification of dorsal fascia, 197
 
 516 
 
 INDEX. 
 
 OSTEOCHONDBO-FIBROMA of jaw, 98 
 OSTEO-CHONDEOMA o£ pclvis, 327 
 
 Osteoma of olecranon, 381 
 OsTEOMATA, multiple, 447 
 Osteomyelitis, 492 
 
 — acute, 360, 413, 422, 423 
 
 — etiology of, 419 
 
 — multiple, 41 
 
 — subacute, 417 
 
 OSTEO-SABCOMA, 45 
 
 — of clavicle, 384 
 
 — of ulna, 385 
 Osteotomy, of femur 432 
 
 — in genu valgum, 461 
 
 — (Rhea Barton's), 440 
 Ostitis becoming acute, 423 
 OvAKiAN CYST, case of, 298 
 
 — iodine injection in, 299 
 OVAEIOIOMY, 300 
 
 P. 
 
 Palmab eascia, contraction of, 375 
 
 PaNAEITIUM PEEIOSTALE, 360 
 
 Panceeas and pyloeus, cancer of, 
 
 508, 510 
 Papilloma of tongue, congenital, 102 
 Paealysis, reflex, 351 
 
 — in spinal disease, 181 
 Paeotid, fibroma of, 97 
 Patella, fracture of, 392 
 Pean on hysterotomy, 314 
 Pedicle, treatment of, 306, 317 
 Pelvic abscess, 322 
 Pelvis, diseases of, 320 
 
 — fracture of, 321 
 Peeiostitis, acute, 413, 492 
 
 — chronic, 367, 424 
 of ribs, 193 
 
 — of jaws, 51 
 
 — of peh-is, 324 
 
 — of skull, 42 
 
 — phosphorus, 71 
 Peeitonitis after herniotomy, 250 
 
 — after ovariotomy, 310 
 
 — encysted, 231, 235 
 Pes gigas, 467 
 Phabynx, haematoma of, 186 
 
 — syphilitic stricture of, 131 
 Phlegmon of leg, 403 
 Phlogogenous poison, 23 
 PnosPHOEUs NECEOsis, 71, 76, 487 
 
 — pathology of, 73, 74 
 
 — treatment of, 73 
 Pigmentation of face, 86 
 Pieogoef's amputation, 443, 473 
 Plastic sttegeky of face, 77, 86 
 Pleueitic effusion in ovarian disease, 
 
 302 
 Pneumothoeax, cases of, 190, 192, 
 195 
 
 Polypi, malignant, of nose, 122, 123 
 Polypoid geowths of vagina, 296 
 Polypus nasi, 99 
 Peematueity, 296 
 Peolapsus eecti, 252 
 Peostate, cancer of, 288 
 
 — hypertrophy of, 282 
 Pseud AETHEOsis, 347 
 
 — of femur, 395 
 - of leg, 396, 414 
 
 Psoas abscess, 229 
 
 Psoitis, 323 
 
 Pulsating saecoma, 334, 450, 451 
 
 Pus, 20 
 
 Pyemia, 19, 487 
 
 — after simple fracture, 392 
 
 — multiple, 356 
 Pyelitis, 259, 266 
 
 — in extroversion, 284 
 
 Pyloeic cancee, removal of, 493, 510 
 
 — sphincter, function of, 495 
 Pyloeus, villous cancer of, 231 
 
 R. 
 
 Radial, aneurism of, 376, 397 
 Radius, fracture of, 347 
 
 — resection of, 375 
 Ranula, treatment of, 101 
 Recklinghausen, V., on anatomy of 
 
 serous membranes, 40 
 Rectum, cancer of, 254 
 
 — diseases of, 250 
 
 — perforating ulcer of, 250 
 
 — prolapse oi, 252 
 
 — removal of, for cancer, 254, 255 
 Redeessement foece, 372, 460 
 Renal tumoue, 258 
 Resection of jaw, 75 
 
 for contracted mouth, 82 
 
 Reteo-peeitoneal abscess, 323 
 
 — cellulitis and abscess, 219 
 Reteo-peeitonitis after lithotomy, 
 
 277 
 
 Reteo-phaeyngeal abscess, diag- 
 nosis of, 186 
 
 Rheumatic coxitis, 432 
 
 Rhinoplastic opeeations, 83, 86 
 
 Ribs, caries of, 194 
 
 — fractures of, 192 
 
 — resection of, for empyema, 195 
 Ring sutuees in enteroraphy, 499 
 Roeitansky on pyloric cancer, 494 
 
 S. 
 Salitaey fistula, 78 
 Saecoma, see Tumoues. 
 Scalp, warty hypertrophy of, 42 
 
 — wounds, 31 
 
 SciEEHOUS cancee of breast, 216 
 and lactation, 216, 221
 
 INDEX. 
 
 517 
 
 Sebaceotts cyst of tongue, 102 
 Secondary fevee, 19 
 Septic-emia, 487 
 
 Septic infection and amputation, 
 475 
 
 — peritonitis, 310 
 
 — poisoning, 5 
 Septo-py^mia, statistics of, 28 
 Serpiginous ulcer, case of, 285 
 Serrati muscles, paralysis of, 197 
 Shock, 312, 490 
 Shoulder-joint, disease of, 369 
 
 — chronic disease of, 487 
 Skull, injuries of, 32 
 
 Smith, Mr. Thomas, on carbolic poison- 
 ing, 490 
 Softening of callus, 394 
 Spasm of shoulder muscles, 377 
 
 — of sphincter vesicae, 259 
 Specific diseases, 22, 24 
 Spencer Wells, Mr. T., on carbolic 
 
 poisoning, 490 
 Spina bifida, cases of, 189 
 Spinal caries, treatment of, 179 
 Spindle-celled sarcoma of arm, 384 
 Spine, diseases of, see Vertebra, 177 
 Spleen, rupture of, 229 
 Spontaneous cure of neuralgia, 67 
 
 — gangrene, 403, 406, 408 
 Staphyloraphy, 79 
 Statistics of amputations, 469 
 Sterno-mastoid, spasm of, 125 
 Sternum, caries of, 194 
 Stomach, dilatation of, 495, 505, 507 
 
 — injury of, 228 
 Stone, see Calculus 
 Strangulated hernia, see Hernia, 
 
 245, 249 
 Stricture atter chancre, 270 
 
 — of oesophagus, cancerous, 127, 128 
 
 — of trachea, 136 
 
 — of urethra, 267, 268 
 
 — syphilitic, 128 
 of pharynx, 131 
 
 — traumatic, 129 
 Struma aneurismatica, 157 
 Subclavian aneurism, 376 
 sucutaneous neurotomy, 68 
 Sycosis, 58 
 Syndactylia, 375 
 Syphilitic ulceration, 365 
 Syphiloma, 55 
 
 Talipes, congenital, 462 
 
 — redressement in, 465 
 
 — spastic, 461 
 
 — treatment of, 462 — 466 
 Tarsus, chronic disease of, 445 
 Tenosynovitis, 362 
 
 Tenotomy, 462 
 
 — gangrene after, 464 
 Testis, cancer of, 295 
 
 — indammation of, 291 
 
 — strangulation of, 245 
 
 — tubercular, 291 
 Thorax, injuries of, 190 
 Thumb, dislocation of, 355 
 Thyroid, diseases of, see Broncho- 
 
 CELE, 156 
 Tibia, subperiosteal removal of, 414 
 Tongue, alveolar cancer of, 112 
 
 — cancer of, 113, 114 
 
 — papilloma of, 102 
 
 — removal of, 114 
 
 — sebaceous cyst of, 102 
 
 — tubercular disease of, 56 
 Tonsils, removal of, 55 
 
 — cancer of, 112 
 Trachea, carcinoma of, 138 
 
 — joapillary cancer of, 134 
 
 — stricture of, 136 
 Tracheotomy, 139, 142 
 Transfusion, 330 
 
 Tuberculous disease of larynx, 133 
 Tuberculosis and fistula in ano, 
 
 251 
 Tumor albus of knee, 441 
 
 — of hip, 431 
 Tumour, adeno-fibroma, 210 
 
 — adeno-cysto-sarcoma, 213 
 
 — alveolar sarcoma, 214, 381, 382 
 
 — angioma cavernosum, 88 
 of side, 202 
 
 — arterio-venous angioma, 86 
 racemose, 87 
 
 — atheroma, 378 
 
 — bursal, 378 
 
 — cavernous and lipoma, 204 
 lymphangioma, 126, 379, 449 
 
 — congenital coccygeal, 337 
 cyst, 43, 126 
 
 — cystic, of back, 201 
 
 enchondroma, 327, 331 
 
 of jaw, 97 
 
 sarcoma of breast, 211 
 
 — echinococcus, of orbit, 96 
 
 — ecchondrosis, 446 
 
 — enchondroma, 379, 380, 446 
 
 — epithelioma, 385, 451 
 of lip, 108 
 
 — — of scalp, 46 
 
 — fasciculatus, 148 
 
 — fatty, 202 
 
 — fibro-cavernous naso-pharyngeal 
 
 polypus, 100 
 
 — fibroma, 380 
 
 of abdominal wall, 237 
 
 of cheek, 96 
 
 of parotid, 97
 
 518 
 
 INDEX. 
 
 Tfmoue, fibroma, of uterus, 298 
 
 — fibro-sarcoma, 44 
 
 — granulation sarcoma, 383 
 
 — of jaw, 122 
 
 — lipoma, 446 
 
 — lympho-sarcoma, 383 
 
 — malignant polypi, of nose, 122, 
 
 123 
 
 — melanoma, 449 
 
 — melanotic sarcoma, 45 
 
 — multiple fibro-fatty, 93 
 fibromata, 202 
 
 — neuro-fibroma, 94, 381, 447, 448 
 
 — naso-pharyngeal polypus, 99 
 
 — of testis, 295 
 
 — osteo-chondro-fibroma, of jaw, 98 
 
 — osteoma, 381, 447 
 
 — osteo-sarcoma, 45, 384, 385 
 
 — papilloma, 305 
 of tongue, 102 
 
 — polypus nasi, 99, 122, 123 
 
 — pulsating sarcoma, 450, 451 
 
 — renal, 258 
 
 — sarcoma of arm, 382 
 
 of back, 204, 205 
 
 of face, 109, 110 
 
 of jaw, 120, 121 
 
 of neck, 127 
 
 of orbit, 116 
 
 of pelvis, 334, 336 
 
 — sebaceous cyst, of tongue, 102 
 
 — serous cyst, 127 
 
 — spindle-celled sarcoma, 337, 384 
 
 — tonsils, cancer of, 112 
 
 — uterine fibroma, 312 
 TuMOUES, distribution of, 479, 481 
 
 — general statistics of, 477 
 Typhtts tjlceeation causing peri- 
 tonitis, 244 
 
 U. 
 
 Ulna, dislocation of, 355 
 
 Ununited feactube, see Pseud- 
 
 AETHEOSIS, 347 
 
 Uppee exteemitt, injuries of, 339 
 Ubano-plastic opeeations, 80 
 Ueetheal fevee, 268 
 
 — stricture, 267 
 
 Ueetheotomt, 266, 267 
 
 — external, 272 
 
 — internal, 268 
 
 Ueinaet oegans, diseases of, 257 
 Ueine in carbolic poisoning, 8, 9, 490, 
 
 491 
 Uteeine fibeoma, 298, 312 
 
 V. 
 
 Vagina, polypoid growths of, 296 
 
 VaEIX ITMPHATICrS, 126 
 Veetebe^, necrosis of, 185 
 Veetebeal cancee, 187, 479 
 
 — caries, prognosis in, 182 
 
 treatment of, 179, 183 
 
 mechanical treatment of, 184 
 
 — column, diseases of, 487 
 
 — — tuberculosis of, 180 
 Vesical ieeitabilitt, 259 
 
 — fistula after strangulated hernia, 
 
 247 
 Vesico-vaginal fistula, 283 
 ViECHOW on neuroma, 448 
 
 — on scrofulous diathesis, 149 
 Volkmann on classification of ampu- 
 tations, 472 
 
 — on treatment of fracture of femur, 
 
 389 
 Volvulus, 237, 311 
 Vomiting in peritonitis, 311 
 
 W. 
 
 Waety htpeeteopht of scalp, 42 
 Webbed fingees, 375 
 Whitlow, 359, 360 
 Winiwaetee, Dr. A., on pyloric can- 
 cer, 494 
 
 — on cancer and sarcoma, 483 
 Wounds, open treatment of, 30, 472, 
 
 474 
 Weist-joint, chronic diseases of, 373, 
 487 
 
 — excision of, 373 
 
 Zymoid ferment, 2 
 
 PRINTED BY J. E. ADLAKD, BARTHOLOMEW CLOSE.
 
 EXPLANATION OF THE PLATES. 
 
 PLATE I. 
 
 Fig. I. — Warty hypertrophy of the scalp. (See p. 42.) 
 Fig. 2. — Racemose arterio-venous angioma of the nose and lip. (See 
 pp. 86, 87.) 
 
 Fig. 3. — Hypertrophy of the integuments of the nose. (See p. 55.) 
 
 Fig. 4a. — Hypertrophy of the integuments of the nose. 
 
 Fig. 4b. — The same, three months after operation. (See p. 55.) 
 
 PLATE II. 
 
 Fig. 6a. — Substernal malignant bronchocele in a man set. 61. The growth 
 pressed on the right innominate vein. (See p. 169.) 
 
 PLATE in. 
 
 Fig. 6b. — From the same case, illustrates the preparation made by Dr. 
 Chiari. The greater part of the integuments of the abdomen are shown. 
 (See p. 169.) 
 
 Fig. 6 c. — From the same. The abdominal integuments have been re- 
 moved. The right and left sides of the heart are injected, and coloured blue 
 and red respectively. The dotted line above the heart shows the dimensions 
 of the substernal tumour in the recent state. lu the preparation the growth 
 had shrunk very much. (See p. 169.) 
 
 PLATE IV. 
 
 Figs. 7 a and 7&. — A child, aet. 6, with exti-oversion of the bladder and 
 epispadias, cured by Prof. Billroth's method. (See p. 286.) 
 
 Fig. 9 c. — Apparatus to provide for retention of urine after operation for 
 extroversion, made by Hammer, of Vienna. (Not referred to in the text.)
 
 EXPLANATION OF THE PLATES {continued). 
 
 PLATE IX. 
 
 Fig. II. — Chronic ostitis of the left femur and tibia, with lengthening of 
 the entbe lower extremity. (See p. 424.) 
 
 PLATE Xn. 
 Fig. 14. — Congenital absence of the femur. (See p. 467.) 
 
 PLATE I. 
 
 Portion of the stomach, 14 centimetres in length, excised in Case I. 
 Anterior view. (See p. 503.) 
 
 PLATE n. 
 
 The same from above. Om. Small omentum. S. Probe. 
 
 PLATE in. 
 
 Fig. I. — Incisions for the resection of the stomach in Case i. A part of 
 the lumen of the stomach not yet closed. L l L, Lembei-t's intestinal sutm-es. 
 (See pp. 498, 503-) 
 
 Fig. 2. — From the same case, after the insertion of all the sutures. (See 
 pp. 498, 503.) 
 
 Figs. 3 and 4. — Eesection of the stomach in Case 2. Vei-tical incisions 
 through stomach and duodenum. N, Occlusion sutures, l L l, Lembert's 
 sutures to hold the stomach and duodenum. (See pp. 498, 501, 505.) 
 
 Fig. 5. — The same, with all the sutures inserted. D, Diverticulum. (See 
 pp. 499, 500, 505, 506.) 
 
 Fig. 6.— (See p. 508.) 
 
 Fig. 7. — Shape of stomach after union of the duodenum to the greater 
 curvature. Case 3. (See p. 508.) 
 
 Figs. 8 and 9.— (See p. 501.) 
 
 Fig. 10. — Insertion of the posterior ring sutures from within. (See p. 499.) 
 
 Fig. II. — Diagram of a section to show the position of the internal intes- 
 tinal sutures, and the superficial sutures of the mucous membrane.
 
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