cancer of the esophagus, perform gastrostomy; in cancer of the pylorus, perform pylorectomy or gastro-enterostomy; in cancer of the bowel, do resection with anastomosis, side-track the diseased area by an anastomosis, or make an artificial anus; in cancer of the penis, amputate.

Cysts. A cyst is a sac containing a fluid or a semi-fluid. Division of Cysts.—Cysts are divided into (1) Retention-cysts, which are due to blocking up of the excretory ducts of glands and accumulation of the glandular secretions. These comprise sebaceous cysts or wens, serous cysts, mucous cysts, salivary cysts, milk-cysts, oil-cysts, and seminal cysts. (2) Exudation-cysts, which are due to accumulations in closed cavities. These comprise synovial cysts (ganglions and bursæ) and dentigerous cysts. (3) Dermoid cysts, which are congenital and arise from inversion of the cutis and imperfectly closed fœtal clefts. (4) Cystomas, which are cysts of new formation due to cystic degeneration of connective tissue. These cysts are found in the neck (hygroma), in the arm-pit, and in the perineum. An example of a cystoma is found in the bursa which will develop from pressure. (5) Extravasation-cysts, that form around blood-extravasations. (6) Hydatid cysts, or cysts due to the echinococcus or tapeworm of the dog. A mother-cyst is formed, which becomes filled with daughter-cysts floating in a saline liquor containing hooklets.

Sebaceous cysts arise when the excretory duct of a sebaceous gland is blocked by dirt or occluded by inflammation. The orifice of the duct is often visible as a black speck over the centre of the cyst. They are very common in the scalp, where they are known as "wens," and upon the face, neck, shoulders, and back. Arising in the skin, and not under it, the skin cannot be freely moved over them, though a large cyst must extend into the deeper tissues. A sebaceous cyst is lined by epithelium and is filled with

foul-smelling sebaceous material. A sebaceous cyst may suppurate.

Treatment.-To treat a sebaceous cyst, dissect it entirely away with scissors or an Allis dissector, trying not to rupture the sac. If even a small particle of it is left, the cyst will return. If it ruptures during removal and it is feared that some portion may remain, swab out the wound with pure carbolic acid. If acid is not used, close without drainage, but if acid is used, drain for twenty-four hours. If an abscess has formed, open it. Grasp the edges of the cystlining with forceps, dissect out this lining with scissors curved on the flat, cauterize with pure carbolic acid, and drain for twenty-four hours.

Dermoid cysts are lined with true skin. They contain sebaceous matter, hair, teeth, or other epiblastic products. They are always congenital, but may be so small at birth as to escape notice for years. They may be distinguished from sebaceous cysts by the fact that they always lie below the deep fascia, and hence the skin is freely movable over them. They are met with at the root of the nose, at the orbital angles, in the eyelids, upon the floor of the mouth, over the sacrum or coccyx, and in the ovaries, the testicles, the brain, the eyes, the mediastinum, the lungs, the omentum, the mesentery, and the carotid sheaths. They are due to imperfect closure of foetal clefts and inclusion of epiblast. If a dermoid cyst contains bones, it shows that mesoblast was included as well as epiblast.

Treatment. To treat a dermoid cyst, excise, if accessible, the same as in the case of a sebaceous cyst. If it lies over bone, go down to the bone: the growth will be found adherent, so remove a portion of periosteum with the cyst (Hearn).

Hydatid cysts occur particularly among people who live shut up with dogs, as is the case in Iceland. The parasite is

swallowed with the food and is taken up by the stomachveins, and penetrates the intestine and peritoneum to find a nest in some neighboring or distant organ or tissue. Open these cysts, scrape, asepticize, and pack with iodoform gauze.

XVII. DISEASES AND INJURIES OF THE HEART AND VESSELS.

Heart and Pericardium.—In an acute pulmonary congestion the venous side of the heart is over-distended with blood, and the surgeon in desperate cases may tap the right auricle (see Paracentesis auriculi). Pericardial effusion, if severe, calls for tapping or aspiration, and purulent pericarditis demands incision and drainage.

Wounds and Injuries.-The heart may rupture and cause instant death, but slight wounds may not prove fatal. A wound of the heart causes hemorrhage, usually copious, but, owing to the interlocking of muscular fibres, the hemorrhage is often slight. If bleeding into the pericardal sac takes place, the signs of a pericardial effusion become manifest. Pain is constant, and attacks of syncope are the rule. Death is apt to occur suddenly from shock, hemorrhage, and inability of the heart to contract because of the severed fibres, or inability of the heart to dilate because of the pressure of blood in the pericardial sac. If a wound of the pericardium or heart does not cause death in the first day or two, inflammation follows (traumatic pericarditis or carditis).

Treatment.-The treatment of heart-wounds consists of recumbency and the lowering of the head. The body is surrounded with hot bottles, opium is given in small doses, and stimulants are applied in moderation, but never to excess. Traumatic carditis or pericarditis is treated in the same way as idiopathic cases.

Phlebitis, or Inflammation of a Vein.-Phlebitis may be plastic or it may be purulent. Plastic phlebitis, while occasionally due to gout, to a febrile malady, or to some other constitutional condition, usually takes its origin from an injury, from the extension to the vein of a perivascular inflammation, or from a thrombus or an embolism. When phlebitis begins a thrombus forms because of the destruction of the endothelial coat, and this clot may be absorbed or organized. Suppurative phlebitis is a suppurative inflammation of a vein, arising by infection from suppurating perivascular tissues. It is most frequently met with in cellulitis or phlegmonous erysipelas, and may arise in the lateral sinus as a result of mastoid suppuration. A thrombus forms, the vein-wall suppurates, is softened and in part destroyed, and the clot becomes purulent. No bleeding occurs when the vein ruptures, as à barrier of clot keeps back the bloodstream. The clot of suppurative phlebitis cannot be absorbed and cannot organize. Septic phlebitis may cause pyæmia, and the infected clots of pyæmia may cause phlebitis.

Symptoms. The symptoms of phlebitis are pain, tenderness in and around a vein, discoloration over it, and solid oedema below the seat of the disease. Suppurative phlebitis causes the constitutional symptoms of infection.

Treatment. The treatment of phlebitis comprises rest in bed, elevation of the part, the administration of tincture of iron, and, locally, lead-water and laudanum. Hot fomentations are used later in the case. Abscesses are opened, asepticized, and drained. Internal treatment is symptomatic (opium, stimulants, etc.). When a vein is involved in this process, ligate, if possible, above and below the clot, open the vessel, and wash out the purulent mass. This is always to be done in infective thrombo-phlebitis of the lateral sinus. Varicose Veins, or Varix.-Definition and Causes-Varicose veins are unnaturally and permanently dilated veins

The causes

which elongate and pursue a tortuous course. of varicose veins are obstruction to venous return and weakness of cardiac action, which lessens the propulsion of the blood-stream.

Varicose veins are chiefly met with on the inner side of the lower extremity, in the spermatic cord, and in the rectum. Varix in the leg is met with during and after pregnancy and in persons who stand upon their feet for long periods. It especially appears in the long saphenous, which, being subcutaneous, has no muscular aid in supporting the bloodcolumn and in urging it on. The deep as well as the superficial veins may become varicose.

Varix of the spermatic cord is known as "varicocele." It is apt to appear about the time of puberty, and most adult men have at least a slight varicocele. Varix is more likely to appear in the left spermatic vein than in the vein of the right side, because the left spermatic vein has no valves (Brinton).

Varix of the veins of the rectum is known as "hemorrhoids" or "piles," which are caused by obstruction to the upward flow in the hemorrhoidal veins, either by obstructive liver disease, enlargement of the uterus or prostate, or the presence in the rectum of fecal masses in a person habitually constipated.

A vein under pressure usually dilates more at one spot than at another, the distention being greatest back of a valve or near the mouth of a tributary. The valves become incompetent and the dilatation becomes still greater. The veinwall may become fibrous, but usually it is thin and often. ruptures. The veins not only dilate, but they also become. longer, and hence do not remain straight, but twist and turn. into a characteristic form. Varicose veins are apt to cause œdema, and the watery elements in the tissues cause eczema of the skin. When eczema is once inaugurated, excoriation