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A MANUAL

MODERN SURGERY

GENERAL AND OPERATIVE

• » f

JOHN CHALMERS ^aCOSTA, M.D.

Clinical Professor uf Surgery, Jefferson Medical College, Philadelphia;
Surgeon to the Philadelphia Hospital, etc.

WITH 386 lEttyrTRATIONS

PHILADELPHIA

W. B. SA UN HERS

925 Wai.m't Strkkt

1898

• • •

-• • •• •
• • • •
•• • •••

• • •

• •

COPYKICHT, 1898, BY

W. B. SAUNDERS.

EUCCTROTYPCO BY
WKtTOOTT & THOMSON. PHIUAOA.

pRcts or

B. SAUNOCIIB, PHILADA.

\8e©

THIS VOLUME IS
DEDICATED, WITH AFFECTIONATE REGARDS, TO

DR. ORVILLE HORWITZ.

THE FELLOW-STUDENT, THE HOSPITAL ASSOCIATE, AND
THE TRUSTED FRIEND OF

THE AUTHOR.

PREFACE TO THE SECOND EDITION.

Ix the preface to the first edition of this work it was
stated that the purpose of the author was to make a book
that would stand between the text-book and the compend.
The ver>' considerable success that has been accorded the
effort seems to indicate that there was a distinct demand for
such a book. In the new edition no attempt has been made
to alter the character or to change the purpose of the
Manual, although it has been practically rewritten, many
entirely new articles added, and a majoritj'^ of the old articles
enlarged, restricted, or other%vise altered. Many of the
changes and additions have been made in response to the
suggestions of reviewers and of teachers of surger>\

The changes are numerous, and it is impossible to enu-
merate them in this place. Among them may be mentioned
the following: Sections have- been added upon the Surger>'
of the Liver and Gall-Bladder, the Spleen, the Pancreas, the
Female Breast, Wounds Inflicted by Modern Projectiles,
Electrical Injuries, and the Use of the Rontgen Rays. The
following operations have been described : Resection of the
Gasserian Ganglion ; Methods of Gastrostomy ; Schede's
Operation of Thoracoplasty ; Use of the Murphy Button ;
various new methods of Enterorrhaphy ; Bodinc's Method
of Colostomy ; Prevention of Hemorrhage in Hip-joint
Amputation by Macewen's Method of Aortic Compression J
Edmund Owen's Operation for Harelip ; Senn's Method of

Resection of the Shoulder-joint, etc.

12 PREFACE TO THE SECOND EDITION.

As in the previous edition, the writings of other authors
have been extensively quoted, and the endeavor has been
always to give proper credit.

The author desires to extend his cordial thanks to Mr.

Thos. F. Dagney, of Mr. Saunders' editorial department,

for much valuable aid rendered during the progress of the

work through the press, and to Mr. R. W. Greene for

making the index.

1629 Locust Street, Philadelphia,
June, 1898.

PREFACE.

The aim of this Manual is to present in clear terms
and in concise form the fundamental principles, the chief
operations, and the accepted methods of modern surgery.
The work seeks to stand between the complete but cumbrous
text-book and the incomplete but concentrated compend.

Obsolete and unessential methods have been excluded in
favor of the living and the essential. There has been no
attempt to exploit fanciful theories nor to defend unprovable
hypotheses, but rather the effort has been to present the sub-
ject in a form useful alike to the student and to the busy
practitioner.

The opening chapter is devoted to Bacteriology because
the author profoundly believes that without some knowledge
of the vital principles of this branch of science the vast im-
portance of its truths will be ill-appreciated, and there will
be inevitable failure in the application of aseptic and anti-
septic methods.

Ophthalmology, gynecology, rhinolog}\ otology, and lar-
yngology have not been considered, because of the obvious
fact that in the advanced state of specialized science only the
specialist is competent to write upon each of these branches.

In Orthopedic Surgery are discussed those conditions
which must in the very nature of things often be cared for
by the surgeon or the general practitioner (such as hip-joint
disease, club-foot. Pott's disease of the spine, flat-foot, etc.).
The limited space at command precluded the introduction of
a special division on diseases of the female breast. A large
amount of space has been devoted to Fractures and Dis-
locations, the enormous practical importance of these sub-
jects calling for their full discussion. Operative Surgery is
considered in separate sections, the most important pro-
cedures being fully described, giving also the instruments
necessary, and the positions assumed by patient and operator.

14 PREFACE.

This method has been adopted to fit the work for use in sur-
gical laboratories.

Many systems, manuals, monographs, lectures, and journal
articles have been consulted, and credit has been given in
the text for statements and quotations. Special acknowl-
edgment is due to the American Text-Book of Surgery,
edited by Keen and White; to the surgical works of
Ashhurst, Agnew, the elder Gross, Duplay and Reclus,
Esmarch, Albert Koenig, Wycth, and Bryant ; to the Man-
ual of Surgery edited by Treves ; to the International En-
cyclopcedia of Surgery edited by Ashhurst; to the Surgical
Pathology of Billroth and of Bowlby ; to the Diagnosis of E.
Pearce Gould ; to the Surgical Dictionary of Heath ; to the
Rest and Pain of Hilton ; to the works on operative sur-
gery of Barker, Jacobson. Treves, Stephen Smith, and Joseph
Bell ; to the Minor Surgery of Wharton ; to the dictionary
of Foster and of Gould ; to the Principles of Surgery of Senn ;
to the orthopedic writings of Sayre ; to the work on Diseases
of the Male Generative Organs of Jacobson ; to the System
of Genito-urinary Diseases edited by Morrow; and to the
treatises on Fractures and Dislocations of Sir Astley Cooper,
Malgaigne, Hamilton, Stimson, and T. Pickering Pick.

The Author returns his thanks to the numerous writers
who courteously authorized the reproduction of special
illustrations, and particularly to Professors Keen and White
for their free permission to draw upon the American Text-
Book of Surgery, from which a number of pictures have been
taken, distinctively those referring to Bandaging; to Mr.
John Vansant for the great amount of labor so ably and
cheerfully performed ; and to Dr. Howard Dchoney for
the preparation of the Index.

2050 I>ocust Street, Philadelphia,
October, 1894.

CONTENTS.

PAGB

I. Bacteriology 17

II. Asepsis and Antisepsis • 42

III. Inflammation 48

IV. Repair 82

V. Surgical Fevers 87

VI. Terminations of Inflammation . 90

VII. Ulceration and Fistula 110

VIII. Mortification or Gangrene 119

IX. Thrombosis and Embolism 132

X. Septicemia and Pyemia 136

XI. Erysipelas (St. Anthony's Fire) 140

XII. Tetanus or Lockjaw 144

XIII. Tuberculosis and Scrofula 148

XIV. Rickets 158

XV. Contusions and Wounds 160

XVI. Syphilis 184

XVII. Tumors, or Morbid Growths 209

XVIII. Diseases and Injurif-s of the Heart and Vessels . . . 239

1. Hemorrhage or Loss of Blood 258

2. 0|ieralions on the Vascular System 274

3. Ligation of Arteries in Continuity 278

XIX. Diseases and Injuries of Bones and Joints 309

1. Diseases of the Bones 309

2. Fractures 321

3. Diseases of the Joints 406

4. Luxations or Dislocations 438

5. Operations upon Bones 475

XX. Diseases and Injuries of Muscles, Tendons, and BuRs^t . . 504

(Operations ujx^n Muscles and Tendons 516

XXI. Orthopedic Surgery 519

XXII. Diseasf>s and Injurif-s of Nkrves 527

1. Diseases of Nerves 527

2. Wounds and Injuries of Nerves 528

3. Operations upon Nerves 530

1 6 CONTENTS,

PAGB

XXIII. Diseases and Injuries of the Head 535

1. Diseases of the Head 535

2. Injuries of the Head 543

XXIV. Surgery of the Spine 577

XXV. Surgery of the Respiratory Organs 596

1. Diseases and Injunes of the Nose and Antrum .... 596

2. Diseases and Injuries of the Larynx and Trachea . . . 598

3. 0{>erations on the Larynx and Trachea 600

4. Diseases and Injuries of the Chest, Pleura, and Lungs . 605
XXVI. Diseases and Injuries of the Upper Digestive Tract 612

XXVII. Diseases and Injuries of the Abdomen 626

1. Stomach and Intestines 633

2. The Peritoneum 655

3. The Liver and Gallbladder 658

4. The Pancreas 664

5. The Spleen *•.... 665

6. Operations upon the Abdomen . 666

XXVIII. Diseases and Injuries of the Rectum and Anus . . 713

XXIX. Anesthesia and Anesthetics 725

XXX. Burns and Scalds 736

XXXI. Diseases of the Skin and Nails 739

XXXII. Diseases and Injuries of the Thyroid Gland .... 743

XXXIII. Diseases and Injuries of the Lymphatics 746

XXXIV. Bandages 748

XXXV. PijisTic Surgery 759

XXXVI. Diseases and Injuries of the Genito-urinary Organs 763

1. Diseases and Injuries of the Kidney and Ureter . . . 768

2. Diseases and Injunes of the Bladder 784

3. Diseases and Injuries of the Urethra, Penis, Testicles,
Prostate, Seminal Vesicles, Prostatic Cord, and Tunica
Vaginalis ^810

XXXVII. Amputations 841

Special Amputations 847

XXXVIII. Diseases of the Breast 859

XXXIX. Skiagraphy, or the Employment of the Rontgen Rays 871

XL. Injuries by Electricity 878

INDEX 883

Modern Surgery.

I. BACTERIOLOGY.

Bacteriology is the science of micro-organisms. Though
a science in the youth of its years, bacteriology has not only
profoundly altered, but it has also revolutionized, pathology,
and our views of surgery will be incomplete, misleading,
and erroneous without its aid.

Micro-organisms, microbes^ or bacteria, are minute

vegetable cells of the class fungi, many of them being vis-
ible only by means of a highly powerful microscope after
they have been brightly stained. The contents of these cells
are protoplasm andnuclear chromatin enclosed by a structure
containing cellulose. The protoplasm can be stained with
anilin colors, and the cell-wall is more readily detected after
treating it with water, which causes it to swell. Many or-
ganisms are colored, others are colorless. Some move (mo-
tile bacteria), others do not move (amotile bacteria) ; among
the motionless ones may be mentioned the bacilli of anthrax
and tubercle, and all cocci. Many bacteria can change
from motile to amotile or from amotile to motile when sub-
jected to changed conditions of life. The oscillations of
cocci are physical and not vital in nature; they are Brun-
onian movements, movements due to alterations in equilib-
rium because of currents or changes of level in the fluid in
which the organisms are held. Bacteria possess the power
of attracting elements necessary' for their nutrition and of
repelling elements antagonistic to them (chemiotaxis or
chemotaxis).

Definite knowledge of these minute bodies and of their
actions dates from the study of fermentation by the cele-
brated Frenchman Pasteur, who in 1858 asserted that every
fermentation has invariably its specific ferment; that this
ferment consists of living cells ; that these cells produce fer-
mentation by absorbing the oxygen of the substance acted
upon ; that putrefaction is caused by an organized ferment ;

2 17

18 MODERN SURGERY.

that all organized ferments are carried about in the air ; and
that to entirely exclude air prevents putrefaction or fermenta-
tion. These statements, which were radical departures from
accepted belief, inaugurated a bitter controversy, and in that
controversy were bom the microbic theory of disease, the
doctrine of preventive inoculation, antiseptic surgery, and
serum-therapy.

The word microbe, which signifies a small living being, was
introduced in 1 878 by the late Professor Sedillot, of Paris. At
that time the nature of these bodies was in doubt; some
thought them animal, and called them microzoaria ; others
thought them vegetable, and called them microphyta ; the
designation ** microbe " does not commit us to either view.
We now know them to be vegetable, but the term "mi-
crobe" has remained in use.

The fungi connected with disease in man are divided into
three classes :

1. Yeasts, Saccharomyces, or Blastomycetes ;

2. Moulds, or Hyphomycetes ;

3. Bacteria, or Schizomycetes.

Yeasts include most of those fungi which can cause alco-
holic fermentation in saccharine matter. They consist of small
cells which multiply by gemmation and which can live with-
out free oxygen. These cells often stick together and form
branches, and contain spores when nourishment is insufficient.
They are thought to be vegetative forms of higher fungi
(Green). The chief importance of yeasts is that they cause
fermentation ; they never invade human tissues, though they
can dwell on mucous membranes, and even in the stomach.
Oidium albicans is an yeast-fungus whose growth upon the
mucous membrane of the mouth, pharynx, and esophagus
causes the disease known as '* thrush." Pekclharing says
that pityriasis capitis is due to the saccharomyces capillitii.

Moulds consist of filaments, each filament being composed
of a single row of cells arranged end to end, and all filaments
springing from a germinal tube which grows from a germi-
nating spore. Moulds are largely connected with processes
of decay. Some of them grow upon inflamed mucous mem-
brane, and some invade the epidermis, producing certain skin
diseases (favus, tinea tonsurans, tinea versicolor, etc.).

Actinomycosis and Madura-foot arise from the lodgement
and growth of moulds (Fig. 1). Actinomycosis is a disease
seen in cattle, and occasionally in men, especially in drovers.
Cattle become infected usually through their food, the fun-
gus entering by a hollow tooth or by a breach of continuity

BACTERIOLOGY. 19

in mucous membrane. The lower jaw is usually the seat of
involvement in cattle (lumpy jaw). A tumor forms, which con-
tains sero-pus, and after a time ruptures and di.scharges mat-
ter containing nodules composed of fungi. The bone may
undergo extensive destruction.
Other bones and various organs
may be infected.

Madura-foot or mycetoma is an
endemic disease of India, which is
probably due to infection with
the Chionypha Carted. The foot
swells and becomes covered with
pustules; the pustules rupture and "" ■■■—•■•'■"'-""■"*-'■
expose sinuses ; each stnus is lined with a firm membrane and
is filled with material which looks like the roe of a fish. The
bones are often extensively destroyed, and gangrene not un-
commonly arises.

Bacteria chiefly claim our attention. It is important to
remember that the term " bacteria," though applied to the
class schisotnycetcs, has also a more restricted application —
that is, to a division of the class ; it may mean either sckizo-
tttycctes in general, or rod-shaped schizomycetes, whose length
is not more than twice their breadth.

Some of the schizmnycctes induce certain fermentations ;
others grow upon dead organic matter, but are not able to
invade living tissues, and are called saprophytes or non-
pathogenic bacteria ; still others, known as the pathogemc,
cause various diseases. Parasitic bacteria can grow on or in
the tissues of the body. Obligate parasites are those which
have not been cultivated outside of the body (as the bacilli
of leprosy). Facultative parasites usually live outside the
body, but may enter into the body and produce disease.
The schizomycetes vary much in shape, size, color, arrange-
ment, mode of growth, and action upon the body. One
form cannot be transformed into another, but each main-
tains its specific identity. Every organism comes from a
pre-existing organism, this being true of all forms, as spon-
taneous generation is impossible.

Forms of Bacteria. — The three chief forms of bacteria
are —

1 . The Coccus or Jificrococcus — berry-shaped, oval, or
round bacterium (Fig. 2);

2. The Bacillus — rod-shaped bacterium (Fig. 3);

3. The Spirillum — corkscrew-shaped or .•ipiral bacterium
(Fig. 4). A short spiral is called a comma bacillus.

MODERN SURGERY.

De Bary compares these forms, respectively, to the bil-
liard-ball, the lead-pencil, and the corkscrew.

Coooi and Bacilli. — We have to do only with cocci and
bacUli. Cocci may be designated according to their arrange-
ment with one another ; namely, when existing singly they

Fic. i.—Micmcocciu. Fic. j.— BixiUtH. I

are called monococci; in pairs they are called diplococd (Fig.
S, a) ; in a chain they are called streptococci (Fig. 5, c) ; in a
cluster like a bunch of grapes they are called staphylococci
(Fig. 5, b); in groups of four they are called tetracacci; in
groups of eight they are called sarcina or woolsack cocci.
Irregular masses, resembling frog-spawn, constitute zooglea
masses (Fig. 6). The gelatinous matter in such a mass is
formed by a transformation in the walls of the bacteria. The
term ascococci is applied to a group of cocci enclosed in a
capsule (G. S. Woodhead).

The cocci are often named according to their function, as,

A ■

Fig. 5,— Foims of cocci. Fic. 6,— ZoBgl« (BalJJ.

for example, " pyogenic," or pus-forming. Cocci may be
named according to the color of the culture. The name
may embody the form, arrangement, color, and function ; for
instance, staphylococcus pyogenes aureus signifies a round,
golden-yellow micro-organism, which arranges itself with its

BACTERIOLOGY,

fellows into the form of a bunch of grapes, and which pro-
duces pus.

The bacilli are long, staff-shaped organisms. Long bacilli
having a wavy outline are called leptothrix. Chain-like ba-
cilli are called strepto-bacilli. Bacilli give origin to many
surgical diseases.

Multiplication of Bacteria. — Bacteria multiply with
great rapidity when placed under suitable conditions. They
can multiply by fission or by spore-formation. Some bacteria
multiply by both methods. In fission, or segmentation, the
cell elongates and about its middle a constriction begins,
which deepens until the cell has divided into two parts,
each of which soon grows as large as its parent (Figs. 7, 8).

—.._,—•*..

^ —

»---—..'

.'•«.--

Fig. 7.— Divisions of a micrococcus (afier Mac^).

j!q^\

t^*'

zrz.^

^^^ "-^^^ -^^
^•- ^«**

\^ — V

^':r:!!::

...•'^«...«^

Fig. 8. — Divisions of a bacillus (after Maci).

All cocci and some bacilli multiply by this method. If
segmentation of a single cell and the growth to maturity
of its products require one hour (it really takes place in less
time, the cholera bacillus requiring but twenty minutes to
divide), a single cell in a single day will have sixteen million
descendants (Cohn). In order, however, for such enormous
multiplication to occur conditions must be absolutely favor-
able to the cells, and conditions are rarely absolutely favor-
able. Were it otherwise all other forms of life would be
destroyed.

Spores. — A spore is a germ, and corresponds with the
seed of a plant. Most of the bacilli multiply by spore-
formation. Cocci do not undergo spore-formation after the
manner of bacilli, though some observers maintain that
cocci occasionally undergo an alteration that makes them
very resistant to any destructive influences (arthrospores).
When spore-formation is about to occur in a bacillus points

(ar»t De Bay).

22 MODERN SURGER Y.

of cloudiness appear in the protoplasm, the cell generally
elongates, and in twenty-four hours the cell is found to consist
of a series of segments like a necklace of beads, each segment
containing a full-grown spore (Fig. 9). The wall of the cell
now liquefies, the segments
separate, the spores are set
free, and each spore under
favorable conditions be-
comes a bacillus. When
the initial cloudiness ap-
pears in the middle of the
cell it is called an " endo-
spore ;" when it appears at
one or both extremities it
is christened an " end-
spore " or " endspores."
When multiplication is by
a single endospore the ba-
cillus does not elongate.
Organisms which when active multiply by fission take on
spore -formation when subjected to certain conditions.

Spore -formation tends to occur when bacilli are about to
die for want of nourishment or when there is an excess of
oxygen present. Each cell, as a rule, contains but one spore,
but may contain several. The spore has a den.se envelope
or covering which is very resistant to destructive agents. So
resistant is the covering that twice the amount of heat is
necessary to kill a spore as to kill an active adult cell.
Spores when placed under conditions unfavorable for devel-
opment may remain inactive for an indefinite period, just as
seeds remain inactive when unplanted. When spores en-
counter favorable conditions they at once develop into adult
cells, just as seeds develop when planted. It seems prob-
able that spores occasionally remain dormant in the human
body for long periods, and finally awaken into activity be-
cau.se of injury or disease of the tissue in which they lie.
Life-conditions of Bacteria. — In order to grow and
to multiply, bacteria require a suitable .soil and the favoring
influences of heat and moisture. The soil demanded con-
sists of highly organized compounds rather than crude sub-
stances, and slight modifications in it may prove fatal to
some forms of bacterial life, but highly advantageous to
others. Some organisms require albuminous matter, others
need carbohydrates ; they all require water, carbon, nitrogen,
oxygen, hydrogen, and certain inorganic materials, especially

BACTERIOLOGY. 23

lime and potassium (Woodhead). All organisms require
water. If dried, no form will multiply, and many forms will
die. The fluids and tissues of the individual may or may
not afibrd a favorable soil for the germs of a disease, or, in
the same person, may afibrd it at one time, and not at an-
other. Some individuals seem to possess indestructible im-
munity from, and others are especially prone to, certain con-
tagious diseases. Impairment of health, by altering some
subtle condition of the soil, may make a person liable who
previously was exempt

The presence of oxygen influences microbic growth. Most
organisms thrive best when exposed to the oxygen of the
air. and they are known as " aerobic." The term " anaero-
bic " is employed to designate organisms that can grow and
multiply and produce particular products only when air is
absent, free oxygen being fatal to them. The tetanus bacil-
lus and the bacillus of malignant edema are anaerobic. An
organism which can grow indifferently where oxygen is abun-
dant or where free oxygen is absent is called a " faculta-
tive-aerobic " bacterium. It may need oxygen ; but if it does,
it is able to obtain it from the tissues when air is excluded.
A sensitive organism which dies when the amount of oxygen
is even slightly diminished is called an " obligate-aerobic "
bacterium. Most microbic diseases in man are due to facul-
tative-aerobic bacteria.

Effect of Motion, Sunlight, Heat, and Cold.— The

majority o{ fungi grow best when at rest; agitation retards
the growth of some and kills others. Sunlight antagonizes
the growth of certain bacteria. Temperature influences bac-
terial growth. Some organisms will only grow within narrow
temperature-limits, while others can sustain sweeping altera-
tions, but most grow best between the limits of from 86° to
104° F. Freezing renders bacteria motionless and incapa-
ble of multiplication, but it does not kill them : they again
become active when the temperature is raised. The absurd-
ity of employing cold as a germicide is evident when the fact
is known that a temperature of 200° F. below zero is not
fatal to germ-life, cell-activities by such a temperature only
being rendered dormant. High temperatures are fatal to
bacteria ; moist heat is more destructive than dry heat, and
adult cells are more easily killed than spores. A temperature
less than 212° F. will kill many organisms, and boiling will
kill every pathogenic organism that does not form spores.
Some spores are not destroyed after prolonged boiling, and
some will withstand a temperature of 120° C. As a practical

24 MODERN SURGERY.

fact, however, boiling water kills in a few minutes all cocci,
most bacilli, and all pathogenic spores ; though the spores
of anthrax, tetanus, and malignant edema are harder to kill
than are the spores of other bacteria.

Chemical Germicides. — Many chemical agents will kill
bacteria, the most certain of them all being corrosive subli-
mate. Koch showed that corrosive sublimate is an efficient
test-tube germicide when present in the proportion of only
I part to 50,000. It is used in surgery in strengths of I part
of the salt to 1000, 2000, 3000, or more parts of water. Badly
infected wounds are occasionally irrigated with solutions of a
strength of i to 500. Contact with albumin precipitates from
a solution of corrosive sublimate an insoluble albuminate of
mercury. In surgical operations by the wet method the mer-
cury may be combined with tartaric acid in the proportion
of I to 5, which combination prevents the insoluble albumi-
nate from being formed.

But though corrosive sublimate under certain conditions
is very powerful, it is not always absolutely reliable. Many
spores are very resistant to its action. Even a I per cent
solution of bichlorid of mercury is not certainly destructive
of the spores of anthrax. Geppert tells us that anthrax-spores
may be active after a 25-hour immersion in a i : 100 solution
of sublimate (Schimmelbusch). In the presence of hydrogen
sulphide corrosive sublimate is useless, inert and insoluble,
sulphide of mercury being precipitated ; hence corrosive sub-
limate is without value as a rectal antiseptic ; in fact, Gerl-
oczy has proved that a concentrated aqueous solution of
sublimate will not disinfect an equal quantity of feces. Cor-
rosive sublimate contained in dressings after a time undergoes
decomposition and ceases to be a germicide. It is not ger-
micidal in fatty tissues because it is unable to attack bacteria
which are coated with oil. Corrosive sublimate is very irri-
tating to the tissues and causes copious exudation. Hence,
after tissues have been irrigated with this agent drainage
must be employed. In some cases the irritated tissues lose
to a great extent their power of resistance, and infection may
be actually facilitated by irrigation with sublimate. In rare
instances corrosive sublimate is absorbed and produces poi-
soning. In spite of these shortcomings and drawbacks it is
a valuable aid to the surgeon and must be frequently used,
especially upon the skin of the patient and the hands of the
operator and his assistants. It should be dissolved in dis-
tilled water, because ordinary water causes a precipitate to
form (common salt prevents the formation of this precipitate).

BACTERIOLOGY, 2$

Because of the facts that corrosive sublimate is poisonous
and very irritant and that serous membranes quickly absorb
it, this agent should not be used upon serous membranes.
It is very irritant to joints, and many surgeons will not in-
troduce it into them. It should never be put within the
dura, and should not be applied, in strong solution at least,
to mucous membranes. It is better to make the solution
when it is needed, so as to have it fresh, for in old solutions
much of the soluble corrosive sublimate has been converted
into insoluble calomel, and the fluid has ceased to be germi-
cidal. In order to make up fresh solutions use tablets, each
of which contains about 7^ grains of the drug— one of
these tablets added to a pint of water makes a solution of a
strength of I to 1 000. Tablets which also contain ammo-
nium chlorid are more soluble than those which contain
corrosive sublimate only. Hot solutions of the drug are
more powerfully germicidal than cold solutions. As corro-
sive sublimate is irritant, leads to profuse exudation, and may
produce tissue-necrosis, it should never be introduced into
an aseptic wound.

Griffin, in Foster's Practical Therapeutics, sets forth the
strengths of solutions applicable to different regions.

For disinfection of the surgeon's hands and the patient's
skin, I : 1000; for irrigating trivial wounds, i : 2000; for irri-
gating larger wounds and cavities, i : 5000 to i : 10,000; for
irrigating vagina, i : 5000 to i : 10,000; for irrigating urethra,
1 : 20,000 to I : 40,000 ; for irrigating conjunctiva, i : 5000 ; for
gargling, i : 5000 to i : 10,000.

Instruments cannot be placed in corrosive sublimate with-
out being dulled, stained, and corroded.

Corrosive sublimate may be absorbed from a wound, a
serous surface, or a mucous membrane, ptyalism and diar-
rhea resulting. The absorption of bichlorid of mercury
may be followed by cramp in the limbs and belly, feeble
pulse, cold skin, extreme restlessness, and even death by
collapse. At the first sign of trouble withdraw the drug
and treat the ptyalism (p. 202).

Carbolic acid is a valuable germicide in the strength of
from 1 : 40 to i : 20. It is certainly fatal to pus-organisms,
but weak solutions do not destroy spores. Unfortunately,
this acid attacks the hands of the surgeon ; consequently in
the United States it is chiefly employed as an antiseptic me-
dium in which to place the sterilized operating-instruments,
or as a germicide to prepare the skin of the patient before
the operation is performed.

26 MODERN SURGERY.

Carbolic acid is very irritant to tissues, and carbolized
dressings may be responsible for sloughing of the wound.
Because of its irritant properties wounds which have been
irrigated with it should be well drained. Carbolic acid, like
corrosive sublimate, is inert in fatty tissues. Carbolic acid
is readily absorbed, and may thus produce toxic symptoms.
Absorption is not uncommon when the weaker solutions are
used, but rarely occurs when a wound has been brushed
over with pure acid, because the pure acid at once forms an
extensive zone of coagulation, which acts as a barrier to ab-
sorption. One of the early indications of the absorption of
carbolic acid is the assumption by the urine of a smoky,
greenish or blackish hue. Examination of such smoky urine
shows a great diminution or entire absence of sulphates when
the acidulated urine is heated with chlorid of barium. This
diminution of precipitable sulphates is explained by the fact
that these salts are combined with carbolic acid, forming sol-
uble sulphocarbolates (Griffin). Such urine is apt to contain
albumin. If during the use of carbolized dressing or the
employment of carbolic solutions the urine becomes smoky,
the use of the drug in any form must be at once discon-
tinued, otherwise dangerous symptoms will soon appear.
These symptoms are subnormal temperature, feeble pulse
and respiration, muscular weakness, and vertigo. If death
occurs, it is due, as a rule, to respiratory failure. The treat-
ment of slow poisoning by carbolic acid consists in at once
withdrawing the drug, giving stimulants and nourishing food,
and administering sulphate of sodium several times a day and
atropin in the morning and evening.

Pure carbolic acid is a reliable disinfectant for certain con-
ditions. It is used to destroy chancroids, to purify infected
areas, to disinfect the medullary cavity in osteomyelitis, to
stimulate granulation after the open operation for hydrocele,
or to purify sloughing burns. The pure acid will not pro-
duce constitutional symptoms, but it occasionally causes
sloughing. Its application causes pain for a moment only,
and then analgesia ensues. Even dilute solutions of carbolic
acid greatly relieve pain when applied to raw surfaces.

Carbolic acid is certainly fatal to but few bacteria and it
fails to kill most spores. It acts more slowly and less cer-
tainly than corrosive sublimate. It requires 24 hours for a
5 per cent, solution to kill anthrax-spores. Pus or blood
(albuminous matter) greatly weakens the germicidal power
of carbolic acid, and fatty tissue cannot be disinfected by it.
It is not even the best of agents in which to place instru-

BACTERIOLOGY, 2/

ments, as it dulls them. After operation upon the mouth it
is used as a wash or gargle, I to 2 per cent, being a suitable
strength. It is used sometimes to irrigate the bladder and
often to cleanse sinuses, but is not employed in the perito-
neal cavity or the brain. It is occasionally injected into tu-
berculous joints.

Kreolin, which is a preparation made from coal-tar, is a
germicide without irritant or toxic effects. It is less power-
ful than carbolic acid but acts similarly, and is used in emul-
sion of a strength of from i to 5 per cent., and does not irri-
tate the skin like carbolic acid.

Peroxid of hydrogen is a most admirable agent for the
destruction of pus cocci. It comes in a 15-volume solution,
which is diluted one-half or two-thirds. It probably destroys
the albuminous element upon which bacteria live, and starves
the fungi. The peroxide of hydrogen is not fatal to tetanus
bacilli. Some surgeons use it to wash out appendicular ab-
scesses. It must not be injected into an abscess unless a
large opening exists, as otherwise the evolved gas may tear
apart structures and dissect up the cellular tissue. In a
deep abscess of the neck the author saw this agent almost
produce suffocation, the gas passing under the mucous mem-
brane and nearly blocking the air-passages.

Iodoform is largely used ; it is not truly a germicide, as
bacteria will grow upon it, but it hinders the development
of bacteria and directly antagonizes the toxic products of
germ-life. It can be rendered sterile by washing with a
solution of corrosive sublimate. It is of the greatest value
when applied to infected areas and tuberculous processes.
Clinically, no real substitute for it has yet been found. It
need not be applied to clean wounds, but the powder is
very useful when dusted in infected wounds. It prevents
wound-discharges from decomposing and greatly allays pain.
Gauze impregnated with iodoform is used to drain abscesses,
to drain the belly under certain circumstances, to pack aside
the intestines and prevent their infection during some abdom-
inal operations, and as packing to arrest intracranial hemor-
rhage. Tuberculous joints and cold abscesses are injected
with iodoform emulsion, which is made by adding the drug
to glycerin or olive oil. The strength of the emulsion is 10
per cent. A solution in ether of a strength of 10 per cent,
may be used to inject the cavity of a cold abscess.

The drug must be used with some caution. Absorption
from a wound sometimes happens, producing to.xic symptoms.
These symptoms are frequently misinterpreted, being usually

28 MODERN SURGERY.

attributed to infection. The symptoms in some cases are
acute and arise suddenly, and consist of a hallucinatory de-
lirium, nausea, fever, watery eyes, contracted pupils, metallic
taste in mouth, yellowness of the skin and eyes, an odor of
iodoform upon the breadth, the presence of the drug in the
urine, the outbreak of a skin eruption resembling measles,
and excessive loss of flesh and strength. Patients with such
acute symptoms usually pass into coma and die within a
week. Such attacks are most apt to arise in those beyond
middle life fsee Gerster and Lilienthal, in Foster's Practical
Therapeutics). In some chronic cases, the first symptoms
observed are moroseness, bewilderment, and irritability, fol-
lowed by depression with unsystematized persecutory delu-
sions, delirium, coma, and even death.

In systemic poisoning by iodoform, stop the use of the
drug and sustain the strength of the patient while nature
is removing the poison.

Iodoform sometimes produces great local irritation of the cu-
taneous surface, shown by crops of vesicles filled with turbid
yellow serum or even bloody serum. These vesicles rupture
and expose a raw oozing surface, looking not unlike a bum.
The use of the drug must be at once abandoned, for to con-
tinue it will not only increase the dermatitis, but will produce
constitutional symptoms. Wash the vesiculated area with
ether to remove iodoform, open each vesicle and dress the
part for several days with gauze wet with normal salt solu-
tion. After acute inflammation ceases apply zinc ointment
or cosmolin.

Europhen is a powder containing iodin, and the iodin
separates from it slowly when the powder is applied to
wounds or ulcers. It does not produce toxic symptoms
readily, if at all, and is a valuable substitute for iodoform.
It is used especially in the treatment of ulcers and burns.

Nosophen is a pale yellow powder containing 60 per cent,
of iodin. Its bismuth salt is known as antinosin. Nosophen
is not toxic, is free from odor, and is the best of the substi-
tutes for iodoform.

Acetanilid is frequently used as a substitute for iodoform.
It is of value when applied to suppurating, ulcerating, or
sloughing areas, but it does not benefit tubercular conditions.
Sometimes absorption takes place to a sufficient extent to
cause cyanosis. If cyanosis arises, stop the drug and order
stimulants by the stomach.

Silver is a valuable antiseptic. Halsted and Bolton have
shown that metallic silver exerts an inhibitive action upon

BACTERIOL OG K 29

the growth of micro-organisms and does not irritate the tis-
sues. Crede has demonstrated the same facts. These state-
ments indicate one great reason why silver wire is so useful
as a suture-material. Halsted is accustomed to place silver
foil over wounds after the wounds have been sutured, and
Crede employs as a dressing a fabric in which metallic silver
is intimately incorporated.

Crede considers that silver lactate (actol) is an admirable
antiseptic. It does not form insoluble albuminates when in-
troduced into the tissues and is not an irritant. Silver citrate
(itrol) is said to be even a better preparation than silver lac-
tate, and it is a useful dusting-powder.

Fonnaldehyd or formic aldehyd has valuable antiseptic
properties. Formalin is a 40 per cent, solution of the gas in
water. Solutions of this strength are very irritant to the
tissues, but 2 per cent, solutions can be used to disinfect
wounds. The stronger solutions are valuable for asepticizing
chancroids and other ulcers. The vapor of formalin is used
to disinfect wounds, and Wood suggests its employment in
septic peritonitis as a means of disinfection after the abdomen
has been opened. A 2 per cent, solution disinfects instru-
ments satisfactorily.

Formalin-firelatin has recently been introduced by Schleich
as an antiseptic powder. When applied to a clean wound it
gives off formalin and keeps the wound aseptic. When it is
applied to a sloughing surface it will not give off formalin
unless it is mixed with pepsin and hydrochloric acid. The
commercial preparation is known as glutol. Formalin-gela-
tin is used to replace bone-defects.

Nucleins, especially protonuclein, possess germicidal
powers. Protonuclein is of value in treating areas of in-
fection, particularly when sloughing exists.

Among other antiseptics of more or less value we may
mention trichlorid of iodin, iodol, chlorid of zinc, chlorid
of iron, loretin, salol, oxycyanid of mercury, fluorid of so-
dium, argonin, sugar, mustard, lannaiol, bichlorid of palla-
dium (in very dilute solution), thymol, potash soap, iodin,
salicylic acid, boric acid, camphor, eucalyptol, cinnamon,
bromin, chlorin (as gas or as chlorin-water), cinnamic acid,
permanganate of potassium or of calcium, chlorate of potas-
sium, alcohol, and normal salt solution.

The best germicide is heat, and the best form in which to
apply heat is by means of boiling water (even better than
steam). One can use boiling water upon instruments and
dressings, but rarely upon a patient and never upon the sur-

30 MODERN SURGERY,

geon. Jeannel, of Toulouse, uses boiling salt solution in
abscess-cavities, and other surgeons employ steam or boiling
water to disinfect the medullary canal in osteomyelitis. Nev-
ertheless, boiling water is rarely applied to the patient, and
in many cases a chemical germicide must be used. The
surgeon should always scrub his hands in a germicidal solu-
tion, and corrosive sublimate is one of the best we possess.

Distribution. — Microbes are very widely distributed in
nature. They are found in all water except that which comes
from very deep springs ; in all soil to the depth of 3 feet ;
and in air, except that of the desert, that over the open sea,
and that of lofty mountains.

Microbes may be useful. Some of them are scavengers,
and clean the surface of the earth of its dead by the process
known as " putrefaction," in which complex organic matter
is reduced to harmless gases and to a mineral condition.
The gases are taken up from the air by vegetables, and the
mineral matter is dissolved in rain-water and passes into
the soil from which it came, to there again be food for
plants, which plants will become food for animals. Other
organisms purify rivers ; others cause bread to rise ; still
others give rise to fermentation in liquors. Microbes may
be harmful. They may poison rivers and soils ; they may
be parasites on vegetable life ; they cause diseases of the
growing vine, and also of wine ; they produce the mould on
stale damp bread ; they occasionally form poisonous matter
in sausages, in ice-cream, and in canned goods ; and they
produce many diseases among men and the lower animals.

With so universal a distribution of these ftmgi, man must
constantly take them into his organism. They are upon
the surface of his body, he inhales them with every breath,
and he swallows them with his food and drink. Most of
them, fortunately, are entirely harmless ; others cannot act
on the living tissues ; but some are virulent, and these are
generally destroyed by the cells of the human body. The
alimentary canal always contains bacteria of putrefaction,
which act only upon the dead food, and not upon the living
body; but when man dies these organisms at once attack
the tissues, and post-mortem putrefaction begins in the
abdomen.

Koch's Circuit. — To prove that a microbe is the cause
of a disease it must fulfil Koch's circuit. It must always be
found associated with the disease ; it must be capable of
forming pure cultures outside the body ; these cultures must
be capable of reproducing the disease; and the microbe

BACTERIOLOGY, 3 1

must again be found associated with the artificially produced
morbid process.

IHsease - productioii. — Disease - producing organisms
which enter the body are usually rapidly destroyed. They
cannot dwell there long without inducing disease, but spores
can lie dormant in the system for years, only waking into
activity when they come in contact with some damaged,
weakened, or diseased part — a so-called point of least re-
sistance (a locus minoris resistentia*) — which affords a nest
for them to develop and to multiply, the cellular activities
of the weakened part being unable to cope with the activi-
ties of the germs. Even large numbers of pathogenic or-
ganisms may induce no trouble in a healthy man ; but let
them reach a damaged spot, and mischief is apt to arise.
Kocher established subcutaneous bone-injuries in dogs, and
these injuries pursued a healthy course until the animal was
fed upon putrid meat, whereupon suppuration took place.
This experiment proves that an organism can reach a dam-
aged area by means of the blood, and it enables us to under-
stand how a knee-joint can suppurate when we merely break
up adhesions, and how osteomyelitis can follow trauma when
the skin is intact. A given number of organisms might pro-
duce no effect on a healthy man, whereas the same number
might produce disease in an individual who was weak or ill-
nourished, suffering from depression or fear, or debilitated by
the habitual use of alcohol. The personal increment plays
a great part in disease-production. Some individuals seem
to be immune to certain diseases; others seem especially
liable to develop certain diseases ; and these immunities and
liabilities may be hereditary.

Toxins. — The action of pathogenic bacteria upon the tis-
sues is of great importance. In the first place, they abstract
from the blood, the lymph, and the cells certain elements
necessary to the body — as water, oxygen, albumins, carbo-
hydrates, etc. — and bring about body-wasting and exhaustion
from want of food. In the second place, bacteria produce a
vast number of compounds, some harmless and others highly
poisonous. The symptoms of a microbic disease are largely
due to the absorption of poisonous materials from the area
of infection. These poisons may be formed from the tissues
by the action upon them of the bacteria (toxins and pep-
tones) or may be liberated from the bodies of degenerating
microbes (bacterial proteid). Bacteria contain and secrete
ferments like pepsin or trypsin, and as albumoses are formed
in the alimentary canal by the action of digestive ferments

32 MODERN SURGERY,

upon proteids, sugars, and starches, so microbic albumoses
are formed by the action of microbic ferments upon tissues.
Just as the albumoses formed in digestion are poisonous
when injected, so the albumoses of microbic action are poi-
sonous when absorbed. The albumoses of microbic action
are called " toxalbumins." These albumoses often operate
as virulent poisons to the body-cells.

A series of compounds formed by the microbic destruction
of tissue is alkaloidal in nature. These poisonous alkaloids
are readily diffusible and, many of them, very virulent. It is
probable that every pathogenic organism has its own special
toxin which produces its characteristic effects, although
the effects are modified by the nature of the soil — that is to
say, by the condition of the tissues. The absorption of tox-
ins may be very rapid ; for instance, the toxins of cholera
may kill a man before the bacillus has migrated from the
intestine. Brieger uses the term toxin to designate all of the
poisonous products of bacterial action. He divides toxins
into alkaloidal or crystallizable and amorphous, the latter
being called toxalbumins.

Ptomains. — By many writers the term " ptomain " is
used to designate these toxins, but in reality a ptomain is
a form of toxin that is due to the action of saprophytic bac-
teria. A ptomain is a putrefactive alkaloid, and a toxin is
any poison of microbic origin. Among these poisonous al-
kaloids may be mentioned tetanin, typhotoxin, .sepsin, putres-
cin, muscarin, and spasmotoxin.

I/eucomams must not be confounded with the above-
mentioned bodies. Leucomains are alkaloidal substances
existing normally in the tissues, and arising from physio-
logical fermentations or retrograde chemical changes. They
are natural body-constituents, in contrast to toxins, which
are morbid. Leucomains are found in expired air, saliva,
urine, feces, tissues, and the venom of serpents. If not
excreted, these bodies may induce illness, and when injected
may act as poisons. Ordinar>' colds and some fevers result
from leucomains ; they play a great part in uremia, and when
excretion is deficient the retained leucomains make the sys-
tem a hospitable host for pathogenic bacteria. Among leu-
comains may be mentioned adenin, hypoxanthin, and xan-
thin, allied to uric acid, and other substances allied to creatin
and creatinin.

Alexins and Antitoxins. — Another group of substances
which may arise from microbic action are known as ** anti-
toxins." When a person suffers from a bacterial malady the

BACTERIOLOGY, 33

toxins of the bacteria, by acting upon the body-cells, cause
the body-cells to produce a product which may kill the bac-
teria (alexin) or may simply antagonize the toxin (antitoxin)
These materials may exist in blood-serum as leucomains, or
may be toxins or toxalbumins absorbed by the blood from an
area of bacterial disease. It is a well-recognized fact in fer-
mentation that after a time the process ceases, and the addi-
tion of more ferment is void of result The same is true of
specific maladies ; thus, if a person recovers, the organisms
disappear, and the injection of more of them produces no
result ; in other words, immunity exists toward the disease.
This immunity was long believed to arise from the exhaus-
tion of some unknown constituent of tissue necessary to the
life of the bacteria. It is now believed to be due partly to
the capacity of the body-cells to destroy germs, and partly
to the production of alexins or antitoxins, which, when they
have developed in sufficient amount, destroy the bacteria or
render bacterial products harmless. In other words, bacteria
not only produce poisons, but also the antidotes for them.
Many observers are endeavoring to find the antitoxin of
each microbic disease for the purpose of applying it thera-
peutically. Great claims are made as to the value of the
antitoxins of diphtheria, tetanus, and suppurations. Roux
maintains that an antitoxin is not derived from a toxin,
but that a toxin stimulates the body-cells to secrete an
antitoxin. He further shows that an antitoxin does not
destroy a toxin, but acts upon the body-cells and renders
them capable of withstanding the poison. Buchner believes
that the reason the leukocytes help to ward off disease is
not because they act as phagocytes to bacteria, but because
they furnish defensive proteids (alexins or antitoxins).
Vaughan and others have proved that blood-serum is germi-
cidal ; that the germicidal agent is dissolved in the alkaline
serum ; that this agent is a nuclein which is furnished by the
white cells, and this nuclein may be extracted and used
therapeutically.

Phagocytes. — The tendency of the white blood-cells and
of the fixed tissue-cells to destroy organisms is undoubted.
This process of destruction is known as ** phagocytosis," and
the destroying cells are called " phagocytes." These cells try
to eat up and destroy the germs. A battle-royal occurs, the
microbes fighting the body-cells with most active ferments ;
the body-cells endeavoring to devour and destroy the bac-
teria (Fig. lo). In some cases the bacteria win absolutely
and the patient dies. In other cases they win for a time and

MODERN SURGERY,

overwhelm the organism, but presently the body-cells, whose
movements were inhibited by the poison, regain their ac-
tivity and successfully recur to the attack. After the attack
is over the body-cells have been educated to withstand this
poison, and new cells in the future retain this capacity ; the
weak cells were killed, the fittest survived, and the descend-
ant cells of the survivors are bom insusceptible. This in-
susceptibility is called immunity^ and lasts for a varying
period. Some persons seem, from birth, immune to certain
maladies. The theory of phagocytosis immunity assumes
an educated white corpuscle and body-cell. This view origi-

FiG. xo. — Phagocytosis : A, successful ; B^ unsuccessful (Senn).

nated ^^^th Sternberg, but it is usually accredited to Metsch-
nikoff. Lankester gave us the term " educated corpuscle."
Protective and Preventive Inoculations. — Our

knowledge of protective inoculations for contagious dis-
eases dates from Jenner's discovery in 1796. Preventive
inoculations with attenuated virus are due to the experi-
ments of Pasteur. This observer discovered the cause of
chicken-cholera, and cultivated the micro-organism of this
disease outside the body. He found that by keeping his
cultures some time they became attenuated in virulence, and
that these attenuated jcultures, inoculated in fowls, caused
a mild attack of the disease, which attack was protective,
and rendered the fowl immune to the most virulent cul-
tures. Cultures can be attenuated by keeping them for
some time, by exposing them for a short period to a tem-
perature just below that necessary to kill the organisms,
and by treating them with certain antiseptics. It has
further been shown that injection of the blood-serum of an

BACTERIOLOG Y. 35

animal rendered immune by inoculation is capable of making
a susceptible animal also immune.

A most important fact is that animals may be rendered
immune to certain diseases by inoculating them with filtered
cultures of the microbes of the disease, the filtrate contain-
ing microbic products, but not living microbes. By this
method animaJs can be rendered immune to tetanus and
diphtheria. Pasteur's protective inoculations against hydro-
phobia owe their power to microbic products, and Koch's
lymph contains them as its active ingredients. The chief
feature in acquired immunity is the presence in the blood and
tissues of elements which can neutralize the toxic products
or which can kill bacteria. These elements are "antitox-
ins " and " alexins." The present knowledge of them arose
from the discovery of Nuttall and Buchner that fresh blood-
serum is germicidal, the power varying for different bacteria
and being limited, for a fixed amount of serum is capable of
destroying a small dose of bacteria only. It has been said
that in tetanus injections of the serum of an immune animal
may cure the disease. The above facts are of immense im-
portance, for on these lines may be solved the problems of
the prevention and treatment of microbic maladies.

Orrhotherapy or serum-therapy is an attempt to utilize
therapeutically the germicidal properties of blood-serum.
It is believed that when a man gets an infectious disease
the toxins act upon the body-cells and cause the formation
by these cells of defensive proteids, alexins, curative nucleins
or antitoxins. These products enable the body-cells to with-
stand further injury by the toxins, the disease comes to an
end, the bacteria die, and the alkaline blood-serum is satu-
rated with protective material. If the above facts are true, it
is an easy deduction that blood-serum containing protective
material should cure the disease if injected into a patient suf-
fering from an attack. Instead of using the blood-serum
itself, some observers have precipitated the curative nuclein
from the serum and used the nuclein in solution in fixed
amounts. Instead of using the serum of persons rendered
immune by an attack of the disease, many physicians have
employed the serum of animals rendered artificially immune
by injections of attenuated cultures of the bacteria. Some
experimenters have employed even the serum of animals nat-
urally immune to the disease. That Pasteur has devised a
method which will usually prevent hydrophobia is certain
(p. 182), and that Murri, of Bologna, has cured a case of
hydrophobia seems proved (p. 182). Hosts of observers

36 MODERN SURGERY,

believe in the utility of tetanus antitoxin and diphtheria
antitoxin.

Inconclusive experiments have been made in the treat-
ment of syphilis by the serum of dog's blood, or the blood-
serum of men laboring under tertiary syphilis ; in the treat-
ment of pneumonia with the blood-serum of persons conva-
lescent from pneumonia ; and in the treatment of sufferers
from septic diseases with antistreptococcic serum — blood-
serum of animals rendered immune to septic infections. Ma-
lignant tumors (both sarcomata and carcinomata) have been
treated with the blood-serum of dogs, which animals had
been injected with fluid expressed from malignant growths
(Richet and Hericourt). Many claims made for serum-
therapy are exaggerated, sensational, and unscientific. That
there is truth in the method seems highly probable, but how
much of it is true is not yet definitely ascertained. It is our
duty to study, experiment, and observe, and to reach a con-
clusion only after honest, careful, and thorough investigation.
A little skepticism is as yet a safe rule.

Antag^onistic Microbes. — Another observation of im-
portance is that certain microbes are antagonistic to one
another. The streptococcus of erysipelas attacks the or-
ganism of anthrax, and is antagonistic to several infectious
diseases (syphilis and tuberculosis), also to sarcoma. We
should note also that the growth of some microbes affects
culture-media favorably or otherwise for the growth of other
organisms, and the same may be true in the tissues of the
human body.

Mixed Infection.— A fact of practical importance to
the surgeon is that an area infected by one form of patho-
genic organism may be invaded by another form. This is
known as a mixed infection, and consists of a primary infec-
tion with one variety of organism, and a secondary infection
with another. Koch found both bacilli and micrococci in
the same lesion of tubercle. A soil filled with pncumococci
favors the growth of pus cocci and tubercle bacilli. Tuber-
culous or syphilitic lesions may be attacked by erysipelas.
Chancre and chancroid can exist together. A syphilitic ulcer
is a good culture-soil for tubercle bacilli (Schnitzler). Sup-
puration in lesions of tuberculosis is due to secondary infec-
tion with pus organisms.

Placental l^ansmission. — The direct transmission of
bacteria from parent to fetus is a problem still in course of
solution. Certain it is that some diseases (as syphilis) are
due to the direct carrying of the microbes by sperm-cell to

BACTERIOLOGY.

germ-cell, or to the transmission of tlie micro-organism
through the septum of separation between the circulations
of the mother and child. In many other diseases the mi-
crobe is not directly transmitted (as in phthisis), but a patient
bom with weakened tissue-cells is prone to fall a prey to the
latter malady.

Special Snrgical Microbes. — Suppuration is caused by
microbes. Can it exist without them? The answer is, no.
Injection of a fluid containing dead organisms will form a
hmited amount of pus ; injection of irritants forms a thin fluid
which may resemble pus, but which is not pus. In surger>'
pus is not met with without the micro-organisms, and the
presence of pus proves the presence of micro-organisms.
Pus microbes, or pyogenic microbes, possess the property of
peptonizing albumin, and thus forming pus. The peptonizing
action is brought about by bacterial proteids or ferments.
The inflammation which surrounds an area of pyogenic in-
fection is caused by the irritant products of bacterial action
(toxalbumins, ammonia, etc.). In the presence of the pyo-
genic peptones inflammatory exudate is unable to coagulate.
The most usual causes of suppuration are the following
micro-organisms :

Staphylococcus pyogenes aureus (Fig, 1 1), the golden-yellow
occus. This is the most usual cause of abscesses (circum-
scribed suppurations) ; 77 per cent, of acute abscesses are due
to staphylococci (W. Watson Cheyne). Staphylococci are

found also in osteomyelitis. The staphylococcus pyogenes
aureus is a facultative anaerobic parasite which is widely dis-
tributed in nature, and is found in the soil, the dust of air,
water, the alimentary canal, under the nails, on and in the
superficial layers of skin, especially in the axilla and peri-

38 MODERN SURGERY,

neum. It forms the characteristic color only when it grows
in air. It is killed in lo minutes by a moist temperature of
58° C, and is instantly killed by boiling water. Carbolic acid
(i : 40) and corrosive sublimate (i : 2000) are quickly fatal
to these cocci.

Staphylococcus pyogenes albus, the white staphylococcus,
acts like the aureus, but is more feeble in power. When this
organism is found upon and in the skin it is called the
staphylococcus epidermidis albus, an organism which Welch
proved to be the usual cause of stitch-abscesses.

Staphylococcus pyogenes citreus, the lemon-yellow coccus,
is found occasionally in acute circumscribed suppurations,
but far more rarely than the other two forms. Its pyogenic
power is even weaker than that of the albus.

Staphylococcus ccretis albtis, found occasionally in acute
abscesses.

Staphylococcus cereus flainis^ found occasionally in acute
abscesses.

Staphylococcus flavescens, occasionally found in abscesses.
Is intermediate between the aureus and albus (Senn).

Micrococcus pyogenes tenuis rarely takes the form of a
bunch of grapes. Is occasionally found in the pus of acute
abscesses.

Streptococcus pyogenes (Fig. 1 2), found in spreading suppu-
rations. Woodhead tells us (Treves' System of Surgery) that
six organisms, each of which bears a separate name, are dis-
cussed under this designation. Three of these organisms he
places in one group, two in another, and says the sixth may
be a separate species.

1st Group. — Streptococcus pyogenes ^ found especially in
spreading suppuration and in very acute abscesses. Cheyne
says that 16 per cent, of acute abscesses contain streptococci.
Is easily killed by boiling, and can be destroyed by carbolic
acid and corrosive sublimate. Exists normally in nasal pas-
sages, vagina, saliva, and urethra.

Streptococcus pyogenics tnalignus, an uncommon organism
found in splenic abscess.

Streptococcus septicus has a strong tendency to break up
into diplococci.

2d Group. — Streptococcus of erysipelas^ found in capillary
lymph-spaces in erysipelas. Many bacteriologists believe it
to be identical with the streptococcus pyogenes.

Streptococais of septicemia and pyemia. Most observers
maintain that it is identical with the streptococcus pyogenes
and streptococcus of erysipelas.

BACTERIOLOGY. 39

3d Group. — Streptococcus articulorum, found in false mem-
brane of diphtheria (see the excellent article by Woodhead in
the System of Surgery by Frederick Treves).

Bacillus pyogenes fcetidus, found especially in the pus of
ischiorectal abscesses.

Baallus pyocyanciis, found by Ernst in blue pus.

Other Surgical Microbes. — Streptococcus of erysipelas
(Fehleisen's coccus), as stated before, is thought to be iden-
tical with the streptococcus
pyogenes. Their difference in
action is believed by Sternberg
to be due to difference in viru-
lence induced by external con-
ditions and by the state of the
tissues of the host. The coc-
cus of erysipelas is somewhat
lai^r than the ordinary form
of streptococcus pyogenes. In-
fection takes place by a wound,
often a very trivial wound, or
by the mucous membrane. The
organism multiplies in the small
lymph-channels. This organ-
ism will cause puerperal fever
in a woman in childbed when
it gains access to " an absorb-
ing surface in the genital tract "

(Senn). The streptococcus may cause suppuration in ery-
sipelas, mixed infection not being necessary to cause pus to
form.

The gonococcus (Fig. 14, the bacillus of Neisser), the diplo-
coccus which causes gonorrhea. Bumm proved that this coc-
cus was certainly the cause of the disease, by reproducing the
disease in a healthy female urethra by inoculation with the
twentieth generation in descent from a pure culture. Diplo-
cocci are found often in the secretions of apparently healthy
mucous membranes, and simulate very closely gonococci.
Gonococci cannot be cultivated upon ordinary media, but
grow best upon human blood-serum. In gonorrhea the
organism is found both inside and outside of pus-cells and
mucus-cells. It is not certain that the gonococcus is pyo-
genic, the pus in gonorrhea being possibly due to mixed
infection. Gonococci stain easily and are readily decolorized
by Gram's method.

Streptococci are found in noma. No specific organism has

MODERN SVKGERY.

been i.solatcd for traumatic spreading gangrene or hospital
gangrene, only pus cocci having been found.

The bacillus tetani (Fig. 15. Nicolaier's bacillus), an an-
aerobic organism, found especially in the soil of gardens, ia I

i^iVi

•'•0-

the dust of old buildings, in street dirt, and in the sweepings -'
of stables. Spores develop at the ends of these bacilli. This ,
organism is capable of producing toxins of deadly power.
Its spores are hard to kill. The drug which is most cer-
tainly fatal to tetanus bacilli is bromin.

The bacillus iuberatlosis (Fig. 16, Koch's bacillus), the ]

cause of all tubercular processes, is met with especially in
dusty air which contains the dried sputum of victims of
phthisis. This infected air is thL- chief means of its trans-
mission, though it maybe conveyed by the milk of tubercu-

BACTERIOLOGY.

lar cows and the meat of tubercular animals. Wounds may
open a gateway for infection.

Bacillus antkracis (Fig. 13), the cause of malignant pus-
tule, or splenic fever.

Bacillus mallei^ the cause of glanders.

Bacillus of syphilis (Lu.stgarten's bacillus). That syphiUs
is due to a micro-organism is highly probable, but thai we
have found the causative organism in Lustgartcn's bacillus is
by no means sure. A fact which points strongly against it
as the cause is that it is found rather in non-contagious ter-
tiary lesions than in contagious secondary lesions.

The bacillus coli communis, called also the bacterium coli
commune or the bacillus of Escherich. Feces invariably

\ * u^ *^

,.>■•<•; >

i incpulumfZlFglrr)

contain this organism. It is believed by many observers to
be the cause of appendicitis, peritonitis, and abscesses about
the intestine. In cases of appendicitis we can rarely get a
pure culture of Escherich's bacillus, but usually find also
streptococci, staphylococci, or pneumococci.

The bacillus of malignant edema (the vibrione septique
of Pasteur), found especially in stagnant water and certain
varieties of soiL

The bacillus of typhoid fezier (Eberth's bacillus) is respon-
sible for some cases of gangrene, some of embolism, and
not a few of bone and joint disease.

We may mention, in conclusion, as of occasional surgical
importance, the bacillus of influenza, bacillus of diphtheria.
bacillus of lepro.sy, bacillus of rhinoscleroma, bacillus of
fedd ozena, bacillus of hemorrhagic septicemia, bacillus lac-
tis aerogenes (an occasional cause of peritonitis),

Proteus vulgaris, or bacterium termo. induces putrefaction
and is responsible for many septic intoxications.

i ^

MODERN SURGERY,

II. ASEP5I5 AND ANTISEPSIS.

Surgical cleanliness may be obtained by either the aseptic
or the antiseptic method. In the aseptic method heat,
chemical germicides, or both are used to cleanse the instru-
ments, the field of operation, and the hands of the surgeon
and his assistants, the surface being freed from the chemical
germicide by washing with boiled water or with saline solu-
tion. After the incision has been made no chemical germi-
cide is used, the wound being simply sponged with gauze
sterilized by heat ; if irrigation is necessary, boiled water or
normal salt solution is used, and the wound is dressed with
gauze which has been rendered sterile by heat. The effort
of the surgeon is simply to prevent the entrance of micro-
organisms into the tissues. Some micro-organisms must
enter, but the number will be so small that healthy tis-
sues will destroy them. The aseptic method should be used
only in non-infected areas. If chemical germicides are
not used, the amount of wound-fluid will be small and the
surgeon can often dispense with drainage. If a wound is to
be closed without drainage, every point of bleeding must be
ligated. It is often advisable to sew up the wound with
Halsted's subcuticular stitch (Fig. 17). If this stitch is em-

FiG. 17. — Halsted's subcuticular suture.

ployed, the skin staphylococcus does not obtain access to
stitch-holes and stitch-abscesses cannot arise. This suture
may consist of catgut, silk, or, preferably, silver wire, this lat-
ter agent being capable of certain sterilization by heat and
exercising a powerful inhibitory action on micro-organisms.
If a wound is closed without drainage, firm compression is
applied over the wound to obliterate any cavity which may
exist. In some regions of the body wounds are sealed with
collodion or iodoform-collodion. If irrigation is not prac-
tised and the wound is dressed with dry gauze, the pro-
cedure is said to be by the ^' dry " aseptic method. In the
antiseptic method the same preparations are made for the
operation as in the aseptic method, but during the operation
sponges impregnated with a chemical germicide are used,

ASEPSIS AND ANTISEPSIS, 43

and the wound is dressed with gauze containing corrosive
sublimate or some other chemical germicide. If the wound
is not flushed with a chemical germicide, and is dressed with
dry gauze, the operation is said to be by the " dry '* antisep-
tic method. The antiseptic method is preferred in infected
areas. Dry dressings are usually preferable to moist dress-
ings, because they are more absorbent and do not act as
poultices, and dry dressings may be used even when the
wound has been flushed. Year by year the aseptic method
becomes more popular. Surgeons have learned that the
most important factor in asepsis is mechanical cleansing by
means of soap and water. The chemical germicide plays a
secondary rather than a vital part. In many regions a strong
chemical germicide must not be used (in the abdomen, in the
brain, in joints, in the pleural sac, and in the bladder), and in
other regions (mucous surfaces and fatty tissue) it is produc-
tive of harm rather than good.

Preparations for an Operation. — The surgeon and his
assistants remove their coats, roll up their sleeves, and
envelop their bodies in aseptic or antiseptic sheets to pro-
tect the patient and themselves. The hands and forearms
are scrubbed with soap and hot sterile water. There is
nothing equal to the ethereal soap of Johnston, which is a
solution of castile soap in ether. Green soap or castile soap
can be used. The brush employed is kept constantly in a
I : 1000 solution of corrosive sublimate. The nails are cut
short, are cleansed with a knife, and the hands are again
scrubbed. The hands are dipped in a hot solution of cor-
rosive sublimate, and with the forearms are scrubbed for at
least a minute, the nails receiving especial care; they are
then dipped for one minute into pure alcohol and are again
bathed with the mercurial solution. Kelly disinfects the hands
by washing them with soap and water, dipping them in a so-
lution of permanganate of potassium (a saturated solution in
distilled water), and decolorizing them in a saturated solution
of oxalic acid and washing off* the oxalic acid in sterile water.

Weir has highly commended the following plan and Stim-
son is also pleased with it. Scrub the hands with a brush
and green soap and in running hot water. Clean under the
nails with a piece of soft wood. Place about a tablespoonful
of chlorinated lime in the palm of the hand, place upon the
lime an equal amount of washing-soda, add a little water,
and rub the creamy mixture over the arms and hands until
the rough granules of sodium carbonate are no longer felt.
Place the paste under and around the nails by means of a

44 MODERN SURGER Y.

bit of Sterile orange wood. Wash off the arms and hands
in hot sterile water/

Instruments are disinfected by boiling for fifteen minutes
in a I per cent, solution of carbonate of sodium and then
rinsing them in a 5 per cent, solution of carbolic acid. The
carbonate of sodium prevents rusting. Boiling unfortunately
destroys to some extent the keenness of the cutting instru-
ments. They are kept in trays containing boiled water. In-
struments can be disinfected satisfactorily by keeping them
for fifteen minutes in a 5 per cent, solution of carbolic acid.
Instruments with handles of wood must not be boiled. If
such instruments are used, they can be disinfected by the use
of carbolic acid, but they should not be used. After the
completion of the operation the instruments should be
scrubbed with soap and water, boiled, and dried. Marine
sponges are rarely used, small pieces of sterilized or anti-
septic gauze being preferred. In the abdomen Ashton's
aseptic gauze pads are employed. These pads are about
ten inches square, and are made of a number, of folds of
gauze stitched loosely at the edges.

Whenever possible, give the patient some days' rest in
bed before a severe operation, and place him on a diet nutri-
tious but not bulky. The night before the operation give a
saline cathartic, and the morning of the operation employ
an enema. Emptying the bowels lessens the danger of
sepsis after operation. It is desirable that the rectum be
empty, because in shock the stomach cannot absorb, and we
may wish to utilize the absorbing power of the rectum and
give stimulants by enema. Whenever possible, give a gen-
eral warm bath the day before. The evening before the
operation scrub the entire field of operation, and well clear
of it, with soap and water ; shave if necessary ; wash with
ether ; scrub well with hot corrosive-sublimate solution
(i : 1000); apply a layer of moist corrosive-sublimate gauze,
and place over this dry antiseptic gauze, a rubber dam, and
a bandage. On removing the dressings to perform the opera-
tion cleanse the part again exactly as before. In emergency
cases disinfection can only be practised just previous to the
operation. Disinfection can be thoroughly effected by the
use of chlorinated lime (Weir, Stimson). Surround the field
of operation with dry sterile sheets.

To clean the vagrina or rectum, use a sponge soaked
with creolin and Johnston's ethereal soap (i : 16), and subse-
quently irrigate with hot saline fluid or boric acid solution.

* Medical Record, April 3, 1897.

ASEPSIS AND ANTISEPSIS, 45

To clean the mouth scrub the teeth with a brush and castile
soap twice a day and rinse out the mouth with peroxide of
hydrogen, or a solution of boracic acid every three hours
for several days.

Irrigration is often practised in septic wounds, but is not
required in aseptic wounds. Among irrigating fluids we may
mention corrosive sublimate, carbolic acid, peroxid of hydro-
gen, boric acid solution, and normal salt solution. Hot
normal salt solution is the best agent with which to irrigate
the peritoneal cavit>', the pleural sac, the interior of joints,
and the surface of the brain. This solution contains 0.7 per
cent, of sodium chloride.

Many surgeons employ Landerer*s dry method in ope-
rating aseptically. No fluid is applied to the wound. As
the wound is enlarged gauze sponges are packed in to arrest
hemorrhage. On the completion of the operation the sponges
are removed, any bleeding points are ligated, and the wound
is closed without drainage.

The favorite li^rature-inaterial is catgut, which is well pre-
pared by boiling in alcohol. Another method is to take raw
catgut, keep it in ether for twenty-four hours, soak it for twenty-
four hours in an alcoholic solution of corrosive sublimate
(i : 5CX)), wind it on sterilized glass rods, and place it for keep-
ing in ether or in alcohol. Fowler's catgut is prepared by
boiling in alcohol, and is carried in hermetically sealed glass
tubes containing alcohol, each tube holding twelve ligatures.
Johnston's quick method of preparing catgut is as follows :
place it for twenty-four hours in ether ; at the end of this
period place it in a solution containing 20 grains of corro-
sive sublimate, 100 grains of tartaric acid, and 6 ounces of
alcohol. The small gut is kept in this for ten or fifteen
minutes, the larger gut from twenty to thirty minutes, but
never longer. It is placed for keeping in a mixture contain-
ing I drop of chlorid of palladium to 8 ounces of alcohol.
This gut is strong and reliable. At the time of operation the
gut is placed in a solution one-third of which is 5 per cent,
carbolic-acid solution and two-thirds of which are alcohol.
Chromicized gut will not be absorbed so readily as other
gut. It is prepared by adding 200 parts by weight of cat-
gut to 200 parts of carbolic acid, 2000 parts of water, and i
part of chromic acid. After remaining in this solution
twenty-four hours it is transferred for permanent keeping to
ether or to alcohol. Kelly and Clark prepare catgut by boil-
ing it in cumol. Senn uses gut prepared with formalin. The
great advantage of formalin gut is that it can be boiled with-

46 MODERN SURGERY.

out injury. Silk can be used for both ligatures and sutures;
many sizes should be kept on hand. Sutures of silk should
be well boiled before using. A convenient method of prepa-
ration is to wind the silk on a glass spool, place the spool in
a large test-tube, close the mouth of the tube with jeweller's
cotton, introduce the tube into a steam sterilizer, and keep it
there for one hour. These tubes are carried in wooden boxes
sealed with rubber corks. Silkworm gut contains fewer bac-
teria than catgut and does not swell when introduced into a
wound. It is a very valuable suture-material, but is not used
for ligatures. Silkworm gut is prepared by placing it in
ether for forty-eight hours and in a solution of corrosive
sublimate (i : looo) for one hour. It is carried in a long
tube filled with alcohol. A few minutes before using the
gut is placed in carbolic acid and alcohol (one-third of a 5
per cent, solution of acid, two-thirds of alcohol). Silk and
catgut should be tied by the reef-knot. Silkworm gut is tied
by the surgeon's knot. The first double knot is double and
tight, the second is single and is lightly tied. If the second
knot is light, it will not cut (Greig Smith). Silver wire is
prepared by boiling.

Most wounds are closed by interrupted sutures of silk-
worm gut, but silk, catgut, chromic catgut, or silver wire can
be used. The old continuous suture (Glover's stitch) is rarely
used. An admirable closure can be effected by Halsted's
subcuticular stitch, and scarcely any scar results. Marcy's
buried tendon sutures are very valuable, especially in hernia
operations and in various operations upon the abdomen.
Kangaroo tendon is the best material for buried sutures.
This tendon is prepared by boiling it for one hour in alcohol
and then treating it by the palladium process exactly as cat-
gut is treated.

Dressingrs are made of cheese-cloth. This material is
boiled in a solution of carbonate of sodium, rinsed out, and
dried ; it is then soaked for twenty-four hours in a solution
containing i part of corrosive sublimate, 2 parts of table-salt,
and 500 parts of water. It is placed in jars, and it may be
kept moist or dry.

Sterilized gauze is prepared by boiling the material in
soda, rinsing, and either boiling it for fifteen minutes or
placing it in the steam sterilizer for the same time.

Iodoform gauze is useful for packing and for dressing foul
wounds. It is prepared as follows : make an emulsion com-
posed of equal quantities by weight of iodoform, glycerin,
and alcohol, and add corrosive sublimate in the proportion

ASEPSIS AND ANTISEPSIS. 47

of I part to the 1000 of the mixture. This mixture stands
for three days. Take moist bichlorid g^uze, saturate it
with the emulsion, let it drip for a time, and keep it in ster-
ilized and covered glass jars (Johnston). Lister's cyanid
gauze (double cyanid of zinc and mercury) is not certainly
antiseptic, and must be dipped into a corrosive-sublimate so-
lution (i : 2000) before using. All forms of gauze can be
bought ready prepared from reliable firms. Some surgeons
place silver foil upon a wound before applying the gauze
(Halsted, p. 29). Small wounds in which drainage is not
employed may often be dressed by laying a film of aseptic
absorbent cotton over the wound and applying, by means
of a clean camel's-hair brush, iodoform collodion (grs. xlviij
to 3j).

When a wound is dressed with gauze a rubber-dam is
sometimes laid over the dressings, so as to diffuse the dis-
charge and prevent it from coming rapidly to the surface.
The use of the rubber-dam is not nearly so common as for-
merly. In an aseptic wound dry dressing uncovered by rub-
ber is the most useful. When a dressing is covered by an
impermeable material it becomes wet, acts as a poultice, and
the discharges on the dressing may undergo decomposition.
Drainage is obtained when needed by rubber or glass tubes,
by strands of horsehair, silkworm gut, or catgut, or by pieces
of gauze. Gauze, catgut, etc., are known as capillary drains.
When moist they drain serum excellently, but pus very
badly, or not at all. Drainage-tubes or strands are brought
out at a portion of the wound which will be dependent when
the patient is recumbent. Drainage is used in all infected
wounds, in most very large wounds, in wounds to which irri-
tant antiseptics have been applied, and in cases in which large
abnormal cavities exist. Dressings must be changed as soon
as soaking is apparent, and the change must be effected with
all of the aseptic care employed in the operation. Stitches
may usually come out about the sixth day. In large
wounds only a few of them are taken out at one time, the
remainder being allowed to remain for a couple of days
longer. When a stitch begins to cut it is doing no good,
and it should be removed, no matter how short a time it has
been in place.

Preparation of Marine Sponges. — Beat out the dust;
place them for forty-eight hours in a solution of hydro-
chloric acid (15 per cent); wash them out with water; place
them for one hour in a solution of permanganate of potas-
sium (siij to 5 pints of water) ; soak for four hours in a solu-

48 MODERN SURGER Y.

tion containing lo ounces of hyposulphite of sodium, 5
ounces of hydrochloric acid, and 3 pints of water ; wash
with running water for six hours. Keep the sponges in a
jar containing corrosive-sublimate solution (i : 1000). After
using, wash in hot water, soak for half an hour in a solution
of sodium carbonate (i : 32), wash in hot water, and replace
in corrosive sublimate. A marine sponge inevitably becomes
foul in its interior, and should not be used.

Senn's Decalcified Bone-chips. — Take the shaft of the
tibia or femur of a recently killed ox, saw it into portions
two inches in length, remove the marrow and periosteum^
and place the fragments of bone in a 1 5 per cent, solution
of hydrochloric acid. Change the solution every twenty-
four hours. In from two to four weeks the bone will be
decalcified. Wash in distilled water, place the pieces of de-
calcified bone for a few minutes in a dilute solution of potash
to neutralize the acid, and then immerse for twenty-four
hours in distilled water. The portions of bone are cut into
strips in the direction of the long axis of the segments.
Each strip is three-quarters of an inch wide and should be
sliced into bits one millimeter thick. These chips are kept
in an alcoholic solution of corrosive sublimate (i : 5CX)).

III. INFLAMMATION.

Definition. — Inflammation is a nutritive disturbance aris-
ing from tissue-damage, and is not an increase of nutrition.
It is defined by Sanderson as *' the succession of changes
which occur in a living tissue when it is injured, provided
that the injury is not of such a degree as at once to destroy
its structure and vitality." The changes alluded to in this
definition comprise — (i) changes in the vessels and the cir-
culation ; (2) departure of fluids and solids from the vessels ;
and (3) changes in the perivascular tissues.

Vasctilar and circulatory changes are essential to in-
flammation in both vascular and non-vascular tissues. In
the former they occur in the inflamed tissues ; in the latter
(cornea and cartilage) they are manifest in neighboring tis-
sues from which the non-vascular area derives its nutritive
material.

Active Hyperemia. — When an irritant is applied ta
tissue there may be a momentary arterial contraction due
to irritation of the nerves, but this contraction is transitory^
and is not an inflammatory phenomenon. The first vascu-
lar phenomenon is dilatation of all the vessels — capillaries^

INFLAMMA TION.

venules, and arterioles — appearing first and being most pro-
nounced in the small arteries. As a result of the dilatation
there are increased rapidity of circulation and increased deter-
mination of blood to the part, and the area of hyperemia
becomes warmer than is normal. This condition of in-
creased circulatory activity is known as " active hyperemia "

'■'f ■* . ... . . , .

Active hyperemia is an mcrease in the amount of moving
blood in a part. Passive hyperemia is an increase in the
amount of blood in a part,
but not of moving blood, as
passive hyperemia or con-
gestion is due to venous ob-
struction, and the blood is
stagnated. Plethora means
an increase in the total
amount of body blood.
Diminution in the amount of
blood in a part is ischemia.

In active hyperemia more
blood goes to the part and
more blood passes through
it, an increased amount of
venous blood comes from
the hyperemic area, the
venous tension is increased,
and the veins may even pul-
sate. The capillaries, which
under ordinary circum-
stances contain but few
blood-cells (Fig. i8), become filled with corpuscles, and even
the smallest capillaries pulsate. The capillaries contain no
muscle-fiber, and hence these tubes cannot actively contract,
contraction or dilatation depending upon the amount of blood
sent to or retained in them. In active hyperemia the in-
creased amount of blood sent to the part causes capillary di-
latation. Fluid elements rarely leave the blood-vessels dur-
ing active hyperemia, but they occasionally do. The wheals
of urticaria are thus formed (Warren). Active hyperemia is
often the first stage of an inflammation, but it is not of neces-
sity followed by other inflammatory changes, and it can be
cau.sed by nerve-section or nerve- stimulation.

During active hyperemia the capillaries are crowded with
corpuscles and the blood in the veins is of a much brighter
red than in health. The red blood-cells are swept along the

— Noimal vcudi and blood-il

AfODERN SCRGER K

centre of the current (in the axia! stream); the white bleu
cells float lazily along near the vessel-wall (Fig. 19).

Retardation. — After active hyperemia has existed for^
variable time the blood-current begins to lessen in velodti
until it becomes more tardy than in health. This is kno'
as " retardation of the circulation." Retardation is first note
in the venules, next in the capillaries, and last in the arteri-
oles ; but arterial pulsation continues. The white cells show
a strong tendency to adhere to the vein-walls, and, as a re-
sult, accumulate against
the inside of, and stick
to, these walls and to one
another, until the veins
are entirely lined with
layers of leukocytes. In
tlie capillaries some leu-
kocytes gather, but not
fi many. In the arteries
i they adhere during car-
'' diac dilatation, but are
u swept away by the force
of the heart's contraction.
Retardation is believed to
be chiefly due to paresis
of the muscular walls of
the arterioles. This
causation seems probable
when we recall Lord Lis-
ter's experiments upon
to 1.,- i.,ui.i.iir, I cvHwirTM.i jnimnii.jn ^j^^ pigmeHt-cells of the

frog's foot. Li.ster proved that inflammation paralyzes the
pigment-cells, and concluded that dilatation at the focus of
an inflammation is due to the paralyzing action of an irritant
Dilatation at a distance from the focus is a retle.K phenomenon
(W. Watson Chcyne).

Oscillation and Stagnation. — By this accumulation of
leukocytes the blood-.stream is progressively narrowed and
the axial current is impeded. The red blood-cells begin to
stick to one another, forming aggregations like rouleaux of
coin, which increase the difficulty the axia! current has to
contend with, until progressive movement ceases and the
contents of the vessels sway to and fro with the heart-beat.
This is the stage of oscillation. In a short time oscillation
ceases and the vessels are filled with blood which docs not
move, and the vessel-walls become irregular in outline or

tXFLAilMA TlOff.

even pouched. This is known as '" stasis" or "stagnation"
(Fig. 20), If stasis persists, coagulation or thrombosis oc-
curs, because the vessel-walls have been so injured by the
irritant as to be practically dead material, and they are no
longer able to prevent
clotting of their contents.
Stasis is chiefly due to
paralysis and damage of
the vessel-walls. We can
then sum up the vascular
changes of inflammation
by stating that they con-
sist in a dilatation of the
vessel-walis, in a primary
acceleration, a secondary
retardation, and a subse-
quent stagnation of the
blood-current with adhe-
sion of leukocytes to the
walls of veins and capil-
laries, and the aggrega-
tion into masses of the
red blood-cells. If stasis
persists, the vessel-walls

become profoundly in- fio. jo.-susi* nf Mnnd and -n^rcdMis or whiw
volved in the inflam- corp,.>ti" in iiifl..niiiiji.on,

matorj' change, and they may rupture or be completely de-
stroyed.

Exudation of Fluids. — It is to be remembered that in
the process of nutrition serum and even white cells pass into
the tissues through the walls of veins and capillaries. In in-
flammation the same thing happens, but the exudation is
vastly greater in amount and is different in composition. In
a slight inflammation, and in the early stage of any inflam-
mation, there is an increase in the fluid exudate, and we
speak of the condition as " serous inflammation." This fluid
is really not serum, but is liquor sanguinis. We find true
serum in passive congestion, not in active inflammation.
The fluid in a serous exudation contains very few white
cells, and hence little or no fibrin can form in it, and coagu-
lation does not take place ; and if the inflammation goes no
further, it is absorbed by the lymphatics. A blister is an
example of .serous inflammation. If the inflammation con-
tinues to intensify, the exudation is altered in character — it
becomes thicker, turbid, and very coagulable. It contains

MODERN SURGERY.

white cells and fibrin-elements, and coagulates in the tissues.
This fluid is known as " lymph " or plastic exudation, and
when it is present we speak of the condition as " plastic in-
flammation." The lymphatics endeavor to absorb the fluid,
but become occluded by coagulation, and the area they
drain becomes swollen, hard, and "brawny." Lymph can be
seen in the anterior chamber of the eye in cases of plastic
iritis. The slighter the inflammation the less albuminous is
the fluid — the higher the inflammation the more albuminous
is the fluid. The focus of an inflammation feels brawny be-
cause of coagulation of a highly albuminous exudate — the
periphery of an inflammation is soft and edematous because
of the presence there of thin and non-coagulable exudate.

Diapedesis or Migration. — Even early in an inflamma-
tion some few white corpuscles pass through the vessel-walls ;

Fig. 21. — ^Stages of the migration of a single white blood-corpuscle through the wall of a vein

(Caton).

but when the inflammation is well established large numbers,
and when it is severe vast hordes, pass into the perivascular
tissues. This process is known as " diapedesis " or " migra-
tion." The leukocytes throw out protoplasmic arms, insert
themselves between the cells of the walls of the vessel, and
pull themselves through by their power of ameboid move-
ment. They do not pass through existing open doors, but
form openings which close after them. This is readily ac-
complished, because the vessel-wall is itself damaged, weak-
ened, and convoluted. The escape of leukocytes takes place
chiefly from the venules, though some migrate through the
capillaries and even the arterioles (Fig. 21).

In very acute inflammation the vessel-walls are so dam-
aged that red corpuscles also escape, making the tissue ap-

INFLAMMA TJON. 5 3

pear as if infiltrated with blood. The white corpuscles often
greatly increase in number in the blood of a person who has
an acute inflammation (leukocytosis), and the blood-making
organs, such as the spleen and lymphatic glands, are often
enlarged. The blood-plaques or third corpuscles are found
to be present in increased numbers. These blood-plaques
are not seen in moving blood, but are found in blood-clot,
their usual proportion to red cells being as i to 20, and they
are especially numerous at the height of fever-processes and
during convalescence from an extensive abscess.

Clianges in the Perivasctilar Tissues. — The exuded

liquor sanguinis coagulates, and as a result of the exudation
of elements of the blood the tissues are softened, separated,
and overfed. The abundance of food causes tissue-cells to
multiply, and this process is known as " cell-proliferation."
To the proliferating cells of the perivascular tissues are added
the migrated leukocytes, the individual tissue-elements are
separated and their identity is destroyed, and a mass is formed
consisting of small round or oval cells held together by ge-
latinous intercellular material. The newly formed cellular
mass is called " embryonic tissue." inflammatory new forma-
tion, indifferent tissue, juvenile tissue, or plastic infiltration.
The tissues have reverted to a condition identical with the
tissues of the embryo, as the first step in repair. Embryonic
tissue may be absorbed by the lymphatics. It may be con-
verted into pus if infected with pyogenic bacteria. It may be
vascularized by the extension into it of capillary loops de-
rived from adjacent capillaries. When embryonic tissue is
filled with blood-vessels, that is to say, when it is vascularized,
it is called granulation-tissue. Granulation-tissue is finally
converted into fibrous tissue. The above complicated pro-
cesses, vascular and perivascular, are not accidents nor hap-
hazard freaks, but are Nature's efforts to bring about a cure.
The acceleration of the circulation is an attempt to wash
away offending material ; when this fails ensuing congestion
is relieved by exudation and migration, the blood becoming
fibrinous and more corpuscular in order that foreign bodies
may be encapsuled or extruded, so that damaged parts may
be amply repaired and vital structures may be protected and
shielded. The exudation of germicidal blood-scrum may
destroy bacteria in the perivascular tissues.

Dilatation is due to the direct effect of the irritant upon
the muscle or its nerve-elements. Retardation and stasis are
due to paralysis of the vessel-wall, which paralysis causes re-
sistance to the passage of the blood-stream and adhesion of

54 MODERN SURGERY,

the corpuscles to the vessel, and which deprives the blood of
a force which normally urges it onward, namely, contraction
of the arterioles. Stasis can be increased by the pressure
of an enormous exudate, producing tension. Tension may
be so great as to produce gangrene.

Tnflatntnation in Non-vascnlar Tissue. — A type of

non-vascular tissue is the cornea, and the cornea can inflame.
When it inflames the episcleral vessels dilate and pour out
exudate, and the fluid exudate and the leukocytes enter into
the corneal lymph-spaces. The exudate coagulates and cell-
multiplication ensues as in any other inflammation. If new
formation takes place, a permanent opacity mars the cornea
as a consequence. When cartilage inflames it becomes filled
with leukocytes, which are obtained from the vessels of the
synovial membrane or the bone, and changes ensue identical
with those previously studied.

Classification of Inflammations* — The various forms
of inflammations are — (i) Simple or common, t\\^,tvf\i\c\i is
due to any ordinary traumatic, chemical, or thermal cause,
and not to bacteria, such as traumatic periostitis or sun der-
matitis. It does not tend particularly to spread. As a rule,
the cause of a simple inflammation is momentary in action ;
(2) vifcctive or specific, that which is due to micro-organisms,
as the streptococcus of er>'sipclas. An unsuccessful attempt
has been made to charge all inflammations to bacteria. It is
true that bacteria can generally be found in inflammatory
areas, but that they are the only causes of inflammation is
accepted by few. Infective inflammations tend to spread
widely; (3) trmunatic, which is due to a blow or an injury;
(4) idiopathic^ which is without an ascertainable cause.
There is certainly a cause, even if it cannot be pointed out,
and the term *' idiopathic " means that we do not know the
cause ; (5) acute, which is rapid in course and violent in
action ; (6) chronic, which follows a prolonged course ; (7)
subacute, which is intermediate in violence and duration be-
tween acute and chronic ; (8) stJienic, characterized by high
action. Occurs in strong young subjects ; (9) asthenic or
adynamic, occurring in the old, the debilitated, and the
broken-down. It is unable to reach a sufficient degree of
intensity to limit itself; (10) parejtchymatous, affecting the
"parenchyma," or active cells of an organ; (11) hiterstitial,
affecting the connective-tissue stroma ; (12) serous, charac-
terized by profuse non-coagulating exudation, as in pleuritis,
or by marked inflammatory edema ; (13) plastic, adhesive,
ox fibrinous, characterized by an exudation which glues to-

INFLAMMA TION, 5 5

gather adjacent surfaces, as in peritonitis; {14) purulent^
phlegmonous^ or suppurative^ when the pus cocci are present
and multiply ; (15) hemorrhagic, whtn the exudate contains
many red blood-cells, as in strangulated hernia and in black
small-pox; (16) croupous, when an inflammation produces
upon the surface of a tissue a fibrinous exudate which can-
not be organized (aplastic lymph), and which is due to the
action of micro-organisms. It occurs most usually on mucous
membrane; (17) dip/itheritic, which differs from croupous in
the fact that the false membrane is in the tissue rather than
upon it; {iS) gangrenous, an inflammation resulting in death
of the part, the gangrene being due to the tension of the
exudate or the violence of the poison; (19) healthy, when
the tendency is to repair; (20) unhealthy, when the ten-
dency is to destruction; (21) latent, diXi inflammation which
for some time does not announce itself by any obvious
symptoms, as the inflammation of Peyer's patches in typhoid
fever ; (22) contagious, when its own secretions can propa-
gate it ; (23) dry, without exudation ; (24) hypostatic, arising
in a region of passive congestion (as a bed-sore) ; (25) malig-
nant^ due to malignant growths ; (26) catarrhal, affecting
mucous membranes; (27) neuropathic, due to impairment
of the trophic functions of the nervous system, as in perfo-
rating ulcer ; and (28) sympat/ietic or reflex, due to disease
or injury of a distant part, as when orchitis follows mumps.

Bxtension of Inflammation. — Inflammation extends
by continuity of structure, by contiguity of structure, by
the blood, and by the lymphatics. Extension by continuity
is seen in phlebitis. Extension by contiguity is seen when a
cutaneous inflammation advances and attacks deeper struc-
tures. Extension by the blood is seen in the formation of
the small-pox exanthem. Extension by the lymphatics is
witnessed in a bubo following chancroid.

Terminations of Inflammation. — Inflammation may
be followed by a return of the tissues to health, and this
return may take place by delitescence, by resolution, or by
new growth. By delitescence is meant abrupt termination
at an early stage, as when a quinsy is aborted by the ad-
ministration of quinin and morphin, and the production of
a sweat ; resolution means the gradual disappearance of the
symptoms when inflammation has passed through its regular
stages; and new growth means that an inflammation has
lasted a considerable time, with ample blood-supply, and
without suppuration has gone on to the formation of em-
bryonic tissue, granulation-tissue, and fibrous tissue. Inflam-

$6 MODERN SURGERY.

mation may terminate in death of the inflamed part, or necro-
sis. Death of the part may be due to suppuration, ulceration,
or gangrene.

The causes of inflammatiotL are — predisposing^ or those
residing in the tissues, and rendering them liable to inflame ;
and exciting, or those which directly awake the process into
activity. The first constitute the inflammable material, the
second the sparks of fire.

Predisposing causes are those which impair the general
vigor, injure the blood, weaken the tissues, or lower nutri-
tive activities. Among these causes are shock, hemorrhage,
nervous irritation, gout, rheumatism, diabetes, Bright's dis-
ease, and syphilis. Plethora renders a person liable to
sthenic inflammations (those characterized by high action).
Tissue-debility renders one prone to adynamic or asthenic
inflammations.

Exciting Causes. — The exciting causes of inflammation are
— traumatic, as blows and mechanical irritation ; chemical, as
the stings of insects, ivy poison, etc. ; thermal, heat and cold ;
and specific, the micro-organisms, causing, for instance, tuber-
cular peritonitis or erysipelas.

Symptoms. — Inflammation announces its presence by
symptoms which are both local and constitutional. The local
symptoms are heat, pain, discoloration, swelling, and dis-
ordered function ; the chief constitutional symptom is fever.

Local Symptoms of Inflammation. — The most promi-
nent local symptoms were known centuries ago to the
famous Roman Celsus, who stated them as " rubor, calor cum
tumore et dolore " — redness and heat with swelling and pain.
As set forth to-day, the local symptoms are — {i) heat; (2)
pain; (3) discoloration; (4) swelling; and (5) disordered
function.

Heat is due to the passage of an increased quantity of
blood through the damaged area and to the arrival at the
surface of the body of warm blood from internal parts. Al-
though an inflamed part may be, and usually is, warmer
than the surrounding parts, its temperature is never greater
than the temperature of the blood. This increase of heat is
especially noticeable when we contrast the feeling of an arm
affected with erysipelas with a sound arm ; the diseased arm
feels much warmer, but still its temperature is not above the
general body-temperature. The extremities in health, as is
well known, show on the surface a temperature below that
of the blood; in an inflamed state their temperature may
nearly equal that of the blood. Heat is always present in

INFLAMMA TION, 5 /

inflammation. The surgeon examines for heat by placing
his hand upon the suspected area and then placing it upon
a corresponding portion of the opposite side of the patient.
If great accuracy is desired, a surface thermometer is used.

Pain is a constant and a conspicuous symptom. It is due
to stretching of or pressure upon nerves from exudate ; to
irritation of nerves ; or to inflammation in the nerves them-
selves, producing cellular changes. Pain is associated with
tenderness (pain on pressure), it is aggravated by motion
and by a dependent position of the part, and it varies in
degree and in character. In serous membranes it is acute
and lancinating, like dagger-thrusts ; in connective tissue it
is acute and throbbing ; in large organs it is dull and heavy ;
in the bone it is gnawing or boring ; in the skin and mucous
membrane it is itching, burning, smarting, or stinging ; in
the urethra it is scalding ; in the testicle it is sickening or
nauseating ; in the teeth it is throbbing ; and in inflamma-
tion under tense fascia it is pulsatile. Pain in inflammation
after presenting itself in one form may change in character.
If a pain becomes markedly throbbing, suppuration may
be anticipated. Pain does not always occur at the seat of
trouble, but may be felt at some distant point. This is known
as a " sympathetic '* pain, and means that a nervous communi-
cation exists between the inflamed part and a distant area, a
nerve-trunk referring pain to its peripheral distribution.

Pain of hepatitis is often felt in the right shoulder. Pain
at the point of the shoulder is felt also in gall-stones and
in cancer of the liver. The pain arises in filaments of the
pneumogastric from the hepatic plexus, which filaments
reach the spinal accessory, pain being expressed in the
branches of the spinal accessory which supply the trapezius
and communicate with the third and fourth cervical nerves.*

Pain of coxalgia is often felt on the inside of the knee,
because the obturator nerve, which sends a branch to the
ligamentum teres, also sends a branch to the interior and
to the inner side of the knee-joint.

Inflammation of an eye with increased tension causes
brow-ache. Inflammation of the neck of the bladder causes
pain in the head of the penis. Inflammation of a testicle
causes pain in the groin. Renal calculus and pyelitis cause
pain in and retraction of the testicle, and pain in the thigh.

If the covering of an organ is involved, pain becomes
more violent ; for instance, a hepatitis becomes much more

* Embleton's view in Hilton on Ktst and Pain^ a book every student should
read.

58 MODERN SURGERY.

painful when the perihepatic structures are attacked. In-
flammation without pain is known as ** latent " (as the inflam-
mation of Peyer's patches in typhoid). The sudden disap-
pearance of inflammatory pain, when not due to opiates,
suggests the possibility of gangrene, for analgesia exists in
gangrene. The characteristics of inflammatory pain are that
it comes on gradually, has a fixed seat, is continuous, is
attended by other inflammatory symptoms, and is increased
by motion, by pressure, and by the hanging down of the
part. If there be no tenderness in a part, the source of the
pain is not local inflammation ; but tenderness may exist
when there is no local inflammation, as in pain referred from
a distant part. Pain of inflammation does not correspond
to an exact nervous distribution. If pain corresponds ex-
actly to an area of a nerve's distribution, the cause of it is
acting on the nerve-trunk or on its roots. If the cutaneous
surface is involved, the lightest touch causes pain. If touch-
ing the skin produces no pain, but deep pressure does pro-
duce it, the deeper structures are the source. Pain in mus-
cle and ligament is developed by motion : in muscle, by
contraction, but not by passive movements with the muscle
relaxed ; in ligament pain is developed by active or passive
movements which stretch the ligament. If, for example, a
man with a stiff* neck has pain on the right side of the back
of his neck on voluntarily turning his face toward the left
shoulder, but is without pain when his face is turned by the
surgeon, who, conversely, induces pain by turning the
patient's face far to the right, this condition indicates the
trouble to be muscular. If, however, no pain arises on
turning the face to the right, but it is manifest on turning
the face actively or passively to the left, the pain is in those
ligaments which stretch when the face is turned to the left
(A. Pearce Gould). In inflammation of the synovial mem-
brane gentle passive motion in any direction causes pain.

The pain of colic differs from that of inflammation. It is
sudden in onset, intermits, recurs in paroxysms, and is re-
lieved by pressure. The pain of inflammation is gradual in
onset, is continuous, and is made worse by pressure. The
pain of neuralgia is often preceded by the onset of cutaneous
anaesthesia of the skin of the part, is very paroxysmal, comes
suddenly, darts through recognized nerve-areas, lasts some
hours, and is apt to recur at a certain hour. It presents no
general tenderness, as does inflammation, but we may find
several points which are acutely sensitive to pressure (Val-
leix's points douloureux). The tender spots of Valleix are

INFLAMMA TION. 5 9

met with in inveterate neuralgia, and occur at points where
nerves ** pass from a deeper to a more superficial level, and
particularly where they emerge from bony canals or pierce
fibrous fasciae" (Anstie).

Pain is often of great value by calling attention to parts
diseased ; but it may be a great evil, racking the organism
and even causing death. If pain continues long, it becomes
in itself formidable : it prevents sleep, it destroys appetite,
and it disorders the mind, and one of the surgeon's highest
duties is to relieve it. The physiognomy or expression of
physical pain presents the following characteristics : Heavy,
fulness about the eyes, and dropping of the angles of the
mouth, added to appearances due to anemia, widespread
tremor, etc. The absence of the physiognomy of pain in a
person who complains of great agony is a strong indication
that the patient exaggerates the gravity of his sufferings or
deliberately deceives.

Discoloration arises from determination of blood to the
part; hence the more vascular the tissue the greater the
discoloration. A non-vascular tissue presents no discolora-
tion, though we find discoloration adjacent in the zone of
blood-vessels which furnish the tissue with nutriment. Dis-
coloration is most intense at the focus or centre of inflam-
matory action. Discoloration varies in tint and in character
according to the tissue implicated and the nature of the in-
flammation. It may be circumscribed or diffuse. Arbores-
cent redness means a distribution in dendritic lines. Linear
discoloration signifies redness running in straight lines, as in
phlebitis. Punctiform discoloration occurs in points, and is
due to vascular rupture. Maculiform redness resembles an
ecchymosis or blotch. Dusky discoloration points to sup-
puration.

Inflammation of the throat and skin produces scarlet dis-
coloration ; inflammation of the sclerotic coat of the eye and
of the fibrous coat of muscle produces lilac or bluish discol-
oration ; inflammation of the iris produces brick-dust, gray-
ish, or brown discoloration ; erysipelas causes a yellowish-
red discoloration ; secondary syphilis causes a copper-hued
discoloration ; and tonsillitis causes a livid discoloration. A
scrofulous ulcer is of a purple color on the edge. Gangrene
is shown by a black discoloration. A scorbutic ulcer is sur-
rounded by an area of violet color.

Redness as a sign of inflammation must be permanent
and joined with other symptoms. Redness due to inflam-
mation disappears on pressure, but returns as soon as the

60 MODERN SURGERY.

pressure is removed. If redness is due to staining of the
surface by dye, pigmentation, or extravasation of blood, press-
ure will not blanch the spot. If on taking off pressure the
redness of inflammation rapidly returns, the circulation is ac-
tive ; if, on the contrary, it very slowly reappears, the circula-
tion is very sluggish and gangrene is threatened. Subcuta-
neous hemorrhage gives rise to a purple-red color which
does not fade when subjected to pressure. Stains of the
surface by dyes fail to disappear on pressure, are distributed
over a considerable surface, show a hue which is uniform
throughout, are obviously superficial, are not associated with
other signs of inflammation, and can be washed away.

A. Pearce Gould, in his excellent little work upon Sur-
gical Diagnosis, tells us that the color of a hyperemic sur-
face may furnish important information. Lividity may mean
failure of the heart and lungs, or simply venous congestion
in the part. In lividity from obstruction of the lungs or
heart the color slowly returns after pressure has driven it
out. In lividity due to local congestion the color quickly
returns when pressure is released and the dilated veins are
often distinctly visible.

Swelling or tumefaction arises in small part from vascular
distention, but chiefly from effusion and cell-multiplication.
The more loose cellular material a part contains, the more it
swells ; hence the eyelids, scrotum, vulva, tonsils, glottis, and
conjunctivae swell very largely when inflamed. A swelling
is soft or edematous when due to uncoagulable effusion, and
it is hard and elastic when produced by coagulated exudate
or embryonic tissue. Swelling may do good by unloading
the vessels and acting like a blister or local bleeding, or it
may do great harm by pressing upon the vessels and cut-
ting off the blood-supply. Swelling of the conjunctiva, or
chemosis, may cause sloughing of the cornea, and swelling
of the prepuce may cause gangrene. A swelling may do
harm by obstruction of a natural passage, as in edema of the
glottis, or by compression of a normal channel, as in the
swelling of the perineum. A swollen area may be covered
with blisters or blebs. This condition is noted particularly
in bums.

Disordered function is always present in inflammation.
It may be manifested by ijicr eased tenderness or sensibility,
a slight touch, it may be, producing torturing pain. Parts
almost or entirely destitute of feeling when healthy (as ten-
dons, ligaments, and bones) become highly sensitive when
inflamed. It may be manifested by increased irritability. In

INFLAMMA TION. 6 1

dysentery the colon constantly contracts and expels its con-
tents ; the stomach does likewise in gastritis ; and the blad-
der acts similarly in cystitis. Spasmodic twitching of the
eyelids occurs in conjunctivitis, and twitching of the muscles
in fracture and after amputation.

Impairfnent of Special Functiofi, — In inflammation of the
eye, when an attempt is made to look at objects, the lids
close spasmodically, and even a little light causes great pain
and lachrymation (photophobia). In inflammation of the
ear noises cause great suffering, and even when in a quiet
room the patient has subjective buzzing and roaring sounds
in his ears (tinnitus aurium). In coryza the sense of smell,
in glossitis the sense of taste, in dermatitis the sense of touch,
and in laryngitis the voice may be lost. In inflammation of
the brain the mind is affected; in arthritis the joints can
scarcely if at all be used ; and in myositis it is difficult and
painful to employ the muscles.

Derangement of Secretions. — In dermatitis the sweat is not
thrown off; in hepatitis bile is not properly secreted; and in
nephritis urea is not .satisfactorily removed. The secretions
may undergo important changes of composition. Pneu-
monia causes rusty sputum, and dysentery causes bloody
mucus (Gross).

Derangement of Absorbents. — In the height of an inflam-
mation the absorbents are blocked and clogged by coagu-
lated fibrin, and they cannot perform their offices.

Constitutional Bymptome of acute inflammation may be
absent, and often are in moderate or limited inflammations ;
but in severe, extensive, or infective inflammations the symp-
tom-group known ?is fever is certain to exist. This is known
as symptomatic, sympathetic, or inflammatory fever, and it
arises in non-septic cases from the absorption of aseptic pyrog-
enous exudate and in microbic inflammations from absorption
of pyrogenous toxic products. In young and robust individ-
uals an acute non-microbic inflammation causes a fever char-
acterized by full, strong pulse, flushed face, coated tongue,
dry skin, nausea, constipation, and possibly acute delirium
(the sthenic type of the older authors). In broken-down and
exhausted individuals an ordinary inflammation, and in any
individuals a bacterial inflammation may cause a fever with
typhoid symptoms (the typhoid, asthenic, or adynamic type).
In inflammatory conditions the leukocytes are markedly in-
creased in number, the condition being spoken of as leuko-
cytosis or transient leukocythemia. Blood plaques are also
increased. The fibrin-ferment is obtained from the white cor-

62 MODERN SURGERY.

puscles ; it is liberated as the corpuscles break up in the ex-
udate, and acting on the liquor sanguinis forms fibrin. The
absorption of fibrin-ferment many believe causes aseptic fever
(page 88). Inflammatory blood contains an increased amount
of albumin and salts. If a person with inflammatory fever is
bled, the blood coagulates rapidly, the clot sinks, and there
is found on the surface a cup-shaped coat, made up of liquor
sanguinis and white cells, known as the " buffy coat," but
this is not a sign of inflammation and occurs normally in the
blood of the horse. The buffy coat forms when blood con-
tains a great number of leukocytes, because these leukocytes
sink more slowly than do the red corpuscles. Cupping oc-
curs because the white corpuscles sink more slowly by the
sides of the tube than far from the sides.

Treatment of Inflammation. — The first rule in treat-
ing an inflammation must be to remove the exciting cause. If
this cause is a splinter in the part, take out the splinter ; if
it is a foreign body in the eye, remove the foreign body ; if
urine is extravasated, open and drain ; take off" pressure
from a corn ; pull out an ingrown nail, and remove irritants
from an infected area by asepticizing. The rule, remove the
cause, applies to a chronic as well as to an acute inflamma-
tion. If the cause of an inflammation was momentary in
action (as a blow), we cannot remove it, for it has already
ceased to exist. After removing the cause, endeavor to
bring about a cure by local and constitutional treatment.

Local Treatment of Inflammation. — It must be remem-
bered that the division of inflammation into stages is natural,
and not artificial, and that a remedy which does good in one
stage may do harm in another. Certain agents are suited to
all stages of an inflammation, namely, rest and elevation.

Rest is of infinite importance, and is always indicated in
acute inflammation. Its principles were first thoroughly
studied by Hilton.^ The means of securing rest differ with
the structure or the part diseased. When rest is used, do
not employ it too long. In cerebral concussion rest must be
secured by quiet, by darkness, by the avoidance of stimu-
lants and meat, by the application of ice to the head, and
by the use of purgatives to prevent reflex disturbance and
the circulation of poisons in the blood. In inflamed joints
rest must be obtained by proper position, associated in many
cases with the adjustment of splints or plaster, or the em-
ployment of extension.

In pleurisy partial rest can be secured by strapping the

* Lectures upon Rest ami Pain.

INFLAMMA TION. 63

affected side with adhesive plaster or by using a bandage or
a binder to limit respiratory movements. \n fractures Nature
procures rest by her splints — the callus — and the surgeon pro-
cures rest by his splints — immovable dressings, or extension.
In fractures of the ribs strap the chest on the injured side. In
cancer of the rectum a colostomy secures rest for the damaged
bowel. In enteritis opium gives rest to the bowel by stop-
ping peristalsis. In cystitis rest is obtained by opium and
belladonna, which paralyze the muscular fibres of the blad-
der. The use of the catheter gives rest to the bladder by
removing urine. A cystotomy allows complete rest by per-
mitting the bladder to suspend its function as a reservoir of
urine. In vesical calculus rest is obtained by cutting or crush-
ing the stone. In inflafned mucous membranes rest is secured
(from the contact of irritants) by touching them with silver
nitrate, which forms a protective coat of coagulated albumin.
Opening an abscess gives its walls rest from tension. In in-
flammations of the eye light must be excluded to obtain com-
plete rest, but tolerable satisfactory rest is given in some cases
by the use of glasses of a peacock-blue tint. In aneurism the
operation of ligation cuts off" the blood-current and gives rest
to the sac. In hernia the operation gives rest from pres-
sure. Instances of the value of rest could indefinitely be
multiplied.

Elevation partly restores circulatory equilibrium. A felon
is less painful when the hand is held up in a sling than when
it is dependent. A congestive headache is worse during re-
cumbency. A gouty inflammation in the great toe is more
painful with the foot lowered than when it is raised. A tooth-
ache becomes worse on lying down.

Relaxation is in reality a form of rest, and consists in
placing the part in an easy position. In synovitis of the
knee semiflexion of the knee-joint lessens the pain. In
muscular inflammations relaxation relieves the pain.

Certain agents are suited to the stage of vascular engorge-
ment, increased arterial tension, and beginning effusion.
These agents are — (i) local bleeding or depletion ; (2) cut-
ting off the blood-supply ; and (3) cold.

Local bleeding or depletion is the abstraction of blood from
the inflamed area. This abstraction relieves circulatory re-
tardation and causes the blood to move rapidly onward;
the corpuscles clinging to the vessel-walls are washed away,
the capillaries shrink to their natural size, and the exudate
is absorbed. In other words, local blood-letting increases
the rate of the circulation, though not its force.

64 MODERN SURGERY,

The methods of bleeding locally are — (a) puncture; {S)
scarification ; {c) leeching ; and (^) cupping.

Puncture is recommended in inflammation, not only
because it abstracts blood locally, but also because it gives
an exit to eflusion under fibrous membranes. It is very use-
ful in relieving tension — for instance, in epididymitis. It is
performed with a tenotome and with aseptic precautions. If
numerous punctures are made, the procedure is termed
" multiple puncture.** This is very useful when applied to
the inflamed area around a leg-ulcer. The late Prof. Joseph
Pancoast was very fond of employing multiple punctures,
designating the operation " the antiphlogistic touch of the
therapeutic knife."

Scarification or Incision. — By means of scarification we
bleed locally, evacuate exudates, and relieve tension. One
cut or many cuts may be made, and these cuts may be deep
or may not even go entirely through the skin, according to
circumstances. Multiple incision is very useful applied to
inflamed ulcers, ulcers in danger of gangrene, and to almost
any condition of great tension.

Leeching, — Leeches must not be applied to a region plen-
tifully endowed with loose cellular tissue, as great swelling
and discoloration are sure to ensue. These regions are the
prepuce, labia majora, scrotum, and eyelids. Leeches should
never be applied to the face (because of the scar), near
specific scars or inflammations, nor over a superficial artery,
vein, or nerve. A leech is best applied at the periphery
of an inflammation and between an inflammation and the
heart. To leech at the inflammatory focus only aggravates
the case. Before applying leeches, wash the part and shave
it if hairy. If the leeches will not bite, smear the part with
milk or with a little blood. In using a leech, place it on
the skin under a glass tube or an inverted wine-glass. Never
pull off* a leech : let it drop off*; and if it refuses to do so,
sprinkle it with salt. After removing a leech, employ warm
fomentations if continued bleeding is desired. Sometimes
the bleeding persists, but this may be arrested by styptic
cotton and pressure. Leeching leaves permanent triangular
scars. The Swedish leech, which is preferred to the Ameri-
can, draws from four to six drachms. Leeching has both a
constitutional and a local effect. It is at the present time
used comparatively rarely, but it is employed by some sur-
geons over the spermatic cord in epididymitis, on the temple
in ocular inflammation, and over the right iliac region in mild
cases of appendicitis.

INFLAMMATION, 65

Cupping: Wet Cups, — In wet cupping apply a cup for a
moment, remove it, incise or puncture the skin, and apply
the cup again to draw the requisite amount of blood. Baron
Heurteloup devised an instrument (Fig. 22) in which the
incision is made by a scarifier. The blood is drawn by a
pump, the tube being placed upon the cut area and the
withdrawal of the piston creating a vacuum. This instru-
ment is known as the " artificial leech." Wet cupping is of
value in pleuritis, pericarditis, and nephritis.

Cutting off tlie Blood-supply. — Onderdonk, of New York,
in 1 8 1 3 recommended ligation of the main artery of a limb
for the cure of inflammation in important structures supplied
by the vessel. The procedure was warmly advocated by
Campbell, of Georgia, for the treatment of gunshot-wounds

Fic. 33. — Heurteloup's artificial leech.

of joints. This plan of treatment is now not to be considered
for a moment ; antisepsis furnishes us with a safer and more
certain plan. Vanzetti, of Padua, advocates digital pressure
to cut off the blood-supply to an inflamed part.

Cold is a very powerful and an extremely useful agent.
It constringes the vessels, prevents migration of corpuscles,
favors the absorption of exudate, retards cell-proliferation,
and relieves pain, swelling, and tension. Cold must not be
applied to the old or to the feeble, as it may induce gan-
grene. It is harmful in advanced inflammations or severe
congestions (as strangulated hernia). There are two forms
of cold, the dr>' and the wet.

Wet Cold. — To apply wet cold, the part is wrapped in
wet linen or muslin and laid upon a rubber sheet folded like
a trough and emptying into a bucket. A vessel filled with
cold water is placed upon a higher level than the bed. A
wet lamp- wick is now taken, one end is inserted into the
water of the vessel, and the other end is laid upon the part.
5

66 MODERN SURGER Y.

Capillary action and gravity combine to keep the part moist
A rubber tube may be used instead of a wick. If a tube is
employed, tie it in a knot or clamp it so that the fluid is de-
livered drop by drop (Fig. 23). Ordinary water or iced
water can be used. If the water be too warm, it can be
reduced to about 45° F. by adding i part of alcohol to every
4 parts of water. A mixture of 5 parts of nitrate of potas-
sium, 5 parts of chlorid of ammonium, and 16 parts of water
produces great cold. If wet cold is used upon an open

wound, the fluid should be antiseptic. Irrigation by cold
fluid is rarely employed at the present day. In severe con-
junctivitis wet cold is applied by means of cloths soaked in
ice-water and frequently changed. Evaporating lotions owe
a portion of their efficacy to the cold they induce.

Dry cold is applied by means of a rubber bag or a blad-
der filled with ground or finely cracked ice, .several folds of
flannel being first laid over the part. A part can be encircled
with a rubber tube through which ice-water is made to flow

INFLAMMATION. 6/

I (Fig. 24). Leiter's tubes, which are made to fit various re-
[ gions and which carry a stream of cold water, can also be
1 used. An ice-bag, if applied at once, is the best treatment
1 for a sprained joint. Ice-bags are very useful in acute mye-
litis, meningitis, joint-inflammation, epididymitis, and other
acute inflammations in the early stage.

Certain agents are suited to the stage of fully developed

inflammation, when we have a great deal of swelling due to

effusion and cell-proliferation. The indicadon in this stage

[ is to abate swelling by promoting absorption. This is accom-

i phshed by (i) compression ; {2) the local use of astringents

"and sorbefacients ; (3) the douche; (4) massage; and (5) in-
termittent heat.

Compression j.s the agent' which is especially useful in fully
developed or in chronic inflammation, but it will do good
I also in the first stage. Compression is of great u.sefulness:
■it supports the vessels and causes them to drink up effusion,
KAnd it strongly rouses the absorbents. This agent is valu-
\ able in most external inflammations with much swelling. In
erysipelas of an extremity the part should be elevated and
the extremity bandaged from the periphery to the body. In
ulcers, especially those with hard and blue edges, the use
of Martin's elastic bandage or of straps of adhesive plaster
gives decided relief. In chronic inflammation of a joint elas-
tic compression is of great value. In epididymitis, after the

68 MODERN SURGERY.

acute stage, the testicle may be strapped with adhesive plas-
ter. In lymphadenitis compression by a weight or by a
bandage is very generally employed. In fractures compres-
sion not only antagonizes spasm, but often combats the
swelling and pain of inflammation. Compression must be
judicious : it must never be too forcible, and it must not be
applied to a limb without including the extremity of it
(never, for instance, strongly compress the elbow without
including the hand, nor the palm without bandaging the
fingers). Injudicious compression causes severe pain, and
may produce gangrene.

Astringcjtts and Sorbcfacients : Solutions of Acetate of Lead,
— Ammonium chlorid was formerly employed in the strength
of 5J to 2 quarts of water; but if long used, it produces pus-
tules and thus causes irritation and pain. A solution of the
acetate of lead is astringent and sorbefacient ; it promotes the
contraction of distended vessels, accelerates the blood-cur-
rent, and urges the absorbents to increased activity. This
agent, in practice, is usually mixed with laudanum, as fol-
lows : Tinctura opii, f 5J ; liquor plumbi subacetatis, fsj ;
aqua, Oj. This solution, spoken of as lead- water and laud-
anum, is extensively used and is very soothing. It can be
employed cold, the evaporation which it undergoes cooling
the part. It is best applied by soaking a double layer of
flannel in the lead-water, laying it on the affected part, and
by means of a sponge squeezing more of the lotion upon it
from time to time. If it is desired to have it very cold, an
ice-bag can be placed upon the soaked flannel. Lead-water
and laudanum may be used warm, the flannel being covered
with oiled silk or waxed paper or a piece of rubber. If it is
desired hot (veritably a poultice), the lead-water is heated
before the flannel is soaked in it. The soaked flannel is ap-
plied to the part and covered with a rubber-dam, and a hot-
water bag is placed upon the dressing. Lead-water is not
used in treating open wounds.

Tincture of iodin acts like lead acetate. It is astringent,
sorbefacient, counterirritant, and antiseptic. It must not be
used pure. For adults it should be diluted with an equal
amount of alcohol, and for children with 3 parts of alcohol.
In using iodin, paint it upon the part with a camel's-hair
brush and fan it dry, applying one or more coats. The re-
peated application of iodin to the skin is of great benefit in
inflammation of the glands, muscles, tendons, joints, and peri-
osteum. Iodin is apt, after a time, to vesicate, and must
not be used in full strength, because it is irritant. It is of

I NFL AM At A TION. 69

especial value in chronic inflammation. In deep-seated in-
flammation it acts as a counterirritant.

Nitrate of silver is a non-irritating astringent of great value
in inflammation of mucous membranes. It forms a protective
coat of coagulated albumen, and is much used in treating the
throat, mouth, and genital organs.

Ichthyol is a drug of decided efficacy in reducing inflam-
matory swelling. It is usually employed in ointments, the
strength being from 25 to 50 per cent. It is best exhibited with
lanolin. When rubbed in over the glands, the joints, and in
lymphatic enlargements it is of great value. In children a
25 per cent., and in adults a 50 per cent., ointment is well
rubbed in twice a day. In inflammatory skin disease, syno-
vitis, thecitis, frost-bite, bubo, chilblain, and in many other
conditions, acute or chronic, the use of ichthyol is indicated.
The odor of ichthyol is highly disagreeable, and when ordered
for a refined person it had better be deodorized. For this
purpose Hare uses oil of citronella, tTlxx to sj of ointment.

Mercurials, — Blue ointment, pure or diluted to various
strengths, is valuable to a high degree. It is spread upon
lint and kept applied over chronically inflamed joints, glands,
tendons, etc. Blue ointment is strongly irritant, and will soon
blister or excoriate a tender skin. It is very beneficial in
periostitis, and is employed largely in chronic inflammations.

The douche consists of a stream of water falling upon a part
from a height. The water may be poured from a receptacle
or may run through a tube, and may either be hot or
cold. Alternating hot and cold streams are very popular in
chronic inflammations of joints and tendons, and they con-
stitute the " Scotch douche." In a sprain of the knee, for
instance, where, after a time, thickening has occurred, pour
upon the part daily, from a height, first a pitcherful of very
hot water, then a pitcherful of very cold water ; then use
friction with a hand greased with cosmoline. The douche
acts by restoring vascular tone and by promoting the action
of the absorbents. Hot vaginal douches are largely employed
in pelvic inflammations.

Intermittent heat is often vcr>'^ useful. In a sprained and
badly swollen ankle much relief can be obtained by plunging
the foot in a bucket of hot water several times a day. The
part is put into water as hot as can be tolerated. Ever>' few
moments some very hot water is added. This gradual ad-
dition of very hot water permits the patient to stand a high
degree of heat.

Massage is a procedure not frequently enough employed.

70 MODERN SUKGERY.

It is powerful for good in chronic inflammations at the period
when rest is abandoned. It acts by promoting the move-
ments of tissue-fluids (blood, lymph, and areolar fluid), stimu-
lating the absorbents, strengthening local nervous control,
and thus improving nutrition. Passive motion in joints acts
as massage.

Certain agents are indicated when embryonic tissue exists
in large amount or when suppuration exists or is threatened,
these agents being the various forms of heat. Heat increases
the mobility of the white corpuscles, increases their migra-
tion, relieves stasis and thus diminishes tension, promotes
tissue-change and cell-activity. Continuous heat may be
used early in an inflammation, as in the first stage of a
pneumonia ; but it is so used only in a deep-seated trouble,
and acts purely as a revulsive, dilating the superficial vessels
and helping to empty the deeper ones. Heat is often used
to relieve pain and without any other purpose.

T\i^ forms of heat are — (i) fomentations; (2) poultices;
(3) water-bath ; and (4) dry heat.

Fomentatiofts. — A fomentation is the application of a liquid
to the surface of the body on sponges or other material.
To apply a fomentation, wring out a piece of flannel in hot
water, lay it upon the part, and cover it with oiled silk
or with waxed paper, changing it as soon as it begins to
cool. The flannel which is dipped into the hot liquid is
known as a " stupe." The turpentine stupe is made by
wringing out the flannel as above and then putting upon it
from 10 to 20 drops of turpentine. Instead of fomenting
the part, steam may be thrown upon it. Fomentations are
used chiefly for their reflex influence over deep congestions
or inflammations. The liquid of a fomentation may, if de-
sired, contain corrosive sublimate, carbolic acid, or other
agents. Fomentations are v^ry useful in relieving pain in
any stage of an inflammation and act also as counter-irri-
tants.

Poultice or Cataplasm. — A poultice is a soft mass applied
to a part to bring heat and moisture to bear upon it. Poul-
tices can be made of ground flaxseed, of slippery-elm bark,
of arrowroot, starch, bread and milk, potatoes, turnips, etc.
To make a flaxseed poultice, scald a spoon and a tin basin,
put the flaxseed into the dry hot basin, and pour upon it
boiling water in sufficient quantity to form a thick paste.
The proper consistence is found when the mass would stick
if it were thrown against a wall. It is now spread to the
thickness of a quarter of an inch upon a piece of muslin, and

INFLAMMATION, 7 1

is covered with a bit of gauze to prevent adhesion to the
skin. Flaxseed retains heat a long time, and a flaxseed poul-
tice needs to be changed only every five or six hours. The
poultice should be covered outside with oiled silk, a rubber-
dam, or waxed paper. It can be kept very warm for a con-
siderable period by placing upon it a bag filled with hot
water. Spongiopilin, when moistened with hot water, is a
good substitute poultice. Lint soaked with hot water and
covered with some impermeable material does very well.
The fermented poultice, which was once popular for gan-
grenous ulcers, was made by sprinkling yeast upon an ordi-
nary cataplasm. The charcoal poultice is made by stirring
charcoal into the usual poultice-mass. A poultice containing
opium is known as a ** sedative " poultice. About gr. ij of
opium to the ounce of poultice-mass relieves pain. An an-
tiseptic poultice is made by partly wringing out gauze in a
hot solution of corrosive sublimate (i : looo), covering it
with oiled silk, and placing a hot-water bag upon it to main-
tain the heat. The antiseptic poultice or fomentation is of
great service in removing sloughs from foul wounds and
ulcers. It is the only form of poultice which is admissible
when the skin is broken. Poultices must not be kept on too
long, as they will then vesicate, especially in adynamic con-
ditions. If a poultice is found to be vesicating, stop using it
or sprinkle it with powdered oxid of zinc. If suppuration
exists or is seriously threatened, do not waste time by using
poultices, but incise at once. If suppuration is simply threat-
ened, incision can prevent it by relieving tension, affording
drainage, and permitting of the local use of antiseptics. If
pus exists, it cannot be evacuated too soon. To use poul-
tices and delay incision is often productive of irreparable
harm. After incision of a purulent focus it is often useful to
apply an antiseptic poultice.

Water-bath, — The continuous hot bath is now rarely em-
ployed except in burns and cases of phagedena, when it often
proves curative. In these cases an antiseptic agent may be
dissolved in the water. Continuous immersion in a warm
bath is used by some surgeons for the treatment of slough-
ing wounds and large purulent areas.

Dry heat is applied by a metallic object dipped in hot
water and laid upon the part ; by Leiter's tubes, through
which hot water flows ; or by the hot-water bag. Some
surgeons use the hot-water bag in cases of mild appendicitis
in order to favor the formation of adhesions. The hot-water
bag is often soothing and beneficial when laid upon an in-

7 2 MODERN SUR GERY.

flamed joint, or on the perineum or the hypogastric region
in cystitis. A bag of hot sand, a hot brick, or a bottle or
can of hot water can be used instead of the bag.

Irritants and Cotoiterirritants in Inflammation, — Irritants
attract an increased supply of blood to the part whereon
they are applied, and are used for their local effects.
Counterirritants are used to affect by reflex influence some
distant part. In chronic inflammation irritants may do good
by promoting the blood-supply, thus favoring the removal
of exudates (liniments in rheumatism and synovitis, and
nitrate of silver in ulcers). Counter-irritants are powerful
pain-relievers when used over an inflamed structure ; they
bring blood to the surface and cause anemia of internal
parts, the site and area of anemia depending on the site, the
area, and the duration of the surface-irritation. To strongly
counterirritate too near an inflammation is harmful instead
of beneficial. (Do not blister for pericarditis directly over
the pericardium. — Brunton.) Counterirritants not only re-
lieve pain and congestion in the earlier stages of inflamma-
tion, but they also promote absorption of exudate in the
later stages. This is seen in blistering old thickened ulcers,
and in painting the chest with iodin to relieve pleuritic effu-
sion. Frictions, besides their pressure-effects, act as counter-
irritants. Frictions may relieve skin-pain, and are associated
with the application of stimulating liniments in the treatment
of stiff joints.

There is no more efficient method of relieving pleural
effusion than by the application of a succession of blisters.
Blisters are also used in the treatment of inflamed joints,
pericarditis, pneumonic consolidation of the lung, acute and
chronic rheumatism, etc. ; and are applied back of the ears
or at the nape of the neck in congestive coma or meningitis.
A blister can be produced in a few minutes by soaking a bit
of lint in chloroform, and, after applying it to the surface,
covering it with oiled silk, and then with a watch-glass.
Equal parts of lard and ammonia will blister in five minutes.
It is easier to blister with cantharidal collodion or blistering-
paper. Before applying a blister, shave the part if it be
hair>' ; then grease the plaster with olive oil and apply it.
Blistering plaster is left in place six hours in the case of an
adult, but only two hours in the case of an old person or a
child ; the plaster is then removed, and if a blister has not
formed, the part must be poulticed for a few hours. When
a blister is obtained, open it with a clean needle. If it be
desired to heal the blister, grease it with cosmolin or with

2 N FLAM MA TION. 7 3

zinc ointment. If it is to remain open, cut away the stratum
comeum and dress with cosmolin, each ounce of which con-
tains six drops of nitric acid.

Pustulation can be effected with tartar-emetic ointment,
with the hot iron, or with Vienna paste. Tartar-emetic oint-
ment was formerly used on the scalp in meningitis. To pus-
tulate with the hot iron, raise the iron to a white heat, lay it
on the part, remove it quickly, apply iced-water cloths for an
hour or two, and then employ a poultice. The hot iron is
the most powerful of counter-irritants, and is used for joint-
inflammations, bone-diseases, and inflammations of the spinal
cord. Vienna paste consists of 5 parts of caustic potash
and 6 parts of lime made into a paste with alcohol. It is
applied for five minutes, and is then washed off with vinegar.

Constitutional Treatment of Inflcunmation. — Certain
remedies are used in inflammation for their general or con-
stitutional effects; these remedies are — (i) general bleeding;
(2) arterial sedatives; (3) cathartics ; (4) diaphoretics ; (5) di-
uretics ; (6) anodynes ; (7) antipyretics ; (8) emetics ; (9) mer-
cur>' and iodids ; (10) stimulants ; and (11) tonics.

General bleedings venesection, or phlebotomy, is suited to the
early stages of an acute inflammation in a young and robust
subject. The indication for its employment is increased arte-
rial tension, as shown by a strong, full, rapid, and incompress-
ible pulse in a vigorous young patient. General blood-let-
ting diminishes blood-pressure and increases the speed of the
blood-current, thus amending stasis, absorbing exudate, and
washing adherent corpuscles from the vessel-wall ; further-
more, it reduces the whole amount of body-blood, thus
forcing a greater rapidity of circulation, decreases the
amount of fibrin and albumin, lowers the temperature, arrests
cell-proliferation, and stops effusion.

This procedure was in former days so highly esteemed
that it settled into a routine formula to be applied to every
condition from yellow fever to dislocation. The terrible
mortality of the cholera epidemics from 1830 to 1835 led
practitioners to question the belief that bleeding was a
general panacea, and from this doubt there was born in
the next generation violent opposition to blood-letting in
any disease. Like most reactions, opposition has gone too
far, the pendulum of condemnation has swung beyond the
line of truth and sense, and thus is universally neglected or
broadly condemned a powerful and valuable resource. Many
physicians of long experience have never seen a person
bled ; its performance is not demonstrated in most schools,

74 MODERN SURGERY,

and but few patients and families will permit it to be done.
But when properly used it is beneficial. It is only appli-
cable, however, to the young, strong, and robust, and not
to the old, weak, or feeble. It is used for violent acute in-
flammations of important organs or tissues, and not for low
inflammations or for slight affections of unimportant parts..
It is used in the early, but not in the late, stages of an
inflammation. It is used when the pulse is frequent, full,,
hard, and incompressible, but not when it is slow, small,,
soft, compressible, and irregular. It is used when the face
is flushed, but not when it is pallid. It is not used in fat
persons, drunkards, very nervous people, or the sufferers
from adynamic, septic, or epidemic diseases. It is of value
in some few cases of congestion of the lungs, pneumonitis^
pleuritis, meningitis, prostatitis, cystitis, and other acute in-
flammatory conditions. (See Phlebotomy, p. 73.)

After bleeding, the patient should be put upon arterial
sedatives, diuretics, diaphoretics, anodynes, and, if necessary^
purgatives. A favorite mixture of Prof S. D. Gross was the
antimonial and saline, consisting of gr. xl of Epsom salt,
gr. -^^ of tartar emetic, 3 drops of tincture of aconite, and gj
of sweet spirits of niter, in enough ginger syrup and water
to make Jss ; given every four hours.

Arterial sedatives are of great use before stasis is pro-
nounced ; but if used after stasis is established, they will
increase it. If stasis exists, relieve it by bleeding before
using the sedatives. Either local bleeding or venesection
abolishes stasis and lowers tension, and arterial sedatives
maintain the effect and hold the ground which is gained.
The arterial sedatives employed are aconite, veratrum viride,
gelsemium, and tartar emetic. These sedatives lessen the
force and the frequency of the heart-beats, and thus slow
and soften the pulse, and are suited to a robust person with
an acute inflammation, but are not suited to a weak man in
an adynamic state.

Aconite is given in small doses, never in large amounts.
One drop of the tincture in a little water is given every half
hour until its effect is manifest on the pulse, when it may be
given every two or three hours. Large doses of aconite
produce pronounced depression, and are dangerous. Aco-
nite lowers the temperature, slows the pulse, and produces
diaphoresis.

Veratrum viride is a powerful agent to slow the pulse and
to lower blood-pressure ; it produces moisture of the skin,
and often nausea. It is given in i-drop doses of the tine-

IN FLA MM A TION. 7 S

ture every half hour until its physiological effects are mani-
fested, when the period between doses is extended to two
or three hours. Ten drops of laudanum given a quarter
of an hour before each dose of veratrum viride will prevent
nausea.

Gelsemium is an arterial sedative highly approved by
Bartholow. It is given in doses of S to lo drops of the
tincture every three or four hours.

Tartar emetic lowers arterial tension and lessens the pulse-
rate. This drug is not largely employed ; if it is used with
the greatest care, it is no better than some other agents, and
if it is not so used it will cause dangerous depression. The
dose is from gr. ^ to gr. -j^ in water every three hours until
the physiological effects are manifest.

Cathartics. — The tongue affords the chief indication for
the use of cathartics. Treatment in an inflammation can be
inaugurated, if constipation exists, by giving a cathartic.
Castor oil can be given in capsules, or the juice of half a
lemon is squeezed into a tumbler, i ounce of oil poured
in, and the rest of the lemon is squeezed on top, thus
making a not unpalatable mixture. Aloin, podophyllum,
the salines, and calomel in 5- or lo-grain doses, followed by
a saline, have their advocates. In peritonitis the salines are
of unquestionable value, a teaspoonful of Epsom salt and a
teaspoonful of Rochelle salt being given hourly until a move-
ment occurs. In the course of inflammation, from time to
time, if there be constipation, coated tongue, and foul breath,
there should be ordered gr. j of calomel with gr. xxiv of
bicarbonate of sodium, made into twelve powders, one being
given every hour ; if the bowels are not moved by the time
the powders are all taken, a saline should be given. If a
violent purgative effect is desired, as in meningitis, croton oil
or elaterium may be ordered. If constipation is persistent,
give fluid extract of cascara sagrada daily (20 to 40 drops),
or a pill at night containing gr. ^ of extract of belladonna,
gr. \ of extract of nux vomica, gr. -f^ of aloin, gr. \ of
extract of physostigma, and gr. ss of oil of cajuput. Enemas
or clysters may be used in some cases. A very useful
enema is composed of f^j of oil of turpentine, fsiss of olive
oil, f.lss of mucilage of acacia, in f.^x of water. Soap-suds
and vinegar in equal parts make a serviceable clyster. A
combination of oil of turpentine, castor oil, the yolk of an
c&g» and water can be used. Asafctida, gr. xxx to the yolk
of one egg, makes a good enema to amend flatulence.

Diaphoretics are very useful. A good sweat in the start

^6 MODERN SURGERY.

of an acute inflammation, such as tonsillitis, may abort the
disease. Dover's powder is commonly used, but pilocarpin
is preferred by some. Camphor in doses of from 5 to lo
grains is diaphoretic, and so are antimony and ipecac. Ace-
tate and citrate of ammonium, opium, alcohol, hot drinks,
heat to the surface (baths, hot bricks, hot-water bags), ser-
pentaria, and guaiac are diaphoretic agents.

Diuretics are useful in fevers when the urine is scanty and
high-colored, and are valuable aids in removing serous effu-
sions and other exudates. Among the diuretics may be men-
tioned calomel in repeated large doses, cocain, caffein, al-
cohol, digitalis, the nitrites, squill, turpentine, copaiba, and
cantharides. The liquor potassae and the acetate of potas-
sium are the best agents to increase the solids in the urine.
The liquor potassii citratis in doses of feij to feiv is efficient
Large draughts of water wash out the kidneys. If the heart
is weak, citrate of caffein is a good stimulant diuretic.

Anodynes and hypnotics may be required. Dover s powder,
besides being diaphoretic, is anodyne. Opium acts well after
bleeding or purgation. If it causes nausea, it should be pre-
ceded one hour by gr. xxx of bromid of potassium. Opium
is used by the mouth, by the rectum, or hypodermatically.
It is used when there is pain, but its u.se is not to be long per-
sisted in if it can be avoided. It is given in doses measured
purely by the necessities of the case. If opium disagrees,
tr>' the combination of morphin with atropin. After an ope-
ration antipyrin or phcnacetin will often quiet pain and secure
sleep. When a person feels ** so tired he can't sleep," alco-
hol in the form of whiskey or brandy must be given. Sleep-
lessness not due to pain is met by chloral, trional, the bro-
mids, or sulphonal. Chloral is dangerous in conditions of
W'eak heart or exhaustion. Bromids must be given in large
doses to be efficient. Sulphonal must be given about four
or five hours before sleep is expected, in doses of from gr.
X to gr. XX in hot milk or hot mint-water. Trional is safe
and very satisfactory. It is given in doses of gr. xv to gr.
XXV in hot water.

Antipyretics. — Diaphoretics, purgatives, and arterial seda-
tives lower temperature, and have previously been alluded to
(p. 74). There are two great classes of febrifuges — those
which lessen heat-production and those which increase heat-
elimination. In the first group we find quinin, salicylic acid
and the .salicylates, kairin, alcohol, antimony, aconite, digitalis,
cupping, and bleeding. In the second group we find alcohol,
nitrous ether, antipyrin, acetanilid, phenacetin, opium, ipecac,

INFLAMMATION, 77

cold to the surface, and cold drinks. In surgical inflammations
it is rarely necessary to employ heroic means to lower temper-
ature. The use of such an agent as antipyrin is contraindi-
cated in the weak and adynamic, and it is never to be thought
of as a means of lowering temperature unless the latter goes
above 103°. Quinin, in doses of gr. xx to gr. xxx given at
4 p. M., may prevent an evening rise ; salol or salicin can be
given during the day. Inunctions of 30 minims of guaiacol
lower the temperature in tubercular conditions and in septic
fevers. These inunctions are made upon the abdomen, and
often produce surprising results. Dujardin-Beaumetz main-
tained that fever is a condition in which the organism is en-
deavoring to oxidize and render inert certain poisonous ma-
terial, and that antipyretic drugs lessen oxidation and actually
make the patient worse. This view is in accordance with the
experience of a number of surgeons. The mere discomfort
of fever may be much mitigated by antipyretic drugs, but the
fever-process is not benefited by them.

Emetics. — Emetics may do good when the patient suffers
from a parched, coated tongue, a dry and hot skin, nausea,
and gastric oppression, but it is very rarely in these days that
we employ them. There can be used 3j of alum in molasses,
gr. XX of sulphate of zinc, or a tablespoonful of mustard and
a teaspoonful of salt given in warm water and followed by
large draughts of warm water. Ipecac in a dose of gr. xx
can be employed. The emetic dose of tartar emetic is gr. ij,
but it is too depressant a drug to trifle with. The sulphuret
of antimony in doses of from i to 5 grains is safe. Apomor-
phin hypodermatically, in a dose of from gr. ^ to gr. \, will
act in five minutes. Emetics are vatuable in inflammatory
conditions of the air-passages, but their use is contraindicated
in diseases of the heart, brain, and bowels, in hernia, in dis-
locations, in fractures, and in aneurysms.

Mercury ami the lodids. — Mercury is an alterative — that
is, an agent which favorably affects body-nutrition without
causing any recognizable change in the fluids or the solids
of the body. Mercury lessens blood-plasticity, hinders the
e.xudation of liquor sanguinis — thus furnishing less food to
the cells in the perivascular tissues — and retards the forma-
tion of embr>'onic tissue. Further, by a stimulant actio4i on
the absorbents it promotes the breaking up of an existing
inflammatory exudate, and hence limits damage from excess
of embr>'onic tissue. The time at which mercury is best
given is when violent symptoms have abated, the guide being
reduced temperature and moist skin. It is often given in con-

78 MODERN SURGERY,

junction with the local use of sorbefacients (the acetate of
lead), and is, when possible, associated with compression. It
is sometimes given until the gums are slightly touched, but
is not given to the point of salivation. When the breath
becomes offensive and the gums tender on snapping the teeth,
or when griping and diarrhea begin, the dose should be re-
duced. In iritis mercury is used to get rid of the plastic ef-
fusion which is causing pupillary fixation and opacity. In
keratitis the gums should be touched lightly. In orchitis,
after the subsidence of the acute symptoms, mercury should
be employed. In pericarditis, meningitis, peritonitis, and in
many chronic and lingering, and in all syphilitic, inflamma-
tions this drug can be used.

Some persons will be salivated with very minute doses of
mercury, cither because of idiosyncrasy or previous satura-
tion. Others can take enormous doses without any appre-
ciable constitutional effect. The action of mercurials can be
favored by a combination with ipecac or with tartar emetic.
(For salivation see p. 202).

In giving mercury, if a prompt effect is desired, give gr. iij
of calomel every three hours until a metallic taste is noted
in the mouth. If the case is not so urgent, gray powder is
a good combination. Children are given calomel and sugar
or mercury and chalk. If it is desired to give the drug for
some time, corrosive sublimate is a suitable form, and small
doses will actually increase the number of red blood-cor-
puscles. Corrosive sublimate is to be given alone or com-
bined only with iodid of potassium. The green iodid of
mercury is a drug suitable for prolonged administration. In
the prolonged use of mercury it will often be necessary to
give at the same time a little opium to prevent diarrhea and
griping. A rapid effect can be obtained by rubbing with a
gloved hand 3J of the oleate of mercury' or 3ss of the
ointment into the groins, the axillae, or the inside of the
thighs. Suppositories of mercurial ointment induce rapid
ptyalism. Hypodermatic injections of corrosive sublimate
or gray oil can be used, and must be thrown deeply into
the muscles of the buttock. Old people, those who are
exhausted, anemic, and broken down, and the scrofulous,
bear mercury badly. If it be given to them at all, it must
only be in small amounts and for a brief time.

Alkaline iodids are useful in removing the products of
inflammation ; they can be given for a long time, and admir-
ably supplement mercurials. Iodid of potassium can be pre-
scribed in combination with corrosive sublimate as follows :

INFLAMMA TION. 79

R. Hydrarg. chlor. corros., gr. ij ;

Potass, iodidi, Xv et Qj ;

Syr. sarsaparillse comp., q. s. ad f5\'iij.— ^I.
Sig. f^ij, in water, after meals.

lodid of potassium, well diluted, is given on a full stom-
ach ; it is never given concentrated nor before meals. A
convenient mode of administration is to procure a concen-
trated solution of the iodid of potassium, remembering that
every drop equals gr. i of the drug, and giving as many
drops as may be desired in half a glass of water after meals.
If the medicine disagrees, add to each dose, after it is put in
water, 3j of the aromatic spirits of ammonia. Extract of lic-
orice is a good vehicle for iodid. If the mixture in water
disagrees, the drug should be given in milk. Capsules are
sati.sfactory, but a drink ef water should be taken just before
and again just after taking a capsule, to protect the stomach
from the concentrated drug. Iodid of sodium may agree
when iodid of potassium does not. When the iodids dis-
agree they produce iodism. The first indications of iodism
are a bad taste in the mouth, running of the eyes and nose,
and sneezing, followed by a feeling of exhaustion, absolute
loss of appetite, nausea, tremor, and skin-eruptions (acne,
hemorrhages, blebs, hydroa, etc.). If iodism occurs, stop
the drug and give the patient Fowler's solution in increas-
ing doses, laxatives, diuretic waters, and also good food and
stimulants if depression is great. Sometimes belladonna does
good in obstinate cutaneous disorders induced by the iodids.

Remedies Directed Against Special Morbid States. — If in-
flammation is associated with rheumatism, gout, scurvy,
syphilis, tuberculosis, or any other constitutional disease or
predisposition, appropriate treatment should be instituted to
control the disease or combat the predisposition, and at the
same time the area of inflammation must be locally treated.
Syphilis is treated by the internal use of mercury and the
iodids ; scurvy, by vegetable juices and potash salts ; rheu-
matism, by the alkalies or salicylates ; gout, by colchicum or
piperazin ; tuberculosis, by the fats, tonics, and an open-air life.

The use of alcoholic stimidants is called for by conditions
rather than by diseases, being indicated by the state of
the patient rather than by the name of the malady. For
a brief acute inflammation in a robust young person alcohol
is not needed ; but all who are weak or exhausted, be they
young or old, all who are aged, those who are accustomed
to alcoholic beverages, those who have high temperatures or
failure of circulation, and those who labor under septic in-

8o MODERN SURGERY.

flammations or adynamic processes — require alcohol to be
given with a free hand. In an acute malady a feeble, com-
pressible, rapid, or irregular pulse, and great weakness of the
first sound of the heart, are indications that alcohol is required.
Low, muttering delirium is a strong indication. There is no
dose of alcohol for these states : it is given for its effect. Two
ounces may be needed in a day, or perhaps twenty ounces.
If the breath of the patient smells strongly of the alcohol,
he is getting too much. If delirium increases after each
dose, alcohol is doing harm. Alcohol is contraindicated in
acute meningitis. In acute illness use whiskey, brandy,
champagne, or alcohol and water. During convalescence
there may be used a little spirit, port, claret, or sherry wine,
or malt liquor. These agents will promote appetite, diges-
tion, and sleep.

Tonics are indicated during convalescence from acute and
throughout the course of chronic inflammations. There may
be used iron, quinin, and str>xhnin in the form of elixir;
iron alone, as in the tincture of the chlorid ; quinin in tonic
doses (gr. vj to gr. viij daily); or Fowler's solution of arsenic
An excellent pill consists of —

H. Acid, arsenos. g^-j?

Strycbniui, gr. ss;

(^)uinini, gr. xlviij;

hVrri redact., gr. vj.
Fl. in pil. Xo. xxiv.
Sig. One after each meal.

Bitter tonics before meals improve the appetite. One of the
best of tonics is tincture of nux vomica in gradually increas-
ing doses.

Antiphioi^istic rcc^itftcn is a term comprising the necessary
directions relating to diet, ventilation, cleanliness, etc.

Diet. — When, in the early stages of an acute inflammation,
the patient cannot eat, there must be administered a cathartic
before food is given. Nausea is combated with calomel and
soda, drop-doses of a 6 per cent, solution of cocain, iced
champagne, iced brandy, chloroform-water, hot water, cracked
ice, or the application of counterirritation to the epigastric
region. When the process is depressive from the start, and
in any case after the earliest stage, feeding is of vital mo-
ment. The great tissue-waste calls for large quantities of
nutritive material, but the impaired digestion demands that
the food shall be easily assimilable; hence it is taken in liquid
form, small quantities being frequently given. Milk contains
all the elements required by the body, and is the food of foods.

INFLAMMA TION, 8 V

If it disagrees, it should be boiled and mixed with lime-water,
or to each dose an equal amount of Vichy or soda-water may
be added. Peptonized milk is a valuable agent. One part
of milk, 2 parts of cream, and 2 parts of lime-water make
a nutritious and digestible mixture. Milk punch is largely
used. Whey may be used when plain milk cannot be taken.
Eggs are highly nutritious, but are apt to disturb the stom-
ach ; they may be given as egg-nog, or simply soft-boiled,
or the yolk can be beaten up in a cup of tea. When con-
siderable nausea exists the yolk of an egg may be added
to 5j of lemon-juice and 3ij of sugar, the glass being filled
with carbonated water. Beef tea is certainly a stimulant,
but its food-powers are questionable. It is prepared by cut-
ting up one pound of lean beef, adding to it a quart of water,
and then simmering, but not boiling, down to a pint, finally
filtering and skimming the liquid. The dose is a wineglass-
ful seasoned to taste. Meat-juice, obtained by squeezing
partly cooked meat with a lemon-squeezer, is also highly
nutritious. Liquid-beef peptonoids are both agreeable and
nutritious ; they are given in doses of 5ss to 3j. Clam-juice
is palatable and digestible. When nothing else will stay on
the stomach koumiss will often be retained. This fermented
milk is nutritious, stimulant, and very useful. Coffee is a
valuable stimulant in febrile conditions. If the stomach re-
tains no food, the patient must be fed entirely by the rectum.
If the stomach rejects most of the food swallowed, mouth-
feeding must be supplemented by nutritive rectal enemata.
When the sufferer feels able to eat a little, any good soup,
strained and skimmed, should be ordered. As the patient
gets better he may be fed on sweetbreads, chops, etc., until
he gradually reaches ordinary diet.

Ventilation and Cleanliness, — The ventilation of the apart-
ment is of the greatest importance. Every day the windows
should be opened widely for a time, the patient of course
being protected. When the windows are open the air of a
room can be quickly changed by swinging the door to and
fro. A constant access of fresh air must be secured, and
the temperature kept at about 68°. The sick man must
be cleaned and be sponged off with alcohol and water every
day if high fever exists. It is important that the bed-cloth-
ing be clean and that the sheet be unwrinkled, as otherwise
bed-sores may form.

Chronic Inflammation. — This condition progresses slowly
and does not produce symptoms of severity either in the
part or the body at large.

82 MODERN SURGER K

Causes. — Blood diseases, as rheumatism and gout ; infec-
tive diseases, as tuberculosis and syphilis ; retained pus in an
ill-drained abscess ; blockage of the duct of a gland ; foreign
body in part ; flow of an irritant secretion (as saliva from a
fistula) ; repeated identical traumatisms of an occupation, etc.
W. Watson Cheyne tells us it is not due to the ordinary
pyogenic organisms (see Cheyne's article in Treves' System
of Surgery),

Tissue-cliangcs. — Practically the same as in acute inflam-
mation, but take place far less rapidly. It is maintained by
Cheyne and others that typical granulation-tissue does not
form, the tissues of the part being replaced by fibrous tissue.
The amount of fibrous tissue produced is relatively very
great. This tissue may cause permanent thickening, or may
contract, and thus diminish the size of a part. Contraction
is very considerable in cirrhosis of the liver and in inter-
stitial nephritis.

Symptoms. — Pain varying in intensity and character ; ten-
derness ; great swelling, which in some cases is followed by
shrinking, and is usually indurated or brawny ; sometimes heat,
rarely discoloration unless the skin is itself inflamed. There
are no constitutional symptoms attributable purely to the in-
flammation. If there are such symptoms, they are due to
the disease which induced the inflammation or to interference
with the function of an organ because of the fibrous mass.
(For treatment of chronic inflammation see articles upon
special regions and particular structures.)

IV. REPAIR.

Repair is an active process by which destroyed tissues
are replaced, and it is due to increased nutritive activity,
rather than to inflammation. Inflammation may occur, or we
may be obliged to induce it when the blood-supply is scanty
or the exudation deficient ; but certain it is that an aseptic
wound heals without many of the evidences of inflammation.

Healing by First Intention. — A wound may heal by
*' first intention." This mode of healing, which is known
as ** primary union," occurs without suppuration, and is
observed in the healing of an aseptic wound. If pus
forms, primary union will not take place. If an incised
wound is asepticized, the hemorrhage arrested, and the edges
brought into nice apposition, slight swelling arises, but no
discoloration appears. Lymph and leukocytes are exuded
from the vessels, fibrin forms in this lymph, and the edges

REPAJR. 83

of the wound are stuck together by a natural cement. In
extensive wounds the exudation is in excess,- and much of
it must be drained away, for its retention will cause ten-
sion and inflammation, and the exudate furnishes a favor-
able soil for the growth of pus organisms. The exudation
is converted into embryonic tissue by multiplication of its
own cells and multiplication of tissue-cells. Embryonic
tissue consists of small round or oval cells held together
by a jelly-like intercellular substance. In a few days some
spindle-shaped cells can be found, and also lai^ cells with
one or more nuclei (epithelioid cells). Prolongations of
embryonic tissue are raised up by capillary loops, which
prolongations fuse with one another end to end, or fuse
with other capillary loops, are hollowed out and become
endothelial tubes or capillaries. By vascularization embry-
onic tissue becomes granulation -tissue. Granulation-tissue
becomes fibrous tissue, and the new fibrous tissue contracts
to a great degree (Figs. 25, 26). The final step in healing is

-^A

levdoplBg rnlD fil
nnctt).

contraction of the fibrous tissue and the covering of the sur-
face with epithelium, which springs from the epithelial cells
upon the edges. This final process is called " cicatrization,"
and consists in contraction of the wound and skimming over
with epithehum. The "immediate union" of some writers
never occurs. This term means the union of microscopical
parts to their counterparts without any eflbrt at repair. A
first union is effected always by fibrin, and next by embryonic
tissue, A wound healing by first intention exhibits no evi-
dence of inflammation. There is some slight tenderness, but
no actual pain. A certain amount of swelling arises because
of exudation of fluid from the blood, and the coagulation of
this fluid makes the wound-edges hard. Venous obstruc-
tion leads in some cases to a considerable fluid swelling.

84 MODERN SURGERY.

During the first twenty-four hours after a wound begins to
heal by first intention the discharge is most plentiful, but
after this period it becomes very scanty and soon ceases
entirely, and can be much diminished in quantity in the first
day by the application of pressure. In a large wound we
notice a profuse flow of bloody serum. Warren says that after
a hip-joint amputation over a pint flows out during the first
twenty-four hours. In a large wound special methods to
secure drainage are required. In a small wound drainage is
obtained between the stitches. The use of irritant germicides
in a wound greatly increases the amount of discharge and ren-
ders drainage necessary in even a small wound for the first
twenty-four hours. In an aseptic wound, "as a rule, one-half
of the stitches are removed on the fifth or sixth day and the
remainder on the eighth day, but for two weeks more the
wound should be rested and supported, as the new tissue is
not very resistant to infection. Aseptic fever always arises
when much exudation is given out, and is due to the ab-
sorption of aseptic pyrogenous material (p. 87).

Healing by Second Intention. — In a wound whose
edges cannot be approximated a great gap has to be filled,
and this is accomplished by granulation. This process is
known as *' healing by granulation '* or " second intention."
In an hour or so after the infliction of such a wound (it may
be in less time) the raw surface is covered with a thin glazed
layer of coagulated blood and exudate. This glaze is fibrin,
which soon becomes filled with leukocytes ; underneath this
fibrin-coat cell-proliferation is proceeding and embryonic ti.s-
sue is forming. The wound-discharge is at first thin and
red, but in a few days becomes purulent and so profuse as to
wash away the discolored fibrin-coat. Granulations are now
disclosed, the embryonic tissue being lifted up in countless
points by capillary loops. When these loops approach the
surface contraction begins in the fibrous tissue in the depth
of the damaged area, which contraction brings the edges of
the wound nearer together and gradually cuts off* by press-
ure the excessive blood-supply which is no longer needed.
When the granulations reach the surface, epithelium in a
thin bluish film grows from the epithelial cells at the edge
and covers the ulcer. Cicatrization is contraction plus skin-
ning over with epithelium. Epithelium can only spring
from the wound-edges, unless there be some epithelial
structural remains in the wound, such as an undestroyed
papilla, a sweat-duct, or a hair-follicle. If the granulations
rise above the surface, constituting exuberant granulations

REPAIR. 8

p»

or proud flesh, they must be cut off or burned away before
-epithelium will grow over the wound. Pale edematous gran-
ulations are usual in tuberculous processes, and if they form
pressure must be applied. The contraction of cicatrization
results from the conversion of granulation-tissue into fibrous
tissue (Figs. 25, 26). Contraction is so great after some
wounds as to cause terrible deformities. This is notably
the case after bums, whose scars or cicatrices contain much
elastic tissue. Coagulation-necrosis of a superficial layer of
granulation-tissue produces a diphtheritic membrane or aplas-
tic lymph. This coagulation-necrosis depends on capillary
closure or lack of capillary development, the embryonic tis-
sue dying for want of nutriment Ulcers heal by second
intention.

Healing by Tliird Intention. — ^This consists in the union
of two granulating surfaces, and is seen in the union of col-
lapsed abscess-walls. The surgeon occasionally seeks to ob-
tain union by third intention by approximating two granulat-
ing surfaces. In subcutaneous wounds, if aseptic, healing oc-
curs without suppuration. First a blood-clot fills the wound,
exudation occurs, and embryonic tissue forms in the walls
of the cavity, embryonic tissue is converted into granulation-
tissue, the new granulation-tissue grows into the clot, which
is broken up and absorbed, and fibrous organization and con-
traction of the new tissue take place. If suppuration occurs,
an abscess forms. Healing under an aseptic blood-clot is
healing "by first intention." The fibrous tissue of a scar
arises from granulation-tissue, which itself arose from embr>'-
onic tissue. The multiplication of connective-tissue cells may
be by direct, but it is usually by indirect, division.
. Cell-division. — Direct cell-division consists in division of
the nucleus followed by division of the entire cell.

Indirect cell-diinsion, or karyokinesis, shows remarkable
changes in the neucleus. The membrane of the nucleus
disappears; the nuclear network becomes first close and
then more open, and the cells become round, if not so be-
fore. The network of the nucleus, now consisting of one
long fiber, takes the shape of a rosette ; next it takes a star-
form — the aster stage ; two sets of V's next form — the equa-
torial stage ; an equatorial line appears and widens, and each
set of V's retreats toward a pole. Thus two new nuclei are
formed, each polar V passing in inverse order through the
previous changes of shape, and the protoplasm of the orig-
inal cell collecting about each nucleus (Fig. 27).

In non-vascular tissues, such as cornea or cartilage, the

86 MODEKN SURGERY.

wound is glued together by fibrin, the exudate having com
along the lymph-spaces from adjacent vascular areas, "
ization occurs by multiplication of fixed tissue-cells and leu- '
kocytes. Divided muscle, if the ends are widely separated,
unites by fibrous tissue. The ends of a divided muscle, if
closely approximated, unite by fibrous tissue, which becomes
filled with muscle-fibres. It is not yet definitely known
whether these fibres arise by growth from the muscle-cells
of the ends of the muscle, or by metamorphosis of the new
connective tissue. Divided nerve, when approximated, can
regenerate. The ends are first united by new connective
tissue ; this new tissue is a bridge for nerve-cells, and is finally
converted into nerve by the growth of cells from both the

dividing (Crem, ftom Flfnuning),

central and distal ends, the cells finally meeting. If the
ends are not approximated, they join by fibrous tissue, tbe
distal end atrophies, and the proximal end becomes bulbous.
The above view is entertained by Mayer and Eichhorst
Waller holds that repair is effected by the central end alone.
When a tendon is divided the ends retract, and the sheath,
as a rule, becomes filled with blood-clot. The blood-clot is
rapidly removed, embryonic tissue replacing it. This new
tissue arises from the sheath, and the cut ends do not partici-
pate in the process. Granulation-tissue is formed; this is con-
verted into fibrous tissue, and after a time the fibrous tissue
becomes true tendon. If no blood-clot forms in the sheath,
the walls of this structure collapse and adhere, and the sep-
arated tendon-ends are held together by a flat fibrous band
formed from the collapsed sheath (Warren's Surgical Pa-
thology). When a bone is broken a large blood-clot forms
in the medullary canal, between the broken ends, below and
outside of the periosteum. Granulation-tissue replaces the

SURGICAL FEVERS. 87

blood-clot, granulation-tissue becomes fibrous tissue, and the
fibrous tissue in many places becomes cartilaginous. In the
second week lime-salts begin to deposit and bone forms (p.
333). Cartilage can heal as cartilage, but usually unites by
fibrous tissue. When an artery is ligated, embryonic tissue
forms in and around it, the walls soften and are converted
into the same tissue, vascularization occurs, fibrous tissue
forms and contracts, and the artery is converted into a
fibrous cord. An ulcer heals in the same manner as does a
wound with loss of substance — ^by second intention. An
abscess heals by collapse of its sides and their adhesion (by
third intention). The sides are embryonic tissue, which is
formed into granulations, these granulations unite, and
organization into fibrous tissue takes place.

V. SURGICAL FEVERS.

The surgeon encounters fever as a result of an inflamma-
tion or an aseptic wound, in consequence of infection, and in
certain maladies of the nervous system. It is important to
remember that, while elevated temperature is generally taken
as a gauge of the intensity of fever, it is not a certain index.
There may be fever with subnormal temperature (as in the
collapse of typhoid or pneumonia), and there may be elevated
temperature without true fever (as in certain diseases of the
nervous system). It is true, however, that elevation of tem-
perature is almost always noted.

The essential phenomena of fever, according to Maclagan,
are — (i) wasting of nitrogenous tissue; (2) increased con-
sumption of water; (3) increased elimination of urea; (4)
increased rapidity of circulation ; and (5) preternatural heat.

Traumatic fevers follow a traumatism and attend the
healing or infection of a wound. The forms are — (i) benign
traumatic fever ; (2) malignant traumatic fever.

Benigrn ti^aumatic fever is divided into two classes — the
aseptic and the septic. There is but one form of aseptic
fever, the post-operation rise. The septic benign fevers are
surgical fever and suppurative fever. The malignant trau-
matic fevers are sapremia, septic infection, and pyemia. In
this section we discuss only the benign fevers.

Aseptic fever appears after a thoroughly aseptic operation
and after a simple fracture or a contusion. It may appear
during the evening of the day of operation or not until the
next day, and reaches its highest point by the evening of the
second day (100° to 102°). This elevation is spoken of as the

88 MODERN SURGERY.

" post-operation rise." Besides the fever there are no obvious
symptoms ; the patient feels first-rate, sleeps well, and often
wants to sit up ; there are no rigors and there is no delirium.
The wound is free from pain and appears entirely normal.
Blood examination shows leukocytosis. This fever is due to
absorption of pyrogenous material from the wound-area, the
material being obtained from clot or inflammatory exudate,
or from both. Many observers believe that the pyrogenous
element is fibrin-ferment, which is absorbed from disintegrat-
ing blood-clot and coagulating exudate. Warren thinks the
fever due to fibrin-ferment, and "also to other substances
slightly altered from their original composition during life."
Some have asserted that the fever is due to nervous shock.

Schnitzler and Ewald have recently studied aseptic fever.*
These observers maintain that aseptic fever can exist when
no fibrin-ferment is free in the blood, that fibrin-ferment can
be free in the blood when there is no fever, and in conse-
quence that fibrin-ferment is not the cause of the elevation
of temperature. They rule out of consideration nervous
shock as a cause, and assert that a combination of several
factors is responsible, nucleins and albumoses which are set
free by traumatism being looked upon as the most active
causative agents. The presence of nuclein in the blood in
aseptic fever is indicated by leukocytosis and by the increase
of the alloxur bodies (including uric acid) in the urine. The
capacity of nucleins and albumoses to cause fever is greater
in the tubercular than in the non-tubercular. The diagnosis
of aseptic traumatic fever is only made after a careful exam-
ination has assured the surgeon there is no obscure or hid-
den area of infection.

In some cases an aseptic fever may appear after an opera-
tion, and later be replaced by a septic fever. If the tempera-
ture remains high after a few days, or if other symptoms
appear, the wound should be examined at once, as trouble
certainly exists.

Traumatic or surgrical fever is seen as a result of infected
wounds where there is inflammation, but no pus. This fever
is due to the presence of fermentative bacteria in the wound
and the absorption of their toxic products. The most active
and commonly present organisms are those of putrefaction.
Fev^er ceases as soon as free discharge occurs, and its appear-
ance is an indication for instant drainage. The temperature
rises pretty sharply in a day or so after the operation, ascends

* See Archiv fur kliniiche Medinn, l5d. liii., H. 3, 1S96; also statement of
their views in Medical Record^ Dec. 19, 1896.

SURGICAL FEVERS. 89

with evening exacerbations and morning remissions, and
reaches its height about the third or fourth day, when sup-
puration sets in ; the temperature begins to drop when pus
forms, if the pus has free exit, and reaches normal at the end
of a week (see Suppurative Fever). Stitch-abscesses are often
found in surgical fever. If a post-operation rise continues
for an unnaturally long time, or if after it has passed away a
secondary rise is noted, suspect infection and examine the
wound. The wound is painful, tender, swollen, discolored,
and often foul. The stitches must be cut, and the area
asepticized, and packed with iodoform-gauze or drained by a
tube. The fact that this fever is apt to cease when suppura-
tion begins led the older surgeons to hope for pus and to
endeavor to cause it to form.

Suppurative Fever, — This fever, which is due to the ab-
sorption of the toxins of pyogenic organisms, occurs after
suppuration has begun, and is found when the pus has not
free exit. It can follow or be associated with surgical fever,
or may arise in cases in which surgical fever has not existed.
Suppuration in a wound is indicated by a rapid rise of tem-
perature— ^possibly by a chill. The skin becomes swollen,
dusky in color, and edematous, pain becomes pulsatile, and
much tenderness develops. The wound must at once be
drained and asepticized. In a chronic suppuration, such as
occurs in the mixed infection of a tubercular area, there
exists a fever with marked morning remissions and vesperal
exacerbations, attended with night-sweats, emaciation, diar-
rhea, and exhaustion. This is known as " hectic fever ;" it
is really a chronic suppurative fever. The treatment of hec-
tic fever consists in the drainage and disinfection if possible,
the excision of the infected area, the employment of a nutri-
tious diet, stimulants, tonics, remedies for the exhausting
sweats, and free access of fresh air.

Other Forms of Fever. — Fever of Tension. — When
there is great tension upon the stitches the spots where
the stitches perforate ulcerate and some fever arises. To re-
lieve the fever of tension cut one or several stitches. This
fever is in some cases surgical, and in some suppurative, ac-
cording as to whether the infective organisms cause fermen-
tation or suppuration.

Fever of Iodoform Absorption (p. 27).

Malaria. — It is wise to examine the blood in supposed sep-
tic fevers, for only by this means can malaria be excluded.
It is more common to mistake sepsis for malaria than mala-
ria for sepsis.

go MODERN SURGERY,

Surffioal Scarlet Fever. — It is maintained by some writers
(notably Victor Horsley and Sir James Paget) that a child is
rendered especially susceptible to scarlet fever by the shock
of a surgical operation. Scarlet fever which develops after
an operation is spoken of as surgical scarlet fever. Warren
quotes Thomas Smith as having had ten cases of scarlet fever
in forty-three operations for lithotomy in children. The
puerperal state is supposed also to predispose to scarlet
fever. Some writers hold that an attack of scarlet fever after
an operation is a coincidence. Others maintain, and with
great show of reason, that a red scarlatiniform eruption ap-
pearing after an operation rarely indicates genuine scarlet
fever, but usually points to infection, as such eruptions are
known occasionally to arise in septicemia.

Hofta has discussed this subject elaborately. He con-
cludes that four types of eruption can follow operation: (i)
a vaso-motor disturbance due to irritation of sensory nerves,
and manifested by a transient urticaria or erythema ; (2) a
toxic erythema due to absorption of aseptic pyrogenous ma-
terial from the injured area — the absorption of carbolic add,
iodoform, or corrosive sublimate, or the effect of ether ; (3)
an infectious rash which is sometimes found in septicemia or
pyemia, and due to minute emboli composed of bacteria,
which emboli lodge in the capillaries ; (4) true scarlet fever,
with the usual symptoms and complications, the organisms
having entered by way of the wound, and the eruption often
beginning at the wound-edges (quoted in Warren's Surgical
Pathology'),

VI. TERMINATIONS OF INFLAMMATION.

Inflammation may terminate in a return of the part to
health or in its death. Recovery' is said to be by delitescence
when the inflammation is arrested at an early stage, and by
resolution when the inflammation passes on regularly to the
formation of cmbr>'onic tissue and this tissue is absorbed.
New formation is the termination of inflammation when there
has been loss of substance or when the embryonic tissue is
not absorbed. Death of a part is by suppuration (molecular
death) or ^anp^rcne (molar death).

Inflammation may terminate in — (i) effusion of liquor san-
guinis ; (2) formation of embr\'onic tissue ; (3) formation of
pus; (4) ulceration ; and (5) mortification.

E£Etision of I/iquor Sanguinis. — The so-called "se-
rum " of inflammation is not serum at all, but is liquor san-

TERMINATIONS OF INFLAMMATION 9 1

guinis, which contains few cells and in consequence does not
tend to coagulate. We meet with true serum in passive con-
gestions, but not in active inflammation. Effusion of " se-
rum " into connective tissue constitutes edema ; and into a
sac, like the peritoneum, dropsy ; dropsy being designated by
the prefix hydro-, as hydrothorax. Abdominal dropsy is
ascites. Anasarca is general effusion of serum resulting
from altered blood-pressure. Edema is made manifest by
the signs of inflammation, the swelling being soft, smooth,
and inelastic, and the parts pitting on pressure. Effusion of
blood liquor can be beneficial, unloading the vessels and
hence relieving pain, tension, and hyperemia. Effusion of
blood liquor can be harmful. In connective tissue fluid in
great quantity can cut off the circulation of certain areas,
thus causing necrosis. Effusion into a cavity causes press-
ure on its contained parts; for instance, in a hydrothorax
the lung is compressed.

Treatment. — Edema can be relieved by multiple punctures ;
but if it threatens necrosis, free incisions must be made. If
the dropsy be considerable, the fluid must be let out by tap-
ping, aspiration, or incision. Tapping must be done as asep-
tically as cutting. In aspirating use full aseptic care. When
it is wished to drain the abdomen, the latter should be opened
with a knife, because an intestine might happen to be glued
to the abdominal wall, and when not detected by previous
percussion, a trocar or a needle could easily perforate. In
a moderate edema use locally compression, and tincture of
iodin diluted with an equal bulk of alcohol. In persistent
edema employ frictions with a stimulating liniment. Inter-
nally, salines and diuretics are indicated. The compound
jalap powder is well suited to dropsies. Mercurials can be
used, and in severe cases also elaterium.

Pormatioii of Embryonic Tissue. — The term " lymph "

is a synonym for fibrinous exudate, coagulable lymph, plastic
infiltrate, indifferent tissue, or embryonic tissue. Granulation-
tissue is va.scularized lymph, and when it forms inflammation
has passed into new formation. It is customary to speak of
new formation as a termination of inflammation, but, as a
matter of fact, inflammation has ceased when it begins. New
formation is discussed in the section upon Repair. In in-
flammation effusion of liquor sanguinis and migration of
white corpuscles take place, fibrin forms in the exudate and
the liquor sanguinis coagulates. This is followed by pro-
liferation of the corpuscles and of the fixed connective-tissue
cells (Fig. 28). Effused liquor sanguinis, which contains

92 MODERN SURGERY.

many corpuscles and which coagulates, is met with in se-
vere inflammation. Lymph may be absorbed or it may be
organized into tissue. If it becomes organized, capillaries
form in it by the extension from the surrounding tissue of '
capillary loops, which raise up the lymph and form granula-
tions. A granuladon may be defined as a small mass of
lymph containing vessels (Fig, 29). If lymph is absorbed,
it is taken up by the lymphatics.

Lymph is divided into two forms — plastic or formative
lymph, that which can be converted into tissue, hence that
which can bring about repair ; aplastic or croupous lymph,
that which develops no fibres and cannot be converted into
tissue, and which in consequence cannot bring about repair.
Effusion of lymph may be beneficial. It repairs all injuries ;
it surrounds and encapsules foreign bodies; it circumscribes

abscesses ; and it often prevents pus from evacuating into
a cavity, gluing together structures to make a channel and
leading the pu.s to the surface. It may be injurious. It forms
adhesions of the brain, pleura, peritoneum, pericardium, and
joint.': ; it produces opacity in the cornea and adhesions of
the iris; it constitutes the false membrane of the larynx or
trachea; and it causes stricture of the urethra and thicken-
ing of organs.

Treatment. — Locally, employ compression, tincture of
iodin, lead-water and laudanum, alternating hot and cold
douches, friction, and massage ; also ichthyol and lanolin.
Internally, use mercurials and iodid of potassium or tartar
emetic. S. W. Gross recommended the following mixture
for inflammatory thickening:

R. Potissii iodiiii. gr. « ;

Hy,lrargyri cblo.idi corrosivi. gr. ^ ;

Anlimonii et [lota^'ii lartralU. gt. A-— M-

Sig. Three times a day, in half a glass of water, aitei meals.

TERMINATIONS OF INFLAMMATION 93

Suppuratioii is a process in which tissues and inflamma-
tory exudates are liquefied by the action of pyogenic organ-
isms, and it is a common termination of infective inflamma-
tion. Localized suppurations are due to staphylococci;
spreading suppurations, to streptococci. Pyogenic bacteria
liquefy exudate by peptonizing it. The pyogenic organisms
are very irritant, and when deposited cause inflammation ; in-
flammation leads to exudation, but the exudate cannot coag-
ulate because it is peptonized by the ferment of the micro-
organisms. If an area of embryonic tissue is invaded by the
pyogenic micro-organisms, it is promptly peptonized. Pep-
tonized exudate or embryonic tissue is called pus. In in-
flammations induced by staphylococci granulation-tissue, as
a rule, forms at the periphery of the inflammation, the micro-
cocci are imprisoned, and the process is circumscribed. In
inflammations induced by streptococci granulation-tissue
rarely forms in time to imprison the micro-organisms and
the suppuration spreads widely. Suppuration can be induced
by the injection of pyogenic bacteria, by their entry through
a wound, and by rubbing them upon the skin. In some rare
instances, especially when the diet has been putrid, they may
enter through the blood and lodge at a point of least resist-
ance. The entry of pyogenic bacteria does not necessarily
cause suppuration, as the healthy human body can destroy
a considerable number, even if given in one " dose ;" but a
large number in a healthy, or even a small number in an un-
healthy, organism almost certainly does. The pus of all acute
abscesses contains bacteria of suppuration, but the pus of
tubercular abscesses does not, unless there be a mixed in-
fection ; in other words, pure tubercular pus is not pus at all.

Can suppuration be induced without micro-organisms ? It
is true that the injection of irritants can cause the formation
of a thin fluid which contains no organisms, but is this non-
bacterial pus really pus ? The same sort of fluid is formed
by injecting cultures of pus cocci which have been rendered
sterile by heat, the organisms being killed, a ferment con-
tained in the bacterial cells being the active agent. Spu-
rious or " aseptic " pus does not concern us, as it is never
found practically. Impaired health or an area of lowered
vitality predisposes to suppuration. The lymphatic glands,
medulla of bones, serous membranes, and connective tissue
are especially prone to suppurate. When a medullary canal
suppurates after a chill to the surface or after a blow that
does not cause a wound, wc know that the organisms must
have arrived by means of the blood.

MODERN SVRGER Y.

Pus may form in twenty-four hours after an inflammation
begins, or it may not form for days. The older surgeons
claimed that pus could do good by protecting granulations
and separating disorganized tissue. It is now held that it is
absolutely harmful by melting down sound tissue and poi-
soning the entire organism. Modem surgery has to a great
degree abolished pus.

If pus stands for a time, it separates into two portions —
(l) a watery portion, the liquor puris or pus-serum, contain-
ing peptone, fat, microbic products, osniazone, and salts, and
not lending to coagulate ( ) a o d port on o sed n enl of
micro-organisms of suppu on pu oq u t^ g 30 d

broken-down tissue. The pus-corpusc!es are either white
blood-cells or altered connective-tissue cells. Some of them
are dead, some have ameboid movements, some are fatty.
others are granular and contain more than one nucleus, and
all are degenerating, A pus-cell is waste-matter, and it can-
not aid in repair.

Forme of Pus. — Laudable or healthy pus. a name long in
vogue, is a contradiction, no pus being healthy. In former
days free suppuration after an operation was regarded as a
favorable indication, and when it occurred the surgeon con-
gratulated himself that surgical fever was at an end. At the

TERAflNATIONS OF INFLAMMATION, 95

present day suppuration after an operation is an evidence of
previous infection, of lack of care, or of infection by the
blood. The so-called laudable pus is seen coming from a
healing ulcer, and is a yellowish-white or a greenish fluid of
the consistence of cream, opaque, with a very slight odor if
it is not putrid, and having a specific gravity of about 1.030.

Malignant, watery , or ichorous pus is a thin, watery, putrid
fluid. It is pus filled with the organisms of putrefaction.

Sanious pus is a form of ichorous pus containing blood
coloring-matter or blood. It is thin, of a reddish color, and
very acrid, corroding the parts that it comes in contact with.
It is found notably in caries and carcinoma.

Concrete or fibrinous pus^ which contains flakes of fibrin
or coagulated fibro-purulent masses, is met with in serous
cavities (joints, pleura, etc.). These masses are found in
infective endocarditis (Bowditch).

Blue pus, — ^The color of blue pus is due to the bacillus
pyocyaneus.

Orange pus is due to the action of sarcina aurantiaca, and
appears in violent inflammations.

Serous pus is a thin serous fluid containing a few flakes.

So-called scrofulous or curdy pus is not pus at all, unless
the tubercular area has undergone pyogenic infection.

So-called gummy pus arises from the breaking down of a
gumma which has outgrown its own blood-supply. It is
not pus.

MucO'pus is found in purulent catarrh — ^that is, in suppura-
tive inflammation of an epithelial structure. It contains pus-
elements and epithelial cells.

Caseous pus comes from the fatty degeneration of pus-
corpuscles or inflammatory exudations. This mass may
calcify. It occurs especially in tubercular processes.

Contagious pus is that which contains and conveys the
elements of some specific contagion, such as small-pox or
a chancroid.

Suppuratioii is announced by the intensification of all
local inflammatory signs. The heat becomes more marked,
the discoloration dusky, the swelling augments, the pain be-
comes throbbing or pulsatile, and the sense of tension is
greatly increased. The skin at the focus of the inflammation
after a time becomes adherent to the parts beneath, and fluc-
tuation soon appears. This adhesion of the skin is a prepa-
ration for a natural opening, and is what is known as ** point-
ing." An important sign of pus beneath is edema of the
skin. This is sometimes noticeable in empyema or pyotho-

96 MODERN SURGERY,

rax and in appendicitis. The above symptoms can be rein-
forced and their significance proved by the introduction of
an aseptic tubular exploring-needle and the discovery of pus.
Irregular chills, high fever, and drenching sweats are very
significant of suppuration in an important structure or of a
large area.

DifEHised Cellulitis or Phlegmonous Suppuration; Puru-
lent Infiltration. — This process may involve a small area or
an entire limb, and is due to infection by the streptococcus
pyogenes or streptococcus of eiysipelas. It is announced in
severe cases by enormous swelling, the development of areas
which feel boggy, a dusky-red discoloration, and great burn-
ing pain. Gangrene of superficial areas is not unusual. The
discharges of the wound, if a wound exists, are apt to dry
up, and the wound becomes foul, dry, and brown. The
adjacent lymphatic glands are much enlarged. The patient
has chills, sweats, and high oscillating temperature, due to
suppurative fever, sapremia, or even septic infection or
pyemia. Diffuse suppuration tends to arise in infected com-
pound fractures, in extravasation of urine, and after the
infliction of a wound upon a person broken down in health.
It is not unusual after scarlet fever, and is typical of phleg-
monous erysipelas. The pus is sanious and offensive. This
diffused suppuration may widely separate muscles, and even
lay bare the bones. It is a ver>' grave condition, and may
cause death by exhaustion, septic intoxication, septic infec-
tion, pyemia, or hemorrhage from a large vessel which has
been corroded. Cellulitis of a mild degree may surround
an infected wound or a stitch-abscess. Its spread is mani-
fested by red lines of lymphangitis running up to the adja-
cent lymphatic glands. Light cases may not suppurate, the-
lymphatics carrvnng off* the poison. Any case of cellulitis is,
however, a menace, and any severe case is highly dangerous
(see Erysipelas),

Acute Abscesses. — An abscess is a circumscribed cavity
of new formation containing pus. We emphasize the fact
that it is a cirannscrihcd cavity — circumscribed by a mass
of embryonic tissue. A purulent infiltration is not circum-
scribed, hence it does not constitute an abscess. An essen-
tial part of the definftion is the assertion that the pus is in a
cavity of new formation, in an abnormal cavity ; hence pus
in a natural cavity (pleural, pericardial, synovial, or perito-
neal) constitutes a purulent effusion, and not an abscess
unless it is encysted in these localities by walls formed of
inflammatory tissue.

T£/!jV/.V/ir/OA-S OF hXFLAMMATIOW.

An acute abscess is due to the deposition and multiplica-
tion of pyogenic bacteria in the tissues or in inflammalory
exudates. These bacteria attack exudates or tissues, form
irritants which intensify the inflammation, and by exerting a
peptonizing action on intercellular substance and fibrin of
the exudate liquefy tissue and the products of inflammation,
and form pus. As a rule, within twenty-four hours after
lodgement of the bacteria the exudation increases in amount,
the migrated leukocytes gather in enormous numbers, the
fibers of tissue swell up, and the connective-tissue spaces
distend with cells and fluid. The connective-tissue cells,
acted on by pus cocci, multiply by karyokinesis, develop
many nuclei, lose their stellate projections, degenerate, and
constitute one form of pus-corpuscle, leukocytes forming

the other. All the small vessels are choked with leukocytes,
this blocking serving to cut off nourishment and tending to
produce anemic necrosis. Liquefaction occurs at many foci
. of the inflammation, drops of pus being formed, the amount
of each being progressively added to and many foci coales-
cing (Fig. 31). The pus-cavity is circumscribed, not by a
secreting pyogenic membrane, but by embryonic tissue
■ whose cells and intercellular material have not as yet
' broken down, and this area of embryonic tissue is circum-
I scribed by a zone of inflammation. As an abscess increases
I size the embr>'onic tissue from within outward liquefies
into pus. and the zone of inflammation beyond continually

98 MODERN SURGERY.

enlarges and forms more lymph. After a time the inflam-
mation reaches the surface, the embryonic tissue glues the
superficial to the deeper parts, liquefaction of this lymph
occurs, a small elevation due to fluid pressure appears (point-
ing), and this elevation thins and breaks from tension and
liquefaction (spontaneous evacuation). When an abscess
forms in an internal organ or in some structure which is
not loose like connective tissue — for instance, in a lymphatic
gland — a mass of pyogenic bacteria, floating in the blood or
lymph, lodges, and these bacteria by means of irritant products
cause coagulation-necrosis of the adjacent tissue and inflam-
matory exudation around it. The area of coagulation-necrosis
becomes filled with white blood-cells, and the dry necrosed
part is liquefied by the cocci. Suppuration in dense struc-
tures causes considerable masses of tissue to die and to be
cast off, and these masses float in the pus. Death of a mass
with dissolution of its elements is necro.sis or inflammatory
gangrene. An abscess heals by the collapse of its walls
and the formation of an abundance of granulation-tissue ; in
many cases the granulations of one wall join those of the
other side, the entire mass of granulations being converted
into ^fibrous tissue, and this tissue contracting (healing by
third intention). If the walls do not collapse, the abscess
heals by second intention.

Porms of Abscesses. — The following are the various
forms of abscesses : acute or phlegmonous^ which follows an
acute inflammation ; strumous, cold, lymphatic, tubercular, or
chronic abscess is due to tubercle, and does not contain true
pus without there is secondary infection. It presents no
signs of inflammation. A lymphatic abscess may form in a
week or two, and hence is not necessarily chronic, which
term may also be used to mean a persistent non-tubercular
abscess ; caseous or cheesy abscess, a cavity containing thick
cheesy masses, is due to the fatty degeneration of exudate,
and most commonly results from the caseation of a tubercu-
lar focus ; circumscribed abscess is one limited by embryonic
tissue ; diffused abscess is an unlimited collection of pus, in
reality not an abscess, but either a purulent effusion or a
purulent infiltration; congestive, gravitative, ivandering, or
hypostatic abscess is a collection of pus or tubercular mat-
ter which travels from its formation-point and appears at
some distant spot (as a psoas abscess) ; critical or consecutive
abscess is one which arises during an acute disease ; diathetic
abscess is due to a diathesis ; embolic abscess is due to an in-
fected embolus ; tympanitic or emphysematous abscess is one

TERMINATIONS OF INFLAMMATION 99

which contains the gases of putrefaction ; encysted abscess, in
which pus is circumscribed in a serous cavity ; fecal or ster-
coraceous abscess is one containing feces in consequence of a
communication with the bowel ; follicular abscess is one aris-
ing in a follicle ; hematic abscess is that which arises around
blood-clot, as a suppurating hematoma ; marginal abscess,
which appears upon the margin of the anus ; pyemic or
metastatic abscess is the embolic abscess of pyemia ; milk
abscess is an abscess of the breast in a nursing woman;
ossifluent abscess, arising from diseased bone ; psoas or tuber-
cular abscess, arising from vertebral caries, following the
psoas muscle and usually pointing in the groin ; sympathetic
abscess, arising some distance from the exciting cause, such
as a suppurating bubo from chancroid, is not in reality sym-
pathetic, because infective material has been carried from the
primary focus; thecal abscess is suppuration in a tendon-
sheath ; tropical abscess is an abscess of the liver, so named
because it occurs chiefly in tropical countries. It usually
follows dysehtery ; urinary abscess, caused by extravasated
urine ; verminous abscess, one which contains intestinal worms
and communicates with the bowel ; syphilitic abscess, which
occurs in the bones during tertiary syphilis ; Brodie's abscess
is a chronic abscess of a bone, most common in the head of
the tibia ; superficial abscess, which occurs above the deep
fascia; deep abscess, occurring below the deep fascia; and
residual or Paget* s abscess, a recurrence of suppuration, it
may be after years, about the residue of a former abscess.

Symptoms of Acute Abscess. — In an acute abscess, as
before stated, a part becomes inflamed and embryonic tissue
forms ; this is liquefied (as above noted) and pus is produced.
If the abscess is in the brain, in the tonsil, or in the neigh-
borhood of the rectum, the odor of the pus is apt to be
offensive. An acute abscess can occur in a person of any
constitution.

Local Symptoms. — Locally there is intensification of in-
flammatory signs ; swelling enormously increases, the dis-
coloration becomes dusky, the pain becomes throbbing and
the sense of tension increases, the cutaneous surface is seen
to be polished and edematous, and after a time pointing is
observed and fluctuation can be detected.

Constitutional Symptoms. — In cases of small collections
of pus in unimportant structures there may be no obvious con-
stitutional disturbance. If the abscess contains much pus or
affects an important part, generally disturbances appear, from
slight rigors or moderate fever to chills, high temperature,

ICX) MODERN SURGERY.

and drenching sweats. The constitutional condition typical
of an abscess is due to the absorption of retained toxins,
and is known *as ** suppurative fever/' When suppuration
is long continued there exists a fever which is markedly
periodic : the temperature rises in the evening, attaining its
highest point usually between 4 and 8 p. m., and then sinks
to normal or nearly normal in the early morning (from 4 to
8 A. M.). When the temperature begins to fall profuse per-
spiration takes place. This fever is known as " hectic.'*

The symptoms of an abscess are somewhat modified by
location, and it is wise to discuss acute abscesses in different
situations.

Acute Abscesses in Various Regions. — Abscess of the

brain in about 50 per cent, of cases results from suppurative
disease of the middle-ear. In abscess of a silent region of the
brain symptoms may long be entirely absent. The usual
symptoms are headache, vomiting, delirium, drowsiness,
optic neuritis, and often a subnormal temperature. Local-
izing symptoms may be present. In but few cases are there
fever and sweats (p. 561). In extradural abscess there is
fever.

Appendicinal or appendicular abscess results from inflam-
mation, usually with perforation of the vermiform appendix,
plastic peritonitis circumscribing the pus. If the pus is not
limited by adhesion, the peritoneum is attacked by diffuse
septic peritonitis (p. 655). The signs of appendicular abscess
are pain, tenderness, muscular rigidity, often swelling, dul-
ncss on percussion, and sometimes fluctuation and skin-
edema in the right iliac fossa, fever, vomiting, sometimes
constipation, and sometimes diarrhea.

Abscess of the liver may not be announced by symptoms
until rupture. It may follow dysentery, may be a result of
the lodgement of infected clots from the hemorrhoidal veins,
or may follow upon the pylephlebitis of appendicitis. We
usually find fever of an intermittent type, profuse sweats,
pain in the back, the shoulder, or the right hypochondriac
region, enlargement of the area of liver-dulness. also hepatic
tenderness, and finally constitutional symptoms of the exist-
ence of pus. Sometimes there are fluctuation and skin-
edema over the liver, and the general cutaneous surface
may be a little jaundiced. The symptoms var>' as the pus
invades adjacent organs (p. 660).

Subphrenic abscess is apt to begin beneath the diaphragm,
though in some few instances the pus forms above this mus-
cle, and sub.sequently gains access to the region beneath. This

TERMINATIONS OF INFLAMMATION. lOI

abscess may contain not only pus, but gas, and also in some
cases fluids from the stomach or intestine. It may arise after
perforation of the bowel or stomach, or it may result from
Pott s disease, perinephric abscess, traumatism, abscess of the
liver, kidney, spleen, or pancreas, empyema or pneumonia
(Greig Smith). The signs are pain, fever, sweats, dyspnea,
cough, and the physical signs of gas in the cavity of the
abscess.

Abscess of the lung gives the physical signs of a cavity ;
the expectoration is offensive and contains fragments of lung-
tissue. Pyemic abscesses may exist and yet escape dis-
covery.

Abscess of the mediastinum causes throbbing retrosternal
pain, chills, fever, sweats, and often dyspnea. A tumor may
appear which pulsates and fluctuates, but the pulsation is not
expansile.

Perinephric abscess usually causes tenderness and pain in
the lumbar region or about the hip-joint, which pain runs
down the thigh and is accompanied by retraction of the tes-
ticle. Induration, fluctuation, or edema of the skin may ap-
pear. The constitutional symptoms of suppuration usually
exist.

Abscess of the antrum of Highmore causes pain, edema-
tous swelling, and crepitation on pressure. Pus escapes from
the nostrils, and a rhinoscopic examination can find the fluid
passing into the nares. The antrum on the side of the ab-
scess cannot be transilluminated by an electric light in the
mouth (Garel's sign).

Abscess of the larynx induces violent cough, pain, interfer-
ence with the voice, swallowing, and breathing, and can be
seen with a laryngoscope.

Prostatic abscess is manifested by chills, fever, and sweats,
developing during an attack of acute prostatitis.

Abscess of the breast can arise from absorption of pyogenic
bacteria from a fissure or abrasion of the nipple. Some sur-
geons maintain that the bacteria enter along the milk-ducts,
while others assert that they gain entry by the lymphatics.
It is most common in nursing women. Its symptoms are
pulsatile pain, dusky discoloration, skin-edema, fluctuation,
and usually constitutional disorder.

Suppurative thccitis or felon is a form of diffuse suppura-
tion (p. 5 1 2).

Palmar abscess is a purulent effusion (p. 5 1 2).

Furuncle and carbtmclc are discussed upon pages 739 and
740.

I02 MODEKX SCRCER V.

Empyema is a purulent effusion (p. 603) into the pleural
sac. It IS technically an abscess if it becomes encapsuled.

Dia^noeis. — The diagno^ of an abscess rests upon— (i)
its histor>'; (2) fluctuation ; (3) pointing; (4) surface-edema ;
and (5) the use of the tubular exploring-needle.

A suspected abscess in a dangerous or important part
under no circumstance should be opened by a bistoury \i*ith-
out knowing that the diagnosis is certainly correct This
knowledge is obtained in some cases by inserting a small
aspirating-needle and obser\'ing the nature of the fluid which
exudes. An abscess which moves with the pulse because it
rests upon an arter>' may be confounded with an aneur>'sm.
The pulse-movements of an abscess are in one direction only;
the abscess is lifted uith each pulse-beat, but does not en-
large, and if a finger is laid upon either side of it the fingers
will be lifted, but not separated. The pulse-movements of
an aneurysm are in all directions ; they are pulsatile, the tu-
mor grows larger, and the fingers will not only be lifted, but
w ill also be separated. The tubular exploring-needle can be
used in doubtful cases ; if aseptic, it will do no harm even to
an aneurysm. Many able surgeons object to the employ-
ment of a grooved exploring-needle, on the ground that
when plunged into infected areas and withdrawn the track
of the penetration becomes infected by the fluid which es-
capes. A rapidly growing, small-cell sarcoma feels not unlike
an abscess ; but the exploring-needle discovers blood, and
not pus. A cystic tumor is separated from an abscess by
the absence of inflammation, or, if it inflames, by the nature
of the contained fluid. Ordinary caution will prevent us
from confounding an abscess with strangulated hernia. A
tubercular abscess is separated from an acute abscess by the
absence of inflammator>' signs in the former.

ProgTiosis. — The prognosis varies according to the num-
ber of abscesses, their location and size, and the strength of
the patient.

Treatment. — In the treatment of an abscess there is one
absolute rule which knows no exception, namely, that when-
ever and wherever pus is found the abscess should be evac-
uated at once, and, after evacuating it, thorough drainage
provided for. It should be opened early, if possible even
before pointing or fluctuation, to prevent tissue-destruction,
subfascial burrowing, and general contamination. Drainage
is continued until the discharge becomes scanty, thin, and
seropurulcnt.

Abscess of the liver requires that an incision be made

TERMINATIONS OF INFLAMMATION I03

along the edge of the ribs down to the liver, which organ
is then stitched to the edges of the wound. In a day or
two after the first operation the two layers of peritoneum
are firmly adherent and the abscess can be opened without
danger of the passage of pus into the peritoneal cavity.
The abscess is opened and washed out, and a tube inserted.
Surgeons occasionally try to locate the pus by the use of an
aspirator before doing the cutting operation (p. 660). Abscess
of the liver is occasionally reached by resecting a rib, open-
ing the pleural sac, and incising the diaphragm (transthoracic
hepatotomy). Abscess of the mediastinum, like all other
abscesses, requires incision and drainage. This is most eas-
ily effected by trephining the sternum. In abscess of the lung
an incision is made and the pleura is exposed. The incision
is usually through an intercostal space ; but if the spaces are
narrow, it will be necessary to resect a rib. If the two layers
of pleura are found adherent, the operation is proceeded with.
If they are not adherent, they are stitched together with a cat-
gut suture, and the surgeon waits 48 hours before continuing.
The operation is completed by locating the pus by means
of an aspirator, evacuating it by the cautery at a dull red
heat, and inserting a drainage-tube into the abscess-cavity
(p. 607). In abscess of the antrum bore a gimlet-hole
through the superior maxillary bone above the canine tooth,
or perforate the bone by means of a trocar. Irrigate daily
with boiled water or normal salt solution. Keep the open-
ing from contracting by inserting a small tent of iodoform
gauze. In persistent cases it may be necessary to draw
a tooth, break through the socket into the antrum, and in-
sert a silver or hard-rubber tube. In very persistent cases
osteoplastic resection of a portion of the upper jaw will be
demanded. In appendicular abscess incise, support abscess-
walls with gauze, in many cases do not remove the appendix,
and insert a drainage-tube and strands of gauze (p. 653).

In abscess of the breast make an incision radiating from
the nipple, or, what is better, incise under the breast by
means of a cut at the inferior thoracic mammary junction, and
enter the abscess from beneath. In abscess of the brain the
skull should be trephined, the membranes incised, and the
abscess sought for, opened, and drained (p. 562). In an ordi-
nary superficial abscess, after cleansing the parts, make the
skin tense, incise with a sharp-pointed curved bistoury, and
let the pus run out itself, pressure being, as a rule, unde-
sirable. If tissue-shreds block up the opening, they must
be picked out with forceps. If the atmospheric pressure

I04 MODERN SURGERY.

will not cause the pus to flow out, make light pressure with
warm, moist, aseptic sponges. After the pus has come away
wash the cavity with peroxid of hydrogen and then with
corrosive solution (i : looo), and pack with iodoform gauze
for two or three days, when the discharge becomes serous.
Pursue rigid antisepsis in dealing with pus. It is true we
already have infection, but infection can take place with or-
ganisms of putrefaction, causing pus to become putrid, or
with other bacteria.

In a deep abscess, or an abscess situated near important
vessels, do not boldly plunge in a knife. Hilton says to
" plunge in a knife is not courageous, as it is without danger
to the surgeon, but may be fatal to the patient." Remember
also that a large amount of pus displaces normal anatomical
relations. Hilton's method of opening a deep abscess (as in
the axilla or neck) is to cut to the deep fascia, nick the fascia
with a knife, and then push into the abscess a grooved director
until pus shows in the groove ; along the groove push a pair
of dressing-forceps, shut ; after they reach the depths upon
them and withdraw, and so dilate the opening ; then insert
a tube and irrigate. In an abscess in the posterior part of
the orbit, after incising transversely a portion of the upper
lid, the abscess should be reached by this method. Always
endeavor to open an abscess at its most dependent part, re-
membering that the situation of this part may depend upon
whether the patient is erect or recumbent. If we do not
make the opening at the lowest point, all the pus will not
run out and the walls will not completely collapse. A deep
abscess must be drained thoroughly until the discharge be-
comes seropurulent. When the tube is removed it is wise
to insert a tent of iodoform gauze just through the outlet of
the abscess. This tent prevents the skin from closing over
the channel. It is reinserted every day until it becomes
clear that there is no longer danger of fluid becoming
blocked and retained. When an abscess contains diverticula
or pouches, they should be slit up or a counter-opening
ought to be made. A counter-opening is made by entering
the dressing-forceps at our first incision, pushing them
through the abscess to the point where we wish to make our
counter-opening, opening the blades, and cutting between
them from without inward. The blades are then closed and
projected through the incision ; they arc opened to dilate
the new door, and closed again upon a drainage-tube which
is pulled through from opening to opening as the instrument
is withdrawn. When pus burrows, insert a grooved director

TERMINATIONS OF INFLAMMATION, IO5

in each channel and slit the sinus with a knife. An abscess
may make an opening through dense fascia, the opening
being small like the neck of an hour-glass (shirt-stud ab-
scess). Always examine to see if such a condition exists,
and if it is found, incise the fascia.

Rest is of the first importance in the healing of an abscess,
and we try to obtain it by bandages, splints, and pressure,
which will immobilize adjacent muscles and approximate
the abscess-walls. If an abscess is slow to heal, use as a
daily injection peroxid of hydrogen followed by I : 1000
corrosive sublimate, or 3 drops of nitric acid to 5j of water,
or 3 grains of zinc sulphate to Sj of water, or a 5 per cent,
solution of carbolic acid, or a 2 per cent, aqueous solution
of pyoktanin, or 20 drops of tincture of iodin to 3j of water or
a solution of bichlorid of palladium. Peroxid of hydrogen is
a dangerous agent to inject into the cavity of a deep abscess
of the neck, as the liberated gas may not escape from the
opening, but may pass widely into the tissues and cause great
distention. The author saw a child who narrowly escaped
death after such an injection. In this patient the gas passed
beneath the pharyngeal mucous membrane and the swelling
almost occluded the air-passages. The constitutional treat-
ment of an abscess depends upon its severity and upon the
importance of the structures involved. In a bad case the
patient should be put to bed, opiates given with a free hand,
the bowels kept active by calomel and salines, skin-activity
maintained, nutritious food insisted on, and stimulants liber-
ally employed.

Purulent Effusions. — See Suppurative Thecitis, Palmar Ab-
scess, Suppurative Synovitis, Purulent Peritonitis, Empyema,
etc.

Tuberctllar abscess, called also chronic, cold, scrofu-
lous, and lymphatic, is an area of disease produced by the
action of the bacilli of tubercle and circumscribed by a dis-
tinct membrane. Ashhurst says that the term " chronic " is
a bad one. " It refers etymologically only to time. A
phlegmonous abscess, if deeply seated, may be of slower
development than a chronic or cold abscess which is super-
ficial." A tubercular abscess is most common in the Ivm-
phatic glands, bones, joints, and subcutaneous connective
tissues, and is rare after the twentieth year. It may contain
quarts of curdy pus. The bacilli of tubercle cause inflam-
mation, and granulation-tissue is formed, which in the centre
undergoes coagulation-necrosis and caseation, and at the pe-
riphery is converted into fibrous tissue. The irritation of

I06 MODERN SURGERY,

toxins produces the exudation, and anemia due to the mass
outgrowing its own blood-supply is the cause of the case-
ation. First, there forms from granulation-tissue a cheesy
matter, which is liquefied into scrofulous, curdy, or tubercular
fluid. This really is not pus, as the tubercle bacillus is not
pyogenic ; if true pus forms, it is because of a secondary
infection with pus cocci — an accident, and not a part of the
natural process of formation of a cold abscess. A cold
abscess may be absorbed, or may become encapsuled by
densely fibrous organization of its limiting-wall into a thick
pyogenic membrane. The fibrous wall of a tubercular ab-
scess is lined by a thin, yellowish membrane, which is stud-
ded with miliary tubercles (Volkmann*s membrane). Tuber-
cular matter rarely invades a muscle, whereas syphilis often
attacks muscle (Warren).

Symptoms. — The term cold abscess is employed for a
tubercular abscess because it presents no inflammatory signs.
There is no local heat; no discoloration unless pointing
occurs ; the parts look paler than natural ; pain is absent in
the abscess, though it may exist at the point of origin of the
fluid ; the tubercular material often wanders from its point
of origin under the influence of gravity ; fluctuation is pres-
ent unless thick walls mask it. Constitutional symptoms
are trivial or absent unless secondary infection occurs. The
swelling may suddenly appear in some spot — ttie groin, for
instance. When it appears suddenly it has travelled from a
distant and older area of disease. The abscess may last for
years without producing pain or annoyance. The tubular
exploring-needle will settle the diagnosis. The constitution
is invariably below normal because of the tubercular infec-
tion, and the temperature is a little above normal. A cold
abscess which is infected with pus organisms exhibits great
inflammation, and septic fever rapidly develops. In tuber-
cular disease of the vertebra the fluid may find its way to
the lumbar region, to the iliac region, or to the immediate
neighborhood of Poupart's ligament, above or below it.

Tubercular Abscesses in Various Regions. — Tu-
bercular abscess of the head of a bone (Brodie's absces.s)
arises in the cancellous structure of a long bone, most often
in the head of the tibia. Pain is continued but not usually
very severe, is of a boring character, and is worse when the
patient is in bed. Attacks of synovitis arise from time to time
in the adjacent joint. There is no such thing as an acute ab-
scess of bone. A pyogenic inflammation of such severity
that it would cause an acute abscess in soft parts, in bone

TERMINA TIONS OF INFLAMMA TION, 107

causes acute necrosis. The organism obtains access to the
bone by means of the blood, and finds in the bone a point
of least resistance.

Betropharsrnfireal or postpharynsreal abscees is usually
due to caries of the cervical vertebrae, but can arise in the
connective tissue of the parts or as a tubercular adenitis.
An abrasion of the mucous membrane may admit the bacilli
to the tissue or tne glands. A swelling projects from the
posterior pharyngeal wall, and there is great interference
with respiration and deglutition. Caseous matter from caries
of the cervical vertebrae may reach the posterior mediastinum
by following the esophagus, or it may appear in front of or
behind the stemomastoid muscle (Edmund Owen).

Dorsal Abscaes. — The tubercular matter in dorsal ab-
scess arises from dorsal caries, flows into the posterior medi-
astinum, and reaches the surface by passing between the
transverse processes. The tubercular matter from dorsal
caries may run forward between the intercostal muscles or
between these muscles and the pleura, pointing in an inter-
costal space at the side of the sternum or by the rectus
muscle. It may open into the gullet, windpipe, bronchus,
pleural sac, or pericardium. It may descend to the dia-
phragm and travel under the inner arcuate ligament to form
a psoas abscess, or under the outer arcuate ligament to form
a lumbar abscess. A psoas abscess points external to the
femoral vessels, a characteristic which distinguishes it at once
from a femoral hernia.

Iliac abscess arises from lumbar caries, the swelling lying
in the iliac fossa and pointing above Poupart*s ligament.

Psoas abscess is usually due to lumbar caries, the fluid
pointing in Scarpa's triangle external to the femoral vessels.
A psoas or iliac abscess, by following the lumbosacral cord
and great sciatic nerve, forms a gluteal abscess. These
abscesses may open into the bowel, bladder, ureter, or peri-
toneal cavity.

Lumbar Abscess. — In a lumbar abscess the fluid produced
by dorsal caries descends beneath the outer arcuate liga-
ment, or the fluid from lumbar caries which collected ante-
rior to or in the quadratus lumborum muscle passes between
the last rib and iliac crest in the triangle of Petit, the small
space bounded by the crest of the ilium, the posterior edge
of the external oblique muscle, and the anterior edge of the
latissimus dorsi muscles.*

* For a lucid description of these al)scesses see Owen's Manual of Anatomy^
from which much of the above is condensed.

I08 MODRR^r SURGRRY.

Chronic abscees of the breast is a caseated area of tu-
berculosis of the breast. A lump is detected which slowly
enlarges and finally ruptures, sinuses being formed. The
axillary glands are apt to be implicated. The patient be-
longs to a tubercular stock, as a rule gives a history of
previous tubercular troubles of various sorts, and has
usually borne children. Chronic abscess of the breast
causes little or no pain.

Treatment. — If a small cold abscess exists in a superficial
structure, open it with aseptic care, rub its walls with bits
of gauze to remove tubercular masses, irrigate with i : looo
mercurial solution, pack with iodoform-gauze, and dress anti-
septically. When the discharge becomes thin and scanty
the packing can be dispensed with. If it be slow in healing,
inject or swab out with a stimulating fluid as in acute abscess,
or inject with iodoform emulsion.

Chronic Abscess of Bone. — Make an incision to bare the
bone. Open the abscess with the trephine, the gouge, or
the chisel ; curet with a sharp spoon and gouge ; cut away
the edges of the bone ^^^th rongeur forceps ; irrigate the cav-
ity with hot corrosive sublimate solution (i : lOCX)), and swab
it out with gauze wet with pure carbolic acid; pack ^^^th
iodoform gauze and apply dry antiseptic dressings. It is
better not to employ an Esmarch apparatus. Bleeding will
not be severe, and when no apparatus is used we can be sure
that all the diseased bone has been removed, because sound
bone bleeds and dead bone does not.

Cold Abscess of Lymphatic Glands. — In non-exposed
portions of the body the capsule should be incised and dis-
sected or scraped away, and the cavity swabbed out with
pure carbolic acid and packed with iodoform gauze. If the
abscess is allowed to burst, it will make an ugly .scar; there-
fore in exposed portions of the body an effort should be
made to prevent a scar. When only a little caseated matter
exists and the skin is not discolored, prepare the parts anti-
septically and carry a silk thread by means of a needle
through the skin, through the gland, and out at its lowest
point. Dress with gauze. In three days the thread can be
taken out and a firm compress applied. When the gland is
almost entirely broken down and the skin above it is purple
and thin, insert a hypodermatic needle through sound skin
into the abscess, draw ofTthe pus, and inject iodoform emul-
sion (lo per cent, of iodoform, 90 per cent, of glycerin or
olive oil). This procedure is to be repeated when pus again
accumulates. By this means we can often effect a cure in

TERMINATIONS OF INFLAMMATION. IO9

a week or so. When an abscess breaks or is at the point
of breaking cut away all purple skin, curet the abscess-
walls (the abscess having become a scrofulous ulcer),
remove the remains of gland and capsule, swab the cavity
with pure carbolic acid, and dress with iodoform and corro-
sive gauze.

Tubercular glands ought to be extirpated before they
caseate and form abscess.

Cold Abecess of Mammary Gland. — Many operators
simply incise, curette, pack with iodoform gauze, and dress
antiseptically. It is wiser to remove the entire gland and
clean out the axilla, in order to prevent both recurrence and
dissemination.

Larfire Gold AbeceBses (Psoas Abscess). — In view of the
facts that these abscesses may cause no trouble for years
and that an operation may be fatal, some eminent surgeons
are opposed to an operation unless the abscess is moving
toward inevitable rupture or is disturbing the functions of
organs by pressure. Most practitioners believe, however,
that this mass of tuberculous matter is a source of danger
through being a depot of infective organisms which may
overwhelm the system, and that death will rarely occur in
the hands of .the operator who employs with intelligence
strict antisepsis. In no other cases is attention to every
detail more important, as a mixed infection can easily take
place, and will probably mean death.

In many cases aspiration can be employed to empty the
cavity, injecting either a 10 per cent, iodoform emulsion
to the amount of 3iij, or Siij of a 5 per cent, ethereal solu-
tion of iodoform after the fluid is sucked out. After inject-
ing the emulsion squeeze and manipulate the fluid into every
nook and cranny. The American Text-book of Surgery
advises the injection of from i to 3 ounces of the following
preparation: iodoform, 10 parts; glycerin, 20; mucil. gum
Arab., 5 ; carbolic acid, i ; water, 100.

Whatever fluid is chosen, the operation must be repeated
three or four times at intervals of four weeks. It is danger-
ous to inject large amounts of iodoform, as poisoning may
be produced (p. 27). Some surgeons incise such an abscess,
inject iodoform emulsion, and sew up without drainage.
Such a procedure often fails and is sometimes followed by
iodoform-poisoning. If aspiration and injection fail, open,
under rigid antisepsis, the most dependent portion of the
abscess, scrape its wall with bits of gauze, and over-distend
with a I : 1000 solution of warm corrosive sublimate. Let

I lO MODERN SURGERY,

the mercurial solution run out and then irrigate the cavit>'
with hot normal salt solution, which will remove the re-
mains of the corrosive fluid. With a long probe find the
highest point of the cavity, and make a counter-opening;
scrape well, search for and remove carious bone, flush out
the whole area with corrosive sublimate, wash out the mei-
curial solution with hot normal salt solution, inject emul-
sion of iodoform, and either make tube-drainage from open-
ing to counter-opening and from bone to counter-opening,
or pack the entire cavity with iodoform gauze. If hemor-
rhage is severe, after injecting with hot salt solution the cav-
ity must be packed. When a large abscess breaks of itself,
it should at once be drained and asepticized as above. In
the treatment of a cold abscess give nutritious food, cod-liver
oil, quinin, iron, and the mineral acids. Removal to the sea-
side is often indicated, and mechanical appliances may be
needed for diseases of the bones and joints. If secondary
infection does occur, the patient develops hectic fever (^. v^.

Dorsal abscess and lumbar abscess are treated after the
same plan as psoas abscess, although one incision only is
usually necessary unless the fluid has travelled to a distant
point.

A postpharyngeal abscess must not be opened through
the mouth. To open it in this manner puts the patient in
danger of suffocation by fluid running into the larynx during
or after the operation. Further mixed infection of the
abscess-area will be certain to ensue. Septic pneumonia
will be apt to arise from inhaled infected particles, and pro-
found gastro-intestinal disturbance will be liable to develop
because of the inevitable swallowing of purulent, putrid, and
tubercular masses. Incise the neck and open by Hilton's
method, going through the sternocleidomastoid muscle or
behind it. Rub the wall with bits of gauze, remove any loose
bone, irrigate with hot normal salt solution, inject iodoform
emulsion, insert a tube or pack with iodoform gauze.

VH. ULCERATION AND FISTULA,

An ulcer is a loss of substance due to necrosis of a
superficial structure. The action of the pus organisms is
the same as in an abscess. A broken abscess becomes an
ulcer, and an ulcer is a half-section of an abscess. The
floor of an ulcer consists of granulation-tissue and corre-
sponds with the abscess-wall. An abscess arises from
molecular death within the tissues ; an ulcer, from molec-

ULCERATION AND FISTULA. Ill

ular death of a free surface. An ulcer must not be con-
founded with an excoriation. In an ulcer the corium is
always, and the subcutaneous tissue is generally, destroyed,
and a scar is left after healing. In an excoriation the mucous
layer of epithelium is exposed, or this is destroyed and the
corium exposed. In an excoriation the corium is never
destroyed, and no scar remains after healing. An ulcer
heals by granulation (p. 84). Embryonic tissue by vascu-
larization becomes granulation-tissue, granulation-tissue is
converted into fibrous tissue, the fibrous tissue contracts,
and by pulling the edges of the ulcer toward each other
lessens the size of the cavity. When the granulations reach
the level of the skin the epithelium at the edges of the ulcer
proliferates and the sore is soon covered over with new
epithelium.

Necrosis may arise from — (i) Inflammation. The press-
ure of the exudate can cut off the circulation, or bacteria
may directly destroy tissue. Suppuration occurs. (2) The
action of pus bacteria, causing primary cell-necrosis. (3)
Bacteria of putrefaction and organisms of suppuration acting
upon a wound. (4) Traumatism or irritants, producing at
once stasis, which is added to by secondary inflammation,
the exudate undergoing purulent liquefaction. (5) Pro-
longed pressure. (6) Deficient blood-supply. (7) Faulty
venous return. (8) Degeneration of a neoplastic infiltration
(gummatous, malignant, or tubercular). (9) Trophic dis-
turbance. (10) Nutritional disturbances (as scurvy). Most
ulcers are due to pus organisms, and even those that arise
from something else (as gummatous degeneration) are apt
to suppurate.

Classification. — Ulcers are classified into groups ac-
cording to the condition of the ulcer and the associated
constitutional state. In the first group we find the varicose,
hemorrhagic, acute, chronic, irritable, neuralgic, etc. In the
second group are placed the tubercular, syphilitic, senile,
scorbutic, etc. All ulcers, whatever their origin, are either
acute or chronic^ and such conditions as great pain, hemor-
rhage, edema, exuberant granulations, phagedena, slough-
ing, eczema, gout, syphilis, scurvy, etc., are to be looked upon
as complications. The leg is so common a site of ulcers as
to warrant a special description of ulcers of this part. In
describing an ulcer state the patient's previous history ; the
supposed cause ; the situation ; the outline ; the duration ;
and the mode of onset of the ulcer. State if the ulcer is
single or if multiple sores exist, and if there is or is not pain.

1 1 2 MODERN SURGER Y.

Whether or not any healing has ever occurred, and the pa-
tient's constitutional condition. Set forth the complications ;
the state of anatomically related glands ; the condition of the
edge, the floor, and the parts about the ulcer, and the nature
and quantity of the discharge.

Acute ulcer of the leg* may follow an acute inflamma-
tion and may be acute from the start, or may be first chronic
and then become acute. It is characterized by rapid progress
and intense inflammation. There is rarely more than one
ulcer. In outline these ulcers are usually oval, but may be
irregular. The floor of an acute ulcer is covered with a
mass of gray aplastic lymph, or it may have upon it large
greenish sloughs. The edges are thin and undermined.
The discharge is very profuse and ichorous, excoriating the
surrounding parts. The adjacent surface is inflamed and
edematous. There is much burning pain. In some cases
the glands in the groin enlarge. When the ulcer spreads
with great rapidity and becomes deeper as well as larger in
surface-area, it is called " phagedenic." If sloughs form,
this indicates that tissue-death is going on so rapidly that
the dead portions have not time to break down and be cast
off. Limited stasis produces molecular death ; more exten-
sive stasis, a slough. Constitutionally, there is gastro-intes-
tinal derangement, but rarely fever.

Treatment. — In treating an acute ulcer of the leg, give a
dose of blue mass or calomel, followed in eight or ten hours
by a saline (.^ij each of Rochelle and Epsom salt). Order
light diet. Deny stimulants except in diphtheritic ulcer.
Administer opium if pain is severe. Insist upon rest in the
recumbent position with the leg elevated. Use a spray of
hydrogen peroxid and the scissors and forceps to get rid of
sloughs, and after sloughs are removed wash the ulcer with
corrosive sublimate solution (i : looo). If the sloughs can-
not be removed completely, use an antiseptic poultice.
After asepticizing local bleeding is of great value. Tie a
fillet below the knee, make multiple punctures in the parts
about the ulcer, and let the patient sit with his leg in tepid
water until six or eight ounces of blood have been lost;
then untie the fillet and dress with antiseptic poultices, keep-
ing the leg elevated. In two days paint around the ulcer
with equal parts of tincture of iodin and alcohol, and repeat
this treatment every day, dusting the ulcer with iodoform,
covering it with gauze, and producing pressure by means of
a roller.

Many cases do very well after local bleeding and antisep-

ULCERATION AND FISTULA, II3

tization by the local use of lead-water and laudanum upon
the inflamed parts around the ulcer, a roller bandage being
applied to make compression. The lead-water and laud-
anum should not be applied to the ulcer, but around about
it The ulcer is dressed with an antiseptic poultice. If the
discharge is offensive, dress antiseptically, apply acetanilid,
aristol, or iodoform, or use gr. iij of chloral to every 5j of
water. A 25 per cent, ointment of ichthyol is very useful
applied around the ulcer. If sloughs continue to form,
touch with a 1 : 8 solution of acid nitrate of mercury or with
a solution of pure carbolic acid, and reapply antiseptic poul-
tices. If an ulcer continues to spread, clean it up with per-
oxid of hydrogen, dry with absorbent cotton, touch with
nitrate-of-mercury solution (i : 8), and apply an antiseptic
poultice. Repeat the application of nitrate of mercury every
day until the ulcer ceases to extend and granulations begin
to form.

In an ulcer covered with a great mass of aplastic lymph
touch daily with solution of silver nitrate (gr. xl to Sj) or
with add nitrate of mercury (i : 15), and dress with iodo-
form and antiseptic fomentations. Give internally tonics,
stimulants, and good food. In any case, when granulations
form we should dress antiseptically with dry dressings, or
we can employ a non-irritant ointment, such as cosmolin.
If granulation is slow, touch every day with a solution of
silver nitrate (gr. x to Sj) and dress antiseptically, or with a
stimulating ointment (resin cerate or 3j of ung. hydrarg.
nitratis to 3vij of ung. petrolii), or with an ointment of copper
sulphate, gr. iij to 5j, or with 3 drops of nitric acid to |j of
gum Arabic.

Chronic tilcer of the leg* is characterized by low action
and slow progress. It may be chronic from the start, or it
may result from acute ulcer. More usually it is found as a
solitary ulcer two inches above the internal malleolus. Syph-
ilitic ulcers often occur in a group, are usually crescentic,
and are frequent upon the front of the knee. A tubercular
ulcer may have no granulations, but is usually covered with
pale edematous granulations, which signify the existence of
a tendency to venous stasis. The edges of the tubercular
ulcer are undermined and irregular, the parts about it are
livid and tender, and the discharge is thin and scanty (p. 152).
An ordinary chronic ulcer is circular or oval, and is sur-
rounded by congested, discolored, and indurated skin, this
induration being due to fibrous tissue, and there is often ec-
zema or a brown pigmentation of the neighboring skin. The

114 MODERN SURGERY.

floor of the ulcer is uneven, and usually is covered with
granulations, each of which is red and the size of a pin-point,
but which may be exuberant or edematous. If granula-
tions are absent, the ulcer has the appearance of a piece of
liver, or is smooth and glazed. The edges are thick, turned
out, and not sensitive to the touch. Occasionally, but
rarely, they are thin and undermined. Some ulcers are
indurated and adherent ; this adhesion to the deeper struc-
tures prevents healing by antagonizing contraction. An
ulcer may fail to heal because of severe infection ; because
of want of rest ; because of absence of granulations, the
result of deficient blood-supply; because of edematous
granulations; because of exuberant granulations; because
of adhesion to deep structures, and because of some con-
stitutional disease.

Treatxaent. — In treating a chronic ulcer, give a saline
every day or so. Treat any existing diathesis. Insist on rest
and, if possible, elevation. Asepticize the ulcer. Draw blood
by shallow scarifications of the bottom of the ulcer and the
skin. If the ulcer is adher-
ent, make incisions like either
of those shown in Fig. 32,
each cut going through the
deep fascia. These incisions,
besides permitting contrac-
tion, allow granulations to
Fio.j..-inci»ioB> for »dhe«iM ulcer, sprout in them, which cause
the absorption of the exudate.
After incision keep the part elevated and dressed antiseptic-
ally for two days. In two days after scarification or incision
scrape the ulcer with a curet until sound tissue is reached.
Use antiseptic poultices for two days more, then paint around
the ulcer with tincture of iodin and alcohol (l : 3), dress the
parts about the ulcer with hot lead-water and laudanuni,
and dress the ulcer antiseptically or with sterile gauze. In
a day or so the lead-water can be discontinued and the
ulcer can be dressed antiseptically with sterile gauze, nor-
mal salt solution, boric add, bichlorid of palladium, chlorin-
water, solution of permanganate of potassium, sulphur,
glutol, protonuclein, or bovinin. Glutol (formalin-gela-
tin) is very useful in some cases and so is protonuclein.
When healing begins, treat as outlined for healit^ acute
ulcer (p. 1 1 3).

Complications. — Remove by scissors and forceps any
useless tissue. Take out dead bone; slit sinuses; trim over-

UL CERA TJON AND FISTULA. 1 1 5

hanging edges. Treat eczema by attention to the bowels and
stomach, and locally by washing with ethereal soap and by
the use of powdered oxid of zinc or borated talcum, the leg
being wrapped in cotton. Avoid ordinary soap, grease, and
ointment Varicose veins demand either ligation at several
points, excision, incision by Schede's method (p. 274), or the
continued use of a flannel roller or a Martin rubber-bandage.
Never operate on varicose veins if any phlebitis exists. In-
flammation is met by rest, elevation, painting the neighbor-
ing parts with dilute iodin, and applying about the ulcer a
hot solution of lead-water and laudanum. For calloused
edges, blister, employ radiating incisions, or cut the edges
away. Ordinary thick edges can be strapped. In strapping
use adhesive plaster and do not completely encircle the limb.
For edematous granulations apply pressure by a flannel
bandage, a rubber bandage, or adhesive plaster strapping.
When the parts are adherent the ulcer is immovable, being
firmly anchored to structures beneath it. In such a condi-
tion completely or partly surround the sore with a cut through
the deep fascia (Fig. 32). This cut sets the ulcer free from
its anchorage and permits it to contract. If the bottom of the
ulcer is foul, dry it and touch with a solution of acid nitrate
of mercury (i : 8) or with crystals of pure carbolic acid. Re-
peat this every third day and dress with an antiseptic poultice
until granulations appear. Superfluous granulations (proud
flesh) should be cut away or mowed down with silver nitrate.
Absence of granulations or scantiness of granulations means
deficiency of blood-supply. The surgeon endeavors to bring
more blood to the part, and to do this induces inflammation.
The usual method of procedure is to apply daily to the sore
a solution of nitrate of silver (10 to 15 grains to the ounce).
In obstinate cases blister the ulcer or scrape it, or paint it
with tincture of iodin, or apply pure carbolic acid, or touch
with the actual cautery.

Irritable ulcer is due to exposure of a nerve and destruc-
tion of its sheath. Find with a probe the painful granulation
and divide it with a tenotome, or curet the ulcer or bum it
with solid stick of silver nitrate. If healing entirely fails,
skin-graft. Among the methods of skin-grafting are — (i)
Reverdin's, (2) Thiersch's, and (3) Krause's. (See Plastic
Surgery^

When a man having an ulcer must go out, use a firmly
applied roller, or, better still, a Martin bandage. This band-
age, which is made of red rubber, limits the amount of arte-
rial blood going to the ulcer and favors venous flow from the

1 1 6 MODERN SI 'RCER Y.

sore and its neighborhood. The bandage should be used as
follows : before getting out of bed spray the sore with hydro-
gen peroxid by means of an atomizer, dry off the froth with
cotton, wash the leg with soap and water, dry it, and put on
the bandage — all of which should be done befiDre putting a
foot to the floor. At night, after getting in bed, take off the
bandage, wash it with soap and water, hang it over a chair
to dry, and again cleanse the leg and ulcer. If these rules
are not strictly observed, the Martin bandage will produce
pain, suppuration, and eczema of the leg.

Tubercular Ulcers (p. 152).

Syphilitic Ulcers (p. 197).

A healthy ulcer is covered with small, bright-red granu-
lations which bleed on touching, are painless, and grow rap-
idly. The edges are soft and show the opalescent blue line
of proliferating epithelium. The sore is movable, the dis-
charge is purulent and yellow, and the parts about are not
inflamed.

Varions Ulcers. — The ftm^us or exuberant ulcer is
especially common in bums and other injuries when cicatri-
cial contraction causes venous obstruction. The granulations
form rapidly and mount above the level of the skin. These
granulations bleed when touched. Bum them off with solid
stick of silver nitrate, or cut them off with a sharp knife ; stop
hemorrhage if there be any, and strap or use the rubber
bandage.

A varicose ulcer is usually single, is oval, round, or ir-
regular in outline, and is most often seen above the inner
malleolus. Its edges are thick, everted, and swollen. This
swelling is largely due to edema, and is found to pit on
pressure. The edges are not undermined, but slope gently
to the floor of the ulcer. The floor is usually covered with
rather large granulations which bleed freely on touching. In
a varicose ulcer the destruction of tissue often begins at the
margin of a congested area and advances toward the centre.
Such an ulcer is usually surrounded by eczema.

Brethistic, irritable, or painfUl ulcers, which are very
sensitive, are due to the exposure of nerve-filaments and
destruction of their sheaths. They are especially found near
the ankle, over the tibia, in the anus (fissure), or in the
matrix of the nail (ingrowing nail). Ciiret an erethistic
ulcer, and touch with pure carbolic acid or with the solid
stick of silver nitrate. Chloral, gr. xx to the ounce, allays
the pain ; so do cocain and eucain for a time.

The indolent ulcer has no granulations and shows no

ULCERATION AND FISTULA. II7

tendency to heal. It requires stimulating applications to in-
crease the blood-supply.

The hemorrhaerio ulcer bleeds easily and profusely. Press-
ure must be applied, and it is sometimes necessary to cut
away or bum away the granulations.

Phagedenic Ulcer. — The phagedenic ulcer, which means
the profound microbic infection of tissues debilitated by
local or constitutional disease, is commonly venereal. This
ulcer has no granulations and is covered with sloughs ; its
edges are thin and undermined, and it spreads rapidly in all
directions. It requires the use of strong caustics or Paque-
lin's cautery followed by iodoform dressing and antiseptic
poultices. Internally, use tonics and stimulants.

The callous ulcer is sunken deeply below the level of the
skin. Its border is hard and knobby. Its floor shows no
granulations, and is either smooth and glistening or foul and
fiver-colored. The discharge is thin and scanty, and the ulcer
varies little in appearance from week to week or even from
month to month. The treatment is scraping and cauteriza-
tion of the ulcer ; cutting through the edges by radiating in-
cisions; application of antiseptic dressings, and a firm band-
age. In some cases strap the ulcer. In severe cases cut the
ulcer out and sldn-graft.

A rodent or Jacob's ulcer is a superficial epithelioma
developing from sebaceous glands, sweat-glands, or hair-
follicles. It requires scraping and cauterization, or, what is
better, excision.

Decubital ulcer, or bed-sore, is due to pressure upon an
area of feeble circulation (p. 1 30).

Neuroparal3rtic or trophic ulcer is due to impairment of
the trophic centres in the cord.

The perforating ulcer, a name given by Vesigne, com-
monly affects the metatarsophalangeal joint or the pulp of
the great toe about a corn. The parts about the corn in-
flame, and pus forms and reaches into the bone. A sinus
evacuates the pus by the side of the corn. As this ulcer
may be present in anesthetic leprosy, paralyzed limbs, and
tabes dorsalis, and as the part on which it occurs is apt to
be sweaty, cold, and more or less anesthetic, and as the sore
may be hereditary, it is usually set down as trophic in origin.
Treatment of a perforating ulcer consists, according to Treves,
in going to bed and poulticing. Every time a poultice is re-
moved the raised epithelium around the ulcer is cut away and
then the poultice is reapplied. In about two weeks an ulcer
remains surrounded by healthy tissue. Treves treats this

1 1 8 MODERN SURCER K

sore with glycerin made to a creamy consistency with sali-
cylic acid, to each ounce of which ITlx of carbolic acid have
been added. He directs the patient to wear during the rest
of his life some form of bunion-plaster to keep off pressure.
If in a perforating ulcer the bone is diseased, it must be re-
moved. This ulcer tends to recur in the same spot or in
adjacent parts, and it may be necessary to amputate the toe
or the foot.

The scorbutic ulcer is covered with a dark-brown crust,
beneath which are pale and bleeding granulations. The parts
adjacent are of a violet color.

Epitheliomatous, sarcomatous, tubercular, and S)rphilitic
ulcers are considered under these respective diseases.

Pisttila. — A fistula is an abnormal communication be-
tween the surface and an internal part of the body, or
between two natural cavities or canals. The first form is
seen in a rectal fistula, a urethral fistula, or a biliary fistula,
and the second form is seen in a vesicovaginal fistula. Fis-
tulae may result from congenital defect, as when there is fail-
ure in the closure of the branchial clefts, and can arise from
sloughing, traumatism, and suppuration. Fistulae are named
from their situation and communications.

A sinus is a tortuous track opening usually upon a free
surface and leading down into the cavity of an imperfectly-
healed abscess. A sinus may be an unhealed portion of a
wound. Many sinuses may be due to pus burrowing subcu-
taneously. A sinus fails to heal because of the presence of
some irritant fluid (as saliva, urine, or bile) ; because of the
existence of a foreign body, as dead bone, a bit of wood, a
bullet, a septic ligature, etc. ; or because of rigidity of the
sinus-walls, which rigidity will not permit collapse. The
walls of a tubercular sinus are lined with a material identical
with the pyogenic membrane of a cold abscess. Sinuses
may be maintained by want of rest (muscular movements)
and general ill-health.

Treatment. — In treating a fistula, remove any foreign
body, lay the channel open, curet, swab with pure car-
bolic acid, and pack with iodoform gauze. In obstinate
cases entirely extirpate the fibrous walls, sew the deeper
parts of the wound with buried catgut sutures and approxi-
mate the skin-surfaces with interrupted sutures of silkworm
gut. Fresh air is a necessity, and nutritious food and tonics
must be ordered.

MORTIFICATION, GANGRENE, OR SPHACELUS. 1 19

VIII, MORTIFICATION, OANORENE, OR SPHACELUS.

Mortification or gangrene is death in mass of a portion
of the sur&ce of the living body — the dead portions being
visible — in contrast to ulceration or molecular death, in
which the dead particles are too small to be seen and are
cast away. Gangrene is in reality a form of necrosis. But
clinically the term necrosis is restricted to molar death of
bone or to death of parts below the surface. In gangrene
the dead portions may either desiccate or putrefy. Gan-
grene may be due to tissue-injury, either chemical or me-
chanical, to heat or cold, to failure of the general health, to
circulatory obstruction, to nerve-disorder, the nerves in-
volved being the vasomotor or possibly the trophic, or to
microbtc infection. A microbic poison can directly destroy
tissues. It can indirectly destroy them by causing such
inflammation that the products obstruct the circulation.
When the mortified portion is entirely dead the process
is spoken of as ** sphacelus."

Classification. — Gangrene is divided into the following
three great groups:

(i) Dry ffongrene, which is due to circulatory interference,
the arterial supply being decreased or cut off. As venous
return is still active, all fluid is taken up from the tissues,
which shrivel and mummify.

(2) Moist firangrrene, which is due to interference not only
with arterial ingress, but also with venous return or capillary
circulation, the dead parts remaining moist.

(3) Septic firanfirrene, arising from virulent septic matter
coming from outside. In this form the septic process causes
the gangrene, and is not merely associated with it.

There are many gangrenous processes which belong under
one or other of the above heads, namely : congenital gan-
grene, a rare form existing at birth ; constitutional gangrene,
arising from a constitutional cause, as diabetes; cutaneous
gangrene, which is limited to skin and subcutaneous tissue,
as in phlegmonous erysipelas; gaseous or emphysematous
gangrene, in which the subcutaneous tissues are filled with
putrefactive gases and crackle on pressure ; diabetic or gly-
cemic, due to diabetes ; hospital gangrene, which is defined
by Foster as specific serpiginous necrosis, the tissues being
pulpefied : some consider it a traumatic diphtheria ; cold
gangrene, a form in which the parts are entirely dead
(sphacelus) ; hot gangrene, which presents some inflamma-
tion, as shown by heat; dermatitis gangrenosa infantum, or

J 20 MODERN SURGERY.

the multiple cachectic gangrene of Simon ; idiopathic gan-
grene, which has no ascertainable cause ; mixed, which is
partly dry and partly moist ; primary, in which the death of
the part is direct, as from a bum ; secondary, which follows
an acute inflammation ; multiple, as gangrenous herpes zoster ;
diabetic gangrene, which arises during the existence of dia-
betes ; gangrenous ecthyma, a gangrenous condition of ec-
thyma ulcers ; pressure, which is due to long compression ;
purpuric or scorbutic, which is due to scurvy; Raynaud's or
idiopatliic symmetrical, which is due to vascular spasm from
nerve-disorder ; senile, the dry gangrene of the aged ; venous
or static, which is due to obstruction of circulation, as in a
strangulated hernia; trophic, which is due to nutritive failure
by reason of disorder of the trophic nerves or centers ;
thrombotic, which is due to thrombus; embolic, which is due
to embolus ; and decubital gangrene, or bed-sores due to
pressure.

Dry or chronic gangrene, Pott'a ffangrene (Fig. 33), arises

from deficiency of arterial blood. Even in a person with
healthy arteries drj' gangrene may result from injury of the
main trunk of an artery (lodging of an embolus, ligation, or
laceration). Gangrene only follows injury when the anas-
tomotic circulation fails to sustain the part. Obstruction
due to thrombus is not unusual in the diseased arteries of
the aged. When an embolus lodges in an artery and causes
gangrene, the case runs the following course: sudden severe
pain at the seat of impaction, and also tenderness ; pulsation
above, but not below, this point ; the limb below the obstruc-
tion is blanched, cold, and ane.sthetic ; within forty-eight
hours, as a rule, the area of gangrene is widespread and
clearly evident; the limb becomes reddish, greenish, blue,

MORTIFICATION, GANGRENE^ OR SPHACELUS. 121

and then black ; the skin itself becomes shrivelled and its
outer layer stony or like horn because of evaporation. The
entire part may become as dry as a mummy, but usually
there are spots where some fluid remains, and these spots
are soft and moist, and the dead tissue where it joins the
living is sure to be moist. The moist areas become foul
and putrid, but the dry spots do not. At the point of con-
tact of the dead and living tissue inflammation arises in the
latter structure, a bright-red line forms, and exudation and
ulceration take place. This line of ulceration in the sound
tissues is called the " line of demarcation." It is Nature's
effort at amputation, and in time may get rid of a large por-
tion of a limb, and then heal as any other ulcer. In dry gan-
grene from arterial obstruction there are gastro-intestinal de-
rangement and some fever. The gangrene does not extepd
up to the point of obstruction, but only to a region in which
the anastomotic circulation is sufficiently active to permit of
the formation of a line of demarcation. Below this point in-
flammatory stasis arises, but before this can go on to ulcera-
tion the parts die. In cases where the arterial obstruction is
sudden and complete the limb may swell considerably. This
is due to the sudden loss of vis a tergo in the arterial system,
venous reflux occurring and fluids transuding. In such a
case, though the tissues contain some fluid and putrefy, the
process is pathologically dry gangrene. Dry gangrene at-
tacks the leg more often than the arm. Thrombus in an
artery rarely causes gangrene except in the aged, as the
circulation has time to adjust itself; but gangrene may fol-
low thrombus, and when it does it comes on more slowly
than does gangrene from embolus.

Senile grangrrene is a form of dry gangrene due to feeble
action of the heart plus obliterating endarteritis or atheroma
of peripheral vessels. The vessels do not properly carry
blood, and may at any time be occluded by thrombosis.
In a drunkard, or in a victim of syphilis or tubercle, the
changes supposed to characterize old age may appear while
a man is young in years. It was long ago said, with truth,
"a man is as old as his arteries." Senile gangrene most
often occurs in the toe or the foot.

Symptoms. — A man whose vessels are in the state above
indicated is generally in feeble health and has a fatty heart
and an arcus senilis (a red or white line of fatty degeneration
around the cornea). His feet feel cold and numb, and they
*' go to sleep " very easily. He is dyspeptic and short of
breath, and his urine is frequently albuminous. The arte-

122 MODERN SURGERY.

ries are felt as rigid tubes, like pipe-stems. He is in much
danger of edema of the lungs and of dry gangrene. A very
slight injury of a toe will produce extensive inflammatory
stasis, which completely cuts off the blood-supply and
causes gangrene of the part. Gangrene is usually an-
nounced by a blue spot, followed by a vesicle which lets
out bloody serum and has a dry floor. The tissues adja-
cent to the dead toe become victims to stasis and gangrene,
and the process ascends until it reaches tissue whose circu-
lation is suflidently good to permit of ulceration instead of
gangrene, when a line of demarcation forms. The dry parts
do not putrefy. They are anesthetic, hard, leathery, and
wrinkled, and resemble a varnished anatomical specimen or
the extremity of a mummy (hence the term mummification).
Before the line of demarcation forms there is some burning
pain ; after it forms pain is rarely present. If embohsm or
thrombus in a diseased vessel caused the gangrene, the pain
is severe. In senile gangrene the periphery is always dry,
the part nearer the body being generally somewhat moist
A line of demarcation may start, but prove abortive, the tis-
sue mortifying above it. This proves that tissue near the line
is in a state of low vitality. An entire leg may become gan-
grenous. When a limited area is gangrenous constitutional
symptoms are trivial or are absent, but when a large area is
involved we find the fever of septic absorption. Death may
ensue from exhaustion caused by sleeplessness and pain, fi-om
septic absorption, or from embolism of internal organs. In
many cases of senile gangrene thrombosis arises in the super-
ficial femoral artery or its branches (Heidenhain),an observa-
tion it is important to bear in mind when amputating.

Treatment of Dry Gangrene. — When injury of a healthy
artery causes us to fear dry gangrene the patient should be
placed in bed and the part elevated a little, kept wrapped up
in cotton-wool and warmed with hot bottles or water-bags.
The dying part is dressed antiseptically, and the surgeon sees
to it that the patient gets plenty of sleep and nourishment.
It is advisable to give tonics and stimulants. Wait for a line
of demarcation and amputate well above it. When on am-
putating no arterial blood flows, perform catheterism of the
artery with a filiform bougie or a fine rubber catheter. In-
sert the instrument into the artery, and work it up and
down to break up the clot. Bleeding will occur; wash
out the clot and then tic the vessel.' If a person is of the
tj'pe in which there is danger of senile gangrene, he should

* See Mancozel's report before second Pan-American Med. G>ngre8S.

MORTIFICATION, GANGRENE, OR SPHACELUS. 1 23

be cautioned against injuring his feet, especially cutting his
corns carelessly, which is highly dangerous; any wound,
however slight, requires rest and antiseptic dressing. He
must wear woollen stockings, put a hot-water bag to his
feet on cold nights, and attend to his general health. A
little whiskey after each meal is indicated, and occasional
courses of nitroglycerin are desirable.

When gangrene occurs, if it is limited to one toe or a por-
tion of several toes, if it is a first attack, if there is no fever
or exhausting diarrhea, if there is no tendency to pulmonary
congestion, if appetite is fair and sleep refreshing, we can await
the formation of a line of demarcation. While awaiting the
line of demarcation dress the part antiseptically and raise it
about two inches from the bed, apply warmth, give the patient
nourishing diet, stimulants, and tonics ; see to it that he sleeps,
and watch for fever, diarrhea, pulmonary congestion, and
kidney-failure. When a line forms, dress with antiseptic fo-
mentations and iodoform, and every day pick away dead bits
with the scissors and forceps. In many cases healing will
occur ; but even when the parts heal the patient will always
be in deadly peril of another attack. If the gangrene shows
a tendency to spread, if it involves more than a portion of
several toes, if it is not a first attack, if there is sleeplessness,
fever, exhausting diarrhea, absent appetite, or a strong ten-
dency to pulmonary congestion, do not delay, but at once am-
putate high up. If the gangrene shows no tendency to limit
itself, or if the patient develops sepsis or exhaustion, at once
amputate high up. The best point at which to amputate is
above the knee, so that the deep femoral artery, which rarely
becomes atheromatous, will nourish the flap. Never amputate
below the tubercle of the tibia. Some operators disarticulate
at the knee-joint. Heidenhain affirms that so long as the
gangrene is limited to one or two toes we should merely
treat it antiseptically, elevate the limb, and wait for the dead
part to be cast off spontaneously ; if, however, it extends to
the dorsum or sole of the foot, amputate at once above the
knee. He further states that gangrene of the flaps almost
always occurs in amputation below the knee, and high am-
putation is indicated in advancing gangrene with or without
fever.' When amputation has been performed and no arte-
rial bleeding occurs, clots exist in the femoral artery. If
such a condition exist, insert into the artery a fine rubber
sound and break up the clot. When blood runs the clot is
washed out (Severeanu).

' Deutsche medicinUche Wochemchrift^ 1891, p. 1087.

124

MODERN SURGERY.

In moist or acute gangrene (Fig. 54) the dead part re-
mains moist and putrefies. It results from interference with
venous return or capillar)' flow, as well as from arterial in-
gress. It may arise in a limb after ligation or destruction of
its main artery and vein, after long constriction, after crushes
and lacerated wounds, and after thrombosis of the vein.
Moist gangrene may follow acute inflammation, or may be

due to local constriction (strangulated hernia), crushing,
chemical irritants, heat, and cold.

Moist gangrene of a limb is seen tj'pically when both
vein and artery are damaged or destroyed. The leg swells
and is pulseless below the obstruction ; the skin becomes cold,
livid, and anesthetic, and is raised up into blebs which contain
serosanguincous fluid. The extremity swells enormously,
there i.s pain at the scat of obstruction, and sapremic symp-
toms quickly develop. The bulla; break and disclose the
deeper structures, which are swollen and edematous. The
fetor is horrible. Portions of the extremity become em-
physematous and crepitate on pressure. A line of demarca-
tion soon forms.

Moist gangrene from inflammation is due to pressure of
the exudate cutting ofl"the blood-supply, or to loss of blood-
circulation because of microbic involvement of vessels and
clotting of blood. It occurs in phlegmonous erysipelas.
When an inflammation is about to terminate in gangrene all
the signs of inflammation, local and constitutional, increase;
when gangrene occurs they cease, bulls and emphysema are
noted, with great swelling and all the other symptoms of
molar death. The sudden cessation of pain is very suggestive
of gangrene. The constitutional symptoms are those of sup-
purative fever and sapremia, or possibly of septic infection.

Treatment of Moist Gangrene. — In extensive moist gan-
grene of a limb wait for a line of demarcation, and amputate
clear of and above it. While waiting for the line to form
dress the dead parts antiseptically, wrap in cotton, apply
heat, and slightly elevate the limb. Give opium, tonics, nour-

MORTIFICATION, GANGRENE, OR SPHACELUS. 1 25

ishing food, and stimulants. In inflammatory gangrene re-
lieve tension by incisions and then cut away the dead parts,
brush the raw surface with pure carbolic acid, dust with
iodoform, and dress with hot antiseptic fomentations. Stim-
ulate freely and feed well.

Gangrene dne to infective organisms comprises — {\\
traumatic spreading gangrene; (2) hospital gangrene; (3)
phagedena; (4) noma vulvae; and (5) cancrum oris.

Fulminating gangrene, gangrenous emphysema, gan-
grene foudroyante, or traumatio spreading gangrene, re-
sults from a virulent infection of a severe wound by strepto-
cocci and oi^nisms of putrefaction. The injury damages
the main vessels of the limb, the pulse below the injury is
imperceptible, and the surgeon is often at this time uncertain
whether to amputate at once or wait This form of gangrene
is commonest after compound fractures, and begins within
forty-eight hours after the accident It does not begin at
the periphery, as does ordinary moist gangrene, but at the
wound-edges, which turn red, green, and finally black ; the
extremity soon undergoes a like change and becomes morti-
fied. The entire limb swells because of edema, the sldn peels
oflT, emphysema sets in, and the extremity becomes anesthetic
and pulpy. The gangrene spreads up and down from the
wound, and red lines run from above the wound. These
are due to lymphangitis, the adjacent lymph-glands swell,
and in thirty-six hours the gangrene may involve an entire
limb. No line of demarcation forms. The system is soon
overwhelmed with ptomalns, and the patient has septic in-
toxication, or he passes into profound collapse with subnor-
mal temperature. Traumatic spreading gangrene must not
be confused with erysipelas. In erysipelas the color is red,
pressure instantly drives it out, and on the release of pressure
it at once returns. In early gangrene the color is purple,
pressure fails to drive it out at all or only does so very slowly,
and if the surface is blanched by pressure, on the release of
pressure the color crawls slowly back.

Treatment — In treating traumatic spreading gangrene a
line of demarcation need not be waited for, as none can form.
Amputation should at once be performed high up, the flaps
are brushed with pure carbolic acid, and stimulants must be
given in large amount.

Hospital gangrene or sloughing phagedena is a disease
that has practically disappeared from civilized communities.
It formerly occurred in crowded, ill-ventilated hospitals. Some
consider it traumatic diphtheria. Koch thinks it is due to

126 MODERN SURGERY.

Streptococci. Jonathan Hutchinson says, " hospital gangrene
is set up by admitting to the wards a case of syphilitic phage-
dena." It may show itself as a diphtheritic condition of
a wound, as a process in which sloughs like masses of
tow form, or as a phagedenic ulceration. The surrounding
parts are inflamed and painful, and buboes form in adjacent
lymphatic glands. The system passes into a low septic
state.

Treatment. — In treating hospital gangrene ether should be
given, the large sloughs removed with scissors and forceps,
the part dried with cotton and cauterized with bromin. Take
a tumblerful of water and into it pour the bromin : this falls
to the bottom ; draw it up with a syringe and inject it into
the depths of the wound. The wound is plentifully sprinkled
with iodoform and is dressed with antiseptic poultices until
the sloughs separate, when the sore is treated as an ordinary
ulcer. Constitutional treatment is that of sepsis. If a limb is
hopelessly damaged by this form of gangrene, we must wait
for a line of demarcation and amputate.

Special Ponus of Gangfrene. — Symmetrioal or Ray-
naud's gangrrene arises in severe cases of Raynaud's disease.
It is a dry gangrene. Raynaud's disease, a vasomotor neu-
rosis seen in children and young adults, is characterized by
attacks of cold, dead bloodlessness in the Angers or toes as a
result of exposure to cold or of emotional excitement (local
syncope). In the more severe cases we may have capillary
congestion and livid swelling (local asphyxia). Chilblains
belong to this group. The patient complains of pain, ting-
ling, and stiffness. It is after local asphyxia that the gan-
grene may appear.

This gangrene is usually seen upon the ends of the fingers
or the toes, but it may attack the lobes of the ears, the tip of
the nose, or the skin of the arms or the legs. When gan-
grene is about to occur the local asphyxia at that point
deepens, anesthesia is complete, and the part blackens and
becomes cold. The epidermis is now raised up into blebs,
which rupture and expose dry surfaces. A line of demarca-
tions forms, and the necrosed area is removed as a slough.
Widespread gangrene from Raynaud's disease is rare ; there
is not often a large area involved — rather a small superficial
portion. Sometimes the disease is seen upon the trunk.
These attacks recur again and again, are often accompanied
by hemoglobinuria (Osier), and are sometimes excited by
cold or by mental disturbance. The pathology is uncertain.
Local syncope is thought to be due to vascular spasm, and

MORTIFICATION, GANGRENE, OR SPHACELUS. \2J

local asphyxia to some contraction of the arterioles with
dilatation of the capillaries and venules.

Treatment of Raynaud's Disease, — When attacks of Ray-
naud's disease are so severe as to threaten gangrene, the
patient should be put to bed ; if the feet are affected, elevate
the legs, wrap the extremity in cotton-wool, and apply heat.
If the hands are affected, they should be elevated, wrapped
up, and the arms and hands warmed. Massage is useful.
When gangrene occurs, dress the part antiseptically until a
line of demarcation forms, and then remove the dead parts
by scissors, forceps, and antiseptic poultices. If amputation
becomes necessary, which will rarely be the case, wait for
a line of demarcation.

Diabetic ganiprene resembles in many points senile gan-
grene, but the dead portions remain somewhat moist and
putrefy. Some attribute it directly to sugar in the blood.
Some think the tissues are simply less resistant to infection.
Many hold that it is of neurotic origin. Heidenhain be-
lieves that it is due to arterial sclerosis. Diabetic gangrene
is most usually met with upon the feet and legs of elderly
people, but it may arise at any age and may attack the gen-
ital organs, thigh, lung, buttock, eye, back, finger, or neck
(Hunt). It may show a single area, may show several areas,
or may be symmetrical. It may arise in any stage of dia-
betes from the earliest to the latest. It may begin as a per-
forating ulcer, and, as in senile gangrene, a trivial injury is
apt to be the exciting cause. It may arise without any ante-
cedent injury. When the gangrene follows a traumatism there
are no prodromic symptoms. When it arises spontaneously
in the skin it is oflen preceded by pain of a neuralgic nature
and attacks of '' livid or violaceous discoloration of the skin,
with lowered surface-temperature and sometimes loss of sen-
sation " (Elliot). This gangrene is often superficial, but may
become deep if it follows an injury or ulcer. The gan-
grenous area is somewhat moist as a rule, but may be dry.
The parts about are livid and may be covered with vesicles.
It spreads slowly, but more rapidly than senile gangrene.
There is little tendency to the formation of any line of de-
marcation, although occasionally spontaneous healing occurs.
Surgeons have become shy of amputating in such cases, but
the experience of Kuster, of Berlin, proves conclusively that
an amputation should be performed at once in diabetic gan-
grene, and should be done above the knee. If we operate
below the knee, the flaps will become gangrenous. It has
been noted that sugar will sometimes disappear from the

128 MODERN SURGERY.

urine after an amputation. Of 1 1 amputations by Kuster,
6 recovered and 5 died; and of these 5, 3 had albumin in
the urine as well as sugar.*

Heidenhain warmly advocates early high amputation, with
the making of short flaps. When the patient dies after ope-
ration he usually does so in coma. In any case after opera-
tion, or in any case not operated upon, treat the diabetes by
means of drugs and diet. Never fail to examine the urine
in every case of gangrene, for diabetes might be present
when it had not been suspected. Surgical operations upon
diabetes are, of course, very dangerous, and are only advised
in emergencies, because the wound is apt to slough and coma
may arise.

Gkuigrrene from ergrotlBm is a peripheral dry gangrene
arising from tonic vascular contraction produced by the ei^ot
in bread made from diseased rye. The gangrene is preceded
by anesthesia, muscular cramp, tingling pains, itching, and
" gradual blood-stasis in certain vascular areas " (Osier).
This form of gangrene occurs in epidemics where rye-bread
is largely used, but is very rare in the United States. It
usually affects the fingers or toes, but may involve an entire
limb, and can be symmetrical. In acute cases death occurs
in from seven to ten days.* In severe chronic cases await a
line of demarcation and then amputate. In superficial cases
dress with hot antiseptic fomentations and elevate the part,
and every day take scissors and forceps and remove the
loose crusts.

Gajigrrene from Frost-bite. — When parts have been badly
frozen the peripheral portions dry up. The parts are deprived
of all blood because of contraction of the vessels and because
plasma coagulates at a few degrees above freezing. Cold
disorganizes the blood, breaking up white corpuscles with
the liberation of fibrin-ferment and the subsequent coagula-
tion of plasma, and destroying red corpuscles with the libe-
ration of hemoglobin. When a patient so afflicted is brought
into a warm atmosphere, blood cannot run into the dead
part, and the living tissues in contact with it inflame, form-
ing a line of demarcation. Hence we note that severe fro.st-
bite causes dry gangrene. If a part which is not so badly
frozen is brought suddenly into a warm atmosphere, inflam-
mation takes place when the blood runs into the frosted
tissues' and moist gangrene results. A frost-bite in which
the skin is livid and not as yet gangrenous should be treated

*^ See the convincing article of Chas. A. Flowers in A mer. Journal of Med,
Sciences^ Nov. ii, 1892. * Pick, in Heath's Surgical Dictionary,

MORTIFICATION, GANGRENE, OR SPHACELUS. 129

by frictions with snow or towels soaked in iced water. As
the skin becomes warmer and congestion disappears the
part should be wrapped in cotton-wool. A sufferer from
frost-bite should not suddenly be brought into a warm room.
When gangrene follows, if only small areas be involved, al-
low the dead part to come away spontaneously, applying in
the meanwhile hot antiseptic fomentations. If separation be
delayed by cartilage, ligament, or bone, cut through the re-
taining structure. If amputation becomes necessary, await
a line of demarcation, as we are not sure how high tissue-
damage extends, and to amputate through devitalized parts
would mean renewed gangrene.

Noma, or cancrum oris, is a gangrene beginning as a
sloughing ulcer on the gums or cheeks, and affecting young
children who live amid filth and squalor or who are conva-
lescing from acute fevers. This disease may destroy large
portions of the cheeks and jaws. The constitutional symp-
toms are diarrhea, fever, and great exhaustion. Death is
the usual result, due frequently to septic bronchopneumonia
(Bowlby). Lingard has found a bacillus which he believes
is causative of noma, but most observers consider pus organ-
isms as causative.

The treatment of noma consists in destruction of the dis-
eased tissue by nitric acid or the actual cautery, the use, lo-
cally and often, of peroxid of hydrogen and antiseptic washes,
and, internally, the employment of nutritious food, stimulants,
and tonics. After arrest of the gangrene a plastic operation
may be required.

Sloug^mng^ is a process of ulceration by which visible
portions of dead tissue are separated. These visible portions
are called " sloughs ;" if they were large, they would be
called " gangrenous masses." A large slough is a gangre-
nous mass ; a small gangrenous mass is a slough ; there is
no difference in the process, which corresponds to the forma-
tion of a line of demarcation. Sloughing requires thorough
cleansing, removal of the sloughs, and antiseptic treatment.
Antiseptic fomentations are applied until granulation is well
advanced.

Phag^edena is a process (most common in a venereal
sore) in which the surrounding tissues are rapidly eaten up,
the sore becoming jagged and irregular, with a sloughy base
and thin edges ; the discharge becoming thin and reddish,
and the encircling tissues becoming deeply congested. This
ulcer has no tendency to heal. It is due to a specific poison
which has not yet been isolated. Noma vulvce is a form of

J30 MODERN SURGERY,

phagedena which attacks the genitals of littie girls who are
unhealthy, dirty, or convalescent from a specific fever.

The treatment of phasredena consists in repeated touch-
ing with tincture of chlorid of iron and the local use of
iodoform, the employment of continued irrigation, or the
application of the cautery, chemical or actual. The parts
are dressed with hot antiseptic fomentation. Whatever else
is done, tonics, stimulants, and nutritious diet must be given.

Decubital Gangrene, or Bed-sore.— A bed-sore is the
result of local failure of nutrition in a person whose tissues
are in a state of low vitality from disease or from injury.
Such sores are due to pressure, aided it may be by the pres-
ence of urine, of feces, and of sweat, by wrinkling of the
sheets, or the dropping of foreign bodies (such as crumbs)
in the bed. These ordinary pressure-sores arise like splint-
sores due to the pressure of a splint upon the tissues over a
bony prominence. They occur over the heels, elbows,
scapulae, trochanters, sacrum, and nucha. The pressure in-
terferes with the blood-supply, the weakened tissues inflame,
vesication occurs, sloughs form, and an ugly ulcer is ex-
posed.

The acute bed-sore of Charcot is seen during certain dis-
eases and after some injuries of the nervous system. These
sores are usual over the sacrum in acute myelitis, and may
appear in four or five days after the beginning of a disea.se
or the infliction of an injury. The surgeon sees acute bed-
sores upon the buttock of the paralyzed side after brain-
injuries, and over the sacrum in spinal injuries. Some believe
these sores are due to vasomotor disorder, but others, notably
Charcot, attribute them to disturbance of the trophic nerves
or centres.

Treatment of Bed-sores. — The " ounce of prevention "
is here invaluable. From time to time, if possible, alter the
position of the patient, keep him clean, maintain the blood-
distribution of the skin by frequent rubbing with alcohol
and a towel, and keep the sheet clean and smooth. When
congestion appears (paratrimma, or beginning sore), at once
use an air-cushion or a water-bed and redouble the care to
frequently change the position of the patient. Not only
protect, but also harden, the skin. Wash the part twice
daily and apply spirits of camphor or glycerole of tannin ;
or rub with salt and whiskey (sij to Oj) ; or apply a mixture
of 5ss of powdered alum, f^ij of tincture of camphor, and
the whites of four eggs ; or paint with corrosive sublimate
and alcohol (gr. ij to 5j) ; or apply tannate of lead or equal

MORTIFICATION, GANGRENE, OR SPHACELUS. I3I

parts of oil of copaiba and castor oil ; or paint on a protective
coat of flexible collodion.

When the skin seems on the verge of breaking, paint it
with a solution of nitrate of silver (gr. xx to %), When
the skin breaks, a good plan of treatment is to touch once
a day with silver solution (gr. x to 5j) and cover with zinc-
ichthyol gelatin. We can wash the sores daily with i : 2000
corrosive-sublimate solution, dust with iodoform, and cover
with soap plaster, with lint spread with zinc ointment, or with
dry aseptic gauze. When sloughs form, cut most of them
off with scissors after cleaning the parts, slit up sinuses, and
use antiseptic poultices. In sloughing Dupuytren employed
pieces of lint wet with lime-juice and dusted the sore with
cinchona and charcoal. In obstinate cases use the contin-
uous hot bath or the intermittent ice poultice. When the
sloughs separate, dress antiseptically or with equal parts of
resin cerate and balsam of Peru. If healing is slow, touch
occasionally with silver solution (gr. x to 5j). Bed-sores,
being expressive of lowered vitality, demand that the pa-
tient shall be stimulated, shall be well nourished, and shall
sleep soundly.

Postfebrile (rangrene. — Dry or moist gangrene may
follow any fever, but is most frequent after typhoid (may
follow influenza, measles, scarlet fever, etc.). Keen, in the
Toner lecture for 1876, collected 113 cases of postfebrile
gangrene, and 43 of these were due to typhoid. It is most
usual in the lower extremities, but may appear in the upper
extremities, cheeks, ears, nose, genitals, lungs, etc. Some
writers have assigned as the cause weakness of cardiac
action, but most observers believe an obstructing clot is the
usual cause. This clot is secondary to endarteritis due to
toxins of the typhoid bacillus.^ It most often appears in the
third week, but may arise far into convalescence. Treatment
presents nothing exceptional. If an extremity is extensively
involved, await a line of demarcation before amputating.

Rtiles when to Ampntate for Gangrene. — In dry

gangrene, due to obstruction of a non-diseased artery, wait
for a line of demarcation. In senile gangrene, if it affect
only one or two toes, let the dead parts be cast off sponta-
neously. If a greater area is involved or the process
spreads, amputate above the knee without waiting for the
line. In ordinary moist gangrene wait for a line of demar-
cation. In traumatic spreading gangrene amputate at once.
In hospital gangrene and in Raynaud's gangrene wait for a

^ Mettler, in New York Med. Jour. ^ March 9, 1895.

132 MODERN SURGERY.

line of demarcation. In diabetic gangrene amputate at once,
high up. In ergot gangrene, in postfebrile gangrene, and in
frost gangrene wait for a line of demarcation.

IX. THROMBOSIS AND EMBOLISM.

Thrombosis is the antemortem coagulation of blood in
the heart or in a vessel, the coagulum remaining at its point
of origin and plugging up the vessel partially or completely.
This process is an essential part in the arrest of hemor-
rhage ; it occurs in phlebitis and arte-
ritis, and affords a frequent basis for
embolism. Thrombi may form in the
veins, in the arteries, and in the heart
Clotting is due to destruction of white
blood-cells, fibrin-ferment being set free,
causing the union of calcium and fibrin-
ogen and thus forming fibrin. Throm-
bosis is more common in the veins than
in the arteries, the slow blood-current
and the existence of valves favoring the
deposit, though not causing it. Fig. 35
shows thrombosis.

Causes of Thrombus. — The essential
' !apiiln7u's'«'in'('Gr«'njr causc of all intravascular thrombi is
damage to the endothelial coat, though
many other conditions favor their formation. Among these
favoring conditions are retarded circulation in tuberculosis,
influenza, and fevers, the blood clotting behind the vein-
valve.i after the endothelium has been damaged by toxins ;
or the pressure of a bandage or of a .splint ; varicose veins ;
ligation of a vessel ; injuries of a vessel ; foreign bodies in a
vessel ; atheroma in arteries ; sutures in a ve.isel ; certain dis-
eases, such as gout, typhoid fever, pregnancy, and septic
processes; phlebitis or arteritis arising in the vessel or from
extension of surrounding inflammation ; and entrance of spe-
cific organisms.

It has been asserted that so long as the endothelium of a
vessel is uninjured a clot does not form. Slowing of the
blood-current in aseptic conditions, it is now taught, will
not cause thrombosis. One of the functions of the endo-
thelial coat is to keep the blood fluid by preventing corpus-
cular disintegration. A thrombus can form only when fibrin-
ferment is set free, and fibrin-ferment can be set free only
when white corpuscles disintegrate. When moving blood

THROMBOSIS AND EMBOLISM. 1 33

coagulates, the third corpuscles first settle out, and then the
leukocytes. This is known as the white or ** antemortem "
thrombus — the clot of moving blood. Thrombi from mov-
ing blood are rarely pure white : they contain some red cor-
puscles, forming mixed thrombi. The red thrombus plugs
vessels which are cut across or ligated ; it also occurs in sep-
tic processes, and is formed after death. A thrombus may
be absorbed, first embryonic tissue and then fibrous tissue re-
placing it (organization). A thrombus may degenerate and
break down (fatty degeneration), giving rise to emboli. A
thrombus may calcify or may undergo purulent liquefaction,
infective emboli being set free. A thrombus in an artery
is apt to extend to the first collateral branch, but does not
pass higher. The blood-current into the branch prevents
further extension. Remember this fact when an artery is
cut near a large branch. If we simply tie the artery, such a
short clot will be formed that the vessel will not be oblit-
erated. Tie not only the artery, but also the branch. A
clot in a vein may extend a long distance. The author has
seen in a postmortem examination a venous thrombus reach-
ing from the ankle to the vena cava.

Symptoms. — The symptoms are dependent on the seat
of the obstruction. An organ or a part of an organ may
exhibit functional aberration. The local signs in a vessel
accessible to touch or sight are the presence of a clot ; if it
be an artery, anemia and the absence of pulse below the
clot.; if if be a vein, swelling and edema below it. There is
usually pain at the seat of trouble, and anesthesia below it.
Moist gangrene may follow venous thrombosis, and dry gan-
grene arterial thrombosis. Thrombophlebitis is inflammation
of a vein in which a septic thrombus forms. We see this
condition sometimes in the lateral sinus of the brain as a
result of suppuration in the middle ear; in any of the cere-
bral sinuses after compound fracture of the skull ; and in the
uterine veins in puerperal sepsis. It is the first step in pye-
mia. Thrombo-arteritis is inflammation of an artery in which
a septic thrombus forms or in which a septic embolus lodges.
It occasionally attacks an aneurysmal sac.

Treatment. — If in a limb, raise the limb a few inches from
the bed, keep it perfectly quiet to avoid detachment of frag-
ments (emboli), paint with iodin or rub with ichthyol, apply
a bandage from the toes up, and place hot bottles around
the extremity. The great danger is the formation of emboli,
so avoid movements and rough handling. In thrombophle-
bitis, if the vessel is accessible, tie it above and below the

134 MODERN SURGERY.

clot, open the vessel, remove the clot, irrigate, and pack with
iodoform gauze. Internally the treatment is stimulant and
supporting. Massage is unsafe. In thrombo-arteritis treat
as in thrombophlebitis.

]Smbolisiii signifies vascular plugging by a foreign body
(usually a blood-clot) which has been brought from a dis-
tance. Emboli may arise either in the venous or in the
arterial system, but lodge only in an artery or in the veins
of the liver. The initial thrombus may form upon diseased
heart-valves or in a vein. It may be composed of fat, mi-
cro-organisms, air, or a portion of a tumor. An embolus is
arrested when it reaches a vessel whose diameter is less than
its own. It is usually caught just above a bifurcation.
When an embolus lodges, it at once partially or entirely
obstructs the circulation, and increases in size by throm-
bosis. A non-septic embolus usually organizes. A soft

embolus may disintegrate and permit
of re-establishment of the circulation.
An embolus may cause an aneurysm.
A septic embolus breaks down, forms
a metastatic abscess, and sends other
emboli onward. Fig. 36 shows an
impacted embolus.

An embolus is more serious than a
thrombus : it causes sudden plugging
which makes dangerous anemia inevit-
able, and it may produce gangrene if
Fig. 36 -Embolus impacted the Collateral circulation fails. In

at bifurcation of a branch of the . • / t

pulmonary artery (Green). OrganS With tcrmmal artCHCS (splcen,

kidney, brain, and lung) there is no
collateral circulation and embolism causes infarction. The
embolus produces an area of anemia; the removal of all
propulsion upon the venous blood causes it to flow back
and stagnate, and vascular elements exude, forming a wedge-
shaped area of red tissue, the embolus being the apex of
the wedge. This is known as the " red infarction," and is
often seen in the lung. The white infarction seen- in the
brain and kidney is not due to retrogression of venous blood,
but is due to anemia and resulting coagulation-necrosis. A
septic embolus causes septic arteritis and a septic infarction,
and a septic infarction suppurates and forms a pyemic
abscess.

Symptoms. — The symptoms depend upon the organ in-
volved. They arc sudden in onset, and consist of loss of
function which may be permanent or which may be followed

THROMBOSIS AND EMBOLISM, 1 35

by inflammation or softening. Embolism of the cerebral
arteries may cause aphasia, paralysis, or coma. Embolism
of the pulmonary artery may cause almost instant death.
Embolism of the central artery of the retina causes blindness.
Embolism of a large artery of a limb produces symptoms
identical with thrombus, except more sudden and decided.

Treatment. — The treatment of aseptic embolism depends
upon the part involved. In a limb, keep the part warm in
order to stimulate the collateral circulation, elevate several
inches from the bed, and insist on perfect quiet. Massage
is unsafe. If gangrene ensues, await a line of demarcation
and amputate. In septic arteritis in an accessible region it
would be good surgery to act as in thrombo-arteritis from
thrombosis. Unfortunately, such a condition is not often in
an accessible region. After an operation upon veins (as the
operation for varicocele or for hemorrhoids), after a cutting
operation, and after fracture, avoid as much as possible move-
ments or handling, as fragments of thrombus may be de-
tached. Operations upon the rectum may be followed by
hepatic embolism and abscess of the liver.

Pat-embolism is an accumulation in the capillaries of
liquid fat after injuries of adipose tissue, high tension forcing
the fat into the open mouths of veins. Some litUe fat may
get into the blood by means of the lymphatics. Fat-em-
bolism occasionally arises in osteomyelitis, after extensive
bruises, crushes, or lacerations, and after amputations, frac-
tures, resections, or rupture of the liver.* This fluid fat ac-
cumulates especially in the capillaries of the lung and brain.

Symptoms. — ^The symptoms are those of edema of the
lungs and exhaustion, often with coma or delirium. There
are restlessness, dyspnea, rapid pulse and respiration, and low
temperature. If life is prolonged a day or two, oil is found
in the urine. Small amounts of oil may be found in the urine
after serious injuries or operations when no symptoms of
embolism exist. Nevertheless, the presence of the oil is
always an ominous sign, and is often a warning. These
symptoms never occur until at least twenty-four hours after
the accident, and rarely before the third day. The symptoms
occur at a later period than those of shock, and at an earlier
period than those of ordinary embolism of the lung. Severe
cases are commonly fatal ; milder cases are often recovered
from.

Treatment. — ^The treatment consists of the ordinary meth-
ods used in shock — stimulants, heat, etc., with dry cupping

^ G. H. Makins, in Heath's Dictiofiary.

136 MODERN SURGERY,

of the chest, the use of diuretics, strychnin, digitalis, and, it
may be, artificial respiration. See that drainage of the wound
is free, if an external wound exists, and thoroughly immobil-
ize the damaged part. In order to prevent fat-embolism after
a severe injury insist on rest. Massage used early after some
injuries is dangerous, as it may force fluid-fat into the vessels.
When a severe contusion gives rise to a large cavity filled
with blood Groube advises incision, to lessen the danger of
fat-embolism.^

X. SEPTICEMIA AND PYEMIA.

Septiceinia, or sepsis, is a febrile malady due to the in-
troduction into the blood of septic organisms or their prod-
ucts. There is no one special causative organism, and any
microbe which produces inflammatory and febrile products
may cause it. Either streptococci or staphylococci may be
present. Septicemia arises by absorption of septic matter by
the lymphatics. Clinically we make two forms of septicemia :
(i) sapremia, septic or putrid intoxication ; and (2) septic in-
fection, true or progressive septicemia. In these conditions
the area of infection is usually discovered by the surgeon,
but when it is not located the case is called by the Germans
cryptogenetic septicemia.

Sapremia, or septic intoxication, is due to the absorp-
tion of poisonous ptomains from a putrefying area. The bac-
teria rarely enter the blood, but their toxins do, and, as these
toxins arc active poisons, the condition is comparable to
poisoning by successive alkaloidal injections, the symptoms
and prognosis depending upon the dose. Even if some of
the organisms enter the blood, they do not multiply in this
fluid. Slight symptoms and recovery follow a small dose;
grave symptoms and death follow a large one. The poison
does not multiply in the blood, and a drop of the blood of a
person laboring under putrid intoxication will not produce
the disease when introduced into the blood of a well person ;
in other words, the disease is not infective. Sapremia results
from the absorption of putrid matter from considerable areas
which are under high pressure. It may follow labor where
putrid fluid is retained in the womb, or follow amputation
where decomposing blood-clot or wound-fluid is pent up
within the flaps. In this condition there always exist a con-
siderable absorbing surface and a large amount of dead mat-
ter which has become putrid. Roswell Park points out' that

* R€Z>. lie Chir.s July, 1 895.

* Treatise on Surgery by Ameiican Authors.

SEPTICEMIA AND PYEMIA. 1 37

sapremia arises from putrefaction of a blood-clot or from
wound-fluids which are retained like foreign bodies in the
tissues, and does not arise from putrefaction of the tissues
themselves. He speaks of the condition as due to the ab-
sorption of poison from a ** putrid suppository." We use
the term putrefaction because this is the usual change, but
any fermentative organism may cause the disorder. Sapre-
mia is a malignant form of surgical fever, and its existence
means an ill-drained wound, and a fermenting and probably
putrid collection of blood-clot or wound-fluid.

Symptofns. — In twenty-four hours or more after labor,
after an injury, or after an operation, there is a chill followed
by high temperature, gastric disturbance, dry tongue, weak,
rapid pulse, great prostration, muscular twitching, restless-
ness, headache, often delirium, diarrhea, foulness of wound,
often drying up of wound-discharge, diminution or suppres-
sion of urine, and a strong tendency to congestion of various
organs. Blood-examination shows leukocytosis. Great ele-
vation of temperature precedes death.

Treatment, — The treatment is to at once drain and asep-
ticize the putrid area and give enormous doses of alcohol.
Strychnin and digitalis are useful. Purge the patient, and
favor diaphoresis, using in some cases the hot bath. Estab-
lish the action of the kidneys ; allay vomiting by champagne,
cracked ice, calomel, cocain, or carbolic acid with bismuth.
Give food every three hours. Feed on milk, milk and lime-
water, liquid beef-peptonoids, and other concentrated foods.
Use quinin in stimulant doses. Antipyretics are useless.
Watch for any visceral congestion, and treat it at once. The
use of saline fluid by hypodermoclysis or venous transfusion
dilutes the poison and stimulates the heart, skin, and kidneys
to activity.

Beptic infection, or true septicemia, is a true infective
process. In sapremia the blood contains toxins of fermenta-
tive organisms, but not the organisms themselves. In septic
infection the blood contains both pyogenic toxins and multi-
plying pyogenic organisms. In sapremia the causative con-
dition is putrid material lodged like a foreign body in the
tissues. In septic infection the tissues themselves are suppu-
rating, and both bacteria and toxins are being absorbed by
the lymphatics. Of course, septic infection may be associated
with septic intoxication or may follow it. In suppurative fever
the tissues suppurate, but only the pyogenic toxins are ab-
sorbed, and not the pyogenic organisms. In septic infection
both the pyogenic bacteria and toxins enter the blood, and

138 MODERN SURGERY,

the bacteria multiply in the blood and produce continually
increasing amounts of poison. The symptoms of sapremia
depend on the dose. In septic infection only a small number
of organisms may get into the blood, but they multiply enor-
mously. The pus microbes cause true septicemia, and reach
the blood chiefly through the lymphatics, but to some degree
by penetrating the walls of vessels. A drop of blood from a
man with septic infection will reproduce the disease when in-
jected into the blood of an animal ; hence it is a true infective
disease. The wound in such cases is often small, and is
commonly punctured or lacerated.

Symptoms, — The type of this condition is met with in
puerperal septicemia or in an infected wound. It begins, in
from four to seven days after labor or an injury, with a chill,
which is followed by fever, at first moderate, but soon be-
coming high. The fever presents morning remissions and
evening exacerbations, and may occasionally show an inter-
mission. When the remission begins there is a copious
sweat. The pulse is small, weak, very frequent, and com-
pressible. The tongue is dry and brown with a red tip.
The vomiting is frequent, and diarrhea is the rule. Delirium
alternates with stupor, and coma is usual before death.
Prostration is very great. Toward the end the face often
becomes Hippocratic. Visceral congestions occur. The
spleen is enlarged, ecchymoses and petechiae are noted,
secretions dry up, urinary secretion is scanty or is sup-
pressed, and the wound becomes dry and brown. Blood-
examination detects disintegration of red globules, and
marked leukocytosis. When a wound inaugurates septi-
cemia, red lines of lymphangitis are seen about it and there
is enlargement of related lymphatic glands. No thrombi
or emboli exist in septicemia. The prognosis is bad, and
in some malignant cases death occurs within twenty-four
hours.

The treatment is the same as for septic intoxication. An-
tistreptococcic serum is employed by some surgeons, but the
value of this method is as yet doubtful.

Pyemia. — Pyemia is a condition in which metastatic ab-
scesses arise as a result of the existence of septic thrombo-
phlebitis, the disease being characterized by fever of an in-
termittent type and by recurring chills. It is not actually
due to free pus in the blood, but to the passage into the
blood of clots infected by streptococci and staphylococci.
If an area of infection leads to thrombophlebitis, lymphatic
absorption of toxins or organisms is apt to be occurring at

SEPTICEMIA AND PYEMIA, 1 39

the same time. Hence in many cases septicemia exists with
pyemia.

In an area of suppuration there are coagulation-necrosis,
thrombosis, and septic inflammation of the adjacent vessels,
and the thrombi are infected. A vessel-thrombus runs up
in the lumen of a vein, and the apex of the purulent clot
softens, a portion of it is broken off by the blood-stream and
carried as an embolus into the circulation. Many of these
poisonous emboli enter into the blood and lodge in some
vessels which are too small to transmit them, and at their
points of lodgement form embolic, secondary, or metastatic
abscesses. Wounds of the superficial parts and bones pro-
duce pyemic infarctions and metastatic abscesses of the lungs.
When these infarctions break into fragments particles may
return to the heart and lodge, or may be sent out through
the arterial .system to form other foci in distant organs. In-
fected areas connected with the portal circulation (intestinal
injuries or suppurating piles) produce abscess of the liver.
Malignant endocarditis is called " arterial pyemia," and is
due to endocardial embolic infection. In this disorder in-
fected emboli lodge in the kidneys, the spleen, the alimen-
tary tract, the brain, or the skin (Osier). Idiopathic pyemia
is a misnomer. Some primary focus of infection must exist
(often in the middle ear).

SymptomB. — The wound becomes dry, brown, and offen-
sive. A severe and prolonged chill or a succession of chills
ushers in the disease; high fever follows, and drenching
sweats occur. The chills recur every other day, every day,
or oftener. After the sweat the temperature falls and may
become nearly normal. The temperature often oscillates
violently. The general symptoms of vomiting, wasting, etc.,
resemble those of septicemia. In some cases the mind
remains clear, in many the delirium is purely nocturnal.
The skin becomes jaundiced, and a profound adynamic
state is rapidly established. The blood shows disintegra-
tion of red corpuscles and leukocytosis. The spleen is
enlarged. The lodgement of emboli produces symptoms
whose nature depends upon the organ involved. Lodge-
ment in the lungs causes shortness of breath and cough,
with slight physical signs. Lodgement in the pleura or peri-
cardium gives pronounced physical evidence. Lodgement in
the spleen produces severe pain and great enlargement. The
parotid gland not unusually suppurates (as in the case of
President Garfield).

In a suspected case of pyemia always look for a wound.

I40 MODERN SURGERY.

and if this does not exist, remember that the infection may
arise from gonorrhea, osteomyelitis, suppuration in the
middle ear, or abscess of the prostate. Chronic pyemia
may last for months ; acute pyemia may prove fatal in three
days. The complications are joint-suppuration, broncho-
pneumonia, pleuritis, endocarditis, pericarditis, peritonitis,
pyelitis, venous thrombosis, and abscesses.

Treatment is the same as for septicemia. Open, drain, and
asepticize any wound and any accessible secondary abscess.

XI. ERYSIPELAS (ST. ANTHONY'S FIRE).

Hrysipelas is an acute, contagious, spreading capillary
lymphangitis due to the streptococcus of erysipelas, which
grows and multiplies in the smaller lymph-channels of the
skin and its subcutaneous cellular layers and of serous and
mucous membranes. The disease is characterized by a rap-
idly spreading dermatitis, by a remittent fever due to ab-
sorption of toxins, and by a tendency to recur. It is al-
ways due to a wound. Idiopathic erysipelas is due to a
small wound which escapes notice. The involved area may
or may not suppurate. Suppuration, some say, does not
require a mixed infection, as the streptococcus is identical
with the streptococcus pyogenics (Osier, Koch) ; others think
suppuration does require mixed infection, as they believe
the streptococcus is not pyogenic. Erysipelas is most
common in the spring and fall, and is most usually met
with among those who are crowded into dark, dirty, and
ill-ventilated quarters ; it attacks by preference the debilitated
and broken-down (as alcoholics and sufferers from Bright's
disease). The disease may become endemic in special places
or localities. The poison of erysipelas will produce puer-
peral fever in a lying-in woman. The streptococcus was
first obtained in pure cultures by Fehleisen (Tillmann's
Pi'inciples of Surgery). This organism is widely diffused.
The question of identity with the streptococcus pyogenes
is discussed on p. 38.

Forms of Erysipelas. — Ambulant, erratic, migratory, or
zuandering erysipelas is a form which tends to spread wide-
ly over the body, leaving one part and going to another.
Bullous er>'sipelas is attended by the formation of bullae.
In diffused er>'sipelas the borders of the inflammation grad-
ually merge into healthy skin. Erythematous erysipelas
involves the skin superficially. Metastatic cr>'sipelas appears
in various parts of the body. Puerpei-al er>'sipelas begins

ERYSIPELAS. I4I

in the genitals of lying-in women, producing puerperal
fever. Erysipelas simplex is the ordinary cutaneous form.
Erysipelas neonatorum begins in the unhealed navel of a
newborn child and spreads from this point. Typhoid try-
sipelas occurs with profound adynamia. Universal erysip-
elas involves the entire body. Cellulitis is erysipelas of the
subcutaneous layers. Phlegmonous erysipelas involves the
skin and subcutaneous tissues, and causes suppuration, and
often gangrene. Edematous erysipelas is a variety of phleg-
monous erysipelas with enormous subcutaneous edema.
Lymphatic erysipelas is characterized by rose-red lines of
lymphangitis. Venous erysipelas is marked by the dark
color of venous congestion. Mticous erysipelas involves a
mucous membrane. Erysipelas may attack the fauces, pro-
ducing a very grave condition.

Clinical Forms. — The clinical forms are cutaneous erysip-
elas, cellulocutaneous or phlegmonous, cellulitis, and mucous
er>'sipelas.

Cutaneous erysipelas most frequently attacks the face.
A fever suddenly appears, rises rapidly, reaches a consider-
able height, and at the time of febrile onset spots of redness
appear on the skin. These spots run together, and a large
extent of surface is found to be red and a little elevated.
Any wound, ulcer, or abrasion which exists becomes dry
and unhealthy, and its edges redden and swell. This com-
bination of redness and swelling extends, and its area is
sharply defined from the healthy skin. The color fades at
once on pressure and returns at once when pressure is
removed. In the hyperemic area vesicles or bullae form,
containing first serum and later it may be sero-pus. Edema
affects the subcutaneous tissues, producing great swelling in
regions where they are lax (as in the eyelids). The anatom-
ically related lymphatic glands become large and tender, and
between them and a wound are often seen the red lines of
inflamed lymphatic vessels. In an ordinarily strong person
the color is bright red or more rarely dark red. A dusky
color precedes suppuration. A blue color precedes gan-
grene or indicates profound cardiac and pulmonary involve-
ment. There is slight burning pain in erysipelas which is
increased by pressure. Erysipelas spreads at its periphery
and fades at its point of origin. It spreads now in one direc-
tion, now in another, influenced, according to Pfleger, by the
furrows of the skin. When spreading stops the swelling
and redness gradually abate, and after they disappear des-
quamation takes place, and the blebs become dry and

142 MODERN SURGERY,

crusted. Cutaneous erysipelas rarely suppurates, but may
do so. The fever is remittent, and usually terminates in
four or five days by crisis.

In strong subjects the symptoms are usually slight. In
the old or debilitated the symptoms are typhoid, delirium
comes on, and death is usual. Possible complications are
meningitis, pneumonia, septicemia, pleuritis, pyemia, endo-
carditis, and albuminuria. Erysipelas neonatorum is gen-
erally fatal. In some instances an attack of erysipelas will
cure an old skin eruption, a new growth, an ulcer, or an area
of lupus. This is the erysipele salutaire of our French
confreres (p. 230).

Treatment, — Isolate the patient, asepticize any wound, and
give a purge. Cases of cutaneous erysipelas tend to get
well without treatment. If a person is debilitated, stimu-
late freely. Tincture of chlorid of iron and quinin are
usually administered. Nutritious food is important. For
sleeplessness or delirium use chloral or the bromids; for
hign temperature, cold sponging and antipyretics. To pre-
vent spreading some have advised injection of the healthy
skin near the blush with a 2 per cent, carbolic solution or
with gr. ^ of corrosive sublimate. Locally, paint the in-
flamed area with equal parts of iodin and alcohol and apply
lead-water and laudanum. If an extremity be involved,
bandage it. Another good application is a 50 per cent, ich-
thyol ointment with lanolin. A very useful method is Von
Nussbaum's. The author applies it somewhat modified, as
follows : wash with ethereal soap, irrigate with a solution of
corrosive sublimate (i : 1 000), dry with a sterile towel, apply
an ointment of ichthyol and lanolin (50 per cent), and dress
with antiseptic gauze. Some use iced-water cloths and some
prefer hot fomentations. Others apply borated talc or sali-
cylated starch. Ringer advised painting every three hours
with a mixture composed of gr. xxx of tannic acid, gr. xxx
of camphor, and .^iv of ether. J. M. Da Costa recommends
pilocarpin internally in the beginning of a case. Antistrepto-
coccic serum has been used in erysipelas, and great results
have been claimed for it. Roger and Charrin's serum may
be used. The dose is 30 c.cm. It is asserted that under its
influence the temperature soon becomes normal. We have
had no personal experience with the serum treatment.

CellulocutaneouB or phlegrmonous erysipelas is charac-
terized by high temperature (i04°-io6°), the rapid onset of
grave prostration, irregular chills, sweats, and a strong ten-
dency to delirium. The parts are not so red as in the pre-

ERYSIPELAS, 1 43

ceding form, but the tumefaction is vastly greater; it is
brawny, comes on early and with exceeding rapidity, induc-
ing a high degree of tension and frequently producing slough-
ing or even cutaneous gangrene. The lymphatic glands are
swollen, but the inflamed lymphatic vessels are hidden by
the tumefaction. In most cases suppuration occurs, and
when this happens the parts become boggy. When the
disease abates sloughs form, which leave ulcers upon being
thrown off. In bad cases muscles, vessels, tendons, and
fascia may slough away. The commonest complications are
suppression of urine, bronchopneumonia, congestion and
edema of the lungs, meningitis, congestion, of the kidneys,
and acute pleurisy. We see this form of erysipelas some-
times after extravasation of urine. It is not a pure strepto-
coccus infection. There is a mixed infection with other pyo-
genic cocci, and often with organisms of putrefaction.

Trcatfnent. — At once asepticize and drain any existing
wound ; apply iodin to the inflamed area and cover it with
lint wet with lead-water and laudanum, and if a limb is in-
volved use a roller-bandage and a sling. Instead of iodin
and lead water, ichthyol may be applied. Open the bowels
with calomel and salines ; order quinin, iron, stimulants, and
nourishing diet. If suppuration occurs, make many incisions
near together, each cut being 2 or 3 inches long. Spray out
by means of hydrogen peroxid in an atomizer, and then
wash with corrosive-sublimate solution (i : 1000). Drain by
means of iodoform gauze in strips. Excise spots of gan-
grene. Dress with many layers of gauze wet with a hot
solution of corrosive sublimate and covered with a rubber-
dam; a hot-water bag being laid upon the dressing. If
sloughs form, cut them partly away and employ antiseptic
poultices. Change dressings often. Antistreptococcic serum
is employed by some. In severe cases employ hypodermo-
clysis or saline transfusion. When granulations begin to
form, treat as a healing wound.

Cellulitis. — In cellulitis redness of the skin is not very
pronounced and is late in appearing, following swelling, and
not preceding it. It is essentially the same condition as
phlegmonous erysipelas, but is often mild in degree. Its
spread is heralded by red lines of lymphangitis ascending
from an infected wound, swelling of glands, and fever. In
slight cases the lymphatics may dispose of the poison and
suppuration fail to occur. In severe cases septicemia arises.
Cellulitis is usually a result of infection not only with strep-
tococci, but also with other pyogenic cocci.

144 MODERN SCRGERY,

Treatment, — Incise and curet the wound and sear it with
pure carbolic acid. Treatment is the same as for the phleg-
monous form.

XII. TETANUS, OR LOCKJAW.

Tetanus is an infectious spasmodic disease invariably pre-
ceded by some injury. The wound may have .been severe,
it may have been so slight as to have attracted no attention,
or it may have been inflicted upon the alimentary canal by a
fish-bone or other foreign body, or may have been situated
in the nose, urethra, vagina, or ear. Idiopathic tetanus is
either not tetanus at all, or is a term expressive of the fact
that we have not found an injury which did exist. This dis-
ease is commonest after punctured or lacerated wounds of
the hands or feet, and before it appears a wound is apt to
suppurate or slough ; but in some instances the wound is
found soundly healed. Tetanus may appear twenty-four
hours after an accident, but it may not arise until several
weeks have elapsed. It prevails more in certain localities
than in others. Colored people are very susceptible, and it
may exist epidemically. Tetanus is due to infection by a
bacillus (first described by Nicolaier and first cultivated by
Kitasato), the toxic products of which, absorbed from the in-
fected area, poison the nervous system precisely as would
dosing with strychnin. This bacillus is found particularly
in garden-soil, in the dust of walls, walks, and cellars, in
street-dirt, and in the refuse of stables.

Symptoms. — Acute tetanus begins within nine days of
an accident. The usual period of incubation is from three
to five days. First, the neck feels stiff, and there is difficulty
in deglutition, the patient thinking he has taken cold, and
next the jaws also become stiff. The neck becomes like an
iron bar, and the jaws as rigid as steel. The muscles of
deglutition become rigid on attempts at swallowing. The
muscles of the back, legs, and abdomen are thrown into
tonic spasm, but the arms rarely suffer. If the infected in-
jury is on the hand or foot, that extremity usually is found
to be rigid. Spasm of the face-muscles causes the risus sar-
donicus, or sardonic smile (contraction particularly of the
musculus sanioiiicus of Santorini). The contraction of the
muscles of the back is often so powerful as to bend the pa-
tient back like a bow and allow him to rest only on his occi-
I)ut and heels. This condition is known as " opisthotonos."
If he is bent forward, so that the face is drawn to the legs, it

TETANUS, OR LOCKJAW. 1 45

is called " emprosthotonos." If his body is curved sideways,
it is designated " pleurosthotonos." An upright position is
" orthotonos.*' The spasm may be so violent as to cause
muscular rupture.

The state is one of widely diffused tonic spasm, aggravated
frequently by clonic spasms arising from peripheral irrita-
tions. These irritations may be draughts, sounds, lights,
shaking of the bed, attempts at swallowing, contact of the
bed-clothing, the presence of urine in the bladder or of feces
in the rectum, or various visceral actions. The agonizing
" girdle-pain " so often met with is from spasm of the dia-
phragm. Each clonic spasm causes a hideous scream by
the constriction of the chest forcing air through a contracted
glottis. Constipation is persistent ; retention of urine is the
rule (because of sphincter spasm). The mind is entirely
clear until near the end — one of the worst elements oi the
disease. Swallowing in many cases is impossible. Talking
is very difficult and it is impossible to project the tongue.
The muscles throughout the body feel very sore. The tem-
perature may be normal, but it is usually a little elevated,
and always rises just before death. Hyperpyrexia some-
times occurs (io8°-iio°), and the temperature may even
ascend for a time after death. Insomnia is obstinate. Death
almost invariably occurs in acute tetanus in two or three days.
It may be due to exhaustion or to carbonic-acid narcosis from
spasm of the glottis or fixation of the respiratory muscles.

Chronic tetanus comes on late after a wound (from ten
days to several weeks). The symptoms are not so severe ;
the muscular spasm is widespread, but it may not be per-
sistent, intervals of relaxation permitting sleep and the taking
of food. It may last some weeks, and not infrequently the
disease can be cured. Trismus is a mild form of tetanus,
the contractions being limited to the face and jaw. Trisvius
ficonatonnn or trismus nasccfitium, which is lockjaw in the
newborn, is due to infection of the stump of the umbilical
cord, and is invariably fatal. Hydrophobic tetanus, head
tetanus, or cephalic tetanus, is a condition in which the
spasms are confined chiefly to the face, pharynx, arid neck,
although the abdominal muscles are usually also rigid. It
follows head-injuries, and gives a better prognosis than does
general tetanus.

Diag^nosis. — Tetanus may be confounded with strychnin-
poisoning or with hysteria. Wood's table makes the diag-
nosis clear : ^

* Nervous Diseases^ by Prof. H. C. Wood.
10

146

MODERN SURGERY.

Tetanus.

Muscular symptoms
usually commence
with pain and sliffness
in the back of the
neck, sometimes with
slight muscular twitch-
ing; come on gradu-
ally. Jaw one of the
earliest parts affected ;
rigidly and persistent-
ly set. .

Persistent muscular
rigidity very generally,
with a greater or less
degree of p>ermanent
opisthotonos, empros-
thotonos, pleurosthot-
onos, or orihotonos.

Consciousness pre-
served until near
death, as in strychnin-
poisoning.

Hysterical Tetanus.

Commences with
blindness and weakness.

Draughts, loud
noises, etc., produce
convulsions, as in
strychnin - poisoning ;
may complain bitterly
of pain.

Eyes open and rig-
idly fixed during the
convulsion.

Muscular symptoms
commence with rigidity
oftheneck,which creeps
over the body, affecting
the extremities last. Jaws
rigidly set before a con-
vulsion, and remain so
between the paroxysms.

Persistent opisthoto-
nos and intense rigidity
between the convulsions
and after the convulsions
have ceased, the opis-
thotonos and intense rig-
idity lasting for hours.

Consciousness lost as
the second convulsion
comes on, and last with
every other convulsion,
the disturbunce of con-
sciousness and motility
being simultaneous.

Crying-»pells alterna-
ting with convulsions.

Strychnin-poisoning.

Eyes closed.

Begins with exhilaration and
restlessness, the special senses
being usually much sharpened.
Dimness of vision may in some
cases be manifested later, after
the development of other symp-
toms, but even then it is rare.

Muscular S3m[iptoms develop
very rapidly, commencing in the
extremities, or the convulsion
when the dose is large seizes
the whole body simultaneously.
Jaw the last part of the body
to be affected ; its muscles re-
lax first, and even when, during
a severe convulsion, it is set, it
drops as soon as the latter ceases.

Muscular relaxation (rarely a
slight rigidity) between the con-
vulsions, the patient being ex-
hausted and sweating. If re-
covery occurs, the convulsions
gradually cease, leaving merely
muscular soreness, and some-
times stiffness like that felt after
violent exercise.

Consciousness always pre-
served during convulsions, ex-
cept when the latter become so
intense that death is imminent
from suffocation, in which case
sometimes the patient becomes
insensible from asphyxia, which
comes on during the latter part
of a convulsion and is almost a
certain precursor of death.

The "slightest breath of air"
produces convulsion. Patient
may scream with pain or may
express great apprehension, but
*' crying-spells " would appear
to be impossible.

Eyes stretched wide open.

Partial spasm in the \ Legs stiffly extended with
leg,producing in Wood's feet everted, as the spasms affect
cases crossing of the feet all the muscles of the leg.
and inversion of the toes, i
If all the muscles were
involved,eversion would
occur, as the muscles of
eversion are the stronger.

TETANUS, OR LOCKJAW. 1 47

Treatment. — Far better than even to treat tetanus well is
to prevent it. Careful antisepsis will banish it as thoroughly
as it has banished septicemia. Every wound must be dis-
infected with the most scrupulous care. Every punctured
wound is to be incised to its depth and thoroughly cleaned
and drained. Puerperal tetanus is prevented by antiseptic
midwifery, and tetanus neonatorum is obviated by the anti-
septic treatment of the stump of the cord. When tetanus
exists, always look for a wound, and if one is found, open it,
cut away sloughs, wash with peroxid of hydrogen and cor-
rosive sublimate, swab it out with bromin, and secure drain-
age by packing it with iodoform gauze.

Isolate the patient, as the disease is infective ; keep him
in a darkened, well-ventilated, and quiet apartment, so as to
exclude as far as possible peripheral irritation. Watch
for retention of urine, and use the catheter if it occurs.
Secure movements of the bowels by salines, castor oil, croton
oil, or enemas. Give plenty of concentrated liquid food, and
stimulate freely with alcohol. If swallowing causes convul-
sions, give an inhalation of nitrite of amyl before an attempt
is made to swallow. If this treatment fails, partially anes-
thetize the patient and feed him by means of a phar>'ngeal
tube passed through the nose. Large doses of the bromid
of potassium, or of this drug with chloral, give the best re-
sults. If bromid is used, give about 3j every four to six
hours. Other drugs that have been used with some success
are gelsemium, morphin, curare, injections and fomentations
of tobacco, physostigmin, anesthetics, cocain, and cannabis
indica. An ice-bag to the spine somewhat relieves the
girdle-pain. Hot baths have been advised.

Yandell says, in summing up Cowling's report on tetanus '}
" Recoveries from traumatic tetanus have been usually in
cases in which the disease occurs subsequent to nine days
after the injury. When the symptoms last fourteen days,
recovery is the rule, apparently independent of treatment.
The true test of a remedy is its influence on the history of
the disease. Does it cure cases in which the disease has set
in previous to the ninth day ? Does it fail in cases whose
duration exceeds fourteen days ? No agent tried by these
tests has yet established its claims as a true remedy for
tetanus." ^

It is now claimed by some obser\'ers that we have a rem-
edy which fulfils the requirements of Yandell in the tetanus

* American Practitioner^ Sept., 1 870.

* Quoted by Hammond, in his Diseases of the Neri'ous System.

148 MODERN SURGERY.

antitoxin of Tizzoni and Cattani. To prepare this antitoxin
a horse is rendered immune to tetanus by inoculations with
mitigated cultivations of the microbe ; stronger and stronger
cultures are given ; the blood is drawn, and the serum is
separated and treated with alcohol and dried in a vacuum.
The antitoxin is dissolved in glycerin, and is used hypo-
dermatically in doses of from 15 to 25 centigrammes. Some
physicians have injected the serum itself. Cures seem to
have followed its use, and if it can be obtained it is our duty
to try it in acute tetanus. Kitasato has shown that injec-
tions of iodoform render animals immune, and Sonnani has
maintained that this drug in a wound prevents the disease.
If antitoxin is not obtainable, give hypodermatic injections
of iodoform 3 to j grs. t. i. d.

XIII. TUBERCULOSIS.

Tuberculosis is an infective disease due to the deposition
and multiplication of the bacilli of tubercle in the tissues
of the body. It is characterized either by the formation of
tubercles or by a widespread infiltration, both of these con-
ditions tending to caseation, sclerosis, or ulceration. A
tubercular lesion may undergo calcification.

A tubercle is an infective granuloma, appearing to the
unaided vision as a semitransparent gray mass the size
of a mustard-seed. The microscope shows that a gray
tubercle consists of a number of
cell-clusters, each cluster constitut-
ing a primitive tubercle. A tj'pi-
cal primitive tubercle shows a cen-
ter consisting of one or of several
poly nucleated giant-cells surround-
ed by a zone of epithelioid cells
which arc surrounded by an area
of leukocytes. When the bacillus
obtains a lodgement the fixed con-
nectivc-ti.-isue cells multiply by kary-
okinesis. forming a mass of nucle-
ated polygonal or round cells, called
" epithelioid " from their resemblance
to epithelial cells, and at the same
time the blood-supply of the growth
ViTowinB^Tjnri.iiMBowiw"!"'' 's limited by occlusion of surround-
ing ves.sfls through multiplication
of their endothelial coats. Somt of these epithelioid cells

TUBERCUL OS/S. 1 49

proliferate, and others attempt to, but fail for want of blood-
supply. Those that fail succeed only in dividing their
nuclei and enormously increasing their bulk (giant-cells).
Giant-cells, which also form by a coalescence of epithelioid
cells, are not always present. The presence of irritant bac-
terial products induces surrounding inflammation and exuda-
tion of white blood-cells (Fig. 37).

The bacillus, when found, exists in the epithelioid cells, and
sometimes in the giant-cells ; it may not be found, having once
existed, but having been subsequently destroyed. It is often
overlooked. In an active tubercular lesion, even if the bacil-
lus be not found, injection of the matter into a guinea-pig
will produce lesions in which it can be demonstrated. A
tubercle may caseate — a process that is destructive and dan-
gerous to the organism. Caseation is due to a coagulation-
necrosis arising from direct microbic action upon a cellular
area which contains no blood-vessels, the nutrition of the
area being cut off by obliteration of surrounding vessels.
This process starts at the center, and the entire tubercle
becomes converted into a soft yellowish-gray mass. Case-
ation forms cheesy masses, which may soften into tubercu-
lar pus, may calcify, and may become encapsuled by fibroid
tissue.

A tubercle may undergo sclerosis, which is an attempt on
the part of Nature to heal and repair. Coagulation-necrosis
occurs in the centre of the tubercle ; ** hyaline transformation
proceeds, together with a great increase in the fibroid ele-
ments, so that the tubercle is converted into a firm, hard
structure " (Osier). Infiltrated tubercle is due to the running
together of many minute infective foci, or to widespread in-
filtration without any formation of foci. Infiltrated tubercle
tends strongly to caseate.

The bacillus of tubercle, discovered by Koch, is a little
rod with a length equal to about half the diameter of a red
blood-corpuscle. It can be stained with anilin, and this stain
is not removable by acids (it being the only bacillus except
leprosy which acts in this way). In its growth the tubercle
bacillus causes the formation of toxins, and the absorption
of toxins induces constitutional symptoms. These bacilli
exist in all active lesions : the more active the process the
greater is their number. They may be widely distributed,
and are occasionally though rarely identified in the blood.
They exist in enormous numbers in phthisical sputum, but
are not found in the breath of consumptives. Their great
medium of distribution is dried sputum mixed with dust.

1 50 MODERN SUKGER Y.

They are found in the milk of tubercular cows, and some-
times in the meat of diseased animals.

Infection may be due to- hereditary transmission. Con-
genital tuberculosis is occasionally, though rarely, seen.
Tuberculosis is apt to appear in young children. Some
think this is due to infection from without upon tissues
whose resistance is lowered by hereditary predisposition;
others think it is due to a tardy development of the germs
transmitted by heredity. That the disease may be present
in a latent form is shown by the experiment in which the
viscera of the fetus of a consumptive mother showed no
tubercles, but produced the disease in guinea-pigs when
inoculated.* Tuberculosis may arise by inoculation, inocu-
lation-tuberculosis being seen in leather-workers and in those
who dissect tubercular bodies (butchers and doctors are
liable to anatomical tubercle). Osier mentions as other causes
of inoculation the bite of a tubercular patient, the washing
of infected garments, and circumcision in which suction is
employed by an individual with phthisis. Granulation-tissue,
chronic abscess, and areas of dermatitis may be infected from
without (G. R. Fowler). Infection through the air is very
common. The bacteria of the dried sputum adhere to par-
ticles of dust and are carried into the lungs. Infection by
meat, milk, and other foods may arise by this dust settling
upon them in quantity. Commonly, however, it is due to
disease of the animals. Milk is a common vehicle of con-
tagion, and it can be infected even when an ulcerated udder
does not exist.

Infection is favored by hereditary predisposition — ^that is
to say, by hereditary tissue-weakness, which, by maintaining
a lowered momentum of nutritive processes, lessens the nor-
mal resistance to infection. Hutley studied 432 cases of
tuberculosis. In 23.8 per cent, one or both parents had the
disease (the father alone in 1 1.5 per cent., the mother alone
in 9.9. per cent., and both in 2.4 per cent.). Two typ)es of
these predisposed persons are mentioned: (i) the sanguine
type, or those with oval faces, clear skin, large blue eyes,
long lashes, a nervous manner, precocious minds, but little
fat, and with long, slender bones, these children being often
graceful and beautiful ; and (2) those with stolid counte-
nances, thick lips and noses, thick, muddy skin, dark, coarse
hair, swollen necks, heavy bones, clumsy gait, and ungainly
figure. The latter type is the phlegmatic form — the classicsd
scrofula.

* Quoted by Osier from Birch-Hirschfeld.

TUBERCUL OSIS. 1 5 1

There is no doubt that an inflammatory area in a person
may become infected when a sound area would escape, the
process of phagocytosis being in this spot limited in activity,
and the germicidal power of the body-fluids being at a low
ebb. The organisms, which are destroyed by healthy cell-
activities, are victorious when those activities are diminished.
Catarrhal inflammations of the air-passages favor phthisis,
and traumatism is not unusually followed by a development
of tubercle. Lowered health, impure air, and improper or
insufficient food all favor the development of tubercle. Any
tubercular process tends to spread locally and to produce
inflammation. A tubercular area is always a danger to the
system ; from this as a focus dissemination may occur, tuber-
cular lesions appearing in a distant part or general tubercu-
losis setting in.

Scrofnla is not a disease. It is a condition of tissues in
which low resisting power makes them hospitable hosts to in-
vading bacilli of tubercle. Some observers teach that scrofula
is tuberculosis of bones, glands, and joints ; others teach that
it is latent tuberculosis until some cause lights it into activity;
while still others say that it is a tendency rather than a dis-
ease. It is certain that some lesions of scrofula are not tu-
bercular (eczema capitis, facial eczema, corneal ulcers, gran-
ular lids, and chronic catarrhal inflammations), and that they
result from ill-health, poor nutrition, bad air, and improper
diet. A person who is recognized as of a scrofulous type
may never develop tubercular lesions. It is unquestionable,
however, that strumous subjects are peculiarly apt to develop
true tubercular lesions. These lesions often appear after a
tissue or an organ has become the seat of a primary non-tu-
bercular inflammation ; the bacilli, which could not live in the
non-inflamed tissue, thrive in the inflamed tissue. Scrofula is
generally of congenital origin, one or both parents being tu-
bercular, scrofulous, or in ill-health ; it may, however, be
acquired as a result of poor food, bad air, crowding, and gen-
eral lack of sanitation. The scrofulous are very prone to
develop tubercular lesions of bones, joints, and lymphatic
glands. When tubercular processes arise the urine is some-
times found to contain indican.

Tubercular Abscess. — For description of tubercular
abscess, see p. 105.

Tuberculosis of the Skin.— Z/////^ begins before the
age of twenty-five, most usually upon the face, especially
the nose. Three forms are recognized: {\) lupus vulgaris^
in which pink nodules appear that after a time ulcerate and

I 5 2 MODERN SUR GER Y.

then cicatrize. These nodules resemble jelly in appearance ;
(2) hipiis exedcns, in which ulceration is very great ; and (3)
hiptis hypertrophicus, in which a very great amount of em-
bryonic tissue is produced (large nodules or tubercles). Lupus
may appear as a pimple, as a group of pimples, or as nodules
of a larger size. The ulcer arises from desquamation, and is
surrounded by inflammatory products which, by progres-
sively breaking down, add to its size. The ulcer is usually
superficial, is irregular in outline, the edges are soft and
neither sharp nor undermined, the sore gives origin to a small
amount of thin discharge, the parts about are of a yellow-red
color, and there is no pain, the edges are solid and puckered
and scar-like. The ulcer is often crusted over, the crusts
being thin and of a brown or black color ; it may be pro-
gressing at one point and healing at another ; and it is slow
in advancing, but often proves hideously destructive. The
scars left by its healing are firm and corrugated, but are apt
to break down. Clinically it is separated from a rodent ulcer
by several points. The rodent ulcer is deep, its edges are
everted, and the parts about filled with visible vessels. It is
not crusted, has not a puckered edge, does not spontane-
ously heal at any point, and its edges and base are hard.
Anatomical tubercle, the vemica nccrogenica of Wilks,
is due to local inoculation with tubercular matter. It is seen
in surgeons, the makers of post-mortems, leather-workers,
and butchers, usually upon the backs of the hands and fin-
gers. It consists of a red mass of granulation-tissue having
the appearance of a group of inflamed warts. Pustules often
form.

ScrofulQdermata or tubercular gummata are chronic
skin-inflammations, the granulation-tissue product of which
breaks down to form small abscesses, sinuses, or ulcers. A
tubercular ulcer has a floor of a pale color, and has no gran-
ulations at all, or is covered with edematous granulations.
The discharge is thin and scanty. It is surrounded by a con-
siderable zone of purple, tender, and undermined skin, which
is apt to slough. When healing occurs the skin puckers and
inverts.

Tuberculosis of Subcutaneous Connective Tissue.

— In this form of tuberculosis nodules of granulation-tissue
form and break down (tubercular abscesses). In the deejjer
tissues these abscesses are usually associated with bone-,
joint-, or lymphatic-gland disease. A large abscess is called
"cold" (see Cold Abscess, p. 105). Tuberculosis of the
mammary gland is rare, but occasionally occurs (p. 108).

TUBERCUL OSIS. 1 5 3

Pulmonary Tuberculosis. — In adults the lungs are
more commonly affected than any other structure. The
lung affection may be primary or may be secondary to some
distant process of tubercular disease. Pulmonary tubercu-
losis belongs to the physician and requires no description
here.

Tuberculosis of the Alimentary Canal. — A tuber-
cular ulcer of the lip occasionally occurs, and is usually mis-
taken for a cancer or ja chancre. A tubercular ulcer of the
tongue is commonly associated with other foci of disease.
Such ulcers are separated from cancer by their soft bases
and edges and by the absence of glandular enlargements,
and from syphilitic processes by the therapeutic test. Con-
firmation of the diagnosis is obtained by cultivations and in-
oculations. Tubercle may affect the pharynx, palate, tonsils,
and very rarely the stomach.

Intestinal tuberculosis may follow pulmonary tubercle,
but it may arise primarily in the mucous membrane of the
bowel or result from tubercular peritonitis. Intestinal tu-
berculosis causes diarrhea and fever, may resemble appendi-
citis, and may cause abscess and perforation. Fistula in ano
is very often tubercular, and when it is the lungs are very
often involved, the pulmonary lesion being primary.

Tuberculosis of the liver causes cold abscess and cirrhosis.
Tubercle may affect the kidneys, bladder, ureters, Fallopian
tubes, prostate, urethra, seminal vesicles, ovaries, and uterus.
Tubercular testicle is not rare. It is rarely primary, being,
as a rule, preceded by tuberculosis of the kidney, bladder, or
prostate. Tubercular orchitis affects one testicle at first, but
the other usually becomes involved. It starts in the epidid-
ymis as a painless nodule. As the vaginal tunic and testicle
become involved a hydrocele forms. The tubercular mass
softens, becomes adherent to the scrotum, and bursts. The
cord is always more or less involved.

Peritoneal tuberculosis may be primary, infection hav-
ing been by way of the blood, may be part of a diffused
process, or may follow intestinal tubercle, the serous and
muscular coats of the bowel having been at some point in
contact or a follicular ulcer having perforated (Abbe). The
germ may have entered by the Fallopian tube. It may be
due to ovarian or Fallopian tuberculosis, or to ulceration
of a tubercular appendix. It causes usually ascites, tym-
pany, and tumor-like formations composed of adherent
bunches of bowel or omentum or distended mesenteric
glands (p. 657).

1 54 MODERN SURGER K

The pericardium may be attacked with tuberculosis pri-
marily or secondarily to pleural tuberculosis. The pleura
is not uncommonly attacked. Tubercular pleurisy may be
acute or chronic. In some instances mixed infection takes
place and suppuration occurs. The tuberculosis may be
primary, but is usually secondary to pulmonary tuberculosis,
and may be due to direct extension or to the rupture of an
area of pulmonary softening.

Tuberculosis of the brain induces meningitis and
hydrocephalus (p. 559).

Tubercular disease of bone is very common in youth ;
is usually preceded by a sprain or a contusion, slight or se-
vere. The injury establishes a point of least resistance, and
in the damaged area the bacilli are deposited and multiply.
The organisms may be deposited directly from the blood, or
may come in an embolism from a distant tubercular focus
(lung or lymph-gland), which embolus is caught in a termi-
nal artery in the end of a long bone and causes a wedge-
shaped infarction (Warren).

Tubercular osteitis, as a rule, begins just beneath the
articular cartilage or in the epiphysis (Warren). The prod-
ucts of the tubercular inflammation may be absorbed, may
be encapsuled by fibrous tissue, or may caseate.

Tubercular disease of the joints is called " white
swelling " and pulpy degeneration of the synovial mem-
brane. Joints arc especially liable to tuberculosis in youth,
although the wrist and shoulder not infrequently suffer in
adult life. Joint-tuberculosis is often preceded by an injury.
The tubercular process may begin in the synovial membrane,
especially in the knee, but it usually starts in the head of a
bone, dry caries resulting, necrosis ensuing, or an abscess
forming which breaks into the joint (p. 408).

Tuberculosis of lymphatic glands is known as " tu-
bcrcular adenitis." It is the most typical lesion of scrofula.
The common antecedent of a tubercular adenitis of the neck
is slight glandular enlargement as a result of catarrhal inflam-
mation of the mucous membrane of the mouth. It is most fre-
quent between the third and fifteenth years. A person not of
the tubercular type may acquire tuberculosis of the glands^
but adenitis is unquestionably of much greater frequency in
the tubercular. Tubercular glands may get well, may even
calcify, but usually caseate if left alone. After healing they
may break down and soften (residual abscess). They very
frecjucntly suppurate because of mixed infection. Though
at first a local disease, inflamed glands may prove to be foci

TUBERCUL OS IS, 1 5 5

of infection, infecting distant organs or the entire system.
Glandular enlargement is in rare instances widely diffused,
but it is far more commonly localized. Enlargement of the
cervical glands is most common. Enlargement of the mesen-
teric glands causes tabes mesenterica.

Cervical lymphadenitis may be confused with lymphade-
noma. The former, as a rule, first appears in the submaxil-
lary triangle, the latter in the occipital or inferior carotid tri-
angles. Tubercular glands weld together, they are apt to
remain localized, and they tend to soften. They may be ac-
companied by other tubercular manifestations. Lymphade-
noma from the start affects many glands in several regions,
shows no tendency to suppurate, and is accompanied by great
debility and anemia. Malignant gland-tumors infiltrate adja-
cent glands and other structures, binding skin, muscles, and
glands into one hard firm mass.

Diafirnosis. — ^The diagnosis may be determined by purely
clinical facts. It may require the use of the microscope,
cultivation-experiments, or inoculations. In a suspected
tubercular lesion remove a portion of the tissue if it be
accessible (by Mixter's cannula) and make sections, stains,
and cultivations. If no bacilli are found, inoculate a guinea-
pig with the suspected material. If it be tubercular, the pig
will develop miliary tuberculosis in a few weeks.

Progrnosis. — The prognosis varies with age, sex, duration,
extent, and situation of the lesion. Prognosis is best in chil-
dren, and is better in males than in females. Tuberculosis
of the skin gives a fair prognosis. Tubercular adenitis is
often cured. Any tubercular lesion is, however, a menace to
the organism, and tends strongly to recurrence.

Treatment. — Destroy the bacilli present and radically re-
move infected areas which are accessible. Never remove only
part of a focus. Incomplete operations are apt to be fol-
lowed by diffuse tuberculosis. Among the many drugs
which have been recommended for local use we mention
the following : iodin, carbolic acid, guaiacol, arsenous acid,
corrosive sublimate, chlorid of zinc (Lannelongue), phosphate
of iron, balsam of Peru (Landerer), camphorated naphtol,
oil of cinnamon, cinnamic acid (Landerer), and iodoform.*
Iodoform used locally upon or in tubercular areas is of
great value, and there is no drug which takes its place.
Lupus may be treated by the application of blue oint-
ment; by curetting, cauterizing with carbolic acid, and

* See article upon "Tuberculosis" by George Ryerson Fowler, Brooklyn
Med, Jour.f Nos. 8 and 9, 1S94.

I 56 MODERN SURGER Y.

dressing with iodoform; by excision, followed in some
instances by sliding in of a flap of sound tissue or im-
mediate skin-grafting. If we are treating a nodular and
non-ulcerated area, wash it with a 2 per cent, solution of cor-
rosive sublimate and inject several nodules with camphorated
naphtol, one drop for each nodule. In seven or eight days
inject other nodules, and so on. Koch's lymph has cured
some cases of lupus. Tubercular glands before breaking
down should be rubbed with ichthyol, and if this fails to cure
they should be removed. When they break down they
should be removed or opened, curetted, and packed. The
rule must be to completely dissect out enlarged lymphatic
glands which fail to quickly respond to treatment, removing
capsules and glands. Climate is of very great importance.
Osier sums up climatic necessities as "pure atmosphere,
equable temperature, and maximum amount of sunshine."
Open-air life is imperative. The patient must have a well-
ventilated sleeping-room, and his house should be free from
dampness. Nourishing diet is essential. To gain in weight
is a constant aim. Give meat, milk, cream, butter, and cod-
liver oil, which may be administered in capsules. The oil is
poorly borne in hot weather, during which it should be dis-
continued. Advancing doses of creasote, arsenic, quinin, and
stimulants have their uses. (For treatment of tuberculosis of
bones, joints, peritoneum, pleura, etc., look under special re-
gional headings.)

Bier's Method. — A few years ago Bier set forth a new
plan for treating tubercular lesions. It consists in causing
venous obstruction and passive congestion. In the area of
passive congestion the tissue-cells form antitoxins which
kill the bacteria or attenuate their virulence. The treatment
is founded upon the principle announced by Laennec, that
" cyanosis is antagonistic to tubercle." The plan is applied
particularly in joint-tuberculosis. An elastic band three
inches broad is placed around the limb, above the seat of
disease, and it is applied sufficiently tightly to cause conges-
tion. Several pieces of lint ought to be interposed between
the skin and the band. By applying a flannel bandage
from the peripher>' to the lower border of the disease the
congestion is limited to the area of trouble. The patient
should wear the band continually and move about with it
on. Some people wear it without any inconvenience, but
others complain greatly after wearing it but a short time.
Bier and others have reported cures. We have seen great
mitigation of pain and temporary' arrest in the advance of

TUBERCUL OSJS, 1 5 7

the malady, but have never seen a cure brought about by
the method.

Koch's Tuberculin, — The specific treatment by Koch's tu-
berculin or paratoloid has excited widespread interest. It
has not fulfilled the expectations which many entertained,
but does benefit some cases, notably lupus. A serious draw-
back to the value of Koch's tuberculin is that it often causes
fever and inflammation to a dangerous degree. In some
cases, as Virchow showed, it produces acute miliary tubercu-
losis. Koch's lymph is a glycerin-extract of a culture of
tubercle bacilli, and the usual dose is i milligram, given hy-
podermatically into the back by Koch's pistonless syringe.
After it has been used for a time the dose may be increased
to 10 milligrams, or even much more. Bergmann gave i
gram. Koch's lymph causes inflammation and necrosis of
tubercular tissue by the action of certain antitoxins. Many
cases it improves. Some cases it apparently cures, but the
disease is apt to return. In pulmonary tubercle it must not
be given if there be much fever or extensive consolidation.
Chiene used tubercuHn largely in joint-cases by giving two
or three doses a day and increasing the dose. It is best to
associate other treatment with the lymph. Tuberculin may
be used for diagnostic purposes in animals. If tuberculosis
exists, an injection of tuberculin produces a marked reaction.
Czemy has shown that in renal tuberculosis in a human
being bacilli are often absent from urine, but an injection of
tuberculin will cause bacilli to appear plentifully. Koch has
recently modified his tuberculin. He makes it as follows :
dried cultures of bacilli are mixed with distilled water, and
the mixture is agitated in a centrifuge. Two layers separate.
The upper layer is the old tuberculin. The lower layer is
the new tuberculin. The new tuberculin is given hypoderm-
atically, at first in very small doses, but finally in doses as
large as 20 milligrams. It is not to be given to far advanced
cases or cases with much fever.

Hunter, of London, declares that Koch's lymph contains
one principle which causes fever, another which causes in-
flammation, and a third which produces atrophy of tuber-
cular foci without either fever or inflammation. This third
desirable element he believes he has isolated in what is
called a " derivative of tuberculin," a modified lymph. Some
remarkable results have followed the use of this material ;
its administration seems entirely safe, and it should thor-
oughly and carefully be tried to ascertain its true rank as a
remedy. The injection of serum obtained from animals re-

1 5 8 MODERN SURGER Y,

fractory to tubercle has been employed, but Richet and
Hericourt have seen no benefit from the plan. Maragliano,
of Genoa, uses a serum which he believes can cure tubercu-
losis. He immunizes animals not by injection of living cul-
tures, but by employing the toxic principles extracted from
them. Progressive vaccinations immunize a dog. The serum
of the animal is injected for the cure of tuberculosis in man
or other animals. If injected with tuberculin, it neutralizes
the general and local reaction of the latter agent. The serum
has apparently benefited many cases, but is useless against
mixed infections.*

XIV. RICKETS.

Rickets is a constitutional disease arising during the
early years of life (the first two or three) as a result of
insufficient or of improper diet and bad hygienic surround-
ings. A deficiency of fat and phosphate in the food or the
use of a diet which, by inducing gastro-intestinal catarrh,
prevents assimilation, causes rickets. The disease is never
congenital, the so-called " congenital rickets " being sporadic
cretinism (Bowlby).

Evidences of Rickets. — The condition is one of gen-
eral ill-health ; the child is ill-nourished, pallid, flabby ; it
has attacks of diarrhea and a tumid belly ; it is disinclined
for exertion and has a capricious appetite; it is liable to
night-sweats and night-terrors ; enlarged glands are often
noted, the teeth appear behind time, and the fontanels close
late. The long bones become much curved, the upper part
of the chest sinks in, curvature of the spine appears, the
head is large and the forehead bulges, and the pelvis is
distorted. Swelling appears in the articular heads of long
bones, by the side of the epiphyseal cartilages, and in the
sternal end of the ribs, forming in the latter case rhachitic
beads. The lesions of rickets are due to imperfect ossi-
fication of the animal matter which is prepared for bone-
formation, and consequently to softening of the bones, which
causes them to bend. The swellings at the articular heads
are due to pressure forcing out the soft bone into rings.
Rhachitic children rarely grow to full size, and the disease
is responsible for many dwarfs. Most cases recover without
deformity, but the time lost during the period when active
development should have gone on cannot be made up, and
some slight deficiency is sure to remain. Bowlegs, knock-

^ Bi-it. Med. Jour. ^ '895. "m 444-

RICKETS. 159

knees, and spinal curvature are usually rachitic in origin.
The disease may be associated with scurvy, inherited syph-
ilis, or tuberculosis.

Treatment. — ^The treatment consists in open air, sunshine,
salt-water baths, sea-air, fresh food (milk, cream, and meat-
juice), cod-liver oil, syrup of the iodid of iron, arsenic, and
some form of phosphorus. It is absolutely necessary to
improve the primary assimilation.

Scurvy. — This disease is rare to-day in adults, but was
at one time very common among those who took long
voyages, or who engaged in campaigns, or were the victims
of sieges. Of recent years it is very uncommon, and has
occurred chiefly among voyagers in the Arctic regions.

It is a constitutional malady due to the consumption of
improper diet, and especially to the employment of a diet
characterized by the absence of vegetables.

The use of salt meat as a staple article seems to favor the
production of the disease. Garrod considered absence of
potassium salts to be the real cause. Absence of variety in
diet, bad water, poorly ventilated quarters, and insufficient
exercise favor the development of the disease.

The disease begins by weakness, drowsiness, muscular
pains, and great susceptibility to cold. The skin is pallid
or dirty white, and is occasionally mottled and often peels
off. The pulse is excessively weak and slow. There is no
fever. After two or three weeks the gums become tender,
painful, and swollen, and bleed at frequent intervals; the
breath becomes offensive, the teeth loosen and even drop
out; subcutaneous hemorrhages take place, giving rise to
petechiae or extensive extravasations; the vision becomes
dim, the urine becomes scanty and of low specific gravity ;
vesicles form, rupture, and give rise to bleeding ulcers, and
ulcers likewise arise from breaking down of blood extravasa-
tions {American Text-Book of Surgery) ; hemorrhages take
place into and between the muscles, and in severe cases be-
neath the periosteum and into joints, and blood may come
from the nose, lungs, kidneys, stomach, and intestines. Deep
hemorrhages are felt as hard lumps. Bleeding at an epiph-
yseal line may separate the epiphysis from the shaft. If
an inflammation or ulceration arises at any point, fever is
observed. It was observed in the expedition in search of
Sir John Franklin that scurvy causes old and soundly healed
wounds to ulcerate. Most cases get well under treatment,
but complete recovery is not attained for a long time. It
is important to remember that though scurvy is rare in

l6o MODERN SURGERY.

adults, it is by no means uncommon in ill-nourished infants.
The author has seen two cases in one of which a large sub-
periosteal hemorrhage was mistaken for sarcoma of the
femur. It may exist with rickets.

Treatment. — Vinegar, lemon juice, onions, cider, nitrate
of potassium, antiseptic mouth washes, strychnin, plenty of
nourishing food, and whiskey or brandy. Secure sleep;
treat ulcers by antiseptic dressings and compression.

Scurvy can be prevented entirely by securing a proper
diet, and maintaining cleanliness and hygienic conditions
(American Text-Book of Surgery),

The following agents are believed to be especially useful
as preventives : fresh meat, lemon juice, cider, vinegar, milk,
eggs, onions, cranberries, cabbages, pickles, potatoes, and
lime juice.

Infantile scurvy may exist alone or with rickets. It oc-
curs most often in the children of the rich, those who have
been brought up on artificial foods. It occurs between the
eighth and eighteenth month. The child is anemic, has gas-
tro-intestinal disorder, spongy gums, weakness of the legs,
general muscular tenderness, night-sweats, and often febrile
attacks (Rotch). May have bleeding beneath skin (blue spots),
bloody urine and stools, bleeding into joints, viscera, or mus-
cles. A subperiosteal hemorrhage is very dense, is tender, is
fusiform in outline, and does not fluctuate. The limb at-
tacked is flexed, and the child will not move it It is some-
times mistaken for sarcoma. Separation of epiphysis may
result from hemorrhage between it and the bone.

Treatvicnt. — Oranges, grapes, meat-juice, potatoes, nour-
ishing food, tonics, and antiseptic mouth-washes.

XV. CONTUSIONS AND WOUNDS.

Contusions. — A contusion or bruise is a subcutaneous

laceration, the skin above it being uninjured (as in the abdo-
men), or being damaged without a surface-breach (as in a
part overlying bone), and blood being effused. If a large
vessel is damaged, hemorrhage is extensive. An ecchymosis
is diffuse hemorrhage over a large area; a hematoma is a
blood-tumor or a circumscribed hemorrhage. In a diffuse
hemorrhage the coagulation of fibrin induces induration;
the serum and leukocytes are absorbed ; the red blood-cells
disintegrate, and the coloring-matter is widely difiTused by
the tissue-fluids (suggillation) ; and hemoglobin is changed
into hematoidin, which cr>'stallizes. In union with these

CONTUSIONS AND WOUNDS. l6l

chemical changes, color-changes ensue, the part being at
first red and then becoming purple, black, green, lemon, and
citron. The stain following a contusion is most marked in
the most dependent area. A hematoma acts as an irritant,
inflammation ensues around it, and it is encapsuled by em-
bryonic tissue, which, by organizing into fibrous tissue, forms
a blood-cyst and gradually absorbs the fluid blood, the cyst-
contents becoming thicker and thicker. A fibrous scar may
remain. A blood-clot with very much indurated surround-
ing tissue, giving a hard edge, is noticed after bruises of the
periosteum. If serum is not absorbed, hematoidin forms
and the fluid becomes clear. A hematoma may suppurate,
an abscess forming; but this rarely happens, except in
drunkards, although it occasionally occurs in persons who
do not use alcohol.

Ssnnptoins. — ^The symptoms are tenderness, swelling and
numbness, followed by considerable pain. The pain rarely
persists beyond the first twenty-four hours. Discolora-
tion appears quickly in superficial contusions, but only
after days in deep ones; shock and loss of function are
present after severe contusions. The swelling is first due
to blood, and is soon added to by inflammatory exudation.

Treatment. — In a severe injury bring about reaction from
the shock. Local treatment consists of rest, elevation, and
compression to arrest bleeding, antagonize inflammation, and
control swelling. Cold is useful early in most cases, but it is
not suited to severe contusions or to contusions in the debili-
tated or aged, as in such cases it may cause gangrene. Lead-
water and laudanum and iodin may be used. In very severe
contusions employ heat and stimulation. When inflamma-
tion is subsiding after a contusion, massage and inunctions
of ichthyol should be employed. Massage and passive mo-
tion are imperatively needed after contusion of a joint. A
contusion should never be incised unless hemorrhage con-
tinues, infection takes place, or a lump remains for some
weeks. For persistent bleeding freely lay open the contused
area, turn out clots, ligate vessels, insert drainage strand or
tube, and close the wound. If gangrene is feared, apply heat
to the part and use iodin locally, and if a slough forms, em-
ploy antiseptic fomentations. Constitutional treatment for
contusion is the same as that for inflammation.

Wounds. — A wound is a breach of surface-continuity
effected by a sudden mechanical force. Wounds are divided
into open and subcutaneous, septic and aseptic, contused,
incised, lacerated, punctured, gunshot, and poisoned.
11

1 62 MODERN SURGERY.

The local phenomena of wonnds are pain, hemor-
rhage, loss of function, and gaping or retraction of edges.

Pain is due to the injury of nerves, and it varies according
to the situation and the nature of the injury. It is influ-
enced by temperament, excitement, and preoccupation. It
may not be felt at all at the time of the injury. At first it
is usually acute, becoming later dull and aching. In an asep-
tic wound the pain is slight, but in an infected wound it is
severe.

The nature and amount of hemorrhage vary with the state
of the system, the vascularity of the part, and the variety of
injur)^

Loss of function depends on the situation and extent of
the injury.

Gaping or Retraction of Edges. — Due to tissue-elasticity.

The constitntional conation after a severe injury is a
state known as shock, which is a sudden depression of the
vital powers arising from an injury or a profound emotion
acting on the nerve-centers and inducing vasomotor paresis,
the blood accumulating in the abdominal vessels and the
amount of circulating blood being much diminished. The
term collapse is used by some to designate a severe condi-
tion of shock, and is employed by others as a name for a
condition of shock produced by mental disturbance rather
than by physical injury. Shock may be slight and transient,
it may be severe and prolonged, and it may even produce
almost instant death. It is more severe in women than in
men. in the nervous and sanguine than in the lymphatic, in
those weakened by suffering than in those who are strangers
to illness. Injur>' of the abdomen produces great shock, and
so does damage to the viscera, the urethra, and the testicles.
Cerebral concussion is a form of shock plus other conditions.
Sudden and profuse hemorrhage causes shock ; so, often,
does anesthetization.

Symptoms. — The symptoms of ordinar>' shock (torpid or
apathetic shock) are a subnormal temperature; irregular,
weak, rapid, and compressible pulse ; cold, pallid, clammy,
or profusely perspiring skin ; shallow and irregular respira-
tion ; and a tendency to urinar}' suppression. Consciousness
is usually maintained, but there is an absence of mental orig-
inating power, the injured person answering when spoken
to, but volunteering no statements and lying with partly
closed lids and expressionless countenance in any position in
which he may be placed. The pupils are dilated and react
but slowly to light. Pain is slightly or not at all appreci-

CONTUS/OXS AND WOUNDS. 1 63

ated. Vomiting may, as in concussion, presage reaction.
Gastric regurgitation after a considerable duration of shock
is not unusual, and is a bad omen. Shock is not rarely fol-
lowed by suppression of urine. If delirium arises, the con-
dition is very grave (delirious shock). Travers called shock
with delirium erethistic shock. It is seen typically after poi-
soning from a serpent-bite. As a matter of fact, such a state is
not genuine shock, but is either a traumatic or a toxic delir-
ium. Many years ago Travers described a secondary or de-
layed form of shock, which comes on several hours after an
injury or violent emotional disturbance. This form of shock
is seen not unusually in those injured in a railroad accident.
It may be a sign of hemorrhage, and is sometimes met with
after the administration of ether or chloroform.

Diafirnosis. — Concealed hemorrhage is difficult to separate
from shock. It produces impairment of vision (retinal ane-
mia), irregular tossing, frequent yawning, great thirst, nausea,
and sometimes convulsions. In shock the hemoglobin is
unaltered; in hemorrhage it is enormously reduced (Hare
and Martin). In hemorrhage recurrent attacks of syncope
are met with. In pure shock such attacks do not occur. In
concealed hemorrhage the abdomen may exhibit physical
signs of a rapidly increasing collection of fluid. Shock and
hemorrhage are often associated. The essential character-
istic of shock is sudden onset, which separates it distinctly
from exhaustion. It arises at a much earlier period after an
injury than does fat-embolism.

Treatment. — In treating ordinary apathetic shock raise the
feet and lower the head, unless this position causes cyanosis.
At least place the head flat and the body recumbent. Apply
hot bottles and hot blankets, and give hypodermatic injections
of ether, brandy, strychnin, digitalis, or atropin, or inhala-
tions of amyl nitrite. Strychnin can be used in large doses ;
gr. ^ can be given every 10 or 15 minutes until 3 doses are
taken. If the skin is very moist, atropin is indicated, alone
or combined with strychnin. A turpentine enema is useful.
Hot coffee or other hot fluids should be given by the mouth
and rectum, and mustard should be placed over the heart,
spine, and shins. The use of hot and stimulating rectal ene-
mata is very important. The rectum may absorb when the
stomach refuses to do so. Enemata of hot normal salt solu-
tion are very beneficial (enteroclysis). The tube is carried
into the sigmoid flexure and the injection is introduced so as
to distend the colon. In severe cases bandage the extrem-
ities in order to send blood to the brain and correct the

164 MODERN SURGERY,

ischemia of the vital centers. For this purpose ordinary
muslin bandages may be used, or gauze bandages, or the
bandage of Esmarch (autotransfusion). Abdominal massage
helps drive out the imprisoned blood, and after massage sets
free the abdominal blood apply a compress and binder. Hy-
podermoclysis is of great value. Insert an aspirator-tube
into the cellular tissue of the buttock, loin, or scapular re-
gion, cleansing the part first. The tube is attached to a
fountain-syringe, which is filled with normal salt solution,
and is hung at a height of two or three feet above the bed
In an hour's time a pint or more of fluid will enter the tis-
sue and be absorbed. In very dangerous cases transfuse
salt solution into a vein (p. 277) and make artificial respira-
tion, and stimulate the diaphragm with a galvanic current.
If shock comes on during operation, the proceeding3 must
be hurried or even stopped, and proper treatment must
be instituted at once. The anesthetizer should give very
little ether when shock becomes at all evident. Should we
operate during shock ? We should only do so when death
without instant operation is inevitable. We must operate, if
it is necessary to do so, to arrest hemorrhage, to relieve
strangulated hernia, intestinal obstruction, obstruction of the
air-passages, compound fractures of the skull, extravasated
urine or intraperitoneal extravasations from ruptured viscera.
If hemorrhage can be temporarily controlled by pressure or
a clamp so much the better, and the permanent arrest can be
effected after the reaction from shock. It is not wise, in the
author's opinion, ever to amputate during shock. A tourni-
quet or Esmarch bandage should be applied, and attempts
be made to bring about reaction, and when reaction is ob-
tained the amputation should be performed. It is only just
to say that some eminent surgeons oppose this rule. Ros-
well Park says that '* shock is often alleviated by the prompt
removal of mutilated limbs which, when still adherent to the
trunk, seem to perpetuate the condition." The same teacher
believes in operating at once upon severe compound frac-
tures.^ After shock has passed away give diuretics to pre-
vent suppression of urine. Delayed shock is treated in the
same manner as apathetic shock if hemorrhage can be ex-
cluded. If hemorrhage is the cause, the bleeding must be
stopped. If delirious shock is due to sepsis, the treatment is
the treatment of sepsis. If it is a nervous delirium, give mor-
phin and other sedatives.

Fat-embolism. — (Seep. 135.)

^ Park's Surgery by American Authors.

CONTUSIONS AND WOUNDS. 1 65

Fever. — (See Fevers, p. 87.)

Treatment of Wounds. — The rules for treating wounds
are— (i) arrest hemorrhage; (2) bring about reaction; (3)
remove foreign bodies ; ^4) asepticize ; (5) drain, coaptate the
edges, and dress ; and (6) secure rest to the part and combat
inflammation. Constitutionally, allay pain, secure sleep, keep
up the nutrition, and treat inflammatory conditions.

Arrest of Hemorr/iage, — To arrest hemorrhage the bleed-
ing point must be controlled by digital pressure until ready
to be grasped with forceps; it is then caught up and tied
with catgut or aseptic silk. Slight hemorrhage stops spon-
taneously on exposure to air, and moderate hemorrhage
ceases after the vessels are clamped for a time ; an injured
vessel of some size must be ligated, even if it has ceased to
bleed. Capillary oozing is checked by hot-water compresses.
If a large artery is divided in a limb, apply a tourniquet
before ligating (see Wounds of Vessels).

Bringing about of Reaction, — (See Shock.)

Remoifol of Foreign Bodies, — Remove all foreign bodies
visible to the eye (splinters, bits of glass, portions of cloth-
ing, gun-wadding, grains of dirt, etc.) with forceps and a
stream of corrosive-sublimate solution. In a lacerated or
contused wound portions of tissue injured beyond repair
should be regarded as foreign bodies and be removed with
scissors.

Cleaning the Wound. — To clean the wound scrub the area
around it with ethereal soap and then with corrosive-sub-
limate solution (1 : 1000). If the surface is hairy, it must be
shaved before the scrubbing. An accidental wound is in-
fected, and must be well washed out with an antiseptic solu-
tion. A clean wound made by the surgeon need not be
irrigated ; in fact, irrigation with an antiseptic fluid leads to
necrosis of tissues, causes a profuse flow of serum, and ne-
cessitates drainage. If clots have gathered in a wound they
must be removed, as their presence will prevent accurate co-
aptation of the edges. In an infected wound they are washed
out with a stream of corrosive-sublimate solution. In a clean
wound they are washed out with hot salt solution. If dirt is
ground into a wound, as is often seen in crushes, pour sweet
oil into the wound, rub it into the tissues, and scrub the wound
with ethereal soap. The oil entangles the dirt, and the soap
and water remove both oil and dirt. After the rough cleans-
ing irrigate with corrosive-sublimate solution. In some cases,
especially in bone-injuries, it is necessary to scrape the
wound with a curet. If a fissure of the skull is infected.

1 66 MODERN SUR GER Y.

enlarge the fissure with a chisel in order to clean it. In a
bad infection one of the most valuable agents for local use is
pure carbolic acid. In wounds which cannot be approxi-
mated it is often wise to employ grafting after the method
of Thiersch. In very small wounds which cannot be ap-
proximated, dust with glutol and dress with dry sterile or
aseptic gauze ; and if sloughs form, apply antiseptic poultices
until granulation begins. A granulating wound is dressed
as a healing ulcer.

Drainage, Closure, and Dressing. — Superficial wounds re-
quire no special drain, as some wound-fluid will find exit
between the stitches and the rest will be absorbed A large
or deep wound requires free drainage for at least twenty-four
hours by means of a tube, strands of horse-hair, silk, or
catgut, or bits of iodoform gauze. An infected wound must
invariably be drained. Good drainage largely compensates
for imperfect antisepsis. If capillary drains be employed,
apply a moist dressing. Divided nerves and tendons must
be sutured. Close the edges with silk sutures or silkworm-
gut if the wound is deep and tension is inevitable. Catgut
is used for superficial wounds and for those where tension
is slight. The interrupted suture is, as a rule, the best.
If the wound is infected, dress with antiseptic gauze ; or with
either aseptic or antiseptic gauze if it is not infected. The
custom once was to cover the gauze with a rubber-dam to
diffuse the fluids, but we now prefer to omit the rubber-dam
and use plentiful dressings. A dry dressing absorbs wound-
fluids quickly and is less likely to become infected. Change
the dressings in twenty-four hours, or sooner if they become
soaked w'ith discharge. After this, in an aseptic wound, the
dressing need not be changed for days. If pus forms, open
the wound at once. Many surgeons sprinkle wounds before
approximation and wound-surfaces after approximation with
a dr>'ing-powder. These powders are of great use in infected
wounds, but are not necessary in clean wounds. Among
the substances employed are salicylic acid, boracic acid,
calomel, acetanilid, aristol, iodoform, subiodid of bismuth,
and glutol. A sloughing wound is dressed with antiseptic
poultices after being opened and dusted with protonuclein,
acetanilid, glutol, or iodoform.

Rest. — Severe wounds require the confinement of the pa-
tient to bed. Bandages, splints, etc., are used to secure rest.
The methods of combating inflammation have previously
been set forth.

Constitutional Treatment. — Bring about reaction from de-

CONTUSIONS AND WOUNDS. 1 6/

pression, but prevent undue reaction. Feed the patient well,
stimulate him if necessary, and attend to the bowels and
bladder. Watch the temperature as the danger-signal, se-
cure sleep, and allay pain. Look out for complications,
namely, inflammation, suppuration, gangrene, tetanus, and
erysipelas.

Incised Wounds. — ^An incised wound is a clean cut in-
flicted by an edged instrument Only a thin film of tissue
is so devitalized that it must die. These wounds have a
splendid chance of union by first intention. A sword-cut is
an incised wound.

Symptopns. — ^The symptoms of incised wounds are sharp
piain for a time, followed by smarting, profuse bleeding, and
decided retraction of the edges.

Treatment. — The treatment of incised wounds is according
to general rules. Do not use styptics, as they cause a large,
soft clot to form, produce irritation, and fayor infection.

Lacerated and Contused Wounds. — A lacerated wound
is a tearing apart of the tissues ; a contused wound is a crush-
ing and pulpefying of tissues. These two forms may be
combined. They are irregular, contain masses of partially
detached tissue and blood-clots, and their edges are cold and
discolored Such wounds tend to necrosis.

Symptoms, — ^The symptoms are excessive shock, slight
hemorrhage, and only a moderately dull pain. Reactionary
and secondary hemorrhages are common. Infection is liable
to occur, and more or less sloughing is bound to ensue.

Treatfnent. — Any damaged vessel, whether it bleeds or
not. is to be tied, the devitalized tissues are cut away, and
foreign bodies are removed. Asepticize with great care and
secure thorough drainage, making if necessary counter-open-
ings. In dressing, put iodoform in the wound and close the
wound only partially. Watch for bleeding during reaction.
When sloughing begins use antiseptic fomentations. A
brush-bum^ which is a contused-lacerated wound due to fric-
tion, requires the use of an antiseptic poultice until the slough
is cast off". In badly lacerated wounds and crushes it is often
necessary to amputate.

Punctured wounds are wounds made by pointed instru-
ments. A punctured wound is usually deep, it closes partly
after withdrawal of the instrument, blood-clot and wound-
fluids cannot get exit, and infection is almost certain if the
instrument carried microbes. The danger is not only of in-
fection by pus organisms, but by tetanus bacteria. Large-
sized foreign bodies may be driven in or a portion of the in-

l68 MODERN SURGERY.

strument may break off. Arrow-wounds are punctured and
incised. Bayonet- wounds are punctured, and so are sticks
from a sword.

Symptoms. — In punctured wounds the pain is rarely severe,
and hemorrhage is slight unless a large vessel be wounded.
Infection is apt to ensue. Varicose aneurysm may be caused
if both a vein and an artery have been punctured.

Treatment. — In treating punctured wounds incise to the
depth of the puncture, stop the hemorrhage, asepticize with
pure carbolic acid in many cases, and drain. An arrow
should never be pulled out, but should be pushed through
or cut down upon by enlarging the wound.

Gunshot- wounds. — Gunshot -wounds are contused or
contused-lacerated wounds inflicted by materials projected by
explosives. A bit of rock or a crowbar hurled by dynamite
inflicts a gunshot-wound, as does a shell-fragment, a pistol-
ball, a small birdshot, a rifle-bullet, a flying cap, a piece of
wadding, grains of powder, a buckshot, a fragfment of wood
broken off by a shell concussion, grapeshot and canister,
or a cannon-ball. Injuries by shell-fragments, portions of a
bursted boiler, pieces of masonry or wood, are either lacer-
ated or punctured wounds, and need no special consideration
here. In this article we treat of injuries caused by bullets
and shot.

At the present day the old round ball is very rarely used,
the conical projectile having taken its place. For the fire-
arms of civilians, as a rule, the bullets are made of lead,
hardened and shaped by compression, or hardened by an
admixture with tin. The conical shape of the pistol-ball,
the great velocity with which it is propelled and with
which it rotates, and its hardness, make it unlikely that
at near range the bullet will only contuse and not enter
the skin. It will almost always enter ; it will occasionally
lodge and often perforate ; it is rarely deflected, and is not
nearly so much flattened by impact as the softer round ball.
A pistol-ball or a spent rifle-ball, however, may fail to enter
the tissues, grazing the surface and inflicting a brush-bum, or
simply contusing the part. A bullet may enter the tissues,
a cavity, or an organ, and lodge there, causing a penetrating
wound. It may enter and emerge, causing a perforating
wound. The bullet may not enter alone, but may carry
with it bits of clothing or other foreign bodies. This com-
plication is much more rare in injur}^ by the conical bullet.

The military surgeon deals with wounds inflicted by small,
densely hard, conical projectiles, which are impelled at a

CONTUSIONS AND WOUNDS, 1 69

great velocity, and are carried to long distances. The old
Springfield rifle, of a caliber of 0.45 inch, projected a bullet
with a velocity of thirteen hundred feet in a second.

The Mannlicher rifle, of a caliber of 0.25 to 0.32 inch, sends
a bullet with a velocity of over two thousand feet a second.
This bullet revolves with great velocity upon its own axis (two
thousand times the first secondhand is effective at several miles.

The bullet of the modern rifle is conical, has a leaden core,
and is hardened by being covered with a mantle or jacket
of copper, steel, nickel, or of alloys of copper and nickel, or
of copper, nickel, and zinc.

The older projectile was apt to lodge ; was often deflected
in the tissues ; was flattened out on meeting with resistant
structures, such as bone or cartilage, and after flattening be-
came larger and tore and lacerated the soft parts and com-
minuted the bone.

The new projectile is apt to perforate, is rarely deflected,
and is so hard that its shape is generally but little altered
on meeting with resistant structures, and hence it was
thought that the new bullet would prove more humane than
the old projectile, and inflict wounds which would be more
easily treated than of old, because the bullets would not
lodge and because extensive damage would not be in-
flicted. This view has proved fallacious. It is true that
in many instances a modem bullet will make a clear track
without laceration or comminution ; but in other instances
it pulpefies structure for a considerable distance around the
track of the ball by what is known as the explosive effect.
This term does not mean that the bullet has exploded, but
that its sudden impact against and rapid rotation in the
tissues have by waves of force caused extensive and dis-
tant damage, and often horrible and irreparable injury. Ex-
plosive effects are seen most often at close range, when the
velocity of the ball and the frequency of its rotation are most
marked. A pistol-ball has no explosive action at all, and the
old-time bullet possessed it only at very close range. The
modern projectile always produces explosive effects up to
five hundred yards. Up to thirteen hundred yards it pro-
duces them upon the skull and brain. At this distance a
single small projectile may entirely destroy the cranium and
brain (see Demosthen's studies of the action of the Mann-
licher rifle). Explosive effects are noted at long distances
upon the liver, spleen, kidney, and lungs, and upon hollow
viscera containing fluid.

Cancellous bone struck by the old-style bullet was much

170 MODERN SURGERY,

comminuted at any range ; struck with the new bullet at a
range of from three hundred and fifty to fifteen hundred
yards, perforation occurs rather than comminution. At a
distance of less than three hundred and fifty yards the new
ball has an explosive effect and causes great damage. Hard
bone is extensively damaged at even long range by the hard
projectile. This projectile theoretically does not flatten, but
practically in many instances it does flatten a little, and in
others its coat is torn off when it strikes hard bone at a dis-
tance of less than eighteen hundred yards. The old-style bul-
let rarely caused much primary hemorrhage, as the vessels
as well as the nerves and tendons were usually pushed aside
rather than cut. Hence secondary hemorrhage was com-
mon because of contusion of the vessel-walls. The modem
bullet cuts rather than pushes aside the vessels. Hence pri-
mary hemorrhage is usual, and may often prove fatal. The
modem bullet rarely lodges at any range, and is rarely de-
flected. Skin is usually split by it. Fascia and muscle are
usually much damaged, but in a transverse wound of muscle
the fibers may be separated rather than destroyed (Conner).
In the warfare of the future numbers of the wounded will
be fortunate in not harboring a ball and in escaping manipu-
lations to extract it. Great numbers of people will be killed
outright and great numbers will receive terrible injuries, from
which recovery, if it takes place at all, will be attained after
much time and agony. The effects of the modem bullet
have been determined by careful study and experiment ; by
a study of the wounds in the Chitral Expedition and of
wounds inflicted by accident or with homicidal or suicidal
intent ; by experiments : firing through boxes filled with
wet sand ; firing into thick oak ; firing at cadavers at fixed
distances with reduced charges (La Garde). Nancrede cau-
tions us to remember that experiments upon the cadaver,
employing reduced charges and standing at fixed distances,
are uncertain in their provings. *' The difference between
the velocity of rotation and angle of incidence with reduced
charges at fixed distances and scr\'ice-charges at actual dis-
tances are marked. The tension of living muscles and fasciae,
as compared with dead tissues, and the physical change of
the semiliquid fat of adipose tissue and medulla to a more solid
condition by the loss of animal heat, influence the results.^"

* Nancrede upon " Gunshot Wounds," in Park's Surgery by American Authors,
For information upon wounds by the modern firearm, see report of Surgeon-
Cieneral of the United States Army, 1893. Demosthen's study of the wounds
inflicted by the Mannlicher rifle. Prof. Conner, in Dennis' System of Surgery.

CONTUSIONS AND WOUNDS. I7I

In injuries from the old-style bullet the wound of entrance
was often smaller than the ball (skin stretched at the moment
of impact and contracted after perforation) ; it was depressed,
and the edges were contused and inverted, and if the weapon
were fired within ten feet usually were blackened from pow-
der and contained powder-grains. If the wound was much
larger than the bullet, it meant that some foreign body had
been carried in. In injuries from the modem bullet the skin
may be split or may be perforated, the wound is usually as
large as the ball, and foreign bodies are not carried by the
ball into the tissue.

In wounds from the old-style bullet the wound of exit was
everted, " triangular, linear, or stellate,'* and much larger than
the wound of entrance ; in wounds from the modern bullet,
if the wound of exit is not in the region of explosive action,
it may be a little larger or a little smaller than the bullet,
but is not noticeably larger than the wound of entrance.
If within the area of explosive action, the wound of exit is
much larger than the wound of entrance, and is irregular
and everted.

Wounds by Cannon-balls. — A cannon-ball weighing
five or six pounds may be imbedded in tissues. A ball or
shell-fragments may tear off a limb or lacerate it exten-
sively. In some cases of injury by spent balls the bone
is destroyed and the muscles disorganized while the skin
is intact.

Wounds by Small Shot. — Single shot may bruise the
surface or may enter the tissues. When many shot enter
together they strike as a solid body. Single shot are usually
deflected from vessels and nerves, and rarely lodge in bone,
but rather flatten on its surface. A load of shot entering
together produces extensive laceration and inflicts damage
which is often irreparable.

Symptoms of a Ghinshot-wound. — Hemorrhage is
often considerable, but ceases spontaneously unless a large
vessel has been divided. If hemorrhage is profuse, the con-
stitutional symptoms of hemorrhage exist. These symp-
toms are of great importance in abdominal wounds (p. 628).
A pistol-ball rarely causes severe primary hemorrhage,
because it rarely penetrates a large artery. It is apt to
push aside a vessel, and secondary hemorrhage is not un-
usual. Even if a large vessel is wounded and a succession of
violent hemorrhages occur, a man may live for several days.
Secondary hemorrhage may follow a gunshot-wound because
of contusion of vessels or of infection.

1/2 MODERN SURGER K

Pain is often not noticed at first, especially if the injured
individual were greatly preoccupied or excited. There may
be a feeling of numbness, but there is usually a dull or
stinging pain. If a large nerve is injured, there may be vio-
lent pain. Even trivial gunshot-wounds frequently produce
profound shock, and yet it may happen that even severe
wounds may be accompanied by but slight shock. In most
gunshot-wounds of the brain, abdomen, and spinal cord the
shock is very great

Q^neral Considerations cus to Treatment. — The dangers
are shock, hemorrhage, and infection. Bullets are aseptic
when they enter a part, and if infection is not inserted in the
track of the ball the wound will in most instances heal
kindly. " The fate of a wounded man is in the hands of
the surgeon who first attends him " (Nussbaum"). The
danger of a wound depends upon the size and velocity of
the bullet, the part struck, " and the degree of asepsis ob-
served during the first examination and dressing" (Nan-
crede). The rules of treatment are : bring about reaction,
arrest hemorrhage, preserve asepsis, and, in some cases, re-
move the ball. Always notice if a wound of exit exists. It
is a good plan, when endeavoring to determine the extent
of injury, to put the parts in the position they were in when
the injury was inflicted. We should try to ascertain the
size and nature of the weapon, and the range at which it was
fired. Examine the clothing to see if any fragments are
missing and could have been carried in. Such fragments
render sepsis almost inevitable. The surgeon must not feel
it his duty to probe in all cases. In many cases it is better
not to probe at all. Explore for the ball when sure that it
has carried in with it foreign bodies ; when its presence at
the point of lodgement interferes with repair ; when it is in
or near a vital region (as the brain) ; and when it is neces-
sary to know the position of the bullet in order to determine
the question of amputation or resection. If the wound is
large enough, the finger is the best probe.

Fluhrer's aluminum probe is a valuable instrument. It
is employed especially in brain-wounds, and is allowed to
sink into the track of the ball by the influence of gravity
after the part has been placed in a proper position. If a
lead bullet is imbedded, it is possible to distinguish the hard
projectile from a bone by inserting the stem of a clay pipe, a
bit of pine wood, or Nelaton's porcelain-headed probe. On
any one of these appliances lead will make a black mark.
No such test can be applied to a modern bullet, for this has

CONTUSIONS AND WOUNDS. 1 73

a hard metal jacket, and will not make a black mark on a
white substance.

The induction-balance of Graham Bell has been employed
to determine the situation of a bullet. The bullet may be
located by Girdner's telephonic probe. In order to construct
this instrument, take a telephone receiver, fasten one of the
wires to a metal plate and the other one to a metallic probe.
Moisten a portion of the patient's body and place the metal
plate in contact with it. The surgeon places the receiver
to his ear and inserts the probe into the wound. If the
probe strikes metal, a click is heard with distinctness. A
bullet may be located by IMicnthaVs probe. This appa-
ratus consists of a mouth-piece, two insulated copper wires,
and a probe. The mouth-piece is composed of two plates,
one of copper and one of zinc, which are applied to the
sides of the tongue. An insulated wire runs from each
plate and into the metal probe. The tip of the probe is
composed of two or four pieces of metal, is separated from
the shank by a washer of rubber, and is attached to the
wires. The operator closes the teeth upon the mouth-
piece and inserts the probe into the wound. If the probe
touches the bullet, a distinct and continuous metallic taste
is appreciable.

The best means of discovering a bullet is to use the fluoro-
scope or take a skiagraph. In order to locate it accurately
view it through a series of squares, insert guide-pins, or
employ Sweet's apparatus (p. 875). Bullets are readily
seen in the superficial soft parts, but are also recognizable
in deeper structures (bone, abdomen, lung, brain, etc.).

Though Nelaton's probe will not show the difference be-
tween ball and bone, it is a valuable instrument to follow the
track of a wound. The porcelain head ought to be larger
than it is usually made — in fact, it should be nearly the size
of the bullet (Senn).

In passing a probe use no more force than in passing a
catheter (Senn). In extracting the ball use very strong
forceps. The old American bullet-forceps is useless for the
extraction of the hard-jacketed ball, as the points of the in-
strument will not penetrate and the instrument will not hold.

If hemorrhage is severe in a gunshot-wound, enlarge the
wound, find the bleeding vessel, and tie it. Before handling
a gunshot-wound asepticize the parts about it. Irrigate with
hot sterile salt solution, and drain with a tube or a bit of
iodoform gauze and dress antiseptically. Primary union
rarely takes place because of the necrosis of damaged tissue

174 MODERN SURGERY.

in the track of the ball, but in some cases it can be obtained
Healing begins in the depths of the wound and extends
toward the wound of entrance, or, if there be also a wound
of exit, tow^ard both. Radical operations may be demanded :
laparotomy (p. 666), trephining (p. 571), rib-resection (p. 610),
joint-resection, and amputation.

Ampiitation^ is sometimes demanded because of great
injury to the soft parts (as by a shell -fragment), the splinter-
ing of a bone, injury of a joint, damage to the chief vessels
or nerves, or the destruction of a considerable part of a
limb. Perform a primary amputation if possible, and make
the flaps through tissue that will not slough. In civil prac-
tice, with careful antisepsis, more questionable tissue can be
admitted into a flap than in military practice, where trans-
portation will become necessary and antisepsis may be im-
perfect or wanting.

In warfare at the present day an attempt is made to limit
the death-rate from gunshot-wounds by protecting them
from infection at an early period after the accident. Es-
march offered a suggestion, which has been adopted in the
German army and other armies. Every soldier carries a
package which contains antiseptic dressings, and at the first
opportunity after the infliction of a wound, if possible on the
field, these dressings are applied by the soldier or by a com-
rade (for even the privates are instructed in the application),
or by an ambulance man. If not applied on the field, they
are applied at the first dressing-station by a surgeon or a hos-
pital steward. Senn considers Esmarch's package too cum-
brous.* He suggests a package containing half an ounce of
compressed salicylated cotton. In the center of this cotton
is an antiseptic powder (2 gm. of boric acid and \ gm. of
salicylic acid). The cotton is wrapped in a triangular gauze
bandage. A safety-pin is placed in the bandage and the en-
tire bundle is wrapped in gutta-percha tissue. Senn says the
triangular bandage is sufficient to hold on a dressing, and it
can be assisted by utilizing the gunstrap, safety-belt, or articles
of clothing.^ (For gunshot-wounds of special structures, see
Bones, Joints, etc.)

Poisoned wounds arc those in which a poison is intro-
duced. This poison may be microbic and capable of self-
multiplication, or it may be chemical, and hence incapable
of multiplication. There are three classes of poisons:* (i)

'^ Jour. Am. Med. AssoCs July 13, 1895.

^ Senn. \w Jour. Atn. Med. Assoc. July 1 3, 1895.

* American Text Book of Surgery.

CONTUSIONS AND WOUNDS. 1 75

mixed infection, as septic wounds, dissection-wounds, and
malignant edema ; (2) chemical poison, such as snake-bites
and insect-stings ; and (3) infection by such diseases as rabies,
glanders, etc.

Septic wounds are those which putrefy, suppurate, or
slough. Open septic wounds freely for drainage, curet, or
cut away hopelessly damaged tissue, wash with peroxid of
hydrogen and then with corrosive sublimate, dust with iodo-
form or glutol, and either use a drainage-tube or pack with
iodoform gauze. The antiseptic poultice is an excellent
dressing. If lymphangitis arises, paint over the inflamed
vessels and glands with iodin and cover with lead-water
and laudanum, and give internally quinin and iron. Watch
the temperature for evidences of general infection or intox-
ication. Stimulate and secure good nourishment, rest, and
sleep.

Dissectioii-wotmds are simple examples of infected
wounds, and they present nothing peculiar except virulence.
They aflect butchers, cooks, surgeons who cut themselves
in operating on an infected area, those who make postmor-
tems, and those who dissect. A dissection-wound inflicted
while working on a body injected with chlorid of zinc pos-
sesses but few elements of danger unless the health of the
student is much broken down. Postmortems are peculiarly
dangerous when the subject has died of some septic process.
When a wound is inflicted while dissecting, wash it under a
strong stream of water, squeeze, and suck it to make the
blood run, lay it open if it be a puncture, swab it out with
pure carbolic acid, and dress it with iodoform and gauze.
If infection shows itself, it must be treated as any other
infected wound.

Malignant edema or gangrenous emphysema arises

most commonly after a puncture. It is due to a specific
bacillus which produces great edema, and to secondary infec-
tion with putrefactive organisms.

Symptomfl.— The symptoms are edema, the fluid being
distinctly bloody, followed by rapidly diffusing gangrene
which is surrounded by a zone of edematous tissue that
crepitates under pressure because it contains gases of putre-
faction. The zone of edema is covered with blebs which
contain thin, putrid, reddish matter. The constitutional con-
dition is one of septicemia. Death occurs, as a rule, in a
few days.

Treatment. — ^To treat malignant edema, if it affect a limb,
amputate at once, high up. If it afTect some other part,

176 MODERN SURGERY,

excise, use the actual cautery, and dress antiseptically.
Stimulate very freely.

Stings and Bites of Insects and Reptiles : Stings
of Bees and Wasps. — A bee's sting consists of two long
lances within a sheath with which a poison-bag is connected.
The wound is made first by the sheath, the poison then
passes in, and the two lances, moving up and down, deepen
the cut. The barbs on the lances make it difficult to rapidly
withdraw the sting, which may be broker! off and remain in
the flesh. Besides bees, hornets, yellow-jackets, and other
wasps produce painful stings. These stings rarely produce
any trouble except pain and swelling. In some rare cases a
bee-sting is fatal ; persons have been stung to death by a
great number of these insects.

Symptoms. — If general symptoms ensue, they appear
rapidly and consist of great prostration, vomiting, purging,
and delirium or unconsciousness. These symptoms may
disappear in a short time, or they may end in death from
heart-failure. Stings of the mouth may cause edema of the
glottis.

Treatment. — To treat a bee-sting, extract the sting if it
be broken off, and apply locally ichthyol, a solution of wash-
ing-soda, tincture of arnica, iodin, or lead-water and lauda-
num. If constitutional symptoms appear, stimulate.

Other Insect-bites and Stings. — The mandibles of a
spider are terminated by a movable hook which has an
opening for the emission of poison. The bite of large
spiders is productive of inflammation, swelling, weakness,
and even death. The bite of the poisonous spider of New
Zealand produces a large white swelling and great prostra-
tion ; death may ensue, or the victim may remain in a de-
pressed, enfeebled state for weeks or even for months. The
tarantula is a much-dreaded spider. A scorpion has in its
tail a sting, and a scorpion's sting produces great prostration,
delirium, vomiting, diaphoresis, vertigo, headache, local swell-
ing, and burning pain, followed often by suppuration, or even
by gangrene and fever. Centipedes must be of large size
to be formidable to man, and the symptoms arising from
their stings are usually only local.

Treatment. — Tie a fillet above the bitten point ; make a
crucial incision, favor bleeding, and swab out the wound with
pure carbolic acid or some caustic or antiseptic (if in the
wilds, burn with fire or gunpowder) ; dress antiseptically if
possible, and stimulate as constitutional symptoms appear.
Slowly loosen the ligature after symptoms disappear. Chlo-

CONTUSIONS AND WOUNDS, 1 77

roform stupes and ipecac poultices are recommended, also
puncture with a needle and rubbing in a mixture of 3 parts
of chloral and I part of camphor (Bauerjie).

Snake-bites. — ^The poisonous snakes of America com-
prise the copperheads, water-moccasins, rattlesnakes, and
vipers. There is also a poisonous lizard. The symptoms
of snake-bite are similar whether it is the bite of an Indian
cobra or of an American rattler, and they depend upon
the dose of poison introduced. Poison injected into a vein
may prove almost instantly fatal. The poison is not ab-
sorbed by the sound mucous membranes. It is discharged
through the hollow fangs of the reptile by contractions of
the muscles of the poison-bag. In most varieties of snakes
the teeth lie along the back of the mouth and are only
erected when the reptile strikes. The poison contains pro-
teid constituents, globulins, and peptones (Mitchell and
Reichert), and probably toxic animal alkaloids (Brieger).
S. Weir Mitchell has shown that rattlesnake venom exerts
a paralyzing action upon the walls of the smaller blood-
vessels, converts the blood into a noncoagulable fluid, causes
the white blood-cells and the fluid elements of blood to ex-
travasate into the tissues, and disintegrates the red corpuscles.

S3nnptoin8. — ^The symptoms are — pain, soon becoming
intense ; mottled swelling of the bitten part, which swelling
may be enormous, and which is due to edema and extrava-
sation of blood, and assumes a purpuric discoloration.
There may be complete consciousness, or there may be
lethargy, stupor, or coma. Some cases present spasms.
The general symptoms are those of profound shock, which
may present delirium (delirious shock). Death may arise
from paralysis of the heart or paralysis of respiration, and
may occur in about five hours, but as a rule it is postponed
for a number of hours. If death is deferred many hours,
profound sepsis comes upon the scene, with glandular en-
largement, suppuration, and sometimes gangrene.

Treatment. — Cases of snake-bite must, as a rule, be treated
without proper appliances. The elder Gross was accus-
tomed to relate in his lectures how he had seen an army
officer blow off his finger with a pistol the moment it was
struck, and thus escape poisoning. In general, the rules
are to twist several fillets at different levels above the bite,
to excise the bitten area, to suck or cup it if possible, and
to cauterize it by a pure acid or by heat. An expedient
among hunters is to cauterize by pouring gunpowder on the
excised area and applying a spark, or by laying a hot ember

178 MODERN SURGERY.

on the wound. When a hot iron is available, use it. The
fillets are not to be removed suddenly, and they had best be
kept on for some time. Remove the highest constricting
band first ; if no symptoms come on after a time, remove
the next, and so on ; if symptoms appear, reapply the fillet
The constitutional treatment is expressed in one word:
stimulate. Our only hope is in large doses of alcohol, and,
if they can be obtained, ammonia, ether, strychnin, or digi-
talis hypodermatically administered. Large doses of str>''ch-
nin hypodermatically are used by many surgeons in India.
Morphin may be given for pain. There is no specific for
snake-poison. Hypodermatic injections in the area adjacent
to the bite of a i per cent, solution of the permanganate
of potassium are commended by some. The local use of
chlorid of lime has recently been recommended. Halford of
Australia praises the intravenous injection of ammonia (lOlTl
of strong ammonia in 20in of water). If a man is bitten by
a large and deadly snake, the surgeon, if one is at hand,
should at once amputate well above the bite.* Attempts are
being made to obtain a curative serum. Animals can be ren-
dered immune by gixing them at first small doses of the
poison and gradually increasing the amount administered.
It is asserted that the serum of immune animals will cure a
person bitten by a venomous snake. Cures have been re-
ported after the use of Calmette's antivenene serum. The
dose is 20 c.c. hypodermatically, repeated if necessary in three
or four hours. Alexander^ treated a case successfully by
making an incision into the bitten area, pouring into the
wound rattlesnake bile, and giving carbonate of ammonium
internally. The poisonous lizard (Gila monster) can kill
small animals, but it is not believed that its bite would prove
fatal to man.

Anthrax (malignant pustule, charbon, wool-sorters' dis-
ease, Milzbrand, or splenic fever) is a term used by some as
synonymous with ordinary carbuncle, but it is not here so
employed. Anthrax, as met with in man, is a disease con-
tracted in some manner from an animal with splenic fever.
It may be contracted by working around diseased animals,
by handling or tanning their hides, by sorting their hair or
wool ; it may be conveyed by eating infected meat or by
drinking infected milk. Flies may carry the poison. Inhala-
tion of poisoned dust may infect the lungs. Catgut ligatures
may be contaminated and carry the poison. Many attempts,

* Charters James Symonds, in Jltath's Dictionary of Practical Surgery.
' Medical Record^ Sept. 5, 1 896.

CONTUSIONS AND WOUNDS, 1 79

not altogether satisfactory, have been made to render ani-
mals immune (Pasteur, Wooldridge, Hankin). Certain or-
ganisms are antagonistic to anthrax (the streptococcus of
erysipelas, the pneumococcus, the micrococcus prodigiosus,
and the bacillus pyocyaneus).

Forms of Anthrax. — There are two forms of the disease
^-external and internal. Internal anthrax may be intestinal
from eating diseased meat or pulmonary from inhalation of
poisoned dust. External anthrax may be anthrax carbuncle
or anthrax edema. The external form appears in from three
to six days after inoculation, and presents a papule with a red
base ; the papule becomes a vesicle which contains bloody
serum ; the vesicle bursts and dries, the base of it swells and
enlarges, other vesicles appear in circles around it, and there
is developed an " anthrax carbuncle," which shows a black
or purple elevation with a central depression surrounded by
one or more rings of vesicles. Pain is trivial. Lymphatic
enlargements occur. Within forty-eight hours after the pus-
tule begins organisms appear in the blood. In loose con-
nective tissue the lesion may be anthrax edema, a spreading
livid edema followed by blebs and even by gangrene. The
constitutional symptoms may rapidly follow the local lesion,
but may be deferred for a week or more. The patient feels
depressed, has obscure aches and pains, and is feverish, but
usually keeps about for a short period. After a time he is
apt to develop rigors, high irregular fever, sweats, acute fugi-
tive pains, diarrhea, delirium, typhoid exhaustion, dyspnea,
cough, and cyanosis. The local carbuncle of anthrax is dis-
tinguished from ordinary carbuncle by the central depres-
sion, the adherent eschar, the absence of tenderness, and the
absence of suppuration of the first, as contrasted with the
elevated centre, the multiple foci of suppuration and slough-
ing, and the acute pain of the second. Anthrax edema dif-
fers from cellulitis in the absence of all tendency to form
pus, and from malignant edema by the greater tendency of
the latter to result in gangrene. If anthrax has a visible
lesion and the constitutional symptoms are slight or absent,
the chance of cure is good.

Treatment. — If a person is wounded by an object sus-
pected of carrying the infection, cauterize the wound with
the hot iron. A sufferer from anthrax must be isolated in a
well-ventilated room. All dressings are to be burnt, all
discharges asepticized, and after the removal of the patient
the bed-clothes are burnt and the room disinfected. A
malignant pustule should be entirely excised, and the wound

l8o MODERN SURGERY.

mopped out with pure carbolic acid or burnt with the hot
iron, and afterward dressed with wet bichlorid-of-mercury
gauze which is covered with an ice-bag. Excision should
be practised even when glands are enlarged, but it will prove
ineffectual if organisms are present in the blood. When
excision cannot be performed make crucial incisions through
the lesion, mop out with pure carbolic acid, and inject around
and in the pustule carbolic acid (i : lo) every six hours until
the disease abates or toxic symptoms appear. The adher-
ent eschar is subsequently removed by antiseptic poultices.
Davaine advised the following plan : Inject the pustule and
the tissues about it at many points every eight or ten hours
with I part of tincture of iodin diluted with 2 parts of water
or with a 10 per cent, solution of carbolic acid, or with a -^
per cent, solution of corrosive sublimate. Dress with wet
antiseptic gauze and apply an ice-bag. Inflamed lymphatic
vessels and glands should be painted with iodin and smeared
with ichthyol. Constitutional treatment is sustaining and
stimulating. Maffucci gives carbolic acid internally, and
also uses it externally. Davies-Colley uses ipecac locally
and gives large doses by the mouth. Pulmonary anthrax
and intestinal anthrax are always fatal. The treatment is
symptomatic.

Hydrophobia, Rabies, or I^yssa. — Hydrophobia is a
spasmodic and paralytic disease due to infection through a
wound with the virus from a rabid animal. The animal
may be a dog, a cat, a wolf, a fox, or a horse. Roux esti-
mates that about 14 per cent, of the people bitten by mad
animals develop the disease. If the bite is on an exposed
part, it is far more apt to cause rabies than if the teeth pass
through clothing. Hydrophobia is almost' invariably fatal.
The saliva is the usual vehicle of contagion, but other fluids
and tissues contain the virus, especially the brain and cord.

Symptoms. — The period of incubation of hydrophobia is
from a few weeks to two years. The initial symptoms are
mental depression, anxiety, headache, malaise, and often pain
or even congestion in the cicatrix, which symptoms are
quickly followed by a general hyperesthesia, pharyngeal
spasms, dyspnea from lar}'ngeal spasms, and constant attempts
to expectorate thick mucus which forms because of congestion
of the air-passages. Attempts at swallowing, as well as lights
and noises, tend to bring on spasms, hence the fear of liquids
(there is spasm from attempts at swallowing or from thinking
of the act). The entire body may be thrown into clonic spasms,
but there is no tonic spasm. The mind is usually clear.

CONTUSIONS AND WOUNDS. l8l

although during the periods of excitement there may be
maniacal furor with hallucinations which pass away in the
stage of relaxation. The temperature is moderately elevated
(ioi° to 103° or higher). This spasmodic stage lasts from
one to three days, and the patient may die during this period
from exhaustion or from asphyxia. If he lives through this
I>eriod, the convulsions gradually cease, the power of swal-
lowing returns, and the patient succumbs to exhaustion in
less than twenty-four hours, or he develops ascending paral-
ysis which soon causes cardiac and respiratory failure.

In hydrophobia death is practically inevitable. Almost
all cases in which it is alleged that recovery ensued were not
true hydrophobia, but hysteria. Wood says that in hysteria,
especially among boys, " beast-mimicry " is common, the suf-
ferer snarling like a dog, and in the form known as "spurious
hydrophobia," in which there may or may not be convulsion,
there are a dread of water, emotional excitement, snarling, and
attempts to bite the bystanders (in genuine hydrophobia no
attempts are made to bite, and sounds are uttered like those
made by a dog).

Lyssa is separated from lockjaw by the spasms of the
larynx and the absence of tonic spasms in the former, as
contrasted with the spasms of muscles of mastication and
the tonic spasms with clonic exacerbations of lockjaw.

Treatment. — When a person is bitten by a supposed rabid
animal, apply constriction above the wound if possible, excise,
and bum with the hot iron. Send the patient to a Pasteur
institute at once, that he may be given preventive inocula-
tions of an emulsion made from the dried spinal cords of
hydrophobic rabbits (attenuated virus). Pasteur discovered
the following remarkable facts : If the virus of a rabid dog
(street rabies) be placed beneath the dura of another dog, it
always causes hydrophobia in from sixteen to twenty days,
and invariably causes death. If the virus is passed through
a series of rabbits it gets stronger (laboratory virus), and if in-
serted beneath the dura of a dog, it causes the disease in from
five to six days, and kills in four or five days. The virus can
be attenuated by passing through a series of monkeys or by
keeping. To get attenuated preparations in a convenient
form he made emulsions from the cords of rabbits dead two
or three weeks. The emulsion obtained from the rabbit
longest dead is the weakest. He injected a dog with emul-
sions of progressively increasing strength and made it im-
mune to hydrophobia. These emulsions cause the body-cells
to develop antitoxins, which are already in the body when

1 82 MODERN SURGERY.

the street rabies virus begins to develop. The report of the
Parisian Pasteur Institute shows that since its foundation there
has been a mortality of 0.5 per cent. The lowest estimated
number of those attacked by hydrophobia before this method
was used was 5 per cent, of those bitten, and all attacked
died ; hence, the Pasteur treatment shows one-twenty-fifth
of the mortality which attends other preventive methods.
The value of this plan seems definitely established. Murri,
of Bologna, cured a case of hydrophobia by injecting emul-
sions of cords of rabbits dead six, five, four, and three days
respectively. This remedy should be tried. In the paroxysm
the treatment in the past was pailiative. If we try only pal-
liative methods, keep the patient in a dark, quiet room, re-
lieve thirst by enemata, saturate with morphin, in the parox-
ysms anesthetize, empty the bowels by enemata, and attend
to the bladder.

Glanders, Farcy, or Bquinia. — Glanders is an infec-
tious eruptive fever occurring in horses and communicable to
man. If the nodules occur in a horse's nares, we call the
disease ** glanders ;" if beneath his skin, it is termed " farcy."
This disease is due to the bacillus of Loffler, and is communi-
cated to man through an abraded surface or a mucous mem-
brane (Osier). The characteristic lesions are infective g^nu-
lomata, which in the nose form ulcers and under the skin
develop abscesses.

Acute and Chronic Glanders. — In acute glanders there is
septic inflammation at the point of inoculation ; nodules form
in the nose, and ulcerate ; there is profuse nasal discharge ;
the glands of the neck enlarge ; there are fever and an erup-
tion like small-pox on the face and about the joints (Osier)
and severe muscular pain. Acute glanders is always fatal.
Chronic glanders lasts for months, is rarely diagnosticated,
being mistaken for catarrh, and is often recovered from.
Diagnosis is made by injecting a guinea-pig with the nasal
mucus.

Acute and Chronic Farcy. — Acute farcy appears from a
skin-inoculation ; it begins as an intense inflammation, from
which run out inflamed lymphatics that present nodules or
" farcy-buds." Abscesses form. There are joint-pain and
the constitutional symptoms of sepsis, but no involvement
of the nares. Chronic farcy may last for months. In it
nodules occur upon the extremities, which nodules break
down into abscesses and eventuate in ulcers resembling
those of tuberculosis.

Treatment. — In treating this disease the point of infection

CONTUSIONS AND WOUNDS. 1 83

is at once to be incised and cauterized, dusted with iodoform,
and dressed antiseptically. Enlarged glands and swollen
lymphatics are to be painted with iodin and smeared with
ichthyol. Bandages are applied to edematous extremities.
Ulcers are curetted, touched with pure carbolic acid, dusted
with iodoform, and dressed antiseptically. The nose is sprayed
at frequent intervals with peroxid of hydrogen, and is fre-
quently syringed with sulphurous acid. The mouth is rinsed
repeatedly with solutions of chlorate of potassium. Open
the abscesses, swab out with pure carbolic add, and dress
antiseptically. Give stimulants and nourishing diet. Morphin
will be necessary for the muscular pain, restlessness, and in-
somnia. Digitalis is eiven to stimulate the circulation and
kidney secretion. Sulphur iodid, arsenite of strychnin, and
bichlorate of potassium have been used. Diseased horses
ought at once to be killed and their stalls torn out and puri-
fied. A man with chronic glanders should be removed to
the seaside. The nasal passages should be kept clean;
ulcers must be cauterized and dressed with iodoform gauze.
Nutritious foods, tonics, and stimulants are necessary.

Actinomycosis is an infectious disorder characterized by
chronic inflammation, and is due to the presence in the tis-
sues of the actinomyces or ray-fungus. This disease occurs
in cattle Humpy jaw) and in pigs, and can be transmitted to
man, usually by the food. At the point of inoculation (which
is generally about the mouth) arises an infective granuloma,
around which inflammation of connective tissue occurs, sup-
puration eventually taking place. Inoculation in the mouth
is by way of an abrasion of mucous membrane or through
a carious tooth. Chewing straw which contains the fungi is
the most common method of infection. The ray-fungi may
pass into the lungs, causing pulmonary actinomycosis ; into
the intestines, causing intestinal actinomycosis ; into the skin,
the bones, the subcutaneous tissues, the heart, the brain, the
liver, etc. Actinomycosis until very recently was looked
upon as sarcoma.

Cutaneous actinomycosis may be secondary to a visceral
area of disease, may be a purely local condition, or may be
associated with some adjacent area of bone-infection. The
gummatous form of the disease resembles a gummatous
syphilitic area, and in it many small purulent pockets open
by fistulae (Monestie).

In the anthracoid there are no distinct purulent collections,
but many fistulae discharge pus at various points (Monestie).

An area of cutaneous anthrax is characterized by the ex-

1 84 MODERN SURGERY.

istence of violet, blue, gray, or black maculae, varying in
size from that of a pin's head to that of a bean, the center
of each macule being white and containing a minute quantity
of pus (Derville).

The pus of actinomycosis contains many sulphur-yellow
bodies, visible to the naked eye and composed of fungi.
These bodies feel gritty when rubbed between the fingers
because of the presence of lime salts.

In actinomycosis of bone the bone enlarges and becomes
painful, the parts adjacent are infiltrated and soften, pus forms
and reaches the surface through fistulae, and the skin is often
involved secondarily.

In actinomycosis the adjacent lymphatic glands are not
involved. The diagnosis must be made from syphilis, sar-
coma, and tuberculosis. The microscopic examination of
the pus makes the diagnosis.

Treatment. — Free excision if possible; otherwise incision,
cauterizing with pure carbolic acid, and packing with iodo-
form gauze. Give internally large doses of iodid of potas-
sium. This drug alone has cured many cases.

Wounds of Mucous Membranes. — If the surgeon intends
to inflict a wound upon a mucous surface, he should see to it
that the patient's general condition is good. Thorough asepsis
is impossible, and a good result depends largely upon the
vital resistance of the tissues. Before operating many sur-
geons irrigate the part frequently with boric acid, a proceed-
ing of questionable value. When ready to sew up, be sure
that all irritant fluids are removed from the wound (saliva
in the mouth, etc.). Cleanse the wound with hot normal salt
solution. The stitches must include submucous tissue as
well as the mucous membrane, and consist of silver wire, silk,
or silkworm gut. After sewing up, wash often with salt so-
lution, and follow it by insufflation of iodoform.

In accidental wounds irrigate with salt solution, dust with
iodoform, and close as directed above. Corrosive sublimate
is so irritant that it does only harm when applied to a mu-
cous membrane.

XVI. SYPHILIS.

Definition. — Syphilis is a chronic infectious, and some-
times hereditary, constitutional disease. Its first lesion is an
infecting area or chancre, which is followed by lymphatic en-
largements, eruptions upon the skin and mucous membranes,
affections of the appendages of the skin (hair and nails),

SYPHILIS. 185

** chronic inflammation and infiltration of the cellulo-vascu-
lar tissue, bones, and periosteum *' (White), and, later, often
by gummata. This disease is probably due to a microbe,
but Lustgarten's bacillus has not been proved to be the one.
One fact against its being the cause is its presence in the
non-contagious late gummata. White quotes Fenger in his
assumption that syphilitic fever is due to absorption of
toxins ; that the eruptions of skin and mucous membranes
in the secondary stage arise from local deposit and multipli-
cation of the virus ; that many secondary symptoms result
from nutritive derangement caused by tissue-products passing
into the circulation ; that the virus exists in the body after
the cessation of secondary symptoms ; and that it may die
out or may awaken into activity, producing " reminders."

During the primary and secondary stages fresh poison can-
not infect, and this is true for a time after the disappearance
of secondary symptoms. Immunity in the primary stage is
due to products absorbed from the infected area. Colles's
immunity' is that acquired by mothers who have borne syph-
ilitic children, but who themselves show no sign of the dis-
ease. Profeta's immunity is the immunity against infection
possessed by many healthy children bom of syphilitic par-
ents. Tertiary syphilitic lesions are not due to the poison
of syphilis,- but to tissue-products from the action of that
poison, or to nutritive failure as a consequence of the disease.
Tertiary syphilis is not transmissible, but it secures immunity.

Transimssioii of Sjrphilis. — This disease can be trans-
mitted— (i) by contact with the tissue-elements or virus —
acquired syphilis ; and (2) by hereditary transmission — hered-
itary syphilis. The poison cannot enter through an intact
epidermis or epithelial layer, and abrasion or solution of con-
tinuity is requisite for infection. Syphilis is usually, but not
always, a venereal disease. It may be caught by infection
of the genitals during coition, by infection of the tongue or
lips in kissing, by smoking poisoned pipes, by drinking out
of infected vessels, or by beastly practices. The initial lesion
of syphilis may be found on the finger, penis, eyelid, lip.
tongue, cheek, palate, anus, nipple, etc. A person may be
a host for syphilis, carry it, give it to another, and yet escape
it himself (a surgeon may carry it under his nails, and a
woman may have it lodged in her vagina). Syphilis can be
transmitted by vaccination with human lymph which contains
the pus of a syphilitic eruption or the blood of a syphilitic
person. Vaccine lymph, even after passage through a per-
son with pox, will not convey syphilis if it is free from blood

1 86 MODERN SURGERY,

and the pus of specific lesions; it is not the lymph that
poisons, but some other substance which the lymph may
carry.

SjTpliilitic Stages. — Syphilis was divided by Ricord
into three stages : (i) the primary stage — chancre and indo-
lent bubo; (2) the secondary stage — disease of the upper
layer of the skin and mucous membranes; and (3) the
tertiary stage — affections of connective tissues, bones, fibrous
and serous membranes, and parenchymatous organs. This
division, which is useful clinically, is still largely employed,
but it is not so sharp and distinct as was believed by Ricord ;
it is only artificial. For instance, ozena may develop during
a secondary eruption, and bone disease may appear early in
the case.

SjTphilitic Periods.— White divides the pox into the
following periods: (i) period oi primary incubation— tht
time between exposure and the appearance of the chancre :
from ten to ninety days, the average being three weeks ; (2)
period of primary symptoms — chancre and bubo of adjacent
lymph-glands ; (3) period of secondary ifiaibaHon — the time
between the appearance of the chancre and the advent of
secondary symptoms : about six weeks as a rule ; (4) period
of secondary symptoms — lasting from one to three years ; (5)
intermediate period — there may be no symptoms or there may
be light symptoms which are less symmetrical and more gen-
eral than those of the secondary period : it lasts from two to
four years, and ends in recovery or tertiary syphilis ; and (6)
period of tertiary symptoms — indefinite in duration. The
fifth and sixth periods may never occur, the disease being
cured.

Primary Syphilis. — The primary stage comprises the
chancre or infecting sore and bubo. A chancre or initial
lesion is an infective granuloma resulting from the poison
of syphilis. A chancre may be derived from the discharges
of another chancre, from the secretion of mucous patches
and moist papules, from syphilitic blood, or from the pus or
secretion of any secondary lesion. Tertiary lesions cannot
cause chancre. It appears at the point of inoculation, and
is the first lesion of the disease. During the three weeks
or more requisite to develop a chancre the poison is con-
tinuously entering the system, and when the chancre devel-
ops the system already contains a large amount of poison.
A chancre is not a local lesion from which syphilis springs,
but is a local manifestation of an existing constitutional dis-
ease, hence excision is entirely useless. If we take the dis-

SYPHILIS, 187

charge of a chancre and insert it at some indifferent point
into the person from whom we took it, a new chancre will
not be formed, because he already has syphilis. Auto-
inoculation of the discharge of an irritated chancre can cause
a non-indurated sore. If we insert the poison into another
f)erson, a chancre is formed. Hence we say that primary
syphilis is not auto-inoculable, but is hetero-inoculable. A
soft sore can be produced in lower animals by inoculation,
but a hard sore cannot. Some observers, notably Kaposi,
of Vienna, advocate the unity theory. This theory main-
tains that both hard and soft sores are due to the same
virus, the infective power of the soft chancre simply being
less than that of the hard, the possibility of constitutional
infection depending, not upon differences in the poison, but
rather upon differences in the soil and in the local processes.
The unicists advocate excision of chancres, soft or hard, to
prevent, if po.ssible, constitutional involvement. Most syph-
ilographers believe in the duality theory, which we have
previously set forth. This theory took origin from the clas-
sical investigations of Bassereau and Rollet. The duality
theory maintains that the soft sore is caused by a different
poison than originates the hard sore, and that a true soft
sore never infects the system.*

Initial I/esions. — An initial lesion, hard chancre, or
infecting sore never appears until at least ten days after
exposure ; it may not appear for many weeks, but it usually
arises in about twenty-five days. There are three chief
forms of initial lesion : (i) a purple patch exposed by peeling
epidermis, without induration and ulceration — a rare form ;
(2) an indurated area under the epidermis, without ulceration
— a very common form ; and (3) a round, indurated, carti-
laginous area with an elevated edge, which ulcerates, expos-
ing a velvety surface looking like raw ham ; it bleeds easily,
it rarely suppurates, it does not spread, and the discharge
is thin and watery. This is the *' Hunterian chancre," which
is rarer than the second variety, but commoner than the
first, and which ulcerates because of dirt, caustic applications,
or friction.

A chancre is rarely multiple, but if it is so, all the sores
appear together as a result of the primary inoculation : they
do not follow one another because of auto-infection. A
hard sore does not suppurate unless irritated by caustics,
friction, or dirt, or unless there be mixed infection with

* For a full discussion of these points see the writings of Fournier, Alfred
Cooper, and Von 2^issl, and especially the great work of Taylor.

1 88 MODERN SURGERY.

chancroid; its nature is not to suppurate. The hardness
may affect only the base and margins of an ulcer or it may
affect considerable areas, but it has well-defined margins and
feels like cartilage encapsuled, so that it can be picked up
in the fingers. This hardness or sclerosis is due to gradual
inflammatory exudation into " the tissues at the base of the
ulcer and to growth of the nodule " (Von Zeissl). It feels
distinct from the surrounding tissues, like a foreign body
lying in the part. A chancre untreated may last many
months. The induration usually disappears soon after the
appearance of secondary symptoms. A copper-colored spot
remains, and does not disappear until the disease is cured.
An induration may again appear before the outburst of some
distant lesion.

Mixed Infection of Chancre and Chancroid. — Von

Zeissl says : " If syphilitic contagion is mixed with pus, a
chancre begins as a circumscribed area of hyperemia and
swelling, which undergoes ulceration, and does not develop
hardness for a period of from ten days to several weeks,
and may develop a nodule after the first ulcer has entirely
healed." We see this condition when mixed infection occurs,
the chancroid poison being quick, and the syphilitic poison
being slow, to act. If chancroid poison is deposited some
time after the syphilitic poison has been absorbed, the indu-
ration may appear in a few days after the chancroid begins.
A soft chancre may appear upon an existing syphilitic nodule
and may eat out the induration.

Diagnosis of Chancre. — We must separate a chancre
from a chancroid and from ulcerated herpes. A chancroid
appears in from two to five days after contagion (always less
than ten days) ; it may be multiple from the .start, but, even
if beginning as one sore, other sores appear by auto-inocu-
lation ; it begins as a pustule, which bursts and exposes an
ulcer ; this ulcer is circular, has thin, sharp-cut, or undermined
edges, a sloughy, non-granulating base, and a thin, purulent,
offensive discharge which is both auto- and hetero-inocu-
lable. These soft sores have no true sclerotic area, do not
bleed, produce no constitutional symptoms, and are apt to
be followed by acute inflammatory buboes which tend to
suppurate. A chancroid causes pain, and the original ulcer
enlarges greatly. A chancre appears in about twenty-five
days after inoculation (never before ten days) ; it is generally
single, but if multiple sores exist, they all appear together,
for their discharge is not auto-inoculable ; if the sore is not
irritated, an auto-inoculation of the products of an irritated

SYPHILIS, 189

chancre can at most produce only a soft purulent ulcer.
It begins as an excoriation or as a nodule ; if an ulcer forms,
its base is covered with granulations and it is red and
smooth ; its discharge is thin and scanty and not offensive ;
its edges are thick and sloping ; it is surrounded by an area
of induration, and bleeds when touched ; it is followed by
secondary symptoms, and there appear about the same time
with it indolent multiple enlargements of the adjacent glands,
which rarely suppurate. A chancre causes little pain, and after it
has existed for a few days rarely shows any tendency to spread.
Herpetic ulceration has no period of incubation ; it may
follow fever, but usually arises from friction or the irritation
of dirt or acrid discharges. It appears as a group of vesi-
cles, all of which may dry up, or some may dry up and
others ulcerate, or they may run together and ulcerate. The
edges of a herpetic ulcer are in " segments of small circles "
(White) ; the ulcer is superficial, has but little discharge, and
does not have much tendency to spread ; it has no indura-
tion ; it is painful ; it has no bubo unless suppuration is
extensive, and there is no constitutional involvement. A
urethral chancre appears after the usual period of incubation ;
it is situated near the meatus, one lip of which is usually
indurated ; the discharge is slight, often bloody, and never
purulent ; indurated multiple buboes arise ; the sore can be
seen, and constitutional symptoms follow (White). A chan-
cre may be mistaken for cancer of the tongue. " A chancre
of this region is brownish-red, a cancer being bright red.
A chancre is soft in the center ; a cancer presents uniformity
of induration. A chancre has a thin, purulent discharge,
free from blood ; a cancer has a non-purulent, bloody dis-
charge. A chancre is followed by indolent lymphatic en-
largements under the jaw ; a cancer is followed by painful
enlargements." A cancer is slower in evolution, is not fol-
lowed by constitutional symptoms, and the lymphatic en-
largements are much later in appearing than in chancre. A
chancre can be attacked by phagedena, a very destructive
form of ulceration which was at one time common, but at
the present day is rare. The ulceration often spreads on all
sides and also deeply into the tissues. In some cases it
spreads in only one direction (serpiginous ulceration), in
some cases sloughing occurs. Phagedena occurs only in
the debilitated (anemic, drunkards, strumous subjects, suf-
ferers from diabetes, Bright's disease, etc. ; salivation can
cause it). The phagedenic ulcer is irregular, with congested
and edematous edges, and a foul, sloughy floor.

190 MODERN SURGERY.

SjTphilitic Bubo. — In syphilitic bubo anatomically related
lymphatic glands enlarge about the same time as induration
of the initial lesion begins. In the very beginning these
glands may be a little painful, but they soon cease to be so.
These enlargements are called " indolent buboes ;" they may
be as small as peas or as large as walnuts, are freely movable,
and very rarely suppurate. The lesion of these glands is
hyperplasia of all the gland-elements and of their capsules,
due to absorption of the virus. If a man is strumous, the
bubo is apt to become enormous, lobulated, and persistent
If the chancre appears on the penis, the superficial inguinal
and femoral glands enlarge, usually on the same side of the
body as the sore ; if the sore is on the frenum, both groins
arc involved. If a chancre appears on the lip or tongue, the
bubo is beneath the jaw. These buboes may remain for many
months ; they do not suppurate unless the sore suppurates or
unless the patient is of the tuberculous type ; and they finally
disappear by absorption or fatty degeneration. About six
weeks after buboes have formed in the glands related to the
lesion, all the lymphatics of the body enlarge. General
lymphatic involvement arises about the same time as the
secondary eruption. The enlargement of the post-cervical
and epitrochlear glands is diagnostically important. These
glandular enlargements persist until after the eruptions have
disappeared.

The bubo of syphilis is always present, while the bubo
exists in only one-third of the chancroid cases. The bubo
of syphilis is multiple, consisting of a chain of movable glands
(the glandular Pleiades of Ricord) ; the bubo of chancroid is
one inflamed and immovable mass. The bubo of syphiHs is
indurated, painless, small, and slow in growth ; the bubo of
chancroid shows inflammator}- hardness, is painful, large, and
rapid in growth ; the first rarely suppurates, the second often
does. The skin over a syphilitic bubo is normal ; that over
a chancroidal bubo is red and adherent. A syphilitic bubo
is not cured by local treatment, but is cured by the internal
use of mercur}' and is followed by secondary symptoms. A
chancroidal bubo requires local treatment, is not cured by
mercur}% and is not followed by secondaries. Herpes, balan-
itis, and gonorrhea rarely cause bubo, but when they do the
bubo in each case is similar to that caused by chancroid. A
positive diagnosis of syphilis can be made when an indurated
sore is followed by multiple indolent buboes in the groin and
by enlargement of distant glands.

General Sjrphilis. — As the general h-mphatic enlarge-

SYPHILIS. 191

ment becomes manifest there is apt to appear a group of
symptoms known as " syphilitic fever." The patient usually
thinks he has a bad cold and is feverish and restless; he
complains of sleeplessness and anorexia ; his face is pale ; he
has intermitting rheumatoid pains in the joints and muscles,
especially of the shoulders, arms, chest, and back, which pains
change their location constantly and prevent sleep ; night-
sweats occur, and the pulse is quite frequent. This fever
usually reaches its height in forty-eight hours, and falls as
the eruption develops. Syphilitic fever does not always arise.
It may reappear during the progress of the disease.

Secondajry Sjrplmis. — The phenomena of secondary
syphilis arise from poisoned blood. Fenger states that the
poison is present in the blood during outbreaks, but not dur-
ing the quiescent periods between outbreaks. Secondary
syphilis is characterized by plastic inflammation, by the for-
mation of fibrous tissue, and by thickening of tissue. Super-
ficial ulcerations may occur. Structural overgrowths appear
(warts).

Sjrphilitic Skin Diseases. — Syphilodermata (syphilides),
due to circumscribed inflammation, may be dry or purulent.
There is no one eruption characteristic of syphilis. This dis-
ease may counterfeit any skin disease, but it is an imitation
which is not perfect and is never a counterpart. Syphilitic
eruptions are often circumscribed ; they terminate suddenly
at their edges, and do not gradually shade into the sound
skin. In color they are apt to be brownish-red, like tarnished
copper; especially is this the case in late syphilides. Hutch-
inson cautions us to remember that an ordinary non-specific
eruption may be copper-colored, especially in people with
dark complexion and when it occurs on the legs. Eruptions
are apt to leave a brownish stain. Early syphilitic eruptions
are symmetrical. Syphilitic eruptions have an affection for
particular regions, such as the forehead, the abdomen and
chest, the neck and scalp, about the lips and the alae of the
nose, the navel, anus, groins, between the toes, and upon the
palms and soles. Early secondary eruptions rarely appear
on the face or hands. Specific eruptions are polymorphous,
various forms of eruption being often present at the same
time, so that roseola is seen here, papules there, etc. These
syphilides do not cause as much itching as do non-spe-
cific eruptions, except when they occur about the anus or
between the toes. They tend to an arrangement in curved
lines.

Forms of Eruption. — The chief forms of eruption are

192 MODERN SURGERY,

(i) erythema, (2) papular syphilides, (3) pustular syphilides,
and (4) tubercular syphilides. Besides these eruptions pig-
mentation may occur (pigmentary syphilide), and blood may
extravasate (purpuric syphilide).

Prince A. Morrow does not believe in erecting the vesicu-
lar syphilide into a special group. He tells us that vesicles
sometimes form on erythemato-papular lesions, but their
presence is an accident and not a regular phenomenon. So,
too, the bullous syphilide is a rare accident in a case, and
even when it occurs soon becomes pustular. The pem-
phigoid syphilide is found almost exclusively in hereditary
disease.*

I. Erythema [maculce, roseola, or spots) presents round,
circumscribed, red, hyperemic spots, about one-eighth of an
inch in diameter, whose color does not entirely disappear on
pressure in an old eruption but does in a recent one. In the
papular form of erythema the spots are a little elevated. It
is rare upon the face and dorsum of the hands and feet. It
attacks especially the chest and belly, but appears often on
the forehead, the bend of the elbow, and the inner portion of
the thigh, the neck, and the flexor surface of the forearms and
arms. Usually erythema follows syphilitic fever, about six
weeks after the chancre appears, and the number and dis-
tinctness of these spots are in proportion to the violence of
the fever. Absent or slight fever means few and transient
spots. In rare cases the disease is very transitory, lasting
but a few hours, but it usually lasts for several weeks if un-
treated. It may pass away or may be converted into a papu-
lar eruption. Mercury will cause it to disappear in a couple
of weeks. In examining for this form of eruption in a doubt-
ful case, let cold air blow upon the chest and belly (Heam) ;
this blanches the sound skin and makes clear any di.scolora-
tion. No desquamation attends this eruption. A brownish
stain remains for a variable time after the eruption fades.
Er\'thcma means, as a rule, a mild and curable attack. Mac-
ulae may be combined with the next form, constituting a
maculo-papular eruption.

The maculo-papular syphilides are evolved from the macu-
lar syphilides. They are slightly elevated, are situated upon
a hyperemic base, and the summit of some of them may un-
dergo slight desquamation. A roseolar area may show one
or several of these macular papules. They are apt to arrange
themselves in segments of a circle, and are symmetrically
distributed. This eruption usually appears early, but may

^ Morrow's SysUm of Genito-urittary Diseases, Syphilology, and Dermatology.

SYPHILIS. 193

appear late. It may fade and reappear several times in the
same patient. The eruption lasts a few weeks.

2. Papular Byphilidee, which are papules or elevations cov-
ered with dry skin, may or may not have a crust. They usu-
ally appear from the third to the sixth month of the disease.
They may be preceded by fever, and often reappear again
and again. They are at first red, but become brownish. They
are firm in feel and vary in size from the head of a pin to a five-
cent piece or larger. They may be present as miliary papules,
lenticular papules, papules which scale off (papulo-squamous
eruption), and moist papules. Papules on fading leave cop-
pery looking stains. Papules upon the palms and soles
constitute the so-called " palmar and plantar psoriasis," which
appears from three months to one year after the appearance
of the chancre. These papules just below the line of the hair
on the forehead constitute the corona venerea. This eruption
affects especially the forehead, the neck^ the abdomen, and
the extremities. The papular or squamous syphilide of the
palms and soles begins as a red spot which becomes elevated
and brownish ; the epidermis thickens and is cast off, and
there then remains a central red spot surrounded by under-
mined skin. If papules are in regions where they are kept
moist (as about the anus), they become covered with a sod-
den gray film which comes off and leaves the papule without
epidermis. These sodden papules are called " flat condylo-
mata," moist or humid papules or plates. Papules which are
at first small may become large. The small or miliary papules
constitute syphilitic lichen. The lenticular papules are most
common, and strongly tend to scale off. The papular syph-
ilide gives a worse prognosis than roseola.

3. Pustular syphilides arise from papules. We have acne
when the apex of a papule softens, impetigo when the whole
papule suppurates, and ecthyma or mpia when the corium is
also deeply involved. Vesicles occasionally precede pustules.
The pustular eruption appears some months after infection
(later than the papular). The pustular eruption gives a very
bad prognosis. Rupia is formed by a pustule rupturing or a
papule ulcerating, the secretion dr>'ing and forming a conical
crust which continually increases in height and diameter,
while the ulceration extends at the edges. When the crust
is pulled off there is seen a foul ulcer with congested, jagged,
and undermined edges. Rupia may be secondary or tertiary,
and it invariably leaves scars. It appears only after at least
six months have passed since the chancre began. Secondary
rupia is symmetrical. Tertiary rupia is asymmetrical.

J94 MODERN SURGERY.

4. Tubercular syphilidee are greatly enlarged papules
intermediate between ordinary papules and gummata.

Diagnosis bctivccji Secondary and Tertiary Syphilidcs. — A
secondary eruption is distinguished from a tertiary eruption
by the following: the first tends to disappear, the second
tends to persist and to spread ; the first is general and sym-
metrical, the second is local and asymmetrical ; the first does
not spread at its edge, the second tends to spread at its
edge, and this tendency, which is designated " serpiginous/'
produces an ulcer shaped like a horse-shoe (Jonathan Hutch-
inson). Secondary lesions appear within certain limits of
time, develop regularly and are dispersed by mercurial treat-
ment. Tertiary lesions appear at no fixed time, develop
irregularly, and are not cleared up by mercury.

.^Sections of the Mucous Membranes. — The chief

lesions in syphilitic affections of the mucous membranes are
mucous patches, warts, and condylomata. The first phe-
nomena of secondary syphilis are, as a rule, symmetrical
ulcers of the tonsils, painless and superficial (Hutchinson).
The borders of the ulcers are gray, and the areas are reni-
form in shape. They rarely last long. Catarrhal inflamma-
tions often occur. Eruptions appear on the mucous mem-
branes or upon the skin. Mucous patches are papules de-
prived of epithelium ; they are gray in color, are moist, and
give off an offensive and virulent discharge. They usually
appear as areas of congestion, swelling, and abrasion of the
epidermis upon the lips, palate, gums, tongue, cheeks, vagina,
labia, vulv^a, scrotum, anus, and under the prepuce. A moist
papule of the skin is really a mucous patch. These patches,
which are always circular or oval, are among the most con-
stant lesions of the secondary stage, appearing from time to
time during many months. If a patch has the papillae de-
stroyed, it is called a *' bald patch." If the papules present
hypertrophied papillae fused together, there appear enlarge-
ments with flat tops, termed " condylomata ;" if the papillae
of the papule hypertrophy and do not fuse, the growths are
called " warts." Mucous lesions of the mouth are commonest
in smokers and in those with bad or neglected teeth. Hutchin-
son says that persistence in smoking during syphilis may cause
leukomata, or persistent white patches. The vagina and lips
of the vulva are often covered with mucous patches. The
uterus may contain mucous lesions which poison the uterine
discharge. The larynx may suffer from inflammation, erup-
tions, and ulceration (hence the hoarse voice which is so
usual). The nasal mucous membrane may also suffer. The

SYPHILIS. 195

rectal mucous membrane may be attacked with patches, and
so may the glans penis and inner surface of the prepuce.
Early in the secondary stage in some cases there is a slight
mucopurulent urethral discharge. Examination with an en-
doscope shows redness of the mucous membrane of the
anterior urethra. The discharge is contagious. The con-
dition may be followed by constriction of the urethral cali-
ber. Mucous patches may form in the urethra and ulcera-
tions can take place.

Affections of the Hair. — In syphilitic affections the
hair is shed to a great extent. This loss may be widespread
(beard, moustache, head, eyebrows, pubic hair, etc.) or it may
be limited. Complete baldness sometimes ensues, but this
is rarely permanent. The hairs are first noticed to come out
on the comb ; on pulling them they are found loose in their
sheaths — so loose that Ricord has said "a man would
drown if a rescuer could pull only upon the hair of the
head." This falling out of the hair, which is known as
" alopecia," begins soon after the fever or about the time
of the eruption, but it may be postponed. The skin of a
syphilitic bald spot is never smooth, but is scaly. The hair
may thin generally, baldness may appear in twisting lines,
or it may be complete only in limited areas. Alopecia
results from shrinking of the hair-pulp, death of the hair,
and casting off of the sheath.

Affections of the Nails. — Paronychia is inflammation
and ulceration of the skin in contact with a nail and extend-
ing to the matrix. The nail is cast off partially or entirely.
Onychia is inflammation of the matrix and is manifested by
white spots, brittleness or extended opacity, twisting, and
breaking off of the nail. The parts around are not affected.
The damaged nail drops off and another diseased nail appears.

Affections of the Hat. — Temporary impairment of
hearing in one or both ears is not uncommon in syphilitic
affections of the ear. Rarely, permanent symmetrical deaf-
ness is produced. Meniere's disease is sometimes caused by
syphilis.

Affections of the Bones and Joints. — In syphilis

there may be slight and temporary periostitis. Pain and
tenderness arise in various bones, the pain being worse at
night (osteocopic pains). The bones usually involved are
the tibiae, clavicles, and skull. Pain like that of rheumatism
affects the joints. Local periostitis may form a soft node
which by ossification becomes a hard node. Symmetrical
synovitis has been noted.

196 MODERN SURGERY,

Affections of the Bye. — Iritis is the commonest trouble
of the eyes. It appears from three to six months after the
chancre, and begins in one eye, the other eye soon becoming
affected. The symptoms are a pink zone in the sclerotic,
ciliary congestion, muddy iris, irregularity of the pupil accent-
uated by atropin, the existence of pain and photophobia, and
sometimes hazy or even blocked pupil. Rheumatic iritis
causes much pain and photophobia, syphilitic iritis compara-
tively little ; there is less swelling in the first than in the sec-
ond ; the former tends to recur, the latter does not. Iritis is
usually recovered from, good vision being retained. Diffuse
retinitis and disseminated choroiditis never occur until a
number of months have passed since the infection. The
symptoms are failure of sight, muscae volitantes, and very
little photophobia. Diagnosis of retinitis and choroiditis is
by the ophthalmoscope.

Affections of the Testes. — Syphilitic Sarcocele.—
The testes enlarge from plastic inflammation. Both glands
usually suffer, but not always. Fluid distends the tunica
vaginalis. The epididymis escapes. The testicle is not the
seat of pain, is troublesome because of its weight, and has
very little of the proper sensation on squeezing. The plas-
tic exudate is generally largely absorbed, but it may organ-
ize into fibrous tissue, the organ passing into atrophic
cirrhosis.

Intermediate Period. — Secondary lesions cease to
appear in from eighteen months to three years. In the
intermediate period no symptoms may appear, but the dis-
ease is still for some time latent and is not cured. Symp-
toms may appear from time to time. These symptoms,
which are called " reminders," are not so severe as tertiary
symptoms ; reminders are apt to be symmetrical, and they
do not closely resemble secondary lesions. Among the re-
minders we may name palmar psoriasis and sarcocele. Sar-
cocele in this stage is bilateral and rarely painful. Bilateral
indolent epididymitis occasionally occurs. Sores on the
tongue, a papular skin-eruption, and choroiditis may arise.
Gummata occur in this stage, but they are apt to be sym-
metrical and non-persistent. Arteritis occurs, beginning in
the intima or adventitia, and causing, it may be, aneurysm,
embolism, or thrombosis. Obliterative endarteritis may
cause gangrene. This vascular condition is frequent in the
brain ; thrombosis may occur, in which case a paralysis
comes on gradually, preceded by numbness, although sud-
den paralysis may occur. These paralyses may be limited.

SYPHILIS, 197

extensive, transitory, or permanent. The nervous System
often sufTers in this stage (anesthetic areas and retinitis).
The viscera are often congested and infiltrated (tonsils, liver,
spleen, kidneys, and lungs).

Tertiary Sjrpl^Uis* — This stage is not often reached, the
disease being cured before it has been attained. It is re-
garded by many as not so much a stage of syphilis as a
condition of impaired nutrition which results from the dis-
ease. This view finds confirmation in the fact that tertiary
lesions do not furnish the contagion. The primary stage
disappears without treatment, the secondary stage tends
ultimately to spontaneous disappearance, but tertiary lesions
tend to persist and to recur. Tertiary lesions may be single
or may be widely scattered; when multiple they are not
symmetrical except by accident These lesions may attack
any tissue, even adder many years of apparent cure ; they all
tend to spread locally, they all leave permanent atrophy or
thickening, they all tend to relapse, and a local influence is
often an exciting cause.

Tertiary akin-eruptions are liable to ulcerate. Various
eruptions may occur: papular syphilides, pustular syph-
ilides, gummatous syphilides, serpiginous syphilides, and
pigmentary syphilides. The characteristic syphilide is rupia^
which is formed by a pustule rupturing or a papule ulcer-
ating. A crust forms because of the drying of the discharge,
ulceration continues under the crust, new crusts form, and,
as the ulcer is constantly increasing peripherally, the new
crusts are larger in diameter than the old ones, and the
mass assumes the form of a cone. An ulcer is exposed
by tearing off the crust, which ulcer has destroyed the
deeper layers of the skin, and on healing always leaves a
permanent scar.

Serpigrinous ulcers are common in tertiary syphilis, and
are especially common about the knees, nostrils, forehead,
and lips. Serpiginous ulceration is spoken of as syphilitic
lupus. It is preceded by a widespread, brown-colored nod-
ular cutaneous infiltration. The nodules suppurate, run
together, crust, and produce an ulcer which spreads rapidly
and is the shape of a horseshoe.

Gumma. — The gumma is the typical tertiary lesion. A
gumma arises from an inflammation the products of which
cannot organize for want of sufficient blood-supply, and
which consequently undergo fatty degeneration. A gumma
presents a center of gummy degeneration, a surrounding
area of immature fibrous tissue, and an outer zone of em-

198 MODERN SURGERY,

bryonic tissue and leukocytes. A gumma, when it is spon-
taneously evacuated, exhibits a small opening or many open-
ings with very thin red and undermined edges ; the ulcer is
slow to heal, and forms a thin scar, white in the center, but
pigmented at the margins and usually depressed (Jonathan
Hutchinson, Jr.). These ulcers when once healed rarely
recur. Such ulcers are apt to be seen upon the legs. The
gummatous ulcer is deep, circular in outline, with under-
mined edges and an uneven floor covered with a thick white
adherent slough. Sometimes there is no slough, but an
e.xtensive area is infiltrated. A gummatous ulcer may coa-
lesce with one or more adjacent ulcers. The discharge is
scanty and tenacious. A gumma in the internal organs may
become a fibrous mass. These gummata form in the skin,
subcutaneous tissues, muscles, tongue, joints, bursae, testes,
spinal cord, brain, and internal organs. In tertiary syphilis
an inflammation may not form a circumscribed gumma, but,
instead, may produce a diffuse degenerating mass. This
type of inflammation, which is seen in bones, is called " gum-
matous." A healing gumma in a mucous canal such as the
rectum or larynx causes thickening and stricture. Tertiary
syphilis is a most common cause of amyloid degeneration
and arterial and nervous sclerosis.

Vajious Lesions. — Hutchinson enumerates the lesions
of tertiary syphilis as follows : Periostitis, forming nodes or
causing sclerotic hypertrophy or suppuration or necrosis;
gummata in various parts ; disease of the skin of the type
of rupia or lupus ; gumma or inflammation of tongue, causing
sclerosis ; structural changes in the nervous system, causing
ataxia, ophthalmoplegia externa and interna, general paresis,
optic atrophy, and paralyses of cerebral nerves; amyloid
degenerations ; and chronic inflammation of certain mucous
membranes (of the mouth, pharynx, vagina, rectum, etc.).
with thickening and ulceration. Unilateral enlargement of
the epididymis is sometimes noted, the mass feeling heavy,
aching a little, but not being very tender. Unilateral sarco-
cele may be met with.

Visceral Syphilis. — In visceral syphilis the lungs may
undergo fibroid induration (syphilitic phthisis). Syphilitic
phthisis is a nonfebrile malady. Gummata may form in the
heart, liver, spleen, or kidneys. The capsule and fibrous septa
of the liver may thicken, the organ being puckered from con-
traction. Amyloid changes may appear in any of the vis-
cera. Albuminuria may occur in tertiary syphilis. It may
be caused by fibroid changes in the kidneys, by the formation

SYPHILIS. 199

of gummata, or by amyloid degeneration. Its occurrence
should be watched for. Mercury and iodid of potassium
have been suspected as causative of albuminuria.

Nervous syphilis may be manifested in disorders of the
brain, cord, or nerves. Brain syphilis is usually a late phe-
nomenon (from one to thirty years), and is more apt to ap-
pear after light secondaries. The lesion may be gumma of
the membranes (tumor), gummatous meningitis, arterial
atheroma, or obliterative endarteritis. A gumma may
eventuate in a scar, a cyst, or a calcareous mass. The
symptoms of brain syphilis depend on the nature, seat,
and rate of development of the lesions. It is to be noted
that syphihtic palsy is apt to be limited, progressive, and
incomplete. Epilepsy appearing after the thirtieth year is
very probably specific if alcohol as a cause can be ruled
out (Wood). Persistent headache, tremor, insomnia or som-
nolence, transitory, limited, and erratic palsies ; unnatural
slowness of utterance, amnesia, vertigo, and epilepsy are
very suggestive. Sudden ptosis is very significant; so is
sudden palsy of one or more of the extrinsic eye-muscles. In
syphilitic insomnia the patient cannot get to sleep at night for
a long while, but when he once gets to sleep he reposes well.
The more usual type of insanity is a likeness or counterpart
of general paralysis. Spinal syphilis may cause sclerosis, a
condition like Landry's paralysis, softening, and tumor.
Neuritis is not uncommon in syphilis.

Treatment of Primary Stage. — A chancre should not
be excised. The disease is constitutional when the chancre
appears, and excision and cauterization inflict needless pain
and do no good. The initial lesion should never be cauter-
ized unless it is phagedenic or becoming so. Order the patient
to soak the penis for five minutes twice daily in warm salt
water (a teaspoonful of salt to a cupful of water), and then
to spray the sore by an atomizer with peroxid of hydrogen
(14-volume solution of peroxid diluted with an equal bulk
of water). The ulcer is then dried with absorbent cotton
and on it is dusted a powder of equal parts of bismuth
and calomel. The buboes in the groin require no local
treatment unless they tend to suppurate. If they persist
or become large, paint them with iodin or smear ichthyol oint-
ment over them, and apply a spica bandage of the groin.
Ichthyol and lanolin make an excellent application for the
enlarged glands, and so does mercurial ointment. Some
authorities give mercury in this stage, claiming that it pre-
vents secondaries. The younger Gross opposed this strongly,

200 MODERN SURGERY.

and affirmed a wish to see the secondary eruption — first,
because it proves the diagnosis; and, second, because it
affords valuable prog^nostic indications (an erythematous
eruption means a light case; an early pustular eruption
means a grave case with serious complications). White
will not order mercury until constitutional symptoms de-
velop. If phagedena arises, place the patient at once upon
stimulants and nutritious diet. Give him quinin, iron, strych-
nin, and whiskey. Secure sleep. Destroy the ulcer by the
use of nitric acid or the electric cautery while the patient is
anesthetized. Dust with iodoform and dress with wet antisep-
tic gauze. Several times a day change the dressings, and at
each change spray with peroxid of hydrogen, irrigate with
bichlorid of mercury solution, and dust with iodoform. It
may be necessary to cauterize several times. These cases
are sometimes fatal and usually produce great destruction of
tissue.

Treatment of Secondary Stage. — In the secondary
stage the aim is to cure the disease. That it can be cured
is known from the fact that reinfection occurs in some
persons. The old axiom, " Syphilis once, syphilis ever," is
not true. Mercury must be used, the form being a matter
of choice. Foumier first advocated intermittent treatment.
In this plan give gr. \ of protiodid of mercury daily for
six months, then stop a month ; then give mercury for three
months, then stop two months. During the first year the
patient is under treatment nine months, and during the
second year eight months. Some prefer the intermittent
and others the continuous plan of treatment. White
greatly prefers the continuous plan. The rule in most cases
is to give mercury for two years. Find the patient's dose
of tolerance, and keep him on this amount. Gross' rule
for continuous treatment was to order pills of the green
iodid of mercury, each pill containing gr. \, The patient
was ordered one pill after each meal to begin with ; the next
day he took two pills after breakfast ; the following day, two
after dinner, and so on, adding one pill every day. This
advance was continued until there was slight diarrhea,
griping, a metallic taste, or tenderness on snapping the
teeth together, whereupon one pill was taken off each day
until all unfavorable symptoms disappeared. This experi-
mentation finds a dose on which the patient can be kept
with entire safety for a long time ; but if it is found that colic
or diarrhea is apt to recur, there must be added to each pill
gr. ^ of opium. The patient is given mercury in this way

SYPHILIS. 20 1

for two years. Every time new symptoms appear the dose
is raised, and as soon as they disappear it is lowered to
the standard. If the protiodid is not tolerated, give the
bichlorid :

B* Hydrarg. chlor. corros., S'j'

Syr. sanaporillae comp., ^iij- — ^•

Sig. f^j, in water, after meals.

Mercury with chalk in i -grain doses four times a day, with
or without Dover's powder in ^grain doses, can be used.
Mercurial inunctions produce a rapid effect, but irritate the
skin. There can be used once a day \ dram of oleate of
mercury (10 per cent) or i dram of mercurial ointment,
rubbed in, one day on the inside of one thigh and the next
day on the inside of the other thigh ; next, the inside of one
arm and then the other arm ; next, one groin and then the
other groin, and so on. After the rubbing the patient puts
on underclothes and goes to bed, and in the morning takes
a bath. The ointment may be smeared on a rag, which is
then worn between the stocking and sole of the foot during
the day.

Fumigation is performed by volatilizing each night 3j of
calomel. The patient sits naked on a cane-seat chair, the
calomel is put upon an iron plate under the chair and is
heated by an alcohol lamp beneath the plate, and wrapped
around the patient is a blanket which drops tent-like to the
floor. The skin becomes coated with calomel, and the sub-
ject, after putting on woollen drawers and an undershirt,
gets into bed. Hypodermatic injections of mercur>' are used
by some physicians. They cause an eruption to disappear
rapidly, but may produce abscesses, and relapses are prone
to occur. The usual plan is to give daily a hypodermatic
injection of corrosive sublimate deep into the back or but-
tocks, the dose being gr. \ of the drug. Thirty such injec-
tions are used unless some indication points to their discon-
tinuance sooner. The treatment is then stopped. If the
symptoms recur, however, the patient is given another
course, the daily dosage being gr. \, the treatment being
again stopped after thirty injections, but continued anew in
^grain doses if the symptoms recur. Orville Horwitz
has recently made thorough trial of this method, and arrives
at the following conclusions : it will not abort the disease ;
it should never be a routine treatment ; in suitable cases it is
very valuable for symptomatic use, as when lesions on the
face or in important structures make a rapid impression de-

202 MODERN SURGERY,

sirable or necessary ; in cases which obstinately relapse under
other treatment, and in syphilis of the nervous system. Some
physicians use the gray oil.

J. WiUiam White, after a large experience with this
method, says that hypodermatic injections of corrosive
sublimate are painful and are strongly objected to by many
patients ; that this method of treatment is occasionally dan-
gerous and even fatal ; that it is liable to be followed by local
complications (erythema, nodosities, cellulitis, abscess, slough-
ing) ; that it cannot be carried out by the patient, but requires
the surgeon's constant intervention. This distinguished syph-
ilographer concludes that hypodermatic medication does not
offer advantages justifying its use as a systematic method of
treatment, and that it encourages insufficient treatment —
those ** short heroic courses " which Hutchinson shows are
followed by the gravest tertiary lesions. "The claim that
by a few injections the time of treatment can be measured by
months or even by weeks, instead of by years, would seem,,
as Mauriac has said, to involve the idea that mercury given
hypodermatically acquires some new and powerful curative
property which, given in other ways, it does not possess." ^
Some surgeons employ intravenous injections of mercury.
Lane injects, at first every other day and later daily, 20ITI of
a 1 per cent, solution of cyanid of mercury. The injectioa
is made in a vein in front of the elbow, the skin is rendered
aseptic, a fillet is tied around the arm, the needle is inserted,,
the fillet is loosened, the fluid is injected, and the needle is
withdrawn. This method of using mercury is painless and
produces a rapid effect. It may be used in nervous syphilis,,
but is not used as a routine. In whatever way mercury is given,,
do not let it salivate (hydrargyrism). Always remember that
mercury may cause albuminuria. Examine the urine at regu-
lar intervals. If albumin appears in urine, cut down the dose
or stop the drug for a time. In the beginning of a case of
syphilis, if the kidneys are found to be diseased, give the
mercury cautiously, and never fail to examine the urine at
regular intervals.

Acute Ptyalism, or Salivation. — In acute ptyalism the
saliva becomes thick and excessive in amount ; the gums be-^
come tender (found first by snapping the teeth), spongy, and
tend to bleed ; a metallic taste is complained of; the breath
becomes fetid ; all the oral structures swell ; the teeth loosen;
the saliva is produced in great quantity ; and there are purging^

* J. William White, in Morrow's System of Gcttito ttrinary Diseases^ ^XP^
ilology, and Dermatology.

SYPHILIS, 203

colic, and exhaustion. Sometimes there is fever and a diffuse
scarHtiniform eruption upon the skin. A chronic hydrargy-
rism may be shown by gastro-intestinal disorder, emaciation,
mental depression, weakness, albuminuria, and tremor. To
avoid salivation cautiously advance the dose and instruct the
patient as to the first signs. He should use a soft toothbrush
and an astringent mouth-wash (gr. xlviij of boric acid to
3iv each of Listerin and water). When ptyalism begins, stop
the drug. Employ the above mouth-wash or one composed
of a saturated solution of chlorate of potassium. Order gr.
Y^ of atropin twice a day, and in bad cases spray the mouth
with peroxid of hydrogen and use silver nitrate locally (gr.
XX to 5j). Give stimulants and nutritious food — ^iron, quinin,
and strychnin. A weekly Turkish bath is of great use. In
chronic hydrargyrism stop the drug, use tonics, stimulants,
open-air exercise, Turkish baths, and good food. The chlo-
rid of gold and sodium forms a good substitute drug. The
use of iodid of potassium is of questionable value.

Treatment of Complications in the Secondary Stage. —
The complications of the secondary stage usually require local
applications in addition to general remedies. Mucous patches
in the mouth should be touched with bluestone every day, an
astringent mouth-wash being employed several times daily.
If the patches ulcerate, they should be touched twice a day
with lunar caustic ; if these areas proliferate, they should be
excised and burned. Vegetations or growing papules on the
skin must, if calomel powder fails to remove them, be cut
away with scissors and be cauterized with chromic acid or
with the Paquelin cautery. Condylomata demand washing
with ethereal soap several times daily, thorough drying, dust-
ing with equal parts of calomel and subnitrate of bismuth or
with borated talcum, and covering with dry bichlorid gauze.
If these simple procedures fail, excise and cauterize.

For psoriasis of the palms and soles diachylon ointment,
mercurial plaster, or painting with tincture of iodin should
be employed. Ulcers of paronychia are dressed with iodo-
form and corrosive-sublimate gauze. Deep cutaneous ulcers
are cleaned once a day with ethereal soap, then sprayed with
peroxid of hydrogen, dressed with iodoform and corrosive-
sublimate gauze, and bandaged. When granulation is well
established dress with i part of unguent, hydrarg. nitratis to
7 parts of cosmolin. In sarcocele mercurial ointment should
be used or the testicle be strapped. Alopecia requires that
the hair be kept short and every night the scalp be cleaned
with equal parts of green soap and alcohol rubbed into a

204 MODERN SURGER Y.

lather with water. After the soap is washed out some hair
tonic should be rubbed into the scalp with a sponge. A
favorite preparation of Erasmus Wilson's consisted of the fol-
lowing ingredients :

B> Ol. amygd. dul.,

Liq. ammonise, dd. f ^ ;

Spt. rosemarini,

Aquae mellis, Od. f3iij.

M. Ft. lotio.

One part of tincture of cantharides to 8 parts of castor oil
may be rubbed into the scalp. Solutions of quinin are
esteemed by some.

In treating persistent skin-lesions, inunctions, injections, or
fumigations may be used ; some prefer mercurial baths. Baths
are suited to patients with delicate skins, to those whose
digestion fails from mercury by the stomach, and to those
whose lungs will not tolerate fumigations. Half an ounce
of corrosive sublimate with 4 scruples of sal ammoniac are
mixed in about 4 ounces of water ; this is added to a bath at
a temperature of 95°. The patient gets into this bath, covers
the tub with a blanket, leaving only his head exposed, and
remains in the bath an hour or so. These baths may easily
cause salivation.

In every case of .syphilis, no matter what constitutional or
local treatment is used, the general health of the patient must
be watched and the use of tobacco be stopped, as its use ren-
ders certain the development of mucous patches and causes
them to persist. Alcohol as a beverage must be cut off: it is
to be used only as a medicine for debility and weakness of
assimilation. An open-air life to a great degree must be in-
sisted upon, and care be observed as to protection from damp
and cold. Flannels must be worn in winter. Have the patient
sponge the chest and shoulders ever)' morning with cold or with
tepid water and then with alcohol, dry himself with a rough
towel, and take a hot bath twice a week or a Turkish bath
once a week. He should wash the anus and nates after every
stool, and ought to dust the axillae, scrotum, perineum, and
internatal region once a day with borated talc. The teeth are
to be looked to and put in perfect order, a soft brush being
used twice a day and an astringent mouth-wash being fre-
quently employed. Meat and milk are largely to be used.
The patient should be weighed weekly : any falling off in
weight is an indication for tonics, concentrated food, and cod-
liver oil. If a patient's health continues to fail on mercury,

SYPHILIS. 205

the drug should be stopped for some time and the patient be
treated with iron, chlorid of gold and sodium, baths, fresh air,
cod-liver oil, and nourishing foods. In treating secondary
syphilis, give mercury for at least eighteen months and bet-
ter for two years. Reminders require mixed treatment (mer-
curials and iodids).

Tertiary Stage. — If at any time during the case there
appear tertiary symptoms, the patient should be put on mixed
treatment. In any case, after two years of mercury add iodid
of potassium to the treatment. White's rule is to use this
mixed treatment for at least six months (if any symptoms ap-
pear), the six-months course dating from their disappearance.
This emphasizes the fact that the iodids alone will not cure
tertiary syphilis. In obstinate tertiaries or in nervous syph-
ilis the iodids should be run up to an enormous amount (from
30 to 250 grains per day). An easy way to give iodid is to
order a saturated solution each drop of which solution equals
one grain of the drug. Each dose of the iodid is given one
hour after meals and in at least half a glass of water. If
the iodid disagrees, it may be given in water containing one
dram of aromatic spirits of ammonia or in milk. The iodid
of sodium may be tolerated better than the potassium salt,
or the iodids of sodium, potassium, and ammonium may be
combined. In giving the iodids begin with a small dose.
During a course of the iodid always give tonics and insist on
plenty of fresh air. Arsenic tends to prevent skin-eruptions.
The iodids when they disagree produce iodism — a condition
which is first made manifest by running of the nose and the
eyes. In some subjects there is an outbreak of acne, vesicu-
lar eruptions or even bullae, or hemorrhages. Iodism calls
for a reduction in dosage, and, if severe or persistent, for the
abandonment of the drug. Some patients who cannot take
the alkalin iodids may take syrup of hydriodic acid. After
the patient has been for six months under mixed treatment
without a symptom, stop all treatment and await develop-
ments. If during one year no symptoms recur, the patient
is probably cured ; if symptoms do recur, there must be six
months more of treatment and another year of watching.
Fournier has insisted that it is a great wrong to tell a syph-
ilitic that he can never marry. He must not marry until he
is cured, and he is not cured until, after the cessation of the
use of iodid, he goes one year without treatment and without
symptoms.

Hereditary Sjrphilis* — Transmitted congrenital syph-
ilis is a hereditary syphilis manifest at birth. Acquired syph-

206 MODERN SURGERY.

ills (except in the case of a woman who obtains the disease
from a fetus) always presents the chancre as an initial lesion ;
hereditary syphilis never does. Hereditary syphilis may pre-
sent itself at birth, and usually shows itself within, at most,
the first six months of extra-uterine life. In rare cases (tardy
hereditary syphilis) the disease does not become manifest until
puberty.

Rules of Inheritance. — According to Von ZeissI,* the rules
of inheritance are as follows :

1. If one parent is syphilitic at the time of procreation, the
child may be syphilitic.

2. Syphilitic parents may bring forth healthy children.

3. If a mother, healthy at procreation, bears a child syph-
ilitic from the father, the mother must have latent pox or
must be immune, having become infected through the pla-
cental circulation. She often shows no symptoms, having
received the poison gradually in the blood, and having thus
received, it may be said, preventive inoculations. Certain it
is that mothers are almost never infected by suckling their
own syphilitic children (Colles's law).

4. If both parents were healthy at the time of procreation,
and the mother afterward contracts syphilis, the child may
become syphilitic, and the earlier in the pregnancy the mother
is diseased, the more certain is the child to be tainted. This
is known as " infection in utero."

5. The more recent the parental syphilis, the more certain
is infection of the ofispring. The children are often stillborn.

6. When the disease is latent in the parents it is apt to be
tardy in the children.

7. The longer the time which has passed since the dis-
appearance of parental symptoms, the more improbable is
infection of the children.

8. In most instances parental syphilis grows weaker, and
after the parents beget some tainted children they bring forth
healthy ones.

Syphilis in the mother is more dangerous to the offspring
than syphilis in the father. The frequent immunity of the
mother is due to the fact that her tissues produce antitoxins
under the influence of the virus.

Many women who labor under hereditary syphilis are
sterile. Many syphilitic women abort, usually before the
eighth month. The fetus ver>'' often dies at an early period
of gestation. This may be due to a gummatous placenta or
to a degeneration of placental follicles.

* Pathology and Treatment of Syphilis.

SYPHILIS. 207

Evidences of Hereditary Syphilis (manifest at, or oftener
soon after, birth). — Hutchinson says that at birth the skin
is almost invariably clear. In from six to eight weeks
"snuffles" begin, which are soon followed by a skin-eruption,
by body-wasting, and by a chain of secondary symptoms
(iritis, mucous patches, pains, condylomata, etc.). The child
looks like a withered-up old man. Eruptions are met with
on the palms and soles. Intertrigo is usual. Cracks occur
at the angles of the mouth, and leave permanent radiating
scars. The abdomen is tumid, and there is apt to be exhaust-
ing diarrhea. The secreting and absorbing glands of the
intestinal track atrophy.^ Enlargement of spleen and liver
occurs. Sometimes synovitis or arthritis arises. Atrophic
lesions may appear in the bones. In the skull the bone may
be softened by removal of its salts or be thinned by the
pressure of the brain. In the long bones the epiphyseal ends
suffer, the attachment of epiphysis to shaft is weak, and sepa-
ration is easily induced. Epiphysitis is common and rarely
causes pain. Epiphysitis rarely suppurates unless in chil-
dren who are old enough to walk (Coutts). Osteophytic
lesions of the skull are shown by symmetrical spots of
thickening upon the parietal and frontal bones (natiform
skulls). In the long bones osteophytes are frequently formed.
A child with precocious hereditary syphilis is apt to die. but
if it lives from six months to one year the symptoms for a
time disappear and for years the disease may be latent.
Diagnosis is difficult after the third or fourth year, especially
if the disease be associated with rickets or tuberculosis. When
the disease begins again the symptoms are various, namely :
noises in the ears, often followed by deafness ; interstitial
keratitis; dactylitis (specific inflammation of all the struc-
tures of a finger) ; synovitis in any joint ; ossifying nodes ; de-
velopmental osseous defects ; suppurative periostitis ; ulcera-
tions ; death of bone ; falling in of nose ; nervous maladies ;
occasionally sarcocele, etc. In hereditary syphilis the eye-
symptoms are of great diagnostic importance. In 212 cases
of congenital .syphilis Foumier found eye-trouble in loi.
Keratitis and 'choroiditis are the most usual forms (Silex).
Bone-trouble occurs in almost half of the cases, but is not
often severe enough to cause symptoms. The tongue often
shows a smooth base (Virchow's sign). Hirschberg believed
choroiditis to be pathognomonic.

Dickgrnosis. — In the diagnosis of hereditar}'' syphilis the
condition of the teeth is of much importance: the temporary

' G)utts, in Brit. Mid. Jour. ^ iii94, No. 1843.

208 MODERN SURGERY.

teeth decay soon, but present no characteristic defect If the
upper permanent central incisors are examined, they are

found defective. Other teeth
may show defects, but in these
alone are defects almost sure to
appear. In hereditary syphilis
„ , they present an appearance of

Fig. 38.— Hutchinson teeth. 1 j j • ^* e t, i.l1_

marked deviation from health,
and are called *' Hutchinson teeth" (Fig. 38). If they are
dwarfed, too short and too narrow, and if they display a
single central cleft in their free edge, then the diagnosis of
syphilis is almost certain. If the cleft is present and the
dwarfing absent, or if the peculiar form of dwarfing be pres-
ent without any conspicuous cleft, the diagnosis may still be
made with much confidence. In early infancy the diagnosis
is made by the snuffles, broad nose, skin-eruptions, wasted
look, sores at the mouth-angles, tenderness over bones, con-
dylomata, and history of the parents. The diagnosis at a
later period is made by the existence of symmetrical inter-
stitial keratitis, choroiditis, smooth base to tongue, deafness
which comes on without pain or running from the ear, ossi-
fying nodes, white radiating scars about the mouth-angles,
sunken nose, natiform skull, deformity of long bones, pain-
less inflammation of epiphyses, and Hutchinson teeth. It
must be remembered that a child bom apparently healthy
and presenting no secondary symptoms may show bone-dis-
ease, keratitis, or syphilitic deafness at puberty.

Treatment. — In infants inunctions are to be used until the
symptoms disappear, but mercury must not be forced or con-
tinued too long after the symptoms are gone. There must be
rubbed into the sole of each foot or the palm of each hand 5
grains of mercurial ointment every morning and night. Brodie
advised spreading the ointment (in the strength of 3j to the
ounce) upon flannel and fastening it around the child's belly.
If the skin is so tender that mercury must be given by the
mouth, White and Hearn advise that gr. ^ to gr. \ of mer-
cury with chalk, with i grain of sugar, be taken three times
a day after nursing. If tertiary symptoms appear, or in any
case when the secondaries disappear,- give gr. ss to gr. j or
more of iodid of potassium several times a day in syrup.
White advocates the continuance of the mixed treatment in-
termittently until puberty. Local lesions require local treat-
ment, as in the adult. A syphilitic child must be nursed by
its mother, as it will poison a healthy nurse. If the baby has
a sore mouth, it must be fed from a bottle; and if the mother

TUMORS OR MORBID GROWTHS. 209

cannot nurse the child, it must be brought up on the bottle.
For the cachexia use cod-liver oil, iodid of iron, arsenic, and
the phosphates.

XVll. TUMORS OR MORBID GROWTHS.

Division. — Morbid growths are divided into (i) neo-
plasms and (2) cysts.

Neoplasms. — A neoplasm is a pathological new growth
which tends to persist independently of the structures in
which it lies, and which performs no physiological function.
A hypertrophy is differentiated from a tumor by the facts
that it is a result of increased physiological demands or of
local nutritive changes, and that it tends to subside after the
withdrawal of the exciting stimulus. Further, a hypertrophy
does not destroy the natural contour of a part, while a tumor
does. Inflammation has marked symptoms : its swelling
does not tend to persist, it terminates in resolution, organ-
ization, or suppuration, and the microscope differentiates it
from tumor. Inflammation, too, has an assignable excit-
ing cause. A new growth is a mass of new tissue ; hence
it is improper to designate as tumors those swellings due
to extravasation of blood (as in hematocele), or of urine
(as in ruptured urethra), to displacement of parts (as in
hernia, floating kidney, or dislocation of the liver), or to
fluid distention of a natural cavity (as in hydrocele or
bursitis).

Classes of Ttlinors. — There are two classes of tumors :
the first class includes those derived from or composed of
ordinary connective tissue or of higher structures. These
all originate from cells which are developed from the meso-
blast. There are two groups of connective-tissue tumors :
{(i) the typical, benign, or innocent, which find their type in
the healthy adult human body ; and {S) the atypical or malig-
nant, which find no counterpart in the healthy adult human
body, but rather in the immature connective tissues of the
embryo.

The second class of tumors includes those which are
derived from or composed of epithelium : {a) the typical,
composed of adult epithelium ; and (p) the atypical, com-
posed of embryonic epithelium.

Miiller's Law. — Muller's law is that the constituent ele-
ments of neoplasms always have their types, counterparts,
or close imitations in the tissues of a normal organism^
either embryonic or mature.

210 MODERN SURGERY.

Virchow's Law. — Vircho\v*s law is that the cells of a
tumor spring from pre-existing cells (hence there is no spe-
cial tumor-cell or cancer-cell).

The term " heterologous " is no longer used to signify
that the cellular elements of a tumor have no counterpart
in the healthy organism, but is employed to signify that a
tumor deviates from the type of the structure from which
it takes its origin (as a chondroma arising from the parotid
gland). Tumors when once formed almost invariably in-
crease and persist, though occasionally warts, exostoses,
and fatty tumors disappear spontaneously. Tumors may
ulcerate, inflame, slough, be infiltrated with blood, or un-
dergo mucoid, calcareous, or fatty degeneration.

Causes. — The causes of tumors are not positively recog-
nized, those alleged being but theories varying in probability
and ingenuity.

The mciusiofi theory of Cohnheitn supposes that more
cmbr>'onic cells exist than are needful to construct the fetal
tissues, that masses of them remain in the tissues, and that
these may be stimulated later into active growth. This
embryonic hypothesis seems to receive a certain force from
the facts that exostoses do sometimes develop from portions
of unossified epiphyseal cartilage, and that tumors often arise
in regions where there was a suppression of a fetal part,
closure of a cleft, or an involution of epithelium (epithelioma
is usual at muco-cutaneous junctures). This theory, which
does not explain the origin of most neoplasms, cannot suc-
cessfully be maintained even as a common predisposing
cause.

Hereditation is extremely doubtful. S. W. Gross found
hereditar}* influence by no means frequent in cancer of the
breast. It is affirmed bv some, denied bv others, and doubted
by a number. At most, hereditary influence may only pre-
dispose. Nevertheless, cases have occurred which cannot
be explained by the term coincidence. In the celebrated
" Middlesex Hospital case," a woman and five daughters
had cancer of the left breast. A. Pearce Gould had
charge of a woman for cancer of the left breast. The mother
of this patient, the mother's two sisters, and two of the
mother's cousins had died of cancer.

Injury and iuflavmiation may undoubtedly prove exciting
causes. A blow is not infrequently followed by sarcoma;
the irritation of a hot pipe-stem may excite cancer of the
lip ; the scratching of a jagged toc^h may cause cancer of
the tongue ; chimney-sweeps' cancer arises from the irrita-

TUMORS OR MORBID GROWTHS. 211

tion of dirt in the scrotal creases ; and warts often arise from
constant contact with acrid materials.

Physiological activity favors the development of sarcoma,
and physiological decline favors the development of cancer.

Parasitic Influence. — This theory does not maintain that
the tumor is the parasite, but that it contains the parasite,
although Pfeiffer and Adamciewicz did at one time assert
that a cancer-cell is not a body-cell, but a parasite resem-
bling an epithelial cell. Some facts render a parasitic origin
of malignant growths not improbable ; as, for instance, the
likeness of some tumors to infective granulomata, their occa-
sional secondary development in distant parts of the body,
the resemblance of the secondary to the primary growths,
and the tenacity of their persistence. A parasitic origin of
cancer is pointed to by its geographical distribution, the dis-
ease being very common in low and marshy districts (Havi-
land).

Some surgeons believe that cancer is contagious, but most
obser\'ers deny it. Guelliott, of Rheims, believes that cancer
is primarily a local infection. He believes this because
Morea and Hanau have inoculated it from one animal to
another of the same species, and if this can be brought
about experimentally he sees no reason why it cannot
happen accidentally. This surgeon says that cancer is very
unequally distributed, that genuine cancer-centers and " can-
cer-houses " exist, and that numerous cases of accidental
infection have occurred.* Mayet, of Lyons, holds that can-
cer can be reproduced by grafting or by the injection of can-
cer-fluid. Graf could not find " cancer-houses " after a care-
ful search.' Geissler claimed to have produced the disease
in a dog by planting fragments of cancer in the subcutaneous
tissue and vaginal tissue, but Czemy, Rosenbach, and others
disputed the claim. Hauser disputes the assertion that can-
cer must be an infectious disease because it is followed by
secondary growths. Secondary growths in an infectious
disease are caused by the bacterium ; secondary growths in
cancer are caused by the transferrence of cells of the growth.*
Hauser says with truth that the close connection between
innocent and malignant growths renders the parasite view
untenable, because to hold it we would be forced to believe
that every tumor has a special parasite or that one parasite
may cause many kinds of tumor.

' Am. Jour. Med. Sn'., June. 1895.

' Archiv.f. klin. Chir., 1895. 1.. p. I44.

• Hauser, in Biolog. Centralbl.^ Oct. i, 1895.

2 1 2 MODERN SURGER V.

There seems to be no doubt that autotransference of can-
cer can occur, although it rarely does so. Sippel has re-
ported a case in which vaginal carcinoma developed at the
point where the vagina was in contact with a pre-existing
cancer of the portio.* Comil has seen it transferred from
one side of the labia majora to the other, and from one lip
to the other. Geissler was unable to transplant cancer, and
Gratia also failed in his attempts. Duplay and Bazin say
that transmissibility is possible, but only under conditions
which are not practically realized. Haviland believes strongly
in " cancer-houses." ^

Tillmanns elaborately discussed the subject of cancer in
the Congress of 1895. His conclusions seem most sound
and scientific. He says there is no evidence of a bacterial
origin of cancer. The parasitic origin has not been proved,
and protozoa have not certainly been found. Cancer can be
transferred from one part to another part of the same indi-
vidual, or from one individual to another of the same species,
but never to one of a different species. It is possible that
cancer can spread by contagion ; this is very rare, but can
happen (as when penile cancer is followed by cervix cancer
in a wife). Because it is sometimes possible to transfer can-
cer, this does not prove that the disease is parasitic or infec-
tious ; it simply shows that tissue has been succe.ssfully
transplanted.

Actinomycosis, long thought to be a true tumor, is now
known to arise from the ray-fungus. There can be no doubt
that changes in the liver which practically constitute a new
growth can arise from the growth of a cell called by Darier
the " psorosperm." A disease due to psorosperms is called
a " psorospermosis." It is affirmed by some that moUuscum
contagiosa m, follicular keratosis, cancer, and Paget's disease
arc due to psorosperms. Some claim to find the parasite in
all cases of cancer, while others can find it in only 4 or 5
per cent, of the cases.

Heneage Gibbes affirms ^ that dilatation of the bile-ducts
of a rabbit's liv^er is caused by the chronic irritation arising
from multiplication of the coccidium oviforme in them, and
not in the columnar cells of the bile-ducts, as has been
stated ; and, further, that the large majority of glandular
cancers show nothing that can be considered parasitic, the
suspicious appearances noted in some few cases being due
to endogenous cell-formation. This coccidium oviforme is

* Centralhl. f. Gyrtak., No. 4, 1 894. ^ /^ancet, April 27, 1894.

' The Amet'ican Journal of Medical ScienceSy July, 1893.

TUMORS OR MORBID GROWTHS. 213

a genus of the sporozoa, class protozoa, the lowest division
of the animal kingdom. To this class belong the monera
and infusoria.

Malignant and Innocent or Benign Tumors. —

Malignant growths , infiltrate the tissues as they grow ;
benign tumors only push the tissues away ; hence malignant
tumors are not thoroughly encapsuled, while innocent tumors
are encapsuled. Malignant tumors grow rapidly ; innocent
tumors grow slowly. Malignant tumors become adherent
to the skin and cause ulceration ; innocent tumors rarely
adhere and rarely cause ulceration. Many malignant tumors
give rise to secondary growths in adjacent lymphatic glands
(cancer, except in the stomach, gullet, and upper jaw, always
so tends) ; sarcoma does not cause them, unless it be mel-
anotic or unless it arises from the testicle or tonsil. Inno-
cent tumors never cause secondary lymphatic involvement,
although the glands near the tumor may enlarge from acci-
dental inflammatory complications. The malignant tumors,
especially certain sarcomata and soft cancers, may be followed
by secondary growths in distant parts and various structures
(bones, viscera, brain, muscles, etc.) ; innocent tumors are not
followed by these secondary reproductions, although multiple
. fatty tumors or multiple lymphomata may exist. Malignant
tumors destroy the general health ; innocent tumors do not.
Malignant tumors tend to recur after removal ; innocent tu-
mors do not if operation was thorough. The special histo-
logical feature of a malignant growth is the possession by
its cells of a power of reproduction which knows no limit,
the cells of the tumor living among the body-cells like a par-
asite, and invading and destroying the body-cells.

Classification. — Tumors may be classified as follows :

I. Connective-tissue tumors.

1. Innocent tumors, or those composed of mature con-

nective tissue :
Upomata, or fatty tumors ; fibromata, or fibrous tu-
mors ; chondromata, or cartilaginous tumors ; osteo-
mata, or bony tumors ; odontomata, or tooth-tumors ;
myxomata, or mucous tumors ; myomata, or muscle-
tumors ; neuromata, or tumors upon nerves ; afigcio-
mata, or tumors formed of blood-vessels; lymphaii-
geiomata^ or tumors formed of lymphatic vessels ;
and lymphojnata, or tumors of lymphatic glands.

2. Malignant tumors, or those composed of embryonic

connective tissue :
Sarcomata,

214 MODERN SURGERY,

II. Epithelial tumors.

1. Innocent tumors, or those composed of mature epi-

thelial tissue:
Adenomata, or tumors whose type is a secreting gland;
and papillomata, or tumors whose type is found in
the papillae of skin and mucous membranes.

2. Malignant tumors, or those composed of embryonic

epithelial tissue :
Carcinomata, or cancers.

I. Innocent Connective-tissue Tumors. — The growths

mimic or imitate some connective tissue or higher tissue of
the mature and healthy organism.

I/ipomata are congenital or acquired tumors composed
of fat contained in the cells of connective tissue, which cells
are bound together by fibers. If the fibers are excessively
abundant, the growth is spoken of as a " fibro-fatty tumor."
A fatty tumor has a distinct capsule, tightly adherent to sur-
rounding parts, but loosely attached to the tumor; hence
enucleation is easy. Fibrous trabeculae run from the capsule
of a subcutaneous lipoma to the skin ; hence movement of
the integument over the tumor or of the tumor itself causes
dimpling of the skin. Lipomata are most frequent in middle
life, and their commonest situations are in the subcutaneous
tissues of the back or of the dorsal surfaces of the limbs ;
they usually occur singly, but may be multiple and some-
times symmetrical. Senn has described the case of a woman
who had a fatty tumor in each axilla. A lipoma is soft,
doughy, mobile, lobulated, of uniform consistence, and may
give on tapping a tremor or pseudo-fluctuation. It may
grow to an enormous size (in Rhodius's ca§e it weighed sixty
pounds), and the growth may be progressive or may be at
times stationary and at other times active. The skin over a
fatty tumor sometimes atrophies or even ulcerates ; the tumor
itself may inflame or partly calcify. When a lipoma has once
inflamed, it becomes immovable. The commonest situation
for lipomata is in the subcutaneous layer of fat. Subcutane-
ous lipoma of the palm of the hand or sole of the foot re-
sembles a compound ganglion, and it is apt to be congenital.
Lipomata of the head and face are rare. In the subcutane-
ous tissues of the groins, neck, pubes, axillae, or scrotum a
mass of fat may form, unlimited by a capsule and known as
a ** diffuse lipoma." A nevo-lipoma is a nevus with much
fibro-fatty tissue. A very vascular fatty tumor is called
lipoma telangiectodes. If the tumor stroma contains large
veins, the growth is called a cavernous lipoma. A tumor

TUMORS OR MORBID GROWTHS. 215

containing much blood can be diminished in size by pressure.
Fatty tumors may arise in the subserous tissue, and when
arising in either the femoral or inguinal canals or the linea
alba they resemble omental hernia and are spoken of as
•• fat-hernia." In the retroperitoneal tissues enormous fibro-
fatty tumors occasionally grow, and these neoplasms tend to
become sarcomatous. Lipomata may arise from beneath
synovial membranes and will project into the joints, being
still covered by synovial membrane. Fatty tumors occasion-
ally arise in submucous tissues, between or in muscles, from
periosteum, and from the meninges of the spinal cord (J.
Bland Sutton). A fatty tumor may undergo metamorpho-
sis. The stroma may be attacked by a myxomatous process
or a calcareous degeneration. The fat-cells themselves may
become calcareous. Oil-cysts sometimes form (Senn).

Treatment. — ^A single subcutaneous lipoma is to be re-
moved. Open the capsule, tear out or dissect out the mass,
and always drain for twenty-four hours, as butyric fermenta-
tion will be apt to occur, and necrosis of small particles of
fat predisposes to infection. Multiple subcutaneous lipomata,
if very numerous, should not be interfered with unless
troublesome because of their size or situation, when they
should be removed. Diffuse lipomata cannot be removed
entirely, and operation is useless. Liquor potassae has been
recommended to limit growth ; it may be taken internally
for a considerable time, but it seems to be useless. Subperi-
toneal lipomata are rarely diagnosticated until the belly has
been opened or the growth has been removed.

Pibromata are tumors composed of wavy fibrous bundles
of adult fibrous tissue. Senn tells us that benign endothe-
lial tumors belong under this head. A fibroma has no dis-
tinct capsule, though surrounding tissues are so compressed
as to simulate a capsule. Fibromata are occasionally con-
genital, are most usual in young adults, but they may occur
at any period of life, in any part of the body containing con-
nective tissue, and are hard and movable. Pure fibromata,
which are rare, are generally solitary, grow slowly, are of
uniform consistence, and have not much circulation. Soft
fibromata grow more rapidly than the hard, may become
quite large, are apt to have distinct pedicles, and arise gen-
erally from the skin of the scrotum, labia, uterus, and on the
inner surface of the arm or the thigh, and from the belly-wall
of a pregnant woman. There may be several of these growths
(the author has seen seven on one person). Hard fibromata
grow slowly ; they may form upon nerves, they may arise in

2l6 MODERN SURGERY.

the mammary gland, they may develop in the lobe of the ear
in a person who wears earrings, and they may spring from
various fibrous membranes, from the periosteum of the nasal
bones (fibrous polypi), and from the gums (fibrous epulides).
Fibromata may become cystic, calcareous, osseous, colloid,
or sarcomatous, and may become inflamed, ulcerated, or even
gangrenous.

A painful subcutaneous tubercle ^ which is a form of fibroma
commonest in females, arises in the subcutaneous cellular
tissue, usually of the extremities. It is firm, very tender,
movable, rarely larger than a pea, and the skin over it seems
healthy. Violent pain occurs in paroxysms and radiates over
a considerable area of which the tubercle is the center. These
paroxysms may occur only once in many days or many times
in one day. Pain may always be developed by pressure, and
may be linked with spasm. Nerve-fibrillae were never found
in these tubercles until a recent period.

A mole is a congenital fibroma of the skin (Senn). It is
rounded or flat, is usually pigmented, is apt to have hairs
growing from it, and varies in size from a pin's head to several
inches in diameter. The tumor rarely grows after the thir-
teenth or fourteenth year. A mole may become malignant, a
melanotic carcinoma may arise from its epithelial structures,
a melanotic sarcoma from its connective-tissue elements.

Fibrous epulis is a fibroma arising from the gums or peri-
odontal membrane (J. Bland Sutton) in connection with a cari-
ous tooth or retained snag ; it is covered by mucous mem-
brane, grows slowly, may attain a large size, and sometimes
has a stem, but is more often sessile. It may undergo myx-
omatous change or may become sarcomatous.

Fibrous tumors may arise from the ovary, the intestine,
and the larynx. Pure fibromata of the uterus are very rare,
but fibromyomata are very common (see Myomata, p. 222);
hence the term " uterine fibroid " should be abandoned.

Molluscum fibrosum is an overgrowth of the fibrous tissue
of both skin and subcutaneous structure. Senn excludes
this form of growth from consideration with fibromata, be-
cause of its infective origin. It may be limited or widely ex-
tended ; it may appear as an infinite number of nodules scat-
tered over the entire body or as hanging folds of fibrous
tissue in certain areas. Keloid is a hard fibrous vascular
growth, with a broad base, arising in scar-tissue ; it is crossed
by pink, white, or discolored ridges, and is named from a
fancied likeness to the crab. It is more common in negroes
than in whites, and is most frequent in the cicatrices of bums,

TUMORS O^ MORBID GROWTHS. 217

though it may arise in the scar of any injury, as the scar
from piercing the ears, and in the scars of syphilitic lesions,
tubercular processes, small-pox, or vaccination. It is rare
in early childhood and in old age. It grows slowly, lasts
for many years, and may eventually undergo involution and
disappear.

Morphea, or spontaneous keloid, is a name used to desig-
nate a growth of this description which does not arise from
a scar; but it seems certain that scar-tissue was present,
though possibly in small amount from trivial injury.

Fibrous and papillomatous growths of a serous membrane
may occur. They are covered with endothelium. Such a
growth of the choroid plexus calcifies early and constitutes
a psammoma. Cholesteatoma is a fibrous growth covered
with endothelium and containing layers of crystalline fat. It
occurs especially in the pia mater, and is called a pearl
tumor.

Treatment. — Enucleate fibromata when in accessible
regions; do not let them remain, as any fibrous tumor
may become a sarcoma. Epulis requires the cutting
away of the entire mass, the removal of the related snag
or carious tooth, and sometimes the biting away of a por-
tion of the alveolus with rongeur forceps. Keloid should
not be operated upon : it will only return, and will also
recur in the stitch-holes. Trust to time for involution,
or use pressure with flexible collodion, by which method
J. M. DaCosta cured a case following small-pox. The
administration of thyroid extract may be of benefit (a gr. v
tablet 3 or 4 times a day). This drug must be given cau-
tiously, as it may cause attacks characterized by fever,
dyspnea, and rapid pulse. A mole ought to be excised,
because, if allowed to remain, it may become malignant.

Chondromata (enchondromata) are tumors formed either
of hyaline cartilage, of fibrocartilage, or of both. Chondro-
mata are apt to occur in certain glands, in the long bones,
the pelvis, the rib-cartilages, and the bones of the hands or
feet, and often spring from unossified portions of epiphyseal
cartilage. They may be single or multiple, are often nodu-
lated, and are most commonly met with in the young.
They have distinct adherent capsules ; they grow slowly,
progressively hollowing out the bones by pressure ; they
cause no pain ; they impart a sensation of firmness to the
touch, unless mucoid degeneration forms zones of softness
or fluctuation ; they are inelastic, smooth or nodular, im-
movable, and often ossify. Chondromata may grow to an

2l8 MODERN SURGERY.

enormous size. A chondroma of the parotid gland or testi-
cle always contains sarcomatous elements, and any chon-
droma may become a sarcoma. Chondromata are notably
frequent in persons who had rickets in early life. Ecchon-
droses, which are "small local overgrowths of cartilage"
(J. Bland Sutton), arise from articular cartilages, especially of
the knee-joint, and from the cartilages of the larynx and
nose. Loose or floating cartilages in the joints may be
broken-off ecchondroses or portions of hyaline cartilage
which are entirely loose or are held by a narrow stalk, and
which arise by chondrification of villous processes of the
synovial membrane ; only one or vast numbers may exist ;
one joint may be involved, or several ; they may produce
no symptoms, but usually produce from time to time violent
pain and immobility by acting as a joint-wedge.

Treatment. — Remove chondromata whenever possible,
for, if allowed to remain undisturbed, they are apt to resent
this hospitality by becoming sarcomatous. Incise the cap-
sule and take away the growth, using chisels and gouges
if necessary. Incomplete removal means inevitable recur-
rence. Amputation is very rarely demanded. Loose bodies
in the joints, if productive of much annoyance, are to be
removed, the joint being opened with the strictest antiseptic
care.

Osteomata. — ^J. Bland Sutton says that osteomata are
ossifying chondromata. Compact osteomata, which are iden-
tical in structure with the compact tissue of bone, occur in
the frontal sinus, mastoid process, external auditory meatus,
and in other regions in those beyond middle life ; they are
small, capped with cartilage, smooth, round, with small,
occasionally cartilaginous bases, and are densely hard.

Cancellous osteomata. which comprise the great majority
of bone-tumors, are similar in structure to cancellous bone.
They spring from and are crusted with cartilage ; they may
have fibrous capsules, and are often movable when recent,
but soon become fixed ; they have broad bases, are angled,
nodular, firm (but not so hard as are the compact osteomata),
painless except when pressed, occur particularly at the ends
of long bones, may grow to large size, and are commonest
in youth. Osteomata near joints become overlaid by bursae
which in rare instances communicate with their related
joints.

The term exostosis has been used as being synonymous
with osteoma, but wrongly so, as an exostosis is an irregu-
lar, local, bony growth which does not tend to progress

TUMORS OR MORBID GROWTHS. 219

beyond a certain point, and which is hence not a tumor.
A true exostosis is seen in the ossification of a tendon-inser-
tion, in a limited growth from the maxillary bones, and in a
local growth from the last phalanx df the big toe, which
growth is known as a " sub-ungual exostosis." Exostoses
of the retrocalcaneal bursa occasionally arise when this bursa
is inflamed. Inflammation of this bursa is known as Achillo-
dynia or Albert's disease. The bony masses sometimes found
in the brain, lungs, testicle, various glands, and tumors are
not true osteomata.

Treatment. — Osteomata which are nonproductive of pain
or trouble do not demand removal. If they produce pain
by pressure, if they press upon important structures, if they
cause annoying deformities, or if they grow rapidly, then
remove them by means of chisels, gouges, or by the sur-
gical engine. Exostosis of the toe should always be re-
moved, to do which the nail should be split and part of it
taken away, and the bony mass be gouged away or be cut
off with forceps.

Odontomata ^ are tumors composed of tooth-tissue and
springing from the germs of teeth or from developing teeth.
J. Bland Sutton divides them into (i) those springing from
the follicle; (2) those springing from the papilla; and (3)
those springing from the whole germ.

Epithelial odontoxnes, or xnultilocailar cystic tumors,
arise from the follicle, occur oftenest in the lower jaw, dilate
the bone, have capsules, and are made up of masses of cysts
which are filled with brown fluid. These cysts are met
with most frequently before the age of twenty. Follicular
odontofnes, or dentigerous cysts, oftenest spring from the
follicles of the permanent molars. In a dentigerous cyst
there exists an expanded follicle which distends the bone,
the follicle being filled with thick fluid and containing a
portion of a tooth. K fibrous odontome is due to thickening
of the tooth-sac, thus preventing eruption of the tooth;
fibrous odontomes are usually multiple, and are apt to occur
in rickety children. A cementome is due to enlargement,
thickening, and ossification of the capsule, the developing
tooth being encased in cement. A compound follicular odon-
tome is due to ossification of portions only of an enlarged
and thickened capsule, and the tumor contains bits of
cementum, portions of dentine, or small misshapen teeth.
A radicular odontofne springs from the papilla and arises

' This section is abridged from J. Bland Sutton's striking chapter upon odon-
tomes in bis recent work on Tumors.

220 MODERN SURGERY.

after the crown of the tooth is formed and while the roots
are forming ; hence it contains dentine and cement, but no
enamel. Composite odontomes are formed of irregular, shape-
less masses of dentine, cement, and enamel. All the above
forms occur in man. They present themselves as hard
tumors associated with teeth or in an area where teeth have
not erupted. They may distend the jaw. Occasionally an
odontome simulates necrosis ; it is surrounded by pus, and a
sinus forms.

Treatment. — The diagnosis is scarcely ever made until
after incision ; hence, be in no haste to excise large por-
tions of bone for a doubtful growth ; incise first and see if
it be an odontome, which requires only the removal of an
implicated tooth, curetting with a sharp spoon, and packing
with iodoform gauze.

Myxomata are tumors composed of mucous tissue.
They are rare as independent growths, although myxo-
matous change is frequent in the stroma of other tumors.
The tissue type of these tumors is found in the vitreous
humor of the eye and in the perivascular tissues of the
umbilical cord (Wharton's jelly). Bowlby states that myxo-
mata are in reality soft fibromata whose intercellular sub-
stance has been replaced by mucin. The myxomatous state
may be a stage in the formation of a fibroma, a stroma not
having developed. Myxomata may result from myxomatous
degeneration of cartilage, of muscle, or of fibrous tissue.
These tumors are soft, elastic, usually pedunculated, tremu-
lous, and vibratory'. The stroma is ver>'^ delicate and carries
minute blood-vessels. Cutting into them causes a straw-
colored, clear jelly to exude ; they grow slowly, are encap-
suled, have but little circulation, and their diagnosis may be
impossible before removal. Some pathologists place myxo-
mata among the malignant tumors, but most consider them
as benign tumors, though they tend strongly to become
sarcomatous (myxosarcomata). A sarcoma may undergo
myxomatous degeneration.

Myxomata may arise from the skin ; from the mucous
membrane of the nose, the frontal sinus, the antrum, the
womb, auditory meatus, and the tympanum (gelatinous
polyps) ; from the parotid and mammar)' glands ; from the
subcutaneous tissue, the nerve-sheaths, the intermuscular
septi, the rectum, and the bladder (polyps). They may be
congenital, but occur most often in young adults, as a result
of inflammation. A sudden increase of growth indicates be-
ginning malignancy (sarcomatous change). When a tumor

TUMORS OR MORBID GROWTHS, 221

begins to undergo myxomatous transformation we give to it
a compound name ; for instance, chondromyxoma, fibro-
myxoma, etc.

Nasal polypi grow from the mucous membrane over the
turbinated bones ; they are soft and jelly-like, of a grayish
color, and have stems or pedicles ; they may be seen through
the anterior nares, may project behind the veil of the palate,
and may bulge out from the passages of the nose ; they may
be, and usually are, multiple ; they may be present in one nasal
fossa or in both ; and they occur most commonly in young
adults.

Hydatid moles of pregnancy are due to myxomatous
changes in the chorion.

Treatment. — In treating myxomata, remove them prompt-
ly and thoroughly, because of the danger of sarcomatous
change. Nasal polyps may usually be twisted off or be re-
moved by the wire snare or galvano-cautery ; but occasion-
ally extensive operations are required for their removal. A
soft myxoma breaks up when removal is attempted, and the
base must be cauterized.

I/ymphomata are tumors composed of lymphatic-gland
structure, and are due to multiplication of pre-existing ade-
noid tissue (idiopathic lymphomata). Lymphomata are most
frequently encountered in the neck and axillae, but are not
unusually met with in the groins. One gland or many may
be involved ; they grow rapidly and attain a large size ; they
are painless, are encapsuled, and are freely movable beneath
the skin ; they do not infiltrate surrounding tissues, and pre-
sent no thickening from inflammation ; they are commonest
between the ages of twenty and thirty-five, but they may
occur in early life. Gross states that the enlargement usually
begins upon one side of the neck, gland after gland being
successively attacked ; in from four to eighteen months the
glands of both sides of the neck, the axillae, the bronchi, and
the mesentery become involved, the patient's health fails, and
death soon ensues. These tumors are said not to be malig-
nant, but certain it is that they tend to recur after removal.
It is impossible to distinctly separate this disease from lymph-
adenoma: they probably are related, or possibly are iden-
tical. Sarcoma of a lymphatic gland arises later in life than
does lymphoma ; it infiltrates surrounding structure, render-
ing the growth immovable, and implicates the related glands
gluing them together; the tumor is painful and the skin
ulcerates. Lymphoma differs from tubercular lymphadenitis
in many ways. It originates in an apparently healthy person;

222 MODERN SURGERY.

it has no tendency to caseation or suppuration ; the growths
do not infiltrate, but remain movable ; and the overlying skin
retains a healthy appearance.

Treatment. — If possible, entirely extirpate a lymphoma ;
but if complete removal is impossible, perform no operation.
In inoperable cases order cod-liver oil and nutritious diet,
insist on open-air exercise, employ inunctions of ichthyol,
give courses of arsenic in advancing doses, and from time to
time administer iodid of potassium and iron in some form.
Fowler's solution as an injection into the growth finds some
advocates.

Myomata are tumors composed of unstriped muscle-fiber
mixed often with fibrous tissue (leiomyomata). Tumors com-
posed of striated muscle-fiber (rhabdomyomata) are very rare
and are always sarcomatous. Leiomyomata are found in
the womb, in the prostate gland, in the walls of the gullet,
vagina, stomach, bladder, and bowel, in the broad ligament,
ovar>', and round ligament, in the scrotum, and in the skin.
Myomata usually begin during or after middle age ; they are
encapsuled, they grow slowly, they are firm and hard, and
they produce annoyance by their size and weight or by ob-
structing a viscus or channel. A leiomyoma of the posterior
and middle of the prostate forms " a middle lobe."

The so-called ** uterine fibroid " is a myoma or fibromyoma.
Uterine myomata may originate within the walls of the womb
(intramural myomata), from the muscular structure of the
mucous lining (submucous myomata), or from the muscular
tissue of the serous covering (subserous myomata). Intra-
mural uterine myomata may be single or be multiple and
may grow to an enormous size. Submucous myomata pro-
ject into the cavit}' of the womb (fleshy polyps). Submucous
myomata distend the uterus and are often accompanied by
menorrhagia or metrorrhagia ; they may project into the
vagina. In some rare cases the projecting tumor is detached
by nature and the patient is cured ; in other cases the myoma
becomes gangrenous. This form of tumor may produce in-
version of the fundus of the womb. Subserous uterine myo-
mata cause trouble only by the inconvenience of weight or
the discomfort of pressure. Uterine myomata may undergo
fatty, calcareous, or myxomatous change, and may be infected
by septic organisms as a result of the use of a uterine sound
or of infection of the pedicle after oophorectomy. Infection
of a uterine myoma causes great enlargement, elevated tem-
perature, sweats, and exhaustion. Uterine myomata, which
are commonest in single women (J. Bland Sutton), arise most

TUMORS OR MORBID GROWTHS. 223

frequently between the ages of twenty-five and forty-five.
They may never produce any symptoms ; some, by enlarg-
ing until they ascend above the pelvic brim, produce abdom-
inal distention; some become jammed or impacted in the
pelvis, and produce by pressure retention of urine, obstruc-
tion to passage of feces, or hydronephrosis. Impaction may
occur temporarily at each menstrual period. Many myomata
produce uterine hemorrhage ; some cause retroversion of the
womb ; some protrude from the cervical canal ; some are so
large that they cause disastrous pressure upon the colon (ob-
struction), upon the iliac veins (intense edema), or upon the
ureters (hydronephrosis). Uterine myomata usually shrink
after the menopause. Pregnancy in a myomatous womb
usually ends in abortion.

The symptoms of myomata of the alimentary canal are
similar to or identical with the symptoms of malignant
growths. Myomata of the skin are rare growths ; they are
encapsuled, firm or elastic, and painless.

Treatment. — Cutaneous myomata are removed in the same
manner as fibrous tumors. Uterine myomata are treated by
rest and the administration of ergot, barium chlorid, and di-
lute sulphuric acid. If this treatment fails to arrest serious
bleeding due to a fleshy polyp, dilate the cervical canal and
remove the growth. If there be dangerous bleeding in a
woman who has some years to wait for the menopause and
who has not a removable polyp as the cause, perform
oophorectomy in order to bring on an artificial menopause.
When a myoma becomes impacted at each menstrual period
remove the ovaries and Fallopian tubes. Hysterectomy is
indicated for some very large tumors, for tumors that grow
after the menopause, and for infected myomata. If the abdo-
men be opened to perform oophorectomy, and the tubes and
ovaries are found so implicated in the growth that they can-
not be removed completely, or the broad ligament is found
so drawn out that a safe pedicle cannot be secured, perform
a hysterectomy.^ A recent suggestion for the shrinkage of
uterine myomata is to ligate both the uterine and ovarian
arteries. If a myoma of the prostate cause severe obstruc-
tion, effect a suprapubic cystotomy and remove the major
portion of the enlarged gland ; or make both a suprapubic
and a j)erineal opening, push the gland into the perineum
and shell it out with the finger, or perform White's operation
(double castration).

' See J. Bland SuUon*s admirable article on '* Uterine Myomata '' in bis work
on Tumors,

224 MODERN SURGERY.

Neuromata. — A true neuroma springs from nerve-tissue
(brain, cord, or nerve-trunks); it is composed of meduUated
or non-medu Hated nerve-fibers which form a plexus or net-
work and which are not continuous with the fibers of the
nerve-trunk or other area from which the tumor grows.
True neuromata, which are rare growths, arise during mid-
dle life ; they are small in size, are due to injury or hered-
itary tendency, and they may be single or multiple. There
is usually around the tumor, rather than in it, severe neu-
ralgic pain, which is greatly intensified by dampness, by
blows, or by rough handling. The parts below a neuroma
are cold, swollen, often anesthetic, and frequently present
motor paralysis or trophic disorder. A false neuroma or
neurofibroma is a tumor growing from a nerve-sheath, and
is identical in structure with the sheath. False neuromata
may be single, but they are often multiple ; they may be as
small as peas or as large as oranges ; they are smooth and
movable, and may cause great pain or may only hurt when
pressed or struck ; they may spring from roots, trunks, or
branches, and they may be linked with the disease known
as " moUuscum fibrosum." In plexiform neuroma some
branches of a nerve enlarge and lengthen like an artery
in a cirsoid aneurysm ; the mass feels like beads or like
a bag of worms ; it is mobile, and no pain is felt on moving
it ; and it is generally congenital. In plexiform neuroma the
nerve-sheath undergoes myxomatous change. Malignant
neuroma means primary sarcoma of a nerve-sheath, though
any neuroma may become sarcomatous.

Traumatic neuromata are occasionally well exhibited after
nerve-section or amputation. On nerve-section the distal
end shrinks and atrophies, the proximal end enlarges and
becomes bulbous. These traumatic neuromata are composed
of fibrous tissue which contains nerve-fibres ; they are usu-
ally, but not always, painful on pressure or during damp-
ness, and they are commonest in stumps which did not heal
by first intention. Painful subcutaneous tubercle is consid-
ered under the head of Fibromata. In performing an ampu-
tation cut the nerves high up, and thus keep them out of
the scar and prevent a tender stump. A tender stump may
be simple, due to anchoring the nerve in a scar, and thus
preventing gliding when the individual moves the ex-
tremity.

Treatment. — A false neuroma is to be removed, if possi-
ble, without destroying the nerve-trunk. If, in removing a
neuroma, it is necessary to exsect a portion of a nerve-trunk.

TUMORS OR MORBID GROWTHS. 22$

always endeavor to suture the ends so as to facilitate resto-
ration of function. For multiple neuromata — ^at least should
the number be large or should molluscum fibrosum exist —
• surgery can do nothing. Plexiform neuromata may often be
removed, but amputation may be required. Painful neuro-
mata in stumps should be excised.

Angiomaia. — These vascular or erectile tumors are
growths composed of blood-vessels.

Simple or capillary anerioznata, nevi, or ''mother's
marks,'* which affect the skin or subcutaneous tissue, are
composed of enlarged and twisted capillaries and of anas-
tomosing vessels surrounded by fat. These growths are
congenital or appear in the first few weeks of lif? ; they are
flat and slightly raised, and are of a bright-pink color if
composed chiefly of arterioles, and are bluish if composed
mainly of venules ; they are but little elevated ; they can
be almost completely emptied by pressure ; they occasion-
ally pass away spontaneously, but usually grow constantly
and may become cavernous ; they may ulcerate and occasion
violent or fatal hemorrhage. One or several large vessels
join a nevus to adjacent blood-vessels. Port-wine or claret
stains are pink or blue discolorations due to superficial nevi
of the skin ; they may be small in extent or they may
involve a very large area, are not elevated, and do not
usually spread. Telangiectasis is a form of nevus involv-
ing the skin and subcutaneous tissue in which many arte-
rioles and venules exist. Simple angiomata are common
on the forehead, the scalp, the face, the neck, the back, and
the extremities. They may appear on the labia, the tongue,
or the lips.

Cavemoiis anerioxnata, or venous nevi, resemble in
structure the corpora cavernosa of the penis; there are
large spaces with thin walls carrying blood, and there may
be distinct vessels as well. Arteries send blood into the
spaces, and veins receive it from the spaces. These chan-
nels and sinuses are enormously distended capillaries. Cav-
ernous angiomata arise in the skin and subcutaneous tis-
sues; they are usually congenital, but may develop from
simple angiomata. These cavernous angiomata are purple
or blue in color, are more distinctly elevated than the capil-
lary nevus, may be either cutaneous or subcutaneous, swell
when the child cries, and are apt to pulsate ; they may be
emptied by pressure, and often look like cysts with very thin
walls. Cavernous angiomata may arise in the breast, the
tongue, the lip, the subcutaneous tissues, or the muscles. If

226 MODERN SURGERY.

an angioma contains an excess of fat, the growth is called
a '* nevoid lipoma."

Plexiform cuigioznata are known as ** cirsoid aneurysms "
or aneurysms by anastomosis (p. 256).

Treatment. — These growths if large or growing must be
treated. A capillary nevus can often be quickly cured by
touching it with fuming nitric acid. A second application
of acid may be required. The growth may be destroyed by
heat — •* a knitting-needle at a dull-red heat or the galvano-
cautery " (Wharton). The application of ethylate of sodium
or the employment of electrolysis will destroy the gro^^'th.

Small port-wine stains may be removed by electrolysis or
multiple incisions, but extensive stains are ineffaceable. Small
nevi may be ligated under harelip pins ; larger nevi may be
strangulated in sections by the Erichsen suture or may be
completely excised. Excision is usually the best plan for the
cure of the cavernous variety of angeiomata. When a large
cavity is left by excision a plastic operation must be performed.
Do not use astringent injections.

I/ymphangiomata are tumors composed of dilated
lymph-vessels, and are often, though not invariably, con-
genital. The lymphatic nevus is a colorless or faintly pink
elevation ; if it is punctured with a needle, lymph flows from
the puncture. One or several nevi may be present in the
same individual. The dilatation is due to blocking of the
lymph-channels. Local lymphangioma of the tongue is
manifested by a cluster of papillary projections containing
lymph. Macroglossia is a congenital enlargement of the
anterior portion of the tongue, which enlargement grows
more and more marked until finally the tongue is forced far
out of the mouth. This condition of tongue-enlargement is
due to lymphangioma of the mucous membrane. Lymph
scrotum is due to a similar growth. A collection of these
warty-looking dilatations is called lymphangiectasis. Just
as there occur cavernous angiomata among blood-vessel
tumors, there occur cavernous lymphangiomata among
lymph-vessel tumors, and the spaces are filled with lymph
instead of with blood. Areas affected with lymphangiectasis
are liable to repeated attacks of er)^sipelas-like inflammation.
Whether this inflammation is causative or secondary is not
known. Certain it is that in tropical countries blocking may
be brought about by the filaria sanguinis hominis, a parasite
which lurks in the lymph-vessels during the day and is found
in the blood only at night. Lymphangiectasis is often the
first stage of an elephantiasis (p. 747).

TUMORS OR MORBID GROWTHS. 22J

Treatment. — Lymphatic nevus requires excision. In
macroglossia remove the bulk of the mass by a V-shaped
cut and so stitch the mucous membrane as to close the
stump. In conditions due to the filaria, anilin-blue has been
given internally with advantage.

Malignant Connective-tissue Tumors, ot Sarco-
mata.— The sarcomata are composed of embryonic tissue.
They develop from connective tissue, have no definite
stroma, and contain no lymphatics. The rapidly growing
forms are very vascular, the blood flowing in vessels whose
walls are very thin or running in canals whose boundaries
are sarcomatous cells. These tumors may pulsate and have
a bruit, and hemorrhages often take place in their substance.
Slow-growing sarcomata have but few vessels. Sarcoma
disseminates by means of the blood and the vessel-walls,
particles of sarcoma being carried by the venous blood to
the heart and from this organ to the lungs, where they lodge
and form secondary growths. Emboli from these secondary
foci are sent out by the arterial blood to various portions
of the body, as the bones, kidneys, brain, liver, etc. This
process is known as " metastasis." Sarcoma follows the
vein-walls for considerable distances and builds elongated
masses inside the veins. Sarcoma tends strongly to infil-
trate adjacent parts. The tumor may possess a capsule when
it is in an early stage, but soon loses this except in very
slow-growing or mixed forms growing by central proliferation.
Sarcomata may arise at any age from birth to extreme senility,
but they are commonest during youth and early middle age.
They are not hereditary, and often follow contusion. They
may be primary or may arise from malignant change in an
innocent connective-tissue growth (chondrosarcoma, fibro-
sarcoma, etc.). A sarcoma does not tend to affect lymphatic
glands except by the accident of its position ; and if it does
implicate them, the sarcomatous elements are carried rather
by the vein-walls and blood than by the lymph (melanotic
sarcoma implicates adjacent glands, and so does sarcoma of
the tonsil or of the testicle). The skin over the tumor may give
way, a bleeding fungus-mass protruding (fungus haematodes),
and suppuration may cause septic enlargement of adjacent
glands. After removal of a sarcoma the growth tends to
recur, and the recurrent tumor may be either more or less
malignant than its predecessor, the degree of malignancy
being in direct ratio to the number and smallness of the cells.
A sarcoma is malignant by local tissue-infection and by dis-
semination. Sarcomata rarely cause pain when they are not

228 MODERN SURGERY.

ulcerated. Sarcomata are commonest in the skin and con-
nective tissue of the extremities, but they arise also from
bone, neuroglia, periosteum, in the lymphatic glands, the
breast, the testicle, the eye, the parotid, and in other parts.
Hemorrhages into a sarcoma often occur, with the result
of suddenly increasing its size and forming blood-cysts.
Sarcomata are subject to partial fatty degeneration, to
myxomatous changes which produce cavities filled with
fluid, to calcification, and occasionally to necrosis of large
masses.

Species of Sarcomata. — The following species of sarco-
mata are recognized :

1. Round-cell, in which the matrix is soft and vascular.
The cells may be small or may be large. The smaller the
cell the more malignant the growth. A small round-cell
sarcoma is the most malignant variety of sarcoma and is soft
in consistence.

2. Spindle-cell, which is composed of bundles of spindle-
cells lying in a matrix which may be homogeneous, but which
may show some attempt at fiber-formation. Rhabdomyoma
is a variety of spindle-cell sarcoma containing striated mus-
cle-cells. These spindle-cell sarcomata often contain carti-
lage.

3. Mixed-cell sarcoma, containing both of the above varie-
ties of cells.

4. Giant-cell or myeloid, which contains some round-cells,
some spindle-ccUs, and large cells with many nuclei, like the
cells of bone-marrow. It is maroon-colored on section. This
is the least malignant form of sarcoma, and it sometimes ad-
mits of complete extirpation and cure. It tends to occur in
the long bones as a central sarcoma.

5. Alveolar, in which the cells are collected in alveoli as
are the cells of cancer. It arises usually from a mole.

6. Melanotic, which may be composed of either round-
cells or spindle-cells containing a black pigment.

7. Lymphosarcoma, which is composed of small round-
cells held in a delicate network, the tissue somewhat resem-
bling that of a lymphatic gland.

Clinical Varieties of Sarcoma. — The following are the
clinical varieties of sarcoma :

Melanotic or black sarcoma, the color of which is due to
pigment in the cells or matrix. These growths are usually
composed of round-cells, but may consist of spindle-cells;
they are sometimes alveolar, and spring from parts which
contain pigment (skin and choroid coat of the eye) ; they are

TUMORS OR MORBID GROWTHS, 229

apt to arise from pigmented moles ; they are very malig-
nant; they implicate related lymphatic glands, and during
their existence the urine contains pigment.

Gliosarcoma is a sarcoma of neuroglia. A pure glioma is
composed of adult connective tissue ; but, as a matter of fact,
pure glioma almost never arises, and the growth practically
always contains numerous small round-cells and is properly
a sarcoma. It springs from the neuroglia of the central ner-
vous system, and is usually of about the consistence of the
cortex of the brain; it is generally single, and does not
cause secondary growths. A gliomatosis of the cord produces
that remarkable disease known as "syringomyelia." The
symptoms of glioma of the brain depend upon its situation.

Hemorrhagic sarcoma is a sarcoma containing blood-
cy'sts, the results of parenchymatous hemorrhages.

Cylindroma, or Plexiform Sarcofna. — In this variety the
cells adjacent to vessels have undergone hyaline degenera-
tion ; the cells distant from vessels are unchanged. Section
shows the normal cells apparently contained in spaces with
hyaline walls.

Mixed tumors consist partly of mature and partly of
embryonic tissue, the cellular elements exceeding the adult
elements in amount. Among these mixed tumors are fibro-
sarcoma or the recurrent fibroid tumor, myxosarcoma,
chondrosarcoma, and osteosarcoma.

Treatment of 8eu:coznata. — Remove a sarcoma at once if
it is in an accessible spot. Never delay removal. Cut well
clear of it. The rapidly growing soft sarcomata will almost
inevitably return, and the very malignant variety, if uninter-
fered with, may terminate life in six months ; but operation
postpones the evil day and renders it possible that death will
occur from metastasis in an organ, and that the patient will
escape the horrors of ulceration and hemorrhage from the
original tumor. Slowly growing and hard tumors offer
some prospects of cure. The mixed tumor (as a recurrent
fibroid) may repeatedly recur, and yet the patient may be
cured at last by a sixth, an eighth, or a tenth operation.
In sarcoma of a long bone amputation should, as a rule,
be performed, though in some cases of giant-cell sarcoma
excision may be employed. In sarcoma of the jaw-bone,
excision ; of the eye, enucleation ; and of the testicle, castra-
tion, is demanded. Sarcoma of the ovary in adults demands
removal, but in children the operation is useless. Sarcoma
of the kidney in adults calls for nephrectomy, but in chil-
dren the operation is of little avail. In melanotic sarcoma

230 MODERN SURGERY.

remove the growth and adjacent lymph-glands, or in some
cases amputate. Removal of a sarcoma when there is no
hope of a cure is often justifiable to prolong life, to relieve
the patient of a foul, offensive, bleeding mass, and to permit
of an easier road to death by means of metastasis to an
internal organ. Wright advocates internal treatment for sar-
coma and for cancer. He advises that bromid of arsenic
be given for a long period of time, the dose being gr. -^ to
gr. ^ after each meal. Before meals gr. x of carbonate of
lime are advised. This treatment, Wright holds, should be
used before, and for many months after, operation, as an aid
to surgery. In inoperable cases it may be tried.*

It has been observed that an attack of erysipelas occasion-
ally greatly benefits a sarcoma, causing large masses of the
growth to soften or to slough and expose a granulating sur-
face. Busch noticed this in 1866. It has been suggested
that in inoperable cases of sarcoma these conditions might be
established artificially. Fehleisen inoculated tumors with
cultures of er>'sipelas. I^ssar in 1891 employed the toxins
(cultures rendered sterile by heat and filtration). In 1892
Colcy began his observations. The first plan was as follows :
a bouillon-culture is made of the streptococci ; this culture is
filtered through porcelain and an injection is given once a day
into and about the sarcoma. The first dose is TTlx, and it is
increased ; it should cause a febrile reaction, and sometimes
establishes softening or suppuration. Coley's present method
is as follows : make cultures of erysipelas cocci in cacao-broth ;
after three weeks inoculate them with the bacillus prodigiosus,
and cultivate the mixed growth for four weeks. They are
maintained at 58° C. until they become sterile. This sterile
fluid contains the toxins. The dose is from i to 8 minims. The
material is very powerful and may cause high fever. Begin
with a small dose and gradually increase until the projjer
amount of reaction ensues (103°- 104^ F.). TJie injection
may be about the sarcoma or at a distant point. The exact
status of this plan is not determined ; it has improved and
even cured some cases, but is not free from danger. Coley
believes that the value of the agent is proved, but Senn,
Keen, Kocher, and others are v^ery doubtful of its value.
Emmerich and Scholl claim good results from the injection
of erysipelas serum. A sheep is injected with cultures of
erysipelas, the blood is drawn, the serum separated, filtered
to remove cocci, and injected about the sarcoma. Results
are not definite. Among other agents which have been used

* Annals of Surgery^ April, 1 893.

TUMORS OR MORBID GROWTHS. 23 1

to inject inoperable sarcoma we may mention alcohol, chlo-
rid of zinc, arsenic, corrosive sublimate, thiosinamin, pepsin,
alkalies, etc. The injection of anilin-products into the sar-
coma, which has received a qualified commendation from
some observers, has been abandoned by most surgeons after
careful trial.

Innocent Bpithelial Tumors. — These growths imi-
tate an epithelial tissue of the mature and healthy organ-
ism.

Fapillomata, or Warts. — These growths are formed
upon the type of cutaneous and mucous papillae. A papil-
loma consists of a fibrous stroma which contains blood-
vessels and lymphatics and is covered by epithelium of
the variety appertaining to the diseased part. Warts grow
from the skin and from mucous membranes ; they may
be single or multiple; they may be painless or may be
ulcerated and bleeding; great masses may gather around
the anus, the vagina, or the penis during the existence of a
filthy discharge, and crops appear on the hands of those
who work in irritant material (as petroleum). A large
crop of warts may disappear in a single night ; hence the
popular belief in the efficacy of charms. A single wart
may reach a large size and become pigmented. The squa-
mous epithelium covering a skin-wart may become horny
(a wart-horn). Other cutaneous horns arise from the nails,
from the scars of burns, or from ruptured sebaceous cysts.

Villous papillomata grow chiefly from the bladder ; they
form tufts like the villous processes of the chorion ; they
may be single or multiple, and may be sessile or peduncu-
lated ; they are very vascular, and are apt to bleed freely.
Papillomata may arise in cysts of the paroophoron, in cysts
of the mammary gland, from the choroid plexuses of the
ventricles of the brain, and from the spinal membranes Any
papilloma may become a cancer.

Treatment. — Venereal warts are treated by repeatedly
washing with peroxid of hydrogen, drying with cotton, and
dusting with a powder composed of equal parts of calomel
and subnitrate of bismuth, or oxid of zinc and iodoform, or
borated talcum. If they do not soon dry up, cut them off
with scissors and burn with the Paquelin cautery. Ordi-
nary warts may usually be destroyed in a short time by
daily applications of lactic or chromic acid. In multiple
warts of the face Kaposi applies daily for several days a por-
tion of the following combination : sublimed sulphur, ,^5 ; gly-
cerin, 31^; acetic acid, 32^. Keeping a wart constantly

232 MODERN SURGERY.

moist with castor oil will often cause it to drop off Warts,
and even extensive callosities, may be removed by painting
once a day for five days with pure carbolic acid and cover-
ing with lint kept wet with boric acid. A convenient plan
is to paint a wart daily with a solution containing i part of
corrosive sublimate to 30 parts of collodion (hydrarg. chlor.
corros., 3^; collodion, 315). Large warts should be freely
excised. Villous papillomata of the bladder demand the
performance of a suprapubic cystotomy in order to remove
them.

Adenomata* — These glandular tumors are composed
of tissue identical with that of normal glands, and they may
contain acini and ducts like racemose glands or tubes like
tubular glands. They grow from secreting glands, but can-
not produce the secretion of the glands from which they
spring, or, if they do secrete, the fluid is retained, and not
discharged by the gland-duct. Adenomata occur in the
mammary gland, the parotid, the ovary, the thyroid gland,
the liver, the sweat-glands, and the prostate, and as pedun-
culated growths from the mucous lining of the intestine and
uterus. They are encapsuled, are usually single, but may be
multiple, arc of slow growth, but may attain a great size ;
they do not tend to recur after thorough removal, do not
involve adjacent glands, and do not disseminate ; they are
firm to the touch ; they tend to become cystic (especially in
the thyroid), the fluid which distends the ducts being due to
mucoid liquefaction of the proliferating epithelium.

Ill the breast a fibro-adenoma has a distinct capsule ; it is
clastic and movable, is usually superficial, and one occasion-
ally exists in each gland. They are most common before
the age of thirty, and are often painful, especially during men-
struation. Cystic adenomata of the brea.st attain a large size ;
they are encapsuled and grow slowly, are most common
after the thirtieth year, and are rarely painful. Both fibro-
adenoma and cystic adenoma may arise in the male breast.
Young unmarried women not unusually develop in the
breast small, very tender, and painful bodies, most usually
around the edge of the areola, which bodies increase in size
and become more tender during menstruation ; they are only
cysts of the mammary tissue.

Adenomata of the thyroid gland begin before the fifteenth
year (Gross). Adenomata may arise in the prostate if that
gland be already the seat of senile hypertrophy. Adenomata
of mucous glands may arise in the young or the middle-
aged.

TUMORS OR MORBID GROWTHS. 233

Treatment. — Adenomata require extirpation. By confus-
ing adenomata of the mammary gland with small cysts of
that structure an erroneous belief has arisen that the former,
as well as the latter, may sometimes be cured by the local
use of iodin, mercury, and ichthyol and the internal use of
iodid of potassium. The treatment is excision.

Malignant Bpithelial Tumors, Carcinomata, or
Cancers. — Cancers are tumors growing from epithelial
surfaces, and are composed of epithelial cells which are
clustered in spaces, nests, or alveoli of fibrous tissue. The
cells of a cluster are not separated by any stroma, and the
walls of the alveoli carry blood-vessels and lymphatics.
The growth may be cancerous from the start, or may have
begun as an innocent epithelial tumor. Cancers are always
derived from epithelium (of glands, of skin, of mucous mem-
brane, etc.), and if found in a non-epithelial tissue must be
secondary. They have no capsules, rapidly infiltrate sur-
rounding tissues, and are firmly anchored and immovable.
In the beginning a cancer is a local lesion, but it soon attacks
related lymph-glands and by means of the lymph, and very
rarely by the blood (Thiersch and Waldeyer), is dissemi-
nated throughout the system, secondary growths arising
which are identical with the parent growth. Cancer is rare
before the age of forty, and never occurs before puberty ;
seems occasionally to be hereditary; and is sometimes
linked with continued irritation as a cause (cancer of the
penis in phimosis ; cancer of the lip from the hot stem of a
clay pipe ; chimney-sweeps' cancer from soot in the scrotal
folds; cancer of the gall-bladder when gall-stones exist).
The weight of opinion is opposed to the theory'- that cancer
is of parasitic origin. Tillmanns says that the presence of
protozoa has never been proved.^ The same author says
that transplantation has taken place, but only by auto-infec-
tion or by transplantation to an animal of the same species.
The facts that transplantation can be sometimes carried out,
and that contagion is a possible occurrence under excep-
tional circumstances, do not prove that cancer is a para-
sitic disease, but simply prove that it can be transplanted.
It is not that the cancer carries a parasite which will cause
the disease in sound tissues, but rather that the cells of the
cancer may themselves take root and grow in sound tissues
(p. 211). Dennis says that all clinical evidence points
strongly to the view that inflammatory changes following

* Verhandlungen der Jeuischtn Gesellschaft fur Chirurgie^ XXIV. Kongress,
1895.

234 MODERN SURGERY.

irritation are responsible for cancer. Cancer is often the
seat of pricking pain ; tends strongly to recur after removal ;
is prone to ulcerate, causing pain, hemorrhage, and cachexia;
makes rapid progress, and is often fatal in from one to two
and a half years. It is more common in women than in
men, and rarely exists with tubercle. After a cancer has
existed for a time in an important structure, or after a super-
ficial cancer has ulcerated and become hemorrhagic, there are
noted in the individual evidences of illness and exhaustion.
We speak of this condition as the *' cancerous cachexia,"
and in it the muscles are wasted, the body-weight is con-
stantly diminishing, the complexion is sallow, the face is
sunken, pearly white conjunctivae contrast strongly with the
yellow skin, the pulse is weak and rapid, and night-sweats
add to the exhaustion. The above condition is due to the
absorption of toxic products from the diseased tissues, and
also to pain, loss of sleep, bleeding, deprivation of exercise^
malassimilation of food, and anxiety. Cancer may kill by
obstructing a canal, by destroying the functions of a viscus
or organ, by hemorrhage, by anemia, by sepsis, or by
exhaustion.

Classification of Carcinoznata. — Carcinomata are classi-
fied as follows: i. Squamous-celled cancer, or epithelioma;
2. Rodent ulcer, or Jacob's ulcer; 3. Spheroidal-celled cancer
{a, scirrhus ; h, encephaloid ; r, colloid) ; and 4. Cylindrical-
celled cancer.

Ef^itheliomata. — An epithelioma may arise wherever there
is pavement-epithelium, and it is especially apt to appear at
the junctions of skin and mucous membrane (as the lips) or
the point of juxtaposition of different kinds of epithelium.
These growths arise in the anus, vagina, penis, scrotum, lips^
tongue, mouth, nose, and other situations. In epithelioma
there is an ingrowth of surface-epithelium into the sub-epi-
thelial connective tissue, colonies of cells growing inward and
forming epithelial nests. It may arise without discoverable
cause, it may follow prolonged irritation, or it may arise in a
wart or fissure. In the nipple it is often, and in the scrotum
and nose it is occasionally, preceded by a persistent eczema^
due probably to psorosperms and known as Pagefs disease.
Paget's disease is not a true eczema, but is rather a malig-
nant dermatitis. A crust gathers on the part, and beneath this
crust is a raw, red, and moi.st surface, the ^(\^q. of which is
slightly elevated and somewhat indurated. In the begin-
ning there is a strong resemblance to eczema. The nipple
is apt to retract. The parts are the seat of a constant itch-

TUMORS OR MORBID GROWTHS. 235

ing and scalding sensation. The area may become cancerous
in a few weeks, but may not for years. Epithelioma generally
begins as a warty protuberance which soon ulcerates. The
malignant ulcer has a hard, irregular base, uneven edges, a
foul, fungus-like bottom, and gives off a sanious or ichorous
discharge. This ulcer is the seat of sharp, pricking pain,
sometimes bleeds, and extends over a considerable area, em-
bracing and destroying all structures. Epithelioma affects
lymphatic glands usually early, but its action may be delayed
for eight or ten months. These glands break down in ulcer-
ation, making frightful gaps and often causing fatal hemor-
rhage. Dissemination is not nearly so common as in other
forms of cancer, but it does sometimes occur.

A rodent or Jacob's ulcer is scarcely ever met with except
upon the face, though Jonathan Hutchinson saw one upon
the forearm, and James Berry one upon the arm. It is
especially common upon the nose and forehead. It begins
after the age of forty as a little warty prominence which
ulcerates in the center, the ulceration progressing at a rate
equal to the new growth. It becomes deep ; is not crusted ;
its edges are hard and everted ; and the parts about contain
numbers of visible vessels. Jacob's ulcer grows slowly, may
last for years, does not involve the lymphatics, produces no
constitutional cachexia, and is rarely fatal. It is an ulcer
with irregular edges and a smooth base of a grayish color,
its discharge being thin and acrid, and is considered to be a
malignant epithelial growth which springs from a sweat-gland,
a sebaceous gland, or a hair-follicle, but Kanthack asserts
that before ulceration the rete and the sweat-glands are nor-
mal, but the sebaceous glands are destroyed. The base and
edges of the ulcer are hard, which differentiates it from lupus,
and from lupus the bacilli of tubercle may sometimes be
cultivated (p. 152). Rodent ulcer begins below the skin,
ordinary epithelioma begins in the skin (Butlin), and a rodent
ulcer contains no cell-nests.

Sphcroidal-cellcd Carcinomata. — {a) Scirrhous carciuovia is
a white and fibrous mass which has no capsule, which infil-
trates tissues, and which draws in toward it, by the contrac-
tion of its outlying processes, adjacent soft parts, thus pro-
ducing dimpling, or, as in the breast, retraction of the nipple.
It is composed of spheroidal cells in alveoli formed of con-
nective-tissue bands. The commonest seat of scirrhus is the
female breast. It occurs also in the skin, vagina, rectum,
prostate, uterus, stomach, and esophagus. It is most fre-
quent in women after forty. It begins as a hard lump which

236 MODERN SURGERY,

is at first painless, but soon becomes the seat of an acute,
localized, pricking pain. This lump grows and becomes ir-
regular and adherent, causing puckering of the soft parts.
After the skin or mucous membrane above it has become
infiltrated ulceration takes place and a fungous mass pro-
trudes which bleeds and suppurates. The adjacent lymphatics
soon become involved, and the constitutional involvement is
rapid and certain.

(^) Encephaloid carcinoftta is a soft gray or brain-like mass.
It is a rare growth, it has no capsule, and it may appear in the
kidney, liver, ovary, testicle, mammary gland, stomach, blad-
der, and maxillary antrum. An encephaloid cancer often
contains cavities filled with blood, and this variety is known
as a ** hematoid " or a " telangiectatic " carcinoma. These
growths are soft and semi-fluctuating, they infiltrate rapidly
and soon fungate, and they terminate life in from a year to a
year and a half If the cells of encephaloid become filled
with melanin, we have the condition known as "melanosis"
or " melanotic cancer."

(r) Colloid carcinoma arises from either a scirrhus or an en-
cephaloid cancer when the cells or stroma undergo colloid
degeneration. On section we see in the center of the growth
a series of cav^ities filled with a material resembling honey or
jelly; the periphery often shows an ordinary scirrhus or
encephaloid cancer. Colloid degeneration is most prone to
attack cancers of the stomach, mammary gland, and intes-
tine.

Cylindrical-celled carcinomata which occur in the rectum
arc known as *' adenoid " or " glandular " cancers. They
may occur in this region at a much earlier age than do can-
cers elsewhere, being not uncommon between the ages of
twenty-eight and forty. At first covered by mucous mem-
brane, they soon ulcerate and inv^olve the submucous and
muscular coats in the growth. They grow rather slowly,
and take usually from four to six years to kill. They usu-
ally, but not always, cause lymphatic involvement and con-
stitutional infection. They are composed of a stroma of
fibers between which lie tubular glands lined with columnar
epithelium and masses of epithelial cells.

Treatment. — Carcinomata demand early and free excision,
with removal of implicated glands. A certain proportion
can be cured. Recurrent growths may be removed as a
palliative measure, to lessen pain and to relieve the patient
from ulceration and hemorrhage. If a growth does not recur
within five years after removal, a cure has probably been at-

TUMORS OR MORBID GROWTHS, 237

tained. A rodent ulcer should be excised or else be curetted
and cauterized with the hot iron or the Paquelin cautery. In
cancer of the lower ///, remove the growth by a V-shaped
incision or cut away the entire lip and remove the glands
beneath the jaw ; in cancer of the tongue y excise this organ
and any enlarged glands ; in cancer of the breast, remove the
breast and pectoral fascia and take away the fat and glands
of the axilla ; in cancer of the rectum, if near the surface,
excise the rectum from below ; if above five inches from the
anus, do the sacral resection of Kraske and then remove the
growth ; in cancer of the esophagus, perform gastrostomy ; in
cancer of the pylorus, perform pylorectomy or gastro-enter-
ostomy ; in cancer of the bowel, do resection with end-to-end
approximation, side-track the diseased area by an anasto-
mosis, or make an artificial anus ; in cancer of the penis,
amputate and remove the glands of the groin. Erysipelas
toxins and erysipelas serum have been tried in inoperable
carcinoma, but without any positive benefit. The same is
true of pyoktanin, thiosinamin, and of all other drugs that
have been suggested.

Cysts* — A cyst is a sac containing a fluid or a semi-fluid.

Division of C3rBtB. — Cysts are divided into (i) 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) Exudatiopi-cysts, which are due to accumulations in closed
cavities. These comprise synovial cysts (ganglions and
bursae). Dentigerous cysts used to be considered under
this head. (3) Dermoid cysts, which are congenital and
arise from inversion of the cutis and imperfectly closed
fetal clefts. (4) Cystomas, which are cysts of new forma-
tion 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 develops from pressure. (5) Extravasation-
cysts, that form around blood-extravasations. (6) Hydatid
cysts, or cysts due to the echinococcus or tape-worm of
the dog. A mother-cyst is formed, which becomes filled
with daughter-cysts floating in a saline liquor containing
booklets.

Sebaceous cysts arise when the excretory duct of a seba-
ceous gland is blocked by dirt or occluded by inflammation.
The orifice of the duct is often visible as a black speck over
the center of the cyst. They are very common in the scalp.

238 MODERN SURGERY.

being 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 a sebaceous cyst. A sebaceous
cyst is lined with epithelium and is filled with foul-smelling
sebaceous material. A sebaceous cyst may suppurate. When
a cyst ruptures and the contents become hard, a horn is
formed. The other form of horn has been previously alluded
to as due to horny transformation of a wart.

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 forms in a sebaceous cyst, open it, grasp the edges
of the cyst-lining 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 imper-
fect closure of fetal 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 ad-
herent, so remove a portion of periosteum with the cyst.

Hydatid cysts are especially common in Iceland, and are
frequent in Australia, but are ver>' rare in the United States.
They are due to the echinococcus. The adult echinococcus
is the tapeworm of the dog (taenia echinococcus), and its
ova or larvae gain access to man's body by accompanying the
food he eats and passing into the alimentary canal, from
which canal they are transported to various organs
by the blood. Osier says the embryo (which has six

DISEASES AND INJURIES OF HEART AND VESSELS. 239

booklets) burrows through the wall of the bowel and en-
ters the peritoneal cavity or muscles ; it may enter the portal
vessels and reach the liver, or may enter the systemic cir-
culation and pass to distant parts. The danger depends on
two factors : ** the situation and the liability of the cyst to
suppurate " (Sidney Coupland). The organs most usually
attacked are the liver and lung. In 60 per cent, of cases the
liver suffers, and in 12 per cent, the lung (Thomas). Cysts
sometimes arise in the intestine, genito-urinary passages, brain,
or spinal canal. When the embryo lodges the booklets dis-
appear and the embryo is converted into a cyst. This cyst
is composed of two layers, an outer capsule (cuticular mem-
brane) and an inner layer (endocyst). The cyst contains clear
fluid (Osier). As the cyst grows, daughter-cysts bud out
from the wall of the mother-cysts, the structure of the daugh-
ter-cysts being identical with that of the mother-cyst. From
the lining membrane of all the cysts, after a time, growths
arise known as scolices, which represent the head of the
echinococcus and exhibit four sucking disks and a row of
booklets (Osier).

The fluid is not albuminous, is occasionally saccharine, is
thin and clear, and may contain scolices or booklets.

A hydatid cyst may calcify, may rupture, or may suppurate.
These cysts are very firm, but usually fluctuate. Palpation
with one hand while percussion is practised with the other
gives a persistent tremor (hydatid fremitus). The fluid should
be drawn and examined. When a cyst suppurates positive
constitutional and local symptoms arise.

Treatment. — In a hydatid cyst of a superficial part incise
and dissect out the sac-w^all (Gardner). Unruptured hydatid
cysts of superficial structures should be dissected out.
Abdominal cysts should be radically removed if possible ;
if this is not possible, stitch to the peritoneum, incise, irri-
gate, and drain with gauze. Bond advocated evacuating the
cyst, closing it with sutures and dropping it back in the
abdomen. Gardner says tapping is dangerous, as it may
cause rupture of the cyst. If aspiration is performed to
settle a diagnosis, operate at once after doing it.

XVIII. DI5EA5E5 AND INJURIES OF THE HEART

AND VESSELS.

Heart and Pericarditim. — In an acute pulmonary con-
gestion the venous side of the heart is over-distended with
blood, and the surgeon in desperate cases may tap the right

240 MODERN SURGERY.

auricle (see Paracentesis Auriculi). Pericardial effusion, if
severe, calls for tapping or aspiration, and purulent peri-
carditis 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 fibers the hemor-
rhage is often slight ; the pericardium may be injured by frag-
ments of a fractured rib. If bleeding into the pericardial sac
takes place, the signs of a pericardial effusion become mani-
fest. 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
fibers, 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 lowering of the head. The body is sur-
rounded with hot bottles, opium is given in small doses, and
stimulants are applied in moderation, but never to excess.
An attempt must be made to suture the wounds in the heart
and pericardium. Access can be gained by resecting one or
more ribs. The wounds should be sutured with silk. Rahn
sutured a wound of the heart and packed the pericardium
with gauze, and the patient recovered. Parrozzani successfully
sutured a wound of the ventricle. Williams reports recovery
after a stab-wound of the heart, the pericardium having been
sutured. Fareni sutured a stab-wound of the left ventricle,
and the patient lived several days. Cappelan sutured a wound
of the heart, and the patient lived two and one-half days.
Traumatic carditis or pericarditis is treated in the same way
as idiopathic cases. Pus in the pericardial sac should be
evacuated by re.scction of the fourth left costal cartilage and
incision of the pericardium (Von Eiselberg's case). Dalton
has sutured the pericardium.

Phlebitis, or Inflammation of a Vein. — Phlebitis may
be plastic, or it may be purulent. Plastic phlebitis, w^hile occa-
sionally due to gout, to a febrile malady, or to some other
constitutional condition, usually takes its origin from a wound
or other injury, from the extension to the vein of a f)eri-
vascular inflammation, or in the portal region from an em-
bolus, V^aricose veins are particularly liable to phlebitis.
When phlebitis begins a thrombus forms because of the

DISEASES AND INJURIES OF HEART AND VESSELS. 24I

destruction of the endothelial coat, and this clot may be ab-
sorbed or organized. Suppurative phlebitis is a suppurative
inflammation of a vein, arising by infection from suppurating
perivascular tissues (infective thrombophlebitis). It is most
frequently met with in cellulitis or phlegmonous erysipelas,
may arise in the lateral sinus as a result of mastoid suppura-
tion, or in the liver from appendicitis or phlebitis of the
rectal veins. A thrombus forms, the vein-wall suppurates, is
softened and in part destroyed, and the clot becomes puru-
lent. No bleeding occurs when the vein ruptures, as a barrier
of clot keeps back the blood-stream. The clot of suppura-
tive phlebitis cannot be absorbed and cannot organize. Septic
phlebitis causes pyemia, and the infected clots of pyemia
cau.se phlebitis.

Symptoms. — The symptoms of phlebitis are pain, tender-
ness in and around a vein, discoloration over it, and solid
edema below the seat of the disease. Suppurative phlebitis
causes the constitutional symptoms of pyemia (p. 138).

Treatment. — The treatment of aseptic phlebitis comprises
rest in bed, bandaging and elevation of the part, and the local
use of lead-water and laudanum or ichthyol. Hot fomenta-
tions are used later in the case. The danger is embolism ;
hence massage and movement are dangerous. When a vein
is involved in pyophlebitis or septic thrombophlebitis ligate,
if possible, above and below the clot, open the vessel, and
wash out the purulent mass. This plan of treatment is
always to be applied in infective thrombophlebitis of the
lateral sinus (p. 564). The constitutional treatment is that of
pyemia.

Varicose Veins, Phlebeetasis, Phlebeetasia, or

Varix. — Definition and Causes. — Varicose veins are un-
natural, irregular, and permanently dilated veins which
elongate and pursue a tortuous course. This condition is
very common, and 20 per cent, of adults exhibit it in some
degree in one region or another. The causes of varicose
veins are obstruction to venous return and weakness of
cardiac action, which lessens the propulsion of the blood-
stream.

Varicose veins may occur in any portion of the body, but
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 blood-column and in urging

242 MODERN SURGERY.

it on. The deep as well as the superficial veins may become
varicose. Verneuil maintained that varix of the superficial
veins was almost always secondary to varix of the deep
veins. By the term " caput medusae " are meant varicose
veins radiating from the umbilicus. The veins of the esopha-
gus may become varicose, and this malady is rarely recognized.
Varicose veins are in rare instances congenital ; they are most
often seen in the aged, but usually begin between the ages
of twenty and forty. They are more common in women
than in men because of the influence of pregnancy.

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 " hemor-
rhoids " 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 incom-
petent and the dilatation becomes still greater. Callender
has pointed out that varix is apt to begin where the deep
vessels join the superficial veins. At this point Treves
says three forces meet, the blood-column above, the valve
below, and the force of the blood-current. At this point the
vein-wall dilates, and from this dilatation the blood-current is
affected and causes another dilatation higher up (Agnew).
The vein-wall 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 edema, and the watery elements in the tissues cause
eczema of the skin. When eczema is once inaugurated ex-
coriation is to be expected. Infection of an excoriated area
produces inflammation, suppuration, and an ulcer.

The skin over varicose v^eins in the leg is often discolored by
pigmentation due to the red blood-cells having escajjed from
the vessel and been broken up. The tissues around a vari-
cose vein become atrophied from pressure, and there is
often met with a very large vein whose thin walls are in

DISEASES AND INJURIES OF HEART AND VESSELS. 243

close contact with skin. In this condition rupture and
hemorrhage are probable. Varicose veins are apt to inflame,
and thrombosis frequently occurs.

Treatment. — The treatment of varix may h^ palliative or
curative, but whichever is followed endeavor first to remove
the exciting cause. In palliative treatment, attend to the
general health, keep up the force and activity of the circu-
lation, and prevent constipation. Recommend the patient
to exercise in the open air and to lie down, if possible, every
afternoon. Locally, in varix of the leg, order a flannel roller
or a Martin rubber bandage to support the veins and drive
the blood into the deeper vessels which have muscular sup-
port. The use of a rubber pad filled with glycerin and
applied over the saphenous vein so as to support the blood-
column and act as a valve, has been recommended. Locally,
in varicocele, pour cold water upon the scrotum twice a day
and order the patient to wear a suspensory bandage. Lo-
cally, in hemorrhoids, use astringent suppositories (p. 7 1 5).
The curative or radical treatment of varix of the leg com-
prises ligation with excision of part of the vein, exposure
and ligation of the vein, multiple subcutaneous ligatures of
catgut, acupressure-pins with twisted sutures, injection of
pure carbolic acid into the perivascular structures, circular
incision around the leg (see Operations upon Vessels).

Nevus* — (See Tumors.)

Arteritis^ or inflammation of an artery, is acute or chronic.

Acute arteritis may result from injury or from extension
of inflammation from the perivascular tissues. This latter
mode of origin is uncommon, as arteries are very resistant
to the spread of inflammation, but we meet with it some-
times in suppurating areas. In a suppurating acute arteritis
the coats ulcerate through, but hemorrhage rarely occurs
unless a considerable portion of the vessel sloughs. Septic
emboli lodging in the arterial system produce acute arte-
ritis. This is seen during the progress of ulcerative endo-
carditis.

Chronic arteritis produces "atheroma." It is due to
increase of blood-pressure from hard work, strains, heart-
disease, or contracted kidney. It is especially common in
drunkards in the larger arteries. It is often met with in
drunkards, but occurs in aged men who never drank. It is
a true saying that " A man is as old as his arteries." In
chronic arteritis exudation of serum and migration of leuko-
cytes take place beneath the intima, and a like exudation soon
becomes manifest in the media, in the adventitia, and even in

244 MODERN SURGERY.

the sheath. Embryonic tissue is formed, which may undergo
resolution, may become fibrous tissue (arterial sclerosis), or
may undergo fatty degeneration (atheroma). When fatty de-
generation occurs the endothelium is destroyed, the vessel-
wall is damaged, and the blood obtains access to the deeper
coats. Calcareous change may follow fatty degeneration.

An atheromatous artery is rigid and inelastic, and the
parts it supplies are cold, congested, and ill-nourished.
Atheroma is a frequent cause of thrombosis, aneurysm, senile
gangrene, and apoplexy. Syphilitic arteritis is characterized
by an enormous growth of granulation-tissue from the inner
coats (obliterative arteritis) of arteries of small size. Calci-
fication of an artery may be secondary to fatty change, or
may occur primarily from deposit of lime salts in the middle
coat. Periarteritis is inflammation of the sheath and outer
coat. An acute arteritis is always local, but a chronic
arteritis may be general.

Treatment of acute arteritis consists of rest, elevation
and relaxation, the application of tincture of iodin, and the
use of lead-water and laudanum. Hot fomentations are
applied later. Abscesses are opened and drained. Inter-
nally, treat any diathesis (rheumatic, gouty, or syphilitic),
maintain kidney secretion, quiet the circulation, and employ
a non-stimulating diet. The part must be kept quiet, as
rough movement would tend to rupture the vessel.

Treatment of Chronic Arteritis. — In treating chronic
arteritis, endeavor to antagonize the dangers to which the
patient is obviously liable. Stop alcohol as a beverage,
though a little whiskey may be taken at meals to aid di-
gestion. Maintain the activity of the skin by daily baths,
and of the kidneys by diuretic waters. The contents of the
bowels are to be kept soft. The diet is to be plain and
is to contain a minimum of nitrogen. If syphilis has existed,
occasional courses of iodid are to be urged. If the arterial
tension at any time becomes inordinately high, give nitro-
glycerin. One danger is apoplexy ; hence excitement and
violent exercise are to be avoided. Another danger is senile
gangrene ; hence the patient should wear woollen stockings,
put a hot bottle to his feet at night, and be careful to avoid
injuring his toes or feet, especially when cutting his corns.
When a patient with atheroma has dyspnea and is of a
livid color, or when the arterial tension is very high, a
moderate bloodletting (sixteen to eighteen ounces) does good.
Still another danger is aneur>'sm, which may appear suddenly
from rupture or gradually from progressive distention.

D/SEASES AND INJURIES OF HEART AND VESSELS. 245

Anetirysni. — An aneurysm is a pulsating sac containing
blood and communicating with the cavity of an artery.
Some restrict the term " true aneurysm " to a condition of
dilatation involving all the coats of the vessel. We shall
consider, with Heath, a true aneurysm to be one in which
the blood is included in one or more of the arterial coats,
and a false aneurysm to be a condition in which the vessel
has ruptured or has atrophied and the aneurysmal wall is
formed by a condensation of the perivascular tissues.

Forms of Aneurysm. — The following forms of aneurysm
are recognized:

1. True aneurysm — one whose sac is formed of one or
more arterial coats.

2. False aneurysm— on^ who.se sac is formed of condensed
perivascular tissues and contains no arterial coat.

3. Traumatic aneurysm — a false aneurysm due to traumatic
rupture s#me time before, the blood being in a sac of tissue
and all wound being healed.

4. Fusiform aneurysm — a variety of true aneurysm, the
sac being spindle-shaped.

5. Consecutive aneurysm — a sacculated aneurysm diffused
by rupture, or a false aneurysm due to gradual destruction
or atrophy of a true aneurysmal sac or to vascular rup-
ture.

6. Sacculated aneurysm — a common form of aneurysm, in
which the dilatation is like a pouch, arising from a part of
the arterial circumference and joining the lumen of the vessel
by an aperture.

7. Dissecting aneurysm — a pouch-like dilatation, due to the
blood which, passing through an aperture in the intima,
enters between the media and adventitia and dissects them
apart. It may or may not join the lumen of the artery at
another point by a fresh aperture in the intima.

8. Arterioi'cnoiis aneurysm, which is divided into aneur-
ysmal varix, or Pott's aneurysm, where there is direct com-
munication between a vein and an artery, and varicose aneur-
ysm, where there is communication between an arter^*^ and a
vein by means of an interposed sac.

9. Acute aneurysm — a cavity in the walls of the heart.
which cavity communicates with the interior of this organ,
and which is due to suppuration in the course of acute endo-
carditis or myocarditis.

10. Aneurysm by anastomosis (see Angeiomata).

1 1. Aneurysm of bone — an inaccurate clinical term used to
designate a pulsatile tumor of bone.

246 MODERN SURGERY,

12. Circumscribed aneurysm — when the blood is circum-
scribed by distinct walls.

13. Cirsoid anetirysm — a mass of dilated and elongated
arteries shaped like varicose veins and pulsating with each
heart-beat.

14. Cylindrical aneurysm — a dilatation of the same dimen-
sions for a considerable space.

15. Embolic or capillary aneurysm — dilatation of terminal
arteries due to emboli.

16. Spontaneous aneurysm — non-traumatic in origin.

17. Miliary aneurysm — a minute dilatation of an arteriole.

18. Secondary aneurysm — one which, after apparent cure,
again pulsates, the blood entering by means of the anasto-
motic circulation.

19. Verminous aneurysm — one containing a parasite. This
form of aneurysm is met with in the mesenteric artery of the
horse.

The sac of a sacculated aneurysm is at first composed of
at least two of the arterial coats, reinforced by the sheath
and perivascular tissues. After a time the blood-pressure
distends the sac, and the inner and middle coats either stretch
with interstitial growth or — what is more common — ^are worn
away and lost. When all the coats are lost, and the blood
is sustained only by the sheath and surrounding tissue, a
true aneurysm becomes a diffused or consecutive aneurysm,
the limiting tissues and sheath being condensed, thickened,
and glued together. This limiting process is deficient in the
brain ; hence cerebral aneurysms break soon after their
formation. When all the arterial coats are lost, the blood-
pressure, acting on the tissues, finds some spots less resistant
than others, the blood follows the lines of least resistance,
the aneurysm grows with great rapidity, and soon ruptures.

An aneurysm may rupture into a cavity (pleura, pericar-
dium, or peritoneum), into the perivascular tissues, or through
the skin. Rupture into the tissues may produce pressure-
gangrene. Wlien rupture occurs through the skin, the hem-
orrhage is not often instantly fatal, but during several days
constantly recurs in larger and larger amounts. The pressure
of an aneurysmal sac causes atrophy of tissues, hard and soft,
bones and cartilages being as easily destroyed as muscles and
fat. Sometimes the perivascular tissues inflame and suppu-
rate, and the sac is opened rapidly by sloughing. An aneurysm
usually progresses toward rupture, the slowest in this progres-
sion being the fusiform dilatations, which may exist for many
years, but which finally eventuate in the sacculated variety.

DISEASES AND INJURIES OF HEART AND VESSELS, 247

In some rare instances there takes place spontaneous cure,
which may result from laminated fibrin being deposited upon
the walls of the sac as the blood circulates through it. This
laminated fibrin is known as an ** active clot," and eventually
fills the sac. The weaker and slower the blood-stream, the
greater is the tendency to the formation of an active clot ;
hence any agent impeding, but not abolishing, the circulation
aids in the deposition. This weakening and slowing of cir-
culation may be brought about by great activity of the col-
lateral circulation deviating most of the blood away from the
area of disease. Sometimes a clot breaks off from the sac-
wall and plugs the artery beyond the dilatation, and the an-
astomotic vessels, enlarging, divert the blood-stream. A large
aneurysm, falling over by its own weight upon the vessel
above the mouth of the sac, may diminish the blood-stream.
The development of another aneurysm upon the same vessel
nearer to the heart weakens the circulation in and may cure
the older one. Inflammation occasionally forms a clot. The
tissues about an aneurysm tend to contract when arterial
force is lessened; hence tissue-pressure may more than
counteract blood-pressure when the circulation is feeble.
Clotting of the blood contained within a sac, circulation
through the aneurysm having ceased, causes a passive clot.
A passive clot, which occasionally cures, may arise from a
twisting of the neck of the sac, preventing the passage of
blood ; from the lodgement of a clot in the mouth of the
sac ; and from inflammation. Spontaneous cure is, unfortu-
nately, very rare.

Causes of Aneurysm. — Gradual distention of arterial coats
which are in a condition of arterial sclerosis, or local loss of
resisting power due to atheroma, may cause aneurysm. Hence
the causes of sclerosis and atheroma are also causes of aneur-
ysm. The principal cause of aneurysm is increased blood-
pressure. This increase may be brought about by severe
labor ; by sudden strains, as in lifting ; by violent efforts, as
in rowing in a boat-race ; by chronic interstitial nephritis ; by
hypertrophy of the heart; by alcoholic inebriety; and by
syphilis. Arterial disease is commonest in the larger vessels
and in the aged, but it may occur in youth. When an aneur-
ysm follows a strain, it may be due to laceration of the media
and loss of resistance at a narrow point. The intima may
lacerate, permitting the blood to come in contact with the
media or causing blood to diffuse between the coats (dissect-
ing aneurysm). An embolus which lodges may cause an
aneurysm on its proximal side. The embolus, if infective.

248 MODERN SURGERY.

causes softening, and if calcareous causes laceration (Osier).
Colonies of micrococci may cause aneurysm.* The parasite
strongyliis armattis causes aneurysm of the mesenteric arteries
in horses. Suppuration around a vessel weakens its coats and
tends to aneur>'sm by inducing acute arteritis and softening.
Sometimes an individual develops multiple aneurysms the
origins of which are absolutely unknown.

The constituent parts of an aneurysm are (i) the wall of the
sac ; (2) the cavity ; (3) the mouth ; and (4) the contents.

Symptoms of Aneurysm. — An oval or globular, soft,
elastic, and pulsatile protrusion, develops in the line of an
arter>'. It is usually quite evident to the touch that the
sac contains fluid, but sometimes in old aneurysms it fisels
firm or even hard, because of the deposit of fibrin upon its
inner surface. In a partially consolidated aneurysm pulsation
may be slight or even inappreciable. This protrusion in-
stantly ceases to pulsate and almost disappears on making
firm pressure on the artery above. On relaxing the pressure
the pulsatile enlargement at once reappears. Direct pressure
upon the tumor may cause it to almost disappear. Pressure
upon the artery below causes the tumor to enlarge. The
pulsation is expansile — that is, it expands in all directions —
and if an index finger be laid on each side of the tumor so
that their points nearly touch, each pulsation not only lifb
the fingers, but it also separates them. On placing a stetho-
scope over the aneurysm or over the vessel below the aneur-
ysm there is imparted to the ear a distinct bruit which travels
in the direction of the blood-stream, is systolic in time, and
is usually blowing in character. In some cases bruit is absent
(when a sacculated aneur>'sm has a very small mouth, when
the circulation is tranquil, or when the sac is full of blood
and clot). When bruit is absent it may sometimes be de-
veloped by muscular exercise or raising the affected Hmb
(Holloway). In rare cases there may be a double bruit. Occa-
sionally in fusiform aortic aneurysm linked with aortic regur-
gitation a diastolic bruit exists. A bruit is arrested by press-
ing upon the artcr>' between the aneurysm and the heart.'
The skin over an aneurysm may be normal or discolored,
and may slough or ulcerate. Aneur^'sm of an extremity is
apt to produce edema and varicose veins, because of pressure
upon large veins and loss of vis a tergo in circulation. The
muscles feel tired, and sometimes there is pain. In internal
ancur>'sms pressure-symptoms arc marked. Thoracic aneur-

^ Sfc Osier on Malii^nant Endocarditis.

* Holloway on " Aneurysm," in Park's Surgery by American Authors.

h/)/S£AS£S A.VD INJURJES OF HEART AND lESSELS. 249

lysm causes intercostal pain; iliac aneurysm causes pain in
I the thigh. Aneurysm of the aorta presses upon the pneu-
mogastric nerve, causing spasmodic dyspnea, and upon the
recurrent laryngeal, causing loss of voice and paralysis of all
the muscles of the larynx except the cricothyroid. The
pulse below an aneurysm is weaker than the pulse of the cor-
responding part of the opposite limb. This is well shown by
the sphygmogiaph, the tracings being rounded without a
sudden rise or an abrupt fall (Fig. 39). The evidences of

rupture are loss of distinctness of outline and increase in area
of the tumor, weakening or disappearance of both bruit and
pulsation, severe pain, edema and coldness of the surface
and possibly syncope. External hemorrhage may arise; the
tissues may become extensively infiltrated with blood ; slough-
tng or gangrene may ensue. Death is frequent, and only in
ver>- rare cases does spontaneous cure take place.

Diagrnosig, — A cyst or abscess over a vessel may show
transmitted pulsation which is not expan.sile, and the tumor
does not disappear on pressure above it. The pulsation
ceases when the growth is lifted off the ves.sel, or when the
position is changed so as to permit it to fall away from the
■vessel. There is no true bruit, and the history is widely dif-
ferent. A growth under a vessel may lift the vessel and
nmulate an aneurysm, but the pulsation is not noted in the
entire growth, the growth does not disappear on proximal
toressure, and there is only a false, and never a true, bruit.
The larger the growth the less is the pulsation due to pres.s-
ure upon the vessel. A sarcoma, especially a soft sarcoma
Attached to the bone, and also a nevoid mass, pulsate and often
liave a bruit ; the tumor never disappears from proximal pre.ss-
ure, though it may slowly diminish in size, to gradually en-
large again when pressure is withdrawn. These growths do
not feel fluid, and are rarely circumscribed. An aneurysm
may cease to pulsate from con.solidation leading to cure, or
from rupture. Rupture of a large aneurysm into a cavity

250 MODERN SURGERY,

induces deadly pallor, syncope, and rapid death. Rupture of
an aneurysm of an extremity into the tissues is made mani-
fest by a sensation of something breaking, by pain, by sud-
den increase in size, by diminution or absence of bruit and
pulsation, by absence of pulse below the aneurysm, by swell-
ing and coldness of the limb, and by shock.

Treatment. — In inoperable aneurysms general, medical,
and dietetic treatment must be tried. It consists chiefly in
rest in bed to diminish the rapidity and force of the circu-
lation and favor fibrinous deposit. Tuffnell's plan is to
reduce the heart-beats by rest and mental quiet, and to
rigidly restrict the diet so as to diminish the total amount
of blood and render it more fibrinous. Liquids are re-
stricted in amount, and the patient lives for twenty-four
hours upon four ounces of bread, a very little butter, eight
ounces of milk, and three ounces of meat. Pursue this plan
for several months if possible, or employ it for several weeks
at a time over and over again. There can be no doubt that
Tuffnell's treatment sometimes cures by decidedly lowering
the blood-pressure. Valsalva long ago suggested rest,
occasional bleeding, and a diet just above the point of star-
vation. In many cases of aneurysm the patient may be
permitted to go about, taking his time about everything and
avoiding work, worry, and excitement. The diet is low and
non-stimulating, and the bowels must be maintained in a
loose condition.

lodid of potassium in doses of 20 grains undoubtedly
does good, and not only in syphilitic cases. It seems to
lower the blood-pressure. Balfour taught that it thickened
the sac. Osier says it relieves the pain. Iron, acetate of
lead, and ergotin are prescribed by some. Digitalis is
contraindicated, as it raises the blood-pressure. S. Solis
Cohen has used with some success the hydrated chlorid
of calcium. Morphin and bromid of potassium are occa-
sionally useful to tranquillize the circulation, allay pain, or
secure sleep. Aconite and veratrum viride have long been
employed. Other expedients arc : the kneading of the sac
to release a clot, in the hope that it will plug the mouth of
the sac or the artery beyond it — this is dangerous ; elec-
tricity; electrolysis; the injection of an astringent liquid;
the insertion of a fine aspirating-needle and the pushing
through it into the sac of a large quantity of silver wire, in
the hope that it will aid in whipping out fibrin. Some
physicians have inserted needles and horse-hair.

Even in an operable case diet and rest are of importance.

DISEASES AND INJURIES OF HEART AND VESSELS. 2$ I

The patient should be in bed for a number of days before
operation, the daily diet consisting of ten or twelve ounces
of solid food with a pint of milk. If the circulation is very
active, use aconite and allay pain by morphin.

Treatment by Pressure, — Instrumental pressure is made by
applying two Signorini tourniquets or some specially devised
apparatus to limit the flow of blood through an aneurysm
without entirely stopping it, the aneurysmal sac being felt
to still slightly pulsate. In some situations Lister's abdom-
inal tourniquet is applied ; in other regions we may use Tuff-
nell's compress, which is like a spring truss and is strapped
in place. A weight suspended over the artery and resting
part of its weight upon the vessel has occasionally brought
about cure. These instruments can be worn for from twelve
to sixteen hours at a time ; usually they are removed to permit
sleep and reapplied the next day, and so on for several
days. Before applying the compress be sure the sac is
full of blood, and render this certain by applying for a few
minutes distal compression. This method may cure, but it
is very painful. It cannot be used successfully in treating
aneurysm of the axillary, subclavian, or carotid. It aids in
the formation of an active clot.

Digital presstire, made with the thumb aided by a weight,
and maintained for many hours by a relay of assistants, has
cured many ca.ses. This method may be used alone or may
be used as an accessory to instrumental pressure. Its chief
field is in the treatment of aneurysm for which other methods
are inapplicable (orbit and root of neck). It entirely cuts
off the blood and promotes the formation of a passive clot.
If cure does not take place in three days, abandon pressure.
It must often be abandoned because of pain.

Direct pressure upon the sac has been used in aneurysm
of the popliteal artery, the pressure being obtained by flexing
the leg ; and in aneurysm of the brachial artery pressure has
been applied at the bend of the elbow by flexing the elbow.
The pressure of a hollow rubber ball has been used in aneur-
ysm of the subclavian.

Rapid pressure completely arrests the passage of blood
through the sac for a limited time, and is applied while the
patient is under the influence of an anesthetic. Take, for
example, a case of popliteal aneurysm : the patient is placed
under ether ; two Esmarch bandages are used, one being put
on the limb from the toes to the lower limit of the aneurysm,
and the other from the groin down to the upper limit of the
sac, and the Esmarch band is fastened above the upper

252 MODERN SURGERY,

bandage. This procedure stagnates the blood both in the
veins and in the arteries, the sac remaining full of blood
Pressure is thus maintained for three or four hours, and on
removing the Esmarch apparatus a tourniquet is put on the
artery above the aneurysm and partly tightened to limit
the amount of blood passing through and thus prevent
the washing away of clot. This method of rapid pressure
sometimes cures by forming a passive clot, but it sometimes
results in gangrene. It was devised by John Reid.

Operative Treatment: By the Ligature, — Ligation of the
main artery is, as a rule, the best procedure. The methods
of ligation are — (i) the method of Antyllus; (2) the method
of Ancl ; (3) the method of Hunter; (4) the method of War-
drop ; and (5) the method of Brasdor.

In the method of Antyllus the sac itself is attacked
Hemorrhage is controlled by the Esmarch bandage, the sac
is opened, its contents turned out, and the artery ligated
immediately above and below the sac. This method is
chiefly employed for traumatic aneurysms, as its use in
aneur>'sms from diseased vessel -walls would mean that the
ligatures were probably applied upon disea.sed areas (Hg.
40). Syme suggested many years ago that extirpation was
the proper operation for aneurysm of the gluteal, iliac, car-
otid, and axillary arteries. In some cases it is the best
method.

The Method of Ariel. — In Anel's method the artery is
ligated close to and above the sac (Fig. 41). It is only used

Fig. 40. — (^Id operation of Antyllus for aneur- Fig. 41.— Anel's operation for aneurysm (/lur.
ysm {Am. Text- Book 0/ Surgery). Text- Book 0/ Surgery).

for traumatic aneur>'sms, and is never employed when the
vessel is diseased.

The Method of Hunter. — This operation, which is the
modern method of ligation, was devised by the illustrious
John Hunter. He recognized the fact that the vessel adja-
cent to an aneur}'sm was apt to be diseased, and he discov-
ered the anastomotic circulation. Putting together these
two facts, he devised the operation which goes by his name.
It consists in applying a ligature between the heart and the

DISEASES AND INJURIES OF HEART AND VESSELS, 253

aneur>'sm, but so far above the sac that collateral branches
are given off between it and the point of ligation (Fig. 42).
This operation, which is done upon a healthy area, does not
at once cut off all blood, but so diminishes the force and
frequency of the circulation that an active clot forms within

Fig. 42. — Hunter's operation for aneurysm {^American Text-Bock of Surgery).

the sac. Thus is lessened the danger of secondary hemor-
rhage and of gangrene. It is, as a rule, the proper opera-
tion for aneurysm. In some cases pulsation does not return
after tightening the ligature; in most cases, however, it
reappears for a time after about thirty-six hours, but is weak
and constantly diminishing. Previous prolonged compres-
sion by enlarging the collateral branches permits strong
pulsation to soon recur after ligation, and thus militates
against cure ; hence it is a bad plan to use pressure in cases
where its success is very uncertain. Occasionally after Hun-
ter*s operation the sac suppurates, producing symptoms like
those of abscess. When rupture takes place there may be
no hemorrhage, or profuse hemorrhage may rapidly kill the
patient, or hemorrhage may recur again and again until death
ensues. Suppuration may occur between the first and thirty-
second week after ligation.* When pus forms open freely
as we would open an abscess, and, if no blood flows, treat
as an abscess, but have a tourniquet loosely applied for sev-
eral days ready to screw up at the first sign of danger. If
hemorrhage occurs, tie the vessel above and below and pack
with iodoform gauze, having the tourniquet ready to tighten.
If bleeding recurs, there is no use reapplying the ligature and
there is little use tying higher up. If dealing with an extrem-
ity, amputate at once.

Distal Ligation, — When an aneurysm is so near the trunk
that Hunter's operation is impracticable, or when the artery
on the cardiac side of the tumor is greatly diseased, distal
ligation may be employed. Distal ligation forms a barrier
to the onflow of blood, collateral branches above the aneur-
ysm enlarge, the blood-current is gradually diverted, and
a clot is formed. Distal ligation is used in some aneurysms

* See the famous case of Sir Astley Cooper.

254

MODERN SURGERY.

of the aorta, iliacs, innominate, carotids, and subclavians. J(
occasionally causes rupture of the sac of the aneutysm.

The operation of Btasdor consists in tying the main (run t
some little distance below the aneurysm (Fig. 43). ll com-
pletely arrests circulation in the sac.

The operation of Wardrop consists in tying one of the
branches of the artery below the aneurysm (Fig. 44). It
partially arrests the circulation in the sac.

After ligating for aneur^'sm by any of these methods,
elevate the limb, keep it warm, and subdue arterial excite-

ment. When moist gangrene follows Hgation, amputate
early, above the ligature. When dry gangrene takes place,
await a line of demarcation. Rupture of the .sac after liga-
tion may produce gangrene or suppuration, the first condition
demanding amputation, and the second incision for drainage.
Injection of agents to produce coagulation (ergot, per-
chlorid of iron, etc.) is very dangerous and is to be utterly
condemned. It may lead to suppuration, gangrene, rupture,
or embolism. Manipulation to break up the clot wa.s sug-
gested by Sir Wm, Fergusson, and has been practised. The
object aimed at is to have a fragment of ciot block up the
vessel upon the peripheral side of the arter>' and act like a
distal ligature. The method is dangerous and should never
be employed.

Amputation for aneurysm is performed in some perilous
cases of subclavian aneurj'sm. instead of distal ligation.

Electrolysis. — An attempt may be made to coagulate the
blood at once, or from time to time an endeavor may be made
to produce fibrinous deposits, but the first method is the
better. It i.s, however, rarely possible to at once occlude

DISEASES AND INJURIES OF HEART AND VESSELS. 255

a sac, and pulsation, which is for a time abolished, recurs
as the gas present is absorbed. Use the constant current.
Take from three to six cells which stand in point of size
between those used for cautery and those used for ordinary
medical purposes. A platinum needle is attached to the
positive pole and a steel needle to the negative pole, both
needles being insulated by vulcanite at the points where the
skin will touch them. The asepticized needle are plunged
into the sac where it is thick and they are kept near together.
The current is passed for a variable period (from half an hour
to an hour and a half). This operation is not dangerous.
Pressure stops the bleeding. Electrolysis often ameliorates,
and sometimes cures, aortic aneurysms.*

Acupressure consists of the partial introduction of a num-
ber of ordinary sewing-needles into an aneurysmal sac and
leaving them in it for five or six days or more.

Introduction of Wire, — Insert into the sac a hypodermatic
or small aspirating-needle, and push through the needle or
cannula a considerable quantity of aseptic gold wire, which
is allowed to remain permanently. Loreta combines elec-
trolysis with the introduction of wire. Cases have been
benefited, and several have been apparently cured by this
method.

Traumatic anetuysm is a condition in which, after punc-
ture or rupture of an artery, a sac has formed of tissue and
if any wound previously existed, it has healed. The treat-
ment consists in ligation by the method of Antyllus, or com-
plete excision. When an artery ruptures and a large mass
of blood is extravasated no sac exists, and it is an error to
designate this condition as a diffuse traumatic aneurysm. In
this condition a large, oblong, fluctuating swelling is found.
If the rent is large, there are bruit and pulsation. There is
no pulsation in the arteries below the aneurysm, and the
limb is cold and swollen. The skin is at first of a natural
color, but becomes thin and purple. If the main vein is also
ruptured, or if the rupture has occurred into a large joint,
amputate ; otherwise perform the operation of Antyllus.

ArteriovetiOtlS aneurysttl is an unnatural passage-way
between a vein and an artery, through which passage blood cir-
culates. There are two forms : (a) aneurysmal varix, or Pott's
aneur>\sm, where a vein and an arter>' directly communicate ;
and (b) varicose aneurysm, where vein and artery communicate
through an intervening sac. These conditions arise usually
from punctured wounds, the instrument passing through one

* See John Duncan, in Heath's Dictionary.

256 MODERN SURGERY.

vessel and into the other, blood flowing into the vein, the
subsequent inflammation gluing the two vessels together,
and the aperture failing to close (aneurysmal varix. Fig. 45).
After the infliction of the wound the two vessels may sepa-
rate ; the blood still flows from artery into vein, and the
blood-pressure, by consolidating tissue, forms a sac of
junction (varicose aneurysm, Fig. 46). Aneurysmal varix
is a far less grave disorder than varicose aneurysm.

Ssnnptoms. — In aneurysmal varix a swelling exists with
the characteristic pulsation, and a loud whirring bruit is
tran.smitted along the veins. The veins above and below
the tumor arc enlarged, tortuous, and pulsating. A distinct
thrill is felt. Pressure over the tumor stops the thrill and
greatly lessens the bruit. The extremity is apt to be swollen
and the part.s are usually painful. When pressure on the
main artery causes the entire disappearance of the tumor.

(Spewi).

the ca.Hc is one of aneurysmal varix; but if on applying this
pressure the veins collapse and a distinct tumor remains
which ma>- be emptied by direct pressure, the case is one of
varicose aiit-urysm. If light pressure on one spot stops both
murmur and thrill, it is aneurj'smal varix. The diagnosis
between the two is often impossible.

Treatment. — Aneurysmal varix often requires only palli-
ative measures, as it does nbt tend to rupture, the veins
becoming thick and rcsi.stant and after a time ceasing to
enlarge. Some form of support is used. If tlie part is
painful or the vein is in danger of rupture, tie the artery
above and below the opening, or excise both vessels for
some little distance each side of the point of trouble. Vari-
cose aneurysm requires the use of the plans ordinarily
adopted in treating aneurj-sm (compression, etc.). If these
fail, tie the artery above and below the opening without
opening the sac, or cxci.se the involved areas of vein, artery,
and sac.

Cirsoid aneoxysm, or anetuysm by anastomosis,
consists in great dilatation with pouching and lengthening of

DISEASES AND INJURIES OF HEART AND VESSELS. 257

one or several arteries. The disease progresses and after a
time involves the veins and capillaries. The walls of the arte-
ries thin and the vessels tend to rupture. Cirsoid aneurysm
is met with upon the forehead and scalp of young people,
where it sometimes takes origin from a nevus.

Symptoms. — A pulsating mass, irregular in outline, com-
posed of dilated, elongated, and tortuous vessels that empty
into one another. The mass is soft, can be much reduced by
direct pressure, and is diminished by compression of the main
artery of supply. A thrill and a bruit exist. Pregnancy
and puberty cause rapid growth of a cirsoid aneurysm.

Treatment. — In treating a cirsoid aneurysm the ligation
of the larger arteries of supply is a wretched failure. Sub-
cutaneous ligation at many points of the diseased area has
effected a cure in some cases, but it has failed in most. Direct
pressure is also entirely useless. Ligation in mass has been
successful. Destruction by caustic has its advocates. Electro-
puncture with circular compres.sion of the arteries of supply
has once or twice effected a cure. Injection of astringents
has been recommended. Verneuil ligated the afferent ar-
teries, incised the tissues around the tumor, and sunk a
constricting ligature into the cut The proper method of
treatment is excision after subcutaneous ligation of every
accessible tributary of supply.^

Wounds of arteries are divided into contused, incised,
lacerated, punctured, and gunshot wounds, and vascular
ruptures.

Contused and Incised "Wounds. — A contusion may de-
stroy vitality and j^e followed by sloughing and hemorrhage.
A contused wound may do little damage, or it may produce
gangrene from thrombus, or it may cause secondary hemor-
rhage. In an incised wound there is profuse hemorrhage.
The artery after a time is apt to contract and retract, and
thus arrest bleeding. A transverse wound causes profuse
bleeding, but there is a better chance for natural arrest than
in an oblique or in a longitudinal wound. In a partially
divided artery, cut it entirely through and tie both ends.
The clot which forms in a cut artery is known as the ** in-
ternal clot ;" it reaches as high as the first collateral branch,
and subsequently becomes organized permanently, obliter-
ates the vessel, and converts it into a shrunken fibrous cord.
Between the vessel and its sheath, over the end of the vessel,
and in the surrounding perivascular tissues is the " external
clot."

* Anderson, in Heath's Dictionary.
17

258 MODERN SURGERY.

Lacerated wounds cause little primary hemorrhage. The
internal coat curls up, the circular muscular fibers of the
media contract upon it, and the external coat is so pulled out
as to cap the orifice of the vessel — all of which conditions
favor clotting. The vessel-wall is so damaged that secondary
hemorrhage is usual.

Punctured Wounds. — In punctured wounds primary hem-
orrhage is slight. Secondary hemorrhage is not usual. Dif-
fuse aneurysm and arteriovenous aneurysm are not unusual
results.

Gunshot-wounds are apt to be contusions which may
eventuate in sloughing and secondary hemorrhage or throm-
bosis and gangrene. A shell-fragment makes a lacerated
wound. A modern rifle-bullet makes a clean-cut division
of an artery. Secondary hemorrhage after gunshot-wounds
tends to occur during the third week. Partial rupture of an
artery may cause sloughing and secondary hemorrhage,
thrombosis and gangrene, and aneurysm. Complete rupture
is a lacerated wound, and is a condition accompanied by dif-
fuse traumatic aneurysm.

Wounds of veins are classified as are wounds of arteries.
The symptom of any vascular wound is hemorrhage.

I. Hemorrhage, or Loss of Blood.

Hemorrhage may arise from wounds of arteries, veins, or
capillaries, or from wounds of the three combined. In arte-
rial hemorrhage the blood is scarlet and appears in jets from
the proximal end of the vessel, which jets are synchronous
with the pulse-beats ; the stream, however, never intermits.
The stream from the distal end is darker and is not pulsatile.
Venous hemorrhage is denoted by the dark hue of the blood
and by the continuous stream. In capillary hemorrhage red
blood wells up like water from a sponge.

In subcutaneous hemorrhage from vascular rupture (diffuse
ancur>'sm) there are great swelling, cutaneous discoloration,
and systemic signs of hemorrhage. If a main artery ruptures
in an extremity, there is no pulse below the rupture, and the
limb becomes cold and swollen. At the seat of rupture a
large fluctuating swelling forms, and sometimes there is bruit
and pulsation. If a vein ruptures in an extremity, intense
edema occurs. Profuse hemorrhage induces constitutional
symptoms, and death may occur in a few seconds. Loss of
half of the blood will usually cause death (from four to six
pounds), though women can stand the loss of a greater rela-

DISEASES AND INJURIES OF HEART AND VESSELS. 259

tive proportion of blood than men. Generally, after the bleed-
ing has gone on for a time syncope occurs, which is Nature's
effort to arrest hemorrhage, for during this state the feeble cir-
culation and the increased coagulability of blood give time for
the formation of an external clot. When reaction occurs the
clot may hold and be reinforced by an internal clot, or it may
be washed away with a renewal of bleeding and syncope. These
episodes may be repeated until death supervenes. Nausea
and vertigo are present, black specks float before the eyes
(muscae volitantes), tinnitus aurium exists. The patient is
restless and tosses to and fro, and great thirst is complained
of. Delirium is not unusual, and convulsions often occur.
After a profuse hemorrhage an individual is intensely pale
and his skin has a greenish tinge ; the eyes are fixed in a glassy
stare and the pupils are widely dilated ; the respirations are
shallow and sighing ; the skin is covered with a cold sweat ;
the legs and arms are extremely. cold ; the pulse is soft, small,
compressible, fluttering, or often cannot be detected ; the
heart is very weak and fluttering; there is muscular tremor;
the patient tosses about, and asks often for water. In hem-
orrhage the hemoglobin is greatly diminished in amount.
When such a dangerous condition is due to a visible hem-
orrhage, temporarily arrest bleeding by digital pressure in
the wound, or the application of an Esmarch band above the
wound (if the bleeding is arterial). In some cases forced
flexion is used. Lower the head, and have compression
made upon the femorals and subclavians, so as to divert
more blood to the brain. Apply artificial heat. Inject by
hypodermoclysis the normal salt solution (10 to 16 ounces)
into the cellular tissue of the buttock, or transfuse the salt so-
lution into a vein, inject ether hypodermatically, then brandy,
and then strychnin in doses of gr. ^. Atropin, digitalis, and
morphin are recommended. Give enemata of hot coffee and
brandy. Apply mustard over the heart and spine. Lay a
hot-water bag over the heart. As soon as reaction is estab-
lished, arrest the bleeding permanently by the ligature.

A severe hemorrhage is apt to be followed by fever — hem-
orrhagic fever — due to the absorption of fibrin ferment from
extravasated blood and its action upon a profoundly debil-
itated system. In this form of fever there are most intense
thirst, violent headache, dimness of vision, great restlessness,
often mental wandering, with a very frequent, weak, and flut-
tering heart. After a severe hemorrhage leukocytes are
increased, not only relatively but absolutely. Red corpuscles
are diminished both relatively and absolutely. Hemoglobin

{

26o MODERN SURGERY.

diminishes ; many of the corpuscles become irregular and
microcytes are noticed.

In treating a patient who has reacted after a severe hem-
orrhage, apply cold to the head to prevent serous effusion
into the brain. Aconite, morphin, and neutral mixture are
given by the mouth. Fluids and ice are grateful. Fre-
quently sponge the skin with alcohol and water (S. W. Gross).
Milk punch, koumiss, and beef-peptonoids are given at fre-
quent intervals. If the hemorrhage is from a spot inacces-
sible to ligation, such as the lung, give the patient 3 grains of
gallic acid, i grain of powdered digitalis, i grain of ergotin,
and \ grain of powdered opium every three or four hours.

Hemostatic agrents comprise (i) the ligature; (2) torsion;
3) acupressure; (4) elevation ; (5) compression; (6) styptics;
7) the actual cautery ; and (8) forced flexion of limbs.

The ligature may be made of silk, floss-silk, or catgut, but
it must be aseptic. The ligatures should be about ten inches
long. The vessel is drawn out with forceps and separated
from surrounding tissues. The forceps are better than the
tenaculum in most cases, because the tenaculum makes a hole
through which blood may subsequently exude. When the ar-
tery lies in hard tissues or is retracted deeply in muscle or &sda,
the tenaculum is best. Tie with a reef-knot. The tightening
of the first knot cuts the internal and middle coats. The
second knot must not be tied too tightly, or it will cut the lig-
ature. Do not jerk the ligature in tying, and cut off closely.
Both ends of the vessel are tied. If an artery is incompletely
divided, tie on each side of the cut and entirely sever the ves-
sel between the ligatures. If a large vein is slightly torn, try
pinching up the vein-walls around the rent and apply a liga-
ture (lateral ligature) (Fig. 48). If a vein is longitudinally torn,
sew up with a Lembert suture of silk (Ricard and Niebergall
have done this successfully). In extensive tears tie both ends
of the vein ; cut the vein between the ligatures. If the bleeding
comes from an artery very close to its point of origin, tie the
main trunk as well as the bleeding branch, otherwise the clot
formed will be too short and secondary hemorrhage will be
inevitable. When the parts about an artery are so thickened
that the artery cannot be drawn out, arm a Hagedom needle
(Fig. 47) with catgut and so pass the latter around the vessel
that the catgut will include the vessel with some of the sur-
rounding tissue, and tie the ligature. This method is pursued
in necrosis, atheroma, scar-tissue, sloughing, etc. Never in-
clude a nerve. If this mode of ligation fails, try acupressure.
Murphy of Chicago has recently shown that longitudinal

DISEASES AND INJURIES OF HEART AND VESSELS. 261

wounds or small lateral wounds of either veins or arteries
can be closed successfully with silk sutures, and if a trans-
verse wound includes more than one-third of the circum-

Fia.4B.-M«hadof

fcrence of the vessel, after the vessel is completely divided
the ends can be successfully united.'

Ttwwiw.— By means of torsion the internal and middle
coats are ruptured and the external coat is twisted. It is a
safe procedure, and is practised upon vessels as large as the
femoral by many surgeons of high standing. Torsion has

the signal merit of not introducing possible infection in liga-
tures. The vessel is drawn out by one pair of forceps, and
another pair is applied transversely half an inch above the
cut end and twisted six or eight times (Fig. 49).
t Se« Mtd. Record., Jan. 16, 1897.

262 MODERN SURGERY.

Acupressure is pressure with a pin. The arrest of hemor-
rhage by acupressure was devised by Sir James Y. Simpson.
A pin is simply passed under a vessel (transfixion), leaving a
little tissue on each side between the pin and vessel. A
needle can be passed under a vessel, and a wire be thrown
over the needle and twisted (circumclusion). The needle
can be inserted upon one side, passed through half an inch
of tissues up to the vessel, be given a quarter-twist, and be
driven into the tissues across the artery (torsoclusion). Some
tissue is picked up on the needle, folded over the vessel, and
pinned to the other side (retrod usion). Acupressure is used
for inflamed or atheromatous vessels, in sloughing wounds,
and where a ligature will not hold.

Elevation is used as a temporary expedient or as an asso-
ciate of some other method. It is of use in wounds of the
bursae, in bleeding from a ruptured varicose vein, and is fre-
quently used with compression.

Compression is either direct or indirect — that is, in the
wound or upon its artery of supply. In the removal of the
upper jaw arrest bleeding by plugging. In injury of a cere-
bral sinus, plug with gauze. Compression and hot water
(120°) will stop capillary bleeding. A graduated compress
is often used in hemorrhage from the palmar arch. A com-
press will arrest bleeding from superficial veins. The knotted
bandage of the scalp will arrest bleeding from the temporal
artery. Long-continued pressure causes pain and inflam-
mation.

Styptics. — Chemicals are now rarely used. In epistaxis
we may pack with plugs of gauze saturated in antipyrin.
In bleeding from a tooth-socket freeze with chlorid of ethyl
spray, and then pack with gauze soaked in lO per cent, solu-
tion of antipyrin or with styptic cotton (absorbent cotton
soaked in Monsel's solution and dried). In bleeding from
an incised urinary meatus pack with styptic cotton. Cold
water, chlorid of ethyl spray, or ice acts as a styptic by pro-
ducing reflex vascular contraction. Hot water produces
contraction and coagulates the albumin. The temperature
should be from 115° to 120° F. A mixture of equal parts
of alcohol and water stops capillary oozing. Paul Camot
has recently shown that a solution of gelatin in normal salt
solution (i : 16) will arrest capillar)^ oozing even in a hemo-
philiac. We have recently employed this mixture with satis-
factory results for capillary oozing from an incised wound in
a victim of leukemia, and for the arrest of epistaxis.

The actual cautery is a most ancient hemostatic. It is

DISEASES AND INJURIES OF HEART AND VESSELS, 263

Still used in some cases after excising the upper jaw, in
bleeding after the removal of some malignant growths, in
continued hemorrhage from the prostatic plexus of veins,
after lateral lithotomy, and to stop oozing after the excision
of venereal warts. We are driven to it in " bleeders " — that
is, those persons who have a hemorrhagic diathesis, and who
may die from having a tooth pulled or from receiving a
scratch. It will arrest hemorrhage, but sloughing is bound
to occur, and when the slough separates secondary hemor-
rhage is apt to set in. The iron for hemostatic purposes
must be at a black heat.

Forced flexion is a variety of indirect compression intro-
duced by Adelmann. It will stop bleeding, but soon be-
comes intensely painful. Forced flexion can be maintained
by bandages. Brachial hyperflexion is maintained by tying
the forearm to the arm. It is often associated with the use
of a pad in front of the elbow. Genuflexion is kept up by
tying the foot to the thigh. It is increased in efficiency by
placing a pad in the popliteal space.

Golden Rules for Procedure in Primary Hemorrhage, —
I. In arterial hemorrhage tie the artery in the wound,
enlarging the wound if necessary. In tying the main artery
of the limb in continuity for bleeding from a point below we
fail to cut off" the bleeding from the distal extremity, and
hemorrhage is bound to recur. If we fail to look into the
wound, we cannot know what is cut : it may be only a
branch, and not a main trunk. The same rule obtains in
secondary hemorrhage (Guthrie's rule).*

2. We can safely ligate veins as we would arteries.

3. In a wound of the superficial palmar arch tie both ends
of the divided vessel.

4. In a wound of the deep palmar arch enlarge the
wound, if necessary, in the direction of the flexor tendons, at
the same time maintaining pressure upon the brachial artery.
Catch the ends of the arch with hemostatic forceps and tie
both ends. If the artery can be caught by, but cannot be
tied over the point of, the forceps, leave the instrument on
for four days. If the artery cannot be caught with forceps,
try a tenaculum. If these means fail, insert a small piece of
gauze in the depth of the wound, put over this a larger piece,
and keep on adding bit after bit, each one larger than its
predecessor, until there is constructed a conical pad the
apex of which is against the extremities of the cut arch and
the base of which is well external to the palm. Bandage

^ For Murphy's observations on anastomosis of vessels, see page 261.

264 MODERN SURGERY,

each finger and the thumb, put a piece of metal over the
pad, wrap the hand in gauze, place the arm upon a straight
splint, apply firmly an ascending spiral reverse bandage of
the arm, starting as a figure-of-8 of the wrist, and hang the
hand in a sling. Instead of applying a splint, we may place
a pad in front of the elbow and flex the forearm on the arm.
The palmar pad is left in place for six or seven days unless
bleeding keeps on or recurs. If bleeding is maintained or
begins again, ligate the radial and ulnar. If this maneuver
fails, we know that the interosseous artery is furnishing the
blood and that the brachial must be tied at the bend of the
elbow. If this fails, amputate the hand. A plan which might
obviate these radical procedures is to incise on a line with
the injury from the web of the fingers to above the carpus,
separating the metacarpal and carpal bones until the artery
is exposed (this is really Mynter's incision for excision of
the wrist).

5. In primary hemorrhage, if the bleeding ceases, do not
disturb the parts to look for the vessel. If the vessel is
clearly seen in the wound, tie it ; otherwise do not, as the
bleeding may not recur. This rule does not hold good
when a large artery is probably cut, when the subject will
require transportation (as on the battle-field), when a man
has delirium tremens, mania, or delirium, or when he is a
heavy drinker. In these cases always look for an artery
and tie it.

6. When a person is bleeding to death, arrest hemorrhage
temporarily by digital pressure in the wound and apply
above the wound a tourniquet or Esmarch bandage. Bring
about reaction and then ligate, but do not operate during
collapse if the bleeding can be controlled by pressure.

7. If a transverse cut incompletely divides an artery, it
may be found possible to suture the cut if it does not in-
clude more than one-third of the circumference of the ves-
sel. Longitudinal cuts can be sutured (Murphy). If sutur-
ing is impossible, or if the surgeon prefers not to attempt it,
apply a ligature on each side of the vessel-wound and then
sever the artery so as to permit of complete retraction.

8. If a branch comes off just below the ligature, tie the
branch as well as the main trunk.

9. If a branch of an artery is divided very close to a main
trunk, tie the branch and also the main trunk. If the
branch alone be tied, the internal clot, being very short, will
be washed away by the blood-current of the larger vessel.

10. If a large vein is slightly torn, put a lateral ligature

DISEASES AND INJURIES OF HEART AND VESSELS. 265

upon its wall. Gather the rent and the tissue around it in a
forceps and tie the pursed-up mass of vein-wall. It is a wise
plan to pass the suture through the two outer coats by means
of a needle and tie the knot subsequently. This expedient

Fig. 50.— Application of lateral ligature to a vein.

prevents slipping. If a longitudinal wound exists in a large
vein, take an intestinal needle and fine silk and sew it up
with a Lembert suture.

11. When a branch of a large vein is torn close to the
main trunk, tie the branch, and not the main trunk. Apply
practically a lateral ligature.

1 2. If, after tying the cardial extremity of a cut artery, the
distal extremity cannot be found even by a careful search
after enlarging the wound, firmly pack.

1 3. In bleeding from diploe or cancellous bone, use Hors-
ley's antiseptic wax or break in bony septa with a chisel.

14. In bleeding from a vessel in a bony canal, plug the
canal with an antiseptic stick and break the wood, or fill up
the orifice of the canal with antiseptic wax ; or, if this fails,
ligate the artery of supply.

15. In bleeding from the internal mammary artery the old
rule was to pass a large curved needle holding a piece of
silk into the chest, under the vessel and out again, and tie
the thread tightly, but it is better to ligate the artery.

16. In bleeding from an intercostal artery make pressure
upward and outward, or throw a ligature by means of a
curved needle entirely over a rib, tying it externally, or,
what is better, resect a rib and tie the artery.

17. In collapse due to puncture of a deep vessel, the bleed-
ing having ceased, do not hurry reaction by stimulants. Give
the clot a chance to hold. Wrap the sufferer in hot blankets.
If the condition is dangerous, however, stimulate to save life.

18. In punctured wounds, as a rule, try pressure before
using ligation.

266 MODERN SURGERY.

19. After a severe hemorrhage always put the patient to
bed and elevate the damaged part (if it be an extremity or
the head).

20. A clot which holds for twelve hours after a primary
hemorrhage will probably hold permanently ; but even after
twelve hours be watchful and insist on rest.

21. If recurrence of a hemorrhage from a limb is feared,
mark with anilin or iodin the spot on the main artery where
compression is to be applied, put on a tourniquet loosely, and
order the nurse to screw it up and to send for the physician
at the first sign of renewed bleeding. This must often be
done in gunshot-wounds.

22. When the femoral vein is divided high up the advice
commonly given is to ligate the vein and also the femoral
artery. Branne taught that because of the venous valves
there is no collateral circulation, and to tie the vein alone
renders gangrene inevitable. Niebergall shows that the
valves may be overcome by moderate arterial pressure, and
thus collateral circulation is established. Hence, when the
femoral vein is divided tie the vein, but leave the artery un-
tied, so as to furnish the necessary pressure.^

23. In extradural hemorrhage trephine. The side to be
trephined is determined by the symptoms, and not by the
situation of the injury. The opening is made on a level with
the upper orbital border and one and a quarter inches be-
hind the external angular process. This opening exposes
the middle meningeal and its anterior branch (Keen). If this
does . not expose a clot, trephine over the posterior branch,
on the same level and just below the parietal eminence.
When the clot is found enlarge the opening with the ron-
geur, scoop out the clot, and stop the bleeding by passing
catgut ligatures on each side of the injury in the vessel
through the dura, under the artery and out again, and then
tying them. If the artery lies in a bony canal, plug the canal
with Horsley's wax.

24. In hemorrhage from a cerebral sinus catch the edges
of the opening with forceps if possible and apply a lateral
ligature, or leave the forceps on forty-eight hours or com-
press firmly with one large piece of iodoform gauze.

25. In extramedullary spinal hemorrhage rapidly advanc-
ing and threatening life perform a laminectomy and arrest
the hemorrhage.

26. In bleeding from a tooth-socket use chlorid-of-ethyl
spray or ice. If this treatment fails, plug with gauze infil-

* XieberjjalJ, in Dent. Zeit. f. Chir.^ vol. xxxvii., Nos. 3, 4.

DISEASES AND INJURIES OF HEART AND VESSELS. 267

trated with tannin or soaked in antipyrin solution of a strength
of 10 per cent., or in Camot's solution of gelatin, close the
jaws upon the plug, and hold them with Barton's bandage.
If this expedient fails, soak the plug in Monsel's solution,
and if this is futile, use the cautery. Pressure on the carotid
and ice over the jaw and neck are indicated. It may be
necessary to tie the external carotid artery.

27. In intra-abdominal hemorrhage open the belly. In
intra-abdominal hemorrhage it is necessary to operate dur-
ing shock. If the blood accumulates so rapidly as to prevent
the location of the bleeding point, compress the aorta or pack
the abdominal cavity with large sponges. In seeking for the
bleeding point remove the sponges one by one, or have the
pressure momentarily relaxed from time to time. In paren-
chymatous hemorrhage try packing with iodoform gauze.
In the liver, if this fails, suture the torn edge or use the cau-
tery. Severe wounds of the spleen demand splenectomy.
Wounds of the kidney may be sutured ; many require par-
tial or complete nephrectomy. Mesenteric vessels are ligated
en masse with silk (Senn). Wounds of stomach and intes-
tines causing hemorrhage require stitching of their edges.
When there are an infinite number of points of bleeding take
a number of sponges, tie a piece of iodoform gauze firmly to
each one, pack many places in the belly with the sponges,
bring the gauze out of the wound, and remove the sponges
from below upward one at a time, securing the bleeding
points as they come into view.

28. In abdominal section for disease of the female pelvic
organs bleeding is limited by the clamp or by pressure-for-
ceps. Ligation en masse is often practised. Use silk. A
large mass can be transfixed and tied in sections. Bleeding
edges are stitched. Areas of oozing are treated with tem-
porary pressure and hot water, or, if this fails, by the cautery.
Packing can be used as a tamponade, which is a gauze pouch,
pieces of gauze being packed into this pouch after its inser-
tion into the belly.

29. A ruptured varicose vein requires a compress, a band-
age from the periphery up, and elevation.

30. For capillary hemorrhage use hot water and compres-
sion, gelatin dissolved in salt solution, or, if these expedients
fail, the cautery. Understand that capillary bleeding docs
not so much mean bleeding from genuine capillaries as it
does bleeding from arterioles and venules.

31. Pressure above a wound stops arterial hemorrhage, but
aggravates venous bleeding. Pressure below a wound stops

268 MODERN SVRCERV.

venous hemorrhage, but increases arterial bleeding. Remem-
ber these facts when applying pressure.

32. In severe epistaxis, or bleeding from the nose, examine
the nose by means of a head-mirror and a speculum.. If a
little point of ulceration is found, touch it with the hot iron.
If the bleeding is a general ooze, if it is high up, or if the
cautery does not arrest it, pack the nares. It may be neces-
sary to pack one nostril or both. Pass a Bellocq cannula
(Fig. 50) along the floor of one nostril into the pharynx,

-Pluggi'

project the stem into the mouth, tie a plug of lint or gau«
to the stem, and withdraw it. Carry out the same procedure
upon the other nostril, pull the strings firmly forward, pack
the nostrils from before backward, and tie the strings around
the plug. If one nostril is packed, tie the string ends around
the plug. Soaking the Hnt or gauze in antipyrin solution or
gelatin solution is a good plan. Do not use subsulphate of
iron, as it forms a disgusting, clotty, adherent mass. If a
Bellocq cannula is not obtainable, push a soft catheter into
the pharynx, catch it with a finger, pull it forward, and tie
the plug to it. Remove the plug in three or four days. Pick
out the front plug first, hold the string of the second plug in
the hand, push the plug back into the pharynx, catch it with
forceps, and withdraw plug and string through the mouth.
33. In gunshot-wounds the primary hemorrhage is slight

DISEASES AND INJURIES OF HEART AND VESSELS. 269

unless a large vessel is cut. The bleeding may be visible or
may be internal (concealed), the blood running into a natu-
ral cavity or among the muscles. Capillary oozing is arrested
by very hot water and compression. Venous bleeding is
usually arrested by compression. If a large vessel is the
source of bleeding, enlarge the wound and tie the vessel.
If the artery cannot be found in the wound, tie the main
trunk.

34. In prolonged bleeding from a leech-bite try compres-
sion over a plug saturated with alum or with tannin. If this
fails, pass under the wound a harelip-pin and encircle it
with a piece of silk. If this fails, use the actual cautery.

35. In severe bleeding from the ear elevate the head, put
an ice-bag over the mastoid, give opium and acetate of lead,
and, if blood runs into the mouth, plug the Eustachian tube
with a piece of catheter.

36. Umbilical hemorrhage in infants requires pressure
over a plug containing tannin, alum, or gelatin solution. If
compression fails, pass harelip-pins under the navel and apply
a twisted suture. If this fails, use the actual cautery.

37. Rectal bleeding requires elevation of the buttocks,
insertion of plugs of ice, ice to the anus and perineum,
astringent injections (alum), and the internal use of opium
and acetate of lead. If these means fail, plug the bowel
over a catheter, or insert and inflate a Peterson bag or a
colpeurynter, or tampon and use a T-bandage. If the bleed-
ing persists or if a considerable vessel is bleeding, stretch
the sphincter, catch the bowel and draw it down, seize the
vessel, and tie it if possible ; if not, leave the forceps in place.
Failing in this, the actual cautery must be used.

38. Subcutaneous hemorrhage, if severe, demands that an
incision be made and ligation be performed.

39. Bleeding from a cut urethral meatus requires the
insertion of styptic cotton and the application of pressure.
Moderate bleeding from the urethra can usually be arrested
by a hot bougie, by hot injections, or by tying a condom
over a catheter, and, after inserting it, inflating the condom
by blowing through the catheter and plugging the orifice
of the instrument, thus using pressure. Sitting with the
perineum on a thickly folded towel is useful. Ice to the
perineum does good. The patient can lie down, have a
folded towel applied to the perineum and a crutch-handle
pushed upon the towel, the lower end of the crutch being
jammed against the foot of the bed. If a solid bougie has
been first introduced, firm pressure can be made by this

270

MODERN SURGERY,

method. If these means are futile, perform an external
urethrotomy and reach the bleeding point.

40. Hemorrhage from the prostate requires hot injec-
tions, the introduction of a large bougie first dipped in vei>'
warm water, and the retention of a catheter for two days.
Perineal section may be required, or suprapubic cystotomy
with packing which does not occlude the ureteral orifices.

41. Vesical hemorrhage usually ceases spontaneously, in
which case the urine must be drawn off and the viscus be
washed out frequently with a solution of boric acid to pre-
vent septic cystitis. If blood-clots prevent the flow of urine,
break them up with a catheter or a lithotrite and inject vin-
egar and water, a 2 per cent, solution of carbolic acid, or a
solution of bicarbonate of sodium. Perfect quiet is to be
maintained, cold acid drinks to be given, ice-bags to be put
to the perineum and hypogastric region, and opium with
acetate of lead, ergot, or gallic acid to be given by the
mouth. If the hemorrhage is severe or persistent, perform
a suprapubic cystotomy.

42. In hemorrhage after lateral lithotomy, ligate if pos-
sible. If the vessel can be caught but cannot be ligated,
leave the forceps in place. If we cannot catch the vessel

with forceps, try a tenaculum. If
the tenaculum fails, pass a threaded
curved needle through the tissues
around the vessel and tie the ligature.
Plugs of ice and injections of hot
water may be tried. These means
failing, pressure is indicated. Take a
cannula, fasten to it a chemise (Fig.
52), empty clots from the bladder,
insert the instrument into the viscus,
and pack gauze between the sides of
the cannula and the chemise. The
chemise is bulged out and pressure
is made. Tie the cannula by means
of tapes to a T-bandage. Pressure
is thus combined with vesical drain-
age. Buckstone Brown makes press-
ure by inflating a rubber bag with air.
The hot iron may occasionally be
demanded.

43. Renal bleeding requires ice to
the loin, tannic acid and opium, gallic acid and sulphuric acid,
and perfect quiet. If the bleeding threatens life and the dis-

FiG. 52. — Cannula i chemise.

DISEASES AND INJURIES OF HEART AND VESSELS. 2/1

eased organ is identified, make a lumbar incision, and suture
or perform nephrectomy ; if not sure which organ is diseased,
perform an abdominal nephrectomy. The use of a cysto-
scope will show from which ureter blood is emerging.

44. Vaginal hemorrhage requires the ligature or the
tampon.

45. Severe uterine hemorrhage (unconnected with preg-
nancy) requires the tampon. Persistent hemorrhage due
to morbid growths may require removal of the tubes and
appendages, ligation of the uterine and ovarian arteries, or
hysterectomy.

46. Hematemesis, or bleeding from the stomach, is treated
by the swallowing of ice, giving tannic acid (dose, 20 or 30
grains) or Monsel's solution (3 drops). Never give tannic
acid and Monsel's solution at the same time, as they mix
and form ink. Opium is usually ordered. Acetate of lead
and opium and gallic acid are favorite remedies, and ergot
is used by many. Give no food by the stomach. If life is
threatened by bleeding from an ulcer, open the belly and
excise the ulcer. If severe hemorrhage follows injury, make
an exploratory laparotomy.

47. In bleeding from the small bowel give acetate of lead
and opium, sulphuric acid, or Monsel's salt in pill form

i3 grains), allow no food for a time, and insist on liquid diet
or a considerable period. If hemorrhage threatens life, do
a celiotomy and find the cause. If ulcer exists, excise it. If
violent hemorrhage follows injury, explore to discover the
cause.

48. In bleeding from the large bowel, use styptic injections
(10 grains of alum or 5 grains of bluestone to 3j of water).
If bleeding is low down, use small amounts of the solution ;
if high up, large amounts. Do not use absorbable poisons.
In dangerous cases perform an exploratory operation to find
the cause. (For rectal bleeding see 37, p. 269.)

49. Hemoptysis, or bleeding from the lung, is treated by
morphin hypodermatically, by perfect rest, by dry cups or
ice over the affected spot if it can be located, and by gallic
acid, which drug aids coagulation.* Of late nitrite of amyl
by inhalation has given good results.

50. In hemorrhage from wound of the lung do not open

* The use of ergot is a general but questionable practice. Bartholow and
others hold that this drug does harm ; it contracts all the arterioles, and hence
more blood flows from an area where there is damage. Purgatives do good in
bleeding from the lung by taking blood to the abdomen and lowering blood-
pressure.

272 MODERN SURGERY.

the chest unless life is threatened. If life is endangered,
resect several ribs, find the bleeding point, ligate or employ
forci pressure. A small cavity may be packed with gauze.
If a large surface is bleeding, fill the pleural sac with gauze
and pack more gauze against the oozing surface.'

Reactionary or Recurrent Hemorrhage (called also
Consecutive, Intermediate, or Intercurrent). — This form of
hemorrhage comes on during reaction from an accident or
an operation — that is, during the first forty-eight hours, but
usually within twelve hours. It is bleeding from a vessel
or vessels which did not bleed during the shock which
accompanied operation, but were overlooked and were n<rt
tied. It may be due to faultily applied ligatures. It is
favored by vascular excitement or hypertrophied heart.
The bleeding is not sudden and severe, but is a gradual
drop or trickle. The Ksmarch apparatus is not unusually
the cause. The constricting band paralyzes the smaller
arteries, which do not bleed during shock and do not con-
tract a.s shock departs ; hence bleeding comes on with reac-
tion. To lessen the danger of the Esmarch apparatus use
a broad constricting band rather than a rubber tube. During
reaction after an amputation, if slight hemorrhage occurs,
elevate the stump and compress the flap.s. If the hemor-
rhage persists or at any time becomes severe, make pressure
on the main artery of the limb, open the flaps, turn out the
clots, find the bleeding point, Hgatc, asepticize, close, and
dress. In any severe reactionary' hemorrhage open the
wound at once and ligate.

Secondary hemorrhage may occur at any time in the
period between forty-eight hours after the accident or opera-
tion and the complete cicatrization of the wound. Secondary
hemorrhage may be due to
atheroma, to slipping of a lig-
ature, to inclusion of nerve,
fascia, or muscle in the liga-
ture, to sloughing, to erysip-
elas, to septicemia, to pyemia,
to gangrene, and to overaction
__ _ _ °'^ ^''^ heart. The great ma-

jority of cases of secondary
Fic, 53.-Am^st of^w^rrhAgt by pi«- hcniorrhage are due to infec-
tion, and the application of
modern surgical principles has rendered secondary bleeding a
rare calamity. If during an operation the vessels are found

' See aullior's case. Annah of Suix^ry, Jaii , 1898.

DISEASES AND INJURIES OF HEART AND VESSELS. 273

atheromatous, acupressure had best be used, or a thread
should be passed, by means of a Hagedom needle, around
the vessel, including a cushion of tissue in the loop of the
ligature (this prevents cutting through) (Fig. 53). One great
trouble with atheromatous arteries is that their coats can-
not contract ; another trouble is that the ligature cuts en-
tirely through them. If after an operation the pulse is found
to be forcible, rapid, and jerking, give aconite, opium, and low
diet. The bleeding may come on suddenly and furiously,
but is usually preceded by a bloody stain in wound-fluids
which had become free from blood.

Treatment of Secondary Hemorrhagre. — The method of
treatment, supposing a case of leg-amputation in which, sev-
eral days after the operation, a little oozing is detected, is to
elevate the stump, apply two compresses over the flaps, and
carry a firm bandage up the leg. If the bleeding is profuse
or becomes so, make pressure on the main artery, open and
tear the flaps apart with the fingers, find the bleeding vessel
and tie it, turn out the clots, asepticize, close, and dress. If
the bleeding begins at a period when the stump is nearly
healed, cut down on the main artery just above the stump
and ligate. In secondary hemorrhage from a blood-vessel
in nodular tissue throw a ligature around the vessel by a
curved needle or tie higher up, or, if this fails, amputate.
When secondary hemorrhage arises in a sloughing wound
apply a tourniquet or an Esmarch bandage, tear the wound
open to the bottom with a grooved director, look for the
orifice of the vessel, dissect the artery up until a healthy
fK)int is reached, cut it across, and tie both ends. If this
fails, include tissue in the ligature or use acupressure. In
secondary hemorrhage from atheromatous vessels use acu-
pressure or include surrounding tissue in the ligature.

Secondary hemorrhage may occur after ligation in con-
tinuity, the blood usually coming from the distal side. If
the dressings are slightly stained with blood, put on a gradu-
ated compress. If the bleeding continues or is severe, make
pressure on the main artery of the limb, open the wound and
ligate, wrap the part in cotton, elevate, and surround with hot
bottles. If this re-ligation is done on the femoral and fails,
do not ligate higher up, as gangrene will certainly occur, but
amputate at once, above the point of hemorrhage. If dealing
with the brachial artery, do not amputate, but ligate higher
up and make compression in the wound. In a secondary
hemorrhage from the innominate tie the innominate again
and also tie the vertebral.

274 MODERN SURGERY.

2. Operations on the Vascular System.

Paracentesis auriculi, or tapping the heart-cavity, has
been suggested for the relief of an over-distended heart from
pulmonary congestion. The right auricle should be tapped.
Push the aspirator-needle directly backward at the right edge
of the sternum, in the third interspace. This operation is not
recommended, as it is highly dangerous and is of question-
able value.

Paracentesis pericardii, or tapping the pericardial sac,
is only done when life is endangered. Introduce the needle
two inches to the left of the left edge of the sternum, in the
fifth interspace, and push it directly backward (thus avoiding
the internal mammary artery).

Operation for Varix of I^eg. — In this operation make,
at several points in the course of the long saphenous vein,
skin incisions each two inches long and in the long axis of
the vessel. Clear the vessel at each incision, apply two liga-
tures an inch apart, and excise the vein between them. Never
operate if the slightest phlebitis exists (Barker). This method
of multiple ligation is the plan of Phelps. Another method
is as follows : the patient stands for a time before a fire to
enlarge the veins. A harelip-pin is pushed into the tissues
an inch from the vein, at the upper end of its varicose por-
tion ; the pin is passed under the vein and emerges an inch
outside of it. A bit of catheter wrapped in gauze is laid over
the vein, and a twisted suture is carried around the pin and
over the pad. This operation is done lower down in one or
two positions ; but it is unsatisfactory', and offers grave dan-
ger of infection. Trendelenburg, at a point below the saph-
enous opening, ties the vein in two places and divides it be-
tween his ligatures. Some surgeons have advised the removal
of the entire length of the long saphenous vein. Madelung
cuts down over the varices and ligates. Schede makes a cir-
cular cut completely around the leg at the junction of the
upper and middle thirds, the incision reaching to the deep
fascia. All bleeding points are ligated and the edges of the
incision are sewn together. Fergusson ties the saphenous
vein near the femoral and removes a section from it. This
makes the varices clearly evident. A semilunar incision is
made to surround the varices, which incision reaches to the
deep fascia. The flap is raised and dissected up, the vessels
arc tied, and the flap is sutured in place. The author of this
operation claims that it is most satisfactory and certain.

Open Operation for Varicocele. — The open operation

DISEASES AND INJURIES OF HEART AND VESSELS, 275

is by far the best procedure for varicocele. The instruments
used are a scalpel, an aneurysm-needle, curved needles, a
grooved director, a dissecting-forceps, an Allis dry dissector,
hemostatic forceps, and scissors.

Operatdon. — The patient is recumbent. He may be anes-
thetized or Schleich's fluid may be injected. The operator
stands on the diseased side. The assistant stands on the
sound side and makes pressure over the inguinal ring of the
affected side. A fold of skin is pinched up on the scrotum,
and the surgeon transfixes it in the line of the cord, so that
he will have an incision about one and a half inches long run-
ning downward from below the external ring. The skin and
fascia are cut with a scalpel, the veins are well exposed by
means of an Allis dissector, and the cord is located and held
aside. A double ligature of strong catgut or chromicized
gut is passed under the veins by an aneurysm-needle. The
threads are separated one inch, tied tightly, and the ends are
left long. Th^ veins between the ligatures are excised. The
two gut ligatures are tied together and cut. This shortens
the cord. The scrotum is sewed up with silkworm-gut, a
small drainage-tube being used for twenty-four hours. Heal-
ing is complete in one week.

Snbcutaneotis I/igature for Varicocele. — In this ope-
ration employ every antiseptic precaution. The patient stands,
and the operator, sitting in front of him, holds the veins in a
fold of skin away from the vas deferens by means of the
thumb and index finger of the left hand. A large straight
needle carrying a double piece of strong silk is passed en-
tirely through the .scrotum, between the veins and the vas.
The needle is again inserted at the puncture from which it
emerged, is carried around under the skin and in front of the
veins, and emerges at its original point of entry. The veins
are thus surrounded by the silk. The patient, who now lies
down, is placed under the first stage of ether, and the double
ligatures are separated as far as possible from each other,
tied, and cut off, the knots slipping in through the puncture.
This operation presents certain dangers. The veins may be
wounded and the vas or other structures may be included.
In an operation it is always best to be able to see what we
are doing ; and the open operation, being safe, is preferred to
the subcutaneous.

Phlebotomy, or Venesection. — The instruments used

in venesection are a lancet or bistoury, a fillet or tape, an
antiseptic pad, and a bandage. A stick should be at hand
for the patient to grasp.

(Bctnard an

276 MODERN SVRGERY.

Operation. — The patient sits on a chair " with the ami
abducted, extended, and inclined outward " (Barker). The
parts are asepticized and a tape is tied around the arm just
above the elbow. The surgeon stands to the right of the
arm, holds the elbow with his left hand, and puts his thumb
upon the vdn below the
intended point of punct-
ure. A tape is tied
above the elbow. The
patient grasps a stick
firmly and works his
fingers to swell the
veins. Either the me-
dian cephalic or median
basilic can be punctured
(Fig. 54). The median
basilic is the more dis-
tinct, and is the vein
usually selected. In
puncturing it, do not go
too deep, as nothing but the bicipital fascia separates it from
the brachial arter>'. The median cephalic may be selected
(we thus avoid endangering the brachial artery) ; under this
vein hes the externa! cutaneous nerve (Fig. 54). Steady the
vein with the thumb and open it by transfixion, making an
oblique cut which divides two-thirds of it. Remove the
thumb and allow bleeding to go on, instructing the patient
to work his fingers. When faintness begins remove the fillet,
put an antiseptic pad over the puncture, apply a spiral reverse
bandage of the hand and arm and a figure-of-8 bandage of
the elbow, and place the arm in a sling for several days.

Transfusion of Blood. — This operation has been a
recognized procedure since 1834, though it has certainly
been known since 1492, when transfusion in the case of
Pope Innocent VIII, was made. Its chief use was in severe
hemorrhage, especially post-partum, in which it served to re-
place the blood lost and supplied something for the heart to
contract upon until new blood formed. Senn insists that the
operation has proved an absolute failure. It does not prevent
death from hemorrhage, and the transferred blood -elements
do not retain vitalitj'. Von Bergmann showed us that after
severe hemorrhage we do not need to inject nutritive ele-
ments, but do need to restore the greatly diminished intra-
cardiac and intravascular pressure. At the present day a
saline fluid is transfused rather than blood. In fact, the ope-

DISEASES AND INJURIES OF HEART AND VESSELS. 277

ration of transfusion has become all but extinct. It exposes
the patient to the danger of embolism and infection, its
employment requires material often hard to obtain, and it
has no single element of value beyond that secured by the
use of salt solution.

TransftiBion of saline fluid is used after severe hemor-
rhage, in shock, in diabetic coma, in post-operative suppres-
sion of urine, and occasionally in sepsis. After a hemor-
rhage its beneficial effects are often prompt and obvious.
This saline fluid increases the arterial tension, gives the heart
enough matter to contract upon, and so restores the activity
of the circulation. We may use a simple apparatus consist-
ing of a rubber tube, a funnel, and an aspirating-needle. Some
employ an Aveling syringe, and others Collin's apparatus

Fig. 56. — Intravenous injection of saline fluid.

(Fig. 56). The last-named instrument can be used without
any danger of air entering with the fluids. Normal salt solu-
tion is the fluid usually employed, salt solution of a strength
of 0.7 per cent, (about a teaspoonful of common salt to a pint
of boiled water). Some surgeons employ an artificial serum
which contains 50 grains of chlorid of sodium, 3 grains of
chlorid of pota.ssium, 25 grains of sulphate and 25 grains of
carbonate of sodium, 2 grains of phosphate of sodium in a
pint of boiled water.^ Szumann's solution consists of 6 parts
of common salt, i part of sodium carbonate, and 1000 parts of
water. The following solution is used by Locke and Hare :
calcium chlorid, 25 gm. ; potassium chlorid, i gm. ; sodium
chlorid, 9 gm. ; sterile water sufficient to make i liter. One

* A. Pcarcc Gould, in Treves' System of Surgery.

278 MODERN SURGERY,

bottle of the commercial fluid when diluted to i liter gives
a solution of the above composition. Whatever fluid is used,
it should be at a temperature of 100° F. From J pint to
2 pints or even more are slowly injected, the condition of
the patient determining the amount given. In one case of
violent hemorrhage the author used 2 quarts. In order to
transfuse this fluid tie a fillet well above the elbow, and expose
by dissection the median basilic vein, or the basilic vein in the
portion of its course where it is superficial to the deep fascia.
Tie the vein. Incise it above the ligature, insert a fine can-
nula, and hold the cannula firmly in the lumen by tightening
a second ligature (Fig. 56). Slowly and gradually introduce
the fluid, carefully watching the pulse. When the tension
of the pulse returns withdraw the cannula, tie the second
ligature tightly, sew up the wound, and dress it aseptically.
In very severe operations an assistant can do transfusion
while the surgeon is operating. It may be necessary to
repeat the transfusion if the circulation fails again.

Arterial TranafVision. — Hueter preferred the arterial
method of transfusion, in order to send the blood more
gradually to the heart, and thus prevent sudden disturb-
ance of the circulation. A little air in an artery will do no
harm, and the danger of venous embolism is avoided. Saline
fluid can be thrown into an artery. The radial artery is
exposed and surrounded by three ligatures, and the thread
toward the heart is at once tied. The distal ligature is
slightly tightened to cut off* anastomotic blood-supply.
The artery is cut transversely half through ; the syringe is
inserted, pointed toward the periphery, and fastened by the
third ligature ; the second ligature is loosened and the blood
is injected. On finishing, the peripheral thread is tied
tightly and that portion of the artery which held the
cannula is excised.

3. Ligation of Arteries in Continuity.
The instruments used in this operation are two scalpels

Fic. 57. — Ane»>rysm-ncedlc of Saviard.

(one small, one medium), two dissecting-forceps, several
hemostatic forceps, toothed forceps, blunt hooks or broad

DISEASES AND INJURIES OF HEART AND VESSELS. 279

Fig. 38. — Dupuytren's aneurysm-
needles.

metal retractors, an Allis dissector, an aneurysm-needle, for
superficial arteries the instrument of Saviard (Fig. 57), for
deep vessels the needle of Dupuy-
tren (Fig. 58), ligatures of catgut,
of chromicized gut, or of silk,
curved needles and needle-holder,
and silkworm-gut, and the reflec-
tor or electric forehead-lamp for
deep vessels.

The position varies according
to the vessel, though the body is
supine except when ligation is to
be performed on the gluteal,
sciatic, or popliteal. The opera-
tor, as a rule, stands upon the
affected side, cutting from above
downward on the right side and
from below upward on the left side.

Operation. — Accurately determine the line of the artery,
and make an incision at a slight angle to this line, avoid-
ing subcutaneous veins, and holding the scalpel like a fiddle-
bow or a dinner-knife while cutting the superficial parts,
and like a pen while incising the deeper parts. On reaching
the deep fascia make out the required muscular gap by the
eye and finger, so moving the extremity as to bring indi-
vidual muscles into action. Treves cautions us not to
depend upon the yellow line of fat, which often cannot be
seen in emaciated people or when an Esmarch bandage
is employed ; nor upon the white line due to attachment to
the fascia of an intermuscular septum. In opening the deep
portion of the wound relax the bounding muscles by altering
the posture. Open a muscular interspace with a sharp knife,
not with a dissector. Make the depths of the wound as long
as the superficial incision. Do not tear structures apart
with a grooved director ; cut them. Arrest hemorrhage as
it occurs. Try to find the situation of the artery with the
finger. Pulsation is present, but it may be very feeble and
hard to detect. The artery feels like a very thin rubber
tube; it is compressible, though not so easily as a vein,
and when compressed feels like a flat band which is thinner
in the center than at the edges (Treves). A nerve feels like
a hard round cord. The veins are soft, larger than their
related arteries, and so very compressible that they can
scarcely be felt when pressed upon, compression causing
distal distention. If the wound can be seen well into, it will

28o MODERN SURGERY.

be noted, as Treves asserts, that " the nerves stand out as
clear, rounded, white cords ; that the veins are of a purple
color and of somewhat uneven and wavy contour ; that the
artery is regular in outline and of a pale-pink or pinkish-
yellow tint, the large vessels being of lighter color than the
small." All the arteries of the upper extremity and all the
arteries below the knee are accompanied by two veins, known
as ** venae comites." The arteries of the head and neck
have each a single attending vein, except the lingual, which
has venae comites. Most of the smaller arteries of the trunk
(pudic, internal mammary, etc.) have venae comites. These
companion veins may lie on each side of the artery or in
front and back of it, and they communicate with one another
by transverse branches crossing the artery. On reaching
the sheath pick up this structure with toothed forceps so
as to make a transverse fold, and thus avoid catching the
artery or vein ; lift the fold to see that it is free, and open
the sheath by cutting toward the edge of the forceps with
a scalpel held obliquely with its back toward the vessel, thus
making a small longitudinal incision (PI. i, Figs, i, 2). Hold
the edge of the incised sheath with the forceps ; pass an
Allis dissector under the vessel and from the forceps ; this
clears one-half of the vessel. Grasp the other edge of the
sheath and pass the blunt dissector all the way around the
vessel. Pass an aneur>'sm-needle under the cleared vessel
away from the forceps holding the sheath. Thread the needle
and withdraw it always from its most dangerous neighbor. If
vcnai comites are in the way, try to separate them ; but if this
proves difficult, include them in the ligature. In small ves-
sels always include them if they arc in the way, as this saves
trouble. If, in passing the needle, a large vein is severely
wounded (such as the femoral), Jacobson advises the em-
ployment of digital pressure in the lower portion of the
wound while the arterj' is being tied on a level above or
below that of the vein-injur>% and after Hgation the main-
tenance of pressure on the wound for a couple of days. A
slight puncture in a vein merely requires a lateral ligature.
A small longitudinal cut can be closed with Lembert sutures
of fine silk. After getting a ligature under an artery press
for a moment upon the artery- over the ligature, which is
held taut ; this pressure will arrest pulsation below if the
ligature is around the main artcr>' and there is not a double
vessel. Tie the thread at right angles to the vessel with a
reef-knot (Fig. 59), rupturing the internal and middle coats.
As the ligature is tightened place the extended index fingers

1. OpcnlBK the ShuLth Tor Ugalion of an Anery (Guciin). 9. Sluaih oTAneTy Open(Gugriii),
t. TI^UBinc the Knot in Usatian (Gueriiii 4, Anmamy of ihc Iliac Artirira, and ihowInK th<
~ 1 al indtion ro> lh«r lliiden^ 1, AUnwihy't indiion (Oucrin}. ;. S. ttallance iind Ed
t Su>r-kiwU

DISEASES AND INJURIES OF HEART AND VESSELS. 281

along the ligature up to the artery (PI. i, Fig. 3), using the
middle joints as the fulcrum of a lever by placing them
against each other.

Ballancc and Edmunds have recently claimed as Scarpa
and Sir Philip Crampton did long since that it is not neces
sary to divide the internal and middle coats to insure oblit
eration. If this claim be true, the danger of secondary
hemorrhage can be greatly lessened
Holmes, however, thinks the older
method the more certain of the two
Ballance and Edmunds recommend that
the artery be surrounded with a doubled
ligature of floss-silk, that each hgature be
tied with one turn of a reef-knot, and that

the final turn be made by gathering together as single pieces
both ends on either side, and tying them to each other. This
knot is known as the " stay-knot " (PI. i, Figs. 5, 6).

The chief dangers after ligation are secondary hemor-
rhage and gangrene. Rigid asepsis usually prevents the
first; rest, elevation, and heat antagonize the second.

Radial Artery. — The line of the radial artery is from
the middle of the front of the elbow-joint to the ulnar side
of the styloid process of the radius. The line in the tab-
atiere is from the apex of the styloid process to the posterior
angle of the first interosseous space.

Anatoiii7 (PI. 2, Fig. 5). — The radial artery, though smaller
than the ulnar, is the direct continuation of the brachial.
It arises from the bifurcation of the brachial half an inch
below the bend of the elbow, runs down the radial side of
the forearm to the front of the styloid process of the radius,
passes beneath the extensor mu.scles of the first metacarpal
bone and of the first phalanx of the thumb, and over the
carpus to the first interosseous space. It is crossed by the
tendon of the extensor secundi internodii pollicis. enters into
the palm between the heads of the first dorsal interosseous
muscle, and forms the deep palmar arch. The artery in the

282 MODERN SURGERY.

Upper two-thirds of its course is somewhat overlaid by the
supinator longus muscle ; in the lower one-third of the fore-
arm it is superficial. In the upper third of the forearm it
lies between the supinator longus on the outside and the
pronator radii teres on the inside ; in the lower two-thirds
of the forearm it lies between the supinator longus on the
outside and the flexor carpi radialis on the inside. Two
venae comites attend the vessel. The radial nerve is to the
outer or radial side of the artery, well removed from the
artery in the upper third, nearer to the artery in the middle
third, far external to the artery in the lower third, the nerve
at this point passing beneath the supinator longus muscle.
The radial artery, from above downward, rests upon the
biceps tendon, the supinator brevis, the flexor sublimis, the
pronator radii teres, the flexor longus pollicis, the pronator
quadratus muscles, and the radius. It has two venae comites.
The best guide to the radial artery in the foreanii is the
outer edge of the flexor carpi radialis muscle or the inner
edge of the supinator longus muscle.

The tabatiere anatomique of Cloquet, or the anatomical
snuff-box, is a triangle whose base is the lower edge of the
posterior annular ligament, the ulnar side being formed by
the extensor secundi internodii pollicis tendon, the radial
side by the extensor ossis metacarpi and the extensor primi
internodii pollicis tendons ; the floor consists of the trape-
zium, scaphoid, their dorsal ligaments, and the base of the
first metacarpal bone.

Operations. — Ligation in the tabatiere is a dissecting-room
operation of but little practical use. The patient is placed
in a recumbent position, the arm is abducted and the forearm
is placed midway between pronation and supination (Barker).
The surgeon stands upon the side operated upon. An in-
cision two inches in length is made along the radial border
of the extensor secundi internodii pollicis muscle. The skin
and superficial fascia arc cut and some venous branches are
divided. The deep fascia is incised and the vessel is easily
found and tied before it passes between the heads of the
first dorsal interosseous muscle (Barker).

Ligation in the Lcnuer Third. — In this operation (PI. 2,
Fig. 6) the patient is supine, the arm is abducted, the fore-
arm is supinated and rested upon a table and held by an
assistant. The surgeon stands on the side operated upon,
and cuts from above downward on the right arm and from
below upward on the left arm. The line of the vessel is
determined, and can be marked with iodin or anilin. An

DISEASES AND INJURIES OF HEART AND VESSELS. 283

incision one and a half inches long is made at a slight angle
to this line and midway between the supinator longus and
the flexor carpi radialis muscles, which incision must not
extend below the level of the tuberosity of the scaphoid
bone. In the superficial fascia watch for the superficial
radial vein, and if it comes into view, push it aside. Incise
the superficial fascia and locate each guide-tendon. Open
the deep fascia in the length of the first cut; try to
separate the veins, but if they strongly adhere, include
them in the ligature. There is no special fascial sheath.
The radial nerve will not be seen, but a division of the
anterior cutaneous is frequently found in relation with the
vessel. The needle can be passed in either direction. A
high origin of the superficialis volae artery is confusing.

Ligation in the Middle Third. — In this operation the posi-
tion is the same as in the preceding. A two-inch incision
is made. Veins of the subcutaneous tissues are avoided.
Lying upon the deep fascia is the anterior division of the
musculocutaneous nerve. Open the fascia ; find the inner
edge of the supinator longus muscle and draw it outward,
flexing the elbow if necessary. Be sure not to get external
to this muscle. Find the vessel where it is bound down by
connective tissue to the pronator radii teres muscle, separate
the veins, and pass the ligature from without in. The nerve
is external.

Ligation in the Upper Third (PI. 2, Fig. 6). — In this ope-
ration the incision is like the last, only higher up. The
artery is between the supinator longus and the pronator
radii teres, which muscles are at once differentiated by the
different direction of their fibers. The artery is usually cov-
ered by the supinator longus muscle, which must be retracted
externally. The nerve is not seen. The ligature is passed
in either direction.

Ulnar Artery. — No one line will overlie the entire ulnar
artery. The line of the upper third runs from the middle of
the front of the elbow-joint to the point of junction of the
upper and middle thirds of the ulna. The line of the lower
two-thirds runs from the tip of the internal condyle of the
humerus to the radial side of the pisiform bone (PI. 2, Figs.

5. 6).

Anatomy (PI. 2, Fig. 5). — The ulnar artery arises from
the brachial bifurcation and runs obliquely inward under the
median nerve and a group of muscles from the internal con-
dyle ; it turns down the arm, being covered in the middle
third of its course by the flexor carpi ulnaris muscle. In the

284 MODERN SURGERY.

lower third it is superficial, between the tendons of the flexor
carpi ulnaris on the inside and the flexor sublimis digitorum
on the outside, the vessel being a little overlapped by the
flexor carpi ulnaris. This vessel rests first upon the brachi-
alis anticus muscle, next upon the flexor profundus, to which
it is bound by a distinct process of fascia, and next upon the
annular ligament, which structure it crosses to become the
superficial palmar arch. Two venae comites attend the vessel.
In the upper third the nerve is well internal, but in the lower
two-thirds the nerve lies near the artery and to its ulnar side.
The guide is the outer edge of the flexor carpi ulnaris.

Operations (PI. 2, Fig. 6). — Ugation of t/ie Lower Third.
— The position in this operation is the same as for the radial
artery. Make a two-inch incision to the radial side of the ten-
don of the flexor carpi ulnaris, which incision is not taken
lower than a point one inch above the pisiform bone. Avoid
the superficial ulnar vein in the subcutaneous tissue. Open
the deep fascia, find the tendon of the flexor carpi ulnaris,
flex the wrist and draw the tendon inward, open a second
layer of fascia, clear the vessel, separate the veins, and pass
the ligature from within outward to avoid the nerve. On
the artery is the palmar cutaneous branch of the ulnar
nerve, and this branch must not be included in the
ligature.

Ligation of the Middle Third (PI. 2, Fig. 6). — In this opera-
tion the position is the same as in the preceding one, the in-
cision being three inches long. Avoid the anterior ulnar vein
and the branches of the internal cutaneous nerve in the super-
ficial fascia. Open the deep fascia a little external to the
superficial cut (Treves). Find the space between the flexor
carpi ulnaris and the superficial flexor, feeling with the index
finger, and when the space is discovered flex the wrist, re-
tract the flexor carpi ulnaris inward and the flexor sublimis
digitorum outward, open the fascia, find the ulnar nerve, look
external to it for the artery, clear the vessel, separate the
venae comites, and pass the needle from within outward. The
ulnar artery should not be ligated in continuity in the upper
one-third of its course.

Brachial Artery. — The line of the brachial artery is from
the junction of the anterior and middle thirds of the outlet
of the axilla, the arm being abducted and the forearm supi-
nated, to the middle of the front of the elbow-joint.

Anatomy (PI. 2, Fig. i). — The brachial artery is the pro-
longation of the axillary, and extends from the lower edge of
the teres major muscle to half an inch below the bend of the

DISEASES AND INJURIES OF HEART AND VESSELS. 285

elbow, where it divides into the radial and ulnar. It lies first
to the inner side of the arm, but passes to the front of the
elbow. It is crossed by no muscle, and is in fact superficial,
barring its being somewhat overlaid in part of its course by
the edge of the biceps muscle. The median nerve is outside
above, crosses over it about the middle of the arm, and
reaches the inside. The coracobrachialis and biceps mus-
cles are external, and both often overlap the vessel. The
ulnar nerve is internal above, and the median nerve below,
the middle. The basilic vein is internal to the artery, being
outside the deep fascia to near the middle of the arm, at
which point it pierces it. The artery above is separated from
the long head of the triceps by the musculospiral nerve and
superior profunda artery and vein ; it rests from above down
on the inner head of the triceps, the coracobrachialis, and
the brachialis anticus. The artery is covered by skin and by
superficial and deep fascia. The internal cutaneous nerve lies
in front of the artery, upon the deep fascia, until it pierces
the fascia along with the basilic vein. The artery has venae
comites, and in its upper, half has also the basilic vein to its
inner side. The guide to the brachial is the inner edge
of the biceps muscle. Just in front of the elbow-joint the
artery lies in a triangle, the base of which is formed by an
imaginary transverse line above the condyles, the apex by
the junction of the pronator radii teres and the supinator
longus. The outer line is the supinator longus, the inner
line is the pronator radii teres, and the floor is formed by the
brachialis anticus and the supinator brevis. From within
outward the triangle contains the median nerve, brachial
arter>', tendon of the biceps, anastomosis of the superior
profunda and radial recurrent arteries, and the musculospiral
nerve.

OperatdonB. — Ligation at the Bend of the Elbow. — In this
operation (PI. 2, Fig. 2) the patient is supine, the arm is mod-
erately abducted and extended, and is allowed to lie upon its
posterior aspect. The forearm is supinated. The surgeon
stands upon the side operated upon, and cuts from above
downward on the right side and from below upward on the
left side. Accurately locate the tendon of the biceps and the
median basilic vein. An incision is made parallel with the
inner edge of the biceps tendon and two inches in length,
the center of this cut being in the crease of the elbow. On
exposing the median basilic vein, retract it downward and in-
ward, open the bicipital fascia, clear the arter>' of fat, separate
the venae comites, and pass the ligature from within outward

286 MODERN SURGERY.

to avoid the median nerve. The above operation is not fre-
quently performed.

Ligation in the Middle of the Ann, — In this operation the
patient is placed supine and abduction of the arm and supi-
nation of the forearm are brought about An assistant holds
the forearm, but the arm should not rest upon the table,
because, if it be allowed to do so, the inner head of the
triceps will be forced forward and may overlie the artery, and
thus complicate the operation. Locate the inner edge of the
biceps, which is the guide. Make an incision three inches
long in the line of the artery. Incise the skin and fascia,
flex the elbow slightly, retract the biceps outward, feel for
the artery, open its sheath, separate its venae comites, and,
having located the median nerve, pass the ligature from it
In the middle of the arm the nerve is in front of the vessel,
above the middle it is external, and below the middle internal.
High up the arm the inner edge of the coracobrachialis is
the guide, rather than the biceps. Above the middle of the
arm the basilic vein is beneath the deep fascia and runs along
to the inner side of the artery ; hence, high up, the artery
has three companion veins, the venae comites and the basilic
vein, and there is seen the ulnar nerve to the inside of the
artery.

Axillary Artery. — To determine the line of the axillary
artery place the arm at right angles to the body, with the
patient supine, and lay down a line from the middle of the
clavicle to the humerus near the inner border of the coraco-
brachialis. The line of the third portion can be approximated
by projecting the line of the brachial upward.

Anatomy (PI. 2, Fig. 3 ; PI. 3, Fig. i). — The axillary artery
is the continuation of the subclavian, and runs from the lower
margin of the first rib to the inferior border of the teres major
muscle. It is divided into three portions by the pectoralis
minor muscle. The first portion is above, the second por-
tion is behind, and the third portion is below, the pectoralis
minor. The position of the artery varies with the position
of the limb. When the arm is parallel with the body the
arter}^ is far from the surface and forms a curve whose con-
vexity is upward and outward. When the arm is at right
angles to the body the vessel is nearer the surface and
straight. When the arm is raised above a right angle the
artery comes near the surface and forms a curve with the
convexity downward.

The first portion of the axillary artery is occasionally
ligated. It lies upon the first intercostal muscle and the

DISEASES AND INJURIES OF HEART AND VESSELS. 287

first serration of the great serratus muscle, and has behind
it the posterior thoracic nerve ; the brachial plexus is external
and posterior to the vessel ; on its inner side is the axillary
vein ; in front of it are the clavicle, the great pectoral muscle,
the subclavius muscle, the costocoracoid membrane, the
cephalic and acromiothoracic veins, and the external anterior
thoracic nerve. The branches of the first part of the axillary
artery are the superior thoracic and the acromiothoracic. The
second part of the artery is not ligated. The brachial plexus
surrounds the second portion. The third part is covered in
front, above, by the great pectoral, but is covered below by
sldn and fascia ; behind, it has the tendon of the subscapularis,
the latissimus dorsi, and the teres major ; the coracobrachi-
alis is on the outer side ; the axillary vein is on the inner
side. It is important to remember that there may be three
veins, one external and two internal. The axillary vein is
formed by the venae comites of the brachial artery joining,
and this new vein effecting a junction with the basilic vein.
The median nerve lies upon the axillary artery in the upper
part of the third portion of the vessel's course, and passes to
the outer side. The musculocutaneous nerve is external,
but it is only seen high up ; the ulnar nerve is internal ; the
lesser internal and the internal cutaneous nerves are internal ;
the musculospiral and the circumflex nerves are behind. The
branches of the third portion of the axillary artery are the
subscapular and the anterior and posterior circumflex.

Operations. — Ligation of the Third Portion (PI. 2, Fig. 4).
— The position in this operation is supine with the shoulders
raised and the arm abducted to a right angle. The surgeon
stands between the patient's arm and side, with his back to-
ward the subject's feet. An incision is made three inches in
length. It begins half-way up the axilla opposite to the head
of the humerus, and comes downward parallel to the lower
edge of the great pectoral muscle and crosses the junction
of the anterior and middle thirds of the outlet of the axilla.
Incise the integuments and fascia. The vein or veins will be
prominent to the inner side and may overlie the vessel. To
the inner side with the veins are the ulnar and internal cu-
taneous nerves. The median is upon and the external cuta-
neous nerve to the outer side of the artery. Feel for the
pulsations of the artery, find the median nerve and draw it
outward, draw the internal nerve and veins inward, clear the
artery from the venae comites, and pass the ligature from
within outward. Apply the ligature well below the cir-
cumflex branches.

288 MODERN SURGER Y.

Ligation of the First Part, — This operation (PL 3, Fig. 2)
was first performed in 181 5 by Chamberlaine of Jamaica.
The position is supine, the upper part of the body being
raised, a sand-pillow being placed between the scapulx to
insure carrying back of the point of the shoulder, and the
arm being brought down along the side. In operating on the
left side the surgeon stands on the outer side of the left arm;
in operating on the right side he stands to the right of the
subject's head and leans over his shoulder. The incision,
which is slightly curved downward, begins external to the
sternoclavicular joint and ends internal to the margin of the
deltoid, thus avoiding the cephalic vein. The incision is half
an inch below the clavicle. Incise skin, platysma myoides
muscle, superficial nerves, and deep fascia. In the outer angle
of the wound watch out for the acromiothoradc artery and
the cephalic vein. Incise the pectoralis major ; draw the pec-
toralis minor down ; retract the lower margin of the wound,
cut through the costocoracoid membrane close to the cora-
coid process and upper border of the lesser pectoral. Bring
the arm to the side so as to relax the structures. Find the
brachial plexus, feel for the artery internal to it, clear the
vessel, draw the vein internally, and pass the needle from
within outward. This avoids the dangerous neighbor, which
is the axillary vein. This operation is difficult, dangerous,
and unusual, and in its performance the axillary vein, which
has a close attachment to the costocoracoid membrane, is
apt to be torn.

Subclavian Artery. — There is no line for this vessel.

Anatomy (PI. 3, Fig. i). — The subclavian artery of the
right side arises from the innominate ; of the left .side, from
the arch of the aorta. The subclavian is divided into three
parts. The first part runs from the origin of the vessel to the
inner border of the scalenus anticus muscle ; the second part
lies behind the scalenus anticus muscle ; and the third part
runs from the outer edge of the muscle to the lower border
of the first rib.

At the present day the first and second portions are not
ligated. The third portion is contained in the subclavian
triangle (Fig. 61), and is superficial. It rises, as a rule, to
half an inch above the clavicle. The subclavian vein is below
the artcr>', being separated from it by the scalenus anticus
muscle. The brachial plexus is above and external to the
artcr>'. The vessel rests upon the first rib, and behind it is
the scalenus medius muscle. The suprascapular and trans-
versalis colli arteries and veins and branches of the cervical

DISEASES AND INJURIES OF HEART AND VESSELS. 289

plexus lie in front of the artery, and the external jugular
vein crosses it at its inner side. The third portion gives off
no branches.

Ligation of the Tlurd Part. — This operation (PI. 3, Fig. 2)
was first successfully performed in 1 817 by Post of New York.
The position is as follows : place the patient upon his back,
raise the shoulders, extend and turn the head toward the
opposite side, pull down the arm, and hold it by pushing the
forearm under the patient's back (Treves). This pulls down
the clavicle, thus increasing the size of the subclavian tri-
angle. The operator stands facing the shoulder, with his
back toward the patient's feet. Draw the skin over the sub-
clavian triangle, half an inch above the clavicle, down upon
this bone, and incise. This maneuver avoids the external
jugular vein and gives an incision half an inch above the
collar-bone. The incision reaches from the anterior edge of
the trapezius to the posterior border of the sternocleidomas-
toid (PI. 3, Fig. 2). and is about three inches long. By this in-
cision are divided the skin, the superficial fascia, the platysma
myoides, the vein running from the cephalic to the external
jugular, and some superficial nerves. Open the deep fascia.
Draw the external jugular vein into the inner angle of the
wound, and do not divide it unnecessarily ; if forced to do so,
tie the vein with two ligatures and cut between them. Find
the outer edge of the anterior scalene muscle, and run the
finger down along it to the tubercule on the first rib. Draw
up the posterior belly of the omohyoid muscle. With the
finger on the tubercle recall the fact that the vein is in front
of the finger and the artery is behind it, and that the sub-
clavian vein is on a lower plane than the artery. The artery
is felt beating as it lies upon the rib. Clear the artery and
expose the lower cord of the brachial plexus. Guard the
* vein with the finger and pass the needle from above down-
ward, as the plexus, which is in more danger than the vein^
is to be avoided. In this operation never cut the transversa-
lis colli or suprascapular arteries, as they are necessary to
the future anastomotic circulation. If the field of operation
is too small, incise the trapezius or sternocleidomastoid or
both.

The vertebtal artery was first successfully ligated by
Smyth of New Orleans.

Anatomy. — This vessel is the largest branch of the sub-
clavian, and is the first branch from the first portion of the
subclavian. The vertebral artery ascends and enters the
foramen in the transverse process of the sixth cervical vcr-

2gO MODE R A' SURGED Y.

tebra (in rare cases the fifth or the seventh), and ascends
through foramina in the cervical vertebrae, passes behind the
articular process of the atlas and over the posterior arch of
this first vertebra, pierces the posterior occipito-atloid liga-
ment, and enters the skull by way of the foramen magnum
(see Gray). It joins its fellow of the opposite side to form
the basilar. At its point of origin it has in front of it the
internal jugular vein and inferior thyroid artery. Gray says
that near the spine it lies between the longus colli and
scalenus anticus muscles, with the thoracic duct to the left
and in front.

Ligation. — Position as for ligation of carotid. Make an
incision three inches in length along the posterior edge of
the sternocleidomastoid muscle. This incision reaches the
clavicle. In dividing the skin and superficial fascia watch
for the external jugular vein and retract it inward. Divide
the deep fascia. Retract the sternocleido inward Open
the space between the longus colli and scalenus anticus
muscles, find the artery, clear it, and pass the needle from
the inner side. Jacobson tells us to remember that the
phrenic nerve lies on the scalene muscle, the pleura is inter-
nal, the internal jugular, inferior thyroid, and vertebral veins
arc over the vessel, and the thoracic duct on the left side
crosses it from within outward.

The Inferior Thyroid Artery. — Anatomy. — The infe-
rior thyroid is a branch of the thyroid axis. It ascends the
neck, passes back of the carotid sheath and the sympathetic
nerve, and reaches the thyroid gland. The recurrent lar)'n-
gcal nerve lies behind the artery. The phrenic nerve is
external to the artery and near to it in the first part of its
course (up to the point of origin of the ascending cervical
branch). The ascending cervical branch takes origin just
before the arter>' begins to dip behind the carotid. In front
of the beginning of the left artery the thoracic duct crosses.
The artery is ligated in the second part of its course (between
its distribution and the origin of the above-named branch).

Ligation. — Position of patient and incision as for common
carotid in triangle of necessity (p. 294). After exposing the
sternocleidomastoid retract it outward, and then retract
outward the carotid artery and also the internal jugular
vein. The artery will be found a little below the carotid
tubercle. It is cleared and ligated. Treves advises ligation
close to the level of the carotid, so as to avoid the recurrent
laryngeal nerve.

Innominate Artery. — First successfully ligated by

DISEASES AND INJURIES OF HEART AND VESSELS, 29 1

Smyth of New Orleans. It is an almost certainly fatal
operation.

Anatomy. — The innominate artery arises from the begin-
ning of the transverse portion of the arch of the aorta, passes
to the back of the right sternoclavicular joint, and divides
into the common carotid and subclavian. It rests upon the
trachea. It has upon its outer side the pleura, the right
innominate vein, and the pneumogastric nerve. Upon its
inner side the remnant of the thymus and the beginning of
the left carotid artery. In front of it are the inferior thyroid
veins of the right side, the left innominate vein, the sterno-
hyoid and sternothyroid muscles, the remnant of the thymus
gland, and sometimes a branch from the right pneumogastric
nerve.

Ligation, — Patient supine, shoulders a little raised, and
head thrown back. An incision from the upper margin of
the sternum three inches in length along the anterior mar-
gin of the stemomastoid. Another cut of the same length
is made along the upper border of the clavicle to meet the
first cut. Dissect up the flap of skin and fascia. Divide the
sternal origin and a part of the clavicular portion of the
stemocleido, and cut the sternohyoid and sternothyroid
just above their sternal origins (Joseph Bell). Retract the
inferior thyroid veins. Divide the dense leaflet of cervical
fascia. Find the common carotid, and trace back along this
vessel until the innominate comes into view. Retract the
left innominate vein downward. The needle is passed from
without inward to avoid the right innominate vein and right
pneumogastric. If the needle is kept close to the artery,
the pleura and trachea will not be injured.^

Region of the Neck. — ^Anatomy. — The side of the neck
is that space between the median line in front and the ante-
rior edge of the trapezius behind, which space is limited be-
low by the clavicle and above by the body of the jaw and
an imaginary line running from the angle of the jaw to the
mastoid process. The sternocleidomastoid muscle divides
this space into an anterior and a posterior triangle, and each
of the triangles is subdivided by other structures, the ante-
rior into four spaces and the posterior into two (Fig. 61).

Anterior Triangle, — The anterior triangle is bounded in
front by the median line of the neck, behind by the anterior
margin of the sternocleidomastoid, and above by the body
of the lower jaw and an imaginary line from the angle of

' See the exceedingly clear and terse account in that excellent book, A Man-
ual of Surgical Operations^ by Joseph Bell.

292

MODERN SURGERY,

Lower jaw.

the jaw to the mastoid process. This space is subdivided
into four smaller triangles, namely, the inferior carotid, the
superior carotid, the submaxillary, and the submental.

The inferior carotid triangle is called the "triangle of
necessity," because the common carotid in it is ligated, not

from choice, but through force of
necessity. It is bounded in front
by the median line, above by the
anterior belly of the omohyoid and
the hyoid bone, and below by the
anterior edge of the stemomastoid.
The floor of this triangle is com-
posed of the longus colli, the sca-
lenus anticus, the rectus capitis an-
ticus major muscles, the sterno-
hyoid and sternothyroid muscles.
The superior carotid triangle is
known as the "triangle of elec-
tion," because, whenever possible,
it is elected to tie the carotid in
this situation. In this region the
carotid is superficial, and there can
be tied either the external, the in-
ternal, or the common carotid, as
may be desired. The triangle is
bounded behind by the anterior
^^^'t of the stemomastoid, above by the posterior belly of
the digastric, and below by the anterior belly of the omo-
hyoid. Its floor is composed of the inferior and middle
constrictors of the pharynx and the thyrohyoid and hyo-
glossus muscles.

The submaxillary triangle is bounded above by the body
of the jaw and an imaginary line from the angle of the jaw
to the mastoid process, behind by the posterior belly of the
digastric and the stylohyoid muscle, and in front by the
anterior belly of the digastric. Its floor is composed of the
mylohyoid and hyoglossus muscles.

The submental triangle is bounded on either side by the
anterior belly of one digastric muscle ; its base is the hyoid
bone and its floor is the mylohyoid muscle.

The posterior triangle is bounded in front by the posterior
border of the stemomastoid, behind by the anterior edge of
the trapezius, and below by the clavicle. The posterior belly
of the omohyoid subdivides it into two smaller spaces, the
occipital and subclavian triangles.

c Clavicle. d

Fig. 6i.— The triangles of the
neck, right-sided view (after Keen) :
I. Submaxillary triangle ; 2. Triangle
of election, or superior carotid tri-
angle ; 3. Submental triangle ; 4.
TriHngle of necejisity, or inferior
carotid triangle ; 5. Occipital trian-
gle; 6. Subclavian triangle; 7. Hy-
oid bone.

DISEASES AND INJURIES OF HEART AND VESSELS. 293

The subclavian triangle is bounded above by the posterior
belly of the omohyoid, below by the clavicle, and in front
by the posterior border of the stemomastoid. Its floor is
formed by the first rib and the first serration of the serratus
magnus muscle.

The occipital triangle is bounded in front by the posterior
edge of the stemomastoid, behind by the anterior border
of the trapezius, and below by the posterior belly of the
omohyoid muscle.

Common Carotid Artery. — The line of the common
carotid artery is from the sternoclavicular articulation to
midway between the angle of the jaw and the mastoid
process, the head being turned toward the opposite side.

Anatomy (PI. 3, Fig. 3). — The right common carotid
arises from the innominate opposite the sternoclavicular
joint; the left common carotid arises from the arch of
the aorta. In the neck the two carotids possess identical
relations. The common carotid runs upward and outward
from behind the sternoclavicular articulation to a level
with the upper border of the thyroid cartilage, at which
point it divides into the external and internal carotid. The
common carotid is contained in a sheath from the cervical
fascia, which sheath also holds, though in separate compart-
ments, the internal jugular vein on the outer side of the
artery and the pneumogastric nerve between the vein and
artery and behind them. The anterior edge of the stemo-
mastoid muscle lies over the artery and is a guide. Low in
the neck the common carotid is deep, being covered by skin,
superficial fascia, platysma, deep fascia, and the stemomas-
toid, sternohyoid, and stemothyroid muscles. Above the
omohyoid the vessel is more superficial, being covered by
the skin, superficial fascia, platysma, deep fascia, and the an-
terior edge of the stemomastoid. Upon the sheath (occa-
sionally within it), above the crossing of the omohyoid
muscle, lies the descendens noni nerve — the descending
branch of the ninth pair of Willis (the hypoglossal). This
nerve is a valuable guide to the sheath in the triangle of
election.

The stemomastoid branch of the superior thyroid artery
crosses the carotid a little below its bifurcation, and the supe-
rior thyroid veins cross it in this region ; the middle thyroid
vein crosses the middle of the line of the artery, and the an-
terior jugular vein crosses low down. The carotid rests upon
the longus colli and rectus capitis anticus major muscles, the
sympathetic nerve lying between the last-named muscle and

294 MODERN SURGERY.

the vessel, outside the carotid sheath. The recurrent laryn-
geal nerve passes behind the carotid below the omohyoid
muscle, and the inferior thyroid artery passes behind the
carotid just above the omohyoid muscle. The carotid is in
relation internally with the trachea, thyroid gland, larynx,
and pharynx. On its outer side are the pneumogastric ner\'e
(which is on a posterior plane) and the internal jugular vein.
On the left side, low down in the neck, the jugular vein often
lies in front, or partly in front, of the artery. Ligation of the
common carotid was first successfully performed in i8a6by
Sir Astley Cooper.

Ligation in the Triangle of Necessity. — In this operation the
position is supine with the shoulders raised, a sand pillow un-
der the neck, and the head turned to the opposite side with
the chin raised. The operator stands upon the side operated
upon. The incision, three inches long, at an angle of five
degrees to the arterial line, runs from the level of the cricoid
cartilage downward and inward toward the sternoclavicular
joint, following the inner border of the sternocleidomastoid.
Open the deep fascia, draw the sternocleidomastoid outward,
retract the sternohyoid and sternothyroid muscles inward,
and feel for the carotid tubercle of Chassaignac. This tuber-
cle is the costal process of the sixth cervical vertebra, and
lies directly under the artery. The tubercle is found about
the point at which the omohyoid crosses the carotid. When
the tubercle is found we know the situation of the artery, and
that the triangle of necessity is below, and the triangle of
election above, the tubercle. Pull the omohyoid muscle up-
ward. Open the sheath of the artery on its inner side, clear
it, and pass the needle from without inward to avoid the in-
ternal jugular vein, remembering that the pneumogastric
nerve is in the same sheath as the artery and vein, pos-
terior and external to the artery. In this operation the in-
ferior thyroid veins are much in the way, the anterior jugular
vein crosses low down, and on the left side, at the root of the
neck, the internal jugular vein may be in front of the carotid
artery. If the incision is not sufficiently wide, divide the
sternocleidomastoid or the sternohyoid and thyroid mu.scles.
In the triangle of necessity the descendens noni nerve does
not serve as a guide to the sheath. (See PI. 3, Fig. 4.)

Ligation in the Triangle of Election. — The position for this
operation is the same as in the preceding one. An incision,
three inches in length, is made along the anterior edge of the
sternomastoid in the line of the arter\', the middle of this in-
cision being opposite the cricoid cartilage. In cutting the

DISEASES AND INJURIES OF HEART AND VESSELS, 295

superficial fascia, avoid the external jugular vein, the course
of which should be outlined before making the incision. The
line of the external jugular is from the angle of the jaw to the
middle of the clavicle. Open the deep fascia, retract the
sternocleidomastoid outward, feel for the carotid tubercle,
draw the omohyoid downward, find the descendens noni
nerve upon the sheath, open the sheath at its inner side, and
pass the needle from without inward. This incision permits
ligation of either the superior thyroid or the external, inter-
nal, or common carotid, and if it be extended up a little, there
can be tied through it, the lingual, and even the facial and
occipital, arteries. (See PI. 3, Fig. 4.)

Bxtemal Carotid Artery. — The line of the external
carotid artery is the upper portion of the common carotid
line.

Anatomy (PI. 3, Fig. 3). — The external carotid artery,
which is one of the terminal branches of the common carotid,
arises on a level with the upper border of the thyroid cartilage
and runs to the level of the neck of the condyle of the lower
jaw. At its point of origin it is covered only by skin, platysma
and fascia, and the edge of the sternomastoid, but as it ascends
it passes beneath the digastric and stylohyoid muscles and
into the parotid gland. The glossopharyngeal nerve, styloid
process, and stylopharyngeus muscle lie between the external
and internal carotid arteries. The hypoglossal nerve crosses
the vessel just below the digastric muscle, and the facial and
lingual veins cross it a little below the nerve. The first
branch is the superior thyroid, which arises from thje very
beginning of the trunk. The lingual arises on a level with
the greater comu of the hyoid bone. The facial and occipital
take origin above the Ungual. Each of them can be ligated
through the incision of this operation.

Operation. — The position is the same as that for ligation
of the common carotid. The point of election is between
the superior thyroid and the lingual. Make an incision three
inches long in the arterial line, from near the angle of the jaw
to opposite the middle of the thyroid cartilage, cut through
the skin, superficial fascia, platysma, and deep fascia, and
retract the sternocleidomastoid outward. Look for the
digastric muscle, find the hypoglossal nerve, and feel for
the greater comu of the hyoid bone. Open the sheath a
little below the hyoid comu and pass the needle from with-
out inward. Ligation of the external carotid has been ne-
glected because ligation of the common carotid is easier.

Internal Carotid Artery. — The lifie of the internal

296 MODERN SURGERY.

carotid is parallel with and half an inch external to the
line for the external carotid.

Anatomy (PI. 3, Fig. 3). — The internal carotid artery, the
other terminal branch of the common carotid, arises on a level
with the upper border of the thyroid cartilage and enters the
carotid canal. The first inch of the artery is the only point
where a ligature is ever applied, this point being covered only
by skin, platysma, fascia, and the sternomastoid ; higher up it
is more deeply placed. It rests upon the vertebrae and the
rectus capitis anticus major muscle. The internal jugular
vein is in the same sheath and external to the artery ; the
pneumogastric is in the same sheath, between the artery
and the vein, but posterior to both. The superior cervical
ganglion of the sympathetic lies behind the origin of the
internal carotid, and between the ganglion and the artery
is the superior laryngeal nerve.

Operation. — In this operation the position is the same as in
ligation of the external carotid. Incision as for the external
carotid, except that it is half an inch external. The stemo-
cleido-mastoid is drawn outward, the external carotid arter)'
is found and drawn inward, the internal carotid is found and
drawn outward, and the needle is passed from without inward
The internal carotid is known by its more external position
and by the fact that it gives off no branches.

Superior Thyroid Artery (PL 3, Fig. 3).— This branches
off from the external carotid below the level of the greater
cornu of the hyoid bone, in the triangle of election. It is at
first superficial, runs first upward and inward, next downward
and forward, passes underneath the omohyoid, sternohyoid,
and sternothyroid muscles, and reaches the thyroid gland.

Ligation. — Same position of patient and surgeon as in
carotid ligation. May be reached through incision employed
in ligation of external carotid. Gross employed an incision
starting at the edge of the hyoid bone, and running down-
ward and outward to the sternomastoid muscle. Cut the
skin, superficial and deep fascia, and find the artery deeply
placed in the triangle of election between the carotid sheath
and the thyroid gland.

I/iMgual Artery. — Anatomy (PI. 3, Fig. 3). — The lingual
artery arises from the external carotid opposite the greater
cornu of the hyoid bone, passes beneath the digastric and
stylohyoid muscles, reaches the margin of the hyoglossus,
passes under that muscle, and emerges from under it to run
along the under surface of the tongue. The place of elec-
tion for ligation is where the artery is beneath the hyoglossus

DISEASES AND INJURIES OF HEART AND VESSELS. 297

muscle and rests upon the genioglossus. Its guide is the
hypoglossal nerve, which lies upon the muscle, but at a
slightly higher level than the artery.

Operation. — In this operation the position of the patient
is recumbent with the shoulders raised and the face turned
away from the side to be operated upon. The surgeon
should stand upon the affected side. A curved incision is
made from a little external to the symphysis of the lower
jaw, downward and outward, to just above the greater comu
of the hyoid bone, and upward and outward to just in front
of the facial artery at the lower edge of the lower jaw. Incise
the skin, the superficial fascia and platysma, and the deep
fascia. Clear the submaxillary gland and retract it well up-
ward. Divide the fascia below the gland by a transverse in-
cision. Find the posterior edge of the mylohyoid and the
bellies of the digastric. Catch one of the digastric tendons
and have it hooked down and out (Treves). Clear the hyo-
glossus muscle with a dissector ; find the hypoglossal nerve
and ranine vein and draw them a little upward. Divide the
hyoglossus muscle transversely a little above the hyoid bone
and below the level of the hypoglossal nerve, find the artery,
and pass the needle from above downward.

Facial Artery. — ^Anatomy (PI. 3, Fig. 3). — Arises from
the external carotid a little above the lingual, runs upward and
forward beneath the body of the inferior maxillary bone,
passes along a groove in the posterior and upper surface of
the submaxillary gland, crosses the body of the lower jaw at
the lower anterior edge of the masseter muscle, and passes for-
ward and upward to the angle of the mouth and side of the nose.

Ligation (PI. 3, Fig. 4). — Is rarely ligated in the cervical
portion, but may be reached through the incision employed
for ligation of the external carotid. The vessel may be tied
before it crosses the submaxillary gland, the styloyhoid and
digastric muscles being drawn up. The vessel is reached in
the facial portion of its course by a one-inch cut at the an-
terior edge of the masseter muscle. Branches of the facial
nerve are pushed aside. The needle is passed from behind
forward to avoid the vein (Jacobson).

Temporal Artery. — The line of the temporal artery
passes " upward over the root of the zygoma, midway be-
tween the condyle of the jaw and the tragus " (Jacobson).

Anatomy. — Arises from the external carotid behind the
condyle of the jaw and in the parotid gland, passes over the
zygoma and divides into two terminal branches.

Ligation. — Patient recumbent and head turned to opposite

298 MODERN SURGERY,

side. An incision an inch in length is made, the superficial
structures and dense fascia are divided, the vein is retracted
backward, and the needle is passed from behind forward.

Occipital Artery. — Takes origin from the posterior sur-
face of the external carotid, below the digastric muscle and
opposite the point of origin of the facial artery. It ascends
beneath the digastric and st>'lohyoid muscles and parotid
gland ; the hypoglossal nerve hooks around it from behind
forward. It crosses the internal carotid artery, the internal
jugular vein, the pneumogastric and spinal accessory nerves;
passes between the mastoid process of the temporal bone and
the atlas ; grooves the temporal bones ; penetrates the trape^
zius and ascends over the occiput.

Ligation. — We can ligate low down through the same
incision as is employed to reach the external carotid. The
hypoglossal nerve is avoided. To tie back of the mastoid
process employ the same position as in ligation of carotid
Carry an incision from the tip of the mastoid upward and
backward, reaching a point midway between the mastoid
and the occipital protuberance (Jacobson). Cut the skin,
the fascia, the sternocleidomastoid, the splenius capitis and
possibly a portion of the trachelomastoid. Bring the head
toward the operator to relax the structures, retract the
edges, and clear the artery where it lies between the mas-
toid and the transverse process of the atlas (Jacobson). An
electric forehead light is of great assistance in finding the
vessel. Pass the needle away from the vein or veins (there
are often several).

Dorsalis Pedis Artery. — The line of the dorsalis pedis
artery is from the middle of the front of the ankle-joint to
the middle of the base of the first interosseous space.

Anatomy (PI. 4, F'ig. i). — The dorsalis pedis is a continua-
tion of the anterior tibial artcr>% and it runs from the bend of
the ankle to the proximal extremity of the first interosseous
space, where it divides into the dorsalis hallucis and the com-
municating arteries. The artery rests, from above downward,
upon the astragalus, scaphoid, and internal cuneiform bones,
and at its point of bifurcation lies between the heads of the
first dorsal interosseous muscle. It may lie in .some persons
a little external to this course. It is held upon the bones by
a distinct layer derived from the deep fascia. This artery is
covered by skin, by superficial and deep fascia, and by the
annular ligament above, and is sometimes partly overlaid by
the extensor proprius pollicis muscle, and is crossed, just be-
fore its bifurcation, by the innermost tendon of the extensor

*r ^""ate- .A

DISEASES AND INJURIES OF HEART AND VESSELS. 299

brevis muscle. The inner tendon of the extensor longus
digitorum is to the outer side of the vessel ; the tendon of the
extensor proprius pollicis is to the inner side, and is a guide.
The artery is ligated in the dorsal triangle of the foot — a
space which is bounded above by the lower edge of the an-
nular ligament, externally by the inner tendon of the extensor
brevis, and internally by the tendon of the extensor proprius
pollicis. The artery has venae comites; the anterior tibial
nerve lies, as a rule, to its inner side, but may be found upon
the artery or to its outer side, and the inner division of the
musculocutaneous nerve is external to the vessel in the
superficial parts.

Operation (PI. 4, Fig. 2). — In this operation the position of
the patient is supine with the legs and feet extended. Heath
flexes the leg partly and rests the sole of the foot directly
upon the table. The surgeon stands below the extremit}',
cutting from above downward. Make an incision two inches
in length along the arterial line, beginning opposite the lower
edge of the annular ligament and running along by the tendon
of the extensor proprius pollicis; cut through the skin and
superficial and deep fascia ; have the toes extended ; retract
the tendon of the extensor proprius pollicis inward, and the
tendon of the extensor longus outward ; clear the artery,
find the nerve, try to separate the venae comites, and pass
the needle from the nerve.

Anterior Tibial Artery.— To locate the /i/te of the
anterior tibial, find a point midway between the head of
the fibula and the tuberosity of the tibia, drop one inch, and
draw a line from the second point to the middle of the front
of the ankle-joint

Anatomy. — ^The anterior tibial artery is one of the termi-
nal branches of the popliteal. It arises opposite the lower
border of the popliteus muscle, passes forward between the
two heads of the posterior tibial muscle, comes to the front
of the leg through an opening in the interosseous mem-
brane, and runs down to the middle of the front of the
ankle-joint. In the upper two-thirds of its course it rests
upon the interosseous membrane, to which it is fastened by
firm fascia ; in the lower third it lies first upon the front of
the tibia and then upon the anterior ligament of the ankle-
joint. For its upper two-thirds the artery has the tibialis
anticus muscle just internal to it; at the junction of the
middle and lower thirds the extensor proprius pollicis comes
from the outside and lies either upon the artery or to its
inner side for the rest of its course. Externally in its upper

300 MODERN SURGERY,

third is the extensor longus digitorum, in the middle third
is the extensor proprius pollicis ; in the lower third, the
proprius pollicis, having crossed to the inner side, the ex-
tensor communis digitorum again becomes the outer boun-
dary. The artery is covered by skin and by superficial and
deep fascia. In its upper third it is deeply set bet\veen the
muscles ; in its middle third it is less overlaid by muscle; in
its lower third it is superficial except where it is crossed by
the extensor proprius and where it is covered by the annular
ligament. The artery has venae comites. In the lower three-
fourths of its course it is accompanied by the anterior tibial
nerve, which in its course in the upper third of the leg is
external to the artery ; in. the middle third it is external and
a little in front of the artery ; and in the lower third it is ex-
ternal to or upon the artery (PI. 3, Fig. 5).

Operations. — ^The ligations of the anterior tibial (PI. 3.
Fig. 6) are (i) in the lower third; (2) in the middle third;
and (3) in the upper third. In all these ligations the sur-
geon stands outside of the extremity, cutting from above
downward on the right side and from below upward on the
left side.

Ligation in the Lower Third. — The surgeon stands to the
outside of the extremity, cutting from above downward upon
the right leg and from below upward on the left leg. Make
an incision three inches long in the line of the artery and
over the annular ligament. This incision is external to the
tibialis anticus muscle and half an inch from the outer border
of the tibia ( Barker). Divide the skin and fascia, retract the
tendon of the tibialis anticus inward, and the tendon of the
extensor proprius pollicis outward, along with the tendons
of the extensor longus. Flex the ankle-joint to relax the
tendons, and clear the artcr)'. Draw the nerve external and
pass the ligature from without inward. In order to recog-
nize the muscles in this as in other ligations, rely largely
upon the finger while the muscles are being moved.

Ligation in the Middle Third. — In this operation the pro-
cedure is similar to the above. Remember that the nen-e
lies upon the vessel and that the extensor proprius pollicis
muscle is external. The nerve is retracted outward and the
needle is passed from the ner\x\ A good rule for detecting
the arter}' is to find the outer edge of the tibia and by this
locate the interosseous membrane, and then, by passing out
along this membrane, discover the artery.

Ligation in the Upper Third. — In this operation the posi-
tion is the same as in the above. Make an incision three

DISEASES AND INJURIES OF HEART AND VESSELS. 30I

inches long in the arterial line. On opening the deep fascia,
do not rely on the eye for finding the muscular interspace,
as often the latter cannot be seen, and neither a white nor a
yellow line is reliable. Place the index finger deep in the
wound and have the tibialis anticus and extensor longus
muscles successively rendered tense by an assistant. In
opening the interspace use the handle of the knife. Relax
the muscles, retract the tibialis anticus inward, and draw
the extensor longus outward. Find the interosseous mem-
brane where it is attached to the edge of the tibia, and the
artery will be found upon this membrane, between the tibia
and the nerve. Clear the vessel and pass the ligature from
without inward to avoid the nerve.

Posterior Tibial Artery. — The line of the posterior
tibial is from the middle of the popliteal space to a point
midway between the tip of the inner malleolus and the point
of the heel (PL 4, Figs. 5, 6).

Anatomy. — ^The posterior tibial is the larger of the two
terminal branches of the popliteal. It arises opposite the
lower border of the popliteus muscle, runs down between
the deep and superficial flexor muscles to midway between
the tip of the malleolus and the point of the heel, and
divides into the external and internal plantar vessels. In its
upper third it is very deep and midway between the tibia and
fibula ; in its middle third it is less deep, having passed inward ;
and in its lower third it is superficial. At the ankle the
artery is beneath the annular ligament. From above down-
ward the posterior tibial artery rests upon the posterior tibial
muscle, the flexor longus digitorum muscle, the posterior
surface of the tibia, and the internal lateral ligament of the
ankle-joint. For the first inch or two of the course of the
artery the posterior tibial nerve is internal ; the nerve then
crosses to the outer side, and remains on that side through-
out the rest of its course. When the knee is partly flexed
and the leg is laid upon its outer surface the artery is be-
tween the operator and the nerve, and the nerve is between
the artery and the table. Back of the malleolus, in the first
compartment, lies the posterior tibial muscle ; in the next
compartment is the flexor longus digitorum muscle ; in the
next are the artery and nerve ; and in the most posterior is
the flexor longus pollicis muscle.

Operations. — Ligation back of the Malleolus. — In this ope-
ration the position of the patient is recumbent with the thigh
abducted and the leg flexed and resting upon its outer sur-
face. The surgeon stands to the outside. Make a two-inch

302 MODERN SURGERY.

semilunar incision corresponding in its curve to the malle-
olus and half an inch posterior to its margin. Cut down
to the annular ligament, incise it, and find the artery and
venai comites. Clear the vessel and pass the needle from
behind forward (to avoid the nerve, which is here posterior
and external). Do not make the preliminary incision nearer
the malleolus than half an inch, as the sheath of the tibialis
posticus muscle would then surely be opened. In sewing
up, suture the ligament by buried sutures (PL 4, Fig. 6).

Ligation in the Middle of the Leg. — In this operation the
position is the same as in the above. Feel for the inner
border of the tibia, and make an incision four inches long
one inch behind the osseous border, parallel with it, and ex-
tending through skin and superficial and deep fascia. Draw
the gastrocnemius outward. Incise the soleus, but not the
fascia beneath the soleus ; cut this fascia, after dropping the
handle of the knife so that the blade is at right angles with
the plane of the tibia. Clear the artery; pass the needle
from without inward (PI. 4, Fig. 6).

The popliteal artery is almost never ligated in con-
tinuity. It can be tied at the upper portion of the popliteal
space, at the lower portion of the popliteal space, or at the
inner side of the thigh.

Anatomy (Fig. 62). — The popliteal artery is the continua-
tion of the femoral, and runs from the opening in the adductor
magnus muscle to the lower margin of the popliteus muscle.
This vessel runs downward and outward behind the knee-
joint and in the popliteal space. The ham or popliteal
space is a lozenge-shaped space, which above the joint is
bounded on the outside by the biceps, and on the inside
by the scmitendinosus, semimembranosus, gracilis, and sar-
torius muscles, while below the joint it is bounded externally
by the plantaris and outer head of the gastrocnemius muscles,
and internally by the inner head of the gastrocnemius muscle.
The floor of this space is formed by the surface of the femur,
the posterior ligament of the knee-joint, the end of the tibia,
and the popliteus fascia. The internal popliteal nerve runs
down the middle of the popliteal space ; it is superficial to
the vessels, in the upper half of the space external to them,
in the lower half internal to them. The external popliteal
nerve is in the outer side of the space. The popliteal vein
is between the nerve and the artery. Above the knee-joint
it is to the outside of the artery, but below the knee-joint it
is to the inner side. The artery lies deeply in the sjjace.

Ligation in Upper Third. — Patient prone. The surgeon

separates it from the nther structures, and passes the needle
fix>m without inward (Fig. 63).

Ligation in Lmver Third. — Make a three-inch vertical
incision between the heads of the gastrocnemius muscle.
Avoid the external saphenous vein and nerve, and retract
them with the popliteal nerve. Separate the artery from the
vein and pass the needle from within outward.

Femoral Artery.— The line of the femoral artery i.s
from midway between the anterior superior spine of the
ilium and the symphysis pubis to the adductor tubercle on
the inner condyle of the femur, the thigh being abducted and
resting upon its outer surface {PI. 4. Fig. 3).

Anatomy. — The femoral arterj* i.s the continuation of the
external iliac trunk; it extends from the lower border of
Poupart's ligament to the opening in the adductor magnus
muscle, and hence occupies the upper two-thirds of the
thigh. The artery' for its first five inches is superficial, lying
in Scarpa's triangle, a .space which is bounded externally by
tiie sartorius muscle and internally by the adductor longus,

304 MODERN SURGERY,

its base being Poupart's ligament and its floor being com-
posed of the psoas, iliacus, pectineus, and adductor longus
muscles, and often the adductor brevis. The artery enters
the triangle as the common femoral, but after a two-inch
course it divides into the profunda (which passes deeply),
and the superficial femoral. The latter vessel is the one
alluded to in this section.

At the base of Scarpa's triangle the vein is internal, the
artery is between, and the ner\'e is external (v. a. n.). At
the apex of the triangle the vein is internal and a little pos-
terior. At the apex of the triangle the superficial femoral
passes under the sartorious muscle and enters into Hunter's
canal, which occupies the middle third of the thigh and
which terminates at the opening by the adductor magnus
muscle. Hunter's canal is bounded externally by the vastus
internus, internally by the adductors longus and magnus, and
its roof is fascia which stretches from the adductor longus to
the vastus. In Hunter's canal the vein is behind the artery
in the upper part, but external to it in the lower part, and
is firmly attached to the artery. There may be two veins.
Inside Hunter's canal, but outside the femoral sheath, is
the long saphenous nerve, which crosses the artery from
without inward.

A way to remember the relation of the femoral vein
to the femoral artery is to recall the fact that the relation
of the vein to the artery is always contrary to the relation
of the sartorius muscle to the artery: when the sartorius
muscle is external to the artery the vein is internal, as at the
base of Scarpa's triangle ; when the sartorius muscle is cross-
ing in front toward the inside of the artery the vein is pass-
ing at the back to the outside, as at the apex of Scarpa's
triangle ; when the muscle is over the artery the vein is back
of it, as in the upper third of Hunter's canal ; and when the
ftiuscle is to the inside of the artery the vein is to the out-
side, as in the lower two-thirds of Hunter's canal. In a
ligation at the apex of Scarpa's triangle the inner edge of
the sartorius is the guide. In a ligation in Hunter's canal
the long saphenous ner\'e is the guide.

Operations. — Ligation of the Superficial Femoral at the Apex
of Scarpa's Triangle. — In this operation the position is supine
with the thigh and leg partly flexed, the thigh abducted,
everted, and rested upon its outer surface on a pillow. The
operator stands to the outside of the leg. From a point cor-
responding to the middle of the triangle, and two and a half
inches below Poupart's ligament, make a three-inch incision

DISEASES AND INJURIES OF HEART AND VESSELS. 305

in the arterial line. Cut the skin and superficial fascia. The
saphenous vein will not be seen unless the incision is internal
to the arterial line; if this vein is seen, draw it inward.
Open the fascia lata, find the inner border of the sartorius
muscle, and draw it outward. The fibers of this muscle run
downward and inward, thus distinguishing it from the ad-
ductor longus, whose fibers run downward* and outward.
Open the common sheath for the artery and vein, and then
incise the individual arterial sheath. Clear the artery and
pass the ligature from within outward (PI. 4. Fig. 4).

Ligation of the Superficial Fejtioral in Hunter's Canal, — In
this operation the position is the same as in the above.
Make a three-inch incision in the middle third, but above
the middle of the thigh, parallel with the arterial line and
half an inch internal to it (Barker). Incise the skin and
superficial fascia, look out for the internal saphenous vein,
open the fascia lata, and find the sartorius and retract it
inward, thus exposing the roof of Hunter's canal, which is
to be opened for an inch or more. Within the canal is seen
the long saphenous nerve, usually upon the sheath. Open
the sheath of the artery, clear the vessel, and pass the needle
from without inward.

Iliac Arteries* — The line of the common and external
iliac is from half an inch below and half an inch to the left
of the umbilicus to midway between the anterior superior
spine of the ilium and the pubic symphysis. The upper
third of this line represents the common iliac, and the lower
two-thirds the external iliac (PI. i, Fig. 4).

Anatomy. — The common iliac arteries arise from the aorta
opposite the left side and lower border of the fourth lumbar
vertebra, and extend to the upper margin of the right and
left sacroiliac joints, where they each bifurcate into an exter-
nal and an internal iliac. The common iliac arteries He upon
the fifth lumbar vertebra, are covered with peritoneum, and
are crossed by the ureters. In women the ovarian arteries
cross the common iliacs. The common iliac veins lie to the
right side of their respective arteries. The right common
iUac artery has in front of it, besides the peritoneum and
ureter (in women also the ovarian artery), the ileum, branches
of the superior mesenteric artery, and branches of the sym-
pathetic nerve. The left common iliac artery has in front
of it, in addition to structures common to both sides (ureter,
ovarian artery, sympathetic branches), branches of the infe-
rior mesenteric artery and the sigmoid flexure with its meso-
colon. The internal iliac artery runs from the sacroiliac joint

306 MODERN SURGERY.

to the upper margin of the great sacrosciatic foramen. It is
very rarely ligated (only in gluteal aneurysm, uncontrollable
hemorrhage from the gluteal or sciatic arteries, or to pro-
duce atrophy of the prostate gland). The external iliac runs
from the sacroiliac joint along the pelvic brim, upon the inner
edge of the psoas muscle, to Poupart's ligament. The exter-
nal iliac vein is internal to the artery. On the right side high
up, it passes behind the artery. The external iliac arter>' has
in front of it peritoneum and subserous tissue (Abemethy's
fascia). The ileum crosses the right, and the sigmoid flexure
the left, external iliac. The genital branch of the genito-
crural nerve crosses the artery low down, and the circumflex
iliac vein crosses it just before it terminates in the femoral.
The spermatic vessels and the vas deferens in the male, the
ovarian vessels in the female, lie upon it, low down. Some-
times the ureter crosses it high up. We find the spermatic
vessels in the male and the ovarian in the female l>ing for
a time upon the inner side of the artery.

Ligation of the Iliac by Abdominal Section. — The best
method for ligating the common, the external or the in-
ternal iliac is by abdominal section. The patient is placed
in the Trendelenburg position. The abdomen is opened
in the midline below the umbilicus. The intestines are
lifted toward the diaphragm, and are held up by gauze
pads. The edges of the incision are retracted. Select the
vessel you wish to tie and decide where you wish to apply
the ligature. Open the peritoneum posteriorly and pass the
aneurysm needle. In ligating either common iliac, pass the
needle from right to left. In ligating the external iliac, pass
the ligature from within outward. In ligating the internal
iliac pass the needle from within outward. It is not neces-
sary- to suture the posterior layer of peritoneum. The abdo-
men is closed without a drain. In these operations be sure
and push the ureter out of the way. This method of oper-
ating is endorsed by Dennis, Hearn, Marmaduke Shield,
Mitchell Banks, and others.

Ligation of the External Iliac by Abernethys Extraperito-
neal Method (PI. I, Fig. 4). — The position of the patient is
recumbent with the thighs extended during the first incisions,
but in the latter stages of the operation they are flexed a little
to relax the abdominal structures. The operator stands to
the outside. The surgeon will find the artery along the psoas
muscle. Mark a j)oint one inch above and one inch external
to the middle of Poupart's ligament, and another point one
inch above and one inch internal to the anterior superior iliac

I J>/SEAS£S AND INJURIES OF HEART AND VESSELS. 307

I spine (Barker). Join these two points by a curved incision

I four inches long and convex downward. Cut the skin, the

fat, the two oblique and the transversahs muscles; open the

transversaUs fascia, draw the peritoneum inward by a broad

ractor, and look for the artery along the pelvic brim. The

ft-anterior crural nerve is seen external to the artery, the vein

H internal to the artery, and the genitocrural nerve is upon

I'tiie artery. Clear the artery near its middle and pass the

308 MODERN SURGERY,

ligature from within outward. In Sir Astley Cooper's ligation
the inguinal canal is laid open.

The Gluteal Artery. — This vessel is a continuation of
the posterior division of the internal iliac. It emerges from
the pelvis at the upper border of the pyriformis muscle. It
rests upon the glutaeus minimus and divides into three
branches, and is covered by the glutaeus maximus muscle.
The superior gluteal nerve lies inferior to the artery (Fig. 64).

Ligation. — Patient is prone. The surgeon standis to the
outside. The incision corresponds to a line drawn from the
posterior superior iliac spine to the upper border of the great
trochanter. Divide the skin, fascia, glutaeus maximus muscle,
and fascia over the glutaeus medius, retract the glutaeus medius
upward. Feel for the great sacrosciatic foramen, and at this
point the artery is found above the pyriformis muscle. Clear
the vessel and pass the needle from below upward (see
Kocher).

The Sciatic Artery. — This artery is the larger of the
terminal branches of the anterior division of the internal iliac
artery. It passes to the lower portion of the great sacrosci-
atic foramen, lying back of the internal pudic artery, and rest-
ing upon the sacral plexus and pyriformis muscle (Gray).
It leaves the pelvis between the pyriformis and coccygeus
muscles and passes downward between the ischial tuberosity
and great trochanter. It is covered by the glutaeus maximus
muscle, rests upon the gemelli, internal obturator and quad-
ratus femoris muscles, and has the great sciatic nerve exter-
nal to it, and the small sciatic nerve external and posterior
(Fig. 64).

Ligation. — Patient lies prone. Surgeon stands to outside.
Incision " corresponds to the middle two-thirds of a line ex-
tending from the posterior inferior iliac spine to the base of
the great trochanter." * Cut the skin, fat, fascia, and glutaeus
maximus muscle. Find the artery at the lower border of the
pyriformis muscle and trace it to its point of emergence from
the pelvis. Pass the ligature from without inward.

Internal Pudic Artery. — Is one of the terminal branches
of the anterior trunk of the internal iliac. It runs to the
lower margin of the great sacrosciatic foramen, and leaves
the pelvis between the pyriformis and coccygeus muscles,
crosses the ischial spine and again enters the pelvis by the
lesser sacrosciatic foramen. The vessel is accompanied by
the internal pudic nerve (Fig. 64).

Ligation. — Position and incision as in ligation of sciatic.

* Kocher's Operative Surgery^ by Stiles.

DISEASES AND INJURIES OF BONES AND JOINTS, 309

The artery is found below the ischial spine. Pass the needle
from below upward to avoid the nerve.

XIX. DISEASES AND INJURIES OP BONES AND

JOINTS.

I. Diseases of the Bones.

Atrophy of bone is a diminution in the amount of bony
matter without change in osseous structure. It arises from
want of use (as seen in the wasting of the bone of a stump)
or from pressure (as seen in the destruction of the sternum
by an aneurysm of the aorta). Eccentric atrophy is the
thinning of a long bone from within, the outer surface
being unchanged. It is usually a senile change. Concentric
atrophy means a thinning of the outer surface of the shaft,
causing a lessened diameter. It is usually linked with eccen-
tric atrophy.

Hypertrophy of bone may be due to increased blood-
supply (as is seen in chronic epiphyseal inflammation), the
bone growing much more than does its fellow. It may arise
from excessive use or from strain, as is seen in the increased
size of the fibula when the tibia is congenitally absent
(Bowlby).

Tiunors of Bone. — Bones give origin to both innocent
and malignant tumors. Myeloid sarcoma takes origin in
the endosteum and expands the bone. The fasciculated
sarcoma is a periosteal growth. Besides these growths we
find osteomata, chondromata, and secondary deposits of can-
cer and sarcoma. Primary cancer of bone does not exist.
A bone may become cystic, and occasionally the cysts are
due to hydatids. Gummata are the commonest growths
found springing from bone.

Actinomycosis of Bone. — Most usual in the jaw, but
may attack the orbit, ribs, sternum, or limbs (p. 183).

Tubercle of Bone. — Tends especially to appear in the
cancellous ends of long bones. Is apt to caseate and destroy
large amounts of bone. The bone does not sclerose, but
undergoes alterations of an osteoporotic nature (see p. 154).

Osteitis, Periostitis, and Osteoperiostitis. — Ostei-
tis, or inflammation of bone, may be due to traumatism,
to a constitutional malady or diathesis, to the extension of
inflammation from some other structure, or to infection. In
inflammation of bone the exudation flows into the Haver-
sian canals and spaces and the canaliculi, the corpuscles of

3IO MODERN SURGERY,

the exudate and the bone-corpuscles proliferate, embryonic
tissue forms, the bone undergoing thinning (rarefaction), not
because of pressure, but because of absorption by voracious
leukocytes and osteoclasts. This process of rarefaction en-
larges all the bony spaces, and by destroying septa throws
many of the spaces into one. If the surface of a bone in-
flames, the periosteum will more or less be separated by the
exudation and the bone will be covered with little pits or
erosions. Inflamed bone is so soft that it can readily be cut
with a knife.

Osteitis may terminate in resolution or it may terminate in
sclerosis, the exudate being converted first into fibrous tissue
and next into dense bone with only a few small cancellous
spaces. If the exudation is under the periosteum, the bone
will be thickened at this point, bone stalactites marking the
points of passage of the vessels. Osteitis may terminate in
suppuration, this condition being known as ^^ caries y In
tubercular osteitis caseation of the inflammatory products
is very apt to arise (tubercular or strumous caries). Acute
osteitis may terminate in necrosis. Osteitis is usually asso-
ciated with more or less periostitis. A simple acute peri-
ostitis without involvement of the bone can arise from trau-
matism, but in all severe cases of periostitis, in all chronic
cases, in all cases due to syphilis, rheumatism, measles, scar-
latina, or enteric fever the bone is involved at the same
time or subsequently. In syphilitic states gummatous de-
generation frequently ensues.

Symptoms of Osteitis and Osteoperiostitis. — As a
chronic process the symptoms o{ osteitis are commonest in the
femur. Its history usually exhibits a record of a cold or an
injur)^ Pain is severe, boring or aching in character, deep-
seated, worse at night, and aggravated by a dependent po.sition
of the part. The symptoms closely resemble those of perios-
titis, with which disease it is almost sure to be linked. Ten-
derness exists on percussion, and sometimes on pressure.
Subperiosteal swelling, fusiform in shape, is noted ; cutaneous
edema and discoloration are observed if a suj>erficial bone
be involved. In syphilis, atrophic osteitis may attack the
cranial bones and produce softening or even perforation, or
osteophytic osteitis may arise, exostoses being formed
Osteoperiostitis may be acute or chronic, circumscribed or
diffused, and may terminate in resolution, organization, or
suppuration. It arises from cold, blows, wounds, strains,
the spread of adjacent inflammation, specific febrile maladies,
pyogenic infection, syphilis, rheumatism, or tubercle. The

DISEASES AND INJURIES OF BONES AND JOINTS. 3 1 1

symptoms are pain (which is worse at night and which is
aggravated by motion, pressure, or a dependent position),
swelling, edema, and discoloration of the soft parts. Pain
in the syphilitic form is not so severe as in other varieties.
Acute necrosis or diffuse periostitis^ a septic inflammation
of bone and periosteum, is commonest in boys about the
age of puberty. It is usually due to cold, a specific fever,
or injury, and generally affects the tibia or femur; the symp-
toms locally are severe; redness, swelling, and pain are
marked ; constitutionally there are rigors, fever, or convul-
sions. Necrosis is apt to result. Pyemia is common. Some
fever always exists. In simple acute periostitis a swelling is
felt upon the osseous surface. The swelling is firmly fixed
and is very tender, but the bone itself is not enlarged. There
is some local heat, discoloration, often fever, and the patient
complains of an aching pain, which is worse at night.

Treatment of Osteitis and Osteoperiostitis. — In syphilitic
forms the treatment consists of rest, elevation of the part,
the local use of iodin and mercurial ointment, and bandag-
ing. Specific treatment is by the stomach or hypodermati-
cally. Operation is rarely justifiable. In other forms, if
the case be recent and severe, put the patient to bed, place
the limb in a splint and elevate it, apply leeches, cold, and
lead-water and laudanum, use a bandage, and order salines
and iodid of potassium. Morphin is used for pain. If these
means fail, order counterirritation by iodin and blue oint-
ment or blisters, and use heat locally. In severe cases take
a tenotome and slit the periosteum subcutaneously to
relieve tension; this procedure often instantly relieves the
pain. Some cases demand a longitudinal osteotomy, which
is performed by taking Hey's saw and dividing the bone
longitudinally into the medullary canal. If pus forms, drain
at once.

Diffuse osteoperiostitis requires early and free incisions,
antiseptics, drainage, rest and elevation of the limb, and
strong supporting and stimulating treatment. Amputation
is sometimes demanded, as when the patient grows weaker
and weaker even after incision, and when a joint is seriously
involved. If the necrosis affects the entire shaft, which
separates from its epiphyses, and new bone has not yet
formed from the periosteum, make a subperiosteal resection
of the shaft.

Chronic perioBtitis is usually syphilitic. A 7iode is a
chronic inflammation of the deep periosteal layers. Nodes
occurring early in the secondary stage remain soft and soon

312 MODERN SURGERY.

pass away, but those occurring two years or more after
infection are apt to cause a bony deposit. A node may
suppurate, leaving a sinus at the bottom of which is a piece
of dead bone. Gumma of the periosteum is one form of
node which is apt to produce caries or necrosis.

Osteoplastic periostitis accompanies chronic osteitis and
causes the deposit of new bone which undergoes sclerosis.
The chief symptom is aching pain, which is worse when
warm in bed, and is aggravated by damp and wet. A
swelling is found at the seat of pain (often over the tibia,
ulna, clavicle, or sternum). The soft parts are uninflamed
and move freely unless softening or suppuration has occurred
Tenderness is manifest.

Treatment, — For the nodes of early syphilis use mercurial
treatment ; for the nodes of late syphilis give mercury and
large advancing doses of iodid of potassium. Blisters, blue
ointment, and iodin used locally, and subcutaneous division
of periosteum, are of value. If suppuration occurs, open
antiseptically.

Abscess of bone is due to tubercular infection. It
is always chronic, never acute. A very acute inflamma-
tion, such as is induced by pyogenic organisms, causes
acute necrosis rather than an acute abscess. After a chronic
abscess begins mixed infection may take place, the seat
of abscess being a point of least resistance. Chronic ab-
scess of bone was first described by Sir Benjamin Brodie,
and is often called " Brodie's abscess." It occurs in the
cancellous structure of the ends of bones — usually in the
head of the tibia, sometimes in the femur or humerus. The
cause of bone-abscess is injury which induces osteitis ; bone-
rarefaction forms a cavity, the inflammatory products case-
ate and sometimes suppurate, and the surrounding bone
thickens and hardens because of growth from the perios-
teum. The abscess is apt to break into a joint, as the joint-
surface is not covered by periosteum and no barrier of bone
is there formed. Brodie's abscess may induce necrosis.

Symptoms. — The symptoms are like those of osteo-
periostitis, only they arc localized and persistent These
symptoms are thickening of bone and soft parts, edema
and discoloration of skin, tenderness, constant pain (sub-
ject to violent exacerbations and made worse by motion,
pressure, or a dependent position), and attack after attack
of synovitis in the nearest joint. Fever and sweats may be
noted.

Treatment. — In treating bone-abscess, trephine the bone

DISEASES AND INJURIES OF BONES AND JOINTS, 313

at the point of the greatest tenderness, and if the abscess is
missed, follow the advice of Holmes and perforate the wall
of bone with the trephine, opening in several directions to
discover the pus. It is often easy to open into the abscess
with a chisel or gouge. If the abscess opens into a joint,
trephine the bone and open and drain the joint. After
opening the cavity gouge its walls clean, dry with gauze,
touch with pure carbolic acid, and pack with iodoform gauze.

Caries is suppurative osteitis, a molecular osseous de-
struction. In some cases caries is a name given to sup-
purative osteitis, in others to tubercular osteitis, in still
others to gummatous osteitis. Osteitis is apt to become
purulent when the bone is exposed to the air, when rest is
not secured, when the health of the individual is below nor-
mal, when a foreign body such as a bullet is in the bone, or
when tubercle or syphilis exists. When caries arises, the
softened and granulating bone breaks down and is dis-
charged through a sinus. After drainage is secured or-
ganization, sclerosis, and healing result. In these cases
new bone usually forms, and a cure results.

Tubercular caries, due to caseation of the products of an
osteitis in a tubercular subject, shows no tendency to self-
cure, no organization or sclerosis takes place and no new
bone forms. The interior of bones, especially of the carpus
and tarsus, being entirely softened and destroyed, thin shells
only are left.

Caries necrotica is a condition in which small but visible
portions of soft and dead bone are cast off; caries sicca is
molecular death of bone without suppuration.

The caseating masses in tubercular caries contain the
tubercle bacillus. If a tubercular collection is evacuated
and infection with pus organisms occurs, genuine suppuration
takes place, and constitutional infection causes suppurative
fever, and may cause death. Purulent osteitis may affect
any part of any bone, but caseous osteitis (tubercular
caries) tends to arise especially in cancellous structures
(heads of long bones, vertebral bodies, ribs and sternum,
and bones of the carpus and tarsus). Tubercular osteitis
of the shaft of a long bone occasionally, but rarely, arises.
Tubercular osteitis is apt to cause tubercular disease in an
adjacent joint. Cold abscesses are frequently due to tuber-
cular osteitis.

Symptoms. — In the beginning the evidences of caries
are usually those of osteitis, but the first sign noted may
be a fluctuating swelling due to pus or to caseated tubercles.

3 1 4 MODERN SURGE R K

After a time, at any rate, a fluctuating swelling is discovered
If not opened, the abscess breaks, voids its contents, and
leaves a sinus from which runs a purulent matter which
after a time becomes thin, reddish, and irritating to the skin,
contains small portions of gritty bone, and has a foul smell.
The opening of the sinus fills up with edematous granu-
lations. A probe introduced to the bottom of the sinus
finds bone which is sieve-like (worm-eaten), and which on
being struck gives a muffled note rather than the clear,
sharp note of necrosis ; the bone is rough, is bared, and is so
soft that the probe can usually be stuck into it In old cases
of caries amyloid disease may arise.

Treatment. — If syphilis exists, give iodid of potassium in
advancing doses and a mild mercurial course. If tubercle ex-
ists, give iodid of iron, arsenic, cod-liver oil, and nourishing
foods, and recommend a change of air. Locally, in all cases,
insist on rest and at once secure drainage, enlarging the open-
ing if necessary and inserting a tube, and even making addi-
tional openings ; syringe often with antiseptic fluids and dress
antiseptically. If the case is seen before the abscess has
opened, open it under strict antiseptic precautions. When the
case is found to be chronic there arises the question of opera-
tion. Incomplete operations are worse than useless, for they
may cause pyemia, and if the case be tubercular may inaugu-
rate systemic diffusion of the infection. If the gouge is used,
try to remove a// carious bone. The diseased bone is white,
crumbles up, and does hot bleed ; the non-carious bone is
pink and vascular. Scrape away all granulations ; swab out
the cavity with pure carbolic acid and pack it with iodoform
gauze. Instead of gouging away bone, there may be used
the actual cautery, sulphuric acid, or hydrochloric acid. In
severe cases excision is required, and in some very rare cases
amputation may be necessary'. Caries of the .spine is con-
sidered under Diseases of the Spine.

Necrosis is the death of visible portions of bone from
circulatory impediment. It is analogous to gangrene. The
cause of necrosis is injur>' (such as the tearing off of perios-
teum) which deprives the bone of blood. Inflammation of
the periosteum further lessens the nutrition. Acute inflam-
mation in bone causes necrosis, the excessive exudation in
the canals and spaces obliterating the blood-vessels by
pressure. The occlusion of vessels by septic thrombi may
lead to necrosis, or the direct action of toxins may first
inflame and finally destroy a portion of the bone. A thin
shell of bone only may necrose from p>eriosteal separa-

DISEASES AND INJURIES OF BONES AND JOINTS. 315

tion, or an entire shaft may die from acute osteomyelitis
or diffuse infective periostitis. Osteomyelitis is the most
usual cause of necrosis. Necrosis is most frequently met
with in the diaphyses of the long bones, caries in the heads
of the bones. A sequestrum may form in a vertebral body,
in the carpus, or in the tarsus, but rarely does ; hence, we
conclude that sequestra do not often result from tubercular
osteitis. A fragment of dead bone is a foreign body; the
healthy bone adjacent to it inflames, softens, and granulates,
and this line of granulation, like the line of demarcation of
gangrene, separates the dead part from the living, the white
dead bone being surrounded by the red zone of granulation-
tissue. A bit of dead bone is called a " sequestrum," and
Nature tries to cast it off A superficial sequestrum is known
as an " exfoliation."

Nature's method of casting off a sequestrum is as follows :
suppuration takes place at the line of demarcadon, osteitis
extends for a considerable distance around this line, the peri-
osteum shares in the inflammation, and new bone forms. A
cavity thus forms within by suppuration, and a box or case
forms without by ossification, the now entirely loosened se-
questrum being so encased that it cannot escape. The pus
finds its way through the new bone, and there is presented
the condition so often seen by the surgeon — namely, a case
of new bone known as the"involucrum." a cavity containing
pus and the dead fragment or sequestrum, and a discharging

FiC- 65.— Diifnm [1lu»nlli>| Iht ronrallon of a t«iii
bone: C. granulalioni IJninginnilucniin; D,i

sinus or "cloaca" (Fig. 65). Nature may eventually get
rid of the fragment, but the surgeon should not wait.

When a portion of the bone surrounding the medullary
canal dies the condition is called "central necrosis." In
some rare cases necrosis occurs without apparent suppura-

3 1 6 MODERN SURGER Y.

tion, a painless swelling of bone simulating sarcoma. Mer-
cury is a Cause of necrosis. The fumes of phosphorus may
cause necrosis of the lower jaw in those with decayed teeth.
Osteomyelitis is the usual cause of necrosis. It may be pro-
duced also by frost-bites and burns. Many fevers (measles,
typhoid, scarlet fever, etc.) are occasionally followed by ne-
crosis. Syphilis and tubercle are occasional causes.

Symptoms. — The symptoms of necrosis are at first those
of osteitis or osteomyelitis. The abscess, when formed, opens
of itself or is opened by the surgeon, and a sinus or sinuses
form in the soft parts as happens in caries. A probe intro-
duced into the sinus strikes upon hard bone with a clear,
ringing note, and often finds a sinus or sinuses in the bone.
In superficial necrosis the discharge is slight and the probe
shows the limitations of the disease. In extensive necrosis
the discharge is profuse, much new bone forms, several sinuses
form far apart, and the probe must pass a considerable thick-
ness of new bone before it finds the bit of dead bone. The
surgeon should not operate until the dead bone is separated
from the living, until a line of demarcation forms, and until
the sequestrum is loose. In youth dead bone loosens quickly,
but in old age slowly. An exfoliation becomes loose sooner
than the sequestrum of central necrosis. In diffuse periostitis
the necrosed shaft loosens quickly. Necrosed portions of
the upper extremity loosen more rapidly than those of the
lower. Chilton states that in the young adult two or three
months will be required to loosen a necrosed fragment in the
lower extremity, and from six weeks to two months in the
upper extremity. A loose sequestrum may be moved by the
probe, and when struck gives a hollow note. In old cases
there is always danger that amyloid disease may arise.

Treatment. — An exfoliation is removed as soon as it is
loose, the seat of trouble is touched with pure carbolic acid
and packing of iodoform gauze is inserted. The treatment
of central necrosis comprises free incisions for drainage,
antiseptic dressing, frequent cleansing, rest, good food,
stimulants, and tonics. When the sequestrum becomes
loose, break through the involucrum with the chisel, gouge,
and rongeur, remove the dead bone with the forceps, clean
the cavity with pure carbolic acid and pack with iodoform
gauze. This operation is known as ** sequestrotomy." If
much of a gap is left by the operation, try to fill this gap
by taking flaps of skin and fastening them to the bottom, by
breaking the edges of the involucrum and turning them in,
or by inserting bone-chips. These chips, which are obtained

DISEASES AND INJURIES OF BONES AND JOINTS, 317

from the compact part of the tibia or femur of an ox, are
decalcified by being placed for a couple of weeks in a 10 per
cent, aqueous solution of hydrochloric acid (which is renewed
every day) ; they are well washed in a weak alkali and then
in water, are cut into strips, are soaked for two days in a
I : 1000 sublimate solution, and are kept in a saturated ethe-
real solution of iodoform. The cavity is made sterile and is
well dusted with iodoform, the bone-chips are dried and in-
serted into the cavity, a capillary drain is employed, the peri-
osteum is stitched over the opening, and so are the soft parts ;
but if this cannot be done, iodoform packing is used to keep
the chips in place. This method we owe to the genius of Senn.
Attempts have been made to fill bone-cavities with gutta-
percha, plaster-of-Paris, etc. (Martin). The difficulty is to
completely asepticize the walls of the cavity. Dressman has
advised for this purpose the use of boiling oil, but it is apt
to cause superficial necrosis. Schleich uses formalin-gelatin
to fill bone-cavities. In some cases of extensive necrosis due
to diffuse infective osteoperiostitis or to osteomyelitis exten-
sive resection or even amputation may be necessary.

Actlte difiiise OSteomyelitiSi a diffuse inflammation of
bone and marrow, is due to infection with pyogenic organisms
(staphylococcus pyogenes aureus and streptococcus pyo-
genes), or to mixed infection of the pyogenic organisms with
the organisms of typhoid fever, of tubercle, etc. It may
arise from a wound, such as a compound fracture, a gunshot-
injury, or an amputation. It may occur when the infection
has been by way of the blood. The causative organisms
may enter the circulation through the lymphatic system or
may pass directly into the blood from a focus of suppuration
in the skin, in the subcutaneous structures, or some deeper
part. The organisms may have been taken into the system
by the tonsil or respiratory organs (Kraske), the intestinal
canal (Kocher), the genito-urinary tract, or from excoriations,
bruises, or small wounds in the skin (Warren). The exan-
themata strongly predispose to osteomyelitis. Typhoid fever,
typhus fever, small-pox, and malarial fever, lessen the vital
resistance of marrow. Some observers teach that the ty-
phoid bacillus is pyogenic (Frankel), but others think that
the toxins of the typhoid organism weaken the marrow and
suppuration arises because of mixed infection with pyogenic
bacteria (Park and Klemm). Keen insists that the typhoid
bacillus has occasionally pyogenic power.* In osteomyelitis
from wound of the endosteum the medulla and cancellous

* Surgical Complications and Sequels of Typhoid Ft^ver^ by W. W. Keen.

3l8 MODERN SURGERY,

tissue inflame and suppurate. The entire length and thickness
of the shaft may be involved, and the periosteum becomes
infiltrated, detached, and retracted from the edges of the
bone-wound. The soft tissues around the bone also inflame
and sometimes slough. More or less necrosis is inevitable.

The symptoniB of acute diffuse osteomyelitis from wound
are — a very severe boring, gnawing, aching f)ain ; great ten-
derness ; deep swelling of the soft parts over the bone ; the
skin is healthy early in the case ; a profuse offensive purulent
discharge containing bone-fragments and tissue-sloughs is
poured out ; the periosteum is red, thick, and separated ; a
("ungating foul mass protrudes from the medullary canal;
rigors, sweats, and fever point to septicemia or pyemia.

Treatment. — In treating acute diffuse osteomyelitis expose
the interior of the bone, curct the medullary cavity, swab it out
with pure carbolic acid, and pack it with iodoform gauze ;
drain ; apply antiseptic dressings ; frequently cleanse ; and use
strong supporting treatment. When the .sequestrum loosens,
it should be removed. Some cases require amputation.

Acute Epiphysitis. — Acute osteomyelitis without a
wound is called ** acute infantile arthritis " or ** acute epiph-
ysitis." It affects the young, especially children of from
one to two years of age, but occasionally arises in older
persons (ten to fourteen years). It begins at the epiphyseal
line. A strain may occur at this point, inflammation follows,
and a hospitable welcome is extended to micro-organisms
which are contained in the body-fluids and which pass
through this area. In some cases chilling of the body is
the predisposing cause. In some patients no history of
injury is obtainable; a preceding illness, especially a specific
fever, being responsible for the weakening of tissue-resistance.
New tissues arc always more susceptible to infection than
old tissues, and one of the most susceptible of new tissues is
the young bone at the end of the diaphysis. Septic organ-
isms may lodge in this area, multiply there and produce
systemic poisons. The femur and tibia are the bones most
often attacked, the hip-joint or knee-joint being secondarily
involved ; the humerus, tibia, radius, ulna, and other bones
may be attacked ; the shoulder-, ankle-, or elbow-joint may
become secondarily affected. The youngest bone around
the ossific centre first inflames, necrosis takes place, a small
sequestrum forms, and the pus around the sequestrum is apt
to make a cloaca and empty into the adjacent joint, lighting
up a suppurative inflammation of the articulation, and into
the medullary canal, causing diffuse osteomyelitis.

DISEASES AND INJURIES OF BONES AND JOINTS. 319

The symptoins of acute epiphysitis usually come on sud-
denly^ and especially at night, and the attack may be so acute
as to cause death by systemic poisoning before a diagnosis
is arrived at. The disease is generally ushered in by a chill,
which is followed by septic febrile temperature. The history
will sometimes contain the statement that the patient was
suddenly chilled after being overheated (sitting in a draft or
in a cellar on a hot day, possibly swimming when very
warm, etc.). There is violent, burning, aching pain in the
bone and great tenderness near the joint; the soft parts,
which at first are healthy in appearance, after a time dis-
color, swell, and present distended veins ; the neighboring
joint swells, and may become filled with pus; the peri-
osteum and the shaft are involved for a considerable dis-
tance; each epiphysis may become affected, the shaft be-
tween being comparatively uninvolved, and the epiphyses
may separate, displacement and shortening taking place. This
disease is often mistaken for rheumatism because of the joint-
swelling, occasionally for typhoid fever because of the fever,
and in some cases for erysipelas because of the redness of
the skin. It gives a very grave prognosis. Sometimes an
epiphysitis shows milder symptoms and is slower in progress
(subacute). These cases are very often mistaken for rheu-
matism. But in rheumatism the joint is the part involved
from the beginning, while in epiphysitis the joint is involved
secondarily after obvious evidence of inflammation well clear
of the articulation. Further, the symptoms of rheumatism
can be rapidly improved by the use of the alkalies or the
salicylates.

Treatment. — In treating acute epiphysitis do not wait for
fluctuation, but incise at once ; break through the bone at
one or more points with a gouge or chisel ; curet ; chisel
away the diseased bone, and if necessary curet the medul-
lary canal ; irrigate with corrosive-sublimate solution ; swab
out with pure carbolic acid ; use iodoform plentifully ; pack ;
drain the joint if it is involved ; employ rest, anodynes, and
strong supporting treatment. Remove dead bone subse-
quently when it becomes loose. Amputation may be
required.

Chronic osteomyelitis is usually linked with osteitis.
It may eventuate in osteosclerosis with filling up of the
medullary canal, or in limited suppuration, or in caseation
of the cancellous tissue (Brodie's abscess), or in necrosis.
A tubercular inflammation is one form of chronic osteo-
myelitis. Syphilis, typhoid fever, etc., may cause it.

320 MODERN SURGERY.

Osteomalacia, or Mollities Ossium. — In this disease

the bones are partly decalcified, and consequently soften and
bend. Many bones are usually involved. It is commoner
beyond than before middle age, though it may occur in
infancy ; it is commoner in women than in men, and preg-
nancy seems to bear more than a casual relation to its pro-
duction. In osteomalacia the medulla increases in bulk
and becomes more fatty, and the osseous matter is absorbed
gradually, first from cancellous tissue and then from the
compact tissue. Some observers believe this curious con-
dition is due to lactic acid in the blood.

Symptoms. — The symptoms of osteomalacia are as fol-
lows : many points of pain which are often thought to be
due to rheumatism ; deformities from twisting and bending
of bone ; and a large excess of calcium salts in the urine.
This disease lasts a number of years, but usually causes
death from exhaustion, though some few cases are arrested
or cured. Fractures occur from very slight force.

Treatment. — In treating osteomalacia in women insist
that pregnancy must not occur. Put braces and supports
upon distorted limbs to prevent fracture. Advise good air,
hygienic surroundings, and nourishing food. Among the
medicines that can be used may be mentioned cod-liver oil,
lime salts, preparations of phosphorus, and bone-marrow.
In women the removal of the ovaries sometimes cures. It
has been asserted that the production of anesthesia by
means of chloroform is of great benefit.

Acromegaly. — This is a disease which causes progres-
sive and often great enlargement of both the bones and soft
parts of the extremities, which enlargement is symmetrical.
The lower jaw projects in advance of the upper jaw, the
nose becomes prominent and thick, the supra-orbital ridges
are accentuated, and the costal cartilages and inner ends of
the clavicles become protuberant. I^ter the larynx, ribs,
shoulder-blades, and vertebrae become involved, and the
back becomes markedly humped (cervicodorsal hump). The
hands and feet are affected in advanced cases. As a rule,
the thyroid gland is enlarged, and a postmortem examina-
tion may detect an enlarged pituitary gland. Severe and
uncontrollable headache is sometimes a distressing feature
of the disease. Treatment is futile. The disease slowly but
surely causes death.

I/Contiasis Ossium (Virchow's Disease). — This is a

hypertrophy limited to the facial and cranial bones, which is
symmetrical, and which begins, as a rule, in the superior

DISEASES AND INJURIES OF BONES AND JOINTS. 32 1

maxillae. The hypertrophy progressively increases, causes
difficulty of mastication, and is accompanied by headache.
It produces distinct deformity of the jaw like a tumor,
whereas acromegaly enlarges all of the proportions of a
bone. Treatment is not satisfactory, as a rule. Recently
Horsley has obtained amelioration by operating and remov-
ing masses of bone.

2. Fractures.

Definition. — A fracture is a solution, by sudden force,
of the continuity of a bone or of a cartilage. Clinically,
under this head are placed epiphyseal separations and the
tearing apart of ribs and their cartilages.

Varieties of Fractures.— The varieties of fractures are
as follows :

Siffiple fracture is a subcutaneous fracture, or one in which
no open wound admits air to the seat of bone-injury. This
Corresponds to a contusion of the soft parts.

Compound fracture is an open fracture, or one in which
an open wound admits air to the seat of bone-injury. This
corresponds to a contused or lacerated wound of the soft
parts.

A primary compound fracture is one in which the breach
in the soft parts is occasioned at the time of the accident,
either by the direct violence of the injury or by the forcing
of a bone or bones through the tissues.

A secondary compound fracture is one in which the breach
in the soft parts occurs after the accident, either from slough-
ing of damaged tissues, from ulceration because of the press-
ure of ill-adjusted fragments, or from the forcing of a bone
or bones through the soft parts because of rough handling,
neglect, or the tossing of delirium.

Complicated fracture is a fracture plus the complication
of a joint-injury, arterial or venous damage, or injury to
the nerves or soft parts. When a fractured rib injures the
lung or when a broken vertebra damages the cord we have
a complicated fracture. The term is a bad one, as it con-
veys no definite meaning, and is no more justifiable than it
would be to speak of " complicated pneumonia " or " com-
plicated typhoid," for we should always give a name to the
complication in any case. It should be remembered that
damage to the soft parts not sufficient to admit air to the
seat of fracture does not make the case a compound fracture,
but rather complicates a simple fracture. Remember also
21

322 MODERN SURGERY,

that even superficial areas of tissue-destruction must be
treated antiseptically, otherwise absorption of pus-elements
and their deposition at the seat of injury may cause diffuse
osteomyelitis.

Complete fracture is that which extends through the whole
thickness of a bone or entirely across it.

Inco7nplete fracture is that which extends only partially
through the thickness of a bone or only partially across it.

A iifiear, hair, capillary, or fissured fracture, or a fissure,
is a crack in a bone with very little separation of the edges.
This is an incomplete fracture, but may be associated with a
complete break.

A green-stick, hickory-stick, ivillow, or bent fracture is a
true incomplete break. It is commonest in the forearm or
clavicle, it arises from indirect force, and it is very rare after
the age of sixteen. It is called ** green-stick " because the
bone breaks like a green stick when forced across the knee,
first bending and then breaking on its convex surface. The
bone, being compressed between two forces, bends, and the
fibers on the outer side of the curve are pulled apart, while
those on its concavity are not broken, but are compressed
In correcting the deformity the fracture is apt to be made
complete. The permanent bending of a bone without a
break may possibly occur in youth.

Depression-fracture occurs when a portion of the thickness
of a bone is driven in by crushing. Fracture by depression
is a result of the bending in of a bone (as the parietal), a
fragment breaking off from the side toward which the bone
is bending. A depressed fracture is complete, not incom-
plete, and by this term is meant an injury in which a frag-
ment of the entire thickness of the bone is driven below the
level of the surrounding surface.

Splinter- and Strain-fracture, — The breaking off of a
splinter of bone (splinter-fracture) or of an apophysis con-
stitutes an incomplete fracture. A strain upon a ligament
or a tendon may tear off a shell of bone, and this injury is
the " strain-fracture " of Callender.

Longitudinal fracture is a fracture whose line is for a con-
siderable distance parallel, or nearly so, with the long axis
of the bone. This is common in gunshot-injuries.

Oblique fracture is a fracture whose line is positively
oblique to the long axis of the bone. Most fractures from
indirect force are oblique.

Transverse fracture is a fracture whose line is nearly trans-
verse to the long axis of the bone (no fracture is mathemati-

DISEASES AND INJURIES OF BONES AND JOINTS, 323

cally transverse). The cause is often but not invariably direct
force. The ^^ fracture en rave " (radish-fracture, so called be-
cause the bone breaks as does a radish) is transverse at the
surface, but not within.

Toothed or dentate fracture is a form of fracture in which
the end of each fragment is irregularly serrated and the frag-
ments are commonly locked together ; hence the deformity
is hard to correct. Most of the simple fractures from direct
force are serrated.

Wedged'Shaped^ V-sltaped, cuneated, or cuneiform fracture
(" fracture oblique spiroide," " fracture en V " of Gosselin,
" fracture en coin ") is a fracture whose line has the shape of
a V, which may be entire or may want the point. It occurs
at the articular extremity of a long bone, and a fissure usu-
ally arises from its point and enters the joint. If complete,
it is a "comminuted fracture."

T'Skaped fracture is a fracture which presents a transverse
or oblique line and also a longitudinal or vertical line. It
occurs at the lower end of either the humerus or femur, the
transverse line being above, and the vertical line (intercon-
dyloid) between, the condyles. If complete, it is in reality a
form of comminuted fracture.

Multiple or composite fracture is a condition in which a
bone is broken into more than two pieces, the lines of frac-
ture not intercommunicating, or a condition in which two or
more bones are broken. Multiple fractures of one bone are
divided into double, treble, quadruple, etc.

Comminuted fracture is a condition in which a bone is
broken into more than two pieces, the lines of fracture inter-
communicating. The bone may be broken into many small
fragments, may present much splintering, or may actually be
ground up.

Impacted fracture is one in which one fragment is driven
into the other and solidly wedged.

Fracture with crushing, or penetration, is a fracture in which
one bone is driven into the other, the encasing bone being so
splintered that the impacting bone is not firmly held.

Pathological, spontaneous, or secondary fracture is one
occurring from a very insignificant force acting on a bone
Tendered brittle by disease.

Ununited fracttire is a term used to designate a fracture
in which bony union is absent after the passage of the period
normally necessary for its occurrence.

Direct fracture is one occurring at the primary point of the
application of force.

324 MODERN SUR GER Y.

Indirect fracture is one occurring at a point distant from
the area of the primary application of force.

Stellate, or starred fracture (fracture par irradiation) is one
in which several fissures radiate from a center. If the frac-
ture be complete, it is in reality a form of comminuted
fracture.

Helicoidal, spiral, or torsion fracture is a fracture resulting
in a long bone from twisting.

Fracture by contre-coup is a fracture of the skull which is
on the opposite side of the head to that which was the re-
cipient of the force.

Epiphyseal Separation or Diastasis. — This injury occurs
only before the age of twenty-five and is commonest at the
lower end of the femur, but it is encountered also at the
lower ends of the tibia and radius and at both extremities of
the humerus. This injury induces deformity, which is often
hard to reduce, and by damaging the cartilage may retard or
inhibit a further lengthening by growth of the limb.

I ntra-uterine fractures are usually due to injuries of the
mother's abdomen sustained toward the end of pregnancy.
Some hold that they can arise as a consequence of the force
of violent uterine contractions. Many so-called " intra-ute-
rinc " fractures are wrongly named, as they result from injury
during deliver}'. In sporadic cretinism (misnamed congenital
rickets) the bones are fragile and ill-ossified, and many frac-
tures may occur /// utero.

Designations According to Seat of Fractures. — Fractures
are designated also according to their anatomical seats ; for
instance, fracture of the upper third of the shaft of the femur,
fracture of the olecranon process of the ulna, fracture of the
middle third of the clavicle, and fracture of the body of the
lower jaw. Intra-articular fracture is one extending into a
joint; intracapsular fracture is one within the capsule of
either the shoulder- or hip-joint ; and extracapsular fracture
is one just without the capsule of either the shoulder- or
hip-joint.

Causes of Fracture. — The causes of fracture are (i) ex-
citing, immediate or direct, and (2) predisposing or indirect.

Bxcitingr causes are {a) external violence and (^) muscu-
lar action.

External violence is the most usual exciting cause. Two
forms are noted : (i) direct violence and (2) indirect force.

Fractures from direct violence occur at the point struck, as
when the nasal bones are broken with the fist. In such frac-
tures the soft parts are damaged ; they may be destroyed at

DISEASES AND INJURIES OF BONES AND JOINTS. 325

once in part, they may be damaged so severely that a portion
sloughs, or they may be damaged so slightly that they do
not lose vitality ; hence fractures by direct violence may be
compound from the start, may become so, or may remain
simple. In fractures by direct force discoloration, due to
effused blood, usually appears at the point struck soon after
the accident In compound fractures by direct violence the
soft-part injury is so great that primary tissue-union cannot
occur.

Fractures from indirect force do not occur at the point of
application of the force, but at a distance from it, the force
being transmitted through a bone or a chain of bones, as
when the clavicle is broken by a fall upon the extended hand.
Such fractures tend to occur in regions of special predilection.
If they are not compound, there is no injury of the surface
over the fracture. If they become compound by projection
of fragments, primary union may still occur. Discoloration
over the seat of fracture is usually not present soon after the
accident, but may occur later. Discoloration rapidly appears
in soft parts at the point where the force was first applied.

Muscular action is a rather rare cause. Fractures thus
produced result from sudden or violent contraction. Bones
so broken are usually diseased. Violent coughing may frac-
ture the ribs; attempting to kick may fracture the femur;
saving one's self from falling backward may fracture the
patella ; throwing a stone may fracture the humerus ; and
sudden extension of the forearm may fracture the olecranon
process of the ulna.

PredisposinfiT Causes. — There are two classes of predis-
posing causes, namely: (i) physiological, natural or normal,
and (2) pathological or abnormal.

Natural Predisposing Causes, — Under this head is consid-
ered the liability to fracture possessed by individual bones
because of their shape, structure, function, or position. Those
predispositions occasioned by special ages are also consid-
ered. In youth epiphyseal separation is commoner than frac-
ture, and a fracture is apt to be incomplete. Fractures are
commonest between the ages of twenty-five and sixty. From
two to four years of age a child is more liable to fracture than
later, because he is then learning to walk (Malgaigne). The
bones of the old are easily broken, but the normal lack of
activity of the aged saves them from more frequent injury.
Thus the predispositions of age are in part due to habits and
in part to bony structure. The bones of the young, being
elastic, bend considerably before they break ; the bones of

326 MODERN SURGERY,

the old, being brittle and inelastic, break easily, but do not
bend. In old age the bones become lighter and more porous,
though they do not. diminish in size. An absorption takes
place from the interior of a bone, particularly at its articular
head, the medullary canal increases in size, the cancellous
spaces become notably larger, and portions of the remaining
bone of the interior show a fatty change. There is no in-
crease in the amount of mineral salts present, as was long
taught. These alterations occur earlier in women than in
men.^ The change of age is a diminution in the amount of
bone present, and sometimes a fatty change in a portion of
what remains. If the atrophy of bone is other than that
normal to senility, it constitutes a pathological predisposing
cause of fracture. Normal predisposing causes include the
person's weight (which determines the force of a fall), mus-
cular development, habits, sex, occupation, and the season
of the year.

Pathological Predisposing Causes, — Hereditary fragility is
a condition commonest among women, often existing in
generation after generation, and in which condition fractures
occur from an infinitely slight force. There exists in these
cases bony rarefaction — in fact, a premature senility.

Ncr-ootis Diseases. — Bony nutrition is dependent on the
spinal cord, and the trophic influence is probably exerted
through the posterior nerve-roots (Gowers). In c^seases of
the anterior cornua bony growth is much interfered with;
in diseases of the posterior columns, as in locomotor ataxia,
a true bony atrophy bespeaks trophic disorder. Syringo-
myelia causes brittlencss of the osseous structures, and in
paralysis agitans bones are thought to break easily. Trophic
changes may occur in the bones of the insane, most com-
monly when insanity is linked to organic disease. About
one-quarter of paretic dements show undue brittleness or
unnatural softness of bone.*^ The bones of maniacs are fre-
quently fragile. In asylum practice fractures are not neces-
sarily an indication of abuse.

Rickets. — Rickets predisposes to fracture because of altered
bone-structure and the great liability to falls.

Atrophy of Bone. — This condition, as has been seen
(p. 309), is normal in senility. It may arise from want of
use, as is observed in the bedfast, in the wasted femur of
hip-joint disease, and in the bones of a stump. It may
arise from pressure, as when an aneur>'sm compresses the
ribs, sternum, or vertebrae. Among other of the patho-

' Humphrey on Old Age. * Spitzka's Manual of Insanity,

DISEASES AND INJURIES OF BONES AND JOINTS. 327

logical predisposing causes are to be mentioned cancer,
sarcoma, and hydatid cysts of bone, caries, necrosis, gout,
scrofula, syphilis, mollities ossium, and scurvy.

Sjnnptoins of Fracture. — History of an Injury. — In
spontaneous fracture there may be no record of violence ;
for instance, when a bone breaks while turning in bed. In
investigating the history, not only seek for a record or for
evidences of violence, but try to determine exactly how the
accident happened.

A sound of cracking is occasionally audible to a bystander
at the time of the injury. The patient may have heard it,
but very rarely does. A rupture of a tendon or a ligament
produces a similar sound.

Pain is usually, but not invariably, present (absent often in
rickets). Malgaigne says that in some fractures the pain is
slight or absent, in others it is torturing, and in most it is
severe for a time after the injury, but gradually abates unless
reinduced by movement. Pain developed at the time of the
accident is far less important as a symptom than that which
can subsequently be produced by movement. In indirect
fracture there is an area of pain at the point of application
of the force, and another at the seat of fracture. Pain at the
seat of fracture can be greatly aggravated by pressure or
movement and is rather narrowly localized.

Deformity or alteration in length or outline is due in part
to swelling and in part to a change in the mutual relation of
the fragments (displacement). The deformity of swelling is
no aid to a diagnosis, as the same thing occurs in contusion,
and it often hides some positive symptomatic distortion. The
swelling is due first to blood and next to inflammatory prod-
ucts and pressure-edema, and is very great in joint-frac-
tures. The deformity of displacement may be produced by
the violence of the injury (as is the depression in a skull-
fracture), by the weight of an extremity (as is the falling of
the shoulder in a fracture of the clavicle), or by muscular
action (as is the pulling upward of the superior fragment of
a fractured olecranon process).

The varieties of displacement are (i) transverse or
lateral, where one fragment goes to the side, front, or back,
but does not overlap the other ; (2) angular, the bony axis
at the point of fracture being altered and the fragments
forming with each other an angle ; (3) rotary, one fragment
rotating in the bony circumference, the other remaining
stationary. As a rule, it is the lower fragment which turns
on its long axis, rotating with it-the limb below the level of

328 MODERN SURGERY.

the break ; (4) overlapping or overriding, when the upper
level of one fragment is above the lower level of the other
fragment. It is usually the lower fragment which is drawn
by the muscles above the upper, but the body-weight and
sliding down in bed may push the upper below the lower.
In overriding the ends are near together and the bones are
usually in contact at their periphery. It is obvious that
overlapping is associated with transverse displacement, as
one fragment must go front, back, or to the side ; (5) pene-
tration or impaction is when one fragment is driven into the
other, thus producing shortening ; (6) separation of the two
fragments occurs in fracture of the patella, olecranon, os
calcis, certain articulations, and in some breaks of the hume-
rus when the arm is not supported.

It is important to remember that a dislocation may produce
displacement, but these two conditions may be differentiated
by the observation that the displacement of fracture tends
to reappear after complete reduction, while that of dislocation
does not reappear. A displacement is hard to detect in a flat
bone and when one of two parallel bones is broken.

Loss of function may be shown by inability to move the
limb because of the break, but it is not always markedly
present, though some degree invariably exists. It is slight
in " green-stick ** and impacted fractures (unless the loss of
power arises from pain or nerve-injury). A person can walk
when the fibula alone is broken, and Hkewise in some cases
of intracapsular fracture of the femur, and can often put the
hand on the head in fractured clavicle (Malgaigne). The
pain of any injur>' or the loss of power from nerve-trauma-
tism may cause loss of movement in the limb. This symp-
tom is of slight diagnostic value in most fractures.

Extravasation of Blood. — A contusion of the surface ac-
companied by skin-abrasion indicates merely the point of
application of direct external violence. If contusion is exten-
sive over a superficial bone, as the tibia or parietal, after
a few hours it often simulates fracture by presenting a soft,
compressible center surrounded by a ring of hard, condensed
tissues and coagulated blood. Direct external violence
may merely occasion ecchymosis, and in fracture from
indirect force ecchymosis may occur in a con.siderable area.
In regard to this symptom, note that even great external
violence may occasion no evident contusion or ecchymosis,
and in any fracture this symptom may be present or absent.
In old people, anemic subjects, and drunkards, extravasa-
tion of blood is frequently marked and persistent. By sug-

DISEASES AND INJURIES OF BONES AND JOINTS. 329

gillation is meant an extravasation of blood which slowly
invades wide areas of tissue and which appears at the sur-
face only after some time, and then usually as a yellowish
discoloration. Linear ecchymosis has been esteemed by
some as a sign of fissure, and it often follows fracture of
the fibula. Linear ecchymosis over the line of the poste-
rior auricular artery was pointed out by Battle as a valuable
sign of fracture of the posterior fossa of the base of the
cranium.

Preternatural mobility is a most important symptom, which
is pathognomonic when surely found. The unbroken bone
is nowhere mobile in continuity. By preternatural mobility
is meant that a bone is mobile in continuity or that there is
abnormality in the direction or extent of joint-mobility. In
some fractures this symptom does not exist (impacted, green-
stick, and locked serrated fractures); in others it cannot
be found (fractures of tarsus, carpus, vertebral bodies) ; in
others it is difficult to obtain, but at times can be developed
(fractures near or into many joints). To develop this symp-
tom, try, when the case admits, to grasp the fragments and
to move them in opposite directions. In fractures of the
shafts of the femur or humerus fix the upper fragments and
carry the knee or elbow in various directions to develop bend-
ing at the point of fracture. In fractured clavicle push the
shoulder downward and inward. In fractures of either bone of
the forearm grasp the opposite bone with four fingers of each
hand and make pressure on the suspected bone alternately
with either thumb, the same proceeding being used in fract-
ures of the leg. In fractures of the neck of the femur note
the rotation-arc of the great trochanter (Desault). In fract-
ures of the lower end of the radius bend the hand back, and
in those of the lower end of the fibula evert the foot (Mai-
sonneuve). In seeking preternatural mobility, remember that
the elastic ribs when being forced in give a sense of bend-
ing, and that the fibula at its middle is " normally flexible "
(Dupuytren). Some rachitic bones may be bent.

Crepitus or crepitation is both a sensation and a sound,
which indicates the grating together of the two rough sur-
faces of a broken bone. This symptom is of great value,
but it is not always present. It is absent in locked serrated
fractures, in impacted fractures, in cases where the broken
ends cannot be approximated (as in overlapping), and is rare
when a fractured surface is against the side, and not the
broken face, of the other fragment, and is unusual in incom-
plete fractures. Crepitus is often absent in epiphyseal sepa-

330 MODERN SURGERY,

ration, in softened bones, and in fractures in or near joints,
and it may be prevented from occurring by blood-clot, fascia,
or muscle between the broken surfaces. The grating found
in tenosynovitis must not be mistaken for the crepitus of fract-
ure : the former is diffused, large, soft, and moist ; the latter
is limited, small, harsh, and dry. The clicking of an inflamed
or eroded joint and the crackling of emphysema must also
be separated from bony crepitus. Crepitus of fracture may
be present at one moment, but absent the next. It is often
not detected during the time swelling is marked, and cannot
be discovered after organization of the callus begins. In but
few fractures is it needful to try to hear crepitus with the
naked ear or with a stethoscope upon the part, but in doubt-
ful cases of fractures of ribs and joints it should be tried.

The above-named symptoms are known as " direct." There
are other symptoms known as ** circumstantial," such as the
flow of blood and cerebrospinal fluid from the ear after
some fractures of the middle fossa of the skull ; emphysema
of the face and epistaxis after fractures of the nasal bones;
hemoptysis and emphysema after crushes of the chest ; dis-
coloration following the line of the posterior auricular artery
after fractures of the posterior fossa of the skull ; and sub-
conjunctival ecchymosis after fractures of the anterior fossa
of the skull.

Diagnosis. — Examine as soon as practicable after the
injury — before the onset of swelling, if possible. Expose the
part completely, taking off the clothing, if necessary, by clip-
ping it along the seams. Compare the part, by attentive
scrutiny, with the corresponding part on the opposite side.
If any deformity be present, it must be ascertained that it
did not exist before the accident. If the nature of the in-
jury' be uncertain, if the patient be very nervous, or if the
part be acutely painful, it is better to give ether to diagnos-
ticate, and set and dress. In injuries of the elbow-joint
always anesthetize before examination, unless an x-ray appa-
ratus is accessible to settle the diagnosis.

A fracture is distinguished from a dislocation by its preter-
natural mobility, its easily reduced but recurring displace-
ment, and its crepitus, as against the preternatural rigidity,
the deformity, difficult to reduce, but remaining reduced, and
the absence of crepitus of a dislocation. Further, in disloca-
tion the bone, when rotated, moves as one piece, whereas in
fracture it does not so move ; in dislocation the bony pro-
cesses arc felt occupying their proper relations to the rest of
the same bone, while in fracture some of them present altered

DISEASES AND INJURIES OF BONES AND JOINTS. 33 1

relations ; in dislocation the head of the bone is found out of
its socket, but in fracture it is felt in its place. It is impor-
tant to remember, moreover, that a fracture and a dislocation
may occur together, and that the rubbing of a dislocated
bone against an articular edge, when the joint has been
roughened by inflammation, simulates crepitus.

Great contusion, by inducing extreme tumefaction, may
mask characteristic deformity and obscure crepitus. When
only a contusion exists pain is apt to be diffused ; but if a
fracture has occurred, the pain is accentuated at some narrow
spot. In many cases, before he can give a certain opinion,
the surgeon must wait some days until the swelling has
largely subsided. In such a case it is best to assume in our
treatment that a fracture exists until the contrary is known.
Combat swelling by rest and the use of lead-water and laud-
anum and moderate compression.

In impaction the diagnosis is difficult. The moderate de-
formity is concealed by swelling ; crepitus and preternatural
mobility do not exist unless the fragments are pulled apart,
and there is not necessarily much loss of function. A con-
clusion is reached largely by considering the nature, direc-
tion, and extent of the violence, the seat of the pain, and by
a careful study of the most minute deformity. Fissures are
hard to recognize. They rarely present any evidence of their
existence except a localized pain and possibly a linear ecchy-
mosis appearing after a few days.

In green-stick fractures the age, the deformity, and possi-
bly crepitus during reduction, help in the diagnosis. Epiphy-
seal separations are diagnosticated by the age, the preternat-
ural mobility, the deformity, the situation of the injury, and
the absence of crepitus or the presence only of a soft crepitus.
Fractures are often hard to recognize when occurring in a
group of bones like those of the carpus and tarsus (which
are firmly joined by dense ligaments) or in one of two paral-
lel bones. There is not always a certainty that a fracture
exists, and when, after a careful examination, there is still an
uncertainty, do not prolong the efforts or use great force, but
treat the case as a fracture until a cure ensues or the diag-
nosis becomes apparent.

We have recently had added to our resources a method
of incalculable value in diagnosticating fracture ; that is, the
use of the force known as the X-ray or the Rontgen ray. We
can look through a part with a fluoroscope and see the bones
as shadows, or we can take a negative of the shadows and
print skiagraphs from it. This method is applicable even

332 MODERN SURGERY.

when the parts are swollen, and even when a limb is clothed
or wrapped in dressings. It is possible to obtain a picture of
a fractured skull after long exposure ; fractured ribs and ver-
tebrae can be detected; and the process is of the greatest
use in detecting fractures of the limbs. In order to obtain
certain results the ;r-rays must be used by an expert. This
method should, if possible, be resorted to in all cases.

Complications and Consequences. — Some of the con-
sequences and complications of fractures are — ^sloughing of
the soft parts, thus making the fracture compound ; extrav-
asation of blood, causing swelling or even gangrene ; rupt-
ure of the main artery or vein of the limb; dislocation;
edema from pressure of extravasated blood, from inflamma-
tory exudation, from tight bandaging, from thrombosis, or,
later, from the pressure of callus ; stiffness of joints from
synovitis with adhesion, from displaced fragments, or from
intra-articular callus ; stiffness of tendons from adhesive the-
citis or from the presence of callus ; paralysis from traumatic
neuritis or the pressure of callus upon nerve-trunks ; muscu-
lar spasm ; painful callus ; exuberant callus ; embolism ; fat-
embolism ; pulmonary congestion ; gangrene ; shock ; septi-
cemia; pyemia; tetanus; delirium tremens; urinary retention;
extensive laceration of the soft parts; rupture of large nerves;
and involvement of joints.

Repair of Fractures. — Simple Fracture. — In a simple
fracture the bone is broken, the medullary contents are lacer-
ated, the periosteum is torn, and the overlying soft parts are
dama^^ed to a considerable degree. The periosteum is
stripped more or less from each fragment, but it is rarely
completely torn through, an untorn portion known as the
periosteal bridge remaining. The amount of blood effused
is usually considerable, and it forms a decided prominence at
the seat of fracture; it gradually gathers because of oozing,
and soon clots. This clot lies in the medullary canal, be-
tween the fragments, under the periosteum at the ends of the
fragments, and in the tissues outside of the periosteum.
Very rapidly after the accident the damaged parts inflame
(bone, endostcum, periosteum, and other peri-osseous struct-
ures). The inflammatory exudate enters into the blood-
clot and destroys it. The clot is simply dead material and
in no way contributes to repair, and it is replaced by em-
br>'onic tissue which quickly becomes vascularized (granula-
tion-tissue).

This granulation-tissue passes into fibrous tissue and then
into bone, only the tissue springing from the periosteal

DISEASES AND INJURIES OF BONES AND JOINTS. 333

bridge going through a cartilaginous stage. The mass of
new tissue around and between the bone-ends is called
callus. It will be observed that the name is applied succes-
sively to embryonic tissue, granulation-tissue, fibrous tissue,
and bone. Warren tells us that callus has no well-defined
outline, and " involves not only the bone and periosteum, but
also the connective tissue and some of the surrounding mus-
cular tissue." Even a few days after the injury the inflam-
matory mass is much firmer than follows inflammation in-
volving other structures, and the bone-ends are deeply im-
bedded in a dense mass.

During the second week the callus is greatly strengthened
by the formation of dense fibrous tissue in and below the
periosteum, of less dense fibrous tissue outside of the peri-
osteum, and of cartilage from the periosteal bridge. This
new tissue contracts decidedly. During the third week ossi-
fication begins at the points farthest from the fracture, and in
the course of a short time (from three to six weeks) is com-
plete. The ossified callus or new bone is spindle-shaped
and spongy.

The term intermediate^ definitive, or permanent callus is
used to describe the material which forms between the fract-
ured ends. The name provisional or temporary callus is
given to the material within the canal (central callus) and
external to the bone (ensheathing callus). The amount of
provisional callus depends directly on the extent of sepa-
ration and the amount of motion between the fragments.
It is Nature's splint, and when the break is not well im-
mobilized a large amount is formed. The greater the
amount of motion the larger the amount of provi.sional
callus.

The ensheathing callus is after a time largely absorbed,
and the central callus in the course of a long time may also
be absorbed, with the restoration of the medullary canal,
although this latter result is rare. An excessive amount of
provisional callus may ossify nearby tendons, may unite two
parallel bones (radius to ulna — tibia to fibula — a rib to its
neighbors), may block a joint just as a stone in the crack of
a door will block a door, or may absolutely abolish a joint.
Fragments, even if entirely detached, often unite, but they
may be surrounded by provisional callus ; sometimes they do
not cause trouble, but sometimes they lead to suppuration.
It takes about one year to remove the temporary callus. If
callus does not get beyond the fibrous state, there exists
that form of ununited fracture known as " fibrous union.*'

334 MODERN SURGERY,

The definitive or permanent callus after a time ceases to be
porous and becomes very dense bone.

CompoTind fractures without much destruction or bruis-
ing of soft parts, if treated antiseptically, become at once
simple fractures and unite as such. If the wound is not
drained and asepticized, septic inflammation occurs, pus
forms, and union by granulation is the best that can be
obtained. Compound fractures by direct violence will not
heal by first intention because of the extensive loss of
vitality of a large area of the soft parts.

Delayed umon may be due to ill-health, want of ap-
proximation, etc. (any of the causes mentioned under the
heading Non-union). It is not non-union, but may eventuate
in non-union.

Non-union of Fractures. — An ununited fracture is a
fracture in which the fragments are not held together by
bone. The causes are local and constitutional. The local
causes 3Lrc (i) want of approximation of fragments (a frequent
cause of want of approximation is interposition of soft tissues,
especially muscle); (2) want of rest; (3) want of blood-
supply (as seen in the heads of humerus and femur, or
when a nutrient artery is torn, or when a thrombus forms in
a vein near the fracture) ; (4) defective innervation ; and (5)
bone-disease. The constitjitional causes are debility, scurvy,
Bright's disease, syphilis, etc. In this condition the broken
ends of the bone round off and the medullary canal in each
fragment becomes closed by bone. The fragments may not
be held together by any material, or they may be held by very
thin and much-stretched fibrous tissue {membranous union),
or by strong, thick, fibrous tissue {ligamentous or fibrous
union). When the ends of the bones come together, are
held by a fibrous capsule, and move on each other, there is
presented a false joint or pseudarthrosis. Such a joint may
after a time secrete serous fluid for lubrication.

Vicious union is union with great deformity, and is often
productive of pain and loss of function. It arises from failure
to coaptate the fragments, from a recurrence of displacement
after reduction, or from yielding of callus after the removal
of splints.

Treatment of Fractures. — If a man is found in the
street with a fracture, further injury must be prevented by
applying, after cutting off the clothing over the fracture, some
temporary support. If an ambulance or patrol-wagon can-
not be obtained, move the patient by hand. If the lower ex-
tremity be involved, an improvised stretcher (a board or a

DISEASES AND INJURIES OF BONES AND JOINTS. 33$

shutter) is placed on the ground beside the patient, who is
placed on the stretcher, the surgeon lifting the injured limb,
and the patient is then carried to the hospital and carefully
transferred to a fracture-bed, or, if taken home, to a small
ordinary bed, a board being placed beneath a rather hard but
even mattress. The temporary appliances are now removed
and a diagnosis by the methods before given is proceeded
with. After determining the injury the fragments must be
adjusted. This should, if possible, be done at once, because
a fracture remaining unreduced may become compound, the
fragments may injure important structures, and they are sure
to cause intense pain. Reduction is easily effected during
shock, as the muscles are in a state of relaxation. If there
is great swelling, reduction may be impossible, and the part
must then be supported and antiphlogistics, sorbefacients,
and moderate pressure be used, avoiding ice and tight band-
aging, which predispose to gangrene. Set the fracture at
the first possible moment. Velpeau*s axiom was to reduce
fractures at once, regardless of pain, spasm, or inflammation,
as reduction is their cure.

If the patient is very nervous, if the pain is severe, or if
rigid muscles antagonize the efforts, then reduce the fracture
under anesthesia. In some fractures (as those of the clavicle)
adjustment is effected by altering the position, and in others
(as those of the femur) by extension and counterextension ;
in some by tenotomy, and in some by kneading, bending,
and coaptation. When extension is employed, always en-
deavor to get a point of counterextension. The extension
is to be made on the broken bone (if possible, in the axis of
the bone), and is to be steady, not jerky nor violent. In
some cases complete reduction is impossible. This may be
due to spasm, to swelling, to the catching of soft parts
between the fragments, to the existence of a loose fragment,
to locking, or to impaction. An impaction by rotation can
generally be released, but it is sometimes undesirable to
reduce it. If the fragments cannot be adjusted without
violence, retain them in the best attainable position, combat
the antagonistic cause^ and set them properly as soon as
possible.

After adjusting the fragments they must be maintained
in position by some retentive apparatus. Avoid pressure
over joints or bony prominences, and particularly guard
against tight or improper bandaging. The circulation in
the fingers or the toes must be observed as an index of
circulation in the Hmb; hence leave those digits exposed.

336 MODERN SURGERY,

A retentive apparatus should prevent the re-occurrence of de-
formity, and not be itself productive of pain or harm. For
the first few days of treatment of a simple fracture the dress-
ing is removed every day, to make sure that deformity has not
recurred, and if it does recur the fragments must at once be
reset. The splints should be padded thoroughly, especially
when over joints or bony prominences, and they should, if
possible, fix the joints immediately above and below the
break. A primary roller should 7infcr be used.

Some surgeons at once apply an immovable dressing.
This proceeding is safe in simple fractures without much
displacement or .soft-part injury. This apparatus is used
also in military practice, with the old and feeble whom we
fear to put to bed, with the young who are very restless, and
with the insane or the delirious. If, however, there is great
deformity, much soft-part injury, or marked swelling, im-
movable dressings may induce sloughing, edema, gangrene,
or faulty union. In the above-named cases use splints for
the first few days ; then, if it is desirable, the immovable
dressing can be applied. It is dangerous to keep old or
feeble persons long in bed, as they are prone to develop
bed-sores and hypostatic pulmonary congestion. The period
for the artificial retention of the fracture varies with the seat
of the fracture and the age and the condition of the patient
Passive motion is to be made in most fractures in from two to
three weeks, though it is sometimes made earlier to prevent
ankylosis. Landerer strongly advocates massage, believing
that it hastens union and prevents wasting. He applies it as
soon as there is no danger of the callus bending (in from
eight to fourteen days). Massage should not t>e used when
great edema points to the possibility of venous thrombosis.
The movements might break up a clot and cau.se fatal em-
bolism.* V^cry early massage may cause fat-embolism. In
fracture of the patella, Barker and many others believe in
wiring, and some surgeons advocate the same procedure in
fracture of the clavicle and fracture of the tibia.

The plan known as the ambulatory treatment of fractures
of the lower extremities has many advocates. Its aim is
not only to get the patient about on crutches, but also to
cause him to use the limb. It is held that this plan of treat-
ment greath' lessens the patient's sufferings and actually
favors union by the stimulation of walking. Bardeleben,
in his report to the German Surgical Congress, gave the
records of 1 16 fractures of the lower extremity thus treated

* Cerne's case, in Normandie mi- J. ; Bull, mid.^ 1895, No. 44.

DISEASES AND lAJUJ^IES OF BONES AND JOINTS. 337

(;7 simple and 12 compound fractures of the leg; 17 simple
id 5 compound fractures of the thigh). The patients were
Dtten about a few days after the accident, were able to
attend to business, had excellent appetites, digested their
fcod perfectly, slept well, and were saved from muscular
mophy. Pilcher has warmly advocated the method. It
can be used in fractures as high up
Kllie middle of the femur. The
ipparatus which we should em-
ploy in the ambulatory treatment
reaches below the sole of the foot,
and is supported firmly above the
seat of fracture, the weight of the
body being transferred from above
the fracture to the firm pad below,
the sole of the foot on which the
patient walks {Fig. 66), This ap-
pliance in a fractured thigh is put
on about one week after the inflic-
tion of the injury. While the pa-
tient sits on the ischial tuberosities
Oitension is made upon the leg.
The seat of fracture is encircled
Wth a thin plaster cast. The sole
"f the other foot is raised by a
rork sole. Albers uses plastcr-of-
Paiis strengthened by bits of wood,
ninning from bclatv the sole of tiie
loat to the iliac crest, when he
'feats a fractured thigh. Krause
"ysin fracture of the ankle carry
"■E dressing to the head of the
'^\ in fracture of the leg carry
" to the middle of the thigh ; in
^ture of the tower end of the femur carry it to the pelvis.'
Bradford warmly advocates the use of Thomas's splint often
combined with p!a.';ter-of- Paris.

Prevention and Treatment of ComplicationB. — In every
•^s of fracture feel for the pulse below the injury in order
to be sure the artery is not ruptured. If the soft parts
We badly contused, try to prevent sloughing by rest, re-
!*a)ai!on, and lead-water and laudantim. If superficial slough-
fcg occurs, treat antiseptically, remembering that a super-
fioal excoriation can admit bacteria which, carried by the
' Ctntraltl.f. Ckir., vol. xxii., 1895.

338 MODERN SURGERY.

blood or lymph, may infect the bones. If a slough leads
down to the fracture, treat the case as one of compound fract-
ure. If there be great blood-extravasation, the danger is
gangrene, and the foot of the bed is to be elevated, or the
extremity, to which splints and bandages are to be loosely
applied, is to be raised ; lead-water and laudanum is applied
if there be much inflammation, and cotton-wool and hot
bottles if the surface be cold. If a bleb forms, it is to be
opened with a needle and dressed antiseptically. If gangrene
occurs, treat by the usual rules. The appearance of bullae
when the circulation is good does not mean gangrene.

Edema may be due to tight bandaging. If it is due to
phlebitis, there is danger of pulmonary or cerebral embolism.
In phlebitis elevate the limb, remove all constriction, and
employ locally tincture of iodin, blue ointment, and lead-
water and laudanum, and internally strong stimulation. In
edema due to weak circulation or venous relaxation use
daily frictions and firm bandaging. If the fracture involves
a joint, carefully adjust the fragments, make passive motion
early, and inform the patient that he will have a stiff joint.

A dislocation occurring with a fracture is reduced at once
if possible. To do this, spHnt the limb and give ether, and
try to reduce while the limb is managed with the splint as
a handle. If this fails, it is best to incise and pull the sepa-

FiG. 67. — Fracturc-hook (McBurney and Dowd).

rated end in place by the hook of McBurney and Dowd (Figs.
67-69) ; but some surgeons say, get the bones in the best pos-
sible position, set them, await union, and then treat the unre-
duced dislocation. Allis is often able to reduce a dislocation
accompanied by a fracture. He uses the untom portion of
periosteum as a hinge, pulls upon the fragment, and forces it
in place by manipulation. A rupture of the main arter>' of
the limb presents the symptoms of absent pulse below the
rupture, a pulsating tumor, and often an aneurysmal thrill

DISEASES AND INJURIES OF BONES AND JO/NTS. 339

nd bruit. This condition demands that the surgeon should
jpply an Esmarch bandage, cut down upon the tumor, turn
rut the clot, and ligate each end of the vessel. If these

Krc. M— FrunurB-hook ippli

measures fail or if gangrene appears, amputate at once
above the seat of the fracture.

Inflammation is to be treated by compression, rest, lead-
water and laudanum, and later by a 50 per cent, ichthyol
^ointment. Muscular spasm requires morpliin internally,

Fig. 69.— Fr

firm bandaging, or even tenotomy. Fat-embolism is treated
by stimulants and artificial respiration. Shock, delirium
tremens. urinar>' retention, etc. are treated according to the
ordinary rules of surgery.

Treatment of Compound Fracturea. — It must first be
idecided, in a case of compound fracture of a limb, if ampu-
'totion is necessary, and the ^-rays are of great value in de-
termining the condition of the bones in a crushed part.
Amputation is demanded when the limb is completely
crushed or pulpefied through its entire thickness; when
extensive pieces of skin arc torn off; when an important
joint is badly splintered; when the main arterj-, vein, and
nerve are torn through; and sometimes when there is vio-
lent hemorrhage from a deep-seated vessel. What is to
be done is to some extent determined by the patient's age

id general health. In a healthy young person, if in doubt.

340 MODERN SURGERY.

give the limb the benefit of the doubt and try to save it : if
the artery alone is ruptured, cut down upon it and tie both
ends ; if the nerve is severed, suture it ; if a joint is opened,
drain and asepticize. If an attempt is made to save the limb,
be ready at any time to amputate for gangrene, secondary
hemorrhage {if re-ligation at original point and compression
high up fail), extensive cellulitis, and profuse and prolonged
suppuration.' When it is determined to try to save the limb,
the part must be cleansed thoroughly by the antiseptic
method (in no injuries is this more important). The firag-
ments are reduced, the ends are resected if necessary, and
arc usually held together by silver wire, copper wire, chro-
micized catgut, or kangaroo-tendon. Thorough through-
and-through drainage is established and tubes are inserted.
The extremity is put in a proper position, the damaged area
and its neighboring parts are enveloped in corrosive-subli-
mate gauze, plaster is at once applied over brackets or over a
well-padded stick of wood, and in the plaster a trap-door is
cut before it sets, over each end of, and around, the drainage-
tube (Fig. 70). These trap-doors are covered with corro-

sive-sublimate gauze, which is held in place by a roller.
The drainage-tubes are usually removed, if suppuration does
not occur, in from forty-eight to seventy-two hours. The
wound is treated as any other wound. A compound fract-
ure of the skull demands trephining. If a fracture of a rib
I See Howard Marsh on "Fractures," in UtMh s Dictionary d/ Prattiial

DISEASES AND INJURIES OF BONES AND JOINTS, 34 1

is compound internally, resect the rib ; if it is compound
externally, dress antiseptically.

Compound fractures may be followed by gangrene, slough-
ing, periostitis, septicemia, pyemia, osteomyelitis, necrosis,
etc. The treatment of these conditions is by well-known
rules.

Treatment of Delayed Union and Ununited Fracture, —
When delayed union exists, seek for a cause and remove
it, treating constitutionally if required, and thoroughly im-
mobilizing the parts by plaster. Orthopedic splints may be
of value. Use of the limb while splinted, percussion over
the fracture, and rubbing the fragments together, thus in
each case producing irritation, have all been recommended.
Blistering the skin with iodin or firing it has been employed.
If the case be very long delayed, forcibly separate the frag-
ments and put up in plaster as a fresh break. If these means
fail, irritate by subcutaneous drilling or scraping, or, better,
by laying open the parts and then drilling and scraping at
many places. Buechner advocates the induction of hyper-
emia by a constricting band, just as Bier induces congestive
hyperemia for tuberculous areas. At first the constriction
is left on only a short time, but the period is lengthened
every day, until in a few days it remains almost continuously
day and night He claims that ten days of almost contin-
uous application cures most cases. Helferich devised this
method in 1887. Lannelongue and Menard inject a i : 10
solution of zinc chlorid between the fragments. Leaving
acupuncture-needles in for days is approved by some, and
electropuncture is advocated by others. Cases of ununited
fracture must be treated by excision of the bony ends and
fibrous tissue, securing the fragments together by periosteal
sutures, by pins, by screws and plates, by ivory pegs, by
screws, by silver or copper wire, by kangaroo-tendon, by
Senn's bone-ferrules, or by chromicized catgut. Delorme
makes an incision, removes bone-splinters and fibrous tissue,
smooths off one end, forces this into the bored-out medul-
lary canal of the other fragment, and sutures the periosteum.
Gussenbauer*s clamp will often give a good result, and was
used for years by Billroth. (See Osteotomy for Ununited
Fracture, p. 482.)

Treatment of vicious Union. — If angular deformity results
from faulty union, it can be corrected by moulding while the
callus is soft. If the callus has become hard, the bone can
be refractured. If faulty union occurs with overriding, an
osteotomy can be performed.

342 MODERN SURGERY,

Special Fractures. — Najswl Bones. — ^The nasal bones,
because of their situation, are often broken. The commonest
site of fracture is through the lower third, where the bones
are thin and lack support. The fracture may be compound
externally or internally. The cause is direct violence. Dis-
placement may not occur at all, but when present it arises
purely from force, and never from muscular action, no mus-
cle being attached to these bones. If the force is from the
front, the nose is flattened ; if from the side, deflected and de-
pressed. Displacement is soon masked by swelling. Crepitus
can sometimes be elicited by grasping the upper part of the
nose with the fingers of one hand and moving it below from
side to side with those of the other hand. Preternatural mo-
bility is valueless as a sign, because of the natural mobility
of the cartilages. Nose-breathing is difficult because of
blocking of the nostrils by blood-clot. Diagnosis is almost
impossible when deformity is absent.

The complications that may be noted are cerebral concus-
sion, brain-symptoms from implication of the frontal bone or
cribriform plate of the ethmoid, and extension of fracture to
the superior maxillary or lachrymal bones. Emphysema of
root of nose, eyelids, and cheeks, is common, and means either
a rent in the mucous membrane of Schneider or a crack in the
frontal sinus. There may be much discoloration because of
subcutaneous hemorrhage. Epistaxis is usual, and is sepa-
rated from the epistaxis in fractures of the base of the skull by
the facts that the bleeding in the first condition is profuse, is,
as a rule, soon checked, and is not followed by an ooze of
cerebrospinal fluid ; whereas in the second condition it is pro-
fuse, continued, and followed by a flow of cerebro.spinal fluid.
Fracture of the bony septum occasionally complicates nasal
fractures, and deviation of the cartilaginous septum often
takes place. The prognosis is usually good.

Treatment. — When there is no displacement, or when a
displacement does not tend to be reproduced after reduction,
use lead-water and laudanum for a few days if swelling exists,
but employ no retentive apparatus of any kind. Order the
patient not to blow his nose for ten days and to syringe it
out daily with a solution of bicarbonate of sodium. If de-
formity be noted, correct it at once, as the bones soon unite
in deformity. If the attempts at reduction are very painful,
or if the subject be a child, a woman, or a nervous man, give
ether or spray the interior of the nose with a 4 per cent solu-
tion of cocain. Reduction is effected by a grooved director
or steel knitting-needle, wrapped in iodoform gauze and

DISEASES AND INJURIES OF BONES AND JOINTS. 343

passed into the nostril ; the fragments are lifted up with this
instrument, and the fingers externally mould them into place.
A rubber dilator can be used in
reduction. This is pushed into
the nose and inflated by air or
water. If hemorrhage is mod-
erate, check it with cold; if se-
vere, by plugging. If flattening
tends to recur, pass a Mason's
pin (Fig. 71) just beneath the
fragments, through the line of
fracture and out the opposite side.
Steady the fragments by a piece
of rubber externally caught on
each end of the pin, or with figure-

of-8 turns around the ends with fio. ?■ — Mmohj pin.

silk. I.^ave the pin in place for

five days. This instrument of Mason's is a sharp, strong,
nickel-plated pin, with a triangular point

If a lateral deformity tends to recur, hold a compress over
the fracture or fix a moulded-rubber splint over the nose by
a piece of rubber-plaster one and a half inches broad and
long enough to reach well across the face, and use compres-
sion for ten days. In neither of the above cases is the nose
to be blown, but in both cases it is to be .syringed daily. In
both cases, cifter dressing, if the swelling be marked, use lead-
water and laudanum. In fractures rendered compound by
tears in the mucous membrane irrigate with normal salt
solution or boracic-acid solution, holding the head so that
the solution will not run into the mouth ; plug with iodo-
form gauze around a small rubber catheter, which instrument
permits nose-breathing; carefully remove the gauze daily
and syringe. In fractures compound externally cleanse anti-
septically externally, and dress with a film of cotton soaked
in iodoform collodion or com-
pound tincture of benzoin, or
apply sterile gauze. Fractures
of the bony septum, if showing
a tendency to reproduction of
deformity, require packing as
above explained, or the use of a
special splint (Fig. 72). Fractures of the nasal cartilages are
to be pinned in place. Fractures of the nose are entirely
united in from ten to twelve days.

Fractoree of tJie LaobrTmal Bone. — The lachrymal

344 MODERN SURGERY,

bone may be broken when the nasal bones, a superior
maxillary bone, or the lateral plate of the ethmoid are
fractured.

Treatment — Treat the chief injury, which is the fracture
of the other bone. Maintain the patency of the lachrymal
duct by passing frequently a clean probe.

Fractures of the Superior Maxillary Bone. — ^Although
a fragile bone, the superior maxillary is rarely broken
except through the alveolar border. It may be broken
by transmitted force from blows on the chin, or on the
head when the chin is fixed; but direct violence is the
usual cause, and the wall of the antrum may be crushed in.
Comminution is the rule, and the injury is often compound.
These fractures induce great swelling, pain, and inability to
chew; mobility and crepitus may be detected. Deformity
is due to the breaking force, and not to the action of any
muscle. When a portion of the alveolar arch is fractured, as
may occur in pulling teeth, the fragment is depressed back-
ward, and there exist irregularity of the teeth (some of which
may be loosened) and inability to chew food. Fracture of
the nasal process is apt to injure the lachrymal duct When
the antrum is broken in there are great sinking over the fract-
ure, depression of the malar bone, and emphysema. Trans-
verse fracture of the upper part of the body of the bone may
cause no deformity. The force sufficient to break the supe-
rior maxillary bone is so great that fractures of other bones
almost certainly occur, and concussion of the brain not infre-
quently exists. Injury of the infraorbital nerve is not unusual,
causing pain, numbness, or an area of anesthesia involving
one-half of the upper lip, the ala of the nose, and a triangle
whose base is one-half the upper lip and whose apex is the
infraorbital foramen. There is also loss of sensation in the
gums and upper teeth of the injured side. Fractures of the
superior maxillary bone occasionally induce fierce hemor-
rhage from branches of the internal maxillary artery, and if
this occurs, watch out for secondary hemorrhage (these ves-
sels being in firm canals).

Treatment. — If the fracture does not implicate the alveolus,
or if no deformity exists, apply no apparatus, but feed the
patient on liquid food for four weeks. Reduce deformity, if
it exists, by inserting a finger in the mouth. If the antrum
is broken in, put the thumb in the mouth and push the malar
bone up and back. In certain cases of deformity make an
incision at the anterior border of the masseter muscle, insert
a tenaculum or aneurysm-needlc, and pull the bone into place

DISEASES AND INJURIES OF BONES AND JOINTS. 345

(Hamilton). If the malar bone or malar process is driven
into the antrum, Wdr tells us to incise the mucous mem-
brane above, and external to, the canine tooth of the upper
jaw. break into the antrum with a bone gouge, insert a
steel sound, lift out the malar bone, and pack the antrum
with gauze. Loose teeth are not to be removed : they are
pushed back into place and held by wiring them to their
firmer neighbors. Hemorrhage is arrested by cold and
pressure. If hemorrhage is dangerously profuse or pro-
longed, tie the external carotid.

If the line of the teeth, notwithstanding the wiring, is not
regular, mould on an interdental splint. The usual splint for
the upper jaw is the lower jaw held firmly against it by the
Gibson, the Barton, or the four-tailed bandage. Every second
day remove the bandage and wash the face with ethereal
soap. The patient, who is ordered not to talk, is to live on
liquid food administered by pouring it into the mouth back
of the last molar tooth by means of a tube or a feeding-cup.
Never pull a tooth to get a space, but if a tooth is lost, utilize
its space for this purpose. After every meal wash out the
mouth with chlorate-of-potassium or boracic-acid solution to
prevent foulness and the digestive disorders it may induce.
Leave off the dressings in five weeks, and let the patient
gradually return to ordinary diet.

In fractures compound externally do not remove frag-
ments, antisepticize, arrest bleeding as far as possible by
ligature, by pressure, or by plugging, wire the fragments if
feasible, dress with gauze, and wash the mouth with great
frequency. Fractures compound internally are treated as
simple fractures, except that the mouth is washed more
frequently.

The malar bone is rarely broken alone. Hamilton says
no uncomplicated case is on record. The malar is a strong
bone resting on a fragile support, and hence it can be used
as a wedge to break other bones and yet itself be unfract-
ured. The cause of fracture is violent direct force. A
fracture of the orbital surface of this bone causes subcon-
junctival hemorrhage like that encountered in fracture of
the base of the skull. Protrusion of the eye may result
either from hemorrhage or from crushing in of the malar
bone. Chewing is apt to cause pain.

Treatment. — Jf no deformity exists, there is practically
nothing to be done. If deformity exists, try to correct it as
in fractures of the superior maxillary. As these cases are
almost invariably complicated by breaks of the upper jaw,

346 MODERN SURGERY,

they are treated in the same manner as the latter injury.
The union is complete in three weeks.

Fracture of the zygomatic arch is very rare. The
causes are (i) direct violence ; (2) indirect force (from depres-
sion of the malar) ; and (3) forcing of foreign bodies through
the mouth. Direct violence is the usual cause. Direct vio-
lence causes inward displacement, and indirect force may
cause outward displacement. The usual seat of fracture is
at the smallest portion of the process — ^that is, on the tem-
poral side of the temporomalar suture (Matas). The symp-
toms are pain, ecchymosis, swelling, displacement, and dif-
ficulty in moving the jaw (because of injury to the masseter).

Treatment. — In simple fracture give ether and try to push
the arch in place. Many surgeons do not make an incision,
as depression will do no harm and the functions of the jaw
will be restored. Simply dress with compress, adhesive
strips, and crossed bandage of the angle ofthejaw(Fig. 267).
Union will take place in three weeks. Matas * advises that
an anesthetic be administered and the parts be aseptidzed
A long semicircular Hagedom needle is threaded with silk,
is entered one inch above the middle of the displaced frag-
ment, is passed well into the temporal fossa, and is made to
emerge half an inch below the arch. The silk is used to
pull a silver wire through around the fracture, and this wire
is employed to pull the bone into position. A firm pad is
applied externally and the wire is twisted over the pad
Matas dresses antiseptically, and on the ninth or tenth day
removes the wire, splint, and dressings permanently.

Fractures of the inferior maxillary bone may, and most
usually do, affect the body, although they occasionally occur
in the rami. Any part of the body may be fractured, the most
usual seat being near the canine tooth or a little external to
the symphysis (Pick). A portion of alveolus may be broken
off. In fractures of the ramus either the angle, the condyloid
neck, or the coronoid process may be broken. In fractures
of the body the posterior fragment generally overrides the
anterior. Fractures of the lower jaw are often multiple
and are almost always compound, because the oral mucous
membrane and alveolar periosteum are torn. The cause is
usually direct violence. Indirect violence (lateral pressure)
may fracture the body anteriorly. Fractures near the angle
are always due to direct violence. Indirect violence may
fracture the condyle (falls on the chin), and so may direct
violence. Fractures of the coronoid are very rare, and they

* iWrt' Orleans Me J. and Surg. Jour. ^ Sept, 1 896.

DISEASES AND INJURIES OF BONES AND JOINTS. 347

arise from great direct violence (usually gunshot-wound or
some other penetrating force).

Symptoms. — In fracture of the body preternatural mobility
and crepitus generally exist. There is bleeding because of
laceration of the gums ; saliva dribbles constantly ; the jaw
is supported by the hand ; great pain exists (possibly from in-
jury of the nerve) ; and deformity is present, shown by inequal-
ity of the teeth if the fracture is anterior to the masseter, the
anterior fragment going downward and backward and the
posterior fragment going upward and forward. The down-
ward displacement is due to muscular action (action of the
digastric, geniohyoid, and geniohyoglossus). The backward
displacement is due to the violence. The temporal muscle
draws the posterior fragment up and to the front In fract-
ure of the neck of the condyle the jaw is drawn toward the
injured side, and the condyle goes inward and forward by the
action of the external pterygoid. In fracture of the coronoid
process the temporal pulls the small fragment up.

Complications. — The complications are — digestive disorders
and diarrhea from swallowing foul discharges ; loosening of
the teeth ; loosened teeth be-
tween fragments ; bleedmg
(usually only oozing from
the gums, but there may be
hemorrhage from the mfe
rior dental); and suppura
tion. Necrosis may follow
these fractures.

Treatment. — Remove a
tooth if between fragments,
but replace it in its socket
after reducing the fracture
Correct deformity. Push m
loose teeth and put back de-
tached ones. Wash out the
mouth with hot water to clean
it and to check bleeding. If
bleeding is very severe, com-
press the carotid for a dme. The fracture can be dressed
with a pad of lint over the chin and Hamilton's four-tailed
bandage (Fig. 73); or put on a splint of paste-board, felt, or
gutta-percha (cut as shown on PI. 5, Figs. 3, 4) moulded to
the part, padded with cotton, and held in place by a Barton's
or a Gibson's bandage (Figs. 264, 266). If apposition of the
fragments cannot be maintained by the above methods, fasten

348 MODERN SURGERY.

the teeth together with wire, wire the fr^ments themselves
together, or have a dentist apply an interdental splint (Fig. 74).
The patient is to be fed on hquid food (see Fracture of tfce
Upper Jaw, p. 345), the mouth is to be washed out frequently,
and the dressings are to be changed every second day. The
union is complete in five weeks. Though these fractures

Fig. 74.^Tater(lcnal ipUnu.

are usually compound, they do not endanger life. If they
are compound, wash the mouth often with a solution of
boracic acid or of chlorate of potassium.

Fractures of the Hyold Bone. — These fractures are Tare
injuries, and are caused by hanging, by the throat being
grasped by an antagonist, and by falls in which the neck
strikes some obstacle. If the bone breaks by throttling, it is
its body which fractures (indirect force). Fractures by mus-
cular action are most unusual.

Spiiptoms. — The symptoms are — a sensation of something
breaking; bleeding from the mouth if the mucous mem-
brane be lacerated; pain, which is worse on opening the
jaws or on moving the head or tongue ; difficulty in swal-
lowing (dysphagia) ; muffled, hoarse, or absent voice ; swell-
ing, and frequently ecchymosis, of the neck. There arc
observed occasionally, though rarely, harsh cough and dysp-
nea, irregularity of bony contour, and crepitus. Always
look into the mouth and see if there can be detected ecchy-
mosis or laceration of the mucous membrane or projection
of a bony fragment. The displacement is due to the middle
con.strictor of the pharynx contracting. This fracture may
destroy life.

Tn-alment. — For dj'spnea be ready to perform intubation
or tracheotomy at a moment's notice. Edema of the glottis
is a great danger. Try to restore the fragments with one

DISEASES AND INJURIES OF BONES AND JOINTS. 349

hand externally and with a finger in the mouth. Put the
patient to bed and have him lie back upon a firm rest so
that his shoulders are elevated. His head is to be thrown
between extension and flexion, a pasteboard splint or collar
is moulded on the neck, and a bandage is applied around
forehead, neck, and shoulders to keep the head immobile.
The patient must not utter a word for a week ; he must at
first be fed by enemata, and then for some time on liquid
diet which is given through a tube early in the case.
Endeavor to control the cough by opiates. A fractured
hyoid bone requires about four weeks to unite.

Fracture of laryngeal cartUagee is caused by direct
violence, as throttling, blows, or kicks. It is rare in young
persons, and is commonest when the cartilages have begun
to ossify. It is a very grave injury (80 per cent, die), death
arising from obstruction to the entrance of air.

Symptoms, — The symptoms, which are severe, are pain,
aggravated by attempts at swallowing or speaking ; swelling,
ecchymosis it may be, and emphysema of the neck ; cough ;
aphonia ; intense dyspnea ; and bloody expectoration if the
mucous membrane is ruptured. There can be detected in-
equality of outline (flattening or projection) and perhaps
moist crepitus. The usual seat of the injury is the thyroid
cartilage.

Treatment. — Cases without dyspnea require quiet, avoid-
ance of all talking, feeding with a stomach-tube, compresses
and adhesive strips over the fracture, and remedies to quiet
cough. Be ready to operate at any moment. In most
cases dyspnea exists, due to projection of the fragments or
submucous extravasation. When there is dyspnea, emphy-
sema, or spitting of blood, at once practise intubation, or, if
unable to do this, open the larynx or trachea below the seat
of fracture. If laryngotomy or tracheotomy is done, try to
restore displaced fragments. If the fragments will not stay
reduced, introduce a Trendelenburg cannula or a tracheot-
omy-tube around which gauze is packed. Take out the
packing in four days, and remove the tube as soon as the
patient breathes well, when the opening is allowed to close.
In these fractures feed with a stomach-tube and keep the
patient absolutely quiet. Union takes place in four weeks.

Fracture of the Bibs. — The ribs, owing to their shape,
elasticity, and mode of attachment, readily bend and as read-
ily recover their shape, thus standing considerable force with-
out breaking. Notwithstanding these facts, the situation of
the ribs so exposes them that in 16 per cent, of all cases of

350 AfODERN SURGERY.

fractures noted by Gurlt these bones were involved. In chil-
dren this injury is rare and is most usually incomplete; it is
common in adults and the aged, and in them is generally
complete. It is more frequent among men than among
women. The ribs commonly broken are from the fifth to the
ninth, the seventh being the one that usually suffers. Fract-
ure of the first rib alone is an excessively rare accident The
eleventh and twelfth ribs are seldom broken. A rib may be
broken in several places, and several ribs are often broken at
the same time. Fracture of a single rib is not nearly so com-
mon as fracture of several ribs. These fractures may be
compound either through the skin or through the pleura, a
damaged lung permitting pneumothorax. Compound fract-
ures are very rare, however, except from bullet-wounds.

Causes. — Direct force, as buffer accidents, blows with heavy
instruments, or being jumped on while recumbent, may pro-
duce these injuries. A fracture from direct violence occurs
at the point struck, and the ends, projecting inward, may
damage the viscera. Indirect force, as great pressure or
blows which exaggerate the natural bony curves, tends to
produce fractures near the middle of the ribs or in front of
their angles and to force the ends outward. A number of
ribs are apt to be broken. Muscular action, as in coughing
or parturition, occasionally, but very rarely, is a cause.

Symptoms. — In connection with the history of the accident
the symptoms arc — acute localized pain (a stitch) on breath-
ing, increased by pressure over the injury, pressure backward
over the sternum, cough, and forcible inspiration or expira-
tion ; respiration is largely diaphragmatic, the patient en-
deavoring to immobilize the injured side; cough is frequent
and is suppressed because of pain. Crepitus is often but not
invariably found. It is sought, first, by resting the palm over
the seat of pain while the patient takes long breaths ; second,
by placing a thumb before and one behind the seat of pain
and making alternate pressure ; and third, by auscultation. It
should be remembered that incomplete fractures are the rule
in children ; hence in them do not expect crepitus. Deform-
ity is usually trivial unless several ribs are broken, because
shortening cannot occur and the intercostal attachments pre-
vent vertical displacement. Preternatural mobility may occa-
sionally be elicited, when the region is not deeply covered
with muscles, by pressing on one side of the supposed break
and observing that a part of, and not the entire, rib moves.
Cellular emphysema without a surface-wound is proof of rib-
fracture. Bloody expectoration suggests lung injury; bloody

DISEASES AND INJURIES OF BONES AND JOINTS, 35 I

expectoration and emphysema prove injury of the lung. A
simple, uncomplicated case in a young person gives a good
prognosis.

The complications are — additional injury, making the fract-
ure externally or internally compound ; laceration of pleura,
pericardium, heart, lung, diaphragm, liver, spleen, or colon ;
rupture of an intercostal artery ; hemothorax ; cellular em-
physema ; pulmonary emphysema ; pneumothorax and pyo-
thorax; traumatic pleurisy; pneumonia; bronchitis; con-
gestion or edema of the lungs.

Treatment — In an uncomplicated case the patient is not
put to bed, as breathing is easier when erect than when
recumbent. Angular displacement outward is corrected by
direct pressure. Displacement inward is soon corrected, as
a rule, by the expansion of ordinary respiratory action ; but
if it is not thus corrected, etherize, the deep breathing of the
anesthetic state almost always succeeding. If ether fails and
dangerous symptoms come on, incise under strict antiseptic
guardianship, elevate, and drain, or sometimes resect the rib.

After correcting any existing deformity immobilize the
injured side. Direct the patient to raise his arms above his
head, to empty his chest by a forced expiration, and to keep
it empty until a piece of rubber plaster (two inches wide) is
forcibly applied seven or eight inches below the fracture and
reaching from the spine to the sternum. The patient is now
allowed to take a breath and is directed to empty the chest
again, another piece of plaster being applied, covering the
upper two-thirds of the width of the previous strip. This
process is continued until the side is strapped well above and
well below the fracture (PI. 5, Fig. 13). Over the plaster
light turns of an inelastic spiral bandage are carried, or pref-
erably a figure-of-8 bandage of the chest, the turns crossing
over the seat of injury. About once a week the plaster is
removed and fresh pieces applied after rubbing off the chest
with soap liniment, drying, and anointing excoriations with
an ointment of oxid of zinc. The dressing is worn for three
or four weeks. The patient avoids cold, damp, and draughts.
The diet is to be nutritious but non-stimulating, and any
cough is at once treated by opiates and expectorants. A
person with this injury who has reached the age of sixty
must take stimulant expectorants (ammonii carb., gr. x, in
infus. senegae, Sss, t. i. d.) or employ a steam-tent several times
a day. The old method of treatment, in which the chest was
included in a forcibly applied broad rib-roller, is not to be
used except as a temporary expedient; it compresses the

352 MODERN SURGERY.

entire chest, causes pain and dyspnea, and tends to loosen
and slip.

Fracture of the ribs complicated with visceral injury is
highly dangerous, and requires confinement to bed. The
treatment is that of the visceral injury. If there be bloody
expectoration, apply adhesive strips as above indicated, put
the patient to bed reclining on a bed-rest, keep him quiet,
subdue the circulation, and employ opium, diaphoretics, and
expectorants (a good mixture consists of squill, ipecac, am-
monium acetate, and chloroform ; opium is given separately).
Inflammations of the lung or the pleura, fortunately, are apt
to be localized, and are treated as are ordinary inflammations
of these parts. If signs of visceral injury are severe from the
start or become worse under medical treatment, incise, re-
sect a rib, arrest hemorrhage, and drain the pleura. In lacer-
ation of an intercostal artery incise and try to ligate ; if un-
able to ligate, resect a rib and apply a ligature. If the signs
point to internal bleeding, resect a rib, search for the bleed-
ing point, and ligate. Emphysema usually soon disappears;
but if it does not, open the cellular tissue, dress antiseptically,
and employ pressure. When there arises a sudden attack
of dyspnea, which is prone to happen in these cases, and in
which there are a blue face and a laboring pulse and suffoca-
tion seems imminent, bleed the patient almost to syncope.

Fracture of the costal cartikiigres is not a common occur-
rence, even in the aged. Such fractures occur either through
the cartilages or through their points of junction with the ribs.
These injuries generally arise from direct violence, the carti-
lage of the eighth rib being most prone to suffer. Indirect
force (such as a blow upon the shoulder) is occasionally the
cause, but when it is the cause some other injury is apt to be
noted. Muscular action is a possible cause.

Symptoms. — Displacement is often absent; but if present, it
is forward or backward of either fragment, and is due chiefly
to the force of the injury, but partly, it may be, to muscular
action. When displacement is absent crepitus will not often
be found ; in fact, crepitus is usually absent in these injuries.
Localized pain, swelling, and ecchymosis are noted. Preter-
natural mobility may or may not be detected. Union by
bone is to be expected.

Trcatmcjit. — If displacement exists, try to reduce it. If
the fragment is displaced backward, reduce by deep inspira-
tions ; if the fragment is displaced forw-ard, reduce by puU-
ini]^ back the shoulders. In this attempt failure is the rule,
and the surgeon should then adopt Malgaigne's expedient

DISEASES AND INJURIES OF BONES AND JOINTS. 353

of applying a truss over the projection for a day or two.
Dress and treat the case as if a rib were broken, removing
the dressings in four weeks.

Fracture of the Sternum. — ^The sternum may be broken,
along with the ribs and spine, from great violence. Fract-
ures of the sternum alone are infrequent, because the bone
rests on a spring-bed of ribs. Fractures of the sternum may
be simple or compound, complete or incomplete, single or
multiple. The most usual injury is a simple transverse fract-
ure at or near the gladiomanubrial junction, at which point
dislocation may also occur. Both fracture and separation
of the ensiform cartilage are very rare. The sternum may
be broken along with the ribs or clavicle.

Causes. — ^The causes of fracture of the sternum are —
direct force, as by falls of embankments or of walls, by car-
crushes, or by the passing of a cart-wheel over the body ;
indirect force, as by falls upon the head, thus driving the
chin against the chest ; by falls upon the feet, the buttocks,
or the shoulder ; by forced flexion or extension of the body
over an edge or angle (as may occur during labor-pains).

Symptoms, — In fracture of the sternum displacement is not
alvrays present^ but when it does occur the lower fragment
is apt to go forward ; displacement may, however, be trans-
verse or angular, or there may be overriding. The posterior
periosteum, which rarely tears, limits displacement, but some
deformity can, as a rule, be detected. The history of the
nature of the accident has a valuable bearing upon the ques-
tion of diagnosis. The position assumed by the patient is
with the head and body bent forward, as attempts to straighten
up cause much suffering. Th^re is fixed and localized pain,
increased by deep respiratory action, by body-movements, or
by cough. Crepitus is sought for by auscultation and by
placing the hand over the injury and directing the patient to
make quick respirations. Mobility may become manifest on
external pressure, during respiration, or while attempts are
being made to bring the body erect. Respiration in these
cases is usually much interfered with. It is not important to
separate diastasis from fracture.

Complications, — Other fractures generally complicate fract-
ure of the sternum, and laceration of the pleura or peri-
cardium and hemorrhage into the anterior mediastinum may
exist Abscess of the mediastinum and necrosis of the ster-
num may appear as late consequences. The prognosis is
good in uncomplicated cases.

Treatment, — ^The deformity attending fracture of the ster-

A«

354 AfODERN SURGERY.

num is to be corrected, if possible, by external pressure. If
overriding is found, effect reduction by bending the body
back over a firm pillow and ordering deep respiration; if
this method fails, give ether and then bend the patient back.
The deformity, if reduced, tends to recur, but the bones unite
well in deformity and no great harm results. The fragments
need not be cut down on or hooked up unless there be inter-
nal injury. After reducing the deformity, cover the front of
the chest with adhesive strips extending laterally from one
axillary line to the other, and vertically from well above the
fracture down to the ensiform cartilage. Place over this
covering an anterior figure-of-8 of the chest. In some cases,
where deformity recurs after reduction, a circular bandage of
the chest is applied and the shoulders are pulled strongly
back with a posterior figure-of-8 bandage. The plaster is to
be renewed once a week.

Some surgeons treat these cases by means of a large
compress held by adhesive plaster and a broad tight roller.
The patient, however dressed, is put to bed and reposes erect
or semi-erect on a bed-rest. This position favors easy respi-
ration and antagonizes the tendency to displacement The
diet should be light, nutritious, and non-stimulating. The
patient is convalescent in four weeks, and the plaster is per-
manently taken off in five weeks. When the ensiform carti-
lage is so bent in as to cause intense pain or injure the
stomach, it should be incised and resected. Edema of the
skin and fever, if they appear, indicate pus, in which case an
incision is made at the edgo. of the sternum and the pus-
cavity is irrigated, drained, and dressed antiseptically.

Fractures of the Pelvis.— ^In some of the indicated fract-
ures serious injury of the pelvic contents is apt to be found.

Fractures of the False Pelvis. — Fractures of this region
are seldom dangerous unless comminuted. There may be
fracture of the iliac crest or of the anterior superior spine,
or the line of fracture may traverse the entire length of the
flanged-out ilium or the bone may be comminuted with the
association of grave visceral damage. The anterior superior
and posterior superior spines may be broken off

Cdifsi's. — The cause of fracture of the false pelvis is gen-
erally violent direct force, as the passage of a wagon-wheel.
the fall of a wall, the kick of a mule, or the force of car-
crushes. Violent contraction of the rectus muscle may tear
off the anterior inferior spine of the ilium.

Synif>tonis. — In fracture of the false pelvis the history of
violent force is noted. The patient leans toward the injured

DISEASES AND INJURES OF BONES AND JOINTS. 355

side. Pain exists, which is aggravated by movements (par-
ticularly by bending forward), by coughing, or by straining
to empty the bowels or the bladder. Ecchymosis and swell-
ing are manifest. Crepitus and preternatural mobility are
detected by moving the crest. Deformity is very rarely pres-
ent. Cases uncomplicated by visceral injury make good
recoveries.

Complications. — The fracture may be, but rarely is, com-
pound, as the parts are well protected with muscles. The
colon may be injured when comminution has taken place.

Treatment, — In treating fracture of the false pelvis put
the patient on a fracture-bed, raise the shoulders, and put a
binder about the pelvis, or encase the pelvis with broad pieces
of rubber plaster, or employ the belt or girdle. Place the
knees over two pillows so as to semiflex the legs and thighs,
and tie the knees together. To restrain thigh-movements it
may be necessary to encase a restless patient with splints or
bind him to sand-bags. If the binder displaces the fragments
or causes pain, abandon it and trust to position. The dress-
ings can be removed in six weeks, and the patient is allowed
to get up in eight weeks. In compound fractures of the false
pelvis asepticize, drain and dress, put on a binder, and direct
the same position to be maintained as for simple fractures.

Fractures of the True Pelvis. — The most usual seat of
these fractures is through the obturator foramen, the ascend-
ing ischial and horizontal pubic rami being broken. A fract-
ure may occur near the symphysis pubis, the symphysis
may be separated, a break may run near to or into the sacro-
iliac joint, the same fracture may occur on each side of the
body of the pubis, and there may be multiple fractures.
Fractures of the acetabulum and of the tuberosity of the is-
chium may occur. Before the seventeenth year the innomi-
nate bone may be broken into its three anatomical segments.
These injuries are highly dangerous because of the damage
which is apt to be inflicted on the pelvic contents. There
may be rupture of the bladder or membranous urethra
and injury of the vagina, the rectum, the uterus, or the
small gut. The cause of pelvic fracture is violent force,
direct or indirect. Front force tends to produce direct, and
side force indirect, fracture.

Symptoms. — In pelvic fracture there is a history of violent
force. There are great shock, ecchymosis which is possibly
linear, swelling, and intense pain increased by attempts at
motion, coughing, and straining. There is also inability to
sit or to stand. Mobility becomes obvious on grasping an

356 MODERN SURGERY,

ilium in each hand and moving the hands. Crepitus may be
noticed by this manoeuver or by moving an ilium with one
hand, a finger of the other hand being inserted in the rectum
or in the vagina. In making movements for diagnostic pur-
poses be very gentle, as rough manipulation permits of
injury by sharp fragments. There may be doubt as to
whether crepitus is to be referred to pelvic fracture or to
fracture of the neck of the femur ; in this case follow the
rule of John Wood : " The surgeon grasps the femur with
one hand and places the other firmly upon the anterior
superior iliac spine or crest or upon the pubes ; then, on
moving the femur and abducting it freely, if a crepitus be
detected, it will be felt the more distinctly by that hand
which rests on or grasps the fractured bone."

Injury of the bladder or urethra is made manifest by
retention of urine, extravasation of urine, hematuria, etc.
In some cases the urine is extravasated into the prevesical
space. Bleeding from the vagina or the rectum points to a
laceration of the part by a fragment. Intestinal injury
induces septic peritonitis. Fractures of the brim of the
acetabulum permit dorsal dislocation of the femur to occur,
which dislocation will not remain reduced. The acetabulum
may be broken by falls upon the feet Fracture of the brim
of the acetabulum causes shortening, which at once recurs
when extension is abandoned — ^inversion and adduction,
although the power of eversion and abduction is preserved
(Stokes). There is crepitus, and the head of the bone goes
with the fragment upward and backward (Stokes). If the
head of the femur be driven through the acetabulum into
the pelvis, the injury is very grave; there are then found
shortening, adduction, and semiflexion of the thigh, absence
of the prominence of the great trochanter, and more capacity
for movement than is noted in dislocation. Fracture of the
ischium rarely occurs alone.

Treatment. — In treating pelvic fractures endeavor to re-
store the parts to a normal position, employing external
manipulation and inserting a finger in the rectum or in the
vagina. If reduction is difficult, give ether. Use a catheter
before dressing, to detect any bladder-injury. Treat as in
fractures of the false pelvis, attending carefully to visceral
injuries. If urinary extravasation occurs, effect a perineal
section. If peritonitis develops, perform a laparotomy. All
visceral injuries are treated by general rules. Remove the
dressings in six weeks, and allow the patient to be about
in twelve weeks. In fracture of the acetabulum, if the limb

DISEASES AND INJURIES OF BONES AND JOINTS. 357

be shortened, give ether and reduce. Treat these fractures
in the same way as intracapsular fractures of the femur
(p. 386). Fractures of the ischium are best treated by
position, the pad, and adhesive plaster.

Fracture of the Sacrum. — ^This injury may arise from
direct force, such as a kick, but it is very rare. The sacral
plexus is usually injured, and if it is there is paralysis in the
territory of its branches.

Symptoms, — ^The symptoms in fracture of the sacrum are
pain, frequently incontinence of feces and retention of urine,
irregularity of the sacral spines, ecchymosis, and crepitus.
Crepitus may be sought for with one hand externally and a
finger of the other hand in the rectum. The lower fragment
goes forward and may obstruct or may tear the rectum.
Paralysis may be found in the area of distribution of the
sacral plexus.

Treatment. — In treating fracture of the sacrum press the
fragments into place with a hand externally and a finger in
the rectum. Do not plug the rectum. Put a pad over the
upper fragment, hold it with plaster or a binder, place the
patient recumbent on a fracture-bed, and insert a large
cushion underneath the pad. Some surgeons give opium
to induce constipation, and allow a fecal support to accu-
mulate in the rectum. Use a clean catheter regularly, and
guard against bed-sores. Union occurs in about four weeks,
when the dressing can be removed. The patient can get
about again in six weeks. If urinary retention persists or
if intractable bed-sores form after eight or ten weeks, cut
down on the seat of injury and elevate or remove the portion
of bone causing pressure.

Fractures of the Coccyx. — ^The coccyx may be broken
or be separated from the sacrum by a fall, a blow, a kick,
or the straining of parturition. Its mobility is so great,
however, that it does not often break.

Symptoms. — ^The chief symptom of fracture of the coccyx
is pain, which is much aggravated by sitting, walking, or
straining at stool. If the index finger is inserted in the
rectum, the displaced bone is felt ; if the thumb of the same
hand is also placed externally, a rocking motion will develop
crepitus and preternatural mobility.

Treatment. — In treating fracture of the coccyx reduce by
external pressure and by the manipulations of a finger in
the rectum. Put the patient to bed and obstruct the bowels
by opium for a number of days. In four weeks the fracture
should be united. If union does not take place, defecation

358 MODERN SURGERY,

and all movements of the coccyx will cause excruciating
pain by pressure on the last sacral nerve. This condition,
known as ** coccygodynia," demands a subcutaneous division,
of the nerve or of the muscles which move the coccyx, or a
resection of the bone.

Fractures of the Vertebra. (See p. 592.)

Fractures of the Skull. (See p. 549.)

Fracture of the Clavicle. — The clavicle is more often
fractured than any other bone. This fracture may occur at
any age, but is notably common before the sixth year (Hulke
says one-half of the recorded cases). It may be simple, mul-
tiple, comminuted, oblique, transverse, complete, incomplete,
or. ver>' rarely, compound. Both clavicles may be broken.
Fractures are most apt to occur just external to the middle,
at the point where the inner or large curve meets the outer
or small cur\e, at which junction the bone is at its smallest
diameter. Fractures of the acromial end are more frequent
than fractures of the sternal end, and less frequent than fract-
ures of the shaft. The causes of clavicle-fractures are direct
violence, indirect violence, and, very rarely, the contractions
of ** the deltoid and clavicular fibers of the great pectoral "
(Treves, from Polaillon).

Fractures of the shaft are usually due to indirect vio-
lence, as falls upon the shoulder or upon the outstretched
hand. In the latter, which is the usual mode of origin, the
concussion of the fall travels up and the body-weight travels
down, and these two forces compress the bone, which snaps
at its weakest point. Fractures from indirect force are
oblique, and in children are of the green-stick form. Fract-
ures from direct force are usually transverse, and are occa-
sionally comminuted. Fractures from muscular action have
boon recorded (Rubini the tenor, recorded by Melay).

Sviuptoms. — In fractures of the shaft the attitude of the
patient is peculiar. He supports the elbow or wrist of the
injured side with the hand of the sound side, and also pulls
the extremity against the chest; the head is turned down
toward the shoulder of the damaged side, as if trying to
listen to something in the joint, thus relaxing the pull of
the sterno-cleido-mastoid muscle upon the inner fragment
The shoulder is nearer the sternum, on a lower level, and
farther front than that of the sound side. Loss of func-
tivMi is shown by inability to abduct the arm. Considerable
pain exists, which is increased by motion, by pressure, and
in lian^ini^ down the extremity without support.

The deformity above noted is described by stating that

DISEASES AND INJURIES OF BONES AND JOINTS, 359

the shoulder goes downward, inwafd, and forward (d. i. f.).
The downward deformity is chiefly due to the weight of the
arm, which pulls down the unsupported outer fragment, and
is contributed to by the action of the pectoralis minor
muscle. The inward deformity is chiefly due to the con-
traction of the pectoralis minor and subclavius muscles
assisted by the action of the pectoralis major. The forward
deformity is due to rotation of the outer fragment, which is
brought about by the serratus magnus muscle carrying the
scapula forward. In this deformity the inner end of the
outer fragment is below and behind the outer end of the
inner fragment, which overrides it. The inner fragment,
though pulled on by the sternomastoid and relatively higher
than the outer fragment, is really but little, if at all, elevated,
marked elevation being prevented by the attachment of the
rhomboid ligament. After noting the deformity, detect with
the finger the irregularity of bony contour. Examine for
preternatural mobility and crepitus by raising and throwing
back the shoulder. In looking for these signs in children it
is to be remembered that the fracture is probably incomplete.
The prognosis is good, the bone uniting, but always with
some shortening and inequality.

Complications, — Fractures of the shaft are rarely com-
pound, because the sharp end of the outer fragment goes
back and because of the free play the skin makes over the
bone (Pickering Pick). Both clavicles may be broken. In
fractures from direct force deeper structures may be injured
by fragments. Thus, injury of the brachial plexus will
induce paralysis. Ribs may be broken at the same time.

Treatment, — In treating fractures of the shaft reduce the
fracture as soon as possible by throwing the shoulder
upward, outward, and backward. If the patient is a girl,
it is desirable to minimize the deformity. Place her upon
her back on a hard bed, with a small pillow under her head,
a firm and narrow cushion between the shoulders, a bag
of shot resting over the seat of fracture, and the forearm
lying on the front of the chest, the arm being held to
the side by a sand-bag. In three weeks there will be union,
practically without deformity. In a child with an incomplete
fracture a handkerchief sling for the forearm, worn three
weeks, is all that is needed. In complete fracture the
Velpeau bandage is efficient (Fig. 273). Before applying
it, place lint around the chest and cotton over the elbow.
Change the bandage every day for the first week, and after
that period every third day. Each time it is changed rub

360 MODERN SURGERY.

the skin with alcohol, ethereal soap, or soap liniment, then
dry it and examine for excoriations, which, if any are found,
are anointed with zinc ointment before the dressing is reap-
plied. The dressing is permanently removed at the end of
four weeks, the arm being worn in a sling for another week.
The classical apparatus of Dcsault is now rarely used (Fig.
276). The posterior fig-
ure-of-8 bandage associ-
ated with the second roller
of Desault, some turns
being made from the elbow
of the injured side to the
shoulder of the well side,
can be used in cases in
which the forward deform-
ity is apt to return. The
apparatus of Fox, which
is very useful, consists of a
pad for the axilla, a sUng
for the forearm, and a ring
for the opposite shoulder,
to which ring are tied the

Fic 7S— Foil'. appiralM for IracluredcUvlcl*. tapCS ffOm both the pad

and the sling (Fig. 75).
The dressing of Moore of Rochester is valuable in an
emergency. It consists of a piece of cotton cloth, two yards
long, and folded like a cra-
vat until it is eight inches
in width at the middle. The
center of the bandage rests
upon the elbow, the poste-
rior tail is carried across
the front of the shoulder
of the injured side. The
forearm is at an acute angle
with the arm, and the other
end of the bandage is car-
ried across the forearm,
across the back over the
opposite shoulder, and ^l^.r^'I^^U'^^'""* '*"°^'^ "'"^
around Ihe axilla, where

the extremities are stitched together. The forearm is sus-
[xrndcd in a bandage siing (S. D. Gross). The four-tailed
bandaf;e is preferred by Pick. Sayre's dressing has many
advocates (Fig. 76). For this there are required two pieces

DISEASES AND INJURIES OF BONES AND JOINTS. 36 1

of rubber plaster, each piece being three inches wide and
sufficiently long to go around the chest one and a half times.
The end of one piece encircles the arm of the injured side just
below the arm-pit ; the plaster strip is pulled across the back
to the other side, to the front of the chest, and returns again
to the middle of the back. This procedure pulls the elbow
back and throws the shoulder out. The hand of the injured
side is placed on the breast of the opposite side, cotton
being interposed, and the second strip of plaster runs from
the elbow of the injured side and the opposite shoulder,
front, around, and back, pressing the elbow fon^'ard, upward,
and inward. If the fragments cannot be coaptated, incise,
clear away the muscle from between them, saw the ends, bore
each end and hold them in contact by means of kangaroo-
tendon or silver wire. The same procedure should be pur-
sued when a fracture is compound or threatens to become so.

In any fracture, if signs indicate pressure upon vessels or
nerves, incise, lift fragments into place and wire them. If the
patient refuses this operation, put him to bed and abduct the
arm. If a vessel is injured, operation is imperatively neces-
sary. After removing the dressings, if the shoulder is found
to be stiff, make passive movements daily ; if these fail, break
up the adhesions after giving ether or nitrous oxid.

Fraotore of the acromial end of the clavicle is due to
direct force. If the fracture is between the two coraco-
clavicular ligaments, deformity is very slight, crepitus is
elicited by manipulating with the fingers, and pain exists, but
loss of function is not markedly manifest unless it is due to
pain. These fractures are treated by binding the arm to the
side with the second roller of Desault, interposing cotton
between the arm and the side, and hanging the hand in a
sling. In fractures external to the ligaments crepitus is
manifest on moving the shoulder, the outline of the bone is
irregular, severe pain exists on movement, and deformity is
pronounced. The deformity is due to the serratus magnus
muscle rotating the scapula forward, the inner end of the
outer fragment of the clavicle often coming in contact with the
anterior surface of the outer portion of the inner fragment.
This fracture is reduced by pulling both of the shoulders
strongly backward, and it is kept reduced by a posterior fig-
ure-of-8 bandage. In fracture external to the ligaments the
displacement frequently cannot be corrected by position and
manipulation. Such cases demand incision and wiring. In
either fracture the dressings are worn for four weeks.

In children, if it is found difficult to immobilize the parts,

362 MODERN BURGER K

the most satisfactory result is obtained by the application of
the Velpeau bandage, which is to be overlaid by a plaster
bandage.

Fracture of the sternal end of the clavicle is very rare.
It is caused by either direct or indirect force. There are
found crepitus, projection at the seat of fracture, rigidity of
the sternomastoid muscle, and shortening of the clavicle.
The inner end of the outer fragment always goes forward,
and often also downward and inward. Reduce these fract-
ures by pulling the shoulders back, and treat them by
means of the posterior figure-of-8 bandage worn for four
weeks. Wiring may be necessary.

Fracture of the Scapula. — This bone is not often broken,
as it rests upon thick muscles and elastic ribs ; it is freely
movable, and it has attached to it a bone which easily breaks.
Fractures of the body of the bone are due to direct violence.
The symptoms are pain (which becomes agonizing on
attempting to rotate the shoulder-blade), ecchymosis, and
swelling. Crepitus is sought for by placing the hand over
the bone and making movements of the arm ; also by hold-
ing the point of the shoulder and lifting up the lower angle
of the bone. The latter plan may display mobility. Tlie
spine of the scapula is uneven only when it itself is fractured
Examine for unevenness of the vertebral border. In fract-
ures of the body of the scapula a shoulder-cap should be
applied, a gutta-percha splint must be moulded over the
scapula, the arm is bound to the side, and the hand is
carried in a sling. The apparatus is worn for four weeks.
Fractures of the spine of the scapula are treated as are fract-
ures of the body of the bone, and for the same time.

Fractures of the Neck. — Fracture of the anatomical neck
has not been proved to exist. Fracture of the surgical neck
is evinced by flattening of the shoulder, prominence of the
acromion, and a lump in the axilla which gives crepitus on
pressure upward and backward. The deformity is reduced
with ease, but it at once recurs. It is treated by placing a
pad in the axilla, a shoulder-cap on the shoulder, applying
the second roller of Desault, and supporting the forearm and
elbow in a sling. A Velpeau dressing can be used, associated
with a folded towel in the axilla. The dressing is to be worn
for five weeks.

Fracture of the g'lenoid cavity, which is not very unusual,
may occur with or without dislocation. It arises from direct
force applied to the shoulder. The existence of this fracture
is determined by excluding fractures of other bones and by

DISEASES AND INJURIES OF BONES AND JOINTS. 363

detecting crepitus when the arm is at right angles to the
body and the humerus is pushed against the glenoid cavity,
the crepitus not being found when the arm hangs by the side.

Treatment here is by the second roller of Desault and a
forearm sling for four weeks ; by careful passive movements
limit ankylosis, but, if it occurs, it will have to be broken up
while the patient is under ether or nitrous oxid.

Fracture of the acromion is often met with as the result
of direct violence. Its existence is indicated by pain, by in-
ability to abduct the arm, by flattening of the shoulder, by
sudden lowering of the point of the shoulder, by mobility,
and by crepitus. To treat a case of this kind, put a large
pad in the axilla with the base down, bind the arm over the
pad with the second roller of Desault, lifting the elbow with
turns of the roller carried over it and the opposite shoulder,
thus splinting the bone in place by the head of the humerus
pushing against the coraco-acromial ligaments. The dress-
ing is to be worn for four weeks.

F*racture of the coracoid, which rarely happens alone,
may arise from direct force or from muscular action. But
little displacement is found. Crepitus and mobility are usu-
ally detected. Inability to shrug the shoulder inward was
pointed out as a symptom by Byers. These cases are well
treated by the Velpeau bandage, which is to be worn for four
weeks.

B*racture8 of the humerus are divided into (i) fractures
of the upper extremity ; (2) fractures of the shaft ; and (3)
fractures of the lower extremity. In examining any fracture
of the humerus, feel at once for the pulse, so as to ascertain
if the artery has been torn ; in any fracture near the head of
the humerus be certain that there is no dislocation.

I. Fractures of the upper extremity include {a) fractures
of the anatomical neck ; {b) fractures of the surgical neck ;
(r) fractures of the head, oblique and longitudinal ; and {d)
separation of the upper epiphysis.

Fractures of the Anatomical Neck of the Humerus. —
The anatomical neck is the constricted circumference of the
articular surface, and fractures of it, though rare, do occur,
especially in the aged. The line of fracture in some cases
follows the insertion of the capsule, in others it is entirely
within the capsule, but in most it is without the capsule
above and within the capsule below ; hence the term " intra-
capsular " is rarely correct as a designation. The cause is
direct violence.

Symptoms. — ^The symptoms in fracture of the anatomical

364 MODERN SURGERY.

neck are pain, swelling, ecchymosis, slight irregulariU' of the
shoulder (which irregularity is soon hidden by tumdaction),
and inability to abduct the arm voluntarily. Deformit>', as
a rule, is slight or is absent, because the capsule is rarely en-
tirely torn from the lower fragment. If deformity exists, it is
due to the muscles inserted on the bicipital groove and to the
coracobrachialis, which pull the lower fragment inward and
fonvard. Treves says that a tear of the reflected fibers of the
capsule leads to subsequent necrosis, because this joint has
no ligamentum teres. In some cases impaction occurs, the
upper fragment impacting in the lower. In this condition
there is very slight shortening and shoulder-flattening, no
crepitus unless the tuberosity is broken off*, and, as Erichsen
says, the head of the bone, while it can be felt through the
axilla, is not in the axis of the limb.

The prognosis of this fracture is good for bony union (Ham-
ilton, Pick, and R. W. Smith), but a stiff" joint is apt to result

Treatment. — Some surgeons treat this fracture by simply
hanging the wrist in a sling and suspending a bag of shot from
the elbow to make extension. The usual plan of treatment is
as follows : flex the arm to a right angle with the body, and
carry up from the base of the fingers to above the elbow the
turns of a spiral reverse bandage. Interpose lint between the
arm and the side, and place a folded towel or a small pad in the
axilla, t>'ing the tapes over the opposite shoulder. Mould a
shoulder-cap (PI. 5, Fig. 8) upon the outer aspect of the arm
and upon the shoulder. This cap, which is made of paste-
board or of felt, should reach below the insertion of the deltoid,
cover one-half the circumference of the arm. and is to be
padded with cotton. The arm with the shoulder-cap is fixed
to the side by the second roller of Desault, and the hand is
hung in a sling. The edges of the bandage had best be
stitched. This apparatus is changed daily for the first few
days, the body and arm being rubbed at each change with
alcohol, soap liniment, or ethereal soap. After this period a
change every third or fourth day is often enough. Passive
motion is started at the end of four weeks, and the dressings
are removed at the end of six weeks. In impacted fracture
do not pull apart the impaction, but apply a cap to the shoul-
der and fix the arm to the side for five weeks. No pad is
used. The fracture unites with deformity.

Fractures of the Surgical Neck of the Humerus. — The
sur<^ical neck is the constricted portion of bone between the
tuijerosities and the upper line of the insertion of the muscles
on the bicipital groove. Fractures in this region are usually

D/SEASES AND IS'JURIES OF SONES AND JOINTS. 365

ransverse, but they may be oblique. The causes are — direct
tree, almost always ; indirect force occasionally ; and mus-
ular action in rare instances.

Symptoms. — The symptoms in fracture of the surgical neck
re — pain running into the lingers from pressure upon the
rachial plexus ; crepitus and mobility on extension ; and
attening, which diilers from the flattening of dislocation in
lat it occurs farther below the acromion and that this pro-
ess is not so prominent. Shortening to the extent of an
ich is noted. The head of the bone can be felt in the gle-
oid cavity, but it does not move on rotating the arm. The
pper end of the lower fragment is felt and moves on rotat-
ig the arm. The displacement is pronounced. The lower
agment is pulled upward by the deltoid, biceps, coraco-
rachialis, and triceps ; inward by the muscles of the bicipital
roove ; and forward by the great pectoral ; thus, the upper
id of the lower fragment projects into the axilla, and the
bow lies from the side and backward. Pean holds that the
olence sends the lower fragment forward. The upper frag-
lent is abducted and rotated outward, which position is due,

is generally taught, to the action of the supraspinatus, in-
aspinatus, and teres minor muscles. In some cases dis-
lacement is forward, and in other cases it is not obvious.
he lower fragment may impact into the upper, in which case
le symptoms are obscure and the diagnosis is made by ex-
usion. If the impaction is solid
id complete, there are the his-
>ry of direct force, the impaired
lovements, the slight deformity,
id the absence of crepitus. In
,1 fractures of the upper end of
le humerus the distinction can
E made from dislocation by feel-
ig the head of the bone under
le acromion and by noting that

does not move on rotating the
rm. The prognosis of these fract-
res is good.

Treattnent. — In treating a case
r fracture of the surgical neck, fic. ».— intemai mpiiar ipiim
:duce by traction and manipula- ir.i*S™koMhthuBw™"°"'"'"'
on ; if there is an impaction, pull

apart Take an internal angular splint (PI. 5, Fig. 6) and
id it well, putting on extra padding at the points that are
} rest against the palm, the inner condyle, and the axillary

366 MODERN SURGERY, I

folds. Lay the arm and pronated forearm upon the splint
Apply a padded shoulder-cap. Fix the splint and cap in
place with a spiral reverse bandage terminating as a spica
of the shoulder, and hang the hand or forearm in a sling
(Fig. 77), The dressing is to be worn for five weeks, and
the rules to be followed in changing it are the same as in
fractures of the anatomical neck. Motions are to be made
after four weeks to amend stiffness. Another plan of treat-
ment is the same as for fracture of the anatomical neck, sup-
porting the wrist only
in a sling so as to get
the extending we^ht
of the elbow, increasii^
this weight in some
cases by hanging to the
elbow a bag of shot
In rare cases — those
with strong anteriorpro-
jection of the lower end
of the upper fragment-
apply an anterior angu-
lar splint (Brinton). In
some cases where the
deformity strongly tends
to recur support by a
plaster-of- Paris trough
on the back and sidesof
arm and shoulder (Fig.
78), and maintain ex-
tension by weights and
F,G. ,B,-App»^™. for^fr=i«u«^,J^ti« hui>«™i a. pu]ieys,thepatientbdng
kept in bed (StimsoniL
Longritudinal and Oblique Fracture of the Head of the
Humerus. — By this term may be designated separation of
the great tuberosity, or separation of a portion of the articular
surface, together with the great tuberosity, from the shaft and
lesser tuberosity (Pickering Pick. Guthrie, and Ogston). The
cause is direct violence to the front of the shoulder.

Symptoms. — The symptoms in longitudinal and oblique
fracture of the head are broadening and flattening of the
shoulder with projection of the acromion. The upper frag-
ment pa.sscs up and out, and the lower fragment passes up
and in to rest on the margin of the glenoid cavity below
the coracoid. The elbow is drawn from the side, there is
some shortening, and the patient cannot abduct his arm. If

DISEASES AND INJURIES OF BONES AND JOINTS. 367

the elbow be grasped and held to the side and the arm be
rotated while the other hand grasps the upper fragment,
crepitus is very positive. . Examination develops wide sepa-
ration of the fragments. The deformity cannot be entirely
corrected, because the biceps tendon gets between the
fragments (Ogston), but a useful Hmb can usually be
obtained.

Treatment — ^The plan which gives the best result in treat-
ing longitudinal and oblique fracture of the head is to place
the patient on his back upon a hard bed with a small firm
pillow under his head, and to abduct the arm above the
head, rotate it outward so that the back of the hand rests
on the bed, and hold it in place by sand-bags. This position
should be maintained for three weeks, at the end of which
jjeriod the fracture can be dressed for three weeks more as a
fracture of the anatomical neck. If the patient refuses to go
to bed, treat the injury as a fracture of the anatomical neck,
padding well over the tuberosities. The dressings should be
worn for six weeks, passive motion being made after four
weeks. In all the above injuries — in fact, in all fractures of
the humerus — feel at once for the pulse, to see if the artery
has been torn.

Separation of the Upper Epiphysis. — The epiphysis is
united during the twentieth year, its separation being a rare
accident and being produced by direct force.

Symptoms. — The chief symptom in separation of the upper
epiphysis is projection of the upper end of the lower frag-
ment inward, forward, and upward beneath the coracoid, and
consequently a projection of the elbow backward and from
the side. If the lower fragment passes forward and not
inward, the elbow simply passes back. The upper end of
the lower fragment is smooth and convex. Rotation of the
shaft develops soft crepitus when the fragments are in
contact.

The prognosis is good for bony union, though the future
gprowth of the limb may be impaired.

Treatment, — The treatment for separation of the upper
epiphysis is a pad in the axilla, a shoulder-cap, binding
the arm to the side, and hanging the hand in a sling.
Wear the dressing for six weeks.

2. Fracture of the Shaft of the Hiimerus. — Fracture
of the shaft of the humerus is a very common accident.
The cause is usually direct violence, such as a blow. The
fracture may arise from indirect violence, such as a fall upon
the elbow. Muscular action is not rarely also a cause, as

368 MODBRH SURGER Y.

in throwing a ball, in catching a tree-limb while falling, or
in turning another's wrist as a test of strength (Treves),

Symptoms. — The symptoms of a fractured shaft are pain,
swelling, ecchymosis, inability to move the arm, mobilit>', and
distinct crepitus. Shortening to the extent of three-fourths
of an inch occurs. The displacement varies with the situ-
ation of the fracture and the direction of the force. If the
fracture is above the insertion of the deltoid, the lower frag-
ment is pulled up by the triceps, bicqjs, and deltoid, and
pulled out by the deltoid, and the upper fragment is pulled
inward by the arm-pit muscles. In fracture below the del-
toid this muscle is apt to pull the lower end of the upper
fragment outward, while the lower fragment passes inward
and upward because of the action of the biceps and triceps.
The prognosis is good, but the fact should always be
remembered that ununited fractures are commoner in the
humerus than in any other bone. Treves believes this to be
due to entanglement of muscle between the fragments, lack of
fi.Yation of the shoulder-joint, and imperfect elbow-suj^rt
Hamilton believes that it is due to the facts that the elbow
soon becomes fixed at a right angle, and that any movement
of the forearm moves the seat of fracture, and not the elbow.
Treatment. — Reduce the fracture by extension, counter-
extension, and manipulation. Apply an internal angular
splint without the shoulder-cap
(Fig. 79). If deformity is not cor-
rected, associate with this splint
three short humeral splints in-
stead of the shoulder-cap used in
fractures near the shoulder-joinL
Splints are to be worn for six
weeks. Passive movements are
not to be made until the fracture
is well united (after six weeks),
for, if made too soon, they pre-
dispose to non-union, and, as no
joint is involved, ankylosis will
not occur. Many surgeons treat
Fig. j9.— iniernji aiwuiir tpiini in (hese fracturcs by applying plas-

fraclurt iif the shall of Ihc hiiineTUB. p -n . ^ j

ter-of-Pans to forearm, arm, and
shoulder (the elbow being flexed to a right angle), and hang-
ing a weight to the elbow. Others apply a trough to the
arm and forearm (Fig. 78). In any case in which it is im-
possible to obtain and maintain correct apposition of the
fragments cut down upon them, and apply sutures.

DISEASES AND INJURIES OF BONES AND JOINTS, 369

3. Fractures of the Lower Extremity of the Humerus.
— These fractures are spoken of as fractures in, or in the
neighborhood of, the elbow-joint, and they include {a) fract-
ure of the external condyle ; {b) fracture of the internal con-
dyle ; (c) fracture of the internal epicondyle ; {d) fracture at
the base of the condyles ; {e) T-fracture ; and {/) epiphyseal
separation. In all injuries of the elbow-joint use ether while
making diagnosis and applying first dressing.

Fracture of the External Condyle of the Humerus. —
A fracture of the external condyle runs into the joint and
the capitellum is usually broken off. This injury occurs
oftenest in children by falling on the hand, but it may occur
from direct force, and may happen to adults.

Symptoms, — The symptoms of fracture of the external
condyle are severe pain, great swelling, and crepitus (found
on pressing or moving the condyle and on rotating the
radius). Mobility may also be discovered. A projection is
felt on the outer and posterior surface of the elbow. The
hand is supinated and the forearm is semiflexed. The patient
cannot use the joint. The first examination must be made
under ether unless an ;r-ray apparatus is accessible, but even
when we have a skiagraph of the part the first dressing should
be put on under ether.

Fracture of the Inner Epicondyle of the Humerus. —
The inner epicondyle is an epiphysis which unites during
the seventeenth year. It not infrequently breaks from mus-
cular action or from direct violence, the fracture not involv-
ing the joint. Crepitus and mobility can be detected. Dis-
placement is slight. The outer epicondyle is never fractured
alone.

Fracture of the Internal Condyle of the Humerus. —
The line of fracture of the internal condyle runs into the
joint, to the trochlear surface of the humerus. The cause
is always direct violence.

Symptoffts, — In fracture of the internal condyle the frag-
ment, accompanied by the ulna, goes upward and backward,
and when the forearm is extended the ulna projects poste-
riorly, the lower end of the humerus being felt in front. The
fragment forms a projection back of the elbow. Crepitus
and preternatural mobility can be found if swelling is not too
great. Crepitus is detected by flexing and extending the
forearm. The space between the condyles is broader than
normal and the forearm takes a bend toward the ulnar side^
the " carrying function '* of the forearm being lost. When a
person carries a heavy object, such as a bucket, he instinc-

370

MODERN SURGERY.

lively rests the inner condyle upon the pelvis, and the nor-
mal deviation of the forearm outward keeps the bucket from
striking the leg. This deviation outward when the inner
condyle is against the ilium gives us the carrying function.

Tclation of Ihc pans vhcn izarryinE ; c shnwh Ihc i.ltE»1ion of aiii of Ihe rDnarin *hei
innel condric n fraciurcd (ificr ANis).

In fracture of the inner condyle the broken condyle ascends
and the " carrying function " is lost (Fig. 80).

Fracture at the Base of the Condyles of the Humerus.
— This fracture is just above the olecranon and is on a h^her
le\'el behind than in front. The cause is direct force upon the
olecranon.

The symptoms arc loss of function and pain from injury of
the median or ulnar nerves. Crepitus and mobility are readily
found. The lower fragment goes backward and upward by
the action of the triceps, biceps, and brachialis anticus. The
lower end of the upper fragment jirojects in front of the joint.
This lesion may be mistaken for dislocation of the bones of

DISEASES AND INJURIES OF BONES AND JOINTS. 3; I

the forearm backward. In fracture the limb is mobile; in
dislocation, rigid. In fracture the deformity is easily reduced
and strongly tends to recur; in dislocation the deformity is
reduced with difficulty and does not tend to recur. In dis-
location there is shortening of forearm but not of arm ; in
fracture there is shortening of arm but not of forearm. In
dislocation there is a smooth large projection below the
crease in front of the elbow ; in fracture there is a sharp
projection above the crease. In fracture there is crepitus ; in
dislocation there is no crepitus. The diagnosis can be set-
tled by the Rontgen rays.

T-fracture of lie Humerus. — This is a transverse fracture
above the condyles plus a vertical fracture between them.
The cause is violent direct force applied posteriorly.

Symptoms. — The symptoms are increase in breadth of the
joint, preternatural mobility, crepitus, pain, and swelling,
mounting uj> of the inner condyle back of the elbow on the
inner side, and of the outer condyle back of the elbow on the
outer side. The hand is supinated; the forearm semiflexed;
the carrying function is lost.

Prognosis and Treatment of Fractures In or Near
the Blbov-joiat. — The prognosis for complete restora-
tion of function is bad, and in most of these fractures
some deformity and considerable stiffness are inevitable.
Callus poured into a joint acts like a stone pushed into
the crack of a door: it limits
or prevents motion. Give
ether for diagnosis and the
first dressing. In all cases
possible use the .r-rays for
diagnosis. After the dress-
ings are applied the x-rays
will show if a displacement
has recurred during the ap-
plication of the splint. If
swelling is so great that the
surgeon dare not apply a
splint, let him rest the arm,

semiflexed, upon a pillow .np.n«rinc«oo»

and apply lead-water and .nD.n«rinc«oo»joini.

laudanum for a day or two. The position for splinting is to
be full supination, which is obtained by so placing the hand
of the patient that he could easily spit into the palm (Brinton).
Apply a well-padded anterior angular splint (a right-angled
splint; PI. 5, Fig. j; Fig. 81). If posterior projection exists.

372 MODERN SURGERY.

mould a pasteboard cup over the elbow and also use the
anterior splint, or apply a posterior trough without the
anterior angular splint (Fig. 78). In applying the anterior
angular splint first fasten the upper end to the arm, then
make extension of the elbow, and fasten the lower end
of the splint to the extended - forearm. This splint is to
be worn for five weeks, removing it carefully every third
day. Begin passive motion at the end of the third week.
Some surgeons oppose the making of passive motion so early,
believing that it leads to further formation of callus. After
the dressings are removed employ passive motion, massage,
hot and cold douches, inunctions of ichthyol or mercunal
ointment, iodin locally, corrosive sublimate and iodid of
potassium internally, and direct the patient to systematically
use the arm. Many surgeons at the end of the second u-eek
apply a Stromeyer splint, which permits the patient and the
surgeon to make some motion by means of the screw (Fig.
108) without removing the dressings. In children or in very
stout people an anterior angular splint will not stay in place,
in which case the arm should be put at a right angle and
plaster-of- Paris be used. If in any case after four weeks non-
union exists, put up the arm in a plaster splint for three or
four weeks more.

Allis warmly advocates treatment in extension. He holds
that the extended position secures the best circulation, and
if either condyle is unbroken gives us a natural splint Fur-
thermore, in fractures of the inner condyle, it restores the
carrying function, which the flexed position does not do. For
one week after the accident the patient stays in bed, with his
arm extended upon a pillow. After swelling subsides the
limb is wrapped firmly in a spiral flannel bandage and plaster
is rubbed in or the bandage is covered with adhesive plaster.

Some surgeons extend the limb and apply an ordinaty
plaster bandage, and in about three weeks substitute an ante-
rior angular splint. The trouble with treatment in extension
is that if ankylosis ensues the limb is nearly useless. Fur-
thermore, it requires confinement to bed.

Jones of Liverpool thinks that splints and bandages are
largely responsible for the stiffness which so commonly en-
sues upon an elbow injury. He advocates treatment by acute
flexion in all elbow injuries except fracture of the olecranon.
In a fracture he extends, supinates, and flexes to reduce the
displacement. He maintains flexion by fastening a bandage
around the wrist and neck. The bandage around the neck
passes through a rubber tube which serves to protect the

DISEASES AND INJURIES OF BONES AND JOINTS. 373

neck. The ball of the thumb should rest against the neck.
The bandage is fastened to a leather band around the wrist.
This position is maintained from three to six weeks.' The
author has treated a number of cases by Jones's method and
now prefers it to any other plan.

Separation of the lower- epiphysis of the humerus is a
not unusual accident. The inferior extremity of the humerus
may be separated, or the condyles may be separated from
each other and from the shaft of the bone.

SymptofPis, — The symptoms are — prominence in front of
the joint, caused by the lower end of the shaft of the hume-
rus ; projection backward of the olecranon ; hand midway
between pronation and supination. Epiphyseal separation
may retard growth and produce deformity.

Treatment. — ^Jones's position or anterior angular splint as
above directed.

Fractures of the uhia comprise the following varieties :
(i) fracture of the coronoid process ; (2) fracture of the olec-
ranon process ; (3) fracture of the shaft ; and (4) fracture of
the styloid process.

Fracture of the coronoid process of the uhia is a rare
injury and practically occurs only as a complication of a
backward dislocation of the ulna or in association with other
fractures.

Symptofns. — When fracture of the coronoid process is
associated with a dislocation there is produced crepitus on
reduction, and it is found that the deformity of the disloca-
tion promptly returns on cessation of extension. The upper
fragment may be pulled up by the brachialis anticus, and
there exists an inability to flex the forearm completely. The
position is one of extension with posterior projection of
the olecranon. The broken piece is felt in front of the
joint

Treatment. — ^The treatment is by an anterior splint whose
angle is less than a right angle ; the splint is to be worn for
four weeks, and passive motion is to be begun in the third
week. Jones's position may be used in treating such a case.
A stiff" joint will probably follow.

Fracture of the olecranon process of the ulna is not an
uncommon injury in adults. Hulkc states that it never
occurs before the age of fifteen, but the writer has seen in
the Jefferson Hospital a girl aged fourteen with a fractured
olecranon. The eause is direct violence or muscular action.
Only a small fragment may be torn away, or the greater part

* Provincial Medical Jour. ^ Dec, 1894, and Jan., 1895.

374 MODERN SURGERY,

of the olecranon may be broken off, and the break may be
comminuted or even be compound.

Symptoms. — The symptoms of fracture of the olecranon
arc — swelling ; partial flexion of forearm ; separation of frag-
ments, the upper piece being pulled up from half an inch to
two inches by the triceps ; the space between the fragments
is increased by forearm flexion and lessened by forearm ex-
tension ; there is inability to extend the arm. Bulging of the
triceps above the fragments and crepitus on approximating
the fragments are observed. In some few cases there is no
separation, the periosteum being untorn or the fascial expan-
sions from the triceps holding the fragments in apposition.
In such cases crepitus can be elicited by rocking the upper
fragment from side to side.

The prognosis is fair, fibrous union being the rule. Some
joint-stifihcss usually occurs, and much ankylosis may be
unavoidable.

Treatment. — This fracture calls for a well-padded anterior
splint, almost but not quite straight. A perfectly straight
splint is uncomfortable, and, by opening a retiring angle be-
tween the fragments and into the joint, favors non-union and
ankylosis. The splint should reach from a level with the
axillary margin to below the fingers. If the upper fragment
does not come in contact with the lower, pull it down by ad-
hesive plaster and fasten the strips to the splint. The author
in one case employed a glove to which strings from the ad-
hesive plaster were attached. After applying the splint keep
the patient in bed for three weeks. The danger of ankylosis in
this fracture is very great, and, in case it occurs in the posi-
tion of extension, an almost useless arm results. Pickering
Pick at the end of three weeks anesthetizes the patient,
presses his thumb firmly down upon the top of the olec-
ranon, puts the forearm at a right angle, and applies an
anterior angular splint and directs it to be worn for two
weeks, passive motion being made every other day. When
the splint is removed try to obtain motion as previously
directed. Non-union requires wiring of the fragments.

Fracture of the shaft of the ulna alone is most apt to be
near the middle, is always due to direct violence, and is not
unusually compound. An injury which breaks the ulna is
very apt to break the radius also.

Svmpton/s. — By running the finger along the inner surface
of the bone there are detected inequality and depres.sion;
crepitus and mobility are easily developed ; there are pain
and the evidences of direct violence. The long axis of the

DISEASES AND INJURIES OF BONES AND JOINTS. 375

hand is not on a line with the long axis of the forearm, but is
internal to it. If deformity exists, it is due to the lower frag-
ment passing into the interosseous space because of the action
of the pronator quadratus muscle ; the upper fragment, acted
on by the brachialis anticus, passes a little forward. The
forearm at and below the seat of fracture is narrower and
thicker than normal.

Treatment. — In treating fracture of the shaft place the
forearm midway between pronation and supination, so as to
bring the fragments together and to obtain the widest pos-
sible interosseous space ; this limits the danger of ankylosis
in this space. The position midway between pronation and
supination is marked by flexing the forearm to a right angle
with the arm and pointing the thumb to the nose. Take
two well-padded straight splints, one long enough to reach
from the inner condyle to below the fingers, the other from
the outer condyle to be-
low the wrist; place a
long pad over the inter-
osseous space on the
flexor side of the limb,
and another on the exten-
sor side ; apply the splints
and hang the arm in a tri-
angular sling (Fig. 82).
Passive motion is to be
made in the third week,

and the splints are to be ^'°- 82.— Two straight spUnt* in fracture of both
^ * ^ , bones of the forearm.

worn for four weeks.

Fractures of the ulna can be treated very efficiently with

plaster-of-Paris.

Fracture of the styloid process of the ulna is due to
direct force. The displacement is obvious.

Treatment. — In treating fracture of the styloid process push
the fragment back into place and use a Bond splint with a
compress for four weeks, or a plaster-of-Paris dressing.

Fractures of the radius include the following varieties :
(a) fractures of its head ; {b) fractures of its neck ; {c) fract-
ures of its shaft; and {d) fractures of its lower extremity.

Fracture of the head of the radius vcr>' rarely occurs
alone, but it may complicate backward dislocation of the
radius.

Symptoms. — The symptoms of fracture of the head of the
radius are crepitus on passive pronation and supination, and
loss of voluntary pronation and supination.

378 MODERN SURGERY,

mounting upon the dorsum of the upper fragment ColUss
fracture, a very common injury, is met with most frequently
in those beyond the age of forty, and oftener in women than
in men. It is due to transmitted force (a fall upon the palm
of the pronated hand), the force being received by the ball
of the thumb and passing to the carpal bones and the edge
of the radius ; a fracture begins posteriorly rather than ante-
riorly, the force driving the fragment upon the dorsal surface
of the radius, the carpus and lower fragment moving upward
and outward. The fragments are not unusually impacted.
In the author's experience dislocation of the lower end of
the ulna is a frequent complication, which arises from a fract-
ure of the ulnar styloid or tearing off of the internal lateral
ligament of the wrist. Some hold that this fracture is due
to sudden traction upon the anterior ligaments, which drag
upon the bone and break it at the point where the cancellous
end of the radius joins the compact shaft.

SyrNptows, — In Colles's fracture the hand is abducted
(drawn to the radial side of the forearm) and pronated,
the head of the ulna is prominent, the styloid process of
the radius is raised, and the lower fragment, which mounts
on the back of the lower end of the upper fragment, causes
a dorsal projection, termed by Liston the " silver-fork de-
formity/' The lower end of the upper fragment can be felt
beneath the flexor tendons above the wrist. The position
in deformity is produced by the force. Some consider it
is maintained by the action of the supinator longus and the
flexor and extensor muscles, but particularly by the exten-
sors of the thumb. Pilcher has demonstrated the fact that
in this fracture a portion of the dorsal periosteum is untom,
and this untorn portion acts as a binding band to hold the
frai^nionts in deformity. Pronation and supination are lost.
In this fracture the hand can be greatly hyperextendcd
(^Maisonneuve's .symptom). Crepitus, which is best obtained
by alternate hyperextension and flexion, can be secured
unless swelling is great or impaction exists. Crepitus on
side movements is rarely obtainable. Impaction may greatly
nuHlify the deformity, though displacement generally exists
tv> <vMne extent, and the fragments do not ride easily on each
oilu r. The styloid process of the ulna may be broken, or
the inferior radio-ulnar articulation may be separated. This
lattv r complication allows the lower fragment to roll freely
ii{VMi the upper, and the characteristic .silver-fork deformit)'
vlv\ N lun appear. If the .styloid process of the ulna is broken,
pu'Nxuiv over it cau.scs great pain. If a person in falling

DISEASES AND nvjL'RIES Of £ONES AKD JOINTS. 379

Strikes the back of the hand and a fracture of the radius
occurs, the lower fragment is driven upon the front surface
of the upper fragment and is felt under the flexor tendons at
the wrist. An elaborate study of fracture of the radius with

1 forward displacement of the lower fragment has been recently

■■published by John B. Roberts.'

Treatment. — In treating Colles's fracture reduce the de-

formity by hyperextension to unlock the fragmenfi and
'relax the dorsal periosteum, followed by longitudinal trac-
i.tion to separate the fragments,

and by forced flexion to force

them into position. This formula

was introduced many years ago

by the late R. J. Levis. The

extremity can be placed upoti a

Levis splint (Fig. 83). the position

maintaining reduction and the

tense extensor tendons giving

dorsal support. Some surgeons

use Gordon's pistol - shaped

splint. The favorite splint in

Philadelphia practice is Bond's.

It places the hand in a natural

position of rest (semiflexion of

the fingers, semi-extension of the wrist, and deviation of the

hand toward the ulna). Two pads are used: a dorsal pad

I Am. pur. Mid. Sci., Jan., 1897.

380 MODERN SURGERY,

which overlies the lower fragment, and a pad for the flexor
surface which overlies the lower end of the upper fragment
A bandage is applied, the thumb and fingers being left free
(Fig. 84; PI. 5, Fig. 7). Passive motion is begun upon the
fingers in three or four days, and upon the wrist during the
second week. The splint is removed in three weeks, and
a bandage is worn for a week or two more because of
the swelling. In applying the Bond splint, do not pull
the hand too much up on the block, or the fracture wU
unite with a projection upon the flexor surface of the
extremity and the tendons of the wrist will be apt to be
caught in the callus. If a stiff joint and limited tendon-
motion eventuate from the fracture, use massage, frictions,
sorbefacient ointments, tincture of iodin, electricity, and hot
and cold douches, or give ether and forcibly break up ad-
hesions. Undoubtedly more or less stiffness often follows
Colles's fracture, and some very able surgeons have been so
impressed with the frequency of its occurrence that they
have dispensed with the use of a splint. Sir Astley Cooper
long ago spoke of placing the arm in a sling as proper
treatment for fracture of the radius. Moore of Rochester
applied a cylindrical compress over the ulna, held in place
for six hours with adhesive plaster, then cut the plaster,
placed the forearm in a sling, and let the hand hang over
the edge of the sling. Pilcher applies a band of adhesive
plaster around the wrist and supports the wrist in a sling.
Storp says that dispensary patients are apt to disarrange
this dressing.^ He wraps a piece of rubber plaster four
inches wide around the wrist, and places a second piece
around the first so arranged as to form a fold over the
radius ; an opening is made through the fold for the passage
of a sling. In ten days the plaster is removed and the fore-
arm is carried in a sling.

Fracture of both the Radius and Ulna near the Wrist.
— Colles's fracture may be complicated by a fracture of the
ulna other than of its styloid process.

SvDiptovis. — In fracture of the radius and ulna near the
wrist the lower ends of the upper fragments come together,
the upjicr fragment of the radius is pronated, and the lower
fragment of the radius is drawn up. Pain, crepitus, mobilit>',
shortening, and loss of function exist.

Trcatvioit. — A fracture of the radius and ulna requires the
use of the Hond splint, as for Colles's fracture.

Separation of the Lower Radial Epiphysis. — ^This acci-

* Arch. f. klin. Chir , liii.

DISEASES AND INJURIES OF BONES AND JOINTS, 38 1

dent occurs in children from falling upon the palm of the
hand. It never happens after the twentieth year.

Symptoms. — In separation of the lower radial epiphysis
the lower fragment mounts upon the upper and produces a
dorsal projection like Colles's fracture, but the hand does not
deviate to the radial side. The deformity resembles that of
a backward carpal dislocation, but is differentiated from dis-
location by the unaltered relation in the fracture between the
styloid processes and the carpal bones.

Treatment. — The treatment in separation of the lower
radial epiphysis consists of the use of a Bond splint, as in
Colles's fracture.

Fractoree of the carpus are not frequent, and they are
usually compound. The cause is violent direct force.

Symptoms. — Fractures of the carpus are indicated by pain,
swelling, evidences of direct force, sometimes crepitus, loss
of power in the hand, and a very little displacement.

Treatment. — Many compound comminuted fractures of the
carpus require amputation. In an ordinary compound fract-
ure, asepticize, drain, dress with antiseptic gauze and a plas-
ter-of-Paris bandage, cutting trap-doors in the plaster over
the ends of the drainage-tube. In a simple fracture use lead-
water and laudanum for a few days. Dress the hand upon a
well-padded straight palmar splint (PI. 5, Fig. 10) reaching
from beyond the fingers to the middle of the forearm, and
place the hand and forearm in a sling. The splint is worn
for four weeks, and passive motion of the wrist is begun in
the second week.

Fracture of the Metacarpal Bones. — Metacarpal fracture
is very common. One or more bones may be broken. The
first metacarpal bone is oftenest broken ; the third is rarely
broken (Hulke). The cause is direct or indirect force.

Symptoms. — The signs of a metacarpal fracture are — dorsal
projection of the upper end of the lower fragment and the
lower end of the upper fragment ; pain ; crepitus ; and often
evidences of direct violence.

Treatment. — ^To treat a fracture of a metacarpal bone re-
duce by extension ; place a large ball of oakum, cotton, or
lint in the palm to maintain the natural rotundity, and apply
a straight palmar splint like that used in fractures of the car-
pus (PI. 5, Fig. 10). It may be necessary to apply a compress
over the dorsal projection. The duration of treatment is three
weeks, and passive motion is begun after two weeks. A plas-
ter-of-Paris dressing is often used.

Fractures of the Phalanges. — The phalanges are often

382 MODERN SURGERY.

broken. The fracture may be compound. The cause usually
is direct force.

Symptoms. — Fracture of the phalanges is indicated M
pain, bruising, crepitus, and mobility, with very little ot
no displacement.

Treatment, — If the middle or distal phalanx is broken^
mould on a trough-like splint of gutta-percha or of paste-
board, which splint need not run into the palm. If tlK^
proximal phalanx is broken, run the splint into the palm olC
the hand. Make the splint of gutta-percha, pasteboard, wood »
or leather. The splint is worn three weeks. A sling mus^
be worn, otherwise the finger will constantly be knocked an
hurt. Some cases require a dorsal as well as a palmar splin
These cases are dressed most satisfactorily with a silicate —
of-sodium or plaster-of- Paris bandage.

Fracture of the femiir is a very common injury. Th^
divisions of the femur are (i) the upper extremity; (2) th^
shaft; and (3) the lower extremity.

I. Fractiires of the upper exlromity of the femur
divided into {a) intracapsular; (p) extracapsular; (c) of
great trochanter ; and (rf) epiphyseal separation (either of"
the great trochanter or the head).

Intracapsular Fracture of the Femur. — This fracture of
the neck is transverse or only slightly oblique, and is not
unusually impacted. The cause is often slight indirect force,
of the nature of a twist, acting upon a person of advanced
years (more often a woman than a man), but not unusually
a fall upon the great trochanter is the cause. A fall upon the
knees, a trip, or an attempt to prevent a fall may produce this
fracture. It more often happens that the fall is due to the
fracture than the fracture arises from the fall. Intracapsular
fracture is never caused by direct force unless it is due to
gunshot violence. The aged are more liable to intracapsular
fracture than the young or the middle-aged, because, first,
the angle which the neck forms with the axis of the femur
becomes less obtuse with advancing years, and may even form
a right angle ; this change is more pronounced in women
than in men ; secondly, the compact tissue becomes thinned
by absorption, the cancelli diminish, the spaces between them
enlarge, the bony portions of the cancellous portion are
thinned or destroyed, and the cancellous structure becomes
fatty and degenerated. Sutton has shown that in very rare
cases this fracture may occur in the young, even before the
union of the epiphyses. Stokes follows Gordon of Belfast
in classifying fractures of the femoral neck. He divides them

DISEASES AXD INJURIES OF BONES AND JO/NTS. 383

into intracapsular and extracapsular, and subdivides intracap-
sular fractures into fracture with penetration of cervix into
head; fracture with reciprocal penetration; intraperiosteal
fracture at junction of cervix and head ; intraperiosteal fract-
ure of center of cervix ; extraperiosteal fracture, with lacera-
tion of cervical ligaments. The last-named fracture is the
most common. The first four forms may unite by bone, the
fifth form Mill not because of non-apposition, lack of nutrition,
effusion of blood, synovitis, or interstitial absorption.* Stokes
claims that we may have penetration, but not impaction.

Symptoms. — In intracapsular fracture there is usually
shortening to the extent of from half an inch to an inch ;
but in some cases no shortening can be detected. Shorten-
ing of a quarter of an inch does not count in diagnosis, for,
as Hunt shows, one limb is often naturally a little shorter
than the other. If the reflected portion of the capsule is not
toni, the shortening is trivial in amount or is entirely absent.
In some cases shortening gradually or suddenly increases
some Uttle time after the accident. This is due to separation
of a penetration, tearing of the previously unlacerated fibrous
synovial reflection, or restoration of muscular strength after
a paresis. A gradually increasing shortening arises from ab-
sorption of the head of the bone. Shortening is due chiefly
to pulling up of the lower fragment by the hamstrings, the
glutei, and the rectus.

Pdifi is usually present in front, posteriorly, and to the
side. The area of pain is localized, and motion or pressure
greatly increases the suffering.

Eversion exists, spoken of as *' helpless eversion," though
/n a very few instances the patient can still invert the leg.
This eversion is due to the force of gravity, the limb rolling
)utward becau.se the line of gravity has moved external 1\'.
That eversion is not due to the action of the external rotator
nuscles, as was taught by Astley Cooper, is proved b)- the
ict that when a fracture happens in the shaft below the in-
ertion of these muscles the lower fragment still rotates out-
ward. This is further demonstrated by the considerations
lat the internal rotators are more powerful than the cxtcr-
al, that some patients can still invert the limb, and that
version persi.sts during anesthesia.^ In some unusual cases
rzfersion attends the fracture. Inversion, if it exists, is due
> the fact that the limb was adducted and inverted at the
me of the accident, and after the accident it remains in this

1 Stokes, in Brit. Me,i. Jour., Ort. 12. 1S95.
* Exlmund Owens; A Manual of Anatomy.

MODERN SURGERY.

position (Stokes). Besides shortening and eversioD, the!
is somewhat flexed on the thigh and the thigh on the pf
vis, the extremity when rolled out resting upon its outer sur-
face. Abduction is commonly present.

Loss of power is a prominent symptom : the limb cm
rarely be raised or inverted; although in rare cases, when
the fibrous synovial envelope is untom. the patient may stuid
or even take steps. Pain is usually trivial except upon mo-
tion, when it may be localized in the joint. In some cases the
pain is violent. Crepitus often cannot be found, either b^
cause the fragments cannot be approximated, because pene-
tration exists, or because they are greatly softened by fatty
change. To obtain crepitus the front of the joint must Ik
examined while the limb is extended and rotated inward
But why try to obtain crepitus ? The diagnosis is readil.v
made without it ; in many cases it cannot be detected, and
the endeavor to obtain it inflicts pain and may product
damage. The.se fractures offer a not very flattering chanci
of repair, and efforts to find crepitus may produce seriou
damage,

Altired Arc of Rotation of the Great Trochanter (DesauU
sign). — The pivot on which the great trochanter revolves
no long^er the acetabulum, and the great trochanter no long'
describes the segment of a circle, but rotates only as the apt
of the femur, which rotates around its own axis. It is nee'
less to try to obtain this sign ; to do so inflicts violence on tl
parts.

Relaxation of the fascia lata (Allis's sign) simply meal
shortening. The fascia lata is attached to the ilium and tl
tibia (iliotibial band), and when shortening brings the tib
nearer to the itium this band relaxes and permits one to pu<
more deeply inward on the injured side, between the grc
trochanter and the iliac crest, and near the knee above tJ
outer condyle, than on the sound side. In this examinatic
each limb should be adducted. AUis has pointed out anothi
sign : when the patient is recumbent the sound thigh canm
be raised to the perpendicular without flexing the leg; tl
injured thigh can be. Lagoria's sign is a relaxation of tl
extensor muscles.

Ascent of the Great Trochanter above Nelatan's IJne. — ^Th
line'is taken from the anterior superior iliac spine to the mo
prominent part of the ischial tuberosity (Fig. 85). In heali
the great trochanter is below, and in intracapsular fract
is above, this line.

Relation of the Trocltanter to Bryant's Triangle (Fig. {

DISEASES AND INJURIES OF BONES AND JOINTS. 385

Place the patient recumbent, carry a line around the body on
a level with the anterior superior spines, draw a line from the
anterior iliac spine on each side to the summit of the corre-
sponding great trochanter, and measure the base of the tri-
angle from the great trochanter to the perpendicular line
from the spine to determine the amount of ascent. The dif-
ference in measurement between the two sides shows the
amount of ascent of the trochanter ; that is, shows the extent
of shortening.

Morris's measurement shows the extent of inward displace-
ment Measure from the median line
of the body to a perpendicular line
dra^^Ti through the trochanter on
each side of the body.

Diagnosis. — Intracapsular fracture
without separation of the fragments
may be mistaken for a mere contu-
sion, and the diagnosis may continue
obscure unless the fragments sepa- fig. 85 -a c d, Bryant's iiio.
rate. Loss of function in contusion itT(oUnr*^' ' ^ ^' ^****°"''
is rarely complete or prolonged,

although occasionally the head of the bone is absorbed.
Early in a contusion and possibly throughout the case, there
is no alteration between the relation of the spine of the ilium
and the trochanter, and no shortening. Contusion of a rheu-
"^tic joint leads to much difficulty in diagnosis. Intracap-
sular fracture maybe confused with extracapsular fracture or
^ith a dislocation of the hip-joint. Extracapsular fracture,
which is common in advanced life, but is met with in middle
life or even occasionally in the young, results usually from
P'cat violence over the great trochanter ; if non-impacted,
fhere are noted shortening of from one and a half to three
inches, crepitus over the great trochanter, and usually, but
"^t invariably, eversion ; if impacted, there is less eversion,
jjf^us is almost or entirely absent, and the shortening is
'^ted to about an inch. Great tenderness exists over the
P^t trochanter in both impacted and non-impacted fract-
^res. The extensor muscles are relaxed. In dislocation on
^c dorsum of the ilium the patient is usually a strong young
adult There is a history of forcible internal rotation. There
^ inversion (the ball of the great toe resting on the inAtep
^ the sound foot), rigidity, ascent of the bone above Nela-
J^n's line, and shortening of from one to three inches. The
"^d of the bone is felt on the dorsum of the ilium, and the
trochanter mounts up toward the spine of the ilium, and

386 MODERN SURGERY,

pressure upon it causes no pain. In dislocation into the
thyroid notch there is possibly aversion, but it is linked
with lengthening.

\n fracture of the brim of the acetabulum there is shorten-
ing which occurs on the removal of extension, inversion,
retained power of everting the limb, abduction, retained
power of adduction, flexion of knee, head of bone drawn
up and back with the acetabular fragment (Stokes). Crep-
itus, which is most distinctly appreciated by a hand resting
on the ilium. In fracture of the fundus of the acetabulum
there is shortening, and the head of the bone enters the pel-
vis (Stokes).

Prognosis. — The prognosis is not very favorable. Old
people not unusually die. Many surgeons have maintained
that bony union never occurs, but it certainly does sometimes
take place. Stokes holds that bony union is possible in
fractures with penetration and even in fractures without
penetration when the fracture is within the p>eriosteum.*
Non-union is not unusual. Permanent shortening to some
degree is inevitable, and the function of the joint is sure to
be more or less impaired. It will be found necessary in many
cases for the patient to always employ support in walking.

Treatment. — In treating a very feeble person for intracap-
sular fracture make no attempt to obtain union. Keep the
patient in bed for two weeks, give lateral support by sand-
bags, tic around the ankle a fillet, to which attach a weight
of a few pounds, and hang the weight over the foot-board
of the bed. When pain and tenderness abate, order the
patient to get into a reclining-chair, and permit him very soon
to get about on crutches. If hypostatic congestion of the
lungs sets in, if bed-sores appear, if the appetite and diges-
tion utterly fail, or if diarrhea persists, abandon attempts at
cure in any case and secure for the sufferer sunshine and
fresh air, simply immobilizing the fracture as thoroughly as
possible by means of pasteboard splints. In the vast major-
ity of patients, no matter how old, undertake treatment We
may be forced to abandon it, but should at least attempt to
obtain a cure. If it is determined to treat the case, com-
bine extension with lateral support by means of sand-bags
and the extension apparatus originally devised by Gurdon
Buck. The extension should be gentle, never forcible. It
is not wise to pull apart a penetration. Place the subject
on a firm mattress, and if the patient be a man, shave the
leg. Cut a foot-piece out of a cigar-box, perforate it for

* See the masterly paper of Stokes, before quoted.

DISEASES AND INJURIES OF BONES AND JOINTS. 387

a cord, wrap it with adhesive plaster as shown on Plate 5,
Figs. 15 and 16, run the weight-cord through the opening in
the wood, and fasten a piece of plaster on each side of the
leg, from just below the seat of fracture to above the malleo-
lus (PI. 5, Fig. 14). The plaster is guarded from sticking to
the malleoli by having another piece stuck to it at each of
these points. Apply an ascending spiral reverse bandage
over the plaster to the groin (Fig. 86). and finish the band-
age by a spica of the groin. Slightly abduct the extremity.
Put a brick under each leg of the bed at its foot, thus
obtaining counter-extension by the weight of the body.
Run a cord over a pulley at the foot of the bed, and get
extension by the use of weights. From ten to fifteen pounds
will probably be necessary at first, but after a day or two
from six to eight pounds will be found sufficient (remember
that a brick weighs about five pounds). Make a bird's-nest
pad of oakum for the heel. Take two canvas bags, one long

Fig. 86.— Adhesive plaster applied to make extension. It should be carried up higher to a

point just below the seat of fracture.

enough to reach from the crest of the ilium to the malleolus,
the other long enough to reach from the perineum to the
malleolus. Fill the bags three-quarters full of dry sand,
sew up their ends, cover the bags with slips, and put the
bags in place in order to correct eversion. The slips may
be changed every third or fourth day. The bowels are to
be emptied and the urine is to be voided in a bed-pan,
unless using a fracture-bed. Maintain extension for five or
six weeks, then mould pasteboard splints upon the part, and
keep the patient in bed for three or four weeks more. In
from eight to ten weeks after the accident the patient may
get about on crutches. Union, if it takes place, is usually
cartilaginous, but is sometimes bony, and there are bound
to be some shortening and some stiflfness of the joint. Pas-
sive motion is not made until after eight weeks have elapsed.
Senn claims that by his method of " immediate reduction
and permanent fixation " bony union is obtained in fractures

388 MODERN SURGEHY.

of the neck of the femur within the capsute. He "places
the patient in the erect position, causing him to stand uith his
sound leg upon a stool or a box about two feet in height;
in this position he is supported by a person on each sde
until the dressing has been applied and the plaster has set

" Another person takes care of the fractured limb, which
in impacted fractures is gently supported and immovably
held until permanent fixation has been secured by the dress-
ing. In non-impacted fractures the weight of the fractured
limb makes auto -ex tens ion, which is often quite sufficient
to restore the normal length of the limb ; if this is not the
case, the person who has charge of the limb makes traction
until all shortening has been overcome as far as possible, at
the same time holding the limb in position, so that the great
toe is on a straight line with the inner margin of the patella
and the anterior superior spinous process of the ilium. In
applying the pi aster-of- Paris
fi^ bandage over the seat of

'"'* fracture a fenestrum, cor-

responding in size to the
dimensions of the compress
with which the lateral press-
ure is to be made, is left
open over the great tro-
chanter.

" To secure perfect im-
mobility at the seat of
fractures, it is not only
necessary to include in the
dressing the fractured limb
and the entire pelvis, but it
is absolutely necessary to
also include the opposite
limb as far as the knee and
to extend the dressing as far as the cartilage of the
eighth rib.

" The splint (Fig. 87) is incorporated in the plaster-of-Paris
dressing, and it mu.st carefully be applied, so that the com-
press, composed of a well-cushioned pad with a stiff, unyield-
ing back, rests directly upon the trochanter major, and the
pressure, which is made by a set-screw, is directed in the
axis of the femoral neck. Lateral pressure is not applied
until the plaster has completely set. Syncope should be
guarded against by the administration of stimulants.
•' As soon as the plaster has sufficiently hardened to retain

DISEASES AND INJURIES OF BONES AND JOINTS. 389

the limb in proper position, the patient should be laid upon
a smooth, even mattress, without pillows under the head,
and in non-impacted fractures the foot is held in a straight
position and extension is kept up until lateral pressure can
be applied.

" No matter how snugly a plaster-of-Paris dressing is
applied, as the result of shrinkage it becomes loose, and
without some means of making lateral pressure it would
become necessary to change it from time to time in order
to render it efficient. But by incorporating a splint in the
plaster dressing (Fig. 88) this is obviated, and the lateral
pressure is regulated, -day by day, by moving the screw, the
proximal end of which rests on an oval depression in the
center of the pad."

Eztracapenilar Fracture (fracture of the base of the
neck). — ^The line of extracapsular fracture is at the junction
of the neck with the great trochanter, and is partly within
and partly without the capsule, the fracture being generally
comminuted and often impacted. The cause is violent direct
force over the great trochanter (as by falling upon the side
of the hip). This fracture is most usual in elderly people,
but is not very uncommon in young adults. Stokes has
described six forms of extracapsular fracture: extracapsu-
lar fracture with partial impaction posterior; fracture with
complete impaction ; fracture with partial impaction above ;
fracture with partial impaction below, the shaft being split ;
splitting of the neck longitudinally without impaction ; com-
minuted non-impacted fracture.*

SymptotHS. — ^When impaction is absent there is marked
crepitus, which is manifested most when the fingers are put
over the great trochanter ; there is great pain, pressure upon
the great trochanter is very painful, swelling and ecchy-
mosis are marked ; there is absolute inability on the part of
the patient to move the limb, and passive movements cause
great pain ; there is shortening to the extent of at le^st one
and a half inches, and sometimes three inches, which short-
ening is made manifest by noting the ascent of the trochan-
ter above Nelaton's line, by comparison of the injured limb
with the sound limb, and by measuring the base-line of
Bryant's triangle on each side. Absolute eversion exists
with slight flexion both of the leg and the thigh. In some
rare cases inversion exists. This happens if at the time of
the accident the limb was inverted and adducted (Stokes).
Lagoria's sign and Allis's sign are present (p. 384). All these

* Brit. Med. Jour., Oct. 12, 1895.

390 MODERN SURGERY,

symptoms follow violent direct lateral force. In the m-
pactcd form of extracapsular fracture, in addition to the
aid given the surgeon by the history, there is severe pain
which is intensified by movement or pressure; shorten-
ing exists to the extent of one inch at least, which \s not
corrected by extension ; there is also great loss of function;
and whereas the limb may be straight or even inverted,
it is usually everted. Crepitus can be easily obtained when
there is no impaction, the trochanter moves in a large
arc of rotation and is above Nelaton's line, the base-line
of Bryant's triangle is shortened, and Allis*s sign is
noted.

Treatment. — In treating extracapsular fracture make ex-
tension, raise the foot of the bed, and apply the extension
apparatus with sand-bags for four weeks ; then apply a
plaster dressing and get the patient up on crutches. Remove
the plaster at the end of four weeks. In impacted extra-
capsular fracture it is best to pull apart the impaction if the
patient is in good physical condition. Southam of Manches-
ter, in an impressive article, has recently insisted on the
absolute necessity of pulling apart an impaction. He gives
ether, and when the patient is anesthetized unlocks the
fragments.^

Fracture of the Great Trochanter. — This process may
be (i) broken off without any other injury, but in most cases
(2) the line of fracture runs through the trochanter, and
leaves one portion of the trochanter attached to the head
and neck and the other part attached to the shaft. The
cause is violent direct force over the great trochanter.

Symptovis and Treatment. — The symptoms of the second
form are similar to those of extracapsular fracture. On
rotating the femur the lower part of the trochanter moves
with it, but not the upper. The lower fragment goes upward
and backward and projects by the side of the sciatic notch.
There are shortening, eversion, crepitus, and altered position
of the trochanter. The symptoms of the first form resemble
those of epiphyseal separation. The treatment of the second
form is like that in extracapsular fracture, and the first
form is treated like separation of the epiphysis of the
trochanter.

Separation of the upper epiphysis of the femoral head
is a very rare result of accident; it occurs most often from
disease and in youth.

Symptoms and Treatment. — The symptoms are like those

* Lancet y Dec. 21, 1895.

DISEASES AND INJURIES OF BONES AND JOINTS. 39 1

of fracture of the neck, except that the crepitus is soft.
The treatment is extension as above directed.

Separatdon of the epiphysiB of the grreat trochanter is
a very rare accident. The cause is direct violence, and the
injury occurs only in youth.

Sytnptotns, — ^The trochanter is found to have ascended
and passed posteriorly ; there is no shortening ; all the
motions of the hip-joint can be obtained; if the thigh is
flexed, abducted, and rotated externally, and the fragment
pushed down and forward, crepitus is obtained — soft in
epiphyseal separation, hard in fracture.

Treatment. — In treating separation of the epiphysis of the
great trochanter flex the leg on the thigh and the thigh on
the pelvis, place the extremity upon its outer surface, keep it
fixed by some form of retentive apparatus, and try to draw
the trochanter downward and forward by adhesive strips or
by a pad and bandage. Some degree of lameness is inevi-
table, even after Bryant*s extension. Bryant's extension
directly upward may admit of the trochanter being pulled
downward upon the bone (Fig. 93). Extension must be
applied for six weeks, and crutches and pasteboard splints
are used for four weeks more.

2. Fracturee of the shaft of the femiir may affect any
portion of the shaft, but especially the middle third, and may
occur at any age. The cause of fractures in the upper third
is usually indirect force ; fractures in the lower third are due
to direct force ; and in fractures of the middle third these two
causes are about equally potential. Fracture from muscular
action occasionally occurs. Oblique fracture is the usual
variety.

Symptofns, — The chief symptom in fracture of the shaft
of the femur is great displacement, except when impaction
occurs or when the break is in a child and the periosteum is
untom. As a rule, the lower fragment is drawn up and is
posterior and somewhat to the inside of the upper fragment,
and undergoes external rotation (the drawing up is due to
the rectus and hamstrings ; the passing inward is due to the
adductor muscles; the rotation outward arises from the
weight of the limb). In fracture of the upper third the
upper fragment is apt to be thrown strongly forward and
outward. Some attribute this to the action of the psoas,
iliacus, and external rotator muscles, but Allis thinks it
is due to the lower fragment pushing the upper fragment
into this position. There is complete loss of function, the
thigh and leg being semiflexed and everted. There are

MODERN SURGERY.

shortening to the extent of two or three inches, pain oa
movement, preternatural mobility, crepitus, and obvious

FicSg.

deformity, and the ends of the fragments can be felt In
impaction there is shortening with altered axis of the limb.

Treatment. — In fractures of the shaft of the femur some •
amount of permanent shortening is almost inevitable. In fract-
ures of the upper third use Agnew's plan — namely, a double
inclined plane with exten,sion in the axis of the partly-flexed
thigh (Fig. 89). If, notwithstanding position and extension,
the upper fragment pro-
jects, push it into place
and bind short splints
upon the Hmb. Extension
is continued for four weeks,
a plaster-of-Paris bandage
being used for four weeks
more, the patient being
then allowed to get about
on crutches. Some sur-
geons, in fractures of the
upper third, apply a plas-
ter-of-Paris bandage to the
leg, thigh, and pelvis, ex-
' tension being made from
the foot while the dressing
is being applied. The
anterior .splint of Nathan R. Smith is much used in the
South in treating fractures of the shaft and the upper ex-
tremity (Fig. 90). In -some fractures of the upper third no
apparatus will maintain reduction. In such cases it is ad-
visable to inci.sc, separate the muscle from between the ends
of the bone, and fasten the ends together with bone ferrules.

394 MODERN SVRGEK Y.

to the cross-bar of the frame and pulling upon the frame
by cords {Fig. 91). In fractures of the lower part of llie
lower third of the shaft use a double inclined plane (H. 5.
Fig. 2) alone. A Mclntyre splint (Fig. 92) is a useful forai
of double inclined plane. At the end of four weeks apply
pla.ster. which is to be worn for four weeks. In children
under three years of age the extension apparatus will not
satisfactorily immobilize the fragments. Fractures of the
thigh in children are reduced by extension and counter-
extension ; a we 11 -padded splint reaching from the axilla to
below the sole of the foot is applied to the outer side of the
limb and body. This splint is held in place by bandages
which are overlaid with plaster of
Paris. It is worn for four weeks, at
which time it is removed and a plas-
ter bandage, applied so as to include
the entire limb, is worn for four weeks

Bryant's extension is very satis&c-
tory in treating a child (Fig. 93).
Both the injured limb and the sound
limb should be flexed to a right angle
with the pelvis, fixed by light splints,
and fastened to a bar above the bed
The weight of the body produces
counter-extension and the child can
be easily cleaned (Bryant's Praftire
of Surgery).

for'^fric?ur7u?ihc*ihi'h"in°" FVaoture just above the Con-
•xm'. dyleB. — The line of this fracture is

well above the epiphyseal line. The
femoral arter)' is in danger from the fragments. The caust.
as a rule, i.s direct violence. Indirect force is sometimes
responsible {falls upon the feet). The knee-joint may be
oix;ned. The fracture is sometimes compound.

Sympttmis. — The upper end of the lower fragment is drawn
upward and backward, because of the action of the rectus,
hamstrings, gastrocnemius, and popliteus. The upper frag-
ment pas.ses inward, and the deformity is very manifest
There are shortening, crepitus, and mobility. The ends of
the fragments can be felt. If the force has been very great
a T-fracture results, and in this the knee is broadened and
cre])itus is got by moving the condyles, one up and the
other down.

Tnatiiifnt. — In treating fracture at the base of the condyles.

DISEASES AND INJURIES OF BONES AND JOINTS, 395

place the limb on a double inclined plane for five weeks,
then begin passive motion once every other day, restoring
the limb to the splint after the movements are completed.
At the end of eight weeks after the accident remove the
dressings, and, if the knee-joint be stiff, use for some time
massage, motions, hot and cold douches, ichthyol inunctions,
etc. Bryant treats this fracture in extension, cutting the
tendo Achillis, if necessary, to amend deformity. It is occa-
sionally necessary to wire the fragments. Some cases de-
mand amputation because of injury to the structures in the
popliteal space.

PracturiB Separatinfir Either Condyle. — The cause of this
fracture is direct force.

Symptoms and Treatment — The broken piece is drawn
upward, the leg bends toward the injury, crepitus exists, the
knee is much broadened, there is no shortening, and con-
siderable swelling is sure to arise. In treating a fracture
separating either condyle, use a double inclined plane as
directed above.

lion^tudinal fractures run up from the knee-joint. The
cause is a fall upon the feet or the knees.

Symptoms and Treatment, — The symptoms of longitudinal
fracture are often obscure. The femur is broadened when
the knee is flexed. The split is detected between the con-
dyles. The treatment is the straight position in plaster for
eight weeks.

Separation of the lower epiphysis occurs only before
the twenty-first year.

Symptoms. — ^The symptoms in separation of the lower
epiphysis are like those of fracture, but crepitus is moist.
The danger is that the growth of bone will be stunted.

Treatment. — The treatment for separation of the lower
epiphysis is a double inclined plane as above directed.

Fracture of the patella is a very common accident. The
cause is direct force (producing vertical, star-shaped, or
oblique lines of fracture) or muscular action (producing a
transverse line of fracture).

B*ractures of the Patella by Muscular Action. — The
knee-cap is more often broken by muscular action than is
any other Jbone. When the knee is partly flexed the middle
third of the patella rests upon the condyles of the femur and
the upper third of the knee-cap projects above them ; when
in this position a contraction of the quadriceps may easily
cause a fracture near the center of the bone (Fig. 94). Both
patellae may be broken at once. In this form of fracture the

396 MODERN SURGERY.

joint, and often the prepatellar bursa, is opened. Fractures
by muscular action are transverse.

Symptoms, — The symptoms in fractures by muscular action
are — rapid and enormous swelling, due to the effusion first
of blood and then of synovia and inflammatory products into

and around the joint ; absolute inability
to raise the limb from the bed. The frag-
ments are widely separated, this separa-
tion being distinctly manifest to the touch
unless swelling is great. The separation
is accentuated by flexion of the leg.
Crepitus is detected if the upper frag-
ment can be pushed down until it touches
Fig 94— Mechanism of the lower piece, but if swelling is great
S;ircXrlt?c: {r'r^vU^ this cannot be done. Union, if it occurs,

will probably be ligamentous, and if the
patient gets about too soon, apparently well-united fragments
will by degrees stretch far asunder.

Transverse Fractures of the Patella. — Treatment. — If the
swelling in transverse fracture of the patella be so great as
to prevent approximation of the fragments, reduce it by
bandaging for a day or two, by using ice-bags and lead-
water and laudanum, or by aspirating the joint. When the
swelling diminishes, bring the two fragments into app>osition,
pull them together by adhesive plaster, and put on a well-
padded posterior splint. Run a piece of adhesive plaster
over the upper end of the upper fragment, draw the bone
down and fasten the plaster behind and below the joint.
Run another piece of plaster over the lower end of the
lower fragment, draw the bone up, and fasten the plaster
behind and above the joint. A third piece is run over the
junction of the fragments to prevent tilting. Agnew's sphnt
admirably accomplishes this approximation (PI. 5, Figs, ii,
1 2). A bandage holds the splint in place, and may be carried
around the knee by figure-of-8 turns. The heel is sometimes
raised upon a pillow so as to extend the leg and to semiflex
the thigh, but this is not essential. Remove and reapply
the dressing every few days, as it inevitably becomes loose.
At the end of three weeks remove the splint permanently
and apply a plaster-of-Paris dressing from ju.st above the
ankle to the middle of the thigh. The dressing is to be worn
tor "tw^^ weeks. At the end of eight weeks let the patient
Wvilk with canes, the joint being kept fixed for four weeks
nu>ro by pasteboard splints or by a light plaster-of-Paris
bandage. For one year after removing the splints and

DISEASES AND INJURIES OF BONES AND JOINTS. 397

plaster a lacing knee-cap and a posterior splint should be
worn to sui^K>rt the joint. The plan of prolonged retention
renders more or less joint-stiffness a certain occurrence, but
this is less of an impediment than the wide separation of the
fragments that inevitably attends an early use of the joint
W. Barton Hopkins, of the Pennsylvania Hospital, has
devised an excellent adhesive-plaster dressing, by means of
which extension is maintained upon the upper fragment.
Bryant of New York has devised an ambulatory dressing.
Malgaigne's hooks (Fig. 95), if employed to treat these
fractures, are to be inserted with the full antiseptic care of
an ordinary surgical opera-
tion. Insert the lower hooks
just below the point of the
patella, entering them under
its edge, press the fragments
together, draw up the skin
over the upper fn^ment to
prevent puckering, and insert
the upper hooks with force

just above the upper fragment, letting the points of the
hooks bear upon the bone. Lock or screw the hooks to-
Sf^ther, dress with antiseptic gauze, and apply a posterior
^pJint. Remove the hooks in three weeks, and treat with
P^^ster as in the preceding case when the special splint was
removed.

Among other plans of treatment may be mentioned wiring
^ fragments (see Operations upon Bones) ; encircling the
^Snients with a subcutaneous silk ligature ; passing a pin

Fig. 95. — Malgaigne's hooks.

^,jT •*•- 96.— Needle specially designed 10 carry a thick wire. The eye is drilled obliquely,
•j^r'^^Mild receive only a little loop on the end of the wire ; this little loop should be made

l*e>i

ousiy {vUU Figs. 97, 98, Barker).

jnrough the tendon of the quadriceps, another through the

*Sa.inent of the patella, and approximating the two by figure-

^^-8 turns with a silk cord, thus drawing together the frag-

!?^^nts. Barker believes strongly in wiring recent transverse

*^^tures. He does it with antiseptic care soon after the

^^ident, and permits passive motion or even slight active

39S MODERN SURGERY.

motion immediately after the operation. Massage is b^un
the day after the operation and is continued for two weeks.
Barker ' uses a special needle (Fig. 96) and silver wire of
the thickness of a No. 1 English catheter. This wire is
straightened and softened in a spirit-flame. He rubs the
fragments together in order to dislodge blood or fibrous
material, and when marked grating occurs he introduces the
wire. A puncture with a small knife is made through the
middle of the upper attachment of the patellar ligament

:n<lW=f

The needle, not carrying any wire, is made to enter through
this opening into the joint, is passed back of the fragments,
pierces the tendon of the quadriceps at the upper edge of
the upper fragment, and its point is cut upon with a knife.
The wire i.s inserted into the eye of the needle and the needle
is withdrawn and unthreaded. The empty needle is pushed
through the lower opening, is carried in front of the joint, is
made to emerge at the upper opening, is threaded again and
witlidrawn (Figs. 97, 98). The wires are threaded into bars
and twisted (Fig. 99),

Fractures of the patella by direct force are vertical,
stellate, oblique, or V-shaped, and are often incomplete.

1 Bril. MfJ.Jour., April II. 1896.

S£AS£S AND INJURIES OF BONES AND JOINTS. 399

Symptoms. — Fractures
of the patella by direct
force are indicated by dis-
coloradoti, swelling, great
difficulty in movement, and
much pain. There may or
may not be crepitus, and
rarely is there separation
of the fragments. " Bony
union occurs in these
fractures.

Treatment. — F r a c t u r e
by direct force requires a
posterior splint, the local
use of lead- water and
laudanum, and the appli-
cation of a bandage. If
there is any separation,
approximate the frag-
ments by bandages and
compresses. The dan-

in these cases is not non-union, but ankylosis ; hence.

n passive motion of the knee-joint in the fourth week

400 MODERN SURGERY,

after the accident. Remove the dressings at the end of six
weeks, and let the patient at once get about.

Fractures of the Legr. — In leg-fractures both bones or
only one bone may be broken.

Fractures of the tibia are divided into (i) fractures of the
upper end ; (2) separation of the upper epiphysis ; (3) fract-
ures of the shaft ; (4) fractures of the lower end ; and (5)
separation of the lower epiphysis.

Fractures of the upper end of the tibia are uncommon.
They may be transverse, oblique, or vertical, running into the
joint. The cause is direct \aolence.

Symptoms. — In fracture of the upper end of the tibia there
is contusion of the soft parts. In a trans^'crse fracture there
are mobility and crepitus, but there is little displacement. In
oblique fracture crepitus and mobility are marked and the axis
of the limb is altered. In vertical fractures entering the joint
there is great swelling of the knee-joint. In cafnminuted
fractures, which exhibit marked signs, union is readily ob-
tained, but if the joint has been damaged stiffness is sure to
ensue.

Treatment. — In treating fractures of the upper end of the
tibia employ a double inclined plane in the form of a Mcln-
tyre splint (Fig. 92) or in the form of a fracture-box (PI. 5,
Fig. i). Lead-water and laudanum are applied about the
knee-joint. At the end of the fourth week begin passive
motion, reapplying the splint after each daily seance. In six
weeks let the patient get about, first with crutches, then with
a cane, then without any artificial support.

Separation of the Upper Epiphysis of the Tibia. — There
is only one recorded case (Pick).

Fractures of the Shaft of the Tibia. — ^The cause of these
fractures is direct force. The fracture is generally transverse
in the upper part of the bone and obhque in the lower part
(Pickering Pick).

Symptoms. — In transverse fracture of the shaft of the tibia
there is no deformity, and the support of the fibula may even
permit of walking ; there is fixed pain ; there may or may
not be inequality of fragments felt by the finger; and there
arc crepitus, mobility, and often linear ecchymosis. In oblique
fractures there usually exist crepitus, a little mobility, and
some deformity. The deformity depends on the direction
of the line of fracture, and, as this line is usually from above
downward, inward, and a little forward, the lower fragment
usually passes behind the upper fragment and rotates inward.

Treatment. — In treating fractures of the shaft of the tibia,

DISEASES AND INJURIES OF BONES AND JOINTS. 4OI

if there be much swelling, put the limb in a fracture-box
(PI. s. Fig. 1 ; Fig. 100) and apply lead-water and laudanum.
A silicate-of-sodium or a plaster-of-Paris dressing is applied
when the swelling subsides, or the dressing is used at once

Fio. loo.— FnOBR-boi (n fnctun oF the

if swelling is slight. The patient gets about on crutches.
The dressing is removed in six weeks, and the patient goes
about for one week on crutches, lightly using the foot, and
then for one week with a cane. At the end of eight weeks
the leg may be used, but not too much at first

Fraotorea of tiie Lower Bnd of the Tibia: Fracture
of the Inner Malleolus. — ^The cause of fracture of the inner
malleolus is direct force.

Symptoms and Treatment. — The symptoms of fracture of
the inner malleolus are some downward displacement, de-
pression above the fragment, mobility, and crepitus. The
treatment is to push the fragment into place and use side-
splints or a fracture-box for two weeks, when a plaster-of-
Paris or a silicate dressing may be substituted and the pa-
tient be ordered to use crutches. Remove the plaster four
weeks after it is applied, and direct the patient to gradually
bear his weight upon the leg, as outlined above.

Separatioa of the lower epiphysis of the tibia is a very
rare accident. The treatment is a fixed dressing for six
weeks.

Fracture of the fibula alone is commoner by far than is
fracture of the tibia alone. Fractures in the upper two-thirds,
which are rare, are usually due to direct force. Fractures in
the lower third are frequent, and they arise from indirect
force.

402 MODERN SURGERY.

Fractures of the Upper Two-thirds of the Fibula.— In

these fractures the cause is direct force.

Symptoms, — In fracture of the upper two-thirds of the
fibula the patient can often walk. The bone is deeply situ-
ated, and displacement cannot often be made out. There is
a fixed pain, which is intensified by movement and by press-
ure. Pressure upon the lower fragment does not move the
upper fragment. Crepitus is sometimes felt, and a linear
ecchymosis is apt to appear. The bone bends normally,
hence slight mobility is of no value diagnostically.

Trcatvicnt. — In treating a fracture of the upper two-thirds
of the fibula apply a plaster-of- Paris or a silicate bandage
and direct that it be worn for six weeks. Weight is not to
be put upon the foot for six weeks after the accident.

Fractures of the Lower Third of the Fibula. — In these
fractures the cause is indirect force, especially twists of the
foot. Forcible inversion of the foot pulls upon the external
lateral ligament and the extenial malleolus, forces the fibula
outward, and tends to break it, the lower fragment being dis-
placed outward. Forcible eversion pulls the internal lateral
ligament off from the inner malleolus (often breaks the mal-
leolus) and fractures the fibula above the ankle, the bone
being displaced inward.

Sympkwis. — In the lower third of the fibula the bone is
superficial, and the irregularity of a fracture is manifest to
the touch. There is localized pain, which is increased by
pressure or by motion. Crepitus may exist. Deformity is
often exhibited by the position of the foot.

Pott's fracture, which is a fracture of the lower fifth of
the fibula accompanied by outward dislocation of the foot,
is due to powerful eversion of the foot. This outward
dislocation is rendered possible by rupture of the deltoid
ligament or — what is far commoner — by the tearing off of
a portion of the internal malleolus.

Treatment. — In fractures of the lower third of the fibula,
after reducing displacement, place the limb in a fracture-box
containing a soft pillow. A bird's-nest pad of cotton or
oakum is made for the heel (Fig. lOO). A fillet around the
ankle fastens the foot to the foot-piece of the box ; a pad
of oakum rests between the foot-piece and the sole. If
dressing Pott's fracture, put a compress above the inner
malleolus and another compress below the outer malleolus.
Close the sides of the box and tie them together uith a
bandage. Swing the box, if desired, on a gallows. Ever)'
day let down the sides of the box and rub the leg, the ankle.

DISEASES AND INJURIES OF BONES AND JOINTS. 403

and the foot with alcohol. In ten days apply a plaster-of-
Paris bandage and let the patient get about on crutches.
Remove the plaster at the end of the fifth week after the
accident, and let the patient go about with crutches for one
week and with a cane for a week longer.

Some surgeons dress Pott's fracture with a Dupuytren
splint. This is a straight splint (PI. 5, Fig. 9) which reaches
from the head of the tibia to or below the toes. This splint
is padded, and a pyramidal pad with the base down is laid
upon the inner surface of the leg, above the inner malleolus,
the splint being put upon the inner surface of the leg, over
the pad. The splint is fastened as shown on Plate 5 (Fig. 9),
and the leg is semiflexed upon the thigh and is laid upon its
outer surface on a pillow. After ten days apply the plaster-
of-Paris bandage, which is to be worn as above directed. In
Pottos fracture Bryant advises the use of a posterior splint,
two lateral splints, and a swing.

Fracture of both bones of the legr, a very common in-
jury, is often compound, and is not unusually comminuted.
Fractures by direct force, such as blows or kicks, are com-
monest in the upper half of the leg. Fractures by indirect
force, as by falls, are commonest in the lower half of the leg.
In fractures from indirect force the tibia breaks first, and
then the fibula breaks at a higher level. The point of
greatest liability to fracture from indirect force is the junc-
tion of the lower and middle thirds. Fractures of the leg
are usually oblique, but they may be transverse if arising
from direct force. Spiral, torsion, or V-shaped fractures and
longitudinal breaks sometimes occur. In oblique fractures,
as a rule, the line of fracture runs downward, inward, and a
little forward.

Symptoms. — Fracture of both bones of the leg is easy of
recognition. The fibular fracture is detected as before de-
scribed. By running the finger along the crest of the tibia
displacement will be found, except in transverse fractures,
when it may not occur. The common displacement is for
the lower fragment to ascend and pass behind the lower end
of the upper fragment and to rotate a little outward, and
for the upper fragment to project in front. This ascent is
due to the action of the gastrocnemius and soleus muscles.
If the line of fracture is in a direction the reverse of that
which is usual, the lower fragment ascends in front of the
lower end of the upper fragment. In fracture of both bones
there are marked mobility, crepitus, pain, and inability to
walk. In fractures from direct force there is more or less

404 MODERN SURGERY.

damage to the soft parts. A fracture near the ankle is dis-
tinguished from a dislocation by the fact that the deformity
is easily reduced, but tends to recur in the fracture, and,
further, that in a fracture the relations of the malleoli to the
tarsus are unaltered.

Treatment. — If the fracture is near the ankle-joint, the
action of the tendo Achillis may maintain deformity, and in
such cases the tendon must be divided. In treating a simple
fracture of the lower two-thirds of the bones reduce by ex-
tension and counter-extension, and use a fracture-box (PL 5,
Fig. i) as in Pott's fracture (p. 402), though the compresses
are not required. If the soft parts are bruised, use lead-H'ater
and laudanum ; if they are abraded, apply antiseptic dress-
ings. The fracture-box may be swung upon a gallows. After
three weeks apply plaster-of- Paris or silicate-of-sodium dress-
ing and let the patient sit up in a chair daily for one week;
at the end of this time the patient may get about with
crutches. At the end of six weeks after the accident re-
move the plaster, and let the sufferer get about with crutches
for two weeks and with a cane for two weeks more. Brinton
dresses a fracture of both bones of the leg for two weeks
in a fracture-box, for two weeks in side-splints, and for two
weeks in an immovable dressing, allowing the patient to get
about as soon as the plaster is put on. Instead of the fract-
ure-box, we may use a posterior splint, two lateral splints,
and a swing. Shrimpton of Paris uses Nathan R. Smith's
anterior splint in fracture of the leg. Many surgeons apply
plastcr-of-Paris in the form of an ambulatory dressing. In
this dressing a solid apparatus reaches up to the lower third
of the thigh and below the sole of the foot. When the
patient walks the weight is transmitted to the thigh. In
fractures of the upper third of the leg the Mclntyre splint
or the double inclined plane is used. If the fracture is com-
pound, asepticize thoroughly, make a counter-opening, insert
a drainage-tube, dress with bichlorid gauze, apply a plaster
bandage, and cut trap-doors over the openings of the tube
(see Fig. 70). Remove the tube, as a rule, in about fortv'-
eight hours ; but the patient's temperature is a better guide
than time.

Fractures of the bones of the foot are rather rare acci-
dents. Owing to the number of the bones and to the
elasticity of their connections, the force of blows and falls
is spread and dissipated. Fractures from direct force are
often compound. The cause of fracture of either the scaph-
oid, the cuboid, or any of the cuneiform bones is direct

DISEASES AND INJURIES OF BONES AND JOINTS, 405

force. Fractures of the os calcis and astragalus arise, as
a rule, from indirect force, such as falls, but the calcaneum
may be broken by direct violence. In rare instances the
OS calcis has been broken by contraction of the great calf-
muscles.

Symptoms. — In fracture of the os calcis there are severe
pain, swelling, crepitus, mobility, often an apparent widening
of the bone, not unusually a loss of the arch of the foot
(Pick). In some cases the posterior fragment is drawn up
by the calf-muscles, and in other cases there is deformity.
In fracture of the astragalus displacement may occur which
resembles that of a dislocation. Crepitus may or may not
be detected. It can be elicited, as a rule, by rotating the
foot while the heel is firmly held. If crepitus cannot be
found, it is not certain that a fracture is present, though the
patient may be unable to stand and there may be swelling
and pain on pressure. Fractures of the other bones are
hard to detect. There may or may not be crepitus, which,
if it exists, is hard to localize ; there is pain on standing and
on pressure, and there is bruising of the soft parts.

Treatment, — To treat a fracture of the os calcis when no
deformity exists, use a fracture-box for two weeks ; maintain
the foot at a right angle to the leg ; apply lead-water and
laudanum ; then put on an immovable dressing, and let it
be worn for four weeks. In fracture of the os calcis with
drawing up of the posterior fragment flex the leg upon the
thigh, extend the foot, and maintain this position by means
of a band around the thigh, the band being fastened by
means of a cord to a slipper (PI. 6, Fig. 5), the leg resting
upon its outer side. At the end of two weeks apply plaster,
and let it be worn for four weeks. Many cases require
incision and nailing or wiring the fragments together. If
the projecting fragment of the os calcis cannot be forced
into place, and if it makes dangerous pressure upon the
skin, excise it ; if it does not make pressure which threatens
sloughing, place the joint in a position favorable for anky-
losis, and immobilize. In a fracture of the astragalus, use a
fracture-box and then an immovable dressing, as in fracture
of the OS calcis without deformity. Fractures of the other
bones of the tarsus are almost invariably compound, and the
injury may require drainage and immovable dressing, excis-
ion, or even amputation.

Fractures of the metatarsal bones are due to direct
force and are almost always compound. Fractures from
crushes usually demand excision or amputation. When

406 MODERN SURGERY.

only one bone is broken displacement is slight, there is
severe pain on motion and pressure, and crepitus can gener-
ally be obtained. A simple fracture of a metatarsal bone
is dressed in an immovable dressing for four weeks.

Fractures of the phalangres of the toes are due to direct
force and are often compound. They may require imme-
diate amputation.

Treatment. — In a compound fracture where amputation is
unnecessary, drain with strands of catgut for forty-eight
hours and dress antiseptically ; at the end of this time apply
over the bichlorid gauze a gutta-percha or a pasteboard
splint extending from beyond the end of the toe to well up
upon the sole of the foot, and fix the splint in place with a
spiral bandage of the toe and instep. The splint is to be
worn for four weeks. In a simple fracture fasten the injured
toe to an adjacent toe or toes by a plaster bandage to be
worn for three weeks.

3. Diseases of the Joints.

Synovitis is a primary inflammation of the synovial mem-
brane alone. If other structures besides the synovial mem-
brane are involved, the condition is known as " arthritis,"
Two forms of simple synovitis exist — namely, acute and
chronic. Some surgeons speak also of subacute cases.

Acute Simple Synovitis. — The causes of acute simple
synovitis are contusions, sprains, twists, and overuse. The
causative influence of exposure to cold or damp has been
much debated. It seems probable that in some cases cold
produces vasomotor paresis of the vessels of the synovial
membrane, a condition which may eventuate in inflammation.
The membrane is red and swollen and the joint contains an
excess of turbid fibrinous fluid. If the inflammation ad-
vances, arthritis arises and sometimes blood is effused.

Symptoms. — The symptoms of acute synovitis are — pain,
which is increased by motion of the joint, by pressure upon
the articulation, and by a dependent position of the limb,
and which is worse at night. Pressure upon the cartilage
does not cause pain, but friction of the synovial membrane
at once develops it. The patient places the limb in the
position which gives the greatest ease, and in this position
the part becomes more or less fixed. A fluctuating swelling
is noted, most marked between the ligaments, which swell-
ing bulges out the synovial area and hides or obscures the
articular heads of the bones. The swelling is due early to

DISEASES AND INJURIES OF BONES AND JOINTS, 407

xtensive secretion of synovia, and later to effusion of liquor
anguinis. Bulging takes place at points where the capsule is
bin, and at such points fluctuation may be detected. Fluc-
uation in the elbow is sought for posteriorly. Fluctuation in
he knee is sought for on either side in front. A large effu-
sion in the knee floats the patella up from the condyles. A
;mall effusion in the knee can be detected by Fiske*s plan ;
hat is, cause the patient to bend forward at the hips, resting
rach hand on the front of the corresponding thigh. The
interior structures of the joint are relaxed, and, by tapping
he patella, even a small effusion can be discovered. The
;kin over the joint is rarely reddened, but feels hot to the
land of the observer (over more superficial joints, but not
)ver shoulder and hip); the joint is partly flexed; fever
rxists, varying in degree with the Size of the joint, the acute-
less of the attack, and the nature of the cause. Suppura-
ion rarely follows simple synovitis, but if it does, rigors
)ccur, there is a septic temperature, and the joint soon
^ves evidence of containing pus (periarticular edema).
Traumatic synovitis without infection tends toward cure
vithout suppuration if the patient is healthy, and after it
mkylosis is rare.

Treatment, — In treating acute synovitis immobilize the
joint. In severe cases place it in such a position that the
imb will still be useful even if ankylosis occurs. In mild
ases we can immobilize in the position of rest (semiflexion),
ipply leeches, use the ice-bag or the Leiter coil, and follow
he cold by lead-water and laudanum. After a day or two
ipply gentle pressure, intermittent heat, and iodin and
chthyol. If the effusion is very great and persistent, and
)ressure, astringents, and sorbefacients fail, aspirate with
intiseptic care. If effusion recurs, apply a plaster-of- Paris
Iressing or use flying blisters and massage. A rubber band-
ige is often useful toward the termination of a case.

Chronic Synovitis. — Chronic synovitis follows acute
ynovitis or it may be chronic from the start. The syno-
rial membrane looks nearly natural, but is edematous, and
he joint contains an excess of fluid. If the quantity of
luid is large, the patella floats up and the disease is called
' hydrops articuli *' or " dropsy." In prolonged cases the
jynovial membrane is thickened in some places, softened in
)thers, and is often adherent, and the villous processes of
he synovial membrane are hypertrophied. If the membrane
>ecomes extensively softened (pulpy degeneration), the soft-
ened areas bulge and suppuration eventually occurs. In the

408 MODERN SURGERY.

knee-joint a traumatic synovitis is sometimes linked with
inflammation of the semilunar cartilages. Roux tells us that
this inflammation may be produced by a squeeze, a twist, or
a direct force, but a squeeze is the common cause. Hyper-
extension of the knee may squeeze the cartilage, and so may
attempting to rise from a stooping posture.* If this injury
has taken place, the condition of disability will be prolonged

Symptovis. — In chronic synovitis pain is absent or is only
present during exercise or from pressure, and is slight even
then ; there is some limitation of movement ; passive motion
may develop creaking or crepitus; fluctuation is apparent;
there is atrophy in the muscles about the joint ; and the
hypodermatic needle will draw out a viscid, straw-colored
or bloody fluid.

Treatment. — For hydrops use rest and pressure (a Martin
rubber bandage or, better, a plaster dressing), massage,
douches, frictions, passive movements, and flying blisters.
Painting the joint with iodin and spreading over it blue
ointment, and inunctions with ichthyol, may do good. The
actual cautery is a valuable expedient. Aspiration and the
subsequent use of a plaster-of- Paris bandage may be tried in
some cases. Some surgeons advise aspiration, washing out
with salt solution, injecting a 5 per cent, solution of caiix)lic
acid, and immobilizing. Incision and drainage constitute a
radical but proper plan. If pulpy degeneration exists, per-
form an excision or an erasion. If pus forms, incise at once
and drain. Internally, treat any existing diathesis and give
good food, tonics, and stimulants. Chronic synovitis is often
greatly benefited by the use of a hot-air apparatus. The
affected part is placed in the apparatus every day, and is
subjected to a temperature of from 250° to 300°.

Arthritis. — By this term is meant not only inflammation
of a synovial membrane, but also of other structures com-
posinti^ and surrounding a joint. It may follow a traumatic
synovitis ; it may be due to pus organisms, to tubercle bacilli,
to infectious diseases (gonorrhea and typhoid fever), to rheu-
matism, to gout, to syphilis, and to lesions of the spinal cord
Arthritis may be either acute or chronic.

Tubercular Arthritis (White Swelling; Strumous Joint;
Pulj^y Degeneration). — Pathoioj^y and Symptoms. — ^The ex-
citing causes of tubercular arthritis may be strains, blows,
twists, or cold. The primar}' infection with tubercle bacilli
is usually in the bone, though it may be in the synovial
membrane, the joint-capsule, or the structures about the

* Gaz. lies Hdp., No. 125, 1895.

£>ISEAS£S AND INJURIES OF BONES AND JOINTS. 409

joint. If the primary infective focus is in the bone, a portion
of the cartilage is destroyed and the joint is opened, or a
sinus forms and perforates the synovial membrane. When
tubercular inflammation attacks the synovial membrane
granulation-tissue is formed, and the capsule and periarticu-
lar structures soon become involved in the process; the
I>arts thicken and soften from caseation, and they may be
covered with tubercles, though but little fluid is usually
effused into the joint. Some few cases present large joint-
effusions. In the ordinary form of arthritis there occurs
what is known as " gelatiniform degeneration ;" the embry-
onic tissue is formed in large amount as fungous growths ;
the structures are markedly edematous and softened ; the
relaxed ligaments yield under pressure ; the natural contour
of the joint is lost, and it becomes spindle-shaped ; all the
structures, articular and periarticular, are glued into one
mass ; the skin about the joint is white, thick, and adherent,
and in it one or more large veins are seen ; fluctuation or
pseudo-fluctuation is noted when caseation has occurred;
pain is not often severe, but it can usually be elicited by
certain motions or by firm pressure (but the pain will always
be severe when the epiphysis is involved) ; the temperature
of the part is somewhat elevated ; deformity results from
destruction of bone, cartilage, and ligament, from muscular
spasms, and from the habitual assumption of certain attitudes
to secure relief from pain; there is soon impairment of joint-
motions. When the products of a tubercular arthritis caseate,
the thick liquid seeks exit by forming sinuses from which
caseous pus runs. If a sinus becomes infected with pyo-
genic cocci, and the joint itself becomes their prey, acute
suppuration arises in the joint, and constitutional involve-
ment is pronounced and perilous to life.

In pannous synovitis a large effusion is formed, there is
but little granulation-tissue, though the tubercles are present
in large numbers, and the ligaments and structures about the
joint are slightly or not at all implicated. The diagnosis
early in a case is difficult, often impossible, and the prognosis
is grave. In only a very few cases, even when recognized
early, is a cure obtained without impairment of joint-func-
tion. The best that can usually be accomplished is a cure
with more or less ankylosis, fibrous or bony; but often
ankylosis is complete. Long after the disease is apparently
cured, it may break forth anew. Tubercular lesions may
arise in a distant organ, or general tuberculosis may occur.
Caseation is apt to produce severe constitutional disorder.

410 MODERN SURGERY.

Infection by pus organisms gives rise to grave danger of
septicemia. Death is not unusual from exhaustion, from
septicemia, from disseminated tuberculosis, from tubercle in
an important organ, or from amyloid disease.

Treatment, — Constitutionally, the treatment is directed
against the tubercular diathesis. Locally, rest is of the
first importance, and it is maintained for many weeks, it
being obtained by splints, by a plaster-of- Paris bandage, or
by extension appliances. Bier's plan of inducing conges-
tive hyperemia may do good (page 156). Aspiration can
be used for fluid accumulations. Caseous masses are often
let alone, or an aspirator is used and the joint drained,
washed out with boiled water, and injected with an emulsion
of iodoform and glycerin (10 per cent). Injections of bal-
sam of Peru or of iodoform emulsion about the joint once
a week are efficient in some cases. If these means fail, if
the patient gets worse, or if the condition of the sufferer
renders dangerous the prolonged conservative course, then
operate, removing the entire diseased area by erasion, by
excision, or by amputation. Always remember that an
incomplete operation, a partial removal, is worse than no
operation, as it opens the portals to systemic infection, and
may be responsible for a general tuberculosis, septicemia, or
pyemia.

Tuberculosis of Special Joints. — ^Tuberouloeis of the
Sacro-iliac Joint (Sacro-iliac Disease). — ^This is an uncom-
mon aflfection, and is especially rare before the age of fifteen.
The disease may begin in the joint, may arise in adjacent
bones, or may result from a cold abscess burrowing into
the joint. In some cases it is associated with extensive
disease of the pelvic bones. The disease, if undetected,
may lead to dissemination of tubercle, to abscess, even to
death.

Syviptoms. — Are often obscure. The disease is usually
confounded with vertebral caries or hip-joint disease. The
patient limps on walking, but can stand on either leg ; there
is pain in the sacro-iliac joint, about the hip, and down the
thigh ; tenderness is manifest on pressure over the joint and
on pushing the ilia together ; there is fulness over the sacro-
iliac joint ; but no flexion of hip unless iliac abscess exists.*

Treatment. — Rest in bed for months, using also a felt case
for pelvis. Counter-irritation by blisters and actual cautery.
In some cases injection of iodoform ; in others incision and

curetting.

* See A. G. Miller, Edinburi:^h Med. Jour, ^ May, 1895.

DISEASES AND INJURIES OF BONES AND JOINTS, 41I

TabercolosiB of the Hip-joint (Hip Disease ; Morbus Cox-
arius; Morbus Coxae; Coxitis; Hip-joint Disease). — The prim-
ary lesion may be in the synovial membrane, but is more often
in the bone. It may begin in the acetabulum ; it may begin in
the femur. If it begins in the femur it usually starts on " the
distal side of the epiphyseal cartilage " (Senn). In some cases
primary tuberculosis arises in the trochanter major, and may
never invcJlve the joint. When the synovial is involved at
one point spreading throughout the joint is rapid. In many
cases the articular cartilages are attacked, and in some cases
the epiphyseal cartilage is destroyed. It is commonest in
diildren, but it may arise in adults and even occasionally in
those of advanced years ; 62 per cent, of cases arise in chil-
dren under ten years of age and 80 per cent, of cases occur
before the twentieth year (Bryant). Traumatism and cold
may be exciting causes. The disease strongly tends to
caseation and the formation of sequestra.

Symptoms, — In tuberculosis of the hip-joint there are
three stages: (i) the stage of microbic deposition and
multiplication, the products of the bacilli causing irritation
and new growth ; (2) the stage of progression, with forma-
tion of embryonic-tissue masses and effusion into the joint ;
wd (3) the stage of caseation, with destruction of the joint
^d often of the structures about it.

The symptoms of the first stage are slight and may be
overlooked entirely. In a child there are night-terrors;
on getting about in the morning the child shows some
l^eness, which wears off during the day, and it soon grows
tired while playing and lies down to rest. There may be
^ slight limp ; a slight adductor spasm may often be noted ;
^'He pain may occur in the hip on tapping the sole of the
'o<^t while the patient is recumbent with the leg extended ;
P^ may be complained of at night in the hip, in the front
^'the thigh, or at the inside of the knee. The diagnosis in
this stage is more or less problematical,
^nthe second stage, or the stage of apparent lengthening,
^^ symptoms are positive. The child limps ; the adductor
"*^scles are rigid; the hip is broadened by an effusion in
^"C joint, and fluctuation may possibly be detected ; the thigh-
"^Uscles are atrophied ; the extremity' is pushed forward, ab-
"^cted, and everted (the patient tilts the pelvis so as to rest
"is weight on the sound limb). In some few cases adduction
exists rather than abduction. The abduction, which is usual,
releases tension of the fascia lata, and thus abolishes pressure
upon the joint through pressure upon the trochanter (Allis).

412 MODERN SURGERY.

The thigh is somewhat flexed. This flexion relaxes the psoas
muscle and prevents pressure of its tendon upon the front
of the joint (Allis). In ver>' rare instances adduction is
present. Pain exists, often sudden or starting, and is located
in the joint, on the front of the thigh, and to the inner side
of the knee in the course of the obturator nerve ; the pain is
aggravated at night ; and full extension and complete abduc-
tion are not possible. The gluteal muscles waste, and the
gluteal crease is on a lower level than is that of the sound
side. The gluteal crease may be nearly or quite eflaced,
because of hypertrophy of the subcutaneous layer (Alexan-
droff"). Jarring of the heel when the extremity is in extension
causes pain in the hip. The above symptoms arise chiefly
from unconscious efforts to obtain ease, from joint-eflusion.
reflex irritation, and involuntary' or spasmodic muscular
contractions. Lengthening in the second stage is apparent,
not real, but this stage is spoken of as the " stage of length-
ening." The position is shown on Plate 6 (Fig. 4). The
fluid effusion may be absorbed or may find its way externally
by means of sinuses. The latter condition is kno\i7i as
** abscess of the hip." The absorption of the exudate or
the rupture of the capsule permits the contracting muscles
to bring the head of the femur into firm contact with the
acetabulum or its brim ; the bones are worn away and
destroyed, shortening results, abduction gives way to ad-
duction, flexion is increased, shortening occurs, and the
third stage is established.

In the tJiird stage the head of the femur goes upward and
outward upon the rim of the acetabulum, the thigh is flexed
and fixed, and attempts at extension when the patient is
recumbent cause the pelvis to tilt forward and occa.sion a
marked lumbar cur\'e (PI. 6, F'ig. 2), which is due to the
pch'is moving with the femur as if ankylosed, and which
disappears on flexion. In the third stage adduction occurs
because of the ascent and movement outward of the head
of the bone. Shortening is marked. After a hip- abscess
finds an external outlet pyogenic infection is very apt to
take j)lacc and inflammation is liable to arise, followed by
that state which is designated as ** hectic." If a cure follows
the third stage, partial or comj)lete ankylosis takes place;
if death ensues, it may be due to .septicemia, tuberculosis of
the viscera, exhaustion, or am\'loid degeneration.

Diagnosis is \k.\x\ easy in well-established cases of hip dis-
ease, but very difficult when the disease is incipient. Always
make a systematic and thorough examination. Undress the

.n ihr l4iinb4t Sp<K of Fining nod Extending ihc DiiuicJ Lrg in Hip llixite
'**^1. J. 4. P™iiiom in CoMlnixAlbert). 5. Slnp-ind-ilipptr Aiipami.t fur Kratiiireot Fm-
■^hrnxnodhcOIuKHmliflcr Himillsn). 6. EiiiiKion in Hip Dltcue(TnvB). ;. Eiim-
•> il» Umb IB I Filled asd Adducicd PwlUon (Trevei). B, Excuiob of the Linb in i Fkied

DISEASES AND INJURIES OF BONES AND JOINTS, 413

patient and place him recumbent upon a table or a hard
mattress, with the legs extended, and note if the heels are
level and if the iliac spines are on the same level (depressed
spine on the affected side means abducted extremity, the
degree of which is determined by carrying the limb out until
the spines are horizontal ; elevation of the iliac spine on the
affected side means adduction, the amount of which is deter-
mined by adducting the limb until the spines are horizontal
Fig. 1 01); try all the movements belonging to the joint, to

Fig. ioi.— Potitiont in hip-joint disease (after the plan of Howard Marsh and Treves).
A. — r/!, lumbar spine ; b d, limb fixed in flexion and abduction — useless for walking, b. — tj^
lumbar spine. Patient corrects the condition in Figure a by curving the lumbar spine for-
ward and rotating the pelvis on its transverse axis, tnus making the femur point downward.
TI1C lumbar spine is curved laterally, the pelvis ascending on the sound side and descending
on the aflfected side (apparent lengthening), c. — i (/.limb fixed In flexion and adduction.
D. — ry, curve of lumbar spine to correct condition in Figure c (apparent shortening).

detect any limitations ; try if bringing down the knee pro-
duces lordosis (PI. 6, Figs. I, 2); look for swelling and for
muscular wasting ; feel if the head of the bone is enlarged ;
observe if motion produces pain or if pressure causes tender-
ness ; and always carefully elicit the history of the attack, of
the person, and of the family.

Hip disease may be confounded with spinal caries in which
a psoas or a lumbar abscess has formed, with sacro-iliac dis-
ease, with infantile paralysis, with congenital dislocation, with
lordosis from rickets, with gluteal abscess, and with bursitis
of the gluteal bursae. In hip disease there is always some
lameness; pain may be severe or may be absent entirely,
and may be in the hip or be referred to the front of the
thigh or to the inner side of the knee. Always remember
that the pain is not characteristic, and that pain in the same
localities may arise from aneurysm of the femoral or iliac
arteries, from abscess in Scarpa's triangle, from caries of
the lumbar vertebrae, from sacro-iliac disease, and from
cancer of the rectum. Altered position of the limb, limita-
tion of movement in the hip-joint, muscular wa.sting, and
swelling soon arise in hip-joint disease.

In disease of the sacro-iliac joint examination shows that

414 MODERN SURGERY,

the movements of the hip-joint are unlimited and produce no
pain, and that pain is developed by pressure over the sacro-
iliac articulation and by pressing the ilia together. In infan-
tile paralysis there is no pain, but there is paralysis with great
muscular atrophy, which comes on with considerable rapid-
ity. In spinal caries with psoas abscess the evidences of dis-
ease of the vertebrae are clear and the pus is located in the
groin external to the femoral vessels. The pus of hip-abscess
generally gathers under the tensor vaginae femoris muscle,
but it may reach Scarpa's triangle by passing through the
cotyloid notch or through the bursa under the psoas mus-
cle ; it may appear under the glutei. Matter from a caseat-
ing acetabulum may reach the inside of the pelvis and appear
above Poupart's ligament.

In gluteal bursitis the symptoms last for many months,
and do not remit as the symptoms of early hip disease are apt
to do. The pain is but moderate, and is aggravated by ex-
ercise, but passes away on going to bed, and is felt back of
the hip and back of the knee. There are a certain amount
of limitation of motion and a positive limp, which arises
early. In marked cases fluctuation can be detected in the
upper gluteal region.*

Prof^uosis. — If the case of hip disease is seen early, the
chances of cure are excellent in children, in whom the dis-
ease may be arrested at any .stage. The longer the duration
of the disease and the older the subject, the more unfavor-
able is the prognosis. The cure takes many months, and
advanced cases only get well by means of ankylosis with
shortening and deformity. Hip disease may recur years after
apparent cure, and a person who has had hip disease runs
a strong chance of developing visceral tuberculosis.

Cojuplications. — The complications that may accompany
hip disease are the following: Abscess^ as above noted.
Tubercular uicuingitis, or the condition known as "acute
hydrocephalus," or *' water on the brain," may arise during the
progress of the case or after apparent cure, and is apt to en-
sue upon incomplete operations. It is almost inevitably fatal.
Auiyloiii, lardaccous, or hhixv dcf^cncration of viscera^ which
condition follows upon profuse and long-continued suppura-
tions, and which is apt to arise in the liver, spleen, kidneys,
or intestinal mucous membrane. Tuberculosis is not the only
cause, syphilis being responsible for at least 30 per cent, of
all cases. In amyloid disease of the liver this organ is much

* Sot' K. (i. lir.icketl's im}X)rtant paper on "Gluteal Bursitis,** in T^t Trans-
actions of the Attierican Orthopedic Association, vol. x.

DISEASES AND INJURIES OF BONES AND JOINTS. 415

enlarged, smooth, painless, and of increased consistency,
there is no jaundice, the spleen is apt to be enlarged, and
albuminuria is the rule. In amyloid kidney large amounts
of pale urine of low specific gravity are voided ; albumin is
usually present in large amount, but may be absent ; globu-
lin may often be found, as may also hyaline, fatty, or granular
casts ; the patient is anemic, and dropsy usually exists. Test
the hyaline casts with iodin for amyloid material. Amyloid
dianges are usually slow in onset, but they may be rapid ;
they are commoner in men than in women, and are most
frequently encountered in individuals between the ages of ten
and thirty. Slight amyloid change may be recovered from,
but an extensive degeneration brings about a fatal result.
Dickinson's theory of how this tissue-change is caused is
that the flow of pus drains off from the body the alkaline
salts, especially the salts of potassium, which drainage re-
sults in visceral depositions of de-alkalinized fibrin. Phthisis
pulmonaiis is a rare complication, but is a common sequence,
heing apt to arise, sooner or later, after the hip disease is
cured.

Treatment. — In the early stage of hip disease the treatment
consists in rest. Place the patient upon a solid mattress and
^pply extension. In children under ten years of age, use a
weight of from three to five pounds ; in children between ten
^d twenty, use a weight of from five to eight pounds. A
long splint is often applied to the sound side to keep the
patient recumbent and horizontal. Always use a cradle to
hold up the bed-clothing. Apply the extension in the
P^g axis of the limb, the extremity being placed in the
une of the deformity due to disease and being supported by
Pillows. In lordosis from thigh-flexion, raise the limb until
^^ iliac spine is straight (PI. 6, Fig. 6). If the spine is de-
Pressed on the affected side, abduct the limb (PI. 6, Fig. 8) ;
jj fte spine is elevated, adduct the limb until the spines are
.^rizontal (PI. 6, Fig. 7). The object in taking these prccau-
"^Hs is to enable the extension to separate the femoral head
^d the acetabulum. Extension will remove flexion in two
^^ks in a recent case and in the course of some months in
^^ older case. As flexion is relieved remove the pillows and
iower the leg so as to keep up extension in the long axis
^^ the thigh. Abduction and adduction cannot be removed
'^y extension.

, Abduction demands no special treatment. In a movable
Joint it will disappear, and in an ankylosed joint it is an ad-
vantage, compensating by apparent lengthening for the short-

4l6 MODERN SURGERY.

cning due to bone-absorption or to stunted growth of the
limb. Adduction requires an addition of several pounds to
the extension weight, the use of a long splint on the sound
limb, and the drawing up of the sound limb by a rope and
pulley toward the head of the bed. The weight used to pull
the sound side toward the head of the bed is equal to that
used to pull the damaged side to the foot of the bed. This
expedient is used for a month or six weeks. In old cases
where the weight will not bring about
extension, anesthetize the patient, gent-
ly straighten the limb a very little, and
reapply the weight.

Extension in a mild case must be
continued for three months after the
symptoms have disappeared, and in a
severe case the period must be six
months. The weight is gradually
taken off; if symptoms recur, the
weight is reapplied ; if they do not
recur, apply a traction splint or a
plaster dressing, put a high-heeled
boot on the sound limb, and send the
patient out on crutches. In young
children extension can be made in a
wheeled carriage, thus enabling the
patient to go out in the fresh air and
sunlight. The general treatment is
tonic and restorative. The joint is so
deeply placed that it is useless to make
external applications. In the treatment of hip disease
Thomas's splint (Fig. 103) is used by many, and it may
be combined with weight extension ; or Sayre's splint (Fig.
103) may be employed. Wyeth's apparatus (Fig. 104) is a
favorite with many American .surgeons.

If the limb is in good position, or has been brought into
good position, either by weight extension or straightening;
under ether, pi aster- of- Paris is a useful dressing. It is put
on from the toes up, and includes the entire extremit>' and
also the pelvis. A patient dressed by plaster may get about
on crutches when the sole of the other foot is raised. If
a ca.se, in .spite of treatment, does not improve or becomes
worse. u.-Jc " intraarticular and parenchymatous injections of
iodoform." .Always tr\' these injections before doing a resec-
tion. Sometimes they succeed and render resection unneces-
-sary. Asepticize the surface, carr>' a small aspi rating-needle

DISEASES AND INJURIES OF BOXES AND JOINTS. 417

Into the joint, irrigate the joint with salt solution, and inject
I sterile emulsion of iodoform and glycerin (10 per cent.J.
; week, if reaction has ceased, repeat the injection. In
mother week repeat again. It may be necessary to give from
Den to twenty injections. The spot for puncture is thus
obtained: Draw a line from a point half an inch outside
of the middle of Poupart's ligament to the outer edge of
the great trochanter. Puncture at the middle of the outer
half of this line (DeVos).

If an abscess forms, incise it with the most thorough anti-
septic care, let the fluid drain away, wash out with salt solu-

tion, remove any sequestra, inject with iodoform emulsion,
insert a tube, and dress antisepticaily. In some cases the
sequestrum is extra-articular. In some cases no sequestrum
is found. The old plan of not operating until rupture was
seen to be inevitable wa.s bad. To open early and antisepti-
caily often means rapid healing, the prevention of burrowing,
a lessened danger of visceral infection, and an earlier cure.

41 8 MODERN SURGERY.

Hectic will not arise if the abscess is opened with antiseptic
care.

Excision of the hip is to be performed when the head of
the femur is detached and lies loose in the joint ; when pro-
fuse suppuration continues for a long time, and other methods
fail to arrest it ; when amyloid disease is beginning ; or when
very faulty position is inevitable without operation. Excision
is an operation of considerable danger, and the older the
person the greater the danger. Schede advocates arthrec-
tomy in some cases as a substitute for resection. Senn tells
us that opinion as to resection has greatly changed of late,
and the operation is advisable in all cases where fixation, ex-
tension, intra-articular and parenchymatous injections have
failed to arrest the disease (see Tuberculosis of Bones and
Joints). When there is extensive disease of the femur, when
excision has been tried and has failed, and when the patient
has not the recuperative power to stand the long si^e
following excision, amputate.*

Knee-joint Diseaae (White Swelling). — After the hip, the
knee is, of all joints, the commonest site for tubercular dis-
ease. Knee-joint disease can begin as a synovitis, but oftener
begins as tubercular inflammation of the femoral or the
tibial epiphysis. The disease rarely attacks the bone above
the epiphyseal line ; a single focus only exists as a rule, and a
sequestrum is rarely formed. In very rare instances the pa-
tella is primarily attacked, or the semilunar cartilages. It may
begin at any age, but is most common in children and young
adults. If an acute synovitis ushers in the case, there may
be large effusion into the knee-joint and partial flexion, but
swelling is usually slight in knee-joint disease. Pulpy de-
generation of the synovial membrane occurs ; the joint
enlarges; the ligaments soften; the skin is edematous;
muscular spasm is marked ; the leg is flexed ; the bones are
displaced backward and outward, the foot being everted;
lameness exists, due chiefly to deformity; pain may be
absent, is often slight, and is rarely severe. When the disease
begins in the bone or an epiphysis there are pain, tenderness,
lameness, swelling, inability to extend the limb completely,
sudden spasmodic muscular contractions, and final involve-
ment of the joint. When an abscess forms, it may destroy
the joint very rapidly or it may break externally.

Treatment, — In treating knee-joint disease employ general
antitubercular treatment and locally apply iodoform oint-
ment or guaiacol. Apply splints (Figs. 105, 106), extension

* See the admirable article of Howard Marsh in Treves's Afanual of Surgery.

DISEASES AND INJURIES OF BONES AND JOINTS. 419

oy), or a plaster-of-Paris bandage, and keep the patient

for a few weeks ; then permit him to go out upon

iitches, with a high-heeled

upon the sound foot.

1 cases in which treatment

Bis begun early the disease

■ may often be arrested in from
I eight to twelve months. If
I the symptoms do not abate
■after a number of weeks, or

■ if the condition grows worse
land an abscess arises, aspirate.
I irrigate, and inject iodoform

■ emulsion. Intra-articular in-
jections are not unusually
curative. Insert the needle
in the angle between the
outer edge of the patella and

. the Hgament of the patella

I (DeVos). Repeat the injec-

I tion in one week if reaction

I lias abated, and advance as

I directed for the injection of the hip-Joint, Some surgeons

I incise the capsule, remove all fragments and tubercular

I fod, irrigate with normal salt solution, inject iodoform

) emulsion, and sew up without drainage (Neuber's plan). If

I these means fail, open the joint and perform an excision or

I an erasion (page 495). Some cases demand amputation.

I
I

tj. — SnyreS double

which, if the patient's health is much impaired, is to be
preferred to excision. Amputation is preferred to excision
in very young children and aged people.

Ankle-joint diseaae may begin in the synovial membrane.

420 MODERN SURGERY.

in the tibial epiphysis, or in the tarsus, but the origin is
usually synovial. The symptoms are pain, swelling, lame-
ness, limitation of joint-movements, and atrophy of the calf-
muscles. Suppuration often occurs, and sinuses form.

Treatment. — The treatment of ankle-joint disease consists
in the employment of antitubercular remedies, applications
of guaiacol or iodoform ointment over the joint, and rest by
means of splints or plaster. Caution the patient to avoid
standing upon the diseased extremity. Injections of iodoform
emulsion may do good. Insert the needle below the outer
malleolus. When caseation occurs, it is often advisable to
open, drain, wash out with normal salt solution, inject iodo-
form emulsion, and put up the ankle-joint in plaster. When
joint-disorganization occurs, perform an excision or an
crasion. Some cases demand amputation (Syme's amputa-
tion being preferred by some, amputation above the ankle
being approved by many). Osteoplastic resection is some-
times advised (Wladimiroff-Mikulicz operation).

Shoulder-joint disease is not common ; it is rare in chil-
dren and is commonest in adults ; it begins either in the
synovial membrane or in the head of the humerus. The gle-
noid cavity is rarely attacked. Pain is slight, atrophy of the
deltoid and other muscles is noted, the joint is stiff, and the
scapula follows the motions of the humerus. Caries sicca is
the usual cause of destruction. In many cases swelling is
not obvious, the joint shrinking because of destruction of the
head of the bone and contraction of the capsule (Senn). If
an abscess forms, it may open in the axilla under the deltoid,
or at some far distant point, but abscess-formation is unusual.

Treatment. — In treating shoulder-joint disease employ anti-
tubercular remedies and apply over the joint guaiacol or iodo-
form ointment. Put on a shoulder-cap, apply the second
roller of Desault, and hang the hand in a sling. Maintain
rest for at least four months. Aspiration and injection of
iodoform emulsion are ver>^ valuable in synovial tuberculosis.
The needle is entered below the acromion, while the arm is
held against the side and the forearm is at right angles to
the arm and across the front of the chest (DeVos). If an
abscess forms, open and drain it. In rare instances dead
bone will have to be gouged away. Caries sicca may
occur. Excision is sometimes required.

Elbow-joint disease may begin in the humerus or the
ulna. The head of the radius is rarely the primary focus.
In some cases the synovial membrane is first attacked. It is
most frequent in young adults. The joint is swollen, its

mSEASES AND INJURIES OF BONES AND JOINTS. 42 1

movements are somewhat limited, the skin is usually hot,
muscular wasting is pronounced, and pain is generally slight.
Pus may form.

Treatment. — In treating elbow-joint disease, employ anti-
tubercular foods, drugs, and hygienic measures ; iodoform
ointment or guaiacol locally ; rest by means of an anterior
angular splint (Fig. 108) and a triangular sling. Injection of

Fig. 108. — Stromeyer's anterior angular splint.

iodoform emulsion may be useful. Insert the needle for
injection by the side of the olecranon. If caseation takes
place, it is often necessary to open the joint and drain.
Splints are to be worn for from four months to a year. If
any considerable area becomes carious, perform an erasion
or an excision.

"WriBtr-joint diseaae may arise at any age, and is some-
times met with in late middle life, or even in old age. The
joint presents a puffy swelling, loses its normal contour, and
becomes spindle-shaped. Hand-movements are impaired,
pronation and supination cannot completely or satisfactorily
be performed, the joint is stiff" and partly flexed, the grasp is
enfeebled, pain may be severe or slight, the skin is usually
hot, and muscular atrophy is marked. This form of tuber-
culosis may begin in the synovial membrane, in the bones, or
in the tendon sheaths.

Treatment. — The essential treatment in wrist-joint disease
comprises cod-liver oil, tonics, good food and fresh air, and
the local application of guaiacol or iodoform ointment. Ap-
ply a Bond splint and sling or put on a plaster bandage, and
maintain rigid rest for from four to six months. Aspiration
and injection of iodoform emulsion is often useful. Enter the
needle at the dorsal edge of the radial, styloid process, and
again at the upper edge of the pisiform bone (DeVos). In
some cases it is well to incise, wash with salt solution, in-
ject iodoform emulsion, and close without drainage. Severe
cases demand incision and drainage with the maintenance of

422 MODERN SURGERY.

rest. A moderate amount of caries is treated by drainage
and rest. Necrosis demands removal of the sequestra. Ex-
tensive caries requires excision.

Acute Suppurative Arthritis. — ^This infection is usually
due to the staphylococcus pyogenes aureus or to the strepto-
coccus pyogenes which find entrance by means of a wound,
by the spontaneous evacuation into a joint of the products
of an osteomyelitis, by extension of suppurative inflammation
through contiguous structures, or by the blood-stream. In
this disease all the joint-structures are involved and suppura-
tion rapidly appears. It is very rarely due to gonorrhea, and
sometimes to septicemia.

Symptoms. — The symptoms of septic arthritis are — fever,
high pulse, sometimes a chill, severe pain, which is aggra-
vated by motion and is worse at night ; discoloration, heat,
and edema of the skin ; partial flexion of the joint ; fluctua-
tion ; and marked constitutional symptoms of sepsis. The
joint tends to rapid disorganization, and fatal septicemia is
very apt to occur. In pyemic arthritis several joints become
infected.

Treatment. — The treatment in septic arthritis consists in
prompt incision, evacuation, antiseptic irrigation, drainage,
antiseptic dressing, and immobilization. Cure is followed,
as a rule, by ankylosis, but in cases treated early the joint
may be preserved.

Infective arthritis arises in the course of an acute infec-
tious disease (such as erysipelas, typhoid fever, influenza,
mumps, dysentery, diphtheria, measles, scarlatina, variola),
and may be due to pyogenic cocci or to the sj>ecific micro-
organism of the acute infectious disease. Joint-inflammation
arising in the course, or as a sequel, of an acute infectious
disease may or may not suppurate.

Symptoms and Treatment. — If no suppuration takes place,
the symptoms of the attack resemble those of rheumatism;
if suppuration occurs, the symptoms are identical with those
of septic arthritis. Suppuration rarely occurs. Ashby has
well described the arthritis which sometimes follows scarla-
tina. It involves wrists, finger-joints, tendons of forearm,
knees, ankles, or spine. The joints are painful, but are
rarely much swollen or discolored (Howard Marsh).

That the organism of typhoid may inflame the joints is
proved (Klemm, Quincke, and others), but whether it does
cause suppuration is not so certain. Some claim that mixed
infection induces suppuration. The typhoid bacilli enter the
bones in many typhoid cases and sometimes cause bone dis-

DISEASES AND INJURIES OF BONES AND JOINTS, 423

ease. Joint disease is more common than bone disease. A
typhoid joint begins when the fever is abating, and more than
one joint may be involved. These joints may recover per-
manently, may ankylose, may dislocate, or may lead to a
fatal sepsis. We may tell this disease from rheumatism by
the fact that it does not migrate, and is uninfluenced by anti-
rheumatic remedies. In slight cases the synovial membrane
only is involved; in more severe cases capsule, cartilage,
ligament, and even bones are involved. Some cases sup-
purate. Keen tells us that septic typhoid arthritis results
from a mixed infection with typhoid bacilli and pyogenic
bacteria, and is identical in symptoms and progress with an
ordinary septic arthritis. The same author points out that
typhoid arthritis proper may be monarticular or polyarticular,
the monarticular form being the most common, and the hip-
joint being the articulation most liable to attack. In most
cases typhoid arthritis causes but little pain. The swelling
is marked, although in the hip it is concealed. Pus rarely
forms. Keen calls attention to the fact that in the eighty-
four cases he collected, spontaneous dislocation occurred in
forty-three, nearly all in the hip.*

Treatment of a mild case, as for simple synovitis : if there
is much fluid in the joint, aspirate and wash out with normal
salt solution. If pus forms, open, irrigate, and drain.

Gonorrheal Axiihritis, or Gk>norrheal Rheumatisni. —
During the progress of gonorrhea every rheumatic attack
is not gonorrheal rheumatism, for ordinary rheumatism is
just as likely to arise when a man has clap as when he has
not this malady. Furthermore, the term is inaccurate, as
gonorrheal rheumatism is not rheumatism at all, but is an
infective disorder of the joints or of the synovial membranes,
the infective material being contained primarily in the urethral
discharge. Occasionally this form of arthritis arises from
gonorrheal ophthalmia (Heiman's case). This infective ar-
thritis sometimes, though rarely, arises during the height of
a gonorrhea, but is more frequently met with in chronic cases
or when the intensity of the inflammation is abating in acute
cases. Men suffer from gonorrheal arthritis far more fre-
quently than do women, and the seizure is very apt to recur
again and again. In some cases many joints are involved,
but in most cases only a few joints suffer. Osier states that
the knees and ankles are most apt to be involved in a gonor-
rheal rheumatism, and that this form of arthritis is peculiar
in often attacking joints that are apt to be exempt in acute

' Keen on The Surgical Complications and Sequels of Typhoid Fever.

424 MODERN SURGERY,

rheumatism ("the sternoclavicular, the intervertebral, the
temporomaxillary, and the sacro-iliac *').

Changes In aftd About the Joint, — The inflammation of
gonorrheal arthritis may be located around rather than in
the joint, and especially in the tendon-sheaths. Suppuration
is unusual, but it may occur in joints and in tendon-sheaths.
Cultivation of the exudate may or may not show the gono-
cocci. Cover-glass preparations stained by Gram's method
may show gonococci. Osier suggests that the non-suppura-
tive cases are due to the action of toxins taken up from the
area of primary infection, and that the suppurative cases are
due to infection with pyogenic bacteria.

Symptofpis. — In gonorrheal arthritis there may be transi-
tory, intermittent, and wandering pains in and about the
joint, without any other symptom ; one or more joints may
become swollen and painful, and moderate fever may develop.
An acute inflammation with intense pain and great swelling
may attack a single joint, in which case fever will be mod-
erate unless suppuration follows. One joint, especially the
knee, may swell to an enormous extent, pain, periarticular
edema, redness, and fever being absent (hydrarthrosis, or
dropsy of a joint). Suppuration in this form is rare. The
tendons, the tendon-sheaths, the bursae, and the periosteum
may inflame. A case of gonorrheal arthritis is often vei)'
hard to check. It may last for a long period, and tends
to recur again and again. Iritis, pleuritis, endocarditis, and
pericarditis have been observed as complications.

The diagnosis between gonorrheal arthritis and acute
rheumatism rests chiefly on the great chronicity, the slight
degree of fever, the excessive tendency to recurrence, and
the absence of profuse acid sweats in gonorrheal rheuma-
tism ; and on the shorter course, the higher fever, the pro-
fuse acid sweats, the lesser tendency to rapid recurrence,
the greater proneness to symmetrical involvement, and the
great liability to cardiac and visceral complications in rheu-
matic fever. Furthermore, in gonorrheal arthritis a gonor-
rheal infection (urethral or ocular) certainly exists or recently
existed ; in ordinary rheumatism a urethral discharge may,
of course, happen to be present. Gonorrheal arthritis \s
apt to affect certain joints which acute rheumatism rarely
attacks.

Treatment. — Internally, in treating gonorrheal arthritis, the
salicylates, the alkalies, salol, and iodid of potassium are use-
less ; iron, arsenic, and str>xhnin are of some benefit. Quinin
is distinctly helpful in some cases. In suppurative cases in-

JD/SEASES AND INJURIES OF BONES AND JOINTS. 425

cise and drain (see Septic Arthritis, page 422). In non-sup-
purative cases treat as in simple synovitis (page 406). In
lingering cases employ the hot-air bath, massage, passive
motion, flying blisters, or the hot iron ; if these means fail,
open the joint, wash it out with some antiseptic fluid, and
dress antiseptically, or aspirate and irrigate with hot normal
salt solution.

Rhetuziatio Arthritis. — Acute rheumatism is a self-limited
febrile malady whose characteristic features are polyarthritis,
profuse add sweats, and a tendency to heart-involvement.

Symptofns of Acute Rheumatism. — In acute rheumatism the
case begins with malaise and fever, and one or more joints
become affected. The inflammation spreads from joint to
joint, is apt to be symmetrical, and when it arises in fresh
joints usually disappears quickly in those previously af-
fected. The temperature is high, the skin sweats profusely,
the joints are red, swollen, hot, and excruciatingly painful,
and the structures about the joints are edematous. After a
short time the inflammation subsides in one joint and passes
into another, the joint first attacked regaining its functions.
Suppuration does not take place. Anemia is pronounced,
exhaustion is profound, the sweat is sour, the saliva is acid;
the urine is acid, scanty, high-colored, often contains albu-
min, and is deficient in chlorids. Cardiac disease is apt to be
produced (endocarditis, pericarditis, or myocarditis). Nodules
may form upon fibrous structures, hyperpyrexia is not un-
usual, and cerebral or pulmonary complications may occur.

Chronic rheumatism rarely follows repeated attacks of acute
rheumatism, but rather arises insidiously in people who have
been exposed to cold and damp, who have suffered from
jx>verty, hardship, and privation, or who have had much
worry. The capsule and the tendon-sheaths thicken, and
there is usually but little effusion in the joint, but the ar-
ticulation becomes stiff* and painful. The joint-cartilages are
occasionally eroded. Muscular atrophy occurs.

Symptoms of Chronic Rheumatistn. — In chronic rheuma-
tism the affected joints are stiff* and painful and are a
little swollen, but not red. Dampness and cold aggravate
the symptoms. One joint or many may be affected, but
usually many are involved. Passive movements cause the
joint to creak and develop crepitus in the tendon-sheaths.
The muscles are wasted. The joints may ankylosc. Anemia
is usually pronounced. There is no fever and no tendency
to suppuration, and the disease is incurable.

The treatment in acute rheumatism comprises the use of

426 MODERN SURGERY.

alkalies, salicylates, etc. (See a book upon medicine, as acute
rheumatism is in the physician's province.) In chronic
rheumatism maintain the general health of the patient, give
courses of iron, arsenic, and strychnin, and an occasional
course of iodid of potassium or a salt of lithium, and, if
possible, send him every winter to a warm climate. Turkish
baths give considerable temporary relief. The waters and
regimen of Carlsbad and Vichy are of positive though tem-
porary benefit, and the sufferer may obtain relief at the hot
springs of Virginia. The patient must avoid damp and
must wear woollens. Frictions, the douche, massage, fl>ing
blisters, counter-irritation with the hot iron, ichthyol oint-
ment, and mercurial ointment are of benefit. Subjecting the
diseased joint to a very high temperature by placing it daily
in a special apparatus often does great good. In partial ank)-
losis give ether and break up the adhesions.

Gk>uty arthritis, which appears especially in the smaller
joints (as the fingers and the metatarsophalangeal joint of
the big toe), is due to a deposition of urate of sodium in the
joint and in the periarticular structures. The irritant urate
of sodium causes inflammation, inflammation forms embry-
onic tissue, embryonic tissue is converted into fibrous tissue,
and the fibrous tissue contracts and thus deforms the joint
and limits its mobility. A great mass of urates in a joint
constitutes a " chalk-stone."

Symptoms. — The premonitory symptoms may be observed
for a day or so, but the acute seizure occurs early in the
morning, the patient, as a rule, being aroused by excruciat-
ing pain in the metatarsophalangeal articulation of the great
toe. The joint swells, and the skin over it feels hot to the
hand and becomes red and shiny. There is often considerable
fever. After a few hours the intensity of the seizure abates,
only to recur again with renewed violence early the next
morning, these remissions and recurrences taking place for
six or eight days, when the attack subsides. In patients with
chronic gout many joints are stiffened and deformed as a re-
sult of repeated attacks. Chalk-stones form, and the skin
above them may ulcerate. Such patients are chronic dys-
peptics, have high-tension pulses, their hearts are hyper-
trophied, and their urine contains albumin and casts.

The treatment of gouty arthritis belongs to the physidan,
and not to the surgeon, although to the latter the symptoms
of the disease should be known, so that it may be diagnosti-
cated from other maladies.

Arthritis Deformans (Rheumatoid Arthritis ; Osteo-ar-

DISEASES AND INJURIES OF BONES AND JOINTS. 427

thritis ; Rheumatic Gout ; Paget's Disease). — In this disease,
which is not a combination of gout and rheumatism, the
synovial membrane and cartilages are affected, the peri-
articular structures are involved, and masses of new bone
are formed.

Arthritis deformans has, as John K. Mitchell pointed
out, a probable nervous origin. It arises especially in per-
sons who have been worried, driven, and harassed. There
is apt to be muscular atrophy; trophic lesions of the hair
and nails are likely to occur, and the syniptoms are- dis-
posed to be symmetrical. The causative Jeiion has not been
determined. Rheumatic gout is commoh^r in women than
in men. The greatest liability exists between the ages of
twenty and thirty, but children may acquire the disease, and
it may also be developed in people beyond middle life.
Apes in captivity may develop it. Arthritis deformans may
attack the rich or the poor ; it does not result from gout, nor
does it often follow rheumatism ; it is not caused by damp
and cold ; and it does not arise from traumatism.

Arthritis deformans differs from gout in the entire absence
of urate deposit, and it differs from chronic rheumatism in
the extensive alterations in the joint-structures. The changes
begin in the cartilage ; the cartilage-cells multiply, the inter-
cellular substance degenerates, the pressure of the bone causes
thinning, and at length the cartilage is entirely destroyed
and the bone is exposed. The exposed bone is altered in
shape, is hardened, and is worn away in the centre, the
periphery increasing in thickness by ossific deposit ; thus
the center becomes deepened by absorption and the periphery
bulged and lengthened by deposit. The fringes of the syno-
vial membrane hypertrophy and multiply, and some of them
are apt to break off (loose cartilages). The capsule and the
ligaments of the joint, as a rule, become fibrous and con-
tract, but they may soften, relax, and permit of dislocation.
The joint usually contains no effusion, but in some cases
there is great effusion (hydrarthrosis). The tendons about
the joint may become fibrous and contracted, they may
ossify, they may be separated from the bone, or they may
be destroyed entirely. Deformity is marked and motion is
limited. The fingers, when involved, show nodules on the
sides of the joints (Heberden's nodules). The vertebrae
may be involved. Almost all the joints may suffer. Sup-
puration does not occur.

Symptoms, — Charcot classifies arthritis deformans into
three forms, and gives their symptoms as follows :

428 MODERN SURGERY.

(i) Heberden's nodosities, which condition is commoner in
women than in men, comes on between the ages of thirty
and fort>% and is especially common in neurotic subjects.
The inteq^halangeal joints become the victims of attacks of
moderate swelling and of some tenderness, which attacks
are not severe, but recur again and again. After a time
small hard swellings (nodosities) appear upon the sides of
the dorsal surfaces of the second and third phalanges, re-
main permanently, and slowly increase in size. The joints
become stiff and creak on movement, the cartilages are de-
stroyed, and contractions and rigidity develop, but there is
no fever and the larger joints are not involved. The malady
is incurable.

(2) Progressive rheumatic gout, which may be acute or
chronic. The aaite form begins as does rheumatic fever.
There are moderate fever, and swelling, without redness, of
a number of joints, of bursae, and of tendon-sheaths; the
joints are stiff and crepitate, and are apt to be symmetrically
involved; muscular atrophy begins early and rapidly be-
comes decided; pain is slight. This acute form is apt to
arise in young women after pregnancy, but is not unusual at
the climacteric and in children. Anemia always exists. The
case is apt to advance progressively until a number of joints
are firmly locked, when it may become stationary. Another
pregnancy will develop anew the acute symptoms. In the
chronic form swelling and pain on movement are noted in
certain joints. The involvement is apt to be symmetrical.
Attacks of swelling and pain alternate with periods of quies-
cence, but the disease does not cease its advance. Articu-
lation after articulation is attacked by the malady until almost
all the joints are involved ; deformity and stiffness become
pronounced, and pain may or may not be severe. There is
no fever. Muscular atrophy is marked.

(3) Partial rheumatic gout attacks one articulation, and it
is most often met with in old men. It may fix itself on the
vertebral column, on the knee, on the shoulder, on the
elbow, or on the hip. The joint grates, and becomes stiff,
swollen, and deformed; the muscles atrophy; there is
usually pain, but fever is absent. Partial rheumatic gout
of the hip-joint in an old person is known as " morbus cox^e
senilis," and partial rheumatic gout of the vertebral articu-
lations causing fixation is called "spondylitis deformans."

Treatment. — Rheumatic gout cannot be cured, but in some
cases it remains stationary for many years. Treat the anemia
by iron, arsenic, good food, and fresh air. Debility is met by

DISEASES AND INJURIES OF BONES AND JOINTS. 429

Strychnin. Hot baths of mineral water do good. Massage
retards the progress of the case, relieves the pain, aids in
the absorption of effusion, and delays fixation. During an
acute exacerbation the joint should be put at rest for a day
or two, and there should be used lead-water and laudanuni,
cold water, or tincture of arnica. Douches and hot baths
improve these cases, but electricity is entirely useless. Put-
ting the affected joint in a special apparatus and subjecting
it to a high degree of heat improves the condition. Counter-
irritants do no good. The patient is unfortunately liable to
develop the opium-habit. If dropsy of a joint arises, try
compression with a Martin bandage, and, if this fails, aspi-
rate and inject diluted carbolic acid. Patients with rheu-
matic gout do best in a warm, dry climate. Cod-liver oil
does good, as it improves nutrition and hence retards the
progress of the disease. Do not be tempted to immobilize
the joints beyond a day or two: fixation only hastens
ankylosis.

C^iaroot's Disease (Tabetic Arthropathy ; Charcot's Joint ;
Neuropathic Arthritis). — This condition is an osteo-arthritis
due to trophic disturbance, arising in a sufferer from loco-
motor ataxia, and is anatomically identical with rheumatic
gout. The knee is most apt to be attacked. The disease
begins acutely, often as a sudden effusion, which after a time
disappears. Pain is slight or is absent, there is no consti-
tutional involvement, and the condition is unconnected with
injury. The bones and cartilages are rapidly destroyed;
fracture is apt to occur; the joint creaks and grates; the
softening and relaxation of ligaments permit an extensive
range of movement ; great deformity ensues ; dislocation is
apt to occur ; muscular atrophy is decided ; and pus occa-
sionally, though very rarely, forms.

Treatment. — The treatment of Charcot's disease consists
in the wearing of an apparatus to sustain the joint. Resec-
tion is recommended by some, but most surgeons do not
advise its performance.

Osteo-arthropathie Hypertrophiante Pneumique
(Marie's Disease). — A condition associated with and pos-
sibly springing from pulmonary disease, and characterized
by enlargement of joints, thickening of finger-ends, and the
formation of a dorsolumbar kyphosis. The joints are pain-
ful, the skin undergoes pigmentation, and profuse perspira-
tion is often present. The head entirely escapes in this
disease, which immunity marks a distinction from acromeg-
aly.

]

430 MODERN SURGERY.

Hysterical joint (Brodie's joint) is a condition mostly
encountered in young women. The disease occurs in the
knee and the hip, and often follows a slight injury which
acts as an autosuggestion, a latent hysteria being awakened
into action and localized, though severity of the injury does
not determine the severity of the symptoms. The disease
may ensue upon an arthritis or may arise without apparent
cause. The patient resists passive motion strenuously and
claims that it causes much pain. There is occasionally
some muscular atrophy from want of use, and the joint
is a little swollen. The skin is hyperesthetic, and a light
touch causes more pain than does deep pressure. The
muscles may be rigid. The joint may be maintained either
in flexion or in extension, but it is rarely in the exact degree
of flexion assumed for ease in a true joint-inflammation, and
the position is apt to be changed from day to day or from
hour to hour. The skin is usually cool, but may be hot,
and a periodically developed heat may be observed, espe-
cially at night, accompanied apparently by much pain. The
pain in some cases is a neuralgia, but in most cases is a pain-
hallucination. In some rare cases organic disease arises in
a hysterical joint.

Hysterical phenomena are seldom isolated, but are asso-
ciated with certain stigmata which may be latent. These
stigmata are concentric contraction of the visual fields,
pharyngeal anesthesia, convulsions, hysterogenic zones,
globus hystericus, clavus hystericus, zones of anesthesia,
especially hemianesthesia, and hyperesthetic areas. Such
patients arc predisposed by inheritance, and have previously,
as a rule, had nervous troubles. Hysterical phenomena, be
it remembered, lack regularity of evolution, and are pro-
duced, altered, or abolished by mental influences and physi-
cal sensations which are without effect in causing, modifying,
or curing organic disease. The general health, as a rule, is
good, but neurasthenia may coexist. In examining these
patients the observer will note that the symptoms disappear
when the attention is diverted ; that they are out of all
proportion to the local evidences of the disease ; that there
is no evidence of joint-destruction ; and that light touching
causes more pain than docs firm pressure. If the patient is
anesthetized, perfect joint-mobilit>' will be found.

Trcatvient. — The treatment in hysterical joints comprises
attention to the general health, the employment of nourish-
ing and easily digested food, the prevention of constipation,
and the administration of tonics if they are needed. The

DISEASES AND INJURIES OF BONES AND JOINTS. 43 1

surgeon must dominate his patient's mind and make her
realize that he is master of the case. He is to be an inex-
orable but just ruler — never a brutal or a cruel one. If
possible, send the patient away from the sympathies of her
home and let her have the rest-treatment of Weir Mitchell.
Local remedies applied to the joint do harm, as a rule, by
concentrating afresh the patient's attention upon the articula-
tion, although the hot iron sometimes does good. Sugges-
tion in the hypnotic state may be tried. The use of morphin
should be avoided as being the worst of enemies. Never
immobilize the joint, and always use massage, passive
motions, and frictions.

Ifetiralg^ of the joints as an independent, isolated
affection is extremely rare, though as a complication of
other diseases it is by no means uncommon. The neuralgia
is more often outside of the joints than in them, and is espe-
cially frequent in the knee and the ankle. Joint-neuralgia
may arise in any person, but it is more commonly present
in young neurotic females. The pain may be persistent, or
it may occur in periodic storms, and it is often associated with
neuralgia in other parts. The pain may be dull and aching,
but it is more often sharp and shooting. Joint-neuralgia is
associated with tenderness on pressure, soreness on motion,
often with transitory swelling without redness, and some-
times with numbness of the extremity. The diagnosis
depends on the temperament of the patient, the sudden
onset of the pain, the absence of constitutional symptoms,
and the free mobility of the joint, especially under ether.
Articular neuralgia may depend upon disease or injury of
the central nervous system, upon malaria, syphilis, neuras-
thenia, rheumatism, gout, hysteria, and neuritis, and may be
due to reflected irritation, especially from the ovaries, the
womb, and the rectum.

Treatment. — ^The treatment to be observed in joint-neu-
ralgia is to maintain the general health ; examine for a
possible exciting cause, and, if found, remove it ; give a long
course of iron, quinin, and strychnin or of arsenic. In rheu-
matic or gouty subjects give suitable drugs and insist upon
proper diet During the attack use phenacetin. Morphin
must occasionally be used in severe cases, but be careful of
it, and never tell the patients they are taking it, as there is a
possibility of their forming the opium-habit. Locally, employ
frictions, ointment of aconite, heat, and keep upon the part
a piece of flannel soaked in a mixture of soap-liniment,
laudanum, and chloroform (Gross). Never let a joint, stiffen ;

432 MODERN SURGERY,

any tendency to do so should be met by daily massage,
frictions, passive motion, and hot and cold douches. In
some rare cases nerve-stretching or neurectomy becomes
necessary.

Articulax Wounds and Injuries. — A penetrating

wound is very serious, and it may be due to compound
fracture, to compound dislocation, to gunshot-wounds, or
to stabs. If a bursa near a joint be injured, secondary
penetration may occur as a result of suppuration. In a
penetrating wound, besides pain, hemorrhage, and swell-
ing, there is a flow of synovial fluid. A small amount of
synovia flows from an injured bursa, a large amount from
an open joint.

Treatment. — If a joint is opened aseptically (as when in-
cised by the surgeon), it gets well nicely under rest and anti-
sepsis. If a joint is opened by a septic body, suppurative
arthritis is apt to arise, and the indications are to irrigate,
drain, dress antiseptically, and secure rest. Normal salt
solution is the best agent for irrigation, as it does not injure
joint-endothelium. Active antiseptics are apt to lessen tissue-
resistance and thus favor infection. In gun shot- wounds, if
antisepsis is not employed, suppuration is inevitable ; hence
military surgeons, as a rule, have advocated amputation or
excision in gunshot-splinterings of large joints. In these
injuries the wound is enlarged, the finger is introduced to
discover and remove foreign bodies, through-and-through
drainage is secured, a tube is inserted, the joint is irrigated,
antiseptic dressings are applied, and the extremity is placed
upon a splint. Very severe cases demand resection or even
amputation. Ankylosis more or less complete follows a
crunshot-wound of a joint. If the joint suppurates, the
drainage must be made more free, sinuses must be slit up
and packed, sloughs must be cut away, dead bone must be
gouged out, and the patient must be placed upon a stimu-
lant and tonic plan of treatment.

Sprains. — A sprain is a joint- wrench due to a sudden twist
or traction, the ligaments being pulled upon or lacerated and
the surrounding parts being more or less damaged. A sprain
is often a self-reduced dislocation (Douglas Graham). The
joints most liable to sprains arc the knee, the elbow, and the
ankle. The smaller joints arc also often sprained, but the
ball-and-socket joints are infrequently sprained, their normal
range of free movement saving them ; they do occasionally
suffer severely, however, as a result of abduction. In a bad
sprain the ligaments are torn ; the .synovial membrane is con-

DISEASES AND INJURIES OF BONES AND JOINTS. 433

tused or crushed ; cartilages are loosened or separated ; hem-
orrhage takes place into and about the joint ; muscles and
tendons are stretched, displaced, or lacerated; vessels and
nerves are damaged; the skin is often contused; and por-
tions of bone or cartilage may be detached from their proper
habitat, though still adhering to a ligament or tendon (sprain-
fractures). Sprains are commonest in young persons and in
adults with weak muscles. They happen from sudden twists
and movements when the muscles are relaxed. A large part
of the support of joints comes from muscles, and when
they are suddenly caught unawares they do not support the
joint and a sprain results. A joint once sprained is very
liable to a repetitionof the damage from slight force. Sprains
are common in a limb with weak muscles, in a deformed ex-
tremity in which the muscles act in unnatural lines, and in a
joint with relaxed ligaments.

Symptoms. — ^The symptoms manifested in sprains are as
follows : severe pain in the joint, accompanied by a weakness.
Nausea, often vomiting, and sometimes syncope. Impair-
ment or loss of motion is present. This condition is suc-
ceeded by a season of relief from pain while at rest, numb-
ness being complained of, and pain on motion being severe.
Wery soon swelling begins if hemorrhage is severe. In any
case swelling begins in a few hours. Movement of the joint
becomes difficult or impossible ; the tear in the ligament may
be distinctly felt ; pain and tenderness become intense ; joint-
crepitus will be detected ; and in a day or two discoloration
becomes marked. Moullin and others have pointed out that
when a muscle is strained the skin above it becomes sensitive,
especially at tendinous insertions over joints. As muscles
are invariably strained when a joint is sprained, there is in-
variably some cutaneous tenderness. There is always ten-
derness over a sprained joint due to capsular injury, bands of
adhesions, etc. Tenderness is apt to arise at certain reason-
ably fixed points: in a hip-joint injury it is found behind the
great trochanter, in a knee-joint injury by the side of the
patella, in an ankle-joint injury to the inner side of the
external malleolus (Culp). When the ligaments of the
back are sprained the back muscles are rigid, the skin is
often sensitive, pain may be awakened by pressure or by
certain movements, but there is no sign of cord injury.

Diagnoeis and Profirnosis. — Sprain-fractures can be diag-
nosticated with certainty only by the .r-rays. In the diag-
nosis of a .sprain fracture and dislocation must be consid-
ered. In fracture, crepitus and mobility exist ; in dislocation,.

434 MODERN SURGER Y. '

rigidity. The diagnosis should be made by a consideration
of the joint involved, of the age, of the nature of the force,
by the length of the limb, by the fact that the patient could
use the joint for at least a short time after the accident, and
by the local feel and movements of the part. In some cases
examine under ether, in some apply the ^-rays. The prog-
7tosis depends on the size of the joint, on the extent of lacer-
ation, and on the amount of intra-articular hemorrhage.
The danger is ankylosis.

Treatment. — ^The first indication is to arrest hemorrhage
and limit inflammation. For the first few hours apply press-
ure and an ice-bag. Wrap the joint in absorbent cotton
wet with iced water, apply a wet gauze bandage, and put on
an ice-bag. In a mild sprain use lead- water and laudanum
or apply at once a silicate dressing. In a severe sprain place
the extremity upon a splint and to the joint apply flannel
kept wet with lead-water and laudanum, iced water, tincture
of arnica, alcohol and water, or a solution of chlorid of
ammonium. The ice-bag should from time to time be laid
upon the flannel for periods of twenty or thirty minutes.
Leeches around the joint do good. Constitutionally, em-
ploy the remedies for inflammation (page 60). Morphin or
Dover's powder is given for the pain. Judicious bandaging
limits the swelling.

After a day or two, if the symptoms continue or if they
grow worse, use hot fomentations, hot lead-water and lauda-
num, the hot-water bag, plunge the extremity frequently in
very hot water, or apply heat by Leiter's tubes. When the
acute symptoms begin to subside, rub stimulating liniments
upon the joint once or twice a day and employ firm com-
pression by means of a bandage of flannel or rubber. Fric-
tions should be made from the periphery toward the body.
Many cases do well at this stage under the local use of
ichthyol and lanolin (50 per cent.), tincture of iodin, or blue
ointment. Later in the case use hot and cold douches,
massage, frictions, passive motion, and the bandage. Van
Arsdale treats these cases by massage almost from the start.
Gibney treats sprains by strapping with adhesive plaster.
Passive motion is begun a day or so after swelling ceases.
If massage causes the swelling to return, abandon it for sev-
eral days and then try it again. Blisters are used when tender
spots persist and stiffness is manifest. If stiffness becomes
marked, move the joint forcibly. Give iodid of ()otassium,
use tonics internally, and insist on open-air exercise. If the
person is gouty or rheumatic, use appropriate remedies.

DISEASES AND INJURIES OF BONES AND JOINTS. 435

Many sprains may be put up in an immovable dressing the first
day or two after the accident. If the joint contains much blood,
aspiration should be practised before the dressing is applied.

Ankylosis. — When a joint-inflammation eventuates in
the formation of new tissue in and about the joint contraction
of this tissue limits or destroys joint-mobility, producing the
condition known as " ankylosis." Ankylosis may be com-
plete (bony) or incomplete (fibrous) ; it may arise from con-
tractures in the joint (true or intra-articular ankylosis) or
from contractures in the structures external to the joint (false
or extra-articular ankylosis).

True or intra-articular ankylosis may arise from any
cause which produces joint-inflammation with formation of
new tissue, and may be due to wounds, contusions, sprains,
dislocations, fractures in or near a joint, movable bodies in a
joint, tubercle, gout, rheumatism, or syphilis. Want of use
of the joints causes partial ankylosis, though this has been
denied. Ankylosis is more apt to take place in a hinge-
joint than in a ball-and-socket joint. In ankylosis from a
general cause (as rheumatic gout) many joints are apt to
suffer. Ankylosis may be due to fibrous tissue, and is then
usually partial ; it may be due to chondrification of fibrous
tissue, and is then incomplete ; it may be due to ossification
of fibrous tissue, and is then complete, the joint being
entirely immobile (osseous or bony ankylosis). The entire
joint may be converted into bone. Only one small joint-
surface may contain adhesions (limited adhesion), or the
entire joint-surface may be bound up in them (diffused ad-
hesion).

Fibrous ankylosis follows aseptic inflammations ; bony
ankylosis is apt to follow infections. Though slight motion
is usually possible in fibrous ankylosis, in some cases it may
be impossible. A joint immovable from fibrous ankylosis is
distinguished from a joint immovable from bony ankylosis
by the fact that in the former attempts at motion are pro-
ductive of pain, and subsecjuently of inflammation. The
incapacity resulting from ankylosis is due, first, to the im-
pairment or destruction of joint-function, and, secondly, to
the fixation at an inconvenient angle (a fixed flexed knee is
worse than a fixed extended knee ; a fixed extended elbow
is worse than a fixed partly flexed elbow).

Treatment. — The effort should always be made to prevent
an ankylo.sis by treating carefully any joint-inflammation and
by beginning passive motion at the earliest safe period. To
limit inflammation is to prevent ankylosis. Many cases of

436 MODERN SURGER K

fibrous ankylosis are improved by passive movements, mas-
sage, frictions, stimulating liniments, inunctions of ichthyol
or mercurial ointment, hot and cold douches, hot-air
baths, and electricity. .Some cases may be straightened
out slowly by screw-splints or by weights and pullejs.
Fibrous ankylosis of the elbow is best treated by using the
joint. Fibrous ankylosis is often corrected by forcible
straightening. If the tendons are much contracted, tenot-
omy should be performed two or three days before forcible
straightening is attempted. In order to straighten, alu-ays
give ether. Suppose a case of ankylosis of the knee : put
the patient upon his back, bring the leg over the end of
the operating-table, grasp the ankle with one hand and the
lower portion of the leg with the other hand, and make
strong, steady movements of flexion and extension until the
limb can be straightened. The adhesions will be felt to
break, the snapping often being audible. At once apply a
plaster-of- Paris dressing, and keep the limb immobile fortuo
weeks. This procedure is not free from danger. Vessels may
be ruptured, nerves may be torn, skin and fascia may be
lacerated, suppuration may ensue from the admission into the
joint of encapsuled cocci, or of organisms in the blood which
find in this area a point of least resistance. Because of the
danger of opening up depots of encapsuled bacilli and coed,
do not forcibly break up an ankylosis that results from a
tubercular or a septic arthritis, but use gradual extension by
weights or by screw-splints. Ankylosis of the knee follow-
ing fracture of the patella is almost sure to recur after
forcible breaking up. The best treatment for knee-ankylosis
is use of the joint. In bony ankylosis of any joint other than
the elbow-joint do nothing if the joint is in a useful position.
If the joint is firmly fixed in an unfortunate position, resort
to excision or an osteotomy. In the elbow excision should
be performed, no matter what the position, in the hope of
obtaining a movable joint. In ankylosis of the jaw surgeons
arc apt to tr>^ to remedy the condition by wedging the jaws
apart with a mouth-gag, and afterward inserting boxwood
plugs at frequent intervals. This method is invariably a feil-
ure.* Ivsmarch's operation is sometimes curative (removal
of a wedge-shaped piece of bone). Some operators excise
the condyle and a portion of the neck. Swain advocates
sawing the bone at the angle.

False or Extra-articular Ankylosis. — In this disease
the joint is intact, but the contractures are in surrounding

^ Swain, in Lancet ^ 1 894, vol. ii., p. 187.

DISEASES AND INJURIES OF BONES AND JOINTS. 437

parts. The causes are muscular, fascial, and tendinous con-
tractures, cicatrices (especially from burns), deposits of bone,
muscular paralysis, tumors, and aneurysm. Contractions of
muscles or tendons may be due to gout, rheumatism, injury,
thedtis, fractures, and dislocations. False ankylosis is seen
in club-foot and in Dupuytren's contraction.

Treatment. — ^The treatment of false ankylosis depends
upon the cause. Recently contracted muscles or tendons
require motions, massage, frictions with stimulating lini-
ments, and hot and cold douches. Old contractions require
division. Whenever possible, excise a cicatrix that causes
false ankylosis, and fill the gap with good tissue. Bony
deposits are gouged away and tumors are removed. Con-
tractures in cases of paralysis require electricity, passive
motion, frictions with stimulating liniments, the hot-air
bath, and general treatment.

I/Oose Bodies in Joints (Floating Cartilages). — The

knee is the joint oftenest affected. These bodies may be free,
may have a stalk or pedicle, may move about and occasion-
ally block the joint, or may lie quietly in a joint-recess or
diverticulum. They may be single or multiple, flat or ovoid,
smooth or irregular, as small as peas or as large as plumSj
and may be composed of fibrous tissue, of bone, or of carti-
lage. There are numerous different modes of origin of these
bodies, many being "detached ecchondroses or pieces of
hyaline cartilage hanging by narrow pedicles " (J. Bland
Sutton), and they result from enlargement and chondrifica-
tion of the villi of the synovial membrane. Some loose
bodies are broken-off* osteophytes ; some arise from blood-
clots; some by projection or herniation of the synovial
membrane, which protrusion is broken off"; others are de-
tached fringes of tubercular synovial membrane. Trauma-
tism is usually an exciting cause. Loose cartilages are com-
monest in adult men.

Symptoms. — Many small bodies give rise to no symptoms
other than those of synovitis. A large body produces pain
and interferes with joint-function. The joint is weak and
a little swollen, and the patient can feel the body and often
can push it into a superficial area of the joint, where it may
be felt by the surgeon. From time to time the body may
get caught, thus suddenly locking the joint and producing
intense and sickening pain, extension and flexion being im-
possible until the body slips out. This accident is followed
by inflammation and effusion.

Treatment. — ^To relieve locking, employ forced flexion and

438 MODERN SURGERY.

sudden extension. Cure can be obtained only by operation.
Asepticize with the utmost care. Let the patient bring the
foreign body to a point where it can be felt ; the surgeon
then fixes it with a pin or holds it with the fingers, ether
being given or cocain being used. The joint is now opened,
the foreign body extracted, and an exploration made to
sec that no other bodies are present. The wound is now-
stitched and the leg is placed upon a splint. Asepsis must
be most rigid. The operation does not cure the causative
lesion, and these bodies are apt to form again.

4. Luxations or Dislocations.

A dislocation is the persistent separation from each other,
partially or completely, of two articular surfaces. A self-
reduced dislocation is called a sprain. There are three forms
of dislocation : (i) traumatic; (2) spontaneous or pathologi-
cal ; (3) congenital.

I. Traumatic dislocations are due to injury. They
arc divided into—completr dislocation, in which the two
articular surfaces are entirely separated and the ligaments arc
torn ; incomplete or partial dislocation, in which the tuo
articular surfaces are not completely separated and the liga-
ments are rarely lacerated ; simple dislocation, in which the
articular surfaces are not brought into contact with the ex-
ternal air; cojiipotmd dislocation, in which the external air
has access to the articular surfaces ; complicated dislocation,
in which, besides the dislocation, there is a fracture, exten-
sive damage of the soft parts, an opening admitting air to the
soft parts, or damage of a nerve or blood-vessel ; primiiirce
dislocation, in which the bones remain as originally displaced;
secondary dislocation, in which the bone assumes a new
position : for instance, a subglenoid luxation of the humerus
is primar}', and it may become secondarily a subcoracoid
luxation because of muscular contraction or attempts at
reduction ; recent dislocation, in which the displaced bone is
not firmly fastened by tissue-changes in its new situation.
and its old socket is not obliterated ; old dislocation, in which
the displaced bone is firmly fastened by tissue-changes in its
new habitat, and the old socket is to a great extent obliter-
ated (whether a dislocation is old or new depends on the
state of the parts rather than on the time which has elapsed
since the accident) ; double dislocation, in which correspond-
ing bones on each side arc dislocated ; single dislocation, in
which only one joint is dislocated ; unilatercU dislocation, in

DISEASES AND INJURIES OF BONES AND JOINTS. 439

which one articulation of one bone is out of place ; bilateral
dislocation, in which symmetrical articulations are dislocated ;
and relapsing ox liabitual diislocation, which recurs constantly
from slight force because of relaxed hgaments or lack of
complete repair after the ligamentous rupture of a first dis-
location.

2. Spontaneous, Fatholosical, or Consecutive Dis-
locations.— Spontaneous dislocation arises from such very
slight force that it often cannot be identified, and it acts on
a joint rendered lax by disease. It may arise in the course
of chronic synovitis and during tubercular joint-disease. In
typhoid fever spontaneous dislocation is not uncommon.
The hip-joint is most often the one attacked. The dislo-
cation follows a severe joint-inflammation, is usually upon
the dorsum of the ilium, and is frequently not noticed until
convalescence. If a typhoid dislocation is seen early, reduc-
tion is easily effected, but if seen late is impossible. The
treatment for irreducible typhoid dislocation is the same as
for any other irreducible dislocation. In Charcot's joint
{arthropathie des ataxiques) this form of dislocation con-
stantly appears. This condition comes on in a few hours,
during the progress of locomotor ataxia, and is without ap-
parent reason. The knee, the shoulder, or some other joint
becomes greatly swollen, fluid gathers in large amount, the
ligaments relax, the joint is destroyed and becomes exces-
sively mobile, but there is no pain, no fever, and no sign of
inflammation (p. 429). In Charcot's joint apply a support.

3. Congenital Dislocations. — The third form, or con-
genital dislocation, is due to a congenital joint-malformation
which renders it impossible for the bone to maintain a nor-
mal position, or is due to external violence during the period
of uterine gestation. Congenital dislocations should not be
confounded with dislocations produced during delivery.
The hip is the joint most often involved. The shoulder
suffers occasionally. Lannelongue maintains that congenital
dislocation of the hip is due to atrophy of the muscles and
of the acetabulum following spinal-cord disease. Verneuil
thinks the dislocation is paralytic. Broca truly says that in
view of the fact that the head of the bone is larger than the
cavity in which it belongs it is entirely useless to attempt
reduction by manipulation or extension. Hoffa and Lorenz
have each devised an operation for this condition (p. 503).
Congenital dislocation of the shoulder requires incision, pos-
sibly excision, or the paring down of the head to fit the
glenoid cavity (Phelps).

440 MODERN SURGER Y.

Traumatic Dislocations. — In the succeeding pages
the traumatic form of dislocations will be particularly con-
sidered.

The causes of traumatic dislocations are divided into prt-
disposing and exciting.

Predisposing causes are (i) Age — dislocations are com-
monest in middle life, the usual lesion of the young being
green-stick fracture, and that of the old being fracture.
Dislocations of the radius are not uncommon in youth.
(2) Muscular development — dislocations being commonest in
those with powerful muscles. (3) Sex — males being more
predisposed than females, because of their occupations and
muscular strength. (4) Occupation predisposes as a cause
according as it demands the employment of muscular force,
as in the carrying of burdens. (5) Nature of the joint—
ball-and-socket joints being more liable to luxation than are
ginglymoid joints, because of their wide range of motion.
(6) Joint-disease predisposes by relaxing the ligaments. (7)
Situation of the joint — some joints being more exposed to
injury than others.

Exciting causes are classified into (i) external violence
and (2) muscular action. External inolence may be direct,
as when a blow upon one of the bones forces it directly
away from the other ; or it may be indirect^ as when a blow
at a distant part of a bone transmits force to its end and
drivx's the bone out of its socket. Muscular action is a
cause when sudden and violent muscular contraction occurs
during the maintenance of a position of the joint which gives
the muscles full sway, and throws the head of the bone
against the weakest part of its retaining ligaments.

Pathologfical Conditions. — In a recent complete trau-
matic dislocation the ligaments are damaged, and may
perhaps show extensive laceration, or may show only a
button-hole laceration through which a bone projects. Ex-
ternal force produces much laceration and little stretching
of the lif^aments ; muscular action produces little laceration
and much stretching of the ligaments (Mears). In some
cases of dislocation due to external violence the structures
about the joint are bruised or otherwise damaged; the old
socket is filled with blood, and the bone in its new situa-
tion lies in a bloody area. Large vessels and ner\'es are
rarely torn, though they may be compressed.

If a dislocation is not soon reduced, inflammation arises
in the old joint and about the displaced bone, and the whole
area is glued together, first by coagulated exudate, and

DISEASES AND INJURIES OF BONES AND JOINTS. 44 1

finally by fibrous tissue. After a time, in ball-and-socket
joints, the old socket fills with fibrous tissue, contracts,
becomes irregular, and may even be obliterated ; the head
of the dislocated bone alters its shape, its cartilage is de-
stroyed or converted into fibrous tissue, and the pressure
of the head of the bone forms a hollow in its new situation,
which hollow becomes surrounded by fibrous tissue or even
by bone. A new joint may form, the surrounding tissue
becoming a compact capsule, and a bursa forming between
the head of the bone and its new socket. In a dislocated
hinge-joint the ends of the bone alter greatly in shape and
their cartilage is converted into fibrous tissue. In an unre-
duced dislocation the muscles shorten or lengthen or
undergo atrophy or fatty degeneration, as the case may be.
An unreduced dislocation of a ball-and-socket joint may
give a fairly movable new joint, but an unreduced disloca-
tion of a hinge-joint rarely allows of much motion.

(General Symptoms of Traumatic Dislocations.— In
general, traumatic dislocations are indicated (i) by pain of
a sickening, nauseating character ; (2) by rigidity voluntary
motion is impossible except to a slight extent in the direc-
tion of the deformity. (For instance, in dislocation of the
inferior maxillary the jaw can be opened a little more, but
it cannot be closed. This rigidity brings about loss of
function. When the surgeon attempts to move the joint
he finds it very rigid) ; (3) by change in the shape of the joint
(as flattening of the shoulder after dislocation of the hume-
rus) ; (4) by alteration in the mutual relations of bony promi-
nences about a joint (alteration of the relation between the
olecranon and humeral condyles in dislocation of the elbow
backward); (5) by feeling the displaced bone in its new
situation ; (6) by missing the head of the bone from its
proper situation ; (7) by alteration in the length of the limb
(in dislocation of the femur into the thyroid foramen the
leg is lengthened, but in dislocation into the dorsum of the
ilium it is shortened) ; and (8) by alteration in the axis of
the bone (in dislocation upon the dorsum of the ilium the
axis of the injured thigh would, if prolonged, pass through
the lower third of the sound thigh) ; (9) by seeing the dislo-
cation with a fluoroscope or looking at a skiagraph of it.

Diagrnosis of Traumatic Dislocation. — A dislocation
may be mistaken for a fracture. In dislocation there is
rigidity, in fracture there is preternatural mobility ; in dislo-
cation there is no true crepitus (may get tendon- or joint-
crepitus), in fracture there usually is crepitus ; in dislocation

442 MODERN SURGERY.

the deformity does not tend to recur after reduction, in
fracture it does recur after extension is relaxed. In a sprain
the movements of the joint are only limited, not abolished,
by an almost complete rigidity. The change which a sprain
may cause in the shape of a joint is due to effusion or to
bleeding ; there is no alteration in the relation of the bony
prominences to one another ; there is no notable alteration
in the length of the limb (a slight increase in length may
arise from joint-effusion, or the head of the bone may sub-
sequently be absorbed, and thus produce shortening after
some weeks) ; there is no alteration in the axis of the bone ;
the head is not felt in a new position, it being found in its
normal place. Always remember that a fracture may exist
with a dislocation. In any doubtful case — ^in fact, in most
cases — give ether, for a dislocation should be reduced while
the patient is anesthetized (except in dislocation of the jaw,
of the fingers, of the carpus, etc.). In some cases swelling
renders the diagnosis difficult or impossible. Always com-
pare the injured joint with the corresponding joint of the
sound side. The Jf-rays constitute a valuable aid to diag-
nosis.

Treatment of Traumatic Dislocations. — Recent Simple
Dislocations, — Reduce simple dislocations under ether, as a
rule. Try manipulation, a procedure in which it is sought
to make the bone retrace its own pathway. If this proced-
ure fails, employ extension and counter-extension. If con-
siderable force is needed, an assistant makes counter-exten-
sion, and the surgeon fastens to the extremity a clove-hitch
which he tics about his waist, and thus secures powerful
extension. Counter-extension may be obtained by bands,
or, in some instances, by the foot of the surgeon. The
clove-hitch is used because it will not tighten by traction,
as a tightening band would lacerate the soft parts (Fig. 112).
If great power is needed, compound pulleys may be em-
ployed, such as the Jarvis adjuster or some similar appli-
ance, but at the present day pulleys are rarely used
(see page 444). If these means fail, cut down upon the
bone and restore it to position ; operation is much safer
than is the application of great force. After reducing a
dislocation, immobilize the joint for a time (time varies
with different joints), and for the first few days combat swell-
\v\^ and inflammation with evaporating lotions. If there
exists a fracture of the dislocated bone, apply splints and
then tr>' to reduce by manipulations, grasping the limb and
the splint with one hand below^ and, if possible, with the

DISEASES AND INJURIES OF BONES AND JOINTS. 443

Other hand above the seat of the fracture. In some cases
with fracture reduction can be much aided by making a
small incision, screwing a gimlet into the head of the bone,
and using this tool as a handle. McBumey incises, drills
a hole in each bone, inserts hooks into them, and pulls the
dislocated bone into position (Figs. 68, 69). When the dislo-
cation has been reduced the bone fragments are wired. Allis
believes that a dislocation can be reduced even when a fract-
ure exists. It is possible to pull the dislocated head down
to the joint, because a portion of periosteum and possibly
tendinous material and muscle still hold the two fragments
as a strap might unite two sticks. The head can be forced
into place by the fingers while traction is being made. If
the fracture is near the joint and the fragments cannot be
fixed, try to reduce the dislocation, first striving to press the
bone into place. This attempt can be greatly aided by
traction upon the lower fragment.

Compound Traumatic Dislocations. — The opening in the
soft parts may be due to external violence or to projection
of a bone. Compound dislocations are very serious. Hinge-
joints are more liable to these injuries than are ball-and-
socket joints. Many cases require excision and amputation ;
one that does not demand excision or amputation should be
treated by counter-opening, by careful antisepsis, by drainage,
and by immobilization, ankylosis generally ensuing, except
sometimes in the small joints. It is scarcely ever necessary
to cut away any portion of the protruding bone to effect
reduction. If a joint is badly splintered, or if the soft parts
are extensively damaged, excise or amputate ; if the main
vessels or the nerves are seriously injured, or if the patient
is so old or so feeble that it is perilous to force him to combat
a long illness, amputate.

Old Traumatic Dislocations. — The problem always pre-
sented in old dislocation is. Shall reduction be tried, or
shall the bones be left alone ? Sir Astley Cooper laid down
this rule : " Do not attempt to reduce a shoulder-dislocation
after three months, nor a hip-dislocation after two months ;"
but this rule was laid down before the days of ether. Do
not select any fixed period of time to determine what action
is advisable. In dislocation of a ball-and-socket joint con-
siderable motion may become possible and a new joint may
form. If movement does not produce pain, a useful new
joint may be obtained by the persistent employment of active
and passive movements ; if movement of the limb does
produce pain, enough motion will not be attempted by the

444 MODERN BURGER K

patient to produce a useful joint. In the former case try to
obtain a useful new joint, and in the latter case try to reduce
the old dislocation.

In trying to reduce an old dislocation, give ether, make
movement to break up adhesions, and persist in making
these motions until the head of the bone is felt to move;
then try at once to reduce by manipulation, extension, or
the pulleys, not waiting for two days, as some suggest If
the head of the bone cannot be made to move, the Dieffen-
bach plan may be followed, which is to cut the tense
restraining bands with a tenotome. Always remember that
dislocations of a hinge-joint, if left unreduced, will never
eventuate in a useful artificial joint Sir Joseph Lister, being
much impressed with the danger inevitably linked with for-
cibly dragging old dislocations into place, prefers to cut
down and restore the bone, employing, of course, the strict-
est asepsis. Many surgeons adhere to this view. In some
old dislocations excision of the head of the bone is the proper
operation.

Special Traumatic Dislocations. — Lower Jaw.—

Without fracture the lower jaw can only be dislocated for-
ward. There are two forms of dislocation — the unilateral,
which is rare, and the bilateral, which is common. Disloca-
tions of the jaw are commonest in women and during middle
life. When the mouth is open contraction of the external
pterygoid may pull the condyle over the articular eminence;
this contraction may be brought about by yawning, vomiting,
scolding, etc. When the mouth is open dislocation of the
lower jaw may be caused by a blow upon the chin ; it may
also be caused by forcing the mouth more widely open by
pushing a bulky body between the teeth.

Symptoms erf Lcnuer-jaw Dislocations. — In the bilateral
form the mouth is open and fixed, and it cannot be closed,
though it can be opened a little more. The condyles are
in front of the articular eminences, and are fixed by the
action of the masscters and internal pterygoids, the coronoid
processes being wedged against the malar bones. The lower
jaw is advanced in front of the upper and the face looks
longer than natural. The lips cannot close, the saliva over-
flows, swallowing and speech are difficult, there is a depres-
sion in front of each ear, the condyles are recognizable in their
new abodes, the coronoid processes are detected by a finger in
the mouth, and the masseters and temporals stand out in a
state of rigidity. Pain may be severe or be absent. In the
ujiilatcral form the chin goes toward the sound side, and the

DISEASES AND INJURIES OF BONES AND JOINTS. 445

mouth is not so widely open as in the bilateral form, neither
is the jaw so fixed. The symptoms are similar to those of
a bilateral luxation, but are not so pronounced. The hollow
in front of the ear and the condyle in an abnormal situation
are only detected upon one side. In an unreduced disloca-
tion the patient may after a time establish some movement
of the jaw, but the power of mastication will always be im-
paired seriously.

Treatment of Lower-jaw Disloeations, — In treating dislo-
cations of the lower jaw the patient is placed with his head
against the back of a chair or against the body of an assist-
ant. The surgeon, after wrapping up his thumbs to protect
them from being bitten, stands in front of the patient, puts
his thumbs upon the last molar teeth, and grasps the chin
with his free fingers. He now presses downward and back-
ward on the jaw, and as soon as the condyle is loosened
closes the jaw over the thumbs by pushing up the chin,
using his thumbs as levers. If this procedure fails, wedges
should be put between the molar teeth and the chin should
be pushed up either by the hands or by a tourniquet whose
band is round the head and chin. In a unilateral disloca-
tion the wedge should only be used on the injured side.
In difficult cases Sir Astley Cooper pushed a round wooden
ruler between the molar teeth, used the upper teeth as a
fulcrum, and raised the end of the ruler as the handle of
a lever. The forceps used by an anesthetizer may depress
the condyle from its point of fixation, whereupon the chin
may be pushed up and back. Nelaton's plan was to
put the thumbs in the mouth and push the coronoid pro-
cesses backward. In an old dislocation always try reduc-
tion, at least up to a period of six or seven months. After
reduction apply a Barton bandage for over two weeks, taking
it off once a day, and begin passive motion in the second
week ; discard the bandage in the third week. Liquid diet
is advisable for three weeks after the accident. An unre-
ducible dislocation requires osteotomy of the neck of the
bone, if the part cannot be restored after incision.

Dislocation of the Clavicle. — Sternal End. — There are
three forms of dislocation of the sternal end of the clavicle,
namely: (i) forward; (2) backward; and (3) upward.

Forward Dislocation of the Sternal End of the Clavicle.
— The causes of forward dislocation of the clavicle are blows,
falls, or pulls which drive or draw the shoulder backward.

Symptoms and Treatment of Fonuard Dislocation of the
Clavicle, — ^The symptoms manifest in dislocation of the clavi-

446 MODERN SURGERY.

cle are — prominence in front of the sternum ; the acromion
is nearer to the sternum on the injured than on the sound
side ; the clavicular origin of the sternocleidomastoid is
rigid ; movement is difficult and painful. To treat a dislo-
cation of the clavicle, pull the shoulders back against the
knee of the surgeon, which is placed between the scapula.
Dress with a posterior figure-of-8 bandage (Fig. 271), or a
Velpeau bandage (Fig. 273), the dressing to be worn for
three weeks. After removal of the dressing apply a truss,
the pad of which is put over the head of the clavicle, and
which instrument is to be worn for a month. Dislocation
of the clavicle is difficult to keep reduced, but even if it
becomes fixed in deformity the motions of the arm will not
be impaired permanently. It can be reduced and fixed by
incision and wiring.

Backward dislocation of the sternal end of the clavicle
is very rare. The causes are direct violence and indirect force,
such as falls or blows which drive the shoulder forward and
inward.

Syjnptoms and Treatment of Backward Dislocation of the
Clavicle. — The symptoms are — pain ; loss of function in the
arm ; inclination of head toward the injured side ; stiffiiess of
the neck ; the shoulder passes forward and inward, and often
falls downward ; a depression exists over the sternoclavicular
joint; the head of the clavicle cannot be felt, or is found
back of the sternum. The displaced clavicle may press upon
the trachea, the esophagus, or the great vessels, inducing
dyspnea, dysphagia, obliteration of pulse in the arm of the
injured side, or great venous congestion of the head (see
Pick). To treat a backward dislocation, pull the shoulders
backward and apply a posterior figure-of-8 bandage (Fig.
271), which must be worn for three weeks. If pressure-
symptoms are urgent, resect the displaced head.

Upward dislocation of a clavicle is very rare. The
cause is indirect force which carries the shoulder downward,
inward, and backward (Smith).

Syjttptows and Treatment of Upivard Dislocation of the
Sternal End of the Claviele.-r-^he chief symptom is impaired
function of the arm ; the shoulder passes downward and
inward, the clavicular axis is altered, and the displaced head
is felt. Dyspnea may or may not exist. To treat this dis-
location, put a pad in the axilla and press the elbow to the
side in order to throw the bone outward, and try to push the
head into place. Apply a Desault bandage (Fig. 276)
and place a firm pad over the sternoclavicular joint. The

DISEASES AXD JXJCKJES OF EOA'ES AND JOINTS. 447

leformity is apt to recur, but a useful limb will nevertheless

e obtained. It may be desirable to wire the bones in place.

Dislocation of the acromial end of the clavicle is almost

ways upward, but it may be below the acromion. The cause

violent force, which, if so applied to the scapula as to drive

^the shoulder forward, may produce a dislocation upward. A

dislocation downward is due to blows upon the upper surface

of the outer end of the clavicle.

Symptoms and Trcatme?:t. — The symptoms of dislocation

»of the acromial end of the clavicle are — prominence of the
cla\-icle upon the top of the acromion ; impaired function of
the arm (it cannot be hfCed over the head) ; the shoulder falls
downward and passes inward; there is apparent lengthening
of the arm ; the head is bent toward the injured side, and the
clavicular origin of the trapezius is strongly outlined (Pick).
, In dislocation downward both the acromion and the coracoid
e very prominent, the clavicular axis is altered, and there
i depression over the sternoclavicular joint A dislocation
■-upward is reduced by pulling the shoulder back and pushing
Bthe bone into place. The old method was to apply a
ilDesault bandage, which was kept on for three weeks, and
fttnore or less deformity was looked for as inevitable. Stim-

n dresses with adhesive plaster. The author has recently
I seen a case treated by the apparatus of Thomas Leidy
VKhoads. The apparatus completely corrected the deformity,

448 MODERN SURGERY.

and the patient made a most satisfactory recover>'. The
essential element of Rhoads's apparatus is a trunk strap
applied as is shown in Fig. 109. Dislocation downward is
reduced and treated in the same manner as dislocation
upward.

The so-called dislocation of the Icwer an^le of the
scapula is not, as it was long thought to be, a disloca-
tion at all. The lower angle and vertebral border de\iate
from the chest. This condition was thought to be due to the
bone slipping from under the latissimus dorsi muscle, but it
is now known to be due to paralysis of the serratus magnus
muscle, the bone being acted upon by the trapezius, pector-
alis minor, levator anguli scapulae, and rhomboid muscles.
Examination shows that the scapula will not rotate normally
forward. This is demonstrated by extending the arms in front
to a right angle, the gliding forward of the scapula upon the
sound side being marked and upon the diseased side being
slight or absent.

Treatment of dislocation of the lower angle of the scapula
comprises massage, electricity, passive motion, and deep in-
jections of strychnin.

Swiidtaneous dislocation of both ends of the clavicle is a
ver>' rare injury. It is treated as is single dislocation.

Dislocations of the Humerus (Shoulder-joint). — These
injuries are quite frequent because of the free mobilit>' of the
shoulder-joint, its anatomical insecurity, and its exposed situ-
ation ; they rarely occur in the very young and in the aged,
and arc oftcncst encountered in muscular young adults.
Four chief forms of shoulder-joint dislocation exist, namely:
(i) forward, inward, and downward, under the coracoid pro-
cess— subcoracoid ; (2) downward, forward, and inward, be-
neath the glenoid cavity — subglenoid; (3) backward, in-
ward, and downward, under the spine of the scapula —
subspinous ; and (4) forward, inward, and upw^ard, under
the clavicle — subclavicular.

A ver>' rare form of shoulder-joint dislocation has been
described, which is know^n as the ** supracoracoid." Another
rare form is the luxatio erecta.

Subcoraeoid Luxation. — The subcoracoid variety of dis-
location embraces three-fourths of all the shoulder-joint
luxations. It may be caused by direct force driving the
head of the humerus forward and inward, or by indirect
force, such as falls upon the hand or the elbow. In this
dislocation the anatomical neck of the humerus lies uf)on
the anterior margin of the glenoid cavity, just beneath

DISEASES AND INJURIES OF BONES AND JOINTS. 449

the coracoid process, and is above the tendon of the sub-
scapularis muscle.

Subglenoid or axillary luxation may be produced by con-
traction of the great pectoral and latissimus dorsi muscles
when the arm is at a right angle to the body, but it is usually
due to falls upon the hand or the elbow when the arm is
raised and the head of the bone is against the lower portion
of the capsule. In this dislocation the head of the bone rests
uf>on the border of the scapula, below the tendon of the sub-
scapularis, in front of the long head of the triceps, and above
the teres muscles. Some observers hold that most disloca-
tions of the shoulder are primarily subglenoid, the position
having been altered by muscular action.

Subspinous luxation is a rare injury. Pick met with this
accident in a man who, while having his hands in his pockets,
fell upon the front of the point of the shoulder. The head
of the bone reposes beneath the scapular spine, between the
infraspinatus and teres minor muscles.

Subclavicular luxation is very rare. It is caused by the same
sort of violence which produces subcoracoid luxation. The
head of the bone rests upon the thorax, below the clavicle
and underneath the pectoralis major muscle.

In the rare form known as the " supracoracoid " the head
of the humerus rests upon the coraco-acromial ligament or
upon the acromion process and the acromion or the coracoid
is always fractured.

Luxatio erecta is an unusual form of subglenoid dislocation.
The arm is upright and the forearm rests behind the occiput
or on the top of the head, and the patient holds it there to
avoid pain. Judd, Hulke, and Cleland have related cases.

Symptoms of Dislocation of the Shoulder-joint. — Dislocation
is diagnosticated by (i) pain of a sickening character ; (2) flat-
tening of the shoulder, the head of the bone having ceased to
bulge out the deltoid muscle; (3) apparent projection of
the acromion through sinking in of the deltoid ; (4) hollow
beneath the acromion, over the empty glenoid cavity, and the
bone missed from its normal habitat. This hollow may be
easily appreciated by the finger, especially when the extrem-
ity is .somewhat abducted; (5) rigidity (some movement is
possible, in the direction especially of an existing deformity,
but mobility is strictly limited and attempts at motion pro-
duce great pain) ; (6) the elbow cannot touch the side when
the hand is placed upon the sound shoulder, and the hand
cannot be placed upon the sound shoulder if the elbow is to
the side — Dugas's sign (this is due to the rotundity of the

450

MODERN SURGERY.

chest. In a dislocation the head of the bone is already touch-
ing the chest, and the bone, being approximately straight,
cannot touch it in two places at the same time. If the elbow
can be placed against the chest with the hand on the sound
shoulder, there cannot be dislocation ; if it cannot be so
placed, there must be dislocation) ; (7) finding the head of
the bone in a new situation; (8) examining by means of
the A'^rays. Symptoms i to 5 inclusive may be grouped as
Erichsen's list of signs. The form of dislocation v^ made
out by a study of the direction of the axis of the limb, the
existence and extent of lengthening or of shortening, and
the situation of the head of the bone.

The following table from T. Pickering Pick's work on
Fractures and Dislocations makes the above points clear:

Subcoracoid.

Subglenoid.

Subspinous.

Subclavicular.

Direction of the
Axis of the Limb.

Alteration in the
Length of the Limb.

The elbow is car-
ried backward and
slightly away from
the side.

The elbow is car-
ried away from the
trunk and slightly
backward.

The elbow is
raised from the side
and carried for-
ward.

The elbow is car-
ried outward and
backward.

Very slight
lengthening.

Very consider-
able lengthening.

Lengthening in-
termediate in de-
gree between the
subglenoid and the
subcoracoid.

Shortening.

Presence of the Head
of the Bone in Nev
Situation.

The head of the
bone cannot easily be
felt; if it can, it b
found at the upper and
inner part of the axilla.

The head of the
bone can easily be fek
in the axilla.

The head of the
bone can be felt and be
grasped beneath the
spine of the scapula.

The head of the
bone can readily be
seen and be felt be-
neath the clavicle.

In a shoulder-joint dislocation the head of the bone may
press upon the brachial plexus and produce pain and numb-
ness, and occasionally a traumatic neuritis or paralysis ; some-
times pressure upon the axillary vein causes intense edema,
and pressure upon the axillary artery diminishes or obliter-
ates the pulse. The axillary vessels may be torn and the
muscles may be lacerated badly. The capsule is torn and
considerable blood is usually effused. Swelling is due first
to hemorrhage, and secondly to inflammation. Partial dis-
locations sometimes, though rarely, occur. What is usually
spoken of as ** partial dislocation " or " subluxation " is a
condition in which the head of the humerus passes foru*ard

DISEASES AND INJURIES OF BONES AND JOINTS. 45 1

under the coracoid because of rupture of the long head of
the biceps or because this tendon slips out of its groove, the
ligaments being intact.

Diagnosis of Shoulder-Joint Dislocation, — In fracture of the
neck of the scapula there is prominence of the acromion and
a hollow below it, a hard body being felt in the axilla ; but
the coracoid process descends with the head of the bone,
which it does not do in dislocation. Furthermore, in fract-
ure there is mobility; in dislocation rigidity. In fracture
crepitus is present ; in dislocation it is absent. In fracture
the deformity is easily reduced, but it at once recurs ; in dis-
location the deformity is with difficulty reduced, but does
not recur. In fracture the elbow can be made to touch the
side when the hand is upon the sound shoulder ; in disloca-
tion it cannot be so manipulated. In fracture of the anatomi-
cal neck of the humerus deformity is slight ; the head of the
humerus is found in place, and does not move when the shaft
is rotated ; and the head is not in line with the axis of the
bone. Crepitus exists in fracture if impaction is absent. In
paralysis of the deltoid there is distinct flattening, but the
bone is felt in place and there is no rigidity. The A-rays
are a great aid to diagnosis.

Treatment of Shoulder-joint Dislocation. — Reduction by
manipulation is usually readily obtained in recent cases of
shoulder-joint dislocation. It is usually well to give ether.
Forward dislocations (subcoracoid, subclavicular, and axillary)
are reduced by Kocher's method (Fig. no): Put the arm

Fic. xio.— Kocher's method of reduction by manipulation : a, first movement, outward
flXMation ; h, second movement, elevation of elbow ; r, third movement, inward rotation and
lowering of the dbow (Ceppi).

against the side, flex the forearm to a right angle with the
arm, perform external rotation of the arm until resistance be-
comes decided, raise the elbow, make internal rotation, bring
the arm across the front of the chest and lower the elbow.
The formula is, flexion of the forearm, external rotation, lift-

452 MODERN SURGERY.

ing elbow forward, internal rotation of the arm, and lowering
the elbow. If in tr>'ing Kocher's plan external rotation of the
humerus does not take place, abandon the method, as per-
sistence will fracture the humerus. Another method of ma-
nipulation is as follows : if the right shoulder is dislocated,
the surgeon stands behind the patient (who is sitting erect);
if the left shoulder is dislocated, he stands in front of the
patient. The surgeon holds the forearm flexed upon the
arm with his right hand and makes external traction and
rotation, and with the fingers of his left hand he tries to force
the bone into place.

In Henry H. Smith's method for forward dislocations the
surgeon stands in front of the patient. If the left shoulder
is dislocated, the surgeon grasps it with his left hand ; if the
right shoulder is dislocated, he grasps it with his right hand,
the thumb resting on the head of the bone. With his disen-
gaged hand the surgeon grasps the elbow, abducts it, makes
traction and external rotation, and suddenly sweeps the elbow
inward, aiming it at the sternum, and tries with his thumb to
push the bone into place. In subspinous luxations reduction
may be effected if the surgeon stands behind the patient,
makes abduction, traction, and internal rotation, sweeps the
elbow inward toward the spine, and with the thumb aids the
bone in its return into position. Raising the elbow far above
the head and sweeping it inward will reduce some disloca-
tions. As the head of the bone slips back a distinct jar is
felt and a snap is heard, the motions of the joint are again
obtainable, and with the hand on the opposite shoulder the
elbow may be made to touch the side.

Reduction by Extension. — In reduction of shoulder-joint
dislocation by extension the patient is anesthetized and
placed upon a low bed or upon the floor. The surgeon
then places his foot, covered only by a stocking, in the axilla.
Place the sole of the foot, not the heel, against the chest high
up, the instep being made to touch the humerus and the heel
the border of the shoulder-blade, a towel being first put into
the axilla to rest the foot against (Fig. 1 1 1). If the left arm
is dislocated, use the left foot, and i^ice versa. The elder
Gross approved of making extension while sitting between
the patient's limbs. Make steady extension, which will in
many cases bring about the reduction. If it fails to cause
reduction, bring the patient's arm across the chest and use
the foot as the fulcrum of a lever. If the humerus is prett>'
firmly ^^ii(\ in its abnormal position, make counter-extension
with a foot in the axilla and make extension by fixing a clove-

DISEASES AND INJURIES OF BONES AND JOINTS. 4S3

hitch (Fig. I r 2) above the elbow and fastening to it bands which
go over one shoulder and under the other shoulder of the
surgeon. The back may be used for extension, the hands
being left free for manipulation (AUis's and Pick's plan).

Lateral extension is used by some surgeons. The patient
Kes down, a lar^e piece of canvas is split, the arm is passed
through the split and the body is thus fixed. The arm is
pulled to a right angle with the body and traction is applied.
The late Prof. Joseph Pancoast favored Sir Astley Cooper's
method of placing the unanesthetized patient in a chair and
using the knee as a fulcrum, pushing
the elbow to the side (Fig. 1 1 3).
Bninus, in the thirteenth century,
devised the method of upward ex-
tension. In applying this method

the surgeon takes his place behind the patient, steadies the
scapula with his hand, and carries the patient's arm upward
and backward above his head, making extension and external
rotation (Fig. 114). La Mothe's method is applied with the
patient supine upon the floor. The surgeon places his foot

454 MODERN SURGERY,

upon tlie shoulder to make counter-extension, and makes
extension as in Brunus's method. It is a useful expedient,
when either of these plans is applied, to have an assistant
make the traction while the surgeon manipulates the head
of the bone. Cock advises, when reduction fails, that an
air-pad be placed in the axilla and the arm be bound to the
side — a method by which reduction will often take place after
two or three days. The pulleys should not be used, as the)'
develop a dangerous force, antiseptic incision being a safer
and a better expedient. After incision try to restore the bone
to place. In an old dislocation it may be necessary to resect
the head of the bone.

In reducing a dislocation the axillary artery or vein may
be ruptured, fracture of the neck of the humerus may take
place, injury to the brachial artery may occur, or the soft
parts may be badly damaged. After reducing a dislocation
apply a Velpeau bandage, keep the shoulder immobile for
one week, then make passive motion daily, reapplying the
dressing after each seance. The patient may wear a sling
alone during the third week, after which period he may use
the arm. (For old dislocations and compound dislocations
see page 443.) Reduction of old dislocations may sometimes
be effected by manipulation. Extension may have to be used,
and ether may be required. In old dislocations try to reduce,
after breaking up adhesions, by forced flexion and strong ex-
tension. After reduction immobilize for three weeks, and
begin passive motion after seven days.

If a dislocation is complicated by a fracture of the humerus,
tr>' to pull the head of the bone opposite the joint. This
may be possible if the two fragments are held partly together
by a fair amount of periosteum and muscle. Traction is made
upon the arm, and an attempt is made to manipulate the head
into the socket (Allis's plan in the hip). McBumey incises,
fixes a hook in the scapula and a hook in the head of the
humerus, pulls the head into place, and wires the fragments
(Figs. 6'j, 6"^, 69). In an emergency gimlets may be used
instead of the hooks. In some cases it is necessary to excise
the head of the bone.

Dislocations of the Elbow-joint. — Injuries of the elbow-
joint are not rare, and they are commonest in children.
Both bones or only one bone may be dislocated, and the
dislocation may be partial or complete.

Dislocation of Both Bones Backward. — The causes of
backward dislocation of both bones of the forearm are
falls upon the extended hand or twists inward of the ulna

DISEASES AND INJURIES OF BONES AND JOINTS. 455

(Malgaigne). The coronoid process lodges in the olecranon
ibssa of the humerus.

SymptotHs of Backward Dislocation. — In complete disloca-
tion of both bones of the forearm the olecranon is very
prominent ; the distance between the point of the olecranon
and the apex of the inner condyle is notably greater than on
the sound side ; the forearm is flexed, supinated, and short-
ened; the lower end of the humerus projects in front of the
joint, below the skin-crease ; the head of the radius is found
back of the outer condyle ; and there are the general symp-
toms of dislocation. Fracture of the coronoid rarely occurs
with backward dislocation, but if it does occur there will
be crepitus and mobility. Fracture at the base of the con-
dyles is distinguished from dislocation of both bones of the
foreann backward by the following points : in fracture there
are found the ordinary symptoms; measurement from the
condyles to the styloid processes does not show shortening ;
there is no alteration of the normal relation between the olec-
ranon process and the condyles ; and the projection in front
"f the joint is above the crease of the bend of the elbow.
Treatment of Backward Dislocation. — Reduction must be
cflccted early in dislocation of both bones of the forearm,
°'' it will be found impos-
™e, and an unreduced

oisJocation means a limb

?''*;out the powers of

"eicioj], pronation, and

^yP'nation. The surgeon

Pj?ces his knee in front

■^ the elbow-joint, grasps

"•^ patient's wrist, presses

"Pon the radius and ulna

'V^h his knee, and bends

^ forearm with consid-

^■^IjJe force, the muscles

P'^Uing the bones into place (Sir Astley Cooper's plan).
^<"ced flexion, traction, and extension may be tried (Fig.
' S). Put the arm in Jones's position for two wcl"'* ^r\i\
"^^Icc passive motion daily after the first few days.
^dislocation of Both Bones Forward. — The cans
*rd dislocation of both bones of the forearm is

^ the olecranon when the arm is flexed. It is

ac,

■^dent

■ of for-
a blow
a rare

., •Symptoms and Treatment. — The symptoms of forward
^location of both bones of the forearm are — forearm

456 MODERN SURGERY.

is flexed and lengthened ; some slight motion is possible;
olecranon is on a level with the condyles if unfractured,
hence its prominence is gone; the humeral condyles are
felt posteriorly, and the radius and ulna are felt anteriorly.
The trcatvicnt of this injury consists in early reduction, which
is accomplished by means of forced flexion and pressure,
placing the part in Jones's position for two weeks, and
making passive motion daily after the first few days.

Lateral dislocations of both bones of the forearm are
usually incomplete.

Symptoms and Treatment of Outivard Dislocation. — The
symptoms of outward dislocation of both bones of the
forearm arc — forearm is flexed, fixed, and pronated; joint
is widened ; the head of the radius projects externally
and has a depression above it; the inner condyle projects
internally and has a depression below it ; the olecranon is
nearer than normal to the external condyle and further
than normal from the internal condyle. Reduction is ef-
fected by extension of the forearm and pressure inward upon
the head of the radius. Apply an ascending spiral reverse
bandage of the forearm, a figure-of-8 bandage of the elbow-
joint, and a sling. Make passive motion after a few days.
The bandages must be worn for two weeks.

Symptoms and Treatment of Inward Dislocation. — In dis-
location inward of both bones of the forearm the posi-
tion of the forearm is the same as that in dislocation out-
ward ; the sigmoid cavity of the ulna projects internally, and
the external condyle projects externally. Reduction }Si
effected by extension of the forearm and pressure outward
on the ulna, subsequent treatment being the same as that
employed in the preceding form.

Dislocation of the uhia alone is very rare, and can only
take place backward.

SymptoDis and Treatment, — Dislocation of the ulna alone
is indicated by the forearm being flexed and pronated. The
head of the radius is found in place, and the olecranon pro-
jects posteriorly. The treatment of this injur>' is the same
as that for dislocation of both bones.

Dislocation of the Radius Forward. — Dislocation of the
radius forward is the commonest form of dislocation of the
elbow. This injuiy is caused by a fall upon the hand with
the forearm in pronation and extension, or is produced by
blows on the back of the joint ; forced pronation alone will
not cause it.

Symptoms and Treatment. — The symptoms in dislocation

DISEASES AND INJURIES OF BONES AND JOINTS. 457

f the radius foru'ard are — forearm midway between prona-
on and supination, and semiflexed; attempts to increase
exion cause the radius to strike against the humerus with

distinct blow ; the head of the radius is felt in front of
lie outer condyle and is missed from its proper abode. Re-
uction is effected by flexion over the knee, extension, and
lanipulation. Subsequent treatment is Jones's position and
assive motion. Deformity is apt to recur after reduction,
ecause of rupture of the orbicular ligament.

Dislocation of the radius backward is caused by falls
n the hand or by blows on the front of the joint.

Symptoffts and Treatment, — Backward dislocation of the
aidius is indicated by the forearm being slightly flexed
nd fixed in pronation, by some impairment of flexion and
xtension, and by the radius being felt behind the outer
ondyle. Reduction is effected by flexion over the knee,
xtension, and manipulation, and the subsequent treatment
» the same as that given for the preceding dislocation.

Dislocation of the radius outward is very rare. In
bis injury the head of the radius is distinctly felt. Reduc-
on is effected by extension and pressure ; the subsequent
reatment is the same as that for the above-mentioned dis-
3cations.

Subluxation of the Head of the Rcidius. — This name is
iven to an injury which is very frequent in children between
wo and four years of age. It results from traction upon the
and or the forearm, and often arises when the nurse or the
lother pulls upon a child's arm to save it from a fall or to
ft it over a gutter. Some writers hold that pronation is
equired, as well as extension, to produce the injury ; many
urgeons claim that extension and adduction are the causa-
ive forces. Hutchinson maintains that supination may cause
ubiuxation. Bardenheuer assigned falls as causes.

The symptoms are very characteristic. The history points
3 the injury. Pain, and often a click, may be felt in the
r'rist at the time of the accident. The arm hangs by the
ide, with the elbow-joint slightly flexed and the forearm
lidway between pronation and supination. Flexion to a
*ss angle than 60° and complete extension are resisted and
re very painful, but movements between 60° and 1 30^ are
'ee and painless.* The movements of the wrist-joint are
'ee and painless. The elbow-joint presents no deformity.
*ressure over the head of the radius causes pain. Strong

* See the instructive article by W. \V. Van Arsdale, in the Annals of Surgery^
ol. ix., 1889.

458 MODERN SURGERY.

pronation is painful ; strong supination is vety painful, and
there seems to be a mechanical obstacle to its perfonnancc
Forced supination develops a distinct click at the head of
the radius, and causes pronation and supination to become
natural and free from pain. The condition will be repro-
duced if a splint is not used. The nature of the lesion is not
understood, and various conditions have been thought to
exist by different observers. Among them may be men-
tioned the following: a slight anterior displacement of the
head of the radius ; a slight posterior displacement ; locking
of the tuberosity of the radius behind the inner edge of the
ulna; dislocation of the triangular cartilage of the wrist;
intracapsular fracture of the radial head; painful paralysis
from nerve-injury; displacement by elongation, the return
of the bone being prevented by collapse of the capsule; and
the slipping up of the margin of the orbicular ligament over
the rim of the head of the radius.

Treatment. — Place the forearm at a right angle to the arm
and make forcible supination ; apply an anterior angular
splint, and have it worn for four or five days, or put the
part in Jones's position for an equal period.

DislocataoQs of the wrist, which are very rare, are
caused by falls upon the hand.

Backward Dislocation of the Wrist — Symptoms. — The
deformity in backward dislocation of the wrist (Fig. 1 16, a}
resembles that of Colles's fracture (Fig. 1 16, b). The fingers
are flexed, the wrist is bent backward, the radius projects

on the front of the wrist, the carpus projects on the dorsal
surface of the forearm, the relation of the styloid process of
the radius to the styloid process of the ulna is unaltered (it is
altered in Colles's fracture), there is rigidity, and crepitus is
absent (Fig. 1 16).

Forward dislocation of the wrist, which is very unusual,
is caused by a fall upon the back of the hand.

Symptoms and Treatment. — In forward dislocation of the
wrist the radius and ulna project posteriorly and the carpus

DISEASES AND INJURIES OF BONES AND JOINTS, 459

projects in front The treatment in both of these dislocations
is reduction by extension and manipulation, the use of a Bond
splint for ten days, and the employment of passive motion
after five or six days.

Dialocation at the inferior radio-ulnar aiidculation,
which is also very rare, is caused by twists.

Symptoms and Treatment, — In forward dislocation at the
inferior radio-ulnar articulation the forearm is pronated, the
space between the styloid processes is diminished, and the
ulna forms a projection posteriorly. In backward disloca-
tion the forearm is supinated, the space between the styloid
processes is diminished, and the ulna projects in front. Re-
duction is accomplished by extension and manipulation. Two
straight splints (as in fracture of both bones) are to be ap-
plied for four weeks, and passive motion is to be made in
the third week.

IMslocation of Individual Carpal Bones. — Pick says
there is one weak spot, which is " between the head of the
OS magnum and the scaphoid and semilunar bones," and the
OS magnum may be forced up. The os magnum is the only
^ne dislocated with any frequency, and the injury is caused
by forced flexion of the wrist.

Symptoms and Treatment, — The symptom of dislocation
of the carpal bones is a firm projection which becomes more
prominent during flexion of the wrist. The treatment is ex-
tension and manipulation, a Bond splint being worn for three
*'eeks.

*^^ocations of metaccupal bones are rare. The first
me^carpal bone is most liable to dislocation.
^y*9tptoms and Treatment, — Dislocations of the metacarpal
^n^s are obvious because of projection. The dislocations
^re reduced by extension and manipulation, a straight splint
^o large pad for the palm are applied (as in fracture of the
"^^^carpus), and the splint is to be worn for three weeks.

^^ocations at the metacarpophalajigreal aorticulations
i? rare, and backward dislocation is the most common.

*^^ cause is a fall upon the hand.

Symptoms and Treatment. — Dislocated metacarpophalan-

?^ articulations are obvious. Reduction is easily effected

y ^xten.sion and manipulation, except in the case of the

^Hib. A splint must be worn for three weeks.

p^islocation of the Metacarpophalangreal Joint of the

-^Uinb. — In this dislocation the phalanx usually passes

^^kward.

'^Jfmptoms, — Symptoms of backivard dislocation are — the

460

MODERN SURGERY,

base of the first * phalanx rests upon the metacarpuil bone;
the head of the metacarpal bone projects forward and button-
holes the muscles of the thumb ; the first phalanx of the
thumb is strongly extended, and the terminal phalanx is
semiflexed. The symptoms oi fonvard dislocation are — ^the
base of the first phalanx is felt in the palm, and the head of
the metacarpal bone is felt posteriorly.

Treatment. — In treating backward dislocation of the meta-
carpophalangeal joint of the thumb, reduction is difficult
because of the head of the bone being caught in the perfora-
tion of the flexor muscle. Always give ether. Keetlc>''s
directions are to adduct the metacarpal bone into the palm
(to relax the muscles) and to have an assistant hold it;
bend the thumb strongly back, extend, pull the thumb
toward the fingers, and suddenly flex. To get a finn
enough grasp for these manipulations use the apparatus
of Charriere or of Levis (Figs. 117, 118). If the abow
maneuvers fail, perform tenotomy or incise freely and

Fig. 117.— Lcvis's splint for reducing dislocation of phalanges.

Fig. 118. — Levis's splint applied.

reduce. After reduction of this dislocation a splint must
be worn for three weeks. In fon\'ard dislocation reduction
is easily effected by strong extension and forced flexion. A
splint is to be worn for three weeks.

Dislocations of the phalangres may be complete or may be
partial. They arc commonest between the first and second
phalanges.

Symptoms and Treatment. — Dislocations of the phalanges
arc obvious. In treating such dislocations employ extension
and manipulation, and use a splint for one week.

n/SEASES AND INJURIES OF BONES AND JOINTS, 46 1

Dislocations of the Ribs and Costal Ccurtikigres. — The
ribs may be dislocated from the vertebrae. This accident is
rarely uncomplicated, and cannot be differentiated from fract-
ure. The diagnosis is rarely made, and the injury is treated
as a fracture. The ribs may be dislocated from their carti-
lages, one or more ribs being displaced. The end of the rib
forms an anterior projection, there is a depression over the
cartilage, and crepitus is absent. Treatment is the same as
that employed for fractured ribs. The costal cartilages may
be displaced from the sternum, forming an anterior projec-
tion upon this bone. Reduction is brought about by placing
the patient upon a table, with a sand pillow between the
scapulae, pushing back the shoulders and chest, and forcing
the cartilage into place. The dressings are the same as those
used in fractured sternum. The cartilages of the lower ribs
(sixth, seventh, eighth, ninth, and tenth) may be separated.
The inferior cartilage goes forward and can be felt. Pick
states that reduction is brought about by causing the patient
to hold the chest full of air while efforts are made to push
the cartilage into place. Dress as for fractured ribs.

Dislocations of the Sternum. — In dislocations of the
sternum the manubrium may be separated from the gladio-
lus in young subjects. The symptoms and treatment are the
same as those in fracture (page 353).

Pelvic dislocations are almost always complicated with
fracture. A pubic bone can be dislocated by falls from a
height or by applying violent force to the acetabula. The
dislocation may be up or down, front or back, and it may
damage the urethra or the bladder. The patient cannot
stand ; there are great pain and recognizable deformity. Treat
by moulding the bones into place, by applying a pelvic belt,
and by rest in bed for four weeks. Dislocations of the
sacro-iliac joint are produced by falls. Movement on the
part of the patient is difficult or impossible ; there is violent
pain, and often paralysis (from pressure upon nerves). In
dislocation backward there is an apparent shortening of the
leg. eversion of the foot exists, and the ilium moves poste-
riorly and upward. In dislocation forward the anterior supe-
rior iliac spine projects and the pelvis is broadened. Sacro-
iliac dislocations are reduced by holding the pelvis firm and
making extension with a pulley. The patient stays in bed
for four weeks and wears a pelvic belt as in fracture.

Dislocations of the Femur (Hip-joint). — These injuries
are rare, as the hip-joint is very strong. They occur in
young adults. In forcible extension the head of the femur

462 MODERN SURGERY,

presses against the capsule, but the capsule here is very
thick, and certain muscles, the rectus, psoas, and iliacus, arc
pulled tight and serve to strengthen the capsule. The head
of the bone cannot go directly upward, because of the ace-
tabulum (Edmund Owen). The weak point of the acetabular
rim is below; the weak part of the capsule is also below;
hence forced abduction is apt to take the head of the bone
through the lower part of the capsule, a dislocation occur-
ring primarily into the thyroid foramen. The signs of the
dislocation depend upon the untorn portion of the capsule.
The Y-ligament and more than the Y-ligament usually
escapes laceration. Vessels are rarely injured. Muscles are
often torn. In some cases the sciatic nerve is lacerated,
bruised, or caught up on the neck of the bone. Four forms
of hip-joint dislocation exist : (i) upward and backi^'ard, on
the dorsum of the ilium ; (2) backward, into the sciatic
notch ; (3) downward, into the obturator foramen ; and (4)
inward, on the pubes.

All dislocations are primarily inward or outward. From
these initial positions the head may be shifted to any region
about the socket within reach of the remnant of untorn cap-
sule (Oscar H. Allis). Allis would reject - the old classi-
fication. He would suggest the following :

IvrrT " * V ^'' present abduction and
TT- i- «< ( outward rotation.

Reversed thyroid :

WA ^ '* ' I ^'' present adduction and
TT- u « ( inward rotation.

Dislocation upon the dorsum of the ilium comprises one-
half of all hip-dislocations. It is caused by a fall or a blow
when the limb is flexed and abducted (as in carrying a
weight upon the shoulder), by a fall upon the knees or feet
by a weight striking the back while bending, etc. Allis says
rotation inward is the chief element in its production. In
this dislocation the head of the femur goes upward and
backward, rests upon the ilium, and is always above the
tendon of the obturator internus muscle. This dislocation
is secondary' to a thyroid dislocation, because of muscular
action shifting the bone from its initial seat of displacement

SiiTus. — Dislocation on to the dorsum of the ilium is indi-
cated by the following symptoms : the buttock looks flat and
broad ; the great trochanter is above Nelaton's line and is

DISEASES AND INJURIES OF BONES AND JOINTS. 463

deq>ly placed ; the head of the bone can be detected in its new

stuation ; deep pressure in front of the joints finds a hollow ;

the leg is shortened by about two or three inches, as a rule ;

the fascia lata is relaxed ; in some thin people

tfae socket can be outlined ; when the patient is

recumbent the injured extremity can be brought

to the perpendicular without flexing the leg

(Alhs) ; the knee is slightly flexed ; the thigh is

sKghtly flexed, inwardly rotated, and adducted

(Fig. 1 19), this is shown by the fact that the axis

of the thigh of the injured side, if prolonged,

wouldpass through the lower third of the sound

thigh); when the capsule is extensively lacerated

there may be no adduction and may be eversion

(Allis) ; the heel is raised, and the great toe of

the foot of the injured side rests upon the front

of the instep or the ankle of the sound side ; F'^j.".' -"'p:

i^dity exists ; voluntary movement is impossi- iTpwarj' ^X

hie, though some passive motion is possible in nT^^Co^")'-'"

the direction of the deformity (the deformity

can be made more marked). If a patient is recumbent and

the knees vertical, the foot of the sound extremity is free of

the bed, but the foot of the injured extremity touches the

bed (AUis's sign).

DiagnoedB. — Examine first without anesthesia, and then
again while the patient Is anesthetized. The ^-rays are
"aluable in diagnosis. Dislocation is separated from intra-
jspsular fracture by noting the inversion, the great shorten-
"ig. the absence of crepitus, the age of the subject, and the
nature of the force. The nature of the force, the inversion,
and Ihe absence of crepitus mark the diagnosis from extra-
'^spsular fracture.

Treaiment. — ^The chief obstacle to reduction in dislocation
"1 to the dorsum of the ilium, Bigelow states, is the untorn
Potion of the capsule, especially the Y-Iigament. The ilio-
'^oral, Y, or Bigelow's ligament resembles an inverted Y,
?"ses from the anterior inferior spine of the ilium, is inserted
into the anterior intertrochanteric line, and is incorporated
into the front of the capsule. To reduce a dislocation this
"E^ent must be relaxed by manipulation or be torn by
'^tension. Manipulation makes the head of the bone re-
^l^e its steps over the same route it took in emerging. Give
f'her; place the patient supine upon a mattress on the floor ;
^^ the leg on the thigh (to relax the hamstrings), the thigh
^ the pelvis ; increase the adduction over the middle line ;

464 MODERN SURGERY.

strongly- abduct ; perform external rotation and extension.
This treatment may be summed up as flexion, adduction,
external circumduction, and extension ; or, as Pick puts it,
" bend up. roll out, turn out, and extend." AUis's advice is to
fix the pelvis to the floor, lift the head of the bone to the ievd
of the socket, rotate outward by carrying the leg toward
the pubis, and extend the femur. If extension and counter-
extension arc employed, make extension in the axis of the
dislocated hmb and obtain counter-extension by a perineal
band. The e.vtension band is fastened to the thigh ly 1
clove-hitch. After reduction put the patient to bed and use
sand-bags (as in fracture of the hip) for four weeks. We
may tie the knees together instead of using the sand-bags.
Passive motion is made in the third week. The pu!le>'s must
not be used in reduction. They may inflict great or ev'oi
fatal injury. If the surgeon fails to reduce the deformitj',
there are two courses open to him. He may leave it alone.
He may operate. If he leaves it alone, the limb will become
ankylosed, though probably useful. Allis thinks the dorsal
region will be the best place to leave it. If he determines
to operate, he must recognize that tenotomy is useless. It
is necessary to make a free incision in order to restore the
bone.

Dislocation into the Sciatic Notch. — In this dislocation
the head of the bone passes backward and a little upward,
and rests upon the i.schium at the margin of the sciatic
notch (not in the notch), below the tendon
of the obturator intemus muscle. The
causis are the same as those given for the
previous dislocation.

Signs. — The signs in dislocation into the
sciatic notch are like those of dislocation upon
the dorsum of the ilium, but they are not so
marked. There are flattening and broaden-
ing of the hip ; ascent of the trochanter
above Nelaton's line ; shortening to the ex-
tent of an inch ; relaxation of the fasda lata.
Allis 's sign is present, that is, if the knee
of the injured side is vertical, the sole of
the foot touches the bed. Flexion, inward
rotation, and adduction exist, but the axis
,nic nuiLiMfooiieri, of thc fcmuT of thc injurcd side passes
through the knee of the sound side, and
the ball of the groat too of the injured side rests upon the
great toe of the sound side (Fig. 120). Other symptoms

DISEASES AND INJURIES OF BONES AND JOINTS, 465

ire identical with those of dislocation upon the dorsum of
he ilium, but are less pronounced. AUis's signs of this
lislocation are of value : if, with the patient recumbent, the
liighs are brought to a right angle with the body, shorten-
ng on the affected side is materially increased ; if the dislo-
rated thigh is extended, the back arches as in hip disease.

Diagnosis and Treatment. — ^The signs of dislocation into
he sciatic notch are similar to, but are less marked than,
hose of dorsal dislocation, and, being a backward disloca-
ion, the reduction and treatment are the same as for dis-
ocation backward upon the dorsum of the ilium.

Dislocation Downward into the Obturator Foramen. —
Downward dislocation is the primary position of most dislo-
rations of the hip, the bone rarely remaining in the thyroid
bramen, but usually mounting up as a result of muscular
iction or of the initial violence. The cause is violent abduc-
ion by falls or by stepping from a moving car.

Si£pis. — Dislocation downward into the obturator foramen
s indicated by flattening of the hip ; the head of the bone
s felt in its new position and is missed from the acetabulum ;
igidity exists ; passive motion is only possible in the direc-
ion of deformity, and that to a slight extent ; a hollow is
loted over the great trochanter, which process is well below
Melaton's line and nearer than normal to the middle line.
There is a depression from relaxed muscles and fascia noted
3Ctween the ilium and femur. The gluteal crease is lower
than is the crease of the opposite side ; there is lengthening
to the extent of one to two inches ; the body is bent forward
by the traction upon the psoas and iliacus muscles, and is also
deviated to the side, thus causing great apparent lengthening ;
the limb is advanced partially flexed and abducted, and the
foot is pointed straight ahead or is a little everted (Fig. 121) ;
Mrhen the patient is recumbent extension is impossible, the
knees cannot be pushed together without great pain, and the.
ibductor muscles are hard and rigid. Allis's sign is absent.
Unreduced dislocations do well, the patient obtaining a very
jseful hip-joint (Sedillot).

Treatment, — In treating dislocation downward into the
obturator foramen give ether and effect reduction if possible
yy manipulation, and, if this fails, by extension. To reduce
yy manipulation, flex the leg on the thigh and the thigh
jn the pelvis, and then perform, in the following order,
ibduction, internal circumduction, and extension. AUis's
rule of reduction is as follows : flex the pelvis to the floor ;
pull the head outward and above the socket; fix the head;

466 MODERN SURGERY.

push knee toward sound knee ; extend femur. If extensian
is made, make traction in the axis of the limb by means of
muslin fastened around the thigh by a clove-hitch. Do not
use the pulleys ; operate rather than use them.

Dislocation upon the pubis is very rare. The head of
the bone usually rests just internal to the anterior inferior

(Cooper).

spine of the ilium. The primary position of the bone is in
the thyroid foramen ; the pubic dislocation, when it occurs,
is always secondary, and is due to the initial force and to
muscular action.

SymptoiHs. — In pubic dislocation the head of the bone can
be felt and seen in its new position; the hip is flattened;
there is a hollow over the great trochanter, this process
being found below the anterior superior spine of the ilium;
there is shortening to the extent of an inch ; the limb is in
abduction with eversion (Fig, 122), and the knees cannot be
approximated without great pain. When the knee is per-
pendicular the foot of the injured side touches the foot of
the bed.

Treatment. — In the treatment of pubic dislocation give
ether and employ manipulation as for thyroid dislocatioa
If this fails, employ extension. The limb is well abducted,
e.xtension is made downward and backward, and the head
of the femur is pulled outward " by a towel around the thigh,
just beneath the groin" (Keetley). The after-treatment is the
same as that for the previous forms.

Anomalous Dislocations of the Hip. — In sufraspitums
dislocation the dislocation of the hip is backward, the head

DISEASES AND INJURIES OF BONES AND JOINTS. 467

o[ the femur resting upon the ilium above or even anterior
to the anterior superior spine. In ischial dislocation the dis-
location is downward and backward, the head of the femur
resting on the ischial tuberosity or in the lesser sciatic notch.
Umiteggia's dislocation is a supraspinous dislocation with
eversion of the limb. In perineal dislocation the head of the
femur is in the perineum. In suprapubic dislocation the head
of the femur passes above the pubes. In subspiftous disloca-
tion the femoral head rests on the horizontal ramus of the
pubes.

Dislocation with Catchin^r Up of Sciatic Nerve upon

Reduction. — ^This accident causes severe pain. The leg is

flexed on the thigh and the thigh is flexed on the pelvis.

Allis tells us that the task of reduction is very unpromising.

We must strive to put the neck of the femur in such a

position that the nerve will "drop off," and yet often the

nerve cannot drop off because it is held by adhesion to the

injured muscles. Allis attempts reduction by the following

plan:

1. Place the patient upon his back and redislocate the

femur.

2. Extend the thigh.

3. Flex the leg on the thigh.

4- Turn ankle out until the leg is horizontal (this causes
the head to look downward).

5- " Shake, shock, jar, adduct and abduct," to disengage
the nerve.

6. Rotate into socket without flexing the leg (without
making the nerve tense).

7- If this fails, make an incision above the popliteal space,
^d draw the nerve out of the wound. Detach the head
"Oni its entanglement and rotate it into the socket.

I^ocation of Head of Femur with Fracture of Shaft.
■^We may incise and replace and wire the fragments. We
P^yuse McBumey's hooks as in the shoulder. We may
^ forced to do a resection of the head.

Allis maintains that it is possible to reduce it by manipu-
^tion. He states that the upper fragment is the entire lever,
^d the lower fragment " is only the agent through which
ve apply our force." The fragments are not completely
?^P^ted, but are connected at one side by material which
J? "partly periosteal, partly tendinous, and partly muscular."
^^ connecting material enables us to make traction upon
the upper fragment, but does not allow " rotation, circum-
duction, and leverage through the agency of the lower frag-

468 MODERN SURGERY.

ment." Hence " the only agency at our command is trac-
tion." If the dislocation is inward (forward), draw the bead
outward and have an assistant make direct pressure upon
the head. If this fails, the assistant holds the head to pre-
vent its slipping into the thyroid depression, and the surgeon
makes traction inward or inward and downward If the
dislocation is outward (backward^ make traction direcdy
upward to lift the head to the level of the socket, and try to
place the head over the socket by traction obliquely upw-ard
and inward. During all these manipulations an assistant
presses upon the trochanter to prevent the head slipping
back. Traction is now made downward and inward, and the
tightened ligament drags the head into place.

Dislocations of the Knee. — These dislocations are rare.
There are four forms — ^forward, backward, inward, and out-
ward. They may be complete or be incomplete ; the com-
monest dislocations are lateral. The cause is violent force,
such as a fall, or in jumping from a moving train, or in
being caught by the foot and dragged.

Dislocation Forwcurd of the Knee-joint. — In the com-
plete form of fonvard dislocation the deformity is obnous.
The limb is usually extended, but it may be flexed. Much
shortening exists ; the condyles are felt posterior and below;
the head of the tibia is felt anterior and above ; the patella is
movable and the quadriceps is lax ; pressure of the cond>'les
upon the contents of the popliteal space arrests the tibial
pulse and causes edema and intense pain. In incompliU
dislocation the symptoms are identical in kind, but are less
pronounced.

Treatment. — Compound dislocation of the knee-joint often
demands excision or amputation. In .simple dislocation gi\'e
ether, have one assistant extend the leg while another makes
counter-extension on the thigh, and the surgeon pushes the
bone into place. Reduction is easy because of ligamentous
laceration. Place the limb on a double inclined plane, and
combat inflammation by the usual methods (see Synovitis,
page 406). Begin passive motion in the third week. The
patient must wear a knee-support for months. If the pop-
liteal vessels are much damaged, gangrene will supervene
and amputation will be demanded.

Dislocation Backward of the Knee-joint. — In the c(m-
plete form of knee-joint dislocation backward displacement
is not so great as in dislocation forward. The head of the
tibia projects posteriorly and above, the femoral condyles
anteriorly and below; the leg is, as a rule, partly flexed,

DISEASES AND INJURIES OF BONES AND JOINTS, 469

but it may be extended, and there is moderate shortening.

In incofnplete dislocation the symptoms are less marked.
Treatment, — ^The treatment of backward dislocation of the

knee-joint is the same as for forward dislocation.

Dislocation Outward of the Knee-joint. — Is usually in-
complete. The inner tuberosity of the tibia in outward dis-
location lies upon the outer condyle of the femur (Pick) ; the
inner condyle of the femur projects internally ; the outer
tibial tuberosity and fibular head project externally, the former
having a depression below it, and the latter above it ; the leg
is semiflexed, but shortening is absent.

Dislocation Inward of the Knee-joint. — Is usually incom-
plete. The outer tuberosity of the tibia in inward dislocation
lies upon the inner condyle of the femur ; the outer condyle
of the femur forms an external prominence, and the inner
tuberosity of the tibia forms an internal prominence. Pick
cautions us not to mistake a separation of the lower femoral
epiphysis for lateral dislocation (the former is reduced easily,
the deformity tends to recur, and there is soft crepitus).

Treatment. — In treating lateral dislocation of the knee-
joint, effect extension and counter-extension as in antero-
posterior dislocations. The leg is moved from side to side
and attempts are made at rotation. The afler-treatment is
the same as that for anteroposterior luxations.

l^ocations of the Patella. — Are usually acquired.
There are thirty-five congenital cases on record (Bajardi).
There are three forms: outward, inward, and edgewise.
The so-called dislocation upward is in reality rupture of the
ligamentum patellae (page 508).

location outwcurd may be due to muscular action or
to direct force, and occurs during extension of the leg. It
^^ionally happens in a person with knock-knees. If the
™slocation is complete, the bone lies upon the external sur-
^ of the external condyle ; if incomplete, the patella rests
?Pon the anterior surface of the external condyle. The leg
^ Extended, flexion is impossible, and attempts at flexion

^l^uce great agony. The knee is wider than normal.

. '^pre is a hollow in front of the joint. The bone is felt

^ *ts new position.

.. t^ocation inward is extremely rare. The signs of this

2J^location are like the signs of dislocation outward, except

^t the patella rests upon the inner condyle.
treatment, — Give ether. Raise the body upon a bed-rest,

^^ flex the thigh. Grasp the patella, depress the margin
the patella which is farthest from the center of the joint

470 MODERN SURGERY.

(Pick). The muscles pull the bone into place. Immobilize
for three weeks, when passive motion is begun.

Dislocation of the Patella EdgewiBe. — The p>atella rotates
vertically, one edge resting between the condyles. As a rule,
the outer border is in the intercondyloid notch (Pick). This
condition is produced by direct force when the extremity is
partly flexed. Twisting and muscular action have been
assigned as causes. The condition is obviously manifest

Treatment. — Give ether. Pick recommends " sudden and
forcible bending of the knee." In some cases the bone can
be pushed into place, the limb being extended and flexed as
in the reduction of a lateral dislocation. In some cases
incision will be necessary.

Dislocation of the Semilunar CartilafireB of the Knee
(the Internal Derangement of Hey; Subluxation of the
Knee-joint). — These interarticular cartilages are attached
in front of and behind the tibial spine, and their convexity
is attached to the edge of the tibial tuberosities by the coro-
nary ligament. The inner cartilage is connected with the
internal lateral ligament, and it has a moderate freedom
of movement; the outer cartilage is not connected with
the external lateral ligament, and is not freely movable,
yet the outer is more often dislocated than is the inner
cartilage. People who kneel much are predisposed to
this accident (Annandale). The cause is a twist when the
knee is flexed, as in stubbing the toe.

Symptoms. — The indications of interarticular-cartilage dis-
location are a sudden, violent, sickening pain in the knee,
that may cause the patient to fall ; the position is one of
fixed semiflexion, voluntary motion being impossible and
passive motion causing fierce pain ; a displacement of either
cartilage away from the tibial spine produces a prominence
on one or the other side of the knee-joint, and a displace-
ment toward the tibial spine makes a prominence on one side
of the ligament of the patella. Subluxation is soon followed
by inflammation of the cartilages and of the joint, and swell-
ing rapidly masks the projection. This accident is usually
mistaken for blocking of the joint by a floating cartilage.
One point in diagnosis is that a loose cartilage changes its
position, but a dislocated cartilage remains always in the same
position (Turner).

Treatment. — In treating dislocation of the semilunar carti-
lages of the knee give ether and reduce by forced flexion and
sudden extension with rotation, at the same time endeavor-
ing to push the projecting cartilage into place. After reduc-

DISEASES AND INJURIES OF BONES AND JOINTS. 47 1

tion combat inflammation, apply a splint, and use the proper
remedies for one week (see Synovitis), then begin passive
motion. As recurrence of the displacement is usual, the
patient should wear a knee-cap for a year or more. If
reduction is impossible, persistent passive motion will usu-
ally secure a useful joint In intractable cases incise and
stitch the cartilages or remove the loosened portion (Annan-
dale).

Dislocations of the Fibula: Dislocation at the Supe-
rior Tibiofibular Articulation. — This injury is rare. The
head of the fibula may go forward or backward. The causes
are direct force and violent adduction of the foot with abduc-
tion of the knee (Bryant).

Symptofns, — In dislocation of the fibula the position is one
of semiflexion, voluntary extension and flexion being impaired
or lost A distinct movable projection is readily noticed in
front or behind, which is found to be continuous with the
fibula. There is a depression over the normal position of the
head of the fibula.

Treatment, — In treating dislocation of the fibula bend the
knee to relax the biceps, and proceed to push the bone into
place. Put a compress over the head of the fibula, apply a
bandage, and put the limb on a double inclined plane for three
weeks. At the end of this time put a lacing knee-support
upon the knee and let the patient up. Displacement being
liable to recur, a knee-cap must be worn for a year.

Dislocations of the Ankle-joint. — These injuries are not
unusual. Fracture is a frequent complication. There are
five forms of ankle-joint dislocation — outward, inward, for-
^rd, backward, and upward.

Lateral dislocations of the cuikle-joint are either outA\'ard
or inward, and may be complete or incomplete. In these
dislocations the a.stragalus rotates. In incomplete dislocations
"there is no great separation of the trochlear surface of the
astragalus from the under surface of the tibia, but the outer
or inner margin of this surface is brought into contact with
^be articular surface of the tibia, and the whole foot presents
^ lateral tuist '* (Pick). The causes of these dislocations are
twists of the joint.

^ympioffis. — Incomplete outward dislocation of the ankle-
joint is known as Potfs fracture (see page 402). Complete
outward dislocation, in which the articular surface of the
^^^alus is completely displaced outward from the articular
surface of the tibia, and which condition is associated with a
^cture of the fibula and separation of the inferior tibiofibu-

472 MODERN SURGERY.

lar articulation, is known as Dupuytren's fracture. In incom-
plete dislocation the foot goes outward and upward, the fibula
is fractured, and the tibiofibular ligaments are torn off. In
Dupuytren's fracture the ankle is broad, the inner malleolus
projects and looks lower than natural, the outer malleolus
ascends with the foot, the foot rotates outward, and creptus
can be found. In inward dislocation which is associated inith
fracture of the inner malleolus there is inversion, the outer
malleolus projects, and crepitus can be found. In incom-
plete separation the symptoms are similar, but are not so
marked.

Treatment, — In treating a case of dislocation of the ankle-
joint the deformity is reduced by flexing the leg on the thigh
and the thigh on the pelvis ; an assistant makes counter-ex-
tension from the knee ; the surgeon makes extension from the
foot, and at the same time rocks the astragalus into place.
Dupuytren's fracture is treated in the same manner as Pott's
fracture (page 402). Dislocation inward is treated in a fract-
ure-box for the same period as Pott's fracture.

Anteroposterior dislocations of the ankle-Joint are rare.
The caiise is the catching of the foot in jumping or falling-
direct violence. In dislocation forward the foot is lengthened,
the heel is not conspicuous, the tibia and fibula project against
the tendo Achillis, and the relation of the malleoli to the
tarsus is altered. In incomplete dislocation the s>Tnptoms
are similar, but less pronounced. In dislocation back\^'ard
the foot is shortened, the tibia and fibula project in front, the
heel is prominent, and the relation between the malleoli and
the tarsus is altered. In incomplete dislocation the s>Tnp-
toms are similar, but less marked.

Treatmeyit. — In anteroposterior dislocation of the ankle-
joint, reduce as in lateral dislocations. Sometimes the tendo
Achillis must be cut. Apply a silicate-of-sodium dressing,
and let it be worn for two weeks ; then begin passive motion,
and let the patient wear side-splints for a week longer.

Dislocation upward of ttie ankle-joint, or Nelaton's
dislocation, is a very rare injury. The astragalus is wedged
between the widely separated tibia and fibula. This dislo-
cation is usually associated with fracture. The cause is a
fall upon the feet from a great height.

Symptoms. — Upward dislocation of the ankle-joint is indi-
cated by the widening of the ankle and by the flattening of
the foot. The malleoli are nearly on a level with the plantar
surface of the foot, and there is absolute rigidity.

Treatment. — In treating upward dislocation of the ankle-

DISEASES AND INJURIES OF BONES AND JOINTS, 473

joint give ether, and try to reduce by powerful extension and
counter-extension. Treat the injury afterward in the same
manner as for an anteroposterior luxation.

Dislocation of the Astragralus. — The astragalus may be
displaced from the bones of the leg and at the same time be
separated from the rest of the tarsus. The displacement may
be forward, backward, outward, inward, or rotary.

Dislocation of the astragalus forward or backward is
caused by falls or twists.

Symptoms, — In forward dislocation the astragalus projects
strongly ; there is shortening of the foot, and the malleoli
approach the plantar aspect of the foot ; the foot is deviated
to one side or to the other, and there is absolute rigidity of
the ankle-joint In incomplete luxations the symptoms are
similar, but less marked. This dislocation may be obliquely
forward. In backward dislocation of the astragalus the foot
is not deviated to either side ; the astragalus projects between
the malleoli and above the os calcis, and the tendo Achillis is
stretched over the projection. Rigidity is absolute. This
dislocation may be obliquely backward.

Lateral and Rotary Dislocations of the Astragalus. —
Lateral dislocations of the astragalus are rare, are always
compound, and are always associated with fracture. In rotary
dislocation the astragalus remains in its normal habitat after
rotating on its own axis, either horizontal or vertical. The
causes of rotary dislocation are twists of the foot when it is
at a right angle to the leg (Harwell). The symptoms of rotary
dislocations are obscure. There is rigidity, but sometimes
portions of the astragalus may be made out.

Treatment of Dislocations of the Astragalus. — In treating
astragalus dislocation reduce under ether by flexing the
knee to relax the gastrocnemius, extending the foot, and
pushing the bone into place. It may be necessary to cut
the tendo Achillis. After reduction put up the foot and leg
in silicate-of-sodium dressing for two weeks, and then begin
passive motion and apply side-splints, which are to be worn
for one week more. If reduction fails, support the limb on
splints, combat inflammation, and endeavor to bring about
union between the dislocated bone and the tissues. Often,
in unreduced dislocation, the skin sloughs over the project-
ing bone. Excision is demanded the moment sloughing is
seen to be inevitable. Cases of compound dislocation of the
astragalus require immediate excision.

Subastragaloid Dislocation. — This condition is a sepa-
ration of the astrag^us from the os calcis and scaphoid.

474 MODERN SURGERY,

without separation of the astragalus from the bones of
the leg. Pick states that the usual classification for these
dislocations is forward, backward, inward, and outward, but
that the displacement is, as a rule, oblique, the foot pass-
ing backward and outward or backward and inward. The
causes are twists.

Symptoms, — In subastragaloid dislocation the astragalus
projects on the dorsum; the foot iseverted in outward dis-
location and inverted in inward dislocation ; the relation of
the malleoli to the astragalus is unaltered ; the ankle-joint is
not absolutely rigid ; the foot " is shortened in front and is
elongated behind " (Pick).

Treatment. — To treat subastragaloid dislocation make
extension in the direction opposite to that of the displace-
ment. In dislocation of the tarsus backward fix a bandage
around the foot, on a level with the heads of the metatarsal
bones, which bandage the surgeon ties around his shoulders.
The surgeon puts one knee in front of the angle and thus
fixes the leg, raises himself up to make extension upon the
tarsus, and moulds the bone into position. Tenotomy may
be necessary. After reduction apply a silicate dressing for
three weeks. The ankle-joint, fortunately, is not involved,
and stiffness of this articulation need not be apprehended
If reduction is impossible, take the same course as in luxa-
tions of the astragalus.

Dislocations of the other tarsal bones are very rare.
Single bones may be dislocated, or the luxation may occur
at the mediotarsal articulation.

Symptoms arid Treatment. — Projection is an obvious
symptom in dislocation of the other tarsal bones. The
treatment is to reduce by extension and moulding, the part
being put up in silicate-of-sodium dressing for two weeks.

Dislocations of the metatarsal bones are rare.

Symptoms and Treatment. — Shortening of the toes and
projection of the dislocated bone are symptoms of disloca-
tion of the metatarsal bones. To treat these dislocations
reduce by extension under ether and put up in a silicate
dressing for two weeks. If reduction fails, the functions of
the foot will not be much impaired.

Dislocations of the phalanges are very rare. The
first phalanx of the big toe is the one most liable to dislo-
cation.

Symptoms and Treatment. — Dislocations of the phalanges
are obvious. The treatmefit is by reduction as in dislocations
of the thumb. Immobilize for two weeks.

5. Opekations in^N Bones.
Osteotomy. — By the term osteotomy the modem surgeon
means hterally the sectioning of a bone for the purpose of
straightening a limb ankylosed in a bad position, correcting
a bony deformity, or amending a vicious union of a fracture.
In a linear osteotomy the bone is transversely divided in one
spot ; in a cuneiform osteotomy a wedge-shaped portion of
bone is removed. The operation of osteotomy may be per-
forme'd with a saw (Fig. 123) or with an osteotome. The saw
creates dust, draws much air into the wound, and lacerates
the tissues to a considerable degree. Most surgeons prefer
the chi.sel or the osteotome. The osteotome slopes down to
a point from each side (Fig. 124) ; the chisel is straight on one
side and on the other is bevelled to a point.

Osteotomy for Oenu Valium, or Knock-knee (Macewen's
Operation, Fig. 126). — In this operation the instruments re-

quired are the scalpel, hemostatic forceps, osteotomes of sev-
eral sizes, a mallet (Fig. 125). and a sand-bag wrapped in an
aseptic towel.

Operation. — The patient lies upon his back, being rolled a
little toward the diseased side. The leg of the disea.sed side is
partly flexed upon the thigh and the thigh upon the pelvis,
and the extremity is laid upon its outer surface, the sand-bag
being pushed between the extremity and the bed. opposite to
the site of section. The flexion of the knee relaxes the
popliteal vessels and saves them from injury. The surgeon,
Irf operating on the right leg, stands outside of that ex-

4/6 MODERN SURGERY.

tremity ; if operating on the left leg, he stands opposite the
left hip (Barker): Enter the knife at the inner si<le of the
knee, just in front of the adductor tubercle of the inner con-
dyle and on a level with the upper border of " the patellar
articular surface of the femur" (Barker); cut down to the
bone, and make an incision upward one inch in length, Id
the direction of the axis of the ,
femur. At the lower an^
of this wound insert an osteo-
tome and turn it to a right

angle with the shaft, half an inch above the epiphysis (Fig.
1 36) ; strike the osteotome several dnies with a mallet ; move
the handle several times toward and from the body, so as to
widen the cut in the bone (Fig. 127); strike the osteotome
again several times, move it again, and continue this process
until the bone is cut one-third through. If the osteotome
becomes tightly fixed, withdraw it and introduce a smaller
one. When the bone is cut two-thirds through withdraw
the osteotome, hold a piece of wet antisepdc gauze over the
opening, and fracture the femur by strong adduction. Do
not suture nor drain the wound, but dress it antiseptically,
wrap the entire extremity in cotton, and apply a plaster-of
Paris dressing up to the groin. This dressing may be re-
mo\ed in two weeks, and the patient may subsequently be
treatedwithsand-bags, as foran ordinary fracture of the thigh,
but ^^ithout exten.sion. This operation is scarcely ever fatal.
Ogston's Operation (Fig. 126). — In this operation the inter-
nal condyle is sawed off obliquely with an Adams saw — a
proceeding which permits the straigthening of the knet
The objection to this operation is that it opens the knee-

DISEASES AND INJURIES OF BONES AND JOINTS. 477

joint, and that this cavity iills up more or less with a mixture
of blood and bone-dust Macewen's operation is decidedly
the safer.

OBteotomy for a Bent Tibia. — In this operation the in-
struments required are the same as those indicated in the
above operation. The tibia is divided transversely or
obliquely (linear osteotomy), or a wedge-shaped piece is
removed (cuneiform osteotomy). The oblique incision is
the best. If the convexity of the tibial curve is inward, cut
the bone from above downward and from in front backward ;
if the curve is forward, section the bone from above down-
ward and from within outward. The fibula need rarely be
interfered with. After the osteotomy the limb is treated
just as it would be for an ordinary fracture.

Osteotomy for Faulty Ankylosis of the Hip-joint. —
This operation is performed in order to allow straightening
of a limb that has undergone bony ankylosis in a faulty
or an inconvenient position. In some cases an attempt is
made to obtain a movable joint, but in most cases the sur-
geon must be satisfied with an ankylosis in extension. Oste-
otomy may be performed through the neck of the femur or
through the shaft of the femur below the trochanters.

Osteotomy throufirh the neck of the femur is performed
(i) with a saw (Adams's operation) or (2) with an osteotome.

I. Adams's Operation (Fig. 128). — In this operation the
instruments required are a scalpel, hemostatic forceps, a
long, blunt-pointed tenotome, and an Adams saw.

Operation, — The patient lies upon his sound hip ; the sur-
geon stands upon the side to be operated upon, and back
of the patient. The knife is entered a
finger's breadth above the great trochanter,
is pushed in until it strikes the neck of the
bone, is then carried across the front of and
at a right angle with the neck, and is with-
drawn, enlarging the wound in the soft
parts, as it emerges, to the extent of an
inch. The saw is now introduced and the
neck is entirely divided. After the osteot-
omy dress the wound antiseptically and
place the extremity straight. To straighten \

the limb it may be found necessary to cut Fig. las.-Osteotomy
contracted tendons and fascial bands. Ihi femur !^a, aSws
Apply the weight-extension apparatus and oJSJdoS.' "' ^"' *
the sand-bags. Begin passive movements
from the start if a movable joint is desired ; few patients can

478 MODERN SURGERY,

tolerate the pain necessary to bring this about. If it is
determined to aim for a stiff joint, treat the case as an intra-
capsular fracture would be treated.

2. With an Osteotome, — The instruments required in this
operation are the same as those used for genu valgum. No
sand-bag is required. The position of the patient is the same
as that in Adams's operation. An incision one inch long is
made, starting just above the great trochanter, ascending in
the axis of the femoral neck, and reaching to the bone. An
osteotome is introduced, is turned to a right angle with the
bone, and is struck with a mallet until the bone is completely
divided. (It is not to be divided partially and then broken.)
The after-treatment is the same as that for Adams's opera-
tion. The operation with the osteotome is to be preferred to
that by the saw.

OBteotomy of the Shaft of the Femur below the Tro-
chanters (Gant's Operation). — In this operation (Fig. 128)
the saw may be used, but the osteotome is to be preferred
The instruments employed are the same as those used for
Adams's operation, plus an osteotome.

Operation. — The position in Gant's is like that in Adams's
operation. A longitudinal incision one inch long is made
upon the outer aspect of the femur and on a level with the
lesser trochanter. The osteotome is inserted and the bone
is completely divided below the lesser trochanter. The
after-treatment is the same as that for Adams's operation.
Gant's operation is the best method for correcting faulty
position in bony ankylosis, and Adams's operation can only
be employed in those cases where the femur still has a neck
which practically is unchanged.

Osteotomy for Faulty Ankylosis of the Knee-joint. —
This operation is performed for bony ankylosis of a knee in
a position of flexion. The instruments employed are the
same as those used for genu valgum.

Operation. — The patient lies upon his back with his thighs
flat upon the bed, the legs hanging over the end of the bed.
The surgeon stands on the patient's right side. Just above
the patellar articular surface upon the femur a transverse
incision is made, one inch in length and reaching to the
bono. The osteotome is introduced and the bone is cut
';c\7;7r through. The leg is then forcibly extended. Do not
extend too violently, or the popliteal vessels may be injured
In cases where the structures of the popliteal space are
tense, do not at once bring the leg into extension, but do
so gradually by means of weights. The wound is dressed

DISEASES AND INJURIES OF BONES AND JOINTS. 479

aseptically, and the extremity is placed upon a double inclined
plane and is treated as for fracture near the knee-joint.

Osteotomy for vicious union of a fracture is performed in
case of angular deformity, and is carried out in the same man-
ner as are the above procedures. It is best, when possible, to
enter the osteotome upon the concavity of the bent bone, so
that the periosteum will not rupture when extension is made,
and the patient will in consequence gain a longer limb.

Osteotomy for Hallux Valfirus. — In this operation a linear
osteotomy is made through the neck of the metatarsal bone
of the great toe, the toe is forcibly adducted, and a splint is
applied to the inside of the foot and the toe.

Osteotomy for Talipes Equinovarus. — The instruments
required in this operation are a scalpel, hemostatic forceps,
a narrow, blunt-pointed saw, special directors, bone-cutting
forceps, sequestrum-forceps, and scissors.

Operation (after Barker). — ^The patient lies upon his back,
the thigh is semiflexed, the knee is bent, and the sole of the
foot rests upon the table. The surgeon stands to the right
side if it is the right limb to be operated upon, or to the left
side if it is the left limb. Feel for the outer surface of the cu-
boid bone, and cut away from over the latter a piece of skin
corresponding in size with the bone-wedge intended to be
removed (this piece of skin must include the bursa which
forms in these cases). Turn the foot outward, find the
astragaloscaphoid articulation, over which make an incision
" from the lower to the upper dorsal border of the scaphoid
bone " (Barker), reaching through the skin only ; place the
foot again in the first position, raise all the soft parts from
off the superior surface of the tarsus, and clear a triangular
surface corresponding with the base of the wedge to be
removed; pass a "kite-shaped" director (Fig. 129) into the
external wound, and cause it to project from the internal
wound; push the saw through the groove of the director
nearest the toes, and saw through the tarsus, from the dor-
sum to the sole, at right angles
to the metatarsal bones; push
the saw through the groove of
the director nearest the ankle,
and saw from the dorsum to the

sole, at right angles to the long Fio. lag.-Davy's director (Pycr

axis of the calcaneum ; grasp the

wedge-shaped piece of bone with sequestrum-forceps, and
cut it out with scissors, with bone-forceps, or with a blunt
bistoury. The wound is well irrigated, the foot is straight-

480 MODERN SURGERY.

ened, the internal wound is sewed up, the external wound is
sutured except at its lowest portion, where a drainage-tube
is to be retained for twenty-four hours, and the wound is
dressed antiseptically. The foot is put up in plaster or is put
upon a Davy splint.

Osteotomy for Talipes Equinus. — This operation is de-
scribed by Mr, Davy, who devised it, as follows : ' "Taking
the hne of the transverse tarsal joint as a guide, on the outer
and inner sides of the foot, and immediately over the joint,
two wedge-shaped pieces of skin are removed, equal in extent
to the amount of bone demanded. The soft structures are
freed on the dorsum of the foot in the way previously
described \ but, as the base of the osseous wedge for
equinus cases is at the dorsum and its apex at the sole, the
parallel wire director, instead of the kite-shaped varus one,
is used. The saw is successively inserted in its grooves,
and by keeping in mind the idea of a keystone a clean
wedge of bone is cut out from the dorsum to the sole of
the foot." The wedge is extracted, and the foot is straight-
ened and is put in plaster or in a Davy splint

Operative Treatment of Beoent Fracturee. — In recent
fractures where reduction is impossible or where displace-
ment recurs in spite of splints, it may be advisable to oper-
ate. In such cases a skiagraph should always be taken,
and it will often decide whether operation is or is not indi-
cated. In most instances of irreducible fracture reduction
of the fragments is impossible because of muscle or fascia
caught between them or because of hardening and shorten-
ing of periosteal soft parts, due to hemorrhage and inflam-

mation. In such cases it may be necessary to make a
tolerably long incision ; the ends of the fragments are loos-
ened from their anchorage, the inflammatory ties are cut,
ti.'isue is removed from between the fragments, and if the
ends are very irregular they are sawn oflf evenly.
' Barker's Manual of Surgical Optralitmi.

DISEASES AND INJURIES OF BONES AND JOINTS. 481

The fragments are bored and brought together, and are held
by silver wire or kangaroo-tendon, or both fragments are sur-
rounded by Senn's bone ferrule, and fixation is thus secured
(Figs, 130, 131). Drainage is unnecessary, the soft parts are

sutured and dressed with sterile gauze, and the extremity is
put up in plaster. If the clavicle is operated upon, aiier
sterile dressings are applied a Velpeau bandage is put on,
and the turns of this bandage are overlaid with plaster-of-
Paris, a trap-door being cut over the seat of operation. In
such operations the author does not use an Esmarch band-
age, as he believes it best to see what is cut and thoroughly
arrest bleeding at the time, rather than run the danger of
oozing and infection.

The author has wired recent fractures of the humerus,
tibia, femur, and clavicle. Arbuthnot Lane believes that
every very oblique fracture of the tibia and fibula low down
should be treated by incision and fixation.' It is necessary
to bear in mind that if one of two parallel lines is broken (as
the radius alone or tibia alone), and it is found necessary to
resect a considerable portion, a like amount should be re-
sected from the companion bone in order to prevent great
deformity.

Recent Transverse Fracture of the Patella (see page
397)-

' Brit. Med. Jour., April 20, 1895.

482 MODEKN SURGERY

Bone -grafting, or Transplantation (see page 3161
Operative Treatment of Unonited F'ractnre.— The
instruments required in this operation are a scalpel, hemo-
static forceps, dissecting -forceps, retractors, Allis's dissector,

^«^

;=«

an awl or special drill {Figs. 132, 1 33), chisels, a mallet, a fine
saw, lion-jaw forceps, and silver wire.

In operating, incise longitudinally down to the seat of
fracture, retract the periosteum from the bone, drill the bones
before cutting them, chisel away the material of imperit-ct
union, saw through each end far enough from the seat of
fracture to reach sound tissue, pass large silver wires through
the holes (this wire should be one-tenth inch in diameter for
the femur, one-sixteenth inch for the patella, etc.) (Fig. IJ+J,

twist the wires a fixed number of times (two complete turns)
in the direction that the hands of a watch move (this is
Keen's direction in case removal of the wires should be

DISEASES AND INJURIES OF BONES AND JOINTS. 483

demanded), sever the ends of the wires, and hammer their
stems against the bone. The wires may never require re-
moval. Dress the part as a recent fracture. Various plans
besides wiring have been employed in ununited fracture.
Gussenbauer's clamp is used by some. Menard and Lanne-
longue inject a i : 10 solution of chlorid of zinc between the
fragments and around their ends, and then immobilize the
parts. Some surgeons unite the fragments with kangaroo-
tendon instead of wire (suturing of bone) ; others use nails
of bone or ivory ; others use screws. Senn asserts that the
above methods will not hold fragments in contact if these
fragments have a tendency to become displaced. Senn
festens the bones together by hollow cylinders of decalcified
bone or ivory, the cylinders being perforated in many places
(bone ferrules) (Fig. 1 30). The soft parts are sutured, no
drain is used, and the limb is encased in plaster.

Ununited Fracture of Patella. — An incision is made in
the long axis of the limb, over the middle of the space
between the fragments, from well
above the upper fragment to well
below the lower piece ; this in-
cision divides all the soft parts.
The soft parts are retracted,
but the periosteum is undis-
turbed; each fragment is bored
(Fig. 13s, 1 ) in one or two
places ; the surfaces of the frag-
ments are cut square through
sound bone with a saw ; all old
reparative material is cut away ;
the wires are passed through the
perforations, twisted, cut off, and
hammered down as before (Fig-

13s, 2). If the ends cannot be __ ^ _ „„„ ,..„™

approximated, it may become nee- ^nune"?^ doin'ui^oThe boncun'n

essary to incise the muscle around

and above the patella or to partially separate the tuberosity

of the tibia and bend this process upward. A small drain

is inserted above the bone, the wound is sutured, aseptic

dressings are applied, and the limb is put upon a Macewen-

splint.

Treves's Operation for Caries of the Iftunbar and
Last Dorsal Vertebne. — In this operation the right loin
is chosen for incision, as a rule. The instruments required
are a scalpel, hemostatic forceps, grooved director, an Allis

m"Tu*irniy°lU^in<

DISEASES AND INJURIES OF BONES AND JOINTS. 485

hose to the exhausting or inward-flowing chamber of the
pump. Next attach one end of the longer elastic hose to
the stopcock A projecting from the stopper, and the other
end to the needle. Care should be taken that all the fittings
or attachments are placed firmly into their respective places.
Now close the stopcock A and open stopcock B, and by
giving from thirty-five to fifty strokes of the pump a suffi-
cient vacuum can be produced to fill with the fluid from the
joint a bottle holding from a pint to a quart. After having
formed the vacuum, close the stopcock B, and the instru-
ment is for use. The trocar may be used to inject antiseptic
agents into the part. The part is dressed antiseptically and
is put at rest upon splints.

Excisions of Bones and Joints. — Excision or resec-
tion of a joint is the removal of the articular portions of the
bones of the joint, and also the cartilage and synovial mem-
brane. In the hip-joint and shoulder-joint the head of the
long bone only may be removed, and not the articular sur-
^ces of both bones. In excision enough bone is known to
2?ve been removed only when the remaining bone bleeds.
*^^cision of a bone is the removal of an entire bone or of a
Pption of it Excision is a conservative operation which
^ften averts amputation.

.. *^cision may be performed by the o/>i'n method, in which
^ ^ Periosteum is not preserved, or it may be performed by
^^'^^Jferiosieal method, in which the periosteum is carefully
^^'^ted by a rugine and the capsular ligament is preserved.
y^ /^^^^tomy, or erosion, is the excision of the diseased syno-
^^'^^mbrane and ligament, and also small foci of disease
t>Oi-|e and cartilage.

^^^sion may be employed for compound dislocation, and

^^«"Vipound dislocatioi\s of the elbow and the shoulder it is

^|J^*ly performed. Excisions for compound dislocations in

0 ner- large joints are ver>' dangerous ; they are rarely at-

^"?P"^^d in battle-field practice, and are to be avoided even in

ciMl piractice unless the patient is young and vigorous and

everyr advantage can be given him during the operation and

^^"^^lescence. Excision for deformity is rarely performed

^l^?^Pt upon the hip, the knee, and the shoulder, and these cx-

cisiori3 must not be employed if the patient's condition leads

^P? to fear the result of a protracted convalescence. Kx-

*^n of the elbow, however, is usually a safe operation. In

, ^*sing for deformit>' always consider the patient's trade and

^ demands of habitual position which it makes upon him.^

* Joseph Bell, in bis Manual of Surgical Operations.

486 MODERN SURGER Y.

Excision is largely employed for joint-disease, especially
for tubercular joints. Bell states that attempts to presence
the Hmb without excision are more largely justifiable in the
lower than in the upper limbs, because operation in the lower
extremity is more dangerous than in the upi>er, and because
a cure without operation in the lower limbs, if this cure can be
brought about, gives as good a result as a cure by excisioa
In the upper extremities the danger from operation is less
than is the danger from waiting. In a young subject an ex-
cision may remove the epiphysis, and thus lead to permanent
shortening, which is productive of less inconvenience and de-
formity in the arm than in the leg. The great danger of ex-
cision operations is that the section may be made through
cancellous bony tissue ; hence suppuration, phlebitis, myelitis,
septicemia, or pyemia may follow ; further, in excision the cut
is through diseased tissue, and a protracted convalescence is
often inevitable. Amputation is effected through healthy
tissue, and the convalescence is short. Excision, however,
when successful, gives the patient a very useful limb.

ErcLsion, or Arthrectomy. — Erasion is the complete re-
moval of diseased synovial membrane, ligaments, etc. This
operation seeks to remove a depot of infection in an early
stage of tubercular synovitis, and it possesses the conspicu-
ous merit of not interfering with the epiphysis. Erasion is
oftenest practised upon the knee-joint. The instruments
required are a scalpel, hemostatic forceps, dissecting-forceps,
toothed forceps, volsellum, scissors, bone-gouges, curets, and
an Esmarch apparatus.

Ej-asion of the Kftce-Joint. — The patient lies upon his back ;
the limb is flexed with the sole of the foot planted upon the
table, and an Esmarch bandage is applied at a point well up
on the thigh. The surgeon stands to the right of the patient
The incision starts in the mid-line of the thigh (on the side
opposite to that occupied by the surgeon), about three inches
above the patella ; it is carried down across the ligament of
the patella and up to a corresponding point on the opposite
side of the thi^^^h. This incision is made down to the bone;
the flap is turned up and the joint exposed ; the knee-joint is
stront^^ly flexed, and the synovial membrane and diseased
ligaments are dissected away with scissors and forceps, great
care being taken that the posterior ligaments (which, fortu-
natch', arc rarely implicated early in the case) are not divided
and that the contents of the popliteal space remain intact.
After removing the diseased ligaments and synovial mem-
brane examine the cartilage and remove any diseased p)or-

DISEASES AND INJURIES OF BONES AND JOINTS. 487

tion, and then examine the bone and gouge away any tuber-
cular foci. Ligate any exposed vessels, irrigate the wound
and dust with iodoform, straighten the extremity, suture to-
gether the ends of the ligamentum patellae, suture the skin
after inserting a drainage-tube in each angle, dust iodoform
over the wound, and dress antiseptically. Put the limb upon
a posterior splint for a few days, then take out the drainage-
tubes, re-dress antiseptically, and put up in a plaster-of-Paris
cast, cutting trap-doors upon each side and keeping the
joint immobile for two or three weeks. This operation is

Fig. 137.

Fig. 138.

Fig. 137. — x-io, AMPtrrA-norts (Joseph Bell): x, of lower third of forearm (Teale's);
a, at shoulder-joint by lar:^e postero-external flap fsecond method) ; 3, at shoulder-joint by
triangular flap from deltoid (third method) ; 4, 5, through tarsus (Chopart'si: 6, 7, at knee-
joint : 8, by single flap (Carden's) ; 9, zo, of thigh (Teale's). a, excision of hip ; b, of ankle-
joint (Hancock's incision).

Fig. 138.— 1-18, AMPtTTATiONS^ (Joseph Bell): z, amputation at wrist-joint (dorsal in-
cision): 3, at wrist-joint ^palmar incision): 3. at forearm (dorsal incision); 4, at forearm
(palmar incuion) ; 5, at elbow-joint (anterior flap) ; 6, at arm (Teale's) : 7, at shouldcr-jnint
(first method); 8, 9, of metatarsus (Hey's) ; 10, 11, at ankle (Symc's) ; 12, 13, of lee, pos-
terior flap (Lee's); za, at knee-joint (Carden's); 15. of thigh (B. Bell's); 16, of thigh
(Spence's) ; 17, of thign in middle third; z8, at hii>-joint. a, excision of wrist (radial in-
cision); B, of wrist (ulnar incision).

only suited to early cases in which the lesion involves chiefly
or purely the synovial membrane and ligaments, and in these
cases it frequently gives a good result, some capacity for
motion being not unusually preserved.

Excision of the Shoulder-joint. — In the shoulder-joint

488

MODERN SURGERY,

partial excision is often performed, the head of the humerus
being removed and the glenoid being undisturbed ; but some
patients require complete excision, the entire glenoid depres-
sion, as well as the head of the humerus, being removed by
the surgeon. Excision of the shoulder-joint is made, i
possible, an intracapsular operation, the capsule being

Fig. 139.

Fig. 140.

Fig. 139.— 1-9, Amputations (Joseph Bell) : i, of arm by double flaps; », at »hoolder-
joint : 3, at ankle-joint by internal ffap (Mackenzie's) ; 4. Sf o> leg just aboYC the anklc-jotst
(Syme's) : 6, 7, below ihe knee (modified circular): B, through condyles of femur (Symc's):
0, at lower third of thigh (Syme s). a, excision of head of humerus ; b, of knee-joiot (kou-
funar incision).

Fk;. 140. — 1-8, Ampi'TATIONS (Joseph Bell) : i, at elbow-jolnt (posterior flap) : a.atshed-
der-joint, posterior incision (first method); 3, at ankle-joint (Mackenzie's) ; 4. through cod-
dyles of femur (Syme's) : 5, at lower third of thigh (Syme's) : 6, at knee (posterior incisioai;
7, of thigh (Spencer's) : 8, at hip-joint, a-g. Excisions ; a, excision of shoulder -jotot (deltotd
flap) ; B, of shouicler-Joint (posterior inci^^ion) : c, of elbow-joint (H -shaped incision); d, of
elhow-jtint (linear inci<iion) ; B, of hip-joint (Gross's) ; P, of os calcis : g, of scapula.

opened, but the capsular attachment to the anatomical
neck not bein<^ interferecJ with. In bad cases, however, the
capsular attachment must be destroyed. This operation is
rare in civil, but is common in military practice ; it is per-
formed in gunshot-wounds, in compound dislocations, in
tubercular disease, and in tumors of the head and upper por-
tion of the humerus. The instruments required are a scalpel,
an Adams saw, an osteotome or chisel, a mallet, an Allis
dissector, a periosteum-efevator, hemostatic forceps, dissect-
inL^-f(^rceps, toothed forceps, lion-jawed forceps, sequestrum-
forceps, metal retractors, curets, and cutting bone-forceps.

DISEASES AND INJURIES OF BONES AND JOINTS. 489

Operation by Anterior Incision. — The patient lies supine;
a pillow is placed beneath the shoulders, and a sand pillow
is put beneath the shoulder to be operated upon. The arm
is held to the side with the outer condyle forward and the
bicipital groove inward (Barker's directions). The surgeon
stands by the affected side. An incision three or four
inches in length is made from just external to the cora-
coid process, running straight down the humerus (Fig.
139, a). This incision divides the border of the deltoid
muscle and brings into sight the long head of the biceps.
The tendon of the biceps is retracted inward, unless it is dis-
eased, in which case it is resected. The knife is carried up
the groove and opens the capsule of the joint. The peri-
osteum is lifted from the neck of the bone while an assistant
rotates the elbow to make the muscles tense. In some
places, if the periosteum tears, muscular insertions must be
cut with a knife. The head of the bone is sawn off while
the bone is in place, or the elbow is strongly pulled back, and
the head of the bone is forced out of the wound, and is then
sawn off at the point required. In ordinary cases remove
only the articular head ; in other cases make the section just
above the surgical neck ; in yet others remove a portion of
the shaft. If the glenoid cavity is found slightly diseased,
any dead bone must be removed by the chisel and mallet
or by the cutting-forceps. If the cavity is seriously diseased,
the entire glenoid should be removed. Scrape away all dam-
aged tissue ; ligate bleeding points ; irrigate the wound with
corrosive-sublimate solution ; swab it out with a solution of
chlorid of zinc (gr. xx to 5j) ; dust with iodoform ; close
the upper portion of the wound and insert a drainage-tube
in the lower angle ; dress the wound antiseptically ; place
a small pad in the axilla; apply the second roller of
Desault; and put the patient in bed with a pillow under
the affected shoulder. In seven days the hand-sling is
substituted for the bandage, and with the elbow hanging
free the patient is permitted to get up and is advised to
move his arm frequently. Drainage is maintained until
the wound is well healed from the bottom. Great limi-
tation of movement inevitably follows upon a shoulder-joint
resection.

Excision by the deltoid flap is performed when the head
of the bone is much enlarged (as by a tumor) or when the
tissues are thick and indurated. The deltoid flap is in
the shape of a V or is semilunar (Fig. 140, a). Raising this
flap exposes the head of the bone most satisfactorily. Bell

490 MODERN SURGERY,

States that when the glenoid cavity is chiefly involved the
incision should be posterior (Fig. 140, b).

Sentis Method. — Senn has recently described * an incision
which does not damage any important vessels, muscles, ten-
dons, or nerves, and which is followed by good functional
results. A semilunar skin-flap is formed, the incision run-
ning from the coracoid process to the posterior border of the
axillary space. This flap is turned up, exposing the upper
half of the deltoid muscle. The acromion is sawn off and
turned down with the attached deltoid. The capsule is now
freely exposed ; it is opened, and either arthrectomy or excis-
ion is performed, according to conditions. In closing the
wound it is not necessary to bore the acromion and pass
silver wires to join the fragments ; it is enough to suture the
periosteum with catgut.

Excision of the Elbow-joint. — This operation is per-
formed for wounds, faulty ankylosis, and chronic articular
disease. Excision must be complete. Endeavor to make
a subperiosteal resection ; this maintains the shape of the
articulation and gives the best chance for a movable joint
The instruments used are the same as those for the shoulder,,
plus a Butcher saw.

Operation, — The patient is "supine, but inclining to the
sound side, the affected arm being held almost vertical, with
the forearm flexed and nearly horizontal" (Barker). The
incision is made on the posterior surface of the joint. A
single posterior incision is usually employed (Fig. 140, d, f).
An incision is made a little internal to the long axis of the
olecranon, and reaching two inches above and two inches
below the tip of the olecranon. This incision goes down to
the bone, and throughout the entire operation the surgeon
must guard and shield the ulnar nerve. The periosteum
and soft parts are well separated ; the olecranon is sawTi off;
forced flexion exposes the joint-cavity freely, and enables
the surgeon to lift the periosteum and soft parts from the
humerus ; the humerus is sawn through at the beginning
of its condyloid processes ; the radius and ulna are cleared
and arc sawn at a level below that of the base of the coro-
noid process of the ulna. Cut and spoon away diseased
tissues, the wound being irrigated, closed, drained, and dressed.
In some cases an H -shaped incision is employed (Fig. 140. c),
but the cicatrix of a transverse cut will limit flexion of the
limb.

After excision of the elbow the patient is put to bed and

^ Phila. Mai. Joiirn., Jan. i, 1898.

DISEASES AND INJURIES OF BONES AND JOINTS. 49 1

the arm is laid upon a pillow, the elbow being placed mid-
way between a right angle and complete extension, the fore-
arm being placed midway between pronation and supination.
No splint is used, as a rule. Esmarch used the splint shown
in Figure 141. The aim in treatment is to obtain a freely
movable joint. Passive motion is begun in one week, when
the patient gets up. The hand is carried for a time in a sling.

Fig. 141. — Esmarch't splint for the treatment of a limb after excision of the elbow-joint.

Bzcifidon of the WriBt-joint. — Bell states that, whatever
method of excision is chosen, three cardinal rules must be
borne in mind: (i) remove all the diseased bone, including
the portions of the radius, ulna, carpus, and metacarpus which
are covered with cartilage ; (2) interfere with the tendons to
the least possible degree ; and (3) begin passive motion of
the fingers very early. Many surgeons prefer the simple
gouging away of diseased foci and the scraping of sinuses
instead of a formal resection of the wrist, amputation being
employed in severe cases or when scraping fails after several
trials. Formal excision is not very often done, and the
results cannot often be considered as very favorable.

Lister's Open Method of Excision. — The instruments re-
quired in this operation are the same as those used for any
resection. Break up adhesions as completely as possible by
forcible movements. Apply a tourniquet or an Esmarch appa-
ratus. The patient lies upon his back, the arm and the fore-
arm being brought, from stage to stage, into the most desirable
pK>sitions. Begin an incision over the middle of the dorsum
of the radius, on a level with the styloid process ; carry it
downward in the direction of the inner edge of the articula-
tion of the thumb with its metacarpal bone, and when the
knife reaches the radial side of the second metacarpal bone
alter the direction of the incision and carry it downward in
the long axis of the metacarpal bone to about its middle
(Fig. 138, a). This is known as the radial incision, and the

492 MODERN SURGERY.

only tendon divided is that of the extensor carpi radialis
brevior muscle. The tissues upon the radial aspect of the
incision are dissected up, the tendon of the extensor carpi
radialis longior muscle is divided at its point of insertion
(Bell), and all the soft structures are retracted outward,
exposing the trapezium, which is cut off from the rest of the
carpus, but which is left in place, as its removal at this stage
endangers the radial artery (Barker). By extending the
hand the tendons are loosened and the carpus is cleared in
the direction of the ulnar border of the hand.

Another incision is made, starting upon the inner surface
of the wrist, two inches above the articular surface of the
ulna, and midway between the ulna and the flexor carp
ulnaris tendon. This incision, which is known as the tdnar
incision, is carried down until it is opposite the middle of
the fifth metacarpal bone in the palm (Fig. 138, b). "The
dorsal lip of this incision is raised " (Bell), and the extensor
carpi ulnaris tendon is divided and dissected from its depres-
sion, but is not separated from the integument. The extensor
tendons are lifted ; the ligaments upon the dorsum and
sides of the wrist-joint are cut ; the flexor tendons are raised
from the carpal bones; the pisiform bone is cut from the
carpus, but is not yet removed; and the unciform process of
the unciform bone is cut with forceps. The anterior radio-
carpal ligament is divided, the carpometacarf)al articulations
are cut through, and the carpus is pulled out with bone-
forceps. The ends of the radius and ulna are forced out of
the uhiar incision. All that portion of the ulna which is
crusted with cartilage is to be removed, the saw-cut is to be
oblique, and the base of the styloid process is to be left
behind. A thin section is to be sawn from the radius, and
the tendon-grooves arc not to be impinged upon. The artic-
ular surface of the ulna is cut away with pliers (Bell). If
foci of disease are discovered beyond these points, they are
to be gougtd out. The ends of the metacarpal bones are
sawn off, and their articular facets are cut away by means
of pliers. The trapezium is dissected out, the end of the
first metacarpal bone is sawn off and its facet is cut away
with pliers, and a portion of the pisiform bone is removed
(the entire bone being removed if it be diseased). The
wound is irrigated, vessels are tied, the radial incision is
closed, the ulnar incision is partly closed, a drainage-tube
is inserted by way of the ulnar incision, the wounds are
dressed antiseptically, and the Ksmarch apparatus is taken
off. The forearm and hand are placed upon a splint which

J3ISEASES AND INJURIES OF BONES AND JOINTS. 493

immobilizes the wrist and leaves the fingers semiflexed. The
splint is worn for many months, until the wrist-joint is immo-
tttle and solid. Esmarch uses the splint shown in Fig. 142.

Passive motion of the fingers is begun after thirty-six
hours.

Ezdaion of Uetaoarpal Bonea and of Phalonffes. —
Hxdsion of a metacarpal bone, except in cases of necro-
sis with the formation of large quantities of new bone,
usually leaves a useless finger; hence amputation is pre-
ferred usually to excision. This rule does not apply to
the metacarpal bone of the thumb, which is occasionally
resected. The incision for this operation is made upon the
dorsum, and is straight. Excision of the proximal phalanx
of the thumb is sometimes performed. Excision for disease
is rarely performed upon the finger-joints, amputation being
preferred, though the operation is sometimes undertaken for
compound dislocation. In the metacarpophalangeal joint
of the thumb excision, if it can be performed, is preferred
to amputation. The incision for resection of this joint is
placed upon the radial aspect.

Sxcision of the Hip-joint. — Some surgeons advocate this
operation ; others, notably Marsh, are emphatically opposed
to it Excision should be performed in the early stage of
tubercular disease if less radical treatment has failed, and in
this stage the usual position of the limb is one of flexion,
abduction, and eversion. In cases of long duration, espec-
ially where dislocation exists, excision is an easy and a com-
paratively safe operation ; in recent cases it is difficult and
carries with it decided dangers, but the peril of delay may
be greater than the peril of an early resection. In cases of
hip disease with involvement of the acetabulum the mor-
tality is 50 per cent, whether operation is or is not at-
tempted. Exdsion is performed especially for tubercular

494

MODERN SURGER Y.

disease and for gunshot-injuries. The instruments required
are those used for other excisions.

Operation by Anterior Innan
(Fig. 143) (Parker's Operation),
— In this operation the patientis
supine, with the thighs extended
as thoroughly as circumstances
permit. The surgeon stands to
the right of the patient An
incision is begun half an inch
below and half an inch external
to the anterior superior iliac
spine, and it is carried down-
ward and a little inward for
about three inches (Fig. 143, d).
If dislocation exists, the indsion
must not be so long. This in-
cision is carried at once deeply
between the muscles, and the
capsule of the joint is opened
The neck of the bone is dixided
from its upper surface doMn-
D'^nKriot''h«uion' '"""''" "'fatic: ward with a sawor an Osteotome,
and without dislocating the
bone through the wound by forcible extension and eversion,
thu head of the bone is removed. AH tubercular fod must
be scraped away, and the flushing gouge is used upon tuber-
cular areas of the acetabulum. All sinuses should be thor-
oughly scraped. Bleeding is arrested, the wound is irrigated
with corrosive-sublimate solution, mopped out with chlorid-
of-zinc solution, and dusted with iodoform. A drainage-tube
is inserted at the lower angle of the incision, and the upper
portion of the cut is closed. The wound is dressed antisep-
ticajjy. Extension is made with the extension apparatus until
healing has obtained a good headway, when a double Thomas's
splint is applied, so that the patient can be taken out daily in
tlie air and sunlight. As a rule, rigid ankylosis results from
resection of the hip. but occasionally a joint results with a
small range of movement.

Operation by Lateral Incision (Langenbeck's Operation).—
In this operation a straight incision two inches long is made
in the direction of the axis of the femur, and runs downward
from the apex of tlie great trochanter. From the beginning
of this inci.sion a curved incision is carried toward the head

of the bone, the convexity of the curve being backward

DISEASES AND INJURIES OF BONES AND JOINTS. 495

(Fig. 1 37, a). Bell advises the use of the saw after bringing
the head of the bone into the wound by abduction and ever-
sion of the thigh. Barker applies the saw with the bone in
si^u, and strongly opposes wrenching the bone out of the
incision, because of the danger of peeling off the periosteum,
which peeling, if it takes place, favors necrosis.

Incision of Gross, — In Gross's operation a semilunar flap
is made with the convexity backward (Fig. 140, e).

Excision of the Knee-joint. — In this operation a com-
plete excision should be performed, and the patella ought to
be removed. This operation is performed in tubercular dis-
ease, in some compound fractures and compound disloca-
tions, and in some cases of angular ankylosis, but it is rarely
employed for gunshot-injuries, amputation being advisable

iAshhurst). The instruments required are the same as those
or the shoulder, plus Butcher's saw.

Operation by Anterior Semilunar Flap, — ^The patient lies
upon his back, and the joint, if not ankylosed in extension,
is semiflexed. The surgeon stands to the right side. An
incision is made, at once opening the joint, starting from one
condyle and reaching the other condyle by a downward
curve which passes through the ligamentum patellae midway
between the tuberosity of the tibia and the inferior margin
of the patella (Fig. 139, b). The flap is dissected up, the
knee is thrown mto forced flexion, the lateral ligaments and
crucial ligaments are cut, and the end of the femur is well
cleared. The blade of Butcher's saw is passed beneath the
bone, which is sawn from below upward (Ashhurst). The
end of the tibia is cleared and a portion is sawn off If, after
sawing, diseased foci are discovered, another section can be
sawn off or the foci can be gouged away. Ashhurst, who has
had a vast experience with this operation, insists that in sawing
through the femur the natural obliquity of the bone must be
borne in mind and the section must be made in " a line parallel
to that of the free surface of the condyles." If the section is
made transverse to the axis of the femur, " the limb, after ad-
justment, will be found to be markedly bowed outward." The
same surgeon says that the epiphyseal line is somewhat higher
on the front than it is on the back of the femur, and in con-
sequence the following rule is formulated for section of the
condyles : the section of the condyles should be " in a plane
which, as regards the axis of the femur, is oblique from be-
hind forward, from below upward, and from within outward."
Ashhurst advocates section of the tibia " in a plane trans-
verse to the long axis of the bone, with a slight anteroposte-

496 MODERN SURGERY.

nor obliquity, so as to correspond with that of the section of
the condyles," and further says also that the patella must be
removed, whether it is diseased or not. and he quotes Pcniere's
observations to the effect that excision of the patella dimin-
ishes the risk of death one-third, and its retention doubles tbe
probability of an amputation becoming necessarj- in the future
After removing the patella the diseased synovial membrane
is clipped away with scissors and all sinuses and diseased
territories are well curetted. The posterior ligament of the
joint is not removed unless it is diseased; its retention pre-
vents displacement and guards the popliteal space. In chil-
dren the fragments should be wired together; in adults this
need not be done. After hemostasis irrigate, dust with iodo-
form, insert a drainage-tube, suture, dress antiseptically, and
adjust the limb upon Price's splint or Ashhurst's bracketed
wire splint. In some cases tenotomy is required to pcmiit
extension. Instead of the bracketed splint, a long fracture-box
may be used. If the femur tends to project anteriorly, use an
anterior splint. If there be a tendency to outward bowing,
adopt Ashhurst's expedient of carrying a strip of adhesii'c
plaster around the outside of the limb and fastening it to the
inner side of the splint. The splint is kept on until bony
union is complete, as in this operation a movable joint is
never sought. Many surgeons use a plaster-of-Paris splint.
which is employed until the parts have become firm and solid
(Fig. 144).

Bxcision of the Ankl»-joint. — This operation is per-
formed chiefly in gunshot-wounds, in compound dislocations,
and in early cases of chronic joint-disease. Complete resec-
tion is employed for chronic joint-disea.se. Excision of the
ankle is a rare operation. The in.struments used are the
same as those employed for any resection.

DISEASES AND INJURIES Of BONES AND JOINTS. 497

Operation (Hancock's Method), — In this operation the pa-
tient lies upon his back, the foot rests upon its inner side,
and the surgeon stands to the outer side of the damaged limb.
Begin an incision just behind and two inches above the ex-
ternal malleolus, and carry it across the front of the joint to a
«>iTesponding point above and behind the internal malleolus
(Fig. 137, b) ; this incision goes only through the skin, and
the flap thus marked out is reflected. " Cut down upon the
external malleolus, carrying the knife close to the edge of the
bone both behind and below the process, dislodge the peronei
tendons, and divide the external lateral ligaments " (Joseph
Bell). Cut the fibula one inch above the malleolus by means
of pliers ; divide the tibiofibular ligament ; turn the foot upon
its outer side ; dissect from their habitat back of the inner
malleolus the tendons of the posterior tibial and the com-
mon flexor of the toes ; carry the knife around the inner
malleolus, close to the bony edge ; separate the internal lat-
eral ligament, and dislocate the lower end of the tibia through
the wound by turning the sole of the foot downward ; saw o/T
the lower end of the tibia and the articular process of the
astragalus, sawing away from the tendo Achiliis, and remove
the fragments with bone-forceps. Cut away diseased syno-
vial membrane, and curet all sinuses and tubercular areas.
Arrest bleeding, irrigate, and drain. Sew up the wound.
Insert a tube at the outer angle, and cause it to emerge at the
inner angle. Apply antiseptic dressings, and put up the foot
in fixed dressing or in splints at a right angle to the leg (Fig.
4S). In Langenbeck's operation the excision is subperios-

teal. If, in an excision of the ankle-joint, the astragalus is
found extensively diseased, remove the entire bone.
Bxciaiou of the Os Oalois. — In caries limited to the os

498 MODERN SURGERY,

calcis most surgeons prefer to gouge away the dead bone,
leaving the periosteum and, if possible, a shell of healthy
bone, and draining thoroughly. Others advocate exdsicm
in some cases. Extensive disease limited purely to the os
calcis is rare, and most surgeons advise gouging for limited
caries, and Syme*s amputation in the event of the disease ex-
tending beyond the periosteum or reaching adjacent bones.

Operation by Subperiosteal Method. — In this operation the
position assumed by the patient is supine with the le^
extended and the foot resting on its inner side. The
incision, which cuts the tendo Achillis and reaches the
bone at once, is begun at the upper border of the os calcis
and the inner margin of the tendo Achillis, and is taken
outward and horizontally forward to a point in front oPthe
calcaneocuboid articulation. A vertical incision is begun
near the forward termination of the initial incision, is carried
across the outer edge and plantar surface of the foot, and
terminates at the external margin of the inner surface of the
OS calcis. Some surgeons carry the vertical incision a little
upward, toward the dorsum (Fig. 140, f). The periosteum
is entirely stripped with an elevator, the os calcis is removed,
the cavity is packed with iodoform gauze, the wound is
stitched, a drain is inserted posteriorly, and the foot is
dressed antiseptically and put up in plaster at a right angle
to the leg, trap-doors being cut for drainage.

Excision of the aatragralus is a rare operation.

Operatio7i by the Subperiosteal Plan. — Barker advises an
incision going at once to the bone, from the " tip of the ex-
ternal malleolus forward and a little inward, curving toward
the dorsum of the foot." The foot is extended and turned
inward, the periosteum is lifted, the bone is removed, and
the wound is treated and the foot is dressed as is done in
excision of the os calcis.

Excision of the Metatarsophalangreal Articulation of
the Great Toe. — In this operation make a lateral incision
and cut off or saw off the proximal end of the first phalanx
and the distal third of the first metatarsal bone.

Excision of the Metatarsal Bone of the Gbrest Toe
(Butcher's Method). — In this operation a lateral straight
incision is made, the periosteum is elevated, and the shaft 'y&
sawn from each extremity and removed.

Excision of the clavicle may be required in dislocation,
in caries, in necrosis, for gunshot-wounds, in tumor of this
bone, as a preliminar\' to ligation of the artery and vein in
certain cases of amputation at the shoulder-joint, or in cases

DISEASES AND INJURIES OF BONES AND JOINTS. 499

of removal of the entire upper extremity. In excision of
the clavicle the position of the patient is the same as that
for ligation of the third part of the subclavian artery (page
288). An incision is made down to the bone, from the
sternoclavicular joint to the acromioclavicular articulation.
If the case is suitable, the periosteum is stripped and the
bone is sawn and removed ; if not, the bone is sawn and
each half is separately disarticulated. The wound is sutured
and dressed, and the limb is put up in a Velpeau bandage.

Ezoimon of the Scapula. — Complete excision of the scap-
ula is most usually performed for tumors. Partial excision
requires no detailed description. In excision of the scap-
ula the patient lies upon his sound side. Treves suggests
the following incisions: one outside the vertebral border
of the scapula, from its superior to its inferior angle;
another from over the acromioclavicular joint, along the
acromion process and spine of the scapula, to meet the
first incision. Syme used an incision carried transversely
inward from the acromion process to the vertebral border
of the scapula, and another cut directly downward from
the center of the first incision (Fig. 140, g). In the
method of Treves* the upper flap is reflected and the
trapezius muscle is divided ; the lower flap is reflected and
the deltoid muscle is divided. The patient's hand is placed
on the sound shoulder ; the muscles of the vertebral border
are divided, the posterior scapular artery is tied, and while
the vertebral border of the scapula is pulled toward the
Surgeon the serratus magnus muscle is cut, the upper border
of the shoulder-blade is cleared, and the suprascapular artery
is tied. The hand is now brought down to the side; the
acromioclavicular joint is disarticulated; the conoid and
trapezoid ligaments are divided ; the muscles of the coracoid
process are cut ; the capsule is incised, with the supraspinatus
and infraspinatus, the subscapularis muscles, and the scapular
origins of the biceps and triceps ; and finally the teres major
and minor muscles are divided, the subscapular artery is tied,
and the bone is removed. The wound is stitched, a drain is
introduced, and antiseptic dressings are applied. The patient
lies upon his back until healing is well under way, when the
arm is placed in a sling. The drainage-tube may be removed
in twenty-four hours.

EzclBion of a Rib. — In caries the gouge and rongeur may
remove the disease. In other cases excision is performed.
In this operation the patient lies upon his sound side. The

* Trevca's Manual of Operative Surgery.

-TTr T iic^ r:e Tiizenc M^ke an incision down to the

: :_-. r. wz -:^ 1:^;:? c'the r.b. The periosteum, if not dis-

.-;•-- r .r:- : r:tr. liie bor.e. and the intercostal arten'b

;:_- --L : : r -n :er.c :-- .\f:er sawing the bone beyond

::_■ .:::::>• t' li^MiJc. rirn.i.c i- During the sawing a metal

-::r'.jT - r lu-i I :er.cj^. r:e rib. between the rib and the

:rr *~-.lt:. 1" "^tt ^errsreun: is diseased, remove it after

-■::_- -JiM r.Z-r: ■fci. intTv. Curet sinuses. Pack uiih

:. ■ -rz z^L,:.:-! "rr -^rce livs. Sew up the wound except at

:. ::* :. I-:^r irrr^kicccilly and apply a binder. If a nl)

r -:_--.-.r.- : :• ^^ler :: zrnr'. :he oieural caxitv, remove it bv

::- - .r:^- -r_-^ fe*Jt:-:r:. ^^li^iic rhe arter\- after a p)ortion of

::. '::: :.^ :».-=:: rrr::':.^;-! cut away the periosteum to pre-

•: -: ■ -t:..::' • :r" rure. ir.d open the pleura. (SeeOpera-

: r :-: : :.:^- .'Te-c ir.'i E.stlanders Operation.)

JjoipiiK^ 2xj:soei of One-half of the Upper Jaw.^

~-^ V-: ■: :::i:cr i v iiMs been removed, but in what fol-

V -:"?<--t:':it :r ?ce-hjlf the jaw will be described.

— •.^ '.criz ■" .< ;:er5:r:zied for malignant tumors of the

■:.:..- - rz^S.-^ir rcr.e :r:ts antrum. Up to 1826, at which

: ". 1.--^-^ ■•" rJi-tbc-^rh suggested the op)eration, tumors

v^ ::'T**:r \"irt reared by scraping them away uith a

■ :...'- <:»«;i\ Jtirr?^:..:! of Lyons in 1S27 performed the first

-^ ::: T '^■- :^se-.":i':r. of the upper jaw. This operation is

.-;'-^.:.j ^.\:-^cc i- a calliative measure, if the orbit is

. -. : -Tc -iv::- ir.i s-bcutaneous tissues arc infiltrated,

'. _:-^.^^- ;.\':i-i? bey?nd the superior maxillar>' and

-. : ■ • .^ 7-.- -^rruner.'s required are a mouth-gag:

^ . ' -r- -^ <_-><.; rf. dissecting, toothed, and hemo-

.- •: ■;-■:> ri;:^i-<un:"'.j: tbrceps ; lion -jaw and seques-

-.-:•- : ;';c>^xtra:::n j: forceps ; a volsella ; a narrow-

' \. . -^i . .1 :.\:iv:l i^i :::a!Iet; a f>eriosteum-elevator; a

■\ . ■ ".ri. -^;:rij:?r; Paquelin's cauter>- ; sponges

• ;• ..-. r,-- :■ ^r:"<s. r.eevilcs. cur\*ed and .straight ; silk

■ ,-.-.*.:-: ci:-~:^ sL.k'.vornz-sutures; large cur\'ed needles;

-■•..--. < .i-rscvc:: bone- wax.

• - - ' • .'.''. :"..:t /•.-.toW'.'. — The patient, whose face has

x: • sM :.•-. s v*A,"t:i in the Trendelenburg position, thus

• - ,: :-, ■.-. >-:ble need of instant tracheotomy. The

^.- • -M*.-> :.^ the rii:ht side of. and faces, the pa-

. -: 7", ••: <:r :?o:h on the diseased side is pulled

7'i ::.:>:.*n Fij:. 146. line .\B» is begun half an inch

\ ... ....... — ^:;:hj> of the eye. and is carried along the

:>:.• ••..>>:. around the ala of the nose, by the margin
: •: '.'str.l. and through the middle of the lip. While

DISEASES AND INJURIES OF BONES AND JOINTS. 501

the lip is being incised the assistant arrests hemorrhage
by grasping the corners of the mouth, and after the lip is
divided the coronary arteries are
at once ligated. Some operators
approach the mucous membrane
cautiously and ligatc the vessels
before opening the cavity of the
mouth. The upper portion of the
wound having been compressed
\xy another assistant during these
manipulations, pressure is now
removed and bleeding points are
ligated. Another incision is now
carried outward from the begin-
ning of the first incision, along the
orbital margin to welt over the
malar bone. The flap is lifted j.V?c'i''.T«ci."nM''"hrio»«jrr'
from the periosteum, and the

bleeding from the infraorbital artery and the small vessels is
icstrained by pressure. The nasal cartilage is separated from
"' le bone, and the nasal process of the superior maxillary is
iwn (line a r, P'ig. 147). The orbital periosteum is lifted
up, and the orbital plate is cut with
forceps from the saw-cut in the supe-
rior maxillary bone to the spheno-
maxillary fissure (line BC, Fig. 147).
The malar bone is sawn or is bitten
through about its center, the cut
running into the sphenomaxillary
fissure and taking a downward and
outward direction (line c n. Fig. 147)'
The soft parts covering the hard
palate are incised in the median line,
a corresponding incision is made
along the floor of the nose near the
septum, and the soft palate is sepa-
rated from the hard palate by a trans-
verse cut. The saw is introduced
through the nose, and the palate is

sawn {line e. Fig. 147). The upper ]»*.; 0, .ecuon of iht inferior
jaw-bone is grasped with Fergusson's ^^mmUliX^x^^ar,'^ *'
uon-jaw forceps and removed, the

removal being aided by the use of the scissors and bone-
cutters ; the latter are used to separate the upper jaw from
the pterygoid process (Treves). Every vessel that can be

sirs

orblul pl»<

502 MODERN SURGERY.

seen is tied, and severe bleeding from bone is arrested by
antiseptic wax. Oozing is controlled by hot water and
pressure or by Paquelin's cautery. Examine carefully to
see if all the diseased area is removed ; if it is not, use
the gouge, scissors, chisel, and saw until healthy tissue is
reached. The wound is packed with iodoform gauze, and
the end of the strip is so placed as to be accessible through
the mouth. The wound is sutured (the mucous membrane
of the lip must be stitched, as well as the skin) and is dressed
antiseptically (the eye being protected by aseptic gauze), and
a crossed bandage of the angle of the jaw is applied.

Excision of One-half of the Lower Ja-w. — In some rare
instances the entire inferior maxillary bone is removed The
lesions necessitating removal of the lower jaw are of the
same nature as cause us to remove the upper jaw. The
instruments required for removal of the lower jaw are those
used for excision of the upper jaw, plus a metacarpal saw
(having a movable back).

In this operation the patient is placed in the same posi-
tion as for excision of the upper jaw, the chin having
been previously shaved. A vertical cut is made through
the chin-tissue, starting below the margin of the lip and
reaching to below the border of the jaw (c D, Fig. 146).
From the point D an incision is carried outward below
the border of the jaw and then back of the ramus, as
shown in the line d e (Fig. 146). Treves's advice is to
carr>' this incision down to the bone, except at the line
of the facial artery, at which point it must go through
the skin only. The facial artery is now to be sought
for, tied in two places, and divided. The periosteum is lifted
from the external surface of the bone, from the symphysis
outward. Haemorrhage is arrested. The buccal mucous
membrane is cut from the alveolus. A lateral incisor tooth
is pulled, and the bone is sawn in the line g (Fig. 147).
The bone is grasped in a lion-jaw forceps and is dra\ni
outward. The mylohyoid insertion is cut; the internal
pterygoid muscle is cut or the periosteum at this spot is
lifted ; the inferior dental artery is cut and tied ; the jaw is
pulled down ; tlie insertion of the temporal muscle upon the
coronoid process is cut away; and the external pterygoid
muscle is divided. The capsule of the joint is opened, and
the bone is separated from the ligaments which still hold it
in place. Bleeding is arrested, the wound is sutured, a tube
is introduced in the posterior portion of the wound and
retained for twenty-four hours, and antiseptic dressings and

DISEASES AND INJURIES OF BONES AND JOINTS. 503

a Gibson or a Barton bandage are applied. Partial excisions
of the alveolus may be performed through the mouth by
means of chisels and rongeur forceps, and Wyeth has re-
moved half of the jaw by this method ; but if any consider-
able part of the body of the jaw is to be removed, it is usually
best to make an incision below the jaw.

Operation for Congenital Dislocation of Hip. — Hoffa*s
Operation, — ^The instruments used are the same as for a
resection. Make the external incision of Langenbeck to
open the joint (page 494). The capsule is incised at its inser-
tion into the neck, and the periosteum and muscles are lifted
from the great trochanter. HofTa claims that in children
less than five years of age the head can be readily replaced
into the acetabulum by flexing the thigh and making direct
pressure upon the head of the bone. After replacing the
head it is held in place while an assistant extends the leg
in order to stretch the muscles. In children over five years
of age cut the muscles which spring from the ischial tube-
rosity and also the adductors with a tenotome ; cut the fascia
lata and muscles which arise from the anterior superior iliac
spine by incision; open the joint and liberate the head;
remove the ligamentum teres ; scrape out the acetabulum,
removing "cartilage, fat, and considerable spongy tissue"
(Tubby) ; and replace the head in the acetabulum. The limb is
maintained in inversion, abduction, and extension for several
weeks, when it is straightened. Massage and passive motion
are beg^n in the fifth week. The patient now gets about,
ivearing an apparatus for many weeks. This apparatus per-
mits the head of the bone to move in the socket, but pre-
vents redislocation.

Lorenz's Operation, — This is a modification of Hoffa's.
The muscles inserted into the greater trochanter and the
lesser trochanter are not cut ; the sartorius, the hamstrings,
and the external portion of the fascia lata are cut (Tubby).

The incision of Lorenz is longitudinally from the anterior
suf)erior spine. Another incision is carried inward from this
at the level of the lesser trochanter. The capsule is opened
by a crucial cut ; the acetabulum is enlarged ; the head of
the bone, if it remains, is inserted into the acetabulum ; if
there is no true head, a new one is formed and inserted into
the cavity. The limb is immobilized in a position of mod-
erate abduction. Massage and passive motion are begun in
the fifth week, and are continued for months.^

* I have drawn from the very lucid description of these operations in A. H.
Tabby's treatise apon « Deformities."

504 MODERN SURGER Y.

XX. DISEASES AND INJURIES OF MUSCLES, TEN-
DONS, AND BURS/E.

Myalgia, or muscular rheumatism, is a painful &-
order of the voluntary muscles and of the fibrous and peri-
osteal areas where they are attached. The term " muscular
rheumatism *' is not strictly correct. It is possible that in
some cases the muscular structure is inflamed, but it is cer-
tain that in many cases the pain is distinctly neuralgic
Muscular rheumatism may be due to cold and wet, to over-
exertion and strain, to acute infectious disorders, to s>'philis,
to chronic intoxications (lead, mercury, and alcohol), and to
disturbances of the circulation. Gouty and rheumatic per-
sons are especially predisposed, men being more liable to
the disease than women. The disease is usually acute, but
it may be chronic.

Sjnnptoms. — Muscular rheumatism is apt to come on
suddenly. The pain, which may be very acute and land-
nating or may be dull and aching, is in some cases con-
stantly present; in other cases it is awakened only by
muscular contraction. The pain is frequently relieved by
pressure, though there is often some soreness. The skin
above the muscle is sometimes tender to light pressure.
The disease usually lasts for a few days, but it tends to recur.
There is little, if any, fever.

Lumbago is myalgia of the muscles of the loins. Rlieu-
matic torticollis is myalgia of the muscles of the neck.
Usually one side of the neck is attacked. The chin is turned
from the affected side and the neck is stiff. Pleurodynia
is myal^^ia of the intercostal muscles. The pain is very
severe, is aggravated by deep respiration, by coughing, and
by yawning, there may be tenderness, and the p>atient tries
to limit chest-movement. In intercostal neuralg^ia the pain
is limited, is not constant, but occurs in distinct paroxysms,
and is linked with the presence of the tender spots of Val-
leix. Pleurodynia lacks the physical signs of pleurisy.
Myalgia must not be confused with the pains of locomotor
ataxia. Ccphalodynia is myalgia of the muscles of the scalp.
The muscles of the shoulder, upper dorsal region, abdomen,
and extremities may also be attacked by myalgia.

Treatment. — Remove any obvious cause. Treat any ex-
isting diathesis, such as gout or rheumatism. Rest is of the
first importance. For lumbago, put the person to bed. For
pleurodynia, strap the side of the chest. A hypodermatic
injection of morphin and atropin into the affected muscles at

DISEASES AND INJURIES OF MUSCLES, ETC. 505

once allays the pain, and a deep injection of water is often
curative. The introduction of four or five aseptic needles
into the muscles, and their retention for a few minutes, some-
times act most favorably. Ironing the skin above the pain-
ful muscles is a useful domestic remedy. Vigorous rubbing
of the area with a piece of ice allays the pain. Hot poultices
do good. If the pain is widely diffused, alters its seat, or is
very obstinate, order hot baths or Turkish baths and admin-
ister diuretics. In chronic cases employ blisters or counter-
irritation by the cautery, give iodid of potassium and nux
vomica, and have the patient take a Turkish bath every
week. The constant electric current finds advocates. In
an ordinary severe case order a hot bath, put the patient to
bed with a hot-water bag over the part, and administer 10
grains of Dover's powder; the next morning order to be
taken four times daily a capsule containing 5 grains of
salol and 3 grains of phenacetin, un^il the pain disappears.
Citrate of potassium, citrate of lithium, chlorid of ammonium,
or the salicylate of colchicin may be ordered.

Infective myositis is a widespread inflammation of the
voluntary muscles, due to an unknown infective cause. It is
a disorder accompanied by pain and stiffness, by cutaneous
edema, and by various paresthesiae. Myositis resembles
trichinosis, and is distinguished from it only by spearing out
a bit of muscle and examining it microscopically. Occasion-
ally diffuse suppuration occurs. Ordinary myositis arises
from injuries, from syphilis, or from rheumatism, and it pre-
sents the usual inflammatory symptoms. Contraction and
adhesions may follow.

Treatment. — Infective myositis is treated by anodynes,
stimulants, nutritious food, hot applications, and rest. If
pus forms, it should be evacuated. Rheumatic myositis calls
for the administration of the salicylates, the alkalies, or salol.
Syphilitic myositis is treated with mercury and iodid of
potassium. The remedies employed for myalgia are used
in traumatic myositis.

Hypertrophy of the muscles may arise from their in-
creased use. In pseudohypertrophic paralysis the bulk of
the muscle is greatly augmented, but it contains less muscle-
structure and more fat or connective tissue.

Atrophy of the tntiscles arises from want of use, from
injury, from continuous pressure, from interference with the
blood-supply, from disease of the nerves or their centers, or
from lead-poisoning.

Degeneration of Mnscles. — The muscles may undergo

5o6 MODERN SURGERY.

granular degeneration, waxy degeneration, fatty degenera-
tion, and calcareous degeneration, and may become pig-
mented.

l/ocal Ossification and Myositis Ossificans.— It is

not unusual for a small portion of bone to form in the peri-
osteal insertion of a muscle which is subjected to frequent
strain. In persons who ride many hours a day there not
infrequently develops the " rider's bone," which is an area of
ossification in the adductor muscles of the thigh. Myositis
ossificans, a widespread ossification of the muscles, is a rare
disorder the cause of which is unknown, and which if not
congenital begins at least in early life.

l^imors of tiie Muscles. — Primary tumors of the mus-
cles are rare. Among those which may occur are sarcoma,
fibroma, lipoma, osteoma, angioma, myxoma, and enchon-
droma. Most cases of supposed primary sarcoma of mus-
cle are in reality cases pf syphiloma (Esmarch).

Sjrphilis may cause inflammation. Gummata may form,
or gummatous infiltration may take place.

Trichinosis or trichiniasis is a disease due to the
embryos of the trichina spiralis. The disease originates
from eating insufficiently cooked meat which contains the
trichinae. These nematodes are carried into the intestine,
there to develop and multiply. In from seven to nine
days a horde of embryos develop in the bowel, and leave
the alimentary canal by passing through the peritoneum or
by means of the blood, and finally reach the connective
tissue of the muscles. From the connective tissue the em-
bryos migrate into the primitive muscle-fibers, where they
dwell and enlarge. Myositis develops, and in the course
of five or six weeks the parasites become encapsuled and
develop no further. The cyst-walls may calcify and the worms
may become calcified, or may live for years. Because in-
fected meat is eaten the disease does not inevitably develop,
and a few embryos lodged in muscle may cause no symp-
toms.

Symptoms.— The symptoms of trichinosis often appear in
a day or two after eating infected meat. The .symptoms of
acute gastro-intestinal catarrh or of cholera morbus are com-
mon, but in some cases no gastro-intestinal manifestations
usher in the disease. In from seven to fourteen days after the
infected meat is eaten the migration of the parasites develops
obvious symptoms. A chill may be noted ; there is usually
fever ; muscular pain, tenderness, swelling, and stiffness are
complained of This condition may be widespread. Involve-

DISEASES AND INJURIES OF MUSCLES, ETC, $0/

ent of the muscles of mastication interferes with chewing ;

the larynx, with audition and respiration ; of the inter-
stals and diaphragm, with respiration. Skin-edema and
:hing are marked. In some cases delirium exists. The
iter saw in the Philadelphia Hospital one fatal case which
is mistaken for erysipelas because of the high fever, the
lirium, and the edematous redness of the face and neck,
yspnea is frequent Mild cases get well in a week or two ;
vere cases may last many weeks. The mortality varies

different epidemics from i to 30 per cent. (Osier). The

agnosis is made by spearing out a piece of muscle, which

then examined for trichinae under a microscope ; or the

3rm may be detected in the feces by means of a pocket-

fis.

Treatment. — To treat trichinosis employ purgatives
*nna and calomel) early in the case, and give glycerin,
id also santonin or filix mas. When muscular invasion
LS taken place, sedatives, hypnotics, nourishing diet, and
mulants are indicated.

Wounds and Contusions of the Muscles. — Wounds

muscles may be either open or subcutaneous. In a longi-
dinal wound the edges lie close together, and hence drain-
;e must be provided for by the surgeon. In a transverse
3und the edges separate widely, and catgut stitches must
: in.serted. Contusions of muscles, like contusions of other
isues, vary in extent and in severity. There are pain (which
increased by attempts to use the muscle), loss of function,
.relling beneath the deep fascia, and discoloration, which
ay appear at once because of superficial damage from the
itial injury, or which may appear in dependent parts after
any days by gravitation of the blood and the blood-stained
rum. As a result of contusion, suppuration, inflammation,

atrophy may arise.
Treatment. — The indications in wounds and contusions

muscles are to obtain rest by means of splints and to
cure relaxation. Limitation of swelling is secured by
mdaging. Inflammation is combated first by cold and lead-
ater and laudanum ; later by iodin, blue ointment, ichthyol,
id intermittent heat. To prevent loss of function employ,

soon as the acute symptoms subside, massage, passive
otion, and stimulating liniments, and, later in the case, elec-
icity (galvanism if the reactions of degeneration exist,
radism if they are absent).

Strains and Ruptures. — ^A strain is a stretching of a
uscle with a small amount of rupture. The muscle is

508 MODERN SURGER Y,

swollen, tender, stiff, weak, and sore, and attempts at motion
produce sharp pain. Strains are common in the deltoid, the
hamstring muscles, the back, the calf, the biceps, and tbc
great pectoral. Strain of the psoas muscle causes pain on
flexing the thigh, and is associated with tenderness in the
iliac fossa. Strain of the right psoas may be mistaken for
appendicitis, but it lacks the intense local tenderness, the
abdominal rigidity, and the constitutional symptoms.
" Lawn-tennis arm " is a strain of the pronator radii teres
muscle. " Rider's leg " is a strain of the adductor muscles
of the thigh. A strain may be the only injury, or may be
associated with some other condition (fracture of bone, dis-
location, sprain, contusion, etc.).

The muscle is often rigid, is tender, and pains greatly when
an attempt is made to use it. The skin over it, especially
over its point of insertion, is usually tender.

A strain of the back is a very common accident which
is often associated with sprains of the vertebral liga-
ments. There is great pain when the patient voluntarily
straightens up. If the vertebral ligaments are not sprained,
the patient can be straightened by passive motion with-
out pain. The skin is tender in certain areas. The mus-
cles are often rigid. There may be unilateral rigidity. In a
back injury make a careful examination to be sure there is
no damage to vertebrae or cord.

Treatment. — Relaxation by suitable position ; rest by the
use of splints or by putting the patient to bed ; bandages for
compression ; hot fomentations or hot lead-water and lauda-
num ; ichthyol. As soon as acute symptoms subside employ
frictions and massage. If there is much pain after a strain,
administer Dover's powder, or even morphin.

Rupture of a muscle is announced by a sudden and \io-
lent pain and by loss of function arising during powerful mus-
cular contraction or strong traction on a muscle. The rupt-
ure may be announced by a clearly audible snap (A. Pearce
Gould). A distinct gap is felt between the ends; great pain
develops on movement ; there are tenderness, loss of power,
and swelling. Strains and rupture may be followed by
atrophy, as are contusions. Among the muscles which
occasionally rupture we may mention the quadriceps, biceps,
triceps, deltoid, etc.

Treatment. — In limited rupture treat as a severe strain.
In treating extensive rupture of an important muscle, when
the ends are widely separated, incise with every aseptic care,
unite the divided ends by sutures of chromic catgut, and

DISEASES AND INJURIES OF MUSCLES, ETC. 509

sew up the skin with silkworm-gut. Treat the part in any
case by rest and relaxation, and combat inflammation by
«^>propriate means. Passive motion and massage are em-
ployed as soon as union is firm. In rupture of the quad-
riceps extensor femoris operation should be undertaken, be-
cause mechanical treatment gives frequently a bad result and
confines the patient to bed for many weeks.

Hernia of Muscles. — When a tear takes place in a mus-
cular sheath a portion of the muscle protrudes. The treatment
is incision and the stitching of the fascia.

Contractions of murcles may result from injury, from
joint-disease, from malposition of parts (as in old dislocation
or torticollis), or from diseases of the nervous system. The
treatment in some cases is sudden extension, in other cases
gradual extension, tenotomy, or myotomy. Macewen recom-
mends the making of a number of V-shaped incisions in the
muscle. In some cases of spasmodic contraction nerve-
stretching is of value.

Dislocation of Muscles and Tendons. — The long

head of the biceps is oflenest displaced. The flexor carpi
ulnaris, the peroneus brevis, the peroneus longus, the tibialis
posticus, the sartorius, the plantaris, the quadriceps extensor
femoris, and the extensors back of the wrist, may be dislo-
cated. What is known as dislocation of the latissimus dorsi,
a condition in which that muscle no longer lies upon the
angle of the scapula, is not a dislocation, but a paralysis.
Most of these accidents are associated with chronic joint-
disease or with fracture, but displacement may exist as a
solitary injury. Dislocation of the long head of the biceps
may occur tolerably early in the progress of rheumatoid
arthritis of the shoulder-joint, and the displaced tendon may
be absorbed.

Symptoms. — After dislocations of a tendon the muscle
of the tendon can still contract, but it acts at a disadvan-
tage ; thus the corresponding joint exhibits partial loss of
function. The displaced tendon can be felt, and a hollow
exists where it normally resides.

When the muscle contracts the tendon is felt to slip from
its groove. When the tendon of the biceps is dislocated the
head of the bone passes forward (so-called subluxation of
the humerus).

Treatment. — In tendon-dislocation reduction is easy, but
the displacement is apt to recur because of laceration of the
sheath. The treatment usually advised is to reduce the ten-
don by relaxation of the limb and manipulation of the tendon.

5 1 0 MODERN SURGER Y.

Place upon a splint, so that the muscle belonging to the ten-
don is relaxed, and apply pressure over the point of injury.
This treatment usually fails, and if the tendon does not be-
come anchored firmly in four weeks we should operate. In
some tendons it is enough to incise, freshen the edges of the
torn sheath, and sew up with kangaroo-tendon or chronuc
catgut. In a tendon lying in a long groove, make a halter
for the tendon by incising the periosteum and suturing it
over the tendon.* Passive movements are begun at the end
of the first week. Even if the tendon will not remain re-
duced, a useful joint will be obtained. Wood of New York
advised in obstinate cases tenotomy and immobilization.

Wotinds of Tendons. — Subcutaneous wounds of ten-
dons are usually inflicted by the surgeon, and they heal well.
Open wounds require rigid antisepsis and the suturing of the
tendon. In wounds of the wrist especially always suture the
tendons (Fig. 149), and be sure to bring the proper ends into
apposition.

Rupture of Tendons. — A violent muscular effort may
rupture a tendon, and a snap may often be heard. The symp-
toms are sudden pain and loss of power, fulness of the asso-
ciated muscle from retraction, and absolute inability to bring
the tendon into action. A gap may often be felt in the tendoa

Treatment. — The best procedure in treating rupture of a
tendon is incision and tendon-suture. Some surgeons relax
the parts and apply splints.

Thecitis or tenosynovitis is inflammation of the sheath
of a tendon.

Acute thecitis may arise from a contusion, from a
wound, from repeated over-action in working, from rheu-
matism, from gonorrhea, from influenza, from the continued
fevers, or from syphilis. In early syphilis certain tendon
sheaths may rapidly develop effusion because of hyperemia
of the sheaths (Taylor).

Symptoms. — In non-s2ippuratk*c cases of thecitis the
symptoms are pain, swelling, tenderness, and moist crep-
itus along the tendon-sheath, due to inflammatory rough-
ening. The crepitus disappears as the swelling increases,
but it reappears as the swelling diminishes. In suppurative
cases the symptoms are great swelling, pulsatile pain, dusky
discoloration, inflammation spreading up the tendon-sheaths,
and the constitutional symptoms of sepsis.

Treatment. — In treating non-suppurative thecitis, employ

* Walsham's case of dislocation of peroneus longus, Brit. Med, Jour, ^ Nov. 2,

1895.

DISEASES AND INJURIES OF MUSCLES, ETC. 5II

splints and apply locally iodin, blue ointment, or ichthyol
Treat any causative constitutional state. In the suppurative
form make free incisions, irrigate, and drain.

Palmar Abscess. — ^A thecal abscess about the flexor
tendons of the fingers travels rapidly upward and is apt to
produce a palmar abscess. A thecal abscess of either the in-
dex ring or middle finger is usually arrested at the lower end
of the palm, but suppurative thecitis of the thumb or the little
finger diffuses pus over a large surface of the palm and also
up the arm. Palmar abscess is a most serious affection.
TThe pus may dissect up all the structures of the palm, may
reach the dorsum, or may pass beneath the anterior annular
ligament into the connective-tissue planes of the forearm.

Treatment. — ^A palmar abscess demands free incision and
drainage at the earliest possible moment. The incision is
made in the line of the metacarpal bone and, if possible,
below the palmar arches. A line transverse with the web
of the thumb is below the palmar arches. In an incision
above this line, try not to cut either arch ; but if one be cut,
at once take means to arrest the hemorrhage (page 263).

Chronic thecitis may follow an acute thecitis, but may
be due to injury, to rheumatism, to gummatous infiltration, to
rheumatoid arthritis, or to a tubercular inflammation of a
tendon-sheath. In tubercular thecitis the swelling is firm or
doughy when due to granulation-tissue, but is fluctuating
when due to fluid. Grating is marked. The tendon-sheath
roay contain numerous small bodies which are either free or
^ attached (rice, riziform, or melon-seed bodies). Tubercle
bacilli are present in the fluid or in the granulation-tissue.
Chronic thecitis is commonest in the tendons of the fingers,
^"5 ^nkle, and the knee ; it may spread to a joint, or it may
?"^ from a tubercular joint. This condition causes very
«ttle pain. In ordinary non-tubercular thecitis the part is
^^k. tender, painful, and stiff, crepitates on motion, and is
swollen.

Treatment. — Tubercular cases are treated as follows : in
^cs in which there is fluid effusion make a small incision,
^^h out with iodoform emulsion, and close the w^ound. In
^^^^ in which there are rice-bodies, open the sheath, evacuate
y^ contents, scrape the walls thoroughly, inject with iodo-
^"^ emulsion, and close the wound. (If the annular liga-
'^^ntis divided, stitch it together; Fig. 152). In cases with
^^^nsive formation of embryonic tissue apply an Esmarch
^^dage, make a large incision, and remove all infected tis-
^^ from the sheath, around the sheath, and from the ten-

5 1 2 MODERN SURGER K

don. In an ordinary traumatic case employ hot and cold
douches, massage, and passive movements, strapping of the
part, inunctions of ichthyol, and the hot-air bath. If
effusion is persistent or rice-bodies exist, make an indsion
and scrape out the tendon-sheath. In rheumatic cases give
anti-rheumatic remedies and employ the hot-air bath. In
syphiHtic cases administer mercury and iodid of potassium.

Gang^lia. — In connection with tendon-sheaths simple
ganglia may develop. They are small, tense, round swell-
ings, which are firm, grow progressively though slowly, are
painless when uninflamed, and contain a fluid of the appear-
ance and consistence of glycerin jelly (Bowlby). These gan-
glia are commonest upon the dorsum of the wrist, and Qiey
occur especially in those who constantly use the wrist-mus-
cles. Paget states that a simple ganglion is due to cystic
degeneration of a synovial fringe inside a tendon-sheath, and
that the fluid of the ganglion does not communicate with the
fluid of the tendon-sheath. Other pathologists believe a sim-
ple ganglion to be a hernia of synovial membrane through a
rent in a tendon-sheath, all communication between the her-
niated part and the tendon-sheath being soon obliterated
Compound ganglion is an old name for tubercular thedtis.

Treatment. — Ganglia are treated by aseptic puncture with
a tenotome, evacuation, scarification of the walls, antiseptic
dressing, and pressure. An old-time method of treatment
was subcutaneous rupture brought about by striking with a
heavy book. Duplay treats a ganglion by injecting a few
drops of iodin through a hypodermatic needle. The cyst is
not evacuated before injection. The parts are dressed anti-
scptically, and cure is obtained in one week. Recurrent
ganglia, very large ganglia, and ganglia with very thick
contents should be dissected out.

Felon, or whitlow, is a violent inflammation of a finger
or a toe which leads to rapid suppuration and sometimes to
gangrene. As a rule, an injury precedes the whitlow, an
abrasion of the surface which admits pus organisms or a
contusion which creates a point of least resistance. The
commonest seat of a felon is the last digit of the finger or
thumb. An abrasion of the surface at this point absorbs pus
organisms and the superficial lymphatics carry them directly
inward, lodging them, it may be, in the subcutaneous tissues,
or it may be beneath the periosteum.

Felons are very rare in infants, but may occur in children.
Women arc more liable to them than are men. Several
fingers may be attacked at once or successively in persons

DISEASES AND INJURIES OF MUSCLES, ETC, 513

of dilapidated constitution. In certain cases of neuritis
painless suppuration may arise.

There are two forms of felons, the superficial and the deep.

Superficial felon, or paronychia, is a cellulitis starting at
the end or side of the digit, and involving the parts around
and below the nail. The pus organisms obtain entrance by
means of an abrasion, a puncture, or an ulcerated " step-
mother." The pain is throbbing and violent ; is increased by
motion, pressure, or a dependent position ; the skin is dusky
red, but the swelling is slight. In about forty-eight hours
pus forms in the superficial parts, the epidermis being lifted
into pustules or blebs, and pus may also form under the nail.
A portion of the nail, or the entire nail, may be lost.

Deep felon, or bone-felon, involves most of the structures
of the finger (periosteum, bone, tendon, tendon-sheath, and
cellular tissue), and may destroy the digit or the finger. It
arises in the same manner as paronychia, but the organisms
are lodged in the deeper parts. The pain is agonizing, en-
tirely preventing sleep, pulsatile in character, associated with
excruciating tenderness, greatly aggravated by motion or a
dependent position, and often extending up the hand and
forearm. The skin is red and edematous, and the part is
enormously swollen. Pus forms quickly; diffuse cellulitis
may arise ; thecal suppuration may occur ; sloughing of the
tendon and subcutaneous tissue may take place ; necrosis of
one or more bones may ensue, and in some cases gangrene
of the finger follows.

In deep whitlow lymphangitis of the forearm and arm is not
unusual, adenitis of the axillary glands is common, and almost
always there is fever. In superficial felon constitutional
symptoms are slight or absent, and lymphangitis and
adenitis arise in a minority of cases.

Treatment. — A superficial felon demands instant incision
in all cases, and the parts are irrigated and dressed with
hot antiseptic fomentations. A bone-felon should be incised
at once to the bone alongside the tendon. Do not wait
for pus to form, but allay tension and prevent pus-formation
by early incision. Do not waste time with poultices : to
wait means agonizing pain, sleepless nights, constitutional
involvement, and perhaps sloughing of tendons or death
of the bone. Incision and drainage constitute the treatment,
followed by irrigation, antiseptic fomentations, and splinting
of the extremity. If the patient cannot sleep, give morphin.
See that the bowels are moved once a day. Give quinin,
iron, and milk punch. Opening a felon is exquisitely pain-
33

5 1 4 MODERN SURGER K

ful ; hence ether should be given to the first stage, nitrons
oxid should be administered, or the superficial parts should
be frozen by a spray of chlorid of ethyl.

Bursitis is inflammation of a bursa. Acute bursitis
arises from strain or from traumatism. The symptomB of
acute bursitis are pain, limited swelling, moist crepitus, fluct-
uation, and discoloration in the anatomical position of a
bursa. Bursitis of the retrocalcaneal bursa (Albert's disease)
is a painful affection which is often overlooked. Walking
causes great pain in the heel. Raising up on the toes is
excessively painful. It is usually associated with flat foot
In these cases osteophytes often form within the bursa.
Bursitis of the gluteal bursae produces symptoms resem-
bling those of incipient coxalgia. But in bursitis the symp-
toms do not remit as in hip disease. There is moderate pain
back of the leg and knee which disappears when the patient
is at rest ; there is marked limp, limitation of motion, and an
area of deep fluctuation in the buttock (Brackett).

It is difficult to separate bursitis of any deep bursa
from synovitis; indeed, the joint is apt to become sec-
ondarily affected. This difficulty is especially vexatious in
distinguishing between joint-injury and injury of the bursa
beneath the deltoid. Suppuration may take place. Direct
force may rupture a bursa. When this accident happens
there arc pain, marked swelling, a large area of moist crepitus,
and later extensive discoloration from blood. Chronu bur-
sitis may follow acute bursitis, or the disease may be chronic
from the start. Its symptom is swelling with little or no pain
unless acute inflammation arises. Chronic bursitis of the sub-
hyoid bursa is known as Boyer's cyst.

Treatment. — Acute bursitis is treated at first by rest and
pressure and with lead-water and laudanum : later with
iodin, blue ointment, or ichthyol. If the swelling persists,
aspirate. If pus forms, incise, swab out the sac with pure
carbolic acid, and pack it with iodoform gauze. A chronic
bursitis may get well from the use of pressure, as the appli-
cation of blue ointment, with treatment of any causative
diathesis ; but most cases require incision and packing. A
ruptured bursa is treated as an acute bursitis. Some cases
of retrocalcaneal bursitis get well from rest, but others
demand incision and drainage. If osteophytic formation
takes place in Albert's Disease remove the bony stalactites
with a rongeur forceps or a gouge.

Housemaid's knee is thickening and enlargement of the
prepatellar bursa, due to intermittent pressure. In eflusion

DISEASES AND INJURIES OF MUSCLES, ETC. 515

3 the knee-joint the fluid is behind the patella and the
le floats up; in housemaid's knee the fluid is above

bone and the osseous surface can be felt beneath it.
[iners* elbow," which is a condition similar to housemaid's
ie, aflfects the olecranon bursa. " Weavers' bottom " is
argement of the bursa over the tuberosity of the ischium.
3ursa which is simply thickened and enlarged rarely gives
\ to annoyance ; but when it inflames, as it is apt to do, it
ises the ordinary symptoms of bursitis,
treatment. — Housemaid's knee is treated by incision and
:king with iodoform gauze. In enlargement of the bursa
leath the ligamentum patellae, if rest and blistering fail to
e, aspirate or incise. In enlargement of the bursa below

tendon of the semimembranosus and also in " weavers'
torn " incise and pack.

Btmion. — A bunion is a bursa due to pressure, and it is
St commonly found above the metatarsophalangeal articu-
on of the great toe, but is occasionally seen over the joint
another toe. When the big toe is pushed inward by ill-
ng boots a bunion forms. When a bunion is not in-
ned it may cause but little trouble, but when it is inflamed

bursa enlarges and the parts become hot, tender, and
:essively painful. Suppuration may occur and pus may
ade the joint, and the bone not unusually becomes dis-
ed.

["reatment. — In treating a bunion the patient must wear
>es that are not pointed, that have the inner borders
light, and that have rounded toes (Jacobson). For a
d case a bunion-plaster gives comfort. Sayre advises

use of a linen glove over the phalanges, which are to be
wn inward by a piece of elastic webbing one end of which
astened to the glove and the other end to
iece of strapping from the heel. A special
)aratus may be worn (Fig. 148). In many
es osteotomy of the first phalanx or of the
t metatarsal bone is required; in some
es excision of the joint is necessary ; in
ers amputation must be performed. When

bursa is not inflamed, but only thickened,
Iters should be employed over it, or there y^^ ^ ^ _g. ,^
>uld be applied tincture of iodin, ichthyol, apparatus for bun-
mercurial ointment. When the bursa in- '°"*
nes, lead-water and laudanum is applied, and intermittent
it by foot-baths gives relief Suppuration demands im-
diate incision and antiseptic dressing. If an ulcerated

5 1 6 MODERN SURGER Y,

bunion does not heal by antiseptic dressing, stimulate it with
silver and dress it with unguent, hydrarg. nitrat. (i part to 7
of cosmolin). Jacobson recommends skin-grafting for some
cases.

Operations upon Muscles and Tendons.

Tenotomy is the cutting of a tendon. It may be oftn
or subaitaneouSy the open operation being preferred in dan-
gerous regions.

Division of the Stemo-cleido-mastoid Mnsde for
Wry-neck. — Subcutaneous tenotomy has been abandoned
It is not only more unsafe than the open operation, but it
never completely divides all of the thickness of the con-
tracted band.

The instruments required consist of a scalpel, dissecting-
forceps, hemostatic forceps, scissors, needles, ligatures, etc
The patient is placed recumbent, the chin being drawn more
toward the opposite side.

A transverse incision is made over the muscle about one-
fourth of an inch above the clavicle. The superficial parts
are divided, the muscle is exposed and sectioned, bleeding
is arrested, and the skin is suturedJ Avoid the anterior
jugular vein, which is underneath the muscle, and also the
external jugular, which is close to the outer edge of the
muscle. Mikulicz advocates the removal of almost the
entire muscle, leaving, however, the upper and posterior
portion where the spinal accessory nerve passes. After
operation for wry-neck support the head with sand bags
until healing occurs, and then inaugurate motions active and
passive.

Subcutaneous Tenotomy of the Tendo Achillis.—

This operation is performed for club-foot, in which the heel
is raised. The tendon is cut about one inch above its point
of insertion. The instrument used for the first puncture is a
sharp tenotome. The patient lies upon his back " ^ith his
body rolled a little toward the affected side " (Treves), the
foot being placed upon its outer side on a sand pillow. The
surgeon stands to the outside. The tendon is rendered
moderately rigid, and the sharp tenotome, with its blade
turned upward, is inserted along the anterior border of the
tendon until the surgeon's finger feels the knife approaching
the outer side. A blunt-pointed tenotome is inserted in place
of the sharp instrument. The tendon is drawn into rigid-
ity, and the surgeon turns the blade of his knife toward the

DISEASES AND INJURIES OF MUSCLES, ETC. 517

tendon, places his finger over the skin, and saws toward his
finger. The tendon gives way with a snap. Treves states
that a beginner is apt not to push the knife far enough
toward the outside, or he may in the first puncture push
the knife through the tendon ; in either case the tendon is
not completely cut. The little wound, which is covered
with a bit of gauze, will be entirely closed in forty-eight
hours. In club-foot cases after tenotomy some surgeons
at once correct the deformity and immobilize the limb in
plaster; some partially correct the deformity and apply
plaster for one week, at which time they remove the plaster,
correct the deformity further, reapply the plaster, and so on ;
other surgeons do not attempt correction of the deformity'
until the cut tendon has begun to unite, when they gradually
stretch the new material.

Subcutaneous Tenotomy of the Tendon of the

Tibialis Anticus. — ^The tendon is divided about one and
a half inches above its point of insertion. It can be made
tense by extending and abducting the foot. The sharp-
pointed tenotome is entered upon the outside of the tendon,
and is passed well around it. The blunt-pointed tenotome
is used to cut the tense tendon.

Subcutaneous Tenotomy of the Tendons of the
Feroneus lA>ngus and Brevis. — These two tendons are
cut together back of the external malleolus, and one and a
half inches above the tip of the malleolus, so as to avoid the
synovial sheath (Treves). The patient lies upon the sound
side, the outer aspect of the deformed foot being upward and
the inner aspect of the ankle of the deformed side resting
upon a sand pillow. The instrument is introduced close to
the fibula, and is carried around the loose tendons. A blunt-
pointed tenotome is now introduced, its edge is turned
toward the tendons, and these structures are cut as they
are made tense.

Subcutaneous Tenotomy of the Tendon of the

Tibialis Posticus. — This tendon is sectioned above the
point where its synovial sheath begins ; that is, above the
internal annular ligament (Treves). The tendon is made
tense and the knife is entered above the base of the inner
malleolus. The knife is entered just back of the inner edge
of the tibia, and is carried around the muscle while it is kept
close to the bone. The tendon is sectioned with a blunt
knife.

Subcutaneous Pasciotomy of Plantar Fascia. —

The contracted bands are discovered by motions which

5l8 MODERN SURGERY.

render them tense, and they are divided just in front of the
attachment to the os calcis. The sharp knife passes between
the skin and fascia at the inner side of the sole of the foot
The fascia is cut from without inward by the blunt-pointed
tenotome. It is usually necessary to section the feisda at
more than one point.

Tendon-sutttre and Tendon-lengthenlns. — The in-
struments required in these operations are an Esmarch appa-
ratus ; curved needles and needle-holder; chromidzcd gut,
kangaroo-tendon, or silk for an ordinary case, silver wire for
a suppurating wound. In performing tendon-suture make
the part aseptic and bloodless. It is wise to apply a rubber
bandage on the proximal side, the bandage being applied
centrifugally, forcing the proximal end of the tendon into
view (Haegler). If searching for the proximal end of a
flexor of the finger, flex the injured finger, and hyper-
extend the adjoining fingers (FiUget). If this expedient &ils,
enlarge the incision, or, what is better, make a large fl^ in
the skin. After finding the ends approximate them, being
sure the proper ends are brought into contact ; stitch them
together with a continuous suture or with one of the sutures
shown in Fig. 149, a, b, and c. In a suppurating wound

suture by silver wire should be tried, though it usually fails.
After suturing, remove the Esmarch apparatus, arrest bleed-
ing, close the wound and dress it antiseptically, relax the
parts, and place the limb on a splint. If, aller suturing,
there is much tension, stitch the cut tendon above the
sutures to an adjacent tendon, and apply a splint, the finger
which was injured being flexed, the others being extended
If only the distal end of the tendon can be found, graft it
upon the nearest tendon with a like anatomical course and
function. When a tendon has been sutured begin gentle

ORTHOPEDIC SURGERY, 519

massage in two weeks. Positive passive motion is begun
in three or four weeks. In old inju-
ries, when the ends cannot be brought
into apposition, lengthen one end or
both ends, either by the method of
Anderson (Fig. 1 50) or by the method
of Czemy (Fig. 151). Poncet makes

Fig. 15a. — Method of suturing
the annular ligament of the
Fig. S5X. — Czemy 's method of tendon-lengthening. wrist.

several zigzag incisions on each side of the tendon, and
when the tendon is pulled upon it elongates decidedly.
These methods of lengthening may be used in cases of de-
formity from a contracted tendon. If the tendon cannot be
lengthened sufficiently, make a bridge of -catgut from one
end of it to the other, or graft in another tendon from the
same person or from one of the lower animals.

The annular ligament is sutured as shown in Fig. 152.

In some cases in which a muscle has been paralyzed,
Nicoladoni and others have divided the tendon of the para-
lyzed muscle and have united its distal end with the tendon
of a normal muscle, the normal tendon being split to re-
ceive it.

XXI. ORTHOPEDIC SURGERY.

This branch of surgery formerly dealt only with the treat-
ment of deformities by means of mechanical appliances, but
of recent years its domain has been enlarged to include the
treatment, surgical and mechanical, of deformities, contract-
ures, and many joint-diseases.

Torticollis (wry-neck) is a condition in which contrac-
tion of certain of the neck-muscles causes an alteration in
the position of the head. The disease is one-sided; the
stemo-cleido-mastoid is the muscle chiefly involved, though
the trapezius, splenius, and other muscles sometimes suffer.
Acute torticollis, which is rare, results from cold or from
injury (see Myalgia). Chronic torticollis may be congenital,
it may be due to nerve-irritation, or it may be due to an
assumed attitude because of eye-defect. Chronic torticollis
may be intermittent, but is usually persistent. The muscle
stands out in bold outline, the head is turned to the oppo-
site side, the ear of the disordered side is turned toward the
shoulder, and the chin is thrown forward. There is no pain.
Spinal curvature may arise. The head may often be restored

5 20 MODERN SURGER Y.

to its normal position by passive movement or by voluntary
effort, but it at once returns to its habitual position. The
corresponding side of the face atrophies. Mikulicz asserts
that torticollis is a chronic fibrous myositis, due often to
compression during labor. He further says that the lesion
known as hematoma of the stemomastoid, which occasionally
follows labor, is not hematoma, but thickening due to myositis.

Ssnnptoms. — Congenital wry-neck is due to central ner-
vous disease, to spinal deformity, or to injury during birth,
and in this form the stemomastoid is shortened, hardened,
and atrophied. It may not be noticed for some years be-
cause of the short neck of infancy, and it is associated \iiith
asymmetrical development of the face. It is almost inva-
riably upon the right side. Spasmodic wry-neck may present
tonic spasm only, intermittent spasm alone, or both may
appear alternately. It is a disease especially of adults ; in
women it is often linked with hysteria. The exciting cause
may be a cold, a blow, or a mental storm ; the predisposing
cause is the neurotic temperament In some rare cases
bilateral spasm occurs, the head being pulled backward and
the face being turned upward. Clonic spasms may come
on unannounced, or they may be preceded by pain and
stiffness; the head can be held still for a moment only;
there is sometimes pain, always fatigue, but during sleep the
contractions cease. The attack will probably pass away, but
will almost certainly recur.

Treatment. — Congenital wr>'-neck is treated by myo-
tenotomy (through an open wound) and the use of proper
braces and supports. The old subcutaneous myotenotomy
should be abandoned, as aseptic incision enables the surgeon
to see and to feci all the contracted bands of fascia, muscle,
and tendon, and to avoid vital structures (page 516). In
spasmodic wr>'-neck treat the neurotic temperament ; in per-
sistent cases stretch, or divide and exsect a part of the
spinal accessory ner\'e. To reach this nerve make an in-
cision along the posterior edge of the sternocleidomastoid,
find the nerve as it emerges from under the middle of the
muscle, and retract the muscle at this point (Keen). For
the treatment of rheumatic wry-neck see Myalgia (page 504).

Dupuytren's contraction is a contraction of the palmar
fascia, of its digital prolongations, and of the fibers joining
the fascia and skin. Fixed contraction of one or more
fingers occurs. The ring-finger and the little finger most
often suffer. The condition may be symmetrical. The dis-
ease arises oftenest in men beyond middle age. The cause

ORTHOPEDIC SURGERY.

521

of this disease is unknown : some refer it to gout or rheu-
matism, others to traumatism, reflex irritation, or neuritis.

Symptoma, — Dupuytren's contraction is indicated by a
small hard lump or crease which appears over the palmar
surface of the metacarpophalangeal joint. This nodule
grows and the corresponding finger is pulled down. In
some cases the tip of the finger is forced against the palm.
The skin becomes dimpled or puckered.

Treatment. — In treating Dupuytren's contraction subcu-
taneous multiple incisions may be made, the tense fascia and
the fasciocutaneous fibers being cut. The finger is straight-
ened and is placed upon a straight splint, which is worn
continuously for a week or ten days and is worn at night for
at least a month. Keen divides the skin by a V-shaped
cut, the base of the V being downward, lifts up the flap,
and dissects out the contracted tissue.

Syndactrllsm (webbed fingers) is always congenital,
and may persist through several generations. Simple incision
of the web is useless ; the operation to be performed is that
of Agnew or of Diday (Figs. 153, 154).

In Agnew's operation a flap of skin from the dorsum is
inserted between the fingers.

In Diday's operation a flap is taken from the dorsal sur-
&ce and another flap is raised from the palmar surface, and
each flap is sutured to the finger from which it springs.

Polydactylisin (snpemtimeraiy digits) is always con-
genital, is often hereditary, and is usually .symmetrical.
There may be an incomplete digit, or there may be an entire
and well-developed finger or toe with a metacarpal or meta-
tarsal bone. The connection to the metatarsus or metacar-
pus may be by a fibrous pedicle only. If the digit is com-
plete, with a metacarpal bone, no operation is required ; if it
is incomplete or is ill-developed, it should be removed.

Trigger-finger or Jerk-finger. — The patient can close
the fingers, but on trying to open them one finger remains

:2Z MODERN SURGERY,

.lOSccL It can be opened by grasping it with the other
:dnd, but flies open with a snap Hke an opening knife (Abbe).
The condition is due to enlargement of the flexor tendon, or
- j» contraction of the groove in the transverse ligament in
::ie palm (Tubby). This condition may be due to ganglion,
jiichondroma, or tenosynovitis.

Treatment. — If a trauma, a ganglion, or inflammation exists,
:reac by ordinary means. If there is no obvious cause, put a
joinpress over the tunnel in the ligament and apply a splint
Mallet-fing^er* — This is called also drop-flnger and nipt-
-ire «.>f the extensor tendon. It is due to a blow in the direc-
ntui oi flexion when the finger is extended. It is supposed to
:>€ ^iue partly to stretching and partly to rupture of the ex-
tensor tendon at the point at which it is the posterior liga-
:iient of the distal interphalangeal joint Abbe has sho^n
riiac baseball players are liable to a condition which is the
reverse of this, in which the last phalanx is dislocated back-
.%ard. Drop-finger is treated by incision and suture of the
tendon to the periosteum (Abbe).

Genu Yalgimi (knock-knee) results from an unnatural
growth of the internal condyle, causing the shaft of the
•ciiiur to curve inward and the internal lateral ligament of
tile knee-joint to stretch, the knees coming close together
ind the feet being widely separated. This deformity is usu-
ul\ noted when the child begins to walk, but it may not
i^»pcar until puberty or even long after. Knock-knee may
'.ii>c from rickets, from an occupation demanding prolonged
-;.aiKiing. or from flat-foot. It may be noted in one knee or
\ x^ch knees.

rt>»atment. — Mild rachitic cases of knock-knee may re-

!uiiM ill slight deformity, or may get well from improvement

1 :iK' i^cneral health. In ordinary cases simply treat the

c^ccx condition. The patient is forbidden to stand or to

*.i.v. uk! the limb, after being put as straight as it can be,

^ *\v\i oi) an external splint and a pad is put over the

v.x>nd>Ic. Later in the case plaster-of- Paris is used.

surgeons prefer to immobilize while the leg is flexed

»giK angle with the thigh. In a severe case the sur-

vv '* ^'Ait inmiobilize afl:er forcibly straightening (causing an

v^f t»\s^.Ml se^xiration) or afl:er the performance of osteotomy

-^ ."" , Osteotomy is preferable to fracture by a mechan-

.(.y^MtK'v ( osteoclasis).
\^^a vamm (bow-legs) is the opposite of knock-knee.

, X, \ *?v>:h legs are bowed out, the knees being m'dely

svxv *ivv\i. the tibiae and femurs, as a rule, being curved, and

.1 V I

V •

ORTHOPEDIC SURGERY.

523

:t being turned in. This disease is due to rickets, the

: of the body producing the deformity in early life.

der people incurable

!gs may arise from ar-

deformans.

itment. — Some mild

3f genu varum recover

iult of improvement of

ralth. Ordinary cases

ated by braces, by plas-

Paris bandages, and

ention to the general
When the bones

hardened osteotomy fh-., is;,— Tiiip« fic, 1=6.— t»i'f«

cated.

b-hand. — A congenital deformity in which the hand

;s from the normal relation to the forearm. It is usu-

sociated with other deformities. In some cases the
and possibly some of the carpal bones are absent.

itment. — By massage and passive motion, by immob-

n, by tenotomy or osteotomy.

Ipes (club-foot) is a permanent deviation of the foot,
are several forms. Talipes cqtdniis {Fig. 155) is a con-
extension ; talipes calcaneus (Fig. 1 56) is a confirmed

1 ; talipes varus is a confirmed adduction and inversion ;

Hpesvalgus is a confirmed abduction and evcrsion. Two

Be forms may be combined, as in talipes equino-varus
57). talipes equino-valgus, talipes calcaneo-varus, and
calcaneo-valgus. The causes of talipes are con-

I or acquired. The congenital form is due to persist-

f the fetal form of the foot Acquired cases may arise

ifantile paralysis,
spastic contrac-
from cicatrices,

raumatisms, from
of bony growth

ng upon bone

nation, or from

!cal contractures.

pes equinus is
congenital. In

ondition the pa- ''"'■ ^" ~^'"'^\psT^^^ *'^"' ''■""*°"*

valks upon the

nd cannot bring the heel to the ground.

pes Calcaneus. — The patient walks upon the heel and

524 MODERN SURGERY.

cannot bring the toes to the ground. The true form is
seen in congenital cases, the flexors of the foot being short-
ened, and the tendo Achillis being lengthened.

Talipes varus is rarely met with without equinus. In this
condition the patient walks on the outer edge of the foot

Talipes valgus is met with in flat-foot. The patient walks
on the inner edge of the foot.

Talipes eqidnO'Varus. — The heel is raised and the patient
walks upon the outer edge of the foot This is the usual
congenital form.

Talipes equino-valgus is very rarely congenital. The heel is
raised and the patient walks upon the inner side of the foot

Talipes ealcaneo-varus is a combination of calcaneus and
varus.

Talipes ealeaneo-valgtis is a combination of calcaneus and
valgus.

Treatment. — In congenital cases the condition is usually
manifest on both sides, and is nearly always talipes equino-
varus. Congenital club-foot should be treated in infancy, and
when a restoration to position can be effected by the hands
of the surgeon, is treated by plaster-of-Paris bandages. If a
child has begun to walk, it may still be possible to correct the
deformity eventually by manipulations, by plaster-of-Paris
bandages, or by club-foot shoes, but mo.st cases require tenot-
omy of the tendo Achillis before the application of the shoe
or the plaster. The club-foot shoe may do good service, but in
many instances it is painful and is not so efficient as plaster.
In severe cases, before applying the plaster, the p>atient is
given ether ; the surgeon cuts the tendo Achillis, the ten-
dons of the anterior and posterior tibial muscles, and the
plantar f^iscia, and forcibly corrects the deformity. In old
cases with alteration in the shape of the bones, cuneiform
osteotomy, or the removal of the cuboid or other tarsal
bones, is indicated. In these cases Phelps adx'ises a trans-
verse incision through all the plantar soft p>arts. In talipes
due to infantile paralysis the operative treatment is the same,
but we should not immobilize in plaster, but rather in some
apparatus which can easily be removed to permit the use of
massage and electricity. In some cases of talipes calcaneus
the surgeon may be forced to shorten the tendo Achillis.
In paralytic cases Nicoladoni's operation is occasionally
employed. This consists in dividing the tendon of the
paralyzed muscle and attaching its distal end to the adjacent
tendon of a healthy muscle. (For full consideration, see a
work on Orthopedic Surgery.)

ORTHOPEDIC SURGERY. $25

Fes planus (flat-foot) is the loss of the arch of the foot
due to muscular paralysis or Hgamentous weakness, to pro-
longed standing, or to trauma. Many cases are due to
rickets. Spurious flat-foot or inflammatory flat-foot occurs
in Pott's fracture, and in inflammation of the ankle-joint or
the tendon of the peroneus longus. Static flat-foot is due to
" lack of balance between the weight of the body and the
strength of the foot" (Moore). All children are born with
flat-feet, but the arch usually begins to form soon after birth,
but in some cases it never forms. This condition is pro-
ductive of much pain on standing. Flat-foot
can at once be recognized by wetting the
sole of the patient's foot with a colored
fluid and causing him to step flrmly upon a
piece of paper (Fig. 1 58, A, b). It can also
be detected by measurement to find the mid-
dle of the foot. In flat-foot the extremity is
lengthened. Flat-foot causes much pain
upon walking ; in fact, the individual may _

be completely crippled. Pain is quickly noni'ai'^fooiruie "{a*
relieved upon sitting down. Walking upon (J')''(Aii«'n?." '" *
the toes is not painful.

Treatment. — In static flat-foot exercise is practised sev-
eral hours a day to increase the arch. Rising upon the toes
again and again is valuable. After exercise the patient rests
for a time, sitting tailor-fashion with legs crossed under him.
Massage is valuable. A shoe should be made containing a
jMCce of steel so arranged as to raise the arch of the foot.
The patient's general health must also be looked to. In
very severe cases operation may be required. Gleich
shortens the foot and raises the arch by sawing through the
OS calcis and fastening the posterior part at a lower level.
Trendelenburg advises supramalleolar osteotomy. This
operation permits us to adduct the foot and put it in this
position in plaster. In paralytic flat-foot, which arises from
infantile paralysis, employ exercise, electricity, and massage.

Fes cavtis (hollow-foot) is an increase in the arch of
the foot, due to contraction of the peroneus longus muscle
or to paralysis of the muscles of the calf It is the opposite
of flat-foot.

Treatment. — A shoe is worn containing a plate of steel in
the sole, and pressure is applied over the instep. Tenotomy,
cutting of the plantar fascia, or excision of bone may be
required.

Hallux valgtlS, or Tarns, a displacement of the great

5 26 MODERN SURG EH K

toe outward or inward, may occur in the young, but it is
most frequent in old men. It arises oftener from wearing
narrow shoes, but may be due to gout, or to rheumatic gout
In hallux valgus a bunion is apt to form over the metatarso-
phalangeal joint.

Treatment. — An arrangement may be worn to straighten
the toe and to protect the bunion (Fig. 148), osteotomy may

be performed upon the metatarsal bone, the
joint may be excised, or amputation may be
required.

Hammer-toe (Fig. 1 59) is the flexion of
one or more toes at the first interphalangeal
'^mc?^t^c.*"' joint. Shattuck shows that this condition is

due to contraction of " the plantar fibers of
the lateral ligaments of the joint." * This disease usually
begins in youth. A bunion is apt to form, and the joint may
be dislocated.

The treatment is excision of the joint or amputation.
Terrier's plan consists in making a dorsal flap, removing a
bursa if one is found, dividing the extensor tendon, opening
the articulation, removing each articular surface with cutting-
forceps, suturing the soft parts, and applying a plantar splint
for two weeks.^

Metatarsalgia (Morton's Disease). — A painful con-
dition of the foot, due to jamming of a ner\'e between the
heads of the fourth and fifth metatarsal bones. It is usually
associated with flat-foot.

Treatment. — Mild cases may be cured occasionally by
wearing well-fitting shoes and employing massage. Some
cases require a brace. Severe cases demand resection of the
fourth metatarsophalangeal joint, or amputation of the fourth
toe, and with it the head of the fourth metatarsal bone.

Coxa vara is bending of the neck of the femur, the hip-
joint bein^ perfectly healthy, and the condition, as a rule,
being unilateral. This condition was described by Miillerin
1889. The disease arises, as a rule, between the thirteenth
and twentieth years, and the commonly accepted view has
been that the deformity is rachitic, but Kredel has recently
reported two congenital cases.^ The patient develops a limp.
and <:^rows tired after slight exertion, but there is no swelling
or tenderness, and little or no pain. Shortening after a time
becomes apparent, and the trochanter can be detected above
Nelaton's line. The extremity is adducted.

^ American Text -book of Sunken'. ' Revue de Chirurgie^ J'lly* '895-

» Centralbl. f. ' Chit:, Oct. 17, 1896.

DISEASES AND INJURIES OF NERVES. $2/

Treatment. — As long as bending is progressing employ
rest When the bone hardens perform osteotomy below the
trochanters.

Plail-joints. — ^After an attack of infantile paralysis in
which the entire lower extremity of each side was involved,
the limbs are limp and swing flail-like when the extremity is
made to move, and the joints are much relaxed. In such
cases the psoas and iliacus muscles are never completely
paralyzed, and the aim of the surgeon is to utilize these
muscles in enabling the patient to walk. In many cases the
application of apparatus is sufficient. In others ankylosis is
established by operation in the ankles and knees, so as to
give the psoas and iliacus control of the legs.

XXII. DISEASES AND INJURIES OP NERVES.

I. Diseases of Nerves.

NetiritiSi or inflammation of a nerve, may be limited
or be widely distributed (multiple neuritis). The first-men-
tioned form will here be considered. The causes of neuritis
are traumatism, wounds, over-action of muscles, gout, rheu-
matism, syphilis, fevers, and alcoholism.

Symptoms. — ^The symptoms of neuritis are as follows:
excessive pain, usually intermittent, in the area of nerve-
distribution. The pain is worse at night, is aggravated by
motion and pressure, and occasionally diffuses to adjacent
nerve-areas or awakens sympathetic pains in the opposite
side of the body. The nerve is very tender. The area of
nerve-distribution feels numb and is often swollen. Early
in the case the skin is hyperesthetic ; later it may become
anesthetic. The muscles atrophy and present the reactions
of degeneration ; that is, the muscles first cease to respond
to ra^i^-interrupted, and next to slowly-int^rrupt^d, faradic
currents ; faradic excitability diminishes, but galvanic excita-
bility increases. When, in neuritis, faradism produces no
contraction, a slowly-interrupted galvanic current which is
so weak that it would produce no movement in the healthy
muscles causes marked response in the degenerated muscles.
In health the most vigorous contraction is obtained by clos-
ing with the — pole ; in degenerated muscles the most
vigorous contraction is obtained by closing with the + pole.
When voluntary power returns galvanic excitability declines,
but power is often nearly restored before faradic excitability
becomes manifest (Buzzard).

Treatment. — The treatment of neuritis consists of rest

528 MODERN SURGERY,

upon splints, ice-bags early in the case, and hot-water bags
later. Blisters are of value in traumatic neuritis. Massage
and electricity must be used to antagonize degeneration.
Deep injections of chloroform may allay pain. Treat the
patient's general health, especially any constitutional disease
or causative diathesis. The salicylate of ammonium or
phenacetin may be given internally. In some cases nen-e-
stretching is advisable.

Netiralg^a is manifested by violent paroxysmal pain in
the trajectory of a nerve. This disease belongs chiefly to
the physician, except in very bad cases. Neuralgia of stumps
and scars belongs to the surgeon, and is due to neuromata,
or entanglement of nerve-filaments in a cicatrix Tic
douloureux and other intractable neuralgias require carefiil
removal of any cause of reflex irritation (stomach, e>'es,
uterus, nose, throat, etc.). Tic douloureux has been treated
by removal of the Gasserian ganglion (page 533); removal
of Meckel's ganglion ; ligation of the common carotid artery;
neurectomy of terminal branches (page 532); division of
motor nerves ; massive doses of strychnin (Dana) and
purgatives (Esmarch).

Treatment of Neuralgia of Stumpe. — Excise the scar;
find the bulbous end of the nerve and cut it off. Senn tells
us to section the nerve by V-shaped cuts, the apex of the V
being toward the body, and to suture the flaps together.
Scnn's method will prevent recurrence. In some cases re-
amputation is performed. In entanglement of a nerve in
a scar remove a portion of a nerve above the scar.

2. Wounds and Injuries of Nerves.

Section of Nerves (as from an incised wound). — In
nerve-section the entire peripheral portion of the nerve de*
generates and ceases structurally to be a nerve in a few
weeks, but after many months, or even after years, the nerve
again regenerates — with difficulty, if union of the ends has
not taken place, with much greater ease if the ends have
united. The proximal end only suffers in the p^ortion im-
mediately adjacent to the section ; it degenerates, but rapidly
regenerates, and a bulb or enlargement composed of fibrous
tissue and small nerve-fibers forms just above the line of
section ; this bulb adheres to the perineural tissues. Union
of a divided nerve is brought about by the projection of an
axis-cylinder from the proximal end or from each end and
the fusion of these cylinders. The nearer the two ends are to
each other the better is the chance of union.

DISEASES AND INJURIES OF NERVES. 529

Symptoms. — Pronounced changes occur in the trajectory
of a divided nerve. The muscles degenerate, atrophy and
shorten, and show the reactions of degeneration. When
union of the nerve occurs the muscles are restored to a
normal condition. If the nerve contains sensory fibers, com-
plete anesthesia (to touch, pain, and temperature) usually
follows its division ; but if a part is supplied by another nerve
as well as by the divided one, anesthesia will not be com-
plete. Trophic changes arise in the paralyzed parts. Among
these changes are muscular atrophy ; glossy skin ; cutaneous
eruptions; ulcers; dry gangrene; painless felons; falling of the
hair; brittleness, furrowing, or casting off of the nails; joint-
inflammations ; and ankylosis. Immediately after nerve-sec-
tion vasomotor paralysis comes on, and for a few days the
paralyzed part presents a temperature higher than normal.
The diagnosis as to which nerve is cut depends upon a study
of the distribution of paralysis and anesthesia.^

Treatment. — In all recent cases of nerve-section, suture
the ends. In 123 cases of primary suture, 119 were cured
in from one day to one year (Willard). In 130 cases of
secondary suture, 80 per cent, were more or less improved
(Willard). If the patient is not seen until long after the
accident, incise and apply sutures (secondary sutures); if
the nerve cannot be found, extend the incision, find the
trunk above and trace it down, and find the trunk below and
follow it up. Even after primary suture loss of function is
bound to occur for a time. After secondary suture sensation
may return in a few days, but it may not return until after a
much longer period ; in any case muscular function is not
restored for months. In partial section of a nerve the ends
should be sutured. In secondary suture it may be necessary
to perform " lengthening " in order to approximate the ends.

Presstire upon nerves may arise from callus, scars^
pressure of a dislocated bone or a tumor, or pressure from
an external body. The symptoms may be anesthetic, para-
lytic, and trophic. The treatment is as follows : remove the
cause (reduce a dislocated bone, chisel away callus, excise a
scar, etc.) ; then employ massage, douches, and electricity.

Dislocation of the Ulnar Nerve at the J^lbow. —

This condition is very rare. It may occur as a complication
of a fracture or a dislocation, or as an uncomplicated condi-
tion. It may be produced by violence or by muscular effort,
which ruptures the fascia whose function is to retain the
nerve back of the inner condyle of the humerus. In some

1 Sec Bowlby on Injuries of Nerves,
34

530 MODERN SURGERY.

cases the symptoms are slight and transitory, the nerve func-
tionating well in its new situation. As a rule, there are pain,
numbness, or anesthesia of the ulnar trajectory, some stiff-
ness of the elbow and stiffness of the little finger or ring finger.
The nerve can be felt in front of the inner condyle of the hu-
merus. In some cases neuritis follows, with trophic change

Treatment. — McCormick's Operation, — Expose the nerve
by an incision, incise the fibrous tissue back of the inner
condyle, and press the nerve into the bed prepared for it and
hold it in place by sutures of kangaroo -tendon passing
through the triceps tendon. Wharton advises suturing also
**the margin of the fascial expansion of the triceps tendon
superficial to the nerve." ^

Contusion of Nerves. — ^The symptoms of contusion of
nerves may be identical with those of section. Sensation or
motion, or both, may be lost. The case may get well in a
short time, or the nerve may degenerate as after section.

The treatment at first is rest, and later electricity, massage,
frictions, and douches.

Punctured Wotinds of Nerves. — The symptoms of
punctured wounds of nerves may be partly irritative (hyper-
esthesia, acute pain, and muscular spasm) and [>artly paralytic
(anesthesia, muscular wasting, and paralysis).

The treatment is the same as that for contusion.

3. Operations upon Nerves.

Netirorrhaphy, or Nerve-suture. — When a nerve is
completely or partially divided by accident it should be
sutured. The instruments required are an Elsmarch ap-
paratus, a scalpel, blunt hooks, dissecting-forceps, hemo-
static forceps, curved needles or sewing-needles, a needle-
holder, and catgut or kangaroo-tendon. In primary suture
render the part bloodless and aseptic. Enlarge the incision
if necessary. If the ends can readily be approximated, pass
two or three sutures through both the nerve and its sheath

and tic them (Fig. 160). If the ends can-

not be approximated, stretch each end

and then suture. Remove the Esmarch

band, arrest bleeding, suture the wound,
fk;. i6o.-Ncfvc-sutiire. drcss antiscptically, and put the part in

a relaxed position on a splint. After
union of the wound remove the splint and use massage,

* A reix)rt of fourteen cases of dislocation of the ulnar nerve at the elbow,
by H. K. Wharton, Am. Jour. Med. Sciences^ OcL, 1895.

DISEASES AND INJURIES OF NERVES. 53 1

Mictions, electricity, and the douche. The operation in some
instances fails, but in many cases succeeds. In some few
cases sensation returns in a few days, but in most cases does
not return for many weeks or months. Sensation is restored
before motor power. Secondary suture is performed upon
cases long after division of a nerve. The part is rendered
aseptic and bloodless; an incision is made; the bulbous
proximal end is easily found and loosened from its adhesions ;
the shrunken distal end is sought for and loosened up (it may
be necessary to expose the nerve below the wound and trace
its trunk upward) ; the entire bulb of the proximal end is
cut off; about one-quarter of an inch of the distal end is re-
moved (Keen) ; each end is stretched,
and the ends are approximated and
sewn together. If even stretching
does not permit of approximation,
^opt one of Bowlby's expedients
(Kg. 161), or graft a bit of nerve
from a recently amputated limb or
from a lower animal (it makes no dif- ^7plifdnIthTencb?B:SJ^ **^
fcj^nce as to whether the grafted

'^'^^e were motor, sensory, or mixed). Mayo Robson has
succeeded in grafting the spinal cord of a rabbit in the
^^dian nerve of a man. The restoration of function was
complete. Von Bergmann suggests shortening the limb by
^^cising a piece of bone. Letievant has attached the cut
^d of the peripheral portion of a divided nerve to an adja-
^^^t uncut nerve. Assaky uses the suture a distance, catgut
Posing from end to end and serving as a bridge for repara-
^e material.

Neurectasy, Neurotomy, and Neurectomy. — Neurec-

^jy, or nerve-stretching, may be applied to motor, sensory, or

^ixed nerves. A nerve can be stretched about one-twentieth

^^ its length (Vogt). Neurectasy has been employed for neu-

^\gia, neuritis, muscular spasm, hyperesthesia, anesthesia.

Panful ulcer, perforating ulcer, and the pains of locomotor

ataxia. The operation, which was once the fashion, seems to

oenefit some cases, but it is not now thought so highly of as

lornierly. The incision for neurectasy is identical with the

incision for neurectomy or neurotomy of the same nerve.

^^urotomy\ or section of a nerve, is only performed upon

small and purely sensory nerves. It is performed chiefly for

P^npheral neuralgia or for some other painful malady. It is

useless because sensation soon returns. Paget saw return of

^'^sation entirely in four weeks after division of the median

532 MODERN SURGER V.

nerve. Corning endeavors to prevent this regeneration by
inserting oil between the ends. He uses oil of theobroma
containing enough paraffin to make the melting-point l05^
The oil is melted, is injected around the nerve, and cold is
applied. The nerve is now sectioned with a canaliculated
knife, the ends are separated widely, more oil is injected, and
cold is again applied. The theory is that this oil, which is
solid at the temperature of the body, devitalizes the nen'e at
the point of section and acts as a barrier to the passage of re-
generating fibers. This method has been applied especially in
cervicobrachial neuralgia.^ Neurectomy, or excision of a por-
tion of a nerve-trunk, is only applicable to sensor>' ner\'es and
to painful affections.

Stretching of the Sciatic Nerve. — Some sui^eons
stretch the sciatic nerve by anesthetizing the patient and
holding the leg and thigh in line, strong flexion being niadc
upon the hip, the entire lower extremity being used as a
lever (Keen). This method, which has caused death, inflicts
needless damage, and the operative plan is safer and better.
The instruments required are a scalpel, hemostatic forceps,
dissecting-forceps, an Allis dissector, retractors, and a scale
with a handle and a hook. The patient lies prone, the
thighs and legs being extended. An incision four inches in
length is made a little external to the middle of the thigh,
and going at once through the deep fascia; the biceps is
found and is drawn outward; the nerve is discovered between
the retracted biceps on the outside and the semitendinosus on
the inside, resting upon the adductor magnus muscle. The
nerve, which is caught up by the finger, is first pulled do^»*n
from the spine and then up from the periphery, and finally
the hook of the scale is inserted beneath the trunk and the
nerve is stretched to the extent of forty pounds. Ven*
rarely is even a single ligature needed. The wound \s sutured
and dressed. If the incision is made at a higher level below
the gluteo-femoral crease, the sciatic nerve will be found just
by the outer border of the biceps.

Neurectomy of the Infraorbital Nerve. — ^The instru-
ments required in this operation are a scalpel, dissecting-
forceps, aneur)'sm-needle, hemostatic forceps, blunt hooks.
an Allis dissector, and metal retractors. The patient lies
upon his back, the head being a little raised by pillows. The
surgeon stands to the outside of, and faces, the patient A
curved incision one and a half inches long is made below
the lower border of the orbit. The nerve lies in a line

* Med. Rcc.y Dec. 5, 1 896.

DISEASES AND INJURIES OF NERVES. 533

dropped from the supraorbital notch to between the two
lower bicuspid teeth. The nerve is found upon the levator
labii superioris muscle, and a piece of silk is passed under
the nerve by an aneurysm-needle and firmly fastened. The
upper border of the incision is drawn upward ; the periosteum
of the floor of the orbit is elevated and held by a retractor ;
the roof of the infraorbital canal is broken through ; the nerve
is picked up far back with the blunt hook and is divided with
scissors, and the entire nerve is drawn out by making traction
upon the silk. The bleeding in the orbit is checked by press-
ure. The wound is stitched without drainage.

Neurectomy of the Supraorbital Nerve. — In this

operation shave off the eyebrow. The instruments required
and the position of the patient are as for the operation upon
the infraorbital nerve. A curved incision one inch long dis-
closes the nerve as it emerges from the supraorbital notch
or foramen at the junction of the inner and middle thirds of
the eyebrow. The nerve is pulled forward and cut off above
and below.

Neurectomy of the Inferior Dental Nerve. — The in-
struments are the same as for any other neurectomy, and in
addition a chisel, a mallet, and a rongeur forceps. Make a
curved incision around the angle of the jaw. Lift the supra-
maxillary branch of the facial nerve downward (Kocher).
Separate the masseter muscle with a periosteum-elevator and
slight touches with the knife. Chisel an opening in the center
of the ascending ramus (Velpeau's rule). This opening ex-
poses the beginning of the dental canal (Kocher). If neces-
sary, the opening may be enlarged with a rongeur. Pull the
nerve out with a hook and remove a piece from it.

Removal of the Gasserian Ganglion. — This opera-
tion is dangerous, bloody, and difficult, and is only under-
taken in very severe cases of tic douloureux, and in cases
upon which less grave procedures have failed. The operation
usually cures the pain if the patient recovers from the
actual procedure. The mortality is from 1 2 to 15 per cent.
In some cases the pain has subsequently returned. Out of
Keen's 9 cases of removal, 3 had corneal trouble, but in
not one case was the eye lost. Some atrophy is apt to be
noted in the tongue, and the eye becomes insensitive and
watery.

Operation. — ^The surgeon is provided with the instruments
for osteoplastic resection of the skull. Krause and others
employ a surgical engine. Special retractors, various hooks,
scalpels, a dry dissector, dissecting- and hemostatic forceps,

534

MODERN SURGERY.

,nd an electric forehead-light are required. Long slripsof
gauze must be ready for packing
in case of hemorrhage. The pa-
tient is placed recumbent, mth
head turned to the opposite sitk
A large osteoplastic flap is formed
in front of the ear (Fig. 162), and
is broken down. Hemorrhage is
arrested. It may be found ihil
the meningeal artery has betn
ruptured. If this accident hte
happened, and the vessel lie* m a
bony canal, plug with Horslcvi
wax. If the vessel is bleeduig
upon the dura, ligate by passing
suture ligatures around it Ifiii>
*'"""'''■ lorn oiTat the foramen spinosum,

pack with iodoform gauze, and postpone the rest of the opera-
tion for forty-eight hours. It may be necessary at any stage

~Hutky->

of this form dable operation to pack the wound and postpone
completion for two days The next step s to 1 ft up the duH
and witi t the brain (F g 163) I- nd the nfer or maxillan'

DISEASES AND INJURIES OF THE HEAD. 535

nerve and clamp it with hemostatic forceps. Find the supe-
rior maxillary nerve and clamp it. Loosen the nerves from
their beds with a dry dissector. Twist the clamp-forceps so
as to reel up the nerves. This pulls out the ganglion intact
with the motor root and the root of origin, as far back as
the pons (Krause's method). Arrest bleeding; close the
flap ; sew the lids of the affected side together ; and cover
the eye with a watch-crystal.

XXIII. DISEASES AND INJURIES OP THE HEAD.

I. Diseases of the Head.

In approaching cases of brain disorder, first endeavor
to locate the seat of the trouble ; next, ascertain the
nature of the lesion ; and finally, determine the best plan of
treatment, operative or otherwise. In all operations upon
the brain the surgeon must be able to determine accurately
the situations of certain fissures and convolutions, the find-
ing of the situations of these convoludons and Assures com-
prising the science of craniocerebral topography.

The regional terms used in craniocerebral topography are
derived from Broca (Fig. 165). The middle meningeal artery

;p)iiiiin( (afier Eimaich).

is found at the pterion, one and one-quarter inches posterior
to the external angular process, on a level with the roof of the
orbit (Fig. 164). The fissures and convolutions of the brain
are shown in Figs. 166, 167, and 168. The fissure of Bichat
is marked by a line on each side drawn from the inion to
the external auditory process. A line from the glabella to
the inion overlies the median fissure and the superior longi-
tudinal sinus. The fissure of Rolando is very important, as

536 MODERN SURGERY.

marking the motor region of the brain. It begins in tbe
median line, half an inch posterior to the middle of the dis-
tance between the inion and gta-
bella (Keen). This fissure runs
downward and forward at an angle
V , of 67, 5 ° for a distance of three aiid
three-eighths inches. Chiene findi
the fissure of Rolando by the follow-
ing method : he takes a square piece

, j ocdpitaL protuber-

ul and lambdoidai •uturo) ° M, m-

■I): CU, obdioD Ithe ugiiu] auiun

may be H-*haped or K-»haped. or

leDipoTdl jwi touch) ; Jf, tuphanian

! or. Miter, Lhe fluporior uephanion
nnnKCtkn orrid^lbr ic— — '"

lor icmpnnl 1^
in): S^inferlo

of paper and folds it into a triangle (Fig. 170. i); theangleBAC
of this triangle is 45° ; the edge d a is folded back on the dotted
line ae; the angle d a e equals half of 45°, or 22.5°, and the
angle CAE equals the same (Fig. 170, 2); unfold the paper
in the line ca; in the figure thus formed bac^45° ^^
eac=22.5''; ea 6 = 67.5°, which is the angle desired f"'^"
the point A in the mid-line of the head, over the point of ori-
gin of the Rolandic fissure; the side ab is laid along the
middle line of the head, and the line a e corresponds to
the fissure of Rolando.' Fig. 169 shows Chiene's scheme
for locating various points upon the brain, Horsley de-
termines the situation of the Rolandic fissure by the use

' Amtrican Ttxt-book of Surgiry.

DISEASES AI^D INJURIES OF THE HEAD.

537

of his metal cyrtometer (Fig. 171). He places the point
marked zero over the inioglabellar line and midway be-
tween the inion and the glabella. To find the fissure of

Fig. 167.— Outer surface of the left hemisphere of the brain (Ecker).

Sylvius (Fig. 167, 5, s\ s!'\ draw a line from the exter-
nal angular process to the occipital protuberance. The
fissure of Sylvius begins on this line one and one-eighth

Fig. 168.— Inner surface of the right hemisphere of the brain (Ecker).

inches behind the external angular process ; the main
branch of the fissure runs toward the parietal eminence;
the ascending branch of the fissure corresponds to the
squamoso-sphenoidal suture, and continues upward in the

MODERN SURGERY.

r an inch above the suture. The prietntrd
Wvbj, f) limits anteriorly the ascending fronUl
runs parallel with and just behind ihc

I suture, and a finger's breadth in front of the fissure
of Rolanda The inlraparietal fissure (Figs. i66, [67, //)
(■itetbc motor region posteriorly. It begins opposite the
I of the lower and middle thirds of the fissure af_

.«lltfeK pMMAi «

I in a line parallel with the longi-
l midway between the Rolandic fissuft
■ncnce. passes by the parieto-occipita) fa-

DISEASES AND INJURIES OF THE HEAD. 539

sure, and downward and backward into the occipital lobe.
The motor areas, which on the outer surface are adjacent to
the fissure of Rolando, are shown in Figs. 166 and 167.

The superior longitudinal sinus is overlaid by a line from
the inion to the glabella. The
lateral sinus is indicated by a
line running from the occipital
protuberance horizontally out-
ward to a point one inch pos-
teriorly to the external auditory
meatus, and from this point by a
second line dropped to the mas-
toid process. The suprameatal
triangle of Macewen is bounded
by the posterior root of the zy-
goma, the posterior bony wall
of the auditory meatus, and a
line joining the two. The ma.s-
toid process is opened through
Macewen's triangle to avoid in-
jury to the lateral sinus. Bark-
er's point, the proper spot to
apply the trephine in abscess of
the temporosphenoidal lobe, is
one and one-fourth inches above
and one and one-fourth inches
behind the middle of the external
auditory meatus. Fig, 172 shows
clearly the main points of craniocerebral topography, obtained
by methods approved by many scientists.

Diseases of the Scalp. — The scalp is composed of skin,
subcutaneous fat, and the occipitofrontalis muscle and apo-
neurosis. The scalp is liable to inflammation from various

proem; FR,)i»urcDf Ralando; IF,
rnrerioi fronul •ulcut ; tPF, inlnpiri-
CHl lukut 1 MMA, aiddk mcninsnl

PE, urinal «ii]iKiice;¥oF,piricial
occi|»tal Ewin ; SF. RrlTimi fiiiuR :
A. ill ucendlni limb; I'S, Up oT Rn-
parwphcnoid^obc. The pIcrioB (10

.u. ,.,. -ri,, ,, ,h, „jj„„ ^^„ ,h„

540 MODERN SURGERY,

causes, and also to other diseases — namely, tumors, cysts,
warts, moles Hocal cutaneous hypertrophies), cirsoid aneur-
ysm (page 250), nevi, and lupus. Abscesses of tlu ualpdit
common. If an abscess forms beneath the pericranium, the
pus diffuses over the area of one bone, being limited by
the attachment of the pericranium in the sutures. If an
abscess forms in the tissue between the occipitofrontalis
and the pericranium, it is widely diffused. Treves calls this
subaponeurotic connective tissue "the dangerous area."
Abscess of the subcutaneous tissue is apt to be limited
because of the great amount of fibrous tissue. Abscess is
treated by instant incision at the most dependent part, anti-
septic irrigation, and drainage.

Diseases and Malformatioiis of the Bones of fhe

Skull. — The bones of the skull are liable to caries, necrosis,
osteitis, periostitis, atrophy, hypertrophy, tumors, etc (sec
Diseases of Bones).

Microcephalus. — By microcephalus is meant unnatural
smallness of the head due to imperfect development Marked
microcephalus is not a common condition, but it is an occa-
sional cause or associate of idiocy. A child may be born
with a skull completely ossified even at the fontanelles, or
the ossification may become complete soon after birth, but
in many cases of microcephalus ossification takes place late
or not at all. In microcephalus the face is apt to be fairly
well developed ; the jaws are prominent ; the forehead is flat;
the cranium and brain are small ; the convolutions of the
brain are simpler than is natural ; there is apt to be marked
asymmetry of the two sides of the brain ; internal hydro-
cephalus may exist; areas of sclerosis and atrophy are
common ; porencephaly is not unusual. Some patients have
perfect motor power; others are slow and inco-ordinate.
Epilepsy, chorea, and athetosis frequently complicate the
case. Idiots of this type often present deformities such as
cleft-palate, strabismus, distorted cars, hypertrophied tongue,
deformed genitals or extremities, ill-shaped and irr^ularly
developed teeth. They exhibit irregular muscular move-
ments, are frequently paralyzed in childhood (infantile para-
plegia or hemiplegia), and suffer from subsequent contract-
ures. These idiots are active, destructive, excitable, and
are liable to be violent and almost demoniacal. Clouston
says they look impish and unearthly.

Treatment. — Skilled training in a school for the feeble-
minded or in an institution for idiots is necessary in treating
microcephalus. Idiots have but little power of attention.

DISEASES AND INJURIES OF THE HEAD. 54 1

and sensory impressions give rise to but few concepts, and
these are feeble and fleeting. In order to educate the idiot
it is highly desirable that speech be acquired, and " the more
strongly the attention can be aroused the more perfect does
speech become " (Kirchhoflf). The principle of the educa-
tion of idiots is to stimulate, co-ordinate, and guide sight,
hearing, and feeling.

Lannelongue of Paris has suggested an operation in cases
of idiocy with premature ossification (see Linear Craniotomy,
P2^^ 577)- I" this procedure the author has no confidence.
Idiocy is a general disorder and not a local brain disease.
Soft parts mould bone, and bone does not mould soft parts.
There is no evidence that the brain is being compressed ; in
fact, the simplicity of the convolutions suggests the contrary.
In many typical cases of microcephalic idiocy there is no
synostosis even years after birth. The operation has been
much abused. It is sometimes fatal, and, although a fatality
may gratify the family, a surgeon is not a legal executioner.
The remarkable improvement which has been reported in
some cases results probably from misconception ; the new
surroundings, the strange faces, the firm discipline, the effect
of the anesthetic, and the shock of the operation attract the
feeble attention and rouse the sluggish senses. Many cases
are brought for operation because they are for the time
being unusually intractable and excitable, and the return
to the usual level of conduct after operation is regarded
as a permanent gain when it is often but a temporary alle-
viation. We believe that scientific training is the proper
treatment, and that the efficiency of training is not in-
creased by the previous performance of craniotomy, and
we follow the precept of Agnew, that a surgeon might
as well cut a piece out of a turtle's back to make a turtle
grow as to cut a piece out of the skull to make the brain
grow.

Diseases and Malformatioiis Inyolving the Brain.

— ^Meningocele is a congenital protrusion of the cerebral
membranes through a bony aperture, the sac containing
some extracerebral fluid. Meningocele feels and looks like
a cyst (is translucent and fluctuates) ; it does not usually
pulsate, it has a small base, it becomes tense on forcible
expiration, and it may be reduced.

Encephalocele is a congenital protrusion not only of
membranes, but also of a portion of the brain as well, the
sac containing some extracerebral fluid. Encephalocele is
small, opaque, does not fluctuate, has a broad base, does

542 MODERN SURGERY,

pulsate, becomes tense on forced expiration, and attempts
at reduction cause pressure-symptoms.

Hydrencephalocele is a congenital protrusion of mem-
branes and brain-substance, the interior of the mass com-
municating with the ventricles and containing ventricular
fluid. This is the most frequent and the most dangerous
form. Hydrencephalocele is larger than a meningocele, is
translucent, fluctuates, rarely pulsates, is pedunculated, is
rendered a little tense on forced expiration, and cannot be
reduced.*

Treatment, — For hydrencephalocele nothing can be done,
and early death is inevitable. In rare instances an enceph-
alocele is converted into a meningocele, and the bom*
aperture closes, thus bringing about a cure. Among the
expedients for treating meningocele and encephalocele are
electrolysis, injection of Morton's fluid (gr. x of iodin.
gr. XXX of iodid of potassium, 3j of glycerin), pressure and
excision. In cases of meningocele, when portions of the ner\'e-
centers are not contained in the sac, Mayo Robson advises the
performance of a plastic operation. He ligates the neck of
the sac, cuts away the sac, sutures the skin-flaps separately,
and leaves the stump outside the line of superficial sutures.
It is usually possible to tell by palpation if nerve-centers are
in the sac, but if in doubt, make an exploratory incision, and
sweep the finger around inside of the sac*

HydrocephaJxis. — In external hydrocephalus the fluid is
between the membranes and the brain ; in internal hydro-
cephalus the fluid is. in the ventricles. Hydrocephalus may
be acute or chronic^ congenital or acquired.

Acute hydrocephalus, which results from meningitis
(particularly tubercular meningitis), is usually internal, but
may be external. The symptoms are headache, elevated
temperature, delirium, stupor, convulsions, paralysis, and
choked disk.

Treatment of acute hydrocephalus is of no avail. Tapping
of the ventricles may be tried.

Chronic hydrocephalus is usually congenital. The cra-
nium enlarges enormously and the bones of the skull are
widely separated. The broad forehead overhangs the eyes.
The child is an idiot, and very often does not learn to walk
or to talk. Convulsions and palsies are common, and blind-
ness is frequent. Such children usually die young.

The treatment of chronic hydrocephalus is rarely of much

* American Text book of Surgery.

"^ Am. Jour. Med. ScknceSy Sept., 1895.

DISEASES AND INJURIES OF THE HEAD. 543

avail. Pressure by strapping with adhesive plaster has been

■ tried. Tappings through a fontanelle may be performed by
I means of a trocar (only Sij or 5iij of fluid being drawn at a

time). If much fluid is drawn, the head must be strapped
afterward. If the skull ossifies, the lateral ventricles may be
' tapped. It has been proposed to drain by tapping the theca
5. of the spinal cord (Quincke). This last operation is called
* lumbar puncture (page 595).

2. Injuries of the Head.

Cephalhematoma (caput succedaneum), which is a col-
^ lection of bloody serum under the scalp of a new-born
- child, results from the pressure of labor. No treatment is
required

Scalp-wotmds are treated as are other wounds. Even a
? large piece of scalp with only a narrow pedicle may not
} slough ; hence try to save any piece that has an attachment.

■ Always shave a wide area and disinfect the wound thor-
oughly. Stitch the wound with silkworm-gut. The hem-
^'^'^age can, in most instances, be controlled by the sutures
^'^ch are used to close the wound. If drainage is required,
^se a few strands of silkworm-gut.

, Contusions of the Head. — Scalp-swelling from hemor-
rnage is usually considerable. The patient may be stunned
^^ dazed. The swelling of hematoma must not be mistaken
^ fracture with depression. In hematoma there is a cen-
r^* depression, hard pressure on the centre finds bone on a
^^I with the general contour of the bone, and the margin
^*^ 3. hematoma is circular, is not quite hard, and is elevated
ai>ove the general contour. In depressed fracture the edge
^ ^n a level with or below the level of the general bony con-
.^^r, and the margin is sharp and irregular. The treatment
^ by means of pressure and the use of lead-water and laud-
^um. If suppuration arises, at once incise.

Concossion or I^aceration of the Brain. — For many

y^rs it has been customary to regard concussion as a con-
dition produced by molecular vibrations in the nervous sub-
stance of the brain. Buret's classical observations have pro-
foundly modified surgical thought, and have led to the
opinion that in concussion of the brain there is injury to the
k*" itself, a rupture of cerebral vessels brought about by
tne advance and recession of a wave of cerebrospinal fluid,
i/us Wave first flows in the direction of the force. Keen
^y^ that there may be slight brain-injuries which can

544 MODERN SURGERY,

properly be called " concussions," but it is better to consider
concussion as synonymous with laceration of the brain. It
seems, however, highly improbable that slight cases of con-
cussion are accompanied by vascular rupture or organic
mischief, the symptoms are too transitory, and reaction too
rapid and complete to permit of any such view. These
slight cases are identical with and at least can not be dis-
tinguished from shock. The cause of concussion is violent
force, either direct (as a blow upon the head) or indirect (as
a fall upon the buttocks). This force shakes, oscillates, or
jars the brain, giving rise to waves of cerebrospinal fluii
which sometimes rupture vascular twigs, large vessels, or
even the membranes. In the slighter ruptures concussion
only exists ; in the severe ruptures compression soon arises.
Symptoms. — In a slight case of brain-concussion the
patient may or may not fall ; his face is pale ; he feels weak,
giddy, nauseated, and confused ; he often vomits, but soon
reacts. In a severe case he lies with complete muscular relax-
ation, cold extremities, pale and cold skin, shallow and quiet
respiration, frequent, small, soft, and irregular pulse (pulse
may not be detectable), and fluttering heart. He seems
unconscious, but can usually be roused to monosyllabic
response by shouting, pinching, or holding a bright light
near his face. Occasionally, however, there is complete un-
consciousness. The urine and feces are often passed in-
voluntarily. The pupils may be unaltered, may be dilated or
contracted, or may be equal or unequal, but in any case the}*
will react to light. Paralysis rarely exists, but if there is
paralysis it is temporary. The temperature at first is sub-
normal. In a severe cortical laceration there will be twitch-
ings or even general convulsions, or the patient will lie curled
up with limbs flexed and eyelids shut, and will resist all
attempts to open his eyes or mouth or to move his limbs (A.
Pearce Gould). P3richsen called this condition "cerebral
irritability." As the patient reacts he will most probably
vomit. Within twenty-four hours he usually improves,
but is feverish and complains of headache and lassitude,
sometimes becomes delirious, and in rare cases develops
mania. After concussion recovery may be complete, but,
on the contrary', a person's whole nature may change: he
may develop hysteria, insanity, or epilepsy, and in many
cases there is complaint for a long time of headache, insom-
nia, low spirits, and lassitude. If the patient in concussion
recedes from, instead of advancing toward, recovery, coma
will set in or inflammation will develop. Keen states that

DISEASES AND INJURIES OF THE HEAD. 545

the prognosis is always uncertain. Any concussion pro-
ducing unconsciousness is a serious injury, because consider-
able laceration has probably occurred.

Treatment. — In treating brain-concussion,' bring about
reaction by the administration of aromatic spirits of ammo-
nia (no alcohol, as this agent excites the brain), by pouring
a few drops of ammonia on a handkerchief and holding it
near the nose, by surrounding the patient (who lies in bed
with a pillow) with hot bottles, by hot irrigation of the head,
by the application of mustard over the heart, and by the
administration of hot coffee or hot saline enemata. Do not
pour fluid into the patient's mouth until he becomes able to
swallow. If he cannot swallow, rely on hot enemata and
h)q>odermatic injections of strychnin. Place the patient in
bed in a quiet room, and watch him. If reaction is inordinate,
apply cold to the head, give arterial sedatives and diuretics,
and purge. For some days or for some weeks, according to
the case, insist on an easy life. Give a plain diet containing
a minimum of meat, administer an occasional purgative, and
secure sleep. Sleep can often be obtained by some simple
expedient, such as the administration of warm milk, placing
a hot-water bag to the abdomen or feet, or applying a mus-
tard plaster for a short time to the back of the neck. In
cases where obstinate wakefulness exists, it becomes neces-
sary to give bromid, chloral, sulphonal, trional, or some
other hypnotic. Morphin is avoided because it is thought
to increase venous congestion of the brain, but the elder
Gross often used it, especially in cerebral irritation. If signs
of compression arise, it is best to trephine, as the compressing
agent may be a clot (see page 548). If inflammation arises,
some surgeons will not trephine ; but it is wise and proper,
especially if the damage seems to be localized, to incise the
scalp and inspect the bone. If a fracture is discovered
and the symptoms are serious, perform an exploratory tre-
phining, open the dura, and secure drainage for inflammatory
products.

In any severe contusion the surgeon should at once
incise the scalp and inspect the bone. For many weeks
after a grave concussion a patient must be kept away
from business and be watched because of the possibility
of an abscess of the brain arising, and because of the lia-
bility of such patients to develop hysteria, neurasthenia, or
insanity.

Compression of the Brain.— The causes of brain-
compression are hemorrhage, depressed fracture, tumor, in-
35

546 MODERN SURGERY.

flammatoiy exudate, pus, and foreign bodies. Death tends
to happen from respiratory failure, not from heart-failure
(Horsley).

Symptom^. — In great or sudden brain-compression com-
plete coma exists without voluntary movement. The slrin
is hot and perspiring ; the respirations are slow and sterto-
rous, and the cheeks flap during expiration ; the pulse is slow
and full, and may be irregular; the pupils are somewhat
dilated, and do not respond readily to light. In a unilateral
compression the pupil on the side of the compressing-cause
is apt to be much dilated if the compression is affecting the
base of the brain. In cerebral compression there are usually
retention of urine, and often incontinence of feces ; paralysis
exists, which may be very limited (monoplegia), may be of
one side (hemiplegia), or may be general. In hemorrhage
into the interior of the brain the unconsciousness is imm^
diate or nearly so. In bleeding from the middle meningeal
artery a period of consciousness intervenes between the in-
jury and the coma, in which period blood collects and the
coma comes on gradually. In compression from depressed
fracture or from a foreign body the symptoms usually come
on at once, but they may be deferred for some hours. Com-
pression from inflammation or pus begins gradually after a
considerable time has elapsed.

A diagnoBis must be made between coma due to brain-
injury and the comatose conditions of apoplexy, uremia,
epilepsy, hysteria, diabetes, opium-poisoning, and alcoholic
intoxication. In hospital practice cases of unconsciousness
without a known histor>' are frequent. In attempting this
diagnosis examine carefully for any evidence of traumatism,
and inquire as to how and where the patient was found, if
any fit occurred, and if a bottle or a pill-box was found near
by or in the pockets. The surgeon should himself exam-
ine the pockets. Smell the breath to notice alcohol or
opium, but always remember that a man may be stricken
with apoplexy while he is drunk, and may fracture his
skull by falling when under the influence of opium or of
alcohol. Draw the urine with the catheter if any ^i-ater is in
the bladder; examine the urine for albumin and alcohol
and take the specific gravity. In doubtful cases of coma
use the ophthalmoscope. In post-cpilcptic coma the tempera-
ture is never below normal, there are no unilateral symptoms,
the condition resembles sleep, and the patient can be aroused
Hysterical coma occurs in boys and women ; there are no ob-
jective symptoms, and the patient, though swallo^iing what is

DISEASES AND INJURIES OF THE HEAD, 547

put into his mouth, cannot be roused (Gowers). In uremia^
besides the condition of the urine (and always remember
that a person with albuminuria is apt to develop apoplexy);
there is a persistent subnormal temperature, and convulsions
are prone to occur. There is edema of the legs, and
paralysis and stertor are absent. In apoplexy hemiplegia
exists, and the initial temperature is for a short time sub-
normal. A single convulsion may have ushered in the case.
Alcoholic unconscumsfiess is often diagnosticated when apo-
plexy really exists. A man will smell of alcohol who has
had one drink, but one drink will not produce coma ; hence
the smell of alcohol is not conclusive. In any case of
doubt some hours of watching will clear up the diagnosis.
Regard a doubtful case as serious until the truth is clear.
In opium-poisoning the pupils are contracted to a pin-point,
the respirations are usually slow, shallow, and quiet, but may
be stertorous, but there is no paralysis. Always remember
that hemorrhage into the pons will produce pin-point pupils,
but it also causes paralysis (crossed paralysis if in the lower
half of the pons) and high temperature with sweating. In
opium-poisoning the temperature is subnormal. In diabetic
coma the pupils will react to a very bright light, the tempera-
ture is subnormal, and the breath and the urine smell like
chloroform.

Treatment. — ^The treatment of brain-compression depends
on the cause. Hemorrhage (extradural or subdural) requires
trephining and arrest of bleeding ; coma from depressed fract-
ure demands trephining and elevation ; foreign bodies must
be removed ; abscesses must be evacuated ; some tumors are
to be removed. In cerebral compression, if death is threat-
ened by respiratory failure, make artificial respiration, and at
once trephine over the supposed region of compression
(Victor Horsley). Horsley has shown that irrigation of the
head with hot water is of great value in bringing about reac-
tion from shock in cases of brain-injury.

Intracraiiial hemorrhagfe may be either sponta?teous or
traumatic. In the vast majority of instances spontaneous
hemorrhage comes from the lenticulo-striate artery (Char-
cot's artery of cerebral hemorrhage), and produces apoplexy,
a disease belonging to the physician except in some ingra-
vescent cases, for which ligation of the common carotid on
the same side as the rupture is indicated. Traumatism during
delivery is a not unusual cause of hemorrhage from the mid-
dle meningeal artery (Richardiere). A traumatic hemorrhage
may take place (i) between the bone and the dura {extra-

548 MODERN SURGERY.

dural) ; (2) between the dura and the brain {subdural) ; and
(3) in the brain-substance (cerebral),

(i) Extradurcd hemorrhagre arises from the middle
meningeal or, more often, from one of its branches. A
spicule of bone may penetrate a venous sinus and pro-
duce extradural hemorrhage, or a sinus may rupture. Rupt-
ure of the meningeal artery or one of its branches is usu-
ally, but not always, accompanied by fracture; in fact, in
some cases not even a bruise can be found. The ruptured
vessel may be upon the opposite side, hence the evidence of
scalp-injury is not a certain sign of the side of the skull
involved. The accident may or may not cause temporary
unconsciousness ; but even if it does, from this unconscious-
ness the patient almost always reacts, and there is a distinct
period of consciousness between the accident and the lasting
coma, the coma being due to pressure from a continually in-
creasing mass of extravasated blood. If the main trunk or
a large branch is ruptured, the period of consciousness is
short ; if a small branch is ruptured, the period of conscious-
ness is prolonged for hours or perhaps for days. As the clot
forms and enlarges the patient becomes heavy, dull, stupid,
and sleepy, he sleeps so soundly he can scarcely be aroused
and snores loudly, and finally passes into stupor and then into
coma. The other signs of this condition are paralysis of the
side opposite the blood-clot (not necessarily of the side op-
posite the injury, for the artery may rupture from contre-coup
on the uninjured side); this paralysis is apt at first to be
localized, but it gradually and progressively widens its do-
main. If the clot extends toward the base, the pupil on the
same side as the clot ceases to react to light, becomes immob-
ile and dilates widely, and, if the clot be on the left side,
aphasia is noted. As the clot enlarges adjacent centers
become involved. The face becomes paralyzed, then the arm,
and finally the leg. Not unusually epileptiform attacks occur,
starting in discharges from the centers which are irritated by
the advancing clot before their function is abolished by press-
ure. The pulse becomes full, strong, usually slow, but
occasionally frequent; the breathing becomes stertorous;
the temperature rises, that of the paralyzed side exceeding
that of the sound side. In a compound fracture the pressure
of escaping blood may force brain-matter out of the wound
(Keen). In extradural hemorrhage from a sinus the symp-
toms cannot be differentiated from those produced by arterial
rupture.

Treatment. — In treating extradural hemorrhage localize

DISEASES AND INJURIES OF THE HEAD. 549

the clot, not by the seat of the wound or contusion, but
entirely by the symptoms. To reach the middle meningeal
artery or its anterior branch, trephine one and one-fourth
inches back of the external angular process, at the level of
the upper border of the orbit (Kronlein) (Fig. 164). If this
incision does not expose the clot, trephine again at the level
of the upper border of the orbit and just below the parietal
eminence. The first incision gives access to the trunk and
to the anterior branch ; the second incision exposes the poste-
rior branch. If signs indicate that the clot is travelling to
the base, the trephine should be used half an inch lower
than the point first indicated. Arrest bleeding by a suture
ligature or by packing (page 266), and always open the dura
and inspect the brain. By this procedure a subdural hem-
orrhage may be discovered which, without it, would have
been missed. Drainage must be employed.

(2) Subdural hemorrhaffe is usually due to depressed
fracture and rupture of the middle cerebral artery or of
a number of small vessels. The symptoms are identical with
those of extradural bleeding, but are usually very rapid in
onset.

The treatment is trephining at the first point, enlarging the
opening upward and backward with a rongeur, opening the
dura, turning out the clot, ligating the bleeding point or
packing, elevating any depression of bone, draining, and
stitching the dura with catgut. Hemorrhage from internal
pachymeningitis requires the same treatment.

(3) Cerebral Hemorrhagre. — The symptoms of cerebral
hemorrhage are identical with those of apoplexy. The treat-
ment is the same as that for apoplexy, except in ingravescent
cases, when the common carotid on the same side as the
clot may be ligated.

Ruptiore of a sinus usually arises from compound fract-
ure or during a brain-operation. The treatment, if the
rupture happens from fracture, is trephining. Enlarge the
opening by the rongeur, pack with one large piece of iodo-
form gauze, or catch the rent with hemostatic forceps, leav-
ing them in place for three or four days, or apply a lateral
ligature or a suture ligature. Elevate depressed bone. In
rupture during an operation control hemorrhage by packing.

Fractures of tne Sktlll may be simple^ compound, de-
pressed^ non-depressed, or punctured. They are divided into
fractures of the vault, usually due to direct force, and fract-
ures of the base, due to extension of fractures of the vault,
to indirect violence (a fall upon the feet, the buttocks, or the

550

MODERN SURGERY.

vault), to forcing of the condyles of the lower jaw against or
through the base, or to foreign bodies breaking through the
orbit, vault of the pharynx, the ear, or the roof of the nos-
trils. Fracture by contre-coup, which occurs on the side
opposite the application of the violence, is very rare. Fract-
ures of the skull are uncommon in early youth, but they
are much more frequent in the aged. Usually the entire
thickness of the bone is fractured, but either the outer or
the inner table may be broken alone. In complete fractures
the inner table is broken more extensively than is the outer
table, because the inner table is the more brittle, because the
force diffuses, and also, as Agnew taught, because the inner
table is part of a smaller curve than is the outer table, and
violence forces bone-elements together at the outer table, but
tears them asunder at the inner table (Figs. 173, 174).

Fig. 173. — Section of outer and inner
tables, with two parallel lines (after Ag-
new).

Fig. 174.— Greater yielding of the iimer
uble than of the outer after the applica-
tion of violence (after Agnew).

Fractures of the Vault. — A fracture of the vault of the
skull may be simple and undepressed, or it may be depressed,
compound, or comminuted. A mere crack may exist in a
bone, and if a rent exists in the soft parts, a bit of dirt or a
hair may be caught in the crack. Fractures of the vault
arise from direct force. A fissure may escape recognition,
although in some cases percussion gives a "cracked-pot"
sound. Any considerable depression can be detected. In a
simple fracture occasionally the cerebrospinal fluid collects
under the scalp and forms a tumor which pulsates and be-
comes tense on forcible expiration (puffy tumor of Pott).
Compound fractures can be readily recognized, but do not
mistake a suture, a Wormian bone, or a tear in the pericra-
nium for a fracture. A fissured fracture is marked by a dark
line of blood which sponging will not remove. Fracture of
the inner table alone can only be suspected (Keen). The
prognosis of fractures of the vault depends upon the extent
of brain-injury rather than upon the extent of bone-injury.
Simple fractures unite by bone; compound fractures with
loss of bone unite only by fibrous tissue. The dangers may

DISEASES AND INJURIES OF THE HEAD, 55 1

be immediate (hemorrhage, brain-injury, and septic inflamma-
tion) or be distant (epilepsy, insanity, and persistent headache).

Treatment, — A simple fracture without depression and
without brain-symptoms is treated expectantly (by rest,
quiet, low diet, purgation, moderate elevation of and cold to
the head, and arterial sedatives). A simple fracture with
moderate depression and without cerebral symptoms is
treated expectantly, and so also is a simple fracture in which
symptoms existed but are abating. Simple fracture with
marked depression requires immediate trephining, even when
brain-symptoms are absent. Some surgeons make an excep-
tion in young children, and wait awhile before trephining,
in the expectation that the expansile brain will lift the de-
pressed but elastic bone up to the level. Trephining in
cases where no symptoms exist, although there is marked
depression, often prevents disastrous consequences arising
in the future, and is known as "preventive trephining"
(Agnew, Keen, Horsley, Macewen, v. Bergmann, and
others). In all compound fractures, shave and asepticize
the entire scalp, enlarge the incision, and explore the bone.
If a fissure exists it must be asepticized, and if a hair or other
foreign body is found in it, in order to effect removal and se-
cure asepsis the outer table of the skull must be cut away
with a chisel, the fissure being thus converted into a broad
groove. In a compound fracture with much depression,
trephine, elevate, and irrigate. In any fracture, trephine if
distinct symptoms exist. In punctured wounds of the brain
(punctured fractures), always trephine, open the dura, and
disinfect (Keen). In any case of fracture of the vault where
trephining has been performed, it is wise to open the dura
and examine the brain.

Fractures of the Base. — A fracture of the base of the
skull may exist in only one of the three fossae, in two of
them, or it may involve all. The middle fossa is oftenest
involved. Fracture of the posterior fossa is the most fatal.
These fractures may be due to direct violence, to indirect
force, and to extension of a fracture of the vault. Extension
from the vault is always by the shortest route. Fracture by
direct violence may arise from the penetration of the nasal
roof, the orbital roof, or the pharyngeal roof by a foreign
body. The posterior fossa may suffer from a fracture by
direct violence applied to the neck. Fractures by indirect
force may arise from blows upon the frontal bone (the orbital
portion of the frontal or the cribriform process of the eth-
moid breaking), from falls upon the chin (the condyle of the

552 MODERN SURGER K

jaw breaking the middle fossa), or from falls upon the but-
tocks, the knees, or the feet (fracture occurring in the poste-
rior fossa). The base is very rarely broken by contre-coup
(Treves).

Symptoms, — Fractures of the base of the skull are apt to be
compound. A solution of continuity in the pharynx, roof
of the nares, orbit, or ear, permits access of air to the seat
of fracture and allows blood and cerebrospinal fluid to flow
externally. In fracture of the anterior fossa the fracture
may be compound, because of laceration of the mucous mem-
brane of the nares or of the conjunctiva. Blood may run
from the nose, its source being the vessels of the mucous
membrane or the dura, the fracture being compound. Epis-
taxis does not prove the fracture to be compound, but only
suggests it ; but if the epistaxis is prolonged, the probability
is greatly increased; and if the flow of blood is succeeded by a
flow of cerebrospinal fluid the diagnosis of compound fracture
is positive. Cerebrospinal fluid only appears when the mu-
cous membrane, the dura, and the arachnoid are each lacer-
ated (Treves). In fractures of the anterior fossa blood is apt
to flow into the orbit, producing subconjunctival ecchymosis,
and some blood is often swallowed and vomited In fractures
of the middle fossa blood may flow from the ear through a
tear in the tympanum, its source being the vessels of the
tympanum, the meningeal vessels, or a sinus. Blood may
flow through the Eustachian tube and come from the nose,
may be spit up, or may be swallowed and vomited. In many
cases a quantity of cerebrospinal fluid flows from the ear, the
discharge being increased by expiratory effort and a position
which favors gravity. The cerebrospinal fluid must not be
confused with either blood-serum or liquor Cotunnii. The
cerebrospinal fluid is always present in large amount; the
liquor Cotunnii can only be present in minute amount
Blood-serum is highly albuminous ; cerebrospinal fluid is
a serous fluid of very low specific gravity, never shows more
than a trace of albumin, and contains considerable chlorid
of sodium and in some instances sugar, which, when present,
reacts to Trommer's and to Moore's tests, but does not reflect
polarized light nor ferment with yeast (Keetley, from Collins).
Treves states ^ that cerebrospinal fluid cannot flow from the
ear in fractures of the middle fossa unless (i) the line of
fracture crosses the internal meatus, (2) unless the prolonga-
tion of the membranes into the meatus is torn, (3) unless a
communication exists between the internal ear and tympa-

^ Applied Anatomy.

DISEASES AND INJURIES OF THE HEAD. 553

num, and (4) unless the drum-membrane is torn. Miles of
Edinburgh ^ claims that bleeding from the ear followed by a
flow of cerebrospinal fluid is not pathognomonic of fracture
of the middle fossa of the base. He maintains that when
the drum is ruptured we may have these signs, when bone
is not broken, the chief source of the blood being the vessels
of the pia and temporosphenoidal lobe, the blood and cere-
brospinal fluid flowing inside the sheath of the auditory
nerve, passing into the vestibule, through the lamina crib-
rosa, and from the vestibule into the middle ear, finding exits
from this space by way of the Eustachian tube, and also
through the rent in the drum-membrane. Profuse serous
discharge may flow from the ear after an injury without fract-
ure when the drum is ruptured, the fluid coming from the
cells of the mastoid. It must be understood that fracture
of the base may exist when there is no flow of blood or of
serous fluid. A fracture of the middle fossa is usually com-
pound, made so, even when the drum is not ruptured, by
the Eustachian tube. In fracture of the posterior fossa blood
accumulates beneath the deep fascia and produces discolora-
tion in the line of the posterior auricular artery (Battle's
sign), the discoloration first appearing near the tip of the
mastoid. The discoloration appears in the line of nerves
and vessels which emerge from the deep fascia, the vessels
passing through openings and the extravasated blood emerg-
ing from the same openings. Fractures of the posterior fossa
are apt to be compound through the pharynx, and in such
cases the patient spits or vomits blood. Compound fract-
ures of the posterior fossa are more fatal than fractures in
either of the other fossae. Fractures of the base are apt to
be associated with paralysis of cranial nerves. Optic neuritis
often arises after the first week. Keen says that in fractures
of the base the temperature is subnormal during the shock,
rises to 100° to 101°, falls again to a little below normal, and
remains normal or subnormal unless there be inflammation
or sepsis.

Treatment, — In treating a compound fracture of the base
of the skull, collect any serous discharge and analyze it, and
disinfect any cavity involved. In fractures of the middle fossa
with ruptured drum clean the ear mechanically, wash it out
with hydrogen peroxid and with a stream of warm corrosive-
sublimate solution of a strength of i : 2000 (turn the head
toward the affected side while washing, so that the mercurial
solution will not run down the Eustachian tube), pack with

' Edinburgh Med. Jour. ^ Nov., 1895.

554 MODERN SURGERY.

iodoform gauze, and apply an antiseptic dressing. Several
times daily the ear is to be irrigated, and insufflated with iodo-
form. The nasopharynx must be frequently irrigated with
normal salt solution or boric-acid solution, and insufflated
with iodoform. The conjunctival sac is frequently irrigated
with boric-acid solution. If after a head-injury blood accu-
mulates back of the drum, this membrane should be incised
to permit of drainage and disinfection. In fractures of both the
middle and anterior fossae the nasopharynx must always be
cleaned. The exact method depends on the choice of the
surgeon. We may wash out these cavities frequently with
hot water, next with peroxid of hydrogen, and finally with
boric-acid solution, or can use normal salt solution. Insuf-
flate the nasopharynx with iodoform, and pack the nose
with iodoform gauze (Keen, Dennis) ; also cleanse the con-
junctival sac frequently. In some cases drainage has been
obtained from the anterior fossa by breaking down the crib-
riform plate and introducing a tube through the nostril
(Allis), and from the middle fossa by trephining above and
behind the external auditory meatus. In a compound fract-
ure of the orbit disinfect and drain. It may be necessary to
trephine the roof of the orbit for drainage. In fracture of
the posterior fossa examine to see if the fracture is com-
pound, into the pharynx, and if it is cleanse with great care
the nasopharynx, and mouth, as previously directed. In a
very extensive fracture of the base, besides use of the
methods set forth above, the entire head should be shaved
and a plaster cap be applied. Cases of fracture of the base
must be put into a quiet and darkened room and be kept
upon a low diet, sleep being secured, and the bowels and
bladder being attended to. If we are not sure whether a
fracture exists or not, keep the man quiet and in a darkened
room, and on a low diet. Attend to the bladder, keep the
bowels loose, examine the nasopharynx with mirrors and
the drum through a speculum.

Wounds of the brain are produced by violence and by
foreign bodies (knives, bullets, etc.). Except when due to
penetration of a fontanelle in a child or of a parietal foramen
in adults, wounds of the brain are accompanied by fracture
of the skull. These wounds are very dangerous : foreign
bodies (bone, hair, clothing, etc.) are often lodged in the
brain, hemorrhage is usually severe, and sepsis is almost
inevitable without proper treatment. These cases are very
fatal, though some astonishing recoveries are on record.

The symptoms of brain-wounds may be slight and long-

DISEASES AND INJURIES OF THE HEAD, 555

deferred or may be immediate and overwhelming; they
depend upon the site and extent of the injury. Localizing
symptoms may exist, and encephalitis with coma is apt to
arise. Abscess not unusually follows.

In treating wounds of the brain always shave the entire
scalp and examine the weapon, if possible, to see if a piece
were broken off. Asepticize, enlarge the wound, trephine,
arrest bleeding, elevate any depression, remove foreign
bodies, irrigate the wound, suture the dura, drain, and dress.

Gtinshot- wounds of the Head. — A penetrating wound
is one in which the bullet enters the head, but does not
emerge; a perforating wound is one in which the bullet
passes through the head and emerges. The bullet of the
modem rifle will rarely lodge, but a pistol-bullet will often
lodge. The wound of entrance is small ; the wound of exit
is large. At the wound of entrance the inner table is more
extensively fractured than the outer table ; at the wound of
exit, the outer table is more widely broken than the inner
table. In these cases there is always great concussion, and
concussion-symptoms exist even when the bullet has not
entered the brain. In moderate concussion the action of
the heart is retarded; in severe concussion it is accelerated.^
A bullet may be lodged within the cranium when merely a
fracture without a bullet-hole can be detected. In these
cases the bullet produces a fracture and enters the cranium,
and then the depressed bone flies back into place (v. Berg-
mann). In such cases if complete perforation occurs, the
one existing opening is the opening of exit. A bullet
may lodge in the bone, between the dura and the bone,
in the brain, between the dura and bone of the opposite
side, or in the bone of .the opposite side, in the nasal fossa,
maxillary antrum, or orbit. Always examine the side of the
head opposite to the wound of entrance to determine if there
is any bulging or fracture. A bullet may pass or cross
the brain and be deflected from the inner surface of the
skull (Fluhrer). Ruth does not believe the bullet can re-
bound from the opposite wall.' The secondary sinnptomB of
gunshot-wounds of the head are varied and uncertain, and
may not be observed at all before death. Fowler wisely
points out that a patient with a gunshot-wound of the
head may have also received other injuries, and the other
injuries may be in part, at least, responsible for cerebral
symptoms.

* Fowler, in Annals of Surgery ^ Nov., 1895.

* See the instructive article by Fowler, in Annals of Surgery y Nov., 1895.

556 MODERN SURGERY.

Treatment. — Bring about reaction (see Concussion). In
severe cases apply heat to the head, and make artificial respi-
ration. It will sometimes be necessary to operate while arti-
ficial respiration is being made. In treating gunshot-wounds
of the head shave and asepticize the whole scalp, disinfect the
entire track of the ball, and arrest hemorrhage at the wounds
of entrance and exit, using the rongeur to expose the bleed-
ing points if the bullet be large, employing the trephine if it
be small. If the bullet has emerged and has been picked up,
examine it to see if it is entire. The bullet, if retained, is to be
sought for. Place the head in such a position that the track
of the ball will be vertical, then introduce Fluhrer's aluminum
probe and let it find its way by gravity. The probe may find
the ball near the wound of entrance, in which case extract
the ball with forceps ; or the probe may find the ball near
the opposite side of the head, in which case make a counter-
opening through the bone at a point the probe would touch
if it were pushed entirely across. Take a new and clean
rubber catheter (No. 9, French), insert a stylet, and carry the
catheter through the wound (Keen). Knowing the depth of
the ball, search for it around the catheter-tube as an
axis, and when found extract it. After extraction drain
the wound by means of a tube. When a counter-opening
exists drain through and through. If the ball cannot be
detected, drain by a tube carried to the depths of the wound.
After dressing always place the head in a position favor-
able for drainage. Fluhrer tells us that when a counter-
opening fails to disclose the bullet, use the new opening
as a doorway through which to search for the ball. He
believes the bullet is not unusually deflected. The angle
of reflection is somewhat greater than the angle of in-
cidence, and the bullet is apt to fall a little toward the
base. Splinters of bone are often driven into the brain
by a bullet, and these are removed whether the ball is
found or not. Several varieties of probes have been com-
mended. Fluhrer uses a large-sized aluminum probe. Senn
uses an instrument shaped like the Nelaton probe, but of the
same diameter as the bullet. (Of course, the porcelain probe
will not show a black mark from contact with a modem
bullet.) Fowler uses a graduated pressure-probe; so long
as the pressure is within the limits of the spring, as
shown by the scale, the probe is in the bullet-track.
Girdncr's telephonic probe is a valuable aid to diagnosis.
Recently bullets have been located by the Rontgen rays.
There can be no doubt that many gunshot-wounds have

DISEASES AND INJURIES OF THE HEAD. 557

been recovered from without operation, and there can be no
doubt that many deaths follow operation (about 33^ per cent,
according to Hahn). Von Bergmann is so impressed with
these facts that he does not operate when symptoms are
absent.

FtmgllS cerebri (hernia of the brain) rarely contains true
brain-substance. It is in most instances a growth fropi the
neuroglia. Hernia cerebri cannot occur if the dura is not
opened ; it is rare in any case unless the brain is damaged,
and is most frequent after septic wounds. In any brain-
operation where the dura is opened suture it ; or, if there be
a great gap in the dura, turn in a flap of pericranium, its
bone-forming surface being upward, and stitch this mem-
brane to the dura (Keen). The evidence of brain-hernia is a
protruding mass which is soft, lobulated, of a dirty-white
color, pulsating, painless to the touch, often bleeding, and
sometimes discharging cerebrospinal fluid. In treating
brain-hernia employ antiseptic dressings. Skin-grafting
benefits some cases. Pressure is dangerous. Excision by
the knife or cautery does no good. After healing, a depres-
sion marks the site of the hernia.

Traumatic inflammation of the brain and its mem-
branes is divided into encephalitis or cerebritis, inflammation
of the cerebrum ; cerebellitis, inflammation of the cerebellum ;
meningitis, inflammation of the meninges ; arachnitis, inflam-
mation of the arachnoid; pachymeningitis, inflammation of
the dura ; and leptomeningitis, inflammation of the arachnoid
and pia.

Fachymenin^tis. — Inflammation of the external layer
of the dura is called pachymeningitis externa. It may arise
from tumor, caries, necrosis, middle-ear disease, sunstroke,
or traumatism. Syphilis is a not unusual cause. The other
membranes may become involved. Suppuration may arise,
having extended by contiguity from neighboring parts. The
symptoms of pachymeningitis externa arc uncertain. They
resemble often those of leptomeningitis (page 558). Pressure-
symptoms may arise. Headache is always present. Paralysis
may or may not exist. If pus forms, the ordinary constitu-
tional symptoms of suppuration arise (high temperature and
sweats), not the symptoms of abscess in the brain. In a
severe case the other membranes become involved.

The treatment consists in removing the cause (carious
bone, pus, middle-ear disease). In pachymeningitis from
traumatism it is sometimes advisable to trephme in order
to drain inflammatory products ; in a case with localizing

558 MODERN SURGERY,

symptoms always trephine ; in an ordinary case, without pus
and with no evidences of traumatism, use wet cups back of
the mastoid processes, apply an ice-bag to the head, and
purge by means of calomel. Use iodid of potassium in most
cases. If sunstroke is the cause, treat accordingly.

Pachymeningitis interna may extend from the pia,
or may extend from the outer layer of the dura. The form
known as hematoma of the dura mater, or pachymeningitis
interna haemorrhagica, may arise during infectious diseases
(typhoid fever and rheumatism), in persons of the hemor-
rhagic diathesis, in diseases causing atrophy of the brain,
in chronic diseases of the heart and kidneys, and in syph-
ilitics. Among the exciting causes are traumatism, in-
flammation in adjacent parts, and, especially, the abuse of
alcohol. In this disease blood is extravasated on the inner
surface of the dura. Many observers do not class hemor-
rhagic pachymeningitis as inflammation, but regard the
hemorrhage as primary.

The Binnptoms of internal pachymeningitis are very
chronic, are not characteristic, and may be absent They
consist usually of persistent headache and apoplectiform
attacks, with contraction of the pupil, slow pulse, and vom-
iting. Choked disk is not infrequent, localizing symptoms
may be made out, and coma is apt to arise.

The treatment is the same as that for external pachy-
meningitis.

Acnte leptomeningitis is a purulent inflammation of
the soft membranes of the brain. The pathological changes
can be noted in the pia and in the brain-substance. The brain
is edematous, the pia purulent, the convolutions are flattened,
the ventricles are distended with fluid, and hemorrhages
occur into the brain-substance. Pus may be localized upon
the pia, but it is usually diffused over one hemisphere or
over both. Various organisms may be found, especially
streptococci, staphylococci, and diplococci. In some cases we
find the bacillus pyocyaneus or the bacillus pyocyaneus
foetidus, which is identical with the colon bacillus and uith
the bacillus meningitis purulenta (Park). Saprophytic or-
ganisms are occasionally present. This disease may be acute
or chronic, and a severe case is spoken of as encephalitis.
Secondary leptomeningitis is apt to affect the convexity;
primary' leptomeningitis is apt to affect the base (Hirt).

The causes of leptomeningitis are epidemic cerebro-
spinal fever, tuberculosis, acute general diseases (pneu-
monia, typhoid, erysipelas, and rheumatism), bone-diseases.

DISEASES AND INJURIES OF THE HEAD, 559

traumatisms, middle-ear disease, syphilis, and sunstroke.
The tissues of the pia and the cerebrospinal fluid con-
tain diplococci identical with pneumococci. Infection may
take place by various avenues. It may pass from the nose
by way of the Eustachian tube to the ear, or from the nose
to the frontal sinus or ethmoid sinuses (Hirt), and from
these situations to the brain. It may pass from the middle
ear or mastoid to the membranes of the brain. In fractures
at the base the organisms enter by way of the pharynx and
the Eustachian tube, or the ear. The BjnnptomB of acute
leptomeningitis are violent headache persisting during delir-
ium, flushing of the face, rigidity of the neck, cerebral vom-
iting, a slow pulse, elevated temperature, photophobia, con-
traction of the pupils, intolerance of sound, hyperesthesia
of the skin and muscles, and delirium passing into stupor
and coma. A chill or a succession of chills may occur.
Choked disk, striabismus, and nystagmus are not unusual.
Convulsions or paralyses may occur. Death is the rule
within one week. The treatment usually consists of purga-
tion with calomel ; bleeding behind the mastoid processes ;
cold to the head; warm baths with cold affusions to the
head ; iodid of potassium, bromid of potassium, or morphin
for vomiting and headache. Some surgeons trephine in
order to relieve pressure and to give exit to inflammatory
products, and this procedure should be employed. It gives
some hope of recovery, and the usually adopted medical
treatment is practically useless ; should the patient recover,
he is guarded for a long time from physical exertion, mental
excitement, worry, irritation, constipation, and insomnia.

Chronic I/eptomeningitis (or Encephalitis). — The
causee of chronic leptomeningitis are the same as those of
the acute form. If traumatism is the cause, the inflamma-
tion arises at a later period than it would in acute encepha-
litis. The Bjnnptoms of concussion follow a head-injury.
Days, or even weeks, after the accident, a series of symp-
toms occur — namely: localized pain at the seat of injury,
often accentuated by tapping; listlessness ; irritability; apathy
regarding business affairs and home obligations, or profound
depression and hypochondria with inability to attend to
business. Choked disk may exist. In any case acute en-
cephalitis may arise, with or without a chill. The treatment
of this disease is symptomatic unless local symptoms exist.
Always operate if localizing symptoms are found. Intense
local pain justifies trephining.

Tubercular Meningitis (Acute Hydrocephalus ; Water

56o MODERN SURGERY,

on the Brain). — This inflammatory condition is due to the
bacilli of tuberculosis. In a child affected with meningitis there
is often a record of a fall, the injury acting as an exciting cause
by establishing an area of least resistance. Prodromal symp-
toms are common (restlessness, irritability, anorexia, change
of character). The disease begins with a convulsion or with
headache, fever, and vomiting (Osier), the child cries out
from pain (the hydrencephalic cry), and the bowels are con-
stipated. The pulse is rapid in the beginning, but later be-
comes slow and irregular. The pupils are contracted, there
is muscular twitching, and the sleep is impaired. The tem-
perature is about 103°. In the second period of the disease
the vomiting ceases, constipation becomes more marked, the
belly retracts, headache is not so violent, and the patient
lies in a soporose condition interspersed with episodes of
delirium. In this stage the pupils dilate and are often un-
equal, the head is retracted, convulsions occur or limited
rigidity is noted, the respirations are sighing, and if a finger-
nail is drawn along the skin, a red line develops (the tdclie
cerebrate^ due to vasomotor paresis). Squint and conse-
quent double vision are usual. In the last stage coma be-
comes absolute and general convulsions or limited spasms
are apt to occur. Optic neuritis exists, and the child passes
to death along a road identical with that of typhoid collapse.
In some cases the examination of cerebrospinal fluid with-
drawn by lumbar puncture throws light upon the diagnosis.
In children the base is usually involved, and the disease is
apt to last from two to four weeks ; in adults the convexity
of the brain is usually involved, and death is apt to occur
in a few days.

The treatment is like that for traumatic meningitis.

Abscess of the brain is a localized collection of pus.
The organisms found are noted upon page 558 (Acute
Leptomeningitis). The causes are suppurative otitis media
(in half of all the cases), fracture of the skull, concussion
of the brain, and general septic diseases. A tubercular
mass may caseate (tubercular abscess). The abscess may
be between the dura and skull (extradural), adhesions
forming and preventing a general leptomeningitis, between
the dura and brain (subdural), or in the brain-substance
(cerebral or cerebellar). Leptomeningitis may arise be-
cause no adhesions form, because septic clot forms in veins
or sinuses, or because infected blood regurgitates in sinuses
(Park). A traumatic abscess is generally beneath the area
to which the traumatism was applied, but it may be on the

DISEASES AND INJURIES OF THE HEAD. 561

opposite side. The infection may begin in the nose (page
553), the orbit, or the middle ear. Roswell Park says in-
fection may pass along blood-vessels, lymph-vessels, nerve-
sheaths, or the prolongations of the membranes which extend
outside of the skull. An acute inflammation of the middle
ear rarely causes abscess, because an acute inflammation in
sound tissues causes the formation of granulation-tissue^
which acts as a barrier to infection. Chronic inflammation
of the middle ear is the most frequent cause of abscess. Park
tells us if the roof of the tympanum is involved, it is per-
forated and abscess of the middle fossa ensues ; if the roof of
the tympanum is perforated toward the mastoid antrum, the
abscess arises in the temporosphenoidal lobe ; if the perfora-
tion is toward the sigmoid groove, the abscess forms in the
cerebellum.^

SyxnptomB of AbBcess of the Cerebral Substance. —
The symptoms due to pus-formation are as follows : there
may be an initial rise of temperature, but (except in extra-
dural abscess) the temperature quickly becomes normal or
subnormal. Toward the end of the case the temperature
may rise and the fever become linked with delirium.
Surface elevation of temperature over the seat of the ab-
scess is occasionally observed. A chill may or may not
occur. Anorexia and vomiting are present. Urinary
chlorids are diminished and the phosphates are increased
(Somerville). Symptoms due to pressure are — headache
(which at first is general, then local, and grows worse
later in the case, and exists even in delirium : this fact dis-
tinguishes it from the headache of fever, which ceases in
delirium) ; pulse is very slow ; respiration tends to the
Cheyne-Stokes type ; drowsiness lapses into stupor and
stupor passes into coma ; paralysis of the sphincters takes
place; convulsions are common ; sensation is rarely impaired;
and paralysis of the basal nerves may occur (third and sixth
especially). The pupil on the same side as the abscess is
dilated and fixed. Choked disk is not invariably found;
if it is unilateral, it is on the same side as the abscess ; if
it is bilateral, it is more marked on the same side as the
abscess. Localizing symptoms, spasmodic and paralytic,
depend upon the center which is irritated or destroyed.
In cerebellar abscess there are vertigo, vomiting, occipital
headache, rigidity of the post-cervical muscles, and inco-
ordination. Choked disk is often absent

Meningitis arises soon after an accident ; an abscess, more

* Park, in Chicago Med. Recordy Feb., 1895.
38

5 62 MODERN SURGERY,

than a week, often many weeks, after an accident. Menin-
:gitis presents high temperature and the general symptoms
fcefore outlined. Mastoid disease may occasion cerebral
symptoms without abscess, or it may cause abscess. In
sinus-thrombosis there is septic temperature, the veins of the
face and neck are enlarged, and a clot can usually be felt
in the jugular. A tumor grows slowly, usually presents
almost from the start distant localizing symptoms, and
double choked disk is frequently present. In tumor the
temperature is apt to be normal.

Treatment. — If abscess is due to ear disease with implica-
tion of the mastoid cells, at once open the mastoid, and after
this proceed to trephine the skull in order to reach the ab-
scess. In any case, if symptoms of abscess exist, trephine
the skull at once. If localizing symptoms are present, open
over the suspected region. If localizing symptoms are not
present and the cause is ear disease, trephine at Barker's
point (Fig. 179). If no pus is found between the bone and
dura, open the membrane. When the dura is opened, if the
abscess is subdural pus will be evacuated ; if the abscess is
in the brain-substance, the brain will bulge very much and
will not be seen to pulsate. A grooved director is plunged
into the brain, in the direction of the abscess, for two or two
and a half inches (Keen). If pus is not found, withdraw the
director and introduce it at another point. When pus is
discovered incise the brain with a knife, enlarge the open-
ing by inserting a closed pair of forceps and withdrawing
the instrument with the blades open. Scrape away the
granulation-tissue lining the abscess-cavity, irrigate with hot
salt solution, and introduce a rubber drainage-tube ; stitch
the dura, but leave an ample opening for the tube ; bring the
tube out through a button-hole in the scalp, and after the
first two days pull the tube out a little every day and cut
off a piece. If the first trephining does not find pus, trephine
again at another point. In cerebellar abscess make a flap
with the base up, and trephine or gouge away the bone just
below the line of the lateral sinus. Puncture the brain as
for cerebral abscess.

Brain Disease from Suppurative Ear Disease.—

Chronic disease of the middle ear is apt to destroy the bone
between the t>^mpanum and the middle fossa of the skull,
and thus produce meningitis, thrombosis of the petrosal or
lateral sinuses, abscess of the temporosphenoidal lobe or of
the cerebellum, or extradural abscess. Chronic otitis media
also induces inflammation or suppuration of the mastoid

DISEASES AND INJURIES OF THE HEAD. 563

cells (empyema of mastoid). Pus in the mastoid may dis-
charge itself into the middle ear, and from this point into
the external auditory canal, through a perforation in the
drum-membrsme (especially in acute cases). In some cases
the pus becomes blocked up within the mastoid process.
Pus in the mastoid may after a time break into the cavity
of the cranium or into the lateral sinus, or may find its
way externally and open into the sheaths of muscles aris-
ing from the mastoid. It not unusually opens into the
sheath of the digastric muscle (Bezold's abscess). These
facts teach the surgeon that chronic ear disease should never
be neglected, but should, if possible, receive the closest atten-
tion of the specialist. If no perforation exists in the drum,
the surgeon must make one. In ordinary cases cleanliness
and antisepsis are sufficient, the ear being syringed every
day with a warm 2 per cent, solution of common salt. If
only a small drum-perforation exists, 10 drops of pure alco-
hol or of corrosive-sublimate solution (i : 5000) are dropped
into the ear daily ; but if a large drum-perforation exists, boric
acid and iodoform (7 to i) are insufflated. Never inject alum.
A strong silver solution is not safe ; if it is used, wash the
ear out afterward with warm salt water. If granulations or
polypi exist, they must be removed (Burnett). Some cases
require the removal of the drum-membrane and the ossicles
of the ear. Many cases of mastoid necrosis are due to tuber-
culosis. If headache, vomiting, and mastoid tenderness exist,
open the mastoid (see Operations), in order to prevent ab-
scess of the brain. In acute otitis media it is very rarely
necessary to open the mastoid. The middle ear is on a
lower level than the antrum of the mastoid, and in most
acute cases both the middle ear and mastoid cells drain safely
through a drum-perforation. Because a man has chronic
otitis media it is by no means always necessary to trephine
the mastoid. In many cases removal of the ossicles and
drum-membrane effects a cure. In chronic otitis media, even
if the mastoid is trephined, the ossicles and membrane ought
to be removed.

Cerebral abscess £rom ear disease is almost always

in the temporosphenoidal lobe, but may arise in the cere-
bellum. The symptoms are a transient rise of temperature
followed by a subnormal temperature ; vomiting ; mastoid,
frontal, and temporal pain. The mind is dull, and stupor
arises which passes into coma ; the bowels are constipated ;
choked disk may be present ; and convulsions or spasms or
paralyses may exist. Trephine and clean out the mastoid.

564 MODERN SURGERY,

and asepticize (sec Operations upon the Skull and BrainV
Trephine at Barker's point, one and one-fourth inches be-
hind, and the same distance above, the middle of the exter-
nal auditory meatus. If pus is not found, open the cerebel-
lum.

Extradural Abscess. — ^The eye-symptoms and pain are
the same in this as in cerebral or subdural abscess, but the
temperature is different, rising to 103° or 104®. There is
often considerable tenderness above and behind the mastoid
Trephine and clean out the mastoid ; follow up a bone sinus
to the abscess, rongeur away the bone, avoiding the lateral
sinus, curet. irrigate, and drain.

Infective Shitis-thrombosis (a form of P>'emia). — The
symptoms of this disease present a history of chronic ear
disease; general headache and pain over the sinus arise;
violent rigors occur ; and the temperature rises and fluctu-
ates greatly. The patient is nauseated, labors under vertigo,
is very restless, is dull and stupid, sometimes delirious, and
the muscles of the neck are stiff. Tenderness and marked
edema are detected over the mastoid. When the clot extends
into the jugular vein there is pain on moving the head and on
swallowing, glands are swollen, and a clot may be felt in the
neck. Exophthalmos and swelling of the eyelids point to
involvement of the cavernous sinus (Jansen). Choked disk
exists in about half of all cases. There is usually a profuse
discharge of pus from the ear. In early cases there is throm-
bosis of the lateral sinus alone, or of the lateral sinus and
jugular vein. In advanced cases other sinuses become in-
volved (superior petrosal, inferior petrosal, both cavernous,
the lateral sinus of the opposite side, the ophthalmic veins,
and the torcular Herophili). A patient with sinus-throm-
bosis is in great danger from pulmonary metastasis and
septic meningitis (Jansen). Septic meningitis is accompanied
by abscess about the sinus.

The prognosis largely depends upon early recognition.
The surgeon should open a mastoid before sinus-thrombosis
arises, and should evacuate a perisinous abscess before a clot
forms in the sinus, or at least before that clot is septic (Jan-
sen).

Treatmient. — Infective sinus-thrombosis is treated as fol-
lows : open and clean out the mastoid, and expose the sinus by
the use of the chisel or rongeur (Fig. 179). Open the sinus as
far as the clot is soft, and cut away the wall of the sinus. In-
troduce a small spoon in the sinus and carry it toward the
torcular Herophili, and scrape away the clot until blood

DISEASES AND INJURIES OF THE HEAD, 565

flows. Stop hemorrhage by plugging a piece of iodoform
gauze into the wound and toward the torcular. Jansen op-
poses removing the entire clot toward the jugular, and does
not tie the jugular, believing that to do so increases the dan-
ger of thrombosis of the inferior petrosal and cavernous
sinuses. Influenced by these views, Jansen removes the soft
clot, but does not disturb the solid clot toward the heart.
Most surgeons differ with him, and after opening the sinus,
turning out the clot and packing, proceed to ligate the jugu-
lar vein at the level of the cricoid cartilage. If, after this
operation, the clot in the jugular becomes septic, incise the
vein up to the base of the skull and pack. It is obviously
futile to do any operation if pulmonary metastasis has taken
place.

Intracranial tumors may be true neoplasms, may be of
parasitic origin, may result from injury, may be tubercular or
syphilitic. Among these tumors are papillomata, gliomata,
sarcomata, cholesteatomata, fibromata, psammomata, myxo-
mata, osteomata, etc. (see Tumors). Cysts sometimes occur.
The symptoms are diffuse and local, and are similar in
many particulars to the symptoms of some other lesions.
Among the symptoms of tumor are headache, slow speech,
stupor or coma, slow pulse, pain on percussion of the cra-
nium, vertigo, vomiting, epileptic convulsions, double choked
disk, partial or complete blindness, extensive or limited
paralyses, paralysis of face, of eye-muscles, or of limbs,
zones of anesthesia and aphasia, word-deafness, word-blind-
ness, agraphia, inco-ordination, and mental disturbances.
The situation of a tumor is determined from localizing
symptoms, their mode of onset and manner of combina-
tion. In some cases the symptoms are not character-
istic, and in some cases there are no localizing symp-
toms. The nature of the tumor, its depth, and whether it
is single or other tumors exist, is, if possible, determined.
Localizing symptoms may be due to irritation or destruction
of functionating power. Irritation causes spasm and destruc-
tion induces paralysis. Convulsions which are local or which
begin locally are known as Jacksonian epilepsy. A local
convulsion points to an irritative lesion of, or immediately
adjacent to, the center which presides over the muscular
movements of the part convulsed. Local paralysis points
to a destructive lesion of the center which presides over the
movements of the paralyzed part. In some cases a center is
damaged and the muscular movements it controls are para-
lyzed, but the adjacent brain-areas are irritated and the mus-

566 MODERN SURGERY,

cles they represent are attacked with spasms. In some cases
an apparently paralyzed part becomes convulsed, the center
not being completely destroyed and sudden hyperemia serv-
ing to awaken spasm. Always note the order of invasion of
different regions and observe if spasm is followed by mus-
cular weakness or anesthesia.

1. Lesions in the Cortical Motor Area. — An irritative le-
sion of the lower third of this area causes spasm of the oppo-
site side of the face, angle of mouth, or tongue ; and this con-
dition is often associated with tingling (Osier). The spasm
may remain limited or may extend widely, and may even
become general. Tumors of the third frontal convolution of
the left side cause motor aphasia. An irritative lesion of the
middle third of the cortical area causes spasm, which is lim-
ited to or begins in the fingers, thumb, wrist, or shoulder
(Osier). An irritative lesion of the upper third of the cor-
tical motor area causes spasm, which is limited to or be-
gins in the toes, ankle, leg, or hip. In these lesions an aura
is occasionally felt in the affected region before the spasm
begins, and there is often numbness after the spasm. De*
structive lesions of this region cause local paralysis, which is
often preceded by local spasm of the same parts, and is often
associated with local spasm of other parts.

2. Tumors of the prefrontal region give no localizing
symptoms, but produce the general symptom.s. Mental dis-
orders are apt to occur. The tumor may grow and subse-
quently involve the motor region,

3. Tumors of the parieto-occipital lobe may occupy a
silent region of this lobe. There may be blindness or para-
phasia when the angular gyrus is affected.

4. Tumors of the occipital lobe produce homonymous
hemianopsia.

5. Tumors of the temporosphenoidal lobe frequently
produce no symptoms. Tumors in the left lobe may cause
deafness.

6. Tumors of any size in or about the corpus striatum cause
hemiplegia by pressure upon the internal capsule. Pressure
upon the optic thalamus produces hemianopsia and hemianes-
thesia. Growths near the basal ganglion produce intense optic
neuritis, and early pressure because of distention of the ven-
tricles. Osier tells us that tumors of the corpora quadri-
gemina arc apt to involve the crura, and later the third nerve.
Ocular symptoms are always present (loss of pupillary reflex
and nystagmus). If the third nerve is involved, there are
paralysis of the motor oculi area on the side of the lesion

DISEASES AND INJURIES OF THE HEAD, 567

(external strabismus, dilated pupil, and drop lid), and hemi-
plegia of the opposite side of the body from pressure upon
the crus. This condition is known as a crossed paralysis.

7. Tumors of the Pons. — Pontine lesions produce symp-
toms by pressure upon the particular nerves which come from
this region, with or without the evidences of pressure upon the
motor path. Forms of crossed paralysis may exist. Lesions
in the lower half of the pons may affect the fifth, sixth, and
seventh nerves on the side of the lesion, and the limbs
on the opposite side. The auditory nerve may be involved
in the lesion. In crossed paralysis the face on the side of
the limb paralysis is usually not affected, but in extensive
tumors it may be paralyzed. Conjugate deviation may occur
away from th^ facial paralysis. In tumors of the upper part
of the pons the pupils may be first contracted from irritation
of the third nerve nuclei, and later dilated from destruction of
these nuclei. Anesthesia as a result of pontine tumors is not
nearly so common as is motor paralysis, and convulsions are
rare.

8. Tumors of the Medulla.' — An extensive lesion inev*
itably causes death. Cranial nerves only may be involved,
but crossed paralysis may take place. Vomiting is com-
mon, retraction of head is not unusual, respiratory and cir-
culatory disturbances and dysphagia are frequently noted;
sometimes there is numbness, and occasionally there are
convulsions; usually there \% inco-ordination, because of
pressure upon the cerebellum.

9. Tumors of the Cerebellum. — Tumors of the middle pe-
duncle cause sudden uncontrollable movements of the trunk,
either toward the side of the tumor or away from it. Vertigo
and nystagmus are common. Symptoms are frequently com-
plicated by evidences of pontine disease proper.

Tumors of the middle lobe of the cerebellum cause a sense
of lost equilibrium and obvious unsteadiness in attempting
to walk, or even to stand (Gowers). The patient has a ten-
dency to fall ; there are giddiness and vomiting.

Tumors of the cerebellar hemispheres produce no localizing
symptoms. The usual unsteadiness of gait is due to press-
ure upon the middle lobe (Nothnagel).^

Treatment. — In brain tumors, where any doubt exists as
to their nature, give a course of iodid of potassium, and as
doubt is the rule, we almost invariably administer it. Give
at first in small amounts, but rapidly increase it until heroic

^ For full consideration of localizing symptoms, see Gowers and Osier, from
which the above has been condensed.

568 AfODERN SURGERY.

doses are taken (lOO or more grains a day). Mercury should
also be given hypodermatically. If iodid of potassium and
mercury relieve the symptoms, operation is unnecessary,
although it may be demanded later in order to remove an
irritant scar. If antisyphilitic treatment fails, the question
of operation must be considered. In many cases of un-
doubted tumor excision for cure is not attempted because
of the absence of localizing symptoms or because of the
inaccessible situation of the growth. Tumors at the base,
tumors of the pons and medulla, of the corpus callosum,
of the basal ganglia, of the deeper parts of the centrum
ovale, are irremovable (Byrom Bramwell). Most tumors of
the cerebellum should not be attacked. In tumors which
are very extensive complete removal is usually out of the
question. There is no use in removing secondary malignant
tumors. It often happens that the brain itself (as in syphilis)
is so extensively diseased, or that other organs (as in tuber-
culosis) are so involved, as to render attempts at removal
futile. Bramwell tells us ^ that he has studied eighty-two cases
of intracranial tumors, and he considers that in only five of
them could the tumor have been entirely removed. Our
conclusion is that though some tumors of the brain may be
successfully removed, extirpation is only to be decided on
after careful study of all the indications and contraindications
offered by the case. The fibromata constitute the best cases
for operation. In cases not operated upon it may be neces-
sary to use the bromids for convulsions and morphin for
headache. The headache is often benefited by purgatives,
courses of potassium iodid, the ice-bag to the head, and the
application of a hot iron to the nape of the neck. Though
thorough extirpation is feasible in but few cases, operation
should often be performed for palliative purposes. Grainger
Stewart, Annandale, Horsley, Macewen, and Keen have ad-
vocated palliative trephining in certain cases.

This procedure is of value in diminishing excessive intra-
cranial pressure, and thus relieving headache and decreasing
the tendency to sudden death from inhibition of the heart
(Hughlings Jackson and Byrom Bramwell) or respiratory
failure.

Palliative trephining will relieve optic neuritis and thus
tend to prevent atrophy and blindness. Bramwell asserts
this positively, and he still believes that high pressure is an
important clement, though not the only element in neuritis.

Most cases of tumor should be trephined for exploration ;

^ Edin. Med. Jour.y June, 1894.

DISEASES AND INJURIES OF THE HEAD, 569

in some cases extirpation may be performed ; in most cases ex-
tirpation is impossible, and the surgeon must be content with
the palliative influence of trephining. A tumor of the brain
is of necessity fatal if unoperated upon, and trephining is not
a very dangerous operation. After palliative trephining, make
an attempt to obtain prolonged drainage of cerebrospinal
fluid.

Operative Treatment of Epilepsy. — The shock of

an accident or a general concussion may establish epilepsy,
especially in those predisposed by heredity or other causes.
Traumatic epilepsy, Le Dentu tells us,' may be due to:
(i) bone-fragments from skull-fracture; (2) outgrowths of
bone due to tumor ; (3) cicatrices of meninges resulting from
laceration of membranes by bone-fragments; (4) chronic
meningitis which ends in sclerosis of membranes; (5)
cysts resulting from intracranial hemorrhage at the point
of fracture; (6) arteriovenous aneurysm. We refer here,
in speaking of traumatic epilepsy, purely to the condition
when it follows a head-injury, and this is the common
meaning of the term. When epilepsy has followed trau-
matism and a scar exists upon the scalp, excise the scar,
especially if it is tender or is the seat of an aura. If, on
lifting the scalp, a depression of bone or a disease of the
bone is manifest, trephine for exploration, even over a silent
area. Remember that epilepsy, as shown by Sachs, may
follow a long-forgotten injury. Where the injury is over a
known center, trephine. This operation is especially indi-
cated when the convulsions begin in the muscles of this
center, in which case remove the center after trephining.
Remove all sources of peripheral irritation (Briggs reported
a case of epilepsy in which there was distinct skull-depres-
sion and necrosis of the tibia, but the cure of the necrosis
of the tibia stopped the fits). Trephining in epilepsy may
disclose a cyst, a dural scar, a brain-scar, a depressed portion
of bone, or eburnation of bone from osteitis (Keen). In ex-
ploratory operations for epilepsy always open the dura. If
epilepsy arises notwithstanding a primary trephining, open
the flap, round the bony edges with a rongeur, and cut out
the scar.*

These operations sometimes seem to cure, but so, occasion-
ally, does any operation. White records^ ninety trephin-

* La Presse Midicale^ June 9, 1894.

* The author, in Hare's System of Practical Therapeutics.

■ " The Supposed Curative Effects of Operations per j^," Annals of Surgery,
August and September, 1 89 1.

570 MODERN SURGERY.

ings in which, though nothing was found, great relief fol-
lowed, and two cases were apparently cured ; he mentions
benefit or apparent cure following tracheotomy, ligation of
the carotid, incision of the scalp, etc. The same effect may
be obtained by a great shock, high fever, the administration
of an anesthetic, or an accident The fact seems to be that any
operation, by means of nervous shock, may interrupt the
epileptic habit ; but in ordinary operations the fits tend to
recur, and soon reach their old standard of frequency. In
the special brain-operations with excision of obvious lesions
or discharging centers the fits usually recur, but they will
rarely reach the old standard of frequency, and will be more
amenable to medical treatment. Bramwell says that when
traumatism is followed by epilepsy and the epileptic discharge
starts from a cortical center which is not beneath the scar,
trephine first at the seat of injury, and if no lesion is met
with, trephine over the discharging center. In epilepsy the
fits are to be studied by a competent observer (Keen), and,
if focal epilepsy or Jacksonian epilepsy exist, and treatment
by drugs has failed, trephining is to be performed over the
diseased center and the explosive focus is to be located by
an electric current and removed. Keen, Horsley, Nancrede^
Macewen, and others practise this, but hope for improve-
ment rather than expect cure. This operation causes paraly-
sis, but the paralysis is rarely permanent, except, perhaps, of
the finer movements.

In non-traumatic chronic epilepsy without localizing symp-
toms trephining is not justifiable unless persistent headache
calls for it as a means of relief from intracranial pressure.
Annandale has recently advised us to consider experimental
operation in such cases when the drug-treatment has failed
and when the patient's condition seems hopeless. He says
there is no chance of improvement without operation, and
operation may possibly disclose a removable lesion.^ After
trephining for epilepsy five years should elapse without a
convulsion before cure is reasonably assured; and if con-
vulsions arise, they must at once be met by medical treat-
ment. A man having once had a convulsion may at any
time have others ; hence he should always be watched. It
is not unusual for a few convulsions to occur soon after an
operation, and then to cease for a considerable time. These
early fits result from habit. Among the operative procedures
suggested for the treatment of epilepsy may be mentioned
circumcision, clitoridectomy, ocular tenotomy, ligation of the

^ Edin. Med. Jour. y April, 1 894.

DISEASES AND INJURIES OF THE HEAD. 57 1

vertebral arteries, removal of the cervical ganglia of the
sympathetic (Alexander), and the actual cautery to the
head (Fere).

Operations on the Skull and Brain. — Trephiningr

(in a fracture of the skull). — Shave the scalp, wash it with
ethereal soap, then with ether, scrub with a brush wet
with corrosive-sublimate solution (i : 1000), and wrap up
the scalp in wet corrosive-sublimate gauze (i : 2000). The
instruments required are a scalpel, an Allis dissector, hemo-
static, dissecting-, and toothed-forceps, trephines of several
sizes (Figs. 175, 176), a periosteum-elevator, a Hey saw.

Fig. 175. — Gait's conical trephine.

Fig. X76. — Crown trephine.

rongeur forceps, a bone-elevator, a dural separator, a tenac-
ulum, small curved and large curved Hagedom needles,
and a needle-holder, catgut, fine silk, silkworm-gut, and
Horsley*s wax. Provide a sand pillow. The patient is
anesthetized unless he is unconscious. The patient lies
upon his back, the shoulders are a little raised, the sand
pillow is placed under the neck, and his head is turned
away from the side to be operated upon. The position
of the surgeon is such that the patient's head is a little to
his left. A large semilunar incision is made with the base
down, which incision goes through the periosteum, and the
flap is lifted. The bleeding vessels of the flap are caught
with forceps. The fracture is sought for and found. The
pin of the trephine is projected beyond the crown and is set
upon sound bone, the crown overhanging the line or edge
of the fracture. The surgeon tries to avoid the region of a
sinus or large artery. A gutter is cut in the bone, the pin is
withdrawn, and the trephining is completed. In going
through the diploe bleeding is copious. The inner table
feels very dense. Stop from time to time, clean out the
gutter with the dissector, and try the bone with an elevator

572 MODERN SURGERY,

to see if it is loose. When the fragment is loose enough,
pry it out and hand it to an assistant, who places it at once
in a bowl of solution of corrosive sublimate (i : 2000), kept
warm by standing in a basin of water at 105°, or who puts it
in warm carbolized towels or in warm normal salt solution.
The edges of the opening are rounded with a rongeur and
the bone is elevated. Sometimes it may be necessary to re-
move splinters and fragments of bone. The dura should be ex-
amined to see if injury exists, and hemorrhage must be stopped.
Bleeding from the dura is arrested by passing a ligature of
silk or catgut under the vessel on each side of the wound.
This is effected by means of a curved needle. Bleeding from
the pia is arrested by direct ligation, or in the same way as is
bleeding from the dura. Bleeding from the diploe is arrested
by the use of Horsley's wax. The wound is cleansed, the
button of bone is re-introduced, or some chips are cut from
the bone and scattered upon the dura. The scalp is sutured
with silkworm-gut and horse-hair or gauze drainage is em-
ployed for a day or two. Sterilized gauze dressings are put
on, a rubber-dam is laid over them, and a gauze bandage wet
with bichlorid of mercury is applied.

Instead of the trephine some surgeons use the chisel, or
gouge, and hammer to remove a portion of the bone. Other
operators maintain that this procedure may cause concussion,
and employ the surgical engine. After removing the frag-
ments the edges of the opening should be smoothed by the
use of the rongeur forceps.

Osteoplastic Resection of the Skull. — Wagner devised
the osteoplastic method of resection. It is employed for the re-
moval of tumors and the Gasserian ganglion, and for explora-
tion. A horseshoe incision is made through the scalp and
periosteum, a groove corresponding to this incision is chiselled
in the bone, the bone is chiselled through, but is left attached
to the scalp. The bone is then broken outward, the fracture
taking place at the base of the bone-flap. After the opera-
tion the bone which is still adherent to the pericranium is
restored to its proper place. Some surgeons use the surgical
engine instead of the chisel, and others make trephine-open-
ings and cut from within outward by means of the Gigli
wire saw (Obalinski). The osteoplastic method of opening
the skull is employed when a large opening is necessary,
as when the operation is first of all for diagnosis. Krause,
Keen, and others employ this plan in operating to remove
the Gasserian ganglion.

Doyen of Rheims has advocated the most extraordinary

DISEASES AND INJURIES OF THE HEAD. 573

exploratory operation. He sections the vault of the skull
from before backward near the median line and forces
one entire side outward, thus exposing half of the brain.
Besides restoring a flap of bone into position, or replacing
a button of bone, or strewing the dura with bone-fragments,
other methods of closing the opening have been practised.
For instance, heteroplasty with decalcified bone-plates and
heteroplasty with celluloid plates or other foreign material.^

Trephininfir the Frontal Sinus. — This operation may be
employed for inflammation of the lining membrane of the
sinus or for empyema. Make a vertical incision in the mid-
dle of the forehead, starting one and one-half inches above
the nasion and terminating at the root of the nose. The
button of bone is removed and the opening is enlarged if
necessary. The mucous membrane is incised, the opening
into the nose is found and is dilated, and a drainage-tube is
passed into the nose from the sinus, the upper end being left
in the sinus. In some severe cases Jacobson advises us to
first curet the sinus, to disinfect it by the use of silver nitrate
or chlorid of zinc, and to insufflate an " aseptic powder." In
some cases resect the mucous membrane. Some surgeons
prefer an osteoplastic resection to trephining.

Trephining the Ma49toid (page 575).

Technique of Brain-operations (after Horsley and Keen).
— Instruments as for fractured skull. In focal epilepsy a fara-
dic battery is required. Always shave the scalp, and always
antisepticize it. In localizations, mark out the fissure upon
the scalp with an anilin pencil or with iodin. Have the
patient semi-recumbent. Mark three points upon the bone
with the center-pin of the trephine before incising the scalp
(both ends of the Rolandic fissure and the point at which
the trephine will be applied). Make a semilunar flap three
inches in diameter, with the base below. Control bleeding in
the flap by forceps pressure. The one and a half inch trephine
should be employed, but if a smaller trephine is used, the
opening must be enlarged with a rongeur. Before enlarging
the opening, separate the dura from the bone by a dural
separator. As a rule, open the dura and examine the
brain. The dura is lifted by rat-toothed forceps and is
opened with scissors along a line a quarter of an inch from
the bone-edge, a broad pedicle of dura being left uncut.
Hemorrhage is arrested by pressure and hot water, or by
passing a curved needle threaded with catgut around any
bleeding vessel. In some cases packing must be left in or

* See Bretans, in Deutsche med. Woch.^ May 17, 1894.

574 MODERN SURGERY,

forceps must be kept on. In packing, never use more than
one piece of gauze, so as to avoid leaving in a forgotten
piece. Upon opening the dura cerebrospinal fluid flows out,
the stream being increased with each expiration. Absence
of pulsation of the brain points to tumor, and a livid color
indicates subcortical growth. An old laceration is brownish.
If the brain bulges through the opening, it means increased
pressure (tumor, abscess, effusion into the ventricles, etc.).
After opening the dura employ no antiseptics except normal
salt solution, especially when the surgeon intends using elec-
tricity to locate a center. Remove any abnormal brain-tissue
which is found. In operating for tumor the dura is opened and
in some cases the brain is incised. The tumor is turned out
by the finger, or, if this is impossible, by the dry dissector, the
scissors, or the sharp spoon. If the entire tumor cannot be
removed, take away as much as possible. The removal of a
portion retards the growth of the remainder (Horsley), and
the trephining, by lessening cerebral pressure, relieves the
symptoms and prolongs life. After removing a tumor arrest
distinct points of bleeding with the ligature alone or the
ligature passed around the vessel by means of a needle.
Pack the tumor-cavity with gauze and bring the end of the
plug out of the wound. Stitch the dura with .silk and
suture the scalp with silkworm-gut. In electrifying the brain
faradism is employed of a strength about sufficient to move
the thenar muscles when applied to them. The current is
applied to the motor area by the double electrode. A careful
observer watches the muscular movements. If, for instance,
the surgeon wishes to remove the thumb-center, he moves
the electrode from point to point until he obtains thumb-
movements. The region is sliced away bit by bit until the
current applied to this zone no longer causes thumb-move-
ments. It will be found impossible to remove only the thumb-
center. Adjacent centers are sure to be more or less dam-
aged, and a certain amount of paralysis follows the operation.
If we wish to tap the ventricles. Keen directs that the tre-
phinc-opening be one and one-fourth inches behind the exter-
nal auditory meatus and the same distance above the base-line
of Reid (Fig. 179, a). A grooved director or metal tube is
passed into the brain in the direction of a point " two and
one-half to three inches above the opposite meatus." The
normal ventricle will be entered at a depth of two to two
and one-fourth inches, but the dilated ventricle will be entered
sooner (Keen). The moment of entiy is marked by lessened
resistance and a flow of cerebrospinal fluid. Drainage can

DISEASES AND INJURIES OF THE HEAD. 575

be maintained by introducing a rubber tube. This operation
has been employed in hydrocephalus. After an aseptic cere-
bral operation, as a rule, do not drain unless hemorrhage has
been considerable. In many cases replace the bone, but not
when the bone is diseased, is infected, or is very compact, or
if it is desired to alter pressure. The dura is sutured by a
continuous silk suture (Fig. 177); the scalp is sutured by
interrupted silkworm-gut sutures (Fig. 178).

Fig. 177.— Continuous suture. Fig. 178.— Interrupted suture.

Operation for Mastoid Suppuration. — The instruments
required in this operation are a scalpel, a gouge, a chisel, a
mallet, curets, a probe, a dissector, dissecting- and hemo-
static forceps, and needles. Provide a sand bag to place
under the neck. An incision is made one-quarter of an inch
posterior to the auricle and down to the bone, and in the
direction of the long axis of the mastoid. The bone is bared
and examined, especially at a point in the line of the incision
which is on a level with the roof of the meatus (Fig. 179, c).
The bone will usually be found softened. Gouge it away
and thus open the mastoid antrum. This bone-opening is
within the limits of Macewen's suprameatal triangle, a space
bounded by the posterior root of the zygoma, the posterior
bony wall of the meatus, and a line joining the two. If the
mastoid is opened in this triangle, the antrum is entered
directly and there is no chance of wounding the lateral
sinus. If, in the adult, pus is not found on opening the mas-
toid antrum, gouge downward and backward, but with great
care, so as to avoid the lateral sinus. After evacuating the
pus, scrape out the cavities with the curet, enlarge the
opening between the mastoid and the middle ear with the
gouge, turn the head toward the side operated upon, and
irrigate the mastoid with corrosive-sublimate solution
(i : 2CXX)); dust in iodoform, pack with iodoform gauze for a
few days, and then introduce a silver drainage-tube. Treat
the causative ear disease. A. Marmaduke Sheild and
Macewen operate on inveterate cases of mastoid disease as
follows : a thick flap is raised behind the auricle, the flap
including the orifice of any sinus and being " left attached by

5/6 MODERN SURGERY.

its stalk." The auricle is '* detached forward and the soft parts
over the mastoid are turned backward by horizontal in-
cision." The "lining membrane of the canal is separated
from the bone." The mastoid is opened and dead bone
and caseous matter are removed, overhanging edges are
chiselled down, and the posterior bony wall is gouged awaj

The skin-flap is pushed into the cavity and is held in place
with pads of gauze. The margins of the flap may be sutured,
but this is not necessary. Macewen calls this procedure
"papering" the cavity with skin.'

If mastoid suppuration has established abscess in tk
tcmporospJunoidal lobe, trephine one and a quarter inches
behind and one and a quarter inches above the middle of
the external meatus {Barker's point, Fig. 179, «), and search

' Lantrt. Feb. 8, 1896.

SURGERY OF THE SPINE, $77

for pus as directed on page 562. If abscess of the cerebellum
exists, trephine below the line of the lateral sinus — that is,
below a line running from the inion to a point on a hori-
zontal line from the roof of the meatus, one inch posterior
to the middle of the meatus. If infective sinus-thrombosis
exists, break into the lateral sinus (Fig. 179, d) through the
mastoid opening and proceed as directed on page 564.

Linear Grcuiiotomy. — Instruments as for any brain opera-
tion, plus, however, several kinds of rongeur forceps. Make
a large flap. Trephine the skull a finger's breadth from the
sagittal suture, and the same distance back of the coronal
suture. Rongeur the bone away in a line parallel with the
sagittal suture up to a point in front of the lambdoidal
suture. Remove the pericranium which covered the bone
excised. Insert the dural separator, or pass it along the
margins. In some cases an additional portion of the bone
is removed over the fissure of Rolando. Various sugges-
tions have been made as to the direction and situation of
bone-sections. Bleeding is arrested and the flap is closed
without drainage.

Removal of Gassexian Qangrlion (page 533).

Operation for Infective Sinus-thrombosis (page 564).

XXIV. SURQERY OF THE SPINE,

Congenital Deformities. — Spina bifida, or hydrorrha-
chitis, is a congenital cystic tumor due to vertebral deficiency,
permitting protrusion of the contents of the spinal canal in
the median line. The laminae or spines of one vertebra or
of several vertebrae may be deficient, most frequently in the
lumbosacral region. Meningocele is a protrusion of dura
mater and arachnoid, the sac containing cerebrospinal fluid,
but no nerves and no cord-substance. Meningomyelocele
(the commonest form) is a protrusion of dura mater and
arachnoid, the sac containing cerebrospinal fluid, nerves,
and cord-substance. The cord may spread upon the sac-
wall or it may pass through the sac and re-enter the canal.
Syringomyelocele is great distention of the central canal,
the sac-wall being formed of the thinned cord. A spina
bifida varies in size from that of a walnut to that of a
child's head ; it grows rapidly during the early weeks of
life ; it is usually sessile, but may present where it joins the
body a definite constriction, or even a pedicle ; the base of
the sac is covered with healthy skin, and the fundus is
covered only by thin epidermis or by the spinal membranes

5/8 MODERN SURGERY.

themselves. Pressure upon the tumor is found to diminish
its size and to increase the tension of the anterior fontanelle,
and possibly to cause convulsions or stupor. The cyst is
translucent, and the margins of the bony aperture are dis-
tinct. Crying, coughing, or pressure upon the anterior
fontanelle makes the tumor more tense. Spina bifida is apt
to be associated with club-foot, with hydrocephalus, and
with rectal or vesical paralysis. Spina bifida usually causes
death. A few meningoceles and a very few meningomyelo-
celes undergo spontaneous cure by the shrinking of the sac
Syringomyelocele is invariably fatal. The cause of death
may be rupture of the sac or marasmus.

Treatment. — Very small protrusions which grow slowly
and are covered with sound skin may be treated by the use
of a compress and bandage, by an elastic bandage, or by
applications of contractile collodion. Some surgeons tap
and drain the sac. Injection is used by many. The sac
being cleaned, the child is placed on its side and a little
chloroform is given. A fine trocar is plunged obliquely in
at the side through sound skin, little or no fluid being drawn
off, and 3j of Morton's fluid is injected fiodin, gr. x ; iodid
of potassium, gr. xxx ; glycerin, 3j). The trocar is with-
drawn and the puncture is sealed with a bit of gauze and
iodoform collodion. The child is put to bed. If the injec-
tion proves successful, the sac shrinks ; if the injection fails,
it may be repeated at intervals of from seven to ten days
(Jacobson, White). Many surgeons prefer excision of the
sac. Bayer treats it as he would a hernia. Robson, in
some cases, excises the entire sac (page 594).

Tumors of the Spine. — Among congenital tumors are
lipomata and cysts (dermoid, congenital, sacral, and fetal).
Tubercle, gumma, psammoma, and fibroma may arise from
the cord or its membranes. Glioma is the most usual
growth. Primary sarcoma is rare. Angeioma may occur.
Carcinoma is never primary. A tumor rarely produces obvi-
ous symptoms until it is as large as a hazel-nut.

Symptoms and Treatment. — Pain, stiffness of the back,
areas of anesthesia, and progressively advancing motor
paralysis are symptoms of spinal tumors. A tumor may
produce the symptoms of compression-myelitis, locomotor
ataxia, or myelitis. In glioma there are apt to be loss of
ability to recognize variations of temperature (or even to
distinguish between heat and cold), loss of the sense of pain,
and paresis and atrophy of muscles. Contractures or para-
plegia may arise. The location of the tumor can be inferred

SURGERY OF THE SPINE. $79

by a study of the territory of paralysis and the zone of
sensory disturbance. The tumor is always somewhat above
the upper limit of anesthesia. In many cases the diagnosis
is impossible. Gradually increasing painful paraplegia, with
pain in the back, or with sensory paralysis after a time ap-
pearing and ascending from the feet toward the trunk, points
to tumor as a cause. The reflexes are at first increased,
but are finally lost from below upward. Spasms may de-
velop, and lateral spinal curvature may arise. If curvature
arises, the concavity of the curve will be on the side of the
tumor. Growths outside the membranes produce partic-
ularly pain and spasm ; growths within the membranes pro-
duce especially motor paralysis and anesthesia. If syphilis is
suspected, give the patient a course of heroic doses of iodid
of potassium. In a focal lesion not due to dissemination of
a known malignant growth perform the operation of lamin-
ectomy to permit of exploration and possibly of removal.

Acute osteomyelitis of the vertebrse is a rare dis-
ease ; it may be associated with osteomyelitis of other bones,
but may occur alone. Infections of the viscera not unusually
accompany it. Any part of a vertebra may suffer from it.
This condition arises from cold, over-exertion, or traumatism,
and is more common in the young than in the old. The
process may be superficial, or it may involve the bone deeply
and widely. Suppuration always occurs; sequestra generally
form ; and phlebitis is a dangerous complication. Any region
of the spine may be attacked, but the lumbar region is par-
ticularly liable to invasion. The situation of the abscess
varies with the situation of the disease. If the bodies are
diseased the pus passes forward (retropharyngeal, mediasti-
nal, psoas, or pelvic abscess). If the vertebral arches suffer,
the pus passes backward (lumbar or dorsal abscess). The
membranes of the cord, the cord itself, the nerves, and the
vertebral articulations are frequently involved in the process.
Staphylococci or streptococci may be grown from the pus.

Symptoms. — General symptoms are those of osteomyel-
itis. Local symptoms depend on the seat of disease. If the
posterior portion of the column is diseased, there is a hard
swelling, which, in the neck, is in the middle line ; in the dor-
sal and lumbar regions, in the middle or to the side ; and in
the sacral region, invariably to one side.

Rigidity always exists. If the vertebral bodies are affected,
rigidity is noted, the spine is tender, and special symptoms
arise dependent on the region affected (retropharyngeal ab-
scess, etc.). Occasionally symptoms of meningomyelitis are

58o MODERN SURGERY,

noted. The constitutional symptoms of sepsis are marked,
the condition is sudden in onset, and purulent collections
diffuse widely and rapidly. These points enable the surgeon
to make a diagnosis between osteomyelitis and Pott's disease.
In osteomyelitis angular deformity very rarely arises, be-
cause the patient is recumbent and because hyperostosis is
taking place.

Treatment. — The patient is kept recumbent. His consti-
tutional treatment is such as will combat sepsis (food, stimu-
lants, etc.). A puriform area must be incised and disinfected.
If bone denuded of periosteum is found, it is touched with a
solution of chlorid of zinc or the actual cautery. If a seques-
trum exists, it is removed. A drainage-tube is inserted and
dressings are applied (Miiller, Makins, Abbot, and Chi-
pault).

Spinal Curvatures. — There are four chief forms of spinal
curvature : (i) lateral curvature (the scoliosis of the older sur-
geons) ; (2) posterior curvature (the excurvation, gibbosity,
or kyphosis of the older surgeons) ; (3) anterior curvature
(the lordosis of the older surgeons) ; and (4) angular curva-
ture (from spinal caries). The normal spine has four curves :
the cervical curve, the convexity of which is forward ; the dor-
sal curve, the concavity of which is backward ; the lumbar
curve, which is convex anteriorly ; and the pelvic curve, which
is concave anteriorly. The dorsal and the pelvic curves, which
are primary, are due to the formation of the cavities of the
chest and pelvis, and depend upon the shape of the bones
(Treves). The cervical and lumbar curves, which are com-
pensatory, depend upon the shape of the intervertebral
disks, and only appear after birth when the erect position
is assumed.

Lateral curvature (scoliosis) is a lateral deviation of the
spinal column, often accompanied with rotation of the ver-
tebrae and associated with increase or with diminution of the
normal curves. Lateral curvature is predisposed to by weak
muscles and ligaments, by the habitual assumption of strained
and unnatural attitudes, by unequal length of the legs, and by
paralysis of one leg. This distortion, which is commonest in
girls, is apt to arise at the age of puberty (it is usually cor-
rected in boys by outdoor exercise). The bones are soft and
the muscles are weak, and this condition is often hereditary.
Rickets is very commonly associated with lateral curvature.
Any condition of ill-health weakens the muscles ; hence lat-
eral curvature may arise after an acute sickness or in a per-
son who outgrows his strength. An empyema with adhe-

SURGERY OF THE SPINE. 581

sions, by pulling on the chest-wall, may produce a curvature
the concavity of which is toward the diseased side.

The weak muscles cease to sustain the spinal column, and
the ligaments stretch, relax, or lengthen. The commonest
curve is toward the right in the dorsal region (be-
cause most people use the right hand more than
the left). As soon as a dorsal curve to the right
arises a compensatory lumbar curve (Fig. 180)
takes place to the left, thus enabling the patient
still to sit or to stand erect. In almost all cases
the vertebrae soon rotate, the bodies turning to the
convexity and the spines turning to the concavity
of the curve ; hence the transverse processes to-
ward the convexity project. The ribs follow the
spinal rotation; the shoulder is elevated on the
side of the convexity, and the hip on the same side La^'^ Jjj^
is raised (Bowlby). The intervertebral disks are curvature to
apt to flatten out on the concavity of the curve. In LmpfiJato^y
very rare instances lateral curvature results from IS^hriJft."'*
caries of a half of one or of several vertebrae. In
a spinal tumor lateral curvature may occur, the concavity of
the bend being on the side of the growth.

Symptoms, — ^An ordinary case of spinal curvature from
weak muscles arises gradually. Stooping is noticed, and
after a time pain is complained of in the dorsal and lumbar
regions, and weakness in the back is detected by the sufferer.
The pain is made more severe by sitting long in one attitude.
Anemia is manifest, and walking is awkward and ungraceful.
When the shoes and clothing are removed, and the child
stands with its back toward the surgeon and the feet sym-
metrically together, the lower angle of the right scapula (in
a dorsal curvature to the right) is unduly prominent and is
elevated above the left ; the normal prominence of the left
iliac crest is lost ; the right iliac crest is unduly distinct ; on
marking the spinous processes with an anilin pencil the curve
becomes manifest ; tenderness is often developed on pressing
the spines ; the normal dorsal anteroposterior curve is exag-
gerated ; the abdomen is protuberant ; the chest is flattened ;
the neck juts forward ; and the breast on the same side as the
concavity of the curve is more prominent and on a lower level
than the other breast. Always observe if the anterior iliac
spines are on a level or not, and always measure the length
of the legs. The patient, with the knees extended, bends
forward with the arms hanging loosely : the erector spinae
muscle between the iliac crest and the last rib is seen to be

582 MODERN SURGERY.

more prominent on the convexity of the lumbar curve than
on its concavity (Bernard Roth), and the angles of the ribs
on the side of the convexity of the dorsal curve are on a
higher level than are those on its concavity. Have the child
assume what it supposes to be an erect attitude, and let the
surgeon correct this into the best possible position (Roth),
and see how long the new position can voluntarily be main-
tained. A large percentage of these patients labor under pes
planus. When there is no osseous deformity (that is, when
the surgeon may, by manipulation and traction, correct the
deformity), and when the spinal muscles are not paralyzed,
the prognosis is good for complete cure. Roth states that
cases without osseous deformity can practically be cured in
one month, but the treatment must be continued for one year
to prevent relapse.^ In cases of moderate osseous deformity
the patient can be improved vastly by three months' daily
treatment (Roth). Even in severe cases of bony deformity
the pain may be relieved and the deformity be modified.

Treatment. — If one leg is too short, let the patient wear
a thick-soled shoe. No treatment for weak muscles has
ever been devised so utterly irrational and absurd as the
prevention of all movement ; and neglect of all treatment for
lateral curvature does less harm than immobilizing the spinal
muscles by braces and supports. The muscular nutrition
in these cases is to be restored, as is muscular nutrition in
any other region, by scientific gymnastics, electricity, the
douche, salt baths, frictions, and massage. Bicycles with
specially constructed seats are used with advantage in some
cases. The mode of exercise to be used should be directed
by some one skilled in orthopedics, and the instruction in
the details must be thorough and persistent. Roth's advice
is to so re-educate the muscular sense that a patient can
again know whether she is or is not standing straight ; to
maintain an improved position in sitting and standing; to
use such clothing as will not interfere with the assumption
of a normal attitude ; to enforce systematic training of the
muscles of the spine and thorax ; and to give attention to
the general health. In some cases where, in spite of all
attempts at correction, deformity increases, it may be neces-
sary to immobilize in hope of obtaining ankylosis and pre-
venting further deformity. In those rare lateral curvatures
due to caries a supporting apparatus must, of course, be
applied.

Anteroposterior curvature (not from spinal caries or

^ Heath's Dictionary of Practical Surgery.

SURGERY OF THE SPINE. 583

from hip-joint disease) is an increase of the normal antero-
posterior curves. Increase of the dorsal curve is posterior
curvature, kyphosis, or excurvation (Fig. 181, a) ; increase of
the lumbar curve is anterior curvature,
lordosis, or saddle-back (Fig. 181, b). ^ ^

Both lordosis and kyphosis are apt to
be present. Scoliosis has nearly always
some anteroposterior curvature asso-
ciated with it. Lordosis is apt to be
compensatory, to prevent the center of
gravity going too far forward. Lordosis
is found in pregnant women and in very
fat men. In an old man kyphosis arises
from flattening out of the vertebral disks

from pressure. Rheumatic gout may ^'°'aiid ioi^MSJ^S!* ^^^
cause it. Anteroposterior curvature is
often due to paralysis of the erector spinae mass (from infantile
paralysis). Pseudo-hypertrophic paralysis causes lordosis.

Symptoms and Treatment, — The symptoms of anteropos-
terior curvature are as follows : the thorax is flattened or
pigeon-breasted; the shoulder-blades are widely separated
and the scapular angles project ; the abdomen is protuberant ;
the patient complains of backache and soon tires. A recent
kyphosis disappears when the patient lies upon his stomach.
The facts that the erector spinae muscles are soft, and that
pain is absent on concussion transmitted from the heels,
separate kyphosis from caries. Lordosis is unmistakable.
When the spine is movable employ the same plan of treat-
ment as that in lateral curvature, suiting the gymnastics
to the deformity (Roth). In painful kyphosis with partial
ankylosis endeavor to make the ankylosis complete to pre-
vent pain, obtaining this result by applying a plaster jacket
which laces up and letting the patient wear it for several
years.

Angrular curvature (Spinal Caries; Spondylitis; Pott's
Disease) is usually due to tubercular caries of the vertebral
bodies, and occurs particularly in children who are predis-
posed to tuberculosis, but it may arise at any age. Any por-
tion of the spinal column may be attacked. The dorso-
lumbar region is most prone to suffer. The chief cause
is tuberculosis, but syphilis, secondary cancer, and acute
myelitis of the vertebrae are occasional causes. Blows or
strains are often exciting causes. Angular curvature may
develop after an exanthematous fever.

The cancellous tissue of the anterior portion of a verte-

584 MODERN SURGERY,

bral body becomes primarily carious, or the inflamma-
tion begins in an intervertebral disk. (The changes of
tubercular osteitis have previously been set forth.) The
body of the vertebra and the vertebral disk are destroyed,
and the process extends to adjacent vertebrae. The weight
which rests upon the spinal column causes softened bone
to crumble, compresses the diseased vertebrae and disks,
and produces angular deformity (the anterior part of the
spine formed by the vertebral bodies is shortened, the pos-
terior part is not, and hence the spines project). In some
cases the disease is spontaneously arrested by organization
of inflammatory products, and ankylosis (fibrous or bony) in
deformity is Nature's cure. In most cases, however, the dis-
ease spreads and caseous pus is formed, which, according to
the route it takes, causes lumbar abscess, dorsal abscess,
psoas abscess, or postpharyngeal abscess (page 106). In
some cases the spinal cord is compressed, but in most
cases it is not, and even when it is compressed paraplegia
is rare and is usually temporary. Compression of the
cord may be caused by the displaced vertebrae or by in-
flammatory material or caseous matter between the bone
and dura mater, but is most often due to pachymeningitis.
Caries of the cervical region constitutes a more danger-
ous disease than caries of either the dorsal or the lumbar
region (dangerous pressure occurs more easily). Death
may be caused by exhaustion, sepsis, hemorrhage, amyloid
disease, pneumonia, peritonitis, pleuritis, tubercular dissemi-
nation, pressure upon the cord, or inflammation of the cord
or its membranes.

Symptoms. — The first symptom of angular curvature is
pain in the back, which is increased by motion, by pressure,
and by vertebral jars. Neuralgic pains pass into distant
parts (sciatica, intercostal neuralgia) and are often linked
with muscular spasm. Pain may not appear until late in the
progress of the case. A chronic bilateral pain in the trunk
or extremities is suggestive of Pott's disease. " Chronic bilat-
eral belly-aches in children are almost diagnostic " (Jordan
Lloyd). The pain of dorsal caries can be relieved by lifting
the shoulders ; the pain of cervical caries by traction on the
head. Cramp in the legs occurs in dorsal and in lumbar caries.
The sufferer from Pott's disease, if a child, grows tired easily,
shows alteration of disposition, becomes moody and irritable,
complains of vague pains in many places, constantly leans,
rests, or lies down, and walks with the back rigid, which
produces a peculiar gait. A painful spot is found by press-

SURGERY OF THE SPINE. 585

ing upon the spines, and the same spot is painful on pressing
the head downward or upon jarring the entire spine. Fara-
dism to the back causes pain. Spasm of the erector spinae
mass is detected (Hilton, Golding-Bird). The presence
of the knuckle due to bending the spine at an acute angle
is a very important sign of the disease. In many cases
angular deformity appears late, in some cases it does not
appear at all. An angular deformity is detected sooner in
those regions where the normal curves are posterior than
where normal curves are anterior (Jordan Lloyd). The
deformity appears early in the dorsal region, but late in the
cervical and lumbar regions. In some rare cases lateral
deformity occurs. Rigidity is an early sign of great impor-
tance. It is always present. Rigidity is manifest very early
in cervical caries, tolerably early in lumbar caries, late in
dorsal caries. Lloyd gives the following practical rules to
enable us to detect rigidity.^ In the cervical region : sit the
patient in a chair and tell him to nod the head. Stiffness in
nodding points to occipito-atloid disease. Tell him to look
far to the right and then far to the left. Stiffness of these
motions suggests atlo-axoid disease. Tell him to place his
shoulders against the back of the chair and carry his eyes
back along the ceiling. Stiffness in this movement indicates
disease below the second cervical vertebra. It is practically
useless to examine the dorsal region of an adult for rigidity,
but such an examination can be made in a child. Place the
patient prone on an adult's lap, mark the tip of each spinous
process with an anilin pencil, make the child stand up straight,
and observe if any of the marks have come nearer together.
If it is seen that two or more marks do not approach each
other, there is rigidity which prevents approximation. To
test for rigidity in the lumbar region lay the naked patient
prone upon a couch. Grasp the patient's ankles and raise
the pelvis from the couch. If the lumbar spine is flexible,
the pelvis can be lifted without raising the chest from the
bed, and the maneuver deepens the hollow of the loin. If
the lumbar spine is stiff, the maneuver lifts the trunk and
produces no alteration in vertical outline of the lumbar
spines. If a child with Pott's disease is asked to pick up
something from the ground, because of rigidity or pain on
movement he will not bend the back, but will bend the
knees or get upon the knees. Paralysis may exist, and it
is due to pachymeningitis more often than to pressure from
bone. Cervical caries causes dyspnea and torticollis, the

* Birmingham Med. Review^ April, 1 897.

586 MODERK SURGERY.

head requiring support with the hand. Dysphagia indicat
abscess. In adults the first signs of Pott's disease to attract
attention are backache, neuralgia, girdle-pain, cramp, or even
paralysis. In sacral caries there \% no deformity and fre-
quently no pain. The diagnosis becomes apparent when
bilateral abscess is detected in the buttocks or groins
(Jordan Lloyd).

Treatment of Caries of the Spine. — When recent caries of
the spine is active and affects a child, when it is accompa-
nied with pain and fever, and when paralysis threaten;
upon perfect rest. Place the child supine on a hard mattri
and, if possible, take it, while still in bed, out of doors dail]
Leeches, blisters, or the hot iron over the area of pain ma;
do good. When the activity of the process abates apply a
fixation apparatus. In diseases at or near the vertebro-
occipital articulation, as long as dyspnea persists, keep the
patient supine with a small hard pillow under the nape
the neck (Hilton) and a sand-bag on each side of the h<

and neck. After several months mechanical support can be
given by Fumeaux Jordan's method. Jordan applies his
support as follows : the patient lies on a flat hard table, his
arms are raised above his head, and traction is made upon
the head by means of a pulley and a weight. Cotton pads
are placed over the ears, the back of the neck, and the clav-
icles, and are held in place by a flannel bandage applied
as a figure-of-8 of the head, neck, and chest. "Hie flannel

SURGERY OF THE SPINE. 587

bandage is overlaid with plaster-of-Paris bandages.^ In disease
of the cervical region below the axis use Say re's jury-mast
(Fig. 183). This appliance relieves the spine from the weight
of the head and acts admirably. In many cases of Pott's
disease some fixation apparatus is employed. The best of
all fixation apparatus is Sayre's plaster-of-Paris jacket applied
while the patient is suspended (Fig. 182). The Sayre appa-
ratus applied in this manner is used for the treatment of
caries of the lumbar region and the lower half of the dorsal
region. When all subjective signs cease substitute for Sayre's
jacket a felt jacket which laces (Golding Bird). Caries of
the upper half of the dorsal region is oflen treated by a
Sayre's jury-mast (Fig. 183), but in many cases the jury-mast
will fail, and it is necessary to place the patient horizontally in
" an open cuirass, fitted to the back from occiput to sacrum,
and combined with pulley extension to the head and pelvis." *

Spinal abscesses are treated as indicated on page 483.
Treves operates to remove the carious bone, making his
incision in the back, but many surgeons do not approve
of the operation. Chipault and Calot have advocated forci-
ble correction of the deformity. The patient is anesthe-
tized, and is placed face down ; one assistant holds the feet,
another the head, another supports the abdomen, and
another the pelvis. While strong traction is made on the
head and feet, the surgeon makes very forcible pressure
on the projection. After the correction of the deformity a
plaster-of-Paris support is applied so as to include the neck,
trunk, and pelvis. Plaster-of-Paris support is used for at least
six months. In some cases Calot resects the spines and
laminae of the diseased vertebrae, and performs osteotomy
of the ankylosed vertebral bodies.*

Some surgeons have warmly advocated laminectomy in
spinal caries paraplegia. This operation is rarely necessary,
but in some few cases is imperatively demanded. Many
cases recover from paraplegia without operation— operation
has a very heavy mortality ; many are not benefited at all by
it, but in some cases it has certainly saved life (page 595).

Laminectomy should not be undertaken until treatment
by rest and fixation has been applied for at least one year
(Willard).

Laminectomy may be necessary in cervical caries to pre-
vent asphyxia. The operation enables the surgeon to re-

* See Children" s Deformities^ by Walter Pye.

* Jordan Lloyd, in Birmingham Medical Review^ April, 1897.

* F. Calot, in Archiv. Prov. de Chirurgie^ Feb., 1 897.

588 MODERN SURGERY,

move masses of inflammatory material which make pressure
on the cord. The dura should not be opened unless there
is evidently trouble beneath it, in which case it is incised and
any tubercular area removed, the dura being subsequently
sutured. Menards removes the transverse processes of the
diseased vertebrae and the heads and necks of the associated
ribs in order to give the surgeon access to the diseased ver-
tebral bodies.

During the course of caries of the spine give fats, tonics,
and nutritious food, and try to get the patient out often into
the fresh air. Sea-air is very beneficial. When all active
disease ceases, and only angular curvature remains, use an
apparatus to combine extension with mechanical support, the
plaster jacket being generally employed.

Injuries of spiiml ligaments and muscles, which
may complicate more serious injuries or may exist alone, are
caused by wrenches, twists, and violent muscular efforts (as
in lifting). Railway accidents may be responsible for these
sprains and strains.

Symptoms. — Injuries of the back, even without cord-
injury, are frequently linked with very deceptive nervous
symptoms. Symptoms are often severe, but are usually
temporary. In some few cases the symptoms are per-
sistent. Secondary disease of the cord is extremely rare.
Any region may be affected, but the lumbar is most usu-
ally injured, and the entire spine may suffer. The three
marked symptoms are pain, tenderness, and stiffness of
the back. At the time of injury, and for a time after, there
is often marked shock, and hysterical excitement is occa-
sionally observed. The cardinal symptoms may arise very
soon, but may not become severe for a day or two. The
pain is not acute when at rest, but becomes acute on move-
ment.^ This pain is felt in the back, and sometimes darts
into the extremities. The muscles are rigid, the spasm
being due to pain. The patient is very careful not to
twist or bend the spine, because to do so increases pain.
In a one-sided injury the rigidity is unilateral, and this
symptom cannot be simulated. Often, but by no means
always, the region of the back is swollen and the skin is
discolored. The tenderness is not of the skin, but of the
muscles. Firm pressure on a real spot of tenderness causes
rapid pulse (Mannkapf). The vertebral spines are regular
and are not mobile. There is no distant paralysis or
hyperesthesia unless the cord is damaged (though in some

^ MouIIin on Sprains,

SURGERY OF THE SPINE, 589

rare cases the bladder and the rectum are paralyzed when
no cord-lesion can be detected), and hyperesthesia may exist
over the spines. Moullin tells us that the extremities feel
weak because they are deprived of proper support on account
of the immobility of the muscles of the back. For the
same reason the action of the abdominal muscles is inter-
fered with, and the power of micturition and of defecation
is impaired (there are constipation and difficulty in emptying
the bladder).

The treatment of recent injuries comprises rest; the
ice-bag and leeching over the painful area; in a day or
two hot fomentations, tincture of iodin, and inunctions of
ichthyol and lanolin ; and, later, massage, douches, and
frictions with a stimulating ointment. Phenacetin relieves
pain, though in some cases opium is necessary. The injury
is called " railway spine " when it is caused by a railway acci-
dent.

After the immediate effects of the accident subside trau-
matic neurasthenia is apt to arise. In this condition the
patient grows tired easily and complains of pains and aches
in the back and loins, interfering with or preventing work ;
paresthesia and numbness exist in the extremities ; in many
cases sexual intercourse is impossible because of premature
ejaculation or of incapacity for erection ; there are dyspepsia,
eye-strain, insomnia, loss of memory, rapid and irregular
pulse, cardiac palpitation, and mental depression or con-
fusion. The reflexes are usually exaggerated, but they can
be exhausted more easily than can the exaggerated reflexes
of organic cord disease (because of irritable weakness). Some
rigidity and tenderness exist in the back, and the skin over
this region is often hyperesthetic. Attacks of retention of
urine may occur. Hypochondria is not unusual.

Treatment of Traumatic Neurasthenia. — Employ rest,
tonics, massage, douches, and frictions to the back. Secure
sleep, and endeavor to bring about a gain in weight. If
sexual incapacity or seminal emissions worry the patient,
dilate the urethra with steel bougies.

Traumatic hysteria develops only in those predisposed by
a neuropathic hereditary tendency ; traumatic neurasthenia
may arise in anybody. In the first disease the accident is
only the exciting cause ; in the second disorder it is the
cause. Many cases of so-called " railway spine" are really
examples of traumatic hysteria. Traumatic hysteria and
neurasthenia may be associated. Neurasthenia is a con-
dition of exhaustion associated with a number of chronic

590 MODERN SURGERY.

disorders; it forms a foundation on which hysteria loves
to build its structure. This structure of hysteria is made up
of morbid impressionability, hyperesthesia of centers, low-
ered self-control, and sensitiveness of the peripheral nervous
system. The accident plays a double part in producing trau-
matic hysteria : first, by its effect on the mind (psychical trau-
matism) ; second, by its effect on the body, which anchors the
attention at one point, and this area of pain or stiffness often
serves as an autosuggestion which undergoes morbid magnif-
ication when viewed through the distorting medium of hysteria.
Erichsen taught that the symptoms of what he named " rail-
way spine" arose from inflammation of the cord and its mem-
branes, a view now abandoned. A blow given to a hysterical
person causes a feeling of numbness, and this negative sen-
sation from local shock may establish the idea of paralysis,
or the traumatism, acting as a suggestion, may inhibit motor
representations and destroy the normal ideas of motion and
feeling (Charcot and Pitre). Terror always causes a feeling
of loss of power in the legs, and the terror of the accident
may thus develop the idea of paraplegia. The site of a trau-
matism may localize symptoms ; for instance, a blow upon
the eye may cause amaurosis or blepharospasm. It is im-
portant to remember Charcot's saying that a hysteria, long
latent and unrecognized, may be awakened into obvious
activity by a blow or an accident. Pitre shows the same to
be true of epilepsy. A not unusual lesion is hysterical trau-
matic monoplegia, not coming on at once after the accident,
but usually some days afterward, and presenting flaccid mus-
cles, the electrical reactions and reflexes remaining normal,
but the muscular sense being lost (Pitre). The muscles
usually waste. The skin of the paralyzed limb is anesthetic
or analgesic. There may be anesthesia limited to a limb,
hemianesthesia, or general anesthesia.^ Hysterical jjaraly-
sis is usually associated with the permanent stigmata of
hysteria — concentric contraction of the visual field, pharyn-
geal anesthesia, convulsive seizure, and hysterogenic zones
(Clarke and Pitre). The permanent stigmata may be latent
Hysterical phenomena lack regularity of evolution, and they
may be produced, altered, or abolished by mental influences
or by physical forces which produce no effect on organic
disease. In most hysterical conditions the general health is
not profoundly impaired.^

Treatment. — By moral means chiefly. Gain the confidence
of the patient. In many cases separation from family and

* J. Michell Clark, in Brain. ' Read the works of Thorbum and Pitre.

SURGERY OF THE SPINE. 59 1

friends is necessary and isolation is desirable. The Weir
Mitchell rest-cure is the best plan of treatment, and all its
details should be carried out faithfully.

Malingering. — Persons injured in accidents often pretend
to suffer from maladies which do not exist in them. Some
get well upon the rendering of a favorable verdict by a jury.
In any case always examine carefully, so as to be able
to exclude malingering. Note the patient's behavior and
motions when his attention is diverted from his disease.
Meningomyelitis can be excluded if there be no spasm nor
paralysis, hyperesthesia, paresthesia, or anesthesia at a dis-
tance (A. Pearce Gould). If pain has lasted for months,
if pressure downward upon the head or shoulders does not
increase pain, if the vertebrae are movable and there is no
angular displacement, exclude caries. Gould states that
when there are wasted muscles, when moderate spine-move-
ment is painless, but effort in bringing the body erect causes
pain in the erector spinas region, the trouble is a strain of
the erector spinse muscle. If the muscle is not wasted, and
the pain is in bending forward rather than in straightening
up, the vertebral ligaments are the seat of trouble. Unilateral
spasm cannot be simulated. The administration of ether may
dispose of a pretended paralysis.

Concttssion of tlie Spinal Cord. — This term has no
definite pathological meaning. It is probable that the condi-
tion is one of laceration of capillaries and of cord-substance.
The symptom is shock, with intense pallor, nausea, often
vomiting, and sometimes syncope. To this condition special
symptoms may be linked — as temporary paralysis, a girdle-
sensation, numbness and loss of power in the limbs, hiccough,
torticollis, coarse tremors, pains in the back and limbs, areas
of anesthesia and analgesia — depending on the portion of
cord lacerated.

Treatment. — The treatment in concussion of the spinal
cord is the same as that for sprains. Traumatic neurasthenia
and hysteria or organic cord-disease may follow this injury.

Contusion of the spinal cord may arise from a sprain,
but it is usually due to extreme flexion of the spine. It
causes hemorrhage into the gray matter of the cord (hema-
tomyelia). The symptoms are motor and sensor>' palsy and
diminished reflexes. Some cases recover, but others end in
myelitis.

Wounds of the spinal cord, which are rare, are usually
fatal. Wounds above the origin of the phrenic nerves cause
almost instant death. Gunshot-wounds are the most usual

592 MODERN SURGERY,

form, the cord being damaged by the bullet and by bone-
fragments. A knife is sometimes thrust in between the
occiput and atlas.

Compression of the spinal cord may be due to blood
or to lymph. Compression from blood may be due to extra-
medullary hemorrhage or to intramedullary hemorrhage.
Extramedullary hemorrhage causes sudden pain in the back,
the pain radiating from compressed nerve-roots; hyperes-
thesia and paresthesia in the area of the radiated pain, spasm
of vertebral muscles supplied by the compressed nerves,
sometimes of muscles whose nervous supply is below the
lesion ; tremors ; convulsions ; retention of urine ; paralytic
symptoms following the signs of irritation, but no absolute
paralysis (Mills). A girdle-sensation is usual. Intramedul-
lary hemorrhage causes pain, a girdle-sensation, abolition of
reflexes, and paralysis. Spasms, rigidity, and paralysis come
on early. Bed-sores, retention of urine, and incontinence of
feces may occur. Paralysis from hemorrhage is gradually
progressive from below upward (crawling paralysis).

Treatment. — If paralysis from spinal-cord bleeding ex-
tends rapidly, and life is endangered through the probable
involvement of a vital center, perform a laminectomy, arrest
the hemorrhage, and remove the clot. It is wise to always
open the dura and inspect the cord. Extramedullary hem-
orrhage may be arrested by packing. Intramedullary hem-
orrhage may be arrested by a suture, ligature, or packing.
If an extramedullary clot is extensive, it is necessary to make
a second laminectomy opening in order to thoroughly wash
it out. The dura must be sutured and drainage is to be
employed. If there is paraplegia, complete anesthesia of
the paralyzed parts, and entire abolition of the deep reflexes,
operation is useless because the cord is destroyed (White).
In some cases with persistent paraplegia the operation should
be undertaken. If operation is not undertaken, cause the
patient to lie upon his side and give morphin hypodermat-
ically. If hemorrhage continues in the cord and if the patient
be plethoric, perform venesection. Some surgeons advise
hypodermatic injections of ergotin. To promote absorption
of the clot and exudate give a combination of carbonate and
acetate of ammonium, order pilocarpin, and employ spinal
galvanism and hot douches (Bartholow).

Fractures and dislocations of the spine are very rare.
The spinal regions most liable to injury are the atlo-axial,
the cervicodorsal, and the dorsolumbar (Treves). A verte-
bra may be fractured alone, but dislocation without fracture.

SURGERY OF THE SPINE. 593

except in the upper cervical region, very rarely occurs.
These two lesions, dislocation and fracture, are so often
associated that the term fracture-dislocation is used by many
surgeons to include them both. The causes of fracture and
dislocation are direct force (rarely) and indirect violence
(commonly). Fracture-dislocation from direct force may
occur at any part of the column, and in this accident the
posterior vertebral segments are driven together, and the
cord, as a rule, escapes injury. Fracture-dislocations from
indirect force most commonly happen in the cervical and
dorsal regions. In the cervical region reduction can usually
be secured, but in the lumbar region reduction is impossible.
In fractures from indirect force the cord generally suffers.

Symptoms. — In fracture-dislocations much displacement is
rare, but some is almost always recognizable (irregularity of
spines or angular deformity). In fractures there are pain
(which is increased on motion), tenderness, ecchymosis, and
motor and sensory paralyses. Priapism, cystitis, and reten-
tion of urine often occur. Horsley has pointed out that in
many cases a paralysis passes away only to subsequently
recur, the recurrence being due to edema of the cord. In
some cases of spinal injury there is temporary paralysis due to
shock. Persistent paralysis may be due to laceration of cord
or compression of the cord by bone, blood-clot, or products
of inflammation. In total division of the cord the deep re-
flexes are abolished, anesthesia exists, and there is vasomotor
paralysis. The extent of paralysis depends on the seat of
the cord-injury. The prognosis depends on the amount of
damage done to the cord. Fracture-dislocations in the cer-
vical region produce obvious deformity, stiffness of the neck,
and irregularity of the spines, and a displaced vertebra may
occasionally be detected by a finger in the pharynx. Crepitus
can rarely be detected unless a spinous process is fractured.
The Rontgen rays aid diagnosis.

Treatment of Fracture-dislocations. — When dislocation
of the body of a vertebra obviously exists attempt reduc-
tion by extension and rotation (White). The maneuver
is very dangerous in the cervical region, and, as deaths
have happened, some eminent surgeons advise against re-
duction when the injury affects that region. In fracture-
dislocation the traditional plan is to straighten the spine,
gently if possible, and to put the patient upon his back
upon a water-bed or upon air-cushions. In fractures in
the cervical region support the head and neck with sand-
bags. Empty the bladder four times every twenty-four

594 MODERN SURGERY.

hours with a soft catheter, which is kept strictly aseptic.
Take every precaution to prevent bed-sores. Some sur-
geons advocate reduction of the deformity by extension and
counter-extension, and by the application of a firmly-fitting
but removable jacket with the suspension collar (as used in
Pott's disease). The head of the bed is raised and the collar
is fastened to it. Every day extend gently from the shoul-
ders in dorsolumbar fracture, and from the chin and occi-
put in cervical fractures. Extension may be maintained
permanently until cure. White says laminectomy should
be performed for fracture or for dislocation when there is
obvious depression of the vertebral arches ; in all cases of
pressure upon the cauda equina ; when there are character-
istic symptoms of spinal hemorrhage; and in some cases
where rapid degeneration becomes manifest. Surgeons, as a
rule, agree that operation will be useless when there are com-
plete persistent anesthesia and entire loss of reflexes, because
these symptoms indicate that total division of the cord has
taken place. It is useless to operate for fracture-dislocation
of the atlas or axis. In ordinary cases treat by extension
for six or eight weeks, and then operate if the case is not
improving. In hemorrhagic cases, or cases with marked
depression of the arches, operate early. If signs of degen-
eration begin within six or eight weeks, operate at once.
" In compound fractures, in injuries of the laminae and spinous
processes without a complete crush of the cord, when symp-
toms are due to hemorrhage, when pachymeningitis arises,
if the Cauda equina is compressed, operate" (Thorbum).

Operations on the Spine. — Operations for Spina
Bifida. — Mayo Robson maintains^ that operation is not de-
manded when the sac is of small size and is well protected
by sound integument; that operation is improper when a
large portion of the column is fissured, or when paraplegia
or hydrocephalus exists; that operation is only advisable
in meningocele, in cases where integument is thin and trans-
lucent, in cases where the cord is flattened out, or the nerves
are fused. Robson has closed the osseous defect by trans-
planting periosteum.

Instriivicnts Required, — Scalpels, dissecting- and hemo-
static forceps, scissors, rongeur forceps, dural sejjarator,
Hagcdorn needles and needle-holder, silk, silkworm-gut or
catgut.

Operation. — Surround the sac by elliptical incisions. Find
the neck of the sac, and if it contains no visible nerves ligate

* Annals of Surgery^ vol. xxii., No. I.

SURGERY OF THE SPINE. 595

it and cut off the protrusion. Push the stump int6 the canal.
Freshen the bone-margins and spring a piece of celluloid
beneath them to close the gap (Park). Suture over the
stump with small sutures of catgut.*

Treves's Operation for Vertebral Caries (page 483).

Laxninectoxny. — The instruments required in laminectomy
are dissecting-, rat-toothed, and hemostatic forceps ; scalpels ;
bone-cutting forceps; rongeur forceps; a dry dissector; a
periosteum - elevator ; sequestrum - forceps ; small scissors,
straight and curved on the flat; a chisel and mallet; re-
tractors ; blunt hooks ; a probe ; tenaculum-forceps ; a
spoon-curet; a sand -pillow; fine needles, curved and
straight, large needles, and a needle-holder.

In the operation of laminectomy the patient lies prone
and a sand-pillow is placed under the lower ribs. Make an
incision down the vertebral spines, the middle of the incision
corresponding to the seat of fracture. The sides of the
spinous process and the laminae are cleared. The perios-
teum is incised in the angle between the laminae and spines,
and it is lifted away from the arch. The spinous processes
are cut off with forceps close to their bases, the laminae are
removed on each side with the rongeur, and the dura is
exposed. In some cases the fragments will be found on
exposing the vertebra, or the blood-clot will be seen between
the dura and the bone; in other cases the dura must be
opened with scissors vertically in the middle line while it is
grasped with rat-toothed forceps. After reaching and re-
moving the compressing cause, or after failing to find or
remove it, close the dura with catgut, drain the length of the
wound with a tube, stitch the superficial parts with silkworm-
gut, and dress antiseptically.'

Puncture of the spinal menineres, or lumbctr puncture,
was devised by Quincke, and has been carefully tried by
many surgeons (Furbringer, Naunyn, and others). It is
employed as a means of diminishing cerebral pressure in
hydrocephalus, cerebral tumor, uremia, and tubercular men-
ingitis. It has proved of little therapeutic value. In some
cases the examination of the fluid has been of diagnostic
value. Stadelmann has reported 37 cases in which tubercle
bacilli were found in the fluid.' Turbidity of the fluid indi-
cates the existence of meningitis. The back is sterilized ; the

* A full consideration of the various plans of operating will be found in an
article by Marcy, in Annals of Surger^'y March, 1895.

* See J. \V. White's description in the Annals of Surgery; July, 1889.

* Berliner klinische Wochemchrift, July 8, 1895.

596 MODERN SURGERY,

patient may lie prone, with a pillow under the belly, or may
sit in a chair, with the body bent forward ; no anesthetic is
required. A Pravaz syringe is employed, and the point is in-
serted at the under surface of a spinous process. In some
cases but a few drops of fluid will be obtained, in other
cases many ounces can be removed.

XXV. SURGERY OF THE RESPIRATORY ORGANS.

I. Diseases and Injuries of the Nose and Antrum.

Poreig^n bodies in the nose are usually introduced
through the anterior nares, but in rare instances they enter
by way of the posterior nares. Small particles are often
expelled spontaneously; larger pieces gather mucus and
become fixed. Some materials swell after lodgement.

Treatment. — Illuminate the nostril, and, if the foreign
body can be seen, insert a hook back of it and effect its
removal by means of forceps. In many cases anesthesia is
required. Some foreign bodies require to be pushed back into
the nasopharynx. Occasionally expulsion may be effected by
inserting a rubber tube into the unblocked nostril and telling
the patient to blow forcibly through the tube. In serious cases
a specialist should be summoned to remove a portion of the
turbinated bone or to perform whatever operation he thinks
best.

Inflammation and Abscess of the Antrum of
Highmore (Maxillary Antrum). — The source of this
disease may be inflammation of the nose or periostitis around
the roots of the teeth. In some cases the opening into the
nose is patent ; in other cases it is partly or completely blocked.
Caries and necrosis may arise. The symptoms are pain,
edematous swelling of the face, and thinning of the bone so
that it may crepitate under pressure. When pus has formed
certain positions of the head will cause a purulent flow from
the nose, and if a speculum is inserted pus may be seen as it
flows into the nose. The opening of the maxillary antrum
into the nose is at the summit of the cavity ; hence the an-
trum drains when the head is inverted. The ethmoidal cells
and frontal sinus drain best when the patient is upright. Wipe
the interior of the nose and place the patient with his head
between his knees. If the nostril fills with pus, it comes from
the antrum (Cobb). In severe cases the jaw expands, the eye
protrudes, and great tenderness of the alveolus exists. Per-
cussion exhibits a dull note. In making a diagnosis it is well
to take the patient into a dark room, insert an electric light into

SURGERY OF THE RESPIRATORY ORGANS. 597

the mouth and note the diminution of light-transmission on
the diseased side as contrasted with the sound side Trans-
illumination may be easily practised by the use of a cautery
electrode, protected by a small glass vial. Any cautery bat-
tery may be employed (plan suggested by Ohls). Explora-
tory puncture will settle a doubtful diagnosis. This may be
by way of the lower meatus, the canine fossa, or the alveolar
process.*

Treatment. — Before pus forms, order the use of hot fomen-
tations, and remove any diseased teeth. When pus has formed
evacuate it at once. Before performing a severe operation try
the effect of opening into the antrum from the nose, by means
of Krause's trocar, followed by insufflation of iodoform. If
this procedure fails, other means may be employed. If
the disease arises from a carious tooth, pull the tooth and
push a trocar through its socket into the antrum. If the teeth
are sound, bore a hole with a large gimlet or with a bone-
drill above the root of the second bicuspid tooth and one
inch above the edge of the gum. A counter-opening should
be made into the inferior nasal meatus. A drainage-tube is
pulled from the first opening into the nose and is allowed to
protrude from the nostril. Irrigate daily with peroxid of
hydrogen. In three or four days discontinue through-and-
through drainage, but prevent the first opening from closing
until the discharge ceases to be purulent. In severe cases
make a free incision through the canine fossa by means of a
chisel.

Distention and Abscess of the Frontal Sinus. —

The usual cause is an injury which may long antedate the
symptoms. This injury causes or leads to blocking of the
infundibulum ; secretion accumulates and distends the sinus ;
and in some cases pus forms. In many cases the fluid slowly
accumulates, and it requires years to produce marked symp-
toms. In other cases infection takes place, and the symptoms
are positive and violent. If the outlet into the nose is not
permanently blocked, the fluid may discharge itself from time
to time. In the chronic cases there is rarely much pain. The
chief sign is a swelling of the inner or upper part of the orbit,
which swelling progressively increases in size and displaces
the eye. If at any time acute symptoms supervene, there
will be pulsatile pain, discoloration, and tenderness.

Treatment. — In some cases it is possible to pass a trocar
upward from the nose into the sinus, and so drain and irri-
gate. In most cases an incision should be made through the

* Q)bb, in Boston Med. and Surg. Jour., May 7, 1 896.

59^ MODERN SURGERY.

soft parts, and the sinus opened by a trephine or chisel. After
the sinus has been opened it must be curetted, the opening
into the meatus should be restored and enlarged, and a
drainage-tube is to be passed from the forehead incision into
the nostril. Some surgeons open the sinus by making an
osteoplastic flap.

2. Diseases and Injuries of the Larynx and Trachea.

Edema of the l/orynx (Edema of the Glottis). — ^The
causes of edema of the larynx are — acute laryngitis ; chronic
diseases, such as tuberculosis, malignant disease, or syphilis ;
inflammatory disorders, such as diphtheria and erysipelas;
acute infectious diseases ; Bright's disease ; aneurysm; whoop-
ing-cough ; pneumonia ; quinsy ; wounds of the larynx ;
wounds of the neck ; scalds and burns of the larynx, and
the inhalation of irritating vapors, such as those of ammonia
and sulphur. The symptoms are sudden and rapidly increas-
ing dyspnea, respiratory stridor, huskiness of the voice, and
finally aphonia. The swollen epiglottis may be felt with the
finger and may be seen with a mirror.

Treatment. — In cases in which edema of the larynx is
not excessively acute make multiple punctures into the epi-
glottis and favor bleeding by the inhalation of steam. In
severe cases perform intubation or tracheotomy.

Wounds and Injuries of the l/orynx. — The larynx
may be injured internally by foreign bodies, and externally
by blows and cuts. A condition often met with is cut throat,
the result usually of a suicidal attempt on the part of the
patient or a homicidal effort on the part of an assailant.
The cut of the suicide is usually in front ; it misses the great
vessels, but divides the cricothyroid or thyrohyoid membrane.
The epiglottis may be incised, or even be cut off". If a large
vessel is cut, death rapidly occurs. The immediate dangers
of cut throat arc hemorrhage, suffocation by blood, entrance
of air into veins, and suffocation by displacement of parts.
The secondary dangers are pneumonia, infection and sepsis,
exhaustion, and secondary hemorrhage. The remote dangers
are stricture and fistula (Keetley).

Treatment. — In wounds of the throat arrest hemorrhage,
remove clots from the lar>'nx and trachea, bring about reac-
tion, asepticize the parts as well as possible, suture the deeper
structures with silver wire, catgut, or kangaroo-tendon, and
the superficial parts with silkworm-gut, dress antiseptically,
and place a bandage around the head and chest so as to

SURGERY OF THE RESPIRATORY ORGANS. 599

pull the chin toward the sternum. If laryngeal breathing
is much interfered with, perform tracheotomy. Feed the
patient through a tube until union has well advanced. The
old method of leaving the wound open is to be condemned.
When sutures are used primary union may be obtained.
This fact was proved by Henry Morris.

Poreign Bodies in the Air-passages. — ^The lodge-
ment of foreign bodies in the air-passages is a frequent acci-
dent Small solid bodies are usually expelled by coughing.
Liquids and solids rarely pass beyond the larynx (except in
laryngeal disease or palsy, wounds of the floor of the mouth,
cut throat, and in people unconscious or very drunk). In
vomiting during or after the administration of an anesthetic,
or in the vomiting of drunkards, the vomited matter may find
its way into the larynx or lungs. There is great danger of
this accident in an operation upon a patient with intestinal ob-
struction who has stercoraceous vomiting. In most instances
of foreign bodies lodged in the air-passages it will be found
that the object was being held in the mouth when a sudden
deep inspiration was taken (often from laughter). The symjy-
toxns are immediate, due to obstruction by the body and to
spasm, and secondary^ due to the situation of the body and
the changes it undergoes or induces.

Lodgement in the pharynx causes violent dyspnea. The
body can be seen or felt.

Lodgement in the Larynx, — In a severe case the patient
fights madly for air ; his face becomes livid and cyanotic ; his
veins stand out prominently ; speech is impossible, though he
may make noises and utter harsh cries ; violent coughing be-
gins, and then vomiting ; he tries to force a finger down his
throat and clutches at his neck ; sweat pours from him ; he
feels a sense of impending dissolution, and he falls down un-
conscious, with incontinence of feces and urine.* In a less
severe case violent dyspnea gradually departs and the patient
lies exhausted ; but dyspnea and cough are liable to recur
suddenly at any time because of spasm, and they may be
induced by a change of position. These attacks of fierce
spasmodic cough are not at first linked with expectoration,
but after inflammation begins there is a profuse and often
bloody expectoration. Inflammation follows more rapidly
the lodgement of a sharp or irregular body than it does that
of a round or smooth body. Inflammation is apt to produce
edema of the glottis, bronchopneumonia, or ulceration and
necrosis of the larynx. Any foreign body in the larynx

* See Moullin's graphic description in his Treatise on Surgery.

MODBKX Sl'RGER Y.

r- ^-^ent produce spasmodic dyspnea, and it is

- j^< . :<-• cause edema of the glottis. The body
t:=3— .: car be detected by the A''-rays.

-? r - ?< Traciua. — The immediate symptoms of a

. - rtL nachea depend on the shape and weight

,-r, T-nedter it becomes fixed in the mucous

•■•kTrs^ IT and fro with the air-current A

- -.-aV isL^ lo the tracheal bifurcation, and, if
• .r* . mnricius, moves with every breath, and

- , "t:--. :i*u>«< violent lar>'ngeal spasm, cough, and

^ >w-:: TiT.-r vr:bout aphonia. The patient is often

^ ...- -^t ncv«nents of the foreign body, and the

^. ... a: ;;'f,T iaem with the stethoscope. The for-

•a X c*unc with the Rontgen rays. A foreign

•r - it:!^:i i> liable to cause death by dyspnea, or

-^.-ru -w .as :t? be caught in the larynx, or may even

.'«.--- -^^^uiiiT or sharp bodies lodge in the mucous

,...^..^.^. ic-uuc:: "Jtrbmmation, frequent cough, and ex-

.•...:, -iiu Tirally lead to ulceration. Bodies which

-.-.a x-.ic irw moisture tend to lodge and to become

,* :4 J •• y^r\*Hchus, — Foreign bodies in the bronchi
u^;^ w t■^: right bronchus. When a small lung-
,:>o-.:ca»i the obstructed side shows diminished
?. \ ,.«m:rt and murmur with occasional whistling
-v.^: rv:st rales; the percussion-note is normal.
.vc '/cv is obstructed all respirator)' sounds
. X- t. ,ind over the unob.structed lung respira-
,^'.-.u\v . the percu.ssion-notc over the obstructed
. >i ^j-^-vMnt, but becomes dull. The A-rays will
. >^ v^o/f tv-* detect some foreign bodies in a bron-
^v-"'^''" "^ "^ bronchus may cause bronchopneu-
>^- xcv, xrr.orrhage, and even gangrene.
,,.:«*^v. s"* A foreign body lodges in the phar>''nx, tr>'
. .1 : V \\ this fails, push it back into the esoph-
vx^o-^vt:: in the larynx or below, if the symptoms
;^v-'- ,:: once perform a quick lar>'ngotomy. If
^. -i^ i-v not so urgent, get a complete histor}' of
.s, ■. . •v* "^-d out the nature of the foreign body. Re
. x^ ' Nx*v is retained in the respiratory tract, and de-
.'',.. ..^ <.:;Kition may be. Often a Iar>'ngologist can
. v'v;'' Nviy from the larynx by means of forceps,
. .. ".'« Seinir used for illumination. The fauces
•v v^^c'* of the lar\'nx should have cocain applied
^*:-. ;\un and spasm. If the surgeon fails in

SURGERY OF THE RESPIRATORY ORGANS. 6oi

extraction by forceps, and laryngotomy has been performed,
continue the search through the opening in the cricothyroid
membrane ; if laryngotomy has not been performed, let it be
done in the form known as thyrotomy (a vertical incision
between the alae of the thyroid cartilage, and the separation
of these alae to permit of exploration). After a thyrotomy
suture the perichondrium with catgut. If the foreign body
is in the trachea or in a bronchus, perform tracheotomy:
this prevents suffocation from laryngeal spasm or edema.
The foreign body may be expelled; if it is not expelled,
search the trachea and bronchi with Gross's forceps, with
probes, with hooks, or with the finger. If the foreign body
cannot be found, put the patient to bed, and maintain a moist
atmosphere in the room. As a rule, when the foreign body is
not found insert a tube. If the foreign body be extracted do
not insert a tube (unless edema of the glottis exists or is likely
to come on), do not suture the wound, but cover it with
moist gauze and let it heal by granulation. Morphin and
sedative cough-mixtures are given. Gross says that even
when a foreign body has long been retained an operation
should be performed so long as the air-passages are not
seriously diseased. What shall be done when a foreign
body is lodged in a bronchus and we are unable to extract
it through a tracheotomy wound ? True said if " the patient
is in danger of death " go through the chest-wall and at-
tempt to remove the body. He said this with a full knowl-
edge of the difficulty of locating the body. This difficulty
has been partly overcome by the -AT-rays, and it seems more
certainly our duty now to pursue this plan than it was a
short time ago. Some surgeons advocate incision from
behind.* It is possible to reach the bronchus, but many
surgeons believe that advances in technique will be necessary
before we can hope to save a patient by opening a bronchus
and removing a foreign body. Paget disbelieves in any direct
incision.

3. Operations on the Larynx and Trachea.

Tracheotomy. — The instruments required in this oper-
ation are the scalpel, dissccting-forceps, a dry dissector,
hemostatic forceps, scissors, a tenaculum, aneurysm-needle,
tubes, tapes, Paquelin cautery, needles, needle-holder, a
mouth-gag, tongue-forceps, foreign-body forceps, retractors,
and, if membrane is present, feathers and a solution of bicar-

* See Stephen Paget's Surgery of the Air-passages.

602

MODERN SURGERY.

bonate of sodium. In a fonnal operation give chlorofonn.
but in an emergency case this cannot be done. The patieiit
may be placed supine with a sand-pillow under the neck
and with the head thrown over the end of the table: If a
child, Liston used to wrap it up to the neck in a sheet to
prevent movements of the limbs, would seat himself on a
chair, place the child upon the nurse's lap, and take its heail
between his knees. If bleeding is profuse when the surgeon
is ready to open the trachea, place the patient in the Trendel-
enburg position with the neck extended. The head must
be exactly in the middle line, and extended (in an adult this
gives two and three-quarters inches of trachea above the
manubrium; in a child of ten, two and a quarter inches; in
a child of six, about two inches). The operator stands to
the right side when the patient is supine. The trachea may
be opened above or below the isthmus of the thyroid gUnd
The isthmus in an adult usually lies over the second and
third rings (Fig. 184). The isthmus in a child usually ties

over the first ring or even over the space between the cri-
coid cartilage and the first ring. The high operation is
always performed except in cases where it is desired to
starch for a foreign body in a bronchus.

High Tracheotomy. — This operation is preferred be-
cause in tlii.-i region the muscles arc distinctly separated (Fig.
185). the main vessels of the neck and the inferior thyroid
vcs>.<.-ls are not encountered, the anterior jugular veins are
small and have verv few transverse branches, and the trachea

SURGERY OF THE RESPIRATORY ORGANS, 603

is near the surface (Treves). Accurately locate the cricoid
and thyroid cartilages. An incision is begun at the upper
border of the cricoid cartilage, and is carried down precisely
in the middle line for about one and a half inches. Treves
advises the operator to steady the skin of the neck with the
fingers of the left hand and to cut with the unsupported right
hand (if the hand be supported, the respirations will interfere
with the operation). Incise the skin, the superficial fascia, and
the anterior layer of the cervical fascia, separate the sterno-
hyoid and sternothyroid muscles, and divide the fascia over
the trachea. This fascia is attached above to the cricoid
cartilage, and it divides below into two layers to invest the
thyroid body and its isthmus. If veins are in the line of the
incision, push them aside, but do not stop to apply a double
ligature. Even if bleeding is profuse, as soon as the trachea
is opened and air enters freely into the lungs venous conges-
tion is relieved and bleeding is apt to cease. If hemorrhage
be violent and the veins are not at once caught by forceps,
it may be well to place the patient in the Trendelenburg
position. Before opening the trachea push the isthmus of
the thyroid gland down ; if it cannot be pushed down suf-
ficiently, make a transverse incision through the fascia at the
upper border of the cricoid cartilage, and lift the fascia, and
the isthmus with it, off the trachea (Bose's method). In-
sert a tenaculum into the cricoid cartilage in order to steady
the tube. Turn the back of the knife toward the sternum,
hold a finger on the blade to prevent too deep a cut being
made, plunge the knife, like a trocar, into the mid-line
of the trachea above the isthmus, and divide two or three
rings from below upward. Do not remove the hook until
the operation is completed. If a foreign body is present,
try to remove it; if success attends the effort, no tube
need be worn, but if the body is not found, use a tube.
In croup or in diphtheria remove membrane (by means
of a feather and a solution of bicarbonate of sodium 3ij,
glycerin 3j, water Jx — Parker) and insert a tube. Grasp an
edge of the cut with the dissecting-forceps, include the
mucous membrane in the bite, bring the head erect, intro-
duce the tube, and remove the tenaculum. Secure the tube
by tapes, and suture the wound below the tube. Remove
the tube at the first moment consistent with safety. In
croup or diphtheria put a screen around the bed ; have
the air moist by steam ; remove the inner tube and clean
every two or three hours at first; clean the outer tube,
and the larynx and trachea whenever required, by means

604 MODERN SURGERY,

of a feather and Parker's solution. A steam spray atomizer
may very often be used with advantage.

Qtiick laryngotomy must never be attempted upon a
child under thirteen years of age, because of the small size
of the cricothyroid space before this age (Treves.) In
view of the difficulty of introducing a tube and of wearing
it so near the vocal cords, laryngotomy should not be per-
formed for croup, diphtheria, or for any condition in which
a tube must be long worn. An incision an inch and a
quarter long is made in the middle line, from above the
lower edge of the thyroid cartilage to below the lower
border of the cricoid. Divide the skin, superficial fascia,
and deep fascia, separate the cricothyroid and sternothy-
roid muscles, divide the deep layer of fascia, and cut the
cricothyroid membrane horizontally just above the cricoid
cartilage. The tube must be shorter than is the tracheotomy-
tube. An operation which opens vertically the cricothyroid
membrane, the cricoid cartilage, and the upper rings of the
trachea is called " laryngotracheotomy."

Intubation of the I/Orynx (O'Dwyer's Operation).—
The instruments required in this operation are a mouth-gag,
an instrument to hold the tube and introduce it, an instru-
ment for extracting the tube, and a graduated scale. The
collar of the tube has a perforation through which a piece of
silk is fastened to draw out the tube. The child is wrapped
in a sheet to secure the limbs, is seated in a nurse's lap, and
its head is held by an assistant. The jaws are to be opened
and held apart by the self-retaining mouth-gag. The sur-
geon sits in front of the patient, wraps the index finger of his
left hand with a piece of rubber plaster, and passes it into the
child's mouth until his finger touches the epiglottis. He
introduces the holder and tube (observing if the silk is free)
along the surface of the tongue until the obturator touches
the epiglottis ; raises the epiglottis with the left index finger,
and passes the tube into the larynx ; places the left index
finger against the tube, and withdraws the holder with the
right hand. The silken thread is tied to the ear, and the
nurse is directed to employ the thread to remove the obtu-
rator if it becomes obstructed or is coughed up. The tube
is removed in two or three days ; if breathing is easy, it is
not reintroduced, but if dyspnea recurs, it is replaced for
two or three days more. If, in introducing the tube, a
mass of false membrane is pushed before it into the trachea,
breathing ceases, and, if the mass is not at once coughed
up, tracheotomy must be performed. Wharton feeds these

SURGERY OF THE RESPIRATORY ORGANS. 605

patients on semi-solids rather than upon liquids (mush,
soft eggs, and corn-starch), and if trouble occurs in swal-
lowing these articles, he feeds by the rectum or by means
of a tube.

4. Diseases and Injuries of the Chest, Pleura, and

Lungs.

Pleuritic efEtasion may arise from foreign bodies, from
injury by fragments of a broken rib, from tumors, and from
inflammation of the lung, but most usually from pleuritis.
Inflammatory effusion is nearly always unilateral (except in
tubercular pleurisy, but even this form is one-sided at the
start).

The signs of pleuritic effusion are — dulness on percussion
over the effusion, this dulness, when the patient is erect,
being at the lower part of the chest and ascending higher
posteriorly than anteriorly (alteration of position alters the
situation of the dulness) ; the intercostal spaces are widened
and the intercostal depressions are obliterated; no breath-
sounds can be detected in the area of flatness when the col-
lection of fluid is large, but in small effusions deeply situated
the breath-sounds are often audible; the percussion-note
above the liquid is hyper-resonant or tympanitic, and is often
associated, at the edge of the liquid, with a friction-sound ;
posteriorly, high up and near the spine, there are bronchial
respiration and bronchophony (DaCosta). In these cases
pain disappears with the advent of effusion, dyspnea comes
on, and the patient lies upon the diseased side. Cough and
fever always exist. In serous effusions the diagnosis may be
confirmed by the introduction of an asepticized aspirating-
needle.

The treatment in this stage is to discontinue arterial seda-
tives and to stimulate if the circulation calls for it. The
exudation is removed by salines, by compound jalap powder,
or by elaterium. If these means fail, if the effusion is exces-
sive, or if it is producing dyspnea, at once aspirate. If pus
forms, drain by operation.

Hmpyema is a collection of pus in the pleural cavity. It
may begin suddenly, but rarely does so. Among the causes
of empyema are those of serous effusion. Empyema is due
to infection of the pleura. The pneumococcus is the causa-
tive organism in many of the cases which follow pneumonia.
This organism lives but a short time, and an empyema due to
pneumococci may possibly be absorbed (Stephen Paget).

6o6 MODERN SURGERY,

Most cases of empyema are due to streptococci and staphylo-
cocci. These organisms may appear in an empyema induced
originally by pneumococci (Stephen Paget). In empyema de-
veloping during or after typhoid fever the typhoid bacillus
may be discovered. In putrid empyema various bacteria
are found. Bouchard thinks acute empyema has a special
organism. The bacilli of tuberculosis are present in tuber-
cular empyema. Empyema may be due to a wound or
contusion, an attack of pneumonia, tubercular pleurisy,
phthisis, typhoid fever, infection of a serous effusion, caries
of a rib, specific fevers, peritonitis, malignant disease of the
pleura, or gangrene of the lung. The sigrns are in reality
those of pleurisy with effusion, viz., dulness on percussion,
absent breath-sounds, bulging of the intercostal spaces, and
sometimes edema of the skin of the chest. The Byxnptoms
are irregular fever, sweats, chills, dyspnea, pallor, and some-
times cough. There is marked leukocytosis. The fingers
may become clubbed. An empyema of the left side may
pulsate. A neglected empyema may break into the lungs,
esophagus, or pericardium, or may point in the lunibar region.
Empyema may cause death by compression of the heart and
lung, pulmonary embolism, pericarditis, peritonitis, cerebral
embolism, cerebral abscess, septicemia (Stephen Paget), or
exhaustion.

The treatment is aspiration, incision and drainage, or
thoracoplasty (see pages 608--610).

Contusions and Wounds of the Chest. — The symp-
toms of contusions of the chest are pain and soreness, and, as
a consequence, abdominal respiration and decubitus upon
the back inclining to the injured side. In severe contusions
the viscera may be injured. The treatment is by strapping
the chest as for fractured ribs (PI. 5, Fig. 13). Non-penetrat-
ing wounds of the chest are not especially grave, and are
treated according to general rules, the chest being immob-
ilized. Penetrating wounds are very grave injuries. Visceral
injury may be inflicted. Emphysema is apt to occur. Pro-
fuse hemoptysis suggests a wound of the lung. In ex-
amining chest-wounds feel with a finger, not with a probe.
In wounds of the pleura cleanse, stitch the pleura with cat-
gut or fine silk, suture the skin, dress with gauze, and immob-
ilize the chest. Wounds of the lung demand absolute rest.
If the bleeding is slight, do not operate ; but if bleeding
threatens life, resect a rib to reach the lung, and arrest hem-
orrhage. Hemorrhage of the lung may in some cases be
arrested by the ligature, in some cases by packing a small

SURGERY OF THE RESPIRATORY ORGANS. 607

wound with gauze, in some cases by the suture ligature. In
a violent secondary hemorrhage following a gunshot-wound
of the lung the author packed the entire pleural cavity with
sterile gauze to obtain a base of support, and arrested the
bleeding by carrying iodoform gauze directly against the
oozing surface.* After arresting hemorrhage in hemothorax,
turn out the clots and employ drainage. If emphysema of
the chest-walls is moderate, strapping or a bandage will con-
trol it ; if it is great, make multiple punctures and then apply
pressure. In hernia of the lung try to restore the protru-
sion, but if restoration is impossible or if gangrene seems
highly probable, ligate the base of the protrusion with silk
and cut away the mass. If foreign bodies in the thorax
can be felt, remove them ; if they cannot be felt, do not
conduct a prolonged search, but leave them to Nature.

Abscess of the lung^ may follow ordinary pneumonia.
It is apt to follow aspiration pneumonia. Osier tells us that it
may arise by the aspiration of septic particles after " wounds
of the neck, operations upon the throat,*' and suppurative
lesions of the nose, larynx, or ear. Cancer of the esophagus
may be a cause, so may perforation of the lung by an abscess,
wound of the lung, impaction of a foreign body in the lung,
suppuration about a focus of tubercle or metastatic abscess.*

Symptoms. — The physical signs of a large cavity are
found, and there is profuse and offensive expectoration,
the expectorated matter containing portions of lung-tissue.
Pyemic abscesses are hard to diagnosticate.

The treatment is purely surgical (Pneumotomy). Make
an incision over the cavity. Resect a portion of one or more
ribs. Expose the pleura. If the two layers of the pleura
are not adherent, suture them together and wait two days.
If they are adherent, proceed at once. Search for the ab-
scess with an aspirator. When the cavity is found, open into
it with the cautery and insert a drainage-tube.

Gangrene of the I/Ung^. — ^This term means the putre-
faction of a devitalized portion of pulmonary tissue. It may
follow pneumonia, or may be due to diabetes, to embolism of
the pulmonary artery, bronchiectasis, tuberculosis, or malig-
nant disease.

Symptoms. — The symptoms of a cavity exist plus the
expectoration of horribly offensive sputum, which contains
fragments of lung-tissue and often altered blood ; there is
some fever, and great exhaustion. The great fetor of the

* Annals of Surgery ^ Jan., 1898.
' See Osier's Practice of Medicine.

6o8 MODERN SURGERY,

discharge is characteristic, and is much more intense than the
fetor of abscess.

The treatment is to operate as for pulmonary abscess.

Tubercular Cavity in the I/Ung. — Surgrical Treat-
ment.— For the past decade surgical thought has been
actively directed toward placing on a scientific footing op-
erations for pulmonary phthisis. The matter is still in a
transition stage, and operations at present have but a very
limited field of application, although Sonnenberg and others
have reported cures. Mosler, a number of years ago, at-
tempted to treat cavities by introducing a trocar into the
cavity and injecting permanganate of potassium solution
through the cannula. Patients were not benefited by this
procedure. Hillier tried injection of corrosive sublimate
into the lung-parenchyma, but the effect of the injections was
disastrous. When the strength of the patient is well preserved
and the pulmonary lesion is circumscribed and slowly pro-
gressive it may be justifiable to perform an operation, open
the cavity, and treat it directly (pneumotomy). Fowler says
it is not justifiable to operate if the disease has come " to a
standstill." The same surgeon states that the only accessible
region is bounded above by the clavicle, to the inner side by
the manubrium, to the outer side by the lesser pectoral mus-
cle, and below by the second rib.*

Manclaise says that pneumotomy is only justifiable in cir-
cumscribed tubercular cavities without peripheral infiltra-
tion and in pulmonary abscesses.* Bronchiectatic cavities are
usually multiple; they are excessively diflficult to locate, and
treatment by pneumotomy should not be attempted. In the
treatment of pulmonary tuberculosis resection of the diseased
area has been proposed (pneumectomy). Tuflfier successfully
performed this operation. Surgeons, as a rule, do not believe
in pneumectomy. Reclus voices the general opinion when
he says the operation is not required if the area of disease is
very limited, as such a condition is frequently curable by
medical means, and it does no good if the area of disease is
extensive.^

Paracentesis Thoracis. — Aspiration will very rarely cure
empyema. It will occasionally cure a small encysted empyema
or a pneumococcus empyema in a child. Its chief use is in
diagnosis, or as a temporary measure when dyspnea is severe

^ See the very full and thoughtful article of George Ryerson Fowler on
♦'The Surgery of Intrathoracic Tuberculosis," ^««a/j of Surg., Nov., 1896.
' La Tribune midicale^ Sept. 21, 1 893.
' Kevue de Chirurgiey Nov. 11, 1 895.

SURGERY OF THE RESPIRATORY ORGANS,

609

or when operation is not indicated. In very large effusions
it is wise to aspirate and withdraw part of the effusion several
days before doing a radical operation. After the aspiration
the patient takes an anesthetic with more safety, and the
danger is obviated of suddenly evacuating a large effusion.
The trocar must not be used except in an emergency ; the
aspirator is greatly to be preferred. The aspirator evacu-
ates the fluid, and, as bacteria do not enter, the lung ex-
pands and infection does not occur. The skin, the instru-
ments, and the surgeon's hands must be asepticized. Give
the patient a little whiskey, and, unless he is very weak, make
him sit up in bed. The arm hangs by the side, and the sur-
geon introduces the needle in the fifth interspace, just in front
of the angle of the scapula. The surgeon marks the upper
border of the sixth rib with the index finger, and plunges in
the needle just above the finger, thus avoiding the intercostal
artery, which lies along the lower border of the rib above.
Always guard the needle with a finger to prevent its going
in too far. After withdrawing the needle, place iodoform
collodion over the opening into the chest. In pleuritic effu-
sion, if the lungs will not expand after tappings, perform
thoracotomy.

Thoracotomy is an incision into the cavity of an em-
pyema. It may be merely an intercostal incision, or may be
an opening into the chest after resecting a portion of a
rib. The instruments required are a scalpel, a grooved
director, forceps (hemostatic and dissecting-), scissors, a dry
dissector, retractors, bone-instruments (in case rib-excision
is required), drainage-tubes, and needles. Chloroform
given the patient, who lies supine at the
edge of the table, with the arm elevated
to a right angle with the body. Make
an incision about three inches in length
along the upper border of the lower rib
bounding the space it is proposed to
penetrate. This space is either the sixth
or the seventh, and the desired site is in
front of the posterior axillary fold. Incise
the superficial structures, divide the inter-
costal muscles near the rib, push a grooved
director through the pleura, and enlarge
the opening by means of forceps and the
finger. The finger removes all masses of tubercular mate-
rial or aplastic lymph within reach. Some surgeons advo-
cate immediate irrigation, but this procedure is unsafe, as it
39

Fig, 186. — Resection of
rib (tlsmarch and Kowal-

6lO MODERN SURGERY,

may produce dyspnea or pleuritic epilepsy, and has caused
death. In some cases a counter-opening is made by cutting
down upon the long probe which is pushed against the chest-
wall after being introduced through the incision; in other
cases it is necessary to resect a rib (page 609; Fig. 186).
A short drainage-tube is introduced and stitched in place. If
a counter-opening has been made introduce another short
tube, but do not pull one tube through both openings. Arrest
bleeding, suture the skin, dust with iodoform, dress with
gauze, wood-wool, and a binder, and have the dressings
changed as soon as they become soaked at one point. This
operation is rarely curative, and in most cases the intercostal
spaces are too narrow to permit of satisfactory drainage. It
is far better to remove a piece of rib as directed on page 609
(see Fig. 1 86). Remove the periosteum and open the pleura.
After opening the pleura insert a finger into the pleural cavity.
Note if the lung can expand. If it is evident that it can ex-
pand, insert a short drainage-tube, close the soft parts, and
dress. Several times a day change the patient's position.
At each change have him on the diseased side for half an
hour, and with the foot of the bed raised for half an hour.
Favor expansion by causing the patient to blow into a wash-
bottle filled with water. Remove the tube when the dis-
charge becomes thin and scanty (about the eighth or tenth
day, as a rule). If the lung is bound down with adhesions
and cannot expand to fill the space vacated by the pus, per-
form the operation of Schede or Estlander.

Thoracoplasty (Estlander's operation) is employed in
old cases of empyema in which drainage has failed, and in
cases with retracted chest-walls, collapsed lungs, thickened
pleura, and cavities whose rigid walls will not collapse.
The procedure recognises the fact that after pus is evacuated,
if the lung is adherent, it cannot expand to fill the space once
occupied by fluid, and that the rigid chest cannot fall in as a
substitute for the lung, and seeks to destroy the rigidity of
the chest and permit it to collapse and thus obliterate the
cavity of the empyema. When the surgeon resects a rib and
finds a cavity with uncollapsable walls, or a lung bound down
with firm adhesions, he should perform thoracoplasty. This
operation causes the obliteration of the cavity by collapsing
that portion of the chest-wall overlying it. The cavity is in
the upper or central part of the pleural space (Treves). The
instruments required are the same as those for resection
of a rib. The position is the same as that for rib-resec-
tion. The length of the incision depends on the size of

SUJICESY OF THE RESPIRATORY ORGANS.

6ii

the cavity. The sui^reon usually removes portions of the
second, third, fourth, fifth, sixth, and seventh ribs. Make a
transverse incision along the center of an intercostal space,
and through tliis incision remove the ribs above and below
by the method set forth on page 609 (the removal of six
ribs will require three incisions). Instead of this incision, we
can make a vertical incision or a U shaped flap. Always
take away the periosteum. Treves recommends that the
cavity be at once washed out with corrosive sublimate
(1 : 1000); that if small it be packed with iodoform gauze
and allowed to granulate ; that if large it be drained by a
large tube, the skin being sutured by silkworm-gut Irri-
gation is thought by many to be dangerous and to possess
no special power for good.

Bohede's OperatioD. — Schede showed that when the
pleura is much thickened
even Estlander's operation
will not permit the chest-wall
to collapse and fill the cavity
once occupied by the fluid.
Instruments, same as for Est-
lander's operation, plus bone-
shears. A U-shaped flap is
made from the level of the
axilla in front to the level of
the second rib and between
the scapula and spine behind.
The lowest level of this incis-
ion corresponds to the lowest
limit of the pleura (Fig. 187).
The flap is loosened and
raised, and the scapula is
lifted with it The ribs from
the second rib down and F"j- isj-inciii™ for sc).tde'. opcntion or
from the costal cartilages to

the tubercles are removed, along with the chest-muscles
and the pleura. This is accomplished by cutting with
bone-shears and scissors. Hemorrhage is arrested. The
pleura is curetted. A drainage-tube or a piece of iodo-
form gauze is introduced, and the raw flap is laid against
the visceral layer of the pleura. The superficial incision
is sutured.

Pneamotomy for Abscess of the I^tuig. — The instru-
ments required are scalpels, hemostatic forceps, dissecting-
forceps, dry dissector, retractors, periosteum elevator, meta-

6l2 MODERN SURGERY,

carpal saw, scissors, needles, curved and straight, Paquelin*s
cautery.

Operation. — Place the patient recumbent with the shoul-
ders a little raised. Make a U-shaped flap over the suspected
trouble. If the intercostal spaces are wide, cut down in a space
to the pleura. If they are not wide, resect a rib. If it is
found that adhesions do not exist between the pulmonary and
costal layers of the pleura, stitch these layers together with
catgut and postpone further operation for forty-eight hours.
If adhesions exist, proceed at once. Incise the aggluti-
nated layers of the pleura, and pass an aspirating-needle
into the lung in various directions. When the abscess is
located open it by the cautery. Carry the Paquelin cautery
slowly into the lung in the direction of the abscess-cavity.
The cautery-knife should be at a dull-red heat.

Fowler calls attention to the fact that lung-tissue is so
insensitive that the administration of ether can be suspended
as soon as the pleura has been opened. When the cautery
opens the cavity withdraw the instrument and insert a drain-
age-tube or a bit of iodoform gauze, and suture the flap of
superficial tissue. If the abscess is not found after one or
two punctures with the aspirating-needle, abandon the
attempt

Tuffier explores for an abscess by what he calls decolle-
ment of the parietal pleura. He exposes the parietal layer,
passes his hand between this layer and the chest-wall, strips
the pleura off* over a considerable area, and is able to feel
the lung below, and thus determine its condition.

XXVI. DISEASES AND INJURIES OF THE UPPER

DIGESTIVE TRACT.

Diseases of the Mouth, Tongtie, and Esophagus.

— Harelip and Cleft Palate. — Harelip is a congenital cleft
in the upper lip due to defective development. Cleft palate
is a congenital fissure in the soft palate or in both the hard
and soft palates. In harelip the cleft is usually complete,
through the entire lip into the nostril, but in rare cases it
may only show as a furrow in the mucous edge or as a split
from the nostril partly into the lip. It is most common on
the left side. In double harelip the central portion of the
lip is often adherent to the tip of the nose (Bowlby). Double
harelip may be free from complication, but is often associated
with a malformation of the alveolus and palate (Heath).
Median harelip is exceedingly rare. In cleft palate the

DISEASES AND INJURIES OF THE DIGESTIVE TRACT. 613

septum of the nose is usually adherent to the palatine proc-
ess opposite the side upon which the fissure exists. In
those rare cases of cleft palate double in front the nasal sep-
tum is attached only to the premaxillary bone, and the pre-
maxillary bone is not attached at all to the superior maxillae.
In harelip there is often a cleft in the alveolus, and almost
always flattening of the corresponding side of the nose.
Harelip is often associated with cleft palate, talipes, and
other deformities. It is a great deformity, and interferes
with sucking, swallowing, and articulation.

Operation for harelip should be performed between the
third and sixth months of life in a child in good health, free
from stomach trouble, cough, or coryza, but operation is not
advisable in the early weeks of life. Always, if possible,
operate before dentition begins (seventh month). If the
child is in poor health, postpone the operation until restora-
tion has so far advanced as to render operation safe. While
waiting for operation be sure the child is getting enough
food. If it cannot suck, feed it with a spoon. If a cleft
exists in the palate, operate first upon the lip, because the
pressure of the parts after the edges of the gap are approxi-
mated aids in the closure of the bony cleft. Cleft palate
interferes with sucking, deglutition, mastication, and articu-
lation. In severe ca.ses the food passes into the nose and
excites inflammation. Loss of control of the palate-muscles
always exists, and liquids and solids are liable to pass into
the windpipe. Clefts in the hard palate should not be oper-
ated on until the second year, but should be operated upon
then, otherwise speech will be permanently affected. Some
surgeons refuse to operate until the tenth or twelfth year,
but operation done this late will not correct speech-defect.
In many cases the passage of food and drink into the nose
can largely be prevented by the use of
a diaphragm. The patient at the period
of operation should be well and free from
cough.

Operation for Harelip, — The instru-
ments required are a tenotome, harelip-
clamps, toothed forceps, hemostatic for-
ceps, scissors curved on the flat and

. . J . . i_. ,1 . • . J • Fig. 188.— Malgaigne's opera-

pointed, straight blunt-pointed scissors, tion for harelip.

needles (straight and curved), silver wire
or silkworm-gut and silk sutures, a mouth-gag and tongue-
forceps, a needle-holder, and sequestrum-forceps, each
blade protected by a rubber tube. Wrap the child in a

6 14 MODERN SURGERY,

sheet; place it supine; raise the head and rest it upon a
sand-pillow. The surgeon stands to the right side of the
patient. Ether or chloroform is given. For single harelip,
separate with the scissors the upper lip from the bone on
each side of the cleft until approximation of the cleft can
be effected without tension. If the maxillary bone of one
side projects more than its fellow, grasp it with sequestrum-
forceps and bend it back (Jacobson and Treves). Clamp
the upper lip at each angle of the mouth to prevent hemor-
rhage. If the edges are of equal or nearly equal length,
and if the gap is not very wide, perform Malgaigne's opera-
tion. This is performed as follows : a flap is detached on
each side, the detachment beginning at the upper angle of the
gap ; each flap is detached above but remains attached below.
The flaps are drawn downward so as to form a prominence
at the vermilion border (Fig. i88). If the edges are pared
so that in closure the vermilion border is even, when the parts
are healed a gutter will be visible at the line of union. The
edges are approximated by an assistant, and silkworm-gut
sutures or silver wires are passed by means of a straight
needle. Each suture goes down to the mucous membrane.
The first suture is passed through the middle of the lip, one-
third of an inch from the cleft. Three or four main sutures
are passed through the thickness of the lip, and are tied and
cut off. Two or three fine silk or catgut sutures are passed
by a curved needle through the vermilion border of the lip
and the mucous membrane of the mouth, and are tied and cut
off. A small piece of gauze is placed over the lip and is held
in place by straps of rubber plaster. After operation prevent
the child crying by feeding it often and giving it small doses
of laudanum. Heath orders two drops of laudanum in one
ounce of distilled water, a teaspoonful to be given every two
or three hours. About the sixth day one-half the sutures
are taken out, and on the eighth or ninth day the remaining
ones are removed. In many cases no further procedure is
necessary, but if after some weeks the prominence at the lip-
border does not shrink, it can be readily clipped away.
Harelip-pins are not used at the present time, and are not
needed if the lip is well separated from the bone. If the
edges of the cleft are of unequal length, Edmund Owen's
operation can be performed (see below under Double Harelip),
or we can perform Mirault's operation, as shown in Fig. 190.
In double harelip the operation is similar to that for single
harelip. If the intervening piece is vertical and is covered uith
healthy skin, complete each operation as for single harelip,

DISEASES AND INJURIES OF THE DIGESTIVE TRACT. 615

closing both fissures at once with silver wire in a strong,
healthy child, closing them at intervals of three weeks in one
not so lusty (Fig. 189X Excise the septum if it is deformed
The premaxillary bone should
in most instances be removed,

Pn. lb.— Incfaioni for double hudip I^. 1^.— M inull'i apastiim for lipglc

(EuBucb and Kemliig). hanUp (Eiiuich).

the skin over it being preserved. Sir Wm. Fergusson was
accustomed to incise the mucous membrane and shell out
this bone. The premaxillary bone can be forced back into
line, being held, if necessary, by catgut suture of the peri-
osteum ; but if saved it is liable to necrose and its teeth soon
decay. Heath removes this bone two weeks before operating
on the lip. If there is much hemorrhage after removal, stop
it with a hot wire or with Horsley's wax. Fig. 189 shows
incisions for double harelip. Edmund Owen's operation is
very useful (Figs, 191, 192). In this operation very thick
flaps are cut. The prolabium and
incisive bone are removed. The
flaps are cut as shown, Fig. 191,

ffisircL (OwiD). iDgeihit ud iTCund by lutucei (Owen).

on one side by line ab, and on the other side by line cde. a
is brought to e, b is brought to d, f is brought to c, and
sutures are applied (Fig. 192).

Operation for Cleft Palate. — It is true that during the early
years of growth the clefts diminish in size ; but to wait too
long before we operate means permanent speech-impairment.
Bony cleft.s should be operated upon during the second year
(Owen). Clefts of the soft palate only may be operated
upon in the first six months (Edmund Owen). If both the
hard and soft palates are cleft, close both at one operation.
Edmund Owen has recently put forth a convincing plea for

6 1 6 MODERN BURGER Y.

early operation.* He says he is operating earlier and earlier,
and quotes Chilton as the gentleman who led him to do so.
Owen maintains that if speech is to be improved operation
must be done early, and he formulates some very valuable
rules of preparation and care: have the child in the best
condition, free from cough and stomach disorder. Operate
in the summer. Place the child under the charge of a nurse
several days before the operation. For suture of the soft
palate {staphylorrhaphy) Treves says the following instru-
ments are essential : tw^D sharp-pointed tenotomes, a blunt-
pointed tenotome, a rectanglar knife, two pairs of long forceps
(one with tenaculum points, one serrated), a fine hook, a pair
of sharp-pointed curved scissors, scissors curved on the flat,
periosteum-elevators, two long-handled needles with eyes at
their points, a suture-catcher, a tubular needle for wire su-
tures, hemostatic forceps. Whitehead's gag and retractors,
silver wire, silkworm-gut, and sponge-holders ; also an elec-
tric forehead light. The patient's body is raised, and his head
is elevated and rested upon a sand-bag. A better position
would be that of Trendelenburg, thus avoiding the trickhng
of blood into the windpipe. Chloroform is given. The gag
is introduced ; the edges of the mucous membrane are pared
with a tenotome ; the sutures are introduced from below up-
ward, silkworm-gut being used for the uvula and lower part
of the velum, silver wire for the remainder of the cleft ; each
suture, as it is passed, is tied or twisted, but is not cut until
the next suture is inserted, thus serving as a handle. If
there is too much tension to allow of the sutures being tied
as they are inserted, all the sutures are passed and loosely
twisted. A longitudinal incision is made upon each side, in-
ternal to the hamular process, the mucous membrane being
cut with a sharp tenotome, the deeper structures being di-
vided with a blunt tenotome ; the sutures are tied or twisted
and cut (Fig. 193). In Fergusson's operation for clefts in the
hard palate {uranoplasty) the mucous edges are pared and
the sutures inserted but not tied. Make an incision upon
each side down to the bone, the incision being midway be-
tween the cleft and the alveolus. Divide the bone on each
side, by means of a chisel, to the full length of the incision,
and, using the chisel as a lever, force each half of the bone
toward the gap. Tie the sutures, and plug each lateral in-
cision with a piece of iodoform gauze (Fig. 194). After the
operation for cleft palate put the patient to bed for one week;
forbid talking ; give fluid or semisolid food at intervals of two

* Lancet, Jan. 4, 1896.

DISEASES AND INJURIES OF THE DIGESTIVE TSACT. 617

or three hours for three weeks; wash out the mouth very
of^en (aiways after eating) with a carbolic solution (1 : lOO)
or a solution of boric acid and listerine. Sutures arc re-
moved in from two to three weeks.

Edmund Owen ' operates as follows ; pare a strip of

li'phyli'"h»phy (El march

mucous membrane from each side of the fissure from the lip
of the uvula to the top of the gap. Make a free incision
" along the alveolar aspect of the palate " close to the teeth.
Lift up the strips of muco-periosteum and shift them toward
the cleft. Sever the attachments of the soft palate to the
posterior border of the hard palate and extend the alveolar
incision well backward. This incision relieves tension. Sew
up with wire ; twi.st each wire and cut each wire, leaving an end
one-eighth of an inch long. This procedure causes the child
to keep his tongue from the suture-line. For the first twenty-
four hours give only water, and after this feed with beef
jelly and liquids.

When feeding is begun attempt irrigation or spraying if
it does not alarm the child. In a day or two the patient can

ily (Eimarch and Kowalilg). " march and KowjJilg).

take sweetened orange-juice, custard-pudding, finely sieved

6l8 MODERN SURGERY.

meat or chicken. The best fluid for irrigation is Condy's
fluid or mild carbolic acid.

Get the child out in the air a day or two after the opera-
tion and keep it out all day. (The entire article of Mr.
Owen's will well repay a careful reading.)

Cancer of the Lip. — Epithelioma is common in the lower
lips of males (page 233). In most instances it may be re-
moved by a V-shaped incision, the wound being closed as in
harelip. The glands from beneath the jaw, whether enlarged
or not, should always be removed. If the growth is exten-
sive, the entire lower lip is removed and cheiloplasty is per-
formed to replace the lip (Figs. 195, 196).

Tongrue-tie is a congenital shortness of the frenum. The
tongue cannot be protruded beyond the incisor teeth. Swal-
lowing is interfered with, and later in life articulation is
impeded. To treat tongue-tie, tear up the frenum with the
thumb-nail. If this fails, catch the frenum in the slit in the
handle of a grooved director, push the director toward the
base of the tongue, and divide the frenum with scissors
curved on the flat and pointed toward the director.

Bannla is a dilatation of one of the ducts of the mucous
glands of Nuhn and Blandin. These glands lie on each side
of the frenum of the tongue. It was long thought that a
ranula arose from obstruction in the duct of the sublingual
gland. A ranula appears upon the floor of the mouth on
one side and pushes the tongue toward the opposite side.
The contents of a ranula resemble mucus or saliva. The
treatment of ranula is by excision of a portion of the cyst-
wall and cauterization of the interior with pure carbolic add
or with 15 minims of a solution consisting of 10 parts of
tincture of iodin, 10 parts of water, and i part of iodid of
potassium ; or by cutting a flap from the cyst-wall and stitch-
ing it aside so as to keep a permanent opening.

Partial Removal of the Tongrue. — This has been practised
many times for cancer of the anterior portion of this organ.
In malignant disease, if one side of the tongue alone is in-
volved, remove one-half of the organ ; if both sides of the
tongue are involved, remove the organ entirely. Even in
partial excision for malignant disease remove all of the
glands from the submaxillary triangle of the diseased side^
even when they are not apparently involved. This is the
only chance for the patient's cure, as these glands are in-
volved long before the involvement is obvious to touch.

In performing the operation of partial excision introduce a
mouth gag, place a silk ligature on each half of the tip of

DISEASES AND INJURIES OF THE DIGESTIVE TRACT 619

the tongue, and draw the tongue out of the mouth (Barker),
SpHt the tongue back in the middle Hne with the scissors,
and loosen the cancerous side from the floor of the mouth
and side of the mouth. Pass a stout silk ligature through
the base of the tongue posterior to the cancer. Draw the
organ out and cut off the diseased side in front of the liga-
ture but back of the disease. Tie the vessels, remove the
constricting and traction threads, and treat subsequently as
in cases of complete removal.

Complete Removal of the Tongrue (Kocher's Method). —
Kocher used to employ a preliminary tracheotomy in tongue-
excision, but the Trendelenburg position renders this proced-
ure unnecessary so far as hemorrhage is concerned. Always
clean the mouth well. The instruments required are a
scalpel, retractors, a dry dissector, hemostatic and dissecting-
forceps, a tenaculum, aneurysm-needle, tenaculum-forceps,
needles, sutures, and scissors.
In this operation the patient is
placed in the Trendelenburg
position, the surgeon standing by
the affected side. Chloroform
is given. An incision is made
from behind the lobe of the ear,
along the anterior edge of the
sternocleidomastoid to about
the middle of the margin of this
muscle. From this point the
incision is carried to the hyoid
bone and then to the symphysis
menti, along the anterior belly
ofthe digastric muscle (Fig. 197).
The flap is dissected and turned up ; the facial and lingual
arteries are ligated ; " the submaxillary fossa is evacuated *'
(Treves) ; the sublingual and submaxillary glands are re-
moved ; the mylohyoid muscle is divided ; the mucous mem-
brane is incised close to the jaw, and the tongue, caught with
tenaculum-forceps, is drawn through the opening. The tongue
is split in the middle with scissors, and the near half is re-
moved. Arrest bleeding. If the whole tongue requires re-
moval, perform a set ligation ofthe lingual artery of the oppo-
site side. Some surgeons stitch the mucous membrane of
the stump to the mucous membrane of the floor of the
mouth ; others employ no sutures. Kocher does not suture
his skin-wound ; many surgeons do, and employ drainage-
tubes. Keen advises closing the floor of the mouth, if pos-

FiG. 197. — Kocher's excblon of tODguc

(Esmarch and Kowalzig).

620 MODERS SCXGEMY.

sible. Some hours after the operation, when qobid^ has
ceased, dust the mouth-wound viith iodoform. The patient,
as soon as possible, is propped up in bed, and he must not *
swallow the discbarges if it can be avoided. The mouth,
ev'er>' half hour, is sprayed out with peroxid of h\*drogen
and washed vnth a carboUc solution ( i : 6o)l E\xrv three
hours after washing the floor of the mouth and the stump,
dry with absorbent cotton and dust with iodoform. For
twepty-four hours after the operation nothing is given by
the mouth except a little cracked ice, the patient being fed
per rectum. At the end of twent>'-four or fortj'-eight hours
some liquid food is given from a feeding-cup. The patient will
soon learn to swallow ; but if he cannot swallow easily, feed
from a tube. Treves, in his clear and positive directions for
after-treatment, states that nutrient enemata are to be con-
tinued until suflficient nourishment is taken by the mouth ;
that the mouth should be flushed out by irrigation, and must
be washed immediately after taking food ; that morphin is to
be avoided ; and that the patient can usually leave the hos-
pital in from seven to ten days. Whitehead removes the
entire tongue from within the mouth by the use of scissors.
He passes a ligature through the tip, cuts the frenum, draws
the tongue strongly forward and separates by a series of clips
with the scissors. The lingual arteries are tied as cut " The
stump should be kept under control, as regards hemorrhage,
by a stout silk ligature passed through the remains of the
glosso-cpiglottidean fold and retained for twent>'-four hours." *

Heath has shown that if the forefinger be passed to the epi-
glottis and used to ** hook forward " the hyoid bone, the lin-
gual arteries arc stretched and portions of the tongue can be
removed almost without bleeding. After Whitehead's opera-
tion always remove the glands from the submaxillary triangles.

Stricture of the Esophagrus. — Fibrous or cicatricial strict-
ure is due to traumatism, chronic inflammation, syphilis,
tuberculosis, ulcer, prolonged vomiting, variola, gout, or to
swallowing a corrosive substance or a boiling liquid. It is
commonest in the young, and is apt to be situated opposite
the cricoid cartilage at the tracheal bifurcation or near the
cardiac end. Cicatricial strictures are usually single, but may
be multiple. Stricture following impaction of a foreign body
is located at the seat of impaction unless the tube has been
injured by efforts at extraction, in which case multiple strict-
ures may exist (Maylard). Strictures which result from swal-
lowing boiling fluid or corrosive liquid are usually very exten-

^ American Text-book of Surgery.

DISEASES AND INJURIES OF THE DIGESTIVE TRACT. 62 1

sive, and may be multiple. Syphilitic stenosis is due to the
healing of a gummatous ulceration, but there is nothing char-
acteristic of this kind of stenosis (Maylard). Tubercular
stenosis is extremely rare. Cancerous stricture occurs in those
beyond middle life, and is far more common in men than in
women (see Morell Mackenzie). Any portion of the canal
may be attacked, but the central portion is least often the
seat of cancer (Maylard, Butlin). The majority of cancers
of the esophagus are epitheliomata, but scirrhus, encepha-
loid, or colloid may occur. Cancer soon ulcerates and
involves adjacent parts by infiltration. The deep cervical
and posterior mediastinal glands are involved (Maylard).
Spasmodic or hysterical stricture, or esophagismus, which is
commonest in women, is associated with the stigmata of
hysteria, and especially with globus (a sense as of a ball
rising in the throat) ; a bougie held against it is only tem-
porarily obstructed. The contraction arises suddenly, and
one passage of a bougie often causes it to disappear.

Symptoms of Cicatricial Stenosis, — The condition may

Kic. 198. — Esophageal instruments : a, b. forceps : c, horsehair probang : u, cuin>catcher ;

E, esophageal bougie.

occur at any age. The chief symptom is diflficulty in swal-
lowing, at first slight, but becoming more and more pro-

622 MODERN SURGERY.

nounced until swallowing is almost or quite impossible. The
dysphagia is first manifested to dry solids, then to all solids,
and finally to liquids. In some cases vomiting occurs after
swallowing. If the stricture is high up, the vomiting is almost
immediate ; if it is low down, the vomiting is delayed, especially
if the canal is dilated above the stricture. From time to time
the patient vomits independently of taking food, the ejected
matter being saliva. Vomited matter is not bloody. The pa-
tient feels weak and hungry, becomes exhausted and ema-
ciated, and suffers from flatulence, gastralgia, and constipation.

There is occasionally slight uneasiness or even pain in the
region of the stricture, possibly " about the epigastrium or
between the shoulder-blades" (Maylard). The stricture may
be located with a bougie. The history of the case is of much
importance in diagnosis. Inquire about impaction of a foreign
body, or swallowing of acids, alkalies, or boiling fluids ; ex-
amine for evidence of syphilis. IS there is no history of in-
jury or syphilis, and the patient is over forty years of age, the
indications point to cancer rather than cicatricial stenosis.
The easy passage of a bougie when the patient is anesthet-
ized shows that spasm is the cause, and not organic disease.
Narrowing due to external pressure is marked by positive
symptoms of the causative disease.*

Treatment. — Gradual dilatation through the mouth is a
method employed for at least a time in almost every case.
Begin with the largest bougie which will easily pass. Warm
the bougie, oil it, pass it gently, and hold it in position for
several minutes, prolonging the time of retention of the
bougie as treatment progresses. Pass an instrument every
second or third day, gradually increasing the size.

Symonds advocates the insertion of a tube through the
stricture and leaving it in place until dilatation is distinct, and
then replacing the tube with a larger instrument. The
patient is fed through the tube. Gradual dilatation from below
has been practised in cases where a bougie could not be
passed from the mouth. A gastrostomy is performed and
after the fistula has become sound the patient is made to
swallow "a shot to which is attached a silk thread" (May-
lard). The silk thread is brought out through the fistulous
orifice and is attached to a bougie, and the dilating instru-
ment is pulled up through the esophagus. Forcible dilata-
tion can be employed through the mouth or through a
gastrotomy opening by means of bougies, tents, or divulsing
instruments. Electroly.sis is used by Fort and others. Some

* See the excellent article in Maylard's Surgery of the Alimentary Canal.

DISEASES AND INJURIES OF THE DIGESTIVE TRACT, 623

surgeons perform internal esophagotomy through the mouth
with a special instrument ; some advocate external esopha-
gotomy ; some incise the esophagus above the stricture and
pass bougies from the wound through the region of stenosis.

Abbe of New York devised a very ingenious operation.
He performs a gastrotomy, passes a conical rubber bougie
from the mouth into the stomach or from the stomach into
the mouth, ties a piece of braided silk to the bougie, with-
draws the instrument and leaves the silk in place. One end
of the silk emerges from the mouth and the other end from
the gastrotomy wound. In some cases he opens the stomach
and also opens the esophagus above the stricture, one end of
the string comes out of the esophagotomy wound and the
other end out of the gastrotomy wound. The string is used
as a string or bow-saw, the stricture is divided, the silk is
withdrawn, full-sized bougies are passed, and the wound or
wounds are sutured. In very bad cases gastrostomy is per-
formed to keep the patient from starving.

Symptoms of Cancerous Stenosis. — The patient is over forty
years of age, is usually a male, and presents the same diffi-
culty of swallowing met with in cicatricial stenosis. The
vomited matter is apt to contain blood, the use of the bougie
causes bleeding ; there are generally decided pain and very
great emaciation. The seat of obstruction is located by
the bougie and by listening over the spine while the patient
is attempting to swallow water. The stomach is the seat of
pain ; the mouth is dry and there is often great thirst. As the
disease infiltrates the involvement of adjacent regions pro-
duces other symptoms. Dyspnea may result from tracheal
pressure. Pleuritis, pericarditis, or pneumonia may arise.

Treatment. — The disease is of necessity fatal, and treatment
is only palliative. Successful excision is not feasible. Feed
upon soft, bland diet in small quantities given frequently.
When trouble is experienced even with such food, pass a
bougie every third or fourth day. When the patient be-
comes entirely unable to swallow soft food we may insert
a Symond's tube or do an esophagostomy (if this can
be performed below the stricture), or perform gastrostomy.
In every doubtful case of esophageal stricture give a course
of iodid of potassium before performing any operation (the
younger Gross).

DivertioTila of the EsophagruB. — Maylard tells us that
these pouches may be due to one of four causes — they may
be congenital; may be due to stricture; maybe caused by
pressure from within, upon a weak spot of the wall ; may

624 MODERN SURCER Y.

be due to traction from without, by the healing and ron-
traction of an area of ijiflammation.

Symptoms. — When the diverticulum is in the neck a lunjp
forms during deglutition, and this lump may be obliterated
by pressure. Food will pass into the stomach only when
the diverticulum is full, A bougie cannot be passed un!t«
the pouch is full of food, at which time it may pass or nuv
not. This latter symptom, the variability in the passage rf
the bougie, is the evidence relied on for diagnosis tn inlh-
thoracic diverticula. By listening with a stethoscope fluid
may be heard to pass into the pouch.

Treatment. — Extirpation and suture, as performed bj't^OD
Bergmann, Hearn, and others.

I^ju^ies of the Bsophagua. — Injuries of the internal sur-
face are more common than injuries from without. Bums
and scalds are among these injuries. Wounds may be in-
flicted by foreign bodies. These injuries cause pain on stial-
lowing. A severe iojury causes bleeding, the blood being
both coughed up and vomited. A severe wound may irvolre
a large vessel and cause violent or fatal hemorrhage. If tht
bronchus or trachea is involved there wilt be " cough and
expectoration of blood, mucus, and food " (Maylard). Thr
pleural or pericardiac sacs may be perforated.

Treatment. — Feed purely by the rectum. Give motphir
hypodermatically. Do not feed by the mouth for ten days,
and even then give only fluid food and jelly. Symptoms nt
met as they arise. In burns by caustics administer the anti-
dote ; give large draughts of water and wash out the stomach-
Injuries of the esophagfUB from outside, without in-
volvement of other etruotures, are rare. Esophageal in-
juries, as a rule, are associated with serious damage to adja-
cent structures. These injuries may be due to stabs or to
bullets. Besides the obvious external signs of the injury
there will be difliculty in swallowing, cough, bloody expec-
toration or vomiting; and mucus or the contents of the
stomach may run out of the wound.

Treatment. — Suture the wound, and feed by the rectum for
ten days.

Foreign Bodies Lodged in the Esophagus. — These acci-
dents occur especially to children and lunatics, and n-otnen
are more apt to suffer from them than are men. An elaborate
list of bodies which have been swallowed will be found in
Poulet's elaborate treatise. There are three spots where a
foreign body is especially apt to lodge — viz. opposite ll"
cricoid cartilage, at the level of the diaphragm, and at the

DISEASES AND INJURIES OF THE DIGESTIVE TRACT, 625

point where the left bronchus crosses the gullet. Small and
sharp bodies may lodge anywhere.

Symptoms, — ^The symptoms are variable; if the body is
large, there will be pain and difficulty in swallowing, and, in
some cases, dyspnea from pressure upon the trachea or
bronchus. Death may result from asphyxia. In some other
cases the symptoms are very slight. If the body is sharp,
there will be hemorrhage and severe pain. The blood may
be hawked up, or may be swallowed and vomited. A patient
may grow accustomed to a foreign body and cease to notice
it ; but, on the contrary, the foreign body may produce in-
flammation, and even may ulcerate into the windpipe, the
pleura, the pericardium, or the aorta. In many cases of im-
paction a patient makes violent efforts to hawk it up, and
produces aphonia. There may be violent retching. Even
after a foreign body has been removed by swallowing or
otherwise a sensation is apt to remain as if it were still
lodged. The diagnosis is made by the history, the detection
of the body by external manipulation, by feeling it with an
esophageal bougie, and, if bone or metal, seeing it with the
fluoroscope or obtaining a skiagraph.

Treatment, — The surgeon should find out if possible the
size, shape, weight, and nature of the foreign body, and locate
its point of impaction. In metal bodies or bone the exact
point of lodgement is determined by the -^y-rays.^ An
anesthetic is usually necessary in a child, a nervous woman,
or a lunatic, and is sometimes necessary in a man. If the for-
eign body is soft, external manipulation may succeed in alter-
ing its shape, so that it may be swallowed or ejected. If the
foreign body is hard, external manipulation may shift its posi-
tion. It is usually impossible to reach the foreign body
through the mouth by means of the fingers (when the body
is in the rear of the pharynx it may be pulled forward or
pushed down). Sharp foreign bodies may be entangled and
carried down when the patient eats mush, bread, or boiled
potatoes. The administration of emetics is an old plan
which occasionally succeeds, but which is often unsafe.
It is not to be advised. Maylard says that when a
mass of food is impacted it is occasionally possible to
soften and disintegrate the mass by administering a mix-
ture containing pepsin. The horsehair probang is a very
useful instrument (Fig. 198, c). It may be used to push a body
downward into the stomach, or to catch the body and pull it
up. When this instrument is withdrawn it opens like an um-

* See cases of White, Keen, Alfred Wood, Maclotyre, and others.
40

626 MODERN SURGERY.

brella. Maylard quotes Morris Richardson to the effect that
in an adult the diaphragmatic opening is about fourteen and
one-half inches from the incisor teeth, a point to be remem-
bered in deciding whether to push down or pull up the im-
pacted article. Esophageal forceps (Fig. 198, a, B)are valuable
in some cases. The coin-catcher (Fig. 198, d) is a useful in-
strument. Crequy's plan of removal is to take a tangled mass
of threads, tie a stout piece of string about the middle of it,
coat it with sugar, and have the patient swallow it. It may
pass the foreign body ; if it does so, on withdrawal it may
entangle the object and extract it. To remove a fish-hook
with line attached, the following plan may prove successful :
. stick the line into a metal catheter, carry the catheter down
to the hook, and push the hook out. If efforts at extrac-
tion through the mouth are futile, it may be necessary to
perform esophagotomy. The cut is made on the left side,
between the trachea and larynx in front and the carotid
sheath behind, the center of the incision being opposite the
cricoid cartilage. After the foreign body is extracted the
mucous membrane is sutured with chromic catgut, and the
superficial structures are closed with silkworm-gut. The
patient is fed by the rectum for eight or ten days. In cases
where the impaction is low down gastrotomy is perfbrmed.
In White's case of jackstone in the gullet gastrotomy was
performed. A string was tied about some rolls of gauze, the
string was passed by mean^ of a whalebone from the stomach
into the mouth, and the body was entangled and drawn out.

XXVII. DISEASES AND INJURIES OF THE ABDOMEN.
Contusion of the Abdominal Wall without Injury

of Viscera. — In some cases of contusion of the abdominal
wall only the parictes are contused ; in other cases the viscera
or the abdominal tissues are injured. Contusion may involve
the skin alone, or may involve the skin, muscles, and perito-
neum. In simple contusioii there is considerable shock if the
injury is severe. There is pain, increased by respiration,
motion, pressure, and attempts at urination or defecation.
When tenderness appears some days after the accident there
is deep-seated injury. Extensive ecchymosis may appear. In
even a severe case there may be no discoloration, and in
even a slight case there may be much discoloration. There
is great ecchymosis in anemic persons, victims of hemi-
plegia, in obese individuals, opium-eaters, and drunkards.
In severe cases the tissues are pulpefied and sloughing inevi-

DISEASES AND INJURIES OF THE ABDOMEN 62/

tably ensues. Abscess occasionally follows contusion. The
prognosis after abdominal contusion is always uncertain. In
treating simple contusion place the patient at rest in a supine
position, with the thighs flexed over a pillow ; obtain reac-
tion from the shock ; and give morphin for pain. After the
patient has reacted it is advisable to place an ice-bag over
the injury from time to time, and in the intervals of its appli-
cation use lead-water and laudanum locally. If much blood
is extravasated, aspirate and apply a binder. After twenty-
four hours apply intermittent heat by the hot-water bag,
employ an ointment of ichthyol, and move the bowels, if
necessary, by salines. Regard every contusion as serious,
and watch carefully for the development of signs of internal
hemorrhage or visceral injury.

Muscular Rupture from Contusion. — In this injury there
are severe shock and pain (increased by respiration and move-
ment). Separation between the fibers of the muscle is dis-
tinct at first, but it is soon masked by effusion of blood.
Such injuries may cause death, or they may lead to hernia.
The rectus is the muscle most apt to rupture. The rupture
is due to sudden contraction rather than to a blow.

The treatment is the same as for simple contusion. Al-
ways apply a binder. A hernia is returned and a compress
is applied over the opening through which it emerged. If
strangulation occurs, operate at once.

Injuries with Damage to the Peritoneum or the

Viscera. — ^Rupture of the Peritoneum. — The peritoneum
may be involved in an abdominal contusion. It may rupt-
ure even without any visceral injury or muscular contusion.
The uterine peritoneum, the parietal peritoneum, the visceral
peritoneum, or the mesentery may rupture. Rupture of
peritoneum causes intra-abdominal hemorrhage (page 627).
The treatment consists in opening the abdomen, arresting
the hemorrhage, and bringing about reaction.

An injury to the peritoneum creates a point of least re-
sistance, and at such a point peritonitis may develop. The
peritonitis is usually local, but may become general. After
any severe intra-abdominal injury the symptoms of perito-
neal shock appear (peritonism), and the patient may rapidly
die. In the condition of peritonism the temperature is sub-
normal; the extremities are cold; the face is pallid and
sunken ; the pulse is small, weak, and very frequent ; the
respiration is shallow and sighing ; there is great thirst ; the
patient is restless and tosses about. Vomiting almost always
occurs. In some cases there is regurgitation rather than

628 MODERN SURGERY,

vomiting. The abdomen is the seat of a violent, persistent
pain. The patient is fearful of impending death. As the
symptoms develop in a grave case they will point to one of
two conditions, hemorrhage or peritonitis.

In intra-abdominal hemorrhage the subnormal temperature
and other evidences of shock persist. Vomiting ceases, but
nausea exists. The patient is uncontrollably restless and tosses
about in bed. The thirst is great. The abdomen is not rigid.
Fainting-spells occur. Blood-examination shows a great
fall in the percentage of hemoglobin. Percussion shows the
existence of an effusion which alters its position as the
patient's position is altered, and which gradually increases
in amount. Dulness is first met with in the loins. Rectal
or vaginal examination may aid in diagnosis. If peritonitis
develops, the vomiting becomes worse, the pain intensifies,
and the abdomen grows rigid and distended.

Ruptnre of the StomacSi without External Wound.

— The usual cause of rupture is a violent blow, although the
accident may happen in washing out the stomach. Rupture
is more apt to occur when the stomach is distended with food
than when it is empty. The rupture may be partial, the perito-
neal coat not being torn. The rupture may be complete. The
region of the pylorus is most apt to be lacerated. The symp-
toms of rupture are collapse, severe pain over the entire abdo-
men, great thirst, excessive tenderness, especially over the epi-
gastric region, occasionally vomiting, the vomited matter being
usually, but not invariably, bloody; tympanitic distention and
muscular rigidity coming on after a few hours. Gas may enter
the abdominal cavity and cause the disappearance of liver-dul-
ncss, but liver-dulness can be abolished by great intestinal dis-
tention. After incomplete rupture local peritonitis is frequent ;
in complete rupture the escape of food into the peritoneal
cavity causes septic peritonitis. To diagnosticate between
complete and incomplete rupture, endeavor to distend the
viscus with hydrogen gas : in incomplete rupture the contour
of the dilated stomach can be made out upon the surface ;
in complete rupture the viscus cannot be distended and the
gas passes into the peritoneal cavity, producing the physical
si|;ns of tympanites (Senn). The treatment in complete rupt-
ure is as follows : if signs of hemorrhage are absent, en-
deavor to bring about reaction before operating. If these
si^ns are present, operate at once. Open the abdomen ; if
tlic rent is not visible, find it by inflating the stomach with
liydro<:^cn ; flush out the stomach and the peritoneal cavit}'
with hot salt-solution ; sew up the stomach-wound with a

DISEASES AND INJURIES OF THE ABDOMEN. 629

double row of silk sutures, the first row being buried and
including the muscular coat and mucous coat, the second
row being Halsted sutures ; drain ; close the wound in the
parietes with silkworm-gut ; feed by the rectum for four days,
and then begin the administration of a very little food by the
mouth. In incomplete rupture the danger is perforation.
The patient is put to bed, and after reaction has taken place,
is fed by the rectum for several days, and morphin is given
hypodermatically.

Ruptnre of tihe Intestine without External Wound.

— The symptoms of this injury are profound shock, tympan-
ites, and pain, rapidly followed by peritonitis if the patient
survives. Vomiting comes on soon after the accident, the
vomited matters being possibly at first bloody and then
stercoraceous. The respiration is thoracic, the tongue is dry,
and great thirst exists. The pulse, which is slow at first,
becomes small and rapid. A high-tension pulse accompanies
tympanites, because the distention of the bowel greatly
decreases the amount of blood in its coats, and thus in-
creases the amount of blood in the rest of the system. Any
portion of the intestine may rupture, but the ileum is most
liable to this accident. Blood in the stools rarely appears
early enough to be of diagnostic value. The escape of gas
into the peritoneal cavity may cause disappearance of normal
liver-dulness. By anesthetizing the patient hydrogen gas
insufflated into the rectum will come from the mouth if
there is no perforation in the stomach or the intestine ; if a
perforation exists, tympanites is much increased. To apply
rectal insufflation of hydrogen, generate the gas in a bottle
by means of zinc and sulphuric acid, catch the gas in a large
rubber bag, and attach the tube from the gas reservoir to a
tip which is inserted in the rectum. Give the patient ether
to relax the abdominal muscles, direct an assistant to press
the anal margins against the rectal tip, and when the patient
is unconscious turn on the stopcock and press upon the
reservoir (Senn).

Treatment. — If symptoms point to dangerous hemorrhage
operate at once, otherwise do not operate until reaction has
been obtained. Give stimulants by the rectum, and a hypo-
dermatic injection of morphin and atropin ; asepticize and
anesthetize. Perform a laparotomy ; check hemorrhage ;
find the rent, and close it by Helsted sutures if possible.
The hydrogen gas test of Senn will discover a perforation.
It may be necessary to perform an end-to-end approxima-
tion or a lateral anastomosis. Flush out the abdominal

630 MODERN SURGERY.

cavity with hot saline solution. Some surgeons cleanse the
abdomen by wiping with gauze. Finney eviscerates, wipes
out the abdominal cavity, and wipes the intestines as he
restores them. Whatever method is used to cleanse the
abdomen remember that infectious material is apt to accu-
mulate between the liver and diaphragm and in Douglas's
pouch. Drainage is to be used.

" In abdominal operations it is frequently imperatively
necessary that the large intestine be recognized with cer-
tainty or the small bowel be positively identified. The size
of the tube will not always aid in this recognition, as a small
intestine may be distended enormously and a large intestine
may be contracted to the size of a finger because of obstruc-
tion above. The longitudinal muscular fibers of the large
bowel are accentuated in three portions ; these accentuations
constitute the three longitudinal bands which begin at the
cecum and terminate at the end of the sigmoid flexure of
the colon. Each band is composed of a number of shorter
bands, the shortness of these constituent bands permitting
the sacculation of the large intestine. Longitudinal bands
and sacculation are not met with in the small gut, their pres-
ence or absence being a means of identification in many
cases; but when the colon is much distended the bands
cannot be seen distinctly and the sacculation disappears.
From the large intestine only spring the appendices epiplo-
icae (small overgrowths of fat in pouches of peritoneum),
but they are sometimes not well marked except upon the
transverse colon, and when emaciation exists they may
almost entirely disappear. The relatively fixed position of
the large intestine and the free mobility of the small bowel
are important points of distinction. The foregoing indicates
that it is not always easy to distinguish between colon and
small gut, and that, according to old rules, it may often be
necessary to make large incisions, to see as well as feel, and
to handle a large extent of the bowel. Any scrap of knowl-
edge that will shorten an abdominal operation, that will per-
mit of as certain work through a smaller incision, and that
will diminish handling of intraperitoneal structures, tends to
increase the chances of recovery. For these reasons the
writer suggests a method of bowel-identification which rests
upon the facts that each bowel has a posterior attachment,
that the origin of the attachment differs according to the
bowel it supports, that a single finger can detect the origin
of the peritoneal support of any section of the bowel, and,
this origin being known, the portion of the bowel it supports

DISEASES AND INJURIES OF THE ABDOMEN. 63 1

is With certainty deducible. In an exploratory operation, for
instance, the finger comes in contact with the bowel : to de-
termine whether it is a large or a small bowel, note first if
the structure is movable or is firmly fixed ; next, pass the
finger over the bowel and let it find its way posteriorly. If
dealing with a small bowel, the finger will reach the origin
of the mesentery between the left side of the second lumbar
vertebra and the right sacro-iHac joint ; if dealing with the
large bowel, the finger will reach the origin of the meso-
colon, or the point where the colon is fixed posteriorly and
to the side.'"

Ruptnre of the liver may be caused by a blow, a fall
from a height, or the concussion of a railroad collision. Occa-
sionally the ends of fractured ribs are driven into the organ.

The symptoins are those previously set forth as attending
severe intra-abdominal inj ury (page 627). In addition there are
tenderness over the liver, and often pain in the abdomen and
back. As a rule, the signs of hemorrhage are present. Sugar
may appear in the urine. The respiration is much embar-
rassed. After a few days the skin may itch and become
jaundiced, but this is rare.

In these cases operate at once if hemorrhage is severe ;
otherwise operate after bringing about reaction. Stop bleed-
ing in the liver by cautery, by suture, or by packing. In a
superficial tear introduce sutures of catgut or silk. In a deep
tear suture the liver to the belly-wall, pack with gauze, and
surround the rent with gauze.

Ruptnre of the GsUl-bladder and the Bile-dncts.

— Rupture of the gall-bladder or the ducts is most apt to
happen from injury when gall-stones exist. Peritonitis, gen-
eral or local, is almost certain to follow such ruptures. Be-
sides those symptoms common to all severe abdominal injuries,
there is often intense jaundice (Deaver).

Treatment. — Suture the laceration or make a biliary
fistula.

Rnptnre of the Spleen, — The spleen may be dislocated
as well as ruptured. Rupture of the spleen is rare without
other serious injuries. An enlarged spleen is far more liable
to injury than a normal organ. The usual symptoms of
abdominal injury are present. In addition there are pain over
the spleen and heart, tenderness over the spleen, and great
shortness of breath. Hemorrhage is generally violent.

Treatment. — At once remove the spleen.

Rnptnre of the Kidney (page 770).

* The author, in Medical Nnvs, June 9, I $94.

632 MODERX SCRGERY.

Rupture of the Ureter (page 772).

Wounds of the Abdonmial WalL — ^Non-penetratiiiff

woundB are to be treated on general principles. Suture uith
great care and apply external support Ventral hernia may
follow a large wound.

Penetratinfir Wounds. — The symptoms of penetrating
wounds of the abdominal wall are usuallv those of shock
and hemorrhage, and later of septic peritonitis. Emphysema
is apt to occur. Viscera may protrude. In an incised or a
lacerated wound some of the contents of the abdomen may
protrude. If protruding viscera are uninjured, they are
cleansed with hot sterile normal salt solution and returned
into the abdomen, the wound being enlarged if necessary.
The belly is flushed out with hot salt solution to remove
blood-clots, a drainage-tube is inserted, the peritoneum is
sutured with catgut, and the muscles and integument are ap-
proximated with silkworm-guL If the viscera are injured,
treat them appropriately. In punctured and in gunshot-
wounds, when the intestine has been perforated, rectal insuf-
flation of hydrogen will often disclose the fact, but e\'iscera-
tion may be necessary. Always arrest bleeding. In punct-
ured wounds enlarge the wound of entrance, examine for
injury of viscera, close perforations if any are found, flush
out the belly, drain, and close the wound. In gunshot-
wounds the bullet may be located by the A -rays. In a case
of gunshot-wound look if there is a wound of exit, and de-
termine if the ball is lodged.

If the symptoms point to severe hemorrhage, open the
belly at once in the middle line, arrest the hemorrhage (page
267), examine the viscera, and endeavor to repair damage.
If the bullet is found, remove it.

If the symptoms do not point to hemorrhage, bring about
reaction before operating. When the patient is ready for oper-
ation follow the track of entrance by means of a knife and
a grooved director ; open the peritoneum at the point the
bullet entered ; arrest hemorrhage ; look for perforations
and close them ; examine viscera ; search for the ball, but
do not search long, and if it is found, remove it ; flush out
the belly with hot salt solution ; dry with gauze pads ; drain ;
and close the wound. In some cases of penetrating wounds
of the abdomen entcrectomy and end-to-end approximation
will be required. All punctures or tears must be sutured (en-
terorrhaphy). Irrigation of the cavity is only required when
the contents of the stomach or the bowel have escaped or when
a considerable hemorrhage has taken place. The surgeon

DISEASES AND INJURIES OF THE ABDOMEN 633

should drain when the contents of the stomach or the in-
testines have escaped, when hemorrhage is severe, or when
the liver, pancreas, kidney, or spleen is damaged. Active
stimulation and artificial heat are needed immediately after
the operation to combat shock. In many cases intravenous
transfusion of normal salt solution is of great value. It may
be given during and after operation. Enteroclysis of hot
saline fluid is useful. The after-treatment consists of rest,
opium in small amounts to arrest peristaltic action, avoid-
ance of food by the stomach for forty-eight hours, and
the administration of brandy and water from time to time.
Feed by the rectum for two days. On the appearance
of the first sign of peritonitis, forty-eight hours or more
after the operation, give a saline cathartic. It is not wise to
purge during the first forty-eight hours after the operation.
When there is no sign of peritonitis, do not purge until the
fourth day. After forty-eight hours liquid food can usually
be given by the stomach. Solid food may be given after
seven or eight days, but the patient must not leave his bed
until the wound is solidly united, because of the danger of
ventral hernia. A support should be worn for a long lime.

Stomach and Intestines.

Foreign Bodies in the Alimentary Canal. — These
accidents are rare except in children, insane people, or
drunkards. Most foreign bodies swallowed are passed with
the feces, but some lodge. Any body which can pass the
esophagus is not too large to pass through the intestines.
A foreign body may lodge in the stomach. In some cases
there are no symptoms. In other cases symptoms are vio-
lent. The severity of the symptoms depends upon the shape
and character of the body.

In some cases it is possible to feel the body from without.
A metal body in the stomach will deflect a magnetic needle
held over the viscus (Pollailon). Many foreign bodies can
be skiagraphed. It is not wise to attempt to recover the
body by inducing vomiting. In some cases gastrotomy is
necessary. When a foreign body has been swallowed the
usual treatment is as follows : a purgative should nn.'cr be
given to expedite the passage of a foreign body, because
increased peristalsis means increased danger of impaction or
of perforation. Endeavor to encrust the foreign body, and
thus lessen the danger of perforation, by feeding with bread
and milk only for several days, and at the end of this period

634 MODERN SURGERY.

give a mild laxative. An exclusive diet of mush or of
mashed potatoes has been suggested. Pain is relieved by
opium. A foreign body rarely lodges in the duodenum, but
may lodge lower down, and may cause ulceration, perforation,
abscess, or intestinal obstruction. Operation may be neces-
sary in such cases.

Cancer of the Stomach. — Innocent tumors and sarco-
mata occasionally attack the stomach, but they are infinitely
rare in comparison with primar}' cancer. This disease is rare
before the age of forty, and is more common in men than in
women. In a very few instances cancer has been found to
have arisen from an ulcer. The forms of cancer met with,
set forth in their order of frequency, are, according to Osier,
epithelioma, encephaloid, scirrhus, and colloidal. Cancer
may be limited to the body of the stomach (either curvature
or either wall), the pyloric end, or the cardiac end, but it may
involve two of these regions, or almost the entire stomach,
or, being multiple, may be found in many parts. It is fatal
in from four months to two years.

Symptoms. — The disease comes on gradually, usually
with indigestion and physical weakness. The patient has
persistent dragging pain, which is increased by eating and
pressure, and attacks of vomiting are frequent. After a
short time the patient becomes very weak and excessively
anemic, and it is often possible to feel a tumor in the
stomach. The vomiting of gastric cancer is at first only
occasional, but as the case progresses becomes more and
more frequent. Vomiting soon after eating occurs when the
cardiac region is involved ; vomiting an hour or so after eat-
ing occurs when the pyloric end is involved. When the body
of the organ is the seat of disease, vomiting may be absent.
The vomited matter is often mixed with a small amount of
altered blood (coffee-ground vomit). In most cases free
hydrochloric acid is not found in the stomach, but lactic acid
is found. Examine with care a patient in whom cancer is
suspected.

Distend the stomach with gas or fluid and map out its
outlines. Feel for a tumor. A tumor can usually be felt if
it involves the pylorus, greater curvature, or anterior wall,
but not in other regions. Give a test-meal, siphon off con-
tents of stomach, and examine for free hydrochloric acid
and for lactic acid. Ewald's test-breakfast is usually em-
ployed. It consists of a dry roll and three-fourths of a pint
of weak tea or warm water. It is given on an empty stomach.
After an hour the stomach-tube is introduced. The fluid is

DISEASES AND INJURIES OF THE ABDOMEN. 635

removed by a pump or by abdominal compression (May-
lard).

Cancer of the cardiac end interferes with the entrance of
food into the stomach, and in such a case the stomach is
shrunken and the esophagus is dilated immediately above
the growth. In cancer of the pylorus the food is partially
or completely arrested as it passes to emerge from the
stomach, and the stomach becomes much dilated. The
vomited matter in a case of cancer rarely contains recog-
nizable fragments of the growth, but fluid with which the
stomach has been irrigated may contain pieces which can be
identified as cancer (Rosenbach).

In cancer of the stomach the general course of the tem-
perature is normal, but there are occasional deviations to
below or above normal. In many cases the urine contains
albumin, indican, acetone, and casts. Cancer of the stomach
is apt to involve adjacent organs or structures, especially
the liver. In many cases exploratory incision is justi-
fiable.

Treatment. — ^The medical treatment consists in lavage,
milk-diet, and the use of morphin. In order to perform lavage
introduce a soft-rubber stomach-tube. Grease the tube with
glycerin, hold the patient's tongue with the left index finger,
carry the tube to the posterior wall of the larynx, and tell
the patient to swallow while the tube is being urged in by
the surgeon. A funnel is inserted into the raised tube and
fluid is poured in. After a time the tube is lowered and the
patient is asked to expel the fluid. This proceeding is re-
peated till the fluid becomes clear.

Surgical treatment aims at the removal of the growth, or
obviating the effect of obstruction at one of the orifices of
the stomach.

In cancer of the body of the stomach, if the growth is not
extensive, excision may be performed ; if it is extensive, it is
useless to attempt it unless the growth is absolutely non-
adherent. Schlatter of Zurich has successfully removed
the entire stomach and attached the esophagus to the small
intestine. In this patient digestion is satisfactorily performed,
although the stomach is gone. Very rarely will cases be
found suitable for such a radical proceeding. In stricture of
the cardiac orifice of the stomach the surgeon usually keeps
the passage open as long as possible by the frequent passage
of a tube, and through this tube introduces liquid food. Some-
times a small tube is introduced and permanently retained. If
a tube cannot be introduced gastrostomy is performed, and

636 MODERN SURGER V.

through this artificial opening the patient is fed (page 678).
In cancer of the pylorus limited in extent and without lym-
phatic involvement, pylorectomy (page 67 5) maybe performed;
but in cancer which has widely infiltrated the coats of the
stomach and has involved the lymphatic glands, gastro-
enterostomy is performed as a palliative measure, the patient
during the rest of his life subsisting upon liquid or semi-
liquid foods and submitting to frequent irrigation of the
stomach to remove food-residue. In cases of ineradicable
cancer it is usually best to create the opium-habit.

Peptic Ulcer of the Stomacli. — Ulcer of the stomach
IS a condition due to digestion of a portion of the stomach-
wall by very acid gastric juice, the destroyed portion having
been the seat of lowered vitality.

Ulcers are more common in females than in males, and are
more frequent in young women than in those of middle or
advanced age. Men about forty and women under forty
are liable. There is usually a single ulcer, but in some
cases there are two or more. The ulcer may heal or may
perforate. The most common seats of ulcer are the pos-
terior wall and lesser curvature, especially in the pyloric
region. Only 2 per cent, of ulcers on the posterior wall
perforate (Alderson), as they tend to form adhesions to adja-
cent structures. Ulcers on the anterior wall are unusual, do
not tend to form adhesions, and are apt to perforate. Dis-
order of menstruation may develop ulcer, so may tight lacing,
and habitually bending over, as in making shoes. Chlorosis
is associated with ulcer in many cases. Traumatism and
swallowing corrosive liquid may lead to ulceration. Alderson
believes that alcoholism, syphilis, and mental anxiety may
lead to the condition. Ulcers due to syphilis and tubercle
are not, be it remembered, peptic ulcers.

Sjnnptoms. — Acid dyspepsia exists, associated with much
flatulence. In most cases, though not in all, food aggra-
vates the condition. In many of these patients vomiting
occurs about two hours after eating. The vomited matter
contains much hydrochloric acid. Hemorrhage from the
stomach tends to occur. The blood may be brought up
with food, and is then black and clotted, or may be vomited
clear and in large amount. In some cases blood from the
stomach is passed by the bowels in part or wholly. Paroxys-
mal pain exists, which is usually, but not invariably, aggra-
vated by taking food. The pain is very violent in the abdo-
men, and also passes to the back, being located between the
eighth and ninth lumbar vertebrae (Alderson).

DISEASES AND INJURIES OF THE ABDOMEN 637

In gastric ulcer it is usual to find tenderness developed by
abdominal pressure.

If the ulcer does not cicatrize, but progresses, causing pain
and hemorrhage, the patient becomes thin, anemic, weak,
and even exhausted.

It is highly probable that many cases of gastric ulcer are
unrecognized ; in fact, as Habershon says, diagnosis is rarely
made unless hemorrhage exists, and in certain latent cases
both vomiting and bleeding are absent.

A gastric ulcer may cicatrize and thus become cured, but
the cure of the ulcer may prove the ruin of the stomach by
producing stenosis of one of the stomach orifices, or hour-
glass contraction of the body of the stomach. An ulcer may
perforate, causing violent pain, shock, and acute peritonitis.
Perforation occurs after a meal or after drinking liquid, and
is brought about by muscular effort. Alderson calls atten-
tion to the fact that the sudden perforation of an ulcer may
be mistaken for poisoning, and he cites the death of the
Duchess of Orleans in 1670.^

Treatment. — Medical, — Rest in bed. Rectal feeding for a
time, followed by the use of a bland diet. Lavage twice a
day. To some cases Carlsbad salts are given (Ziemssen),
to others silver nitrate, bismuth subnitrate, or oxalate of
cerium. If pain is severe opium is required.

Surgical. — If the patient grows worse in spite of medical
treatment, if the hemorrhage has been profuse, if the pain is
violent, or if tenderness is marked, open the abdomen and
inspect the stomach. An ulcer may be removed by an ellipti-
cal incision in the long axis of the stomach, the coats being su-
tured by the usual method. If the patient is bleeding to death
because of an ulcer, open the abdomen while an assistant is
giving an intravenous injection of salt solution, open the
stomach, turn out clot, find the source of bleeding, and ex-
cise the ulcer. In perforation bring about reaction from
shock, open the abdomen, excise the ulcer, wash out the
stomach, sew up the perforation, wash out the abdomen,
and close. Of late a number of cases have been success-
fully operated upon (see Barling, etc.).

Cicatricial stenosis of the orifices of the stomach

results from the healing of an ulcer, the swallowing of a cor-
rosive substance, or a traumatism from a foreign body. Con-
striction of the cardiac orifice is indicated by gradually
increasing difficulty in swallowing. After a time the esopha-
gus above the stricture dilates or pouches; the fluid food

* Provincial Med. Jour.y Dec. 2, 1895.

638 MODERN SURGERY.

passes into the stomach, but the solid food lodges in the
esophageal f)ouch and is soon regurgitated The site of the
stricture is located by a bougie, and by having the patient
swallow while ausculting over the esophagus and cardiac
end of the stomach. If the constriction be malignant, the
patient will be found to be beyond middle life, the vomit is
occasionally bloody, emaciation is rapid and decided, and
occasionally the supraclavicular glands are enlarged A
tumor of the cardiac end of the stomach can rarely be
felt. If the constriction be cicatricial, the history will exhibit
the cause. Constriction of the pyloric orifice causes retention
of food and dilatation of the stomach. Dyspeptic symptoms
will be found to have been long present A tube passed into
the stomach permits of the injection of fluid so as to fill the
stomach. When the fluid runs out it contains portions of
undigested food eaten days before, and measurement of the
liquid shows that the capacity of the stomach is enormously
increased. If hydrogen be forced through the tube, the
outline of the distended stomach is at once made clear.
The usual method of distending the stomach is by a
Seidlitz powder: two solutions are made; the bicarbonate
solution is swallowed at once, and the tartaric solution is
taken afterward in small amounts at a time. Percussion
over the distended stomach indicates the size of the
viscus.

In malignant disease of the pylorus a tumor may often be
made out ; there are tenderness and considerable persistent
pain, great emaciation and sometimes enlargement of the
supraclavicular glands. Vomiting of bloody fluid occurs.
In cicatricial stenosis of the pylorus there may be paroxysms
of pain, there is no tenderness, emaciation is not so rapid in
onset, and the supraclavicular glands are never enlarged.
Vomiting occurs, but the ejected matter is not bloody.
Illumination of the stomach by the gastrodiaphanoscope
may aid the diagnosis, the area of malignant growth inter-
fering with the transmission of light.

Treatment. — Cardiac stenosis requires dilatation with
bougies and the maintenance of the restored caliber. If
this dilatation from above is unsatisfactory, perform a gas-
trotomy, push a small bougie from the mouth into the
stomach, tie a string to the bougie, draw the string through
the stricture, use the string as a saw to cut the fibrous
bands, pass a full-sized bougie, close the wound in the
stomach, and maintain the caliber by the repeated passage
of dilating instruments. If no instrument can be passed

DISEASES AND INJURIES OF THE ABDOMEN. 639

through the stricture from above, perform a gastrotomy,
introduce an instrument from below, and use Abbe's string
saw. If no instrument can be passed from below, convert
the gastrotomy into a gastrostomy. Pyloric stenosis is
treated by a gastrotomy and digital divulsion of the strict-
ure (Loreta's operation), by pyloroplasty (Heineke-Mikulicz
operation), by gastro-enterostomy, or by pylorectomy.

Intestinal Obstruction (Ileus or Enterostenosis). —
Intestinal obstruction is a condition in which fecal move-
ment is mechanically impeded or prevented. It may be
either partial or complete. Acute obstruction is due to a
sudden narrowing or occlusion of the lumen of a portion
of the intestine. Chronic obstruction is due to a gradual
narrowing of the lumen of a portion of the intestine, and it
may at any time become acute. If obstruction to circulation
in the wall of the bowel occurs, the condition becomes one
of strangulation. Intestinal obstructions are classified' as
follows :

1. Strangulation by bands or in apertures, the commonest
form, is due to peritoneal adhesions, but the band may come
from the omentum. Strangulation may take place by
Meckel's diverticulum, a structure due to persistence of the
vitelline duct, and coming off from the ileum from twelve to
thirty-six inches above the ileocecal valve. Strangulation
may take place beneath an adherent appendix, a Fallopian
tube, a portion of mesentery, or the pedicle of an ovarian
tumor, or it may take place in an omental or a mesenteric
aperture. Strangulation by bands or in apertures usually
involves the ileum, and sometimes the colon. This form of
obstruction is identical with hernia, excepting in the absence
of an external protrusion.

2. Volvulus^ or twisting of the bowel. The twist may be
about the mesenteric axis or on the axis of the bowel itself,
or two intestinal coils may be twisted together. Volvulus is
commonest in the sigmoid flexure.

3. Intussusception is the invagination of a portion of bowel-
wall into the lumen of an adjacent part. One-third of all
cases of obstruction are due to this cause (Treves). Most
cases of obstruction in children are due to intussusception.
There are four varieties : the ileocecal, in which the ileum
and the ileocecal valve pass into the cecum and colon ; the
colic, in which the large intestine is prolapsed into itself; the
ileal, in which the small intestine alone is involved ; and the
ileocolic, in which the ileum prolapses through the ileocecal

* After Treves, in Heath's Dictionary-

640 MODERN SURGERY.

valve. The first variety is the commonest Intussusception
is due to active peristalsis.

4. Stricture of the intestine^ which may be either cicatricial
or cancerous.

5. Obstruction by Tumors of the Bowel and by Foreign
Bodies, — Tumors may be innocent or malignant. Foreign
bodies include besides certain substances that have been
swallowed, gall-stones, and enteroliths or intestinal calculi.
Foreign bodies are apt to lodge in the lower portion of the
ileum or in the cecum, and they may cause ulceration at
the seat of lodgement. If a gall-stone is sufficiently large
to cause obstruction, it cannot have passed the duct, but
must have ulcerated into the bowel from the gall-bladder
(Treves).

6. Obstruction by tumors^ etc. outside the bowel, among the
causes of which are ^retroflexion or retroversion of the womb,
especially in pregnancy, cysts or tumors of the kidneys,
ovaries, uterus, etc., floating kidney, and enlarged spleen.
Obstruction from any of the above causes takes place in
the rectum or the sigmoid flexure.

7. Obstruction from fecal accumulation is due to paresis
or paralysis of the bowel and the diminution or abolition of
peristalsis. Obstruction may follow an abdominal opera-
tion. Paresis or paralysis arises in the colon. Treves
mentions among the rare forms of obstruction kinking of
the bowel, adhesions matting the bowels together or com-
pressing the gut, and shrinking of the mesentery.

Symptoms of Acute Obstruction. — Severe colic comes
on suddenly, the pain varying in intensity, but at no time
entirely ceasing ; there is constipation which soon becomes
absolute, not even wind being passed ; vomiting is early —
first of the contents of the stomach, next of bilious matter,
and finally of feces (stercoraceous) ; the abdomen becomes
distended and tender ; some fever may be found at the start,
but collapse soon arises ; the temperature becomes subnor-
mal ; the face Hippocratic ; the pulse rapid and feeble. The
amount of urine passed is very small. In obstruction of the
upper third of the ileum true fecal vomiting cannot occur.
The tongue is dr>% the mind is clear, and muscular cramp
may occur. Intestinal peristalsis above the obstruction may
be detected through the abdominal wall. If obstruction is
high up in the small intestine, tympanites does not occur.

Sjnnptoms of Chronic Obstaniction. — At intervals there
arise attacks of pain which become gradually more frequent
and severe and are linked with vomiting and constipation.

DISEASES AND INJURIES OF THE ABDOMEN 64I

the vomiting not being stercoraceous and the constipation
not being absolute. Between the painful seizures the patient
complains of constipation alternating with fluid diarrhea,
distention of the belly, some abdominal uneasiness, ano-
rexia, and dyspepsia. The attacks recur with increasing
frequency and severity, and acute obstruction may arise or
the patient may be worn out by pain, vomiting, and want
of food.

Diagrnosis. — The determination of the seat of lesion re-
quires rectal examination. An intussusception may some-
times be felt. Vaginal examination may be demanded. Pain
is apt to arise at the seat of obstruction or to radiate from
there. Palpation may detect a tumor. Rectal insufflation
of hydrogen may locate the obstruction by causing great
distention below it. Entire suppression of urine, early vomit-
ing which is not truly stercoraceous, absence of abdominal
distention, and rapid collapse, mean obstruction in the duo-
denum or in the jejunum. Early vomiting, which is often
stercoraceous in a rapidly progressive case with great dis-
tention of the umbilical region, means obstruction of the
ileum or the cecum (Pepper). Distention of the entire
abdomen and of the flanks, linked with tenesmus, with
less intensity of symptoms, less rapidity of progress, and
less diminution of urine than in the above-cited forms,
means obstruction low down in the colon or in the rectum
(Pepper). A test for obstruction in the adult large intes-
tine is an injection by a fountain syringe : if six quarts can
be introduced, there is no obstruction in the large intestine ;
if less than four quarts can be introduced, there is probably
obstruction in the large intestine. The passage of a sound
in the rectum is generally useless and is often unsafe.

Tlie determination of the causative condition is always diffi-
cult and is often impossible. Intussusception is the common
cause in children. A sausage-shaped tumor can usually be
felt in the right iliac fossa, tenesmus exists, and bloody mucus
is passed. The abdomen is rarely distended or tender. Vom-
iting occurs, but it is seldom stercoraceous. The prolapse
may sometimes be detected by digital exploration of the rec-
tum. In obstruction from bands, internal hernia, etc. there
is a record of antecedent peritonitis, of a traumatism, of a vio-
lent effort, or of pelvic pain. The attack is sudden in onset,
is fierce in character, and is usually excited by violent exer-
cise or the taking of food. Vomiting is early and intractable,
and it soon becomes stercoraceous ; pain is violent ; peristal-
sis above the obstruction is forcible ; tympanites and ab-

642 MODERN SURGERY.

dominal tenderness appear after the attack has lasted for
some little time; obstruction is complete, no wind even
being passed ; collapse soon appears ; no tumor can be
detected, and rectal examination is negative. Volvulus, which
is usually located in the sigmoid flexure, is preceded by con-
stipation. The symptoms come on with explosive sudtJeo-
ness, and rapidly attain great severity. Constipation is abso-
lute ; vomiting is late and is rarely stercoraceous ; no tumor
can be detected ; rectal examination is negative ; abdomiiul
distention and tenderness are early and pronounced; peris-
talsis above the volvulus is vigorous; collapse is nol »
rapid nor so grave as in the previously-considered forms.
Obstruction by a foreign body may sometimes be infeircd
by the history of some such body ha^ng been s«-a!loftfd
The obstructing body may occasionally be felt during palju-
tion, or may be discovered with the -\'-rays. Abdomiiul
distress may exist for days or weeks before obstruclioii
occurs. Vomiting is late and is rarely severe, but pain.
tenderness, and distention are marked. In obstruction from
gall-stones there will be a record of one or more attack^ o(
hepatic colic. Pain is early and acute, and vomiting is invari-
able and usually becomes stercoraceous. In obstruction from
fecal accumulation chronic obstruction evolves into acuw
obstruction, pain and vomiting are late or even absent, and
the dough-like mass of feces may often bo felt by rectal ex-
amination or by abdominal palpation. In some cases the
fluid elements of the feces pass, but the solid elements agglu-
tinate to the walls of the bowel (the diarrhea of constipabony
Obstruction from stricture or from pressure comes on acuw'y
after a prolonged period of disturbance, during which period
attack after attack of temporary obstruction, complctir or
partial, takes place. A history of blood or pus in the slool*
would indicate tumor of the bowel; a history- of blood or
pus having been absent would indicate pressure from without
(Pepper). In functional obstruction there is no local pain-
no tenderness, no tumor, no tendency to collapse, but simpiv
distention and absolute constipation, and possibly non-fecal
vomiting occurring in a neurotic or hysterical subject A
phantom tumor due to a local distention of the intestine fro""
limited muscular spasm disappears under ether. Obstruc-
tion may follow an abdominal operation (post-operative (^
struction) ; it may arise a day or so after operation ; it n^y
arise in ten or twelve days after operation ; it may not anse
for weeks or months (Legeve), It may be due to son"
cause at the seat of operation (adhesion of the bowel to s

DISEASES AND INJURIES OF THE ABDOMEN 643

raw surface, volvulus, catching under adhesions, etc.). It
may be due to some cause distant from the seat of operation
(displacement of intestine, bands, etc.). It may arise from
paralysis of a portion of the bowel, which may or may not
be due to sepsis.*

Separation of Intestinal Obstructiofi from Other Diseases. —
Always examine for a strangulated hernia at every hernial
outlet. If obstruction is complicated with an irreducible
hernia above the seat of lesion, the hernia will always en-
large and become tender because of accumulation of feces
(Pepper). Functional obstruction may attend peritonitis or
may follow the reduction of a hernia. Appendicitis with
peritonitis may cause symptoms similar to those of obstruc-
tion, but there are fever, a history of trouble in the right iliac
fossa, and the vomiting is not stercoraceous. Acute hemor-
rhagic pancreatitis produces symptoms so nearly identical with
those of intestinal obstruction that a diagnosis cannot always
be made. Poisoning by arsenic or by corrosive sublimate
should not be confounded with intestinal obstruction.

Prognosis. — Without surgical interference most cases of
acute intestinal obstruction die within ten days, usually within
seven days. Death may be due to shock, to exhaustion, to
perforation, to peritonitis, or to obstruction of respiration and
circulation by tympanites. Recovery occasionally happens
by the formation of a fistula externally or into another por-
tion of the bowel. In acute obstruction from foreign bodies
the obstructing body occasionally passes. Volvulus and
strangulation by bands are almost invariably fatal unless an
operation is performed. In intussusception recovery occa-
sionally follows the sloughing away of the prolapsed gut, but
stricture almost inevitably follows this rare event. Func-
tional obstruction gives a good prognosis. The prognosis
of chronic obstruction depends upon the causative lesion,
and is not nearly so grave as is that of acute obstruction.

Treatment. — In any abdominal case, where the diagnosis is
uncertain and the patient is shocked, give an enema of brandy
and hot water, wrap the patient in blankets, surround him
with hot-water bottles, and study the development of symp-
toms and signs. In half an hour, as a rule, reaction will be
brought about, and a probable diagnosis may be made (Greig
Smith). In acute obstruction it is usually customary to
empty the stomach by lavage and to evacuate the rectum
by means of copious injections given while the patient is in
the knee-chest position. Hutchinson's method of taxis and

* Legcve, Gaz. des Hdp.y Nov. 23, 1895.

644 MODERN SURGERY,

massage is uncertain, and is more liable to inflict harm than
to confer benefit. Some surgeons apply constant compres-
sion to the abdomen by means of straps of adhesive plaster.
Puncture of the intestine with an aseptic hypodermatic needle
introduced obliquely to relieve gaseous distention is a de-
cidedly dangerous proceeding. The passage of a small tube
from the anus to the sigmoid flexure will empty the colon of
gas if no obstruction intervene. In intussusception give
no food by the stomach; give opium and belladonna to stop
peristalsis, wash out the rectum with copious injections, give
an anesthetic, and insufflate hydrogen gas or carbonic acid gas
in order to distend the bowel. Some surgeons treat intussus-
ception by forcing air into the rectum by means of an ordinary
bellows, and others inject water by a fountain syringe, the
reservoir standing at a height of three feet. D*Arcy Power
believes in the value of hydrostatic pressure in intussuscep-
tion in children. He states that the child should be anesthet-
ized and the large intestine filled gradually with hot saline
fluid, the reservoir not being raised more than three feet
above the patient. The fluid should be retained for ten
minutes. The author is of the opinion that injections of gas
or liquid should be tried during the first twenty-four hours
of the attack, but not later, because later ulcer or gangrene
may exist. Pressure cannot be closely regulated, and if the
bowel is much damaged may lead to rupture. If the case is
not seen until after the first day, or if injections have been
used and have failed, laparotomy should be performed.

Frederick Holme Wiggin has made a study of the reported
cases of laparotomy for infantile intussusception, and con-
siders that operation done within the first forty-eight hours
will give a mortality of 22.2 per cent* (see Operation for In-
tussusception, page 694).

In obstruction from fecal impaction use large rectal injec-
tions and give small repeated doses of salines or a mixture of
castor oil and oil of turpentine. If there are signs of inflamma-
tion, do not give cathartics, even in small doses, but give opium
and belladonna to arrest vomiting and to relax spasm. Im-
pactions in the rectum can be spooned away. In acute intesti-
nal obstruction, if the symptoms grow worse, do not wait,
but open the abdomen before collapse comes on and find
the cause of the obstruction. If it is a gall-stone or entero-
lith, try to crush it without opening the intestine ; if this fails,
push it up a little distance, incise the bowel, remove the stone,
and close the incision with Halsted sutures. If there is fecal

1 Med. Record, Jan. 18, 1896.

DISEASES AND INJURIES OF THE ABDOMEN 645

obstruction, break up the masses by pressure and push the
fecal plug down without opening the bowel. If there is
intussusception, reduce the prolapse and shorten the mesen-
tery ; but if reduction is impossible, perform an anastomosis,
or a resection and enterorrhaphy, or make an artificial anus.
In volvulus untwist and shorten the mesentery ; but if this is
impossible, treat as an irreducible invagination. In obstruc-
tion from adhesions try to separate them and straighten out
the bowel, stitching healthy peritoneum over each raw spot
to prevent recurrence. Anastomosis may be necessary. In
flexion separate the intestines^ remove the flexion by a
V-shaped incision, and suture the wound in the bowel (Senn).
In chronic obstruction it is often advisable to perform an ex-
ploratory laparotomy and determine by the condition what
is to be done. Some tumors external to the bowel are re-
moved. Growths in the bowel-wall may be removed by resec-
tion of the involved portion of intestine. Anastomosis may be
performed, or an artificial anus may be necessary. Post-oper-
ative obstruction coming on soon after a surgical operation
is often not recognized for a time, and the surgeon will be in
doubt as to whether he is dealing with peritonitis or intesti-
nal paresis. When in doubt wash out the stomach with
warm salt solution, administer salines in small doses fre-
quently repeated, and employ enemata. If these measures
are not soon successful, open the abdomen ; never wait for
the advent of stercoraceous vomiting (see Legeve).

Pecal Fistula. — A fistula is an abnormal opening in the
intestine through which gas or a portion of the feces escapes
(Fig. 199). If all the intestinal contents escape through the

Fig. 109 — Fecal fistula : a, direction Fic. «oo.— Artificial anus, showing spur :

of fecal flow ; b, b, belly-waU. a. spur ; b, b, belly- wall ; c, direction uf fecal

flow.

opening, it is called an artificial anus (Fig. 200) (Senn). A
surgeon may make a fistula deliberately (intentional fistula).
A fistula may be the product of disease or injury {accidental
fistula). Senn gives the following as the causes of accidental
fistula : wounds, injury of the intestine, intestinal ulceration,
intestinal strangulation, foreign bodies in the intestinal canal,
malignant tumors, actinomycosis, pelvic and abdominal ab-
scess, appendicitis, injury of the bowel during an abdominal

646 MODERN SURGERY,

operation, the application of ligatures, catching by sutures,
and the employment of drainage-tubes.

Treatment. — Many fistulae close spontaneously. This can
only be hoped for if the opening is quite small, if the general
health of the patient is good, when the cause has passed away,
when the fistula is not lined with mucous membrane, and
when there is no spur (Figs. 199, 200). In most cases of
fistula not high up it is well to give nature a chance. The
part is cleansed frequently with peroxid of hydrogen, the pa-
tient is kept recumbent, food is given which does not leave
much residue, pads of gauze with pressure are applied, and
the bowels are kept regular.

If the track is lined with granulations, it may be touched
with lunar caustic; if it is lined with mucous membrane, with
the actual cautery; any collection of pus which exists should
be drained. If these methods fail, an operation must be
performed. The fistula may be sutured by extraperitoneal
manipulation (Greig Smith); it may be covered with skin
(Dieffenbach) ; the spur may be removed by means of a clamp;
or resection may be performed. In some cases exclusion
of the fistulous part is necessary, the bowel being divided
above the fistula, the end near the fistula sutured, and the
other end anastomosed to the bowel below the fistula.

Ulcer of the Bowel. — In typhoid fever and in dysentery
ulceration occurs. An ulcer may be due to tuberculosis or
cancer. Ulcer in the duodenum sometimes follows a severe
burn of the surface (Curling's ulcer). An ulcer may heal, and
by causing thickening and constriction produce intestinal ob-
struction. It may perforate, causing collapse and subsequent
peritonitis. In perforation the liver-dulness is greatly dimin-
ished or disappears because of free gas in the peritoneal
cavity. Perforation of a typhoid ulcer is accompanied by
marked leukocytosis; there is great shock, which is usually
followed by a temporary reaction, severe pain as a rule,
tenderness, costal respiration, abdominal distention, vomit-
ing which may become eventually stercoraceous, constipa-*
tion, percussion-dulness of the flank, and Hippocratic face.

Treatment. — The intestinal obstruction due to the healing
of an ulcer is treated by intestinal anastomosis or resection.
If an ulcer perforates, the surgeon aims to bring about re-
action. If this attempt succeeds, the abdomen is opened and
is flushed out with hot saline fluid, special care being taken to
flush away infected material from the pelvis and from between
the liver and diaphragm. The perforation is to be found and
sutured.' It is not necessary to excise it. A suprapubic in-

DISEASES AND INJURIES OF THE ABDOMEN, 647

dsion in addition to the first incision renders drainage better,
and in some cases posterior drainage is inserted tl^rough the
right kidney pouch. A drainage-tube is placed in each in-
cision, and a tube is inserted in the suprapubic incision and
is carried into Douglas's pouch, and the upper incision is left
open, strands of iodoform gauze being placed over the area
of rupture and in several places among the intestines. In
perforation Finney always eviscerates, closes the perforation,
wipes out the peritoneal cavity with gauze pads, and returns
the bowels slowly into the abdomen, wiping them carefully.

Malignant Tumor of the Intestine. — Sarcoma is very
rare, but does arise sometimes in young persons and enlarges
very rapidly. Cancer is not uncommon, attacking especially
the middle aged. It is particularly common in the neighbor-
hood of the ileocecal valve and in the sigmoid flexure. It
produces pain at the seat of growth, and after a time intestinal
obstruction. It is usually possible to feel the tumor, which
is hard and immovable. The patient wastes rapidly and is
apt to occasionally pass blood at stool. The growth is not
very rapid and glands are not involved early. In some cases
the supraclavicular glands enlarge.

Treatment. — Early in the case exploratory laparotomy
should be performed, followed if possible by excision with
end-to-end approximation. If excision is impossible, the
growth should be sidetracked by performing lateral anasto-
mosis. In advanced cancer of the large bowel make an
artificial anus above the tumor.

Appendicitis. — Appendicitis, which is an inflammation
of the vermiform appendix of the cecum, is almost invariably
the primary lesion of all of those various conditions known
as typhlitis, perityphlitis, paratyphlitis, etc. — terms which no
longer imply pathological entities, and are in most instances
well relegated to obscurity. The appendix is a diverticulum
(musculomembranous in structure) which comes from the
posterior and internal part of the head of the colon, and
which has no physiological function (in herbivora and rodents
it is a functionally active organ). The structure of the appen-
dix is identical with the structure of the colon, except that
the muscular structure is ill developed and trivial in amount
The appendix averages about four and a half inches in length,
and its diameter is, as a rule, about equal to that of a No. 9
English bougie ; its canal is narrow and is partly closed by
the valve of Gerlach (Talamon). The appendix enters the
cecum at its posterior internal part, which is usually the seat
of the most intense pain in inflammation, and corresponds to

648 MODERN SURGERY,

a point on the surface two inches from the spine of the ilium,
on a line drawn from the umbilicus to the anterior superior
iliac spine, which is known as " McBurney's point" The
free part of the appendix in one-third of all persons is in
relation with the posterior surface of the cecum ; in almost
one-third of all persons it is fixed in the iliac fossa, so that if
perforation occurs the contents will be voided in the retroper-
itoneal tissue (iliac abscess). In some cases it is external to
the cecum ; in some it passes downward, and in some inward
In about two-thirds of all cases the appendix is completely
covered with peritoneum ; in one-third of all cases it is in
contact, in some part of its length, with cellular tissue
(Talamon). Robinson has called attention to the fact that
the appendix is frequently in contact with the psoas muscle
in men.

Etiologry and Pathologry. — Appendicitis is very rare in in-
fants, but is common at any period beyond childhood, being
more frequent in young and middle-aged people than in the
aged. Appendicitis is a bacterial disease. It is produced
occasionally by pus cocci, but most commonly by the action
of the bacterium coli commune of Escherich. These microbes,
which normally inhabit the appendix, are harmless when the
appendix is healthy, but become active for harm when the
diverticulum is bruised, obstructed, or in a state of catarrhal
inflammation. When non-traumatic inflammation occurs
swelling of the mucous membrane occludes the opening
into the colon, and the lumen of the appendix dilates and
fills up with a thick or mucopurulent fluid. Ulcers some-
times form, which may only involve the mucous membrane,
may pass deeply into the coats, or may even perforate. Dieu-
lafoy ^ maintains forcefully that appendicitis is due always to
the conversion of the appendix into a closed cavity. Various
conditions may bring about this transformation. Partial ob-
struction may be caused by calculi, which are composed of
stercoral material mixed with salts of lime and magnesia
These calculi are not formed in the colon, but are formed in
the appendix. Dieulafoy speaks of the condition as appen-
dicular lithiasis, and says the condition has a tendency to run
in family lines, and has a kinship with gout and rheumatism.
Obstruction may be caused by local infection of a catarrhal
area, by the formation of a fibrous stricture, or by several
causes acting in unison. The theory that concretions form
in the colon, and are forced into the appendix by peristalsis,
has been very largely abandoned. Talamon taught that the

* Progris MidicaU, No. II, 1896.

DISEASES AND INJURIES OF THE ABDOMEN. 649

appendix resents the presence of the concretion, reflex contrac-
tion of the muscular coat taking place, which is accompanied
by violent pain (appendicular colic). The muscular structure
is so rudimentary that it does not seem probable that at-
tempts at contraction, even should they arise, would produce
violent pain and distant symptoms. Pozzi believes that ap-
pendicular colic may be caused by torsion, or bending of the
appendix, or malposition of the diverticulum, and holds that
pain may arise when there is no lesion in the appendix and
no inflammation of the peritoneum or pericecal structures.*
Foreign bodies, such as pins, fish-bones, nails, buttons, date-
stones, cherry-stones, and grape-seeds, may enter the appen-
dix, but they do so far less often than is generally supposed,
most alleged grape-seeds from the appendix being only fecal
concretions. Fitz found concretions is 1 5 cases out of 3CX).
Ranvier collected the records of 459 post-mortems, and found
reported 179 fecal concretions and 16 foreign bodies. Ap-
pendicitis due to a foreign body, such as a grape-seed or a
pin, is known as traumatic; appendicitis in which a concretion
is the assumed cause is known as stercoral. A foreign body
may produce instant perforation at the site of the body. If
impaction of a foreign body or concretion occurs, the orifice
of the appendix is closed, the circulation is soon cut off, the
secretions are retained, the coats become congested, the diver-
ticulum enlarges enormously, microbes multiply with great
rapidity, and the wall of the congested appendix inflames and
may become gangrenous or ulcerated, and is finally perforated.
Interference with the blood-supply of the appendix will pre-
dispose to appendicitis. This may be brought about by twists,
bruises, adhesions, concretions, pressure, or bands ; and the
psoas muscle may play a part in the production of these con-
ditions. In women appendicitis is occasionally secondary to
tubo-ovarian disease. Appendicitis is rarer in women than
in men, probably because the appendix of a woman has a
better blood-supply, the additional supply coming through
the folds of the appendiculo-ovarian ligament. Catarrhal
conditions of the intestine, habitual constipation, indiges-
tion with flatulence, predispose to appendicitis. Some hold
that catarrhal appendicitis may result from extension of a ca-
tarrh of the colon, and may also arise from external trauma-
tism. If before perforation the appendix adheres to the cellu-
lar tissue behind the cecum, cellulitis or abscess without peri-
tonitis may result. When appendicitis goes on to perforation,
there is always some peritonitis ; but if the steps to perfora-

* Progrh MidicaU, No. 19, 1896.

6SO MODERN SURGERY.

tion are gradual, the peritonitis may be local, and will some-
times by formation of adhesions make a barrier between the
appendix and the peritoneal cavity before perforation occurs.
When perforation takes place suddenly diffused septic perito-
nitis is inevitable. Peritonitis may arise without perforation
by contiguity of structure or by migration of the bacterium
coli commune through the congested walls of an obstructed
appendix. In some cases perforation takes place into the
peritoneal cavity, but pus is circumscribed by matting to-
gether of the intestines with plastic exudate. The appendix
may become gangrenous very rapidly or after some time. A
case of appendicitis in which gangrene and perforation come
on very quickly is spoken of as fulminating appendicitis. In
some cases, if the perforation is very small and the appendix
is swathed in lymph, or if perforation does not occur, the in-
flammation may subside. Perforation rarely occurs from
liquid pressure or from the pressure of concretion ; it is
generally due to ulceration produced by the action of micro-
organisms. Appendicitis which subsides may at any time
recur, and the life of the patient is under constant menace.
An enormous number of people have had appendicitis. Toft
recorded 5CX) autopsies, and in 36 per cent, of them there
were positive signs of past attacks. The disease is occasion-
ally unsuspected during life. These facts prove that the dis-
ease may subside without the aid of surgery.

Forms of Appendicitis. — In what is known as appendicu-
lar colic the appendix is temporarily obstructed because of
swelling of the mucous membrane of the outlet, and the
stercoral contents are retained in the diverticulum. This
condition is called by Fergusson " constipation of the appen-
dix." It is not appendicitis, but if not relieved will rapidly
eventuate in appendicitis.

Simple parietal or catarrhal appendicitis is not limited to
the mucous membrane; hence the term catarrlial is not
strictly correct. Forty-eight hours after the mucous coat
begins to inflame the peritoneal coat will probably be in-
volved. In simple appendicitis the diverticulum enlarges,
fills up with mucus, and its coats become infiltrated with
inflammatory exudate. This inflammation may undergo
resolution or suppuration, or may become chronic. In
a catarrhal inflammation secondary to catarrh of the colon
the case may be chronic from its origin. If the lumen of
the appendix is gradually obliterated, the condition is de-
nominated obliterative appendicitis (Senn). This progressive
obliteration may result from repeated attacks of inflamma-

DISEASES AND INJURIES OF THE ABDOMEN 65 1

tion or may be simply a degenerative change. In appen-
dicitis with a concretion the attack may subside, the fluid
elements may be absorbed or flow back into the bowel, and
resolution of the exudate may take place ; but if the con-
cretion remains in the appendix, recurrence is probable.
Recurrent appendicitis, it is said, may be due to inordinate
size of the mouth of the appendix, making of this diverticu-
lum a drag-net for foreign bodies ; but it is more probable that
it is due to smallness of the opening, so that it quickly closes
and converts the appendix into a closed vase filled with septic
material. Suppurative appendicitis is due to purulent infiltra-
tion of the walls. Pus in the lumen is not purulent appen-
dicitis. Gangrenous appendicitis is a moist or septic gangrene,
due to interference with the circulation and to tissue-destruc-
tion by the action of micro-organisms. Perforations occur,
and they are often multiple. The entire appendix may slough
off. Interference with circulation may be caused by an ob-
struction, by a bend, or twist, or bruise of the appendix, or
by the action of virulent organisms on an appendix whose
tissue-resistance is lowered by injury or disease. In gan-
grenous cases the vessels of the meso-appendix are usually
obstructed by thrombi or the changes of arteritis (Van Cott).

Fowler suggests the following classification of cases of
appendicitis: (i) endo-appendicitis ; (2) parietal appendicitis;
(3) peri-appendicitis ; (4) para-appendicitis.

As a matter of fact, appendicitis is always one disease,
which varies in intensity, and it is useless to divide it into a
great number of symptomatic groups. In rare instances
appendicitis is due to tubercular ulceration and typhoid
ulceration. Genuine appendicitis may arise during typhoid
fever.

Symptoms. — In what is known as appendicular colic there
are colicky pain about the umbilicus and right iliac fossa, nau-
sea and vomiting, and usually constipation, but no tenderness
in the iliac fossa and no abdominal rigidity. This condition, if
not soon relieved, is followed by the evidences of inflamma-
tion. The symptoms of genuine appendicitis are as follows:
in some cases the patient feels out of sorts for a day or two.
Constipation is very generally present, but in rare cases
there is diarrhea. The sufferer complains of anorexia, dys-
pepsia, flatulence, colicky pain, and a feeling of weight, sore-
ness, or pain in the right iliac fossa. Nausea is often present,
and vomiting may occur. The tongue is coated. Examina-
tion discovers tenderness, rigidity, fullness, and pain in the
right iliac fossa. The tenderness is most marked about

6s 2 MODERN SURGERY.

McBurney's point. There is moderate fever, and the pulse is
about lOO or less. The patient may get well, the symptoms
gradually passing off. He may get gradually worse. The
tenderness increases ; the pain becomes agonizing and radi-
ates toward the umbilicus, and the patient draws up the
right leg to relieve it. Pressure upon the left side often
causes pain in the right iliac region. A rectal or vaginal
examination may make out tenderness, or enable the surgeon
to feel a lump. The pulse increases in frequency, the fever
rises, the abdominal distention and rigidity become more
marked, vomiting begins and becomes worse, and the res-
piration becomes shallow and thoracic. There are great
thirst, anorexia, constipation, and mental anxiety. Absolute
obstruction sometimes takes place. The urine is scanty
and highly colored. Hiccoughs develop. If the inflammation
continues for one or two days, swelling is often observed
in the right iliac fossa, or is detected by a vaginal or rectal
examination, or by bimanual palpation, or by examination
under ether. It is not wise to forcibly palpate in acute ap-
pendicitis, as it may cause rupture. If the appendix is
enlarged, and the individual has a thin abdomen which is
not rigid, it is often possible to palpate the appendix. Some-
times it may be felt when the patient is anesthetized, though
it could not be detected before.

A case of appendicitis may come on suddenly with pain, pre-
monitory symptoms having never occurred. There are nausea
and bilious vomiting, constipation, and distention of the abdo-
men. Such attacks are not to be considered as colic from the
lodgement of a calculus. They are inflammatory, and are
associated w^th fever and the other symptoms previously
set forth. Examination detects tenderness in the right iliac
fossa. The point of greatest tenderness is known as " Mc-
Burney*s point." This is apt to be about two inches from
the anterior superior spine of the ilium, on a line drawn from
the spine to the umbilicus. Pain at McBumey*s point is
linked with local muscular rigidity and hyperesthesia of skin.
Such a case, like the former cases described, may get well or
may get worse. In some cases all the symptoms are violent
from the beginning, the attack tends to linger, and is followed
by persistent soreness of the appendix and harassing digestive
disturbances. Any case of appendicitis may become suddenly
desperately grave because of perforation or gangrene. The
temperature falls, hiccough begins, abdominal distention, pain,
and tenderness become marked and general, and the pulse
becomes very rapid. In some cases these grave symptoms

DISEASES AND INJURIES OF THE ABDOMEN 653

are present almost from the start (fulminating cases). A sud-
den perforation produces collapse, and, if reaction takes place,
suppurative peritonitis arises. Peritonitis, be it remembered,
often arises without either perforation or gangrene (Dieula-
foy). If pus forms, it may be unlimited by adhesion. In
such cases there is the rapid onset of fatal peritonitis and
septicemia. Pus may be limited by adhesions and be practi-
cally extraperitoneal. In such a case a lump is felt in the
right iliac region ; and dusky discoloration and edema of skin
sometimes exist In an abscess case there are usually irregu-
lar fever and sweating. A limited collection of pus may be
liberated into the peritoneal cavity by rupture of the abscess-
wall. Such a rupture may be caused by pressure or muscular
effort, and it gives rise to shock, and is followed by diffused
peritonitis. An abscess may rupture externally, or into the
vagina, intestinal tract, or bladder.

Terminations. — Appendicitis may terminate in recovery,
in death, or in a condition of lowered vitality, renewed
attacks being certain to occur. Adhesions may form as a
result of appendicitis, general peritonitis may arise, the
appendix may slough or become perforated, or abscess may
ensue upon local peritonitis. Pylephlebitis and abscess of
the liver may follow appendicitis.

Treatment. — In appendicular colic give a saline cathartic,
apply a hot-water bag to the right iliac fossa, and watch the
development or abatement of the symptoms with anxious
care. Many surgeons give a purgative in the beginning of
a case of even undoubted appendicitis. This plan of treat-
ment was begun with the belief that an inflammation of the
appendix was associated with fecal impaction in the head of
the colon, an idea which has been entirely exploded. It
does not seem safe to give a purgative in genuine appen-
dicitis, because violent peristalsis and increased tension may
serve to produce perforation. In mild cases leech over the
right iliac fossa, apply an ice-bag, give an enema, place the
patient on a bland liquid diet, administer antipyrin for the
pain, and maintain rest in bed. If the case is not better in
thirty-six hours, operate. If it becomes worse within that
time, operate at once (if pulse becomes very rapid, if fever
rises, if sweats are observed, if temperature is very oscil-
lating, if distention, rigidity, pain, or tenderness become
more marked, if shock arises). In any severe case operate
at once. Opium should not be used. It masks the symp-
toms, makes the patient feel comfortable, and gives a false
sense of security. In an appendicitis even with slight symp-

6S4 MODERN SURGER K

toms many surgeons maintain that an operation should be
performed at once, because the mildness of the symptoms
is no assurance that even in an hour or two gangrene or per-
foration will not occur. Early operation is comparatively safe;
operation after perforation, gangrene, or septic peritonitis
arises must be done, but it is not unusually futile. Murphy,
Deaver, and others operate at once in every case. Keen, Senn,
White, Grieg Smith, and others strongly oppose this plan.
Other surgeons, in a first attack, if the symptoms are mild,
wait and temporize, apply a hot-water bag over the right iliac
fossa to favor plastic exudation, and give opium in full doses.
Some begin treatment by the administration of salines, apply
an ice-bag over McBumey's point, and after a free movement
of the bowels give opium and keep the patient on liquid
diet. If the symptoms become worse, they recommend
operation. The author does not believe that it is proper
to always operate. Such a rule makes decision easy, but
not of necessity right. In a case with severe symptoms
operate at once, but in an ordinary mild case watch the
patient for a few hours. McBumey says, if six hours after
the beginning of the attack the patient is no worse,' there is
no pressing danger, and if in twelve hours symptoms are
not intensified, they will soon begin to abate ; but if in the
twelve hours the case has become worse, operation is neces-
sary.^ It is well, if possible, to operate in an interval in
preference to operating in an attack. McBumey says, if in
twenty-four hours from the onset of an attack the severity
of the symptoms lessens, it is usually possible to wait for an
interval ; but if during the second twenty-four hours the
abatement in symptoms has not gone on and there is doubt
as to the condition, operate at once. It is not safe to delay
operation in a pus case, hoping that the pus may become
well limited. It may become limited, but it may instead pass
up toward the liver or down into the pelvis, and delay is
fraught with peril. The interval operation can be performed
about three weeks after the attack, or later. If there has
been but one acute attack, there may never be another, and
operation need not be done unless tenderness persists or
there are colicky pain and tenderness after exercise. But
if a man has had two attacks, he is certain to have others,
and an interval operation must be performed (see Opera-
tion for Appendicitis).

1 A': K Polyclinic, Jan. 15, 1897.

DISEASES AND INJURIES OF THE ABDOMEN, 655

The Peritoneum.

Peritonitis. — In rare instances peritonitis is said to be
primary, following a cold; but most surgeons doubt this.

Pkiatdo peritonitis is due to an aseptic cause (traumatism
or chemical irritation); it remains limited, and is really a
process of repair rather than of inflammation. The symp-
toms of plastic peritonitis are local pain, tenderness, and
rigidity. Fever exists, due to the absorption of fibrin-fer-
ment and the products of tissue-change; adhesions form,
which may be either temporary or permanent. Recovery
is the rule. The treatment comprises saline purgatives
followed by rest, a liquid diet, and local heat (hot-water
bag or fomentations).

Difituse septic peritonitis is apt to destroy life even before
the peritoneum presents any marked change. Death ensues
from the absorption of toxic alkaloids. Septic peritonitis
may arise during puerperality, through lymphatic infection ;
it may be due to infection from without by an operation or
an accident; to perforation of an ulcer; to gangrene of a
portion of the intestine ; to rupture of an abscess into the
peritoneal cavity; or to migration of micro-organisms
through a damaged wall of the bowel. It is made mani-
fest by a chill, shock, or rapid collapse ; very rapid pulse,
which is at first wiry and later gaseous ; a temperature which
may be at times febrile, but which is apt to be subnormal or
which soon becomes so ; dry tongue, delirium, and persistent
vomiting. Rigidity may exist, and also intestinal obstruction ;
often, but not invariably, there is distention. In puerperal peri-
tonitis or septic peritonitis from operation there is often no
pain ; in perforative peritonitis there is acute pain. Patients
usually die within five or six days. Treatment is rarely
successful. Stimulants are strongly pushed. The patient
is fed upon liquids (koumiss especially). The abdomen is
opened in the middle and also upon one or both sides.
Any perforation is closed. In some cases a suprapubic
incision is also made, in other cases an opening is made in
the loin. In a woman Douglas's sac is opened through
the vagina. The peritoneal cavity is wiped out with gauze
pads or is flushed out with gallons of hot normal salt solu-
tion. Special attention is given to cleansing Douglas's
pouch and the space between the liver and diaphragm.
The wounds are left open, and drainage is maintained by
strips of iodoform gauze.

In flbrinoplastic peritonitis the septic organisms are

6S6 MODERN SURGERY.

fewer or less virulent, the products of germ-action are lim-
ited and surrounded by adhesions, and circumscribed sup-
purative peritonitis is apt to arise.

Suppurative peritonitis differs clinically from septic peri-
tonitis in the fact that it is more apt to be circumscribed
and less apt to be fatal. The causes of both are identical
In septic peritonitis death occurs from absorption of tox-
ins before obvious pathological changes occur in the
peritoneum; in suppurative peritonitis the microbes are
fewer, are less virulent, or vital resistance is more decided,
and suppuration follows marked changes in the peritoneum.
In suppurative peritonitis the pyogenic bacteria are always
present, and there exists in the peritoneum a wound or
damaged area to constitute a point of least resistance.

Symptoms, — Chilliness or a rigor is common, followed by
fever, the temperature rising to I02° or 104° ; pain is intense,
and is accentuated by motion and pressure; the attitude of
the patient is assumed to relieve pain (he lies upon his back,
with the shoulders raised and the thighs drawn up) ; there
are vomiting, obstinate constipation, and distention and
rigidity of the abdominal walls. The pulse is rapid ; is at
first wiry, but may become gaseous. The constipation may
be due either to tympanitic distention or to the shock of a
perforation inhibiting intestinal peristalsis. Vomiting is fre-
quent. In perforation gas often passes into the peritoneal
cavity and obscures the liver-dulness ; in tympanites without
perforation the liver is pushed up and its dulness usually
remains, but on a higher level. Pus unconfined by adhe-
sions will gravitate to the most dependent part of the peri-
toneal cavity. Circumscribed suppurative peritonitis presents
the signs of a deep abscess (swelling, dulness on percussion,
local rigidity, irregular temperature, sweats, and possibly
edema of the belly-wall). In some cases of suppurative
peritonitis there is no tympanitic distention or rigidity; in
some cases there is no fever, and a subnormal temperature
may even exist. The high-tension pulse of peritonitis is due
to the tympanitic distention emptying the bowel-walls of
blood, and thus increasing the amount of fluid in the other
vessels of the bodv.

Treatment. — In the beginning of ordinary peritonitis with-
out perforation give a saline cathartic, which will empty the
peritoneal cavity of fluid, will favor the elimination of mi-
crobes, and will combat inflammation. The old-time remedy
was opium, but Tait proved its inefficiency, and showed that
it masked the symptoms and often created a false sense of

DISEASES AND INJURIES OF THE ABDOMEN, 65/

security in the very midst of imminent dangers. The usual
method of administering salines is to give 3j of Rochelle salt
and 3j of Epsom salt every hour until a free movement
occurs. This treatment will often cut short a beginning
peritonitis, and will frequently prevent a peritonitis after an
abdominal operation. Give an enema of turpentine at the
same time as the saline. If this treatment fails, open the
belly, explore for the causative condition, remedy it, flush,
and drain. In perforative peritonitis do not give cathartics :
they will only increase the extravasation and prevent its lim-
itation by lymph. As soon as the patient has reacted from
the shock of the perforation perform a laparotomy, suture
the perforation, flush out the belly, and drain. A circum-
scribed abscess is to be opened and the primary lesion sought
for and, if found, removed. Do not tear the lymph-barriers
in an attempt to find the primary lesion ; rather let it go un-
discovered. Pack iodoform gauze against the intestines to
reinforce the barrier of lymph, and insert a tube. In some
cases make incision for drainage in the opposite side of the
belly, above the pubes or through the right kidney pouch.
It is frequently advisable to leave the wounds open and
drain with iodoform gauze. Every patient with peritonitis
requires stimulants and frequent feeding with liquid food.

Tubercular peritonitis is seen by the surgeon as a pri-
mary local tuberculosis, though it occurs also as an associate
of phthisis and as a part of a general tuberculosis. Abdom-
inal section with or without drainage cures not a few cases.
Why it cures is doubtful. Abbe thinks that the fluid acts as
a culture-medium for bacilli. When the fluid is removed the
tissues regain their powers of resistance, and the inflammation
which follows the operation, plus the vital resistance of the
tissues, causes fibroid transformation of the peritoneal tuber-
cles ; but aspiration will not cure, while incision will.

Subphreilic Abscess. — A subphrenic abscess is a col-
lection of pus beneath the diaphragm. The pus, as a rule>
occupies a part of the lesser peritoneal cavity ; in rare in-
stances it is extraperitoneal (when it is of renal origin) ; in some
cases it is contained in the area between the diaphragm, car-
diac end of the stomach, and liver or spleen. It is an unusual
thing for such an abscess to break into the general cavity of
the peritoneum, but it may break into the pleural sac (Maydl).

Causes. — Perforation of a gastric ulcer, perforation of the

gall-bladder or gall-ducts, ulceration of the duodenum, disease

of the liver, spleen, pancreas, intestine, appendix, or kidney,.

hydatid disease, internal injury, metastasis, external injury^

6s 8 MODERN SURGERY,

caries of rib, or disease of the pleura may be responsible
for a subphrenic abscess (Maydl).

Symptoms. — There are the constitutional symptoms
of suppuration and a swelling in the subdiaphragmatic
region, these symptoms ensuing upon one of the causative
conditions before mentioned. In many cases the abscess-
cavity contains gas as well as fluid. Empyema and sub-
phrenic abscess resemble each other. In empyema the
upper limit of the fluid is concave ; in subphrenic abscess it
is convex. In empyema the flow of pus through an aspirat-
ing-needle will be most marked during inspiration ; in abscess,
during expiration — the same is true of the rush of gas. In
empyema the needle does not oscillate ; in abscess it does.^
The fact that an abscess contains gas is shown by the ex-
istence of a tympanitic percussion-note over a part of the
cavity and an alteration in the area of tympany with an
alteration in the position of the patient. An abscess of the
liver does not contain gas and alters decidedly the outlines
of the organ.

Treatment. — Incision and drainage. The incision in some
cases may be made through the abdominal wall (epigastric
region, iliac region, hypochondrium, or loin). In other
cases the chest-wall is incised, a rib is resected, the pleura is
opened, and the diaphragm is incised.

The Liver and Gall-bladder.

Wounds of the I<iver. — A wound of the liver causes vio-
lent hemorrhage which is usually rapidly fatal. Such a wound
is apt to divide bile-ducts and allow of the escape of bile into
the peritoneal cavity. Bile if sterile will do little harm, but if it
contains organisms will produce a diffuse peritonitis. Patients
do not always die from a serious traumatism of the liver.
Some recover because operation has been performed. Some
few recover without operation. This last fact is proved by
reports of autopsies in which scars were found in the liver-
parenchyma (Nussbaum). The fatality which usually ensues
on a liver injury may be due to hemorrhage or peritonitis.
If a surgeon is called to a patient suffering from wound of
the liver, he must open the abdomen to arrest hemorrhage.
In a penetrating wound, the w^ound in the abdominal wall
must be enlarged. If the left lobe of the liver is wounded,
or if the question as to which lobe is wounded is uncer-
tain, the incision should be median. If the right lobe

* Wliarton and Curtis, Practice of Surgery,

DISEASES AND INJURIES OF THE ABDOMEN, 659

is wounded, make a curved incision along the line of the
costal cartilages. In some cases these two incisions are
joined/ The convex surface of the liver can be reached by
Lannelongue's plan. In this the eighth, ninth, tenth, and
eleventh costal cartilages are resected and the ends of the
ribs are drawn well out. When the wound in the liver is found
deep sutures of catgut should be inserted in the liver and
the capsule should be stitched with fine silk (Schlatter). If
sutures fail to arrest hemorrhage, stitch the liver to the
belly-wall and employ gauze packing. It is useless to try
packing without first attaching the liver, because pressure
will simply push the liver away and will not stop the bleeding.
The cautery should not be used if the wound is large, be-
cause, even if it arrests primary hemorrhage, secondary
hemorrhage will be apt to occur. After arresting hemor-
rhage wash out the abdomen with hot saline fluid, insert
drainage, and close the abdominal wound.

Hydatid cysts of the liver may be of small size and pro-
ductive of no signs or symptoms ; or may be of large size
and productive of the signs of tumor. In the epigastrium
the mass may be prominent and may fluctuate. In cyst of
the right lobe the dulness is found in the axillary line and the
growth encroaches on the pleura. In a large cyst fluctu-
ation and hydatid fremitus may exist. Hydatid fremitus is a
vibration imparted'to the palpating fingers of one hand when
the fingers of the other hand knock upon the cyst. There
may be no discomfort produced by even a large cyst, but, as
a rule, the patient suffers from a dragging sensation in the
epigastrium, and pressure-symptoms. Suppuration in the
cyst produces the symptoms of septicemia. Rupture of the
cyst produces shock, and even death. If the shock is re-
covered from, inflammation arises, the area of which depends
upon the structures damaged. The escape of even a small
quantity of hydatid fluid into the peritoneal cavity produces
urticaria (hydatid toxemia). Aspiration for diagnostic pur-
poses is not advisable.

Treatment. — Exploratory incision may be necessary to
confirm the diagnosis, and the operation is completed at this
time. After exposing the cyst it is packed around with gauze
and a trocar is introduced. When the fluid is evacuated the
sac is incised and is drawn partly through the wound and is
attached to the wound-margins. The endocyst can be re-
moved by the hand or by irrigation. A large drainage-tube
is introduced (marsupialization). If there is a considerable

^ See Schlatter, Beitrage zur Klinischen Chirurgie^ Bd. xv., Heft ii., 1 896.

66o MODERN SURGER V,

thickness of liver-tissue over the cyst, incise the liver with
the cautery-knife. Bond devised the following operation for
hydatid cyst : open abdomen, draw up the cyst and surround
it with gauze, evacuate contents by means of a trocar and
cannula, open cyst, turn out the endocyst, irrigate cyst with
corrosive sublimate, dust in iodoform, sew up the cut in the
cyst-wall, drop the cyst back into the belly, and close the
abdominal wound.

Abscess of the liver may be due to the presence of
ameba coli. An abscess so caused is usually single, is
known as a tropical abscess because of its frequency in hot
climates, and is usually preceded by dysentery. Such an
abscess may last from four weeks to several years. Abscess
of the liver may follow upon a blow in the hepatic region, or
upon suppuration of the gall-passages. It may be metastatic,
such abscesses being multiple. It may be caused by foreign
bodies and parasites (Osier).

Symptoms. — Osier tells us that the solitary abscess in
rare instances produces no symptoms for a considerable time,
death usually ensuing from rupture. As a rule, the liver is
distinctly enlarged, tender, and painful. There may be pain
in the right shoulder and back. The patient loses flesh;
there is a septic fever, with evening rises and morning remis-
sions, and severe sweats, except in very chronic cases, when
there may be no pyrexia. The skin and -conjunctivae show
the existence of slight jaundice. In some cases there is diar-
rhea, in others constipation. An abscess may lead to pyo-
thorax, may break into the lung, may rupture externally, or
into the bowels, stomach, or pericardial sac. In pyemic
abscess the liver is enlarged and tender, there is slight jaun-
dice, and the general symptoms of pyemia are present.

Treatment. — In tropical abscess make an exploratory in-
cision. If the abscess is adherent to the parietal peritoneum,
and is not covered by liver-substance, at once proceed to
operation. If it is not adherent, or is covered by a con-
siderable layer of liver-substance, stitch the visceral peri-
toneum to the parietal peritoneum and postpone further
interference for forty-eight hours. The operation consists in
evacuating the pus with a trocar and cannula, incising the
abscess, stitching its edges to the edges of the abdominal
wound, irrigating, and inserting a drainage-tube. If the
abscess is covered by a layer of liv^r-tissue, after locating it
with a cannula open into it with a cautery-knife and arrest
hemorrhage by packing. When the parietal and visceral
peritoneum are adherent, packing will arrest bleeding; if they

DISEASES AND INJURIES OF THE ABDOMEN 66 1

are not adherent packing will only push away the movable
liver (John O'Connor). If pyothorax exists, resect a rib,
open the pleural sac, and reach the abscess in the liver by an
incision through the diaphragmatic pleura and the diaphragm.
A pyemic abscess should not be operated upon unless it
points, because in this condition multiple abscesses invariably
exist.

Displaced I/iver, — This condition is very rare. It is
due to relaxation of the ligaments of the liver. It may
occur alone, but is more often a part of a general abdominal
relaxation (Glenard's disease). The liver may descend into
the lower abdomen.

Treatment. — By the use of a support. If this fails to
give relief, open the abdomen and fasten the liver to the
abdominal wall (hepatopexy). Ramsay, in a case, rubbed
the upper surface of the liver with gauze to promote ad-
hesion, and transfixed the round ligament with a suture,
which was also carried around the cartilage of the seventh
rib. Richelott, Areilza, and Treves have operated for this
condition.

Gall-stones. — Gall-stones are formed during life in the
gall-bladder, or bile-ducts, by the agglutination of materials
which have precipitated from bile. The conditions of the
body which lead to the formation of gall-stones are desig-
nated by the term cholelithiasis (Brockbank). But one stone
may be present, or great numbers may exist. Solitary
stones may be nearly round or cylindrical. When several
stones, or many stones, exist the mutual pressure often leads
to the formation of facets (Naunyn). Brockbank gives the
following varieties of gall-stones : pure cholesterin stones,
stratified cholesterin stones, common or gall-bladder cal-
culi, mixed bilirubin calcium calculi, pure bilirubin calcium
calculi, and certain rare forms. Gall-stones usually take
origin in the gall-bladder, but may arise in the common duct,
the cystic duct, the hepatic duct, or the smaller ducts of the
liver. As a rule, however, calculi in the common or cystic
duct were not formed there, but were transported from the
gall-bladder or hepatic ducts.

Causes. — The chief causes are advancing years, insufficient
exercise, excess of nitrogenous food, gouty tendencies, ca-
tarrhal inflammation of the bile-ducts, conditions which inter-
fere with the emptying of the gall-bladder, typhoid fever, car-
diac disease, and cancer of the liver. The disease is more
common in the insane than in the mentally sound, and in
women than in men. The special liability of women may be

662 MODERN SURGERY,

brought about by tight lacing, pregnancy, inactivity, or
movable right kidney. There are two forms of the condi-
tion to be considered. The acute type, due to efforts made
by the gall-bladder or duct to expel the concretion, and the
chronic condition, in which a calculus is lodged for a long
time, or in which, as soon as one calculus is passed into the
intestine, " another begins its journey " (Brockbank).

Symptoms. — ^The formation of a stone requires several
months, and during the antecedent period of gastro-intes-
tinal catarrh, " the prodromal state " of Kraus, certain symp-
toms usually exist, viz. : constipation, flatulence, loss of
appetite, migraine, uneasy sensations in the epigastrium or
right hypochondrium, sallowness of skin, slight yellowness of
the conjunctivae, scantiness of urine, which excretion is satu-
rated with uric acid, and may after a time contain a little bile.
If this condition is not arrested by treatment it grows worse.
The abdomen becomes decidedly distended, pressure over
the stomach or liver may cause distinct uneasiness, or even
pain ; acid indigestion is very troublesome, violent attacks
of migraine occur, constipation becomes more decided, the
feces become clay-colored, gastralgia may occur, the skin is
apt to be slightly jaundiced, itching is complained of, the
patient is irritable and sleeps poorly. The liver is found to
be enlarged, and the urine contains distinct amounts of bile.
When the patient reaches this stage gall-stones are very
liable to form. These symptoms may pass away even if a
concretion forms. It is quite true that in some cases a stone
exists for years without causing trouble, but, as a rule, it
greatly aggravates the condition. When a stone forms
pain is apt to become a marked feature of the case. A
sense of pressure or of soreness in the hepatic region has
added to it sudden and transient paroxysms of pain, due
to the passage of thick bile from the gall-bladder and small
ducts, or of gravel from the small ducts urged on by bile-
pressure. When a stone begins to pass from the gall-blad-
der violent colic is experienced. Such a colic usually
comes on very suddenly, and often about three hours after a
meal. It may, however, come on gradually, the patient
complaining greatly of flatulence. The pains are violent,
spasmodic, and paroxysmal, and are over the hepatic and
epigastric regions, ** radiating upward over the right half of
the thorax " (Kraus). The patient is profoundly nauseated,
and usually vomits, the abdomen is distended, and a con-
dition almost of collapse is soon reached. The attack lasts
a variable time, and terminates by the stone passing into the

DISEASES AND INJURIES OF THE ABDOMEN. 663

intestine or falling back into the bladder. After its conclu-
sion, if the feces are examined carefully during several days,
the stone may be discovered. The fact that no stone is
discovered does not prove that no stone was passed, because
a cholesterin stone will be destroyed in the intestinal canal.
Jaundice almost invariably follows the attack. If the stone
is impacted, after a time the pains become less violent, but
again and again the patient suffers from aggravation of them.
An individual may get about with impacted stone, but again
and again fierce attacks of colic occur, and the patient be-
comes and remains deeply jaundiced. In certain cases
attacks of gall-stones are accompanied by febrile seizures
resembling malaria.

Gall-stones may lead to suppurative inflammation of the
gall-bladder or bile-passages, ulceration, occlusion of the
neck of the gall-bladder, dilatation of the stomach from the
formation of adhesions which kink the pylorus, abscess, peri-
tonitis, empyema of the gall-bladder, and cancer of the gall-
bladder.

Treatment. — In the prodromal stage and after recovery
from an attack insist on the patient taking considerable out-
door exercise. Order him a cold sponge-bath every morn-
ing, move the bowels freely every day, and order a simple
diet. The patient should avoid all highly seasoned foods,
pastry, rich soups, fatty food, cheese, alcohol, and sweets.
Alkalies internally are of value.

During the attack give an enema and apply hot turpentine
stupes over the hepatic region. Give a hypodermatic injection
of morphin and atropin. If vomiting does not occur, let the
patient drink a large amount of warm water to favor it. After
the attack give a purgative.

When the attack has terminated look carefully for any
evidence of inflammatory trouble in the hepatic region.

In certain cases operation becomes necessary. Mayo
Robson advises operation in the following cases : * in fre-
quently recurring biliary colic without jaundice, whether the
gall-bladder is enlarged or not ; in cases of enlargement of
the gall-bladder without jaundice, even if there is no pain ;
in persistent jaundice which was ushered in by pain, painful
seizures occurring, whether or not febrile attacks occur ; in
empyema of the gall-bladder; in peritonitis beginning in
the gall-bladder region ; in intrahepatic abscess and in
abscess about the liver, gall-bladder, or bile-ducts ; in some
cases where the stones have been passed, but adhesions

* Mayo Robson on the Gall-bladder and Bile-ducts.

664 MODERN SURGERY,

remain and produce pain ; in fistula cases ; in some cases of
persistent jaundice due to obstruction of the common duct,
although there may be a possibility of cancer existing ; in
phlegmonous cholecystitis and gangrene of the gall-bladder.
Besides these conditions which may be produced by gall-
stones, Robson operates for wounds of the gall-bladder,
rupture of the gall-bladder, infective and suppurative cholan-
gitis, and for some conditions of chronic catarrh of the bile-
ducts and gall-bladder.^

The common operation is cholecystotomy (or cholecystost-
omy), which consists in opening the gall-bladder, removing the
stones, and closing the bladder again, or in making a fistula
of the gall-bladder (page 697). If calculi exist in the common
duct, it may be possible, after celiotomy, to manipulate them
back into the bladder. In some cases cholecystotomy is per-
formed, or a fistula is made, and the duct and bladder are fre-
quently irrigated. In other cases the stone may be crushed
by the fingers manipulating the duct and the concretion
within it. The duct may be opened, and after the removal
of the stone closed by sutures (choledochotomy). If the
stone is impacted near the outlet of the duct, the duodenum
is incised and the stone removed (choledocho-duodenot-
omy). A dilated bile-duct may be anastomosed to the
bowel (choledocho-enterostomy) or to the surface (chole-
dochostomy). The obstruction may be side-tracked by
anastomosing the gall-bladder to the bowel (cholecystenter-
ostomy) (page 697).

The Pancreas.

Hemorrhage. — Pancreatic hemorrhage is a recognized
cause of sudden death. The symptoms arise without warning,
and comprise severe pain, nausea, vomiting, abdominal ten-
derness, distention, great restlessness, constipation, and col-
lapse. The blood may collect in the lesser peritoneal cavity,
or about the spleen and left kidney (Prince and F. W.
Draper).

Acute Pancreatitis. — Hemorrhagic pancreatitis occurs
in people in middle life, and especially in tipplers. It begins
suddenly : there are violent pain, nausea and vomiting, moder-
ate fever, constipation, distention, and rapid collapse (Regi-
nald Fitz, and Osier and Welch). Inflammation of the pan-
creas with pus-formation is, as a rule, more chronic. The

* Robson's treatise, from which the above is taken, is a valuable expofiitioo
of the surgery of the gall-bladder and bile-ducts.

DISEASES AND INJURIES OF THE ABDOMEN 665

symptoms are similar at the beginning of the attack and a
septic fever develops. In some cases the pancreas becomes
gangrenous.

Treatment. — In view of the difficulty of distinguishing
acute pancreatitis from intestinal obstruction and perforated
ulcer of the stomach, in any case where either of these con-
ditions is suspected an exploratory laparotomy is indicated.
Osier speaks of cases of hemorrhagic pancreatitis in which
operation was followed by recovery.

Cysts of the pancreas occasionally follow injury. They
are due, as a rule, to obstruction of the orifice of the
common duct or of the pancreatic duct by calculi, tumor-
pressure, or cicatricial contraction. These cysts may grow
rapidly or slowly. They usually produce considerable pain
and gastro-intestinal disturbance. Examination of the abdo-
men maps out a mass which is usually median, is elastic,
and is dull at some parts but resonant at others (where it is
crossed by the colon). The fluid of the cyst is apt to con-
tain urea, and will convert starch into sugar.

Treatment. — ^Tapping is contraindicated. It might do
much damage. In Keen's case, if an aspirating-needle had
been introduced it would have perforated both walls of the
stomach. Confirm the diagnosis by an exploratory incision.
It may be possible to extirpate, but it is better to incise the
cyst, stitch its edges to the belly- wall, and drain.

The Spleen.

Wounds and Rupture. — A wound of the spleen causes
great hemorrhage, and if no surgical aid is offered will
rapidly produce death. The treatment consists in celiotomy
and splenectomy.

Rupture of the spleen produces the signs and symptoms
of intra-abdominal hemorrhage. It can only be certainly
recognized after exploratory celiotomy. If such a con-
dition is suspected while intravenous saline transfusion is
being employed, the surgeon opens the abdomen, and if
the spleen is ruptured, removes it.

Abscess of the spleen is a rare condition which is
metastatic in origin. Pain is felt, and enlargement is noted
in the splenic region, and the symptoms of- pyemia exist.
The treatment consists in incision and drainage.

Wanderings Spleen. — The spleen may wander into any
part of the general peritoneal cavity. This condition is
almost never met with except in women. It is most com-

666 MODERN SURGERY.

mon in women who have borne children (J. Bland Suttnrl
A wandering spleen may undergo atrophy, engox^anem,
or axial rotation (J. Bland Sutton). The organ, whien dis-
placed, drags upon the stomach, producing dilated stomach :
it may interfere with the bile-duct, causing jaundice : it may
cause intestinal obstruction by forming adhesions, or tdsk
cause uterine retroflexion or prolapse by passing into the
pelvis.

J. Bland Sutton says this condition may endanger life, as
it may lead to rupture of the stomach, intestinal obstruction,
splenic abscess, or splenic rupture.* A wandering spleen can
be identified by the fact that it has a notch upon its edge,
and can be pushed about the abdomen. When this con-
dition exists the spleen may be missed from its normal
situation. Always examine the blood in order to deter-
mine if leukemia or malaria exists.

Treatment. — GreifTenhagen advocates suturing the organ
in place (splenopexy). Most surgeons prefer to perform
splenectomy. Splenectomy should not be undertaken if
leukemia exists. In such a case apply a support and employ
medical treatment for the existing disease.

Operations upon the Abdomen.

Abdominal Section (Celiotomy; Laparotomy). — In

opening the abdominal cavity for exploratory" purposes or
to gain access to some area of abdominal or pel\*ic disease,
the patient is carefully prepared as for any other operation.
The instruments required dej^end upon the nature of the case.
As a rule, there are required scalpels, scissors, a dxy dis-
sector, two pairs of dissecting-forceps, hemostatic forceps,
pedicle-forceps, Hagedorn needles, calyx-eyed intestinal nee-
dles, a needle-holder, drainage-tubes, gauze pads, sponges,
silk, catgut, silkworm-gut, the Paquelin cauteiy, an electric
light, also a bag, a tube, and a saline solution for hypo-
dermoclysis or transfusion. Always count the instruments,
sponges, and pads, and write down the number, and count
them again after operation. This rule is adopted so that no
instrument, sponge, or pad will be left in the abdomen.
The abdominal pads and sponges are not used when drv'.
Dr>' sponges injure the peritoneum and favor the subse-
quent development of adhesions (Sanger). The pads and
sponges should be wrung out in normal salt solution before
using.

* British Med. Joum.^ Jan. i6, 1897.

DISEASES AND INJURIES OF THE ABDOMEN. 667

Operation. — In some cases the patient is placed recum-
bent, in others is put in the position of Trendelenburg (Fig.
201). The patient is to be care-
fully protected from cold, the ex-
tremities and the chest are cov-
ered with blankets, and sterilized
sheets are placed well around the
field of operation. The surgeon
steadies the skin of the belly with
the fingers of his left hand, and, '''°- "'""^'u^"'**''"'""'
holding the knife in the right

hand, makes an incision about two inches long. This in-
cision is often made in the middle line midway between the
pubes and umbilicus, but may be in the semilunar line, in the
epigastric region, or in some other situation. The first cut
goes to the aponeurosis. Clamp the vessels. Do not hunt for
the hnea alba below the umbilicus, but go right through or be-
tween the recti muscles. Above the umbilicus the linea alba
is very distinct and the sui^eon often cuts through it. Divide
the transversalis fascia, beneath which is a little fat, and expose
the peritoneum. The latter structure is recognized by its glis-
tening appearance, by the pase with which it can be pinched
up between the finger and thumb, and by the readiness with
which its opposed surfaces may be made to glide over each
other. On identifying the peritoneum, catch it at each .side of
the incision with forceps, raise a fold, nick it with a knife, and
open it with scissors to the length of the external wound.
To prevent stripping of the peritoneum a good plan is
to anchor it to the belly-wall with a stitch on each side of
the incision. Through the wound thus made the abdomen
and its contents are explored, the trouble located, and deter-
mination made as to whether or not further operation is advis-
able, and, if it is advisable, what form it shall take. It may
be necessary to enlarge the wound. Thi.s is done by placing
the index and middle fingers of the left hand in the belly,
with their pulps against the peritoneum, in the line where
the surgeon will cut, to serve as supports to the scissors and
as guards to intraperitoneal structures. The scissors are
introduced and the wound is enlarged upward around the
umbilicus if necessary. As soon as the incision is complete
it is a good plan to push a large pad into Douglas's pouch
and leave it there until the operation is completed. Slender
adhesions are broken off with the finger or are pushed off
with gauze; firm adhesions are tied and cut.

The toilet of the peritoneum is important after the opera-

668 MODERN SURGER K

•

tion is completed. Following a clean laparotomy, when but
little blood has flowed into the cavity, flushing out is not
required ; if much blood has flowed or if any septic matter
has passed into the peritoneal cavity, after removing the
sponge from Douglas's pouch flush out the belly thor-
oughly with hot normal salt solution, empty out most of
the fluid, but let a pint or more remain in the abdomen.
The retention of saline fluid in the belly minimizes shock. If
there is widespread infection, eviscerate, wipe out the peri-
toneum with pads soaked in hot normal salt solution, and
wipe the intestines carefully, slowly returning them as they
are wiped. Extravasated septic matter is apt to collect
between the liver and diaphragm, and this area must be
carefully wiped or irrigated In some cases it is desirable
to drain through a lumbar incision. Rutherford Morrison
has pointed out that on the right side a lumbar opening >\ill
drain a pouch which holds over a pint of fluid, and which,
with the patient recumbent, is the most dependent portion
of the peritoneal cavity. In some cases a drainage-opening is
made on each side of the belly or above the pubis. In septic
cases it may be advisable to pack with iodoform gauze instead
of inserting tubes. Before closing the wound stop hemor-
rhage and count the instruments and sponges. In most
instances drainage is not needed, but it must be used in
septic cases and when hemorrhage has been severe. We
may drain by a rubber tube, strands of gauze, or a glass
tube. If a glass tube is used, it is introduced at the lower
angle of the wound and reaches the bottom of the pouch of
Douglas. This tube is repeatedly emptied during the prog-
ress of the case by means of a syringe. In closing the
wound some surgeons close the peritoneum with a continu-
ous catgut suture and close the belly-wall with interrupted
sutures of silkworm-gut ; some operators close with inter-
rupted silkworm-gut sutures, including peritoneum, muscles,
and skin in each stitch. In badly infected cases the wound
is often kept open. Dress with aseptic gauze and wood-
wool, and apply a flannel binder.

For fton'SJippurative appendicitis the incision is two
inches internal to the anterior superior iliac spine and per-
pendicular to a line drawn from the spine to the umbilicus
(Fi<^. 202). The incision is usually one and a half to tM'O
inches in length, but if there are many adhesions it may be
necessary' to make it longer. After opening the perito-
neum find the appendix by the following method: follow
the parietal peritoneum outward with the finger, then back-

DISEASES AND INJURIES OF THE ABDOMEN. 669

ward, then inward; the first obstruction it encounters is
the colon. Pass the finger down to the head of the col&n,
find the appendix, usually posterior and internal, and hft it
into the wound. In some cases it will be advisable to deliver

the head of the colon from the belly ; in other cases this will
not be necessary. Surround the appendix with iodoform
gauze to prevent infection. In most cases the neck of the
appendix is tied with strong silk, the appendix is cut off, and
the stump is cauterized with pure carbolic acid and is inverted
into the cpats of the colon by Lembert sutures. An excellent
method is to turn up a cuff of peritoneum, pull down the
other coats, hgate at the base, cut through the tube, let the
musculomucous stump retract, and tie or suture the perito-
neal cufT over the stump. This plan was devised by Barker

670

MODERN SURGERY,

Fig. 203. — Barker's technique
of operation for removal of the
appendix.

(Fig. 203). Some remove the appendix by an elliptical incision
around its base, and close the colon-wound by Lembert sutures.
Some invaginate the appendix into the lumen of the colon.
If there is no abscess, perforation, or gangrene, and no pus

within the appendix or in its coats,
drainage is unnecessary; otherwise
it is necessary. If the operation is
in a distinct interval, pus is absent,
and we can proceed without appre-
hension. Such an operation should
not be performed until three weeks
have passed since the acute attack.
If there is any question as to the
presence of pus,* surround the ap-
pendix zone with iodoform gauze
before breaking down adhesions and
liberating the appendix. This gauze
protects healthy structures from in-
fection. In an interval case McBur-
ney proceeds as follows : he makes the skin incision in the
direction of the fibers of the external oblique muscle, sepa-
rates the fibers of this muscle by blunt dissection, retracts
them, separates the internal oblique fibers by blunt dissec-
tion and retracts them, separates the fibers of the transver-
salis in the same way and retracts them, opens the transver-
salis fascia and peritoneum. No muscle-fibers are cut, and
hernia is not apt to follow. Such a wound is closed as fol-
lows : a continuous catgut suture for the peritoneum, suture
of kangaroo-tendon for transversalis fascia, muscles restored
to place, and skin closed by a subcuticular stitch.

If an abscess is believed to exist, make an incision parallel
with Poupart's ligament and over the area of dulness on
percussion (Willard Parker's oblique incision). If the abscess
is adherent to the belly-wall, such an incision will not enter
the free peritoneal cavity. If after opening the abdomen an
abscess is thought to exist, although it is not adherent to the
belly-wall, surround the abscess with gauze before opening it.
This gauze is placed under the margins of the incision in the
peritoneum all around the appendix area; a piece is carried
toward the pelvis and another piece toward the liver. Over-
lay this gauze with gauze pads (Van Hook). Adhesions are
broken through with the finger, and when pus app>ears it is
at once wiped away. If the appendix lies loose in the
abscess-cavity, if it is sloughed off or but loosely attached
to the abscess-wall, remove it. If the appendix is firmly

DISEASES AND INJURIES OF THE ABDOMEN, 67 1

fixed in the abscess-wall, do not remove it. To remove it
under these circumstances may rupture the wall and allow
pus to enter the peritoneal cavity where it is not protected
by pads and gauze. Deaver, Murphy, and others tell us to
always try to remove the appendix. We do not believe
this to be a safe rule to follow. To insist on removing the
appendix may cause death. When the appendix is left
it usually sloughs away. It is true a fecal fistula may result,
but this usually heals spontaneously. Even if it does not
heal the surgeon acted properly, because a fecal fistula may
be remedied by another operation, but there is no remedy
for death. There are very few cases on record where an
appendix has subsequently given trouble when left after
operation. When Deaver decides to remove such an appen-
dix he makes an incision in the median line of the abdomen,
packs around the periphery of the abscess with gauze, opens
the abscess, disinfects, inserts drainage, and then removes the
surrounding gauze and closes the median incision. Irriga-
tion should not be employed in appendicular abscess. The
force of the stream may break down barriers of lymph and
spread infection. After the evacuation of the pus, whether the
appendix was removed or not, take out the pads, but leave
the long strands of iodoform gauze in place (Van Hook).
Introduce iodoform gauze into the abscess-cavity and insert
a rubber tube, partially suture the wound, and dress with dry
gauze. In forty-eight hours all the gauze is removed and
fresh pieces are inserted for drainage. After this the gauze
drain is changed daily. An interval case should be up and
about in from ten days to two weeks after operation. An
abscess case may require a much longer time for complete
recovery, and a fecal fistula sometimes results in cases in
which the appendix was not removed. Morris maintains
and proves that these large pieces of iodoform gauze some-
times cause intestinal obstruction and sometimes iodoform-
poisoning, but the risk must be taken.

^terorrhaphy, or Suture of the Intestine. — Sur-
gical opinion has greatly altered in regard to this oper-
ation since the day when John Bell wrote his famous attack
on Benjamin Bell. John Bell said : " If in all surgery there
is a work of supererogation, it is this operation of sewing up
a wounded gut." To-day we know that if in all surgery
there is a proceeding of imperative necessity, it is the sewing
up of a wound in the intestine. To perform this operation
take fine sterile silk and thread a thin, round, straight calyx-
eyed needle with it (Fig. 204). This needle is very useful,

672 MODERN SURGERY.

as it can be threaded rapidly by pushing the calyx eye down
upon the silk thread white the latter is kept taut. Lemberfs
suture (Fig. 205, a) is at right angles to the wound. It goes

down to, but not through, the mucous membrane. It is
formed by picking up a fold of the intestine (one-twelfth
to one-eighth of an inch wide) one-eighth of an inch from
the edge on one side of the wound, passing the needle
through, picking up a fold on the opposite side of the
wound, and passing the needle through. On tying the
threads the serous membrane is inverted and peritoneum
is brought into contact with peritoneum. For many years
it was taught that this suture should include only the serous
coat, but Halsted, in 1887, showed that it must include the
tough submucous coat. The submucous coat is strong, and
will hold a suture. The other coats are thin, tear easily, and

will not hold a suture. So thin are the coats that a surgeon
could not suture the serous coat alone were he to tiy.
Sutures which include both muscular and serous coats
tear out easily. The needle should catch up the submu-
cous coat, but should not penetrate the intestine.' Dupuy-
' Halsted, Am. Jour. Med. ScitHca, Oct., 1887,

DISEASES AND INJURIES OF THE ABDOMEN 6/3

treris suture (Fig. 204, b) is simply a continuous Lembert
suture running obliquely across the wound. Cushing's right-
angled suture (Fig. 206) is a continuous suture catching up
the submucous coat and serving to invert the serous layer.
Halsted's mattress or quilt su-
ture is shown in Fig. 207. Each
stitch picks up the submucous
coat. Mattress sutures do not
tear out easily, they oppose
evenly considerable surfaces, and
do not constrict the tissue as
much as Lembert stitches. The
Czemy-Lembcrt suture is a suture
passed through the serous mem-
brane on one side of the wound,
made to perforate the mucous
membrane, and to emerge at a
corresponding point of the serous
membrane. A Lembert suture
is added (Fig. 208). As at present used, the Czemy suture
is carried to, but not through, the mucous membrane. Gus-

1
)
)

Fig. 307. — A, Habted sutures untied ;
B, Halsted sutures tied and serous sur-
face inverted.

Fig. 908. — Czemy-Lembert suture.

Fig. 909. — Czemy-Lembert suture as at
present used.

Fig. 2ZO. — Gussenbauer's suture.

senbauer's is similar to the Czemy-Lembert suture, except
that it applies the Czemy and the Lembert with one suture,

674 MODERN SURGER K

and this suture does not pass through the mucous bcbi-
brane {Fig. 2lo). WUjUr's sutttre unites broad layers oitiie
serous coat, the knots being tied
internally (Fig, 211). Senn sws
that after suturing a large wouBd
of the stomach or of intestine a
strip of omentum ought to he
laid over the wound and fa^uoA
by catgut sutures (omental graft).
These grafts adhere and are 1
safeguard against leakage. For
other methods of enterorrhapbj'.
Fio m.-weiflit-i •uiuic. see Intestinal Resection and An»i-

tomosis.
Digital DilatatJou of Pjrlonis for Cicatricial Ste-
nosis (I^reta'S Operation).— For a week before operation
feed the patient by encmata supplemented by the stomach
administration of peptonized milk, and wash out the stomach
once a day. A few hours before operation wash out the
stomach again. Place the patient recumbent and administer
ether. Make a vertical incision in the linea alba. The in-
cision begins one inch below the ensiform cartilage and
should be five inches in length. When the peritoneum has
been opened the stomach is drawn out of the wound, any
adherent omentum is separated, and the pylorus is carcfiiUy
examined. The stomach, after being surrounded with gauw
pads, is opened near the center of its anterior surface, " but
rather nearer to its pyloric end " (Jacobson).

Insert the index finger through the stomach wound and
follow that with the middle finger. The pylorus can be well
dilated by .separating the fingers. If the stenosis is so tight
as to prevent the entry of a finger, first introduce a pair of
hemostatic forceps and open the blades a little when they
are within the lumen of the constricted area. The wound in
the stomach is closed by Halsted sutures of silk and the
abdominal wound is closed.

Pyloroplasty (Heineke-Mlkullcz Operation).— Pre-
pare the patient as for Lorela's operation. Open the ab-
domen in the middle line. Draw up the pylorus as well as
possible and pack hot moist gauze pads around it; make an
incision through the stricture and in a direction co^^espont^
ing to the long axis of the stomach and bowel. Catch an
ancurysm-needle under the upper margin of the incision and
draw it up, and an aneur>sm-needle over the lower margin
and draw it down. The effect of traction is to convert the

DISEASES AND INJURIES OF THE ABDOMEN. 675

transverse wound into a vertical one. The sutures are ap-
plied so as to maintain the wound in a vertical line. The
mucous membrane is sutured with a continuous suture of
silk, and interrupted Halsted sutures of silk close the peri-
toneal and muscular coats.

Pylorectomy (Excision of the Pylorus). — Prepare
the patient as directed above. A removal of any portion of
the stomach constitutes a gastrectomy, and pylorectomy is a
gastrectomy in which the pylorus is removed. The best in-
cision through the abdominal wall is transverse over the mid-
dle of the tumor. A small incision is made first to permit of
exploration, and if the growth is found to be removable the
incision is enlarged. The center of the incision is over the
most prominent part of the tumor, and the direction of the
incision corresponds with the long axis of the pylorus.
Draw the tumor into the wound, and tuck pads about the
stomach and the pylorus to catch extravasated fluids. Free
the pylorus ; incise between forceps the great omentum near
the greater curvature of the stomach, and ligate each end in
segments; treat the lesser omentum in the same manner.
The greater and the lesser omentums are divided only to an
extent sufficient to permit removal of the growth. Repack
the gauze pads and tie a rubber tube around the duodenum
below the growth. In making the excision remember that
the stomach-wound will be much larger than the duodenal
wound, and a special method of suturing will be required to
approximate the two wounds in size. The lines of incision
are shown in Fig. 2 1 2. The stomach is cut with scissors
until two-thirds of its depth is divided, and the organ is
washed out. After stopping hemor-
rhage this cut is closed by a contin-
uous suture for the mucous membrane
and by Halsted sutures for the other
coats. The remaining portion of the
stomach is cut through. The duo-
denum is cut through its upper half
below the growth, and is fastened to
the stomach by Halsted sutures at the ^'°- »" -Py>o«^o»y-
upper border and W6Ifler*s sutures at the posterior borders.
Wolfler's sutures are applied from inside; pierce all the
coats, and bring broad layers of the serous coat into appo-
sition. The remainder of the duodenum is cut through,
and its anterior and inferior parts are united to the stomach
by a double row of sutures, as set forth above (Fig. 212).
Stitch the edges of the cut omenta to the stomach, cleanse

676 MODERN SURGERY.

the parts, replace the stomach, close the abdominal incisioi
and dress the wound. Give nothing by the mouth f
twenty-four hours. Thirst can be relieved by enemata of
water or by the hypodermatic injection of boiled water.
After twenty-four hours begin with stomach -feeding, start-
ing with dessertspoonful -doses of peptonized milk every
hour. Another method of performing pylorectomy is to
excise the growth as directed above, suture the opening in
the stomach, and implant the duodenum in the anterior or
posterior wall of the stomach, making an incision through
the stomach-wall to permit of it. Kocher advocates implan-
tation of the duodenum in the posterior wall of the stomach.
Kocher's method of pylorectomy is shown in Figs. 213, 214, '

led by "he middle u^ i^e< ^tgen.

i''«B,»;^S

The Junction between the duodenum and the posterior v
of the stomach may be effected by a large Murphy button,

Gastrotomy. — This term is used to designate the opt
tion of opening the stomach for the accomplishment of som
purpose, and immediately closing the incision in the gastric
wall when that purpose is accomplished. Gastrotomy may

DISEASES AND INJURIES OF THE ABDOMEN, 6jJ

be performed to permit of the removal of foreign bodies, of

exploration of the stomach and its extremities, of divulsion
of the pyloric orifice, of the treatment of an esophageal

. Kochct' method oT

stricture, or a stricture of the cardiac orifice of the stomach,
or of the removal of a foreign body in the esophagus.

The patient is prepared as for pyiorectomy. The incision
may be vertical in the middle line or identical with the in-
cision for pyiorectomy. If a large foreign body can be felt,
the incision is made directly over it (Jacobson). When the
peritoneal cavity is opened the surgeon decides as to the
point where the stomach is to be incised, and draws this por-
tion out through the wound, packing gauze pads under and
around it. The .stomach is opened by means of scissors, the
cut being at a right angle to the long axis of the viscus
(Jacobson). Any bleeding vessel is ligated with catgut. The
purpose for which the stomach was opened is now to be car-
ried out, the interior of the stomach and the surface of the
extruded portion are irrigated with hot salt solution, and the
stomach-wound is sutured with silk. A row of deep sutures
is introduced. These sutures pass through all the coats. A
row of Halsted sutures is then in.serted. The abdominal
wound is closed without drainage.

6yS MODERN SURGERY.

Gastrostomy is the making of a permantnt gastric fistula,
through which opening the patient can be fed. The opera-^
lion is employed in cases of esophageal obstruction, T'
surgeon must endeavor to perform an operation which \

liqudy ihercin.

not permit of leakage. Prepare the patient as for gaitrotoi
In Witzel's method an incision is made four inches long,
ning to the left from the middle line, just below the border
of the ribs. After opening the peritoneal cavity seize the
stomach, bring it out of the wound, and pack gauze around
it. Introduce a rubber tube into the stomach and enfold it
by a double row of Lembert sutures (Figs, 215, 216). This
tube should be five inches long and of the same diameter as
a No. 25 French bougie. The opening in the stomach is to-
ward the cardiac extremity, the tube is placed parallel with
the belly-wound, and the outer end of the tube emerges in
the median line. The stomach is returned, and is stitched
by three sutures to the abdominal wall. The tube is retained
in place by a catgut stitch through the wall of the tube and
the stomach-wall. The abdominal incision is sutured and a

DISEASES AND INJURIES OF THE ABDOMEN. 679

damp is placed on the tube. When the patient is fed a fun-
nel is slipped into the tube, the clamp is removed, and liquid
food is poured into the funnel. After the wound heals it is
not necessary to permanently retain the tube. It is passed
when the patient desires food. Kader has modified Witzel's
method. A small incision is made in the stomach and a tube
is introduced. Two Lembert sutures are passed so as to
form a fold on each side of the tube and turn the stomach-
wall inward around the tube, Lembert sutures arc inserted
in the furrow on each side of the tube. Two more folds are
formed over the first two. The stomach-wail is stitched to the
parietal peritoneum and sheath of the rectus muscle (Willy
Meyer). The Ssabanejew- Frank operation is preferred by
many surgeons. Fenger's incision is made (a curved incision
at the margin of the costal cartilages of the left side). A cone
of the stomach is pulled out of the wound and is passed under
a bridge of skin which has been prepared for it. The stomach
is fixed above the margin of the ribs and opened (Figs. 217,
218J. Van Hacker makes the gastric fistula through the left
rectus muscle, and Hahn
between two of the rib
cartilages (Willy Meyer).
Emanuel Senn devised

the following method: a cone of the stomach is pulled out
of the abdominal wound, and this cone is puckered by the
insertion of two drawing-string sutures of chromic catgut
through the serous and muscular coats. A cuff of gastro-
colic omentum is sutured by silk around the neck of the

A I

68o MODERN SURGERY,

puckered cone. The stomach is sutured to the bdly-vall
with silk, the sutures, including the omental cufT, the senws
and muscular coats of the stomach, and the stnictuies of
the belly-wall, except the skin. The skin is partially sutured
The stomach may be opened at any time.

Gastro-enterostomy ^Senn's method) is the establish-
ment of a permanent fistula between the stomach and the
small intestine, in order to side-track the pylorus. The stom-
ach is irrigated as before pylorectomy. In the operation of
gastro-enterostomy a median incision is made through the
abdominal wall, from below the xiphoid cartilage to the um-
bilicus. An opening is made in the stomach, in the direction
of the long axis of the viscus, and its edges are stitched nkith
a continuous catgut suture. The contents of the bowel are
forced along to below the point where an incision is to be
made; a rubber tube is fastened around the boivel abo\'e
this point, and another below it ; an incision is made in the
long axis of the bowel, and the margins of the wound are

sutured in the same manner as the
stomach-wound. Bone plates are in-
troduced into the stomach and intes-
tine, and the ligatures are tied as in
intestinal anastomosis (page 637).
Catgut rings or rubber rings may be
used. Fig. 2 1 9 shows Wolfler's meth-
od of gastro-enterostomy. Kocher s
method is as follows: aAer opening
^"'''"'M^T^mX"'''"^ the abdomen, lift up the omentum.

pull up a loop of intestine and find
the point where the jejunum appears from under the meso-
colon. Select a loop sixteen inches from the origin of the
jejunum and prepare to attach it to the stomach. Wolfler
showed that the intestine should be applied to the stomach in
such a manner that the direction of peristalsis in the bowel
must correspond to the direction of the stomach-tide. This
can be accomplished by having the proximal portion of gut to
the left, and the distal portion to the right. The operation is
to be so performed that after its completion the stomach-con-
tents pass into the distal portion of the gut, and the intesti-
nal contents do not tend to enter the stomach. In order to
accomplish this Kocher hangs the intestine to the stomach-
wall in such a manner that the proximal portion of the loop is
posterior and ascending, and the distal portion is anterior and
descending. The bowel is hung to the stomach by a con-
tinuous serous suture of silk, the ends of which are left long.

DISEASES AND INJURIES OF THE ABDOMEN 68 1

The intestine is opened by a curved incision, the convexity
of which is downward. The stomach is opened so that the
convexity of the cut is upward. The valve-like portion of
the bowel-wall is sutured to the stomach below the incision
in that viscus. The two openings are well approximated
by sutures.

Gastro-enterostomy may be quickly performed by the use
of a large-sized Murphy button. Murphy says that in some
reported cases the button has slipped back into the stomach,
but this accident can be prevented by the use of an oblong
button and by making the anastomosis on the posterior stom-
ach-wall. The same surgeon advises us to scarify the peri-
toneum to hasten union, and says supporting sutures about
the button are not required, except when considerable ten-
sion exists. There is no question that an anastomosis on the
anterior wall, accomplished by a Murphy button, can be
speedily performed. Anastomosis on the posterior wall can-
not be performed speedily, and it sacrifices the great advan-
tage of the button operation — that is, speed. In spite of the
reported cases, we can truthfully assert that the danger of
the button producing grave trouble is slight.

Gastrogastrostomy is an operation performed for hour-
glass contraction of the stomach, a condition which occasion-
ally ensues on the healing of an ulcer. In this operation an
anastomosis is effected between the pyloric and cardiac ends.
Wolfe, Watson, Wolfler, and Eiselberg have performed this
operation. Weir and Foote maintain that double gastro-
enterostomy, " tapping each sac," is a preferable procedure.^

Gastroplicanon (Brandt's Operation of Stomach-
reefing for Dilated Stomach). — Apply sutures in the ante-
rior wall so as to form reefs, then tear through the great omen-
tum and apply sutures in the posterior wall. The sutures pass
through tne serous and muscular coats, and 1 50 to 200 are
inserted. This operation is of questionable value, and must
never be used if stenosis of the pylorus exists, and stenosis
of the pylorus is the most common cause of gastric dilatation.

Bnterectomy, or Resection of the Intestine with
Anastomosis by Circular Bnterorrhaphy. — After open-
ing the abdomen isolate the loop of intestine it is intended to
resect. Push a rubber tube through the mesentery close to
the bowel, above the seat of operation, and pass a rubber tube
through the mesentery below the seat of operation. Empty
this segment of bowel by squeezing and stroking, tighten the

* F. S. Watson, in Boston Med. and Surg. Jour., April 2, 1896; Weir and
Footc, Medical News, April 25, 1896.

682

MODERN SURGERY.

rubber tubes, and clamp them to keep the bowel empty. Ii
stead of tubes, strips of iodoform gauze may be used to
circle the bowel. The diseased intestine is resected, each in-
cision being carried through a healthy segment. The lumen
of each end of the divided gut is irrigated with salt solution.
The divided surfaces are approximated by a double row of
sutures — a continuous suture for the mucous membrane, and
Lembert's, Dupuytren's, or Cushing's suture to effect inver-
sion. Thoroughly satisfactory approximation can be effected
by one row of Halsted sutures. If a redundant fold of
tery is left, it can be stitched at its raw edge. Many surgeons
remove a V-shaped piece of mesentery and tie the mesen-'
teric vessels. The tubes are removed, and the wound
cleansed, closed, and dressed. Fig. 220 shows the tu!

and

:ted ^J

onS^^H
ien^^^H

:be^^|

■ko*.|S'

\tcoo& step (EflBjir^ 1

fastened for excision of the bowel, and Fig. 221 shows enter-J
orrhaphy with stitching of the redundant mesentery.

Senn effects invagination by means of a ring {Fig. 223).

If the two segments of bowel are unequal in size, the nar< J
rower part of the bowel should be cut obliquely and thai
larger part should be cut transversely. To meet this com-1
plication Billroth devised lateral implantation. Suppose the!
cecum has been resected : its lower end is closed by Lembcrtfl
sutures, an opening is made in the long axis of the periphery 1
of the colon opposite the mesocolon attachment, and the end I
of the ileum is sutured into this incision.

Senn advises the insertion of an anastomosis-ring in the I
ileum, the invagination of the colon as the ring is pulled into
place, and firm suturing of the line of junction. By Senn's
method the ileum may be implanted into the end of the colon or
into aslitin the wall of a large bowel after the end of the colon
has been closed. In some cases, where one portion of bowel

DISEASES AND INJURIES OF THE ABDOMEN. 6S3

is larger than the other, lateral anastomosis is the prefer-
able method. For a full week after an intestinal resection
the patient is fed chiefly by nutrient encmata. During the
first twenty-four hours nothing is given by the stomach but

.. .dchhalf ofih.buiiDiiin plaet,

s ihe coinplciei] union of ihe Inietiini: by the Marphy button - the slip
Kcn cloieil by linear union (aflEr ZuckerLiIuil ).

bits of ice. and for the next six days but a ver>' little liquid
food is allowed to be swallowed.

The use of Murphy's button permits of rapid approximation
after resection {Fig. 222, f). This button closely approximates
the portions of the intestine within its bite, rapid adhesion
taking place. The diaphragm of tissue undergoes pressure-
atrophy, and liberates the button, which is passed per anum.
It is claimed that the button-opening contracts but slightly.

684 MODERN SURGERY.

For end-to-end or side-to-side approximation of the small
intestine a No. 3 button is used. For similar operations on
the large intestine a No, 4 button is employed (Murphyi
After the resection one-half of a button is inserted into each
segment, and is held in place by a purse-string suture of silk
which passes through all the coats (Fig. 222). The redun-
dant mucous membrane is tucked in or clipped off, so that it
will not be interposed between the serous surfaces. The serous
surfaces are scratched with a needle and the two halves of the
button are locked (Fig, 222). It is not necessary to surround
the margin of junction with sutures. Murphy says that liquid
nourishment should be given as soon as the patient has recov-
ered from the effects of the ether, and that the bowels should
be moved at an early period and frequent evacuations should
be maintained. If the button does not pass in four weeks,

examine the rectum for it' The situation of the button can
be ascertained by the -Y-rays. After intestinal resection
Halsted performs circular enterorrhaphy by means of his
mattress-sutures.

Maunscll has devised a most ingenious method of cir-
cular enterorrhaphy. The two portions of bowel are at-
tached by two fixation-sutures which penetrate all the
coats (Fig, 224). An incision one and one-half inches in
length is made through the wall of the proximal seg-
ment of gut, about one inch from its edge. The fixa-
tion-sutures are brought through this opening, traction is
made upon them, the distal portion of the bowel is in-
vaginated into the proximal portion, and the ends emerge
from the opening, their peritoneal surfaces being in contact
' John B, Murphy, in Mid. Neva Feb, 9, 1895.

DISEASES AND INJURIES OF THE ABDOMEN. 685

(Fig. 224). Sutures of silk are passed through both sides of
the area of invagination, the threads are caught up in the cen-
ter, cut, and tied on each side. The iixadon-sutures are cut ofT.
The invagination is reduced by traction. The longitudinal cut
is closed by Lembert sutures.

Mayo Robson performs circular enterorrhaphy over a
bobbin of decalcified bone (Fig. 225). Allingham uses
a bone bobbin the shape of two cones joined at thdr

MODERN SURGERY.

apices. The bobbin is decalcified except an area at the
center (Fig. 226), Kocher performs circular enterorrhaphy
as follows : a fixation-suture is introduced through the bowel

AUingliiin'i decildfltd bone bobbin.

at the mesenteric attachment and another is inserted at an
opposite point. The intestinal ends are approximated by
a continuous silk suture, which passes through all of the

of circular esterorrluphy.

coats, but which includes more of the serous than of the
mucous coat. The suture-line is overlaid by a continuous
Lembert suture which includes the serous and a portion of

DISEASES AND INJURIES OF THE ABDOMEN. 687

the muscular coat. Harris removes a portion of mucous
membrane from the distal end by means of a curet Three
needles are threaded with fine silk. The first needle is
pushed through the bowel-wall to one side of the mesentery.
The point of the needle picks up a portion of the distal end
transversely. The needle is used as a lever to invaginate the
distal end into the proximal end. The same procedure is
carried out with the other needles. When invagination is
effected the needles are pulled through and the threads are
tied. The free end of the bowel is now sutured to the in-
vaginated part by interrupted sutures or by a continuous
suture broken once (Fig. 227).'

Some surgeons employ inflatable rubber cylinders in
making an end-to-end anastomosis (Halsted, Downes, Re-
der). Halsted shows that the use of the inflatable rubber
cylinder enables the surgeon to finish the operation more
quickly and to dispense with clamps ; arrests the vermicular
motion of the intestine; makes easy the adjustment of two
pieces of intestine of unequal size ; and renders it pos.sible to
apply stitches rapidly, evenly, and securely.' Three presection

— Uic of Hililed • inSi

sutures are inserted ; a portion of bowel and a V-shaped piece
of mesentery are resected, the mesenteric incision being so
made as to leave a vessel uncut at each edge to supply each
end of the divided intestine. The mesenteric vessels are

' CAicage Mtd. Keeord, Jan., 1897.

' Phila. Mfl. Jour., Jan

. 1898,

688 MODERN SURGERY.

ligated and the ends of the bowel are pulled together W-1
the presection stitclies, two of which are tied. The col- j
lapsed rubber cylinder is pushed into the bowel by means of
forceps and is inflated with a syringe (Fig. 228). Twelve
mattress sutures arc inserted and the bag is collapsed and
withdrawn and the sutures are tied, the stitch a being tied
first (Fig. 228). The slit in the mesentery is sewed in such

:m^^

(Dlooirh'ph)' (Halswd).

which nourish the bowdl

a way that the mesenteric vessels
are not interfered with (Fig. 229).

I,ateral Intestinal AnastomosiB. — Approximation '
may be effected by other methods than by end-to-end junc-
tion or by implantation. Lateral anastomosis may be prac-
tised after inte.stinal resection or may be done with prelimi-
nary resection for the purpose of short-circuiting the fecal
current to avoid an obstruction.

Operation with Rings. — In this operation a portion of I

bowel above the obstruction and a loop below the obstruct
tion are brought into the wound. These segments .

DISEASES AND INJURIES OF THE ABDOMEN. 689

emptied, and are kM)t empty by fastening around them
rubber tubes or iodoform strips. Two tubes are needed for
each loop of bowel. Pack in
gauze pads. Make an in-
cision in one loop, in the
long axis of the bowel, on
the surface away from the
mesentery ; permit the con-
tents to escape externally ;
irrigate this segment with
saline solution ; and introduce
the bone plate of Senn (Fig.
230, a) or Abbe's catgut ring.
Calyx-eyed needles are used,
and the threads of the ring
are carried through the coats
of the bowel and are gath-
ered together in the bite of
a pair of forceps. The other
loop of intestine is treated „ ., v j r .....

*^ . ., „, Fio. 131.— Melhodof paiHngihttilViutura

in a similar manner. Ihe in iiuertriii the rinp or Abbe

intestines are so brought

together that the two wounds are opposite each other, the
po.sterior sutures being tied first, the upper next, then the

lower, and finally the antenor threads The ends of the
threads are cut off and the entire anastomosis is surrounded
by a layer of Lambert sutures or is encircled by Cushing's

690

MODERN SURGERY,

suture. Fig. 230, b, shows an intestinal anastomosis partly
finished, and Fig. 230,0, shows an anastomosis complete.
Fig. 231 shows the passing of the sutures when the catgut
rings of Abbe are employed. After an intestinal resection,
each end can be closed and anastomosis effected as described
above. Lateral anastomosis can be accomplished with a
Murphy button, the intestine being prepared for the button
as is shown in Fig. 232.

Abbe's method of anastomosis without mechanical aid
is as follows: after resecting the bowel and mesentery
and closing the ends of the bowel he places the extrem-
ities side by side and applies two rows of a Dupuytren
suture, one-quarter of an inch apart. These rows of
sutures are an inch longer than the slit in the bowel
will be (Fig. 233), the thread at the end of each row

Fig. 233. — Suturing intestines in apposition before incision (Abbe).

being left long. An incision is made in the bowel, one-
quarter of an inch from the sutures, both rows of threads
being on the same side of the cut. This incision is four
inches long. The other portion of bowel is then incised in

Fig. 234, — Showing the four-inch incision and sewing of the edges (Abbe).

the same way. The adjacent cut-edges are united by a
whip-stitch which goes through all the coats, and the free
cut-edges arc stitched in the same manner (Fig. 234). The

DISEASES AND INJURIES OF THE ABDOMEN. 69I

surgeon now -utilizes the long threads of the first sutures,
and brings the serous surfaces of the opposite sides together
by means of Dupuytren's suture. Halsted performs anasto-
mosis as follows : he places the two portions of bowel with
their mesenteric borders in contact. Six quilted sutures of

silk are introduced, tied, and cut off {Fig. 235, a). At each
end of this row of sutures two quilted sutures are intro-
duced, tied, and cut (Fig. 235,*)- A number of quilted sutures
are introduced, as is shown in Fig. 235, c. The intestinal
openings are made with scissors, and the sutures last intro-
duced are tied and cut off (Fig. 235, d).

J. Shelton Hor.sley has suggested an ingenious method
of intestinal anastomosis which secures for the sutured
portion a greater diameter than that normal to the intes-
tine.' After resection of the intestine and a V-shaped piece
of mesentery, the ends of the bowel are placed side by
side, the opening.? being in the same direction, and are
clamped in place (Fig. 236). The first stitch approxi-

1 a™ York P.'lydinU.

692 MODERN SURGER Y.

mates the two limbs of the bowel near the mesenteric at-
tachment, is carried obliquely for about two inches to the

... uiDpoiitic>nandK>'UpedbyEhcArteTy.ferccpt.
dally Applied, iKc tepium pjtnlycui vmiy. and th?

. roiv of lulum (DTerhaixl) ; r, lh« teptum ; ^ ^aig.

border opposite the mesenteric attachment and continued
over the other side (Fig. 236). The septum is cut away, a
margin being left one-third of an inch wide. The edge of
the shelf made by cutting the septum is sutured. When the

suture reaches the end of the shelf it is continued by in-
vaginating the rest of the resected ends (Fig. 237).

DISEASES AND INJURIES OF THE ABDOMEN. 693

Bodine's method of intestinal anastomosis is referred, to
at page 695.

Consideration of Methods of Intestinal Approxima-
tion.— The best method of uniting a divided intestine is a
matter of dispute. The Murphy button can be applied with
great rapidity, and rapid operation is of immense importance
in intestinal work. The opening left by the Murphy button is
small (too small some surgeons think), but it does not strongly
tend in most instances to contract because the tissue-dia-
phragm is separated by tissue-atrophy and not by inflamma-
tory gangrene. Occasionally the opening made by the but-
ton contracts and gives trouble ; occasionally the lumen of
the button blocks with feces; occasionally the button is
retained, this later complication being especially frequent
after gastro-enterostomy. If the button is used, liquid food
should be given soon after the effect of the anesthetic has
passed off, and movement of the bowels should be obtained
at an early period after operation and frequent evacuations
should be maintained. The button gives better results in
end-to-end approximation than in lateral anastomosis. The
decalcified bone plates of Senn, the catgut rings of Abbe,
the catgut strands inside of rubber tubing of Brokaw,
Chaput's button, Allingham's bone bobbin, Robson's bone
bobbin, Clark's bobbin. Miller's bone buttons, buttons of
leather, potato, and carrot, all have their adherents. Of
mechanical appliances the best are the metal button, the
bone ring, and the inflatable rubber cylinder. Of recent
years many surgeons have abandoned all mechanical aids,
and have returned to closure without any mechanical de-
vice whatever. The ideal operation is without these con-
trivances. But such devices are time-savers, and to lessen
the time of operation will often save life. What method to
follow must be determined in each particular case by a study
of the necessitiea of the case. Nevertheless it may be pos-
.sible to formulate a few general rules. If the condition of
the patient is excellent and the bowel is in a fairly healthy con-
dition well above and well below the seat of trouble, end-to-
end approximation should be performed by circular enteror-
rhaphy, and this can be greatly facilitated by the use of an
inflatable rubber cylinder. If the condition of the patient is
such as to make haste necessary, use a Murphy button. If
the bowel below the seat of trouble is much contracted,
do not use a Murphy button, but use Senn's bone plate, or
Robson's bobbin, or, better still, do circular enterorrhaphy
with the aid of inflatable cylinders. If the surgeon is

694 MODERN SURGERY,

obliged to join a very much distended bowel to a very much
contracted bowel, perform end-to-side approximation (implan-
tation) with the bone plate of Senn, by simple suturing, or
else effect side-to-side junction by the method of Abbe/

Operation for Intussusception. — If hydrostatic press-
ure or air distention fails to relieve the condition, operation
should be performed. The abdomen is opened, and the
surgeon endeavors by manipulation to reduce the intussus-
ception by pushing it back, not by pulling it out. If
the intussusception is gangrenous, perform intestinal resec-
tion and circular enterorrhaphy. The same rule main-
tains when malignant disease of the gut exists (D'Arcy
Power). It is inadvisable to make an artificial anus. Maun-
sell's operation is suited to cases of irreducible intussuscep-
tion. It is performed as follows : a longitudinal incision is
made in the intussuscipiens. The intussusception is gently
pulled upon and is caused to protrude from this opening.
Two straight needles threaded with horse-hair are passed so
as to transfix the base, and one-fourth of an inch above the
needles the intussusception is cut off. The needles are
carried completely through, the sutures are hooked up in
the middle and cut, and the two ends are tied on each side.
These sutures unite the intussusception to the intussuscipiens.
The two surfaces are now carefully approximated by sutures.
The sutures are cut. The stump is replaced. The longi-
tudinal incision is closed with Lembert sutures.*

Senn's Operation for Fecal Fistula. — Suture the

opening transversely with Czerny sutures of silk in order
to prevent infection. Cleanse the abdomen thoroughly.
Open the abdomen and separate the edges of the bowel
from the parietes. Attach the intestine to diminish the
flexion which causes the spur. Apply Lembert sutures
over the Czerny sutures. Another method is to open the
abdomen above the fistula, insert the fingers, cut out the
skin and tissues around the fistula in an elliptical course,
leaving them attached to the bowel, draw the bowel from
the abdomen, pack gauze around, remove the tissues ad-
herent to it, and suture the fistula transversely (Heam).

Hnterostomy is the making of an artificial anus. If per-
formed in the large bowel, it is called colostomy.

Inguinal Colostomy. — Maydl's Operation. — In this
operation a vertical or oblique incision four inches long is made

^ See the discussion of this subject by the late Greig Smith in his Abdominal
Surgery.

* r. Pickering Pick, Quarterly Afed, Jour.^ Jan., 1897.

DISEASES AND INJURIES OF THE ABDOMEN. 695

over the portion of colon to be incised. In all cases where it
is possible, do a left inguinal colostomy. The colon usually
bulges into the wound, but if it does not it may easily be found
by following with the finger the parietal peritoneum outward,
backward, and inward, the first obstruction it encounters
being the mesocolon. Draw the colon out of the wound
until its mesenteric attachment is level with the abdominal
incision. Push a glass bar through a slit in the mesocolon
near the bowel, and wrap the ends of the bar with iodoform
gauze to prevent slipping. Instead of the bar a piece of
gauze can be employed, or a bridge of skin can be made
under the bowel by suturing the two skin edges. The two
parts of the flexure are stitched together by sutures which
penetrate to and catch the submucous coat (Fig. 238). If the

Fio 138 — Insulnal colotwmy (aftcT Zi

colon has to be opened during the operation, stitch the serous
coat of the bowel to the parietal peritoneum before opening.
Whenever possible, wait from twelve to twenty-four hours
before opening. The colon is opened by the cautery or by
scissors. If the artificial anus is to be permanent, make a
transverse incision through the bowel. Some surgeons cut
one-fourth way through the colon when it is first opened,
and entirely across at a later period. If the artificial anus
is to be temporary, the incision is longitudinal. This opera-
tion has great advantages: it is quick, certain, reasonably
safe, and satisfactorily prevents fecal accumulation below the
opening.

Bodine has devised a method of colostomy which permits
of a future restoration of the fecal current by an easily per-
formed anastomosis. This surgeon maintains that the spur
after colostomy should reach to and remain at the level of

696

MODERN SURGERY.

fluIUTVJ, paued back Edio the cavity niid «tiichcd into Ihc abdomiDai wound. The leviaa it
left protiuding, ud Ac dotwd lint ipdicuei where the pioinuron ii to be clipped off.

the skin, a condition impossible of attainment by hanging
the bowel over a rod or piece of gauze, because a spur thus

formed is not thick and rigid and is inevitably dragged below
the skin-level, and wlien this dragging has taken place some

DISEASES AND INJURIES OF THE ABDOMEN 697

fecal matter will pass into the bowel below the artificial anus.
Bodine opens the abdomen, sutures the parietal peritoneum
to the skin, seeks for the lesion, and draws it with six inches
of healthy bowel out of the incision. He lays the limbs of
the loop side by side. He inserts a silk stitch, beginning at
the point where exsection is to be made, and for six inches
unites the two segments close to their mesenteric borders.
The loop is dropped into the abdomen until the beginning
of the suture is on a level with the skin, and at this point it
is fastened to the abdominal wound with a continuous catgut
suture. The protruding lesion is cut off along the dotted
line (Fig. 239). The artificial anus is thus established.
When it is desired to close the artificial anus, divide the sep-
tum with scissors or a Grant clamp, and close the abdominal
wound (Fig. 240).*

Lumbar colostomy is a most unsatisfactory operation,
which does not completely intercept the fecal current, and
which leaves the patient in a condition of wretched dis-
comfort. It is rarely performed at the present day.

We should not make an artificial anus in the small bowel
if it is possible to avoid doing so. One can be made with
comparative rapidity near the ileocecal valve, but the higher
it is made the more likely is the patient to perish because of
lack of nourishment.

Cholecystotomy is the operation of opening the gall-
bladder in order to remove gall-stones or secure drainage.
The patient is placed recumbent with a sand-pillow under the
back. A vertical incision is made in the right linea semiluna-
ris. The peritoneum is opened. If the gall-bladder is dis-
tended, it is surrounded with pads and aspirated, and is then
opened. Gall-stones are removed by forceps, the scoop, or
irrigation. The gall-ducts are examined by the fingers exter-
nal to them. If a stone is wedged in the duct, try to manipu-
late it back into the gall-bladder. If this fails, introduce an
instrument from the gall-bladder and break up the stone ; if
this fails, open the duct, remove the stone, and close the in-
cision in the duct (Mayo Robson). Pass a rubber tube which
has no side perforations into the gall-bladder, and suture the
gall-bladder to the abdominal aponeurosis (Mayo Robson).
The drainage-tube can usually be dispensed with in one week.

Cholecjrstenterostomy consists in making an anasto-
mosis between the gall-bladder and intestine, preferably the
duodenum. It is employed in cases of irremovable obstruc-
tion of the cystic or common duct. It can be done most

1 N Y, Polyclinic, Feb. 15, 1897.

MODERN SVRGER Y-

rapidly and successfully by means of a small Murphy buttoi
Before the gall-bladder is incised it is aspirated. The <

ation is shown in Fig. 241, and is similar in performance t»^
intestinal anastomosis.

Splenectomy. — This operation is performed for wounds (
and rupture of the .spleen, cysts, floating spleen, and non-
leukemic splenic hypertrophy. It should not be performed
if leukemia exists. The incision is from the anterior superior
spine of the ilium to the ribs (Bryant). The peritoneum is
opened. Adhesions are divided between ligatures. If the
spleen is adherent to the pancreas, tt may be necessary to re-
move a fragment of the last-named organ (Esmarch). Ligate
the suspensory ligament and cut it. Bring the spleen well
out of the wound. Surround it with gauze pads. Transfix
the pedicle with stout silk. Tie it firmly, leaving the ends
long for a time, and cut through the pedicle beyond the
ligature. Ligate the vessels separately with catgut. Cut
off the long ends of the silk ligature and drop the pedicle J

DISEASES AND INJURIES OF THE ABDOMEN 699

back, unless apprehensive of bleeding, when it may be fast-
ened to the surface. The wound is closed without drain-
age.

Abdominal Hernia or Rupture. — This condition is the
protrusion of k viscus or part of a viscus from the abdominal
cavity. MacCormac says the term implies that the pro-
truded viscus is covered with integument ; hence a protrusion
of viscera through a wound does not constitute a hernia. A
hernia has three parts — the sac, the sac-contents, and the
sac-coverings. The sac is formed of peritoneum. A con-
genital sac is due to developmental defect, and is found
only in the inguinal or umbilical region. An acquired sac
is due to intra-abdominal pressure bulging the peritoneal
covering of the internal abdominal ring and converting it
into a pouch. The sac comprises a body, a neck, and a
mouth. A sac once formed is almost certain to persist,
because it adheres by its outer surface to surrounding parts,
and hence the sac of a hernia is irreducible even when the
contents are reducible. The neck of the sac is due to the
constriction through which the sac passes ; it becomes fur-
rowed and folded, and the adhesion of these folds causes thick-
ening and rigidity. Hernia of the bladder or of the cecum
has no sac, or but a partial sac. The contents of the sac de-
pend chiefly on the situation, a portion of the ileum being the
usual contents. The colon, the stomach, the great omentum,
the bladder, and other structures may enter the hernial sac.
An enterocele contains only intestine ; an epiplocele contains
only omentum ; an entero-epiplocele contains both omentum
and intestine ; a cystocele contains a portion of the bladder.
The coverings of the sac, which vary with its situation, will
be set forth during the consideration of special hernia. In
old hemiae the layers are never distinct, fat and muscle waste,
tissues adhere, and the skin stretches and atrophies. The
sac of a hernia occasionally becomes tubercular. This
condition arises in old hemiae. It may either remain local
in the hernial sac or spread to the general peritoneum.
Renault tells us that tuberculosis of a hernia is made mani-
fest by increase in size, pain on pressure, and loss of body
weight.

Causes of Hernia, — The male sex is most liable to hernia.
It occurs at all periods of life, and hereditary predisposition
sometimes seems to exist. Excessive length of the mesen-
tery has been assigned as a cause. Any laborious occupa-
tion predisposes to rupture. Any condition which weakens
the abdominal wall predisposes (muscular relaxation from

700 MODERN SURGERY,

ill-health, relaxation of abdominal walls following the termi-
nation of pregnancy, the removal of a large tumor, or
tapping for ascites, and wounds or abscesses of the ab-
dominal wall). The exciting cause is muscular effort (strain-
ing at stool, coughing, lifting weights, jumping, straining to
make water, and the sexual act). All congenital hemiae are
due to structural defects. Hernia is divided clinically into
reducible^ irreducible, incarcerated, inflamed, and strangu-
lated.

Reducible Hernia. — In this form of hernia the contents
of the sac can be reduced into the abdominal cavity. At a
known hernial opening the patient has a smooth enlargement
(narrower above than below), which began to grow from
above and extended downward. A distinct neck can often
be felt. In enterocele, straining, lifting, or standing enlarges
the mass ; the tumor becomes smaller and may disappear on
lying down ; cough causes impulse or succussion ; the tumor
is elastic, and on reduction the mass suddenly disappears
and there is a gurgling sound. In epiplocele the mass is
often irregular and compressible, and feels boggy rather than
elastic ; muscular effort does not have much influence in en-
larging it ; impulse on coughing is slight ; percussion gives
a dull note, and reduction is accomplished gradually and
produces no gurgling sound. In entero-epiplocele some parts
of the tumor are smooth, elastic, and tympanitic, others are
dull on percussion, irregular, and flabby ; but the diagnosis
of this especial form is uncertain. The victims of reducible
hernia complain of some pain on exertion, of dyspepsia, and
often of constipation.

When a hernia is beginning to form a patient complains
of muscular pain in the lower abdomen, and this condition
may exist for weeks before it is recognized that a hernia is
present. An inguinal hernia should be recognized before it
protrudes from the external ring. The tip of the finger is
inserted in the ring and the patient is asked to cough. If
a hernia has entered the canal, succussion will be detected
on coughing. In a healthy man the external ring should
admit the tip of the little finger, but not the end of the index
finger. If the end of the index finger can be made to enter
the ring, that aperture is dilated, and even if there is no hernia
in the canal, in future a hernia will exist. In a man, if the
surgeon desires to examine the ring, he inverts the skin of
the scrotum over the finger and carries the finger to or in
the ring.

Treatment of Reducible Hernia, — Palliative Treatment, —

DISEASES AND INJURIES OF THE ABDOMEN 7OI

Prevent constipation, forbid sudden strains and violent exer-
cise, and order a truss. The continued employment of a
truss, especially in young persons, may bring about a cure.
The day truss should be applied before rising in the morn-
ing and be removed after lying down at night, when a light
truss should be substituted. A special truss is applied for
bathing. In very fat people there is always trouble in
adjusting a truss. A femoral hernia is more difficult to keep
reduced than an inguinal hernia. In those cases in which
the gut is replaceable, but a portion of omentum is irre-
ducible, it is difficult to maintain reduction with a truss.
In an oblique inguinal hernia the pad of the truss fits over
the internal abdominal ring; in a direct inguinal hernia,
over the external abdominal ring ; in a femoral hernia, over
the femoral ring at the level of Gimbernat*s ligament.
MacCormac's rule to measure for a truss is as follows : in
either inguinal or femoral hernia start the tape frqm the
lower part of the hernial opening, carry it up to the anterior
superior iliac spine of the same side, then take it around the
body, one inch below the crest of the ilium, to the other
anterior superior iliac spine, and then to the upper part
of the hernial opening.* A well-fitting truss will keep the
hernia up even when the patient sits in a position to relax
the abdominal walls and coughs and strains. A truss is
always uncomfortable at first, but a person soon grows used
to it. It should be kept scrupulously clean, and it is well
to dust borated talc powder upon the skin under the pad at
least once a day. A truss which does not keep the hernia up
or which causes pain does harm. Too strong a spring tends
to enlarge the hernial orifice, and thus aggravates the case.
Bryant insists that even after an apparent cure with a truss
the instrument must be worn for a long time.

Radical treatment seeks to permanently cure by plugging
the mouth of the sac or by obliterating the canal of descent.
Radical operations should be performed when a strangulated
hernia is operated upon, in ordinary cases of reducible hernia
in which a truss is very painful or does not keep the bowel
up, in most cases of irreducible hernia, and in any case
which has occasional attacks of obstruction. It used to be
believed that a cure would fail if the subject was under three
years of age, but Coley and others have proved that it is a
very successful operation in children.

Macciven's Operation for biguinal Hernia, — The instru-
ments required in this operation are scalpels, a blunt, straight

' Treves's Manual of Surgeiy, " Hernia."

702

MODERN SCRGER Y.

bistoury, a dry dissector, a grooved director, scissors,

hernia-director, hernia- needles (Fig. 242), dissecting-forceps,!
toothed forceps, hemostatic for-'
ceps. an aneurj'sm-needle, blunt J
hooks, half-curved needles, nee-1
die-holder, and chromicized cat-fl
gut sutures. The patient lies'!
recumbent, the thigh being ab-a
ducted and partly flexed and rest-
ing on a pillow beneath the knee.
The bowel is reduced, and an
incision three inches long is made in the direction of the
inguinal canal, the center of the incision corresponding to
the external ring. The sac is freed from its attachments
below and is lifted up. The surgeon introduces a finger into

D/SBASES AND INJURIES OF THE ABDOMEN. 7O3

about the periphery of this aperture (Fig. 243, a). A chromi-
cized catgut stitch is fastened to the lowest portion of the sac,
and is passed through the sac several times, so that pulling on
the stitch will purse the sac (Fig. 243, b), The free end of
this stitch is carried through the internal ring into the belly,
and is pushed out through the abdominal muscles one inch
above the internal ring, the skin being pushed aside so as to
escape perforation by the needle. The thread is tightened so
as to fold up the sac and pull it into the belly. This plugs
the ring (Fig. 243, c). The thread is handed to an assistant
to keep tight until the sutures are introduced into the ring,
when the sac is permanently anchored by taking several
stitches in the external oblique muscle. A strong catgut
suture is passed with a Macewen needle through the con-
joined tendon from below upward, the ends of this suture
being carried through Poupart's ligament and the outer
borders of the internal ring from within outward. This
suture is tightened and closes the internal ring. The ex-
ternal ring is sutured and the skin is stitched together
(Fig. 243, e).

In congenital hernia the sac is divided in its middle and the
lower part is closed by stitches of chromic catgut, forming a
tunica vaginalis. The upper part of the
sac is slit posteriorly to permit the escape
of the cord, and is closed by stitches of
chromiccatgut. Theoperationisfinished
as in the acquired form (Fig. 244). After
this operation the patient should stay in
bed for about four weeks, and must not
work for eight or nine weeks. Workmen
after this operation should always wear
a pad and a spica bandage. Children
require no pad. Never apply a truss,
as strong pressure will atrophy the
curative scar.

Bassinls Operation for Inguinal Her-
nia.— This operation removes the spermatic cord from the
old canal and places it in a new canal, and this new canal is
oblique. The instruments employed are the same as for
Macewen's operation, excepting the special needles, which
are not needed. Hagedom needles are employed to insert
the stitches. The suture-material is kangaroo -ten don or
chromicized catgut. Silk or silver wire is apt to make
trouble — it may be long after the operation. The posi-
tion is the same as in Macewen's operation. An incision is

made from the external ring to a point external to the ii

nal ring. The sac is exposed and twisted, its neck is ligate

and it is cut off in front of
the ligature. The spermatic
cord is lifted (Fig. 245, A) ; ihe
border of the rectus muscle,
the edges of the internal ob-
lique and tile trans vcrsahs
muscles, and the transversalis
fascia, are sutured to the tot
shelf of Poupart's ligament
low the cord (Fig. 245, b).
border of the external oblique
is sutured to the upper shelf of
I'oupart's ligament above the
cord (Fig, 245, ^)- The skin is
sutured by interrupted stitches
of silkworm-gut or the edges
of the wound are approximated
by a .subcuticular stitch of cat-
gut or silver wire. In this
operation the author is accus-
tomed to treat the sac as in Macewen's operation, carrying
out the rest of the procedure as directed above. In a pure
Bassini operation the funnel-shaped depression in the peri-
toneum at the point of emergence of the cord remains and
predisposes to hernia, but the use of Macewen's plan for
treating the sac obviates this. Halsted makes a new in-
guinal canal and a new internal ring, removes the larger
veins to lessen the diameter of the cord, cuts away the sac
and sutures it exactly as the peritoneum is sutured
a laparotomy, places the cord between the external
jique muscle and the integument, and closes the skia
incision with a subcuticular suture. Halsted's subcutic-
ular suture is almost identical with the subcuticular suture
of Kendal Franks of Dublin. Chassaignac, as long ago as
1851, recommended a subcutaneous suture. Halsted's suture
is not subcutaneous, but subcuticular or intradermal. The
material employed may be silver wire, catgut, or silk. It is
inserted by means of a medium-sized Hagedorn needle held
in a needle- holder. It is carried through the derma at the
one margin of the wound and then of the other, and so on.
When it is inserted the ends of the suture are pulled and
the wound is approximated. In introducing this suture
the needle does not pass through the epiderm, and hence

salis ^^

Tb^S

DISEASES AND INJURIES OF THE ABDOMEN 705

there is no danger of infecting the wound with the staphy-
lococcus epidermidis albus. Kocher exposes the aponeu-
rosis of the external oblique, makes a small incision through
the aponeurosis above and external to the internal ring, and
draws the sac through this incision and sutures it in place.

Fowler's operation is as follows : an incision is made
parallel with Poupart's ligament from the spine of the pubis
to the level of the internal ring, and a flap is turned up. The
inguinal canal is opened and the sac and cord isolated. The
sac is opened, its contents reduced, it is cut off, and its
edges grasped with forceps. The deep epigastric artery and
vein are sought for, each is tied in two places and divided
between the ligatures. The index finger is introduced into
the belly, and on this as a guide the floor of the canal is
divided (transversalis fascia, subserous tissue, and peritoneum).
The cord is placed in the peritoneal cavity. The edges of
the opening are sutured so that broad serous surfaces are
approximated, through-and-through sutures being passed
from side to side. The cord is brought out at the inner
end of the incision, the lower angle of the cut being at such
a level that the cord curves upward and forward as it leaves
the abdomen. The inguinal canal, the gap in the aponeuro-
sis, and the skin are closed.^

After a radical cure the patient should remain in bed four
weeks.

Radical Cure of Umbilical Hernia. — Make an elliptical
incision through the skin around the mass. Endeavor ta
separate the sac from the superficial tissues. If this cannot
be done, open the sac and separate it from the contents.
Even if the sac can be stripped from the skin, always open
it and separate the contents. Return any bowel which may
be present, and do not forget that there may be a small
portion of bowel completely incased in omentum. Tie inta
segments and cut off the superfluous omentum and return
the stump into the belly. Excise the umbilicus (omphalec-
tomy). Suture the peritoneum with a continuous catgut
suture. Close the musculofascial wall with two layers of
interrupted kangaroo-tendon sutures. Close the skin by
interrupted sutures of silkworm-gut or a subcuticular stitch.

Radical Cure of Femoral Hernia. — Chjeyne ligates the
neck of the sac, stitches the stump to the abdominal wall,
dissects out a flap from the pectineus muscle, stitches this
flap to Poupart's ligament and to the abdominal wall, and
thus fills up the crural canal. Bassini makes an incision

* Annals of Surgery ^ Nov., 1897.
45

706 MODERN SURGER K

parallel with Poupart's ligament, ties the neck of the sac,
■cuts below the ligature, and returns the stump into the belly.
He attaches by deep sutures Poupart's ligament to the pec-
tineal aponeurosis as high up as the pectineal eminence, the
cord or round ligament being drawn out of the way. Super-
ficial sutures are passed between the pubic portion and the
iliac portion of the fascia lata.

The operation of Fabricius is as follows: an incision is
begun over the pubic spine and is carried outward for five
inches parallel with Poupart's ligament. The sac is exjxjsed,
isolated, and opened, and its contents are reduced, its neck
is ligated, the sac is cut off, and the stump is dropped back.
An incision is now made below Poupart's ligament so as to
separate this structure and the fascia lata, and the flap of
fascia is turned down. The crural sheath and the vessels are
retracted, and the origin of the pectineus muscle is sutured
to Poupart's ligament. The flap of fascia lata is sutured
to the aponeurosis of the external oblique, and the skin is
sutured.

Irreducible Hernia. — The swelling in irreducible rupture
presents the usual evidences of hernia, shows an impulse on
coughing, but cannot be replaced in the abdomen. Some-
times a portion is reducible and a portion is irreducible. A
hernia may become irreducible because of the size of the
mass, because of adhesions, or because of great growth of
omental fat. An irreducible hernia is liable to be bruised
and to cause much distress and pain, and is always a menace
to life because of the danger of obstruction and strangulation.
A small irreducible hernia can be supported by a hollow
padded truss ; a large hernia of this variety is carried in a
bag-truss. The patient must not take very active exer-
cise, must keep the bowels regular, and must live upon
a plain diet. Most of these cases should be treated by
operation.

Incarcerated or Obstructed Hernia. — Obstruction takes
place by the damming up of feces or of undigested food.
the fecal current being arrested, but the blood-current in
the walls of the bowel being undisturbed. Incarceration
is commonest in irreducible hernia, umbilical hernia, and
during the existence of constipation. The tumor enlai^es
and becomes tender, painful, and dull on percussion ; press-
ure diminishes it in size : it is irreducible, but still pre-
sents impulse on coughing. The abdomen is somewhat
distended and painful ; there are nausea, constipation, and
not unusually slight vomiting. Constitutional disturbance

DISEASES AND INJURIES OF THE ABDOMEN, 707

is slight and constipation is not absolute, gas at least
usually passing. Vomiting is not fecal. The treatment is
rest in bed in a position to relax the belly, an ice-bag over
the hernia, and a little opium for pain. Do not give a
particle of food for twenty-four hours; when the active
symptoms subside give an enema, and after this acts a dose
of castor oil. Do not employ taxis, as bruising the bowel
may produce strangulation.

Inflamed Hernia. — Inflammation of a hernia is local peri-
tonitis due to injury of an irreducible hernia. The mass
becomes tender, painful, and hot. In enterocele much fluid
forms ; in epiplocele the mass becomes hard. The hernia
cannot be reduced; there is constipation, often vomiting,
usually fever, but the mass still shows impulse on coughing.
Vomiting is not fecal. Some gas is usually passed through the
bowels. Constitutional symptoms are slight. The treatment
is rest in bed with abdominal relaxation, an ice-bag to the
tumor, a small amount of opium by the mouth if pain is
severe, an enema, and when this acts a saline. If pus forms,
incise and drain.

Stran^rulated hernia is a condition in which, if the hernia
contains bowel, not only is the fecal circulation arrested,
but the circulation of blood in the bowel-wall is also ar-
rested The bowel is irreducible and obstructed, and the
blood ceases to circulate. If the hernia contains omentum,
the omental vessels are tightly constricted. Strangulation
is commonest in old inguinal ruptures in active, middle-aged
men, and is more frequent in enteroceles than in epiploceles.
It may be due to entry into the sac of more intestine or
omentum, which has been forced down by sudden movement
or violent effort. It may be due to active peristalsis or to
congestion, and it may arise from inflammation or from in-
carceration. The constriction is usually at the neck of the
sac, in the outside tissues, or even in the sac itself In an
hour-glass hernia the constriction is in the body of the sac.
Adhesions within the sac may cause strangulation. Spas-
modic contraction of the tissues about the neck of the sac
is an exploded hypothesis. When strangulation once begins
the hernia swells, a furrow forms on the bowel at the seat
of constriction, the bowel and omentum below the con-
striction become deeply congested and edematous, and,
finally, the hernia passes into a state of moist gangrene.
The gangrene may be in spots or the entire mass may be
gangrenous. The sac is apt to inflame, and inflammation
produces fluid and lymph ; serum accumulates in the sac.

708 MODERN SCRGERY.

being first clear, then bloody, and finally brown and foul.
When gangrene is once established the bowel is in danger
of rupturing. At the point of contraction there may be
a line of ulceration. A strai^ulated femoral hernia becomes
gangrenous more raptdly than does a strangulated inguinal
hernia.

Sjrmptt^ms. — An indi\idual who has a hernia is seized \%ith
violent colicky- pain about the umbilicus, and the paroxysms
of colic become more and more frequent, until finally the pain
mav become continuous. The hernia is found to be irre-
dudble ; larger than usual, tender, painful, and dull on per-
cussion, and \i'ithout impulse on coughing. Eructations of
gas are firequent Uncontrollable vomiting and prostration
come on. Vomiting, as a rule, is an early symptom, and one
which increases in se\"erit\*. Occasionally it only follows
the s\i-alloi»-ing of liquids. In rare cases it does not arise for
t^ent\--four to fort\--eight hours. During the course of a
strangulation \x>miting may cease for a day or more, and it
not unusually ceases toward the end, when prostration is
profound. The early vomiting is due to reflex causes, the
later vomiting is due to waves of {>eristalsis which produce
regurgitation (Macready). The vomiting is first of the ali-
inentary contents of the stomach, next of mucus and bil-
ious matter, and finally of the contents of the small bowel
(fecal or stercoraceous vomiting). Stercoraceous vomiting
rarely arises until strangulation has lasted forty-eight
hours, and may not appear until much later. " It is sel-
dom met with in ingiinal, more often in femoral, and more
often still in obturator hernia " (Macready). Prostration is a
marked symptom of a strangulated hernia, and it increases
hour by hour and goes on to collapse. Early in the case
there may be some elevation of temperature, but later it
becomes normal or subnormal. The pulse is small, irregu-
lar, rapid, and ver\' weak — the extremities cold, the face
Hippocratic. Constipation is absolute, no gas even being
passed, though in the very beginning there may be some
diarrheal passages from below the constriction. The urine
is scanty and high-colored, and contains only a small
amount of the chlorids ; the tongue becomes dry and brown ;
the thirst is torturing; and the patient often has an urgent
desire to go to stool. Pains in the abdomen and in the
hernia become violent, and collapse rapidly increases. When
gangrene begins the symptoms apparently lessen in violence:
there is a "delusive calm." Vomiting usually ceases, though
regurgitation may take its place ; hiccough begins ; the pain

DISEASES AND INJURIES OF THE ABDOMEN. 709

abates or disappears; the pulse becomes very feeble and
intermittent ; collapse deepens, and delirium is usual. It is
a safe clinical rule that in strangulated hernia cessation of
pain without the relief of constriction or the use of opiates
means that gangrene has begun. In a pure omental hernia
strangulation produces similar but less decided symptoms.
In Littre's hernia only a portion of the circumference of the
bowel is constricted, usually in the femoral ring. In a
strangulated Littre's hernia constipation is rarely absolute
and the tumor is often undiscovered. In some cases of
strangulation there are muscular cramps in the legs (Berger).
In children convulsions are not unusual.

Treatment, — In treating strangulated hernia place the
patient upon his back, bend the knees over a pillow, and
rigidly interdict the administration of food. An attempt is
to be made to effect reduction by gentle manipulation or
taxis. In applying taxis to a femoral or inguinal hernia, flex
and adduct the thigh of the affected side. In applying taxis
to an umbilical hernia, both thighs should be flexed upon
the abdomen. Always lower the shoulders and head and
raise the pelvis, and accomplish this by lifting the foot
of the bed and placing pillows under the pelvis. Grasp
the neck of the sac with the fingers and thumb of one
hand, and employ the other hand to squeeze the hernia and
urge it toward the belly. In direct inguinal hernia the
pressure should be backward and a little upward ; in umbil-
ical hernia it should be backward ; in oblique inguinal hernia
it should be upward, outward, and backward; in femoral
hernia it should be downward until the hernia enters the
saphenous opening, and then " backward toward the pubic
spine" (MacCormac). If the bowel is reduced, it passes
from the hand witn a sudden slip and enters the belly
with an audible gurgle; omentum, when reduced slowly,
glides back without gurgling. Taxis is never to be con-
tinued long, and it is not even to be attempted in cases of
great acuteness, in cases where strangulation has lasted for
several days, in cases known to have previously been irre-
ducible, in cases associated with stercoraceous vomiting, or
in an inflamed or gangrenous hernia.

If taxis fails, obtain the patient's permission to operate.
Anesthetize; try taxis again while ether is being dropped
upon the hernia to cause cold ; if it fails, at once perform
herniotomy. Taxis possesses certain dangers : it may rup-
ture the bowel ; it may rupture the neck of the sac and
force the bowel through the rent; it may strip the peri-

7IO MODERN SURGERY,

toneum from around the hernial orifice and force the bowel
betiveen the detached peritoneum and the abdominal wall ;
it may reduce a hernia into the belly when the bowel is
still strangulated by adhesions; it may reduce the hernia
en masse or en blac^ the sac and strictured bowel being
forced together into the abdomen. By reduction en bissac
is meant the forcing of a congenital hernia into a congenital
pouch or diverticulum. In any of the above accidents
strangulation may persist after apparent reduction by taxis,
and this condition calls for instant laparotomy — ^in most
instances through the hernial aperture. If taxis is success-
ful, put the patient to bed, apply a pad and bandage, allow
the patient to take no food until vomiting ceases, merely
permitting him to suck bits of ice, and keep him on a liquid
diet for several day's. At the end of the first week give
solid food ; if the bowels have not acted by this time, ad-
minister an enema, following it by a dose of Epsom salts if
there is no pain and no disp>osition to vomit. Some sur-
geons advocate inversion as a valuable aid to taxis.

Herniotomy. — ^The instruments required in herniotomy are
a scalpel, a hernia-knife and director (Fig. 242, b), hemostatic
and dissecting-forceps, blunt hooks, scissors, a dry dissector,
partly-curved needles, and a needle-holder. Drainage-tubes
should be ready. In the operation the patient lies upon his
back with the shoulders raised, the surgeon standing to
the patient's right side. In oblique inguinal hernia it has
been the custom since the days of Scultetus to raise a fold of
skin at right angles to the axis of the external ring and
transfix it, the wound which results being extended until it
becomes three inches in length. This incision possesses
no special merit. It is better to cut from without inward,
and to make the same incision as for the performance of a
radical cure in a non-strangulated case. The tissues are
divided until the sac is reached, and no attempt is made to
specially identify them. The sac is known by the fat which
usually covers it, by the arborescent arrangement of its ves-
sels, by the fact that it can be pinched up between the finger
and thumb and the layers rolled over each other, and by the
fluid within the sac. Should the sac be opened? In very
recent cases it is usually unnecessary, but if there is any
doubt as to the condition of the bowel, or if a radical cure
is to be attempted, open the sac and be certain as to the con-
dition of its contents. The general rule should be to open
the sac. The sac is opened and the contents examined for
fecal odor (which is not unusual) and for gangrenous smell ;

DISEASES AND INJURIES OF THE ABDOMEN. 71 1

the thickness of the bowel is estimated, and the color and
luster are determined. In oblique inguinal hernia nick the
constriction upward and outward, as shown in Fig. 246. In
direct inguinal hernia the cut is made upward and inward.
Always pull the bowel down and examine the seat of con-
striction to see what damage has been inflicted at that point.
If the bowel glistens, if the proper color comes back after irri-
gation with very hot water, and if there are no spots of gan-
grene, restore the bowel to the abdomen, and do a rascal
cure. If the bowel is in a doubtful condition, fasten it to
the incision, apply a dressing, and watch the development of
events. If the bowel is gangrenous, our action depends upon
the condition of the patient If the patient is in good condi-
tion, resect the gangrenous portion, and perform end-to-end
anastomosis by means of a Murphy button. If the patient's
condition is bad, make an artificial anus, and at a later period
perform anastomosis. An arti-
ficial anus can be made by the
method of Bodine (page 695).
In most cases do not open the
bowel at once, because it may
recover in a day or two, when
it can be restored to the belly ;
or it may slough and form an
artificial anus. In such a doubt-
ful case, fasten the bowel to the

belly-wall with sutures, dust it Fio.J4«.-HniiioioiByiBii ,„..„.

with iodoform, dress it with hot

antiseptic fomentations, and await future developments. Gan-
grenous omentum requires ligation and resection. If the
bowel is fit to reduce, push it just inside the ring, irrigate
the parts, insert a drain, and sdtch. In most cases perform
a radical cure. In femoral hernia we can make the incision
one inch internal to, and parallel with, the femoral vessels,
and crossing the tumor and ligament (Barker) ; but it is bet-
ter to make the incision of Fabricius for radical cure. Divide
the constriction by cutting upward and a little inward. In
umbilUal hernia make a slightly-curved incision a little to
one side of the middle of the tumor, open the sac, separate
adhesions, and divide the constriction by cutting upward or
downward, and sometimes also laterally.

After an operation for strangulated hernia put the patient
to bed ; bend the knees over a pillow ; give no food by the
mouth for thirty-six hours (MacCormac), only allowing the
patient bits of ice to suck ; give nutnent enemata containing

7 r 2 JfCZZJLV SCSGEIt Y.

brandy ; and cse corphfn hypodennatically. If the boweb
have not acted bv rhe erxi of the first week, give an enema
and follow this by a ^linr Remov-e the drainage-tube on
the third day. At the end of about three weeks, if a radical
cure has not been attenxpced, get the patient up, first apply-
ing a pad and a spica bandage to the groin, and later a truss.
If a radical cure has been made, the patient should stay in
bed for one month. A truss should not be worn if a radical
cure has been made.

Anatomical VarutUs cf Henda, — In direct inguincd hernia
the bowel passes out through Hesselbach's triangle internal
to the deqp epigastric arter\'. It enters the inguinal canal
low down, and passes outside the conjoined tendon or forces
the conjoined tendon before it or splits through the tendon.
The neck of the sac is internal to the deep epigastric artery.
The coverings of this hernia, when it passes external to the
conjoined tendon, are the same as for indirect inguinal hernia ;
when a direct hernia pushes before it the conjoined tendon,
its coverings are skin, superficial &scia, intercolumnar fascia,
conjoined tendon, tranversalis &scia, subserous tissue, and
peritoneum. In indirect inguinal hernia the bowel passes
through the internal abdominal ring external to Hesselbach's
triangle and external to the deep epigastric artery. It passes
down the inguinal canal and emerges from the external ring ;
it may enter the scrotum or labium (scrotal or labial hernia),
or it may not. The neck of the sac is external to the deep
epigastric arter>'. Its coverings are skin, superficial fascia,
intercolumnar fascia, cremaster muscle, infundibuliform fascia,
.subserous tissue, and peritoneum. Congenital or encysted in-
guinal hernia is a hernia into an unclosed vaginal process.
The bowel in congenital hernia has one layer of peritoneum
in front of it. The testicle is posterior. In funictdar hernia
the vaginal process is closed below and open above, and a
hernia takes place into the unclosed funicular process. The
bowel has one layer of peritoneum in front of it. The testi-
cle is posterior. In infantile hernia the vaginal process is
occluded above, and not below, and the septum of occlusion
is [)ushed down by the hernia. In infantile hernia the bowel
has three layers of peritoneum in front of it. The testicle is
in front. Always remember that congenital hernia may not
appear for several months after birth. Congenital hernia
conceals or buries the testicle; acquired hernia does not.
\x\ fcvi oral hernia the bowel descends along the femoral canal,
and the neck of the sac is at the femoral ring. The neck
of a femoral rupture is always external to the pubic spine;

DISEASES AND INJURIES OF THE RECTUM AND ANUS. J II

the neck of an inguinal rupture is always internal to the
pubic spine. Femoral hernia is never congenital. Its cov-
erings are skin, superficial fascia, cribriform fascia, crural
sheath, septum crurale, subserous tissue, and peritoneum.
Umbilical hernia may be congenital (the ventral plates
having closed incompletely), infantile (the citatrix of the
umbilicus having stretched), or acquired. Ventral hernia
is a protrusion at any part of the anterior abdominal wall
except at the umbilicus or above it. Epigastric hernia is
a protrusion of peritoneum in the space bounded by the
ensiform cartilage, the ribs, and the umbilicus. The sac of
peritoneum may be empty, may contain omentum, or omen-
tum and bowel. The stomach very rarely passes into the
sac. The protrusion is usually, but not invariably, through
the linea alba. Preperitoneal hernia is a sac between the per-
itoneum and transversalis fascia. This form of hernia is some-
times produced by making taxis on an inguinal hernia, when
the internal ring is small or is blocked by an undescended
testicle. In properitoneal inguinal hernia, which is the most
common form, there are two sacs detectable, one in the
scrotum, the other parallel with Poupart's ligament, and as
one sac is emptied the other distends (Breiter of Zurich).
Obturator hernia passes through the obturator membrane
or the obturator canal, and is felt below the horizontal
ramus of the pubes, internal to the femoral vessels. Lumbar
hernia occurs at the edge of, or through, the quadratus lum-
borum muscle. Sciatic hernia passes through the great
sacrosciatic foramen. In diaphragmatic hernia some viscera
of the abdomen pass through a natural or an accidental open-
ing into the thorax. Pudendal hernia protrudes into the lower
part of the labium. Perineal hernia presents in the perineum,
between the rectum and the prostate gland or between the
rectum and the vagina. Hernia into the foramen of Winslow
is very rare.

XXVIII. DISEASES AND INJURIES OF THE RECTUM

AND ANUS.

HetnorrhoidSy or Piles. — There are three varieties of
varicose tumors of the rectum, namely : internal, which take
origin within the external sphincter; external, which take
origin without the external sphincter; and mixed hemor-
rhoids, which are a combination of the two.

External hemorrhoids are covered with skin. Internal

714 MODERN SURGERY.

hemorrhoids are covered with mucous membrane. The term
external hemorrhoids is not strictly accurate, as hemorrhage
does not occur in external piles, and all external piles are not
related to the external hemorrhoidal veins. An external
pile may involve the veins or the skin. If the veins are in-
volved, there may be varicosity of the plexus, a condition due
to straining, often associated with internal piles and produc-
tive of no particular annoyance. Symptoms appear when
phlebitis arises ; phlebitis causes thrombus, and the vein com-
monly ruptures.

External Hemorrhoids. — ^\Vhen a vein inflames the parts
are itchy, painful, and swollen, and defecation increases the
pain. When the vein ruptures a livid, soft enlargement ap-
pears near the edge of the anus, accompanied by decided pain
and other evidences of inflammation. These blood-tumors
may get well if let alone, or they may suppurate. External
piles are apt to be multiple, and cause no pain except when
inflamed. When the superfluous tags of skin around the
anus enlarge, they give rise to much pain and inflammation.
These cutaneous outgrowths are often spoken of as a form
of external piles. These cutaneous piles are due to some
inflammation, and are frequently secondary to inflammation,
of the anus or in the rectum.

Symptoms and Treatment, — An inflammatory enlargement
is detected, which is tender and painful. Pain is increased by
defecation. These piles do not bleed. In treating external
hemorrhoids some surgeons merely use remedies to combat
the inflammation. An old plan of treatment is to incise the
blood-tumor, turn out the clot, and pack with a bit of iodo-
form gauze. Matthews freezes the part or injects cocain,
catches up the blood-tumor with a volsellum, excises the
tumor and the tabs of inflamed skin, dusts the part with
iodoform, and dresses it with antiseptic gauze. The bowels
should not be allowed to move for two days. Never inject
external piles with carbolic acid : it causes great inflamma-
tion, excessive pain, and is not free from danger. If the
patient declines operation, order rest, a non-stimulating diet,
avoidance of tobacco (Matthews), the use of saline purga-
tives, injections into the rectum of cold water several times a
day, sponging of the anus frequently with hot water, and the
application of hot poultices. As the acute symptoms begin
to disappear use lead-water and laudanum ; when they have
nearly subsided apply zinc ointment. Extract of hamamelis
is a valuable application to external piles.

Internal hemorrhoids are varicose tumors of the internal

DISEASES AND INJURIES OF THE RECTUM AND ANUS. 7 1 5

hemorrhoidal plexus, and are found internal to the external
sphincter, just within the anus, and they prolapse easily.
They are not simple varicosities, but new tissue has been
formed, and they are in reality angeiomata. They are
covered with mucous membrane. Capillary piles are small,
sessile, with a surface like a mulberry, and bleed freely.
Children are not very liable to develop piles excepting this
capillary form. Venous piles are the most common variety.
They extend from just above the anal margin of the rectum
for an inch or more. They are purple in color, soft, irregular
in outline, and are usually multiple. They bleed when irri-
tated by hard fecal masses, but not so easily as the capil-
lary piles. Each pile is composed of a varicose vein, some
little fibrous tissue, and a few arterial twigs. Arterial piles
are very unusual. They are large, smooth, pedunculated,
bleed easily and freely, and contain, besides a distended vein,
arteries of some size.

Anything producing venous congestion in the rectum —
constipation, diseases of the rectum, enlargement of the
prostate, pregnancy, tumors of the womb, congestion of the
liver, cirrhosis of the liver, certain diseases of the heart and
lungs, sedentary occupations, relaxing climate, and stricture
of the urethra — will cause hemorrhoids.

Symptoms and Treatment. — If there is no bleeding and no
protrusion, the piles give no trouble. The first symptom is
usually hemorrhage, and rectal examination by the finger
and by the speculum will make clear the condition. After a
time, during defecation, the piles protrude ; they may reduce
themselves when the patient stands up, or it may be neces-
sary to push them in. Pain does not exist in uncomplicated
cases, and pain during or after protrusion means " abrasion,
fissure, or ulceration" (Matthews). Palliative treatment will
not cure, but it will give great comfort. Some people only
suffer at rare times when the liver is congested, and such
subjects will not submit to operation. Remove, if possible,
the cause (alcohol, irritating foods, want of exercise, etc.) ;
restrict the diet; insist on regular exercise; give a course of
Carlsbad salt, and follow this by the stomach use of bichlo-
rid of mercury (gr. -^jj after each meal). Prevent constipation
by a nightly dose of fluid extract of cascara. After each
movement wash the parts and syringe out the rectum with
cold water, and dry outwardly with a soft rag. If the hemor-
rhoids prolapse, after restoring them and injecting water,
insert a suppository containing gr. v of the extract of ham-
amelis, and use another suppository at bedtime. When

7i6

MODERX SURGERY.

the piles prolapse and indune* rub Allingham's ointment on
the parts (33 each of ext. of conium and ext of hyoscyamus,
5 of exL of belladonna, and |j of cosmolin). Matthews
uses gr. xij of cocain, 5} of iodoform, 5ss of ext. of opium,
and 5 of cosmolin. If the piles are protruding and reduc-
tion cannot be edSictei put the patient to bed, g^ve a hypo-
dermatic injection of morphin, and apply hot poultices. If
reduction cannot soon be effected, operate.

Operathi TreatmatL — Give a saline the morning before,
and an enema the evening before, the operation, and wash out
the rectum well the morning of the operation. In treating
by injection cf cjrMic acid the tumors are drawn out or the
patient strains them out, an injection is given by a hyf)oder-
matic s\Tinge into the center of the pile, and as each pile
is injected it is pushed into the rectum. The dose for each
pile is ID drops of a solution containing 3 parts of glycerin,
3 of water, and i of pure carbolic add. The injection is
rarely curati\"e, is very painful, and may produce hemorrhage,
phlebitis, p\'emia, stricture, and even death (W. T. Bull).
The clamp amJ cautery are used in intemo-extemal piles.
The padent is anesthetized, the sphincter is stretched, and the
pile is caught with forceps and drawn outside of the sphincter.
Smith's clamp is applied with the ivory surface against the mu-
cous membrane of the bowel,
the pile is cut off. and the stump
is seared with the Paquelin cau-
tery at a dull-red heat. Excis-
ion is preferred by Allingham.
He stretches the sphincter.

Fig. 247. — Extirpation of hemorrhoids
(Esmarch and Kowalzig.)

Fig. 2^Z.—SS, the lower circular incision
along Hilton's white line; Af, tube of mucous
mcniDranc dissected from the sphincter BB.
Dotted line showing the place for the upper
circular incision (Edmund Andrews).

holds it open with a retractor, catches up the pile, cuts it
off, and twists the bleeding vessels. Some prefer to pass

DISEASES AND INJURES OF THE RECTUM AND ANUS, JIJ

a silk or catgut suture, cut off the tumor, and tie the thread
(Fig. 247). White/iead^s operation is suited to severe cases,
when the piles are extremely large and form a protruding cir-
cular mass. Only a surgeon who can master violent hemor-
rhage should venture to perform it The entire pile-bearing
area of mucous membrane is dissected out, and the cut mar-
gin of mucous membrane is pulled down and stitched to the
surface. The sphincter must be dilated as a preliminary
(Fig. 248). This operation is sometimes followed by dis-
astrous consequences, especially by fecal incontinence.*

The application of the ligature is the easiest and most
generally useful method. In this operation, after anes-
thetizing, stretch the sphincter and treat each hemorrhoid
separately. Catch a pile with a pair of forceps or a vol-
sellum, pull it down, and cut a gutter through the skin-
margin if the pile is of the mixed variety ; tie the small
piles without transfixing, but transfix the large piles; tie
with silk (coarse silk for the large piles, finer silk for the
small piles) ; cut off the tumor beyond the thread, and
cut the ligatures short. Treat the other piles in the
same manner. Irrigate with hot normal salt solution, dust
with iodoform, pack a piece of iodoform gauze into the rec-
tum, and apply a gauze pad and a T-bandage. Give some
morphin to lock up the bowels, and keep the patient on a
light diet for three days, at the end of which time a saline
may be given. Just before the bowels act remove the dress-
ings and give an enema of warm water. After the movement
wash out the rectum first with peroxid of hydrogen and
next with hot salt solution, dust with iodoform, and apply
a gauze pad over the anus. Irrigate daily until healing is
complete. After the tenth day examine with a speculum to
see that the ligatures have come away ; if any are found in
place, remove them.

Prolapse of Anus and Rectum. — If the mucous mem-
brane is prolapsed, the condition is called " prolapsus ani ;"
if the entire thickness of the rectal wall is prolapsed, it is
called "prolapsus recti." Prolapse, which is apt to occur
from excessive straining at stool, is commonest in feeble, ill-
nourished children. Piles and worms may be complicated
with prolapse. Straining from phimosis, stone in the blad-
der, or stricture may be causative. Prolapse may be either
large or small, but tends to recur again and again, and
eventually the mucous membrane inflames, ulcerates, or
sloughs. Strangulation of the prolapsed part may occur.

* Andrews, in Matthcw*s Medical Quarterly^ Oct., 1895.

7l8 MODESX SUXCEXY.

Treatment. — Palliative treatment forbids stiwting it
stool. If prolapse occurs, the parts are bathed in cold
water and restored. Constipation must be prevented («l^
mata of water or glycerin may be used). If a prolapse t
caught firmly, place the patient in the knee-chest position,
wash the mass with cold water, grease it with cosmolin,
insert a finger into the rectum, and apply taxis around tbe
finger (Matthews), If this fails, cover a finger with a band-
kerchief and insert the wrapped digit into the rectum; if ihis
prove futile, invert the patient. Severe cases require ether
After reduction apply a compress, direct it to be won
except when at stool, and before each act of defecatioo gjvt
an injection of cold water containing an astringent (tannin
or fluid ext. hydrastis). Some cases require excision of ik
mucous membrane, the di\'ided edge of this membrane being
stitched to the skin. In other cases tlie protrusion is strokiil
with the cautery and restored. In persistent cases of rectal
prolapse open the abdomen and attach the colon to ibc
belly-wall (colopex)').

Ulcer of the Ret:ttliti. — Simple ulcer is due to abrasion
with fecal mas.ses, and is apt to be single. Its base and
edges are neither prominent nor hard, Syplii/itic ulcer is i
tertiary lesion commonest in women. There are nuroerouf
small ulcers, but little indurated, with sharp-eut edges which
are not undermined. These ulcers fuse together and consti-
tute one large irregular ulcer; fibrous tissue forms in ihc
wall of the bowel, induration becomes noticeable, and strict-
ure follows. There is profuse discharge, and fistulae an: ip!
to form. In syphilis there may be a breaking down of a
huge gummy mass. Tubercular ulceration presents a conies!
ulcer with overhanging edges and a pale-red base. There
is some mucous discharge, some tenesmus, and a little paia
Dysentery, catarrh, neoplasms, and foreign bodies produa
ulceration. The symptoms are constipation, burning pain
on defecation, straining at stool, and blood and mucus in
the stools. The dia^rnoeis is made by digital examination
and inspection through a speculum.

Treatment. — In simple ulcer empty the bowel by the ad-
ministration of a .saline cathartic, wash out the rectum with
hot water after the saline has acted, introduce a speculum,
touch the ulcer with pure carbolic acid or silver nitrate U'
xJ to 5j), place the patient in bed, restrict him to a liquid dirt,
an d every day inject iodoform and olive oil or insufflate iodo-
form into the rectum. If this fails, give ether, stretch llw
spliincter, incise the ulcer through its entire thickness, and

DISEASES AND INJURIES OF THE RECTUM AND ANUS. 719

cauterize with fuming nitric acid, caring for the case subse-
quently as we would a patient who had had piles ligated. In
tubercular ulcer improve the general health, send the patient
to a genial climate, or at least into the sunlight and fresh air,
prevent constipation, give nutritious food, especially fats, wash
out the rectum every day with hot water and insufflate iodo-
form or inject iodoform emulsion. Touch the ulcer once a
week with silver nitrate (gr. x to Sj). In syphilitic ulcer give
anti-syphilitic treatment and treat the ulcer locally as is done
in tubercular ulcer. Dysenteric ulcer requires injections of
hot water, the touching of the ulcer with pure carbolic acid,
and insufflations of iodoform.

Stricture of the rectum may arise from syphilitic
tissue, from ordinary inflammatory tissue, from cicatrices
of operations, from sloughing, from tubercular or dysen-
teric ulceration, and from cancer. The usual seat of simple
stricture is from one inch to one and a half inches above
the anus. The deposit may be limited to the submucous
coat, or all the coats may be involved. A syphilitic lesion
or a tubercular lesion may cause rectal stricture; but in
some cases such lesions simply open the tissues to the in-
fection, and a benign rectal stenosis results.

The s3nnptoin8 of rectal stricture are constipation, pain
on defecation, straining at stool, the presence of blood and
mucus in the stools, an open anus, and the passage of stools
flattened' out into ribbons. The stricture is found by the fin-
ger or by the bougie. In syphilitic cases, tubercular cases,
and in benign cases, the fibrous thickening is in the submu-
cous coat, and in syphilitic and tubercular cases the mucous
membrane is ulcerated. Complete obstruction may come on,
and distended abdomen with colic is very usual.

The treatment is rest, non-stimulating diet, warm-water
injections, mild laxatives, and hot hip-baths. Cocain sup-
positories may be needed. Any existing disease is treated.
Bougies are passed every other day. Use a soft-rubber
bougie, warmed and oiled, and introduce it gently. If only
the method of gradual dilatation is employed, the bougie
must be used always. For fibrous strictures forcible dilatation
(divulsion) by a special instrument is employed or incision
is practised. Incision (proctotomy) may be either external
or internal. In internal proctotomy one or more incisions
are made through the stricture down to healthy tissue, the
first cut being in the middle line posteriorly. External
proctotomy, which divides the sphincters, is apt to leave
incontinence as a legacy. Electrolysis finds some advo-

720 MODERN SURGERY.

cates, but on what grounds it is difficult to see. In some
cases the rectum should be removed. In incurable cases
perform inguinal colostomy.

Cancer of the recttiin may be epithelioma, but it is
often scirrhus. It not unusually occurs before the thirty-
fifth year, and is seen as early as the twenty-fourth year.
The retroperitoneal and inguinal glands are involved late or
not at all. Extensive ulceration occurs. A hard ring is apt
to encircle the rectum.

Ssnnptoms and Treatment. — The symptoms of rectal
cancer are like those of simple stricture, except that the
pain is greater, the hemorrhage more severe, and constipa-
tion is apt to alternate viith diarrhea. The finger and the
speculum make the diagnosis. In rectal cancer metastasis
occurs late. The most favorable cases for operation are
those in which the growth is small and movable. Accurately
define the extent of the growth and endeavor to make out if
it has invaded the cellular tissue outside of the rectum, the
prostate, the bladder, the sacrum, the uterus, etc. Cases of
widespread invasion should not be subjected to radical oper-
ation. Palliatkfe treatment is as follows : every day introduce
a tube through the stricture, wash out the rectum with warm
water, and after washing inject emulsion of iodoform (gr. x to
5j of sweet oil). Injections of chlorid of zinc (gr. j to 5j of
water) lessen the foulness of the discharge. Eventually co-
lostomy is performed. This operation gives great comfort to
the patient, and allays pain and prolongs life by intercepting
the feces before they reach the cancer. This operation is
employed for inoperable cancer, for obstruction, and in cases
where metastasis has occurred. Operative treatment includes
one of several procedures. Internal proctotomy does some
good. Excision of the rectum from below (Cripp's oper-
ation) is practised if not more than three inches require re-
moval, if the peritoneum is not invaded, and if the adjacent
organs are free from disease. The peritoneum must not be
opened in Cripp's operation. After the growth is removed
the divided rectum is pulled down and sutured to the skin.
Excision of the rectum after excising a portion of the sacrum
(Kraske's operation. Fig. 249) is an operation which permits
removal of the entire tube, portions of the colon, and even of
adjacent parts. If the peritoneum is opened, it must be closed
with sutures. The lower end of the upper segment of bowel
is fastened in the wound. The upper end of the lower seg-
ment may be fastened to the wound or closed. Kraske's
operation may be done by an osteoplastic method, the bone

DISEASES AIQD INJURIES OF THE RECTUM AND ANUS. 72 1

not being removed. It is well to precede a Kraske operation
several weeks by an inguinal colostomy, which permits of
cleansing the lower bowel from feces and allows the sur-
geon to operate with a fair chance of escaping infection,
A preliminary colostomy may make the operation of extir-
pation more difficult b> fixmg the Intestine, and thus inter-
fering with the necessary drawing down of the gut (E. H.

Taylor). If the growth is extensive and the mesocolon short,
it may be best to perform a right inguinal colostomy ; but in
most cases left inguinal colostomy is preferred (Gerster).

Foreign bodies in the rectimi, if small, are extracted
with forceps and the fingers ; if large, ether must first be
given and the sphincter must be dilated.

Wounds of the rectum require free drainage, antiseptic
irrigation, and antiseptic dressing.

Ischiorectal abscesses are situated in the ischiorectal
fossa. They travel in the line of least resistance, which is
upward, and more often burst into the bowel than externally.
They are caused by cold, by external traumatisms, by per-
forations of the rectum by hard fecal masses, or by the
passage of bacteria into the fossa through a fissure, an ulcer,
or an ulcerated pile. They may be either acute or tubercu-
lar. The BymptomB are the same as those of abscess any-
where, the swelling, however, being brawny and fluctuation
being hard to detect.

The treatment is instant incision, the cut radiating from

722 MODERN SURGERY.

the anus like the spoke of a wheel. Incision is followed by
irrigation and packing with iodoform gauze or the insertion
of a drainage-tube.

Imperforate AntlS. — There are two forms of this con-
dition. In one form the rectum empties into the bladder,
vagina, or urethra. In the other form there is no rectal
opening either upon the surface of the body or in the uri-
nary organs. The diagnosis is usually at once apparent,
except in cases where the anus looks normal, when the
diagnosis will often not be made until symptoms of obstruc-
tion arise.

Treatment. — If the rectum bulges when the child cries,
open into it with a knife and keep the opening patent by
inserting a plug of iodoform gauze. In cases in which the
rectum is more deeply seated a catheter is introduced into
the bladder, an incision is made from the anus to the coccyx,
the rectum is sought for, is sewed to the anus, and is incised
In some cases Keen and others have performed Kraske's
operation, pulling down the rectum to the anal mai^n,
sewing it there, and incising the occluded anus. If the rec-
tum cannot be found or cannot be pulled down, an artificial
anus must be made.

Pisttlla in ano is the track of an unhealed abscess. An
abscess in the anal region is apt to refuse to heal because of
the constant movement of the parts (produced by respiration,
coughing, the passage of gas, defecation, etc.). The passage
of feces will keep a fistula open. If a tubercular ulcer per-
forates, a tubercular sinus forms, and a tubercular sinus is apt
to follow a cold abscess of the ischiorectal space. Fistula is
often associated with phthisis pulmonalis, and is not un-
usually linked with piles, cancer, or stricture.

There arc three varieties of fistula- — the blind external
(Fig. 250, a), the blind internal (Fig. 250, b), and the com-
plete (Fig. 250, c). The external opening is usually near the
anus, but may be far away, and there may be only one path-

A \\ C

FlU i5\ — FistuU In ano: a. binui external: b. blind internal; c, complete (Esmarcfa aad

Kowalrig).

way or there may be several sinuses. In a healthy individual
the external orifice is small and a mass of granulations sprouts

DISEASES AND INJURIES OF THE RECTUM AND ANUS. 723

from it In tubercular fistula the external orifice is large
and irregular, with thin and undermined edges, shows no
granulations, extrudes smali quantities of sanious pus, and
the skin about it is purple and congested. In a fistula fol-
lowing an anal abscess the internal opening is just above the
anus, between the two sphincters. In fistula following an
ischiorectal abscess the internal opening may be above the
internal sphincter. In an old fistula the track becomes
fibrous and cannot collapse. The symptmns of fistula are the
passage of feces and gas through the opening and the flow
of a discharge which stains the clothing. In a complete
fistula a probe can be carried from the external opening into
the bowel. After a time incontinence of feces is apt to come
on, repeated attacks of inflammation thickening the rectum
and destroying its sensibility. From time to time the open-
ing will block, and new abscesses form. In examining a
fistula use Brodie's probe, as its flat handle enables one to
locate the direction the bent instrument has taken, and its
slender shaft will find its way through a very small channel.
Treatment. — In treating a fistula cleanse the parts, as
cleanly work, though it will not prevent pus, will limit sup-
puration. The external parts are washed with soap and
water. The rectum, which must be empty, is irrigated with
hot saline solution. Corrosive sublimate should not be used
in the rectum, because it is irritant, causes a flow of serum,
and hence lessens tissue-resistance, and is rendered inert as an
antiseptic by being converted into sulphid of mercury. Anes-
thetize the patient. Pass a grooved director through the sinus,
bring its point out externally, and lift the tissues between
the sinus and the surface. Incise the tissues (Fig. 251).
Push the finger to the depth of the wound,
to determine that the sinus does not
ascend above the internal opening. Look
for branching sinuses, and if any are found,
slit them open. Curet all sinuses, and if
they are very fibrous, clip them away with
scissors. Cut away diseased skin; irri-
gate with salt solution ; pack with iodo-
form gauze ; and dress with gauze and
a T-bandage. In forty-eight hours re-
move the dressings, irrigate with per-
oxid of hydrogen and then with salt
solution, dust with iodoform, insert lightly
to the depths of the wound a piece of iodoform gauze,
and reapply the dressings. Dress the wound thus every

724 MODERN SURQER K

day until healing is almost complete. It is unnecessary to
confine the bowels beyond forty-eight hours, at which period,
if they have not moved, an enema is given. If the dressing
at any time becomes stained with feces, re-dress at once.
Get the patient out of bed as soon as possible. Cut the
sphincter at a right angle to its fibers, and do not cut it more
than once at one operation. If there are two fistulae, cut
one through, and when one heals cut the other. In some
straight sinuses the tract can be extirpated and the parts
sutured, primary union occasionally resulting. If fecal in-
continence results from an operation for fistula, remove the
scar tissue and endeavor to suture the separated muscular
fibers. Should an operation be undertaken if phthisis exists ?
Many of the old masters said no, Matthews sums up the
modem view : in incipient phthisis operate ; in- rapidly pro-
gressive fistula operate whether cough exists or not ; if much
cough exists, do not operate unless the fistula is rapidly pro-
gressive ; in the last stages of phthisis do not operate.

Pruritus of the anus is a symptom, and not a disease.
It may be due to piles, fissure, seat-worms, eczema, nerve-
disturbance, kidney disease, jaundice, constipation, inebriety,
opium-habit, torpid liver, dyspepsia, alcohol, tea-drinking,
vesical calculus, smoking, urethral stricture, uterine dis-
ease, diabetes, ovarian trouble, and mental disorder. The
itching is worse at night, and is often of fearful intensity.

Treatment. — Remove the cause. Prevent constipation.
Further, several times a day, wash the parts with very hot
water, dry them, and apply a mixture containing 3J of cam-
pho-phenique and sj of water (Matthews). Matthews com-
mends the following mixture : chloral, 3J ; gum-camphor,
3ss ; glycerin and water, each 3j.^ In this disease a *' scarf-
skin " forms, which must be made to peel off by iodin, pure
carbolic acid, corrosive sublimate (grs. iv to 3j of cosmolin),
calomel (^ij to 5j of cosmolin), or campho-phenique. In
obstinate cases paint the parts, night and morning,, with a
mixture of 60 grs. of alum, 30 grs. of calomel, and 300 grs.
of glycerin, or smear with an ointment composed of J^ of a
part of oleate of cocain, 3 parts of lanolin, 2 parts of vaselin,
and 2 parts of olive oil (Morain). In very severe cases
touch with a solution of silver nitrate (i : 10) or employ the
Paquelin cautery.

Fissure of the anus is an irritable ulcer at the anal ori-
fice producing spasm of the sphincter. Pain exists because
of twigs of nerves upon the floor of the crack. Fissure is

^ Diseases of the Rectum.

ANESTHESIA AND ANESTHETICS. J 2$

caused by constipatioh or traumatism. The symptom is
violent, burning pain, sometimes beginning during defecation,
but usually at the end of the act, and lasting for some hours.
Constipation exists, and often pruritus. Examination dis-
closes a fissure, usually at the posterior margin, running up
the bowel one-quarter to one-half an inch. Piles often exist
with fissure.

Treatment. — The palliatvve treatment is to prevent con-
stipation, to wash out the rectum with cold water, and apply
an ointment made by evaporating 5ij of the juice of conium
to 3ij and adding it to 3j of lanolin and gr. xij of persul-
phate of iron. Pure ichthyol may do good. In operative
treatment stretch the sphincter. In order to stretch the
sphincter the patient is to be anesthetized, the surgeon's
thumbs are inserted into the rectum, and the parts are
stretched until the thumbs touch the ischia. After stretch-
ing the sphincter incise the floor of the fissure, scrape it with
a curet, and touch with nitrate of silver stick.

XXIX. ANESTHESIA AND ANESTHETICS.

Anesthesia is a condition of insensibility or loss of feel-
ing artificially produced. An anesthetic is an agent which
produces insensibility or loss of feeling. Anesthetics are
divided into — (i) General anesthetics^ as amylene, chloroform,
ethylene chlorid, ether, bromid of ethyl, nitrous oxid, and
bichlorid of methylene ; (2) Local anesthetics, as alcohol,
bisulphid of carbon, chlorid of ethyl, carbolic acid, ether
spray, cocain, ice and salt, and rhigolene spray.

General anesthesia may be induced to abolish the usual
pain of labor and of surgical procedures ; to produce mus-
cular relaxation in herniae, dislocations, and fractures; and
to aid in diagnosticating abdominal tumors, joint-diseases,
fractures, and malingering.

Heart disease is not a positive contraindication to surgical
anesthesia. It is quite true that anesthetics are dangerous
in people with fatty hearts, but shock is equally dangerous,
and the surgeon stands between the Scylla of anesthesia
and the Charybdis of shock. Whenever possible, prepare
a patient for anesthesia. Always examine the urine if the
nature of the case allows time. If albumin exists, operation
is not contraindicated ; but the peril of anesthesia is greater,
and certain dangers are to be watched for and guarded
against If much albumin is present, postpone operation
except in emergency cases. If much sugar exists, the danger

726 MODERN SURGERY,

is considerable, as diabetic coma occasionally develops. Give
a purgative the night before giving the anesthetic. In the
morning allow no breakfast if the operation is to be per-
formed at an early hour ; but if the patient is very weak,
order a little brandy and beef-tea. If the operation is to
be about noon, give a breakfast of some beef-tea and toast
or a little consomme; never give any food within three
hours of the operation, but brandy is admissible if it is
required. If the stomach is not empty at the time of
operation, vomiting is almost inevitable and portions of
food may enter the windpipe ; if the stomach contains no
food, vomiting is far less likely to happen, and even if it
occurs and vomited matter should enter the windpipe it will
do little harm, as it consists chiefly of liquid mucus. In
cases of intestinal obstruction in which there has been ster-
coraceous vomiting, there is much danger that vomiting will
occur during anesthetization. Vomiting of this sort is pro-
fuse, sudden, and dangerous. It may flood the bronchial tubes
and cause death by suffocation. In such a case wash out the
stomach before giving the ether. Vomiting is dangerous also
because of the great cardiac weakness which precedes and
follows it. Before giving the anesthetic see that artificial
teeth are removed and that the patient does not have a piece
of candy or a chew of tobacco in the mouth. Always have
a third party present as a witness, because in an anesthetic
sleep vivid dreams often occur, and erotic dreams in women
may lead to damaging accusations against the surgeon. Place
the patient recumbent, and see that the clothing is loose, par-
ticularly that there is no constriction about the neck and
abdomen. Do not have the head high unless this p>osition is
demanded by the exigencies of the operation. The anesthe-
tizer must have a mouth-gag, a pair of tongue-forceps, a hy-
podermatic needle in working order, and solutions of strych-
nin, atropin, digitalis, and brandy. It is always well to have
an electric battery and a can of oxygen at hand. Accidents,
it is true, are rare, but they may happen at any time, and
hence the surgeon should always be prepared for them. Any
danger which arises must be met with promptness and decis-
ion, or action will be of no avail. Many surgeons give a
hypodermatic injection of morphin a short time before opera-
tion, to steady the heart, prevent vomiting, and aid the bring-
ing about of insensibility with very little of the anesthetic.

The two favorite anesthetics are ether and chloroform.
Chloroform is more dangerous than ether in general cases,
though it is more agreeable, less irritant to the lungs and

ANESTHESIA AND ANESTHETICS. 727

kidneys, and quicker in its action. Recovery from chloro-
form is quicker and quieter than that from ether, but chloro-
form-vomiting lasts longer than ether-vomiting. Chloroform
may induce sudden and even fatal syncope. Hare's experi-
ments on animals indicate that chloroform may kill by re-
spiratory failure occurring secondarily to failure of the vaso-
motor center ; but certain it is that clinically the danger of
chloroform is paralysis of the heart, and this condition may
come on so rapidly that death may occur almost before an
attempt can be made to save life. Berkley Hill has proved
that most chloroform-deaths that take place after consider-
able of the anesthetic has been taken, arise from paralytic
distention of the heart. Sudden death, when inhalations of
chloroform have just commenced, may be due to the nasal
reflex. If ether kills, it does so through the respiration, and
not the heart, iand there is usually time to undertake means
of resuscitation, which means are apt to be successful. Chloro-
form is to be preferred to ether in the following cases : for
children under ten years of age, in whom ether causes a great
outflow of bronchial mucus, which may asphyxiate ; for people
over sixty, free from advanced cardiac disease, at which age
most persons have some bronchitis, and ether chokes them
up with mucus. Ether also irritates the kidneys, which at
the latter age are apt to be weak or diseased. Chloroform is
preferred for labor cases, when moderate anesthesia only is
required; and for operations on the mouth and nose. In
cleft palate chloroform should always be used to limit cough
and to minimize salivary flow. In ligation of a large artery
which is overlaid by a vein, ether exercises the unfortunate
influence of greatly enlarging the vein. Hence in such a
case chloroform makes the operation easier. In goiter oper-
ations ether should not be used, as it enlarges enormously
the veins. Chloroform is preferred for patients with difficult
respiration from any cause ; for patients with kidney disease
and for patients with diabetes. Some surgeons do not use
ether in abdominal operations because they believe it may
cause persistent oozing of blood, but this view is not in
accord with the author's experience. Ether is safer in
patients with heart disease, and is the best and safest anes-
thetic for general use. Both ether and chloroform may
induce changes in the blood. In many cases they produce
a diminution of hemoglobin. In some cases they produce
alteration in the shape of the corpuscles. This is especially
true in anemic blood. Ether produces leukocytosis. These
blood-changes indicate that prolonged anesthesia may mili-

728 MODERN SURGER Y.

tate against recovery from a severe operation. In anesthesia
the temperature drops from one to three degrees, hence
the patient should be carefully covered during the oper-
ation. The question as to the effect of ether on the kidnera
is much disputed. Most surgeons believe that it tends lo
cause albuminuria or increase existing albuminuria; olhirs
deny this.

Administration of Chloroform. — In administering
chloroform have at hand a mouth-gag, tongue-forceps, .1
clean towel, a hypodermatic syringe, solutions of strjxhrin,
alropin, and brandy, an electric battery, and a can of ox\'gen
Use only pure chloroform (Squibb's), The patient must be re-
cumbent. No special inhaler is required, but the drug nuy
be given upon a thin towel, a napkin, or a piece of lint The
inhaler of Esmarch is very useful. In operations about
the face Souchon's instrument is serviceable. Souchons
apparatus is so arranged that chloroform may be given
through a tube which is introduced through the nose, the
instrument being well out of the way of the operator.
Some surgeons cocainize the nares before giving chloro-
form, so as to prevent the dangerous nasal reflex (Rosenberg).
The chloroform- vapor must be well mixed with air. The
chloroform is sprinkled on the fabric with a drop-bottle. Put
the napkin well above the mouth, add five drops of chloro-
form, and tell the patient to take deep and regular breaths.
Add a few more drops of chloroform, and when the patient
grows so accustomed to it as not to choke, turn the wet part
of the fabric toward the face and place it near the mouth ; do
not touch the mouth with the wet lint, because it will blister.
It is a good plan to smear the lips with cosmolin to prevent
blistering. If the drug is given gradually, struggling is not
usually violent or prolonged. Never pour on a large amount
at one time. During the stage of excitement do not suspend
the administration of chloroform unless respiration becomes
difficult, in which case suspend it until the patient takes one
or two respirations. Chloroform-vapor is not inflammable,
hence it is safer than ether when a hot iron is to be used
about the face and when there is a lighted lamporasto«
in a small room ; but the presence of flame decompoics
chloroform into irritant products of chlorin, which some-
times cause the patient and the surgeon to cough. A com-
bination of chloroform and oxygen is used by some admin-
istrators. The patient who is anesthetized with the mfi^
vapor retains a good color, but it requires a considciabtftj
time to render him unconscious.

ANESTHESIA AND ANESTHETICS.

729

Administration of Ether, — Ether is best given by
means of an Aliis inhaler (Fig. 252). Have at hand the
same instruments as for chloroform.
Place the dry inhaler over the
mouth and nose, let the patient
take several breaths to gain confi-
dence, pour a few drops of ether
into the cone, let the patient take
several more breaths, and so on,
gradually increasing the amount of
ether. Never suddenly add a large
amount of the anesthetic : it causes
coughing and often vomiting. When
the patient becomes thoroughly an-
esthetized, diminish the amount of
ether; when bleeding is profuse, do
the same. If a hot iron is to be used
about the face, take away the cone
and fan away the ether before bringing the iron near. Have
any light set high up, as ether-vapor is heavier than air, and
no explosion is possible until it reaches the level of the flame.
If the vapor takes fire, cover the patient's mouth and nose
with a towel. The use of oxygen with ether delays the pro-
duction of unconsciousness.

Anesthetic State from Ether or Chloroform. — The
inhalation of an anesthetic produces irritation of the fauces,
some cough, a profuse secretion of mucus, acts of swallow-
ing, dilatation of the pupils, flushed face, and sometimes strug-
ghng (especially in children and in drunkards). The cough
soon ceases, the respirations become rapid and often convul-
sive, the pulse becomes frequent, and the patient passes into
a condition of active intoxication with preservation of sight
and touch, loss of hearing and smell, diminution of pain and
sensibility, and often with illusions or hallucinations. From
this state many subjects (strong men and drunkards) pass
into a stage of rigidity in which the muscles become rigidly
fixed, the breathing impeded, the respirations stertorous, and
the face bluish and congested. Too rapid forcing of the an-
esthetic tends to cause rigidity, and a .skilled anesthetizer en-
deavors to avoid its production, because it is dangerous. The
next stage is one of insensibility : the pupils are contracted,
but may react slightly to light; the conjunctival reflex is
gone ; the lids are closed; if the arm is lifted and allowed to
fall, it drops as a dead weight ; the skin is cool and moist,
and often wet with sweat; the respirations are easy and shal-

i
t

730 MODERN SURGERY.

low ; the pulse is slow ; and there is complete unconscious-
ness to pain. The loss of the conjunctival reflex is the usually
accepted sign that the patient is unconscious. In a young child
this reflex is soon exhausted by touching the eye, but the
sign is unreliable. If a baby is to be anesthetized, the admin-
istrator places his finger in the infant's hand. The child
grasps the finger, and relaxes its grasp when unconscious.
If anesthesia is deep, the contracted pupils will not react to
light ; if anesthesia is profound, the pupils dilate, but will not
react to light.

Always bear in mind that a dilated pupil reacting to light
and associated with preserved conjunctival reflex means that
anesthesia is not complete ; that a contracted pupil reacting
to light and without conjunctival reflex means moderate an-
esthesia ; that a contracted pupil not reacting to light and
without conjunctival reflex means deep anesthesia; that a
dilated pupil not reacting to light and associated ^ith lost
conjunctival reflex means dangerously profound anesthesia ;
that weak pulse and pallor may be due to nausea, but always
require instant attention ; that vomiting may be due to forcing
strong vapor upon the patient, but that it may also be due
to his partially emerging from a state of insensibility.

Watch the pulse carefully to see if it becomes very weak,
irregular, abnormally slow, or abnormally fast. Syncope
may be due to nausea, shock, hemorrhage, or the giving of
too much of the drug. Watch the respiration, and do not
forget that the chest-walls and belly may move when no air
is entering the lungs ; hence always listen to the breathing.
Obstruction of the air-passages may be due to some foreign
matter, as blood or vomit, lodging in the bronchial tubes,
windpipe, larynx, or pharynx ; to falling back of the tongue
(swallowing of the tongue) ; to closure of the epiglottis ; or
to the glottis being pushed against the pharyngeal wall by
bending the head forward. Some patients with occluded
nostrils may fail to get enough air because of closure of the
lips. A patient may appear to forget to breathe. Shock is
manifested by deadly pallor, weak and irregular pulse, slow
respiration, cold extremities, and a drenching sweat.

Treatment of Complications. — In rare cases edema of
the lungs occurs. This condition is treated by instant vene-
section, the inhalation of nitrite of amyl, and the administra-
tion of stimulants and nitroglycerin hypodermatically. Vofnit-
ing due to too much anesthetic is corrected by givmg a few
breaths of air ; vomiting due to incomplete anesthesia is
amended by giving more of the vapor. When the patient

ANESTHESIA AND ANESTHETICS. 73 1

vomits, hang the head over the ec^e of the bed, separate
the jaws with the gag, and wipe out the vomited matter,
mucus, and saliva. Shock is treated by diminishing the
amount of the anesthetic given, by the hypodermatic in-
jection of brandy, strychnin, or atropin (the last-named
drug is very useful when there is a profuse sweat), by sur-
rounding the patient with hot-water bottles, or by wrapping
him in hot blankets and lowering the head of the bed. A
tendency to syncope requires lowering of the head of the
bed, suspension of the anesthetic, and hypodermatic injection
of strychnin. In extreme syncope^ which is most apt to
occur from chloroform, do not wait for breathing to cease, but
suspend the anesthetic, open the mouth with the gag, catch
the tongue and make rhythmical traction while an assistant
is making slow artificial respiration, and lower the head of the
bed. If the patient does not at once improve, invert him com-
pletely, holding him by the legs and continuing artificial
respiration by compressing the sternum (Nelaton). By con-
tinuing artificial respiration the blood is urged on through
the heart Berkley Hill holds that in the failure which arises
soon after administration of chloroform is begun the trouble
is due to vasomotor paralysis with starvation of the nerve-
centers. In such a case he applies abdominal compression
and inverts the patient, making artificial respiration at the
same time. In the failure which occurs after considerable
chloroform has been taken there are paralytic distention of
the heart, fulness of the venous system, and loss of the com-
pensations for the hydrostatic effects of gravity. In such a
condition empty the distended heart of venous blood by
raising the patient into an erect position ; and after a mo-
ment place him recumbent and make artificial respiration.
Give hypodermatic injections of ether, brandy, strychnin, or
even of ammonia. Put mustard over the heart and spine.
Employ faradism to the phrenic nerve (one pole to the epi-
gastric region, the other to the right side of the root of the
neck). Let fresh air into the room, put hot-water bottles
around the legs, apply friction to the extremities, wrap the
patient in hot blankets, give an enema of brandy, and hold
ammonia or nitrite of amyl to the nose.

" Forgetting to breathe " is met by removing the inhaler
and waiting a moment ; a breath will usually be taken soon ;
but if it is not taken, open the mouth and pull forward the
tongue ; this causes a reflex inspiration. Obstruction to
breathing from bending forward of the head may be amended
by changing the position of the head or by pulling forward

732 MODERN SURGERY,

the tongue. Cyanosis^ if slight, is met by removing the in-
haler while the patient takes a breath or two of air ; but if
the condition grows worse, suspend the drug, dash cold water
in the face, force open the jaws, pull forward the tongue,
make artificial respiration until a breath is taken, and then give
oxygen for a time. If these means fail, stretch the sphincter
ani and bleed from the external jugular vein. If a breath is not
now taken, do tracheotomy. In respiratory or heart failure
forced artificial respiration by Fell's method is of great value.
In Feirs method a tracheal tube is inserted, and by means of
a foot-bellows air is forced into the lungs, after first passing
through a warming chamber. Wood says, instead of a tra-
cheal tube, we may use a face-mask and an intubation-tube.
" Swallowing the tongue " is corrected by pulling the tongue
forward. If it tends to recur, lay the head upon its side or
keep the tongue anchored with forceps. Closure of the
epiglottis is corrected by pulling the patient's head over
the edge of the table and pushing strongly back upon his
forehead. This maneuver lifts the hyoid bone, and with it
the epiglottis. The epiglottis can be lifted by passing a
spoon-handle or the index finger over the dorsum to the
base of the tongue and pressing forward. If, in obstruction
to respiration, the above means fail, make artificial respira-
tion at once ; if obstruction continues, perform tracheotomy.

After stopping the anesthetic in an ordinary case, have
the patient carefully watched until consciousness and intelli-
gence are entirely restored. The face is washed with cold
water and the patient is kept recumbent. If vomiting occurs,
his head is hung over the edge of the bed and the mouth is
subsequently wiped out. Inhalation of the vapor of vinegar
is of great service in post-anesthetic vomiting (Lewin, Macken-
rodt). Draughts of hot water may relieve vomiting by wash-
ing out the mucus from the stomach. Inhalation of oxygen
rapidly brings a patient out of the anesthetic state, and aids
in the arrest of vomiting. Do not permit a person to take
food for eight hours after the administration of an anes-
thetic.

Primary Anesthesia. — Instruct the patient to count out
aloud and hold one arm above his head. Give the ether
rapidly. In a short time he becomes mixed in his count
and his arm sways or drops to the side. There is now a period
of insensibility to pain lasting only about half a minute, and
during this period a minor operation can be performed. The
patient quickly reacts from primary anesthesia without vom-
iting (Packard).

ANESTHESIA ANJ) ANESTHETICS, 733

Bthyl bromid is sometimes used for short operations.
The unconsciousness is obtained in one-half minute and is
rapidly recovered from, and there is no after-sickness. The
unconscious lasts about three minutes. Three drachms are
given to a child, and six drachms to an adult. A towel is
put over the face, and the entire amount to be given is poured
on at once, and as soon as the patient is unconscious the
towel is taken away and no more of the drug is given
(Cumston). Cases have been reported in which sudden
death has followed the administration of this drug, and it
should not be given if there is disease of the heart, lungs, or
kidneys'

Schleich has recently introduced a new anesthetic
agent which he claims is safer than chloroform. This sur-
geon maintains that a material is safe as an anesthetic only
when almost all of the amount taken in at an inspiration
is expelled on expiration. The anesthetic is unsafe in
direct proportion to the amount absorbed; and the lower
the boiling-point of an anesthetic, the less is absorbed;
hence an anesthetic agent, to be safe, should have a low
boiling-point. Schleich makes three solutions. The first
contains (by volume) i^ oz. of chloroform, \ oz. of petro-
leum ether, and 6 oz. of sulphuric ether. The second con-
tains i^ oz. of chloroform, \ oz. of petroleum ether, and 5
oz. of sulphuric ether. The third contains i oz. of chloro-
form, \ oz. of petroleum ether, and 2\ oz. of sulphuric
ether. The anesthetic can be given in an Esmarch inhaler, an
Allis inhaler, or a towel. Meyer and Maduro have tried this
method. They consider these solutions safer than ether or
chloroform. The anesthetic state is quiet, reaction is rapid,
and vomiting occurs in but half the cases.

NitroU8-Oxid Gas may be used to obtain anesthesia
for brief operations. It is sometimes useful to anesthetize
with nitrous oxid and maintain the unconsciousness with
ether. In a more prolonged operation nitrous oxid can be
given mixed with oxygen. This gas is stored in steel
cylinders, in which it is liquified. The gas is passed into a
rubber bag, and is given to the patient by means of a tube
and a mouth-mask, a wedge being placed between the
patient's molar teeth, and the nostrils being closed by the
anesthetizer's fingers. The wedge must be held by a string
so that it cannot be swallowed. The patient becomes un-
conscious in about one minute, and we know the patient is
anesthetized by the stertor and cyanosis and the insensitive-

* See Cumston, in Boston Med. and Surg, Jour.^ Dec. 20, 1894.

734 MODERN SURGERY,

ness of the conjunctivae. Watch the pulse, and if it flags at
once suspend the administration.

I/Ocal Anesthesia. — ^Freezing' with Ice and Salt. —

Take one-quarter of a pound of ice, wrap it in a towel, and
break it into fine bits ; add one-eighth of a pound of salt ;
then place the mixture in a gauze bag and lay it upon the
part. The surface becomes pallid and numb, and in about
fifteen minutes is decidedly analgesic. A spray of rhigolcne
freezes in about ten seconds. It is highly inflammable.
Chlorid of ethyl comes in glass tubes. Remove the cap
from the tip of the tube and hold the bulb in the palm : the
warmth of the hand causes the fluid to spray out. Hold the
tube some little distance from the part and let the fine spray
strike the surface. The skin blanches and whitens, and is
ready for the operation in about thirty seconds. Ether-spray
anesthesia was suggested by Benjamin Ward Richardson.

Cocain Hydrochlorate. — Always bear in mind that cocain
is sometimes a decidedly dangerous agent. There are on rec-
ord fourteen deaths from cocain (Reclus). Never use over
two-thirds of a grain upon a mucous surface, and never in-
ject hypodermatically more than one-third of a grain. The
urethra is a particularly dangerous region, and so is the
face. Mild cases of cocain-poisoning are characterized by
great tremor, restlessness, pallor, dry mouth, talkativeness,
and weak pulse. In severe cases there is syncope or de-
lirium. Death may arise from paralysis or from fixation
of the respiratory muscles (Mosso). Cases with a tendency
to respiratory failure require the hypodermatic injection
of str}xhnin. In cases with tetanic rigidity of muscles
give enemata of chloral, hypodermatic injections of nitro-
glycerin, or inhalations of the nitrite of amyl. In cases
marked by delirium, if the circulation is good, give chloral
or hyoscin. In any case give stimulants, employ a catheter,
and favor diuresis. Cocain-poisoning is always followed by
a wakeful night. Cocain should not be used if the kidneys
are inefficient. In using cocain tr>' to prevent poisoning.
Have the patient recumbent. One minute before giving the
cocain administer one drop of a i per cent, alcoholic solu-
tion of trinitrin, repeating the dose once or twice during the
operation. In operation on a finger, after making the part
anemic tie a tube around the root of the digit before inject-
ing cocain, and after the operation gradually loosen the tube.
A hot solution of cocain is more efficient than a cold solu-
tion (T. Costa) ; hence hot solutions can be used in much
less strength and are safer. Merck prepares a safer agent

ANESTHESIA AND ANESTHETICS, 735

than the hydrochlorate, and that is, the phenate of cocain.
This is a honey-like material, soluble in alcohol. It is used
locally in from 5 to 10 per cent, solutions. It takes longer
to act than does the hydrochlorate, and it coagulates the
tissue-albumin, and thus absorption is lessened. It causes
anemia and anesthesia, and retards germ-growth (Kyle).
GliJck and Bartholow some time ago advised a mixture com-
posed of cocain hydrochlorate and carbolic acid.

Eucain hydrodhlorate is far safer than cocain, and in
most cases is to be preferred to it. It is used in the strength
of from 2 to 5 per cent. It can be boiled without destroying
its properties, and hence can be readily rendered sterile. Un-
fortunately, it occasionally happens that the injection of eucain
causes sloughing, especially at the extremities, in fatty tissue,
in tendon-sheaths, and in bursae.

Infiltration-anestheBia was devised by Schleich of Leipsic,
who was dissatisfied with cocain, because it is not safe and
sometimes fails to produce satisfactory anesthesia owing to
want of thorough diffusion. He found that salt solution
(A P^'* cent), if. injected into uninflamed parts, produced
anesthesia. To obtain this anesthesia the part must be dis-
tended by wide infiltration. If minute quantities of cocain,
morphin, and carbolic acid are added to the solution, the
anesthesia becomes more thorough and more prolonged,
and can be obtained even in inflamed areas.

Schleich uses three solutions :

No. I, a strong solution, which is used in inflamed areas :
cocain hydrochlorate, 0.20 gm.; morphin hydrochlorate,
0.025 gm. ; sodium chlorid, 0.20 gm. ; distilled water, 100
gm. ; phenol (5 per cent), 2 drops.

No. 2, a medium solution, which is employed in most
cases: cocain hydrochlorate, o.io gm. ; morphin hydro-
chlorate, 0.025 gm. ; sodium chlorid, 0.20 gm. ; distilled
water, 100 gm. ; phenol (5 per cent), 2 drops.

No. 3 is used for extensive operations : cocain hydro-
chlorate, O.oi gm. ; morphin hydrochlorate, 0.005 g"^- J so-
dium chlorid, 0.20 gm. ; distilled water, lOO gm. ; phenol (5
per cent.), 2 drops.

The injections are begun in the skin, not under it (Fig.
253), and are made one after another until the area to be
operated upon is surrounded above, below, and on all sides
with Schleich's solution. This infiltration can be made pain-
lessly by touching with pure carbolic acid the point where
the needle is to be inserted, or by freezing this area with ethyl
chlorid. When deeper tissues are reached they are infiltrated

736 MODERN SURGERY.

before incising them. If a nerve comes in sight, touch it with
a drop of pure carbolic acid (Lund). Schleich's fluid is more
efficient when cold.' Van Hook says that the anesthesia ob-
tained by this method is due to artificial ischemia, pressure

upon the tissues, the direct action of the drugs, and the low-
ered temperature.* The method is very efficient and can be
used for operations of considerable magnitude.

XXX. BURNS AND SCALDS.

Bums and scalds are injuries due to the action of caloric.
Scalds are due to heated fluids or vapors. There is no true
pathological difference between burns and scalds. Dupuy-
tren classifies burns into six degrees, as follows: (i) charac-
terized by erythema ; (2) characterized by dermatitis with the
formation of vesicles ; (3) characterized by partial destruction
of the skin, which structure is not, however, entirely burnt
through ; (4) characterized by destruction of the skin to the
subcutaneous tissue; (5) characterized by destruction of all
superficial structures and of part of the muscular layer ;
(6) characterized by " carbonization " of the whole thickness
of the muscles.

The symptoniB are local and constitutional. Local symp-
toms are pain and inflammation, which vary in nature, in
intensity, or in degree according to the extent of tissue-
damage. Constitutional symptoms are shock, followed by a
severe reactionary fever, with a strong tendency to conges-
tion of internal parts. The constitutional symptoms which
follow a severe burn are due in part to the absorption of
toxic materials from the seat of injury, these materials hav-

BUIiNS AND SCALDS. 737

ing been formed by the action of heat on the body-cells and
fluids. Sepsis is not infrequent. The stages are often desig-
nated as prostration^ reaction, and suppuration. Death may
be due to shock, to sepsis, to exhaustion, to congestion of
the brain, lungs, or kidneys, or to Curling^s ulcer of the
duodenum.

Treatment. — ^The local treatment of slight bums (as sun-
burn) is to moisten the parts frequently with a saturated solu-
tion of bicarbonate of sodium, a solution of citrate of lime,
or a I : 8 solution of phenol sodique. In bums of moderate
degree a mixture of zinc ointment with iodoform, though
not antiseptic, is a comfortable dressing. The author has
been using normal salt solution for a number of years, and
likes it very much. Some surgeons use a saturated solution
of picric acid. Carron oil consists of equal parts of linseed
oil and lime-water. It allays the pain of a bum, but it is a
filthy preparation, and its use is followed by much pus-for-
mation. Cosmolin gives comfort as a dressing, but should
not be used on the face, lest it cause pigmentation. The elder
Gross used lead paint. A solution of nitrate of potassium
allays the pain. In a severe bum cut away the clothing,
avoid exposure to cold, wash the part with a solution of
peroxid of hydrogen and then with a warm solution of
boric acid, open the vesicles with an aseptic needle, dust
with iodoform, and dress with aseptic cotton, or else dress
with lint soaked in salt solution. Aseptic dressing of a burn
is often painful, and may demand the use of an anesthetic.
Change the dressings no oftener than is required, and at
each change wash the burn with peroxid of hydrogen and
boric acid, take away sloughs, and reapply iodoform and
cotton or salt solution. Where extensive destruction of
tissue has taken place use splints and extension to limit con-
tractures, and skin-graft as soon as possible. If granulation
is slow, stimulate with copper-sulphate or mild silver-nitrate
solutions. Exuberant granulations require buming down.
Flabby granulations require pressure. If healing is slow, or
if the bum is extensive, skin graft. When an extremity has
been carbonized amputation must be performed. In constitu-
tional treatmenthnng about reaction ; combat pain with opium ;
and keep the bowels and kidneys active. If suppuration
occurs, give tonics, stimulants, and concentrated foods.
Complications are treated according to general rules.

Scalds of the glottis are due to the inhalation of steam
or of ignited gas. A child may scald the glottis by trying
to drink from the spout of a kettle (Moullin). The symp-
47

738 MODERN SURGERY,

toms are pain, dysphagia, and dyspnea. Edema of the
glottis comes on quickly. The treatment is tracheotomy or
intubation of the larynx in severe cases ; in mild cases, scari-
fication of the larynx.

Effects of Cold. — Local Effects, — Cold produces numb-
ness, pricking, a feeling of weight, redness of the surface
followed by stiffness, local insensibility, and mottling or pal-
lor. Sudden intense cold causes the formation of blebs, the
coagulation of blood in the superficial veins, and violent
pain in the limb. Cold locally produces frost-bite (page 1 2%\
The constitutional effects of cold are at first stimulating, then
depressing, and are exhibited by uneasiness, pain, and an
intense drowsiness which, if yielded to, is the road to death
by way of internal congestion. Death from prolonged cold
resembles in appearance death from apoplexy. Death from
sudden and overwhelming cold is caused by anemia of the
brain from weak circulation and capillary embolism. To
bring a partly-frozen person into a warm room may cause
death by embolism.

Treataient. — Frost-bite is treated as outlined on page 1 28.
When a person is nearly frozen to death place him in a cool
room, but under no circumstance in a cold bath, make arti-
ficial respiration, rub him down with flannel soaked in alcohol
or in whiskey, and follow this by rubbing with dry hands.
After a time wrap the patient in warm blankets and give an
enema of brandy. Mustard plasters are to be applied over
the heart and spine. As soon as swallowing is possible
brandy is administered by the mouth. As the condition
improves gradually raise the temperature of the room and
give liot drinks.

Chilblain, or pernio, is the secondary effect of cold. It
usually appears as a local congestion upon the toes, the
fingers, or the nose, and it is apt now and then to inflame
and ulcerate. A chilblain is apt to become congested by
approaching a fire or by taking exercise, and when con-
gested it itches, tingles, and stings. Frequent attacks of
congestion produce crops of vesicles ; these vesicles rupture
and expose an ulcer, which in rare instances sloughs.

Treatment. — Prevent congestion of the legs and feet if
chilblain affects the toes. Order large shoes and woollen
stockings and forbid tight garters. The patient with pernio
must take regular outdoor exercise and must not loiter
around a hot fire. Every morning and evening he should
take a general cold sponge-bath, following by rubbing with
alcohol and frictions with a coarse towel, and he should

DISEASES OF THE SKIN AND NAILS. 739

sleep with warm stockings on or with his feet upon a hot-
water bag. When a chilblain is only a congested spot it
should be washed tu'ice a day in cold salt water, rubbed dry
with flannel, and subjected to applications of tincture of
iodin and soap liniment (i : 2), tincture of cantharides and
soap liniment (i :6), or equal parts of turpentine and olive
oil (W. H. A. Jacobson). Jacobson says itching is relieved
by painting belladonna liniment upon the part and allowing
it to dry. If vesicles form, paint with contractile collodion ;
if ulcers form, dress antiseptically. If ulcers are sluggish,
use equal parts of resin cerate and spirits of turpentine. A
good antiseptic and protective is the following : oxid of
zinc, gr. vj ; chlorid of zinc, gr. xx ; gelatin, Jij ; distilled
water, 3j.

XXXI. DISEASES OF THE SKIN AND NAILS.

Dermatitis venenata results from irritants and from
garments containing arsenic, but is generally due to rhus-
poisoning. Rhus-poisoning arises from the poison-oak, the
poison-ash, the poison-ivy, and other species of sumach.
Actual touching of the plants is not always necessary.

The symptoms are burning and itching, redness and
edema of the face and hands. A vesicular eruption begins
between the fingers, and the eruption and the inflammation
spread widely over the body. There may be some slight
fever.

The treatment, when a moderate area is involved, com-
prises the application of cloths wet with black wash or lead-
water and laudanum. If an extensive area is involved, apply
grindelia robusta (siv to Oj of water) or moisten the surface
frequently with sweet spirits of niter. For the face use
borated-talc powder. Oxid-of-zinc ointment containing 10
gr. of carbolic acid to 5j gives great relief A I : 8 solu-
tion of phenol sodigue allays pain and itching.

Furuncle, or boil, is an acute and circumscribed inflam-
mation of the deep layer of the true skin and the subcuta-
neous cellular tissue following on bacterial infection of a
hair-follicle or a sebaceous gland. A boil is caused by in-
fection of a hair-follicle, through a slight wound (by scratch-
ing, shaving, etc.), with the staphylococcus pyogenes aureus.
Boils are very common during Bright's disease, diabetes,
gout, tuberculosis, and disorders of menstruation and diges-
tion ; and crops of boils are apt to appear during convales-
cence from typhoid fever. Boils are commonest in the spring.

740 MODERN SURGERY,

and sometimes an epidemic of furunculosis appears in a hos-
pital, a jail, or an asylum.

The symptoms of a boil are as follows : a red elevation
appears, which stings and itches ; this elevation enlarges and
becomes dusky in color ; a pustule forms, that ruptures and
gives out a very little discharge which forms a crust In-
flammatory infiltration of adjacent connective tissue advances
rapidly, and the boil in about three days consists of a large,
red, tender, and painful base capped by a pustule and some
crusted discharge. In rare instances, at this stage, absorp-
tion occurs, but in most cases the swelling increases, the
discoloration becomes dusky, the skin becomes edematous,
the pain becomes fierce and pulsatile, and the center of
the boil becomes raised. About the seventh day rupture
occurs, pus runs out, and a " core " of necrosed tissue is
found in the center of a ragged opening. This core con-
sists of the sebaceous gland and hair-follicle, which have
undergone coagulation-necrosis (Warren). In a day or two
more the core will be discharged, and healing by granulation
will occur. A blind boil lasts only three or four days and
has no core. The constitution often shows reaction during
the progress of a boil. Boils may be either single or mul-
tiple. The development of one boil after another, or the
formation of several boils at once, is known as "furunculosis."
Boils are commonest upon the neck and the back.

The treatment consists of crucial incision, removal of
necrotic tissue, irrigation with peroxid of hydrogen and cor-
rosive sublimate, and antiseptic dressing.

Aleppo boils (endemic boils of the tropics) are papules
appearing upon the exposed parts of the body. These
papules, which ulcerate and do not cicatrize for at least a
year, are due to a pathogenic bacterium and leave ineradi-
cable scars.

Carbuncle (benign anthrax) is a circumscribed infectious
inflammation of the deeper layer of the true skin and of the
subcutaneous tissue, with fibrinous exudation in which
multiple foci of necrosis arise and the tissue adjacent to
each necrotic plug becomes gangrenous. The infection
takes place through a hair-follicle. It is really a boil with
extensive infiltration of adjacent tissues. A boil may become
a carbuncle, and pus from a carbuncle inoculated into a
healthy person may cause either a boil or a carbuncle.
The causative organism seems to be the staphylococcus
pyogenes aureus. The local symptoms in the start resem-
ble those of a boil, but the constitution sympathizes from

DISEASES OF THE SKIN AND NAILS. 74 1

the beginning (a chill and a septic fever) and the pain is
agonizing. The inflammatory area enlarges enormously, is
boggy to the touch, is dusky in color, is edematous, and the
skin is not freely movable over the deeper parts. In a few
days many pustules appear, each pustule marking the site
of a focus of necrosis. Large vesicles filled with bloody
serum very frequently occur. In some cases, about the
tenth day, the pustules rupture, the necrotic plugs are dis-
charged, and the case slowly progresses toward cure ; but
in many cases the carbuncle spreads at the periphery while
pustules are rupturing near the center of inflammation, and
pus forms in the deeper tissues, reaching the surface through
many small openings, each of which is partly blocked by a
plug of dead tissue. A carbuncle in this stage resembles a
honeycomb, discharges bloody pus, and large masses of
skin and subcutaneous tissue are destroyed. The entire
carbuncular mass may become gangrenous, and a sudden
and almost complete cessation of pain points to this compli-
cation. An ordinary carbuncle remains acute for about
three weeks, but healing requires a month more. The
most dangerous situations in which to have a carbuncle are
the face and neck (tends to produce septic phlebitis, septic
clots in the cerebral sinuses, or infective emboli). The most
usual positions for carbuncle are the neck, the back, and the
buttocks. The diagnosis of carbuncle is made by noting
the multiple foci of necrosis and the profound constitu-
tional involvement.

Treatment. — Give ether, make free crucial incisions, re-
move dead and necrosing tissue with the scissors and
forceps, curet pockets, stop hemorrhage by pressure and
hot water, cauterize with pure carbolic acid, dust with iodo-
form, pack with iodoform gauze, and dress with hot antiseptic
fomentations. Cover the gauze with a piece of some im-
permeable material and lay a hot-water bag upon the dress-
ing. Every day, or several times a day, remove the dressings,
wash with peroxid of hydrogen, irrigate with corrosive-sub-
hmate solution, dust with iodoform, and reapply the iodoform
gauze and antiseptic fomentation. Keep up this treatment
until sloughs are separated, and then dress with dry anti-
septic gauze. In some carbuncles it is wise to extirpate
the entire mass. Secure sleep by morphin, give quinin, milk-
punch, and nourishing diet, and attend to the bowels and
kidneys.

ClavuSi or Com. — A com is a tender, painful, and cir-
cumscribed thickening of the epidermis, and is commonest

742 MODERN SURGERY,

over one of the joints of the toes. Hard corns are situated
on exposed parts of the digits ; soft corns appear between
the digits, where the parts are kept constantly moist Corns
are caused by pressure.

Treatment. — By wearing well-fitting boots corns upon the
toes will usuallydisappear. Soak the feet often in water con-
taining bicarbonate of sodium, dry them, and apply a circular
corn-plaster to the com to take off the pressure of the boot
Another method is to touch the com with iodin every night
and pare away the hard tissue every morning. An old and
valuable plan is to paint the com every night with a mixture
composed of salicylic acid, 3iss ; extract of cannabis indica,
gr. X ; and collodion, |j, and to scrape this mixture away
every morning. Soft corns are treated by washing the feet
often with ethereal soap, drying, gently removing the sodden
epithelium, dusting with borated talc, and placing absorbent
cotton between the toes. Incurable soft corns require the
freshening of the adjacent sides of the two toes and suturing
them together (thus converting two toes into one). In
inflamed corns employ rest and lead-water and laudanum,
and let out pus when it forms. Remember that in old per-
sons the cutting of a com may cause senile gangrene. In
the inflamed and painful feet of a person who has corns
nothing gives so much relief as washing the feet with
ethereal soap, soaking in hot water, and wrapping the feet
for half an hour in cloths wet with a mixture composed
of linseed oil and lime-water, each, ^ij, and spirits of cam-
phor, 5j.

Warts. — (See page 231.)

Onychia is inflammation of the matrix of the nail. A
" run-around " is suppuration of the matrix and the root of
the nail, of traumatic origin. It requires incision, trimming
away of the buried edge of the nail, and packing with iodo-
form gauze. Malignant onychia, which is inflammation and
ulceration of the entire matrix, occurs only in a person of
dilapidated constitution. This condition requires removal of
the entire nail, cauterization of the matrix, dressing with
iodoform gauze, and the internal use of stimulants, tonics,
and nourishing diet. Ingrown toe-nail is due either to
lateral hypertrophy of the edge of the nail or to the forcing
of the soft tissues over the margin of the nail. The con-
dition is treated by splitting the nail, removing the piece of
nail, the soft tissue, and the adjacent matrix, and dressing
antiseptically.

DISEASES AND INJURIES OF THE THYROID GLAND. 743

XXXII. DISBASES AND INJURIES OP THB THYROID

QLAND.

Wotinds cause violent hemorrhage which is difficult to
arrest Ligatures cut out and forceps will not hold. The
hemorrhage is arrested by suture-ligatures, purse-string su-
tures, the actual cautery, or removal of the bulk of the gland.

The thyroid gland may be absent at birth. Cong^tal
atrophy or congenital hypertrophy may exist

Acqtdred atrophy leads to myxedema, a condition char-
acterized by the presence of a firm subcutaneous swelling in
the face, neck, and limbs ; slow speech ; mental dulness ; and
subnormal temperature. The condition is identical with that
produced by removal of the entire gland (cachexia struma-
priva).

Cretinism is a form of idiocy due to atrophy of glandu-
lar elements in the thyroid, although the size of the gland is
often increased. The body is dwarfed ; the face, neck, and
extremities resemble those parts in myxedema, and a low
grade of idiocy exists. Myxedema and cretinism are treated
by the internal administration of thyroid extract

Congestion of the thyroid may be caused by violent
exertion, prolonged effort, febrile maladies and venous ob-
struction. It is treated by removing the cause and applying
heat locally. Tracheotomy may be required.

Inflammation of the thyroid (acute or inflammatory
goiter) may be caused by a septic or febrile malady, rheu-
matism, muscular strain causing vascular rupture, a wound
or contusion of the thyroid. But one lobe is affected. The
ordinary symptoms of inflammation are present In addition
there are dysphagia, dyspnea, venous congestion of the face,
epistaxis, nausea and vomiting, and possibly delirium. It
may terminate in resolution, suppuration, or fibrous indura-
tion.

Goiter. — A goiter is an enlargement of the thyroid gland
not due to malignant tumor or to inflammation. Goiter may
affect a portion of one lobe, both lobes, or both lobes and the
isthmus, and it may occur sporadically or endemically. In
Switzerland it is very common. Among the alleged causes are
the playing of wind-instruments, the drinking of snow-water,
and the use of water impregnated with the salts of lime. He-
reditary influence is frequently noted. The forms of goiter
are as follows : simple hypertrophy, a hypertrophy of the
gland-tissue, usually symmetrical, in reality an adenoma;
cystic goiter or bronckocele, in which cysts form in hypertro-

^44 MODERN SURGERY,

phied glands, or rarely in non-hypertrophied thyroids, the
cysts being either single or multiple, being due to mucoid or
colloid degeneration, and containing a fluid sometimes clear
and thin, sometimes viscid, and often coffee-ground in char-
acter ; and fibrous goiter, a fibrous induration which is apt to
arise in old bronchoceles, and which may pass into a calca-
reous condition. Parenchymatous goiter is enlargement of
the whole gland. By the term malignant goiter we mean
malignant disease of the thyroid gland, either sarcoma or
carcinoma.

The Bymptoms are^-congestion of the head and neck from
enlargement of veins ; occasionally cerebral symptoms (ane-
mia, syncope, even convulsions) from pressure on carotids ;
irritation of recurrent laryngeal nerve (causing spasm of the
glottis or laryngeal paralysis) ; compression of the trachea
(dyspnea). Rapidly-growing goiters are often fatal; slow-
growing goiters are rarely fatal. A goiter moves up and
down as the patient swallows. A malignant goiter grows
rapidly, becomes adherent, infiltrates, and quickly produces
metastasis. Both sarcoma and carcinoma produce metastasis
by way of the venous system.

Treatment. — lodid of potassium and arsenic internally
have been advised ; ointment of red oxid of mercury locally
is advocated by some writers. The local use of iodin benefits
many cases. The administration of thyroid extract may do
much good. Cystic goiters may be aspirated and injected
with a solution of iodin. Electrolysis may benefit a soft
goiter, the negative pole being pushed into the growth, the
positive pole being applied to its surface. In considering
the propriety of operation remember that a goiter which
begins at puberty may pass away. We should operate on
every non-malignant goiter which is increasing rapidly in size,
and on every' goiter which causes much respirator)' trouble,
but should not operate simply for deformity (Bergeat). If
enucleation or extirpation is performed, do not give ether or
chloroform. These agents greatly increase bleeding, and are
dangerous. Do the operation without any anesthetic or with
the aid of local anesthesia (cocain, eucain, or Schleich's fluid).
It is a great advantage to have the patient conscious, because
by asking him to speak during the operation the surgeon
can tell if the recurrent laryngeal nerve is being touched.
In most cases intraglandular enucleation is performed, in
some cases extraglandular enucleation, in other cases these
two methods are combined (Bergeat). Ligation of the
thyroid arteries has been recommended. Enucleation, if pos-

DISEASES AND INJURIES OF THE THYROID GLAND, 745

sible, is the desirable operation. It may easily be employed
for the removal of a single colloidal or cystic area (Socin).
Thyroidectomy or extirpation is employed when enuclea-
tion is impossible. The entire thyroid is not removed; a
portion of the gland is left behind, otherwise myxedema will
arise (Kbcher). Unilateral extirpation is the usual method.
In sarcoma or cancer of the thyroid extirpation may be
attempted. The operation will occasionally prolong life,
but it will rarely effect a cure.

Exophthalmic Goiter (Graves's Disease; Basedow's
Disease; Pulsating Goiter). — In atypical case there are rapid
pulse, protrusion of the eyeballs, and enlargement of the thy-
roid gland ; but any one of these conditions may be absent.
The enlargement may be unilateral, but is usually bilateral.
A systolic bruit is usually audible over the thyroid region.
Von Graefe's sign may be present ; this consists of retraction
of the eyelids, and inability of the lids to follow the eyes in
looking down. The lids in some cases cannot be completely
closed, and when the eyeball is suddenly turned up the lid
and brow may fail to act together. In some cases the lids
pulsate, in some ocular palsies exist, in others photophobia or
nystagmus. Patients may suffer from neuralgia, colic, choreic
movements, tremor, flushes of heat, and gastric crises. Dysp-
nea often exists, and albuminuria and polyuria are not un-
common. Hemoptysis, hematemesis, or mental disturbance
is sometimes noted.

Exophthalmic goiter may arise after emotional excitement
or depression, during pregnancy, or during the existence of
locomotor ataxia, paresis, epilepsy, neurasthenia, hysteria,
and other nervous troubles. Cohen considers it to be a vaso-
motor ataxia. Its real cause is uncertain ; but is probably
the action upon the sympathetic system of some poisonous
product of thyroid action.

Treatment. — Thyroid extract more often does harm than
good. Electricity is said to be of benefit. Most cases are
treated by improving the general health, and employing digi-
talis. Thymus extract has been used by some. Extirpation
of the cervical ganglion of the sympathetic, and division
of the nerve below the ganglion, have been employed with
benefit (Jaboulay). Ligation of the thyroid arteries may do
good. Incomplete removal is the operation commonly em-
ployed in severe cases ; it has cured eighty per cent, of the
cases operated upon. In some cases thyroid intoxication
follows operation. In other cases very rapid growth follows
incomplete removal, and the operation seems actually to have

746 MODERN SURGERY,

done harm. Sudden death occasionally follows the opera-
tion of thyroidectomy. The removal of an exophthalmic
goiter is difficult; the capsule and blood-vessels rupture from
slight force, and the use of ether and chloroform is very
dangerous. All cases should not be operated upon ; in fact^
only those cases should be operated upon in which medical
treatment has proved futile, or in which there is profound
toxemia or excessive dyspnea. If the operation is performed^
neither ether nor chloroform should be given, as either of
these agents will greatly increase bleeding and prove dan-
gerous. Operation is to be done under local anesthesia
(eucain, cocain, or Schleich's fluid).

XXXIll. DISEASES AND INJURIES OP THE

LYMPHATICS.

I/ymphangitis is inflammation of lymphatic vessels. Re^
Hcular lymphangitis, which is inflammation of lymphatic
radicals, is seen in some circumscribed inflammations of the
skin. It is apt to attack the hands, causing redness and
swelling, fading at the point of initial trouble while it spreads
at the periphery ; it is caused by micro-organisms derived
from decomposing animal matter (Rosenbach). Erysipelas
also causes it (see Erysipelas). Tubular lymphangitis, which
is due to the entry into the lymphatic ducts of virulent micro-
organisms or toxic materials, is seen in dissecting-wounds,
septic wounds, snake-bites, etc. It is announced by edema
and by minute, hard, red streaks running from the wound up
the extremity. Suppuration may occur.

Infective lymphadenitis, or inflammation of the glands,
may follow lymphangitis or may be due to the deposition of
infective material, the lymph-vessels not being inflamed. In
septic lymphadenitis there are pain, tenderness, and swelling ;
in severe cases there are chill and septic fever. Suppuration
may arise. The treatment is to drain and asepticize the
wound, to apply iodin, blue ointment, or ichthyol over the
glands and vessels, and to employ rest and compression.
Internally, milk punch, quinin, and nourishing diet are re-
quired. If the glands do not rapidly diminish in size after
disinfection of a wound, and if they are in an accessible
region, extirpate them. If suppuration of the glands occurs,
incise and drain.

Acute lymphadenitis, or acute inflammation of the lym-
phatic glands, may be due to tubercle, syphilis, glanders, cold,
or traumatism. Suppuration may or may not occur. In in-

DISEASES AND INJURIES OF THE LYMPHATICS. 74,7

flammatory lymphadenitis there are pain, heat, and nodular
swelling. In severe cases there is fever. The treatment is
to asepticize any area of infection, place the glands at rest,
apply cold and lead-water and laudanum, or inject into the
gland every day 5 minims of a 3 per cent, solution of carbolic
acid to prevent suppuration. If the glands do not rapidly
shrink, extirpate them. If pus forms, evacuate, drain, and
asepticize.

Chronio lyxnphadenitiB is almost invariably syphilitic or
tubercular. It requires constitutional treatment and the local
use of ichthyol, iodin, or blue ointment. If these remedies
are not rapidly successful, tubercular glands should be re-
moved, but syphilitic glands will rarely require such radical
treatment.

I/jnnpliailgiectasis (varicose lymphatics), or dilatation
of the lymphatic vessels, is due to obstruction. It results,
as a rule, from chronic lymphangitis or the pressure of a
tumor, and is most usually situated in the pubic, the inguinal,
or the scrotal regions, or on the inner side of the thigh.
There are two forms : the varicose, in which the vessels have
a tortuous outline, like varicose veins, but are covered only
by surface-epithelium ; and lymphatic warts (lymphangioma
circumscriptum), in which wart-like masses spring up, these
masses being covered with epithelium and filled with lymph.
In most cases of lymphangiectasis there is considerable hard
edema. Rupture of the dilated vessel causes a flow of lymph
{lympharrhed),

I/jrmphaiiS^Oliia is an advanced stage of lymphangi-
ectasis (page 226). The treatment in mild cases is to
pierce each vesicle with the negative pole of a galvanic
battery and pass a current. In severe cases destroy the
mass with the Paquelin cautery or excise it with a knife or
with scissors.

Klephantiasis. — True elephantiasis (elephantiasis Ara-
bum) is chronic hypertrophy of the skin and subcutaneous
tissues following upon a lymphangiectasis produced by a
nematode worm (the filaria sanguinis hominis). Spurious
elephantiasis is hypertrophy of the skin and subcutaneous
tissue due to chronic inflammation (in a leg which pos-
sesses an ancient ulcer, or in the scrotum of a man with
urinary fistula). The treatment is massage and bandaging,
sometimes ligation of the artery of supply, extirpation, or
amputation.

Malignant I/ymphoma, or Hodgkln's Disease. —
(See page 221.)

748 MODERN SURGERY.

XXXIV. BANDAGES.

A bandage is a fibrous material which is rolled up and is
then employed to retain dressings, applications, or appliances
to a part, to make pressure, or to correct deformity. It may
be composed of plain gauze, of gauze infiltrated with plaster-
of-Paris or soaked in silicate of sodium, of gauze wet with
corrosive-sublimate solution, of flannel, of calico, or of un-
bleached muslin. Unbleached muslin, which is the best
material for general use, is washed to remove the sizing,
is torn into strips, and the edges are stripped of selvage.
One end is folded to the extent of six inches, this is folded
upon itself again and again until a firm center is formed,
and over this center the bandage is rolled. In a well-rolled
bandage the center cannot be pushed out of the rolL A
roller bandage is divided into the initial end, which is within
the roll, the body or rolled part, and the terminal end, which
is free. In applying a bandage the outer surface of the
terminal end is first laid upon the part.

A cylindrical part of the body may be covered by a cir-
cular bandage, each turn exactly covering the previous turns.
A conical part may be covered by a spiral bandage, each turn
ascending a little higher than the previous turn. As each turn
of a spiral bandage is tight at its upper and loose at its lower
edge, the reverse was devised to correct this inequality;
hence a conical part should be covered by a spiral reversed
bandage. To make a reverse hold the roller in the nght
hand, start the bandage obliquely upward (do not have
more than six inches of slack), place the thumb across
the fresh turn, fold the bandage down without traction,
and do not make traction until the turn has been carried
well around the limb. A projecting point is covered with
figure-of-8 turns. The groin, shoulder, breast, or axilla can
be covered by figure-of-8 turns, each succeeding turn ascend-
ing and covering two-thirds of the previous turn and form-
ing a figure like " the leaves on an ear of corn." Such a
figure is called a " spica." In bandaging an extremity the
peripheral turns should be tighter than the turns nearer the
body. Never apply a tight bandage to the leg or the arm
without including the foot or the hand. In firm dressings
leave the ends of the fingers exposed, and use them as an
index of the condition of the circulation in the part.

Spiral Reversed Bandage of the "Upper Extremity.

— To apply this form of bandage use a roller two and a half
inches wide and eight yards long. Take a circular turn

BANDAGES.

749

about the wrist, and a second turn to hold the first ; pass
obliquely across, the back of the hand to the extremities of
the fingers; ascend the hand to the root of the thumb by
several spiral turns ; cover the wrist by ascending figure-of-8
turns ; ascend the forearm by spiral reversed turns ; cover
the elbow by a figure-of-8, and the arm by spiral reversed
turns ; end the bandage by two circular turns, and pin them
together (Fig. 254).

Spiral Bauda«:e of All the Pingen (Gauntlet).— The
gauntlet bandage requires a roller one inch wide and one
and a half yards long. Take two circular turns around the
wrist, pass obliquely across the wrist to the root of the thumb,
and descend to its tip by spiral turns ; cover in the thumb
by ascending spiral reverses, and return to the wrist Cover
in each successive finger in the same manner, and terminate
by two circular turns around the wrist (Fig. 255).

Flc. ij6.— Dcml.tiunilet bindags.

Spiral Bandage of the Palm or DorBum of the
Hand (Demi-gauntlet). — The demi-gauntlet requires a roller
one inch wide and four yards long. This bandage has only
a limited value ; it must not be applied tightly, as it makes
much pressure at the finger-roots, but leaves the fingers free.
If it is desired to cover the palm, supinate the hand : if to
cover the dorsum, pronate the hand. Take two circular turns

750

MODERN SURGERY.

around the wrist, sweep around the root of the thumb, and
return to the point of origin. Treat each finger in the same
way. End by circular turns around the wrist (Fig. 256).

Spica of the Thumb. — For this bandage use a roller
one inch wide and three yards long. Start at the wrist, and
reach the tip of the thumb as in applying a spiral bandage
of a finger. Make a series of ascending figure-of-8 turns
between thumb and wrist, each ascending turn overlying
two-thirds of the previous turn ; terminate with a circular of
the wrist (Fig. 257).

Fig. 957.— spica of the thumb.

Selva'8 Thumb Bandage (Fig. 258).— Lay the terminal
end of the bandage on the outer side of the second phalanx
of the thumb, near the base of the phalanx. Carry it over

Fig. 358. — Selva's thumb-bandage applied.

the palmar side of the pulp of the last phalanx to the inner
side of the second phalanx. The surgeon holds this turn in
place with his left thumb and index finger. The roller is
returned in a recurrent manner to its place of origin, over-
laps the preceding turn, and is placed as much as possible
on the dorsum. The roller is carried over the dorsum of
the terminal phalanx and is turned around the tip, the loop
crossing over the center of the nail. Figure-of-8 turns are
now made over the dorsum of the hand, over the palm, and
returning to the terminal phalanx, and an ascending spica
is made.'

Spiral Reversed Bandage of the I/Ower Extremity.

— Take a roller two and a half inches wide and seven yards
long, and make two circular turns just above the malleoli,
and an oblique turn across the dorsum of the foot to the

^ Medical JVrws, Sept. 28, 1 895.

BANDAGES.

751

metatarsophalangeal articulation ; make a circular turn, and
cover the foot with ascending spiral reversed turns ; return to
the ankle by a figure-of-8 ; ascend the leg by spiral reverses ;
cover the knee by a figure-of-8, and the thigh by spiral re-
verses ; terminate by two circular turns TFig. 259).

Bandage of the Foot covering tne Heel (American

Bandage of the Foot). — Take a roller two and a half inches

wide and seven yards long. The
bandage is begun as is a spiral
reversed bandage of the lower
extremity. After the foot is well
covered by ascending spiral re-
versed turns carry the bandage
directly around the point of the

Fig. 359.~Spiral reversed bandage
of the lower extremity.

Fig. 360. — Method of covering the heel.

heel and return to the instep; from this point carry it
around the back of the ankle, down the side of the heel,
under the heel, up to the instep, around the ankle in the
opposite direction, down the opposite side of the heel, and
under the heel and up to the instep; take the roller to
above the malleoli, and end by a circular turn (Fig. 260).

Bandage of the Foot not covering the Heel (French

Method). — Take a roller two and a half inches wide and six
' yards long. Make a spiral reversed bandage of the foot and
a figure-of-8 of the ankle-joint (Fig. 261).

Spiral Bandage of the Foot covering the Heel

(Ribbail's Bandage; Spica of the Instep). — Take a roller
two and a half inches wide and six yards long. Apply as
a spiral reversed bandage of the lower extremity until the
metatarsus is well covered. Carry the bandage, parallel with
the margin of the foot (the inner or outer margin, according
as to whether it is the left foot or the right), around the pos-
terior aspect of the heel, along the opposite margin of the
foot to cross the original turn at the median line of the dor-

MODERff SURGERY.

sum. Make a number of these ascending turns, each turn
covering in three-fourths of the previous turn; terminate by
circular turns above the ankle (Fig, 262).

Crossed Bandage of both Eyes (Figure-of-S of both
Eyes). — Take a roller two inches wide and six yards long.
Make a circular turn around the forehead from right to left,
a second turn to hold the first, a turn downward over the
left eye, under the left ear, around the back of the neck, and
upward under the right ear and over the right eye ; repeat
these turns, and terminate by a circular turn of the forehead
(Fig. 263).

Barton's Bandage (Figure-of-8 of the Jaw and Occiput).
— Take a roller two inches wide and five yards long. Place
the initial extremity of the bandage behind the inion ; pass
over the right parietal bone, across the vertex, down the left
side in front of the ear, under the chin, up the right side in

BANDAGES. 753

front of the ear, across the vertex, and across the left parietal
bone to the point of origin. A turn is now taken forward along
the right side of the jaw to the chin, and backward along the
left side of the jaw from the chin to the nape of the neck ;
repeat these turns, and pin the points of junction (Fig. 264).
In Barton's bandage the ear lies in an uncovered triangle.
The bandage may be finished by circular turns around the
forehead. Barton's bandage is u.sed for fracture of the
lower jaw.

Borsch'9 eye-bandage is convenient and useful (Fig.
265). A narrow bandage is laid along the head and per-
mitted to hang down the face in front of the sound eye. A
circular bandage is applied around both eyes and over the
narrow bandage (a). The narrow strip is lifted and pinned,
and the sound eye is thus uncovered. Of course, the pos-
terior end of A should first be pinned to the circular turn.

Gibson's Bandage. — Take a roller two inches wide and
six yards long. Make three vertical turns around the head
and the jaw in front of the ear ; reverse the bandage above
the level of the ear, and carry it horizontally around the fore-
head and head three times; drop the bandage to the nape
of the neck, and take three turns around the neck and jaw ;
terminate by taking from the nape of the neck a half turn
upward, carrj'ing the bandage forward to the forehead, and
pinning it over the neck and over the forehead. Pin each
point of junction (Fig. 266). Gibson's bandage is used for
fracture of the lower jaw.

Crossed Bandage of the Angle of the Jaw (Oblique
Bandage of the Jaw). — Take a roller two inches wide and six

754 MODERN SURGERY.

yards long. Make a circular turn around the forehead to-
ward the affected side, and a second turn to hold the first ;
take the turn to the back of the neck ; cany it forward on the
sound side, under the ear and chin ; now make a series of turns
around the head and jaw, in front of the ear on the injured
side, but back of the ear on the sound side : these turns
successively advance on the sound side only ; terminate by
going backward under the ear of the sound side to the nape
of the neck, and then by taking two circular turns around

the forehead (Fig. 267). This bandage is u.sed for fractures
of the ramus of the jaw and for holding dressings upon the
face and the cranium.

Spica of the Groin (Figure-of-8 of the Thigh and Pel-
vis).— For one groin the roller is three inches wide and seven
yards long; for both groins, three inches wide and ten yards
long. Take two circular turns, from right to left, around the
waist, then down over the front of the right groin, around
the back of the thigh, up over the front of the right groin,
around the waist, down over the front of the left groin,
around the back of the thigh, up over the left groin, and
around the waist. The map being thus laid out, the turns
are continued and ascended, each turn overlying one-third
of the previous turn, and the bandage is completed by a
circular turn around the waist (Fig. 268). Pin the crossed
pieces.

Spica of tiie Shotllder. — Take a roller two and a half
inches wide and seven yards long. Make a circular turn
and several spiral reversed turns around the upper arm ; then,
coming from behind forward, carry the bandage over the

BANDAGES.

755

shoulder, across the front of the chest, through the opposite
arm-pit, and return across the back to the shoulder. Make
successive and advancing turns (Fig. 269).

Fig. 368. — Spica of the groin.

Fig. 269. — Spica of the shoulder.

Figure-of-8 bandages of the elbow, both shoulders (pos-
terior figure-of-8), the neck and axilla, and of the breast
are shown in Figs. 270, 271, 272, 277.

Fig. 270. — Figure-of-8 bandage of the elbow.

Fig. 371. — Posterior figure-of-8 of both
shoulders.

Velpeau'8 Bandage. — Take a roller two and a half
inches wide and ten yards long. Place the palm of the hand
of the injured side upon the shoulder of the .sound side, inter-
posing cotton between the arm and the side. Start the band-
age at the axilla of the sound side posteriorly, carry it across
the back to the shoulder of the injured side, down the front of

7S6 MODERN SURGERY.

the arm and under the arm just above-the elbow, returning to
the point of origin; repeatthis turn, but, on reaching the axilla
tht; second time, cross the back and pass around the chest,
including the arm; keep on with these turns, each alternate
turn going over the injured clavicle, each alternate turn
encircling the arm and the body, the first turns advancing

and the second turns ascending (Fig. 273). Pin the crossed
pieces. This bandage is used for fracture of the clavicle.

Desatilt's ApparattiB. — This apparatus consists of three
rollers, a pad, and a sling. Each roller is two and a half
inches wide and seven yards long. The pad, which is

wedge-shaped, is inserted into the axilla with the base up.
The first roller is used to hold the pad (Fig. 274). The
second roller binds the arm to the side over the pad. This

pad is a fulcrum, the shoulder is the weight, the arm is the
lever, and the second roller of Desault corrects the inward
deformity of a fractured clavicle (Fig. 275). The third
roller corrects the downward and forward displacement. It
starts in the axilla of the sound side anteriorly, crosses the
chest to the shoulder of the injured side, runs down the

back of the arm, around the elbow, and crosses the chest
to the point of origin, forming the anterior triangle ; it is
now carried through the axilla of the sound side to the
back, crosses the back to the shoulder of the injured side,
runs down the front of the arm. around the elbow, and
across the back to the axilla of the sound side, forming the
posterior triangle (Fig. 276). The formula for the Desault
bandage is : start in the axilla of the sound side anteriorly,
run from the axilla to the shoulder, from the shoulder to the
elbow, from the elbow to the axilla, and pass to the back ;
from the axilla to the shoulder, from the shoulder to the
elbow, from the elbow to the axilla, and pass to the front.
Pin the crossed pieces and hang the hand in a sling (Fig.
276).

Recurrent Bandage of the Head. — Take a roller two
inches wide and six yards long. Make two circular turns
horizontally around the forehead and head ; when the middle
of the forehead is reached, catch the bandage, take a half
turn, carry the bandage to the occiput, let an assistant catch
it, take a half turn, bring the roller forward to the forehead,
covering a portion of the preceding turn ; continue this pro-
cess until the scalp is well covered; terminate with two cir-
cular turns around the forehead and head (Fig. 278). It is

7S8 MODERN SURGERY.

often advisable to take a turn around the head and chin.
Pin the crossed pieces.

Recnrrent Bandage of a Stump.— Take a roller two
inches wide and six yards long. Make two light circular
turns around the root of the stump; make recurrent turns
covering the stump as is done in covering the head ; take a
circular turn around the root of the stump, oblique turns to
the top of the stump, circular turns around the tip, and
apply an ascending spiral reversed bandage (Fig. 279).

T-Bandage of the Perineum. — Pass the transverse
part around the body above the iliac crests, and pin it in
front; bring one of the tails over the dressing and up
between the thigh and the genitals of one side, and the
other tail over the dressing and up between the thigh and
the genitals of the opposite side; secure these tails to the
horizontal band.

Handkerchief Bandages. — Take unbleached muslin
one yard square. The muslin folded once makes an oblong
bandage: bringing its diagonal angles together makes a
triangle bandage; a crm-al is formed by folding a triangle
bandage from summit to base; a cord is a twisted cravat.
The triangle makes an admirable sling.

Fixed Dressings. — Plaster-of-Paris Bandage. — Cover
the extremity with a cotton or flannel bandage or with a
woollen stocking. Take a gauze roller infiltrated with plaster
and place it endwi.ie in a basin of tepid water, the water
covering the plaster. When bubbles cease to arise,
squeeze the bandage and apply it -icilhout much ti?isi<m,
smoothing out each turn with a moistened hand. As each

PLASTIC SURGERY, 759

bandage is taken from the basin drop a fresh one into the
water. Apply four thicknesses of bandage, and finish the
dressing by sprinkling dry plaster over the bandage and
smoothing it with wet hands. The ordinary plaster will set
in from fifteen to thirty minutes. If it is desired to have it set
more rapidly, put salt or alum in the water ; if to have it set
more slowly, pour stale beer into the water. The plaster
bandage is removed by sawing it down the front or by
moistening with dilute hydrochloric acid and then cutting
through the moistened line with a strong knife. Gigli has
devised a mode of application which enables us to remove
the dressing with ease. A layer of cotton is placed around
the limb. A piece of parchment paper which has been wet and
shaken out is placed over the cotton. A cord greased with
vaselin is laid upon the paper in a position corresponding to
the line we will wish to saw through the plaster. Apply the
plaster bandage and see that the ends of the cord project
beyond the bandage. When desiring to remove the band-
age take a steel wire, make nicks on one side of it by means
of a file, and attach the string to the wire. Pull the wire
under the bandage. Attach each end of the wire to a
wooden handle and saw through the plaster.'

Silicate-ofHSpdium Dressingr. — Protect the part as is done
for a plaster bandage. Bandage the limb loosely with an
ordinary gauze bandage, paint this bandage with silicate of
sodium, apply another bandage and paint it, and so on until
six layers are applied. Gauze bandages soaked in silicate
are better than ordinary bandages. Silicate dressings require
from twelve to eighteen hours to dry, and they are removed
by softening with warm water and then cutting.

XXXV. PLASTIC SURGERY.

Plastic surgery includes operations for the repair of de-
ficiencies, for the replacement of lost parts, for the restora-
tion of function in parts tied down by scars, and for the cor-
rection of di.sfiguring projections. A plastic operation can
be successful after lupus only when the disease has been
cured. It is useless to do a plastic operation during active
syphilis, and a plastic operation for a syphilitic loss of subr
stance is to be performed only after the patient has been
thoroughly treated and the disease has been apparently
cured. The first step of a plastic operation consists in mak-
ing raw the surfaces which are to be brought together ; the

^ La Semaine Mid,^ Nov. 3, 1 895.

760 MODERN SURGERY,

second step is the complete airest of bleeding ; the third
step is the approximation of the surfaces without tension ;
the fourth step is to close any gap from which tissue may
have been transplanted ; and the final step is the application
of the dressings/ The following are the methods used : *

Displacement is the method of stretching or of sliding:
(i) approximation after freshening the edges (as in hare-
lip; (2) sliding into position after transferring tension to
other localities (linear incisions to allow of stretching of
the skin over large wounds). Interpolation is the method
of borrowing material from an adjacent or a distant region
or from another person: (i) transferring a flap with a
pedicle^ which flap is put in place at once or is gradually
gotten into place by a series of partial operations (as in
rhinoplasty, when a flap is transverse from the forehead);
(2) transplanting without a pedicle^ which is performed by
placing in position and by fixing there portions of tissue
recently removed from the part, from another part of the
same individual, or from a lower animal (as replacement of
the button of bone after trephining, transplanting a piece of
bone from a lower animal to remedy a bone-defect in a
human being, or the grafting of a piece of nerve from a lower
animal or an amputated human limb to remedy a loss of
nerve in a human being in nerve-grafting, or skin-graft-
ing). Retrenchment is the removal of redundant material
and the production of cicatricial contraction.

Skiii-gjafting^. — In Reverdin's method the surface to
be grafted should possess healthy granulations which are at
the skin-level. The grafts should, if possible, come from the
person to be grafted.

Grafts may come from another person or from a lower
animal, but such grafts are not apt to grow, and even
when they do grow fail to furnish a secure cicatrix. Frog-
skin furnishes unsatisfactor}'' grafts. Arnot has employed
the lining membrane of a hen's tgg, cut in strips and
applied upon the wound with the shell-surface upper-
most. Lusk has blistered the skin with cantharides and
grafted portions of the epidermis. In order to graft small
fragments of human epithelium, cleanse the skin from which
the grafts are to come, the ulcer, and the skin about it, and,
if corrosive sublimate is used, wash it away with a stream
of warm normal salt solution. Thrust a sewing-needle
under the epidermis to raise it, cut off the graft with a pair
of scissors, and place the cut surface of the graft upon the

* American Textbook of Surgery, * Ibid.

PLASTIC SURGERY. 76 1

ulcer. After applying a number of grafts, place thin pieces
of gutta-percha tissue over the grafts and extending on each
side of the ulcer, and so placed as to have distinct inter-
vals between them, the gaps permitting drainage. This tis-
sue, after being asepticized, is moistened with warm normal
salt solution (^ of i per cent.). Dress with a pad of aseptic
gauze moistened with salt solution ; place over this gauze a
rubber-dam, and over the latter absorbent cotton and a
bandage. In the case of children apply a light silicate
bandage. Put the patient in bed. In forty-eight hours re-
move all the dressings except the gutta-percha tissue, irri-
gate with normal salt solution, and reapply the dressings.
All signs of the grafts will often have disappeared. In a
day or two, at the site of grafting, bluish-white spots should
appear, which are islands of epidermis. Each graft is capa-
ble of forming about half an inch of cicatrix. Grafting also
stimulates the edges of the ulcer to cicatrize and contract
At the end of seven days the special dressings can be dis-
pensed with. The spot from which the grafts are taken is
dressed antiseptically. Reverdin's method does not limit cica-
tricial contraction to any great degree, and the new skin is
apt to break down.

Thiersch's Method. — ^Thoroughly asepticize the ulcer, the
surrounding skin, and the site from which the graft is to
come (the inner side of the arm or the thigh), and wash
away the mercurial preparation with normal salt solution.
Apply dressings wet with salt solution. On bringing the
patient into the operating-room remove the dressings from
the ulcer, scrape the ulcer and its edges, irrigate with salt
solution, and compress to arrest hemorrhage. Grafts are then
obtained by putting the prepared skin upon the stretch and
cutting strips with a razor. While the razor is being used
the part is constantly irrigated with salt solution. Mixter*s
apparatus enables one to perform this operation with great
neatness and speed. This apparatus consists of a knife and
an open square with sharp points on the under surface. The
square is forced down upon the front of the thigh, the epi-
dermis mounts up in the opening to above the level of the
metal sides, and the grafts may be cut with ease. In Hal-
sted's clinic the skin of the thigh is made tense by pressing
upon it with a piece of asepticized wood, the wood is drawn
slowly along, and is followed closely by the sharp catlin,
with which the surgeon cuts long grafts. The grafts are
pressed into place, and each graft overlaps a little the edges
of the wound and the adjacent grafts. The skin-wound is

762 MODERN SURGER Y-

drcssed antisepticalij', and the: grafted area is dressed a
Reverdin's method. Recently it has been suggested that a^
ring of aseptic gauze be made to encircle the limb below I
the grafted area, and another ring above the grafted area ; on 1
these pads little strips of wood wrapped in asepdc gauze are 1
so laid as to make a cage, and around this cage the dressings 1
are applied (moist chamber plan).

Fro. »Sd.— Mayer'i dtwiiiig forThlenth'i mclhod gf >liin.gnfting (Am. Ttsil-Btak^ 1

Krause's Method. — In this method the grafts are com-l
posed of the entire thickness of the skin. The ulcer is extir-"
pated and asepticized and bleeding is arrested. The flap ii
cut one-sixth larger than the surface to be covered. Fat is I
kept out of the graft. The bit of tissue is laid upon the ulcer,
the edges of the graft being brought against the edges of the |

ulcer. It is not neces.sary to employ sutures. The part iri
dressed in a moist chamber. If the graft perishes, remove il

DISEASES OF GENITOURINARY ORGANS. 763

RllillOplasty. — The complete operation may be per-
formed by transferring a flap from the forehead. This is
known as the Indian operation. The edges of the defect are
made raw. A model of the desired nose is made out of gutta-
percha, and its outlines are marked upon the forehead, and
the cut is made one-quarter of an inch outside of the out-
line so as to allow room for retraction. The flap is turned
down and sutured in place (Fig. 281), care being taken not
to cut off* the blood-supply in the pedicle. Plugs of gauze
or tubes are inserted to support the flap.

The complete operation can be performed by the Italian
method (Tagliacotian method). In this method the flap is
marked out on the arm, and is made twice the size of the
desired nose, and the flap is left attached by a broad pedicle.
The nasal defect is sewed, and the flap is sutured in place,
the hand being held upon the head by a special apparatus
(Fig. 282). The raw surface upon the arm is dressed. In
about three weeks the flap is cut loose from the arm, and is
pared and corrected as may be necessary.

The operations for harelip and cleft palate, and plastic
operations on muscles, nerves, tendons, and bones, are
considered in other portions of the work.

XXXVI. DISEASES AND INJURIES OF THE GENITO-
URINARY ORGANS.

Hemattlria. — By this term is meant the voiding of
bloody urine or pure blood, the blood arising from any por-
tion of the urinary apparatus, and the condition being a
symptom and not a disease. Hematuria may be a symptom
of disease or of injury of some part of the urinary system,
of blood-disorganizations (purpura, scurvy, or variola), or of
metallic poisoning (mercury, lead, or arsenic). The color of
the urine in hematuria may be anything between a light red
and a decided black, but these colors may be produced by
agents other than blood. Senna and rhubarb make urine
red ; carbolic and salicylic acids, brown ; beet-root and
sorrel, the color of blood ; methylene-blue, blue. In jaun-
dice, melanosis, and splenic fever the urine becomes brown.
Be sure that bloody urine in the female is not due to admix-
ture with menstrual blood.

Tests for Blood. — Spectroscope Test. — Fresh urine
diluted with water shows the two absorption-bands of oxy-
hemoglobin. The addition of ammonium sulphid causes
the two bands to give place to the band of reduced hemo-

764 MODERN SURGERY.

globin. If bloody urine stands for some time, the four bands
of methemoglobin are discovered (v. Jaksch).

Heller's Test. — ^Add potassium hydrate to the urine, and
boil: a red precipitate of earthy phosphates and hematin
forms. Throw the precipitate upon a filter and treat with
acetic acid : a red solution is produced, which soon fades.

Rosenthal's Test. — Take the precipitate from caustic pot-
ash, dry it, and test it for hematin ; put some of the dry
sediment on a slide, add a crystal of common salt, apply a
cover-glass, and cause a few drops of glacial acetic acid to
flow under the glass ; warm, but do not boil. Teichmann's
crystals will appear on cooling.

Struve's Test. — ^Test the urine with hydrate of potassium^
and add acetic acid in excess: a dark precipitate forms^
which will yield crystals of hematin when treated with sal
ammoniac and glacial acetic acid.

Alxnen's Test. — ^Take 10 c.c. of urine, and pour upon its
surface a mixture of equal parts of tincture of guaiac and
old oil of turpentine : at the point of junction of this fluid
with the urine there forms a white ring which turns blue.

Microscope Test. — ^The microscope shows numerous cor-
puscles except in a very alkaline urine, when but few cor-
puscles may be found.

In hemoglobinuria— a condition sometimes occurring in
burns, acute maladies, and metallic poisoning — there is pres-
ent blood-coloring matter, which is shown by Heller's test
and by Almen's test. The spectroscope shows methemo-
globin. The microscope shows no corpuscles or only a few,
but discloses masses of pigment.

Bleeding from the Kidney-substance. — Bleeding

from the pelvis of the kidney and from the ureter may be due
to inflammation, congestion, contusion, stone, vicarious men-
struation, hemorrhagic diathesis, powerful diuretics, fevers,
purpura, tumors, catheterization of the bladder, etc. Blood
is thoroughly mixed with the urine, and no sediment forms
(smoky urine). The corpuscles are profoundly altered, are
devoid of coloring-matter, and show pale-yellow rings. The
severity of the hemorrhage is measured by the number of
the corpuscles. Von Jaksch states that the diagnosis
between renal and ureteral hemorrhage rests on the nature
of the casts and the epithelium present. From the pelvis
of the kidney and from the ureter come small epithelium,
the cells from the superficial layers being polygonal or
elliptical, those from the deeper layers being oval or irregu-
lar. In hemorrhage from the ureter the cells are few; in

DISEASES OF GENITO-UFINARY ORGANS. 765

hemorrhage from the pelvis they are plentiful and rest upon
one another like "tiles on a roof " (v, Jaksch). Cells from
the tubules of the kidney are small, granular, and polyhedral,
have large nuclei, and are often so arranged as to form
cylinders (epithelial casts). The urine of renal hemorrhage
is apt to be acid unless alkalies have been administered,
unless the bleeding has been severe, or unless pus is present
in the urine. A very large rcna! hemorrhage may cause the
passage of almost pure blood. In renal hematuria there
are aching in the loin, numbness of the corresponding leg,
and often renal colic. The use of the cystoscope enables the
surgeon to determine if the hemorrhage is vesical or renal,
and if it comes from one or both kidneys. If the bladder-
fluid is kept clear, the blood can be seen flowing out of the
ureter of the damaged organ.

Catheterization of the ureters may give valuable informa-
tion. Kelly performs this operation in women with the

greatest ease. A.septic precautions are observed. A specu-
lum is inserted, tlie orifice of the ureter is cleansed with a
bit of cotton, and the catheter is inserted, and the urine is
collected in a sterile test-tube. Kelly's catheter is of flexible
silk, 30 cm. in length, 2 mm. in diameter, with a blunt coni-

766 MODERN' SURGER K

cal end and an oval eye. The catheter is pushed into
the ureter 1 2 or 15 mm. The rate of flow in a given time
proves the competence of the kidney. The male ureter
can be catheterized by means of the instrument of Nitze

(Fig. 283).

Kelly has recently catheterized the ureter in a man by in-
serting a straight speculum, placing the patient in the knee-
chest position to inflate the bladder with air, and introducing
a metallic catheter.

Vesical hemorrhage, including hemorrhage from

the prostate, may follow the relief of retention of urine,
may be due to stone, inflammation, tumor, etc., or may arise
from traumatisms, instrumental or otherwise. The color of
the urine is usually bright red, but if long retained in the
bladder it becomes black and often tarry. The reaction is
alkaline. The clots, when floated out, are large and without
definite shape. In micturition the urine is clear or only a
little colored at the beginning, but becomes darker and darker
as micturition ends, at which time the flow may consist of
almost pure blood. In very small vesical hemorrhages the
urine may be smoky. Crystals of triple phosphate indicate
bladder disorder. The microscope shows colorless and
swollen corpuscles and many polygonal cells. Symptoms
of bladder mischief usually exist, but cystoscopic examina-
tions or exploratory suprapubic cystotomy may be demanded
for the diagnosis.

Urethral Hemorrhage. — In urethral bleeding blood
comes independently of micturition, or blood comes out first
and is followed by clear urine. Urethral hemorrhage arises
from an acute urethritis, from an inflamed stricture, from the
passage of an instrument, or from some other traumatism.

The source of urethral hemorrhage can be ascertained by
the use of the endoscope.

Pain in Genito-tutinary Diseases. — Pain as a symp-
tom of genito-urinary disease may be found at some point
distant from the seat of lesion. A stone in the bladder
causes pain in the head of the penis just back of the meatus ;
stone in the kidney induces pain in the loin, the groin, the
thigh, and the testicle ; inflammation of the testicle causes
pain in the line of the cord in the groin. In other cases of
genito-urinary disease pain is felt at the seat of lesion, as in
urethritis and prostatitis. Pain felt before micturition, and
being relieved by the act, is found in cystitis and in retention
of urine. Pain is felt during micturition in inflammation of
the bladder, prostate, and urethra, and in the passage of

DISEASES OF GENITOURINARY ORGANS, 767

gravel or stone. Pain which is acute at the end of micturi-
tion is noted in stone in the bladder, in inflammation of the
neck of the bladder, and in inflammation of the prostate
gland. The pain of stone in the bladder, it may be observed,
is ameliorated by rest and is aggravated by exercise. The
pain of acute prostatitis is intensified by defecation.

Frequency of Mictorition. — Frequent micturition
arises from irritation of the sensory nerves, from phimosis,
contracted meatus, inflammations, very acid urine, calculi,
urethral stricture, and hyperesthesia of the urethra. Fre-
quency of micturition may be due to spinal irritability from
concussion or from sexual excess, from contraction of the
bladder rendering the viscus unable to hold much, from
worry, anxiety, fear, or from excessive urinary secretion, as
in diabetes or in the first stage of contracted kidney. Fre-
quent micturition exists in obstruction by enlarged prostate
and in atony of the bladder-walls. Hypersecretion of urine
plus bladder intolerance is known as " nervousness," and is
found in hysteria. Frequency of micturition increased by
inozfcmcnt is observed in stone and tumor of the bladder ;
increased by resty is found in enlarged prostate and atony of
the muscular walls of the viscus. Frequency of micturition
with diminution of stream-caliber suggests a constriction of
the urethral diameter; frequency of micturition with dimin-
ished force suggests a posterior stricture, enlarged prostate,
or bladder atony. Slowness of micturition hints at enlarged
prostate, atony, or urethral stricture.

Thompson's diagnostic questions are as follows :

" I. Have you any, and, if so, what, frequency in passing
water? Is frequency more manifest during the night or the
day? Is frequency more manifest during motion or rest?
Does any other circumstance affect it?

'* 2. Is there pain on passing urine, and, if so, is it before,
during, or after the act? What is its character — ^acute,
smarting, dull, transitory, or continuous ? What is its seat ?
Is it felt at other times, and is it produced or intensified by
sudden movements?

" 3. What is the character of the stream ? Is it small or
large ; twisted or irregular ; strong or weak ; continuous, re-
mitting, or intermitting ? Does it come by the meatus, or
partly or entirely through fistulae?

"4. Is the character of the urine altered? What is its
appearance, color, odor, reaction, and specific gravity ? Is
it clear or turbid, and, if turbid, is it so at the time of pass-
ing ? Does it vary in quantity ? Are the normal constitu-

DISEASES OF GENJTO-URINARY ORGANS. 769

between movable and floating kidney, but practically there
is no rigid line of demarcation, as a movable kidney may
have as large a range of movement as a floating kidney.
When a movable kidney becomes fixed in an abnormal
situation the organ is spoken of as dislocated. The organ
may drop below the brim of the pelvis, may cross the verte-
bral column, or may reach the anterior abdominal wall.
Women more often suffer from movable kidney than do
men, and it is found in the great majority of cases upon
the right side. Floating kidney is always congenital.
Among the assigned causes of the movable condition are
to be named traumatisms, strains, abdominal-wall laxity
from pregnancy, absorption of peritoneal fat from wasting
disease (Edebohls), and tight lacing.

S3rinptomB of Both Forms. — There may be no discomfort
whatever, or the patient may be a confirmed invalid. The
usual symptoms are epigastric pain (just to the left of the
middle line), which disappears when the kidney is replaced,
dragging pain in the loin, and paroxysms like nephritic colic.
There is a sense of a moving body in the abdomen, and the
patient has aggravated indigestion, often accompanied by
vomiting. Constipation is the rule, and violent attacks of
cardiac palpitation are common. Most subjects of this
kidney-mobility are extremely nervous, many of them hys-
terical or hypochondriacal. In women the sexual organs
are almost invariably deranged, and menstruation aggravates
the pain and discomfort. All the symptoms are intensified
by exertion and are modified by rest. The urine is normal.
The proof of the existence of movable kidney is the finding
of a tumor (movable on respiration, change of position, and
palpation) shaped like that organ, pressure upon which oc-
casions no sensation or causes pain or a sickening feeling.
A " lumbar recess " (Morris) may be found, and percussion
over the loin gives resonance. In some cases a movable
kidney can be readily detected when the patient stands up,
but is hard to find when he is recumbent. Franks's method
of examination is very satisfactory. The patient is placed
recumbent. If dealing with a right kidney, the surgeon
stands to the right side and pushes four fingers of his left:
hand in the loin below the twelfth rib, and rests the thumb
lightly in front just below the ribs. The patient takes a full
breath and holds it a moment, and just before he empties
his lungs the surgeon presses his thumb up deeply below
the ribs. During expiration the thumb follows the Hver,
and the fingers press toward the front. If with the right
49

770 MODERN SURGERY.

hand the kidney can be felt entirely below the left hand, the
case is one of movable kidney. If such a condition is de-
tected, press hard with the right hand, and gradually loosen
the grasp of the left hand, and the kidney will slip between
the fingers and ascend. A normally mobile kidney descends
so that its lower half can be felt, but it moves back during
expiration.^ A movable kidney must not be mistaken for
a distended gall-bladder, a tumor of the mesentery, stomach,
or omentum, a phantom tumor, an ovarian tumor, or a can-
cer of the pancreas. Sometimes a movable kidney endan-
gers life, rupture of the kidney or twisting or rupture of the
ureter occurring, the ultimate cause of death being albumi-
nuria, uremia, or hydronephrosis.

Treatment. — Mobile kidney is treated as follows: (i) The
rest-treatment of Weir Mitchell may be tried ; it often markedly
mitigates the symptoms, but does not seem to cure. (2)
Bandage aftd pad should always be tried, using the pad of
Dunning or Newman : this will cure not a few cases.
Edebohls uses only a bandage of elastic webbing or a well-
fitting corset. (3) Nephrorrliaphy is the proper procedure
in most instances (page 783). It is the author's experience
that if the patient has had marked nervous symptoms for a long
time, nephrorrhaphy will rarely cause them to permanently
pass away, even though the kidney remains firmly anchored.
(4) Nephrectomy is necessary only in very rare cases ; it may
be done for dislocated kidney, when kidney disease exists,
or when nephrorrhaphy has failed in a case of great severity.

Injuries of the Kidney. — Laceration or rupture is
caused by falls and by blows upon the back or the belly.
The blood may or may not extravasate into surrounding
structures. The sympto^ns are pain in the loin, shooting
into the testicle or the thigh ; frequent and painful passage
of bloody urine or suppression of urine ; the loin is full and
is dull on percussion, and collapse or evidences of internal
hemorrhage exist. Bloody urine is not proof of renal injury,
and kidney damage may occur without hematuria. The use
of the cystoscope or catheterization of the ureters will show
from which kidney blood comes.

Treatment. — If the shock is profound with increasing ful-
ness of the loin, whether hematuria exists or not, or if blood
comes profusely from the urethra, make an explorator)''
lumbar incision and stop the bleeding by packing, or by a
purse-string suture (Figs. 284, 285), or, if necessary, perform
partial, or even complete, nephrectomy. Ordinarily the cases

* British Med. Journ., Oct. 12, 1 895.

DISEASES OF GENITO-URINARY ORGANS.

771

are treated by rest in bed and by feeding with liquid food or by
nutritive enemata to prevent vomiting. Opium, tannic acid, or
gallic acid may be used. Apply ice-bags to the loin and the

Fig. 984.—" Pune-string " suture applied to a perforation (after Schachner).

side of the abdomen, and after bleeding ceases strap the loin
and apply a binder. If large blood-clots cause pain or reten-
tion, introduce a catheter and inject the bladder with boric

Fig. 985. — Showing the application of a double "purse-string" suture for the arrest of

hemorrhage in large wound (after Schachner) .

acid, or use the tube and evacuator of a Bigelow apparatus.
If this procedure fails, open the bladder by a suprapubic
incision and drain.

Perforatingr wounds of the kidney, if purely posterior, do
not involve the peritoneum ; if anterior, they do. The symp-
toms are escape of blood and urine by the wound; hematuria
is usual, but not invariable ; pain as in rupture ; the patient
may be unable to micturate ; and nausea, vomiting, and con-
stitutional signs of hemorrhage exist. Traumatic peritonitis,
perinephric abscess, or general sepsis may ensue. Confirm

^^2 MODERN SURGERY,

the diagnosis by exploration with the finger. Extraperi-
toneal injuries give a good, and intraperitoneal a bad,
prognosis.

Treatment. — If the wound in perforated kidney is extra-
peritoneal, enlarge it to permit of drainage, and arrest hem-
orrhage by packing and hot water, or by a purse-string suture
(Figs. 284, 285). Asepticize the wound, insert a drainage-
tube down to the kidney, dress often with bichlorid gauze,
keep the patient in bed on a low diet, and give gallic acid
and opium. In some cases nephrectomy, partial or complete,
will be required. In intraperitoneal wounds perform an
abdominal section and remove the damaged organ (see
Nephrectomy).

Wounds of the Ureter. — The ureter may be wounded
by the surgeon accidentally during the performance of an
abdominal operation, or it may be wounded intentionally, as
in Morris's cases, in which a malignant growth was incorpo-
rated with the ureter. Wounds of the ureter as a result of
accidental violence are almost invariably associated with other
serious injuries.

Treatment. — Remember that the upper three-fourths of
the ureter can be reached by an extraperitoneal incision,
which is a prolongation of the incision for lumbar nephrec-
tomy, running from the twelfth rib downward, and forward
to one inch anterior to the spine of the ilium, and then
parallel to Poupart's ligament until a point is reached above
its middle (Fenger). The lower one-fourth of the ureter can
be reached by abdominal section or by sacral resection
(Cabot). If it seems probable that the ureter is wounded or
ruptured explore, and if this is found to be the case en-
deavor to restore the continuity of the tube (Fenger). If the
ureter is cut across near the bladder, implant the proximal
end into the bladder (Van Hook, Penrose, Kelly). If it is
cut above the bladder portion, perform lateral implantation
by Van Hook's method (page 784).

A longitudinal wound of the urethra inflicted during an
abdominal operation should be sutured, but if the duct can-
not be readily reached, simply make a posterior incision and
drain, as the longitudinal wound will heal by granulation if
no sutures are inserted (Van Hook).

Renal Calcnlus. — A stone in the kidney is formed by
the precipitation of urinary salts into the renal epithelial cells
and the gluing together of these salts and cells by material
from mucus or blood-clot, this mass serving as a nucleus
on which accretion takes place. Most calculi escape when

DISEASES OF GENITOURINARY ORGANS. 773

small as gravel. The caiise is a highly acid urine, which
induces catarrh of the renal tubes. This high concentration
of urine is favored by a sedentary life, by the ingestion of
much alcohol or nitrogenous food, by constipation, by an
inactive skin, and by a torpid liver. The children of poverty
are liable to calculi because of the use of unsuitable foods
and the formation of great amounts of nitrogenous waste.
Males more often suffer than do females, certain locations
favor the development of the malady, and a family tendency
sometimes exists.

Symptoms. — ^The symptoms of stone in the kidney may
not appear for years, but generally they are manifested early.
The patient usually complains of pain in the loin, and some-
times of pain in the iliac region. Deep percussion over the
kidney causes pain in the loin, even when pressure is pain-
less (Jordan Lloyd's symptom). Pain is aggravated by exer-
cise. The urine is often somewhat albuminous, and may
from time to time contain blood. Frequency of micturition is
noted during the day, but not at night. The urine may be
purulent. Nephritic colic is due to the washing of a calculus
into the orifice of the ureter, which it blocks, tears, or dis-
tends. The pain is either sudden or gradual in onset, is fearful
in intensity, and runs from the lumbar region down the cor-
responding thigh and spermatic cord (the testicle being
retracted) and into the abdomen and shoulder-blade. There
are nausea, vomiting, collapse, sometimes unconsciousness or
convulsions. Frequent attempts at making water are pro-
ductive of pain, but of little urine. The urine is usually, but
not always, smoky from blood. After a time the pain
vanishes, the stone having passed into the bladder or having
fallen back into the pelvis of the kidney. A calculus retained
in the kidney eventually excites pyelitis. There is pus in
the urine, and soreness or pain in the loin exists. Kelly
says : even if pus is found we are not always sure from
which kidney it came. Pain or swelling may point to one
side, but we are not sure that the other organ is not also
affected. If able to pass the renal catheter into one ureter,
attach a syringe, and by making suction draw out any pus
which may be present. In renal calculi cases this fluid is
apt to contain fragments of uric acid. By using a renal
bougie coated with dental wax it may be possible to make
scratches on the instrument when it comes in contact with a
concretion.* Slight attacks of colic occur from the passage
of small stones or of plugs of mucus. When a stone is im-

* Howard Kelly, in Med. News, Nov. 30, 1895.

774 MODERN SURGERY.

pacted in the pelvis the point of greatest tenderness on press-
ure is below the last rib, by the edge of the erector spinas
muscle. When a stone is impacted in the ureter the point of
greatest tenderness is either in the loin below the level of the
kidney or in the iliac region (Perkins). In many cases a
stone in the kidney or ureter can be skiagraphed. If a
stone partly obstructs the ureter, the urine is pale and of
low specific gravity and free from albumin. Jordan Lloyd
says that impaction near the bladder causes symptoms sim-
ilar to stone in the bladder. Impaction near the kidney is
accompanied by hematuria and pyuria. In stone in the
ureter prodding the loin does not cause pain (Lloyd).
Entire obstruction of the ureter induces hydronephrosis or
pyonephrosis. Nephrolithiasis may cause death by ex-
haustion, by sepsis, by rupture of a hydronephrosis, or by
amyloid degeneration.

Treatment. — For the gravel of the uric-acid diathesis use
alkalies, especially the liquor potassii citratis, and reduce the
amount of nitrogen in the diet to a minimum, at the same
time washing out the organs by copious draughts of Poland
water or Londonderry lithia. Piperazin, in doses of gr.
V to gr. viij three times a day, is highly commended. Exer-
cise is to be insisted on. When gravel is phosphatic order
strychnin, the mineral acids, and rest at the seaside. When
oxalate of lime is found restrict diet, use the mineral acids,
recommend travel or rest amid new surroundings, and give
an occasional course of sodii phosphas, .^ss three times a day,
drunk in Buffalo lithia water. Nephritic colic is relieved by
hypodermatic injection of morphin and atropin, the hot bath,
diluent drinks, or the inhalation of ether. After the attack
wash out the bladder with an evacuator. If a stone impacts
in the ureter, perform the operation of ureterolithotomy.
The diagnosis of this impaction is often possible only by^
exploratory laparotomy. If the symptoms point to stone in
the kidney, medical treatment having been used without
avail, and there being no evidence of organic disease of the
other kidney, make an exploratory lumbar incision ; feel the
surface of the kidney with the finger, sound the inside of the
organ with a needle, and if a stone is detected, incise the
kidney and remove the stone. Keen is of the opinion that
operation should not be performed if the urea is below i per
cent. If, after nephrolithotomy, suppression of urine occurs,
cut into the other kidney, as in half of all cases a stone will
be found lodged there.

Abscess of the kidney is caused by traumatism, by

DISEASES OF GENITOURINARY ORGANS. 775

calculus, by stricture of the urethra, by disease of the blad-
der, by the union of miliary abscesses, or by pyemia.

The s3nxiptoms are pus in the urine (this is usual, but
not invariable), hematuria in traumatic cases, and pain run-
ning into the groin. The urine is usually alkaline. Consti-
tutional symptoms of suppuration exist, the fever being far
higher than that usually met with in renal tuberculosis.
The bladder should be examined with a cystoscope to deter-
mine that the turbid urine flows from a ureter and to identify
the diseased side. It is well, if possible, to catheterize the
ureters.

The treatment in the early stage is rest, morphin, purga-
tion, anodynes, and ice-bags to the loin, followed in forty-
eight hours by hot fomentations. When the diagnosis is
clear incise the loin, open and stitch the kidney to the ab-
dominal wall, or, if the organ be badly damaged, remove it.

Pyelitis and pyelonephritis, which usually affect only
one gland, are caused by urethral stricture, by stopping of
the ureter by blood-clot, by vesical paralysis, by stone in the
bladder or in the kidney, and by enlargement of the prostate
gland.

Symptoms. — A patient who has, or who has had, reten-
tion of urine develops high fever, often preceded by a chill ;
headache, stupor, and dry tongue are noted. Unlike acute
Bright's disease, there is neither edema nor dry skin, con-
vulsions do not occur, and the urine is plentiful and contains
pus and, but rarely, blood. The prognosis is very bad.

The treatment is to remove the obstruction if possible.
If the urine be acid, give liquor potassii citratis ; if alkaline,
give benzoic acid. Gallic acid, eucalyptol, and small doses
of copaiba or cubebs are recommended. Venice turpentine,
camphor, and opium may be given in pill-form. Quinin is
used to stimulate the patient and to lower fever. The bladder
is to be washed out every day with boric-acid solution (gr.
iij-5j). Cups, dry or moist, and hot sand-bags or bran-bags
are to be applied to the loin. Alcohol may be sparingly
administered. Urotropin has lately been used with benefit.

Perinephritis is an inflammation of the perinephric fatty
tissue produced by cold, febrile disease, slight traumatism,
or spread of inflammation from another part.

The S3rmptoms of this condition are rigidity of the spine,
the inclination being toward the affected side, flexion of the
thigh, and often pain in the knee. The symptoms resemble
those of hip-joint disease in the second stage. Suppuration
may or may not take place.

776 MODERN SURGERY.

The treatment is wet cups to the loin, ice-bags to the loin,
rest, purgation by salines, morphin for pain, and, after the
acute stage, potassium iodid internally and ichthyol locally.

Perinephric Abscesses. — An abscess in the perinephric
fat is known as a perinephric or perirenal abscess. Primary
abscess is caused by chills, acute febrile disturbances, or by
pus flowing from some other part, as the spine. Slight
traumatisms by producing hemorrhage make the peri-
nephric region a point of least resistance, and lead to
abscess. The causative injury may be produced by dig-
ging, stamping, coughing, falling, carr>'ing a burden, lifting
a weight, riding on a horse or in a jolting wagon. Consecu-
tive abscess is secondary to kidney inflammation, suppura-
tion, calculus, tuberculosis, or cyst. In the consecutive form
the symptoms may be masked by the malady to which peri-
nephric abscess is secondary. As a rule, in perinephric
abscess there are found the constitutional symptoms of
suppuration. The local symptoms are a deep aching and
paroxysmal pain intensified by lumbar pressure. Edema of
the corresponding foot and lameness are not unusual. The
thigh is often drawn up. Edema of the skin is usual, but
fluctuation is rare. The exploratory incision will settle a
doubtful diagnosis.

The treatment is to lay open the abscess, wash it out,
and drain.

Hydronephrosis is a condition of the kidney in which
an impediment to the outflow of urine is caused by obstruc-
tion in the ureter, the bladder, or the urethra, the calyces of
the kidney becoming over-distended with urine and the gland-
ular tissue being absorbed by pressure. It has been asserted
by Albanan that secretion of urine ceases in a kidney whose
ureter is blocked, distention being due purely to congestion.
This condition may be congenital, due usually to twisting
of the ureter or to valve-formation obstructing the ureter
at its point of junction with the pelvis of the kidney, the
valve being produced because the ureter passes into the
kidney pelvis at an unnatural angle. Occasionally imper-
forate meatus produces hydronephrosis of both kidneys.
The causes of the acquired form arc the pressure of pelvic
growths or pregnancy, inflammation or tumor of the blad-
der, stone in the bladder, kidney, or ureter, twisting or kink-
ing of the ureter of a movable kidney, enlargement of the
prostate gland, and stricture of the urethra. This acquired
hydronephrosis may involve both kidneys, all of one kid-
ney, or only a part of a single gland.

DISEASES OF GENITO-URINARY ORGANS. TJJ

Symptoms. — Hydronephrosis is most frequent in females.
When tumor is absent there may be no symptoms, or there
may be pain in the back and abdomen, frequent micturition,
a persistent or intermittent diminution in urine, or even occa-
sional anuria. A tumor may be found in the loin, which
growth is dull on percussion and may come and go, a large
urinary flow occasionally occurring when it disappears. Hy-
dronephrosis may last a long while if only one kidney be
involved, but death is not far distant if both glands suffer.
Death occurs from anemia, from pressure on adjacent organs,
or from rupture into the peritoneal cavity. The diagnosis is
aided by the use of the cystoscope and by catheterizing the
ureters.

Treatment by aspiration may cure, but the operation may
have to be done repeatedly. Tapping on the left side is
performed just below the last intercostal space ; on the right
side the tap is made midway between the last rib and the
crest of the ilium. Some few cases have been cured by
catheterizing the ureter (Pawlik). The proper operation in
most cases is nephrotomy, stitching the edges of the cut
kidney to the surface. After the kidney has been opened
explore the ureter by means of a uterine sound or an elastic
bougie. A healthy ureter will permit the passage of an
instrument of the size of from No. 9 to 1 2 (Fenger). If the
opening of the ureter into the pelvis cannot be found, open
the pelvis or open the ureter. A valve is slit longitudinally
(Fenger). If a permanent suppurating fistula ensues or if
the organ is found extensively damaged, nephrectomy is to
be performed, provided the other kidney is in reasonably
good condition.

Pyonephrosis, or surgical kidney, is a condition in
which the pelvis and the calyces of the kidney are distended
with pus or with pus and urine. The whole kidney may
be destroyed. This condition has the same causes as
has hydronephrosis, for it is in reality usually an infected
•hydronephrosis. In some cases the inaugural malady
is pyelitis, which causes blocking of a ureter. Watson of
Boston has reported two cases associated with obliteration
of the ureter by a mass of fibrous tissue (stricture of the
ureter).

S3rinptoms. — At first the symptoms are those due to the
obstructing cause, plus pyelitis. Pus may appear in the
urine in incomplete obstruction, or it may intermittently
come and go. Constitutional symptoms of suppuration are
soon manifest. A tumor may appear in the loin, like the

778 MODERN SURGER K

tumor of hydronephrosis. If only one kidney is involved,
and if the disease is due to blocking of a ureter, recovery
is to be expected. The diagnosis is rendered more cer-
tain by the use of the cystoscope and by catheterizing the
ureters.

The treatment in the early stages comprises removal, if
possible, of the cause of obstruction and the employment of
measures directed to the cure of the pyelitis. If obstruction
is not complete, palliative measures may be employed for
the tumor. If fever is continued, if there is great visceral
derangement, if pain is severe and constant, and if the tumor
continually grows, perform a nephrotomy, stitching the organ
to the surface if possible, or removing it if it is hopelessly
disorganized.

Chronic Tuberculosis of the Kidney.— This condi-
tion may begin in one kidney, no other depot of infection
existing in the body. In such cases the organisms were
deposited from the blood. The other kidney is usually
involved subsequently, the process in the first kidney affect-
ing the bladder and secondarily the other kidney. The
important point is that tuberculosis of the kidney arising in
this manner is at first a unilateral disease.

Tuberculosis of the kidney may arise secondarily to tuber-
culosis of the prostate and bladder. In such a condition the
kidney disease is usually bilateral.

Symptoms. — Renal tuberculosis of arterial origin may ex-
hibit no symptoms until the disease is far advanced. Renal
tuberculosis secondary to disease of the bladder or prostate
always presents symptoms.^ A \itxy common symptom is
the sudden onset of polyuria and frequent micturition. The
patient is annoyed day and night, and in some cases mic-
turition is distinctly painful. Paroxysms of renal pain are
not unusual. The urine is acid, and may contain pus or
blood. Tubercle bacilli may be found in the urine or in
the sediment, but they may be absent. Repeated examina-
tions should be made before it can be stated certainly that
bacilli are absent. The presence of bacilli proves the diag-
nosis, but their absence does not negative it (Willy Meyer).
If bacilli are not found, inject some of the urinarj'- sediment
into a guinea-pig, and note if tuberculosis arises in the
animal. The urine may or may not be albuminous.

Czerny has shown that in cases of tubercular kidney in
which bacilli are not found in the urine, the administration
of tuberculin will cause great numbers to appear. This agent

^ F. Tilden Brown, New York Med. Jour. ^ April lo, 1897.

DISEASES OF GENITOURINARY ORGANS, 779

will also cause a marked febrile reaction if tuberculosis exists.
In spite of the important diagnostic result of a dose of tuber-
culin it is scarcely wise to give it, as it may cause dissemi-
nated tuberculosis.

In many cases the kidney is obviously enlarged, and this
area is frequently tender and occasionally painful. The
patient loses flesh, and there is nocturnal fever followed by
sweating. The use of the cystoscope furnishes important
information. It shows from which ureter turbid urine is com-
ing. Catheterization of the ureters should be practised by
some one who is accustomed to employ it. Always examine
carefully to determine if one or both kidneys are involved,
if the bladder is diseased, and if the prostate gland or semi-
nal vesicles are tubercular.

Treatment. — Nephrectomy is not justifiable in the very
beginning of a case, because such a case may attain to a
cure by a combination of medical and hygienic treatment,
and the weakening effect of the operation of nephrectomy may
cause the other kidney to rapidly develop tuberculosis. Tell
such a patient to lead an outdoor life. Brown recommends
camp-life in the Adirondacks during the summer, and sends
such patients south during the winter. If a patient cannot go
to another climate, urge upon him the necessity of being much
out of doors. Insist upon the taking of plenty of nutritious
food. Order courses of creasote or guaiacol carbonate.

If the kidney is markedly enlarged, if there is profuse
hematuria, if the fever is high and persistent, if only one
kidney is involved, and if the bladder and prostate are free
from disease, perform nephrectomy. In cases with involve-
ment of the other kidney or of the genito-urinary tract lower
down, nephrectomy is rarely justifiable, although nephrot-
omy for drainage may greatly benefit the patient for a
time.

Operations on the Kidney and Ureter. — ^Nephrot-
omy means incision of a kidney, but the term is sometimes,
though wrongly applied, to the exploratory exposure of the
kidney without incision. The instmments required are scal-
pels, a blunt-pointed bistoury, dissecting-forceps, toothed for-
ceps, a grooved director, hemostatic forceps, spatulae, metal
retractors, a fountain syringe, an Allis dissector, Hagedoni
needles, and an Abbe needle-holder. If looking for a stone,
have a large harelip-pin to sound with, forceps and a scoop
to remove the stone, and a periosteum-elevator to scrape
away adherent calculi. The patient lies upon the sound side,
a sand-pillow being placed under the loin. The iiuision is

780 MODERN SURGERY,

made half an inch below the last rib and close to the outer
border of the erector spina; mass, and runs obliquely doi^-n-
ward and forward toward the iliac crest for three inches, the
incision being enlarged later if required. Di\'ide the sldn, the
superficial fascia, the fat, the external oblique, the posterior
border of the internal oblique, and the outer edge of the latis>
simus dorsi. This incision exposes the lumbar fasda. Push
aside the last dorsal nerve and incise the lumbar fascia, when
the perirenal fat will bulge into the wound. Two distinct
layers of fat exist Tear this fat through with dissecting-
forceps or with an Allis dissector to expose the kidney,
which can now be opened while it is forced into the wound
by the hand of an assistant making abdominal pressure.

Kocher's incision for nephrotomy is begun in the angle
bet^'een the sacrolumbalis muscle and the t^-elfth rib, and is
carried do^^^^wa^d, forward, and outward to the axillarj" line.
This incision divides the skin, subcutaneous tissues, lumbar
fascia, the latissimus dorsi, and the serratus posticus inferior
muscles.

Edebohls's method enables the surgeon to most thor-
oughly explore the kidney, because this organ is brought
outside of the body. The patient lies prone, with a large
cylindrical inflated rubber pad beneath his abdomen. A ver-
tical incision is made close to the border of the erector spins
muscle, from just below the last rib to just above the iliac
crest. The fatt>' capsule is well separated from the kidney front
and back. The patient is pulled by the legs toward the foot
of the table, the pad remaining stationar}'. This change of
position brings the pad beneath the chest, abdominal respi-
ration takes place, the kidney is forced out of the wound,
and can be thoroughly examined.

Nephrolithotomy. — In this operation the incision is the
same as in nephrotomy. If the kidney is not much enlarged,
it can be brought out by Edebohls's method. Feel the kid-
ney for a stone, or, if this procedure fails, e.xplore with a needle
or a pin. If no stone is found, open the pehis, let an assist-
ant grasp the pedicle with his fingers or with a pair of forceps,
each blade of which is covered with a bit of rubber tube, while
the surgeon opens into and explores with the finger. If a
stone is detected, open the kidney-tissue, loosen the calculus
with the nail, and remove it with the finger, with a scoop, or
with forceps. After removing the stone suture the incision
with catgut, and release the pressure on the pedicle. Hem-
orrhage will rarely occur. If in spite of this plan bleeding
occurs, take out the stitches and apply pressure and hot

DISEASES OF GENITOURINARY ORGANS. 78 1

water, or in some cases plug with iodoform gauze for twenty-
four hours. When hemorrhage ceases put a large drainage-
tube down to the kidney. Close the wound in the muscles
and integument and dress antiseptically. The dressings must
be changed frequently and the tube should be shortened
daily.

Nephrectomy is the removal of a kidney. There are two
methods of nephrectomy, the lumbar and the abdominaL Be-
fore performing nephrectomy ascertain the competence of the
kidneys. If at least i per cent, of urea is not being excreted,
it is very unsafe to operate. Be sure the patient possesses two
kidneys. Examination of the bladder by a cystoscope will
show the ureteral orifices, a strong indication that both kid-
neys are present. Nevertheless, when we reflect that a
horseshoe kidney has two ureters the proof is not absolute.
Catheterization of the ureters is advisable if it can be per-
formed, but it will probably require a specialist to perform
it. Proof absolute of the presence of two kidneys consists
in feeling both of them. If in doubt as to the question, and
if uncertain as to the competence of the organ which is to
be left, feel each kidney during the operation and before
removing either, or perform a preliminary exploratory
laparotomy.

Lumbar Nephrectomy. — The instruments required for
this operation are scalpels, a blunt-pointed bistoury, forceps
as used in the preceding operation, a clamp, retractors,
spatulae, blunt hooks, an aneurysm-needle, a pedicle-needle,
a grooved director, stout silk, an Allis dissector, sharp
spoons, and a Paquelin cautery. The patient is placed on
the sound side and a pillow is placed under the loin. Sev-
eral incisions have been proposed. In many cases the
oblique incision is first made to permit of exploration. This
incision is begun half an inch below the last rib and by the
edge of the erector spinae muscle, and is carried downward
and forward toward the iliac crest. In some cases a kidney
can be removed through this cut. In other cases the cut
must be enlarged. It can be enlarged by extending the cut
downward. Morris enlarges it by adding to it a vertical
incision, which begins one inch below the origin of the
oblique cut. K6nig*s incision for nephrectomy consists of
a vertical cut by the edge of the erector spinae, carried almost
to the iliac crest, from which point it is curved forward
toward the umbilicus, and is carried to or even through
the rectus muscle. After thorough exposure lift the kidney,
and separate it from the peritoneum, if possible, with the

782 MODERN SURGERY,

finger; clamp the pedicle; pass an armed aneurysm-needle
between the vessels of the pedicle; ligate in two places; cut
between the threads ; and arrest hemorrhage by ligature or
by the cautery. If the ureter be healthy, ligate it with silk
and drop it back ; if it be foul and purulent, scrape it with
a spoon, wash it with corrosive sublimate, and touch it with
pure carbolic acid, and then either ligate it and drop it back
or sew it into the wound. If hemorrhage persists from the
wound, plug with gauze. Put in a drainage-tube and close
the wound. If the peritoneum be accidentally opened, close
it with Lembert's suture. Kocher's method is excellent,
and enables the surgeon to feel the opposite kidney before
removing the one which is known to be diseased. The
incision is begun as described on page 781, and is car-
ried forward so as to expose the reflection of the perito-
neum onto the colon in the posterior axillary line.* At this
point the peritoneum is opened, and the hand is inserted
into the abdominal cavity and feels the other kidney. If
another kidney exists and it is found to be healthy, the
diseased organ is removed.

Abdominal nephreotomy is more dangerous than the
lumbar operation. The same instruments are required as
are used in the preceding operation. The position is supine.
The incision is that of Langenbeck — four inches long in the
linea semilunaris, its center corresponding to the umbilicus.
Open the abdomen, introduce a hand, feel the kidneys, and
if both show serious disease do not perform nephrectomy.
Keep the small intestine away by sponges, push the colon
toward the umbilicus, incise the outer layer of the meso-
colon, and bare the kidney. Strip off the peritoneum from
the kidney and its vessels, and ligate the vessels by pass-
ing strong silk through the center of the pedicle with an
aneurysm-needle. Ligate the ureter if healthy, and cut. If
the ureter is septic, fasten it to an opening made in the loin
by cutting onto forceps pushed to the outer edge of the
quadratus lumborum. Stop bleeding, irrigate the belly-
cavity, and dress as usual, employing drainage only when
septic matter has gotten into the peritoneal cavity or when
oozing is persistent.

Partial Nephrectomy. — This operation may be performed
in some cases for wounds, cysts, and innocent tumors. After
removing the damaged or diseased part bleeding points are
ligated with catgut. The wound-surfaces are approximated
as well as possible by catgut sutures. Drainage is intro-

* Kocher's Text book of Operative Surgery.

DISEASES OF GENITOURINARY ORGANS. 783

duced. The value 01 partial nephrectomy in some cases
seems certain, and we should apply it when possible instead
of the complete operation.'

Benipuncture. — This is an operation devised by Reginald
Harrison for the relief of albuminuria due to elevated ten-
sion. The kidney is exposed in the loin and the capsule is
punctured or incised. Simple incision of the capsule will
usually relieve nephralgia.

Nephrorrhaphy (or Nephropexy) is fixation of a mobile
kidney. The kidney is exposed in the loin as above detailed,
and is forced out of the wound by Edebohls's method. The
fibrous capsule is incised longitudinally and a cuff is turned
down on each side. Sutures traverse the kidney-substance
and two layers of capsule on each side. The upper suture
catches the periosteum of the last rib, the lower sutures
catch the lumbar fascia. Drainage is not required. The
suture-material is kangaroo-tendon or chromicized catgut.
Kocher's incision is shown in Fig. 64, Many surgeons
simply pass sutures through the uncut capsule and kidney-
substance, and fasten the kidney to the lumbar fascia. Other
surgeons split the capsule, pull it into the wound, and pass
sutures through only the capsule and wound-edges. After
nephrorrhaphy keep the patient in bed for three weeks. A
kidney which has been anchored will not unusually loosen
at some future time.

Ureterolithotomy. — If the stone is impacted in the upper
two-thirds of the tube, make the incision advised for wounds
of the ureter (p. 772). The operation is extraperitoneal. The
tube is opened by a longitudinal incision. The stone is re-
moved. The ureter is explored by means of a sound. It is
not necessary to suture the ureter. The tissues above the
ureter are sutured and a drainage-tube is carried to the ureter
(Fenger). If the stone cannot be reached by the extra-
peritoneal method, open the peritoneal cavity and incise the
ureter. After removing the stone suture the wound in the
ureter with silk inversion-sutures, fasten an omental graft
over the suture-line (Fenger), and drain.

Uretero-ureterostomy (Van Hook's Operation). — In this
operation ligate the lower end of the divided ureter with
silk or catgut. About one-fourth of an inch below the liga-
ture make an incision in the lon^ axis of the tube. This
incision is in length equal to twice the diameter of the tube.
Each end of a piece of fine catgut is threaded to a fine

* See Oscar Bloch in British Med. Jour.^ Oct. 17, 1 896; also, reports of
Czemy, Bardenheuer, Tuflfier, KUmmell.

784

MODERN SURGERY.

needle. This thread is passed through the upper end of
the ureter (Fig. 286). The needles are made to enter the
lower end of the tube through the door made by the sur-

FiG. 286.— Van Hook's method of ureteral anastoinoKto.

geon. They are pushed through the wall of the ureter one-
half an inch below the window (Fig. 286). Traction upon
the strings causes invagination and the ligature-ends are tied.
If the operation is intraperitoneal, the ureter is wrapped
about with peritoneum.

Diseases and Injuries of the Bladder.

Retention of Urine. — By this term is meant an inability
to empty the bladder. The retention may be complete, not
a drop emerging, or it may have been complete, a dribbling
setting in after a time, due to paralysis of the bladder, which
cannot contain more fluid, expulsion of the ov^erflow from the
ureters being produced by atmospheric pressure. This con-
dition is known as the engorgemcjit, the oi^erfiow, or the in-
continence of retention. There may be a partial retention
from enlarged prostate, a portion only of the urine being
voided. Retention may be caused by — ^i) obstruction, result-
ing from urethral stricture, hypertrophied prostate, inflamed
prostate, occluded meatus, impacted calculus, urethral tumors,
complete phimosis, fecal impaction, and pressure from large
tumors, or by (2) defective expulsiofi, resulting from paralysis.

DISEASES OF GENITOURINARY ORGANS. 785

disease or injury, atony, reflex inhibition, shock, muscular
weakness of fevers, and the action of such drugs as bella-
donna, opium, or cantharides.

Symptoms. — In acute retention there is an agony of desire
to urinate, the patient making acutely painful straining-efforts,
during which feces are often passed. There are severe pain
and aching in the abdomen, thighs, perineum, and penis.
All the symptoms rapidly increase, a typhoid state is inau-
gurated, and death closes the scene unless relief be given.
If retention is from time to time alleviated by the passage
of a little water, the symptoms are slower in evolution and
are less intense, and the case is said to be chronic. Some
cases of gradual onset, due to atony, are very insidious, the
patient feeling no particular pain and complaining only of
the dribbling, which is really the overflow of retention, and
is not a sign that the bladder is successfully emptying itself.
In any case of retention the bladder rises above the pubes,
and there is found a pyriform, elastic, fluctuating tumor (dull
on percussion) in the hypogastrium, which tumor gradually
enlarges until the bladder is evacuated or incontinence sets
in. The flanks give a clear percussion-note, and the tumor i&

Fig. 387. — Gouley's tunnelled catheter, threaded over a filiform bougie.

more prominent when the patient is erect than when recum-
bent. Long continuation of obstructive disease, producing
partial retention with or without attacks of complete reten-
tion, disorganizes the kidneys. Acute and complete retention
may induce rupture of the urethra or urinary suppression.

Treatment. — Place the patient upon his back, keep him
warm, and if instrumentation does not rapidly succeed, give
an anesthetic. Be sure that every instrument is aseptic.
In organic stricture try to pass a soft catheter; if this
fails, endeavor to insert a hard catheter. Try a large size
first, and gradually go to smaller sizes if the larger instru-
ment will not pass the obstruction. When the instrument
enters the bladder draw off* but half of the urine, withdraw
the instrument, wait a few hours, insert it again and then
empty the bladder and wash out the viscus with hot boric-

786 MODERN SURGERY.

acid solution. To draw off all of the urine at once is dan-
gerous, because the sudden relief of pressure from distended
veins leads to bleeding from the mucous membrane and
hemorrhage into the bladder-walls. Fig. 289 shows several
varieties of rubber catheters, and Fig. 291 shows a silk
catheter. Fig. 290 shows the proper curve and the im-
proper curve for a, metal instrument. After the bladder has
been emptied the patient is wrapped in blankets, a bag of
hot sand is placed against the perineum, and a hot-water bag
over the hypogastric region ; when he recovers from the
effect of the anesthetic he is given suppositories of opium
and belladonna, and tablets of salol and boric acid are
administered for several days. If it is found impossible to
insert a rubber instrument or a metal catheter, make an
attempt to carry a filiform bougie into the bladder. Fig. 288
shows filiform bougies. If the stricture is known to be
organic from previous history, at once insert a filiform
bougie. On this bougie Gouley's tunnelled catheter can be
threaded (Fig. 287) and carried into the bladder, the viscus

being half emptied. Instead of carrying in the
/" \ I catheter, we can leave the filiform in place,

and fasten it. The filiform bougie will act
as a capillary drain, and in a few hours
will empty the bladder. Then insert an-
other bougie beside the first, and so on
for several days, using also opium, order-
Fio. 288— Poinu ing rest in bed, and making no attempt to
w gu'rii ''*'^''" dilate the stricture forcibly until retention

has ceased and inflammation has subsided.
If no bougie can be passed, aspirate or perform cystotomy (su-
prapubic or perineal). In spasmodic stricture hold a good-sized
metal catheter firmly against the face of the spasmed area :
relaxation will occur and the instrument will eventually pass.
An individual who has an organic stricture which has given
but little trouble may develop attacks of retention because
of inflammatory edema of the mucous membrane and spasm
of the urethral muscles. These attacks are temporary, and an
instrument can usually be inserted when employed as above
directed. In iuflaminatio7is give a hot hip-bath and sup-
positories of opium and belladonna, and then use a hot
sand-bag to the perineum and a hot-water bag over the
hypogastrium. If these fail or if the symptoms are urgent,
pass a soft catheter. In the occluded meatus of the tte^u-
bom incise with a tenotome. In a congenital cyst of the
sifius pocularis pass a steel bougie, which will rupture

DISEASES OF GENITOURINARY ORGANS.

787

the cyst. In complete phimosis split up the prepuce. In
impacted stone try to pull it out with urethral forceps; if
this fails, push it in or cut. In fecal impaction scrape out
with a spoon. In enlarged prostate insert a coude cath-
eter (Fig. 289, K) strengthened by the insertion of a filiform

Fig. 389. — a, French olivary gum catheter: ^, Mercier's elbowed catheter (coud^) ;
Cf Mercier's douible-dbowed catheter ; </, curved gum catheter.

bougie nearly to the beak (Brinton), or pass a silver instru-
ment with a large curve. In retention from expulsive defect
use a soft catheter. Cases of retention require warmth, con-
finement to bed, the administration of laxatives, free action
of the skin, and the use of such drugs as salol, boric acid,
and quinin to asepticize the urine. In some few cases no
instrument can be in.serted in the bladder. In most of such
cases aspirate — ^which may be done several times if necessary
— and in a day or two, when swelling and congestion abate,
an instrument can be passed. A small trocar or an aspirator-
needle is pushed into the bladder, the trocar or needle being
inserted in the median line, just above the pubes, and taking
a course downward and backward. The parts are first pre-
pared antiseptically, and the puncture is dressed with iodo-
form and collodion. Only half of the urine is withdrawn
at a first aspiration. Rectal puncture is now obsolete. The
perineal incision is not advocated for retention unless rupture
of the urethra has taken place. When a catheter is used for
retention the patient must be recumbent to minimize shock.

Injuries of the Bladder. — This viscus is so deeply situ-
ated, and the abdominal walls are so elastic, that it is rarely
injured when empty. If the bladder be full and the abdomen
be tense — which is common in alcoholic intoxication — force
applied upon the abdomen may injure the bladder.

Contiision of the Bladder. — In this condition there are
noted, vesical hematuria, tenesmus, severe cystitis, and an
impediment to the flow of water because of clots. Hemor-

788 MODERN SURGERY,

rhage may be very severe and sepsis may arise, even causing
death. When contusion exists retention is relieved by a
clean soft catheter ; if this fails because of occlusion of the
eye of the catheter with blood-clot, there must, from time
to time, be forced through the catheter by an irrigator a solu-
tion of sodium bicarbonate in cooled boiled water. Gross's
blood-catheter can be used, or the evacuator of Bigelow
may be employed. The patient is put to bed, a hot-water
bag is applied to the hypogastrium, morphin is administered
in moderate doses, the bladder is washed out several times

Fig. 990. — A B E shows the proper curve ^reduced in size) for unyielding male urethral

instruments ; C B D snows an improper curve.

a day with boric-acid solution to disintegrate and remove
blood-clots, and the urine is diluted and rendered aseptic by
the stomach administration of salol, boric acid, and liquor
potassii citratis. Hemorrhage usually ceases on relieving
distention ; if it does not, some more radical measure must
be employed (see Hematuria).

Besides contusions, the bladder maybe injured by bullets;
by stabs or punctures through the abdomen, the vagina, or
the uterus ; or by penetration by a fragment of a fractured
pelvic bone. The symptoms of such conditions are those
of rupture of the bladder (^. z/.). In any intraperitoneal
wound at once open the abdomen, suture the wound in the
bladder- wall, irrigate the peritoneal cavity, and drain the
bladder by means of a retained catheter, a perineal section,
or a suprapubic cystotomy. In an extraperitoneal wound
drain the wound by a tube, and drain the bladder by a re-
tained catheter, a perineal section, or a suprapubic opening.

Rupture of the bladder occurs in three forms: (i) intra-
peritoneal— a rupture involving the peritoneal coat ; (2) ex-
traperitoneal— a rupture of a portion of the bladder not
covered by peritoneum ; and (3) subperitoneal — a rupture of
the mucous and muscular coats, the urine diffusing under

DISEASES OF GENITO-UFINARY ORGANS. 789

the peritoneal investment The causes are of two kinds,
predisposing and exciting. Predisposing causes are — disten-
tion of bladder ; drunkenness ; ulceration ; degeneration or
atony of the bladder-coats. Exciting causes are — obstruc-
tion to outflow of urine (by stricture or enlarged prostate) ;
external violence ; falls upon the feet and the buttocks, as
well as upon the abdomen; lifting; straining at stool, in
micturition, or during parturition ; and the forcing of injec-

^<<',<js^^,,^<^^^^^^''^T'^''''^''^''^^

Fig. 391. — English silk-web catheter.

tions into the bladder. This accident is commoner in men
than in women (10 to i), and is rare in children.

Symptoms^ Diagnosis, and Treatment. — The symptoms are
not always definite, and every characteristic one may be for
a time absent, the patient seeming in some rare instances to
possess the power of retaining his urine and of voiding it.
As a rule, however, there are found some or all of the follow-
ing symptoms, following an accident or occurring during the
progress of a causative disease : collapse ; excessive desire
to urinate ; inability to do so ; a catheter, when used, brings
away pure blood or a very little bloody urine ; the catheter
occasionally slips through the tear into a cavity, and more
bloody water comes away ; severe hypogastric pain comes
on after a temporary sense of relief from retention ; shock
is so severe that death may ensue ; if reaction follows, there
is delirium, often septicemia and peritonitis ; extensive infil-
trations of urine may occur. In intraperitoneal rupture gen-
eral peritonitis is certain to arise, but its appearance may
be postponed for several days if the urine is healthy. In
these cases the extravasation is noted as a simple swelling,
probably on one side only. In extraperitoneal rupture the
urine may infiltrate the perineum, the scrotum, the thighs,
and under the integuments of the abdomen and the back,
and may soon induce sloughing. In subperitoneal rupture
peritonitis is apt to arise. Injecting fluid fails to lift the
bladder into the hypogastric region so as to be recognizable
on percussion. If there is injected a measured amount of
fluid, less will run out than went in.

In doubtful cases pump air into the bladder. A bicycle
pump can be used (Brown), or a Davidson syringe (Keen).
Keen's directions are to insert a catheter, empty the blad-
der of urine, and connect to the catheter a disinfected

790 MODERN SURGERY.

Davidson's syringe, a mass of absorbent cotton being fast-
ened over the distal end of the syringe. Air after it has
filtered through the cotton is pumped into the bladder : an
unruptured bladder will rise above the pubes as a pyriform
tumor, tympanitic on percussion ; a ruptured bladder will not
so rise, but the air will pass into the general peritoneal cavity.
In intraperitoneal rupture the general peritoneal cavity will be
distended with the air. In extraperitoneal rupture injection
will produce emphysema of the extra vesical connective tissues.
On removing the syringe the air rushes out again if the
bladder is unruptured, but little if any comes away if it is
ruptured. Senn recommends injecting hydrogen gas instead
of air. The treatment of rupture of the bladder is the same
as that for wounds of the bladder.

Atony of the bladder is a condition in which the expul-
sive power of the bladder is diminished or lost because of
impairment of muscular tone. The bladder is very thin,
and the muscles are flaccid and often the seat of fatty degen-
eration. Sometimes the bladder is very large and sometimes
it is very small. A slight degree of atony is physiological
after middle age. The causes are senility, distention from
true paralysis, chronic over-distention from obstruction, and
acute over-distention.

Symptoms. — In atony of the bladder the patient passes
water frequently (a symptom probably existing for some
years), and especially at night ; he may even do so while
asleep. The stream, when voluntarily passed, has no pro-
jection, but drops at once from the end of the penis. Resid-
ual urine exists for years and may at any time set up cystitis,
and retention with incontinence is apt to occur. This con-
dition is not vesical paralysis resulting from a lesion of the
nervous system.

Treatment. — In treating atony of the bladder measure
the residual urine : if it amounts to four ounces, use a soft
catheter night and morning ; if it amounts to six ounces,
use the catheter every eight hours ; if it amounts to eight
ounces, use the catheter every six hours (J. W. White).
The patient should be taught how to use the catheter and
how to keep it sterile. (For methods of disinfecting cath-
eters see article on Hypertrophy of the Prostate Gland.)
The bladder is from time to time washed out with gr. iij to
the ounce of boric-acid solution at a temperature of ioo° F.
Str>xhnin, electricity, ergot, and cantharides may be ordered.

Vesical Calculus, or Stone in the Bladder. — The

salts normally in solution in the urine may deposit as calculi

DISEASES OF GENITOURINARY ORGANS, 79 1

and may be imprisoned in any portion of the urinary tract.
The commonest calculi are those composed of uric acid,
urates, calcium oxalate, and fusible phosphates. The for-
mation of uric-acid and urate calculi is explained under
Renal Calculus (page 772). Vesical calculi are usually
renal calculi that have passed the ureter and become
enlarged by new accretions. Phosphatic calculi may be
formed in the bladder when chronic cystitis causes and
maintains an alkaline urine. Uric-acid calculi are smooth,
round or oval, and hard, but easily broken. On section
they present the color of brick-dust and are marked by
concentric rings. Their nuclei are dark by comparison.
They are soluble in dilute potassium hydrate, and with
effervescence in nitric acid. They are combustible, and
leave scarcely any ash. Urate of sodium and urate of
ammonium often occur together in stones, and these calculi
are not in rings, are not so hard as the uric-acid stones,
and are fawn-colored on section. Oxalate-of-lime stones
are round with many projecting nodes like the mulberry,
hence the term " mulberry calculus." They are very hard,
and section shows the color to be brown or green and that
they possess wavy, concentric rings. This form of calculus
is soluble in hydrochloric acid. Fusible calculus, which is
composed of magnesic ammonic phosphate with phosphate
of lime, constitutes the commonest form of phosphatic
stones and of large stones. It is light, soft, smooth, and
white, and shows no laminae on section. Some rare forms
of stone are composed of xanthic oxid, cystic oxid, calcium
phosphate or carbonate, and magnesic ammonic phosphate
(triple phosphate).

A stone may be formed having layers of different sub-
stances ; for instance, there is often found a uric-acid nucleus
surrounded by phosphates, the latter surrounded by uric
acid or urates, and these again by phosphates. In some
cases oxalate of lime alternates with uric acid, urates, or
phosphates (Bowlby). Bowlby states that the alternating
uric-acid and phosphatic layers are due to the altering reac-
tions of the urine; that when the urine is acid uric acid
is deposited on the stone, but when cystitis makes the urine
alkaline the stone receives a phosphatic coat.

Anything that favors the formation of an excessive uri-
nary deposit may cause vesical calculus, and among such
causes are defective digestion, failure in processes of oxida-
tion, excess of solids and nitrogenous elements in the diet,
deficient exercise, etc. If to the urinary condition estab-

792 MODERN SURGERY.

lished by the above conditions a catarrh of the genito-uri-
nary tract is added, pus or mucopus in the concentrated urine
may induce stone. Children are predisposed to uric-add
stones, and old people to phosphatic stones. In an old
man with enlarged prostate and chronic cystitis a stone
forms rapidly about any accidental nucleus. The nucleus
may be phosphate-crystals glued together by mucus, a
blood-clot, uric-acid gravel, or a foreign body. Stone is
rare in females because of the shortness, the large diam-
eter, and the ready dilatability of the urethra. Stone is very
rare in the negro. Gout, rheumatism, lithemia, enlarged
prostate, vesical atony, urethral stricture, and catarrhal in-
flammation of the kidney, the ureter, and the bladder, are
predisposing causes.

S3niiptoin8. — In not a few cases the vesical symptoms are
antedated by an attack of nephritic colic. The severity of
the symptoms depends more on the roughness of the stone
than on its size. A small, rough calculus will produce intoler-
able anguish, whereas several large, smooth stones will cause
but moderate pain. A patient with stone in the bladder
complains of frequency of micturition, particularly in the
daytime, the desire being sudden, uncontrollable, and in-
voked or aggravated by exercise. This symptom is more
positive in youth than in old age. Pain of a sharp, burning
character is experienced at the end of micturition, due to
the contraction of the empty bladder upon the stone. The
usual seat of this pain is the under surface of the head of
the penis, a little behind the meatus, and the pain may con-
tinue for some time. By pulling on the penis to relieve this
pain the prepuce often becomes pendulous. This pain varies
in severity, being worse during cystitis and after exercise ; it
may be absent in encysted stone, it may even almost disap-
pear, and it is always worse in the young than in the old.
Stone in chronic cases of atony and in cases of vesical
paralysis causes neither marked pain nor frequency of
micturition.* Attacks of cystitis in a man with calculus
are spoken of as attacks of stone. When a stone is small it
may during micturition roll into the urethral orifice, and so
cause a sudden interruption of the flow of water, the stream
again starting when the patient changes his position. This
symptom is rare in the old, the stone in them dropping into
the sac back of the prostate and belou^ the urethral orifice.
Hematuria may or may not be noted ; it is most usual after
exercise, and occurs at the end of the urinary act. Pus or

* American Text-book of Surgery.

DISEASES OF GENITO-URINARY ORGANS, 793

mucopus will be observed if cystitis occurs. Priapism occurs
in some cases. Pain of a reflex nature may be felt in the
rectum, in the perineum, or in some distant part.

The above symptoms, even if all are present, do not prove
that an individual has a stone in the bladder. To prove the
presence of a stone, it must be touched with a sound and
the contact must be felt and heard. To sound a patient, have
the bladder well filled with water, and place him recumbent
with the knees drawn up. Never sound a person while he
is standing, because of the danger of syncope. In an ordi-
nary case use a sound with a very slight curve; in a man
with hypertrophied prostate use a sound with a short and
decided curve. The caliber of a stone-sound is No. 13
French. The instrument is carefully boiled and anointed with
glycerin. Examine the entire bladder systematically, and
never operate unless a stone be both heard and felt. The
stone may be hard to find, or it may elude the instrument
entirely when it is encysted, when it rests in a diverticulum,
when it is fixed to the roof or anterior wall of the viscus, or
when it is crusted with lymph or blood-clot. In doubtful
cases always insist on a second examination, giving ether if
the first was very painful. Occasionally a small stone will
be found by using a Bigelow evacuator, the current causing
the calculus to knock against the tube. In many cases stone
in the bladder may be detected by means of the JT-rays. A
stone, when it is detected, should always be measured by an
arrangement like a lithotrite. The composition of the stone
is assumed from an examination of fragments which pass by
the urethra or which adhere to the measure. Remember that
the outer layer of a calculus may be soft phosphate and the
inner portion may be the harder uric-acid, urates, or oxalates.
Examine for stone in females with a straight sound, and in
cases of uncertainty dilate the urethra and explore the bladder
with the little finger.

Treatment. — In people predisposed to stone (for instance,
by lithemia) the physician should foresee the danger and essay
to antagonize it. Insist on the urine being kept dilute by the
freest use of water and of milk, and reduce to a minimum
the amount of alcohol, meat, sugar, and fat which is taken.
Let the patient live chiefly on green vegetables, salads, bread,
fruit, eggs, fish, poultry, weak tea or coffee, water, milk, and,
if desired, a little red wine. Continued purging does harm by
concentrating the urine, though a laxative may be employed
when indicated. Moderate open-air exercise is of immense
importance, sunshine and fresh air being Nature's correctives

-^ j£:z £i:y izjL zul r.

fcr i r-ciiriic :c — 7*crisct nDOzrirc pDiPC. If tie urine be
Ttr^r ttTi*. -*-t p:^era.:ir, ^ x"*' i: ^. xx :i2i-y. Bqaic pcC2ssn

- ^^ ^^^ ._^,_^-__ ' ^ _ - — •» " _ ■^ _ - « "■*? «

:f ^c i-fc JLiir :c s*:*:iz — Trivtl 2nd rest ii the seaside or ai

WlirT. = itrr>e is :oze ^rrzK-i h if iz izLt crcsm to timk
ct iLf>:I-*'-r^ n. .\r. rocrxr-rc riust be iirfc. Tbe opersnon
s^-rzz^rz icc^sn-ds ur*:- ire s^e. tbe >r<:e :■:" the bladder and
tbe rr:-?Cire. tb«t £liiibiZrr.- rt tbe urt^brs^ tbe 4dcr>e%' ccvn-
chfin, tbe 5ize ar.o rrG-p>st:oc: :f tbe 5C>:>e.anc tbe sinziber

Cystitis. — t:5an:2Lai>>:: c-c tbe bladder is. as a rule, a

con:r>bcaS::i cf socne ocber disease « tbe fjenito-urinan-
tract- b-t It mav arise frosi cold and wet. Traumatism from
a catbeter. tbe pre^etice zi a stone, tbe spread of a '*2rediral
infl-.r^rr-rtt: ?ri. :>-.is baectiori, tbe existence of t jbeirulosis or
cancer, and tbe use :•€ sucb a dru^ as car.tharides, znay pro-
duct :t- It aooears not unusuallv curiniT an exantbetnatous
fe%'er or in c rnditfons of vesical paralyas : it oiten folJon-s
retenncn. frequently acr?n:pan:es enlarged pr:-state and ure-
thnil stnrrure. mi s?n:et:n:e5 an:>es :r?ni crncentnatfon of
unr.e :r a:c:n:z-in:es b'iiier c^:-\^h>. A ru:e c\'>t:r:s causes

:s prj>tr.t a catarrha.! c:> charge 'vhich is n:ixec '^^ith unnan*
element?, semn:, mucus, often cus and epitbelial debris. Ul-
ceration, slou^hir.^. or false-membrane formation may occur.
Chronic cv'stit:? i? an inflammatory* condinon al'i.vavs due to
bactcna. We frccuentlv soeak --f a chronic c\*stitis as due to

tum.:»r of the bladder. These ciir.ditions do not cause
chrorr.z q.stitis. but act by rencerir.^ the bladder vulnerable
to m.:cro-or;;anism5. Am*on^ the causative ori::ani<ms we
mav m-jntion the bacillus co'A com.munis. the sronococcus.
the bacillus tuberculosis, the bacillus rvohosis. and the
varioj- •j\'0''enic bacteria t Leonard Freeman-.

In chrr-nic cystitis ther*. is an enormous production of
thick-, stick'^- mucus and the urine becomes alkaline. The
'.-xce-sive secretion of mucus and tht_ creat number o\
b.ict'jria convert the urea into carb-^-nate -M ammonium, and
t'ni- :>»roduction. bein;^ irritant to the bladder-walls, makes

DISEASES OF GENITOURINARY ORGANS, 795

the inflammation worse. In chronic cystitis the bladder is
contracted and has very thick walls, and the mucous mem-
brane is thick, edematous, congested, and filled with large
veins. The bladder may be ulcerated or be encrusted with
urinary salt. The urine contains bacteria, triple phosphate,
pus, blood, and mucus, the blood emerging with the last drops
of water. Pyelitis may arise as a result of chronic cystitis.

S3nnptoins of Acute Cystitis. — Great frequency of mic-
turition, with the passage at each act of a very small quan-
tity of urine; the desire to urinate is almost constant, and
there is intensely painful straining (tenesmus). The pain is
acute and scalding, and may be felt above the pubes or in
the perineum; it often runs into the loins and the thighs
and radiates over the sacrum. Pain above the pubes indi-
cates involvement of the fundus, and pain in the perineum
and in the head of the penis points to inflammation of the
bladder-neck. The urine, at first clear, loses its transparency,
becomes full of thick mucus, and often contains a little blood
or pus. The patient not unusually has some fever. A rectal
examination causes violent pain. If ischuria takes place, there
will be a chill and high fever, and anuria may occur or vesical
rupture may ensue.

Treatment. — In treating acute cystitis try to remove the
cause. If cystitis arises from the administration of canthar-
ides, put the patient in bed and give him liquor potassii
citratis. If it comes from the use of a clean sound, order
rest in bed, suppositories of opium and belladonna, diluent
drinks, and the use of ammonii benzoas or of lupulin. If
the inflammation is septic (as from the use of a dirty sound),
or is very acute, put the patient in bed, keep him warm, and
use a hot sand-bag to the perineum and hot fomentations or
poultices to the hypogastrium. Hot hip-baths may be used.
The hips had best be elevated and the bowels be emptied by
salines and glycerin enemata. An exclusive milk-diet is
desirable. The patient should drink copiously of sweetened
water containing a few drops of aromatic sulphuric acid or
of milk of almonds. An excellent remedy is the combina-
tion of equal parts of the infusion of herba hemiare and
chenopodium ambrosioides, three glassfuls, sweetened with
sugar, being given every day (v. Zeissl). If the pain and
straining still continue, order —

B. Ext. sem. hyoscyamin., grs. viij ;

Ext. cannabis indicse, grs. viij ;

Sacchar. alba, grs. xlviij. — M.
Div. in pulv. No. xx.
Sig. One powder every three hours. (Von Zeissl.)

796 MODERN SURGERY,

Or,

B* Camphora, grs. viij ;

Ext. cannabis indicse, grs. viij ;

Sacchar. alba, gis. xlviij. — M.

Div. in pulv. No. xx.
Sig. One powder every three hours. (Von Zeissl.)

Suppositories of extract of belladonna are of great value.
Suppositories each containing gr. j of ichthyol are of service ;
and one should be used every four hours. If these remedies
fail, the surgeon will be driven to opium, which, unfortu-
nately constipates ; when it is used, secure evacuations by
glycerin suppositories or by enemata. Give a suppository
containing gr. j of powdered opium and gr. \ of the extract
of belladonna every three or four hours. Hypodermatic in-
jections of morphin may be required. If retention occurs,
use a soft catheter. If much blood is passed, give internally
the tinctura ferri chloridi and blister the perineum. A very
acute cystitis is rarely arrested within a week or ten days.

Symptoms of Chronic Cystitis. — This condition may be
a legacy from acute cystitis, or it may appear without any
acute precursory phenomena. There will be found frequency
of micturition, but not so great as in the acute form ; there
will be slight tenesmus, and moderate pain from time to time,
running toward the head of the penis. Constitutional symp-
toms arise only when kidney-damage has become pronounced
or sepsis has occurred from absorption. The urine is ammo-
niacal, fetid, and turbid; it is filled with viscid, tenacious
mucus or with muco-pus ; it contains a great excess of
phosphates, and occasionally clots of blood. The condition
of chronic cystitis with the production of immense quanti-
ties of thick mucus is often called " chronic catarrh of the
bladder." This state of the bladder may eventuate in the
formation of stone or in the production qf serious diseases
of the bladder, the ureters, and the kidneys. It often occa-
sions retention. Chronic cystitis may be due to tuberculosis.
Some cases come on suddenly, many tubercle bacilli being
found in the urine. In many cases no tubercle bacilli are
found. The tubercular products caseate or fibrous organi-
zation takes place. A cystitis for which no cause can be
found, and which is accompanied by pyuria and pain, is
possibly tubercular. The cystoscope in these cases should
only be used by an expert.

Treatment. — In treating chronic cystitis remove the cause
if possible, get rid of a stone, evacuate residual urine fre-
quently, dilate a stricture, and remove a tumor. For chronic

DISEASES OF GENITOURINARY ORGANS, jgj

cystitis there are used certain remedies by the mouth. Water
is drunk in large amounts, also iron spring-water (Marienbad,
etc.). Salol and boric acid, gr. v of each four times a day,
are very valuable. Salol in fluid extract of triticum repens
does good ; so does chlorate of potassium, gr. x daily. Alum,
tannic acid, uva ursi, copaiba, cubebs, buchu, and turpen-
tine have all been recommended, and possibly may be of
some benefit. Urotropin is useful in cases of chronic cyst-
itis. This drug prevents the development of bacteria in the
urine (Nicolaier), and antagonizes the tendency to sepsis and
urinary poisoning. It is given in s-grain capsules, from four
to six being given daily. Whatever remedy is used, see that
the bowels move once a day, and that the skin is active.
Champagne and beer must be avoided in chronic cystitis.
If residual urine gathers, a soft catheter must be regularly
used. If it is possible to introduce a catheter of consider-
able size, catheterization may be all that is needed in the case.
If it is not possible, or if the case is very severe, the bladder
must be washed out daily with peroxid of hydrogen (25 to
40 per cent, solution), nitrate of silver (i : 8ocx>), boric acid
(S to 10 per cent), carbolic acid (i : 500), corrosive sublimate
(from 1 : 50CX> to i : 20,000), or permanganate of potassium
( I to 4000). If nitrate of silver or permanganate of potassium
is used, first rinse out the bladder with distilled water. If any
other agent is used, wash out the bladder with boiled water.
The daily injection of a 2 per cent, solution of ichthyol may
prove useful. Some surgeons occasionally employ, at intervals
of a number of days, strong silver solutions (30 or 40 grains
to the ounce). If a strong solution is used, after the drug flows
out wash out the bladder with a solution of common salt.
The bladder is usually washed out by attaching to the free
end of a soft catheter, the other end of which is in the blad-
der, a tube which is connected with a graduated bottle, the
force being obtained by elevating the reservoir (fountain
irrigation). The bladder can be irrigated without using a
catheter, the resistance of the compressor muscle of the
urethra being overcome by the pressure of a column of
water. The reservoir is raised to the height of six feet.
The patient sits in a chair. The tube of the reservoir has
upon it a clamp to control the flow, and in its end a large
bulbous tip which will fill the meatus. The tip is inserted
into the urethra, the clamp on the tube is loosened, and the
patient is directed to take a deep inspiration. In a short
time the bladder fills with water, the tube is removed, and
the patient empties the viscus naturally (Felick). In some

798 MODERN SURGERY,

cases it is necessary to wait quite a while for the column of
water to tire out the muscle. If the fluid will not enter,
direct the patient to urinate, and then make another
attempt. After a little practice a patient learns how to
admit the fluid.

In tubercular cystitis Collin advises the instillation of the
following mixture into the bladder and posterior urethra:
S gm. of guaiacol, i gm. of iodoform, lOO gm. of sterile olive
oil. About 30 minims of this are injected (1.2 c.c.) once a
day. In ordinary non-tubercular cystitis he uses a i per cent,
solution in oil of guaiacol carbonate. If these methods fail
to improve a chronic cystitis and the patient's health is
breaking down, drain by perineal or suprapubic cystotomy
(see Perineal Section, page 736) and through the incision
wash the bladder frequently and thoroughly.

Tumors of the Bladder. — These tumors may be either
innocent or malignant, the latter being the commonest.
Innocent tumors are papillomata or villous tumors, mucous
polypi, and fibrous polypi ; malignant tumors are sarcoma
(rare) and carcinoma, encephaloid (rare), epithelioma (com-
mon).

Symptoms. — The innocent tumors rarely cause cystitis or
irritation, though by obstructing the ureters or the urethra
they may induce disease of the kidneys. Often hemorrhage
is the only phenomenon produced by a papilloma or a
mucous polyp. Malignant tumors cause cystitis, and the
urine contains mucus, blood, and pus. Innocent tumors are
hard to feel with the sound, but malignant tumors are easily
felt. In some cases a tumor can be detected by a bimanual
examination (a finger in the rectum and the fingers of the
other hand on the abdomen). Make a careful study to
determine whether or not growth has infiltrated the pros-
tate, the seminal vesicles, the rectum, or the perivesical tis-
sues. The bleeding in bladder-growths is apt to be profuse,
and it occurs intermittently. Bleeding follows the use of a
sound. The urine should be examined microscopically to
see if it contains villi, portions of fibroma, colonies of cancer-
cells, or fragments of epithelioma (White). A cystoscope
should be employed in order to reach a diagnosis. In
doubtful cases exploratory^ suprapubic cystotomy is advis-
able.

The treatment is by suj)rapubic c\'stotomy and removal
of the growth. The perineal operation only enables the
surgeon to reach and remove growths of small size, pedun-
culated growths, and growths near the neck of the bladder

DISEASES OF GENITO-URINARY ORGANS. 799

(see Operations on the Bladder). Chismore has suggested
the removal of polypoid growths by means of Bigelow's
evacuator. When the growth catches in the eye of the
instrument it is torn off by slight traction and gentle rock-
ing, and the suction which is being made carries it into the
reservoir.

0]>eration8 on the Bladder. — Lateral Lithotomy. —
Lithotomy is the removal of a stone from the bladder.
Lateral lithotomy is an operation which is ^v^xy year be-
coming less popular, but which is still employed by many
famous surgeons, especially for stone in children. This
operation should not be performed if the stone is over two
inches in its short diameter; it is rarely justifiable if the
stone weighs three ounces or more (Cage) ; and it must not
be performed for encysted stone, or on a person with a deep
perineum, a narrow pelvic outlet, or an enlarged prostate.
For one week before the operation keep the patient in bed,
wash out the bladder daily with hot boric-acid solution, and
administer salol and boric acid by the mouth, gr. v of each
four times a day. The night before the operation give a
saline, order a hot bath, and have the perineum, the scrotum,
the buttocks, and the inner sides of the thighs cleansed and
dressed antiseptically. In the morning an enema is to be
given. At the time of operation the bladder should contain
several ounces of urine. The instruments required are a lith-
otomy-knife, a straight probe-pointed bistoury, a grooved
staff, a stone-sound, stone-forceps and scoops, a tenaculum,
an aneurysm-needle, a fountain syringe, curved needles and
a needle-holder, hemostatic forceps, a tube with chemise
(Fig. 52), a Paquelin cautery, a Clover crutch, and a litho-
trite.

In performing the operation^ place the patient upon his
back and find the stone by sounding. If the stone is not dis-
covered by the sound, do not operate. Place the buttocks so
that they project beyond the edge of the table, introduce the
staff into the bladder, flex the legs and thighs, and fasten
the patient in the lithotomy position with a crutch. During
the first incision the handle of the staff is held toward the
belly ; after the first cut the staff is set perpendicularly and
is hooked up under the pubes. An incision is made, start-
ing just to the left of the raphe of the perineum and one
and a quarter inches in front of the edge of the anus, and
passing downward and outward to between the anus and the
ischial tuberosity, but one-third nearer the former than the
latter. In the adult this incision is three inches long. The

800 MODERN SURGE R K

first incision is superficial and does not reach the staff, but
it is this incision which may cut the rectum. After making
the first cut the nail of the left index finger feels for the
groove of the staff, the staff is hooked up, the knife is
entered into the groove and is pushed into the bladder, and
as it is withdrawn the wound is enlarged. As the knife
enters the bladder there is a gush of fluid. The finger fol-
lows the knife and stretches the wound, the staff is with-
drawn, and the stone is felt for and extracted with forceps.
Lister showed years ago the value of keeping the finger in
the wound. This maneuver retains some water in the blad-
der, and as a consequence causes the stone to rest at the
lowest part of the viscus, and when the forceps are in-
troduced they at once come upon the stone. In with-
drawing the stone make traction in the axis of the pelvis,
and do not rotate the calculus until it is entirely out of
the prostatic urethra. Wash or scrape away debris or
incrustation, see that no other stone is present, syringe
out the bladder with hot salt solution, insert a tube,
apply antiseptic dressings around the tube, and put on
a T-bandage. The end of the tube which is external to
the dressings is fastened to the tails of the T-bandage.
A rubber cloth is put on the bed, under the body and
legs, and the patient's buttocks rest upon a mass of old
linen, the scrotum being raised on a pad The knees are
bent over pillows. Change the linen as soon as it becomes
wet. Remove the tube in forty-eight hours. The urine
begins to come by the urethra from the eighth to the twelfth
day. In children the incision is not so long, and is dilated
with forceps instead of with the finger ; no tube is required.
In lateral lithotomy the prostatic and membranous portions
of the urethra are opened, the prostate gland is partly
divided with the knife, and the wound is dilated with the
finger.

Suprapubic Lithotomy. — This operation is the removal
of a stone through an opening over the pubes. It is in many
instances the preferable operation. It is used for the removal
of multiple calculi, for very hard stones, for stones above
one and a half inches in diameter, for calculi in men with
enlargement of the prostate, for foreign bodies incrusted with
sediment, when the perineum is deep, when the pelvic outlet
is narrow, and when the urethra will not permit the use of
a lithotritc. The patient is prepared as for lateral lithotomy,
except that the pubes are shaved, and the lower part of the
abdomen and the upper part of the thighs are disinfected.

DISEASES OF GENITOURINARY ORGANS, 8oi

During the operation the penis is wrapped with a piece of
antiseptic gauze. The instruments required are a scalpel,
a probe-pointed bistoury, scissors, a tenaculum, blunt hooks,
hemostatic forceps, retractors, dissecting-forceps, a dry dis-
sector, an electric forehead-light, a rectal bag, a brass syringe
or a bicycle-pump, a sound, rubber tubing, rubber catheters,
stone-forceps and scoops, a bladder-tube, curved needles and
a needle-holder, and a graduated glass jar for injecting the
bladder.

In performing the operation place the patient in the Tren-
delenburg position. It is necessary to distend the bladder
and raise it in order to have a prevesical space uncovered
by peritoneum. Have an assistant oil the rectal bag and
push it above the sphincters. Draw off the urine with a soft
catheter, wash out the bladder with warm boric-acid solution
(i : 32), and inject the bladder with the same solution. In a
child under the age of five inject three to four ounces ; in an
adult inject ten to twelve ounces. Withdraw the catheter
and tie a tube around the penis to prevent the escape of fluid.
Bristow suggested the injection of air. Some surgeons
simply inject air by means of a catheter and a brass syringe
or a Davidson syringe. If air is injected, a rectal bag is
not used, and the patient is placed on his back rather than
in the position of Trendelenburg. The best method of in-
jecting air is that of F. Tilden Brown, by means of a bicycle-
pump. A catheter is introduced, the bladder is washed out,
the catheter is fastened to a bandage, the bicycle-pump is
attached, the operation is proceeded with, and when the
transversalis fascia is exposed the bladder is filled with air,
the soft catheter is clamped, and the bladder is opened.*
After injecting the bladder with fluid, if the viscus is not well
lifted, inject the rectal bag with water and clamp its tube with
forceps. In a child inject from two to four ounces of warm
water into the rectal bag; in an adult inject ten ounces. Make
a three-inch longitudinal incision in the median line of the hy-
pogastric region, terminating over the symphysis. When the
perivesical connective tissue is reached, cut it. If the peri-
toneum should appear, push it up. Hold the wound-edges
apart by retractors. The large veins are seen, giving the
bladder a blue color. Avoid these veins if possible, but even
if they should be cut bleeding will stop when the bladder is
opened and the rectal bag is removed. Clamp bleeding ves-
sels ; catch the bladder transversely with a tenaculum at the
upper angle of the wound ; open the viscus in the middle line

* F. Tilden Brown, Annals of Surgery ^ Feb., 1897.
51

802

MODERN SURGERY.

above, and cut toward the pubes ; catch the edges of the bladder
with hemostatic forceps, and remove the tenaculum. Explore
the bladder, remove the stone or stones, scrape away incrus-
tations, ligate bleeding vessels outside the bladder, and irrigate
the viscus with hot saline solution. Introduce a tube into
the bladder, and attach to its external end a long tube to
siphon off the urine. The bladder can be drained very
satisfactorily by Keen's siphonage apparatus (Fig. 292).

Fig. 292. — Keen's siphonage apparatus : X, cavity to be drained ; /f, reservoir; A', tube
from cavity ; B, lube from reservoir; H, clamp on tube from reservoir; Z.Z,. Z>,glass tulies;
C, rubber tube connecting cavity-drain with reservoir-drain; E, S-shaped rubber tube maiiw
tained in shape by hooking up ai F: G, vessel containing antiseptic fluid.

Suture the muscles and fascia at the upper part of the
wound. Dress with dry antiseptic gauze and a rubber-
dam, the dressings and binder being split to go around the
tube. Catch the urine which siphons over in a bottle con-
taining some antiseptic fluid. Change the dressings as often
as they become wet. Take out the tube in four or five days,
and allow the wound to heal by granulation. The patient
may get up in two weeks. Many Continental surgeons advo-
cate immediate suture of the bladder after incision. The
suture-material should be silk or catgut. Albert, Vincent,
l^assini, DcVlaccos, and others advocate immediate suture.
After suture a catheter is kept in the bladder to drain the vi.scus.
Immediate suture may be employed in patients of any age, but

DISEASES OF GENITOURINARY ORGANS. 803

should not be used if the urine is very septic or if pyeloneph-
ritis exists. In some cases the attempted closure will fail ;
in others it will only partially succeed ; in the majority it will
prove successful ; but even if it only partially succeeds it will
tend to prevent dissemination of urine in the prevesical cellu-
lar tissue.

Crushmgr of Vesical Calculi. — This is now done in one
sitting, the old operation of Civiale, requiring repeated crush-
in gs, being obsolete.

Litholapaxy (Bigelow's operation, or rapid lithotrity) is
the operation for removing a stone in the bladder in one sit-

ting by thoroughly crushing the stone and completely wash-
ing away the fragments. Sir H. Thompson says this method
is suited to twenty-nine cases out of thirt}'. Litholapaxy
should be employed if the bladder will hold at least six
ounces of fluid and is in a fairly healthy condition ; if the
urethra is tolerant and penetrable by instruments; if the
stone is not too hard, docs not weigh over two and three-
quarters ounces, and is not over two inches in diameter. It
is not suited for multiple calculi, for large and hard calculi,
for encysted stones, or for a patient with enlarged prostate,
with vesical atony, or with cy.stitis. An easily dilatable strict-

MODERX SURGER Y.

lire need not prevent the surgeon from doing litholapaxyj
The stricture can first be dilated, and later Bigelow's operaiJ
tion can be performed, but firm, gristly strict"!
ures demand a cutting operation. If the
thra is intolerant of instrumentation, the pa-
tient being prone to febrile attacks when it is
attempted, cut instead of crushing. People
with kidney disease will do better after this
operation than after cutting (Cage). In dia- .
betes, locomotor ataxia, and conditions of J
exhaustion patients are best treated by Bige-9
low's operation, unless cystitis exists.

The preparation of the bladder is the same as for lith-l
otomy. Be sure to measure the stone, and to ascertain^

DISEASES OF GENITO-URINARY ORGANS.

also whether a lithotrite can readily be introduced and ma-
nipulated. The ■ instruments required are a stone-sound,
lithotrites (several sizes) (Figs, 294-256), an evacuating-bulb
and tubes (straight and curved) (Figs, 293, 297), soft catheters,
a glass irrigator to inject the bladder, and instruments in case
the surgeon is forced to cut. The patient is anesthetized
and is placed upon his back, a pillow is' inserted under
the pelvis and he is well wrapped up. The urine is drawn
and a measured amount of warm boric acid is allowed to
flow into the bladder. This plan is better than having
the patient retain his urine, as in the latter case there is
no certainty as to the amount of fluid in the viscus. It is
well to introduce at least five
or six ounces of fluid if pos-
sible. If the bladder will not
hold four ounces the opera-
tion is unsafe (Thompson).
The lithotrite is now intro-
duced, the handle being grad-
ually raised to a vertical posi-
tion as the penis is drawn
up on the shaft, but not
being depressed until the
instrument has passed by its
own weight into the prostatic
urethra. Thompson's plan
for catching the stone is as
follows: after introducing
the lithotrite, let its lower
end rest for a few seconds
on the bottom of the blad-
der, so that currents will
subside ; then draw back the
male blade, wait a moment,
close the blades, and in al-
most every instance the stone
will be caught. If the stone is

the calculus is well held, lock the instrument, and break the
foreign body by screwing. When resistance suddenly ceases
the stone has either slipped or has been crushed; if crushed,
the blades should have been felt forcing through the stone
and the calculus should have been heard to break. When
resistance ceases catch and crush again as abo\'e directed.
Rapid movements with the lithotrite are improper, as they
establish currents which are apt to push away the stone. If

ght, press firmly to see that

8o6 MODERN SURGERY,

the above maneuver does not catch the stone, see if the cal-
culus be near the neck of the bladder. Pull the instrument
close to the vesical neck, and open it, not by pulling the male
blade, but by pushing the female blade. If the operator still
fails to catch the stone, or if, after crushing, a large fragment
knocks against the evacuator, which fragment cannot pass^
conduct a careful search : turn the blades to the right side,
open, and close ; then to the left side, open, and close ; next
turn the point around behind the prostate, open, and close.
In these side turns of the lithotrite, in order to crush, turn
the instrument very slowly, so as to detect the catching of
the bladder-wall if it has occurred, and crush the stone in
the middle of the bladder with the blades up. After crushing
several times, proceed to evacuate. Fill the aspirator with
warm saline fluid. Insert an evacuating catheter, its point
being in the center of the bladder, let the fluid and fragments
run out, and attach the aspirator to the catheter ; turn the
valve, and compress and relax the bulb so that an ounce or
more of fluid is forced in at each squeeze, the compression
coinciding with expiration. The debris falls into a bulb,
and the pumping is continued until fragments cease to pass,
whereupon the point of the catheter is pushed against the
floor of the bladder and another trial is made. If fragments
which cannot gain exit are felt knocking against the tube,
withdraw the evacuator, crush again, and again use the aspi-
rator. When no more debris comes away and no more frag-
ments are felt, withdraw the tube and carefully sound the
bladder. Keyes advises the operator to seek for a final frag-
ment by listening with a stethoscope while pumping at the
bulb and searching the bladder with the tube. This operation
will rarely occupy over forty minutes, though Bigelow has
protracted it for three hours, the patient recovering. A seri-
ous complication is severe bleeding, due to damage done
with the instrument or to the presence of a tumor w^hich
easily bleeds. The injection of moderately hot water usually
checks hemorrhage, but if bleeding is dangerous in amount
the operation of litholapaxy should be abandoned and a
suprapubic lithotomy be performed.

If clogging of the lithotrite with fragments occurs,
forcible pushing of the blades together repeatedly will
probably amend it ; but it will never happen if the sur-
geon uses a proper form of instrument. A lithotrite with a
fenestrated blade will not lock. Forbes's lithotrite is a
very powerful instrument, the blades of which will not lock.
If the blades of a lithotrite should become forcibly and

DISEASES OF GENITOURINARY ORGANS. 807

hopelessly locked, make a perineal section, clear out the
blades, close them, and then withdraw the instrument.

After-treatment, — Put the patient to bed, apply a bag of
hot water to the hypogastrium, and give him a hypodermatic
injection of morphin as he recovers from ether. Give a hot
hip-bath every night, and administer liquor potassii citratis
in moderate doses every day. If urethral fever occurs use
quinin and morphin, wash out the bladder several times daily
with warm boric-acid solution, and tie in a rubber catheter.
If retention occurs use the catheter. If cystitis appears
treat as in an ordinary case. The urine ceases to be
bloody in two or three days, and the patient may get up
in a week.

Litholapaxy in Male Children. — It was considered until
quite recently that a child, because of the small size of its
bladder, the small diameter of the urethra, and the readiness
with which the mucous membrane is lacerated by even
slight violence, was a bad subject for crushing. Lateral
lithotomy is known to be eminently successful when per-
formed upon children. The elder Gross did this oper-
ation upon 72 children with only 2 deaths. Keegan, how-
ever, has persuaded the profession that rapid lithotrity
is perfectly applicable to children: he shows that the
bladder of a child of even less than two years of age is
quite large enough to allow the surgeon to manipulate an
instrument, that the mucous membrane is in no danger if
the operator be careful, and that the urethra is by no means
so small as was supposed. The urinary meatus must often
be incised, and after doing this, Keegan states, there can be
passed in a boy of from three to six years a No. 7 or 8
lithotrite (English), and in a boy of from eight to ten years
a No. 10 or even a No. 14. It is, however, just to state
that the operation is more delicate than a like procedure on
older persons, and that no one is justified in doing it who
has not had considerable experience in adult cases. Further-
more, it should be noted that Keegan's mortality by this
operation has been 4.3 per cent., while Gross's mortality
from lateral lithotomy on children was 2.67 per cent.

Special paints of litholapaxy on male children are as fol-
lows : use well-fenestrated lithotrites ; have a stylet to punch
out the fragments blocking the evacuator; and crush the
stone to a fine mass. There can usually be employed a No.
8 lithotrite and a No. 8 evacuating-tube.

Operation for Stone in Women. — If the stone be small
give the patient ether, place her in the lithotomy position^

BoS MODERN SURGERY.

dilate the urethra with a uterine dilator until it admits the
index finger, and remove the stone with the finger, the
scoop, or the forceps. If the stone is found to be too
large to pass, crush it with a lithotrite and get rid of the
debris by the evacuator. Large stones (two ounces) may
require a suprapubic lithotomy. Vaginal lithotomy is never
required. If done it is very likely to leave as a legacy a
vesicovaginal fistula. In female children dilate the urethra,
crush the stone, and evacuate.

Cystotomy. — This term means the opening of the bladder,
and it is usually applied to an opening made for drainage,
for diagnosis, for the removal of stones and tumors, and for
the treatment of ulcers. This opening may be done by (i)
a suprapubic cut (as in suprapubic lithotomy), (2) a lateral
perineal cut (as in lateral lithotomy), or (3) a median perineal
cut (as in median lithotomy).

Suprapubic Cystotomy. — The operation is employed to
allow the surgeon to explore the bladder, to treat an ulcer,
or to provide drainage, or to remove a tumor. If the oper-
ation is for calculi, it is known as suprapubic lithotomy
(page 800). After the bladder is opened its interior can be
illuminated by the rays of an electric lamp, which appliance
is fastened with a mirror to the forehead of the operator.
The operation is described on page 801. If an ulcer is found,
it is scraped with a curet or a spoon. Most cases of tumor
require suprapubic cystotomy. It is true that a small single
growth at the vesical neck is accessible by median cyst-
otomy, but the area for manipulation is very narrow and the
growth cannot be seen. Every large growth, all cases of
multiple tumors, and all cases of tumor with great depth of
perineum or with enlarged prostate require suprapubic cyst-
otomy, an operation which allows one to feel and to see
the growth, which gives room for manipulation, and which
permits thorough exploration of the entire bladder. The
patient is put in the Trendelenburg position if water dis-
tention is used, but is placed horizontally if air distention
is employed. After opening the bladder as for stone
(page 800) hold the edges of the incision apart by a .speculum
(speculum of Keen or Watson) or by retractors and throw
in the electric ravs. Growths when seen can be twisted
off, a pair of forceps holding the base and another pair
being used to twist. Broad growths are transfixed, li-
gated, and severed. Some growths (as cancer) are removed
piece by piece with Thompson's forceps, the base being
scraped. Soft growths are scraped away with a curet, a

DISEASES OF GENITO-VRINARY ORGANS. 809

spoon, or a finger-nail. If bleeding is severe, check it by
pressure, by iced water, or even by the actual cautery.

Median Cystotomy. — The same incision is made in the
perineal raphe in median cystotomy as for median hthot-
omy. A grooved staff is introduced and is hooked up
under the pubes; an incision is made into the membranous
urethra and is extended backward for tliree-quarters of an
inch, and a finger is carried into the bladder. If searching

for a growth, find it with the finger, catch it with Thompson's
forceps, and twist it off Soft growths can be scraped away.
Stop bleeding by digital pressure or by injections of iced
water. If median cystotomy does not allow access to the
tumor, perform suprapubic cy.stotomy.

Growths in the Female Bladder, — Dilate the urethra as
in a case of stone, and scrape, twist, pull, or ligate the
g[rowth away. If the growth is large or if there are multiple
growths, perform suprapubic cystotomy.

8lO MODERN SURGERY.

Diseases and Injuries of the Urethra, Penis, Testicles^
Prostate, Seminal Vesicles, Spermatic Cokd, and
Tunica Vaginalis.

Injuries may arise from traumatism to the perineum or
the penis, from cuts and twists of the penis, from the pop-
ular " breaking " of a chordee, from tying strings around the
organ, from forcing rings over it, from the passage of instru-
ments, or from the impaction of calculi. Violence inflicted
upon an erect penis may fracture the corpora cavernosa. The
writer saw one man with a glass rod broken off in the canal,
he having been in the habit of introducing it at the dictate of
morbid sexual excitement. A patient in the Insane Depart-
ment of the Philadelphia Hospital had a ring around his
penis, which organ was lacerated into the urethra. These
injuries are treated on general principles.

Perineal Bruises. — If the perineum be bruised without
rupture of the urethra, the perineum and scrotum swell and
become discolored ; water is passed with difficulty because the
extravasated mass of blood in the peri-urethral tissues oc-
cludes more or less the canal ; the water is not bloody ; and
there are pain and profound shock. Some authors desig-
nate as rupture those cases in which laceration of the
spongy tissue occurs, without involvement of the mucous
membrane or of the fibrous coat, but they are properly
contusions.

Treatment. — Place the patient in bed and establish reac-
tion, and when reaction is complete employ opiates for the
relief of pain. Place lint, wet and kept wet with lead-water
and laudanum, upon the perineum, alternating every two
hours with a fifteen-minute application of the ice-bag. If,
notwithstanding these measures, swelling continues, intro-
duce a silver catheter (No. 12 E.), tie it in, and make firm
pressure upon the perineum by a firmly-applied T-bandage
or by a crutch braced against the thighs or the foot-board of
the bed. P2ven when swelling is slight retention may occur
from projection of a submucous blood-clot into the canal of
the urethra. Punctured iuou7ids of the urethra require ordinary
dressings. Incised woujids of the urethra, when longitudinal,
are closed by suture. Healing is rapid, and ill consequences
are not to be feared. Stricture does not follow. When the
wound is transverse, introduce a catheter, suture the wound
over the instrument, and remove the catheter at the end of
the third day. If a catheter cannot be introduced, employ
sutures, but at the first evidence of extravasation open the

DISEASES OF GENITO- URINAR Y ORGANS, 8 1 1

wound, and if drainage is not free perform an external
perineal urethrotomy.

Rupture of the Urethra. — By this term is meant a lac-
erated or a contused wound of the urethra, destroying par-
tially or entirely the integrity of the canal. A lacerated
wound may be induced by fracture of the cavernous bodies
during erection, the symptoms being severe hemorrhage, in-
tense pain, retention of urine, and inability to pass an instru-
ment ; infiltration of urine occurs, and gangrene is a common
result The writer has seen one case of rupture of the penile
urethra due to a man's slipping while shaving, the penis
being caught in a partially open drawer, the drawer being
shut by his body coming against it. Rupture, however, is
almost invariably located in the perineum, and it arises when
the urethra is suddenly and forcibly pressed against the arch
of the pubes by a blow, by a kick, or by falling astride a
beam or a fence-rail. The lesion of urethral rupture consists
in some cases of laceration of the spongy tissue and the mu-
cous membrane, a cavity being formed which communicates
with the canal, and which fills with urine during micturition.
In other cases not only the spongy tissue and the urethral
mucous membrane are rent asunder, but the fibrous coat is
also torn, the canal opening directly into the perineal tissues,
among which a huge cavity forms, that fills with blood and
later with clot, urine, and pus. The urethra may be torn
entirely across, but in most cases a small portion at least of
its circumference is uninjured. Rupture never occurs pri-
marily and alone in the prostatic urethra ; it is extremely rare
in the membranous urethra unless due to pelvic fracture ; and
it is very unusual in the penile urethra. The seat of rupture
in the great majority of cases is in the region of the bulb.
Very rarely is the skin broken.

Symptoms. — The symptoms of rupture of the urethra
are considerable pain, aggravated by motion, pressure, and
attempts to pass water; great shock; in some cases mic-
turition is still possible, blood preceding and discoloring the
stream, for some blood usually runs into the bladder ; reten-
tion soon comes on ; in a vast majority of the cases retention
is absolute from the very first, and it is due to the interruption
in the integrity of the canal and to the occlusion of the chan-
nel by blood-clots. Bleeding, which is usually free, lasts for
several hours, some little blood generally appearing externally
and much being retained in the perineum, inducing progress-
ive swelling. The presence of a large swelling is regarded as
evidence of urethral rupture. The blood which is effused in

8 1 2 MODERN SURGER K

the perineum may extend under the fascia to the penis and
scrotum ; the swelling soon becomes reddish, purple, or even
black, and pressure upon it is apt to cause blood to run from
the meatus. This swelling enlarges when attempts are made
to urinate. After a time, if the surgeon does not act, the
urine fills the perineal cavity and widely infiltrates, and there
ensue gangrene, sloughing, and sepsis, life being endangered
or fistulae being left as legacies. In rupture of the urethra
the course of the extravasated urine will often enable one to
locate the seat of injury. In rupture of the membranous ure-
thra, if uncomplicated, the urine remains between the two
layers of the triangular ligament until a channel is opened for
it by sloughing or by the knife. When extravasation occurs
behind the posterior layer of the ligament the urine finds
its way to the perineum in the neighborhood of the anus.
When the rupture is in front of the anterior layer the urine,
directed by the deep layer of the superficial fascia, finds its
way into the scrotum and up on the belly, but does not pass
into the thighs. A contusion is distinguished from a rupture
by the facts that in the former the perineal swelling is not
very extensive and does not enlarge on attempting mictu-
rition, while in the latter it is extensive and does enlarge
on attempting to pass water. Furthermore, contusion
does not cause urethral hemorrhage, while rupture does.
A contusion sometimes, but not often, prevents the pas-
sage of a catheter; a rupture almost always, but not in-
variably, does so. The mortality from severe rupture with
extravasation is about 14 per cent. (Kaufman).

Treatment. — In some cases it is possible to suture the
urethra, and this procedure should be carried out when pos-
sible. In order to suture perform suprapubic cystotomy and
make a perineal section. Find the posterior end of the rupt-
ured urethra by passing a catheter from the bladder into the
urethra. Suture with silk. The sutures pass through all of the
coats of the urethra. The roof of the canal is sutured first, then
a steel sound is introduced from the meatus, and the urethra
is sutured around the instrument. The sound is withdrawn
and the bladder is drained by Cathcart's siphon as modified
by Keen.* In recent cases of ruptured urethra the usual treat-
ment is as follows : immediate perineal section with turning out
of the clot ; trimming off of lacerated edi^es ; finding the prox-
imal end of the urethra, passing a catheter from the meatus
into the bladder, and leaving it /// situ until healing has begun
around it. In cases of stricture it is a good plan to excise the

* See Weir's report in MfJ. R.\\^'\/, May 9, 1S96.

DISEASES OF GENITOURINARY ORGANS, 813

cicatricial tissue. In cases with extravasation lay open freely
all pockets of urine and proceed as above. If the proximal
end of the urethra cannot be found, either open the bladder
by Cock's method of perineal section without a guide, cut-
ting toward the apex of the prostate gland and carrying the
incision forward into the rent, or perform a suprapubic cyst-
otomy with retrograde catheterization ; that is, push an instru-
ment from the bladder into the wound, and use it to guide
a catheter passed from the meatus into the bladder. The
wound is packed with iodoform gauze, and the bowels are
tied up with opium for a few days. Many surgeons strongly
disapprove of the custom of retaining the catheter, believing
that the instrument does no real good, as urine is certain to
get between the catheter and the walls of the urethra. In fact,
it is quite enough to stuff the wound with gauze, the patient
urinating through the wound for the first few days, after
which time a catheter is used. Whatever method is em-
ployed, healing will require from six to eight weeks, and
the patient must during the rest of his life, from time to
time, introduce large-sized bougies.

Foreign Bodies in the Urethra. — These bodies may
be calculi, bodies introduced by injury, as shot, bone, etc.,
bodies entering from a fistulous opening into the rectum, or
bodies introduced from the meatus, as broken bits of cathe-
ters, straws, pins, etc. The symptoms vary with the size
and the nature of the body. Sometimes there are almost no
symptoms ; at other times there are found great pain, reten-
tion of urine, and hemorrhage. Examination is made by feel-
ing carefully with a finger in the rectum and by searching
very gently with a sound, taking care not to push the body
back. If the bladder is well filled with water when the body
becomes impacted, inject a little oil into the meatus, close
the lips with the fingers, and direct the patient to forcibly
attempt urination, the surgeon opening the meatus when the
urethra is widely distended, the foreign body being often
forced out. If this maneuver fails, and the foreign body
is impacted in the pendulous urethra, prevent its backward
passage by at once tying a rubber tube around the penis.
Try to squeeze the body out, and, if unsuccessful, endeavor
to catch it with a wire loop, with a scoop, or with the long
urethral forceps. If these methods fail, cut down upon the
body and remove it, dividing any existing stricture. If a
hairpin is in the canal, the feet of the pin are almost always
pointing to the meatus ; to prevent them catching on at-
tempted withdrawal, the penis must be squeezed to approxi-

8 14 MODERN SURGERY,

mate the feet, and when they are adjacent a p>art of a silver
catheter is slipped over to retain them in this p>osition, when
the pin can be extracted. If this fails, drag the penis against
the belly, by rectal touch force the sharp ends out through
the integument, cut one end off, and then withdraw the other.
An ordinary large-headed pin is forced out in the same ii-ay,
and when the head is turned externally it is extracted fiom
the meatus. If a lithotrite loaded with fragments be caught
in the urethra, the surgeon must perform a perineal section,
clean and close the blades, and withdraw the instrument

Urethritis^ or Inflammation of the Urethra. — Ure-
thral inflammations can be divided into two classes: (l)
simpU\ in which infection is due alone to pyogenic coed,
and (2) specific, in which the gonococcus is present.

Simple urethritiB may be due to several causes, such as
traumatism ; great acidity of the urine ; chancer in the ure-
thra ; contact with menstrual fluid, leukorrheal discharge,
the discharge from malignant disease of the uterus, ordinal}'
pus, or acid vaginal discharge ; the passage of instruments ;
irritant diuretics; strong injections; worms in the rectum;
venereal excess and masturbation ; and the passage or im-
paction of foreign bodies. A temporary and mild urethritis
sometimes accompanies early syphilitic eruptions. Simple
urethritis is less severe and prolonged than gonorrheal ure-
thritis, though clinically in the early stage the surgeon can-
not invariably distinguish between the two forms. The gono-
coccus is never found in the discharge of simple urethritis.
In the non-specific inflammation pus is not always present
many cases stopping short of pus-formation after a \-ar\-ing
period of catarrh, but any catarrh may become purulent.
A simple urethritis may be caused or may be prolonged for
an indefinite period by the presence of large amounts of
oxalate in the urine or the existence of the uric acid
diathesis (see Goutv Urethritis).

Treatment. — Seek for the cause and remove it. Correct
anv abnormal condition of the urine bv means of suitable
diet, druijs, and mode of life. Mild astrinj^jent injections are
useful. It niav be necessarv to flush out the urethra re-
peatedly with a solution oi silver nitrate ( I : 8000).

Traumatic Urethritis. — The pain in traumatic urethritis
is coincident with the introduction of the foreiOT bodv. The
dischari^e, which may be bloody, mucous, mucopurulent, or
purulent, comes on within twenty-four hours.

Ly\Atmen:. — If the inflammation is slight, prescribe diluent
drinks, paregoric, and a saline. If severe, put the patient to

DISEASES OF GENITOURINARY ORGANS. 815

bed, apply hot fomentations to the perineum, give diluent
drinks, employ suppositories of opium and belladonna, and
watch for fever and other complications.

Gk>uty UrethritiB. — ^This condition first manifests itself in
the posterior urethra, not in the anterior, as does clap. Its
symptoms are great vesical irritability; pain on urina>
tion ; discharge, usually scanty, associated with uric acid in
the urine or other symptoms of gout. The treatment com-
prises dieting and the usual remedies for gout. Purgatives
are given freely, and full doses of colchicum, piperazin, uro-
tropin, or the alkalies ; hot baths, low diet, diluent drinks,
and diaphoretics are indicated. A chronic discharge from
the prostatic region is apt to linger ; for this there is nothing
better than the usual gouty remedies and saline waters with
copaiba, cubebs, or sandalwood oil. In many cases it is
necessary to flush out the urethra once a day with a solu-
tion of silver nitrate (i : 8000).

Eozexnatoiis UrethritiB. — Berkeley Hill states that this
disease is very obstinate, is probably associated with gout,
and is met with in adults of full habit or who are beer-
drinkers and who have eczema of the surface of the body.
He states also that the glans penis near the meatus is red
and tender, and that the interior of the urethra is in the
same condition. Pain is constant, and it is aggravated on
micturition. The discharge is scanty. The treatment com-
prises injections of cold water or irrigation with iced water,
and internally the administration of arsenic with the alkalies.

Tubercular urethritis is due to a tubercular ulcer, which
is most apt to be seated near the vesical neck. There is a
little pain on micturition, but there is intense pain at one
spot on passing a bougie. The discharge is slight and at
times bloody. The bladder is very irritable, and severe
cystitis arises and persists. The treatment includes fresh
air, sunlight, warmth, good food, and cod-liver oil. The
bladder is washed out once a day with boric-acid solution,
but after a time the surgeon will be forced to drain by peri-
neal or suprapubic cystotomy.

Gonorrhea (Clap; Specific Urethritis; Tripper;

Venereal Catarrh). — Gonorrhea is an acute inflammation
of the genital mucous membrane, of venereal origin, due to
the deposition and multiplication of gonococci in the cells
of the membrane and a mixed infection with the cocci of
suppuration. In the male, clap begins within the meatus
and fossa navicularis and extends backward throughout the
length of the urethra. The mucous membrane swells and

8l6 MODERN SURGERY.

becomes hyperemic, and there is a discharge, first of mucus
and serum, and then of pus. In severe cases the discharge
is bloody (black gonorrhea). For a week or more the in-
flammation increases, then becomes stationary for a time,
and then declines, the discharge growing less profuse and
thinner, a watery discharge lasting for some little time.
An ordinary case of genuine gonorrhea lasts from six to ten
weeks, and even a case limited purely to the anterior urethra
will rarely be cured within four or five weeks. During the
acute stage the entire penis swells and the corpus spongi-
osum becomes infiltrated with inflammatory exudate.

Symptoms of Acute hiflammatory Gonorrhea. — The period
of incubation of gonorrhea is from a few hours to two
weeks. The patient notices on arising a drop of thin fluid
which glues together the lips of the meatus, and he feels
some pain on urination. The meatus is red and swollen.
Within forty-eight hours the first stage^ or the stage of
increase, becomes established. The meatus is now red^
swollen, and everted (fish-mouth meatus) ; micturition causes
severe pain (ardor urinae) ; chordee occurs, especially when
the patient is warm in bed. By chordee we mean a condition
of painful erection in which the penis is markedly bent. The
rigid infiltration of the corpus spongiosum prevents it dis-
tending to accommodate itself to the enlarged corpora caver-
nosa, and in consequence the organ curves. There is frequent
micturition with tenesmus, and a profuse discharge which is
yellow, greenish, or even bloody. The complications of this
stage are balanitis (inflammation of the mucous membrane of
the glans penis), ^rt:/a;/^/^^//////i" (inflammation of the surface of
the glans and the mucous membrane of the prepuce), ///////^j/j
(thickening and contraction of the foreskin so that the glans
cannot be uncovered), and paraphimosis (catching and fixa-
tion of the retracted prepuce behind the corona glandis).
In the second or stationary stage^ which lasts from the end
of the first week to the end of the second, the acute symp-
toms of the first stage continue. The complications of
this stage are peri-urethral abscess, lymphangitis, solitary
and painful bubo of the groin which may suppurate, inflam-
mation of Cowper's glands, inflammation of the prostate or
of the bladder, and gonorrheal ophthalmia. In the third or
subsiding stage the symptoms gradually abate, the discharge
becoming scantier and thinner, and finally drying up. This
stage is of uncertain duration, and in it there may occur
epididymitis, or inflammation of the epididymis. Among
other possible complications we may mention gonorrheal

DISEASES OF GENITOURINARY ORGANS. 817

arthritis (page 423), infective endocarditis, tenosynovitis,
pyelitis, perichondritis, and peritonitis. Every urethral dis-
charge should be examined for gonococci in order to
make a positive diagnosis. This examination is made sev-
eral times during the progress of the case, so as to deter-
mine when the organisms disappear. The examination
can be easily made. Place a drop of discharge upon a
cover-glass, lay another cover-glass over this, and slide the
glasses apart. Dry the slides in the flame of an alcohol
lamp. Bring the cover-glasses in contact with a saturated
solution of methyl-blue in 5 per cent, carbolic-acid water.
The staining-material is allowed to remain in contact with
the slides for five or ten minutes, the glasses are washed
with water, placed in a solution of 5 drops of acetic acid to
20 c.c. of water, and kept there " long enough to count one,
two, three slowly," and again washed with water. Exami-
nation with the microscope shows the gonococci stained
blue.^

Subacute or catarrhal gronorrhea develops in men who
have previously had gonorrhea, as a result of prolonged or
repeated coition or of contact with menstrual fluid or leukor-
rheal discharge. There is profuse mucopurulent discharge^
very little pain on micturition, rarely chordee or marked
irritability of the bladder.

Irrita^ve or Abortive Gonorrhea. — In this disease the
symptoms, which are identical with those of beginning clap,
do not increase, but are apt to disappear within ten days.

Chronic Urethral Discharges. — Chronic Urethral
Catarrh, which may follow gonorrhea, is characterized by
the occasional presence of a drop of clear, tenacious liquid.
This discharge becomes more profuse as a result of sexual
excitement or the abuse of alcohol.

The persistence of a small amount of milky discharge,
because of localization of inflammation in one spot or the
production of a granular patch or a superficial ulcer, charac-
terizes chronic gonorrhea. There is some scalding on urina-
tion ; erections produce aching pain ; there are pain in the
back and redness and swelling of the meatus. All the .symp-
toms are intensified by sexual excitement, by coitus, by
violent exercise, or by alcoholic excess.

Gleet. — If a chronic urethritis lasts over ten weeks it is
called gleet. In gleet the lips of the meatus are stuck together
in the morning, and squeezing them discloses a drop of

^ Schfitz's method, as set forth by R. W. Taylor in his work upon Veturettl
Diseases.

8l8 MODERN SURGERY,

Opalescent mucopurulent fluid. During the day the dis-
charge is rarely found. There are frequency of micturition,
pains in the back, and dribbling of urine, and a bougie Hill
usually find a stricture of large caliber. A discharge may be
maintained by chronic prostatitis. In this condition there are
frequency of micturition ; a sense of weight or dull pain in the
perineum ; diminished projectile force of the stream of urine ;
there is often a tendency to sexual excitement and premature
emission. In chronic anterior urethritis there is a discharge
from the meatus or sticking together of the lips in the morn-
ing. In chronic posterior urethritis there is no dischai^e of
pus from the meatus. If two beaker glasses are placed upon
a stand and the patient is directed to urinate first in one
and then in the other, if he suffer from chronic anterior
urethritis, only the first portion will be cloudy and show
shreds ; if he suffers from posterior urethritis of not very
long standing, both portions will be a little clouded, the first
with clap shreds, the second with hook-shaped shreds. In
a very chronic case neither sample will be cloudy, but the
first portion will contain shreds.

Treatment of Acute Ghonorrhea. — Abortive treattnent
should be tried if the case is seen early. The writer formerly
believed that by cleansing the urethra several times a day
with peroxid of hydrogen, following the hydrogen by the
injection of oil of cinnamon and benzoinol, many cases of
gonorrhea could be quickly aborted. Further observations
confirmed by bacterial investigation have shown that he was
in error. True gonorrhea cannot be aborted by the above-
mentioned plan. Other abortive methods are the use of hot
retro-injections of corrosive-sublimate solution (1:20,000),
two pints being run through the urethra once a day ; strong
injections of nitrate of silver or of tannin ; scraping the
meatus or the urethra adjacent with cotton, and injecting 15
drops of a 3 per cent, solution of nitrate of silver. If in
seventy-two hours the symptoms are not greatly improved,
abortive treatment should be abandoned. Recent studies
render it almost certain that there is no real abortive treat-
ment. Abortive treatment, to be efficient, would have to be
carried out before the gonococci penetrated the epithelial
cells ; in other words, would need to be instituted before the
symptoms of the disease appear. Janet says that we must
alter our conception as to what constitutes abortive treatment,
and he doubts if a case of true gonorrhea was ever really
aborted.* The method of irrigation with solutions of perman-

* Ann. d. mat. d. org.gin.-urin.^ 1896, p. 1031.

DISEASES OF GENJTO URINARY ORGANS. 819

ganate of potassium is really a prophylactic treatment. Janet
applies his treatment as evidences of trouble present them-
selves, and before acute symptoms appear, and claims that
in most persons the disease can be arrested in from eight to
twelve days. The same plan of treatment is useful in a well-
developed case.

Janet's method is as follows : an irrigator is filled with a
warm solution of permanganate of potassium (i : 4000). The
patient after emptying his bladder is seated upon a chair and
his sacrum rests upon the extreme front edge of the chair
(Valentine). The reservoir is joined to a glass nozzle by a
rubber tube. The nozzle is introduced into the meatus, and
the fluid is permitted to run gradually at first, with full force
later. In anterior trouble the fluid runs out of the meatus
by the side of the nozzle. The anterior urethra is always
irrigated first, the reservoir being two feet above the chair.

In posterior urethritis, after the anterior urethra has been
irrigated, the reservoir is raised from six to seven feet above
the bed, the meatus is held tight about the nozzle, and the
fluid overcomes the force of the compressor urethrae muscles
and bladder sphincter and enters the bladder. If the muscles
do not quickly relax, continue the hydrostatic pressure for
several minutes, when relaxation will usually occur ; but if it
does not do so, tell the patient to urinate and then repeat the
irrigation (Valentine). When the bladder is full the tube is
withdrawn and the patient micturates. This procedure is
practised once or twice a day for five or six days or even
longer, and the strength of the solution is gradually increased
up to I : icxx). It has been claimed that after one or two
weeks of this treatment gonococci permanently disappear in
the majority of cases. Valentine of New York ^ has con-
structed the following table, which is of use to a practitioner
who wishes to employ irrigations with permanganate of
potassium in the treatment of acute gonorrhea :

First day : two anterior irrigations, i : 2000, 1 : 4000.

Second day : the same, 1 : 3000, i : 4000.

Third day: one intravesical, i : 6000 ; one anterior, i : 6000.

Fourth and fifth days : one intravesical, i : 3000.

Sixth and seventh days : one intravesical, i : 3000 or
1:2000.

Eighth and ninth days: one intravesical, i : 2000 or i : 1000.

Tenth day: one intravesical, 1 : 1000; anterior irrigation,
I : 5000.
If a stricture exists, it is not advisable to employ this treat-

* N. y, Med, Record, June 5, 1897.

820 MODERN SURGERY,

ment. The author has had the best satisfaction from irriga-
tions with fluid containing silver nitrate (i : I2,0CX) to 1 : 8000).
In treating a developed case, order plain, non-stimulating diet
and the avoidance of alcohol, sexual excitement, wet, and
violent or prolonged exercise. The patient should sleep
under light covers and drink much water daily (Seltzer,
Apollinaris, or ordinary water containing bicarbonate of so-
dium). If the foreskin is long, the discharge should be caught
by placing bits of absorbent cotton over the meatus and within
the prepuce. If the foreskin is short, cut a small opening in
a square piece of old linen, slip this linen over the glans,
catch it back of the corona, and bring the ends forward with
the prepuce. If the glans is completely naked, pin an old
stocking-foot upon the undershirt and in it hang the penis.
Order a man to wear a suspensory bandage.

Irritative gonorrhea will subside in a few days. The
above directions should be applied, and the anterior urethra
should be washed out several times daily with peroxid of
hydrogen, or irrigated once a day with a hot solution of per-
manganate of potassium ( i : 4000). In catarrhal gonarrhea, at
once order injections (i grain to the ounce of sulphate of zinc;
or zinci sulphas gr. viij, plumbi acetas gr. xv, water 3viij ; or
gr. V of sulphocarbolate of zinc to 5j of water ; or White's
prescription of Z] each of acetate of zinc and tannic acid, ^iij
of boric acid, 5vj of liq. hydrogen, peroxid.). For injecting
use a blunt-pointed hard-rubber syringe of a capacity of three
drams. Let the patient sit on a chair, his buttocks hanging
over the edge ; throw in a syringeful and let it at once run
out ; throw in another syringeful and hold it in from three to
five minutes. In acute gonorrhea order two capsules three
times a day, each capsule containing 5 grains of salol, 5 grains
of olcoresin of cubebs, 10 grains of balsam of copaiba, and I
grain of pepsin. After the patient micturates he should
employ a mild astringent injection. If an astringent injection
causes much pain, use a sedative injection — ^3ij of boric acid,
gr. viij of aqueous extract of opium, and 5viij of liquor
plumbi subacetatis dilutus. As the inflammation subsides
increase the strength of the injection. A good plan is to
order an eight-ounce bottle and eight half-grain powders of
sulphate of zinc. Direct the patient to fill the bottle with
water, in which one powder is dissolved ; when this is used
dissolve two powders in a bottlcful of water, and so pro-
gressively increase the strength. When the discharge ceases
stop the injections gradually. Whenever a syringeful is
taken from the bottle a syringeful of water is put into the

DISEASES OF GENITOURINARY ORGANS. 821

bottle, and thus pure water is soon obtained, at which point
injection is discontinued.

Argonin, which is a combination of albumin, silver, and an
alkali, is highly recommended by some authors as a local
remedy for gonorrhea (Schaffer, Guthiel). A solution of
this material is non-irritant, the silver is not precipitated by
chlorids, and the agent destroys gonococci. It is used by
injection or irrigation. If used by irrigation employ a 1 : 500
solution twice a day. If used as an injection employ a i : 200
solution six or eight times a day. When the discharge is
found free from gonococci and remains free for three days,
stop the argonin and use an astringent injection.

Methylene-blue internally is occasionally of service in
gonorrhea. A capsule containing gr. ij of the drug is given
three times a day. It turns the urine greenish-blue and occa-
sionally induces strangury.

Ardor urincB is relieved by urinating while the penis lies
in hot water and by administering an alkaline diuretic.
Chordee requires a bowel-movement in the evening and
sleeping in a cool room, under light covers, and on a hard
mattress ; bromid is given several times daily, and a con-
siderable dose is given at night ; it may be necessary to use
suppositories of opium and camphor or to give hyoscin.
Balanitis requires frequent washing with warm water, drying
with cotton, and dusting with borated talc or with boric acid
and subnitrate of bismuth (1:6). Balanoposthitis requires lead-
water and laudanum and injections of black wash under the
prepuce until edema of the foreskin subsides, and then clean-
liness externally and a powder. P/timosis requires soaking the
penis in hot water, injections of hot water beneath the foreskin,
followed by black wash and the use of lead-water and lauda-
num externally. If this fails, circumcision must be performed.
If paraphimosis occurs, grasp the head of the penis with the
left hand, squeeze the blood out, and try to push* the head
back while with the right hand the penis is pulled upon, as
if we intended to lift the individual by this organ. If this fails,
cut the collar on the dorsum with scissors. Bubo requires
iodin, ichthyol, or blue ointment, a spica bandage, and rest If
a bubo suppurates, it must be opened or aspirated. Acute pros-
tatitis and cystitis require confinement to bed, a milk-diet, the
use of alkaline diuretics, hot sand-bags to the perineum and
hypogastrium, suppositories of opium and belladonna or ich-
thyol, leeching the perineum, and the discontinuance of the bal-
sams and injections. Abscess of the prostate requires instant
opening. In retention of urine the patient should try to pass

822 MODERN SURGERY,

the urine while in a hot bath ; if this fails, a soft catheter is
used. After relieving the bladder put the patient to bed and
apply hot sand-bags as for prostatitis. Chronic prostatitis re-
quires cold hip-baths, cold-water encmata, deep urethral injec-
tions, plain diet, avoidance of alcohol and over-exertion, coun-
ter-irritation of the perineum, and the relief of stricture or
phimosis. Great benefit is occasionally derived from passing
a soft bougie covered with blue ointment. In epididymitis
put the patient to bed, stop injections, shave the hair from
the groin and leech over the cord, elevate the testicles, keep
the parts covered with lint wet with lead-water and laudanum,
and from time to time apply an ice-bag. Give a cathartic, a
fever-mixture, and suitable doses of bromid of potassium and
morphin. The application of 20 drops of guaiacol in 3j of
cosmolin or olive oil gives great relief. When swelling
lingers, after tenderness subsides strap the testicle with
adhesive plaster. A lingering case is benefited by the inter-
nal use of iodid of potassium and the local use of ichthyol.
In gonorrheal ophthalmia secure a watch-crystal over the
unaffected eye, put the patient in a darkened room, rub out
the infected conjunctival sac with cotton soaked in a 2 per
cent, solution of silver nitrate, wash out the affected eye often
with hot boric-acid solution, keep the pupil dilated with atro-
pin, leech the temple, give purgatives, and employ hot mus-
tard foot-baths. Always send for an ophthalmologist.

Treatment of Chronic Urethral Dischargres. — Gradually
dilate the urethra with metal sounds. In chronic gonorrhea
try to locate any existing granular or ulcerated patch with
a bulbous bougie. When the point is discovered apply to it,
by a deep urethral syringe, a few drops of a 2 per cent, solu-
tion of nitrate of silver. The strength of the silver solution
can gradually be increased, or other solutions can be substi-
tuted (sulphate of copper or sulphocarbolate of zinc). Pass a
large bougie every other day. Copious retro-irrigation with
hot solutions of corrosive sublimate (i : 20,000), permanganate
of potassium (i : 3000), or nitrate of silver (i : 8000) does good.
In many cases an electric endoscope is an indispensable in-
strument. By means of it the surgeon is enabled to locate
the trouble and treat it locally. A common cause of chron-
icity is lingering inflammation of glandular .structures and
lacunae. These spots should be touched through an endo-
scope tube, from time to time, with silver nitrate (3 per cent.).
A granular patch should be treated in the same manner. In
any lingering case of gonorrhea examine the urine, and direct
suitable treatment for oxaluria, lithemia, or phosphaturia,

DISEASES OF GENITO- URINARY ORGANS. 823

if any one of these conditions exist. Such morbid states of
the urine are occasionally responsible for great prolongation
of the inflammation. In some cases a discharge is kept up by
inflammation of the seminal vesicles (page 834). When may
a man be considered well of gonococcus infection ? When
shreds disappear from the urine ; when an examination on
three successive days fails to find gonococci ; when the urine
is free from pus, and when there has been no discharge for
ten days.

Gonorrhea of the rectum occasionally, though very
rarely, occurs. It may result from pederasty, or in a woman
from a flow of infectious material from the genitaUa to the anus.

Gonorrhea in the female may affect the vulva, the
vagina, the urethra, or the uterus. The danger is the devel-
opment of metritis or salpingitis. The treatment for vul-
vitis is to place the patient upon a low diet and put her at rest
with the pelvis elevated ; every two or three hours spray the
parts with peroxid of hydrogen, dry them with absorbent
cotton, and dust them with equal parts of starch and oxid
of zinc. In severe cases purge, use hot baths, apply lead-
water and laudanum locally or paint the vulva with silver
solution (gr. xl to 3j), and leech the groins. If the vulvo-
vaginal gland suppurates, open it. For vaginitis follow the
same general directions. Syringe out the vagina every two
hours, first with Oj of hot solution of bicarbonate of sodium,
next with Oj of hot water, and finally with Oj of astringent
solution (a teaspoonful of lead acetate, a teaspoonful of zinc
sulphate, a teaspoonful of alum, or four teaspoonfuls of tannin
to the pint of hot water) (White). As the attack subsides,
use vaginal suppositories, each containing gr. v of tannic acid.
In some cases apply solutions of silver nitrate i : 200, and
tampon with boroglycerid and ichthyol, 8 per cent. (Le
Blonde). Metritis must be prevented, and it is a wise pre-
caution to apply iodin from time to time. For urethritis use
astringent injections locally and copaiba and cubebs by the
mouth. In chronic cases use strong solutions of silver
nitrate. The urethra and bladder may be irrigated with sil-
ver nitrate (i : 8000). For uterine gonorrhea observe the same
general management. Swab out the uterus with tincture of
iodin ; use tampons of iodoform gauze and injections of
peroxid of hydrogen.

Stricture of tiie urethra, or narrowing of the urethral
caliber, is divided into inflammatory^ spasmodic, and organic.
The so-called inflammatory or congestive stricture is not a
stricture, but is an inflammatory sweUing of the mucous

824 MODERN SURGERY.

membrane. Spasmodic stricture does not exist alone, but
complicates organic stricture, a hyperesthetic urethra, or an
inflamed bladder. Organic stricture is a fibrous narrowing
of the urethra, due, as a rule, to chronic gonorrheal inflam-
mation or to traumatism. Traumatic strictures occur in the
bulbous or membranous urethra, and are due generally to
force applied to the perineum, the urethra being squeezed
between the subpubic ligament and the vulnerating body.
Strictures resulting from gonorrheal inflammation occur in
the penile, bulbous, or membranous urethra. Stricture never
forms in the prostatic urethra, except as a result of trau-
matism. Recent strictures are soft and are easily distended.
Old strictures and traumatic strictures are very dense. A
resilient stricture is one which contracts quickly after dilata-
tion. The nearer a stricture is to the meatus, the more
fibrous it is. A congenital stricture is congenital narrow-
ness of a portion of the urethra, usually the portion near the
meatus. The more fibrous a stricture is, the more it narrows
the urethra and the less dilatable it is. A stricture may be
annular (forming a ring around the urethra), tubular (sur-
rounding the urethra for a considerable distance), or bridle
(when a band crosses the urethra from wall to wall). A
stricture of large caliber will admit an instrument larger
than a No. 1 5 French sound. A stricture of small caliber
admits an instrument smaller than a No. 1 5 French sound.
An impermeable stricture will not admit the passage of any
instrument. Impermeable is more or less a relative term.
A stricture may be impermeable when an anesthetic is not
used, and permeable when the patient is anesthetized, or may
be impermeable to one surgeon, but permeable to another.
Impermeability is often a temporary condition due to inflam-
matory edema about an organic stricture.

Symptoms and Results of Stricture. — There is usually
a history of repeated attacks of urethritis. A chronic dis-
charge may exist, the amount of which is variable. There
is a feeling of weight in the perineum, soreness of the
back, hypochondriacal fancies, and frequency of micturition.
There is difficulty in starting the stream in micturition;
the stream is small, twisted, often forked, and it dribbles long
after the conclusion of micturition, so that the penis must be
" milked " before it is returned within the clothing. The
urethra back of the stricture dilates, a pouch forms, drops
of urine collect and decompose, and a chronic inflammation
results in the mucous membrane or the parts adjacent, which
inflammation may go on to ulceration or to peri-urethral ab-

DISEASES OF GENITOURINARY ORGANS. 825

scess. A urinary fistula results from the opening externally
of a peri-urethral abscess. Retention of urine may occur,
not from obliteration of the tube by the growth of the
stricture, but by edematous swelling in the neighborhood of
the stricture, due to cold, wet, venereal excitement, the use
of alcohol, over-exertion, etc. Spasm of the muscles re-
sults, and contact of the urine increases the spasm, and spasm
plus edema of the mucous membrane closes the urethra.
Spasm may exist in the urethra itself and in the muscles of
the neck of the bladder, but is only a temporary condition.
In old strictures the bladder is hypertrophied and often fas-
ciculated, and is very liable to cystitis. The diagnosis of
stricture and of its location is made by the use of exploratory
bougies. In this examination the author follows to a great
extent the plan of Ramon Guiteras, which is as follows : *
have the patient pass urine into two glasses. Examine the
urine for clap-shreds. Cloudiness in the first glass shows that
urethral discharge exists. Cloudiness in the second glass
points to cystitis. The patient is placed recumbent with his
shoulders elevated, and the urethra is washed out with warm
salt solution. Bulbous sounds are inserted, beginning with
No. 1 5 French. If this passes with ease, take a larger size
and note where strictures are situated .by the catch on with-
drawal. If No. 1 5 does not pass, use a smaller size. Remember
that the posterior layer of the triangular ligament catches a
bulbous instrument on withdrawal. If the meatus is too
small to permit of exploration, divide it with a curved bis-
toury, cutting from within outward. After cutting the meatus
bleeding is arrested with styptic cotton, and a piece of ab-
sorbent cotton is tucked into the cut. After each act of
micturition the patient inserts a fresh bit of cotton, and
after three days the urethral examination is proceeded with.
Treatment. — Strictures of large caliber in the deep urethra
require gradual dilatation. A steel bougie is introduced every
third or fourth day, the size being gradually increased. Never
anoint a bougie with cosmolin, as it may become a nucleus
for a stone in the bladder ; use oil or glycerin. Before pass-
ing an instrument the patient urinates and his urethra is
washed out with boiled water. The sound is rendered sterile
by boiling before using. Gradual dilatation can be effected by
the use of the dilator of Oberlander, the tube being distended
to the extent of three millimeters every fifth day. If after
dilatation there is urethral spasm, pain, or very frequent
micturition, suspend the treatment for a number of days

* Med. Record t Nov. 14, 1896.

826 MODERN SURGERY.

and order each night a hot hip-bath and a dose of paregoric
In effecting gradual dilatation by sounds the instrument
should be introduced every fifth day, and during the treat-
ment the patient should not use alcohol, should refrain
from sexual excitement, should avoid cold and damp, and
should take internally capsules containing boric acid and
salol. It is rarely necessary to dilate above No. 32 French.
After the surgeon finishes treatment he teaches the patient
to use an instrument and directs him to pass it once a month.
Strictures in the pendulous urethra, if soft, are treated by
gradual dilatation ; if fibrous and contractile, by internal
urethrotomy. In performing internal urethrotomy prepare
the patient carefully ; for several days before the operation
give salol and boric acid by the mouth, and wash out the
bladder repeatedly with boric-acid solution. Be thoroughly
aseptic. Anesthetize the patient. Before cutting irrigate the
urethra with warm normal salt solution, and after cutting
irrigate again and tie in a rubber catheter. These precau-
tions will prevent urethral fever. In cutting, insert Gross's
urethrotome (Fig. 302) back of the stricture, spring out the
blade, cut the stricture on the roof of the urethra, close
the blade, withdraw the instrument, and pass a full-sized
bougie.

Stricture of the meatus requires incision with a knife and
the use of a meatus bougie until healing is complete. Strict-
ures of small caliber in front of the membranous urethra re-
quire gradual dilatation and, if this fails, internal urethrotomy
or divulsion. Internal urethrotomy can be performed with
the urethrotome of Maisonneuve (Fig. 300). This instru-
ment is shaped like a sound, has a groove upon its surface,
and into this groove a shaft cariying a triangular knife can
be inserted. The staff is screwed to a guide, the guide is car-
ried into the bladder, and the staff follows it. The point of
the staff is carried to the prostatic urethra and the guide curls
up in the bladder. The penis is held upon the stretch, the
blade is inserted and pushed down through the stricture.
This instrument cuts the stricture, but not the healthy
ureter. For divulsion the patient is prepared as for inter-
nal urethrotomy. The divulsor of Gross, or of Sir Henry
Thompson, or of Gouley (Figs. 301, 303, 304) is intro-
duced, the blades are separated, the instrument is with-
drawn, a large bougie is passed, and a catheter is tied in
the bladder. Strictures of small caliber in the deep ure-
thra require gradual dilatation ; if this fails, employ external
urethrotomy. In strictures of the deep urethra, if only a fili-

DISEASES OF GEmTO-URINARV ORGANS. 827

form bougie can be introduced, the bougie can be left in place
and in a day or two another can be slipped in beside it, until in
a few days the channel is permeable by a metal bougie. A

Fio. »99.— Syme'i >uS Fio. joa— MiiioDiwuTe'i URIhrntam.

tunnelled catheter can be slipped over the filiform bougie,
both be withdrawn, and a metal bougie passed. A tun-
nelled and grooved staff can be carried in over the bougie

828

MODEXN SURGERY.

and external urethrotomy be performed Thompson's dilator
can be carried in over the filiform and the stricture be di-
vulsed. Fort's method of electrolysis is of value. This
surgeon treats stricture by linear electrolysis. His instru-
ment looks like a whip, and it has a platinum blade pro-

jecting from about the center. The blade is connected with
the negative pole of a galvanic battery and the positive pole
is placed over the pubes. The guide carrying the blade is
inserted into the urethra, and when the blade comes against
the stricture the current is turned on and the platinum passes

DISEASES OF GENITOURINARY ORGANS.

829

rapidly through the constriction. The current is turned off
and the instrument is carried onward until it strikes another
stricture, when the current is again turned on, and so on.
The necessary current-strength is 10 to 15 ma. The op-

FiG. 303.'~Thompson's divulsor.

eration requires twenty to thirty seconds and causes but
little pain. After its performance a sound is passed, a No.
22 of the French scale. The patient need not be confined
to bed after this operation. By Fort*s method we act

Fig. 304.— Gouley's divulsor.

purely upon the diseased tissue. In impassable stricture
of the deep urethra perform external perineal urethrotomy
without a guide (the operation of Cock or of Wheelhouse).
Urethral Fever. — Any operation upon the urethra may
be followed by a chill owing to shock (urethral shock), and
this may be followed by a nervous fever. Urethral fever
proper is a sapremia which may follow a urethral opera-
tion. This condition is due to absorption of toxic elements
which may be in the urine, may have been in the urethra, or
may have been introduced from without. It usually follows
the first urinary act after operation. It begins with a violent
chill and presents the characteristics of a septic fever. It is
accompanied by a marked tendency to urinary suppression,
and may eventuate in septicemia or pyemia. Urethral fever
can be prevented by rigid antisepsis. If this fever should
arise, a catheter must be tied in the bladder, the bladder and
urethra must be repeatedly irngated with aseptic or anti-
septic fluids, and the patient must be given urinary antiseptics
and stimulants by the mouth.

830 JtOVEJtX SCXGERY.

Perineal section is external perineal urethrotomy. There
are three methods, the operatioo of S\Tne, of Wlieelhouse,
and of Cock.

8yxne*8 OpermtioQ. — This operation is employed if a
stricture is \-er\- contractile, if dilatation fails to cure, or if
urethral instrumentation causes fe\"er. The patient is anes-
thetized, S>"me'5 staff •, f^- ^99 > is introduced, and the sur-
geon mikes an incision in the midline of the perineum and
exDOses the stafT fust abox-e the shoulder of the instrument
The kniie is carried along the groove and di\ides the strict-
ure. A catheter is oassed into the bladder from the meatus
and is retained tor se\*eral da\"s. and the wound is dressed
antiseoticillv. After the catheter is removed it must be
used e\'er\" six hours until the urine comes entirely b>' the
mearusw From time to time, for the rest of the patient's
life, a fuIUsized sound should be passed.

TXTheelhoiiae's Opermtion. — This operation is employed
tor the treatment of impermeable stricture. Wlieelhouse's
staff is rvissed into the urethra until it blocks on the stricture.
The r^rineum is incised down to the staff and in front of the
stricture. The edges of the cut urethra are held apart with
fcrcese?, the surgeon seeks for the opening through the strict-
ure, passes a nne pcobe through it, dixides the stricture, carries
into the blavkkr from the wound an instrument known as a
cor^e: :? ii'ire the canal and furnish a solid noor to fidlitare

O.A.W ..... . ^.^^w.. . .. '~7m. JL V..:L»..k^C««.. . «« 4«.& W..V. ^V.*. ^C«. ... ,-,\ -._=C Jk.

A:":;.T thrvix^ ?r four days the cirheter is removed ari is then
pi>>ev: rH^cutrr.tly. The perine.il .vound is, of cour^?e. cresse-i

Cooks Operation. — This o:>era::?n ooer.s the ur^fthn
.... ... .. ■ ■.

..... -".^..^^^ ..... ...w .«.^...... .-..cr . • . v^c^.v ....^c. .V «..cr — -, -, ■ * < ^

i^ . .i- ._. A..^. T*— .i^w... ... w..>^C' ...V. ...w .^. .1- - . . .. K.*t. >.. .. ^ 1 ^C. ^ _

•~_-— • -• •••.3 ,r*^**r* *< •-*.* *T *V^ — j-;«- •-^.a ~-» .-j,^ **•-=. *—-—"- -

.-^. - . . - . .—.<.. ^. .... w .- .^J. w. w^^ .. wX. «..^ ... . • ... . .— ."ZT - * ■ r^ _^

.rviT::.! >l! 'htlv. the hli.!;? 15 rl2,C^d ^ llttl;^ "bL""— r^ I"** ~"'r*

• • * • ■ a

Epispadias :> i crr.^er.it^I j'.ert ir. the c:rp«?r:i r.iv-rr.:-?u.
th:: rrv f rf the urcthri beir.^ ibs-or.t. It is r;^me'd:e'd "'. i
r . .-.> t: c J r<: r.i t: : r. .

IS a c^r.^eritul cleft cr. the f:>:r :c tire

DISEASES OF GENITOURINARY ORGANS. 83 1

urethra, this channel being a gutter instead of a canal. It is
remedied by a plastic operation.

Chancroid (soft chancer; the local venereal sore) is
a pyogenic ulcer, usually of venereal origin. The name
chancroid was introduced by Clerc, who believed that a soft
sore resulted from inoculating a person already syphilitic
with the products of a hard sore. He further held that when
a soft sore arose the syphilitic poison lost its infective prop-
erties, and " could be transmitted as a soft sore to a healthy
person, and not cause general infection." * This form of ulcer
is not connected with the syphilitic poison and is not due to
any special or chancroidal poison, but is produced by inflam-
matory products or irritating secretions. In fact, soft sores
may arise without a causative sexual intercourse, as is seen
sometimes in cases of herpes in a man with gonorrhea, the
herpetic ulcers becoming chancroids. As a rule, chancroids
are of venereal origin, and result from contact with other
chancroids, pus, mucopus, or areas of ulceration. There is
no special germ. A chancroid appears soon after inter-
course, usually within five days, always within ten days. It
is first manifested by a pustule which ruptures and discloses
an ulcer. This ulcer has sharply-defined and undermined
margins; it looks "punched out;" the base is gray and
sloughy; the discharge is profuse, purulent, foul, and auto-
inoculable, and causes fresh chancroids by flowing over the
parts. The area around a chancroid is red and inflamed, and
considerable pain is apt to be complained of. The original
chancroid spreads and new sores appear. The edge of a
chancroid is not indurated unless caustics have been used or
there is mixed infection with syphilis. Inflammatory indura-
tion fades gradually into the tissues, but the induration of a
hard chancre is sharply defined. When a chancroid after a
time displays marked and sharply-outlined induration it
points to mixed infection of chancroid and syphilis. Chan-
croids are not followed by constitutional symptoms, but are
apt to be accompanied by painful inflammatory buboes which
are prone to suppurate. In hospital practice about 30 per
cent, of patients develop buboes. The bubo may be one-
sided or bilateral. If pus forms, it does not contain organisms.
The adenitis of chancroid is due purely to the absorption of
toxins. Cases have been reported in which non-indurated
sores were followed by syphilis. It is probable that a
mixed infection existed, and that induration was overlooked,
because a papular initial lesion was underneath the chancroidal

* Syphilis t by Alfred Cooper.

832 MODERN SURGERY,

ulcer. When inflammation in chancroids is high a rapidly
destructive ulceration known as phagedena may arise, but
this process is far more common in syphilitic sores.

Treatment. — Ordinary cases of chancroid are treated by
spraying with peroxid of hydrogen, drying with cotton, touch-
ing each sore first with pure carbolic acid and then with pure
nitric acid, and dusting with iodoform or with calomel. Every
few hours after this application the patient soaks the penis in
hot salt water (a teaspoonful of salt to half a pint of water),
sprays the sores with peroxid of hydrogen, dries with cot-
ton, and dusts with iodoform or with calomel. As soon as
granulation begins the sores should be dressed with i part of
ointment of nitrate of mercury to 7 parts of cosmoHn. Mild
cases do well without cauterizing, peroxid of hydrogen being
frequently used and a drying powder being employed. In
chancroids with phimosis slit up the foreskin, bum the edges
of the wound with pure carbolic acid, and treat the sore
by cauterization. A set circumcision often fails because
of infection of the stitch-holes. Phagedena requires the in-
ternal use of iron, quinin, and milk-punch, and the local
use of powerful caustics (bromin or nitric acid or even of
the actual cautery). In some cases continuous antiseptic
irrigation is valuable. When a bubo first begins order rest,
apply iodin or an ointment of belladonna or ichthyol, and
make pressure by a spica bandage of the groin. Some
surgeons advise the injection of 20-40 minims of a solu-
tion of carbolic acid (gr. x to the ounce), but we have
never seen any benefit from it. Some inject a i per cent,
solution of bichlorid of mercury, but the proceeding
causes intense pain. Welander recommends the injection
of a I per cent, solution of benzoate of mercury. We
have had no experience with these methods. If the bubo
persists, even though it does not suppurate, it should be
completely excised. If pus forms, several methods of treat-
ment are open to us. Aspiration, injection with a solution
of carbolic acid, squeezing out the acid and injecting 10
per cent, ointment of iodoform and glycerin, and sealing the
opening with collodion (Scott Helms). Hayden makes a
puncture, squeezes out the pus, washes out the cavity with
peroxid of hydrogen and then with corrosive-sublimate
solution, injects warm iodoform ointment, and dresses with
cold, moist, corrosive-sublimate gauze to set the ointment.
Otis, Fontain, Perry, and others commend this plan. We
have often found it to succeed. If the above-mentioned
plan fails, if it is not used, or if an ulcer or sinus exists,

DISEASES OF GENITOURINARY ORGANS. 833

incise, curet, cauterize with pure carbolic acid, cut away
hopelessly infiltrated skin, and pack the wound with iodo-
form gauze. In some cases it will be necessary to extirpate
fragments of gland.

Phimosis is a condition of the prepuce that renders
retraction over the glans impossible. It is usually congenital,
but it may arise from inflammation. Congenital phimosis
causes retention of sebaceous matter, which decomposes and
lights up inflammation. The prepuce is
apt to grow fast to the glans. Congeni-
tal phimosis may induce irritability of the
bladder, incontinence of urine, prolapse
of the rectum, and various nervous symp-
toms. The treatment is circumcision.
Asepticize the parts. Grasp the foreskin

and the mucous membrane with two for- ^".IdK^'i'i^.*

ceps, draw the prepuce forward, catch the
skin (at the point it is desired to cut) horizontally between the
handles of a pair of scissors, and cut olTthe redundant prepuce.
Retrench the excess of mucous membrane by cutting around
with scis.sors one-quarter of an inch from the glans, stitch the
skin to the mucous membrane with catgut, and dress with
sterile gauze (Fig. 305).

Fracture of the penis, which is a laceration of the caver-
nous bodies with extravasation of blood, occurs occasionally
during coition. The treatment consists of cold and bandaging
to arrest bleeding, and occasionally incisions to let out clot.

Gangrene of the penis arises from phagedena, from
tying constricting bands around the organ, from' fracture
with excessive hemorrhage, and from paraphimosis. If ex-
tensive, it requires amputation.

Cancer of the penis is commonest in persons with phi-
mosis. In a limited epithelioma of the foreskin circumcision
is performed and the glands of the groin are removed ; if can-
cer affects the glans, amputation is required, and the glands
are removed.

Amputation of the Penis.~Ricord advised cutting off
the organ with a single stroke of the knife, making four slits
in the mucous membrane of the urethra, and stitching each
of these flaps to the skin. Treves splits the skin of the
scrotum along the raphe, separates the halves of the scrotum
down to the corpus spongiosum, passes a metal catheter
down to the triangular ligament, inserts a knife between the
corpus spongiosum and the corpora cavernosa, withdraws
the catheter, cuts the urethra across, detaches the urethra

834 MODERN SURGERY.

from the penis back to the triangular ligament, cuts around
the root of the penis, divides the suspensor>'^ ligament,
detaches each crus from the pubes, slits up the corpus spon-
giosum half an inch, stitches its edges to the rear end of the
scrotal incision, introduces a drainage-tube, ligates the ves-
sels, and sutures the wound.

Seminal Vesiculitis. — Inflammation of the seminal ves-
icles is due to the extension of a gonorrheal inflammation or
a pyogenic process.

Acute inflammation is made evident by frequent and pain-
ful micturition, pains in the anus, rectum, and perineum, and
possibly the hip-joint, back, and thigh. Defecation and mic-
turition are excessively painful. Persistent erections may take
place, and in some cases bloody ejaculations occur. Rectal
examination detects the enlarged and tender vesicles external
to the lateral lobes of the prostate and on a higher level.

Treatment. — Abandon local urethral treatment and treat
the patient as for acute prostatitis.

Chronic vesiculitis may result from the acute form or may
come on insidiously in an individual with gonorrhea. It is one
of the causes of chronic urethral di.scharge. The patient suffers
from imperative and frequent demands to micturate, and he
has a gleety discharge which becomes worse and better, but
does not disappear. This chronic inflammation is believed
to persist because of narrowing of the duct, and consequent
incomplete drainage of the vesicle.

Treatment. — Treat the posterior urethritis by ordinar>'
methods. Use hot rectal enemata. Milk the ducts by
Fuller's method once ever>' seven days. The patient's
bladder should be full. He leans over a chair-back, the
knees being straight and the body at a right angle to the
thighs. The surgeon introduces his finger into the rectum
and makes pressure over the pubes with the fist of the other
hand. The finger comes in contact with the lower half of
the vesicle ; it makes firm pressure for a moment, and is then
drawn slowly toward the duct. This stroking is repeated
several times. The other vesicle is treated in the same
manner. This maneuver empties the vesicle and hastens
the resolution of inflammation. After the completion of the
stripping the patient makes water.

Hypertrophy of the prostate gland is a senile change
occurring only after the age of fifty, and being most apt to
occur after the age of sixty. All the lobes may be enlarged
equally, all may be enlarged but unequally, or only one lobe
may be enlarged. Prostatic hypertrophy causes narrowing

DISEASES OF GENITOURINARY ORGANS. 835

and lengthening of the urethra, and gives this tube a tor-
tuous course. The opening of the urethra into the bladder
is pushed to a higher level, and there forms behind it a pouch
in which urine collects. This urine, which is known as
residual urine, may collect in large quantity ; it cannot bq
voluntarily expelled, and it is apt to decompose, producing
cystitis. The bladder enlarges, thickens, and becomes fas-
ciculated, micturition becoming very difficult and sometimes
impossible. An enlarged middle lobe will block the urine and
the bladder inevitably becomes greatly distended. In hyper-
trophy of the prostate the ureters, the renal pelves, and calyces
may distend, and surgical kidney may develop.

SymptomB. — In 80 per cent, of all cases there is only slight
inconvenience. The stream of urine is slow to start and falls
feebly from the end of the penis. The last drops fall entirely
without control, and there are occasional episodes of noc-
turnal frequency of micturition. In 20 per cent, of all cases
the bladder cannot entirely be emptied and residual urine
collects in the bladder. Frequency of micturition comes on,
particularly at night ; the patient has to get up often ; the
bladder never feels empty ; and cystitis is apt to arise. The
urine, at first acid and clear, becomes neutral and cloudy, and
finally ammoniacal and turbid, and contains bacteria, muco-
pus, precipitates of phosphates, and blood. Above the pubes
there is aching pain, soon spreading to the perineum, which
pain is increased when the bladder is distended and during
micturition. Enlargement of the lateral lobes can be detected
by a finger in the rectum. The rectum becomes irritable,
and piles form or prolapse of the mucous membrane occurs.
Attacks of retention of urine may occur. The bladder be-
comes thin and distended, or hypertrophied, rigid, and fascic-
ulated. In rare cases true incontinence is caused by the
median lobe growing toward the neck of the bladder and
preventing closure. The health breaks down because of
pain, restless nights, indigestion, and disorder of the bowels.
The kidneys may become involved (inflammation of the pel-
ves or calyces, or surgical kidney) and suppression may
occur. Septic fever may arise. Calculi may form in the
bladder. Death is due to exhaustion, suppression of urine,
or septic cystitis. If a foul catheter is used, septic cystitis
is certain to occur ; but micro-organisms sometimes enter
by passing along the urethral mucous membrane.

Treatment. — Many cases can be treated by regular cath-
eterization. Alexander has formulated several sound rules as
to when catheterization is the proper treatment. He says ;

836 MODERN SURGERY.

if the patient is intelligent and dexterous, if cystitis is not
severe, if the amount of residual urine is not very large, if
obstruction is not great, if the bladder retains considerable
expulsive power, and if catheterization is easy and painless,
.rely upon this simple plan of treatment. Prevent cystitis by
emptying the bladder each evening with a coude catheter.
If there is trouble in passing the catheter, strengthen the in-
strument by inserting a filiform bougie as a stylet (Brinton).
In some cases a metal instrument with a large curve is
used. Teach the patient to use the instrument himself.
A dirty instrument may cause fatal infection. It is true that
some people use dirty instruments for long periods without
trouble, but in most cases there will be trouble if it is
attempted. It is absolutely necessary to use only perfectly
aseptic instruments. Metal instruments are sterilized by
boiling in water. Rubber catheters can be cleansed by
washing with soap and running water and boiling, or, after
washing, soaking in corrosive-sublimate solution. Woven
instruments can be placed in a glass cylinder, the bottom of
which is like a sieve. This jar is placed for twenty-four
hours in a vessel which contains formalin. The vapor of
formalin is an excellent germicide, and does not injure the
catheter. After sterilization the instruments are kept ready
for use in a glass cylinder which contains calcium chlorid.*
Guyon scrubs the catheters with soap and water, dries them
outside and inside, places them in a sealed jar, and ex-
poses them to the vapor of sulphurous acid for forty-
eight hours. If there are three ounces of residual urine,
use the catheter only at night. If there are six ounces,
use it night and morning. If there are more than six
ounces of residual urine, add one more catheterization
a day for every additional two ounces present until . the
catheter is used six times in the twenty-four hours. It
should never be used oftener than this. Gradual dilatation
with steel sounds is of benefit, but forcible dilatation is not
advisable. TeM the patient to avoid violent exercise, cold,
damp, sexual excitement, and the use of alcoholic liquor,
prevent constipation and indigestion, and direct him to drink
plenty of Poland water. A hot hip-bath at night adds to
his comfort. Hot enemata are of value. If a large quan-
tity of residual urine exists, or if cystitis begins, wash out
the bladder daily with boric-acid solution, or normal salt
solution, or nitrate of silver (i : 12,000), and give urotropin
or salol and boric acid by the mouth. In some severe

J K. W. Frank, in Bfrliner klin. lVo<h.^'^o. 44, 1 895.

DISEASES OF GENITO URINARY ORGANS, 837

cases, if a large-size rubber catheter be tied in the bladder for
a few days, great relief is obtained. Retention of urine can be
relieved by the introduction of a coude catheter strengthened
with a whalebone, of a silver instrument with a prostatic curve,
or by aspiration. If the symptoms grow constantly worse,
if the suffering becomes severe, if the patient cannot uri-
nate without the use of an instrument, if catheterization is
painful or impossible, if the patient is too careless or ignorant
to trust with a catheter, if only a catheter of very small size
can be introduced, if attacks of obstinate retention occur,
if there is persi.stent cystitis or hematuria, if the residual
urine gradually increases in amount, a radical operation
should be performed.

Suprapubic cystotomy may be performed, the opening
being kept permanently patent (Hunter McGuire's oper-
ation).

Suprapubic prostatectomy may be performed. After the
bladder is opened the mass of prostate is enucleated or cut
away with scissors or with cutting-forceps. The suprapubic
cut is allowed to heal. Perineal prostatotomy may be per-
formed, the gland being split and perineal drainage tempo-
rarily employed. McGill's of)eration is suprapubic pros-
tatectomy, the gland being removed partly by enucleation
and partly by the employment of cutting rongeur-forceps.
Fuller performs a suprapubic cystotomy, makes a small
incision through the mucous membrane of the gland,
enucleates the gland with the finger, and drains through
an incision in the membranous urethra. Belfield makes a
suprapubic cut and a perineal cut, and with the finger in the
perineum pushes the gland into easy reach of the finger in
the bladder.

Perineal prostatectomy may be employed. Some surgeons
make a curved incision across the perineum and dissect out
the gland. NicoU first performs suprapubic cystotomy,
opens the perineum down to the prostate, splits the capsule
of the prostate, inserts two fingers of the left hand into the
bladder, and pushes the prostate down into the perineum.
The surgeon enucleates the gland through the perineal
wound without damaging the mucous membrane of the
bladder. Alexander makes the suprapubic cut and uses
it for the same purpose as Nicoll, but he opens the mem-
branous urethra on a grooved staff, enucleates the gland,
and inserts a drainage-tube through the perineal wound.
Bottini of Padua, by means of a sj>ecial instrument, cauter-
izes the prostate repeatedly. This instrument is shaped like

838 MODERN SURGERY.

a catheter and carries a platinum blade which is heated by
an electric current.

In 1893 J. William White introduced the operation of
bilateral orchidectomy. He proved that removal of the
testicles causes a rapid shrinking in an enlarged prostate.
Part of this shrinking may be due to diminution of conges-
tion and edema, but true atrophy undoubtedly occurs. Ver}'
remarkable results have been recorded. In most cases the
patient becomes absolutely comfortable. Some cases dis-
pense entirely with the catheter. Cystitis ceases, and desire
to urinate frequently becomes less marked. Unilateral
orchidectomy has been employed, but it is not satisfactory.
Division of the vas deferens, vasectomy, may be employed
instead of orchidectomy. It is slower in its results, but just
as certain. In spite of the great simplicity of orchidectomy
the mortality has been considerable (from 11 to 18 per cent).
In several instances mental disturbance has followed the
operation, but there is no real evidence that it was due to
this special form of operation and would not with certainty
have followed any other.

Retained and Malplaced Testicle. — The testicle may

be arrested in its passage to the scrotum : it may remain in the
lumbar region ; it may reach the internal abdominal ring ; it
may lodge in the inguinal canal ; it may emerge from the
external ring, but fail to enter the scrotum ; or it may pass
into unnatural positions, as into the perineum or the crural
canal. It may or may not be functionally active. A re-
tained testicle is subject to attacks of orchitis and is apt
to become sarcomatous. Sometimes a testicle descends
after being retained for months.

Treatment. — If one testicle is undescended one year after
birth, and the other testicle is sound, the former should be
removed if it is found impossible to draw the gland into the
scrotum and fasten it. Always try to get a retained gland
into the scrotum.

Orchitis is inflammation of the testicle. Aaitc orchitis
may be due to cold, wet, traumatism or epididymitis, gout,
mumps, rheumatism, or a specific fever. The testicle is
round, swollen, tender, and ver\^ painful, the scrotum is red
and swollen, the tunica vaginalis is filled with fluid, and there
is fever. Clironic orchitis results from the acute form or from
a chronic urethral inflammation, and is almost alwavs com-
hincd with epididymitis. Syphilis or tubercle may be respon-
sible for chronic orchitis.

riic treatment of the aaifc form consists of rest in bed and

DISEASES OF GENITOURINARY ORGANS. ' 839

applications as for epididymitis (see below). The chronic
form requires the removal of the causative lesion, a suspen-
sory bandage, inunctions of ichthyol or mercurial ointment,
and iodid of potassium by the mouth. Strapping may do
good. Castration may be required.

Castration (Excision of a Testicle). — In this operation an
incision is made over the cord, commencing just outside the
external ring and running down over the base of the tumor.
Clamp the cord and divide near to the ring, remove the
testicle, ligate the spermatic artery alone, and then ligate
the entire thickness of the cord. The cord is sutured with
chromic gut or silk. Drainage is not required. It is often
advisable to remove a considerable amount of scrotal skin.

BpididjrmitiSi or inflammation of the epididymis, is usu-
ally due to inflammation of the urethra. It is apt to occur in
the stage of decline of a gonorrhea, and is announced by a
complete cessation of the discharge. It may result from the
passage of a urethral instrument, the voiding of urine which
contains fragments of calculi, or as a complication of pros-
tatic hypertrophy. Acute epididymitis is characterized by
swelling about the testicle, pain in the groin, and tenderness
over the posterior part of the testicle. The pain becomes
acute, swelling rapidly increases, and the constitution sym-
pathizes. The swelling is due partly to engorgement of the
epididymis and partly to fluid in the tunica vaginalis (acute
hydrocele). Chronic epididymitis is usually linked with
orchitis, and it follows an acute attack or a chronic urethral
inflammation.

Treatment by puncture with an aseptic tenotome, if
fluctuation is marked, relieves tension and pain. Leech-
ing over the external abdominal ring, use of an ice-
bag, elevation, lead-water and laudanum, laxatives, and
opium are used in the acute stage. Painting with 1 5 drops
of guaiacol in i dram of olive oil relieves the pain greatly.
Strapping is employed as the inflammation subsides. The
treatment of the chronic form is the same as that for chronic
orchitis.

Hydrocele (chronic hydrocele) is a collection of fluid
in the tunica vaginalis testis. An enlargement of the testis
may cause it, but in most instances the cause is unknown and
no signs of inflammation exist. The fluid is albuminous, but
it does not coagulate spontaneously ; it is thin, straw-colored,
and may contain crystals of cholestcrin. The testicle is at
the lower and back part of the sac. The pyriform mass
fluctuates, is translucent, grows from below upward, and the

840 MODERN SURGERY,

introduction of an exploring-needle permits the yellow fluid
to flow out

Treatment. — Simply tapping the sac with a trocar is only
palliative ; air must run in as fluid runs out, and suppura-
tion may occur, which ^*nll be dangerous without drainage.
Never tap a rigid sac. The injection of irritants should be
abandoned, as it exposes the patient to serious danger
because of inflammation occurring without provision for
drainage. Heam incises the sac, dries its interior with bits
of gauze, swabs it out wth pure carbolic acid, packs it with
iodoform gauze, and dresses it antiseptically. The packing
is removed in twenty-four hours and the wound is allowed
to close. If the sac is rigid and uill not collapse, either
stitch it to the skin and pack it or excise a large portion of
its parietal layer and insert a drainage-tube (Volkmann's
operation). It has recently been proposed to tap the sac
with a trocar and cannula, to leave the cannula in place as a
drain for some days, and to dress antiseptically.

Cong^enital hydrocele is hydrocele through an unclosed
funicular process into the tunica vaginalis. If the pelvis is
raised, the fluid runs back into the peritoneal cavity, from
which it originally came. The treatment is a truss to oblit-
erate the funicular process.

Infantile hydrocele is a collection of fluid in a funicular
process and the tunica vaginalis, the funicular process being
closed above, but not below. The treatment is to puncture
the sac and to scarify the sac-wall with a needle.

Encysted Hydrocele of the Cord. — In this variety the
funicular process is obliterated above and below, but it is
patent between these two points, and fluid collects. The
treatment is the same as that for infantile hydrocele. If this
fails, incise and pack.

Ptmicnlar Hydrocele. — The funicular process is closed
below, but is open above. Raisin<^ the pelvis causes the
fluid to trickle back into the peritoneal cavity. The treat-
ment is a truss.

Encysted hydroceles of the testicles and of the epididymis
may occur. Diffused hydrocele of the cord is simply edema
of the cord. Hydrocele of a hernia is the distention of a
hernial sac with peritoneal fluid.

Hematocele. — Vaginal hematocele is blood in the tunica
vaginalis, the result of traumatism, a tumor, or the tapping
of a hydrocele. There is a pyriform tumor, which fluctu-
ates, but which <T^radually becomes firmer ; the scrotum is
livid, and the testicle is below and posterior to the tumor.

AMPUTA TIONS. 84 1

The encysted form of hematocele of the cord is a hydrocele
of the cord into which bleeding has occurred. The diffused
form is due to extravasation of blood into the cellular sub-
stance of the cord. Encysted hematocele of the testicle is due
to effusion of blood into an encysted hydrocele of the testicle.
Parenchymatous hematocele is extravasation of blood into
the substance of the testicle.

The treatment of a recent case of vaginal hematocele is
to put the patient to bed, support the scrotum, and apply an
ice-bag over the testicle. If the swelling does not soon
abate, incise, irrigate, and pack.

Varicocele is varicose enlargement of the veins of the
pampiniform plexus. An irregular swelling exists in the
scrotum and extends up the cord. This swelling feels like
" a bag of earth-worms ; " it exhibits a slight impulse on
coughing ; the scrotal skin and cremaster muscle are attenu-
ated ; the testicle lies at the bottom of the swelling and is
softer and smaller than normal ; the swelling diminishes on
lying down and increases on standing or on making pressure
over the external ring. There is usually some discomfort,
aching, or dragging in the testicle or the groin, and even
neuralgic pain in the cord. There is sometimes mental de-
pression and hypochondria.

Treatment. — In treating varicocele, reassure the patient :
tell him there is no real danger of impotence ; order cold
shower-baths, correct constipation and indigestion, give occa-
sional tonics, and order the patient ' to wear a suspensory
bandage. If the testicle becomes much atrophied, if the
pain and the dragging are annoying, or if the mind is much
depressed, operate (see page 261).

XXXVII. AMPUTATIONS.

An amputation is the cutting off of a limb or a portion
of a limb. Removal of a limb or a portion of a limb at a
joint is known as " disarticulation." Amputation may be
necessary because of the existence of severe injury, of gan-
grene, of tumors, of intractable disease of bones or joints,
of ulcers which will not heal, of traumatic aneurysm, etc.
A re-amputation may be required because of the existence
of a defect or disease in the stump.

Classification. — Amputations are classified as follows:
(i) As to time of operation after the injury : a primary ampu-
tation is performed soon after the occurrence of the accident
— as soon as the sufferer reacts from shock, and before he

842 MODERN SURGERY.

develops fever ; a secondary amputation is performed some
time after the accident, suppuration having supervened
(Stokes) ; and an intermediate amputation is performed dur-
ing the existence of fever, but before the development of
suppuration. (2) As to the situation, where the bone is
divided or according to which joint is cut through. (3) As
to the form and situation of the flap.

In performing an amputation maintain rigid asepsis; com-
pletely remove the hopelessly- damaged portion ; sacrifice as
little of the sound tissue as possible ; prevent hemorrhage
during the amputation, and carefully arrest it after the opera-
tion ; have enough sound tissue in the flap to cover the bone,
and enough skin to cover the muscles ; and secure drainage
at a dependent point.

Hemorrhage is prevented by the elastic bandage of Esmarch
(Fig. 306). In an ordinary case apply this bandage from the
periphery to well above the line of the prospective i

encircle the limb with the elastic band (not a thin tube), and
remove the bandage. The bandage and band, which are asep-
ticized before using, arc applied to the limb, which has been
carefully sterilized. After the band has been applied the limb
should not freely or forcibly be moved, because of the danger
of tearing muscles which arc firmly set by the compressing
band. When clastic compression is u.scd in an operation the
surgeon should be very careful to tie ci'cry visible vessel.

AMPUTATIONS. 843

The paralysis of the small vessels induced by pressure often
prevents bleeding, and unless their mouths be found and the
vessels be tied reactionary hemorrhage will occur. Reac-
tionary hemorrhage is the great danger after the use of the
Esmarch bandage, and paralysis or sloughing may also fol-
low its employment If there be an area of suppuration or
of gangrene or an extra-osseous malignant growth, do not
apply the bandage as directed above. One bandage can
be applied from the periphery to near the lower border of
the area of growth or infection, and another, from near the
upper border of this area, up the limb. The contents of
the area (tumor-cells and fluid or septic products) are not
squeezed into the circulation. In cases like the above many
surgeons hold the extremity in a vertical position for five
minutes, lightly stroking it toward the body with the hand,
and at once apply the constricting band As a matter of
£ict, this plan satisfactorily empties the limb of blood, and
it is not necessary in any case to force the blood out by
■ elastic compression. Some surgeons prefer the tourniquet.
Figs. 308 and jog show two forms of tourniquet. To
apply Petit's tourniquet, place the plates in contact, apply

a small firm compress over the artery and a broad thick
compress over the outer surface of the limb, buckle the
tapes around the limb so that the plate is over the broad
pad, and tighten the tourniquet by separating the plates
with the screw (Fig. 307). When a tourniquet is applied to

844 MODERN' SURGER V-

arrest bleeding during transportation, bandage the limb, i
the compress pad to a bandage, and place the plates i
the instrument over the pad. Signorini's horseshoe tourni-
quet may be used upon the brachial artery. In hip-joint
and shoulder-joint amputations Wyeth's pins are passed,
and after the limb Is emptied of blood the band is fastened
above them. These pins prevent the bands from slipping.

The instruments and appliances required are Esmarch's
apparatus or tourniquet, amputating-knives. a bone-knife,
scalpels, saws, a lion-jawed forceps, bone-cutting forceps^J
a periosteum -elevator, retractors of linen, dissecting-, hemo-
static, and toothed forceps, a tenaculum, an aneurysm-needle,,!

a probe, scissors, needles, ligatures, sutures ofsilkworm-gutu^
dressings, bandages, and solutions. A retractor has two tail
for the thigh and arm and three tails for the leg and fore
arm : it is made by taking a piece of muslin eight inched
wide and twelve inches long and cutting tails on one side]
eight inches in length.

Methods of .Ajnptttating;. — Circular Method (Fig.^
311). — The surgeon should stand to the right of the limb '
and use a long amputating- knife
which cuts from heel to point. After
an assistant has retracted the skin
the operator divides the soft parts
by a scries of circular cuts. Do not
cut at once to the bone, but divide
the skin and subcutaneous tissues. |
At the retracted edge of the first c
*''™""' divide the superficial muscles, and!

after these muscles retract divide the deep muscles. Incise
the periosteum with a bone-knife, push up the periosteum
with an elevator, and after the application of the retractor^
."jaw the bone, starting the saw from heel to point
periosteal flap can be made to cover the end of the boi
but it is unnecessary. In this amputation is formed 1

AMPUTATIONS. 845

cone whose apex is the bone and whose base is the skin-
edge. In one form of circular amputation {amputation
a la manchette) the retracted slctn is cut by a circular
sweep of the knife, a cuB" of skin and subcutaneous tissue is
freed and turned up, and the muscles are cut circularly at
the edge of the tumed-up cut (Fig. 312). The pure circular

Fin. 31J.— Orculu iDiinuIlan : diiKcting up the iklp-Bi

amputation is performed on the arm and the thigh ; the
amputation a la manchette is performed chiefly through the
wrist and the lower forearm.

Modified Circular Method. — In this operation the cir-
cular skin-cut may be modified by making a vertical incision
to join the first wound, the muscles being cut by a circular
sweep or by making two vertical skin- incisions. Listen's
modification consists in dissecting up two short semilunar
integumentary flaps and in dividing the muscles circularly.
This is known as the "mixed method" (Fig. 313). The

modified circular can be used upon the thigh, the leg, the
arm, and the forearm.

846 MODERN SURGERY.

Elliptical Method. — This method stands midway between
the circular operation and the operation by a single flap.
An elliptical incision is made through the skin and subcu-
taneous tissues, the tissues are pushed up or turned back,
and the muscles are divided circularly or cut partly by
transfixion. This method is employed particularly in certain
disarticulations.

Oval or Racket Method. — In an m^al amputation the
incision through the skin and subcutaneous tissue is an oval
with a pointed end or a triangle, and the other parts down
to the bone are cut from without inward. When a longi-
tudinal incision down to the bone (Fig. 318, a^ b) extends
from the point of the oval {a, b) the operation is called
the " racket " amputation. If the longitudinal cut joins
a circular cut, the operation is known as a " T ** am-
putation. The oval or racket operation is performed at
the metacarpophalangeal, metatarsophalangeal, and shoul-
der-joints; the T operation may be performed at the hip-
joint.

Flap Method. — A flap may be composed of skin only or
of both skin and muscle^ but the skin-flap must always be
longer than the muscle-flap, so that the latter will be covered

by it. A flap containing much
muscle heals badly, but the best
flap has a moderate amount of
muscle (enough skin to cover
the muscle and enough muscle
to cover the bone). Flaps may
be single or double. Double
flaps may be lateral or antero-
posterior, sqitare or [S'Shaped,
equal or unequal, and they may
be cut by transfixion (Fig. 314),

Fig. 314.— Amputation of the thigh by • ,. /• ., i . • j

transfixion (Gross). by cutting from without mward,

by dissection, or by cutting the
skin from without inward and the muscles by transfixion.
VVlicn an amputation is completed, tie the main vessels,
pull down the nerves and cut them high up. smooth the
flaps, take off the constricting band, and after arresting
hemorrhage apply sutures. In some cases the deep parts
arc stitched with a continuous catgut suture and the super-
ficial parts arc closed with silkworm-gut ; in other cases the
deep parts are not stitched at all, the skin alone being
sutured with silkworm-gut. Drainage-tubes should be used
except in amputations of the fingers and toes.

AMPUTA TIONS. 847

Special Amputations.

Fingers and Hand. — In amputating the thumb and in-
dex finger save every possible scrap of tissue. In either of the
fingers, if it be necessary to amputate above the middle of the
middle phalanx, the attachment of the flexor tendons will be
cut oflT and the finger will be liable to project directly back-
ward, so that it is better with these fingers either to disarticu-
late at the metacarpal joints or to stitch the flexor tendons to
the periosteum. The flexor tendons have fibrous sheaths ex-
tending from the proximal end of the distal phalanx to the
metacarpophalangeal articulations, these sheaths being thin
and collapsible opposite the joints, but being thick and rigid
opposite the shafts of the bone. The fibrous sheath is known
as the thecUy and when it is cut in an amputation it should be
closed, otherwise it may carry infection to the palm of the
hand. The theca does not exist over the distal phalanx, and
it is not distinctly visible over the joint between the distal and
middle phalanges. To effect closure over the shaft of a bone,
strip up the periosteum and pass catgut sutures vertically
through the theca and the periosteum (Treves). In amputa-
tion of the fingers and the thumb an Esmarch bandage is un-
necessary, though pressure may be made upon the arteries
at the wrist. Only two or three ligatures are necessary.
Close with a very few sutures, so as to favor drainage between
the threads.

The distal phalanx is best removed by a long palmar flap
(Fig. 315, a). The palmar flap (a) is marked out by cutting
through the skin and subcutaneous tissue.
The incisions are next carried to the bone,
the flap is dissected from the bone, the fin-
ger is strongly flexed, a transverse incision
(b) is carried across the dorsum on a level ^'° oPthl'fin^r*'*""
with the base of the third phalanx, the soft
parts are pushed back, the joint is opened, the lateral liga-
ments are cut from within outward, the third phalanx is
forcibly extended, and the remaining structures are cut from
below upward. The middle phalanx can be removed by the
same method (c). The proximal phalanx can be removed
by a long palmar flap or by a long palmar and a short dorsal
flap (d, e).

Disarticulation of a metacarpophalangeal joint is

best performed by the oval or racket method. The incision
upon the dorsum (a) is begun just above the head of the
metacarpal bone, is carried down to beyond the base of the

848

MODERN SURGER Y.

Fig. 316. — A, disarticu-
latiun of a metacarpopha-
langeal joint : c, amputa-
tion of a fingor with the
metacarpal bone.

phalanx, and involves the skin only (Fig. 316). One incision
sweeps around the finger at the level of the web, going only
through the skin (b); the finger is extended and the palmar
cut is carried to the bone ; each lateral incision is carried to

the bone while the finger is bent in the
opposite direction, the flaps are dissected
back to the joint, the finger is strongly
extended, the joint is opened from the
palmar side, and disarticulation is eflected.
Cutting off the head of the metacarpal
bone improves the appearance of the
stump but weakens the hand, hence in a
workingman it must not be done unneces-
sarily. If it is necessary to remove a
metacarpal bone, the incision (c) is made
from the carpometacarpal joint.
Amputation of the thumb through

its distal or proximal phalanx is performed
identically as is an amputation of a finger.
Amputation of the thumb, with a portion or the whole of its
metacarpal bone, is performed by the oval or racket incision.
Amputation of the wrist-joint can be done by the
circular method or by a double flap. In the double-flap
amputation a dorsal flap is made by carrying a semilunar
skin-incision between the styloid processes ; the skin is lifted,
the wri.st is forcibly flexed, the joint is opened by a trans-
verse cut, and a long semilunar palmar flap which includes
only the skin and fascia is made by dissection.

Amputation through the forearm may be effected
by the circular method (Fig. 312), the modified circular,

or the flap operation. An ex-
cellent plan is to make a
semilunar dorsal skin-flap and
a semilunar skin-flap on the
flexor surface. The flaps are
raised, the muscles are cut circularly (Fig. 317), the interos-
seous space is cleared with the knife, a three-tailed retractor is
applied, the periosteum is pushed up, and the bones are sawn
half an inch above the flap. In sawing the bones, start the
.saw upon the radius, draw it from heel to point, make a fur-
row on the radius and ulna, and saw both bones at same time.
After sawing, cut away any irregular edge with bone-pliers.
In the lower third Teale's amputation may be done, the dor-
sal flap being the long one. In Teale's amputation rectangu-
lar flaps are made. The long flap is equal in width and length

Fig. 317. — Modified circular amputation
of the forciirm (Bryant).

AMPUTATIOKS. 849

to one-half the circumference of the limb at the point where
it is to be sawn. The short flap is equal in width to the long
flap, but is only one-fourth its length. The two longitudinal
cuts are at first taken only through the skin, but the two
transverse cuts go at once to the bone. The flaps are dis-
sected up from the interosseous niembrane and the bone. In
the middle or the upper third of a fleshy arm two semilunar
skin-flaps can be cut from without inward, and the muscle
can be cut by transfixion.

Disarticulation of the elbow-joint can be done by
the elliptical method or by a long anterior and short poste-
rior flap. In the latter operation the forearm is partly flexed
and a skin-cut marks out a long anterior flap, the knife being
entered opposite the external condyle and being withdrawn
one inch below the internal condyle. The muscles, which
are bunched forward, are cut by transfixion. A posterior
semilunar flap is made, which separates the attachments of
the radius, the ulna is cleared, and the triceps is cut at its in-
sertion (Bell). Gross advocated sawing through the olecranon
and the inner trochlear surface.

Amputation of the arm is best performed by marking
out with a knife two equal semilunar anteroposterior flaps,
the first cut being carried through the skin alone, the mus-
cles being then transfixed with a long knife. Teale's method
is shown in Fig. 138. The circular or the modified circular
amputation may be performed.

IMsaitictilation at the Shotilder-joint.— In this oper-
ation Wyeth's pins must be passed to hold the Esmarch
band in place. The anterior pin is entered at the middle of
the lower margin of the anterior axillary fold, and emerges
one inch within the tip of the acromion. The
posterior pin is entered at a corresponding
point on the posterior axillary fold, and
emerges more posteriorly than the first pin
and an inch within the tip of the acromion.
The Esmarch band is applied above the pins.

Larre7's Operation. — In this method of
shoulder-joint disarticulation the limb is held
from the side and an incision is made down ^ _

to the bone, the incision beginning just below wiioii m ihe iiw""-
and in front of the acromion and running iimy".^™i'ion|
vertically for four inches down the outer sur- ^tiiiS^T'^™"'*
face of the arm (Fig. 318, a b\ From the
center of this incision an oval incision (c(/, cf)is carried
around the arm, the inner aspect of the oval reaching as low

850 MODERN' SURGERY.

as the lower end of the vertical cut. The oval incision at
first involves only the skin and subcutaneous tissues. The
anterior structures are divided close to the bone, and the
posterior structures are next cut. To disarticulate, cut the
capsule transversely upon the head of the bone; while the
arm is rotated outward cut the subscapularis, and while the
arm is rotated inward cut the supraspinatus and infraspinatus
and the teres minor. Cut away any tissue holding the hu-
merus to the body ; cut away hanging nerves, capsule-frag-
ments, and tissue-shreds, and sew up the wound vertically.
Bell advises an oval incision with a racket handle. Spence
used an anterior racket incision.

Dupuytren's Method. — In Dupuytren's shoulder-joint dis-
articulation a U-shaped flap is marked out by a skin-incision
(Fig. 318,/^). If the amputation is to be at the right shoul-
der the arm is carried across the chest ; the knife is entered at
the root of the acromion, follows the margin of the deltoid,
and is withdrawn at the coracoid process, the arm being

gradually abducted and pulled off from the
chest. If the left shoulder is to be ampu-
tated, the procedure is reversed (Treves).
The knife now cuts through the deltoid and
raises a flap composed of this muscle, the
shoulder-joint is exposed, and disarticulation
is effected as in Larrey's method. The knife
is passed down back of the bone and a short
internal flap is cut. Lisfranc's amputation is
by transfixion with the formation of an ante-
rior and a posterior flap, and can be performed
very rapidly, but only a most skilful surgeon
should attempt it.

Fic. 319 -Am. Amputation of the Toes and the Foot.

putation of mcta- ^ » • 1 • • ,

tarsal bones. — Only m the great toe is partial amputation

performed, and it is effected by the formation of
a long plantar flap, just as a long palmar flap is formed from
the finger. Amputation at the metatarsophalangeal joints
is performed by an oval or racket incision (Fig. 319, c).
Amputation of a toe with removal of its metatarsal bone is
shown in Fig. 319, ^? ^ and d c.

Amputation at the Tarsometatarsal Articulation.

— Lisfranc's method (after Tre\'es). — In order to ampu-
tate the right foot by this method begin an incision on the
outer border of the foot, behind the tubercle of the fifth
metatarsal bone ; carrv the incision forward one inch and
sweep it across the foot half an inch below the tarsometa-

AMPUTATIONS. 85 1

tarsal articulations ; bring the incision to the inner edge of
the foot, half an inch in front of the tarsal articulation of the
big toe, and carry the cut straight along the inner margin
of the foot until it reaches a point three-fourths of an inch
above the articulation of the metatarsal bone of the great
toe. A very short semilunar dorsal skin-flap is thus
formed. After the skin -flap is dissected back for a
quarter of an inch the tendons are divided, and the flap,
which now contains all the soft parts, is dissected back to
above the joint. A long plantar flap is cut, reaching from
the origin of the first flap to the necks of the metatarsal
bones. The skin-flap is dissected up until the hollow
behind the heads of the metatarsal bones is reached, when,
with the toes in extension, the tendons are cut across and
a flap composed of all the soft parts is dissected up to
above the tarsometatarsal joint. Fig. 320 shows the line of
Lis franc at the tarsometatarsal articu-
lation. The joint is opened from the
outer side according to the following rule :
in separating the fifth metatarsal direct
the edge of the knife toward the distal
end of the first metatarsal ; in separating
the fourth metatarsal direct the knife
toward the middle of the first metatar-
sal ; in separating the third metatarsal
carry the knife almost directly across.
The separation is facilitated by bending
down the front of the foot, and at the same
time the tendons of the peroneus brevis
and tertius are divided. Open the joint
between the first metatarsal and the
inner cuneiform bone, turning the knife
toward the middle of the shaft of the fifth metatarsal, and
at the same time divide the tibialis anticus muscle. Treves

says that in disarticulation of the second metatarsal the
knife is to be held as a trocar, it is to be thrust between the

852 MODERN SURGERY.

base of the first and second metatarsal bones until the point
strikes bone (Fig. 321). and is then to be raised to a perpen-
dicular and the cut is to be made toward the external malle-
olus to sever the ligament of Lisfranc (Fig. 322). Divide

any remaining ligaments, and also the tendon of the pero-
neus longus muscle. The skin-incisions in the Uft foot are
begun on the inner side, and in disarticulating the tarsal
joint of the great toe is first opened. Fig. 323 shows the
parts after disarticulation at the line of Lisfranc.

Hey's Method. — In Hey's method the incision is practi-
cally the same as that for Lisfranc's amputation. The four
external metacarpal bones are disarticulated, but the first
metatarsal is removed by sawing a portion of the internal
cuneiform bone. Guerin advised sawing all the bones across.
Skcy advised the division of the head of the second meta-
tarsal. Fig. 320 shows the line of Hey.

Amputation through the Middle Tarsal Joint.—
Chopart's Amputation. — Make a transverse incision

through the skin of the instop, two inches below the
ankle-joint; cut the tendons and muscles, expose the tar-
sus, and make on each side a small longitudinal incision

AMPUTA riONS. 853

reaching to below and in front of the corresponding malle-
olus. The flap thus formed is retracted. The plantar flap
is made as in Usfranc's amputation. Open the astragalo-
scaphoid joint, then the calcaneocuboid joint, and disardcu-
late. Fig, 320 shows the line of Chopart. Fig. 324 shows
the parts after Chopart's disarticulation. In amputation
tJtrmtgh the tarsus Forbes of Toledo advises making flaps
as in Chopart's amputation, disarticulating the scaphoid
from the cuneiform bones, and sawing through the cuboid.
Fig. 320 shows the line of Forbes.

Amputation at the Ankle-joint. — Srme'B Method.—
The foot is held at a right angle to the leg, and a skin-
indsion is carried, from just below the external malleolus,
straight across or a little backward across the sole to a
corresponding point on the opposite side. Do not take
this incision near to the inner malleolus, as to do so will
endanger the posterior tibial artery. The incision is carried
to the bone, the flap being pushed back and separated from
the bone by means of a strong knife and the thumb-nail until
the tuberosity of the os calcis has been reached. The foot
is now extended and a transverse cut is made across the
dorsum, joining the two ends of the first incision ; the ankle-
joint is opened, the lateral ligaments are cut, disarticulation
is effected, and the foot is finally completely removed by
severing the tendo Achillis. A thin piece of bone including
both malleoli is sawn from the tibia and fibula. The flap is
perforated posteriorly to secure drainage.

Puroffoff 'b Uethod. — In this method of ankle-joint ampu-
tation the incisions are the same as those for Syme's ampu-

854

MODERN SURGERY,

Fig. 326.~S6dillot's
amputation of the leg
(Wyeth).

tation. Do not dissect the flap from the posterior portion
of the OS calcis, but saw off this bony projection obliquely
and leave it adherent to the tissues. The saw is used after
disarticulation of the ankle-joint; it is passed behind the

astragalus, cutting downward and forward.
The ends of the tibia and fibula are sawn
off, and the sawn os calcis is brought into
contact with the sawn tibia and fibula. The
lines a and b (Fig. 325) show the sections
made by the saw.

Amputations of the I^g. — In am-
putations of the leg by the long anterior
flap, cut through the skin, dissect up the
anterior muscles with the flap, and cut all
the posterior tissues with a single trans-
verse sweep. Amputation by the redan-
gnlar flap, Teale's method, is very useful
(see page 848). The long flap is anterior,
and is in length and breadth equal to one-
half the circumference of the limb. The
short flap is one-fourth the length of the
long flap. The flaps are dissected up. the
bones are sawn, the long flap is turned upon itself, and its
edges are sutured to the edges of the short flap.

S^dillot's legr-amputation (Fig. 326) is by a long exter-
nal flap. A longitudinal incision is made along the inner
edge of the tibia, the tissues are drawn toward the fibula,
a knife is introduced and passed to the outer edge of the
tibia, just touching the fibula, and is brought out posteriorly,
thus transfixing the calf-muscles and cutting an external flap.
A convex incision is made on the inner side, the bones are
cleared and are sawn one inch above the flaps, half an inch
more being taken from the fibula than from the tibia, and
the tibia being bevelled anteriorly.

Modified Circular Amputation of the Legr. — Cut semi-
lunar skin-flaps, lay them back, and cut circularly to the
bone at the edge of the tumed-up flap. Another method
of modified circular amputation is by adding to the circular
cut a vertical incision down the front of the leg. In sawing
the bones of the leg the surgeon, who stands to the outer
side of the right leg or to the inner side of the left leg,
divides the fibula first, and at a higher level than the tibia,
and bevels the anterior surface of the tibia. In sawing the
left fibula the saw points to the floor ; in sawing the right
fibula it points to the ceiling.

AMPUTA TIONS, 855

Amputation of the Legr by a Lonsr Posterior and a Short
Anterior Flap. — In this operation a posterior U-shaped flap
is made, equal in length and breadth to the diameter of
the limb. The skin-incision is begun one inch below the
point where the bone is to be sawn, and behind the inner
edge of the tibia, and is carried to a point posterior to the
peronei muscles. The gastrocnemius muscle is divided trans-
versely at the level of the flap, the soft parts on either side
in the line of the flap being cut to the bone. Through these
vertical cuts the muscles are lifted
from the bones and are divided
through their lower part by cut-
ting from within outward. The
anterior flap is formed by making
a semilunar skin-flap and by cut-
tine: the muscles across at its re- ^»G- 3f7.-Amputatlon of the leg by

^ , , y Y^. \ ^ A long postenor flap (Grofts).

tracted edge (Fig. 327). Ampu-
tation of the leg by lateral flaps is not a popular operation, as
it offers too much encouragement to subsequent protrusion
of the bone. Bier endeavors to broaden the support after
amputation by performing a cuneiform osteotomy and bend-
ing the lower fragment to a right angle with the upper, and
obtaining union of the fragments.

Amputation just below the Knee. — The seat of election
is one inch below the tuberosities. No muscle is needed in
the flap. Cut two flaps of skin, equal in size and semilunar
in shape, these flaps beginning anteriorly two inches below
the tuberosity of the tibia. One flap is antero-extemal and
the other is postero-internal. The flaps are pulled up, the
anterior muscles are cut as high up as possible, and the pos-
terior muscles are cut through the middle of the portion ex-
posed (Bell). The bone is sawn one inch below the tuber-
osity.

Disarticulation of the Knee. — In disarticulation by the
long anterior flap, make a long anterior skin-flap, incise the
ligament of the patella, turn up the flap with the patella,
open the joint, and complete the disarticulation by cutting
from within outward and downward. The knee may be dis-
articulated by means of a long anterior and a short posterior
flap.

Amputation throufirh the Femoral Condyles. — Synte's
Method by a Long Posterior Flap. — Carry a skin-incision, with
a very slight downward curve from one condyle to the other,
across the middle of the patella. Cut down to the bone,
retract the flap, and cut the quadriceps above the patella.

8$6 MODERN SURGER V.

Insert a long knife at one angle of the wound, pass it back
of the femur, and make it emerge at the opposite angle, cut-
ting a posterior flap eight inches long. Retract the posterior
flap, clear for sawing, and section the condyles horizontally.
Garden made a curved section of the condyles at their widest
part. In children Buchanan showed that we can easily sepa-
rate the lower femoral epiphysis. In Gritti's supracondyloid
amputation an oblique incision is made. The upper end of
the incision is posterior and just above the condyles. Its
lower end is anterior and two finger-breadths below the
patella (Kocher). The ligament of the patella is cut, the
flap is turned up, the femur is sawn at the base of the
condyles, the articular face of the patella is sawn off", and
the sawn patella is fastened to the sawn femur and the flaps
are sutured. Sabanejeff makes an anterior flap, opens the
knee-joint from behind, saws the condyles at their broadest
part, takes a bone-flap from the anterior portion of the tibia
and fastens it to the femur.

Amputation of the Tbigrh. — In thigh-amputation in the
lower third either a flap or a circular operation may be per-

formed. In a double-flap operation a semilunar skin-incision
should be made from without inward, and the muscles should
be cut by transfixion (Fig. 328). In the lower third Teale's
flap or the long anterior flap may be employed. The ampu-
tation by a long anterior flap consists in making a lengthy
skin-flap, reflecting it, cutting the anterior structures to the
bone, again entering the long knife at one angle of the incision,
pushing it back of the femur, bringing it out at the other
angle, and cutting the structures behind the bone directly

AMPUTATIONS. 857

backward. Bell amputates by a long anterior semilunar
flap and a short posterior flap. In amputations in the
upper two-thirds of the thigh the best plan is to mark
out equal anterior and posterior semilunar skin-flaps, di-
vide the skin with a scalpel, enter the long knife at one
angle of the anterior flap, bring it out at the other angle,
and cut the muscles by transfixion. Cut the posterior flap
in the same manner. Some surgeons prefer a long ante-
rior semilunar flap and a short posterior semilunar flap.
The pure circular amputation is not adapted to the
thigh.

Disartdouiation at the Hip-joint. — Disarticulation at the
hip-joint can be effected while the circulation is controlled
by Macewen's method of compression of the aorta (Fig. 329).

The weight of the assistant's body is thrown upon the
patient's aorta by the right fist, placed slightly to the left of
the umbilicus. McBurney has suggested the prevention of
bleeding by making a small abdominal incision and having
an assistant make direct digital pressure upon the iliac
artery. In the bloodless method of Wyeth (Fig. 330) the
band of the Esmarch apparatus is held up by Wyeth's

858 MODERN SURGERY.

pins, the outer pin being inserted one and a half inchi
below and a little internal to the anterior superior spini
of the ilium, and brought out just back of the great tj
chanter. The inner pin is entered one inch below th(
level of the crotch, and interna! to the saphenous opcninj
and it emerges one and a half inches in front of the tube
osily of the ischium. The hip is brought well over the edj
of the table, a circular incision is made down to the d<
fascia six inches below the constricting band, and is joined b)
a longitudinal skin-cut reaching from the band to the level
of the circular incision, and the cuff is reflected to the level
of the lesser trochanter. The muscles are cut by a circular
sweep at the level of the retracted cufT the capsule is opcm
freely, the cotyloid ligament is cut posteriorly, the thigh n
bent upward, forward, and inward to dislocate the bead
the bone, and, using the thigh as a handle, the round liga-
ment is incised and the limb removed. After ligating the
vessels and introducing tubes the flaps are sewn together
tically. The old transfixion operation is practically extinct.

lar I

K"^ -amputation maybe employed. It consists of an external
straight incision down to the bone, starting over the great
trochanter, down the outer side of the limb, and a circular
incision through the skin five inches below the constricting
band, the muscles being cut by a circular sweep at the level
of the retracted skin. This method affords easy access to
the joint. The bloodless method of Wyeth, as applied to
the hip-joints and shoulder-joints, is one of the most notablCj
modern advances in the art of surgerj'. Larrey amputate!

DISEASES OF THE BREAST, 859

by lateral flaps, and Listen by anteroposterior flaps. For-
neaux Jordan's method consists in dividing the soft parts
low down, tying the bloodvessels on the face of the stump,
shelling out the femur from the soft parts, and disarticulating.

XXXVIII. DISEASES OF THE BREAST.

Mammillitis and Fissure. — The nipple may inflame
as a result of injury, but the condition is rarely encoun-
tered except in a woman who is nursing a baby. It is most
common after a first pregnancy, when the nipple is deformed
or when the skin is delicate. The nipple is slightly injured
during nursing, and the epithelium is macerated by the milk
and saliva. If the inflammation is not arrested, an area ex-
coriates or an irritable ulcer forms (a fissure). This fissure
is often surrounded by an area of acute inflammation, and
nursing causes intense agony. Because of the pain the
mother is apt to extend the intervals between nursing, and
as a consequence the breasts become swollen with retained
milk. The ulcer not unusually bleeds when taken by the
child. Besides the fact that a fissure causes pain to the
mother, it often leads to grave trouble. It is a suppurating
area, and as such may lead to abscess of the mother's
breast, or may impair the health of the nursing child.

Prevention of Fissure. — During pregnancy the nipples
should be carefully attended to. They should be washed
often in sterile water and bathed in alcohol, and if retracted
ought to be drawn out repeatedly. During lactation the
nipples are washed in sterile water, dried, and dusted with
borated talc powder as soon as an act of nursing is com-
pleted. Washing the nipples regularly with the following
solution tends to prevent the formation of a fissure : iodid
of mercury, gr. ij ; alcohol, 5jss ; glycerin and distilled
water, aa a pint (Lepage). If a small abrasion appears,
order the woman to wear a nipple-shield during nursing,
and after each act of nursing to wash the part with hot
sterile water, dry, and dust borated talc over the surface. If
a fissure forms, wean the child at once, and dry up the milk
in both breasts. It is useless to try to dry it up in one
breast. Milk may be dried up by applying ointment of bella-
donna locally and administering iodid of potassium inter-
nally; by strapping the breasts with adhesive plaster (Parker);
or by applying to the nipples six times a day a 5 per cent, so-
lution of cocain in equal parts of glycerin and water (Joise).
The fissure is not treated by ointments. These preparations

86o MODERN SURGERY.

are septic, prevent drainage, and aggravate maceration. Wash
the fissure twice a day with peroxid of hydrogen, dress it with
gauze wet in boric-acid solution (gr. x to 3j of water), and
cover the dressing with waxed paper. If the fissure resists
treatment, touch it with lunar caustic.

Acute Mastitis and Abscess. — Acute inflammation of
the breast, as a result of injury of the breast or nipple, may
occur in either sex at any time of life. Very commonly in
both sexes a few days after birth the breast becomes dis-
tended with a material which in reality is milk. The fluid
is usually small in quantity. The process is physiological,
and, as a rule, ceases spontaneously (Guelliot). If it lingers,
the application of belladonna ointment will stop secretion.
If the nurse meddles with and tries to squeeze out the fluid,
acute mastitis is apt to arise in one gland, or occasionally in
both. The skin of the breast reddens, the gland swells and
becomes tender and painful, the child loses its appetite and
becomes feverish, restless, and sleepless. Such a condition
is treated by the local use of lead-water and laudanum. If
pus forms, the local signs and constitutional symptoms are
aggravated. Evacuate the pus, dress with hot antiseptic
fomentations, and be sure that the child is well nourished.
Tonics and stimulants are indicated.

A condition identical with the secretory activity of the
glands of the new-born may occur in either sex at pubert}'.
The methods of treatment are the same in both cases. As a
matter of fact, rarely more than one lobule at this period in-
flames, and suppuration is most unusual.

Mastitis is most usually met with in a woman who is nurs-
ing a child, and is due to bacterial infection. Primipara are
particularly liable to develop mastitis. So are women with
deformed nipples. In many cases an abrasion of the nipple
exists, and through this breach of continuity organisms gain
entrance to the breast-tissue. The abrasion may be so slight
that it can only be detected when the nipple is examined
through a magnifying-glass (Marmaduke Shield). Strepto-
coccic infections are very generally due to inoculation of a
fissure of the nipple. Organisms may pass up the milk-ducts,
coagulating the milk and penetrating through the walls of
the acini. Staphylococci usually adopt this route in reaching
the breast-tissue. Occasionally causative organisms reach
the breast through the arteries (in septicemia and in septic
wounds of the genital organs).

Symptoms. — There are pain, swelling, and tenderness in
the breast, and in most cases a fissure or abrasion exists.

DISEASES OF THE BREAST, 86 1

There is a febrile condition. Occasionally a chill ushers in
the attack.

Treatment. — Stop nursing. Arrest the secretion of milk.
Treat the nipple as advised on page 859. Support the
breast and apply ichthyol ointment or lead-water and laud-
anum.

A mastitis may undergo resolution ; it may terminate in or-
ganization and induration ; it may eventuate in suppuration.

Acute abscess of the breast follows an acute mastitis.
There may be but one area of suppuration, or multiple foci
may exist, which eventually fuse. The symptoms of mas-
titis, local and constitutional, are greatly aggravated. After
a time the skin becomes dusky and edematous. The axillary
and superficial cervical glands enlarge. The abscess will
eventually open spontaneously at one or more points, leaving
branching fistulae. A superficial abscess is situated just
beneath the nipple, and pus may flow from the nipple.

An intramammary abscess is in the depths of the gland.
There are often multiple foci of suppuration. Nodules are
felt in the gland, pus may run from the nipple, but cutaneous
redness is late in appearing.

Retromammary abscess is a rather rare condition. It may
occur alone or be associated and connected with an area of
intramammary suppuration. This condition may result from
metastasis or from caries of a rib. The breast is lifted up
by the fluid beneath it.

Treatment. — Open a superficial abscess by an incision
radiating from the nipple. Treat as any other acute
abscess. An intramammary abscess should be opened
by a radiating incision, and pockets of pus should be broken
into with the finger. An examination is made to determine
if a retromammary abscess also exists. If this is found to
be the case, an incision is made at the point of junction of
the thorax and mammary gland, and at the lower border
of the gland. The gland is raised from the chest-wall, the
pus evacuated, and a drainage-tube is inserted. If retro-
mammary abscess exists alone, make the last-named incision
in the first place.

Chronic Mastitis. — This condition may be present in
only a portion of the breast, or may attack many lobules
(lobular mastitis). The ordinary form may arise after weaning
a child, or may be due to a blow, to the pressure of corsets,
or to numerous slight traumatisms. It may occur in the
young, the middle aged, or the old. The patient has slight
pain at times in the gland. Examination detects a firm,

862 MODERN SURGERY.

elastic area, which is somewhat tender and does not present
distinct edges. The skin is not adherent to the mass unless
suppuration occurs. If the mass is pressed against the chest
by the surgeon's fingers, it becomes evident that no real
tumor exists.

Treatment. — Remove any cause of irritation. Support
the breast in a sling. Apply ichthyol ointment. During
the night employ a hot-water bag. If pus forms, treat
as before directed.

Chronic lobtilar mastitis is a condition in which
numerous lobules become indurated. The real cause of
this condition is unknown. It may occur at any age after
puberty, and often attacks both breasts. Such a breast
is apt to be painful, especially at the menstrual periods ; it
feels unnatural, solid, and careful examination detects numer-
ous indurated areas, each of which is of small size. At
the menstrual period the breast enlarges and new nodules
may be detected. In some of these cases violent neuralgic
pains are present in the gland (mastodynia). Chronic lobular
mastitis is apt to lead to cyst-formation. When cysts form
fluid may occasionally discharge from the nipple.

Treatment. — Support the breast and apply ichthyol oint-
ment or belladonna ointment. Examine the generative organs
and correct any existing abnormality. Improve the general
health by good food, tonics, and open-air life. In cases
where multiple cysts are known to exist the question of
treatment is uncertain. There seems to be no doubt that
such cases tend in some instances to eventuate in cancer. We
believe that the proper treatment is extirpation of the breast.

Tuberculosis of the Mammary Gland. — (See page
1 08.)

Cysts and Tumors of the Nipple and the Mam-
mary Gland. — Tumors are rare in the nipple, but do some-
times occur. The following growths are occasionally seen:
fibroma, angeioma, papilloma, myxoma, myoma, and epithe-
lioma. Sebaceous cysts of the nipple and areola are not ver)'
unusual. A cancer of the nipple may be a primar>' growth, or
ma\' be secondary to gland cancer. Primar>' epithelioma of
the nipple presents the .same general characters as epithelioma
in any other region. It begins as an indurated area in the
areola, or an excoriation of the nipple. Ulceration soon
occurs. The ulcer is irregular in outline, has hard edges, fur-
nishes a foul red flow, and the discharge is sanious and fetid.
The niammar}' gland becomes infiltrated at an early period.
The subclavian glands enlarge, and later the axillar>' glands.

DISEASES OF THE BREAST, 863

This growth must not be confounded with a chancre of the
nipple.

Treatment of Tumors of tfie Nipple. — Innocent tumors are
to be excised and the breast need not be removed.

Epithelioma of the nipple requires the complete extirpa-
tion of the breast, and also the clearing out of the lymphatic
contents of the axilla, and possibly of the subclavian triangle.

Paget'8 Disease of the Nipple (Malignant Derma-
titis).— This condition is a chronic inflammation of the
epithelial layer of the nipple and areola occurring in women
beyond middle life, and is a not unusual precursor of epi-
thelioma of the nipple and of duct cancer. Paget's disease
is not a simple eczema, it is not associated with the usual
causes and attendants of eczema either local or constitu-
tional, and is not cured by remedies which control the
ordinary disease.

The diseased area is raw and red, and from it exudes
copiously a thick, yellow discharge. In some cases Paget's
disease is secondary to duct cancer, auto-infection of the
nipple having been effected by the fluid flowing from the
ducts. Investigations have shown the presence of psoro-
sperms in an area of Paget's disease.

Treatment consists of removal of the entire breast and
clearing out of the axilla and subclavian triangle.

Ttimors of the Mammary Gland. — These tumors
may be innocent or malignant. The innocent tumors are

Fibro-adenomata or Cystic Adenomata, Myxomata,
Villous Papillomata, and Angriomata. — It is maintained
by most authorities that any innocent tumor of the gland
may and often does become malignant.

Fibro-adenoma. — The nomenclature of these growths
is in a state of great confusion. The name of fibro-aden-
oma was given by Cornil and Ranvier to the same sort of
growth which the younger Gross called a fibroma, Billroth
an adeno-fibroma, and Sir Astley Cooper a chronic mam-
mary tumor. It is doubtful if a pure fibroma ever occurs
in the mammary gland (Senn). A fibro-adenoma consists
of acini surrounded by fibrous tissue. Each of these
structures proliferates, but the fibrous tissue does so
much more rapidly than the glandular. A growth of this
character is surrounded by a capsule, and is movable. It
is firm, elastic, lobulated, superficially situated, and of slow
growth. It is unassociated with retracted nipple, glandular
enlargement, adhesion to the skin, or cachexia, and may
occur at any age up to fifty, but is most common between

864 MODERN SURGER Y.

twenty and thirty (J. Bland Sutton). Such a tumor is rarely
very painful, but it may be tender on rough handling and
may be painful at the menstrual period. As a rule, there is
but one of these tumors in a mammary gland, but one may
exist in each gland.

Treatment, — Extirpation of the tumor.

Cystic adenoma (adenocele) is a rare form of slowly-
growing tumor, which is apt to grow to a large size, which
is nodular in outline, hard to the touch, and firmly attached
to the breast, but mobile upon the chest. A cystic adenoma
has a distinct capsule. This form of tumor is painless, and
is most apt to occur in women between thirty and forty
who have born children. The growth is adherent to the
skin, but the cutaneous surface is not discolored, the cuta-
neous veins are not distended, the axillary glands are not
enlarged, and the nipple is not retracted. From the walls
of the dilated acini papillomatous growths are apt to arise
(intracystic vegetations).

Treatment, — Removal of the breast.

M3rxoina is a rare tumor, and only occurs in a person of
middle age. The growth is solitary, is soft, may be round
or lobulated, and occasionally fungates. The nipple is not
retracted, the superficial veins are not distended, and the
axillary glands are not enlarged.

Treatment, — Removal of the mammary gland.

Angioma. — This form of tumor is very rare. It may
arise secondarily to a nevus of the skin (Sutton). The
diagnosis of angioma of the skin is readily made. In
a cavernous angioma of the breast it will be found that
the tumor can be lessened in size by pressure, and will be
increased in size by coughing, laughing, and holding the
breath. Pulsation may be detected and a bruit may be
audible.

Treatment. — For treatment of nevus see page 226. If a
cavernous angioma exists in the mammary gland, it will be
necessary to extirpate the gland.

Cysts of the Mammary Gland. — Involution cysts
(cystic degeneration of the mamma) occur in women
who arc approaching the menopause. They occur earlier
in those who arc sterile than in those who have bom chil-
dren, and may arise after chronic mastitis. The paren-
chyma of the gland undergoes atrophic change, but the
ducts remain, become blocked and dilated. Numerous
small cysts form, and both glands, as a rule, suffer. Villous
growths may arise in the walls of the ducts. In some cases

DISEASES OF THE BREAST, 865

there is much white fibrous tissue between the cysts (cystic
fibroma).

The subjects of this disease are often nervous, hysterical,
and despondent. One or more ill -defined indurations are
detected. Frequently there is a history of discharge from
the nipple and of attacks of lancinating pain in the breast.
Cystic breasts are dangerous, because the intracystic vege-
tations are liable to eventuate in duct cancer.

Treatment, — In such cases, after confirming the diagnosis
by an exploratory incision, remove the entire breast (Snow).

Lacteal cyst (galactocele) is an accumulation of milk
brought about by blocking of some of the milk-ducts. It
arises soon after the delivery of the child, and grows rapidly.
A large quantity of milk may collect, and rupture of the
cyst-walls can occur, the fluid passing into the glandular
connective tissue.

A galactocele is rounded, fluctuates distinctly, and increases
in size during nursing. There is little or no pain. In
some cases the contents of the cyst coagulate and a solid
mass is formed.

Treatment, — Incision and drainage.

Hydatid cyste are rare, but do occasionally occur.

Treatment, — Excision.

Malignant tnmors of the mammary gland are ten

times more common than innocent tumors.

Sarcoma. — Sarcoma of the mammary gland is a very rare
growth (less than 10 per cent, of breast tumors). It may occur
at any age from pubert}' to old age, but is most common from
twenty to thirty-five. The growth may be composed of round
cells or spindle cells, both varieties may be present, and
myeloid cells may be found. Circumscribed sarcoma arises
usually between the ages of twenty and thirty; it is firm to the
touch, as it contains much fibrous tissue, is painless, does not
grow very rapidly, glands are not involved, and there is no
cachexia. The nipple is not retracted. The growth may
adhere to the skin. It is composed of giant-cells or spindle-
cells, and rarely returns after extirpation of the breast.

Diffused sarcoma is composed of small round cells,
arises in the center of the breast, and grows with great
rapidity. It is most commonly met with about the age of
thirty-five, and a history of injury can often be elicited. The
tumor is soft, some parts being softer than others because
of cyst-formation. It is usually mobile upon the thorax,
though it soon becomes adherent to the skin. The tumor
reaches a very great size, and soon fungates through the

866 MODERN SURGERY,

skin. There is little or no pain. The cutaneous veins over
the tumor are distended, the nipple is not retracted, and the
axillary glands are not often enlarged. Diffuse sarcoma is
apt to recur after removal.

Treatment, — Remove the breast, and if the muscles of the
chest-wall are infiltrated, remove them. The axillary glands
are removed if they are enlarged, but not otherwise. Opera-
tion will not cure when metastases exist. If the case is in-
operable, we can try the use of Coley's fluid. If the toxins
of erysipelas fail to arrest the progress of the disease, keep
the patient as comfortable as possible by the administration
of cocain and morphin.

Carcinoma or Ceuicer of the Mammary Gland. — The
great majority of mammary tumors belong to the genus
carcinoma. Cancer is due to proliferation of the epithelium
of the acini (acinous cancer) or of the ducts (duct cancer).

Acinous cancer is vastly commoner than duct cancer.
Usually there is much connective tissue and but Httle
parenchyma in the growth (scirrhus cancer). In some
cases there is Httle connective tissue and much parenchyma
(encephaloid or medullary cancer). If colloid degeneration
of the parenchyma or stroma occurs, the growth is spoken
of as colloid cancer.

Scirrhus, the common form of acinous cancer, is almost as
hard as stone. On section it is concave, and Sutton says
" resembles an unripe pear." The tumor is without a cap-
sule, and the epithelial cells are surrounded by masses of
fibrous tissue. Portions of tissue, even some distance away
from the tumor, contain foci of proliferating embryonic epi-
thelial cells. In atrophic or withering scirrhus the fibrous
stroma contracts and epithehal cells undergo fatty degenera-
tion (Senn).

Causes and Symptoms. — Seirrlius is more common among
women who have born children than among those who have
not. Heredity is manifest in only about lO per cent, of cases
(Bryant). The younger Gross found it in one case out of
nine. Trauma has no apparent influence in producing can-
cer. The disease is rare before the age of thirty-five, and
is most common between forty-five and fifty. The author
operated for scirrhus of the breast on a woman only
twenty-seven years of age. Henry saw a woman of
twenty-one with cancer. It is frequently met with in
the aged. These tumors are rare in the negro race.
A hard nodule is found in the breast, usually under the
nipple, but possibly far away from it. The growth is nod-

DISEASES OF THE BREAST. 867

ular, and is immobile from the beginning. In a large, fat
breast there is often a deceptive sense of rtiobility, because
some of the breast-tissue moves with the tumor. The cancer
may have been present for a considerable time before being
discovered. In obscure lesions of bones and viscera examine
the mammary glands, because the trouble might be due to
metastasis from an undiscovered carcinoma of the breast.
Retraction of the nipple is present in over one-half of the
cases (S. W. Gross). It occurs when the growth is near the
nipple, and is due to the contracting fibrous tissues of the
tumor pulling on the milk-ducts. If the growth is far away
from the nipple, a dimple is apt to form on the skin of the
breast because of the pulling upon the suspensory fibers.

Glandular enlargement in the axilla soon follows the ap-
pearance of a scirrhus ; the glands become very hard and
adherent. In over 60 per cent, of persons the glands of the
axilla are felt to be enlarged when the patient first comes for
treatment. Because the surgeon cannot feel enlarged glands is
no proof that there are none. As a matter of fact, the glands
are usually involved within two months of the beginning of
the disease, but the involvement can rarely be detected ex-
ternally until months later. Enlargement of the axillary
glands is followed by enlargement of the glands in the pos-
terior cervical triangle and in the mediastinum. Herbert
Snow has shown that the blocking of the axillary glands
often leads to regurgitation of lymph containing cancer-cells,
the cells being thus deposited in the head of the humerus
and the thymus gland. Cells in the thymus, after a time>
cause a projection of the sternum (the sternal symptom).
When the axillary lymphatics are extensively involved the
arm swells from obstruction to the lymph-flow (lymph
edema) or pressure upon the vein. The tumor usually
grows rather slowly unless lactation is established, then it
grows rapidly. As it grows it infiltrates adjacent structures
(the pectoral fascia, pectoral muscles, subcutaneous cellular
tissue, and skin). When the skin is destroyed an ulcer forms,
and around this ulcer the skin becomes red and filled with
cancerous nodules, which feel like shot in the skin. Metas-
tases are apt to occur into the bones, liver, brain, pleura,
spine, thymus gland, and rarely the eye.

Pain is usually present in scirrhus carcinoma. It is lan-
cinating and neuralgic in character, and not brought on or
increased by handling. It ceases if colloid degeneration be-
gins. The general health is usually unimpaired until ulcer-
ation takes place, when cachexia arises. The cancer en cui-

868 MODERN SURGERY,

rassc of Velpeau is a condition in which the lymphatic vessels
of the skin are extensively invaded, the growth itself being
adherent to the wall of the thorax. In this condition the
chest-wall is fixed, respiration is difficult, and the temperature
is commonly somewhat elevated.

In atrophic or unthcring scirrhus the contraction is so
great that it seems as though the mammary' gland had
been removed. The duration of scirrhus. when left to run
its course, varies, but the disease generally produces death
within two and a half years. Occasionally it causes death
within a year. In atrophic scirrhus the patient may live for
many years.

Duct cancer is not a common growth. It arises from the
duct-walls in conditions of cystic degeneration of the mam-
mary gland. The tumor is softer than the acinous growth,
and is not nodular. There is no pain, no retraction of the
nipple, no skin dimple. Serous or bloody fluid may often be
squeezed from the nipple. A duct cancer grows, infiltrates
slowly, and involves adjacent glands later than does scirrhus.

Treatfnent of Carcinoma of the Mammary Gland. — The
treatment is early and thorough operation, the earlier and
the more thorough the better. The older surgeons oper-
ated simply to prolong life a few months ; the modem
surgeon operates with the hope of curing the patient. In
1878, Billroth's statistics showed only 8 cures in 143
cases. In 1896, W. Watson Chcyne reported 12 cures out
of 21 cases (57 per cent.). The operation should remove
the breast and much of the skin above it, the pectoral fascia,
and often the pectoral muscles ; the fat and glands of the
axilla, and sometimes the fat and glands of the subclavian
triangle. If three years after an operation there has been no
return, we regard the case as cured (Volkmann's limit). Cer-
tain cases are unsuited for a radical operation : cases in which
metastases exist ; cases of caficcr en euirasse ; cases where
axillary involvement is very great. Cheyne would also rule
out cases where large glands may be felt above the clavicle,
believing that in such cases the mediastinal glands must be
cancerous.^

Halsted's Operation. — Halstcd performs a ver\' radical
operation. He removes suspected tissue in one piece, and
thus prevents carcinoma cells falling in the wound, for it is
well known that if such cells should fall into the wound thev
may grow just as may a graft of healthy epithelium. The
neck, shoulder, the arm to the elbow, the entire surface of

* Sec Objects and Limits of Operations for Cancer y by W, Watson Cheyne.

DISEASES OF THE BREAST.

869

the chest down to the waist, the breast itself, the axilla, the
side and the back must be sterihzed. It is necessary to have,
besides scalpels, and the ordinary instruments for an opera-
tion, a great number of hemostatic forceps (80 to lOO). Place
the patient recumbent, with a sand-pillow under the shoul-
der of the affected side. The shoulder is right at the edge
of the bed, and a nurse holds the arm from the side. Hal-
sted describes his operation as follows : ' The skin incis-
ion is made as shown in Fif;. 331, and is carried at once
throu^'h the fat. The triangular skin flap {a, b, c,) is turned

down. The costal insertions of the great pectoral muscle
and the muscle are .split between the clavicular and costal
portions and up to a point on the clavicle opposite to the
scalene tubercle, and at this point the clavicular portion of
the muscle and the tissue overlying it are cut through close
to the clavicle, and the apex of the axilla is at once exposed.
The cellular tissue under the clavicular portion of the muscle
is dissected from the muscle, and the splitting of the muscle
is continued on to the humerus. The part of the muscle to
be removed is cut through close to its humeral insertion.
The whole mass circumscribed by the first incision (skin,
breast, areolar tissue, and fat) is raised with considerable force
in order to put the submuscular fascia on the stretch as it is
stripped from the thorax close to the rib.s. It is well to in-
clude the delicate sheath of the pectoralis minor muscle.
The lower and outer boundary of the lesser pectoral having

^ Jektu Hopkins Boip. Kiporls, vol. iv, ; Aatiali b/ Surg., Nov., 1S94.

870 MODERN SVRGER K

been passed and exposed, the muscle is cut at a right angle
to its fibers and a little below the middle. The tissue over
the minor muscle near its coracoid insertion is divided as far
out as possible, and is then reflected inward to prepare for
the reflection upward of this part of the minor muscle.
The upper portion of the minor muscle is retracted upward
{Fig. 332). The small blood-vesseis under the minor mu.s-
cle are carefully separated from it, are dissected out very

clear, and are ligated close to the axillary vessels. Having
exposed the subclavian vein at the highest possible point
below the cla\'ic!e, the contents of the axilla are dissected
away with a sharp knife and the vein and its branches are
stripped absolutely clean. The loose tissue about the arter\-
and the nerves should also be removed. When the vessels
are cleared the axillary contents are rapidly stripped from
the inner walls of the axilla and the lateral wall of the
thorax. The fascia which binds the mass to the chest is cut
close to the ribs and the serratus magnus mu.scle. JusI
before reaching the junction of the posterior and lateral
walls of the axilla, an assistant draws the triangular flap of
skin outward in order to spread out the tissue which lies
upon the subscapularis, teres major, and latissimus dorsi
muscles. The operator cleans the posterior wall of the
axilla from within outward. The subscapular vessels a"--
clearly exposed, and are caught before they are cut. In some
cases the subscapular nerves are removed, in others they arc
permitted to remain. Having passed these nerves the mass

SKIAGRAPHY, OR EMPLOYAfENT OF R'ONTGEN RA YS, 8/1

is turned back into its normal position and severed from
the body of the patient by a stroke of the knife from b
to Cy repeating the first cut through the skin. Every bleed-
ing point, however small, is tied with fine silk, from 60 to
100 ligatures, or even more, may be required.

After the completion of the operation the wound into the
axilla is closed with a subcuticular stitch of silver wire; if a cut
has been carried above the clavicle, it is closed in the same man-
ner, and the edges of the elliptical opening are brought nearer
together by a purse-string subcuticular stitch. Thiersch grafts
cut from the patient's thigh are used to cover the gap. Silver
foil is placed over the wound, this is covered with gauze,
bandages are applied, and the dressing is overlaid by a plas-
ter-of-Paris bandage, which includes the head, neck, chest,
and arm. The area from which grafts were taken is dressed
with sterile gauze or an ointment containing boric acid.

XXXIX. SKIAGRAPHY, OR THE EMPLOYMENT OF

THE RONTGEN RAYS.

The cathode rays were discovered by Hittorf, in 1869,
while passing an induction current through a vacuum-tube.
Crookes of London greatly improved the vacuum-tube, and
obtained a rarefaction which left in the tube but the one-
millionth of an atmosphere. This last-named observer found
that when an interrupted current of high potential is passed
through a vacuum which is nearly perfect, fluorescence takes
place. In a Crookes tube the positive electrode is placed at
some indifferent point, and the current from the negative elec-
trode flows not to the positive, but directly to the wall of the
tube opposite the cathode, and at this point the phospho-
rescent glow is detected.

In 1895, Rontgen of Wiirzburg, while making a study of
cathode rays as developed in Crookes's tubes, discovered
the energy which he named the A-rays. Rontgen showed
that at the wall of the Crookes tube opposite the nega-
tive electrode a new and hitherto unknown energy is gen-
erated. Because of the uncertain character of this energy
he gave to its manifestation the name of the X or unknown
rays.

The Jf-rays are invisible ; cannot be deflected, reflected,
refracted, or concentrated ; are not influenced by the mag-
net ; and produce none of the ordinarily recognized effects
of heat. They cause fluorescence in certain substances,
notably in tungstate of calcium (Edison), platinocyanid of

8/2 MODERN SURGERY,

barium (Rontgen), and platinocyanid of potassium. They
have a marvellous power of penetration, and pass through
many substances which are opaque to sunlight, ultra\iolet
light, and ordinary electric light. They are readily trans-
mitted by water, organic substances, leather, cloth, paper,
and flesh. Bone transmits them less easily, and metal
still less easily, but no substance absolutely prevents their
transmission. An ordinary dry photographic plate is
sensitive to the rays. If the rays are intercepted by a
body not readily permeable which is placed between the
Crookes tube and the photographic plate, a shadow will be
cast, and a picture of this shadow will be formed upon the
plate. Such a picture is known as a skiagraph or radio-
graph. If a body more or less resistant to the rays is placed
between the tube and a fluorescent screen, the body casts a
shadow on the screen, and the portion of the screen free
from shadow glows with fluorescence. Such a screen is
known as a fluoroscope. It will thus be seen that the X-
rays enable the surgeon to look beneath the skin and to see
those things which before the discovery of Rontgen were
unseeable during Hfe.^

The real nature of the ^-rays is unknown. They are not
heat-rays ; they are not ultraviolet rays. Rontgen thinks
they are longitudinal ether-waves. Monell .says, "They
appear to be originated at the site of the greatest electrical
activity within the tube, and their real nature is as unknown
as the nature of heat, gravity, electricity, mind, and of life
itself"

To obtain the rays a good apparatus is essential. An
ordinary medical battery is incapable of producing them, as
it is absolutely necessary to have a current of high tension.
The discoverer used a Ruhmkorff coil, but this is by no means
the most satisfactory apparatus to employ. Some experi-
menters have made use of a " powerful static machine and
transformer coils" (Monell). Swinton uses twelve half-gallon
Leyden jars and discharges them through the primary coil,
the secondary circuit being a Tesla oil coil.

The current is best taken from the street-light circuit.
Monell says that this current should be controlled by an
interrupter, the interruptions of which are lOO per second
The interrupted current is to be passed into an induction coil,
and the secondary current is to be conveyed into the Crookes

* See Rdntgen's re{X>rt to the Physico- Medical Society of Wiirzburg, F^ec,
1895 ; also the article upon the A'- rays by S. II. Monell, in the Brooklyn Medical
Journal^ May, 1896.

SKIAGRAPHY, OR EMPLOYMENT OF RONTGEN RA YS. 873

tube by two wires. The secondary current thus produced
will furnish a spark five or six inches long.

When the surgeon is about to use the A'-rays, he must re-
move from the person of the individual anything that might
cause confusion or lead to error. If the foot is to be exam-
ined, remove the shoes, because shoes contain nails ; if the
hand is to be examined, remove the gloves if they are fast-
ened with buttons of bone or metal ; if the thigh is to be
examined, remove coins, keys, knives, etc., from the pocket ;
a garter, if it has a metal clasp, should be taken off.

In order to get the best results from the Rontgen rays, not
only must the apparatus be good, but the man who uses it
must be expert. Pictures taken by an unskilled man lack
clearness of outline, and may even lead to positively erro-
neous conclusions. Nevertheless, a person used to the em-
ployment of scientific apparatus can very soon become suffi-
ciently expert to take fairly clear pictures which should not
lead to error. Morris H. Richardson^ maintains that the
Rontgen rays can be employed successfully in the routine
office practice of a general practitioner.

The surgeon may utilize the A'- rays by means of a fluoro-
scope. Edison's fluoroscope consists of four sides of a
box, one end being open and made to fit tightly over
the observer's eyes, the other end being closed with
cardboard made fluorescent by smearing it with mucilage,
and, before the mucilage is quite dr>', sprinkling it with
crystals of tungstate of calcium. If it is desired to examine
the hand with a fluoroscope, the extremity is held opposite
an excited Crookes tube and from six to ten inches away
from it, the end of the fluoroscope which is covered with
fluorescent paper is placed near the surface of the hand
which is away from the tube, and the observer looks through
the other end of the instrument. The flesh seems but a dim
haze and the shadows of the bones are distinctly outlined.
The fluoroscope can be easily used, and gives reliable results
in studies upon the hands and feet, but when deeper struct-
ures are to be investigated, or when absolute accuracy is
essential, it is better to take a skiagraph. The value of
fluoroscopy is constantly increasing as better electrical appli-
ances and Crookes's tubes are being made.

If thick tissues require to be penetrated by the rays, if
great accuracy is necessary, or if a permanent record is to
be retained, a skiagraph must be taken. In taking these
pictures dry plates can be used ; the plate need not be re-

* Medical Nnvs^ Dec, 1896.

874 MODERN SURGERY.

moved from its wooden case during the process, and it is not
necessary to conduct the proceeding in a dark room. The
tube should be from twelve to fifteen inches away from the
surface of the body. The plate must be fastened to the
surface exactly opposite the tube. It is necessary to ob-
serve care in the adjustment of the plate, because the X-
rays travel only in straight lines, and any carelessness of
adjustment will lead to curious and misleading aberration
in the picture. The length of exposure necessary varies
with the thickness of the tissues, the structure of the
part, the nature of the body we wish a picture of, and the
perfection of the apparatus, from three minutes to one hour.
Prolonged exposure is undesirable if it can be avoided, as it
may produce an ^-ray " burn."

The so-called X'T^.y " bum" is not a bum at all. A bum
is due to the contact of heat, is accompanied with pain
from the moment of application, and is followed by inflam-
matory changes, beginning on the surface. An Jf-ray "bum"
is not manifest for several days or even several weeks after
the application of the rays, at which period an inflammator>'
or a gangrenous process arises, which begins within the
ti.ssues and subsequently involves the surface.* These bums
are often accompanied by loss of hair or nails in the damaged
area, they require months to heal, if they heal at all, are very
painful, and are not improved by treatment which relieves ordi-
nary' burns. In some cases the consequences are very serious.
In a case reported by J. P. Tuttle, it became necessary to ampu-
tate the thigh .^ The lesions occasionally produced by the
-V-rays are probably trophic changes. Sections made by
Vissman from Tuttle's case indicated that the lesion was a
gangrenous process due to arteritis of the smaller vessels.
These .V-ray injuries are most liable to occur when a
Ruhmkorff coil is used, and no such condition has been
caused by a static machine (Tuttle). It has .been suggested
that a thin piece of aluminum placed upon the part while
it is exposed to the A^-rays will prevent the occurrence of
these injuries. Skin-grafting may succeed in remedying an
ulceration, but, as a rule, the grafts do not grow, or if they
adhere, are very apt to break down after a time. In many
cases the best treatment is excision (Powell).

The uses of the ^V-rays are legion. They are of the
greatest possible value in the location of foreign bodies.
especially bodies of metal, glass, or bone, such as bullets,

* E. B. Bronson, in the debate on J. P. Tuttle's case, Medical Record^ March
5, 189S. * Med. Record, May 5, 1S98.

J. Cm* nhnwn in Flgurt ., Tlirte Month) alltr ll.e Optralion ol Wiring. Nine mnnlhl
CnKlbcni tkiBgraphi an; fmin Ilic A* K;>y [jburolory of ihc Jcrcnim MciIIl^ College

SKIAGRAPHY, OR EMPLO YMENT OF RONTGEN RA YS. 875

and needles, glass, splinters, etc. Bullets are readily de-
tected in the extremities; have been found in the lung-
substance and bronchi (Rowland), in the brain (Schier, Bris-
saud and Londe, Henchen and Sennauer, Bruce, Willy
Meyer), in the abdomen, the pelvis, a joint, the spine, and
the eye. The X-ray^ will enable us after an abdominal
operation to locate a Murphy button and tell when it has
loosened and descended. Foreign bodies, especially if

Fic 333— W. M. Swetf

metallic, in the esophagus, stomach, intestine, and air-pas-
sages ; enteroliths, and mineral calculi in the salivary ducts,
bladder, ureter, and kidney, can be detected. Henry Morris
tells us that a calculus in the kidney may exist and yet
escape detection with the rays, because the kidney is very
deeply placed, is under the ribs and close to the verte-
bral column. Occasionally a drainage-tube lo.st in the pleural
sac may be discovered. Gall-stones cannot be discerned.
The rays may fail to disclose a foreign body because of its
being overshadowed by a bone (Carless), but prolonged expos-

876 MODERN SURGER Y.

ure or the taking of another {Hcture with the part in another
position will bring it into view. In many cases a skiagrai^
does not indicate how deeply in the tissues a foreign body
lies, or upon which side of a bone it is lodged.' If there is
doubt, take several pictures from different positions (tri-
angulation), skiagraph over a surface marked in squares,
insert guide-needles into the tissues before taking the final
picture, or employ Sweet's apparatus. Sweet's apparatus
has been used successfully for the location of foreign bodies
in the eye. but a modification of the original ajqiaratus
has recently been used to skiagraph other regions of the
body. Fig. 333 shows this apparatus. The negative ex-
hibits the pointers, and the position of the foreign body can
be determined by the use of projection-lines (Figs. 334, 335).
In detecting fractures and dislocations the Rontgen rays are
of great value, especially when there is much swelling, when
there is little displacement, and when the fracture is in
or about a joint. The rays enable us to determine the
nature of the injury, the amount of splintering, the exist-

ence of impaction, the question whether or not the frag-
ments are in contact or can be brought into contact; the
direction of the line of fracture, the variety of deformity,
the existence of more than one fracture, the presence of
epiphyseal separation or dislocation alone or with a fiacturc,
' llallle'f COM in Lancil, Feb. 39, 1896.

SKIAGRAPHY, OR EMPLOYMENT OF RONTGEN RA YS. 877

the existence of an ununited fracture, and the question if the
splints are holding the fragments in accurate apposition.
Fractures of the skull, if involving both tables of the vault,
may be recognized ; it is possible that fractures of the inner
table may be found ; fractures of the base can be seen, but
with difficulty (White). Fractures of the spine never show
very clearly. To take a picture of a fractured rib, first limit
chest-motion by bandaging (White). Morris tells us to be

Fig. 335. — Sweet's projection-lines for locating foreign bodies in the eye : tf, transverse
ion ; b, vertical section. The same principle is used in locating foreign bodies in other

section
structures.

somewhat skeptical in accepting unreservedly the evidence
offered by a skiagraph, as slight carelessness in taking the
picture may mean great distortion and consequent error. The
JT-rays may be of value in enabling the surgeon to recognize
rheumatoid arthritis ; bone- and joint-tuberculosis (the tuber-
cular area being lighter than the sound bone) ; the amount of
acetabular rim present in congenital dislocation of the hip-joint

8/8 MODERN SURGERY,

(Rowland) ; the state of the bones in a crushed limb (J. Hall
Edwards) ; bone deformity ; osseous tumors ; bone displace-
ment (as in Morton's foot) ; osteomyelitis ; caries ; necrosis ;
and osteosarcoma. By skiagraphy we are enabled to decide on
the proper situation to perform osteotomy, and if a deformity
of the foot can be amended without operation (Willard).
The position of the fetus in utero can be definitely made out.
Applied to the soft parts, the new process has obtained
interesting but not as yet many practically useful results.
Fibrous tumors can be seen, but malignant tumors, unless
they contain calcareous or fibrous elements, cannot be defi-
nitely made out ; loose bodies in a joint can often be detected.
The shadow of the heart can be made out, and the outlines
of the diaphragm, kidney, and liver can be thrown upon the
screen. If the stomach is distended with gas, it shows as a
light area upon a dark background (Hedley). If food is
eaten after being mixed with subnitrate of bismuth, the out-
line of the viscus becomes fairly distinct. Thickened pleura,
pleural effusion, pulmonary consolidation, pericardial effu-
sion, aortic aneurysm ; cavities in the lungs, and atheromatous
blood-vessels may be made out with more or less distinctness.
If a sinus is injected with iodoform emulsion, a picture of it
can be taken, because the emulsion casts a shadow when
placed in the path of the ^V-rays (J. Hall Edwards). Up to
the present time no positive evidence has been offered to
prove that the Rontgen force is possessed of any therapeutic
value.

XL. INJURIES BY ELECTRICITY.

Effects Produced by I/ightning. — An individual may
be struck directly, or he may be shocked by an induced cur-
rent, the lightning having struck a nearby object. A person
can be struck while in a room, but there is more danger
when exposed especially in the open country. To be
under a single tree during a thunderstorm is dangerous,
but to be in a wood or under a hedge is reasonably safe.
The victim of lightning may be killed instantly. Death
is the fate of over one third of those struck. Tidy states
that out of 54 cases, 21 died and 33 recovered. Post-
mortem examination may fail to reveal a lesion, but in
many cases severe burns are discovered ; in some there are
laceration of tissue, crushing of bones, and fearful injur)*.
Hums are especially apt to occur at the points where the
current entered and emerged. The clothes are usually

INJURIES B V ELECTRICITY. 879

singed and torn. The typical lightning-marks are arborescent
tracings, representing the course of blood-vessels, produced
by disorganization and effusion of blood as the fluid travels
through it. Occasionally metal objects, such as buttons,
knives, money, keys, etc., are fused, and spread as a metallic
film over a considerable portion of the surface of the body.
Bichat stated that in death from lightning rigor mortis does
not occur. This statement is now known to be an error (see
the three cases reported by M. Tourdes). As a rule, there
is early vigor mortis, retained fluidity of blood, and disten-
tion of the brain with venous blood. The cause of death by
lightning was supposed by Hunter to be due to destruction
of muscular contractility, and by Richardson to the resolu-
tion of the blood into gases. It seems probable that some
deaths are due to actual disorganization of vital structure
and that others are due to shock or inhibition. In many
cases struck by lightning recovery will take place even when
the individual is apparently dead. Sestier reported fj cases
struck by lightning, and in 7 of them the persons were
apparently dead for a number of hours.^ Brouardel says in
such cases the death-like state may be ascribed to inhibition,
caused by a maximum degree of stimulus.* When death
from lightning is not immediate the condition may be as above
outlined, the individual being apparently dead, without ob-
vious respiration or pulse. He may be insensible, with slow
and labored respiration, a weak and irregular pulse, and
dilated pupils, and may remain in this condition for a few
minutes or for several hours. The above condition is not to
be distinguished from severe concussion of the brain. Every
individual suffering from the effects of lightning should have
his entire body carefully examined to see if physical injuries
exist (fractures, wounds, bums, ecchymoses, arborescent
tracings). The consequences of lightning-stroke are many
and various. There may be rapid and complete recovery,
gradual recovery, traumatic neurasthenia, sloughing burns,
partial paralysis, which is usually recovered from (Noth-
nagel), but which may be permanent, hysteria, blindness,
change of character, and actual insanity.

Treatment. — Do not pronounce a person dead until a thor-
ough attempt at resuscitation has been made. Do not give
alcoholic stimulants. If the respiration is feeble and apparently

^ Sestier, De la Foudre^ Paris, 1866. Quoted by Brouardel in his lectures
upon "Death and Sudden Death."

* Benham's translation of Brouardel 's lectures upon " Death and Sudden
Death.'*

88o MODERN SURGERY.

absent, make tongue traction and artificial respiration. Apply
the stream of a cold douche to the head, rub the limbs with
mustard, put a mustard plaster over the heart and another to
the back of the neck, wrap the individual in hot blankets,
and give enemata of hot saline fluid. In some cases venesec-
tion has seemed to be of benefit. When the individual reacts
treat any existing condition symptomatically, and treat par-
ticular physical injuries according to their character.

Bffects of Artificial Currents. — Workmen for electric
companies ; pedestrians in the streets of a city which is
lighted by electricity or in which trolley cars are em-
ployed; roofers and firemen are liable to be injured by
electricity. An alternating current is decidedly more
dangerous than a continuous current of equal strength.
An artificial current acts like lightning. It may produce
instant death ; it may produce unconsciousness, deHrium, ster-
torous respiration, Cheyne-Stokes' breathing, or clonic spasms.
Its effects can be often recovered from. Not unusually the
victim is apparently dead, but subsequently recovers. D'Ar-
sonval reports the case of a man who was apparently killed
by the passage of 4500 volts. No attempt at resuscitation was
made for one-half an hour, and yet he recovered when artificial
respiration was employed. Donnellan reports a case of re-
covery after the passage of 1000 volts. Slight shocks may
cause temporary numbness, and even motor paralysis. An
electric shock frequently causes burns or ecchymoses. and oc-
casionally wounds. Wounds caused by electricity bleed pro-
fusely and are apt to slough. An electric burn looks like a
blackened crust; it is surrounded by pale skin, and for twent)'-
four hours remains dry, when inflammatory' oozing begins and
the skin around it reddens. These burns are not as painful as
are ordinary burns, but recovery' requires a long time. When
inflammation begins and suppuration occurs, tissue is exten-
sively destroyed, tendons, bones, and joints may suffer, some
portions become deeply excavated, and other portions show
dry adherent masses of dead and dying tissue, and a bum
which was at first small may be followed by a large area of
moist gangrene;^ lack of tissue-resistance, due to trophic dis-
turbance, is largely responsible for the progress of the slough-

Treatment. — If a person is in contact with a live w ire, the
first thing to do is, if possible, to shut off the current. If it
is not possible to shut off the current, catch a portion of the

^ See the article l>y N. \V. Shaq^e on " Peculiarities and Treatment of Electrical
Injuries," in Phila. Med, Jour. ^ Jan. 29, 1898.

INJURIES BY ELECTRICITY, 88 1

clothing of the victim and pull him away from the wire,
but do not touch his body with a bare hand. If a pair of
rubber gloves can be obtained, the subject can be moved
with impunity and the wires can be safely cut. If it is not
possible to drag a person away from electric wires, the sur-
geon can wrap his hands in dry cloth and lift the portion
of the body in contact with earth or wire, and thus break the
circuit and permit of removal of the body.^ A dry cloth can
be pushed between the body and the ground, and the body
can then be removed from the wires. It may be possible to
push the wires away by means of a dry piece of wood, or to
cut them with shears which have wooden handles and which
are perfectly dry. Treat the general condition in the manner
set forth in the article qn lightning-stroke (page 879). Very
severe burns may be caused. The author has dressed a num-
ber of electric burns with hot fomentations of salt solution
during the first few days. This facilitates the separation of
the sloughs and seems to aid the weakened tissues in resist-
ing microbic invasion ; after sloughs separate, the part is
dressed with dry sterile gauze. Antiseptic dressings can be
used from the beginning, but they often fail entirely to arrest
the sloughing. Iodoform produces much irritation. Ointments
are very unsatisfactory. When the dressings are changed the
part should not be washed with corrosive sublimate, as this
agent produces much irritation ; peroxid of hydrogen should
be employed, followed by hot normal salt solution. Sharpe
removes sloughs by applying the following mixture : 2 parts
of scale pepsin, i part of hydrochloric acid, U.S.P. ; 120
parts of distilled water. This mixture is washed off after
two hours with peroxid of hydrogen. The same surgeon
treats necrosis of bone by injecting every few hours a 3 per
cent, solution of hydrochloric acid, using every second day
the pepsin solution, and when necrotic areas come away
packing with gauze. Skin-grafting by Reverdin's method
or Thiersch's method is rarely successful. In some regions it
is possible to slide a large flap in place to cover a granulat-
ing area which will not heal. In a very severe case amputa-
tion or resection may be necessary.

' See the directions in Med. Record ^ Dec. 28, 1895, ^^'om Med. Press.

INDEX.

Abbb's catgut rings in intestinal anastomosis,
689
method of intestinal anastomosis, 690
operation for stricture of esophagus, 623
string saw. 639
Abdomen, diseases and injuries of, 6a6

operations upon, 666
Abdominal hernia, 699
nephrectomy, 783
section, 666

for appendicitis, 668
wall, contusions of, 6a6

gunshot-wounds of, 63a

penetrating wounds of, 633

wounds of, 63a
Abeniethy's extraperitoneal method of Hgat*

ing external iliac artery, 306
Abscess, acute, u6

symptoms ut, 99
appendicinal or appendicular, 100

treatment of, 103
Bezold's, 563
Brodie's, 312
cerebral, 560
cold, 105, 106

of lymphatic glands, 108
diagnosis of, loa
disused, 98
dorsal, 107
extradural, 560, 564
forms of, q8
healing of, 87
iliac, 107

intramammary, 861
ischiorectal, 721
large cold, 109
Inmbar, 107
lymphatic, 98
mediastinal, loi
metastatic, 99
of antrum of Highmore, loi, 596

treatment of, 103
of bone, 312

chronic, 108
of brain, 100, s6o

symptoms of, s6i

treatment of, 103, 568
of breast, loi , 860

acute, 861

chronic, 108

treatment of, 103
of cerebellum, 577
of frontal sinus, 597
of hip, 414
of kidney, 774
of larynx, loi
of liver. 100, 660

treatment of, 102
of lung, loi, 607

pneumotomy for, 611

treatment ot, 103
of lymphatic glands, 108
of mammary gland, cold, 109
of maxillary antrum, 596

Abscess of mediastinum, loi
treatment of, 103

of prostate from gonorrhea, treatment of,
82 1

of scalp, 540

of spleen, 665

of temporosphenoidal lobe, 576

opening of, 104

Paget's, 99

palmar, loi, 511

perinephric, loi, 776

perinephritic, loi 776

postpharyngeal, 107

prognosis ot, 102

prostatic, loi

psoas, 107, X09

residual, 99

rest in, 63

retromammary, 86x

retropharyngeal, 107

scrofulous, 98

shirt-stud, 105

subdural, 560

subphrenic, 100, 657

treatment of, loa

tubercular, 105

varieties of, 98
Acetanilid^ 28

as a drying-powder, x66
Achillodynia, 219
Acid, carbolic, as an antiseptic, as
Acquired syphilis, 185
Acromegaly, 320
Actinomyces, 183
Actinomycosis, 18, 183

cutaneous, 183

of bone, i94y 309

treatment of, 184
"Active clot," 247
Active hy[>eremia, 48
Actol, 29
Acupressure in hemorrhage, 26a

in secondary hemorrhage from atheroma-
tous vessels, 273

in treatment of aneurysm, 255

in varix, 243
Acute abscess, 96, 9^
symptoms of, 99

rheumatism, 435

tetanus, 144
Adamciewicz on cancer-cells, tii
Adams's operation, 477

saw, 475. 476
Adenitis, tubercular, 154
Adenocek of mammary gland, 864
Adenoid cancer, 236
Adenomata, 232

cystic, of mammary gland, 864

treatment of, 233
Aerobic bacteria. 23
Agnew's dressing for fracture of femur, 39s

operation for webbed fingers, 521

splint for patella. 396
Air-passages, foreign bodies in, 599

883

884

INDEX.

Albert's disease, 319, 514

Albuminuria in syphilis, 198

Alcoholic unconsciousness, S47

Aleppo boil, 740

Alexander's niethod of prostatectomy, 837
method of treating snake-bite, 178
rules for catheterization in hypertrophy of
prostate, 836

Alexins, 32

Alimentary canal, foreign bodies in, 633
tuberculosis of, 153

Allingham's decalcified bone bobbin, 685
method of excision of hemorrhoids, 716

Allis ether inhaler, 729

Aliis's rule fur reduction of dislocation of
femur, 465

sign, 384, 463, 464
Alloxur bodies in the urine, 88
Almen's test for blood in urine, 764
Alopecia in syphilis. 195

treatment of, 203
Aluminum probe, Fluhrer's, 17a
Alveolar sarcoma, 228
Ambulatory treatment of fractures, 336
Amotile bacteria, 17
Amputation, 841
a la manchette, 845
at ankle-joint, 853

PirogofTs method, 833
Syme's method, 853
at elbow-joint, 849
at hip-joint, 857
by bloodless method of Wyeth, 857
Jordan's, 859
Larrey's method, 858
Liston's, 854
at knee-joint, 855
at metacarpophalangeal joint, 847
at middle tarsal joint, 85a
at the shoulder-ioint, 849

Dupuytren s method, 859
Larrey's method. 849
Lisfranc's method, 850
at tarsometatarsal articulation, 850
Hcy's method. 852
Lisfranc's method, 850
at wrist-joint. 848
by transfixion, 846
Choparl's, 852
circular. 844

modified. 845
classification of. 841
during shock, 164
elliptical. 846
flap method, 846
for aneurysm, 254
for chondroma, 218
for compound fracture, 339
for gangrene. 131
for gunshot- wounds, 174
for malignant edema, 175
for osteoperiostitis. 311
for sarcoma of a long bone. 229
for snakebite, 178
in di.il>clic gangrene, 127, 128
intermediate, 842
methods of. 844
modified circular, 845
of the arm. 849
of fingers, 847

distal phalanx of. 847
middle phalanx of, 847
proximal phalanx of, 847
of foot, 850
Chopart's, 850
Forbes's, 853
Hey's, 852
lisfranc's, 850

Amputation of forearm. See Am^utaiwn
th r if ugh /area rm .
of hand, 847
of leg, 854
by lateral flaps, 855
by long posterior and short anterior flap,

855

by rectangular flaps, 854

Garden's method, 856

Gritti's method, 856

just below knee, 85s

modified circular, 854

SabanejefTs method, 856

Sedillot's method, 854

Syme's method, 855

through femoral condyles, 85s

through knee-joint, 855
of penis, 833
of thigh, 856

Bell's method, 857
of thumb, 848
of toes, 850
oval, 846

prevention of hemorrhage in, 84s
primary. ^42
racket. 846
secondary, 84a
T-shaped, 858
through the forearm, 848
bv Teale's method, 848
Wyeth's bloodless, of hip-joint. 857
Amyloid degeneration due to syf^ilis, 198
Anaerobic bacteria. 23
Anastomosis, intestinal, 681

rings, 681
Anatomical snuflf-box, 28a

tubercle, xsa
Anderson's method of tendon-lengthening, 519
Anel's operation for aneurysm, asa
Anesthesia, 735
by freezing, 734
general, 735
local, 734

preparation for, 735
primary, 732

treatment of complications of, 730
Anesthetic state from ether or chloroform, 729
Anesthetics, 725

Anesthetization as a cause of shock, lia
Aneurysm, 245
acupressure in, 255
acute. 245
amputation for, 254
arteriovenous. 245, 355
by anastomosis, 245, 256
capillary, 246
causes of, 247
circumscribed, 246
cirsoid, 226, 246. 256

symptoms and treatment of, 257
consecutive, 245
cylindrical, 246
diagnosis, 249

from cyst or abscess. 349

from growths beneath a vessel, 349
dissecting. 245
electrolysis in, 354
embolic. 246
false. 245
forms of, 245
fusiform, 245
miliary. 246

-needle of Dupbytren, 379
of bone, 245
of Saviard, 278
operation for, Anel's, 25a

Antyllus's, 252

brasdor's, 254

INDEX.

885

Aneutytm, operation for, Hunter's, 353
Wardrop s, 254
operative treatment of, 353
Pott's, «55
pulsation of, 348
sacculated, 345
secondary, 346
spontaneous. 346
siymptoms of, 348
traumatic, 345
treatment of, 350
by digital pressure, 351
by direct pressure, 351
by ligation, 353
by pressure, 251
bv rapid pressure, 351
1 uffnell's plan of, 350
traumatic, 355
true, 345
varicose, 355

treatment of, 356
verminous. 346
Aneurysmal bruit, 848
varix, 355
symptoms of, 356
treatment of, 356
Angioma of mammary gland, 864
Angiumata, 335
capillary, 335
cavernous, 335
plexiforni, 336
simple, 32$
treatment of, 336
Angular curvature of spine, 583
Ankle-joint disease, 419

dislocations of, 471
Ankylosis, 435

extra-articular, 436
£ilse, 436

tieaiment of, 437
fibrous, 435
intra-articular, 435
true, 435
treatment of, 435
Anodynes in inflammation, 76
Antagonistic microbes, 36
Antemortem thrombus, 1^3
Anterior angular splint, Stromeyer's, 431

triangle of the neck, 391
Anteroposterior curvature of spine, 583
Anthrax, 178
benign, 740
carbuncle, 170

edema of, differentiation from cellulitis, 179
external, 179
forms of, 179
internal, 179
intestinal, 180
pulmonary, 180
treatment of, 179
Antinosin, 38
Antiphlogistic regimen, 80
Antipyretics in inflammation, 76
Antisepsis, 43
Antiseptic poultice, 71

as a wound dressing, 166, 167, 175
Antistreptococcic serum, 36
in erysipelas, 143, 143
in septicemia, 138
Antitoxin of tetanus, 148
Antitoxins, 32
Antivenene serum, 178
Antrum of Highmore, diseases and injuries

of, 596
inflammation and abscess of, 596
Antyllus operation for aneurysm, 353
Anus, diseases and injuries of, 713
fissure of, 734

Anus, imperforate, 733

prolapse of, 717

pruritus of, 724
Apathetic shock, 162
Aplastic lymph. 92
Appendicinaf abscess, too
Appendicitis, 647

abdominal section in, 668

catarrhal, 650

etiology of. 648

foreign bodies as a cause of, 649

forms of, 650

gangrenous, 651

obliterative,65o

operation for, 668

pathology of, 648

simple parietal, 650

stercoral , 649

suppurative, 651

symptoms of, 6;5i

terminations 0(^653

traumatic, 649

treatment of, 653
Appendicular ab»cess, 100
treatment of, 103

colic, 649, 650

lithiasis. 648
Approximation of divided intestines, con-
sideration of methods of, 693
Arachnitis, 557
Arcus senilis, 131

Ardor urina: in gonorrhea, treatment of, 821
Ar^onin, 29

Anstol as a drying-powder, 166
Arm, amputation of, 849
Amot, grafts of the lining membrane of hen's

ejjg, 7^
Arterial filter, 715

pyemia, 139

sclerosis from syphilis, 198

sedatives in inmimmation, 74

transfusion, 378
Arteries, ligation of, in continuity, 378

wounds of, 357
Arteriovenous aneurysm, 355
Arteritis, 343

acute, 243
treatment of, 344

chronic, 343
treatment of, 344

in syphilis, 196

obliterative, 344

syphilitic, 344
Artnrectomy, 485, 486
Arthritis, 408

acute infantile, 318
suppurative, 433

deformans, 436
symptoms of, 427
treatment of, 438

gonorrheal. 423

gouty, 436

in hereditary syphilis, 307

infective, 432

neuropathic, 439

rheumatic, 425

rheumatoid, 436, See Arthritis de/ormanx.

tubercular, 408
pathology and symptoms of, 408
treatment of, 410

typhoid, 422, 423
Arthopathie des ataxiques, 439
Arthropathy, tabetic, 429
Articular neuralgia, 431
Artificial anus, 645

leech, Heurteloup's, 65
Ascococci, 20
Asepsis, 42

886

IXDEX.

Aseptic fever. 87
(jT^uze. 46

P«*. 93
A^ptic wounds. 161

Ashton's asepiic g^iiie p^ds. 44

AsphyxiJi. IvKoI. 136

Aspiration v«f joints. 4>S

.Aspirator, pneumatic. 4S4

As^Jikr method of nenre>suCunof , 531

Astringents in iniljiiiunauoo, 66

AiJXiA from syphilid, 198

Ather ma. 243. 244

Atony of rl.+dJer. 790

Atr:>ph\ of t>one. j.-ij

concentric, 309

eccenlr:C. 309

of m'j*cle>. 5-5

of thyroi J gland. "43
Autotraf»fus:.^n m %nock. 164
Aveling syringe in transfusion. 277
Axillary artery, anatomy of, »s6

ligation of. js6-»i3

BACilXf5 anthracJs, 41

coli com!nuni>, 41

maliei. 41

of anthrax, 41

of glanders. 4t

of gonorrhea, 39

of K vh. 149

v^ Lofler a cause of fenders, iSa

of Lustptrten. 41

<4 malignant edema, 41

of Neisser, 39

oi Nicola ier. 144

of syphilis. 41

c«f tetanuo. 144

of mbercul -»is. 40, 149

of typh.'id ie%-er, 41

pyoc\-aneu«. 30
antagonistic to anthrax, 179

p^- .'•genes f<stidus. 99

tet.<ni. 49

t;;Sercu osi>. a-"*. 149
Bavt-' . :-

Atr : :; ir. : ar.ier. bic. rj

am.;: r. :-

d sir:! jv;- . •'. ?

effect v.* — . .: n. heat, and cokt upon. 23

i fe cord : ."* o\ 2:

ir.u.:;p'. ca: or. .^f. 71
pa -.».■>.. t.c.ii

; -. ■ « -f ..

Baste .i. pr,":e:i. ;i
Riiv:er:y«>:\ , :--4t
Bac:cr:uT. c.-I. commure. 41

ter:::.\ 4:
Ealar::^* ^:^

tiea:-.?: : v :". fn
Ra'.apof'.sth.: *. Sir-. Sjx
Rk d ruich :n ^Np": '.••.. j^
T-A ■•■.-.-<> fr> rr. syph *. 105
B.ir -.nzr. An:ercan. :• ihc fx>t. 751

H.xr. ■ •"■*^. 34". -^s

B. rsch *. •.>! eye. 75;

: rc-lar. -4?

c rd. -sS

cra\ii. -5 5

crossed, . r" a-'g'.? .-^f -aw. -ta

* 1 -.■- *.. C\ O, Ni

• *

Dfsa-.ts. ->T

F>n'..5r :*■.'*. r4r

hgu -{.-.:"-?. :f S :h -ye*. -52

Bandage. ipiuntJet, 749
Gibson's. 347. 733
Hamilton's. 347
handkerchief 738
oblique, of jaw, 753
obkjng. 75&
of etbow, 755
of fuuc cohering the heel, 751

DOC covering the heel, 751

French, 751
of neck and axilla. 755
piastcTHaf-Paris, 758
recurrent, of head, 757

ol Slump, 7^8
Ribbail's. 751'
Selva's thumb. 750
silicateK>i-sodium, 759
spica. of groin. 754

of instep. 751

of shoulder. 754

cf thumb, 750
spiral. 748

of all the finders, 74a

of fsxn oorenng the heel, 751

of palm or dorsam oi hand, 749

of upper extremity, 748

trrcned. of lover extremity, 790
T>, of perineum, 758
triangie. 758
Vdpeau's, 755
Bandages, 748
Barker s needle for wiring fnctared patdb,

operauon lor exasMn of Tcrmifbrm wpes-
d:x.«69

pc«nuc39
Barton s bandafe, 347, 759

fracture, xrf
Basedcw's cHvraic. 745
Bassini. method of opersdv fc* femoral bei^

Bassini *s operatkm for inguinal
Bayer, treatment of spina baMa, 578
Beast- mimicry i:: fa3*drof4K.<bsa. la's
Be:-scre, 117. xw
Bee*, "lin^* ^f. 17^

Belncl.i's meth.yi cf pr^tAtect.-aiy. 557
Bej.:<^ carsula in parsirsg r.ar£^. 363
Heel's a=:rutau.'n at sh c:Iic;-^c«st. Su

v-f t^ig*s. 557
Ber.:gr. ar.thrax. 74^. See ^M'rmn^-^

B-r.t :.-ia. ossctcsay f.r. 4-*

IVro.d's abscess. 5*.:

Bichas's fr^sure. l.>caf/e r-f. s ti

B:eT*5 m»:h.-»i -i as;c::a£!:= :f Jeg by iattnl

=:esho«: cf :rcAt:rsg r_SerriJj*». si
F-cr! w's exacuasre. S;;

l::hojr::e. n?.4

^•perat: r. set
B:^'s ap;urans« frr Hlt ijess. js;
Biie-duct*. r-peure .f. ■:>:
B;I. roth's saeiS.xf :£ l»";er

toa .>..*, r«
B::es .-f ;r*ec?s

ri" sna'i^cs. : —

Kai.Ser. a>p:r3k£?:K rf -^^
*::ry rf, "^ac
chrrsic catarrt .-f. -"je
co«r-:*j:ei .f. *?-
«::scaMS i3»i rraTcs cC.
fecaa'.e. g-.wr^c x. 30c

:i 'jia ..n.: . c>;p^:. 752
V :* :r. ^h a:.d ri.\.s. -54

•"s*

:?era::.E.s .:«,

INDEX.

887

Bladder, rupture of, 788

stone in, 790. See Vesical calculus.

tumors of. 798

wounds of, 788
Blastomycetes, 18
Bleeding from kidney, 764

from ureter, 764

{general, in inflammation, 73
ocal, in inflammation, 63
methods of, 64
Blind boil. 740 •

Blisters in inflammation, 79
Bleeders, 263

Bleeding. See Metnorrhage.
Blood in urine, tests for, 763

loss of, 258

-serum, germicidal power of, 35. See Hem-
orrhage.

transfusion of, 276
Bloodletting in atheroma, 244
Blue ointment, 69

pus. 05
Bodine s method of colostomy, 695
Boil, 739. See Furuncle.

Aleppo, 740

blind, 740
Bond's splint, 3TO, 380
Bone, abscess oC 312
symptoms of, 31a
treatment of, 312

actinomycosis of, 309

atrophy of, 309
as a predisposing cause of fracture, 327

caries of, 31^. See CunW.

•chips for filling bone cavities, 317
Seun's decalcified, 48

chronic abscess of, xo8

cyst of, 309

felon. 513

ferrule, Senn's, 481

-grafting, 316

Kummat.1 of. 309

healing of. 86

hypertrophy of, 309

innammation of. 309

•marrow in treatment of osteomalacia, 321

necrosis of, 314
from osteitis, 310

sclerosis of. from osteitis, 310

tubercular diseases of, 154

tubercle of, 309

tumors of, ^09
Bones, afiections of, in syphilis, 195

diseases and injuries of, 309

diseases of, 309

of skull, diseases and malformations of,

535
operations upon, 475

Boric acid, 29

as a drying-powder, x66
Borsch's eye-bandage, 753
Bose's method, 603

Bottini's cauterization of prostate, 837
Bougie, esophageal, 621

filiform, 786
Bowel, obstruction of, 639

ulcer of, 646
Bow-legs, 522
Boyer's cyst, 514
Brachial artery, anatomy of, 284

li^^ation of, 284-286
Brain, abscess of, 100, 560

compression of, 545

concussion of, 541

diseases and malformations of, •;4i

-disease from suppurative ear disease, 562

hernia of, 557

inflammation of, 557

Brain, laceration of, 543

malformations of, 541

-operations, technique of, 573

syphilis, 190

tumor of, 562

water on, 559

wounds of, 554
Brainard's bone-drills, 489
Brandt's operation of stomach-reefing, 681
Brasdor's operation for aneurysm, 254
Breast, abscess of, loi, 860

acute abscess of, 861

chronic abscess of, 108

diseases of, 859

inflammation of, 860
Bridge, periosteal, in simple firacture, 33a
Brodie's abscess, 99, 106, 319

joint, 430
Bronchoccle, 743
Bronchus, foreign body in, 600
Brunonian movements, 17
Bruns's upward extension method of leduc-

ing shoulder-joint dislocations, 453
Brush-bum, 167

Bryant's extension for fracture of thigh in
children, 394

triangle, 384
Bubo, chancroidal, 831

in gonorrhea, treatment of, 8ai

syphilitic, 190
treatment of, 199
Buck's extension-apparatus, 386
Buflycoat, 62
Bunion, 515
Burns, 736

symptoms of, 736

treatment of, 736

-.V-ray, 874
Bursitis, 514

gluteal, 414
Butcher's method of excision of metatarsal

bone of great toe, 498
Button, Murphy's, 681, 683

Calculi^, renal, 772

vesical. 790. Sc^ Vesical calculus.
Callous ulcer, 117
Callus, 333

Calmette's antivenene serum, 178
Calomel as a drying-powder, 166

fumigation in syphilis, aoi
Calyx-eyed needle, 672
Cancers, 233. See Carcinomata.

adenoid, 236

autotransference of, 212

causes of, 210-2x2

contagiousness of, aix

en cuirasse, 867

glandular, 936

•nouses, 21:

melanotic, 236

of lip, operation for, 618

of mammary gland, acinous, 866
duct, 868
treatment of, 868

of penis, 833

of rectum, 720
rest in, 63

of stomach, 634
symptoms of, 634
treatment of, 635

of tongue, diflferentiation of, from chancer,
189
Cancerous cachexia, 334
Cancrum oris, 129
Cannon-balls, wounds by, 171
Cannula 4 chemise, 270
Capillary angiomata, 225

Chtiie elotti dimingi, ,1

•- * T 15!!!^ Shir,'' '?^''-

■■=— 3»&i'Tirisr;

I n irnnimriclurc, 78s

II Vmonhige, 169

SiEirin'.'^'

CholccyilulIcrwiDiry, 664.691
Ch.>l«y.l»ioinv.*ftj.«9j
ChulnlDchciduodiiioliMiir. C6,
ChstohichqiHsi. W4
Chsldiihiuii. &•

CotcyKoi^nia, jsG
C«k'i''op«ra"ion ol^'

Df lymphatic ffl

■t^^ct^

Com rcSi™of h2m J

dUftrtntiailon of, frtnn alcoholic

TroiD hymeneal coma, 546
ftom pml^pilcplic conn, m

emOTrhage, diign^i of, t
Lrophy of bone, 309

wry-iKck, )»
CangntiDn uf Ihyroid gland, 74

™oV.li4w.j™.di

"■JM

^ TMrnv/Mii «/" *r>-

rawlin; paralytii, »j

orbload-doL, 69
:urlin^i"u'lccr.«4C

Cylindroma. «»
Cyi'bcwaL'fcs

incyMiti.,*}
Idcdian, Soij

^r hemorrhage rroni proiute, 170
for myoiDa of the pmiate, 323

dcrm'oid7"i'

890

INDEX.

('.fnny-ljemheri suture, '^73

C2«rny'» method of tendon-kngthming, 519

tfAtryUlt^ in %yphiU%, i'.j

\}AUfU, kiitiirc of the pericardium, 340

" l>jng«;r'/ti% arc;*," 54^/

Il.«ri«:r, pw^r'Aprrm, 312

I>'Ar*/inVi4l'ft CMve of electric «troke, 880

D.tVMine, mcth'^l of treating malignant pus*

title, I'f^i
\}»yy\ dire<,lor, 47^^
\ikto\\rn\Kt\i of piirictal pleura, 61a
Ilet.iitiit.il MMngrcfie, 130

u\i.r.r, 117
Pccuhitiift, 117, 130
I>eep a(i«tcefcft, i/)
I)rucrierMii<in, gelatinifortn, 409

ol riiii\clc%, 305

pulpy, 4#»}i

rrjt.tinriH f»f, 527
I>elMyi-(I union, treatment of, 341
I delirious vhock, 163
I)clirium in f»h<>ck, 163
Ilelitefccence of inflammation, 55
Ilemarcution, line of, 121
I)emigauntlet bandage, 749
Ilcmokthen'k studio of action of Mannlicher

rifle, i6>i
Dentigerous cyst«, 219
Depletion in inflammation, 63
I)epreikhion-fracture, 52a
DermatitiK venenata, 739
Dermoid cysts. 238
I)c!iault'ii iippuratuft, 756

bandage in fractureof clavicle, 360, 361,446,

447
in fracture of humerus, 364

in fracture of scapula, 362, 363

»•«". 384
DrHcenuens noni nerve as a guide to sheath

of common carotid in ligation, 293
Diabetic gangrene, 137
Di.ipctlcvjs in inflammation, 53
Diaphorrtii's in inflammation, 75
Diaphragmatic herni.i, 713
DiaitluM of cunstipation, 643
Diasta«'iv. 3.»4
Diatlu'lir abscos";. 08

Dirk.in'..in*'» iIuntv. amyb^id tlegcneration. 415
Diilay's operation for webbed finger*. «i3i
Dicflcnbach plan of treating old tr.tumatic

({i^locati«>n>, 444
Diffuse lipoma, ;i4
DitTiiscvl abscew, gS

Dc« >ttve tract. di>oase> and injuries of, 612
Di»:ital vblalation of p\U>rii*. 674
D c-t'-. Mipcrnunierarv. 5-"i
D phthrria. trachejlv'niy in. 603
I 'ipl.s..vci. .v^

Dipi evens of gonorrhea. 39
Diiiit cell v'.iv'.v.. n. ^i
D.s.iitc;il..!iv'n a: ankle-joint. 853

At rI'o.»« -ioinl. c^4j

at hip i .!;:. ?=;-

a! kntc. Sii

at mf:..varp- phalangeal joint of hand. S47

at sh> ;:;.ur-'o'.rt. j-^s;

a: !..•> :n«:a:ar>ai .-rticwlati. n. ^5o
I • Nr..se y vi.;v: n. 51

.. • cs phaj:.:^. ^Ir

■ • -»..

.r.r..r>-vrfan<.r

j»:

Disease of skin and nails, 799
ol thyroid gland, 743
of tongue, 613
Disinfection of hands, 43
of in&truments, 44
of patient, 44
Dislocated kidney, 769
Dislocations at metacarpophalangeal articula-
tions, 459
axillary, 449
bilateral, 439
complete, 4^8
complicated, 438
compound, 438

traumatic, 443
congenital, 439
consecutive, 439
double, 438
habitual, 439
incomplete. 438
Monteggia's, 467
Nelaton's, 473
of ankle-joint. 471

anteroposterior, 473

lateral, 471

upward, 473
of astragalus, 473
of carpal bones, 459
of clavicle. 445

acromial end, 447

backward, of sternal end, 446

sternal end, forward, 445

upward, 446
of costal cartilages, 461
of elbow-joint, 454

backward, 455

forward, 455

inward. 456

outward, 456
of femur, 461

downward into obtnraicr 1

ischial, 467

on to dorsum of ilin«, 46a

on to the pubes. 4^^

into sciatic notch. 4r4

Monteggia's, 467

(>crineal. 4C7

subspinous. 467

suprapubic. 4^?

supraspinous. 466

with catching '^y z£ scur
rcduct:ca, 4t-r
of fibula. 4-1
of forearm. latcnC. 45^
of head of fccur »-.ir i:

467
of hip. an- ma. -"U* ^x

congemra-. ope—in :«t i:r jar:
ofh'p-J "ir.t. «t: See J~*:i.* fir; ifc ■■■ •.•■r*.'
of humerus. 445

ot infer.sr rajjo^^i.ru.- ^rztZiXMiai. <5i
of knee. 4r»5

hack wari, 4T*

fv rm-ird . «f>?

:-WAri. 4Si

•uiwjirj:. 4T*:.
of .: wer ■.*» . <««
I-:" mctacA'T- I S-o» ♦^
or" -r.eLaoi'7>-9«r-.Arjpt-. .r:cc ^51

.■•• rr.j'-c.-es «->t

0>:" pAtC-.i. 4?V.

cf p*r v* 4*:

frrw.ri •■?*

t actt

INDEX,

891

Dislocations of ribs, 461
of sca{>ula, lower angle, 4^8
of semilunar cartilages of icnee, 470
of shoulder-joint, 448
diagnosis of, 451
reduction by extension, 45a
symptoms of, 449
treatment of, 451
of spine, 592
of sternum, 461
of tarsal bones, 474
of tendons, C09
of ulna at elbow-joint, 456
of ulnar nerve at elbow, 539
of the wrist, 458
backward, 458
forward, 458
old. 438
partial, 448
pathological, 449
primitive, 438
recent, 438
relapsing, 439
sacro-iliac, 461
secondary, 438
simple, 438
single, 438
spontaneous, 439
subastragaloid, 473
subclavicular, 449
subcoracoid, 448
subglenoid, 449
subspinous, 449
traumatic, 438
causes of, 440
compound, 443
diagnosis of, 441
old. 443

pathological conditions of, 440
recent simple, 442
special, 444
symptoms of, 441
treatment of, 442
unilateral, 438

with fracture, treatment of, 338
Dislocations, 438
Displaced liver, 661
Displacement in fracture, 337

in plastic surgery, 760
Dissection-wounds, 175
Diuretics in inflammation, 76
Diverticula of esophaeus, 633
Division of stemocleiaomastoid for wry-neck,

516
Donnellan'> case of electric stroke, 880
Dorsal abscess, 107

Dorsalis pedis artery, ligation of, 298, 399
Douche in inflammation, 6^
Doyen, exploratory operation of, 573
Drainage, 47

of wounds, 166
Dressings, gauze, 46

of wounds, 166
Dropsy, 407

of joint in gonorrheal arthritis, 434
Dry aseptic method, 42
cold in inflammation, 66
gangrene, 119. 120
treatment of. 122
heat in inflammation, 71
Drying-powder in wound dressings, 166
Duality theory of syphilitic infection, 187
Diigas s sign, 449

Dupuytren's aneurysm-needle, 379
classification of bums, 736
contraction. 520

symptoms of, 521
fracture, 472

Dupuytren's operation for amputation at
shoulder-joint, 850
splint, 403
suture, 673

Ear. affections of. in syphilis, 195

disease, cerebral abscess from, 563
brain-disease from, 563
Eberth's bacillus, 41
Eccentric atrophy of bone, 309
Ecchondroses, 218
Ecchymosis, 160
Echinococcus as a cause of hydatid cysts,

338
Eczematous urethritis, 815
Edebohls's method of treating mobile kidney,
770
of nephrotomy, 780
Edema. 91

from fracture, treatment of, 338

in anthrax, 179

malignant, from wounds, 175

of glottis. 598

of larynx, 598

periarticular, 407

treatment of, 91
" Educated corpuscle," 34
Elbow, miners', 515

-joint disease, 430
dislocations of, 454
excision of, 490
Election, triangle of, 393
Electric stroke, effects of, 880

treatment of, 880
Electricity, injuries by, 878
Electrolysis m aneurysm, 350, 354

in angiomata, 236
Electropunciure for cirsoid aneurysm, 357

for delayed union of fractures, 341
Elephantiasis, 747

arabum, 747
Elevation in treating contusions, 161

in treating inflammation, 63

in treatment of hemorrhage, 36a
Embolic abscess, 98
Embolism, 134

fat, 135

symptoms of, 134

treatment of, Z35
Embryonic tissue, 5^

formation of, in healing, 8^
formation of, in inflammation, 91
Emphysema, gangrenous, 135

from wounds, 175
Emphysematous abscess, 98
Emprosthotonoft in tetanus, 145
Empyema. io3, 605
En oissac, reduction of hernia, 710
Encephalitis. 559
Encephalocele, 541
Encephaloid carcinoma, 336
Enchondromata. 217. See Chondromata.
Encysted abscess, o^
Endarteritis in syptiilis, 196
Endo-appendicitis, 651
Endocyst, 239
Endospore. 32
Enterectomy, 68x
Enteritis, rest in, 63
EnterocelCj 6^
Entcrodysis m shock, 163
Entero-epiplocele, 699
Enteroliths in obstructed bowel. 640
Enterorrhaphy, 671
Enterostenosis, 639
Enterostomy, 694
Epididymitis, 839

in gonorrhea, 816

890

INDEX,

Czerny-Lexnbert suture, 673

Czerny's method of tendon-lengthening, 519

Dactylitis in syphilis, 207
Dalton, suture of the pericardium, 240
" Dangerous area," 540
Darier, psoro&perm, 212
D'Arsonval's case of electric stroke, 880
Davaine, method of treating malignant pus-
tule, 180
Davy's director, 47^
Dicollcment of parietal pleura, 612
Decubital gangrene, 130

ulcer, 117
Decubitus^ 117, 130
Deep abscess, 99
Defeneration, gelatiniform, 409

of muscles, 505

pulpy, 408

reactions of, 527
Delayed union, treatment of, 341
Delirious shock, 163
Delirium in shock, 163
Delitescence of inflammation, 55
Demarcation, line of, 121
Demigauntlet bandage, 749
Demosthen's studies of action of Mannlicher

rifle, 160
Dentigerous cysts, 219
Depletion in inflammation, 63
Depression-fracture, 522
Dermatitis venenata, 739
Dermoid cysts, 238
Desault's apparatus, 756

bandage in fracture of clavicle, 360, 361, 446,

447
in fracture of humerus, 364
in fracture of scapula, 362, 363

*ign. 384
Descendens noni nerve as a guide to sheath

of common carotid in ligation, 293
Diabetic gangrene, 127
DiapcdeMs in inflammation, 52
Diaphoretics in inflammation, 75
Diaphragmatic hernia, 713
Diarrhea of constipation, 642
Diastasis, 324
Diathetic abscess. 98

Dickins<jn's theory, amyloid degeneration. 415
Diday's operation for webbed fingers. 521
Dicffeiibach plan of treating old traumatic

dislocations, 444
Diff"use lipoma, 214
T)ifl"used abscess, 98

Digestive tract, diseases and injuries of, 612
r)igital diialalion of pyloni?, 674
Digit-*, supernumerary, 521
Diphtheria, tracheotomy in. 603
l)iplococci, 2u

Diplococcus of gonorrhea, 39
I)irect cell-division, 85
Disarticulation at ankle-joint, 853

at elbow-joint. 849

at hip-joint, 857

at knee. 855

at metacarpophalangeal joint of hand, 847

at shoulder-joint, 849

at tarsometatarsal articulation, 850
Disease production, 31

of esophagus. 612

of genito-iirinary organs, 763

of the hr.ul, 535

of the joirits, 406

of kidney, 7^18

of lymphatic s, 746

of mouth. (ii\i

of rt-ctum and anus, 713

t)f scalp. 539

Disease of skin and naOt, 799
of thyroid gland, 743
of tongue, 612
Disinfection of hands, 43
' of instruments, 44
' of patient, 44
Dislocated kidney, 769
Dislocations at metacarpophalangeal aiticula*
tions, 459
axillary, 449
bilateral, 439
complete, 438
complicated, 438
compound, 438

traumatic, 443
congenital, 439
consecutive, 439
double, 438
habitual, 439
incomplete, 438
Monteggia's, 467
Nelaton's, 472
of ankle-joint, 471

anteroposterior, 472

lateral, 471

upward, 472
of astrasalus, 473
of carpiu bones, 459
of clavicle, 445

acromial end, 447

backward, or sternal end, 446

sternal end, forward, 445

upward, 446
of cosul cartilages, 461
of elbow-joint, 454

backward, 455

forward, 435

inward, 456

outward, 456
of femur, 461

downward into obturator foramen, 465

ischial, 467

on to dorsum of ilium, 462

on to the pubes, 466

into sciatic notch, 464

Monteggia's, 467

perineal. 4O7

subspinous, 467

suprapubic. 467

supraspinous, 466

with catching up of sciatic nerve upon
reduction, 467
of fibula, 471
of forearm, lateral. 456
of head of femur with fracture of shaft,

467
of hip, anomalous, 466

congenital, operation for, 503
of hip-joint. 461 . See Dislocations o/fetHur.
of humerus, 448

of inferior radio-ulnar articulation, 459
of knee, 468

backward, 468

forward, 46S

inward, 469

outward. 469
of lower jaw, 444
of metacarpal bones, 459
of mctacarpophalangealjomt, 459
of metatarsal bones, 474
of muscles, 509
of patella. 469

edgewise, 470
of pelvis, 461
of phalanges. 460, 474
of radius backward, 457

forward, 456

outward, 457

I\DEX.

891

Dttlocatkmt of ribs, 461
of ftcapola, lover aii|k. 44i
of MmUitnar cartilages of kaee, 470
of shoulder-joint. 44t

diagnoftb of. 451

recniction \rf ezteauoa, 45a

tymptotts of. 449

treatment of. 451
of spine. 592
of stemam. 461
of tarsal bones. 474
of tendons, C09
of ulna at elbov-joiat, 456
of ulnar nenre at elbow. 539
of the wnst. 458

backvard. 4^

forward, 4^
old. 438
partial. 448
patholofica], 449
primitiTe. 4^
recent, 438

'•iaiwing, 439
sacro-iliac. 401
secondary, 438
simole, 438
single. 438
spontaneous. 439
subastragaloid, 473
subcbvtcular. 449
subcoracoid. 4^
subglenoid, 449
subspinoos. 449
traumatic. 438

cau»esof. 440

compound. 443

diagiKysis of. 441

old. 443

patholo^cal cooditioos of. 440
recent »imple. 443
special. 444
symptoms of. 441
treatment of. 443
unilateral. 438

with fracture, treatment of, 338
Di«locations, 438
Displaced liver, 661
Dispbcement in fracture. 327

in plastic uu^/ay, 760
Disftection-wounds, 175
Diuretics in inflammation. 76
Diverticula of esophagus, 693
Division of stemocleicfomastoid for wry-neck,

516
Donnellan's case of electric stroke, 880
Dorsal abscess, 107

Dorsalis pedi» artery, ligation of, 298, 299
Douche in inflammation, 6^
Doyen, exploratory operation of, 573
Drainage, 47

of wounds, 166
Dressings, gauxe, 46

of wounds, 166
Dro|»)r. 407

of j<nnt in gonorrheal arthritis, 424
Dry aseptic method, 4a
cold in inflammation, 66
gangrene, 119. 120
treatment of, 122
heat in inflammation, 71
Drying-powder in wound dressings, 166
Duality theory of syphilitic infection, 187
Dugas s sign, 449

Dupuytren'k ancurysm-needle, 279
classification of bums. 736
contraction, 520

symptoms of, 531
fracture. 473

Dopvytrea's opoatioa for ampotatioo at

shoulder-joint. 850
splint. 403
suture. 673

Eak. affiections of. in «y^ilia. 195
disease, cerebral absceu froa. 563
brain-disease horn. 563
Eberth's bacillus. 41
Elccentnc atrophy of booe. 309
Ecchoodroses. 218
Ecchymosis. 160
Echinococcus as a cause of hydatid cysts.

23»

Ecrematous urethritis, 815
Edcbohls's method of treating aoUle kidney.
770
of nephrotomy, 780
Edema. 91

from fracture, treatment of, 338

in anthrax, 179

malignant, from wounds, 175

of glottic. 598

of larynx. 598

periarticular, 407

treatment of, 91
" Educated corpuscle," 34
Elbow, miners', 51;

-joint disease, 420
dislocations of, 454
excision of, 490
Election, triangle of, 393
Electric stroke, eflects of, 880

treatment of, 880
Elect ricity, injuries by, 878
£lectroI>'sis in aneurysm, 350, 354

in angiomata, 236
Elect ropunctu re for cirsoid aneurysm, 257

for delayed union of fractures, 341
Elephantiasis, 747

arabum, 747
Elevation in treating contusions, 161

in treating inflammation, 63

in treatment of hemorrhage, 36a
Embolic abscess, 98
Embolism, 134

fat. 135

symptoms of. 134

treatment of, Z35
Embr^'unic tissue, 51

formation of, in healing, 8|
formation of, in inflammation. 91
Emphysema, gangrenous, 135

from wounds, 175
Emphysematous abscess, 98
EmprONthotonos in leunus, 145
Empyema, 102, 605
En bissac, reduction of hernia. 710
Encephalitis. 559
Encephalocele. 541
Encephaloid carcinoma, 236
Enchondromata. 217. Sec Ch^ndrotnata.
Encysted abscess, <k)
Endarteritis in syphilis, 196
Kndo-appendicitis, 651
Endocyst, 239
Endospore, 2a
Entcrcctomy, 6S1
Enteritis, rest in, 63
Enteroccie, 6^>
Entcroclysis m shock, 163
Entero-cpiplocele, 699
Enteroliths in obstructed bowel, 640
Enterorrh.iphy. 671
Entcrostenosis, 639
Enterostomy, 694
Epidulymitis. 839

in goiiorrhe.i, 816

894

INDEX.

Fracture.^ of femur, intracapsular, differentia-
tion of, from extracapsular, 385
1'ust above condyles, 394
ongitudinal, ^95

separating either condyle, 395

separation of the epiphysis of the great
trochanter, 391

separation of lower epiphysis, 395

shaft of, ^i

upper epiphysis of head of, 390

upper extremity of, 38a
of nbula, 401

lower third of, 402

upper two-thirds of, 40a
of forearm, both bones of, 377
of humerus, 363

anatomical neck of, 363

at lower epiphysis, 37^

at upper epiphysis, ■^€^

base of, condyles of, 370

external condyle of, ^>9

head of, 366

inner epicondyle of, 369

internal condyle of, 369

lower extremity of, 369

shaft of, 367

surgical neck of, 364

T-fracture, 371

upper extremity of, 363
of hyoid bone, 148
of inferior maxillary, 346
complications of, 347
symptoms of, 347
treatment of, 347
of ischium, 357
of lachrymal bone, 343
of laryngeal cartilages, 349
of leg, 400
of malar bone, 34s
of metacarpal bones, 381
of metatarsal bones, 405
of nasal bones, 342

treatment o^ 342
of patella, 305

by direct force, 398

by muscular action, 395

transversa, 396
of pelvis, 354
of penis, 833
of phalanges, 381
of toes, 4;"j8
of radius, 375

above insertion of pronator radii teres
muscle, 376

and ulna near wrist, 381

below insertion of pronator radii teres
muscle, 376

head of, 375

lower extremity of, 377

neck of, 376

shaft of, 376
of ribs, 349

causes of, 3S0

complications of, 351

symptoms of, 350

treatment of, 351
of sacnim, 3:;7
of scapula, 362

acronuim of, 362

CO ra CO id process of, 363

glenoid cavity of, 36a

neck of. 362
of skull, 54.J

base of. 551

vault of, 550
of spine, 592
of sternum 353

causo of, 353

Fractures of sternum, complications of, 353

symptoms of, 353

treatment of, ^53
of superior maxillary, 34^
of tibia, by separation of lower epiphysis,
401

by beparation of upper epiphfsis, 400

inner malleolus, 401

lower end of, 401

shaft of, 400

upper end of, 400
of true pelvis, 355
of ulna, 373

coronoid process of, 373

olecranon process of, 373

styloid process of, 375
of zygomatic arch, 346
overlapping of fragments in, 338
overriding of fragments in, 398
pain in, 327
pathological, ^93

?:netration of fragments in, 328
ott's, 402
predisposing causes of, 395
preternatural mobility in, 329
radish, 323

recent, operative treatment of, 480
reduction of, 335
repair of, 333
rest in, 62

secondary, 393
separation of Ji
simple, 391

separation of fragments in, 398
'tnple, 391
repair of, 3.'

repair of, 339
sound of cracicing in, 397
spiral, 324
splinter-, 322
spontaneous, 393
starred, 394
stellate, 324
strain, 329
swelling in, 327
symptoms of, 327

circumstantial. 340

direct, 330
transverse, 322
treatment of. 334

of edema from, 338

of gangrene from, 338

of inflammation in, 339

of phlebitis from, 338

of sloughing in, 337. 338
T-shaped, 323
toothed, 323
torsion, 324
union ol, fibrous, 333, 334

ligamentous, 334

membranous, 334

vicious, 334
ununited, 323, 334

operative treatment of, 482

treatment of, 341
varieties of, 321
V-shaped, 323
vicious union of, 334
wedge-shaped, 323
wilK)w, 322
wiring of, 336
with crushing, 323
with dislocation, treatment of, 338
with penetration. 323
Freezing, anesthesia by, 734
Frontal sinus, distention and abscess of, 597

trephining of, 573
Frost-bite, gangrene from, 128

treatment of, 7^8
Fuller's method of " milking " the seminal
ducts, 834

INDEX.

89s

Fuller's method of prottatectomy, 837
Fulminating gangrene, 125
Fungi. 18
Fungous ulcer, 116
Fungus cerebri, 557

luematodeft, 227
Funicular hernia, 71a
Furuncle, 739

symptoms of, 740
Furunculosis, 740

Galactocblb, 865
Gall-bladder, rupture of, 632
Gall-stones^ 661

causes of, 661

symptoms of, 662

treatment of, 663
Ganglia, 512

treatment of, 512
Gangrene, 119

acute, 124
■ amputation for, 131

classification of, 119

chronic, 120

decubital, 130

diabetic, 127

discoloration in, 59

dry, 119, 120

foudroyunte, 125

from contusion, treatment of, 161

from ergotism, 128

from fracture, treatment of, 338

from frost-bite, 128

from infective organisms, 125

fulminating, 125

hoiipital, 125

moist, no, 124

of lung, 007

of penis. 833

postfebrile, 131

Pott'^l, X20

Raynaud's, 126

senile, i2z

septic, 119

symmetrical, ia6

traumatic spreading, 125
Gangrenous emphysema, 125

from wounds, 175
Garel's sign, zoi

Gasserian ganglion, removal of, 533
Gastro-enterostomv, 180

for cancer of pylorus, 237

for pyloric obstniction, 639
Gastrogastrostomy, 681
Gastroplication, 681
Gastrostomy, 678

for cancer of esophagus, 237
Gastrotomy, 676

in cardiac stenosis, 639
Gauntlet, 749
Gauze, Iodoform, preparation of, 46

Lister's cyanid, 47

pads. Ashton's, 44

sterilized, preparation of, 46
Gelatiniform degeneration, 40^
Geni to-urinary diseases, pain in, 766

organs, diseases and Injuries of, 763
Genu valgum, 522
osteotomy for, 473

varum. 522
Germicides, chemical, 24
Giant-cell sarcoma, 228
Gibney, method of treating sprains, 434
Gibson's bandage, 3^7, 753
Gila monster, bite of, 178
Girdle-pain in tetanus, 145
Girdner's telephonic probe, 173
Glanders, 182

Glanders, diasnosis of, 182

treatment of, 183
Glandulx Pleiades of Ricord, 190
Glandular cancer, 236
Gleet, 817

Glenard's disease, 661
Gliosarcoma, 229
Globus, 621
Glottis, edema of, 598
Glovers' »titch, 46
Gliick and Bariholow, anesthetic mixture of,

735
Gluteal artery, ligation of, 308

bursitis, 414
Glutol, -^9

in dressing wounds, 166
Goiter, 743

cA'stic, 743

exophthalmic, 745

fibrou.% 744

pulsating, 745

symptoms of, 744

treatment of, 744
Gonococci, determination of, 817
Gonococcus, 39
Gonorrhea, 815

abortive, 817

acute inflammatory, 816
treatment of, 810

black, 816

catarrhal, 817

in the female, 823

irritative, 817

of rectum, 823

subacute, 817
Gonorrheal artnritis, 423

changes in ihe joints in, 424

ophthuTmia, 8^22

rheumatism, 423
Gordon's pistol-shaped splint, 379
Gouley's divulsor, 826

tunnelled catheter, 785
Gout, rheumatic. 427. See Arthritis t^for-

mans.
Gouty arthritis, 426
Graft, omental, 674
Grant's clamp, 697

operation, ^78
Granulation, healing by, 84

-tissue, 5^
in repair of fractures, 3^2
Graves's disease, 745
Gravitative abscess, 98
Green-stick fracture, ^2
Gntti's amputation of leg, 856
Gross, antimonial and saline mixture, 74

incision of, 495
Gross's divulsor, 826, 828

method of amputation at elbow-joint, 840

rule for continuous treatment of syphilis,
200

urethrotome, 826. 8a8
Guerin's method of amputating fool, 852
Guitiras's (Ramon) method orexamining for

urethral stricture, 825
Gumma in tertiary syphilis, 197
Gummy pus, 95
Gunshot- wounds, 168

amputation for, 174

dressing of, 173

hemorrnage in, 171, a68

of arteries, 258

of head, 555

treatment of, 556

pain from, 172

shock from, 172
symptoms of, 171

treatment of, 172

896

INDEX,

Gussenbauer's clamp in delayed union of

fractures, 341
suture, 673
Guthrie's rule for treatment of hemdrrhage,

263
Guyon's method of sterilizing catheters, 836

Hagboorn needle, use of, in ligation, 360
Hair, affections of; in syphilis, 105
Hahn, method of gastrostomy, 679
Hallux valgus, 525

varus, 525
Halsted's inflatable rubber cylinder for cir-
cular enterorrhaphy, (A^

mattress-suture, 673

method of lateral intestinal anastomosis,
691

operation for cancer of breast, 868
for inguinal hernia, 704

subcuticular stitch, 43, 704
Hamilton's bandage for fracture of inferior
maxillary, 347

bone-drills, 482
Hammer-toe, 526

Hancock's method of excising ankle-joint, 497
Handkerchief bandages, 758
Hands of operator, disinfection of, 43
Hard chancer, 187
Harelip, 612

operation for, 613
Harris's method of circular enterorrhaphy,

687
Hayden's treatment of chancroidal bubo, 83a
Head, contusions of, 543

diseases of, 53^

gunshot -wounds of, 555

injuries of, 543

tetanus, 1^5
Healing by nrst intention, 82

by granulation, 84

by second intention. 84

by third intention, 85
Healthy pus, 94
Heart, diseases and injuries of, 939

suture of, 240

Upping of, 274

wounds and injuries of, 240

-wounds, treatment of, 240
Heat as a germicide, 29

forms of, for use in inflammation, 70

intermittent, 69
Heberden's nodules or nodosities, 427, 428
Hectic fever, 89, 100
Heiman's case of arthritis from gonorrheal

ophthalmia, 423
Heineke-Mikulici operation, 630, 674
Helfcrich method of treating cielayed union

of fractures, 341
Heller's test for blood in urine, 764
" Helpless eversion," 383
Hematemesis, 271
Hematic abscess, 90
Hematocele, 840

encysted, of the cord, 841
of the testicle, 841

parenchymatous, 841

vaginal. 840
Hematoid carcinoma, 236
Hematoma, 160

of dura mater, 558
Hematuria, 763

renal, 764
Hemoptysis, 271
Hemorrhage, 258

actual cautery in. 262

acupressure in, 262

as a cause of shock, 162

capillary, treatment of, 267

Hemorrhage, cerebral, 548, 549
compression in. 262

concealed, diagnosis of, from shock, 163
consecutive, 272

constitutional symptoms of, 358, 359
elevation in, 262
extradural, 266, 547, 548
extramedullary spinal, 366
following lateral lithotomy, 370
forced flexion in, 263
from bladder, 370, 766
from cerebral sinus, 366
from diploe, 265
from ear, 260
from femoral vein, 266
from intercostal artery, 265
from kidney, 270
from large bowel, 271
from leech-bite, 269
from lung, 271

treatment of, 260
from mammary artery, 365
from nose, 268
from palmar arch, 363
from prostate, 370
from punctured wounds, 365
from small bowel, 371
from stomach, 271
from tooth socket, 363, 366
from urethra, 369
from urinary meatus, 369
from varicose vein, 367
from vessels in bony canal, 365
from wounds, 163

arrest of, 165
In abdominal section, 367
in amputation, prevention of, 843
In gunshot- wounds, 171, a68
intercurrent, 373
intermediate. 373
Intra-abdominal, 367
intracranial, 547
ligation in, 260
pressure in, 267

primary golden rules for procedure in, 263
reaction after, tre^itment of, 260
reactionary, 272
rectal, 269
recurrent, 272
renal, 270
secondary, 373

treatment of, 373
styptics in, 262
subcutaneous, 258. 369
subdural. 548, 549
syncope in, 259
torsion in, 261
treatment of constitutional symptoins of,

--'59

umbilical, 269

urethral, 766

uterine, 271

vaginal, 271

vesical, 270, 7<i6
Hemorrhagic fever, 359

sarcoma, 228

ulcer, 117
Hemorrhoids, 242, 713

arterial, 715

capillar>', 715

excision of, 716

external, 714

internal, 714
operative trcatmcr.t of, 716

ligation of, 717

venous, 715
Hemostatic agents, 260
Hepatitis, pain in, 57

INDEX.

897

Hepatopexy, 661
Hcpatotomy, transthoracic, 103
Hereditary fragility of bones, xit

syphilis, 185, 205. See Syphitts.
Hereditation as a cause uf tumors, aio
Hernia, abdominal, 699
anatomical, varieties of, 712
causes of, ^
congenital inguinal, 7x2
diaphragmatic, 71 )
direct inguinal, 713
-director, 702
encysted inguinal, 713
epigastric, 713
femoral, 712
Bassini's operation for, 705
Fabricius's operation (or, 706
funicular, 712 «

herniotomy in, 711
incarcerated, 706
indirect inguinal, 7x3
infantile, 712
inflamed, 707

Inguinal, Bassini's operation for, 703
Fowler's operation for. 705
Macewen's operation for, 70X
into the foramen of Winslow, 713
irreducible, 706
Littri's, 709
lumbar, 713
•needles, 702

oblique inguinal, herniotomy iii, 710
obstructed, 706
obturator, 7x3
of the brain, 557
of muscles, 509
perineal, 713
properitoneal, 713
pudendal, 713
reducible, 700
palliative treatment of, 700
radical cure of, 705
treatment of, 70X
sciatic, 713
strangulated, 707
symptoms of, 708
treatment of, 709
umbilical. 713
herniotomy in. 71 x
radical cure of, 705
ventral, 713
Herniotomy, 710
Herpetic ulcer, differentiation of, firom chan«

cer, 189
Hetero-inoculation, 187
Heterologous tumors, 210
Heurteloup's artificial leech, 65
Hey, internal derangement of, 470
Hey's amputation at tarsometatarsal joint,

85a
High tracheotomy. 602
Hilton's method of opening abscess, 104
Hip disease, 4x1. See Tuberculosis 0/ kip-
Joint.
differentiation from sacro-iKac disease, 413
from spinal caries, 4x3
excision of, 418

-joint disease, 41 x. See Tuberculosis 0/
kip-joint.
dislocations of, 46X
excision of, 493
Hodgen's splint for fractures of the thigh, 393
Hoffa's operation, 503

for congenital dislocation of hip, 503
Hollow-foot, 525
Horsley's cyrtometer, 537, 539
method of intestinal anastomosis, 69X
of locating fissure of Rolando, 536

Hospital gangrene, X3S
Hot-water bag, 71
Housemaid'slcnee, 5x4

treatment of, 515
Humerus, dislocations of, 448

fracture of, 363. See Fracture.
Hunterian chancer, X87
Hunter's canal, 304

derivative of tuberculin, 157

operation for aneurysm, 2^2
Hutchinson's knee-joint sphnt, 4x9

teeth, 208
Hydatid cysts, 238
of liver, 659
of mammary glamd, 865
treatment of, 239

fremitus, 239
Hydrargyrism, 202, 203
Hydrarthrosis in gonorrheal arthritis, 494
Hydrencephalic cry, 560
Hydrenccphalocele, 543
Hydrocele, 839

congenital, 840

encysted, of the cord, 840

funicular, 840

infantile, 840

of a hernia, 840
Hydrocephalus, 543

acute. 5A2, 559
Hydronephrosis, 776

symptoms of, 777

treatment of, 777
Hydrophobia, 180

antitoxins of, x8i

differentiation of, from lockjaw, x8i

spurious, 181

treatment of, 180
Hydrophobic tetanus, 145
Hydrops articuli, 407
Hydrorrhachitis, 577
Hyoid bone, fracture of, 348
Hyperemia, active, 48

passive, 49
Hypcrflexion, brachial, 263
Hypertrophy of bone, 309

of muscles, 505
Hyphomycetes, 18
Hypodermoclysis, X37

in erysipelas, 143

in hemorrhage, 259

in shock, X64
Hypospadias. 830
Hypostatic abscess, 98
Hysterectomy for uterine hemorrhage, 971

for uterine myomata, 223
Hysteria, traumatic, 589
Hysterical joint, 430

IcHORUS pus, 95
Ichthyol, 69
Ileus, 639
Iliac abscess, 107
arteries, anatomy of, 505
ligation of, 305, 307
Iliofemoral triangle of Bryant, 384 .
Immediate union, 83
Immunity, 34
Imperforate anus, 723
Incarcerated hernia, 706
Incised wounds, 167
treatment of, 107
Incision of Gross of excision of hip-joint, 49$
Inclusion theory of Cohnheim, 210
Indian operation for rhinoplasty, 763
Indifferent tissue, 53
Indirect cell-division, 85
Indolent bubo, 190
Induction-balance of Graham Bell, 173

898

INDEX.

Infantile hernia, 712

scurvy, 160
Infection, septic, 137
Infective myositis, 505

sinus-thrombosis. 564
Infected wounds, dressing of, 166

arthritis, 422
Inferior maxillary bone, fracture of, 346
Infiltration-anesthesia, 735

purulent, 96
Inflamed hernia, 707

joints, rest in, 62
Inflammation. 4)^-^2

as a cause of tumor, 210

causes of. 56

cell-proliferation in, ^3

changes in perivascular tissue in, 53

chronic, 81

circulatory changes in, 48

classification of, 54

constitutional symptoms of, 61
treatment of, 73

cupping in, 65

definition of, 48
of secretions in 61

derangement of aosorbents in, 61

diapedesis in, 52

discoloration in, 59

disordered fiinction in, 60

effusion of liquor sanguinis in, 90

extension of. 55

exudation of fluids in, 31

fever in, 61

formation of embryonic tissue in, 91

from fhicture, treatment of, 339

impairment of special function in, 61

in non-vascalar tissue, 54

migration in, p

of antriim of Highmore. 596

of thyroid giand, 743

oscillation in, 50

pain in, 57

plastic. 52

relaxation in, 63

retardation of circulation in, 50

ser us. - 1

sta«:n.iti .>n of circul.iti jn in, 51

swelling: in. f>\.

sympt-.m-i i.f. 56

tcnrjrrne-is in, 6j

terniin.iti'jns of, 55, 90

trc ilmcnt of. 6.'

tu:ii^f.»c:i -n in, (>j

variclic'' of, 54. 55

va'.cular ;»nd circulatory changes. 48

va>cular chaii^e«i in. 48

vcnoeclion in. 73
Inflainniat ^ry fever. ^1
In<:ri'wn t'.c-r.ail. 74^
In),;uinal colj^t my, 694
Injury as a cau«e of tumor, 210
Inn. m.natc artery, anatomy of, 251

liC^'ti ^n of, 2^1
Inoc.i'.-it! 'Hs, pr -tcctive and preventive. 34
In^rrcis. bite* and stin.;s of, 176
In» n-.nia in syphilid, i .\,
Instruments. «:<infrction '>f. 44
Inter. smI t.Cwragia, 504

Intcrd.iital ^v'.ini f->r fracture <A inferior
m.i\: !.iry hone. 34S
in !'r,n.t,:rc ■ !" ^ipcr: -r max.liant' Lone, 345
In:trmirtent hi:. it n intl.tmmat: jn, 6^
In:-::. .1 ..:,thr.ix, 17^

l.Tt- rj. .1: '. in pl.'i'itic surf-jry. 76J
Irjtcrtr c :' r.crcd.ttry syp'iiiii. 207
!:.;':<: ::..'. ■■..-•. .i:::si'.. 6:1
..jtcr.i., *: -.'.

Intestinal approzimatioQ, 693
obstruction, 639
acute, 639

symptoms of, 6fO
chronic, 639

symptoms of, 640
diagnosis of. 641

differentiation from other diKase», 643
prognosis of. 643
treatment of, 643
tuberculosis. 153
Intestine, malignant ttimor of, 647
resection of, 63 1

rupture of. without external wouiid, 609
suture of, 671
Intoxication, septic, 136
Intracapsular fracture of femur, 36»-3S
Intracranial hemorrhage, 547

tumors, 565
Intraparietal fissure. 538
Intubation of larynx, 604

for fracture of hyoid bone. 348
of laryngeal cartilages. 349
Intussusception. 6j9
operation for, 694
Inversion of leg in intracapsular fractnre of

femur. 383
Involucrum of bone. 31s
lodism from syphilitic treatment, 305
Iodoform, 27
absorption. fe%'er of, 27
emulsion. 27
gauze. 46
lodol, 29

Iritis, differentiation of rheumatic, from syph-
ilitic, 196
in syphilis, i^
Irreducible hernia. 706
Irrigation of voimds, 45, i^
Irritable ulcer. 116
Irritants in inflammation. 73
Ischiorectal abscess. 721
Italian method of rhinopilasty. 763
hr...l,.-.

Jacob's ulcer. 117, 2.^5

Janet'> nicth. d of treating g^n-^rrhca. £19

Jerk -finger. 521

Jubert''- ^ulure, f>~x

J..hn<lon'^ cthere.il s."»ap. 4.'

method "'f jircp.ir.ng caigjt. 45
Joints, aspiraf-.n of, 4S4

di'>'ra!>e<i >i. 406

and injuric* of. 409

exci^.'jii of. 4^5

fl'.'.iling cartilages in. 437

!■:■ -St; h.i<l'e> in. 437

neural.; a of, 431

s> philitic affections of, ijs

:u*r.'rcular di-easc of, 154

fjL'.rcuI NiN. 1 ^4

w ,und< and injuries of. 432
J:nc*"s na>i.il <plint. 3*5

J- V : .:. f r treatment f tracrures, 3-2. 373
J.r ; n^ arr.pi:t..:- n at h p-; n: r.iy

m:tK .': ■ : fcaiing cano ^f >p-n«. sSt
Jiir> -m ^st r'! >a\ re. 5-7
)i:\ en .c t.i>ue. 5;

Kangak'i -rFNP- X sui-ro. 4^
K.tr\ kir'.e-iis. -:

Keer.'s ::ii.i>::r. f r reaching spinal acces>ory
r.erve. ^2.
tr-'.it.Tiert • f I» ijuyfer/s cTiract-.r.. Jii
K-!.y. v.v'.' ■.:• r.r.-.*. r. .: urr'.ers 7-5

:::•. •.'■■■d '' '.■•-'.:.U•^^l•.^.^ . ••erator'* hard>. 45
• jr- -.•..r::-.^ v ..t^ut. 45
Kc!.\ N v..(thcter. r^^

INDEX.

899

Keloid, 216
spontaneous, 317
treatment of, 217
Kidney, abscess of, 774
bleeding from, 764
diseases and injuries of, 768
dislocated, 769
floating or wandering, 768
injuries of, 770
laceration or rupture of, 770
mobile. 768
symptoms of, 769
treatment of, 770
movable, 768
operations on, 779
perforatine wounds of, 771
removal of, 781
surgical. 777
tuberculosis of, 778
treatment of, 779
tumors of, 768
Kite-shaped director, 479
Knee-joint disease, 418
excision of, 486
subluxation of, 470
Knock-knee, 532

osteotomy for, 475
Kocher, experiment of, 31

method of operating for inguinal hernia, 705
Kocher's excision of tongue, 619
incision for nephrorrhaphy, 783

lor nephrotomy. 780
method of circular enterorrhaphy, 686
of gastro-enterostomy, 680
of lumbar nephrectomy, 782
of pylorectomy, 676

of reducing dislocations of shoulder-joint,
45»
Koch's bacillus, 40
circuit, 30
lymph. 35, 157

in tuberculosis, 156
tuberculin, 157
Konig's incision for nephrectomy, 781
Kraske, sacral resection of, 237
Kraske's operation, 730
Krause's method for removal of Gasserian
ganglion, 535
of skin-grafting, 762
Kreolin, 27
Kyphosis, 583

Lacerated wounds. 167
Lachrymal bone, fracture of, 343
lacteal cyst, 865
Lagoria's sii^n, 384
Laminectomy, 595

for spinal caries, 587

in extrameduUary spinal hemorrhage, 366
La Mothe's method of reducing shoulder-
joint dislocation, 453
Landerer's dry method, 43
Langenbeck's incision for abdominal nephrec-
tomy, 783

operation, 494
Lankester, educated corpuscle, 34
Lannaiol, 29

Lannelongue's method of treating delayed
union of fraciures, 341
of exposing the liver, 659

operation for microcephalus, 541
Laparotomy, 666

for non-suppuralive appendicitis, 668
Larrey's amputation at nip-joint, 858

operation for amputation at shoulder. 849
Laryngeal cartilages, fracture of. 349
Laryngotomy for fracture of laryngeal carti-
lages, 349

Laryngotomy, quick, 604
Laryngotracneotomy, 604
Larynx, abscess of, 101
diseases and injuries of, 598
edema of, 598
foreign body in, 599
intubation of, 604
operations on, 601
wounds of, 598
Lateral curvature of spine, 580

sinus, location of, 539
Laudable pus, 94
Lawn-tennis arm, 508
Lead-water and laudanum, 68
Leech, artificial, 65
Leeches in osteitis, 311
Leeching, 64
Leg, chronic ulcer of, 113

ulcer of, XI3
Leiomyomata, 333
Leiter's tubes, 67
Lemhert's suture, 673

for longitudinally torn vein, 360, 365
Leontiasis ossium, 330
Leptomeningitis, acute, 558

chronic, 559
Leptothrix, 31

Leukocytes in Inflammation, 61
Leukocytosis, 53
Lcukomains, 33
Leukomata in syphilis, 194
Levis's splint, 379, 460
Ligation by means of Hagedorn needle, a6o
in inflammation, 65
in continuity, instruments for, 378
in the tabatiere, 382
in triangle of election, 294

of necessity, 294
of arteries for aneurysm, 25a-35<
in continuity, 278
incision for, 279
of axillary artery, 386-288
in the first part, 3S8
in the third portion, 387
of brachial artery, 284-386
at bend of elbow, 285
at middle of arm, 286
of carotid artery, common, 293-395
external, 295
internal. 205
of dorsalis peois artery, 398, 399
of facial artery, 397
of femoral arterj', 303-305

at apex of Scirpa's triangle, 304
in Hunter's canal, 305
of femoral vein, 266
of gluteal artery, 308
of iliac arteries, 305-307

by ahdominsil section, 306
external, by Abemethy's method, 306
of inferior thyroid artery, 390
of innominate arter>', 291
of lingual artery, 2^
of occipital artery, 298
j of popliteal artery, 302

of pudic artery, internal, 308
of radial artery. 281-283
in lower third, 282
in middle third, 283
in upper third, 283
of sciatic artery, 308
of subclavian artery, 388, 389
of temporal artery, 297
of thyroid artery, superior, 396
of tibial artery, anterior, 299-30X

posterior, 301
of ulnar artery, 283, 284
of vertebral artery, 288, 290

goo

INDEX,

Ligature, lateral a€o

•material, 45

subcutaneous, fur varicocele, 375
Ligatures, 260
Lightning, injuries by, 878

stroke, 878

treatment of, 879
Lilienthal's probe, 173
Line of demarcation, lat
Linear craniotomy, 577
Lingual artery, ligation of, 296
Lipoma, cavernous, 314

diflfu^e, 214

nevoid. 2^6

telangiectodes, 314
Lipomata, 214

treatment of, 3x5
Liquor pur is, 94

sanguinis, effusion of, in inflammation, 90
Lisfranc's amputation at shoulder-joint, 850

at tarsometatarsal articulation, 850
Lister's abdominal tourniquet in aneurysm,
251

cyanid gauze, 47

experiment, 50

method for excision of wrist-joint, 491
Liston, amputation at hip-joint, 859

modified circular ampuution, 845

silver-fork defonnity, 378
Litholapaxy, 803

in male children, 807
Lithotomy, 799

lateral, 79^9

suprapubic, 800
Lithotrites, 804, 805
Littre's hernia, 709
Liver, abscess ot, 100, 660

displaced, 661

hydatid cysts of, 659

rupture of. 631

wounds of, 658
Lizard, poisonous, bite of, 178
Llo^'d's (Jordan) symptom, 773
Local anesthesia, 734

Locke and Hare, solution for intravenous in-
jection, 277
Lockjaw, diagnosis of, from hydrophobia, 181.

Sec Tetanus.
Locus minoris resistentiae, 31
Lordosis, 583
Lorenz's operation for congenital dislocation

of hip. 439. 503
Lorcta's operation, 639, 674
Loretin, 29
Lumbaco, 504
Lumbar abscess, 107

hernia, 713

nephrectomy. 781

puncture. 543, 595
Lumpy jaw, 19. 1H3
Lung, abscess of. 101. 607

diseases and injuries of 605

gangrene of, tV-7

tubercular cavity in, surgical treatment of,
608

Lupus, 151

cxedciis. if?2

hypertrojihicus, 15-*

syphilitic. 297

vulgaris, i ^i
Lusk. method yi{ ^kin-jjrafting, 760
Lust^jartcJi's bacillus, 41

in syphilis, 183
Luxatii> crecta, 449
Luxations, 438, See Diilocutions.
Lymph e«lcm:». 867

effusion of, 91, 02
LyniphadcnKis. .«cute. 746

Lyniphadenitis. chronic, 747

infective, 746
Lymphangiectasis. 336, 747
Lymphangioma, 747

circumscriptum, 747
Lymphangioma ta, 336

treatment of, 337
Lymphangitis, 746

from septic wounds, 175

reticular, 746

tubular, 746
Lymphatic abscess, 98

glands, tuberculosis of, 154

nerves, 226

warts, 747
Lymphatics, diseases and injuries of, 746
Lymphomata, 33x

idiopathic, 231

treatment of, 333
Lymphorrhea, 747
Lymphosarcoma, 228
Lyssa, 180. See Hydrophobia.

MacCormac's rule for measuring for a truss,

701
Macewen's method of compression of aorta
in amputation at hiCKJoint, 857
of operating in mastoid aisease, 575
operation of osteotomy for genu valgum, 47s

for inguinal hernia, 701
triangle, 539
Macroglossia, 336
Macular syphilides, i^
Maculo-papular syphilides, 19a
Madura foot. 19
Maisonneuve's symptom, 378

urethrotome, 826
Malar bone, fracture of, 345
Malaria, fever of, 89
Malgaigne's hooks, 397
method of treating fracttu^ of costal carti-

Jagcs, 353
Malignant edema following wound, 175
onychia, 742
pustule, 178. See Anthrax.

excision of, 179
tumor of intestine, 647
tumors, 237, 233
Malingering by persons injurod in accidents,

59 »
Mallet-finger, 522

Mammary gland, adenocele of, 864

angioma of, 864

cancer of, 866

carcinoma of, 866

cold abscess of. 109

cystic adenoma of, 864

cystic degeneration of, 864

cysts of. 864

fioro-adenoma of, 863

hydatid cysts of, 865

involution cysts of, 864

malij^nant lu-nors of, 865

myxoma of, 864

s.trcoma of, 865

tuberculosis of, 108

tumors of, 863
Mammiilitis, 859

Mannlichcr rifle, velocity of bullet of. 169
Maragli.tno's antitubercular serum, 158
Marpin.^l abscess, 99
Marie's disease, 429
Marine sponges, preparation of, 47
Marsupialization, 659
Mason's pin. 343
Mastitis, acute, 860

symptoms of. 860

treatment of, 861

INDEX.

901

Mastitis, chronic, 861
lobular, 86a
treatment uf, 862

lobubr. 861
Mastodvnia, 863

Mastoid suppuration, operation for, 575
MattresH-suture, 673

Maunsell's method of circular enterorrhaphy,
684

operation for intav^usception, 694
Maxillary antrum, inflammation and abscess

of, 596
Maydl's operation, 694

McBumey's method of compressing iliac ar-
tery in amputation at hip-joint, 837
of reducing shoulder-joint dislocations

with fracture, 455
removing vermiform appendix, 670

point, 648, 652
McCormick's operation, 530
McGill's operation, 837
McGuire's operation, 837
Mclntire's splint, 394
Mediastinum, abscess of, 101
Melanotic cancer, 236

sarcoma, 228
Menard's method of treating delayed tuion
of fractures, 341

operation for spinal caries, 588
Meniere's disease in syphilis, 195
Meningitis, tubercular, 559
Meningocele. 541, 577
Meningomyelocele, 577
Mercurials, 69
Metastasis in the dissemination of sarcoma,

237
Metastatic abscess, 99
Metatarsalgia, 536

MetschnikofTs theory of phagocytosis, 34
Microbes, 17. 18

antagoni<(tic, 36

oi suppuration, ^7

placental transmission of, 36
Microcephalus, 540
Micrococcus, 19

prodigiosus antagonistic to anthrax, 179

pyogenes tenuis, 38
Micro-organisms, 17
Microphyta, 18

Micrmcopic test for blood in urine, 764
Microzoaria, 18
Micturition, frequent, 767
•• Middle lobe." 722
Migration of cells in inflammation, 52
Milk abncess, 99
Milzbrand. 178. See Anthrax.
Miners' eloow, 515
Mixed infection, 36

with chancer and chancroid, 188
Mixter's apparatus, 761

cannula in tubercular adenitis, 155
Mobile kidney. 768
Moist gangrene, 119, 134
Mole, 266

excision of, 217
Mollities ossium. 320. See Osteomalacia.
Molluscum fibrosum, 216
Monococci, 20

Monsel's »alt in hemorrhage from small in-
testine, 271

solution in hematemesis, 271
Monteggia's dislocation, 467
Moore s dressing for fracture of clavicle,

360
Morbid growths, 209-239
Morbus coxx, 411. Sec Tuberculosis 0/ hip-
joint.
senilis, 428

Morbus coxariiis, 411. See Tuberculosis 0/

hip-joint.
Morphea, 217
Morris's measurement, 385

method of lumbar nephrectomy, 781
Mortification, 119
Morton's disease, 526
Mother's marks, 335
Motile bacteria, 17
Moulds, x8

Mouth, cleansing of, 45
Mucopus, 95
Mucous membranes, syphilitic affections of,

, »94

patches in syphilis, 194
treatment of, 203
Mulberry calculus, 791
Mtiller's law, 209
Multiple incision, 64

puncture, 64
Mummification, 122

Murphy button, use of, in gastro-enterostomy,
681
in intestinal anastomosis, 683
Murri, hydrophobia antitoxin, 35
Miiscae volitantes in hemorrhage, 959
Muscles, atrophy of, 305

contractions of, 509

degeneration of, 505

dislocation of, 509

healing of. 86

hernia of, 509

hypertrophy of, 505

o&sification of, 506

rupture of, 508

strain of, 507

tumors of, 506

wounds and contasions <^, 507
Muscular rheumatism, 504
Myalgia, 504

symptoms of, 504
. treatment of, 504
Mycetoma, 19
Myomata, 233

intramural, 933

submucous, 333

subserous, 333

treatment of. 333
Myositis, infective, 505

ossificans, 506
Myxedema, 743

Myxoma of mammary gland, 864
Myxomata, 220

treatment of, 221
Myxosarcoma, 320, 329

Nail2, affections of, in syphilis, 19s
Nasal bones, fracture of, 34a

polypi, 321
Necessity, triangle of, 393
Neck, anatomy of, 391

triangles of, 391, 793
Necrosis, acute, 311

central, 315

in ulceration, 11 1

of bone, 314

symptoms of, 316

treatment of, 316
N^laton's dislocation. 473

line, ascent of great trochanter aboTe, in
intracapsular fracture of femur, 384

porcelain probe, 172
Neoplasms, 209
Nephrectomy, 781

abdominal. 782

for mobile kidney. 770

for sarcoma of kidney, 229

for tuberculosis of kidney, 779

902

INDEX.

Nephrectomy for voundcd kidney, 772

nr wounds of kidney, 267

in renal hemorrhage, 371

lumbar, 781

partial, 783
Nephrolithotomy, 774, 780
Nephropexy. 783
Nephrorrhaphy, 783

for mobile kidney, 770
Nephrotomy, 779
Nerve, healing oT 86

in6ammation of, 527

-Mretching, 531

-suture. 530
Nerres, contusion of, 530

diseases cf. 527

operations u(>oa. 530

pres-^ure upon, U9

punctured wounds of, S90

section of. 53S

symptoms cf. 539

treatment of, 539
Nenrous diseases as pretfispoftiog to
326

sclerosis from syphilis, 198

syphilis. ic)9
Ncrvou:ii>cs« of bladder. ;
Netiber's plan ibr creatms

Neural|na. 538

intercostal. 504

of joints. 431

of stumps, treatment of, $>(

treatment of. 431
Neurasthenia, traumatic. 5S9
Neurectasy. 531
Kenrectoay. 553

of ialcTicr dental nerre*. 533

of infira-orbital oerre. 533

of supra-orbital ncrre. 533
Neuritis. 537

in syphUt^. 199
Nrurj^rrma. 2-14
Neur,-=ijili. i2\

pV\i' '-n. *r4

trea:~i-r: . •'. -^4
Ntur.^;vAri.> : . u-.cr. X17
Ncur.-fa:^v: inr.n: *. 4^
Neur~rr^jp-n> . 5?-^
Nc-ur^:-rr.y. 151
Noo:>i '.:jv=a. r:^
Ne\ v^.;p»- ri-i. r:4
N«fv;:>. :x=;^>*:.,- r;^
N;v, iiJ.T V .reru: '. 5x4

^ rT"-?. cv ■»t^ ^i. i ?■»

■ >

'^\-!

r*jr-t > C;>ri>? -

:::.>;•*

OnuGATX-ACKOBic bacterii

parasites. 19
Obstructed bonia, 706
Obstruction of intestine, 639. See ImUstmml

Obturator benua, 813
Occipital artery, licuion o^ a9t

triangle. 393
Odoniomata, 319

treatment of. sao
O'Dwycr's operation. 604
Ogstoo's operation, 476
Oidium albicans. 18
Omental graft. 674
Omphalectomy. 705
Onychia. 74a

in syphilis. 195
Oophorectomy for tttcrine ■jOMili, S23
Operation. Abbe's, 633

Adams's. 477

Bassmi's. for inguinal berma, 703

Bigek>w's, Soi

Brandt's, of stoaucb-rccfti^ 66«

Cock's. 830

Cripp's, 780

Esuander's 610

Fcrgossoo's, 616

for mastoid suppmntion, 575

for spina faiMa, 594

for ▼aiioocde, 374

for Tarix of Iqg, 374

Grant's. 47*

Halsted's. for cancer of faRnst, tGB, Kg

Haneke-Mikniicz, 639, 674

HoCa's. 503

Rraske's. 730

Lannekngue's. 541

Langcsbcdc's. ^4

Lorenz's. 503

Loreta's. 639. «74

Macewcn's. 475
for inguinal hemia, 701

Ma-.as«<I!'*. 694

Ma> il'f'. 6^

M:C:<-r::ck's. -y>

i»'I>*vrr*s. 604

:f FatTic:-* for fe^«ral ber&ia, 706

« ^r:-c'*. 4^^

:c iro:r«i»e=. 666

:e "-ary-iLx isi rrichea. ^m
ca **;-L_ Ar>i traia. 571

rj= vi-<-^aj- system, t^a

• ♦wtr *. >rT cjeft of haro palate, i^^

Pirkcrs. «i4

rrt^vira: 'rcfe. Jcc. 45

Sr-.r >. icr focal &&znU, 094

Tru«- 4.. 4^

V , ». r-jLr-T:*>. i.»r

Wr --Sod*. *:-
Wr ::.,£: =

'•^ 'tr.:. =. i. ir:<-»:rri«al. iicaULKut of. ia

v^.^r''-e:ojs :a tecazss^. X44

v>-7--c-.T» « :t trtaisss, 145:

- 5»

INDEX.

903

Ossifluent abscess. 99
Osteitis, 309

purulent, 313

suppurative, 313. See Caries.

symptoms of, 310

treatment of, 311

tubercular, 154, 313
Osteo-arthritis, 463. See Artkriiu de/or-

mans.
Osteo-arthopathic hypertrophiante pneu-

mique, 42^
Osteocopic pains in syphilis, 195
Osteomalacia, 330

symptoms of, 320

treatment of, 320
Osteomata^ 218
Osteomyelitis, acute diffuse, 317

as a cause of necrosis, 315

chronic, 319

of vertebrae, 579
Osteoperiostitis, 310

diffuse, 311

symptoms of, 310

treatment of, 3x1
Osteophytes in hereditary syphilis, 207
Osteoplastic periostitis, 31a

resection of skull, 57a
Osteosarcoma, 229
Osteotome, 475
Osteotomy, 475

cuneiform, 475, 477

for bent tibia, 477

for foulty ankylosis of hip-joint, 477
of knee-joint, 478

for genu valgum, 475

for Hallux valgus, 479

for knock-knee, 475

for talipes equinovarus, 479

for talipes cquinus, 480

for vicious union of fracture, 479

linear, 475, 477

longitudinal, for osteitis, 311

of shaft of femur below trochanters, 478

mallet, 475

through neck of femur, 477
Ovaries, removal of, in osteomalacia, 320
Overlapping of fragments in fracture, 328
Owen's operation tor cleft hard palate, 617

for double harelip, 615
Oxycyanid of mercury, 29

Pacmvmbningitis, S57

externa, 557

interna, 558
haemorrhagica, 558
Paget's abscess, 99

disease, 2^4, 427. See Arthritis dfformans,
of nipple, B63
Painful ulcer, 116
Palmar abscess, 101, 511

pad in hemorrhage from palmar arch, 264
Pancreas, cysts of, 66$

hemorrhage from. 664
Pancreatitis, acute, 664
" Papering " of mastoid cavity, 576
Papillomata,23i

treatment of, 231

villous, 231
Papular syphilides, 10;^
Papulosquamous sypnilides, 193
Para-appendicitis, 651
Paracentesis auriculi, 274

pericardii, 274

thoracis, 608
Paralysis, crawling, 592
Paraphimosis in gonorrhea, 816

treatment of, 821
Parasites, facultative, 19

Parasites, obligate, 19
Parasitic bacteria, 19

origin of tumors, 211
Paratoloid, 157
Paratrimma, 130
Paresis from syphilis, 198
Parker's oblique incision, 670

operation, 494
Paronychia, 513

in syphilis, 19c
treatment of; 203
Passive hyperemia, 4^^
Pasteur's preventive tnoculations, 34, 35

vibrione septique, 41
Patella, fracture of, 395

wiring of, 483
Pelvis, fracture of, 355
Penis, amputation o^ 833

cancer of, 833

fracture of, 833

p;angrene of, 833

injuries of, 810
Peptic ulcer of stomach, 636
Perforating ulcer, 117
Peii-appendicitis, 651
Periarteritis, 244
Periarticular edema, 407
Pericardial effusion, 240
Pericarditis, purulent, treatment of, a40

traumatic, 240
Pericardium, diseases of, 239

upping of, 274
Perineal bruises, 8zo

section. 830
for hemorrhage from prostate, 270
Perinephric abscess, xoi, 776
Perinephritis, 775
Perineum, bruises of, 810
Periosteal bridge in simple fracture, 332
Periosteum, inflammation of, 3x0, 3x1

nodes of, 311

slitting of, for osteitis, 31 X
Periostitis, 310, 311

chronic, 311

diffuse, ^it

in syphilis, X95

osteoplastic, 312

simple, acute, 310, ^zz
Peritoneal tuberculosis. 153
Peritoneum, rupture ot, €^^

toilet of, after celiotomy, 667
Peritonism, 627
Peritonitis, 65^

diffuse, septic, 85S

fibrinoplastic, 6s5

plastic, 655

suppurative, 656

tubercular, 657
Pernio, 738

Peroxid of hydrogen, 27
Pes cavus, 525

planus, 528
Petit's tourniquet, 843
Phagedena. 129

differentiation of, from chancer, 189

sloughing, 125

treatment of, 832
Phagedenic ulcer, 1x2, X17
Phagocytes, 33
I Phagocytosis, 33
Phenate of cocain as an anesthetic, 735
Phimosis, 833

in gonorrhea, 816
treatment of, 82Z
Phlcbectasia, 241
Phlebectasis, 241
Phlebitis, 240

from fracture, treatment of, 338

904

INDEX,

Phlebitis, symptoms of, 241

treatment of, 341
Phlebotomy, 275

in inflammation, 73
Phlegmonous abscess, 98

erysipelas, 143

suppuration, 96
Photophobia, 61
Phthisis, syphilitic, 198

Physiological activity as a cause of sarcoma,
211

decline as a cause of cancer, 3ii
Pick's table of dislocations of shoulder-joint,

450
Pticher on treatment of Colles's fracture, 380
Piles, 342, 713. Sec Hemorrhoids.
Ptrogoff's amputation at ankle-joint, 853
Placental transmission of bacteria, 3(3
Plaster-of- Paris bandage, 758
Plastic infiltration, 53

inflammation, 52

lymph, 92

surgerv. 759
Pleura, diseases and injuries of, 605
Pleurisy, rest in, 62

tubercular, 154
Pleuritic efl'usion, 605
Pleurodynia, 504
Plexiform angiomata, 326

sarcoma, 239
Plugging of nares for epistaxb, 268
Pneumococcus antagonistic to anthrax, 179
Pneumotomy, 607

for abscess of lung, 61 1
Pointing of abscess, 98

of pus, 95
Points douloureux, 58
Poisoned wounds, 174
Polydactylism, 521
Polyps, 320

flesh V, 222

nasal. 222
Popliteal artery, ligation of, joa
Port- wine stains. 226
Postfebrile j;.ingrcMe. i ^i
'• P.ist-ojKT.ition rise." 83

Po>tpharyni;<^«*I iibscess, 107
Pot.i«ih so.ip, .vj
Potl's di«;e.»se. 3S3. 5S6

f«.»rcihlc corixction in, 587
svmploms of. «iS4
fracture. 41^2
gangrene. t^>
Poulncc. antiseptic. 166, 167
Precentral sulcu>. 53S
Pre|v«rations for an operation, 44
Pres^iure in hemorrhage. 267

uvv->n nerve>. 520
PrevoTi:ive inv.H-ulation, 34

trephining. 5";i
Primary intection, 36
syphi^iis. aS6
union. S^
Pfvvtotomy for stricture of rectum, 7ig
Profeia's immunity against syphilis, 1S5
Prvlapsc v^f anus and nrctum, 717

tre.iimenl ot. 71S
Pro!ap>i:> an:. 717

recti. 7:-
JVv^j>eri;v^pea! hernia. 713
Prc^tate gland. aS^ce^s of. from gODorrhea.
trratment .^!. S-'i
hypvrrtr.^phy ot. ^=54
pr.>talect. my f^r. S;-
syr'.p'.oms of. > 55
treatment of. S;5
Prv^st-ttectomy for hypcrtr^^phy cf prv»tate.

Prostatic abscess, xoi

Prostatitis, acute, from gonorrhea, treatment
of, 821

chronic, from gonorrhea, treatment of, 83a
Protective inoculations, 34
Proteus vulgaris, 41
Protonuclein, 39

as a wound dressing, 166
Pruritus of anus, 724
P ^eudofluctiuttion of lipoma, 314
Psoas abscess, 99, 107, 109
Psoriasis in syphilis, treatment of, 203
Psorosperm of Darier, 313
Psorospermosis, 312
Psychical traumatism, 590
Ptomains, 32
Ptosis in syphilis, 199

Ptyalism, acute, from syphilitic medication,
203

from use of corrosive sublimate. 35
Pudic artery, internal, ligation of, 308
Pulmonary phthisis, surgical treatment of.
608

tuberculosis, 153
Pulpy degeneration, 408
Pulsating goiter. 745
Pulse in shock, 163
Puncture, bloodletting by, 64

lumbar, 543, 595

multiple, 64

of spinal meninges, 595
Punctured wounds, 167

" Purse-string" suture in perforation of kid-
ney, 771
Purulent infiltration, 96

pericarditis, 340
Pus, " aseptic," 93

-corpuscles, 94

forms of, 94

microbes, 37

•serum, 94
Pustular syphilides, 193
Pyelitis, 775
Pyelonephritis, 775
P>cmia, 138

arterial. 139
Pyemic abscess, 99
Pylorectomy, 675

for cancer of pylorus, 337, 636

for pyloric stenosis, 639
Pylor.tplasty. 674

for pyloric stenosis, 659
Pylorus, digital dilatation of, 674

excision of, 675

sten.*sis of. 638
Pyogenic cocci, 20

microbes, 37

organisms as causes of osteomyelitis, 317
Pyonephrosis. 777

j Qi'iLT suture. 673
i (Quincke's lumbar rmncrure. S9S
fr hydrocepaalus. 543

K ABIES. I So See Hydro^k^^im.
Radial artery, anatomy of, 281

inc:si<>n. 4-31

ligation of. 2S1. See Ugxticm.
Radiograph, 872
Radj>h-t'racture. 333
Radian, fracrare of. 375

subluxation c! head of. 457
Ra:!»av spine. tSo
Ran :la; ti8

Ra:t':esr.ake bile in treating snake4iite, 178
Ra»h Je mallet fcr c^teotv^my. 475
Ray-'urgus. i?;
Rayr^;:j':» gangmae, xa6

INDEX.

905

Reactionary hemorrhage, aja
Rectum, cancer of, 720

cleansing of. 44

diseases and injuries, 713

excision of, 720

foreign bodies in, 791

gonorrhea of, 823

prolapse of 7x7

stricture of; 7x9

ulcer of, 7x8

wounds of, 721
Recurrent hemorrhage, 279
Red thrombus, 133
Reducible hernia, 700
Reduction of fracture, 335
Reei^icnot in ligation, 280, a8x
Regurgitation in shock, 163
Reid, method of rapid pressure in aneurysm,

253
Relaxation in inflammation, 63
Reminders in the causation ofsyphilis, 185

in intermediate period of syphilis, X97

treatment of, 205
Removal of Gasserian ganglion, 533
Renal calculus, 772
symptoms of, 773
treatment of, 774
Repair, 82
Resection of intestine, 68t

of rib, 610

of sacrum, 720
Residual abscess, 99
Resolution of inflammation, $5
Retardation of circulation, 50
Retention of urine, 784

from enlarged prostate, treatment of, 787
from gonorrhea, treatment of. Sax
Retinal anemia from shock, 163
Retinitis in syphilis, i^
Retrenchment in plastic surgery, 760
Ketrodusion, 262
Retropharyngeal abscess, 107
Reverdin's method of skin-grafting, 760
Rhabdomyomata, 22a
Rheumatic arthritis, 425

gout. 437. See Arthritis tU/orman*.
partial, 428
progressive, 429

torticolliii. 504
Rheumatism, acute, 425

chronic, 425

gonorrheal, 423

muscular, 504
Rheumatoid arthritis, 426. See Arthritis de'

/orntans.
Rhigolene, anesthesia by, 734
Rhinoplasty, 763
Rhoad's apparatus, 447
Rhodius's case of lipoma, 214
Rib, excision of, 499

fracture of, 349

resection of, 610
Rickets. X58

a predi.^posing cause of fracture, 326

congenita], 158

treatment of, 159
Ricord, glandulx Pleiades, x^o
Ricord's method of amputating penis, 833
Rider's leg, 508
Rifle bullets, wounds by, 169
Risus sardoniciis in tetanus, 144
Robson's treatment of spina bifida, 578
Robson's decalcified bone bobbin, 685

opernticm for meningocele, 542
Rodent ulcer, 117, 235
Roger and Charrin's scrum, 142
Rnlandu's fissure, location of. 535
Rontgen rays, employment of, 871

Rontgen rays in diagnosing fractures, 331
Rosenthal's test for blood in urine, 764
Roseola of syphilis, X92
Round-cell sarcoma, 228
Rubber-dam in dressings, 47, x66
Run-around, 742
Rupia, 193

in tertiary syphilis, 197
Rupture, 69^^. See Hernia.

ot abdominal wall from contusion, 627

of bile-ducts, 631

of gall-bladder, 631

of intestine without external wound, 699

of liver, 631

of muscle, 508

of peritoneum, 627

of a sinus, 549

of spleen, 631, 665

of stomach without external wound, 698

of tendons, 5x0

Sabanbjepp's amputation of leg, 856
Saccharomyces, x8

capillitii, 18
Sacro-iliac disease, 410
Sacrum, fracture of, 357

resection of, 720
Saddle-back, 583
Salicylic acid, 29

Salivation from mercurial treatment of syph-
ilis, 202
Salol, 29

Sanderson, definition of inflammation, 48
Sanious pa^, 95
Sapremia, 136
Saprophytes, 19
Sarcina, 20
Sarcocele, syphilitic, X96

treatment of, 203
Sarcoma, alveolar, 228

black, 228

clinical, varieties of, 228

giant-cell, 228

hemorrhagic, 229

melanotic. 228

mixed-cell, 228

myeloid, 228

of^bone, 309

of mammary gland, 865

plexiform, 229

round-cell. 228

spindle-cell, 228
Sarcomata, 227

species of, 228

treatment of, 229
Sardonic smile in tetanus, 144
Saviard, aneurysm-needic ol', 279
Sayre's adhesive-plaster dressing, 360

extension for knee-joint disease, 4x9

knee splint, 418, 419

jury-mast, 587

long splint, 416

plaster-of-Paris jacket, 587
Scalds. 736

of glottis, 737
Scalp, diseases of, 539

-wounds, 543
Scapula, excision of, 499

fracture of, 362. See Fracture.
Scarification, 64
ScaHet fever, surgical, 90
Scarpa's triangle, 303
Schede's method of treating varix of leg, 274

operation, 611
Schizomycetes, 18
Schleich s fluid in operation for varicocele, 275

new jjeneral anesthetic, 733

solutions for infiltration-anesthesia, 735

rJ"

luf cftreating disk>>
ir -iai:aif3cr-jciBC, 453
irrnr iridic far tracture of femur.

r-'-r - .msTcr-

.rrniijj

■.ST-A.

366

I ^ 1 .:5.

fer administering chl<»t>-

ferfakwd, 763

u'Skr-oued carrinomata, 33s
748

2f jsacp. 751
v'saoMkr.754
^ansb. 75D

of. 176

:«*ia. 577
iTcracons for, 594
£r?a'="^€Pt of, 578

rsiTU 3k: rd. compression of. 593
;^r-:-u>sion of. 591
rictusion of, 591
r-rraturcs, 580
-a:cnds of. 501
S^ii-e. ongenital deformities of. 577

r^crjres and dislocations cf. 5^

:-perations on. 594

*=jgery of, 577

rjnors of, 578
^JirilJum. 19
Sp>en, abscess of, 665

mpture of, 631. 665

vanderine, 6(65

wounds of. 665
Splenectomy, 666, 698

for wounas of spleen, rf-
Splenic fever, i68. See -■(•cii-ijr.
Splenopexy, 666
Splint. Agnew's. yf:

anterior angular. :x "Hizains icir ^buw-
joint, 371

Bond's, 379. 3S0

Dupuytren. 403

Fox's, for clavkae afc

Gordon's pi«tn-«iua«*r. ^70

Hodgen's. 305

internal angular. .:a<

in fracture orf Vunmfl»» flft

Jones's nasAl. .^^^^

Levis's, 379, 4»»:

Mclntyre's, 31a

Sayre't, ^

INDEX.

907

Splint, Sayre's, for knee, 418

Thomas's, 416

Watson's swing-splint. 496
Splinter-fracture, 322
Spondylitis, 583

deformans, 428
Sponges, gauze. 45

marine, perforation of, 47
Spongiopilin, 71
Spontaneous keloid, 2x7
Spores, 21
Sporulation, 22
Sprain, 432

diagnosis of, 433

fracture, 43^

prognosis of, 433

symptoms of, 433

treatment of, 434
Springfield rifle, velocity of bullet of, 169
Spurious hydrophophia, 181
Ssabanejew- Frank operation for gastrostomy,

679
St. Anthony's fire. See Erysipelas.
Stagnation in inflammation, 51
Staphylococci, 20
Staphylococcus cereus flavus, 38

epiclermidis albus, 38

flavescens, 38
pyogenes albus, 38

aureus, 20, 37
a cause of acute diffuse osteomyelitis,

3«7
as a cause of boils, 739

citreus, 38

Staphylorrhaphy, 616

Stasis of blood in inflammation, 51

Stay-knot, 281

Stenosis of cardia, 637

of pylorus, 638
Stercoraceous abscess, 99
Sterilized gauze, 46

Sternal symptom in carcinoma of breast, 867
Sternberg's theory of phagocytosis, 34
Sternum, fracture of, 353
Slings of bees and wasps 176

of insects, 176
Stitch-abscess in surgical fever, 89
Stomach, cancer of, 634

-orifices, cicatricial stenosis of, 637

peptic ulcer of, 636

-reefing. 681

rupture of, without external wound, 628
Stone in bladder, 790. See Vesical calculus.

operation for, in women, 807
Strain-fracture, 322

of a muscle, 507
Strangulated hernia, 707. See Hernia.
Strangulation of intestine, 639
Streptobacilli, 21
Streptococci, 20
Streptococcus articulorum, 39

of erysipelas, 38, 140
antagonistic to anthrax, 179

pyogenes, 38
as a cause of osteomyelitis, 317

septicus, 38
Stretching of sciatic nerve, 532
Stricture of esophagus, 620
cancerous, 623
cicatricial or fibrous, 620
treatment of, 622
of rectum, 719

of urethra, 823
symptoms and results of, 824
treatment of, 825

organic, catheterization in, 785

spasmodic, catheterization in, 786
Stromeyer's anterior angular splint, 421

Strongylus armatus as a cause of aneurysm

in horses, 248
Strumous abscess, 98

joint, 408
Slruve's test for blood in urine, 764
Stupe, 70

turpentine, 70
Styptics in hemorrhage, 263
Subasiragaloid dislocation, 471
Subclavian artery, anatomy 01, 288
ligation of, 288, 289

triangle, 293
Subcutaneous drilling and scraping for de-
layed union of fractures, 341

ligature tor varicocele, 225

tuoercic, painful, 2x6
Subcuticular suture, Halsted's, 42
Subdural abscess, 560

hemorrhage, 548, 549
Subluxation of head of radius, 457

of knee-joint, 470

of shoulder-joint, 450
Submaxillary triangle, 292
Submental triangle, 392
Subphrenic abscess, too, 657
Sugsillation, 160
Sunburn, treatment of, 737
Superficial abscess, 99
Superior longitudiiial sinus, location of, 539

maxillary bone, fracture of, 344
Supernumerary digits, 52X
Suppuration, 93

phlegmonous, 96
. symptoms of, 95
Suppurative fever, 89

tnecitis, loi
Sureery of the respiratory organs, 596

of the spine, 577
Surgical fevers, 87, 88

kidney, 777

scarlet fever, 90
Suture & distance, 531

continuous, 46
of dura, 575

Cushing's right-angled, 673

Czerny-Lembert, 673

Dupuytren's. 673

Gussenbauer's, 673

Halsted's, 42
mattress or quilt, 673

interrupted, of^ scalp, 575

{obcrt's, 673
.embert's, 672
of intestine, 671
Wolfler's 674
Suturing of^ annular ligament of wrist, 519
Swedish leech, 63
Sweet's apparatus for locating foreign bodies

by A'-rays, 876
Swelling in inflammation, 60
Sylvius' fissure, location of, 537
Syme's amputation at ankle-joint, 853
for ankiejoint disease, 420
incision for excision of scapula, 499
method of amputating leg, 855
operation of external urethrotomy, 830
staff. 830
Symmetrical gangrene, 126
Sympathetic abscess, 99

fever, 61
Symptomatic fever, 6x
Syncope, local, 126
Syndactylism, 521
Synovitis, 406
acute, simple, 406
symptoms of, 406
treatment of, 407
chronic, 407

J.VDEX.

TT-acrZLi. -Z^'TSi: -t '}' ^Y 3.

^■sj'ta- z.

XA«.

a» :a, xjx
:rf: lie

«7-a*:'r:s:4 3^ ^5

rT^u:9. r-azadcn. sSc, 196

rua :r .nngrtance of, aa6

a^^-vxruia arua K«rcunal Kreatment of, aao

4er7i;j:3iju;^ slccrs in, 197
*A_;i -rri-c-.CA in, 197
••irri.cs je!iir:>cs of. i^

=-:u»ai :r£C c::c^enital, 305

srsA-nms :t'. ^ primary »tagc, 199
jx ^einrnifary Ka(e. zco
uf --01171 mratajoi in the secondary stage

>--^»-««.-— . 191

^Kyeiia as a cause of brittleness 01

g< L-uy :m.id)txde. 577

of treating ankylosis, ^36
[s's sofaitioD for intrarenous injection,

V- »■

■r«::w-'^'.:> a. -je. 3JC

ri irjtomique. 282
.,fi- - ■'' -i::aJ artery in. 282
T **•?:. : r-.-'ir: pithy. 479
Tir*.- .-e-trra-e, 560
Tr-r -I M" rco.xois, 2»S
T;^ ji::c.a:: credtod of rhinoplasty, 763

ra.rjre":-ra;jus, 524
3.-:jL:T<o-Tarj». 524

r-- t --■ral^as. 524
ec. ^>var-s. 524
,-*ne"-t:ciy for, 479

.■<T-.-c:-=y for. 580
r-rj:r^=t of, 524

^ir*-5. ?^;. 524
Tirctr^ :- edetna. 91

:r -.i* reart -cavity, 274

:'"' percardiai sac, 274
Titzr-lx. bite of, 176
r-r-=CJkge of perineum, 758
!».<'« jLsputation through forearm, 848

±i.; -.= amputation of thigh, 856

c^tV>i o( amputating the arm, 849
ct laputating the leg, 8s4
TeCa=y>ccuists. 225
T«^Ar^^>e^^tatJC carcinoma, 236
Tcjcr>:c.-:c prohe, Girdncr's, 171
TcsL^rar^re after wounds as a danger-siguli

jt sb.>ck. 162
TcKporal artery, ligation of, 297

INDEX.

909

Tendon, healing of, 86

-lengthening, 5x8

suture, 518
Tendons, dislocation of, 509

rupture oi. 510

wounds of, 510
Tenosynovitis, 510
Tenotomy, 516

of tendo Achillis, 5x6

of tendons of peroneus longus and brevis,

517 ,

of tendon of tibialis amicus, 517
of tibialis posticus, 5x7
Terminations of inflammation, 90
Terrier's treatment of hammer-toe, 536
Tertiary syphilis, X97. iiec SxPki/ts.

syphilitic eruptions, X97
Testicle, excision of, 839

malplaced, 838

retained, 838

syphilitic aflfections of, 196
Tetanus, X44

antitoxin, X48

cephalic, 145

chronic, 145

diagnosis of, 145

head, 145

hydrophobic. 145

symptoms of, 144

table of diflferential diagnosis for, 146

treatment of, 147
Tetracocci, 20
T-fracture o( humerus, 371
Thecal abscess, 99
Thecitis, 510

acute, 510
symptoms of, 5x0
treatment of, 5x0

chronic, 51 x
treatment of, 511

suppurative, lox
Thiersch's method of skin-grafting, 361
Thigh, amputation of, ai6
Third intention, healing by, 85
Thomas's splint, 4x6

Thompson's diagnostic questions in diseases
of urinary organs, 767

divulsor, 826

evacuator, 805

lithotrite, 804

vesical forceps, 809
llioracoplasty, 610
Thoracotomy, 609
Thrombo-arteritis, X33
Thrombophlebitis, 133, 341

treatment of, 241
ThrombosiH, 133

in syphilis, 197

symptoms of, X33

treatment of, 1 33
Thrombus, antemortem, X33

causes of, X32

red. 133

white, 133
Thrush, 18

Thumb, amputation of, 848
Thymol. 29
Thyroid artery, inferior, ligation of, 290

extract in treatment of fibromata, 217
in treatment of goiter, 744

gland, atrophy of, 743
congestion of, 743
diseases and injuries of, 743
inflammation of, 743
wounds of, 743
Thyrotomy, 601
Tibia, fracture of, 400
Tibial artery, anterior, ligation of, 299-30X

Tibial artery, posterior, ligation of, 301
Tinnitus aurium,6x

in hemorrhage, 259
Toe-nail, ingrown, 743
Toes, amputation of, 850
Tongue, complete removal of, 619

partial removal of, 6x8

•tie, operation for, 618
Torpid shock, 163
Torsion in hemorrhage, 361
Torsoclusion, 263
Torticollis, 519

congenital, 520

rheumatic, 504

symptoms of, 520

spasmodic, 530

treatment o^ 530
Tourniquet, 843
Toxalbumins, 33
Toxins, 3X
Trachea, foreign bodies in, 600

operations on, 6ox

wounds and injuries of, 598
Tracheotomy, 6ox

for fracture of hyoid bone, 348

for fracture of laryngeal cartilages, 349

high. 603
Transfixion, 363

amputation by, 846
Transfusion, arterial, 378

of blood, 276

of saline fluid, 277
Transthoracic hepatotomy, X03
Traumatic carditis, 340

dislocations, 438. See Disiocationt.

fever, 85.

hysteria, 589

inflammation of brain and its membranes

557
neurastlienia, 589

pericarditis, 340
Traumatism, psychical, S90
Trendelenberg on method of treating varix of
the leg, 374

position, 667
Trephinine, 571

in extradural hemorrhage, 266

of bone for abscess, 212

the frontal sinus, 573
Treves's " dangerous area," 540

method of amputating penis, 833
of excision of scapula, 499

operation. 483
Triangle, inferior carotid, 292

occipital, 293

of election, 292
ligation in, 294

of necessity, 392
ligation in. 294

of the neck, 29X
anterior, 291
posterior, :i92

Scarpa's, 303

subclavian, 293

submaxillary, 292

submental, 292

superior c»rotid, 292
Triangular sling, 375
Trichiniasis, 506
Trichinosis, 506
Trichlorid of iodtn, 29
Trigger-finger, 52X

treatment of, 522
Tripper, 8x5. Sec Gonorrhea.
Trismus, 145

nascentium or neonatorum, 145
Trophic ulcer. 117
Tropical abscess, 99

INDEX.

911

Vagina, cleansing of, 44

Valcntine'ii method ofirrigation for gonorrhea ,

819
Valleix's points douloureux, 58
Valsalva, treatment of aneurysm, 250
Van Hacker's method of gastrostomy, 679
Van Hook's method of treating wouniu of
ureter, 772

operation, 783
Varicocele, 242, 841

open operation tor, 274

subcutaneous ligature for, 275
Varicose aneurysm, 255

lymphatics, 747

ulcer, 116

veins, 241
Varix, 241

aneurysmal, 255

of leg, operation for, 274

treatment of, 243
Vascular system, operations on, 274
Veins, inflammation of, 240

wounds of, 258
Vclpcau's bandage, 755

in forward dislocation of clavicle, 446
in fracture of clavicle, 359

rule, 533
Venae comites, 280

Venereal catarrh, 815. Sec Gonorrhea.
Venesection, 275

in inflammation, 73
Ventral hernia, 713
Verminous abscess, 99
Verruca necrogenica, 152
Vertebral artery, anatomy of, 289

ligation of, 289
Vesical calculus, 700
composition o\, 791
crushing of, 803
symptoms of, 792
treatment of, 793
Vicious uninn, treatment of, 341
Virchow's disease, 320

law, 210

sign. 207
Viscera, congestion of, in syphilis, 197
Visceral syphilis, 198
Volkmann's limit, 868

membrane, 106

operation, 840
Volvulu>, 639
Vomiting in shock, 163
Von Graefe's sign, 745

Von ZeissI, formula for treiitment of acute
cystitis, 795

Wagnbk's osteoplastic resection of skull,

572
Wandering abscess, 98

kidney, 768

spleen, 665
Wardrop's operation for aneurysm, 254
Warts, 231

in syphilis, 194

lymphatic, 747
Wasps, stings of, 176
Water-bath in inflammation, 71

on the brain, 559
Watson's plastcr-of-Paris swing splint, 496
Weavers' bottom, 515
Webbed fingers, 521
Weir, method of disinfecting operator's

hands, 43
Wens, 238
Wet cold in inflammation, 65

cups, 65
Wheelhoiise's operation of perineal urethrot-
omy, 830

White swelling, 154, 408, 4x8

thrombus, 133
White's division of syphilitic periods, 186

operation of bilateral orchidectomy, 838
for myoma of prostate, 223

rule for treating tertiary syphilis, 205
Whitehead's operation, 717

for removal of tongue, 620
Whitlow, 512. See Felon,
Wiring of bones for ununited fracture, 482

of fractured patella, 397

of fractures, 336

of ununited fracture of patella, 483
Witzel's method of gastrostomy, 678
WladimiroflT-Mikulicz operation, 420
Wolfler's method of gastro-enterostomy,68o

suture, 674
Wool-sac cocci, 20

-sorters' disease, 178. See Charium,
Wounds, 161

by cannon-balls, 171

bv small shot, 171

cleansing of, 165

closure of, 166

complications of, 167

constitutional treatment of, z66

contused, 167
of arteries, 257

dissection of, 175

drainage of, 166

dressing of, 166

gunshot-, 168

amputation for, 174
dressing of, 174
of arteries, 258

incised, 167
of arteries, 257

irrigation of, 163

lacerated, 167
of arteries, 258

local, phenomena of, 163

of abdominal wall, 632

of arteries, 257

of brain, 554

of chest, 606

of heart, 240

of kidney, 770

of larynx, 598

of liver, 658

of mucous membranes, 184

of rectum, 721

of spleen, 665

of tnyroid gland, 743

of ureter, 772

of veins. 258

poisoned, 174

punctured, 167
of arteries, 258

septic, 175

treatment of, 165
Wrist, dislocation of, 458

-joint disease, 421
excision of, 491
Wry-neck, 519. See Torticollis.
Wyeth's apparatus for hip-disease, 416

bloodless amputation at hip-joint, 857

A'rav apparatus in diagnosticating fractures,

330. 331
'• burn,'^ 874

employment of, 871

for discovery of^ foreign bodies in esophagus,

625
value of, in surgery, 874

Vbasts, 18

ZOOGLEA, 20

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Atlas of Operativ Surgery. By Dr. O. ZircKFRKANDL, of Vienna. Edited by J. Chalmers
DaCosta, M.D., Clinical Professor of Surgery. Jetterson Medical College, Philadelphia: Survjeon
to the Philadelphia Hospital. With 24 colored plates, and 217 text illustrations. c5loth,fo«°<^'

Atlas of Syphilis and the Venereal Diseases. Bv- Prof. Dr. Franz Mra^ek, of Vienna. Edited
by L. Boi/roN BANr.s, M.D., late Professor of Genito-Urinary and Venereal Diseases. NewVork
Posl-Gratluaic Medical School and Hospital. With 71 colored plates from original water-color?,
and 16 black-and-white illustrations. Cloth, I3.50 net.

IN PREPARATION.

Atlas of External Diseases of the Eye. By Dr. O. Haab, of Zurich. Edited bv G E
i)K ScHWKiNiT/. M.l)., Professor of Ophthalmology, Jefferson Medical College, Philadelphia
With 100 colored illustrations.

Atlas of Skin Diseases. By Prof. Dr. Franz Mrackk, of Vienna. W^ith 80 colored plates from
original walei -colors.

Atlas of Pathological Histology. Atlas of Operative Gynecology.

Atlas of Orthopedic Surgery. Atlas of Psychiatry.

Atlas of General Surgery. Atlas of Diseases of the Ear.

THE AMERICAN TEXT-BOOK SERIES.
AN AMERICAN TEXT-BOOK OF APPLIED THERAPEUTICS.

By 43 Distinguished Practitioners and Teachers. Edited by James C
Wilson, M.D. , Professor of the Practice of Medicine and of Clinical
Medicine in the JefTecson Medical College, Philadelphia. One hand-
some imperial octavo volume of 1336 pages. Illustrated. Cloth,
J7.00 net; Sheep or Half Morocco, gS.oo net. Solil by Subscripiion.
" As a vorlc either for study or reference il will be of great value 10 the pmctilicmer, u
it a TirlDBlly an exposition of such clinical Iherapeutics as experience has taught 10 t>e ol
tbe most value. Taking it all in all, no recent publication on therapeutics can be compared
with ibis one in practical value to tbe working physician." — Chicago Clinical RftHrui.

" The whole iield of medicine has been well covered. Ytit. work is thoroughly prac-
tical, and while il n intended for practitioners and students, it a a beiler book /or the genera]
practitioner than for the student. The young practitioner especially will find il extremely
suggestive and helpful.'' — The Indian Lancet.

AN AMERICAN TEXT-BOOK OF THE DISEASES OF CHILDREN.

By 63 Eminent Contributors. Edited by Louis Starr, M.D., Physi-
cian to the Children's Hospital, Philadelphia, etc.; assisted by
Thompson S. Westcott, M.D., Attending Physician to the Dispen-
sary for Diseases of Children, Hospital of the IJniversity of Pennsyl-
vania. In one handsome imperial octavo volume of 1190 pages,
profusely illustrated. Cloth, ^7.00 net; Sheep or Half Morocco,
jS.oo net. Sold by Subscription.
"This is far and away the best text -hook on children's diseases ever published in the
English language, and is certainly the one which is best adapted to American readers.
We coDgratolate the editor upon the result of his work, and heartily conuncnd it lo the
•ttention of every smdenl and practilioner. " — American Journal of Iks Medical Sciences.

AN AMERICAN TEXT-BOOK OF DISEASES OF THE EYE, EAR,
NOSE. AND THROAT.

By 58 Prominent Specialists. Edited by G, E. de Schweinitz, M.D.,
Professor of Ophthalmology in the Jefferson Medical College, Phila-
delphia; and B, Alexander Randall, M.D., Professor of Diseases
of the Ear in the University of Pennsylvania and in the Philadelphia
Polyclinic. Ready soon.

Bluitcated Catalogue oE the "American Test-Books"

I free upon applicatioi

4 Medical Publications of W. B. Saunders.

AN AMERICAN TEXT-BOOK OF GENITO-URINARY AND SIGN
DISEASES.

By 47 Eminent Specialists and Teachers. Edited by L. Bolton
Bangs, M.D. , Late Professor of Genito-Urinary and Venereal Diseases,
New York Post-Graduate Medical School and Hospital; and W.
A. Hardaway, M.D., Professor of Diseases of the Skin, Missouri
Medical College. Cloth, $7.00 net; Sheep or Half Morocco, $S, 00 net

This Imtest addition to the series of ** Americmn Text- Books '* it is coafidently believed will meet
Che requirements of both students andpractitioners, giving, as it does, a comprehensive and detailed
presentation of the Diseases of the Genito^Urinary Organs, of the Vener^ Diseases, and of the
Affections of the Skin.

Having secured the collaboration of well-known antliorities in the branches represented in the
■ndertaking, the Editors have not restricted the Contributors in regard to the particular views Kl
forth, bat have offered every facility for the free expression of their mdividual opinions. The work
will therefore be found to be original, ;ret txMnogeneoos and fully representative of the several depart-
ments of medical science with which it is concerned.

AN AMERICAN TEXT-BOOK OF GYNECOLOGY, MEDICAL AND
SURGICAL.

By 10 of the Leading Gynecologists of America. Edited by J. M.
Baldy, M.D.y Professor of Gynecology in the Philadelphia Polyclinic,
etc. Handsome imperial octavo volume of over 700 pages, with 360
illustrations in the text, and 37 colored and half-tone plates. Cloth,
$6.00 net; Sheep or Half Morocco, '$7. 00 net. Sold dy Subscription,

** It is practical from beginning to end. Its descriptions of conditions, its recommeo*
drntioos for treatment, and above all the necessary technique of different operadoos, are
deariy and admirably presented. ... It is well up to the most advanced views of tlie
day, and embodies all the essential points of advanced American gynecology. It is (ksdoed
to make and hold a place in gynecological litcrmture which will be pecoliariy its own."—
Medical Record, New York.

AN AMERICAN TEXT-BOOK OF LEGAL MEDICINE AND TOXI-
COLOGY.

Edited by Frederick Peterson, M.D., Clinical Professor of Mental
Diseases in the Woman's Medical College, New York; Chief of Clinic,
Nervous Department, College of Physicians and Surgeons, New York;
and Walter S. Haines, M.D., Professor of Chemistry, Pharmacy,
and Toxicology in Rush Medical College, Chicago. In Preparatioru

AN AMERICAN TEXT-BOOK OF OBSTETRICS.

By 15 Eminent American Obstetricians. Edited by Richard C. Nor-
Ris, M.D. ; Art Editor, Robert L. Dickinson, M.D. One handsome
imperial octavo volume of over 1000 pages, with nearly 900 beautiful
colored and half-tone illustrations. Cloth, $7.00 net; Sheep or Half
Morocco, §S.oo net. Sold by Subscription,

•* Permit me to i^ay that your American Text-Book of Obstetrics is the most magnificeot
medical work that I have ever seen. I congratulate you and thank you for this superb work,
which alone is sutticient to plac« you first in the ranks of medical publishers." — ALEXANDER
J. C. Skene, Prc/dscr cf Gyne^olo^- in the Long Island College Hospital^ Brooklyn^ iVJ'

** This is the most sumptuously illustrated work on midwifery that has jret appeared. lo
the number, the excellence, and the beauty of production of the illustrations it far surpasses
ever)* other lxx>k ujx>n the subject. This feature alone makes it a work which no medic*!
librar)- should omit to purchase." — British Medical Journal.

** As an authority, as a book of referenct, as a * working book ' for the student or pr*^'
titioner, we commend it because we believe there is no better.'* — American Journal of t^
Afedi<\jl S. iWi.r.f .

Dhsstratcd Otaloeue of the "^American Tezt-Boob^ lent frae tspoa appttcatioo.

Medical Publications of W. B. Saunders. 6

AN AMERICAN TEXT-BOOK OF PATHOLOGY.

Edited by John Guit^ras, M.D., Professor of General Pathology and
of Morbid Anatomy in the University of Pennsylvania ; and David
RiESMANy M.D., Demonstrator of Pathological Histology in the
University of Pennsylvania. In Preparation.

AN AMERICAN TEXT-BOOK OF PHYSIOLOQY.

By I o of the Leading Physiologists of America. Edited by William
H. Howell, Ph.D., M.D., Professor of Physiology in the Johns Hop-
kins University, Baltimore, Md. One handsome imperial octavo
volume of 1052 pages. Illustrated. Cloth, {6.00 net; Sheep or Half
Morocco, $7.00 net. Sold by Subscription,

** We can commend it most heartily, not only to all students of ph3r5iology, but to every
physician and pathologist, as a valuable and comprehensive work of reference, written l^
men who are of eminent authority in their own special subjects.'* — London Lancet.

'* To the practitioner of medicine and to the advanced student this volume constitutes,
we believe, the best exposition of the present status of the science of physiology in the*
English language.*' — American Journal of the Medical Sciences.

AN AMERICAN TEXT-BOOK OF SURGERY. Second Edition.

By 13 Eminent Professors of Surgery. Edited by William W. Keen,
M.D., LL.D., and J. William White, M.D., Ph.D. Handsome
imperial octavo volume of 1250 pages, with 500 wood-cuts in the text,
and 39 colored and half-tone plates. Thoroughly revised and enlarged,
with a section devoted to ** The Use of the Rontgen Rays in Surgery."
Cloth, $7.00 net; Sheep or Half Morocco, {8.00 net. Sold by Sub-
scription.

•* Personally, I should not mind it being called THE Text- Book (instead of A Text-
Book) , for I know of no single volume which contains so readable and complete an account
of the science and art of Surgery as this does." — Edmund Owen, F.R.C.S., Member of
the Board of Examiners of the Royal College of Surgeons ^ England,

** If this text-book is a fair reflex of the present position of American surgery, we must
admit it is of a very high order of merit, and that English surgeons will have to look very
carefully to their laurels if they are to preserve a position in the van of surgical practice.*'—
London Lancet.

AN AMERICAN TEXT-BOOK OF THE THEORY AND PRACTICE
OP MEDICINE.

By 12 Distinguished American Practitioners. Edited by William
Pepper, M.D., LL.D., Professor of the Theory and Practice of Medi-
cine and of Clinical Medicine in the University of Pennsylvania. Two
handsome imperial octavo volumes of about 1000 pages each. Illus-
trated. Prices per volume : Cloth, $5.00 net ; Sheep or Half Morocco,
$6.00 net. Sold by Subscription.

« I am quite sure it will commend itself both to practitioners and students of medicine,
and become one of our most popular text-books/' — Alfred Loomis, M.D., LL.D., Pro-
fessor of Pathology and Practice of Medicine^ University of the City of New York.

" We reviewed the first volume of this work, and said : * It is undoubtedly one of the
best text-books on the practice of medicine which we possess.' A consideration of the
second and last volume leads us to modify that verdict and to say that the completed work
is in our opinion the best of its kind it has ever been our fortune to see." — New York Medical
Journal.

Illartraled Cttalogue of the ^American Text-Books^ sent free upon appUcatiofu

4 Mediesd PmMiaitMms of IT. B. SsoDMf ers.

AS AMESnCAS YEAMt-BOOK OF JUEDtONE AND SLK0ERY.

A 'i»srrr ' '^-^r ir 5*uirL-fi: I. .%^^ad 1:11 i A-rrrcri^iriTe Opinion in al
^rs«i:r:« 'J. M-t;i.i:-ze izii imi'^r /. imr^ fr:ci joiimiis, monographs
asri i*i--:cc«Li -J. ±e "fa: tx Amiir.iar. ard Foreign aathors anc
.^.-j-wt. .t3r.-,rj- 'Litlecrsd ird iri'u^-iii, Titi crtrical editorial com
aier-ts. 17 -riiT-tinc yTLirrxjxz, JCfica^isQ irii i^acriers. osder the geneiai
eiiT-^r-il :>.arr^ :c G £.:&:;£ K- '>:clz:. M. D. C>se rLULdsome imperial
fXXk''* ~ '_*ir.ie sc acoir :i-c la^-a. U-i53r3i in stvle, size, and
y-^enl nix.*-:- -viii riu* --.Vxer-jiiz. T*xi-Bcok" Scries, Cloth,

•■ It ■? ::r:ini.r -i-: trrt-.-r -r^itft T, nfimr* ii»-«!C — rii; rtsearci aad hsdastrr of the distin-
^psarjtfi 'jarjt f' *■: irm -wii rn Ir >.ixii: xjft *3i; *•£**: ji lie iernce oc the Year- Book, or the
w*axa. ir.ii i.:nn«iar.i:» j -.ie Luicrbocxn:! n *i-^ iiicartxisit o« scienoe that have been
^Smrgii -v-.r::i'^ -.{ ir..\,-j^.-:. I: s Ttiu-n 3ii:r; ±ar x sere cccnpilation c^ abstracts,

irx. iii ^a>:i i*^-*.i n - t-nnsf.*! 1: «ir«rRaes!i isii iciie cuocrihabcrs th« reader has the
4idrBX>c» -r i.-r-o;- rrT_»:iL ir.fmnrTr.irao asti txi«>iCi:c^ . . . proceeding from wrileis
foT.-y -.-salirisri -.: -•^:m -ti-j-v^ 'a&As, It is <=rcaC3callT a book which should find

a pt*iit :i r»-^ sus-.ra. _bnr7. mil is 31 lereral rs^ipects more nscftil than the famoos

ANDERS* PRAC11CE OF MEDICINE. Second Editioa.

A Text-Book of the Pnctice of Medidiie. By James M. Andeks,
M.D-, Ph.D.- LL-D.. Proasssor of ibe Practice of Medicine and of
C'.irAcjil Mecicin*. Medico-Cainrsical CoUese, Philadelphia. In one
hand=o:r-e ocrav^ To.'zmt of 12S7 pages, mlly illustrated. Cloth,
5^. CO ce: : S'zteo or Hilf Morocco. Jo.^o net.

*• It :i in *'»r«l>=£ ":c«:i..— cc&rise, cjmLiihe.s&lfe, thoroogfa, and up to date. It is*
crc'i:: :; tz'i : :cr. => r^ Lun •"a:. it U a credi: :o th< jrcfession of Philadelphia — tons."
TAy=_- •-. ''''.'-• ?•. .'"" •> ;•';*' .*vf /^"^.ri.r ."" .V/- :-■:»:/ ^«^ Clinual Medicine^ Jeffcricn

•• ! ::r.T it: Tr Anitr? •:<:•: ri^x :"*5 :bc "i<<: !ite wc^k on Medical Practice, bat br
far :h-? 'nv. *.- u :.i- t--r :ct-: t^::: -r~*i I: is crrci*^, systematic, thorough, and fully up
to 'iate I', tvtn '.--:: I : r.?: itr :: a crt-a: crei: :o '>:<h the author and the publisher. "—
A. C. «_ . V. : L«. rii'.VAlTL- P^ir.^m: :'':is /^:jt^'x: //.■njf.-/\j'iu' Me Jical Association.

ASHTONS OBSTETRICS. Fourth Edition, Revised.

Essentials of Obstetrics. By W. E.\sterly Ashton, M.D., Pro-
fessor of Oyr.eco".c.:y in the Mecico-Chirurgical College, Philadelphia.
Crownroctavo. 252 pages; 75 illustrations. Cloth, $1.00; interleaved
for r.ote<, 51.25.

[See S.iurJc-rs' Question- Compemis, page 21.]
** Em>-::e> ihr wh ".c >u': tc: in a nut-^he'il. We cordially recommend it toourrtjd-

• • • • If" ■ ■

BALL'S BACTERIOLOGY. Third Edition, Revised.

Essentials of BacterioIog>' ; a Concise and Systematic Introduction
to thtr Study c.f Micro-organisms. By M. V. Ball, M.D., Bacteriol-
o^ri-t to St. A.:nes* Hospital, Philadelphia, etc. Crown octavo, 21^
])agos : 82 iilv.-trations, some in colors, and 5 plates. Cloth, 51.00;
interleaved for notes, -51.25.

[See X/.v'/./Vrjr' Question- Compendsy page 21.]

" Thr- studfiii »i J r.utiti. r.tr can readily obtain a knowledge of the suhject from a p<^
of ihi- book. The ir.u-;r.i:\i.- are clear and satisfactory." — Medical Record, New ^^

Medical Publications of W. B. Saunders. 7

BASTIN'S BOTANY.

Laboratory Exercises in Botany. By Edson S. Bastin, M.A.,
late Professor of Materia Medica and Botany, Philadelphia College of
Pharmacy. Octavo volume of 536 pages, with 87 plates. Cloth, $2.50.

" It is unquestionably the best text-book on the subject that has yet appeared. The
work is eminently a practical one. We regard the issuance of this book as an important
eyent in the history of pharmaceutical teaching in this country, and predict for it an unquali-
fied success.'* — Alumni Rtport to the Philadelphia College of Pharmacy,

''There is no work like it in the pharmaceutical or botanical literature of this country,
and we predict for it a wide circulation." — American Journal of Pharmacy,

BECK'S SURGICAL ASEPSIS.

A Manual of Surs^ical Asepsis. By Carl Beck, M.D., Surgeon to
St. Mark's Hospital and the New York German Poliklinik, etc. 306
pages; 65 text-illustrations, and 12 full-page plates. Cloth, $1.25 net.

" An excellent exposition of the * very latest * in the treatment of wounds as practised
by leading German and American surgeons." — Birmingham (Eng.) Medical Review,

**This little volume can be recommended to any who are desirous of learning the details
of asepsis in surgery, for it will serve as a trustworthy guide." — London Lancet.

BOISLINIERE'S OBSTETRIC ACCIDENTS, EMERQENCIES, AND
OPERATIONS.

Obstetric Accidents, Emers^encies, and Operations. By L. Ch.

BoisLiNiERE, M.D., late Emeritus Professor of Obstetrics, St. Louis
Medical College. 381 pages, handsomely illustrated. Cloth, ^2.00 net.

<* It is clearly and concisely written, and is evidently the work of a teacher and practi-
tioner of large experience." — British Medical Journal.

" A manual so useful to the student or the general practitioner has not been brought to
our notice in a long time. The field embraced in the title is covered in a terse, interesting
way." — Yale Medical Journal.

BROCKWAY*S MEDICAL PHYSICS. Second Edition, Revised.

Essentials of Medical Physics. By Fred J. Brockway, M.D.,
Assistant Demonstrator of Anatomy in the College of Physicians and
Surgeons, New York. Crown octavo, 330 pages ; 155 fine illustrations.
Cloth, J 1. 00 net ; interleaved for notes, ^1.25 net.

[See Saunders* Question- Compends, page 21.]

" The student who is well versed in these pages will certainly prove qualified to com-
prehend with ease and pleasure the great majority of questions involving physical principles
likely to be met with in his medical studies." — American Practitioner and News.

<*We know of no manual that affords the medical student a better or more concise
exposition of physics, and the book may be commended as a most satisfactory presentation
of those essentials that are requisite in a course in medicine." — New York Medical Journal.

<* It contains all that one need know on the subject, is well written, and is copiously
illustrated." — Medical Record ^ New York.

BURR ON NERVOUS DISEASES.

A Manual of Nervous Diseases. By Charles W. Burr, M.D.,
Clinical Professor of Nervous Diseases, Medico-Chirurgical College,
Philadelphia; Pathologist to the Orthopedic Hospital and Infirmary
for Nervous Diseases ; Visiting Physician to St. Joseph's Hospital, etc.
In Preparation.

8 Medical Publications of W. B. Saunders.

BUTLER'S MATERIA MEDICA, THERAPEUTICS, AND PHAR-
MACOLOQY.

A Text-Book of Materia Medica, Therapeutics, and Pharma-
cology. By George F. Butler, Ph.G., M.D., Professor of Materia
Medica and of Clinical Medicine in the College of Physicians and
Surgeons, Chicago; Professor of Materia Medica and Therapeutics,
Northwestern University, Woman's Medical School, etc. Octavo, 858
pages, illustrated. Cloth, I4.00 net; Sheep, I5.00 net.

** Taken as a whole, the book may fairly be considered as one of the most satisfactory
of any single-volume works on materia medica in the market," — Journal of the American
Medical Association.

" The work is executed in a clear, concise, and practical manner, and shoald meet with
a hearty endorsement from the students of our up-to-date colleges. The book will be found
a valuable work of reference for the practitioner." — American Medico-Surgical Bulletin.

CASSELBERRY ON THE NOSE AND THROAT.

Diseases of the Nose and Throat. By W. £. Casselberry, Pro-
fessor of Laryngology and Rhinology in the Northwestern University
Medical School, Chicago. In Preparation.

CERNA ON THE NEWER REMEDIES. Second Edition, Revised.

Notes on the Newer Remedies, their Therapeutic Applications
and Modes of Administration. By David Cerna, M.D., Ph.D.,
formerly Demonstrator of and Lecturer on Experimental Tiierapeutics
in the University of Pennsylvania ; Demonstrator of Physiology in the
Medical Department of the University of Texas. Rewritten and
greatly enlarged. Post-octavo, 253 pages. Cloth, ^1.25.

'•These * Notes ' will be found very useful to practitioners who take an interest in the
many newer remedies of the present day." — Edinburgh Medical Journal.

" The appearance of this new edition of Dr. Cerna's very valuable work shows that it
is properly appreciated. The book ought to be in the possession of every practising physi-
cian."— New York Medical Journal.

CHAPIN ON INSANITY.

A Compendium of Insanity. By John B. Chapin, M.D., LL.D.,

Physician-in-Chief, Pennsylvania Hospital for the Insane ; late Physi-
cian-Superintendent of the Willard State Hospital, New York ; Hon-
orary Member of the Medico-Psychological Society of Great Britain,
of the Society of Mental Medicine of Belgium. Cloth, $1.25 net.

The author has given, in a condensed and concise form, a compendium of Diseases of
the Mind, for the convenient use and aid of physicians and students. The work will also
prove valuable to members of the legal profession and to those who, in their relations to the
insane and to those sup[X)sed to l>e insane, often desire to acquire some practical knowledge
of insanity presented in a form that may be understood by the non -professional reader.

CHAPMAN'S MEDICAL JURISPRUDENCE AND TOXICOLOGY.
Second Edition, Revised.

Medical Jurisprudence and Toxicology. By Henry C. Chapman,
M.D., Professor of Institutes of Medicine and Medical Jurisprudence
in the Jefferson Medical College of Philadelphia. 254 pages, with 55
illustrations and 3 full-page plates in colors. Cloth, $1.50 net.

"The best book of its class for the undergraduate that we know of.'* — Ne7v York
Medical Tivies.

Medical Publications of W. B. Saunders. 9

CHURCH AND PETERSON'S NERVOUS AND MENTAL DISEASES.

NerviHis and Mental Diseases. By Archibald Church, M.D.,
Professor of Mental Diseases and Medical Jurisprudence in the North-
western University Medical School, Chicago ; and Frederick Peter-
son, M.D., Clinical Professor of Mental Diseases in the Woman's
Medical College, New York ; Chief of Clinic, Nervous Department,
College of Physicians and Surgeons, New York. In Preparation.

CLARKSON'S HISTOLOGY.

A Text-Book of Histology, Descriptive and Practical. By

Arthur Clarkson, M.B., CM. Edin., formerly Demonstrator of
Physiology in the Owen*s College, Manchester; late Demonstrator of
Physiology in Yorkshire College, Leeds. Large octavo, 554 pages;
22 ^gravings in the text, and 174 beautifully colored original illustra-
^ tions. Cloth, strongly bound, |6.oo net.

'* The work must be considered a valuable addition to the list of available text-books,
and is to be highly recommended." — New York Medical Journal.

**This is one of the best works for students we have ever noticed. We predict that the
book will attain a well -deserved popularity among our students." — Chicago Medical Recorder.

**The volume is a most valuable addition to the armamentarium of the teacher.'' —
Brooklyn Medical Journal.

CLIMATOLOGY.

Transactions of the Eig^hth Annual Meeting of tlie American
Climatological Association, held in Washington, September 22-25,
1 89 1. Forming a handsome octavo volume of 276 pages, uniform with
remainder of series. (A limited quantity only.) Cloth, $1.50.

COHEN AND ESHNER'S DIAGNOSIS.

Essentials of Diagnosis. By Solomon Solis-Cohen, M.D., Pro-
fessor of Clinical Medicine and Applied Therapeutics in the Philadel-
phia Polyclinic ; and Augustus A. Eshner, M.D., Professor of Clinical
Medicine in the Philadelphia Polyclinic. Post-octavo, 382 pages; 55
illustrations. Cloth, I1.50 net.

[See Saunders* Question- Compends^ page 21.]

« We can heartily commend the book to all those who contemplate purchasing a *com-
pend.' It b modem and complete, and will give more satisfaction than many other works
which are perhaps too prolix as well as behind the times/* — Medical Review ^ St. Ix^uis.

CORWIN'S PHYSICAL DIAGNOSIS.

Essentials of Physical Diagnosis of the Thorax. By Arthur
M. CoRwiN, A.M., M.D., Demonstrator of Physical Diagnosis in Rush
Medical College, Chicago ; Attending Physician to Central Free Dis-
pensary, Department of Rhinology, Laryngology, and Diseases of the
Chest, Chicago. 200 pages, illustrated. Cloth, flexible covers, $1.25 net.

" It b excellent. The student who shall use it as his guide to the careful study of
I^3r8ical exploration upon normal and abnormal subjects can scarcely fail to acquire a good
working knowledge of the subject." — Philadelphia Polyclinic.

•*A most excellent little work. It brightens the memory of the differential diagnostic
signs, and it arranges orderly and in secjuence the various objective phenomena to logical
solution of a careful diagnosis. " — Journal of Xen'ous and Mental Diseases.

Medical Publications of W. B. Saunders.

CRAOIN*S QYNiCCOLOQY. Fourth Edition* Revised.

Essentials of Oymecoiogy. By Edwin B. Cragin, M.D., Attend-
ing Gyncecologist, Roosevelt Hospital. Out-Patients' Department^ New
York, etc. Cromi octavo, 200 pages; 62 fine illustrations. Cloth,
$1.00: interleaved for notes, $1.25.

[See Saunders^ Question- ComfenJs, page 21.]

** A haniiy volume, and a distinct improTcment on students' compends in general. No
anthor who was not himself a practical g3mecologist could have ccmsulted the student's needs
90 thoroughly as l>r. Cragin has done." — .lAfi/u-a/ AVtvr j^. New York.

CROOKSHANK*S BACTERIOLOGY.

A Text-Book of Bacteriology. By Edgar M. Crookshank, M.B.,
Professor of Comparative Pathology and Bacteriology-, King's College,
London. Octavo volume of 700 pages, with 273 engTa\-ings and 22
original colored plates. Cloth. $6.50 net : Half Morocco, $7.50 net.

** To the student who wishes to obtain a good '■isume of what has been done in bacteri-
olc(^. or who wishes an accurate accvxint of the vaiioas mecbods of research, the book nuj
be reowunended with oxindence that be will nod there what he re^qnires^** — London Lamd.

DaCOSTA*S SURQERY. Second Ed., Revised and Gmtly Enlarged.

Modem Surger>'« General and Operative. By John Chalmeks
DaCosta. M.D., Clinical Professor of Surgery, Tcfierson Medical
College, Riiladeiphia ; Surgeon to the Philadelphia Hospital, etc
Handsome octavo volume of 900 pages, profosely illostnited. Cloth,
JL4.00 net : Half Morocco, $5-00 net.

v!ikb so well fulfils
5-*, BrssLol. Er:glind.

•• We kr^ow of tv^ sanall work 00 saai^err in ^>e Frj^gfe 1

DE SCHWEiNTTZ ON DISEASES OF THE EYE. Second Editioo,
Revised.

Diseases of the Eye, A Handbook of Ophthalmic Practice.

Fy Cr- K :v S.h'»vv:m7j. M.D.. Fr::es5cr cf O^-ihilniolo^" in the

\ >* • •••» ^ ->•* -»•- -^•- _vc t& * •*■* « — -% ^ «« j» - *'-.<* "*>*~ '^""^ t "*. ■*■ ^ .^ ^ •■'^'"1^-. **nn»

:v>. C'-cth. jU.cc r.rt , Sr.e^: ,?r rLil:" Mrrccco. 5;. cc net.

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rrtn '. .c*;" " i -^"x .:i"C^-f 1 xr;; >i.: .>' V^ trj:: ^■r:>.;a^ si-jresa- iw-j^ts .t " — ^ViLU^J'

DORU\ND'S OBSTETRICS.

A Manual of ONstetiics. ?t V\' a NnrwL^x TTSLL-wr. MD,

« * ,

• ^

-^ ». \ ;

.A^^ :lirt*s vTlcch. 52.5c net.

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Medical Publicationa of W. B. Saunders. 11

FROTHINQHAiVI'S QUIDB FOR THE BACTERIOLOGIST.

Laboratory Quide lor the Bacteriolosrist. By Langdon Froth-
INGHAM, M.D.V., Assistant in Bacteriology and Veterinary Science,
Sheffield Scientific School, Yale University. Illustrated. Cloth, 75 cts.

** It is a convenient and useful little work, and will more than repay the outlay neces-
sary for its purchase in the saving of time which would otherwise be consumed in looking
up the various points of technique so clearly and concisely laid down in its pages." — Ameri-
can Medico- Surgical Bulletin.

QARRIQUES' DISEASES OP WOMEN. Second Edition, Revised.

Diseases of Women. By Henry J. Garrigues, A.M., M.D., Pro-
fessor of Gynecology in the New York School of Clinical Medicine ;
Gynecologist to St. Mark's Hospital and to the German Dispensary,
New York City, etc. Handsome octavo volume of 728 pages, illus-
trated by 335 engravings and colored plates. Cloth, 114.00 net;
Sheep or Half Morocco, II5.00 net.

*' One of the best text-books for students and practitioners which has been published in
the English language ; it is condensed, clear, and comprehensive. The profound learning
and great clinical experience of the distinguished author Bnd expression in this book in a
most attractive and instructive form. Young practitioners to whom experienced consultants
may not be available will tind in this book invaluable counsel and help." — Thad. A.
Reamy, M.D., LL.D., Professor of Clinical Gynecology ^ Aledical College of Ohio.

QLEASON'S DISEASES OP THE EAR. Second Edition, Revised.

Essentials of Diseases of tlie Ear. By E. B. Gleason, S.B.,
M.D., Clinical Professor of Otology, Medico-Chirurgical College,
Philadelphia ; Surgeon-in-Charge of the Nose, Throat, and Ear Depart-
ment of the Northern Dispensary, Philadelphia. 208 pages, with
114 illustrations. Cloth, $1.00 ; interleaved for notes, I1.25.

[See Saunders^ Question- CompendSy page 21.]

<* It is just the book to put into the hands of a student, and cannot fail to give him a
useful introduction to ear-affections ; while the style of question and answer which is adopted
throughout the book is, we believe, the best method of impressing facts permanently on the
mind . ' ' — Liverpool Medico- Ckirurgical Journal.

QOULD AND PYLE'S CURIOSITIES OF MEDICINE.

Anomalies and Curiosities of Medicine. By George M. Gould,
M.D., and Walter L. Pyle, M.D. An encyclopedic collection of
rare and extraordinary cases and of the most striking instances of
abnormality in all branches of Medicine and Surgery, derived from an
exhaustive research of medical literature from its origin to the present
day, abstracted, classified, annotated, and indexed. Handsome im-
perial octavo volume of 968 pages, with 295 engravings in the text,
and 12 full-page plates. Cloth, $6.00 net; Half Morocco, J7.00 net.
Sold by Subscription.

"One of the most valuable contributions ever made to medical literature. It is, so far
as we know, absolutely unique, and every page is as fascinating as a novel. Not alone for
the medical profession has this volume value : it will serve as a book of reference for all who
are interested in general scientific, sociologic, or medico-legal topics." — Brooklyn Medical
Journal.

** This is certainly a most remarkable and interesting volume. It stands alone among
medical literature, an anomaly on anomalies, in that there is nothing like it elsewhere in'
medical literature. It is a l)ook full of revelations from its first to its last page, and cannot
bat interest and sometimes almost horrify its readers." — American Medico- Surgical Bulletin.

12 Medical Publications of W. B. Saunders.

QRIFFIN'S MATERIA MEDICA AND THERAPEUTICS.

Manual of Materia Medica and Therapeutics. By Henry A.

Griffin, A.B., M.D., Assistant Physician to the Roosevelt Hospital,
Out-Patient Department, New York City. In Prepar€ttum.

GRIFFITH ON THE BABY.

The Care of the Baby. By J. P. Crozer Griffith, M.D., Clini-
cal Professor of Diseases of Children, University of Pennsylvania ;
Physician to the Children's Hospital, Philadelphia, etc. i2mo, 392
pages, with 67 illustrations in the text, and 5 plates. Cloth, $1.50.

** The best book for the use of the young mother with which we are acquainted. . . .
There are very few general practitioners who could not read the book through with adran-
tage, * ' — Archives of Pediatrics,

**The whole book is characterized by rare good sense, and b evidently written by a
roaster hand. It can be read with benetit not only by mothers but by medical students and
by any practitioners who have not had large opportunities for observing children.'' — Ameri-
can Journal of Obstetrics.

ORIFFITH'S WEIGHT CHART.

Infant's Weight Chart. Designed by J. P. Crozer Griffith, M. D.,
Clinical Professor of Diseases of Children in the University of Penn-
sylvania, etc. 25 charts in each pad. Per pad, 50 cents net.

A conTenient blank for kee|>ing a record of the child's weight during the first two yens
of life. Printed on each chart is a curve representing the average weight of a healthy infimt,
so that any deTiation from the normal can readily be detected.

GROSS, SAMUEL D., AUTOBIOGRAPHY OF.

Autobioi^raphy of Samuel D. Gross, M.D., Emeritus Professor of

Surgery in the Jefferson Medical College, Philadelf^iia, with Rcmi^
niscences of His Times and Contemporaries. Edited by his Sons^
Samvk.i. W. GkvXns. M.D.. LL.D., late Professor of Principles of Su^^
gory and of Clinical Surgery in the Jefferson Medical College, an^
A. Hallfr Gross, A.M., of the Philadelphia Bar. Preceded by ^
Memoir of Pr, Gross, by the late Austin Flint, M.D.. LL.D. l^^
two handsome volumes, each containing over 400 pages, demy octaves 9
extra cloth, gilt to|>s. with fine Frontispiece engraved on steel. Pric^
jXT volume. $-.50 net.

•• IV. r»rv>>s wa> :>errjr5 the mv>>: eminent expor.cn: of medica! science that Amcricr-^
has >cl ir\v:uvi\: H> Auioi. u-izra: hy. related a> it i< w::b a fulness and compIetCDei> "^
seUiom tv^ Ix* !^^ur/. •.:: >\:.-h \rvVvv. :> an interesting and viluaMe rook. He comments o^^
ma:n thirp*, es'.yv.Ji'v. o:" o^^urMr. ov. Rie\:icjil men and medicau powrtice, in a veiy iniere>*^ "
ing X* ,»> . ' " — .';.-' ..Vv. . :«-■. - . 1 ^^ r. i j r. . Er.i;Iind .

HA.MPTONS NLRSING.

Nursing: : Its Principles and Practice. By Isabel Adams Hamf^ -
ivN, Gr.'»viu.:u^ of the New York Tnir.'.r*: School for Nurses attache^^
:v> IV/.cw.o Ho<: ::,\' : S.;:>er.r.:er.der-: of Nurses, and Principal of tl»^
rr.i.r.irc SvhvV^'. for N.:r?e>. Johr^ Hopkins Hospital, Baltimore. M3. -
i::r.v\ ^>^ :v.^c:s, : rof'.:>c-v illustritr.:. Cloth. 52-oc net.

• V

•■ Ssr'/.^— '-ixcr ■«;■ :yr-v,>^.-. jl S.^V V7*r :'; >-.:": f-r: :rjL; rii> ^!tet. u* so much I'leosuT*
AS : . r ;xvrr v-> \\ v ^» . _\: >:t. r.^ t ..— ; --.. :;.: r--=i:«frS' of ccjomx pTc»fe>>ion tb^
v: vv V " vr :'*" .^ •- •: T" '' sr:.: i ci:h c: u> :o .«ecocsc a traiz:i2^ school in hina-

Medical Publications of W. B. Saunders. 13

HARE'S PHYSIOLOGY. Third Edition, Revised.

Essentials of Physiology. By H. A. Hare, M.D., Professor of
Therapeutics and Materia Medica in the Jefferson Medical College of
Philadelphia; Ph)^ician to the Jefferson Medical College Hospital.
Containing a series of handsome illustrations from the celebrated
"Icones Nervorum Capitis'* of Arnold. Crown octavo, 239 pages.
Cloth, $1.00 net; interleaved for notes, $1.25 net.

[See Saunders* Question- Compendsy page 21.]

" The best condensation of physiological knowledge we have yet seen." — Medical
Record^ New York.

HART'S DIET IN SICKNESS AND IN HEALTH.

Diet in Siclcness and in Heaitli. By Mrs. Ernest Hart, formerly
Student of the Faculty of Medicine of Paris and of the London School
of Medicine for Women; with an Introduction by Sir Henry
Thompson, F. R. C. S. , M. D. , London. 220 pages ; illustrated. Cloth,
I1.50.

" We recommend it cordially to the attention of all practitioners ; both to them and to
their patients it may be of the greatest service.'* — New York Medical Journal.

HAYNES' ANATOMY.

A Manual of Anatomy. By Irving S. Haynes, M.D., Adjunct
Professor of Anatomy and Demonstrator of Anatomy, Medical Depart-
ment of the New York University, etc. 680 pages, illustrated with 42
diagrams in the text, and 134 full-page half-tone illustrations from
original photographs of the author's dissections. Cloth, $2.50 net.

<* This book is the work of a practical instructor— one who knows by experience the
requirements of the average student, and is able to meet these requirements in a very sati»
wXxxj way. The book is one that can be commended." — Medical Record^ New York.

HEISLER'S EMBRYOLOGY.

A. Text-Book of Embryology. By John C. Heisler, M.D., Pro-
fessor of Anatomy in the Medico-Chirurgical College, Philadelphia.
In Preparation,

HIRSTS OBSTETRICS.

A Text-Book of Obstetrics. By Barton Cooke Hirst, M.D.,
Professor of Obstetrics in the University of Pennsylvania. In Prepa-
ration.

HYDE AND MONTGOMERY ON SYPHILIS AND THE VENEREAL

DISEASES.

Syphilis and the Venereal Diseases. By James Nevins Hyde,
M.D., Professor of Skin and Venereal Diseases, and Frank H. Mont-
gomery, M.D., Lecturer on Dermatology and Genito-Urinary Diseases
in Rush Medical College, Chicago, 111. 618 pages, profusely illustrated.
Cloth, $2.50 net.

« We can commend this manual to the student as a help to him in his study of venereal
•diseases. * * — L iverpool Medico- Ch irurgical Journal.

"The best student's manual which has appeared on the subject." — St. Louis Medical
and Surgical Journal.

14 Medical Publications of W. B. Saunders.

JACKSON AND QLEASON*S DISEASES OF THE EYE» NOSE, AND
THROAT. Second Edition, Revised.

Essentials of Refraction and Diseases of the Eye. By Edward
Jackson, A.M., M.D., Professor of Diseases of the Eye in the Phila-
delphia Polyclinic and College for Graduates in Medicine ; and —

Essentials of Diseases of the Nose and Throat. By E. Bald-
win Gleason, M.D., Surgeon-in-Charge of the Nose, Throat, and
EsLT Department of the Northern Dispensar>' of Philadelphia. Two
volumes in one. Crown octavo, 290 pages; 124 illustrations. Cloth,
j 1 . 00 ; in terleaved for notes, $1.25.

[See Saunders^ Question -Cinnfends, page 21.]

•• Of great value to the beginner in these branches. The aathors are both capable men,
and know what a student most needs.** — Medical Record ^ New York.

KEATINQ*S DICTIONARY. Second Edition, Revised.

A New Pronouncing^ Dictionary of Medicine, with Phonetic
Pronunciation, Accentuation, Etymology, etc By John M.
Keating, M. D. , LX.. D. , Fellow of the College of Physicians of Phila-
delphia; Vice-President of the American F^iatric Society; Editor"
•* Cyclopaedia of the Diseases of Children," etc.; and Henrv
Hamilton, Author of ** A New Translation of Virgil's ^neid into*
English Rh3rme," etc.; with the collaboration of J. Chalmers Da-
Costa, M.D., and Frederick A. Packard. M.D. With an Appendix
containing Tables of Bacilli, Micrococci, Leucomalnes, Ptomaines;
Drugs and Materials used in Antiseptic Surgery; Pdisons and their
Antidotes; Weights and Measures; Thermometric Scaks; New
Official and Unofficial Drugs, etc. One volume of over 800 pages.
Prices, with Denison's Patent Ready- Reference Index: Cloth, $5.00
net: Sheep or Half Morocco, $6.co net; Half Russia. $6.50 net.
Without Patent Index: Cioth. $4.00 net: Sheep or Half Morocco,
$^.co net.

** I Jtm much p'eised with Kcatinjr's Diciior.aiy, ari >halt uie pleasure in recommend-
iag i: to mv clashes. ' —Henry M. Lyman. M.D.. /'•-.; v..;.— cf :ir Prmcitles and Practue

" 1 Ais ocr.v:nc*d tha: •: will U? a very valuable *i;uiict to mr study-table, convenient
♦n sire and >urr.c:ec:ly full :Vr oniir.ary u>e." — C. A. LiNrsLiY, M.D., Prcfesscr cf the

KEATINGS LIFE INSL'R.ANCE.

Mow to Examine for Life Insurance. Bv Tohx M. Keating,
M.D.. Fellow of the Colleiie o: Ph\-s:c:ans of Philadelphia; Vice-
Pre<:cer.: or" the A-ierican P.^ciiatric Society- : Elx-President of the
Asi>oc:at:or, of L:fe Insurance Mecioal Directors. Roval octavo, 211
pices: w::h f.vo larce half-tone illusrmuons, and a plate prepared by
Dr. McClelLm from >i\N::al cisseciions ; also, numeroos other illustra-
tions. Cl:*th, <2.cc net.

" Tr. > - 'r\ •'.•.: :" e :r-:>: U5^~^l r»>:k -»-::>. ii5 v-'. irpe'Arfi ce inscrance examination.

i >-. -^:: - : - i^ ^ • :;rr>: xr i :r.*-.v.-r:ir..^ N : :ii* >a?c valaar'e r^.Traoo of the volume

- Yj-". 11. -' .M .•;!■.>.-:> ::' .:>:r.::v:r.> :jv>ue-: : : r. e ir * x i — •" ^ y iiyfjciar.s by twenty four

■-: . -^^e-:i.: ; : - .m" :5 :f :r - : ; j.r.::\ !-" :V: -.r.rse al.c*. ibe Sco£ sbixili be at the right

'1- • :: c-;:-' ; -^^ : ii; -::::;:r>:ri :- i- < >v<\:jL rnnch ci =)e>ixa: soeaoe.*" — Tic MfJUdi

Medical Publications of W. B. Saunders. 15

KEEN ON THE SURGERY OF TYPHOID FEVER.

The Surreal Complications and Sequels of Typlioid Fever.

By Wm. W. Keen, M.D., LL.D., Professor of the Principles of Sur-
gery and of Clinical Surgery, Jefferson Medical College, Philadelphia ;
Corresponding Member of the Soci6t6 de Chirurgie, Paris ; Honorary
Member of the Soci6t6 Beige de Chirurgie, etc. Octavo volume of
386 pages, illustrated. Cloth, $3.00 net.

This monograph is the only one in any language covering the entire subject of the
Surgical Complications and Sequels of Typhoid Fever. It will prove to be of importance
and interest not only to the general surgeon and physician, but also to many specialists — laryn-
gologists, gynecologists, pathologists, and bacteriologists.

KEEN'S OPERATION BLANK. Second Edition, Revised Form.

An Operation Blanic, witli Lists of Instruments, etc. Required
in Various Operations. Prepared by W. W. Keen, M.D., LL.D.,
Professor of the Principles of Surgery in Jefferson Medical College,
Philadelphia. Price per pad, containing blanks for fifty operations,
50 cents net.

KYLE ON THE NOSE AND THROAT.

Diseases of tlie Nose and Tliroat. By D. Braden Kyle, M.D.,
Clinical Professor of Laryngology and Rhinology, Jefferson Medical
College, Philadelphia; Consulting Laryngologist, Rhinologist, and
Otologist, St. Agnes' Hospital ; Bacteriologist to the Philadelphia
Orthopedic Hospital. In Preparation.

LAINE'S TEMPERATURE CHART.

Temperature Cliart. Prepared by D. T. Lain^, M.D. Size 8 x 13^
inches. A conveniently arranged Chart for recording Temperature,
with columns for daily amounts of Urinary and Fecal Excretions,
Food, Remarks, etc. On the back of each chart is given in full the
method of Brand in the treatment of Typhoid Fever. Price, per pad
of 25 charts, 50 cents net.

" To the busy practitioner this chart will be found of great value in fever cases, and
especially for cases of typhoid." — Indian Lancet, Calcutta.

LOCKWOOD'S PRACTICE OF MEDICINE.

A Manual of the Practice of Medicine. By George Roe Lock*
WOOD, M.D., Professor of Practice in the Woman's Medical College
of the New York Infirmary, etc. 935 pages, with 75 illustrations in
the text, and 22 full-page plates. Cloth, I2.50 net.

" Gives in a most concise manner the points essential to treatment usually enumerated
in the most elaborate works." — Massachusetts Medical Journal,

LONG'S SYLLABUS OF GYNECOLOGY.

A Syllabus of Gynecolos^y, arranged in Conformity with •• An
American Text-Book of Gynecology," By J. W. Long, M.D.,
Professor of Diseases of Women and Children, Medical College of
Virginia, etc. Cloth, interleaved, $1.00 net.

** The book is certainly an admirable rhumi of what every gynecological student and
practitioner should know, and will prove of value not only to those who have the ' American
Text-Book of Gynecology,' but to others as well." — Brooklyn Medical Journal,

16 Medical Publications of W. B. Saunders.

MACDONALD'S SURGICAL DIAGNOSIS AND TREATMENT.

Surg^ical Diag:nosis and Treatment. By J. W. Macdonald, M.D.
Edin., L.R.C.S., Edin., Professor of the Practice of Surgery and of
Clinical Surgery in Hamline University; Visiting Surgeon to St.
Barnabas' Hospital, Minneapolis, etc. Handsome octavo volume of
800 pages, profusely illustrated. Cloth, $5.00 net; Half Morocco,
|6.oo net.

" A thorough and complete work on surgical diagnosis and treatment, free from pad«
ding, full of valuable material, and in accord with the surgical teaching of the day." — The
Medical Neivs^ New York.

** The work is brimful of just the kind of practical information that is useful alike to
students and practitioners. It is a pleasure to commend the book because of its intrinsic
value to the medical practitioner." — Cincinnati Lancet- Clinic,

MALLORY AND WRIGHT'S PATHOLOGICAL TECHNIQUE.

Pathological Technique. A Practical Manual for Laboratory Work
in Pathology, Bacteriology, and Morbid Anatomy, with chapters on
Post-Mortem Technique and the Performance of Autopsies. By Frank
B. Mallory, A.m., M.D., Assistant Professor of Pathology, Harvard
University Medical School, Boston; and James H. Wright, A.M.,
M.D., Instructor in Pathology, Harvard University Medical School,
Boston. Octavo volume of 396 pages, handsomely illustrated. Cloth,
I2.50 net.

" I have been looking forward to the publication of this book, and I am glad to say that
I Bnd it to be a most useful laboratory and post-mortem guide, full of practical information,
and well up to date." — ^William H. Welch, Professor of Pathology, Johns Hopkins Uni-
versity, Baltimore, Md,

MARTIN'S MINOR SURGERY, BANDAGING, AND VENEREAL
DISEASES. Second Edition, Revised.

Essentials of Minor Surgery, Bandaging, and Venereal
Diseases. By Edward Martin, A.M., M.D., Clinical Professor of
Genito-Urinary Diseases, University of Pennsylvania, etc. Crown
octavo, 166 pages, with 78 illustrations. Cloth, 51.00 ; interleaved for
notes, $1.25.

[See Saunders' Question- Compends, page 21.]

" A very practical and systematic study of the subjects, and shows the author's famil-
iarity with the needs of students." — Therapeutic Gazette.

MARTIN'S SURGERY. Sixth Edition, Revised.

Essentials of Surgery. Containing also Venereal Diseases, Surgi-
cal Landmarks, Minor and Operative Surgery, and a complete de-
scription, with illustrations, of the Handkerchief and Roller Bandages.
By Edward Martin, A.M., M.D., Clinical Professor of Genito-
Urinary Diseases, University of Pennsylvania, etc. Crown octavo, 338
pages, illustrated. With an Appendix containing full directions for the
preparation of the materials used in Antisei)tic Surgery, etc. Cloth,
$1.00; interleaved for notes, $1.25.

[See Saunders' Question- Compends, page 21.]

** Contains all necessary essentials of modem surgery in a comparatively small space.
Its s»yle is interesting, and its illustrations are admirable.'' — Medical and Surgical /Reporter.

Medical Publications of W. B. SauBders. 17

MCFARLAND*S PATHOGENIC BACTERIA.

Text-Book upon the Pathoj^enic Bacteria. Specially written
for Students of Medicine. By Joseph McFarland, M.D., Pro-
fessor of Pathology and Bacteriology in the Medico-Chirurgical Collie
of Philadelphia, etc. Octavo volume of 359 pages, finely illustrated.
Cloth, 1 2. 50 net.

" Dr. McFarland has treated the subject in a systematic manner, and has succeeded in
presenting in a concise and readable form the essentials of bacteriology up to date. Alto-
gether, the book is a satisfactory one, and I shall take pleasure in recommending it to the
students of Trinity College."— H. B. Anderson, M.D., Professor of Pathology and Bac-
teriology^ Trinity Medical College^ Toronto.

MEIQS ON FEEDING IN INFANCY.

Feeding: In Early Infancy. By Arthur V. Meigs, M.D. Bound
in limp cloth, flush edges, 25 cents net.

" This pamphlet is worth many times over its price to the physician. The author's
experiments and conclusions are original, and have been the means of doing much good."^
Medical BulUHn.

MOORE'S ORTHOPEDIC SURGERY.

A Manual of Orthopedic Surgery. By James E. Moore, M.D.,
Professor of Orthopedics and Adjunct Professor of Clinical Surgery,
University of Minnesota, College of Medicine and Surgery. Octavo
volume of 356 pages, handsomely illustrated. Cloth, $2.50 net.

A practical book based upon the author's experience, in which special stress is laid
upon early diagnosis, and treatment such as can be carried out by the general practitioner.
The teachings of the author are in accordance with his belief that true conservatism is to
be found in the middle course between the surgeon who operates too frequently and the
orthopedist who seldom operates.

MORRIS'S MATERIA MEDICA AND THERAPEUTICS. Fourth
Edition, Revised.

Essentials of Materia Medica, Therapeutics, and Prescription-
Writing. By Henry Morris, M.D., late Demonstrator of Thera-
peutics, Jefferson Medical College, Philadelphia ; Fellow of the College
of Physicians, Philadelphia, etc. Crown octavo, 250 pages. Cloth,
$1.00; interleaved for notes, I1.25.

[See Saunders^ Question- CompendSj page 21.]

" This work, already excellent in the old edition, has been largely improved by revi-
sion."— American Practitioner and News.

MORRIS, WOLFF. AND POWELL'S PRACTICE OF MEDICINE.
Third Edition, Revised.

Essentials of the Practice of Medicine. By Henry Morris, M. D.,
late Demonstrator of Therapeutics, Jefferson Medical College, Phila-
delphia ; with an Appendix on the Clinical and Microscopic Examina-
tion of Urine, by Lawrence Wolff, M.D. , Demonstrator of Chemistry,
Jefferson Medical College, Philadelphia. Enlarged by some 300 essen-
tial formulae collected and arranged by William M. Powell, M.D.
Post-octavo, 488 pages. Cloth, ^2.00.

[See Saunders" Question- Compends, page 21.]

" The teaching is sound, the presentation graphic ; matter full as can be desired, and
style attractive." — American Practitioner and News.

18 Medical Pablications of W. B. Saunders.

MORTEN'S NURSE'S DICTIONARY.

Nurse's Dictionary of Medical Terms and Nursing^ Treat-
ment. Containing Definitions of the Principal Medical and Nursing
Terms and Abbreviations ; of the Instruments, Drugs, Diseases, Acci-
dents, Treatments, Operations, Foods, Appliances, etc. encountered
in the ward or in the sick-room. By Honnor Morten, author of
**How to Become a Nurse," etc. i6mo, 140 pages. Cloth, 51.00.

'* A handy, compact little volume, containing a large kmount of general information, all
of which is arranged in dictionary or encyclopedic form, thus facilitating quick reference.
It is certainly of value to those for whose use it is published." — Chicago Clinical Rci'irw.

NANCREDE'S ANATOMY. Fifth Edition.

Essentials of Anatomy, including the Anatomy of the Viscera.
By Charles B. Nancrede, M.D., Professor of Surgery and of Clini-
cal Surgery in the University of Michigan, Ann Arbor. Crown octavo,
388 pages; 180 illustrations. With an Appendix containing over 60
illustrations of the osteology of the human body. Based upon Gray's
Anatomy, Cloth, |i.oo; interleaved for notes, ^1.25.

[See Saunders" Question- Compends^ page 21.]

"For self-quizzing and keeping fresh in mind the knowledge of anatomy gained at
school, it would not be easy to speak of it in terms too favorable." — American Practitioner,

NANCREDE*S ANATOMY AND DISSECTION. Fourth Edition.

Essentials of Anatomy and Manual of Practical Dissection.

By Charles B. Nancrede, M.D., Professor of Surgery and of Clinical
Surgery, University of Michigan, Ann Arbor. Post-octavo ; 500 i>ages,
with full-page lithographic plates in colors, and nearly 200 illustrations.
Extra Cloth (or Oilcloth for the dissection -room), ^2.00 net.

" It may in many respects be considered an epitome of Gray's popular work on general
anatomy, at the same time having some distinguishing characteristics of its own to commend
it. The plates are of more than ordinary excellence, and are of especial value to students
in their work in the dissecting room." — Journal of the Arnerican Medical Association.

N0RR1S*S SYLLABUS OF OBSTETRICS. Tliird Edition, Revised.

Syllabus of Obstetrical Lectures in the Medical Department
of the University of Pennsylvania. By Richard C. Norris,
A.M., M.D., Demonstrator of Obstetrics, University of Pennsylvania.
Crown octavo, 222 pages. Cloth, interleaved for notes, $2.00 net.

*' This work is so far superior to others on the same subject that we take pleasure in
calling attention briefly to its excellent features. It covers the subject thoroughly, and will
prove invaluable both to the student and the practitioner." — Medical Record ^ New York.

PENROSE'S DISEASES OF WOMEN. Second Edition, Revised.

A Text-Book of Diseases of Women. By Charles B. Penrose,
M.D., Ph.D., Professor of Gynecology in the University of Pennsyl-
vania; Surgeon to the Gynecean Hospital, Philadelphia. Octavo
volume of 529 pages, handsomely illustrated. Cloth, $3.50 net.

** I shall value very highly the copy of Penrose's * Diseases of Women* received.
I have already recommended it to my class as THE BEST lx>ok."— Howard A. Kelly.
Professor of Gynecology and Obstetrics, Johns Hopkins University, Ballimore, Md.

'* The book is to Ixi commended without reserve, not only to the student but to the
general practitioner who wishes to have the latest and best modes of treatment explained
with absolute clearness." — Therapeutic Gazette.

Medical Publications of W. B. Saunders. 19

POWELL'S DISEASES OF CHILDREN. Second Edition.

Essentials of Diseases of Children. By William M. Powell,
M.D., Attending Physician to the Mercer House for Invalid Women
at Atlantic City, N. J. ; late Physician to the Clinic for the Diseases of
Children in the Hospital of the University of Pennsylvania. Crown
octavo, 22 2 pages. Cloth, |i.oo; intierleaved for notes, $1.25.

[See Saunders* Question- Compends, page 21.]

" Contains the gist of all the best works in the department to which it relates."^
American Practitioner and News.

PRINGLE'S SKIN DISEASES AND SYPHILITIC AFFECTIONS.

Pictorial Atlas of SIcin Diseases and Syphilitic Affections
(American Edition). Translation from the French. Edited by
J. J. Pringle, M.B., F.R.C.P., Assistant Physician to the Middlesex
Hospital, London. Photo-lithochromes from the famous models in
the Museum of the Saint-Louis Hospital, Paris, with explanatory wood-
cuts and text. In 12 Parts. Price per Part, $3.00. Complete in
one volume, Half Morocco binding, $40.00 net.

** I strongly recommend this Atlas. The plates are exceedingly well executed, and
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'*The introduction of explanatory wood-cuts in the text is a novel and most important
feature which greatly furthers the easier understanding of the excellent plates, than which
nothing, we venture to say, has been seen better in point of correctness, tnsauty, and general
merit." — New York Medical Journal.

PYE'S BANDAGING.

Elementary Bandaging: and Surg^ical Dressing. With Direc-
tions concerning the Immediate Treatment of Cases of Emergency.
For the use of Dressers and Nurses. By Walter Pye, F.R.C.S., late
Surgeon to St. Mary's Hospital, London. Small i2mo, with over 80
illustrations. Cloth, flexible covers, 75 cents net.

•* The directions are clear and the illustrations are good.** — London Lancet.

*< The author writes well, the diagrams are clear, and the book itself is small and port-
able, although the paper and type are good.*' — British Medical Journal. .

RAYMOND'S PHYSIOLOGY.

A Manual of Physiology. By Joseph H. Raymond, A.M., M.D.,
Professor of Physiology and Hygiene and Lecturer on Gynecology, in
the Long Island College Hospital ; Director of Physiology in the
Hoagland Laboratory, etc. 382 pages, with 102 illustrations in the
text, and 4 full-page colored plates. Cloth, ^1.25 net.

" Extremely well gotten up, and the illustrations have been selected with care. The
text is fully abreast with modem physiology." — British Medical Journal.

RONTQEN RAYS.

Archives of the Rontgen Ray (Formerly Archives of Clinical
Skiaj^raphy). Edited by Sydney Rowland, M.A., M.R.C.S., and
W. S. Hedley, M.D., M.R.C.S. A series of collotype illustrations,
with descriptive text, illustrating the applications of the new photo-
graphy to Medicine and Surgery. Price per Part, gi.oo. Now ready:
Vol. I., Parts I. to IV.; Vol. II., Parts I., II.

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Each book is of convenient siie (5x7 inches) , containing on an average 250 pages,
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1. ESSENTIALS OF PHYSIOLOGY. By H. A. Hare, M.D. Third edition,

revised and enlarged. ($i.oo net.)

2. ESSENTIALS OF SURGERY. By Edward Martin, M.D. Sixth edition,

revised, with an Appendix on Antiseptic Surgery.

3. ESSENTIALS OF ANATOMY. By Charles B. Nancrede, M.D. Fifth

edition, with an Appendix.

4. ESSENTIALS OF MEDICAL CHEMISTRY, ORGANIC AND INORGANIC.

By Lawrence Wolff, M.D. Fourth edition, revised, with an Appendix.

5. ESSENTIALS OF OBSTETRICS. By \V. Easterly Ashton, M.D. Fourth

edition, revised and enlarged.

6. ESSENTIALS OF PATHOLOGY AND MORBID ANATOMY. By C. E.

Armand Semple, M.D.

7. ESSENTIALS OP MATERIA MEDICA, THERAPEUTICS, AND PRE-

SCRIPTION-WRITING. By Henry Morris, M.D. Fourth cdiUon, revised.

a, 9. ESSENTIALS OP PRACTICE OF MEDICINE. By Henry Morris,
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Third edition, enlarged by some 300 Essential Formulae, selected from eminent
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10. ESSENTIALS OP GYNAECOLOGY. By Edwin B. Cragin, M.D. Fourth

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11. ESSENTIALS OP DISEASES OF THE SKIN. By Henry W. Stelwagon,

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H. ESSENTIALS OP DISEASES OF THE EYE, NOSE, AND THROAT.

By Edward Jackson, M.D., and E. B. Gleason, M.D. Second ed., revised.

15. ESSENTIALS OP DISEASES OF CHILDREN. By William M. Powell,

M. D. Second edition.

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17. ESSENTIALS OF DIAGNOSIS. By S. Solis Cohen, M.D., and A. A. Eshner,

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revised.

21. ESSENTIALS OF NERVOUS DISEASES AND INSANITY. By John C

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22. ESSENTIALS OF MEDICAL PHYSICS. By Fred J. Brockway, M.D.

Second edition, revised. (Jl.oonet.)

23. ESSENTIALS OF MEDICAL ELECTRICITY. By David D. Stewart, M.D.,

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being encumbered with the introduction of "case*," which so largely expand Ibe
ordinary leal-bcxJi. These manuals will therefore form an admirable colleclioa of
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Any of these Manuals will be mailed on receipt of price (see next page for LU)u

Saunders^ New Series of Manuals^

VOLUMES PUBLISHED.

PHYSIOLOGY. By Joseph Howard Raymond, A.M., M.D., Professor of Physiology
and Hygiene and Lecturer on Gynecology in the Long Island College Hospital;
Director of Physiology in the Hoagland Laboratory, etc. Illustrated. CloSi, $1.25 net

SURQERY, General and Operative. By John Chalmers DaCosta, M.D., Clini-
cal Professor of Surgery, Jeiferson MedicsJ College, Philadelphia; Surgeon to the
Philadelphia Hospital, etc. 5>econd edition, thoroughly revised and greatly enlarged.
Octavo, 900 pages, profusely illustrated. Cloth, ^.00 net ; Half Morocco, $5.00 net.

DOSE-BOOK AND MANUAL OP PRESCRIPTION- WRITING. By £. Q.

Thornton, M.D., Demonstrator of Therapeutics, Jefferson Medical College, Phila-
delphia. Illustrated. Cloth, $1.25 net.

SURGICAL ASEPSIS. By Carl Beck, M.D., Surgeon to St. Mark's Hospital and
to the New York German Poliklinik, etc. Illustrated. Cloth, $1.2$ net.

MEDICAL JURISPRUDENCE. By Henry C. Chapman, M.D. Professor of Insti-
tutes of Medicine and Medical Jurisprudence in the Jefferson Medical College of Phila-
delphia. Illustrated. Cloth, $1.50 net.

SYPHILIS AND THE VENEREAL DISEASES. By James Nevins Hyde, M.D.,
Professor of Skin and Venereal Diseases, and Frank H. Montgomery, M. D.,
Lecturer on Dermatology and Genito- Urinary Diseases in Rush Medical College,
Chicago. Profusely illustrated. (Double number.) Cloth, I2.50 net

PRACTICE OP MEDICINE. By George Roe Lockwood, M.D., Professor of
Practice in the Woman's Medical College of the New York Infirmary; Instructor in
Physical Diagnosis in the Medical Department of Columbia College, etc. Illustrated.
(Double number.) Cloth, $2.50 net.

MANUAL OF ANATOMY. By Irving S. Haynes, M.D., Adjunct Professor of
Anatomy and Demonstrator of Anatomy, Medical Department of the New York
University, etc. Beautifully illustrated. (Double Number.) Cloth, $2.50 net.

MANUAL OP OBSTETRICS. By W. A. Newman Dorland, M.D., Assistant
Demonstrator of Obstetrics, University of Pennsylvania ; Chief of Gynecological Dis-
pensary, Pennsylvania Hospital, etc. Profusely illustrated. (Double number.) Cloth,
I2.50 net.

DISEASES OF WOMEN. By J. Bland Sutton, F.R.C.S., Assistant Surgeon to
Middlesex Hospital and Surgeon to Chelsea Hospital, London ; and Arthur E.
Giles, M.D., B.Sc. Lond. , F.R.C.S. Edin., Assistant Surgeon to Chelsea Hospital,
London. Handsomely illustrated. (Double number.) Cloth, $2.^0 net.

VOLUMES IN PREPARATION.

NOSE AND THROAT. By D. Braden Kyle, M.D., Clinical Professor of Laryn-
gology and Rhinology, Jefferson Medical College, Philadelphia ; Consulting Laryngolo*
gist, Rhinologist, and Otologist, St. Agnes' Hospital ; Bacteriologist to the Philadel-
phia Orthopedic Hospital and Infirmary for Nervous Diseases, etc.

NERVOUS DISEASES. By Charles W. Burr. M.D., Clinical Professor of Nervous
Diseases, Medico-Chirurgical College. Philadelphia; Pathologist to the Orthopaedic
Hospital and Infirmary for Nervous Diseases; Visiting Physician to the St. Joseph
Hospital, etc.

*•* There will be published in the same series, at short intervals, carefully-prepared works
on various subjects by prominent specialists.

Pamphlet containing specimen pagcs^ etc« lent fttt upon application*

24 Medical Publications of W. B. Saunders.

SAUNDBY'S RENAL AND URINARY DISEASES.

Lectures on Renal and Urinary Diseases. By Robert Saundby,
M.D. Edin., Fellow of the Royal College of Physicians, London, and
of the Royal Medico-Chirurgical Society ; Physician to the General
Hospital ; Consulting Physician to the Eye Hospital and to the Hos-
pital for Diseases of Women; Professor of Medicine in Mason College,
Birmingham, etc. Octavo volume of 434 pages, with numerous illus-
trations and 4 colored plates. Cloth, I2.50 net.

** The volume makes a favorable impression at once. The style is clear and succinct
We cannot find any part of the subject in which the views expressed are not carefully thought
out and fortified by evidence drawn from the most recent sources. The book may be cordidly
recommended." — British Medical Journal,

SAUNDERS* POCKET MEDICAL FORMULARY. Fourth Edition,
Revised.

By William M. Powell, M.D., Attending Physician to the Mercer
House for Invalid Women at Atlantic City, N. J. Containing 1750
formulse selected from the best-known authorities. With an Appen-
dix containing Posological Table, Formulae and Doses for Hypo-
dermic Medication, Poisons and their Antidotes, Diameters of the
Female Pelvis and Foetal Head, Obstetrical Table, Diet List for Various
Diseases, Materials and Drugs used in Antiseptic Surgery, Treatment
of Asphyxia from Drowning, Surgical Remembrancer, Tables of
Incompatibles, Eruptive Fevers, Weights and Measures, etc. Hand-
somely bound in flexible morocco, with side index, waJlet, and flap.
$1.75 net.

** This little book, that can be conveniently carried in the pocket, contains an immense
amount of material. It is very useful, and, as the name of the author of each prescription
b given, is unusually reliable." — Medical Record ^ New York.

SAUNDERS' POCKET MEDICAL LEXICON. Fourth Edition,
Revised.

A Dictionary of Terms and Words used in Medicine and
Surgery. By John M. Keating, M.D., Fellow of the College of
Ph\-sicians of Philadelphia; Editor of the ** Cyclopaedia of Diseases
of Children," etc.; Author of the **Xew Pronouncing Dictionary of
Medicine;" and Henry Hamilton, Author of **A New Translation
of Virgil's .-Eneid into English Verse;" Co-Author of the **New
Pronouncing Dictionary of Medicine." 32mo, 280 pages. Cloth,
75 cents; Leather Tucks, ^i.oo.

** Remarkably accurate in terminology, accentuation, and definition." — Journal of the
American Midical Associaticn.

SAYRE'S PHARMACY. Second Edition, Revised.

Essentials of the Practice of Pharmacy. By Lucius E. Sayre,
^LD., Professor of Pharmacv and Materia Medica in the University of
Kansas. Crown octavo, 200 ixiges. Cloth, $1.00; interleaved for
notes, $1.25.

[See SaunJers' Question- Compcriiis, page 21.]

** The topics are treated in a simple, practical manner, and the work forms a ver}' useful
student's manual." — Boston Medical and Surreal J^^drnul.

Medical Publications of W. B. Saunders. 25

SEMPLE'S LEGAL MEDICINE, TOXICOLOGY, AND HYGIENE.

Essentials of Legal Medicine, Toxicology, and Hyi^iene. By

C. E. Armand Semple, B. A., M. B. Cantab., M. R. C. P. Lend.,
Physician to the Northeastern Hospital for Children, Hackney, etc.
Crown octavo, 212 pages ; 1 30 illustrations. Cloth, 1 1 . 00 ; interleaved
for notes, $1.25.

[See Saunders* Question- Compends, page 21.]

** No general practitioner or student can afford to be without this valuable work. The
subjects are dealt with by a masterly hand." — London Hospital Gazette.

SEMPLE'S PATHOLOGY AND MORBID ANATOMY.

Essentials of Pathology and Morbid Anatomy. By C. E.

Armand Semple, B.A., M.B. Cantab., M.R.C.P. Lond., Physician to
the Northeastern Hospital for Children, Hackney, etc. Crown octavo,
1 74 pages; illustrated. Cloth, $1.00; interleaved for notes, $1.25.

[See Saunders' Question- Compends,^2%<^ 21.]

<* Should take its place among the standard volumes on the bookshelf of both student
and practitioner." — London Hospital Gazette.

SENN'S QENITO-URINARY TUBERCULOSIS.

Tuberculosis of the Qenito-Urinary Orj^ans, Male and Female.

By Nicholas Senn, M.D., Ph.D., LL.D., Professor of the Practice of
Surgery and of Clinical Surgery, Rush Medical College, Chicago.
Handsome octavo volume of 3^0 pages, illustrated. Cloth, I3.00 net.

<* An important book upon an important subject, and written by a man of mature judg-
ment and wide experience. The author has given us an instructive book upon one of the
most important subjects of the day." — Clinical Reporter.

" A work which adds another to the many obligations the profession owes the talented
author. '' — Chicago Medical Recorder,

SENN'S SYLLABUS OF SURGERY.

A Syllabus of Lectures on the Practice of Surgery, arranj^ed
in conformity with •• An American Text-Book of Surgery." By

Nicholas Senn, M.D., Ph.D., Professor of the Practice of Surgery and
of Clinical Surgery in Rush Medical College, Chicago. Cloth, |2.oo.

" This syllabus will be found of service bj the teacher as well as the student, the work
being superbly done. There is no praise too high for it. No surgeon should be without
it.»'— A^«e, York Medical Times.

SENN'S TUMORS.

Patholos^y and Surg^ical Treatment of Tumors. By N. Senn,
M. D. , Ph. D. , LL. D. , Professor of Surgery and of Clinical Surgery,
Rush Medical College ; Professor of Surgery, Chicago Polyclinic ;
Attending Surgeon to Presbyterian Hospital; Surgeon-in-Chief, St.
Joseph's Hospital, Chicago. Octavo volume of 710 pages, with 515
engravings, including full-page colored plates. Cloth, J6.00 net;
Half Morocco, $7.00 net.

** The most exhaustive of any recent book in English on this subject. It is well illus-
trated, and will doubtless remain as the principal monograph on the subject in our language
for some years. The book is handsomely illustrated and printed, and the author has given a
notable and lasting contribution to surgery." — Journal of the American Medical Association.

26 Medical Publications of W. B. Saunders.

SHAW'S NERVOUS DISEASES AND INSANITY. Third Editioii,
Revised.

Essentials of Nervous Diseases and Insanity. By John C.
Shaw, M.D., Clinical Professor of Diseases of the Mind and Nervous
System, Long Island College Hospital Medical School; Consulting
Neurologist to St. Catherine's Hospital and to the Long Island College
Hospital. Crown octavo, i86 pages; 48 original illustrations. Cloth,
|i.oo ; interleaved for notes, ^1.25.

[See Saunders' Question- Compends, page 21.]

"Clearly and intelligently written." — Boston Medical and Surgical Journal.

** There is a mass of valuable material crowded into this small compass." — American
Medico-Surgical Bulletin.

STARR'S DIETS FOR INFANTS AND CHILDREN.

Diets for Infants and Children in Healtli and in Disease. By

Louis Starr, M.D., Editor of **An American Text-Book of the
Diseases of Children." 230 blanks (pocket-book size), perforated
and neatly bound in flexible morocco. I1.25 net.

The first series of blanks are prepared for the first seven months of infant life ; each
blank indicates the ingredients, but not the quantities, of the food, the latter directions being
left for the physician. After the seventh month, modifications being less necessary, the diet
lists are printed in fiill. Formulae for the preparation of diluents and foods are appended.

STELWAQON'S DISEASES OF THE SKIN. Third Edition, Revised.

Essentials of Diseases of the Slcin. By Henry W. Stelwagon,
M.D., Clinical Professor of Dermatology in the Jefferson Medical
College, Philadelphia; Dermatologist to the Philadelphia Hospital;
Physician to the Skin Department of the Howard Hospital, etc.
Crown octavo, 270 pages; 86 illustrations. Cloth, ji.oonet; inter-
leaved for notes, J1.25 net.

[See Saunders* Question- Compendsy page 21.]

** The best student's manual on skin diseases we have yet seen." — Times and Register,

STENGEL'S PATHOLOGY.

A Manual of Pathology. By Alfred Stengel, M.D., Physician
to the Philadelphia Hospital ; Professor of Clinical Medicine in the
Woman's Medical College; Physician to the Children's Hospital;
late Pathologist to the German Hospital, Philadelphia, etc. In
Preparation,

STEVENS' MATERIA MEDICA AND THERAPEUTICS. Second
Edition, Revised.

A Manual of Materia Medica and Therapeutics. By A. A.

Stevens, A.M., M.D., Lecturer on Terminology and Instructor in
Physical Diagnosis in the University of Pennsylvania; Demonstrator
of Pathology in the Woman's Medical College of Philadelphia. Post-
octavo, 445 pages. Cloth, §2.25.

*'The author has faithfully presented modem therapeutics in a comprehensive work,
and, while intended particularly for the use of students, it will be found a reliable guide and
sufficiently comprehensive {or ihe physician in practice." — University Medical Magcmne,

Medical Publications of W. B. Saunders. 27

STEVENS' PRACTICE OP MEDICINE. Pourth Edition, Revised.

A Manual of tlie Practice of Medicine. By A. A. Stevens, A.M.,
M.D., Lecturer on Terminology and Instructor in Physical Diagnosis
in the University of Pennsylvania ; Demonstrator of Pathology in
the Woman's Medical College of Philadelphia. Specially intended
for students preparing for graduation and hospital examinations. Post-
octavo, 511 pages; illustrated. Flexible leather, $2.50.

** The frequency with which new editions of this manual are demanded bespeaks its
popularity. It is an excellent condensation of the essentials of medical practice for the
student, and may be found also an excellent reminder for the busy physician." — Buffalo
Medical Journal.

STEWART'S PHYSIOLOQY.

A Manual of Physiolos:y, with Practical Exercises. For
Students and Practitioners. By G. N. Stewart, M.A., M.D.,
D.Sc, lately Examiner in Physiology, University of Aberdeen, and
of the New Museums, Cambridge University ; Professor of Physiology
in the Western Reserve University, Cleveland, Ohio. Octavo volume
of 800 pages; 278 illustrations in the text, and 5 colored plates.
Cloth, I3.50 net.

<* It will make its way by sheer force of merit, and amply deserves to do so. It is one
of the very best English text-books on the subject." — London Lancet,

*'0f the many text-books of physiology published, we do not know of one that so
nearly comes up to the ideal as does Prof. Stewart's volume." — British Medical JoumaL

STEWART AND LAWRANCE*S MEDICAL ELECTRICITY.

Essentials of Medical Electricity. By D. D. Stewart, M.D.,
Demonstrator of Diseases of the Nervous System and Chief of the
Neurological Clinic in the Jefferson Medical College; and E. S.
Lawrance, M.D., Chief of the Electrical Clinic and Assistant Demon-
strator of Diseases of the Nervous System in the Jefferson Medical
College, etc. Crown octavo, 158 pages; 65 illustrations. Cloth,
fi.oo; interleaved for notes, I1.25.

[See Saunders^ Question- Compends^ page 21.]

*' Throughout the whole brief space at their command the authors show a discrininating
knowledge of their subject." — Medical News.

STONEY'S NURSING. Second Edition, Revised.

Practical Points in Nursing. For Nurses in Private Practice.

By Emily A. M. Stonev, Graduate of the Training-School for Nurses,
Lawrence, Mass.; late Superintendent of the Training-School for
Nurses, Carney Hospital, South Boston, Mass. 456 pages, illustrated
with 73 engravings in the text, and 8 colored and half-tone plates.
Cloth, $1.75 net.

" There are few books intended for non -professional readers which can be so cordially
endorsed by a medical journal as can this one." — Therapeutic Gazette.

" This is a well-written, eminently practical volume, which covers the entire range of
private nursing as distinguished from hospital nursing, and instructs the nurse how best to
meet the various emergencies which may arise, and how to prepare everything ordinarily
needed in the illness of her patient." — American Journal of Obstetrics and Diseases of
Women and Children.

" It is a work that the physician can place in the hands of his private nurses with the
assurance of benefit." — Ohio Medical Journal,

28 Medical Publications of W. B. Saunders.

SUTTON AND GILES' DISEASES OF WOMEN.

Diseases of Women. By J. Bland Sutton, F.R.C.S., Assistant
Surgeon to Middlesex Hospital, and Surgeon to Chelsea Hospital,
London ; and Arthur E. Giles, M.D., B.Sc. Lond., F.R.C.S. Edin.,
Assistant Surgeon to Chelsea Hospital, London. 436 pages, hand-
somely illustrated. Cloth, ^2.50 net.

**The book is very well prepared, and is certain to be well received by the medical
public. ' * — British Medical Journal.

**The text has been carefully prepared. Nothing essential has been omitted, and its
teachings are those recommended by the leading authorities of the day.'* — Journal of the
American Medical Association.

THOMAS'S DIET LISTS AND SICK-ROOM DIETARY.

Diet Lists and Sick-Room Dietary. By Jerome B. Thomas,
M.D., Visiting Physician to the Home for Friendless Women and
Children and to the Newsboys' Home ; Assistant Visiting Physician
to the Kings County Hospital. Cloth, ji.50. Send for sample sheet.

" The idea is good, and the lists are copious." — London Lancet.

** Its practical usefulness places it among the requirements of every practitioner."—
Chicago Medical Recorder.

THORNTON'S DOSE-BOOK AND PRESCRIPTION-WRITINQ.

Dose-Book and Manual of Prescription-Writing. By £. Q.

Thornton, M.D., Demonstrator of Therapeutics, JefTerson Medical
College, Philadelphia. 334 pages, illustrated. Cloth, I1.25 net.

<< Full of practical suggestions; will take its place in the front rank of works of this
sort.'* — Medical Record^ New York.

VAN VALZAH AND NISBET*S DISEASES OF THE STOMACH.

Diseases of tiie Stomacli. By William W. Van Valzah, M.D.,
Professor of General Medicine and Diseases of the Digestive System
and the Blood, New York Polyclinic; and J. Douglas Nisbet, M.D.,
Adjunct Professor of General Medicine and Diseases of the Digestive
S\-stem and the Blood, New York Polyclinic. Octavo volume of 674
pages, illustrated. Cloth, ^13. 50 net.

VIERORDT'S MEDICAL DIAGNOSIS. Third Edition, Revised.

Medical Diagnosis. By Dr. Oswald Vierordt, Professor of Medi-
cine at the University of Heidelberg. Translated, with additions,
from the second enlarged German edition, with the author's permission,
by Francis H. Stiart, A.M., Nf.D. Handsome royal octavo volume
of 700 [xiges ; 17S fine wood-cuts in text, many of them in colors.
Cloth. 54.00 net ; Sheep or Half Morocco, $5.00 net; Half Russia,
5:;.^o net.

" A irea>un- of practical information which will be found of daily use to even' busy
practiiiimtT who will consult it." — C A. LlNDSLKV, M.D., Professor of (he Theory and

* »-« #• ,• ■»* I/. -*•-•#•.' I * / tt*' ^t'C**\

*• K.iR '.y is a NH>k publishoii with which a reviewer can find so little fault as with the
vo:u:i)e boK^io us. Kach particular item in the consideration of an organ or apparatus, which
i> :uce-<arv to vletermine a diagnosis of any disease of that organ, is mentioned; nothing
ste:r.> t\ r^:. ttcn. The chapters vmi diseases of the circulatory and digestive apparatus and
rcrNv u>. s\>:cm are oix^cially full and valuable. The reviewer would repeat that the book is
o::c t : the be>i — proVv\b\y :h( ba: — v\\\\d\ has fallen into his hands.'' — University Medical

» ♦

Medical Publications of W. B. Saunders. 29

WARREN'S SURGICAL PATHOLOGY AND THERAPEUTICS.

Surgical Patholog^y and Therapeutics. By John Collins Warren,
M.D., LL.D., Professor of Surgery, Medical Department Harvard
University; Surgeon to the Massachusetts General Hospital, etc.
Handsome octavo volume of 832 pages; 136 relief and lithographic
illustrations, 33 of which are printed in colors, and all of which were
drawn by William J. Kaula from original specimens. Cloth, |6.oo
net; Half Morocco, J7.00 net.

*' There is the work of Dr. Warren, which I think is the most creditable book on
Suigical Pathology, and the most beautiful medical illustration of the bookmaker's art, that
has ever been issued from the American press." — Dr. Roswell Park, in the Harvard
Graduate Magazine.

** The handsomest specimen of bookmaking that has ever been issued from the American
medical press." — American Journal of the Medical Sciences.

** A most striking and very excellent feature of this book is its illustrations. Without
exception, from the point of accuracy and artistic merit, they are the best ever seen in a work
of this kind. Many of those representing microscopic pictures are so perfect in their coloring
and detail as almost to give the beholder the impression that he is looking down the barrel
of a microscope at a well-mounted section." — Annals of Surgery,

WEST'S NURSING.

An American Text-Book of Nursins:. By American Teachers.
Edited by Roberta M. West, late Superintendent of Nurses in the
Hospital of the University of Pennsylvania, fn Preparation,

WOLFF ON EXAMINATION OF URINE.

Essentials of Examination of Urine. By Lawrence Wolff, M. D. ,
Demonstrator of Chemistry, Jefferson Medical College, Philadelphia,
etc. Colored (Vogel) urine scale and numerous illustrations. Crown
octavo. Cloth, 75 cents.

[See Saunders^ Question- Campendsy page 21.]
** A very good work of its kind — ^very well suited to its purpose." — Times and Register,

WOLFF'S MEDICAL CHEMISTRY. Fourth Edition, Revised.

Essentials of Medical Chemistry, Organici and Inorganic.

Containing also Questions on Medical Physics, Chemical PhysiolQgy,
Analytical Processes, Urinalysis, and Toxicology. By Lawrence
Wolff, M.D., Demonstrator of Chemistry, Jefferson Medical College,
Philadelphia, etc. Crown octavo, 218 pages. Cloth, J i. 00; inter-
leaved for notes, %\.2^.

[See Saunders* Question- Compends^ page 21.]

The scope of this work is certainly equal to that of the best course of lectures on
Medical Chemistry." — Pharmaceutical Era.

CLASSIFIED LIST

OF THE

Medical Publications

W. B. SAUNDERS,

925 Walnut Street, Philadelphia*

ANATOMY, EMBRYOLOGY,
HISTOLOGY.

CUrkson— A Text-Book of Histology,
Hmynes — A Manual of Anatomy, . . .
Heisler — A Text- Book of Embiyology,
Nancrede — Essentials of Anatomy, . .
Nancrede — Essentials of Anatomy and

Manual of Practical Dissectkm, . . .
Semple — Essentials of Pathology and

Morbid Anatomy,

BACTERIOLOGY.

Ball — Essentials of Bacterioloey, . . .
Crookshank—A Text- Book of Bacteri-
ology.

Frothingham — Laboratory Guide, . .

Ifallory and Wright— Pathological

Technique,

If cParland— Pathogenic Bacteria, . .

CHARTS, DIET-USTS, ETC

Griffith— Infant*s Weight Chart, . . .
Hart — Diet in Sickness and in Health, .

Keen — Operation Blank

L>ain6 — Temperature Chart. .....

Meigs — Feeding in Early Infancy, . .
Starr — Diets for Infants and Children, .
Thooaas — Diet- Lists and Sick-Room
Dietary,

CHEMISTRY AND PHYSICS.

Brockway — Elssentials of Medical Phys-

18
25

10
II

16
17

KS,

Wolff — Elssentials of Medical Cnemistry,

CHILDREN.

An American Text -Book of Diseases

of Children

Griffith — Core of the Riby

Griffith — Infant's Wei^ihi Chan. . . .
Meigs — Keedir-g in E-u'v Infancy. . .
Powell — E>>en::a'.> of I >i>- of Children,
Starr — Diets for Infants and Children. .

DI.AGNOSIS.

Cohen and Eshner— Essentials of Di-

A^..\ ^.>« ........... .

Corwin — Physij^a'. Pia^.o^is

Macdonald — S-jr^r^ca" P-.-i^.-sis and

Vierordt — Mci:.M' I^..i^n.^is

DICTIONARIES.

Keating — IV—iour.jini: r-.cti-^r.ary. . .

Morten — Nurse" 5 P-.v:::.narv

Saunders* i\x!^e: Me\iu-al Lexicon. .

.3
12

1:
10

9
9

I.t

EYE, EAR, NOSE, AND THROAT.

An American Text- Book of Diseases

of the Eye, Ear, Nose, and Throat, . 3
Casselberry — Dis. of Nose and Throat, 8
De Schweinitz — Diseases of the Eye, . 10
Gleason — Essentials of Dis. of the Ear, ii
Jackson and Gleason — Essentials of

Diseases of the Eye, Nose, and Throat, 14
Kyle — Diseases of the Nose and Throat, 15

QENITO-URINARY.

An American Text-Book of Genito-
urinary and Skin Diseases, 4

Hyde and Montgomery — Syphilis and
the Venereal Diseases, 13

Martin — Essentials of Minor Surgery,
Bandaging, and Venereal Diseases, . 16

Saondby — Renal and Urinary Diseases, 24

Senn — Genito-Urinary Tobercnlosis, . 25

GYNECOLOGY.

American Text-Book of Gynecology, 4
Cragin — Essentials of Gynecology, . . 10
Garrigues — Diseases of Women, ... 11
Long — Syllahas of Gynecology, ... 15
Penrose — Diseases of Women, .... 18
Sutton and Giles — Diseases of Women, 2S

MATERIA MEDICA, PHARMACOL-
OGY, AND THERAPEUTICS.

An American Text-Book of Applied

TheraDeutics. 3

BuUer-lText-Book of Materia Medica,

Therapeutics and Pharmacolc^, ... 8
Cema — N\<es on the Newer Remedies, 8
Griffin — Materia Med. and Therapeutics, 12
Morris — Essentials of Materia Medica

axkl Therapeutics, . 17

Saunders* Pocket Medical Formnlarr, 24
Sayre — Essentia's of Pharmacy. ... 24
Stevens — Essen lials of Materia Medica

ai:d Then:>eu:ics 26

Thornton— rVs^ Book and Manual of

Prescri J t. on- Writing 28

Warren— Surreal Pi'JjoIogy and Ther-

ar>ri^..c^« . .......... 20

MEDICAL JtRISPRtl>ENCE AND
TO.XICOLOGY.

An American Text>Book of Legal
Medicine arxi ToxioxvTgy 4

Chapman — Medfcil Inriscvndence and
T.vidv>^ 8

Semple — E>?eT:rals of Le^ Medidne,
To\:«o"c^. and Hygseae 25

Medical Publications of W. B. Saunders.

NERVOUS AND MENTAL

DISEASES, ETC.

Burr — ^Nervous Diseases, 7

Chapin — Compendium of Insanity, . . 8
Church and Peterson — Nervous and

Mental Diseases, 9

Shaw — Essentials of Nervous Diseases

and Insanity, 26

NURSING.

•

An American Text-Book of Nursing, 29

GrifiBth— The Care of the Baby, ... 12

Hampton — Nursing, 12

Hart — Diet in Sickness and in Health, 13

Meigs — Feeding in Early Infancy, . . 17

Morten — Nurse's Dictionary, .... 18

Stoney — Practical Points in Nursing, . 27

OBSTETRICS.

An American Text-Book of Obstetrics, 4
Ashton — Elssentials of Obstetrics, ... 6
Boisliniere— Obstetric Accidents, Emer-
gencies, and Operations, 7

Dor land — Manual of Obstetrics, . . . lo
Hirst — Text-Book of Obstetrics, ... 13
Norris — Syllabus of Obstetrics 18

PATHOLOGY.

An American Text-Book of Pathology, 5
Mallory and Wright — Pathological

Technique, x6

Semple — E^entials of Pathology and

Morbid Anatomy, 25

Senn — Pathology and Surgical Treat*

ment of Tumors, 25

Stengel — Manual of Pathology, ... 26
Warren — Surgical Pathology and Thera-
peutics, 29

PHYSIOLOGY.

An American Text-Book of Physi-
ology, 5

Hare — Essentials of Physiology, . . . 13
Raymond — Manual of Physiology, . . 19
Stewart — Manual of Physiology, ... 27

PRACTICE OF MEDICINE.

An American Text-Book of the The-
ory and Practice of Medicine, .... 5

An American Year-Book of Medicine
and Surgery, 6

Anders — Text-Book of the Practice of
Medicine, 6

Lockwood — Manual of the Practice of
Medicine, 15*

Morris — Essentials of the Practice of
Medicine, 1 7

Rowland and Hedley — Archives of
the Roentgen Ray, I9

Stevens — Manual of the Practice of
Medicine, 27

SKIN AND VENEREAL.

An American Text-Book of Genito-
urinary and Skin Diseases, 3

Hyde and Montgomery — Syphilis and
the Venereal Diseases, 13

Martin — Essentials of Minor Surgery,
Bandaging, and Venereal Diseases, . 16

Pringle— Pictorial Atlas of Skin Dis-
eases and Syphilitic Affections, ... 19

Stelwagon — Essentials of Diseases of
the Skin, 26

SURGERY.

An American Text-Book of Surgery, 5
An American Year-Book of Medicine

and Surgery, 6

Beck — Manuid of Surgical Asepsis, . . 7
DaCosta — Manual of Surgery, .... 10

Keen— Operation Blank, 15

Keen — The Surgical Complications and

Sequels of Typhoid Fever, 15

Macdonald — Surgical Diagnosis and

Treatment, 16

Martin — Essentials of Minor Surgery,

Bandaging, and Venereal Diseases, . 16
Martin — Essentiab of Surgery, .... 16

Moore — Orthopedic Surgery, 17

Pye — Elementary Bandaging and Surgi-
cal Dressing, 19

Rowland and Hedley— Archives of

the Roentgen Ray, 19

Senn — Genito-Urinary Tuberculosis, . 25

Senn— Syllabus of Surgery, 25

Senn — Pathology and Surgical Treat-
ment of Tumors 25

V^^arren — Surgical Pathology and Ther-
apeutics, 29

URINE AND URINARY DISEASES.

Saundby — Renal and Urinary Diseases, 24
Wolff — Essentials of Examination of
Urine, 29

MISCELLANEOUS.

Bastin — Laboratory Exercises in Bot-
any, 7

Gould and Pyle — ^Anomalies and Curi-
osities of Medicine, 11

Keating — How to Examine for Life
Insurance, 14

Keen — Surgical Complications and Se-
quels of Typhoid Fever, 15

Rowland and Hedley — Archives of
the Roentgen Ray, 19

Saunders' Medical Hand-Atlases, . . 2

Saunders' New Series of Manuals, 22, 23

Saunders' Pocket Medical Formulary, . 24

Saunders' Question-Compends, . . 20, 21

Senn — Pathology and Surgical Treat-
ment of Tumors, 25

Stewart and Lawrance — Essentials of
Medical Electricity, 27

Thornton — Dose- Book and Manual of
Prescription-Writing, 28

Van Valzab and Nisbet — Diseases of
the Stomach, • . • . 28

t, Prcf oration i«

C^ IH?

rf:^C«=

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- «.

. I

ClATk

HAyn

tt «8l*

N^mci

K^ncx

XAan

S^mp^

X^oH

B»ll— ^

ology,

M ^llory

^Tcchn

CHA

GrieXith--

Lai -«n6— 1

Tkic^ mas—
X> ictary,

;HEM

Bro *
VSTo -

of
Gri
Gri
Mei

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Of F^^^^

Cor^

Vier

Mor
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-z ■» X ^^

ir*

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th— <■»
Diets

- T\ and E

onald —
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\"=i

In Preparation for Early Publication*

AN AMERICAN TEXT-BOOK OP DISEASES OF THE EYE, EAR, NOSE,
AND THROAT.

Edited by G. E. de Schweinitz, M.D., Professor of Ophthalmology in the Jeffer-
son Medical College, Philadelphia; and B. Alexander Randall, M.D., Professor
of Diseases of the Ear in the University of Pennsylvania and in the Philadelphia
Polyclinic.

AN AMERICAN TEXT-BOOK OP PATHOLOGY.

Edited by John Guit^ras, M.D., Professor of General Pathology and of Morbid
Anatomy in the University of Pennsylvania; and David Riesman, M.D., Demoo-
strator of Pathological Histology in the University of Pennsylvania.

AN AMERICAN TEXT-BOOK OP LEGAL MEDICINE AND TOXICOLOGY.

Edited by Frederick Peterson, M.D., Clinical [Professor of Mental Diseases in
the Woman's Medical College, New York ; Chief of Clinic, Nervous Department,
College of Physicians and Sui^eons, New York ; and Walter S. Haines, M.D.,
Professor of Chemistry, Pharmacy, and Toxicology in Rush Medical College, Chicago,
Illinois.

STENGEL'S PATHOLOGY.

A Manual of Pathology. By Alfred Stengel, M. D., Physician to the
Philadelphia Hospital; Professor of Clinical Medicine in the Woman's Medical
College; Physician to the Children's Hospital; late Pathologist to the German
Hospital, Philadelphia, etc.

CHURCH AND PETERSON'S NERVOUS AND MENTAL DISEASES.

Nervous and Mental Diseases. By Archibald Church, M.D., Professor of
Mental Diseases and Medical Jurisprudence in the Northwestern University Medical
School, Chicago ; and F"rederick Peterson, M.I)., Clinical Professor of Mental
Diseases in the Woman's Medical College, New York ; Chief of Clinic, Nervous
Department, College of Physicians and Surgeons, New York.

HEISLER'S EMBRYOLOGY.

A Text-Book of Embryology. By John C. Heisler, M.D., Professor of
Anatomy in the Medico-Chirurgical College, Philadelphia.

KYLE ON THE NOSE AND THROAT.

Diseases of the Nose and Throat. lU- D. Bradkn Kyle, M. D., Clinical Pro-
fessor of l^ryni^olofj^' antl Khinoloj^', Jefferson Medical Colleuie, Philadelphia; Con-
sulting I^rynfjologist, Khinnlojijist, and Otoloi^isl, St. Al^ucs' HosjMlal; Bacteriologist
to the Philadelphia Orthopedic Hospital and Intirmar)- for Ner\ous Diseases, etc.

HIRST'S OBSTETRICS.

A Text-Book of Obstetrics. By Barton Cooke Hirst, M.D., Professor of
Obstetrics in the University of Pennsylvania.

WEST'S NURSING.

An American Text-Book of Nursing. By American Teachers. Edited by
Rc»BERTA M. West, Late Superintendent of Nurses in the Hospital of the University
of Pennsylvania.

LANE MEDICAL LIBRARY

JUN -9 133?

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