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A  MANUAL  OF  SURGERY 


STEWART 


A  MANUAL  OF  SURGERY 


FOR  STUDENTS  AND  PHYSICIANS 


BY 


FRANCIS  T.  SJEWART,  M.  D. 

PROFESSOR  OP  CUNICAL  SURGBRY.  JBPPBRSON  MBDICAL  COLLBGB;  SUROBON  TO  THB  GBRMANTOWN 
hospital;  OUT-PATIBNT  SURGBON  to  THB  PENNSYLVANIA   HOSPITAL 


SECOND  EDITION 


WITH  553  ILLUSTRATIONS 


PHILADELPHIA 

P.  BLAKISTON'S  SON  &  CO. 

1012  WALNUT  STREET 
1911 


COPYXIGHT,   191 1,  BY  P.  BlaKISTON'S  SoN   &  Co. 


Prinisd  h 
Tkg  MapU  Preu 


>>7 


TO 

DR.  ROBERT  G.  LE  CONTE 

AS  A  TRIBUTE   TO 
HIS  ABILITY   AS  A   SURGEON 


54,345 


PREFACE  TO  SECOND  EDITION. 


In  preparing  this  revision,  the  burden  of  which  has  been  considerably 
lightened  by  the  assistance  of  Dr.  W.  Estell  Lee  and  Dr.  Edward  J.  Klopp, 
painstaking  efforts  have  been  made  to  free  the  text  of  errors  and  ambiguities 
and,  particularly  in  those  sections  dealing  with  diagnosis  and  treatment,  to 
render  it  more  c6mprehensive  and  more  helpful.  In  the  endeavor  to  over- 
take surgical  progress  many  additions  have  been  found  necessary,  but  this 
new  matter  has  been  composed  with  the  chief  aim,  as  expressed  in  the 
original  preface,  always  in  view.  Thanks  to  the  ungrudging  attitude  of  the 
publishers  a  large  number  of  new  and  original  illustrations  also  have  been 
inserted. 

The  increased  amount  of  space  thus  demanded,  although  partly  offset 
by  sacrificing  obsolescent  methods,  by  simplifying  the  classification  of  certain 
subjects,  and  by  discarding  some  of  the  old  illustrations,  has  caused  the 
volume  to  grow  in  size,  but  it  is  hoped  that  in  its  enlarged  and  more  com- 
plete form  the  book  may  merit  as  kind  a  reception  as  that  accorded  its 
predecessor  and  prove  even  more  useful. 

F.  T.  S. 


vn 


PREFACE  TO  FIRST  EDITION. 


The  following  pages  have  been  prepared  for  the  undergraduate,  whose 
crowded  hours  demand  a  manual  stripped  of  verbiage  and  imessentials,  and 
for  the  medical  practitioner  who  seeks  a  guide  to  present-day  surgery.  The 
chief  desire,  therefore,  has  been  to  set  down  concisely  and  completely  those 
facts  which  the  student  must  know,  and  to  make  such  suggestions  in  diag- 
nosis and  treatment  as  will  best  aid  the  physician  in  his  daily  practice — in 
short  the  main  aim  has  been  to  be  brief  and  practical.  For  these  reasons 
historical  matter  and  bibliographical  references  have  been  omitted,  and  em- 
phasis has  been  laid  on  those  details  which  experience  teaches  to  be  of  the 
greatest  clinical  importance. 

Although  information  has  been  drawn  from  many  sources,  most  aid 
has  been  derived  from  the  text-books  of  Da  Costa,  Tillmanns,  and  Rose 
and  Carless,  from  the  operative  surgeries  of  Binnie,  Bryant,  and  Treves, 
and  from  the  systems  of  Ashhurst,  Delbet,  and  Le  Dentu,  and  Von  Berg- 
mann.  Von  Bruns,  and  Von  Mikulicz.  Mention  must  be  made,  likewise,  of 
the  freedom  with  which  the  ideas  of  Gibbon,  Harte,  Heam,  Hutchinson, 
Keen,  Le  Conte,  and  Roberts  have  been  appropriated. 

Owing  to  the  liberality  of  the  publishers  it  has  been  possible  to  insert 
many  original  illustrations;  most  of  those  labeled  Pennsylvania  Hospital 
have  been  made  from  photographs  secured  while  acting  for  Dr.  Robert 
G.  Le  Conte  in  that  institution.  Thanks  are  due  also  to  Dr.  Charles 
F.  Mitchell,  Dr.  James  W.  Macintosh,  and  Dr.  W.  Estell  Lee  for  valuable 
assistance  in  preparing  portions  of  the  manuscript,  in  reading  proof,  and  in 
making  the  index.  F.  T.  S. 


IX 


CONTENTS. 


Chapter  Page 

I.  Diagnosis  and  Rontgen  Ray i 

II.  Anesthesia 14 

III.  Bacteriology 25 

rV.  Surgical  Technic 34 

V.  Bandages 45 

VI.  Inflammation  and  Repair 58 

VII.  Suppuration 68 

VIII.  Ulceration,  Sinus,  Fistula 74 

DC.  Gangrene 79 

X.  Contusions  and  Wounds  (Mechanical  Injuries) 86 

XI.  Chemical,  Thermal,  and  Electrical  Injuries 97 

XII.  General    Conditions    and    Special    Infections    Following 

Wounds loi 

XIII.  Tumors  and  Cysts 136 

XIV.  Skin  and  Cutaneous  Appendages 158 

XV.  Vascular  System 169 

XVI.  Lymphatic  System 217 

XVII.  Nerves 221 

XVIII.  Muscles,  Tendons,  Bursas 235 

XK.  Bones 246 

XX.  Joints 296 

XXI.  Head 329 

XXII.  Spine 354 

XXIII.  Ear,  Neck,  Thyroid  Gland 375 

XXIV.  Respiratory  System 387 

XXV.  Breast 410 

XXVI.  Upper  Digestive  Apparatus 417 

XXVII.  Abdomen 440 

XXVIII.  Rectum  and  Anus 515 

XXDC.  Urinary  Organs * 523 

XXX.  Genital  Organs  (Male  and  Female) 548 

XXXI.  Extremities 614 

Index 643 


XI 


MANUAL  OF  SURGERY. 


CHAPTER  I. 
DIAGNOSIS  AND  RONTGEN  RAY. 

Diagnosis  is  the  process  whereby  the  nature  of  a  disease  is  determined; 
the  term  is  applied  also  to  the  result  of  this  process,  i.e.,  the  name  of  the 
disease.  In  many  instances  the  condition,  a  crushed  foot  for  instance,  is  self- 
evident  and  a  direct  diagnosis  may  be  made;  in  others  the  symptoms  suggest 
two  or  more  affections,  which  must  be  distinguished  by  differential  diagnosis; 
and  occasionally  a  diagnosis  by  exclusion  must  be  made;  thus  in  a  case 
of  retroperitoneal  sarcoma,  it  may  be  necessary  to  consider  all  the  other 
forms  of  abdominal  tumor,  and  to  rule  them  out  one  by  one,  because  of  the 
absence  of  special  symptoms,  until  finally  the  real  cause  of  the  growth  is 
determined.  In  order  to  be  complete  a  diagnosis  should  include  the  organ 
or  part  affected  {anatomical  diagnosis)  j  the  nature  of  the  affection  (pathological 
diagnosis),  the  constitutional  change  resulting  from  or  causing  the  local  lesion, 
the  presence  or  absence  of  independent  or  associated  maladies,  and  the  indi- 
viduality of  the  patient. 

A  diagnosis  is  made  by  interrogating  the  patient  (subjective  symptoms)  and 
by  physical  examination  {objective  symptoms  or  signs).  The  chief  factors  in 
diagnosis  are  to  obtain  correct  facts,  to  interpret  them  properly,  to  know  what 
to  look  for,  and  above  all  to  look.  "More  mistakes  are  made  by  want  of 
looking  than  by  want  of  knowing."  In  practice  the  analytical  method  is  usu- 
ally employed;  the  attention  is  first  directed  to  the  offending  part,  and  by 
examination,  coupled  with  questioning  the  patient,  one  considers  the  condi- 
tions most  likely  to  be  the  cause  of  the  symptoms,  and  then  by  further  examin- 
ation the  diagnosis  is  finally  reached.  The  synthetical  or  historical  method  is 
more  scientific,  more  accurate,  and  better  adapted  for  the  keeping  of  written 
records.  It  consists  of  (a)  the  history  {anamnesis) y  which,  with  the  name  of 
the  patient  and  the  date  of  examination,  includes  (i)  the  age,  (2)  address  and 
nationality,  (3)  sex,  (4)  social  condition,  (5)  family  history,  (6)  previous  his- 
tor}',  and  (7)  the  history  of  the  present  illness;  and  (b)  the  physical  examination 
{status  presens)y  which  comprises  (8)  an  examination  of  the  affected  part,  (9) 
an  examination  of  regions  clinically  related  to  the  affected  part,  and  (10)  a 
general  examination  of  the  whole  body. 

I .  The  apparent  as  well  as  the  real  age  should  be  noted.  In  childhood 
irritability  of  the  nervous  system  is  marked,  and  high  fever  and  convulsions 
may  be  caused  by  trivial  affections  which  would  cause  no  such  disturbances 
in  the  adult.  A  malignant  neoplasm  in  a  child  would  probably  be  a  sarcoma, 
in  later  life  a  carcinoma.     Ulcers  in  children  may  be  due  to  tuberculosis 


2  DIAGNOSIS  AND  RONTGEN   RAY. 

or  congenital  syphilis;  in  adults  syphilitic  and  traumatic  ulcers  are  frequent; 
later  in  life  the  varicose  ulcers  and  epitheliomata  predominate.  In  the 
child  an  injury  to  an  extremity  may  result  in  a  greenstick  fracture  or  epiph- 
yseal separation,  the  same  in  an  adult  might  cause  a  complete  fracture  or  a 
dislocation.  In  intestinal  obstruction  one  would  suspect  imperforate  anus  in 
the  new  bom,  intussusception  in  infancy,  and  impacted  feces  or  cancer  in 
old  age.  In  children  difficulty  in  urination  would  probably  be  due  to  phimo- 
sis or  calculus,  in  adults  to  stricture,  in  old  age  to  enlarged  prostate.  In 
childhood  infantile  paralysis,  congenital  syphilis,  rickets,  adenoids,  prolapse 
of  the  anus,  rectal  polypi,  malformations,  nevi,  noma,  foreign  bodies  in  the 
air  passages,  tuberculous  lymph  glands,  acute  infectious  osteomyelitis, 
postpharyngeal  abscess,  hemophilia,  renal  sarcoma,  hydrocephalus,  cretinism, 
and  intussusception  are  common;  in  adokscence  appendicitis,  gastric  ulcer, 
osteoma,  chondroma,  tuberculosis  of  bones  and  joints,  and  sexual  disorders 
are  frequent;  in  middle  age  aneurysm,  carcinoma,  floating  kidney,  mollities 
ossium,  and  gall-stones  are  most  apt  to  occur;  in  old  age  hypertrophy  of  the 
prostate  and  degeneration  of  the  circulatory  apparatus,  leading  to  gangrene 
and  other  disorders,  are  prone  to  develop.  Hernia  is  most  frequent  at  the 
extremes  of  life.  Infancy  and  old  age  do  not  stand  operations  well,  but 
infants  who  escape  the  immediate  dangers  of  operation  often  convalesce 
more  rapidly  than  adults. 

2.  Not  only  the  present,  but  previous  addresses  should  be  ascertained,  as 
well  as  the  place  of  birth.  Goiter  is  prevalent  in  Switzerland,  Tyrol,  South- 
eastern France,  Northern  Italy,  parts  of  England,  and  in  the  Himalayas  and 
Andes;  leprosy  in  Norway  and  the  tropics;  bilharzia  hematobia,  tetanus, 
filariasis,  and  hepatic  abscess  in  the  tropics;  rachitis  in  densely  populated 
centers;  vesical  calculus  in  India  and  parts  of  England;  hydatid  disease  in 
Iceland  and  Australia.  The  Negro  is  more  susceptible  to  tuberculosis, 
aneurysm,  elephantiasis,  tetanus,  and  benign  neoplasms,  especially  the  fibro- 
mata; less  liable  to  malignant  disease,  stone  in  the  bladder,  varicose  veins, 
appendicitis,  congenital  deformity,  enlarged  prostate,  and  gall-stones;  and 
less  resistant  to  operative  procedures.  The  Hebrew  suffers  frequently  from 
intestinal  and  rectal  disorders,  and  is  more  prone  to  develop  diabetes  with 
its  surgical  complications;  his  symptoms  should  be  analyzed  with  due  con- 
sideration to  his  highly  sensitive  nervous  system. 

3.  The  sex  is  occasionally  of  some  importance  in  making  a  diagnosis.  Ex- 
cluding diseases  of  the  reproductive  orgnnSj  females  are  more  liable  to  goiter, 
floating  kidney,  enteroptosis,  gall-stones,  mollities  ossium,  Raynaud's  disease, 
myxedema,  stricture  of  the  rectum,  tuberculous  peritonitis,  arthritis  defor- 
mans, hysteria,  and  functional  nervous  troubles,  but  they  stand  operations 
better  than  men.  Males  are  more  apt  to  develop  aneurysm,  actinomycosis, 
appendicitis,  cerebral  abscess,  cystic  kidney,  cirrhosis  of  the  liver,  Dupuy- 
tren's  contraction,  hematoma  auris,  hemophilia,  intussusception,  lymphade- 
noma,  pancreatitis,  stricture  of  the  urethra,  stone  in  the  bladder,  cancer  of 
the  lip,  stomach  and  rectum,  and  conditions  produced  by  exposure,  hard 
work,  and  injurious  habits. 

4.  Under  the  social  condition  note  whether  the  patient  is  single  or  mar- 
ried, widow  or  widower.  If  a  woman,  elicit  the  menstrual  histor}',  the  amount 
and  character  of  leukorrhea,  the  number  of  children  and  miscarriages,  the 
date  of  the  last  confinement,  and  the  presence  or  absence  of  puerperal  com- 
plications.   Ascertain  the  nature  of  previous  occupations  as  well  as  the  present 


THE  HISTORY.  3 

one.  Active  occupations  predispose  to  hernia,  aneurysm,  and  various  forms 
of  injury;  sedentary  occupations  to  gall-stones,  hemorrhoids,  ulcer  of  the 
stomach,  and  functional  neuroses;  standing  occupations  to  varicose  veins  and 
flat-foot.  Certain  occupations,  by  forcing  the  individual  to  assume  a  particular 
attitude  or  to  use  a  certain  set  of  muscles,  produce  alterations  in  the  form  of 
the  body,  thus  the  shoemaker,  tailor,  and  rag-picker  become  round  shouldered, 
and  one  who  carries  a  load  on  the  same  shoulder  day  after  day,  or  who  uses  one 
arm  or  leg  constantly,  may  develop  scoliosis.  Constant  pressure  on  a  part, 
necessitated  by  many  occupations,  may  produce  deformity,  callosities, 
burse,  and  even  neoplasms.  Skin  handlers  and  wool-sorters  are  predisposed 
to  anthrax;  hostlers  to  glanders  and  tetanus;  butchers,  doctors,  and  veterinar- 
ians to  anatomical  tubercle  and  other  infections;  painters,  potters,  plumbers, 
lead-makers,  tailors,  and  seamstresses  to  lead  poisoning;  match-makers  to 
phosphorous  necrosis  of  the  lower  jaw;  morocco  workers  and  those  who  use 
adds  to  ulcers  of  the  hands  and  forearms;  and  those  who  handle  grain  to 
actinomycosis. 

5.  The  family  history  includes  an  investigation  into  the  diseases  which 
have  occurred,  or  the  cause  of  death,  in  the  parents,  grandparents,  uncles  and 
aunts,  brothers  and  sisters,  husband  or  wife,  and  children.  Especially  to  be 
inquired  for  are  calculus,  malformations,  hemophilia,  syphilis,  tuberculosis, 
rheumatism,  and  alcoholism. 

6.  In  the  previous  history  note  the  habits  of  the  individual,  especially 
regarding  alcohol,  which  predisposes  to  aneurysm,  delirium  tremens,  tuber- 
culosis, neuritis,  etc. ;  tobacco,  which  predisposes  to  carcinoma  of  the  mouth 
and  nervousness;  tea  and  coffee,  with  reference  to  neuroses  and  gastric 
disorders;  and  the  sexual  life,  particularly  as  to  excesses  and  masturbation. 
Inquiry  should  be  made  also  for  previous  injuries,  diseases,  and  operations. 
Injuries  may  be  followed  by  sarcoma,  tuberculosis,  epilepsy,  abscesses,  and 
many  other  disorders.  Among  the  diseases  which  may  have  occurred  the 
most  important  are  syphilis  and  tuberculosis.  Certain  diseases  predispose 
to  subsequent  attacks  of  the  same  malady;  among  such  are  appendicitis,  sal- 
pingitis, gall-stones,  kidney-stones,  erysipelas,  delirium  tremens,  neuralgia, 
rheumatism.  Others  render  a  patient  more  vulnerable  to  dissimilar  affec- 
tions; appendicitis,  gall-stones,  and  osteomyelitis  often  follow  typhoid  fever; 
stricture  of  any  of  the  canals  of  the  body,  ulceration  involving  those  canals; 
vesical  calculus,  renal  colic;  arthritis,  gonorrhea.  Operations  are  responsible 
for  a  host  of  evils,  e.g.,  laparotomy  may  be  followed  by  hernia,  adhesions, 
or  intestinal  obstruction,  ovariectomy  by  amenorrhea,  gastroenterostomy  by 
ulcer  of  the  jejunum,  thoracotomy  by  scoliosis,  trephining  by  epilepsy,  thyroid- 
ectomy by  tetany,  myxedema,  or  aphonia.  The  history  of  removal  of  a  tumor 
may  explain  obscure  brain  symptoms  due  to  metastases.  We  recently  saw 
a  case  in  which  a  hernia  cerebri  was  incised  for  an  abscess,  a  mistake  that 
could  not  have  occurred  had  the  physician  known  that  a  decompressive 
operation  had  been  performed. 

7.  The  history  of  the  present  illness  includes  not  only  the  symptoms, 
but  the  supposed  cause,  the  duration,  the  manner  of  onset,  and  the  previous 
treatment.  As  to  the  supposed  cause,  there  may  be  a  history  of  exposure  to  one 
of  the  infective  diseases,  such  as  erysipelas  or  syphilis;  in  this  connection  it  is 
important  to  ascertain  the  time  elapsing  between  the  exposure  to  infection 
and  the  beginning  of  the  symptoms,  i.e.,  the  period  0/ incubation.  The  dura- 
tion sometimes  has  considerable  bearing  on  the  diagnosis,  e.^.,  a  luxcvoi  >n\v\05\ 


4  DIAGNOSIS  AND   RONTGEN  RAY. 

has  lasted  a  number  of  years  is  probably  benign,  one  which  has  lasted  but  a 
few  months  and  is  growing  rapidly  is  probably  malignant.  The  onset  is 
sudden  in  appendicitis,  perforative  peritonitis,  various  colics,  and  acute  in- 
fections; aneurysm,  tumors,  ascites,  and  strictures  of  various  kinds  come  on 
slowly.  The  previous  treatment  may  be  of  assistance  in  diagnosis;  it  may  have 
failed,  e.g.,  a  tumor  or  ulcer  unmodified  by  mercury  and  potassium  iodid  is 
probably  not  syphilitic,  chills  uninfluenced  by  quinin  are  not  malarial; 
it  may  have  succeeded,  e.g.,  a  scrotal  tumor  disappearing  temporarily  after 
withdrawal  of  a  serous  fluid  is  a  hydrocele,  after  taxis  a  hernia;  it  may  have 
intensified  the  symptoms,  e.g.,  intestinal  obstruction  is  made  worse  by  purga- 
tives, internal  hemorrhage  by  stimulants;  or  it  may  have  created  additional 
mischief,  e.g.,  drug  eruptions,  mercurial  stomatitis,  catheter  cystitis,  carbolic 
acid  gangrene,  iodoform  delirium,  splint  sores,  crutch  palsy,  ligature  sinus, 
paraflGm  tumor.  X-ray  bum,  cystoscopic  ulcer.  It  may  also  obscure  the 
diagnosis,  e.g.,  chancre  and  epithelioma  may  be  disfigured  by  caustics,  the 
symptoms  of  peritonitis  may  be  clouded  by  opium,  and  an  unconscious  man 
who  has  been  given  whiskey  may  be  wrongly  treated  as  an  alcoholic. 

8.  The  local  ezamication  needed  will  usually  be  indicated  by  the  patient. 

By  inspection  the  size,  shape,  situation,  and  color  of  the  lesion  may  be 
determined,  as  well  as  abnormal  motion,  and  the  lesion  may  be  studied  with 
reference  to  the  influence  of  posture,  active  or  passive  motions,  etc. 

Whenever  possible  the  size  of  a  lesion  should  be  expressed  in  exact  terms, 
thus  a  tumor  may  be  measured  with  calipers  or  tape  measure,  instead  of  being 
compared  in  size  with  an  orange  or  other  object.  The  length  of  a  limb  com- 
pared with  that  of  its  fellow  is  of  the  greatest  value  in  the  diagnosis  of  fractures 
and  dislocations,  as  are  also  the  length  of  the  urethra  in  enlarged  prostate,  the 
width  of  the  intercostal  spaces  in  empyema,  and  the  size  of  the  head  in  hy- 
drocephalus and  microcephalus. 

The  sJtape  may  be  accurately  determined  by  a  plaster  cast,  soft  lead  strips, 
photographs,  or  autoprints,  e.g.,  in  flat-foot.  It  is  frequently  of  assistance 
in  recognizing  surgical  conditions,  especially  fractures  and  dislocations.  As 
other  examples  may  be  mentioned  the  notched  teeth  of  hereditary  syphilis, 
the  pear-shaped  swelling  of  a  hydrocele,  and  the  fusiform  enlargement  of  a 
tuberculous  joint. 

The  situation  of  a  lesion  may  indicate  not  only  the  anatomical  but  also 
the  pathological  diagnosis  (see  diagnosis  of  ulcers  and  tumors). 

The  color  should  always  be  observed.  Localized  yellowish  discoloration 
may  be  caused  by  an  old  bruise  or  a  nitric  acid  stain;  bronze  patches  by 
syphilis,  tuberculosis,  scurvy,  abdominal  tumors,  oil  of  cade,  blistering  agents, 
exposure  to  electric  light  or  the  X-ray,  and  the  pressure  of  garters,  belts,  or 
collar  buttons;  white  patches  by  ergotism,  scars,  frost  bite,  carbolic  acid, 
leukoplakia,  Raynaud's  disease,  neuritis,  and  leprosy;  redness  by  acute  in- 
flammation or  hyperemia  (disappears  on  pressure  but  returns  immediately 
on  removal  of  the  pressure)  or  by  dyes,  etc.  (does  not  disappear  on  pressure 
and  may  be  washed  off) ;  hlueness,  or  lividity,  by  venous  obstruction,  nevus 
(returns  quickly  after  pressure  is  removed),  beginning  gangrene  (returns 
slowly  after  the  relief  of  pressure),  and  ecchymosis  (unaffected  by  pressure); 
blackness  by  moles,  warts,  gangrene,  and  melanotic  sarcoma;  greenish  dis- 
coloration by  chloroma;  change  of  color  by  nevi;  and  linear  discoloration  by 
lymphangitis,  rarely  phlebitis  and  neuritis.  The  mingling  of  purple  and  red 
is  often  observed  over  malignant  growths.    Petechia  and  ecchymosis  are  un- 


PALPATION.  5 

affected  by  pressure;  they  occur  in  many  diseases,  but  it  will  suffice  here  to 
mention  only  those  which  interest  the  surgeon,  viz.  scurvy,  hemophilia,  io- 
dism,  jaundice,  pyemia,  septicemia,  snake  poisoning,  and  lightning  stroke. 
Occurring  several  days  after  an  injury,  ecchymosis  indicates  rupture  of 
some  deep  structure,  such  as  muscle  or  bone. 

Absence  of  motion  is  noticed  in  most  inflammatory  troubles,  e.  g.,  the  chest 
in  pleurisy,  the  abdomen  in  peritonitis;  it  is  caused  by  a  tonic  contraction 
of  die  muscles,  which  gives  another  important  sign,  rigidity.  Pulsation  may 
be  expansile  (the  swelling  enlarges  in  all  its  diameters  with  each  cardiac 
systole),  e.g.,  in  aneurysm,  tumore  communicating  with  the  cranial  cavity, 
and  very  vascular  growths,  such*  as  goiter,  some  sarcomata,  and  certain 
angiomata;  or  transmitted  (the  movement  is  in  one  direction  only),  e.g.,  in 
tumors  situated  over  an  artery  and  in  the  abdomen  of  nervous  individuals. 
Transmitted  pulsation  ceases  if  the  tumor  can  be  lifted  or,  by  posture,  made 
to  fall  away  from  the  artery.  Increased  motion  is  exemplified  in  the  hurried 
respiration  of  intrathoracic  disease,  and  the  active  peristalsis  of  intestinal 
obstruction. 

In  addition  to  the  aids  to  the  eye  which  have  already  been  mentioned  are 
the  microscope,  instruments  for  looking  into  cavities  of  the  body  (ophthalmo- 
scope, laryngoscope,  bronchoscope,  etc.),  aspiration  to  determine  the  con- 
tents of  a  cavity  or  swelling,  and  exploratory  incision.  Diaphany,  ortrans- 
lucency,  is  employed  to  detect  disease  of  the  maxillary  antrum,  by  placing  a 
light  in  the  mouth;  to  determine  the  size  of  the  stomach,  by  passing  a 
light  into  this  organ;  and  to  ascertain  the  nature  of  some  swellings,  such  as 
hydrocele  and  meningocele,  by  placing  the  tumor  between  the  light  and  the 
eye,  in  a  dark  room,  and  looking  through  the  barrel  of  a  stethoscope  or  a 
tube  of  ))aper. 

Palpation  is  used  to  corroborate  inspection,  to  ascertain  the  size,  shape, 
position,  etc.,  of  a  lesion  which  cannot  be  seen,  e.g.,  by  rectal  or  vaginal 
examination;  and  to  determine  the  consistency,  sensation,  mobility,  and 
local  temperature.  The  consistency  of  normal  tissues  may  be  modified  by  the 
presence  of  solids,  fluids,  or  gases.  Solids,  of  which  the  most  prominent  ex- 
ample is  tumor  formation,  may  cause  the  tissues  to  become  harder  (osteoma, 
etc.)  or  softer  (myxoma,  etc.).  Fluid  infiltrates  the  tissues  giving  rise  to 
edema,  or  accumulates  in  a  cavity  giving  rise  to  fluctuation.  Edema, 
which  is  shown  by  the  persistence  of  an  indentation  after  digital  pressure, 
occurs  in  contusions,  inflammations,  suppuration,  obstruction  to  the  venous  or 
lymphatic  circulation,  extravasation  of  urine,  and  in  diseases  of  the  heart, 
lungs,  liver,  and  blood.  Hysterical  edema  and  myxedema  do  not  pit  on 
pressure.  Fluctuation  is  the  wave  felt  by  the  hand  on  one  side  of  a  swelling 
when  a  sharp  tap  is  given  to  the  other  side.  In  order  to  obviate  the  mistake 
due  to  a  wave  transmitted  through  the  skin  and  subcutaneous  tissues,  the 
hand  of  an  assistant  may  be  placed  on  the  swelling,  between  the  hands  of  the 
examiner.  This  sign  is  often  difficult  to  obtain  when  the  fluid  lies  beneath 
firm  fascia  or  thick  muscle,  is  small  in  quantity,  or  under  great  tension,  and 
it  is  often  fallacious  in  semisolid  tumors.  Another  sign,  which  is  often  called 
fluctuation,  is  the  raising  of  the  fingers  of  one  hand  when  the  fingers  of  the 
other  hand  push  into  the  swelling;  it  may  be  obtained  in  normal  tissues,  in 
soft,  elastic  or  movable  tumors,  and  in  tumors  containing  gas,  as  well  as  in 
swellings  which  contain  fluid.  Error  may  sometimes  be  avoided  in  eliciting 
this  sign,  e.g.,  in  muscular  tissue,  by  testing  it  longitudinally  as  well  as  trans- 


6  DIAGNOSIS  AND   RONTGEN  RAY. 

versely.  Gas  in  the  tissues  (emphysema)  causes  a  doughy  swelling  which 
crepitates  on  pressure.  This  crepitus^  which  is  crackling  in  character, 
should  not  be  confused  with  that  of  fracture  or  osteoarthritis,  which  is  harsh 
and  osseous;  of  epiphyseal  separation,  which  is  soft  and  cartilaginous;  of 
synovial  inflammation,  which  is  creaking  and  leathery;  or  with  that  of  blood 
dot  or  hydatid  disease,  which  is  moist  and  yielding.  In  certain  bone  diseases 
(cysts,  sarcomata,  craniotabes,  disease  of  the  frontal  and  maxillary  sinuses)  a 
crackling  sensation  may  be  obtained  on  pressure  (parchment  crepitus),  owing 
to  thinning  of  the  osseous  tissue;  and  in  synovial  inflammations  with  rice 
bodies  a  special  form  of  crepitation  may  be  obtained  by  forcing  the  bodies 
along  the  sac.  Related  to  crepitus  is  thrill,  which  may  be  felt  over  an  aneu- 
rysm or  vascular  tumor,  and  sometimes  in  the  case  of  a  foreign  body  in  the  air 
passages. 

Aside  from  pain,  disorders  of  sensation  (hyperesthesia,  hypesthesia, 
anesthesia,  paresthesia,  alteration  of  the  heat  sense  or  thermoesthesia,  of  the 
pressure  sense,  etc.)  are  mainly  of  value  in  diseases  and  injuries  of  the  nerv- 
ous system.  Pain  is  the  most  frequent  symptom;  and  tenderness,  which  is 
of  more  value  to  the  surgeon  than  pain,  is  pain  on  pressure.  Its  situation 
does  not  always  indicate  the  seat  of  disease.  In  a  lesion  near  the  origin  of 
a  nerve  pain  may  be  felt  in  the  periphery;  in  a  lesion  at  the  periphery,  at  the 
end  of  another  branch  of  the  same  nerve.  Certain  diseases  of  the  brain  and 
spinal  cord  produce  pain  at  the  nerve  terminations.  General  pain  or  aching 
of  the  body  may  be  present  in  acute  infections  or  intoxications.  If  pain 
corresponds  exactly  to  the  distribution  of  a  nerve,  the  cause  will  probably 
be  found  along  the  trunk  or  at  the  root  of  that  nerve;  the  pain  of  a  local  lesion 
does  not  confine  itself  to  the  distribution  of  a  single  nerve.  Absence  of  tender- 
ness in  a  painful  region  generally  but  not  invariably  indicates  that  the  pain  is 
referred,  but  even  in  referred  pain  tenderness  may  be  present.  Pain  in  the 
top  or  the  back  of  the  head  may  be  due  to  pelvic  disease;  in  the  supraorbital 
regions  and  the  temples  to  disease  of  the  eye;  in  the  side  of  the  head  and  the 
ear  to  disease  of  the  teeth ;  in  the  forehead  to  disease  of  the  nose  or  the  naso- 
pharynx; above  the  left  clavicle  to  disease  of  the  colon  or  the  diaphragm;  in 
the  side  of  the  chest  to  disease  of  the  vertebra  or  the  spinal  cord;  in  the  right 
shoulder  to  hepatic  disease;  in  the  nipple  and  the  breast  to  uterine  disease; 
between  the  shoulders  to  disease  of  the  stomach  and  intestines;  in  the  sacral 
region  to  intrapelvic  disorders  or  disease  of  the  testicle,  rectum,  or  hip;  in  the 
epigastrium  or  any  portion  of  the  abdomen  to  diseases  of  the  spine  or  the 
spinal  cord;  along  the  outer  side  of  the  thigh  and  in  the  heel  to  ovarian  dis- 
ease; at  the  inner  side  of  the  knee-joint  to  disease  of  the  hip;  in  the  sole  of  the 
foot  to  disease  of  the  prostate,  ovary,  or  rectum;  in  the  head  of  the  penis 
to  vesical  calculus. 

The  character  of  pain  is  sharp,  knife-like,  or  lancinating  in  acute  inflam- 
mations of  serous  membranes;  dull  or  bruise-like  in  inflammations  of  mucous 
membrane,  connective  tissue,  and  parenchymatous  viscera,  and  in  chronic  in- 
flammation; paroxysmal  in  floating  kidney,  labor,  neuralgia,  colics,  spinal 
tumor,  and  intestinal  obstruction ;  shifting  in  hysteria,  rheumatism,  and  flatu- 
lence ;  gnawing  or  boring  in  cancer,  diseases  of  bone,  and  sometimes  in  lithemia ; 
aching  in  muscles;  burning  and  itching  in  the  skin;  smarting  or  scalding  in  the 
urethra;  nauseating  in  the  testicle;  throbbing  in  suppurative  inflammations; 
bearing  down  (tenesmus)  in  cystitis,  proctitis,  and  labor.  Pain  which  sud- 
denly ceases  may  be  due  to  the  passage  of  a  stone,  the  sudden  overcoming  of 


GENERAL  EXAMINATION  ^ 

some  obstruction,  or  to  beginning  gangrene.  It  is  also  studied  with  reference 
to  the  effect  of  pressure,  change  of  weather,  movements,  etc.  Most  pains 
are  worse  at  ni^t,  particularly  those  due  to  carcinoma,  diseases  of  bone, 
rheumatism,  locomotor  ataxia,  and  neuritis.  Much  allowance  must  be  made 
for  the  variation  in  individual  tolerance  to  pain.  The  degree  of  tenderness 
may  to  some  extent  be  gauged  by  the  effect  upon  the  facial  expression  and  the 
pulse,  and  by  the  presence  or  absence  of  involuntary  muscular  rigidity. 

Abnormal  mobility  is  found  in  fractures,  ruptures  of  ligaments,  dissolu- 
tion of  joints,  floating  kidney,  etc.;  more  or  less  immobility  in  ankylosis, 
inflammatory  or  neoplastic  infiltrations,  and  in  growths  springing  from  a 
fixed  portion  of  the  body,  e.g.,  osteoma. 

The  local  temperature  is  elevated  in  inflammatory  diseases,  lowered  in 
gangrene  and  trophic  lesions.  It  may  be  accurately  measured  with  a  surface 
thermometer. 

As  aids  to  palpation  may  be  mentioned  probes  and  sounds,  placing  the 
patient  in  various  postures,  and  measures  for  relaxing  muscles,  particularly 
general  anesthesia. 

Percussion  is  employed  to  outline  organs,  determine  the  composition  of 
accumulations  in  cavities  and  the  presence  of  gas  in  tumors,  detect  points  of 
tenderness,  and  occasionally,  as  in  hydrocephalus  and  certain  fractures,  to 
elicit  the  cracked-pot  sound.  Auscultation  is  used  to  detect  disease  in  the 
chest,  the  presence  or  absence  of  intestinal  peristalsis,  the  bruit  of  an  aneu- 
rysm, the  sound  of  a  fetal  heart,  the  succussion  splash  of  a  dilated  stomach, 
the  deglutition  sound,  and  the  garrulity  of  wounds  communicating  with  the 
respiratory  apparatus.  Crepitus  which  cannot  be  felt  may  occasionally  be 
heard,  e.g.,  in  fractures  of  the  ribs.  As  aids  to  auscultation  may  be  mentioned 
the  stethoscope,  the  phoriendoscope,  and  the  telephonic  probe. 

The  sense  of  smell  may  reveal  necrosis  of  bone,  gangrene  of  soft  tissues, 
fecal  fistulae,  stercoraceous  vomitus,  and  ammoniacal  urine.  The  odor  of  the 
breath  is  of  value  in  diagnosticating  uremia,  acetonemia,  diabetes,  and 
some  forms  of  poisoning.  The  odor  in  pyemia  is  that  of  hay,  in  hepatic 
abscess  liverish,  in  actinomycosis  earthy,  in  jaundice  and  peritonitis  musty,  in 
the  critically  ill  cadaveric. 

9.  An  examination  of  the  regions  clinically  related  to  the  affected 
part  is  of  the  greatest  importance.  A  part  should  always  be  compared  with 
that  of  the  opposite  side  of  the  body,  to  detect  deviations  from  the  normal, 
e.g.,  in  fractures  and  dislocations;  and  to  ascertain  whether  the  same  lesion  is 
present  on  both  sides,  e.g.,  hernia,  tuberculous  epididymitis,  chronic  mastitis, 
salpingitis,  syphilitic  eruptions,  and  many  other  conditions  are  often  bilateral. 
In  local  infections  and  neoplasms  the  anatomically  related  lymph  glands 
must  be  examined,  and  conversely  in  lymphadenitis  the  regions  which  the 
lymph  glands  drain  must  be  scrutinized.  One  should  make  sure  the  pidse  is 
present  below  fractures  and  dislocations,  motion  and  sensation  below  wounds; 
examine  the  superficial  veins  for  distention  in  tumors,  the  muscles  for  atrophy 
in  joint  disease,  the  spine  for  scoliosis  in  asymmetry  of  the  lower  limbs,  the 
knee  for  effusion  in  fractures  of  the  femur,  the  liver  for  cirrhosis  in 
hemorrhoids. 

10.  A  careful  general  examination  is  too  often  neglected.  Attention 
need  be  called  only  to  the  fact  that  stomatitis  may  be  caused  by  chronic 
nephritis;  furunculosis  and  gangrene  by  diabetes;  varicose  veins  of  the  leg  by 
disease  of  the  heart;  amenorrhea  by  anemia;  ulcer  on  the  sole  of  the  foot  by 


8  DIAGNOSIS  AND  RONTGEN  RAY. 

disease  of  the  spinal  cord;  and  to  the  fact  that  abdominal  disorders  may  be 
simulated  by  disease  of  the  lungs,  spine,  spinal  cord,  and  by  hysteria.  The 
height  and  weight  should  be  noted.  A  progressive  decrease  in  height  is  found 
in  diseases  like  arthritis  deformans.  The  patient's  best  weight  and  his 
present  weight  should  be  taken.  Cachexia  means  marked  emaciation,  great 
weakness,  and  profoimd  anemia;  it  is  seen  in  carcinoma,  diabetes,  tubercu- 
losis, chronic  suppuration,  large  ovarian  cysts,  hereditary  syphilis,  organic 
disease  of  the  stomach,  stricture  of  the  esophagus,  and  in  obstructions  of  the 
thoracic  duct. 

The  facial  expression  is  of  great  value  to  the  experienced  eye.  As  exam- 
ples may  be  mentioned  the  vacant  expression  of  adenoids,  the  anxious  expres- 
sion of  peritonitis,  the  pale  frightened  face  of  acute  hemorrhage,  the  threaten- 
ing and  suspicious  facies  of  delirium  tremens,  the  staring  expression  of  exoph- 
thalmic goiter,  the  mask-like  expression  of  paralysis,  the  unmeaning  grimaces 
of  hysteria,  the  risus  sardanicus  of  tetanus,  and  the  weazened  face  of  heredi- 
tary syphilis.  The  Hippocratic  face — "The  sharp  nose,  hollow  eyes, 
collapsed  temples;  the  ears  cold,  contracted,  and  their  lobes  turned  out; 
the  skin  about  the  forhead  being  rough,  distended  and  parched;  the  color 
of  the  whole  face  brown,  black,  livid  or  lead  colored," — is  the  face  of 
impending  death. 

Posture, — Lying  on  the  back  and  constantly  slipping  toward  the  foot  of 
the  bed  is  seen  in  acute  infections  or  great  weakness,  the  dorsal  position  with 
both  legs  drawn  up  in  peritonitis,  the  ventral  posture  in  intestinal  colic, 
sometimes  in  abdominal  aneurysm  and  spinal  caries.  The  patient  may  lie 
upon  the  affected  side  in  empyema,  and  be  coiled  up  on  one  side  in  cerebral 
irritability  and  in  various  forms  of  colic.  Great  restlessness  in  bed  indicates 
nervous  irritability,  acute  hemorrhage,  sometimes  shock ;  it  is  a  bad  sign  in  the 
critically  ill.  The  body  may  be  bent  forward  so  that  it  rests  upon  the  fore- 
head and  feet  {emprosthotonos) ,  backward  so  that  it  rests  upon  the  occiput 
and  heels  (opisthotmios) ,  or  laterally  (pleurosthotonos)  in  meningitis,  strychnin 
poisoning,  tetanus,  or  hysteria.  Orthopnea y  in  which  the  patient  sits  up  and 
grasps  some  firm  object  in  order  to  fix  the  accessory  muscles  of  respiration,  is 
often  observed  in  diseases  of  the  heart  and  lungs,  large  accumulations  in  the 
thorax  or  abdomen,  and  in  foreign  bodies  in  or  stenosis  of  the  air  passages.  A 
shufiiing  gait  with  a  rigid  body  suggests  caries  of  the  spine,  a  waddling  gait 
coxa  vara  or  congenital  dislocation  of  the  hips.  The  head  is  thrown  back  and 
the  feet  apart  in  large  abdominal  tumors  and  accumulations. 

The  pulse,  temperature,  and  respirations  should  be  taken,  and  one  should 
ascertain  the  condition  of  the  organs  of  digestion,  the  spleen,  the  genitouri- 
nary apparatus,  the  heart  and  blood  vessels,  the  lungs,  the  organs  of  special 
sense,  and  the  nervous  system.  In  special  cases  chemical  and  microscopical 
examinations  of  various  secretions,  excretions,  and  discharges  may  be 
required. 

Blood  Examinations. — The  red  cells  may  be  increased  in  number 
(polycythemia)  when  the  blood  is  concentrated,  e.g.,  as  the  result  of  profuse 
sweating,  vomiting,  diarrhea,  starvation,  and  exercise;  when  oxygenation  is 
impaired,  e.g.,  by  high  altitudes,  cyanosis,  and  cardiac  and  pulmonary 
disease;  in  myxedema,  purpura,  diabetes,  and  direct  blood  transfusion ;  and  as 
the  result  of  active  hemogenesis,  thus  after  hemorrhages  the  blood-making 
organs  may  in  time  supply  more  than  enough  cells  to  replace  those  which 
have  been  lost.     Oligocythemia  (decrease  in  the  number  of  red  cells)  takes 


LEUKOCYTOSIS.  9 

place  when  the  blood  is  diluted  by  the  ingestion  of  large  amounts  of  fluid, 
saline  infusion,  and  when  the  genetic  powers  are  overtaxed,  e.g.,  by  child- 
birth, lactation,  and  at  puberty.  Anemia,  or  a  reduction  in  the  number  of 
red  cells  and  the  percentage  of  hemoglobin,  may  be  primary,  in  which  no 
cause  can  be  found,  e.g.,  pernicious  anemia  and  chlorosis;  or  secondary,  the 
most  common  causes  of  which  are  acute  and  chronic  hemorrhage,  bacterial 
infections,  malignant  growths,  malnutrition,  intestinal  and  blood  parasites, 
and  chemical  poisons,  such  as  lead,  mercury,  and  the  coal-tar  derivatives. 

Mikulicz  believed  that  no  general  anesthetic  should  be  given  when  the 
hemoglobin  is  below  30  per  cent.,  but  surgeons  do  not  adhere  to  this  rule,  ex- 
cepting, perhaps,  in  cases  in  which  delay  will  cause  not  only  no  further  de- 
terioration in  the  quality  of  the  blood,  but  also  some  improvement. 

Leukocytosis,  particularly  of  the  polynuclear  cells,  indicates  an  inflamma- 
tory lesion,  but  only  when  other  symptoms  of  the  lesion  are  present,  and  only 
when  other  causes  for  an  increase  in  the  white  cells  have  been  excluded; 
hence,  from  the  standpoint  of  surgical  diagnosis,  leukocytosis  may  be  divided 
into  the  noninfectious  and  the  infectious. 

Noninfectious  leukocytosis  may  be  physiological,  e.g.,  in  infants,  during 
pregnancy  and  digestion,  and  after  exercise  and  bathing.  It  may  occur  in 
rickets,  cirrhosis  of  the  liver,  chronic  nephritis,  gout,  carcinoma,  and  sarcoma 
(the  lymphocytes  being  in  excess  in  lymphosarcoma).  It  may  follow  the 
administration  of  certain  drugs,  e.g.,  the  salicylates,  coal-tar  derivatives, 
potassium  chlorate,  camphor,  digitalis,  some  of  the  aromatic  oils,  tuberculin, 
thyroid  extract,  and  quinin,  acute  and  chronic  hemorrhage,  general  anesthe- 
sia, and  consequently  the  various  surgical  operations  (a  rising  leukocytosis 
after  the  second  or  third  day,  however,  would  be  highly  presumptive  of  a 
septic  complication).  The  leukocytosis  of  lymphatic  and  of  splenomedul- 
lary  leukemia  are  easily  recognized  by  the  increase  in  the  lymphocytes  in  the 
former,  and  of  the  myelocytes  in  the  latter.  Agonal  leukocytosis,  which 
occurs  just  before  death,  is  due  to  the  gathering  of  the  leukoc)rtes  along  the 
walls  of  the  capillaries  as  the  result  of  the  feeble  circulation,  or  to  a  terminal 
infection. 

Infectious  leukocytosis,  with  a  few  exceptions  (influenza,  measles,  typhoid, 
and  a  pure  infection  of  tuberculosis),  may  accompany  any  of  the  bacterial 
diseases,  the  most  important  of  which,  from  a  surgical  standpoint,  are 
those  of  pyogenic  origin.  The  degree  of  inflammatory  leukocytosis  depends 
upon  the  virulence  of .  the  microorganism  and  the  Resisting  powers  of  the 
patient,  and  some  idea  of  the  nature  of  these  factors  may  be  obtained  by 
comparing  the  leukocyte  count  with  the  general  condition  of  the  patient.  If 
leukocytosis  is  slight  (12,000  to  15,000)  or  absent,  it  means,  when  the  general 
condition  is  good,  that  the  infection  is  trivial,  well  encapsulated  or  chronic, 
or,  when  the  general  condition  is  bad,  that  the  infection  is  overwhelming.  If 
leukocytosis  is  marked  (20,000  or  higher)  it  means,  when  the  general  condi- 
tion is  good,  that  the  infection,  although  serious,  is  probably  being  localized 
or  conquered,  or,  when  the  general  condition  is  bad,  that  the  infection, 
although  actively  combated,  is  too  great  for  the  patient's  resistance.  As 
with  the  temperature,  pulse,  and  respirations,  repeated  observations  are  of 
more  value  than  a  single  observation.  A  rising  leukocytosis  indicates  a 
spreading  infection  or  pus  formation. 

lodophUia  (iodin  reaction  in  the  leukocytes)  also  is  found  in  septic  proc- 
esses, but  as  it  occurs  in  many  other  conditions,  e.g.,  malaria,  late  typhoid, etc.. 


lO  DIAGNOSIS  AND   RONTGEN   RAY. 

it  is  of  little  value  to  the  clinician.  Eosinophilia  occurs  in  parasitic  diseases, 
such  as  hydatid  cysts,  trichiniasis,  anchylostomiasis,  and  filariasis,  but  it  is 
found  also  in  asthma  and  certain  skin  diseases,  hence  its  value  is  not  absolute. 
The  presence  of  filaria  is  readily  determined,  however,  by  a  microscopic 
examination  of  the  blood  during  the  night. 

An  estimation  of  the  coagulation  time  of  the  blood  is  particiilarly  indicated  in 
cases  like  chronic  jaundice  and  hemophilia,  in  which  operation  may  be  fatal 
from  uncontrollable  oozing  of  blood.  Normally  it  is  from  three  to  six  min- 
utes. 

Hemolytic  tests  should  be  made  before  direct  blood  transfusion.  In  this 
connection  should  be  mentioned  also  the  Wasserman  reaction  for  syphilis  and 
the  hemolytic  test  for  carcinoma. 

Among  the  diseases  which  may  simulate  surgical  conditions,  and  which 
may  be  excluded  by  a  blood  examination,  are  malaria  (malaria  parasites), 
typhoid  fever  (Widal  reaction  and  leukopenia),  lymphatic  and  splenomed- 
ullary  leukemia  (enormous  leukocytosis,  particularly  of  the  lymphocytes 
in  the  former,  and  of  the  myelocytes  in  the  latter),  and  lead  poisoning  (baso- 
philic granulations  in  the  red  cells) .  It  may  be  recalled  that  pneumonia,  which 
may  simulate  intraabdominal  inflammation,  causes  a  leukocytosis  and  that 
Hodgkin's  disease  produces  no  distinctive  blood  changes.  Examination  of 
the  blood  for  bacteria  and  acetone  is  sometimes  desirable,  both  for  diagnosis 
and  prognosis.     For  Cryoscopy  see  Chapter  xxix. 

Recently  some  stress  has  been  laid  upon  the  importance  of  accurately  deter- 
minating the  blood  pressure  in  surgical  conditions.  One  may  employ  for  this 
purpose  the  Riva-Rocci  sphygmomanometer.  A  rubber  cylinder  is  placed 
around  the  limb  and  then  inflated  until  the  pulse  is  cut  off.  The  amount 
of  pressure  in  the  cylinder  is  recorded  by  a  mercury  manometer.  According 
to  this  instrument,  which  is  subject  to  error,  the  average  blood  pressure  is 
130  mm.  of  mercury. 


THE  RONTGEN  RAY. 

The  Rontgen  or  X-ray  penetrates  substances  opaque  to  the  ordinary  forms 
of  light,  casts  shadows,  causes  fluorescence  of  certain  salts,  and  has  the  same 
chemical  action  upon  photographic  films  as  sunlight.  Unlike  sunlight  it  is 
invisible  and  cannot  be  polarized,  refracted,  or  reflected.  The  rays  are 
believed  to  be  transverse  vibrations  of  ether,  differing,  however,  from  those 
of  ordinary  light  in  being  irregular  and  of  unequal  lengths. 

The  apparatus  necessary  for  the  production  of  the  X-ray  consists  of  a 
sealed  glass  vacuum  tube  (Crookes  tube),  containing  two  or  three  electrodes, 
and  a  machine  capable  of  generating  electrical  currents  of  high  voltage. 
One  of  the  electrodes,  the  cathode,  is  a  concave  metallic  disk,  which  is  con- 
nected with  the  negative  terminal  of  the  exciting  apparatus.  At  the  focus 
of  this  reflector  is  a  metallic  disk  called  the  target.  The  electrode  connected 
with  the  positive  terminal  is  called  the  anode.  Electrical  discharges  suitable 
for  exciting  a  Crookes  tube  may  be  obtained  from  static  machines,  high  fre- 
quency coils,  or  the  ordinary  induction  coil.  In  a  properly  excited  Crookes 
tube  there  is  a  current  of  electricity  flowing  toward  the  cathode,  from  the  con- 
cave surface  of  which  it  is  focused  upon  the  target.  As  far  as  we  know  the 
Rontgen  rays  originate  at  this  point.     As  the  Rontgen  rays  are  invisible. 


INTERPRETATION   OF   SKIAGRAPHS. 


II 


the  green  light  seen  in  an  excited  tube  is  merely  a  fluorescence  of  the  glass 
produced  by  the  rays. 

The  Fluaroscope  consists  of  a  piece  of  cardboard  on  one  side  of  which 
is  spread  a  thin  layer  of  finely  ground  crystals  of  barium  platino-cyanid. 
This  screen  is  fitted  in  one  end  of  a  light-proof  box,  also  made  of  cardboard, 
with  the  other  end  fashioned  as  an  eye-piece,  to  allow  the  operator  to  see  the 
ciystal  side  of  the  screen.  When  brought  near  an  active  Crookes  tube, 
the  crystals  become  luminous  and  give  off  a  faint  green  light.  The  trans- 
parency of  substances  to  the  X-rays  varies 
according  to  their  atomic  weights.  If  the 
hand  be  placed  between  an  excited  tube  and 
the  fluorescent  screen,  the  softer  tissues  will 
appear  as  faint  shadows,  and  the  bones, 
which  are  more  dense,  as  dark  shadows. 
When  these  shadows  fall  upon  a  photographic 
plate,  the  silver  bromid  is  changed  as  with 
light  rays,  and  if  the  plate  is  then  developed,  a 
permanent  record  of  the  shadows  is  obtained 
(Radiograph,  or  Skiagraph),  To  make  good 
pictures  requires  skill  and  much  time,  con- 
sequently most  practitioners  refer  their  cases 
to  an  X-ray  specialist.  The  physician,  how- 
ever, should  have  some  knowledge  of  the 
interpretation  of  plates,  be  familiar  with  the 
indications  for  the  use  of  the  X-ray  (diag- 
nostic and  therapeutic),  and  know  the  dangers 
which  may  arise. 

The  interpretation  of  X-ray  pictures  is 
a  study  in  shadows,  which,  like  those  cast  by 
a  candle  light,  are  subject  to  distortion  in  size 
and  in  shape,  the  least  distortion  occurring 
when  the  object  is  very  thin,  is  in  close  contact 
with  the  screen  or  plate,  is  as  far  from  the 
tube  as  the  rays  are  effective,  and  when  the 
object  and  the  target  are  in  a  plane  perpen- 
dicular to  the  plate,  hence  one  should  know 
the  distance  between  the  tube,  the  object,  and 
the  plate,  the  angle  at  which  the  picture  was 
made,  and,  if  possible,  the  size  of  the  object 
(Figs.  I  and  2).  The  kind  of  tube  employed 
also  influences  the  results.  A  high  vacuum,  or  hard,  tube  gives  a  small 
quantity  of  deeply  penetrating  rays  and  little  contrast  between  the  tissues 
of  different  densities;  a  low  vacuum,  or  soft,  tube  a  large  quantity  of  feeble 
rays  and  decided  contrast  between  the  various  tissues.  One  must  be 
familiar  with  the  shadows  of  normal  tissues  at  different  ages.  In  the  child 
the  bones  cast  faint  shadows  and  some  of  the  epiphyses  are  not  visible  until 
puberty.  Ununited  epiphyses  may  be  mistaken  for  fragments  of  bone, 
epiphyseal  junctures  for  lines  of  fracture  (see  Fig.  190).  Other  sources  of 
error  are  defective  plates;  congenital  abnormalities,  e.g.,  a  bipartite  scaph- 
oid; superimposed  shadows,  which  may  be  recognized  by  taking  a  second 
plate  at  a  different  angle;  enlarged  bronchial  glands,  simulatm^  ^xv!&Mrj%xcv\ 


^ 


Fig.  I. — Note  the  size  of  the 
object  (a)  and  its  shadow  (b)  when 
the  former  is  near  the  tube  and 
some  distance  from  the  plate;  and 
of  the  object  (c)  and  its  shadow 
(d)  when  the  object  is  far  from 
the  tube  and  near  the  plate. 


12  DIAGNOSIS  AND   RONTGEN   RAY. 

and  fecal  masses,  calcified  lymph  glands,  phleboliths,  and  like  conditions, 
which  may  be  mistaken  for  calculi  and  foreign  bodies. 

As  a  diagnostic  agent  the  Huoroscope  permits  quick  and  easy  examina- 
tions, but  the  images  lack  detail,  so  that  small  foreign  bodies,  and  fractures 
without  deformity  are  frequently  overlooked.  Moreover,  the  danger  to  the 
operator  is  considerable,  as  it  is  necessary  to  have  the  hands  in  close  proximity 
to  the  tube  for  long  periods  of  time.  Consequentiy  the  fluoroscope  should  be 
employed  only  to  observe  the  movements  of  aneurysms,  the  heart,  the 
lungs,  the  diaphragm,  and  of  the  stomach  and  intestines  during  peristalsis. 
The  radiograph  gives  a  permanent  picture  with  delicate  detaU  and  sharp 
outlines  not  found  in  the  fluoroscopic  image. 

These  pictures  are  of  great  value  in  localizing  foreign  bodies,  either  ex- 
traneous, such  as  bullets,  needles,  etc.,  or  those  formed  within  the  tissues, 
such  as  renal  and  vesical  calculi.     Minute  fragments  of  coal,  wood,  and  glass 


^^\ 


•^'  / 


.•i 


vi 


Fig.  2. — Diagram  showing  distortions  produced  by  the  X-ray.  The  horizontal  line 
represents  the  X-ray  plate,  seen  in  profile;  the  objects  above,  broken  bones;  those  belo\v; 
the  shadows  as  seen  on  the  plate.  On  the  left  is  shown  an  oblique  fracture  with  over-lap- 
ping, the  shadows  of  which  indicate  a  transverse  fracture  with  separation;  on  the  right  a 
transverse  fracture  with  no  overlapping,  the  shadows  of  which  Indicate  an  oblique  fracture 
with  overlapping  As  the  shadows  of  the  fragments  nearer  the  tube  are  larger  and  less 
distinct  than  those  close  to  the  plate,  an  expert  might  detect  these  errors  merely  from  the 
skiagraph,  but  a  novice  could  easily  be  deceived.  In  all  doubtful  cases  a  second  plate,  at 
right  angles  to  the  first,  should  be  taken  or,  better,  stereoscopic  plates  made. 

Other  than  lead-glass,  however,  may  evade  detection,  particularly  if  over- 
shadowed by  bone,  or  some  distance  from  the  plate.  A  preliminary  skia- 
graph is  taken  and  a  mark  made  on  the  skin  direcdy  over  the  foreign  body. 
Another  plate  is  then  placed  in  position,  and  the  target  of  the  X-ray  tube 
fixed  directly  over  the  mark  on  the  skin,  the  distance  between  the  target,  the 
skin,  and  the  plate  being  measured.  The  tube,  with  the  vertical  distance 
from  the  plate  remaining  constant,  is  moved  three  inches  to  the  left  and  an 
exposure  made,  then  three  inches  to  the  right  of  the  starting  point  and  a 
second  exposure  made.  The  plate  is  now  developed,  the  distance  between 
the  two  images  measured,  and  the  depth  calculated  (Fig.  3).  With  the 
stereoscope  the  depth  of  the  foreign  body  and  also  the  perspective  of  the 
various  planes  of  tissue  can  be  actually  seen.  Two  radiographs  are 
taken  on  separate  plates,  at  different  angles,  as  in  the  process  of  localiza- 
tion.    These  plates  are  then   viewed  simultaneously  through    two  mirrors, 


THERAPEUTIC  EFFECTS   OF   THE   X-RAY. 


13 


which  join  at  right  angles,  their  common  edge  being  midway  between  the 
plates,  and  at  a  distance  from  them  equal  to  that  of  the  lateral  move- 
ments of  the  tube.  The  X-ray  is  indicated  in  the  diagnosis  of  so  many 
conditions,  other  than  those  already  mentioned,  that,  in  order  to  avoid 
repetition,  we  must  refer  the  student  for  additional  information  to  subse- 
quent pages,  particularly  those  dealing  with  fractures,  dislocations,  bone 
diseases,  sinus  and  fistula,  the  lungs  and  pleural  cavity,  subphrenic  abscess, 
the  esophagus,  the  stomach,  the  intestines,  and  the 
kidney.  We  ^all  there  call  attention  to  some  of  the 
methods  employed  to  render  transparent  structures 
opaque  and  thus  facilitate  radiographic  examinations, 
e.g.,  the  introduction  of  bismuth  into  sinuses  and  the 
stomach,  of  collargol  into  the  pelvis  of  the  kidney,  of 
styleted  catheters  into  the  ureters. 

The  therapeutic  effects  of  the  rays  may  be  classi- 
fied as  follows:  (i)  The  production  of  atrophic  changes 
in  the  appendages  of  the  skin;  (2)  the  destruction  of 
organisms  in  the  tissues;  (3)  the  stimulation  of  the 
metabolic  processes  of  the  tissues;  (4)  the  destruction  of 
certain  pathological  tissues;  and  (5)  their  anodyne  effects. 
In  hypertrichosis,  sycosis,  favus,  and  tenia  tonsurans  it  is 
desirable  to  remove  the  hair.  Atrophy  and  decreased 
functional  activity  of  the  sebaceous  glands  are  indicated  in 
comedo  and  acne.  Though  the  rays  apparently  have  no 
effect  on  organisms  growing  upon  culture  media,  they 
have  a  decided  effect  upon  their  growth  when  in  the 
living  tissues.  Thus  tuberculous  ulcers  and  sinuses  and 
those  due  to  ordinary  pyogenic  organisms  may  dry  up 
when  exposed  to  the  rays.  A  similar  effect  is  produced 
upon  diseases  due  to  mycelial  fungi,  such  as  tenia  barba;, 
tenia  tonsurans,  favus,  and  blastomycosis.  The  de- 
struction of  these  organisms  is  probably  brought  about 
by  tissue  cells  stimulated  to  activity  by  the  rays.  Their 
effect  upon  the  metabolic  processes  is  still  problematical, 
but  their  influence  upon  the  blood  in  certain  anemias, 
notably  splenomedullary  leukemia,  is  unquestionable. 
The  only  form  of  carcinoma  which  can  be  cured  by  the 
X-rays  is  chronic  superficial  epithelioma,  and  even  in  this 
excision  is  quicker  and  safer.  In  inoperable  carcinoma 
and  sarcoma  the  rays  are  often  of  decided  value  in 
lessening  discharge,  diminishing  fetor,  and  ameliorating 
pain,  and  occasionally  the  growth  shrinks  for  a  time.  Some  surgeons 
advise  exposures  after  all  operations  for  carcinoma  and  sarcoma,  to  prevent 
recurrence.  Good  results  have  been  claimed  for  this  agent  in  exophthalmic 
goiter.  In  making  therapeutic  applications  of  the  X-ray,  the  operator 
should  always  protect  the  healthy  parts  by  a  shield  of  lead,  leather,  or 
aluminium.  As  an  anodyne  the  X-rays  have  been  used  not  only  in 
malignant  disease,  but  also  in  neuralgia  and  other  painful  affections,  some- 
times with  excellent  results. 

Untoward  Effects. — The  X-ray  bum  is  characterized  by  delayed  onset 
and  remarkable  sluggishness  in  healing.    The  acute  bum,  i.e.,  one  resulting 


Fig.  3. — I  and  2 
correspond  to  the 
shadow  of  the  foreign 
body  and  are  J  inch 
apart,  the  same  dis- 
tance as  the  shadows 
on  the  plate;  3  and  4 
correspond  to  the  two 
positions  of  the  tube; 
5  corresponds  to  the 
distance  of  the  target 
from  the  plate.  The 
point  where  the  lines 
intersect  represents 
the  depth  of  the 
foreign  body  from 
the  surface  next  to 
the  plate.  (American 
Practice  of  Surgery.) 


14  ANESTHESIA. 

from  a  single  prolonged  exposure,  usually  appears  on  the  second  or  third  day, 
but  may  be  delayed  as  late  as  the  fourteenth  day.  It  is  essentially  an  in- 
flammatory process,  appearing  at  first  much  like  the  erythema  of  simbum; 
if  subsidence  does  not  occur  in  this  stage,  vesicles  and  blebs  develop  which 
rupture  and  expose  the  inflamed  corium;  occasionally  the  deeper  structures 
are  invaded,  and  extensive  sloughing  may  occur.  The  microscopic  changes 
are  those  of  degeneration  and  inflammation.  Chronic  bums  occur  in  those 
constantly  exposed  to  the  rays.  They  appear  slowly  after  an  incubation 
period  of  from  three  to  eleven  years.  The  clinical  features  are  at  first  much 
like  those  of  acute  bums,  but  the  red  color  changes  to  a  bronze  or  yellow,  the 
nails  show  rugae  of  malnutrition,  telangiectatic  spots  develop,  and  the  skin 
becomes  glossy  because  of  the  loss  of  glands  and  hair.  Cracks  and  hyper- 
keratoses appear  and  ulcers  form,  often  exposing  the  tendons  and  even  the 
bones,  and  occasionally  undergoing  epitheliomatous  degeneration.  The 
skin  seems  to  be  easily  protected  by  the  ordinary  clothing,  for  no  case  has 
been  reported  except  upon  the  exposed  surfaces.  Several  styles  of  gloves 
have  been  devised  for  the  protection  of  the  hands,  but  the  most  satisfactory 
suggestion  appears  to  be  the  use  of  a  large  screen  made  of  some  substance 
impervious  to  the  rays,  as  heavy  plate  glass,  sheet  iron,  or  lead,  behind 
which  the  operator  may  stand.  If  healing  does  not  occur  after  the  usual 
applications  for  ulcer,  an  X-ray  burn  may  be  excised,  and  the  resulting  raw 
surface  closed  by  a  plastic  operation  or  covered  with  skin  grafts.  Pro- 
longed exposure  to  the  X-rays  may  cause  sterility  in  either  sex,  sometimes 
transient,  sometimes  permanent. 


CHAPTER  II. 
ANESTHESIA. 


Anesthesia  is  a  condition  of  insensibility  induced  by  anesthetic  agents. 

GENERAL  ANESTHESIA  is  associated  with  unconsciousness,  and  is 
indicated  to  abolish  pain  during  surgical  operations,  renal  colic,  etc. ;  to  con- 
trol convulsive  seizures;  to  secure  muscular  relaxation  in  order  to  make  a  diag- 
nosis, or  to  carry  out  such  treatment  as  reduc^tion  of  a  hernia  or  a  dislocated 
joint;  and  to  abolish  volition  in  order  to  detect  a  malingerer.  Except  for  the 
purpose  of  saving  life,  it  is  contraindicated  in  profound  shock,  great  exhaustion, 
and  in  acute  or  advanced  renal,  circulatory,  or  pulmonary  disease.  The 
general  anesthetics  most  frequently  employed  are,  in  the  order  of  their  safety, 
nitrous  oxid  (one  death  in  300,000),  ether  (one  death  in  15,000),  ethyl  chlorid 
(one  death  in  12,000),  and  chloroform  (one  death  in  3,000). 

The  choice  of  a  general  anesthetic  depends  principally  upon  the  con 
dition  of  the  patient  and  the  character  of  the  operation.  In  brief  operations 
(from  two  to  five  minutes)  in  which  muscular  relaxation  is  not  desired,  such 
as  the  extraction  of  a  tooth  or  the  incision  of  an  abscess,  nitrous  oxid  is  by  far 
the  safest  anesthetic.  When  nitrous  oxid  is  not  obtainable,  ethyl  chlorid  may 
be  used  for  the  same  purpose.  For  longer  operations  in  which  muscular 
relaxation  is  not  important,  nitrous  oxid  combined  with  oxygen  or  with 


PREPARATION  FOR  ANESTHESIA.  1 5 

atmospheric  air  is  the  safest  anesthetic.  For  the  ordinary  major  operations 
of  surgery,  in  most  of  which  muscular  relaxation  is  desired,  ether  is  the  best 
and  saiest  anesthetic,  and  should  always  be  employed  unless  there  are  dis- 
tinct contraindications.  The  most  important  contraindication  to  ether  is 
inflammaiion  0/ some  portion  of  the  respiratory  apparatus,  owing  to  its  irritating 
action  upon  mucous  membranes.  Of  secondary  importance,  and  by  no 
means  absolute,  are  marked  arteriosclerosis,  because  of  the  danger  of  vascu- 
lar rupture  from  the  struggling  incident  to  the  etherization ;  disease  of  the 
kidneys  (although  many  authors  hold  the  reverse  opinion,  believing  chloro- 
form to  be  more  irritating  to  the  kidneys  than  ether;  in  these  cases  local 
anesthesia  should  be  employed  whenever  possible);  operations  about  the 
nose  or  mouth,  in  which  the  anesthetic  can  be  applied  intermittently  only, 
and  in  which  chloroform,  being  more  powerful,  will  better  maintain  anesthe- 
sia (this  contraindication  ceases  to  exist  if  one  employs  the  Rupert  apparatus) ; 
operations  in  which  the  actual  cautery  may  be  needed  in  the  region  of  the 
mouth,  owing  to  the  inflammability  of  ether,  although  it  may  be  used  in  these 
cases,  if  the  precaution  is  first  taken  to  remove  the  anesthetic  and  fan  away  the 
fumes;  and  operations  performed  in  the  presence  of  an  exposed  artificial 
light,  although,  since  ether  vapor  is  heavier  than  air  and  descends,  the  danger 
in  these  cases  is  obviated  by  placing  the  light  several  feet  above  the  level  of  the 
patient's  head.  Ether  should  not  be  administered  in  the  presence  of  fire  in  an 
open  grate  or  stove.  Chloroform  does  not  distend  the  veins  like  ether,  hence 
makes  bleeding  less  annoying,  and  it  is  quicker  in  its  action,  more  agreeable 
to  the  patient,  and  more  convenient  to  the  anesthetist  and  operator,  especially 
in  operations  about  the  head,  face,  and  neck ;  but  these  advantages  are  over- 
balanced by  its  increased  danger.  Chloroform  is  no  safer  in  children  or 
during  pregnancy  than  at  any  other  time.  It  is  preferable  in  military  sur- 
gery, because  it  economizes  space  and  time,  and  is  generally  employed 
in  the  tropics,  owing  to  the  great  volatility  of  ether.  In  diabetes  nitrous 
oxide  mixed  with  oxygen  is  the  safest  general  anesthetic ;  ether,  however,  is 
sometimes  employed,  but  chloroform  is  absolutely  contraindicated. 

The  preparation  for  anesthesia,  in  cases  requiring  a  major  opera- 
tion in  which  there  is  no  emergency,  should  extend  over  two  or  diree  days, 
during  which  time,  in  addition  to  the  special  preparations  for  the  operation 
itself,  the  patient  should  be  carefully  examined,  particularly  for  the  presence 
of  disease  of  the  heart,  blood  vessels,  lungs,  and  kidneys.  The  condition  of 
the  nose,  throat,  and  mouth  should  be  known,  and  in  many  cases  a  careful 
examination  of  the  blood  will  be  required.  The  bowels  ^ould  be  moved 
by  a  laxative,  and  an  enema  administered  the  morning  of  the  operation. 
The  diet  should  be  light  and  easily  digestible.  No  solid  food  should  be 
given  on  the  day  of  operation,  although  a  cup  of  tea,  cofifee,  or  consommd 
may  be  given  not  less  than  six  hours  before  the  time  of  anesthesia.  In  the 
feeble  and  exhausted  purgation  should  be  avoided,  and  stimulating  or  nutri- 
tive enemas  may  be  continued  until  within  a  few  hours  of  the  operation. 
Just  before  operation  the  patient  should  pass  urine,  or,  if  necessary,  be 
catheterized.  If  a  woman,  hair-pins  should  be  removed  and  the  hair  braided 
and  done  up  in  a  cap  or  towel.  Artificial  teeth  or  other  foreign  bodies 
should  be  removed  from  the  mouth,  and  the  lips  and  nostrils  greased, 
especially  if  chloroform  is  to  be  used.  The  patient  shouW  be  protected 
from  cold,  and  jewelry  of  various  kinds  should  be  put  away  in  a  safe  place. 
In  cases  of  intestinal  obstruction  the  stomach  should  be  washed  out  ^revvovi?. 


l6  ANESTHESU. 

to  the  administration  of  the  anesthetic,  in  order  to  prevent  sudden  death  from 
inundation  of  the  lungs  with  vomited  fecal  matter.  In  minor  surgical  pro- 
cedures the  period  of  preparation  mentioned  above  will  not  be  required.  In 
all  these  cases,  however,  a  complete  examination  should  be  made.  A  patient 
should  never  be  anesthetized  without  removing  the  shoes  and  without  making 
sure  that  all  clothing  about  the  neck,  chest,  and  abdomen  is  loose;  corsets 
always  should  be  removed.  With  the  possible  exception  of  nitrous  oxid,  a 
patient  should  never  be  anesthetized  in  the  sitting  posture. 

The  anesthetist  should  ascertain  whether  the  patient  has  previously  taken 
an  anesthetic,  and  whether  addicted  to  the  use  of  alcohol  or  other  drugs. 
He  should  know  the  results  of  the  urinalysis,  listen  to  the  heart  and  limgs, 
study  the  pulse,  note  the  color  of  the  skin  and  mucous  membranes,  and 
assure  himself  that  the  mouth  is  free  of  foreign  bodies.  His  hands  should  be 
clean,  and  in  operations  on  the  head  and  neck  they  should  be  sterilized 
and  he  should  wear  a  sterile  gown  and  cap.  In  addition  to  the  anesthetic 
and  inhaler  one  should  provide  himself  with  a  mouth-gag,  tongue  forceps, 
a  pair  of  hemostats  with  gauze  sponges  for  swabbing  out  the  pharynx,  a  hypo- 
dermic syringe  with  strychnin  and  atropin,  and  a  tracheotomy  tube.  It 
is  desirable  to  have  also  a  solution  of  boric  acid  for  the  eyes  in  case  they  be- 
come irritated,  and  in  some  instances  oxygen  may  be  needed;  an  electric  bat- 
tery is  very  rarely  demanded.  A  third  person  should  always  be  present  to 
assist,  if  necessary,  in  restraining  the  patient  and  to  act  as  a  witness,  as  unjust 
accusations  are  occasionally  made  against  the  anesthetizer,  especially  by 
females. 

The  administration  of  ether  may  be  by  the  open  method,  in  which  a 
plentiful  supply  of  air  gains  entrance  to  the  lungs;  by  the  semi-open  metitod^  in 

which  the  entrance  of  air  is  slightly 
limited,  but  in  which  the  expiratory 
products  are  not  retained;  or  by  the 
closed  method,  in  which  the  air  is 
decidedly  restricted,  and  in  which  the 
expiratory  products  are  retained  and 
rebreathed.  In  the  open  metiiod, 
which  is  very  slow,  the  ether  is  in- 
haled from  a  folded  towel,  held  over 
the  patient's  nose  and  mouth  in  such  a 
way  as  not  to  exclude  the  air.  The 
closed  method  is  quick  and  economizes 
Fig.  4.— Alhs'  Inhaler.  ether,   but   is    more  dangerous  than 

either  of  the  other  methods.  Those 
who  use  the  closed  method  find  the  Clover  inhaler  satisfactory.  It 
consists  of  a  dome-shaped  ether  reservoir  surrounded  by  a  water  chamber, 
which  maintains  the  ether  at  the  proper  temperature  for  evaporation.  A 
fenestrated  metal  tube  runs  through  the  reservoir  from  a  large  rubber 
bag  to  the  face  piece.  By  rotating  the  reservoir  varying  quantities  of 
vapor  escape  into  the  rubber  bag,  from  which  it  is  breathed  backward 
and  forward  with  the  expiratory  products;  fresh  air  may  be  admitted 
from  time  to  time  by  raising  the  face  piece.  The  semi-open  method 
is  the  one  commonly  employed.  An  inhaler  may  be  improvised  by 
rolling  a  folded  towel  or  a  piece  of  gauze  into  the  shape  of  a  cone.  The 
Allis  inhaler  (Fig.  4)  consists  of  a  cylindrical  metal  frame  with  slits  in 


ADUINtSnuVTION   OF  KTHKH. 


the  sides,  through  which  a  bandage  is  threaded  Ivavkwatxi^  And  for- 
wards; this  is  enclosed  in  a  leather  case  or  foldcil  Io>^t1  wht\h  |m>jif\t» 
beyond  the  frame  and  is  fitted  to  the  patient's  fa^t^.  The  inhaler  is  places! 
over  the  patient's  nose  and  mouth,  and  after  seNxral  hrt^ath^  ha\t^  Iveen  taken 
to  lessen  fright,  the  ether  is  applied  drop  by  dn>p  until  the  |>atient  ts  anesthe- 
tized, the  intervals  between  the  drops  becoming  shorter  as  the  |>attent  Ins^^mes 
accustomed  to  the  vapor.  In  operations  on  the  head)  fait^,  mouthy  and  nev  k 
anesthesia  may  bt  induced  by  one  of  the  foregoing  methotis  and  maintainetl 
by  means  of  the  Rupert  apparatus  or  one  of  lis  mollifications  (Fig.  5).  By 
means  of  a  hand  bulb  or  a  foot  pump  air  is  fon  eil  through  a  Imttlc  of  cther^ 
which  is  placed  in  a  can  of 
water  at  a  temperature  of  98®  F. 
The  ether  vapor  enters  the 
mouth  or  nostril  through  a  metal 
or  rubber  tube.  During  the  first 
stage  of  anesthesia,  which  ends 
with  the  loss  of  consciousness, 
the  pulse  is  accelerated,  the 
pupils  large  and  mobile,  and  a 
rather  pleasant  feeling  of  drow.si- 
ness,  and  tingling  in  the  extremi- 
ties, is  experienced.  Many  pa- 
tients breathe  deeply,  others 
hold  their  breath;  in  the  latter 
instance  all  that  need  be  done 
is  to  remove  the  cone  for  a 
moment.  Cough  is  rarely  an- 
noying if  the  drop  method  l>e 
employed.  With  the  onset  of 
unconsciousness  there  is  a  short 
period  of  analgesia  (primary 
anesthesia),  during  which  brief 
operations  may  be  performed. 
The  second  stage ,  or  the  stage 
of  excitement,  extends  from  the 
loss  of  consciousness  to  the  lr>ss  of  reflexes.  Memory,  volifl/m,  and 
intelligence  are  abolished,  while  laughing,  shouting,  and  sfru^^in^  wny 
occur.  Slight  movement^)  of  the  extremities  shoulrl  ntd  l>e  r^sfr<iin^/l  twh^^ 
they  interfere  with  the  anesthetist,  as  surh  often  evok^-s  f^Tf^ttr  ^ffij^j(Iin^. 
The  pulse  is  rapid,  the  pupils  are  dilated  and  rca/t  to  Iif(ht,  jin/l  th^  miiivl^s 
may  be  rigid  or  thrown  into  clonic  r/mtra^  ti^m*.  At  fhh  1\mc  f h^  btf afhinj; 
may  be  irregular  or  temporarily  suspended.  The  fa^  e  i^  f  fmfi^t^^^f],  ^tmff\m^<^ 
cyanodc,  and  often  covered  with  p>eri^pirati/'>n.  More  or  \e^<i.  f r<4hy  mvf  u^  1^ 
present  in  the  mouth  and  throat,  and  .v>metin^^  if  \itfomf*<  ^x/^^<iv^. 
Dmiag  the  third  stage  the  breathing  is  derp  and  audiM^,  fh^,  \m\<f  full  and 
regular,  the  muscles  relaxed,  and  the  romeal  reflex  ah;<>lishM.  T^'riKhinjf 
the  cornea  with  the  finger,  however,  may  prMu^-^  irrit;4hon,  ;»nd  if  i^  rruKb 
bcoer  Amply  to  separate  the  lids  and  notire  the  ^^xf^Xiff  r,r  n^^n^^  oi  p»a<' 
cidxcy.  The  poptis  are  of  moderate  .^i/e  and  r^^rt  to  li fijht.  f^iUfM  fo»piU 
tailmg  CO  react  to  light  indicate  a  danuferou"*  dea^r^e  <'»f  an<»^*^h<»-ii;»  frjririfl^ 
dns  stage  a  traxunent  roseoious  rash  may  i-^e  nr>tirM. 


h'Ui.  ^.  MtfiWfwA  Hit\rt't\  n\t\tnttiUtn  Nnif 
that  thi"  rthrr  rr%cr^trit  \%  onlv  hulf  fill#'/|  fitu\  \hni 
the  k/ng  tuhr  in  it  i<i  niinthrn  to  thf  \tuw\t,  if  lh^ 
nhort  tuhr  wrrr  (tmnf(tf<]  with  th^  piirnp,  li<)ui/| 
<rlhrr  wfjijUl  hr  fhtvtn  from  thf  rr<i*'tvtiit.  Kvf-fi 
whm  !h#r  tiil/f^  Htf  f»r#/|ifrly  nrrnnt(tt\,  »  %^itny  /rf 
rthfT  mtty  }tr  lortf*]  from  th^  r^v-rvfrir,  hftut-  th^ 
Amall  U/ffIc  (rn  ihr  \Ht,  whir  h  /i<ts  «<«  n  tfttu)*'tt^f. 


l8  ANESTHESU. 

Rectal  etherization  has  been  employed  in  operations  about  the  upper 
respiratory  passages.  A  bottle  of  ether  to  which  a  rubber  rectal  tube  is 
attached  is  placed  in  water  at  a  temperature  of  120°  F.,  or  the  ether  vapor 
may  be  forced  into  the  rectum  by  means  of  the  Rupert  apparatus,  a  rectal 
tube  being  substituted  for  the  mouth  piece.  The  disadvantages  of  the 
method  are  the  greater  time  necessary  to  induce  anesthesia,  and  the  un- 
pleasant sequelae,  such  as  prolonged  stupor,  meteorism,  and  bloody  diarrhea. 
The  administration  of  chloroform  requires  more  skill  and  care  than 
etherization.  A  preliminary  hypodermic  injection  of  atropine  is  advisable, 
as  this  drug  prevents  reflex  inhibition  of  the  heart,  owing  to  its  depressing 
effect  on  the  pneumogastric  nerves.  The  chloroform  may  be  inhaled  from  a 
handkerchief  or  a  piece  of  gauze,  but  a  special  mask,  such  as  the  Skinner  or 
Esmarch  (Fig  6),  each  of  which  consists  of  a  wire  frame  covered  with  one 

layer  of  flannel,  is  more  convenient. 
The  inhaler  is  held  just  over  the  nose 
and  mouth  and  the  chloroform  dropped 
on  it.  The  average  adult  patient  will 
require  one  drop  of  chloroform  every 
four  or  six  seconds  to  maintain 
anesthesia.  The  vapor  should  always 
be  liberally  mixed  with  air;  liquid 
Fig.  6. — Esmarch  Mask.  chloroform  should  never  be  allowed 

to  touch  the  skin,  as  it  may  produce 
blistering.  The  phenomena  of  chloroform  anesthesia  are  in  the  main  similar 
to  those  of  ether.  The  first  and  second  stages  are  shorter,  the  vapor  is  more 
pleasant,  and  being  less  irritating  than  ether,  not  so  much  mucus  is  poured 
out.  An  excess  of  chloroform  causes  the  patient  to  hold  his  breath,  and  if 
the  inhaler  is  not  withdrawn  at  this  time,  the  patient  may  take  a  deep  inspira- 
tion and  get  an  overdose.  This  accident  has  resulted  in  death,  and  should 
be  recalled  when  chloroforming  crying  children,  and  when  a  surgeon  attempts 
to  operate  before  the  third  stage  is  reached,  thus  causing  the  patient  to 
breathe  deeply.  During  the  stage  of  muscular  excitement,  which  is  less 
marked  than  with  ether,  the  respirations  should  be  watched  with  great  care. 
Chloroform  vapor  is  not  inflammable,  but  in  the  presence  of  a  naked  flame 
gives  off  irritating  products  (phosgene  and  hydrochloric  acid),  which,  in  a 
small  room,  may  cause  irritation  of  the  eyes  and  respiratory  passages.  The 
tiiird  stage  is  characterized  by  quiet  respirations  which  are  often  difl&cult  to 
appreciate.  The  pulse  is  sluggish  and  feeble  in  contrast  to  the  full  and  rapid 
pulse  of  ether.  The  pupil  is  moderately  contracted  imless  the  anesthesia  is 
profound,  when  it  dilates.  As  with  ether,  dilated  pupils,  failing  to  react  to 
light,  indicate  a  dangerous  degree  of  anesthesia.  Throughout  the  anesthesia 
the  pulse  and  respirations  should  be  carefully  watched.  The  character  of  the 
respirations  may  be  determined  by  listening  to  them,  by  observing  the  move- 
ments of  the  chest  and  abdomen,  and  by  noting  the  patient's  color.  The 
pulse  may  be  felt  at  the  temple. 

Oxygen  combined  with  ether  or  chloroform  tends  to  prevent  spasm 
of  the  respiratory  muscles  and  cyanosis.  That  it  lessens  irritation  of  the 
kidneys  and  post-anesthetic  vomiting  is  doubtful.  The  oxygen,  after  bub- 
bling through  the  anesthetic,  is  conveyed  to  the  face  piece  through  a  rubber 
tube.  It  may  be  given  also  by  placing  the  end  of  the  oxygen  tube  in  or 
beneath  the  inhaler. 


ANESTHETIC  MIXTURES.  19 

Nitrous  ozid  comes  in  steel  cylinders,  in  which  it  has  been  liquefied  by 
pressure.  It  is  allowed  to  escape  into  a  rubber  bag  in  which  it  is  vaporized, 
and  from  which  it  passes  through  a  tube  to  a  mouth  piece.  A  piece  of  cork  or 
wood  to  which  a  string  is  attached,  so  that  it  cannot  be  swallowed,  is  placed 
between  the  molar  teeth  and  the  mouth  piece  adjusted.  The  jgas  is  then 
turned  on  and  the  nostrils  closed  by  the  thumb  and  finger.  The  patient 
becomes  cyanotic,  the  pupils  dilate,  and  squint  is  often  seen.  With  the  onset 
of  unconsciousness,  which  is  usually  complete  in  about  one  minute,  the 
breathing  becomes  stertorous  and  muscular  twitchings  are  observed.  The 
duration  of  complete  anesthesia  is  about  one  minute.  The  pulse  and 
respirations  should  be  carefully  watched.  Nitrous  oxid  is  contraindicated 
in  advanced  disease  of  the  heart  or  arteries.  It  is  often  used  to  induce  anes- 
thesia, which  is  then  continued  by  ether,  with  the  object  of  reducing  the  period 
of  narcosis,  the  amount  of  ether  used,  and  the  impleasantness  of  the  early 
stages  of  ether  anesthesia.  Anesthesia  may  be  induced  with  an  ordinary 
nitrous  oxid  apparatus  and  etherization  begxm  with  an  ordinary  inhaler. 
Much  better  is  an  apparatus  which  allows  the  gradual  administration  of 
ether  before  the  nitrous  oxid  is  discontinued.  Hewitt  uses  a  Clover's 
inhaler  to  which  is  attached  a  charged  gas-bag  holding  about  two  gallons 
of  gas.  By  means  of  a  stop-cock  the  patient  is  allowed  to  breathe  about 
one-half  the  nitrous  oxid,  the  remaining  half  being  breathed  backwards  and 
forwards  during  the  gradual  admission  of  the  ether.  Nitrous  oxid  anes- 
thesia may  be  prolonged  by  mixing  the  gas  with  atmospheric  air,  or  by 
combining  it  with  oxygen ;  the  latter  method  is  the  safer.  For  the  administra- 
tion of  nitrous  oxid  and  oxygen  Hewitt  employs  an  apparatus  consisting  of 
two  steel  cylinders  containing  the  respective  gases ;  these  communicate  with  two 
bags  which  are  connected  with  the  mixing  chamber,  to  which  the  mouth  piece 
is  attached  This  method  may  be  employed  in  operations  of  considerable 
duration,  provided  muscular  relaxation  is  not  necessary. 

Ethyl  chlorid  may  be  used  in  brief  operations  as  a  substitute  for  nitrous 
oxid,  and  as  a  preliminary  to  ether.  Like  ether  it  is  highly  inflammable, 
and  is  easily  administered  without  special  apparatus.  It  may  be  given  with 
a  closed  inhaler,  or  by  spraying  it  upon  gauze  placed  over  the  nose  and 
mouth.  Ten  cc.  are  usually  sufficient  for  this  purpose.  Anesthesia  is  in- 
duced in  from  one-half  to  two  minutes;  the  patient  rapidly  recovers,  usually 
without  vomiting  or  other  disagreeable  phenomena.     See  also  local  anesthesia . 

Ethyl  bromid  is  somewhat  similar  in  its  effects  to  ethyl  chlorid,  and  may 
be  used  for  the  same  purposes,  but  is  less  safe.  It  may  be  given  from  a 
closed  mask  or  from  a  towel.  The  entire  dose  of  from  15  to  30  grams  is 
poured  into  the  cone  at  once  and  all  air  excluded.  Narcosis  is  quickly  in- 
duced and  recovery  rapidly  follows.  Ethyl  bromid  is  a  cardiac  depressant, 
and  is  contraindicated  in  children,  in  the  weak  and  anemic,  and  in  those 
suffering  from  cardiac  disease,  alcoholism,  and  kidney  affections. 

Anesthetic  mixtures,  the  best  known  of  which  is  the  A.  C.  E.  mixture 
(alcohol  I,  chloroform  2,  ether  3),  should  rarely  or  never  be  employed.  That 
they  possess  advantages  over  ether  is  doubtful,  that  they  are  more  dangerous 
is  positive.  Many  operators  prefer  to  give  gr.  J  to  J  of  morphin  hypoder- 
matically  a  short  time  before  beginning  the  anesthesia,  to  shorten  the 
preliminary  stages,  make  them  more  pleasant,  and  to  limit  the  amount  of 
anesthetic  necessary.  The  practice  should  not  be  a  routine  one,  but  in  certain 
cases,  such  as  morphin  or  alcoholic  habitues,  it  may  be  advatvla^^toM^.    'W^cis- 


20  ANESTHESIA. 

cin  or  atropin  is  sometimes  given  just  before  ether  in  order  to  lessen  the 
amount  of  mucus  secreted.  Recently  scopolamin-marphin  anesthesia  has 
been  tried.  One  milligramme  of  scopolamin  (hyoscin),  and  25  milligrammes 
of  morphin  are  divided  into  three  doses,  which  are  injected  hypodermically 
2i,  li  and  i  hour  before  operation  (Korff).  The  patient  falls  into  a  soimd 
sleep  which  lasts  for  five  or  six  hours  after  the  last  injection.  Inhalations  of 
chloroform  or  ether  may  be  necessary.  Several  deaths  have  been  reported 
and  the  method  cannot  be  recommended. 

Complications  during  anesthesia  arise  chiefly  from  interference  with 
the  respiratory  or  circulatory  apparatus,  the  former  more  particularly  with 
ether  and  nitrous  oxid,  the  latter  with  chloroform. 

Respiratory  difficulties  may  be  due  to  many  causes  not  direcdy  connected 
with  the  anesthetic,  such  as  faulty  posture  of  the  patient,  assistants  leaning 
on  the  chest,  tight  bandages  about  the  neck  or  chest,  swellings  within  or  about 
the  air  passages,  excessive  distention  of  the  abdomen,  and  diseases  of  the 
lungs.     Any  of  these  should,  of  course,  be  promptly  removed  if  possible. 
It  may  be  said  at  once  that  great  rapidity  or  cessation  of  the  respirations, 
associated  with  cyanosis  and  rapid  pulse,  calls  for  vigorous  measures.     If  the 
cause  is  not  obvious,  the  mouth  should  be  opened,  the  tongue  drawn  forward, 
and  the  pharynx  cleared.     If  this  does  not  overcome  the  difl&culty,  oxygen  and 
strychnin  should  be  administered,  artificial  respiration  employed  and,  if 
necessary,  tracheotomy  performed.     Only  those  causes  more  or  less  directly 
connected  with  anesthesia  will  be  considered  at  this  time.    ForgeUing  to 
breathe,  or  holding  the  bteath,  may  be  encountered  in  the  early  stages,  and  is 
met  by  withdrawing  the  anesthetic  and  perhaps  dashing  a  little  ether  on  the 
chest  or  abdomen.    Falling  backwards  of  tfie  tongue  over  the  epiglottis  re- 
quires the  turning  of  the  patient's  head  to  one  side,  and  pressure  behind  the 
angles  of  the  jaw,  so  as  to  lift  it  forward.     Rarely  will  the  mouth-gag  and 
tongue  forceps  be  necessary  for  this  purpose.     The  best  tongue  forceps  is  a 
double  tenacxilum,  which  secures  a  firm  hold  without  crushing  or  bruising. 
The  tongue  may  be  pressed  forward  also  by  passing  a  finger  into  the  pharynx, 
a  procedure  which  at  the  same  time  will  reveal  any  other  form  of  obstruction. 
Falling  together  o/tlie  lips,  especially  in  toothless  patients,  with  or  without  nasal 
obstruction,  may  interfere  with  respiration.    All  that  need  be  done  is  to 
place  the  finger  or  the  end  of  a  towel  between  the  lips.    Mucus,  saliva,  blood, 
pus,  vomitus,  or  other  liquids  may  be  removed  from  the  pharynx  by  turning 
the  head  to  one  side,  and  swabbmg  with  gauze  sponges  secured  by  a  hemostat. 
Spasm  oj  the  respiratory  muscles  requires  the  same  treatment  as  falling  back- 
wards of  the  tongue.     If  there  is  great  rigidity  of  the  muscles  of  the  jaw, 
tracheotomy  may  be  necessary.    Paralytic  arrest  of  respircUion  may  be  pre- 
cipitated with  great  suddenness,  especially  with  chloroform.     With  ether  the 
approach  is  more  gradual;  the  respirations  become  weaker  and  weaker,  the 
pupils  dilate  and  remain  immobile,  the  color  grows  dusky  and  the  pulse 
feeble.     The   treatment    is    artificial    respiration,    the   administration   of 
strychnin  subcutaneously,  and  inhalations  of  oxygen.     Edema  0/  the  lungs 
is  not  often  encountered.     The  patient  may  be  inverted  to  favor  drainage 
from  the  lungs,  and  oxygen  and  cardiac  stimulants  administered.    Vene- 
section is  sometimes  employed  to  relieve  the  right  side  of  the  heart,  and  arti- 
ficial respiration  should  be  performed  if  breathing  ceases.     Cyanosis  is 
simply  a  symptom  which  has  for  its  cause  one  of  the  conditions  mentioned 
above.     Artificial    respiration   is    best    done    by    the  Sylvester   method. 


CntCULATORY  DIFFICULTIES. 


21 


One  should  first  make  sure  that  the  air  passages  are  clear,  and  draw  out  the 
tongue  to  establish  free  air  way.  The  operator  stands  at  the  patient's  head, 
grasps  the  arms  at  the  elbows,  presses  them  firmly  against  the  sides  of  the 
chest  to  induce  expiration  (Fig.  7),  then  draws  the  arms  upward  until  they 
almost  meet  above  the  head,  in  order  to  raise  the  ribs  by  means  of  the 
pectoral  muscles  and  thus  cause  inspiration  (Fig.  8).  These  movements 
should  be  repeated  about  fifteen  times  a  minute.  Lahorde^s  method  consists 
in  alternately  drawing  upon  and  relaxing  the  tongue  at  intervals  of  four 
seconds.  FeWs  method  consists  in  the  introduction  of  a  tube  into  the  larynx, 
or  through  a  tracheotomy  wound,  respiration  being  maintained  by  means  of 
a  foot-bellows.  When  the  bellows  are  connected  with  a  laryngeal  tube,  the 
apparatus  is  known  by  the  name  of  Fell-0*Dwyer. 


Fig.  7. — ^Expiration. 

Figs.  7  and  8. — Artificial  Respiration. 


Fig.  8. — Inspiration. 
(Esmarch  and  Kowalzig.) 


Circulatory  Difficulties. — ^A  mild  degree  of  syncope  sometimes  results 
from  nausea  and  vomiting.  Cardiac  failure  may  result  from  operative 
manipulations  during  light  narcosis,  overdose  of  the  anesthetic,  hemorrhage, 
shock,  or  from  arrest  of  respiration.  Among  the  measures  which,  after 
withdrawing  the  anesthetic,  may  be  adopted  in  cardiac  failure,  are  the 
subcutaneous  administration  of  strychnin,  atiopin,  digitalis,  or  nitroglycerin, 
inversion  of  the  patient,  artificial  respiration,  faradism  of  the  phrenic  nerve 
(one  pole  on  the  epigastrium,  the  other  at  the  junction  of  the  external  border 
of  the  stemomastoid  with  the  clavicle),  rubbing  the  extremities  toward  the 
heart,  compression  of  the  abdominal  aorta,  stretching  of  the  sphincter 
ani,  rhythmic  pressure  over  the  precordium,  and  direct  massage  of  the  heart 

(p.  175).  , 

Coughing  and  swaUamng  during  the  induction  of  anesthesia  indicate  that 
the  vapor  is  too  strong.  Coughing,  swallowing,  or  vomiting  during  the  third 
stage  indicate  returning  consciousness  and  call  for  more  anesthetic.  Vomit- 
ing is  often  heralded  by  swallowing,  shallow  breathing,  pallor,  feeble  pulse,  and 
dilated  pupils,  a  group  of  symptoms  which  may  be  confused  with  shock ;  in  the 
latter  the  anesthetic  should  be  withdrawn,  in  the  former  it  should  be  increased 
in  order  to  prevent  the  vomiting.  If  vomiting  occurs,  the  head  should  be 
turned  to  one  side  and  the  stomach  contents  allowed  to  escape,  swabbing  out 
the  pharynx  if  necessary.  Hiccough  is  most  apt  to  occur  during  abdominal 
operations  and  usually  demands  an  increase  of  the  anesthetic. 


22  ANESTHESIA. 

Recovery  from  anesthesia  varies  in  duration  according  to  the  character 
and  quantity  of  the  anesthetic  and  the  condition  of  the  patient.  After  nitrous 
oxid  and  ethyl  chlorid  it  occurs  immediately  on  withdrawal  of  the  anesthetic, 
usually  without  any  special  phenomena.  After  ether  and  chloroform  the 
respirations  are  quiet,  the  eyeballs  rotate,  the  lid  reflex  returns,  swallowing 
begins,  and  vomiting  often  follows.  The  anesthetist  or  a  competent  nurse 
should  remain  with  the  patient  until  there  are  distinct  signs  of  recovery.  The 
head  should  be  low  and  turned  to  one  side,  and  the  patient  kept  warm.  Vom- 
ited matter  should  be  received  in  a  towel  or  basin  without  raising  the  head. 
Food  is  rarely  given  before  six  hours,  and  often  not  for  many  hours.  Vomit- 
ing is  more  frequent  after  ether,  but  is  apt  to  be  more  severe  and  protracted 
after  chloroform.  As  a  rule  it  ceases  of  itself  and  no  treatment  is  required. 
In  persistent  cases  the  most  effective  measure  is  gastric  lavage. 

After  effects  more  frequently  follow  ether  than  other  anesthetic  agents. 
Vomiting  has  been  referred  to  above.  Bronchial  and  pulmonary  affections 
are  often  due  to  the  irritation  of  ether,  but  may  arise  also  from  exposure  of 
the  patient  or  from  the  inhalation  of  septic  material.  Post-anesthetic  pneu- 
monia is  of  the  lobular  variety  and  quickly  follows  anesthesia.  An  accidental 
pneumonia  may  be  of  the  lobar  variety  and  may  not  arise  for  a  number  of 
days.  Preventive  measures  consist  in  the  use  of  a  clean  inhaler,  the  exclusion 
of  foreign  material  from  the  air  passages,  and  the  careful  protection  of  the 
patient.  Renal  complications  may  occur  after  ether,  chloroform,  or  ethyl 
chlorid.  Whether  they  are  more  frequent  after  ether  than  after  chloroform 
does  not  seem  to  be  satisfactorily  settled.  The  urine  is  alwajrs  decreased  in 
quantity  during  the  first  twenty-four  hours  after  anesthesia,  and  should  be 
carefully  watched.  If  signs  of  renal  incompetency  appear,  heat  should  be 
applied  over  the  kidneys,  diuretics  administered,  and  water  given  by  mouth, 
rectum,  subcutaneously,  or  intravenously.  Acetonuria  (p.  103)  may 
develop  after  chloroform,  rarely  after  ether.  Apoplexy  may  occur  in  those 
with  chronic  arterial  disease,  but  is  rare  if  the  patient  is  skillfully  and  thoroughly 
anesthetized ;  the  struggling  induced  by  pushing  the  anesthetic  or  by  operat- 
ing before  anesthesia  is  complete  is  dangerous  in  these  cases.  Complete 
anesthesia  is  usually  less  to  be  feared  than  fright  and  pain.  Jaundice  and 
insanity  have  followed  anesthesia.  Post-anesthetic  paralysis  may  result 
from  cerebral  hemorrhage  or  embolism,  but  is  usually  the  result  of  pressure, 
e.g.,  a  wrist  drop  due  to  the  hanging  of  an  arm  over  the  edge  of  a  table.  This 
subject,  with  the  position  to  be  assumed  by  the  upper  extremities,  is  referred 
to  in  Chap.  IV. 

Local  Anesthesia  is  the  production  of  insensibility  in  the  parts  to  be 
operated  upon,  without  destroying  the  general  bodily  sensibility  or  producing 
imconsciousness.  It  is  indicated  in  minor  operations,  and  in  major  surgery 
when  general  anesthesia  is  contraindicated.  It  is  not  satisfactory  in  children 
or  in  nervous  patients.  Local  anesthesia  may  be  induced  by  freezing,  or  by 
the  application  or  injection  of  various  drugs. 

Freezing  may  be  produced  by  spraying  the  parts  with  ether,  rhigolene, 
chlorid  of  methyl,  liquid  air,  or  chlorid  of  ethyl.  Chlorid  of  ethyl  is  the  agent 
usually  employed.  It  is  put  up  in  glass  tubes,  and  is  sprayed  on  the  part 
from  a  distance  of  about  one  foot.  When  the  part  becomes  hard  and 
white  it  is  ready  for  incision.  The  anesthesia  lasts  from  one  to  two  minutes. 
Both  the  freezing  and  the  thawing  are  painful.  In  the  absence  of  ethyl 
chlorid  freezing  may  be  induced  by  ice  and  salt,  in  the  proportion  of  two 


t 


LOCAL  ANKSTITF.TICS. 


pans  of  the  former  to  one  of  the  latter,  plated  in  a  gauze  bag  and  applied  to 
the  skin;  analgesia  results  in  about  fifteen  minutes, 

Cocain  kydroclilorid  is  an  efficient  local  anesthetic,  but  is  not  mthout 
danger.  Death  has  resulted  from  one  dram  of  a  20  per  cent,  solution  instilled 
into  the  urethra,  and  from  swabbing  the  lar)Tix  with  a  2  per  cent,  solution. 
Not  more  than  one-half  a  grain  should  be  used  for  injection,  not  over  two- 
thirds  of  a  grain  should  be  applied  to  a  mucous  membrane.  Cocain  poison- 
ing is  characterized  by  headache,  nausea  and  vomitiiig,  pallor,  tremor,  rest- 
lessness, dryness  of  the  mouth,  dilatation  of  the  pupils,  weak  pulse,  prolonged 
insomnia,  and  in  severe  cases  by  delirium,  unconsciousness,  and  heart  failure. 
The  treatment  consists  in  placing  the  patient  recumbent,  appl)dng  external 
heat,  and  administering  cardiac  stimulants.  Cocain  is  contraindicated  in 
glaucoma  because  it  dilates  the  pupils;  it  is  said  also  to  have  a  deleterious 
effect  upon  diseased  kidneys.  As  cocain  is  destroyed  by  prolonged  boiling, 
the  solution  is  best  prepared  (fresh  each  time)  by  adding  to  normal  salt 
solution  the  crystals  which  have  been  sterilized  in  glass  tubes  at  300*^  F.,  dry 
heat,  for  fi Iteen  or  twenty  minutes*  The  strength  of  the  solution  should  be 
from  2  to  4  per  cent,  for  the  eye,  4  per  cent*  for  the  urethra,  2  per  cent,  for 
the  bladder,  5  to  10  per  cent,  for  the  rectum,  vagina,  mouth,  nostrils,  and 
from  i  to  I  per  cent,  for  injection  into  any  portion  of  the  body. 

Eticain  hydrochlorid  is,  for  pracUcal  purposes,  just  as  powerful  as 
cocain,  one-quarter  as  toxic,  and  is  not  destroyed  by  boiling.  Solutions  for 
injection  should  be  from  i  to  4  per  cent.  It  does  not  cause  dilatation  of  the 
pupil,  nor  is  it  followed  by  as  marked  congestion  as  cocain.  Sloughing  has, 
however,  been  observed  in  a  few*  instances  after  its  use, 

Stavaia,  oovocaiii,  and  tropacocain  are  closely  related  to  cocain,  but 
the  first  is  four  times  and  the  other  two  seven  times  less  toxic  than  it  and  all 
are  just  as  anesthetic.  7'hey  come 
already  steriUzed  in  closed  tubes. 
For  injection  a  i  per  cent,  solution  in 
sterile  water  or  salt  solution  may  be 
employed. 

Adrenalin  chlorid,  when  added 
to  any  of  the  above  drugs,  causes  ex- 
sanguination  of  the  part  by  constrict- 
ing the  blood  vessels,  thus  lessening 
the  hemorrhage,  limiting  absorption, 
and  intensif}ing  and  prolonging  the 
anesthesia.  Barker  prepares  a  solu- 
tion by  adding  to  100  cc.  of  boiled 
distilled    water    i    cc.    of    adrenalin 

chlorid  (i  to  1,000),  3  grains  of  eucain,  and  12  grains  of  sodium  chlorid. 
Nat  more  than  fifteen  drops  of  adrenalin  chlorid  should  be  added  to  any 
solution  for  injection. 

Schleich*s  solution  produces  anesthesia  by  causing  an  artificial  edema, 
the  tension  resulting  in  ischemia  and  in  pressure  on  the  nerve  endings,  hence 
the  term  infiltration  anesthesia  (Fig.  9).  StctiU  water  or  normal  sail  soluiwn 
produces  much  the  same  effects,  but  is  not  quite  as  efficient.  Schleich  uses 
three  solutions  as  follows:  No.  i  (for  the  most  painful  operations — not  more 
than  5  drams  should  be  used)  consists  of  cocain  hydrochlorid  gr.  iii,  morphin 
hydrochlorid  gr.  J,  sodium  chlorid  gr.  iii.  distilled  water  f  3 iiis,  acid  carbolic 


Fig.  9,^ — Method  of  injecting  local  anes- 
thetics into  ihe  skin.  The  fluid  is  intro- 
duced into  and  not  beneath  the  skin,  which 
is  elevatcfl,  tense,  and  white. 


24  ANESTHESIA. 

(5  per  cent.)  gtt.  iii.  Solution  No.  2  (of  which  not  more  than  10  drains 
should  be  injected)  is  used  in  less  painful  operations,  and  is  the  same  as  No.  i 
except  that  the  cocain  is  reduced  to  gr.  iss.  Solution  No.  3  (used  in  deeper 
and  less  sensitive  tissues  and  in -extensive  operations — 11  oz.  may  be  injected) 
contains  but  gr.  J  of  cocain.  Adrenalin  chlorid  also  may  be  added  to  these 
solutions. 

The  injection  of  local  anesthetics  may  be  by  the  direct  methody  i.  e.,  the 
drug  is  injected  into  the  tissues  to  be  operated  upon,  or  by  the  indirect 
method  {regional  anesthesia),  in  which  the  drug  is  injected  into  {intraneural)  or 
about  (paraneural)  the  nerve  or  nerves  supplying  the  part  with  sensation, 
into  the  blood  vessels  of  the  part  {Bier,  Ransohoff),  or  into  the  subarachnoid 
space  of  the  spinal  cord  {spinal  anesthesia) .  In  the  direct  method,  whenever  pos- 
sible, e.g.,  in  the  fingers,  toes,  and  penis,  a  tight  ligature  should  be  placed  above 
the  area  to  be  anesthetized,  after  it  has  been  exsanguinated  by  elevation,  or  in 
some  cases,  by  pressure ;  this  in  itself  has  a  benumbing  influence,  as  well  as 
restricting  the  anesthetic  solution  to  the  injected  area.  After  making  sure 
that  all  air  has  been  driven  from  the  syringe  (a  hypodermic,  antitoxin,  or 
special  syringe  may  be  employed),  the  point  of  the  needle  is  inserted  obliquely 
into  the  skin  imtil  the  eye  is  just  beneath  the  epidermis;  in  other  words,  an 
effort  is  made  to  enter  the  true  skin  and  not  the  subcutaneous  tissues.  Care 
should  be  taken  not  to  enter  a  vein.  A  few  drops  of  the  solution  are  in- 
troduced, producing  a  white  wheal ;  the  needle  is  then  pushed  a  little  further, 
and  the  process  repeated  imtil  the  proposed  line  of  incision  is  marked  out  by 
a  white  and  elevated  ridge  (Fig.  9).  From  five  to  ten  minutes  should  elapse 
before  making  the  incision.  If  the  deeper  structures  are  to  be  severed,  they 
also  should  be  infiltrated,  or  one  of  the  more  powerful  solutions  may  be 
dropped  in  the  wound.  Intra-  or  paraneural  injections  may  be  employed  in 
amputation  of  the  finger,  by  forcing  the  solution  into  the  tissues  about  its 
base,  when  the  entire  finger  will  become  anesthetic.  In  amputation  of  the 
leg  the  tissues  over  the  sciatic  and  long  saphenous  nerves  may  be  infiltrated 
with  Schleich  solution,  and  the  nerves  exposed  and  injected  with  a  ^  to  i  per 
cent,  cocain  solution.  In  amputations  of  the  thigh  it  will  be  necessary  to  in- 
ject the  anterior  crural  instead  of  the  long  saphenous  nerve.  Many  other 
operations  may  be  performed  by  this  method. 

In  Bier's  intravenous  anesthesia,  after  rendering  the  limb  bloodless 
with  an  Esmarch  bandage,  a  tourniquet  is  placed  above  and  another  below 
the  field  of  operation.  Under  infiltration  anesthesia  a  cannula  is  inserted  into 
a  superficial  vein  immediately  below  the  proximal  tourniquet,  and  from  40 
to  100  cc.  of  novocain  (.5  per  cent,  in  salt  solution),  at  the  temperature  of 
the  body,  injected  towards  the  periphery.  Anesthesia  is  induced  between  the 
tourniquets  in  from  2  to  5  minutes;  beyond  the*  distal  tourniquet  in  from 
5  to  15  minuses,  when  the  distal  tourniquet  may  be  removed.  At  the  comple- 
tion of  the  operation  the  proximal  band  is  removed  gradually,  to  prevent 
rapid  diffusion  of  the  novocain.  Ransohoff  applies  an  Esmarch  band  to  the 
limb  with  sufficient  firmness  to  obstruct  the  venous  flow,  and  under  infiltra- 
tion anesthesia  injects,  with  a  fine  needle,  4  to  8  cc.  of  a  .  5  per  cent,  cocain 
solution  into  the  main  artery.  Anesthesia  results  in  2  minutes,  after  which 
the  band  may  be  tightened  to  check  oozing.  These  methods  are  still  in  the 
experimental  stage  and  must  be  used  with  caution.  They  are  contrain- 
dicated  in  the  presence  of  vascular  disease. 

Spinal  anesthesia,  or  medullary  narcosis,  is  produced  by  the  injection 


BACTERIOLOGY.  25 

of  a  local  anesthetic  into  the  subarachnoid  space.  Cocain  and  eucain  are 
seldom  used  at  the  present  time.  Stovain  has  a  strong  aflSnity  for  the  motor 
nerves  and  may,  in  high  anesthesia,  cause  paralysis  of  the  respiratory  mus- 
cles. Tropacocain  and  novocain  possess  less  of  this  aflSnity,  hence  are  safer; 
the  usual  dose  is  from  one-half  to  one  grain.  The  solution  is  prepared  by  dis- 
solving the  drug  selected  (previously  sterilized)  in  cerebrospinal  fluid,  which  is 
drawn  into  the  syringe  containing  the  anesthetic,  after  the  introduction  of  the 
needle  into  the  subarachoid  space.  In  order  to  make  the  solution  of  a  higher 
specific  gravity  than  the  spinal  fluid  and  s6  remain  in  the  lower  part  of  the 
spinal  theca.  Barker  uses  distilled  water  i  cc,  glucose  .05  grams,  and  stovain 
.1  gram.  The  syringe  should  be  boiled  in  plain  water,  as  the  soda  solution 
employed  for  other  instruments  may  diminish  the  efficacy  of  the  anesthetic. 
The  patient  lies  on  the  side  or  assumes  the  sitting  posjture;  in  either  case  the 
back  should  be  bent  forward  in  order  to  increase  the  space  between  the 
vertebral  arches.  The  operator  places  one  finger  upon  the  spine  of  the 
fourth  lumbar  vertebra,  which  is  on  a  line  drawn  between  the  two  iliac  crests, 
and  enters  the  needle,  fitted  with  a  stylet,  just  below  and  to  the  right  of  this 
point,  in  a  slightly  upward  and  inward  direction,  until  the  dura  has  been 
punctured,which  in  the  adult  is  usually  at  a  depth  of  two  and  one-half  inches. 
The  stylet  is  withdrawn  and  one  dram  of  the  cerebrospinal  fluid  allowed 
to  escape.  The  anesthetic  solution  is  then  slowly  injected,  the  needle 
withdrawn,  and  the  pimcture  sealed  with  collodion.  The  patient  is  then 
placed  in  the  proper  position  for  operation,  but  never  should  the  head  and 
shoulders  be  on  a  lower  level  than  the  lumbar  vertebrae,  as  the  fluid  may 
gravitate  towards  the  medulla  and  cause  respiratory  paralysis.  Anesthesia 
results  in  about  five  minutes  and  lasts  from  one  to  three  hours  or  longer. 
No  attempt  should  be  made  to  induce  anesthesia  above  the  diaphragm. 
Headache,  nausea,  and  vomiting  are  frequent  sequelae,  and  evidence  of 
transient  and  permanent  cord  injuries  has  been  noted.  The  chief  dangers 
are  infection,  injury  to  the  cord,  and  poisoning  from  the  anesthetic  employed. 
The  mortality  has  been  estimated  at  i  in  200.  From  what  has  been  said  it 
may  be  gathered  that  the  method  is  destined  to  pass  into  desuetude. 


CHAPTER  III. 
BACTERIOLOGY. 


Bacteria,  schizomycetes,  or  fission  fungi,  are  microscopic,  non-nucleated, 
unicellular,  vegetable  organisms,  devoid  of  chlorophyl  and  consisting  of 
protoplasm  inclosed  in  a  cell  wall.  The  terms  germ,  microbe,  and  micro- 
organism also  are  loosely  applied  to  bacteria  and  allied  organisms. 

According  to  shape  (Fig.  10)  bacteria  are  divided  into  cocci  (spherical), 
bacilli  (rod-like  or  cylmdrical),  and  spirilla  (spiral).  Cocci  are  divided 
according  to  number  into  monococci  (existing  singly),  diplococci  (in  pairs), 
Mracocci  (groups  of  four),  and  sarcina  (cubical  groups  of  eight);  according 
to  arrangement  into  streptococci  (chain-like)  and  staphylococci  (irregular 
masses  like  bunches  of  grapes).     Globular  masses  (zooglea)  held  together 


26 


BACTEiaOLOGY. 


by  gelatinous  matter  are  called  ascococcu  Bacilli  in  chain  formation  are 
called  streptohacUli.  A  leptothrix  is  a  long  thread-like  bacillus  which  many 
class  with  the  molds. 

The  distribution  of  bacteria  is  almost  universal.  They  exist  in  the 
air,  water,  food,  soil,  alimentary  canal  (being  most  numerous  in  the  mouth, 
lower  ileum,  and  cecum),  nose,  lower  urethra,  and  vagina,  and  even  in  the 
hair  follicles  and  sweat  glands  of  the  skin. 


Sardiue  (packet  coed). 


XL« 


Coed. 


Staphylococd. 


FlagdUle 
Badlli. 


With  cap- . 
sules 


.  Monococcus. 
Centrally  situated  spores. 

Clostridia  forms. 
Knobbed  bacteria  with 
terminal  spores. 


Diploccoci. 


Tetracocd. 


Zooglea. 


Slender  badlfi. 

Short  badlfi. 

B^uiDi  in  chaiiu.(strepl«^dIU). 

Vibrib  (spirilhim). 


Comma  badlli. 


SpirochKta. 


Fig.  lo. — Diagram  illustrating  the  nomenclature  of  schizomycetes  based  upon  their 
morphology.     (Coplin  after  Shenk.)     X  about  700  diameters. 


The  reproduction  of  most  bacteria  takes  place  by  fission,  i.e.,  the  cell 
simply  divides  into  two  or  more  fragments  when  it  has  reached  the  stage  of 
maturation.  A  few  bacilli  (e.g.,  B.  anthracis,  tetani,  and  edematis  maligni) 
and  spirilla  multiply  by  sporulation.  A  spore  is  analogous  to  the  seed  of  a 
plant,  and  may  appear  in  the  end  of  the  organism  {endspore),  or  in  the 
middle  {endospore),  thus  making  the  organism  club-shaped  or  fusiform. 
Although  as  a  rule  only  one  spore  forms,  a  number  may  develop  throughout 
the  length  of  the  organism,  presenting  a  bead-like  appearance.  A  spore  has 
a  dense  capsule  which  renders  it  very  resistant  to  all  kinds  of  disinfectants. 


INFECTION.  27 

For  development  bacteria  require  a  temperature  at  or  near  that  of  the 
human  body.,  moisture,  and  food.  Their  food  consists  of  complex  organic 
compounds,  such  as  are  foimd  in  the  bodies  of  animals  and  in  plants.  Aero- 
bic bacteria  require  oxygen  for  their  development;  anaerobic,  e.g.,  the  bacillus 
of  tetanus,  of  malignant  edema,  and  the  bacillus  aerogenes  capsulatus,  the 
absence  of  oxygen.  Most  pathogenic  micro-organisms  are  faculkUive 
anaerobes,  i.e.,  they  thrive  best  with  oxygen,  but  have  the  faculty  of  living 
without  it.  An  obligate  ana^obe  cannot  live  with  oxygen.  The  terms  facul- 
tative and  obligate  are  applied  also  to  aerobes  and  to  parasites  and  sapro- 
phytes. Parasites  grow  in  living  tissues,  saprophytes,  or  putrefactive 
organisms,  in  dead  tissues.  Like  the  cells  of  the  human  body,  bacteria 
attract  elements  essential  for  their  growth  (positive  chemotaxis)  and  repel 
those  which  are  harmful  {negaiive  chemotaxis).  Motile  bacteria  possess 
the  power  of  moving  from  place  to  place  by  means  of  thread-like  processes, 
or  fiageUa  (e.g.,  B.  typhosus  and  B.  coli),  or  by  means  of  a  rotary  or  un- 
dulatory  motion;  amotile  bacteria  (all  cocci  and  most  bacilli)  depend  for 
transportation  upon  fomites  or  upon  physical  or  chemical  currents.  In 
common  with  other  minute  particles  suspended  in  fluid,  bacteria  osciUate 
{Brownian  movements). 

Bacterial  death  is  caused  by  disinfection  (p.  31)  and  by  the  cells  and 
fluids  of  the  human  body  (p.  29). 

Freezing  renders  bacteria  inert,  but  does  not  destroy  them.  Drying 
renders  them  dormant,  but  permits  of  their  dissemination  by  means  of  the 
air.  It  is  important  to  remember  that  bacteria  are  not  blown  or  driven  from 
moist  surfaces,  and  that  a  table,  for  instance,  which  is  wiped  with  a  moist 
doth  is  not  as  dangerous  from  a  surgical  standpoint  as  one  which  is  dusted. 
Direct  sunlight,  the  X-rays,  electric  currents,  and  electric  light,  are  detri- 
mental to  the  growth  of  microbes. 

Bacterial  products  represent  the  excretions  of  bacteria,  the  substances 
generated  by  their  decomposition,  and  the  compounds  resulting  from  the 
action  of  either  of  these  on  the  tissues.  Bacteria  may  produce  alcohols; 
acids,  such  as  lactic,  acetic,  and  butyric;  alkalies,  e.g.,  ammonia;  and 
pigments  (chromo genie  bacteria),  e.g.,  bacillus  pyocyaneous;  some  are 
capable  of  causing  phosphorescence  (photogenic).  The  aero  genie  (gas 
producing)  bacteria  are  the  bacillus  aerogenes  capsulatus,  the  bacillus  of 
malignant  edema,  and  the  saprophytes,  the  most  prominent  of  which  is 
the  baciUus  coli.    Zymogenic  bacteria  cause  fermentation. 

The  ferments  are  known  as  enzymes.  These  ferments,  like  the  digestive 
juices,  emulsify  fats,  change  albumin  into  peptone  and  starch  into  sugar. 
The  enzymes  may  be  absorbed  in  the  human  body  and  produce  disease. 
The  poisonous  substances  elaborated  by  bacteria  are  the  ptomains,  the  toxal- 
bumins,  and  the  toxins.  A  piomain  is  a  crystallizable  alkaloid  produced 
by  the  action  of  bacteria  on  dead  animal  matter.  Toxalbumins  are  amor- 
phous albumoses  produced  by  the  action  of  enzymes  on  albumin.  Toxins 
are  crystallizable  alkaloids  existing  in  the  protoplasm  of  bacteria  and  excreted 
by  them  (ectotoxin),  as  in  diphtheria  and  tetanus,  or  liberated  by  their  death 
(endotoxin),  as  in  tuberculosis.  The  term  toxin  as  commonly  employed 
means  any  or  all  of  the  poisonous  substances  elaborated  by  bacteria,  and  the 
condition  resulting  from  the  absorption  of  these  toxins  is  called  toxemia. 

Infection  is  said  to  have  taken  place  when  pathogenic  (disease  producing) 
bacteria  invade  living  tissues  and  cause  symptoms.     Bacteria  which  are 


28  BACTERIOLOGY. 

incapable  of  producing  disease  are  spoken  of  as  non-pathogenic,  and  many 
of  these  are  not  only  harmless,  but  even  useful,  producing  alcoholic  and 
acetous  fermentation,  and  cleansing  the  earth  of  dead  animal  and  vegetable 
matter  by  putrefaction.  To  demonstrate  that  a  micro-organism  is  the  specific 
cause  of  a  given  disease,  it  should  fulfil  Koch^s  postulates,  which  are,  that  it  be 
foimd  in  every  case  of  that  disease,  that  it  be  absent  in  normal  tissues  under 
normal  conditions,  that  it  be  cultivated  in  pure  culture,  that  these  cultures  be 
capable  of  reproducing  the  disease,  and  that  the  germ  be  again  cultivated  in 
pure  culture  from  the  infected  animal.  To  these  has  been  added  the  isolation, 
from  the  cultures  of  the  organism,  of  a  toxin  which  will  produce  the  disease  or 
elaborate  an  antitoxin  in  susceptible  animals. 

The  usual  methods  of  infection  are  through  wounds  (inoculation), 
through  the  mucous  membrane  of  the  alimentary  canal  (ingestion),  through 
the  mucous  membrane  of  the  respiratory  passages  (inhalation).  Bac- 
teria rarely  pass  through  intact  healthy  skin.  It  is  known  that  micro- 
organisms may  pass  through  the  placenta.  Germinal  infection  (infected 
ovum  or  spermatozoon)  is  very  doubtful,  although  it  is  generally  taught 
to  be  the  cause  of  some  cases  of  congenital  syphilis.  A  wound  may  be 
infected  with  one  variety  of  bacteria  only,  and  a  secondary  infection  with 
another  variety  may  occur;  this  is  known  as  mixed  infection,  and  explains 
the  care  with  which  a  surgeon  sterilizes  his  hands  and  instruments,  even 
when  the  tissues  are  known  to  be  infected.  In  mixed  infection  one  form  of 
bacteria  may  antagonize  another  form  (enantobiosis),  or  the  varieties  may 
harmonize  in  their  development  (symbiosis). 

Disease  production  is  not  the  direct  result  of  the  deposition  of  bacteria, 
that  is,  the  process  is  not  a  mechanical  one.  They  may  injure  the  tissue 
cells  by  stealing  their  food,  but  as  a  rule  the  morbid  phenomena  are  due  to 
the  absorption  or  local  action  of  toxins.  The  production  of  disease  depends 
on  the  dose  of  the  micro-organisms  and  their  virulence,  and  also  upon  the 
resistance  of  the  tissues.  Many  of  the  organisms  entering  the  tissues  are 
swallowed  by  the  leukocytes  or  dissolved  by  the  bactericidal  action  of  the 
blood  serum,  so  that  probably  a  large  number  are  necessary  for  the  produc- 
tion of  morbid  phenomena.  The  virulence  of  micro-organisms  differs 
according  to  many  conditions;  those  which  at  one  time  are  benign  may  at  a 
later  period  become  extremely  harmful.  The  susceptibility  of  the  tissues 
also  varies  considerably  under  different  conditions;  thus  their  resistance  is 
decreased  by  prolonged  exposure  to  cold,  mechanical  injury,  alcoholism, 
diabetes,  kidney  disease,  imderfeeding,  overcrowding,  etc. 

Insusceptibility,  or  immunity,  to  an  infection  may  be  natural  or  acquired. 
Natural  immunity  is  illustrated  in  the  negro,  who  possesses  an  inherent 
resistance  to  yellow  fever.  Acquired  immunity  may  be  active  or  passive. 
Active  immunity,  so  called  because  the  tissue  cells  are  activated  to  form  anti- 
bodies, is  produced  by  a  previous  attack  of  a  disease,  e.g.,  syphilis  and  the 
exanthemata;  by  direct  inoculation,  such  as  was  once  employed  in  small-pox, 
and  is  still  used  for  certain  diseases  in  animals;  by  the  introduction  of  attenu- 
ated virus,  e.g.,  vaccination  for  small-pox  and  the  prophylactic  treatment  of 
hydrophobia;  and  by  the  injection  of  bacterins  (p.  30).  Passive  immunity  is 
produced  by  the  injection  of  immime  serum  (p.  29),  and  involves  no  action 
on  the  part  of  the  tissue  cells. 

Theories  of  Immunity. — The  body  defends  itself  against  infection  (i) 
by  destroying  bacteria  and  (2)  by  neutralizing  their  toxins. 


IMMUNITY.  29 

(i)  The  antibacterial  methods  of  defense  are  (a)  phagocytosis  and  (b) 
bacteriolysis,  (a)  Phagocytosis  is  the  process  whereby  microbes  are  devoured 
and  digested  by  certain  cells  of  the  body,  especially  the  leukocytes;  these 
cells  are  called  phagocytes.  Leukocytosis,  local  or  general,  or  both,  is 
nature's  effort  to  supply  a  sufficient  number  of  phagocytes  to  overcome  the 
invading  bacteria,  and  the  surgeon  sometimes  tries  to  assist  nature  in 
this  effort,  e.g.,  by  applying  heat,  inducing  passive  hyperemia  (Bier),  or  by 
injecting  nucleinic  acid  (Mikulicz)  or  horse  serum  (Petie).  The  substances 
in  the  blood  serum  which  prepare  bacteria  for  phagocytosis  are  termed 
opsonins  (see  also  bacterin  treatment,  p.  30). 

(b)  Bacteriolysis  is  the  dissolving  of  bacteria,  in  the  blood  serum  and 
body  fluids,  by  an  albuminous  substance  {bacteriolysin)  furnished  chiefly 
by  the  leukocytes.  Buchner  believes  there  is  but  one  bacteriolysin,  which 
he  calls  alexin,  for  all  bacteria  and  that  it  exists  in  normal  serum;  others,  that 
there  is  a  separate  antibody  manufactured  for  each  bacterium.  The  serum 
of  animals  immunized  to  the  bacilli  of  typhoid  fever,  cholera,  and  the  bacillus 
coli,  cause  agglutination,  or  clumping,  of  the  respective  microbes.  The 
Widal  test  for  typhoid  fever  is  based  on  this  phenomenon.  This  clumping 
is  probably  a  preliminary  step  to  bacteriolysis,  but  some  attribute  it  to 
specific  bodies,  called  agglutinins  or  precipitins. 

(2)  The  antitoxic  method  of  defense  consists  in  the  formation  of  anti- 
toxins by  the  blood  and  tissue  cells  as  the  result  of  the  action  of  bacterial 
antigens.  An  antigen  is  any  substance  (bacterial  toxins,  alien  blood  serum 
and  cells,  certain  animal  poisons,  etc.)  which  causes  the  generation  of  anti- 
bodies (lysins,  agglutinins,  antitoxins,  opsonins).  Antitoxins  neutralize 
toxins  but  have  no  effect  on  bacteria. 

Ehrlich  explains  the  phenomena  of  immunity  by  the  side-chain  theory. 
He  believes  that  every  living  cell  consists  of  a  central  body,  and  of  a  number 
of  other  chemical  groups  or  side-chains  {receptors)  which  are  especially  con- 
cerned with  nutrition.  A  toxin  consists  of  two  chemical  groups,  the  toxic 
carrying  portion  (toxophore)  and  a  combining  portion  (haptophore) .  When 
a  toxin  enters  the  circulation,  it  must  find  receptors  to  fit  its  haptophore 
group,  in  order  to  exert  a  deleterious  action  on  the  cells.  The  toxophore 
group  without  its  haptophore  group,  and  a  toxin  whose  haptophore  group 
cannot  find  an  affinity  for  receptors,  are  harmless.  When  a  toxin  combines 
with  a  cell,  the  receptors  are  destroyed,  and  the  cell  makes  an  effort  to  supply 
the  loss,  producing  many  more  receptors  than  are  necessary;  these  are  thrown 
into  the  circulation  and  constitute  antitoxin,  because  when  they  meet  with 
the  toxin,  they  immediately  combine  with  its  haptophore  group  and  render  it 
inert.  Certain  of  these  receptors,  called  also  immune  bodies  and  ambocep- 
tors, have  two  combining  groups,  one  (cytophile)  for  bacteria  or  other  cells, 
the  other  (complementophile)  for  the  complement.  The  complement  (bac- 
teriolysin, alexin)  dissolves  bacteria  after  being  fixed  to  them  by  the 
amboceptor. 

In  accordance  with  the  theories  outlined  above,  infections  may  be  pre- 
vented or  combated  by  means  of  (i)  immune  serums,  (2)  attenuated  forms 
of  virus,  and  (3)  bacterins. 

(i)  Immune  serums,  when  injected  into  the  body,  produce  passive 
immunity.  They  are  obtained  from  specially  immunized  animals,  and  are 
(a)  antitoxic  or  (b)  antibacterial,  (a)  Antitoxic  serums  are  laden  with  anti- 
toxin, produced  by  the  injection  of  toxins  into  an  animal;  such  are  the  anti- 


30  BACTEiaOLOGY. 

toxins  of  pneumonia,  plague,  hydrophobia,  diphtheria,  tetanus,  staphy- 
lococcic and  streptococcic  infections,  and  antivenine;  the  last  is  non-bacterial. 
(b).  Bactericidal  serums  contain  bacteriolysins  and  amboceptors,  hence  kill 
bacteria;  such  are  the  typhoid,  dysentery,  anthrax,  tuberculosis,  syphilis  (?), 
and  cholera  serums.  TTiose  serums  which  are  of  interest  to  the  surgeon 
receive  notice  under  the  diseases  for  which  they  are  used. 

Serum  disease  is  the  name  given  to  certain  symptoms  which  occasionally 
follow  serotherapy,  sometimes  immediately,  but  more  often  after  an  intemid 
of  from  eight  to  twelve  days.  The  most  frequent  of  these  symptoms  are 
pain  and  swelling  at  the  site  of  injection,  pain  and  swdling  of  the  adjacent 
lymph  glands,  pains  in  the  joints,  fever,  general  urticaria  or  erythema,  slight 
albuminuria,  and  leucopenia.  Great  weakness,  dyspnea,  cough,  edema  of 
the  face,  and  swelling  of  the  tongue  may,  however,  occur,  and  a  few  cases  of 
sudden  death  have  been  reported.  Asthmatics  are  especially  prone  to 
suffer  from  disagreeable  or  dangerous  sequela.  The  nature  of  serum 
disease  is  not  thoroughly  understood,  but  when  it  follows  a  second  injection 
of  serum,  it  is  supposed  to  be  due  to  supersensitiveness.  Super  sensitiveness , 
or  anaphylaxisy  in  contradistinction  to  prophylaxis,  is  the  increased  suscepti- 
bility to  serum  (or  to  any  proteid)  arising  in  an  animal  as  the  result  of  a 
sub-toxic  dose  previously  administered,  the  theory  being  that  the  tissue 
cells  have  been  educated  by  the  first  injection  to  split  up  die  proteid,  hence 
when  a  second  injection  is  given  the  process  takes  place  so  rapidly  that  the 
animal  is  overwhelmed  by  the  toxic  portion  of  the  proteid. 

(2)  An  attenuated  virus  is  employed  in  the  prophylactic  treatment  of 
hydrophobia  (p.  117),  and  small-pox  is  prevented  by  vaccination  with  an 
attenuated  form  of  small-pox  (cow-pox). 

(3)  A  bacterin,  or  vaccin,  is  a  suspension  of  dead  bacteria  with  their 
toxins  in  salt  solution.  Tuberculin,  which  must  be  put  in  this  class,  contains 
however,  only  toxins  and  is  made  up  with  glycerin  or  water  (p.  135). 
Here  should  be  mentioned  also  Coley's  fluid,  which  on  empirical  grounds  is 
used  in  the  treatment  of  malignant  growths  (p.  148).  Bacterins  are  in- 
jected into  the  body  wnth  the  idea  of  inducing  active  immunity,  especially 
by  increasing  the  opsonic  index  and  thus  stimulating  phagocytosis.  The 
opsonic  index  is  the  amount  of  opsonin  (p.  29)  in  the  patient's  serum  com- 
pared with  that  in  normal  serum.  It  is  determined  by  dividing  the  num- 
ber of  bacteria  ingested  by  the  leukocytes  of  healthy  blood,  by  the  num- 
ber ingested  by  those  of  the  patient's  blood,  100  or  more  leukocytes 
being  searched;  thus  if  400  are  found  in  the  leukocytes  of  normal  blood 
and  300  in  those  of  the  patient's  blood,  the  opsonic  index  is  .75.  The 
hope  that  the  opsonic  index  might  be  of  value  in  diagnosis  and  prognosis 
seems  far  from  realization,  and  as  a  guide  to  the  dose  of  bacterins 
it  is  seldom  employed.  Bacterins  should,  whenever  possible,  be  autogenous, 
i.e.,  made  by  taking  the  organisms  directly  from  the  individual  to  be  treated. 
When  this  is  not  done  one  may  employ  a  stock  bacterin,  i.e.,  one  already 
prepared  from  the  organisms  furnished  by  another  individual  suffering  from 
the  same  infection.  The  stock  bacterins  supplied  by  manufacturing  chemists 
have  the  number  of  bacteria  in  each  cc,  usually  40  to  600  millions,  marked  on 
the  tubes.  The  initial  dose  varies  according  to  the  infection,  5  to  25  millions 
being  the  average.  This  is  followed  by  a  fall  (negative  phase),  dien,  in  a 
few  days,  by  a  rise  in  the  opsonic  index  (positive  phase).  The  injections  are 
generally  given  at  intervals  of  from  5  to  10  days,  and  never  when  the  negative 


DISINFECTION.  3 1 

phase  manifests  itself  clinically  by  aggravation  of  the  symptoms.     The 
status  of  this  form  of  treatment  in  not  yet  fixed.     It  seems  to  be  of  distinct 
value  in  many  chronic  localized  suppurative  processes,  and  it  is  contrain- 
dicated  in  acute  spreading  infections  accompanied  by  toxemia. 
Other  pathogenic  micro-organisms  besides  bacteria  are: 

1.  HypomyceUs,  or  mold  fungi,  which  consist  of  filaments,  or  hyphae, 
often  forming  an  interlacing  network,  called  the  mycelium;  these  fungi 
multiply  by  sporulation.  Some  of  the  diseases  produced  by  molds  are 
thrush  {atdium  albicans) y  actinomycosis  (actinomyces  or.  ray  fungus), 
mycetoma,  or  Madura  foot  (streptothrix  Madurae),  favus  (achorion  Sch5n- 
leinii),  and  certain  other  skin  diseases. 

2.  The  yeastSy  blastomycetes,  or  saccharomycetes,  which  multiply  by  bud- 
ding, or  gemmation,  cause  bread  to  rise,  and  are  responsible  for  many  forms  of 
fermentation.  Blastomycetic  dermatitis  is  due  to  yeast  fungi,  and  some  sup- 
pose that  a  yeast  causes  cancer. 

3.  Protozoa,  which  are  microscopic  unicellular  organisms  belonging  to  the 
lowest  form  of  animal  life.  Malaria  (plasmodium  malariae)  trypanosomiasis 
(sleeping  sickness),  and  certain  forms  of  dysentery  (ameba  coli)  are  due  to 
protozoa,  and  carcinoma,  syphilis  (spirocheta),  variola,  and  moUuscum  con- 
tagiosum  are  supposed  to  be  due  to  protozoa. 

Special  surgical  micro-organisms  are  mentioned  under  the  diseases  for 
which  they  are  responsible. 

Disinfection,  or  sterilization,  is  the  destruction  of  germs  outside  or  on 
the  surface  of  the  body;  germs  within  the  tissues  can  be  destroyed  only  by  the 
tissues.  The  agent  by  which  disinfection  is  effected  is  called  a  disinfectant^ 
or  germicide.  An  antiseptic  restricts  or  prevents  the  development  of  micro- 
organisms; as  commonly  employed,  however,  the  term  is  synonymous  with 
germicide  and  disinfectant.  A  deodorizer,  e.g.,  charcoal,  may  destroy  an 
offensive  odor,  but  is  not  necessarily  an  antiseptic.  A  sepsis  means  the  absence 
of  bacteria;  antisepsis  includes  all  the  measures  taken  for  the  destruction  of 
bacteria.  Sterilization  may  be  divided  into  (i)  mechanical,  (2)  thermal, 
and  (3)  chemical. 

1.  Mechanical  sterilization  is  the  mordant  for  other  forms  of  disinfection ; 
it  consists  in  shaving,  scrubbing  with  soap  and  water,  and  irrigation.  With- 
out it  many  chemical  disinfectants  are  useless,  with  it  even  9ie  mildest  are 
highly  efficient. 

2.  Thermal  disinfection,  or  heat,  is  the  most  effectual  of  all  forms  of  steril- 
ization, and  should  be  used  whenever  possible.  Moist  heat  (boiling  water 
or  other  liquids,  and  steam)  is  more  efficient  than  dry  heat.  Steam  may  be 
quiescent  (simple  steam),  live  steam,  or  steam  under  pressure.  Live  steam 
is  better  than  simple  steam,  and  steam  under  pressure  is  the  best  of  all. 
An  autoclave  (Fig.  11)  is  a  sterilizer  into  which  steam  is  introduced  under 
high  pressure.  A  vacuum  is  first  created,  thus  allowing  greater  penetration 
of  the  steam  into  the  articles  within  the  chamber.  The  steam  is  under  a 
pressure  of  from  10  to  15  pounds  to  the  square  inch  at  240°  F.  At  the  com- 
pletion of  the  process  of  sterilization  a  vacuum  is  again  created  and  the 
objects  dried.  By  means  of  this  apparatus  complete  sterilization  (10  pounds 
pressure  at  240*^  F.)  of  ordinary  dressings,  etc.,  takes  place  in  three-fourths 
of  an  hour.  Material  for  sterilization  in  the  autoclave  should  be  loosely 
packed,  should  not  come  in  contact  with  the  walls  of  the  sterilizer,  and 
should  be  heated  before  the  steam  is  turned  on.     Simpler  and  chea^^er 


BACTERIOLOGY. 


'^g^l 


sterilizers,  without  the  advantage  of  pressure,  also  are  on  the  market.     Dry 
heat  (flame»  hot  air,  actual  cautery,  etc.)  is  rarely  employed. 

3.  Chemkal  di  sin  feci  wn  is  of  less  value  than  the  mechanical  and  the  ther- 
mal methods.  A  chemical  sufficiently  strong  to  be  rapidly  germicidal  will  kill 
not  only  bacteria,  but  also  the  tissue  cells.  Of  the  many  chemical  di,sinfec- 
iants  the  most  important  are  given  below. 

Bkhiorid  of  mercury  (torfosive  sttbiimate)  is  a  white  poisonous  powder, 
used  as  a  solution  in  water.  It  is  one  of  the  best  chemical  disinfectants,  but 
is  very  fastidious  in  its  action;  thus  it  decomposes  when  brought  in  contact 
with  metallic  apparatus,  and  is  inert  in  the  presence  of  alkalies  and  albumins, 
so  that  solutions  must  be  made  with  distilled  or  filtered  water.  The  union  of 
bichlorid  of  mercurj'  with  aibumin  may  be  prevented  by  the  addition  of 
tartaric  acid,  which,  it  should  be  remembered,  will 
have  the  same  effect  also  on  alliumins  which  may  be 
administered  to  combat  poisoning.  Bichlorid  solu- 
tions should  be  fresh,  as  standing  for  some  time 
impairs  their  power,  owing  to  the  formation  of  an 
oxychlorid;  this  may  be  prevented  by  the  addition  of 
ammonium  chlorid.  For  convenience  bichlorid  is 
put  up  in  tablets  containing  7 . 3  grains  of  corrosive 
sublimate  and  an  equal  amount  of  ammonium 
chJorid ;  one  of  these  tablets  added  to  a  pint  of  water 
makes  a  i  to  1000  solution.  It  is  not  a  good  rectal 
antiseptic,  because  in  the  presence  of  hydrogen 
\l  '  ]f^^^^"^^^  sulphid  it  is  changed  into  the  insoluble  sulphid  of 
■-^•^ I ^^J^^*^^  mercury;  and  it  is  a  poor  antiseptic  in  fatty  tissues, 
because  it  will  not  reach  bacteria  which  are  coated 
with  oil.  It  is  never  used  in  clean  wounds,  as  it 
destroys  some  of  the  cells  and  causes  e.xudation; 
and  because  of  its  irritating  qualities,  it  is  never 
applied  to  serous  membranes,  such  as  the  peritoneum,  meninges,  pleura,  and 
synovial  membranes.  For  the  skin  it  is  employed  in  the  strength  of  i  to  icxx>; 
for  wounds,  1  to  2000;  for  the  vagina  i  to  5000;  for  the  urethra,  1  to  10,000;  and 
for  the  conjunctiva'*  i  to  40,000.  Unless  one  Is  accustomed  to  its  use  corrosive 
sublimate  frequently  causes  a  cracking  and  blackening  of  the  hands.  Occa- 
sionally bichlorid  of  mercury^  causes  a  severe  dermatitis  with  the  formation  of 
pustules,  and  it  is  .sometimes  absorbed  from  wounds,  producing  constitu- 
tional symptoms  of  poisoning,  \iz.,  salivation  (p.  129)  stomatitis,  metallic 
taste  in  the  mouth,  foul  breath,  vomiting,  colicky  pains  in  the  abdomen, 
diarrhea,  and  in  very  severe  cases  collapse  and  death;  the  drug  is  withdrawn, 
of  course,  on  the  first  indication  of  absorption. 

Carhdic  add,  or  phenol,  occurs  as  crystals  which  deliquesce  on  exposure 
to  air,  the  resulting  tluid  being  called  pure  carbolic  acid.  It  is  a  less  powerful 
germicide  than  bichlorid  of  mercury,  and  is  rarely  used  in  wounds  because 
of  its  irritating  efiFecls,  although  it  penetrates  fatty  tissues.  It  is  a  good 
deodorizer,  however,  and  is  often  put  into  ointments  because  of  its  feeble 
anesthetic  properties.  It  is  not  used  on  the  hands,  because  it  roughens  and 
cracks  them  and  impairs  their  sensibility.  W'hen  powerful  solutions  are 
applied  for  a  long  time,  gangrene  may  result.  It  linds  its  chief  office  in  the 
disinfection  of  materials  which  do  not  stand  boiling  well.  Pure  carbolic  acid 
is  occasionally  employed  to  sterilize  badly  infected  wounds,  alcohol,  which 


Fig.  u. — Autoclave. 


DISINFECTANTS.  33 

is  a  powerful  antidote,  being  used  one  or  two  minutes  later  for  the  purpose  of 
neutralization.  When  the  weaker  solutions  (i  to  5  per  cent.)  are  continuously 
applied  to  a  wound,  absorption  and  poisoning  may  ensue;  the  pure  acid 
produces  a  superficial  area  of  coagiilation  which  prevents  its  absorption. 
One  of  the  first  symptoms  of  absorption  is  smoky,  greenish,  or  blackish 
urine  (carboluria).  Later  there  may  be  vomiting,  headache,  vertigo, 
sweating,  feeble  pulse,  irregular  and  rapid  breathing,  great  weakness,  and 
subnormal  temperature.  The  treatment  consists  in  withdrawal  of  the  drug, 
stimulation,  and  sodium  sulphate  or  Epsom  salts. 

Lysol  and  creolin  are  coal-tar  derivatives,  which  are  feebler  than  carbolic 
acid,  but  less  toxic  and  irritating.  Creolin  is  a  good  rectal  disinfectant  in 
the  strength  of  3  per  cent.  Lysol,  2  per  cent.,  is  used  in  obstetrics,  as  it  acts 
also  as  a  lubricant  for  the  hands. 

Hydrogen  peroxid  is  frequently  employed  to  cleanse  suppurating  areas. 
It  is  a  fluid  which,  when  applied  to  a  wound,  sets  free  from  ten  to  fifteen  times 
its  volume  of  oxygen,  producing  ebullition,  and  probably  destroying  the 
elements  upon  which  bacteria  live.  It  should  be  kept  in  a  dark  and  cold 
place,  should  ordinarily  be  used  in  half  strength,  and  should  never  be  injected 
into  deep  sinuses  unless  a  large  external  opening  exists,  as  the  liberated  gas 
may  do  great  harm  by  pressure. 

Permanganate  of  potassium  is  used  as  a  deodorizer  in  foul  wounds,  slough- 
ing tumors,  etc.,  in  the  strength  of  from  yV  to  5  per  cent.  It  is  used  also  for 
disinfecting  the  hands  (saturated  solution  in  water)  and  as  an  antidote  to 
snake  poisoning.    Condy's fluid  is  a  2  per  cent,  solution  in  water. 

Alcohol  is  employed  chiefly  for  the  preservation  of  surgical  materials, 
such  as  sutures,  etc.,  for  the  disinfection  of  instruments  with  keen  edges, 
and  to  remove  fafty  material  from  the  skin  previous  to  the  application  of 
bichlorid  of  mercury.  Gasoline,  ether,  and  turpentine  also  are  occasionally 
useful  for  the  last  purpose. 

Formaldehyd  is  a  powerful  antiseptic  gas,  which  is  sold  as  a  40  per  cent, 
solution  in  water,  under  the  name  of  formalin.  It  is  very  irritating,  and 
should  never  be  applied  to  living  tissues;  some  operators  employ  a  2  per  cent, 
solution  for  the  disinfection  of  instruments.  Glutol,  or  formalin  gelatin,  is  a 
powder  which  gives  off  formalin  when  brought  in  contact  with  wound 
secretions. 

Boric  acid  (saturated  solution  in  water)  is  a  mild  antiseptic,  which  is  indi- 
cated when  more  powerful  but  more  irritating  disinfectants  cannot  be  em- 
ployed. Thiersch's  fluid  is  sterile  water  containing  i  gr.  of  salicylic  acid 
and  6  gr.  of  boric  acid  to  the  ounce. 

Tincture  of  iodin  is  now  being  widely  employed  for  disinfection  of  the 
skin  previous  to  operation,  as  described  on  p.  39.  It  is  strongly  recom- 
mended also  for  the  sterilization  of  infected  wounds.  It  may  be  applied, 
full  strength,  at  long  intervals,  or  the  wound  may  be  irrigated  daily  with  a 
I  per  cent,  solution.  In  irrigating  large  wounds  with  iodin  solution,  the 
possibility  of  poisoning  should  be  kept  in  mind. 

Iodoform  is  a  yellow  powder  with  a  disagreeable  smell.  It  liberates  iodin 
when  brought  in  contact  with  wound  secretions,  and  so  creates  an  un- 
favorable field  for  bacteria;  but  bacteria  may  grow  upon  dry  iodoform, 
so  that  it  must  be  sterilized  for  at  least  five  minutes  by  washing  in  a  i  to 
10,000  bichlorid  of  mercury  solution.  It  is  frequently  used  as  iodoform 
gauze,  or  as  an  emulsion  in  ether,  glycerin,  vaselin,  or  sweet  oil.     Its  chief 


34  SURGICAL  TECHNIC. 

value  is  in  tuberculosis,  owing  to  its  ability  to  produce  fibrous  tissue  as  the 
result  of  the  irritating  action  of  the  iodin.  Iodoform  sometimes  causes 
a  severe  dermatitis,  and  occasionally  constitutional  symptoms  of  poisoning. 
In  some  cases  there  is  marked  gastrointestinal  irritation,  such  as  vomiting  and 
diarrhea;  in  others  cerebral  symptoms,  such  as  delirium  or  melancholia;  in 
either  case  there  is  fever,  yellowness  of  the  conjunctivae,  suffusion  of  the  eyes 
with  contraction  of  the  pupils,  a  metallic  taste  in  the  mouth,  an  odor  of  iodo- 
form upon  the  breath,  and  iodin  in  the  saliva  and  urine.  A  rash  upon  the 
skin,  rapid  emaciation,  and  nephritis  are  not  infrequent.  Many  substitutes 
have  been  proposed  for  iodoform,  but  nothing  as  efficient  for  tuberculous 
cases  has  yet  been  created.  The  odor  of  iodoform  may  be  made  less  dis- 
agreeable by  the  addition  of  one  of  the  aromatic  oils.  Except  in  tuberculous 
cases,  the  author  never  uses  iodoform  and  rarely  any  other  antiseptic  powder, 
unless  it  be  thymol  iodid.  Powders,  as  ordinarily  used  from  a  box  which  is 
exposed  to  the  air  and  dust,  are  laden  with  germs;  hence  they  are  contrain- 
dicated  in  aseptic  wounds,  and  much  better  means  of  disinfection  may  be 
found  for  infected  wounds.  A  cetanilid  when  freely  used  is  positively  danger- 
ous; cyanosis  and  collapse  may  follow,  especially  in  the  old,  the  young,  or  the 
debilitated. 

The  salts  of  silver  f  e.g.,  silver  nitrate,  lactate  (actol),  citrate  (itrol),  collargol, 
protargol,  and  argyrol  have  antiseptic  properties.  All  but  the  first  are  pro- 
prietary preparations.  The  indications  for  these  salts  will  be  given  in  sub- 
sequent pages.     Silver  foil  is  occasionally  applied  to  wounds. 


CHAPTER  IV. 
SURGICAL  TECHNIC. 

An  operation  is  performed  with  greater  comfort  to  the  surgeon,  and  greater 
safety  to  the  patient,  in  a  hospital  than  in  a  private  house.  A  well-equipped 
hospital  is  suppled  with  an  anesthetizing  room,  an  operating  room,  a  recovery 
room,  and  rooms  for  the  surgeons  and  nurses  to  change  their  clothing.  The 
most  essential  factor  in  an  anesthetizing  room  is  that  it  be  well  lighted,  in  an 
operating  room  that  it  may  be  easily  and  thoroughly  cleansed,  and  in  a  recov- 
ery room  that  it  has  some  means  of  immediately  summoning  aid  in  an  emer- 
gency. There  are  also  auxiliary  rooms  for  the  sterilization  of  the  material 
used  during  an  operation,  for  the  storing  of  instruments,  dressings,  etc. 

Instruments  are  usually  kept  in  an  air-tight  glass  case,  in  the  bottom  of 
which  are  small  open  compartments,  containing  calcium  chlorid  for  the  ab- 
sorption of  any  moisture  which  may  gain  access  to  the  closet  and  tarnish  the 
instruments.  Instruments  should  be  all  metal,  with  as  few  corrugations, 
indentations,  and  joints  as  possible,  in  order  to  facilitate  proper  cleaning. 
They  are  sterilized  by  boiling  for  fifteen  minutes,  in  water  to  which  has  been 
added  sodium  carbonate,  in  the  strength  of  i  per  cent,  (i  J  dr.  to  the  pint), 
for  the  purpose  of  preventing  rusting.  As  ebullition  tends  to  dull  sharp 
instruments,  they  should  be  protected  by  a  wrapping  of  cotton  and  boiled  for  a 
shorter  period,  chisels  and  scissors  for  five  minutes,  knives  and  needles  for 
three  minutes;  or  placed  in  a  solution  of  carbolic  acid  (5  per  cent.),  formalin 


SUTURES  AND   LIGATURES.  35 

(2  per  cent.),  or  alcohol  (95  per  cent.),  for  30  minutes.  These  solutions 
should  be  used  also  for  instruments  with  wooden  or  ivory  handles,  which 
are  cracked  by  boiling.  Instruments  containing  lenses,  e.g.,  the  cystoscope, 
are  ruined  by  boiling  and  by  alcohol,  hence  must  be  disinfected  in  a  solution 
of  carbolic  acid  (5  per  cent.)  or  formalin  (2  per  cent.).  The  sterilizer  con- 
sists of  a  copper  tray,  with  a  securely  fitting  lid,  and  a  perforated  false  bottom 
with  handles;  the  false  bottom  prevents  injury  to  the  instruments  due  to 
the  exposure  to  the  direct  intense  heat  on  the  floor  of  the  sterilizer,  and  facili- 
tates their  removal  at  the  completion  of  boiling,  the  bottom  being  lifted 
from  the  sterilizer  by  means  of  hooks  passed  trough  the  handles  of  the 
false  bottom.  After  sterilization  instruments  may  be  placed  in  a  tray  con- 
taining sterile  water  or  spread  on  a  dry  sterile  sheet;  in  either  case  they  should 
be  covered  with  sterile  towels  until  the  operation  is  begun.  At  the  comple- 
tion of  an  operation  the  instruments  should  be  scrubbed  with  soap  and  water, 
sterilized,  and  dried,  before  replacing  them  in  the  closet. 

Sutures  and  LigatvLTts.— Silkworm  gut,  or  fishing  gut,  is  the  thread 
drawn  from  the  silkworm  killed  when  ready  to  spin  the  cocoon.  It  is  strong, 
smooth,  readily  tied  in  a  secure  knot,  and  is  easily  sterilized  by  boiling.  In 
many  hospitals  it  is  placed  in  long  glass  tubes,  which  are  securely  corked,  and 
boiled.  It  is  then  ready  for  instant  use,  the  tube  being  submerged  in  bichiorid 
or  carbolic  acid  solution  before  being  uncorked.  With  the  latter  method, 
however,  it  is  desirable  to  soak  the  silkworm  gut  in  boiling  water  for  a  few 
minutes  before  using,  in  order  to  render  it  pliable.  As  silkworm  gut  is  not 
absorbable,  it  is  used  only  on  surfaces  from  which  it  may  be  subsequently  re- 
moved, and  as  it  stiffens  while  drying,  it  is  not  used  in  such  regions  as  the 
axilla,  perineum,  etc.,  without  shotting,  as  the  ends  might  occasion  discom- 
fort by  pricking  the  tissues. 

Silk  is  plaited,  floss,  or  twisted.  It  is  strong,  very  pliable,  and  may  be  tied 
in  a  firm  knot.  It  may  be  sterilized  by  boiling  in  water  for  a  half  hour.  This 
diminishes  the  strength  of  the  silk,  however,  and  a  better  method  is  to  place 
the  material,  wound  on  glass  spools,  in  a  test  tube  plugged  with  cotton;  the 
tube  is  then  placed  under  10  pounds*  pressure  in  an  autoclave  for  one-half 
hour,  and  the  process  is  repeated  the  following  day,  and  again  on  the  third 
day  (fractional  sterilization),  the  theory  being  that  any  spores  which  may  have 
escaped  destruction  during  the  first  sterilization  will  have  developed  into 
adults  by  the  second  or  third  day,  and  will  then  be  more  easily  killed.  Silk 
is  extensively  used  in  abdominal  surgery  for  the  tying  of  pedicles  and  for 
suturing  intestines.     It  is  not  absorbable. 

Catgut  comes  from  the  submucous  coat  of  the  sheep's  intestine.  Being 
absorbable,  it  is  generally  used  for  ligatures  and  for  buried  sutures.  After 
being  put  into  the  tissues  it  swells  and  tends  to  become  untied,  so  that  it  should 
always  be  tied  in  three  knots  and  the  ends  left  at  least  J  inch  long.  It  may 
be  sterilized  by  one  of  a  number  of  different  methods;  boiling  in  alcohol, 
cumol,  or  xylol,  and  sterilization  by  dry  heat  are  efficient,  but  require  special 
apparatus.     The  following  methods  are  simple  and  reliable : 

Claudius  uses  iodized  catgut.  After  the  raw  catgut  has  been  wound  on  a 
glass  spool  it  is  soaked  for  eight  days  in  a  solution  of  one  part  of  iodin  and 
one  part  of  potassium  iodid  in  100  parts  of  water.  Before  using  it  is  placed 
in  a  3  per  cent,  solution  of  carbolic  acid  or  in  sterile  salt  solution,  to  remove 
the  surplus  iodin.  Unused  catgut  may  be  replaced  in  the  iodin  solution. 
Catgut  thus  prepared  is  absorbed  in  froYn  12  to  16  days,  according;  to  vis  svife* 


StntGICAL  TECHNIC. 

To  render  the  gut  less  absorbable,  soak  il  in  a  i  to  2000  aqueous  solution  of 
chromic  acid  for  24  hours  before  sterilization, 

Congdon  uses  a  modiikation  of  Hoffmeister's  method;  he  winds  raw  cat- 
gut on  a  glass  cylinder  in  a  single  layer,  and  places  it  in  a  3  per  cent,  solutioi 
of  formalin  for  from  i^  hours  to  4  hours,  according  to  the  size  of  the  gut,  Af-^ 
ter  it  has  been  washed  in  running  water  for  the  same  length  of  time  that  it  has 
been  in  the  formalin  solution  it  is  dried  in  the  open  air  and  stored  away 
for  future  use.  Catgut  prepared  by  this  method  may  be  boiled  bke  silk. 
When  it  is  desired  to  have  the  catgut  resist  absorption  for  a  longer  period,  a  5 
per  cent,  solution  of  formalin  is  used  instead  of  the  3  per  cent,  solution,  and 
the  gut  is  left  in  this  solution  twice  as  long  as  that  stated  for  the  3  per  cent, 
solution;  it  is  then  washed  in  running  water  for  the  same  length  of  time  that 
it  has  been  submerged  in  the  formalin  solution.  By  the  latter  method  No. 
4  gut  will  resist  al>sorption  for  from  four  to  six  weeks. 

Baritetrs  Method. — The  calgut  is  rolled  into  htde  coils,  which  are  strung 
on  a  thread  and  suspended  in  a  beaker  glass,  without  touching  the  sides  or 
bottom,  by  bringing  the  ends  of  the  thread  through  a  small  opening  in  a 
pasteboard  cover,  which  is  placed  on  the  receptacle.  The  same  opening  ad- 
mits a  thermometer,  the  bulb  of  which  is  on  a  level  with  the  topmost  coils. 
The  catgut  is  covered  with  liquid  petrolatum,  the  temperature  of  which  is 
gradually  raised  to  212°  F.  by  placing  the  beaker  in  a  sand  bath.  After  12 
hours  the  temperature  is  increased  to  300°  F.  in  the  course  of  an  hour,  and 
then  the  oil  is  allowed  to  cooL  After  allowing  the  superfluous  oil  to  drop 
from  the  catgut,  the  coils  are  placed  until  needed  in  a  1  per  cent*  solution  of 
iodin  in  Columbian  spirits.  This  method,  as  modi  tied  byLff,  is  employed  in 
the  Pennsylvania,  Jefferson,  and  Germantown  Hospitals.  Lee  drys  the 
gut  in  a  dry  air  sterilizer,  at  100^  C,  for  15  minutes,  then  covers  it  w^ith 
liquid  petrolatum  and  raises  the  temperature  to  140°  C.,  where  it  is  main* 
tained  for  15  minutes.  At  the  end  of  12  hours  the  temperature  is  again 
raised  to  140"^  C.  and  there  kept  for  15  minutes.  The  gut  is  preserved  in  a 
j\  per  cent,  solution  of  iodin  in  akohol  (95  per  cent.). 

Kangdro&  tendon  is  obtained  from  the  tail  of  the  kangaroo,  and  may  be 
prepared  in  the  same  manner  as  catgut-  WTien  chromicized  it  may  not  be 
absorbed  by  the  tissues  for  tw^o  months.  It  is  used  for  suturing  bone,  or 
when  an  absorbable  suture  which  will  last  a  long  time  is  desired. 

Some  surgeons  employ  living  strips  0/ fascia  from  the  margins  of  the  wound 
which  they  desire  to  close. 

Siherwire  may  be  used  for  suturing  bone;  care  should  be  taken  in  twisting 
the  ends  of  the  wire,  lest  it  break.  Although  silver  wire  is  said  to  have  ami 
septic  properties,  it  frequently  causes  suppuration  and  sinus  formation  when 
allowed  to  remain  in  the  tissues  for  a  long  time,  and  should  very  rarely 
be  used  except  for  the  indication  just  mentioned.  Ir&n  •wire  has  been  recom- 
mended  as  a  substitute  for  silver  wire  in  bone  work,  as  it  is  not  so  easily 
broken:  aluminum  bronze  wire,  which,  unlike  silver  or  iron,  is  ultimately  ab- 
sorbed, has  been  utilized  for  the  same  purpose;  these  wires  may  be  sterilized 
by  boiling. 

Horsehair  may  be  used  for  the  nice  appro.ximation  of  skin  where  there  is 
no  tension;  it  may  be  lK)iled  in  water. 

Pagensiecher*s  celluioid  iltread  is  linen  thread  impregnated  with  celluloid; 
it  has  the  advantages  of  silkworm  gut,  as  well  as  great  flexibility.  WTien 
placed  in  the  tissues  it  absorbs  a  large  quantity  of  fluid  but  does  not  soften. 


^ 


Dressings  arc  commonly  made  of  cheesecloth,  or  gauze.  Cotton  or  any 
material,  however,  which  will  absorb  Huids  and  which  may  be  sterilized,  may 
be  used  for  this  purpose.  The  sizing  should  be  removed  from  cheesecloth  by 
boiling  in  a  solution  of  carbonate  of  soda,  but  in  the  material  coming  from  a 
surgical  house  this  process  has  already  been  effected.  The  material  is  cut 
into  suitable  lengths  for  various  operations,  folded,  and  wrapped  in  covers 
of  drilling  or  heavy  muslin,  which  are  secured  by  a  pin.  These  packages  are 
Sterilized  under  lo  pounds'  pressure  for  forty- five  minutes,  and  are  kept  in 
covered »  sterilized  gUss  jars  until  required.  Antiseptic  dressings  are  pre- 
pared by  soaking  gauze  in  solutions  of  various  antiseptics. 

Sea  sponges  are  expensive  and  difficult  to  prepare,  but  are  still  preferred 
by  some  eminent  surgeons.  In  their  place  most  surgeons  use  small  pads  of 
gauze,  which  are  sterilized  like  dressings.  For  intraabdominal  work  large 
gauze  pads,  six  or  more  inches  square,  consisting  of  six  layers  of  gauze,  the 
edges  of  which  are  turned  in  and  stitched  to  prevent  the  detaching  of  any 
threads^  are  employed  to  isolate  the  field  of  operation.  To  one  corner  of 
each  pad  is  sewed  a  piece  of  tape,  whicii  emerges  from  the  wound  and  is 
secured  by  a  hemostal,  in  order  tJiat  it  shall  not  be  forgotten.  A  belter  plan 
is  to  prepare  a  pad  four  yards  long,  six  inches  broad,  and  four  layers  in  thick- 
ness; as  much  of  this  as  may  be  necessary  is  packed  into  the  abdomen.  The 
gauze  is  then  cut  and  the  end  allowed  to  protrude  from  the  wound,  and  it  is 
de6nitely  known  that  but  one  piece  of  gauze  is  within  the  abdomen.  These 
pads  are  sterilized  with  the  dressings. 

Iodoform  gauze  is  prepared  by  mixing  4  ounces  each  of  iodoform,  glycerin, 
and  alcohol,  and  5  gr.  of  bichlorid  of  mercury;  sterile  gauze  is  soaked  in  this 
mixture,  allowed  to  drip  till  almost  dr}%  and  then  stored  in  covered,  disin- 
fected glass  jars. 

Caps,  gowns,  sheets,  and  towels,  are  sterilized  with  the  gauze.  Basins, 
pitchers,  instrument  trays,  scrubbing  f>rushes,  and  glass  drainage  tubes 
may  be  boiled,  or  soaked  in  i  to  500  bichlorid  of  mercury  solution.  Articles 
made  of  hard  rubber,  such  as  pessaries,  syringe  nozzles,  etc.,  should  be 
washed  with  soap  and  water,  and  disinfected  in  a  i  to  500  bichlorid  of  mer- 
cur>'  solution.  Soft  rubber,  e.g.,  drainage  tubes,  catheters,  etc.,  should  be 
boiled  in  plain  water  for  five  minutes,  and  stored  in  bichlorid  of  mercur)' 
solution.  Varnished  catheters  may  be  sterilized  in  formalin  vapor.  Instru* 
ments  containing  leather,  such  as  the  hypodermatic  syringe,  are  sterilized  by 
soaking  in  a  solution  of  carbolic  acid.  Lister*s  oiled  silk,  rubber  tissue  (thin 
sheets  of  gutta-percha),  rubber  dam,  and  wax  or  paraffin  paper  are  sterilized, 
after  washing,  by  soaking  in  bichlorid  of  mercury  solution.  As  heat  shrivels 
rubber  tissue,  care  should  be  taken  to  have  the  solution  cooL  Silver  foil  is 
sterilized  by  ^ry  heat.  Cargile  membrane  is  made  from  the  peritoneum  of 
the  ox,  is  used  as  a  protective,  and  comes  already  sterilized. 

Water  or  normal  salt  soluthn  {{^  per  cent.,  or  i  dr.  of  salt  to  the  pint  of 
water)  is  filtered  into  clean  glass  flasks,  which  arc  plugged  with  cotton  and 
then  boiled. 

The  surgeon,  the  assistantSi  and  the  nurses  should  wear  sterile  suits  of 
duck  or  linen,  and  have  the  hair  covered  with  sterile  caps  or  gauze.  Most 
surgeons  use  a  gauze  mask  to  prevent  contamination  of  the  wound  by  the 
shower  of  saliva  which  accompanies  talking. 

There  are  three  methods  frequently  employed  for  the  disin/ectwn  of  the 
hands,  the  first  step  of  each  consisting  in  thorough  scrubbing  of  the  hands 


i 


38  SURGICAL  TECHNIC. 

and  forearms,  up  to  and  above  the  elbows,  with  soap  and  hot  water,  which  is 
frequently  changed.  The  brush  should  have  been  sterilized  by  boiling  just 
before  use,  and  special  attention  should  be  given  to  folds  and  creases,  and  to 
the  spaces  beneath  and  around  the  nails.  The  nails  should  be  trimmed,  the 
subungual  spaces  cleansed  with  a  nail  cleaner,  and  the  scrubbing  continued, 
according  to  diflferent  surgeons,  for  from  five  to  fifteen  minutes.  The  longer 
period  is  preferable,  and  should  invariably  be  timed  by  the  clock. 

In  theFurbringer  method,  after  step  one,  the  hands  are  scrubbed  in  absolute 
alcohol  for  one  minute,  then  soaked  and  scrubbed  in  bichlorid  of  mercury 
solution  I  to  1000  for  at  least  one  minute,  special  attention  being  given  to 
the  nails.  . 

In  the  Kelly  method,  after  step  one,  the  hands  are  soaked  in  a  saturated 
solution  of  potassium  permanganate  until  the  skin  is  stained  a  dark  brown 
color;  the  skin  is  then  decolorized  by  washing  in  a  saturated  solution  of  oxalic 
acid;  next  the  acid  is  removed  by  sterilized  lime  water;  and  finally  the  hands 
are  scrubbed  for  one  minute  in  bichlorid  of  mercury  i  to  1000. 

In  the  Weir  or  Stimson  method,  after  step  one,  a  heaping  teaspoonful  of 
chlorid  of  lime  and  the  same  quantity  of  sodium  carbonate  are  placed  in  the 
palm  of  the  hand,  and  made  into  a  thick  cream  by  the  addition  of  water;  this 
is  rubbed  over  the  hands  and  forearms,  and  around  and  under  the  nails,  for 
from  three  to  five  minutes.  The  hands  are  now  washed  in  sterile  water  or  in 
dilute  ammonia  solution,  to  remove  the  odor  of  chlorin. 

As  absolute  sterility  of  the  hands  cannot  be  secured,  most  surgeons,  after 
employing  one  of  the  methods  given  above,  use  rubber  gloves.  Rubber  gloves 
are  sterilized  by  washing  with  soap  and  water,  and  boiling  in  a  i  per  cent, 
solution  of  sodium  carbonate  for  fifteen  minutes.  They  are  drawn  on  the 
hands  while  filled  with  sterile  water,  or  by  using  glycerin  as  a  lubricant,  or 
they  may  be  dried,  and  slipped  on  with  ease  after  the  interior  has  been 
dusted  with  sterile  talcum.  Oil  should  not  be  used  for  lubrication,  as  it 
injures  the  rubber.  Gloves,  however,  are  not  ideal;  they  impair  sensation, 
necessitate  very  firm  pressure  in  holding  a  slippery  structure  like  the  intestine, 
and  tend  to  make  an  operator  slovenly  in  the  disinfection  of  his  hands;  they 
also  cause  perspiration,  thus  washing  from  the  deeper  layers  of  the  skin 
bacteria,  which  gain  entrance  to  the  wound  through  punctures  and  tears  in 
the  gloves,  an  accident  which  demands  a  fresh  glove,  after  washing  the  hand 
in  bichlorid  solution.  After  the  hands  have  been  prepared  for  operation  a 
sterile  gown  with  sleeves  reaching  the  wrists  should  be  put  on. 

The  Patient. — For  preparation  for  anesthesia  see  section  on  anesthesia. 
The  dangers  common  to  all  operations  are  those  of  anesthesia,  hemorrhage, 
shock,  and  infection.  Special  dangers  of  individual  operations  receive 
mention  with  the  description  of  the  various  operations.  Whenever  possible 
the  patient  should  be  under  observation  for  at  least  two  days  before  operation, 
in  order  that  the  patient  himself,  as  well  as  the  disease,  may  be  carefully  studied. 
The  history  is  taken,  and  a  thorough  examination,  especially  of  tlie  heart, 
lungs,  urine,  and  blood,  is  made.  The  diet  should  be  free  of  vegetables 
and  consist  principally  of  albumins,  in  order  to  leave  little  residue  in  the 
intestines,  which  are  cleared  by  laxatives,  usually  calomel,  gr.  \  every  hour 
for  eight  doses,  followed  by  magnesium  sulj)hate,  oz.  J.  This  prevents 
autointoxication,  and  in  abdominal  work  renders  the  intestines  docile,  so  that 
they  may  be  kept  from  the  operative  field  by  gauze  packing.  Before  opera- 
tions on  the  mouth,  esophagus,  and  gastrointestinal  tract  the  number  of 


PREPARATION   OF  THE  PATIENT.  39 

bacteria  in  the  alimentary  canal  may,  aside  from  purgation,  be  diminished 
by  removing  carious  teeth  and  tartar,  frequently  rinsing  the  mouth  with 
an  antiseptic  wash,  and  sterilizing  all  food.  The  patient  is  given  a  daily 
soap  and  water  bath. 

The  day  before  operation  the  part  to  be  operated  upon  is  shaved,  and  then, 
after  disinfection  of  the  hands,  it  is  surrounded  with  sterile  towels,  and 
thoroughly  scrubbed  with  soap  and  water,  using  a  sterile  brush  with  soft 
bristles,  or  a  piece  of  gauze  if  the  skin  is  tender.  Special  attention  is  given  to 
folds  and  creases  in  the  skin,  and  to  such  places  as  the  umbilicus.  It  is  im- 
portant to  scrub  not  only  the  immediate  region  of  the  proposed  wound,  but 
also  neighboring  regions,  e.g.,  for  a  brain  operation,  not  only  the  head,  but 
also  the  neck  and  ears,  and  for  a  breast  amputation,  not  only  the  breast,  but 
also  the  neck,  axilla,  arm,  opposite  breast,  and  the  upper  part  of  the  abdomen. 
For  an  abdominal  operation  the  disinfection  should  extend  aroimd  to  the 
spine,  up  to  the  breasts,  and  down  to  the  pubes,  including  the  upper  part 
of  the  thighs;  for  a  gynecological  operation  it  is  necessary  to  disinfect  also 
the  vagina.  After  scrubbing  with  soap  and  water,  the  skin  is  rubbed  with 
alcohol  (70  per  cent.),  in  order  to  dissolve  the  sebaceous  matter  and  fat  in  the 
mouths  of  the  glands,  and  thus  clear  the  way  for  the  bichlorid  of  mercury  solu- 
tion, I  to  1000,  with  which  the  part  is  next  scrubbed.  In  children,  in  adults 
with  sensitive  skins,  as  well  as  on  the  scalp,  a  i  to  2000  solution  should  be 
employed.  With  hard  and  filthy  skin,  sudi  as  is  often  found  on  the  feet,  a 
soap  poultice,  made  by  soaking  a  thick  pad  of  gauze  in  soap  suds,  should  be 
applied  for  many  hours  before  the  disinfection.  Gauze  soaked  in  bi- 
chlorid of  mercury  (i  to  2000)  and  covered  with  waxed  paper,  or,  better,  a 
dry  sterile  dressing,  is  applied  to  the  disinfected  region  imtil  the  time  of 
operation,  when  the  whole  procedure  is  repeated.  Some  surgeons  omit  the 
preliminary  scrubbing,  others  claim  that  the  scrubbing  at  the  time  of  opera- 
tion is  objectionable,  in  that  it  uncovers  bacteria  in  the  skin  by  loosening 
fresh  layers  of  epidermis;  an  increasing  number  are  painting  the  skin  with 
tincture  of  iodin  (3  percent.)  the  day  before  and  again  at  the  time  of  operation. 
Grossich,  the  originator  of  the  iodin  method,  removes  the  hair  immediately 
before  operation  by  dry  shaving,  claiming  that  water  swells  the  superficial 
layers  of  the  epidermis  and  interferes  with  penetration  of  the  iodin ;  he  then 
applies,  without  preliminary  scrubbing,  the  official  tincture  of  iodin,  which  is 
allowed  to  dry  spontaneously.  The  ear  may  be  sterilized  by  prolonged 
syringing  with  a  carbolic  solution,  i  to  100,  or  with  a  bichlorid  of  mercury 
solution,  I  to  2000;  the  nose  by  spraying  with  Dobell's  solution,  followed  by 
carbolic  acid,  i  to  100;  the  mou^  by  having  the  teeth  put  in  order  and  tartar 
removed  by  a  dentist,  and  by  the  use  of  a  good  tooth  powder  and  brush 
several  times  a  day,  followed  by  a  thorough  rinsing  with  a  carbolic  acid  solu- 
tion, I  to  100;  and  the  bladder  by  irrigation  with  potassium  permanganate,  i 
to  5000,  argyrol,  i  to  1000,  or  by  a  saturated  solution  of  boric  acid.  The 
vagina  is  scrubbed  with  a  piece  of  gauze,  with  soap  and  water,  then  copiously 
douched  with  bichlorid  of  mercury  solution,  i  to  4000.  The  rectum  may  be 
cleansed  of  fecal  matter  by  an  enema  of  soap  and  water,  then  irrigated  with 
creolin,  i  to  3  per  cent. 

No  food  ^ould  be  given  for  at  least  six  hours  before  operation,  in  order 
that  the  stomach  may  be  empty  and  that  vomiting  may  not  occur.  Several 
hours  before  operation  the  rectum  should  again  be  cleansed  by  a  soap  and 
water  enema,  i  pint,  so  that  any  stimulating  or  nutritious  fluids  may  be  ab- 


40 


I 


sorbed  in  rase  their  injection  becomes  necessan\  Immediately  before  opera-] 
tion  the  patient  should  pass  unne  or  be  catheterized,  so  that  there  will  be  no 
danger  of  injur\'  to  the  bladder  in  an  abdominal  operation,  and  so  that  the 
surgeon  wil!  know  the  exact  quantity  of  urine  secreted  subsequent  to  opera- 
tion. Before  going  to  the  operating  room,  those  parts  of  the  chest*  abdomen, 
and  limbs  which  are  not  to  F>e  operated  upon,  should  be  covered  with  a  steril- 
ized shirt,  leggings,  etc,  to  protect  the  patient  from  draughts. 

In  an  emergency  in  which  the  patient  is  admitted  immediately  before 
the  operation,  the  same  precautions  regarding  the  l)Iadder  and  rectum 
should,  as  a  rule,  be  observed.  The  disinfection  is  usually  made  by  thci 
process  given  above,  after  the  patient  has  been  anesthetized.  In  cases  of] 
intestinal  obstruction  it  is  of  the  greatest  importance  to  wash  out  the  stomach] 
previous  to  anesthetization,  to  prevent  suffocation  by  the  large  quantities  of] 
fetid  fluid  which  are  regurgitated  while  the  patient  is  unconscious.  In  acci- 
dent cases  in  which  macliine  grease  and  dirt  cover  the  part,  cleansing 
greatly  facilitated  by  the  previous  application  of  sweet  oil. 

The  Operation, — In  all  '*  clean  cases/^  and  even  in  septic  cases  in  the  cra- 
nium, chest,  abdomen,  and  joints,  the  surgeon  performs  an  aseptic  operation^ 
i.e.,  the  [>reparations  mentioned  above  are  carried  out,  but  after  the  incision  has 
been  made  no  antiseptics  are  used,  sterile  water  or  salt  solution  being  em- 
ployed for  irrigating  the  wound,  and  sterile^  not  antiseptic,  gauze  being  used 
to  dress  the  wound.  In  septic  and  emergency  operations  not  involving  the 
cavities  just  mentioned,  the  surgeon  may  perform  an  antiseptic  operation^  i.e., 
antiseptics  are  used,  not  only  in  the  preparation  of  the  patient,  but  also  to 
flush  the  wound,  and  antiseptic  gauze  is  used  for  dressings. 

The  operating  table  is  covered  with  a  blanket  wrapped  in  a  sterile  sheet; 
in  special  cases  an  electric  mattress  or  a  number  of  hot  water  bags  are  used 
to  maintain  the  heat  of  the  body.  When  the  patient  is  placed  on  the  table, 
care  should  be  taken  that  the  arms  are  properly  disposed.  If  the  arm  is  allowed 
to  hang  over  the  edge  of  the  table,  if  the  patient  is  allowed  to  lie  on  the  arm 
twisted  under  the  back,  or  if  the  arms  are  stretched  far  above  the  head  for  a 
prolonged  period »  an  annoying  paralysis  may  result.  In  cases  not  involving 
the  chest  or  upper  abdomen  the  arms  may  be  folded  across  the  chest  and 
secured  by  turning  back  the  shirt.  In  operations  on  the  upper  abdomen 
the  arms  shoukl  Ije  elevated  not  higher  than  a  right  angle  with  the  body  and 
the  hands  secured  above  the  head.  Never  should  the  arms  be  so  tied  that  they 
may  not  be  readily  freed  for  the  purpose  of  artificial  respiration  should  it 
suddenly  become  necessary.  After  the  part  to  be  operated  upon  has  been 
exposed  by  a  nurse  whose  hands  are  not  disinfected,  the  surgeon's  assistant 
places  sterile  towels  over  the  adjacent  clothing,  and  redisinfects  the  part  by 
the  process  already  given.  All  the  clothing  of  the  patient  is  now  covered  by 
fresh  sterile  sheets  or  towels.  In  operations  about  the  face  or  neck  the  hair 
should  be  covered  by  a  sterile  rubber  cap  or  a  sterile  towel.  In  operations 
approaching  the  nose  and  mouth  it  is  important  also  that  the  anesthetizer 
disinfect  his  hands,  wear  a  sterile  gown,  and  use  a  sterile  piece  of  gauze, 
a  cone  wrapped  in  a  sterile  towel,  or  the  Rupert  apparatus,  for  the  anesthetic. 
As  a  rule  one  assistant  is  sufficient  for  alnriost  any  operation;  the  fewer  hands 
that  come  in  contact  with  the  wound  the  less  the  danger  of  infecUon.  At 
least  three  nurses  are  commonly  on  duty  during  an  operation;  one  nurse 
attends  to  the  sutures  and  ligatures,  a  second  takes  care  of  the  sponges  and 
dressings,  and  a  third,  *' dirty  nurse,*'  exposes  the  field  of  operation,  assists 


THE  OPERATION. 


41 


the  etherizer,  gets  additonal  instruments  that  may  be  called  for,  and  does 
whatever  else  may  be  necessary  that  one  with  disinfected  hands  cannot  do. 
Before  and  after  operations  involving  the  abdomen  or  other  large  cavity,  not 
only  sponges  and  padS^  but  also  instruments  and  needles,  should  be  carefully 
counted,  to  make  sure  that  none  has  been  left  behind. 


Incisions  should  be  clean-cut  and  of  equal  depth  throughout.  The  way 
the  knife  is  held  to  make  incisions  is  Dlustrated  in  Figs.  12  to  17.  Tearing 
the  tissues  by  blind  and  blunt  dissection  should  be  avoided  as  much  as  possible, 
as  bruising  is  more  likely  to  be  followed  by  suppuration.  As  soon  as  divided, 
blood  vessels  are  caught  by  hemostats  (Fig.  1 26)  which  should  grasp,  not  a 
large  amount  of  tissue,  but  the  bleeding  point  alone.     Under  no  circumstances 


42  SURGICAL  TECHNIC. 

should  the  skin  be  crushed  with  hemostatic  forceps.  The  assistant  keeps  the 
wound  free  of  blood,  not  by  scrubbing,  but  by  quickly  mopping  with  a  gauze 
sponge.  As  soon  as  an  instrument  has  been  used,  it  should  be  washed  in 
sterile  water  and  replaced  in  the  instrument  tray.  •At  frequent  intervals 
during  the  operation  the  hands  should  be  washed  in  sterile  water.  When 
the  towels  surrounding  the  field  of  operation  become  soiled,  they  should 
be  replaced  or  covered  by  fresh  ones.  Sometimes  during  the  operation, 
and  always  at  its  completion,  it  is  desirable  to  flush  the  woujid  with  hot 
sterile  water  or  normal  salt  solution,  to  free  it  from  blood  clots  and  mechanic- 
ally disinfect  it.  At  this  time  it  will  be  found  that  the  smaller  vessels  which 
have  been  clamped  do  not  bleed  after  removal  of  the  forceps.  Larger  vessels 
should  be  ligated  with  catgut;  torsion  is  not,  as  a  rule,  a  satisfactory  method 
for  dealing  with  these  vessels.  If  the  bleeding  has  not  been  stopped,  dots 
will  accumulate  and  infection  be  favored.  The  deeper  layers  of  the  wovnd 
are  brought  together  with  catgut  sutures,  the  skin  with  silkworm  gut  (see 
wounds). 

Drainage  is  not  required  in  an  aseptic  wound  treated  by  the  aseptic  method, 
if  hemorrhage  has  been  carefully  controlled.  If  there  is  infection,  if  strong 
antiseptics  have  been  used,  if  there  is  still  some  bleeding,  or  if  it  is  feared  that 
sutures  put  in  a  hollow  viscus  may  not  hold,  drainage  must  be  instituted. 
Drainage  may  be  effected  by  rubber,  silver,  or  glass  tubes;  by  strands  of  catgut, 
horsehair,  or  silkworm  gut;  or  by  strips  of  gauze  or  rubber  tissue.  Wlien 
used,  it  is  often  desirable  to  surround  gauze  with  rubber  tissue,  in  order 
to  prevent  its  adhering  to  the  tissues  (cigarette  drain).  The  writer,  particu- 
larly in  abdominal  cases,  frequently  employs  the  Mikulicz  drain.  This 
consists  of  a  thin  gauze  bag,  filled  with  a  separate  strip  of  gauze,  which  may 
be  removed  and  the  cavity  irrigated  without  disturbing  the  bag.  The  bag 
remains  in  place  until  it  is  loose.  A  drain  should,  whenever  possible,  be 
placed  in  the  most  dependent  part  of  a  wound  or  cavity.  In  women  the 
peritoneal  cavity  may  often  be  drained  through  the  vagina,  thus  permitting 
closure  of  the  abdominal  wound  as  well  as  facilitating  the  discharge.  The 
objections  to  drainage  are  that  it  delays  union,  produces  a  wider  scar,  invites 
infection,  encourages  adhesions,  and  in  abdominal  cases  predisposes  to 
hernia  and,  because  of  adhesions,  to  intestinal  obstruction;  drain  tubes  may 
cause  pressure  necrosis  of  the  intestine  and  fecal  fistula,  hence  should  rarely 
be  used  in  the  abdomen.  A  copious  dressing  of  sterile  gauze  is  now  applied, 
and  maintained  in  place  by  suitable  bandages.  Occasionally  in  septic  cases 
it  is  desirable  to  use  antiseptic,  instead  of  sterile,  gauze. 

After  Treatment. — The  patient  is  put  into  a  warm  bed  with  no  pillow, 
and  the  head  turned  to  one  side,  so  that  in  case  vomiting  occurs,  there  will  be 
less  danger  of  the  vomited  material  falling  into  the  trachea.  In  all  cases  a 
physician  or  a  nurse  should  remain  with  the  patient  until  he  has  fully  recov- 
ered from  the  cflFects  of  the  anesthetic.  Shock,  if  present,  should  be  com- 
bated at  once  (p.  loi).  If  the  patient  is  unable  to  void  urine,  a  catheter 
may  be  passed  every  eight  hours.  As  a  rule,  even  in  abdominal  cases,  small 
quantities  of  water  may  be  given  as  soon  as  the  post-anesthetic  nausea  has  dis- 
appeared. Continued  vomiting,  especially  after  abdominal  operations,  is  an 
ominous  sign.  It  is  best  treated  by  gastric  lavage.  For  thirsif  when  water 
cannot  be  taken  by  the  mouth,  an  enema  of  8  oz.  of  salt  solution  may  be  given 
every  four  or  six  hours.  In  the  few  cases  in  which  rectal  injections  actually 
cause  nausea,  they  should  of  course  be  discontinued,  and  the  salt  solution 


OPERATION   IN  A   PRIVATE  HOUSE.  43 

given  beneath  the  skin.  The  practice  of  leaving  a  large  quantity  of  salt 
solution  in  the  abdomen  after  celiotomy  prevents  thirst  and  favors  elimina- 
tion. Fever  after  operation  is  considered  on  page  103.  The  character  of 
the  pulse  furnishes  a  surer  index  of  the  patient's  condition  than  the  tempera- 
ture. Especially  during  the  first  twenty-four  hours  one  should  watch  for 
the  symptoms  of  hemorrhage  (p.  196).  Backache  may  be  due  to  renal  con- 
gestion or  muscle  strain;  it  is  relieved  by  hot  applications,  support  to  the 
back,  and  by  increasing  the  urinary  output.  As  soon  as  the  stomach  has  be- 
come quiet,  and  usually  at  the  beginning  of  the  second  day,  the  patient  is 
given  I  gr.  of  calomel  in  divided  doses,  followed  in  one  hour  by  magnesium 
sulphate,  oz.  J.  If  the  bowels  do  not  move  three  or  four  hours  later,  an  enema 
of  soap  and  water,  i  pint,  is  given.  If  this  is  ineffectual,  an  enema  consisting 
of  magnesium  sulphate  i  oz.,  glycerine  i  oz.,  turpentine  ^  oz.,  and  soap  and 
water  i  pint,  may  be  tried.  An  enema  consisting  of  alum  i  oz.,  in  a  pint  of 
water,  is  also  hi^y  efficient.  The  passage  of  a  rectal  tube  up  into  the  sig- 
moid flexure  will  often  be  followed  by  the  expulsion  of  gas.  These  measures 
are  of  special  importance  after  an  abdominal  operation,  particularly  when 
the  constipation  is  associated  with  tympany  and  vomiting,  which  often  in- 
dicate a  beginning  peritonitis  or  intestinal  obstruction  (Chap,  xxvii).  Symp- 
toms of  sepsis  usually  come  on  in  from  two  to  five  days  after  operation;  for  the 
symptoms  and  treatment  the  reader  is  referred  to  the  chapters  on  suppuration 
and  fevers,  and  to  the  sections  on  regional  surgery.  After  the  bowels  have 
moved  the  patient  begins  to  take  liquid /cot/  in  small  quantities,  and  as  con- 
valescence progresses  the  quantity  is  increased;  semi-solid  food  follows,  and 
finally  the  regular  diet  is  reached.  The  dressings  are  changed  when  they 
become  soiled  with  wound  fluid,  or  with  discharges  from  the  mouth,  rectum, 
or  urethra;  when  it  is  desirable  to  remove  drainage  or  stitches;  and  when  there 
are  signs  of  suppuration.  They  should  not  be  disturbed  unless  there  is 
some  definite  indication,  as  exposure  of  the  wound  always  involves  some  risk 
of  infection.  If  a  drain  has  been  used  because  of  hemorrhage,  it  may  be  re- 
moved at  the  end  of  twenty-four  or  forty-eight  hours,  and  not  replaced. 
Drainage  for  infection  usually  demands  frequent  dressings.  The  stitches  may 
be  removed  in  a  week  or  ten  days,  according  to  the  amount  of  support  needed. 
A  stitch  abscess  usually  makes  its  appearance  in  from  five  to  ten  days;  it 
requires  the  removal  of  the  stitch  and  drainage  of  the  abscess  cavity.  The 
sequelae  of  special  operations  are  considered  with  the  various  operations. 
Operation  in  a  Private  House. — Excepting  an  emergency,  the  proposed 
operating  room  should  be  carefully  prepared.  It  should  be  well  lighted,  and 
heated  by  steam,  hot  water,  or  hot  air;  there  should  be  no  exposed  fire  to 
provide  dust,  or  to  ignite  the  ether  if  such  be  used.  A  bath  room  with  hot  and 
cold  water  should  be  convenient,  but  there  should  be  no  plumbing  in  the  room 
itself.  Everything  which  is  not  necessary  for  the  operation  should  be  removed 
from  the  room,  including  curtains,  shades,  and  carpets.  Wood  work  and 
painted  walls  should  be  scrubbed  with  soap  and  water;  papered  walls 
may  be  rubbed  down  with  bread.  At  the  time  of  operation  the  temperature 
of  the  room  should  be  at  least  70^  F.  The  windows  may  be  smeared  with 
soap  to  discourage  inquisitive  neighbors.  If  the  room  is  heated  by  hot 
air,  the  register  should  be  covered  by  a  moist  towel  in  order  to  catch  the  dust. 
In  an  emergency  carpets  and  furniture  should  be  covered  with  clean 
sheets  or  linen,  and  under  no  circumstances  should  dust  be  stirred  up.  It 
is  convenient  to  have  in  the  room  the  following  articles:     Kitchen-table, 


SURGICAL   TECHNTC. 


dfning-tahle,  bureau  or  table,  wash-stand  or  table,  another  small  table,  four 
wooden  chairs,  several  cleati  l^lankcts  and  sheets,  at  ieast  a  dozen  clean  towels, 
two  basins,  a  large  pitcher  of  warm  water,  and  a  bucket  or  slop  jar.  The 
kitchen -table  serves  for  the  operating  table.  Very  often  this  will  prove 
to  he  too  short,  and  a  smaller  table  will  have  to  he  placed  at  either  end  for 
the  patient's  head  or  feet.  Beneath  the  table  should  be  spread  a  sheet  of 
mackintosh  or  oilcloth,  or  a  number  of  papers,  for  the  protection  of  the  lloor, 
and  alongside  of  the  table  should  be  placed  the  bucket  or  slop  jar.  The 
dining-table  may  be  used  for  instruments,  sutures,  and  sponges;  the  bureau 
for  extra  supplies,  splinis,  etc.;  the  wash-stand  with  the  two  basins  for 
scrubbing  the  hands.  The  etherizer  sits  on  one  chair  and  uses  a  second  for 
his  hypodermatic  syringe  and  other  necessities;  on  the  third  chair  is  placed 
a  basin  containing  sterile  water  for  the  assistant;  the  fourth  chair  is  used 
by  the  operator  to  sit  upon  in  perineal  cases,  or  when  inverted,  to  put  under 
the  patient^  if  the  Trendelenburg  position  is  found  necessar)^  Previous  to 
operation,  two  wash-boilers,  half  or  three-quarters  full  of  water,  should  be 
provided;  in  one  is  placed  a  pitcher,  three  basins,  and  a  sheet.  The  water  in 
each  is  boiled  for  a  half  hour,  and  that  in  the  boiler  containing  the  pitcher,  etc., 
allowed  to  cool  without  removing  the  lid.  The  water  in  the  second  wash- 
boiler  is  kept  hot.  The  water  from  a  kitchen  boiler  is  sterile,  and  may 
be  used,  providing  the  pipes  are  first  thoroughly  flushed.  The  instruments 
may  be  taken  to  the  house  in  a  copper  sterilizer,  and,  after  boiling,  both  the 
sterilizer  and  its  lid  may  be  used  as  trays  for  the  instruments  and  sutures. 
The  operating  table  is  covered  with  a  blanket  and  a  sheet,  and  over  this  is  put 
a  Kelly  pad  or  a  piece  of  rubber  sheeting,  which  drains  into  the  bucket  or 
slop  jar.  Wliile  the  surgeon  is  sterilizing  his  hands,  the  patient  is  anesthe- 
tized in  an  adjoining  room.  After  the  hands  have  been  sterilized,  a  sterile 
gown  is  put  on,  and  the  sheet  is  removed  from  the  boiler,  wrung  out,  and 
spread  over  the  dining-lable;  on  this  is  placed  the  sterilizer  and  the  two 
basins  from  the  boiler,  in  one  of  which  is  put  sterile  ivater,  and  in  the  other 
bichlorid  of  mercur)^  solution.  The  instruments,  sutures,  sponges,  and 
dressings  are  arranged  on  the  dining-table  in  the  order  in  which  they  will  be 
needed.  The  patient  is  carried  into  the  room  by  the  etherizer  and  a  member 
of  the  family,  so  that  neither  the  surgeon  nor  his  assistant  will  soil  tlie  hands. 
The  assistant  sterilizes  his  hands  with  the  surgeon,  puts  on  a  sterile  gown, 
scrubs  the  patient,  and  redisinfects  his  hands  while  the  surgeon  applies  the 
alcohol  and  bichlorid  of  mercury.  A  towel  should  be  soaking  in  the  bichlorid 
of  mercury  solution,  so  that  if,  in  an  emergency,  it  is  necessary*  to  handle  some 
unstcfilized  object,  the  towel  may  be  used  and  the  hand  saved.  1 1  is  better 
to  have  caps,  gowns,  sheets,  towels,  and  dressings  sterilized  at  the  surgeon's 
office  or  hospital  and  sent  to  the  patient's  house,  as  boiling  them  at  the  house 
previous  to  operation  necessitates  the  use  of  wet  materials.  One  of  the 
great  inconveniences  in  operating  in  a  private  house  is  the  forgetting  of  some 
instrument  that  is  needed,  or  the  wanting  of  some  instrument  or  appliance 
to  meet  an  unexpected  condition  which  has  arisen.  For  this  reason  it  is  a 
good  plan  to  have  a  list  of  the  different  instruments,  etc.,  which  may  be  needed 
in  various  operations,  to  check  these  off  as  they  are  packed  into  the  hand-bag, 
and  to  be  prepared  for  any  possible  emergency.  The  following  articles  may 
be  needed  in  any  operation:  Anesthetic,  mouth-gag,  tongue-forceps, 
hypodermatic  syringe,  strychnin,  atropin,  adrenalin,  tracheotomy  tube, 
razor,  soap,  nail-brush,  lubrichondrin   or  other   sterile  lubricant,  alcohol, 


k 


BANDAGES.  45 

catheter,  carbolic  acid,  bichlorid  of  mercury  tablets,  glass  syringe,  caps  (towels 
or  gauze  may  be  used  for  this  purpose),  gowns  (sterile  sheets  will  do  in  an 
emergency),  gloves  if  they  are  used,  dressings,  sponges,  bandages,  sterilized 
towels  and  sheets,  adhesive  plaster,  two  scalpels,  tissue  forceps,  hemostatic 
forceps,  probe,  two  pairs  of  scissors,  needles,  needle  holder,  aneurysm  needle, 
retractors,  curette,  drainage  tubes,  silk,  catgut,  silkworm  gut,  safety  pins, 
Kelly  pad,  instrument  sterilizer,  and  an  infusion  apparatus.  Special 
instruments  that  may  be  needed  in  various  operations  are  mentioned  in 
connection  with  the  operation  in  subsequent  pages.  The  after  care  of  a 
patient  in  a  private  house  differs  in  no  way  from  that  in  a  hospital.  It  is 
essential  that,  in  an  emergency,  the  nurse  or  caretaker  have  some  means  of 
immediately  coDununicating  with  the  surgeon;  there  should  be  a  telephone  in 
the  house,  or  the  nurse  should  know  where  the  nearest  one  is  situated.  The 
bed  room  should  have  been  thoroughly  cleansed  previous  to  operation, 
and  the  following  articles  should  be  handy:  Pillows,  blankets,  sheets, 
mackintosh  spread,  hot  water  bottles  or  bags,  towels,  dressings,  bandages, 
bed-pan,  urinal,  feeding-cup,  medicine  measure,  temperature  chart  and  note 
book,  carbolic  acid  or  bichlorid  of  mercury,  ice,  enema  syringe,  catheter, 
hypodermatic  syringe,  strychnin,  atropin,  and  morphin. 


CHAPTER  V. 
BANDAGES. 


Bandages  are  employed  to  hold  dressings  or  splints  in  place,  to  exert  pres- 
sure, and  to  maintain  parts  in  position  after  the  correction  of  deformity. 

Various  kinds  of  material  may  be  employed.  Muslin  is  strong  and 
cheap.  Flannel  is  soft  and  elastic  and  adapts  itself  uniformly  to  uneven  sur- 
faces; it  is  used  principally  for  eye  and  abdominal  bandages,  and  as  a  primary 
roller  beneath  plaster-of-Paris.  Gauze  is  light,  and  readily  adaptable  to  the 
various  parts;  it  is  applied  without  making  reverses,  and  is  less  liable  to  dis- 
placement than  muslin.  Rubber  is  used  when  firm  pressure  is  desired. 
Plaster-of-Paris  J  silicate  of  soda,  starch,  etc.,  are  used  when  absolute  immo- 
bility is  demanded. 

The  roller  bandage  has  a  body,  an  initial  and  a  terminal  extremity, 
an  inner  and  outer  surface,  and  an  upper  and  lower  edge.  In  preparing  a 
muslin  roller  bandage  the  material  is  torn  into  strips,  the  selvage  removed, 
and  one  end  folded  repeatedly  until  a  small  cylinder  is  formed.  This  is  held 
between  the  thumb  and  index  finger  of  one  hand,  with  the  body  underneath, 
while  the  free  extremity  passes  between  the  thumb  and  index  finger  of  the 
other  hand,  with  the  thumb  above.  By  pronating  and  supinating  both  hands 
and  making  tension,  the  free  portion  of*  the  bandage  is  wound  tightly  and 
evenly;  a  loosely  rolled  bandage  is  not  easily  applied.  By  the  use  of  a 
machine,  bandages  can  be  rolled  better  and  more  (juickly.  After  winding, 
the  remaining  selvage  is  removed  and  the  end  folded  under  and  pinned. 

A  part  is  bandaged  in  the  position  in  which  it  is  to  be  retained ;  a  bandage 
applied  to  a  limb  in  extension  will  be  too  tight  when  the  limb  is  flexed. 


46 


BANDAGES. 


one  applied  in  flexion  will  become  loose  during  extension.  It  should  be  ap- 
plied neatly  and  with  uniform  firmness;  if  too  tight,  it  will  cause  pain,  perhaps 
inflammation,  or  even  gangrene;  if  too  loose,  the  dressing  will  soon  become 
displaced.  Bony  prominences  and  tender  points  should  be  padded,  and 
apposed  skin  surfaces  separated  by  lint  or  cotton.  To  begin  a  bandage, 
apply  the  outer  surface  of  the  initial  extremity  to  the  part  at  its  smallest  di- 
ameter, and  hold  it  with  the  left  hand  until  fixed  by  a  few  turns  of  the  roller. 
The  terminal  end  is  secured  by  pinning  it  in  such  a  way  that  the  point  will 
be  concealed,  and  will  not  enter  the  tissues  when  the  part  is  moved,  by 
splitting  the  bandage  and  tying  the  two  ends  around  the  part,  or  by  encircling 
the  part  with  a  strip  of  adhesive  plaster.  A  bandage  is  removed  by  cutting 
with  blimt  pointed  scissors,  or  by  gathering  the  folds  in  a  loose  mass  as  it  is 
unwound. 

Varieties  of  Bandages. — The  circular  bandage  (Fig.  i8)  is  applied  trans- 
versely to  cylindric  parts.  The  oblique,  or  rapid  spiral,  is  applied  in  ascend- 
ing turns,  between  which  there  are  uncovered  spaces.  The  spiral  bandage 
may  be  ascending  or  descending,  each  successive  turn  overlapping  a  portion 
of  the  preceding  one.  The  spiral  reversed  bandage  (Fig.  19)  is  used  on 
parts  which  are  conical  in  shape.  After  fixing  the  initial  extremity,  the 
body  is  carried  off  obliquely  for  four  or  ^\^  inches,  the  applied  turn  held 


Fig.  18.— I.  Circular    Fig. 
turns.    2 .  Oblique  turns. 
3.  Spiral   turns. 


19. — Spiral  reversed 
of  the  forearm. 


Fig.  20. — ^Figure  of  8  of  knee. 


by  the  thumb  of  the  left  hand,  the  portion  of  bandage  between  the  hands 
slackened,  the  right  hand  holding  the  body  of  the  bandage  changed  from 
extreme  supination  to  pronation,  and  the  bandage  passed  around  the  limb 
and  drawn  firm.  The  reverses  should  be  in  line,  and  should  not  be  made 
over  bony  prominences,  lest  they  cause  discomfort.  The  figure  of  8  band<ige 
(Fig.  20)  consists  of  two  loops  of  bandage  forming  a  figure  of  8,  and  is  used 
to  cover  projecting  parts,  such  as  the  elbow  and  knee  in  flexion.  When  a 
number  of  turns  are  made,  each  oneliigher  than  the  preceding  one,  they  form 
what  is  called  a  spica  bandage  (Fig.  48).  The  recurrent  bandage  (Fig.  23) 
is  used  for  amputation  stumps,  the  top  of  the  head,  or  the  end  of  a  finger.  It 
is  applied  by  fixing  the  initial  extremity  by  circular  turns,  making  reverses 
over  the  end  of  the  part  until  it  is  covered,  and  then  terminating  by  a  few 
spiral  or  spiral  reversed  turns. 


BANDAGES   OF  THE  HEAD.  47 

Tailed  bandages  are  made  from  strips  of  muslin,  which  vary  in  length 
and  width  according  to  the  part  to  be  covered.  Each  end  is  torn  into  two  or 
more  pieces  up  to  within  a  few  inches  of  the  center. 

Handkerchief  bandages  are  made  of  handkerchiefs  or  other  pliable  ma- 
terial, and  are  especially  useful  in  emergency  cases.  A  hankerchief  folded 
squarely  across  the  middle  forms  a  rectangle,  diagonally  a  triangle,  and  when 
rolled  loosely  it  forms  a  cravat. 


BANDAGES  OF  THE  HEAD. 

Barton's  Bandage  (Fig.  21). — 6  yards  x  2  inches.  Place  the  initial 
extremity  of  the  bandage  just  beneath  the  occipital  protuberance,  carry  the 
roller  obliquely  upward  under  the  right  parietal  eminence,  across  the  vertex, 
downward  over  the  left  zygomatic  arch,  under  the  chin,  upward  over  the 
right  zygomatic  arch,  over  the  top  of  the  head,  crossing  the  first  turn  in  the 
median  line,  downward  and  backward  under  the  left  parietal  eminence  to  the 
starting  point,  forward  under  the  right  ear,  around  the  front  of  the  chin,  and 
back  again  to  the  starting  point.  Three  complete  turns,  each  exactly  covering 
the  other,  are  thus  made,  and  a  pin  inserted  at  each  crossing  point.     The  ban- 


Fig.  21. — Barton's  bandage.  Vic  22.  -Gibson's  handagc. 

dage  is  employed  in  fractures  and  dislocations  to  fix  the  lower  jaw.  (ireat 
care  must  be  exercised  in  the  application  of  any  bandage  to  the  jaw  or  net  k, 
especially  in  unconscious  patients,  as  it  may  interfere  with  resi)iration  or  the 
escape  of  vomited  material. 

Gibson's  Bandage  (Fig.  22). — 6  yards  x  2  inches.  Place  the  initial  ex- 
tremity upon  the  vertex,  pass  downward  in  front  of  the  left  ear,  under  the  chin, 
and  up  in  front  of  the  right  ear  to  the  point  of  starting.  Repeat  this  turn 
twice.  On  arriving  at  the  right  temple  for  the  third  time,  reverse  the  ban- 
dage and  carr>'  it  horizontally  around  the  head  from  forehead  to  occiput. 
On  arriving  above  the  left  ear  for  the  third  time,  drop  the  bandage  downward 
and  carr)'  it  around  the  nape  of  the  neck,  under  the  right  ear,  around  the 
front  of  the  chin,  and  back  beneath  the  left  ear  to  the  nape  of  the  netk. 
Repeat  this  turn  twice,  and  then,  after  pinning  the  bandage,  make  a  reverse 
over  the  top  of  the  head  in  the  median  line.  Insert  a  pin  at  ea(  h  crossing 
point.  This  bandage  is  used  for  the  same  purposes  as,  but  is  less  secure 
than,  the  Barton  bandage 

Oblique  of  the  Jaw. — 6  yards  x  2  inches.  If  the  left  jaw  is  to  be  ban- 
daged, place  the  initial  extremity  a!)ovc  and  in  front  of  the  right  ear,  and 
pass  around  the  forehead  from  your  left  to  right,  applying  two  horizontal  turns 


48 


BANDAGES. 


from  forehead  to  occiput;  on  arriving  above  the  left  ear,  pass  down  obliquely 
across  the  back  of  the  neck,  forward  under  the  right  ear,  under  the  chin,  up 
over  the  left  side  of  the  face  at  the  edge  of  the  orbit,  obliquely  over  the  vertex, 
down  behind  the  right  ear,  under  the  chin,  and  up  over  the  aflFected  side, 
where  each  turn  overlaps  the  preceding  one  from  the  orbit  to  the  ear.  Behind 
the  right  ear  the  turns  overlie  each  other.  On  arriving  above  the  right  ear 
with  the  last  turn,  the  bandage  is  reversed  and  terminated  as  it  was  begun  by 
encircling  the  head  from  forehead  to  occiput.  If  the  right  jaw  is  to  be  ban- 
daged, substitute  right  for  left,  and  left  for  right,  in  the  above  description. 
This  bandage  is  used  for  the  retention  of  dressings  to  the  parotid  region  and 
angle  of  the  jaw. 

Recurrent  of  the  Head  (Fig.  23) . — 6  yards  x  2  inches.  Beginning  at  the 
right  temple  two  horizontal  turns  are  applied;  from  the  center  of  the  forehead, 
where  the  bandage  is  pinned  or  held  by  an  assistant,  it  is 
reversed  over  the  head  in  the  median  line  to  the  occiput, 
where  it  is  held,  and  brought  back  to  the  forehead  cover- 
ing one-half  of  the  median  turn.  It  is  then  carried  back 
and  forth  from  the  center  of  the  forehead  to  that  of  the 
occiput,  alternately  on  each  side  of  the  median  line,  each 
turn  covering  two-thirds  of  the  preceding  turn.  The 
bandage  is  completed  by  two  horizontal  turns.  It  may 
be  made  more  secure  by  a  turn  passing  under  the  chin,  or 
by  a  cap  with  bands  fastened  under  the  chin.  Instead 
of  longitudinally,  the  recurrent  turns  may  be  applied 
transversely. 

Crossed  Bandages  of  One  Eye. — 5  yards  x  2  inches.  To  bandage  the 
left  eye  begin  at  the  left  temple,  and  fix  by  two  horizontal  turns  from  forehead 
to  occiput,  from  the  patient's  left  to  right.  On  arriving  for  the  second  time 
above  the  right  ear,  pass  down  under  the  occiput,  under  the  left  ear,  up  ob- 
liquely over  the  left  cheek,  over  the  left  eye,  and  up  over  the  side  of  the  head. 


Fig,  23. 
Recurrent  of  head. 


Fig.  24. 
Crossed  bandage  of 
both  eyes.     (Gould.) 


Fig.  25. 
Borsch's  eye  bandage. 


Fig.  26. 
Oblique  bandage  of 
head,  to  be  completed 
by  a  circular  turn. 


A  second  or  perhaps  a  third  turn  is  applied,  covering  the  preceding  one  one-half 
from  below  upwards  on  the  cheek  and  from  above  downwards  on  the  head. 
These  oblique  turns  may  be  alternated  with  horizontal  occipito-frontal  turns, 
by  which  the  bandage  is  terminated.  It  is  more  comfortable  to  the  patient 
to  have  the  ear  on  the  affected  side  covered  with  cotton  and  included  in  the 


BANDAGES   OF  THE  HEAD. 


49 


bandage.  To  bandage  the  right  eye  begin  at  the  same  point,  and  carry  the 
bandage  from  the  operator's  left  to  right. 

The  crossed  bandage  of  both  eyes  (Fig.  24)  is  practically  a  figure  of  8 
bandage  with  circular  turns  around  the  head. 

Borsches  eye  bandage  is  shown  in  Fig.  25. 

The  occipital  frontal  bandage  consists  of  figure  of  8  turns  applied  to 
the  head  longitudinally. 


Fig. 


27. — Knotted  bandage 
of  temple. 


Fig.  28.— Four  tailed 
bandage  of  head. 


The  oblique  bandage  of  the  head  (Fig.  26)  consists  of  figure  of  8  turns 
applied  transversely. 

The  head  and  neck  bandage  also  is  a  figure  of  8  bandage.  The  ban- 
dage is  fixed  by  turns  around  the  head  above  the  ears,  then  carried  across  the 
back  of  the  neck,  around  the  throat,  and  back  to  the  starting  point. 

The  Imotted  bandage  of  the  templei  used  for  hemorrhage,  is  shown  in 
Fig.  27,  a  double  roller  being  employed. 

The  four  tailed  bandage  is  shown  in  Fig.  28.  It  may  be  applied  to  the 
forehead  by  t3ring  the  ends  under  the  chin  and  behind  the  head;  to  the  occi- 


Fig.  29. — Square  cap  of  head. 


Fig.  30. — Square  cap  of  head. 


put  by  tying  the  ends  around  the  forehead  and  under  the  chin ;  or  to  the  chin 
by  tying  the  ends  over  the  vertex  and  behind  the  neck. 

The  occipito-frontal  triangle  is  a  handkerchief  bandage  which  is  applied 
by  placing  the  base  of  the  triangle  on  the  nape  of  the  neck  and  bringing  the 
apex  forward  over  the  forehead.  The  ends  of  the  base  are  knotted  over  the 
apex,  which  is  turned  up  over  the  knot  and  pinned. 

In  the  vertico-mental  triangle  the  base  of  the  triangle  is  placed  on  the 
top  of  the  head  with  the  apex  backward;  the  two  ends  of  the  base  are  knotted 
under  the  chin  and  the  apex  pinned  at  one  side  of  the  head. 
4 


so 


BANDAGES. 


The  cravat  may  be  used  for  various  parts  of  the  head  when  applied  in  the 
form  of  a  figure  of  8. 

The  square  cap  of  the  head  is  illustrated  in  Figs.  29  and  30.  The  hand- 
kerchief is  folded  in  the  form  of  a  rectangle,  With  one  of  the  free  edges  pro- 
jecting an  inch  or  more  beyond  the  other.  The  outer  comers  are  tied  imder 
the  chin;  the  inner  comers  are  drawn  out,  carried  backwards,  and  knotted 
behind  the  head. 

BANDAGES  OF  THE  UPPER  EXTREMITY. 

The  spiral  of  the  finger  (Fig.  31) — ij  yards  x  i  inch — ^is  applied  by 
placing  the  initial  extremity  lengthwise  on  the  finger,  making  one  or  two 
reverse  turns  over  the  end  of  the  finger,  then  reversing  and  covering  the  finger 
by  ascending  spiral  tums. 


Fig.  31. 
Spiral  of  finger.     (Ooulcl.) 


Fig.  32. 
Gauntlet.     (Gould.) 


Fig.  33. 
Demigauntlet.     (Gould.) 


The  Spica  of  the  Thtunb. — 3  yards  x  i  inch.  Fix  the  initial  extremity 
by  two  cicurlar  turns  around  the  wrist,  and  carry  the  bandage  to  the  tip  of 
the  thumb,  which  is  encircled  once.  Figure  of  8  turns  around  the  thumb 
and  wrist,  each  one  overlapping  the  previous  one  and  altemating  with  a  cir- 


FlG. 


34. — Spica  of  shoulder. 
(Gould.) 


Fig.  35. — Brachio-cervical  triangle. 
(Esmarch  and  Kowalzig.) 


cular  tum  around  the  wrist,  are  now  applied  until  the  thumb  is  covered.    The 
bandage  is  terminated  by  a  circular  turn  around  the  wrist. 

Gauntlet  Bandage  (Fig.  32). — 3  yards  x  i  inch.    Fix  the  initial  extrem- 
ity around  the  wrist,  and  pass  across  the  palm  to  the  base  of  the  thumb  if 


BANDAGES  OF  THE  UPPER  EXTREMITY. 


SI 


bandaging  the  left  hand ;  pass  by  an  oblique  turn  to  the  tip  of  the  thumb,  which 
is  encircled  leaving  the  tip  uncovered;  cover  the  thumb  by  ascending  spiral  or 
spiral  reversed  turns,  then  pass  across  the  dorsum  of  the  hand  to  the  ulnar 
side  of  the  wrist  and  encircle  once.  The  index  finger  is  bandaged  next,  and 
so  the  other  fingers,  the  bandage  being  terminated  by  a  turn  around  the  wrist. 
Demigauntlet  Bandage  (Fig.  33). — Fix  the  initial  extremity  around  the 
wrist.     If  bandaging  the  dorsum  of  the  left  hand,  pass  to  the  base  of  the 


Fig.  36. — Oblique  triangle  of  arm  and  chest.     (Davis.) 

little  finger,  encircle  it,  then  pass  to  the  radial  side  of  the  wrist  and  encircle  it. 
The  bandage  is  then  carried  to  the  base  of  the  ring  finger,  and  in  turn  to  all 
the  others,  alternating  a  turn  around  the  finger  with  one  around  the  wrist. 
Spiral  Reversed  of  the  Upper  Extremity  (Fig.  19). — 7  yards  x  2  J  inches. 
Fix  die  initial  extremity  by  circular  turns  around  the  wrist.  Pass  obliquely 
across  the  dorsum  of  the  hand  to  the  tips  of  the  fingers  and  make  a  circular 


Fig.  37. — Oblique  triangle  of  arm 
and  chest,  second  method.  (Esmarch 
and  Kowalzig.) 


Fk;.  38. — Triangle  for  susfiending 
arm  from  injured  side.  (Esmarch 
and  Kowalzig.) 


turn.  The  fingers  are  covered  by  spiral  reversed  turns,  the  back  of  the  hand 
and  wrist  by  figure  of  8  turns,  the  forearm  and  hummus  by  spiral  reversed 
turns,  and  the  bandage  terminated  as  a  spica  of  the  shoulder.  If  the  ell>ow 
is  to  be  dressed  in  fiexion,  figure  of  8  turns  are  used  in  this  region.  A  bandage 
may  be  applied  also  to  the  upper  extremity  in  a  series  of  figure  of  8  turns. 
This  is  more  secure  than  the  spiral  reversed. 


52 


BANDAGES. 


Spica  of  the  Shoulder  (Fig.  34) . — 8  yards  x  2  J  inches.  Fix  the  initial  ex- 
tremity by  circular  turns  around  the  humerus  on  a  level  with  the  axillary  fold. 
If  bandaging  the  right  shoulder,  carry  the  bandage  across  the  front  of  the 
chest,  through  the  left  axilla,  and  across  the  back  to  the  arm.  Encircle  the 
arm  and  chest  alternately,  making  each  successive  turn  ascend  higher  than  the 
previous  one,  by  exposing  one-half  or  two-thirds  its  width,  until  the  shoulder 
is  completely  covered.  A  descending  spica  is  applied  by  fixing  the  bandage  as 
described,  and  placing  the  first  turn  high  up  over  the  shoulder  and  overlap- 
ping from  above  downwards. 

The  figure  of  8  of  the  neck  and  axilla  is  applied  by  encircling  the 
neck,  then  passing  under  the  axilla,  and  ascending  to  the  starting  point,  the 
turns  intersecting  over  the  shoulder. 

A  few  of  the  handkerchief  bandages  and  slings  for  the  upper  ex- 
tremity are  shown  in  Figs.  35  to  38. 


BAWDAGES  OF  THE  TRUNK. 

The  spiral  bandage  of  the  chest  consists  of  overlapping  spiral  turns,  as- 
cending from  the  waist  to  the  level  of  the  axillae.  The  final  spiral  turn  is 
pinned  at  the  spine  and  the  bandage  carried  over  one  shoulder  to  the  middle 
of  the  sternum  where  it  is  again  pinned.  It  is  then  brought  back  across  the 
opposite  shoulder  to  the  spine,  thus  acting  like  suspenders. 

The  figure  of  8  of  the  shoulders — 6  yards  x  2  J  inches — may  be  applied 
anteriorly  (Fig.  39)  or  posteriorly. 

Suspensory  Bandage  of  the  Breast  (Fig.  40). — 7  yards  x  2 J  inches. 
Place  the  initial  extremity  on  the  scapula  of  the  affected  side,  and  pass  over 
the  opposite  shoulder,  down  obliquely  under  the  affected  breast,  and  beneath 


Fig.  39. — Anterior  figure  of  8  of 
shoulders.     (Gould.) 


Fig.  40. — Suspensory  of  breast. 
(Gould.) 


the  axilla' to  the  starting  point.  Continue  around  the  chest  under  the  sound 
breast,  and  across  the  lower  portion  of  the  affected  one.  These  turns  are 
alternately  continued,  each  one  overlapping  from  below  upwards,  until  the 
breast  is  covered.  To  dress  both  breasts  apply  an  oblique  turn  to  one  side, 
then  a  circular  turn,  then  an  oblique  turn  to  the  opposite  side. 

Velpeau's  Bandage  for  Fractured  Clavicle  (Fig.  41). — 7  yards  x  2^ 
inches.  First  place  the  arm  in  the  Velpeau  position,  the  hand  of  the  injured 
side  on  the  opposite  shoulder.  From  the  axilla  of  the  sound  side  pass  across 
the  back,  over  the  outer  part  of  the  injured  shoulder,  down  across  the  middle 
of  the  arm,  behind  the  elbow,  across  the  chest,  and  through  the  axilla  of  the 
sound  side  to  the  point  of  starting.     Next  apply  a  horizontal  turn  on  a  level 


BANDAGES   OF   THE   TRUNK. 


ith  the  affected  elbow.     Repeat  these  turns  until  the  elbow  is  covered  with 
he  vertical,  and  the  wrist  with  the  horizontal  turns.    The  vertical  turns  should 
verlap  two- thirds  of  each  preceding  turn,  and  the  horizontal  ones,  one- third. 
iSccure  the  bandage  by  strips  of  adhesive  plaster. 

Desault*s  Bandage  for  Fractured  Clavicle  (Fig.  42).— Three  bandages, 
7  yards  x  aj  inches,  and  a  wedge-shaped  pad.  The  pad  is  placed  in  the 
of  the  injured  side,  base  up.  The  arm  is  allowed  to  hang  by  the  side, 
and  the  forearm  is  tlexed  at  a  right  angle.  The  tirst  bandage  is  used  to  hold 
the  pad  in  place.  Beginning  at  the  base  of  the  pad,  descending  spiral  turns, 
circling  the  chest,  are  applied  do^^Ti  to  its  apex  near  the  elbow,  and  then 
Wending  spiral  turns  back  to  its  base.  To  hold  the  pad  up  in  the  axilla,  the 
6rst  bandjige  may  be  terminated  with  a  figure  of  8  turn  of  the  opposite 
shoulder.     The  second  bandage  binds  the  arm  to  the  side.     Beginning  at  the 


Ftc.  4t. — ^Vclpeau  bandage. 
(Gould.) 


Fig.  42.— Desautt  bandage. 
(Gould.) 


Fig.  43. — Many  tailed 
bandage  of  abdomen. 


axilla  of  the  sound  side,  on  a  level  with  the  base  of  the  pad,  descending  spiral 
turns  are  applied,  with  increasing  firmness,  down  to  the  elbow  so  as  to  carry 
the  shoulder  outwards.  The  third  bandage  is  applied  in  the  form  of  an 
anterior  and  a  posterior  triangle^  the  apex  of  each  being  formed  Ijy  the  axilla 
of  the  sound  side»  and  the  base  by  the  humerus  of  the  injured  side.  Begin 
the  bandage  at  the  axilla  of  the  sound  side  posteriorly,  pass  over  the  affected 
shoulder,  down  in  front  of  and  parallel  with  the  humerus,  under  the  elbow,  and 
across  the  back  to  the  starting  point.  The  anterior  triangle  is  applied  in  the 
same  way»  by  continuing  the  bandage  through  the  axilla,  across  the  chest, 
over  the  shoulder  of  the  injured  side,  down  behind  the  humerus,  under  the 
cllx>w,  and  back  across  the  front  of  the  chest  to  the  starting  point.  The 
formula  of  both  triangles  is,  from  axilla,  to  shoulder,  to  elbow,  and  back  to 
axilla.  These  turns  are  repeated  two  or  three  times,  each  succeeding  turn 
covering  in  two- thirds  of  the  preceding  one.  The  third  bandage  carries  the 
injured  shoulder  upwards  and  backwards. 

The  doMble  T  bandage  of  the  chest  consists  of  a  broad  band  which 
encircles  the  chest,  and  to  which  are  attached  two  narrow  bands,  one  passing 
'  ^ver  each  shoulder. 

The  double  T  bandage  of  the  abdomen  is  similar  to  the  above.  The 
vertical  strips  are  attached  to  the  lower  edge,  and  are  passed  from  behind 
fon^^ard  between  the  thighs  and  pinned  in  front,  to  prevent  the  binder  from 
slipping  up  on  the  abdomen. 

The  many  tailed  or  Scultetus  bandage  of  the  abdomen  (Fig.  43)  con- 
sists of  a  piece  of  flannel  long  enough  to  reach  one  and  a  half  times  around  the 


54 


BANDAGES. 


body  and  wide  enough  to  reach  from  the  costal  border  to  the  pubic  bone. 
Each  end  is  torn,  for  one-third  the  length  of  the  bandage,  into  several  tails. 
The  untom  portion  is  placed  behind,  and  the  tails  are  overlapped  alternately 
in  front,  from  above  downwards,  and  secured  by  safety  pins. 

The  T  bandage  of  the  perinetun  consists  of  a  strip  of  muslin  about  2) 
inches  wide,  and  long  enough  to  fasten  around  the  abdomen.    To  the  center 


Fig.  44. — Triangle  for  suspending  breast.     (Davis.) 

of  this  is  attached  a  strip  about  fiv€  inches  wide  and  about  two  feet  long, 
which  passes  between  the  thighs  and  is  fastened  in  front,  either  by  pinning  it 
to  the  horizontal  band,  or  by  tearing  it  into  two  bands  (in  the  male)  and 
knotting  each  to  the  horizontal  band. 

The  handkerchief  bandage  for  suspending  the  breast  is  illustrated  in 
Fig.  44. 

BANDAGES  OF  THE  LOWER  EXTREMITY. 

Foot  Bandage  Covering  the  Heel  (American). — 6  yards  x  2  inches. 
Fix  the  initial  extremity  at  the  ankle  by  two  circular  turns,  pass  obliquely 
across  the  dorsum  of  the  foot  to  the  base  of  the  toes,  and  apply  a  complete 
circular  turn.    Ascend  over  the  dorsum  by  several  spiral  reversed  turns  imtil 


Fig.  45. — American  bandage  of  heel;  circular 
turns  about  ankle  have  been  omitted. 


Fig.  46. — Spica  of  foot. 


opposite  the  heel,  around  which  the  bandage  is  carried  by  a  circular  turn;  next 
pass  above  the  heel,  beneath  the  arch  of  the  foot,  then  up  over  the  instep 
(Fig.  45).  Similar  turns  are  applied  to  cover  the  other  side  of  the  heel,  and 
the  bandage  terminated  by  encircling  the  ankle. 


BANDAGES   OF  THE  LOWER  EXTREMITY. 


55 


The  foot  bandage  not  covering  the  heel  (French)  is  the  same  as  the 
above,  except  that  the  ankle  is  covered  by  figure  of  8  turns  and  the  heel 
remains  exposed. 

The  spica  bandage  of  the  foot  is  explained  by  Fig.  46. 


Fig.  47. — Figure  of  8  of  leg.     (Davis.) 


Fig.  48. — Spica  of  groin. 


The  spiral  reversed  of  the  lower  extremity  is  similar  to  that  of  the 
upper  extremity. 

The  figure  of  8  of  the  leg  is  shown  in  Fig.  47. 

Spica  Bandage  of  One  Groin  (Fig.  48).— 7  yards  x  2^  inches.  Fix  the 
initial  extremity  at  the  upper  portion  of  the  right  thigh  near  the  perineum,  by 
two  circular  turns;  pass  obliquely  across  the  front  of  the  pelvis,  just  above 


Fig.  49. — Sacro-pubic  triangle. 
(Esmarch  and  Kowalzig.) 


Fig. 


50. — Scrotal  triangle. 
(Davis.) 


the  pubes,  to  the  top  of  the  left  thigh,  across  the  back,  obliquely  down  across 
the  first  turn  at  the  junction  of  the  thigh  with  the  scrotum,  and  then  around 
the  thigh.  These  turns  are  repeated,  overiapping  from  below  upwards 
{ascending  spica).  The  bandage  may  be  applied  also  by  encircling  the  pelvis 
higher  up  and  overiapping  from  above  downwards  {descending  spica), 
Spica  of  Both  Groins. — 12  yards  x  2^  inches.    Fix  the  initial  extremity 


56 


BANDAGES. 


as  in  the  single  spica,  and  pass  obliquely  across  the  front  of  the  pelvis  to  the 
opposite  side  of  the  abdomen,  across  the  back,  and  obliquely  downward  to 
the  outer  side  of  the  left  thigh.  Apply  a  circular  turn  to  the  left  thigh,  and 
from  the  inner  side  of  the  thigh  pass  obliquely  upward  and  outward  over  the 
same  hip;  then  apply  a  drcidar  turn  around  the  waist,  pass  across  the  back 
again ,  and  down  in  front  of  the  right  thigh ;  carry  the  bandage  around  the  thigh, 
and  from  the  outer  side  of  the  thigh  repeat  the  turns,  overiapping  from  below 
upwards,  and  terminating  by  a  circular  turn  around  the  abdomen  or  thigh. 
A  spica  bandage  may  be  apj^ed  to  the  outer  aspect  of  the  thigh  or  to  the 
buttock  in  the  same  way. 

Figs.  49  to  53  demonstrate  the  use  of  the  handkerchief  bandages  of 
the  lower  extremity. 

Fixed  dressings  are  largely  used  to  immobilize  parts  after  fractures,  os- 
teotomy, and  tenotomy,  and  in  the  treatment  of  inflammatory  affections  of 


Trutngule 
of  knee. 


Tibial 
triangle. 


Fig.  52. — ^Malleolo-phalan- 
geal  triangle.  (Esmarch  and 
Kowalzig.) 


Tibial 
cravat. 


Tarso- 
malleolar 
cravat. 


Fig.  5 1 . — Handerchief 
bandages  of  lower  extrem- 
ity.    (Davis.) 


Fig.  53. — Gerdv's  extension 
cravat.     (Davis.) 


joints  and  deformities.  Among  the  materials  which  have  been  used  for  this 
purpose  are  glue,  gum  arabic,  parafl&n,  and  tripolith,  but  those  most  com- 
monly employed  are  plaster-of-Paris,  silicate  of  soda,  and  starch. 

Plaster-of -Paris  is  the  best  material  for  a  fixed  dressing.  Coarse  cotton 
or  crinolin  bandages  are  rolled  by  hand  or  machine,  the  meshes  being 
filled  with  dry  plaster.  Owing  to  the  hydroscopic  powers  of  the  plaster-of- 
Paris,  the  bandages  should  be  kept  in  air  tight  receptacles,  or  baked  before 
use  in  order  to  drive  off  the  moisture.  Bony  prominences  are  first  padded 
and  a  flannel  bandage  applied.  The  plaster-of-Paris  bandages  are  sub- 
merged in  water  until  the  bubbles  of  air  cease  to  escape,  and,  after  squeezing 


FOCEB  BANDAGES. 


S7 


out  the  excess  of  water,  applied  evenly  to  the  ljml>  imlil  the  desired  thickness 
is  obtained,  making  as  few  reverses  as  possible.  I'he  appearance  of  the 
cast  is  improved  by  coating  it  with  plaster-of-Paris  cream,  which  is  prepared 
by  mixing  equal  quantities  of  plaster-of-Paris  and  water.  The  cast  may  be 
strengthened  by  incorporating  in  it  strips  of  wood^  metal,  cardboard,  etc,^ 
and  it  may  be  coaled  with  a  layer  of  silicate  of  soda  or  varnish,  to  render  it 
impervious  to  water.  The  finest  grade  of  plaster  hardens  in  fifteen  mhiutes^ 
the  coarser  grades  in  a  longer  time.  The  hardening  process  may  be  hastened 
by  using  hot  water,  or  by  adding  salt  (one  ounce  to  the  quart  of  water), 
alum,  or  cement;  it  may  be  delayed  by  using  cold  water,  or  by  adding  starch, 
glue»  dextrine,  or  milk.  When  nearly  dry  the  cast  should  be  cut  with  a 
sharp  knife;  in  order  to  protect  the  patient,  a  narrow  strip  of  sheet  lead  or 
similar  material  may  be  placed  over  the  flannel  bandage  before  the  plaster 
is  applied.  The  hardened  plaster  may  be  cut  with  a  knife,  saw,  or  shears, 
after  the  Une  of  division  has  been  moistened  with  hydrochloric  acid,  vinegar. 


Fig.  54. — Stirrup  plaster-of-Paris  dressing  for  knee.     (Esmarch  and  Kowalztg.) 


or  salt  water.  When  there  is  a  wound  which  will  require  dressing,  it  should 
be  surrounded  by  a  strip  of  lead  or  other  material  which  will  form  a  projection 
through  the  plaster  dressing  and  indicate  the  portion  to  be  cut  away,  or  the 
area  may  be  left  uncovered  when  the  plaster  is  applied.  Another  method, 
particularly  useful  after  resection  of  joints,  is  to  apply  the  cast  in  two  sections 
which  are  connected  by  metal  or  wooden  arches  (Fig.  54),  the  ends  of  the 
arches  being  horizontal  to  be  incorporated  in  the  plaster-of-Paris.  Plasier- 
of-Paris  splints  may  be  made  by  spreading  plaster-ofParis  cream  between 
layers  of  linen,  which  are  molded  to  the  parts  and  allowed  to  harden. 

Silicate  of  soda  can  be  bought  as  a  solution,  which  is  sometimes  called 
liquid  glass.  It  may  be  applied  in  the  same  way  as  plaster,  or  a  few  layers  of 
gauze  bandage  may  be  applied  and  painted  with  the  solution,  this  process 
being  continued  until  the  desired  thickness  is  obtained.  The  silicate  cast 
b  light  and  strong,  but  has  the  disadvantage  of  dr)ing  very  slowly  (twenty- 
four  hours);  the  process  may  be  hastened  by  adding  pulverized  chalk  or 
cement. 

The  starch  bandage  is  used  when  a  very  firm  splint  is  not  required. 
The  bandage  is  soaked  in  a  solution  of  starch,  made  with  iKiQing  water,  and 
applied  like  the  plaster  bandage.  It  also  requires  twenty-four  hours  or  more 
to  harden. 


58  INFLAMMATION. 


CHAPTER  VI. 
mFLAiaCATION. 

Inflammation  consists  of  (i)  changes  in  the  blood  vessels,  (2)  the  passage 
of  fluids  and  solids  from  the  blood  vessels,  and  (3)  changes  in  the  perivascular 
tissues. 

The  predisposing  causes  of  inflammation  comprise  those  conditions 
which  lower  the  general  vitality,  such  as  old  age,  cardiac  and  vascular 
derangement,  alcoholism,  plethora,  gout,  syphilis,  rheumatism,  tuberculosis, 
diabetes,  B right ^s  disease,  anemia,  and  diseases  and  injuries  of  the  nerves. 
The  exciting  causes  are  injury  and  infection.  Injury  may  be  mechanical, 
such  as  blows  and  wounds;  chemical,  such  as  strong  acids  or  alkalies,  stings 
of  insects,  and  bites  of  animals;  or  thermal,  either  heat  or  cold;  all  of  which 
kill  the  tissue  cells,  the  resulting  products  of  the  dead  cells  acting  as  irritants. 
Infection  is  by  far  the  most  common  cause,  and  the  most  important  factor 
even  in  traumatic  inflammation.  Bacteria  induce  inflammation  by  their 
toxins,  which  act  directly,  and  also  indirectly,  like  trauma,  by  killing  the 
cells,  which  set  free  irritating  products. 

1.  The  changes  in  the  blood  vessels  consist  of  a  momentary  c(w/r(u:/i(?n, 
followed  by  active  hyperemia,  i.e.,  a  dilatation  of  the  blood  vessels  with  a 
marked  acceleration  in  the  velocity  of  the  blood  stream.  After  a  time  retarda- 
tion of  the  blood  current  occurs,  and  the  stream  becomes  slower  and  slower 
{passive  hyperemia),  until  in  some  cases  it  no  longer  progresses,  but  sways 
backward  and  forward  (oscillation);  finally  all  motion  may  cease  {stctsis)^  and 
the  blood  may  coagulate  (thrombosis)  or  rupture  the  vessel  wall  (rhexis). 
While  these  changes  are  taking  place,  the  leukocytes  separate  from  the  axial 
stream  and  mass  themselves  along  the  walls  of  the  blood  vessels  (margina- 
tion),  while  the  red  corpuscles  run  together,  forming  rows,  or  rouleaux.  The 
blood  plaques  are  increased  in  number  and  tend  to  associate  with  the  leuko- 
cytes along  the  sides  of  the  stream. 

2.  The  passage  of  fluids  and  solids  from  the  vessels,  or  exudatioiii  begins 
as  soon  as  the  blood  vessels  have  dilated.  The  exuded  material  includes 
liquor  sanguinis  or  plasma,  red  cells,  leukoc)rtes,  and  blood  plaques.  Nor- 
mally the  liquor  sanguinis  leaves  the  interior  of  the  blood  vessels  to  nourish 
the  tissue  cells,  and  the  excess  is  absorbed  by  the  lymphatics,  but  in  inflam- 
mation the  amount  is  much  greater  than  that  which  can  be  removed  by 
the  lymph  vessels.  The  process  is  probably  not  a  simple  filtration,  but  may 
be  likened  to  secretion,  in  that  the  endothelial  cells  play  an  active  part. 
This  fluid  dilutes  the  toxins,  contains  bactericidal  and  antitoxic  sera,  and  in 
chronic  inflammation  increases  the  nourishment  of  the  tissues.  The 
leukocytes,  particularly  the  polymorphonuclears,  migrate  from  the  vessels  by 
insinuating  a  little  process  between  the  endothelial  cells,  which  have  been 
weakened,  stretched,  and  probably  separated  as  the  result  of  the  dilatation  of 
the  vessel ;  this  process,  or  pseudopodium,  gradually  works  its  way  through 
the  vessel  wall  until  it  reaches  the  exterior,  when  the  body  of  the  leukocyte 


VARIETIES   OF   INFIAMMATION. 


59 


.  into  the  pseudopad  and  is  then  in  the  perivascular  tissues.  Although 
the  leukocytes  migrate  to  some  extent  from  the  capillaries  and  arterioles,  the 
process  is  most  active  in  the  %'enules;  migration  begins  with  the  onset  of 
hyperemia t  and  continues  as  long  as  the  blood  is  in  motion.  There  is  a  vast 
increase  in  the  number  of  leukocytes,  not  only  in  the  inflammatory  area,  but 
also  in  the  general  blood  stream  (leukocytosis).  The  red  cells  and  blood 
plaquesi  being  incapable  of  ameboid  movements,  are  passively  carried 
through  the  vessel  walls  with  the  plasma  {diapedcsis). 

3.  Changes  in  the  Perivascular  Tissues. — As  the  result  of  the  breaking 
up  of  some  of  the  ieukoc)tes,  which  sets  free  fibrin  ferment,  the  plasma 
coagulates,  forming  inflammatory  lymph;  the  serum  which  forms  infiltrates 
the  tissues,  gi\ing  rise  to  edema.  The  leukocytes  destroy  bacteria,  devour 
particles  of  dead  tissue,  and  pass  back  into  the  circulation  through  the  lym- 
phatics; if  suppuration  ensues  they  form  pus  cells.  The  red  Ijlood  cells  and 
the  blood  plaques  are  disintegrated,  and  reabsorbed  by  the  lymphatics,  or 
are  devoured  by  the  leukocytes  and  tibroblasts.  The  connective  tissue  cells 
proliferate,  and  the  resulting  cells  are  known  as  fibroblasts.  It  is  believed 
that  the  leukocytes  neither  multiply,  nor  enter  into  the  formation  of  new  tissue. 
The  mass  formed  by  the  fibroblasts  is  called  embryonic  or  indiflerent  tissue^ 
because  it  repairs  any  of  the  various  tissues  in  which  it  may  be  found. 

In  inflammation  of  non -vascular  tissue ^  e.g.,  the  cornea  and  cartilage, 
the  surrounding  l>lood  vessels  dilate,  and  exude  their  contents  into  the  lymph 
or  intercellular  spaces  of  the  tissues,  where  the  *e.\udation  undergoes  the 
changes  already  described. 

The  pathology  of  chronic  infiammation  is  practically  the  same  as 
that  of  the  acute  form,  except  that  the  phenomena  are  less  active  and  much 
longer  in  duration.  The  chief  difference  is  seen  in  the  behavior  of  the  peri- 
vascular tissues,  which  in  chronic  inflammation  become  thickened  and  hard- 
ened as  the  result  of  the  proliferation  of  the  fixed  connective  tissue  cells; 
later,  particulariy  in  syphilitic  and  tuberculous  subjects,  marked  degenerative 
changes  may  take  place  in  this  tissue. 

Inflammation  extends  by  continuity,  as  when  it  creeps  along  a  surface 
or  plane  of  tissue;  by  canliguily,  as  when  it  spreads  from  one  organ  or  tissue 
to  another,  from  the  ovary  to  the  appendix  for  instance;  by  the  blood  vessels 
or  lymphatic's  J  the  bacteria  floating  free  in  the  stream,  or  being  carried  by  cells 
or  emboli. 

Inflammation  terminates  in  recovery  or  in  death  of  the  tissues. 
Recover)^  takes  place  suddenly  {delitescence);  gradually,  the  exudate  being 
absorbed  by  the  lymphatics  {resolution};  or  with  new  growth^  the  embnr'unic 
tissue  becoming  vascularized,  or  organized,  and  the  fibroblasts  forming 
fibrous  tissue.     Death  occurs  as  suppuration,  ukcratimt,  or  gangrmc. 

The  varieties  of  inflammation  are:  Aa4tt\  which  is  sudden  in  onset  and 
runs  a  severe  course;  subacute^  which  is  more  tardy  and  less  severe  than  the 
acute;  chronic^  which  is  of  a  low  grade  and  lasts  for  a  long  time;  sthenic^  a 
robust  infiammation  in  a  robust  indindual;  asthenic,  or  adynamic,  a  low 
grade  inflammation  in  an  old  or  a  debilitated  individual;  parenchymatous,  in 
which  the  parenchyma  or  secreting  ceils  of  an  organ  are  affected;  interstitial^ 
invohing  the  connective  tissue  of  an  organ;  traumatic,  due  to  an  injur)^ 
idiopaiJiic,  in  which  the  cause  cannot  be  found;  simple,  or  common,  due  to 
non-bacterial  irritation;  injeciive,  or  specific,  due  to  bacteria;  serous,  charac- 
terized by  a  profuse  exudation  of  serum;  plastic^  adhesive,  or  fibrinous^  m 


6o 


INFLAMMATION. 


which  the  exudate  causes  adjacent  organs  to  adhere;  purulent^  phhgmmtmis^ 
or  mppumiive,  characterized  by  the  formation  of  pus;  hemorrhagk,  m  which 
the  exutiate  contains  considerable  blood;  fatanhal,  affecting  mucous  mem- 
branes and  causing  an  increased  flow  of  mucus;  croupaus,  or  pseudo- 
memhranaus,  characterized  by  the  formation  of  a  false  membrane  consisting 
of  fibrin  and  cells;  dipkiheritk,  in  which  the  false  membrane  is  formed  from 
the  tissues  rather  than  from  the  exudate;  gangrmmis,  resulting  in  gangrene; 
and  sympathctit:^  reflex,  or  metastaiic,  when  the  process  appears  in  a  distant 
tissue^  as  inflammation  of  the  breast,  ovary,  or  testicle  following  mumps. 

The  symptoms  of  acute  inflammation  are  local  and  const itutionaL 
When  the  symptoms  are  slight  or  absent,  e.g.,  in  some  instances  of  intlamma- 
tion  of  Peyer's  patches  in  enteric  fever,  the  condition  is  called  latent. 

The  local  symptoms  are  pain^  heat,  redness,  swelling,  and  disordered 
function  (^f^/or,  caior,  rubor,  tuttwr./imclw  lo'sa). 

Pain  is  due  to  pressure  upon  the  nerve  terminals  by  the  dilated  vessels 
and  the  exudate,  or  to  irritation  the  result  of  bacterial  toxins  or  chemical 
changes  in  the  part.  It  is  increased  by  pressure  with  the  hand  (tetidemess), 
and  by  raising  the  blood  pressure,  e.g.,  by  placing  the  inflamed  part  in  a 
dependent  position;  in  organs,  such  as  the  eye,  testicle,  and  bone,  which  are 
covered  by  dense  fascia  or  fibrous  tissue,  and  in  which  swelling  cannot  easily 
occur,  the  pain  is  much  more  severe.  In  \iscera  covered  by  serous  mem- 
brane the  pain  is  dull  until  the  serous  membrane  is  reached,  when  it  becomes 
severe  and  lancinating.  *  Inflammatory  pain  is  slow  in  onset,  remains  in  one 
situation,  persists,  and  is  accompanied  by  other  signs  of  inllammation. 

Heat  is  due  to  the  large  amount  of  blood  brought  to  the  inflamed  area, 
and  in  inflammadons  on  the  surface  is  easily  appreciated  by  the  hand.  The 
temperature  as  shown  by  a  surface  thermometer,  however,  is  never  greater 
than  that  of  the  blood  in  the  internal  organs,  hence  as  a  symptom  local  heat 
is  of  value  in  superficial  inflammation  only. 

Redness  is  due  to  the  increased  amount  of  blood.  In  the  early  stages  it  is 
bright,  and  returns  with  great  rapidity  after  the  relief  of  pressure,  showing  an 
active  circulation;  as  the  velocity  of  the  blood  stream  decreases,  it  becomes 
more  dusky,  and  returns  more  slowly  after  the  removal  of  pressure.  During 
the  stage  of  stagnation  it  may  be  impossible  to  remove  the  color  by  pressure. 
In  avascular  tissue  the  redness  is  seen  at  the  edges  of  the  part.  In  inflamma- 
tion of  the  iris  it  is  absent  owing  to  the  amount  of  pigment  in  that  structure. 
In  non- vascular  tissues  and  in  serous  membranes  the  intlamed  part  may  be 
white;  when  a  number  of  red  corpuscles  have  been  forced  into  the  tissues^ 
there  may  be  yellowish  discoloration. 

Swelling  is  due  partly  to  the  dilatation  of  the  vessels,  but  principally  to 
exudation  and  cell  proliferation.  It  %'aries  with  the  severity  of  the  inflam- 
mation and  the  structure  of  the  part,  and  as  a  rule  is  in  inverse  proportion  to 
the  severity  of  the  pain ;  in  regions  covered  by  dense  fascia  it  is  more  marked 
in  adjacent  parts,  as  is  illustrated  by  the  puffiness  of  the  back  of  the  hand  in 
palmar  abscess.  The  swelling  pits  on  pressure  [edema)  and  is  at  first  soft, 
becoming  harder  with  coagulation  of  the  exudate  and  cellular  proliferation; 
late  softening  indicates  suppuration. 

Disordered  function  is  due  to  pain,  swelling,  or  to  chemical  changes  in  the 
cells.  It  may  be  expressed  as  increased  action  (frequent  micturition  in 
cystitis),  decreased  action  (small  amount  of  urine  in  nephritis),  or  absence  of 
action  (intestinal  paresis  in  peritonitis). 


tBEATUENT  OF   INFLAHHATION. 


6l 


ne  constitutional  symptoms  vary  with  the  cause^  severity,  and  ex- 

i  the  intlammalion,  and  the  part  involved.  In  the  milder  forms  they 
are  slight  or  absent.  In  simple  inllammations  they  are  due  to  the  absorplion  of 
fibrin  ferment  liberated  by  the  degenerating  leukocytes,  hence  identical  with 
those  of  aseptic  fever  (p.  103) ;  in  bacterial  inflammations  to  the  absorption  of 
toxins,  or  toxins  and  bacteria,  hence  identical  with  those  of  sepsis  (p.  103). 

The  treatment  of  inflammation  consists  in  (i)  removal  of  the  cause,  (2) 
rest  of  the  part,  (3}  reduction  of  the  hyperemia,  (4)  promotion  of  absorption, 
and  (5)  constitutional  treatment. 

i»  Any  causative  irritation  should  be  removed,  e,g,,  a  foreign  body  in  the 
conjunctiva  producing  conjunctivitis,  a  stone  in  the  bladder  causing  cystitis. 
Micro-organisms  are  removed  by  proper  incisions  and  disinfection. 

2,  Rest  should ♦  as  far  as  possible,  be  both  physical  and  physiological. 
It  diminishes  the  amount  of  blood  taken  to  the  part  and  prevents  the  irritation 
or  motion.  Physical  rest  is  obtained  in  arthritis  by  means  of  splints,  in 
pleuritis  by  strapping  the  chest;  physiob>gical  rest,  in  inflammations  of  the 
eye  by  dark  glasses,  in  nephritis  by  purgatives  and  diaphoretics,  in  inflamma- 
tion of  the  brain  by  sedatives.  In  severe  inflammations  rest  in  bed  is  of 
value,  in  that  it  lessens  the  number  of  heart  beats,  and  thus  decreases  the 
quantity  of  blood  pumped  into  the  inflammatory  area.  Rest  may  be  secured 
also  by  relaxation,  e.g.,  extension  in  coxalgia,  semi-flexion  of  the  knee  in 
inflammation  of  that  juint. 

3.  Reduction  of  Hyperemia* — Elevation  reduces  hyperemia,  lessens 
pain,  and  limits  exudation.  It  is  particularly  applicable  in  inflammations  of 
ibc  extremities,  but  may  be  used  also  in  other  regions,  e.g.,  raising  the  head 
on  a  pillow,  supporting  the  breast  by  a  bandage,  elevating  the  testicle  with  a 
suspensory  bandage. 

Local  blood  kUing  may  be  carried  out  by  punctures,  scarification,  incision, 
ching,  and  cupping.  Aseptic  ptimlures  relieve  tension  by  allowing  blood 
1  exudate  to  escape,  and  are  useful  in  parts  which  are  greatly  swolien  anti 
in  wliich  incisions  are  not  indicated.  Scarification^  or  the  making  of  small 
super6cial  incisions,  is  used  for  the  same  purpose.  Free  incisions,  entering 
deeply  into  the  inflammatory^  mass,  are  indicated  when  suppuration  is  threat- 
ejied,  when  pus  is  actually  present,  and  when  the  tension  is  so  great  that 
gangrene  is  feared.  Leeches  should  never  be  used,  because  there  are  cleaner 
and  better  ways  for  remo\ing  blood  and  exudate.  Cupping  is  used  to  draw 
blood  up  under  the  skin  (dry  cupping),  or  actually  to  remove  it  from  the  tissues 
(wet  cupping).  Dry  cupping  may  be  accomplished  by  greasing  the  edge  of 
a  glass,  and  igniting  a  small  piece  of  blotting  paper,  soaked  with  alcohol, 
which  has  been  placed  in  the  bottom  of  the  glass.  As  soon  as  the  flame 
disappears,  the  edge  of  the  glass  is  pushed  into  the  skin ;  the  tissues  are  sucked 
up  as  the  air  in  the  glass  ccx>ls  and  contracts.  There  are  special  instruments 
made  for  this  purpose,  in  which  a  vacuum  is  created  by  means  of  a  rublier 
bulb.  The  bulb  is  emptied  of  air  and  the  glass  applied  to  the  skin;  when 
the  hand  is  removed  from  the  bulb,  the  tissues  are  pulled  up  into  the  glass. 
Wei  cupping  is  performed  in  the  same  manner  as  dry  cupping,  except  that 
the  skin  is  previously  scarified  or  punctured,  so  that  a  certain  amount  of 
blood  is  drawn  from  the  tissues.  The  ^^arlipcial  leech''  is  a  syringe-like 
instrument  which  draws  blood  from  a  part  after  previous  scarification. 
Because  of  its  hygroscopic  powers,  glycerin  may  be  used  for  depletion. 
Cataplasma  kaolin i,   which  is  composed  of  kaolin,   glycerin,   boric  acid, 


1 


62 


INFLAMMATION. 


Mm 


thymol,  methyl  salicylate,  and  oil  of  peppermint^  is  used  as  a  local  applica- 
tion for  its  depletive  effect. 

Cold  contracts  the  vessels,  acts  as  an  anesthetic^  and  is  indicated  in  the 
early  stages  of  inflammation.  After  the  occurrence  of  exudation  it  hinders 
the  evolution  of  the  process  and  prevents  absorption.  It  should  be  applied 
continuously,  not  intermittently.  Intense  cold  applied  for  a  long  time 
may  result  in  sloughing,  hence  should  be  used  with  the  great  caution 
at  the  extremes  of  life  and  in  the  debilitated.  Wei  cold  is  not  as 
easily  managed  as  dry  cold  and  is  more  depressing  to  the  tissues,  but  is  very 
useful  at  the  onset  of  sthenic  inflammations.  Over  the  part  may  be  suspended 
a  reser\^oir  filled  with  cold  water,  from  which  a  strip  of  gaii^e  acting  as  a 
wick  decends  to  the  iollamed  part  (see  also  Fig.  77).  If  there  is  a  breach  in 
the  skin,  the  solution  should  be  sterile  or  antiseptic.  A  Kelly  pad  or  a  piece 
of  mackintosh  should  be  placed  beneath  the  partt  to  direct  the  fluid  into  a 

receptacle  beside  the  bed.  Cold  com- 
presses are  frequently  employed  in  inflam- 
mations of  the  eye.  Two  or  three  small 
pads  of  gauze  are  put  on  a  cake  of  ice; 
as  soon  as  the  pad  which  has  been  placed 
on  the  eye  becomes  warm,  it  is  replaced 
by  a  fresh  one,  and  the  old  one  is  placed 
on  the  ice.  Cold  may  be  generated  also 
by  evaporating  lotions,  such  as  lead-water 
and  laudanum  (t  02,  each  of  liquor 
plurabi  subacetatis  dilutus  and  tinctura 
opii  to  I  pint  of  water),  equal  parts  of 
alcohol  and  water,  and  a  solution  of 
ammonium  chlorid  in  water  (i  to  a  drams 
to  a  pint) ;  these  solutions  may  be  applied 
by  means  of  cloths  laid  on  the  part,  or  by  means  of  a  resen^oir  and  wick  as 
dt^cribcd  above.  Dry  lold  may  be  applied  by  means  of  tin  cans,  bottles, 
bladders,  etc.,  filled  with  ice  water,  or  by  the  rubber  ice  cap,  all  of  which 
should  be  protected  by  a  covering  of  llannel.  An  inflamed  part  may  be 
covered  or  enveloped  with  a  coil  of  rubber  tubing  (Fig.  55)  through  which  ice 
water  is  constantly  moving  by  syphonage.  The  same  principle  is  utilized 
in  Leiler^s  tubes,  which  consist  of  a  coil  of  narrow  leaden  pipes  made  to  fit 
various  regions  of  the  body. 

Bier's  treatment  directly  antagonizes  the  principles  set  forth  above. 
Bier  believes  the  increased  number  of  leukocytes  and  the  increased  amount  of 
Ijacteriolytic  blood  serum  to  be  helpful  rather  than  harmful,  and  therefore 
seeks  to  produce  a  *' passive  hyperemia"  by  constriction  above  the  inflamed 
area,  or  by  a  suction  apparatus  (which  acts  like  a  cup)  in  regions  in  which 
constriction  is  inapplicable.  The  vacuum  apparatus  also  draws  pus  and 
sloughs  from  an  inflamed  wound.  It  is  applied  for  3  minutes,  then  removed 
for  5  minutes,  this  procedure  being  repeated  for  three-fourths  of  an  hour  each 
day.  In  the  extremities  a  rubber  bandage  is  placed  above  the  affected  part 
and  drawn  right  enough  to  retard  the  venous  return,  without  interfering  with 
the  arterial  circulation.  If  white  edema,  coldness,  or  anesthesia  result » the 
constriction  is  too  tight.  The  bandage  remains  in  a  place  a  number  of  hours 
each  day^  sometimes  as  long  as  twenty-two,  and  should  markedly  lessen  pain. 
In  the  presence  of  suppuration  a  small  incision  is  made  and  the  wound  is  not 


Fig.  55. — Es marches  cold  coil. 


TRIL^TMENT    OF    INFLAMMATION* 


packed  with  gauze.  The  pus  is  at  first  increased  in  amount  and  then  rapidly 
disappears.  The  method  appears  to  be  of  some  value  in  mild  and  well 
localized  infections,  but  distinctly  harmful  in  virulent  and  spreading  infiam- 
mations,  diabetes,  and  atheroma.  It  is  suited  only  for  cases  which  are  under 
constant  sur\^eillance,  and  it  requires  some  skill  and  judgment  for  its 
proper  application. 

4,  Absorption  is  promoted  by  (a)  compression,  (b)  massage,  (c)  astrin- 
gents and  sorbefacients,  (d)  heat^  (e)  douches,  and  (f)  counterirritation. 

(a)  Comprcssmi^  judiciously  applied  and  carefully  watched,  may  be  used 
in  the  first  stage  of  inllammalion  to  limit  the  swelling  and  give  the  paralyzed 
vessels  a  chance  to  recover  themselves.  Firm  compression  before  swelling 
has  fully  developed  increases  pain  and  may  result  in  gangrene.  At  a  later 
period  it  hastens  absorption  and  is  a  measure  of  great  value.  In  acute  cases 
compression  should  be  elastic,  the  part  lieing  thickly  covered  with  loose  gauze 
or,  better,  cotton,  and  bandaged  from  the  end  of  the  extremity  to  above  the 
point  of  inflammation.  In  the  terminal  stage  of  acute  inflammation  and  in 
subacute  and  chronic  inflammation,  firm  compression  with  a  thin  rubber 
bandage,  adhesive  plaster  strapping,  tampons,  or  a  shot  bag  is  frequently 
employed » 

(b)  Massage  finds  its  chief  value  in  the  treatment  of  subacute  or  chronic 
inflammation  about  Joints.  Efflmrage  consists  in  rubbing  the  limb  with  the 
hand,  emphasis  being  placed  upon  the  upstroke  so  as  to  encourage  the  tlow  of 
blood  and  lymph  from  the  part.  Pitrissage,  or  kneading^  and  tapoiemmt, 
or  tapping,  also  quicken  the  circulation  and  hasten  absorption.  Care  should 
be  exercised  in  advising  <  ompression  and  massage  in  the  treatment  of  phle- 
bitis or  other  inflammations  in  which  there  is  danger  of  dislodging  a  dot,  and 
also  in  indiN-iduals  with  atheromatous  arteries  or  tuberculous  foci. 

(c)  Astringents  are  largely  used  in  inflammations  of  mucous  membranes. 
The  efficienc}'  of  lead- water  and  laudanum  depends  partly  upon  the  astrin- 
gent effect  of  the  lead- water.  Silver  nitrate  is  a  bland  astringent, 
frequently  used  on  mucous  membranes;  it  coagulates  the  superficial 
albumen,  and  forms  a  protective  shield  for  the  parts  beneath.  Tincture  of 
todin  should  never  be  placed  on  acutely  inflamed  tissues,  becatse  of  its 
irritating  qualities,  but  it  is  often  employed  as  a  counlerirritant  in  deep- 
seated  inflammations.  Its  absorptive  powers  when  applied  locally  are  proba- 
bly slight^  although  it  is  often  used  as  a  sorbefacient  in  the  form  of  an  oint- 
ment.  Ichtbyol  may  be  used  in  the  form  of  an  ointment  as  strong  as  50  per 
cent.,  remembering,  however,  that  it  occasionally  produces  irritation  of  the 
skin;  or  it  may  be  sprayed  or  painted  upon  a  part,  in  the  strength  of  r  dram 
to  the  ounce  of  water.  Mercurial  ointment  is  often  employed  in  chronic 
inflammation.  If  used  for  a  long  time,  it  should  be  diluted  one-half  or  one- 
fourth,  as  the  pure  ointment  may  vesicate  the  skin  or  salivate  the  patient. 
Belladonna  ointment  is  another  valuable  sorbefacient,  especially  when  com- 
bined with  equal  parts  of  ichthyol,  mercurial  ointment,  and  vaselin  or  lanolin. 

(d)  Heal  is  rarely  used  in  the  first  stage  of  inflammation,  because  the 
amount  necessary  to  contract  the  vessels  is  too  great  for  comfort;  that  which 
is  comfortable  to  the  patient  relaxes  the  tissues,  lessens  tension,  relieves  pain, 
assists  absorption,  and  in  the  presence  of  bacteria  hastens  suppuration.  In 
mflammations  below  the  surface  it  acts  as  a  counterirritant  by  diverting 
blood  from  the  affected  part.  It  is  applied  as  fomentations,  poultices,  baths. 
or  as  dry  heat*     Tht  fomentniimt,  or  stupr^  is  a  piece  of  flannel,  spoTv^o^\\\Tv^ , 


64 


INFLAMMATION. 


or  similar  material,  soaked  in  a  hot  liquid,  which  may  be  water,  lead- water 
and  laudanum,  tiirpentine  and  water,  etc.,  or  an  antiseptic  solution  (anlisepik 
fomeniiUiott).  The  flannel  is  wrung  out  until  almost  dry,  then  applied 
to  the  part  and  covered  with  some  material,  sych  as  wax  paper  or  oiled 
silk,  which  will  retain  the  heat;  over  this  may  be  placed  a  hot  water  bag, 
which  is  refilled  as  often  as  may  be  necessary.  In  a  turpentine  stupe  from  i 
to  20  drops  of  turpentine  are  sprinkled  upon  the  HanneL  A  poidike,  or  rata- 
plasm,  may  be  made  of  arrow  root,  bread,  bran,  potatoes,  hops,starchj  slippery 
elm,  turnips,  and  many  other  such  materials,  but  flaxseed  is  the  substance  usu- 

ally  employed.  Charcoal 
poultices  are  sometimes  used 
for  deodorizing  foul  ulcers. 
The  selected  material  is  made 
into  a  thick  paste  with  hot 
water  (yeast,  lead- water  and 
laudanum,  or  an  antiseptic 
solution), spread  upon  muslin, 
lint»  or  linen,  to  the  thickness 
of  a  fourth  or  half  inch,  and 
covered  with  gauze,  or  coated 
with  olive  oil,  so  that  it  will 
not  stick  to  the  skin;  oiled 
silk  or  wax  paper  is  placed 
over  the  poultice  to  prevent 
evaporation  and  loss  of  heat. 
The  poultice  should  be 
changed  about  every  two 
hours.  Poultices  should  never 
be  employed  where  there  is 
an  open  wound;  if  heat  and 
moisture  are  desired  in  such 
cases,  as  for  the  separation  of 
a  slough,  the  antiseptic  fomen- 


^-yt'^3-x-y^^ 


Fig.  56. — Hot-air  apparatus. 


tatlon  should  be  used.  A  general  warm  bath  is  sometimes  used  in  extensive 
burns,  partial  baths  in  badly  infected  wounds.  The  silz  bath,  or  hip-bath,  is 
of  value  in  pelvic  and  abdominal  inflammations.  Dry  heat  may  be  obtained 
by  heating  sand  bags,  salt  bags,  cloths,  or  bricks;  by  bottles,  cans,  bladders, 
or  rubber  bags  filled  with  hot  water;  and  by  means  of  rubber  or  leaden  tubing, 
as  described  under  cold.  The  hot  air  apparatus  (Fig.  56)  is  chiefly  employed 
in  chronic  inflammatory  affections  of  joints.  The  limb  is  wrapped  in  lint 
and  placed  in  the  apparatus,  the  temperature  of  which  may  be  raised  as 
high  as  300°  F.     The  part  may  be  baked  for  one  hour  several  times  a  week. 

(e)  The  dmicke  is  a  stream  of  water  used  for  flushing,  for  conveying  medic- 
aments, or  for  the  mechanical  effect  produced  by  the  stream  directed  against 
the  tissues.  Hot  vaginal  douches  are  of  great  value  in  pelvic  inflammations, 
and  duuches  are  useful  also  in  other  cavities  of  the  body.  The  *^ Scotch 
douche'*  is  of  service  in  low  grade  chronic  inflammation;  it  consists  in  alter- 
nately pouring  hot  and  cold  water  upon  a  part.  The  heat  relaxes  and  the 
cold  contracts  the  vessels,  which  are  strengthened  by  this  form  of  exercise. 

(f )  Counierirritalimt  is  the  process  whereby  a  struct  11  re  Is  affected  reflexly 
by  means  of  an   irritant  at  a  distant  point.     It  relieves  pain,   promotes 


TREATMENT   OF   INFLAMMATION. 


65 


absorption,  and  is  used  principally  in  chronic  inflammation.  Irritants, 
such  as  silver  nitrate,  tincture  of  iodin,  and  copper  sulphate,  are  sometimes 
applied  to  stimulate  a  sluggish  area  of  inflammation  into  activity.  Blisters 
(epispastics)  are  produced  by  confining  chloroform  beneath  oiled  silk  or 
a  watch  glass,  by  croton  oil,  by  ammonia  mixed  with  an  equal  part  of  some 
ointment  base,  and  by  cantharidal  collodion  or  cantharidal  plaster  (fly 
blister).  A  blistering  plaster  is  moistened  with  sweet  oil,  and  applied  after 
the  skin  has  been  shaved  and  washed  with  soap  and  water.  A  blister  usually 
forms  in  from  five  to  six  hours,  in  tender  skins  in  a  much  shorter  period;  it 
should  be  punctured  with  an  aseptic  needle  and  dressed  with  a  bland  ointment. 
Frictions  with  stimuhtiug  liniments,  do  good  by  their  counterirritation  and 
massage.  Rubefacients,  e.g.,  mustard,  spice,  or  capsicum  plaster,  and  tur- 
pentine stupes,  produce  redness  of  the  skin.  Mustard  plasters  come  already 
prepared,  it  being  necessary  simply  to  dip  them  in  warm  water  before  applica- 
tion.    A  mustard  plaster  may  be  made  by  mixing  equal  parts  of  mustard  and 


Fig.  57. — Paquelin  thermocautery. 

flour,  with  a  little  vinegar  or  water,  the  paste  being  spread  u{)on  a  cloth  and 
covered  with  gauze.  The  addition  of  the  white  of  an  egg  prevents  vesication. 
When  a  more  severe  form  of  counterirritation  is  required,  the  hot-iron  (actual 
cautery),  or  escharotics  (potential  cautery),  such  as  antimonial  ointment, 
caustic  potash,  or  arsenical  paste,  may  be  applied.  The  cautery-iron  is 
heated  in  a  fire,  and  in  an  emergency  may  be  improvised  from  a  telegra{)h 
wire,  a  curling-iron,  or  a  poker.  Much  more  convenient  is  the  Paquelin 
thermocautery  (Fig.  57).  After  heating  the  platinum  point  (a)  over  an  alcohol 
lamp,  benzine  vapor  is  blown  from  the  bottle  into  the  point  by  the  rubber 
bulb  (b),  care  being  taken  to  keep  the  heated  point  higher  than  the  bottle 
lest  an  explosion  occur.  The  more  rapidly  the  bulb  is  squeezed,  the  hotter 
will  be  the  tip.  For  counterirritation  the  cautery  should  be  red  hot  and 
allowed  to  touch  the  skin  lightly;  it  should  not  be  used  over  a  bony  i)romincnce, 
a  large  nerve,  or  a  blood  vessel. 

5.  Constitutional  treatment  may  not  be  needed  in  trivial  inflammations; 
in  the  severer  forms  of  acute  inflammation  the  treatment  is  that  of 
sepsis  (p.  106).  The  internal  remedies  for  hastening  absorption  are 
mercury  and  the  iodids,  especially  in  chronic  inflammation.     The  same 


66 


INFLAMMATION. 


rule  holds  good  in  the  general,  as  in  the  local,  treatment  of  inflam- 
mation, to  find  the  cause  and  try  to  remedy  it.  Many  cases  of  chronic 
inflammation  are  tuberculous,  syphilitic,  gouty,  or  rheumatic,  and  poor 
results  in  the  local  treatment  of  acute  inflammation  may  be  due  to  some 
general  disorder,  such  as  Bright's  disease  or  diabetes.  These  constitutional 
afifections  should,  of  course,  receive  appropriate  treatment.  Tonics ^  such 
as  iron,  quinin,  and  strychnin,  will  be  found  of  value  in  most  forms  of  in- 
flammation, both  acute  and  chronic.  In  certain  inflammations  of  bacterial 
origin  serotherapy  may  be  tried.  The  senmi  treatment  of  specific  diseases 
is  referred  to  in  subsequent  pages,  it  being  necessary  in  this  place  merely 
to  call  attention  to  the  great  value  of  antitoxin  in  diphtheritic  inflammations. 


REPAIR. 

Destroyed  tissue  is  usually  replaced  by  fibrous  tissue  (repair),  and  not  by 
the  highly  specialized  cells  characteristic  of  the  tissue  {regeneration).  Repair 
takes  place  most  rapidly  in  healthy  vascular  tissues  which  have  been  carefully 
brought  together,  kept  aseptic,  and  put  at  rest.  Infection,  strong  antiseptics, 
separation  of  the  tissues,  motion,  lack  of  blood  supply,  and  many  constitu- 
tional diseases,  prominent  among  which  are  syphilis,  tuberculosis,  nephritis, 
and  diabetes,  retard  repair. 

The  first  of  the  phenomena  of  repair  are  identical  with  those  of  inflam- 
mation, except  in  intensity,  hence  the  absence  of  clinical  signs.  Inflammation 
is  a  pathological  process  that  may  or  may  not  end  in  repair,  which  is  a  phys- 


I'lG.  58. — Karyokinesis,  or  indirect  cell-division  (Zieglcr);  a,  cell  with  nucleus  in  quies- 
cent state.  The  nucleus  contains  nucleoli  and  a  network  of  threads;  6,  fonnation  of  coarse 
chromatin  threads  in  nucleus;  c,  disappearance  of  nucleolus  and  membrane  of  nucleus; 
arranj^cmcnt  of  threads  in  loops  forming  the  "rosette";  </,  angles  of  loops  directed  ton^-aid 
the  jx)les  of  the  cell,  which  are  formed  of  achromatic  threads;  e,  beginning  division  of  the 
cell ;  this  is  followed  by  a  gradual  return  of  the  nucleus  to  the  quiescent  state  (a). 

iological  process.  There  is  a  slight  dilatation  of  the  vessels,  exudation  of 
liquor  sanguinis,  and  the  escape  of  many  leukocytes  and  a  few  red  cells  and 
blood  plaques.  The  leukocytes  devour  and  remove  devitalized  cells  and 
l)loocl  clot.  The  fixed  connective- tissue  cells  and  the  endothelial  cells  pro- 
liferate by  the  indirect  method  {mitosis  or  karyokinesis),  in  which,  instead 
of  simple  segmentation,  cell  division  is  preceded  by  changes  in  the  nucleus 
( Fig.  58).  These  new  cells  are  called  fibroblasts,  or  indifferent  cells,  and  form 
a  mass  called  indifferent  or  embryonic  tissue.  The  leukocytes  wander  back 
into  the  circulation  or  are  devoured  by  the  fibroblasts.  From  the  walls  of 
the  capillaries  little  buds  of  protoplasm  shoot  out,  which  unite  with  similar 


protesses  from  other  vessels  and  become  canalized,  i,e,,  form  new  capillaries; 
thus  vascularization,  or  organization,  of  the  mass  is  brought  about,  and  the 
new  tissue  is  spoken  of  as  granulation  tissue.  In  regeneration  the  paren- 
^  hyma  cells,  or  specialized  cells,  of  a  tissue  or  organ  also  proliferate.  The 
fibroblasts  elongate  and  develop  librilUe,  which  interlace  and  form  fibnms 
;:  v:(/-  (cicatricial  or  scar  tissue).  Fibrous  tiss^ue  is  at  first  red,  but  later 
iHitracls,  compresses  the  newly-formed  capillaries,  and  thus  in  the  course 
of  time  becomes  dense,  hard»  and  white.  In  wounds  of  the  skin  or  mucous 
membrane  the  gap  at  the  surface  is  covered  with  epidermis,  which  growls, 
not  from  the  granulation  tissue,  but  from  the  epithelium  at  the  margins  of 
the  wound. 

When  an  incised  wound  heals  without  suppuration,  the  process  is  called 

healing  by  first  intent  ion  ^  or  primary  unimi.     The  bleeding  is  checked  by  small 

dols  in  the  mouths  of  the  vessels,  and  the  wound  margins  are  glued  together 

by  the  fibrin  of  the  extra vasated  blood.     The  small  amount  of  devitalized 

tissue  and  blood  clot  is  soon  absorbed,  and  healing  progresses  as  described 

above.     Healing  by  second  intention ^  or  by  granulation,  occurs  when  the  lips 

of  a  wound  are  separated  as  the  result  of  infection  or  the  loss  of  a  large 

amount  of  tissue.     In  the  former  instance  the  dead  tissue  is  gotten  rid  of  by 

sloughing  or  suppuration.    Many  of  the  fibroblasts  are  separated  from  their 

fellows  by  the  peptogenic  action  of  the  toxins  on  the  intercellular  substance, 

and  discharged  from  the  wound  as  pus  cells.     The  mass  of  cells  which 

1  remains  becomes  vascularized,  forming  granulation  tissue.     Each  granula- 

[  tion  is  made  of  a  series  of  capillary  loops  surrounded  by  and  nourishing  hhro- 

t  blasts.     Healthy  granulations  are  bright  red,  smooth,  and  firm.     The  fibro- 

J  blasts  multiply,  new  capillaries  are  formed,  and  finally  the  ca\ity  is  filled.     As 

the  granulations  grow  upward  the  fibroblasts  at  the  bottom  of  the  ca\ity 

k  become  fibrous  tissue,  which  contracts  and  lessens  the  size  of  the  healing 

lurca.     In  the  meantime  the  epithelium  at  the  edges  of  the  wound  has  been 

I  creeping  inward  by  a  proliferation  of  its  cells  {epidermization),  but  the  new 

I  cuticle  does  not  contain  hair  follicles,  sweat  glands,  or  sebaceous  glands.     If 

j  granulations  grow  above  the  level  of  the  skin  (exuberant  granulations ^  or 

\ proud  flesh),  epithelial  proliferation  is  checked  until  the  granulations  are 

,  removed.     These  granulations  are  usually  large,  pale,  tlabby,  and  edematous. 

'  \V  hen  two  dean   granulating  surfaces  imite  after  being  brought  together, 

healing  by  third  intention  is  said  to  occur.     Healing  by  organization  of  a  blood 

I  fJol  is  seen  where  a  ca\ity  is  filled  with  an  aseptic  biood  clot.     The  process 

(  differs  in  no  respects  from  that  which  has  already  been  described.     The  clot 

,  acts  as  a  scaffolding  for  the  granulations  and  is  gradually  absorbed.     In  the 

repair  of  non-vascular  dssue  leukocytes  and  serum  come  from  adjacent  tis- 

tues.     In  the  cornea  the  wound  is  at  first  glued  together  by  fibrin,  which  is 

later  replaced  by  proliferated  corneal  cells.     In  a  ver)^  trivial  injury  the 

resulting  tissue  may  be  transparent;  in  a  severe  injur)'  fibrous  tissue  forms 

and  an  opaque  scar  results.     In  wounded  cartilage  mut  h  the  same  process 

takes  place »  but  the  cartilage  cells  make  little  effort  at  regeneration,  and  the 

resulting  cicatrix  is  always  fibrous  tissue. 

Skin  and  mucous  membrane  are  repaired  by  fibrous  tissue  covered  by 
epithelium;  the  deeper  layers  of  the  skin,  the  hair  follicles,  and  the  sebaceous 
and  sweat  glands  are  not  regenerated.  Wounds  involving  the  cuticle  alone 
are  not  followed  by  permanent  scars;  those  which  pass  into  or  through  the 
deep  skin  leave  a  permanent  scar.     The  pathological  changes  that  may 


68  SUPPURATION. 

take  place  in  scars  are:  Excessive  contraction,  which  is  frequently  seen  after 
extensive  bums,  especially  about  joints.  In  these  cases  liberation  of  the  parts 
by  proper  incisions,  and  filling  the  resulting  gap  by  a  plastic  operation,  is  to  be 
considered.  In  the  various  canals  of  the  body  contraction  results  in  stricture. 
Hyperplasia  of  scar  tissue,  or  false  keloid  (see  chapter  on  skin).  Painful  scars 
are  due  to  the  pressure  of  the  contracting  tissue  on  a  nerve  filament.  Relief 
is  obtained  by  excising  the  painful  area,  or  by  finding  and  excising  the  in- 
volved nerve.  Owing  to  lack  of  nourishment,  scars  are  prone  to  ulcerate;  such 
ulcers  are  difficult  to  heal  and  occasionally  develop  into  epitheliomata 
{Marjolin's  ulcer). 

Blood  vessels,  after  division  or  ligation,  are  closed  by  clot,  which  is  finally 
replaced  by  fibrous  tissue.  After  aseptic  ligation  it  is  claimed  that  healing 
may  occur  without  the  formation  of  a  thrombus  (Chap.  xv).  Repair  of 
tendon  and  muscle  takes  place  by  fibrous  tissue,  but  striped  muscular  fiber 
may  regenerate  after  trivial  wounds.  Bone  is  repaired  by  bone  (Chap.  xix). 
Nerves  may  regenerate  (Chap.  xvii).  Regeneration  of  the  brain  and  spinal 
cord  is  possible  but  very  rare  (Chap,  xxi,  xxii).  Lymphatic  tissue  and  gland- 
ular organs  may  regenerate,  but  in  the  latter  destroyed  parenchyma  is 
usually  replaced  by  scar  tissue. 


CHAPTER  VII. 
SUPPURATION. 


Suppuration  is  the  liciucfaction  of  the  products  of  inflammation,  the 
resulting  fluid  being  called  pus. 

The  cause  of  suppuration  is  almost  invariably  infection  with  bacteria. 
The  puruloid  material  resulting  from  the  injection  of  sterile  irritants,  such  as 
mercury  and  croton  oil,  is  theoretically  not  pus.  Constitutional  diseases 
which  lower  the  resistance  of  the  tissues,  especially  diabetes  and  nephritis, 
predispose  to  suppuration.  Locally,  injuries  in  which  the  tissues  are  bruised 
or  lacerated  are  prone  to  suppurate. 

The  Pyogenic  or  Pus  Producing  Bacteria.— The  staphylococcus  pyo- 
genes aureus  is  an  amotile,  facultative  anaerobe,  grows  in  clusters  like  grapes, 
thrives  best  at  the  temperature  of  the  body,  is  normally  present  on  the  skin,  in 
the  nose,  mouth,  rectum,  and  vagina,  and  represents  about  lo  per  cent,  of  the 
germs  in  the  air  of  an  operating  room;  hence  the  most  common  organism 
generating  pus.  It  may  remain  latent  in  ice  and  dry  pus  for  days;  in  the 
human  body,  especially  in  osteomyelilic  foci,  for  many  years.  It  produces 
golden-yellow  colonies  on  culture  media,  and  is  instantly  killed  by  boiling 
water.  It  is  strongly  leukotactic,  i.e.,  attracts  leukocytes  from  the  blood; 
hence  usually  causes  a  limited  infection  which  is  walled  in  by  cell  barriers;  it 
may,  however,  be  found  in  spreading  suppurations  and  produce  fatal  results. 
Staphylotoxin  causes  degeneration  of  tissue  cells  and  constitutional  symptoms. 
The  staphylococcus  pyogenes  allms  and  the  staphylococcus  pyogenes  cUreus  are 
varieties  of  the  staphylococcus  pyogenes  aureus.  The  former,  which  is 
probably  identical  with  the  staphylococcus  epidcrmidis  albuSy  shows  a  white 


PATHOLOGY  OF  SUPPURATION.  69 

color  in  its  growth,  and  is  commonly  found  in  stitch  abscesses,  the  normal 
habitat  of  the  organism  being  upon  and  in  the  crypts  of  the  skin;  the  latter 
organism  produces  a  lemon-yellow  color.  The  streptococcus  pyogenes  (chain 
coccus)  is  identical  with  the  streptococcus  erysipelatis.  It  is  an  amotile,  fac- 
ultative anaerobe,  grows  best  at  the  temperature  of  the  body,  and  is  found  on 
the  skin  and  mucous  membranes  and  in  dust  and  sewage.  It  is  readily  killed 
by  the  usual  antiseptics,  but  may  remain  latent  in  ice  and  in  a  dry  form  for 
months.  It  sometimes  has  a  favorable  influence  on  sarcoma,  but  as  a  second- 
ary invader  in  tuberculosis  and  other  infections  it  increases  tissue  destruction 
and  the  violence  of  the  general  symptoms.  It  is  feebly  leukotactic,  conse- 
quently produces  a  thin  watery  pus,  readily  invades  the  lymph  channels,  and 
causes  spreading  inflammations  and  widespread  suppuration.  Its  toxin  is 
hemolytic  and  causes  serious  constitutonal  symptoms.  The  bacillus  colt 
communis  is  morphologically  identical  with  the  typhoid  bacillus.  It  is  a 
plump  straight  rod,  possesses  flagellae,  is  actively  motile,  is  a  facultative 
anaerobe,  and  generates  gas  with  a  fecal  odor.  It  normally  inhabits  the  in- 
testine as  a  harmless  saprophyte,  but  becomes  pathogenic  when  it  invades 
damaged  tissue,  e.g.,  strangulated  bowel,  or  lodges  in  foreign  soil,  e.g.,  in  the 
gall  bladder  or  genito-urinary  apparatus.  The  hacillus  pyocyaneus  is  fre- 
quently present  in  wounds  and  ulcers  which  are  not  dressed  regularly;  it 
produces  green  or  blue  pus  and  is  of  little  significance,  although  a  few  cases 
of  general  infection  have  been  reported.  It  is  aerobic,  motile,  having  a  polar 
flagellum,  and  is  found  in  water  and  in  the  mouth  and  alimentary  canal. 
Other  pathogenic  organisms  occasionally  found  in  suppurative  processes  are 
the  staphylococcus  cereus  albus,  staphylococcus  cereus  flavuSy  staphylococcus 
flavescenSy  micrococcus  tetragenus,  micrococcus  pyogenes  tenuis^  gonococcus, 
pneumococcusy  and  the  bcicillus  0/  typhoid  /every  inftucnzay  and  diphtheria. 
Non-pathogenic  saprophytes  cause  putrefactive  changes  in  foul  wounds.  The 
bacillus  oj  tuberculosis  and  the  ameba  coli  (the  cause  of  tropical  dysentery 
and  hepatic  abscess)  originate  not  true  pus,  but  a  puruloid  material. 

Pyogenic  bacteria  usually  enter  the  tissues  through  wounds;  they  may, 
however,  make  their  way  through  the  hair  follicles,  sebaceous  glands,  or  sweat 
ducts.  When  suppuration  occurs  in  a  subcutaneous  lesion,  such  as  a  hema- 
toma, micro-organisms  reach  the  area  by  way  of  the  blood,  probably  having 
entered  the  circulation  through  the  tonsils,  the  lungs,  or  the  intestinal  canal. 

The  pathology  of  suppuration  is  that  of  inflammation,  plus  the  peptoniz- 
ing influence  of  pyogenic  bacteria,  i  e.,  by  means  of  enzymes  they  digest  or 
liquefy  the  intercellular  portion  of  the  inflammatory  exudate.  Staphylococci 
and  other  organisms  of  low  virulence  give  the  inflammatory  exudate  about  the 
area  of  infection  a  chance  to  organize  and  form  a  barrier  to  further  dissemina- 
tion, thus  an  abscess  is  formed.  Organisms  of  high  virulence,  such  as  the 
streptococcus,  prevent  coagulation  of  the  exudate,  and  the  infection  quickly 
spreads  far  and  wide.  The  same  result '  may  ensue  with  less  virulent 
bacteria  when  the  tissues  have  little  resistance. 

Pus  consists  of  liquor  puris  (liquefied  intercellular  exudate  and  microbic 
products)  and  pus  cells  (dead  and  dying  leukocytes  and  connective-tissue 
cells). 

Varieties  oj  Pus. — Normaly  healthy y  or  laudable  pus  is  generally  due  to  the 
staphylococcus;  it  tends  to  remain  localized,  and  the  tissues  from  which  it 
comes  quickly  recover  after  thorough  drainage  has  been  established.  It  is  a 
greenish-white,  creamy  fluid,  alkaline  in  reaction,  and  of  a  specific  gravity 


of  [030.     It  may  be  odorless  or  smell  like  paste.    Sanims  pus  is  mixed  with 
blood,   and   is  sometimes   seen  in    caries   and   carcinoma.     Malignant  of 
ichorous  pus  is  watery,  acid,  and  very  irritating  to  the  tissues.     Blue  pus  is 
due  to  the  bacillus  pyocyaneus,  orange  pus  to  hematoidin  crystals  the  result 
of  degeneration  of  red  blood  corpuscles,  and  stinking  pus  to  the  bacteria  of 
putrefaction  or  the  bacillus  coli  communis.     Cmcrete  or  (ibrinous  pus  contains 
Jlakes  of  lymph ;  sermts  pus,  a  large  quantity  of  serum ;  and  muro-pus^  mucus. 
Gas  produdng  pus  is  due  to  the  l>acteria  of  putrefaction,  bacillus  of  malignai^t  j 
edema,  l>acillus  aerogenes  capsulatus,  bacillus  coli  communis,  or  to  commu« 
nication  with  one  of  the  air-conlaining   viscera.     Tuhcrcui&us,  scroJulousA 
caseous,  or  curdy  pus,  found  in  tuberculous  processes,  and  gummy  pus,  the! 
result  of  a  degenerating  gumma,  are  not,  strictly  speaking,  pus. 

Suppuration  may  be  diffuse  (cellulitis,  p.  11 1)  or  circumscribed  (abscess)* 
An  abscess  is  a  "circumscribed  cavity  of  new  formation  containing  pus.-'l 
Suppuration  begins  in  the  centerof  theintlammatory  area,  and  steadily  extends! 

by  melting  down  the  surrounding  embr)^onicj 
tissue.     An  abscess  at  this  stage  exhibits  five! 
zones:  (i)  The  pus,  (2)  a  zone  of  melting  downl 
embryonic   tissue,  (3)  a  zone  of  inflammatory] 
tissue   filled   with  leukocytes,  fdiro blasts,  and] 
thrombosed   vessels,    (4)  inflammatory    tissue  1 
containing  many  leukocytes,   v\itb  the  bloo 
stream  in  the  stage  of  retardation,  and  (5) 
zone  of  active  hyperemia  with  beginning  exu*l 
dation  (Fig.  59).     These  zones  increase  in  size! 
as  the  abscess  enlarges,  not  in  mathematical  I 
circles,  but  in  the  direction  of  least  resistance,] 
until  finally  the  abscess  reaches  the  surface  or] 
a  cavity  and  empties  itself.     The  tissues  at  the] 
surface   pass   through   the   various  stages   ofi 
inrtammation  and  liquefy,  until  ultimately  nothing  remains  but  a  very  ihial 
layer  which  is  pushetl  up  by  the  pus  below  {poinling),  ^vmg  the  abscess  a  char- 
acteristic acuminate  appearance.     When  this  thin  layer  liquefies,  the  abscessi 
** bursts**  and  spontaneous  evacuation  occurs.     After  an  abscess  has  emptie 
itself  or  ceased  to  spread,  the  inflammatory  phenomena  subside,  and  the 
embryonic  tissue  forming  its  walls  is  organized  into  granulation  tissue;  at 
this  stage  the  zones  of  an  abscess  are  (1)  the  pus,  (2)  zone  of  granulation 
tissue,  (3)   fibrous  tissue,   (4)  slightly  hyperemjc  normal  tissue  {Fig.  59).. 
The  varieties  of  abscesses  may  be  designated  according  to  the  structure 
involved,  as  lacunar,  involving  a  lacuna  of  the  urethra; /o/Zfcii/ar,  invol\^ng- 
a  follicle;  psoas^  traveling  in  the  psoas  sheath;  ihecal,  involving  a  tendonj 
sheath;  bursal ,  invol\ing  a  bursa;  brain;  puhnmiaty,  etc.     According  to  dura- 
lion  nn  abscess  may  be  acute  or  phlegm omms,  or  chronic  {congestive^  coldA 
strunufus,  lympkaiir,  caseous,  cheesy,  or  iuberculaus).     Other  terms  used  tol 
describe  abscesses  are,  circumscribed  (isolated  by  granulation  tissue);  </i^K5^J 
(infiltrating   the   tissues);   graviiatlngy  wandering,   or  kyposlatic    (travelingj 
from  one  point  to  another,  r.jg.,  psoas  abscess);  diathetic  or  constitutianalA 
(due  to  some  constitutional  disorder);  symptomatic  (constituting  a  sign  of 
another    disease);    critical,    or    consecutive    (occurring    ciuring    an    acute 
disease);  atheromatous  (occurring  beneath  the  intima  in  endarteritis);  can- 
aiicular  (communicating  with  a  duct);  gangrenous  (the  surrounding  parts  be- 


Fig.  59. — IJiagram  iHuslraling 
zones  m  spreading  (ujjper  half) 
and  healing  abscess  flo^vur  half). 


TREATMENT  OF  ABSCESS. 


came  gangrenous);  iympanitic,  or  tmphyscmaious  (tontiiiiiijig  gas);  encysted 
(limited  by  adhesions  in  a  serous  cavity)  ;/ffiii,  or  strrcoracemts  (communicat- 
ing with  the  bowei) ;  hemaik  (containing  broken  down  biood) ;  iropital  (in  the 
liver  following  amebic  dysentery);  marginal  (near  the  margin  of  the  anus); 
pyemic,  melastalUj  emboiic,  muftipiCf  or  miliary  (due  to  septic  emboli) ;  milk 
(in  the  breast  of  a  nursing  woman);  shiri-stud  (the  cavity  of  a  deep  abscess 
communicates  with  a  superficial  abscess  by  a  narrow  sinus);  perjorating 
(brea^king  into  some  cavity);  ossijiurnt  (due  to  diseased  Ixme);  secondary^ 
or  sympathetic  (occurring  some  tlistance  from  the  infecting  lesion,  e.g., 
abscess  of  axilla  after  infected  linger);  urinary  (due  to  extravasated  urine); 
residual,  or  Paget' s  abscess  (recurring  months  or  years  later);  syphilitiff  or 
gummatous  (due  to  syphilis);  Brodirs  (tuberculous  abscess  near  the  epiphy- 
seal line  of  a  long  bone) ;  superficial  (above  the  deep  fascia) ;  and  deep  (lielow 
the  deep  fascia). 

The  symptoms  of  an  acute  abscess  are,  (i)  the  local  symptoms  of  in- 
flammation, plus  fluctuation  and  pointing;  (2)  pressure  symptoms;  and  (3) 
constitutional  symptoms* 

1,  The  local  symptoms  of  intlammation  all  become  intensified ;  the  swelling 
is  greater,  edema  more  marked,  heat  more  apparent,  redness  more  dusky, 
pain  more  severe  and  often  throbbing  in  character,  and  the  function  of  the 
part  is  lost  or  greialy  impaired.  As  the  abscess  matures,  signs  of  fluctuation 
manifest  themselves;  the  abscess  becomes  acuminate,  pfnntlng  occurs,  and 
spontaneotis  evacuation  follows. 

2,  The  pressure  symptoms  depend  upon  the  size  and  seat  of  the  abscess; 
in  the  cranium  an  abscess  produces  symptoms  of  compression  of  the  brain; 
in  the  tonsD,  dysphagia;  in  the  neck,  dyspnea.  Large  blood  vessels,  especially 
veins,  are  occasionally  compressed  but  very  rarely  ulceraltMi, 

5.  The  constitutional  symptoms  var}'  from  a  slight  rise  in  temperature 
to  the  severer  grades  of  septicemia  or  even  pyemia  (q.v.).  Leukocytosis 
occurs  when  there  is  free  absorption  of  the  toxin  and  active  resistance  of 
the  tissues.  It  may  be  absent  in  trivial  suppurations,  in  very  severe  forms 
in  which  all  resistance  is  overcome,  and  in  those  abscesses  of  a  subacute  nature 
which  are  thoroughly  walled  in  by  fibrous  tissue. 

The  diagnosis  of  a  superficial  abscess  is,  as  a  rule,  easily  made.  A  sus- 
pected abscess  near  a  large  blood  vessel  should  always  be  carefully  investi- 
gated, in  order  to  avoid  the  calamity  of  opening  an  aneurj'sm.  An  aliscess 
lying  over  an  artery  will  be  raised  with  each  pulsation  of  the  heart;  the  pulsa- 
tion of  an  aneur)^sm  is  in  all  directions,  so  that  its  enlargement  will  be  felt 
when  it  is  grasped  from  above  downward,  as  well  as  from  side  to  side. 
Placing  two  fingers  near  together  upon  the  mass,  and  observing  whether  they 
are  simply  raiset!  (abscess),  or  raised  and  separated  (aneur>^sm),  with  each 
pulsation  of  the  heart,  is  occasionally  useful  In  some  cases  changing  the 
position  of  the  patient,  so  that  the  mass  will  fall  away  from  the  arter>%  will 
be  of  value  (see  aneurysm).  In  doubtful  cases  a  fme  trocar  or  aspirating 
needle  wiU  settle  the  diagnosis.  Lipomata  and  small-celled  sarcomata 
not  infrequently  present  pseudo fluctuation,  and  a  cyst  actually  tluctuates; 
in  these  conditions,  however,  the  absence  of  inflammatory  phenomena,  and 
the  aspirating  needle  if  necessary,  will  dispel  all  doubt. 

The  prophylactic  treatoieiit  consists  in  the  thorough  disinfection  of  all 
abrasions  and  wounds.  In  severe  inliammations  early  incision  will  occasion- 
ally prevent,  or  at  least  limit,  the  formation  of  pus.     Suppuration  is  often  en- 


72  SUPPURATION. 

couraged  when  it  is  known  to  be  inevitable,  by  the  application  of  antiseptic 
fomentations.  When  pus  is  once  formed,  the  part  should  be  incised,  with 
antiseptic  precautions,  at  a  point  most  suitable  for  subsequent  drainage. 
The  interior  should  generally  be  explored  with  the  ^ger,  and  in  many  cases 
it  will  be  found  possible  to  remove  the  cause,  e.g.,  an  inflamed  appendix  or 
carious  bone.  The  abscess  should  not  be  squeezed,  but  as  a  rule  it  should  be 
washed  out  with  an  antiseptic  solution.  Curettage  is  usually  undesirable. 
Drainage  may  be  effected  by  tubing,  gauze,  or  strips  of  rubber  tissue. 
Dressings  should  be  changed  frequently  and  the  part  kept  at  rest.  Heat  is 
often  grateful  to  the  patient.  If  there  is  pain  severe  enough  to  interfere  with 
sleep,  or  if  the  fever  persists,  it  will  usually  be  found  that  drainage  is  insuffi- 
cient and  that  a  larger  incision  is  indicated.  When  an  abscess  is  situated  in  a 
dangerous  region,  such  as  the  neck,  one  may  employ  HUlan*s  method,  i.e., 
the  skin  and  deep  fascia  are  incised,  and  after  a  director  has  been  pushed  into 
the  cavity,  a  pair  of  closed  hemostatic  forceps  is  passed  along  the  groove,  then 
opened,  and  withdrawn  while  open  so  as  to  dilate  or  tear  the  structures.  In 
some  cases  a  counter-opening  is  desirable  for  better  drainage,  or  for  through  and 
through  irrigation.  This  is  made  by  pushing  a  pair  of  forceps  against  the 
opposite  wall  of  the  abscess,  and  cutting  down  upon  the  end  with  a  knife. 
(For  Bier*s  treatment  see  p.  62).  The  constitutional  treatment  is  that  of 
sepsis  (p.  107). 

Chronic  abscesses  may  be  syphilitic  in  origin;  they  may  result  from 
infection  with  pyogenic  organisms,  the  abscess  wall  having  become  fibrous 
tissue;  they  may  occur  in  the  liver  from  infection  with  the  ameba  coli,  or 
in  the  pelvis  from  infection  with  the  gonococcus;  and  they  may  occur  in  the 
brain.  The  term  chronic,  however,  as  usually  employed,  means  tuberculous, 
and  it  is  with  such  that  we  shall  deal  under  this  heading.  The  abscess  is 
formed  by  the  liquefaction  of  tuberculous  tissue  (see  tuberculosis),  and 
although  it  may  occur  in  any  portion  of  the  body,  it  is  most  frequently  found 
in  connection  with  bones,  joints,  and  lymphatic  glands.  The  contents  is 
not  true  pus,  but  a  yellowish- white,  odorless  fluid  containing  cheezy  masses 
of  broken  down  tissue,  coagulated  fibrin,  a  few  cells  undergoing  fatty  de- 
generation, and  frequendy  cholesterin  crystals;  there  are  no  pyogenic 
organisms,  and  few  or  no  tubercle  bacilli,  although  injection  of  the 
fluid  into  guinea-pigs  produces  miliary  tuberculosis.  The  abscess  wall  is 
composed  of  two  layers,  the  inner  ( Volkmann's  layer)  consists  of  large  flabby 
granulations,  grayish-yellow  or  purplish  in  color,  containing  miliary  tubercles, 
and  is  easily  detached  from  the  outer  layer,  which  is  composed  of  dense 
fibrous  tissue  {pyogenu  ov  prophylactic  membrane). 

The  abscess  forms  without  inflammator)'  S3anptoms,  hence  the  term  cold. 
Pain,  when  present,  is  due  more  to  pressure  upon  surrounding  parts  than  to 
the  disease  process  itself,  and  tenderness  is  often  absent  in  the  abscess  itself, 
although  usually  demonstrable  in  the  tissue  primarily  diseased.  The  skin 
may  be  paler  than  normal  {white  swelling) ;  while  softening  and  fluctuation  are 
usually  quite  evident,  owing  to  the  absence  of  inflammatory  infiltration.  As 
the  cause  of  trouble  is  often  deep,  the  pus  is  prone  to  make  its  way  beneath 
dense  fascia;,  and  to  appear  on  the  surface  at  a  point  far  distant  from  the 
original  focus.  In  tuberculosis  of  the  dorsolumbar  spine  pus  may  appear  in 
the  lumbar  region,  iliac  region,  perineum,  or  in  the  thigh.  When  a  tuber- 
culous abscess  suddenly  makes  its  appearance  on  the  surface,  it  has  usually 
come  from  a  distance  and  broken  its  way  through  some  resistant  structure,  as 


TREATMENT   OF  CHRONIC  ABSCESS.  73 

its  formation  generally  occupies  weeks  or  months.  An  imtreated  tuberculous 
abscess  may  reach  the  surface  and  evacuate  itself,  or  be  walled  in  by  fibrous 
tissue.  In  the  latter  event  the  contents  become  putty-like  in  consistency, 
calcified,  or  absorbed  and  replaced  by  fibrous  tissue.  When  such  an  area 
again  becomes  active,  it  is  called  a  residual  abscess. 

CanstiHUianal  symptoms  may  be  absent.  Progressive  loss  of  weight  with 
pallor  is  often  absent  in  uncomplicated  tuberculous  abscesses,  and  there  is  no 
leukocytosis.  After  the  abscess  bursts  and  other  organisms  gain  entrance,  the 
discharge  is  thick,  purulent,  and  increased  in  amount,  and  constitutional 
symptoms  of  mixed  infection  are  present,  viz.,  those  of  hectic  fever  and,  if 
the  suppuration  is  long  continued,  amyloid  disease.  Secondary  infection  by 
way  of  the  blood  is  possible  but  rare. 

Hectic  fever  (chronic  septic  intoxication)  occurs  only  when  there  is  mixed 
infection ;  it  may  be  found  not  only  in  the  tuberculous,  but  in  any  case  in  which 
there  is  protracted  suppuration.  It  is  due  to  the  persistent  absorption  of 
toxins,and  is  characterized  by  a  daily  afternoon  rise  in  temperature,  at  which 
time  the  cheeks  become  flushed  (hectic  flush)  y  the  eyes  bright,  and  the 
pulse  quickened;  during  the  night  the  temperature  falls  rapidly  with  profuse 
sweating  (night  sweat)]  and  the  patient  soon  becomes  weak  and  emaciated. 

Amyloid  disease  (albuminoid^  lardaceouSy  waxyy  or  colloid  degeneration) 
finally  supervenes.  The  cause  of  this  condition  is  not  known;  it  may  be  due 
to  the  chronic  toxemia,  or  to  the  discharge  draining  from  the  blood  alkaline 
salts.  The  walls  of  the  capillaries  and  arterioles  and  eventually  the  viscera, 
especially  the  spleen,  liver,  and  kidneys,  become  infiltrated  with  an  albu- 
minoid or  waxy  material.  The  mucous  membranes,  particularly  those 
of  the  intestines,  likewise  are  frequently  involved.  The  affected  organ 
is  large,  pale,  heavy,  and  smooth.  Owing  to  the  changes  in  the 
intestinal  mucosa,  disorders  of  digestion  and  diarrhea  are  present.  The 
cachexia  is  due  partly  to  the  prolonged  suppuration  and  partly  to  the 
visceral  changes.  The  diagnosis  is  easily  made,  when  in  the  course 
of  a  prolonged  suppuration,  the  spleen  and  liver  enlarge,  and  there  is 
diarrhea  and  polyuria,  with  albumin,  and  amyloid  casts  giving  the  iodin 
reaction.  The  time  necessary  for  the  production  of  amyloid  disease  varies 
within  wide  limits;  the  shortest  period  probably  being  three  months.  Amy- 
loid disease  should  be  prevented  by  the  active  treatment  of  chronic  suppura- 
tion. Its  onset,  although  serious,  is  an  indication  for,  rather  than  a  con- 
traindication to,  operation,  as  the  process  may  be  checked  in  its  early  stages. 

The  diagnosis  of  a  cold  abscess  is  made  by  its  chronic  course,  the  absence 
of  inflammatory  symptoms  and  leukocytosis,  and  frequently  by  the  detection 
of  changes  in  the  bones  or  joints  from  which  it  has  arisen.  In  doubtful 
cases  aspiration  may  be  used.  The  diagnosis  of  tuberculosis  is  given  in  more 
detail  on  p.  134. 

The  treatment  is  incision  under  scrupulous  antiseptic  precautions  and 
removal  of  the  cause  (necrotic  bone,  tuberculous  lymph  glands,  etc.). 
After  removal  of  the  granulations  with  a  curette,  the  cavity  should  be  thor- 
oughly irrigated,  and  packed  with  iodoform  gauze.  If  the  limits  of  the 
abscess  cannot  be  reached,  or  if  the  cause  cannot  be  removed,  the  incision 
may  be  sutured,  in  order  to  avoid  secondary  infection  during  the  subsequent 
dressings.  In  cases  in  which  the  abscess  is  small,  particularly  when  connected 
with  a  lymphatic  gland,  excision  of  the  whole  abscess  cavity  and  suture  of 
the  wound  is  indicated.     Simple  aspiration  and  aspiration  followed  by  ir- 


74  ULCERATION. 

rigaiion  with  a  weak  antiseptic  solution  are  occasionally  successful.  Iodo- 
form emulsion  (lo  per  cent,  in  glycerin  or  olive  oil)  may  be  injected,  after 
tapping  and  irrigation,  once  a  week  until  healing  occurs.  Not  more  than 
4  or  5  drams  should  be  used  in  an  adult,  and  not  more  than  2  or  3  drams  in  a 
child,  because  of  the  danger  of  poisoning.  Ethereal  emulsions  become 
gaseous  after  injection,  and  in  certain  regions  may  produce  harmful  pressure. 
Bier  makes  a  small  incision  and  applies  a  vacuum  pump  (p.  62).  Beck 
evacuates  the  pus  through  a  small  opening,  fills  the  cavity  with  bismuth 
paste  (p.  79),  and  applies  a  sterile  dressing.  If  the  opening  heals  and  the 
fluid  reaccumulates,  the  wound  is  reopened  and  the  fluid  allowed  to  escape: 
the  injection  is  not  repeated.  It  may  be  necessary  to  adjust  apparatus  if 
the  abscess  proceed  from  bones  or  joints.  The  constitutional  treaimetU  is 
that  of  tuberculosis  (p.  135). 

Abscesses  in  various  parts  of  the  body  which  require  special  mention 
will  be  found  in  those  sections  devoted  to  regional  surgery. 


CHAPTER  VIII. 
ULCERATION. 


Ulceration  is  the  progressive  loss  of  tissue  due  to  molecular  destruction 
of  superficial  structures.     Ulceration  of  bone  is  called  caries. 

The  causes  of  ulceration  may  be  grouped  under  the  following  headings: 

1.  Simple  ulcers  include  those  due  to  pyogenic  organisms;  inflammation; 
traumatism  (mechanical,  chemical,  thermal) ;  deficient  circulation,  such  as 
is  caused  by  scars,  atheroma,  the  lodging  of  an  embolus,  pressure  (splint 
sores  and  bed  sores),  and  passive  congestion  (varicose  ulcer) ;  nervous  lesions 
(corneal  ulcer  following  removal  of  the  Gasserian  ganglion,  perforating  ulcer 
of  the  sole  in  locomotor  ataxia) ;  constitutional  diseases,  such  as  gout,  scurvy, 
diabetes,  and  mercurialism ;  and  those  due  to  the  loss  of  so  much  tissue  that 
healing  cannot  take  place. 

2.  Ulcers  due  lo  specific  bacteria  occur  in  chancroid,  tuberculosis,  syphilis, 
leprosy,  glanders,  and  anthrax. 

3.  Malignant  ulcers  are  caused  by  the  breaking  down  of  malignant 
growths. 

Pathologically  an  ulcer  presents  the  changes  which  are  found  in  the  wall 
of  an  abscess,  the  suppuration  being  in  excess  of  the  reparative  process.  As 
ulceration  extends,  adjacent  structures  may  be  involved,  e.g.,  a  leg  ulcer  may 
produce  caries  or  necrosis  of  the  tibia;  occasionally  large  vessels  are  opened, 
and  ulcers  in  the  gastrointestinal  canal  may  perforate  and  cause  generalized 
peritonitis.  When  an  ulcer  ceases  to  extend  and  the  reparative  processes 
are  in  excess  of  those  of  destruction,  strictly  speaking,  the  lesion  ceases  to  be 
an  ulcer  and  becomes  a  healing  wound. 

The  diagnosis  of  ulcers  is  made  by  considering  the  (i)  mode  of  onset, 
(2)  duration,  (3)  number,  (4)  amount  of  pain,  (5)  size,  (6)  shape,  (7)  situation, 
(8)  floor,  (9)  edges,  (10)  discharge,  (11)  surrounding  tissue,  (12)  condition  of 
the  adjacent  lymph  glands,  and  (13)  the  age  and  (14)  general  condition  of 
the  patient. 


DUGNOSIS  or   ITLCEItATION. 


75 


1.  Mo<k  of  Onset. — An  injury  may  inaugurate  many  forms  of  ulceration 
besides  the  traumatic,  e.g.,  tuberculous,  syphilitic,  varicose,  etc.  An  ulcer 
due  to  an  embolus  is  preceded  by  a  small  area  of  gangrene.  Pressure  ulcers 
are  found  after  the  removal  of  splints  and  apparatus.  An  ulcer  which  has 
l>een  preceded  by  a  swelling  may  be  the  result  of  inflammation,  tuberculous 
abscess,  gumma,  or  a  breaking  down  neoplasm. 

2.  Duration. — Traumatic  ulcers  are  acute;  malignant  uUers  may  last 
months,  varicose  ulcers,  years. 

3.  A  number  of  ulcers  scattered  over  the  body  commonly  indicates  some 
general  disease,  although  chancroids  (local  infection)  are  multiple  and  chancre 
(constitutional  disease)  is  single. 

4.  Pain. — The  perforating  ulcer  of  the  sole  of  the  foot  and  other  trophic 
ulcers  may  be  painless;  acute  ulcere  in  healthy  tissues  are  accompanied  by  a 
burning  or  stinging  pain.  Intense  pain  without  inflammation  is  experienced 
ID  the  erethistic*  irritable,  or  neuralgic  uker. 

5.  Size. — Bed  sores,  varicose,  phagedenic,  and  malignant  ulcers  may 
attain  a  large  size.  The  ordinary  traumatic^  trophic,  and  syphilitic  ulcers  are 
smaller. 

6.  Shape, — Syphilitic  uJcers  are  circular,  semi-lunar,  irregular,  or  serpig- 
inous, and  often  punched  out  in  appearance.  Tuberculous  ulcers  are  ovoid 
or  ragged. 

7.  Situation. — Traumatic  ulcers  occur  in  regions  exposed  to  injurj^,  such 
as  the  shin  and  elbow.  Ulcers  on  the  lips  of  the  thigers  and  toes  may  be 
due  to  defective  circulation  Tuberculous  ulcers  are  frequent  al>out  the 
mouth  and  in  the  vicinity  of  lymph  glands  (neck,  axilla,  groin)  and  joints; 
syphilitic  ulcers  about  the  genitals  and  in  the  neighl)orhood  of  joints;  lupoid 
ulcers  on  the  face;  carcinoma  about  the  face,  mouth,  breast,  rectum,  and 
genitals;  scorbutic  ulcers  on  the  gums;  and  varicose  ulcers  in  the  lower  third 
of  the  leg. 

S,  The  Floor. — A  healing  ulcer  is  covered  with  firm,  bright  red  granula- 
tions; an  extending  ulcer  with  disintegrating,  grajish-yeUow  tissue  and  no 
granulations;  a  stationary  ulcer  with  a  few,  feeble,  yellowish  granulations  on  a 
smooth  and  glistening  surface;  and  a  scorbutic  ulcer  with  a  thick,  soft  crust  of 
dotted  blood.  Large,  pale^  edematous  granulations  suggest  tuberculosis 
or  some  other  deliilitating  malady;  in  many  of  these  cases  will  be  found  a 
sinus  leading  down  to  necrotic  bone  or  caseating  glands.  The  floor  may 
be  covered  with  diphtheritic  false  membrane.  A  syphilitic  ulcer  (Fig.  80) 
may  show  the  characteristic,  dirty-yellow,  tough  slough  of  gummy  degene ra- 
tion.   In  some  cases  a  section  should  be  removed  for  microscopic  examination. 

9,  In  a  spreading  ulcer  the  edges  are  inflamed,  thickened,  eroded;  in 
the  indolent  or  callous  ulcer  hard,  well  defmed,  and  raised  above  the  surface; 
Hid  in  a  healing  ulcer  sloping,  with  three  zones,  (i)  a  red  zone  of  granulation 
tissue,  (2)  a  blue  or  purplish  zone  of  beginning  epidermization,  (3}  a  white 
lone  of  skin.  Undermined  edges  are  seen  especially  in  syphilis  and  tuber- 
culosis, and  thick,  non-granulating,  everted  edges  in  carcinoma. 

10.  The  discharge  may  be  fetid  in  any  ulcer,  from  contamination  with 
saprophytes;  it  is  profuse,  watery,  ichorous,  and  often  mixed  with  blood  in  a 
spreading  ulcer;  fetid  andsaniousin  a  scorbutic  ulcer;  seropurulent  in  a  healing 
ulcer;  puruJent  and  irritating  in  an  indolent  ulcer.  In  a  gouty  ulcer  urate  of 
soda  may  be  detected;  in  other  ulcers  examination  of  the  discharge  may  be 
made  for  various  forms  of  organisms. 


^6  ULCERATION. 

11.  The  surrounding  tissues  may  show  evidence  of  syphilis  or  defective 
circulation,  or  they  may  be  healthy.  In  malignant  ulcers  the  surrounding 
tissues  are  the  seat  of  a  neoplastic  infiltration;  loss  of  sensation  and  hair,  and  a 
shiny  appearance  indicate  trophic  changes. 

12.  The  adjacent  lymph  glands  may  be  enlarged  in  any  form  of  ulcera- 
tion, from  the  absorption  of  bacterial  products.  In  ordinary  pyogenic  ulcers 
they  show  the  signs  of  acute  inflammation.  In  early  syphilis  the  enlarge- 
ment is  general,  and  the  glands  are  discrete  and  do  not  mat  together;  in  carci- 
noma they  enlarge,  infiltrate  the  surrounding  tissues,  and  are  often  of  stuny 
hardness;  in  tuberculosis  they  mat  together,  become  adherent  to  the  skin, 
form  sinuses  which  discharge  caseous  pus,  and  are  often  painless. 

13.  Age. — Ulcers  in  children  are  often  tuberculous  or  due  to  congenital 
syphilis;  in  old  age  varicose  and  malignant  ulcers  are  more  common. 

14.  Gefieral  Condition  of  the  Patient. — Examine  for  tuberculosis,  syphilis, 
gout,  scurvy,  diabetes,  nephritis,  cardiac  disease,  and  for  any,  cause  that  im- 
pairs the  general  health. 

The  treatment  of  ulceration  may  be  considered  under  the  following 
headings,  (i)  removal  of  the  cause,  (2)  disinfection,  (3)  rest,  (4;  elevation,. 
(5)  other  measures  to  promote  healing. 

1 .  Removal  of  the  cause,  when  possible,  converts  the  ulcer  into  a  healing 
wound.  Varicose  veins  may  be  removed  or  supported,  an  ingrowing  toe 
nail  excised,  tuberculous  glands  extirpated,  and  jagged  teeth  extracted. 
One  should  look  for  and  combat  the  conditions  mentioned  above  among 
the  constitutional  causes  of  ulceration. 

2.  Disinfection  is  often  synonymous  with  removal  of  the  cause.  Microbic 
invasion,  if  not  the  primary  cause,  is  at  least  a  secondary  factor  in  all  forms 
of  ulceration.  Disinfection  is  usually  carried  out  by  spraying  with  peroxid 
of  hydrogen  and,  according  to  the  condition  of  the  ulcer,  washing  with  bi- 
chlorid  of  mercury  or  salt  solution. 

3.  Rest  is  as  important  here  as  in  inflammation.  In  an  ulcer  of  the  cornea 
rest  is  secured  by  bandages  or  dark  glasses,  in  an  ulcer  of  the  stomach  by 
rectal  feeding  or  gastroenterostomy,  in  an  ulcer  of  the  anus  by  dilatation  or 
division  of  the  sphincter,  and  in  vsome  other  regions  by  placing  the  patient 
in  bed  or  by  the  use  of  splints. 

4.  Elevation  is  indicated  in  all  forms  of  ulceration  in  which  it  may  be 
secured;  even  in  those  due  to  deficient  arterial  circulation  the  tissues  are  apt 
to  be  filled  with  fluid. 

5.  Other  measures  to  promote  healing  may  be  studied  according  to  whether 
the  ulcer  is  (a)  spreading,  (b)  stationary,  or  (c)  healing. 

(a)  In  an  acute  inflamed  ulcer,  which  is  not  infrequent  in  alcoholics  and  in 
the  debilitated,  the  part  should  be  elevated,  disinfected,  and  dressed  with 
hot  antiseptic  fomentations,  held  in  place  by  a  bandage  applied  from 
the  extremity  of  the  limb  to  above  the  ulcer.  If  sloughing  is  present,  heat 
will  hasten  separation,  and  the  sloughs  may  be  removed  with  forceps  and 
scissors.  Powders  are  usually  contaminated  with  micro-organisms,  and  form 
a  crust  which  interferes  with  the  proper  toilet  of  the  part.  Ointments  are 
difficult  to  sterilize,  interfere  with  drainage,  and  are  hard  to  remove;  if  they 
are  used,  lanolin  or  vaselin  makes  the  best  base.  Lard  should  never  be  em- 
ployed as  it  quickly  putrefies.  The  adjacent  lymph  glands,  if  swollen,  may 
be  covered  with  a  20  per  cent,  ichthyol  ointment;  if  suppurating,  they  should 
be  exci.scd.     Attention  should  always  be  given  to  the  general  health  by  the 


TREATMENT   OF  ULCERATION.  ^^ 

idministration  of  laxatives,  or  by  other  measures  to  promote  elimination; 
tonics,  such  as  iron,  quinin,  strychnin,  are  usually  indicated,  and  sedatives 
may  be  necessary.  Phagedenic  ulceration  is  occasionally  seen  in  syphilis, 
in  fact  in  any  ulcer,  but  it  most  frequently  attacks  chancroid,  and  was 
It  one  time  common  as  hospital  gangrene.  Depraved  vitality  probably  has 
IS  much  to  do  with  the  process  as  the  virulency  of  the  infection.  The  ulcer 
spreads  with  great  rapidity,  and  requires  powerful  disinfectants,  such  as  the 
ictual  cautery,  pure  carbolic  acid,  or  nitric  acid,  while  the  general  condition  of 
the  patient  is  improved  by  tonics  and  stimulants. 

(b)  The  indolent,  chronic,  or  callous  ulcer  is  most  frequently  seen  on  the 
owcr  third  of  the  leg,  in  the  latter  half  of  life  {varicose  ulcer — ^Fig.  112),  but  is 
encountered  also  in  syphilis  and  tuberculosis  and  after  large  bums.  It  is 
3val  in  shape,  usually  painless,  and  may  last  for  years.  It  has  humped-up, 
[lard  and  congested  edges,  and  a  smooth,  glistening,  dirty-yellow  floor  with  a 
few  feeble  granulations.  The  discharge  is  often  irritating  and  causes  eczema 
di  the  neighboring  skin  (eczematous  ulcer) .  The  ulcer  is  firmly  attached  to  the 
surrounding  parts,  so  that  contraction  is  prevented;  adjacent  vessels  may  be 
compressed,  causing  a  persistent  edema,  sometimes  with  an  overgrowth  of  the 
subcutaneous  tissues  resembling  elephantiasis.  In  some  cases  there  is  marked 
pigmentation  of  the  surrounding  skin,  owing  to  the  escape  and  disintegra- 
tion of  red  blood  cells.  The  irritable,  erethistic,  neuralgic,  or  painful  ulcer  is 
jften  seen  in  these  cases,  and  is  due  to  the  exposure  of  nerve  filaments.  It  is 
treated  by  cauterizing  or  excising  the  painful  spot,  by  passing  a  tenotome 
above  it  to  divide  the  aflFected  nerve  filament,  or  by  curetting  the  whole  ulcer. 
The  treatment  of  chronic  indolent  ulcers  is  frequently  tedious  and  disappoint- 
ing, as  they  often  occur  in  patients  who  cannot  afford  the  time  to  care  for 
them  properly.  Any  existing  constitutional  disease  should  receive  attention , 
especially  diseases  of  the  heart  and  blood  vessels.  Strychnin,  digitalis, 
and  nitroglycerin  are  often  of  service.  Varicose  veins  should  be  treated 
(p.  181).  If  possible,  rest  and  elevation  should  be  secured.  The  ulcer  may 
be  cleansed,  if  sloughs  exist,  with  hot  antiseptic  fomentations  (boracic  acid , 
carbolic  acid,  salt  solution).  Massage  of  the  surrounding  parts  is  often 
beneficial.  Compression  is  usually  indicated;  it  may  be  made  by  a  muslin 
bandage,  by  a  flannel  bandage,  by  Martin's  rubber  bandage,  or  better  by  the 
Randolph  bandage,  which  consists  of  elastic  webbing  that  does  not  tend  to 
macerate  the  skin  like  the  rubber  bandage;  another  useful  form  of  compres- 
sion is  secured  by  overlapping  strips  of  adhesive  plaster  which  encircle  the 
limb  two-thirds  only.  A  piece  of  lint  the  exact  size  of  the  ulcer,  soaked  in 
copper  sulphate,  grains  10  to  the  ounce,  is  first  placed  over  the  sore.  Unna's 
dressing  consists  of  gelatin  5  parts,  oxid  of  zinc  5  parts,  boric  acid  i  part, 
^ycerin  8  parts,  and  water  6  parts;  these  are  mixed  and  liquefied  in  a  water 
f>ath.  After  cleansing  the  part,  a  gauze  bandage  is  applied  from  the  extrem- 
ity of  the  limb  to  above  the  ulcer  and  painted  with  the  fluid ;  several  layers 
of  gauze  may  thus  be  applied  and  painted.  The  liquid  solidifies  on  cooling  and 
resembles  adhesive  plaster,  so  that  most  of  its  virtue  lies  in  the  compression 
exerted;  this  dressing  may  be  left  in  place  until  it  loosens  (one  to  three  weeks) . 
If  there  is  much  discharge,  the  dressing  may  be  applied  every  few  days,  or, 
better,  the  ulcer  itself  may  be  left  uncovered  for  drainage  and  cleansing. 
Schulzc  purifies  the  ulcer  with  soap  and  water,  and  dresses  it  with  a  solution 
3f  acetate  of  aluminium  (2  per  cent,  in  water)  until  the  discharge  decreases 
and  loses  its  odor;  a  piece  of  lint  the  size  of  the  ulcer  is  then  soaked  in  spirits 


78  ULCERATION. 

of  camphor,  and  applied  beneath  absorbent  cotton,  rubber  dam,  and  a 
compression  bandage.  The  camphor  is  reapplied  every  other  day,  after 
washing  with  a  a  per  cent,  solution  of  carbolic  acid.  In  cases  in 
which  there  is  marked  congestion,  scarification  or  blistering  of  the  ulcer  and 
surrounding  parts  has  been  advised.  When  healing  is  prevented  by  adhe- 
sions to  the  underl3dng  structures,  the  edges  may  be  liberated  by  curved  inci- 
sions on  each  side  of  the  ulcer,  or  by  radiating  incisions  through  its  margins, 
or  the  whole  ulcer  may  be  excised.  In  very  large  ulcers  which  have  involved 
bone,  which  resist  treatment,  and  which  occur  in  patients  who  cannot  afford 
to  be  ill  for  a  long  time,  amputation  must  be  considered.  Weakyfimg(ms,or 
eocuberant  ulcers  are  covered  with  exuberant  (proud  flesh)  or  edematous  granu- 
lalionSf  often  occur  in  debilitated  patients,  and  are  best  treated  by  removal  of 
the  granulations  with  scissors  or  curette  and  touching  the  base  with  pure 
nitrate  of  silver.  Deficient  granulations  require  applications  of  silver  nitrate 
(lo  gr.  to  the  ounce),  copper  sulphate  (gr.  lo  to  the  oz.),  balsam  of  Peru,  red 
wash  (zinc  sulphate  gr.  2,  compound  tincture  of  lavender  m.  10,  water  i 
ounce),  argyrol  (10  per  cent.),  or  tincture  of  iodin  (half  strength).  Hemor- 
rhagic ulcers  are  seen  in  anemia  and  scurvy;  the  principal  indications  are  to 
treat  the  constitutional  condition  and  apply  pressure.  Eczema  requires 
cleansing  with  sweet  oil,  and  the  application  of  ichthyol  (5-10  per  cent.),  lead- 
water  and  laudanum,  Unna's  dressing,  liq.  carbonis  detergens  (i  ounce  to  liq. 
plumbi  subacetat.  dil.  i  pint),  oxid  of  zinc  ointment,  or  boracic  add  oint- 
ment. In  some  cases  healing  is  prevented  by  turning  in  of  the  skin  edges,  a 
condition  which  is  met  by  freeing  the  edges  with  incisions. 

(c)  In  a  simple  ulcer,  after  removal  of  the  cause,  all  that  need  be  done  is 
to  maintain  cleanliness  and  the  tissues  will  effect  repair.  In  large  ulcers 
situated  near  a  joint,  the  limb  should  be  placed  in  the  best  position  to  pre- 
vent contraction  during  the  healing  process.  In  many  of  these  cases  skin 
grafting  (p.  168)  should  be  employed. 

Trophic  ulcers,  bed  sores,  and  those  ulcers  occurring  in  groups  2  and  3  are 
considered  under  their  respective  headings  in  later  chapters. 


SINUS  AND  FISTULA. 

A  sinus  is  an  abnormal  canal  leading  from  the  surface  of  the  body  down 
into  the  tissues;  it  is  lined  with  granulations  and  usually  ends  in  the  cavity 
of  an  unhealed  abscess.  Sinuses  are  caused  by  (i)  foreign  bodies,  either 
exogenous  (e.g.,  a  bullet,  needle,  or  non-absorbable  ligature),  or  endogenous, 
e.g.,  a  caseating  gland,  necrotic  bone,  or  carious  tooth;  (2)  deficient  drainage, 
that  is,  the  orifice  heals,  pus  accumulates,  another  abscess  forms,  spontaneous 
evacuation  occurs,  and  the  process  is  repeated  over  and  over;  (3)  want  of  rest; 
(4)  infection  of  the  walls ^  especially  by  the  tubercle  bacillus;  (5)  ingrowth  of 
epithelium;  (6)  fibrous  rigidity  of  the  walls  which  prevents  their  coming 
together;  and  (7)  general  debility. 

The  treatment  is  removal  of  the  cause.  The  sinus  should  be  widely 
opened,  thoroughly  explored,  carefully  disinfected,  and  loosely  packed  with 
gauze,  so  that  it  may  heal  from  the  bottom.  In  ligature  sinuses  the  ligature 
may  often  be  removed  by  fishing  with  a  crochet  needle.  In  some  cases,  e.g., 
those  caused  by  rigid  walls  or  ingrowth  of  epithelium,  exdsion  should  be 
performed.     In  tuberculous  sinuses  not  suited  for  radical  operation  Bier's 


GANGRENE.  79 

suction  pump  (p.  62)  or  the  injection  of  Beckys  bismuih  paste  may  be  tried. 
Two  preparations  of  bismuth  paste  are  used.  The  first  consists  of  bismuth 
subnitrate  33  per  cent.,  and  vaselin  67  per  cent.;  the  second  of  bismuth  sub- 
nitrate  30  per  cent.,  white  wax  5  per  cent.,  paraffin  5  per  cent.  (120^  melting 
point),  and  vaselin  60  per  cent.  The  vaselm,  wax,  and  paraffin  are  sterilized 
by  boiling,  and  the  bismuth  stirred  in  after  the  mixture  has  been  removed 
from  the  fire.  As  the  bismuth  gravitates  to  the  bottom  the  mixture  should  be 
heated  and  stirred  before  using.  Care  should  be  taken  to  exclude  water,  as  it 
destroys  the  homogeneous  quality  of  the  mixture  and  interferes  with  its 
retention  in  the  sinus.  The  syringe  should  have  a  blunt  nozzle  like  that 
of  a  urethral  syringe.  The  mouth  of  the  sinus  is  sterilized  with  alcohol,  the 
nozzle  of  the  charged  syringe  pressed  against  it,  and  the  injection  made  imtil 
the  patient  complains  of  pressure.  A  piece  of  gauze  is  then  pressed  against 
the  opening  until  the  paste  has  set;  an  ice  bag  will  hasten  this  process.  The 
first  preparation  is  used  for  diagnosis  (by  taking  a  radiograph  after  the  injec- 
tion) and  during  the  early  part  of  the  treatment,  the  second  preparation  when 
it  is  desired  to  retain  the  paste  in  the  sinus  and  when  there  is  no  danger  of 
damming  up  pus.  Healing  may  follow  a  single  injection,  or  it  may  be  neces- 
sary to  repeat  the  injection  once  a  week.  The  bismuth,  which  is  bactericidal 
and  astringent,  is  absorbed  and  replaced  by  fibrous  tissue.  If  septic  symp- 
toms supervene  the  bismuth  may  be  dissolved  with  hot  olive  oil  and  with- 
drawn with  a  Bier  suction  pump.  More  than  100  grams  of  the  33  per  cent. 
paste  should  never  be  injected,  because  of  the  danger  of  bismuth  poisoning 
(stomatitis,  black  line  on  the  gums,  diarrhea,  cyanosis,  desquamative  nephri- 
tis, emaciation),  and  in  the  vicinity  of  large  veins  the  possibility  of  embolism 
should  be  kept  in  mind.  No  matter  what  local  treatment  is  adopted  con- 
stitutional diatheses  should  receive  proper  attention. 

A  fistula  is  an  abnormal  canal  between  two  anatomical  cavities,  or 
between  an  anatomical  cavity  or  a  gland  and  the  surface  of  the  body.  Fis- 
tulae  are  the  result  of  (i)  developmental  defects,  e.g.,  branchial  and  umbilical 
fistula;  (2)  injuries,  e.g.,  aerial,  salivary,  and  vesico-vaginal  fistuke;  (3)  disease, 
e.g.,  urinary  and  anal  fistulae;  and  (4)  purposive  operations,  e.g.,  gastric  and 
biliary  fistuke.     Each  of  these  will  be  considered  in  its  appropriate  place. 


CHAPTER  DC. 
GANGRENE. 


Mortification,  or  gangrene,  is  death  of  all  the  tissues  composing  a 
portion  of  the  body.  Death  of  the  soft  parts  alone  is  called  sloughing,  or 
sphacelation,  and  the  dead  tissue  a  slough,  or  sphacelus.  Necrosis  is  the 
death  of  a  visible  portion  of  bone,  the  dead  mass  a  sequestrum;  the  term 
necrosis  is  applied  also  to  the  death  of  a  portion  of  an  internal  organ  in  which 
infection  does  not  occur. 

The  signs  of  gangrene  are  (i)  loss  of  arterial  pulsation;  (2)  loss  of  heat, 
the  temperature  of  the  part  becoming  that  of  its  surroundings;  (3)  loss  of 
sensation,  a  dead  limb  may,  however,  have  pain  or  sensation  referred  to  it, 
just  as  a  patient  whose  arm  has  been  amputated  may  feel  pain  in  his  fingers; 


8o  GANGRENE. 

(4)  loss  of  function;  (5)  loss  of  natural  color,  the  part  becoming  pale,  then 
purplish  or  greenish  in  moist  gangrene,  and  black  in  dry  gangrene. 

According  to  the  changes  which  ensue,  gangrene  is  divided  into  two  forms, 
the  dry  and  the  moist. 

Dry  gangrene  {mummification)  results  when  the  tissues  have  very  little 
fluid  in  them  at  the  time  of  death.  It  is  usually  but  not  invariably  due  to 
gradual  cutting  oflF  of  the  arterial  supply.  The  fluid  in  the  tissues  evaporates, 
the  part  becoming  dry,  hard,  wrinkled,  shriveled,  and  finally  deep  black  in 
color  (Fig.  60).  The  tissues  above  the  area  of  gangrene  are  usually  in- 
flamed.    The  odor  is  slight  unless  putrefactive  organisms  are  present. 

Moist  gangrene  occurs  when  the  tissues  are  full  of  fluid  at  the  time  of 
death .  It  usually  follows  sudden  blocking  of  the  arterial  supply  or  obstruction 
to  the  venous  return.  There  is  great  swelling,  the  formation  of  blebs,  and 
loosening  of  the  whole  epidermis.  The  color  changes  from  white  to  purple, 
and  finally  becomes  greenish  or  blackish;  there  is  a  very  oflFensive  odor,  due  to 
putrefaction,  and  the  tissues  become  soft  and  rotten  (Fig.  61),  and  frequently 
contain  gas.  Aseptic  moist  gangrene,  in  which  putrefaction  is  absent,  is  rarely 
seen  by  the  surgeon,  but  should  be  striven  for  by  strict  antisepsis,  when  it  is 
known  that  a  part,  e.g.,  a  limb  after  ligation  of  the  main  artery,  is  about  to 
fall  into  moist  gangrene. 

Gangrene  terminates  in  (i)  death  of  the  individual,  or  (2)  in  separation 
of  the  dead  part  from  the  living.  In  the  internal  organs  a  small  aseptic  area 
of  gangrene  may  be  absorbed  or  encysted.  On  the  surface,  or  in  the  internal 
organs  if  the  process  be  septic,  separation  takes  place  by  ulceration,  the  line 
between  the  living  and  dead  tissues  being  called  the  line  of  demarcatiim. 

According  to  etiology  gangrene  may  be  classified  into  three  groups:  (i) 
Indirect  gangrene,  which  is  caused  by  interference  with  the  blood  supply,  and 
in  which  the  general  condition  of  the  patient  is  usually  an  important  factor, 
includes  (a)  senile,  (b)  pre-senile,  (c)  diabetic,  (d)  post-febrile,  (e)  Raynaud's, 
(f)  and  ergot  gangrene,  (g)  ainhum,  and  (h)  gangrene  from  embolus,  (i) 
ligature  of  the  principal  artery  of  a  limb,  (j)  thrombosis  of  an  artery  the  result 
of  injury,  and  (k)  obstruction  of  the  principal  artery  and  vein;  (2)  direct 
gangrency  the  result  of  direct  trauma  to  the  tissues,  includes  gangrene  from 

(a)  severe  crushes,  (b)  prolonged  pressure,  (c)  chemical  injuries,  (d)  the  X-ray, 
(e)  frost  bites,  and  (f)  burns  and  scalds;  (3)  Mixed  or  microhic  gangrene,  in 
which  the  tissue  cells  are  directly  killed  by  bacterial  toxins  and  the  blood 
vessels  occluded  by  thrombosis,  includes  (a)  traumatic  spreading  gangrene, 

(b)  hospital  gangrene,  and  (c)  noma. 


(i)  INDIRECT  GANGRENE. 

(a)  Senile,  chronic,  or  Pott's  gangrene  is  the  result  of  obliterating 
endarteritis,  and  occurs  in  the  old,  in  whom  the  heart  is  generally  feeble  and 
the  kidneys  diseased,  thus  contributing  to  the  impairment  of  nutrition.  It 
is  most  frequent  in  the  lower  extremity,  but  occasionally  attacks  the  upper  ex- 
tremity or  even  the  nose  and  ears.  The  arteries  become  calcareous,  much 
reduced  in  calibre,  and  inelastic.  The  actual  onset  of  gangrene  is  often 
determined  by  a  slight  injury  or  inflammation,  which  induces  thrombosis  in 
the  smaller  vessels;  or  a  thrombus  may  form  in  the  artery  supplying  the  part. 

The  prodromal  symptoms  are  coldness,  numbness,  tingling  or  cramp- 


INDIRECT   GANGRENE.  8 1 

like  pains,  and  sometimes  intermittent  claudication.  The  leg  (for  such  is 
the  part  usually  affected)  is  congested,  the  color  returns  slowly  after  pressing 
the  Anger  on  the  skin,  and  the  pulse  at  the  ankle  is  very  faint.  The  gangrene 
starts  as  a  little  area  of  inflammation,  which  usually  ulcerates  and  then  dries, 
forming  a  black  slough,  which  gradually  spreads  into  the  adjacent  tissues  and 
assumes  the  characteristics  mentioned  under  dry  gangrene.  The  surround- 
ing tissues  are  inflamed,  the  redness  becoming  purple,  and  finally  black  as 
the  process  advances.  When  tissues  are  reached  in  which  the  blood  supply 
is  sufficiently  active  to  prevent  thrombosis,  a  line  of  demarcation  forms. 
Occasionally  a  spurious  line  of  demarcation  will  begin  to  form,  but  the 
gangrene  advances  beyond  it.  Severe  pain  and  marked  exhaustion  are  often 
present,  and  if  infection  occurs,  a  fetid  odor  arises  and  symptoms  of  sepsis 
super\'ene.  Death  occurs  from  exhaustion,  septic  absorption,  or  from  com- 
plicating cardiac,  pulmonary,  or  renal  disease. 

The  prophylactic  treatment  in  those  who  exhibit  prodromal  symptoms 
consists  in  avoidance  of  injury,  careful  attention  to  the  slightest  bruise  or  cut, 
cardiac  stimulants,  nitroglycerin,  massage,  and  keeping  the  feet  warm  with 
woolen  stockings  in  the  day  time  and  a  warm  water  bag  at  night.  The 
treatment  of  the  gangrene  itself  depends  upon  its  extent  and  the  general 
condition  of  the  patient.  If  but  one  or  two  toes  are  affected  and  the  general 
health  good,  one  should  wait  for  a  line  of  demarcation,  in  the  meantime 
keeping  the  foot  dry,  warm,  elevated  and  antiseptic.  In  order  to  prevent 
the  spread  of  the  gangrene,  an  anastomosis  between  the  femoral  artery  and 
vein,  to  permit  the  veins  to  carry  blood  to  the  undernourished  tissues,  has 
been  tried  in  a  few  cases,  without,  however,  encouraging  results.  When  the 
line  of  demarcation  forms,  the  casting  off  process  may  be  assisted  by  scissors, 
and  the  remaining  ulcer  treated  antiseptically,  or  a  formal  amputation  may 
be  performed.  If  the  gangrene  spreads  to  the  foot  or  higher,  if  symp- 
toms of  sepsis  arise,  or  if  the  general  condition  of  the  patient  is  such 
that  he  will  not  withstand  the  tedious  efforts  of  nature  to  rid  him  of  the 
gangrenous  part,  immediate  amputation  should  be  performed  well  above  the 
limits  of  the  disease.  Most  surgeons  advise  amputation  through  the  lower 
third  of  the  thigh,  as  at  any  lower  point  recurrence  of  the  gangrene  is  almost 
certain  to  follow.  The  tissues  should  be  bruised  as  little  as  possible,  the  tlaps 
made  of  the  same  length,  so  that  they  will  be  well  supplied  with  blood,  and 
the  Esmarch  band  omitted,  as  it  favors  the  formation  of  a  thrombus  in  the 
femoral  artery.  This  disadvantage  of  elastic  constriction  contraindicaics 
also  the  Moszkowitz  test  for  determining  in  advance  the  probable  line  of 
demarcation  (p.  624).  The  deep  femoral  artery,  which  helps  to  nourish 
the  flaps  when  amputation  is  performed  at  this  point,  rarely  becomes  athero- 
matous. 

(b)  Presenile,  or  spontaneous  gangrene,  is  the  same  as  senile  gan- 
grene, except  that  it  attacks  the  young.  It  is  more  frequent  in  Hebrews 
and  is  often  improperly  called  Raynaud's  gangrene.  The  treatment  is  that 
of  senile  gangrene.  The  cause  of  the  arteritis  (p.  184),  if  ascertainable,  also 
should  be  combated. 

(c)  Diabetic  gangrene  likewise  is,  in  most  instances,  due  to  an  obliter- 
ating endarteritis.  Sugar  in  the  blood  lessens  the  resistance  of  the  tissues  and 
acts  as  a  contributing  factor.  Some  believe  the  cause  to  be  a  peripheral 
neuritis.  The  gangrene  is  apt  to  be  inaugurated  by  a  slight  wound,  which 
liecomes  infected  an<i  necrotic,  the  process  extending  and  involving  the  whole 

6 


. 


82  ^^^^^"^  GANGRENE, 

limb;  it  may  occur  in  any  portion  of  the  body,  but  is  most  frequent  in  the 
lower  extremity,  in  the  latter  half  of  life.  It  may  be  dry  if  the  arterial  disease 
is  far  advanced,  but  is  much  more  likely  to  be  of  the  moist  variety,  and  is 
then  often  very  rapid  in  its  progress.  The  treatment  is  that  of  senile  gangrene. 
Even  after  high  amputation  the  flaps  are  apt  to  become  gangrenous,  and 
many  eases  die  in  diabetic  coma  after  operation*  Albuminuria,  the  presence 
of  acetone,  diacetic,  or  oxybutyric  acid  in  the  urine,  or  an  increase  in  the 
amount  of  ammonia  excreted,  makes  the  prognosis  particularly  unfavorable. 
The  administration  of  bicarbonate  of  soda  for  several  days  before  operation 
is  thought  to  be  beneficial.  The  diabetes  should,  of  course,  be  treated  medi- 
cally and  dietetically,  A  local  anesthetic  may  be  employed  to  lessen  the  dan- 
ger; if  a  gene  ml  anesthetic  is  used,  nitrous  oxid  and  oxygen  is  the  safest; 
ether  is  to  be  preferred  to  chloroform. 

(d)  Post-febrile  gangrene  may  occur  during  the  convalescence  from 
any  fever,  especially  those  of  long  duration  like  typhoid.  It  may  be  drj^  or 
moist,  and  is  due  to  art erio thrombosis  the  result  of  endarteritis,  or  to  Lhe 
lodging  of  an  embolus.  The  occurrence  of  gangrene  from  phlebitis  alone  is 
doubtful.     The  ireatmefU  is  that  of  senile  gangrene. 

(e)  Raynaud's,  or  S3^minetrical  gangrene,  is  a  form  of  dry  gangrene  oc- 
curring in  Raynaud's  disease,  which  is  a  vaso- motor  neurosis  most  frequently 
found  in  young,  anemic,  hysterical  females.  The  cause  probably  lies  in  the 
vaso-motor  centers.  It  usually  attacks  the  lingers  or  toes,  occasionally  other 
parts  of  the  body,  and  sometimes  follows  exposure  to  cold,  sometimes 
emotional  disturbances.  Hemoglobinuria  and  scleroderma  occur  in  some 
cases.  There  are  three  stages:  (i)  The  parts  become  white,  stiff,  and  painful 
(local  syncope),  owing  to  spasm  of  the  arterioles;  then  (2)  cold,  blue,  and 
congested  {local  asphyxia);  or  if  the  attack  terminates  in  this  stage,  red,  hot, 
and  swollen;  and  finally  in  unfavorable  cases  (5)  dr}',  black,  and  anesthetic 
(gangrene),  as  the  result  of  thromboarteritis.  The  process  usually  remains 
superlicial,  although  a  phalanx  may  become  necrotic.  The  treat  men!  is 
that  of  senile  gangrene,  and  attention  to  the  associated  neurosis.  Thyroid 
extract  is  occasionally  beneficial.  In  the  first  stage  an  Esmarch  band  may 
be  applied  above  the  affected  part  for  several  minutes;  when  it  is  removed 
blood  rushes  into  tlie  paretic  vessels. 

(f)  Ergot  gangrene  is  verj-  rare  at  the  present  time.  It  is  due  to  a 
spasmodic  contraction  of  the  arterioles,  from  eating  bread  made  with  diseased 
rye.  The  gangrene  is  dry  and  superficial,  but  may  spread  rapidly  and 
involve  an  entire  limb,  especially  if  there  is  associated  arteriosclerosis  and 
infection.  The  fingers  and  toes  are  the  parts  most  often  affected.  The 
treatment  is  that  of  senile  gangrene^  with  measures  for  promoting  the  elimina- 
tion of  the  ergot. 

(g)  Ainhum  is  a  peculiar  trophic  lesion  affecting  the  little  toe,  rarely  the 
other  toes  or  the  fingers.  It  almost  alw^ays  attacks  negroes  and  is  confined 
to  tropical  and  subtropical  countries,  A  furrow  of  callous  tissue  forms 
around  the  base  of  the  toe  and  slowly  deepens  until  the  toe  falls  off. 
Division  or  excision  of  this  furrow  may  be  of  service,  but  amputation  it  the 
usual  result. 

(h)  Gangrene  from  Embolus. — In  the  lower  extremity  an  embolus 
usually  lodges  at  the  bifurcaton  of  the  femoral  or  the  popliteal,  in  the  upper 
extremity  at  the  point  where  the  superior  profunda  is  given  off  or  at  the  bifur- 
cation of  the  brachial.     As  ligature  of  the  main  arterj-  of  a  limb  is  usually  in- 


INDIRECT   GANGRENE.  83 

sufficient  of  itself  to  cause  gangrene,  so  with  the  lodgment  of  an  embolus; 
the  coUateral  circulation  is  likely  to  be  established  unless  there  be  a  previous 
diminution  in  the  vitality  of  the  part,  e.g.,  from  cardiac  disease,  endarteritis, 
or  an  associated  general  disease.  The  symptoms  and  general  facts  of  em- 
bolism are  given  in  Chap.  xv.  Owing  to  the  sudden  cutting  off  of  blood 
pressure,  venous  blood  surges  back  into  the  limb,  which  becomes  bluish, 
swollen,  edematous,  and  finally  the  seat  of  moist  gangrene.  Dry  gangrene, 
however,  occasionally  f oUows,  particularly  if  there  has  been  previous  chronic 
malnutrition  of  the  limb  the  result  of  endarteritis.  The  treatment  is  that  of 
senile  gangrene.  We  have  in  one  instance  successfully  removed  an  embolus 
from  Ae  femoral  artery,  subsequently  suturing  the  wound  in  the  vessel, 
(i)  Gangrene  from  ligature  of  the  principal  artery  of  a  limb  seldom 
occurs  if  the  general  health  is  imimpaired  and  the  limb  soimd.  The  same 
general  facts  apply  here  as  in  gangrene  from  embolus.     Except  in  emergency 


Fig.  60. — Dry  gangrene  from  embolus.     (Jefferson  Hospital.) 

cases  it  is  a  good  plan  to  compress  the  artery  at  intervals  for  several  days 
before  ligation,  in  order  to  encourage  the  formation  of  an  efficient  collateral 
circulation.  In  many  instances  there  is  a  loss  of  one  or  two  toes,  the  result 
of  dry  gangrene.    The  treatment  is  that  of  senile  gangrene. 

(j)  Gangrene  from  thrombosis  of  an  artery  the  result  of  injury  oc- 
casionaUy  occurs,  the  symptoms  and  treatment  being  practically  identical 
with  those  of  embolic  gangrene.  Lejars  and  the  author  have  each  opened 
the  femoral  artery,  removed  a  thrombus,  and  then  sutured  the  vessel.  In 
each  case  the  thrombosis  recurred  and  the  limb  was  amputated  for  gangrene. 

(k)  Obstruction  of  the  principal  artery  and  vein,  the  result  of  ligature 
or  injury,  is  almost  sure  to  be  foUowed  by  gangrene.  This  is  the  form  of 
gangrene  which  occurs  in  strangulated  hernia  and  in  a  limb  which  is  tightly 
constricted  by  bandages.  When  a  large  artery  has  been  wounded,  the  venae 
comites  may  be  obstructed  by  the  extravasated  blood.  The  gangrene  is  of 
the  moist  variety.  The  treatment  in  cases  complicated  by  serious  crushing  of 
the  surroimding  parts  is  immediate  amputation;  in  other  cases  one  should 
wait  for  a  line  of  demarcation,  unless  the  occurrence  of  sepsis  prevents  such  a 
course. 


84 


(2)  DIRECT  GANGRENE, 

(a)  Severe  crushes  (Fig.  61),  such  as  are  produced  by  machinen'  and 
railroad  accidents,  may  directly  destroy  the  tissueSi  which  if  allowed  to 
remain,  putrefy,  the  gangrene  being  of  the  moist  variely.  The  (reatmmt 
is  immediate  amputation  (sec  amputations). 

(b)  Gangrene  from  prolonged  pressure  is  seen  principally  in  bed  sores 
and  after  the  use  of  improperly  applied  splints.  The  so-called  Irophk  gan- 
grene usually  occurs  in  parts  which  have  been  deprived  of  sensation,  as  the 
result  of  pressure  or  irritation  which  continues  simi>ly  because  the  patient 
does  not  know  of  its  existence;  vasomotor  paresis  is  a  secondary  factor. 

(Gangrene  the  result  of  pressure 
from  splints,  bandages^  or  ap- 
paratus, is  generally  the  resiiJt 
of  carelessness,  but  occasionally 
occurs  when  such  accusation 
cannot  be  made  with  justice, 
for  instance,  in  an  old  person 
with  badly  diseased  arteries^  or 
in  a  limb  in  which  the  vessels 
have  been  occluded  by  an  injur)'. 
The  gangrene  is  generally  super- 
ficial (slough),  Ijut  may  extend 
deeply  and  widely  if  the  parts 
become  septic.  The  sloughs  are 
allowed  to  separate  under  anti- 
septic dressings,  and  the  ulcer 
is  skin  grafted  to  hasten  healing 
and  prevent  contractures. 

Bed  sores  (decubitus, 
decubital  gangrene)  are  the 
result  of  prolonged  pressure  on 
tissues  whose  resistance  is  low- 
ered by  long  illnesses.  They 
are  most  apt  to  occur  over 
bony  prominences,  such  as  the  occiput,  scapula^  elbows,  sacrum, 
trochanters  (Fig.  227).  and  heels.  At  first  the  part  becomes  red,  and  in 
the  center  of  the  red  area  appears  an  excoriation  or  small  blister,  which  is 
soon  rublied  off;  the  resulting  ulcer  spreads  into  the  surrounding  tissues, 
or  a  large  slough  forms.  In  neglected  cases  or  in  cases  in  which  there  is 
impairment  of  sensation,  the  sore  rapidly  increases  in  extent  and  depth,  and 
may  involve  even  the  bone,  in  which  event  exhaustion  and  death  may  follow 
from  severe  pain  and  septic  absorption,  or,  if  recovery  ensues,  healing  may  not 
occur  for  months  or  even  years.  In  disease  or  injury  of  the  nervous  system, 
especially  fractures  of  the  spine,  bed  sores  may  appear  within  a  day  or  two 
(acute  bed  sores) .  The  (prophylactic  ireatnumt  consists  in  changing  the  position 
of  the  patient,  so  as  to  give  as  much  rest  as  possible  to  the  parts  exposed  to 
pressure,  and  the  use  of  circular  air  cushions,  or  of  a  water  or  air  bed;  these 
should  be  neither  too  full,  which  makes  them  too  hard,  nor  too  empty,  which 
allows  the  body  to  rest  on  the  bed  supports.  Parts  exposetl  to  pressure 
should  be  inspected  frequently,  and  the  circulation  maintained  by  rubbing 


Fig.  61, — Moist  gangrene  from  injur)'. 
I  Pe  n  n  sy  I  v  a  n  i  a  Hrjs  pita!-) 


IK.  (>.■.  ('ar))i)li(  ati«l  ^anj^Trnr.  A  sj)linl(T  \\<)un<l  of  ihc  finj^er  was  treated  by  the 
applic  .iiioM  nt'  a  solution  of  carbolic  aciti  of  unknown  slrenglh  for  l"ive  hours,  at  the  end  of 
whiih  time  the  linmT  \\a>  iol<l.  while,  and  nunih.     Amputation.      ( JcfTcrson  Hospital.) 


MICROBIC  GANGRENE.  85 

with  salt  and  whisky  (a  tablespoonful  to  the  pmt),  or  with  alum  and  alcohol 
(15  grains  to  the  pint),  followed  by  powdering  with  talcum,  boric  acid,  or 
stearate  of  zinc.  The  ^eet  should  be  kept  clean  and  smooth,  rough  hand- 
ling avoided,  hot  water  bags  if  used  applied  with  great  caution,  and  special 
care  taken  that  no  particles  of  food  find  their  way  beneath  the  patient.  If 
the  sheet  becomes  soiled  with  urine  or  feces,  or  wet  with  perspiration,  it 
should  be  changed  at  once.  If  there  is  incontinence  of  urine  a  permanent 
urinal  may  be  used.  When  redness  or  congestion  is  first  noticed,  the  skin 
may  be  protected  by  collodion,  soap  plaster,  or  a  thick  layer  of  some  bland 
ointment.  Irritants  of  all  sorts  should  be  avoided.  After  the  sore  has  formed 
it  should  be  cleansed  with  peroxid  of  hydrogen,  half  strength,  and  bichlorid 
of  mercury,  i  to  2000.  Sloughs  should  be  removed  and  sinuses  opened.  In 
very  large  bed  sores  the  patient  may  be  placed  in  a  continuous  bath,  as 
advised  for  bums.  Healing  may  be  stimulated  as  already  indicated  in  the 
section  on  ulcers. 

(c)  Corrosive  chemicals  directly  destroy  the  tissues.  Carbolic  acid  gan- 
grene (Fig.  62)  requires  special  notice,  because  it  may  follow  the  continuous 
application  of  even  a  weak  solution  (1-20),  especially  if  the  drug  is  confined 
by  an  impervious  covering  imder  a  tight  bandage.  As  carbolic  acid  induces 
anesthesia,  the  mischief  may  not  be  suspected  if  the  dressing  remain  undis- 
turbed. The  condition  is  most  frequently  seen  in  a  finger  or  toe,  and  is  of 
the  dry  variety.  If  an  entire  finger  or  toe  be  gangrenous,  wait  for  a  line  of 
demarcation  and  amputate.  If  the  superficial  parts  only  are  affected,  assist 
separation  of  the  slough  with  hot  fomentations  and  remove  it  with  scissors. 

(d)  X-ray  gangrene  is  considered  in  Chap,  i.,  (e)  frost  bites  and  (f) 
bums  and  scalds  in  Chap.  xi. 

(3)  MICROBIC  GANGRENE. 

(a)  Traumatic  spreading  gangrene  (malignant  edema,  emphysema- 
tous gangrene,  gangrene  foudroyante)  is  a  gangrenous  cellulitis  which 
spreads  with  frightful  rapidity,  as  the  term  foudroyante  (lightning-like)  indi- 
cates. It  may  follow  the  most  trivial  scratch,  as  well  as  an  extensive  injury, 
particularly  when  the  resistance  of  the  tissues  has  been  lowered  by  debilitat- 
ing maladies  of  a  general  nature.  The  infection  is  usually  a  mixed  one,  the 
suppuration  depending  upon  the  ordinary  pyogenic  bacteria,  especially  the 
streptococcus  pyogenes,  and  the  emphysema  upon  the  bacillus  acrogenes  cap- 
sul^tus  (an  amotile,  aerogenic,  spore  producing  anaerobe,  sometimes  found 
in  the  soil,  the  feces,  and  on  the  skin),  the  bacillus  of  malignant  edema  (a 
motile,  flagellated,  spore-producing,  aerogenic  anaerobe,  found  in  soil, 
manure,  and  dirty  water),  the  bacillus  coli  communis,  or  nonpathogenic 
saprophytes.  Clinically  the  picture  is  the  same,  and  the  form  of  infection  can 
be  determined  only  by  bacteriological  examination. 

The  symptoms  are  those  of  a  rapidly  spreading  cellulitis  (Chap,  xii), 
accompanied  by  severe  pain,  great  swelling,  and  livid  discoloration.  The 
gangrene  begins  in  the  margins  of  the  wound  and  rapidly  follows  the  extend- 
ing cellulitis.  Blisters  containing  a  thin,  dark,  irritating  fluid  appear,  and  the 
tissues  become  greenish  and  finally  black,  and  crackle  owing  to  the  presence 
of  gas.  A  line  of  demarcation  does  not  form.  The  general  symptoms  are 
those  of  profoimd  septicemia.  The  mortality  is  55  per  cent.,  death  usually 
occurring  in  from  three  to  seven  days. 


86  CONTUSIONS  AND  WOUNDS. 

The  treatment  is  immediate  amputation  high  above  the  extending  gan- 
grene. At  the  beginning,  when  the  process  is  still  localized,  free  incisions, 
with  constant  irrigation  or  immersion  in  a  warm  antiseptic  fluid,  may  pos- 
sibly check  the  infection.  The  patient  should  receive  vigorous  treatment 
to  eliminate  the  toxins  and  sustain  the  strength.  Anti-streptococdc  serum, 
although  rarely  beneficial,  may  be  administered. 

(b)  Hospital  gangrene  (wound  phagedena)  was  an  active  form  of  ulcer- 
ation or  gangrene  attacking  woimds  in  the  preantiseptic  days.  It  was  treated 
by  removing  the  sloughs  with  scissors,  then  applying  bromin,  nitric  acid,  or 
the  actual  cautery,  or  by  amputating,  and  by  stimulating  and  sustaining 
general  treatment. 

(c)  Noma  is  a  gangrenous  process  occurring  most  often  between  the 
second  and  twelfth  years.  Cancrum  oris  (gangrenous  stomtUitis)  is  noma 
of  the  mouth,  noma  pudendi  is  the  same  process  in  the  genitals;  the  condition 
occasionally  occurs  in  other  parts.  About  half  of  the  cases  follow  measles, 
but  it  may  be  seen  after  other  infectious  diseases,  and  occasionally  in  diabetes 
and  nephritis.  The  causative  organism  has  not  been  isolated,  but  is  prob- 
ably the  ordinary  pyogenic  bacteria  acting  on  tissues  whose  resistance  has 
been  reduced  by  the  preceding  disease. 

The  symptoms  are  inaugurated  by  an  abrasion,  which  becomes  inflamed 
and  finally  sloughs.  The  part  swells  and  becomes  extremely  fetid,  but  pain 
is  not  a  prominent  feature.  The  gangrene  rapidly  makes  its  way  through  the 
whole  cheek,  and  may  involve  even  the  adjacent  bone.  The  general  symp- 
toms are  those  of  sepsis  (q.v.) ;  occasionally  pyemia  arises  from  involvement 
of  the  facial  vein.  Inhalation  pneumonia  is  very  apt  to  develop.  Often 
the  temperature  falls  to  normal  or  subnormal  before  death,  which  occurs  in 
from  70  to  90  per  cent,  of  the  cases. 

The  treatment  is  removal  of  the  slough  with  scissors,  under  chloro- 
form, and  the  application  of  nitric  acid,  pure  carbolic  add,  or  the  actual 
cautery.  Ether  is  dangerous  in  the  presence  of  the  actual  cautery.  The 
mouth  is  frequently  washed  with  boric  acid  solution  or  liquor  antisepticus. 
Hot  antiseptic  fomentations  of  boric  acid  are  applied  to  the  exterior,  and 
the  patient  is  given  nourishing  liquid  food,  with  dcohol,  iron,  and  strychnin. 
If  recovery  ensues,  the  loss  of  tissue  may  be  supplied  by  a  plastic  operation. 
In  noma  pudendi,  in  addition  to  the  measures  already  mentioned,  the  patient 
may  be  placed  in  an  antiseptic  bath. 


CHAPTER  X. 
CONTUSIONS  AND  WOUNDS. 

Mechanical  injuries  of  the  tissues  are  of  two  kinds,  contusions  and 
wounds. 

A  contusion  is  an  injury,  generally  the  result  of  blunt  violence,  in  which 
some  of  the  tissues  of  a  part  are  irregularly  torn  or  ruptured,  but  the  part  as  a 
whole  remains  intact  and  its  surface  continuity  unbroken.  It  may  occur  in 
any  region,  but  here  we  refer  only  to  contusions  of  the  skin  and  subjacent 
cellular  tissue.  Contusions  of  spedal  structures  are  discussed  on  subsequent 
pages. 


CONTUSIONS  ANB  WO0NBS. 

The  symptoms  are  pain,  tenderness,  swelling,  discoloration,  impaired 
function,  and  in  severe  forms  shock.  The  swelling  is  due  partly  to  exuda- 
tion, but  principally  to  subcutaneous  bleeding  {exiravasatian}^  the  blood 
either  infiltrating  the  tissues  {ecchymosis^  or  sugillation)  or  accumulating  as 
a  localized  fluctuating  swelling  {hematoma).  An  ecchymosis  when  minute 
is  called  a  petechia,  when  very  large  a  suffusion.  The  amount  of  blood 
extravasated  varies  with  the  size  of  the  vessels  injured  and  the  construction 
of  the  part,  thus  in  lax  tissues,  e.g.,  the  scrotum  and  eyelids,  it  is  generally 
extensive,  while  in  the  scalp  it  is  usually  slight.  It  is  apt  to  be  excessive  in  the 
delicate,  in  females,  in  hemophilia  and  allied  conditions,  and  trifling  in  the 
robust.  The  blood  in  an  ecchymosis  soon  coagulates  and  is  disintegrated 
and  absorbed;  the  red  corpusiies  liberate  pigment,  which,  as  seen  through 
the  skin,  is  at  first  black,  then  blue,  changing,  as  absorption  progresses,  to 
brown,  green,  yellow,,  and  finally  disappearing.  A  hematoma  is  surrounded 
by  a  deposit  of  fibrin,  so  that  the  edges  feel  hard  and  the  center  soft;  it  may 
be  absorbed,  converted  into  a  fibroid  mass,  become  inspissated  and  calcified, 
result  in  a  cyst,  or  suppurate.  A  hematoma  differs  from  an  abscess  in 
that  it  appears  immediately  after  an  injur)'  without  signs  of  inflammation, 
and  is  at  first  soft  and  later  hard,  while  an  abscess  is  first  bard  and  later  soft. 
contusion  may  terminate  in  resolution,  inflammation,  suppuration,  slough- 
fibroid  thickening,  or  tumor  formation,  particularly  sarcoma,  and  it 
metimes,  by  establishing  a  point  of  lessened  resistance,  determines  the 
site  of  chronic  inflammatory  lesions,  notably  tuberculosis.  The  possibility 
of  a  complicating  injury  to  important  vessels  or  nerves,  to  muscles,  ten- 
dons, bones,  joints,  and  viscera  should  always  be  kept  in  mind. 

The  treatment  of  contusions  is  first  reaction  from  shock,  if  it  be  present, 
and  locally,  measures  to  check  bleeding  and  limit  swelling,  viz.,  ice,  evaporat- 
ing lotions,  compression,  elevation,  and  rest.  In  the  asthenic,  and  in  severe 
contusions  in  which  there  is  danger  of  sloughing,  heat  with  very  moderate 
compression  should  be  employed.  In  the  presence  of  an  abrasion  hot  or 
cold  antiseptic  dressings  should  be  applied.  During  the  subsiding  stage 
ichthyol,  compression,  and  massage  will  hasten  aljsorption.  Incision  is  not 
indicated  unless  a  large  vessel  has  been  injured,  or  unless  the  tension  is  so 
great  as  to  threaten  sloughing.  If  a  hematoma  persists,  it  may  be  aspirated 
and  firm  compression  applied.  The  slight  fever  which  results  from  the 
absorption  of  the  fibrin  ferment  of  the  extra vasated  blood  needs  no  special 
treatment. 

A  wound  is  a  mechanical  injury  with  a  breach  in  the  surface  continuity. 
Wounds  may  be  incised,  contused,  lacerated,  punctured,  or  gunshot;  aseptic, 
septic  (infected),  or  poisoned;  complicated  or  uncomplicated;  penetrating 
(which  enter  but  do  not  go  through  a  part)  or  perforating  (which  go  entirely 
through  a  part);  open  or  subcutaneous  or  submucous.  The  last  includes 
ruptures  of  muscles,  viscera,  etc,  and  fractures  of  bones.  An  abrasion^  or 
exeoriaiion,  is  a  rubbing  off  of  the  epidermis  without  breaking  of  the  corium, 
a  brush  bum  a  superficial  contused,  lacerated,  burned  wound  caused  by 
friction  and  the  resulting  heat,  as  when  an  individual  rapidly  slides  down  a 
steep  incline. 

The  symptoms  of  uncomplicated  wounds  are  pain,  hemorrhage,  gaping 
of  the  edges,  loss  of  function,  and  in  severe  wounds  shock. 

The  local  treatment  is  (i)  to  arrest  hemorrhage;  (2)  disinfect,  remove 
foreign  bodies  and  devitalized  tissues;  (3)  coaptate  divided  structures,  drain, 


A 


88 

and  dress;  (4)  secure  rest.  (See  Chaps,  on  hemorrhage  and  technicj  The 
conslitulional  treatment  is  (i)  that  of  shock  (p.  102),  the  presence  of  which 
forbids,  as  a  rule,  anything  more  than  hemostasis  and  the  application  of  a 
temporary  dressing;  (2)  general  hygienic  measures,  including  regulation  of  the 
diet,  the  bowels,  and  the  secretions;  (3)  attention  to  sepsis  (p.  106),  should  it 
arise,  and  to  any  general  dyscrasia  which  may  be  present. 

Incised  wounds  are  those  in  which  the  edges  are  cleanly  cut  and  sharply 
defined;  they  are  usually  produced  by  keen  instruments,  but  occasionally  by 
blunt  force,  e.g.,  the  clean-cut  wound  of  the  scalp  which  may  result  from  the 


Fig.  63 .^Superficial  and  deep 
rupted  sutures. 


intcr- 


Fic*  64* — Button  suture. 


blow  of  a  club.  Pain  is  severe  at  the  time  of  injury,  but  usually  subsides 
quickly;  bleeding  is  profuse  because  the  vessel  w^alls  have  not  been  squeezed 
together  but  cleanly  severed.  The  gaping  depends  upon  the  length  and  situa- 
tion of  the  wound,  being  wide  when  the  wound  crosses  and  slight  when  it 
parallels  muscle  fibres  or  a  line  of  ''cleavage'^  in  the  skin,  which  line  is  often 
marked  by  a  wrinkle.  The  amount  of  bruising  present  is  only  microscopic, 
so  that  with  reasonable  precautions  an  incised  wound  heals  by  first  intention. 
Treatment. — Bleeding  ceases  spontaneously  if  no  large  vessel  has  been 
injured.     If  a  large  vessel  has  been  injured »  it  may  be  caught  at  once  with 


Fig.  65,— Quilled  suture.  Fig.  66. — Tmsted  suture,     i  Esmarch  and  Kowalxig,) 

hemostatic  forceps,  compressed  with  a  sterile  sponge,  or  controlled  by  a  tour- 
niquet above  the  wound.  In  the  meantime  measures  should  be  taken  to  com- 
bat shock  if  it  be  present.  After  careful  disinfection  a  thorough  examination 
is  made  to  determine  the  amount  of  injury  done.  Divided  nerves,  tendons^ 
or  muscles  may  be  seen  in  the  wound,  sensation  and  motion  may  be  inves- 
tigated in  the  parts  beyond  the  wound.  If  any  of  these  structures  have  been 
severed,  they  are  to  be  sutured  with  chromicized  catgut. 

The  margins  of  the  wounds  may  be  coaptated  by  bandaging,  by  sterilized 
adhesive  plaster,  by  gauze  plastered  down  with  collodion,  or  by  small  metal 
dips  with  serrated  edges  (Michel  damps)  which  are  applied  and  removed 


SUTURES. 


89 


with  special  forceps,  but  these  measures  are  not  nearly  so  satisfaclory  as 
sutures.  Deep  parts  should  be  approximated  with  hurled  stiiures  of  catgut. 
When  there  is  much  tendency  towards  retraction  of  the  edges,  or  when  a 
wound  is  deep,  two  varieties  of  sutures  will  be  required,  viz.,  deep  sutures 
{retention  sutures,  or  sutures  0/  reiaxatian)  and  superpcial  sutures,  or  sutures 


y3 


Hm'  t9d0  iL 


"ffwtn^  Uffsfit 


FlC.  6y. — ^Tension  in  suturing.  FlC.  68.^ — Combined  retention  and  coapta- 

tion suture.  The  needle  is  inserted  at  i, 
brought  out  at  2,  reia^rted  at  3,  and  emerges 
at  4,  passing  through,  the  loop  at  5.  When 
drawn  light  it  holds  the  wound  edges  firmly 
together  and  prevents  inversion  of  the  skin, 
as  sho^Ti  in  the  lower  part  of  the  illustration. 

of  caaptaium  (Figr63).  Retention  sutures  are  usually  of  silkworm  gut,  but 
may  be  of  silk  or  silver  wire;  they  are  inserted  an  inch  or  more  from  the 
margins  of  the  wound,  traverse  the  entire  thickness  of  the  divided  parts,  and 
arc  then  tied,  or  are  fastened  to  lead  buttons  (Fig.  64),  which  distribute  the 
pressure.  The  quilt  suture  (Fig.  65)  and  the  tivistcd  suture  (Fig.  66)  are 
varieties  of  the  retention  suture.  Superficial  sutures  are  ii^serted  near  the 
margins  of  the  wound  for  coaptation  only;  they  should  not  be  tight  enough  to 


Fio.  69. — Continuous  or  Glover's 
suture.  (Esmardiand  Kowaizig.) 


Fig.  70. — Continuous  button-hole  suture. 
^Walsham). 


produce  wrinkJingor  to  invert  the  edges  of  the  skin  (Fig.  67).  In  the  former 
insUnre  stitch  abscess  is  fostered,  in  the  latter  healing  is  prevented.  We 
frequently  employ  a  combined  retention  and  coaptation  suture  as  sho\vn  in  Fig. 
f>8.  The  interrupted  suture  consists  of  separate  stitches,  tied  so  that 
the  knot  rests  over  one  of  the  suture  holes,  and  not  on  the  wound.  The 
continumts  &r  Glover's  stikh  (Fig.  69)  traverses  the  entire  length  of  the  wound 


i 


90 


CONTUSIONS  AND  WOUNDS. 


without  interruption.  The  hutUm-hoU  stUch  (Fig.  70)  makes  tension  at  right 
angles  to  the  wound.  When  desirable  a  continuous  suture  may  be  tied  after 
each  insertion  (Fig.  71).  The  Halsted  subctUicular  suture  (Fig.  72)  is  a  con- 
tinuous suture  inserted  into  the  deeper  layers  of  the  skin,  but  not  penetrating 
the  epidermis.  Catgut  is  the  best  material  for  this  suture,  although  silkworm 
gut  or  silver  wire  is  often  used,  the  ends  being  left  long  and  protruding  from 
each  angle  of  the  wound,  so  that  it  may  be  removed  when  heaHng  is  complete. 
The  suture  gives  a  fine  cicatrix  without  the  presence  of  suture  scars.     Theo- 


FiG.  71. — Ford's  suture:  showing  two  square  FiG.  72. — Halstead's  sub- 

knots,  a  single  knot,  and  the  method  of  €x>m-  cuticular  suture, 

pleting  a  square  knot.     (DaCosta.) 

retically  the  staphylococcus  epidermidis  albus  lies  undisturbed  in  the  super- 
ficial layers  of  the  skin  and  does  not  cause  stitch  abscesses.  Care  should  be 
taken  to  approximate  the  deeper  structures  with  catgut  or  to  apply  firm  pres- 
sure, so  that  the  dead  space  beneath  will  be  obliterated  and  the  formation  of 
a  hematoma  prevented.  Sutures  should  be  tied,  not  in  a  granny  knot  (Fig, 
73),  but  in  a  reef  knot  (Fig.  74),  or,  if  there  is  much  tension,  in  a  surgeon's 
knot  (Fig.  75).  Sutures  are  removed  in  from  seven  to  ten  days,  or  at  any 
time  if  they  cut  or  the  wound  becomes  infected.  Other  varieties  of  sutures 
are  described  in  connection  with  the  operations  for  which  they  are  used. 


Fio.  73.  -  Granny  knot. 


Fig.  74. — Reef  knot. 


Fig.  75. — Surgeon's  knot. 


Drainage  is  discussed  in  the  chapter  on  technic.  In  woimds  which  have 
been  completely  closed,  dry  sterile  gauze  should  be  applied,  and  retained  in 
place  by  a  bandage  or  binder.  In  infected  wounds  a  dressing  wet  with  bi- 
chlorid  of  mercury,  1-5000,  should  be  employed.  Rest  is  secured  by  confining 
the  patient  to  bed  in  serious  cases,  or  by  splints,  slings,  sedatives,  etc.  Refer- 
ence has  already  been  made  to  some  of  the  complications  of  woimds,  viz., 
inflammation,  suppuration,  and  gangrene,  others  are  discussed  in  Chap.  xii. 
A  contused  wound  is  one  whose  edges  are  bruised  as  the  result  of  a 
crushing  or  tearing  force.     A  lacerated  wound  is  one  whose  edges  are  irre- 


PUNCTUltED  WOUNDS.  9 1 

gular  or  torn,  and  is  produced  in  the  same  way  as  a  contused  wound.  Since 
contusion  and  laceration  are  commonly  associated,  these  woimds  will  be 
discussed  together.  The  bleeding  is  often  trivial,  owing  to  the  fact  that  the 
vessels  are  torn;  the  inner  and  middle  coats  give  way  first,  curl  up,  and  plug 
the  vessel.  In  other  cases  the  vessels  are  crushed',  and  the  walls  adhere  to 
each  other  with  sufficient  firmness  to  stop  hemorrhage.  The  edges  separate 
less  widely  than  in  an  incised  wound  of  the  same  size,  but  the  amount  of 
devitalized  tissue  is  much  greater,  and  before  repair  occurs  this  must  be 
removed  by  the  surgeon  or  by  nature.  As  nature's  method  is  usuaUy  sup- 
puration, wounds  of  this  character  are  very  apt  to  heal  by  second  intention. 
Wound  complications  and  shock  are  much  more  frequent  than  in  incised 
wounds.  Among  contused  and  lacerated  wounds  are  some  of  the  most 
dreadful  which  a  surgeon  is  called  upon  to  treat,  such  as  those  resulting  from 
the  tearing  off  of  a  scalp  or  the  avulsion  of  a  limb.  An  aseptic  contused 
and  lacerated  wound,  such  as  is  sometimes  made  by  the  surgeon,  may 
heal  by  first  intention,  especially  if  drainage  be  employed  for  a  few  days, 
^lien  infection  occurs,  and  such  is  the  result  in  practically  all  accidental 
wounds  of  this  character,  inflammation  and  suppuration  are  sure  to  occur, 
often  with  serious  constitutional  sjrmptoms  of  sepsis. 

The  treatment  in  a  severe  contused-lacerated  woimd,  in  the  absence  of 
urgent  hemorrhage,  is  directed  to  the  shock.  After  this  has  subsided,  the 
patient  should  be  anesthetized  in  order  thoroughly  to  disinfect  the  wound. 
Tissue  whose  vitality  is  questioned  should  be  removed  if  it  is  imimportant, 
in  other  cases  it  should  be  retained  imless  known  to  be  badly  infected.  All 
visible  vessels,  whether  bleeding  or  not,  are  ligated,  and  provision  made  for 
abundant  drainage.  It  is  important  to  introduce  as  few  sutures  as  possible, 
and  to  be  sure  that  they  do  not  unduly  constrict  the  tissues,  otherwise  the  sub- 
sequent swelling  will  cause  necrosis.  The  woimd  is  dressed  with  hot  anti- 
septic fomentations.  The  later  treatment  depends  upon  the  complications. 
If  there  are  symptoms  of  sepsis,  the  whole  woimd  should  be  opened,  redisin- 
fected,  and  packed  with  antiseptic  gauze.  Sloughing  demands  hot  antiseptic 
fomentations,  and  removal  of  the  slough  at  the  earliest  possible  moment. 
Secondary  hemorrhage  may  occur  at  this  period  from  the  separation  of  a 
slough  involving  the  wall  of  an  artery.  The  general  health  should  of  course 
receive  proper  attention.  The  indications  for  amputation  are  given  in  the 
section  on  amputations. 

Punctured  wounds  and  stabs  are  deep,  narrow  wounds  caused  by  any 
long,  narrow  instrument,  from  a  needle  to  a  sword.  The  outer  opening  is 
trivial  in  size,  the  danger  depending  upon  the  injury  to  the  deeper  structures 
and  the  nature  of  the  infection  which  may  have  occurred.  These  wounds  are 
especially  favorable  for  the  development  of  anaerobic  organisms,  the  most 
important  of  which  is  the  tetanus  bacillus. 

The  treatment  depends  upon  the  character  of  the  vulneraling  instru- 
ment and  the  damage  which  has  been  inflicted.  If  possible,  the  instrument 
should  be  inspected  to  ascertain  if  any  portion  of  it  has  been  broken  off  and 
left  in  the  tissues.  The  X-ray  also  may  be  used  for  this  purpose.  If  a  por- 
tion of  the  instrument  has  been  left  in  the  wound,  the  wound  should  be 
enlarged,  the  foreign  body  extracted,  disinfection  made,  and  drainage 
instituted.  PractioJly  all  punctured  wounds,  especially  those  known  to  be 
infected,  such  as  those  produced  by  dirty  nails  or  the  teeth  of  animals, 
should  be  incised,  disinfected,  and  drained.     Instruments  like  fish-hooks,  and 


92  CONTUSIONS  AND  WOUNDS. 

needles  with  barbed  ends,  which  become  entangled  in  the  tissues,  require 
incision  for  their  extraction,  or  removal  of  the  barb  after  it  has  been  pushed 
through  adjacent  skin.  After  all  punctured  wounds  the  advisability  of  a 
prophylactic  injection  of  tetanus  antitoxin  should  be  considered  (see  tetanus). 
Punctured  woimds  or  stabs  may  injure  large  vessels,  nerves,  tendons,  or  any 
of  the  viscera.    Injuries  of  these  structures  are  dealt  with  in  later  chapters. 

Gunshot  wounds  are  a  special  variety  of  contused-lacerated  wounds,  pro- 
duced by  missiles  thrown  by  explosives. 

In  civil  life  gimshot  wounds  are  usually  produced  by  small  shot,  revolver 
and  hunting  rifle  bullets,  and  blank  cartridges.  The  bullet  of  civil  life  is 
made  of  lead,  moves  at  a  low  velocity  (700  ft.  per  second),  is  readily  deformed, 
frequently  lodges  in  the  tissues,  often  carries  with  it  particles  of  clothing,  and 
practically  always  causes  an  infected  wound.  The  entrance  wound  is  slighdy 
smaller  than  the  bullet,  and  may  be  pimched  out,  ragged,  or  inverted.  The 
tract  of  the  bullet  is  surrounded  by  contused  and  devitalised  tissue,  which  is 
very  likely  to  become  necrotic  and  suppurate.  The  wound  of  exit  is  larger 
than  the  bullet,  everted,  and  more  ragged  than  the  wound  of  entrance.  The 
bullet  is  apt  to  be  deflected  by  bone  or  dense  fasda,  and  often  pushes  nerves, 
tendons,  and  blood  vessels  out  of  the  way  instead  of  cutting  them,  so  that  se- 
rious primary  hemorrhage  is  usually  absent,  although  secondary  hemorrhage 
from  sloughing  of  contused  vessels  may  occur.  Injured  bones  are  generally 
splintered  or  comminuted.  Small  sholj  if  at  close  range,  produces  extensive 
laceration  and  burning  of  the  tissues,  into  which  are  driven  the  shot,  powder- 
grains,  and  portions  of  the  clothing.  At  a  longer  range  the  shot  may  simply 
contuse  the  tissues  without  entering,  or  may  enter  and  be  scattered  in  the  soft 
parts,  usually  producing  little  damage  unless  a  delicate  structure  like  the 
eye  has  been  struck.  Wounds  by  blank  cartridges  are  contused,  lacerated, 
burned  wounds,  in  the  depths  of  which  a  wad  is  lodged,  and  are  especially 
dangerous  because  of  the  frequency  with  which  tetanus  follows. 

The  treatment  of  wounds  due  to  the  leaden  bullet  is  that  of  any  other 
infected  wound  in  which  a  foreign  body  is  lodged.  Hemorrhage,  if  present, 
should  be  checked  at  once,  and  if  necessary  the  patient  reacted  from  shock. 
For  determining  the  position  of  the  bullet,  the  X-ray  is  by  far  the  best  means. 
In  the  absence  of  the  X-ray  one  should  ascertain  the  direction  from  which  the 
bullet  was  fired  and  the  position  of  the  body  at  the  time,  examine  the 
clothing  for  the  position  of  perforations  in  relation  to  the  skin  wound  as 
well  as  to  determine  whether  portions  are  absent,  and  see  whether  or  not 
there  is  a  wound  of  exit.  After  disinfection  the  wound  may  be  explored 
for  the  bullet  and  any  foreign  body  which  has  been  carried  in  with  it. 
This  is  best  done  with  the  sterilized  finger,  enlarging  the  wound  if  necessary. 
When  deeply  lodged  out  of  reach  of  the  finger,  a  probe  may  be  employed. 
N^laton's  probe  is  one  whose  end  is  capped  with  porcelain,  on  which  a 
black  stain  is  found  after  it  has  rubbed  against  lead.  The  same  result  may 
be  had  with  the  stem  of  a  clay  pipe  or  a  probe  of  pine  wood.  Fluhrer's 
aluminum  probe  is  occasionally  employed  in  brain  woimds  because  of  its 
lightness.  It  is  allowed  to  find  its  way  along  the  tract  of  the  bullet  by  gravity. 
Various  electrical  devices  have  been  invented  for  the  detection  of  bullets, 
such  as  Beirs  induction  balance,  Girdner's  telephonic  probe,  and  Lilienthal's 
electric  probe.  Girdner's  telephonic  probe  is  made  by  fastening  a  metal  plate, 
which  is  moistened  and  placed  in  contact  with  the  patient's  body,  to  one  of  the 
wires  of  a  telephone  receiver,  and  using  the  other  one  as  a  probe;  a  click  is 


GUNSHOT  WOUNCS. 


9$ 


heard  when  the  probe  strikes  the  bullet.  LOienthars  probe  may  be  impro- 
vised as  follows:  A  piece  of  copper  wire  is  wrapped  around  a  silver  coin,  and 
another  piece  around  a  copper  coin,  the  connection  in  each  instance  being 
covered  with  sealing  wax.  One  of  the  wires  is  insulated  by  rubber  tubing 
or  adhesive  plaster^  to  within  an  eighth  of  an  inch  of  the  end.  These  two  wires 
arc  now  twisted  together  to  form  a  prol»e,  the  bright  ends  being  alwut  one- 
sixteenlh  of  an  inch  apart  and  nowhere  touching  each  other.  A  drop  of  melted 
sealing  wax  may  be  used  to  fix  them  in  pos^ition  and  at  the  same  time  act  as 
a  head  for  the  pro  lie,  the  ends  of  the  wire,  of  course,  being  exposed.  The 
coins  are  placed  in  the  surgeon *s  mouth,  one  on  each  side  of  the  tongue  and 
not  touching  each  other.  When  the  tips  of  the  wires  come  in  contact  with  the 
bullet,  a  peculiar  metallic  taste  is  appreciated  by  the  operator.  Probes,  how- 
ever, will  not  detect  pieces  of  cloth.     The  bullet  may  he  removed  with  the 


Fir..  76.— Bullet  forceps- 

itDger,  or  with  strong  forceps,  such  as  the  sequestrum  forceps  or  special  forcep 
(Fig.  76).  The  wound  is  then  disinfected  with  bichlorid  of  mercur}'  solution 
and  drained  with  gauze.  When  a  large  number  of  shot  are  scattered  in  the 
tissues,  or  when  the  exact  location  of  a  bullet  h  not  known,  less  risk  will  often 
lie  taken  in  lea\ing  the  bullet  than  in  a  long  or  mutilating  operation  to  remove 
it*  The  treatment  of  Ijullet  wounds  of  the  head,  chest,  and  abdomen  is  con- 
jered  in  the  sections  on  regional  surgery. 

Blank  rartridge  wounds  should  invariably  be  treated  by  anesthetizing  the 
Itient,  removing  the  wad  and  devitalized  tissues,  carefully  disinfecting  the 
wound,  and  draining  it  with  gauze.  The  administration  of  a  prophylactic 
dose  of  antitetanic  serum  also  is  strongly  recommended  (see  telanus). 

Gunpowder  stains  arc  best  removed  by  picking  out  each  grain  with  a  sharp 
pointed  tenotome.  Irritating  ointments  followed  by  poulticing  may  be  used 
with  the  hope  that  the  grains  will  be  discharged  by  suppuration.  The  appli- 
cation  of  equal  parts  of  ammonium  iodid  and  distilled  water  has  been 
recommended;  the  spots  gradually  turn  red,  and  the  red  marks  are  faded  by 
the  application  of  dilute  hydrochloric  acid.  FJectrolysis  and  caustics  cause 
permanent  scarring.  When  the  stains  are  quite  superficial,  the  upper  layer 
of  the  skin  may  be  shaved  off,  and  the  raw  surface  covered  with  a  Thiersch 
graft. 

In  military  surgery  about  nine-tenths  of  the  wounds  are  due  to  bul- 
lets, and  one-tenth  to  artillery  missiles.  The  modem  rifle  Imllet  (Krag- 
Jorgensen,  Lee-Metford,  Mauser,  etc.)  consists  of  a  lead  core,  hardened  by 
the  addition  of  from  2  to  5  per  cent,  of  tin  or  antimony,  and  enclosed  in  a 
dense  jacket,  usually  of  cupronkkel,  80  parts  of  the  former  to  20  of  the  latter. 
It  is  long,  conical,  and  of  reduced  caHbrc,  usually  between  6 J  and  8  mm. 
The  muzzle  velocity  is  very  great,  2000  ft.  and  upw^ard  per  second,  the  bullet 
rcTolving  on  its  own  axis  as  the  result  of  the  rilling  some  2000  times  the  first 
second:  it  is  capable  of  producing  a  mortal  wound  at  4000  meters  distance. 
The  trajectory  is  comparatively  Hat,  hence  the  accuracy  of  aim  much 
increased.     The  modem  bullet  rarely  lodges  and  is  seldom  deflected,  unless 


J 


94  CONTUSIONS  AND  WOUNDS. 

at  great  distances  (over  1200  meters).  When  the  velocity  is  diminished,  or, 
as  the  result  of  indirect  or  ricochet  shots,  the  bullet  may  be  deformed,  cany- 
ing  with  it  particles  of  clothing,  and  produce  an  infected  wound  much  like 
the  leaden  bullet;  in  other  cases  it  does  not  deform  or  carry  clothing  with  it, 
and  produces  a  sterile  wound.  The  character  of  the  wound  varies  with  the 
tissue  injured  and  the  range  or  velocity  of  the  bullet.  In  the  soft  parts 
(muscle,  fascia,  skin,  vessels,  nerves,  tendon)  direct  shots,  up  to  about  2000 
meters,  produce  a  clean  perforation.  The  wound  of  entrance  is  slightly 
smaller  than  the  bullet,  vdth  cleanly  cut  depressed  margins;  the  wound  of 
exit  is  slightly  larger  than  the  bullet  and  often  stellate  or  slit-like.  The  walls 
of  the  tract  are  apt  to  be  smooth,  with  very  little  tearing  or  laceration.  The 
bullet  is  not  deflected  by  bone  or  fascia,  and  it  severs  instead  of  pushing  aside 
nerves,  tendons,  and  blood  vessels,  thus  increasing  the  frequency  of  violent 
primary  hemorrhage  and  traumatic  aneurysm;  in  recent  wars  in  which  this 
bullet  has  been  used,  arterio-venous  aneurysm  has  been  comparatively 
frequent.  These  wounds  are  usually  sterile,  and,  if  subsequent  infection  is 
prevented,  heal  by  primary  union.  Great  destruction  of  tissue,  however, 
occurs  under  certain  conditions.  At  close  range  (under  500  meters)  there  is 
an  explosive  effect,  due  to  waves  of  force  transmitted  from  the  bullet  to  the 
surrounding  parts.  This  effect  is  still  seen  in  the  brain,  parenchymatous 
organs,  hollow  viscera  containing  fluid,  and  in  the  diaphyses  of  long  bones 
up  to  1000  meters, "  while  clean  perforations  in  the  liver,  spleen,  and  kidneys 
can  hardly  be  said  to  occur  at  any  range."  Lacerated  woimds  are  produced 
also  by  ricochet  shots.  Pain  is  usually  slight  at  the  time  of  injury,  but  later 
may  become  very  severe.  In  cancellous  bone  a  clean  perforation  is  produced, 
but  in  hard  bone  there  is  comminution,  gradually  diminishing  with  increased 
range;  '* typical  perforations  in  the  diaphyses  are  not  to  be  expected  at  any 
range. "  At  close  range  soft  bone  may  be  splintered.  At  short  range  wounc^ 
of  the  head  are  extensive  and  practically  always  fatal;  over  1600  meters,  clean 
perforations  may  occur;  and  beyond  2000  meters  the  bullet  may  lodge,  com- 
paratively little  harm  being  done  unless  an  active  portion  of  the  brain  is 
injured.  Abdominal  wounds  are  less  serious  than  with  the  old  bullet,  but 
still  give  a  very  large  mortality.  Chest  wounds  are  decidedly  less  dangerous 
than  formerly,  excepting  those  cases  which  die  at  once  from  hemorrhage. 

The  Dum-Dum  bullet  has  a  soft  nose,  that  is,  the  tip  of  the  lead  core  is  left 
uncovered.  It  has  been  used  in  battles  with  the  uncivilized,  because  when 
it  strikes,  the  lead  core  spreads  out,  or  mushrooms,  inflicting  extensive 
damage  and  stopping  the  charge  of  an  individual  no  matter  where  it  strikes. 

Wounds  by  artillery  missiles  have  no  essential  differences  from  other  large 
contused-lacerated  wounds. 

The  treatment  of  gunshot  wounds  on  the  battle-field  is  limited  to  the 
arrest  of  bleeding  by  tourniquet  or  other  form  of  compression,  and  the  pro- 
tection of  wounds  from  infection  by  the  application  of  an  antiseptic  dressing, 
a  small  package  of  which  is  carried  by  each  soldier.  At  the  field  hospital 
the  wounds  are  more  thoroughly  reviewed,  bleeding  points  ligatured,  foreign 
bodies  and  easily  accessible  bullets  removed,  and  disinfection  carried  out. 
Amputations  and  resections  are  very  much  less  frequent  than  formeriy,  owing 
to  the  character  of  the  wounds  and  to  the  protective  antiseptic  dressings. 
In  comminuted  fractures  detached  portions  of  bone  are  removed  and  proper 
splints  applied.  Gunshot  fractures  of  the  skull,  even  with  clean  perforations, 
demand  trephining  for  the  removal  of  depressed  portions  of  the  inner  table. 


POISONED   WOUNDS. 


95 


Chest  wounds  are  treated  by  an  external  occlusive  dressings  In  marked 
contrast  to  the  custom  in  civil  life  (Chap,  xxvii),  abdominal  wounds  are  dealt 
with  expectantly,  unless  there  is  some  distinct  indication  for  operation  beyond 
the  fact  of  penetration  of  the  peritoneal  cav-ily ;  this  is  due  to  the  lack  of  facili- 
ties for  abdominal  section,  and  to  the  now  clearly  established  fact  that  patients 
may  recover  without  operation,  after  even  the  viscera  have  been  perforated. 
In  addition  to  the  character  of  the  wound  recover)-  is  favored  owing  to  the  fact 
that  the  intestinal  canal  is  generally  empty  at  the  time  of  injun,%  and 
that,  when  struck,  the  intestine  violently  contracts  and  remains  in  such  a 
condition  for  a  sufficiently  long  period  for  adhesions  to  form. 

Poisoned  wounds  are  contaminated  with  some  animal  or  nonbacterial 
vegetable  poison.  Among  the  former  are  the  poisons  of  snakes  and  insects, 
among  the  latter  curare  and  other  plant  extracts,  some  of  which  are  used 
by  savages  to  poison  weapons  of  warfare. 

It  is  customary  to  consider  under  this  heading  dissection  and  post-mor- 
tem wounds,  because  the  infection  to  which  they  give  rise  was  at  one  time 
thought  to  be  due  to  a  specific  virus  generated  in  the  dead  body.  It  is  true 
that  an  abrasion  may  become  inflamed  from  the  irritation  of  injection  fluids 
or  saprophytic  organisms,  but  the  virulent  Infections  are  produced  only  by 
pathogenic  organisms^  which  are  especially  numerous  in  septic  operations 
on  the  living,  and  in  the  body  a  few  hours  after  death;  hence  the  predisposi- 
tion of  students,  surgeons,  butchers,  and  pathologists.  Wounds  acquired  in 
the  operating  room  rarely  l>etome  infected,  because  of  the  frequent  use  of 
antiseptics;  in  the  dissecting  room  wounds  are  apt  to  be  less  serious  than 
those  acquired  in  an  autopsy  on  a  body  into  which  no  antiseptic  preservative 
fluid  has  been  injectetb  The  infection  varies  in  nrulency  with  the  nature 
and  number  of  the  bacteria  and  the  resistance  of  the  individual,  being  most 
frequent  in  those  who  are  '*run  down.*^  In  the  graver  forms  there  are  wide- 
spread cellulitis,  lymphangitis,  and  profound  toxemia,  which  may  result 
fatally.  As  a  prophylactic  measure  some  anoint  the  hands  with  sterile  vase- 
tin,  but  much  more  efficient  is  the  wearing  of  rubber  gloves.  If  a  wound  is 
received,  the  base  of  the  tniger  should  be  compressed  with  a  bandage  or  with 
the  opposite  hand,  in  order  lo  encourage  bleedings  and  the  part  washed  with 
soap  and  water,  sucked  with  the  mouth,  and  disinfected  with  bichlorid  of 
mercury  solution,  i  to  500.  A  deep  and  narrow  wound  should  be  incised  in 
order  to  facilitate  disinfection.  The  part  is  dressed  with  gauze  wet  in  bi- 
chlorid solution,  and  at  the  first  indication  of  infection  incision  and  redisin- 
fection  should  be  practised. 

Insect  stings,  produced  by  hymenopiera,  such  as  bets,  wasps,  hornets, 
and  yfU(rtv  jackets,  cause  pain  and  swelling,  but  are  not  dangerous  unless 
there  be  a  great  number,  unless  infection  occurs,  or  unless  the  injuries  are  in 
the  mouth  or  throat,  in  which  event  edema  of  the  glottis  may  arise.  As  the 
poison  is  acid  it  may  be  neutralized  with  dilute  ammonia  water,  or  a  solution 
of  bicarbonate  of  soda;  if  there  be  much  swelling,  ice,  or  lead- water  and 
laudanum  may  be  applied.  The  w^asp  has  a  pointed  sling  and  may  inflict 
several  injuries;  but  that  of  a  bee  is  barbed  and  remains  in  the  tissues,  from 
which  it  should  be  extracted  with  small  forceps,  after  being  made  prominent 
by  rhe  pressure  of  a  watch  key.  The  bites  oiftks.fieas,  gnats,  bedbugs ^  and 
mosquU&es  are  never  serious,  unless  the  insect  is  soiled  with  some  form  of  in- 
fection at  the  time  of  the  bite,  or  unless  the  wound  is  subsequently  infected 
by  scratching.     Special  mention,  however,  should  be  made  of  the  r6le  played 


1 


96  CONTUSIONS  AND   WOUNDS. 

by  the  fly  in  transmitting  typhoid  fever  and  other  diseases,  and  by  the  mos- 
quito in  transmitting  malaria,  yellow  fever,  and  filariasis.  Gad-flies  deposit 
eggs  in  the  hides  of  animals,  but  rarely  in  the  human  skin.  Ticks  {ixodes) 
bury  themselves  in  the  skin,  producing  great  annoyance,  sometimes  localized 
suppuration,  rarely  a  spreading  cellulitis.  Large  spiders,  including  the 
tarantula  and  the  scorpion,  may  cause  great  swelling  and  serious  constitutional 
disturbances,  but  seldom  death.  Bites  by  the  more  poisonous  insects  are 
treated  by  placing  a  ligature  above  the  bitten  point,  incising  the  bite  and  suck- 
ing it,  washing  with  a  strong  solution  of  permanganate  of  potassium  or 
cauterizing  with  silver  nitrate,  and  then  dressing  antiseptically.  The  ligature 
is  gradually  loosened,  and  symptoms  of  prostration  watched  for  and  treated, 
if  they  appear,  by  alcohol  and  other  stimulants. 

Snake  bites  are  harmless  unless  produced  by  venomous  snakes,  the  varie- 
ties of  which,  in  the  United  States,  are  the  rattlesnake,  moccasin,  copper- 
head, and  viper;  with  these  is  usually  classed  a  poisonous  lizard,  the  Gila 
monster.  The  venom  is  injected  from  the  poison  sac  on  each  side  of  the 
jaw,  through  the  hollow  fangs  of  the  teeth,  into  the  wound;  it  is  a  sterile, 
viscid,  yellowish,  acid  fluid,  with  a  peculiar  odor,  and  contains  several 
proteids,  a  peptone,  and  a  globulin,  all  of  which  are  toxic. 

The  character  of  the  S3rinptoms  is  the  same  with  all  varieties  of  venomous 
snakes,  but  difTers  in  degree  with  the  amount  and  virulence  of  the  venom  and 
the  resistance  of  the  individual.  The  bitten  part  is  the  seat  of  great  pain  and 
begins  to  swell  immediately.  As  the  swelling  extends  ecchymotic  spots,  due 
to  extra vasated  blood,  are  noticed,  and  symptoms  of  severe  prostration  ap- 
pear, sometimes  with  vertigo,  convulsions,  delirium,  or  other  nervous  symp- 
toms. Snake  venom  has  a  hemolytic  action  on  blood  cells,  and  dissolves  also 
the  endothelial  cells  of  the  capillaries,  thus  accounting  for  the  ecchymotic 
spots.  Death  may  occur  very  rapidly  if  the  poison  enters  a  vein,  or  it  may 
be  postponed  a  number  of  hours  or  even  days,  the  parts  being  the  seat  of  a 
spreading  cellulitis.     The  mortality  is  about  25  per  cent. 

The  treatment  is  to  constrict  the  limb  tightly  by  a  ligature  above  the  bite, 
which  should  be  incised,  and  as  much  as  possible  of  the  poison  removed  by 
cupping,  or  sucking  and  scjueczing.  The  wound  should  then  be  cauterized, 
preferably  with  the  actual  cautery,  and  dressed  with  a  saturated  solution  of 
I)ermanganate  of  potassium.  Constitutional  symptoms  are  met  by  stimula- 
tion with  ammonia,  alcohol,  str>'chnin,  and  digitalis.  When  the  symptoms 
subside,  the  ligature  is  cautiously  loosened,  and  if  they  reappear,  again  tight- 
ened and  further  stimulation  administered.  In  some  cases  amputation  has 
been  f)erf()rmed.  Calmette  believes  that  the  toxins  of  all  snake  venom  are 
the  same,  and  that  they  can  be  neutralized  by  the  same  antitoxin.  This 
antitoxin  (antivcnenc)  is  made  by  injecting  into  a  horse  increasing  doses  of  the 
mixed  venom  of  the  cobra,  80  per  cent.,  and  viper,  20  per  cent.  Other 
observers  believe  each  species  of  snake  has  a  specific  venom,  and  that  an 
antitoxin  would  have  to  be  prepared  for  each.  It  seems  certain,  however, 
that  Calmette's  antivcnenc  is  effective  not  only  in  cobra  bites,  but  in  any 
form  of  snake  bile,  so  that  it  should  be  used  whenever  possible.  From  10  to 
40  cc.  are  injected  into  the  region  of  the  bite,  or  if  much  time  has  elapsed, 
directly  into  a  vein.  Calmelte  advises  injections,  into  and  aroimd  the  seat  of 
inoculation,  also  of  from  20  to  30  cc.  of  a  fresh  i  per  cent,  solution  of  chlorid 
of  gold  and  calcium,  and,  after  removal  of  the  ligature,  thorough  irrigation  of 
the  part  with  a  solution  of  sodium  hypochlorite  or  calcium  chlorid. 


BURNS  AND   SCALDS.  97 


CHAPTER  XI. 

CHEMICAL,  THERMAL,  AND  ELECTRICAL  INJURIES. 

BURNS  AND  SCALDS. 

Bums  and  scalds  are  injuries  due  to  heat ,  scalds  to  fluids  or  gases,  bums 
to  flames  or  heated  solid  bodies.  Injuries  due  to  chemical  substances,  such 
as  strong  acids  and  alkalies,  also  are  called  bums.  Burns  are  divided  into 
three  degrees:  (i)  Hyperemia,  or  redness;  (2)  blistering;  (3)  charring,  or  car- 
bonization. Dupuytren's  classification  is  as  follows:  (i)  Erythema;  (2)  blis- 
tering; (3)  partial  destruction  of  the  skin;  (4)  destruction  of  the  entire  skin; 
(5)  destruction  of  the  subcutaneous  tissues  and  part  of  the  muscles;  (6)  car- 
bonization of  the  entire  part. 

The  surgeon  should  bear  in  mind  the  danger  of  these  injuries  when  using 
hot-water  bags,  hot  douches,  and  the  hot-air  apparatus,  and  the  danger  of 
using  ether,  ethyl  chlorid,  or  collodion  near  a  naked  flame  or  the  actual 
cautery. 

The  sjrmptoms  of  bums  and  scalds  may  be  studied  under  three  headings: 
(i)  Those  the  direct  result  of  the  injury;  (2)  those  occurring  during  the  stage 
of  inflammation  and  sloughing;  (3)  those  occurring  during  the  stage  of  repair. 

1.  The  symptoms  of  the  first  stage  are  intense  pain,  and  shock  varying 
with  the  extent  and  severity  of  the  bum. 

2.  If  the  patient  survives  the  shock,  fever  develops,  due  at  first  to  the 
absorption  of  toxins,  the  result  of  destruction  of  the  tissues,  and  later  to  the 
suppuration  which  follows.  There  is  a  marked  leukocytosis  and  polycy- 
themia, and  an  increase  in  the  coagulability  of  the  blood,  which  sometimes 
leads  to  extensive  thrombosis  and  subsequently  to  embolism.  The  internal 
organs  in  a  severe  bum  become  congested,  and  actual  inflammation  of  some 
of  the  viscera  may  ensue.  Congestion  of  the  brain  or  lungs  is  not  infrequent, 
but  the  viscera  most  apt  to  be  affected  are  the  kidneys,  ginng  rise  to  albumin- 
uria and  decreased  quantity  or  even  suppression  of  urine,  and  the  gastroin- 
testinal canal,  causing  vomiting  and  diarrhea,  and  later  ulceration,  especially 
in  the  duodenum  (Curling* s  ulcer).  Duodenal  ulcer  is  supposed  to  be  due  to 
the  irritation  of  toxin  laden  bile;  it  has  the  same  symptoms  and  treatment  as 
that  due  to  other  causes.  Delirium  or  convulsions  may  occur  from  congestion 
of  the  brain.  During  this  stage,  which  lasts  from  two  to  five  weeks  or  longer, 
there  is  active  suppuration  with  the  separation  of  sloughs. 

3.  During  the  stage  of  repair  there  may  be  no  constitutional  symptoms 
except,  perhaps,  weakness  or  anemia,  unless  the  wounds  are  very  large  and 
freely  suppurating,  when  there  will  be  some  fever  (hectic),  and  possibly  amy- 
loid disease  if  the  suppuration  persists  for  a  long  time. 

The  prognosis  depends  upon  the  age  and  general  condition  of  the  patient, 
and  the  extent,  severity,  and  location  of  the  bum.  In  the  young,  the  old, 
or  the  debilitated,  limited  bums  of  the  first  degree  may  prove  fatal.  If  a 
bum  of  the  first  degree  extends  over  more  than  two-thirds  of  the  surface  of 


98 


CHEMICAL,   THERBIAL,   AND   ELECTRICAL  INJURIES* 


the  body,  death  is  likely  lo  follow,  the  same  result  is  probable  in  a  bum  of  the 
second  or  third  degree  involving  one-third  of  the  surface  of  the  body.  Bums 
of  the  thorax  or  abdomen  are  much  more  serious  than  those  of  the  limbs. 
Death  may  be  due  to  asphyxia  from  smoke  at  the  time  of  the  accident,  to 
shock  immediately  after  the  accident,  and  later  to  sepsis,  exhaustion,  or 
internal  complications.  Bums  of  the  third  degree  are  always  followed  by 
scars,  w^hirh,  when  extensive,  tend  strongly  to  contract,  causing  flexures  of 
joints^  ectropion,  ankylosis  of  the  jaw^  etc. 

Treatment. ^A  person  whose  clothing  is  on  fire  should  be  thro'wii  on  the 
floor  and  rolled  in  a  rug,  overcoat*  shawl,  or  blanket,  in  order  to  smother  the 
flame;  water  should  not  be  used,  as  the  steam  will  produce  scaJding,  In 
trivial  burns  of  the  first  degree  the  principal  indication  is  to  relieve  the  pain ; 
this  is  best  done  by  the  use  of  cold  lead- water  and  laudanum,  the  application 
of  a  bandage  to  exclude  the  air,  and  by  elevation.  Blisters  may  be  punctured 
with  an  aseptic  needle,  allowing  the  epidermis  to  remain,  then  dusted  with 
thymol  iodid,  and  dressed  with  a  2  per  cent,  carbolic  solution,  which  is  not 
only  antiseptic  but  also  analgesic.  Picric  acid  may  be  used  in  limited  bums 
of  the  first  and  second  degree,  but  not  in  extensive  or  deep  bums,  as  poisoning 
may  result.  Lint  or  gauze  is  soaked  in  a  i  per  cent,  watery  solution  of  picric 
acid  and  applied  to  the  burned  part,  and  over  this  sterilized  cotton  or  gauze 
is  bandaged.     The  dressing  is  left  in  place  several  days* 

In  severe  burns  the  first  indication  is  to  relieve  pain  by  the  hypodermatic 
injection  of  morphin  and  to  react  from  shock;  no  attempt  should  be  made  to 
dress  the  burn  until  reaction  has  been  obtained.  The  clothing  should  be  cut, 
and,  if  it  sticks,  should  be  soaked  In  sweet  oil  or  salt  solution  and  allowed  to 
drop  ofT.  The  dressing  of  one  part  should  be  completed  before  exposing 
an  additional  area.  In  extensive  burns  the  patient  may  be  kept  in  a 
warm  bath  (100*=  to  105°).  If  there  is  much  charred  tissue,  the  patient  may 
be  anesthetized  and  the  devitalized  parts  cut  away.  One  of  the  best  w^ays  of 
dressing  a  large  burn  is  by  strips  of  sterilized  rubber  tissue  about  an  inch 
broad,  allowing  a  fourth  inch  between  each  strip,  and  placing  over  this  sterile 
gauze  which  has  been  wrung  out  in  warm, sterile,  salt  solution.  The  gauze  is. 
changed  as  often  as  it  becomes  saturated  with  discharges,  leaving  the  rubbei 
tissue  in  place,  thus  eliminating  much  of  the  pain  and  distress  which  is  alw-ays^ 
an  unpleasant  feature  in  the  dressing  of  these  cases.  Carron  oil  (equal  pa 
of  linseed  oil  and  b me  water) »  to  which  oil  of  eucalyptus  in  the  proportion 
of  I  to  10  has  been  added  for  its  antiseptic  properties,  makes  a  good  applica- 
tion. Menthol  i,  olive  oil  9,  and  lime-water  10,  has  been  recommended  as  an 
antiseptic  and  analgesic;  a  saturated  solution  of  bicarbonate  of  soda  or  of 
boric  acid  also  may  be  employed.  Ointments  have  the  same  objections  here 
as  in  the  treatment  of  ulcers.  Recently  satisfactory  results  have  Iieen  obtained 
by  exposing  burns  to  the  air  and  simply  dusting  them  with  stearatc  of  zinc, 
removing  scabs  when  pus  collects  beneath  them.  Because  of  their  poisonous 
properties,  dressings  containing  acetanilid,  anti pyrin,  carbolic  acid,  carbonate 
qL  Icadt  cocain,  creolin,  iodoform,  phenol  sodique,  or  lead- water  and  lauda- 
num, should  not  be  used  on  extensive  bums.  If  a  liml)  has  been  completely 
carbonized,  amputation  should  be  performed  as  soon  as  shock  has  subsided. 

The  canst itutimal  treatment  is  6rst  that  for  shock,  and  later,  concentrated 
liquid  diet  and  plenty  of  water,  together  with  suitable  stimulation,  if  it  is 
required.  Complications  should  be  met  according  to  general  indications. 
During  the  stage  of  healing  it  may  become  necessary  to  use  stimulating  appli- 


FROST   BITE.  99 

cations  or  to  remove  prominent  granulations.  In  an  extensive  granulating 
wound  skin  grafting  not  only  hastens  cicatrization,  but  limits  subsequent 
contraction.  Splints  should  always  be  used  in  bums  about  joints,  to  lessen 
the  tendency  towards  contraction. 

In  hums  by  acids,  a  weak  alkali,  such  as  lime-water,  and  in  bums  by 
alkalies,  a  weak  acid,  such  as  a  dilute  solution  of  acetic  acid,  should  be  ap- 
plied. In  carbolic  acid  bums  alcohol,  if  applied  at  once,  will  act  as  a  neu- 
tralizing agent.  Yellow  phosphorus  sticks  to  and  burrows  into  the  skin, 
and  bursts  into  flame  on  being  exposed  to  the  air;  the  part  should  be  put 
under  cold  water,  to  which  should  be  added  a  solution  of  chlorid  of  iron, 
or  liquor  sodae  chlorinatae.  Bums  of  the  mouth,  pharynx,  glottis,  and  esophagus 
are  usually  produced  by  chemicals,  although  the  accident  may  occur  from 
boiling  fluid  or  superheated  steam.  These  cases  are  treated  by  having  the 
patient  suck  bits  of  ice,  by  the  application  of  ice  extemally,  and  in  a  bum 
of  the  mouth  by  antiseptic  washes.  One  should  watch  for  edema  of  the 
glottis,  and  treat  it  according  to  the  directions  on  p.  399.  In  bums  of  the 
esophagus  the  chemical  should  be  neutralized,  and  the  patient  fed  on  albumin 
water  or  by  rectum;  the  danger  of  passing  a  stomach  tube  should  be  recalled. 
In  two  or  three  weeks  bougies  should  be  cautiously  passed,  in  order  to  antici- 
pate the  formation  of  a  stricture. 

X-ray  bums  (see  chapter  I). 


THE  EFFECTS  OF  COLD. 

The  local  effects  of  cold,  or  frost  bite,  like  bums,  may  be  divided  into 
three  degrees:  (i)  Erythema,  or  redness;  (2)  blistering,  or  bleb  formation;  (3) 
sloughing,  or  gangrene. 

The  sjrmptoms  of  freezing  are  first  coldness,  then  numbness,  and  finally 
anesthesia;  owing  to  the  contraction  of  the  vessels  the  parts  become  deathly 
pale.  In  severe  cases  thrombosis  and  disorganization  of  the  blood  occur. 
When  the  parts  are  warmed  there  is  a  buming,  itching,  or  tingling  pain,  and 
redness  and  swelling  due  to  the  overfilling  of  the  paretic  blood  vessels.  In 
frost  bites  of  the  first  degree  this  inflammation  disappears  in  the  course  of  a 
few  days,  but  may  recur  on  slight  exposure  to  heat  or  cold  {chilblain,  or 
pernio),  and  is  most  frequent  on  the  toes,  ears,  fingers,  and  nose.  Chilblains 
itch  and  bum  and  sometimes  ulcerate.  In  frost  bites  of  the  second  degree 
reaction  is  attended  with  greater  swelling,  a  livid  color,  and  the  formation  of 
blisters,  or  blebs.  In  the  majority  of  these  cases  frost  bite  of  the  third  de- 
gree, or  gangrene,  occurs.  Gangrene  is  due  to  the  direct  effect  of  cold  or  to 
the  reactionary  inflammation.  In  the  former  instance  thrombosis  occurs 
in  the  vessels  and  the  part  becomes  pale,  anesthetic,  and  brittle;  fingers  and 
toes  may  break  like  glass.  Reaction  does  not  occur  because  the  blood  cannot 
again  enter  the  part,  which  now  undergoes  the  changes  incident  to  dry  gan- 
grene. In  the  latter  instance  severe  inflammation  follows,  and  the  gangrene 
is  due  principally  to  the  obliteration  of  the  vessels  by  the  pressure  of  the  in- 
flammatory exudate;  owing  to  the  large  amount  of  fluid  in  the  tissues,  the 
gangrene  is  of  the  moist  variety. 

The  treatment  oi frost  bite  is  the  gradual  restoration  of  circulation,  so  that 
the  vessels  may  have  a  chance  to  reco\*er  their  tone  before  a  large  amount 
of  blood  enters  the  part.     The  frosted  area  should  first  be  rubbed  with  ice 


lOO  CHEMICAL,   THERMAL,  AND   ELECTRICAL  INJURIES. 

water  or  snow;  as  the  circulation  is  restored,  it  may  l)e  very  gradually  wanned 
by  omitting  the  snow  and  using  the  hand  only.  The  temperature  of  the 
room  should  be  slowly  elevated,  and  the  part  wrapped  in  cotton.  When 
marked  inflammatory  reaction  follows,  free  incisions  should  be  made  to 
relieve  tension.  If  gangrene  occurs,  w^ait  for  the  line  of  demarcation  and 
amputate,  unless  it  be  moist,  septic,  and  rapidly  progressing,  when  imme- 
diate amputaticm  becomes  mandatory. 

Chilblains  are  treated  by  attention  to  the  general  health,  which  is  often 
below  par,  and  by  warm  coverings  at  the  first  approach  of  cold  weather. 
The  part  may  be  rubbed  with  alcohol  and  water,  belladonna  liniment,  whisky 
and  salt,  soap  liniment,  or  menthol  and  olive  oil  i  to  lo;  or  tincture  of  iodin, 
ichthyol,  contractile  collodion,  adhesive  plaster,  or  diachylon  may  be  applied. 
Massage  is  often  useful.  When  ulcers  form  they  should  be  treated  anti- 
septically. 

The  constitutional  effects  of  cold  are  drowsiness,  slowing  of  the  pulse 
and  respirations,  and  dilatation  of  the  pupils.  .  The  blood  is  driven  from  the 
surface  to  the  internal  organs,  which  become  markedly  congested.  Death 
is  probably  due  to  cerebral  anemia  from  failure  of  the  circulation.  The 
treatment  of  freezing  of  the  whole  body  is  brisk  rubbings  with  cold  cloths,  and 
afterwards  with  the  warm  hands.  The  patient  should  first  be  taken  into  a 
cool  room,  the  temperature  of  which  is  very  gradually  elevated,  as  sudden 
reaction  may  result  in  embolism,  or  in  rupture  of  blood  vessels,  especially 
those  of  the  brain.  Artificial  respiration  may  be  needed,  and  stimulation 
should  be  given  hypodermatically,  or  by  mouth  as  soon  as  the  patient  is  able 
to  swallow.     The  extremities  should  be  elevated  in  order  to  limit  gangrene. 


INJURIES  BY  ELECTRICITY. 

Lightning  stroke  is  produced  by  an  aerial  current  of  electricity.  A 
person  may  be  struck  directly  by  the  primary  current,  or  injured  by  an  induced 
current  when  the  lightning  strikes  some  neighboring  object.  The  accident 
is  most  frecjuent  in  the  open  country,  where  there  are  few  buildings,  trees,  etc., 
to  divide  the  current.  The  mortality  is  about  50  per  cent.  Lightning  either 
kills  directly  or  causes  severe  l)urns  or  extensive  lacerations,  sometimes  tear- 
ing a  limb  (ompletely  from  the  body.  Lightning  marks  are  brownish-red, 
zigzag,  or  arborescent  lines,  radiating  from  the  point  struck  along  the  course 
of  blood  vessels,  and  are  due  to  the  decomposition  of  the  red  corpuscles, 
with  the  subsefjucnt  transudation  of  the  coloring  matter  through  the  vessel 
walls. 

The  symptoms  in  a  case  not  immediately  fatal  are  those  of  profound  shock 
and  compression  of  the  brain.  Various  nervous  disturbances,  such  as  paral- 
ysis, anesthesia,  blindness,  insanity,  hysteria,  etc.,  may  be  seen.  Excepting 
})lindness  and  lesions  due  to  hemorrhage  into  the  brain  or  spinal  cord,  these 
phenomena  usually  disappear  after  a  greater  or  lesser  interval. 

The  treatment  is  symptomatic;  first  of  all.it  is  necessary  to  react  from 
shock.  It  is  important  to  rememl)er  here,  as  in  opium  poisoning  and  drown- 
ing, that  a  j)ers()n  may  be  apparently  dead,  and  yet  be  revived  by  prolonged 
artificial  respiration.  When  reaction  has  been  obtained,  the  patient  should 
be  carefully  examined  for  fractures,  lacerations,  burns,  etc.  Bums  are  often 
slow  in  healing,  probably  owing  to  the  effect  of  the  electricity  on  the  trophic 


SHOCK.  lOI 

nerves;  the  treatment  is  that  of  burns  from  other  causes.  The  effects  of 
artificial  currents  are  similar  to  those  of  lightning  and  are  treated  in  the  same 
way.  When  a  person  is  ensnared  with  a  live  wire,  the  current  should  be 
turned  off;  if  this  is  not  possible,  the  wire  may  be  removed  with  thick  rubber 
gloves,  mackintosh,  thick  and  dry  woolen  cloth,  or  dry  wood,  or  occasionally 
the  current  may  be  short  circuited  by  dropping  some  object,  such  as  an  iron 
bar,  on  the  two  wires. 


CHAPTER  XII. 


GENERAL   CONDITIONS   AND   SPECIAL   INFECTIONS 
FOLLOWING  WOUNDS, 

SHOCK. 

Shock  is  a  general  prostration  of  the  vital  powers  the  result  of  injury  or 
emotion.  Loccd  shock  is  numbness  or  anesthesia  of  a  part  which  has  been 
injured,  and  is  seen  most  frequently  in  gunshot  wounds.  Collapse  is  the  final 
stage  of  shock,  or  sudden  profound  shock  coming  on  acutely.  Exhaustion 
presents  similar  symptoms  to  shock,  but  comes  on  gradually,  often  following 
some  exhaustive  disease,  such  as  carcinoma  or  tuberculosis. 

The  causes  of  shock  are  afferent  impulses  transmitted  along  the  sensory 
or  sympathetic  nerves,  or  in  emotional  shock  along  the  neves  of  special  sense, 
to  the  vital  centers,  especially  the  vaso-motor  centers,  which  are  thus  weakened 
or  exhausted  (shock),  or  paralyzed  (collapse) ;  consequently  there  are  marked 
lowering  of  the  blood  pressure,  weakening  of  the  propelling  force  of  the  heart 
and  arteries,  collection  of  the  blood  in  the  veins,  especially  the  large  abdom- 
inal veins,  and  anemia  of  the  brain,  lungs,  and  superficial  parts  of  the  body. 

The  sjrmptoms  vary  in  intensity  according  to  the  severity  and  situation 
of  the  injury,  the  psychical  condition,  age,  sex  (women  are  more  susceptible), 
and  previous  general  condition  of  the  patient,  and  according  to  various  other 
factors,  such  as  hemorrhage,  exposure  to  cold,  etc.  In  torpid  or  apathetic 
shock  there  are  marked  pallor  of  the  skin  and  mucous  membranes,  cold 
clammy  perspiration,  elongated,  pinched,  expressionless  face,  half  open 
mouth,  half  closed  shrunken  eyes,  lusterless  cornea,  dilated  pupils  reacting 
slowly  to  light,  weak  and  rapid  pulse,  accelerated  (occasionally  slow)  shallow 
and  irregular  respirations,  mental  apathy,  subnormal  temperature,  impaired 
sensation  of  the  skin,  retention  of  urine,  and  sometimes  incontinence  of  feces. 
If  the  shock  is  due  to  or  aggravated  by  hemorrhage,  there  may  be  great  rest- 
lessness and  other  symptoms  commonly  associated  with  the  loss  of  a  large 
quantity  of  blood.  .During  the  period  of  reaction  there  may  be  vomiting, 
great  restlessness  or  excitement,  and  even  delirium  {erethistic  shock),  particu- 
larly in  conditions  like  extensive  burns,  in  which  a  toxic  factor  is  added. 
Shock  which  does  not  appear  for  several  hours  {delayed  or  secondary  shock) 
is  most  frequently  seen  after  railway  accidents,  alcoholic  intoxication,  and 
severe  emotional  storms.  After  operation  delayed  shock  is  almost  always  due 
to  hemorrhage. 

The  symptoms  of  hemorrhage  are  practically  identic  al   with  those  of 


I02  GENERAL  CONDITIONS  AND   SPECIAL  INFECTIONS. 

shock,  in  fact  the  condition  after  hemorrhage  is  shock  due  to  loss  of  blood.  In 
concealed  hemorrhage  one  does  not  see  the  blood,  and  the  question  arises 
whether  the  symptoms  are  due  to  shock  alone,  or  to  shock  the  result  of  hemor- 
rhage. In  hemorrhage  there  is  apt  to  be  greater  restlessness,  and  instead  of 
torpidity,  great  anxiety  and  foreboding  on  the  part  of  the  patient,  who  com- 
plains of  loss  of  sight,  asks  for  water,  and  gasps  for  air;  the  skin  and  mucous 
membranes  are  excessively  pale,  and  the  p'ulse,  although  very  frequent,  is 
likely  to  be  larger  and  more  compressible  than  that  of  shock.  The  hemo- 
globin is  greatly  lessened  in  hemorrhage  (but  not  for  a  number  of  hours)  and 
unreduced  in  shock.  The  most  reliable  signs  are  those  of  fluid  in  a  cavity, 
i.e.,  in  the  chest  or  abdomen.  In  case  of  doubt,  especially  after  an  abdom- 
inal operation  or  injury,  an  exploratory  incision  should  be  made. 

The  prophylaxis  of  shock  is  possible  in  surgical  operations.  In  addition 
to  reassuring  a  nervous  patient,  the  physical  condition  may  be  improved, 
and  such  examinations  made  as  are  described  under  technic.  With  the 
patient  in  poor  condition  shock  may  be  anticipated  by  the  application  of 
warm  water  bags,  the  hypodermatic  injection  of  strychnin  and  atropin,  the 
careful  covering  of  the  patient  during  operation,  the  avoidance  of  excessive 
purgation  and  prolonged  abstention  from  food  before  operation,  and  by 
celerity,  gentleness,  and  careful  hemostasis  during  the  operation.  The  part 
to  be  operated  upon  may  be  placed  in  a  slightly  higher  position  than  the  rest 
of  the  body  in  order  to  lessen  hemorrhage.  The  use  of  a  local  anesthetic 
for  the  prevention  of  shock  in  extensive  operations  is  of  doubtful  value,  as 
the  fright  of  the  patient,  and  the  increased  time  necessary  for  the  performance 
of  the  operation,  owing  to  the  struggles  of  the  patient,  more  than  counter- 
balance any  depressing  influence  of  a  general  anesthetic.  In  head  operations 
Crile  applies  a  temporary  clamp  to  the  carotid,  places  the  patient  in  a  pneu- 
matic rubber  suit,  and  elevates  the  upper  part  of  the  body  45®.  In  operations 
on  the  dangerous  area  of  the  lar}'nx,  in  which  sudden  collapse  may  follow 
from  reflex  inhibition  of  the  heart  and  respiration  as  the  result  of  stimulation 
of  the  superior  laryngeal  nerve,  he  advises  a  preliminary  dose  of  atropin,  or 
the  application  of  cocain  to  the  nerve  endings  in  the  larynx;  in  the  extremities 
he  blocks  the  nerve  trunks  by  injecting  into  them  cocain. 

The  treatment  of  shock  consists  in  raising  the  feet  and  lowering  the  head; 
the  application  of  carefully  protected  warm  water  bags;  the  hypodermatic  in- 
jection of  ether  i  3,  brandy  i  3,  strychnin  gr.  .f^,  digitalin  gr.  -j^,  atropin  gr. 
^ },  ^,  or  camphorated  oil  i  3 ;  inhalations  of  ammonia,  alcohol,  or  oxygen;  the 
rectal  injection  (enteroclysis)  of  hot  coffee  i  pint,  whisky  i  ounce,  or  turpen- 
tine i  ounce  with  salt  solution;  and  autotransfusion,  hypodermocylsis,  or 
intravenous  infusion  (p.  182)  of  adrenalin  chiorid  in  the  strength  of  from  i  to 
50,000  to  I  to  100,000  in  salt  solution.  As  a  rule  from  10  minims  to  a  half 
dram  of  a  i  to  looo  solution  is  dropped  into  two  quarts  of  salt  solution, 
which  is  slowly  injected  into  a  vein.  Autotransfusion  is  the  application  oi 
bandages  to  the  extremities  for  the  purpose  of  driving  the  blood  to  the  vital 
centers.  Crile  uses  the  same  principle  by  the  application  of  a  rubber  suit, 
which  is  blown  up  with  a  bicylc  pump.  Mustard  plasters  may  be  put  over 
the  heart  and  on  the  extremities,  and  stretching  the  sphincter  ani  has  been 
recommended.  If  the  respirations  fail  despite  stimulation,  artificial  respi- 
ration should  be  performed.  Transfusion  of  blood  (p.  182)  and  massage  of 
the  heart  (p.  1  75)  have  been  employed  in  a  few  cases.  Operations  are  not,  as 
a  rule,  performed  during  the  presence  of  shock,  unless  it  is  known  that  the 


SEPSIS.  103 

shock  is  being  increased  by  the  condition  for  which  the  operation  would  be 
performed,  e.g.,  hemorrhage,  perforation  of  a  hollow  viscus,  and  some  cases 
of  crushed  extremities. 

AUTOINTOXICATION. 

Autointoxication  usually  means  that  form  of  toxemia  resulting  from 
the  absorption  of  putrefying  intestinal  contents,  but  includes  also  many 
other  varieties  of  intoxication,  such  as  those  due  to  deficient  elimination 
from  the  kidneys  and  other  excretory  organs,  to  the  absorption  of  disinte- 
grating portions  of  the  body  when  sterile  (aseptic  wound  fever),  and  to 
interference  with  glands  like  the  thyroid.  Most  of  the  autointoxications  are 
strictly  medical,  but  are  of  great  interest  to  the  surgeon  because  of  the  fre- 
quency with  which  they  complicate  surgical  conditions.  In  order  to  pre- 
vent autointoxication,  the  excretory  organs  should  receive  proper  investiga- 
tion and  care. 

AcetonurlEi  acetonemia,  aciduria,  or  acid  intoxication  is  a  condition  in 
which  acetone  and  diacetic  acid,  one  or  both,  are  present  in  the  urine;  it  oc- 
curs in  a  number  of  different  diseases  and  sometimes  follows  an  operation  or 
injury.  The  symptoms  are  drowsiness  or  restlessness,  followed  by  stupor  or 
delirium.  The  pulse  increases  in  frequency  and  there  may  be  fever.  Nau- 
sea and  vomiting  often  occur,  and  the  breath  has  a  sweetish  or  chloroform- 
like odor.  It  is  supposed  to  be  due  to  some  interference  with  body  metabo- 
lism, and  is  fatal  in  a  certain  proportion  of  cases.  The  treatment  consists 
in  the  use  of  measures  to  increase  elimination,  stimulation  if  necessary, 
and  the  use  of  bicarbonate  of  soda  by  mouth  or  rectum,  subcutaneously 
or  intravenously. 

Traumatic  diabetes  may  follow  injuries  and  operations,  involving  not 
only  the  brain,  spinal  cord,  liver,  pancreas,  and  kidney,  but  also  other  organs 
and  parts.  It  generally  appears  within  a  day  or  two  and  is  transient,  seldom 
leading  to  serious  consequences. 

The  only  other  autointoxication  with  which  we  shall  deal  here  is  aseptic 
fever. 

Aseptic  fever  {reactionary y  simple  traumatic y  or  resorption  fever)  is  seen 
after  subcutaneous  injuries,  such  as  contusions,  fractures,  and  sprains,  and 
after  aseptic  operations.  It  is  due  to  the  absorption  of  sterile  products  of  cellu- 
lar disintegration,  chiefly  fibrin  ferment,  from  extravasated  blood  or  from 
exudate,  hence  is  apt  to  be  of  greater  degree  after  the  use  of  strong  antiseptics. 
The  only  symptom  is  a  slight  rise  in  temperature,  rarely  more  than  101°  F., 
which  disappears  by  the  end  of  the  second  or  third  day.  If  the  fever  persists 
beyond  this  time,  especially  if  other  symptoms  appear,  it  is  almost  surely 
due  to  some  other  cause,  most  likely  infection  of  the  wound.  The  erythem- 
atous and  urticarial  rashes  which  are  sometimes  described  in  connection 
with  this  condition  are  probably  due  to  intestinal  derangement,  as  they  sub- 
side after  the  bowels  have  been  freely  evacuated.  Aseptic  fever  requires  no 
treatment. 

SEPSIS. 

SepsiSi  or  "blood  poisoning,"  includes  sapremia,  septic  intoxication, 
septicemia,  and  pyemia.  The  former  two  are  due  to  the  presence  of 
toxins  alone  in  the  blood  (toxemia),  the  latter  two  to  the  presence  of  toxins 


104  GENERAL  CONDITIONS  AND   SPECIAL  INFECTIONS. 

and  bacteria  {bacteremia) .  These  toxins  and  organisms  may  be  of  any  variety, 
but  in  the  following  paragraphs  septic  intoxication  and  septicemia  are  defined 
in  their  restricted  sense  as  referring  to  pyogenic  toxins  and  pyogenic  bacteria. 

Sapremia  is  due  to  the  absorption  of  the  products  of  putrefaction;  hence, 
properly  speaking,  autointoxication  from  decomposing  intestinal  contents  is 
sapremia.  Saprophytic  organisms  are  rarely  found  alone  in  surgical  afiFcc- 
tions,  consequently  a  pure  form  of  sapremia  is  rarely  seen.  The  best  example 
is  that  due  to  the  absorption  of  ptomains  from  a  decomposing  placenta  after 
child  birth,  although  a  more  or  less  pure  form  may  be  seen  as  the  result  of 
putrefaction  of  blood  clots,  wound  secretions,  or  large  tumors.  Since  sapre- 
mia is  so  frequently  linked  with  other  septic  processes,  and  is  clinically 
indistinguishable  from  septic  intoxication,  the  term  should  be  discarded. 

Septic  intoxication  (pyogenic  toxemia)  is  due  to  the  absorption  of  pyo- 
genic toxins.  The  usual  cause  is  pus  under  pressure,  e.g.,  an  unopened 
abscess  or  a  badly  drained,  suppurating  wound.  As  granulation  tissue 
blocks  lymphatic  spaces,  toxins  are  not  readily  absorbed  from  its  surface, 
unless  pressure  be  added ;  thus  in  a  completely  drained  abscess  there  are  no 
constitutional  symptoms;  if  the  drainage  be  defective,  however,  or  if  the 
lymph  spaces  be  opened  by  curettage,  absorption  takes  place.  Chronic 
septic  intoxication  is  hectic  fever. 

The  sjrmptoms  appear  usually  in  from  one  to  three  days,  and  vary  in 
degree  according  to  the  character  and  virulency  of  the  toxin,  the  amoimt  of 
absorption,  and  the  resistance  of  the  individual.  They  manifest  themselves 
as/<n'er,  or  pyrexia,  which  is  a  syndrome  characterized  by  a  rise  in  tempera- 
ture (often  preceded  by  a  chill),  quickening  of  the  pulse  and  respirations, 
headache,  backache,  diffuse  muscular  soreness,  general  weakness;  by  dis- 
ordered secretions,  causing  dryness  of  the  mouth,  coating  of  the  tongue, 
thirst,  impaired  appetite  (sometimes  vomiting),  constipation  or  diarrhea, 
scanty  high  colored  urine  containing  an  excess  of  urea  and  urates,  dryness  of 
the  skin  or  sweating;  and  by  nervous  disturbances  varying  from  delirium  to 
coma.  There  is  a  leukocytosis  unless  the  intoxication  is  slight  or  over- 
whelming, but  no  organism  in  the  blood.  In  the  young  and  robust  the 
symptoms  arc  apt  to  be  active  {sthenic  fever) ;  in  the  debilitated,  in  the  old,  and 
even  in  the  young  they,  when  protracted,  are  apt  to  be  of  a  low  type  and 
associated  with  marked  exhaustion  {typhoid  state,  asthenic  or  adynamic  fever). 
The  local  symptoms  are  those  of  inflammation,  and,  if  there  be  a. wound, 
usually  a  copious  and  foul  smelling  discharge. 

Septicemia  {pyogenic  bacteremia)  is  septic  intoxication  plus  the  presence 
of  living  pyogenic  bacteria  in  the  blood  stream,  and  differs  from  pyemia  only 
by  the  absence  of  secondary  abscesses.  The  organisms  gain  entrance  to  the 
blood  by  the  lymph  vessels  as  the  result  of  pressure  in  an  abscess  (5econd4iry 
septicemia),  or  possibly  in  some  cases  pass  directly  into  the  open  capillaries 
without  the  existence  of  suppuration  {primary  septicemia).  Cryptogenic 
septicemia  presents  no  wound  or  focus  of  suppuration;  a  forgotten  needle 
puncture,  or  an  abrasion  on  the  skin  or  one  of  the  mucous  membranes  may 
l)e  responsible  for  these  cases,  which  become  fewer  as  the  surgeon  increases  in 
expcrien(e  and  investigates  with  more  care.  Bacteria  in  the  circulating 
blood  are  devoured  by  the  leukocytes,  or  dissolved  by  the  bacteriolytic  action 
of  the  blood  scrum,  thus  terminating  the  process;  or,  if  sufficiently  numerous 
or  virulent,  and  especially  if  the  individual  has  not  suflicent  resistance  to 
manufacture  antibacterial  serums  or  opsonins,  they  multiply,  continue  to 


toxins,  and  are  ^Tstribuied  to  vari<»us  parts  mtlielxJHy,  where  they 
may  cause  secondary  or  metastatic  abscesses  (pyemia);  some  arc  eliminated 
by  the  excretory  organs,  and  some  are  destroyed  by  the  tissue  cells.  There  is 
no  specific  micro-organism  of  septicemia,  any  one  of  the  pyogenic  bacteria 
seemingly  being  capable  of  producing  the  condition,  although  the  strepto- 
coccus  bears  the  worst  reputation  in  this  respect. 

The  symptoms  may  be  noticed  a  few  hours  after  a  wound,  or  not  for 
several  days.  There  is  usually  a  chill,  with  a  rapid  rise  io  temperature  to 
i04**  or  105^  F.;lhe  fever  persists^  being  lesii  in  the  morning  and  greater  in  the 
evening;  in  many  cases  there  are  violent  chills  at  irregular  periods,  followed 
by  high  temperature  and  drenching  sweats.  The  pulse  increases  in  rapidity 
and  decreases  in  tension.  In  severe  cases  the  pulse  rate  reaches  1 50  or  more, 
finally  becoming  so  rapid  and  weak  that  it  cannot  be  counted.  Inhere  is 
often  marked  depression  of  the  nervous  system,  the  patient  being  stupid  and 
quiet  (typhoid  state);  or  delirium,  restlessness,  picking  at  the  bed  clothes 
and  twitching  of  the  tendons;  in  either  case  coma  precedes  death.  Although 
the  respirations  arc  quickened,  signs  of  imperfect  oxygenation  of  the  blood 
are  often  seen  in  the  face,  which  may  be  cyanotic.  The  tongue  is  dry,  coated, 
red  at  the  edges,  pointed  at  the  tip,  and  sordes  are  present  upon  its  dorsum 
and  upon  the  lips.  There  are  loss  of  appetite,  occasionally  vomiting,  often 
diarrhea.  Petechia?  may  appear  in  the  skin  and  mucous  membranes,  and, 
owing  to  the  disintegration  of  red  blood  cells,  hematogenous  jaundice  may 
develop.  The  skin  may  present  eruptions  also  in  the  form  of  vesicles  or 
pustules,  or  simulating  urticaria,  measles,  or  scarlet  fever.  The  urine  is 
srajity,  high  colored,  and  contains  albumin,  toxins,  and  frequently  bacteria; 
the  spleen  and  often  the  liver  are  enlarged,  and  there  may  be  leukocytosis. 
Bacteria  may  be  discovered  in  the  blood  by  cultural  methods. 

The  hcai  mamj'eshUlons  vary  from  slight  inllammalion  to  the  graver 
forms  of  cellulitis  and  are  not  always  characteristic,  although  in  many  cases 
the  wound  discharges  a  thin  pus,  while  the  activity  of  the  lymphatic  vessels 
is  shown  by  red  lines  of  lymphangitis  running  to  the  nearest  lymph  glands, 
which  are  swollen  and  tender,  or  even  suppurating.  The  veins  about  a  sup- 
purating wound  may  become  inflamed,  and  blocked  with  coagulated  blood 
(thrombophlebitis).  Bacteria  may  invade  and  soften  this  thrombus,  portions 
of  which  may  be  washed  into  the  blood  stream  as  emboli. 

Pyemia  is  septicemia  plus  secondary  or  metastatic  aliscesses,  due  to  the 
bacteria  lodging  in  various  parts  of  the  body,  or  to  septic  emboli  the  result 
of  a  thrombophlebitis;  these  abscesses  may  be  found  in  any  part  of  the  body, 
but  are  most  frequent  in  the  bones,  where  bacteria  are  readily  deposited  from 
the  capillaries  owing  to  the  slowly  moving  lilood  current,  and  in  those  organs 
which  have  terminal  arteries,  such  as  the  brain,  spleen,  kidney,  and  lung. 
Eml>oli  arising  in  the  area  drained  by  the  portal  vein  lodge  in  the  liver  (see 
embolism).  Compared  with  preantiseplic  days,  pyemia  is  comparatively 
rare  at  the  present  time,  but  is  especially  prone  to  follow  thrombophlebitis 
of  the  facial  veins  in  infections  in  this  neighljorhood,  thrombophlebitis  of 
the  lateral  sinus  the  result  of  middle-ear  disease,  and  pylephlebitis  the  result 
of  inflammations  about  the  rectum,  appendi.\,  etc. 

The  symptoms  are  those  of  septicemia,  plus  the  secondary  aijscesses, 
which  usually  appear  during  the  second  week;  they  are  generally  announced 
by  an  additional  chill,  but  may  develop  insidiously,  sometimes  without  even 
pain  or  tenderness^  and  they  are  commonly  small  and  multiple.     Pyemia  may 


I 


Io6  GENERAL  CONDITIONS  AND  SPECIAL  INFECTIONS. 

run  its  course  in  a  few  days  (ctcuU  pyemia),  or  it  may  last  a  number  of  months 
{chronic  pyemia).  It  is  usually  fatal,  although  recovery  has  occurred  despite 
the  presence  of  secondary  abscesses  in  the  internal  organs.  In  pyemia  there 
is  said  to  be  a  characteristic  sweet  odor  not  unlike  that  of  hay. 

Surgical  scarlatina  is  the  name  given  to  the  scarlet  rash,  probably  the  result 
of  vaso-motor  disturbance,  seen  in  cases  of  sepsis.  True  scarlatina  may, 
however,  occur  after  operations  and  accidental  wounds,  especially  in  children. 
Since  the  period  of  incubation  is  shorter  than  in  the  non-surgical  form,  it 
may  be  that  the  micro-organism  of  scarlet  fever  enters  through  the  wound. 
Scarlet  rashes  may  occur  likewise  from  the  absorption  of  ether,  bichlorid  of 
mercury,  carbolic  acid,  and  iodoform. 

The  diagnosis  of  sepsis  b  made  by  finding  the  causative  lesion  and  ex- 
cluding other  febrile  maladies.  The  causative  lesion  is  sometimes  difficult 
to  locate,  particularly  in  the  so-called  cryptogenic  or  spontaneous  form,  in 
which  it  may  be  necessary  to  review  the  entire  body  before  finding  the 
source  of  infection.  Regions  especially  liable  to  be  overlooked  are  the  ear, 
teeth,  throat,  urethra,  rectum,  in  women  the  pelvic  organs,  and  in  children 
the  bones,  particularly  the  tibia.  An  insignificant  wound  that  has  healed 
may  be  the  starting  point  of  even  the  gravest  forms  of  sepsis,  and,  conversely, 
a  wound,  even  if  suppurating,  may  be  complicated  by  other  forms  of  fever. 
Here  it  should  be  noted  that  tonsillitis  may  be  the  cause  and  pneumonia,  en- 
docarditis, etc.,  the  result  of  sepsis.  The  exclusion  of  aseptic  fever  is  made  by 
the  healthy  appearance  of  the  wound  and  the  brief  duration  of  the  fever,  of 
autointoxication  by  stimulating  the  excretory  organs.  When  there  is  marked 
depression  of  the  nervous  system  and  general  exhaustion,  typhoid  fever  (Widal 
reaction,  leukopenia)  and  miliary  tuberculosis  (p.  134)  may  be  simulated, 
while  the  occurrence  of  chills  is  often  wrongly  interpreted  as  malaria;  in  the 
last  a  blood  examination  will  reveal  the  presence  of  malarial  parasites. 
The  occurrence  of  skin  rashes,  particularly  in  children,  will  bring  up  the 
question  of  the  acute  exanthemata,  especially  measles  and  scarlet  fever. 
The  form  of  sepsis  is  toxemia  (sapremia  or  septic  intoxication)  if,  in  the  pres- 
ence of  an  inflamed  or  suppurating  wound,  the  symptoms  promptly  sub- 
side after  thorough  drainage  and  disinfection.  If  the  wound  does  not  show 
evidences  of  irritation,  the  constitutional  disturbance  may  be  due  to  septicemia, 
but  is  more  probably  the  result  of  some  medical  complication.  The  con- 
tinuation of  fever  after  the  opening  of  an  abscess  or  wound,  excluding 
medical  complications,  usually  means  inefficient  drainage,  that  is,  a 
continuation  of  the  septic  intoxication,  or,  if  the  wound  is  perfectly 
drained,  septicemia.  In  the  latter  instance,  the  absorption  of  bacteria  may 
he  evidenced  by  red  and  tender  lymph  vessels  coursing  along  the  surface  and 
ending  in  inflamed  lymph  glands;  the  constitutional  symptoms  are  more 
severe  than  in  septic  intoxication,  and  chills  are  more  likely  to  occur.  A 
positive  diagnosis  can  be  made  only  by  recovery  of  the  organisms  from  the 
l)l()od  stream,  or  from  the  excretions,  particularly  the  urine.  Leukocytosis 
occurs  in  all  forms  of  sepsis,  as  does  also  iodophilia.  The  diagnosis  of 
pyemia  is  made  by  the  metastatic  abscesses,  which,  when  superficially 
situated,  are  easily  detected;  but  when  deeply  seated  in  the  viscera,  they  are 
apt  to  be  small  and  numerous,  and  often  their  presence  can  only  be 
suspected. 

The  treatment  of  sepsis  is  first  prophylaxis.  All  wounds  accidentally 
received  should  be  carefully  disinfected  and  the  most  scrupulous  antiseptic  or 


TREATlfENT  OP  SEPSIS. 


TO7 


ptic  precautions  taken  duniig  operations  and  the  delivery  of  pregnant 
imcii.  After  labor  the  placenta  should  be  carefully  inspected  to  make 
sure. that  none  of  it  has  been  left  behind ^  after  miscarriage  curettage  of  the 
uterus  is  often  done  with  the  same  end  in  view.  It  is  Important  before  opera- 
lions  also  to  increase  the  resistance  of  the  patient  by  suitable  treatment. 
The  local  treatfmni  is  that  of  the  causative  lesion,  viz.j  inflammation, 
suppuration,  gangrene,  etc.  Uncomplicated  sapremia  or  septic  intoxication 
rapidly  subsides  if  the  local  cause  be  found  and  removed.  If  the  symptoms 
continue,  all  the  putrefying  material  has  not  been  removed,  drainage  is  not 
efficient,  or  bacteria  are  elaborating  toxins  in  the  blood  stream  (septicemia). 
In  the  last  the  oudook  is  always  grave,  although,  as  has  already  been  indica- 
ted, destruction  of  bacteria  and  recover}^  may  follow.  In  pyemia  secondary 
abscesses  should  be  incised  and  drained,  but  unfortuiiately,  in  the  viscera, 
this  is  often  impracticable  owing  to  their  multiplicity.  An  accessible  vein 
,  file  anbj eel  of  thrombophlebitis  should  be  excised,  or  (e.g.,  lateral  sinus) 
€|WUv  the  clot  removed,  and  the  cavity  packed  with  gauze;  in  order  to  pre- 
vent the  further  dissemination  of  septic  emboli,  the  vein  may  be  tied  between 
the  thrombus  and  the  heart;  in  the  extremities  amputation  may  be  rec|uired. 
The  general  treatment  is  (i)  specific,  (2)  eliminative^  (3 J  symptomatic. 
(t)  Specific  treatment  aims  to  destroy  bacteria  in  the  blood  stream  or  to  neu- 
tralize their  toxins.  Unfortunately,  pyogenic  bacteria  in  the  blood  stream 
arc  inaccessible.  The  injection  of  antiseptics  into  the  circulation,  in  sufficient 
strength  to  be  of  value,  is  dangerous.  Antistreptococdc  serum,  which  at  first 
seemed  to  give  much  promise,  has  been  found  to  be  ineffectual;  it  may,  how- 
ever^  l>e  empk»yed  in  10  cr.  doses  repeated  every  three  or  four  hours,  particu- 
larly if  bacteriological  examinations  prove  the  infection  to  be  due  to  strep* 
tccocci;Hke  diphtheria  antitoxin,  which,  too,  has  been  used  in  septic  conditions 
without  success,  it  may  produce  ervlhematous  or  urticarial  eruptions  and 
pains  in  the  joints,  and  several  cases  have  been  reported  in  svhich  sudden 
death  followed  the  injection  of  the  serum.  Vauine  treatment  (p.  30)  is 
still  on  trial,  Quinin,  iron,  and  large  doses  of  alcohol  (whisky  or  brandy) 
are  regarded  by  many  as  almost  specific  in  septic  processes.  (2)  The  most 
efficient  means  of  combating  sepsis  is  by  elimination  of  the  micro-organisms 
and  their  products.  Purgation^  especially  by  calomel  and  salines,  lowers  the 
bl<x)d  pressure,  drains  off  toxins  through  the  bowel,  and  ciears  the  intestinal 
tract  of  material  which  may  be  absorlDed  and  aggravate  the  symptoms.  If 
nature  has  anticipated  the  physician  by  the  production  of  a  diarrhea,  such 
should  not  be  checked  unless  excessive.  Diuretics^  such  as  calomel,  caffeine, 
squill,  sweet  spirits  of  niter,  acetate  of  potassium,  and  large  quantities  of  water 
by  mouth  or  rectum,  are  of  great  value  in  removing  toxins  from  the  blood, 
in  lowering  temperature,  and  in  reducing  blood  pressure.  When  both  the 
stomach  and  rectum  are  irritable,  the  same  principle  may  be  utilized  by  in- 
jecting salt  solution  into  the  subcutaneous  tissues,  or,  exceptionally,  directly 
into  a  vein.  Diaphoretics  are  not  often  used,  as  when  they  are  indicated  in 
septic  conditions  profuse  sweats  are  generally  present,  Venesectiim  is  occa- 
sionally employed  to  lessen  the  amount  of  toxin  in  the  circulating  blood, 
especially  when  followed  by  the  intravenous  injection  of  salt  solution.  It 
should  never  be  used  in  infancy,  old  age,  or  in  the  debilitated.  (3)  Symp- 
ionuUic  tre^meni  depends  upon  the  indications.  Rest  in  bed,  predigested 
liqtiid  food,  and  proper  nursing  are  always  required  in  severe  cases  of  sepsis. 
The  l>cst  anodyne,  if  the  condition  is  to  last  but  a  short  time,  is  opium  or  one 


I08  GENERAL  CONDITIONS  AND   SPECIAL  INFECTIONS. 

of  its  derivatives.  In  most  surgical  inflammations  pain  severe  enough  to  pre- 
vent sleep  calls  for  incision  and  drainage  of  the  affected  part.  Nervousness 
is  best  met  by  the  bromids,  and  sleeplessness  not  caused  by  pain  by  sulphon- 
ethylmethane  or  sulphonmethane.  The  coal-tar  products  and  chloral, 
because  of  their  depressing  effects,  are  usually  to  be  avoided.  The  best 
antipyretic  is  an  ice  cap  on  the  head,  and  general  sponging  with  ice  water, 
or  equal  parts  of  alcohol  and  water;  drugs  should  be  rarely  employed.  Per- 
sistent fever  usually  means  that  further  search  for  the  source  of  infection, 
with  proper  incisions,  disinfection,  and  drainage,  should  be  carried  out. 
In  many  cases  stimulants,  such  as  alcohol,  strychnin,  ammonium  car1>onate, 
and  digitalis  will  be  needed. 


DELIRIUM. 

Mental  aberration  after  an  operation  or  injury  may  be  due  to  many  causes. 
The  delirium  of  sepsis  should  be  excluded,  and  careful  inquiry  made  into  the 
previous  mental  condition  of  the  patient,  and  into  previous  habits,  especially 
regarding  the  use  of  alcohol,  opium,  and  cocain ;  delirium  may  follow  ether 
and  chloroform,  and  may  be  due  to  iodoform  or  carbolic  acid  absorption. 
Delirium  is  due  to  an  intoxication  in  a  person  who  has  some  bodily  illness,  and 
should  not  be  confused  with  insanity,  which  is  a  disease  of  the  mind,  often 
in  an  otherwise  healthy  body. 

Delirium  tremens  (mania  a  potu)  is  of  frequent  occurrence  in  chronic 
alcoholics  after  accidents  or  operations  which  require  confinement  to  bed, 
especially  when  the  individual's  customary  dose  of  alcohol  is  not  given. 
At  first  there  are  restlessness,  insomnia,  and  nightmare.  In  the  course  of 
two  or  three  days  the  patient  becomes  delirious;  there  are  incessant  incohe- 
rent talking,  constant  motion,  a  characteristic  tremor  of  the  hands  and  of 
the  tongue  when  protruded,  and  hallucinations  of  sight  and  often  of  hearing; 
the  patient  sees  grotesque  individuals  making  grimaces,  or  more  commonly 
fights  snakes,  rats,  or  insects,  which  he  imagines  are  crawling  over  and  about 
him.  The  pulse  increases  in  rapidity,  and  the  temperature  rises,  rarely  above 
103°  F.,  except  in  fatal  cases,  in  which  all  the  symptoms  increase  in  intensity, 
death  occurring  from  exhaustion.  Recovery  is  the  rxile  unless  the  patient 
is  otherwise  in  i)ad  health,  or  develops  pneumonia,  which  is  a  frequent  com- 
plication. 

The  prophylactic  treatment  in  alcoholic  subjects  who  are  to  undergo 
operation,  or  who  have  sustained  an  injury,  consists  in  the  administration 
of  their  customary  tipple,  tonics,  and  nourishing  food;  if  alcohol  has  been 
withheld  it,  with  bromids,  should  be  given  at  the  first  appearance  of  tremor, 
restlessness,  or  insomnia,  and  the  patient  carefully  watched,  because  at  the 
outbreak  of  delirium,  he  may  tear  off  his  dressings,  or  get  out  of  bed  and 
jump  through  a  window.  In  some  cases  alcohol  seems  to  make  the  condition 
worse,  or  at  least  has  no  effect  in  checking  it.  When  the  attack  has  once 
developed,  the  indications  are  to  (juiet  ihc  nervous  symptoms,  to  sustain 
ihe  strength,  and  to  maintain  a  constant  watch.  The  nervous  sedatives 
most  frequently  employed  are  the  bromids,  sulphonethylmethane,  and  sul- 
phonmethane; chloral  is  too  dc|)rcssing  to  the  heart,  and  morphin,  because  of 
its  effects  upon  the  secretions,  should  be  used  only  in  exceptional  cases  or  in 
extreme  mania.     Paraldehyde  and  hyoscin  are  highly  recommended  by  some 


ERYSIPELAS.  IO9 

authorities.  The  strength  is  maintained  by  nourishing  liquid  food,  strychnin, 
and  digitalis,  while  capsicum  is  usually  given  for  its  e^ect  upon  the  stomach. 
Although  strapping  the  patient  in  bed  aggravates  the  nervous  symptoms,  it  is 
usually  necessary.  Careful  attention,  of  course,  should  be  given  to  the 
lx)wels  and  kidneys. 

Tratimatic  deliritim,  or  deliritim  nervosum,  is  an  afebrile  delirium 
occasionally  encountered  after  injuries  or  operations,  particularly  in  children, 
the  senile,  and  the  hysterical.  Many  individuals  become  flighty  from  pain 
alone.  Delirium  nervosum  appears  several  days  after  an  operation  or  injury 
and  may  last  a  week,  very  rarely  terminating  in  death.  It  is  closely  allied 
to  the  ** delirium  of  coUapse,^^  which  is  seen  in  some  cases  of  shock,  or  after 
the  sudden  fall  of  a  high  temperature,  and  which  may  last  a  few  hours  or  a 
few  days.  The  treatment  of  delirium  nervosum  is  nervous  sedatives,  atten- 
tion to  the  general  health,  and  the  removal  of  any  local  irritation  which  may 
be  present. 

'Genuine  insanity  occasionally  develops  after  an  operation  or  injury;  it 
is  usually  of  the  conf usional  type,  but  may  be  of  any  variety.  The  prognosis 
is  good  unless  there  are  systematized  delusions,  a  strong  ancestral  history  of 
insanity,  or  unless  there  has  been  previous  trouble  with  the  intellect. 


ERYSIPELAS. 

Erysipelas  (St.  Anthony's  fire)  is  an  acute  contagious  and  infectious  in- 
flammation of  the  skin,  and  occasionally  of  the  mucous  membranes. 

The  cause  is  the  streptococcus  erysipelatis  (identical  with  the  streptococ- 
cus pyogenes),  which  lodges  in  an  abrasion  or  wound,  and,  passing  into  the 
capillary  lymphatics  of  the  skin,  gives  rise  to  inflammation  of  these  vessels 
and,  by  contiguity,  of  the  remaining  dermal  structures.  Chronic  alcoholism, 
kidney  affections,  and  other  causes  of  general  debility,  favor  the  development 
of  the  disease,  and  in  certain  individuals  there  is  a  natural  predisposition,  the 
disease  breaking  out  repeatedly  on  the  slightest  provocation.  It  is  most 
prevalent  in  the  spring,  and  is  especially  prone  to  occur  in  epidemics  in  over- 
crowded hospitals  with  defective  sanitation.  Idiopathic  erysipelas  is  that 
form  in  which  no  port  of  entry  can  be  found.  Infection  through  sound  skin 
or  mucous  membrane  is  possible,  but  in  the  vast  majority  of  the  idiopathic 
cases  it  is  probable  that  the  abrasion  is  so  slight  or  so  situated,  e.g.,  just 
within  the  nostrils,  that  it  escapes  detection. 

The  symptoms  appear  within  a  few  hours  or  not  for  several  days  after 
infection.  They  may  be  inaugurated  by  a  chili,  with  headache  and  malaise, 
the  rash  appearing  a  number  of  hours  later,  but  in  many  cases  the  local  changes 
first  attract  attention.  The  wound  will  have  a  dry,  dirty-yellowish  appear- 
ance, and  be  surrounded  by  a  bright  red,  shiny  swelling,  which  spreads 
irregularly,  resembling  a  growing  map;  the  redness  disappears  on  pressure, 
and  there  is  a  sensation  of  burning,  tension,  or  stiffness,  but  no  acute  pain, 
unless  dense  structures  like  the  scalp  are  invaded;  there  is  edema,  which,  in 
loose  structures  like  the  scrotum  and  eyelids,  becomes  very  great.  Owing  to 
the  intensity  of  the  dermatitis,  vesicles  and  bulla?  frequently  develop  and  often 
contain  a  purulent  fluid.  Suppuration,  however,  is  not  common  unless  the 
organism  gains  access  to  the  subcutaneous  tissues,  when  the  condition  is 
called  cellulo-cutaneous  or  phlegmonous  erysipelas  (see  cellulitis).     The  skin  is 


no  GENERAL  CONDITIONS  AND   SPECIAL  INFECTIONS. 

hot  and  tense,  the  margins  of  the  swelling  abrupt  and  sharply  defined,  and 
the  adjacent  lymph  glands  swollen  and  tender.  The  fever  is  of  the  continu- 
ous variety  and,  especially  in  facial  erysipelas,  is  apt  to  subside  by  crisis.  In 
those  whose  health  has  been  depressed  by  general  illness,  in  alcoholics,  and  in 
erysipelas  about  the  head  and  face,  great  prostration  with  delirium  is  likely 
to  develop.  As  the  rash  spreads  it  fades  in  those  areas  which  were  first 
attacked,  leaving  a  brownish  discoloration  and  a  branny  desquamation. 
Erysipelas  of  the  fauces  causes  great  swelling,  which  may  spread  to  the 
glottis  and  produce  severe  dyspnea.  Occasionally  erysipelas  will  spread  from 
its  point  of  origin,  successively  involving  contiguous  areas  {amhulatU,  erraticj 
migratory,  or  wandering  erysipelas).  Again  it  may  jump  from  one  region  of 
the  body  to  some  distant  region  {metastatic  erysipelas).  Erysipelas  which 
begins  in  the  cicatrizing  umbilicus  of  the  new-bom  {erysipelas  neancUorum)  is 
very  fatal.  Every  now  and  then  a  malignant  growth,  chronic  ulcer,  or  ancient 
skin  disease  will  disappear  after  it  has  been  invaded  by  erysipelas  {erysipelas 
salutaire).  The  disease  lasts  from  a  few  days  to  several  weeks.  The 
mortality  is  from  5  to  7  per  cent.  Death  is  usually  the  result  of  toxemia, 
although  it  may  arise  from  a  complication,  such  as  meningitis,  pneumonia, 
endocarditis,  nephritis,  or  pyemia. 

The  diagnosis  of  erysipelas  is  rarely  difficult.  It  is  most  frequently  con- 
fused with  cellulitis,  in  which  the  redness  is  more  dusky,  the  margins  not  so 
abrupt  and  irregular,  and  the  pain  deeper  and  more  throbbing. 

Treatment. — The  prophylactic  treatment  consists  in  the  isolation  of 
cases  of  erysipelas  which  develop  in  a  surgical  ward.  During  an  epidemic 
none  but  imperative  operations  should  be  performed.  Those  who  nurse  or 
dress  cases  of  erysipelas  should  not  come  in  contact  with  surgical  or  obstetrical 
patients. 

The  local  treatment  consists  in  the  careful  disinfection  of  any  existing 
wounds  and  the  application  of  antiseptic  fomentations.  The  various  solu- 
tions and  ointments  which  have  been  recommended  seem  to  have  little  effect 
upon  the  progress  of  the  disease;  the  most  popular  of  these  is  ichthyol,  25 
per  cent.  Cataplasm  of  kaolin  makes  a  comfortable  application.  Evapo- 
rating lotions  and  cold  compresses  ease  the  pain,  but  should  be  used  cau- 
tiously in  asthenic  cases.  Irritating  medicaments,  e.g.,  iodin,  turpentine,  etc., 
should  not  be  applied  to  the  inflamed  area.  In  order  to  prevent  the  spread  of 
erysipelas,  the  inflamed  area  has  been  surrounded  by  a  circle  painted  with  a 
strong  solution  of  silver  nitrate  or  tincture  of  iodin,  by  injections  of  a  3  per 
cent,  carbolic  acid  solution  or  other  antiseptic,  by  incisions,  and  by  a  circle 
burned  with  the  cautery.  All  these  methods  aim  to  produce  a  barrier  of 
leukocytes,  in  other  words,  an  inflammation  is  produced  to  stop  an  inflam- 
mation. The  results  of  this  homeopathic  form  of  treatment  do  not  justify  its 
continuance.  The  application  of  pressure  by  collodion  or  strips  of  adhesive 
plaster  is  occasionally  effective  in  limiting  the  inflammation.  When  sup- 
puration is  threatened,  or  in  the  cellulo-cutaneous  variety,  incisions  are 
indicated.  Erysipelas  oj  the  fauces  should  be  treated  by  sprays  or  gargles 
of  mildly  antiseptic  solutions,  and  by  the  application  of  ice  extemaUy;  the 
patient  should  be  carefully  watched  for  evidences  of  edema  of  the  glottis, 
which  may  require  tracheotomy. 

Constitutional  treatment  should  be  conducted  on  general  lines,  i.e.,  elimina- 
tion should  he  attended  to,  stimulation  and  nervous  sedatives  used  if  neces- 
sary, liquid  food  given  at  frequent  inter\'als,  and  cold  sponging  employed  for 


CELLULITIS.  Ill 

excessive  fever.  Tincture  of  chlorid  of  iron,  lo  to  20  drops  three  or  four 
times  a  day,  is  regarded  by  some  as  a  specific,  especially  when  combined  with 
quinin.  Pilocarpin  given  internally  has  been  recommended  for  its  action  on 
the  skin.  Antistreptococcic  serum  should  theoretically  be  of  great  value. 
Mormorek,  the  originator  of  antistreptococcic  serum,  has  treated  423  cases  of 
erysipelas  with  his  serum,  with  a  mortality  of  3.87  per  cent.  The  serum 
has  been  injected  around  the  area  of  inflammation,  as  well  as  in  indifferent 
portions  of  the  body. 

Erysipeloid  is  an  infective  dermatitis  caused  by  inoculation  of  a  wound 
or  abrasion  with  putrid  animal  matter,  hence  is  most  frequent  on  the  hands  of 
cooks,  butchers,  and  fish  dealers.  The  swelling  is  red,  painful,  and  sharply 
defined,  and  tends  to  spread  over  the  rest  of  the  hand.  Suppuration,  lym- 
phangitis, and  the  formation  of  vesicles  do  not  occur,  and  general  symptoms 
are  slight  or  absent.  The  treatment  is  disinfection  of  the  woimd  and  mildly 
antiseptic  dressings. 

CELLULITIS. 

Cellulitis,  or  inflammation  of  the* areolar  connective  tissue,  may  be  found 
in  any  region  in  which  there  is  cellular  tissue  (see  cellulitis  of  the  neck,  pelvic 
cellulitis,  felon,  periproctitis,  etc),  but  here  we  refer  only  to  the  subcutaneous 
variety.  It  may  be  acute  or  chronic.  Chronic  cellulitis  is  always  circum- 
scribed; it  may  follow  the  acute  form,  but  is  more  often  seen  as  a  thickening 
of  the  tissues  about  some  long-continued  source  of  irritation,  e.g.,  a  chronic 
ulcer,  and  subsides  when  the  cause  is  removed.  Acuie  cellulitis  may  be 
circumscribed  or  diffuse.  Acute  circumscribed  cellulitis  occurs  about  in- 
flamed wounds,  spreading  ulcers,  and  tight  stitches.  The  inflamed  tissues 
occasionally  suppurate  or  slough,  but  the  process  remains  localized  and 
promptly  subsides  with  appropriate  treatment. 

Acute  diffuse  cellulitis  ( diffuse  phlegmon,  phlegmonous  snppuratioHy  puru- 
lent infiltratim)  is  a  widespread  suppurative  inflammation  of  the  subcutane- 
ous cellular  tissue.  It  is  usually  caused  by  the  infection  of  wounds  with  the 
streptococcus  pyogenes,  and  is  indistinguishable  clinically  from  cellulo-cutane- 
ous^  or  phlegmonous  erysipelas.  The  less  severe  varieties  are  due  to  staphy- 
lococci. In  either  case  the  dose  and  virulency  of  the  organism  and  the 
general  condition  of  the  patient  determine  the  extent  and  severity  of  the 
process. 

The  sjrmptoms  may  appear  within  a  few  hours  or  not  for  two  or  three 
days  after  the  infection  of  a  wound.  The  inflammation  spreads  rapidly,  and 
may  extend  over  a  whole  limb.  There  are  intense  pain,  great  swelling  and 
edema,  dusky  redness,  and  elevation  of  the  local  temperature  The  lym- 
phatic vessels  running  from  the  infected  area  may  be  tense,  red,  and  tender, 
and  the  glands  into  which  they  empty,  painful  and  swollen.  The  suppura- 
tion may  spread  not  only  beneath  the  skin,  but  between  muscles,  beneath 
fascia,  and  even  to  the  bone.  The  subcutaneous  tissue  sloughs,  and  gan- 
grene of  the  skin  may  occur  from  the  cutting  off  of  its  blood  supply.  When 
the  tendency  to  gangrene  is  excessive  and,  as  the  result  of  infection  with 
aerogenic  bacteria,  gas  is  present  in  the  tissues,  the  condition  is  called 
gangrenous  cellulUis,  emphysematous  gangrene,  etc.  (p.  85).  The  constitu- 
tional symptoms  are  those  of  septic  intoxication  or  septicemia ;  occasionally 
pyemia  develops. 


112 


GENERAL  CONDITIONS  AND   SPECIAL  INFECTIONS. 


Treatment. — Cellulitis  may  be  prevented  by  the  scrupulous  disinfec- 
lioo  of  all  abrasions  and  wounds,  and  their  exclusion  from  septic  contamina- 
tion by  sterile  or  antiseptic  dressings.  It  may  be  abc^rted  by  opening,  disin- 
fecting, and  draining  inllamed  wounds.  When  it  has  once  gained  head- 
way, free  incisions  should  be  made^  whether  there  be  suppuration  or  not,  in 
order  to  relieve  tension  and  drain  the  tissues  of  the  inflammatory  exudate  and 

bacterial  products.  In  the  milder 
varieties  early  incisions  may  prevent 
suppuration^  in  the  severer  forms  they 
will  at  least  limit  it;  these  incisions 
are  disinfected  by  peroxid  of  hydro- 
gen, followed  by  hot  bichlorid  of 
mercury  solution,  i  to  looo,  and  arc 
lightly  packed  with  gauze,  the  whole 
part  being  covered  with  a  bichlorid 
dressing.  The  limb  should  be  ele- 
vated, frequently  dressed  and  irri- 
gated, and  further  incisions  made  if 
spreading  continues.  I n  fl  a  m ed 
lymph  vessels  and  glands  may  be 
covered  with  ichthyol  ointment;  if  the 
glands  suppurate,  they  should  be 
freely  extirpated.  If  there  is  a  ten- 
dency to  sloughing,  warm  antiseptic, 
fomentations  should  be  applied,  and 
the  sloughing  tissue  removed  as 
quickly  as  it  forms.  In  some  cases 
constant  irrigation  (Fig.  77)  ^^ith  a 
mild  antiseptic  solution,  or  immer- 
sion of  the  part  in  a  continuous 
warm  bath,  may  be  employed  The  treatment  of  gangrenous  cellulitis  is 
given  on  p.  85,     The  constitutional  treatment  is  that  of  sepsis  (//.t*.). 


._j 


Fig.  77. — Constant   irrigation. 
fEsraiirch  and  Kowaliig.) 


TETAHUS. 


Tetanus  (lockjaw)  is  an  infectious  disease  characterized  by  tonic  spasms 

of  the  muscles,  especially  those  of  mastication. 

The  cause  is  the  bacillus  of  tetanus,  which  is  a  rod  like  organism,  usu- 
ally presenting  a  distinct  enlargement  at  one  end,  owing  to  the  presence  of  a 
spore  (drumstick  bacillus).  It  is  an  anaerobe,  a  fact  which  explains  the 
frequency  of  tetanus  after  punctured  wounds,  which  quickly  heal  at  the  sur- 
face and  form  an  ideal  chamber  for  the  growth  of  the  organism.  In  the 
absence  of  air  it  may  be  slightly  motile,  owing  to  the  presence  of  fiagella\ 
It  is  most  frequently  found  in  cultivated  earth  and  in  the  feces  of  animals^ 
hence  the  susceptibility  of  hostlers  and  *'sons  of  the  soil."  The  predisposi- 
tion which  is  supposed  to  be  possessed  by  the  negro  is  probably  due  to  this 
fact.  As  heat  favors  the  development  of  the  organism,  the  disease  is  par- 
ticularly prevalent  in  the  tropics.  Aside  from  punctured  wounds,  the 
bacillus  finds  a  most  favt^rable  field  for  development  in  septic  wounds, 
owing  to  the  absorption  of  oxygen  by  other  organisms  present  (symbiosis). 


TETANUS.  113 

Punctured  wounds  of  the  sole  of  the  foot  are  notorious  for  the  frequency 
with  which  they  are  followed  by  tetanus,  because  the  vulnerating  body, 
often  a  rusty  nail,  has  become  contaminated  by  lying  in  contact  with  the 
earth.  Blank  cartridge  wounds  are  particularly  dangerous.  Tetanus 
has  followed  also  the  injection  of  gelatin  for  aneurysm,  the  injection  of 
diphtheria  antitoxin,  and  vaccination.  Occasionally  no  wound  can  be  found 
{idiopathic  tetanus),  although  it  is  possible  in  these  cases  that  the  bacilli 
enter  the  tissues  through  an  ulcer  or  abrasion  in  the  alimentary  canal.  The 
bacilli  have  little  tendency  to  migrate  from  the  point  of  inoculation,  being 
rarely  found  in  the  blood.  Tetanotaxin  is  composed  of  two  bodies,  viz., 
tftanospasmin,  which  produces  convulsions,  and  tetanolysin,  which  destroys 
red  blood  cells.  The  toxin  reaches  the  ganglia  of  the  central  nervous  sys- 
tem, not  by  the  blood,  but  by  the  motor  nerves,  along  the  axis  cylinders  of 
which  it  slowly  creeps,  thus  explaining  the  long  incubation  and  the  congested 
appearance  of  the  nerves  leading  from  the  wound.  The  sensory  nerves  take 
no  part  in  the  process.  That  portion  of  the  toxin  which  finds  its  way  into  the 
general  circulation  is  not  absorbed  directly  by  the  ganglia,  but  is  distributed 
to  the  ends  of  the  motor  nerves  throughout  the  body,  then  passing  upward 
along  these  nerves  to  the  cord;  thus  the  period  of  incubation  is  the  same  when 
the  toxin  is  injected  into  even  the  subarachnoid  space. 

The  period  of  incubation  of  acute  tetanus  varies  from  a  few  hours 
to  two  weeks,  usually  being  within  ten  days.  The  first  symptom  is  stiffness 
of  the  lower  jaw,  which  later  becomes  fixed,  the  patient  being  unable  to  open 
,  the  mouth  (trismus,  or  lockjaw) .  The  spasm  extends  more  or  less  rapidly  to  the 
other  voluntary  muscles  of  the  body.  Spasm  of  the  muscles  of  expression 
moulds  the  face  into  a  characteristic  grin  (risus  sardonicus).  As  the  muscles 
of  the  back  are  the  more  powerful,  generalized  convulsions  usually  cause  the 
patient  to  rest  upon  the  head  and  heels  {opisthotonos),  but  the  whole  body  may 
be  stiff  and  straight  (prthotonos),  bent  to  one  side  (pleurosthotonos),  or  curved 
forward  (emprosUiotonos),  Spasm  of  the  pharyngeal  muscles  causes  dyspha- 
gia, of  the  diaphragm  girdle  pain,  of  the  laryngeal  muscles  dyspnea,  of  the 
sphincter  vesicae  retention  of  urine,  of  the  sphincter  ani  constipation.  The 
mind  is  clear,  and  the  pain  very  great,  owing  to  the  cramp-like  contracture  of 
the  muscles,  which  never  entirely  relax,  and  which  are  thrown  into  more 
acute  contraction  by  the  slightest  irritation,  such  as  a  draught  of  air,  an 
attempt  to  take  food,  etc.  During  these  convulsions  the  patient  is  cyanotic- 
from  spasm  of  the  respiratory  muscles,  the  body  is  covered  with  sweat,  the 
eyes  protrude,  and  muscles  may  be  ruptured,  teeth  broken,  or  the  tongue 
bitten  through.  The  temperature  is  usually  normal  at  the  beginning,  but 
generally  rises  before  death,  and  continues  to  rise  after  death,  often  reaching 
108®  or  no®  F.  The  end  usually  comes  within  four  or  fwe  days,  from  heart 
failure  or  asphyxia  during  a  convulsion,  or  from  exhaustion. 

Chronic  tetanus  has  a  longer  period  of  incubation  than  the  acute 
form,  milder  symptoms,  and  a  much  better  prognosis.  Sometimes  the  spasms 
are  limited  to  that  portion  of  the  l)ody  in  which  the  infection  has  taken  place. 
In  cephalic  tetanus  (tetanus  paralyticus,  kopf  tetanus,  tetanus  hydrophohicus) , 
which  follows  injuries  in  the  area  supplied  by  the  cranial  nerves,  trismus  and 
dysphagia  are  often  accompanied  by  facial  paralysis,  from  neuritis  of  the 
seventh  nerve.  Chronic  cephalic  tetanus  presents  a  fairly  good  prognosis 
(25  per  cent,  mortality),  but  in  some  cases  it  is  acute  and  associated  with 
generalized  convulsions,  and  is  then  quite  as  grave  as  ordinary  acute  tetanus. 
8 


114  GENERAL  CONDITIONS  AND   SPECIAL  INFECTIONS. 

Tetanus  neoncUoruniy  or  trismus  nascentiumy  is  tetanus  in  the  new-bom, 
due  to  infection  through  the  navel. 

The  mortality  of  acute  tetanus  is  from  80  to  90  per  cent.,  of  the  chronic 
variety  from  40  to  50  per  cent.  A  long  period  of  incubation,  a  normal  tem- 
perature, and  limitation  of  the  spasms  to  the  head  and  neck  are  favorable 
signs.     If  death  does  not  occur  within  a  week,  recovery  may  be  expected. 

Diagnosis. — Trismus^  or  closure  of  the  jaws,  arising  from  inflammatory 
troubles,  etc.  (see  p.  431),  is  not  accompanied  by  rigidity  of  the  neck  or  gen- 
eralized convulsions,  and  the  cause,  e.g.,  tonsillitis,  unerupted  wisdom  tooth, 
etc.,  will  readily  be  found  upon  examination.  In  strychnin  poisoning  there  is 
complete  relaxation  between  the  spasms,  including  the  jaw  muscles,  so  that 
the  mouth  may  be  widely  opened;  the  convulsions  are  more  abrupt  in  onset, 
and  the  hands  are  tightly  contracted,  an  unusual  sign  in  tetanus;  and  there 
may  be  hyperesthesia  of  the  retinae  with  green  vision.  In  hysteria  there  may 
be  blindness,  laughing  or  crying  spells,  loss  of  consciousness,  and  during  the 
spasm  closure  or  quivering  of  the  eyelids.  Occasionally  the  patient  is  rigidly 
fixed  in  one  position  and  remains  so  for  hours  (catalepsy).  Wood  states  that 
in  hysteria  the  feet  are  crossed  and  the  toes  inverted ;  in  spasm  of  all  the 
muscles  of  the  leg  the  feet  are  turned  out,  because  the  muscles  of  ever- 
sion  are  stronger.  Tetany  is  characterized  by  tonic  local  spasms,  especially 
of  the  hands  and  feet,  and  trismus  is  rarely  present.  In  hydrophobia  the 
convulsions  are  limited  to  the  muscles  of  respiration  and  deglutition,  are  clonic 
and  not  tonic,  and  are  associated  with  mania.  Bacteriological  examination 
of  any  existing  wound  may  be  of  value  in  doubtful  cases. 

The  Treatment. — The  prophylactic  treatment  consists  in  the  careful  disin- 
fection of  all  wounds.  Punctured  wounds,  unless  produced  by  an  evidently 
clean  instrument,  should  be  enlarged  by  incision,  disinfected,  and  drained. 
They  should  not  be  cauterized,  because  the  resulting  eschar  excludes  the  air 
from  the  deeper  portions,  and  thus  favors  the  development  of  the  tetanus 
bacillus.  In  wounds  in  which  infection  by  the  tetanus  bacillus  is  suspected, 
viz.,  those  ( ontaminated  by  earth  or  manure,  and  those  due  to  the  blank  car- 
tridge, the  most  scientific  procedure  is  to  take  a  smear  and  a  culture  from  the 
wound  before  disinfection;  if  tetanus  bacilli  are  recovered,  the  wound  should 
be  excised  and  antitoxin  administered,  10  cc.  daily  for  two  weeks.  It  must 
be  noted,  however,  that  Reynier  has  reported  41  cases  in  which  the  prophy- 
lactic injection  of  antitoxin  has  failed.  Reference  has  already  been  made  to  the 
treatment  of  blank  cartridge  wounds.  Gelatin  and  various  antitoxins  should 
not  be  used  subcutaneously  until  they  have  been  proved  free  from  tetanus  by 
injection  into  susceptible  animals.  Vaccination  against  small-pox  should  bie 
performed  by  washing  with  soap  and  water,  then  with  alcohol,  and  finally 
with  sterile  water;  a  sterile  knife  or  needle  should  be  employed,  and  the  virus 
used  should  be  that  which  comes  in  hermetically  sealed  tubes;  after  applica- 
tion to  the  scarified  surface,  it  should  be  allowed  to  dry,  and  the  wound  then 
dressed  with  sterile  gauze. 

When  the  disease  has  once  manifested  itself,  the  wound  should  be  excised 
and  the  part  dressed  with  antiseptic  fomentations.  In  wounds  too  large  for 
excision,  and  even  in  smaller  wounds,  amputation  may  property  be  consid- 
ered. The  most  useful  antiseptics  in  wounds  which  are  not  excised,  arc 
strong  tincture  of  iodin,  i  per  cent,  solution  of  silver  nitrate,  and  bicMorid 
of  mercury,  i  to  500.  Stretching  the  main  nerve  trunks  supplying  the  af- 
fected part  has  been  employed  with  occasional  success;  it  may  be  that  this 


HYDROPHOBIA.  1 1 5 

procedure  interferes  with  the  transference  of  the  toxin  along  the  nerves.  Far 
better,  at  least  theoretically,  is  the  injection  of  antitoxin  into  these  nerves;  for 
this  purpose  the  patient  should  be  chloroformed,  and  the  motor  nerves  which 
supply  the  region  primarily  infected  exposed  as  near  the  cord  as  possible  and 
each  injected  by  a  fine  hypodermic  needle  with  from  5  to  10  or  20  cc.  of  anti- 
toxin (Rogers) .  This  procedure  may  be  repeated  daily  if  there  is  no  improve- 
ment in  the  symptoms.  In  urgent  cases  Rogers  has  injected  from  20  to  30  cc. 
of  antitoxin  into  the  lowest  portion  of  the  cervical  cord.  When  injected  sub- 
cutaneously,  the  antitoxin  neutralizes  only  that  portion  of  the  toxin  which  is 
in  the  circulating  blood,  and  not  that  which  is  in  the  nervous  system,  as  it  is 
not  absorbed  by  the  nerves  as  is  the  toxin.  Antitoxin  has  been  injected  also 
around  the  infected  part,  directly  into  a  vein,  into  the  subarachnoid  space, 
and,  after  making  a  small  trephine  opening  in  the  skull,  directly  into  the 
frontal  lobes  of  the  brain.  The  antitoxin  has  been  introduced  also  into  the 
lateral  ventricle.  Of  124  acute  cases  treated  by  antitoxin  the  mortality  was 
71.77  per  cent.,  of  138  chronic  cases  15.94  per  cent.  (Lambert).  Tetanus 
antitoxin  is  manufactured  by  immimizing  a  horse  with  ascending  doses  of  the 
toxin ;  the  antitoxin  is  contained  in  the  blood  serum,  and  is  sold  either  as  a  fluid 
or  as  a  powder.  The  dose  is  from  20  to  30  cc.  subcutaneously,  intravenously, 
or  subdurally,  and  5  cc.  when  injected  directly  into  the  brain.  The  dried 
serum  may  be  given  in  doses  of  from  3  to  4  grams  repeated  daily.  It  is  proba- 
ble that  with  the  onset  of  symptoms  the  tetanus  toxin  has  already  fatally  em- 
braced the  cells  of  the  central  nervous  system,  and  that  antitoxin  adminis- 
tered in  any  form  is  quite  impotent  to  repair  the  damage  already  done. 
Emulsions  of  fresh  brain  tissue  have  been  injected  hypodermatically,  on  the 
principle  that  the  toxin  would  imite  with  these  nervous  cells  and  thus  become 
neutralized. 

Even  though  antitoxin  is  employed,  the  patient  should  be  isolated  in  a 
darkened  chamber  and  guarded  from  all  forms  of  irritation.  Bromids, 
chloral,  and  morphin  should  be  regularly  administered,  and  the  convulsions 
controlled  by  chloroform.  If  trismus  is  marked,  nasal  feeding  may  be  adopted, 
by  the  passage  of  a  rubber  catheter  into  the  pharynx  through  the  nose,  or 
food  may  be  administered  by  rectum.  Other  drugs  which  have  been  recom- 
mended are  curare,  cannabis  indica,  gelsemium,  physostigma,  and  iodoform. 
Baccelli  claims  satisfactory  results  from  the  hypodermic  injection  of  from 
10  to  30  drops  of  a  I  per  cent,  solution  of  carbolic  acid  every  three  or  four 
hours.  V^enesection  to  lessen  the  amount  of  toxin  in  the  circulating  blood, 
followed  by  intravenous  infusion  of  salt  solution  is  occasionally  employed. 
The  subarachnoid  injection  of  magnesium  sulphate,  cocain,  etc.,  as  in  spinal 
anesthesia,  also  has  been  used  and  appears  to  be  of  some  value  in  controlling 
the  convulsions. 


HYDROPHOBIA. 

Hydrophobia  (rabies,  lyssa)  is  an  infectious  disease  resulting  from  the 
bites  of  animals,  especially  the  dog,  cat,  and  wolf.  The  specific  micro-or^^an- 
ism  has  not  been  isolated.  The  virus  is  found  in  the  saliva,  in  the  central 
nervous  system,  and  occasionally  in  the  lachrymal  gland,  pancreas,  and  marn- 
mary  gland.  It  is  not  found  in  the  blood,  and  further  resembles  the  toxin 
of  tetanus  in  that  it  has  a  marked  affinity  for  the  central  nervou?.  s^'s\erc\,  vo 


Il6  GENERAL  CONDITIONS  AND   SPECIAL  INFECTIONS. 

which  it  is  conveyed  by  the  nerves.  As  in  tetanus,  the  wound  is  often  punc- 
tured, and  may  heal  before  the  onset  of  symptoms,  and  again  become  pain- 
ful as  the  disease  develops.  Between  lo  and  25  per  cent,  of  those  bitten  by 
rabid  animals  subsequently  develop  hydrophobia.  Cases  have  been  re- 
ported in  which  the  disease  has  followed  the  mere  licking  of  the  hand  by  a 
rabid  dog.  Bites  through  clothing,  which  may  wipe  the  virus  from  the  teeth 
of  the  animal,  are  less  dangerous  than  those  on  exposed  parts,  while  bites  in 
parts  richly  supplied  by  nerves,  such  as  the  face  and  hands,  are  the  most 
dangerous.  The  virus  is  present  in  the  saliva  for  several  days,  sometimes  as 
long  as  eight,  before  the  development  of  symptoms,  thus  sustaining  the  pop- 
ular belief  that  hydrophobia  may  follow  the  bite  of  a  dog  which  later  becomes 
rabid.  The  period  of  incubation  in  man  varies  from  a  few  weeks  to  several 
months,  the  average  being  forty  days.  The  disease  is  most  frequent  during 
the  summer  months.  The  gross  changes  usually  found  after  death  are  those 
of  congestion  of  the  brain  and  membranes.  Microscopically,  the  most  im- 
portant findings  are  (i)  aggregations  of  embryonic  cells  in  the  motor  nuclei 
of  the  medulla  and  cord  (rabic  tubercles  of  Bab^s);  (2)  degeneration  of  fhe 
cerebrospinal  and  sympathetic  ganglia,  especially  the  plexiform  ganglia 
of  the  pncumogastric  nerve  and  Gasserian  ganglion,  the  nerve  cells  being 
replaced  by  proliferated  endothelial  cells  derived  from  the  capsule;  and  (3) 
Negri  bodies  (thought  by  Negri  to  be  protozoa  and  the  cause  of  rabies),  which 
are  small  bodies  found  in  the  cells  of  the  central  nervous  system,  particularly 
in  the  Purkinje  cells  of  the  cerebellum  and  in  the  large  ganglion  cells  in  the 
region  of  Ammon's  horn.  The  degenerative  lesions  of  the  ganglia  and  the 
Negri  l)odies  are  pathognomonic,  so  that  a  positive  diagnosis  may  be  made  by 
the  examination  of  an  animal  after  death.  In  order  that  these  changes  may 
occur,  the  animal  should  not  be  killed,  but  allowed  to  die  from  the  disease. 
The  head  may  then  be  removed  and  sent  to  a  reliable  pathologist  for  diagnosis, 
which  may  be  further  confirmed  by  injecting  an  emulsion  of  the  nervous  tissue 
into  a  susceptible  animal.  In  animals  the  presence  of  foreign  bodies,  such 
as  stone,  hair,  etc.,  in  the  stomach,  owing  to  the  depraved  appetite  character- 
istic of  the  disease,  strongly  points  to  rabies. 

In  the  dog  the  symptoms  appear  usually  in  from  three  to  five  weeks  after 
infection.  In  the  raging,  or  maniacal  rabies,  there  is  first  a  stage  of  depression, 
characterized  by  irritability,  restlessness,  abnormal  appetite  (for  rubbish,  etc.), 
dysphagia,  and  nausea.  This  stage  lasts  for  two  or  three  days,  and  is  the 
dangerous  one  for  man,  because  the  disease  may  not  be  suspected.  This  is 
followed  by  a  stage  of  madness,  or  frenzy,  lasting  three  or  four  days,  in  which 
the  dog  charges  about,  barking  furiously  with  a  hoarse  bark,  and  biting 
anything  with  which  it  comes  in  contact;  this  stage  terminates  in  paralysis 
and  death.  From  the  beginning  there  is  a  large  quantity  of  ropy  saliva 
secreted.  In  the  qtiiet,  or  melancholy  form,  the  disease  skips  from  the  first  to 
the  third  stage,  death  occurring  within  two  or  three  days  from  the  beginning. 

In  man  the  symptoms  of  the  first  stage  are  restlessness,  excitability,  a 
vague  terror,  insomnia,  anorexia,  and  occasionally  some  thickening  of  the 
cicatrix,  which  may  be  the  seat  of  a  burning  or  itching  pain.  These  symp- 
toms last  about  twenty-four  hours,  and  are  succeeded  by  the  second  stage, 
in  which  there  are  dysphagia  owing  to  spasm  of  the  pharynx,  and  dyspnea 
from  spasm  of  the  respiratory  muscles.  The  spasms  are  clonic  in  character, 
may  bc( ome  more  or  less  generalized,  and  arc  precipitated  by  the  slightest 
irrih'jlion.  especially  by  attempts  to  swallow  li(|uid,  hence  the  term  hydro- 


ANTHRAX.  117 

phobia.  As  in  the  dog,  there  is  a  large  quantity  of  ropy  mucus  and  saliva 
secreted.  Owing  to  the  spasm  of  the  respiratory  muscles,  noises,  which  have 
been  likened  to  the  barking  of  a  dog,  may  be  produced.  During  this  stage 
there  are  outbreaks  of  mania  with  lucid  intervals.  There  is  usually  very 
little  fever,  and  at  the  end  of  from  one  to  three  days  death  occurs  from  a 
rapidly  ascending  paralysis.  No  authentic  case  of  infection  of  man  by  man 
has  bcJen  reported.     The  disease  invariably  results  in  death. 

The  Treatment. — In  the  prophylactic  treatment  should  be  mentioned  the 
muzzling  of  dogs.  A  wound  produced  by  a  supposedly  mad  dog  should  be 
squeezed  and  sucked,  and  disinfected  with  bichlorid  solution  (i  to  1000); 
cauterization  is  not  recommended.  When  on  an  extremity  a  ligature  should 
be  placed  above  the  bite  imtil  the  wound  has  been  disinfected.  Excision  is 
preferable,  and  may  be  efficacious  even  a  number  of  days  after  the  injury, 
as  the  virus  tends  to  remain  localized  and  merely  creeps  along  the  nerves. 
The  animal  should  not  be  killed,  but  allowed  to  die  of  the  disease,  if  it  be 
really  present,  when  a  positive  diagnosis  may  be  made.  As  soon  as  possible 
after  inoculation  the  patient  should  be  given  the  Pasteur  treatment  (antirabies 
vaccination),  which  is  prophylactic  and  not  curative.  It  is  founded  on  the 
principle  of  inducing  active  immunity  by  the  injection  of  ascending  doses  of 
the  virus.  The  most  virulent  virus  obtainable  is  secured  by  passing  the  poison 
from  a  dog  through  a  succession  of  rabbits,  imtil  the  incubation  period  is 
shortened  from  three  weeks  to  seven  days.  When  the  virus  has  reached  its 
maximum  intensity,  it  is  called  virus  pee,  in  contradistinction  to  the  virus  in 
accidentally  infected  animals,  whose  strength  is  not  known.  The  spinal 
cords  of  rabbits  which  have  died  after  inoculation  with  the  virus  fixe  gradually 
lose  their  virulence  by  drying,  imtil  at  the  end  of  fourteen  days  they  are 
practically  innocuous.  The  vaccine  consists  of  about  i  cm.  of  the  spinal 
cord  of  a  rabbit  killed  by  the  fixed  virus,  emulsified  with  5  cc.  of  sterile  broth 
or  salt  solution.  About  3  cc.  of  this  emulsion  are  used  as  an  injection  twice 
a  day.  On  the  first  day  3  cc.  of  a  fourteen  day  cord  and  3  cc.  of  a  thirteen  day 
cord  are  injected,  and  the  strength  is  gradually  increased,  until  on  the  eight- 
eenth day  2  cc.  of  a  three  day  cord  are  used.  In  bites  about  the  head  and 
face,  in  which  the  period  of  incubation  is  shorter,  the  virulency  of  the  injec- 
tions may  be  increased  more  rapidly.  If  the  patient  lives  within  a  day's 
journey  of  a  reliable  Pasteur  Institute,  the  virus  may  be  sent  to  him  by  mail 
and  injected  by  the  family  physician.  Of  104,347  cases  in  which  the  Pasteur 
treatment  has  been  used, but  .73  per  cent,  developed  hydrophobia  (Bernstein). 
The  serum  of  artificially  immunized  sheep  has  been  recommended,  both  for 
prophylactic  and  curative  purposes,  but  has  apparendy  never  been  used  in 
man.  After  the  symptoms  have  once  appeared,  chloroform,  chloral,  and 
morphin  should  be  employed,  and  the  patient  carefully  guarded  from  all 
forms  of  irritation. 

Pseudohydrophobiay  or  lyssophohia,  is  a  mixture  of  hysteria  and  fright,  and 
is  invariably  followed  by  recovery. 

ANTHRAX. 

Anthrax  {malignant  pustule,  wool-sorter's  disease,  splenic  fever,  charhon, 
Milzbrand)  is  an  acute  infectious  disease  occurring  in  animals,  particularly 
catde,  and  occasionally  communicated  to  man.  Dogs,  cats,  pigs,  the  major- 
ity of  birds,  and  cold  blooded  animals  are  naturally  immune  to  anthrax.  The 
disease  is  common  in  Russia,  Himgary,  and  certain  parts  of  France  and 


ii8 


GENERAL  CONDITIONS  AND  SPECUL  INFECTIONS. 


I 


Germany,  and  comparatively  infrequent  in  England  and  the  United  States, 
It  is  caused  by  the  anthrax  bacillus,  a  non- motile,  facultative  anaerobe  with 
square  or  slightly  cupped  ends,  which  is  equal  in  length  to  the  diameter  of  a 
red  blood  corpuscle  or  even  longer,  and  which  has  a  tendency  to  form  chains. 
When  cultivated  outside  the  body  it  forms  spores,  which  have  the  greatest 
resistance  to  all  forms  of  antiseptics.  The  bacillus  is  found  in  local  lesions, 
in  the  circulating  blood,  and  in  the  various  organs  of  the  body.  In  animals 
it  enters  the  body  through  the  gastrointestinal  tract  with  the  food.  More 
rarely  the  lungs  are  infected  by  inhalation.  In  man  the  organism  usually 
lodges  in  a  wound  or  abrasion,  although  the  gastrointestinal  and  pulmon- 
ary varieties  may  occur.  Infection  may  be  conveyed  by  flies,  and  by  catgut 
prepared  from  diseased  animals.  Farmers,  butchers,  veterinar)'  surgeons, 
and  those  who  handle  hides,  wool,  horse-hair,  etc.,  are  predisposed  to 
infection. 

In  exlemai  anthraXf  the  usual  lesion  in  man,  the  symptoms  appear  in 
from  a  few  hours  to  five  or  six  days  or  even  longer.  The  character  of  the 
local  lesion  largely  depends  upon  the  structure  of  the  part;  thus  in  dense, 
highly  vascular  tissue  aniltrax  carbtmdt\  or  malignant  pustule^  results, 
and  in  lax  parts,  with  a  poorer  blood  supply,  anthrax  edema  occurs.  M 
lignant  pustule  {Fig.  78)  begins  as  a  small,  red,  burning  or  itching  pimpi 
capped  by  a  vesicle,  which  rapidly  grows  in  size 
V  n      The  surrounding  tissues  become  infiltrated,  and  a 

■  secondary    ring   of   vesicles   develops  around   the 

I  primary  vesicle,  which  soon  bursts  and  turns  black, 

^^^^^^^  forming  a  slough;  in  the  meantime  the  lymphatic 

^^^Hflf^H  glands  enlarge  and  grow  tender.     The  process  may 

^^^^^^^^^^,  be  arrested  at  this  point,  the  slough  separating  and 
^^^^^^^^^n(  the  resulting  ulcer  healing  by  granulation.  Anthrax 
^^^^^^^^H|l  edema  k  characteri^^ed  by  a  rapidly  spreading,  livid 
^^^^^BHH^I  edema,  which  is  associated  with  vesicles  fliled  uith 
^^^BIBHBiJBMI  dark  bloody  serum,  and  followed  by  gangrene  of 
the  skin  and  subcutaneous  tissues.  In  either  form 
Fig.  78.— Anihraxpusiulc  of  external  anthra.x  pain  is  slight  and  suppuration 
absent,  and  in  many  instances  the  constitutional 
symptoms  are  few  and  mild.  When  the  process 
spreads  and  bacteremia  develops,  there  are  symp- 
toras  of  general  intoxication,  such  as  high  temperature,  rapid  pulse, 
vomiting,  embarrassed  respiration,  and  delirium,  the  patient  dying  in  from 
one  to  seven  days  from  the  onset.  Inkmal  anthrax  also  occurs  in  two 
forms.  In  intestinal  anthrax  there  are  vomiting  and  blood  stained  diarrhea; 
in  the  pulmonary  form  cough,  rapid  respiration,  cyanosis,  and  physical 
signs  of  pneumonia;  the  symptoms  in  either  instance  rapidly  progressing  to 
collapse  and  death. 

The  diagnosis  should  always  be  confirmed  by  bacteriological  examination* 
Ordinary  carbuncle  is  distinguished  from  anthrax  by  the  presence  of  pain, 
numerous  points  of  suppuration,  and  a  chronic  course.  The  spreading  forms 
of  cellulitis  differ  from  anthrax  edema  by  the  greater  pain,  the  marked  ten* 
dency  to  suppuration,  and  the  absence  of  the  characteristic  adherent  sloughs. 
The  prognosis  of  external  anthrax  is  more  favorable  in  the  carljuncular  form 
than  in  anthrax  edema.  The  mortality  is  25  per  cent.  Recovery  is  rare 
aSter  infection  of  the  lungs  or  intestinal  canal. 


M 
^ 


on  the  arm  i>f  . 
worked  in  hides, 
vania  HospilaL) 


man  who 
(PcnnsyU 


ACTINOMYCOSIS.  II9 

The  treatment  is  excision  whenever  possible,  the  resulting  wound  being 
cauterized  with  the  actual  cautery  or  with  nitric  acid.  In  other  cases  free 
incisions  should  be  made,  and  bichlorid  of  mercury,  i  to  1000,  iodin,  i  to  2  in 
water,  or  carbolic  acid,  2  or  3  per  cent.,  injected  into  and  around  the  infected 
tissues.  The  wotmd  should  be  dressed  with  wet  bichlorid  compresses,  i  to 
1000.  Ipecac  has  been  used  locally  and  internally.  The  constitutional  treat- 
ment is  that  of  septicemia.  The  patient  should  be  isolated,  dressings 
burned,  and  discharges  disinfected.  After  removal  of  the  patient  a  room 
should  tmdergo  the  most  rigid  disinfection,  owing  to  the  great  resistance  of 
the  spores.  Very  favorable  results  have  recently  been  reported  from  the  use 
of  Sdavo's  serum,  which  is  made  by  immunizing  asses  with  attenuated 
cultures  of  the  bacillus;  30  to  40  cc.  are  injected  into  the  flank  in  three  or 
four  different  places,  or  in  severe  cases  directly  into  a  vein.  Cattle  are  pro- 
tected from  anthrax  by  inoculating  them  with  a  virus  weakened  by  heat. 

GLANDERS. 

Glanders  {Farcy ^  Equinia,  Malleus)  is  an  infectious,  contagious  disease 
occurring  in  animals,  particularly  horses,  asses,  and  mules,  and  occasionally 
transmitted  to  man.  The  specific  organism,  the  bacillus  malleiy  is  an  amotile, 
facultative  anaerobe,  looking  somewhat  like  the  tubercle  bacillus.  It  gains 
entrance  to  the  tissues  through  a  wound  or  abrasion  of  the  skin,  or  through  the 
unbroken  mucous  membrane  of  the  conjunctivae  or  respiratory  passages. 
The  period  of  incubation  is  four  or  five  days.  Glanders  may  be  acute  or 
chronic,  and  is  characterized  by  the  development,  imder  the  skin  or  mucous 
membrane,  of  nodules  that  suppurate  and  give  rise  to  ulcers,  which  may 
burrow  deeply  and  attack  the  bone.  These  nodules  may  be  scattered  also  in 
the  various  viscera.  The  term  farcy  is  sometimes  restricted  to  the  cutaneous 
form,  when  the  nodules,  which  develop  chiefly  along  the  lymph  vessels,  are 
called  "farcy  buds."  The  constitutional  symptoms  are  those  of  septicemia. 
Death  may  occur  within  a  week  in  acute  glanders.  In  the  chronic  form  the 
lesions  are  more  circumscribed  and  develop  more  slowly,  recovery  occurring 
in  50  per  cent,  of  the  cases. 

Diagnosis. — Acute  glanders  may  be  mistaken  for  such  suppurative 
affections  as  small-pox,  although  the  lesions  are  deeper  and  there  is  absence  of 
umbilication.  In  the  ulcerative  stage  it  may  be  confused  with  syphilis  or 
tuberculosis.  In  doubtful  cases  a  history  of  exposure  to  infection  and  a 
bacteriological  examination  will  settle  the  diagnosis.  In  animals  mallein,  a 
bacterial  product  made  like  tuberculin,  is  injected  subcutaneously,  causing 
fever  and  localized  swelling  if  glanders  is  present. 

Preventive  treatment  consists  in  the  destruction  of  infected  animals.  In 
man  nodules  are  extirpated,  ulcers  curetted  and  disinfected,  and  abscesses 
opened  and  cauterized.    The  constitutional  treatment  is  that  of  septicemia. 

ACTINOMYCOSIS. 

Actinomycosis  is  an  infectious  disease,  occurring  principally  in  cattle 
(Jumpy  jaw),  and  occasionally  in  man.  The  cause  is  the  ray  fungus^  or 
actinomyceSy  which  belongs  to  the  streptothrices,  a  group  of  micro-organisms 
lying  between  the  moulds  and  bacteria.  It  is  anaerobic,  and  occurs  in  clumps 
consisting  of  a  central  mass,  with  radiating  threads  or  mycelia  with  club-like 


I20  GENERAL  CONDITIONS  AND   SPECIAL  INFECTIONS. 

ends.  The  ray  fungus  is  widely  distributed  in  nature,  but  is  most  frequently 
found  in  various  forms  of  grain,  from  which  it  enters  the  tissues  through 
the  respiratory  tract  (e.g.,  by  inhaling  dust  during  the  grinding  of  com), 
through  the  alimentary  tract  (from  the  chewing  of  raw  grain,)  or  through 
an  abrasion  or  wound  of  the  skin. 

Pathologically  the  process  resembles  a  chronic  inflammation,  which, 
owing  to  the  abundant  round-celled  infiltration  and  proliferative  changes  in 
the  connective  tissue  cells,  forms  tumor-like  masses.  The  ray  fungus  is 
probably  not  pyogenic,  but  suppuration  is  prone  to  occur,  as  the  result  of 
secondary  infectic^n  with  pus  germs.  The  disease  occurs  most  frequently  in 
the  lower  jaw  and  adjacent  tissues,  less  frequently  in  the  respiratory  tract  and 
intestines,  and  rarely  in  the  skin. 

The  symptoms  are  those  of  a  firm  and  painless  swelling  that  gradually 
increases  in  size  and  finally  breaks  down  at  various  points,  giving  rise  to  si- 
nuses that  discharge  pus  having  a  peculiar  earthy  odor  and  containing  minute, 
gritty,  sulphur-yellow  bodies,  which  under  the  microscope  are  found  to  be 
masses  of  actinomycetes.  The  lymphatic  glands  are  not  at  first  involved,  but 
may  become  so  later,  owing  to  mixed  infection,  which  is  responsible  also  for 
the  constitutional  symptoms.  The  process  spreads  from  its  point  of  origin, 
involving  tissues  by  contiguity  irrespective  of  their  structure.  Rarely  it  may 
break  into  a  vein,  causing  a  general  dissemination  of  the  actinomycetes  {acli- 
nomycoUc  pyemia) .  If  all  the  organisms  are  discharged  by  suppuration,  spon- 
taneous recovery  may  occur;  indeed  this  may  happen  in  portions  of  the  mass, 
giving  a  nodular  and  puckered  appearance,  which  has  been  regarded  as 
almost  pathognomonic.  When  involving  the  cervico-facial  region  trismus  is 
frequently  seen.  The  prognosis  is  favorable  if  the  disease  is  so  situated  as 
to  be  accessible  to  surgical  treatment,  and  exceedingly  unfavorable  in  regions 
like  the  internal  organs,  in  which  it  cannot  be  completely  eradicated,  death 
occurring  from  exhaustion,  sepsis,  or  pyemia. 

The  treatment  is  excision,  if  the  lesion  be  small;  in  other  cases  the  sinuses 
should  be  widely  opened,  curetted,  swabbed  with  tincture  of  iodin  or  cauter- 
ized with  pure  nitrate  of  silver,  and  packed  with  iodoform  gauze.  The  con- 
stitutional treatment  consists  in  the  use  of  large  doses  of  iodid  of  potassium, 
which  is  given  for  one  week,  then  discontinued  for  three  or  four  days,  and 
given  for  another  week.  The  interruptions  allow  resistant  spores  to  develop 
into  adult  forms,  when  they  arc  more  readily  destroyed  by  the  drug.  Iodid  of 
potassium  in  i  per  cent,  solution  may  be  used  as  an  injection  into  and 
around  the  focus  of  infection.     The  X-rays  also  have  been  used. 

MYCETOMA  OR  MADURA  FOOT. 

Mycetoma,  or  madura  foot,  is  an  infectious  disease,  almost  invari- 
ably attacking  the  foot,  and  occurring  most  frequently  in  India  and  rarely  in 
America.  The  disease  is  closely  related  to  actinomycosis,  being  caused  by 
the  strcptothnix  madura.  Following  an  injury  to  the  foot,  there  develops  a 
nodular  inflammatory  swelling  that  breaks  down  and  forms  sinuses  discharg- 
ing a  watery  pus,  which  contains  masses  of  the  organism  in  the  form  of  whitish 
or  black  granules.  In  the  former  instance  the  disease  is  called  paie^  or 
ochroid,  in  the  latter  black,  or  melanoid  mycetoma.  The  foot  becomes  greatly 
enlarged  and  deformed,  and  the  leg  atrophied.  In  very  early  cases  the  area 
may  be  excised;  later  amputation  is  the  only  treatment. 


SYPHILIS.  121 

LEPROSY. 

Leprosy  (lepra,  elephatUiasis  Gracorum)  is  an  infectious  and  feebly  con- 
tagious disease  caused  by  the  bacillus  lepra ^  which  closely  resembles  the 
tubercle  bacillus,  though  it  is  more  readily  stained  and  less  frequently  curved. 
Excepting  some  of  the  Gulf  states  and  portions  of  the  Pacific  coast,  leprosy 
is  very  rare  in  the  United  States,  but  is  common  in  Mexico,  South  America, 
Norway  and  Sweden,  and  in  the  Orient.  It  occurs  in  two  forms,  the  tuber- 
cular and  the  anesthetic,  which  are  often  associated.  The  period  of  incuba- 
tion is  generally  from  three  to  five  years.  TuherctUaiedy  or  cutaneous  leprosy, 
occurs  most  frequently  on  the  face,  hands,  feet,  and  extensor  surfaces  of  the 
elbows  and  knees.  After  a  period  of  feverishness  with  digestive  disturbances, 
there  appear  little  hyperemic  nodules,  which  may  disappear  only  to  reappear. 
Later  the  redness  fades  and  the  nodules  increase  in  size,  occasionally  be- 
coming as  large  as  a  hen's  egg,  and  break  down  to  form  indolent  ulcers,  or 
are  converted  into  contracting  cicatricial  tissue,  which  causes  hideous 
deformities,  that  of  the  face  being  characteristic  (leotUiasis  leprosa);  the 
mucous  membranes  and  the  viscera  likewise  may  be  involved,  and  there  is 
atrophy  of  the  testicles  or  ovaries  with  loss  of  sexual  power.  Anesthetic,  or 
nervous  leprosy,  begins  with  neuralgia  and  tenderness  of  certain  peripheral 
nerves,  most  frequently  the  median,  ulnar,  saphenous,  and  peroneal.  Later 
there  are  anesthesia,  paralysis,  and  trophic  disturbances,  the  last  involving 
the  bones,  joints,  and  muscles,  as  well  as  the  skin,  and  producing  great  deform- 
ity. WTiitish  or  brownish  spots  appear  on  the  skin,  and  gradually  grow  larger 
and  coalesce.  As  the  result  of  injuries  to  the  anesthetic  areas,  various  second- 
ary infections  may  occur,  producing  widespread  ulceration,  or  even  gangrene 
(lepra  mutilans).  Death  occurs  in  from  one  to  twenty  years,  from  exhaus- 
tion, or  from  some  complication,  not  uncommonly  tetanus  or  tuberculosis. 

The  treatment,  in  addition  to  isolation  of  the  patient,  is  symptomatic,  no 
specific  drug  being  known.  Of  the  many  remedies  which  have  been  tried, 
chaulmoogra  oil,  15  to  20  drops  daily,  on  bread,  seems  to  l>e  the  most  lK;ne- 
ficial.  Oudin  is  a  warm  advocate  of  radiotherapy.  In  the  very  earliest 
stages  excision  of  the  diseased  areas  may  be  considered.  In  the  anesthetic, 
variety  nerve  stretching  has  been  recommended.  Ulcers,  gangrene,  etc.,  arc 
treated  according  to  general  surgical  principles;  amputations  and  other 
operations  may  be  required,  the  wounds  in  such  cases  healing  without  misha  p 

STPHILIS. 

Syphilis  is  a  highly  contagious  disease  due  to  the  spirocheta  (treponema) 
pallida  (Schaudinn  and  Hoffman),  an  actively  motile,  unirellar,  spiral 
parasite  (probably  a  protozoon),  varying  from  4  to  14  *i  in  length,  and  pr^ssess- 
ing  pointed  ends  and  from  3  to  12  curves  (Fig.  79J.  TTic  spiro'  heu  may  Ix: 
found  in  the  primary  and  in  all  secondary'  lesions,  also  in  the  \A(ttA,  urine, 
saliva,  lymph  glands,  and  internal  organs.  It  has  l>een  found  in  -mall 
numbers  in  gummata  and  in  large  numbers  in  still -U>m  s^-phiiiti'  fetu*.^-.. 
.\lthougb  it  has  never  been  cultivated  outside  of  the  Uxly.  it  \jT^yl'i'*:* 
syphilis  in  apes,  from  the  leaons  of  which  it  r.an  again  \jt  re^ovfrreri. 

Methods  of  InfectioilS. — Elxcepting  i>  ■  ccmK^ptional  ;%phiii:."  ir.  -Ah;r  h 
a  mother  is  contaminated  by  a  sj-philitic  fetus  the  father  havir,^  t.^e  '^ii-./^i-/:, 
through  tbe  placenlal  drcnlation.  acquired  v.phili:  Ls  always  '2,  iriitfated  v/  a 


122  GENERAL  CONDITIONS  AND  SPECIAL  INFECTIONS. 

chancre,  the  result  of  infection  of  an  abrasion  or  other  solution  of  continuity 
of  an  epithelial  surface,  usually  of  the.genital  organs  during  sexual  intercourse. 
Syphilis  insoniium  is  a  term  applied  to  the  disease  innocently  acquired,  the 
chancre  in  these  cases  often  being  extragenital,  e.g.,  on  the  lip  from  the 
use  of  an  infected  glass  or  pipe.  The  disease  may  be  carried  by  a  third 
person  who  does  not  acquire  the  disease;  thus  an  uncleanly  surgeon  niay  con- 
vey the  virus  on  his  finger  from  one  patient  to  another.  Cangenikdy  or  heredi- 
tary syphilis,  does  not  present  a  chancre;  it  is  (i)  the  result  of  syphilis  in  one  or 

both  parents  previous  to  conception,  or 

/  (2)  of  infection  through  the  placenta  in 

^ — 'T/'^^s.  ^^^^  *^^  mother  acquires    the    disease 

y^  ^plrC  y  ^^JN.  subsequent  to  conception.    The  disease 

^••'/^-%^}g  is  actively  contagious  for  several  years, 

/l^^y^j^^  Si\j\        ^'^'*  during  the  primary  and   secondary 

/  .  ^  /  )  ^  \J^^  f^  \       stages.      When   the  tertiary  stage  has 

I  i  <!^/^2M    .^y^^^    1  \    ^^^^  reached  the  disease  is  said  to  be  no 

\      /I? —  /i.  .Ji..  ../  Jb  longer  contagious,  although  the  organ- 

A.....V..../\--jy2^    \\    ^ J\   '    isms  have   been   demonstrated    in    the 

\    (^1      /     ^^y  lesions.    The  germ  of  syphilis  is  difficult 

sO^  05^  \  ^^^  to  kill,  thus  a  wound  will  frequently  be 

''^^^^^       '.:1>^.  ^  the  site  of  a  chancre  though  carefully 

Fig.  79.— Spirocheta  from  a  case  of    disinfected  within  even  a  few  hours  after 

syphilis.    (McWeeney).  its  infection.     One  attack  of  the  disease 

A,  A.  Pairs  united  at  one  end.    B,  b.    generally,  but  not  always,  confers  *m- 

Twi^ted    forms,      c.    Double    length     ^^^^^^      ^g^g^      subsequent      attacks. 

Colics*  immunity  is  that  possessed  by  a 
mother  who,  although  having  a  syphilitic  husband  and  giving  birth  to 
syphilitic  children,  yet  herself  remains  untainted.  Prof  eta*  s  immunity  is 
that  possessed  by  healthy  children  of  syphilitic  parents. 

The  period  of  incubation  is  from  one  week  to  three  months,  the  average 
being  twenty-one  days.  During  this  time  the  breach  of  surface  through  which 
the  organism  has  entered  the  body  heals  and  no  signs  of  trouble  are  manifest, 
unless  there  has  been  at  the  same  time  infection  with  chancroidal  or  pyogenic 
bacteria. 

The  disease  itself  is  divided  into  three  stages:  The  primary  stage  com- 
prises the  chancre  and  indolent  bubo.  The  time  elapsing  between  the  ap- 
pearance of  the  chancre  and  the  second  stage,  usually  about  six  weeks,  is 
called  the  period  of  secondary  incubation.  The  second  stage  consists  prindpsdly 
of  superficial  lesions  of  the  skin  and  mucous  membranes.  It  lasts  from  one 
to  three  years,  and  is  followed  by  recovery,  or  by  a  latent  or  intermediate 
period,  lasting  from  a  few  months  to  many  years  (usually  two  to  four  years), 
in  which  the  symptoms  are  slight  or  absent.  The  third  stage,  the  duration  of 
which  is  indefinite,  consists  of  gummatous  degeneration  or  diflFuse  sclerotic 
changes  in  various  parts  of  the  body.  In  some  cases  the  secondary  merges 
with  or  overlaps  the  tertiary  stage,  so  that  no  distinct  line  can  be  drawn 
between  them. 

The  typical  chancre,  or  initial  lesion,  begins  as  a  minute,  erythematous, 
painless  papule,  which,  as  it  enlarges,  becomes  indurated  and  loses  its  epithe- 
lial covering,  appearing  as  a  round,  oval,  or  linear  erosion,  whose  center  is 
covered  by  a  grayish,  glistening  film,  and  whose  border  is  the  color  of  raw 
muscle.     Suppuration  is  slight  or  absent,  the  discharge  being  scanty,  thin,  and 


SYPHILIS. 


123 


watery*  Chancre  is  usually,  but  not  b variably,  single.  When  multiple  all  the 
chancres  appear  at  the  same  time,  as  the  infection  is  not  antoinoculable.  A 
chancre  does  not  always  present  the  same  appearance^  being  modified  accord- 
ing to  its  situation  and  the  presence  or  absence  of  complications,  which  are 
rare.  On  the  skin  a  chancre  not  exposed  to  maceration  or  irritation  does  not 
ulcerate,  or  at  most  simply  desquamates,  forming  a  scab.  When  subjected  to 
irritation  or  maceration  it  ulcerates  {Hunlerian^  ar  ulcerative  tlmncre),  then 
being  oval  or  roiind»  with  sloping  edges.  The  characteristic  features  of  a 
chancre  may  be  masked  by  the  presence  of  phagedena  (p,  77)  or  other  forms 
of  infection;  in  a  **  mixed  chancre^^^  in  which  chancroidal  and  syphilitic  organ- 
isms are  both  present,  the  diagnosis  can  rarely  be  made  from  appearances 
alone.  The  induradon  of  a  chancre,  which  is  due  to  sclerosis  of  the  blood 
vessels  and  hyperplasia  of  the  connective  tissue  cells,  is  circumscribed  and  of 
the  consistency  of  hard  rubber  or  cartilage,  but  varies  in  thickness  according 
to  the  structure  of  the  affected  part;  thus  on  the  glans  penis  it  may  feel  like  a 
piece  of  paper  (Joliaceous  induration)  or  a  visidngcard  {parch  tnenl  mduralim)^ 
while  in  laxer  dssues  it  is  greater  in  extent  and  may  feel  like  a  foreign  body  in 
the  tissues  {nodular  induraiion).  In  rare  cases  induration  does  not  occur  for 
several  weeks  after  the  appearance  of  ulceration;  in  fact,  in  verj'  rare  instances 
it  may  never  occur.  With  the  healing  of  the  chancre  (usually  in  from  four  to 
six  weeks)  the  induration  gradually  disappears,  but  if  originally  extensive,  it 
may  still  be  detected  for  months  or  years.  LitUe  or  no  scar  results,  unless  the 
corium  has  been  destroyed  by  ulceration,  ,  Ulceration  or  rein  duration  at  the 
site  of  the  original  chancre  (chancre  rediLx)  may  occur  after  years  as  the  result 
of  reinfection  (very  rare)  or  gummatous  degeneration.  The  most  frequent 
situation  of  chancre  in  the  male  is  the  balanopreputial  fold,  in  the  female  the 
inner  surface  of  the  labia  majora.  Fournier,  however,  has  seen  chancre  on 
every  part  of  the  body  except  the  siAc  of  the  foot,  A  chancre  may  be  easily 
overlooked,  e.g.,  when  on  the  os  uteri,  when  of  the  non-ulcerating  or  descfua- 
mating  variety,  and  when  situated  in  some  extragenital  region. 

The  syphilitic  bubo  (sateliite  bubo)  is  a  constant  consort  of  the  chancre, 
appearing  with  its  induration.  The  enlarged  glands  appear  in  the  groin 
when  the  lesion  is  upon  the  external  genitals,  in  the  submaxillary  region  when 
on  the  lip,  and  in  the  axilla  when  on  the  breast  or  hand.  They  are  (i)  small, 
(2)  non  inflammator}'  (paiidess,  freely  movable,  not  covered  by  adherent  or 
reddened  skin,  and  do  not  suppurate),  (3)  hard  (induration  of  the  chancre 
transferred  to  thelymphatic  glands),  and  (4)  polyganglionic  (pleiadof  Ricord), 
feeling  like  a  group  of  almonds  (amygdaloid)  beneath  the  skin.  An  inflam- 
raalory  bubo  the  result  of  any  other  form  of  infection,  including  chancroid 
and  gonorrhea,  pursues  an  acute  course,  with  pain,  greater  swelling,  fixity 
of  the  glands,  adherent  and  reddened  skin,  l>oggy  induration,  edema,  and 
eventual  suppuration,  and  does  not  respond  to  syphilitic  treatment. 

The  diagnosis  of  chancre  may  be  confirmed  (i )  by  fmding  the  spirocheta 
palUda  in  the  discharge,  (2)  by  the  Wassermann  (or  Noguchi)  scrum  reaction,* 

♦The  Waisemiann  reaction  appears  fifteen  to  thirty  days  after  the  chancre,  and  disap- 
pears when  recovery  takes  place,  when  the  disease  becomes  inactive,  and  when  the  patient 
n  sarumted  with  antisyphihtic  remedies.  The  nature  of  the  reaction  is  not  understood. 
It  15  nol,  as  was  at  first  thought,  the  result  of  fixation  of  the  complement  by  immune  bodies 
m  the  patieni's  scrum.  The  test,  which  requires  a  trained  laborator)'  worker  with  a 
complete  knowledge  of  the  principles  of  hemolysis,  is  performed  as  follows:  .05  cc.  of  the 
patient's  scnwn,  heated  for  one  hour  at  55^  C,  is  mixed  with  .  5  cc.  of  normal  salt  solution^ 
-I  cc.  o£  an  alcoholic  extract  of  ox  s  liver,  and,  to  act  as  complemetilj  .  i  cc,  cA  ^mt?^-'^^^^ 


124  GENERAL  CONDITIONS  AND   SPECIAL  INFECTIONS. 

which  is  present  in  from  80  to  90  per  cent,  of  cases  of  active  syphilis,  and 
only  occasionally  in  other  infections  (yaws,  leprosy,  sleeping-sickness),  (3) 
by  the  therapeutic  test  (i.e.,  prompt  response  to  antis3rphilitic  treatment), 
or  (4)  by  waiting  for  secondary  symptoms..  Extragenital  chancres  occur 
most  frequently  about  the  mouth,  breasts,  and  anus,  and  are  usually  larger, 
but  less  indurated,  than  the  genital  chancre.  The  discharge  is  more  profuse, 
the  base  of  the  ulcer  covered  with  a  dirty  membrane  or  scab,  the  adjacent 
lymph  glands  are  apt  to  be  larger  and  more  tender,  and  the  constitutional 
symptoms  more  severe.  Of  particular  interest  to  surgeons  and  obstetricians 
is  chancre  oftfie  finger,  which  is  frequently  mistaken  for  a  whitlow,  as  it  is  often 
accompanied  by  considerable  pain  and  discharge.  It  is  distinguished  by  its 
sharp  circumscription,  dense  induration,  long  duration,  failure  to  react  to 
antiseptic  treatment,  and  by  enlargement  of  the  epitrochlear  gland. 

Chancroid  has  no  period  of  incubation,  is  rarely  seen  except  on  the  glans 
penis  or  prepuce,  commences  as  a  pustule  or  ulcer,  is  frequently  multiple,  and 
is  autoinoculable;  it  is  usually  irregular  in  shape,  punched  out,  and  excavated, 
with  a  dirty  yellowish,  uneven  base  and  a  copious  purulent  discharge;  if  indu- 
ration is  present,  it  is  softer  than  that  of  chancre,  fades  off  gradually  into  the 
surrounding  tissues,  and  disappears  with  the  healing  of  the  ulcer;  it  is  painful, 
does  not  confer  immunity  against  a  second  attack,  is  more  frequently  compli- 
cated by  extensive  ulceration  and  suppurative  bubo,  is  healed  by  local  meas- 
ures and  uninfluenced  by  mercurial  treatment,  and  the  bacillus  of  Ducrey 
may  be  found  in  the  discharge. 

Herpetic  ulceration  about  the  genitals  follows  fevers,  neuralgia,  or  irrita- 
tion from  dirt  or  discharges,  and  has  no  period  of  incubation.  It  com- 
mences as  a  number  of  vesicles,  which  may  run  together,  forming  a  large 
irregular  ulceration  whose  edges  are  made  up  of  segments  of  circles.  The 
discharge  is  purulent  but  not  abundant,  vesicles  which  have  not  burst  may 
be  found,  bubo  is  commonly  absent,  the  ulceration  is  painful,  superficial, 
not  indurated,  and  it  heals  under  local  treatment. 

Urethral  chancre  may  be  mistaken  for  urethritis.  The  period  of  incuba- 
tion of  chancre  is  over  ten  days,  that  of  urethritis  under  one  week.  In  chancre 
the  pain  is  felt  only  at  the  meatus,  in  urethritis  it  extends  along  the  whole 
urethra;  chordee  is  absent  in  the  former  and  present  in  the  latter.  The  dis- 
charge in  chancre  is  scanty,  serous,  and  sometimes  bloody;  in  urethritis 
it  is  profuse,  purulent,  and  less  frequently  blood  stained.  The  character- 
istic induration  may  be  felt,  and  superficial  ulceration  seen,  in  chancre,  gener-- 
ally  in  one  of  the  lips  of  the  meatus.  The  bubo  of  chancre  is  constant  and 
practically  never  suppurates;  in  urethritis  bulx)  is  absent,  or  if  present, 
usually  suppurates.  Chancre  is  followed  by  constitutional  symptoms,  which 
are  absent  in  urethritis.  Microscopic  examination  of  the  discharge  may 
reveal  the  spirocheta  or  the  gonococcus,  and  the  blood  may  be  examined  for 
the  Wassermann  reaction. 

Labial  chancre  may  be  confused  with  ephithelioma.  Chancre  in  this 
region  shows  no  marked  preference  for  either  sex;  it  may  be  seen  on  either 

serum.  The  mixture  is  incubated  for  one  and  one-half  hours,  "to  alk>w  fixation  of  the 
complement  to  occur."  Next  is  added  ''  i  cc.  of  a  5  per  cent,  suspension  of  sensitized 
corpuscles  (usually  sheep's  or  ox's  ),  i.e.,  corpuscles  io  which  has  been  added  a  sufficient 
<|uantity  of  immune  serum  to  proflucc  lysis  on  the  addition  of  complement."  The  mixture 
is  then  incubatcil  for  another  hour.  **  If  lysis  of  the  corpuscles  does  not  occur,  the  comple- 
ment has  been  fixed"'  and  the  result  is  positive  (Muir  and  Ritchie). 


SYPHILIS.  125 

lip  and  is  more  frequent  in  the  young.  The  general  health  is  unaffected  and 
pain  is  slight  or  absent.  The  ulcer  is  smooth,  with  elevated,  sloping,  regular 
borders,  a  glistening  or  varnished  base,  and  sharply  defined,  characteristic  in- 
duration ;  it  matures  in  two  or  three  weeks.  Enlargement  of  the  submaxillary 
glands  is  usually  found  from  the  beginning,  a  history  of  exposure  to  syphilis 
may  be  obtained,  and  the  diagnosis  may  be  corroborated  by  finding  the  spi- 
cochetae,  by  the  Wassermann  and  therapeutic  tests,  or  by  waiting  for  the  second- 
ary symptoms.  Epithelioma  is  more  frequent  in  males  (20  to  i), is  practically 
always  upon  the  lower  lip,  is  seen  after  middle  life,  affects  the  general  health, 
and  may  be  painful;  the  borders  are  irregular,  thickened,  and  everted,  and 
the  base  is  covered  with  scabs,  removal  of  which  discloses  bleeding,  fungous 
granulations;  the  induration  is  not  as  hard  as  that  of  chancre  and  gradually 
diffuses  into  the  surrounding  tissues;  the  ulcer  requires  months  for  its  develop- 
ment, the  submaxillary  glands  are  usually  not  palpable  for  four  or  five  months 
or  even  longer,  a  history  of  chancre  in  youth  may  be  obtained,  the  growth 
is  uninfluenced  by  mercurial  treatment,  secondary  symptoms  do  not  occur, 
and  microscopical  examination  will  give  the  picture  of  epithelioma. 

Tuberculous  ukeratian  of  the  tongue  is  distinguished  from  chancre  by  the 
presence  of  the  lesion  on  the  inferior  surface  of  the  tongue  (chancre  being 
more  frequent  on  the  dorsum),  and  the  presence  of  several  ulcers;  by  its 
greater  extent,  deeper  invasion,  irregular  outline,  steep  or  undermined  borders, 
yelloiiish  uneven  base,  absence  of  induration,  excessive  pain,  and  yellowish 
tubercles;  by  the  absence  of  secondary  symptoms  of  syphilis,  of  the  spiro- 
cheta,  and  of  the  Wassermann  reaction,  and  the  failure  of  mercurial  treat- 
ment; and  by  the  diagnostic  methods  of  tuberculosis  given  on  p.  134. 

The  secondary  stage  of  syphilis  consists  of  lesions  of  the  skin  (syphilides), 
mucous  membranes  (mucous  patches),  appendages  of  the  skin  (onychia,  paro- 
nychia, alopecia),  enlargement  of  the  lymph  glands  in  different  parts  of  the 
body,  neuralgic  pains,  inflammation  and  thickening  of  the  periosteum,  ar- 
thropathies, iritis  (rarely  other  forms  of  eye  disease),  epididymitis,  and  in- 
terference with  the  general  health  (fever,  anemia,  disorders  of  digestion)  and 
with  the  process  of  reproduction.  During  this  period  the  disease  is  not 
serious  for  the  patient,  but  is  dangerous  for  those  with  whom  he  comes  in 
contact  and  for  his  offspring.  Abortion  is  frequent,  or  if  the  child  goes  to 
term,  it  is  apt  to  die  soon  after  birth.  The  lesions  during  this  period  are 
widely  scattered,  almost  always  superficial,  and  tend  towards  recovery  even 
without  treatment. 

The  first  symptom  may  be  the  rash  on  the  skin,  fever,  or  neuralgic  pains. 
The  '^ fever  of  eruption*^  is  usually  tri\'ial  and  falls  with  the  development  of  the 
eruption;  syphilitic  fever  occurring  later  may  be  intermittent,  remittent,  or 
continuous,  and  has  been  mistaken  for  such  diseases  as  rheumatism,  malaria, 
and  typhoid  fever.  With  the  onset  of  secondary  symptoms  the  lymphatic 
glands  all  over  the  body  enlarge  and  assume  the  features  of  the  original  bubo. 
The  post-cervical  and  epitrochlear  glands  are  of  diagnostic  value,  because 
they  are  seldom  enlarged  from  local  pyogenic  infection.  The  blood  contains 
the  organism,  and  shows  a  slight  leukocytosis  with  a  diminution  in  the  red 
cells  and  hemoglobin. 

5y^///7iV/«  generally  appear  in  from  six  to  seven  weeks  after  the  appearance 
of  the  chancre,  occasionally  earlier,  and  sometimes,  notably  when  mercurial 
treatment  has  been  administered  from  the  beginning,  not  for  several  months. 
The  secondary  skin  rashes  {syphilodermata)  may  (i)   ape  any  form   of 


126  GENERAL  CONDITIONS  AND  SPECIAL  INFECTIONS. 

cutaneous  eruption,  but  are  always  an  imperfect  counterfeit;  they  are  (2) 
often  apyretic,  (3)  slow  in  evolution,  (4)  non-inflammatory,  (5)  seldom  itching 
or  painful,  (6)  often  of  a  ham  or  copper  color,  (7)  apt  to  occur  in  circles  or  seg- 
ments of  circles,  and  (8)  when  affecting  the  extremities,  most  frequent  on  the 
flexor  surfaces  (which  includes  the  sole  of  the  foot  and  the  palm  of  the  hand); 
(9)  they  tend  to  recover,  and  are  (10)  superficial,  (11)  profuse,  (12)  dissemi- 
nated, (13)  polymorphous,  (14)  symmetrical,  and  (15)  desquamating;  (16) 
syphilis  in  other  parts  of  the  body  may  exist,  (17)  the  rash  responds  to 
mercurial  treatment,  (18)  the  Wassermann  test  may  be  present,  and  perhaps 
(19)  the  spirocheta  may  be  found.  For  the  features  of  the  tertiary  syphilides 
see  the  tertiary  stage. 

The  chief  varieties  of  the  syphilides ,  progressing  from  the  early  and  super- 
ficial to  the  late  and  deep,  are  as  follows:  i.  Erythema  (diffuse  redness)  or 
roseola  (maculae  or  spots)  occurs  principally  upon  the  trunk ;  there  is  no  eleva- 
tion of  the  surface  and  the  redness  disappears  upon  pressure.  2.  Papules  may 
be  small  and  miliary  {syphilitic  lichen)  or  large  (occasionally  four  or  five 
inches  in  diameter);  they  may  desquamate  (papulo-squamous  syphilides), 
or  in  moist  regions,  as  about  the  genitals,  they  may  become  excoriated  {tnoist 
papules,  mucous  patches  of  tfie  skin,  or  flat  condylomata).  Papulo-squamous 
syphilides  upon  the  palms  and  soles  are  called  palmar  and  plantar  psoriasis; 
papules  on  the  forehead  the  corona  Veneris;  and  when  the  size  of  lentils 
lenticular  papules.  3.  Vesicles  rarely  form  in  syphilis,  but  a  herpetiform 
syphilide  is  described.  4.  Pustules  arise  from  breaking  down  papules,  hence 
syphilitic  acne  when  the  apex  of  the  papule  suppurates,  syphilitic  impetigo 
when  the  whole  papule  breaks  down,  and  syphilitic  ecthyma  or  rupia  when 
the  true  skin  is  deeply  invaded.  In  rupia  successive  layers  of  scabs  resem- 
bling an  oyster  shell  form.  In  ecthyma,  if  a  scab  forms,  it  is  easily  detached, 
exposing  a  punched  out  ulcer  surrounded  by  a  red  zone  of  hyperemia.  5. 
Tubercular  syphilides  are  large  papules  or  small  gummata.  6.  Besides  these 
type's  of  eruption,  discoloration  of  the  skin,  peculiarly  of  the  neck,  may 
occur  {pigmentary  syphilides). 

The  mucous  membranes  are  affected  somewhat  like  the  skin.  The  sore 
throat  of  secondary  syphilis  consists  of  a  reddening  of  the  fauces  or  tonsils, 
which  is  sharply  limited,  reniform  in  shape,  and  often  followed  by  ulceration, 
the  ulcerated  area  being  shallow  with  a  grayish  color  and  steep  edges.  Mucous 
patches  are  papules  due  to  the  overgrowth  of  papillae,  which,  owing  to  the 
sodden  condition  of  the  epithelium,  are  white  in  color;  they  are  circular  or 
oval  in  outline,  may  progress  to  ulceration,  originate  a  highly  contagious 
discharge,  and  are  commonly  seen  in  the  mouth  and  about  the  anus  and 
genitals.  Condylomata  are  large  tubercles  due  to  hypertrophy  of  papillae; 
they  look  somewhat  like  warts,  often  appear  in  cauliflower-like  masses,  and 
occur  most  frequently  about  the  anus  and  genitals.  Eruptions  or  inflamma- 
tions in  the  larynx  produce  syphilitic  hoarseness,  in  the  ears  transient 
deafness. 

Syphilitic  alopecia  is  usually  detected  at  the  time  of  the  sore  throat  and 
skin  eruptions.  It  may  involve  the  head  alone  or  the  entire  body.  It  occurs 
as  a  general  thinning  of  the  hair  or  in  irregular  patches.  The  skin  is  apt 
to  be  scaly.     As  the  follicles  are  not  destroyed,  the  hair  is  usually  reproduced, 

The  nails  may  be  shed  owing  to  inflammation  of  the  matrix  {onychia). 
or  the  skin  around  the  base  of  the  nail  may  he  inflamed  or  ulcerated  {paro- 
nychia). 


The  Inmrs  in  various  regions  may  be  the  seat  of  fugitive  pains,  which  are 
usually'  more  severe  at  night  {asieocopic  pains).  Nodes  due  to  periostitis  may 
form,  especially  on  the  skuU,  clavicle,  and  tibia.  In  the  joints  a  symmetrical 
synovitis  may  be  noticed, 

SyphilUic  iritis  makes  its  appearance  in  from  three  to  six  months  after  the 
chancre-  It  affects  one  eye  at  first,  but  is  ver}'  apt  to  spread  to  the  other. 
There  are  pain,  impairment  of  vision,  photophobia,  lachrymation,  a  pericor- 
neal zone  of  hyperemia,  blurring  of  the  pupil,  often  a  change  in  color  of  the 
iris,  and  irregularity  of  the  pupil,  which  is  usually  small  and  fails  to  react  to 
atropin. 

Syphilitic  epididymitis  may  occur  late  in  the  secondary  period,  and  con- 
sists of  gummatous  nodules  which  are  quickly  dispersed  by  mixed  treatment; 
it  may  affect  one  or  both  sides.  Syphilitic  ofchitis  {syphilitic  sarroceie)  is  a 
diffuse  sclerosis  of  the  testicle  itself  and  belongs  to  the  tertiary  period. 

In  the  intermediate  period  the  symptoms  may  be  latent,  or  there  may  be 
"reminders,'^  such  as  the  syphilides,  principally  syphilitic  psoriasis,  and 
epididymitis.  Retino-choroiditis  and  endarteritis  may  occur,  the  latter 
producing  various  forms  of  paralysis,  owing  to  anemia  of  the  motor  centers. 

The  tertiary  stage  is  characterized  by  ditluse  sclerosis  or  gummatous 
degeneration  of  any  part  of  the  body.  The  lesions  are  discrete,  widely 
separated,  and  larger  and  less  common  than  in  the  secondary  stage;  they  are 
often  serious  to  the  patient  Imt  not  to  others.  Although  any  of  the  sypinlides 
may  occur,  the  cutaneous  eruptions  are  almost  always  tubercular  or  gumma- 
tous. The  tertiary  resemble  the  secondary  syphilides  except  in  the  following 
particulars:  They  in%'olve  the  whole  thickness  of  the  skin,  do  not  so  readily 
respond  to  treatment,  appear  irregularly,  tend  strongly  to  ulcerate  and 
spread,  and  are  monomorphous,  asymmetrical,  irregular  in  distribution,  and 
not  so  widely  disseminated.  The  ulcers  are  excavated,  haWng  sharply  cut  or 
undermined  edges  and  a  ragged  base;  they  are  painless,  circular,  or  semi- 
lunar in  shape,  often  covered  by  thick  crusts  or  a  tough,  adherent,  dirty 
yellow  slough,  and  are  not  apt  to  enlarge  the  lymphatic  glands;  and  they 
leave  permanent  scars  which  are  smooth,  white,  and  depressed  l>elow  the 
level  of  the  surrounding  skin.  Tertiary  ulcers  may  take  on  a  phagedenic 
action,  boring  deeply  into  the  tissues,  or  eating  along  the  surface  in  circles 
or  undulating  lines  {serpiginmis).  Severe  lertiar}^  are  said  to  follow  mild 
secondary  symptoms,  and  mild  tertiary,  violent  secondary  symptoms. 

In  diffuse  sclerosis  chronic  intlammator}^  changes  are  followed  by  hyper- 
plasia of  the  fibrous  tissue,  giving  rise  to  endarteritis^  and  disease  of  the 
testicle  (sarcocele),  liver,  spleen,  kidneys,  heart,  nervous  system,  and  other 
tissues  or  organs. 

The  gumma  is  a  nodular  mass  (in  reality  a  large  tubercle)  consisting  of 
proliferated  connective  tissue  cells,  leukocytes,  and  sometimes  giant  cells, 
which,  owing  to  the  thickening  of  the  blood  vessels  and  the  cutting  off  of  the 
blood  supply,  undergoes  necrotic  changes  (fatty  or  gufnmatot4s  degeneration). 
With  proper  treatment  this  mass  may  be  absorbed,  or  the  necrotic  tissue 
becomes  semi-fluid  and  breaks  through  the  skin,  leaving  a  circular  ulcer  with 
red,  undermined  edges,  and  a  characteristic,  dirty,  yellowish-white,  adherent 
slough  (Fig.  80).  In  some  of  the  internal  organs,  such  as  the  brain,  testicle, 
and  liver,  the  necrotic  tissue  may  become  encysted  and  calcified.  Gummata 
may  be  single  or  multiple.  Occasionally,  instead  of  a  well  localized  nodule, 
there  may  be  a  diffuse  gummatous  degeneration  of  a  considerable  area.     The 


121 


GENERAL  CONDITIONS  AND  SPECIAL  INFECTIONS. 


en  I  ^j 
iedS 


scars  resulting  from  gum  mat  a,  when  situated  in  a  canal  of  the  body,  may 
produce  stricture. 

Parasyphiiis  and  metasyphilis  are  terms  applied  to  what  some  call  the 
quaternary  stage,  in  which  lesions  of  the  skin  (e.g.,  leukoderma),  of  the 
mucous  membranes  (e.g..  leukoplakia),  of  the  nervous  system  (e.g.,  tabes  and 
dementia  paralytica),  and  of  other  structures  may  occur,  lesions  which  are 
the  result  of  syphilis,  but  are  no  part  of  the  disease  itself,  as  ihey  do  not 
react  to  specific  treatment. 

Tertiary  lesions  affecting  special  structures  are  noticed  in  subsequent 
pages  as  occasion  dcmioids. 

The  diagnosis  of  tertiary  lesions  is  made  (i)  by  the  local  features  m^ 
tioncd  above;  (2)  by  the  history,  in  the  taking  of  which,  if  chancre  is  deni 
one  should  inquire  particularly  whether  there  h 
been  transient  loss  of  hair,  sore  throat  or  mouth, 
skin  rashes,  and  in  women  frequent  miscarriages; 
1 3)  by  evidences  of  previous  sypihilis,  e.g.,   peri- 
od'ejl  nodes  (especially  on  the  skull,  clavicle,  and 
lilHa),  iritis,  old  scars,  and  patches  of  induration 
on  the  genitals;  (4)  by  the  thera[>eulic  test,  whi<.h 
is  not  ahvays  reliable;  (5)  by  the  Wassermann 
Fi(i>    80.— Ulcerating    reaction;   and   possibly   (6)    by  recover^'  of  the 
gumtna     of     hand.       Note     spi  rochet  a. 

punched  out  appearance.  The  prognosis  of  syphilis  is  favorable  if  proper 

treatment  be  administered  in  the  early  stages  for 
a  sufficiently  long  period,  it  being  generally  belicve<l  that  cure  will  result  in 
the  large  majority  of  these  cases.  When  the  disease  comes  under  observa- 
tion late,  when  the  patient  fails  to  carry  out  the  treatment,  when  there  is 
an  associated  general  disease,  notably  tuberculosis,  often  the  best  that  can  be 
done  is  to  keep  the  disease  under  control.  Some  cases  seem  to  be  malignant 
and  do  not  recover  though  proper  treatment  l)e  given  from  even  the  begin- 
ning. A  patient  should  not  be  permitted  to  marry  until  the  disease  is  cured, 
i.e.,  absence  of  symptoms  for  at  least  one  year  after  the  cessation  of  treat- 
ment, and  never  within  four  years  of  the  date  of  the  chancre. 

The  best  prophylactic  measure,  according  to  Metschnikof!,  is  the  rub-  . 
bi ng  of  calomel  ointment  (calomel  33,  lanolin  67)  into  the  site  of  inocula-JM 
tion;  this  Is  said  to  prevent  chancre  if  performed  within  18  hours  of  the  inter-T^ 
course.  The  treatment  of  the  disease  itself  consists  in  the  employment  of 
mercury  during  the  primary  and  secondary, stages,  and  of  mercur\^  and  iodids 
during  the  tertiary  stage.  In  view  of  the  difficulty  of  making  a  positive 
diagnosis  from  the  appearance  of  the  chancre  alone^  many  surgeons  used 
to  withhold  constitutional  treatment  until  the  appearance  of  secondar>' 
symptoms.  Now  in  even  the  earliest  stages  a  positive  diagnosis  can  be 
reached  by  the  detection  of  the  spirocheta  and  the  Wassermann  reaction. 
Some  prefer  intermiUmi  trcaimrttt,  believing  that  after  a  lime  the  mercury 
ceases  to  be  elective  and  the  tissues  need  a  rest.  Protiodid  of  mercur)', 
grain  |,  is  given  daily  for  six  months,  then  a  rest  of  a  month  is  taken,  and  treat- 
ment again  given  for  three  months,  nine  months  of  treatment  being  given 
during  the  first  year,  and  eight  months  during  the  second.  In  the  continuous 
method  protiodid  of  mercur}^  grain  i,  is  given  in  pill  form  three  times  a  day 
after  meals,  the  dose  being  increase<i  one  pill  each  day,  so  that  on  the  second 
day  the  patient  takes  i,  on  the  third  i  grain,  and  so  on.  until  the  gums  become 


SPYHIUS. 


129 


lender,  the  hrealh  fetid,  and  the  bowels  loose.  The  dose  is  then  cut  in  half 
and  the  patient  kept  on  this  for  two  years.  If  in  the  absence  of  other  symp- 
toms diarrhea  tends  to  persist,  opium,  grain  j^,  may  be  added  to  each  pill. 
Any  of  the  other  preparations  of  mercury  may  be  used  in  a  similar  way* 
When  mercury  is  not  well  l>ome  by  the  stomach,  it  may  be  used  by  inunc- 
lion,  I  dram  of  the  ointment  being  rubbed  into  a  different  portion  of  the 
body  each  day.  so  as  to  avoid  irritation  of  the  skin;  the  method  is  highly 
efficacious  but  dirty,  Intmmuscuiar  injrrtmts,  e,g,.  of  corrosive  sublimate, 
grain  j  daily,  are  painful,  possess  some  danger,  and  should  be  very  rarely 
employed.  Mercury  has  been  used  also  by  Jfu  mi  gat  ion;  a  dram  of  calomel 
is  volatilized  from  a  water  bath,  which  is  placed  under  a  cane  seat  chair  upon 
which  the  patient  sits  naked,  the  fumes  being  confined  by  a  blanket  which 
reaches  from  the  patient^s  neck  to  the  lloor.  In  somewhat  the  same  way 
mercury  has  been  introduced  into  the  body  through  the  skin  by  means  of 
baths  (Hg  CI  J  3ss  to  a  bath-tub  full  of  water),  in  which  the  patient  lies  for  an 
hour  or  longer.  Intravenous  jnjedians  should  not  be  employed.  Unsuccessful 
attempts  have  l>een  made  to  treat  syphilis  with  the  siTum  of  naturally  im- 
mune  animals,  or  of  human  beings  in  the  tertiary  stage. 

In  all  cases,  at  least  during  the  early  stages,  the  patient  should  be  seen  fre- 
([uently,  or  cautioned  as  to  symptoms  of  mtrcurialism  (hydmrgyrism,  ply- 
aiism^  salivation) y  which  ow^ng  to  the  presence  of  an  idiosyncrasy,  may  rap- 
idly follow  even  small  doses.  The  gums  become  soft,  spongy,  tender,  and 
bleed  easily;  there  is  an  excessive  production  of  thick  saliva,  with  fetid  breath, 
metallic  taste  in  the  mouth,  colicky  pain  in  the  abdomen,  and  diarrhea.  In 
more  severe  cases  the  teeth  loosen,  the  alveolar  process  l^ecomes  necrotic,  and 
severe  ulceration  of  the  mouth  develops.  Chrmiic  mercurial  ism  h  manifested 
by  digestive  disorders^  salivation,  loss  of  weight,  albuminuria,  mental  depres- 
sion, tremor,  and  general  weakness.  These  symptoms  may  be  prevented  by 
careful  regulation  of  the  dose  of  mercury,  by  having  the  teeth  put  in  order, 
by  cleansing  the  mouth  several  times  a  day  with  tooth  powder  and  tooth 
brush «  by  the  use  of  a  mouth -wash  containing  chlorate  of  potash,  and  by  pro- 
hibiting the  use  of  tobacco.  Salivation  is  treated  by  discontinuing  the  mer- 
cur>%  by  gi\ing  a  sabne  purge,  and  by  the  use  of  antiseptic  and  astringent 
mouth-washes.  Albuminuria  calls  for  an  intermission  or  a  great  reduction 
in  the  dose  of  the  mercury. 

The  general  health  should  not  be  neglected,  and  if  necessary  tonics  should 
be  employed.  The  contagious  nature  of  the  malady  should  be  impressed  upon 
the  patient,  who  should  be  directed  to  have  separate  eating  and  toilet  utensils^ 
to  avoid  kissmg,  to  sleep  alone,  and  to  bathe  frequently,  paying  special  atten- 
tion to  naturally  moist  parts  of  the  body,  such  as  the  axillae  and  the  perineum. 
At  the  end  of  two  years  the  patient  should  take  tnixed  treatment  (hydrarg. 
chlor.  cor,  gr.  i,  potassium  iodid  3ss,  syrup  sarsaparill-e  comp.  f^iii-foii  in 
water  after  meals)  for  six  months  or  longer,  or  if  there  have  been  symptoms, 
the  mixed  treatment  should  continue  for  six  months  from  the  last  symptom. 

The  lesions  of  tertiary  ayphilis  are  controlled  by  mixed  treatmenl.  The 
mercury  is  used  for  its  antisypbilitic  action  and  the  iodids  for  the  absorption 
of  gummatous  tissue.  Iodid  of  potassium  or  sodium  may  be  given  in  a  satu- 
rated watery  solution,  each  drop  of  w^hich  contains  1  grain  of  the  iodid.  It  is 
customary  to  begin  with  5  or  10  drops  of  this  solution  in  plenty  of  water  after 
meals,  and  increase  the  dose  i  drop  each  day,  until  in  some  intractable 
cases  as  much  as  60  or  more  grains  a  day  are  given.     Toxic  eflFects  are  mani- 


T^O  GENERAL   CONDITIONS  AND  SPECIAL  INFECTIONS. 

fested  by  coryza.  felicl  breath,  disorders  of  digestion^  and  cutaneous  emptions 
(acne,  vesicles,  buHa*).  The  lodid  should  be  discontinued  and  elimination 
stimulated.  Belladonna  and  arsenic  have  been  used  lo  prevent  the  skin 
eruptions. 

All  forms  of  syphilis  are  said  to  yield  with  astonishing  rapidity  to  salvaT- 
san  (Khrlich^s  '*6o6-*),  whidi  is  a  yellowish  powder  containing  34.16  per 
cent,  arsenic,  the  chemical  name  being  dioxydiiimidoarsenobenzoldihydro- 
chlorid>  Salvarsan  is  given  subcutaneously.  intramuscularly,  or  intra- 
venously. At  first  one  dose  was  thought  to  be  suft'it  ient  to  effect  a  cure,  as 
the  spirochetie  disappeared  in  a  few  days,  and  the  Wassermann  reaction 
became  iiegalive.  Relapses  followed,  however,  and  now  Ehrlich  advises 
an  intravenous  injecticm»  to  be  repeated  in  two  or  three  weeks,  if  recover)' 
has  not  occurred  and  the  Wassermann  reaction  is  still  positive  Others 
think  a  second  injection  should  not  be  given  in  less  than  eight  weeks,  and 
many  follow  the  primary  injection  by  the  regular  mercurial  treatment - 
The  simplest  method  of  i>reparing  the  ilrug  for  injection  is  that  of  Alt,  slightly 
moflilied.  The  powiler,  which  tomes  in  glass  ampoules  containing  0.6 
gram,  the  average  dose,  is  shaken  with  30  c.c.  of  warm  normal  salt  solution, 
in  a  glass-stoppered  bottle,  until  dissolved.  About  2  cc.  of  normal  sodium 
hydroxid  solution  is  then  added.  This  precipitates  a  yello\dsh  sediment, 
which  is  redisstilved  l>y  adding  more  of  the  sodium  hydroxid  solution,  drop 
by  drop,  until  the  duid  is  clear.  If  the  intravenous  route  is  chosen,  enough 
salt  solution  should  be  atldcd  to  bring  the  quantity  up  to  250  cc.  A  large 
vein  is  made  prominent  by  compression,  punctured  with  a  platino-iridum 
needle,  and,  after  a  few  drops  of  bloo<i  have  escaped,  the  needle  attached 
by  means  of  a  rubber  lube  to  a  graduated  glass  reservoir  containing  salt 
solution.  As  soon  as  the  salt  solution  Ijegins  to  liow  into  the  vein,  the  rubber 
tube  is  pinched,  the  salt  solution  poured  from  the  reservoir,  and  the  pre- 
pared salvarsan  introduced-  The  drug  must  be  prepared  immediately 
before  injection,  and  should  not  be  given  to  those  with  nonsyphih'tic  organic 
diseases,  especially  of  the  kidneys,  heart,  blood  vessels,  oi>tic  or  auditory^ 
nerves,  or  central  nervous  system,  or  to  those  who  have  previously  had  arsen- 
ical treatment  or  who  possess  an  idiosyncrasy  to  arsenic.  The  patient  should 
be  kept  in  bed  for  one  week  after  the  injection.  Intravenous  injections 
are  often  followed  by  a  chill,  subcutaneous  and  intramuscular  injections  by 
a  painful  induration  and  occasionally  by  sloughing,  and  all  methods  of  ad- 
ministration by  fever  and  sometimes  by  vomiting  and  waten.^  stools.  Among 
the  more  serious  symptoms  which  have  been  noted  are  blindness,  deafness, 
hematemesis,  melena,  albuminuria,  vesical  paralysis,  irregularity  of  the 
heart,  jaundice,  and  convulsions.  During  the  fifteen  months  in  which  the 
drug  has  been  used  (from  Sept.,  u>og,  to  Jan..  igto)  death  has  followed 
the  injection  in  twelve  instances.  It  is  not  possible  at  the  present  time  to 
determine  the  real  value  of  **f>o6'';  some  think  it  a  specific  which  will  cure 
in  one  or  two  doses,  others  that  it  is  not  superior  to  mercur}-.  It  is  possible, 
however,  to  decide  that  it  is  a  verv'  powerful  drug  capable  of  producing 
alarming  symptoms  and  even  death,  that  it  is  still  in  the  experimental  stage, 
and  that  it  should  be  used  with  great  caution  and  only  by  those  who  have 
learned  the  techtMc  of  administration  from  the  experienced.  Perhaps  less 
dangerous  arsenical  preparations,  given  more  often  and  in  small  doses,  will 
prove  lo  be  as  eflicient  even  if  slower.  Murphy  has  olitained  remarkable 
results  with  sodium  cacodylate,  which  may  be  given  in  doses  of  14  to  2 


SYPHILIS.  13  r 

grains,  in  pills,  hypodermicalJy,  or  by  enema,  repeated  at  inten^als  of  three 
or  four  days, 

Local  treaimatt  in  syphilis  is  of  secondary  importance.  Excision  of  the 
chancre  is  not  recommended,  as  It  has  no  iiiiluence  on  the  general  symp- 
toms. A  chancre  should  be  kept  clean  by  immersion  in  a  i  to  5000  bichlorid 
of  mercury  solution  and  dusted  with  an  antiseptic  powder.  Syphilitic  buboes 
requires  no  local  treatment,  unless  they  suppurate  l>ecause  of  mixed  infection. 
Mucous  patches  in  the  mouth  and  syphilitic  sore  throat  may  be  touched 
with  nitrate  of  silver,  30  grains  to  the  ounce,  and  astringent  and  antiseptic 
mouth  washes  used;  mucous  patches  in  other  regions  and  comlylomata 
should  be  disinfected  with  peroxid  of  hydrogen  and  bichlorid  of  mercur)' 
and  dusted  with  calomel.  Nonulcerative  tertiary  lesions  are  treated  by  the 
application  of  mercurial  oinlmenL  (Jummata  should  not  l>e  opened,  as 
even  when  fluctuating,  absorption  from  the  inlernat  administratitHi  of  potas- 
sium iodid  is  still  possible.  Ulcerating  gummata  should  be  kept  si  rupxilously 
clean,  since  secondary  infection  may  make  them  exceedijigly  foul.  inauj.;nrate  a 
phagedena,  or  markedly  interfere  with  their  healing.  In  some  of  these 
cases  hectic  fever  with  amyloid  degeneration  of  the  viscera  oc(  urs. 


Fic,  81. — Congenital  syphilis  showinj^ 
sU  of  skull  and   facial  bonc^  wiih 


Fio.  82. — CongeniLal  syphilis  showing 
necrasiH  of  facial  bones  anrl  rh agarics, 
( J  cfFerson  Hospi  La  I  /) 


Congenital  or  inherited  syphilis  results  from  the  flisease  in  either  or 
U»th  of  the  pa  rents.  It  is  pro!>at>le  thai  parents  who  have  completed  the 
secondary  stage,  i.e.,  after  three  or  four  years,  are  no  longer  capable  of 
transmitting  llae  disease  to  their  offspring,  although  exceptions  to  this  rule  are 
noted,  and  it  is  possible  for  parents  in  even  the  contagious  period  to  bring 
forth  healthy  children.  The  occurrence  of  Colles*  and  Pn*f eta's  immunity 
and  the  freejuent  y  (»f  abcjrlion  in  syphilis  have  alrearly  been  mentioned. 

Any  of  the  lesions  of  sy[>hilis,  excepting,  of  rourse,  the  primary  chancre, 
may  be  encountered  when  the  disease  is  inherited  and  the  spirochetae  have 


132 


GENERAL  CONDITIONS  ANB  SPECIAL  INFECTIONS. 


been  demonstrated  in  these  legions.  ,\lthough  the  disease  may  be  manifest 
at  birth,  or  may  not  show  itself  for  a  number  of  years,  the  first  symptoms 
are  usually  noticed  within  a  few  weeks  or  months  of  birth.  Of  peculiar 
diagnostic  value  are  the  wrinkled,  shriveled  up,  old  man  appearance,  marked 
anemia,  the  hoar>e  cry  due  to  inflammation  of  the  larj^ngeal  mucous  mem- 
brane, and  snuffles  due  to  inflammation  of  the  nasal  mucous  membrane. 
The  last  may  go  on  to  ulceration  and  be  associated  with  destruction  of  the 
nasal  bones  and  cartilages,  causing  a  falling  in  of  the  bridge  of  the  nose 
(Fig,  8i)*  The  spleen  and  liver  are  usually  enlarged.  Mucous  patches 
about  the  lips  may  leave  radiating  scars  {rhagades),  especially  at  the  angles 
of  the  mouth  (Fig.  82),  Pemphigus,  particularly  on  the  palms  and  soles, 
is  one  of  the  earliest  and  most  characteristic  skin  eruptions.  Inflammation 
and  thickening  at  the  epiphyseal  junctions  of  the  long  bones»  and  periosteal 
nodes,  which ,  on  the  cranium,  give  rise  to  the  natiform  skull  also  are  com- 
mon.  Many  die  during  this,  the  secondary  stage,  and  those  that  survive 
may  pass  through  an  mtermediate  or  latent  period  of  variable  length,  some* 
times  lasting  until  the  second  dentition,  puberty,  or  even  longer. 

Among  the  tertiary  phenomena  which  require  special  mention  are  sudden 
deafness  in  both  ears  without  pain  or  discharge,  interstitial  keratitis  (cornea 
has  a  ground-glass  appearance,  and  later  a  salmon 
color  due  to  vascularization,  both  are  usually  in- 
volved), Hutchin.son  teeth  (the  permanent  upper  and 
median  incisors  are  dwarfed,  separated,  and  nar- 
rower at  the  crown  than  at  the  root,  the  cutting 
edge  being  curved  wth  the  convexity  upwards^Fig. 
83),  and  dactylitis  (chronic  painless  enlargement  of 
a  fmger  or  toe,  due  to  gummatous  infiltration  or 
syphilitic  osteomyelitis— Fig.  221. 

The  treatment  should  be  not  only  antisyphilitic, 
but  also  tonic,  including  such  drugs  as  cod-liver  oil, 
iodid  of  iron,  and  the  phosphates.  Mercury  is  best  administered  by 
rubbing  5  or  10  grains  of  the  ointment  into  the  soles  of  the  feet  daily t  or  by 
placing  it  on  the  inner  side  of  the  belly  band.  If  there  is  much  irritation  of 
the  skin,  hydrarg.  cum  creta,  grain  |,  with  i  grain  of  sugar,  may  be  given 
three  times  a  day  after  nursing.  Potassium  iodid,  |  to  r  grain,  in  simple 
syrup,  gradually  increased,  is  given  three  times  a  day  with  the  onset  of 
tertiary  symptoms.  The  treatment  should  be  continued  for  at  least  two 
years,  and  recommenced  at  each  outbreak  of  symptoms. 


Fig.  83. 
Iccth, 


-Hutchinson 
( Warren.) 


TUBERCULOSIS, 


Tuberculosis  is  an  infectious  and  contagious  disease  caused  by  the  bacillus 
of  tuberculosis.  The  tubercle  haciUns  is  a  rod-shaped  facultative  anaerobe, 
measiiring  from  1.5/1  to  ;^,$fi  in  length.  It  may  be  straight  or  curved  and  is 
frequently  seen  in  pairs;  it  is  nun -motile  and  probably  develops  only  in  living 
tissues,  although  capable  of  maintaining  its  vitality  for  a  long  time  outside 
the  l>ody.  Its  toxin  is,  as  yet,  little  understood.  The  bacillus  enters 
the  body  through  wounds  on  the  exterior,  through  the  respiratory  tract, 
through  the  alimentary  canal  (infected  milk  or  meat),  or  in  the  fetus,  through 
the  placenta.     The  most  fretiuent  method  is  by  the  inhalation  of  dust,  along 


k 


TUBERCULOSIS. 


^33 


with  which  the  bacilli  are  carried.  Animal  tuberculosis  differs  in  some  re- 
spects from  human  tuberculosis,  but  is  probably  only  a  modified  form  of  the 
same  disease;  that  the  two  are  intercommunicable  seems  to  be  proved. 
Tuberculosis  is  exceedingly  common,  indeed  some  would  have  us  believe  that 
we  all  are  at  least  a  little  tuberculous.  Naegeli  found  tuberculosis  of  some 
sort  in  97  per  cent,  of  700  autopsies.  There  seems  to  be  no  way  to  avoid 
taking  these  organisms  into  the  body,  but  something  more  than  the  tubercle 
bacillus  is  required  for  the  development  of  the  disease,  viz.,  inherited  sus- 
ceptibility, poor  food,  overcrowding,  depressed  vitality  following  prolonged 
illness  or  mental  strains,  or  local  injuries.  The  disease  is  rarely,  but  the 
predisposition  frequently,  transmitted  from  parent  to  child.  Those  who 
possess  this  predisposition  {strumous,  scrofulous ,  or,  heiier ytuberculous  diathesis) 
are  often  frail,  anemic,  and  precocious;  the  skin  is  apt  to  be  delicate,  the  com- 
plexion fair,  the  hair  fine,  the  lashes  long,  the  head  large,  the  cranial  bosses 
prominent,  the  nose  short  and  broad,  the  lips  thick,  the  lower  jaw  small,  the 
muscles  soft,  the  bones  slender,  the  epiphyses  enlarged,  the  chest  small  and 
flat;  and  there  is  frequently  a  tendency  to  eczema,  catarrhal  inflammation 
of  the  mucous  membranes,  non-tuberculous  enlargement  of  the  lymphatic 
glands,  corneal  ulcers,  granular  lids,  and  carious  teeth. 

Tuberculosis  may  occur  at  any  age,  and  in  any  portion  of  the  body,'but  is 
most  common  in  early  life  and  in  the  respiratory  apparatus,  genitourinary 
organs,  bones,  joints,  lymph  glands, 
serous  membranes,  brain,  liver,  and 
spleen.  The  so-called  **  senile  tuber- 
culosis** presents  no  essential  differ- 
ence from  the  disease  in  the  young. 

Tuberculosis  is  characterized  by 
the  formation  of  nodules  or  tubercles, 
which  vary  in  size  from  i  or  2  mm.  to 
masses  as  large  as  a  pea,  and  by  the 
occurrence  of  inflammatory  changes 
between  and  around  these  tubercles; 
in  truth,  the  inflammatory  changes 
may  constitute  the  whole  process,  the 
tubercles  being  inconspicuous  or 
absent.  A  tubercle  is  formed  as  fol- 
lows: The  bacilli  lodge  in  the  intima  Fig.  84. 
of  the  small  vessels,  in  which  inflam- 
matory changes   occur,  leading  to  a 

proliferation  of  the  endothelial  cells  (endarteritis),  and  suhseciuently  to  a 
proliferation  of  the  connective-tissue  cells  and  of  the  leukocytes  which 
have  wandered  from  the  blood  vessels;  thus  a  little  mass,  or  tubercle,  is 
formed,  which  is  grayish  in  color  and  more  or  less  translucent.  Atypical 
tubercle  (Fig.  84)  contains  one  or  more  giant  cellsy  which  are  due  to  the 
fusion  of  epithelioid  cells  and  show  many  nuclei;  surrounding  these  cells 
are  the  epithelioid  cells  (proliferated  connective-tissue  cells),  which  are  midway 
in  size  between  the  giant  cells  and  the  leukocytes  and  contain  a  single  nucleus; 
the  outermost  zone  is  made  up  of  proliferated  leukocytes  {lymphoid  cells). 
The  bacilli  may  be  found  in  the  giant  cells  and  occasionally  in  the  epithelioid 
cells.  The  giant  cell  is  by  no  means  characteristic  of  tuberculosis,  as  it  is 
found  in  many  other  pathological  conditions.     With  the  onset  of  necrotic 


-Diagram  of  the  minute  struiiure 
of  a  tubercle,     ((loulcl.) 


1^4  GENEHAL   CONBITTONS  AND   SPECIAL  INFECTIONS. 

rhanges  in  the  luhunk',  xhv  lonlli  are  no  Icmj^er  flL*morisiral>le,  Iml  I  hey  «»r 
iheir  spores  are  undoulitediy  present,  for  the  injection  of  sueh  material  into 
guinea -pigs  produces  tuljertulosis.  As  the  vessel  from  which  it  started  lie- 
comes  oliliterated  by  the  proliferated  cells,  a  ti]!)ercle  is  avascular;  and  as  no 
new  vessels  arc  formed  owing  to  the  anemia  and  the  specific  action  of  the 
bacillus,  degenerative  changes  occur.  There  is  at  tirst  a  hyaline  change,  then 
ci)agulation  necrosis,  next  fatty  degenerationp  and  tinaily  the  production  of 
cheesy  material  uasealims,  orcdsemis  necrosis).  A  tubercle  undergoing  casea- 
tion is  called  a  yelUnv  or  crude  tuberdt\  The  fatf  of  a  tubercle  is  largely  influ- 
enced Ijy  the  general  and  local  resistance  of  the  tissues.  In  favorable  cases 
it  may  undergo  atrophy  and  completely  disappear^  or  become  encapsuJaied 
by  dense  scar  tissue,  the  cheesy  material  either  being  abscjrbed  or  calcJlied. 
In  the  latter  instance  the  healed-in  tuljcrculous  material  may  remain  latent 
for  a  long  time  ami  again  be  awakened  to  activity*  In  unfavorable  cases  the 
caseous  material  liquefies,  forming  tuberculous  pus  (see  suppuration). 

Tuberculosis  extends  by  continuity  or  contiguity  of  tissue,  possibly 
aided  by  the  ameboid  movements  of  the  leukocytes,  as  the  bacillus  itself 
is  non-motile;  in  other  instances  it  gains  entrance  to  the  lymph  or  blood  stream 
and  is  transportetl  to  distant  parts.  When  the  l>acilli  enter  the  blood  stream 
and  produce  muJtiple  tubercles  widely  distributed  throughout  the  body  {acute 
getieral,  or  miliary  iuherailosis),  a  sort  of  tuberculous  pyemia  results,  a  condi- 
tion which  closely  resembles  and  is  often  mistaken  for  typhoid  feven 

The  diagnosis  may  be  considered  under  the  following  headings:  (i) 
The  history  of  a  family  predisposition,  of  previous  tuberculous  lesions,  of  an 
unfavorable  occupation,  of  unhygienic  surroundings,  of  habitual  association 
with  tuberculous  inflividuals;  (2)  generai  symploms,  such  as  wcak^ncss,  anemia, 
loss  of  a|>petite,  imtigestion,  progressive  loss  of  weight,  and  slight  alterncK)n 
rise  in  the  temperature;  (5)  the  type  0/ patient  (p.  133);  and  (4)  evidences  oj tu- 
berculosis elsewhere  in  the  body  are  all  suggestive  but  not  conclusive.  (5)  The 
local  features  y  which  will  be  described  in  connection  with  the  disease  in  special 
structures,  and  which  may  require  special  means,  e.g.,  the  X-ray,  cystoscope. 
etc.,  for  their  demonstration,  are  often  distincitve;  sometimes  the  tul>ercules 
can  be  seen.  The  insidious  onset,  marked  chronicity,  and  tendency  to  re- 
currence which  characterizes  most  forms  of  surgical  tul>erculosis  shijuld  be 
noted  in  this  place,  (6)  Recovery  of  the  tubercle  bacillus  assures  the  diagnosis, 
but  even  when  these  are  not  demonstrable,  (7)  inoculation  of  a  guinea-pig  may 
result  in  generalized  tuliercuJosis.  (8)  Microscopic  examination  of  the  diseased 
tissues  will  usually  show  the  characteristic  structure  of  the  tubercle.  (9) 
Cytologif  examination  of  tuberculous  fluids  may  reveal  an  excess  in  the 
number  of  lymphocytes.  ( 1  o)  Blood  examination  may  show  a  relative  lympho- 
cytosis. Leukocytosis  and  iodophilia  are  indicative  of  mixed  iiifeciion. 
Tubercle  bacilli  are  rarely  found  in  the  blood.  The  value  of  the  agglutina- 
tion test  is  doubtfuL  A  persistently  low  tube rculo -opsonic  fwwer  of  the 
b  1 00  d ,  a  ceo  rd  i  n  g  to  W  ri  g  h  t ,  m  ea  n  s  t  u  be  r  c  ul  osi  s .  ( i  r )  T  h  e  /  u  bercnl  in  test  m  ay 
be  performed  in  four  ways;  (a)  suhcutaneous  inject  ion  causes,  in  a  tuberculous 
subject,  a  reaction  which  consists  of  a  rise  of  temperature  of  from  1°  to  3°, 
and  a  general  feeling  of  illness,  occasionally  with  nausea  and  vomldng.  The 
tuberculous  lesion  itself  undergoes  inflammatory  changes.  The  method 
should  rarely  be  employecb  because  of  the  disagreeable  reaction,  the  possi- 
bility of  stimulating  the  process  or  of  inoculating  the  patient  with  tubercle 
bacilli,  and  because  of  the  uncertainty  of  the  test  (the  margin  of  error  has 


TUBERCULOSIS.  1 35 

l>een  estimatcci  at  10  per  cent.).  It  cannot  be  employed  when  the  patient's 
temperature  rises  to  or  above  100°  F.  The  dose  for  diagnostic  purposes  is 
.1  mg.  for  delicate  individuals,  and  i  mg.  for  those  who  are  fairly  robust;  if  no 
reaction  is  obtained  from  smaller  doses,  they  may  be  increased  to  5  or  10 
m^.  (b)  The  CalmeUe  method  consists  of  instilling  one  drop  of  a  i  per  cent. 
solution  of  tuberculin  into  the  eye;  if  conjunctivitis  follows  the  test  is  positive. 
The  method  is  not  without  danger,  particularly  if  the  eye  is  not  normal, 
(c)  The  Von  Pirquet  method  consists  in  inoculating  the  tuberculin  into  the 
arm  after  scarifying  the  skin;  in  the  tuberculous  a  papule  forms  at  the  site 
of  vaccination,  (d)  The  Moro  test  is  performed  by  rubbing  into  the  skin  of 
the  chest  or  abdomen,  over  an  area  of  four  square  inches,  a  small  quantity 
of  an  ointment  consisting  of  5  cc.  of  old  tuberculin  and  5  grammes  of  anhy- 
drous wool  fat.-  In  a  day  or  two  a  number  of  small  papules  appear,  if  the 
patient  is  tuberculous. 

The  prognosis  is  go  d  if  the  lesion  is  localized  and  so  situated  as  to  be 
susceptible  of  eradication  by  surgical  means;  the  danger  of  recurrence, 
however,  is  always  present.  In  general,  it  may  be  said  that  the  prognosis 
is  better  in  children  than  in  adults.  Undoubtedly  many  cases  of  unsuspected 
tubeoculosis  recover  without  treatment,  but  when  the  process  has  extended 
sufficiently  to  be  recognizable,  particularly  in  medical  tuberculosis,  it  has 
gained  such  a  foothold  that  recovery  is  always  doubtful. 

The  treatment  is  local  and  constitutional.  The  most  important  measure 
in  the  local  treatment  is  rest.  Of  some  value  is  the  injection  into  the  lesion  of 
various  drugs,  among  which  may  be  mentioned  carbolic  acid  (3  per  cent.), 
tincture  of  iodin,  chlorid  of  zinc  (i-io),  balsam  of  Peru,  oil  of  cloves  (i-io  in 
olive  oil),  and  epecially  iodoform  emulsion  (10  per  cent.).  It  is  probable  that 
by  irritation  these  medicaments  stimulate  the  fibroblasts,  and  thus  produce 
firm  fibrous  tissue  which  encapsulates  the  tubercles.  Bier  claims  good  re- 
sults from  the  production  of  a  permanent  congestion,  by  a  rubber  tournicjuet 
placed  on  the  limb  above  the  tuberculous  area,  the  principle  being  based  on 
the  fact  that  a  congested  lung  does  not  become  tuberculous.  (See  p.  62.) 
In  certain  cases  operative  measures,  such  as  incision  and  curettage,  excision, 
amputation  of  a  diseased  limb,  or  removal  of  destroyed  organs,  will  be  indi- 
cated. The  Finsen  light  and  the  X-ray  have  proved  of  great  value  in 
lupus. 

The  constitutional  treatment  consists  of  fresh  air,  good  food  (meats,  milk, 
eggs,  cream,  butter),  and  plenty  of  sunshine.  Tonics  are  usually  indicated, 
and  a  prolonged  stay  at  the  seashore,  particularly  in  surgical  tuberculosis, 
is  of  the  greatest  value.  The  discharges  should  be  carefully  disinfected, 
and  susceptible  individuals  should  not  associate  with  those  in  whom  the 
disease  is  active.  Koch's  tuberculin  is  probably  of  some  value  in  the  early 
stages  of  tuberculosis,  but  is  rarely  employed  by  surgeons.  It,  of  course,  is 
impotent  against  the  pyogenic  organisms  which  are  found  so  frequently  in 
tuberculous  lesions,  and  it  should  never  be  employed  alone,  but  always  in 
conjunction  with  other  remedial  measures.  The  dose  of  the  old  tuberculin 
is  o.ooi  cc,  injected  under  the  skin  of  the  back;  if  the  patient  fails  to  read, 
the  doses  are  gradually  increased.  The  dose  of  the  new  tuberculin  (T.  R.) 
is  0.002  mg.  every  second  day,  increased  gradually  until  20  mg.  is  reached,  so 
that  a  rise  in  temperature  of  more  than  a  half  degree  is  avoided.  The 
treatment  may  then  be  discontinued  or  repeated  after  a  long  interval.  The 
old  tuberculin  (T.)  is  a  glycerin  extract  of  tubercle  bacilli  from  which  the 


136  TUMORS  AND  CYSTS. 

bacteria  have  been  removed  by  filtering  through  porcelain.  The  new  tuber- 
culin (T.  R.)  is  made  by  triturating  dried  bacilli  in  an  agate  mortar,  the  re- 
resulting  powder  being  put  into  distilled  water  and  the  solution  centrifugal- 
ized.  The  upper  portion  of  this  fluid  is  the  tuberculin  O.  (Oberer),  which 
has  the  same  properties  as  the  old  tuberculin;  the  remaining  fluid,  tuber- 
culin R.  (Rucksiand),  causes  a  general  but  not  a  local  reaction,  its  curative 
effect  being  due  to  the  production,  in  the  blood,  of  antibodies  to  the  tuberde 
bacilli.  Koch's  latest  tuberculin,  B.  £.  (BasiUenemulsian), is  an  emulsion 
of  ground  tubercle  bacilli  in  equal  parts  of  glycerin  and  water,  the  dose  being 
that  of  T.  R.  Klebs  claims  good  results  from  the  use  of  tuherculocidiny  or  anti- 
phthisifty  which  is  tuberculin  from  which  the  noxious  portions  have  been 
separated.  An ti tuberculous  serum  made  by  immunizing  animals  with  toxins 
of  the  tubercle  bacillus  have  been  employed,  notably  by  Maragliano  and 
Marmorek;  the  value  of  these  serums  has  not  been  determined.  Among  the 
drugs  which  have  been  used  internally  in  tuberculosis  may  be  mentioned 
arsenic,  iodin,  creosote,  guaiacol,  cod-liver  oil,  lacto-phosphates,  hypophos- 
phites,  strychnin,  animal  and  vegetable  digestive  ferments,  iron,  mineral  and 
fruit  acids,  vegetable  tonics,  and  nucleins. 

Tuberculosis  of  special  structures  is  considered  under  various  headings 
throughout  the  book. 


CHAPTER  XIII. 
TUMORS  AND  CYSTS. 

A  tumor,  or  neoplasm,  is  a  mass  of  newly  formed  pathological  tissue 
which  tends  to  persist  or  grow  and  which  performs  no  physiological  function. 
Clinically,  however,  the  word  tumor  is  often  applied  to  a  swelling  of  any  sort. 
An  inflammatory  swelling  differs  from  a  neoplasm  in  that  it  has  a  definite 
cause  and  tends  to  subside ;  a  hypertrophy,  in  that  it  is  the  result  of  increased 
work  and  persists  only  so  long  as  the  demand  for  such  work  exists.  The 
tissue  of  a  neoplasm  has  its  prototype  in  the  human  body,  either  adult  or 
embryonic  ( A/ wZ/rr '5 /ai^;),  and  its  cells  invariably  originate  from  preexisting 
cells  of  the  body  (Virchow's  law). 

The  cause  of  neoplasms  is  not  known.  Cohnheim^s  inclusion  theory 
is  that  an  excess  of  embryonic  cells  is  manufactured  during  intrauterine  life, 
and  that  those  which  are  not  used  in  the  construction  of  the  fetal  tissues 
remain  in  the  body  in  a  latent  condition,  until  some  irritation  stimulates  their 
development.  The  influence  of  heredity  is  probably  much  less  important 
than  was  formerly  believed.  Injury  and  irritation  are  undoubtedly  important 
factors  in  some  instances;  thus  sarcoma  may  follow  a  single  injury,  car- 
cinoma some  form  of  constant  irritation,  e.g.,  epithelioma  of  the  lip,  the 
result  of  sfnoking  a  short  stemmed,  clay  pipe.  Many  unsuccessful  attempts 
have  been  made  to  establish  the  infective  nature  of  tumors ,  distincdy  sarcoma 
and  carcinoma.  Sarcoma  is  most  frequent  during  the  early  half  of  life,  or 
the  period  of  physiological  activity;  carcinoma,  during  the  later  part  of  life,  or 
the  period  of  physiological  decline. 


PAPILLOMA.  137 

Clinically  tumors  may  be  divided  into  the  benign  and  the  malignant. 

A  benign,  innocent,  adult,  or  typical  tumor  may  be  multiple,  strongly 
resembles  in  structure  the  tissue  from  which  it  springs,  grows  slowly,  is  en- 
capsulated, does  not  infiltrate  surrounding  tissues,  is  usually  movable  (not 
adherent),  seldom  ulcerates,  does  not  cause  metastases  in  the  lymphatic 
glands  or  in  distant  parts  of  the  body,  does  not  recur  after  thorough  removal, 
and  is  serious  only  when  so  situated  as  to  press  on  important  structures. 

A  malignant,  atypical,  or  embryonic  tumor  is  usually  single,  is  com- 
posed of  cells  resembling  those  found  in  the  embryo,  grows  rapidly,  is  not 
encapsulated,  infiltrates  the  surroimding  tissues  (fixed),  and  often  progresses 
to  ulceration,  causes  metastases  in  adjacent  lymph  glands  or  in  distant  parts 
of  the  body,  frequendy  recurs  after  excision,  is  always  serious,  and  ultimately 
destroys  life  no  matter  what  its  position. 

Tumors  may  be  classified  according  to  their  origin  as  follows: 

(I)  Epithelial  tumors  (derived  from  the  epiblast  or  the  hypoblast). 

(A)  BenigHy  or  innocent  tumors  (those  composed  of  adult  epithelial 

tissue), 
(i)  Papilloma,  or  warty  growth. 
(2)  Adenoma,  or  glandular  tumor. 

(B)  Malignant  tumorSy  or  carcinomata  (those  composed  of  embryonic 

epithelial  tissue), 
(i)  Epithelioma. 
(2)  Glandular  carcinoma, 
(chorioepi  thelioma .) 

(II)  Connective  tissue  tumors  (those  derived  from  mesoblastic  tissue.) 

(A)  Benign  (those  conforming  to  types  of  adult  mesoblastic  structures), 
(i)  Fibroma  (fibrous  tumor). 

(2)  Lipoma  (fatty  tumor). 

(3)  Chondroma  (cartilaginous  tumor). 

(4)  Osteoma  (bony  tumor). 

(5)  Myxoma  (mucous  tumor). 

(6)  Myoma  (muscle  tumor). 

(7)  Hemangioma  (tumor  composed  of  blood  vessels) . 

(8)  Lymphangioma  (lymphatic  vessel  tumor). 

(9)  Neuroma  (nerve  tumor). 

(10)  Odontoma  (tooth  tumor). 

(11)  Glioma  (tumor  of  neuroglia). 

(B)  Malignant  tumors,  or  sarcomata  (those  conforming  to  embryonic 

mesoblastic  tissue). 
(Endothelioma). 
(Hypernephroma) . 

(III)  Mixed  tumors,  or  teratomata  (those  composed  of  epiblastic, 

mesoblastic,  and  hypoblastic  structures). 

I.  Epithelial  tumors,  or  those  derived  from  the  epiblast  or  the  hypoblast. 

(A)  Innocent  Epithelial  Tumors.— (i)  Papillomata,  or  warts,  are  de- 
rived from  cutaneous  or  mucous  papillae,  which  they  closely  resemble  in  struc- 
ture. They  are  essentially  benign,  but  may  become  carcinomatous  during 
the  later  half  of  life.  They  occur  at  any  age,  may  be  single  or  multiple,  are 
often  due  to  irritation  (e.g.,  venereal  warts  from  acrid  discharges,  warts  of  the 
hands  from  uncleanliness),  and  sometimes  disappear  without  treatment. 
Skin  warts  are  usually  dark  in  color  owing  to  the  depositioiv  oi  pv^xcv^TvN.. 


138 


TUMORS   AND    CYSTS. 


(^)mlylumata  And  muroiis  paU  hcs^  iire  piipillomaluus  in  Uiiluru.  !'///«>«« 
waris  ajnsist  uf  liraiithing  tufts  resemblii^g  t  horionit  villi,  arc  mojit  fre(|m»»l 
in  the  bladder,  and  are  very  vascular  and  covered  by  a  ihin  epithelial  layer 
which  is  easily  l>roken,  causing  frequent  and  occasionally  fatal  hemorrhages. 
Villous  warts  are  found  also  in  the  pelvis  of  the  kidney »  and  in  cysts,  more 
parlicularly  those  arising  in  connection  with  glands,  such  as  the  breast, 
thyroid,  and  ovary. 

The  trealmeni  is  removal  by  caustics,  knife,  scis&ors,  or  special  in&iru 
ments,  accord  in  j^  to  their  location. 

(2)  Adenomata  spring  from  glandular  tissue,  which  they  closely  resem 
in  structure.  They  grow  slowly,  are  benign,  occasionally  follow  an  inju 
and  are  encapsulated.  They  may  undergo  falty,  cystic  {cystaden4)nt 
mucoid  {adenomyxoma)  or  carcinomatous  degeneration  {adenorarcinoma) 
Sarcomatous  degeneration  of  the  librous  stroma  produces  an  aiienosarcoma. 
Adenomata  may  occur  in  any  gland,  hut  are  most  frequently  found  in  the 
breast,  prostate,  thyroid,  parotid,  ovary,  testis,  and  in  the  lachrymal,  cutane- 
ous, and  mucous  glands.  There  are  two  varieties,  the  acinous,  or  rat t-most 
adenoma^  which  consists  of  communicating  sacs,  or  acini,  lined  with  epithe 
Hum,  and  the  tulmlar  mftnonnj  (found  principally  in  the  intestine,  where  there 
are  numerous  tubular  glands),  which  consists  of  tubules  lined  with  cylindrical 
epithelium;  the  latter  are  peculiarly  liable  to  become  carcinomatous  {adeno- 
carcinoma).  When  the  connective  tissue  is  excessive  in  amount,  the  tumor 
is  known  as  a  fibroadenoma. 

The  treat ntenl  is  excision, 

(B)  Carcinomata,  or  cancers,  consist  of  masses,  or  nests,  of  epithelial 
cells  surrounded  by  librous  tissue  in  the  form  of  alveoli,  which  communicate 
with  one  another  and  with  the  lymphatics,  thus  accounting  for  the  frequency 
of  secondary  growths  in  the  lymphatic  glands.  The  epithelial  cells  are  loosely 
thrown  together  and  are  not  separated  by  an  intercellular  matrix.  The  blood 
vessels  run  in  the  bbrous  stroma,  have  distinct  walls,  and  do  not  communicate 
with  the  alveoli.  The  growth  spreads  by  infiltrating  the  surrounding  tissues 
in  the  form  of  processes  (roots)  and  is  never  encapsulated.  It  is  at  first  local 
and  usually  single,  hence  curable  by  excision;  later  the  lymphatic  glands 
become  involved  and  finally  metastases  occur  in  distant  parts  of  the  body 
(carcinomatosis).  On  reaching  the  surface  carcinoma  ulcerates,  giving  rise  to 
a  foul,  purulent,  and  often  bloody  discharge  which  rapidly  exhausts  the  pa- 
tient, causing  emaciation,  a  sallow  color  of  the  skin,  and  an  anxious  expres- 
sion of  the  face  {cancrrmts  cachexia).  In  carcinoma  of  the  viscera,  particu- 
larly of  the  digestive  tract,  cachexia  is  earlier  in  onset  and  more  rapid  in 
progress,  because  of  the  interference  with  nutrition.  It  may  be  that  the 
cachexia  is  in  part  due  to  the  absorption  of  toxins  from  the  malignant  growth. 
Carcinoma  is  most  frequent  after  the  thirty-fifth  year.  Of  the  secondary 
changes  that  may  occur  fatty  degeneration  is  the  most  important,  indeed  it 
may  be  said  to  be  almost  constant  in  the  later  stages  of  large  cancers.  Cuta- 
neous epithelioma  may  undergo  a  horny  transformation.  Mucoid  and 
colloid  degeneration  may  occur,  and  occasionally  pigmentation,  cyst  forma- 
tion, or  calcification.  Cancer  of  the  penis  in  rare  instances  may  be  due  to 
cancer  of  the  cervix  uteri,  and  under  favorable  circumstances  a  portion  of  the 
growth  may  be  grafted  up<^n  another  portion  of  the  patient's  lx>dy,  but  the 
disease  is  by  no  means  contagious  in  the  ordinary  sense  of  the  word* 

(i)  Epithelioma  may  be  squamous-  or  cylindrical-ceUed. 


CAHaNOBIA, 


139. 


Sqttamous  epitfielioma  may  occur  on  any  ]x*rliiin  of  ihu  skin  ur  mucous 


fitfinb 


linine,  hut  must  frequently  arises  where  skin  antl  mucous  niemf>ranc 
meet,  or  where  two  varieties  of  epithelium  come  together,  The  fa%'onte 
aites  are  the  nose,  lower  lip,  penis,  scrotum,  vulva,  anus,  tongue,  palate, 
gums,  tonsils,  larynx,  pharynx,  esophagus,  blatlder,  and  os  uteri.  The 
epithelial  cells  grow  from  the  surface  into  the  lymph  spaces  in  the  form  of 
culumns,  and  are  prone  to  arrange  themselves  into  globular  masses  called 
pearls.  The  disease  begins  as  a  nodule  or  fissure  which  quickly  ulcerates; 
in  ivLKX  the  ulceration  may  progress  more  rapidly  than  the  epithelial  pro- 
liferation, so  that  in  a  strict  etymological  sense,  the  term  tumor  cannot  be 
applied «  With  the  exception  of  rodent  ulcer,  which  will  be  described 
under  diseases  of  the  skin,  epithelioma  presents  all  the  features  of  malignancy 
mentioned  above.  The  ulcer  is  irregular,  with  a  non-granulating  base,  hard, 
everted  edges,  and  ati  irritating  discharge,  which,  on  the  skin,  may  form  a 
scab-  On  section  the  surface  is  firm  and  white.  It  contains  but  little  fluid, 
but  on  pressure  may  exude  fine,  white,  worm-like  masses.  Epithelioma  is 
less  malignant  than  glandular  carcinoma,  the  disease  sometimes  lasting  for 
years.  The  most  marked  exception  to  this  statement  is  epithelioma  of  the 
tongue,  which  may  cause  death  in  a  few  months.  Epithelioma  occurring  in 
ibe  margin  of  an  old  ulcer  is  called  Marjdins  ulcer.  Lymphatic  glands  are 
often  not  involved  for  a  number  of  months,  and  metastatic  growths  in  distant 
portions  of  the  body  are  not  common. 

Cylindruai-  or  (olumnar-cdled  fpilheli&ma  (malignant  adenoma)  might 
properly  be  ilassified  with  glandular  carcinoma;  it  arises  from  cylindrical 
epithelium  on  the  surface  or  in  the  glands  of  the  mucous  membranes^  being 
most  frequent  in  the  uterus  and  intestinal  tract.  The  growth  is  less  common 
than  squamous  or  glandular  cancer  but  occurs  much  earlier  in  life,  a  fact 
which  is  pariicuiarly  true  of  the  rectum.  It  consists  of  little  cavities  or 
tubules  lined  by  a  number  of  layers  of  epithelium  \\ithout  a  basement 
membrane, 

(2)  Glandular,  or  acinous  carcinoma,  springs  from  glandular  epithel- 
ium, and  consists  of  acini,  or  alveoli,  of  t  onnective  tissue  tlllcfl  with  epithelial 
cells.  It  is  usually  nodular,  the  degree  of  hardness  var)ing  with  the  amount  of 
fibrous  tissue.  A  si m pie  aircinoma  is  one  in  which  the  epil helium  and  connec- 
tive tissue  exist  in  alwul  the  same  proportion  as  in  the  normal  gland.  In  a 
xfirrhus,  or  hard  cancer,  there  is  an  excess  of  tibrous  tissue.  On  section  the 
surface  l>ecomes  concave  owing  to  the  contraction  of  the  filirous  tissue,  is 
white  and  glistening,  creaks  under  the  knife,  dnd  exudes  a  milky  fluid  con- 
taining degenerated  epithelium  and  oil  globules.  A  scirrhus  is  a  dense 
nodular  growth  firmly  imbedded  in  the  tissues,  causing,  when  just  beneath 
the  skin,  a  puckering  or  dimpling  owing  to  the  contraction  of  the  fibrous 
tissue.  In  some  cases  this  contraction  is  so  marked  that  the  tumor  decreases 
in  size  (atrophic^  i7rwUheringsfirrhus),\\hhoui,  however,  marketlly  interfering 
"rith  general  dissemination  of  the  growth.  Scirrhus  is  most  frequent  in  the 
breast  and  alimentary  canal,  particularly  the  pylorus.  Encephahnd,  medtd' 
lary,  or  soft  cancer  contains  an  excess  of  epithelial  cells;  consequently  it  is  a 
soft  nodular  mass  which  grows  very  rapidly  (hence  the  term  acute  cancer), 
quickly  involves  the  lymphatic  glands,  and  is  speedily  fatal;  after  ulceration 
it  presents  a  fungating,  lileeding  surface  {fuftgtis  hcmatodes).  On  section  it 
looks  not  unlike  brain  tissue  into  which  hemorrhages  have  occurred.  The 
central  portion  of  the  growth  may  be  semi-fluid,  or  in  some  instances  actual 


I 


I40  TUMORS  AND  CYSTS. 

cysts  may  be  found.  It  is  much  less  common  than  scirrhus,  and  is  most  fre- 
quent in  the  breast  and  testicle.  Colloid^  or  gelatinous  cancer,  is  the  result  of  a 
colloid  or  myxomatous  degeneration  of  any  glandular  carcinoma.  It  is 
most  frequent  in  the  abdominal  cavity,  and  is  occasionally  found  in  the 
breast.  •      • ■ 

Chorio-epitJielioma  (deciduoma  malignum,  syncytioma  malignum)  may  be 
placed  provisionally  among  the  carcinomata  because  it  is  epithelial  in  origin 
and  malignant  in  nature.  The  tumor  arises  from  the  chorionic  epithelium 
following  pregnancy,  and  resembles  in  appearance  the  placental  tissue, 
blotched  with  blood.  In  nearly  half  the  cases  there  has  been  a  hydatidi- 
form  mole.  It  quickly  gives  rise  to  secondary  growths  in  distant  portions 
of  the  body  by  breaking  into  the  blood  vessels. 

The  treatment  of  carcinoma  is  early  and  wide  excision,  together  with 
the  lymphatic  glands  into  which  the  infected  area  drains;  in  one  mass  if 
possible,  in  order  not  to  sever  the  lymphatic  vessels,  as  such  an  accident  may 
sow  the  wound  with  cancer  cells  and  cause  recurrence.  If  operation  be  eariy 
and  thorough,  cure  may  be  expected,  but  as  most  cases  come  to  operation 
late,  complete  eradication  is  often  not  attained  and  recurrence  follows. 
Even  in  cases  in  which  cure  cannot  be  expected,  removal  of  the  growth  is 
often  indicated  to  relieve  pain  or  to  take  away  a  foul-smelling,  bleeding, 
ulcerating  mass.  Superficial  epithelioma  of  the  skin,  notably  rodent  ulcer, 
may  be  cured  by  the  X-rays  or  radium,  and  in  such  cases  only  should  these 
agents  be  used  alone  when  the  growth  is  operable;  after  excision,  however,  it 
is  often  advisable  to  employ  radiotherapy,  with  the  hope  of  preventing  or 
retarding  recurrence. 

In  the  treatment  of  inoperable  carcinoma  it  is  often  possible  only  to  relieve 
pain  by  such  drugs  as  morphin  and  to  disinfect  ulcerating  surfaces.  In 
some  cases  removal  of  large  portions  of  the  growth  by  excision  or  curettage, 
followed  by  cauterization  with  zinc  chloridorthe  actual  cautery,  or  by  fulgura- 
tion,  may  be  indicated  for  pain,  hemorrhage,  or  fetor.  Fulguration  (de 
Keating-Hart),  which  "consists  in  projecting  on  the  operative  field  a  shower 
of  sparks  supplied  by  an  alternating  current  of  high  frequency  and  high 
tension,"  causes  a  superficial  necrosis  and  is  probably  no  better  than  cauter- 
ization; it  requires  chloroformization,  as  ether  is  dangerous  because  of  the 
sparks.  In  other  cases  pain  may  be  abolished  by  severing  the  nerve  which 
supplies  the  affected  region,  and  occasionally  life  may  be  prolonged  by  ligation 
of  the  principal  arteries  nourishing  the  part.  In  inoperable  growths  about 
the  face  and  jaws  Dawbam  excises  both  external  carotids.  Among  palliative 
operations  may  be  mentioned  gastrostomy  for  cancer  of  the  esophagus, 
gastroenterostomy  for  cancer  of  the  pylorus,  inguinal  colostomy  for  cancer  of 
the  rectum,  and  tracheotomy  for  cancer  of  the  larynx.  In  inoperable  carci- 
noma of  the  breast  Beatson  removes  the  ovaries,  with  temporary  benefit  in  some 
cases.  The  various  cancer  serums  have  proved  of  value  in  the  hands  of  their 
inventors  only.  Coley's  fluid  may  be  tried  in  inoperable  cancer,  but  it  finds 
its  chief  indication  in  sarcoma  (q.v.).  The  injection  of  drugs,  such  as  pyok- 
tanin,  thiosinamin,  methyl  violet,  etc., is  of  such  little  value  that  their  use  may 
be  ignored.  The  X-rays  are  often  of  decided  benefit  in  mitigating  pain, 
lessening  discharge,  and  diminishing  fetor. 

II.  Mesoblastic,  or  connective-tissue  tumors,  are  those  derived  from 
mesoblastic  tissue. 

(A)  Innocent  connective-tissue  tumors,     (i)  Fibromata  are  tumors 


LIPOMA. 


Ut 


composed  of  fibrous  tissue.  The  growth  may  be  hard  or  soft  according  to 
the  density  of  the  fibrous  tissue  and  the  amount  of  liquid  which  it  con- 
tiiiiis.  Fibromata  may  arise  from  fibrous  tissue  in  any  part  of  the  l>ody,  but 
are  most  commonly  found  in  connection  with  the  periosteum  (e.g.,  fibrous 
tpuUs  of  the  jaw),  subcutaneous  tissues  (fihr&us  polypi  of  the  rectum  and  naso- 
pharynx), nerve  sheaths  (false  neuroma),  tendons,  uterus,  ovaries,  and  kid- 
neys, Kfloid  is  a  hard  fibroma  of  the  skin  developing  spontaneously  {Iruc 
keloid)  or  attacking  scar  tissue  {tifairklai^  or  false  keloid),  Mollusfum 
fihrosum  is  a  soft  fibroma,  which  may  occur  as  numerous  small  nodules,  or 
as  a  diiTuse  form  in  which  the  skin 
hangs  in  pendulous  folds  (pachyder 
mtU&ceU).  Fibromata  are  usually 
munded^  lobulated,  encapsulated,  and 
of  slow  growth.  With  the  excepting 
of  keloid  (see  chapter  on  skin)'  ami 
fibromata  which  contain  sarcomatous 
elements,  recurrence  does  not  take 
place  after  removal,  which,  again  ex 
ccpling  keloid,  is  in  general  terms 
the  treatment.  Fibroma  is  often 
associated  with  other  forms  of  tumor 
growth,  giving  rise  to  compound  terms, 
such  as  fibrolipoma,  fibro myxoma, 
fibromyoma,  and  fibrosarcoma,  while 
^stic,  colloid,  and  calcareous  degen- 
erations may  occur. 

(2)  Lipoma ta  (Fig.  85)  are  com- 
fiosrd  of  fat  resembling  that  of  the 
Iploic  appendages.  A  lipoma  is 
t,  lobulated,  and  elastic,  often 
senting  pseudo-fluctuation;  it  is 
delicately  encapsulated,  and  when 
situated  in  the  subcutaneous  tissues 
is  ovoid  in  shape,  and  causes  a  dim- 
pling of  the  skin  when  moved,  owing 
to  the  numerous  fibrous  strands  which 
pass  from  the  capsule  to  the  skin. 
A  fatty  tumor  may  contain  an  excess 
of   6brou5  tissue   (fibrolipoma),  or  a 

brge  number  of  dilated  blood  vessels  {neiolipoma).  They  grow  slowly, 
temctimes  reach  a  very  large  size,  are  commonly  smgle  but  may  be 
multiple  (Fig.  86),  and  are  most  frequent  in  mid-life  but  occur  also  as  con- 
genital gro\Nihs.  Among  the  secondary  changes  are  calcification,  ossification, 
ulceration,  inflammation,  mucoid  softening,  and  cystic  degeneration.  Lipo- 
mata  occasionally  change  their  location  as  the  result  of  gravity,  and  sometimes 
become  pedunculated.  Sukutanetms  iiponiata  are  most  common  on  the  back 
and  about  the  shoulders,  Submucotts  lipomata  are  rare.  Subsynot*ial 
Hpomaia  may  project  into  a  Joint  in  the  form  of  a  villous  growth  (lipoma 
arhoresrens)  and  be  associated  with  an  increase  in  the  joint  fluid  (^moi*itis 
Upomaiosis).  Subserous  lipomata  of  the  abdomen  may  form  large  retro -perit- 
oneal tumors,  or,  when  occurring  anterioriy,  may  insinuate  themselves  through 


Fit; 


85. — Laj-ge  lipoma  of  arm. 
{Jeffcrsrjn  Hospital  ) 


I 


MVXOlfA. 


M3 


i 


congenital  openings  in  the  ahdominal  wall  or  even  make  for  themselves  an 
opening  (e.g.^  epigastric  hernia)  and  draw  the  peritoneum  after  them,  thus 
pnxiucing  a  hernia*  Subfacial  lipomata  of  the  palm  or  sole  may  be  mistaken 
for  a  compound  ganglion.  Fatty  tumors  beneath  the  oixipitofronialis  are 
often  connected  with  the  periosteum,  and  are  most  frequent  on  the  forehead. 
Intermuscular  lipomata,  which  often  spring  from  the  periosteum,  are  fre* 
qucnily  mistaken  for  a  chronic  abscess  or  a  sarcoma.  Diffuse  lipoma  is  a 
localized  obesity,  frequently  occurring  in  the  cervical  region  as  double  chin 
or  double  neck.  The  fat  in  this  variety  is  granular  and  resembles  omentum. 
The  treatment  is  excision,  which,  in  the  ordinary,  circumscribed  subcuta- 
neous variety,  is  readily  done  by  incising  the  capsule  and  enucleating  the  growth 
with  the  finger;  adhesions,  however,  may  make  this  difficult.  In  the  diffuse 
variety  dietetic  measures  may  be  tried,  and  liquor  potassje,  m.  lo  t,d.,  for  a 
pmlonged  period  has  been  advised.  These  measures,  however,  will  be  found 
nf  little  use,  and  complete  exiision,  which  is  often  troublesome,  offers  the 
only  chance  of  cure. 

(3)  Chondroma  is  a  tumor  composetl  of  cartilage,  often  occurs  at  puberty, 
is  found  most  frequently  growing  from  bones,  particularly  those  of  the  hand, 
fool,  femur,  and  pelvis,  and  is  occasionally  seen  in  the  salivary  glands,  breasts, 
ovaries,  testicles,  tendons,  and  muscles-  The  secondary  changes  which  may 
lake  place  are  fatly,  mucmd,  calcareous,  and  cystic  degenerations,  while 
ossification  is  not  infrequent,  parliculariy  in  those  which  spring  from  the 
epiphyseal  lines  of  long  hones.  In  the  parotid  and  testicle  mixed  tumors 
may  occur,  i.e.,  the  growth  may  be  associated  with  myxoma  or  sarcoma,  or 
tiolh.  Ecchmtdroma,  or  ecfhondrosis,  occurs  as  a  spur  or  roun<led  out-grow ih 
from  lx>nes  or  cartilages.  Knchondrimw  springs  from  the  inner  surface  of  bone, 
projecting  into  the  marrow  cavity.  All  forms  are  hard  and  inelastic,  grow 
slowly,  and  may  be  single,  symmetrical,  or  multiple.  The  treatment  is  re- 
movd.     In  mixed  tumors  recurrence  may  be  expected. 

(4)  Osteoma  (bony  tumor)  is  really  an  ossified  chondroma^  hence  subject 
lo  the  general  statements  made  in  the  precetling  paragraph.  It  usually 
develops  where  bone  and  cartilage  meet,  cither  projecting  from  the  exterior 
of  the  bone  {exostosis)  or  from  the  interior  {endostosis};  and  is  composed  of 
L'c»mp;tcl  bone  (osteoma  durum),  cancellous  bone  (osteoma  spongiosum)^ 
or  extremely  dense  bone  in  which  no  blood  vessels  or  Haversian  canals 
are  found  {eburnated  osteoma).  Osteoma  rarely  reaches  a  large  size,  and 
usually  ceases  growing  when  adult  life  is  reached.  Borste  not  infrequently 
develop  over  an  exostosis  as  the  result  of  pressure.  A  subungual  exostosis. 
most  fret|uenlly  seen  beneath  the  nail  of  the  great  toe,  is  exceedingly  painful 
and  necessitates  removal  of  the  nail  in  order  to  expose  and  remove  the 
jfrowth.  Diffuse  hypertrophy  of  the  Ijones  of  the  face  (leontiasis  ossea) 
and  the  bony  growths  found  in  muscles  and  tendons  as  the  result  of  irrita- 
tion ( m  y  OS  it  is  oss  ifica  ns )  a  re  ost  eom  a  t  o  u  s  i  n  n  a  t  u  re .  1 '  h  e  t  real  m  ent  i  s  re  m  ox  a  I , 
except  in  cases  in  which  a  formidable  operation  would  be  necessary  for  a 
growth  which  is  producing  but  litde  annoyance. 

(5)  Myxoma  is  composed  of  mucoit!  tissue,  resembling  the  Whartcjn's 
jelly  of  the  umbilical  cord  or  the  vitreous  humor  of  the  eye.  It  is  most  com- 
mon  in  the  subcutaneous,  subserous,  and  submucous  tissues,  and  in  the  peri- 
neurium, and  is  a  soft  gelatinous  growth  which  may  be  sessile  or  peduncu- 
lated, in  the  latter  in.stance  forming  a  polyp.  Hydatid  moles  are  due  to  myx- 
omatous degeneration  uf  rhurionic  villi.     Myxoma  is  often  associated  with 


I 


TUMORS  AND  CYSTS. 

Other  forms  of  tumor,  and  not  infrectuently  recurs  after  removal,  owing  to  tl 
presence  of  sarcomatous  elements;  for  this  reason  the  trealmenl  should 
early  and  thorough  extirpation. 

(6)  Myoma  occurs  as  leiomyoma  (smooth  non -striated  muscle  cells)  or  as 
rhabdomyoma  (striated  muscle  elements).  Leiomyoma  is  most  common  in 
the  uterus  (where,  owing  to  the  quantity  of  tibrous  dsstie  present,  it  is  called 
fibramyoma),  gastrointestinal  tract,  and  prostate.  It  is  encapsulated,  firm 
in  consistency,  reddish  on  section,  and  frequently  stratified  or  concentric  in 
arrangement.  Among  the  secondary  changes  which  may  occur  are  infiam- 
maiion,  ulceration  or  necrosisj  and  cystic^  fatty,  myxomatous,  or  calcareous 
degeneration.  It  may  be  excessively  supplied  with  large  blood  vessels 
{myoma  lavenwsum).  Rhabdomyoma  is,  as  a  rule,  chiefly  sarcomatous,  the 
proportion  of  striped  muscular  fiber  being  small;  it  is  rare,  mostly  congenilat, 
and  is  found  in  the  kidney,  ovary,  and  testicle.     The  trtaimrnl  is  excision. 

(7)  Hemangiomata,  or  tumors  composed  of  blood  vessels,  occur  in 
three  forms. 

(a)  Simple  nri^^Hs,  or  angioma  telangitYtalkumj  consists  of  dilated  capillaries^ 
arterioles,  and  venules.  When  the  arterioles  are  principally  involved,  the 
growth  is  bright  red  {nevus Jfam mens,  or  strawberry  mark);  when  the  venules 
predominate,  the  color  is  dark  red  {neinis  venosuSy  or  port  wine  mark).  These 
tumors  are  slightly  elevated,  usually  located  on  the  face  or  neck,  and  are 
commonly  congenital,  hence  the  terms  birth  mark,  mother's  mark,  A  nevus 
may  remain  unchanged,  disappear,  or  rapidly  increase  in  size*  Violent 
hemorrhage  results  from  injury  or  ulceration. 

(b)  Cavernous  angioma  is  composed  of  irregular  sinuses,  and  resembles 
in  structure  the  corpus  cavemosum,  indeed  may,  like  it,  be  erectile.  The 
arteries  empty  irametlialely  into  the  venous  spaces  without  the  intervention 
of  capillaries.  Such  growths  occur  in  the  skin  (nex^us  prominens),  subcutane- 
ous tissue,  and  in  the  viscera,  particularly  the  liver,  but  are  seldom  congenital, 
A  simple  angioma  may  become  cavernous  in  type.  The  term  teiangie^ialk 
is  applied  to  various  tumors  which  contain  an  excess  of  blood  vessels,  cavern- 
ous to  those  in  which  these  blood  vessels  are  of  very  large  calibre;  these 
changes  are  most  frequent  in  sarcomata,  fibromata,  and  carcinomata.  An 
angioma  occasionally  becomes  sarcomatous.  A  cavernous  angioma  may  be 
emptied  on  pressure,  and  sometimes  there  are  pulsation  and  bruit.  Spon- 
taneous cure  from  inflammation  is  possible^  the  process  leading  to  thrombosis 
with  subsequent  organization  of  the  clot. 

(c)  Piexi/orm  angioma  (ratemose  aneurysm,  aneurysm  by  anastomosis, 
cirsoid  aneurysm)  is  really  not  a  tumor  but  a  varicose  condition  of  arteries, 
which  become  elongated,  thickened,  and  convoluted.  Arterial  varix  is  a 
varicosity  of  one  artery  only  (see  chapter  on  vascular  system). 

The  treatmefii  of  hemangiomata  is  excision  whenever  possible.  Elliptical 
incisions  are  made  around  the  growth  in  the  healthy  tissues,  and  the  resulting 
w^ound  sutured.  Ligation  by  placing  a  pin  through  the  base  of  the  nevus  and 
winding  a  ligature  beneath,  or  by  tying  the  base  of  the  nevus  in  sections,  is 
much  less  preferable  than  excision.  Cauttrizatimt  w^ith  fuming  nitric  acid, 
ethylate  of  soda,  or  the  actual  cautery,  may  be  employed  if  the  grow^th  is  mi- 
nute and  superficial.  The  injection  of  coagulating  fluids,  such  as  Monsel's 
solution,  carbolic  acid,  and  boiling  water  may  produce  embolism,  and  possesses 
no  advantages  o%^er  f/cdro/y 51. r,  which  is  useful  in  cases  in  which,  owing  to  the 
extent  of  the  growth,  excision  is  impossible,  and  in  cases  in  which  a  mini- 


ODONTOMA. 


I4S 


Fig.  87.— Congenital  cavernous 
lymphangiojTia. 


mum  of  scarring  is  desired.  One  or  more  needles  conneL ted  with  the  positive 
pole  of  a  battery  are  inserted  into  the  growth,  while  a  large  electrode  con- 
nected with  the  negative  pole  is  placed  on  some  indifferent  part  of  the  body; 
the  needles  should  be  insulated  to  near  the  point  in  order  to  protect  the  skin. 
From  25  to  200  milliamp^res  may  be  used  for  from  ten  to  fifteen  minutes;  an 
anesthetic  may  be  required.  The  mass  becomes  firm  owing  to  the  coagula- 
tion of  blood,  and  the  hardness  gradually  disappears  with  the  absorptitm  of 
the  thrombus.  The  number  of  applications  will  vary  with  the  size  of  the 
growth,  the  inten  al  between  the  seances  being  about  ten  days.  Payr  recom- 
mends, particularly  in  inoperable  angiomata,the  inirodnciion  of  slivers  of  mag- 
nesium in  all  directions  through  a  small 
wound;  the  metal  is  absorbed  and  induces 
coagulation.  Pusey  freezes  small  ne\'i  with 
carbon  dioxidt  snow,  which  is  collected  in  a 
piece  of  chamois  from  a  metal  cylinder 
and  moulded  to  the  shape  of  the  lesion,  to 
which  it  is  applied  with  forceps  for  from 
ten  to  thirty  seconds.  After  the  scab 
which  forms  drops  off  little  or  no  scarring 
foUowSp  unless  the  freezing  has  been  pro- 
longed, Radioikerapy  has  given  satisfac- 
tory results  in  some  superficial  growths. 

(8)  Lymphangioma  is  a  tumor  made 
up    of    dilated    lymph    vessels  (lymphan- 

girclasis),  or  more  frequently  lymph  spaces  (ravemous  lymphangioma — Fig, 
87).  Lymphangiomata  are  very^  prone  U>  inflammation  and  this  sometimes 
results  in  their  disappearance.  The  condition  may  be  seen  in  the  tongue 
{macroglossia)^  in  the  lip  [ma^nxhciUa),  or  in  the  skin  {nnms  lymphatims). 

L  Congenital  cystic  hygroma  is  due  to  dilatation  of  lymph  spaces.  Lymphad- 
en^ma^  or  lymphoma,  and  lymph  edema  and  varicosities  due  to  obstruction  of 
lymph  vessels,  are  described  with  the  diseases  of  the  lymphatic  system.  The 
treaiment  of  lymphangioma  is  that  of  hemangioma. 
(9)  Neuroma  (see  p.  222). 
(10)  Odontoma  is  a  tumor  composed  of  dental  tissue.  Sutton  describes 
bf%'en  varieties:  i .  Epithelial  odontoma  (Jibrocyslic  disease  of  the  jaw)  springs 
_  Dom  the  enamel  organ  and  forms  an  encapsulated  cystic  tumor,  usually  in 
the  lower  jaw.  The  growth  may  be  very  large  and  has  been  mistaken  for 
sarcoma.  This  variety,  although  of  epiblastic  origin,  is  mentioned  here  so  as 
not  to  separate  it  from  the  other  odontomata,  which  arise  from  mesoblastic 
structures.  2.  Follicular  odontoma  (dentigerous  cysl)  is  a  cavity  containing 
an  unerupted  permanent  tooth.  3.  fibrous  odontoma  is  a  thickening  of  the 
gbrous  capsule  of  the  tooth  sac,  which  may  become  so  great  as  to  prevent 
eruption  of  the  tcx)th;  it  is  said  to  occur  in  rickety  children.  4.  Ccmentoma 
encases  the  tooth  in  cement;  it  is  seen  in  ruminants  but  rarely  in  man.  5. 
Radictdar  odontoma  arises  from  the  tooth  papilla  after  eniptitjn  of  the  crown, 
and  consists  of  cementum  and  dentine.  6,  Compound  follicular  odontoma  is  a 
ftbrous  tumor  containing  numerous  denticles  which  erupt  at  intervals.  7. 
Composite  odontoma  is  composed  of  a  mixture  of  enamel,  dentine,  and  cemen- 
tum. The  treatment  of  dentigerous  cyst  is  removal  of  the  anterior  wall,  with 
cauterization  and  packing  of  the  ca\ity.  In  other  forms  of  odontoma  exci- 
sion may  l>e  indicated. 
to 


I 


(i  i)  Glioma  is  a  tumor  sprmging  from  the  neuroglia;  it  cojisists  of  round 
cells,  from  which  tine  processes  extend,  forming  an  inlCTlacing  reticulum. 
Gliosis  refers  to  a  diffuse  glioma tous  change,  such  as  is  seen  in  the  spinal  cord 
in  syringomyelia.  A  glioma  may  l>ecome  infiltrated  with  blood,  develop 
cysts,  or  undergo  a  sarcomatous  change,  indeed  some  authors  believe  it 
to  be  always  sarcomatous,  hence  the  term  gUosanoma.  Glioma  of  the  eyc-j 
ball^  a  growth  which  springs  from  the  retina  in  children,  is  always  a  round^ 
celled  sarcoma.     The  inatment  of  glioma  in  suitable  rases  is  exdsion. 

(B)  Sarcomata^  or  malignant  connective  tissue  tumors,  are  com- 
posed of  embryonic  or  immature  tissues  of  mesoblastic  origin.     They  are 
often  smooth,  regular  in  outline,  and  enclosed  by  a  pseudocapsule,  but  may 
l>c  infiltrating  in  cbaracter.     They  resemble  flesh  in  consistency  and  color^l 
hence  the  term,  but  these  features  vary  with  the  number  and  character  of  the 
cells,  and  the  presence  or  absence  of  secondar}^  changes,  such  as  hemorrhagesj 
formation  of  cysts,  myxomatous  degeneration,  and  necrosis,  all  of  whici] 
cause  softening.     Those  containing  bone,  cartilage,  or  much  tibrous  tissue 
are  hard  in  consistency  and  pale  on  section.     Sarcomata  are  usually  strik- 
ingly deficient  in  the  amount  of  intercellular  sul>stance  compared  with  thcl 
numbenif  emljryonic  cells,  which  vary  in  size  and  shape,  are  nucleated,  andj 
are  usually  without  a  bmiting  meml>rane.     The  blood  vessels  are  numerous 
and  may  cause  the  tumor  to  pulsate;  they  consist  of  channels,  the  walls  of 
which  are  the  sarcomatous  cells,  separated  from  the  blood  stream  by  a  singlel 
layer  of  endothelium,  thus  accounting  for  the  fact  ihat  sarcoma  spreads  by  ihel 

blood  vessels,  and  for  the  frequency] 
of       hemorrhagic       extra  vasation.l 
Melanotic    sarcoma    and    sarcomai 
of  the  tonsil,  testicle,  thyroid,  and" 
lymph  glands  may  spread  by  the 
lymphatics.     Sarcomata  may  occur 
at  any  age,  but  are  more  frequent 
in  the  first  half  of  hfe;  they  possess  \ 
all    the    features    of    malignancy.*" 
When    the    growths   are    multiplcj 
and    widespread    the    comlition  i*l 
tailed      sarcomatosis.        Although 
some   forms   of  sarcoma  exude   a 
whitish  tluid  on   settion,    it    never 
resembles  the  milky  juice  of  cancer. 
It  is  often  dilTicult  for  the  micro*j 
scopist   to   distinguish   between    round -celled   sarcoma    and   intlammatory 
tissue,   indeed   inHammalory   tissue   may   become  sarcomatous,   and    sar- 
comatous tissue  may  develop  into  the  maturer  forms  of  connective  tissue. 
Sarcomata  are  divided  according  lo  the  size  of  the  cells  into  \,i)  the  round-1 
celled  (small  and  large),  (2)  the  spindle-celled  {small  and  large),  and  (3)  the 
myeloid,  or  giant-celled. 

(i)  The  round-ctlkd  sanomata  (Fig.  88)  are  soft,  have  an  abundant 
blood  supply,  may  pulsate,  grow  very  rapidly,  and  give  rise  to  early  metas- 
tases, owing  to  the  facility  with  which  the  small  cells  are  washed  away  by  the 
blood  stream.  Lymphosarroma  is  a  rounfl-celled  sarcoma  attacking  lym- 
phatic glands  and  other  lymphadenoid  tissues,  which  it  re.^embles  histolog 
ii  ally,  the  inierrdlular  struma  forming  a  reticulum.    (Itioromti  isa  lymphosar- 


88. —  Rnijrul  1  rli,  .1     inotiKi  i)[  I  high  m  a 
child.     ■  I'L-iiiisyivaJiui  ituHpiLal.) 


SARCOMA. 


U) 


toraa  springing  from  I  he  periosteum  of  the  skull,  and  giving  rise  to  raetastatit: 
growths  in  other  portions  of  the  body;  on  section  it  has  a  greenish  color,  the 
nature  of  which  is  not  known.  The  blood  changes  may  be  those  of  lym- 
phatic leukemia.  Alveolar  sarcoma  also  may  be  classed  among  the  round- 
celled  sarcomata,  although  spindle-cells  likewise  are  found  in  the  gnivvth;  it 
resembles  cancer  in  the  formation  of  fibrous  alveoli  in  which  the  cells  are 
nested.  The  blood  vessels  run  in  the  walls  of  the  alveoli.  The  growth  is 
most  common  in  the  skin,  often  developing  from  moles  or  warts.  LUioma  is 
nfgarded  as  a  form  of  sarcoma  by  some  authors.  Mycosis  fun  go  ides  has 
been  described  as  multiple  sarcomata  of  the  skin,  the  histological  picture 
being  that  of  a  network  derived  from  the  connective  tissue,  in  the  meshes 
of  which  are  lymphoid  cells.  Many  authors  believe  it  to  be  bacterial  in 
origin. 

(2)  Spindk-celUd  sarcoma  consists  of  large  or  small  spindle  cells  frequently 
arranged  in  bundles;  the  stroma  may  he  quite  evident,  giving  the  growth  a 
fihn>us  appearance  (fibrosarcoma).  These 
growths  are  apt  lo  originate  in  dense  con- 
nective tissues  (tendons,  fascia,  periosteum), 
and*  when  composed  of  large  cells,  often 
show  a  slight  degree  of  malignancy,  recur- 
ring after  excision  but  not  giving  rise  to 
metastases, 

(1)  The  giant'CtUed  sarcoma  consists  of 
multinucleated  giant  cells  (my elo plaques) 
and  round  or  spindle  cells.  Owing  lo  the 
frequency  with  which  it  occurs  in  bones,  it 
is  often  called  myeloma,  or  myeloid  sarcoma. 
Epulis  is  usually  a  giant -eel  led  sarcoma. 
The  growth  is  relatively  benign;  secondary 
growths  rarely  occur  and  complete  recovery 
may  follow  excision.  Some  pathologists 
describe  myeloma  as  a  benign  tumor  composed  of  tissue  identical  wrth  the 
refl  marrow  of  young  bone. 

Xfelanolic  sarcoma,  or  melanosarcoma  (Fig.  89),  may  lie  any  of  the  varieties 
described  above  in  which  the  tumor  becomes  dark  in  color  owing  to  the 
dieposition  of  black  or  brown  pigment,  which  in  some  instances  is  tlue  to  the 
decomposition  of  extravasated  !>lood.  More  frequently  the  growth  origin- 
ates in  pigmented  structures,  such  as  moles,  warts,  or  the  retina.  It  is 
exceedingly  malignant,  rapidly  becoming  disseminated  and  causing  death. 
Beyond  the  pigmentation  and  great  virulency,  the  tumor  dilTers  from  other 
sarcomata  only  in  the  fact  that  it  spreads  by  the  lymph  vessels. 

Eruiathelioma  springs  from  the  endothelium  of  blood  vessels  {hcmangioni- 
rSathfiioma),  lymph  vessels  {lymphangioendothelioma),  or  serous  membranes, 
most  frequently  that  of  the  meninges,  pleura,  or  peritoneum,  but  may  be 
found  in  many  other  situations.  Histologically  the  growth  strongly  resem- 
bles carcinoma,  the  endothelial  cells  being  nested  in  acini,  hence  the  term 
endotitelial  cancer;  owing  to  its  mesolilastic  origin,  however,  it  may  l>e  classed 
among  the  sarcomata.  When  the  endothelial  cells  arc  clumped  in  small 
nodules  of  a  glistening  pearl-like  appearance,  it  is  known  as  choir stcatoma. 
Psammtnna  (sand  tumor),  or ditrtiettihrihelioma.iwcnTsm  the  meninges,  choroid 
plexus,  and  the  pineal  gland ;  it  contains  calcareous  matter  in  the  form  of  ftnc 


YiG.  89. — Melanotic  sarcoma  of  ki^. 


M 


148 


concretions.  PerUhelioma^  or  angiaaarcomay  springs  from  the  adventida  of 
blood  or  lymph  vessels  and  is  seen  most  frequently  in  the  skin,  salivary  glands, 
and  serous  membranes.  The  term  does  not  apply  to  the  number  of  blood 
vessels  in  the  growth,  although  these  may  be  numerous  and  large  {UlangUc- 
ialic  sarcoma),  Clyihtdroma,  or  pkxiform  sarcoma^  is  a  perithelioma  in  which 
hyaline  or  mucoid  degeneration  takes  place  in  the  cells  surrountling  the  blood 
vessels,  the  sections  presenting  a  piexiform  arrangement.  Many  endothe- 
liomala  grow  slowly  without  causing  metastases,  but  recur  after  excision; 
others  are  highly  malignant* 

Hypernrpkroma  springs  from  the  suprarenal  gland,  or  from  aberrant  rests 
of  suprarenal  tissue,  which  may  be  found  in  many  portions  of  the  body,  par- 
ticularly in  the  genitourinary  tract  It  is  said  to  be  the  most  common  malig* 
nant  tumor  of  the  kidney.  It  is  usually  lobulated,  of  a  grayish -red  or  yellow 
color,  and  frequently  infiltrated  with  extra vasated  blood,  giving  rise  to  blue 
or  black  areas  or  cyst -like  caWties.  The  tumor  is  generally  encapsulated; 
it  may  remain  small  and  benign,  or  grow  rapidly  and  cause  metastases  in  the 
lungs,  liver,  bones,  and  other  parts. 

The  treatment  of  sarcomata  is  early  ajid  thorough  excision,  which  in 
the  least  malignant  varieties  may  be  followed  by  permanent  recovery^  but  in 
the  small  round-celled  and  melanotic  growths  will  very  Ukely  be  followed  by 
recurrence.  In  those  growths  which  affect  the  lymph  glands,  these  should 
be  removed  with  the  tumor. 

In  inoperable  sarcoma  measures  similar  to  those  mentioned  in  the  treat- 
ment of  inoperable  cancer  may  be  tried.  In  rare  instances  growths  believed 
to  have  been  sarcomata  have  undergone  spontaneous  resolution;  but  in 
making  this  statement  one  should  not  fail  to  call  attention  to  the  difficulty 
often  experienced  by  the  pathologist,  as  well  as  the  surgeon,  in  difTerentiating 
sarcoma  from  syphilis  and  chronic  inflammations.  Owing  to  the  fact  that 
sarcomata  occasionally  disappear  after  an  attack  of  erysipelas,  these  growths 
have  been  treated  by  inoculations  with  the  streptococcus  of  erysipelas.  More 
recently  the  toxins  instead  of  the  living  organisms  have  been  used.  Coley*s 
fluid  is  a  sterilized  culture  of  the  streptococcus  of  erysipelas  and  the  badllus 
prodigiosus.  The  initial  dose  is  \  minim  injected  into  or  around  the  growth; 
the  dose  is  gradually  increased  until  a  reaction  of  from  101*^  to  103^  F.  is 
obtained,  then  repeated  every  two  or  three  days  for  three  weeks,  w^hen  it 
shouiti  be  discontinued  if  there  is  no  improvement.  If  the  growth  diminishes 
in  size,  the  injections  may  be  continued  until  the  tumor  has  disappeared,  or 
until  it  begins  to  grow  again.  The  spindle-celled  sarcoma  offers  the  best 
prospects  for  cure,  while  the  round -celled  and  melanotic  forms  are  probably 
influenced  little  if  at  all,  Coley's  tluid  seems  to  be  of  undoubted  value 
in  a  few  cases,  and  deserves  a  trial  in  inoperable,  but  never  in  operable, 
growths.  The  X-rays  may  be  employed,  but  seem  to  have  less  effect  than  in 
carcinoma. 

(Ill)  Teratomata  are  congenital  tumors  composed  of  cpiblastic,  meso- 
blastic,  and  hypoV>lastic  structures,  and  are  most  frequent  in  the  ovar}%  testicle, 
and  sacral  region.  The  tumor  may  contain  any  tissue,  adult  or  embr%^onic, 
hence  may  be  benign  or  malignant.  The  simpler  forms  contain  dermal 
structures  (dermoid  cyst)  and  are  due  to  the  healing  in  of  epiblastic  tissue  in 
the  deeper  structures,  the  more  complex  forms  are  probably  due  to  the  inclu- 
sion of  a  blighted  ovum  or  rudimentary  twin  (fetus  in  fetu).  They  are  to  be 
treated  bv  excision, 


CYSTS.  149 

CYSTS. 

A  cyst  is  a  new  growth  consisting  of  a  wall  and  fluid  or  semifluid  con- 
tents. Cysts  arise  from  (A)  the  distention  of  preexisting  spaces  or  are  (B) 
of  new  formation. 

(A)  Distention  cysts  may  be  due  to  (i)  retention,  (2)  exudation,  or  (3) 
extravasation. 

(i)  Retention  cysts  are  caused  by  the  obstruction  of  the  duct  of  a  gland, 
the  duct  beyond  or  the  adni  becoming  distended  with  the  normal  secretion, 
which  in  the  course  of  time  may  be  altered  in  appearance  and  surrounded 
by  new  fibrous  tissue.  Such  cysts  are  most  common  in  sebaceous  glands 
{wens)y  mucous  glands,  salivary  glands  {ranula),  and  in  the  breast,  pancreas, 
testicle,  kidney,  and  liver. 

(2)  Exudation  cysts  are  due  to  the  accumulation  of  fluid  in  preexisting 
cavities  which  are  not  provided  with  an  excretory  duct.  Serous  cysts,  ac- 
quired bursas,  and  hygromata  are  the  result  of  dilatation  of  lymph  spaces,  gan- 
^on  and  hydrocele  the  result  of  exudation  into  closed  serous  cavities.  Exuda- 
tion into  fimctionless  canals  is  typified  in  cysts  of  the  urachus,  vitello-intes- 
tinal  duct,  parovarium,  paroophoron,  Kobelt's  tubes,  Gartner's  duct,  branchial 
clefts,  and  thyro-glossal  duct.  Certain  cysts  of  the  thyroid  and  ovary  (those 
arising  from  the  Graafian  follicles)  are  exudation  cysts. 

(3)  Extravasation  cysts  follow  hemorrhage  into  a  preexisting  cavity,  e.g., 
tunica  vaginalis  testis  (hematocele).  Extravasation  of  blood  into  tumors  or 
other  tissues  also  may  give  rise  to  cyst-like  cavities. 

(B)  Cysts  of  new  formation  arise  in  various  ways. 

(i)  Dermoid  cysts  are  lined  by  epithelium  and  contain  epithelial  prod- 
ucts, such  as  hair,  nails,  teeth,  sebum,  mucus,  (a)  Sequestration  dermoids 
arise  from  the  inclusion  of  a  portion  of  the  epiblast  in  situations  where  embry- 
onic segments  unite,  e.g.,  in  the  middle  line  of  the  body  and  in  the  region  of 
the  facial  and  branchial  clefts.  In  the  face  the  most  common  situation  is 
just  behind  the  external  angular  process  of  the  frontal  bone  (orbito-nasal 
deft),  in  which  region  an  opening  may  persist  in  the  skull  and  the  dermoid  be 
connected  with  the  dura  mater,  (b)  Tubulo-der molds  are  those  developing 
in  fimctionless  ducts  or  obsolete  canals,  the  most  common  situations  being 
the  thyro-glossal  duct  and  the  post-anal  gut.  (c)  Ovarian  dermoids  may  con- 
tain not  only  dermal  structures,  but  also  mesoblastic  structures,  such  as  bone 
and  cartilage;  in  the  latter  instance  they  are  supposed  to  be  due  to  the  inclu- 
sion of  a  blighted  ovum  {teratoma),  (d)  Implantation  dermoid  {acquired,  or 
traumatic  dermoid)  is  due  to  the  thrusting  of  epithelial  cells  into  the  sub- 
cutaneous tissues,  usually  as  the  result  of  a  punctured  wound. 

(2)  Blood  cysts  may  arise  from  extravasation  of  blood  (hematoma).  A 
second  variety  often  foimd  in  the  neck  is  of  doubtful  origin;  it  has  a  thin  wall 
and  communicates  with  the  interior  of  a  vein. 

(3)  Cysts  due  to  foreign  bodies  are  an  effort  on  the  part  of  nature  to  en- 
capsulate these  alien  substances.  Under  this  heading  may  be  considered  also 
parasitic  cysts,  two  of  which  require  notice. 

Hydatid  cyst  is  caused  by  the  echinococcus,  the  larva  of  the  tape-worm  of 
the  dog  {tenia  echinococcus).  The  ova  are  taken  into  the  human  alimentar}' 
canal  with  food  or  water;  the  embryo  is  then  freed,  enters  the  blood  or  lymph 
stream,  and  finally  lodges  in  an  organ  where  it  forms  a  cyst.  The  wall  of  the 
cyst  is  composed  of  three  layers,  externally  a  layer  of  fibrous  tissue,  then  a 


Fig.  90. — Diagrams  of  cchinococcus  cycle  (after  LeuJtart,  2^egter.  and  I^ndon). 

I-  The  lape-worm^  about  6  mm.  in  length,  appearing  like  chalk-while  dots  in  the  duo- 
denum of  the  dog.  2.  f>vum,  about  o.oi  mm,  in  diameter,  showing  six-hooked  embno. 
2a.  Embryo  free  from  its  shell.  3.  Cyst  difierentialed  into  outer  lanciinaled  layer  and 
parenchyma.  4.  Acej^halocysl  stage.  An  outer  laminateil  layer  and  an  inner  parenchy- 
matous layer,  both  now  vascular,  enclosing  Ouid.  5.  lirotxl  capsules.  6.  Brood  capsules 
showing  development  of  scolex  or  tape-worm  head,  7.  Daughter  cysts.  8.  Daughter 
and  grand-daughter  cysts,  9.  Grafje-like  mass  of  daughter  cysts,  mother  cyst  having  dis- 
appeared, to.  Shrinkage  of  mother  cyst,  causing  parasitic  wall  to  be  folded,  and  between 
theie  folds  is  vascular  fibrous  tissue  belonging  to  the  adventitious  c>st,  the  whole  forming 
ft  semi-solid  or  solid  mass,  having  a  honeycomb-like  foliated  apjiiearance  on  section,  com- 
pared to  the  heart  of  a  cabbage,  or  resembling  colloid  cancer.  1 1.  Scolices,  with  rostcllum 
and  booklets  protruded  or  retracted,  like  a  vorticella,  just  visible  as  specks  when  the  fluid 
is  held  up  to  the  light,  and  measure  about  0,3  mm,  12  and  12a,  Hooklets^  highly  magni- 
fied.    (Walsham.) 


^ 


JMORS. 


tSJ 


cmicular  or  lamellar  layer  {niofyst),  and  liiiijig  these  a  piirciKbvmaltvus 
germinal  layer  (endtKysi)  whieh  acts  as  a  Imddiiig  or  liroorl  membrane. 
From  this  inner  layer  heads,  or  scoliees,  wilh  four  suckers  and  a  circle 
of  booklets  develop,  either  singly  or  in  groups  {brood  rapsutes)^  and  form 
daughter  cysts  (Fig.  go).  The  lluid  of  a  hydatid  cyst  is  clear,  1009  to  1015 
in  Sp.  Gr,  neutral  or  aikalin  in  reaction,  and  contains  a  trace  of 
albumin  and  a  large  quantity  of  sodium  rhloriti.  Microscopicidly  the 
tharacteristic  booklets  may  be  fouJicl.  Even  large  hydalid  cysts  may  he 
sterile^  i.e.,  contain  no  daughter  cysts;  the  walls,  however,  show  the  char- 
acteristic lamination.  A  multilocular  hydaliil  consists  of  numerous  small 
cysts  not  inclosed  by  a  mother  cyst;  they  are  most  frequent  in 
l>onc  and  in  the  spinal  cord.  Hydatid  cysts  may  grow  to  a  large  size 
Ijcfore  the  parasite  dies,  the  contents  then  become  inspissated,  and  may 
disappear,  or  l3e  converted  into  a  mortar-like  mass  with  calcification  of  the 
wall  of  the  cyst.  The  symptoms  of  a  hydatid  cyst  are  those  of  pressure  on 
surrounding  parts,  eosinophilia,  and,  in  the  event  of  suppuration,  sepsis. 
If  rupture  occurs  hydatid  urticaria  or  hydatid  toxemia  may  ensue.  Hydatid 
cysts  are  exceedingly  rare  in  the  United  States,  and  are  most  common  in 
Iceland  and  Australia.  Any  part  of  the  bo^ly  may  t>e  attacked,  but  the  disease 
is  most  common  in  the  liver,  lungs,  kidney,  and  brain.  The  treatment  is 
excision  if  possible;  in  other  cases*  evacuation,  removal  of  the  endocyst,  and 
drainage. 

The  cystkercus  cellulosd^  which  is  the  larva  of  the  taiia  solium,  or  pork 
tape  worm,  gains  entrance  to  the  tissues  in  the  same  way  as  the  echinococcus 
Cysticerci  from  the  tmia  saginata  also  have  occurred  in  a  few  cases,  Cysli- 
ccrci,  i.e.,  the  cysts,  are  usually  multiple,  hard,  and  rarely  as  large  as  a  hazel- 
nut. The  symptoms  are  due  to  pressure  ami  depend  ufion  the  situation. 
The  favorite  sites  are  the  subcutaneous  tissues,  the  central  nervous  system, 
and  the  eye.  Calcification  and  suppuration  are  possil>ilities.  Eosinophilia 
occurs.     If  favorably  locatetl  cysticerci  should  be  excised. 

(4)  Cysts  of  degeneration  such  as  arise  in  tumors  require  no  special 
comment. 

DIAGNOSIS  OF  TUMORS. 


One  must  first  be  sure  that  a  pathologic  swelling  is  present.  Neurotic  indi- 
viduals sometimes  imagine  they  have  a  tumor  when  they  discover  for  the  first 
lime  an  inequality  in  the  ribs,  a  self-inllated  stomach,  the  roll  of  epigastric 
fat,  or  the  lobules  of  the  breast  which  can  be  picked  up  l)etween  the  fmgers 
(p.  413).  Phantom  tumor  (p.  445)  and  pregnancy  may  occasionally  deceive 
even  the  most  able  clinician.  Other  forms  of  tumors  liesides  neoplasms  and 
cysts  are  mentioned  in  the  following  paragraphs,  because  in  practice  one  must 
often  consider  all  these  swellings  before  making  the  diagnosis  of  a  new 
growth. 

History. — (i)  The/aw»7y  history,  (2)  age,  (3)  naiionaUiy,  (4)  sex,  (5) 
oaupalion,  (6)  previous  history  of  the  patient,  and  (7)  pmious  treat tnctit  of 
the  swelling  may  have  some  bearing  on  the  diagnosis  (see  Chap,  i  and 
p.  156). 

(8)  OnseL^—{3i)  Sttdden  onset  can  take  place  only  when  normal  structures 
or  contents  of  structures  are  suddenly  displaced,  e.g.,  fractures  of  bone; 
ruptures  of  muscles  or  other  parts;  dislocation  of  organs  (hernia,  prolapses), 


i 


152  TUMORS  AND  CYSTS. 

joints,  muscles,  tendons,  nerves;  escape  of  air  (emphysema,  pneumato- 
cele), blood  (hematoma,  hematocele,  traumatic  aneurysm),  or  other  fluid 
(extravasation  of  urine,  spurious  meningocde)  into  the  tissues.  A  neoplasm 
never  springs  suddenly  into  existence,  but  having  been  present  some  time  it 
may  be  suddenly  noticed,  or  having  been  concealed  it  may  be  abruptly  ex- 
truded from  its  hiding  place,  e.g.,  polyps,  hemorrhoids,  loose  bodies  in  joints, 
tumors  of  the  spermatic  cord  lying  within  the  abdomen.  A  cold  abscess  like- 
wise may  apparently  arise  instantaneously  when  it  perforates  a  dense  fascia. 
(b)  Rapid  onset  occurs  in  acute  inflammatory  processes,  edema  from  nervous 
(angioneurotic)  or  hemic  disturbances  or  from  interference  with  the  circula- 
tion, and  in  obstruction  to  the  ducts  of  actively  fimctionating  glands,  e.g. 
swelling  of  the  salivary  glands  or  gall  bladder  from  calculus,  caked  breast,  re- 
tention of  urine  from  stricture.  It  should  be  recalled  that  the  constant  irri- 
tation produced  by  inflammation,  calculi,  etc.,  may  be  the  cause  of  neoplasms, 
especially  carcinoma,  and  that  inflammation,  edema,  and  obstructive  dis- 
tention of  ducts  or  glands  may  be  the  result  of  new  growths.  We  have  seen 
several  cases  of  acute  cancer  and  round-celled  sarcoma,  notably  about  the 
jaws  and  breast,  which  owing  to  their  rapid  development  have  been  indsed 
for  abscesses.  Many  of  the  conditions  mentioned  under  (a)  may  arise  rap- 
idly instead  of  suddenly  when  the  causes  are  less  active,  (c)  Slow  onset  is 
characteristic  of  chronic  inflammation,  hypertrophies,  some  forms  of  edema, 
most  neoplasms  and  cysts,  aneurysm,  varix,  and  of  swellings  due  to  gradual 
displacement  of  parts,  e.g.,  kyphosis,  exophthalmos,  and  many  hemix. 
Chronic  inflammatory  masses  due  to  the  irritatfon  of  a  ligature  or  other 
foreign  body  have  occasionally  been  excised  for  neoplasms. 

(9)  The  duration  of  a  neoplasm  is  generally  a  matter  of  months  or  years; 
in  the  former  instance,  if  large,  it  may  be  malignant,  in  the  latter  it  is  probably 
benign.  Tumors  dating  from  birth,  i.e.,  congenital,  are  usually  the  result 
of  malformation  or  maldevelopment,  e.g.,  hernia,  hydrocele,  branchial  cysts, 
congenital  dislocations,  meningocele,  and  teratomata,  but  include  also  heman- 
geioma,  lymphangeioma,  lipoma,  fibroma,  hypertrophies,  and  masses  of 
callus  from  intrauterine  fractures.  Occasionally  tumors  of  congenital  origin 
do  not  appear  or  are  not  noticed  until  some  time,  perhaps  years,  after  birth. 

(10)  The  progress  is  indicated  by  the  rate  and  manner  of  growth.  Sta- 
tionary neoplasms  are  benign.  Diminution  in  size  may  occur  (a)  suddenly 
when  the  contents  of  a  swelling  escape  from  rupture  of  the  tumor  (e.g., 
ovarian  cyst,  intraperitoneal  abscess),  from  dislodgement  of  an  obstruction 
in  a  duct  (e.g.,  distended  urinary  or  gall  bladder),  or  from  displaced  parts 
slipping  back  into  their  normal  place  (e.g.,  hernia  and  prolapse),  or  (b) 
gradually  from  absorption  of  fluid  (pus,  blood,  serum,  milk,  etc.)  or  solids 
(fibrin,  granulation  tissue,  callus,  etc.),  or  from  contraction  of  fibrous  tissue 
(e.g.,  masses  of  adhesions,  withering  scirrhus). 

Increase  in  size  depends  upon  the  activity  of  the  underlying  cause  and  the 
resistance  of  the  surrounding  tissues,  (a)  Sudden  enlargement  of  a  tumor 
may  be  due  to  inflammation,  heinorrhage  into  its  interior,  obstruction  of 
circulation  (e.g.,  ovarian  cyst  with  twisted  pedicle),  partial  obstruction  of 
a  duct  becoming  complete  (e.g.,  sudden  swelling  of  a  hydronephrotic  kidney), 
augmentation  of  contents  made  up  of  normal  structures  (e.g.,  hernia,  prolapse), 
or  rupture  of  the  tumor  (e.g.,  aneurysm),  (b)  Rapid  enlargement  occurs  in 
inflammatory  processes,  many  forms  of  edema,  some  cysts,  and  in  acute 
carcinomata  and  small-celled  sarcomata.     Other  malignant  tumors  develop 


. 


quickly  Ijut  nut  so  fast  as  the  htst  mentioned,  (t)  Slmv  gnnvth  gt-neraOy 
indicates  a  l>enign  neoplasm,  a  chronic  iiiflammalory  process,  an  aneurysm,  a 
varix,  a  cyst,  or  a  hypertrophy,  but  may  occur  in  malignant  neoplasms  of  low 
virulency^  The  rate  of  growth  changes  from  slow  to  rapid  when  a  benign 
neoplasm  becomes  malignant,  or  a  malignant  tumor  breaks  through  a  dense 
barrier,  such  as  fascia  or  bone,  (d)  Inter mittcni  eniargement  may  l>e  due  to 
intermittent  obstruction  of  a  duct  (e.g.,  hydronephrosis  and  recurrent  disten- 
tion of  the  gall  bladder  from  ball-valve  calculus),  intermittent  activity  of  a 
gland  whose  duct  is  partly  obstructed  (e.g.,  swelling  of  the  parotid  after 
meals  in  salivary  calculus),  intermittent  interference  with  the  circulation  (e.g. 
recurrent  varix  in  repeated  pregnancies),  successive  attacks  of  inflammation, 
increased  displacement  of  normal  structures  (e.g.,  hernia  and  prolapse) 
vascular  dilatation  in  growths  with  a  rich  blood  supply  (e.g.,  nevus,  goiter, 
some  sarcomata),  or  to  adventitious  pouches  (e.g.,  esophageal  diverticulum). 

The  direction  of  the  gr(nvth  is  well  defined  by  fascia  or  other  dense  struc- 
tures in  many  abscesses,  notably  psoas  and  palmar  abscess,  in  extravasation 
of  urine,  hernia,  effusions  into  closed  cavities,  and  in  some  neoplasms;  or  it 
may  follow  the  path  taken  by  the  structures  involved,  e.g.,  lymphadenoma, 
varices,  diffuse  lipoma,  hypertrophies,  sarcoma  of  muscle  (in  the  early  stages). 
Caitinomata,  as  a  rule,  extend  roost  rapidly  in  the  direction  of  the  lymph 
IBjftoiv  but  both  carcinoma  and  sarcoma  grow  in  all  directions  and  infiltrate 
coi^guous  tissues  irrespective  of  their  structure.  Benign  tumors  do  not 
infiltrate,  they  expand,  and  push  aside  or  compress  adjacent  parts  without 
invading  them  with  tumor  cells. 

(ii)  The  amount  of  pain  depends  more  upon  the  sensitiveness  of  the 
tissue  involved,  the  structure  of  the  part,  whether  loose  or  un>nelding,  the 
rapidity  of  the  growth,  the  presence  or  absence  of  inflammator)^  or  obstruc- 
tive complications,  and  the  temperament  of  the  indixiduab  than  upon  the 
nature  of  the  tumor,  although  with  equal  circumstances  the  pain  in  malig- 
nant disease,  owing  to  its  infiltrating  character,  is  more  severe  than  in  benign 
neoplasms.  It  must  be  emphasized,  however,  that  many  malignant  tumors, 
especially  in  the  early  stages,  are  painless.  The  interpretation  of  the  situa- 
tion and  the  character  of  pain  is  given  on  p.  6. 

Local  Examination, — (i)  The  siiuation  of  a  tumor  is  imporant  to  estab- 
lish not  only  the  anatomical  but  also  the  pathological  diagnosis.  Epithelial 
growths,  unless  secondar)%  can  arise  only  in  epiblastic  or  hypoblastic 
tissues;  connective- tissue  tumors  only  in  mesoblastic  tissues.  Certain  tumors 
have  a  predilection  for  certain  structures  or  organs,  e.g.,  a  tumor  arising  from  a 
nen-e  is  almost  sure  to  be  a  neuroma,  a  fibroma,  a  myxoma,  or  a  sarcoma;  a 
tumor  of  the  stomach,  a  carcinoma.  The  tumors  common  in  other  organs  are 
mentioned  in  the  sections  on  regional  surgery.  The  position  of  a  swelling 
may  correspond  with  one  of  the  ca\ities  of  the  body  or  with  the  site  of  fetal 
relics  or  folds  and  thus  betray  its  nature,  e.g.,  syno%ilis,  bursitis,  hydrocele, 
distended  urinary  or  gall  bladder,  branchial  cysts,  meningocele.  Change  of 
position  may  occur  as  the  result  of  gravity  in  lipoma  and  hematoma;  of  a  long 
pedicle  in  ovarian  cysts,  floating  kidney,  wandering  spleen,  and  similar  tu- 
mors; of  attachment  to  freely  movable  structures  like  the  intestine  or  omen- 
tum; of  muscular  contraction  in  intussusception,  and  foreign  bodies  or  fecal 
masses  in  the  intestine;  of  continued  growth  (see  "direction  of  growth**  above) ; 
or  as  the  result  of  reducibility  of  the  tumor  (see  "  reducibility ''  below).  The 
situation  of  a  superficial  tumor  may  be  apparent  at  a  glance.     Deep  tumors 


u 


jj^  ^mmmr   "^  TUMORS  AND   CYSTS. 

may  somclimes  la*  loraleil  liy  palpation,  l>y  Iniugies  {t\i^.,  in  \hv  urethra 
bladder,  esophagus),  l>y  iiislmnriLMits  for  iuspeiiing  the  interior  uf  cavities 
(e.g.,  tystoscDpe,  proctusi  opc%  etc. J,  by  distending  a  viscus  (e.g.,  bladder, 
stomach,  colon)  and  studying  its  relaUons  with  the  mass,  by  the  X-ray,  and 
sometimes  onJy  by  the  pressure  symptoms. 

(2)  The  pressure  symploms  depend  upon  the  size  and  situation  of  the 
growth.  The  skin  may  be  stretched,  thin,  bloodless,  and  sometimes  ulcer- 
ated. Aricrics  are  more  often  dispiacetl  than  compressed,  although  diminu- 
tion or  abolition  of  the  pulse  beyond  the  tumor  and  possibly  gangrene  may 
occur.  A  delayed  pulse  is  not  caused  by  pressure  but  by  aneurysm  (p.  189). 
Obliteration  of  veins  leads  to  edema,  varix,  and  dilatation  of  collateral 
branches;  of  lymph  vessels  to  edema  which  pits  l?ut  slightly  on  pressure. 
Nervous  siructn res  are  irritated  (pain,  hyperesthesia,  spasm,  increased  reflexes) 
or  destroyed  (anesthesia,  paralysis,  trophic  changes,  loss  of  reflexes) .  MuscUs 
and  other  soft  tissues  may  be  stretched,  distorted,  or  atrophied,  hones  ex- 
panded, erodeil,  or  absorbed,  sometimes  leading  to  spontaneous  fracture,  and 
joinis  dislocated  or  rendered  useless.  Organs  may  be  displaced  (exophlhab 
mos,  hernia,  prolapse)  or  the  parenchyma  tlegenerated,  leading  to  grave  func- 
tional disturbances.  Pressure  on  the  Matlder  may  lessen  its  capacity  and 
cause  frequent  micturition,  on  the  birih  canal  dystocia,  on  ducts  retention  of 
secretion,  on  the  air  passages  cough  and  dyspnea,  on  the  esophagus  dysphagia, 
and  on  the  bowel  symptoms  of  intestinal  obstruction. 

(3)  The  size  of  a  tumor  from  a  diagnostic  standpoint  is  of  value  only 
when  considered  with  its  duration  (indicating  the  rate  of  growth)  and  the 
symptoms;  malignant  tumors  rarely  attain  a  large  size  without  causing 
serious  general  symploms  or  local  degenerative  changes. 

(4)  The  shape  of  a  swelling  may  correspond  with  that  of  a  normal  organ 
(e.g.^  sarcoma  of  the  ovary,  spleen,  kidney)  or  cavity  (c,g,»  in  synovitis  and 
hydrocele).  The  form  is  often  hemispherical  in  abscess;  globular  in  cysts, 
sacculated  aneurysm,  and  soft  malignant  tumors;  ovoid  in  lipoma;  warty  or 
villous  in  papilluma;  lobuiated  in  lipoma,  adenoma,  chondroma,  epiplocele, 
ganglia,  and  swellings  due  to  intlammalion  or  retention  of  secretion  in  acinous 
glands  (e.g.,  breast  and  parotid);  nodular  in  scirrhus;  cauliQower  in  intracys- 
tic  papilloma  and  in  ulcerating  malignant  tumors-  polyjMjid  in  papilloma, 
fibroma,  and  myxoma. 

(5)  The  margins  are  sharply  defined  in  encapsulated  and  benign  growths, 
diffuse  and  ill-defined  in  infiltrating  growths  and  inllammator)^  processes. 

(6)  Mobiiity  of  a  growth  under  overlying  and  over  subjacent  parts  is 
generally  indicative  of  benignity  or  of  its  presence  in  or  attachment  to  mov- 
able structures.  In  the  latter  instance  it  will  be  immovable  in  the  direction 
in  which  the  structure  is  immovable  (e.g.,  tumors  of  muscle,  tendons,  nerves, 
and  vessels  are  movable  perpendicularly  to  but  not  in  the  axis  of  these 
structures),  or  when  the  structure  is  made  tense  (e.g.,  muscle,  tendon),  or 
when  the  structure  is  lixed  with  the  other  hand  (e.g.,  the  breast).  A 
tumor  attached  to  a  muscle  or  its  tendon  moves  during  contraction  uf  the 
muscle;  to  the  trachea  (e.g.,  goitre),  during  deglutition;  to  the  liver,  spleen, 
or  kidney,  during  respiration.  A  tumor  which  disappears  when  a  muscle  is 
contracted  lies  beneath  it,  one  which  is  made  more  prominent  is  either  a 
hernia  or  lies  superficial  to  the  muscle.  Immohility  means  attachment  to  a 
fixed  structure  (e.g.,  bone),  inflammation  or  inflammatory  adhesions,  neo* 
plastic  infiltration  (i.e.,  malignancy),  or  confinement  beneath  tense  structures 


L 


^5! 

Kke  muscle  or  fastiii.     The  iast  may  lie  recognize*!  Iiy  relaxing  the  must  le  ur 
fascia,  when  the  tumor  hecumes  movable, 

(7)  The  ransistcney  of  a  solid  benign  tumor  is  that  of  the  tissue  uf  which 
is  composed,  viz.,  bone,  cartilage^  librous  tissue,  fat,  etc.  Malignant 
^owths  may  be  as  hard  as  bone  or  so  soft  that  they  give  a  deceptive  sense  of 
luctualion;  the  softer  the  tumor  the  more  malignant  it  is.  PiJting  on  pres- 
sure indicates  edema  (p,  5),  dermoid  cyst,  blood  clot,  or  impacted  feces,  A 
stift  (imighy  sensaiian  may  be  noticed  in  gaseous  or  fecal  tumors,  blood  cIoIt 
dermoid  cysts,  and  in  tuberculous  affections  of  serous  or  synovial  cavities. 
The  consistency  of  tumors  may  sometimes  be  revealed  by  the  X-ray.  The 
significance  of  crepilation  and  alteration  of  the  loeal  iemperatun,  which  may 
Ije  noticed  at  this  lime,  are  given  on  pages  6  and  7  respectively,  and  of 
pulsation^  tlirill,  and  bruit  (which  is  audible  thrill)  on  p.  5,  6  and  189. 

Fluid  tumors  are  recognized  liy  fluctuation  (p.  5),  translucency  (p,  5), 
exploratof)*  puncture,  or  in  some  cases  by  emptying  a  viscus  by  the  natural 
route,  e.g.,  catheterization  in  distended  bladder. 

Gaseotis  swellings  are  due  to  the  presence  of  a  gas-containing  viscus,  as  in 
pneumocele  and  enterocele;  to  a  leak  in  an  air-containing  structure,  as  in 
cutane<ms  emphysema  ajid  pneumatocele;  to  the  introduction  of  the  gas 
from  without,  as  in  emphysema  after  closing  a  large  wound  or  after  a  careless 
hypodermoclysis;  or  to  aerogenic  bacteria,  as  in  emphysematous  gangrene 
and  physometra.  The  tumor  is  generally  yielding  and  elastic,  hence  often 
gives  a  deceptive  sense  of  tluctuationr  and  it  is  often  reducible.  Crepitation 
may  be  obtained  when  the  gas  is  finally  divided,  as  in  pneumocele  and  cu- 
taneous emphysema;  gurgling,  when  it  is  mixed  with  iluid,  as  in  enterocele; 
and  a  tympanitic  note  on  percussion,  when  sufficient  gas  is  present.  Oc- 
casionally the  gas  can  be  seen,  e.g.,  in  emphysematous  gangrene,  and  in 
certain  cases  it  may  be  evacuated  l>y  puncture,  incision,  or  when  in  the 
bladder  or  uterus  by  catheterization. 

Variaiion  in  consistent  y  indicates  the  presence  of  normal  tissues  of  differ- 
ent structure,  as  in  enteroepiplocele;  several  types  of  tumor  formation,  as  in 
teratoma,  adenomyxoma^  cystadenoraa,  etc.;  or  the  changes  to  be  mentioned 
in  the  next  paragraph. 

Change  in  consistency,  involving  either  a  portion  of  or  the  whole  tumor, 
results  in  hardening  or  softening. 

Hardening  arising  (a)  sudden! y  or  rapidly  and  associated  with  an  increase 
in  size  may  be  due  to  any  of  the  conditions  mentioned  above  under  "sudden  " 
and  **  rapid  enlargement/'  except  rupture  of  tumors,  (h)  Gradual  harden  in  g 
with  increase  in  size  may  be  due  to  the  increased  tension  attending  the  growth 
of  cysts  aiid  encapsulated  tumors,  or  to  change  in  the  type  of  tissue  composing 
the  tumor,  e.g.,  when  a  lipoma  becomes  a  fibrolipoma  or  the  embryonic  cells 
of  a  sarcoma  developed  into  maturer  forms  of  connective  tissue  (Jibrous, 
cartilaginous,  osseous).  Gradua!  hardening  wilk  decrease  in  size  is  the  result 
of  absorption  or  solidification  of  the  tluid  contents  of  a  swelling:  e.g.,  in 
cysts,  abscesses,  hematoma ta,  aneurysms,  thrombophlebitis;  of  resolution  of 
inflammatory^  processes;  of  organization  of  granulation  tissue;  of  ossification 
of  callus;  or  of  the  contraction  of  fibrous  tissue,  e.g.,  in  cicatricial  masses 
and  withering  scirrhus. 

Safienittg  arising  (a)  suddenly  with  increase  in  size  is  generally  due  to 
edema.  Svddtn  softening  u4th  decrease  in  size  may  be  due  to  rupture  of  a 
cyst,  aneurysm,  or  abscess  into  a  norma!  cavity,  to  the  partial  dislodgment 


i 


156  TUMORS  AND  CYSTS. 

of  an  obstruction  in  a  duct  or  canal,  or  the  partial  reduction  of  a  hernia,  (b) 
More  or  less  gradual  softening  with  increase  in  size  may  occur  when  a  benign 
growth  becomes  malignant,  when  a  malignant  growth  breaks  through  firm 
fascia  or  bone,  when  a  tumor,  usually  malignant,  undergoes  degenerative 
changes  (cystic,  mucous,  fatty,  colloid,  necrotic),  or  when  an  inflammatory 
mass  suppurates.  It  should  be  noted  that  neoplasms  and  cysts  may  become 
inflamed  and  suppurate,  and  that  necrotic  changes,  particularly  in  carci- 
noma, may  result  in  the  formation  of  a  puruloid  material  which  may  lead  to 
the  diagnosis  of  acute  abscess,  the  presence  of  the  growth  being  overlooked. 
Gradual  softening  with  decrease  in  size  points  to  the  absorption  of  the  contents 
of  a  swelling  whose  walls  remain  of  the  same  size,  e.g.,  serous  and  synovial 
effusions. 

Intermittent  hardening  and  softening  is  due  to  muscular  contraction,  e.g., 
in  intestinal  obstruction,  particularly  intussusception,  and  in  pregnancy  (see 
also  "intermittent  enlargement*'  above). 

(8)  The  reducihility  of  a  swelling  in  part  or  as  a  whole  may  suggest  its 
nature.  Reduction  may  be  effected  by  compression  or  manipulation  in  angio- 
mata,  varix,  aneurysm,  tumors  with  a  rich  blood  supply,  edema,  meningocele, 
reducible  hydrocele,  bursae  communicating  with  joints,  tumors  of  the  sper- 
matic cord,  partly  descended  testicle,  certain  abscesses  (e.g.,  psoas,  empyema 
necessitatis) ,  and  in  dislocations  of  normal  structures  (nerves,  tendons,  musde, 
bone,  cartilage,  hernia,  prolapse) ;  by  position^  e.g.,  elevation  or  the  recum- 
bent posture,  in  many  of  the  swellings  just  mentioned,  and  flexion  of  the 
knee  in  bursae  about  this  joint;  by  pressure  on  the  artery  feeding  the  tumor  in 
aneurysm  and  telangiectatic  growths;  by  pressure  on  the  vein  supplying  the 
swelling  in  varix  and  venous  tumors  (in  applying  this  test  one  must  be  sure  of 
the  direction  of  the  venous  current  since  it  may  be  reversed,  as  in  varix  of  the 
leg  (q.v.) ;  by  catheterization  in  distended  hollow  viscera,  e.g.,  the  urinary 
bladder;  by  purgation  in  fecal  impaction;  or  hy  anesthesia^  e.g.,  in  phantom 
tumor. 

The  phenomena  attending  reduction  should  be  noted.  An  enterocde  dis- 
appears with  a  gurgle,  certain  varices  with  a  thrill,  synovial  effusions  contain- 
ing rice  bodies  with  a  peculiar  crepitus,  swelling  due  to  dislocated  joints, 
muscles,  or  tendons  often  with  an  audible  snap,  and  meningocele  sometimes 
with  symptoms  of  cerebral  compression. 

Most  reducible  swellings  reappear  or  increase  in  size  when  maneuvers 
opposite  to  those  mentioned  above  are  attempted,  and  those  communicating 
with  the  cerebrospinal  canal,  thorax,  and  abdomen  may  swell  when  the 
patient  strains  and  have  an  impulse  on  coughing.  It  is  important  not  to 
mistake  a  false  for  a  true  impulse  on  coughing,  the  former  is  nonexpansile. 

(9)  A  number  of  tumors y  if  such  are  all  primary,  usually  points  to  benig- 
nancy,  but  it  should  be  recalled  that  one  of  these  tumors  may  undergo  malig- 
nant changes.     Multiple  malignant  tumors  are  almost  always  secondary. 

(10)  The  skin  over  the  growth  may  be  ctdherent  because  the  tumor  lies 
in  this  structure,  because  of  inflammation,  or  because  of  infiltration  with  cells 
of  malignant  tumors.  A  sebaceous  cyst  is  always  attached  to  the  skin  at  one 
point,  a  subcutaneous  lipoma  at  many  points,  as  is  shown  by  dimpling  of 
the  skin  when  an  attempt  is  made  to  pinch  it  up  between  the  fingers;  the  latter 
should  not  be  confused  with  the  multiple  depressions,  apparent  without 
raising  a  fold  of  skin,  which  occur  in  scirrhus  (see  carcinoma  of  the  breast). 
Mere  tension  exerted  by  a  large  tumor  may  make  the  skin  apparently  adher- 


DIAGNOSIS   OF  TUMORS. 


157 


exit.  The  calor  of  ihe  skin  (p,  4)  and  the  presence  or  absence  f>f  prefanccrous 
dermaiases  (p.  163)  should  be  noticed.  Distention  of  the  superficial  veins 
over  a  growth  may  be  caused  by  any  tumor  which  obstructs  the  deeper  veins, 
or  by  tumors  with  an  abundant  blood  supply,  conspicuously  sarcoma;  in 
the  former  the  veins  distal  to  the  growth  also  are  enlarged  and  perhaps  edema 
may  be  present*  in  the  latter  the  venous  engorgement  is  confined  to  the  growth 
and  the  parts  proximal  to  it.  Nodules  in  the  skin  about  a  tumor  are  usually 
secondary  malignant  growths.  Uktralkm  of  a  benign  tumor  may  occur  from 
friction,  pressure,  or  pyogenic  infection;  it  may  be  due  to  one  of  the  infectious 
granulomata^notably  syphih's  and  tuberculosis; and  it  is  common  in  malignant 
tumors  (see  diagnosis  of  ulceration,  p.  74).  Bleeding  from  an  ulcerating 
tumor,  aside  from  hemangioma  and  \illous  papillomata,  points  strongly  to 
malignancy. 

(ii)  Adjacent  lymph  glands  may  be  enlarged  in  any  form  of  ulceration 
(sec  pp.  76  and  2ig);if  ulceration  is  not  present  the  growth  is  probably  car- 
cinoma»  although  as  already  stated  certain  sarcomata  may  spread  l>y  the 
l}nniph  vessels  (p.  146). 

(12)  Explof alary  incisimt  to  expose  the  growth  is  employed  particularly 
in  abdominal  tumors.  Incision  of  the  swelling  itself  is  sometimes  indicated 
before  proceeding  to  extirpation;  cases  have  occurred  in  which  the  tongue  or 
breast  has  been  excised  and  the  swelling  found  to  be  simply  a  cold  abscess; 
again,  cases  of  fibrocystic  disease  of  the  lower  jaw  and  chronic  inflammatory^ 
swellings  due  to  foreign  bodies  have  been  subjected  to  formidable  operations 
with  the  belief  that  the  swelling  was  sarcomatous. 

(13)  Exrisiatt  of  a  portion  of  the  tumor  for  microscopic  examinadon  is 
occasionally  necessary-  to  estabbsh  a  correct  diagnosis.  In  these  cases, 
whenever  possible,  the  patient  should  be  prepared  for  a  radical  operation 
and  a  section  of  the  growth  removed,  frozen,  and  examined  at  once.  Allow- 
ing days  to  elapse  between  the  exp>loratory  exdsion  ami  the  extirpation,  in 
cases  of  malignant  disease,  may  permit  of  dissemination  of  the  tumor  cells 
from  the  cut  surfaces.  If  delay  must  be  accepted  the  raw  surfaces  should  be 
cauterized.  Here  we  may  mention  the  possibility  of  making  a  diagnosis  by 
chemical  and  bacteriological,  as  well  as  microscopic,  examinations  of  tluids 
obtained  by  aspiration  (e.g.,  in  ranula,  galactocele,  pancreatic  cyst,  hydatid 
disease,  hydronephrosis,  tuberculous  abscess) ;  of  secretions  (e.g.,  examination 
of  the  stomach  contents  in  gastric  carcinoma) ;  of  excretions  (e.g.,  by  recover}' 
of  portions  of  the  growth);  and  of  discharges  (e.g,,  in  the  infectious 
granulomata). 

General  Examination. — Cachexia  (p.  8)  occurs  in  mah'gnant  tumors, 
but  as  a  late  sign,  hence  its  absence  should  not  influence  the  diagnosis  in  the 
cariy  stages.  Metastases  slK>uld  be  sought  for,  not  only  in  lymph  glands, 
but  in  other  portions  of  the  body*  parlicularly  the  lungs,  the  liver,  and  the 
bones;  and  a  search  made  for  evidences  of  diseases,  like  syphilis  and  tuber- 
culosis, which  might  cause  a  localized  swelling.  The  heart  is  examined  as  a 
matter  of  routine;  in  many  cases  of  fibromyoma  of  the  uterus  it  undergoes 
brown  atrophy.  Blood  examination  may  reveal  anemia,  leukocvtosis,  and  the 
hemolytic  reaction  in  the  later  stages  of  malignant  disease,  lymphocytosis  in 
chloroma,  the  Wassermann  reaction  in  gummata,  and  eosinophilia  in  para- 
sitic cysts.  Apart  from  local  conditions  the  urine  may  show  the  Bencc- 
Jones  albumose  in  myeloma^  sugar  and  the  Cammidge  reaction  in  pancreatic 
tumors* 


I 


IS8  SKIN  AND  CUTANEOUS  APPENDAGES. 


CHAPTER  XIV. 
SKIN  AND  CUTANEOUS  APPENDAGES. 

Excepting  erythema  nodosum,  affections  of  the  skin  which  do  not  demand 
operative  treatment,  and  those  which  are  dealt  with  in  other  sections  of  the 
book,  e.g.,  erysipelas,  syphilodermata,  bums,  frost  bites,  etc.,  are  not  included 
in  this  chapter. 

Erythema  nodosum  must  be  mentioned,  because  its  local  manifesta- 
tions may  be  mistaken  for  abscesses,  gummata,  or  bruises.  It  is  most 
frequent  in  young  females,  and  is  characterized  by  fever,  and  the  formation 
of  nodules,  varying  in  size  from  that  of  a  pea  to  that  of  a  pigeon's  egg,  usually 
on  the  shins,  but  occasionally  on  other  portions  of  the  body.  These  nodules 
are  at  first  bright  red,  painful,  tender,  and  often  so  soft  as  to  give  a  sense  of 
fluctuation,  but  they  should  never  be  opened,  as  spontaneous  resolution 
always  takes  place  in  the  course  of  a  few  weeks.  As  the  swelling  subsides, 
the  color  passes  through  the  various  shades  of  a  bruise,  hence  the  term 
erythema  cantusiformis.  The  disease  is  probably  an  angioneurosis,  and  is 
often  associated  with  rheumatism.  The  treatment  is  rest  in  bed,  lead 
water  and  laudanum  locally,  and  salicylates  internally. 

Blastomycosis  is  an  infectious  disease  due  to  blastomycetes,  and  is  most 
commonly  found  in  the  skin  of  the  upper  extremities  and  face.  A  few  cases 
of  general  infection  have  been  reported.  The  organism  is  spherical  or  ob- 
long, surrounded  by  a  double  capsule,  and  may  contain  a  nucleus  or  spore- 
like body,  vacuoles,  and  granules.  Multiplication  takes  place  by  budding. 
Beginning  as  a  small  papule  the  lesion  becomes  pustular  and  discharges  a 
glairy,  sticky  secretion.  The  ulcerating  surface  gradually  enlarges  and 
becomes  covered  with  soft,  friable  papillae.  The  margin,  one  of  the  char- 
acteristic features,  is  raised,  indurated,  and  a  dusky  red  in  color,  and  scattered 
through  it  may  be  seen  small  miliary  abscesses.  The  disease  may  last  for 
years.  The  diagnosis  is  confirmed  by  microscopical  examination  of  the  pus. 
The  prognosis  is  good,  provided  the  treatment  is  instituted  early,  when  a  cure 
may  be  expected  in  from  three  months  to  a  year.  The  treatment  is  exci- 
sion, or  when  this  is  not  possible,  the  continued  use  of  potassium  iodid 
with  local  antiseptics  and  the  Rontgen  ray  (Ricketts). 

A  boil,  or  furuncle,  is  an  acute  inflammation  of  a  limited  portion  of  the 
skin  and  subcutaneous  tissue  around  a  hair  follicle,  sweat  or  sebaceous  gland. 
Infection  is  commonly  due  to  the  staphylococcus  pyogenes  aureus.  Bright's 
disease,  diabetes,  and,  in  fact,  any  condition  which  lowers  the  general  resist- 
ance predispose  to  crops  of  boils.  A  boil  may  be  preceded  by  a  slight  wound 
or  abrasion,  such  as  that  which  follows  shaving,  scratching,  or  irritation  from 
a  collar  button,  but  in  many  instances  no  such  history  can  be  obtained. 
Secondary  boils  are  caused  by  infection  of  surrounding  hair  follicles  by 
organisms  from  the  primary  boil. 

The  symptoms  are  a  stinging  and  itching  sensation  due  to  the  formation 
of  a  small  red  pimple,  which  increases  in  size,  becomes  more  painful,  and 
forms  a  conical  elevation,  deep  red  in  color  and  very  tender.     Occasionally 


CARBUNCLE. 


159 


the  process  extends  no  further  and  the  inflammation  gradually  subsides 
without  suppuration  (blind  boil).  As  a  rule  the  pain  and  swelling  increase, 
the  color  becomes  more  duskvt  and  a  pustule  forms;  this  ruptures  and  exposes 
a  ""core,''  or  slough,  consisting  of  a  necrotic  sebaceous  gland  or  hair  follicle. 
After  separation  of  the  slough  the  canty  heals  by  granulation. 

The  treatment  is  hot  fomentations ^  and  incision  when  maturation  occurs. 
Tonics  are  required,  and  calx  sulphurata,  grain  y'^  t.  d.,  and  fresh  brewer's 
yeast,  f3I  before  or  during  meals,  have  been  recommended  to  hinder  the 
formation  of  new  boiis,     Vaccine  treatment  is  still  on  triab 

Oriental  boil  (alrppo  bott,  Buska  kdtmi,  Dehlt  sore)  is  confined  to  the 
tropics  and  is  contagious.  It  begins  as  a  papule,  which  ulcerates,  the  ulcer 
healing  only  after  months  and  leaving  an  ugly  scar.  The  treatment  is 
cauterization  or  excision. 

Carbuncle  is  an  acute  inflammation  of  a  limited  portion  of  the  skin  and 
subcutaneous  tissue,  with  the  formation  of  multiple  sloughs.  Like  a  boil  it  is 
due  to  the  staphylococcus  pyogenes  aureus  and  occurs  in  individuals  whose 
general  resistance  is  depressed  by  diabetes,  B right's  disease,  or  any  other 
debilitating  condition ;  in  fact,  a  carbuncle  is  a  boil  with  multiple  cores.  Car- 
buncles are  most  frequent  on  the  back,  nape  of  the  neck,  and  buttocks. 
The  infection  enters  a  hair  follicle,  reaches  the  subcutaneous  tissue  through  the 
little  column  of  fat  in  which  the  hair  follicle  ends,  then  spreails  1  ale  rally,  and 
a^ain  finds  egress  through  columns  of  fat  {coiumnm  adiposes]  to  I  he  surface, 
thus  giving  a  sieve-like  appearance. 

The  symptoms  at  the  outset  may  be  those  of  a  boil,  or  there  may  be  a  deep 
infiltration  of  the  subcutaneous  tissues.  In  either  event  the  process  spreads 
until  in  some  cases  it  reaches  the  diameter  of  six  or  more  inches.  All  the 
symptoms  of  acute  inflammation  are  present.  While  the  process  is  still 
extending,  the  central  portion  becomes  more  soft  and  develops  numerous  pus- 
tules, which,  bursting,  uncover  grayish  sloughs,  so  that  at  this  stage  a  car- 
buncle resembles  a  sponge,  the  meshes  of  which  are  filled  with  pus  and 
necrotii  tissue.  Many  of  the  openings  coalesce  while  new  ones  are  forming 
at  the  periphery.  In  a  favorable  case  the  inllammalion  subsides,  the  sloughs 
separate,  and  the  cavity  heals  by  granulation.  The  constitutional  symptoms 
are  those  of  septic  intoxication,  septicemia,  or  pyemia.  Carbuncles  occurring 
in  vascular  regions,  such  as  the  face  and  lips,  arc  more  serious  because  of  the 
danger  of  septic  phlebitis,  which  in  facial  cases  is  prone  to  spread  to  the  caver- 
nous sinus.     The  mortality  of  facial  carbuncle  is  said  to  be  50  per  cent. 

The  treatment  is  excision  in  those  cases  which  are  seen  early  and  in 
which  the  carljuncle  is  favorably  situated;  the  wound  is  allowed  to  granulate 
under  antiseptic  dressings.  In  other  cases  the  honey-combed  mass  should  be 
opened  freely  by  crucial  incisions,  and  as  much  of  the  necrotic  tissue  as 
possible  removed  by  forceps  ami  scissors.  The  wound  should  thwi  be  disin- 
fected with  peroxid  of  hy<lrogen  and  bich lurid  of  mercury  solution^  1  to 
T.ooo,  and  dressed  with  warm  antiseptic  fomentations.  The  constitutional 
treatment  is  that  of  sepsis. 

Multiple  areas  of  cutaneous  gangrene  may  occur  in  certain  skin  diseases, 
{gangrtfimis  urticaria,  herpes,  crylhema,  etc.) :  in  acute  infective  fevers,  possibly 
as  the  result  of  embolism;  in  hysteria,  perhaps  from  self -inflicted  injuries 
with  caustics;  and  they  may  arise  spontaneously  or  from  some  obscure  change 
in  the  nervous  system.  The  sloughs  should  l»e  allowed  to  separate  under  an- 
tiseptic fomentations,  and  treatment  di reded  to  the  underlying  cause. 


( 


l6o  SKIN  AND  CUTANEOUS  APPENDAGES. 

A  clavus,  or  com,  is  a  circumscribed  h)rpertrophy  of  the  epidermis 
with  the  projection  into  the  skin  of  a  homy  plug  of  the  same  material.  A 
callosity  differs  from  a  com  in  the  absence  of  the  ingrowing  central  plug. 
Coras  are  the  result  of  long  continued  pressure,  and  are  rarely  seen  except  on 
the  feet.  Hard  corns  occur  on  the  dorsal  surface  of  the  toes,  particiilariy 
the  little  toe,  soft  corns  between  the  toes,  where  they  become  sodden  from  the 
constant  presence  of  moisture.  Both  varieties  are  painful,  and  may  become 
inflamed  and  suppurate. 

The  treatment  is  removal  of  pressure  by  the  wearing  of  well  fitting  shoes 
or  the  application  of  a  circular  com-plaster  of  felt.  The  com  itself  may  be 
removed  with  a  sharp  knife  after  the  parts  have  been  softened  by  soaking  in 
hot  water.  Any  existing  deformity,  e.g.,  hammer-toe,  should  be  corrected. 
Corns  may  be  treated  also  by  the  application  of  tincture  of  iodin,  silver  nitrate, 
or  salicylic  acid ;  the  first  and  second  may  be  used  in  a  pure  form,  the  last  in 
a  mixture  consisting  of  salicylic  acid  5i)  extract  of  cannabis  indica  gr.  x,  and 
collodion  3i-  These  applications  may  be  used  daily  for  a  week  or  longer. 
When  the  corns  are  between  the  toes,  the  part  should  be  frequently  washed, 
dried,  dusted  with  stearate  of  zinc,  and  the  toes  separated  by  cotton. 

Horns  (comu  cutaneum)  are  dry  and  solid  outgrowths  from  the  skin  and 
consist  of  comified  epithelium.  They  sometimes  arise  from  warts  or  from 
sebaceous  glands.     They  should  be  excised. 

A  wart  {verruca)  is  a  papilloma  of  the  skin,  which  is  commonly  pigmented 
and  often  seen  on  the  hands  of  young  persons  (v.  vulgaris)  and  on  the  back 
and  arms  of  the  elderly  (v.  senilis).  It  may  be  broad  and  flat  (v.  plana), 
filamentous,  notably  about  the  face  (v.  fUiformis),  divided  into  finger-like 
processes,  particularly  on  the  scalp  {v.  digitala),  or  conical  (v,  acuminaU), 
especially  about  the  mouth,  anus,  and  genitals  (venereal  warts  p.  559).  The 
surface  may  be  smooth,  cauliflower-like,  or  homy  {wart-horn).  Warts  are 
often  multiple  and  appear  and  disappear  without  cause.  They  may  be 
treated  by  daily  cauterization  with  lactic,  chromic,  nitric,  or  glacial  acetic  acid, 
or  by  excision. 

A  mole  is  a  circumscribed  hypertrophy  of  the  skin,  usually  congenital, 
pigmented  {nevus  pigmentosus) ,  and  covered  with  hair  {nevus  pilosus) .  White 
moles  are  often  hairless  {nei>us  spilus)  and  acquired.  A  mole  may  have  a 
papillary  surface  {nevus  verrucosus)  or  be  infiltrated  with  fat  {neims  lipoma- 
todes).  The  most  interesting  point  about  a  mole  is  that  its  base  strongly 
resembles  in  structure  an  alveolar  sarcoma;  in  fact,  it  may  in  later  life  origin- 
ate such  a  growth,  usually  of  the  melanotic  variety.  Moles  so  situated  as  to 
produce  disfigurement  may  be  excised;  moles  which  are  spreading  rapidly 
must  be  excised. 

Tuberculosis  of  the  skin  occurs  in  a  variety  of  forms  (macules,  papules, 
pustules,  tui)ercles),  many  of  which,  e.g.,  lichen  scrofulosum,  eczema  scrof- 
ulosum, etc.,  belong  strictly  to  a  work  on  dermatology.  Only  those  tuber- 
culous lesions  of  the  skin  which  more  particularly  concem  the  surgeon  will 
be  described  here. 

Tuberculosis  ulcerosa  {ulchre  des  phthisiques)  is  an  imcommon  form  of 
tuberculous  ulceration,  occurring  almost  exclusively  at  muco-cutaneous  junc- 
tions as  the  result  of  internal  tuberculosis.  The  ulcers  are  shallow,  generally 
very  painful,  and  have  irregular  ed^jes.  The  base  is  bathed  in  a  scanty  sero- 
purulent  discharge  and  occasionally  shows  miliary  tubercles.  The  treat- 
ment is  that  of  tuberculosis,  with  local  applications  of  silver  nitrate. 


TirBERcm.osis  of  the  skin. 


tup 

m 


Verruca  necrogenica  {anatomical  luberrle,  Imkher^s  wart)  ciccurs  upon 
the  dorsal  surface  of  the  hand  of  pathologists,  surgeons,  butchers,  or  others, 
as  the  result  of  local  infeciion  with  the  tubercle  bacillus.  It  consists  of  a 
warty-like  mass  often  presenting  small  pustules.     The  ireatmettt  is  excision. 

Scrofuloderma  (tuberculous  gummala)  is  the  result  of  infection  of  the 
skin  or  subcutaneous  tissues,  and  consists  of  a  tuberculous  mass  of  variable 
size,  which  breaks  down  and  eventuates  in  an  ulcer.  These  iubercHhus  ulcers 
have  bluish,  undermined,  irregular  edges,  and  are  often  covered  by  a  crust, 
under  which  may  be  found  pulpy  and  edematous  granulations.  Healed 
tuberculous  ulcers  are  characterized  by  puckering  or  inversion  of  the  skin. 
The  irealment  is  removal  of  the  congested  and  undermined  skin  and  of  the 
edematous  granulations,  the  wound  being  packed  with  iodoform  gauze. 

Lupus  vulgaris  is  a  tuberculous  infection  of  the  skin,  rarely  beginning 
after  the  age  of  thirty,  and  most  frecjuently  seen  upon  the  face,  particularly 
the  nose  and  cheeks,  althxmgh  other  portions  of  the  body,  notably  the  extrem- 
ities^ may  be  attacked.  The  disease  is  essentially  a  local  one,  although 
generalization  of  the  tubercle  bacilli  may  occur.  It  begins  as  a  pinkish  or 
brownish-yellow  nodule  [tupoma);  other  nodules  form,  usually  along  the 
course  of  the  blood  vessels.  Thus  the  resulting  patches  are  often  irregular  or 
serpiginous.  Pain  is  absent  and  the  lesion  may  feel  6rm  or  soft.  When 
resolution  takes  place  without  ulceration,  the  nodules  shrink,  producing  a 
thin  scar  covered  by  scaly  epithelium  (lupus  ex/t)liativus).  Clceration  with 
subsequent  cicatrization  is  more  common,  the  periphery  breaking  down  as  the 
older  portions  are  healing.  Ulceration  may  be  excessive  (luptis  ^xttlcerans,  or 
lupus  exfikns),  or  there  may  be  a  tendency  towards  the  formation  of  exuber- 
^t  fungoid  granulations  (  lupus  hyper Irifphicus),  The  disease  may  invade 
ijacent  mucous  membranes  or  destroy  adjoining  cartilage;  a  nose  thus 
ected  presents  a  "lopped-off  **  appearance,  in  contradistinction  to  the 
sunken-in*^  nose  of  syphilis.  A  lupoid  ulcer  is  irregular,  owing  to  the  fact 
that  it  progresses  at  one  side  while  healing  at  the  other.  The  base  is  covered 
hy  ** apple  jelly"  granulations,  originating  a  sero-purulent  discharge  that 
forms  a  thick  brownish  crust.  The  margins  are  elevated  and  thickened,  and 
contain  the  lupoid  tubercles  or  consist  of  cicatricial  tissue.  The  surrounding 
parts  are  congestcfl  and  yellowish-red  in  culor,  and  adjacent  lymph  glands 
may  be  enlarged.  The  scar  resulting  from  the  healing  of  a  lupoid  ulcer  is 
puckered,  yellowish,  and  possesses  but  little  \itality,  reulcerating  on  the 
slightest  provocation. 

Diagnosis. — Lupus  erythematosus  is  generally  regarded  as  non-tuberculous 
in  origin,  although  possessing  some  featHres  in  common  with  lupus  \^lgaris. 
When  occurring  on  the  face,  the  usual  situation,  it  appears  as  a  symmetrical 
erythema,  which  has  been  likened  to  a  butterfly  with  outstretched  wings.  It 
begins  after  puberty  and  is  attended  with  a  branny  desquamation,  the 
scales  of  which  are  inspissated  sebum,  derived  from  plugs  w  hich  distend  the 
orifices  of  the  sebaceous  glands.  Although  ulceration  is  very  rare,  recover^' 
b  attended  by  the  formation  of  thin  cicatricial  tissue.     The  remaining  condi- 

ns  to  be  differentiated  from  lupus  vulgaris  aTesyphilitif  ulceration  (p.  127), 
"i^heliama  (  p.  162),  and  blastomycosis  (p.  158), 

Treatment. — The  general  health  should  be  attended  to,  and  the  X-ray  or 
the  Finsen  light  applied  locally.  In  the  absence  of  the  apparatus  necessary 
for  phototherapy,  the  lesion  may  be  scarified,  excised,  or,  after  thorough 
curetting,  cauterized  with  the  actual  cautery  or  chemical  caustics. 


\ 


Sous  APPENDAGES. 


superfidalj  or  tlat  form, 


as  a 


Epithelioma  of  the  skio  occurs  a 
deep-seated,  or  nodular  variety. 

Superficial  epithelioma  develops  primarily  as  yellowish-red  or  brownish 
patches  scattered  over  the  surface,  or  as  a  secondar)^  atlection  attacking  warts, 
scars^  nevi,  fissures,  etc. 

Rodent  nicer  (Jacob's  ulcer)  is  a  peculiar  form  of  superficial  epithelioma, 
almost  invariably  limited  to  the  upper  two-thirds  of  the  face  (Fig.  91),  It 
occurs  in  old  age,  and  begins  as  a  little  nodule  which  ulcerates.  The  ulcer 
is  rounds  oval,  or  irregular,  with  indurated  everted  edges  and  a  smooth, 
glossy,  pinkish  surface;  the  discharge  is  slight,  pain  is  absent,  adjacent  lymph 

glands  arc  not  involved,  metastases 


r"        ^"  ^     f^         11     *^^**  "*-^*  occur,  and  the  general  health 

fSjttk^gi^^^^K^^.     '     ^^    unimpaired    except   in    the  later 

stages,  death  resulting  from  hemor- 
rhage or  from  the  local  destruction 
of  important  organs.  The  disease 
progresses  very  slowly,  sometimes 
lasting  thirty  or  forty  years,  and 
occasionally  cicatrizes  in  spots,  the 
scars  later  breaking  down.  The 
uker  advances  principally  along  the 
surface,  although  in  the  later  stages 
it  extends  deeply  and  destroys  every- 
thing in  its  path,  including  the 
liones.  The  disease  may  originate 
in  any  (tf  the  epidermal  structures, 
Deep-seatedf  or  nodular  epi- 
thelioma, may  follow  the  superficial 
form,  or  begin  primarily  as  a  nodular 
growth  involving  the  whole  skin  and 
invading  the  subcutaneous  tissues. 
Ulceration  occurs,  producing  an  ir 
regular*  offensive,  easily-bk^ding 
excavation,  with  an  indurated  base; 
pain  is  present  and  involvement  of 
the  lymph  glands  and  metastases 
occur.  These  growths  occur  most 
frequently  on  the  scalp,  forehead » 
lips,  tongue,  penis,  scrotum,  labia,, back  of  the  hand,  and  in  cicatrices. 

LctUkular  carcinoma  is  best  seen  as  recurrences  in  the  neighborhood  of  the 
scar  following  amputation  of  the  breast;  it  is  alveolar  in  structure,  and  ap- 
pears as  hard,  glistening,  reddish  or  brownish  nodules,  which  subsequently 
ulcerate,  fnvade  the  lymphatics,  and  destroy  life. 

The  treatment  of  carcinoma  of  the  skin  is  early  and  thorough  excision, 
with,  in  the  deep-seated  form,  the  adjacent  lymph  glands.  Caustics  and 
radioiherapiy  should  never  be  employed  in  operable  cases  of  deep-seated 
epithelioma.  Superficial  epithelioma,  conspicuously  rodent  ulcer,  may  be 
cured  Iiy  the  X-ray,  radium,  or  the  Fin  sen  light.  When  the  above  measure 
cannot  be  carried  out,  cauterization  with  the  thermocautery,  or  by  means  of 
caustic  pastes  containing  potassium  hydrate,  chlorid  of  zinc,  or  arsenic,  may 
be  used. 


Fig.  q  I -—Rodent  ukrr,      i  Pennsylvania 
HospiiaL) 


KELOID. 


163 


Prtcancermis  (Urmaiosfs  urc  iliust rated  by  Paget' s  dhmse  of  the  nipple 

411);  by  the  soot-warts  which  precede  chimney  sweeps'  cancer  of  the  scro- 
tum; by  the  dry,  thickened  skin,  often  covered  with  an  acnedike  eniption, 
which  precedes  the  lar-and -paraffin  cancer  seen  on  the  hands  anil  forearms  of 
those  who  work  in  coal-tar  and  paraffin;  by  keratosis  senilis^  in  which  the 
epidermis  becomes  thickened,  horny,  and  discolored;  by  xerodtrma  pigmen- 
tosum, which  begins  with  fret  kledike  pigmentations  on  the  face  and  hands; 
and  by  the  roughened,  fissured,  glossy  skin  following  chrimk  X-ray  burns. 
The  areas  of  telangiectasis,  pigmentation,  keratosis,  and  atrophy  resulting 
from  hyper  sensitiveness  to  light,  and  scars,  warts,  and  pigmented  moles  all 
predispose  to  malignant  changes.  De  Morgan's  spots  are  bright  red  nevoid 
spots  often  seen  on  the  chest  and  alidamen  of  cancerous  subjects;  they  may, 
however,  occur  in  healthy  individuals.  In  this  connection  may  be  mentioned 
the  white  patches  (leukopiakia)  which  occur  on  the  mucous  membrane  of  the 
mouth,  and  which  are  often  followed  by  epithelioma  (p.  425). 

Sarcoma  may  arise  from  the  connective  tissue  of  the  skin  or  occur  as  sec- 
ondar)'  metastatic  nodules.  Moles  sometimes  form  a  starting  point  for  the 
melanotic  variety;  some  authorities,  however,  believe  that  the  majority  of  pig- 
mented growths  resulting  from  moles  are  carcinomaltms.  Frimar}'  sar- 
coma may  be  single  or  multiple;  seconrlary  sarcoma  is  always  multiple.  The 
treatment  is  excision  whenever  practicalde;  in  the  melanotic  variety  the  neigh- 
lK>ring  lymph  glands  also  should  be  removed.  Amputation  may  l>e  required. 
In  inoperaiile  cases  the  X-ray  and  Coley's  tluid  may  be  tried. 

Idiopaihii  multiple  hemorrhagif  sartoma  appears  first  on  the  hands  and 
feet  as  minute  reddish  brown  l«mors,  whith,  as  they  enlarge,  become  bluish- 
red,  sometimes  resembling  angiomata  The  growths  are  sometimes  conllu- 
ent  and  may  form  extensive  areas  of  infiltration;  occasionally  some  of  ihem 
atrDphy,  leaving  deeply  pigmented  spots.  The  pigmentation  is  due  to 
hemorrhage.  The  disease  spreads  slowly  to  the  trunk  and  terminates  in 
death,  no  treatment  being  of  avail. 

M ycasis  fungmdes^\\h\i:h  is  thought  to  be  sarcomatous  in  nature,  is  charac- 
terised by  the  development  of  an  urticarial  or  eczematoid  eruption,  the  lesions 
changing  lo  reddish  or  bluish  tumors  and  ultimately  undergoing  fungoid 
ulceration.  No  treatment  has  anv  intlucnce  on  the  disease,  which  is  always 
fatab 

Leukemic  tumors,  which  are  probably  sarcomatous,  may  be  widely  scat- 
tered in  the  skin  in  leukemia  and  pseudoleukemia, 

Keloid  is  a  hyperplasia  of  scar  tissue,  classified  as  a  fibroma.  It  forms  a 
heupe<l  up,  pinkish  mass,  often  covered  with  bright  red  vessels,  and  frequently 
extemls  into  the  surrounding  skin  by  clawdike  projections,  hence  the  term. 
Theoretically  a  distinction  is  made  between  true,  or  spotiianeaus  kdaid  (mor- 
ffttea),  which  does  not  arise  from  a  scar,  and /aixi^  keloid,  which  always  springs 
fmm  a  cicatrix.  The  belief  is  common  that  spontaneous  keloid  is  always  pre- 
<  edcd  by  a  minute  scar  which  has  escaped  detection.  Keloid  occurs  most  fre- 
<|ucntly  in  the  colored  race,  is  painless,  grows  slowly,  and  occasionally  atro- 
phies in  old  age.  The  treatment  is  most  unsatisfactor)^  Excision  or  cauteriza- 
tion is  followed  by  recurrence;  among  the  measures  for  which  success  has 
l»een  claimed  are  thyroid  extract  and  thiosinamin  given  internally,  and  the 
X-rays,  electrolysis,  and  elastic  compression  applied  locally. 

A  sebaceous  cyst  is  due  to  occlusion  of  the  excretory  duct  of  a  sebaceous 
gland  by  dirt  or  inspissated  sebum.     It  is  rounded,  usually  firm  but  elastic^ 


( 


164 


CUTANEOUS 


freely  movaljle  on  the  deeper  parts  unless  intlamed,  and  invariably  attached 
to  the  skin  at  one  point.  The  orifice  of  the  obstructed  duct  can  often  be  seen, 
and  occasionally  sebaceous  matter  can  be  expressed  from  it.  These  cysts 
may  be  found  wherever  there  are  sebaceous  glands,  but  are  most  common  on 
the  scalp  {wens).  They  may  reach  a  large  size,  are  often  multiple,  and  may 
become  inflamed  and  suppurate.  When  the  over- 
lying skin  ulcerates,  the  contents  putrefy  and  a  fetid 
ulcer  results;  this  has  been  mistaken  for  epithelioma 
and,  indeed,  occasitmally  undergoes  carcinomatous 
degeneration.  Cakifjcation  sometimes  occurs. 
When  the  sebum  projects  from  the  orifice  of  the 
duct,  it  may  dry  and  gradually  form,  by  addition 
from  below,  a  srhacr&us  horn.  The  treat menl  is 
enucleation  after  incising  the  overlying  skin.  This 
is  usually  very  simple,  unless  adhesions  with  the  sur- 
rounding parts  have  been  contracted  as  the  result  of 
inflammator)^  changes.  If  any  of  the  cyst  wall  re- 
mains, recurrence  is  apt  to  take  place.  Some  sur- 
geons translix  the  cyst,  and  after  emptying  it,  seize  the  cyst  wall  with 
hemostatic  forceps  and  tear  it  out.  H*  rns  and  ulcerating  and  inflamed 
cysts  should  be  excised. 

Onychia  (ungual  whitloac,  nm-armmd)  is  an  inflammation  of  the  matrix 
of  a  nailj  usually  beginning  at  one  side  (paronychia),  and  frequently  followed 


VI 


f 


iigna. 


-Onychia    ma- 
(Moullin.) 


>   llllllll 


Fig.  93. 


■^. 


Fig.  94. 


/       7 


Fig.  95. 


Fig.  96. 
Plastic  operttions  by  stretching  the  omrgins  of  sidn. 


(Esmarch  and  Kowalarig.) 


by  suppuration  which  extends  beneath  and  around  the  semilunar  fold  and 
loosens  the  naib  It  is  an  afTection  to  which  surgeons  and  nurses  are  peculiarly 
liable,  particularly  when  run  down  in  health.  The  treaimttil  is  removal  of  the 
loosened  portion  of  the  nail  and  disinfection  of  the  suppurating  focus,  to- 
gether  with  atteniion  to  the  general  health. 


ONYCHAUXIS. 


165 


Onychia  maligna  (Fig.  92)  is  a  chronic  fungating  inflammation  of  the 
matrix,  usually  of  syphilitic  or  tuberculous  origin.  The  treatment  is  removal 
of  the  nail,  antiseptic  fomentations,  and  attention  to  the  underlying  diathesis. 

Onychauxis  is  hypertrophy  of  the  nails,  in  length,  breadth,  and  thickness. 
It  may  be  congenital,  and  sometimes  occurs  in  syphilis  and  ichthyosis.    The 


I 


1  ill i { 1 1 


niiiiii 


Fig.  97. 


1 1  i  1 1^1 1 1 1 


Fig.  98. 


niiiiiii 


Fig.  99. 


Fig.  100. 


(   f  f   I     I    I   f  I 
J  1  Ml  1   J  1  i 


Fig.  1 01. 


Plastic  operations  by  sliding  flaps.     (Esmarch  and  Kowalzig.) 

nails  are  often  furrowed  and  yellowish  or  brownish.  Onychogryposis 
(claw  nail)  is  mostfrequently  seen  in  later  life;  it  commonly  afTects  the  great 
toe,  and  is  frequently  preceded  by  injury  or  neglect.  The  treatment  is  trim- 
ming of  the  nails  by  strong  scissors  or  bone  forceps,  or  removal  of  the  entire 
nail. 


i66 


SKIN  AND  CUTANEOUS  APPENDAGES. 


Ingrowing  toe-nail  {onychocryptosis)  is  caused  by  narrow  shoes  and  l)y 
c  utting  the  nail  at  the  corners  instead  of  straight  across.  The  edge  of  the 
nail,  usually  that  of  the  great  toe,  is  l>uried  in  inflamed  or  ulcerating  soft 
parts  at  the  side  of  the  toe.  The  treatment  in  the  early  stages  is  the  introduc- 
tion of  small  pieces  of  cotton  or  gauze  beneath  the  overgrowing  soft  parts, 


ji/iin 


"^P 


Fig.  1 02. 


Fig.  103. 


Fig.  104. 


Fig.  105. 
Plastic  operations  with  pedunculated  flaps.     (Esmarch  and  Kowalzig.) 

the  use  of  square-toed  shoes,  and  trimming  the  nail  square  across;  adhesive 
plaster  may  be  so  arranged  as  to  press  the  skin  from  the  edge  of  the  nail. 
In  the  presence  of  ulceration  the  best  treatment  is  removal  of  a  wedge- 
shaped  piece  of  tissue,  consisting  of  the  affected  third  of  the  nail  and  the 
underlying  matrix,  so  that  recurrence  cannot  take  place.     This  may  be 


PLASTIC   SITBGERY. 

<Ume  uiuler  loial  anesthesia.     The  lips  of  the  \v<aiii(l  may  Itu  approximated 
liy  sutures  placed  proximal  and  distal  to  the  naiL 

Plastic  surgery  in  its  hroadestsense  iiuludes  all  operations  for  the  correc- 
tkm  of  deformities,  the  hlling  of  deficiencies,  and  the  removal  of  redundant 
tissue.  Plastic  operations  on  other  tissues  than  the  skin  (tenoplasty,  neuro- 
plasty,  etc.)?  and  plastic  operations  fur  special  conditions,  e.g.,  hare-lip,  hypo- 
spadias, etc.»  are  dealt  with  in  other  set  tions  of  the  book. 


Fia.  to6. 


,f^??M^*H^ 


Fig.  107. 
riftstic  operations.     Incisions  lo  relieve  tension.     (Esmarch  and  Kowiilzig.) 

Plastic  operations  for  cutaneous  defects  are  performed  by  stretch- 
ing (Figs.  93  to  q6)  or  slkling  (Figs.  97  to  101)  the  skin  al>out  a  wound  after  it 
has  been  undermined,  by  transplantation  of  petlunculated  llaps  (Figs.  102  to 
105),    by   relaxation   incisions   {Figs.    ro6  and    107),   or   l>y  skin   grafting. 
I       Success   depends  upon   strict  asepsis,   the   relief  of   all   tension,   thorough 
I       freshening  of  the  parts  to  be  united,  and  the  proper  selection  of  cases;  the 

^^^P  Fic,  108. — Double  pedunculated  flap.     ^Rinnic.) 

debilitated,  the  syphilitic,  and   those  with   infected  wounds   are  unfit  for 
such  operations. 

The  use  of  pedunculated  flaps  from  near  or  distant  parts  is  illustrated  in 
the  various  methods  of  rhinoplasty  (qv.);  such  flaps  consist  of  the  entire 
thickness  of  the  skin,  should  be  about  one-sixth  larger  than  the  area  to  be 
filled  in  order  to  provide  for  shrinkage,  and  should  be  Si>  arranged  as  to  have  a 
free  bkK)d  supply  without  twisting  the  pedicle.  A  double  pedunculated 
flap  may  be  employed  for  certain  defects  (Fig.  108).  In  order  to  insure  its 
viability,  a  flap  may  he  separated  from  the  underlying  tissues  l)y  oiled  silk 


i 


until  its  survival  is  assured,  wheji  »me  of  the  pedicles  may  be  divided  and  the 
flap  transferred  to  the  defect- 

SkiQ  grafting  is  the  use  of  entirely  tietached  portions  of  the  skin  for 
covering  raw  surfaces.  Grafts  are  best  taken  from  the  arm  or  thigh  of  the 
patient,  or  from  friends.  Grafts  from  the  lower  animals  are  rarely  satis- 
factory, but  those  from  a  recently  amputated  limb  have  Ijeen  successfully 
employe<b 

Wolf*s  method  consists  in  outlining  the  dap  one-sixth  larger  than  the  , 
area  to  be  tilled,  removing  all  fat  from  its  under  surface,  and  placing  it  in  ^ 
the  defect,  where  it  is  held  by  the  pressure  of  the  dressings. 

Thiersch's  method  is  generally  used  for  fresh  or  granulating  surfaces. 
After  the  raw  surface  has  l>een  disinfected  no  antiseptic  should  be  used. 


iu^.  :o9.  Fig.  t  to. 

Thiersch's  skin  gralling.     (Esmarch  and  Kowalzig.) 

Exuberant  granulations  are  removed  with  a  sharp  curette  and  bleediBg] 
stopped  by  pressure  with  hot  pads.  The  parts  from  which  the  grafts  are  lo 
be  taken  should  be  sterilized  and  then  washed  with  salt  solution.  The  skin 
is  stretched  by  pressure  with  the  hand,  and  a  long  strip  of  epidermis,  as  thin 
as  possible,  is  shaved  off  with  a  sharp  razor  (Fig.  109).  The  graft  lies  on 
the  blade  of  the  razor  in  a  series  of  plaits  and  is  slid  onto  the  raw  surface  by 
fixing  one  end  of  the  graft  l)y  slight  pressure  and  carrying  the  razor  close  to 
and  parallel  with  the  wound  (Fig,  no).  Ail  air  bubbles  should  be  pressedi 
from  beneath  the  graft,  which  is  then  covered  with  strips  of  rubber  tissue  or 
silver-foiU  and  dr)^  sterile  gauze.  The  wound  may  be  entirely  covered  with 
such  grafts.  The  dressing  is  changed  at  the  end  of  a  week  unless  infection 
occurs.  RecenUy  w^e  have  been  splinting  grafts  with  a  single  layer  of 
gauze  fastened  at  the  margins  of  the  w^ound  with  collodion »  thus  securing 
free  drainage  into  the  outer  dressings,  preventing  maceration,  and  allowing 
irrigation  with  salt  solution  if  the  discharge  be  copious. 

Reverd  in 's  method  is  performed  by  Ufting  a  small  portion  of  the  skin  with 
a  needle  and  remo\ing  it  with  curved  sdssors.  The  upper  layer  of  the  cutis 
vera  should  be  included.  A  number  of  these  grafts  are  placed  on  the  granula- 
tions, raw  surface  downw^ards,  and  the  wound  dressed  as  in  the  Thiersch 
method.  These  grafts  at  first  apparently  disappear  owing  to  disintegration 
of  the  epidermis,  but  later  appear  as  bluish  white  spots,  from  w  hich  the  epithe- 
lial growth  proceeds  in  all  directions. 

Mangold t's  method  consists  in  *' scraping  the  sterilized  skin  with  a  razor, 
down  to  the  papillary  layer,  and  spreading  the  mixture  of  epithelial  cells  and 
blood   thus  obtained   upon   a   clean,   bloodless^   non-granuladng   wound." 

Mucous  membrane  from  man  or  animals  also  has  been  successfully 
transplanted,  and  skin  has  been  used  to  take  the  place  of  mucous  membrane. 
When  Haps  are  used  for  the  latter  purpose,  the  skin  should  l>e  hairless. 
Thiersch  grafts  do  not  reproduce  hair. 


THROMBOSIS.  1 69 


CHAPTER  XV. 

VASCULAR  SYSTEM. 

In  the  present  chapter  we  have  freely  used  the  article  by  LeConte  and 
the  author,  in  the  "American  Practice  of  Surgery,"  on  the  "Surgery  of  the 
Heart  and  Blood  Vessels,"  to  which  the  reader  is  referred  for  an  extended 
discussion  of  the  subjects  herein  treated. 

THROMBOSIS. 

Thrombosis  is  the  formation  of  a  clot  {thrombus)  within  the  circulatory 
apparatus  during  life. 

The  causes  in  the  order  of  their  importance  are,  (i)  changes  in  the  vessel 
walls,  the  result  of  inflammation,  necrosis,  degeneration,  neoplastic  infiltra- 
tion, or  trauma;  (2)  changes  in  the  blood,  the  result  of  toxemia  or  anemia; 
(3)  changes  in  the  blood  current,  resulting  in  retardation,  e.g.,  from  diminution 
in  the  calibre  of  the  vessels,  cardiac  weakness,  or  prolonged  maintenance  of 
the  horizontal  position,'  or  resulting  in  the  production  of  eddies,  e.g.,  when  the 
blood  flows  into  an  aneurysm  or  varix.  As  coagulation  of  blood  depends 
upon  the  presence  of  fibrin  ferment,  which  causes  the  fibrinogen  and  the 
calcium  salts  of  the  plasma  to  unite  and  form  fibrin,  and  as  flbrin  ferment  is 
liberated  by  diseased  or  injured  endothelial  or  blood  cells,  slowing  of  the 
circulation  alone,  without  either  of  the  other  factors,  will  not  cause  throm- 
bosis, indeed,  a  vessel  may  be  ligated  at  two  points  without  coagulation  taking 
place  for  a  long  time  between  the  ligatures.  As  a  matter  of  fact,  one  of  the 
other  factors  is  almost  always  present;  thus,  slowing  of  the  blood  current  is 
in  itself  capable  of  inducing  nutritive  changes  in  the  vessel  walls,  and  in  the 
enfeebled  circulation  attending  fevers  there  is  toxemia  and  often  degenera- 
tive alterations  in  the  vascular  tunics. 

The  nature  of  the  thrombus  depends  upon  whether  it  is  formed  slowly 
from  a  moving  current  of  blood  (;white  thrombus)  or  is  the  result  of  complete 
stasis  {red  thrombus).  The  white  thrombus  is  composed  of  gradually  depos- 
ited white  corpuscles  and  fibrin;  when  a  considerable  number  of  red  corpuscles 
enter  into  its  formation  it  is  called  a  mixed  thrombus.  The  clot  which  is 
first  formed  {primary,  or  autochthonos  thrombus)  usually  begins  as  a  parietal 
mural  thrombus,  which  gradually  enlarges  until  it  fills  the  lumen  of  the  vessel 
{occluding,  or  obturating  thrombus).  It  may  then  by  subsequent  additions 
{induced  thrombus)  become  a  continued,  or  propagating  thrombus,  usually 
extending  in  the  direction  of  the  blood  current.  The  term  secondary  is 
applied  to  induced  thrombi  and  to  those  forming  about  an  embolus.  A 
thrombus  is  generally  adherent  to  the  vessel  walls  and  its  advancing  end 
conical.  The  end,  e.g.,  when  it  projects  into  a  collateral  vessel,  may  be 
washed  away  as  an  embolus  (Fig.  iii),  or  the  entire  thrombus  may  loosen 
and  float  into  the  blood  stream.  The  terms  infective  and  aseptic,  or  bland, 
refer  to  the  presence  or  absence  of  bacteria. 

The  changes  which  a  thrombus  may  undergo  are  (a)  organization, 
i.e.,  the  clot  is  replaced  by  fibrous  tissue  as  in  repair  elsewhere;  (b)  canaliza- 


lyo 


iim  lis  the  result  of  iruumplelc  organizaticm,  thus  reestablishinj;  the  cirrub- 
tioii;  (e)  taitifkajkm,  forming  in  the  veins  ])hlelH>!iihs  unci  in  the  arteries 
iirterioHlhs;  and  (d)  iiqufftutiim  or  sqfienhig  ihe  result  of  aseplii  degeneration 
(simple  softening)  or  suppuration  (seplit  softening),  tausiiig  embolism  and  in 
septic  softening  pyemia. 

Lacalization  of  Thrombi. — Cardtdi  iliromhi  are  of  no  practical  impor- 
tance to  t  h  e  s  u  rgeo  n .  A  rt  rr  ial  th  to  m  b  i  a  re  m  <  j  st  f  re*  ]  u  e  n  t  i  n  l  h  e  lo  w  e  r  ext  re  mi  t  y 
as  the  result  of  injury  (p.  185),  endarteritis,  or  the  impaction  of  an  embolus 
(see  gangrene  and  emlKiHsm).  Venims  thrombi  are 
much  more  common  than  the  other  varieties,  Ijecause 
of  the  tomparatively  sluggish  circulation  in  the  veins, 
the  presence  of  valves,  and  the  composition  of  venous 
bl  00  d ,  es  pec  ial  ly  t  h  e  i  n  c  rease  d  a  m  o  uui  t  of  C  (_>  ^ .  V'e  ji  ous 
thrombosis,  unlike  that  occurring  in  the  arteries,  usualiy 
attacks  the  veins  on  the  left  side  of  the  body.  The  left 
lower  limb  is  the  favorite  site,  owing  to  the  greater 
length  and  obliquity  of  the  left  common  iliac  vein,  which 
IS  crossed  by  the  right  common  iliac  and  the  left  internal 
iliac  arteries,  and  which  may  l>e  pressed  upon  also  by  a 
loaded  rectum.  CapiUary  thrombi  are  generally  due 
to  local  conditions,  such  as  injuries,  severe  in  ll  am  ma- 
tions,  etc.;  when  the  larger  vessels  are  blocked,  the 
capillaries  remain  patent  unless  gangrene  follows. 

The  results  of  thrombosis  depend  upon  ihc  loca- 
tion and  the  extent  of  the  thrombus,  the  rapidity  with 
which  it  is  formed,  and  the  condition  of  ihe  collateral 
vessels.      Apart    from    the    constitutional    symptoms^ 
which  vary  accor<iing  to  whether  the  thrombus  is  septic 
or  aseptic,  and  the  lial>ility  tt)  embolism,  the  phenomena 
are   mainly  those  of  obstruction  to  the  blood  stream, 
the  symptoms  and  treatment  of  which  are  given  in  the  sections  on  embolism 
and  contusions  of  arteries  and  in  the  section  on  phlebitis.     Thrombotic 
gangrene  is  discussed  on  p.  8;^,  post-operative  thrombosis  on  p.  177, 


Fir..  I  I  [  .-=-,4  . 
Thrombus.  B.  Em- 
bolus resulting  from 
detach mtri I  of  the  end 
of  the  ihrombus  which 
projected  inio  the 
larger  vessel.  Arrow 
indicates  dircctimi  nf 
blcKjd   stream. 


EMBOLISM. 


Embolism  is  the  sudden  blocking  of  a  blood  vessel  by  a  foreign  body  (em- 
bolus)  which  has  been  brought  by  the  blood  stream  from  some  more  or  less 
distant  part.  I'^mboli  are  usually  detached  portions  of  throm!ji»  but  they  may 
be  vegetations  from  the  valves  of  the  heart,  detached  atheromatous  plates,  fat 
globules,  air  bubbles,  portions  of  tumors,  cells  from  some  of  the  normal 
structures  of  the  body,  masses  of  bacteria,  or  parasites,  such  as  the  scolices  of 
the  echinococcus  and  the  tilaria  sanguinis  honiinis.  Various  forms  of  dust 
when  inhaled,  and  particles  of  paraffin  and  insoluble  preparalionsof  mercury 
when  injected  subcutaneously,  may  tloat  off  into  the  blood  stream  as  emboli. 

The  site  of  impaction  of  an  embolus  dcpentls  on  its  origin.  Those 
arising  in  the  area  flrained  by  the  portal  vein  lodge  in  the  liver;  those  arising 
in  the  general  venous  circulation  pass  through  the  right  heart  and  lodge  in  the 
lungs;  and  those  from  the  left  heart  or  aorta  may  lodge  in  any  portion  of  the  ^ 
body.  Rarely  an  embolus  originating  in  a  vein  finds  its  way  into  the  arterial 
circulation  through  a  patent  foramen  ovale  {frossed,  or  paradoxkal rmbolism) 


i 


KMBOLTSM. 


Jft 


ftti  >l\\\  more  rarely  is  il  IranAporttMl  in  ii  (iireilion  upposile  lo  thai  uf  ihe 


>cl  sir 


Kev( 
be 


ream  {retrogradr  I'mhotism),  An  embolus  usually  Knlgcs  at  the  puiiU 
where  a  vesi^l  suddenly  diminishes  in  size,  e.g.,  where  a  large  f>ranch  is 
given  off  or  where  bifurcation  lakes  pi  a  re. 

The  effects  of  embolism^  which  depend  upon  the  size,  seat,  and  nature  of 
ibe  emlnjius,  and  the  condition  of  the  collateral  circulation,  may  be  studied 
under  two  headings:  (i)  .1/  the  stal  of  impaitimt  an  embolus  induces 
secondary  thrombosis,  and  the  mass  may  undergo  the  changes  already 
describetl  under  thrombus.  Non-alisorliable  foreign  bodies,  if  minute,  may 
be  transported  by  the  leukocytes  to  the  liver,  spleen,  or  bone  marrow;  larger 
foreign  bodies  are  encapsulaletl  with  fibrous  tissues .  Animal  parasites 
perish  and  are  absorbed  or  encapsulated,  or  penetrate  the  vessel  wall  and 
ievelop  in  the  surrounding  tissues.  Tumor  cells  may  proliferate  and  give 
to  metastatic  growths.  Bacteria  may  prcniuce  changes  identical  with 
those  at  the  original  point  of  infection.  Embolic  aneurysms  are  thought  to 
be  caused  by  a  softening  of  the  vessel  wall,  the  result  of  bacterial  activity  (see 
aneurv^m).  (2)  The  parts  stipplied  by  tin  I'mbotized  artery  beccjme  anemic, 
but  if  there  is  an  efficient  collateral  circulation  the  anemia  may  disappear 
and  no  harm  result.  If  an  embolus  blocks  a  terminal  artery  (i.e.,  one  having 
no  collateral  anastomoses,  except  capillary^  with  adjacent  arteries,  such  as 
occur  in  the  brain,  retina,  spleen,  kitlncy,  and  lung)  or  one  with  a  poor 
coDateral  circulation,  the  part  beyond  becomes  gangrenous:  in  the  viscera 
this  area  is  called  an  infarct,  and  is  wedge-shaped  with  the  base  towards  the 
periphery  of  the  organ.  The  infarct  may  remain  bloodless  (white,  or  anemic 
infarcl),  or  liccome  infiltrated  with  blood  {rrd,  or  hemorrhagir  infarct)  whii  h 
comes  from  adjacent  capillaries  and  passes  through  the  altered  vessel  walls  of 
the  part.  In  either  case  subsetjuent  organization  occurs  and  the  area  remains 
as  a  scar,  which  may  be  pigmented  in  the  hemorrhagic  infarct,  or  calcified, 
especially  in  the  lungs;  occasionally  infarcts  in  the  brain  form  cysts.  If  the 
embolus  is  septic  the  infarct  undergoes  moist  septic  gangrene  or  forms  an 
al>scess  (metastatic  abscess). 

The  symptoms  of  emljolism  are  sudden  severe  pain  at  the  point  of  impac- 
tion or  in  the  ischemic  area;  absence  of  ptdsaiion,  which  may  l>e  detected  not 
only  in  obstruction  of  superficial  arteries  liui  also  in  embolism  of  any  artery 
baWng  superficial  bran<  hes:  hardening  of  (he  vessel  at  the  site  of  the  embolus; 
increase,  after  a  time,  in  the  numl>er  and  size  of  the  coiiatera!  vessels;  rise  in 
the  general  blood  pressure  at  the  time  of  occlusion  of  a  large  artery  (causing, 
if  the  abdominal  aorta  is  affected,  acute  dilatation  of  the  heart,  edema  of  the 
lungs,  bloody  stools,  etc.),  gradually  diminishing  with  the  establishment  of 
the  collateral  circulation;  and  in  the  ischemic  area  pal  tor,  fall  of  temperature, 
hyptsthcsia^  and  paresis,  followed,  in  the  event  of  gangrene,  by  the  discolora- 
tion of  gangrene,  anesthesia,  and  paralysis.  Hemorrhage,  as  a  manifestation 
of  infarction ^  may  show  itself  externally  when  the  lung  (hemc>ptysis),  kidney 
(hematuria),  or  bowel  (bluiidy  stools)  is  affected.  The  remaining  symptoms 
of  infarction  arc  impairment  or  abolitinn  t^f  the  si>ecial  funuions  of  the  organ 
affected.  Pulmonary  embolism  is  discussed  below,  mesenteric  embolism  on 
page  452 ;  for  the  details  of  infarction  of  other  vis*  era  the  student  is  referred  to 
a  text -book  on  internal  meciicine. 

Diagnosis  between  Embolism  and  Thrombosis.— The  onset  is  sudden 
in  embolism,  gradual  in  thrombosis.  It  may,  however,  be  slow  in  the  for- 
mer if  the  embolus  does  not  at  once  completely  occlude  the   arter)%   and 


a  b  r  u  [>t  i  n  1  h  e  hi  U  e  r  i  f  I  h  c  t  h  R >  m  hii  s  f o r m  s  ra  pi  d !  y .  T  he  du  ra lion  of  lb  e  %y  m p - 
^JWA  may  be  brief  in  embolism,  liecause  the  collateral  vessels  promptly  dilale. 
When  an  artery  is  slowly  occluded  the  collateral  vessels  progressively  enlarge , 
so  that  by  the  time  the  blood  stream  is  completely  arrested,  they  are  incapable 
of  the  further  dilatation  required  to  nourish  the  afTected  part,  hence  the  symp- 
toms are  permanent  or  of  long  duration.  If,  therefore,  the  collateral  vt^s^ei^ 
are  enlarged  at  the  onset  the  condition  is  probably  thrombose.  The  finding 
of  the  ratisative  iisien  may  he  difficult  or  impossible.  Embolism  h  so  much 
more  frequent  in  arteries  that,  in  the  absence  of  a  detinite  cause  for  throm 
l)osis,  the  condition  is  generally  regarded  as  embolism^  even  when  the  sourci 
of  the  embolus  cannot  be  discovered. 

The  treatment  is  first  prevention  (see  pulmonai*}^  emWism).  The 
measures  to  be  taken  to  prevent  gangrene  in  embolism  of  the  arteries  of  the 
extremities  are  identical  wnth  those  mentioned  under  senile  gangrene 
Removal  of  an  embolus  in  an  accessible  region  is  possible.  The  treatment  o] 
embolic  gangrene  is  given  on  page  82,  of  mesenteric  embolism  on  page 
452,  The  treatment  of  other  forms  of  visceral  infarction  belongs  to  the  phy- 
sician, if  w^e  except  the  incision  of  secondary  abscesses  and  the  excision  of' 
organs  whose  main  artery  is  1j locked,  e,g,,  spleen  and  kidney. 

Pulmonary  tmbolisni  may  follow  thrombosis  due  to  tlisease  or  injury 
(see  thrombosis  and  phlebitis) ;  labor,  owing  to  the  increased  coagulability  of 
the  blood,  the  trauma  of  childbirth,  the  wide  veins  of  the  uterus,  and  the 
contractions  of  the  uterus;  the  injection  of  coagtilating  fluids  into  venous 
tumors,  of  paraffin  for  cosmetic  purposes,  and  of  mercury  in  syphilis;  and 
certain  operations  (p.  177). 

The  symptoms,  excluding  infective  emboli  which  give  rise  to  septic  proc 
esses,  depend  upon  the  size  of  the  embolus  and  the  condition  of  the  pulmo 
nary  circulation.  1.  Minute  emboli  give  no  symptoms.  2.  EmlKjli  large 
enough  to  block  a  medium  sized  branch  of  the  pulmonary  artery  may  be 
followed  by  trifling  symptoms,  owing  to  the  number  and  large  size  of  the 
capillaries  which  supply  the  affected  area.  If,  however,  the  pulmonary 
circulation  is  sluggish,  hemorrhagic  infarction  may  occur,  the  symptoms 
being  those  of  pleuropneumonia.  Bloody  expectoration  may  be  absent 
and  necrosis  of  the  infarct  does  not  necessarily  follow.  Many  cases  of  pleu- 
risy and  mild  pneumonia,  appearing  within  a  few  days  or  a  week  after  opera- 
lion,  are  in  reality  flue  to  emliolism.  3.  A  large  embolus  occluding  the 
pulmonar}'  artery  or  one  of  its  main  branches  causes  death  within  a  few 
minutes.  If  the  vessel  is  not  completely  blocked  life  may  be  prolonged  for 
h  o  u  rs ,  o  r  rec  o  ve  ry  m  a  y  f  ol  1  o  w .  In  t  h  ese  c  a  ses  t  he  p  a  t  i  e  n  t  s  udde  n !  y  c  o  m  pi  a  i  n  s 
of  severe  pain  aliout  the  heart  and  dyspnea;  the  respirations  are  rapid,  the 
face  cyanotic,  the  eyes  protruding,  the  pupils  dilated,  the  cervical  veins 
swollen,  and  the  pulse  quick,  weak,  and  perhaps  irregular  In  other  cases 
there  is  delirium,  coma,  or  convulsions.  At  the  onset  examination  of  the 
chest  may  reveal  nothing  abnormal; later,  signs  of  edema  of  the  lungs  appear. 
Excluding  injuries  to  the  major  veins,  emboli  sufficiently  large  to  block  the 
main  pulmonary  vessels  rarely  occur  before  the  second  or  third  week  of  phle- 
bitis or  after  the  sixth  week.  The  acrident  often  follows  some  movement, 
pardcularly  sitting  up  in  bed,  which  necessitates  acute  flexion  of  the  groin, 
thrombosis  being  most  frequent  in  the  left  femoral  vein  (p,  170).  The 
prophylactic  treatment  is  that  of  phlebitis  (p.  178).  Embolic  pneumonia 
is  managed  like  ordinary  pneumonia.     In  occlusion  of  the  pulmonary  artery 


1         I 

4 


EMBOLISM. 


^73 


or  one  of  hs  large  branches,  if  the  palient  live  long  enough,  lanliac 
stimulants,  oxygen,  and  perhaps  Ijleefling  may  be  employed.  Trendelen- 
burg suggests  thoracotomy,  incision  of  the  pulmonar>^  arter)-,  and  extraction 
of  the  embolus;  this  has  been  attempted  in  five  cases,  withoutt  however,  a 
single  recovery. 

Air  embolism  may  occur  during  the  administration  of  an  intrauterine 
douche  after  laborj  during  intravenous  infusion,  and  especially  during  opera- 
tions at  the  l>ase  of  the  neck  when  the  veins  are  gaping  from  pathological 
change,  anatomical  disposition,  or  the  result  of  traction.  The  amount  of  air 
which  might  be  introduced  into  a  vein  by  the  ordinary  hypodermic  syringe 
would  probably  be  insufficient  to  cause  serious  trouble.  It  is  necessary  that 
a  large  amount  of  air  be  introduced  suddenly. 

The  symptoms  are  a  gurgling  sound  due  to  the  sucking  of  air  into  the  vein, 
extreme  pallor  or  lividity  of  the  face,  marked  acceleration  and  then  cessation 
01  the  pulse  and  respirations,  and  occasionally  a  gurgling  sound  over  the  heart. 
There  may  be  convulsions  preceding  deaths  which  usually  takes  place  within 
a  few  minutes,  although  it  may  be  postponed  for  several  hours  or  even  days. 
The  cause  of  these  symptoms  is  overdistention  of  the  right  heart  and  the  pul- 
monary vessels  with  air,  and  air  embolism  of  I  he  coronary  and  cerebral 
arteries. 

The  treatment  is  immediate  pressure  on  the  wounded  vein  to  prevent  the 
further  entrance  of  air.  Blood  may  be  withdrawn  from  a  vein  of  the  arm  to 
relieve  the  distention  of  the  heart,  cardiac  stimulants  ^iven  subcutaneously, 
and  artificial  respiration  performed.  Puncture  of  the  right  auricle  with 
an  aspirating  needle  has  Ijeen  proposed. 

Fat  embolism  may  follow  injuries  of  fatly  tissue  in  any  part  of  the  hmh\ 
but  is  most  frequent  after  fractures  of  long  bones.  As  with  air,  it  is  probable 
that  a  large  quantity  of  fat  must  be  introduced  into  the  circulation  in  a  short 
time  in  order  to  produce  serious  symptoms;  indeed,  a  small  quantity  of  fat  is 
normally  present  in  the  blood.  The  symptoms  are  similar  to  those  produced 
by  other  forms  of  emboli.  The  fat  is  washed  through  the  right  heart  to  the 
lungs,  where  it  fills  the  vessels,  producing  sudden  death;  or,  if  the  quantity  be 
smaller,  severe  pain,  dyspnea,  rapid  pulse,  hurried,  shaHow  respirations, 
cyanosis,  and  sometimes  hemoptysis.  At  the  onset  the  temperature  is  apt  to 
be  subnormal,  but  later  it  ascends.  The  physical  signs  are  at  first  indefinite; 
there  may  be  a  normal  percussion  note,  restriction  of  the  respiratory*  excur- 
sion, and  coarse  rales;  if  the  patient  survives,  the  later  signs  are  those  of  con- 
solidation. If  the  oil  globules  are  forced  through  the  pulmonar)'  capillaries, 
there  may  be  fat  in  the  urine  or  total  suppression  of  urine,  and  symptoms  of 
cmljolism  of  the  brain  (convulsions,  paralysis,  coma,  etc).  Unlike  embolism 
due  to  blood  clot,  which  is  usually  postponed  for  a  week  or  longer  after  an 
operation  or  injur}%  fat  embolism  commcmly  occurs  within  36  or  72  hours. 
This  fact  distinguishes  it  likewise  from  shock,  which  immediately  follows  an 
injury* 

Ib  order  to  prevent  this  accident,  injured  fatty  tissues  should  be  kept 
at  rest,  and  if  there  is  much  tension,  the  result  of  accumulation  of  wound 
fluids,  stitches  should  be  removed  or  incisions  made.  The  treatment  of  the 
condition  itself,  in  the  acute  cases,  is  external  heat,  cardiac  stimulants,  and 
artificial  respiration.  The  wound  should  always  be  opened  to  prevent  the 
fresh  entrance  of  fat  into  the  circulation.  The  later  treatment  is  that  of  the 
complications. 


2 


THE  HEART  AftD  PERICARDIUM, 

Overdistention  of  the  heart  wiih  biuod,  ihe  result  of  acute  pulmonan' 
affections,  or  with  air  from  air  embolism,  has  been  treated  by  tapping  the 
cavity  of  the  heart.  As  the  right  auritie  siilTers  most  from  this  overdistention 
owing  to  the  thinness  of  its  walls,  it  is  selected  for  puncture  (paracentrns 
aurifuH).  The  needle  may  be  introdut  ed  in  the  third  intercostal  space  at  the 
right  etlge  of  the  sternum  and  pushed  directly  backwards.  It  iraverses  the 
anterior  edge  of  the  right  lung  and  the  pericardium  before  reaching  the 
auricle.  The  operation  is  attended  with  the  danger  of  a  fatal  hemorrhage 
and  should  rarely,  if  ever,  l>e  performed. 

Wounds  of  the  heart  may  i>e  produced  by  penetration  from  without,  eg  . 
by  gunshot  or  stab  wounds,  frat  tured  ribs,  or  by  foreign  bodies  from  the  esoph- 
aguSi  stomach,  or  bronchus.  The  heart  may  burst  as  the  result  of  blunt 
force  to  the  thorax  or  epigastrium,  and  it  may  rupture  spontaneously  (dis- 
ease of  the  myocardium  or  coronary  artery,  neoplasms,  go mmata,  echinococu, 
abscess,  aneurysm,  etc.). 

Symptoms. — Inslanin neons  dtailu  which  probably  results  from  injury  to 
the  nervous  mechanism  of  the  heart,  is  very  rare,  and  more  apt  to  fidlow 
a  severe  blow  over  the  heart  or  epigastrium  than  a  penetrating  wound 
(so-called  (anrusMiim  of  the  heart).  The  symptoms  in  a  case  not  immediately 
fatal  are  those  of  acute  anemia  or  of  compression  of  the  heart,  depending  upon 
whether  the  blood  escapes  into  the  pleural  cavity  or  externally,  or  upon  its  re- 
tention in  the  pericardium.  Occasionally  the  patient  may  walk  or  even  run 
for  a  consideral>le  distance  before  falling  to  the  groun(L  When  the  blood 
escapes  into  the  pleural  cavity  (the  pleura  is  injured  in  over  go  per  cent,  of 
the  cases)  there  will  i>c.  in  addition  to  the  symptoms  oi  aatte  anenua  (p,  196), 
the  signs  of  a  pneumohemothurax.  Faipalion  may  detect  the  apex  beat 
A  whizzing  sound  due  to  the  presence  of  air  in  the  pericardium,  a  friction 
sound,  or  a  bruit  not  unlike  that  heard  over  an  aneurysm  may  be  heard. 
If  the  blood  escapes  externally  it  may  do  so  in  jets,  but  a  continuous  stream 
accentuated  by  coughing,  movements  of  the  patient,  and  similar  efforts,  is 
more  common.  When  the  blood  is  confined  to  the  pericardium  the  phenom- 
ena are  those  of  Lompressioft  of  the  heart.  The  pulse  is  slow,  irregular,  and 
feeble,  or  absent,  the  apex  beat  impeneptible,  the  breathing  hurried  and 
superficial,  the  face  cyanotic,  the  cervical  veins  dilated,  and  the  patient 
unconscious,  but  the  senses  return  on  providing  an  exit  for  the  bloocj.  There 
may  be  a  splashing  sound  disappearing  with  the  filling  of  the  pericardium, 
at  which  time  the  area  of  precordial  dulness  will  be  vastly  increased  (see 
pericardial  elTusion).  Death  after  sn'erai  days  or  weeks  is  usually  the  result 
of  sepsis  (pericarditis,  empyema,  pneumonia,  etc.),  although  secondary  hem- 
orrhage is  a  possibility »  and  clot,  but  not  air,  embolism  has  been  reported. 
Spontaneous  rrajirry  occurs  in  1  percent,  oi  penetrating  and  nine  percent. 
of  nonpenetrating  wounffs.  The  wound  is  repaired  by  fibrous  tissue,  not 
muscle,  hence  the  possibility  of  sut>sec[uent  aneur>'sm,  rupture,  and  of 
murmurs  from  alterations  of  the  cardiac  onlkes.  Pericarflial  adhesions 
probably  always  follow  wounds  of  the  pericardium,  but  cause  symptoms  in 
only  a  few  of  the  cases. 

The  diagnosis  is  not  always  easy.  The  supertlt  lal  wound  tnay  I>c  in  the 
abdomen  or  back  and  the  genera!  symptoms,  at  least  in  the  lieginning,  slight. 
External  bleeding  may  be  profuse  and  spurting  from  an  intercostal  or  internal 


PERICARDITIS.  175 

mammary  artery  antl  absent  In  a  wound  of  the  heart.  The  only  safe  procedure 
in  doubtful  case^  presenting  a  wound  in  the  region  of  I  he  heart  is  to  enlarge 
the  wound,  ascertain  if  it  penetrates  the  chest  wall,  and  if  there  be  symptoms 
of  hemorrhage  or  "heart  tamponage,*'  to  explore  the  pericardium  and  the 
heart. 

The  treatment  is  suture  of  the  heart.  An  anesthetic  should  beemployt^d 
unless  the  patient  be  unconscious.  The  heart  may  be  exposed  extrapleu- 
rally,  but  the  pleura  is  usually  wounded  l>y  the  vulnerating  instrument,  and 
the  patient's  condition  is  not  such  as  to  sustain  an  operation  protracted  by  a 
small  opening  in  the  chest  wall  and  by  the  careful  manipulations  necessary 
to  avoid  the  pleura.  Collapse  of  the  lung  could  be  prevented  by  positive 
or  negative  pressure  (p.  406)*  but  such  has  not  yet  been  used  in  an  operation 
for  suturing  the  heart.  An  atypical  osteoplastic  flap  with  the  base  towards 
the  sternum,  either  in  the  right  or  left  chest  according  to  indications,  and 
including  as  many  ribs  as  may  be  necessary  for  proper  exposure,  usually 
from  two  to  four,  will  be  indicated  in  most  of  the  cases.  The  wound  in  the 
pericardium  is  enlarged  and  the  bleeding  from  the  heart  controlled  by  a 
linger,  by  compression  of  the  heart,  by  dislocating  it  forwanl,  or  by  pressing 
it  against  the  sternum.  Rehn  says  the  operation  may  be  made  bloodless  by 
campressing  the  vena*  cavie,  at  their  junction  with  the  right  auricle,  between 
two  fingers;  in  animals  this  procedure  has  been  continued  for  ten  minutes 
without  permanent  harm  following.  The  sutures  may  be  of  silk  or  catgut, 
intrwiuced  by  means  of  a  cur\'ed,  intestinal  needle.  A  continuous  suture 
may  Ijc  applied  more  rapidly  than  an  interrupted  and  presents  fewer  knots 
on  the  surface  of  the  heart.  The  heart  may  be  steadied  Ijy  the  lingers,  by 
forceps,  or  by  sling  sutures.  If  the  heart  ceases  to  beat  it  should  be  sutured 
quickly  and  massage  performed.  After  removing  the  bloofl  from  the  peri- 
cardium and  pleura,  these  cavities  may  be  closed,  or  if  thought  advisable, 
drainage  may  l»e  introduced.  We  have  sutured  the  heart  in  five  cases  with 
three  recoveries  antl  have  notes  of  igo  cases,  with  76  recoveries. 

Maasage  of  the  heart,  by  compressing  the  ventricles  between  the  thumb 
and  fingers,  60  times  to  the  minute,  has  been  employed  for  suspended  anima- 
uon  due  to  anesthetics,  wounds  of  the  heart,  etc,  the  heart  being  exposed  by 
thoracotomy,  or  manipulated  through  the  diaphragm  after  opening  the  abdo- 
men. The  thoracic  route  should  be  selected  only  when  a  breach  in  the 
thoracic  wall  already  exists,  e,g.,  in  operations  on  the  heart  and  lungs;  in 
all  other  instances  the  sut>diaphragmatic  method  is  easier  and  safer.  Of 
fifty-three  rases  collected  by  Macquet  eleven  were  successful.  Cardiac 
massage  may  l>e  performed  also  by  making  rhythmical  pressure  (60  per 
minute)  over  the  third,  fourth,  and  fifth  costal  cartilages  on  the  left  side.  In 
all  cases  it  is  important  to  maintain  the  respirations  and  the  bodily  heat  by 
artificial  means. 

Pericarditis  is  caused  by  contusions  or  wounds;  infectious  diseases,  such 
.*»:<  pyemia  or  septicerliiat  rheumatism,  tuberculosis,  and  pneumonia;  and  by 
the  extension  of  infectious  processes  in  the  neighlx^rhood  of  the  pericardium. 
The  nature  of  the  primar\'  infection  determines  the  character  of  the  micro- 
organism found.     Primary  pericarditis  is  very  rare. 

The  symptoms  are  often  masked  by  those  of  the  primar>'  illness  and  the 
condition  is  frequently  overiooked.  There  are  dyspnea,  cough,  fever, 
leukocytosis,  small  weak  pulse,  iiccasionally  the  pulsus  paradoxus,  fre<|uently 
delirium,  pain  and  tenderness  over  the  heart,  pain  radiating  down  the  left  arm 


VASCULAR  SYSTEM. 

or  inlo  the  epigastrium,  and  a  friction  sound,  perhaps  with  fremitus,  disap- 
pearing as  the  sac  fills  with  effusion.  In  pericardial  effusion  the  precordial 
dulness  increases  and  becomes  pear-shaped^  the  precordium  bulges,  the 
cardiac  sounds  become  faint  and  distant,  and  there  may  be  aphonia  and 
dysphagia;  the  apex  beat  is  alKJve  the  lower  boundar)'  of  dulness  or  is  absent ; 
dulness  in  the  fifth  right  interspace  close  to  the  sternum  {Raich's  sign)  may  be 
present;  percussion  reveals  tlatness  with  marked  resistance;  an  area  of  dulness 
with  bronchial  breathing  near  the  angle  of  the  left  scapula  {Bamberger's  sign) 
may  be  present,  as  may  also  Ewarfs  sign^  in  which  the  first  rib  is  separated 
from  the  clavicle  so  that  the  former  may  be  palpated  its  entire  length.  The 
effusion  may  sometimes  be  demonstrated  with  the  X-ray.  If  the  fluid  be- 
comes purulent,  there  may  be  intermittent  fever  and  edema  of  the  chest  walk 
Exploratory  puncture  will  confirm  the  diagnosis.  The  most  common  condi- 
tions for  which  pericardial  effusion  is  mistaken  are  dilatation  of  the  heart, 
pleural  effusions,  and  pneumonia.  When  the  pain  is  referred  to  the  abdomen, 
such  conditions  as  appendicitis,  perforation  of  the  intestine,  and  acute  gastri- 
tis, may  be  simulated. 

The  treatmeot,  in  the  absence  of  effusion,  is  medical.  Serous  effusion, 
when  excessive,  demands  aspiration.  Hemorrhagic  ejjusim  (hemoperi- 
card  turn)  arising  immediately  after  a  wound  demands  explomtoiy  pericar- 
dotomy.  At  a  later  period  tapping  may  suffice,  although  even  then  peri- 
cardotomy  may  be  necessary  to  remove  clots  if  the  symptoms  persist.  Non- 
traumatic hemopericardium,  excluding  scurvy,  is  generally  due  to  a  fatal 
malady  (e.g.,  rupture  of  the  heart,  bursting  of  an  aneurysm,  tul)crculosis, 
cancer,  Bright "s  disease),  hence  relief  from  tapping  is  only  temporary.  In 
{yurident  cffusimi  ipyoperifardium^  empyema  of  the  pericardium)  pericardotomy 
is  required.  Puncture,  as  in  pleural  empyema,  should  not  be  used,  except 
for  diagnosis,  or  for  palliation  in  cases  too  ill  to  stand  pericardotomy. 

Paracentesis  Pericardii  (tapping  of  the  pericardium). — The  diagnosis 
of  pericardial  effusion  can  be  assured  only  by  exploratory  puncture,  w*hich 
should  be  made  with  an  ordinary  hypodermic  syringe.  Large  trocars  are 
dangerous.  A  line  needle  may  fail  to  evacuate  thick  pus,  but  it  will  rarely 
fail  to  obtain  enough  for  diagnostic  purposes.  Although  puncture  of  the 
heart  with  a  fine  needle  is  generally  harmless,  death  may  follow,  either  im- 
mediately from  injury  to  the  coordination  center,  or  later  from  hemoperi- 
cardium.  The  needle  should  be  introduced  in  the  fourth  or  fifth  left  inter- 
space close  to  the  edge  of  the  sternum,  so  as  to  avoid  the  pleura  and  internal 
mammary  artery  (LeConte).  If  no  fluid  is  withdrawn,  it  may  be  entered  in 
the  fifth  intercostal  space,  two  inches  from  the  left  border  of  the  sternum. 
Never  should  the  puncture  be  made  at  the  spot  where  friction  is  heard,  or 
w^here  the  heart  sounds  are  very  distinct.  If  the  fluid  is  serous  or  sanguine- 
ous  an  aspirator  should  be  connected  with  the  needle;  if  pus  is  recovered 
pericardotomy  is  mandatory, 

Pericardotomy  (incision  of  the  pericardium)  without  reseition  of  a 
costal  cartilage  is  indicated  when  the  patient  is  unable  to  stand  a  general 
anesthedc.  The  tissues  should  be  infiltrated  with  Schleich*s  fluid,  and  an 
incision  made  in  the  fourth  or  fifth  intercostal  space,  lieginniiig  at  a  point  one 
inch  from  the  sternal  liorder  and  extending  to  a  point  an  inch  within  the  nip- 
ple line.  This  avoids  the  internal  mammary  artery,  which  runs  parallel 
with,  and  a'half  inch  external  to,  the  edge  of  the  sternum,  but  may  injure  the 
pleura;  the  two  layers  of  pleura,  however,  are  frequently  adherent  at  this 


point  in  pyopericarditis,  and  the  wound  will  be  of  no  consequence.  The 
pericardium  is  incised  and  a  rubber  drainage  tube  inserted.  When  a  general 
anesthetic  is  employed  a  portion  of  the  fourth  or  fifth  costal  cartilage  may  be 
resected  close  to  the  sternum,  Ugaling  the  internal  mammary  vessels  if  neces* 
sary.  Roberts  ad%ises  turning  up  a  t!ap,  consisting  of  the  fourth  and  fifth 
costal  cartilages,  the  soft  tissues  of  the  third  interspace  being  used  as  a  hinge. 
Irrigation  with  salt  solution  may  be  cautiously  used  for  the  removal  of  clots 
or  masses  of  fibrin. 

Cardiolysis  is  a  resection  of  varying  amounts  of  bony  tissue  (ribs  and 
sternum)  in  order  to  uofelter  a  heart  hnHind  to  the  chest  wall  by  chronic 
mcdiastinoperi carditis,  which  manifests  itself  by  dyspnea,  ascites,  and  other 
symptoms  of  cardiac  insufficiency,  together  with  systolic  retraction  of  the 
intercostal  spaces,  retraction  of  the  lower  lateral  and  lower  posterior  por- 
tions of  the  chest  (Broadbenl's  sign)^  diastolic  shock  or  rebound,  absence 
of  respiratory  movements  in  the  epigastrium,  pulsus  paradoxus  (Kus^imatirs 
sfgn)f  and  diastolic  collapse  of  the  cervical  veins  {Frudrekh*s  sign).  In  the 
few  cases  in  which  this  operation  has  been  performed  the  results  have  been 
gratifying. 

THE  VEINS. 

Phlebitis,  or  inflammation  of  a  vein,  may  be  acute  or  chronic. 

Acute  phlebitis  is  caused  by  inflammatory  atlections  in  the  neighbor- 
hood of  a  vein  (periphlebitis),  injuries,  primary  thrombosis  (thrombophle- 
bitis), varix,  and  by  such  constitutional  affections  as  rheumatism,  guut»  and 
the  infectious  fevers.  Post-operative  phkbitis  is  sometimes  due  to  infection, 
but  most  of  the  cases  following  aseptic  operations  are,  we  think,  to  be  ascribed 
to  non- bacterial  changes  in  the  blood  and  slowing  of  the  circulation,  because 
the  operations  most  likely  to  be  followed  by  thrombophlebitis  are  those  in- 
volving varices,  those  on  anemic  patients,  especially  hysterectomy  for  1  deed- 
ing fibromyoma,  and  those  necessitating  a  prolonged  stay  in  bed,  e.g.,  abdom- 
inal section,  and  because,  like  thrombosis  from  other  general  conditions, 
the  process  is  usually  located  in  the  left  femoral  and  iliac  veins,  the  reasons 
for  which  are  given  on  page  jjo.  Phlebitis  of  the  lower  extremity  compli- 
cates 2  per  cent,  of  all  abdominal  operations,  30  per  cent,  of  these  following 
hysterectomy,  15  per  cent,  oophorectomy,  10  per  cent,  appendicitis,  and  5 
r  cent,  renal  operations.  Large  emboli  are  detached  in  about  2  per  cent. 
the  cases,  and  of  these  about  one-third  are  fatal  (sec  pulmonary  embolism). 

The  pathological  changes  usually  begin  in  the  intima,  because  it  is  the 
finil  to  yield  in  contusions  and  is  directly  exposed  to  toxins  circulating  in  the 
Wood.  The  endothelial  cells  degenerate  and  liberate  fibrin  ferment,  and 
this  with  the  concomitant  roughening  of  the  ijitima  leads  to  thrombosis. 
The  fate  of  the  thrombus  has  been  mentioned  on  page  i6g.  The  outer 
coats  swell  owing  to  the  dilatation  of  the  vasa  vasorum  and  the  subsequent 
ejcudation.  The  inflammatory  exudate  and  the  thrombus  may  l>e  absorbed 
or  organized  {exudative  phlebitis),  or  undergo  suppuration  (suppurative 
phiebiiis).  The  former  is  responsible  for  the  massive  emlx>li  which  cause 
sudden  death,  the  latter  for  the  small  septic  emboli  which  cause  metastatic 
abscesses  (pyemia).  Phlebitis  may  be  sharply  localised  to  a  small  segment 
»*«f  a  vein,  ni»tai>ly  in  varix  of  the  leg,  or  it  may  involve  most  of  the  veins  of  an 
extremity,  e.g.,  in  phlegmasia  alba  dolens.     If  it  i*egins  in  a  small  vein  it 


spreads  in  the  direction  of  the  blood  current^  if  in  a  large  vein  in  both  direc- 
tions. Sometimes,  however;  it  jumps  from  one  segment  to  another,  partic- 
ularly in  gouty  phlebitis.  Multiple  patches  of  phlebitis  in  various  parts  of 
the  body  may  occur  also  in  rheumatism,  chlorosis,  and  tuberculous  or  can- 
cerous cachexia. 

The  symptoms  are  local  and  jreneral.  The  local  symptoms  are  (a)  those 
of  inflammation,  viz.,  pain  and  tenderness  along  the  vein,  which  may  be  felt 
as  a  firm  cord  when  the  vein  is  superficial^  elevation  of  the  local  temperature 
and  redness  when  the  perivascular  tissues  are  involved,  and  fluctuation  in  the 
event  of  suppuration,  and  (b)  thtjse  of  oljstruction  to  the  venous  current,  viz., 
edema  and  passive  congestion  in  the  region  disial  to  the  thrombus,  and 
ultimately  enlargement  of  the  collateral  veins.  Other  symptoms,  referable 
to  disturbance  of  special  functions,  arise  when  the  viscera!  veins  are  affected. 
The  gmetal  symptoms  vary  from  a  slight  rise  of  temperature  to  the  severer 
forms  of  septicemia.  A  progressive  increase  in  the  pulse  rate,  even  without 
fever  (Mahler's  symptom),  should  make  one  suspect  a  beginning  phlebitis. 
Embolism  causes  sudden  death,  pulmonarv^  infarction  (see  pulmonary  embo* 
lism),  or,  in  the  case  of  septic  emboli,  pyemia. 

The  prophylaxis  of  post-operative  phlebitis  includes  careful  pre- 
paratory treatment,  especially  of  the  heart  and  lungs  if  they  are  functionally 
impaired;  asejisis,  rigorous  hemostasis,  protection  from  cold,  and  avoidance 
of  rough  manipulations  of  the  tissues  during  operation;  and  after  operation 
attention  to  shock,  the  secretions,  and  the  bowels,  and  allowing  the  patient 
to  resume  the  regular  diet  and  to  sit  up  as  early  as  possible.  Wlien  a  pro- 
longed stay  in  bed  is  necessary  centrij>etal  massage,  active  movements  of  the 
arms  and  legs,  and  l>reathing  exercises  may  be  ordered.  If  conditions  favor- 
able for  thrombosis  exist,  citric  acid,  30  grains  three  times  daily,  may  be 
given  to  lessen  the  coagulative  tendency  of  the  blood,  or  the  milk  may  be 
decalcified  by  adding  to  each  pint  30  grains  of  citrate  of  soda  (Wright  and 
Knapp). 

The  treatment  of  phlebitis  itself  is  attention  to  any  existing  constitu- 
tional disease,  absolute  rest  in  the  recumbent  posture  to  lessen  the  force  of 
the  circulation  and  prevent  the  detachment  of  emboli,  elevation  of  the  part, 
and  the  application  of  cataplasma  kaolini,  lead-water  and  laudanum,  or 
other  evaporating  lotion,  or  equal  parts  of  ichthyol,  lielladonna,  mercury,  and 
lanolin,  which  should  be  laid  on,  not  rulibed  in,  and  held  in  place  with  a  loose 
bandage.  Tight  bandaging,  inunctions,  and  massage  are  dangerous.  Sitting 
up  is  not  absolutely  safe  until  the  clot  has  become  organized  or  absorbed  (six 
to  eight  weeks),  when  gentle  passive  motions  and  light  frictions  may  be  em- 
ployed to  hasten  absorption  of  the  edema.  An  elastic  bandage  should  be  worn 
for  the  same  purpose.  In  supjjurative  phlebitis  the  vein  should  be  excised, 
or,  if  this  is  not  possible,  incised  and  disinfected,  and  a  ligature  placed  be- 
tween the  area  of  inflammalion  and  the  heart,  in  order  to  prevent  pyemia: 
thus  in  thromiiosis  of  the  lateral  sinus  due  to  otitis  media,  the  internal 
jugular  vein  should  be  tied  in  addition  to  the  opening  and  disinfection  of 
the  sinus. 

Chronic  phlebitis^  or  phlebosclerosis,  is  a  condition  similar  to  arte- 
riosclerosis. The  vein  walls  are  thickened  as  the  result  of  acute  inilammation, 
or  of  overdislention,  e.g.,  in  varicose  veins  or  other  forms  of  obstruction.  Like 
arteriosclerosis  it  may  be  widespread  as  the  result  of  such  conditions  as 
syphilis,  gout,  alcoholism,  etc.     The  treatment  is  that  of  the  cause. 


Varix   (varicose  veins,  phlebectasia)   is  an  elongated,  pcrmanenily 

Slated,  tortuous  vein  with  ihi<  kened  waits.     It  is  most  frequent  in  the  in- 

rmal   and   external  saphenous  veins  of  the  leg  (Fig.  T12),  and  it  is  with 

ich  that  we  shall  deal  at  the  present  time,  other  manifestations  of  this 

Ibnorroality,  such  as  varicorele  and  hemorrhoids,  being  discussed  in  other 

lections  of  the  lx)ok. 

The  causes  uf  varix  ure,  (i)  weakness  of  the  tvalis  of  the  veins,  either 
hereditary  or  acquired  (phlebitis);  (2)  retardatimi  of  the  venous  circulaiion^ 
e.g.,  by  cardiac  or  pulmonary  disease,  prolonged  standing,  and  obstructions, 


J- It.,  1 1  J. ^Varicose  vt-ir 


f  iTrier  amJ  Alglavc 


Ich  as*  garters*  tumors,  pregnant  or  displaced  uterus,  etc.;  (3)  compensatory 
%latatian^  suth  as  occurs  in  the  superficial  veins  of  the  leg  when  the  deep 
tins  arc  blocked;  and  (4)  an  abnormal  opening  between  an  artery  and  vein^ 
jrh  as  occurs  in  aneurysmal  varix.  The  condition  is  frecjuently  present  in 
5uth»  l)ut  usually  gives  no  trouble  until  middle  life  is  reached.  Women  are 
(lore  liable  to  varix  than  men,  owing  to  the  inlluencc  of  pregnancy. 

Pathology.-  The  dilatation  induces  at  first  hypertrophy  of  the  tunica 
acdia  and  tnially  chronic  inflammatory  changes  with  proliferation  of  the 
^nncctivr-tissuc  elements.  The  new  tissue  causes  the  vessel  walls  to 
^iiken  and  elongate,  and  the  elongation  eventuates  in  tortuosity.     Owing 


i8o 


VASCULAR   SYSTEM* 


to  the  distention  of  the  vein,  and  to  the  crippling  of  the  valves  by  the  sclerotic" 
process,  the  latter  structures  become  incompetent,  and  the  waUs  o£  the  vein 
most  support  a  column  of  blood  extending  to  the  heart,  and  bear  the  brunt 
of  every  sudden  increase  in  the  intravenous  l^lood  pressure,  e.g.,  by  coughing, 
straining,  etc.  In  old  cases  periphlebitis,  causing  the  vein  to  adhere  to  the 
ennroning  tissues,  is  always  present^  and  the  inflammatory  changes  may 
extend  to  the  remaining  structures  of  the  leg.  Lymphangitis  seriously 
augments  the  edema,  renders  it  firmer  in  character,  and  sometimes  leads 
to  enormous  hyperplasia  of  the  subcutaneous  tissues  (pse u do-el ep ban tia- 
sis).  The  arteries  may  sufifer  like  the  veins  and  even  become  thrombosed. 
The  nerves  and  muscles  may  be  attacked  by  interstitial  inflammation,  and 
the  bones  beneath  ulcers  may  be  the  seat  of  osteoporosis  or  even  caries. 
The  skin  is  thickened,  often  pigmented  owing  to  rupture  of  dilated  vasa 
vasorum,  and  frequently  reddened^  ec^ematous,  or  ulcerated. 

Symptoms. — Varices  usually  develop  insidiously,  although  in  acute 
obstructive  lesions  and  In  arteriovenous  aneurysm  they  may  arise  quickly. 
Both  legs  are  affected  in  70  per  cent,  of  the  cases,  the  left  alone  in  20  per  cent., 
and  the  right  alone  in  10  per  cent.  Even  when  bilateral,  however,  the  atlec- 
tion  is  generally  more  pronounced  on  the  left  side,  for  the  same  reasons 
that  venous  thrombosis  is  more  frequent  on  this  slda  (p.  170).  In  an  un- 
complicated case  there  may  be  pain  in  the  leg  and  sole  of  the  foot,  heaviness 
of  the  limb,  and  edema,  particularly  after  walking  or  standing,  and  some- 
times muscular  cramps.  When  varices  begin  in  the  deep  veins,  the  usual 
point  of  origin  according  to  some  authors,  these  symptoms  may  be  misin- 
terpreted until  the  superficial  veins  dilate,  when  the  condition  is  readily 
recognized.  The  veins  are  at  first  uniformly  distended,  but  subsequently 
become  fusiform  in  places  or  even  sacculated.  Valvular  incompetence  may 
be  demonstrated  by  striking  the  upper  part  of  the  vein  with  a  finger  and 
palpating  the  fluctuation  wave  thus  induced  at  a  lower  level,  or  by  noting 
the  impulse  transmitted  along  the  blood  column  when  the  patient  coughs. 
Trendelenburg's  test  is  as  follows:  After  the  patient  lies  down  and  elevates 
the  limb,  compression  is  applied  lo  the  upper  part  of  the  saphenous  vein 
and  the  patient  told  to  stand.  If  the  vein  slowly  distends  from  below 
upward  the  valves  are  competent;  if  it  remains  empty  and,  alter  the 
compression  is  removed,  suddenly  fills  from  above  downward  the  valves 
are  incompetent  and  the  circulation  reversed. 

Complications.^ — Rupture  of  a  deep  varix  in  the  calf  occurs  under 
similar  circumstances,  gives  the  same  symptoms,  and  requires  the  same  treat- 
ment as  rupture  of  the  plantaris  (p.  236).  Rupture  of  a  superficial  varix 
may  result  from  trauma,  ulceration,  or  simply  from  coughing  or  straining; 
in  the  last  instance  usually  where  the  vein  is  greatly  thinned  as  the  result 
of  a  saccular  dilatation.  The  bleeding  is  more  profuse  than  under  normal 
conditions,  because  of  the  incompetent  valves  and  the  rigidity  of  the  vein, 
which  prevents  its  collapse;  and  when  the  circulation  is  reversed  the  hemor- 
rhage is  more  copious  from  the  upper  end  of  the  vein. 

Thrombophkhitis ^  usually  exudative  and  localized  to  a  segment  of  the 
vein,  is  a  frequent  complication,  owing  to  the  sluggish  circulation  and  the 
alterations  in  the  walls  of  the  vein,  and  one  which  may  result  in  obliteration 
of  the  vessel  and  spontaneous  recovery.  KmboHsm  is  not  as  menacing  as  in 
a  non-varicosed  vein,  thanks  to  the  frequency  of  reversal  of  the  circulation, 

Ukeraiian^  the  type  of  which  has  been  described  on  page  77,  is  the  most 


frequent  tomplicatiun.  It  may  follow  the  rupture  of  a  supertidal  varix  or  a 
perivenous  abscess,  or  start  m  a  scratch,  area  of  eczema,  or  minule  spotof 
ne\  rosis.  The  last  is  due  to  capillary  thrombosis  consequent  upon  the  blood 
pressure  in  the  veins  equalizing  that  in  the  arteries. 

Ecuma  and  kindred  dermatoses,  lymphangUis^  and  inflammatory  changes 
in  the  other  tissues  of  the  leg  have  been  mentioned  in  the  paragraph  on 
pathology. 

The  treatment  may  be  palliative  or  radical.  Palliative  treatment  con- 
sists in  removal  of  circular  garters  and  all  forms  of  dress  which  constrict  the 
abdomen,  gentle  massage  if  the  skin  is  healthy,  attention  to  constipation  and 
any  existing  cardiac  or  pulmonary  atfection,  and  the  application  of  an  elastic 
stocking  or  bandage.  The  bandage  should  be  taken  off  at  bedtime  and  the 
skin  rubbed  with  alcohol;  after  the  morning  bath  the  limb  should  be  pow- 
dered with  stearate  of  zinc  and  the  bandage  reapplied.  The  radical  treat- 
mentj  or  operation,  is  followed  by  the  best  results  in  a  unilateral  circumscribed 
varicosity.  In  addition  to  these  cases,  operation  is  indicated  when  there 
are  thin-walled  diverticula  which  threaten  to  burst;  when  elastic  compres- 
sion is  not  tolerated;  when  ulcers  or  eczema  refuse  to  heal;  when  there  is 
great  pain;  when  thrombosis  occurs;  when  portions  of  the  varix  are  situated 
over  the  crest  of  the  tibia,  where  as  the  result  of  injury  they  may  rupture  or 
become  inflamed;  and  when  the  valves  are  incompetent  as  shown  by  the  tests 
already  described.  Excluding  the  general  condition  of  the  patient,  operation 
is  contraindicated  when  the  varicosity  is  compensatory  to  thrombosis  of  the 
deep  veins,  as  this  would  lead  to  permanent  edema.  In  many  of  these  cases 
elastic  compression  also  increases  the  circulatory  difhculties.  Excisimt  is  the 
best  operation  when  practicable.  In  some  cases  this  necessitates  an  incision 
extending  from  the  saphenous  opening  to  the  ankle ^  or  better  a  succession  of 
incisions,  the  vein  being  readily  enucleated  beneath  the  skin  l>ing  between  ibe 
cuts.  Phelps  uses  multiple  ligatures  (thirty  or  forty).  Trendelenburg  breaks 
the  long  column  of  blood  which  the  veins  of  the  leg  must  support  by  excising 
about  four  inches  of  the  internal  saphenous  vein  at  the  juncture  of  the  mid<lle 
and  lower  thirds  of  the  thigh.  The  latest  statistics  for  this  operation  (Goer- 
lich)  show  that  79  per  cent,  were  symptomatically  cured  or  vastly  improved, 
although  the  varicosities  recurred  in  alx)ut  half  the  cases.  Sehede  encircles 
the  leg  with  an  incision  at  the  junction  of  the  upper  and  middle  thirds,  ties  all 
visible  veins,  and  sutures  the  wound. 

Venesection  (phlebotomy),  or  the  opening  of  a  vein  to  abstract  blood, 
has  two  principal  indications,  (1)  to  relieve  overdistention  of  the  right 
heart  from  any  cause,  and  (2)  to  diminish  the  amount  of  toxins  in  the  hiody 
in  conditions  like  uremia.  In  the  tatter  instance  bleeding  is  generally  fol- 
lowed by  the  intravenous  injection  of  salt  solution.  The  operation  is  usually 
performed  at  the  bend  of  the  elbow  upon  the  median  basilic  vein,  which  is 
larger  and  more  distinct  than  the  median  cephalic,  but  has  the  disadvantage 
of  l>'ing  directly  over  the  brachial  artery,  which  may  be  wounded  if  the  knife 
is  thrust  too  deeply.  A  bandage  is  ried  around  the  arm  above  the  elbow, 
just  tight  enough  to  arrest  the  venous  return  without  interfering  with  the 
arterial  supply.  The  patient  grasps  a  bandage  or  makes  a  hard  tist  so  as  to 
press  the  blood  from  the  muscles  into  the  superficial  veins.  The  vein  is 
steadied  with  the  left  hand,  and  opened  with  the  right  hand  by  an  oblique 
incision.  The  blood  is  collected  in  a  graduated  receptacle  until  a  sufficient 
quantity  has  been  withdrawn,  when  a  finger  is  placed  over  the  bleeding, yomt, 


I 


VASCl 


the  liamliige  al)ove  the  elhow  rt'movc^l,  and  a  sterile  gau^c  pail  handagerl 
uver  I  he  wound. 

Transfusion  of  blood  may  l>c  direct,  or  immediaie,  m  which  the  bknid  is 
tx>nveyed  directly  from  ihe  vessels  uf  one  individual  inlo  ihose  of  another,  or 
indirect^  or  mediatcy  in  which  the  Ijlood  of  one  individual  is  first  whipped  to 
remove  the  librtn  and  liltered  before  it  is  injected  into  the  vessels  of  the  set  on  d 
individual  Both  of  these  methods  were  at  one  time  extensively  practised, 
but  owing  to  the  disasters  which  followed,  probably  as  die  result  of  embolism 
or  hemolysis,  and  owing  to  the  fact  that  in  cases  in  which  intravascular  injec- 
tions  are  indicated  all  that  is  needed  is  a  duid  for  the  heart  and  arteries  to  w^ork 
upon,  transfusion  has  given  place  to  infusion  of  normal  salt  solution.  Crile, 
however^  has  recently  revived  direct  transfusion  by  anastomosing  the  radial 
arter)^  of  one  individual  with  any  convenient  super ticial  vein  of  another.  Under 
local  anesthesia  both  arter)'  and  vein  are  exposed,  tied  belgw^  and  secured 
with  an  arterial  clamp  above,  Each  is  then  cut  above  the  ligature  and  the 
adventitia  of  the  central  end  pulled  (iown  and  snipped  otf  with  scissors. 
The  vessels  may  then  be  united  by  the  Carrel  method.  Crtle  uses  a  little 
tube  which  has  two  grooves  ;n  its  outer  surface.  The  central  end  of  the 
vein  is  pulled  through  the  tube,  turned  back  over  it  like  a  cuff,  and  held  in 
place  by  a  ligature  which  is  tied  in  the  second  groove.  The  artery  is  next 
drawn  over  the  everted  vein  and  secured  by  a  ligature  in  the  first  groove. 
The  clamps  are  then  removed  and  the  anastomosis  covered  with  a  hot  moist 
sponge,  to  relax  the  artery.  The  lime  the  blood  Is  allowed  to  tlow  depends 
upon  the  effects  noted,  but  is  usually  from  20  to  40  minutes.  In  acute  hemor- 
rhage and  shock  and  in  pathological  hemorrhage  direct  transfusion  has 
proved  of  value,  but  in  Ijlood  diseases  and  toxemias  it  seems  of  little  use. 
As  there  is  some  danger  of  hemijlysis  the  effect  of  the  llono^^s  blood  upon 
that  of  the  recipient  should  always  be  studied  before  transfusion.  If,  owing 
to  lack  of  facilities  or  time  (the  test  occupies  24  hours) » this  cannot  be  done, 
intravenous  infusion  of  salt  solution  should  be  employed.  Transfusion  may, 
of  course,  be  performed  later  if  such  seems  to  be  indicated.  In  order  to  pre- 
vent acute  dilatation  of  the  heart,  which  sometimes  follows  the  rapid  intro- 
duction of  a  large  quantity  of  blood  into  the  circulation,  Dorrance  and 
Ginsburg  suggest  veiii-to-vein  instead  of  artery-to-vein  transfusion.  As 
the  veins  are  larger  than  the  arteries,  venovenous  is  much  easier  to  perform 
than  arteriovenous  anastomosis,  but,  owing  to  the  composition  of  venous 
blood,  the  chances  of  thrombosis  are  probably  greater.  Aside  from  the 
possifnlity  of  conveying  tlisease  from  one  individual  to  another,  which  can 
be  avoided,  at  least  in  one  direction,  by  selecting  a  healthy  donor,  and  in  ad- 
dition to  clot  embolism  and  hemolysis,  the  accidents  which  may  attend  or 
follow  transfusion  are  those  of  infusion,  mentioned  below\ 

Intravenous  infusion  of  salt  solution  (p.  .^7)  finds  its  chief  indication 
after  severe  hemorrhages,  but  is  used  also  in  shock,  in  to.xemic  conditions, 
after  venesection,  in  order  to  "wash  the  Idood,"  and  as  a  diuretic  w^hen  little 
or  no  urine  is  being  secreted.  The  infusion  apparatus  consists  of  a  gradu- 
ated reservoir  connected  with  a  blunt  beveled  cannula  by  means  of  a  ruliber 
tube.  In  an  emergency  a  fountain  syringe  or  an  ordinar)'  funnel  and  an 
aspirating  needle  may  be  employed.  The  entire  apparatus  should  be 
sterilized  by  boiling,  or  if  sterilized  by  chemical  means,  all  traces  of  the  anti- 
septic should  be  removed  by  tlushing  with  normal  salt  solution  before  use. 
The  fluid  may  be  injected  into  any  vein  of  sufficient  calibre,  but  the  median 


^ 


ARTEIUTIS. 

i^liW  or  iht*  mtemal  saphenous  is  usually  the  rrnjsl  convcnieiiL  A  bajidaj^e 
lied  aroiuid  Ihe  iimJj  in  ortler  to  make  I  he  veins  prominent,  and  the  vein 
exposed  by  an  incision  and  two  ligatures  of  catgut  passed  beneath  iL  One 
ligature  is  pulled  into  the  lower  angle  of  the  wound  and  tied.  The  vein  is 
lien  opened  by  a  transverse  incision,  and  the  cannula  inserted  after  some  of 
lie  solution  has  been  allowed  to  [low  through  it  in  order  to  exclude  air.  The 
upper  ligature  should  be  tied  about  the  cannula  by  the  first  half  of  a  surgeon *s 
kjiot,  so  that  at  the  completion  of  the  operation  it  may  be  tightened  and 
secured  by  a  second  turn  after  the  cannula  has  been  withdrawn.  The 
temperature  of  the  tluid  should  l>e  110°  F.  in  the  reservoir,  as  it  Itjses  some 
heat  before  entering  the  vein.  The  amount  injected  will  usually  vary  be- 
tween one  and  two  quarts,  according  to  the  results  noted.  If  the  cannula  is  in 
the  vein,  and  the  bandage  around  the  limb  has  been  removed^  the  lluid 
flows  readily  with  the  reservoir  elevated  several  feet  and  no  pumping  ap- 
paratus is  necessary.  At  the  completion  of  the  operation,  the  wound 
is  sutured  and  a  sterile  dressing  applied.  Kucttner  suggests  introducing 
oxygen  with  the  salt  solution.  "A  reservoir  is  filled  with  1000  c.c.  of  salt 
solution,  and  oxygen  allowed  to  flow  in  from  a  tank  until  100  c.c.  of  the  solu- 
tion is  displaced.  The  reservoir  is  then  closed  and  shaken  until  the  oxygen 
is  absorbed  by  the  solution'*  (Lexer-Bevan).  The  dangers  of  intravenous 
infusion  (which  are  common  also  to  transfusion),  excluding  air  embolism, 
which  can  be  prevented  by  proper  icchnic,  are  acute  dilatation  of  the  heart 
and  edema  of  the  lungs  and  brain  if  too  much  solution  is  introduced,  and 
recurrence  of  bleeding  if  all  wounded  vessels  have  not  been  secured.  The 
chill  which  sometimes  follows  intravenous  infusion  is  apparently  harmless. 
Hypodermoclysis,  or  the  subcutaneous  injection  of  salt  solution,  and 
enteroclysis,  in  which  the  liuid  is  introduced  into  the  rectum,  may  l>e  used 
to  substitute  or  supplement  infusion  when  time  is  not  an  element  of  great 
importance.  Hypodermoclysis  is  performed  with  the  same  precautions  as 
intravenous  infusion,  by  introducing  an  aspirator  needle  into  the  loose  connec- 
tive tissue  of  the  buttock,  back,  abdomen,  or  axilla.  The  needle  is  connected 
with  a  reservoir  by  means  of  a  rubber  tube,  and  the  reservoir  held  several 
feet  above  the  p4>int  of  insertion  of  the  needle,  so  that  the  tluid  is  slowly 
forced  into  the  tissues,  forming  a  swelling  which  slowly  subsides  as  the  tluid 

■is  absorbed.  If  more  than  a  pint  is  injected,  the  needle  should  be  introduced 
in  another  situation.  Occasionally  suppuration  or  sloughing  follows, 
particularly  in  sepii(  tases. 

Contusions  of  veins  may  result  in  fissunng  of  the  intima  and  thromljo- 
phlebitis,  particularly  if  the  vein  is  diseased,  as  in  varix.  The  symptoms  and 
treatment  of  thrombosis  from  injury  are  that  of  phlebitis.  Sloughing  of  the 
%ein  and  secondar}^  hemorrhage  are  most  frequent  after  infected  gunshot 
wounds- 
m  Wounds  of  veins  are  classified  like  wounds  of  arteries  (p.  185).    The 

isymptoms  and  treatment  are  given  in  the  section  on  hemorrhage  (p.  195). 
The  dangers  are  severe  or  fatal  primar}^  hemorrhage,  air  embolism,  clot 
embolism  (which  if  septic  will  lead  to  pyemia),  phlebitis,  edema,  gangrene, 
and  secondary  hemorrhage. 

THE  ARTERIES. 

Arteritis,  or  inflammation  of  an  artery,  may  be  acute  oichronk.     Ana- 
tomically, it  may  be  divided  into  periarteritis,  mesarteritis,  and  endarteritis. 


i 

1 


J 


i84 


VASCULAR  SYSTEM. 


but  as  a!l  three  coals  are  usually  more  or  less  affected  at  the  same  time,  this 
classification  is  of  little  %'aliie. 

Acute  arteritis  may  he  suppurative  (necrotic)  or  produclivc  (phislic) 
Acute  suppurative  arteritis  results  from  suppurative  lesions  in  the  neigh- 
boring tissues,  or  from  an  infected  embolus.  In  the  smaller  vessels  the  process 
usually  leads  to  thrombosis,  in  the  larger  arteries  the  walls  may  give  way  and 
serious  hemorrhage  result.  Secondary  hemorrhage  is  practically  always  due 
to  this  cause.  An  acute  infectious  endarteritis  resembling  malignant  en- 
docarditis, with  which  it  is  usually  associatedi  has  been  described.  Acute  pro- 
ductive, or  plastic  arteritiSj  occurs  as  the  result  of  injury  or  the  lodgment 
of  an  embolus,  in  the  alisence  of  infection.  It  is  nature's  method  of  closing 
vessels  after  ligation,  torsion,  and  wounds*  The  vasa  vasorum  dilate,  exuda- 
tion occurs,  the  intima  proliferates,  and  the  clot  becomes  organized,  the 
new^  connective  tissue  obliterating  the  lumen  of  the  vessel  (see  arrest  of 
hemorrhage).  Acute  arteritis,  manifested  by  pain,  tenderness,  and  occa- 
sionally redness  and  swelling  along  the  course  of  an  arter>',  particularly  of 
the  lower  limb,  occasionally  occurs  during  the  course  of,  or  just  subsequent  to, 
the  infectious  fevers.  In  these  cases  thrombosis  and  gangrene  may  develop. 
The  treatment  of  acute  arteritis  occurring  in  the  course  of  infectious  fevers 
is  that  of  phlebids.  The  treatment  of  threatened  gangrene  from  arterio- 
thrombosis  has  already  been  discussed.  Acute  suppurative  arteritis  is 
seldom  suspected  until  the  occurrence  of  secondary  hemorrhage. 

Chronic  arteritis  {arterimclerosis,  dtrmic  endarieritis,  al^teroma)  is  a 
chronic  inflammatory  and  degenerative  process  of  the  arterial  walls.  The 
disease  may  involve  the  capillaries  as  well  as  the  arteries  {ar  Urioc  a  pillar y 
abrosis)  and  may  invade  even  the  veins  (angiosclerosis). 

The  causes  of  arteriosclerosis  are  old  age,  and  chronic  intoxications, 
among  which  may  be  mentioned  syphilisj  gout,  alcoholism,  lead  poisoning, 
nephritis,  rheumatism,  and  diabetes.  The  increased  blood  pressure  incident 
to  habitual  overeating  and  muscular  overwork  is  said  to  be  of  etiologic 
importance  and  the  disease  is  somedmes  found  after  acute  infections,  such 
as  scarlet  fever,  t>T>hoid  fever,  and  influenza. 

Arteriosclerosis  may  be  i in um scribed  or  diffuse.  In  the  former,  commonly 
seen  in  the  large  vessels,  particularly  the  aorta,  the  deeper  layers  of  ihe  intima 
proliferate  and  give  rise  to  more  or  less  nodular  patches,  which  may  become 
fibrous,  calcified  (aihrromalous  plate) ^  or  fatty;  in  the  last  event  a  cheesy  mass 
may  be  formed  (a/Afroma//>w.^aif5f<'i5),  which  on  discharging  leaves  a  necrotic 
patch  {aihtromaiotis  ulcer).  The  middle  coat  of  the  artery  is  invaded  by  the 
disease  and  the  outer  coat  is  thickened.  Diffuse  arteriosclerosis  more  com- 
monly attacks  the  small  vessels.  The  entire  arterial  wall  becomes  thickened, 
and  the  internal  coat  undergoes  fatty  degeneration  {atheroma)  and  may  sub- 
sequently become  calcified, 

Arieriosclerosis  is  recognized  by  increased  arterial  tension,  hypertrophy 
of  the  heart,  accentuation  of  the  aortic  second  s*>und,  and  by  feeling 
the  superficial  arteries,  which  are  found  to  be  thickened,  rigid,  or  even 
calcified. 

Although  the  treatment  belongs  to  the  physician,  the  surgical  relations 
of  arteriosclerosis  should  not  be  overlooked.  Chronic  arterids  results  ( ij 
in  dilatation  or  rupture  when  the  degenerative  changes  in  the  musculo- 
elastic  median  coat  predominate;  {2}  in  narrowing  or  obliteration  when 
the  proliferation  of  the  subendothelial  layer  is  in  excess  {endarteritis obliterans); 


or  (3)  simply  in  kiss  of  elasticity*  without  alteration  of  the  lumen,  when  these 
cb&nges  are  equalized. 

1.  Aneurysm  is  most  frequently  due  to  syphilitic  arteritis.  Syphilitic 
arterUis  attacks  a  series  of  vessels,  a  single  vessel,  or  a  segment  of  a  vessel, 
and  is  sometimes  bilateral;  the  middle  coat  is  most  affected,  being  invaded 
with  round  cells,  and  its  fibres  degenerated,  atrophied,  or  fragmented;  rupture 
may  follow,  as  in  apoplexy,  or,  if  only  the  middle  coat  gives  way,  a  scar  re- 
sults, which  may  subsequently  yield  and  form  an  aneurysm  (see  p.  188);  the 
latter  applies  particularly  to  large  arteries;  the  tendency  in  small  vessels 
is  towards  obliteration.  The  possibility  of  arterial  rupture  should  be  kept  in 
mind  when  attempts  are  made  to  reduce  an  old  dislocation  or  to  straighten 
a  contracted  joint,  in  an  individual  with  atheroma. 

2.  Narrowing  of  the  arteries  may  be  responsible  for  many  nutritional 
disturbances,  among  which  may  be  mentioned,  as  of  surgical  interest, 
neuralgia,  pancreatitis,  gastric  and  intestinal  ulceration,  arteriosclerotic 
colic,  intermittent  claudication,  and  gangrene.  Arteriosclerotic  colic  may 
simulate  gallstones,  appendidtis,  and  other  abdominal  affections.  In  ad- 
vanced arteriosclerosis  wounds  are  often  slow  in  healing,  and  in  these  cases 
only  urgent  operadons  should  be  performed.  Even  a  trivial  operation  on  the 
toe  may  inaugurate  gangrene,  and  after  enterorrhaphy  necrosis  of  the  mar- 
gins of  the  incision  and  fecal  fistula  are  of  frequent  occurrence.  Primary 
hemorrhage  from  a  narrowed  artery  is  comparatively  slight,  but,  owing  to 
the  danger  of  cutting  through  of  the  ligature,  secondary  hemorrhage  is 
relatively  frequent.  Diseased  arteries  are  predisposed  to  thrombosis  from 
injury%  hence  the  danger  of  the  Esmarch  band,  of  Bier's  treatment^  and  of 
tight  bandages  in  those  with  arteriosclerosis. 

3»  Loss  of  elasticity  in  collateral  arteries  accounts  for  many  of  the  bad 
results  after  ligation,  thrombosis,  and  the  i  mpatlion  of  an  embolus.     Diseased 

t arteries  may  supply  a  part  with  adequate  nourishment  w  hen  it  is  at  rest  but 
iail  to  dilate  in  response  to  increased  at  tivity,  thus  lack  of  elasticity  in  the 
cerebral  vessels  may  cause  transient  paralysis,  in  the  cardiac  vessels  angina 
pectoris,  in  the  abdominal  vessels  arteriosclerotic  colic,  and  in  the  arteries  of 
the  leg  intermittent  claudication.  The  last  manifests  itself  as  attacks  of 
pain  and  weakness,  especially  in  the  calf,  and  is  a  prodromal  symptom  of 
gangrene. 

Injuries  of  arteries  may  be  contusions  or  wounds* 
Contusion  of  an  artery  varies  in  its  results  according  to  the  violence  of 
the  injury  and  the  state  of  the  arterial  walls.  Normal  arteries,  owing  to 
their  elasticity,  are  not  often  seriously  affected  by  a  contusion  unless  it  be  of 
the  severest  grade.  In  atheromatous  arteries  a  slight  contusion  may  be  fol- 
lowed by  rupture  of  the  inner  coats  and  thrombosis,  the  detachment  of  an 
atheromatous  plate,  sloughing  and  hemorrhage,  or  aneurysm;  if  the  artery 
be  the  main  vessel  of  an  extremity  gangrene  may  ensue.  The  treatment  of 
a  contused  artery  consists  in  absolute  rest,  and  preparations  for  the  im- 
mediate control  of  hemorrhage  should  it  occur.  In  the  event  of  thrombosis 
prophylactic  measures  against  gangrene  should  be  taken  {p.  81).  The 
treatment  of  thrombotic  gangrene  is  given  on  p.  83. 

Wounds  of  arteries  may  be  incised,  punctured,  gunshot,  or  lacerated, 
Ruptures  of  arteries  also  come  under  this  heading.  An  incised  wound  is 
fciilowed  by  profuse  hemorrhage,  which  is  more  severe  in  transverse  than  in 
loogitudinal  and  oblique  wounds.     Panctured  waunds  produced  U^  Ne.t^ 


< 


c 


Ijnc  11151  mmcjils,  such  as  an  inlfstiiuil  m*cdlt%  t  ause  1ml  link-  hemorrha^', 
which  is  easily  and  pcrmanvnily  cuntruHerl  hy  pressure  applied  for  a 
short  time.  If  ihe  opening  is  of  larger  size  ihe  f)lecding  is  copious  an*!  may 
exsangiiinale  the  patienl,  or  if  the  wound  in  the  skin  is  dosed  by  suture,  clot, 
or  dressing,  a  diffuse  traumatic  aneurysm  may  develop.  Gunshot  injuries 
are  usually  contusions  (see  above)  or  laceralioiis.  The  modern  bullet  may, 
however,  produce  a  clean-cut  wound  and  an  aiarming  or  fatal  hemorrhage. 
A  lacerated  wound  involving  the  entire  circumference  of  an  artery  is  usually 
followed  by  slight  hemorrhage,  owing  to  the  curling  up  of  the  interna!  coat, 
the  contraction  of  the  middle  coat,  and  the  prolapse  of  the  stretched  exiemal 
coat  over  the  end  of  the  artery.  Secondary  hemorrhage,  however,  i^  likely  to 
occur  unless  the  vessel  is  permanently  secured  by  a  ligature.  Partial  lacera- 
tions do  not  permit  retraction  and  contraction,  hence  spontaneous  hemos- 
tasis  (p.  196}  is  uncommon.  Hupture  may  follow  severe  injuries  or  strains, 
particularly  in  the  presence  of  atheroma,  and  the  surgeon  should  always  have 
this  injury  in  mind  when  reducing  an  old  dislocation,  when  forcibly  straighten- 
ing a  contracted  joint,  or  when  giving  ether  to  an  aged  individual.  Partial 
rnpiitrt'j  i,e,,  of  the  middle  and  inner  coats,  may  be  regarded  as  a  contusion 
(p.  185).  Compieie  rupture  results  in  a  lacerated  wound.  Unless  the  blood 
escapes  through  an  external  wound  or  into  one  of  the  large  cavities  of  the 
body,  a  difjuse  traumatu  aneurysm  {falxe  Irau malic  aut'urysm^  arterial  hema- 
toma) develops,  the  symptoms  of  which  differ  somewhat  from  those  of  a  true 
aneurysm,  owing  to  the  fact  that  the  effused  blood  forms  a  soft  clot  w  hich  is 
constantly  enlarged  by  the  leaking  artery.  There  is  sudden  and  acute  pain, 
followed  by  rapid  swelling  and,  after  a  time,  i>y  ecchymosis  of  the  skin.  The 
sixc  of  the  swelling  is  enormous  when,  as  in  the  axilla,  the  tissues  are  lax,  and 
small  when  growth  is  restrained  by  dense  fascia,  e.g.,  in  the  palm  and  at  the 
bend  of  the  elbow.  It  is  tense,  seldom  fluctuates,  cannot  be  reduced  by 
pressure,  and  owing  to  the  absence  of  a  distinct  wall  is  mi»re  irregular  and  not 
as  sharply  defined  as  a  true  aneurysm.  Pulsation  is  usually  preset ,  thrill 
and  bruit  often  absent^  but  these  signs  depend  upon  the  size  of  the  opening 
in  the  artery.  Even  when  the  wotmd  does  not  involve  the  entire  circum- 
ference of  the  artery,  the  pulse  below  may  be  absent  as  the  result  of  pressure 
from  the  effused  blood,  and  this  leads  to  coldness,  numbness,  pallor,  and 
partial  paralysis  of  the  limb.  The  constitutional  symptoms,  which  are  those 
of  hemorrhage,  vary  with  the  amount  of  blood  extravasated.  The  swelling 
may  rupture,  resulting  in  immediate  death:  suppurate  with  the  same  result; 
persist  as  an  aneurysm;  cause  gangrene  by  pressure  on  the  vessels  of  the  limb; 
or  the  blood  may  coagulate,  the  opening  in  the  vessel  heal,  and  the  dot  be 
absorbed  or  organized. 

The  treatment  of  wounds  of  arteries  is  that  of  hemorrhage  (p,  197); 
ruptures  are  dealt  with  in  the  same  way  as  open  wounds,  after  making  an 
incision  to  expose  the  source  of  bleeding  (p,  203), 

Arterial  varix  corresponds  to  a  varicose  vein,  a  single  arter>^  is  dilated, 
elongated,  thickened,  and  tortuous.  When  a  number  of  adjacent  arteries 
are  similarly  affected,  the  condition  is  called  cirsoid  aneurj^sm.  Cirsoid 
aneurysm  {pkxiform  angioma,  ra^-emose  aneurysm,  anrurysm  by  anastomosis) 
is  most  frequently  found  in  the  scalp,  and  less  commonly  in  the  extremities, 
labia  pudendi,  and  spermatic  cord.  Some  cases  develop  from  a  preexisting 
angioma,  some  after  trauma,  and  some  spontaneously.  It  can  be  mistaken 
for  no  other  condition,  as  the  pulsating  varicose  arteries  are  readily  seen  ant! 


felL  Thrill  and  hriiii  arc  tiftcn  prcscnl,  liiul  pressure  oji  the  main  feetlin^ 
art<:n'  materially  reduces  the  size  nf  the  mass  aiid  the  force  of  the  pulsation* 
The  skin  is  usually  thinned  and  s+>melimes  ulcerates,  giving  rise  tu  alarming 
hcinorrhage.  Excision  is  the  best  irmtmenlf  but  is  often  impracticable; 
Among  other  methods  which  have  been  tried  are  ligation  or  compression  of 
the  main  artery  or  arteries  of  supply,  galvano-cauterization,  electrolysis,  the 
X-rays,  and  the  injection  of  coagulating  tluids.  When  affecting  the  hand 
amputation  may  be  required. 

Aneurysm  is  a  hollow  tumor  containing  blood  and  communicating  with 
ihc  lumen  of  an  artery.  Excluding  the  cirsoid  variety,  which  has  just  been 
dt'-4  nb«*d  and  uhirh  is  really  a  form  of  arterial  varix,  aneurysms  are  divided 


-Thoracic  iincurysm  showing  laminated  cluU     dN 


Uania  Hospital.) 


pri  in  airily  into  the  simple,  or  arierial^  VLixd  the  arierlovenans  (p.  194).  When 
rfterring  to  the  former,  however,  it  is  customary  to  employ  the  term  aneurysm 
miihout  a  qualifying  adjective. 

The  parts  of  an  aneurysm  arc,  (i)  the  sac  wall,  (2)  the  contents,  and  {3) 
the  mouth.  I.  The  sac  wall  is  composed  of  one  or  more  of  the  arterial  coats 
<7ri*r  anmrysm)  or  of  condensed  perivascular  tissues  {fahc  anenrysin).  As  a 
matter  of  fact,  the  walls  of  any  aneurysm  of  large  size  consist,  not  of  the  walls 
uf  the  vessel,  but  of  librous  tissue,  and  even  a  false  aneurysm  which  has 
existed  for  any  length  of  time  may  be  h'ned  by  a  structure  identical  with  the 
intima,  2.  The  contents  vary  according  to  the  size,  character,  and  duration 
of  the  aneurysm.  At  first  the  contents  is  tluid  blood  only.  As  the  aneurysm 
enlarges,  however,  and  becomes  more  and  more  sacculated,  parUcularly 
if  the  mouth  remains  small  or  is  so  located  as  to  protect  the  walls  from  the  full 
force  of  the  circulation ^  the  blood  is  throw  n  into  eddies,  and  this  leads  to  the 
reparation  of  fibrin^  which  is  deposited  on  the  interior  of  the  sac  in  concentric 
layers  {Vlg^  ii3)»  the  outer  and  older  layers  being  dr)-  and  light  in  color,  the 
inner  and  younger  soft  and  red.     Spontaneous  cure  may  be  eftecled  \\\  vVi\^ 


VASCULAR  SYSTEM. 

way.  3.  The  mouth  of  Ihe  sac  is  the  portal  through  which  the  bkiod  enters 
the  ancurji^m;  upon  its  size  and  situation  depends  to  a  large  extent  the 
rapidity  with  whieh  the  aneurysm  enlarges. 

According  to  whether  the  whole  or  only  a  portion  of  the  circumference  of 
an  artery  is  in%'olved  an  aneurysm  is  said  to  be  fusiform  (tubulated)  or  saccu- 
lated. 

Fusiform,  or  hibulaied  aneurysm,  is  a  dilatation  and  elongation  of  a  section 
of  an  artery.  It  is  most  frequent  in  the  cranium,  the  thorax,  and  the  abdo- 
men, and  is  always  spontaneous  in  origin.  Although  the  walls  arc  seldom 
coated  with  layers  of  fibrin  rupture  is  unusual,  death  generally  being  due  to 
pressure  upon  the  surrounding  organs. 

Saauiated  anmrysm  springs  from  the  side  of  an  artery,  rarely  from  the 
side  of  a  fusiform  aneurysm.  There  are  two  forms,  the  circumscribe^l,  in 
which  the  sac  wall  is  distinct  and  complete,  and  the  diffuse^  in  which  the 
blood  has  extra vasated  into  the  surrounding  tissues.  The  latter  is  said  to 
be  primitive  when  due  to  rupture  of  an  artery  (p.  i86)»  and  consecutive 
when  due  to  rupture  of  ao  aneur}'sm  (p.  189). 

According  to  etiology  aneurysms  are  divided  into  the  traumatic  and  the 
spontaneous. 

Traumatic  aneurysm  may  be  true  or  false,  but  is  always  sacculated.  True 
iraumatk  aneurysm  may  result  from  an  arterial  contusion  which  causes  the 
inner  coats  to  rupture,  or  from  a  wound  of  the  outer  coats,  leading  to  a  hernia 
of  the  intima  (hernial  aneurysm).  False  traumatic  aneurysm  follows  a  pene- 
trating wound  or  a  complete  rupture  of  an  artery  (p.  186). 

SpantaneouSj   or  idiopaihic  aneurysms^  may  be  congenital  or  acqtiired. 

Congenital  aneurysms  are  rare,  and  due  to  defective  development  of  the 
elastic  elements  of  the  arteries,  hence  often  mukifjle. 

Acquired  spotUanemis  aneurysms ^  although  occasionally  due  to  infective 
softening  of  the  vessel  walls  from  the  impaction  of  an  embolus  (embolic 
aneurysm)^  to  ulceration  of  the  outer  coats  {aneurysm  by  erosion),  or  of  all  the 
coats  (e.g.,  when  an  artery  perforates  into  an  abscess),  are  almost  always  the 
result  of  chronic  arteritis  combined  with  an  increase  in  the  blood  pressure. 
As  has  already  been  pointed  out  on  page  185,  chronic  arteritis,  particularly 
the  syphilitic  variety,  causes  marked  degenerative  changes  in  the  musculo- 
elastic  tunica  media,  and  this,  especially  in  the  early  stages,  before  compensa- 
tory thickening  of  the  intima  occurs,  leads  to  aneurysmal  dilatation.  In 
dissecting  aneurysm^  which  is  a  rare  form  confined  almost  exclusively  to  the 
aorta,  the  blood  makes  its  way  through  an  atheromatous  ulcer  and  dissects 
the  outer  from  the  inner  half  of  the  middle  coat,  forming  a  sort  of  sac,  which 
may  again  open  into  the  arter>*  through  another  atheromatous  ulcer,  or  rup- 
ture into  the  perivascular  tissues.  Increase  in  the  blood  pressure,  the  result 
of  hypertrophy  of  the  heart,  straijis,  laborious  occupations,  and  xiolent 
exercise,  is  an  important  factor  when  combined  with  disease  of  the  arteries, 
hence  the  predisposition  of  the  male  sex  (7  to  i),  and  of  the  fourth  and  fifth 
decades,  during  which  arteriosclerosis  frequently  begins,  Imt  during  which 
the  bodily  condition  is  such  as  to  lead  to  overexertion. 

The  Sj^ptoms  of  aneurysm  are,  (i)  those  peculiar  to  the  aneurysm  itself 
and  (2)  those  due  to  pressure,  i.  The  symptoms  peculiar  to  the  aneurysm 
itself  are,  the  presence  of  a  swelling  in  the  line  of  an  arter}^;  movability  of 
the  tumor,  in  the  absence  of  adhesions,  transversely  to  but  not  in  the  axis 
of  the  artery;  reducibility   on  direct  pressure  and'  fiuciuation,  but  only 


ANEURYSM. 


X89 


in  the  early  stages  when  the  walls  are  thin  and  thecontents  h  iluid;  pulsation 
svTichronoos  with  each  cardiac  systole  and  expansile  in  character,  i,e.,  in 
at!  directions,  so  that  the  palpating  lingers  are  not  only  lifted  but  sepa- 
rated ;  cessation  of  pulsation,  with  shrinkage  and  softening  of  the  tumor,  when 
proximal  pressure  is  made  on  the  artery,  distal  pressure  acting  in  a  reverse 
manner;  the  presence  over  the  sac  and  along  the  artery  of  a  systolic  bruit, 
which  is  usually  loud  and  harsh;  occasionally  a  thrill  corresponding  with 
the  bruit;  an<l  retardation  of  the  pulse  below,  due,  not  to  pressure,  but  to 
the  additional  time  consumed  by  the  blood  current  in  passing  through 
the  aneurysm,  hence  almost  a  pathognomonic  sign*  2.  The  pressure  symp- 
toms are  similar  to  those  of  other  

tumors.  Pressure  on  the  arUry 
causes  diminution  in  t  he  size  of  the 
pulse  distal  to  the  tumor,  hente 
enlargement  of  the  collateral 
arteries;  on  thcrnnj  edema  and 
distention  of  their  superficial 
branches;  on  the  nerves  pain  and 
possibly  paralysis  and  trophic 
disorders;  on  the  muscles  dis- 
placement and  atrophy;  on  the 
bon^s  erosion,  severe,  constant, 
boring  pains,  and  occasionally 
spontaneous  fracture;  on  the 
trachea  dyspnea;  on  the  eso- 
ph4igus  dysphagia;  on  the  recur- 
rent lar)Tigeal  nerv^e  change  in 
the  voice  and  brassy  cough;  on 
the  cervical  sympathetic  nerve 
(p.  2J4)  dilatation  of  the  pupil 
and  widening  of  the  palpebral 
fissure  and  later  contraction  of 
the  pupil  and  ptosis  (Fig.  114); 
on  the  thoracic  duct  inanition;  on  the  phrenic  nerve  hiccough. 

The  duration  of  aneurysm  is  usually  a  matter  of  some  years,  spontane- 
ous recovery  or  death  l>eing  the  natural  termination.  Spcmtanemts  nrovery 
is  rare.  It  may  be  due  to  obliteration  of  the  sac  with  laminated  fibrin;  to 
suppression  of  the  circulation  within  the  sac,  the  result  of  the  impaction  of 
an  embolus  aljove  or  lielow'  tht-  mouth,  or  the  pressure  of  the  aneurysm  itself 
on  the  artery;  or  to  inllammation  of  the  sac.  The  aneurysm  becomes  solid, 
and  is  ultimately  represented  by  a  mass  of  tibrous  tissue.  Dcaih  h  the 
result  of  rupture  of  the  sac,  pressure  upon  important  structures,  cerebral 
cmlx>lism,  or  sepsis  from  suppuration  of  the  sac  or  gangrene  of  the  parts 
nourished  by  the  artery. 

Rupture  of  an  aneurysm  is  the  result  of  stretching  and  thinning  of  the 
wall  from  inlrasaccuJar  tension,  or  uf  ulceration,  suppuration,  or  gangrene  of 
the  sac*  Rupture  through  the  skin  may  be  immediately  fatal,  or  death  may 
be  deferred  several  days,  the  blood  leaking  from  a  small  opening  {leaking 
anrurysm),  which  h  at  limes  temporarily  plugged  by  a  clot  Rupture  in- 
ternally^ into  one  of  the  cavities  or  hulUiw  organs,  causes  sudtlen  pain,  symp- 
toms of  acute  anemia,  and  death.    If  the  aneurysm  breaks  into  the  esopha^s 


Fic-  114, — Aneurysm  of  the  innominate 
artery  lriMite<t  by  wiring  and  electrolysis, 
(Pi-nnsylv^nia  Hospitab)  Note  piosis  from 
pressure  on  the  cervical  syropathelic  nerve. 


i 


190 


VASCOLAK   SYSTEM. 


or  trachea  blood  will  pour  from  the  mouth.  Ruplore  into  the  subLUtane- 
ous  tissues  is  aiinounceiJ  by  severe  pain,  increase  in  the  size  of  the  swelling, 
indistinctness  of  its  outline,  diminution  or  disappearance  of  pulsation  and 
bruit  owing  to  coagulation  of  the  blood,  and  cessation  of  the  pulse  below 
the  swelling.  Death  from  acute  anemia  follows,  or  if  the  surrounding 
tissues  restrain  the  blood,  a  consecutive  false  aneurysm  develops. 

Inflammation  of  ilte  sar,  when  mild  in  chara*  ler,  thickens  the  walls  and 
encourages  coagulation  of  the  blood.  In  the  severer  form  there  is  redness  of 
the  skin,  pain,  elevation  of  the  local  temperature,  and  edema,  ihe  last  causing 
the  aneurysm  to  become  less  distinct  in  outline.  Suppuration  or  gangrene  of 
the  sac  may  follow. 

Gangrene  of  the  parts  distal  to  the  aneurysm  may  be  caused  by  oblitera- 
tion of  the  artery  from  the  pressure  of  the  aneurysm,  from  the  pressure  of 
extra vasa ted  l*lood  when  rupture  occurs,  from  the  impaction  of  an  emljolus 
derived  from  the  aneurysm,  or  from  thrombosis  the  result  of  inllammation. 

The  diagnosis  of  aneurysm  may  be  difbt  ult  or  even  impossilile,  since 
pulsation  and  bruit  may  be  absent  in  an  ancient  aneurysm,  and  present  in 
other  tumors.  A  cyst,  tumor,  or  chronic  abscess  lying  upon  an  artery  may 
be  lifted  with  each  pulse  beat,  and  cause  a  murmur  by  narrowing  the  artery.  ^ 
but  the  pulsation  is  not  expansile,  and  it^  with  the  murmur,  ceases  if  the  tumor 
is  separated  from  the  vessel.  Compression  of  the  artery  above  or  below  the 
tumor  does  not  have  the  same  effect  as  in  aneur}^sm,  and  after  remo\ing  the 
proximal  compression  the  first  pulsation  is  of  full  strength,  while  in  aneurysm 
it  may  take  several  pulse  waves  to  distend  the  sac  and  make  the  pulsation  as 
strong  as  it  was  before.  Any  tumor  which  presses  on  an  artery  may  make  the 
distal  pulse  smaller,  but  retardation  is  caused  only  by  aneurysm,  a  sign  which 
becomes  more  evident  after  temporarily  com[)ressing  the  arter>'  above  the 
swelling;  in  a  non-aneurysmal  tumor  the  pulse  reappears  at  once,  in  an 
aneurysm  several  beats  may  be  lost.  The  ex  pi  orator}^  needle  may  some- 
times be  employed  to  determine  the  contents  of  the  swelUng.  Pulsating  sar- 
comata and  angiomata  may  not  correspond  to  the  line  of  an  artery  or  affect 
the  pulse  below.  Pressure  on  the  artery  proximal  to  the  growth  may  cause 
it  to  shrink,  but  not  so  markedly  as  in  aneurysm,  and  it  may  be  more  irregular, 
less  distinct  In  outline,  and  more  variable  in  consistency;  bruit  may  be 
present.  Aneurysmal  pain  has  been  mistaken  for  rheumatism,  neuralgia, 
lumbago,  etc.  The  X-ray  is  often  of  value  in  diagnosticating  aneurysms 
in  the  thorax  and  abdomen. 

The  treatment  of  aneurysm  may  be  medical  or  surgical. 

Medical  treatment  aims  to  decrease  the  blood  pressure  and  increase  the 
coagulability  of  the  blood.  It  is  used  as  an  auxiliary  to  surgical  treatment, 
or  when  surgical  Ireatment  cannot  be  applied,  l^n/ndrs  nuihod  consists  in 
absolute  rest  in  bed  for  at  least  three  months,  and  a  daily  diet  of  six  ounces  of 
bread,  a  Htllc  butter,  three  ounces  of  meat,  and  eight  ounces  of  milk.  Among 
the  dn4gs  recommended  are  iodid  of  potassium,  especially  in  syphilitic  cases, 
iron,  acetate  of  lead,  ergotin,  aconite,  veratrum  viride,  and  calcium  chlorid. 
Opium  or  the  l>romids  are  used  for  pain,  purgatives  to  thicken  the  blood  and 
prevent  straining  from  constipation.  Venesection  has  been  employed  when 
the  blood  pressure  is  very  high.  I^ggs  have  been  recommended  to  increase 
the  coagulability  of  the  blood.  Lancereaux  reports  good  results  from  the 
hypodermatic  injection  of  a  i  or  2  per  cent,  solution  of  gelatin  in  normal 
salt  solution;  about  200  ct ,  are  injected  beneath  the  skin  of  the  thigh  ever)' 


ANEURYSM. 


1()I 


ten  days,  until  from  ten  to  thirty  injections  have  been  given.  As  twenty-three 
deaths  from  tetanus  have  followed  this  method  of  treatment  (Dieulafoy), 
the  gelatin  should  be  thoroughly  sterilized,  or,  better,  since  its  coagulalive 
effects  are  not  destroyed  by  digestion,  administered  liy  mouth.  Gelatin  is 
said  to  be  irritating  to  the  kidneys,  hence  is  contraindicated  in  the  presence 
of  renal  disease.     Many  surgeons  doubt  the  eflkacy  of  this  treat  men  I. 

The  surgical  treatment  roirsists  of  (i)  compression  of  the  artery  or  the 
aneurysm;  (2)  the  temporary  or  permanent  introduction  of  foreign  bodies; 
or  (5)  operative  treatment. 

I.  Compression  of  th€  sac  itself  by  bandages,  or  by  flexion  of  the  limb, 
e.g.,  in  aneur>sms  at  the  bend  of  the  ell>ow  or  knee,  and  massage  ofihe  sar, 
with  the  idea  of  occluding  the  artery  with  a  fragment  of  the  clot,  are  ancient 
methods  which  arc  apt  to  lie  followed  by  rupture  or  suppuration  of  the  sac,  or 
gangrene  of  the  limb.     Re  id's  method  of  rapid  cure  by  compression  aims 
10  retain  the  blood  in  the  sac  until  it  coagulates.     The  patient  is  anesthe- 
tized, and  an  elastic  bandage  applied  from  the  exlremily  to  the  root  of  the  limb, 
excluding   the  aneurysm,    which   shoultl    be   full   of  blood.     A  tourniquet 
is  then  applied  above  the  band,  and  allowed  to  remain  for  an  hour  and  a  half, 
after  which  it  is  gradually  loosened,  so  as  to  prevent  a  sudden  gush  of  blood, 
which  might  wash  aw  ay  the  clot.     This  method  is  occasionally  successful,  but 
is  often  followed  by  gan  grene .     Pressure  on  ike  artery  feeding  the  aneurysm  m  ay 
be  made  by  the  thumb  (digital  pressure),  a  method  which  refjuires  relays  of 
assistants,  or  by  means  of  tourni(|uets  or  compressors  (in stru menial  eompres- 
si(m)f  the  pressure  being  continuous  or  intermittent.     The  skin  should  be- 
protected  with  a  piece  of  chamois  and  by  shifting  the  point  of  pressure,  and 
the  main  vein  and  nerves  avoided.     Although  some  assert  that  it  is  not  cs.sen- 
tial  to  obliterate  the  pulse,  complete  suppression  of  the  circulation  through  the 
sac  gives  the  best  results.     In  the  intermittent  method  pressure  is  made  for  a 
numl)er  of  hours  each  day,  but  the  patient  allowed  to  sleep  at  night.     In  the 
fontintious  method  pressure  is  sometimes  maintained  for  two  or  three  days,  but 
if  coagulation,  which  reveals  itself  by  absence  of  pulsation  and  hardening  of 
the  aneurysm,  does  not  occur  within  thirty  six  hours  the  method  should  be 
..abandoned.     As  the  pressure  is  agonizing  to  the  patient  narcotics  are  re- 
quired.    Pressure  upon  the  artery  distal  to  the  aneurysm  may  be  employed 
as  an  aid  to  proximal  pressure,  or  in  cases,  such  as  aneurysm  of  the  root  of 
the  carotid,  in  which  proximal  pressure  cannot  be  applied.     Intermittent 
pressure  is  useful  in  dilating  the  collaterals  before  the  application  of  a  ligature, 
thus  preventing  gangrene.     The  treatment  of  aneurysm  by  proximal  pres- 
sure is  successful  in  about  50  per  cent,  of  the  cases  and  is  attended  by  b'ttle 
danger,  but  is  tedious,  extremely  painful,  and  is  rapidly  being  displaced  by 
the  operative  metho<ls. 

2.  The  introduction  of  foreign  bodies  into  the  sac  should  be  per- 
formed only  in  inoperable  cases.  Atttpundure  consists  in  the  introduction 
of  fine  needles  in  such  a  way  that  they  will  cross  one  another  and  whip  the 
filirin  from  the  blood;  they  are  withdrawn  after  several  days.  Macewen's 
metliad  consists  in  the  introduction  of  a  long  needle,  with  which  the  whole 
lining  membrane  of  the  sac  is  scratched,  the  idea  being  to  excite  a  mild  inflam- 
mation which  will  cause  the  walls  to  thicken  and  the  bhiod  to  coagulate. 
Motyre's  method  consists  in  the  introduction  of  a  number  of  yards  of  coileil 
steel  wire  thnmgh  a  cannula;  the  wire  assumes  a  spiral  shape  in  the  sac,  anil 
is  allowed  to  remain  pr rmanently.     Silk,  horse-hair,  catgut,  and  other  mate- 


tgi 


abdoraen  or  hack. 


m^wt0' 


Fig,  Its  — 


115. — Methods  of  ligation 
for  aneurysm* 


rials  have  been  used  in  a  similar  way.  FJecirolysis  may  be  employed  by  intro- 
ducing two  needles  whith  are  insulated  where  they  come  in  contact  with  the 
tissues.  The  points  of  the  needles  are  slightly  separated,  and  a  constant 
current  of  from  5  to  6  milliamp^res  passed  through  the  sac  for  from  one-half 
to  two  hours.  A  combination  of  the  last  tw^o  methods  {Moore-Corradi 
puihod)  has  proven  of  some  value  in  sacculated  aneurj^sms  of  the  aorta. 
The  author  hasof>tained  marked  and  lasting  improvement  in  one  case,  and 
one  case  has  been  reported  in  which  cure  apparently  occurred.  From  five  to 
lifteen  feet  of  drawn  gold  wire,  according  to  the  size  of  the  sac,  is  introduced 
through  a  gold  cannula  insulated  with  porcelain,  and  connected  with  the 
p<jsitive  pole  of  a  galvanic  battery,  the  negative  pole  being  applied  to  the 
The  current  is  gradually  increased,  often  to  80  miliiam- 
p^res,  and  as  gradually  decreased  to  zero,  from 
forty-five  minutes  to  one  and  one-half  hours 
Ijeing  consumed  in  the  process;  the  cannula  is 
then  withdrawn,  and  the  wire  cut  off  close  to 
the  skin,  beneath  which  it  is  buried.  The 
method  is  not  without  danger.  Coagulating 
injectimts,  such  as  Monsers  solution,  atetate 
of  lead,  and  tannin,  have  been  employed  while 
pressure  is  made  upon  the  artery  on  both  sides 
of  the  aneurj'sm.  The  method  is  not  recom- 
mended in  aneurysms  of  the  extremities^  which 
are  better  treated  by  operative  measures,  and  in  other  cases  it  may  be 
followed  by  very  serious  results  owing  to  the  dislodgment  of  emboli, 

3.  Operative  treatment  includes  ligation,  imision,  endoaneurysmor- 
rhaphy,  extirpation,  arterial  anastomosis,  and  amputation. 

Ligation  may  be  performed  in  one  of  tive  ways.  AncVs  method  (Fig, 
J 15)  is  ligation  immeiliately  above  the  sac.  Hunler*s  operation  (Fig,  115) 
is  ligation  alxjve  but  some  distance  away  from  the  sac,  so  that  anastomotic 
branches  will  exist  betw^een  the  ligature  and  the  aneurysm;  thus  the  blood 
supply  to  the  sac  is  not  completely  cut  off,  but  is  greatly  diminished,  allowing 
contraction  and  gradual  consolidation.  Although  most  surgeons  prefer 
the  Hunter  to  the  And  operation,  we  l>elieve  the  former  increases  the  danger 
of  recurrence  if  the  anastomotic  branches  between  the  ligature  and  the  aneu- 
rysm remain  pervious,  and  the  danger  of  gangrene  of  the  limb  if  these  branches 
suffer  obliteration.  The  objection  that  the  artery  is  more  diseased  near  the 
aneurysm  is  not  a  valid  one,  as  the  degenerative  changes  are  often  more 
marked  in  the  segment  which  would  be  ligated  in  the  high  operation. 
Proximal  ligation  is  contraindicated  when  serious  disease  of  the  heart  or  a 
a  coexisdng  internal  aneur>'sm  is  present,  because  of  the  sudden  rise  of  blood 
pressure  that  follows  ligation  of  a  large  artery;  when  compression  of  the 
feeding  artery  does  not  materially  diminish  the  pulsation;  when  the  arteries 
are  extensively  diseased;  when  inflammation  is  present;  when  gangrene  of 
the  limb  is  threatened;  and  when  the  bone  is  deeply  eroded.  The  accidents 
which  may  follow  are  secondar\^  hemorrhage,  suppuration  and  rupture 
of  the  sac,  gangrene  of  the  limb,  and  secondary  aneurysm  at  the  point  of 
ligation.  Return  of  pulsation  in  the  sac  is  observed  in  the  majority  of  cases 
after  a  day  or  two,  owing  to  the  establishment  of  a  collateral  circulation;  in 
favorable  cases  as  the  sac  contracts  this  diminishes  and  finally  disappears- 
Pulsalion  beginning  a  number  of  days  after  operation  generally  means  recur* 


ANEURYSM.  193 

rence  of  the  aneurysm.  Pesquin's  method  (Fig  115),  or  ligation  above  and 
below  the  sac,  is  indicated  only  in  cases  which  are  better  treated  by  extirpa- 
tion. Brasdar's  operation  (Fig.  1 15),  or  ligation  of  the  artery  distal  to  the  sac, 
is  employed  only  in  cases  in  which  a  proximal  ligature  cannot  be  applied, 
e.g.,  aneurysm  of  the  root  of  the  carotid.  Wardrop^s  operation  (Fig.  115)  is 
ligation  of  one  of  the  branches  of  the  artery  distal  to  the  sac.  e.g.,  ligation 
of  the  subclavian  in  aneurysm  of  the  innominate. 

Incision  of  the  sac  (method  of  Antyllus),  after  ligating  the  artery 
immediately  above  and  below,  is  indicated  in  the  presence  of  suppuration. 
The  sac  is  cleared  of  its  contents,  packed  with  gauze,  and  allowed  to 
granulate. 

Endoaneurysmorrhaphy  {Matas  operation)  will  probably  be  the  operation 
of  the  future  in  all  cases  in  which  the  circulation  through  the  sac  can  be 
provisionally  controlled.    The  circulation  is  arrested  by  means  of  a  tourni- 
quet or,  when  this  is  impractica-  ^ 
ble,  by  exposure  and  compres-                                  ^ 
sion  of  the  main  artery  on  each                               j  [  \ 

side  of  the  aneursym.     The  sac  J:r^CrC  '  yk/V^ — -SHIN 

is  then   opened  and    emptied,  ~C^^>^^0^  v   y^C<:;;^ 

and,  according  to  the  character  ^^^^V^NJft^ii^^^^^''^ 

of  the  aneurysm,  an  obliterative,  ^^^^oi^OP^^S^^^  —  3 

restorative,     or     reconstructive  ^^^^^^^irW^^^ 

operation    performed.      In  the  ^'llfni" ^ 

obliterative  operation^   which   is  IjUl  . 

indicated  in  a  fusiform  aneur-  J^^C~~'~"" 

ysm,  the  orifices  of  the  sac,  and  vfe^P 

of  any  collateral  arteries  which  x;;^ 

may   open   into   the  aneurysm,  Fig.  116. — Diagram  of  obliterated  sacculated 

are    sutured     with    chromicized      aneurysm,   parent  artery  preserved.      (Matas.) 
«*«.,♦   u.,*  ♦u^  ^^«4.:^,.:*w  ^(  *k«       I-  Sutures  closing  mouth  of  sac.      2.  Lembert 
catgut,  but  the  contmuity  of  the     ^^^^^^^  ^^^^^j^^  ^^  ^^  ^^    ^  Through-and- 

artery  is  not  restored.  In  the  through  sutures  bringing  roof  and  floor  of  sac  in 
restorative  operation^  which  is  contact,  and  tied  over  roll  of  gauze.  4.  Sutures 
applicable  onlv  to  a  small-  holding  skin  and  sac  in  contact  with  bottom  of 
mouthed  saccular  aneurysm,  the     ^^^^  ^  * 

mouth  of  the  sac  is  sutured  without  impinging  on  the  lumen  of  the  vessel, 
thus  curing  the  aneurysm  without  cutting  of!  the  circulation  of  the  limb. 
In  either  case  the  walls  of  the  sac  with  the  overlying  skin  are  inverted  and 
so  sutured  as  to  obliterate  the  sac  (Fig.  116).  Matas  suggests  that  in 
certain  fusiform  aneurysms  it  may  be  possil3le  to  reconstruct  the  arterial 
channel  by  suturing  two  folds  of  the  sac  over  a  rubber  catheter,  in  a 
manner  similar  to  the  formation  of  the  canal  in  the  Witzel  gastrostomy 
(Fig.  374).  The  cathetci;  is  removed  before  the  last  sutures  are  tied. 
Even  in  cases  in  which  the  circulation  through  the  main  artery  is  stopped, 
gangrene  is  less  likely  to  follow  than  after  other  methods  of  operation, 
because  the  collateral  circulation  is  practically  undisturbed.  The  state  of 
the  collateral  circulation  may  be  determined  before  any  of  the  operations 
mentioned  above  by  the  Matas  method  (p.  624). 

Extirpation  of  the  sac,  after  ligation  of  the  artery  above  and  below,  is 
followed  by  permanent  cure,  but  in  a  large  aneur>'sm  is  a  formidable  opera- 
tion which  may  seriously  interfere  with  the  collateral  circulation  and  be 
followed  by  gangrene.     It  is  the  best  operation  in  small  aneurysms,  and  ma^ 


tm 


VASCtJLAR  SYSTEM. 


be  tried  previous  to  amputation  in  cases  which  have  recurred  after  other 
methods  of  treatment^  or  in  cases  in  which  the  sac  has  ruptured  or  is  in- 
flamed and  suppurating. 

End-to-end  anastoinosis  of  the  artery,  after  excising  the  sac,  is  m- 
dicated  in  small  traumatic  aneurysms,  but  in  the  spontaneous  variety  is  less 
apt  to  be  successful,  because  of  the  diseased  state  of  the  artery. 

Amputation  of  the  limb  is  indicated  in  gangrene^  in  marked  erosion  or  dis- 
solution of  a  joint,  in  some  cases  of  rupture,  suppuration,  or  secondar}^  hemor- 
rhage, and  in  a  rapidly  growing  aneurysm  which  has  resisted  other  means  of 
treatment.  Amputation  of  the  arm  has  been  performed  to  lessen  the  quan- 
tity of  blood  flowing  through  a  sul>clavian  aneurysm. 

Arteriovenous  aneurysm  (Fig,  117)  is  the  condition  resulting  from  an 
abnormal  communication  between  an  artery  antl  a  vein.    The  traumaik  variety 

usually  follows  a  stab  or  gunshot  wcmnd; 
the  spontaneous  variety  is  rare  and  results 
from  the  rupture  of  an  arterial  aneury^sm 
into  a  vein,  the  aorta  and  vena  cava  being 
the  vessels  most  often  affected.  The  arter\' 
may  communicate  directly  with  the  vein 
{aneurysmal  varix)  or  there  may  be  an 
inter\Tning  sac   (varicose  aneurysm). 

The  important  symptoms  are  pulsation 
of  the  vein,  which  becomes  varicose,  and  a 
characteristic  thrill  and  bruit,  the  latter 
resemliling  the  buzzing  of  a  fly.  Both 
thrill  and  bruit  are  continuous, 'but  rein- 
forced at  each  cardiac  systole,  and  trans- 
mitted along  the  vein,  both  centrally  and 
peripherally.  Proximal  pressure  on  the 
artery,  compression  of  the  intermediary  sac,  or  closure  of  the  arterial  open- 
ing by  pressure  on  the  vein,  causes  the  swelling  to  shrink,  and  the  thrill, 
bruit,  and  pulsation  to  cease;  distal  pressure  intcnsibes  these  signs.  Edema, 
cyanosis,  and  motor,  sensory,  and  trophic  disturljances  are  of  common 
occurrence,  while  in  arteriovenous  aneurysm  of  the  common  carotid  and 
jugular,  headache,  vertigo,  and  other  cerebral  symptoms  may  appear.  The 
conditiijn  may  slowly  advance,  or  remain  stationary  for  years.  Rupture  is 
more  frequent  in  varicose  aneurysm  than  in  aneurysmal  varix- 

The  diagnosis,  even  in  the  absence  of  venous  pulsation,  is  assured  if  the 
characteristic  thrill  and  bruit  are  present.  The  bruit  of  an  arterial  aneurysm 
is  intermittent  and,  although  sometimes  propagated  along  the  artery,  is 
never  transmitted  towards  the  heart.  The  venous  hum,  occasioned  by  pres- 
sure or  anemia,  which  is  at  times  heard  at  the  rf>ot  of  the  neck,  although 
continuous  and  transmitted  towards  the  heart,  is  intensibed,  not  by  cardiac 
systole,  but  by  diastole  or  inspiration.  In  cirsoid  aneur}sm  pulsation  is 
uniform  and  confmed  to  the  arteries,  thrill  and  bruit  weak  or  absent;  proxi- 
mal compression  of  the  main  artery  does  not  wholly  suppress  these  signs,  and 
the  condition  is  most  fretjuent  on  the  scalp  and  hanil,  where  arteriovenous 
aneurysm  seldom  occurs.  The  differential  diagnosis  l>etween  aneur)'smal 
varix  and  varicose  aneurysm  is  seldom  possible  without  exploratory  incision, 
although  a  soft,  oval,  lluctuating,  easily-reducible  swelling  points  to  the 


Fm,  1 17.— Diagram  of  arterio- 
vcnous  ancur>"sm,  A.  Atifurv'smal 
varix.  B^  Varicose  anrurjsm. 
(Wabham.) 


HEMOKHHAGE.  T95 

fonner,  and  a  firm,  irregular,  immobile  tumor  which  cannot  be  completely 
reduced,  to  the  latter. 

The  treatment  of  aneur>^smal  varix  is  the  application  of  an  elastic  band- 
age. If  this  does  not  check  the  progress  of  the  growth,  if  pain  is  severe  or 
rupture  threatened,  operation  is  demanded.  Varicose  aneurysm  should 
never  l>e  treated  expectantly.  The  ideal  operation  is  separation  of  the  vessels 
\*ith  suture  of  the  openings,  thus  preserving  the  circulation.  When  this  is  in- 
applicable extirpation,  after  t>ing  both  vessels  al>ovc  and  below,  is  the  best 
procedure.  Proximal  h'galion  of  the  artery,  ligation  of  the  artery  above  and 
below,  or,  better,  ligation  of  txith  vessels  above  and  below  may  be  indicated 
when,  owing  to  dense  adhesions  or  unfavorable  situation,  extirpation  seems 
too  formidable. 

HEMORRHAGE. 

Hemorrhage  is  divided,  (i)  according  to  its  cause,  into  spontaneous  and 
traumatic;  (2)  accordhig  to  the  vessels  injured,  into  arterial,  venous,  and  cap- 
illary; (3)  according  to  the  time  following  the  injury,  into  primary,  intermedi- 
ary, and  secondary;  and  (4)  according  to  its  location,  into  external  and 
internal. 

I. — Sponkmeaus  hemorrhage  is  the  result  (i)  of  ulcerative,  degenerative, 
or  inflammatory  diseases  of  the  vessel  walls;  (2)  of  increase  in  blood  pressure, 
e.g.,  hypertrophy  of  the  heart,  straining,  coughing,  vomiting,  and  convulsions; 
(3)  of  alterations  in  the  constitution  of  the  blood,  e.g.,  severe  forms  of  anemia, 
notably  progressive  pernicious  anemia  and  leukemia,  snake  bite,  phosphorous 
poisoning,  raaiaria,  yellow  fever.j'aundicc,  scurvy, and  purpura  hemorrhagica; 
and  (4)  of  obscure  nervous  influences,  e.g.,  hysteria,  vicarious  menstrualioo, 
and  certain  other  nen'ous  conditions.  The  cause  of  bleeding  in  hemophilia 
is  not  known.  Traumatic  hemorrhage  is  the  result  of  wountls  of  vessels, 
or  of  contusions  which  weaken  the  vessel  wall  and  are  followed  by  rupture. 

2.— In  artniai kemorrhagf  the  iilood  is  bright  red,  and  is  pumped  from  the 
vessel  in  spurts  synchronous  with  the  cardiac  systole.  If  oxygenation  of  the 
blood  is  deficient  from  any  cause,  the  blood  may  be  dark  in  color,  e.g.,  in 
deep  narcosis  and  asphyxia.  Pressure  on  the  artery  between  the  wound  and 
the  heart  stops  the  bleeding,  unless  the  collateral  circulation  is  well  developed; 
pressure  distal  to  the  wound  augments  the  bleeding  only  when  the  artery  is 
incompletely  severed.  In  vrnmts  hemorrhage  the  blood  is  dark  in  color  and 
flows  in  a  steady  stream.  Bleeding  from  the  central  end  of  a  severed  vein 
soon  ceases,  unless  the  valves  are  incompetent  or  absent,  or  unless  a  large 
branch  opens  into  the  vein  between  the  wound  and  the  next  valve  atxne. 
Pressure  on  the  vein  below  the  wound  checks  the  Ijleeding;  pro.ximal  pressure, 
if  the  wound  is  lateral,  increases  the  bleeding.  The  opposite  is  true,  how- 
ever, when,  as  in  certain  varices,  the  circulation  is  reversed.  The  application 
of  a  tournitjuet  to  the  limb  above  the  wound  makes  the  bleeding  worse,  unless 
the  constriction  is  tight  enough  lo  compress  the  arteries,  when  the  bleeding 
will  cease,  after  the  peripheral  segment  of  the  vein  and  its  tributaries  have 
emptied  themselves.  Capiliury  hemorrhage  is  characterized  by  a  general 
oozing  of  blood.  The  term  parenrhymattms  is  sometimes  apph'cd  to  a  free 
general  oozing  from  all  the  vessels. 

3. — Primary  hemorrhage  occurs  at  the  time  of  inju^)^  Inicrmediary, 
reactionary,  recurrent,  or  consecutive  hemorrhage  is  the  bleeding  which 


* 


KIL  SYSTEM. 


I 


recurs  within  twenty-four  hours  of  the  cessation  of  primary  hemorrhage.  It 
is  due  to  the  cutting  through  (in  friable,  inflammatory,  or  neoplastic  tissue,  or 
in  atheroma),  slipping  off,  untying,  or  breaking  of  a  ligature;  or  to  the 
washing  of  coagula  from  the  ends  of  the  vessels  as  the  result  of  increased 
blood  pressure  coincident  with  reaction  from  shock.  Secmtdary  hemorrhage 
occurs  after  twenty -four  hours*  It  may  be  due  to  the  causes  mentioned 
above,  liut  is  usually  the  result  uf  infection,  which  opens  the  vessel  by  ulcera- 
tion or  sloughing,  Ijy  breaking  down  the  coagulum,  or  liy  disintegrating  an 
a  l>sorba  bl  e  1  igat  u  re . 

4. — In  fxtenial  hemorrka^t^  the  Ijluotl  escapes  from  an  external  wound. 
In  internal  hemorrhage  it  accumulates  in  the  tissues  (extravasation,  p.  87; 
diffuse  traumatic  aneurysm,  p.  186),  in  one  of  the  canities  of  the  body  (hema- 
tocele), or  in  one  of  the  hollow  \iscera.  Various  other  names  are  applied  to 
hemorrhage  according  to  its  location,  such  as  epistaxis  (nose  bleed),  hematem- 
esis  (vomiting  of  i)lood),  metrorrhagia  (uterine  hemorrhage  between  the 
menses),  hemothorax  (bleeding  into  the  pleural  cavity),  etc. 

The  constitutional  symptoms  of  hemorrhage  arc  rapid,  feeble,  easily 
obliterated,  dicrotic  pulse;  subnormal  temperature  with  cold,  clammy  skin; 
increased  and  frequently  irregular  respirations  with  dyspnea  {air  hunger); 
marked  pallor  of  the  skin  and  mucous  membranes;  faib'ng  sight  and  dilata- 
tion of  the  pupils:  ringing  in  the  ears  (iiuniius  auriuni);  restlessness,  muscular 
twitching,  or  convulsions;  thirst,  and  sometimes  nausea,  vomiting,  ordehrium; 
recurring  attacks  of  vertigo  or  syncope;  and  fmallvj  in  fatal  cases,  collapse  and 
death.  These  symptoms  vary  in  frequency  and  intensity  according  to  the 
amount  of  blood  lost  and  the  rapidity  with  which  such  loss  takes  place. 
The  most  important  symptoms  are  a  rising  pulse,  a  falling  temperature,  and 
increasing  pallor.  A  sudden  violent  hemorrhage  may  cause  death  in  a  few 
seconds,  small  but  repeated  bleedings  may  not  effet  t  the  same  result  for  years. 
It  is  said  that  loss  of  half  of  the  l>lood  [the  total  amount  of  blood  is  an  eighth 
the  body  weight)  usually  causes  death.  The  effects  of  hemorrhage,  how- 
Tver,  are  much  greater  in  infants,  in  the  aged,  and  in  the  debilitated,  and 
much  less  in  women  during  parturition.  After  a  severe  hemorrhage  reaction 
is  attended  by  a  slight  rise  in  temperature  {hemorrhagic  fn-er),  the  result  of 
nervous  intluences  or  the  absorpjtton  of  fibrin  ferment.  There  is  sometimes 
a  low  form  of  delirium,  and  as  the  result  of  the  asthenia,  the  patient  is  pre- 
disposed to  infective  processes.  Although,  owing  to  the  contraction  of  the 
vessels  and  the  absorption  of  fluids,  the  blood  pressure  is  quickly  restored,  the 
number  of  red  cells,  the  amount  of  hemoglobin,  and  the  sp>ecific  grax'ity  of  the 
biood  are  reduced,  while  the  number  of  leukocytes  is  increased  for  a  number 
of  days,  no  doubt  the  result  of  the  large  quantity  of  lymph  taken  up  by  the 
circulation  at  this  time. 

Natural  arrest  of  hemorrhage  may  be  only  temporary,  or  it  may  be 
permanent.  Temporary  hemrKstasis  is  e fleeted  in  the  following  manner:  A 
severed  artery  retracts  within  its  sheath  because  of  its  elasticity;  its  oritice  is 
iliminished  in  size  l»y  conlraciion  of  the  transverse  muscular  hbers  in  the 
media,  by  a  curling  up  of  the  inlima,  and  by  the  pressure  uf  the  peri%^ascular 
tissues,  and  as  the  result  of  the  fall  in  blood  pressure  and  the  increased  coagu- 
lability of  the  blood  consequent  upon  hemorrhage,  a  clot  {external  coagulum) 
gradually  forms  in  and  around  the  sheath*  until  it  is  sufticiently  firm  to  resist 
the  diminishing  force  of  the  circulation.  The  bleeding  is  now  checked,  and 
coagulation  proceeds  within  the  vessel  [intental  coagtdiim)  until,  in  some  cases. 


1 


ITEMORRJIACK.  T97 

the  iirst  callateral  braiich  is  reai  lied.  This  dot  may  be  washed  out  with  the 
increase  in  the  forie  of  the  heart  during  the  reaction  from  shocks  hence  over- 
stimulation should  be  avoided.  After  wounds  of  veins  the  process  is  much 
the  same,  although,  for  the  reasons  pointed  t^ut  under  thrombosis,  coaguhitiun 
occurs  more  promptly.  Hemostasia  is  delayed,  however,  when  the  vein 
remains  gaping,  because  of  rigidity  of  its  walls,  as  in  v:irix,  or  because  of  its 
attachment  to  environing  structures,  such  as  is  normally  the  case  with  veins  in 
l>ones,  at  the  root  of  the  neck,  and  with  the  cranial  sinuses.  Capillary 
bleeding  soon  ceases  as,  owing  to  the  minute  size  of  the  vessels,  the  smallest 
coagula  readily  till  their  orifices.  Pernmncnl  hcmostasis  is  the  result  of  dis- 
placement of  the  internal  clot  by  fibrous  tissue,  the  changes  being  those 
already  described  under  repair.  For  the  fate  of  extravasated  blood  see 
page  87. 

The  diagnosis  of  hemorrhage  is  attended  with  difficulty  only  when  the 
bleeding  is  internal;  it  is  then  most  likely  to  be  mistaken  for  shock  ((|.  v). 

The  treatment  of  hemorrhage  is  conslituLional  and  local .  T  he  fmtsliin- 
tian4xl  treat  men  f,  which  is  that  of  shock  (p.  102),  should  be  instituted  while 
measures  are  being  taken  to  control  the  bleeding,  and  not  before,  because  of 
the  danger  of  increasing  the  loss  of  blood.  The  local  trmtmcnt  embraces 
(i)  cold,  (2)  heat,  (3)  elevation,  (4)  styptics,  (5}  compression,  (6)  acupres- 
sure, (7)  fo re i pressure,  (8)  torsion,  (9)  ligature,  and  (lo)  suture  of  the  vessel. 

1,  Cold  in  the  ftjrm  of  ice»  cold  water,  ur  evaporating  lotions  will  hasten 
the  arrest  of  hemorrhage  from  small  vessels,  but  should  not  be  used  in  open 
wounds  because  of  the  danger  of  sepsis.  Exposure  of  a  wound  to  air  facili- 
tates coagulation  partly  as  the  result  of  the  lowered  temperature.  The  ice 
bag  is  frequently  employed  in  internal  hemorrhages  not  suitable  for  operation. 

2.  Heat  in  the  form  of  hot  water  (120^  to  1  5o^F.)  is  sometimes  useful  as 
a  hemostatic;  it,  bke  cold,  stimulates  the  muscular  libers  of  the  vessels  to 
contract.  Warm  water  relaxes  these  fibers  and  encourages  bleeding.  .The 
actual  cautery  should  rarely  be  employed,  as  it  causes  sloughing,  which  inter- 
feres with  the  healing,  and  predisposes  to  seconrlary  hemorrhage.  When 
used,  it  shouhl  l*c  at  a  dull  red  heat;  if  l>right  red  it  1  uts  like  a  knife  and  does 
not  stop  bleeding.  FAeciroiumostash^  m  which  the  tissues  to  be  divided 
during  an  operation  are  crusheil  with  special  furceps  and  baked  with  an 
electric  current,  possesses  no  advantages  over  the  ligature. 

3.  Elevation  alone  may  stop  hemorrhage  from  the  larger  veins;  it  is 
especially  applicable  in  bleeding  from  the  extremities. 

4,  Styptics,  such  asantipyrin,  Monsel's  suluiion  (cotton  containing  Mon- 
sel's  salt  is  called  styptic  cotton),  akohol,  turpentine,  tannic  or  gallic  acid, 
silver  nitrate,  alum,  sodium  chlorid,  vinegar,  chlorid  of  zinc,  and  tincture  of 
matico,  are  seldom  used  by  the  surgeon,  as  most  of  them  produce  a  tough 
coagulum  which  interferes  with  healing.  Adrenalin  chlorid,  however,  contracts 
the  vessels,  and  is  frequently  employed,  particularly  in  bleeding  from  mucous 
membranes.  It  may  be  applied  by  a  swab  or  as  a  spray  io  the  strength  of 
from  I  to  1,000  to  I  to  to,ooo,  or  given  internally  in  the  dose  of  from  5  to  10 
grains  of  the  suprarenal  extract.  At  least  one  case  of  poisoning  has  resulted 
from  its  use  locally;  when  administered  internally  for  a  long  time  it  is  said  to 
cause  arteriosclerosis,  ticlatiri,  5  to  ro  per  cent,,  in  normal  salt  st)lution 
{Camot's  solution),  has  lieen  used  locally  as  a  hemostatic ;  reference  has  already 
been  made  to  the  importance  of  having  it  absolutely  sterile  and  to  its  use 
tJitemally.     Among  the  drugs  which  increase  the  coagulaliility  of  the  blood. 


I 


VASCULAR   SYSTEM. 


yr  cuntracl  the  vessels,  when  taken  inlernallyT  ^re  turpentine,  oil  of  engeron, 
opium,  (lilule  sulphuric  acid,  acetate  of  lead,  ergot,  hamanielis,  gelatin,  and 
chlorid  of  calcium.  Chlorid  of  calcium,  gr.  x,  t-i-d.,is  frecjuently  employed 
to  increase  the  coagulability  of  the  lilood  previous  to  operation  in  cases  of 
chronic  jaundice, 

(5)  Compression  may  he  direct  or  indirect,  i.e.,  upon  tlie  ends  of  the 
divided  vessel,  or  upon  the  vessel  some  distance  from  the  vvounti. 

Direct  compression  may  be  made  with  the  fingers,  or  with  tampons,  com- 
presses, or  pads.  The  ultimate  principle  of  all  hemostatic  agents  is,  of 
course,  pressure  in  some  form.  Direct  di glial  compression  will  control  the 
most  violent  hemorrhage  from  any  part  of  the  circulatory  apparatus,  and  is  to 
be  employed  in  an  emergency  until  more  perma- 
nent hemostasis  can  be  secured.  Cajnllary  hemor- 
rhage, or  a  general  oozing  from  small  arterioles 
and  venules,  is  quickly  checked  by  the  pressure 
of  aseptic  gauze  which  has  l)een  steeped  in  hot 
water.  Firm  gauze  parking  will  control  any 
venous  and  many  forms  of  arterial  bleeding. 
The  graduaied  compress,  which  is  made  of  .layers 


Fti\ ,   i  1 8. — CoJpeurynter. 


Fig.    119. — Catheter  ^ 
chemise.     (Heath.) 


^ 


of  gauze  successively  increasing  in  size  from  below  upwards,  so  as  to  form 
an  inverted  pyramid  or  cone,  was  at  one  lime  used  to  control  arterial  hemor- 
rhage in  regions  in  which  incisions  to  expose  the  wounded  vessels,  e.g.,  the 
palmar  arches,  might  injure  important  structures.  The  pressure  exerted 
on  oozing  points  by  the  apposition  of  a  wound  w^ith  suturt's  or  sterile  adhesive 
strips  is  frequently  sufficient  to  control  bleeding,  especially  when  such  pressure 
is  reinforced  by  a  firm  bandage.  Bleeding  from  heme  may  be  controlled  by 
plugging  the  openings  with  antiseptic  wax,  catgut,  filaments  of  gauze,  or 
fragments  of  l>one  produced  by  striking  the  bone  with  the  blunt  end  of  a 
chisel;  a  large  canal  may  be  filled  with  a  bit  of  sterilized  wood.  In  the  rectum 
pressure  may  be  made  by  introducing  and  inrtatinga  colpeurynter  (Fig.  1 18J. 
The  shirted  cannula  {cannula  d  chemise)  is  used  after  lithotomy,  to  make 
pressure  and  maintain  drainage  (Fig.  119);  the  shirted  portion  is  stuffed  with 
gauze.  In  bleeding  from  a  tooth  socket  the  cavity  may  be  packed  with  gauze 
containing  an  astringent,  and  the  pressure  augmented  by  bandaging  the  jaws 
tightly  shut.  In  the  urethra  pressure  may  be  etTected  by  inserting  a  large 
sound,  or  in  the  deep  urethra  by  compressing  the  perineum.  A  method 
Sot  making  direct  pressure  on  the  internal  mammary  artery  is  mentioned  on 


HEMOHRFIAGE. 


199 


p.  405.  Other  forms  of  ilireit  pressure,  viz.,  acupressure,  furci pressure, 
ligation,  etc.,  are  dealt  with  later.  Indirect  pressure  is  employed  chieHy 
to  control  bleeding  until  more  permanent  measures  can  be  applied,  or  to 
prevent  hemorrhage  during  operations,  lii  the  limbs  a  tourniquet  (Figs. 
I20.  t2i,  i22)t  applied  above  the  wound,  is  the  most  reliable  procedure; 
in  an  emergency  a  belt,  a  pair  of  suspenders,  or  a  handkerchief  may  be 
lied  about  the  limb,  and  tightened  by  pushing  a  stick  beneath  the  band 


Fic  120. — Esmarch  LsamL 


FlO.  121- — ^Petil's  lournic|uct  applied 
lo  the  hrachicil. 


and  twisting  it.  A  tourniquet  should  be  applied  above  the  elbow  or 
knee,  as  the  vessels  in  the  forearm  and  leg  are  protected  by  bones  and 
not  so  readily  compressed.  The  dangers  of  the  tourniquet  are  injury 
to  the  nerves  and  soft  tissues,  especially  if  the  limb  is  moved  about; 
conlusion  or  rupture  of  the  artery,  particularly  in  atheroma;  and 
\  gangrene  if  the  tourniquet  is  left  in  place  for  several  hours.  A  dis- 
advantage  is  the  increased  oozing  of  blood  following  the  removal  of  the 
tourniquet.  In  operations  the  vessel  may  he 
compressed  at  a  distance  by  a  clamp,  tape,  or 
the  fingers  of  an  assistant,  lumed  flexion  is 
seldom  employed  at  the  present  time;  a  pad 
is  placed  in  the  popliteal  space,  groin,  or  bend 
of  the  elbow,  and  the  limb  secured  in  strong 
6exion  by  means  of  a  l>andage.  Indirect 
digital  compression,  although  lacking  the 
disadvantages  of  the  tourniquet,  calls  for  a 
strong,  skilled  hand  and,  if  pressure  must  be  Fio,  122.— Signorim'stourmquet. 
continued  for  a  long  time,  relays  of  assistants. 

The  common  carotid,  the  vertebral,  and  the  in/mor //ifym<f  arteries  may  be 
compressed  against  the  transverse  process  of  the  sixth  cemcal  vertebra 
(Chassaignac's  fubercie)  at  the  anterior  margin  of  the  sternomastoid;  the 
Jacialy  against  the  lower  jaw  just  in  front  of  the  masseter;  the  labial 
and  cor(mary\  by  grasping  the  lip  at  the  angle  of  the  mouth  between 
the  fingers;  the  Icmporat.  against  the  zygoma  immediately  in  front  of  the 
ear;  the  occipital,  against  the  skull  about  midway  between  the  mastoid 
process  and  the  external  occipital  protuberance:  the  subclavian,  against  the 
tirsl  rib,  by  the  thumb,  or  l)y  the  padded  handle  of  a  cloor  key,  pressed 


downward^  bai  kward,  and  inward  jusi  behind  tht"  ilavjcle  and  lu  the  ouier 
side  of  the  slernomastoid ;  the  axillary^  against  the  head  of  the  humerus 
at  the  inner  border  of  the  roraco-braLhialis,  with  the  arm  raised  to  a  right 
angle;  the  bradiial,  against  the  humerus  at  the  inner  edge  of  the  biceps;  the 
radial,  at  the  wrist,  just  outside  of  the  flexor  carpi  radialts;  the  ulnar,  in  the 
same  situation^  just  outside  of  the  flexor  carpi  ulnaris;  the  abdominal  aorla^ 
if  the  patient  is  not  too  stout,  against  the  vertebra^  on  a  level  with  and  just 
lo  the  left  of  the  umbilicus;  the  external  iliac,  against  the  brim  of  the  pelvis, 
above  the  middle  of  Poupart^s  ligament;  the  common  Je moral,  immediately 
below  Poupart's  ligament,  by  pressing  upwards  and  backwards  miilway 
r>elween  the  symphysis  pubis  and  the  anterior  supenor  spine  of  the  ilium; 
the  popliteal,  against  the  femur  a  trille  lt>  the  inner  side  of  the  mitfdle  of  the 
popliteal  space;  the  anterior  tilfiaL  midway  between  the  two  malleoli;  the 
posterior  iibial^  hM  an  inch  behintl  the  tip  of  the  interna!  malleolus.  When 
there  is  danger  of  secondary  hemorrhage,  the  point  for  compression  may  l>e 
marked  with  ink  or  iodin,  so  that,  in  the  event  of  bleeding,  the  nurse  may 
press  on  the  right  spot  at  once.  It  is  much  better,  however,  in  such  cases, 
to  apply  an  Esmarch  band  loosely  to  the  liml>;  if  hemorrhage  occurs  the 
Ijand  can  then  be  tightened  without  regard  to  the  situation  of  the  artery. 

(6)  Aeupressyre  is  rarely  employed,  (i)  A  long  needle  may  be  pushed 
into  the  tissues,  then  over  the  vessel,  and  again  into  the  tissues,  in  the  same 
way  that  one  fastens  a  llower  to  the  lapel  of  a  coat;  (2)  the  needle  may  be 
passed  into  the  tissues  on  one  side  of  the  vessel,  twisted  180^,  and  rehiserted 
into  the  tissues;  or  (3)  the  needle  may  be  thrust  under  the  vessel,  and  wire 
or  silk  passed  over  the  ends  of  the  needle  in  a  figure  of  S  fashion, 

(7)  Forcipressurej  or  the  crushing  of  the  end  of  the  vessel  with  hem- 
oslatic  forceps,  is  frequently  employed  with  very  small  vessels;  thus,  many 
of  the  litde  blee<iing  points  caught  with  hemostatic  forceps  during  an  opera- 
tion require  no  further  attention  after  the  forceps  have  been  removed  at  the 
end  of  the  operation.     When  ligation  is  very  difficult  anrl  the  vessel  large,  the 
forceps  may  be  left  in  place  for  twenty-four  c^r  forty-eight  hours,  being,  of  ^J 
course,    protected    with    sterile    dressings.     Forcipressure   before   lighting  ^^| 
en  masse  renders  bleeding  from  shrinkage  of  the  tissues  much  less  likely  ^^ 
to  occur.     Very  pcnverful  forceps  (vasotribe,  or  angiotribc)  are  sometimes 
used  for  this  purpose,  and  some  surgeons  do  not  even  ligate  after  remonng 
the  instrument. 

(8)  Torsion  is  useful  in  certain  plastic  operations  where  the  presence  of 
knotted  ligatures  is  undesirable.  It  should  not  be  used  i!i  cases  of  atheroma. 
Free  torsion  is  the  twisting  of  a  vessel  several  times  after  the  application  of 
hemostatic  forceps;  it  is  used  chietly  for  small  vessels.  Larger  vessels  are 
occluded  by  limited  iorsion;  the  artery  is  drawn  from  its  sheath  with  a  pair  of 
forceps,  grasped  close  to  the  tissues  with  a  second  pair,  then  twisted  with  the 
Hirst  forceps.  Torsion  mptures  the  inner  and  middle  coats,  which  contratt 
and  curl  up,  and  twists  the  outer  coat;  the  end  *>f  the  vessel  should  never  be 
twisted  ofT, 

(9)  Ligation  is  the  method  of  choice  when  dealing  with  vessels  large 
enough  to  be  seen  by  the  naked  eye.  Catgut  is  the  material  usually  employed, 
although  with  very  large  arteries  or  with  thick  pedicles  many  surgeons  prefer 
silk.  Ligation  may  l>e  lotoi  or  cirtumferenlial,  when  the  vessel  is  occluded  by 
the  ligature,  or  lateral  when  a  wound  in  the  side  of  a  vessel  is  closed  without 
interrupting  the  circulation.     A  firntmftrmtial  ligature  is  applied  to  the 


HEMORimACE. 


20t 


'  lileeding  end  of  u  vessiel  {tntmaiiatt'  ligatifm),  or  io  ihe  vessel  some  dislante 

i  from  the  wound  {ligation  in  cmiinuity,  pi.  203).     In  the  former  the  end  of  the 

vessel  is  seized  with  hemostatic  forceps,  drawn  a  h'ttle  from  its  sheath,  when 

such  exists,  and  the  ligature  tied  aliove  the  forceps  in  a  reef  knot  (Fig.  74).     If 

catgut  is  used,  a  third  knot  always  should  be  added.     As  it  is  ditTicull  to 

I  catch  small  vessels  without  including  a  little  of  the  surnmnding  tissue,  the 

'  forceps  should  be  removetl  as  the  ftrst  knot  is  tightened,  otherwise  the  Hgalure 

may  slip  nlT  when  the  forceps  are  removed.    A  suture-ligature  (Fig.  i  23)  is  one 

passed  through  the  tissues  about  an  artery  l>y  means  of  a  needle.     It  is  used 

in  dense  tissues  from  which  the  vessel  cannot  be  drawn;  in  necrotic  tissues 

[and  in  atheroma  in  order  to  prevent  cutting  through  of  the  ligature;  in  tissues 

like  the  dura,  mesenter)',  and  omentum;  and 
in  any  region  in  which  there  is  danger  of 
si  i  jj  p  i  n  g  o  f  t  h  e  1  i  g;i  lure,  A  later  a  I  liga  t  u  re  i  s 
one  applied  to  the  side  of  a  vessel,  generally  a 
vein,  after  the  edges  of  the  wound  have  been 


Fig.    I aj.— Suture-ligature. 
(Esmarch   and    Kowalzi^, ) 


Fig.   114. ^Lateral  ligature. 
(Esmarch  and   Kowalzi^.} 


frawn  up  in  the  form  of  a  cone  with  hemostatic  forceps  (Fig.  124).  The 
\tffc4:ts  oj  a  Hgalure,  when  it  is  lied  lightly,  are  rupturcof  the  inner  and  middle 
coats,  which  relratl  an<l  invert,  and  the  formation  of  a  small  thromlms,  which 
IS  tinaily  replaced  by  filirous  tissue.  Atheromatous  arteries  and  very  large 
arteries,  e.g.,  the  subclav  ian  aiul  iliac,  should  be  tied  only  firmly  enough 
to  approximate  the  walls,  without  rupturing  the  intima,else  the  ligature  may 
'  cut  through,  or  the  vessel  may  dilate  and  rupture  immediately  proximal  lo  the 
point  of  ligaticm;  some  surgeons  apply  this  rule  lo  all  vessels.  The  ligature 
itself  is  encapsulated  if  of  nonabsorbable  material.  The  iigatjon  of  a  large 
arter>*  causes  a  rise  in  the  general  blood  pressure,  which  gradually  falls  as 
the  collateral  circulation  is  cstablisheib 

(10)  Suture  of  blood  vessels  {angiorrhaphy)  is  the  ideal  method  of 
itcaling  with  womnls  of  arteries  whose  ligation  might  lead  to  gangrene  or 
other  serious  disturbance  in  the  parts  which  they  supply,  e.g.,  the  common 
carotid,  axillary,  brachial »  aorta,  external  iliac,  femoral,  popliteal,  and  large 
abdominal  arteries.  The  danger  of  tearing  out  of  the  sulurea,  even  in  the 
presence  of  atheroma,  is  no  greater  than  that  of  cutting  through  of  a  ligature, 
and  if  thrombosis  occurs,  the  clot  may  form  slowly  enough  tii  allow  the 
collateral  vessels  to  dilate,  a  distinct  advantage  over  ligation.  Although 
occlusion  of  the  main  veins  of  the  limbs  is  usually  followed  by  nothing  worse 
than  edema,  gangrene  may  result  if  the  collateral  vessels  are  diseased  or 
injured,  if  the  circulatiun  is  sluggish  fnmi  cardiac  or  pulmonary  derange- 
ment, or  if  the  Aiiality  of  the  part  is  impaired  by  debilitating  maladies,  hence 
suture  should  be  preferred  to  ligation.  In  wounds  of  the  superior  mesenteric, 
portal,  vena  cava  above  the  origin  of  the  renals,  and  both  internal  jugulars 
suture  must  be  chosen,  as  ligation  generally  ends  in  death.     The  technic  of 


202 


VASCULAR  SYSTEM. 


angiorrhaphy,  which  includes  arieriorrltafihy  (syture  of  arteries)  and  ffhlci 
rhaphy  (suture  rif  veins)  is  as  follows:  After  controlling  the  tircuiation  by  lb 
application  of  a  tourniquet,  or  by  compressing  the  vessel  above  and  below  the 
wound  between  the  lingers  of  an  assistant  or  by  rubber-coated  clamps,  the 
sheath  is  pushed  back,  but  no  further  than  is  absolutely  necessary,  and  the 
edges  of  the  wound,  if  lacerated,  made  smooth  with  a  sharp  knife;  scissors 
produce  too  much  bruising.  The  sutures  should  be  of  fine  silk,  threaded  on 
I  he  finest  needle,  and  sterilized  by  boiling  in  vaselin,  as  suggested  by  Carrel, 
who  applies  vaselin  also  to  the  margins  of  the  wound  to  prevent  drying.  In 
a  lateral  wound  the  operation  may  be  facilitated  by  passing  a  guide  suture, 
to  be  held  by  an  assistant,  through  each  end  of  the  wound.  The  continuous 
suture  is  more  rapid  and  less  apt  to  permit  leakage  betw^een  the  points  of 

insertion  than  the  interrupted.  The  suture 
should  penetrate  all  of  the  coats  of  the  vessel, 
and  slightly  evert  the  margins  of  the  wound  so 
as  to  bring  intima  in  contact  with  intima,  the' 
points  of  insertion  being  about  one  miilimeter 
apart.  The  bWd  current  is  now  slowly  turned 
on  while  pressure  is  applied  to  the  suture  line 
until  the  stitch  holes  cease  to  bleed.  The 
sheath  is  then  sutured,  then  the  fascia,  then 
the  skin.  If  more  than  one-third  of  the  cir- 
cumference of  the  vessel  is  cut,  the  section 
should  be  completed  and  an  end-to-end 
anastomosis  performed.  Although  various 
forms  of  special  apparatus  may  l>e  used  foi 
this  purpose,  the  best  method  is  that  of  Carrel 
After  cutting  the  ends  of  the  vessel  square 
across  and  trimming  away  any  of  the  external 
coat  which  prolapses  into  the  lumen,  three 
guide  sutures  are  passed  through  both  ends  of  the  vessel  at  p*>ints  equi- 
distant around  the  circumference,  which,  by  traction  on  these  sutures,  is 
transformed  into  a  triangle,  whose  sides,  after  being  elongated  as  much  as 
the  elasticity  of  the  vessel  permits,  thus  preventing  stricture,  are  sutured 
with  a  continuous  suture  (Fig.  125).  The  author  has  successfully  sutured 
the  axillary  artery  in  three  instances,  the  radial  in  one,  the  femoral  in  three, 
and  the  popliteal  in  one,  four  of  these  being  end  to-end  anastomoses. 

Rtsunie.— The  treatment  of  alarming  hemorrhage  from  ^ny  optm  waitnd  is, 
lust,  the  immediate  control  of  bleeding  by  the  application  of  digital  pressu 
to  the  vessels  in  the  wound;  then,  in  the  extremities,  the  application  of  a 
tourniquet  above  the  wound.  Nothing  further  should  be  done  until  the 
patient  has  reacted  from  shock,  when  the  parts  may  be  carefully  disinfected 
and  the  vessels  ligated,  enlarging  the  wound  as  much  as  may  be  necessary, 
and  remembering  that  both  ends  of  large  arteries  and  veins  should  be  tied. 
The  desirability  of  suturing  important  vessels  instead  of  occluding  them  by 
ligation,  should  be  borne  in  mind.  A  general  oozing  which  seemiJigly  comes 
from  no  particular  point  is  controlled  by  firm  gauze  packing,  or  by  suture  of 
the  wound  and  the  application  of  a  firm  bandage.  An  artery  capable  of  pro-^^ 
ducing  vigorous  bleeding  must  be  ligated  in  the  wound,  though  even  an 
operation  is  necessary  for  such  purpose.  Ligation  in  continuity  for  hemor- 
rhage should  be  performed  only  under  very  exceptional  circunistanceSi  as  it  is 


Fig.   125,— Carrel's    lechnic   for 
anaslomosis  of  blcxxi  vessels. 


LIGATION   OF  ARTERIES. 


203 


often  ijiefl'eilual,  owing  to  ii  free  tollaleral  cirtulatwjn;  again  the  bleeding 

Vessel  may  be  a  large  vein,  or  an  artery  not  de  rived  from  I  he  vessel  ligatured. 

Possibly  in  cases  in  which  the  tissues  are  rotten  from  infection,  or  in  which 

packing  fail^  to  control  permanenlly  a  bleeding  artery  whose  exposure  would 

necessitate  the  destruction  of  important  structures,  ligation  in  continuity 

may  be  indicated.     In  the  former  instance  recurrence  of  bleeding  would  call 

for  amputation.     In  regions  such  as  the  neck  where  elastic  constriction  is 

lini practicable,  digital  compression  must  be  maintained  until  the  wound  has 

I  been  sufficiently  enlarged  to  secure  the  vessel  with  hemostatic  forceps.     The 

[patient  may  then  be  reacted  from  shock,  and  the  hemorrhage  controlled  as 

I  outlined  above.     Dangerous  hemorrhage  in  the  difsi  iw  abdomen  is  treated, 

I  after  opening  these  caviues,  by  ligation,  suture,  gauze  packing,  or,  in  rare 

nstances.  by  the  cautery;  often  an  important  organ,  e.g.,  spleen,  kidney,  or 

tuterus,  must  be  removed.     In  these  cases  the  surgeon  must  operate  immedi- 

idy,  in  the  presence  of  even  the  most  profound  shock.    Hemorrhage  into  the 

w^mimm  or  spinal  canal  is  dangerous,  not  from  ihe  loss  of  blood,  but  from  the 

[pressure  exerted  upon  the  central  nervous  system;  it  is  controlled,  after 

I  trephining  or  laminectomy,  by  ligature  or  packing.    The  treatment  of  serious 

thieving  into  the  subcuianeous  lissnes,  including  dijfuse  traumatk  aneurysm,  is 

[immediate  digital  pressure  on  the  main  artery  alxne,  until  a  tourniquet  can  be 

[applied;  after  the  patient  has  reacted  from  shock,  the  bleeding  vessel  is 

[exposed  by  incision  and  ligated  or  sutured,    Serl&us  bleeding  from  arterioles^ 

im€iudci,  or capilkttie5  is  dealt  with  under  hemophilia. 

Hemophilia  {hemorrhagic  diathesis)  is  a  congenital  and  hereditary  ten- 
dency to  excessive  bleeding,  arising  spontaneously,  or  from  wounds  of  even 
the  most  trivial  character.  The  cause  is  not  known.  It  is  far  more  frequent  \n 
_males  than  in  females,  but  females  are  much  more  liable  to  transmit  the 
ease  to  their  offspring;  indeed  a  female  Monging  to  a  bleeder  family, 
'but  who  is  not  herself  subject  to  the  affection,  is  likely  to  beget  bleeder 
children,  especially  if  they  be  males.  The  presence  of  hemophilia,  which 
may  be  suspected  from  the  history^  and  confirmed  by  estimating  the  coagula- 
tion time  of  the  blood,  contraindicates  all  but  the  most  urgent  operations. 
Other  forms  of  spontaneous  hemorrhage  are  mentioned  on  page  [95. 

The  treatment  consists  in  the  internal  administration  of  tonics  and  the 
careful  avoidance  of  all  forms  of  injury;  even  the  most  trivial  operations, 
like  vaccination  or  circumcision,  must  Ijc  regarded  as  highly  dangerous.  In 
the  presence  of  bleeding  ergot,  acetate  of  lead,  thyroid  extract,  or  calcium 
chlorid  may  be  given  internally,  while  adrenalin  or  Carnot's  solution  and 
prolonged  pressure  \\ith  elevation  are  used  locally.  The  application  of 
clotting  blood  from  a  healthy  individual  has  been  tried,  and  direct  transfusion 
of  normal  blood  suggested,  Weil  injects  10  to  20  cc.  of  normal  horse  serum 
into  a  vein,  or  20  to  40  cc.  beneath  the  skin;  antidiphlheritic  serum  also  has 
been  used  in  hemophilia  and  other  hemorrhagic  diseases.  Escharotics  or  the 
actual  cautery  may  temporarily  check  the  oozing,  but  it  is  very  likely  to  recur 
with  the  separation  of  the  sloughs.  Petechiie  and  ecchymoses  require  no 
local  treatment;  hematomata  and  hemarthroses  shoyld  be  protected  from 
injury  and  never  opened. 

LIGATION  OF  ARTERIES  IN  CONTINUITY. 

The  indications  for  ligation  in  continuity  are  aneur)sm,  arterial  hemor- 
rhage  under  the  circumstances  mentioned  above,  maligna.nl  ^lowilvs  wUo^ft 


4 


Fig.   126,— d,  Scalpclii;  t,  c,  forceps;  d,  hcmosiat,  €,  iraciion  loops; /»  ligature;  g,  ten- 
aculum; A,  grooved  director;  1,  it,  /,  aneurj'sm  needles;  fn,  bent  probe;  «,  o,  pt  rctraclor-S. 
(Br>'ant.) 

carotid  has  been  tiecl^  and  epilepsy,  for  which  the  vertebral  has  been  tied. 
In  cases  in  which  ihe  necessity  for  ligation  is  not  pressing,  the  state  of  the 
collateral  circulation  may  be  determined  before  operation  by  the  Matas  method 
(p,  624).  If  the  collateral  circulation  is  inadequate  it  may  be  rendered  more 
active  by  intermittent  compression  of  the  artery.     The  instruments  commonly 


p 


LIGATION    dl 


20? 


r/ 


/ 


^s. 


equired  are  shown  in  Fig.  126.     Chromicized  catgut  should  be  used  for  all 
[but  the  largest  vessels,  for  which  floss  silk  is  the  best  material. 

The  operation  ts  precedtxl  by  mapping  out  the  course  of  the  vessel  by  an 
(Unaginar)'  line.     The  skin  and  fascia  are  then  divided  along  this  line,  impor- 
tant structures  drawn  aside,  and  the  vessel  located  by  means  of  anatomical 
^guides,  e,g,,  a  muiicre,  a  bony  promi- 
aence,  a  nerve,  or  another  vessel.    The 
I  artery  itself  is  recognized  by  its  pinkish 
[color,  the  thickness  of  its  walls,  and 
I  by  pulsation,  the  veins  being  dark  in 
Jcolor,  thin  walled,  and  non- pulsating. 
The  arteries  of  the  upper  extremity, 
Jthe  leg,  and  most  of  the  smaller  arteries 
jof  the  trunk  have  venx-  comites;  those 
I  of  the  thigh,  the  head,  and  neck,  ex- 
Icept  the  lingual,  have  but  one  com- 
[panion  vein.   Pressure  upon  the  vessels 
I  will  distend  the  vein  and  collapse  the 
Jartery  and  obliterate  the  pulse  below 
|the    point    of   pressure.      The   anal- 
Dmical    guides,    however,    are    more 
etiable  than  the  individual  features  of 
[le  artery,  as  even  pulsation  may  be 
transmitted  to  the  vein,  or  be  absent  in 
le  artery  as  the  result  of  pressure  t»r 
hemorrhage.     The  sheath  of  the  arter)^ 
is  opened  for  aliout  half  an  inch  by 
lifting  it  from  the  artery  with  forceps, 
and  incising  just  beneath  the  forceps  with  the  t!at  of  the  knife  towards  the 
artery  (Fig.  127  A).     The  sheath  is  then  held  by  forceps,  and  separated  from 
J  the  artery  by  an  aneurysm  needle  armed  with  the  ligature,  which  is  carried 
iround  the  vessel,  in  the  direction  away  from  the  most  imfwrtant  neighbor- 
"ing  structure,  which  is  usually  the  vein  (Fig.  127  B).     The  ligature  is  then 

M^       tied  in  a  reef  knot  (Fig.  74)  by  placing  the 

Jf^^t^       ends  of  the  thumbs  or  index  fingers  upon 

I  yS^    jm  the  knot,  and  separating  them  by  using  the 

gi      9  middle  joint  as  the  basis  of  support  (Fig. 

§l^m^^^^^^^^m^^m         '^7  ^)'     '^'he  second  knot  should  be  tied 

F^^^^^^H^^^^I^^K        hrmly,  but  should  not  be  jerked,  as  such 

llBll^^HH^^H^Hi         '^'^y  hreak  the  ligature;  a  third  knot  always 

p  \\        mW      should  be  added  when  catgut  is  employed. 

VV^Jf        V^  With  the  smaller  arteries  the  ligature  may 

^w^  ^  be  tied  with  sufhcient  firmness  to  rupture  the 

inner  coats.     With  very  large  arteries  this 

may   result    in    the   cutting  through  of  the 

ligature,  or  in  dilatation  and  rupture  immediately  proximal  to  the  ligature. 

these  vessels  the  walls  should  be  approximated  only,  the  stay  knot  being 

^ployed  (Fig.  128).     The  principal  dangers  following  ligation  in  continuity 

ire  sccondar}'  hemorrhage  and  gangrene. 

The  innominate  artery   has   been   tied  forty-three  times   with   .seven 
eco\'cries,  the  chief  cau.ses  of  death  being  sepsis,  secondary  hemorrhage, 


I'IG.  127. — This  diagram  represents 
three  distinct  opera  tions .  A .  Open  i  ng  I  he 
shcalh.  B.  Drawing  ligature  round  the 
arten'.     C\  Tying  artery.     {Moullin.) 


Fic,  118.— Stay  knot,     (Ballancc 
and  Edmunds.) 


1 


2o6 


VASCULAR  SYSTEM. 


and  cerebral  lesions.  An  incision  is  carried  for  three  or  four  inches  along  the 
anterior  margin  of  the  right  sternoniastoid  to  the  epistemal  notch,  then  out- 
ward along  the  upper  margin  of  inner  third  of  the  clavicle,  severing  the  skin,  pla- 
tysma,  and  the  superficial  and  deep  fasciic.  The  sternohyoid,  sternothyroid, 
and  inner  edge  of  the  sternomastoid  are  divided  and  retracted.  The  anterior 
jugular  vein  is  severed  between  two  ligatures,  the  carotid  sheath  opened,  and 
the  carodd  artery  followed  to  the  bifurcation  of  the  innominate.  Resection  of 
the  stemocla\icular  articulation  may  be  necessary  to  expose  the  vessel 
properly.  The  inferior  thyroid  veins  are  tied  or  drawn  aside,  the  right  inter- 
nal jugular  and  right  innominate  vein  are  pushed  to  the  right,  and  the  left 
innominate  vein  h  displaced  downwards.  A  strongly  curved  aneurysm 
needle  h  passed  from  without  and  below,  upwards  and  inwards,  care  being 
taken  not  to  injure  the  pneuniogastric  nerve  and  pleura,  which  lie  to  the 
right*     The  ligature  should  be  of  floss  silk,  tied  in  a  stay  knot. 


^\ 


Fig,  130* — Ligature  of  ihc  common  cartoid  and  facial  arteries.     (Moutlln.) 

The  conunon  carotid  arises  from  the  innominate  on  the  right,  from  the 
arch  of  the  aorta  on  the  left  The  iine  of  the  artery  is  from  the  sternoclavicular 
articulation  to  midway  between  the  angle  of  the  jaw  and  the  tip  of  the 
mastoid,  the  vessel  bifurcating  al  the  upper  Ixirder  of  the  thyroid  cartilage. 
Whenever  possil>le  the  vessel  is  tied  above  the  anterior  belly  of  the  omohyoid, 
i.e.,  in  the  superior  carotid  triangle,  or  the  triangk  &J  election,  as  here  the 
vessel  is  more  superficial  and  the  operation  less  difficult.  The  triangle  of 
election  is  bounded  alKjve  by  the  posterior  belly  of  the  digastric,  l>ehind 
hy  the  sternomastoid,  and  in  front  by  the  anterior  belly  of  the  omohyoid. 
The  inferior  carotid  triangle,  tailed  the  triangk  of  necessity  because  the  vessel 
is  tied  here  only  when  absolutely  necessary,  is  bounded  above  by  the 


I' 


.^ 


LIGATION   OF   ARTERIES. 


207 


'  belly  of  the  omohyoifl,  below  l>y  the  sterrK) mastoid,  and  in  front  hy  the  median 
'line.  Ligation  in  the  triangle  of  election  (Fig.  129)  is  tarried  out  with 
a  sand  pillow  beneath  the  neck,  the  head  turned  towards  the  opposite  side, 
and  the  chin  raised.  A  three  inch  incision,  the  tenter  of  which  is  on  a  level 
with  the  cricoid  cartilage,  is  made  along  the  arterial  line,  severing  the  skin, 
and  t)oth  layers  of  the  superficial  fascia,  Ijetween  which  lies  the  piatysma,  and 
exposing  the  anterior  edge  of  the  sternomastoid,  which  is  the  muscuiar  guide 
to  the  artery.  After  cutting  the  deep  fascia  which  is  attache*!  to  the  Ixirder 
of  the  stemomastoid,  this  muscle  is  retracted  outwards,  the  omohyoid  drawn 
downw*ards,  and  the  costal  process  of  the  sixth  cervical  vertebra  (carotid 
tul>ercle  of  Chassaignac),  which  Hes  immediately  under  the  artery  at  the  point 
where  it  is  crossed  by  the  omoyhoid,  felt  with  the  linger.  The  sheath  of  the 
vessel  is  identified  by  means  of  the  dcscendms  nmti  mnr,  which  descends 
Upon  it,  and  opened  on  the  inner  side  to  avoid  the  internal  jugular  vein, 
which  lies  to  the  outer  side  in  a  separate  compartment.  The  pneumogastric 
nerve  lies  liehind  and  between  the  artery  and  vein,  in  a  separate  ci>m  pari  men  t 
of  the  same  sheath.  The  needle  is  passed  from  without  inwards. 
Ligation  in  tlie  triangle  of  necessity  (Fig.  129)  is  performed  by  making  a 
three  inch  incision  down^vard  along  the  arterial  line  from  the  level  of  the 
cricoid  cartilage.  The  sternomastoid  is  drawn  outwards,  the  sternohytjid 
and  sternothyroid  inwards,  the  omohyoid  upwards.  The  sheath  is  opened  on 
the  inner  side  and  the  operation  completed  as  descriljed  above.  The  inferior 
thyroid  veins  may  be  tied  if  they  are  in  the  way;  in  the  lower  part  of  the  neck 
the  anterior  jugular,  and  on  the  left  side,  the  internal  jygular,  lie  in  front  of 
the  artery  and  must  be  carefully  retracted.  Ligation  of  the  common  carotid, 
in  one-fourth  of  the  cases,  results  in  cerebral  complications,  which  may  be 
immediate,  such  as  collapse  from  cerebral  anemia,  or  which  lake  the  form 
of  cerebral  softening,  causing  hemiplegia.  One-half  of  those  developing 
intracranial  troyble  die. 

The  internal  carotid  is  rarely  ligated.  The  Hhc  of  the  artery  is  parallel 
with  and  a  trifle  external  (not  internal  as  one  would  suspect  from  the  name) 
to  that  of  the  external  carotid.  The  musettlar  guide  is  the  sternomastoid, 
and  the  incision  that  for  the  external  carotid.  The  sternomastoid  is  retracted 
backwards,  the  pxisterior  lielly  of  the  digastric  upwards,  and  the  external 
carotid  forwards.  The  needle  is  passed  from  without  inwards,  carefully 
avoiding  the  internal  jugular  vein  and  the  pneumogastric  nerve. 

The  external  carotid  extends  from  the   bifurcation  of  the  common 

'carotid,  on  a  level  with  the  superior  border  of  the  thyroid  cartilage,  to  naidway 

between  the  external  auditory  meatus  and  the  condyle  of  the  lower  jaw'.    The 

line  of  the  arter)^  is  the  upper  portion  of  that  for  the  common  carotid,  the 

\  muscular  guide  the  sternc>mastoid,  and  the  position  of  the  patient  that  for 

^ligation  of  the  common  carotirb     A  three  inch  incision,  with  the  center  at  the 

great  cornu  of  the  hyoid  bone,  is  made  along  the  arterial  line,  severing  the 

[skin,  both  layers  of  the  superficial  fascia,  which  includes  the  [ilatysma,  and 

Uhe  deep  fascia.     The  sternomastoid  is  retracted   outwards,   the  posterior 

belly  of  the  digastric  and  the  stylohyoid  upwards,  and  the  hypoglossal  nerve 

I  inwards.     The  point  of  election  for  ligation  is  opposite  to  the  tip  of  the  great 

I  cornu  of  the  hyoid  bone,  and  between  the  superior  thyroid  an'l  lingual 

arteries.     T'he  superior  thyroid,  lingual,  and  facial  veins,  which  lie  in  front 

of  the  artery,  should  be  avoided,  and  any  lymphatit  glands  which  are  in  the 

way  removed.     The  needle  is  passed  from  without  inward,  carefully  avoiding 


208 


VASCULAR   SYSTEM. 


the  superior  laryngeal  nerve,  which  lies  behind  the  artery.  The  artery  is 
distinguished  from  the  common  carotid  and  from  the  internal  carotid  by 
the  presence  of  hranrhes. 

The  superior  thyroid  arises  from  the  external  carotid  close  to  its  origin, 
passes  upwards  and  inwards,  then  downwards  and  forwards  to  the  thyroid 
gland.  A  two  inch  incision,  with  its  center  on  a  level  with  the  upper  edge 
of  the  thyroid  cartilage,  is  made  along  the  carotid  line,  and  the  externa! 
carotitl  exposed.  The  artery  is  then  tied,  care  being  taken  to  avoid  the  su- 
j)erior  thyroid  veins  and  the  superior  laryngeal  nerve. 

The  lineal  artery  (Fig.  130)  may  l)e  tied  close  to  its  origin  through  the 
incision  for  the  exposure  of  the  external  carotid,  or  under  the  hyoglossus 


LV 


V^^AMirit 


Gm^yJtyffA 


\SeaJ4 


Fig.    130. — Ligaiure  of  subclavian   and    lio|Tual   arteries.     (Moullin.) 

in  the  submaxillary  triangle.  In  the  latter  operation  the  patient  is  placed  in 
the  same  position  as  that  for  the  ligation  of  the  carotid.  A  curved  incision, 
with  its  center  opposite  the  greater  cornu  of  ihe  hyuid  bone,  is  made  from 
lielow  and  external  to  the  symphysis  menti,  to  below  an<l  within  the  point 
where  the  anterior  edge  of  the  masseter  joins  the  lower  border  of  the  Jaw, 
severing  the  skin,  both  layers  of  the  superlicial  fascia,  and  the  platysma.  The 
submaxillary  gland,  which  lies  in  a  compartment  of  the  deep  fascia,  is  rctractefi 
upwards  after  severing  the  deep  fascia,  thus  exposing  the  two  bellies  of  I  he 
digastric,  the  posterior  edge  of  ihe  mylohyoid,  ami  the  hyoglossus.  The 
digastric  tendon  is  retracted  downwards,  and  the  hypoglossal  nerve  (the  guide 
to  the  artery)  and  the  ranine  vein,  which  cross  the  hyoglossus,  are  pushed 
upwards;  the  hyoglossus  is  divided  transversely  between  the  nerve  ancj  the 
hyoid  bone.  The  artery  lies  immediately  beneath  the  muscle  on  the  middle 
constricler  of  the  jjharynx,  and  is  tied  by  passing  the  needle  from  above 
il  own  wards. 

The  facial  artery  (Fig.  129)  may  be  lied  thixjugh  the  incision  for  ligation 


LIGATION   OF  ARTERIES. 


209 


of  the  external  carotid,  or  at  the  point  where  it  crosses  the  lower  border  of  the 
jaw  immediately  in  front  of  the  masseter,  by  making  a  small  transverse  incis- 
ion through  the  skin,  platysma,  and  fascia.  The  needle  is  passed  from 
behind  forwards,  to  avoid  the  vein,  which  lies  behind. 

The  temporal  artery  may  be  tied  in  front 
of  the  auditory  meatus  at  the  point  where  it 
crosses  the  zygoma.  A  small  vertical  incision 
is  made  through  the  skin  and  fascia,  between 
the  tragus  and  the  condyle  of  the  jaw,  and  the 
vessel  tied  just  above  the  root  of  the  zygoma, 
avoiding  the  auriculo-temporal  nerve  and 
branches  of  the  temporo-facial  portion  of  the 
seventh  nerve. 

The  occipital  artery  may  be  tied  at  its 
origin,  through  the  incision  made  for  the  ex- 
ternal carotid,  or  behind  the  mastoid  process. 
In  the  latter  operation  an  incision  is  made  from 
the  tip  of  the  mastoid  upwards  and  backw^ards 
towards  the  occipital  protuberance.  The 
posterior  fibers  of  the  stemomastoid,  the 
splenius,  and  the  trachelomastoid  are  severed, 
and  the  vessel  tied  between  the  mastoid  process 
and  the  transverse  process  of  the  atlas. 

The  subclavian  artery  (Fig.  130)  arises 
from  the  innominate  on  the  right,  and  the  arch 
of  the  aorta  on  the  left,  and  extends  from  the 
stemoclaN-icular  joint  to  the  lower  border  of 
the  first  rib.  It  is  divided  into  three  parts  by 
the  scalenus  anticus,  the  first  portion  l>ing  to 
the  inner  side  of  the  muscle,  the  second  behind, 
and  the  third  to  the  outer  side.  The  third  por- 
tion lies  in  the  subcla\ian  triangle,  which  is 
formed  by  the  clavicle  below,  the  posterior 
belly  of  the  omohyoid  on  the  outer  side,  and 
the  posterior  border  of  the  stemomastoid  on 
the  inner  side.  Ligation  of  the  first  or  second 
portion  is  very  rarely  performed.  The  line  of 
the  third  portion  is  from  the  posterior  border 
of  the  stemomastoid  to  the  anterior  border  of 
the  trapezius,  half  an  inch  above  and  parallel 
to  the  clavicle.  The  muscular  guide  is  the 
outer  border  of  the  scalenus  anticus,  which 
lies  approximately  behind  the  outer  border  of 
the  stemomastoid.  The  bony  guide  is  the 
tubercle  on  the  first  rib  into  which  the  scalenus 
anticus  is  inserted,  the  artery  lying  directly  behind  it.  In  ligation  of  the 
third  part  of  the  artery  the  thorax  is  raised,  the  neck  extended,  and  the 
head  turned  to  the  opposite  side.  The  size  of  the  subclavian  triangle  is 
increased  by  pulling  down  the  arm,  and  fixing  it  in  this  position  by  pushing 
the  forearm  under  the  l)ack.  An  incision  is  made  over  the  cla\icle,  from 
the  outer  margin  of  the  stemomastoid  to  the  inner  margin  of  the  trapezius, 

'4 


Fig.  131. — Diagram  to  show 
the  collateral  circulation  after 
ligature  of  common  carotid,  sub- 
clavian, and  axillary  arteries. 
A.  Common  carotid.  B.  Internal 
carotid.  C.  External  carotid. 
I).  Vertebral.  E.  Circle  of  Willis. 
F.  Basilar.  G.  Subclavian.  H. 
Thyroid  axis.  I.  Inferior  thyroid . 
J.  Superior  thyroid.  K.  Occipital. 
h.  Princeps  cervicis.  M.  Deep 
cer\'ical.  N.  Transversalis colli. 
().  Suprascapular.  P.  Posterior 
.scapular.  Q.  Dorsalis  scapulae. 
R.  Infrascapular.  S.  Subscap- 
ular. T.  I^ng  thoracic.  U. 
Short  thoracic.  V.  Superior  in- 
terco.stal.  X.  Internal  mam- 
mar)'.  Y.  and  Z.  Aortic  inter- 
costals.     (Walsham.) 


2IO 


VASCtJLAR  SYSTEM, 


after  the  skin  has  been  drawn  down.  This  maneuver  protects  the  external 
jugular  vein,  and  when  the  skin  is  released  leaves  the  wound  half  an  inch 
above  the  clavicle.  The  incision  involves  the  skin,  superficial  fascia  and 
platysma,  and  the  deep  fascia.  The  external  jugular  vein  is  retracted  inward 
or  divided  between  two  ligatures,  the  posterior  belly  of  the  omohyoid  retracted 
upwards,  and  the  scalenus  anticus  with  the  tubercle  on  the  first  rib  iden- 
tified. The  transverse  cer\ical  and  the  suprascapular  arteries  should  not  be 
injured,  as  they  assist  in  the  collateral  circulation.  The  subclavian  vein  lies 
in  front  of  and  below  the  fmger  as  it  rests  on  the  scalene  tubercle;  the  artery 
lies  behind  and  can  be  felt  pulsating  on  the  first  rib.  The  brachial  plexus 
Ue&  above  and  to  the  outside,  the  low-er  cord  passing  behind  the  vessel. 
With  the  finger  guarding  the  vein^  the  needle  is  passed  from  alx>ve  down- 
wards close  to  the  artery,  to  avoid  the  lowest  cord  of  the  plexus.  There  is 
also  some  danger  of  wounding  the  pleura. 

The  internal  mammary  artery  courses  downwards  on  the  inner  surface 
of  the  chest  waii,  about  half  an  inch  from  the  edge  of  the  sternum.  Il  may 
be  tied  after  dividing  the  intercostal  structures  outwards  from  the  edge  of  the 
sternum  for  an  inch  or  more.  In  order  to  secure  both  ends  of  a  divided 
internal  mammary,  which  is  absolutely  necessary  owing  to  the  freedom  of  the 
collateral  circulation,  a  portion  of  the  costal  cartilage  may  be  resected. 

The  vertebral  artery  has  been  tied  for  wounds,  secondary  hemorrhage 
following  ligature  of  the  innominate,  and  for  epilepsy.  An  incision  dividing 
the  skin,  superficial  fascia,  platysma,  and  rlecp  fascia,  is  made  along  the 
lower  half  of  the  posterior  Inirder  of  the  sternomastotd.  This  muscle  is 
retracted  forwards  with  the  external  jugular  vein  and  the  scalenus  anticus, 
upon  which  lie  the  phrenic  nerve  and  the  transverse  cervical  artery.  The 
transverse  process  of  the  sixth  cervical  vertebra  is  defined,  and  the  artery 
found  below  this  point  in  the  interval  between  the  scalenus  anticus  and  the 
iongus  colli.  The  vein  lies  sup>erficial  to  the  artery  and  is  drawn  to  the  outer 
side^  the  needle  being  passed  from  without  inwards,  care  being  taken  to  avoid 
the  pleura  antl  the  thoracic  duct. 

The  inferior  thyroid  may  l)e  tied  through  the  incision  made  for  ligation 
of  the  common  carotid  in  the  triangle  of  necessity.  The  sterno mastoid  and 
the  carotid  sheath  are  drawn  outwards,  the  omohyoid  upw^ards,  and  the 
sternohyoid  and  sternothyroid  divided  if  necessary.  The  artery  is  found 
below  the  transverse  process  of  the  sixth  cervical  vertebra  and  behind  the 
carotid  sheath.  Care  should  be  taken  not  to  injure  the  middle  cervical  gan- 
glion, the  recurrent  laryngeal  nerve,  the  esophagus,  or,  low  down  in  the  neck, 
the  thoracic  duct. 

The  axillary  artery  extends  from  the  lower  border  of  the  first  rib  to  the 
lower  border  of  the  tendon  of  the  teres  major.  It  is  divided  into  three 
portions  by  the  pectoralis  minor,  the  first  portion  being  above,  the  second 
behind,  and  the  third  below  that  muscle.  The  line  of  the  artery  is  from  the 
middle  of  the  clavicle  to  the  junction  of  the  anterior  and  middle  thirds  of 
the  outlet  of  the  axilla.  The  second  jxjrtion  of  the  artery  is  not  tied,  owing  to 
its  depth  and  to  the  fact  that  il  is  closely  surrounded  by  large  nen'e  trunks. 
Ligation  of  the  first  portion  may  be  accomplished  through  an  incision 
from  the  coracoid  process  of  the  scapula  to  within  one  inch  of  the  sterno- 
clavicular joint,  parallel  with  and  half  an  inch  below  the  clavicle.  After 
dividing  the  superficial  structures,  the  clavicular  portion  of  the  pectoralis 
major  is  severed  and  the  costo coracoid  membrane  incised  below  the  sub- 


LIGATION   OF  ARTERrKS, 


211 


clanus.  The  acroraiothoradc  arter)'  and  cephaHc  vein  are  avoided,  the 
pcctoralis  minor  drawn  downwards,  and  the  needle  passed  from  below  up- 
wards to  avoid  the  vein»  which  is  below  and  to  the  inner  side,  while  the  finger 
guards  the  brachial  plexus,  which  lies  above  and  to  the  outer  side.  In 
ligation  of  the  third  portion  (Figs.  132,  532)  the  arm  is  abducted,  and  a 
three  inch  incision  made  along  the  inner  border  of  the  rordnj^rarZ/iti/ij,  divid- 
ing the  skin  and  fascia*.  The  median  nerve  lies  on  the  artery  and.  with  the 
musculocutaneous  nerve,  which  is  more  external,  is  drawn  outwards.  The 
axillary  vein  and  the  ulnar  and  internal  cutaneous  nen^es,  which  lie  to  the 
inner  side,  are  separated,  and  the  ligature  passed  from  within  outwards* 

The  brachial  artery  underlies  a  line  drawn  from  the  junction  of  the  ante- 
rior with  the  middle  third  of  the  outlet  of  the  axilla,  to  a  point  midway  between 


WKm^m 


fffdm'  ^»^^^f<mmm  m^nm^ 


Fic,  tja, — Ligature  of  axil  1  an' 
artery*    (Moultin.) 


Fig.  133* — Ligature  of  hrachial 
artery.     (Moullin.) 


the  two  condyles  of  the  humerus,  The  mnscuiar  guide  is  the  inner  Ijorder 
of  the  biceps.  Ligation  at  the  middle  of  the  ami  (Figs.  133,  531)  is 
conducted  with  the  arm  abcfucled  and  the  forearm  supinated.  There  should 
be  no  support  beneath  the  arm  for  fear  that  the  soft  structures  might  be 
pushed  forwards  over  the  artery  and  so  complicate  the  operation.  An  inci- 
sion two  or  three  inches  long  is  made  along  the  inner  border  of  the  liiceps,  sev- 
ering the  skin  and  fascia\  The  muscle  is  retracted  outwards  and  the  median 
nerve,  which  at  the  middle  of  the  arm  crosses  the  artery  from  without  inwards, 
located.  The  nerve  is  displaced  to  the  more  convenient  side,  and  the  needle 
passed  fmm  it,  after  separating  the  vena?  comites  and,  above  the  middle  of 
the  arm,  the  basilic  vein,  which  here  lies  beneath  the  deep  fascia  and  close  to 
the  artery*  The  ulnar  nerve  lies  to  the  inside.  At  the  bend  of  the  elbow 
(Fig.  530)  the  biceps  tendon  is  the  guide.  A  two  inch  incision  is  made  along 
the  inner  edge  of  the  biceps  tendon  extending  down  to  the  crease  of  the 
elbow.  The  median  basilic  vein  is  drawn  downwards  and  inwards,  the 
bicipital  fascia  incised,  the  vena?  comiles  separated,  and  the  ligature  passed 
from  within  outwards  to  avoitl  the  median  nerve. 

The  ulnar  artery  curves  from  its  point  of  origin  about  one  inch  l*elow 
the  Iwnd  of  the  elbow,  to  the  ulnar  side  of  the  forearm^  thence  passes  down- 
ward to  the  radiai  side  of  the  pisift»rm  iKine.     The  Vnte  of  (he  upper  third  is 


1 


212  VASCULAR  SYSTEM. 

from  the  middle  of  the  front  of  the  elbow  joint  to  the  junction  of  the  upper  and 
middle  thirds  of  the  ulna.  The  line  of  the  kwer  two-thirds  is  from  the  apex 
of  the  internal  condyle  of  the  humerus  to  the  radial  side  of  the  pisiform  bone. 
The  muscular  guide  is  the  outer  border  of  the  flexor  carpi  ulnaris.  Ligation 
at  the  wrist  (Fig.  134)  is  accomplished  by  making  an  incision  an  inch  or 
more  in  length  along  the  radial  border  of  the  flexor  carpi  ulnaris,  which  is 
drawn  inwards  after  the  deep  fascia  has  been  opened.  The  ligature  is  passed 
from  within  outwards  to  avoid  the  ulnar  nerve,  which  lies  to  the  ulnar  side 
of  the  artery.  Ligation  of  the  middle  third  (Fig.  529)  is  performed  by 
making  a  three  inch  incision  in  the  line  of  the  vessel,  dividing  the  deep  fascia, 
and  separating  the  flexor  carpi  ulnaris  from  the  flexor  sublimis  digitorum; 
this  interspace  is  marked  by  a  whitish  or  yellowish  line,  which  is  often  indis- 
tinct and  sometimes  absent,  but  may  always  be  distinguished  by  moving  the 
wrist  and  the  fingers. 

The  radial  artery  underlies  a  line  drawn  from  midway  between  the  tips 
of  the  condyles  of  the  humerus,  to  the  ulnar  side  of  the  styloid  process  of  the 

radius.      The   muscular  guide  is  the  inner 
Tkffi fascia  border  of  the  supinator  longus.    For  ligation 

in  the  upper  third  (Fig.  529)  make  a  three 
inch  incision  along  the  line  of  the  vessel, 
divide  the  fascia;,  retract  the  supinator  longus 
outwards,  and  pass  the  needle  from  without 
inwards.  The  radial  nerve  lies  to  the  radial 
side  of  the  vessel.  For  ligation  above  the 
wrist  (Fig.  134)  an  incision  is  made  in  the  line 
of  the  vessel,  the  fasciae  divided,  and  the  vessel 
Fui.  134.  -Ligature  of  the  radial  ^^^i^^  between  the  supinator  longus  and  the 
and  ulnar  arteries.    (Nfoullin.)      flexor  carpi   radialis.     In  this  situation  the 

radial  nerve  lies  on  the  dorsum  of  the  forearm 
and  is  not  encountered.  A  small  superficial  vein  may  overlie  the  artery, 
and  branches  of  the  external  cutaneous  nerve  may  be  seen.  At  the  back 
of  the  wrist,  or  in  la  tabaiihe  (snuff  box),  which  is  bounded  internally  by 
the  tendon  of  the  extensor  primi  intemodii,  and  externally  by  the  extensor 
secundi  intemodii  pollicis,  the  line  of  the  artery  is  from  the  tip  of  the  styloid 
process,  to  the  posterior  angle  of  the  first  interosseous  space.  An  incision 
is  made  between  the  tendons,  from  the  styloid  process  to  the  base  of  the 
first  metacarpal  bone.  Beneath  the  skin  will  be  found  the  superficial 
radial  vein  and  a  few  branches  of  the  radial  nerve.  The  deep  fascia  is 
then  opened  and  the  artery  exposed. 

The  abdominal  aorta  has  been  tied  15  times  with  15  deaths,  although 
one  patient  lived  10  days,  one  39  days,  and  one  48  days.  The  operation  is 
ptTformcd  by  opening  the  abdomen  in  the  median  line,  retracting  the  in- 
testines, incising  the  posterior  parietal  peritoneum,  and  tNing  the  vessel. 
The  common  iliac  artery  extends  from  the  aorta,  opposite  the  left  side 
of  the  luxly  of  the  fourth  lumbar  vertebra,  for  two  inches,  to  the  upper  end 
of  the  sacroiliac  synchondrosis.  The  line  of  the  arter)'  is  the  upper  two  inches 
of  a  line  drawn  from  a  point  half  an  inch  below  and  to  the  left  of  the  umbilicus, 
tt>  midway  between  the  anterior  superior  spine  of  the  ilium  and  the  symphysis 
pubis.  The  vessel  may  l)e  tied  by  the  transperitoneal  or  by  the  retroperitoneal 
route.  The  transperitoneal  route  is  preferable.  The  abdomen  is  opened 
through  the  loft  rectus  muscle  bv  an  incision  whose  center  is  a  little  below 


LIGATION   OF  ARTERIES. 


213 


the  umbilicus.  The  intestines  are  pushed  aside,  the  posterior  parietal  perito- 
neum opened,  and  the  needle  passed  from  the  patient's  right  to  left,  on  both 
sides  of  the  body,  as  the  vein  lies  behind  the  artery  on  the  right  side,  and 
behind  and  internal  to  it  on  the  left.  In  the  retroperi- 
Umeal  meihod  an  incision  is  made  from  just  above  the 
internal  abdominal  ring,  above  and  parallel  to  Poupart's 
ligament,  curving  upwards  as  the  outer  end  of  this 
structure  is  readbed,  to  near  the  tip  of  the  cartilage 
of  the  eleventh  rib.  The  abdominal  muscles  and  the 
transversalis  fasda  are  divided,  and  the  unopened  peri- 
toneum pushed  upwards  and  inwards.  The  ureter 
crosses  the  artery,  but  usually  adheres  to  the  peritoneum 
and  is  carried  out  of  harm*s  way  with  it.  The  deep 
muscular  guide  is  the  inner  border  of  the  psoas  magnus 
muscle.  The  ligature  is  passed  as  in  the  previous 
operation. 

The  internal  iliac  may  be  tied  extraperitoneally  or 
transperitoneally  through  the  incisions  given  for  the 
common  iliac. 

The  gluteal  artery  emerges  from  the  pelvis  through 
the  upper  part  of  the  great  sacrosciatic  foramen,  at  the 
junction  of  the  upper  and  middle  thirds  of  a  line  drawn 
from  the  posterior  superior  spine  of  the  ilium  to  the  top 
of  the  great  trochanter.  An  incision  is  made  along  this 
line,  the  fibers  of  the  gluteus  maximus  separated,  the 
deep  fasda  opened,  and  the  artery  exposed  by  separating 
the  gluteus  medius  from  the  pyriformis.  The  sciatic 
and  internal  pudic  arteries  may  be  reached  through  an 
indsion  parallel  with,  but  one  and  one-half  inches  lower 
than,  that  used  for  the  gluteal  artery.  The  fibers  of  the 
gluteus  maximus  are  separated,  and  the  vessels  found 
emerging  from  the  lower  part  of  the  great  sacrosciatic 
foramen,  at  the  lower  border  of  the  pyriformis  and  just 
below  the  great  sciatic  nerve. 

The  external  iliac  artery  underlies  the  lower  two- 
thirds  of  a  line  drawn  from  one-half  inch  below  and  to 
the  left  of  the  umbilicus,  to  midway  between  the  anterior 
superior  spine  of  the  ilium  and  the  symphysis  pubis. 
The  artery  may  be  tied  by  the  transperitoneal  method 
through  an  incision  in  the  middle  line  or  in  the  semi- 
lunar line.  The  extraperitoneal  method  (Fig.  136)  is  per- 
formed through  an  incision  about  four  inches  in  length, 
extending  from  one-half  inch  above  the  middle  of 
Poupart's  ligament,  to  a  point  one  inch  above  and  one 
inch  internal  to  the  anterior  superior  iliac  spine.  After 
dividing  the  skin,  superfidal  fascia,  and  external  oblique, 
internal  oblique,  and  transversalis  muscles,  the  trans- 
versalis fasda  is  cautiously  opened,  and  the  peritoneum 
pushed  upwards  and  inwards  until  the  psoas  muscle,  along  the  inner  border 
of  which  the  vessel  runs,  has  been  exposed.  The  needle  is  passed  from 
within  outwards  to  avoid  the  vein.     One  should  be  careful  not  to  \iL\\Mfc  IVna 


I-'IG.  135.  — Dia- 
gram to  show  the 
collateral  circulation 
after  ligature  of  the 
axillary,  brachial, 
radial,  and  ulnar 
arteries.  A.  Bra- 
chial; B.  Radial;  C. 
Ulnar;  D.  Superior 
profunda;  E.  Inferior 
profunda;  F.  Anas- 
tomotica  magna;  (i. 
Radial  recurrent;  H. 
I  n  lerosseous  recu  r- 
rcnt;  I.  Anterior  and 
K.  Posterior  ulnar 
recurrent;  J.  Axil- 
lary; L.  Common  in- 
terosseous; M.  Poste- 
rior interosseous;  N. 
Anterior  interosse- 
ous; O  O.  Anterior 
and  posterior  carf)al ; 
P.  Deep  palmar  arch; 
Q.  Su{)erficial  \^\- 
mar  arch;  R.  Poste- 
rior circumflex;  S. 
Subscapular. 

(Walsham.) 


214 


VASCITLAK  SYSTEM. 


epigastric  or  the  cin  urn  Ilex  artery,  as  they  are  imptirtant  aids  in  establish- 
in|^  the  collateral  cin  ulatiun. 

The  line  of  the  femoral  artery  h  from  midway  l>etween  the  aiUerior  su- 
perior spine  of  the  ilium  and  the  symphysis  pubis,  to  the  inner  tondyle  of  the  , 
femun  The  fftusfniur  guide  is  the  sartorius,  which  lies  external  to  the  vessel 
in  the  upper  third,  in  front  in  the  middle  third,  and  to  the  inner  side  in  the] 
lower  third.  The  artery  may  l)e  ligated  just  below  Poupart*s  ligament,  at 
the  apex  of  Scarpa's  triangle,  or  in  Hunter's  canal.  Ligation  of  tJie  com- 
mon femoral  just  below  Poupart's  ligament  is  rarely  performed,  because  its 
numerous  branches  may  interfere  with  perfect  occlusion,  and  the  collateral 
circulation  is  much  more  free  after  ligation  of  the  external  iliac.  >\n  incision 
through  the  skin  and  superficial  fascia  is  made  in  the  line  of  the  artery,  from 


W 


£Sni 


MMrttrut^ 


136* — Ligature  of  external  iliac  and  superficial  femoral  arteries.     In  this  figure  the  in- 
cision for  the  femoral  artery  15  placed  ivta  low.     (MouUin.) 


^ 


a  little  above  Poupart's  ligament  downwards  for  two  or  three  inches.  The 
superficial  veins  and  the  lymphatic  glands  are  drawn  aj^ide^  the  fascia  lata  I 
divided,  and  the  sheath  opened.  The  needle  is  passed  from  w-ithin  outwards  1 
to  avoid  the  vein.  The  anterior  crural  nerve  lies  to  the  outer  side,  For^^ 
ligation  of  the  superficial  femoral  at  the  apex  of  Scarpa's  triangle  (Figs.^H 
136,  553)  an  incision  four  inches  in  length,  the  center  of  which  is  four  inches 
below  Poupart's  ligament,  is  made  along  the  arterial  line,  di\iding  the  skin 
and  fascia?.  The  sartorius  is  retracted  out^vards,  and  the  needle  passed  from 
within  outwards  to  avoid  the  vein,  which  in  this  situation  iies  to  the  inner  side 
of  and  behind  the  artery.  The  internal  cutaneous  nerve  lies  in  front  of  ihe 
vesseb  and  the  long  saphenous  nerve  lies  to  the  outer  side  on  a  deeper  plane. 
For  ligation  in  Hunter's  canal  (Fig.  552)»  a  four  inch  incision  is  made  in 
Jhe  line  of  the  arter}'  in  the  midflle  third  of  the  thigh.     After  dividing  the 


tIGATIOK  OF  ARTEIUEj;, 


215 


fascia  lata  the  sarturius  is  retrarlcil  inwanls,  the  tibrtms  rmif  of  Hunler's 

canal,  running  from  the  addurtur  hmgus  to  the  vastus  interaus,  incised,  and 

the    sheath    of   the    vessel    exposed.      The   long 

saphenous  nen'e  lies  upon  the  sheath  and  should 

be  drawn  out  of  the  way.     The  needle  is  passed 

from  without  inwards  to  avoid  the  femoral  vein, 

which  lies  behind  and  slightly  to  the  outer  side. 

The  popliteal  artery  (Fig.  545)  extends  from 
the  lower  end  nf  H  miter's  lanal,  at  the  j  on  it  ion  of 
the  middle  and  lower  thirds  of  the  thigh,  lo  the 
lower  border  of  the  popliteus  muscle.  The  iine  of 
the  anery  is  from  a  point  one  inch  internal  lo  the 
upper  angle  of  the  popliteal  space,  passing  mid- 
way lietween  the  condyles  of  the  femur,  to  the 
apex  of  the  lower  angle  of  the  space.  The  muscu- 
lar guide  in  the  upper  third  is  the  inner  border  of 
the  semimembranosus;  in  the  iower  part  the  vessel 
lies  midway  between  the  heads  of  the  gastrocne- 
mius. The  internal  popliteal  nerve  is  superficial 
lo  the  arter)%  and  the  vein  is  external  above,  but 
crosses  the  vessels  lower  down,  lying  between  the 
aner>'  and  the  internal  popliteal  nerve.  The  ex- 
ternal popliteal  nerve  lies  well  to  the  outer  side. 
In  ligation  of  the  upper  third  an  inrision  four 
inches  in  length  is  made  along  the  outer  border  of 
the  semimembranosus,  which  is  retracted  inwards, 
the  internal  popliteal  ner\'e  displaced  outwards, 
and  the  needle  passed  from  without  inwards,  as 
in  this  situation  the  vein  is  slightly  external.  The 
loiver  part  of  the  vessel  may  be  lied  through  an 
incision  midway  between  the  heads  of  the  gastroc- 
nemius, which  are  separated  while  guarding  the 
external  saphenous  vein  from  harm.  The  vein 
and  nerve  are  drawn  to  the  inner  side,  and  the 
needle  passed  from  within  outwards. 

The  posterior  tibial  artery  is  marked  by  b 
line  from  the  center  of  the  popliteal  space,  to  a 
point  a  fmger's  breadth  behind  the  internal  mal- 
leolus. Ligation  in  the  middle  of  the  leg 
(Figs.  138,  542)  is  performed  with  the  leg  flexed 
and  lying  on  the  outer  side.  An  incision  four 
inches  long  is  made  a  hnger*s  breadth  l>ehind  the 
internal  l>order  of  the  tibia,  dividing  the  skin  ant  I 
superficial  and  deep  fascia%  and  avoiding  the  long 
saphenous  vein  and  nerve.  The  gastrocnemius  is 
drawn  inwards,  the  solcus  and  the  aponeurosis  on 
its  under  surface  severed  and  retracted  back- 
wards, and  the  ves.sel  with  the  posterior  tibial 
ner\'e  to  the  outer  side  exposed  on  the  tibialis 
posticus.  After  separating  the  venair  co mites  the 
needle  is  passed    from    without    inwards.      For 


'l\ 


Fig.  137. —  Diagram  of  the 
collateral  rirculation  after 
ligature  of  the  common 
iliiic,  external  and  inlernaJ 
iliac,  femoral,  tjoplileal,  and 
arteries  of  the  leg.  A. 
Common  iliac:  B.  Ejtiemat 
ifiac;  C.  Internal  iliac;  !>. 
Last  lumbar;  E.  1 1 io- lum- 
bar; y.  Epigastric;  G.  Cir* 
cumflex  iliac;  H.  Obtura- 
tor; L  Gluteal;  J.  Lateral 
sacral;  K.  Sciatic;  L,  Ex- 
ternal circumtlex;  M,  Pro- 
funda; N.  Internal  drcum- 
flcx;  O.  Femoral;  I\  Comes 
ischiatici;  Q  Q  Q.  Perfor- 
ating; R,  Anastomotica 
magna;  S  S.  Superior  artic- 
ular;  TT.  Inferior  articular; 
I'.  Tibial  recurrent,  V. 
Popliteal ;  W,  Am  erior  tibial ; 
X,  Posterior  tibial;  Y.  Pero- 
neal.    (WalsluimO 


206 


VASCULAR   SYSTEM. 


and  cerebral  lesions.  An  indsion  is  carried  for  three  or  four  inches  along  the 
anterior  margin  of  the  right  stemomastoid  to  the  epistcmal  notch,  then  out- 
ward along  the  upper  margin  of  inner  third  of  the  clavicle,  severing  the  skin,  pla- 
tysma,  and  the  superhcial  and  deep  fasciae.  The  sternohyoid,  sternothyroid, 
and  inner  edge  of  the  sternomasloid  are  divided  and  retracted.  The  anterior 
jugular  vein  is  severed  between  two  ligatures,  the  carotid  sheath  opened,  and 
the  carotid  artery  followed  to  the  bifurcation  of  the  innominate.  Resection  of 
the  sternoclavicular  articulation  may  l>e  necessary  to  expose  the  vessel 
properly.  The  inferior  thyroid  veins  are  tied  or  drawn  aside,  the  right  inter- 
nal jugular  and  right  innominate  vein  are  pushed  to  the  right,  and  the  left 
innominate  vein  is  displaced  downwards.  A  strongly  curved  aneur>^sm 
needle  is  passed  from  without  and  below,  upwards  an<l  inwards,  care  being 
taken  not  to  injure  the  pneumogaslric  nerve  and  pleura,  which  lie  to  the 
right*     The  ligature  should  be  of  tloss  silk,  tied  in  a  stay  knot. 


^! 


--  nfr¥9 


Fig.  1^9. — Ligaiure  of  ihc  common  cartoid  and  fadat  arteries.     (MoulHn,) 

The  common  carotid  arises  from  the  innominate  on  the  right,  from  the 
arch  of  the  aorta  on  the  left .  The  line  0J the  artery  is  from  the  sternoclavicular 
articulation  to  midway  between  the  angle  of  the  jaw  and  the  tip  of  the 
mastoid,  the  vessel  bifurcating  at  the  upper  border  of  the  thyroid  cartilage. 
Whenever  possible  the  vessel  is  tied  above  the  anterior  belly  of  the  omohyoid, 
i.e.,  in  the  superior  carotid  triangle,  or  the  triangle  of  ekctian,  as  here  the 
vessel  is  more  superficial  and  the  operation  less  difficult.  The  triangle  of 
election  is  bounded  al>ove  by  the  posterior  belly  of  the  digastric,  l)ehind 
by  the  stemomastoid,  and  in  iuml  by  the  anterior  belly  of  the  omohyoid. 
The  inferior  carotid  triangle,  ( ailed  the  triangle  af  necessity  because  the  vessel 
is  tied  here  only  when  absolutely  necessa^)^,  is  bounded  above  by  the  anterior 


p 


207 


ly  of  the  nmohyoirl,  helow  by  the  stemomastoid,  and  in  front  by  the  median 
Ligation  in  the  triangle  of  election  (Fig.  i2q)  is  carried  out  with 
a  sand  pillow  Ijeneath  the  neck,  the  head  turned  towards  the  opposite  side, 
and  the  chin  raised.  A  three  inch  incision,  the  center  of  which  is  on  a  level 
with  the  cricoid  cartilage^  is  made  along  the  arteria!  line,  severing  the  skin, 
and  both  layers  of  the  supertkial  fascia,  between  which  lies  the  platysma,  and 
exposing  the  anterior  edge  of  the  sternomastoid,  which  is  the  mtisfular  guide 
to  the  artery »  After  cutting  the  deep  fascia  which  is  attached  to  the  border 
of  the  stemomastoid,  this  muscle  is  retracted  outwards,  the  omohyoid  drawn 
downwards,  and  the  costal  process  of  the  sixth  cerdcal  vertebra  (carotid 
tut>crcle  of  Chassaignac),  which  lies  immediately  under  the  artery  at  the  point 
where  it  is  crossed  by  the  omoyhoid,  felt  with  the  fniger.  The  sheath  of  the 
vessel  is  identified  by  means  of  the  descaufms  nmi  nert'e,  which  descends 
upon  it*  and  opened  on  the  inner  side  to  avoid  the  internal  jugular  vein^ 
which  lies  to  the  outer  side  in  a  separate  compartment.  The  pneumogastric 
nerv'e  lies  behind  and  l>etween  the  artcr}'  and  vein,  in  a  separate  compartment 
of  the  same  sheath.  The  needle  is  passed  from  without  inwards. 
Ligation  in  tlie  triangle  of  necessity  (Fig.  129)  is  performed  by  making  a 
three  inch  incision  downward  along  the  arterial  line  from  the  level  of  the 
cricoid  cartilage.  The  stemomastoid  is  drawn  outwards,  the  sternohyoid 
and  sternothyroid  inwards,  the  omohyoid  upwards.  The  sheath  is  opened  on 
the  inner  side  and  the  operation  completed  as  described  above.  The  inferior 
thyroid  veins  may  be  tied  if  they  are  in  the  way;  in  the  lower  part  of  the  neck 
the  anterior  jugular,  and  on  the  left  side,  the  internal  jugular,  lie  in  front  of 
the  arter}'  and  must  be  carefully  retracted.  Ligation  of  the  common  carotid, 
in  one-fourth  of  the  cases,  results  in  cerebral  complications,  which  may  be 
immediate,  such  as  collapse  from  cerebral  anemia,  or  which  take  the  form 
of  cerebral  softening,  causing  hemiplegia.  One- half  of  those  developing 
intracranial  trouble  die. 

The  internal  carotid  is  rarely  ligated.  The  line  of  the  artery  is  parallel 
with  and  a  trifle  external  (not  internal  as  one  would  suspect  from  the  name) 
to  that  of  the  external  carotid.  The  muscular  guide  is  the  stemomastoid, 
and  the  incision  that  for  the  exiernal  carotid.  The  stemomastoid  is  retracted 
backwards,  the  posterior  l>elly  of  the  digastric  upwards,  and  the  external 
.  carotid  forwards.  The  needle  is  passed  from  without  inwards,  carefully 
'  avoiding  the  internal  jugular  vein  and  the  pneumogastric  nerve. 

The  external  carotid  extends  from  the  bifurcation  of  the  common 
carotid,  on  a  level  with  the  superior  border  of  the  thyroid  cartilage,  to  midway 
between  the  exiernal  auditory  meatus  and  the  condyle  of  the  lower  jaw.  The 
line  of  the  arter>'  is  the  upper  portion  of  that  for  the  common  carotid »  the 
muscular  guide  the  stemomastoid,  and  the  position  of  the  patient  that  for 
ligation  of  the  common  carotid.  A  three  inch  incision,  with  the  center  at  the 
great  cornu  of  the  hyoid  bone,  is  made  along  the  arterial  line,  severing  the 
^skin»  both  layers  of  the  superficial  fascia,  which  includes  the  jjfatysma,  and 
the  deep  fascia.  The  stemomastoid  is  retracted  outwards,  the  p<jsterior 
belly  of  the  digastric  and  the  stylohyoid  upwards,  and  the  hypoglossal  nerve 
inwards.  The  point  of  election  for  ligation  is  opposite  tt)  the  tip  of  the  great 
comu  of  the  hyoid  bone,  and  between  the  superior  thyroid  anil  lingual 
arteries.  The  superior  thyroid,  lingual,  and  facia!  veins,  which  lie  in  front 
of  the  artery,  should  be  avoided,  and  any  lymphatic  glands  which  arc  in  the 
way  removed.     The  needle  is  passed  from  without  inward,  carefully  avoiding 


2I« 


LYMPHATIC  SYSTEM. 


Congenital  lymphangiectasis  may  ok  yrus  varkose  lymph  vessels  more 
or  It'ss  genrralizcil  over  tcrlaiii  ptjrttons  of  the  liody,  or  as  a  localized  lym- 
phatic dilatation  with  marked  proliferation  of  the  connective  tissue  elements 
of  the  part,  such  as  is  seen  in  macroglossia  {p.  424),  macrockeiila  (p.  420), 
and  in  fieims  iympkaiicus. 

Acquired  lymphangiectasis  is  the  result  of  obstruction  from  tumors, 
cicatrices,  filana,  thrombolymphangitis,  or  removal  or  destruction  of  lymph 
glands.     Rupture  of  dilated   lymph    vessels   is   followed   by  lymphorrkea, 
causing  chyluria,  chykms  ascites,  fhyiotJtarax,  fhyhms  diarrhea,  chylous  hydro- 
ceifj  etc.     Obstructive  lymphangiectasis  is  accompanied  by  a  solid  or  lym- 
phatic edema  in  which  there  is  little  or  no  pitting  on  pressure.     The  skin  and 
subcutaneous  tissues  are  greatly  thickened,  the  former  presenting  a  coarse, | 
corrugated   surface   covered   with   lymphatic  warts ^ 
which  may  ulcerate  and  give  rise  to  lymphatic  fistultt. 
When  the  obstruction  is  caused  by  the  iilaria  san- i 
guinis  hominis,  the  condition  is  called  elephantiasis* 
Arabum,  or  true  elephantiasis;  when  the  result  of  other 
forms  o  f  o  list  ruction,  ps  eu  doeieph  a  n  t  ia  sis .     El  ep  h  a  n  - 
tiasis  Arabum  is  rarely  seen  outside  of  the  tropics. 
The    parts    most   frequently   affected   are   the  legs 
(Barhadoes  kg),  scrotum  (tig.  i4i)»and  vulva.     Thej 
hyperplasia   is   enormous,   the   scrotum    sometimesl 
reaching  the  ground.     The  filaria  sanguinis  hominis  I 
passes   its    intermediate   stage  in  the  body   of  the 
mosquito,   the   ova    entering   the    human   bidy   by 
means  of  contaminated   water,  or  possibly  directly, 
from    the   bite  of   a   mosquito.     The   worm    finally* 
lodges  in  the  lymphatics,  produces  obstruction,  and 
liberates  a  large  numl^er   of   embr}^os.     The  adult 
worm  may  be  as  long  as  three  inches.     The  embryos  are  about  j^\  in.  in 
length,  and  are  found  in  the  blood  during  the  night,  or  at  least  during  the 
time  that   the  patient  selects   for  repose.     Areas  of  lymphangiectasis  are 
subject  to  attacks  of  indammalion,  often  associated  with  chill  and  fever 
(eiephanimd  fe^'er),  and  sometimes  eventuating  in  abscess. 

The  treatment  of  lymphatic  varix  is  excision.  Elephantiasis  may  bc^ 
treated  by  massage  and  elastic  bandages,  elevation,  ligation  of  the  artery  of 
supply ^  or  removal  of  the  diseased  tissue,  e.g.,  by  amputation  of  the  scrotum 
or  the  lower  extremity.  In  a  few  cases  of  true  elephantiasis  the  parent 
filaria  has  been  localized  and  removed. 
Lj^phangioma  (see  section  on  tumors). 
Acute  lymphangitis  always  follow  infective  processes  within  the  area 
drained  by  the  inflamed  vessels.  The  walls  of  the  lymphatics  and  generally 
the  tissues  surrounding  the  vessels  take  on  the  ordinary  changes  of  inflam- 
mation, and  lymph  thromliosis  may  ensue.  The  process  ends  in  resolution 
or  in  suppuration.  In  the  former  instance  recovery  may  be  only  partial, 
obliteration  or  dilatation  of  the  vessels  ensuing. 

The  symptoms  are  those  of  sepsis.  In  Itibular  lymphangiiisj  in  which  the 
large  lymph  vessels  alone  are  involved,  red  lines  may  be  seen  coursing  from 
the  infected  area  to  the  nearest  glands.  There  may  or  may  not  be  tenderness 
and  edema.  In  ret  if  arm  lymph  an  gilts  the  capillar)'  lymph  vessels  are  affected 
and  the  redness  is  general;  this  condition  is  practically  the  same  as  ery^sipelas. 


Fio.  1 4 1 .— Elcphaniiasis 
of  scrotum,     (Nolan.) 


LYMPHADENITIS. 


219 


In  either  instance  suppuralioii  may  Ik*  t'luuiinlerLHl,  either  along  the  lymph 
vessels  OT  in  the  lymphatit  glamJs. 

The  treatment  is  primarily  the  dismfection  of  the  wound  from  which  the 
absorption  of  infection  is  taking  place.  The  limli  should  he  elevated  and  put 
at  rest,  and  the  lymph  vessels  covered  with  an  ointment  containing  ichthyul, 
belladonna,  and  mcrrur)-.  In  ihe  early  stages  cold,  and  later  heat,  may  be 
of  semce.  Suppuration  demands  incision  and  drainage.  The  constitutional 
treatment  is  that  of  sepsis. 

Chronic  lymphangitis  may  follow  an  acute  attack,  or  it  may  be  chronic 
from  the  beginning,  e.g.,  in  syphilis,  tuberculosis,  and  elephantiasis.  The 
treatment  is  thai  of  the  cause;  in  some  instances,  particularly  in  the  tuber- 
culous variety,  excision  may  be  attempted. 

Acute  l3rmphadenitis  is  due  to  the  same  causes  as  acute  lymphangitis, 
and  occasionally  follows  cold  or  injury,  inflammator}^  processes  in  contiguous 
stnictores,  or  infection  from  the  lilood  stream.  The  lymph  vessels  may  or 
may  not  participate  in  the  inflammation.  The  glands  enlarge  as  the  result 
of  the  hyperemia  and  exudation,  ant!  the  surrounding  tissues  are  usually  more 
or  less  involved  in  the  process  {perladeniiis). 

The  symptoms  are  those  of  fever  in  all  but  the  mildest  cases.     The  glantls 
rare  tender  and  palpably  enlarged.     In  the  severer  cases  the  overlying  skin 
ecomes  red,  edematous,  and  adherent,  and  the  glands  are  welded  into  one 
iiass,  which  finally  softens  owing  to  the  formation  of  pus. 

The  treatment  in  the  early  stages  is  that  of  acute  lymphangitis.     The 

>urce  of  infection  is  often  of  a  trivial  nature  and  frequently  overlooked. 

scratch  on  the  foot  is  sufficient  to  produce  kv  femoral  adaiith,  in  which  the 

^ands  about  the  saphenous  opening  are  involved.     In  inguinal  adenitis,  in 

irbich  the  glands  running  paraUel  to  Poupart's  ligament  are  inflamed,  and 

to  which  the  term  bubo  is  commonly  applied,  the  penis,  urethra,  scrotum, 

lower  part  of  the  abdomen,  anus,  perineum,  and  buttock  should  be  carefully 

examined.     In  cenmal  adenitis  the  scalp  should  be  inspected  for  conditions 

like  eczema  or  pediculosis,  the  ear  for  chronic  inflammation  or  skin  lesions, 

the  b'ps  for  cracks  or  ulcers,  the  teeth  for  caries,  the  gums  for  pyorrhea,  and 

I  the  tongue  and  throat  for  lesions  through  which  infection  might  gain  access. 

'When  suppuration  is  threatened  poultices  may  be  applied,  but  pus  should  be 

evacuated  as  soon  as  it  forms. 

Chronic  lymphadenitis  follows  the  acute  form,  particularly  when  the 
ISource  of  irritation  has  nol  been  removed;  it  also  occurs  as  the  result  of 
ichronic  infection,  particularly  by  the  infectious  granulomata,  the  most  impor- 
ptant  of  which  are  syphilis  and  tuberculosis. 

The  diagnosis  of  the  cau.se  of  chronically  enlarged  glands  involves  a 
consideration  of  the  chronic  simple  form,  ihe  tuberculous  and  syphilitic 
varieties,  Hodgkin*s  disease,  lymphatic  leukemia,  and  primary  and  secondary 
new  growths.     In  chronic  simple  lymphadenitis  some  source  of  continuous 
irritation  in  the  area  drained  by  the  lymph  glands  may  l>e  discovered.     Al- 
though the  glands  are  enlarged  and  perhaps  tender,  they  do  not  tend  to  mat 
together  or  to  suppurate.     Removal  of  the  source  of  irritation  results  in  cure. 
If  recovery  does  not  follow  appropriate  treatment,  a  strong  suspicion  of  tuber- 
iculosis  should  l>e  entertained.     Tuberculous  lymphadmitis  progresses  despite 
loual  treatment,  and  successively  involves  gland  after  gland.     The  glands 
bhow  a  strong  tendency  to  adhere  to  each  other  and  to  the  skin,  and  to  undergo 
aus  degeneration.     The  condition  is  most  common  in  children,  in  whom 


220  "^^^«    J  LYMPHATIC    SYSTEM. 

5ther  si(jus  of  tuberculosis  may  be  recognized.  The  family  histurj'  is  of  st»me 
importance.  The  use  of  tuberculin  for  diagnosis  is  not  generally  employed 
(see  diagnosis  of  tuberculosis,  p.  1,^4).  In  the  neck  tuberculous  glands  usu- 
ally make  their  appearance  first  in  the  sybmaxillary  triangle.  Syphiliik 
lymphadenitis  is  diagnosticated  by  the  history  of  a  sore,  by  associated  lesions 
of  syphilis,  by  the  Wasserman  test,  and  by  the  results  of  treatment.  The 
glands  are  hard,  discrete,  not  adherent  to  each  other  or  to  the  skin,  do  not 
tend  to  suppurate,  and  are  neither  painful  nor  tender.  The  enlargement  in 
the  primary  stage  is  confined  to  the  glands  anatomicaUy  related  to  the  sore; 
during  the  secondary  period  the  distribution  is  general,  the  epitrochlear  and 
post-cervical  glands  always  being  involved;  in  the  tertiary  period  the  glands 
may  become  gummatous,  the  diagnosis  then  resting  upon  the  histor)' 
and  the  results  of  treatment.  In  Hodgkins  disease  (pseudoleukemia,  general 
lymphadenosis)  the  enlargement  is  usually  first  noticed  at  the  root  of  the  neck, 


FiG.  142.— Hodgkin*s  disease,     (Longcope — Pennsylvania  Hospital.) 

and  then  spreads  to  other  groups  of  glands,  sometimes  involving  the  lymphatic 
structures  throughout  the  body  and  often  the  spleen.  The  glands  increase 
rapidly  in  size,  forming  enormous  masses  in  which  the  individual  glands  are 
readily  made  out,  the  mass  resembling  a  bunch  of  large  grapes;  there  are  little 
or  no  pain,  periadenitis,  and  rarely  suppuration  (Fig.  142).  In  some  instances 
the  disease  remains  localized  for  a  considerable  time.  The  nature  of  the 
contlition  is  not  quite  clear,  some  believing  it  to  be  sarcomatous,  some  tuber- 
culous, and  some  a  distinct  morbid  entity.  Recurring  attacks  of  inter- 
mittent fever  are  common.  The  Ijloud  shows  no  cbaracteristic  changes 
beyond  those  of  a  progressive  anemia.  If  a  marked  leukocytosis,  or  a  relative 
lymphocytosis  without  an  increa.sc  in  the  number  of  white  cells,  is  found,  the 
condition  is  called  lympkaik  leukemia.  The  disease  is  fatal  in  from  a  few 
months  to  several  years.  Malignant  disease  of  the  lymph  glands  is  charac- 
terized by  rapid  growth,  and  by  infiltration  of  the  surrounding  tissues,  inciud- 
ing  skin,  muscle,  etc.  There  is  considerable  pain,  and  there  may  be  soften- 
ing, with  later  the  discharge  of  a  pultaceous  materiab  If  carcinomatous,  it  is 
always  secondary  to  a  primary'  growth  elsewhere.  Lymphosarcoma,  mela- 
notic sarcoma,  and  sarcoma  of  the  tonsil,  testis,  and  thyroid  also  cause  sec- 


NEURITIS.  221 

ondary  growths  in  the  lymph  glands.  In  the  absence  of  a  primary  growth 
it  is  sarcomatous  (lymphosarcoma).  Lympkadenoma  and  lymphoma  are  terms 
loosdy  employed  to  designate  chronically  enlarged  glands,  either  inflamma- 
tory or  neoplastic  in  nature. 

The  treatment  of  chronic  lymphadenitis  when  of  a  simple  nature,  consists 
in  rest  of  the  part,  the  removal  of  all  forms  of  irritation,  the  local  application 
of  iodin,  belladonna,  mercury,  or  ichthyol,  and  the  administration  of  tonics. 
In  the  presence  of  syphilis  antis3rphilitic  treatment  should  be  given.  Tuber- 
cuhus  adenitis  demands  thorough  removal  of  the  diseased  glands  by  opera- 
tion, imless  the  general  condition  of  the  patient  forbids  such  treatment. 
Recurrence  takes  place  in  probably  half  of  the  cases,  and  should  be  dealt  with 
in  the  same  manner  as  the  primary  focus.  Fresh  air,  good  food,  and  tonics 
are  always  essential.  When  thorough  removal  is  impracticable,  as  much 
of  the  broken  down  gland  tissue  as  possible  should  be  removed  with  the 
curette.  Hodgkin*s  disease  and  lymphatic  leukemia  may  be  treated  by  the 
X-ray,  the  internal  administration  of  arsenic,  and  injections  of  Coley's  fluid. 
If  the  glandular  enlargement  is  sufficiently  localized,  extirpation  should  be 
advised.    Malignant  disease  of  lymphatic  glands  requires  thorough  removal. 

Status  lymphaticuSi  or  lymphatisnoi,  is  a  hyperplasia  of  the  thymus, 
spleen,  lymph  tissues,  and  lymphatic  glands  of  the  entire  body,  including  the 
lymphoid  bone  marrow.  It  may  be  associated  with  rickets,  goiter,  or  hypo- 
plasia of  the  heart  and  aorta.  It  may  be  found  in  adults  but  is  most  frequent 
in  children.  This  condition  is  of  interest  to  the  surgeon,  because  every  now 
and  then  it  is  responsible  for  sudden  death  during  or  some  time  subsequent  to 
o{>eration,  often  of  the  most  trivial  nature.  The  cause  of  death  is  not  clear; 
in  a  few  instances  pressure  of  the  enlarged  thymus  on  the  trachea  seems  to  be 
responsible,  but  in  most  cases  a  lympho-  or  thymo-toxemia  better  fits  the 
conditions  found  postmortem.  The  diagnosis  of  lymphatism  should  make 
one  hesitate  to  perform  an  o{>eration  of  election.  The  patients  are  usually 
anemic,  the  tonsils  hypertrophied,  the  lymph  glands  generally  enlarged,  the 
thyroid  more  prominent,  and  the  thymus  increased  in  size,  giving  dulness  on 
percussion  over  the  sternum,  and  sometimes  causing  attacks  of  thymic 
asthma,  which  some  consider  identical  with  laryngismus  stridulus.  In  at 
least  seven  instances  the  enlarged  thymus  has  been  dealt  with  surgically.  A 
portion  may  be  removed,  or  the  gland  may  be  drawn  up  and  fastened  in  the 
neck. 


CHAPTER  XVII. 
NERVES. 


Neuritis  may  be  acute  or  chronic;  limited  to  a  single  nerve  or  group  o 
ner\'es,  or  widely  distributed  {polyneuritis j  or  multipk  neuritis).  It  is  caused 
by  external  influences,  such  as  cold,  injuries  (p.  223),  and  extension  of  in- 
flammation from  contiguous  structures;  or  by  toxic  or  infectious  agents 
reaching  the  nerves  through  the  blood,  such  as  lead,  arsenic,  alcohol,  diph- 
theria, gout,  rheumatism,  sjrphilis,  beri-beri,  etc. 

The  symptoms  of  the  localized  form,  which  alone  is  amenable  to  surgical 
treatment,  are  sharp  pain  and  tenderness  along  the  ner\'e,  which  is  sometimes 


222 


NERVES. 


palpably  swollen.  In  ihe  early  stages  there  may  be  hyperesthesia  of  the 
skin,  and  iwjtrhing  or  spasms  of  the  muscles;  later  with  the  onset  of  degen* 
erative  changes  there  are  paresthesia,  such  as  numbness  or  formication,  and 
possibly  complete  anesthesia,  paresis  or  paralysis  of  the  muscles,  and  various 
trophic  lesions,  such  as  edema,  glossy  skin,  loss  of  the  hair  ami  nails,  anky- 
losis of  joints,  ulrers,  localized  sweating,  and  atrophy  of  the  muscles  (which 
show^  the  reaction  of  degeneration,  p.  224}.  Particularly  in  traumatic  cases 
the  inflammation  may  spread  upwards  to  the  spinal  cord,  and  even  to  the 
corresponding  nerve  on  the  opposite  side  of  the  body.  The  duration  of 
neuritis  varies  from  days  to  months  or  years,  and  recovery  may  be  complete 
or  only  partial. 

The  treatment  is  removal  of  the  cause  if  possible,  and  during  the  early 
stages,  complete  immobiiization,  cold  or  heat,  and  nervous  sedatives.  Counter- 
irritation  with  a  series  of  lilistcrs  is  often  of  value.  Any  existing  diathesis 
should  be  treated.  In  the  later  stages  strychnin,  massage,  electricity,  and 
active  and  passive  motions  for  the  prevention  or  alleviation  of  degenerative 
changes  are  indicated.  When  internal  medication  fails,  the  nerve  may  be 
pierced  with  needles,  which  are  allowed  to'remain  for  a  short  time  {acupimc- 
lure);  injected  with  cocain,  chloroform,  alcohol,  Schleich's  solution,  or 
osmic  acid  (p.  227);  cut  (fieuroiomy)]  resected  (neuri'ciomy);  or  avulsed  if  the 
nerve  itself  is  of  little  importance;  when  the  nerve  is  an  important  one,  it 
may  be  seretched(Mmr<'r^an');  or  the  sheath  opened  and  the  libres  separated 
by  blunt  dissection;  and  finally,  in  desperate  cases,  the  sensory  roots  in  the 
spinal  canal  or  the  skull  may  be  divided  or  the  ganglia  excised. 

Neuralgia  is  a  paroxysmal  stabbing  or  burning  pain  in  a  nerve  or  group 
of  nerves,  lasting  from  a  few  seconds  to  hours,  and  recurring  at  widely  varying 
intervals.  The  nerve  may  be  tender  at  a  point  where  it  leaves  a  bony  canal 
or  courses  over  a  resistant  structure  {points  dmdmircux)  and  pressure  on  these 
points  may  precipitate  an  attack.  The  muscles  may  twitch  or  be  violently 
cf>ntracted  during  the  paroxysm,  and  trophic  changes  may  be  found  in  the 
area  over  which  the  nerve  presides. 

The  causes  of  neuralgia  are  those  of  neuritis,  or  those  of  reflex  irritation, 
such  as  carious  teeth,  errors  of  refraction,  worms,  and  diseases  of  the  nose, 
throat,  ovary,  etc.  Anemia,  nervous  temperament,  and  physical  debility 
strongly  predispose  to,  if  not  actually  cause,  the  disease  in  many  cases. 
Neuralgia  is  called  true  when  no  cause  can  Ije  found,  sec(mdar\\  or  sympto- 
maiiCt  when  due  to  some  general  or  local  affection.  The  more  thoroughly 
one  studies  the  disease  the  more  often  will  the  source  of  irritation  be  dis- 
covered; thus  sciatica  may  be  due  to  a  pelvic  tumor,  intercostal  neuralgia  to 
spondylitis  or  a  tumor  of  the  spinal  cord,  and  neuralgia  of  the  testicle  to  an 
incipient  hernia. 

The  treatment  of  symptomatic  neuralgia  is  that  of  the  cause.  In  true 
neuralgia,  the  general  health  should  be  built  up  by  fresh  air,  good  food,  and 
tonics.  Nervous  sedatives  and  hypnotics  are  used  during  the  attack,  which 
in  some  cases  may  be  terminated  by  pressure  over  the  nerve,  or  l>y  freezing 
with  chlorid  of  ethyl.  Morphin  is  often  alisolutely  necessarj^  but  in  chronic 
cases,  as  in  neuritis,  should  be  used  with  caution.  The  surgical  treatment  is 
that  of  neuritis,  for  the  special  forms  of  neuralgia  the  reader  is  referred  to 
the  section  on  special  nerves  and  to  the  chapters  on  regional  surger)\ 

Tumors  of  nerves  include  the  tn4e  neuromata  (rare),  matle  up  of  medul- 
latcd  (myelinif)  or  non-mcdulhitcd   (awyelinh)  nerve  fibers,  and  the  false 


INJimrES   OF   NERVKS 


223 


meuromata,  which  are  usually  fibrous  or  myxomatous  growths  arising  from 
the  peri-  or  endo-neurium.  Occasionally  sarcoma  develops  in  the  same 
siiuation. 

False  neuromata  may  be  single  or  multiple,  and  vary  greatly  in  size.  A 
painfid  subcutaneous  tuhenk  is  a  small  fibroma  developing  from  the  sheath  of 
a  nerve  filament.  When  involving  a  large  nerve,  a  false  neuroma  may  be 
painless  except  when  pressed  upon.  The  function  of  the  nerve  is  seldom 
disturlied*  A  piexiform  neuroma  is  a  myxo fd jromalous  degeneration  of  the 
branches  of  a  nerve,  which  can  be  feit  beneath  the  skin  as  enlarged  and  tor- 
tuous filaments.  It  occurs  eariy  in  life  or  is  congenital,  and  is  usually  painless. 
Generalized  neurofibromatosis,  or  Reckiingkauseti'.'i  disease,  consists  of  a 
widespread  thickening  of  the  nerve  sheath,  with  the  development  of  multiple 
tumors  springing  from  the  connective  tissue  of  the  nerve.  The  tumors  may 
be  tender  or  there  may  be  no  symptoms.  Paralysis  is  uncommon.  The 
disease  is  of  long  duration  and  finally  terminates  in  death,  often  owing  to  the 
development  of  sarcoma.  In  some  cases  the  skin  undergoes  changes  re- 
sembling those  of  molluscum  ftbrosum. 

The  treatment  of  neuroma  is  removal  If  this  cannot  lie  effected  without 
destroying  the  continuity  of  the  nerve,  this  should  be  done  and  the  ends 
sutured.  A  piexiform  neuroma  may  be  removed  if  limited  in  extent.  Gen- 
eralized neurofibromatosis  is  not  amenable  to  surgical  treatment.  The 
treatment  of  traumatic  neuroma,  a  term  often  applied  to  the  bulbous  prox- 
imal end  of  a  di\ided  nerve,  is  excision. 

Injuries  of  Nerves* — Cootusion  of  a  nerve  causes  violent  pain,  and  if 
severe,  signs  of  incomplete  or  complete  section  of  the  nerve  (vide  infra).  It 
may  be  followed  by  neuritis  and  subsequent  degeneration.  The  treatment  is 
rest,  and  later  massage  and  electricity.  If  the  symptoms  are  those  of  com- 
plete section  and  the  reaction  of  degeneration  appears,  the  nerve  should  be 
exposed  by  an  incision,  when  it  may  be  discovered  that  the  \n\nT\  is  a  rupture 
instead  of  a  contusion,  in  which  event  the  nerve  should  l)c  sutured.  Usually 
the  site  of  injury  is  marked  by  a  thickened,  indurated  area,  w^hich  should 
be  resected,,  and  the  ends  of  the  nerve  sutured.  If  no  change  in  the  nerve 
can  be  found,  the  incision  is  closed. 

Compression  of  a  nerve  may  be  caused  by  tumors,  aneurysms,  fracture^ 
dislocations,  cicatricial  tissue,  callus  formation,  tourniquets,  splints,  crutches, 
etc.  Acute  comprcssian,  such  as  that  due  to  lying  on  the  arm  during  sleep 
or  other  unconscious  states,  causes  anesthesia  and  paralysis,  or  in  the 
slighter  forms  a  sensation  of  numbness  or  tingling.  Vhronw  compression, 
gradually  produced,  causes  at  first  increase  in  the  function  of  the  nerve,  i.e., 
neuralgia,  and  twitching  or  spasms  of  the  muscles,  and  later,  anesthesia, 
paralysis,  and  trophic  changes.  The  treatment  is  removal  of  the  cause, 
massage,  and  electricity.  After  the  liberation  of  a  ner\c  from  callus  or 
cicatricial  tissue  {neurolysis}  its  sheath,  if  much  thickened,  should  be  split 
longitudinally,  in  order  to  relieve  the  fd>ers  of  the  pressure  thus  exerted,  and 
the  nerv^e  may  be  wrapped  in  muscle,  fascia,  or  Cargile  membrane  to  prevent 
the  reformation  of  adhesions. 

Complete  rtiptiire  or  section  of  a  peripheral  ner\^e  is  followed  by  (1) 
immediate  paralysis  if  it  contains  motor  fibers;  (2)  immediate  anesthesia  if 
it  contains  sensory  fibers;  anil  (3)  by  tropic  changes, 

(i)  Paralysis  involves  all  the  muscles  supplied  exclusively  by  the  nerve. 
It  may  lie  recalled  that  certain  muscles  are  supphed  liy  more  than  one  nerve, 


224  NERVES. 

and  that  as  most  movements  are  the  result  of  the  action  of  several  muscles, 
it  is  necessary,  in  order  to  determine  the  exact  extent  of  the  paralysis,  to 
investigate  the  muscles  themselves  rather  than  the  movements  which  tiiey 
produce. 

(2)  Anesthesia  of  the  skin  is  complete  only  in  the  area  supplied  exclusively 
by  the  nerve;  in  the  parts  which  it  supplies  in  common  with  other  nerves,  loss 
of  sensation  is  incomplete  or  absent.  Sherren  divides  the  peripheral  sensory 
nerve-fibers  into  three  classes:  (a)  Nerve- fibers  of  deep  sensaiion  recognize 
deep  pressure  and  the  position  and  movements  of  the  bones  and  joints. 
They  accompany  the  motor  nerves  to  the  muscles  and  course  through  ten- 
dons, ligaments,  and  bones,  hence  deep  sensation  is  rarely  impaired,  unless 
the  nerve  is  divided  above  all  its  motor  branches  or  unless  the  muscles  and 
tendons  are  severed,  (b)  ProtopcUhic  nerve- fibers  are  important  agents  in  the 
production  of  reflex  movements.  They  appreciate  pain,  e.g.,  a  pin  prick, 
and  great  variations  in  temperature,  but  tibe  sensations  are  badly  localized, 
radiate  widely,  and  are  accompanied  by  tingling.  As  the  protopathic  fibers 
of  adjacent  nerves  overlap  to  a  considerable  extent,  section  of  a  single  nerve 
results  in  a  loss  of  their  functions  in  a  small  and  variable  area,  (c)  EpicrUic 
nerve- fibers  perceive  and  accurately  localize  light  touches,  e.g.,  of  a  hair, 
trivial  changes  in  temperature,  and  the  contact  of  two  points,  e.g.,  of  a  com- 
pass, close  together.  These  fibers  do  not  overlap  so  much  as  the  proto- 
pathic fibers,  hence  after  section  of  a  nerve  their  functions  are  destroyed  over 
a  well  defined  and  larger  area,  which  corresponds  in  outline  to  that  given  in  an 
anatomical  treatise  as  representing  the  distribution  of  the  nerve. 

(3)  The  trophic  changes  are  at  first  hyperemia  and  elevation  of  the  local 
temperature,  owing  to  vasomotor  paralysis;  later  the  parts  become  cold  and 
livid.  If  neuritis  is  absent,  the  skin  becomes  dry,  rough,  scaly,  and  edema- 
tous; if  neuritis  is  present,  thin,  smooth,  shiny,  and  often  bathed  with  sweat. 
In  the  latter  instance  vesicular  and  pustular  eruptions,  painless  ulcers  and 
subcuticular  abscesses,  and  chilblains  may  occur.  The  nails  may  become 
curved,  brittle,  and  ridged  transversely  and  longitudinally,  sometimes  being 
shed  as  the  result  of  paronychia.  The  hair  likewise  becomes  brittle  and  is 
lost.  The  subcutaneous  tissues  and  the  bones  may  atrophy,  and  the  joints, 
especially  those  of  the  fingers,  may  be  the  seat  of  a  plastic  synovitis  that 
eventuates  in  ankylosis.  The  muscles  atrophy  and  are  ultimately  replaced 
by  fibrous  tissue,  deformities  often  resulting  from  contraction  of  the  unop- 
posed normal  muscles.  The  electrical  reactions  are  altered.  The  nerve 
slowly  fails  to  respond  to  the  faradic  and  galvanic  currents,  all  excitability 
disappearing  after  twelve  days.  The  muscles  cease  to  react  to  the  faradic 
current  in  from  three  to  eight  days,  but  during  the  first  few  weeks  excitability 
by  the  galvanic  current  is  increased  and  the  reaction  of  degeneration  appears, 
i.e.,  the  anodal  closure  is  greater  than  the  cathodal  closure  contracture,  which 
is  the  reverse  of  normal.  As  the  degenerative  changes  in  the  muscles  advance, 
excitability  by  the  galvanic  current  slowly  diminishes,  until  finally,  after  a 
year  or  perhaps  several  years,  all  contractility  is  lost,  and  recovery  cannot 
occur. 

Secondary,  or  Wallerian  degeneration,  takes  place  in  the  proximal  segment 
as  far  as  the  first  node  of  Ranvier,  and  in  the  entire  distal  segment,  the 
medullary  substance  undergoing  segmentation,  and  with  the  axis-cylinders 
finally  becoming  absorbed.  These  changes  are  said  to  occur  whether  the 
nerve  is  sutured  at  once  or  not.     If  the  nerve  does  not  unite,  the  central  end 


NEURORRHAPHY. 


225 


becomes  bulbous,  owing  to  the  formation  of  fibrous  tissue,  in  which  coils  of 
new  axis-cylinders  appear.  Thus  the  end-bulb  is  really  a  neurofibroma, 
and  sometimes,  particularly  after  amputations,  it  becomes  excessively  painful 
(see  amputations).  The  perpheral  end  also  may  become  bulbous,  but  more 
commonly  it  shrinks. 

Regeneration  is  thought,  by  some,  to  be  due  to  the  outgrowth  of  the  imde- 
generated  axis-cylinders  of  the  proximal  segment,  which,  when  the  ends  of 
the  nerve  are  approximated  and  occasionally  when  the  ends  are  separated 
some  distance,  force  their  way  downwards  through  the  distal  segment. 
Others  believe  the  axis-cylinders  are  reformed  by  proliferation  of  the 
neurilemma  cells,  and  that  the  distal  segment  regenerates  even  when  not 
brought  in  contact  with  the  proximal  segment;  certain  it  is  that  sensation 
sometimes  returns  so  rapidly  after  secondary  suture  as  to  be  explainable 
only  by  the  union  of  the  axis-cylinders  from  each  segment.  As  a  rule  re- 
generation is  not  completed  for  at  least  several  months.  Restoration  of 
function  is  first  manifested  by  an  improvement  in  the  nutrition  of  the  part. 
Sensation  always  reappears  before  motion,  which  in  many  cases  is  never 
perfectly  regained. 

The  treatment  is  immediate  suture,  or  neurorrhaphy.  The  ends  should 
be  brought  together  by  one  or  two  sutures  of  chromicized  catgut  passing 
through  the  nerve,  and  the  sheath  stitched  with  the  same  material.  In 
secondary  neurorrhaphy,  i.e.,  weeks  or  months  after  the  nerve  has  been  divided, 
it  will  be  necessary  to  resect  a  portion  of  each  end  to  remove  cicatricial  tissue 

Fig.  143.        Figs.  144,         i45»  *46,  147.  Fig.  148. 

Neuroplasty.  Nerve  transplantation  or  anastomosis;  paralyzed        Suture  ^  distance. 

nerve  shaded. 

before  bringing  the  ends  together.  The  part  should  be  dressed  in  the  position 
in  which  there  is  the  least  tension  on  the  sutures.  In  cases  in  which  there  is  a 
wide  gap  between  the  ends  of  the  nerve  the  defect  may  be  remedied  by  (i) 
stretching  each  segment,  (2)  nerve  grafting  from  lower  animals,  (3)  neuro- 
plasty (Fig.  143),  (4)  transplantation  (Figs.  144  to  147),  (5)  resection  of  bone 
to  shorten  the  limb,  (6)  suture  h  distance  (Fig.  148),  or  by  (5)  tubulization, 
which  consists  of  placing  each  end  of  the  nerve  in  an  excised  segment  of  a  vein, 
a  segment  of  formalinized  artery,  or  in  a  tube  of  decalcified  bone  or  other 
material,  to  prevent  the  intervention  of  surrounding  structures.  When  the 
ends  of  a  nerve  are  brought  direcdy  in  contact  more  or  less  function  is  re- 
stored in  alx)Ut  75  per  cent,  of  the  cases.  Of  22  cases  of  nerve  grafting  3  were 
*'goo<r'  results  and  3  *'fair;"  of  1 1  cases  of  neuroplasty  4  were  complete  or 
partial  successes;  of  10  cases  of  transplantation  5  were  satisfactory;  of  2 
cases  of  suture  d.  distance  2  were  successful;  and  the  only  case  of  tubulization 

15 


22C 


NEI 


resulted  negatively  (Powers).  After  any  case  of  neurorrhaphy,  massage, 
electrit'ity,  and  passive  motions  should  be  used  as  long  as  the  paralysis 
continues. 

Partial  sectioo  of  a  mixed  ner\T,  if  not  more  than  one-third  is  dinded, 
may  cause  no  symptoms.  Paralysis,  when  present^  is  incomplete,  and, 
although  the  muscles  may  fail  to  respond  to  faradism,  they  react  promptly 
to  tlie  galvanic  current  and  without  showing  the  reaction  of  degeneration, 
i.e.,  polar  reversal  Anesthesia  involves  principally  the  epicritic  nerves,  i.e., 
those  which  appreciate  light  touch.  Trophic  disturbances  are  slight  or 
absent,  unless  a  neuritis  is  inaugurated.  Aside  from  removal  of  a  foreign 
body,  which  might  prevent  union  of  the  divided  fibers  or  cause  irritation, 
the  treatment  is  expectant;  and  the  prognosis  is  good. 


LESIONS  OF  SPECIAL  NERVES. 

In  affections  of  the  cranial  nerve  trunks  the  loss  of  function  is  on  the  same 
side  as  the  lesion;  if  the  lesion  be  central,  i.e.,  in  the  brain,  the  symptoms  are 
referred  to  the  opposite  side  of  the  body. 

The  olfactory  nerve  may  be  injured  in  fractures  of  the  cribriform  plate 
or  in  contusions  of  the  forehead,  resulting  in  transitory  or  permanent  anosmia 
(loss  of  smell). 

The  optic  nerve  also  may  l^e  involved  in  a  fracture  of  the  base  of  the  skull, 
resulting  in  rupture  or  compression  of  the  nerve.  In  the  former  event  blind- 
ness is  permanent,  in  the  latter,  particularly  when  due  to  blood,  vision  may 
lie  restored.  The  optic  nerve  may  be  compressed  also  by  inflammations  in 
the  orbit,  or  by  tumors,  aneurysms,  foreign  bodies,  or  cicatricial  tissue.  Optk 
nttiriiis  (papiltilis,  choked  disc)  is  usually  the  result  of  increased  intracranial 
pressure,  such  as  occurs  in  tumor,  abscess,  etc,  of  the  brain. 

The  third  nerve  (motor  oculi)  may  be  affected  centrally  in  cerebral 
affections,  or  peripherally  by  trauma,  tumors,  etc.  The  nerve  supplies  the 
iris  and  all  the  muscles  of  the  orbit  except  the  superior  oblique  and  the  exter- 
nal  rectus.  Paralysis  of  the  nerve  causes  ptosis,  external  squint  with  the  eye 
turned  a  little  downwards,  mydriasis,  loss  of  accommodation  owing  to  paraly- 
sis of  the  ciliary  muscle,  and  slight  exophthalmos  owing  to  the  loss  of  tension 
exercised  by  the  muscles. 

The  fourth  nerve  (patheticus)  supplies  the  superior  oblique,  paralysis 
of  which  causes  impaired  movement  of  the  eye  downwards  and  outwards. 

The  fifth  or  trigeminal  nerve  supplies  the  face  with  sensation  and  the 
muscles  of  mastication  with  motion.  It  is  rarely  affected  in  head  injuries, 
but  is  often  the  seat  of  neuralgia.  Trifacial  or  trigeminal  neural gia,  called 
also  tic  dmdtmreux  in  contradistinction  to  tic  conimhif,  which  is  a  spasm  of  the 
facial  muscles,  and  which  mayor  may  not  be  associated  with  neuralgia  of  the 
fifth  nerve»  usually  begins  in  the  infraorbital  or  inferior  dental  branches.  It 
is  characterized  by  paroxysms  of  excruciating  pain,  often  provoked  by  the 
slightest  irritation » such  as  a  breath  of  air  or  attempts  at  mastication.  There 
may  be  lacrymation,  an  increase  in  the  amount  of  saliva  and  nasal  mucus, 
unilateral  sweating  of  the  head,  and,  as  already  mentioned,  spasm  of  the 
facial  muscles.  There  are  two  forms,  the  retlex  or  symptomatic,  which 
may  occur  at  any  time  of  life,  and  true  tic  douloureux,  which  generally 
occurs  after  the  fortieth  year,  and  which  is  thought  to  be  due  to  a  senile 


997 

sclerosis  of  the  nerve  or  the  blood  vessels.  The  treatment  is  the  removal 
of  any  retlex  irritation,  such  as  errors  of  refraction,  diseases  of  the  nose, 
teeth,  ear,  etc.,  and  the  combating  of  any  existing  constitutional  affection, 
such  as  malaria,  anemia,  syphilis,  gout,  rheumatism,  or  other  toxic  or 
infectious  condition.  Of  the  many  local  measures  which  have  l>cen 
used  may  be  mentioned  cold,  heat,  menthol,  belladonna,  croton  chloral, 
blisters,  the  cautery,  freezing  of  tender  points  (points  dtmlourtux),  and 
the  galvanic  current.  Nerve  sedatives  and  hypnotics  must  be  used  for 
the  pain.  Strychnin  in  increasing  doses,  until  some  physiological  results 
have  been  obtained,  has  been  highly  recommended.  When  these 
measures  fail  operative  treat nietit  will  lie  demanded,  f'acial  neuralgia  has 
been  treated  by  ligation  of  the  common  carotid,  resection  of  the  superior  cer- 
vical ganglion  of  the  sympathetic,  and  by  stretching  the  seventh  nerve  when 
associated  with  tic  convulsif,  hut  practically  all  surgeons  prefer  to  attack  the 
fifth  nerve  itself.  Simple  division  of  the  nerve  and  nerve  stretching  are  very 
transient  in  their  effects  and  are  not  recommended.  In  order  to  effecl  a 
physiological  section,  which  is  claimed  to  be  permanent,  5  or  10  m.  of  a  1.5 
per  cent,  solution  of  osmic  acid  arc  injected  into  the  branches  of  the  nerve 
after  they  have  been  exposed  by  incision.  Alcohol  (80  percent.),  formalin, 
and  other  substajices  have  been  used  in  a  similar  way.  The  favorite  treat- 
ment, however,  is  resection  of  the  peripheral  branches  of  the  nerve,  which 
may  have  to  be  repeated,  owing  to  the  regeneration  of  these  filaments. 
;  Regeneration  is  especially  likely  to  occur  when  the  nerve  occupies  a  bony 
canal,  hence,  after  resection,  some  surgeons  plug  the  canal  with  gold  foil, 
dental  paste,  etc.  When  the  entire  nerve  is  involved  or  recurrences  are  fre- 
quent,  more  formidable  operations  are  required,  even  to  resection  of  the 
Gasserian  ganglion. 

Resection  of  tJie  supraorbital  nerve  may  be  performed  through  an 
I  incision  about  one  inch  long  in  the  line  of  the  eyebrow,  after  this  has  been 
;  removed  by  shaving.  The  nerve  makes  its  exit  through  the  supraorbital 
i  notch  or  foramen,  at  the  junction  of  the  inner  and  middle  thirds  of  the  upper 
I  margin  of  the  orbit.  As  much  of  each  end  as  possible  is  removed, 
i  The  supratrochlear  nerve  may  be  found  at  a  point  where  a  line  drawn 

I       from  the  angle  of  the  mouth  to  the  inner  canthus  touches  the  upper  margin  of 
I       the  orbit. 

I  The  infraorbital  nerve  emerges  from  the  infraorbital  foramen  about  one- 

third  inch  below  the  middle  of  the  lower  margin  of  the  orbit.  A  cun-ed  in- 
1  cision  is  made  below  the  lower  margin  of  the  orbit  and  the  nenx  isolated. 
''  The  periosteum  of  the  orbital  floor  is  then  elevated,  the  roof  of  the  infraor- 
I  biial  canal  opened,  and  the  nerve  divided  as  far  back  as  pcjssible  and  drawn 
I  out  through  the  foramen.  By  this  method  even  the  main  trunk  of  the  supe- 
[      rior  maxillary  may  be  reached  and  divided. 

I  The  superior  maxillary  nerve  and  Meckel's  ganglion  may  be  removed 

by  the  Camochan-Chavasse  operation,  A  T-shaped  incision  is  made,  the 
horizontal  portion  of  which* runs  from  canthus  to  canthus  beneath  the  lower 
margin  of  the  orbit,  and  the  vertical,  downwards  from  the  center  of  this 
incision  to,  but  not  into,  the  mouth.  The  infraorbital  nerve  is  isolated  and 
secured  with  a  piece  of  silk,  and  both  the  anterior  and  posterior  walls  of  the 
antrum  are  opened  by  a  gouge  or  chisel,  care  being  taken  not  to  injure  the 
internal  maxillary  artery.  The  infraorbital  canal  is  opened  on  the  roof  of 
the  antrum,  and  the  nerve  divided  on  the  cheek  and  pulled  down  through  the 


228  NERVES. 

antrum.  It  is  then  traced  backwards  to  the  foramen  rotundum,  where  after 
slight  traction  it  is  divided.  Meckel's  ganglion  is  brought  away  with  the 
nerve.  The  same  procedure  has  been  carried  out  through  the  orbit,  and 
from  the  side  of  the  face  after  resection  of  the  zygoma  and  coronoid  process 
of  the  lower  jaw. 

The  inferior  dental  nerve  may  be  resected  by  making  an  incision  along 
.the  lower  border  of  the  jaw  back  to  the  angle.  The  masseter  is  scraped  from 
the  bone,  which  is  then  chiseled  or  trephined  about  one  and  one-fourth  inches 
above  the  angle,  so  as  to  remove  the  outer  half  of  the  thickness  of  the  bone 
and  expose  the  nerve  at  its  entrance  into  the  inferior  dental  foramen.  The 
nerve  is  lifted  from  its  bed  by  a  sharply  curved  hook,  and  as  much  of  each  end 
as  possible  removed  by  avulsion.  The  inferior  dental  may  be  resected  also 
through  the  mouth.  A  gag  is  placed  between  the  teeth  of  the  opposite  side, 
and  an  incision  made  along  the  anterior  border  of  the  ramus  of  the  lower 
jaw  to  the  last  molar  tooth.  After  separating  the  internal  pterygoid  muscle 
from  the  bone  and  locating  the  spine  of  Spix,  at  the  base  of  which  is  the 
inferior  dental  foramen,  a  hook  is  passed  around  the  nerve  and  as  muck  of 
it  as  possible  removed. 

The  lingual  nerve  may  be  exposed  in  the  mouth  by  making  an  incision 
midway  between  the  tongue  and  the  gum  of  the  last  molar  tooth,  or  externally 
by  an  incision  in  the  submaxillary  triangle. 

The  auriculo-temporal  nerve  may  be  exposed  at  the  root  of  the  zygoma 
by  a  vertical  incision  between  the  temporal  artery  and  the  pinna. 

The  buccal  nerve  may  be  exposed  by  a  vertical  incision  through  the 
mucous  membrane  and  buccinator  fibers,  the  center  of  the  incision  being  at 
the  middle  of  the  anterior  border  of  the  vertical  ramus  of  the  inferior  maxHla. 

The  inferior  maxillary  nerve  may  be  divided  at  the  foramen  ovale  after 
resection  of  the  zygoma  or  coronoid  process,  or  both.  Another  method  is  to 
deepen  the  sigmoid  notch  of  the  lower  jaw  three-fourths  of  an  inch  or  more. 

Myxter's  operation  is  a  resection  of  the  second  and  third  divisions  of  the 
fifth  nerve  at  their  exit  from  the  skull,  after  temporary  resection  of  the  zygoma. 
In  Abbe's  operation  the  external  carotid  is  ligated  and  a  vertical  incision 
made  above  the  middle  of  the  zygoma.  The  skull  is  then  opened  by  gouge 
and  rongeur,  and  the  second  and  third  divisions  exposed  extradursdly  and 
severed  at  the  foramen  rotundum  and  foramen  ovale.  A  slip  of  gutta-percha 
tissue  is  placed  over  the  foramina  in  order  to  prevent  the  junction  of  the 
divided  nerves. 

Removal  of  the  Gasserian  ganglion  is  indicated  in  cases  in  which  the 
entire  ner\e  is  involved,  or  in  which  less  dangerous  operations  have  failed. 
In  the  Hartley- Krause  method  a  horseshoe-shaped  osteoplastic  flap  consisting 
of  scalp  and  bone  is  made  in  the  temporal  region  with  the  base  at  the  zygoma. 
In  raising  this  flap  the  middle  meningeal  artery  is  often  injured.  The  dura 
mater  is  not  opened,  but  is  stripped  from  the  middle  fossa  of  the  skull  until 
the  second  and  third  divisions  of  the  nerve  are  found;  these  are  traced  back- 
ward to  the  ganglion  at  the  apex  of  the  petrous  j)ortion  of  the  temporal  bone. 
The  dural  envelope  (cavum  of  Meckel)  of  the  ganglion  is  then  opened,  the 
ganglion  separated  from  this  envelope,  the  second  and  third  divisions  divided 
near  their  foramina,  and  the  ganglion  twisted  out  with  forceps.  Gushing, 
after  cutting  through  the  zygoma  at  each  end,  opens  the  skull  lower  down, 
so  as  to  avoid  injury  to  the  middle  meningeal  artery.  Rose  reaches  the 
ganglion  through  the  pterygoid  region  after  resecting  the  zygoma  and  the 


LESIONS   OF   SPECIAL  NERVES.  229 

coronoid  process  of  the  lower  jaw.  In  Horsley^s  method  the  dura  is  opened 
and  the  ganglion  removed.  In  the  Spiller-Frazier  operation  the  sensory 
root  of  the  ganglion  alone  is  divided.  The  mortality  of  these  operations  is 
from  10  to  20  per  cent.,  but  the  chance  of  permanent  cure  in  those  who  sur- 
vive is  very  great.  Ulceration  of  the  cornea  may  occur,  and  should  be  antici- 
pated by  suturing  the  eyelids  together  at  the  time  of  operation,  and  later,  if 
there  is  the  slightest  irritation,  by  the  wearing  of  a  watch  glass  over  the  eye. 
The  cavernous  sinus  and  the  sixth  nerve  have  both  been  injured  during 
o{>eration. 

Division  of  the  sixth  nerve  causes  internal  squint  as  the  result  of  paraly- 
sis of  the  external  rectus. 

The  seventh  or  facial  nerve  may  be  paralyzed  (BelPs  palsy)  within  the 
cranium  from  tumor,  abscess,  hemorrhage,  thrombosis,  embolism,  softening 
of  the  brain,  etc.;  in  its  passage  through  the  Fallopian  canal  from  fracture  of 
the  base  of  the  skull  and  middle  ear  disease,  causing  compression  or  neuritis ; 
and  at  its  emergence  from  the  styloid  foramen  by  trauma,  tumors,  and  neu- 
ritis from  cold.  When  the  nerve  is  affected  in  the  cortex,  corona  radiata,  or 
internal  capsule,  the  lower  half  of  the  opposite  side  of  the  face  is  paralyzed, 
usually  with  hemiplegia,  and  the  reactions  of  degeneration  are  absent.  When 
the  lesion  is  in  the  lower  part  of  the  pons,  the  face  is  paralyzed  on  the  same 
side,  and  the  arm  and  leg  on  the  opposite  side  {crossed  paralysis)  j  owing  to 
the  fact  that  the  motor  fibers  to  the  arm  and  leg  decussate  in  the  medulla. 
A  lesion  between*  the  brain  and  the  Fallopian  canal  is  often  accompanied  by 
deafness,  and  the  paralysis  involves  the  entire  face  of  the  same  side.  Section 
of  the  facial  ner\'e,  where  it  is  accompanied  by  the  chorda  tympani,  i.e., 
between  the  geniculate  ganglion  and  the  lower  part  of  the  Fallopian  canal, 
causes  loss  of  taste  over  the  anterior  two-thirds  of  the  corresponding  half  of 
the  tongue. 

The  treatment  is  removal  of  the  cause,  whenever  possible.  Massage, 
electricity,  and  iodid  of  j)otassium  are  used  in  cases  not  suitable  for  surgical 
treatment.  In  cases  of  extracerebral  origin  in  which  electrical  examination 
reveals  the  presence  of  fairly  healthy  muscles,  the  nerve  may  be  severed  at 
the  stylomastoid  foramen  and  the  distal  end  sutured  into  the  spinal  accessory 
or  hypoglossal  nerve  (Fig.  145).  The  extent  of  recovery  is  limited  to  associ- 
ated movements  in  conjunction  with  the  shoulder.  The  cases  most  suitable 
for  operation  are  those  in  which  the  palsy  has  lasted  for  six  months  without 
any  signs  of  recovery.  The  operation  may  be  done  also  in  severe  cases  of 
facial  tic  (clonic  spasms  of  the  facial  muscles)  which  have  resisted  medical 
treatment  and  neurectasy  (Ballance  and  Stewart). 

The  eighth  or  auditory  nerve  may  be  involved  in  tumors,  meningitis, 
hemorrhage,  or  traumatism,  often  resulting  in  incurable  deafness.  It  has 
been  divided  for  uncontrollable  tinnitus  of  peripheral  origin. 

Lesions  of  the  glossopharyngeal  nerve  are  rare;  paralysis  would  affect 
taste,  swallowing,  and  possibly  speaking. 

The  tenth  or  pneumogastric  nerve  may  be  compressed  by  tumors  or 
aneurysms,  or  injured  in  fracture  of  the  base  of  the  skull  or  in  operations  on 
the  neck.  Irritation  may  cause  vomiting,  inhibition  of  the  heart,  and  spasm 
of  the  laryngeal  muscles.  Division  of  one  pneumogastric  may  be  followed 
by  few  or  no  symptoms,  but  division  of  both  nerves  causes  death  from  paral- 
ysis of  the  laryngeal  muscles.  A  lesion  of  the  pneumogastric  nerve  in  the 
lower  part  of  the  neck,  or  of  the  recurrent  laryngeal  branch,  causes  paralysis 


230 

of  the 


NERVES. 


ties  of  one  side  of  the  larynx,  with  resulting  hoarseness  and  im- 


• 


must  J 
paired  phonation. 

The  eleventli  or  spinal  accessory  nerve  is  exposed  to  wounds  and 

many  forms  of  irritalion.  Seilion  of  the  branch  which  joins  the  pneumo- 
gastric  resuUs  in  paralysis  of  the  laryngeal  muscles.  The  external  branch  is 
distributed  to  the  stemomastoid  and  trapezius,  which  muscles  may  not  be 
completely  paralyzed  after  division  of  the  nerve,  as  they  receive  filaments 
also  from  the  cervical  ner\'es*  The  nerve  has  been  stretched  or  di\ided  for 
spasmodic  torticollis. 

The  twelfth  or  hypoglossal  nerve  when  divided,  causes  paralysis  of  one 
side  of  the  tongue,  which,  when  protruded,  is  directed  to  the  paralyzed  side; 
degiutilioD  also  may  be  impaired. 

The  phrenic  nerve,  when  irritated,  causes  hiccough,  and  when  divided, 
paralysis  of  the  diaphragm^  which,  if  unilateral,  is  often  scarcely  noticeable, 
but  if  bilateral  may  cause  Instant  death. 

The  brachial  pleius  may  be  injured  (a)  above  or  (h)  below  the  clavicle. 

(a)  Suprai'iaviiuldr  injuries  may  be  direct,  e,g.,  from  penetrating  w^ounds, 
fracture  of  the  clavicle  or  cervical  spine,  or  pressure  of  a  cervical  rib;  or 
indirect,  the  nerves  being  overstretched  or  ruptured  as  the  result  of  traction, 
the  direction  an^l  violence  of  the  force  determining  the  grade  and  extent  of  the 
paralysis^  of  which  there  are  three  common  tvpes.  ^H 

(i)  The  upper  arm,  or  Dudienne-Erb  type,  is  the  most  frequent.  It  I^H 
due,  not  to  the  pressure  of  the  clavicle,  as  has  been  thought,  but  to  a  forcing 
apart  of  the  head  and  shoulder,  the  brunt  of  the  strain  falling  upon  the 
anterior  primary  division  of  the  fifth  cervical  nerve,  hence  paralysis  of  the 
deltoid,  supraspinatus,  infraspinatus,  biceps,  brachial  is  anticus,  supinator 
longus,  and  supinator  brevis,  which  causes  loss  of  abduction  and  outward 
rotation  of  the  arm  and  loss  of  tlexion  and  supination  of  the  forearm.  Sensa- 
tion is  not  impaired.  When  the  traction  is  less  severe  only  the  upper  part 
of  the  fifth  cervical  may  be  ruptured,  resulting  in  paralysis  of  the  deltoid  and 
spinati;  as  these  cases  follow  a  blow  on  the  shoulder  they  are  frequendy 
diagnosticated  as  injury^  to  the  circumflex  nerve  (Sherren). 

(2)  The  imver  arm^  or  Klnmpke  type,  is  caused  by  upward  traction  on 
arm,  e.g.,  when  a  man  saves  himself  from  a  fall  from  a  height  by  clutching 
a  projection  of  some  sort.  In  these  cases  the  first  dorsal  nerve  is  stretched  or 
torn,  and  the  intrinsic  muscles  of  the  hand  and  often  the  cervical  sympathetic 
nerve  are  paralyzed.  Anesthesia  exists  over  the  inner  side  of  the  arm  and 
forearm,  and  occasionally  along  the  ulnar  border  of  the  hand. 

(3)  The  whole  plexus  type  may  be  due  to  upward  or  doivTiward  traction, 
when  of  severe  grade.  All  the  muscles  of  the  upper  extremity,  excluding  the 
rhomboids  and  the  serratus  magnus,  are  paralyzed,  usually  with  impairment 
of  the  functions  of  the  cervical  sympathetic  nerve.  Anesthesia  exists  over 
the  whole  limb,  excepting  the  area  along  the  inner  side  of  the  arm  supplied 
by  the  in  t e re os to-humeral  nerve. 

(b)  Infrachvkular  injuries,  aside  from  penetrating  wounds^  are  usually 
the  result  of  direct  pressure,  e.g.,  from  a  crutch,  from  dislocation  or  fracture 
of  the  upper  end  of  the  humerus  or  attempts  to  reduce  the  deformity  in  these 
cases,  especially  by  the  heeb  in -axilla  method.  The  two  common  forms  are 
the  whole  plexus  type,  which  differs  from  that  of  the  supraclavicular  variety, 
in  that  the  anesthesia  is  complete,  and  the  inner  cord  type,  which  gives  the 
symptoms  of  injury  to  the  ulnar  nerv^e,  with  paralysis  of  the  muscles  of  th^ 


ndy 


scles  01  tn^^ 


hand  supplied  by  ihe  median  nerve.  Lesions  of  the  mdtr  cord  are  accom- 
panied by  paralysis  of  ihe  biceps,  coracobrachialis,  and  the  muscles  inner- 
vated  by  the  median,  except  those  of  the  hand,  and  by  anesthesia  of  the 
outer  side  of  the  forearm.  Lesions  of  the  poskriar  lord  cause  symptoms 
identical  ^ith  those  of  the  musculospiral  and  circumtlex  nerves. 

Post-aneslhetk  paralysis  of  the  brachial  plexus  is  usually  of  the  Duchennc- 
Erb  type,  the  causative  traction  being  exerted  by  the  abducted  arm  hanging 
from  the  edge  of  ihe  table.  Those  cases  which  follow  elevation  of  the  arm 
above  the  patient's  head  are  due  to  pressure  of  the  upper  end  of  the  humerus, 
and  are  of  the  infraclavicular  variety  (see  p.  40). 

Brachial  birth  paralysis  usually  involves  the  left  arm  and  is  usually  due 
to  forcible  separation  of  the  head  from  the  shoulder,  hence  of  the  Dochenne- 
Erb  type,  although  the  lower  arm  type  may  follow  a  l>reech  presentation 
with  the  arms  extended,  and  in  severe  cases  the  whole  plexus  may  be  involved. 

The  treatment  of  brachial  paralysis  depending  upon  direct  wounds,  or 
pressure  from  callus,  displaced  bone,  etc.,  is  that  of  the  same  injuries  affect- 
ing other  nerves.  Spontaneous  recovery  is  the  rule  in  post -anesthetic  paraly- 
sis, crutch  palsy,  and  lesions  of  similar  intensity.  Birth  paralysis  ultimately 
disappears  in  perhaps  three-fourths  of  the  cases,  !>ui  in  adults  not  more  than 
40  per  cent,  of  the  traction  paralyses  due  to  great  violence  recover  without 
operation.  In  all  cases,  as  soon  as  the  tenderness  due  to  the  accident  has 
subsided,  massage,  electricity,  and  passive  motions  should  be  ordered,  If» 
in  the  course  of  several  months,  improvement  does  not  follow  this  form  of 
tieatment,  and  especially  if  the  muscles  show  the  reaction  of  degeneration, 
operation  should  be  advised.  Kennedy,  how^ever,  counsels  delay  in  birth 
palsy  for  at  least  one  year.  An  incision  is  made  from  the  junction  of  the 
upper  and  middle  thirds  of  the  posterior  border  of  the  sternomastoid  to  the 
junction  of  the  middle  and  outer  thirds  of  the  clavicle,  and,  if  the  lower 
branches  of  the  plexus  must  be  exposed,  the  clavicle  divided  temporarily. 
After  severing  the  deep  fascia  an  attempt  is  made  to  identify  the  individual 
parts  of  the  plexus,  often  a  most  difficult  undertaking,  owing  to  the  mass  of 
cicatricial  tissue  in  which  they  are  imbedded.  If  the  ner\xs  have  been 
divided  they  are  sutured;  if  destroyed  by  scar  tissue,  resected  and  then 
united.  If  so  much  of  a  nerve  must  be  excised  that  its  ends  cannot  be  brought 
together,  the  distal  segment  is  anastomosed  with  a  neighboring  nerve.  If 
operation  on  the  nerves  fails,  muscular  transplantation  may  be  tried.  In 
Duchennc-Erb  paralysis  Tubby  has  restored  flexion  of  the  forearm  by  trans- 
planting a  portion  of  the  triceps  to  the  biceps,  and  abduction  of  the  arm  by 
transplanting  a  portion  of  the  pectoralis  major  and  trapezius  to  the  deltoid. 

Neuritis  of  any  of  the  nerves  of  the  arm  may  spread  to  ami  involve  the 
entire  brachial  plexus,  and  the  plexus  is  occasionally  the  seat  of  intractable 
neuralgia,  for  w^hich  it  has  been  exposed  and  stretched. 

The  posterior  thoracic  nerve  may  be  injured  or  inflamed,  causing 
paralysis  of  the  serratus  magnus,  or  winged  scapula  (p.  614). 

The  circumflex  nerve  winds  around  the  neck  of  the  humerus  three- 
fourths  of  an  inch  above  the  middle  of  the  deltoid.  It  is  often  involved  in 
injuries  aljout  the  shoulder,  resulting  in  paralysis  of  the  deltoid  and  teres 
minor,  and  transient  anesthesia  of  the  posterior  fold  of  the  axilla. 

The  musculospiral  nerve  may  be  injured  in  fractures  of  the  humerus, 
especially  where  it  lies  close  to  the  bone  in  the  musculospiral  groove.  It  is  fre- 
quently compressed  also  in  crutch  palsy  and  by  lying  on  the  arm,  and  is- 


232 


NERVES. 


pcculiariy  prone  to  be  affected  by  lead  poisoning.  Di\ision  of  the  nen'e  near 
I  he  plexus  causes  paralysis  of  the  extensor  muscles  of  the  elbow,  wrist  {wrisi' 
drop)  J  fingers,  and  thumb,  and  of  the  supinators  of  the  forearm  (Fig.  149). 
Extension  of  the  terminal  phalanges  may  still  be  accomplished.by  the  interos- 
sei  and  lumbricales.  Sensation  is  lost  over  the  anterior  and  posterior  aspects 
of  the  radial  side  of  the  elbow  and  forearm,  the  radial  side  of  the  posterior 
surface  of  the  wrist  and  hand,  and  over  the  dorsal  surface  of  the  thumb,  first, 


Fig.  149. — Wrist-drop  after  section  of 
musculospiral  nerve,     ((rowers.) 


Fig.  150. — Hand  after  section 
of  median  nerve.     (Dagron.) 


second,  and  half  the  third  fingers  (Fig.  152).  In  cases  of  pressure  palsy 
massage  and  electricity  will  be  required,  recovery  usually  ensuing  in  a  vari- 
able length  of  time.  When  caught  in  callus  or  divided,  operation  wUl  be 
necessary. 

The  median  nerve,  when  divided  above  the  bend  of  the  elbow,  causes 
paralysis  of  the  pronators,  tlexor  carpi  radialis,  pal  maris  longus,  flexor  longus 
pollicis,  flexor  sublimis,  and  the  radial  half  of  the  flexor  profundus  digitorum, 
with  the  following,  which  alone  are  involved  in  an  injury  just  above  the  wrist, 

abductor,  opponens,  and  outer  half  of 
the  flexor  brevis  pollicis,  and  the  two 
radial  lumbricales.  There  is  loss  of  sen- 
sation in  the  skin  of  the  radial  side  of  the 
hand,  the  flexor  surface  of  the  thumb, 
and  in  the  first,  second,  and  half  the  third 
fingers,  which  are  involved  to  a  varying 
degree  also  on  the  dorsal  surface  (Fig. 
152).  There  are  loss  of  pronation,  im- 
paired radial  flexion  and  abduction  of 
the  wrist,  loss  of  the  hand  grasp  on  the 
radial  side,  and  wasting  of  the  thenar 
eminence  (Fig.  150).  Flexion  of  the  proximal  phalanges  by  means  of  the 
interossei  is  still  possible. 

The  ulnar  nerve  supplies  the  flexor  carpi  ulnaris,  the  ulnar  half  of  the 
flexor  profundus,  the  two  ulnar  lumbricales,  all  the  interossei,  the  muscles  of 
the  little  finger,  the  adductors  of  thumb,  the  ulnar  half  of  the  flexor  brevis 
pollicis,  and  the  skin  of  the  anterior  and  posterior  surfaces  of  the  ulnar  side 
of  the  hand,  including  the  little  finger  and  the  ulnar  half  of  the  ring  finger. 
After  dinsion  of  this  nerve  there  are  anesthesia  in  the  area  just  mentioned 


Fig.  1 5 1 . — Hand  after  section  of 
ulnar  nerve.     (Gowcrs.) 


locaimi  of  the  ubiar  nerve  in  front  of  the  inner  condyle  may  occur;  it  has  been 
treated  by  suturing  a  tlapof  fibrous  tissue  over  the  nerve  to  the  triceps  tendon, 
after  reduction  has  been  effected. 

The  lumbar  plexus  may  be  affected  by  injuries,  by  tumors,  and  by  dis- 
ease of  the  vertebne.     It  supplies  sensation  to  the  lower  part  of  the  abdomen^ 


234 


NERVES, 


^ 


the  anterior  and  lateral  aspects  of  the  thigh,  and  to  portion  of  the  inner  side  of 
the  leg  and  foot.  It  supplies  also  the  tlexors  and  the  adductors  of  the  hip, 
the  cxtensorii  of  the  leg,  and  the  t  remaster. 

The  obturator  nerve  may  be  injured  during  parturition,  resulting  in 
paralysis  of  the  adductors  of  the  thigh,  the  patient  being  unable  to  cross  the 
legs.     External  rotatitm  also  is  impaired. 

The  anterior  crural  nerve,  when  divided,  results  in  paralysis  of  the  ex- 
tensors of  the  knee,  and  anesthesia  over  the  front  and  sides  of  the  tblgli, 
anrl  the  inner  side  of  the  leg^  fool,  and  big  toe  (Fig.  152). 

The  sacral  plexus  innervates  the  rotators  and  extensors  of  the  hip,  the 
flexors  of  the  knee,  all  the  muscles  of  the  foot,  and  the  skin  of  the  buttock, 
posterior  surface  of  the  thigh,  outer  and  posterior  portion  of  the  lower  leg, 
and  almost  the  entire  foot.  It  may  be  compressed  by  pelvic  tumors  or  inflam- 
mations, injured  during  child  birth,  or  involved  in  a  neuritis,  which  is  often 
an  extension  from  the  sciatic  nerve. 

The  superior  gluteal  nerve  supplies  the  gluteus  mcdius  and  minimus, 
hence  its  division  results  in  loss  of  abduction  and  circumduction  of  the  thigh. 

The  small  sciatic  nerve  is  not  often  injured.  Its  division  results  in 
paralysis  of  the  gluteus  maximus,  and  anesthesia  of  the  posterior  surface  of 
the  middle  third  of  the  thigh,  and  of  the  upper  half  of  the  calf  of  the  leg. 

The  great  sciatic  nerve,  when  severed  near  the  sciatic  notch,  causes 
paralysis  of  the  llexors  of  the  leg  (which  are  also  extensors  of  the  hip),  ant!  of 
all  the  muscles  below  the  knee  joint;  the  latter  muscles  alone  are  involved 
when  the  injury  is  below  the  middle  of  the  thigh.  Anesthesia  exists  in  the 
outer  half  of  the  leg,  and  in  the  sole  and  the  greater  part  of  the  dorsum  of  the 
foot-  This  nerve  is  frequently  aflfected  by  a  very  painful  form  of  neuralgia 
{sdatjfa)j  in  intractable  cases  of  which  neurectasy  may  be  required.  This 
has  been  accomplished  by  flexing  the  extended  lower  extremity  upon  the 
gibdomen,  under  an  anesthetic.  In  the  open  operation  the  nerve  is  exposed 
midway  between  the  great  trochanter  and  the  tuber  ischii,  by  an  incision 
three  or  four  inches  long,  made  in  the  middle  of  the  thigh  from  the  gluteal 
fold  downwards.  The  lower  border  of  the  gluteus  maximus  is  exposed, 
the  ham-string  muscles  retracted  inwards,  and  the  nerve  hooked  up  by  the 
hngcT  and  stretched  both  centrally  and  peripherally,  enough  force  being  used 
to  lift  the  lower  extremity  from  the  table. 

The  external  popliteal  nerve  may  be  severed  in  cutting  the  tendon  of  the 
biceps  subcutaneously,  or  compresseil  against  the  neck  of  the  tibula  by  ban- 
dages or  splints.  Section  of  this  nerve  causes  paralysis  of  the  peroneal  group  of 
muscles,  the  tibialis  anticus,  and  the  extensor  longus  and  brevis  digitorum, 
with  anesthesia  of  the  outer  half  of  the  anterior  surface  of  the  leg  and  the 
dorsum  of  the  foot.  The  ankle  cannot  be  flexed  on  the  leg  (foot-drap),  and  in 
old  cases  talipes  equinus  develops. 

The  internal  popliteal  nerve,  when  divided,  causes  paralysis  of  the 
muscles  of  the  calf,  extensors  of  the  foot,  llexors  of  the  toes,  and  of  the  muscles 
of  the  sole  of  the  foot.  Talipes  calcaneus  develops  after  a  time,  and  the  toes 
become  claw  dike,  owing  to  extension  of  the  proximal  and  flexion  of  the  second 
and  third  phalanges.  There  is  anesthesia  along  the  back  of  the  leg  and  over 
the  sole  of  the  foot. 

The  cervical  sympathetic  nerve  may  be  injured  by  wounds,  or  com- 
pression by  tumors  or  aneurysms.  Irritation  of  the  nerve  causes  unilateral 
sweating  of  the  head  and  face,  dilatation  of  the  pupil  on  the  same  side, 


rNJUHIES   OF   MUSCLES, 


235 


J  of  tie  palpebral  fissure,  Lontraction  of  the  blood  vessels  of  the  head 
ck,  and  tachycardia.  Division  of  the  nerve  causes  contrat  lion  of  the 
pupiL  ptosis  and  narrowing  of  the  palpeliral  lissure,  decrease  of  ocular 
tension  with  recession  of  the  eyeliall,  dilatation  of  the  vessels  of  the  head  and 
neck  with  increase  in  the  flow  of  tears,  nasal  mucus,  and  sweat,  an^l  brady- 
cardia. Excision  of  the  cervical  sympathetic  ganglia,  or  Jonnesco's  opera- 
tion, has  been  performed  for  epilepsy,  exophthalmic  goiter,  tic  douloureux, 
and  glaucoma.  An  incision  is  made  along  the  anterior  border  of  the  stemo- 
mastoid,  the  carotid  sheath  with  its  contents  retracted  forwards,  and  the 
upper  or,  in  some  cases,  the  entire  three  ganglia  excised.  The  value  of  the 
operation  is  not  yet  fixed. 


CHAPTER  XVm, 

^P  BTDSCLES,  TENDONS,  BURSiiE. 

I  Conhision  of  muscles  is  followed  by  swelling,  and  by  late  ecchymosis  if 

I  some  of  the  blood  vessels  have  been  injured.  Pain  and  tenderness  are  made 
I  worse  by  active  motion,  but  are  unaffected  by  passive  motion,  unless  the 
r     muscle  is  stretched  by  such  procedure.     The  treat mmt  is  rest  and  relaxation 

I  of  the  muscles,  the  application  of  ichthyol  or  evap<) rating  lotions,  and  later 
massage. 
Woimds  of  muscles  gap  widely  if  they  traverse  the  muscle  fibers.  A 
wound  parallel  with  the  fibers  causes  little  or  no  separation.  Suturing  is 
readily  carried  out  in  longitudinal  or  ol>lique  wounds,  but  is  often  difficult  m 
transverse  wounds,  the  stitches  tearing  out  when  approximation  is  attempted. 
In  such  cases  mattress  sutures  may  be  employed,  or  a  number  of  sutures  may 
be  placed  in  each  end  of  the  muscle  and  tied,  then  the  ends  of  the  sutures  in 
the  upper  segment  tied  to  those  in  the  lower  segment.  Chromicized  catgut 
is  the  best  suture  materiab  The  muscles  should  be  relaxed  by  suital>le 
posture  or  splint,  and  massage  and  electricity  employed  when  healing  has 
been  completed. 

Strain  of  muscles  is  an  overstretching  of  the  fil>ers  with  fKissibly  some 
tearing.     The  symptoms  and  treatment  arc  those  of  contusion  of  muscle. 

Rupture  of  muscles  and  tendons  usually  occurs  as  the  result  of  great 
violence  to  a  contracted  muscle,  or  as  the  result  of  a  sudden,  powerful,  and 
strongly  opposed  contraction,  but  may  follow  even  feeble  efforts  in  muscles 
degenerated  io  consequence  of  senility  or  fevers.  Rupture  of  the  sheath 
or  of  the  deep  fascia  may  result  in  hernia  of  the  musde,  a  protrusion  which 
is  most  marked  during  contraction,  and  which  often  disappears  during 
relaxation  of  the  muscle^  when  the  opening  m  the  aponeurosis  may  be  felt 
through  the  skin.  In  recent  cases  rest  ami  rela.xation  are  required.  Later 
if  the  hernia  is  large  and  causes  inconvenience,  the  opening  in  the  sheath  may 
be  sutured.  A  muscle  most  frequently  ruptures  at  the  junction  with  its  ten- 
don, although  the  belly  itself  or  the  tendon  may  tear.  In  some  cases  the  tendon 
is  torn  from  its  attachment,  bringing  with  it  a  portion  of  the  bone.  At  the 
time  of  rupture  there  is  a  sudden  sharp  pain,  with,  in  some  cases,  an  audible 
snap.  This  is  followed  by  loss  of  function,  tenderness,  pain  on  motion, 
swelling,  and  ecchymosis.    The  gap  may  be  felt  in  superficial  muscles. 


A 


236  MUSCLES,   TENDONS,   BURSiE. 

Among  the  muscles  and  tendons  most  frequently  ruptured  are  the  biceps, 
quadriceps,  ligamentum  patellae,  sternomastoid  (during  labor),  flexors  of  the 
forearm,  rectus  abdominis,  and  plantaris.  In  rupture  of  the  plantaris,  which 
not  uncommonly  occurs  in  tennis,  boxing,  etc.,  there  is  a  sharp  pain  in  the  calf 
like  the  sting  of  a  whip  {coup  defouet),  tenderness,  swelling,  and  after  a  day 
or  two  ecchymosis  along  the  posterior  surface  of  the  leg;  identical  symptoms 
are  produced  by  the  rupture  of  a  deep  varix. 

The  treatment  in  partial  ruptures  is  rest  and  relaxation;  in  large  or  com- 
plete ruptures  of  important  muscles  the  ends  should  be  approximated  with 
chromic  catgut  sutures  and  the  part  splinted.  Massage,  electricity,  and 
passive  motions  are  employed  after  union  has  taken  place. 

Dislocation  of  tendons  is  most  frequent  at  the  point  where  a  tendon 
passes  along  a  bony  groove  in  order  to  change  its  direction,  e.g.,  the  long 
tendon  of  the  biceps,  and  the  tendons  about  the  wrist  and  ankle.  There 
are  pain  and  weakness,  and  in  some  cases  the  dislocated  tendon  can  be  felt, 
with  the  groove  in  which  it  normally  lies.  In  dislocation  of  the  long  end  of 
the  biceps  the  head  of  the  humerus  passes  slightly  forwards  (subluxalian). 

The  treatment  is  reduction  of  the  tendon,  relaxation  of  the  muscle,  and 
the  application  of  a  splint,  with  pressure  over  the  tendon  to  hold  it  in  place. 
If  this  treatment  fails  in  the  course  of  six  weeks  or  two  months,  the  tendon 
may  be  exposed  by  incision  and  the  edges  of  the  torn  sheath  sutured  with 
catgut.  This  operation  is  most  frequently  indicated  in  dislocation  of  the 
peroneus  longus  tendon  from  behind  the  external  malleolus. 

Myositis,  or  inflammation  of  muscles,  may  be  acute  or  chronic. 

Acute  myositis  may  be  due  to  injuries  {traumatic  myositis),  infection 
from  the  surrounding  parts,  exposure  to  cold  {rheumatic  myositis),  and  to 
infectious  fevers.  The  symptoms  are  pain,swelling,  tenderness,  and  some- 
times edema  of  the  skin.  When  due  to  local  infections  or  pyemia,  suppura- 
tion follows.  Polymyositis  affects  many  muscles,  is  of  obscure  origin,  and 
strongly  resembles  trichinosis,  hence  the  term  pseudotrichinosis.  When 
there  is  an  overproduction  of  fibrous  tissue  the  muscle  is  shortened,  thus  in 
the  sternomastoid  torticollis  may  be  produced,  and  in  the  forearm  Volkmann^s 
contracture  {ischemic  myositis).  The  latter  is  due  to  compression  of  a  splint 
or  bandage,  and  is  often  associated  with  splint  sores  and  neuritis,  although 
pain  is  not  a  prominent  symptom.  The  flexor  muscles  are  shortened,  so 
that  the  wrist  and  fingers  cannot  be  extended  at  the  same  time  (Fig.  153.) 

The  treatment  is  rest,  sedative  applications,  and  constitutional  treatment 
according  to  the  general  condition  of  the  patient.  Suppuration  will  require 
incisions.  Massage  and  electricity  are  indicated  to  prevent  muscular  con- 
tractures, which,  when  present,  may  require  tenotomy  or,  better,  tendon 
lengthening;  resection  of  bone  to  shorten  the  limb  also  has  been  performed 
in  certain  cases. 

Chronic  myositis  results  from  the  acute  form,  or  from  syphilis,  tuber- 
culosis, rheumatism,  actinomycosis,  or  the  lodgment  of  parasites  (trichina, 
echinococcus).  It  may  cause  suppuration,  or  degeneration  with  fibrous 
overgrowth.  In  the  latter  event  ossification  may  occur,  particularly  in  the 
vicinity  of  bone,  or  where  the  parts  are  constantly  irritated  or  strained,  e.g., 
rider^s  hone  due  to  ossification  of  the  upper  portion  of  the  adductor  tendons  of 
the  thigh,  and  localized  ossification  of  the  deltoid  in  soldiers.  In  myositis 
ossificans  progressiva  a  large  part  of  the  muscular  system  may  be  calcified. 
The  cause  is  not  known.     It  is  most  frequent  in  young  males,  and  is  some- 


THECITIS.  237 

times  associated  with  shortening  of  the  thumbs  and  great  toes.  The  treat- 
ment is  directed  to  the  cause.  In  localized  myositis  ossificans  the  bony 
plates  may  be  excised.     In  the  progressive  form  treatment  is  of  no  value. 

Tumors  of  muscle  include  fibroma,  myxoma,  lipoma,  angioma,  chon- 
droma, osteoma,  myoma,  and  most  important  of  all,  sarcoma;  carcinoma  is 
always  secondary.  A  desmoid  is  a  fibroma  or  fibrosarcoma  of  the  rectus 
abdominis,  usually  occurring  in  women  who  have  borne  children.  A  tumor 
in  a  muscle  is  movable  prependicularly  to  but  not  in  the  axis  of  the  muscle, 
and  becomes  fixed  when  the  muscle  is  contracted.    The  treatment  is  excision. 

TenosjmovitiSy  thecitis,  or  inflammation  of  a  tendon  sheath,  may  be 
acute  or  chronic.  Acute  tenosynovitis  is  caused  by  injury,  strains,  overuse, 
neighboring  infections,  gout,  rheumatism,  syphilis,  gonorrhea,  and  the  in- 
fectious fevers.  The  symptoms  are  swelling  and  tenderness,  with  pain  and 
fine  crepitus  upon  motion.  Suppuration  may  occur  when  the  sheath  has 
been  opened  by  a  wound,  or  when  the  thecitis  is  secondary  to  neighboring 
infections.  The  symptoms  are  then  intensified,  the  skin  reddened,  and 
constitutional  symptoms  of  sepsis  present.  The  treatment  is  immobilization 
on  a  splint,  with  the  application  of  ichthyol  or  evaporating  lotions.  Pus 
formation  demands  incision  and  drainage,  which,  if  carried  out  early,  may 
prevent  sloughing  of  the  tendon.  Massage  and  active  and  passive  motions 
are  useful  in  the  later  stages  to  prevent  adhesions. 

Suppurative  thecitis  of  the  finger  constitutes  one  of  the  varieties  of  felon, 
or  whitlow,  of  which  four  forms  are  described :  i .  The  subcuticular y  or  blister- 
like, is  due  to  pus  superficially  located  under  the  epidermis,  the  removal  of 
which  is  followed  by  prompt  recovery.  2.  The  subcutaneous  form  is  a  cellu- 
litis of  the  pulp  of  the  finger,  usually  preceded  by  an  injury  or  abrasion,  and 
located  over  the  last  phalanx.  There  are  swelling,  redness,  edema  most 
marked  on  the  back  of  the  finger,  and  severe  throbbing  pain,  particularly 
when  the  arm  is  dependent.  Painless  and  destructive  felons  may  occur  in 
certain  nervous  maladies,  notably  that  form  of  syringomyelia  known  as 
Morvan^s  disease.  Fluctuation  is  rarely  detected  unless  the  abscess  is  about 
to  break.  Unless  promptly  treated  the  process  may  spread  to  the  tendon 
sheath  and  involve  even  the  bone.  The  treatment  is  incision,  care  being  taken 
not  to  open  the  tendon  sheath,  light  gauze  packing,  and  hot  antiseptic  fomen- 
tations. 3.  The  thecal  form  follows  the  variety  just  described,  or  is  associated 
with  bone  felon.  The  sheaths  of  the  flexor  tendons  are  invaded,  and  there  is 
great  pain  on  flexing  the  finger,  otherwise  the  signs  are  the  same  as  those  of  the 
preceding  variety,  although  the  constitutional  symptoms  are  apt  to  be  more 
marked.  There  is  great  danger  of  sloughing  of  the  tendon,  and  spreading  of 
the  suppuration  into  the  palm  (palmar  abscess).  The  latter  event  is  most 
common  when  the  thumb  or  little  finger  is  involved,  because  their  tendon 
sheaths  communicate  with  the  common  palmar  sac  (Fig.  154).  The  treat- 
ment is  free  and  early  incision  under  a  general  anesthetic,  and  antiseptic 
fomentations,  The  swelling  is  most  marked  on  the  dorsum  of  the  hand, 
owing  to  the  resisting  nature  of  the  palmar  fascia,  and  constitutional  symptoms 
alwajTs  are  present.  The  incisions  should  be  along  the  middle  of  the  meta- 
carpal bones,  and  below  a  line  crossing  the  palm  at  the  level  of  the  web  of  the 
thumb,  in  order  to  avoid  the  superficial  palmar  arch  and  its  branches  (Fig. 
154).  It  may  be  necessar>'  to  incise  above  the  arches,  and  above  even  the 
wrist.  Openings  on  the  dorsum  also  may  be  recjuired  for  through  and  through 
drainage.     Lymphangitis  and  lymphadenitis  are  not  unusual,  and  should  be 


23^ 


MUSCLES,    TENDONS,    BURS.E. 


treated  as  described  under  these  headings.  The  hand  should  be  kept  at 
rest  on  a  splint,  but  passive  motion  should  liC  commenced  as  soon  as  the  in- 
flammation subsides,  in  order  to  prevent  adhesions  of  the  tendons  to  their 
sheaths,  4.  The  sttbperio steal,  or  bone  felafi^  may  be  primary,  but  is  often 
secondary  to  the  subcutaneous  or  thecal  variety,  or  to  paronychia.  The 
symptoms  are  those  of  sulxytaneous  felon,  with  possibly  a  greater  amount  of 
pain.  The  treatment  is  early  incision  down  to  the  bone,  and  later  the  re- 
moval of  as  much  I  nine  as  becomes  necrotic;  this  may  Ije  the  whole  distal 
phalanx  and  occasionally  part  of  the  second  phalanx. 

Chronic  tenosynovitis  may  follow  the  acute  form,  in  which  case  the 
sheath  is  distended  with  synovial  fluid.     There  are  weakness,  swelling  and 


Fig.  155. 


Fig. 


^54' 


Fig.  153. — ^Volkmann's  conlracturc,  from  ihe  pressure  of  a  spUnl;  ireated  by  tenclon 
lengihcning. 

F[G.  1 54. — Diagram  showing  the  usual  arrangement  of  ihe  tendon  sheaths  of  the  hand 
(shaded)  and  the  relations  of  the  palmar  arches  (in  red)  to  the  lines  of  the  palm.  Note 
also  ihe  position  of  the  digital  arteries. 

fluctuation  along  the  tendon  sheath,  and  possibly  crepitus.  In  most  instances 
the  condition  is  tulierculous.  Tuberculous  tenosynovitis  may  present 
the  same  si|^s,  or  the  swelling  may  he  doughy  owing  to  the  thick,  pulpy 
granulation  tissue  which  lines  the  sheath.  Often  there  can  be  felt  slipping 
beneath  the  fingers  little  rounded  bodies  (rice,  ri/iform,  or  melon  seed  bodies), , 
which  are  laminated  masses  of  fibrin.  The  Inaiment  of  chronic  tenosynovitis 
is  attention  to  any  existing  constitutional  disease,  and  locally  the  use  of  a 
splint,  with  compression  or  counted rritation.  If  this  fails,  the  sheath  may 
be  opened,  its  contents  evacuated,  iodoform  emulsion  injected,  and  the 
wound  closed;  or  an  attempt  may  be  made  to  remove  the  diseased  sheath  by 
dissection. 

Ganglion  is  a  tense  sac  connected  with  a  tendon  sheath,  and  tilled  with  a 
transparent,  whitish,  jelly-like  material.  It  may  follow  an  injury  or  strain, 
and  is  then  probably  due  to  an  encarcerated  hernia  of  the  synovial  lining 
of  the  tendon  sheath;  in  other  instances  it  is  due  to  a  localized  thedtis  or  to 


239 

a  colloid  degeneration  of  a  synovial  fringe.  It  is  most  common  on  the  back 
of  the  wrist,  hut  may  occur  elsewhere.  It  is  painful  and  tender  when  increas- 
ing in  size,  but  usually  givers  no  trouble  when  it  has  ceased  to  grow,  except 
possibly  for  some  weakness  of  the  affected  tendon.  It  may  be  so  hard  as  to 
resemble  an  exostosis.  Compound  gangHon  is  a  tuberculous  thelitis  of  the 
flexor  tendons  of  the  wrist,  projecting  above  and  below  the  annular  ligament. 
The  treat tnent  is  rupture  of  the  ganglion  by  strong  pressure  with  the  thumbs^ 
or  by  dealing  it  a  sharp  rap  with  a  book;  expression  of  the  contents  through 
a  small  puncture,  and  firm  pressure  for  several  days;  the  injection  of  iodin ;  or 
in  recurring  cases  excision* 

OPERATIONS  ON  TENDONS. 

Tenotomy,  or  division  of  a  tendon,  may  be  open  or  siibtutaneaus.  It  is 
employed  chielly  in  cases  of  deformity,  and  occasionally  to  overcome  muscu- 
lar spasm,  e.g.,  cutting  of  the  tendo  AchiUis  in  fractures  of  the  leg.  The  sub- 
culaneaus  method  should  be  used  only  in  regions  in  which  important  structures 


"^^^ggg 


< 


Kivvi 


FiC*  tS5»  Frc.  156.  Fig.  157.  Fig.  158. 

Figs.  155  10  158. — Trnorrhaphy.     (Monofl  and  V'anverls.) 


I  are  not  close  to  the  tendon.  Under  aseptic  precautions  a  sharp  pointed 
tenotome  is  pushed  through  the  skin  to  the  tendon,  and  is  then  replaced  by  a 
blunt  pointed  tenotome,  which  is  passed  over  or  under  the  tendon.  The 
I  tendon  is  then  made  tense  and  is  cut  by  a  sawing  motion.  The  little  punc- 
I  ture  is  scaled  by  collodion.  In  the  oprn  method  an  incision  is  made  over  the 
tendon  and  the  set  lion  carried  imt  under  the  eye,  so  that  there  is  little  danger 
of  wounding  neighboring  slructiires.  The  wound  is  then  sutured.  After 
either  method  the  deformity  is  corrected,  and  the  parts  are  immobilized 
with  plaster-of-Paris  or  other  form  of  splint. 


240 


MUSCLES,   TENDONS,   BURS^. 


Division  of  the  sternocleidomastoid  muscle.     (See  torticollis.) 
The  tendo  Achillis  is  divided  subcutaneously.    With  the  foot  on  its 
outer  side  and  the  tendon  relaxed,  the  tenotome  is  inserted  about  one  inch 


f 


A  B 

Fig.  159. — Tenorrhaphy.     (Binnic.) 


Fig.  160. — Tenorrhaphy.     (Binnic.) 


Fig.  161.  Fig.  162. 

Figs.  161  to  163. — Tenorrhaphy.     (Vulpius.) 


Fig.  163. 


al)ove  the  os  calcis,  and  the  tendon  divided  after  it  has  been  made  taut  by 
flexion  of  the  foot. 

The  tibialis  anticus  is  divided  about  one  inch  above  its  insertion.     The  ' 


OPERATIONS   ON   TENDONS. 


241 


tenotome  is  introduced  from  the  outside  and  the  section  made  from  below 
upwards. 

The  peroneal  tendons  are  cut  just  above  and  behind  the  external  mal- 
leolus, in  which  situation  the  synovial  sheath  is  absent.     The  tenotome  is 


Fig.  164. — Tenorrhaphy.     (Binnic.)  Fig.  165.- -Tenorrhaphy.     (Binnie.) 


Fig.  166.  Fig.  167.  Fig.  168. 

Figs.  166  to  168. — Tendon  lengthening.     (Monod  and  Vanvcrts.) 


introduced  between  the  bone  and  the  tendons,  whirh  are  made  tense  and 
severed  from  below  upwards. 

The  tibialis  posticus  is  severed  above  the  internal  annular  ligament  and 
alH)ve  the  origin  of  the  synovial  sheath.     The  tenotome  is  inserted  just 
16 


242 


MUSCLES,     TENDONS,  BURS^. 


above  the  base  of  the  inner  malleolus,  between  the  tendon  and  the  tibia,  and 
hugs  the  bone  closely.  There  is  some  danger  of  injury  to  the  posterior 
tibial  vessels. 


H 


Fig.  169. — ^Tendon  lengthening.     (Binnie.) 


Fig.  170. — ^Tendon  lengthening. 
(Binnie.) 


Fig.  171 . — Catgut  graft.  (Esmarch 
and  Kowalzig.) 


Fig.  172. — Tendon  lengthening 
by  transplantation  of  osseous  inser- 
tion.    (Monod  and  Vanverts.) 


Fig.  174.  Fig.  175. 

Figs.  173  to  175.— Tendon  shortening.     (Binnie.) 

The  plantar  fascia  is  divided  subcutaneously  just  in  front  of  the  os  calcis, 
l)y  inserting  a  tenotome  between  the  fascia  and  the  skin  from  the  inner  side 
of  the  sole,  and  cutting  towards  the  bone. 


OPERATIONS   ON   TENDONS. 


243 


The  semimembranosus  and  the  semitendinosus  may  be  divided  subcu- 
taneously  just  above  the  knee  joint,  but  section  of  the  biceps  f  emoris  is  best 
done  through  an  open  incision,  because  of  the  proximity  of  the  popliteal 
nerve. 

Tenorrhaphy  (tendon  suture)  is  best  performed  with  chromicized  catgut. 
The  various  methods  are  shown  in  Figs.  155  to  165;  Figs.  164  and  165  show 
the  methods  for  preventing  the  tearing  out  of  sutures. 


I'"  Sutures. 


Fig.  176.  Fig.  177.  Fig.  178. 

Figs.  176,  177,  i78.-~Tendon  Transplantation.     (Vulpius.) 


Fig.  179.  Fig.  180. 

Fios.  179,  180. — ^Tendon  transplantation.     (Vulpius.) 

Tendon  lengthening  is  occasionally  employed  in  deformities  due  to 
shortened  tendons,  or  in  cases  in  which,  after  accidental  division  of  a  tendon, 
the  approximation  is  difficult  owing  to  retraction  of  the  ends  (Figs.  166  to  1 70) 
When  the  ends  of  a  divided  tendon  cannot  be  sufficiently  elongated  to  approx- 
imate them,  the  lower  end  may  be  sutured  to  a  neighboring  tendon  with  a 
similar  function  or  to  the  periosteum;  a  graft  may  be  made  from  adjacent 
fibrous  tissue,  from  a  neighboring  tendon  (Fig.  177),  from  the  tendon  of  an 


244 


MUSCLES,   TENDONS,   BURSiE. 


Fig.  i8i. 


Fig.  184. 


Fig.  182. 


Fig.  183. 


FIG.  z86. 


Fic.  1S7.  Vui.  188.  ?'ic.  180. 

Fi(;s.  181  to  189.     Tendon  transi)lantati()n.     iVulpius.) 


anicnaU  or  from  calgul  (Vl^-  17 1),  'ir  Ihe  osseous  msertkm  may  he  trans- 
planietJ  (Fig.  172). 

Tendon  shortening  is  illustrated  in  Figs*  173  lo  175. 

Tendon  transplantation  has  been  employed  for  the  relief  of  deformities 
due  to  paralyzed  muscles.  The  tendoji  of  the  paralyzed  muscle  may  be 
divided,  and  its  distal  end  threaded  through  a  split  in  an  active  tendon  and 
there  sutured  (Fig*^.  161  to  163).  Other  methods  are  elucidated  in  Figs. 
176  lo  189;  the  paralyzed  tendons  are  shaded. 


^ 


DISEASES  OF  BURS^, 


AdTtntitious  bursas  not  uncommonly  develop  in  situations  habitually 
exposed  to  pressure,  e.g.,  on  the  shoulder,  under  the  scapula,  and  over  the  in- 
ternal condyle  in  knock  knee. 

Wounds  of  bursas  differ  from  ordinary  wounds  in  that  the  continuous 
escape  of  syno\ial  tluid  may  interfere  with  healing  and  necessitate  excision  of 
the  bursa  or  destruction  of  its  lining  membrane. 

Acute  bursitis  is  usually  the  result  of  traumatism.  The  symptoms  are  a 
painful  and  tender  circumscribed  swelling  in  the  situation  of  a  bursa,  which 
fluctuates  and  is  frequency  the  seat  of  a  fine  crepitus.  Suppuration  may 
occur  as  the  result  of  infection  through  a  wound  or  from  the  blood.  The 
ireatmefit  is  rest,  the  application  of  ichthyol  or  evaporating  lotions,  and  later, 
compression  to  hasten  absorption.  If  suppuration  occurs  incision  and 
drainage  are  indicalccb 

Chronic  bursitis  may  follow  the  acute  form,  or  result  from  chronic  irrita- 
tion, syphilis,  tuberculosis,  gout,  or  rheumatism.  The  bursa  is  enlarged  and 
fluctuates,  owing  to  the  effusion  of  serous  fluid  within.  In  old  cases  the  walls 
may  be  so  thickened  as  to  simulate  til>roma.  In  tuberculous  cases  the  swell- 
ing may  be  doughy,  owing  to  the  thick  layer  of  edematous  granulations  bning 
the  cavity,  or  rice  iHKlies  may  be  <letectcd.  In  late  syphilis  there  may  be  a 
gummy  degeneration,  and  in  gout  deposits  of  urate  of  soda  (tophi). 

The  treatment  in  simple  cases  is  rest,  compression,  and  counlerirritatiun 
with  blisters  or  iodin.  If  the  effusion  persists  it  may  be  aspirated  or  the 
bursa  excised.  In  tuberculous  cases  and  in  those  with  thick  walls,  excis- 
ion should  be  performed.  Constitutional  treatment  will  be  needed  in  the 
presence  of  syphilis,  tuberculosis,  gout,  or  rheumatism. 

Among  the  bursa-  which  are  more  commonly  diseased  are  the  following: 
A  btirsa  (n>er  the  metatar so- phalangeal  joint  of  the  big  toe  is  called  a  btmion  (see 
hallux  valgus) » the  retrofakaneat  ^^r5(j,  when  inflamed,  Albert's  disease  (Chap, 
xxxi).  The  prepatellar  bursa  is  often  enlarged  as  the  result  of  frequent  kneel- 
ing, and  is  known  as  htmse  maid's  knee.  The  infra  patellar  bursa  lies  between 
the  ligamentum  patella?  and  the  tuberosity  of  the  tibia,  and  when  inflamed 
causes  a  tluctuating  swelling  on  each  side  of  the  tendon,  which  is  more  marked 
when  the  leg  is  extended.  The  symptoms  may  be  somewhat  similar  to  a 
dislijcated  semilunar  cartilage,  owing  to  the  pinching  of  the  ligamenta  alaria, 
which  are  crowded  back  between  the  bones.  Of  the  popliteal  bursa:  the  one 
which  lies  between  the  gastrocnemius  and  the  semimembranosus,  and  extends 
beneath  the  inner  head  of  the  gastrcKnemius,  is  most  frequently  enlarged. 
It  is  hard  and  prominent  when  the  leg  is  extended,  and  may  exhibit  trans- 
mitted  pulsation;  when  the  leg  is  flexed  it  is  soft  and  may  be  difficult  to  detect. 


246  ^^^^^^^i^  BONES. 

It  is  tedious  to  remove,  and,  as  it  frequently  commtinkatcs  with  the  joint,  a 
ligature  or  suture  will  he  required  lo  close  the  s>Txovial  Tucmbrane  at  this  point. 
The  iliopeciineal  imrsay  when  enlarged,  presents  a  swelling  at  the  base 
of  Scarpa's  triangle,  which  may  be  mistaken  for  psoas  abscess,  hip 
disease,  or  a  neoplasm.  The  httrsa  of  the  great  trochanter,  when  inflamed, 
causes  abduction  and  eversion  of  the  thigh,  and  a  swelling  which  is 
most  marked  jyst  behind  the  great  trochanter.  It  is  distinguished  from 
coxalgia  by  the  absence  of  restricted  movements  of  the  hip  joint.  Enlarge- 
ment of  the  hj4rsa  ai^er  the  tuber  ischii  is  known  as  Weaver's  bottom,  of 
the  oiecranon  hursa^  min4^r*s  etbmtK  Enlargement  of  the  subdeltoid  bursa 
causes  a  prominence  of  the  deltoid,  but  the  shoulder  joint  itself  is  in  no 
way  affected. 


CHAPTER  XLX. 

BONES. 

INJURIES  OF  BONES. 

A  fracture  has  been  defined  as  a  sudden  solution  of  the  continuity  of  a 
bone,  generally  from  external  violence. 

The  Varieties.— Fractures  are  divided  as  follows*,  i.  According  t^  the 
cause,  into  traumatic  and  pathological  or  sponlaneous  (resulting  from  trivial 
force  to  a  diseased  bone).  Traumatic  fractures  are  subdivided,  according 
to  the  nature  of  the  force,  as  explained  on  p.  247,  2.  According  to  the  lines  of 
fracture,  into  transverse,  longitudinal ^  otMque,  spiral,  dentatey  stellate,  V  shaped, 
and  T-shaped,  A  comminuted  fracture  is  one  in  whit  h  1  he  bone  is  broken  into 
three  or  more  fragments^  with  intercommunication  of  the  fracture  lines,  A 
multiple  fracture  is  one  in  which  there  is  more  than  one  fracture  in  a  bone,  the 
lines  of  which  do  not  communicate.  Fractures  of  several  different  bones  also 
are  spoken  of  as  multiple  fractures.  A  splintered  fracture  is  one  in  which  a 
splinter  of  osseous  tissue  is  broken  from  a  bone.  3,  According  to  the  degree 
of  fracture,  into  complete,  which  extends  completely  through  a  bone,  and  in- 
complete^  in  which  the  bone  is  not  completely  divided,  A  green- stick  fracture 
{infraction)  is  an  incomplete  fracture  resulting  from  the  bending  of  a  bone, 
the  osseous  tissue  of  the  convex  side  separating  and  that  of  the  concave  side 
remaining  intact*  A  fissure  fracture  is  an  incomplete  fracture  occurring  as  a 
crack,  usually  in  the  outer  table  of  the  skulL  A  subperiosteal  fracture,  which 
may  or  may  not  extend  through  the  rest  of  the  bone,  leaves  the  periosteum 
int  a  c  t .  4 .  A  ccording  to  th  t  p  os  it  ion  of  th  e  ft  a  g  m  ents,  in!  o  i  m  pacted ,  in  w  hic  b 
one  fragment  is  forced  into  the  other,  and  depressed,  in  which  the  bone  is 
crushed  in.  Other  terms  used  with  reference  to  displacement  are,  transverse, 
rotary,  angular,  and  longitudinal  (either  overlapping  or  separation).  5, 
According  to  the  presence  or  absence  of  a  wound  in  the  soft  parts,  into  closed 
or  simple,  in  which  there  is  no  external  wound  in  the  soft  parts,  and  open  or 
compound,  in  which  such  a  wound  exists.  A  complicated  fracture  is  one  in 
which  there  is  injury  to  an  important  vessel,  nerve,  joints  or  viscus._  6. 
According  to  the  situation  of  the  fracture,  into  intraarticular  or  extraarticular ^ 
with  reference  to  a  joint,  and  intra-  or  extracapsular ,  with  reference  to  the 


L 


FRACTtlRES. 


247 


capsular  ligament  of  a  joint.  Epiphyseal  separaii&n  also  may  be  put  under 
this  heading. 

An  intraukrine  frmtiin'  occurs  before  birth,  a  amgeniial  fraciurc  at  Inrth. 

The  causes  of  fracture  are  predisposing  and  exciting. 

The  predisposing  causes  are  physiological  and  pathoiogicaL  Among  the 
fonner  are  age.  sex,  occupation,  season  of  the  year,  and  structure  and  position 
of  the  bone.  Fractures  are  frequent  in  infancy  liecause  of  the  many  tumbles 
which  occur  at  this  time,  but  owing  to  the  elasticity  of  the  bones,  the  breaks 
are  often  incomplete  or  of  the  green  stick  variety.  In  old  age  the  brittleness 
of  the  bones  is  such  that  even  a  trivial  injury  may  produce  fracture.  During 
adolescence  and  adult  life  fractures  are  more  frequent  in  the  male  sex,  owing 
to  the  greater  exposure  to  injury.  Occupations  entailing  daily  exposure  to 
injury  predispose  to  fracture.  In  winter  fractures  are  more  frequent  because 
of  the  presence  of  slippery  ice  under  foot.  The  structure  and  position  of 
certain  bones  render  them  more  liable  to  fractures.  The  pathological  causes 
are  atrophy  0/  bone ^  the  causes  of  which  are  given  on  p.  293;  general  disease  of 
the  osseous  sysiem^  such  as  osteomalacia,  rickets,  idiopathic  fragilitas  ossiym, 
and  ostitis  deformans;  and  localized  disease  of  bone  ^  such  as  malignant  disease, 
caries,  necrosis,  echinococcus,  actinomycosis,  s)^hilis,  gout,  rheumatism, 
scurvy^  tuberculosis,  and  cysts. 

The  exciting  causes  are  exlemal  violence  and  muscnhr  action,  e.g.,  frac- 
ture of  the  patella  from  contraction  of  the  quadriceps.  The  former  may  be 
direct  (the  lx>ne  breaks  directly  Ijeneath  ihe  point  injured),  in  which  case  the 
fracture  is  usually  transverse  or  comminuted,  or  indirect  (the  bone  breaks  at 
some  distance  from  the  point  of  violence).  Gunshot  and  punctured  fractures 
arc  special  varieties  of  direct  fractures.  Indirect  fractures  may  be  designated 
according  to  the  nature  of  the  force  as  betiding  (e.g.,  fracture  of  the  clavicle 
from  a  fall  on  the  shoulder),  torsion  (e.g.,  fracture  of  the  tibia  from  twisting 
of  the  leg),  compressioni  e.g.,  certain  fractures  of  the  skull,  and  fracture  of 
the  tarsus  from  a  fall  on  the  foot),  or  avulsion  fractures  (e.g.,  fracture  of  the 
internal  malleolus  through  the  action  of  the  internal  lateral  ligament  when  the 
foot  is  everted)  ► 

An  intrauterine  fracture  is  the  result  of  violent  uterine  contractions,  or 
of  blows  upon  the  abdomen.  Multiple  intrauterine  fractures  occur  in 
syphilis.  Congenital  fractures  result  from  uterine  contractions,  or  more 
frequently  from  the  manipulations  of  the  obstetrician. 

Epiphyseal  separation,  or  diastasis,  occurs  before  the  age  of  twenty- 
two  (see  Fig.  190),  The  bones  most  frequently  alTected  are  the  humerus, 
radius,  femur,  and  tibia.  As  the  end  of  a  diaphysis  is  usually  cup-shaped  to 
receive  the  convex  epiphysis^  the  deformity  is  often  difficult  to  reduce.  A 
pure  epiphyseal  separation  is  uncommon  except  in  infants;  in  older  children 
the  line  of  cleavage  usually  involves  at  least  a  part  of  the  end  of  the  diaphysis. 
During  the  process  of  repair  the  epiphyseal  cartilage  may  prematurely 
ossify  and  thus  interfere  with  subsequent  growth.  Suppuration  occasionally 
follows,  and  partial  detachment  or  sprain  of  an  epiphysis  sometimes  precedes 
tuberculous  disease.  Spontaneous  separation  is  always  the  result  of  some 
disease  of  the  epiphysis,  such  as  rickets,  scurvy,  syphilis,  tuberculosis,  or 
acute  infections. 

The  Symptoms.— Excepting  certain  cases  of  spontaneous  fracture,  there 
is  a  history  of  injury,  al  which  time  the  patient  may  feel  something  give  way, 
or  hear  a  cracking  sound.     Pain  is  severe  at  the  time  of  injury,  but  may 


248 


BONES. 


l>e  insignificant  in  pathological  fractures.  The  location  of  acute  tenderness 
is  of  great  value  in  diagnosis.  Swelling  quickly  super\Tnes,  and  within  a 
day  or  two  blebs,  or  bulLe,  may  form,  the  exuded  serum  from  the  deeper 


J£W4PAt>»f 


Fk;.  190.  —Time  of  Iwny  union  of  the  various  epiphyseal  junctions.     (Brewer.) 


tissues  passing  l)eneath  the  epidermis.  Ecchymosis  occurs  within  a  few  hours 
or  not  for  one  or  more  days,  according  to  the  depth  of  the  broken  bone  and 
the  extent  of  the  injur}'  to  the  soft  parts.    Loss  of  Junction  is  caused  by  pain,  or 


COMPLICATIONS    OF   FRACTURES. 


240 


by  loss  uf  m*fchaiiical  support; it  may  be  absent  in  an  iacompletf  ur  impailed 
fracturCp  or  in  a  fracture  of  a  bone  whose  function  is  supplemented  by  another 
bone,  e.g.,  the  fil^ula.  Musiular  spasm  is  a  common  symptom,  particularly 
in  the  arm  and  thigh.  Deformity^  or  change  in  the  length  or  contour  of  a 
limh^  is  due  to  displacement  of  the  fragments  by  the  force  of  the  injur}\  by 
the  weight  of  the  limb,  or  Ijy  muscular  action.  Preicrtmiumi  mobility  may 
be  obtained  by  grasping  the  limb  just  above  ao<l  below  the  fracture  and  mak- 
ing pressure  in  opposite  directions^  or  by  moving  the  limb  as  a  whole.  In 
fractures  of  the  forearm  or  leg,  the  parallel  bones  may  be  alternately  pressed 
together  above  and  below  the  seat  of  fracture.  A  deceptive  sense  of  abnor- 
mal mobilitiy  may  be  present  in  elastic  bones  like  the  hbula  and  ribs,  in  bone 
diseases  like  rickets,  in  normal  infants,  and  in  the  neighlx>rhood  of  joints. 
Abnormal  mobility  may  be  absent  in  an  impacted,  an  incomplete,  or  an  in- 
traarticular fracture.  Crepitus  is  a  grating  sensation  or  somid  obtained  by 
rubbing  the  ends  of  the  bone  together.  It  may  be  absent  in  an  incomplete  or 
an  impacted  fracture,  in  one  in  which  the  fragments  are  greatly  overlapped 
or  widely  separated,  or  in  one  in  which  soft  tissues  lie  between  the  fragments. 
It  is  dry  and  harsh,  and  thus  diflFers  from  the  crackling  of  air  or  blood  beneath 
the  skin,  or  the  creaking  of  inBamed  synovial  membranes,  viz.,  those  of 
joints,  tendons,  and  bursa?,  I'he  crepitus  of  epiphyseal  separation  is  soft  or 
moist- 

The  constitutional  symptoms  are  trivial  or  absent  in  simple  uncom- 
plicated cases.  Shock  is  usually  absent,  except  in  severe  or  complicated 
fractures.  Fracture  fever  is  an  aseptic  fever  due  to  the  absorption  of  fibrin 
ferment,  the  temperature  being  elevated  one  or  two  degrees  during  the  tirst 
two  or  three  days  or  longer,  according  to  the  amount  of  blo4jd  extra vasated. 

The  Diagnosis. — The  injured  limb  should  be  compared  with  the  sound 
limb  by  inspection,  palpation,  and  measurement.  An  ancient  deformity 
should  not  be  mistaken  for  a  recent  one.  A  knowledge  of  the  normal  relations 
of  bt»ny  prominences  will  aid  in  the  (juick  recognition  of  deformity.  If  a 
slethosc*»pe  is  placed  over  one  enrl  of  the  bone  and  the  other  end  percussed* 
the  sound  may  not  reach  the  ear  if  a  fracture  exists.  In  many  cases,  owing 
to  rigidity  of  the  muscles,  pain,  and  fright,  a  proper  examination  can  ije  made 
only  under  an  anesthetic.  In  doubtful  cases  an  X-ray  examination  should 
be  made.  A  more  accurate  idea  of  the  amount  and  character  of  the  dis- 
placement is  obtained  by  taking  two  skiagraphs,  one  at  right  angles  to  the 
other  or  by  making  stereoscopic  plates  (see  Fig.  2).  Single  exposures, 
especially  in  the  region  of  the  elbow,  knee,  ankle,  and  in  oblique  frac- 
tures of  the  long  bones,  may  sometimes  show  apparently  normal  shadows, 
when  a  fracture  really  exists.  Epiphyses  cannot  be  recognized,  of  course, 
until  sufficiently  ossitied  to  cast  shadows.  In  interpreting  skiagraphs  the 
inexperienced  may  mistake  an  ununited  epiphysis  for  a  fragment  of  bone, 
and  an  epiphyseal  juncture  for  a  line  of  fracture. 

The  complications  of  fractures  are:  (i)  Those  occurring  at  the  time  of 
injur}',  which  may  be  (a)  general,  i.e.,  shock,  or  (b)  local,  such  as  sprain, 
dislocation,  and  injuries  to  the  vessels,  nerves,  muscles,  or  viscera;  (a)  those 
appearing  during  the  time  of  treatment  or  later,  which  again  may  be  (a) 
general,  such  as  sepsis,  tetanus,  fat  or  clot  embolism,  hypostatic  congestion 
of  the  lungs,  delirium  tremens,  delirium  nervosum,  and  suppression  or  reten- 
tioD  of  urine;  or  (b)  local,  such  as  excessive  swelling  from  effusion  of  serum  or 
extravasation  of  blood;  inflammation,  ulceration,  sloughing,  or  ^n^rene^ 


% 
\ 


250 


BONES. 


from  swellings  pressure  of  splints  t*r  bandages,  or  from  thrombosis;  musiular 
spasm;  necrosis  of  bone;  stiffness  or  ankylosis  of  joints;  atrophy  of  muscles* 
either  from  disuse,  or  from  panilysis  the  result  of  nerve  injur)^;  excessi\'e 
callus  formation,  usually  the  result  of  imomplete  reduction;  tumors  of  bone; 
stiffness  of  tendons  from  thecitis;  contractures  of  muscles  from  myositis 
or  neuritis;  neuralgia;  crutch  paralysis;  persistent  edema,  due  to  vasomotor 
paralysis  or  venous  thrombosis;  vicious  union;  non-union;  delayed  union; 
and  fibrous  or  cartilaginous  union. 

Repair  of  fractures  is  analtfgous  to  the  repair  of  other  wounds,  except 
that  the  reparative  material  ultimately  becomes  fxine  instead  of  scar  tissue. 
Immediately  following  a  fracture  blood  extravasates  between  and  around  the 
fragments, which  are  frequently  united  by  a  bridge  of  untom  peiiosteuiD. 
The  surrounding  blood  vessels  dilate,  and  serum  and  leukocytes  escape  into 
the  tissues.  The  connective  tissue  cells  proliferate  (fibroblasts)  and  replace 
the  blood  clot,  which,  during  the  first  week  or  ten  days,  is  gradually  absorbed 
and  devoured  by  the  leukocytes.  At  the  same  time  there  occurs  a  prolifera- 
tion of  the  osteoblasts,  which  are  found  in  the  medulla  and  the  deeper  layers 
of  the  periosteum.  This  mass  of  actively  multiplying  cells  is  vascularized 
from  neighboring  vessels,  l>ecomes  calcilied,  and  is  finally  transformed  into 
bone  as  the  result  of  the  acri%ity  of  the  osteoblasts*  If  the  osteoblasts  are 
slow  in  action,  calcification  is  preceded  by  the  formation  of  fibrous  tissue  by 
the  fibroblasts,  or  in  some  instances  l>one  fails  to  form  and  the  fragments  are 
united  by  fit>rous  tissue  only.  When  the  osteoblasts  are  more  active,  bony 
re[>roduction  is  preceded  by  the  formation  of  cartilaginous  tissue,  which  in 
some  cases  is  as  far  as  repair  extends,  the  union  being  cartilaginous  only. 
During  the  process  of  repair  the  ends  of  the  bone  become  softened  as  the 
result  of  a  rarefying  ostitis,  the  roughened  ends  being  smtwthed  by  a  process 
of  absorption  and  covered  with  granulations,  svhich  are  probably  deriinod 
chiefly  from  the  medulla.  The  compact  bone  itself  is  thought  to  take  but 
little  part  in  the  process  of  repair.  The  mass  of  reparative  material  which 
forms  between  and  around  the  fragments  is  called  callus.  The  callus 
surrounding  the  fracture  is  called  enshealhing  or  rxiernal  caiius,  that  in  the 
medullary  canal  internal  or  central  laUus^  and  that  between  the  ends  of  the 
bone  intermediate  callus.  The  ensheathing  callus  is  fmally  absorbed, 
although  it  may  persist  and  interfere  with  the  motions  of  joints  or  tendons, 
unite  the  Ijone  to  a  neighboring  bone,  or  engulf  an  adjacent  nerve.  The 
central  callus  also  may  be  absorbed,  although  this  is  not  common.  Ossifi- 
cation begins  in  the  first  week  and  is  complete  in  from  ten  days  (in  the  small 
bones  of  the  face)  to  six  or  eight  weeks  (in  the  femur). 

The  treatment  of  simple  fracture  is  (i)  reduction,  {2)  retention,  (3) 
restoration  of  function. 

In  transporting  a  patient  with  a  broken  limb  it  may  be  necessary  to  im- 
provise splints  from  canes,  umbrellas,  etc.  A  fractured  humerus  may  be 
fastened  to  the  chest,  a  broken  forearm  may  be  supported  by  pushing  a 
folded  newspaper  up  the  sleeve  of  a  coat,  the  lower  limti  may  be  tied  to  its 
fellow  or  held  between  the  rolled  up  ends  of  a  blanket. 

(i)  Rediulion,  or  sfUing,  of  a  fracture  should  be  performed  as  soon  after 
the  accident  as  possible.  It  is  accomplished  by  manipulations  to  relax 
muscles  or  other  soft  structures  while  the  ends  of  the  bone  are  being  maneu- 
vered into  place.  Relaxation  may  be  obtained  by  traction;  by  extension  and 
counterextension;  by  posture,  e.g.,  dexion  of  the  leg  in  fracture  of  the  tibia; 


TllEATMENT   OF   FHACTUKES. 


251 


by  tenotomy,  e.g.,  of  the  tendo  Athillis  in  fractures  near  the  ankle;  and  liy 
general  anesthesia,  which  always  should  be  employed  if  redurtion  cannot 
otherwise  Ik:  readily  effected.  In  addition  to  muscular  contraction  the 
ot>stades  to  reduction  are  interlocking  of  the  fragments,  separation  of  the 
fragments  by  soft  parts  or  bone,  entanglement  of  one  fragment  in  the  fascia 
or  skin,  and  impaction.  In  the  last  instance  reduction  is  contra  indicated 
unless  the  deformity  is  excessive. 

(2)  Retention  or  immobilizaiion  is  maintained  by  some  form  of  splint. 
which  may  be  of  wood,  metal,  felt,  leather,  plastcr-of-Paris,  etc.  Before  the 
application  of  a  splint  abrasions  should  be  covered  with  stearate  of  zinc\  and 
blebs  punctured  without  removing  the  epiilermis.  The  splint  should  be 
thickly  padded,  particularly  where  prominent  subcutaneous  bony  points  will 
rest.  As  a  general  rule  the  joints  above  and  below  the  fracture  should  be 
immobilized.  The  limb  should  not  be  bandaged  beneath  the  dressing 
holding  the  splint  in  place,  unless  such  bandage  is  of  soft  material  loosely 
applied  for  the  purpose  of  padding.  Great  care  should  be  exercised  not  to 
make  the  bandage  too  tight,  for  fear  of  sloughing  or  gangrene.  If  the  fingers 
or  toes  are  left  exposed,  they  will  serve  as  an  index  to  the  general  condition  of 
the  limb.  If  they  become  cold,  blue,  or  numb,  or  if  there  is  great  pain  in  the 
Umb«  the  bandages  should  be  removed  and  the  parts  inspected. 

The  so-called  fixed  dressings  (see  section  on  bandages),  such  as  starch, 
silicate  of  soda*  and  piaster-of-Paris,  are  frequently  employed  after  the  sub* 
sidence  of  swelUng,  although  many  surgeons  apply  them  as  a  primary  dress- 
ing. The  dangers  of  the  latter  method,  viz.,  sloughing  or  gangrene  due  to 
great  swelling  beneath  the  case,  and  undetected  displacement  of  the  frag- 
ments, are  prevented  by  cutting  the  dressing  immediately  after  its  appli* 
cation  if  it  encases  the  entire  limb,  or  by  applying  the  material  as  a  large 
poultice  would  be  applied  and  then  allowing  it  to  harden. 

Plastic  splints^  such  as  cardboard,  felt,  leather,  and  gutta  percha,  are  cut  to 
the  desired  pattern,  soaked  in  hot  water  to  render  them  pliable,  and  allowed 
to  harden  whUe  bandaged  to  the  iimb,  Gooch's  flexible  wooden  splints  con- 
sist «?f  thin  strips  of  fir  glued  upon  canvas;  ihey  are  flexible  transversely  and 
rigid  longitudinally. 

{3)  Restoration  a/ function  is  obtained  first  by  accurate  reduction  and  the 
application  of  evaporating  lotions  or  an  ice  bag  to  limit  effusion,  and  during 
the  subsequent  treatment  by  massage  and  passive  and  active  motions.  In 
the  early  part  of  the  treatment  of  a  fracture  the  patient  should  be  seen  each 
day,  and  the  dressings  removed  if  such  be  indicated;  later,  in  many  instances, 
the  dressing  should  be  done  every  two  or  three  days.  The  parts  should 
be  inspectetb  the  skin  kept  In  good  condition  by  gentle  friction  with  alcohol, 
and  in  suitable  cases  the  muscles  masseed  and  the  neighboring  joints  moved, 
in  order  to  prevent  atrophy  and  stiffness.  Lucas-Championni^re  advises 
massage  from  the  very  beginning  in  all  fractures  except  those  of  the  patella. 
In  many  instances  in  which  there  is  no  tendency  towards  recurrence  of  dis- 
placement the  bone  is  not  even  splinted,  and  active  motions  are  encouraged 
at  an  early  period.  There  is  no  doubt  of  the  value  of  massage  and  early 
mobilization  of  joints  during  the  treatment  of  fractures,  but  in  all  cases  the 
fragments  themselves  must  be  immobilized  and  kept  so  until  the  callus  is 
sufhciently  firm  to  obviate  all  danger  of  recurrence  of  displacement. 

Some  surgeons  treat  fractures  of  the  lower  extremity,  as  high  as  even  the 
middle  of  the  femur,  by  the  ambulutory  method.    A  large  pad  is  placed  beneath 


252  ^^^^^^^^^^^  BONES. 

the  M>le  of  llie  fool  and  a  pliister  ( ast  applin!  to  aliovt*  the  seat  of  fratlurt%  so 
that  when  the  patient  walks  the  weight  of  the  body  is  supported  f>y  the  limb 
af>ove  the  fracture. 

In  cases  in  which  sut  t  essful  reduclion  cannot  be  secured  or  maintained, 
o/)f*m^n'(*/rf(J/w^i/ is  indicated,  provi<ling  aseptic  details  caii  be  observed  and 
the  requisite  skill  is  possessed  by  the  operator;  hence  the  more  conservative 
plan  of  splint  treatment  should  be  employed  by  one  who  does  not  possess  such 
qualitkations.  The  fragments  should  be  exposed  by  a  suitable  incision  and 
the  obstacle  to  reduction  removed ;  this  will  often  be  found  to  be  muscle,  fascia^ 
or  other  soft  parts  between  the  fragments.  *)ften  it  will  be  necessary  to  saw 
off  a  portion  of  each  fragment  lief  ore  approximation  can  be  accomplished,  and 
in  the  forearm  or  leg  an  equal  portion  of  the  companion  bone  also  must  be 
removed.  The  fragments  are  held  in  position  liy  silver  wire  passing  through 
holes  bored  in  the  lione,  or  by  kangaroo  tendon  or  aluminium  bronze  wire, 
both  of  which  are  ultimately  absorbed.  Fixation  is  secured  also  by  means 
of  silver  plates  which  are  fastened  to  each  fragment  by  screws,  or  by  ivoiy 
pegs,  metallic  staples,  bone  ferrules,  or  special  clamps.  The  incision  is  then 
closed  or  drained  according  to  indications,  and  the  limb  immobilized  by 
plaster-of-Paris  or  a  suitable  splint.  When  non -absorbable  material  has  been 
used  to  tix  the  fragments,  its  removal  is  not  infrequently  demanded  after 
union  has  occurred,  owing  to  the  formaliun  of  sinuses. 

The  treatment  of  compound  fractures  isjhat  of  the  wound  in  the  soft 
parts  and  of  the  broken  bone  itself.  The  constitutional  symptoms  are  more 
severe  than  in  simple  fracture,  there  being  a  varying  amount  of  shock  accord- 
ing to  the  degree  of  injury,  and  later  a  higher  rise  in  temperature,  even  when 
asepsis  has  been  maintained.  The  dangers  are  hemorrhage  and  sepsis. 
Severe  primary  hemorrhage  is  controlled  by  the  tournicjuet,  and  measures 
taken  to  react  the  patient  from  shtjck.  In  the  absence  of  shock  the  palieni 
should  be  anesthetized  and  thorough  disinfection  carried  out.  The  h*mb 
should  be  shaved,  scrulibed  with  soap  and  water,  and  washed  w^ilh  bichlorid 
of  mercury,  i  to  1,000.  In  some  cases  the  injury  will  be  found  so  extensive 
that  amputation  will  be  required.  If  amputation  is  not  necessary,  de\'italized 
tissues,  tissues  into  which  tlirt  has  been  ground,  and  completely  detached 
fragments  of  bone  should  be  removed,  enlarging  the  wound  in  the  skin  as 
much  as  may  be  necessary.  Pieces  of  Ixnie  firmly  attached  to  the  soft  parts 
often  retain  their  vitality  and  may  be  left  in  place.  The  fracture  is  fixed 
by  wire  or  other  means,  the  hemorrhage  controlled  in  the  usual  way,  and  the^ 
injuries  to  the  soft  parts  ref>aired,  e.g.,  suturing  of  a  torn  nen-e  or  muscle. 
The  wound  is  again  disinfected  by  irrigation  with  hot  bichlorid  of  mercury 
solution,  and  drained  by  a  large  rubber  tube,  which  if  necessary  may  traverse 
the  entire  limb,  emerging  at  a  counteropening  on  the  opposite  side.  The 
external  wound  is  sutured  as  far  as  judgment  dictates^  and  the  limb  splinted. 
If  a  plaster  cast  is  applied,  windows  should  be  made  over  the  wounds  to 
permit  subsequent  dressings. 

Fracture  complicated  with  dislocation  is  treated  by  first  reducing  the 
dislocation  by  manipuiations,  aided,  if  need  be,  by  a  splint  to  give  sufficient 
rigidity  to  the  limli;  or  through  an  incision  the  articular  end  of  the  l>one 
may  be  maneuvered  into  place  by  the  fingers  or  by  a  hook.  Some  ad\isc 
setting  the  fracture  and,  after  union  has  Ijeen  olitained,  trying  to  reduce  the 
dislocation. 

Ununited  fracturesj  delayed  union,  and  non-union  are  due  to  imper- 


i. 


FRACTURE    01 


\L    BONES. 


immobilization:  the  presence  of  muscle  or  other  soft  tissue  between  the 
Igments;  marked  overlapping;  wide  separation;  defective  nutrition  of  the 
bone  as  the  result  of  injury  to  its  blmKl  supply;  general  or  local  diseases  of 
bones,  such  as  are  menuoned  among  the  pathological  causes  of  fracture 
(p.  247);  or  to  constitutional  diseases,  such  as  syphilis,  gout,  rheumatism, 
scun'Vt  or  other  affections  causing  del  lilit  y.  Nonunion  may  be  distinguished 
from  delayed  union  by  the  absence  of  pain  and  the  presence  of  voluntary 
motion  in  the  former.  These  conditions  are  most  common  in  the  patella, 
olecranon,  and  similar  situaticms  where  strong  muscular  contraction  tends 
to  separate  the  fragments,  and  in  the  midflle  of  the  humerus  and  upper  and 
lower  thirds  of  the  femur. 

Abxnlute  non-itnum,  i.e.,  when  there  is  absolutely  no  attempt  at  repair,  is 
seldom  seen  apart  from  malignant  disease  of  Ixme.  In  most  instances  the 
ends  of  the  bone  become  rounded,  the  medullary  canal  closed,  and  the 
fragments  joined  by  filjrous  tissue  (fibrous  union).  In  a  pscttdoarthrasis, 
or  false  joint,  the  fragments  are  held  together  by  a  capsule  of  fibrous  tissue, 
within  which  is  developed  a  bursa  the  result  of  the  friction  of  one  bone  on  the 
other,  and  the  enils  of  the  liroken  fragments  are  covered  with  cartilage. 

The  treatment  of  drlayrd  union  is  prolonged  immobilization  in  plaster-of 
Paris,  and  attention  to  the  general  health.  Some  advise  the  induction  of  con- 
gestion or  intlammation  by  rublnng  the  ends  of  the  bone  together,  by  scraping 
the  ends  with  a  long  and  strong  needle  pushed  in  through  the  skin,  by  the 
injection  of  a  10  per  cent,  solution  of  chU>rid  of  zinc,  or  by  applying  a  rubber 
band  around  the  limb  above  the  fracture.  Bier  injects  fresh  blood  between 
the  fragments.  The  internal  administration  of  thyroid  extract  and  potassium 
iodide  are  thought  to  encourage  callus  formation.  Xon-uniim  is  treated  by 
resection  of  the  ends  of  the  fragments,  and  fastening  them  together  by  one  of 
the  methods  mentioned  above.  When  the  ends  are  overlapped  and  resection 
would  prove  a  formidaljle  operation  nwing  to  the  situation  of  the  bone,  screws 
or  pegs  may  be  inserted  into  drill  holes  which  traverse  each  fragment 
transversely. 

Vicious  union,  or  union  with  great  deformity,  is  due  to  imperfect  reduc- 
tion, recurrence  of  displacement,  bending  or  overproduction  of  callus  subse- 
quent to  the  removal  of  splints,  or  to  bone  tliseascs,  such  as  fragtlitas  ossium 
and  osteomalacia.  It  may  be  treated,  in  the  early  stages  while  the  callus  is 
plastic,  by  pressing  the  bones  into  place,  and  later,  if  deformity  or  disability 
is  marked,  by  osteotomy,  by  chiseling  away  projecting  areas,  or  by  resecting 
the  callus  and  fastening  the  fragpicnls  with  wire,  plates,  etc. 

Disunited  fracture,  or  separatitm  after  the  fragments  have  united,  may 
occur  from  nolence,  and  occasionally  during  the  progress  of  an  exhausting 
disease. 

SPECIAL  FRACTURES. 


The  nasal  hones  are  usually  broken  in  their  lower  third,  the  fracture 
Ijeing  frequently  compound  through  the  skin  or  mucous  membrane.  The 
cause  is  direct  violence,  the  de^ee  and  direction  of  which  determine  the 
amount  and  character  of  the  displacement.  The  nasal  srpium  is  often  injured, 
resulting  in  lateral  displacement,  which  may  later  give  rise  to  nasal  obstruc- 
tion. The  sympiomx  are  pain,  swelling,  cre[jitus,  deformity,  and  epistaxis, 
Abnormal  mobility  may  be  fallacious  in  the  lower  third  owing  to  the  great 


254  BONES. 

mobility  of  the  cartilages.  The  complications  are  emphysema,  cerebral  con- 
cussion, fracture  of  the  iieighl>oring  facial  bones  or  of  the  base  of  the  ante- 
rior fossa  of  the  skull,  and  later  suppuration  and  necrosis  of  bone  or  cartilage. 

The  treatment  shoukJ  be  prompt,  as  the  [>ones  early  consolidate  in 
deformity.  In  all  cases  the  septum  should  be  examined  to  determine  whether 
or  not  it  is  broken.  No  apparatus  is  needed  if  there  is  no  deformity  or  if 
the  deformity  does  not  recur  after  reduction.  Reduction  is  accomplished  by 
external  pressure,  and  by  lifting  the  fragments  from  within  by  means  of  a 
padded,  narrow  instrument^  such  as  a  grooved  director,  or  by  a  rubl^er  bag 
which  is  passed  into  the  nose  and  distended  with  air.  The  septum  may  be 
straightened  by  a  fm ger  introduced  into  either  nostril  or  by  septum  forceps. 
Either  cocairi  or  ether  anesthesia  may  be  necessary.  In  depressed  fractures 
reduction  may  be  maintained  by  packing  the  nostrils  with  gauze,  or  by  pass- 
ing a  strong  pin  [Mason's  pin)  through  the  skin,  beneath  the  fragments,  and 
making  external  pressure  by  means  of  gauze,  held  in  place  by  figure-of-S 
turns  of  silk  around  the  ends  of  the  pin.  Lateral  displacement  requires  an 
external  compress  or  molded  splint,  held  in  place  by  adhesive  plaster,  or  an 
apparatus  consisting  of  a  metallic  band  around  the  forehead,  with  a  support, 
provided  with  a  pad  and  screw  for  making  pressure,  running  down  to  one  side 
of  the  nose.  If  the  septum  is  deformed,  it  may  be  held  in  place  by  gaujse 
packing,  or  by  means  of  vulcanite  or  metallic  tubes,  which  have  perfora* 
tions  in  the  side  for  drainage,  and  which  are  made  in  various  sizes.  Roberts 
inserts  one  or  more  long  pins  into  the  septum  in  such  a  way  as  to  press  on 
the  denation  as  the  stem  of  a  flower  is  pressed  upon  when  pinned  to  the  lapel 
of  a  coat.  In  any  case  the  nose  should  be  sprayed  several  times  daily  with 
an  antiseptic  solution,  and  the  patient  cautioned  about  l>lowing  or  wiping  the 
nose.  The  prognosis  is  usually  good,  although  some  deformity  is  ver}'  apt 
to  remain  in  had  cases.     Union  is  complete  in  from  ten  days  to  two  weeks. 

The  lachrymal  bone  is  rarely  broken  alone,  and  the  treatment  is  directed 
principally  lo  the  neighboring  bone.  Obstruction  of  the  lachr)'mal  duct 
may  be  prevented  by  the  passage  of  a  prol>e. 

The  malar  booe  is  fracture<l  by  direct  violence,  usually  with  injury  to 
adjoining  hemes.  Sometimes*  the  whole  bone  is  pressed  into  the  bones  on 
which  it  rests.  The  symptoms  are  deformity,  conjunctival  hemorrhage  when 
the  orbital  surface  is  involved,  and  interference  with  the  motions  of  the  lower 
jaw  when  depression  is  sutTicient  to  encroach  upon  the  coronoid  process. 
Crepitus  and  abnormal  mobility  may  l>e  absent.  In  favorable  cases  the 
deformity  can  be  corrected  by  pressure  beneath  the  l>one  within  the  mouth. 
If  this  is  unsuccessful,  particularly  in  cases  in  which  the  movements  of  the 
lower  jaw  are  impaired,  the  bone  may  be  elevated  through  an  external  inci- 
sion.  No  retentive  apparatus  is  required,  as  displacement  does  not  recur. 
The  bone  unites  in  two  weeks. 

The  zygoma  is  fractured  f>y  direct  force,  or  l>y  indirect  force  when  the 
malar  is  depressed.  There  is  usually  an  indentation  just  behind  its  junction 
with  the  malar  bone.  The  (reahnent  consists  in  the  application  of  pressure 
within  the  mouth  or  e.xternally,  in  order  to  effect  reposition.  Failing  in  this, 
especially  if  the  movements  of  the  lower  jaw  are  defective,  a  piece  of  silver 
wire  may  be  passed  through  the  skin  and  lieneath  the  depressed  fragment,  in 
order  to  pull  it  into  place.  A  retentive  apparatus  is  seldom  required. 
Union  is  complete  in  two  or  three  weeks. 

The  superior  maxilla  is  usually  broken  by  direct  hlows,  which  in  most 


FRACTURE  OF  THE  JAWS. 


255 


I 


instances  break  also  iontiguous  bones.  It  may,  however,  be  broken  by  in- 
direct force  through  the  chin.  The  frai  ture  is  almost  ahvays  compound  and 
comminuted,  and  often  bilateral  There  are  pain,  great  swelling  of  the  face, 
and  interference  with  mastication;  deformity,  abnormaJ  mobility,  and 
crepitus  are  detected  through  the  nose,  mouth,  or  cheek.  The  complkalimts 
are  emphysema ,  violent  hemorrhage  from  the  internal  maxillary  or  its 
branches,  and  injury  to  the  lachrymal  duct,  infraorbital  ner^e,  or  the  brain. 
Suppuration  and  necrosis  may  occur.  The  treatment  is  careful  disinfection, 
and  molding  of  the  bone  into  position  through  the  nose  or  mouth,  or  through 
an  external  wound  if  it  be  present.  Loose  teeth  should  be  put  back  in  place 
and  fastened  to  their  fellows  by  wire.  In  fractures  involving  the  alveolus  the 
lower  jaw  may  be  used  as  a  splint  by  means  of  the  Barton  or  the  Gibson 
bandage,  or  an  interdental  splint  may  be  employed.  It  may  be  necessary  to 
insert  a  tube  into  the  nose  to  maintain  its  patency.  The  nose  and  mouth 
should  be  washed  several  times  a  day  with  an  antiseptic  .solution,  and  the 
w*ounds  dressed  daily.  Liquid  food  is  administered  through  a  nasal  tube,  or 
by  passing  it  into  the  mouth  behind  the  last  teeth.  The  bone  unites  in  three 
or  four  weeks. 

The  inferior  maxilla  is  generally  liroken  by  direct  \iolence,  but  a  frac- 
ture near  the  middle  line  may  result  from  a  force  which  presses  the  bodies 
together,  and  fracture  of  the  condyle  may  follow  a  fall  on  the  chin.  The 
bone  is  most  frequently  broken  ^ust  external  to  the  symphysis,  owing  to  the 
weakness  occasioned  at  this  point  by  the  deep  socket  of  the  canine  tooth.  As 
a  rule  the  fracture  is  compound  internally,  and  not  infrequently  there  are 
multiple  breaks.  The  ,^ymptoms  are  pain,  laceration  of  the  gum  at  the  point 
of  fracture,  bleeding  from  the  mouth,  swelling  of  the  face,  abnormal  mobility, 
crepitus,  and  deformity  as  demonstrated  by  imperfect  alignment  of  the  teeth. 
When  the  bone  is  broken  in  front  of  the  masseter,  the  jxisterior  fragment  is 
pulled  upward  by  the  masseter  and  temporal  muscles,  while  the  depressors 
of  the  jaw  draw  the  anterior  fragment  downwards  and  backwards.  The 
jaw  is  drawn  towards  the  injured  side  in  fractures  of  the  condyle;  in  fractures 
of  the  coronoid  that  process  is  drawn  upwards  by  the  temporal  must  le.  The 
f<>m/»/i'c<2/ii?#i.v  are  suppuration,  and  necrosis  of  bone,  with  the  ills  that  they 
may  produce,  e.g.,  cervical  adenitis,  and  digestive  or  pulmonary  disorders 
from  swallowing  or  inhabng  foul  discharges.  Fracture  of  the  iDase  of  the 
skull  may  be  produced  if  the  condyles  are  driven  forcibly  upwards. 

The  treatment  consists  in  reduction  by  direct  pres.su re,  immobilization, 
and  careful  and  frequent  cleansing  of  the  mouth.  In  cases  in  which  there  is 
little  tendency  to  displacement,  sufficient  immobilization  may  be  obtained  by 
a  molded  chin  piece  (Fig.  i(j6)  of  felt,  cardboard,  leather,  or  thick  flannel 
impregnated  with  plaster-of- Paris,  the  chin  cup  being  held  in  place  by  a 
Barton  or  a  Gibson  bandage.  If  the  displacement  tends  to  recur,  and  this 
is  true  in  the  large  majority  of  cases,  the  adjoining  teeth,  if  not  loose,  may 
be  tied  together  with  wire,  or  fastened  by  .Angle's  bands,  which  are  thin 
pieces  of  metal  that  are  clamped  about  several  teeth  in  each  jaw  by  means 
of  a  screws,  the  jaws  being  held  together  by  wire  or  silk  running  from  the 
clamps  on  the  lower  jaw  to  those  on  the  upper  jaw.  Hammond's  splint  con- 
sists of  a  wire  frame  work  which  surrounds  all  the  teeth  of  the  lower  jaw 
and  which  is  fastened  in  place  at  several  points  by  wire  running  lietvveen  the 
teeth.  In  many  instances  accurate  apposition  can  be  obtained  only  by  wir- 
ing the  jaw  itself,  or  by  what  is  far  belter,  an  interdental  splint.     Interdental 


2S6 


BONES. 


Fig.  igi. — Hardrubber 
splint^  wilh  ^rtns  and  bandage 
applied.     Qloriarty.) 


splints  are  made  of  vulcanite,  hard  rubber,  or  metal,  from  a  plaster-of-Pam 
€ast  of  the  teeth ;  they  can  be  made  only  by  a  skilled  dentist.  An  irapressioa 
of  the  teeth  is  first  taken  by  a  dental  modeling  compound,  vvhiLh  is  softened 
by  heat  and  allowed  to  harden  on  the  teeth.  A  plaster  cast  of  the  two  jaw<. 
is  made  from  ihis  mold,  the  cast  of  the  lower  jaw  severed  at  the  point  of 
fracture,  the  displacement  in  the  cast  corrected,  and  an  interdental  splint 
made  from  the  plaster  cast.  Bars  curving  backwards  over  the  cheeks  are 
sometimes  attached  to  support  a  bandage  passing  under  the  chin,  so  that  the 
jaw  will  be  held  in  place  even  when  the  mouth  is  open  (Fig.  191).  Moriarty 
fastens  a  metallic  chin  piece  to  these  side  l:»ars  by  several  vertical  support>, 

Matas  has  constructed  an  adjustable  metallit 
^^a^^^l^Hj      interdental  splint,  which  may  be  applied  by  any 

^^^^P^^^L    ^      medical  man  without  special  dental  skill.     The 

^^^^^  ^^H^    1      splint  is  a  sort  of  clamp  which  holds  the  jaw  he- 

^^^ ^^B  I  ween  a  mouth  piece  and  a  chin  cup.     It  is  made 

^^^H  ^T^      ^H|  in  three  sizes,  the  smallest  for  children,  the  medium 

^^^B  ^^  for  youths,  and  the  largest  size  for  adults;  the 

l^^^h^  chin  cup  may  be  adjusted  to  varicms  degrees  of 

■^^^^^^^^    -^  prognathism  by  a  sliding  joint  (Fig.  192).     If  the 

l^^^^^F^  Jf  teeth  are  loose,  the  gutter  of  the  mouth  picte  may 

i       ^^^^ JJ^L^  be  filled  with  a  dental  modcb*ng  composition.      In 

I  ^^^^^^^^^W^  \\\\\  case  the  moutJi  and  teeth  should  be  frequently 
w^^^^^^  ^^^*  di^ansc<l  and  irrigated  with  a  mild  antiseptic  solu- 
tion. If  inadvisable  to  open  the  mouth,  the 
patient  may  be  fed  as  described  under  fracture  of 
the  upper  jaw.  Fractures  of  the  coronoid  prtKCiis 
and  the  condyle  are  treated  by  a  Barton  or  a  (iibson  bandage. 

The  hyoid  bone  may  be  fractureil  by  constriction,  such  as  occurs  in 
throttling  and  hanging.  The  symptoms  are  pain,  swclhng,  deformity,  bleed- 
ing from  I  he  mouth,  and  interference  with  t>rcathing,  speaking,  or  swallowing. 
Abnormal  mobility  and  crepitus  are  present  in  a  few  cases.  The  iteatmrnl 
consists  in  the  correction  of  the  deformity,  if  possible,  by  a  finger  in  the 
mouth  and  the  hand  externally,  and  the  application  of  a  molded  cardboard 
splint  to  the  neck.  The  head»  neck,  and  lower  jaw  may  be  immol>ilized,  and 
the  patient  fed  by  rectum;  talking  is  forbidden.  The  bone  unites  in  four 
w*eeks.     Kdema  of  the  glottis  may  demand  intubalitm  or  irachedtomy. 

The  laryngeal  cartilages  may  lie  fractured*  particularly  in  old  age  owing 
to  the  deposition  of  lime  salts.  The  symptoms  are  similar  to  those  of  fracture 
of  the  hyoid  bone,  except  that  dyspnea  and  interference  with  the  voice  are 
more  marked  and  emphysema  more  common.  The  treatment  is  similar  to 
that  of  fracture  of  the  hyoid  bone. 

The  ribs  may  be  broken  by  direct  violence,  or  by  indirect  nolence,  eg,, 
compression  of  the  chest,  in  which  case  the  rib  breaks  at  its  most  convex  part, 
or  near  the  angle.  In  a  few  cases  violent  muscular  action,  such  as  occurs  in 
coughing  and  straining,  is  responsible  for  the  accident.  In  early  life  the  ribs 
are  very  elastic  and  incomplete  fracture  is  not  uncommon.  As  a  rule  more 
than  one  rib  is  broken,  those  suffering  most  frequently  bting  from  the  fifth 
to  the  ninth,  as  the  upper  ribs  are  better  protected  and  the  lower  ribs  more 
movable.  The  fracture  may  be  compound  into  the  lung  or  through  the  skin. 
The  sympioms  are  localized  pain  increased  by  movements  of  the  chest  or  pres- 
sure over  the  sternum,  grunting  respt rations,  .suppressed  cough,  emphysema 


nUCTUHE   OF   THK   STERNUM. 


257 


U  the  lung  is  wounded,  and  rarely  deformity  or  abnormal  mobility.  Crepitus 
is  frequently  absent;  it  is  obtained  by  placing  the  hand  or  the  ear  over  the 
point  of  greatest  tenderness  while  the  patient  lakes  a  full  breath,  or  by  alter- 
nately pressing  on  the  bone  on  either  side  of  the  fracture.  Hemoptysis  indi- 
cates injury  to  the  lung.  The  com  pi  ual  tons  are  injury  to  the  heart,  lung, 
diaphragm,  liver,  spleen,  and  colon,  and  hemothorax,  pneumothorax,  pleurisy, 
pneumonia,  bronchitis,  and  empyema. 

The  treatment  is  immobilization  of  the  affected  side  of  the  chest  with 
adhesive  plaster.  In  the  male  the  chest  should  be  shaved  and  a  piece  of  lint 
placed  over  the  nipple.  Adhesive  plaster  strips,  three  inches  wide  and  long 
enough  to  extend  about  three- fourths  around  the  chest,  are  applied   from 


FtG.  19a.— The  Malas  splint  for  fracture  of  ihc  Imver  jaw.  The  splint  consists  of  ihc 
folloviingdetachabk  fxirls:  {a)  a  niouth  piece  of  soft  metal  (block  tin);  ih)  d  liatnp  adjusted 
and  tightened  with  a  screw;  (c)  a  chin  plate  (of  p<?rf orated  aluminum),  which  can  be 
moved  backward  or  fonvard  by  sliding  on  the  lower  limb  of  the  clamp,  Thb  is  fixed 
and  held  in  place  by  a  thumb-screw. 


below  upwards  during  expiration,  each  strip  overlapping  the  preceding  one 
(Fig,  196).  The  dressing  is  changed  once  a  week,  and  discarded  at  the  end 
of  three  weeks,  or  later  if  there  is  much  pain.  If  strapping  increases  the 
pain,  it  should  not  be  employed,  as  the  ends  of  the  bone  are  proliably  driven 
inwards;  these  cases  should  be  conftned  to  bed  with  a  compress  between  the 
shoulders.  In  the  presence  of  marked  displacement  which  is  irreducible  by 
external  manipulations,  the  deformity  may  be  corrected  through  an  incision, 
and  the  fracture  immobilized  by  suture.  The  patient  should  be  guarded 
from  draughts,  and  sedative  expectorants  employed  if  there  be  cough. 

The  costal  cartilages  may  be  broken,  or  separated  from  the  ribs  or 
sternum.     The  symptoms  anil  treatment  are  those  of  fracture  of  the  rib. 

The  sternum  is  usually  fractured  at  or  near  the  junction  of  the  manu- 


brium  with  the  gladiolus,  as  the  result  of  direct  \iolence,  although  it  majlie 
broken  by  indirett  force  from  excessive  extension  or  flexion  of  the  body,  such 
as  occurs  in  fractures  of  the  .spine,  and  by  muscular  action  in  the  same  wiy 
that  the  ribs  may  be  broken.  The  upper  fragment  passes  behind  the  lowtr 
fragment,  sometimes  producing  severe  dyspnea  and  occasionally  in/un*  to 
the  aorta.  The  sympioms  are  pain,  deformity,  abnormal  mobility,  crepuui, 
bending  forward  of  the  body,  and  in  many  cases  dyspnea  and  cough.  Cam^ 
plifatitnt^  are  freqiient,  there  usually  being  fractures  of  the  ribs  and  spine, 
and  often  injuries  to  the  thoracic  viscera;  aneurysm  of  the  aorta^  medlastinids, 
and  necrosis  of  the  sternum  are  late  complications. 

The  treatment  is  rest  in  bed,  with  a  compress  between  the  shoulders^  and 
a  brt>ad  strip  of  adhesive  plaster  carried  across  the  chest  over  the  fraclure- 


FiG.  195.^ — ^The  Sayre  dressing  for 
fimciure  of  (he  clavicle;  jxtsterior  view, 
(Heath.) 


KiG,  194— The  Sayre  dressing  for 
fraclure  of  ihe  clavicle;  anterior  new. 
(Healh.) 


Reduction  may  sometimes  be  accomplished  by  e.xtending  the  spine  and  mak- 
ing pressure  on  the  lower  fragment  while  the  patient  F>reathes  deeply.  If 
this  fails  and  there  is  dyspnea  due  to  the  depression,  the  displacement  may  be 
corrected  and  the  fragments  fixed  in  position  through  an  external  incision. 
Union  is  complete  in  live  or  six  weeks. 

The  clavicle,  with  the  possible  exception  of  the  radius,  is  broken  more 
frerjuendy  than  any  other  bone  in  the  lx>dy,  owing  to  its  slenderness,  its 
exposed  position,  and  to  its  transmitting  the  force  of  blows  or  falls  from  the 
upper  extremity  to  the  trunk.  Consequently  the  usual  cause  of  fracture  is 
indirect  violence,  although  direct  \dolence  also  is  responsible  for  a  certain 
number  of  cases.  The  injury  is  most  frequent  m  children,  and  is  then  often 
of  the  green  stick  variety.  The  fracture  may  be  located  at  the  sternal  end 
(unusual),  just  external  to  the  middle  where  the  tw^o  curves  of  the  bone  meet 
(the  usual  situation),  between  the  coracorlavicular  ligaments,  in  which  case 
there  is  little  displacement,  or  at  the  acromial  entb  at  which  p<jint,  too,  the  dis- 
placement may  be  slight.  The  symptoms  are  those  of  fractures  in  general. 
The  patient  supports  the  elbow  with  the  band  of  the  uninjured  side,  and  bends 
the  head  towards  the  affected  clavicle  to  relax  the  sternomastoid,  which  pulls 
on  the  inner  fragment  only.  The  shoulder  with  the  outer  fragment  is  dis- 
placed downw^ards,  inwards,  and  forwards,  owing  to  the  weight  of  the  ex- 
tremity  and  the  contraction  of  the  muscles  running  Irom  the  chest  to  ihe 
ghoulder.     The  inner  fragment  ascends  slightly,  as  the  result  of  the  action  of 


FRACTURES   OF   THE   SCAPtO.^. 


2S9 


the  sternoraastoid.     The  coml>lkjiiwns  are  injuries  to  the  brachial  plexus, 
subdavnan  vessels,  pleura,  and  lung. 

The  treatment  which  gives  the  least  deformity  is  the  placing  of  the  patient 

upon  a  firm  mattress,  with  a  pad  between  the  scapujte,  a  shot-bag  on  the 

affected  shoulder;  and  the  arm  bound  to  the  chest  with  upward  presisure  on 

the  elbow.     Union  is  usually  firm  in  three  or  four  weeks,  when  the  patient 

may  be  allowed  to  get  up  with  the  arm  in  a  sling.     But  palients  do  not  often 

select  this  form  of  treatment.     In  an  incomplete  fracture  with  Uttle  deformity 

a  sling  for  the  forearm  is  all  that  is  needed.   Reduction  is  easy  to  accomplish  by 

carrying  the  shoulder  backwards,  outwards,  and  upwards,  but  in  ambulatory 

rases  is  ver)'  difBcult  to  maintain.     The  Sayrc  dressing  is  one  of  the  best  for 

this  purpose.     Two  strips  of  adhesive  plaster  three  or  four  inches  wide,  ami 

long  enough  to  extend  around  the  chest  one 

and  one-half  limes,  are  prepared.      Lint  pow- 

dered  with  zinc  stearate  is  placed  in  the  ft>ld 

of  the  ellx)w  and   between  the  arm  and  the 

chest.     A  collar  of  lint  as  wide  as  the  adhesive 

strip  is  placed  about  the  arm  just  below  the 

axilla,  and  over  this  is  applied  the  end  of  one  «>f 

the  strips  of  plaster^  so  as  to  form  a  loop;  the 

strip  is  now  used  to  pull  the  arm  backwards, 

and  is  fastened  around  the  chest  (Fig.  iq^). 

The  hand  of  the  alTet  ted  side  is  placed  on  the 

opposite   shoulder,    and    the   second   strip  of 

plaster,  with  a  hole  for  the  point  of  the  ellxuv, 

is  run  from  the  back  of  the  sound   shoulder, 

under  the  elbow  of  the  affected  side,  over  the 

sound  shoulder,  to  the  back  (Fig.  194),  thus 

drawing  the  elbow  forwards  and  upwards,  and, 

with  the  aid  of  the  first  strip,  which  acts  as  a 

fulcrum,  forcing  the  shoulder  backwards  and 

outwards.     A  pad,  held  in  |)lace  by  a  strip  uf 

adhesive  plaster,   may   be  placed   just   al>ovc 

the  cJavide  to  press  the  fragment  downwards. 

The  Velpeau  bandage  is  frequently  employed, 

that  of  Desault  is  seldom  used  (see  bandaging) 


Fig.  1Q5,— Fractures  *>f  the 
neck  of  the  scapula.  A, 
Through  the  glenoid  fossa;  B, 
ih rough  ihe  anatomical  neck; 
C,  through  the  surgical  neck, 
(Rose  and  Carlcss.) 


A  posterior  figure -of -8 
bandage,  puUlng  the  shoulders  backwards,  may  be  combined  with  an  axillary 
pad,  and  a  forearm  sling  which  pulls  the  ellxiw^  inwards  and  upwards.  The 
fragments  may  be  wired  when  the  fracture  is  compound  or  multiple,  or  when 
there  is  great  deformity,  pressure  upon  nerves  or  bhwd  vessels,  or  a  sharp 
fragment  which  threatens  to  perforate  the  skin.  The  progtwsjs  is  \cry  good 
concerning  the  function  of  the  arm,  but  after  a  complete  fracture  between 
the  rhomboid  ligament  on  the  inside  and  the  coracoclavicular  ligament  on 
the  outside,  deformity  to  a  greater  or  lesser  degree  is  sure  to  persist. 

The  body  of  the  scapula  is  l>roken  by  direct  violence.  The  sympioms 
arc  swelling,  abnormal  mobility,  crepitus,  and  pain  upon  aliduction  of  the 
arm  or  n^)tation  of  the  scapula.  Deformity  is  usually  absent.  The  treatment 
is  immobilization  of  ihe  shouhler  anti  arm  by  a  bandage  passing  around  the 
chest,  and  a  sliog  for  the  forearm.  Strapping  the  chest  in  a  way  somewhat 
similar  to  that  used  for  the  ril>s  also  is  usefuL 

The  surgical  neck  of  the  scapula,  when  broken  (Fig.  195) >  causes 


"260 


BONES. 


Oattening  of  the  shoulder,  promineiiLe  of  the  acromion,  lengthening  of  the  arm 
(from  acromion  to  external  condyle),  a  swelling  in  the  axilla,  and  crepitus  on 
rotating  or  raising  the  arm.  The  deformity  is  reduced  by  pressing  upwards 
on  the  elbow  and  on  the  axillary  swelling,  a  pad  placed  in  the  axilla,  and  a 
Velpeau  bandage  applied.     The  dressing  may  be  removed  in  fi%'e  weeks. 

The  anatomical  neck  of  the  scapula  or  the  glenoid  canity  may  in  rare 
instances  be  broken,  resulting  in  slight  lengthening  of  the  arm  and  a  fullness 
of  the  axilla.  Crepitus  may  be  obtained  by  pushing  up  on  the  elbow  or 
by  rotating  the  arm.     The  Ireaiment  is  that  for  fracture  of  the  surgical  neck. 

The  acromion  process  is  broken  by  direct  violence.  The  symptoms  are 
pain,  loss  of  abduction  of  the  arm,  flattening  of  the  shoulder,  and  abnormal 
mobihty  and  crepitus,  obtained  by  pushing  upwards  on  the  elbow.  The 
treatment  iion^his  in  pushing  the  elbow  upwards^thus  supporting  the  acromion 
process  with  the  head  of  the  humerus.  The  position  is  maintained  for  four 
weeks  by  a  Velpeau  bandage  or  the  third  roller  of  Desault. 

The  coracoid  process  may  be  broken  by  direct  violence  or  muscular 
action,  but  the  accident  is  rare.  Deformity  is  not  noticed,  but  crepitus  and 
abnormal  mobility  are  often  olitainal)le.  A  Velpeau  bandage  should  be 
worn  for  four  weeks. 

The  humerus  may  be  l>rokcn  through  the  upper  extremity^  the  shaft,  or 
the  lower  extremity. 

The  upper  extremity  of  the  humerus  may  be  broken  at  the  anatomical 
neck,  at  the  surgical  neck,  or  through  the  head  of  the  bone  or  the  tuberosities, 
or  the  upper  epiphysis  may  be  separated. 

The  anatomical  neck  of  the  humerus  is  broken  by  direct  violence  ap- 
plied  to  the  shoulder,  particularly  in  the  agccL  The  line  (if  fracture  may  be 
wholly  within  the  capsule  of  the  joint  {intracapsular  fracture),  but  in  many 
instances  it  extends  beyond  the  capsule.  Impaction  is  frequent,  and  even 
when  the  head  of  the  bone  is  movable  on  the  shaft  it,  as  a  rule,  still  remains 
attached  to  the  capsule  at  some  parts,  so  that  necrosis  is  not  as  frequent  as 
one  might  expect.  The  symptoms  are  pain,  swelling,  broadening  of  the  neck 
of  the  bone,  interference  with  the  functions  of  the  shoulder,  slight  shortening 
of  the  arm  from  acromion  to  external  condyle,  and  in  unimpacted  cases 
abnormal  mobility  and  crepitus;  the  last  two  symptoms  are  obtained  by  grasp- 
ing the  head  of  the  bone,  and  gently  rotating  the  humerus  by  manipulating  the 
ellxiw  with  the  other  hand.  These  movements  should  never  be  \iolent,  be- 
cause of  the  danger  of  separating  an  impaction,  or  tearing  away  that  portion 
of  the  capsule  which  remains  attached  to  the  head. 

The  treatment  in  impacted  fracture  is  a  sling  for  the  limb,  gentle  massage 
from  the  beginning,  and  early  passive  motion.  In  other  cases  a  pad  should 
be  placed  in  the  axilla,  a  cap  of  cardboard  or  felt  (Fig.  196)  molded  to  the 
shoulder,  and  the  arm  and  forearm  (flexed  to  a  right  angle)  bandaged  to  the 
side.  Union  may  not  occur  for  five  or  six  weeks  or  longer.  The  prognosis 
is  good  as  far  as  union  is  concerned,  but  stiffness  of  the  joint,  atrophy  of 
the  muscles,  and  persistent  pain  are  common  sequelae . 

The  surgical  neck  of  the  humerus  is  usually  broken  by  direct  violence, 
occasionally  liy  indirect  violence,  rareiy  by  muscular  action.  The  symp- 
toms arc  pain  (which  may  be  reflectcil  along  the  large  nerves  from  pressure), 
abnormal  mobility,  crepitus,  shortening  of  the  limb  (one  inch  or  more),  a  de- 
pression just  lielow  the  shoulder,  anil  abduction  of  the  elbow  from  the  side  of 
the   l>ody.     The   upper  end  of  the  lower  fragment  passes  into  the  axilla, 


THE   HUMf:RUS. 


261 


^es  attached  to  the  bicipital  groove, 

^racobrachialis,  and  triceps;  the 

Mtwards  by  the  muscles  in- 


•  :i'r»lc  inclined  plane  fracture-box.     3.  Jaw-cup  (un- 

ri-rior  angular  splint.     6.  Internal  angular  splint. 

■..   Dupuytren  splint  in  Pott's  fracture.     10.  Agnew 

'.     II.  Agnew  splint  for  fracture  of  the  patella.    12. 

.Lit  he  chest  in  fractured  ribs.     14.  Extension  apparatus 

Adhesive  strips  for  extension  apparatus.  (I)aC'osta.) 

.  it  impaction  be  present  the  signs  are  obscure  and 

i  lu'  deformity  resembles  that  of  dislocation  of  the 

i«  r  the  depression  is  lower  (Fig.  197),  the  head  of  the 


I 


bone  is  in  plat  e,  and,  when  the  arm  is  rolatctl^  there  is  immoljiliiy  of  ihe  head 
with  crepitus.  The  X-my  should  Uv  used  in  doubtful  cases.  The  complua 
tions  are  injuries  of  the  iixiUary  vesstds  or  nerves,  particularly  the  circiunileJi 
nerve,  which  passes  around  the  bone  at  or  near  the  line  of  fracture. 

The  treatmeot  is  that  of  fracture  of  the  anatomical  neck,  or  an  internal 
angular  splint  and  a  shoulder  cap  (Fig.  196),  the  splinted  arm  being  carried  in 
a  sling.  Reduction  is  accomplished  by  extension,  counterextension,  and 
manipulation.  Extension  may  be  maintained  during  the  course  of  treatment 
by  attaching  a  weight  to  the  elbow.  Gentle  passive  motions  are  begun  at 
the  end  of  three  weeks.  The  progno^iis  is  good,  but  in  the  old  and  rheumatic 
stilTness  and  pain  are  frequent  legacies. 

The  head  of  the  humerus  may  be  broken  by  direct  violence,  but  the  acci- 
dent is  rare,  and  seldom  recognized  without  the  aid  of  the  X-rays.  It  is 
treated  by  immobilizing  the  shoulder. 

The  greater  tuberosity  may  be  broken  by  direct  violence,  or  torn  from 
the  humerus  by  contraction  of  the  attached  muscles.  The  injury  may  com- 
plicate fracture  through  the  neck  or  anterior 
dislocation  of  the  shoulder;  The  symptoms  M 
are  pain,  swelling,  crepitus,  anrl  loss  of  out*  ■ 
ward  rotation  of  the  arm.  If  completely  de- 
tached, the  fragment  is  drawn  upwards  and 
backwards  by  the  supra-  and  infraspinatus 
muscles.  The  treatmeni  is  that  of  fracture  of 
the  anatomical  neck,  or,  if  there  is  much 
separation,  incision  with  wiring  or  pegging 
the  fragment  in  place.  A  theoretically  cor- 
rect but  impracticable  plan  is  to  plate  the 
patient  In  l)ed  and  hold  the  arm  abducted  and 
rotated  outward  by  means  of  sand  bags.  ^ 

The  lesser  ttiberosity  is  said  to  have  been  fractured  but  three  times,™ 
Separation  of  the  upper  epiphysis  of  the  humerus  occurs  before  the 
twentieth  year,  as  the  result  of  direct  violence,  but  the  accident  is  not  common. 
The  symptoms  resemble  those  of  fracture  of  the  surgical  neck,  except  that  the 
crepitus  has  a  much  softer  quality.  Displacement  is  often  slight  owing  to 
the  presence  of  an  unlorn  periosteal  bridge.  The  tnalmenf  is  that  of  fracture 
of  the  surgical  neck.  Reduction  is  sometimes  difficult,  owing  to  the  conical 
shape  of  the  upper  end  of  the  shaft  and  the  smallness  of  the  upper  fragment, 
but  is  of  the  greatest  importance,  because  of  the  danger  of  arrest  of  growth 
in  the  limb.  It  is  best  accomplished  by  slight  rotation,  and  by  bringing  the 
elbow  forwards  and  upwards,  as  the  untorn  periosteal  bridge  is  usually 
situated  on  the  posterior  surface  of  the  bone. 

The  shaft  of  the  humerus  is  frequently  broken,  usually  by  direct 
violence,  but  also  by  indirect  force,  and  occasionally  by  muscular  action. 
The  sympiifms  are  those  of  fracture  in  general.  The  displacement  depends 
on  the  situation  of  the  fracture.  When  above  the  insertion  of  the  deltoid,  the 
upper  fragment  is  drawn  inwards  by  the  muscles  which  are  attached  to  it, 
while  the  lower  fragment  passes  upwards  and  outwards  (Fig.  198).  When 
below  the  insertion  of  the  deltoid,  the  upper  fragment  is  drawn  outwards, 
while  the  lower  passes  upwards  ami  inwards  (Fig.  199).  The  lomplkaiions 
are  injuries  to  the  brachial  ve.ssels  and  the  nerves,  particulariy  the  muscu- 
lospiral,  which  lies  close  to  the  bone;  non-union  is  more  frequent  here  than  in 


FfG.  iQ7,~A,  normal  shoulder; 
B,  dislocation  of  shoulder:  C, 
fracture  of  surgical  neck  of 
humerus.     (Rose  and  Carless.) 


FRACTURES   OF   THE   HUMERUS. 


26^^ 


any  other  hone  in  the  Ihh1)%  prohalily  owing  to  llie  method  of  treatment,  in 
which,  as  the  result  of  imperfet  t  fixation  of  the  shimlder,  movements  at  the 
leat  of  fracture  are  not  entirely  prevented. 

The  treatment  is  reduction  by  extension  and  threct  pressure^  and  the 

application  of  an  internal  angular  splint  (Fig.  196),  extending  from  the  axilla 

to  the  tingcrs,  and  a  molded  external  splint.     The  forearm  is  carried  in  a 

-  sling.     If  desirable,  weight  may  be  attached  to  the  elbow  for  extension.     The 

dressings  are  removed  in  five  or  six  weeks  if  the  fracture  is  firm. 

The  lower  extremity  of  the  humerus 
may  be  broken  afnive  the  condyles  (siipraam^ 
dyloid  JriUtare),  above  and  between  the  con- 
dyles (T-  or  y -shaped  fracture),  or  through 
either  condyle  or  epicondyle,  or  the  lower 
epiphysis  may  be  separated. 

The  examination  of  an  injured  elbow 
should  be  made  with  the  greatest  care,  in 
order  to  exclude  fracture  and  dislocation. 
General  anesthesia  is  often  necessary  in 
fracture,  to  permit  diagnosis  and  facilitate 
reduction,  and  the  X-rays  should  be  used  in 
all  doubtful  cases.  The  injured  elbow  is 
compared  with  that  of  the  opposite  side 
while  both  are  in  a  similar  position.  There 
are  four  landmarks  whose  position  must  be 
determined,  viz.,  the  two  condyles,  the 
olecranon,  and  the  head  of  the  radius.  In 
the  normal  extended  elbow  the  tip  of  the 
olecranon  h  a  tritle  below  the  intercon- 
dyloid  line^  but  nearer  the  internal  than  the 
external  condyle,  while  the  three  points  are 
in  a  plane  parallel  to  the  back  of  the  arm 
when  the  forearm  is  Hexed  to  a  right  angle. 
The  intercondyloid  line  is  perpendicular  to 
that  of  the  axis  of  the  arm.  The  head  of  the 
radius  is  immediately  below  the  outer  con- 
dyle, at  the  bottom  of  a  dimple,  which  is 
easily  seen  when  the  arm  is  extended. 
Normally  the  axis  of  the  supinated  and  ex- 
tended forearm  is  directed  away  from  the 
body,  forming  an  angle  of  about  15  degrees 
with  that  of  the  arm  (Fig.  200).  Deviations 
from  this  angle  should  be  noted,  as  well  as 
any  lateral  motion  which  is  not  present  in  the  normal  elbow.  Measure- 
ments may  be  made  from  the  tip  of  the  acromion  to  the  tip  of  the  external 
condyle,  from  the  tip  of  the  external  condyle  to  the  styloid  process  of  the 
radius,  and  from  the  tip  of  the  olecranon  to  the  tip  of  the  styloid  process  of 
the  ulna,  as  well  as  between  the  condyles  anfl  from  either  condyle  to  the 
olecranon. 

Supracondyloid  fracture  is  caused  by  a  fall  on  the  hand  when  the  ell^ow 
IS  ticxed,  or  by  direct  violence.  The  syfupioms  are  pain,  swelling,  loss  of 
function,  abnormal  mobility,  crepitus,  and  deformity.     The  lower  fragment 


Fig.  198. — Skiagraph  of  fracture 
of  the  humenis  above  the  insertifin 
of  I  he  deltoid.  (Pennsylvania 
Hospital.) 


j^A 


^jonrnti  Hhm  towamm  tndLwani  (F%.  joi).  In  disiixatiiin  tke  rebtioB  of 
the  olccraiioo  U>  die  condyles  b  altaiDd,  ininctttrr  the  rdMJdams  mie  nonnal: 
in  (fidocatioo  the  fofcaim  is  ihoiieaed,  in  ^actiife  the  xrni  k  shortenefl 


FiC.  tgg.  —Fracture  uf  tEe  bumenis  below  the  insertion  of  ibc  dellokl.     0?ettn*y*irafiui 

Hospital.) 

In  clisloraiion  the  lower  end  of  the  humerus  causes  a  smooth  projection  xt 
or  ^x-low  the  creajM;  of  the  elbow;  in  fracture  the  up|>er  fragment  presents 
II  sharp  projection  above  the  crease.  In  dislocation  reduction  is  difficult 
but  permanent,  in  fracture  reduction  is  easy,  but  difficult  to  maintaLn;  there  b 
no  crepitus  or  abnormal  mobility  in  dislocation,  and  the  X-ray  will  show 


Fi«.  joo—Oul lines  of  upper  cxircmily 
to  show  A,  normal  carrying  angle;  B, 
cubituft  varu,^;  C,  cubit ujt  vatj^uA.  (Rose 
and  Ciirle«».) 


Fig*   20 j, — SupracomJyloid  frsiclure    of 
humerus.     (Gray,) 


the  bones  out  oi  place.     As  complicalions  may  be  mentioned  injuries  to  the 
brachial  iirlury  iincl  median  nerve. 

The  treatment  is  the  application  of  an  anterior  angular  splint  (Fig.  196), 
and  a  posterior  molded  trough  to  the  back  of  the  elbow,  after  effecting  reduc- 


^ 


¥ 


FRA 


tjon  by  drawing  downwards  and  forwards  on  the  lorearm,  and  pressing  hack- 
wards  on  the  upper  fragnnent,  A  Stroraeyer  splint  is  hinged  and  provided 
with  a  screw,  so  that  the  angle  may  be  changed  and  thus  some  passive 
mution  secured  without  removing  the  dressings.  The  Jones  position^  i.e., 
acute  flexion  of  the  ellx)w,  is  maintained  by  tying  the  wrist  to  the  neck,  or  by 
meaiis  of  a  broad  adhesive  strap  passed  around  the  arm  and  forearm,  which 
are  supported  by  a  iigure-of-8  sling  (Fig.  202).  It  is  the  best  form  of  treat- 
ment for  all  fractures  about  the  elbow\  except  those  nf  the  olecranon  (sepa- 
rates the  fragments),  T-fractures  of  the  lower  end  of  the  humerus  (coronoid 
wedges  fragments  apart),  fractures  with  great  swelling  (shuts  off  <  irculation). 


FlC»  203. — Fastening  tigurt  -of-tfight  craval  over  folded  compression  on  opposite  side  of 
chest.     Elbow   region   open    to    inspection.     (Sctidder.) 

and  fractures  involving  the  groove  of  the  ulnar  nerve  (nerve  slips  into  line  of 
fracture).  Acute  flexion  reduces  the  fragments,  and  "holds  them  in  place 
between  the  coronoid  process  of  the  ulna  and  the  trochlear  surface  of  the 
olecranon  in  front,  and  the  triceps  piisteriorly;  it  preserves  the  carrying  func- 
tion, and  gives  a  useful  elbow  even  in  the  presence  of  ankyiusis;  one  must 
make  sure  that  the  compression  at  the  elbow  is  not  too  great  by  feeling  the 
radial  pulse  at  the  wrist.  Some  surgeons  treat  all  fractures  of  the  elbow  in 
the  extended  position,  by  means  of  a  long  splint  or  a  plaster  cast.  It  is  the 
best  position  in  those  cases  in  which  the  Jones  method  is  contraindicated. 
It  preserves  the  carrying  angle,  but  if  ankylosis  occurs  the  limb  is  in  the 
w*orst  possible  position.     The  right  angle  pi>sition  rarely  holds  the  fragments 


1 


254 


BONES. 


mobility  of  the  cartilages.     The  complicaiums  are  emphysema,  cerebral  < 
( ussion,  fracture  of  the  neighVx>ring  facial  bones  or  of  the  base  of  the  anle- 
rior  fossa  of  the  skuU,  and  later  suppuration  antJ  necrosis  of  bone  or  cartilage. 

The  treatment  should  be  prompt,  as  the  bones  early  consolidate  in 
deformity.  In  all  cases  the  septum  should  be  examined  to  determine  whether 
or  not  it  is  broken.  No  apparatus  is  needed  if  there  is  no  deformity  or  if 
the  deformity  does  not  recur  after  reduction.  Reduction  is  accomplished  by 
external  pressure^  and  l)y  lifting  the  fragments  from  within  by  means  of  a 
padded,  narrow  instrument,  such  as  a  grooved  director,  or  by  a  rubber  bag 
which  is  passed  into  the  nose  and  distended  with  air.  The  septum  may  be 
straightened  by  a  fmger  introduced  into  either  nostril  or  by  septum  forceps. 
Either  cocain  or  ether  anesthesia  may  be  necessar)'.  In  depressed  fractures 
reduction  may  be  maintained  by  packing  the  nostrils  with  gauze,  or  by  pass- 
ing a  strong  pin  (\fasmt\s  pin)  through  the  skin,  beneath  the  fragments,  and 
making  external  pressure  by  means  of  gauze,  held  in  place  by  figure-of-8 
turns  of  silk  around  the  ends  of  the  pin.  Lateral  displacement  requires  an 
external  compress  or  molded  splint,  held  in  place  by  adhesive  plaster,  or  an 
apparatus  consisting  of  a  metallic  band  around  the  forehead,  with  a  support, 
provided  with  a  pad  and  screw  for  making  pressure,  running  down  to  one  side 
of  the  nose.  If  the  septum  is  deformed,  it  may  be  held  in  place  by  gauze 
packing,  or  by  means  of  vulcanite  or  metallic  tubes,  which  have  perfora- 
tions in  the  side  for  drainage,  and  vvhich  are  made  in  various  sizes,  Roberts 
inserts  one  or  more  long  pins  into  the  septum  in  such  a  way  as  to  press  on 
the  deviation  as  the  stem  of  a  flower  is  pressed  upon  when  pinned  to  the  lapel 
of  a  coat.  In  any  case  the  nose  should  be  sprayed  several  times  daily  with 
an  antiseptic  solution,  and  the  patient  cautioned  about  blowing  or  wiping  the 
nose.  The  prognosis  is  usually  good,  although  some  deformity  is  very  apt 
to  remain  in  bad  cases.     Union  is  complete  in  from  ten  days  to  two  weeks. 

The  lachrymal  bone  is  rarely  broken  alone,  and  the  treatment  is  directed 
principally  to  the  neighboring  bone.  Obstruction  of  the  lachr)^ma!  duct 
may  be  prevented  by  the  passage  of  a  probe. 

The  malar  bone  is  fractured  by  direct  violence,  usually  with  injur}'  to 
adjoining  bones.  Sometimes  the  whole  lx>ne  is  pressed  into  the  bones  on 
which  it  rests.  The  symptoms  are  deformity,  conjunctival  hemorrhage  when 
the  orbital  surface  is  involved,  and  interference  with  the  motions  of  the  lower 
jaw  when  depression  is  sufficient  to  encroach  upon  the  coronoid  process. 
Crepitus  and  abnormal  mobility  may  be  absent.  In  favoraljle  cases  the 
deformity  can  be  corrected  by  pressure  beneath  the  bone  within  the  mouth. 
If  this  is  unsuccessful,  particularly  in  cases  in  which  the  mo%Tments  of  the 
lower  jaw  are  impaired,  the  bone  may  be  elevated  through  an  external  inci- 
sion. No  retentive  apparatus  is  required,  as  displacement  does  not  recur. 
The  bone  unites  in  two  weeks. 

The  zygoma  is  fractured  by  direct  force,  or  by  indirect  force  when  the 
malar  is  depressed.  There  is  usually  an  indentation  just  behind  its  junction 
with  the  malar  bone.  The  treatment  consists  in  the  application  of  pressure 
within  the  mouth  or  externally,  in  order  to  effect  reposition.  Failing  in  this, 
especially  if  the  movements  of  the  lower  jaw  are  defective,  a  piece  of  silver 
wire  may  be  passed  through  the  skin  and  beneath  the  depressed  fragment,  in 
order  to  pull  it  inlri  place.  A  retentive  apparatus  is  seldom  required. 
Tnion  is  complete  in  two  or  three  weeks. 

The  superior  maxilla  is  usually  broken  by  dirett  blows,  which  in  most 


255 

instances  break  also  lontiguous  bones.  It  may,  however,  be  broken  by  in- 
direct force  through  the  chin.  The  fracture  is  almost  always  compound  anti 
com  minuted,  and  often  bilateral.  There  are  pain,  great  swelling  of  the  face, 
and  interference  with  mastication;  deformity,  abnormal  mobility,  and 
crepitus  are  detected  through  the  nose,  mouth,  or  cheek.  The  compHraiions 
are  emphysema,  violent  hemorrhage  from  the  internal  maxillary  or  its 
branches,  and  injury  to  the  lachrymal  duct,  infraorbital  nene,  or  the  brain. 
Suppuration  and  necrosis  may  occur.  The  treatment  is  careful  disinfection, 
and  molding  of  the  bone  into  position  through  the  nose  or  mouth,  or  through 
an  external  wound  if  it  be  present.  Loose  teeth  should  be  put  back  in  place 
and  fastened  to  their  fellows  by  wire.  In  fractures  involving  the  alveolus  the 
lower  jaw  may  be  used  as  a  splint  by  means  of  the  Barton  or  the  Gibson 
bandage,  or  an  interdental  splint  may  be  employed.  It  may  be  necessary  to 
insert  a  tulie  into  the  nose  to  maintain  its  patency.  The  nose  and  mouth 
should  l>e  washed  several  times  a  day  with  an  antiseptic  solution,  and  the 
wounds  dressed  daily.  Liquid  food  is  administered  through  a  nasal  tube,  or 
by  passing  it  into  the  mouth  behind  the  last  teeth.  The  bone  unites  in  three 
or  four  weeks. 

The  inferior  maztUa  is  generally  broken  by  direct  \iolence,  but  a  frac- 
ture near  the  middle  line  may  result  from  a  force  which  presses  the  bodies 
together,  and  fracture  of  the  condyle  may  follow  a  fall  on  the  chin.  The 
bone  is  most  frequently  broken  *just  external  to  the  symphysis,  owing  to  the 
weakness  occasioned  at  this  point  by  the  deep  socket  of  the  canine  tooth.  As 
a  rule  the  fracture  is  compound  internally,  and  not  infrequently  there  are 
multiple  breaks.  The  symptoms  are  pain,  laceration  of  the  gum  at  the  point 
of  fracture,  bleeding  from  the  mouth,  swelling  of  the  face,  abnormal  mobility, 
crepitus,  and  deformity  as  demonstrated  by  imperfect  alignment  of  the  teeth. 
When  the  bone  is  broken  in  front  of  the  masseter,  the  posterior  fragment  is 
pulled  upward  by  the  masseter  and  temporal  muscles,  while  the  depressors 
of  the  jaw  draw  the  anterior  fragment  downwards  and  backwards.  The 
jaw  is  drawn  towards  the  injured  side  in  fractures  of  the  condyle;  in  fractures 
of  the  coronoid  that  process  is  drawn  upwards  by  the  temporal  muscle.  The 
complications  are  suppuration,  and  necrosis  of  bone,  with  the  ills  that  they 
may  produce,  e.g.,  cervical  adenitis,  and  digestive  or  pulmonary  disorders 
from  swallowing  or  inhaling  foul  discharges.  Fracture  of  the  base  of  the 
skull  may  be  produced  if  the  condyles  are  driven  forcibly  upwards. 

The  treatment  consists  in  redut  tion  by  direct  pressure,  immobilization, 
and  careful  and  frequent  cleansing  of  the  mouth.  In  cases  in  which  there  is 
little  tendency  to  displacement,  sufficient  immobilization  may  be  obtained  by 
a  molded  chin  piece  (Fig,  196)  of  felt,  cardboard,  leather,  or  thick  flannel 
impregnated  with  pi  aster -of -Paris,  the  chin  cup  being  held  in  place  by  a 
Barton  or  a  Gibson  bandage.  If  the  displacement  tends  to  recur,  and  this 
is  true  in  the  large  majority  of  cases,  the  adjoining  teeth,  if  not  loose,  may 
be  tied  together  with  wire,  or  fastened  by  Angle's  bands,  whit  h  are  thin 
pieces  of  metal  that  are  clamped  about  several  teeth  in  each  jaw  by  means 
of  a  screw,  the  jaws  being  held  together  by  wire  or  silk  running  from  the 
damps  on  the  lower  jaw  to  those  on  the  upper  jaw,  Hammond's  splint  con- 
sists of  a  wire  frame  work  which  surrounds  all  the  teeth  of  the  lower  jaw^ 
arid  which  is  fastened  in  place  at  several  points  by  wire  running  between  the 
teeth.  In  many  instances  accurate  apposition  can  be  obtained  only  by  wir- 
ing the  jaw  itself^  or  by  what  is  far  better,  an  interdental  splint.     Interdental 


268  BONES. 

weeks.  When  the  fracture  is  below  the  insertion  of  Uie  pronator  radii  teres,  the 
upper  fragment  passes  inwards  and  forwards,  owing  to  the  action  of  the 
biceps  and  the  pronator  teres,  which  hold  it  also  between  pronation  and 
supination.  The  lower  fragment  passes  into  the  interosseoiis  space  and  is 
pronated  by  the  pronator  quadratus;  the  supinator  longus  tilts  the  upper 
end  inwards,  but  is  not  sufficiently  powerfiU  to  overcome  the  pronation. 
The  treatment  is  the  same  as  that  for  fracture  of  the  shaft  of  the  uhia,  the  arm 
being  placed  midway  between  pronation  and  supination,  because  of  the  dan- 
ger of  union  with  the  ulna  by  callus  formation.  The  dressings  may  be 
removed  in  four  weeks. 

The  lower  end  of  the  radius  is  broken  with  great  frequency.  A  Colles' 
fracture  is  nearly  transverse,  and  is  situated  within  one  inch  of  the  articular 
surface  of  the  radius;  it  may,  however,  be  oblique  laterally  or  anteroposte- 
riorly.  A  Barton's  fracture  involves  the  posterior  lip  of  the  lower  end  of  the 
radius,  the  line  of  fracture  entering  the  wrist  joint.  Colles'  fracture  is  most 
frequent  in  old  women,  but  may  occur  in  either  sex  at  any  age.  It  is  practi- 
cally always  the  result  of  a  fall  upon  the  palm  of  the  extended  and  pronated 
hand.     Impaction,  fracture  of  the  lower  end  of  the  ulna  or  its  styloid  process. 


Fig.  203. — Col les' fracture  showing  silver  Fic.    204. — Fracture   of    lower  end  of 

fork  deformity.  radius  with  anterior  displacement,  show- 

ing gardener's  spade  deformity. 

and  tearing  of  the  internal  lateral  ligament  with  subsequent  dislocation  of  the 
lower  end  of  the  ulna,  are  not  unusual  complications.  As  a  rule  a  strip  of 
periosteum  on  the  posterior  surface  remains  untom. 

The  S3anptoms  are  swelling,  localized  pain,  and  loss  of  function.  Abnor- 
mal mobility  and  crepitus  are  frequently  absent.  The  lower  fragment  passes 
upwards  and  backwards  as  the  result  of  the  direction  of  the  violence,  pro- 
ducing the  silver  fork  deformity  (Fig.  203) ;  as  most  of  the  force  is  transmitted 
through  the  ball  of  the  thumb,  the  displacement  is  also  outwards,  thus  causing 
abduction  of  the  hand  and  prominence  of  the  styloid  process  of  the  ulna, 
which  is  found  on  a  level  with  or  lower  than  the  radial  styloid,  which  is  nor- 
mally the  lower  point.  The  lower  fragment  is  also  tilted,  because  the 
brunt  of  the  force  is  received  on  the  posterior  lip  of  the  articular  surface, 
which  looks  downwards  and  backwards  instead  of  downwards  and  forwards. 
The  hand  is  pronated,  and  separated  from  the  forearm  by  a  deep  depression 
on  the  flexor  surface,  caused  by  the  posterior  displacement  of  the  lower  frag- 
ment and  the  prominence  of  the  lower  end  of  the  upper  fragment.  The  dis- 
tance between  the  styloid  processes  is  lengthened  and  that  between  the 
external  condyle  and  the  radial  styloid  is  shortened.  In  rare  instances,  as 
the  result  of  falls  on  the  back  of  the  hand,  the  lower  fragment  is  displaced 
forward  instead  of  backward  (Fig.  204). 

The  Treatment. — Reduction  is  accomplished  by  hyperextension,  to  free 
the  fragments  and  relax  the  untom  dorsal  periosteum,  and  direct  pressure 


FIACTUUE  OF  THE  BONES  OF  THE  FOREARM. 

on  the  lower  fragment,  lo  force  it  in  place,  as  the  wrist  is  flexed  and  the  hand 
adducted  (towards  the  ulna).  These  movements  may  be  quickly  performed 
by  locking  the  lingers  beneath  the  wrist  and  using  the  thumbs  to  control  the 
lower  fragment.  Great  force  is  often  required  to  reduce  this  fracture,  and 
unless  such  can  be  eflfected  quickly  and  at  the  first  attempt,  the  patient  should 
Ije  anesthetized.  Reduction  is  best  maintained  by  means  of  the  Bond  splinl 
(Fig.  196),  fully  padded  Ijeneath  the  hollow  of  the  wrist,  so  that  when  placed 
on  the  splint  the  hand  wili  be  semi-llexed  and  adducted.  A  small  pad  is 
placed  on  the  back  of  the  forearm  over  the  lower  fragment,  and  another  on 
the  rJexor  surface  over  the  lower  end  of  the  upper  fragment.  The  fingers  are 
not  bajidaged.  The  dressings  are  changed  every  two  or  three  days,  and 
while  the  fragments  are  held  firmly  in  place  with  one  hand,  the  fingers  and 
wrist  are  gently  moved,  at  even  the  second  dressing.  The  splint  may  be 
permanently  removed  in  three  weeks.     The  Lens  splint  (Fig.  205)  acts  on  the 


Fic.  ao5,— The  Levis  splint. 


same  principle  as  the  Bond  splint.  Roberts  uses  a  straight  posterior  splint. 
In  simple  Colics'  fracture  in  the  young  and  healthy  ihe  prognosis  is  good  both 
regarding  contour  and  funt  tion,  but  if  there  is  comminution  or  much  impac- 
tion, some  deformity  will  result  no  matter  what  treatment  is  employed,  while 
iji  cases  with  associated  joint  injury,  or  in  the  old  and  rheumatic,  limitation  of 
motion  frequently  follows  the  most  careful  treatment.  If  the  bone  has  united 
in  deformity  and  there  is  much  impairment  of  function,  reduction  after 
osteotomy  should  be  considered. 

Separation  of  the  lower  epiphysis  of  the  radius  may  occur  before  the 
twentieth  year,  the  epiphysis  passing  backwards.  It  differs  from  tVilles* 
fracture  in  that  the  dorsal  swelling  is  less,  the  fiexor  or  diaphyseal  projection 
is  greater,  lateral  deformity  is  rarely  present,  and  crepitus  is  softer  and  more 
easily  obtained.  The  Irfalmml  is  that  of  Colles'  fracture.  The  danger  of 
interference  with  the  growth  of  the  radius  should  be  borne  in  mind. 

Fracture  of  both  bones  of  the  forearm  (Fig.  ao6)  may  be  due  to  direct 
or  indirect  violence;  it  is  most  frequent  in  the  middle  and  lower  thirds.  As  a 
rule  the  upper  fragments  are  approximated  and  pronated,  while  the  ends  of 
the  lower  fragments  also  approach  each  other  and  may  be  found  in  front  of  or 
t)eh]nd  the  upper  fragments,  hence  the  forearm  is  narrowed  from  side  to 
side  and  thickened  anteroposteriorly^  There  are  also  shortening,  rrepitus, 
preternatural  mobility,  pain,  and  swelling,  and  loss  of  active  rotation. 

The  treatment  of  fractures  below  the  insertion  of  the  pronator  teres  is  the 
same  as  that  for  fracture  of  the  shaft  of  the  ulna,  the  forearm  being  placed  mid- 


d 


70 


BONES. 


viay  lietwecn  pronation  and  supination,  and  the  interosseoos space prescrred 
by  means  of  pads.  In  fractures  above  this  point  the  forearm  should  be  put 
on  an  anterior  angular  splint,  in  full  supination.  If  there  is  a  persisleol  ten- 
dency to  ulnar  bo^ving  of  the  forearm,  i.e.,  con%-ei  towards  the  ulaar  siik, 
the  elbow  may  be  extended  and  a  long  straight  splint  or  a  plaster  cast  applied 
Union  is  ustially  firm  in  four  weeks. 

The  carpal  bones  are  seldom  broken,  except  in  crushes  in  w  hich  the  frac- 
ture is  compound  and  associated  with  injuries  to  neighboring  bones.  Until 
the  advent  of  the  Xray  simple  fractures  of  the  carpal  bon^  were  usually 
treated  as  sprain,  weak  wrist,  rheumatism,  etc.  -\lthough  any  of  the  carpal 
bones  may  be  involved  in  a  simple  fracture,  the  scaphoid  is  the  one  most 

frequently  broken,  often  being  asso- 
ciated with  anterior  dislocation  of 
the  semilimar  bone;  the  proximal 
fragment  passes  fomard  with  the 
semilunar.  There  is  a  *' history  of 
a  fall  on  the  extended  hand ;  local- 
ized swelling  of  the  radial  half  of 
the  wrist  joint;  acute  tenderness  in 
I  he  anatomical  snuff-box  when  the 
hand  is  adducted:  limitation  of  ex- 
tension by  muscular  spasm^  the 
overcoming  of  which  by  force 
causes  unbearable  pain.  The 
possibility  of  the  existence  of  a 
bipartite  scaphoid  should  be  con- 
sidered in  interpreting  X-rays  of 
simple  fracture  of  the  scaphoid" 
(Codman  and  Chase),  Crepitus 
may  be  obtained  in  some  instances 
of  simple  f rat  lure  of  the  carpus. 
The  treatment  in  compound  fractures  is  disinfection  and  the  application  of 
a  straight  palmar  splint,  or  pos.sif>ly  resection  of  Ijone  or  amputation.  In 
simple  fractures  deformilVT  if  present,  should  be  reduced  by  traction  and 
direct  pressure,  and  the  wrist  immobilized  fur  three  or  four  weeks  by  a 
palmar  or  dorsal  splint.  If  pain  and  stitlness  persist  after  fracture  of  the 
s<  aphoid,  excision  of  the  hone  through  a  dorsal  incision  may  give  relief. 

The  metacarpal  bones  may  be  broken  Ijy  direct  or  indirect  force. 
Hennrtt's  fraciure  is  a  fracture  of  the  upper  end  of  the  metacarpal  bone  of  the 
thumb  involving  the  articular  surface.  The  symptoms  are  pain,  swellings 
crepitus,  abnormal  mobility,  posterior  angular  deformity^  and  flattening 
of  the  knuckle  of  the  affected  bone.  The  treatment  is  reduction  by  traction 
and  direct  jrressure,  and  the  application  uf  a  straight  palmar  splint,  well  pad- 
ded to  till  up  the  hollow  of  the  palm.  It  may  be  necessar>'  to  apply  a  dorsal 
pad  over  the  deformity,  and  permanent  extension  to  the  linger  by  adhesive 
strips  passing  to  the  end  of  lhesph*nt.  The  dressing  should  be  worn  for 
three  weeks. 

The  phalanges  are  generally  broken  by  direct  violence,  which  frequently 
rentiers  the  fraciyre  i  nmpound.  The  symptoms  are  pain,  swelling,  mobility^, 
crepitus,  loss  of  function,  and  little  or  no  deformity.  The  treatment  is  the 
application  of  a  molded  spHnt  of  cardboard  or  a  straight  wixiden  splint, 


FiC,  3o6. — Fracture  of  both  bones  of  the 
forearm.     rPennsykama  HospiuL) 


FRACTUHES   OF   THE    PELVIS. 


271 


I 


which  in  fracture  of  the  proximal  phalanx  should  extend  into  the  palm.  In 
some  cases  it  may  be  desirable  to  bandage  adjacent  fingers  together  on  a 
splint,  so  as  to  provide  lateral  support.  The  splint  may  be  discarde<l  in 
three  weeks. 

Fractures  of  the  pelvis  are  due  to  direct  \iolence,  as  in  a  crushing  acci- 
dent, or  to  violence  transmitted  through  the  vertebral  column  or  the  femora* 

Fractures  of  the  false  pelvis,  i.e.,  of  the  spines,  crests,  or  ala  of  the  ilia» 
are  not  in  themselves  serious,  as  dispiacement  is  slight.  The  comfflications 
may»  however,  be  highly  dangerous;  they  are  more  often  associated  with  com- 
minuted  fractures,  and  involve  the  abdominal  viscera.  The  syniptotns  are 
pain,  swelling,  ecchymosis,  mobility,  crepitus,  and  but  little  or  no  deformity. 
The  trealmtnt  is  rest  in  bed,  with  the  shoulders  elevated  and  the  thighs  flexed 
to  relax  the  muscles,  and  the  application  of  a  broad  Oannel  binder  around  the 
pelvis.  Rupture  of  the  bowel  will  require  laparotomy.  L'nion  occurs  in 
four  or  tivc  weeks. 

Fractures  of  the  true  pelvis  are  always  serious  because  of  the  rlanger  of 
cofMplicaHons,  such  as  rupture  of  the  bladder  or  urethra,  or  injury  to  the  bowel, 
uterus,  or  vagina.  The  fracture  usually  extends  into  the  obturator  foramen, 
either  through  the  horizontal  ramus  of  the  pubes  or  the  ascending  ramus  of 
the  ischium.  It  may  be  associated  with  fracture  through  the  opposite  sacro- 
iliac joint,  or  there  may  be  many  lines  of  fracture  in  different  parts  of  the 
pel  vi  c  ring.  The  sy  mpio  m  s  a  re  s  h  o  c  k ,  pe  1  vi  c  pain,  es  pec  i  ai  ly  on  co  u  gh  i  n  g , 
straining,  or  moving  the  legs,  swelling,  ecchymosis,  inability  to  sit  or  stand, 
and  rarely  deformity.  Mobility  and  crepitus  may  be  obtained  Ijy  grasping 
the  pelvis  on  each  side  and  making  alternate  pressure,  or  by  inserting  the 
finger  into  the  vagina  or  rectum  while  one  side  of  I  he  pelvis  is  moved  on  the 
other.  It  should  be  remembered  that  rough  manipulations  may  drive  sharp 
fragments  into  the  viscera.  Bleeding  from  the  urethra,  vagina,  or  rectum 
should  be  most  carefully  investigated. 

The  treatment  is  lirst  to  react  the  patient  from  shock,  and  carefully  ex- 
clude visceral  injuries,  which,  if  present,  are  to  be  repaireil  as  described 
under  their  respective  headings.  The  fragments  arc  reduced  by  external 
manipulation,  or  by  combined  external  and  internal  manipulation,  and  the 
patient  placed  on  a  firm  bed  or  a  Bradford  frame,  with  a  broad  l)inder  cn- 
circh'ng  the  pelvis.  In  some  fractures  of  the  pubic  bone  wiring  may  be  indi- 
cated. Union  occurs  in  afjoul  six  weeks,  but  the  patient  should  be  kept  in 
bed  several  weeks  longer,  then  allowed  to  get  about  with  a  firm  binder 
and  crutches. 

Fracture  of  the  acetabulum  may  complicate  dorsal  dislocation  of  ihe 
femur,  the  posterior  lip  giving  way;  or  the  head  of  the  femur,  in  falls  on  the 
trochanter,  may  fissure  the  acetabulum,  or  even  perforate  it  and  enter  the 
pelvis,  in  which  case  the  viscera  may  be  damaged.  In  fracture  of  the  pos- 
terior lip  the  head  of  the  femur  is  easily  reduced,  with  crepitus,  !)ut  the 
deformity  shows  a  strong  tendency  to  recur.  When  the  head  of  the  f)one  has 
been  driven  into  the  pelvic  cavity,  a  fracture  of  the  neck  of  the  femur  may  be 
simulated,  but  there  is  less  mobility,  and  greater  flattening  of  the  trochanter, 
and  the  head  of  the  bone  may  be  palpated  through  the  rectum.  'The  treat- 
ment is  reduction  by  traction  and  externa!  manipulation,  and  the  application 
of  permanent  extension  as  in  fradure  uf  the  ntnk  of  the  femur. 

The  sacrum  is  broken  by  direct  violence.  Comminution  may  lie  present, 
and  injury  to  the  sacral  plexus  is  frequent,  perhaps  causing  paralysis  of  the 


272 


BONES. 


bladder  and  rectum.  In  a  transverse  fracture  ttie  lower  fragment  generally 
passes  forwards,  and  may  press  upon  or  tear  the  rectum.  Mobility  and 
crepitus  may  be  detected  by  placing  one  fmger  in  the  rectum  and  making  ex- 
ternal pressure.  The  treatment  Is  reduction  by  pressure  within  the  rectum, 
and  the  appb cation  of  a  pelvic  binder,  with  a  large  pad  over  the  upper  part  of 
the  sacrum,  so  that  exlenial  pressure  will  not  be  made  on  the  lower  fragment. 
Laceration  of  the  rectum  may  require  suture.  In  the  presence  of  injury  to 
the  sacral  plexus  elevation  and  fixation  of  the  depressed  fragments  through 
an  externa!  incision  will  be  indicated.  In  these  cases  great  care  must  be 
taken  lest  bed  sores  develop  or  lest  infection  of  the  bladder  from  catheteriza- 
tion result.     The  bone  unites  in  four  or  five  weeks. 

The  ccccyx  is  normally  mobile,  but  it  may  be  broken  by  a  fall  or  a  kick. 
The  symptoms  are  pain,  more  marked  on  walkings  coughing,  and  defecation, 
and  nKjbility,  crepitus,  and  perhaps  turning  in  of  the  fragment,  appreciable 
on  rectal  examination.  The  treaitnent  is  rest  in  bed  for  four  weeks;  the  bone 
cannot  be  splinted.  Coccygodynia  is  a  severe  form  of  neuralgia  following 
injuries  to  the  coccyx.  It  may  be  due  to  non-union  or  vicious  union,  but 
occasionally  occurs  in  cases  in  which  there  has  been  no  fra<  ture.  The  pain  is 
similar  to  that  occurring  in  fracture,  and  may  be  so  harassing  as  to  induce 
neurasthenia.  If  relief  cannot  be  obtained  by  medical  treatment,  the  coccyx 
may  be  excised  through  a  straight  incision  in  the  middle  line,  care  lieing 
taken  not  to  injure  the  rectum. 

Fractures  of  the  upper  extremity  of  the  femur  inclurle  intra-  and 
extracapsular  fractures  of  the  neck,  fractures  uf  the  great  trochanter,  ami  sep- 
aration of  the  upper  epiphysis. 

Intracapsular  fracture  of  the  neck  of  the  femur  is  most  frequent  in 
elderly  women »  although  it  may  occur  in  either  sex  or  at  any  age.  In  old 
age  the  neck  of  the  bone  is  more  horizontal,  and  the  bony  tissue  is  atrophied 
and  in  Id  t  rated  with  fat,  hence  slight  indirect  force,  such  as  catching  the 
toe  in  a  piece  of  carpel,  or  suddenly  throwing  the  weight  of  the  body  upon 
the  lower  extremity,  is  a  frequent  cause  of  this  accident  in  the  elderly.  Im- 
paction is  unusual,  and  although  some  of  the  reflected  fibers  of  the  capsule 
or  a  portion  of  the  periosteum  may  remain  untorn,  the  head  of  the  bone,  as 
a  rule,  is  entirely  separated  except  for  its  attachment  to  the  acetabulum  by 
the  ligamentum  teres,  through  which  it  receives  sufficient  blood  to  maintain 
its  vitality.  Hence  non-union  or  at  best  fibrous  union  is  a  frequent  occur- 
ence, particularly  in  the  aged  and  debilitated. 

The  symptoms  are  pain,  Htde  or  no  swelling  and  ecchymosis  (unless  the 
patient  has  fallen  on  the  trochanter  after  the  neck  has  broken),  loss  of  func- 
tion, helpless  eversion  (the  limi>  l}ing  on  its  outer  side  as  the  result  of  graWty 
and  the  action  of  the  external  rotators;  inversion  is  possible  but  ver}^  rare), 
crepitus  if  there  is  no  impaction,  lessened  arc  of  rotation  of  the  great  trochanter 
(the  radius  extending  to  the  line  of  fracture  instead  of  to  the  acetabulum), 
inward  displacement  of  the  great  trochanter  (found  by  measuring  the  distance 
between  the  median  line  of  the  liody  and  the  outer  surface  of  each  trochanter), 
and  slight  shortening  (one-half  to  one  inch),  which  in  a  few  days  may  increase 
to  two  or  more  inches,  owing  to  muscular  spasm,  unlocking  of  impacted  frag- 
ments, or  laceration  of  untorn  periosteal  or  fil>rous  tissue.  Shortening  may 
be  determined  by  one  of  the  following  methods:  1 ,  The  limbs  may  l)e  meas- 
ured from  the  anterior  superior  spine  of  the  ilium  to  the  internal  malleolus* 
The  patient  should  be  perfectly  tiat  and  straight  upon  a  firm  bed,  so  that  a 


Fig.  J07  -  Bnant's  triangle;  C  B, 
Ifst-tinc  for  fratlure  or  shortening 
of  neck  of  femur.     (Moullin.) 


Straight  line  drawn  from  the  episternal  nutch  tu  midway  between  the  internal 
malleoli  will  intersect  the  umbilicus,  the  symphysis  pubis,  and  the  midpouit 
between  the  knees,  and  a  line  passing  through  each  anterior  superior  spine  of 
the  ilium  will  be  perpendicular  to  the  axis  of  the  body.  The  tip  of  the  ante- 
rior superior  spine  and  the  tip  of  the  internal  malleolus  are  marked  with  a  pen- 
cil, and  in  measuring  the  skin  is  not  pressed  upon  lest  it  become  displaced.  A 
difference  of  a  quarter  of  aji  inch  is  not  unusual  normally,  and  exceptionally  it 
may  be  even  much  greater,  so  that  in  case  of  doubt  the  XlhUv  may  be  measured 
to  determine  the  presence  or  absence  of  symmetry.  Normally  a  straight  line 
from  the  anterior  superior  spine  to  the  tip  of  the  malleolus  passes  through  the 
center  of  the  patella.  2.  Xetdton's  line  is  one  passing  from  the  anterior  su- 
perior spine  of  the  ilium  to  the  most  promi- 
nent part  of  [the  tuberosity  of  the  ischium. 
Normally  when  the  lower  limb  hes  in  the 
axis  of  the  body,  the  top  of  the  trochanter 
touches  the  middle  of  this  line;  in  fracture 
it  passes  above  the  line.  3.  Bryant's  triangle 
(Fig.  207)  consists  of  a  line  from  the  anterior 
superior  spine  to  the  top  of  the  trochanter, 
and  another  from  the  anterior  superior 
spine,  drawn  downwards  perpendicularly 
to  the  axis  of  the  body,  to  meet  at  a  right 
angle  one  draw^n  upwards  from  the  trochaji- 
ten  Shortening  of  the  last  line  as  com- 
pared with  the  opposite  side  of  the  body,  shows  the  amount  of  shortening 
of  the  limb.  4.  Relaxation  of  the  fascia  lata,  as  determined  by  pressure 
above  the  great  trochanter,  also  indicates  shortening  of  the  femun  In 
children,  in  whom  this  fracture  is  more  common  than  was  once  supposed, 
there  is  usually  the  history  of  a  severe  fall  rather  than  a  trivial  twist,  and 
the  fratlure  is  often  impacted  or  of  the  green-stick  variety,  so  that  the 
disability  may  be  slight  and  the  bony  injury  readily  overlooked.  Later, 
however,  owing  to  the  lack  of  proper  treatment,  the  neck  bends  (coxa 
vara)  and  a  permanent  limp  is  produced,  which,  with  the  slight  pain 
and  limitation  of  motion,  may  be  mistaken  for  hip  disease.  The  symp- 
toms of  fracture  of  the  femoral  neck  in  children  are  slight  eversion,  limita- 
tion of  abduction,  and  shortening;  crepitus  and  abnormal  mobility  are 
usually  absent.  The  diagnosis  is  confirmed  by  the  X-ray.  The  com  pli- 
cations in  the  old  are  mainly  due  to  conlinement  to  bed,  e.g.,  bed  sores  and 
hypostatic  pneumonia.  Non-union,  fibrous  union,  atrophy  and  absorption 
of  the  head,  in  the  old,  and  coxa  vara  in  the  young,  arc  among  the  sequela?. 
The  treatment  is  seldom  satisfactor>%  Aged  patients  rarely  tolerate  con- 
finement to  bed  for  the  necessary  length  of  time  to  olvtain  union,  and,  should 
there  be  evidences  of  impairment  of  the  general  health,  the  patient  should  be 
allowed  to  sit  up  and  leave  the  bed  at  the  eadiest  possii>le  date,  making  no 
attempt  to  fix  the  fracture.  The  usual  method  of  treatment  is  by  Buck's 
extension  apparatus,  with  sand  bags  for  lateral  support.  The  patient  is 
placed  on  a  firm  mattress,  which  h  kept  flat  by  boards  placed  between  it  and 
the  frame  of  the  bed.  Impaction  should  never  be  broken  up,  except  possibly 
in  the  young,  hence  one  should  never  try  lo  obtain  crepitus  and  mobility,  and 
should  be  careful  in  moving  the  patient.  A  hairy  leg  should  be  shaved,  and 
tfie  foot  and  ankle  bandaged.  A  strip  t»f  adhesive  plaster,  about  two  inches 
18 


274 


BONES. 


wide,  and  long  enough  to  run  from  the  seat  of  the  fracture  to  below  the  sole  of 
the  foot  and  back  again ,  is  prepared  by  fastening  to  its  center  a  piece  of  board, 
wnth  a  hole  in  the  middle,  and  a  h'tde  longer  than  the  width  of  the  foot  (Fig. 
196),  The  plaster  is  applied  to  the  sides  of  the  lower  extremity  up  to  the 
seat  of  the  fracture,  and  the  bandage  continued  over  the  plaster.  A  piece  of 
rope  is  knotted,  then  passed  through  the  opening  in  the  board  and  over  a  pul- 
ley at  the  end  of  the  bed  (Fig.  196).  To  this  should  be  attached  a  weight  of 
five  pounds  (a  brick  weighs  about  live  pounds),  unless  there  is  great  shortai- 
ingand  no  impaction,  in  which  case  the  weight  should  l>e  sufficient  to  restore 
the  normal  length  of  the  limb.  The  foot  of  the  bed  is  raised  live  or  six  inches, 
to  obtain  counterextension  by  the  weight  of  ihe  body.  The  limb  is  slightly 
abducted,  rotated  inward  to  correspond  with  the  other  limb,  and  supported 
from  the  sides  by  sand  bags,  the  outer  reaching  from 
the  chest  to  below  the  foot,  and  the  inner  from  the 
perineum  to  below  the  foot.  A  pad  is  placed  beneath 
the  popliteal  spacCi  and  a  bird*s  nest  of  cotton  beneath 
the  heel  to  relieve  pressure.  A  cradle  (Fig,  208)  may 
be  placed  over  the  leg  to  suppc^rt  the  bed  clothing. 
The  patient  should  be  kept  in  bed  six  or  eight  weeks, 
Fig.  208. — Cradle,  and  should  bear  very  little  weight  on  the  extremity  for 
three  months  from  the  time  of  injur}%  indeed  crutches,  or 
at  least  a  cane,  are  usually  necessary  for  many  months,  if  not  permanently- 
Senn  encases  the  pelvis  and  the  lower  extremity  in  plaster-nf -Paris,  leaving 
an  opening  over  the  great  trochanter,  upon  which  lateral  pressure  is  made  by 
means  of  a  screw  apparatus  which  has  been  incorporated  in  the  plaster. 

The  Thomas  hfp  splinl  (Fig.  242)  immobilizes  the  fracture  by  fixing  the 
pelvis  and  the  thigh,  and  allows  the  patient  to  be  moved  about  without  dan- 
ger of  disturbing  the  fragments.  The  splint  is  of  iron,  with  bands  encircling 
the  chest,  thigh,  and  calf.  The  method  is  an  excellent  one  if  the  splint  is  al 
hand  and  the  practitioner  possesses  the  requisite  skill  to  adjust  it.  In  chil- 
dren Whitman  advises  the  breaking  up  of  impaction  under  anesthesia,  and 
fixation  of  the  limb  at  the  limit  of  normal  abduction,  by  means  of  a  plaster-of- 
Paris  spica.  He  believes  this  treatment  may  be  applicable  also  to  certain 
cases  in  adult  life.  If  non-union  occurs  in  young  and  healthy  adults,  the  frag- 
ments may  be  fixed  by  passing  screws  through  the  trochanter  into  the  head 
of  the  lione,  after  exposing  these  parts  by  incision.  The  prognosis  is  bad 
in  the  old.  Death  may  occur  from  shock,  exhaustion,  or  from  pneumonia 
or  other  visceral  disease.  Complete  recovery  is  rare,  there  usually  being 
pain,  weakness,  and  limping.  In  cases  of  non-union  not  suitable  for  opera* 
tion,  some  relief  may  be  obtained  by  means  of  a  hip  support. 

The  so-called  extracapsular  fracture  of  the  neck  of  the  femur  is  in  real- 
ity extracapsular  behind  only,  the  line  of  fracture  in  front  being  covered  by  the 
caspule.  The  cause  is  direct  violence  to  the  trochanter,  as  a  fall  on  the  hip, 
hence  impaction  is  common;  if  the  violence  be  greater  the  trochanter  is  in- 
volved, sometimes  with  extensive  comminution*  The  symptoms  are  much 
the  same  as  those  of  intracapsular  fracture,  except  that  in  the  former  there  is 
greater  pain,  swelling,  ecchymosis,  and  primary  shortening,  and  later  more 
thickening  as  the  result  of  callus  formation.  The  treatment  is  the  same  as 
that  of  intracapsular  fracture.  The  progttosis  is  very  much  more  favorable 
than  in  intracapsular  fracture ; Ixmy  union  is  the  rule,  although  some  shorten- 
ing  is  inevitable. 


FRACTURES  OF  THE  FEMUR, 


275 


Fracture  of  the  great  trochanter  is  the  result  of  direct  violence,  the  line 
of  fracture  running  through  the  base  of  the  trochanter  to  the  lower  part  of 
the  neck  of  the  bone.  The  symptoms  are  very  similar  to  those  of  extracapsu- 
lar fracture.  The  lower  fragment  with  the  lesser  trochanter  passes  upwards 
and  backwards  towards  the  sciatic  notch,  and  may  be  palpated  posteriorly. 
The  trealmait  is  that  of  extracapsular  fracture. 

Separation  of  the  great  trochanter  without  fracture  of  the  shaft  is  very 
rare,  and  in  youth  is  due  to  separalimi  of  the  epiphysis  of  Uie  great  trochanter. 
The  cause  is  direct  violence.  The  symptoms  are  mobility  of  the  trochanter 
and  crepitus.  The  length  of  the  limb  and  the  motions  of  the  hip  joint  are 
not  affected*  The  trealmrnl,  if  there  is  little  or  no  displacement,  is  that  of 
fracture  of  the  neck.  If  the  fragment  is  pulled  upwards  and  backwards 
away  from  the  shaft,  the  thigh  may  be  flexed  and  rotated  externally,  while 
adhesive  straps  are  applied  to  pull  the  trochanter  do wti  wards.  Far  better 
in  such  a  case  is  fixation  by  wire»  screws,  or  pegs,  through  an  open  incision. 

Separation  of  the  epiphysis  of  the  head  of  the  femur  is  uncommon, 
but  may  occur  in  early  life.  Growth  of  the  limli  may  be  impaired,  or  coxa 
vara  may  result.  The  symptoms  are  those  of  intracapsular  fracture,  although 
less  marked  and  accompanied  by  soft  crepitus.  The  treaiment  is  that  of 
intracapsular  fracture. 

The  diagnosis  of  injuries  about  the  hip  should  be  made  only  after  a 
comparative  examination  of  both  sides.  The  tape  measure  and  the  X-ray  are 
the  greatest  aids.  In  contusion  or  sprain  mensuration  will  reveal  neither 
shortening  of  the  limb  nor  flattening  of  the  hip,  although  individual  variations 
from  the  normal  should  be  remembered.  It  should  be  recalled ,  however, 
that  shortening  may  sometimes  occur  late  after  contusion,  owing  to  atrophy 
and  absorption  of  the  head  oi  the  bone.  Crepitus  with  shortening  may  be 
found  in  chronic  osteoarthritis  of  the  hip,  but  they  antedate  the  accident  and 
are  probably  associated  with  similar  changes  in  other  joints;  moreover,  the 
trochanter  is  more  often  prominent  than  flattened,  and  there  is  no  relaxation 
of  the  fascia  lata.  An  impacted  fracture  gives  no  crepitus,  and  presents  a 
large  arc  of  rotation  of  the  great  trochanter,  but  is  accompanied  by  shortening 
which  is  not  ailected  by  extension.  Dislocation  occurs  in  young  aduhs,  never 
as  the  result  of  direct  violence,  but  always  from  force  applied  to  the  Ijnee, 
foot,  or  back  when  the  thigh  is  tlexed;  there  is  no  crepitus  and  the  head  of  the 
bone  may  be  felt  in  its  new  position.  In  dorsal  dislocation  the  limb  is  ad- 
ducted  and  inverted,  while  in  forward  dislocation  there  is  abduction  and 
outward  rotation;  in  the  obturator  variety  of  the  latter  there  is  lengthening 
of  the  limb. 

Fractures  of  the  shaft  of  the  femur  are  most  frequent  in  the  middle 
third.  Fracture  of  the  upper  third  is  uncommon  and  usually  due  to  indirect 
violence.  Fracture  of  the  lower  third  is  usually  due  to  direct  violence.  The 
middle  of  the  !>one  may  be  broken  in  either  way  and  occasionally  from  muscu- 
lar action.  The  fractures  are  generally  oblique  and  displacement  is  the  rule, 
hence  injury  to  the  soft  parts  is  of  frequent  occurrence,  and  occasionally 
the  vessels  or  nerves  are  lacerated. 

The  symptoms  are  pain,  swelling,  muscular  spasm ,  abnormal  mobility, 
crepitus,  deformity,  and  shortening.  In  the  upper  thiril  the  upper  fragment 
is  pulletl  forwanls  by  the  iliopsoas,  an<l  tlrawii  oulwards  and  rotated  exter- 
nally by  the  external  rotators;  the  lower  fragment  is  pulled  upwards  by  the 
flexors  and  extensors  of  the  lug,  inward  by  the  arlductor  muscles,  and  rolled 


J 


276 


BONES. 


outwards  by  the  weight  of  the  limb.  In  the  middle  third  the  displacement 
is  much  the  same,  although  here  any  variety  of  deformity  may  be  produced, 
according  to  the  form  and  the  direction  of  the  violence.  In  the  lower  third 
the  gastrocnemius  draws  the  lower  fragment  backwards,  and  thus  endangers 
the  popliteal  vessels. 

The  treatment  of  fractures  of  the  upper  third  is  flexion  of  the  thigh  and 


Fig        ^       !     !        r  of  ihc  shaft  of  ihc  femur* 
(Petias^ylvania  Hospital.) 

traction  to  reduce  the  deformity,  and  the  application  of  a  double-inclined 
plane  (Fig.  196}  with  extension  in  the  axis  of  the  thigh,  A  shot  bag  may  be 
placed  over  he  upper  fragment  if  it  is  too  short  to  be  retained  by  an  anterior 
splint.  Th  principle  of  the  double-inclined  plane  is  utilized  also  in  the 
Mc  Intyre  spbnt,  the  Nathan  R.  Smith  anterior  splint,  and  the  Hodgen  splint. 
The  Nathan  R.  Smith  splint  is  made  of  strong  wire,  bent  to  the  desired  shape; 


Fic.  2 10.— H(xJgen*s  suspension  splint,     (Heath.) 

it  is  applied  to  the  anterior  surface  of  the  limb  and  suspended  by  cord  and 
pulley.  The  Hodgen  splint  consists  of  two  long  pieces  of  wire  joined  at  each 
extremity  and  at  the  middle  by  a  cross  piece.  The  limb  rests  in  a  trough  of 
flannel  attached  to  the  frame.  \  Buck's  extension  is  applied,  and  attached 
ttj  the  foot  piece,  and  further  extension  made  by  suspending  the  limb  by 
cords,  passing  obliquely  upwards  to  a  vertical  post  at  the  foot  of  the  bed 


FRACTURES   OF   THE    FEMUR. 


277 


(Fig.  a  10).  All  forms  of  treatment,  however,  are  unsatisfactory,  and  if  the 
displacement  is  marked  and  the  patient  young  and  healthy,  operative 
fixation  should  be  considered.  In  frar lures  of  ike  ntidtik  third  a  Buck^s 
extension  is  applied  up  to  the  seat  of  fracture^  and  enough  weight  attached 
to  the  cord  to  overcome  the  shortening.  Lateral  dis- 
placement is  corrected  by  sand  bags,  lateral  splints,  or  a 
molded  splint.  In  the  loiter  third  horizontal  traction  as 
in  the  middle  third  may  be  tried,  but  if  there  is  a  marked 
tendency  to  displacement  of  the  lower  fragment  back- 
wards, the  double-ini lined  plane  should  be  used. 
Tenotomy  of  the  tendo  ALhillis  is  useful  in  some 
cases.  Bardenheuer  treats  fractures  in  all  parts  of 
the  femur,  and  indeed  fractures  in  oLher  bones  of  the 
extremities^  by  lateral  as  well  as  longitudinal  exten- 
sion (Fig,  211).  Fractures  of  the  thigh  unite  in  six  or 
eight  weeks» 

In  children  Bryant*s  method  may  be  used;  the  limb 
is  splinted,  flexed  to  a  right  angle  with  the  body,  and 
extension  made  from  a  cross  bar  above  the  bed  (Fig.  212). 
The  child  may  be  fastened  to  a  Bradford  frame,  which  is 
simply  an  oblong  of  gas  pipe  to  which  canvas  is  attached, 
a  space  being  left  beneath  the  buttocks.  Van  Arsdale*s 
triangular  splint  is  made  of  thick  cardboard,  in  the 
shape  of  two  cards  of  spades  joined  at  their  apices  (Fig. 
213).  When  the  splint  has  been  folded,  it  forms  a  tri- 
angle, segment  2  being  molded  to  the  abdomen  and  seg- 
ment 3  to  the  thigh,  '*The  extreme  flexed  position  of 
the  thigh  relaxes  all  the  muscles  and  neutralizes  any 
tendency  to  displacement;  the  child  can  sit  on  the  lloor 
or  chair  and  creep  about,  and  the  genital  and  anal  re- 
gions are  well  away  from  the  dressings'*  (Gallant).  The 
splint  is  worn  for  three  weeks. 

The  prognosis  in  childhood  is  very  good,  but  de- 
creases with  the  advance  of  years,  so  that  in  adult  life 
probably  only  one-half  secure  limbs  which  give  them  no 
trouble,  and  in  old  age  perfect  functional  results  are 
very  rare.  Excepting  incomplete  fractures,  some  short- 
ening  is  inevitable. 

Supracondylar  fracture  of  the  femur  is  identical 
with  fracture  of  the  lower  third  of  the  bone. 

T-  or  Y-shaped  fracture  exists  when  a  supracon- 
dylar fracture  is  complicated  Ijy  a  separation  of  the  con- 
dyles one  from  the  other.  The  lower  end  of  the  femur 
is  broadened,  one  condyle  may  be  moved  on  the  other 
with  crepitus,  and  the  knee  joint  is  filled  with  blood. 
The  trtaimenl  is  that  of  fracture  of  the  lower  third  of 
the  femur. 

Fracture  of  either  condyle  is  the  result  of  direct  force.  The  fragment 
is  displaced  upwards  and  the  leg  deviated  towards  the  alTected  side;  there  are 
crepitus,  broadening  of  the  lower  end  of  the  femur,  and  distention  of  the 
joint,  but  no  shortening.     The  treatment  is  a  double-mcUu^^i  ^l-asv^. 


Fig.  211. — Banlen- 
heuers  method  of 
treating  fractures  of 
du*  femur,  (tr)  Di- 
rection of  traction  by 
Buck's  extension  ap- 
]mratus;  ih)  of  tmc- 
t ion  on  lower  end  of 
up^jer  fragment,  hy 
band  passing  around 
the  injured  thigh  and 
under  ihe  sound 
I  high;  ic)  of  traction 
on  upper  end  of 
lower  fra^ent,  by 
band  passing  around 
the  thigh;  ((/)  of  trac- 
tion by  band  to  dx 
the  pelvis.  Ench  of 
these  bands  passes 
over  a  pulley  at  the 
side  of  the  bed  and  is 
attached  to  a  weight. 
The  upper  end  of  *he 
distal  fragment  is 
forced  outwards  also 
by  ad  ducting  the 
limb. 


THE   PATELI^\. 


270 


J'     Citation  of  a  posterior  splint >  with  mid 

-W       elling.     If  there  is  great  disterition  of 

<»tT  Ijy  a  trocar  and  cannula.     After  the 

lure  may  be  treated  by  the  non-uperalive 


»out  risk  to  life  and  is  generally  followed  by 
es  more  time  than  treatment  by  operation. 
«Tal  practitioner  who  is  not  surrounded  by 
■  -^  in  which  the  fibrous  capsule  of  the  ^2l- 
Lfj-^iuns  are  not  torn  through ^  i.e.,  cases  in 
L' I  jii  ra- 
il serva- 
itround- 
posterior 
ich  is  ele- 
^s,  and  the 
and  held 
adhesive 
rom  below 
Tuve  the  upper 
'he  inner  side 
knee.  The 
way  carries 
ds.  A  third 
Fross  the  line  of 
JBg  of  the  frag- 
les  to  the  thigh 
Bsive  plaster,  to 
f  extension  appa- 
"lax  the  quadriceps 
e  upper  fragment. 
Ig,  196)  is  simply  a 
th  rotating  pins  on 
tachment  and  tightening  of  the  strips  of  adhesive  plaster 
le  fragments  in  place.  Massage  may  be  used  from  the 
g  the  fifth  or  sixth  week  the  splint  may  be  removed,  and 
1  to  walk  with  a  molded  support  to  keep  the  knee  stiff; 
;  used  at  this  time,  but  active  movements  are  reserved  until 
nths;  all  support  is  removed  at  the  end  of  six  months, 
rcatmcnt  of  fracture  of  the  patella  is  gaining  in  favor,  and 
surgeons  is  almost  routine  practice.  It  should  never  be 
facilities  for  aseptic  work  are  available,  as  infection  of 
f  result  in  its  destruction,  in  amputation  of  the  limb^  or  in 
ence  is  more  rapid  after  the  operative  treatment,  and  it 
mce  for  accurate  apposition  and  bony  union.  Granting 
it  is  particularly  indicated  in  cases  in  which  there  is  wide 
h  soft  tissues  inter\Tne  between  the  fragments  after  their 
cases  of  com[>ound  fracture,  refracture,  or  fibrous  union 
ion  of  the  limb  is  considerably  impaired.  In  the  laborer 
:upation  nect^sitates  prolonged  standing  or  much  walking, 
e  best  chance  for  a  strong  patella.     Operative  treatment 


Fig.  2 14. — Skiagraph  of  fracture  of  patella, 
(.Pennsylvania  Ht>s|iiilal.) 


Separation  of  the  lower  epiphysis  uLturs  before  the  twenty-first  year,  is 
I  he  most  frequent  uf  all  epipliyseal  separations,  and  is  usually  the  result 
of  the  leg  being  caught  in  the  spokes  of  a  wheeL  The  symptoms  are  much  like 
those  of  supracondylar  fracture,  except  that  the  crepitus  is  moist,  and  the 
lower  fragment  is  often  displaced  forwards  owing  to  the  action  of  the  quad- 
riceps on  the  tibia;  the  lower  end  of  the  diaphysis  passes  backwards,  thus 
endangermg  the  popliteal  vessels.  Suppuration  may  occur  and  the  growth 
of  the  bone  may  be  impaired-  The  trealmint  is  reduction  by  traction  while 
pressure  is  made  on  the  fragments  and  the  thigh  gradually  dexed.  The 
limb  is  then  put  on  a  double-inclined  f>lane. 

Longitudinal  fractures  entering  the  knee  joint  may  cause  broadening 
of  the  bone,  but  are  difficult  to  detect.  The  Ireatmcnt  is  immobilization  in  a 
horizontal  position  for  six  or  eight  weeks.     Occasionally  a  small  piece  of 


Fig*  213. — Br) ant's  vertical  ex- 
tension for  fracture  of  femur  in 
children. 


¥m.  2  I  J. — Segments  i,  2,  3,  4,  each  cut  the  leng 
of  child's  thigh  from  groin  to  patella,  and  flanges  C 
to  D  the  same  widtJiK  The  M-idtii  of  sections  i  and 
4  equal  thickness  of  the  middle  of  the  thigh.  Fold 
on  dotted  lines  overlapping  1  and  4 after  moistening, 
(Annals  of  Surgeiy.) 


the  articular  surface  of  one  of  the  condyles  is  chipped,  but  unless  an  X-ray 
picture  is  taken,  the  diagnosis  is  rarely  made  until  some  time  later,  when 
a  foreign  body  is  detected  in  the  joint. 

Fracture  of  the  patella  is  produced  by  direct  violence,  or  much  more  fre- 
quently by  muscular  action.  Fracittres  by  tlirect  violence  are  usually  vertical 
or  oblique,  and  not  infrequently  comminuted.  As  a  rule  the  fibrous  capsule 
of  the  patella  is  n<^t  separated  to  any  great  extent  so  that  marked  displacement 
is  absent.  The  treatment  of  these  cases  is  immolnlization  of  the  knee  by  a 
posterior  splint  for  six  weeks.  Effusion  into  the  joint  is  reduced  by  cold  and 
compression  and  later  by  massage;  in  four  weeks  gentle  passive  motion  is 
begun. 

Fractures  due  to  muscular  action  are  transverse  or  slighdy  oblique,  the 
fibrous  capsule  usually  tearing  so  ihat  marked  separation  takes  place.  The 
joint  is  therefore  usually  opened.  When  the  knee  is  half  Oexed,  the  middle 
of  the  patella  lies  against  the  condyles  of  the  femur^  while  tiie  upper  portion 
projects  above;  in  this  ptisition  sudden  contraction  of  the  quadriceps,  as  in 
an  attempt  to  save  oneself  from  a  fall,  may  result  in  a  transverse  fracture. 
The  symptoms  are  pain,  effusion  of  blood  into  the  knee  joint,  inability  to  use 
the  limb  although  walking  backwards  is  |x>ssible^  separation  of  the  frag- 
ments, and  if  they  can  be  brought  together,  crepitus.  The  separation  is  pro- 
duced by  the  action  of  the  quadriceps  and  also  by  the  effusion  in  the  knee 
joint. 


FRACTURE  OF  THE  PATELIA. 


379 


The  treatment  is  at  first  the  apphcation  of  a  posterior  splint,  with  cold 
and  compression  to  reduce  the  swelling.  If  there  is  great  distention  of 
the  joint,  the  effusion  may  be  drawn  off  by  a  trocar  and  cannula.  After  the 
swelling  has  been  controlled  the  fracture  may  be  treated  by  the  non -operative 
method  or  by  operation. 

The  non-operative  method  is  without  risk  to  life  and  is  generally  followed  by 

useful  joint,  although  it  consumes  more  lime  than  treatment  by  operation. 
It  should  be  employed  by  the  general  practitioner  who  is  not  surrounded  by 
facilities  for  perfect  asepsis.  Cases  in  which  the  fibrous  capsule  of  the  pa- 
lella  and  the  lateral  fascial  expansions  are  not  torn  through,  i.e.,  cases  in 
which  there  is  but  little  or  no  separa- 
tion, are  l>est  treated  by  the  conserva- 
tive plan  no  matter  what  the  surround- 
ings. The  limb  is  placed  on  a  posterior 
splint,  the  lower  end  of  which  is  ele- 
vated to  relax  the  quatlrireps,  and  the 
fragments  are  approximated  anti  held 
in  place  by  two  strips  of  adhesive 
plaster,  one  of  which  passes  from  below 
the  joint  on  the  outside,  above  the  upper 
fragment,  then  down  to  the  inner  side 
the  lower  part  of  the  knee.     The 

cond  strip  in  a  simjlar  way  carries 
the  lower  fragment  upwards.  A  third 
strip  should  be  put  across  the  line  of 
fracture  to  prevent  tilting  of  the  frag- 
ments. Hopkins  applies  to  the  thigh 
a  wickerwork  of  adhesive  plaster,  to 
which  is  attached  an  extension  appa- 
ratus in  order  to  relax  the  quadriceps 
and  pull  down  the  upper  fragment. 
Agnew's  splint  (Fig.  196)  is  simply  a 
posterior  splint  with  rotating  pins  on 
the  side  for  the  attachment  and  tightening  of  the  strips  of  adhesive  plaster 
applied  to  hold  the  fragments  in  place.  Massage  may  be  used  from  the 
beginning.  During  the  tlfth  or  sixth  week  the  splint  may  be  removed^  and 
the  patient  allowed  to  walk  with  a  molded  support  to  keep  the  knee  stiflF; 
passive  motions  are  used  at  this  time,  but  active  movements  are  reserved  until 
the  end  of  two  months;  all  support  is  removed  at  the  end  of  six  months. 

The  operaiive  treatment  of  fracture  of  the  patella  is  gaining  in  favor,  and 
indeed  with  some  surgeons  is  almost  routine  practice.  It  should  never  be 
employed  unless  facilities  for  aseptic  work  are  available,  as  infection  of 
the  knee  joint  may  result  in  its  destruction,  in  amputation  of  the  limb,  or  in 
death.  Convalescence  is  more  rapid  after  the  operative  treatment,  and  it 
offers  the  best  chance  for  accurate  apposition  and  l>ony  union.  Granting 
a  healthy  subject,  it  is  particularly  indicated  in  cases  in  which  there  is  wide 
separation,  in  which  soft  tissues  inten-ene  between  the  fragments  after  their 
apposidon,  and  in  cases  of  compound  fracture,  refraclure,  or  fil>rous  union 
in  which  the  function  of  the  limb  is  considerably  impaired.  In  the  laborer 
or  in  one  whose  occupation  necessitates  prolonged  standing  or  much  walking, 
operation  offers  the  be^t  chance  for  a  strong  patella,     Operative  treatment 


Frc. 


4,— Sk-iagraph  of  fraclyreof  patella, 
(Pennsylvania  Hospital.) 


28o 


BONES. 


may  he  either  subcutaneous  or  open.  As  an  example  of  the  former  may  be 
mentioned  the  antero-posierior  suture  of  Barker.  A  special  instrument  some- 
vvhal  like  an  aneurysm  needle  sharpened  at  the  end  is  passed  through  a 
knife  puncture  just  below  the  patella,  then  beneath  the  bone  to  and  through 
the  skin  above  the  upper  fragment,  where  it  is  threaded  with  silver  wire  and 
withdrawn  to  the  point  of  entrance  and  unthreaded;  it  is  then  pushed  upwards 
between  the  skin  and  the  fragments  to  the  opening  above,  threaded  with  the 
other  end  of  the  wire,  and  withdrawn.  After  rubbing  the  fragments  together 
to  dislodge  blood  or  soft  tissues,  the  ends  of  the  wire  are  twisted,  cut  short,  and 
pushed  beneath  the  skin.  In  a  somewhat  similar  manner  Roberts  passes  a 
silk  suture  around  the  fragments  laterally  (circumferential  suture).  The 
subcutaneous  possesses  all  the  dangers  of  the  open  method  without  its 
advantages,  viz.,  evacuation  of  the  joint,  removal  of  the  fibrous  or  other  tissue 
from  between  the  fragments,  and  accurate  apposition.  The  opeti  opcraiimi 
is  performed  by  exposing  the  fracture  by  a  longitudinal  or  transverse  incision, 
preferably  the  latter.  The  joint  is  irrigated  with  salt  solution,  the  fragments 
brought  together  after  removing  any  intervening  soft  structures,  and  two 
wire  sutures  passed  obUquely  through  the  fragments  so  as  not  to  enter  the 
joint.  The  wound  is  closed  without  drainage.  When  the  fragments  come 
together  without  much  tension,  it  is  preferable  to  omit  the  silver  wire  and 
simply  suture  the  fibrous  capsule  of  the  patella  and  the  lacerations  in  the 
lateral  fascial  expansion  with  strong  chromicized  catgut.  Massage  is  begun 
as  s*>on  as  the  wound  is  healed,  and  the  patient  is  allowed  out  of  bed  with  a 
molded  splint  at  the  end  of  three  or  four  weeks,  when  passive  motions  are 
commenced ;  all  dressings  are  removed  in  two  months,  and  at  the  end  of  three 
or  four  months  recovery  is  complete. 

The  prognosis  after  n  on -op  era  Live  treatment  is  good  regarding  the  func 
tion  of  the  leg,  although  fibrous  union  is  the  rule  and  some  stiffness  and  weafc 
ness  are  generally  present.  After  operation  bony  union  may  be  secured* 
but  pain  and  stiffness  are  by  no  means  unusual.  Of  373  cases  of  fracture  of 
the  patella,  48  suffered  a  refracture  at  the  same  point,  in  periods  ranging  from 
a  few  months  to  four  years;  the  majority  of  these  were  treated  by  the  conser- 
vative plan  (Lauper). 

The  tibia  may  be  fractured  at  the  upper  end,  at  any  portion  of  the  shaft, 
and  at  the  lower  end,  and  the  tubercle,  or  the  upper  or  lower  epiphysis  may  be 
separated. 

The  tipper  end  of  the  tibia  is  broken  by  direct  violence.  The  symptoms 
are  often  masked  by  the  swelling  of  the  overlying  soft  parts.  When  the  frac- 
ture is  transverse  there  is  but  little  displacement,  when  oblique  the  leg 
deviates  from  the  axis  of  the  limb.  The  fissure  may  enter  the  joint,  which  wiU^H 
then  be  greatly  distended.  Mobility  and  crepitus  are  present.  The  /r^aiaJB 
ment  is  reduction  by  traction  and  pressure  on  the  fragments,  and  im- 
mobilization on  a  doul>le  inclined  plane  or  in  a  plaster  cast,  for  four  or 
five  weeks. 

The  tubercle  of  the  tibia  may  be  torn  off  by  violent  contraction  of  the 
quadriceps^  in  individuals  under  the  age  of  twenty.  The  fragment  is  drawn 
upwards,  and  the  injury  may  be  mistaken  for  fracture  of  the  patella,  in  which, 
how^ever,  there  is  no  depression  at  the  upper  extremity  of  the  tibia,  the  upper 
end  of  the  lower  fragment  is  serrated,  and  a  finger  pressed  l>etween  the 
fragments  touches  the  femur.  If  the  separation  is  partial  the  diagnosis 
is  made  by  pain,  tenderness,  localized  sw^elling,  and  the  X-ray.     The  treatment 


FRACTtTRES   OF   THE   BONES   OF  THE   LEG. 


281 


is  a  posterior  splint;  if  there  is  much  separation,  the  tubercle  may  be  fasteTied 
in  place  by  wiring  or  pegging. 

Separation  of  the  upper  epiphysis  of  the  tibia  is  an  extremely  rare 
injury  which  may  occur  before  the  sixteenth  year  and  be  productive  of 
dwarfing  of  the  leg.  The  Ireatment  is  that  of  fracture  of  the  upper  end  of 
the  tibia. 

The  shaft  of  the  tibia  is  usually  broken  by  direct  violence,  occasionally 
by  indirect  violence  or  torsion.  Generally  speaking  the  fracture  is  transverse 
when  in  the  upper  part  of  the  bone,  oblique  or  spiral  when  in  the  lower  portion 
(Fig.  21$)*  The  symptoms  are  localized  pain, 
irregularity  of  the  crest  of  the  tibia,  crepitus,  and 
mobility.  In  transverse  fractures  there  may  be 
no  deformity,  and  even  in  oblifjue  fractures  the 
splinting  action  of  the  tibula  may  prevent  much 
displacement;  as  a  rule,  however,  the  upper  frag- 
ment is  tilted  forwards  by  the  quadriceps,  while 
the  lower  fragment  is  rotated  inwards.  The 
tr^aifneni  is  the  application  of  a  fracture  box  (Fig. 
196),  until  the  swelling  has  been  controlled  by 
evaporating  lotions  or  the  ice  bag;  the  leg  is  then 
put  up  in  a  plasler-of -Paris  cast,  which  is  worn 
for  five  weeks.  The  cast  should  be  split  before 
it  has  hardened,  so  that  it  may  be  removefi  ever)' 
few  days  for  inspection  and  massage  of  the  leg. 

The  internal  malleolus  is  broken  by  direct     ; 
force,  or  its  tip  may  be  torn  oflf  by  the  internal 
lateral  ligament  when  the  foot  is  strongly  everle<  i      ^ 
The  symptoms  are  pain,  mobility,  crepitus,  cfTusi' m 
into  the  ankle  joint,  and  possibly  downward  tlis- 
piacement  of  the  fragment.     The  treatment  is  that 
of  fracture  of  the  shaft.    Wiring  or  pegging  should     : 
be  considered  if  there  is  much  displacement,  as     ^ 
vicious  union   in   this   situation   is   followed  by 
lameness. 

Separation  of  the  lower  epiphysis  of  the 
tibia  is  ver>'  rare.     The  treatment  is  that  of  fracture  of  the  shaft- 

The  fibula  may  be  broken  by  direct  or  indirect  force,  or  by  muscular 
action  (biceps). 

The  upper  end  of  the  fibula,  when  broken,  causes  localized  pain,  partic- 
ularly on  adduction  of  the  leg.  There  may  be  no  displacement,  or  the  upper 
fragment  may  be  drawn  up  by  the  biceps.  Crepitus  and  mobility  are  present ; 
the  external  popliteal  ner>'e  may  be  injured.  The  irtatmeni  is  the  application 
of  a  plaster  cast  for  five  weeks.  If  there  is  displacement  the  knee  may  be 
flexed  to  relax  the  biceps. 

The  shaft  of  the  fibula,  when  broken,  causes  localized  pain  and  tender- 
ness. Deformity  is  not  seen,  but  on  pressing  the  tibia  against  the  fibula, 
crepitus  and  abnormal  mobility  may  be  detected.  As  the  bone  is  normally 
elastic,  comparison  with  the  other  leg  should  be  made  before  deciding  that 
abnormal  mobility  is  present.     The  treat mmt  is  a  plaster  cast  for  live  weeks. 

The  lower  end  of  the  fibula  may  be  broken  by  direct  force,  but  the  usual 
cause  is  a  twist  of  the  foot.     Pott's  fracture  is  caused  by  eversion  and  abduc- 


lOT 


Skiajp-aph   of 

ire    of    tibia. 

Hospital.) 


1 


lion  of  the  fout,  rarely  by  inversiuii  and  ailduc  tion.  Tn  a  typical  case  there 
ari!  three  lesions,  a  fracture  of  the  filnila  about  three  inches  al>ove  the  lip  of 
the  malleolus,  a  fracture  of  the  internal  malleolus  due  to  traction  of  the  inter- 
nal lateral  ligament  (or  rupture  of  the  ligament),  and  rupture  of  the  tibio- 
fibular ligament  (or  aVulsion  of  that  part  of  the  tibia  to  which  it  is  attached). 
The  number  of  lesions  and  consequently  the  amount  of  deformity  depend 
upon  the  degree  of  eversion  and  abduction.  In  the  slighter  forms  the  internal 
malleolus  alone  is  broken  or  the  internal  lateral  ligament  ruptured.  Con- 
tinuation of  the  force  presses  the  astragalus  against  the  external  malleolus 
and,  with  the  tibiofibular  ligament  as  a  fulcrum,  breaks  the  fibula  above  the 


F 


Flo.  216. — Skiagraph  of  fracmrc-dislocation  of  ankle,     d'ennsyivania  Hospitnl.) 


ankle  by  indirect  force,  the  upper  end  of  the  fragment  passing  towards  the 
tibia.  These  mjuries  cause  simply  marked  eversion  of  the  foot.  If  the 
tibioliljular  ligament  also  ruptures,  or  the  tibia  to  which  it  is  attached  gives 
way,  there  is  added  displacement  of  the  foot  upwards  and  backwards;  to  this 
variety  the  X^rm  fraciurc-dislocat ion  (Fig.  216)  may  be  properly  applied.  If 
the  outward  dislocation  is  complete  the  injury*  is  called  Dupuyiren' s  fracture. 
Occasionally  the  fracture  of  the  fibula  is  accompanied  by  a  transverse  fracture 
of  the  tibia  immediately  above  the  inner  malleolus,  in  which  case  the  pro- 
jection of  the  lower  end  of  the  upper  fragment  of  the  tibia  may  be  mistaken 
for  the  internal  malleolus.  In  Pottos  fracture  by  inversion  the  astragalus 
presses  against  and  fractures  the  internal  malleolus,  and  the  fibula  is  broken 
above  the  ankle  by  the  violent  traction  on  the  external  lateral  ligament,  the 
tibiofibular  joint  acting  as  a  fulcrum. 


FRACTURES  OP  THE  BONES  OF  THE   LEG. 


283 


P'rc,  2  17. — Fracture  of  bolh  bones  of  the  leg. 
(Pennsylvania   Hospila!.) 


The  symptoms  in  a  lyjat  al  rase  are  eversion  of  the  ftjol  with  ilisphicemeiil 
upwards  and  liaikwards.  There  is  great  swelling,  the  ankle  joint  being 
distended  with  blotKL  The  ititernal  miiUeijlus  is  prominent,  the  ankle  juiiU 
widened,  and  the  foot  shortened,  i.e.,  frotn  the  tibia  to  the  t«ies.  There  are 
three  points  of  great  tenderness,  corresponding  with  the  three  lesions  men- 
tioned above;  the  joint  can  be  moved  laterally  and  ante ro- posteriorly,  and 
crepitus  obtained. 

The  treatment  is  reduction  by  carrying  the  foot  inwards,  forwards,  and 
downwards,  and  the  applicatit)n  of  a  fracture  Ijox  until  the  swelling  has  been 
controlled.  The  foot  is  fastened  to  the  foot-piece  of  the  box  by  a  bandage, 
and  pads  so  arranged  as  to  maintaui  reduction.  When  the  swelling  has 
subsided,  the  leg  may  be  put  up  in  plaster,  which  is  permanently  removed 
at  the  end  of  the  tifth  week.  Dupuylrcn's  splint  is  a  straight  board  extending 
from  the  knee  to  five  or  six 
inches  below  the  fool.  The 
lower  extremity  is  notched. 
The  splint  is  applied  to  the 
inner  surface  of  the  lirab, 
after  being  thickly  padded 
down  as  far  as  a  point  corre- 
sponding to  the  internal  mal- 
leolus, so  that  the  foot  may 
be  inverted  over  the  lower  end 
of  the  pad  by  bandages,  ex- 
tending from  the  foot  to  the 
errations  in  the  end  of  the  splint  (Fig.  196).  This  splint  is  well  suited  to 
ases  in  which  there  is  e version  and  upward  displacement^  but  does  not  cor- 
ect  backw^ard  displacement  of  the  foot.  If  reduction  cannot  be  effected  or 
maintained,  even  after  flexion  of  the  knee  or  division  of  the  tendo  Achillis, 
ation  of  the  fragments  by  operation  is  indicated. 

Fracture  of  tie  shafts  of  both  hones  of  the  leg  (Fig.  217)  may  be  due 
direct  violence,  in  which  tasc  the  fracture  may  be  transverse  and  at  the 
amc  level  in  each  bone;  indirect  violence  frequently  produces  an  oblique  or 
fa  spiral  fracture  at  about  the  junction  of  the  middle  and  lower  thirds  of  the 
tibia,  the  fibula  pelding  at  a  higher  level.  All  the  symptoms  of  fracture  are 
in  evidence.  As  a  rule  the  lower  fragments  pass  up  behind  the  upper  frag- 
ments, owing  to  the  action  of  the  calf  muscles,  and  are  rotated  outwards  by 
the  weight  of  the  fmit, 

The  treatment  is  reduction  by  flexing  the  knee  to  relax  the  calf  muscles, 
and  traction  on  the  foot  while  the  bones  are  forced  into  place;  division  of  the 
tendo  Achillis  is  occasionally  necessary.  The  iimb  may  then  be  placed  in  a 
fracture  box,  and  after  the  sul>sidence  of  swelling  in  a  plaster-of- Paris  cast. 
Some  surgeons  apply  molded  lateral  splints,  others  the  Nathan  R.  Smith 
anterior  splint.  The  ambulatory  treatment  also  may  be  useil  in  this  region. 
Splints  may  be  removed  in  th'e  or  six  weeks.  Whatever  treatment  is  em- 
ployed, one  should  guard  against  rotation  of  the  lower  fragments  and  shorten- 
ing; the  former  is  absent  if  the  inner  surface  of  the  great  toe,  the  internal 
malleolus,  and  the  inner  eilge  of  the  patella  are  in  the  same  plane. 

The  prognosis  oj  jrac lures  0/  ihe  leg  in  the  young  is  quite  favorable;  in 
adult  life  and  more  so  in  old  age,  pain,  stiiTness,  and  swelling  may  be  present 
for  many  months.     Next  to  the  patella  and  humerus  non-union  is  more  fre- 


I 


984  ^^^^^  BONES, 

f|uent  in  this  region  than  anywhere  else.  After  a  classical  Pott's  fracluiv 
some  stiffness  of  the  ankle  and  deformity  are  almost  inevitable.  Should  the 
eversion  persist  there  will  be  traumatic  flat-foot,  which  will  necessitate  a 
support  to  the  instep,  or  possibly  in  some  cases  osteotomy  of  the  tibia  and 
fibula. 

Fracture  of  the  astragalus  is  due  to  direct  violence  or  to  a  fall  on  the  sole 
of  the  foot.  Many  of  the  slighter  forms  are  incorrectly  diagnosticated  as 
sprains  of  the  ankle,  as  there  are  pain  and  great  swelling*  In  the  absence  of 
deformity  and  crepitus  a  correct  diagnosis  can  be  made  only  with  the  X-ray 
There  are  often  associated  lesions  of  neighboring  bones.  The  treatfntnl 
is  a  fracture  Ijox,  and  later  a  plaster-of -Paris  cast  for  live  weeks. 

The  OS  calcis  is  usually  broken  by  a  fall  on  the  foot,  and  rarely  from  no- 
lent  contraction  of  the  calf  muscles.  The  line  of  fracture  may  be  in  almost 
any  direction :  if  in  the  anterior  portion  of  the  bone  there  may  be  no  deformity, 
if  through  the  sustentaculum  tali  there  will  be  flattening  of  the  foot,  and  if 
more  posterior  the  fragment  may  be  drawn  up  by  the  calf  muscles.  In  the 
latter  instances  crepitus  and  mobility  may  be  detected.  The  heel  is  often 
enlarged  from  side  to  side.  The  treatment j  in  the  absence  of  deformity,  is  a 
fracture  box,  and  later  a  removable  plaster-of -Paris  cast  for  four  weeks. 
Widening  of  the  heel  may  be  corrected  with  lateral  pads,  flatteniJig  of  the 
foot  with  an  instep  support*  When  the  posterior  fragment  is  drawn  upwards, 
the  tendo  A  chillis  may  be  cut  or  the  knee  bent,  and  the  foot  lixed  in  plantar 
flexion  by  a  slipper  whose  heel  is  connected  with  the  thigh  by  a  cord.  Far 
more  satisfactory,  however,  is  wiring  or  pegging  the  fragment  in  place. 

The  remaining  bones  of  the  tarsus  may  be  broken  by  direct  \^Qlence, 
which  is  usually  of  such  a  nature  as  to  cause  an  open  wound  and  comminu- 
tion of  bone,  hence  excision  of  fragments  with  drainage,  or  in  some  cases  am- 
putation, is  required. 

The  metatarsal  bones  may  be  broken  by  direct  or  indirect  violence.  The 
fracture  is  frequently  compound.  The  usual  symptoms  of  fracture  arc  pres- 
ent.    The  treatment  is  a  molded  splint  for  four  weeks. 

Fractures  of  the  phalanges  of  the  foot  are  usually  compound,  and  often 
require  amputation.  In  other  cases  the  toes  should  be  fixed  on  a  molded 
splint  of  cardboard,  extending  well  op  on  the  sole  of  the  foot. 


DISEASES  OF  BONES. 

Inflammation  of  bone  begins  in  the  periosteum  or  the  medulla,  from 
which  structures  the  osseous  tissue  receives  its  blood  supply.  The  phenomena » 
viz.,  hyperemia,  exudation,  and  changes  in  the  perivascular  tissues^  are  much 
the  same  as  in  other  structures,  except  that  death  of  the  bone  is  more  likely  to 
ensue,  owing  to  the  unpelding  character  of  the  canals  in  which  the  vessels 
run.  Inllammation  here  as  elsewhere  terminates  in  resolution,  new  growth 
{condensing  ostitis ^  or  osteosclerosis) ^  or  death  of  the  part.  Death  of  bone  is 
brought  about  by  ulceration  {cari^Sf  osteoporosis^  or  rare/aciiofi),  abscess 
formation^  or  gangrene  (necrosis).  Anatomically,  inflammation  of  bone  may 
be  divided  into  periostitis,  ostitis,  and  myelitis;  clinically,  however,  periostitis 
is  always  linked  with  inflammation  of  the  subjacent  bone,  myelitis  with 
involvement  of  the  surrounding  osseous  tissue,  hence  the  terras  osteoperiositis 
and  osteomyelitis  are  more  nearly  corrects 


J 


^ 


INFLAMMATION    O^ 


Osteoperiositis  (periostitis)  may  be  acute  or  chronic,  localized  or  diffuse. 
In  the  aatit  form  the  periosteum  is  red  and  swollen.  This  is  followed  by 
resolution  {simple  periostitis),  by  suppuration  (purultni  perwstitis),  or  hy  per- 
manent  thickening  owing  to  the  deposition  of  new  bone  {ossifying  or  osteo- 
plastic periostitis). 

The  causes  of  osteoperioslitis  are  cuntusions,  wounds  (including  fracture), 
extension  from  neighboring  tissues,  and  infection  by  way  of  the  lilood,  such 
as  rheumatism,  gout,  gonorrhea^  syphilis,  pyemia,  tuberculosis,  and  acute 
infectious  fevers.  Periostitis  may  occur  also  al  the  point  of  attachment  of 
muscles  which  are  used  to  an  abnormal  extent,  or  as  the  result  of  pressure, 
e.g.,  periostitis  of  the  os  calcis  in  liat  fool.  Marie's  disease,  or  pulmonary 
hypertrophic  osteoarthropathy^  is  an  enlargement  of  the  Ijonesof  the  forearms, 
hands,  legs,  and  feet  from  ossifying  osteoperiostitis,  and  occurs  in  association 
with  chronic  lung  disease. 

The  symptoms  are  aching  pain,  worse  at  night  and  increase{l  by  pressure, 
palpable  thickening  of  the  periosteum  in  subcutaneous  bones,  and,  in  the 
event  of  suppuration,  edema  and  redness  of  the  skin  and  later  softening  of 
the  swelling.  After  the  al>scess  has  been  opened,  denuded  bone  may  be 
felt,  which,  as  a  rule,  undergoes  caries  or  necrosis  to  a  variable  extent,  and 
is  removed  by  the  surgeon  or  separated  by  nature.  In  the  presence  of  sup- 
puration there  will  be  constitutional  symptoms  of  sepsis.  In  ehrmiic  periosti- 
tis, in  the  absence  of  suppuration,  there  may  be  no  symptoms  but  a  tender 
swelling  of  the  bone.  Ossifying  periostitis  may  produce  exostoses  or  osteo- 
phytes,  particulariy  about  a  chronically  inOamed  joint. 

The  treatment  of  acute  periostiris  is  rest,  elevation,  and  heat  locally. 
Constitutional  treatment  is  directed  towards  any  existing  diathesis.  Sup- 
puration demands  incision  and  drainage.  Chronic  periostitis  is  treated  by 
iodin  or  by  mercurial  ointment  locally,  and  potassium  iodid  internally,  even 
in  the  absence  of  a  syphilitic  taint.  The  cause  should,  of  course,  be  removed 
if  possible.  Removal  of  newly  formed  bone  or  osteophytes  is  occasionally 
in<bcated. 

Acute  osteomyelitis  is  also  described  by  some  authors  under  the  follow- 
ing headuigs:  acute  infective  osteomyelitis,  acute  septic  osteomyelitis,  acute 
diffuse  infective  periostitis,  acute  diaphysitis^  acute  panostitis,  acute  necrosis. 
Perhaps  panostitis  is  the  l>est  term,  as  all  the  structures  of  the  bone  are  sooner 
or  later  involved. 

The  cause  is  always  infection  by  micro-urganisms,  among  which  are 
the  staphylococcus,  streptococcus,  pneumococcus,  gonococcus,  typhoid 
bacillus  and  the  l>acillus  colt  communis.  Bacteria  may  gain  entrance  through 
a  wound,  e.g.,  in  compound  fracture,  amputation,  osteotomy,  etc;  or 
infection  may  extend  from  neighboring  tissues,  or  come  by  way  of  the  blood, 
e.g.,  in  infectious  fevers,  notably  measles  and  scarlet  fever.  Typhoid 
osteomyelitis  is  always  subacute  i^r  chronic.  When  osteomyehtis  occurs  in  a 
healthy  individual  without  an  open  wountl,  the  organisms  are  supposed  to 
have  entered  the  blood  through  the  tonsils,  or  through  the  respiratory,  in- 
testinal ,  or  genitourinary  mucous  membranes.  In  some  of  these  cases  chilling 
uf  the  body,  or  a  strain,  sprain,  or  contusion,  precedes  the  outbreak  of  symp- 
toms. Children  are  peculiarly  liable  to  this  form  of  osteomyelitis,  the  process 
usually  starting  in  the  end  of  the  diaphysis,  rareiy  in  the  epiphysis  {aiute 
epiphysHis),  The  neighboring  joint  is  apt  to  be  involved  if  the  epiphyseal 
line  lies  within  the  *  apsulc  Uicttte  inftSfttile  artltrifis).     In  the  diaphyseal  end 


1 


286  ^B^^I^HP  BONES. 

of  growing  bone,  or  metaphysis  as  it  is  sometimes  called^  the  vessels  are  ar- 
ranged  in  terminal  loops,  which  retard  the  blood  stream  and  favor  the  depo- 
sition  of  organisms;  moreover^  this  region  is  more  exposed  to  injuries  from 
wrenches  or  twists.  The  fa%^orite  sites  for  osteomyelitis  are  where  the  great- 
est growth  in  length  takes  plare^  viz,,  the  lower  end  of  the  femur,  the  upper 
end  of  the  tibia,  the  npper  end  of  the  humerus,  and  the  lower  end  of  the  radius. 
Although  it  is  possible  for  the  mildest  cases  to  terminate  without  suppuration, 
such  an  event  is  of  rare  occurrence.  As  a  rule  suppuration  of  the  medulla 
occurs,  and  pus  appears  in  the  Haversian  canals  and  finally  lifts  the  perios- 
teum from  the  bone,  thence  infiltrating  the  surrounding  tissues.  Necrosis 
of  a  portion  or  of  even  the  entire  shaft  follows.  Involvement  of  more  than 
one  bone  is  uncommon  {muUlplt  osteomyelitis) ^  and  occasionally  the  disease 
reappears  in  the  same  situation  {osteomyelitis  recidiva). 

The  symptoms  are  sudden  in  onset,  generally  beginning  with  a  chill, 
which  is  followed  by  high  fever.  The  limb  is  painful  and  tender^  and  soon 
becomes  hot,  swollen,  and  edematous.  The  superficial  vessels  are  distended, 
and  finally  pus  may  make  its  way  to  the  surface  and  g  e  rise  to  fluctuation. 
If  there  is  a  wound  the  discharge  will  be  copious  and  ofl'ensive  and  the  bone 
tender.  It  may  be  possible  to  see  the  thick,  red,  and  separated  periosteum 
and  the  fungous  suppurating  medulla.  The  X-ray  may  show  a  subperios- 
teal exudate,  liut  acute  osteomyelitis  ought  to  be  recogniified  clinically  long 
before  there  is  sufficient  destruction  of  bony  tissue  to  show  in  a  skiagraph. 
The  constitutional  symptoms  are  those  of  septicemia  or  pyemia,  and  these 
may  predominate  and  mask  the  local  phenomena,  so  that  a  diagnosis  of 
typhoid  fever  or  some  similar  condition  may  be  made.  The  adjacent  joint 
is  often  swollen,  usually  with  sterile  serum,  sometimes  with  pus. 

In  the  mildest  cases  of  osteomyelitis  the  only  symptoms  are  pain  and  slight 
fever.     The  so-called  growing  pains  are  supposed  to  be  due  to  this  cause. 

The  diagnosis  may  be  ditticult,  but  is  most  frequently  not  made  because 
of  an  incomplete  or  careless  examination.  RJietimatism  alTects  more  than  one 
joint,  the  tenderness  is  most  marked  in  and  not  above  or  below  the  joints  the 
local  phenomena  are  less  marked,  and  the  constitutional  symptoms  are  less 
serious.  Gonorrheal  rhaimatism  is  preceded  l>y  gcmorrhea  and  does  not  give 
tenderness  in  the  l)one.  Typhoid  fei^er  is  slow  in  onset  and  does  not  present 
local  bony  symptoms  in  the  early  stages;  the  blood  shows  the  Widal  reaction, 
and  a  leukopenia  instead  of  a  high  leukocytosis.  Tuhercidous  arthritis  starts 
in  the  epiphysis,  not  in  the  diaphysis;  the  onset  is  slow,  and  the  local  and 
constitutional  symptoms  much  less  severe.  CeUulitis  is  always  associated 
with  a  wound,  the  swelling  does  not  involve  the  bone,  and  on  incision,  which  is 
the  proper  treatment,  the  periosteum  and  bone  are  found  unaffected.  In 
infantile  scurvy  the  bone  is  tender  and  enlarged,  but  many  bones  are  apt  to  be 
involved,  and  there  are  other  evidences  of  rickets,  with  marked  anemia, 
swollen  and  bleeding  gums,  and  perhaps  normal  temperature. 

The  prognosis  is  always  grave.  Death  may  occur  from  septic  absorp- 
tion before  the  local  signs  are  well  marked.  Later  dangers  are  exhaustion  and 
amyloid  disease.  The  neighboring  articulation  may  be  destroyed,  resulting 
in  cither  ankylosis  or  tlail  joint;  growth  of  the  limb  may  be  checked  from 
involvement  of  the  epiphyseal  cartilage;  or  it  may  l>e  necessary  lo  remove  the 
liml}  because  of  septic  symptoms,  or  because  repair  of  the  bone  is  impossible 
owing  to  destruction  of  the  periosteum. 

The  treatment  is  immediate  drainage.     After  making  a  longitudinal 


NECROSIS. 


287 


mdsxon  in  the  soft  parts  the  periasleum  is  reflected,  and  the  medulhi  opened 
with  a  trephine^  gouge,  or  chisel  (Fig.  220).  Sufficient  bone  is  removed  to 
expose  al!  the  infected  medullLi,  thus  in  some  instances  it  is  necessary  to 
chisel  a  gutter  in  the  bone  almost  from  one  end  to  the  other.  In  children, 
excluding  the  rare  cases  in  which  the  epiphysis  as  well  as  the  diaphysis  is 
diseased,  care  should  be  taken  not  to  injure  the  epiphyseal  line,  because  of  the 
danger  of  interfering  with  the  growth  of  the  limb.  The  suppurating  medulla 
is  removed  by  gentle  curettage,  in  order  to  do  as  little  harm  as  possible  to  the 
endosteum,  which  may  possilily  have  some  intluence  in  subsequent  repair. 
The  wound  is  irrigated  with  hot  bichlorid  of  mercury  solution  and  packed 
with  gauze.  The  constitutional  treatment  is  that  of  septicemia.  Should 
drainage  fai!  to  mitigate  the  constitutional  symptoms,  amputation  may  be 
performeti  as  a  life  saving  measure.  The  i real m ait  of  the  subsec|uent 
necrosis  is  given  below. 

Chronic  osteomyelitis  (chronic  ostitis)  follows  the  acute  form  or  is 
chronic  from  the  beginning.  To  the  latter  class  belong  the  chronic  bone  in- 
flammations caused  by  typhoid  fever,  syphilis,  tuberculosis,  actinomycosis, 
leprosy,  and  glanders,  Typfnndal  osieomyeliiis  usually  appears  during 
convalescence,  the  tibia  and  ribs  being  most  frequently  affected.  The  infec- 
tion may  be  a  pure  one  or  mixed  with  pyogenic  organisms.  Like  the  gall- 
bladder and  spleen,  the  medulla  of  bones  may  harbor  typhoid  bacilli  for 
years  before  causing  trouble.  Workers  in  wool,  jute»  and  mother-of-pearl 
may  breathe  in  particles  of  these  substances,  which  finally  lodge  in  the 
medulla  and  cause  sudden  painful  swellings  at  or  near  the  end  of  the 
diaphysis;  suppuration  does  not  occur. 

The  symptoms  of  an  osteomyelitis  which  is  chronic  from  the  start  are 
pain,  tenderness,  swelling,  and  but  slight  constitutional  disturbance.  These 
cases  may  terminate  in  suppuration,  or  in 
hypertrophy  of  the  bone  {(fxteosdcrosisy  cmi- 
tUnsing  ostiiis):  in  the  former  the  X-ray 
shadows  are  less  dense,  in  the  latter  more 
dense  than  nnrmaL 

The  treatment  is  rest,  ichthyol  or  mer- 
curial ointment  locally,  and  iodid  of  potas- 
sium inlemally.  If  these  measures  fail  or  if  pus 
forms,  the  bone  should  be"opened  and  d  rained. 

Necrosis,  or  gangrene  of  bone,  is  death  of  a  portion  of  bone  en  masse. 
The  dead  portion  (sequfstritm)  varies  in  size  from  a  small  superficial  flake, 
such  as  follows  suppurative  periostitis,  to  a  mass  representing  the  entire  shaft 
of  the  bone,  such  as  not  infrequently  follows  acute  osteomyelitis. 

The  causes  are  acute  and  chronic  intlammations  of  the  periosteum,  Ixine, 
ajid  medulla.  Removal  of  periosteum  in  the  absence  of  inflammation  does 
not  induce  necrosis.  Injury  to  the  nutrient  artery  or  the  lodgment  of  an 
embolus  is  rarely  a  cause  of  necrosis.  Phosphorus  and  mercury  may  cause 
necrosis  of  the  lower  jaw,  particularly  in  the  presence  of  carious  teeth,  which 
j permit  infection  of  the  bone  whose  nutrition  is  altered  by  the  poison.  Quirt 
necrosis  is  a  rare  condition  following  injury;  it  is  unaccompanied  Ijy  sup- 
puration. 

The  sfquestrum  separates  from  the  living  hune  by  a  line  uf  ulceration  or 
demarcation  much  the  same  as  in  gangrene  u(  soft  parts.  The  surrounding 
living  bone  usually  undergoes  a  condensing  nstitis  and  liecomes  much  harder 


Fig.  2i8.^«i    Sequestrum i  p,  in* 
volucrum;  </,  ctoaat!.    (Billroth.) 


'/V, 


2»:yrLT. 


t.         r.i.l  t.:.:  y^y^^nu  *»fj'iii:ren  aiiiv  be  discharged  spontane- 

;/*.•   i  .:  ■  .•:    v:li_-  ^ir""ri."-L7  -tszscs  iz.  iH  but  very  small  aseptic 

•    .  -    -      .T.-u^.*  i-.s.rzo-.c.  -virMot  suppuration  is  possible. 

"..i  -    ;:  ..-t-rrt   -c  '..-Kimllj  jxaied.  spontaneous  discharge 

•  *    «.•  :     .•^■;  ..-it  *  :,\'.^ ,i3.t:  =iat  continue  for  years.    The 

r    I  -..   -.     -r-.-."-.^  -t-t  ievirf^rir:  in  these  cases  is  called  the 
.»r.  >.*.'-* 'T.  in-:  -i:^  anas  leading  from  the  surface 
:    » -  : .  zs*  li-'frr  ir.  ^hich  the  sequestrum  lies  is 
i..-^-:  '.r.t  \*:'2»:z   Fiz.  21^1, 

T  .'.^  symptoms  or  necrosis  are  a  discharging  sinus 
',r  rir.-L'r^  T»h::h  have  resulted  from  a  preceding 
• '.  '^yj.  za,::  ve  in  n^ mmation  of  the  bone.  The  necrotic 
rr.a-^  may  ?>e  fell  by  the  probe  or  demanstzated  hj 
the  X-ray.  In  a  skiagraph  a  sequestrum,  became  of 
it-,  [x^ro-^ity.  appears  as  a  light  shadow,  sunomidcd 
by  a  dear  area,  representing  the  cavitj  in  which  it 
lies  I'hig.  219;. 

The  treatment  in  the  eariy  stages,  that  h,  after 
providing  ample  drainage  for  the  sumniiatifeiBflui- 
mation  which  has  induced  the  necrosis^  ialnqiat 
antiseptic  irrigations  and  dressings  mitfl 
trum  has  separated,  or  at  least  until  the 
process  has  reached  an  end.  This  time  ^aiki  with 
the  iiffc  and  general  condition  of  thepaticB^lkBwe 
and  situation  of  the  sequestrum,  and  thfTipiMe  of 
tlie  necrosis.  Generally  speaking  the  *^ 
for  sequcstrotomy,  i.e.,  removal  of  the 
two  or  three  months  after  the  original 
drainage.  The  bone  is  exposed  by 
sion,  the  periosteum  retracted,  sufficient 
riMUovod  by  gouge  or  chisel,  the  dead  bone 
with  fonops  (Fig.  220),  and  the  cavity  injgitfad irith 
an  antiseptic  solution  and  packed  with  iodoftm 
^au/e.  If  the  sequestrum  has  not  sqiaiatady  the 
^leail  Inme  must  be  chiseled  away.  Dead  faoBcii 
sotUT  tlian  normal,  often  whitish  in  appeanuioe^ nd 
I  «•       I*     M.tu;<.\|«ii    «loo<  not  bletxi  when  cut.    If  the  cavity  is  nnll  it 

•' * ,»'n.x»:!ii-.    j^ipi^iiv  nlU  with  stimulations,  which  are  uhimitdr 

•;;;;;.,;;;^^''';V::;./:- ■    utI.u.v.  by  Ivne/  if  it  is  large,  healing  is  vciydo;, 
'.,  n..  ....  ^  ItK-v-.o  ;hc  :ollowinc  methods  to  assist  repair.    The 

..;\v.\   h,is  :vc::  r.Ued  with  aseptic  sponge,  decald- 

A   I inp      x\r.::.i  ;v.\-^.;,   :\.;>:or-^^*:- Paris,  bbmuth    paste   (p.  79), 

,1    \  i.'...i  .:»M    i»M\-;.-.v  .^    :v.;  •■ '.  .1::.:  ^v.oform,  etc.,  but  owing  to  the 

.   .  .X ...».-'    x../-    ".^i^",;  >  ...:  >:rr.ply  as  foreign  bodies  and  aie 

M ii  ...  .*■»!. X,       Ka*-^    ".■;  iT.  er.A>uraging  results  haw  been 

,  n . .    J  vx  •  1 ' '  *  ^  *  "'^         •     >".,*:,  ->:>:>  of  iodoform  20  parts,  sper- 

,     ..  , •    ^»  V.  •„•..- .v--^      The  cavity  is  rendered  dty and 

'..    .   \      >      ,  .  »v     .*  X.*    V*     ;«  -"^>".  i~  10  the  cavity  and  allowed 

..I       J  '     XX    \  >.     «.-   :.-i  nfpXaced  by  fibrous  tissue 

\  vv  .    ^^  ^fi  ■T'-klls  of  the  cavity  by  nails 

.       *       '  -r* -ike  depression  lined  vith 


NECROSIS. 


289 


skin.  Skin  grafting  has  been  used  with  a  simitar  idea.  In  a  case  in  which 
part  of  the  tibia  had  been  lost,  Morton  united  the  lower  ends  of  the  bones  of  a 
dog*s  leg  to  the  upper  end  of  the  tibia,  and  five  weeks  later  amputated  the 
dog's  leg  and  placed  the  bones  in  contact  with  the  astragalus.  A  useful  leg 
resulted,  Huntington  closed  a  defect  in  the  tibia  by  severing  the  fibula  at  its 
upper  end  and  placing  it  in  contact  with  the  upper  end  of  the  tibia.  After 
onion  had  occurred  the  lower  end  of  the  libula  was  transferred  to  the  lower 
end  of  the  tibia.     We  have  filled  a  gap  in  the  lower  end  of  the  tibia  by  trans- 


i  ;^^^^^^^^WSi*** 


Fio.  J20.— (1)  rcriosteal  separator,  {2)  lion-jawed  forceps^  (3 J  cureile,  i^)  sequestrum 
forceps  {5)  Macewcn's  osteotome,  (6)  chisel,  (7)  gouge,  (8)  chain  saw,  (9)  bone  cutting 
fcwreps, 

planting  a  metatarsal  hone,  with  the  skin  and  soft  tissues  which  cuvercfl 
it.  WTien  the  periosteum  has  not  been  destroyed,  it  can  conlidently  be 
expected  to  replace  even  the  entire  shaft  of  the  bone.  Nichols  has  re- 
cently investigated  this  subject  and  the  following  is  from  his  paper:  *'The 
operation  consists  of  an  incision  through  the  skin  and  ossified  periosteum 
down  to  the  necrotic  shaft*  retlexion  of  the  periosteum,  removal  of  the  shaft, 
either  entire  or  partial,  folding  of  the  plastic  periosteum  in  such  a  way  as  tu 
approximate  the  internal  layers,  suture  of  the  edges  by  absorbable  sutures, 
^9 


290 


BONES. 


I 


suture  of  the  soft  tissues,  with  pro%ision  for  moderate  drainage  and  complete 
immobilization."  The  shaft  is  sufficiently  solid  for  use  in  from  four  to  eight 
months.  In  regions  such  as  the  thigh  or  arm  where  there  is  no  companion 
bone  to  act  as  a  splint  and  maintain  the  length  of  the  limb,  one  should  wail 
until  the  periosteal  shell  of  regenerating  hone  is  sufruiently  advanced  to  pre- 
sence the  contour  of  the  limb  and  prevent  .shortening.  This  stage  is  reached 
when  the  periosteal  shell  as  determined  by  the  X-ray  is  equal  in  thickness  to 
one-fourth  of  the  diameter  of  the  original  shell . 

Caries  {oskoporosisy  rarefying  osliiist  ukeraiimi  ofbmte)  is  molecular  death 
of  bone.  The  bone  is  soft  and  honey- combed,  and  crumbles  when  pressed 
upon  by  a  probe.  Caries  is  the  result  of  intlammalion,  particularly  that 
form  due  to  syphilis  or  tuberculosis.  The  ulceration  which  separates  living 
bone  from  dead  is  a  form  of  caries.  The  spaces  in  carious  bone  (Hawship^i 
iacumr)  are  the  result  of  suppuration,  or  absorption  by  large  giant  cells 
(osteoclasts).  Caries  sia  a  is  caries  without  suppuration.  In  caries  fun  gosa 
there  is  an  excess  of  granulation  tissue.  Caries  necrolica  is  the  form  in  which 
small  crumbling  fragments  are  discharged.  The  symptoms  of  caries  are  those 
of  necrosis,  except  that  the  probe  delects  rough  and  fria!>le  bone  instead  of  a 
firm  sequestrum. 

The  treatment  is  exposure  of  the  l)one,  and  removal  of  the  diseased  tissue 
with  curette  or  gouge,  the  cavity  being  filled  with  iodoform  gauze.  The 
limits  of  the  disease  are  reached  when  the  bone  becomes  pink  and  firm  and 
bleeds  on  cutting. 

Tuberculosis  of  bone  may  be  generalized  in  the  course  of  acute  miliary 
tuberculosis.  Localized  tuberculosis  is  most  frequent  in  early  life^  and 
usually  follows  infection  in  some  other  portion  of  the  body,  notably  the  lungs 
and  the  lymph  glands.  It  begins  in  the  periosteum,  or  more  frequently  in  the 
cancellous  tissue  of  short  bones  or  the  epiphyses  of  long  bones.  Tuberculosis 
of  the  phalanges  is  called  tuherrulous  dtictyliiis,  or  spina  ventosa  (Fig.  221). 
Occasionally  the  disease  begins  in  a  joint  and  secondarily  involves  the  bone. 
The  pathology  is  much  the  same  as  that  of  tuberculosis  elsewhere,  the  tuber- 
culous mass  undergoing  caseation  and  liquefaction,  and  being  surrounded  by 
a  zone  of  inflamed  bone.  The  diseased  bone  may  separate  as  a  sequestrum, 
but  as  a  rule  it  undergoes  caries,  which  progressively  invades  the  surroimding 
bone.  When  the  process  remains  localized  and  undergoes  suppuration,  it 
forms  an  abscess  (Brodie's  abscess),  which  is  lined  by  a  pyogenic  membrane 
and  surrounded  by  a  zone  of  condensing  ostitis.  Such  abscesses  are  most 
frequent  in  the  ends  of  long  bones,  particularly  the  tibia  and  femur.  Trau- 
matism, often  slight  in  nature,  frequently  determines  the  site  of  the  lesion. 

The  symptoms  are  boring  pain,  tenderness,  and  thickening  of  the  bone. 
The  X-ray  will  show  the  disease  as  soon  as  the  process  of  disintegration  is 
advanced  far  enough  to  lessen  the  density  of  the  bone  and  long  before  the 
clinical  period  of  softening.  If  allowed  to  progress^  the  cbsease  invades  the 
neighboring  joint,  or  the  pus  linds  its  way  to  the  soft  parts  about  the  bone  and 
finally  presents  itself  beneath  the  skin,  sometimes  a  long  distance  from  its 
point  of  origin.  After  the  abscess  breaks  or  is  opened,  infection  with  pyo- 
genic organisms  causes  hectic  fever,  and  in  neglected  cases  this  leads  to  ex- 
haustion or  amyloid  disease. 

The  treatment  is  removal  **f  the  diseased  lissue  by  g*>uge,  curette,  excision, 
or  in  some  cases  even  by  amputation.  Iodoform  is  used  in  the  wounds,  and 
the  general  health  built  up  as  much  as  po&%vblt  {^.  1^5),     In  the  early  stages 


RICKETS. 


291 


before  the  fonnation  of  pus,  or  in  the  later  stages  if  the  site  of  the  disease 
is  inaccessible,  the  affected  parts  are  immobilized  by  plaster-of-Paris  or  by 
other  means,  and  a  cure  sometimes  obtained. 

Syphilis  of  bone  occurs  in  the  secondary  and  tertiary  periods,  and  like 
tuberculosis,  the  site  is  often  determined  by  trauma.  In  the  secondary  stage 
osteocopic  pains  occur,  apparently  with  no  organic  change  in  the  bones. 
The  periostitis  of  the  second  stage  results  in  resolution,  rarely  in  suppuration, 
and  most  frequently  in  ossification  of  the  exudate,  leaving  a  permanent  node. 
In  the  tertiary  stage  the  bone  may  become  the  seat  of  a  condensing  ostitis, 
or  gummata  may  form  in  the  periosteum,  bone,  or 
medulla,  the  skull,  sternum,  and  tibia  being  the 
favorite  sites.  With  appropriate  treatment,  the 
gummatous  material  may  be  absorbed,  but  fre- 
quently degeneration  occurs  and  the  puruloid 
material  ultimately  evacuates  itself  through  the 
skin.  The  bone  is  then  carious  and  worm-eaten, 
and  beyond  this  there  may  be  a  zone  of  sclerotic 
osseous  tissue.  Necrosis  occurs  in  some  cases 
owing  to  the  constriction  of  the  vessels  by  the  sur- 
rounding sclerotic  tissue;  the  sequestra  in  such 
cases  may  not  separate  for  years.  Should  sepsis 
supervene,  the  soft  parts  become  infiltrated  with 
foul  smelling  pus,  which  in  the  skull  may  spread 
to  the  brain  or  its  membranes.  As  in  tuberculosis, 
amyloid  disease  may  appear.  Syphilitic  dactylitis 
(Fig.  221)  occurs  in  the  late  secondary  stage  as  a 
periostitis,  or  in  the  tertiary  stage  as  a  gummatous 
osteomyelitis. 

Congenital  syphilis  produces  the  same  bone 
lesions  as  the  acquired  form.  The  site  of  the 
disease,  however,  is  more  often  influenced  by 
rapid  growth  than  by  traumatism,  hence  the  frequency  of  syphilitic 
epiphysitis y  or  osUachondritis  as  it  is  sometimes  called.  The  ends  of  the 
bones  enlarge  in  these  cases,  and  present  some  resemblance  to  rickets. 
The  swellings,  however,  occur  much  earlier  in  life  than  rickets,  are 
associated  with  other  symptoms  of  syphilis,  and  are  influenced  by  syphilitic 
treatment.  Suppuration,  separation  of  the  epiphysis,  and  deformity  may 
follow.  Periosteal  nodes  occur,  and  when  situated  about  the  anterior 
fontanelle  are  called  Parrot* s  trades.  Craniotahes  is  a  thinning  of  the 
calvarium,  which  may  crackle  on  pressure.  Occasionally  a  bone  is  stimu- 
lated to  overgrowth,  and  when  there  is  a  companion  bone,  as  in  the  forearm 
or  leg,  marked  curvature  results. 

The  treatment  is  that  of  syphilis.  Sinuses  should  be  kept  clean  lest 
septic  symptoms  supervene.  Necrotic  or  carious  bone  is  treated  as  already 
indicated. 

Rickets,  or  rachitis,  is  a  constitutional  disease  due  to  malnutrition,  and 
often  associated  with  bad  hygienic  surroundings  and  improper  diet.  It 
usually  occurs  during  the  first  three  years  of  life.  The  so-called  congenital 
rickets  is  generally  achondroplasia  or  osteogenesis  imperfecta. 

The  symptoms  in  the  early  stages  are  disorders  of  digestion,  anemia,  sweat- 
ing about  the  head,  swelling  of  the  abdomen,  andenlarg^tm^YvloixVv^v^Vfcfcxv 


Fig.  221. — Spina  vcntosa, 
so  called  because  of  the 
Bask-like  inflation  of  the 
bone;  it  may  be  due  to  any 
of  the  causes  of  bone  in- 
flammation, but  is  usually 
syphilitic  or  tuberculous. 


292 


BONES. 


L 


The  important  changes  are  those  in  the  bones  (Fig.  222),  in  which,  althougb 
there  is  an  active  proliferation  of  the  cellular  elements,  prompt  calciJicatian 
does  not  occur.  The  epiphyses  are  swollen  and  tender,  and  the  shafts  of  the 
long  bones  softened^  Later  ossification  occurs,  frequently  with  deformity. 
The  head  l>ecomes  square  and  the  frontal  eminences  prominent,  the  fontan- 
elles  and  sutures  close  late,  and  craniotabes  may 
occur.  Eruption  of  the  teeth  is  delayed,  and  they 
are  often  dwarfed,  deformed,  and  the  seat  of  early 
caries.  The  spine  may  become  curved  and  the 
chest  *' chicken-breasted."  The  ribs  are  enlarged 
al  their  junctions  with  the  costal  cartilages 
(raihiiic  rosary)^  and  there  may  be  a  marked 
groove  extending  from  the  axilla  down  towards 
the  end  of  the  .sternum  {Harrison's  sulcus) .  The 
pelvis  may  be  distorted  and  the  limbs  curved, 
e.g.,  bow-legs,  knock-knee,  etc.  Growth  of  the 
entire  body  is  often  defective. 

The  treatment  is  correr  tion  of  the  diet»  fresh 
air,  sujTshine,  and  attention  to  the  Ixmels,  together 
with  cod -liver  oil,  syrup  of  the  jodid  of  iron,  and 
hypophosphites.  Deformities  are  prevented  by 
keeping  the  patient  in  bed,  and  they  are  corrected, 
while  the  bones  are  soft,  by  daily  manipulations 
and  iiraces.  After  two  or  three  years  deformities 
usually  require  osteotomy  or  other  form  of  opera- 
tion. 

Scurvy  rickets  {aiute  riikd^,  inJantUc  scurvy, 
MwUrr-Barlaw  disease)  is  a  combination  of  rickets 
and  scurvy,  either  of  which  may  predominate.  It 
is  most  frequent  in  the  children  of  the  well-to-do, 
and  arises  from  malnutrition  resullnig  from  the 
administration  of  artificial  foods.  The  symptoms 
of  rickets  may  or  may  not  be  marked  when  the 
scoriiUlic  features  predominate.  There  may  be 
sfKmgy,  lileeding  gums,  and  bleeding  from  the 
mucous  membranes,  beneath  the  skin  or  perios- 
teum, or  into  the  muscles  or  joints.  An  epiphysb 
is  sometimes  separated  from  a  diaphysis  by 
Fig.  2::.  Sri.  ;.,i.  of  a  liemorrhage,  and  the  pain  and  swelling  caused 
child  six  years  oki,  showing  Ijy  this  or  by  bleeding  l>eneath  the  periosteum* 
ihc  osseous  changes  of  rickets,  particularly  when  associated  with  fever,  mav  be 
HmpUau'''  ^^''^"^>''''^"^^  mistaken  for  acute  osteomyelitis  (q.v.).  Recovery 
occurs  in  91  per  cent,  of  the  cases.  The  treaimtni 
is  fresh  milk,  beef»  or  lime  juice,  and  the  juice  of  oranges,  lemons,  grapes,  or 
apples.  A  painful  limb  should  be  kept  quiet,  and  in  some  cases  bandaged  or 
splinted. 

Achondroplasia  {chmtdrodystropia  fdalis,  micromdia)  is  a  rare  con- 
genital  disease  characterized  by  defective  development  of  certain  portions 
of  the  skeleton.  Death  at  or  soon  after  Inrth  is  the  rule,  aUhough  in  a  few 
instances  adult  life  has  been  reached.  I1ic  trunk  is  of  normal  length,  but 
the  hones  of  the  limbs  are  short  and  \iQ\\ed,  and  abnormally  thickened  at  the 


HYPEHTHOPHY   OF    BONE. 


293 


points  where  the  muscles  are  altached .  All  the  fingers  are  fif  the  same  length, 
and  a  wide  interval  exists  between  the  second  and  third  fingers,  giving  rise  tn 
the  *^ trident  hand.**  The  base  of  the  nose  is  depressed  and  the  vault  of  the 
cranium  large,  but  the  intelligence  is  in  no  way  impaired.  The  pelvis  is 
small,  the  belly  prominent  owing  to  lumbar  lordosis,  and  the  genitals  normal. 
Rickets  differs  from  this  condition  in  thai  h  is  post-natal;  the  hones  are  soft, 
not  hard;  the  trunk  is  affected;  there  is  no  pug  nose;  and  the  cranium  is 
Ijossed.  In  cretinism  the  intelligence  is  defect ive»  the  hair  scanty  and  coarse ♦ 
and  the  patients  improve  after  taking  thyroid  extract.  Syphilitic  pug  nose  is 
due  to  Ixme  disease,  not  to  premature  union  of  the  liones  at  the  base  c>f  the 
skull  as  in •  achondroplasia.     There  is  no   treatment   for  achondroplasia. 

Atrophy  of  boot  may  be  congenital;  or  it  may  be  due  to  inriammation; 
disease  or  injury  of  the  epiphysis;  disuse;  pressure,  e.g.,  from  a  tumor  or 
aneurysm;  or  to  disease  or  injury  of  the  nervous  system,  e.g.,  tabes,  section  of 
nerves,  syringomyelia,  paresis  and  other  forms  of  insanity.  It  is  normal  in 
old  age,  as  is  best  seen  in  the  cranium,  lower  jaw,  and  neck  of  the  femur. 
Atrophied  bone  breaks  easily,  so  that  one  should  bear  the  above  causes  in 
mind  during  forcible  manipulations,  such  as  are  employed  in  breaking 
joint  adhesions,  etc. 

Fragilitfts  ossiunif  or  osteopsathyrosis,  is  a  condition  in  which  there 
is  an  alinormal  pretJisposition  to  fractures,  even  from  slight  force.  There 
are  two  forms,  the  iditrpathic  and  the  symptomatic.  Idopathic  fragilitas 
ossitim  is  congenital  and  often  hereditar)*.  In  some  cases  {osieogenesis 
wiper/rrta)  fractures  occur  before,  during,  or  soon  after  birth,  and  the  children 
are  stilbbom  or  survive  only  a  few  months.  In  others  the  tendency  to  frac- 
tures is  most  marked  between  the  second  and  twelfth  years,  and  usually 
disappears  with  the  advent  of  adult  life.  Union  is  prompt  but  often  with 
considerable  deformity.  The  cause  and  pathology  are  not  known.  The 
symptomatii  Jorm  is  due  to  any  of  the  other  conditions  mentioned  among  the 
pathological  causes  of  fracture  (p.  247). 

Osteomalacia,  or  mollities  ossium,  is  a  disease  in  which  the  bones  be- 
come abnormally  llexible  owing  to  the  absorption  of  calcareous  material. 
It  is  rare  in  the  male  and  peculiarly  frecjuent  in  puerperal  women.  The 
cause  is  not  known.  The  bones  become  distorted  and  break  with  greater  ease 
than  normally;  in  the  latter  instance  non-union  often  occurs.  Of  great  im- 
portance is  deformity  of  the  pelvis,  because  of  the  diflicalties  which  may  arise 
during  labor.  It  is  usually  compressed  laterally,  the  pubes  passing  forwards, 
thus  giving  it  a  triangular  shape.  The  patient  is  weak  and  emaciated,  and 
complains  of  pain  in  various  parts  of  the  skeleton.  Death  after  many  years 
is  the  usual  result,  although  recover}^  occasionally  occurs.  The  trealmeni  is 
tonic  and  stinrulating,  with  phosphates,  cod -liver  oil,  and  Ixme  marrow. 
Braces  may  be  needed,  and  means  should  be  taken  to  prevent  pregnancy. 
Removal  of  the  ovaries  sometimes  results  in  cure. 

Hypertrophy  of  bone  may  be  congenital,  or  it  may  be  due  to  increased 
use,  e.g.,  where  muscles  are  attached,  or  to  increased  nutrition  the  result  of 
inflammation.  (Jiant  growth  of  the  fingers  or  toes  (macrodactylia),  of  an 
entire  limb,  or  of  the  entire  body,  may  be  congenital  or  acquired;  the  cause  is 
not  kno\^^l,  Progressive  hypertrophy  of  the  bones  of  the  skull  is  called 
Uantiasis  ossium  (Fig,  223).  It  begins  in  early  life,  and  terminates  fatally 
after  a  number  of  years,  sometimes  from  compression  of  the  l>rain.  No 
curative  treatment  is  known. 


BONES. 


Acromegaly  is  a  skdelal  o%'i*rgru\vih  Hue  to  tumor  or  hv^rtrnphy 
of  the  pituitary  body.  All  parts  of  the  IkkIy  are  enlarged^  pardcularly  ihc 
forearms,  hands,  legs,  and  feet,  as  well  as  the  jaws,  lips,  nose,  and  orbital 
ridges.  The  hands  are  spade-shaped  and  ihe  fingers  have  been  compared 
to  sausages;  the  face  is  triangular  with  the  base  downwards  (the  face  of 
Paget 's  disease  is  triangular  with  the  base  upwards,  that  of  myxedema  is 
moon-shaped).     The  thyroid  gland  is  often  enlarged  and  arteriosclerosis 

is  not  uncommon.  The  princi- 
pal symptoms  are  headache  and 
malaise.  The  disease  is  fataJ, 
usually  after  many  years.  The 
Inatmcni  is  sympiomatic,  unless 
evidences  of  tumor  of  the  pitui- 
tary body  be  present,  when  its 
removal  is  indicated  (sec  p,  353). 
Airamkria  is  the  reverse  of  acro- 
megaly, and  is  very  rare. 

Ostitis  deformans,  or 
Paget^s  disease,  consists  of  en- 
largement or  softening  of  I  he 
Ixtnes,  usually  after  the  age  of 
forty.  The  cranium  enlarges 
but  the  facial  bones  are  not  in- 
volved, the  face  being  triangular 
with  the  base  upwards.  The 
patient  diminishes  in  height 
owing  to  kyphosis  and  outward 
curvature  of  the  lower  extremi- 
ties. The  chest  is  sunken  and 
the  pelvis  broadened.  The  pa- 
,tient  complains  of  rheumatic 
pains  and  has  an  awkw^ard  gait. 
The  disease  is  very  slow*  in 
progress.  Multiple  sarcomata 
The  treaimefU  is  symptomatic,  no 


Fig.  223. 


-LtfonLiasis  ossium. 
Hospital) 


(Pennsylvania 


I 


of  the  bones  develop  in  some  cases, 
remedies  being  known. 

Tumors  of  bone  may  be  benign  or  mahgiiant.  The  benign  tumors  are 
osteoma,  chondroma  (p,  143),  fibroma ^  lipoma,  myxoma,  and  angioma. 
The  only  priman'  malignant  tumor  of  bone  is  sarcoma,  although  it  may  be 
invaded  secondarily  by  carcinoma  (especially  from  the  breast,  thyroid,  and 
prostate)  and  sarcoma.  Metastatic  osseous  growths  are  sometimes  the 
first  sign  of  hypernephroma. 

Periosteal  sarcomsi  is  of  the  spindle-  or  roimd*celled  variety,  grows 
rapidly,  and  causes  early  metastases,  although  it  may  undergo  more  or  less 
complete  ossification,  as  shown  in  Fig.  224.  Central  sarcoma,  beginning  in 
the  osseous  tissue  or  medulla,  causes  expansion  of  the  bone,  and  is  usually 
found  near  the  end  of  a  long  bone,  but  rarely  invades  the  joint.  If  of  the 
round-  or  spindle-celled  variety  the  degree  of  malignancy  is  high,  if  giant- 
celled,  or  myeloid,  it  is  comparatively  benign.  The  overlying  bone  may  be- 
come so  thin  as  to  crackle  on  pressure,  and  spontaneous  fracture  is  not 
unusual.     In  all  forms  ui  sarcoma  pulsation  may  occur  owing  to  the  great 


TUMORS   OF    BONE.         ^^^^^^^  295 

amy,  and  some  degree  of  ossilicalion  is  usually  pn-sfnt;  the  superlirial 
s  are  disleiujed  and  clearly  evident  beneath  the  whitened  skin.     He  mar- 
aagic  infiltration  and  tyslic  degeneration  are  of  frequejit  onurrence. 

The  diagnosis  may  be  very  difiitult,  owing  lo  the  resemblance  to  chronic 
Bteoperiostitis,  or  syphilitic  or  tuberculous  disease  of  Iwne.  Sarcoma  grows 
teadily.  is  irregular  in  contour  and  density,  is  apt  to  pulsate,  causes  disten- 


FiG,  224. — 'SarojiTiii   of   the   femur,   showing   raaid.Lisi)<  spimki*  oi   bLinc 
(Pennsylvania  HospitaK) 

ji  the  superficial  veins,  and  may  give  a  crackling  sensation  on  pressure 
||g  to  thinning  of  the  bone.     The  X-ray  shadow  of  the  tumor  is  often 

j>ly  limited,  while  in  inflammatory  bone  diseases  there  is  apt  to  be  diffuse 

[lottling;  it  shows  absorption  of  bone  in  the  more  malignant  cases,  spicules 
adiating  at  right  angles  to  the  bone  in  the  more  benign  varieties  (Fig,  224). 
)ften  a  positive  diagnosis  can  be  made  only  after  exploratory  incision. 
The  treatment  in  all  but  the  myeloid  form  is  early  amputation  through 


JOINTS* 

the  next  joint  above.  In  the  myeloid  variety  exctsiun  of  the  growth  aJune 
often  results  in  cure,  although  in  some  instances  amputation  well  alx»ve  the 
growth  is  required. 

Cysts  of  bone  are  usually  due  to  degeneration  of  sarcoma  or  myxoma, 
and  occasionally  arise  in  osteomalacia  and  ostitis  deformans.  Dtrmoid 
cysts  are  rare.  Cysts  of  the  jaw  have  already  been  mentioned.  Hydatid 
cysl^  occur,  and  are  to  be  treated  by  removal  of  the  cyst^  or  if  very  extensive 
by  amputation. 


'^^1 


CHAPTER  XX. 

JOINTS. 

INJURIES  OF  JOINTS. 

Wounds  of  joints  should  always  be  regarded  with  apprehension.  Kx-" 
tensive  wounds  are  often  assoiiated  with  dislocation  or  compound  fracture, 
A  small  penetrating  wouikI  may  !>c  recognized  by  the  esiape  of  s)Tiov)aI  duid, 
although  this  may  not  occur  if  the  aperture  is  valvu- 
lar; A  probe  should  not  be  employed.  The  external 
parts  should  be  disinfected,  and  the  joint  immobilized 
with  a  splint,  in  a  position  which  will  give  the  l>est 
function  in  the  event  of  ankylosis.  At  the  first  symp- 
toms of  infection^  viz.,  pain,  swellijig,  fever,  etc,  the 
wound  should  Ite  enlarged,  the  pus  washed  from  the 
joint  cavity  with  sterile  salt  solution,  and  drainage 
with  gauze  or  tubes  instituted.  Resection  or  ampu- 
tation may  be  necessary  if  severe  constitutional 
symptoms  continue.  If  the  joint  is  wounded  by  an 
instrument  which  is  known  to  be  grossly  infected, 
one  should  not  wait  for  the  appearance  of  septic 
symptoms,  but  open,  disinfect,  and  drain  the  joint 
at  once. 

A  sprain  has  been  defined  as  a  self- reduced  dis- 
location; as  the  result  of  a  twist,  some  fibers  of  the 
ligaments  are  stretched  or  lacerated  and  the  s)movial 
membrane  contused.  The  symptoms  are  severe 
pain,  tenderness,  swelling  of  the  joint  from  effusion 
of  blood  and  lymph,  loss  of  function,  and  in  some 
instances  shock.  Many  cases  of  fractures  about 
joints  have  in  the  past  been  diagnosticated  as  sprains. 
If  the  swelling  is  great,  fracture  can  be  excluded  only 
by  the  X-ray. 

The  treatment  during  the  first  twenty-four  hours  is  elastic  compression, 
and  cold  in  the  form  of  an  ice  bag  or  evaporating  lotion,  thus  limiting  effusion. 
Compression  is  best  made  with  a  firm  liandage  over  a  layer  of  cotton.  Later 
absorption  should  be  promoted  by  heat  and  massage.  The  joint  should 
be  kept  at  rest  until  the  pain  and  swelHng  have  disappeared.  Com- 
pression with  a  certain  degree  of  fixation  may  be  obtained  by  applying 
overlapping  strips  of  adhesive  plaster  around  the  joint  as  shown  in  Fig,  225. 


Fig,  2  25. — Strapping  of 
joints.     (Healh.) 


FAt   DISIXX'ATION   OF   THK  mV\ 

Subsequent  stiffoess  may  be  relieved  Ijy  ihe  hot  air  treatment  and  by  frictions 
rwith  stimulating  liniments.  The  ffrogno^is  is  good  in  uncomplicated  cases; 
suppuration  is  rare,  allhough  tuberculosis  may  occur  in  those  prone  to  this 
disease,  and  persistent  pain  and  stiffness  arc  common  in  the  gouty  and 
rheumatic  and  in  the  old.  Absorption  of  the  head  of  the  femur  may  occur 
after  sprain  of  the  hip.     Ankylosis  is  the  chief  danger. 


DISLOCATIONS. 


A  dislocation,  or  luxation,  is  an  abnormal  displacement  of  the  articular 

end  of  a  bone/    Dislocations  may  be  congenital  or  acquiredj  and  the  latter 

may  be  traumatic  or  spontaneous  (pathological). 

Congenital  dislocations  are  usually  due  to  defective  development,  al- 
though it  is  possible  that  a  few  are  due  to  violence  to  the  mother's  abdomen 

iuring  pregnancy,  or  to  a  vicious  position  of  the 
Ichild  in  the  uterus,  the  result  of  tumors,  etc,     ~^ 
f  Although  various  Joints  may  be  affected  in  this 

way,  in  90  per  cent,  of  the  cases  the  hip  is  in- 

volved* 

Congenital  dislocation  of  the  hip  h  more 

frequent  in  females,  both  or  more  commonly 
^one  joint  being  involved.     Damany  states  that 

the  luxation  rarely  exists  at  the  time  o(  birlh. 

but  occurs  during  the  first  year  of  life,  owing  to 
I  an  increased  forward  obliquity  of  the  aceta- 
[bulum  and  an  exaggeration  of  the  normal 
Uorsion  of  the  femur,  thus  causing  a  progressive 
I  displacement  oj  the  head  of  the  femur  when  the 
[thighs  are  extended.  However  this  may  be, 
I  congenital  dislocation  of  the  hip  is  seldom 
[recognized  until  the  child  begins  to  walk.  The 
I  dislocation  causes  atrophy  of  the  abandoned 

acetabulum,  stretching  or  rupture  of  the  round 

Kgament,  shortening  and  ante  version  of  the 
I  neck  of  the  femur,  flattening  of  the  head  of  the 

bone  from   before  backwards,  and  elongation 

with  occasionally  hour-glass  constriction  of  the 

capsule  of  the  joint.     The  limb  is  atrophied 

and  the  muscles  altered  in  length.     The  head 

of  the  bone  almost  invariably  passes  onto  the 

dorsum  of  the  ilium,  thus  causing  shortening 

with  flexion  and  adduction  of  the  thigh,  com- 

pensator)'  obHquityof  the  pehis,  and  anterior 

curvature  of  the  lumbar  spine  (Fig.  226).     In 

bilateral  dislocation  there  is  a  peculiar  waddling  gait,  in  unilateral  cases  there 

is  limping  and  associated  scoliosis.     In  early  cases  the  length  of  the  limb 

may  be  restored  by  traction. 

The  treatment,  when  the  condition  is  recognized  before  the  child  begins 

to  walk  and  before  marked  changes  in  the  soft  structures  occur,  is  con- 

tinous  traction  on  the  limb  to  bring  the  head  of  the  bone  down  to  the  acet- 


Fig.   226. — Bilateral   congenital 
dislocation  of  hip.     (Hopkins.) 


298 


ibuli 


ihile  the  li  ml  I  is  fixed 


JOINTS, 
iljdutli**: 


abulum^  whiJe  itie  limii  is  iixca  in  aiMiutii<m  and  pressure  is  made  over  the 
great  Irurhantcn     This  Irealmeol  must  be  continued  for  six  months  or  a 
year.     At  a  later  pericut,  up  tu  four  or  five  years  in  bilateral  cases  and  aln^ul^ 
seven  years  in  unilateral  cases,  ihf^ Lorenz  bhodltss  method  may  be  tried.     The  ' 
author  of  this  method  claims  50  per  cent,  anatomic  cures*    Under  anesthesia 
the  shortened  muscles  are  stretched  by  flexion,  extension,  and  abduction  of 
the  thigh ^  during  the  last  of  which  the  adductor  muscles  are  powerfully  ] 
kjieadetb     The  head  of  the  bone  is  then  drawn  down  to  the  levd  <>f  the  acet* 
abulum  l>y  traction  on  the  leg,  and  the  thigh  tlcxed  on  the  abdomen,  rotated 
iniemally,  abducted,  and  finally  rotated  outwards  while  pressure  is  made  on 
the  trochanter.     With  the  limb  in  licxionp  abduction,  and  e version,  a  plaster- 
of -Paris  cast  is  applied  to  the  pelvis  and  thigh  as  far  as  the  knee.     The  child 
is  allowed  to  walk  with  the  limb  in  this  position  in  order  to  deepen  ihe  acet- 
abulum.    At  the  end  of  three  months  the  cast  is  removed,  the  flexion  and  | 
abduction  lessened,  and  another  cast  put  on  for  three  more  months. 


Fig.  227. — Dislcxration  of  hip  in  typhoid  fever»  and  large  bed  sore.    (Pennsylvama  Hospitaf ) 

In  children  too  old  for  the  bloiidless  method  Hoffaand  Lorenz  have  each 
devised  a  bloody  metltod.  The  former  opens  the  joint  by  an  incision  similar 
to  that  of  Langenbeck  in  resection  of  the  hip,  severs  shortened  fil>ers  of  mus- 
cle and  fascia,  enlarges  the  acetabulum  with  a  gouge,  reduces  the  dislocation, 
fixes  the  limb  in  eversion  and  abduction  for  a  few  weeks,  and  fmally  straight- 
ens the  limb,  Lorenz  opens  the  joint  from  in  front,  dc»es  not  cut  the  muscles, 
but  severs  the  ham  strings  if  necessary.  The  rest  of  the  operation  is  much 
the  same  as  that  of  Hoflfa. 

Patliological  dislocations  occur  from  slight  force  or  spontaneously,  as 
the  result  of  disease,  such  as  tuberculosis,  osteoarthritis,  Charcot's  disease, 
and  unopposed  action  of  muscles  in  paraly.sis.  Those  occurring  in  the 
course  of  fevers  (Fig.  227)  are  due  to  distention  of  the  joint,  and  are  most 
frequent  at  the  hip,  owing  to  habitual  flexion  of  the  thighs  in  bed. 

Traumatic  dislocations,  like  fractures,  may  be  simple  {dosed),  compound 
{open},  c&mphtc,  imompleie  (subluxation),  or  complicated  (associated  with  in- 
jury of  the  soft  parts,  vessels^  nerves,  or  viscera).  Affacture-disicKalUm  is  one 
associated  with  a  fracture  entering  the  joint  (Fig.  216). 

The  causes  of  traumatic  dislocations  are  predisposing  and  exciting.  The 
predisposing  causes  are  powerful  muscular  developmentj  thus  dislocations 


TRAUMATIC    DISLOCATIONS. 


I 


are  more  frequenl  in  males  and  in  middle  life;  Ditupalions  which  demand 
hard  lalx>r  aB<!  exposure  io  iojury;  siruclure  and  situation  of  the  joint.,  e.g, 
the  shoulder,  which  is  a  lial!  and  sv)cket  joint  ami  expensed  lo  many  injuries; 
and  diseases  or  previous  injuries  of  joints  which  relax  the  ligaments  or  mark- 
edly alter  the  axis  of  the  limb.  The  exciiing  causes  arc  external  violence 
(direct,  or  more  commonly,  indirect)  and  muscular  action. 

The  pathology  consists  of  a  tearing  of  the  ligaments  and  frequently  of 
the  soft  structures  around  the  joint,  owing  to  the  displacement  of  the  articu- 
lating surfaces;  efTusion  of  blood  into  and  about  the  joint;  contusion  of  the 
synovial  membrane  and  articular  cartilages;  and  occasionally  fracture,  or 
compression  or  rupture  of  important  nerves,  vessels,  or  viscera.  If  the  dis- 
location is  reduced*  the  subsequent  traumatic  intlammation  subsides  with 
or  without  adhesions.  If  the  torn  ligaments  are  not  fully  repaired,  there 
is  a  predisposition  to  the  recurrence  of  the  dislocation.  In  an  unreduced 
dislocation  the  organization  of  the  effused  blood  and  exudate  fills  the  normal 
rticular  cavity  with  fibrous  tissue  and  fixes  the  head  in  its  new  situation, 
here,  if  persistent  movements  are  made,  it  may  form  a  pseudoarthrosLw  The 
displaced  head  becomes  more  or  less  deformed,  and  wears  a  hollow  in  the 
bone  on  which  it  rests.  The  surrounding  muscles  atrophy,  and  are  altered  in 
length  to  accomodate  themselves  to  the  new  position  of  the  limb* 

The  symptoms  are  pain,  swelling,  ecchymosis,  rigidity  of  the  muscles,  loss 
of  function,  and  deformity,  as  evidenced  by  the  alteration  in  the  axis  and 
length  of  the  limb,  by  the  disturbed  relations  of  the  bony  prominences  about 
the  joint,  and  by  feeling  or  seeing,  with  or  without  the  X-ray,  the  empty  artic- 
ular cavity  and  the  displaced  bone  in  its  new  situation. 

The  treatment  is  (i)  reduction,  (2)  retention,  (3)  restoration  of  function. 
( T )  Reduction  should  be  made  at  the  earliest  pf)ssibie  period  by  manipulation 
or  extension,  with  or  without  anesthesia,  according  to  the  difficulties  encoun- 
tered. Manifndalion  consists  in  such  movements  of  the  limb  as  will  cause  the 
dislocated  l^me  to  reenter  the  joint  by  the  path  through  the  ^, 
torn  capsule  which  it  has  already  traversed,  hence  it  should 
l>e  employed  whenever  possible,  because  but  little  additional 
injury  is  inflicted  upon  the  tissues.  F^vimsiofi,OT  more  com- 
monly extension  and  counterextension,  are  used  to  draw  the 
dislocated  bone  into  place  despite  the  resistance  of  muscles 
and  other  structures.  Fx tension  is  made  by  the  hands  of  the 
surgeon,  by  a  broad  band  fastened  about  the  extremity  in  a 
clove-hitch  (Fig.  228)  and  passed  around  the  waist  or  shoulders  of  the 
surgeon,  or,  much  more  rarely,  by  comiJ^mntl  pulleys.  Cmnfcrex tension 
is  obtained  by  the  hands  of  an  assistant »  by  a  broad  band,  or  by  the  knee  or 
the  foot  of  the  surgeon.  The  application  of  great  force,  however,  is  very 
dangerous,  and  if  sufficient  relaxation  cannot  be  obtained  with  ether, 
reduction  through  an  incision  should  be  employed.  The  bone  usually 
goes  back  into  place  with  an  audible  snap.  (2)  After  reduction  the  joint 
is  immobilized  until  the  laceration  in  the  capsule  has  healed.  (3)  During 
the  first  twenty-four  hours  compression  with  a  bandage  and  the  application 
of  evaporating  lotions  or  an  ice  bag  serve  to  limit  the  swelling.  Subsequently 
absorption  is  hastened  by  massage,  heat,  and  liniments,  and  at  the  end  of 
from  ten  days  to  two  weeks  passive  motions  are  begun. 

Compound  dislocations  are  very  grave  injuries,  which  require  disinfec- 
tion of  the  surrounding  soft  parts,  copious  irrigation  of  the  joint  with  hot  salt 


Fig,  228, 
Clovr- hitch* 


JOINTS, 

abulum,  while  the  limb  is  fixet!  in  abduction  and  pressure  is  i 
great  trcHhanter.     This  treatment  must  be  continued  for  six  p^- 
year.     At  a  later  period,  up  to  four  or  6vc  years  in  bOatera' 
seven  years  tn  unilateral  cases»  the Lorens  bhodiess  mOkad  ma 
author  of  this  method  claims  50  per  cent,  anatomic  cures.    In] 
the  shortened  muscles  are  stretched  by  flexion,  exten<ioT> 
the  thigh,  during  the  last  of  which  the  adductor  n 
kneaded.     The  head  of  the  bone  is  then  drawn  do^^^n  t 
abulum  by  traction  on  the  leg,  and  the  tbi^  flexed  or 
internally,  abducted,  and  tinally  routed  out 
the  trochanter.     With  the  limb  in  flexion^  at 
I  af*Faiis  cast  is  applied  to  the  pdvis  md  thigb  ^^  i 
h  aUowed  to  walk  ^\ith  the  limb  in  thb  posltkm  ir 
abiJaiii.     At  the  end  of  three  monlhs  tBe  cast  i^ 
abductkm  le^^sened,  aini  aiKilher  cast  put  on  fm  '  i 


rJ'rriJl?  tlif 

dts- 

-.-^  lacing 
-i-  i!iio  I  he 
m  oi  the  ex-] 
iitg,  tiymffl] 


•a  of  lii|>  bv  t 


,  piDjectioii 
with 
tliere  is 
vanetf  I 

t  sound 


Uicn  too  oil! 
I  a  UMitfy  meA^' 
llc»  tint  of  Lft&gcit'     ' 

nbtnr 


^  * ' 


^>*«b3r 


.as:«£k 


nSLOCATIONS   OF   THE   SHOULDER.  3OI 

"ion  exists  over  the  joint,  the  acromion  is  nearer 

'^e  head  and  neck  are  painful  or  impossible, 

^lohagia,  or  congestion  of  the  head,  from 

Mood  vessels.     Reduction  and  treat- 

Ttion,  except  that  pressure  is  not 

Auction  cannot  be  promptly 

head  of  the  bone  may  be 

iolent  depression  of 
.'.  >ituation,  where  it 
■kMcf  falls  downwards 
.1 1  H>w  inwards  over  a  pad 
'    on  the  head  of  the  bone. 
J  on  for  several  weeks. 
.  K'  dislocated  downwards,  but  the 
i-c  is  violence  to  the  shoulder.     In 
iiir  J  hivicle  is  prominent,  the  shoulder 
III  its  movements  are  limited.     Dislocation 
"\cr  the  joint  and  a  prominence  of  the  acro- 
!»i'  j)ulled  backwards,  and  pressure  made  upon 
u  nr  uptm  the  acromion  according  to  the  displace- 
■'\\\\)  is  then  passed  over  the  shoulder  and  under  the 
.iv  I-  Ijy  a  band  passing  around  the  chest.     Some  deform- 
iM'r>i.>t,  and  in  bad  cases  suturing  of  the  bones  with  silver 
■'»  tin<lon  should  be  considered, 
ttion  of  the  lower  end  of  the  scapula  (see  scapulum  alatum). 
•jcation  of  the  shoulder  is  the  most  frequent  of  all  dislocations, 
•'»  tlie  exposed  position  and  great  mobility  of  the  joint,  and  the  dis- 
.  Tiion  l)ctween  the  head  of  the  humerus  and  the  depth  of  the  glenoid 
■  Kv.     The  usual  cause  is  a  fall  upon  the  outstretched  hand  or  elbow,  aA- 
iiMiinh  direct  violence  or  muscular  action  also  may  be  resp<m.sible  for  this 
injury.     As  a  rule  the  head  of  the  l)one  is  forced  through  the  weakest  portion 
of  ihc  capsule,  i.e.,  the  lower  and  inner  part,  into  the  axilla;  it  remains  in  this 
siiualicm  (subglenoid) ,  or,  as  the  result  of  muscular  action  or  the  direction 
of  the  force,  passes  backwards  and  downwards  beneath  the  spine  of  the 
scapula  {subspinaus)j  forwards  and  upwards  beneath  the  clavicle  (subcla- 
vicular),  or  most  commonly  (three- fourths  of  all  the  cases)  forwards  and 
downwards  beneath  thecoracoid  process  (subcoracoid).     The  subclavicular, 
subcoracoid,  and  subspinous  tlislocations  may,  however,  be  primar}',  i.e.,  the 
head  of  the  bone  may  pass  directly  to  its  new  situation  without  first  entering 
the  ax^'lla.     Two  other  forms,  which  are  very  rare,  may  be  mentioned,  viz., 
the  supracoracoidy  in  which  the  head  of  the  humerus  passes  above  the  coracoid 
and  usually  fractures  it  or  the  acromion  process,  and  luxatio  erecta,  in  which 
the  head  of  the  bone  lies  in  the  axilla,  but  the  humerus  projects  upwards 
against  the  head  of  the  patient. 

The  symptoms  of  all  varieties  of  dislocation  of  the  shoulder  are  (i)  pain, 
swelling,  rigidity,  ecchymosis,  and  loss  of  function;  (2)  flattening  of  the  shoul- 
<ler  and  prominence  of  the  acromion  process  (Fig.  2  2(>),  so  that  a  ruler  can  be 
made  to  touch  the  acromion  process  and  the  external  C(mdyle  at  the  same 
time;  (3)  a  hard  swelling  in  the  situation  abnormally  occupie<l  by  the  head  of 
the  bone;  (4)  Dugas'  sign,  i.e.,  projection  of  the  elbow  from  the  side  when  the 


302 


JOINTS. 


hand  is  on  the  c^pofiite  shoulder*  and  inahUity  to  place  the  hand  on  the  oppo- 
she  shoulder  when  the  ellxjw  is  forced  against  the  side  (this  may  be  absent  in 
some  subcoracoid  dislocations);  (5)  increase  in  the  vertical  measurement 
around  the  axilla  (Callaway's  sign)  with  lowering  of  one  of  the  axillary  folds 
(Bryant's  sign) ;  and  (6)  displacement  as  shown  by  the  X-ray.  The  variety  of 
dislocation  may  be  diagnosticated  by  the  situation  of  the  head  of  the  bone;  by 
the  axis  of  the  limb,  I  he  ellww  projecting  from  the  side^in*all  instances,  but 
decidedly  backwards  in  the  subcoracoid  and  subcla\icular  forms,  slightly 
backwards  in  the  subglenoid,  and  forwards  in  the  subspinous;  by  the  length 
of  the  limbj  which  is  lessened  in  the  subclavicular,  increased  ven^  litde  ii  at 


Fig.  239, — SiiijttJiNnipul  disJocatioti  of  the  shoulder.     (Pennsylvania  Hospital/) 

all  in  the  subcoracoid,  slightly  increased  in  the  sulispinous,  and  decidedly  ^J 
increased  in  the  subglenoid;  and  by  the  X-ray.  Rupture  or  compression  of  ^H 
the  axillary  vessels  or  brachial  plexus  may  occur.  Subluxation  of  the 
shoulder  is  a  condition  in  which  the  head  of  the  Ixme  passes  fonvards,  ov^ing 
\o  rupture  or  displacement  of  the  long  head  of  the  biceps. 

The  treatmeiit  is  reduction  by  manipulation  or  extension,  employing 
ether  if  much  difficulty  is  encountered.  Kocher^s  mrthod  is  useful  in  forward 
dislocations.  The  elbow  is  flexed  to  a  right  angle  and  pressed  to  the  side.  ^J 
External  rotation  is  then  performed  by  carrying  the  forearm  outwards  unUl  ^H 
it  is  at  a  right  angle  with  the  body.  If  this  does  not  cause  reduction,  the  ellxiw  ^^ 
is  drawn  towards  the  median  line,  and  finally  internal  rotation  is  performed 
by  placing  the  hand  ou  the  sound  shoulder.  External  rotation  relaxes  the 
posterior  unlorn  portion  of  the  capsule,  which  lies  across  the  glenoid  cavity, 
and  causes  the  opening  in  the  capsule  to  gap.     When  the  elbow  is  carried 


DISLOCATIONS   OF   THE   ELBOW. 


3<^3 


forward,  the  capsule  above  the  rent  is  relaxed,  and  the  tower  margin  of  the 
opening  acts  as  a  laut  band  which  directs  the  head  of  the  bone  into  the  glenoid 
ca\ity.  The  melhod  should  not  be  used  if  there  is  great  resistance  to  exter- 
nal rotation,  as  in  such  instances  the  neck  of  the  bone  may  be  broken.  In 
Smilh's  mcih&d^  for  antenor  dislocation,  the  surgeon  stands  in  front  of  the 
patient  and»  if  the  left  humerus  is  dislocated,  grasps  the  shoulder  with  his 
left  hand,  the  fingers  resting  on  the  scapula  and  the  thumb  on  the  head  of  the 
bone.  With  I  he  right  hand  the  elbow  is  abducted  to  a  right  angle,  extended, 
everted,  and  carried  towards  the  sternum  while  pressure  is  made  on  the  head 
of  the  bone.  For  the  right  shoulder  the  position  of  the  surgeon's  hands  is 
reversed.  In  subspinous  ilislocation  the  surgeon  stands  behind  the  patient 
and  in  a  similar  manner  abducts  and  extends  the  arm;  external  rotation  is 
then  performed,  and  the  ellH>w  carried  towards  the  spine  while  the  thumb 
presses  the  bone  forwards  into  the  glenoid  cavity.  In  reduction  by  extension 
the  patient  lies  down,  and  the  arm  is  pulled  directly  outwards  while  counter- 
extension  is  made  by  placing  the  unshoed  foot  against  the  chest  close  to  the 
head  of  the  bone.  If  this  fails,  the  arm  is  carried  downwards  while  the  foot 
is  used  as  a  fulcrum  to  drive  the  head  of  the  bone  into  place.  Some  surgeons 
make  the  extension  downwards,  others  place  the  foot  over  the  acromion 
and  pull  the  arm  above  the  head.  Cooper's  method  consists  in  placing 
the  knee  in  the  axilla  of  a  sitting  patient  and  forcing  the  elbow  to  the  side. 
In  all  methods  of  extension,  and  particularly  in  the  vertical  form,  there  is 
danger  of  injury  to  the  axillary  nerves  or  vessels.  After  reduction  the  joint 
should  be  immobilized  for  a  week  or  ten  days  by  a  Velpeau  bandage. 

Recurrent  disiotation  of  the  shmilder  is  due  to  relaxation  of  the  capsule  as 
the  result  of  nonunion  of  the  laceration  in  it  or  stretching  of  the  cicatrix. 
The  shoulder  may  be  strengthened  by  a  support,  or,  after  making  an  incision 
similar  to  that  recommended  for  excision  of  the  joint,  the  gap  in  the  capsule 
may  l»e  sutured  or  the  capsule  reefed. 

Dislocations  of  the  elbow  are  most  frequent  in  children,  and  are  caused 
by  direct  or  indirect  violence.  In  dislocation  of  both  bones  of  the  forearm 
the  displacement  may  be  l>ack wards,  forwards,  or  lateral. 

Dislocation  of  both  bones  backwards  is  the  most  frequent  variety. 
The  coronoid  process  lodges  hi  the  olecranon  fossa,  the  forearm  being  tlexed, 
midway  between  pronauon  and  supination,  and  shortened.  Occasionally 
the  coronoid  process  is  broken  (mol)iHty  and  crepitus).  The  lower  end  of 
the  humerus  displaces  the  artery  and  soft  tissues  forwards,  and  projects  at  or 
below  the  crease  of  the  elbow;  the  upper  ends  of  the  hones  of  the  forearm 
form  a  projection  posteriorly,  and  the  relations  between  the  olecranon  and 
condyles  are  markedly  altered.  For  diagnosis  see  fractures  about  the  elbow. 
The  treatment  is  reduction  by  strong  traction,  and  flexion  of  the  forearm  across 
the  knee,  which  is  placed  in  the  bend  of  the  ellxiw  while  the  patient  is  in  the 
sitting  position  (Cooper's  method).  The  arm  is  placed  in  the  Jones  position 
for  a  week  or  ten  days. 

Dislocation  of  both  bones  forwards  seldom  occurs  without  fracture  of 
the  olecranon.  The  forearm  is  lengthened  and  Hexed,  and  the  normal  prom- 
inence of  the  olecranon  is  absent.  The  trealmenl  is  pressure  downwards  on 
the  l>ones  of  the  forearm  by  the  knee  in  the  bend  of  the  elbow,  the  forearm 
licing  drawn  upon  an<l  flexed  by  one  hand,  while  the  other  makes  forward 
traction  on  the  humerus.  The  arm  is  then  dressed  in  the  Jones  position  for  a 
week  or  ten  days. 


fl 


i 


304  JOINTS. 

Lateral  dislocation  of  both  boaes,  either  outwards  or  inwards,  is  infre- 
quent and  usually  incomplete.  In  either  instance  the  forearm  is  flexed  and 
fixed,  and  the  joint  widened ;  the  form  of  displacement  is  determined  by 
stud)ing  the  relations  of  the  bony  landmarks  about  the  elbow.  Reduction 
is  made  by  traction  on  the  forearm,  the  upper  end  of  which  is  pushed  inwards ' 
or  outwards  according  to  the  form  of  dislocation.  The  arm  should  be  placed 
in  the  Jones  position  for  a  week  or  itn  days. 

Dislocation  of  the  ulna  alone  is  rare,  and  can  occur  only  in  a  backward  | 
direction;  the  forearm  is  flexed,  fixed,  and  pronated,  and  the  olecranon  is  j 
unduly  prominent.  The  treatment  is  the  same  as  that  for  dislocation  of  both  ] 
bones  of  the  forearm  backwards. 

Dislocation  of  the  radius  alone  may  be  forwards,  backwards,  or  out- 
wards. 

Forward  dislocation  is  the  usual  variety ;  it  results  from  a  fall  on  the  j 
hand  when  the  forearm  is  pronated  and  extended,  or  from  direct  violence  to  , 
the  posterior  part  of  the  joint.     The  forearm  is  midway  between  pronation 
and  supination,  and  cannot  be  Hexed  beyond  a  right  angle,  as  the  head  of  the 
bone  strikes  the  lower  end  of  the  humerus.     The  head  can  be  felt  rotating  | 
beneath  the  skin,  and  a  depression  is  noticed  posteriorly  beneath  the  external  1 
condyle.     Reduction  is  the  same  as  thai  for  dislocation  of  lx)th  bones  for- 
wards.     The  arm  should  be  kept  in  the  Jones  position  for  several  weeks,  as 
deformity  is  likely  to  ret  ur  owing  to  rupture  of  the  orbicular  ligament. 

Backward  dislocation  is  rare,  and  is  caused  by  a  fall  on  the  hand,  or  a 
blow  on  the  head  of  the  bone  from  the  front.  The  forearm  is  flexed,  fixed»  , 
and  pronated,  and  the  head  of  the  bone  can  be  felt  rotating  behind  the  exter- 
nal condyle.  Redutlion  is  the  same  as  that  for  both  bones  backwards,  the 
arm  being  fixed  in  the  Jones  position  for  several  weeks,  although  recurrence 
of  the  deformity  is  not  as  menacing  to  the  function  of  the  elbow  as  in  the  pre- 
ceding dislocation. 

Outward  dislocation  Is  very  rare.  The  head  of  the  bone  may  be  felt 
external  to  the  outer  condyle;  it  is  reduced  by  extension  and  direct  pressure, 
and  the  forearm  is  dressed  in  flexion. 

Dislocation  of  the  radius  forwards  and  ulna  backwards  is  exceed- 
ingly rare,  and  causes  great  deformity  and  imfiairment  of  function. 

Subluxation  of  the  head  of  the  radius  occurs  in  children  as  the  result 
of  a  fon ible  pull  on  the  forearm.  The  head  of  the  bone  is  displaced  do^Mi- 
ward  and  a  fold  of  the  orbicular  ligament  becomes  pinched  in  the  joint. 
The  forearm  is  flexed,  pronated,  and  powerless,  and  pain  and  tenderness, 
increased  by  supination,  exist  over  the  head  of  the  radius.  The  forearm 
should  be  forcibly  supinated  and  then  flexed,  and  the  ell>ow^  immobilized 
for  a  few  days. 

Dislocation  of  the  wrist  is  rare,  but  may  follow  a  fall  on  the  hand  or 
direct  violence.  The  displacement  may  be  backwards  or  forwards;  the  de- 
formity of  the  former  resembles  Colles*  f  ractur<r,  but  the  styloid  processes  of  the 
ulna  and  radius  project  beneath  the  skin  on  the  flexor  side  of  the  wrist,  and 
their  relations  to  each  other  are  not  disturbed.  In  forward  dislocation  the 
deformity  is  reversed.  Reduction  is  etiected  by  traction  on  the  hand  and 
pressure  over  the  deformity,  an^l  the  wrist  is  immobilized  on  a  Bond's  splint 
for  two  weeks. 

Dislocation  of  the  lower  end  of  the  ulna  forwards,  or  more  commonly 
back  wards,  occasionally  occurs  in  twists  of  the  forearm;  the  deformity  is 


DISLOCAnONS   OF   THK   PHALANGES. 


305 


.A 


readily  detected,  and  easily  reduced  by  extension  and  pressure.  The  forearm 
and  hand  should  be  splinted  for  several  weeks- 
Dislocation  of  the  carpal  bones  is  uncommon  apart  from  crushes.  It 
is  possible  for  the  second  row  of  bones  to  be  dislocated  backwards  or  forwards 
from  the  first,  or  for  any  one  of  the  carpal  bones  to  be  individually  dislocated. 
The  most  frequent  injur)'  is  anterior  dislocalion  of  the  semilunar,  a  sort  of 
silver-fork  deformity  resulting,  owing  to  the  prominence  of  the  os  magnum, 
and  the  depression  just  above  it  caused  by  the  forward  displacement  of  the 
semilunar,  which  is  felt  under  the  flexor  tendons  of  the  wrist-  The  relations 
l>etween  the  styloitl  processes  and  the  radius  are  unaltered,  although  the  dis- 
tance from  the  radial  styloid  to  the  base  of  the  hrst  metacarpal  is  lessened 
Reduction  may  be  effected  by  hyperextension,  then  hyperflexion  over  the 
thumbs  of  an  assistant,  which  press  on  the  semilunar  (Codman  and  Chase). 
Excision  of  any  of  the  bones  may  be  demanded  in  irreducible  dislocations. 
Dislocations  of  the  metacarpal  bones,  ix.,  at  the  carpometacarpal 
joint,  are  infrequent-  The  metacarpal  bone  of  the  thumb  is  the  one  most 
frequently  displaced,  the  cause  being  powerful  flexion  or  direct  violence. 
The  base  of  the  Iwne  forms  a  posterior  prominence,  which  is  easily  reduced 
but  hard  to  keep  in  place.  An  adhesive  strap  should  l>e  put  over  the  joint, 
and  the  thumb  fixed  in  abduction  on  a  palmar  splint  for  two  weeks  or 
longer. 

Dislocations  of  the  metacarpo-phalangeal  joints,  excepting  that  of 
the  thumbs  are  infrequent.  Forward  dislocations  are  readily  recognized  and 
easily  reduced-  Backward  dislocation  of  the 
thumb  or  of  any  of  the  hngers  is  often  difficult 
to  reduce,  and  the  treatment  of  the  former  will 
ser\*e  as  a  guide  for  that  of  the  latter-  There  are 
three  forms  of  backward  dislocation  of  the  thumb- 
The  incomplete  some  persons  are  able  to  produce 
at  will  by  hyperextending  the  thumb  until  it 
forms  an  obtuse  or  even  a  right  angle  with  the 
metacarpal  bone.  The  comphie  is  caused  by 
forced  extension,  the  (irst  phalanx  projecting 
backwards  at  a  right  angle,  the  terminal  phalanx 
being  dexed,  and  the  head  of  the  metacarpal 
bone  forming  a  prominence  anteriorly  (Fig-  230). 
The  anterior  ligament  is  lacerated,  and  with  the 
sesamoid  lH)nes  is  pulled  up  on  the  posterior 
surface  of  the  head  of  the  metacarpal  bone,  the 
long  flexor  tendon  slipping  to  the  inner  or  the 
outer  side.  The  complex  form  may  be  caused  by  flexion  of  the  thumb  in 
attempts  to  reduce  the  complete  form.  The  thumb  is  parallel  with,  but 
posterior  to,  the  metacarpal  bone. 

Reduction  consists  in  increasing  the  extension,  making  strong  traction, 
pushing  the  base  of  the  thumb  downwards,  then  pressing  on  the  head  of  the 
metacarpal  bone  and  flexing  the  thumb.  If  this  is  unsuccessful,  as  it  often 
is,  a  palmar  incision  should  be  made  over  the  head  of  the  metacarpal  bone 
and  the  ligament  nicked  between  the  sesamoid  bones^  when  replacement  will 
be  easy.     \  splint  should  be  used  for  at  least  three  wceks- 

Dislocations  of  the  phalanges  may  be  backwards,  forwards,  or  lateral. 
Deformity  is  ob\ious  and  reduction  usually  easy.     In  difficult  cases  a  firmer 


Fic-  i^o, — Complcle 
backward  dislocation  uf 
Ihumb.     (Agnew.) 


3o6 


JOINTS. 


grasp  on  the  finger  can  be  secured  by  the  Levis  apparatus  (Figs.  231,  232). 
The  fingers  should  be  splinted  for  one  week. 

Dislocations  of  the  ribs,  costal  cartilages,  sternum,  and  pelvis  are 
very  rare,  and  give  the  same  signs  and  require  the  same  treatment  as  fractures. 

Dislocations  of  the  hip  are  comparatively  infrequent  owing  to  the  great 
strength  of  the  joint.  The  cause  is  never  direct  violence,  }>ut  always  force 
transmitted  from  the  feet  or  knees,  or  from  the  back  when  the  hips  are  flexed. 
After  the  fortieth  or  fiftieth  year  dislocation  is  very  rare  owing  to  the  fragility 
of  the  neck  of  the  femur,  which  predisposes  to  fracture.  The  upi>er  portion 
of  the  hip  joint  is  formed  by  the  rim  of  the  acetabulum;  the  capsule  is  mark- 
edly strengthened  in  front  by  the  iliofemoral  or  Y-ligament  and  to  a  lesser 
degree  by  the  pubofemoral  ligament,  while  posteriorly  it  is  reinforced  by  the 
ischiofemoral  ligament;  hence  the  weakest  portion  of  the  joint  is  below,  and 


Fig.  231. 


Fig.  21^2, 
Figs.  231  and  3^2. — Levis  apparatus  for  dislocations  of  the  phalanges. 


it  is  through  this  part  o[  the  capsule  that  the  head  of  the  bone  usually  pa 
when  dislocated,  thence  passing  forwards  or  backwards  according  to  tl 
presence  of  abduction  or  adduction  at  the  time  of  the  accident.  The  in- 
nominate bone  is  made  of  two  planes,  the  ilio-ischiatic  and  the  pobo-ischialic, 
which  meet  and  form  a  right  angle  at  a  line  drawn  from  the  anterior  superior 
spine  of  the  ilium,  through  the  acetabulumj  to  the  tuberosity  of  the  ischium. 
When  the  head  of  the  femur  escapes  through  the  lower  portion  of  the  capsule, 
it  slides  off  this  angle  upon  one  or  the  other  of  these  planes,  according  to 
the  direction  of  the  force;  hence  all  dislocations  of  the  hip  are  either  inward 
(Jorward)  upon  the  puljo-ischiatic  plane  or  outward  (backward  or  dorsal) 
upon  the  ilio-ischiatic  plane.  The  head  may  lie  upon  any  portion  of  either 
of  these  planes  within  a  circle  whose  radius  is  the  untorn  portion  of  the 
capsule;  consequently  i\llis»  to  whom  belongs  the  credit  for  working  out  this 
problem,  subdivides  the  inward  dislocations  into  the  (a)  high  (pubic  and 
subspinous  of  other  writers),  (b)  middle  (thyroid  of  others),  (c)  l€nv  (perineal 
of  others),  and  (d)  reversed;  and  he  divides  the  outward  or  dorsal  into  the-^a) 
high  (on  dorsum  of  ilium),  (b)  Itrw  (sciatic^  or  dorsal  below  the  tendon  of 
others),  and  (c)  mrrsed  (everted  dorsaL  anterior  oblique,  and  supraspinous 
of  Bigelow).  In  three-fourths  of  the  cases  the  dislocation  is  outwards,  and 
in  two-thirds  of  these  it  is  high,  i.e.,  upon  the  tlorsum  of  the  ilium;  of  the  in- 
ward dislocations  the  middle  (into  the  thyroid  foramen)  is  the  most  frequent. 


DISLOCATIONS    OF    THE   HIP. 


307 


Some  writers  state  that  the  head  of  the  bone  may  be  pushed  through  the 

capsule,  e.g>,  by  force  applied  to  the  knee  when  the  thigh  is  flexed  and  ad- 
ducted,  directly  onto  the  dorsum  of  the  ilium,  but  Allis  explains  all  cases  by 

leverage;  thus  outward  dislocations  are  caused  by  liexion,  adduction*  and 
iward  rotation  of  the  thigh,  which  pr>^  the  head  out  of  place  by  the  fulcrum 
ction  of  the  iliofemoral  ligament,  which  passes  across  the  front  of  the  neck 
the  bone;  inward  dislocations  are  caused  by  abduction,  the  head  of  the 

bone  being  forced  out  of  the  socket  by  the  great  trochanter  impinging  against 

the  rim  of  the  acetabulum,  which  acts  as  the  fulcrum. 

The  ligamentum  teres  is  of  course  ruptured.     If  the 

tear  in  the  capsule  is  close  to  the  femur,  its  infold- 
ing   may    offer   an   obstacle   to   reduction.      The 

Y-ligament  is  rarefy  ruptured;  tearing  of  its  outer 

branch  permits  ihe  femur  to  rotate  externally  antl 

results   in    reversed    (everted   dorsal)   dislocations. 

If  the  entire  ligament  is  ruptured,  the  head  of  the 

bone  will  be  freely  movable  instead  of  fixed.     The 

muscles  about  the  joint  are  contused  or  lacerated  to 

a  greater  or  lesser  degree.     Rupture  of  the  obtu- 

rator  inlernus  allows  the  head  of  the  bone  to  ascend 

and    become  high   dursal;   if   the   muscle  remains 

intact,  the  low   dorsal  (dorsal  IjcIow  the  tendon) 

will  likely  ensue.     It  is  possible,  however,  for  the 

head  to  leave  the  joint  above  the  tendon  of  this 

muscle j  or  leaving  it  lower  down  to  ascend  in  front 

of  the  tendon.     The  sciatic  nene  may  be  contused, 

compresssed,  or  lacerated,  but  the  femoral  vessels 

are  very  rarely  injuretb 

In  dorsal  or  outward  dislocation  the  thigh  is 

llexcd,  adductedj  rotated  internally,  and  shortened, 

while  the  trochanter  is  above  Nulaton's  line  and 

farther  away  from  the  median  line  of  the  body,  so 

that  the  hip   appears   broadened.      A    depression 

exists  over  the  front  of  the  joint  ajid  the  head  of 

the   Injnc   can   be   felt   posteriorly.     The   knee   is 

flexed  and  the  heel  raised.      Passive  movement  is 

possible   only   in  the  direction  of  deformity,  and 

indeed  the  alTected  limb  can  be  flexed  to  a  right 

angle  with  the  body  without  bending  the  knee.     If 

both  knees  are  flexed  while  the  thighs  are  vertical, 

the  patient  lying  down,  the  foot  on  the  atTected  side  touches  the  bed.     In  the 

high  dorsal  (Fig.  2^^)  these  signs  are  all  marked,  in  the  low  dorsal  they  are  less 

in  evidence;  e.g.,  in  the  former  there  is  two  or  three  inches  shortening,  the 

axis  of  the  affected  thigh  passes  through  the  lower  third  of  the  sound  thigh, 

the  foot  passes  over  the  sound  ankle;  in  the  latter  the  shortening  is  an  inch 

or  less,  the  axis  of  the  fern  or  passes  through  the  sound  knee,  the  foot  crosses 

the  great  toe  of  the  sound  side.     In  the  reversed  dorsal  the  lower  limb  is 

rotated  externally  instead  of  internally,  owing  to  tearing  of  the  outer  branch 

of  the  Vdigament.     For  diagnosis  from  fractures  see  p.  275. 

Reduction  should  be  performed  under  ether  w  ith  the  patient  lying  on  the 

back.    Bigdaw*$  method  consists  in  flexion  of  the  leg  on  the  thigh  and  the 


Fig.  J33.— High  doraal 
dislocation  of  the  hip, 
(Tlllmanns.) 


3o8 


JOINTS. 


thigh  an  the  abdomen,  adduction,  inversion^  strong  traction  upwards,  and 
external  circumduction,  i.e.,  the  knee  is  swept  upwards  towards  the  opposite 
shoulder,  then  towards  the  shoulder  of  the  same  side^  and  fmally  downwards 
with  the  limb  in  extension  (Fig.  234).  As  there  is  some  danger  of  hooking 
up  the  sciatic  nerve  by  the  head  of  femur  in  this  method,  A  His  flexes 
the  thigh,  performs  internal  rotation  by  carrying  the  foot  outwards,  draws 
the  thigh  upwards  to  lift  the  head  to  the  level  of  the  acetabulum,  and 
has  an  assistant  push  inwards  on  the  head  as  the  thigh  is  rotated  externally 
and  extended.  In  this  method  it  is  necessar)'  to  6x  the  pelvis  firmly  to 
the  lloor  by  straps  or  by  the  hands  of  an  assistant.  Reduriion  by  extension 
is  made  by  traction  in  the  axis  of  the  displaced  thigh  while  pressure  is 
made  over  the  great  trochanter.  Extension  by  pulleys  destined  to  rupture 
ihc  Y-ligament  is  dangerous  and  should  never  be  employed.  After  reduction 
the  patient  is  confined  to  bed  for  two  or  three  weeks  with  the  legs  tied 
together. 

Inward  or  forward  dislocations  are  characterized  by  flexion,  abduction, 
and  external  rotation  of  the  thigh.  The  hip  is  (fattened,  the  trochanter  being 
nearer  the  median  line;  the  acetabular  cavity  is  empty;  and  the  head  of  the 
bone  may  be  detected  in  its  new  position.  The  adductor  muscles  are  promi- 
nent ami  the  knees  cannot  be  approximated*  In  the  high  thyroid  disloca- 
tion, i.e.,  upon  the  pubes  (Fig.  235),  flexion  is  less  marked,  but  eversion  is 
greater  and  the  limb  is  shortened  about  one  inch ; 
in  the  low  thyroid  (Fig.  236)  flexion  is  greater  and 
the  limb  is  lengthened  one  or  more  inches.  In  the 
reversed  thyroid  external  rotation  may  be  so  great 
that  the  toes  point  directly  backwards. 

In  the  reduction  of  inward  dislocations  Bige- 
/(m-  advised  flexion  of  the  leg  and  thigh  as  in  the 
treatment  of  dorsal  dislocation,  then  abduction, 
eversion,  strong  traction  upwards,  and  internal 
circumduction,  i.e.,  the  knee  is  swept  upwards 
towards  the  shoulder  of  the  same  side,  then 
towards  the  opposite  shoulder,  and  finally  down- 
wards with  the  limb  in  extension  (Fig.  237).  AlUs^ 
in  order  to  avoid  injury  to  the  sciatic  ner\'e,  flexes 
and  abducts  the  thigh,  makes  strong  traction  up- 
wards, and  adducts  while  an  assistant  pushes  on 
the  head  of  the  femur.  Reductioft  by  tjctensim 
alone  is  made  by  traction  in  the  axis  of  the  dis- 
placed thigh,  the  unshoed  foot  being  placed  in  the  groin  for  counterex- 
tension.  After  reduction  the  subsequent  treatment  is  the  same  as  in  thfl 
dorsal   variety. 

The  knee  may  be  dislocated  forward,  backward,  inward,  or  outward,  and 
these  may  l>e  complete  or  incomplete,  the  symptoms  consequently  varying 
in  degree.     The  cause  is  violent  force,  either  direct  or  indirect. 

In  forward  dislocation  the  lower  end  of  the  femur  passes  backwards] 
and  compresses  the  popliteal  vessels,  and  the  tibia  is  displaced  forward. 
The  leg  is  shortened  and  extended,  although  it  may  be  flexed;  in  the  former 
case  the  patella  is  loose.  Backward  dislocation  is  more  frequently  due  tc» 
disease  of  the  knee  joint  than  to  injury.  The  ieg  is  shortened  and  usually 
somewhat  flexed,  and  compression  of  the  popliteal  vessels  or  nen'es  is  gener- 


FiG.  234.— Bigelo  w's 
method  of  reducing  back- 
ward dislocation  of  flip. 


BIStOCATIONS   or  THE  PATELLA. 


309 


ally  absent.  Inward  and  outward  dislocatians  are  usually  iiuomplcle. 
The  leg  is  partly  flexed  and  often  rotated,  but  not  shortened, 

Redtiction  is  accomplished  by  traction  and  direct  pressure  while  the  leg 
is  extended  and  the  thigh  ilexed.  The  knee  should  be  immobilized  on  a 
splint  for  three  weeks,  and  a  support  worn  for  some  time  longer. 

Dislocations  of  the  patella  are  due  to  muscular  action  or  direct  violence. 
An  insidious  outward  dislocation  may  be  caused  by  knork-knees  or  hydrar- 
throsis. The  pateila  may  be  dislocated  upwards,  downwards,  outwards,  or 
inwards,  or  it  may  be  rotated  on  its  perpendicular  or  horizontal  axis,  or  there 
may  be  a  combination  of  any  of  these  varieties. 


Flc,  23 5. — High  ih)Toid  (pubic) 
dislocation.     (Till  in  Anns,) 


Fic.  236. — Lovr  ihyroicl  dis- 
location.    CTiltmanns,) 


Bislocation  upwards  or  downwards  is  due  to  rupture  of  the  ligamen- 
tum  patelia;  or  the  quadriceps  tendon,  and  is  to  be  treated  as  a  rupture  of  a 
tendon. 

Outward  dislocation  is  the  most  frequent  variety;  it  usually  occurs  when 
the  limb  is  extended,  as  in  flexion  the  patella  is  firmly  held  between  the  con- 
dyles of  the  femur.  The  patella  lies  upon  the  anterior  or  outer  surface  of  the 
externa!  condyle,  according  to  whether  the  dislocation  is  incomplete  or  com- 
plete; in  the  former  the  outer  edge  projects  forward,  in  the  latter  the  inner 
border  presents  in  front.  The  leg  is  extended,  the  knee  broadened,  and  the 
intercondyloid  notch  perceptible.  Reduction  is  made  by  pressure  inwards 
on  the  outer  margin  of  the  patella  while  the  thigh  is  tlexcd  and  the  leg  ex- 


310 


JOINTS. 


'^■^ 


N, 


tended  to  relax  the  quadriveps.     Intisioii  is  needed  in  some  cases.     The 
knee  should  he  immobilized  for  several  weeks. 

Inward  dislocation  is  rare;  the  signs  and  the  treatment  are  the  revei 
of  those  of  outward  dislocation. 

In  rotation  on  the  perpendicular  axis  (vertical  or  edgewise  dislocation) 
either  the  outer  or  the  iJiner  border  of  the  patella,  usually  the  latter,  lies  ' 
tween  the  condyles  while  the  opposite  border  projecis  forward.  In  two  cases 
the  bone  has  been  turned  over,  the  articular  surface  looking  forwards.  Rc' 
dnctimi  may  be  effcctetl  by  pressure  while  the  knee  is  extendet!,  but  is  often 
more  difficult  than  at  first  sight  appears,  and  incision  may  be  necessary. 

Rotation  on  the  horizontal  axis  has  been  recorded  in  six  instances,  and 
the  author  has  seen  one  case  which  has  not  been  reported.  In  five  of  these 
the  tendon  of  the  quadriceps  was  torn  and  the 
upper  border  of  the  patella  wedged  between  the 
femur  and  the  tibia,  in  two  the  low^er  edge  was 
forced  into  the  joint,  the  articulating  sufface  of 
the  patella  looking  upwards.  In  five  cases  inci- 
sion was  necessarj'  to  free  the  patella. 

Dislocation  of  the  semilunar  cartilages  of 
the  knee  joint  {subluxation^  internal  derangement 
oj  the  knee)  follows  a  twist  of  the  partly  Hexed 
knee.  The  condyles  fix  the  cartilages,  which 
torn  from  the  tibia  by  rotation  of  the  leg, 
attachments  of  the  cartilages  to  the  dbia  being 
relaxed  when  the  knee  is  bent.  The  internal 
cartilage  is  the  one  usually  affected.  Any  of  its 
attachments  or  even  the  cartilage  itself  may  be 
ruptured 

The  symptoms  are  severe  pain  in  the  knee  and  effusion  into  the  joint, 
whicJi  is  locked  in  flexion,  i,e.,  flejcion  may  be  increased  but  extension  is 
impossible.  Sometimes  there  is  no  locking,  and  these  cases  are  often  diag- 
nosticated sprains.  In  the  latter  tenderness  is  more  generalised,  and  exten- 
sion may  relieve  rather  than  increase  the  pain.  The  displaced  cartilage 
is  occasionally  felt,  but  more  often  palpation  will  reveal  nothing  but  marked 
tenderness  along  the  front  of  the  upper  surface  of  the  tibia.  Recurrences 
are  frecjucnt. 

The  treatment  is  reduction  by  increasing  the  flexion,  rotating  the  leg, 
making  firm  pressure  over  the  situation  of  the  displaced  cartilage,  and 
extending  the  leg.  Often  spontaneous  reduction  occurs  before  the  surgeon  is 
called.  The  synovitis  should  be  treated  and  the  knee  immobilized  for  five  or 
six  weeks.  In  order  to  prevent  recurrence  an  elastic  knee-cap  should  be  worn' 
for  several  months.  If  relapses  are  frequent  a  brace  may  be  applied  (Fig. 
238),  or  the  joint  may  be  opened  by  a  curbed  incision  along  the  upper  edge  of 
the  tibia,  and  the  cartilages  stitched  to  the  periosteum  with  catgut,  or  excised 
if  they  are  ruptured  or  deformed. 

The  Sbula  may  be  dislocated  at  either  end,  either  backwards  or  forwards. 
The  injury  is  very  rare.  The  leg  is  tlattened  from  side  to  side  and  a  depres- 
sion is  found  over  the  end  of  the  bone,  which  is  felt  in  its  displaced  position. 
Reduction  is  effected  by  flexion  of  the  knee  and  direct  pressure,  the  leg  being 
put  up  in  plaster-of-Paris  for  several  weeks.  At  the  upper  end  displace- 
ment is  likely  to  recur  owing  to  the  contraction  of  the  biceps 


Fig,  137. — Bigc  low's 
melhod  of  rcductng  fonvani 
dislocation  of  hip. 


are^H 
th^H 

eing  ^\ 

k 


4 


k 


Nation. 


3" 


J 


Dislocations  of  the  ankle  joint  are  often  t omplkated  l»y  fracture.  In 
ihe  order  of  their  frequemy  the  displacements  are  outwards,  inwards,  luirk- 
wardi^,  forwards,  and  upwards. 

Lateral  dislocation  is  caused  by  a  twisting  or  turning  of  the  fimi,  and 
the  resulting  injur)'  is  a  fracture-dislocation,  known  as  Pott's  fracture  or 
Dupuytren's  fracture  (q,v). 

Dislocation  backwards  is  caused  by  stumbling  when  jumping  or  run- 
ning, or  by  direct  violence;  both  malleoli  are  commonly  broken.  The  heel  is 
prominent,  the  dorsum  of  the  foot  shortened,  and  the  rebitions  between  ihe 
malleoli  and  the  tarsus  altered.  Forward  disloca- 
tion may  occur  without  fracture.  The  dorsum  of 
the  foot  is  lengthened^  the  heel  inconspicuous,  and 
the  normal  hollow^  in  front  of  the  ten  do  Achillis 
bulged  by  the  tibia  and  hbula.  Both  these  disloca- 
tions are  reduced  by  strong  traction,  direct  pressure, 
and  rotation,  while  the  knee  is  luenl  to  relax  the 
tendo  Achillis,  which  in  some  instances  it  may  be 
necessary-  to  sever.  The  after  trealment  is  that  of 
fractures  about  the  ankle. 

Upward  dislocation  of  the  ankle  is  a  rare  injur>^ 
in  which  the  astragalus  is  thrust  upward  between  the 
tibia  and  hbula  as  the  result  of  a  fall  upon  the  feet* 
The  ankle  is  widened  and  the  foot  tlaltenedj  the 
malleoli  having  descended  towards  the  sole  of  the 
fool.  Reduction  is  made  by  powerful  traction  and 
countcrtraction,  the  after  treatment  being  that  of 
fracture. 

In  dislocations  of  the  astragalus  the  bone,  as 
the  result  of  falls  or  twists,  is  detacheil  from  the 
remaining  tarsal  bones  as  well  as  separated  from  the 
bones  of  the  leg.  The  displacement  may  be  com- 
plete or  incomplete,  the  bone  passing  forwards  or 
backwards,  or  rotating  upon  its  perpendicular  or  horizontal  axis;  or  these 
lesions  may  be  combined. 

In  forward  dislocation  the  astragalus  forms  a  prominence  in  front  of  the 
ankle,  the  dorsum  of  the  foot  and  the  leg  arc  shortened,  and  the  malleoli  are 
nearer  the  sole  of  the  fool,  which  is  either  turned  inwards  or  outwards.  In 
backward  dislocation  the  astragalus  lies  between  the  malleoli  and  the  tendo 
Achillis,  If  either  horizontal  or  vertical  rotary  dislocation  alone  occurs, 
the  astragalus  simply  rotates  without  being  displaced  from  between  the  bones 
of  the  leg  and  the  bones  of  the  foot;  a  positive  diagnosis  can  seldom  be  made 
without  the  X-ray, 

Reduction,  if  the  bone  is  not  completely  displaced,  is  effected  by  traction 
on  the  foot  and  direct  pressure  on  the  astragalus  while  the  knee  is  flexed  to 
relax  the  calf  muscles.  If  the  dislocation  is  complete,  reduction  is  rarely 
possible,  and  excision  will  be  required 

Subastragaloid  dislocation  is  a  disnipture  of  the  joints  between  the 
astragalus,  and  the  os  calcis  and  scaphoid^  as  the  result  of  twisting.  It  is 
possible  for  the  foot  to  pass  forward,  backward,  inward,  or  outward,  but  in 
most  instances  the  displacement  is  backwards  and  inwards^  or  backwards  and 
outwards.     If  the  displcaement  is  backwards  and  inwards,  the  external 


Fig.  3 58,— Brace  for 
dislocated  s<^mi  lunar  car- 
tilage. The  mechanism 
fMfrmits  flexion  and  ex- 
tension ,  but  prcvcnti  rota- 
Lion.     (Walsham.) 


% 


312  JOINTS. 

malleolus  is  prominent,  while  the  situation  of  the  internal  is  occupied  by  a 
hollow.  The  foot  is  inverted  and  the  astragalus  conspicuous,  thus  resem- 
bling talipes  equino-varus.  If  the  dislocation  is  backwards  and  aiUufords,  the 
deformity  is  the  reverse  of  the  preceding  form  and  resembles  talipes  equino- 
valgus.  In  either  of  these  varieties  the  foot  is  shortened  on  the  dorsum  and 
the  heel  elongated,  while  the  tendo  Achfllis  forms  a  curve  which  is  concave  in 
the  direction  of  the  displacement. 

Reduction  is  accomplished  by  traction  in  an  opposite  direction  to  that  of 
the  deformity,  the  leg  being  flexed  or  the  tendo  Adullis  cut  to  secure  muscular 
relaxation.     The  foot  and  ankle  are  put  up  in  plaster  for  several  weeks. 

Dislocations  of  the  remaining  tarsal  bones  are  quite  rare,  and  are 
treated  by  extension  and  direct  pressure  upon  the  displaced  bone  or  bones. 

Dislocations  of  the  metatarsal  bones  are  uncommon,  and  cause  a  back- 
ward or  forward  projection  with  shortening  of  one  toe,  if  one  bone  is  dislo- 
cated, or  shortening  of  the  entire  foot,  if  all  the  bones  are  dislocated.  Reduc- 
tion is  made  by  extension  and  pressure,  a  splint  or  a  cast  being  worn  for  two  or 
three  weeks. 

Dislocations  of  the  toes  are  very  rare,  the  metatarso-phalangeal  joint  of 
the  great  toe  being  affected  most  frequently.  The  symptoms  and  treatment 
are  similar  to  those  of  like  injuries  of  the  hand. 


DISEASES  OF  JOINTS. 

Examination  of  a  diseased  joint  should  be  preceded  by  obtaining  the 

history  of  the  patient  and  of  the  disease. 

The  cause  of  most  joint  affections  is  injury,  infection,  or  nervous 
disturbances. 

If  the  cause  is  a  severe  injury  and  the  onsel  immediate  the  condition  is 
probably  a  sprain,  ruptured  ligament,  intraarticular  fracture,  or  a  dislocation. 
A  trivial  injury  followed  by  immediate  distention  of  a  joint  strongly  suggests 
hemarthrosis  due  to  hemophilia.  A  trivial  injury  followed,  after  an  interval, 
by  an  insidious  joint  disease  points  to  tuberculosis. 

Infecti<m  gains  entrance  through  a  wound,  extends  from  neighboring 
structures,  or  comes  by  way  of  the  blood,  e.  g.,  in  pyemia,  acute  infectious 
fevers,  syphilis,  gonorrhea,  and  tuberculosis.  Gout  and  rheumatism  may, 
at  least  for  convenience,  be  placed  under  this  heading,  although  some  might 
consider  *' faulty  metabolism**  a  more  appropriate  legend. 

The  nervous  disorders  which  may  be  responsible  for  joint  disease  are 
central  (e.  g.,  locomotor  ataxia,  syringomyelia),  peripheral  (e.  g.,  neuritis, 
section  of  nerves),  or  emotional  (e.  g.,  hysteria). 

As  the  nature  of  hemophilia  is  not  known,  it  will  not  fit  in  any  of  these 
classes. 

The  symptoms  of  a  general  nature,  when  present,  are  those  of  sepsis  or 
of  the  general  diseases  just  mentioned. 

The  local  symptoms  that  annoy  the  patient  are  pain  and  interference  with 
the  function  of  the  joint.  If  these  are  intermittent  the  trouble  may  be  due  to 
a  dislocated  cartilage  or  a  loose  body;  if  remittent  and  chronic  to  osteoar- 
thritis. Chronicity  with  slow  but  steady  progress  indicates  tuberculosb.  It 
should  be  recalled  that  pain  may  be  referred  to  distant  parts;  thus  hip  joint 
disease  may  cause  pain  in  the  knee,  disease  of  the  vertebral  joints  pain  in 


SYNOVITIS. 


the  areas  supplied  by  the  spinal  nerves,  A  number  of  joints  may  be  involved 
in  general  infectionst  e.  g.,  in  pyemia,  rheumatism »  gonorrhea,  osteoardiritis, 
and  in  the  acute  infectious  fevers. 

In  the  local  examination  one  should  always  compare  the  joint  with 
that  of  the  opposite  side. 

The  pasiiian  of  the  joint  is  generally  one  of  flexion ;  in  hysteria  it  may  be 
rigidly  extended* 

The  skin  may  be  white  in  tuberculosis,  ecchymolic  after  injuries,  hyper- 
emic  in  acute  inflammation.  Numbness  immediately  after  trauma  may  be  due 
to  local  shock;  persistent  anesthesia,  nerve  injury  or  hysteria. 

The  amount  of  sufeiling  may  be  accurately  determined  with  a  tape-meas- 
ure, being  careful  to  measure  the  corresponding  joints  on  each  side  of  the 
body  at  the  same  place  and  to  have  the  joints  in  the  same  position.  The 
situation,  shape,  and  consistency  of  the  swelling  should  be  noted.  It  may  in- 
volve the  joint  ca\ity  alone  (synovtis),  or  also  the  ends  of  the  bones  (arthritis), 
or  it  may  be  extraarticular,  e.  g.,  in  bursitis,  tenosynovitis,  cellulitis. 

Heal,  redness,  and  edema  are  characteristic  of  acute  inflammation^  some- 
times induced,  however,  by  irritating  applications. 

Atrophy  of  neighboring  muscles  may  occur  in  any  case  of  long  duration, 
even  in  hysteria,  but  is  most  marked  in  osteoarthritis  depending  upon  injur\^ 
or  inflammation  of  the  nerves  and  in  tuberculosis. 

Crepitus  on  pressure  or  motion  may  indicate,  by  its  character  (p.  6), 
blood  clot,  rice  bodies,  synovitis,  or  arthritis.  Its  exact  situation  must  be 
ascertained,  as  it  may  originate  in  adjacent  bursa?  or  tendon  sheaths,  a  fact 
that  can  sometimes  be  elicited  by  moving  the  bursa,  e.  g.,  prepatellar  bursa, 
or  the  tendons,  e.  g.,  those  of  the  wrist,  without  moving  the  joint. 

Alteration  of  the  relations  of  the  bany  landmarks  about  a  joint  indicates 
fracture  or  dislocation,  either  of  which  may  be  the  result  of  injur}'  or  disease. 

Modems ^  both  active  and  passive,  are  usually  restricted  or  abolished,  but 
occasionally  the  joint  may  be  abnormally  movable,  e.  g.,  in  Charcot's  disease. 
Caution  must  be  exercised  to  fix  adjacent  parts  lest  their  movement  be 
wrongly  interpreted  as  belonging  to  the  joint  under  inspection,  thus  the 
scapula  must  be  immobilized  in  examining  the  shoulder  Joint,  the  pelvis  in 
examining  the  hip  joint. 

The  X-ray  may  show  distension  of  the  joint  cavity,  lesions  of  the  carti- 
lages and  bones,  displacements,  movable  liodies,  and  similar  conditions. 

During  the  second  stage  of  general  anesthesia  rigidity  due  to  voluntary 
muscular  contraction,  e,  g.,  in  hysteria  and  in  malingerers,  ceases,  but  deep 
anesthesia  is  necessar>'  to  relax  involuntary  muscular  spasm.  Limitation  of 
movements  after  complete  anesthesia  indicates  ankylosis,  true  (p.  324). 

Aspiration  is  indicated  when  the  nature  of  an  effusion  is  doubtful. 

Incision,  for  exploration,  should  be  reserved  for  cases  in  which  all  other 
methods  of  diagnosis  fail  and  in  which  the  disability  is  marked. 

Synovitis  is  inflammation  of  the  synovial  memlirane  alone,  the  remaining 
structures  of  the  joint  being  unaffected.     It  may  be  acute  or  chronic. 

Acute  synovitis  is  caused  by  injury  or  cold,  or  it  may  be  secondary  to  dis- 
eases like  gout,  rheumatism,  gonorrhea,  syphilis,  pyemia,  and  the  infectious 
fevers.  The  synovial  membrane  is  red  and  swollen,  and  the  joint  is  dis- 
tended with  fluid  consisting  of  synovia,  inflammatory  exudate,  and  sometimes 
blood,  hence  it  is  coagulable.  Precipitated  lymph  may  be  absorbed,  or  be- 
come organized  and  result  in  adhesions. 


314  JOINTS. 

The  symptoms  are  pain,  tenderness,  increased  heat,  a  fluctuating  sveiliiv. 
and  in  some  cases  hyperemia  of  the  skin.  The  muscles  fix  the  joint  in  it 
most  comfortable  position,  usually  some  degree  of  flexion,  in  which  positiai 
there  is  more  room  for  the  fluid.  The  effusion  stretches  the  softer  tsam 
entering  into  the  formation  of  the  joint  and  leaves  it  a  little  weakened  mi 
relaxed,  at  least  temporarily.  Tlie  constitutional  symptoms  vaiy  wA 
the  cause  of  the  synovitis  and  the  size  of  the  joint.  Suppuration  rarely  occur 
except  in  wounds  of  joints  or  pyemic  conditions.  Effusion  ift  deteaed  in  the 
various  joints  as  follo^^'s:  The  shoulder  is  increased  in  size,  and  swelling  mar 
be  noticed  along  the  bicipital  groove  and  in  the  axilla.  In  subdeltoid  buiatis 
axillary  swelling  is  absent,  and,  although  active  motions  are  painful,  gende 
passive  movements  of  the  shoulder  may  be  painless.  In  the  elbow  the  svdl- 
ing  is  most  prominent  on  either  side  of  the  olecranon  and  tendon  of  the 
triceps.  In  the  wrist  swelling  is  most  marked  posteriorly.  In  the  kip  efc- 
sion  is  usually  not  detected,  but  reliance  is  placed  upon  the  tendenies&. 
limitations  of  movements,  and  upon  the  position  of  the  thigh  in  flexion,  abduc- 
tion, and  external  rotation.  In  the  knee  swelling  is  detected  upon  either  side 
of  the  patella  and  its  ligament,  and  beneath  the  quadriceps.  The  patdla  i« 
floated  away  from  the  condyles,  and  if  tension  is  not  too  great  it  may  be 
pushed  backward  by  the  fmger  and  made  to  tap  on  the  femur.  In  the  antit 
fullness  may  be  seen  in  front,  but  is  most  in  evidence  on  either  side  of  eidi 
malleolus. 

The  treatment  is  immobilization  and  elevation  of  the  joint,  and  in  the 
first  stage  cold  in  the  form  of  an  ice  bag  or  evaporating  lotions;  later  absorp- 
tion should  be  promoted  by  the  use  of  heat,  compression,  and  ointments  con- 
taining ichthyol,  belladonna,  mercury,  or  iodin.  If  the  effusion  is  large  or 
unaffected  by  other  forms  of  treatment,  aspiration  may  be  advisable.  Sup- 
puration demands  incision  and  drainage.  The  position  of  the  joint  should  be 
such  as  to  give  a  useful  limb  even  in  the  event  of  ankylosis.  TTius  the  elbow 
is  put  on  an  internal  angular  splint,  the  hip  and  knee  are  fixed  in  extension, 
the  wrist  midway  i)etwecn  tlexion  and  extension,  the  ankle  at  a  right  angle, 
and  the  shoulder  with  the  arm  to  the  side.  During  the  convalescing  stage. 
liniments,  massage,  and  elastic  compression  are  useful. 

Chronic  synovitis  follows  the  acute  form  or  is  chronic  from  the  begin- 
ning. The  synovial  membrane  is  thickened  and  the  joint  contains  an  exce?? 
of  lluid,  which,  when  large  in  quantity,  is  called  hydrops  articuli.  The  symp- 
toms are  slight  pain  when  the  joint  is  moved,  fluctuation  owing  to  the  presence 
of  effusion,  weakness  with  restriction  of  motion,  atrophy  of  neighboring 
muscles,  and  in  some  cases  crepitus  on  pressure  or  when  the  thickened  layer? 
of  synovial  membrane  are  rubbed  together  by  motions  of  the  joint.  In  some 
situations,  e.g.,  the  knee,  hypertrophied  synovial  fringes  may  be  palpated. 

The  treatment  is  immobilization,  compression,  and  counterirritation 
with  blisters,  iodin,  or  occasionally  the  actual  cautery;  stimulating  liniments 
and  massage  are  useful,  as  well  as  an  ointment  containing  equal  parts  o: 
irhthyol,  belladonna,  mercury,  and  lanolin.  Baking  the  joint  by  mean> 
of  a  .specially  constructed  hot-air  apparatus  (Fig.  56)  usually  gives  at  least 
temporary  relief.  Aspiration  is  occasionally  employed.  Arthrotomy  ii 
reserved  for  cases  whirh  resist  all  other  forms  of  treatment.  In  these  case? 
the  joint  is  irrigated  with  salt  solution  and  hypertrophied  fringes  removed: 
other  undiagnosticated  conditions,  such  as  loose  bodies,  ruptured  or  inflamed 
semilunar  cartilages,  lipoma  arbore.scens,  tuberculous  disease,  etc.,  may  be 


ARTHRITIS.  315 

■*  found  and  will  require  treatment.  Constitutional  treatment,  of  course, 
'i  should  be  administered  in  the  presence  of  any  diathesis. 
^  ^  Arthritis  is  inflammation  of  not  only  the  synovial  membrane,  but  also  the 
B  cartilages,  bones,  and  ligaments  of  an  articulation,  in  a  word  all  the  structures 
■  €f  a  joint.  It  may  be  acute  or  chronic,  and  arise  from  injuries,  extension 
I  from  neighboring  tissues  (most  often  bone),  infection  from  the  blood,  e.g.,  in 
I  pyemia,  syphilis,  gonorrhea,  gout,  tuberculosis,  and  acute  fevers  (variola, 
I  scaiiet  fever,  t3rphoid  fever,  measles,  erysipelas,  pneumonia,  etc.),  or  it  may 
c  be  due  to  nervous  influences.  Clinically,  arthritis  is  distinguished  from 
r  qrnovitis  by  the  tender,  swollen  articular  ends  of  the  bones,  by  the  greater 
;  pain  on  active  as  compared  with  passive  motion,  and  in  the  later  stages, 
I  after  the  cartilages  and  bones  have  become  eroded,  by  starting  pains  (p.  317), 
by  cartilaginous  or  bony  crepitus,  and  by  the  X-ray. 

Acute  infective  arthritis  is  always  due  to  micro-organisms,  which  enter 
the  joint  through  a  wound,  from  neighboring  tissues,  or  by  way  of  the  blood, 
e.g.,  in  pyemia  and  acute  infectious  diseases.  The  entire  joint  and  the  peri- 
articular structures  participate  in  the  inflammation,  which  in  the  event  of 
suppuration  destroys  the  cartilages,  relaxes  the  ligaments  (sometimes  permit- 
ting luxation),  and  invades  the  neighboring  bone  and  soft  structures. 

The  symptoms  are  great  pain  and  tenderness,  and  fixation  of  the  joint, 
which  is  hot,  swollen,  and  fluctuating.  There  are  redness  and  edema  of  the 
skin  and  severe  constitutional  symptoms  (septic  intoxication  or  septicemia). 
The  ends  of  the  bones  enlarge  (ostitis),  and  finally,  in  progressing  cases, 
ulcerate  (caries),  at  which  time  starting  pains  (p.  317)  may  occur  and  osseous 
crepitus  be  obtained.  If  proper  treatment  is  witheld  and  the  patient  survive, 
pus  perforates  the  capsule,  infiltrates  the  surrounding  tissues,  and  finally 
breaks  through  the  skin,  the  joint  becoming  abnormally  movable  and  dislo- 
cated to  a  greater  or  lesser  degree.  The  patient  may  die  from  toxemia  during 
the  acute  stage,  or  succumb  to  chronic  infection  and  exhaustion  in  the  later 
stages.  Should  recovery  ensue  ankylosis  is  almost  inevitable.  Joint  inflam- 
mations occurring  during  or  after  acute  infectious  fevers  more  commonly 
terminate  without  suppuration,  the  symptoms  then  being  much  like  those  of 
rheumatic  synovitis,  one  or  several  joints  being  involved.  In  some  cases, 
notably  in  typhoid  arthritis,  there  is  little  pain,  although  dislocation  may 
occur. 

•  The  treatment  in  the  absence  of  suppuration  is  that  of  acute  synovitis. 
In  doubtful  cases  aspiration  of  the  joint,  with,  if  need  be,  microscopic  exami- 
nation of  the  fluid,  will  reveal  the  presence  or  absence  of  pus.  In  suppurative 
arthritis  the  treatment  consists  in  freely  opening  the  joint,  irrigating  with  salt 
solution,  establishing  copious  drainage,  immobilizing  the  joint  in  a  useful 
position,  and  treating  constitutionally  as  for  sepsis.  Excision  or  amputation 
will  be  required  if,  after  free  drainage,  septic  symptoms  threaten  life. 

Gonorrheal  arthritis  (gonorrheal  rheumatism)  is  due  to  the  gonococcus, 
which  is  carried  by  way  of  the  blood  from  the  urethra,  or  rarely  from  the 
conjunctiva  in  gonorrheal  ophthalmia.  As  a  rule  it  appears  during  the  sub- 
siding stages  of  an  acute  gonorrhea  or  in  chronic  cases.  Men  are  said  to  be 
more  frequently  affected  than  women,  but  this  is  probably  owing  to  the  fact 
that  the  diagnosis  is  seldom  made  in  the  latter.  One  or  several  joints  may 
be  involved,  generally  the  former,  the  knee,  ankle,  and  wrist  being  most 
frequently  affected.  The  inflammation  may  be  acute  or  chronic,  and  varies 
in  extent  as  well  as  in  degree.    Although  the  s3movial  membrane  alone 


3t6  ^^^^F^T  joints, 

may  be  involved,  the  ligaments  and  periarticular  structures  are  very  apt  to 
be  thickened  and  infiltrated.  Except  in  the  mildest  cases,  the  pain  is  severe 
and  there  is  fever.  Suppuration  may  occur,  and  ankylosis  is  very  prone  to 
follow  even  the  milder  cases.  Endocarditis  and  like  complications  of  general 
infection  occasionally  occur.  In  doubtful  cases  some  of  the  fluid  from  the 
joint  may  be  secured  by  aspiration  for  bacteriological  examination. 

The  treatment  is  unsatisf  aclor>%  the  disease  being  apt  to  persist  or  recur 
The  urethritis  should  be  combated,  and  the  joints  immobilized  and  treated 
locally  as  in  other  forms  of  arthritis.  As  soon  as  the  pain  subside-s,  passive 
motions  should  be  employed  to  prevent  ankylosis.  Among  the  internal 
remedies  which  have  been  used  are  the  salicylates,  iron,  quinin,  strychnin, 
and  the  iodids.  If  suppuration  occurs,  the  joint  should  be  opened,  irrigated, 
and  drained.  Rogers  and  Torrey  claim  good  results  from  the  hypodernaic 
injection  of  an  antigonococcus  serum,  prepared  by  injecting  cultures  of  the 
gonococcus  into  rabbits.  From  twenty  to  sixty  minims  are  administered 
every  day  or  every  other  day  until  the  pain  and  disability  subside.  Vaccines 
made  from  the  gonococcus  also  have  been  employed. 

Syphilitic  gummatous  arthritis  occurs  in  the  tertiary  period.  The  on- 
set is  insidious;  the  disease  begins  in  one  portion  of  the  joint,  and  is  associated 
with  but  litde  pain.  If  unchecked  it  finally  reaches  the  surface,  when  the  ciiar- 
acteristic  gummy  material  will  be  exposed.  The  symmetrical  form  of  syno- 
vitis occurring  in  the  secondar)'  period  has  already  been  mentioned.  There 
is  also  a  form  of  gummatous  synovitis  resembling  tuberculosis,  and  a  form  of 
chondro arthritis  analogous  to  osteoarthritis.  The  histor>',  the  evidences  of 
syphilis  elsewhere,  the  Wassermann  reaction ^  and  the  response  to  appropri- 
ate treatment,  are  important  factors  in  making  the  diagnosis.  The  treatmeni 
is  that  of  syphilis;  excision  or  amputation  may  sometimes  be  required. 

Tuberculous  arthritis  (white  su*eiiingy  pulpy  degauraium)  is  much  more 
common  in  children,  the  joint  generally  being  invaded  from  an  adjacent 
epiphysis;  in  adults  the  primary  focus  is  probably  in  the  synovial  mem- 
brane as  often  as  it  is  in  the  neighboring  bone.  The  tubercle  bacillus  is  trans- 
ported by  the  blood  to  the  joint,  in  which  an  area  of  lessened  resistance  has 
often  l)een  created  by  some  slight  injur)',  the  patient  possessing  a  hereditary 
predisposition  to  the  disease. 

The  pathological  anatomy  is  as  follows:  Wlien  beginning  in  the  syn- 
ovial membrane,  whitish  or  pinkish  pulpy  granulations  are  formed  and  even- 
tually fill  the  joint,  giving  a  characteristic  doughy  feel  In  other  cases  the 
membrane  is  covered  mth  small  tubercles  and  the  joint  is  filled  with  fluid. 
The  tubercles  caseale  and  liquefy,  forming  tuberculous  pus.  The  ligaments 
become  softened  and  finally  destroyed;  the  cartilages  are  eroded  and  eventu- 
ally the  bones;  and  the  surrounding  soft  tissues  are  edematous.  Wlien  the 
disease  begins  in  the  bone,  tlie  changes  are  those  of  tuberculous  ostitis  (p.  290),  J 
the  joint  being  affected  secondarily.  In  any  case  the  tuberculous  pus  gener-  | 
ally  finds  its  way  to  the  exterior  by  one  or  more  sinuses.  " 

The  symptoms  are  very  slow  in  onset.  At  first  there  is  slight  pain,  caus- 
ing some  limitation  of  motion  and,  in  the  lower  extremities,  limping.  Later, 
swelling  is  noticed  and  the  muscles  rigidly  hold  the  joint  in  a  semiflexed  posi- 
tion. In  a  well  developed  case  the  joint  is  spitidk- shaped,  due  not  only  to  the 
swelling,  but  also  to  the  atrophy  of  the  neighboring  muscles,  and  the  skin  is 
wkikf  owing  to  obliteration  of  the  subjacent  vessels,  and  is  adherent  to  the 
parts  beneath.    A  peculiar  doughy  or  elastic  sensation  is  imparted  to  the 


y 

^ 


d 


TUBERCITLOSTS   OF  JOINTS. 


317 


fingers  on  palpation,  but  fluctuation  is  detected  only  when  a  cold  abscess 
approaches  the  surface,  or  in  the  rare  cases  in  which  the  effusion  predomi* 
nates.  Rice  bodies  are  sometimes  found  in  the  latter  variety.  Night  cries 
{starting  pains)  indicate  erosion  of  cartilage  or  bone;  when  the  patient  falls 
asleep  the  rigid  muscles  relax,  permitting  some  alteration  in  the  relation  of 
the  joint  surfaces,  and  producing  severe  pain  which  causes  the  patient  to 
wake  with  a  start.  Partial  or  even  complete  luxatimt  may  be  induced  by 
tonic  contractions  of  the  muscles  upon  the  disorganized  joint.  The  local 
temperature  of  the  joint  is  raised,  and  later,  w^hen  sinuses  form,  hectic  fever 
develops  owing  to  mixed  infection* 

The  diagnosis  may  be  diffu  ult  in  the  eariy  stages,  in  deep  seated  joints, 
and  in  cases  with  a  large  effusion,  which  resembles  chronic  synovitis.  The 
examination  of  aspirated  tluid  and  the  X-ray  are  often  of  great  value,  and 
some  recommend  the  tuberculin  test.  Doubtful  cases  should  be  regarded  as 
tuberculous. 

With  proper  treatment  the  prognosis  is  good  regarding  life,  metastases 
being  uncommon.  Ankylosis  generally  follows,  and  indeed  is  nature*s 
method  of  cure.  In  late  cases*  i.e.,  those  with  sinuses,  the  patient  may 
dei'elop  amyloid  disease  or  die  of  exhaustion. 

The  treatment  is  consthutional  (p.  135)  j^nd  iocaL  The  local  treatment 
in  the  early  stages  is  immobilization,  often  for  months,  by  sphnt,  plasler-of- 
Paris,  or  extension  apparatus.  Baking  with  the  hot-air  apparatus  has  been 
used.  Bier's  method  has  already  been  mentioned.  An  aspirating  needle 
may  be  introduced  into  ihe  joint,  any  existing  Buid  allowed  to  drain  away,  and 
10  per  cent,  iodoform  emulsion  (two  to  live  drams  according  to  the  age  of 
the  patient)  or  other  antiseptic  (p.  135)  injected  into  the  joint  at  intervals 
of  a  w*eek  or  longer.  As  soon  as  detected,  abscesses  shouUi  be  tapped  with 
a  large  trocar  and  cannula,  irrigated  with  salt  solution,  and  injected  with 
iodoform  emulsion.  If  the  disease  continues  to  progress,  or  if  the  general 
condition  of  the  patient  is  such  as  to  forbid  prolonged  treatment,  the  joint 
should  be  opened  and  the  tuberculous  tissue  removed  by  erasion  (arthrec- 
tomy)  or  excision,  according  to  its  extent.  Amputation  is  indicated  in  cases 
too  far  advanced  for  excision,  or  in  cases  in  which  excision  has  failetl, 

Tubercnlosis  of  Special  Joints. —  In  the  shoulder  joint  the  disease  is 
more  frec^uent  in  adults  than  in  children,  but  is  not  common  in  either.  It  usu- 
ally begins  in  the  head  of  the  humerus  and  rarely  attacks  the  glenoid  cavity. 
Abscesses,  which  are  rather  unusual,  point  on  cither  side  of  the  deltoid  or  in 
the  axilla.  In  caries  sicca,  which  occurs  more  often  here  than  in  any  other 
joint,  instead  of  doughy  swelling,  there  is  shrinkage  due  to  muscular  atrophy 
and  destruction  of  the  head  of  the  humerus.  Immobilization  should  be  per- 
sisted in  for  a  number  of  months.  If  sinuses  form,  however,  excision  of  the 
head  of  the  humerus  w^ill  usually  be  required. 

The  elbow  is  affected  more  often  than  either  the  shoulder  or  the  wTist;  the 
disease  is  most  frequent  during  adolescence,  beginning,  in  the  order  ol  their 
frequency,  in  the  synovial  membrane,  or  in  the  epiphysis  of  the  humerus, 
ulna,  or  radius.  The  characteristic  spindle-shaped  swelling  is  well  marked* 
Abscesses  point  on  either  side  of  the  olecranon,  or  occasionally  follow  the 
ulnar  nerve  and  present  on  the  inner  side  of  the  arm.  Immobilization  at  a 
right  angle,  with  the  forearm  midway  between  pronation  and  supination,  is 
ihe  correct  treat menl  in  the  early  stages,  Ijut  if  the  bones  are  much  involved, 
either  erasion,  or  in  adults  excision,  is  the  quickest  and  best  treatment. 


3i8 


JOINTS. 


Tuberculosis  of  the  wrist  is  comparatively  infrequent,  but  may  be  met 

with  at  all  ages.  It  may  begin  in  the  synovial  membrane,  or  be  secondar)' 
to  disease  in  the  carpal  bones,  lower  end  of  the  radios,  or  neighboring  tendon 
sheaths.  If,  after  several  months  of  immobilisation  v^ith  or  without  in- 
jections, the  disease  is  not  checked,  erasion  or  excision  is  usually  advisable^ 
and  if  the  disease  is  very  extensive,  amputation  will  offer  the  only  hope  of 
relief. 

Tuberculosis  of  the  sacroiliac  joint  is  of  infrequent  occurrence,  and  is 
most  commonly  seen  in  adults.  It  may  be  synovial  in  origin  but  more 
often  arises  in  adjacent  bones.  There  is  pain  in  the  back,  in  the  joint,  or 
do\\Ti  the  thigh,  which  is  increased  on  standing,  walking,  or  rocking  the  pelvis 
with  the  hands.  The  patient  limps  and  puts  most  of  his  weight  on  the  sound 
leg,  the  body  being  bent  forw  ard  and  away  from  the  affected  side,  thus  caus- 
ing apparent  lengthening  of  the  limb  corresponding  lo  the  diseased  joint . 
There  may  be  swelling  and  tenderness  directly  over  the  articulation,  and  in 
the  later  stages  abscesses  discharge  in  this  situation,  in  the  lumbar  region, 
in  the  iliac  fossa,  in  the  groin,  or  even  alongside  the  rectum. 

The  diagnosis  may  be  difficult  in  the  early  stages.  Lumbago  follows  expo- 
sure to  cold,  affects  both  sides,  and  is  transient  in  character.  Sciatica  causes 
a  ver>*  severe  shooting  pain,  tenderness  of  the  nerv^e,  no  apparent  lengthening 
of  the  limb,  and  no  increase  in  pain  when  the  iliac  bones  are  pressed  together 
or  pulled  apart.  Hip  disease  causes  rigidity  of  adjacent  muscles  and  limi- 
tation of  hip  movements,  which,  if  the  pelvis  is  supported,  are  not  present  in 
sacroiliac  disease.  If  there  is  an  iliac  abscess  in  sacroiliac  disease,  the  thigh 
may  be  fiexed,  but  the  hip  can  he  freely  moved.  In  disease  of  the  spin^  diere 
are  pain,  tenderness,  rigidity,  and  perhaps  deformity  in  the  affected  segment. 
The  prognosis,  owing  to  the  deep  situation  of  the  joint,  is  often  unfavorable. 

The  treatment  is  rest  in  bed  with  a  felt  or  plaster-of-Paris  case  for  the  pelvis. 
If  abscesses  form,  the  joint  should  be  opened,  and  the  diseased  tissue  removed 
as  thoroughly  as  possible,  with  gouge,  chisel,  or  curette. 

Hip  joint  disease  {mortms  c&xee,  coxitis,  c&xaigia)  without  qualification 
means  tuberculosis  of  the  hip,  although  any  other  form  of  joint  disease  may 


Ftc  atg. — Lordosis  of  lumbar  spine 
when  limo  is  straight.  P:  Psoai  muscle. 
(Walsham.) 


Fig.  240. — Disappearance  of  lordo- 
sis when  limb  is  flexed.  P.  Psoas 
miiscle.     (Walsham.) 


occur  in  this  articulation.  The  disease  may  originate  in  any  of  the  structures 
of  the  joint,  but  the  primary  lesion  is  most  often  in  the  femoral  epiphysis. 
It  is  ver)'  much  more  frequent  in  children  than  in  adults. 

The  symptoms  in  the  beginning  are  slight  lameness  and  stiffness  of  the 
hip.  Pain  is  present  in  the  hip  or  along  the  inner  side  of  the  knee  (both  joints 
being  supplied  by  the  obturator  nerve),  and  is  increased  by  movements  of  the 
joint.  Very  likely  a  history^  of  tuberculous  disease  in  the  immediate  ancestors, 
and  a  history  of  a  slight  injury,  will  be  obtained.  Examination  reveals  limi- 
tation of  the  movements  of  the  hip  and  slight  flexion,  flue  to  rigidity  of  the 
muscles  which  guard  tlie  joint  With  the  child  in  the  recumbenl  posture 
the  lumbar  spine  will  curve  forwards  if  the  knee  on  the  affected  side  is  pressed 


TUBERCULOSIS   OF   JOINTS. 


319 


t  to  the  table  (Figs,  259,  240).  Slight  fullness  about  the  joint  or  mus- 
int  atrophy  may  be  observed  at  this  time.  With  the  progress  of  the  dis- 
ease flexion  increases  and  is  associated  with  abduction  and  eversion  of  the 
thigh,  a  position  which  relaxes  the  ligaments,  increases  the  capacity  of  the 
joints  and  thus  secures  the  greatest  comfort.  If  the  patient  stands  or  walks, 
most  of  the  weight  is  borne  on  the  sound  leg,  Lausing  lowering  of  the  pelvis 
on  the  diseased  side  with  apparent  lengthening  of  the  limb  (Fig.  241 -B),  and 
a  compensatory  lateral  curve  of  the  lumbar  spine,  convex  towards  the  affected 
side.  Flexion  may  be  obscured  by  compensatory  lordosis,  abduction  by 
tilting  of  the  pelvis  and  lateral  curving  of  the  lumbar  spine,  but  eversion 
is  never  masked.     At  this  stage  muscular  rigidity  is  well  marked,  the  pelvis 


^ 


i 


Fig.  241. — Effecis  of  abduction  (A)  and  adduction  (C)  in  causing  apparent  lengthening 
(B)  and  apparent  shortening  (D)  of  ihe  limb  in  hip  disease,  when  the  limbs  arc  pamilen 
Note  effect  on  lumbar  spine.     In  C  and  I)  foot  should  be  inverted,     (Walsham.) 

moving  upon  any  attempt  to  move  the  thigh ;  if  the  lumbar  spine  is  made  to 
approach  the  table  by  flexing  the  sound  thigh  on  the  abdomen,  the  thigh  on 
the  diseased  side  will  rise  according  to  the  amount  of  flexion  present.  The 
gluteal  crease  is  obliterated  (due  to  muscular  atrophy  and  flexion)  or,  if 
present,  is  on  a  lower  level  than  its  fellow,  and  some  fullness  may  be  detected 
in  the  upper  part  of  Scarpa's  triangle.  Pain  increases,  is  rendered  more 
severe  by  any  jarring  motion  to  the  knee  or  foot,  and  is  apt  to  wake  the 
patient  suddenly  from  sleep  (night  cries,  starting  pains).  Abscesses  may 
now  form  and  point  in  the  buttock,  above  or  below  Poupart's  ligament, 
on  the  inner  side  of  the  thigh,  or  most  frequently  at  the  front  of  the  great  tro- 
chanter; hectic  fever  is  thus  established,  and  anemia  and  emaciation  become 
more  marked.  The  ligaments  are  softened  and  weakened,  the  limb  flexed, 
adducted,  and  inverted,  the  pelvis  elevated  on  the  diseased  side,  and  the  lum- 
bar spine  convex  towards  the  sound  side.  Hence  the  limb  appears  shortened 
(Fig.  241 -D);  later,  owing  to  erosion  of  bone  or  in  some  cases  to  tlislocation 
backwards,  real  shortening  becomes  evident.  Ankylosis  and  recover}^  are 
possible  at  any  period ;  death  occurs  from  tuberculosis  elsewhere,  or  in  the 
late  stages  from  septicemia,  exhaustion,  or  amyloid  disease. 

The  diagnosis  may  be  very  difhcult  in  the  early  stages.  The  patient 
should  always  be  stripped  and  both  sides  carefully  examined.  Pain  in  the 
knee,  especially  in  a  child,  always  indicates  a  careful  examination  of  the  hip. 
Spinal  disease,  sacroiliac  disease,  infantile  paralysis,  and  other  conditions  not 


3» 


JOINTS. 


I 


immediately  connected  with  the  joint  are  not  associated  with  restricted  motiom 
of  the  hip.  In  inflammation  of  the  subpsoas  bursa  there  may  be  pain  on 
extending  the  hip,  but  after  Jlexion  the  thigh  may  be  rotated  without  dis- 
comfort.  In  gluteal  bursitis  there  may  be  limp  and  restriction  of  motion^  but 
not  the  characteristit  deformity  of  hip  disease;  in  some  cases  fluctuation  or 
crepitus  may  be  obtained  over  the  bursa.  In  flexion  of  the  thigh  due  to  intra- 
abdominal disease,  Oie  movements  of  the  hip  are  free.  Any  form  of  joint 
disease  may  occur  in  the  hip,  and  if  the  synovial  cavity  is  distended  there 
will  be  flexion,  abduction,  and  eversion.  Chronic  inflammation  of  the  hip 
in  childhood  should,  however,  always  be  regarded 
as  tuberculous  unless  proved  otherwise.  The  X-ray 
is  of  value  in  differentiating  from  dishcaJian  and  in 
determining  the  presence  and  extent  of  bone  disease. 
The  prognosis  is  favorable  if  the  diagnosis  is  made 
early  and  the  proper  treatment  instituted.  In  the 
later  stages  recover}^  will  always  be  associated  with 
shortening  and  ankylosis. 

The  treatment  in  the  early  stages  is  rest  in  bed, 
and  traction  Ijy  Buck's  exieosion  apparatus  to  over- 
come muscular  spasm  and  prevent  deformity.  If 
flexion  is  marked,  extension  should  be  at  first  in  the 
axis  of  deformity,  and  as  the  muscular  spasm 
diminishes,  it  may  be  gradually  lowered  to  a  hori- 
zontal position.  Young  children  who  are  difficult  to 
keep  still  should  be  strapped  to  a  Bradford  frame. 
The  proper  weight  for  traction  will  vary  between 
one  and  six  pounds  or  more,  according  to  the  age 
and  the  effects  of  the  extension.  The  constitutional 
treatment  is  that  of  tuberculosis  in  general  (p*  155). 
When  the  deformity  has  been  corrected  and  pain 
has  subsided,  a  brace  may  lie  applied  and  the 
patient  allowed  to  get  about  on  crutches.  Of  the 
many  mechanical  appliances  which  have  been  used,  the  Thomas  hip 
splint  (Fig.  242)  or  one  of  its  modifications  is  the  most  useful.  A  palten  or 
thick  soled  shoe  is  worn  on  the  foot  of  the  sound  side,  and  the  patient  walks 
with  crutches,  the  afifected  limb  hanging  some  distance  away  from  the  ground, 
thus  acting  as  an  extension  weight.  In  the  presence  of  deformity  the  brace 
may  be  bent  to  accommodate  itself  to  the  altered  position  of  the  iimb.  Some 
surgeons  apply  plaster-of-Paris  to  the  limb  and  pelvis.  Traction  splints  are 
those  which  may  l)e  lengthened  by  a  sliding  rod  or  movable  foot  piece, 
counterextension  being  supplied  by  perineal  bands.  A  brace  should  be 
worn  for  six  months  a'ter  all  symptoms  have  disappeared.  Intraarticular 
injections  of  iodoform  or  other  antiseptics  are  occasionally  used.  Abscesses 
should  be  tapped  with  trocar  and  cannula  and  injected  with  iodoform  emul- 
sion. Sinuses  may  be  injected  with  Beck's  paste,  but  if  they  persist  or  recur 
they  should  be  explored,  and  necrotic  or  carious  bone  removed  by  erasion. 
Formal  resection  of  the  hip  results  in  immediate  shortening,  and  in  children 
interferes  with  the  growth  of  the  femur,  so  that  it  should  not  be  performed 
unless  the  disease  progresses  despite  other  means  of  treatment.  If  excision 
fails,  or  if  there  is  an  extensive  osteomyelitis  of  the  femur,  amputation  will 
be  required. 


Fig.  242. — ThoinEih  hi|> 
splint.  Palten  on  sound 
limb. 


» 


The  knee,  with  the  possible  exception  of  the  hip,  is  more  frequently 
attacked  by  tubenulosis  than  any  other  joint.  The  term  white  swdUng 
when  used  alone  means  tuberculosis  of  the  knee.  In  children  the  disease 
usually  begins  in  the  lower  end  of  the  femur,  in  adults  in  the  syno\^a!  mem- 
brane. The  symptoms  are  those  of  joint  tuberculosis  in  general.  Flexion 
is  present,  and  in  the  later  stages  backward  dislocation  of  the  tibia  often 
occurs.  The  treat m^tf  is  immobilisation  with  plaster-of -Paris  or  a  traction 
knee  splint  (Fig,  243).  Iodoform  injections  are  often  useful.  If  the  progress 
of  the  disease  is  not  checked  liy  these  measures,  or  if 
the  case  is  seen  in  a  late  stage,  erasion  or  excision  will 
be  indicated.  Amputation  should  be  reserved  for  cases 
in  which  the  disease  is  ver>'  extensive*  or  in  w^hich  exci- 
sion has  failed. 

Ankle  joint  disease  begins  most  frequently  in  the 
synovial  memlirane,  next  in  the  astragalus;  it  may,  how- 
ever, commence  in  the  tibia  or  fibula,  or  be  secondary  tu 
disease  of  the  tarsus  or  tendon  sheaths.  The  usual 
symptoms  of  joint  tuberculosis  are  present;  the  foot  is 
extended,  as  in  this  position  the  narrowest  part  of  the 
articulating  surface  tif  the  astragalus  is  between  the 
tibia  and  fibula.  Anteropasteriur  movements  are 
marketlly  limited,  but  inversitni  and  eversion  of  the  foot 
may  be  made  if  the  subastragalui^I  anil  mid-larsal  joints 
are  free  of  disease,  The  trait mrnt  is  immobilization  in 
plasler-of -Paris  with  the  foot  at  a  right  angle  to  the  leg. 
Iodoform  injections  may  be  tried  U  the  disease  continues 
to  progress.  In  the  presence  of  sinuses  or  disorganiza 
lion  of  the  joint  erasion  or  excision  should  be  per- 
formed. The  disease  is  apt  to  invade  other  tarsal  bones 
besides  the  astragalus  and  to  extend  into  the  surrounding 
soft  tissues;  in  these  cases  amputation  will  be  the  opera- 
tion of  choice. 

Rheumatic  arthritis,  when  ande,  is  characterized 
by  fever,  atifl  and  sf>ur  smelling  sweats,  concentrated 
highly  acid  urine»  and  by  the  successive  involvement  of 
a  number  of  joints;  and  il  is  often  complicated  by  sore  throat,  pericarditis, 
endocarditis,  or  pleurisy.  The  history  of  previous  attacks  is  often  obtained. 
There  is  nothing  characteristic  in  the  local  symptoms  ttj  distinguish  it  from 
infective  arthritis,  indeed,  many  believe  it  to  be  infective  in  origin,  and  even 
incision  and  irrigation  of  the  joints  have  been  recommended.  For  a  full 
consideration  of  this  subject  the  reader  is  referred  to  a  book  on  practice  of 
medicine,  it  being  necessar}-  in  this  place  only  to  caution  against  a  too  ready 
diagnosis  of  rheumatism  without  a  i  arcful  investigation,  particularly  if  but 
one  joint  is  involved. 

In  the  chronic  variety  the  history,  the  involvement  of  several  joints,  the 
presence  of  cardiac  lesions,  and  the  detection  of  rheumatic  nodules  on  tendons 
or  fasctia,  or  about  joints,  will  usually  lead  to  a  correct  diagnosis.  The  syn- 
ovial membranes  and  the  ligaments  are  thickened  and  sometimes  the  carti- 
lages eroded:  grating,  or  crepitus,  may  be  felt  on  moving  the  joint,  and  anky* 
tosis  occasionally  occurs.  In  the  latter  event  adhesions  may  be  broken 
under  cthen 


li;.  24  J. — TbumaA 
kni-f  splifiL  The 
metal  plate  is  several 
inches  below  the  foot. 
A  pa  I  ten  is  worn  on 
ihc  Hrjunfi  foal,  and 
the  apparatus  is  sus- 
pend erf  Uy  the  strap 
over  the  opposite 
shouldtT 


i 


322 


JOINTS. 


Gouty  arthritis  is  rharactertzed  by  sudden  severe  pain,  which  oktn 
romes  on  during  the  night  and  attacks  the  smaller  joints,  particularly  \hx\ 
Ijetween  the  great  toe  and  its  metatarsal  Inme.  The  articulation  Is  swollen, 
ihe  skin  redt  shiny »  and  edematous?,  and  there  is  moderate  fever.  A  histor>'(rf 
previous  attacks  may  be  elicited,  and  other  e\idences  of  gout,  e,g.»  icpkt 
(chalky  deposits  in  or  around  the  joint),  dyspepsia,  and  atheroma  may  be 
present.  For  the  treatment  the  reader  is  referred  to  a  book  on  intemal 
medicine. 

Osteoarthritis  (rhmmatoid  arthrUis,  arthrhh  defarmansy  rheumaiic  gtnd^ 
malum  seniir)  is  a  chronic  disease  of  joints  associated  with  great  deformity. 
The  cause  is  not  known.  Some  believe  it  to  be  of  nervous  origin  because  of 
the  accompanying  trophic  lesions,  others  that  it  is  due  to  micro-organisms 
because,  in  about  half  the  cases,  it  is  preceded  by  some  infectious  disease.  It 
is  more  common  in  women,  and  is  sometimes  associated  with  disease  of  the 
uterus  or  ovaries.  Traumatism  is  often  a  factor  in  monarticular  cases;  the 
disease  is  not  ver)^  uncommon  in  the  old  after  a  Colles*  fracture,  or  after  a 
fracture  of  the  neck  of  the  femur.  It  may  occur  at  any  period  of  life,  but  i< 
most  frerjucnt  after  middle  age.  The  cartilages  become  eroded  and  the  cnii^ 
of  the  bones  exposed,  the  synovial  membrane  and  the  ligaments  are  markcdb 
thickened,  and  exostoses,  or  osteophytes,  form  about  the  joint,  leading  tu 
ankylosis  and  great  deformity.     Partial  dislocation  may  occur. 

The  disease  begins  in  several  ways:  k  Hehtrden's  nodes  are  UiUe  hard 
knobs  developing  on  the  <iorsal  surfaces  of  the  second  and  third  phaJange>. 

subsequently  to  recurring  at- 
tacks of  inflammation  in  ibc 
inteq>halangeal  joints,  which 
Inially  become  ankyloseil. 
They  are  most  cominon  in 
neurotic  women  between  I  he 
ages  of  thirty  and  forty,  an<i 
»i  i  li^Jo'vS^  are    incurable.       a.    Genrfd 

progressive  osleoarthrUis  \yt- 
gins  as  an  acute  process 
somewhat  resembling  rheu- 
matism, or  more  commonly 
in  a  chronic  manner.  In  the 
latter  variety  the  joints  of  the 
hands  usually  swell  and  be 
come  tender,  and  with  the 
subsidence  of  inllammation 
they  creak,  becoming  mort* 
and  more  deformed  with 
each  succeeding  attack.  Other  joints  are  gradually  involved,  until  in  the 
worst  cases  praci^icaUy  ever}'  articulation  in  the  body  may  be  affected.  The 
muscles  atrophy  and  by  their  contractures  further  increase  the  deformity. 
The  progress  of  the  disease  is  very  slow,  and  although  no  remedy  is  known,  it 
may  be  spontaneously  arrested  at  any  stage.  3-  The  monarticular  form  \s 
the  only  c^ne  which  concerns  the  surgeon.  It  occurs  rhietly  in  old  men  suh- 
sc<]uently  to  injury.  In  the  hip  il  is  known  as  morbus  foxcc  senilis,  in  the  spine 
as  afxmdylilis  deformans;  spoftdylosts  rhizomdiquc,  or  ankylosis  of  the  spine, 
hips,  and  shoulders  is  a  form  of  osteoarthritis.     In  the  early  stage  there  are 


Fig.  244. — Usleoarthrilis  of  elbow;  note  ostco- 
phylcs  and  cnoritious  li|js  on  the  ends  of  ihe  bones 
(Maullin.) 


W 


HYSTERICAL  JOINT, 


323 


pain,  stiffness,  and  perhaps  a  little  swelling  and  creaking  in  the  joint.  Later 
motion  is  less  free,  bony  crepitus  becomes  eudent,  neighboring  muscles 
airophvt  osteophytes  form,  and  tinally  ankylosis  occurs.  Occasionally, 
however,  the  joint  becomes  Umjsc  and  the  bones  displaced.  The  diagnosis  is 
made  by  the  chronic  nature  of  the  atTection,  the  absence  of  suppuration,  the 
deformity  (lipping  of  the  ends  of  the  hones  and  osteophytes — Fig.  244), 
crepitus,  the  frequent  history  of  injury^  and  the  advanced  age  of  the  patient 
The  ffrognosis  is  unfavorable. 

The  treat metU  is  unsatisfactory.  The  general  health  should  l^e  improved, 
colds  and  draughts  avoided,  and  perhaps  iodid  of  sodium  or  arsenic  adminis- 
tered,  UTien  the  joints  are  swollen  and  tender  they  should  be  treated 
like  synovitis.  During  the  c|uiesccnt  perioil,  the  hot-air  apparatus,  stimulat- 
ing h^niments,  massage,  and  passive  motions  are  useful,  as  they  hinder  the 
development  of  ankylosis.  WTicn  the  disease  is  h*mited  to  one  joint,  e.g.,  the 
temporomaxillar}',  shoulder,  elbow,  or  knee,  excision  may  be  performed  if 
the  function  of  the  articulation  is  seriously  disturbed. 

Neurop&thic  arthritis  resemliles  osteoarthritis,  and  is  the  result  of 
disease  or  injury  of  the  central  or  peripheral  nervous  system.  That  form 
occurring  in  locomotor  ataxia  is  called  Charcots  disease.  The  joints  of  the 
lower  extremity »  particularly  the  knee,  arc  most  frequently  affected.  As  the 
result  of  a  slight  injury,  or  often  without  such  history,  the  joint  rapidly  and 
painlessly  swells,  and  in  even  a  few  hours  may  be  dislotated,  or  so  freely 
movable  that  it  can  be  beni  in  any  direction.  The  disease  may,  however, 
run  a  chronic  course  and  tni\  in  ankylosis.  A  somewhat  similar  joint  affec- 
tion occurs  in  syringomyelia,  but  the  joints  involved  are  usually  those 
of  the  upper  extremity,  and  suppuration  is  more  frequent  than  in  Charcot*s 
disease. 

The  treatment  of  neuropathic  arthritis  includes  that  of  the  causative  dis- 
ease. In  some  forms  massage  and  passive  motions  are  indicated,  but  in 
Charcot*s  disease,  if  there  is  a  tendency  towards  ankylosis,  it  should  be  en- 
courage^i.  As  this  is  seldom  the  case  some  form  of  support  will  usually  l>e 
required.  Resection  has  been  performed,  but  is  not  generally  regarded  with 
favor.  If  suppuration  or  extensive  disorganization  occurs,  amputation 
might  be  the  best  treatment. 

Neuralgia  of  joints  usually  depends  upon  some  local  or  constitutional 
cause,  although  cases  occur  in  which  neither  of  these  can  be  found.  After 
injur)'  loose  bodies,  adhesions,  or  small  areas  of  inflammation  may  be  respon- 
sible. It  may  be  due  to  disease  of  the  central  or  peripheral  nervous  system, 
or  be  retlejc  from  disease  or  injury  of  nerve  libers  coming  from  the  same 
trunk  that  supplies  the  joint,  and  it  may  be  associaietl  with  gout,  rheumatism, 
syphilis,  malaria,  neurasthenia,  or  hysteria.  Like  neuralgia  elsewhere,  the 
pain  is  paroxysmal.  The  treatment  is  that  of  the  causative  lesion,  if  such  can 
be  found;  other  cases  are  treated  as  neuralgia  elsewhere. 

Hysterical  joint  (rwuromirfiesis)  is  characterized  hy  pain  and  tenderness, 
hyperesthesia  or  anesthesia  of  the  overlvdng  skin,  rigidity  of  the  joint,  mus- 
cular atrophy  from  disuse,  and  absence  of  local  heat  and  swelling,  unless  these 
be  present  from  the  use  of  irritating  applications.  The  condition  is  most 
frequent  in  the  knee  and  hip,  usually  of  young  women.  Some  cases  follow 
injury,  others  arise  spontaneously.  1'he  diagtwsis  is  made  by  carefully 
excluding  all  organic  disease,  and  f>y  finding  associated  symptoms  of  hysteria. 
The  joint  may  be  fixed  in  a  position  contrary  to  that  usually  assumed  in  dis- 


324  JOLVTS. 

eaMr.  and  be  freely  movable  under  light  anesthesia  or  niien  the  padoit's  attai- 
tion  is  diverted.  The  position  of  the  limb  may  raxy.  sometimes  quite  sod- 
(ienly.  The  trtatment  is  that  of  hysteria.  Elearidty.  massage,  and  passTc 
motions  are  useful,  but  may  do  harm  by  concentrating  the  paxient's  ancntioa 

upf^n  the  joint. 

Hemiithrosis  (effusion  of  blood  into  a  joint),  apart  from  in  jury,  may  be 
due  to  a  numlxrr  of  causes  (see  sp>ontaneous  hemorrhage).  In  hemophilia. 
following  a  slight  injur>'  or  sometimes  sp>ontaneously.  a  joint  becomes  dis- 
tende<j  vvith  blood,  which  may  gradually  be  absorbed,  leaving  the  joint  again 
normal,  or  Ixxome  organized  and  lead  to  adhesions  and  oUiteration  of  the 
joint.  l*he  histor}'  is  the  most  important  factor  in  diagnosis.  The  treaimaU 
is  immobilization  and  compression.  Massage  and  passive  motion  may  be 
used  with  caution  in  the  later  stages.  Under  no  circumstances  should  the 
joint  be  aspirated  or  opened,  as  such  treatment  might  be  foUowed  by  uncoo- 
trollable  hemorrhage. 

Loose  bodies  in  joints  {joint  mice)  consist  of  bbrin,  fatty  tissue,  fibious 
tissue,  cartilage,  or  bone.  Those  made  of  fibrin  are  usually  small  and  numer- 
ous, and  are  best  seen  in  tuberculosis  of  joints,  bursas,  or  tendon  sheaths  (rice 
bodies).  <^)c( asionally  they  are  due  to  other  causes,  e.g.,  a  small  foreign 
tK)dy,  blood  clot,  or  detached  synovial  villus,  around  which  the  fibrin  collects. 
Such  loose  l>odies  frequently  l>ecome  fibrous.  Bodies  which  are  at  first  pedun- 
culated and  afterwards  become  loose  by  rupture  of  the  pedide,  may  be  fattj 
(in  lipoma  arlioresc  ens),  fibrous,  cartilaginous,  or  bony,  according  to  the  tis- 
sue from  which  they  spring;  they  may  be  also  neoplasms,  or  result  from  hyper- 
trophy of  synovial  villi,  desiccation  of  cartilage,  or  detachment  of  osteophytes 
in  ( hronir  arthritis.  The  most  frequent  cause,  however,  is  injury,  a  portion 
of  bone,  or  more  fre(juently  cartilage,  being  detached  from  the  articular 
surface,  usually  the  internal  ( ondyle  of  the  knee,  which  is  the  joint  generally 
affc<  terl.  Though  even  completely  detached,  these  Ixxlies  may  continue  to 
grow,  being  nourished  by  the  synovial  fluid. 

The  symptoms  are  severe  pain  and  temporar}'  locking  of  the  joint, 
followed  \)y  su!>a(  ule  synovitis,  and  caused  by  the  loose  body  lodging  between 
the  enrls  of  the  l>ones  or  in  a  synovial  recess.  These  attacks  recur  from 
time  to  lime,  and  owing  to  repealed  distention,  the  ligaments  may  become 
relaxed  and  the  joint  weakened.  Loose  bodies  may  sometimes  be  palpated. 
but  are  ver}'  elusive,  hence  the  name  joint  mice.  If  bony  in  nature  they  may 
Ije  deteded  by  the  X-ray.  The  symptoms  closely  resemble  those  of  a  dis- 
lo(  ated  semilunar  cartilage,  but  in  loose  bodies  the  locking  of  the  joint  is 
usually  of  brief  duration,  and  there  is  no  marked  tenderness  over  the  site  of 
the  semilunar  cartilage. 

The  treatment  is  removal  by  a  small  incision  directly  over  the  loose  body, 
whi(h  should  be  held,  whenever  possible,  by  the  fingers  of  the  other  hand, 
or,  better,  transfi.xed  by  a  needle  before  the  patient  is  anesthetized,  otherwise 
the  body  may  elude  even  the  most  careful  search  after  the  joint  is  opened. 
Some  surgeons  employ  a  local  anesthetic,  thus  enabling  the  patient  to  bring 
the  loose  body  to  the  surface,  in  case  it  escapes  the  operator.  The  joint 
should  be  exi)lored  for  other  loose  bodies,  closed  with  sutures,  and  immo- 
bilized for  a  week  or  two. 

Ankylosis  is  rigirlity  or  immobility  of  a  joint.  False  ankylosis  is  caused 
by  extraarticular  lesions,  such  as  cicatrices,  shortening  of  muscles,  adhesions 
of  tendons,  and  contraction  of  fascia;  it  may  be  bony  as  the  result  of  ossifica- 


ANKYLOSIS. 


tion  of  periarticular   intlammalory  filirous   tissue  or  of  musdes  (n\v*)siiis 
ossificans). 

In  true,  or  intraarticular  ankyhs is,  the  joint  surfaces  are  united  by  fibrous 
tissue,  cartilage,  or  bone.  Fibrmis  ankyhsis  is  usually  incomplete,  unless 
the  entire  Joint  is  obliterated  by  short  bands  of  strong  fibrous  tissue;  the  latter 
may  sometimes  be  differentiated  from  bony  ankylosis  tiy  the  X-ray,  by 
pain  on  attempts  to  move  the  joint,  and  by  subsequent  signs  of  inflammation, 
if  these  attempts  have  been  very  forcible.  Cartilaginaus  or  batty  ankylosis 
is  complete  (no  motion),  except  in  some  cases  of  ossification  of  the  periarticu- 
lar structures,  and  in  some  cases  caused  by  the  interlocking  of  osteophytes  in 
osteoarthritis,  The  rausfs  of  true  ankylosis  are  the  various  forms  of  syno- 
vitis and  arthritis.  It  may  be  caused  also  by  an  unreduced  dislocation  or  frac- 
ture, or  by  disease,  e.g.,  caries  which  alters  the  shape  of  the  ends  of  the  Ijones 
so  that  they  no  longer  fit  each  other  (ankyhsis  of  deformity}.  Simple  immobil- 
ization of  the  large  joints  without  inllammation  does  not  lead  to  ankylosis, 
although  if  prolonged  it  may  cause  stiffness  owing  to  the  atrophy  of  the 
periarticular  structures.  The  cjfects  of  ankylosis  vary  with  its  degree,  the 
angle  of  fixation  (a  straight  knee  and  an  eibow  bent  to  a  right  angle  are  much 
more  useful  than  a  bent  knee  and  a  straight  elbow),  the  Joint  affected  (e.g., 
in  the  shoulder  ankylosis  is  compensated  for  by  movements  of  the  clavicle 
and  scapula),  and  the  amount  of  atrophy  of  the  bones  and  soft  parts;  in 
children  there  may  be  stunting  of  the  growth  of  a  limb. 

The  treatment  is  prophylactic  and  curative.  The  prophylactic  treat- 
ment consists  in  limiting  effusions  or  intlammator)'  exudates,  which  by  organ- 
ization cause  ankylosis;  and  in  preventing  the  union  of  synovial  surfaces  by 
early  passive  movements.  If  ankylosis  is  inevitable  the  joint  should  be  placed 
in  a  position  which  will  be  of  most  serv^ice  to  the  patient.  In  incompkte 
ankylosis  due  to  limited  synovial  adhesions,  daily  attempts  to  moi^e  the  joints 
without  causing  intolerable  pain,  will  stretch  or  break  the  adhesions  and 
result  in  cure.  If  the  adhesions  are  more  extensive,  the  joint  may  be  forcibly 
moved  while  the  patient  is  under  a  general  anesthetic.  This  treatment 
causes  a  recurrence  of  the  inflammation,  and  the  joint  must  be  imraobiiized 
until  it  has  subsided,  when  massage  and  passive  motions  are  begun.  In 
long  standing  CESCs/ortibly  breaking  adhesions  under  an  anesthetic  occasion- 
ally results  in  fracture  of  atrophied  bone,  or  tearing  of  shortened  blood 
vessels,  nerves,  skin,  or  other  soft  tissues.  It  should  not  be  attempted  after 
the  subsidence  of  a  tuberculous  arthritis  for  fear  of  recurrence.  Other  cases 
of  ankylosis  which  should  be  left  alone  are  those  occurring  in  patients  (the 
old,  feeble,  etc.)  w^hose  general  condition  forbids  operation  or  painful  manip- 
ulations, particularly  when  the  joint  is  in  a  useful  position.  Electricity  and 
massage  are  benetkial  in  maintaining  nutrition  and  preventing  atrophy  of 
muscles.  If  the  adhesions  are  ver)'  extensive,  forcibly  breaking  them  under 
an  anesthetic  will  be  followed  by  so  much  intlammatory  reaction  that  they  mi\ 
reform  before  passive  motions  can  be  started.  In  these  cases  a-s  well  as  in 
complete  ankylosis,  T^Qox try  can  be  secured  only  by  operation,  which  always 
should  be  undertaken  if  the  joint  be  fixed  at  a  \icious  angle.  Osteotomy  has 
been  employed^  chiefly  in  ankylosis  of  the  hip  and  knee,  to  straighten  a  limb 
that  is  fixed  at  an  inconvenient  angle.  In  ankylosis  of  the  hip  the  bone  is  cut 
through  the  neck  or  just  below  the  trochanters,  after  making  an  incision  from 
just  below  the  anterior  superior  spine  vertically  downwards  for  three  or 
more  inches.     Adams'"  subcutaneous  osteotomy  of  the  neck  of  the  femur  is  ^er- 


326 


JOINTS, 


formed  by  inlroduijing  a  knife  midway  hctween  the  iroi  hanter  and  the  ante- 
rior superior  spine  of  the  ilium,  and  pushing  it  inwards  until  it  reaches  the 
neck  of  the  bone.  An  Adams'  saw  (Fig,  245)  is  then  introduced  and  the 
neck  of  the  bone  divided.  The  limb  is  straightened  and  the  bone  reunites. 
In  ankylosis  of  the  knee  the  bone  is  tlivided  above  the  joint  in  much  the  same 
way  as  for  genu  valgum.  Excision  may  be  performed,  e,g.,  at  the  elbow^  to 
obtain  a  movable  joint,  or,  e.g.,  at  the  knee  when  it  is  bent,  to  place  the  limb 
although  still  rigid  in  a  more  useful  position.  Perhaps  the  best  method  i* 
exposure  of  the  joint  by  an  incision  suitable  for  resection,  and  division  or 
removal  of  all  adhesions,  bony  prominences,  etc.,  which  interfere  with  move- 
ment (arihrolysis).  To  maintain  mobility  various  foreign  bodies,  such  as 
celluloid^  rubber,  magnesium,  etc.,  have  been  placed  between  the  ends  of  the 
hones,  but  are  almost  uniformly  unsuccessful,  in  that  the  foreign  substance 
is  usually  discharged  and  the  ankylosis  recurs.     The  interposition  of  a  flap 


Fic.  245.— Adams'  osteotomy  saw. 

of  muscle  or  fascia  {arthroplasiy)  seems  to  offer  the  best  prospects  for  a  new 
and  movable  joint.  After  operations  of  this  character  the  joint  may  be  filled 
with  sterile  olive  oil  or  Mquid  vaseline  to  prevent  the  reformation  of  adhesions. 
Lexer  has  resected  the  knee  and  successfully  transplanted  to  its  place  the 
knee-joint  of  a  recently  amputated  Itmb, 

False  ankylosis  is  treated  acconbng  to  the  cause;  it  may  require  excision 
of  a  cicatrix;  tenotomy  or  tenoplasty;  myotomy  or  myoplasty;  removal  of 
areas  of  ossification,  etc.  It  should  be  recalled  that  any  of  these  operations 
may  be  needed  to  assist  also  in  the  cure  of  a  true  ankylosis. 

Arthrodesis  is  just  the  opposite  of  arthrolysis,  i.e.,  the  surgeon  attempt? 
to  secure  ankylosis  in  a  tlail  joint,  such  as  may  follow  paralysis.  The  joint 
is  opened,  either  arthectomy  or  excision  performed,  and  the  bones  fastened 
together  with  wire  or  nails. 

In  eras  ion,  or  arthrectomy,  the  joint  is  opened  by  an  incision  suitable 
for  resection,  and  the  diseased  tissues  (usually  tuberculous)  alone  removed 
by  scissors  and  forceps,  or  by  curette.  W'hen  applicable,  erasion  is  to  be  pre- 
ferred to  resection,  since  it  causes  neither  immediate  shortening  nor  subse- 
quent interference  with  the  growth  of  the  limb. 


i 


EXCISION  OF  JOINTS. 

Excision,  or  resection,  of  a  joint,  i.e.,  of  the  articulating  ends  of  the  bones 
with  the  cartilages  and  synovial  membrane,  is  performed  to  remove  an  articu- 
lation destroyed  by  injur}'  or  disease  (usually  tuberculosis),  thus  avoiding 
amputation,  or  to  render  a  limb  more  useful,  e.g.,  in  irreducible  luxations  or 


EXCISION    OF   TIIK    WRIST. 


327 


other  forms  of  iinkylosis.  There  is,  of  t i>ursc,  imnudialc  shorteiving  of  the 
limb,  and  in  youth,  if  an  entire  epiphysis  is  removed,  inierfereiice  with  sub- 
sequent growth,  hence  resection  of  joints,  especially  those  of  the  lower 
extremity » in  which  the  greatest  growth  takes  place  and  in  which  shortening 
causes  the  greatest  inconvenience,  should  be  avoided  whenever  possible. 
There  are  two  general  methods  of  excision.  The  suhperi&skal,  or  conserva- 
tive, in  which  the  periosteum,  joint  capsule,  and  attached  ligaments  and  ten- 
dons arc  saved,  is  the  ideal  operation,  as  l>onc  may  lie  reformed  from  the 
periosteum,  and  movements  of  tlie  joint  preserved  by  the  muscular  attach- 
ments. It  is  rarely  applicable,  however,  because  these  structures  are  usually 
involved,  and  in  certain  joints,  notably  the  elbow,  new  bone  might  interfere 
with  free  motion.  In  the  radkai  method  the  periosteum  is  sacrificed.  The 
incisions  should  be  so  made  as  to  enter  the  joint  l>y  the  shortest  way  with  a 
minimum  amount  of  injury  to  the  surrounding  tissues.  Drainage  with 
gauze  or  a  rul>ber  tube  is  almost  invariably  required. 

The  shoulder  joint  may  be  excised  through  an  anterior  oblique  incision, 
three  or  four  inches  in  length,  extending  from  thecoracoid  process  downward 
and  outward  along  the  anterior  border  of  the  deltoid  muscle,  the  patient  being 
supine,  close  to  the  edge  of  the  table,  and  the  shoulders  raised.  The  pectoro- 
deltoid  groove  is  opened,  the  cephalic  vein  and  the  pectoral  muscles  retracted 
inward  and  the  deltoid  outward,  thus  uncovering  the  biceps  tendon,  to  the 
outer  side  of  which  the  capsule  of  the  Joint  is  incised.  After  depressing  the 
elbow  and  rotating  the  humerus  inward,  the  supra-  and  infraspinatus  and 
teres  minor  are  separated  from  the  greater  tuberosity,  and  the  subscapularis 
from  the  lesser  tuberosity  after  rotating  the  bone  outward.  Flexing  the  elbow 
relaxes  the  tendon  of  the  biceps,  which  is  then  displaced  inward,  and  the  head 
of  the  hone  delivered  through  the  wound  and  divi*led  with  a  saw.  If  the 
glenoid  cavity  is  involved,  the  diseased  bone  is  removed  with  a  curette,  or  as 
a  sequestrum.  The  arm  is  bound  to  the  chest  over  an  axillary  pad,  to  pre- 
vent displacement  of  the  end  of  the  humerus  under  the  coracoid.  Passive 
motions  are  begun  as  soon  as  the  stitches  have  been  removed. 

The  elbow  joint  (Fig.  5,50)  may  be  resected  through  a  posterior  median 
incision  (Langenbeck),  about  four  inches  in  length,  with  the  tip  of  the  olec- 
ranon  process  at  its  middle,  the  arm  lying  across  the  patient's  body.  The 
periosteum  and  the  inner  half  of  the  triceps  tendon  are  separatefl  from  the 
ulna  and  olecranon  and  pushed  inwards  with  the  ulnar  nerve,  then  the  inter- 
nal lateral  ligament  and  ihe  common  origin  of  the  dexor  muscles  separated 
from  the  inner  condyle.  The  periosteum,  outer  half  of  the  triceps  tendon, 
anconeus,  external  lateral  ligament,  extensors  of  the  forearm,  and  supinator 
brevis  are  next  st  raped  from  the  bone  on  the  outer  side,  and,  after  tlexing  the 
forearm,  the  ends  of  the  bones  delivered  through  the  wound  and  removed  with 
a  saw.  The  forearm  is  placed  on  an  internal  angular  splint  for  a  wec*k  or 
ten  days,  after  which  daily  passive  motions  are  made. 

Of  all  excisions  thai  of  the  wrist  joint  is  the  least  satisfactor>\  The 
operation  is  difficult  and  tedious,  and  so  much  of  the  bony  structures  usually 
have  to  be  removed  that  the  hand  is  often  useless  afterwards.  The  simple.st 
method  is  that  of  Langenbeck.  A  straight  dorsal  incision  is  made  from  the 
middle  of  the  metacarpal  bone  of  the  index  finger  to  the  middle  of,  and  three- 
fourths  of  an  inch  above,  the  lower  extremity  of  the  radius.  The  incision 
passes  along  the  racbal  side  of  the  tendon  of  the  extensor  indicis.  The  ten* 
dons  of  the  index  hnger  are  retracted  to  the  ulnar  side  and  the  lower  border 


328  JOINTS. 

of  the  annular  ligament  divided.  The  fibrous  sheaths  of  the  extensor  ten- 
dons, the  insertion  of  the  supinator  longus,  the  annular  and  capsular  ligaments, 
and  the  periosteum  are  separated  from  the  end  of  the  radius,  and  the  tendons, 
ligaments,  and  periosteum  from  the  ulna.  Flexing  the  hand  opens  the  radio- 
carpal joint  and  facilitates  excision  of  the  first  row  of  carpal  bones.  It  may 
be  necessary  to  remove  those  of  the  second  row  and  even  the  bases  of  the  meta- 
carpal bones.  The  lower  ends  of  the  radius  and  ulna  are  next  delivered  and 
divided  with  a  saw.  If  the  tendons  of  the  extensor  radialis  longior  and 
brevior  are  in  the  way,  they  may  be  divided  and  later  sutured.  A  straight 
splint  is  applied  with  the  forearm  midway  between  pronation  and  supination. 
The  fingers  should  be  flexed  and  extended  daily,  beginning  on  the  second  or 
third  day,  but  the  wrist  should  remain  fixed  until  healing  is  complete;  indeed 
in  some  cases  a  flail  joint  results  and  a  permanent  support  is  needed. 

The  hip  joint  may  be  entered  from  three  aspects,  anteriorly  through  the 
straight  incision  of  Barker,  laterally  through  a  curved  (White)  or  straight 
(Langenbeck)  incision,  and  posteriorly  through  the  angular  incision  of 
Kocher.  With  the  anterior  incision  no  muscular  structures  are  divided  and 
very  little  damage  is  done  to  the  surrounding  tissues,  but  the  joint  is  poorly 
exposed  at  the  bottom  of  a  deep  wound  which  is  not  well  situated  for  sut 
sequent  drainage.  The  lateral  and  posterior  incisions  necessitate  the  cutting 
of  muscles  and  inflict  greater  damage  on  the  tissues,  but  they  render  the  joint 
more  accessible  and  facilitate  drainage.  The  anterior  incision  extends  from 
one-half  inch  below  the  anterior  superior  spine  of  the  ilium  downward 
and  slightly  inward  for  three  or  four  inches.  The  joint  is  exposed  by 
retracting  the  tensor  vaginae  femoris  and  glutei  outwards,  the  sartorivs  and 
rectus  inwards.  Branches  of  the  circumflex  artery  are  encountered  and 
ligated.  The  joint  capsule,  cotyloid  ligament,  and  periosteum  of  the  femur 
are  incised  in  the  line  of  the  wound,  and  as  air  enters  the  joint,  the  articulat- 
ing surfaces  of  the  bones  may  be  separated  and  the  ligamentum  teres  cut. 
The  periosteum  with  the  attached  muscles  is  then  separated  from  the  greater 
tuberosity,  and  the  bone  cut  with  an  Adams'  or  a  chain  saw,  or  with  a  chisel. 
The  line  of  division  may  be  above  or  below  the  greater  trochanter.  The 
acetabulum  is  curetted,  and  if  drainage  be  necessary,  a  counteropening  made 
posteriorly. 

Langenbeck^ s  external  incision  extends  from  a  point  three  inches  above  the 
upper  border  of  the  great  trochanter  down  over  that  prominence  for  four  or 
five  inches  in  the  long  axis  of  the  femur,  the  patient  l>'ing  upon  the  sound  side 
with  the  thigh  flexed  at  an  angle  of  forty-five  degrees.  The  skin  and  fascia 
are  divided  and  the  fibers  of  the  gluteus  maximus  separated,  thus  exposing  the 
gluteus  medius  and  pyriformis,  which  arc  separated  with  retractors.  The 
capsule  of  the  joint  and  periosteum  over  the  greater  trochanter  are  then  in- 
cised in  the  line  of  the  wound,  an  additional  transverse  incision  being  made  if 
necessary,  and  the  periosteum  and  muscles  elevated.  After  cutting  the  coty- 
loid and  round  ligaments,  the  thigh  is  adducted  and  rotated  outward,  thus 
forcing  the  head  of  the  bone  through  the  wound.  The  bone  is  usually 
divided  below  the  great  trochanter,  as  its  removal,  if  the  periosteum  and  mus- 
cles are  intact,  does  not  interfere  with  subsequent  motion;  if  permitted  to 
remain  it  interferes  with  drainage  and  may  become  diseased.  A  Buck's 
extension  is  applied  to  the  leg,  which  is  supported  laterally  by  sand  bags. 
The  cavity  becomes  filled  with  fibrous  tissue  which  permits  limited  motion. 

In  the  knee  joint  (Fig.  545)  fixation  and  not  motion  is  desired  after  resec- 


CONTUSIONS   OF   THE   SCALP.  329 

tion.  An  anterior  semilunar  incision  is  made  from  the  posterior  and  upper 
border  of  one  condyle  to  the  other,  the  convexity  closely  approaching  the  in- 
sertion of  the  ligamentum  patellae.  After  flexing  the  leg  to  a  right  angle,  the 
superficial  tissues,  ligamentum  patelke,  and  the  anterior,  lateral,  capsular, 
and  crucial  ligaments  are  divided  in  turn.  Carefully  protecting  the  popliteal 
structures,  the  condyles  of  the  femur  are  freed,  then  cut  in  a  plane  at  right 
angles  to  the  long  axis  of  the  bone.  The  head  of  the  tibia  is  similarly  exposed 
by  retraction  of  the  tissues,  pushed  forward,  and  the  articulating  surface 
shaved  off.  The  patella  and  all  of  the  infected  synovial  membrane  and 
bursa;  are  then  removed,  and  a  rubber  tube  placed  behind  the  bones,  to 
emerge  at  each  angle  of  the  wound.  The  bones  may  be  fixed  together  with 
wire,  nails,  by  suturing  the  ligaments,  or  merely  by  a  fixed  dressing  (see 
Pig-  54)-  The  splint  or  plaster  cast  should  be  worn  for  at  least  eight  weeks. 
The  ankle  joint  is  seldom  resected,  as  a  modem  artificial  leg  gives  a 
more  useful  limb  than  the  ankylosed  and  fixed  joint  usually  following  ex- 
cision. In  the  Langenbeck  operation  a  hook-shaped  incision  is  first  made 
around  the  lower  end  of  the  fibula;  starting  three  inches  above  the  tip  it 
follows  the  posterior  border,  curves  around  the  external  malleolus,  and 
passes  upward  on  the  anterior  border  for  one  inch.  The  periosteum  and 
overlying  tissues  are  separated  from  the  bone,  which  is  divided  at  the  upper 
end  of  the  wound  and  drawn  outward,  when  the  ligaments  attached  to  the 
lower  end  are  cut.  A  second  incision,  one  and  one-half  inches  in  length, 
curves  around  the  internal  malleolus,  and  this  in  joined  by  a  vertical  cut, 
two  inches  long,  made  in  the  median  line  of  the  tibia  (anchor-shaped  incision). 
The  bone  is  freed  and  removed  as  on  the  outer  side.  A  part  or  the  whole  of 
the  astragalus  may  be  removed  through  either  wound,  preferably  the  inner. 
Another  method  is  to  make  a  transverse  incision  across  the  front  of  the  joint 
connecting  both  malleoli.  The  tendons  and  anterior  tibial  nerve  are  sutured 
at  the  completion  of  the  operation.  A  fenestrated  plaster  cast  is  applied 
with  the  foot  at  a  right  angle  with  the  leg. 


CHAPTER  XXI. 

HEAD. 

THE  SCALP. 


Contusions  of  the  scalp  cause  an  effusion  of  blood  into  the  tissues  which 
may  amount  to  a  hematoma.  In  new-bom  children  the  effusion  due  to  pres- 
sure around  the  presenting  part  is  called  cafmt  succedaneum.  Cephalhema- 
toma maybe  (i)  superficial  in  the  subcutaneous  tissues,  the  swelling  being  con- 
fined to  the  injured  part  only;  (2)  subaponeurotic  in  the  loose  tissue  beneath 
the  occipital  frontalis,  in  which  case  a  fluctuating  swelling  reaching  from  the 
eyes  to  the  occiput  may  be  present;  and  (3)  subpericranial,  the  attachments  of 
the  periosteum  at  the  sutures  confining  the  effusion  to  one  bone.  Contusions 
of  the  scalp  require  special  mention  only  because  of  the  danger  of  associated 
injury  to  the  brain,  for  the  symptoms  of  which  a  careful  examination  should 
always  be  made.    A  hematoma  may  be  mistaken  for  a  fracture  of  the  skull 


330  HEAD. 

because  of  its  indurated  margin  and  soft  center.  The  margin,  howe\'er,ts 
regular,  pits  on  pressure  (sometimes  with  moist  crepitation),  and  is  above  the 
contour  of  the  head;  in  doubtful  cases,  particularly  if  there  are  symptoms  of 
intracranial  mischief,  the  parts  should  be  incised  and  carefully  expkmd. 
I'he  treatment  does  not  differ  from  that  of  contusions  in  other  parts  of  the 
l>ody. 

Wounds  of  the  scalp  always  require  a  careful  examination  for  fracture 
of  the  skull  or,  in  the  absence  of  this,  for  signs  of  concussion  or  intracranial 
hemorrhage.  It  should  be  recalled  also  that  laceration  of  the  scalp  mar 
have  been  the  result  of  a  fall  caused  by  a  serious  constitutional  disease  or  tlK 
taking  of  a  poison.  If  the  wound  is  too  small  for  exploration  and  there  are 
any  suspicious  symptoms,  it  should  be  enlarged.  A  slit  in  the  pericranium 
may  feel  like  a  fracture,  but  all  doubt  is  dispelled  by  careful  inspection.  A 
suture  will  not  be  taken  for  a  fracture  if  one  recalls  the  situation  of  the  suture 
andobser\'es  that  it  does  not  bleed.  In  the  temporal  region  a  wound  of  the 
fascia  may  resemble  a  fracture,  but  the  supposed  cerebral  tissue  (temporal 
muscle)  will  harden  when  the  patient  shuts  his  jaw.  A  superficial  scalp 
wound,  even  if  infected,  is  rarely  a  serious  matter;  if,  however,  the  loose  sub- 
aponeurotic tissue  has  been  opened  and  infected,  suppuration  may  spread  to 
the  attachments  of  this  structure,  i.e.,  to  the  eyebrows,  zygoma,  and  superior 
curved  line  of  the  occipital  bone.  A  flap  of  scalp,  even  of  the  largest  size, 
retains  its  vitality  owing  to  the  fact  that  the  vessels  run  in  the  scalp  and  do 
not  come  from  the  subjacent  structures.  The  treatment  is  that  of  wounds 
elsewhere. 

Traumatic  or  spurious  meningocele  is  a  collection  of  cerebrospinal 
fluid  beneath  the  scalp  following  a  fracture,  usually  in  a  child.  It  pulsates, 
has  an  impulse  on  coughing,  and  may  be  reducible.  The  irealmaU  is  the 
same  as  that  of  meningocele. 

Abscess  of  the  scalp  may  he  due  to  infection  from  the  exterior  or  to  dis- 
ease of  the  cranial  bones.  Suppuration  is  limited  in  the  same  way  as  extrav- 
asation in  cephalhematoma.  In  the  subaponeurotic  form  the  abscess  is 
bounded  only  by  the  attachments  of  the  aponeurosis  of  the  occipital  frontalis. 
In  these  cases  the  constitutional  symptoms  are  severe  and  the  infection  may 
spread  to  the  intracranial  structures.  Incision  should  be  made  above  the 
zygoma  on  eat  h  side,  above  the  superior  curved  line  of  the  occipital  bone 
behind,  anil,  if  necessary,  above  the  brows  in  front. 

Tumors  (using  the  term  in  its  broadest  sense)  springing  from  the  scalp  or 
the  subjacent  structures  are  pulsating  or  non-pulsating.  The  pulsating 
tumors  include  ordinary  aneurysm,  arteriovenous  aneurysm,  arterial  varix, 
anjijioma,  circoid  aneurysm,  sarcoma  (of  bone  or  meninges),  meningocele 
(true  and  si)urious),  encephalocele,  hydrencephalocele,  hernia  cerebri,  and 
other  tumors  if  situated  over  an  ojjen  fontanelle.  Among  the  non-pulsating 
tumors  are  i)apilloma  (wart),  horns,  moles,  epithelioma,  Abroma  (when  dif- 
fuse and  involving  a  large  part  of  the  scalp  it  is  known  as  pachydermatocele), 
sarcoma,  sebaceous  cyst,  dermoid  cyst,  subaponeurotic  lipoma,  gumma,  syph- 
ilitic nodes,  exostosis,  and  [)neumatocele.  The  c  mi  genital  tumors  arc  hemat- 
oma, angioma,  meningocele,  encephalocele,  hydrencephalocele,  and  dermoid 
cyst.  The  last  is  usually  situated  at  the  outer  canthus  of  the  eye  or  root  of 
the  nose,  and  sometimes  communicates  with  the  interior  of  the  skull  through 
a  congenital  opening  in  the  l)one.  Most  of  these  affections  have  already 
been  described,  the  rest  will  be  described  below. 


CEREBRAL  LOCALIZATION.  33 1 

Craniocerebral  Topography  and  Cerebral  Localization.— Fig.  246 
shows  Broca*s  points  marked  on  the  skull.  The  longitudinal  fissure^  contain- 
ing the  longitudinal  sinus,  underlies  a  line  drawn  from  the  glabella  to  the 
inion  and  passing  along  the  sagittal  suture.  The  fissure  o/Bichal  separates 
the  cerebrum  from  the  cerebellum,  contains  the  lateral  sinus,  and  is  indicated 
by  a  line  drawn  from  the  inion  to  the  external  auditory  meatus.  The  fissure 
of  Sylvius  runs  from  a  point  one  and  a  quarter  inches  behind  the  external 
angular  process  of  the  frontal  bone  and  the  same  distance  above  the  zygoma, 
to  a  point  three-fourths  of  an  inch  below  the  most  prominent  part  of  the  parie- 
tal eminence.    The  main  fissure  corresponds  to  the  first  three-fourths  of  an 


Fig.  246. — Skull  showing  the  points  named  by  Broca.  As^  asterion  (junction  of  the  oc- 
cipital, parietal,  and  temporal  bones) ;  Basion,  middle  of  anterior  wall  of  foramen  magnum ; 
By  breg^ma  (junction  of  the  sagittal  and  coronal  sutures) ;  G,  ophryon  (on  a  level  with  the 
superior  border  of  the  eyebrows,  and  corresponding  nearly  to  the  glabella,  the  smooth  swell- 
ing between  the  eyebrows);  ^,  gonion  (angle  of  the  lower  jaw);  /,  inion  (external  occipital 
protuberance) ;Z;,,  lambda  (junction  of  sagittal  and  lambdoidal  sutures);  TV,  nasion  (junction 
of  the  nasal  and  frontal);  Oh,  obelion  (the  sagittal  suture  between  the  parietal  foramina) ; 
P,  pterion  (point  of  junction  of  great  wing  of  sphenoid  and  the  frontal,  parietal,  and  squa- 
mous bones.  This  may  be  H-shaped  or  K-shaped,  or  "  retourn^,"  in  which  the  frontal  and 
temporal  just  touch) ;  S,  stephanion  (or,  better,  the  superior  stephanion,  intersection  of  ridge 
for  temporal  fascia  and  coronal  suture) ;  5',  inferior  stephanion  (intersection  of  ridge  for 
temporal  muscle  and  coronal  suture).     (American  Test-book  of  Surgery.) 

inch  of  this  line,  and  the  horizontal  limb  to  the  remaining  portion,  the  ascend- 
ing limb  passing  upwards,  parallel  to  the  coronal  suture,  for  one  inch  from 
the  junction  of  the  main  fissure  and  the  horizontal  limb.  The  fissure  of  Ro- 
lando extends  from  one-half  inch  behind  the  midpoint  between  the  glabella 
and  the  inion,  downward  and  forwards  for  three  and  three-eighths  inches,  at 
an  angle  of  67}  degrees.  This  angle  may  be  found  by  taking  a  square  piece 
of  paper  and  folding  one  corner  back  on  the  line  A  C  (Fig.  247),  i.e.,  from  the 
middle  of  the  side  D  B  to  the  comer  A.     The  side  E  A  is  then  placed  in  the 


33^ 


HEAD. 


middle  line  of  the  head,  and  the  line  A  C  corresponds  to  the  fissure  of  Rolando, 
the  angle  E  A  C  being  67}  degrees.  Horsley's  cyrtometer  (Fig.  248)  is  in 
instrument  for  marking  out  the  fissure  of  Rolando.  The  preceniral  or  verikd 
sulcus  (Fig.  249)  lies  just  behind  and  parallel  to  the  coronal  suture,  or  one 
convolution  (roughly  one  finger's  breadth)  in  front  of  the  fissure  of  Rolando. 
The  intraparietal  sulcus  begins  one  convolution  behind  the  junction  of  the 
middle  and  lower  thirds  of  the  fissure  of  Rolando,  passes  upward  midway 
between  the  Rolandic  fissure  and  the  parietal  eminence,  then  curves  back- 
wards between  the  longitudinal  fissure  and  the 
parietal  eminence  into  the  occipital  lobe.  The 
supramarginal  convolution  lies  behind  the  in- 
traparietal fissure  and  curves  over  the  extremity 
of  the  fissure  of  Sylvius,  uniting  posterioriy. 
with  the  angular  convolution^  which  arches 
over  the  extremity  of  the  superior  temporal 
fissure  (Fig.  251). 

Kronlein^s  metltod  (Fig.  250)  of  craniocere- 
bral topography  is  as  follows:  A  horizontal 
line,  A  B,  is  drawn  through  the  lower  margin 
of  the  orbit  and  upper  margin  of  the  external 
auditory  meatus.  Above  and  parallel  with  this 
is  a  second  line,  C  D,  on  a  level  with  the  upper  margin  of  the  orbit.  Three 
vertical  lines  are  now  drawn,  the  first  passing  through  the  middle  of  the 
zygoma,  E  F,  the  second,  G  H,  through  the  condyle  of  the  lower  jaw,  and  the 
third,  T  J,  through  the  posterior  margin  of  the  mastoid  process.  A  line 
drawn  from  K  to  J  corresponds  between  L  and  J  to  the  fissure  of  Rolando. 
The  line  K  M,  which  bisects  the  angle  J  K  N,  corresponds  to  the  horizontal 
limb  of  the  fissure  of  Sylvius.  If  this  line  is  continued  backwards  to  the 
middle  line  of  the  head  (O)  it  indicates  approximately  the  situation  of  the 


Fig.  24/. 


►.  ,  .^1  ■  .  .61  .  . .«!  .  ,  51  .  .  .»l  ■  ■  »l  .  .  A  .  ■  o| 


l».    l»..K..H..i«..|r..4 


ViVr.  248.- -Horsley's  cyrtometer. 


parietooccipital  fissure.  K  and  N  are  the  points  to  trephine  for  the  anterior 
and  posterior  branches  of  the  middle  meningeal  artery. 

It  should  be  recalled  that  the  cerebral  centers  exhibit  exaltation  or  aboli- 
tion of  function  according  to  the  degree  of  disease  or  injury;  thus  there  may 
be  mania  or  coma,  spasm  or  paralysis,  hyperesthesia  or  anesthesia,  if  the 
intellectual,  motor,  or  sensory  centers  respectively  are  involved. 

The  motor  area  (Figs.  251,  252)  occupies  the  ascending  frontal  convolution 
(which  lies  just  in  front  of  the  fissure  of  Rolando)  and  extends  to  the  mesial 


CEKEBRAL  LOCAUZATION. 


333 


surface  i>f  the  brain.  On  the  cortex  the  leg  center  occupies  tbe  tipper  thirdi 
the  arm  center  the  middle  third,  the  face  center  the  lower  third;  on  the  median 
surface  from  before  backward  are  the  centers  for  the  head,  trunk,  and  leg. 
The  motor  area  presides  over  the  muscles  of  the  opposite  side  of  the  body. 
A  lesion  in  a  motor  center  causes  localized  convulsions  followed  by  paralysis 


BREGMA 


a^l±^ 


^^^^^ 


<m 


POSmONOF  PARIETAL 


\PARITO-OtCIPITAL 


GLABELLA  ^ 


y 


»AtS£iS^ 


I  LAMBDA 


/FtSSURfOf  BrCMAT 
IN  ION 


FlC,  249*— Uiagram  showing  rel4iiioti>^  lo  ihe  skull  of  the  miflcilc  meningeal  ariery  on  rcJ), 
the  superior  longituclinaf  ami  ialrral  siTiii?vc.s  (in  hluc),  ami  thu  ftrincij>*il  fissures. 


(monoplegia) ;  paralysis  without  preceding  spasm  occurs  in  subcortiLal  lesions. 
I^esions  of  the  internal  capsule  cause  hemiplegia  without  convulsions;  of 
the  pons,  paraly**is  of  the  face  on  the  same  side  and  of  the  limlis  on  the  oppo- 
site side  (crossed  paralysis).  Spastic  paralysis  indicates  a  lesion  of  the  con 
ducting  tract  rather  than  the  motor  centers.  The  centers  for  general  sni- 
saiitm,   arranged   in   like  order,   lie  in   the  .,  f  h        j 

postcentral  or  ascending  parietal  convolu- 
tion, just  behind  the  fissure  of  Rolando, 
The  center  for  visum  h  in  the  cuneus,  which 
lies  in  the  occipital  lobe  between  the  parieio- 
occipital  and  calcarine  fissures  (Fig.  2^2): 
unilateral  destruction  of  this  area  results  in 
hemianopsia,  or  blindness  of  the  correspond 
in  g  h  al  f  o  f  ea c  h  r e  ti  n  a .  T  h e  <j  wlit  ory  c e  n  t  c  r 
is  in  the  middle  and  posterior  parts  of  the 
first  temporosphenoidal  gyrus,  while  smell 
and  l<}sir  are  located  in  the  uncus,  which  is 
the  anterior  extremity  of  the  hippocampal 
convolution;  these  centers  are  bilaterab 
hence  both  sides  must  be  damaged  to  cause  total  abolition  of  hearing,  smell, 
or  taste.  The  center  for  speech  is  the  posterior  half  of  the  third  left  frontal 
convolution  {Broca's  convoUdion),  \n  right  handed  people;  in  the  left  handed 
it  is  on  the  right  side.  Destruction  of  this  center  causes  motor  aphasia,  or 
loss  of  speech.     It  is  usually  associated  with  agraphia,  or  inability  to  wTite, 


Fig.  150.  — Kronlein's  method  of 
craniocerebral  topography. 


1 


Fig.  252. — (Walsham.)  Me^lian  surface  of  left  cerebrum.  G  F.  Cyrus  fomicatus; 
perhaps  connccled  with  general  sensjiiion,  its  impairment  causes  hemianesthesia,  C. 
Cuneus,  C  M  K.  Callosomarginal  fissure.  Q.  Quacirate  lobule.  C  F,  Citlcanne  fissure. 
l\  I'nciiiale  lobukv 

the  posterior  half  of  the  first  or  second  temporal  cnnvoluiioTnand  word  blind- 
ness  (alexia),  in  which  the  angular  and  supramarginal  gyri  are  al  fault. 
Apraxiaf  or  loss  of  memor)'  of  the  use,  color,  odor,  taste,  etc.,  of  objecls, 


'.,  01  ODjecls.     I 


.  _  Ih^d 


tECHNIC  OF  CEKEBKAL  SURGERY.  335 

alsi>  points  to  a  lesion  in  the  supramarginal  and  angular  gyri.  The  sttreog* 
nosik  cmter  is  in  the  superior  parietal  lobule;  a  lesion  in  this  region  causes 
aster eo gnosis,  or  loss  of  power  to  recognize  the  size  and  shape  of  oUjecls. 
Reason^  inUlHgcftce,  and  will  are  supposed  to  reside  in  the  superior  and  mifldle 
frontal  lonvolutions,  particularly  those  of  the  left  side.  AfTetlions  of  the 
cerebellum^  especially  of  the  middle  Uibc,  cause  vertigo  and  ataxia;  lesions 
of  the  lateral  lol>e  cause  the  patient  to  fail  towards  the  alTected  side.  Those 
portions  of  the  brain  in  which  lesions  do  not  cause  localizing  symptoms  are 
called  silent  or  latent  regions,  viz.,  the  anterior  f>orlion  of  the  frontal  lobes, 
the  teraporosphenoida!  lobes  except  in  part  on  the  left  side,  a  large  part  of 
the  parietal  and  occipital  lobes,  and  a  portitm  of  the  cerebellum* 

The  technic  of  cerebral  surgery  includes  the  instructions  laid  down 
under  general  tethnic  (<(.%.).  Asa  prophylactic  measure  against  meningitis 
hexamethylenamine^  which,  according  to  Crowe,  passes  rapidly  into  the 
cerel>rospinal  fluid  and  gives  it  a  certain  amount  of  antiseptic  prnwer,  maybe 
given, gr.  v  t,  d,,  before  and  after  operalittn,  A  special  assistant  should  be 
assigned  to  make  blood  pressure  reconis  at  fretjuent  intervals;  if  the  l>lond 
pressure  falls  !>elow  100  the  operation  should,  if  possible,  be  interrupted,  and 
completed  at  a  later  period.  The  head  is  shaved  and  carefully  examined 
for  scars,  etc.  It  is  disinfected  with  soap  and  water,  alcohol,  and  bichlorid  of 
mercury,  i  to  4,000,  the  day  before  operation,  and  again  at  the  time  of  opera- 
tion. In  emergency  cases  disinfection  tan  be  carried  out  only  immediately 
before  operation.  Ether  increases  the  bleeding,  Ijut  is  safer  than  chloro- 
form for  anesthesia.  The  fissures  may  be  marked  out  with  an  aniline  pencil 
or  with  iodin,  but  as  it  will  be  necessary  to  reflect  the  soft  parts,  the  center-pin 
of  a  trephine  should  be  forced  through  the  scalp,  in  order  to  mark  the  bone, 
in  three  places,  viz.,  at  each  end  of  the  fissure  of  Rolando,  and  at  the  point 
which  will  occupy  the  center  of  the  trephine  opening.  The  head  should  be 
raised  on  a  sand  pillow  in  order  to  give  it  firm  support  and  lessen  bleeding. 
Unless  the  operation  can  be  performed  by  enlarging  an  existing  wound,  a 
horseshoe  shaped  flap,  with  I  he  base  dovvnwartls  to  preserve  the  blood  supply 
and  including  the  periosteum,  Is  rellec  ted  from  the  skulb  The  skull  may  be 
opened  with  a  trephine,  gouge,  chisel,  (iigli's  wire  saw,  or  with  a  special 
drill  and  saw  attached  to  a  dental  engine  or  electric  motor,  and  any  of  these 
openings  may  be  enlarged  with  rongeur  forceps,  after  separating  the  dura 
from  the  skull  with  a  Horsley's  dural  separator,  with  which  the  inner  surface 
of  ihe  skull  may  also  be  explored.  The  trephine  (Fig,  253)  is  a  hollow  cylin- 
der with  a  saw-edge.  It  is  provided  with  a  center-pin,  which  projects  be- 
yond the  saw-edge,  and  holds  the  instrument  in  place  until  a  ^*ft^ove  in  the 
skull  has  been  made.  The  pin  is  then  withdrawn,  and  the  section  completed 
by  twisting  the  trephine  from  left  to  right  and  from  right  to  left.  When  the 
diploe  has  been  reached,  there  will  be  more  bleeiling  and  lessened  resistance. 
The  inner  table  is  recognised  l>y  its  density;  at  this  lime  one  should  proceed 
with  cauticm  and  frec|uenlly  lest  the  depth  of  the  groove  with  the  flat  end  of  a 
probe.  If  one  segment  of  the  circle  is  cut  through  before  the  remainder,  the 
trephine  is  tilted  so  as  to  avoid  injury  to  the  dura.  The  trephine  should  be 
conical,  or  proWded  with  guards,  so  that  it  cannot  plunge  suddenly  into  the 
brain.  A  trephine  three-fourths  of  an  inch  in  diameter  is  the  best  size  for 
most  puqDoses.  Very  large  trephines  are  diflkull  to  manage,  owing  to  the 
amount  of  bone  to  be  cut  and  the  t  urvature  of  the  skull.  By  osteofflastic 
resection  is  meant  the  turning  back  of  a  trap-door,  consisting  of  scalp  and 


I 


id 


1 1 )  Cii^li  wkv  saw;  (2)  Horsfey's  dura!  separalar;  (3)  rongeur  forccfjii»  ^4)  Ire- 
phinc;   (5)^  Keen's  rongeur  farcef>s. 


the  base  and  al  each  corner  of  a  ^rr-shaped  flap,  with  a  trephine,  or,  belter, 
with  a  Hudson  burr  (Figs.  254,  255,  and  256),  the  intervening  bone  may  l>e 
severed  with  forceps  (Fig.  257),  or  with  the  Cfigli  wire  saw,  which  is  passed 
from  one  opening  to  the  other  lieneath  the  l)one  and  over  a  grooved  director, 
the  bone  being  tlivided  from  within  outwards,  on  a  bevel,  thus  preventing 
the  bone  from  pressing  on  the  brain  when  it  is  replaced*  Stellwagen  has 
invented  an  ingenious  instrument  for  quickly  making  a  trap-door  in  the  skull. 
Osteoplastic  resection  is  used  chiefly  for  exploratorj^  purposes  or  for  the  re- 


TLCHNIC    Ol-    CLREBRAL    SURGERY. 


337 


I     moval  of  tumors,  in  other  words,  when  it  is  desirable  to  expose  a  large  extent 

I    of  the  cortex. 

The  dura  Is  opened  ahout  one-fourth  inch  away  from  the  bone,  so  that 
subsequent  suturing  will  be  facilitated.  It  is  lifted  from  the  brain  with  rat- 
tootJi  forceps,  nicked  with  a  knife,  and  the  tlap  completeti  with  scissors. 


Fiu.  254.  Flo.  255.  Fio.  25«. 

Figs.  354  to  256.  —Hudson's  hurrf^.  These  burrs  are  driven  by  a  hand-brace,  and  cut 
rapidly  through  the  skull,  but  bind  as  soon  as  they  reach  the  dura,  thus  preserving  that 
membrane  from  injury.  The  smallest  burr  is  used  5rst,  then  the  opening  wiiicned  with 
the  brgeir  burrs. 

No  antiseptic  should  be  used  afler  the  dura  is  opened.  It  should  be  noted 
whether  the  membranes  are  edematous,  and  whether  the  brain  pulsates  or 
bulges.  Bulging  and  absence  of  pulsation  incficate  a  marked  increase  in 
intracranial  pressure  (tumor,  abscess,  cyst,  etc.).  Lividity,  a  yellownsh 
color,  or  an  increase  in  density  as  determineil  by  the  finger,  point  to  a  tumor. 
The  exposed  centers  may  be  stimulated  with  Keen's  double  brain-electrode 


■ 


Fig.  3 57. -^Hudson's  modification  of  the  De  Vilbiss  forccjjs. 


in  order  to  corroborate  the  findings  of  craniocerebral  topography.  The 
current  shuuld  be  no  more  powerful  than  that  required  to  move  the  musdes 
of  the  thumb.  If  further  exploration  is  desirable,  the  brain  may  be  punttured 
with  a  needle  or  grooved  director,  or  even  incised.  In  removing  diseased 
brain  tissue  anteroposterior  incisions  do  less  harm  to  the  centers  than  those 
placed  in  a  vertical  direction. 


33« 


HEAD. 


L 


Hemorrhage  from  the  stalp  is  controlled  temporarily  with  hemostatic  for- 
ceps, permanently  with  ligatures  or  sutures.  Bleeding  from  the  l>one  is  checked 
by  gauze  pressure,  by  crushing  the  edge  of  the  bone  with  forceps,  or  best  by 
Horsley-s  wax  (beeswax  7,  almond  oil  i,  salicylic  acid  i).  Blood  vessels 
in  the  dura  and  brain  may  l>e  tied  with  fine  suture-ligatures  of  silk  or  cat- 
gut, general  oozing  may  be  controlled  with  hot  compresses.  Bleeding  from 
a  sinus  may  readily  lie  controlled  by  gauze  packing,  which  should  be  left 
in  place  several  days;  other  procedures  for  the  same  purpose  are  to  calch 
the  wound  with  forceps,  which  remain  for  several  days,  to  apply  a  lateral 
ligature,  to  suture  the  opening,  and  to  ligate  the  entire  sinus.  -  The  indications 
for  drainage  are  the  same  here  as  elsewhere. 

The  dura  should  l>e  sutured  with  catgut,  the  scalp  with  silkworm  gut,  and 
a  copious  dressing  applied.  The  head  should  be  slightly  elevated,  and  the 
patient  kept  absolutely  quiet. 

Excepting  osteoplastic  resection,  the  bone  is  ordinarily  not  replaced,  the 
defect  in  the  skull  being  remedied  in  time  by  dense  fibrous  tissue.  Bone, 
either  in  chips  or  in  the  form  of  a  button,  may,  however,  be  replaced,  if  during 
the  operation  it  is  kept  in  salt  solution  at  a  temperature  of  105  degrees.  Osse- 
ous delects  in  the  skull  have  been  filled  with  decalcified  bone  chips^  wnth 
plates  of  celluloid,  tin,  etc.,  and  with  a  portion  of  the  outer  table  of  the  neigh- 
boring skull,  transferred  to  the  opening  liy  means  of  a  flap  of  scalp.  Attempts 
have  been  made  to  prevent  adhesions  between  the  brain  and  overlying 
structures  by  interpcjsing  rubl>er  tissue,  egg  membrane,  gold  and  silver 
foil,  etc. 


mjIJRlES  TO  THE  CRAI^IUM  AND  ITS  CONTENTS. 

Concussion  of  the  brain  is  due  tcj  a  shaking  or  jarring  of  the  brain  by  di- 
rect (e.g.,  a  blow  on  the  head)  or  indirect  force  (e.g.,  a  fall  on  the  buttocks^ 
In  the  mildest  form  no  anatomical  changes  take  place,  but  in  the  seve: 
variety  there  are  lacerations  of  the  brain  tissue  and  biood  vessels.  If  the 
bleeding  from  these  lacerations  is  sufficiently  great  to  exert  pressure  on  the 
brain,  the  condition  is  one  of  compression  rather  than  concussion. 

The  symptoms  vary  from  lerap^)ra^y  giddiness  or  stunning,  to  collapse 
and  dealh.  In  a  well  marked  case  there  is  unconsciousness  which  is  rarely 
complete,  in  that  the  patient  may  be  partly  roused  by  shouting,  pricking  the 
soles  of  the  feet,  etc.  The  muscles  are  relaxed,  the  skin  cold  and  pale,  the 
temperature  sulmormal,  the  respirations  slow  and  shallow,  the  pulse  weak 
and  rapid.  The  pupils  are  equal,  react  to  light,  and  are  usually  dilated. 
The  red  exes  are  sluggish  or,  in  the  severest  cases,  abolished.  The  sphincters 
are  relaxed,  so  that  iJivoluntary  evacuations  from  the  bowel  may  occur,  but 
retention  of  urine  is  more  common  than  its  expulsion  owing  to  relaxation  of 
the  bladder  muscle.  Transient  paralyses  may  exist.  This  is  the  stage  of 
collapse,  which  may  last  from  minutes  to  hours;  it  ends  either  in  death  or  in 
the  stage  of  reaction,  which  may  be  inaugurated  by  a  convulsion,  or  more 
commonly  by  slight  movements  of  the  extremities  and  vomiting.  The  symp- 
toms mentioned  above  gradually  disappear,  the  temperature  rises,  perhaps 
to  TOO*'  F.  or  a  little  al»ove,  and  there  is  heatlache,  drowsiness,  or  irritability, 
which  may  last  a  number  of  days. 

The  prognosis  should  always  be  guarded,  although  in  most  cases  com- 


COMPRESSION    OF    TlIK    BRAIN* 


339 


plete  and  permanent  recovery  follows.  The  early  dangers  are  compression 
from  hemorrhage,  and  inllammation  of  the  brain  or  meninges.  Among 
the  sequela'  may  be  mentioned  cerebral  irritability,  inveterate  headache, 
vertigo,  loss  of  memory,  change  in  character,  insanity,  epilepi>y,  diabetes, 
neurasthenia,  and  possibly  tumur  or  abscess.  Frequently  the  patient^s 
memory  is  defective  for  the  events  immediately  preceding  the  accident. 

The  treatment  dynng  the  stage  of  collapse  is  the  application  of  external 
heat  and  the  administration  of  stimulants  as  in  shock.  Alcohob  however^ 
should  not  be  given,  because  of  its  exciting  effect  on  the  brain,  and  care  should 
he  taken  not  to  overslimulate.  When  reaction  has  been  obtained,  the  patient 
should  be  kept  in  bed  in  a  quiet  room,  an  ice  bag  placed  on  the  head,  the 
liowels  opened  with  a  purge,  iiud  the  catheter  used  if  there  is  retention  of 
urine.  The  diet  should  be  tluitl,  and  sedatives  used  if  necessary.  If  uncon- 
sciousness is  prolonged,  a  suspicion  of  greater  injury  than  concussion 
should  always  be  entertained.  After  severe  concussion  the  patient  should 
avoid  mental  exertion  for  a  number  of  weeks  or  months. 

Cerebral  irritability  may  come  on  in  a  few  hours  or  days  after  severe 
concussion  of  the  brain.  The  patient  lies  curleil  up  on  his  side,  is  restless, 
irritable,  or  delirious,  and  perhaps  has  involuntary  evacuations  from  the 
bladder  and  bowels;  the  eyes  are  closed,  the  pupils  contracted  but  react  to 
light,  the  temperature  sbghtly  elevated,  the  pulse  weak  and  slow.  The 
condition  lasts  a  few  days  or  several  weeks,  ami  entls  in  complete  recovery 
or  in  permanent  impairment  of  the  mental  faculties.  The  treatment  is  the 
same  as  that  for  the  second  stage  of  concussion. 

Compression  of  the  brain  may  be  caused  l>y  depressed  fracture,  foreign 
body,  intracranial  hemorrhage,  hydrocephalus,  inllammatory  pnulucts 
(including  ai>scess  and  edema),  and  by  cysts  and  tumors  (including  gurnma 
and  tuberculous  deposits).  It  may  be  iocalized  to  a  single  center  or  group 
of  centers,  e.g.  in  depressed  fracture,  or  gaieraUted,  e.g.,  in  hydrocephalus; 
or,  e.g.,  in  intracranial  hemorrhage,  it  may  begin  as  the  former  and,  as  the 
pressure  increases,  gradually  merge  into  the  latter. 

The  pathological  changes  arc,  first,  a  displacement  of  the  cerebro- 
spinal lluid,  then  compression  of  the  blood-vessels,  the  veins  collapsing 
primarily,  owing  to  their  thin  walls  and  the  low  intravenous  bliwd  pressure, 
and  linally  capillary  anemia,  with  loss  of  function  in  the  anemic  parts.  As 
the  cranial  cavity  is  divided  into  three  compartments  by  the  falx  and  the  ten- 
tori  um»  pressure  in  one  of  these  compartments  may  become  very  great 
before  causing  generalized  compression.  When  snbtenlorial  pressure  is 
increased  and  the  blood  supply  to  the  medulla  decreased,  the  vasomotor  cen* 
ler  at  once  becomes  mure  active  and  the  blood  pressure  rises;  thus  there  may 
be  oscillations  in  the  blood  pressure  and  consequently  irregularity~of  the 
medullary  circulation,  with  irregular  action  of  the  respirator)'  center  (Cheyne- 
Stokes  respiration)  and  intermittent  pulse.  Finally  intracranial  exceeds  the 
limit  which  intravascular  pressure  may  attain  and  death  ensues. 

The  symptoms  are  immediate  in  depressed  fracture,  foreign  bodies,  and 
apoplexy.  The  onset  is  delayed  in  middle  meningeal  hemorrhage  and  in 
inflammatory  exudates,  and  is  very  gradual  in  tumors,  cysts,  and  chronic 
hydrocephalus.  In  traumatic  cases  the  symptoms  may  be  precedeil  by  or 
mixed  with  those  of  concussion,  hnal  campression  causes  irritation  or 
paralysis  of  the  center  alTecled,  according  to  the  degree  of  pressure.  The 
symptoms  of  generalized  eompressum,  and  this  is  usually  what  is  meant  when 


I  and  th 


340  ^^^^^^^■r  HEAD, 

one  speaks  of  cerebral  compression,  are,  when  the  condition  develops  gradu^ 
ally,  likewise  (1)  those  of  irritation  and,  ns  the  pressure  l>ecomes  more  marked, 
those  of  paralysis  of  (2)  the  cortical  and  finally  {3)  the  bulbar  centers,     U).^d 
During  the  tirst  stage  there  may  be  headache,  vertigo,  restlessness,  deli rium,^| 
convulsions,  vomiting,  tinnitus,  contracted  pupils,  and  choked  disc.     The 
pulse  is  slow  and  full,  the  blood  pressure  elevated,  antl  the  respirations  more 
rapid  and  deeper,  from  stimulation  of  the  vagus,  vasomotor,  and  respiratory^^ 
centers.     The  temperature  varies  with  the  cause  of  compression,  thus  traumat^B 
hemorrhage,  and  shock  lower  it,  while  inflammator}'  conditions  and  lesions  of 
the  pons  and  medulla  elevate  it.     (2)  In  the  second  stage,  or  the  stage  of 
fully  developed  compression,  the  excitement  gives  place  to  stupor  and  finally 
to  complete  unconsciousness,  i.e.,  the  patient  cannot  be  roused  by  shouting, 
pricking  the  soles  of  the  feet,  etc.     As  the  medullary  centers  resist  longer 
than  the  cortex  the  pulse  remains  full  and  slow  and  the  blood  pressure  high. 
The  respiratory  center  is  the  first  of  the  medullary  centers  to  show  signs  of 
weakening,  hence  the  breathing  becomes  slow  and  stertorous.     The  stertor 
is  due  to  paralysis  of  the  soft  palate,  the  flapping  of  the  cheeks  to  paralysis 
of  the  facial  muscles,     (3)  In  the  final  stage  the  respirations  are  rapid,  irreg- 
ular, and  of  the  Cheyne-Stokes  variety;  the  pupils  are  dilated,  perhaps  un- 
equal, and  do  not  respond  to  light;  and  there  are  retention  of  urine  from 
paralysis  of  the  bladder,  and  involuntary  fecal  evacuations  from  relaxation 
of  the  sphincter  anj.     Localized  paralyses  maybe  detected  on  one  side  of  the 
body  in  the  early  stages,  but  in  the  final  stage  all  the  muscles  are  equally 
relaxed.     The  blood  pressure  falls  (paralysis  of  the  vasomotor  center)  and  the 
pulse  becomes  rapid  and  often  intermittent  (paralysis  of  the  vagus  center),  fl 
death  ultimately  occurring,  however*  from  respiratory  failure,  as  the  heart  il 
continues  to  beat  for  some  minutes  after  breathing  ceases. 

The  diagnosis  may  be  very  difficult  in  cases  in  which  no  history  caji  be 
obtained.  There  are  many  causes  for  coma,  but  only  those  most  frequently 
confused  with  compression  are  mentioned  below.  The  student  is  advised 
to  compa  re  the  symptoms  of  compression  and  concussion .  In  acute  alcohol  is  m 
the  patient  is  not  absolutely  unconscious;  the  pupils  are  dilated,  equal, 
and  react  to  light;  the  pulse  is  frequent;  and  there  are  no  paralyses.  Dilated 
varices  on  the  face,  injected  eyes,  and  the  odor  of  ak  ohol,  are  of  lesser  im- 
portance, since  an  alcoholic  may  have  a  fracture  of  the  skull,  and  an  injured 
man  may  have  been  given  whisky.  A  drunken  individual  improves  after 
washing  out  the  stomach  and  as  the  effects  of  the  alcohol  pass  away.  In 
tioubtful  cases  any  contusion  of  the  scalp  should  be  investigated  by  incision, 
and  the  patient  watched  for  symptoms  of  compression.  In  opium  poisoning 
the  respirations  are  very  slow,  the  pupils  small,  and  paral>^es  absent.  A 
farewell  letter  or  an  empty  bottle  may  be  found  in  the  patient's  pocket,  and, 
the  drug  may  be  recovered  from  the  stomach.  It  should  be  recalled  that  iaJ 
pontine  hemorrhage  the  pupils  are  contracted^  but  there  are  crossed  paralysi 
and  a  high  temperature.  In  uremia  the  coma  follows  convulsions,  the  tem- 
perature is  subnormal,  the  face  and  feet  are  edematous,  the  pupils  are  nor- 
mal or  dilated,  albuminuric  retinitis  is  sometimes  present,  albumin  and  casts" 
are  found  in  the  urine,  and  paralyses,  except  in  rare  cases,  are  absent.  In 
apoplexy  all  the  symptoms  of  compression  are  present,  and  the  diagnosis  can 
l>e  made  only  by  the  history  and  the  absence  of  local  evidences  of  injury. 
Diabetic  coma  follows  somnolence,  the  respirations  are  rapid,  the  pulse  weak»j 
and  there  are  sugar  in  the  urine,  a  sweet  odor  to  the  breath,  and  no  paralys 


OF  TITE   SKtJlt, 

In  some   cases  of  siibduraJ   hemorrhagt;  and  fratturc  of  the  skull  bloody 
cerebrospinal  fluid  may  be  obtained  by  lumbar  puncture. 

The  treatment,  which  is  removal  of  the  compressing  agent  whenever  pos- 
sible, is  given  in  more  detail  in  discussing  the  causative  conditions  mentioned 
abo^'e.  Irrespective  of  the  cause,  however^  it  may  be  advisable  lo  trephine 
simply  for  the  relief  of  pressure. 

Fractures  of  the  skull  are  dinded  into  those  of  the  vault  and  those  of 
the  base.  They  are  produced  in  four  ways,  (i)  Bending,  or  impression  frac- 
tures  (confined  always  exclusively  to  the  vault),  are  due  to  violence  restricted 
to  a  small  area  of  the  skull,  e.g.,  a  blow  from  a  hammer,  the  bone  bending  in- 
ward until  it  breaks.  As  wilh  a  stick  that  is  broken  by  bending » the  fracture 
begins  and  is  more  extensive  on  the  surface  made  convex  by  the  bending, 
i.e.,  the  inner  table,  (2)  Bursting,  or  compression  fractures,  may  involve  the 
vault,  the  base,  or  both.  As  the  skull  is  elastic,  when  the  head  is  scjueezed 
between  two  objects  the  axis  between  the  poles  of  compression  is  shortened, 
the  ei^uator  lengthened,  and  the  meridians  of  longitude  separated,  the  greatest 
gap  occurring  at  the  equator,  hence  the  line  of  fracture  runs  parallel  with  the  di- 
rection of  the  compressing  force.  (3)  SpliUing,  or  wedge  action,  is  exemplified 
when  an  instrument  like  a  chisel  is  driven  into  the  skull,  the  bone  splitting 
like  a  piece  of  wood.  (4)  Kxpl&sive  action  occurs  in  some  gunshot  wounds, 
j  waves  of  force  being  transmitted  from  the  bullet  to  the  cranial  contents, 
I         the  skull  sutTering  extensive  comminution. 

Fractures  of  the  vault  are  caused  by  direct  or  indirect  violence;  in  the 
:  latter  instance  the  bone  yields  from  compression  of  the  skull.  Like  fractures 
elsewhere  those  of  the  skull  may  be  simple  or  compmmd,  fompleie  or  partial. 
^^jThe  best  example  of  incomplete  fracture  is  that  of  the  outer  table  in  the  region 
^^Bof  the  frontal  sinus,  the  inner  table  being  uninjured.  Fracture  of  the  inner 
^^fttable  alone  is  rare.  In  children  the  skuil  may  be  indented  without  fracture 
^^rt>f  either  table.  The  usual  injury  is  a  pssured  fracture ;li  several  fissures  radi- 
I  ate  from  one  point  the  injury  is  called  a  sieilate  fra4lure.  Depressed  fractures 
are  generally  comminuted.  The  depression  may  slope  evenly  from  the  si^und 
l>one  {saucer  or  pond- shaped  froi lure),  OT  the  iT;cLgmGnl  or  fragments  may  be 
completely  detached  and  depressed  below  the  inner  table  (gulter  fracture) . 
PumtMred  fractures  are,  as  a  rule,  comminuted  and  depressed,  but  the  area  in- 
volved is  smalL  In  all  complete  fractures  the  inner  table  is  usually  more 
involved  than  the  outer,  owing  to  its  lack  of  support  and  greater  brittleness, 
and  owing  to  the  ditlusion  of  the  force,  as  pointed  out  above. 

Symptoms  in  a  simple  I  issu  re -fracture,  apart  from  local  bruising,  may  be 
absent*  and  the  condition  can  be  recognized  with  certainty  only  by  the  X-ray, 
or  after  exploratory  incision,  which  should  be  done  if  there  are  e\idences  of 
compression  or  severe  concussion.  Occasionally  a  cracked-pot  sound  is  ob- 
tained, and  in  rare  instances  a  spurious  meningocele  forms  (p.  330).  In 
simple  depressed  fracture  the  indentation  may  be  masked  by  swelling.  An 
old  scar  or  a  hematoma  may  feel  like  a  depression  (p.  319).  In  compound 
cases  the  fracture  may  be  seen  and  felt,  and  if  the  dura  is  injured  there  will 
be  an  escape  of  cerebrospinal  fluid  and  possibly  of  brain  tissue.  The  possi- 
bility of  mistaking  a  suture,  a  slit  in  the  pericranium,  or  a  tear  in  the  temporal 
fascia  for  a  fracture  should  be  recalled  (p.  330).  Fracture  of  the  inner  table 
alone  is  diagnosticated  only  after  trephining  for  the  associated  brain  symp- 
toms. The  general  cerebral  symptoms  may  be  those  of  concussion  or  com- 
pression.   The  localizing  cerebral   signs  depend  on    the   region    involved 


342 


HEAD. 


(p,  3,p),  The  prognosis  is  ihat  of  the  complicating  injury  of  ihe  l»rain, 
Ihe  immediate  dangers  are  shack,  laceration  of  the  brain,  and  comprc^- 
sion  from  bone  or  blood.  The  inlermeiliate  danger  is  septic  inllammation; 
and  the  remote  dangers  those  of  concussion  {({,  v,).  Of  all  cases  of  frac- 
tured skull  thai  recover  about  one-half  develop,  in  some  degree,  remote  ill 
effects,  and  probably  20  per  cent,  of  these  are  seriously  affected. 

Treatment  is  required  for  (i)  disinfection,  (2)  depression,  or  (3)  conaprts* 
sion.     I .  All  compound  fractures  must  be  disinfected;  v^hen  the  injury  is  evcii- 
a  fissure,  it  will  often  be  necessar>'  to  remove  the  line  of  fracture  by  goug 
or  rongeur,  owing  to  the  presence  of  hair  or  dirt  which  has  been  driven  int 
the  cratk.     2.  If  depression  exists,  whether  the  fracture  is  simple  or  cot 
pound  and  whether  there  are  symptoms  of  intracranial  trouble  or  not.  lb 
bone  should  be  pried  into  place  by  an  elevator.     If  an  opening  sufficient] 
large  for  the  elevator  does  not  exist,  it  will  be  necessary  to  trephine,  the  cenle 
pin  being  placed  upon  the  sound  bone  near  the  fracture.     If  there  is  muc 
comminution,  it  may  be  better  to  remove  the  fragments*     In  simple  depressed 
fractures  in  children  the  same  rule  should  apply  as  in  adults,  although  somc^— 
authors  advise  expectant  treatment  in  these  cases.     The  reason  for  trephinin||^| 
in  depression  without  symptoms  is  to  prevent  subsequent  cerebral  Iroublesl^" 
e*g.,  epilepsy,  insanity.     Punctured  fractures  require  trephining  both  for 
depression  and  disinfection.     3.  All  fractures,  whether  simple  or  compound, 
with  symptoms  of  compression  require  trephining.     The  only  cases  which 
are  treated  expectantly  are  those  of  simple  fracture  without  depression  or 
symptoms,  and  those  in  which  the  injury  is  very  extensive. 

Fractures  of  the  base  of  the  skull  are  caused  by  direct  violence,  as 
stabs  or  gunshot  wounds  through  the  orbit,  nose,  mouth,  ear,  or  occiput,  in 
which  case  the  fracture  may  be  depressed;  a  similar  injury  results  from  a 
blow  on  the  chin  which  drives  the  condyles  of  the  jaw  into  the  middle  fossa, 
or  from  a  fall  on  the  head,  feet,  or  buttocks,  which  drives  the  vertebral 
column  upwards  into  the  posterior  fossa.  Direct  fractures  are  caused  also 
by  blows  at  the  level  of  the  base  of  the  skull,  which  split  the  base  as  a  chisel 
does  a  piece  of  wo(kL  Indirect  fractures  are  caused  by  extension  of  a  fracture 
of  the  vault  {irradiatimi)^  or  by  a  squeeze  of  the  heatl,  the  resulting  fracture 
running  parallel  with  the  direction  of  the  compressing  force  {tntrsiing  frarlure) , 
modi  tied,  however,  by  the  lines  of  least  resistance  in  the  base  of  the  skull. 
Most  fractures  of  the  base  are  compound,  communicating  with  the  air  through 
the  orbit,  nose,  pharynx,  or  ear.  Fracture  of  the  middle  fossa  is  the  most 
frecjuent;  fracture  of  the  posterior  the  most  fatal,  because  of  the  vital  centers 
therein  contained.  The  dangers,  both  immediate  and  remote,  are  those 
of  fracture  of  the  vault,  except  that  here  the  important  structures  at  the  base 
and  the  cranial  nerves  arc  much  more  likely  to  be  implicated. 

The  symptoms  arc  usually  those  of  severe  concussion  or  compression, 
although  both  may  be  absent.  The  temperature  is  at  lirst  subnormal 
from  shock,  then  rises  to  ickd^  or  toi°  I'\,  and  subsequently  falls  to  normal 
or  subnormal,  A  continuous  rise  indicates  extensive  injury  to  the  brain  or 
meninges.  Fractures  involving  the  anterior  fassa  may  cause  prolonged  epis- 
taxis  followed  by  a  llow  of  cerebrospinal  fluid  from  the  nose,  and  subconjunc- 
tival hemorrhage,  which  is  recognized  by  its  occurrence  after  several  hours 
or  days  and  by  the  fact  that  it  comes  from  behind  forwards,  i.e.,  no  white 
sclerotic  can  be  seen  posterior  to  it.  If  the  bleeding  is  profuse  the  eye  may  be 
pushed  forward.     Escape  of   brain   tissue  from  the  nose  or  orbit  b 


k 


roil  IS  rarc^B 


INIAI  nr.i 


343 


> 


The  first,  seajntl.  oi  ihinl  t  ninial  iutvcs  may  l>t."  injurud,  lii  fracliins  of  ihc 
middle  fossa  blo<»<l  and  tt'rehrospinal  lluicl,  rart'ly  lira  in  tissut;,  may  cscapt: 
from  the  cars  and  occasionally  from  the  nose  or  moulh.  It  shoukl  Ije  recalled 
that  bleeding  from  the  ear  may  he  caused  by  injury^  to  the  bone  or  cartilage, 
or  by  rupture  of  the  tympanum,  without  fracture  of  the  base»  and  that  a 
serous  tluid  may  come  from  the  mastoid  cells  and  inner  ear.  Cerebrospinal 
tluid  may  be  recognized  by  its  watery  character,  by  the  increase  in  ilovv  on 
straining  or  coughing^  and  by  chemical  examination;  it  is  alkaline,  contains 
a  large  quantity  of  chlorids  and  a  trace  of  all>umin,  and  gives  the  reaction 
for  sugar  with  Fehling's  test.  Ecchymosis  may  be  seen  in  the  temporo- 
parietal region.  The  cranial  nerves  most  likely  to  l>e  injured  are  the  sixth, 
seventh,  and  eighth.  In  the  posierior  fossa  the  blood  infiltrates  the  muscJes 
at  the  back  of  the  neck,  but  is  prevented  from  reaching  the  skin  by  the  cervical 
fascia,  except  along  the  course  of  the  posterior  auricular  artery,  thus  causing 
a  crescentic  line  of  ecchymosis  behind  the  ear  (Battle's  sign).  Escape  of 
blood  from  the  mouth  and  injury  to  the  cranial  nerves  are  rare.  Optic 
neuritis  occasionally  occurs  a  week  or  more  after  fracture  of  the  posterior 
fossa.  Bloody  cerebrospinal  tluid  may  be  obtained  by  lumbar  puncture, 
even  three  or  four  weeks  after  the  injury.  The  X-ray  seldom  reveals  the 
fracture. 

The  treatment  is  first  to  react  from  shock  as  indicated  under  concussion 
of  ihe  brain.  The  patient  should  be  put  in  a  dark  and  quiet  room,  the  nose, 
pharynx,  or  ear  disinfected  (p.  3q),  according  to  the  situation  of  the  frac- 
ture, and  in  case  of  the  ear  the  canal  plugged  with  sterile  cotton  and  a  ban- 
dage applied  over  an  external  dressing.  Ice  should  be  api>lied  to  the  head,  a 
purgative  administered,  and  the  patient  kept  cm  a  Huid  diet.  In  a  punctured 
wound  of  the  orbit  involving  the  base  of  the  skull,  it  will  be  necessary  to  en- 
large the  wound  in  order  to  disinfect  thoroughly;  in  some  of  these  cases  it 
may  be  advisable  to  trephine  above  the  orbit  lo  remove  depressed  fragments 
and  disinfect.  Symptoms  of  compression  indicate  bilateral  subtemporal 
decompression  (Cushing),  i.e.,  removal  of  a  portion  of  bone  under  each  tem- 
poral muscle,  with  imision  of  the  dura;  hexamethylenamine  is  then  given 
for  its  antiseptic  elTect  on  the  cerebrospinal  iluid.  The  mortality  is  in  the 
neighborhood  of  75  per  cent. 

Intracranial  hemorrhage  may  be  spontaneous  (e.g.,  apoplexy)  or  trau- 
matic SpfmJattrims  hemorrhage  belongs  tu  the  jihysician  rather  than  to  the 
surgeon,  although  in  tertain  cases  of  ingravescent  apoplexy  the  common 
carotid  artery  has  been  tied,  and  in  ordinary  apoplexy  the  rcmijval  of  a 
section  of  the  skull  has  been  suggested  in  order  to  relieve  compression, 
Traumaik  hemorrhage  may  be  extradural  (between  the  dura  and  the 
bone),  subdural  (between  the  dura  and  the  brain),  or  cerebral  (within  the 
brain). 

Extradural  hemorrhage  may  be  due  to  a  wounded  sinus,  but  is  most 
commonly  caused  by  rupture  of  the  middle  meningeal  artery  or  one  of  its 
branches.  Fracture  is  usually  but  not  invariably  present.  Rarely  the 
f>leeding  is  iwi  the  opposite  side  to  that  which  has  been  struck  (amlre  coup). 

The  symptoms  are  divided  into  three  periods,  the  first  or  the  second  of 
which^  however,  may  be  absent,  (1)  Temporary  t4nfonschj4^ncss  from  con- 
cussion, during  which  the  pulse  is  feeble  and  conscquendy  the  bleeding  slight ; 
(2)  a  period  of  const iausfiess  that  varies  according  lo  the  size  of  the  vessel 
injured  from  a  very  brief  period  to  a  number  of  hours,  during  which  the 


344  HEAD. 

pulse  grows  stronger  and  the  hemorrhage  increases;  hence  (3)  seamdary 
uncansciotisness  due  to  compression,  which  comes  on  gradually  as  the  dot 
increases  in  size.  The  patient  becomes  stupid  and  finaJly  comatose;  paraly- 
sis, perhaps  preceded  by  twitching,  develops  in  one  center,  usually  the  head 
or  arm,  and  slowly  creeps  to  adjacent  centers  until  the  whole  opposite  side  of 
the  body  is  involved;  the  pupil  of  the  afifected  side  becomes  dilated  and 
immobile  owing  to  the  extension  of  the  clot  to  the  base  of  the  brain;  and 
choked  disc  develops  on  each  side,  being  more  marked,  however,  on  the 
side  corresponding  to  the  hemorrhage.  The  pulse  is  more  frequent  than  in 
other  forms  of  compression  owing  to  the  loss  of  blood;  the  temperature, 
particularly  on  the  paralyzed  side,  rises;  and  in  case  of  fracture  blood  finds 
its  way  externally.  Lumbar  puncture  reveals  the  cerebrospinal  fluid  dear 
of  blood. 

The  treatment  is  trephining  one  and  one-fourth  inches  behind  the  exter- 
nal angular  process  of  the  frontal  bone,  on  a  level  with  the  upper  margin  of 
the  orbit,  thus  exposing  the  middle  meningeal  and  its  anterior  branch;  if  the 
dot  is  not  found,  a  second  opening  should  be  made  at  the  same  level  just 
beneath  the  parietal  eminence,  i.e.,  over  the  posterior  branch  (Figs.  249  and 
250).  The  side  to  be  trephined  is  that  opposite  the  paralysis,  and  not  neces- 
sarily the  side  on  which  injury  to  the  scalp  or  skull  is  evident.  The  clot  is 
removed  with  the  finger  and  the  artery  secured  by  a  suture-ligature.  If  the 
artery  has  been  ruptured  where  it  lies  in  an  osseous  canal,  such  may  be 
plugged  with  wax,  gauze,  or  sterile  wood,  or  gently  crushed  with  forceps. 
The  only  means  of  diagnosticating  hemorrhage  from  a  sinus  are  the  situation 
of  the  injury,  and  possibly  the  slower  onset  of  symptoms  owing  to  the  low 
pressure  of  the  blood  in  the  sinus.  The  means  of  controlling  hemorrhage 
from  a  sinus  have  already  been  indicated  (p.  338).  The  mortality  of  extra- 
dural hemorrhage  without  operation  is  90  per  cent.,  with  operation  33J  per 
cent. 

Subdural  hemorrhage  arises  from  injuries  to  the  inner  wall  of  the  venous 
sinuses,  from  rupture  of  the  middle  meningeal  artery  if  the  dura  has  been 
opened,  and  most  frequently  from  wounds  of  the  middle  cerebral  or  its 
branches. 

The  symptoms  are  those  of  concussion,  rapidly  merging  into  compression 
owing  to  the  widely  diffused  clot.  In  rare  instances  the  clot  may  be  limited 
and  give  localizing  symptoms.  Lumbar  puncture  discloses  bloody  cerebro- 
spinal tluid. 

The  treatment,  if  the  clot  can  be  localized,  is  trephining  over  the  region 
indicated  by  the  symptoms,  removal  of  the  coagulated  blood,  hemostasis  by 
ligature  or  packing,  and  drainage.  In  other  cases  bitemporal  decompression 
may  be  performed.  As  a  rule,  however,  the  injur}'  is  widespread  and  but 
little  can  be  accomplished  by  operation. 

Cerebral  hemorrhage  due  to  trauma  is  accompanied  by  injuries  so 
diffuse  that  death  (juickly  follows,  and  operation  is  indicated  only  in  the  pres- 
ence of  localizing  symptoms.     See  also  wounds  of  the  brain. 

Wounds  of  the  internal  carotid  artery  within  the  skull  are  quickly 
fatal  if  the  wound  is  large,  but  if  small,  recovery  sometimes  occurs  with  the 
development  of  an  aneur}'smal  varix  between  the  artery  and  the  cavernous 
sinus.     The  treatment  is  ligation  of  the  common  carotid  in  the  neck. 

Intracranial  hemorrhage  in  the  new-bom  may  occur  during  difficult 
labor  and  after  the  application  of  forceps,  from  overriding  of  the  cranial 


WOUNDS    OF   THK    BRAIN. 


345 


Ixjnes,  particularly  the  parietal,  in  which  case  the  veins  emptying  into  the 
superior  longitudinal  sinus  are  torn. 

The  symptoms  are  irregular  respirations  or  asphyxia,  a  bulging,  feebly 
pulsating  anterior  fontanelle,  unequal  pupils^  and  usually  conv^ulsions; 
lumbar  puncture  reveals  bloody  cerebrospinal  fluid.  The  few  cases  that 
survive  develop  idiocy,  epilepsy,  or  some  form  of  birth  palsy,  e.g.,  spastic 
hemiplegia,  or,  if  both  leg  centers  are  involved,  spastic  paraplegia. 

l^he  treatment  is  removal  of  the  dots,  after  making  an  osteoplastic 
flap  in  one  or  both  parietal  regions,  according  to  whether  the  bleeding  is 
unilateral  or  bilateral. 

Wounds  of  the  brain  may  be  non-penetrating,  i.e.,  those  which  do  not 
communicate  with  the  exterior,  or  penetrating,  i.e.,  those  associated  with  an 
external  wound. 

Non-penetrating  wounds  are  caused  by  falls  and  blows,  and  may  or  may 
not  be  associated  with  simple  fracture  of  the  skuIL  They  vary  in  degree  from 
a  limited  contusion  tu  extensive  lacerations  or  pulpilication.  The  amount 
of  hemorrhage  depends  upon  the  situation  and  extent  of  the  injury.  If 
the  patient  recovers,  the  etiused  blood  may  be  absorbed  and  the  site  of  the 
laceration  be  marked  by  a  depressed  cicatrix,  or  the  extra vasated  blood  may 
become  organized  as  a  brownish  adherent  layer  or  form  a  cyst.  In  other 
cases  inflammatory  phenomena  supervene  and  cause  softening  of  the  brain 
tissue,  which,  if  not  extensive  or  involving  important  centers,  may  result  in 
complete  recovery,  Tn  more  serious  cases  the  intlammation  spreads  to 
the  meninges,  and  compression  of  the  brain  ensues  as  the  result  of  eilema  or 
exudation.  It  is  generally  thought  that  cerebral  tissue  once  destroyed  is 
never  regenerated;  if  the  functions  of  such  tissue  reappear,  it  is  supposed  to 
be  due  to  compensatory  action  of  neighboring  centers. 

The  symtoms  are  those  of  severe  concussion,  indeed  if  a  patient  does  not 
react  promptly  from  concussion,  contusion  or  laceration  of  the  brain,  or  hem- 
orrhage is  probably  present.  Death  may  be  instantaneous  if  the  vital  centers 
are  involved.  Symptoms  of  compression,  if  present  from  the  beginning,  in- 
dicate depressed  fracture,  or  extensive  hemorrhage  from  the  brain  tissue;  com- 
pression coming  on  later  is  due  to  bleeding  from  the  meningeal  vessels  or 
sinuses,  or  to  a  spreading  edema  or  inflammatory  exudate.  The  localizing 
symptoms  depend  upon  the  portion  of  brain  injured.  The  remote  elTects 
are  those  of  concussion. 

The  treatment  depends  up>on  the  symptoms.  If  concussion  is  present  it 
should  be  treated;  if  signs  of  compression  arise  the  skull  should  be  trephined 
according  to  the  localizing  symptoms,  and  depressed  bone,  elevated, 
hemorrhage  checked,  or  drainage  instituted,  according  to  the  cause  of 
compression. 

Penetrating  wounds  of  the  brain  are  caused  by  blows,  falls,  stabs,  and 
gunshot  wounds  and,  excepting  rare  cases,  e.g.,  a  puncture  through  an  open 
fontanelle  or  foramen,  are  accompanied  by  fracture  of  the  skulk 

The  S3rmptoms  are  those  of  compound  fracture  of  the  skull  with  those 
of  non-penetrating  wounds  of  the  brain.  In  punctures  such  as  a  stab  wound, 
in  which  important  centers  are  not  injured,  there  may  be  no  symptoms 
referable  to  the  brain,  as  the  injur)^  is  not  of  such  a  nature  as  to  produce 
concussion.  For  general  facts  regarding  gunshot  wounds  see  p.  92.  In 
all  open  wounds  of  the  brain  there  is  danger  of  septic  meningitis,  fungus 
cerebri,  and  cerebral  abscess.     If  proper  disinfection  can  be  carried  out  and 


HEAD, 

sLeriiity  malniafiiL'ij,  iht^  >uUscijueirt  rtmrsc  is  the  same  as  in  n on -pcnc! rating 
wounds. 

The  treatment  is  reaction  from  shoik,  and  exploration,  by  enlarging  the 
scalp  wound  if  nccessar>\  Depressed  fragments  of  fxine  should  be  removed, 
the  opening  in  the  skulK  if  small,  enlarged  with  rongeur  forceps,  hemorrhage 
controlled,  accessihle  foreign  bodies  removed,  ihe  wound  in  the  brain  dis* 
infected  by  a  gentle  stream  of  Ixjric  or  salt  solution,  drainage  by  gauze  or  rub- 
ber tube  instituted,  the  dura  sutured  as  far  as  possible,  and  the  piatient 
watched  for  symptoms  of  meningitis  or  abscess.  The  best  means  for  locating 
a  bullet  is  the  Xray.  If  a  prfibe  is  employed,  it  should  be  very  light,  e.g., 
the  Fluhrer  aluminum  probe,  and  allowed  to  follow  the  tract  by  gravity, 
the  head  being  placed  in  a  position  rendering  this  possible.  If  the  bullet 
cannot  be  found  by  a  careful  but  gentle  search,  or,  if  a  formidable  operation 
would  be  necessary  to  remove  it,  even  if  localized  by  the  X-ray,  it  should  be 
allowed  to  remain  unless  causing  distinct  symptoms. 

Hernia  cerebri  is  a  protrusion  of  the  brain  tissue  beneath  the  scalp, 
through  a  traumatit  defect  in  the  skull,  as  the  result  of  increased  intracranial 


i 


Fig.  358. — Fungus  cerebri  following  an  operatian  for  brain  tumor.  (Pennsylvania  Hospital.) 


pressure,  e,g.,  after  an  operation  for  an  irremovable  tumor.     When  there  is 

a  defect  in  the  scalp  the  condition  is  called  prolapse  of  the  brain.  It  pulsates, 
has  an  impulse  on  coughing,  and  may  be  partly  reducible,  causing  symptoms 
of  comprcssitm  of  the  brain.  .According  to  the  cause  of  increased  intracranial 
pressure,  it  increases  or  decreases  in  size.  If  uncovered  by  scalp,  septic  men* 
ingitis  is  likely  to  occur;  and  if  of  large  size,  gangrene  frequently  results. 
Prolapse  of  the  brain  should  not  be  confused  with  fungus  cerebri  (Fig.  258), 
w*hich  is  simply  exuberant  and  edematous  granulations  from  the  neuroglia,  as 
the  result  of  wounds  of  the  brain.  Since  the  latter  occurs  only  w  hen  there  is 
an  opening  leading  down  to  the  brain,  care  should  be  taken  after  operation 
to  suture  the  dura  whenever  possible;  when  a  portion  of  the  dura  has  been 
destroyed,  Keen  remedies  the  defect  by  a  flap  of  pericranium,  which  is  sutured 
in  place  with  the  osteogenetic  surface  outwards.  The  treatment  of  hernia 
cerebri  is,  if  |K)ssible,  the  removal  of  the  cause  of  the  increased  intracranial 


5CEPHAT,US. 


M7 


pressure.  The  protudin^  l>nim  should  f)c  pnitectcd,  and,  if  uncovered^ 
dressed  with  j^tcrile  gauze  to  prevent  seplit  tontamiiiation.  l^ressure  may 
be  dangerous,  and  amputation  should  l>e  employed  only  when  sloughing  has 
occurred.  The  prognosis  is  unfavorable.  Fungus  lerebri  is  treated  by 
slicing  off  the  granulations,  or  by  cauterizing  them  with  silver  nitrate.  The 
condition  is  not  serious. 


DISEASES  OF  THE  CRANIUM  AKD  ITS  CONTENTS, 


For  diseases  of  the  cranial  bonas  see  chapter  on  diseases  of  bone. 

A  meningocele  is  a  sac  of  cerebral  membranes  containing  cerebrospinal 
fluid  and  proluding  through  a  congenital  opening  in  the  skulL  It  occurs 
most  frequently  in  the  middle  line,  midway  between  the  foramen  magnum 
and  the  posterior  fontanelle,  but  may  be  found  also  at  the  root  of  the  nose, 
at  any  of  the  fonlanelles,  or  at  the  base  of  the  skulb  It  is  round,  translucent, 
pedunculated,  and  reducible;  and  it  has  an  impulse  on  coughing,  fluctuates, 
and  rarely  pulsates.  Spurious  meningocele  is  described  on  p.  ^t^o.  The 
irratment  is  excision  of  the  sac  and  tlosure'of  the  opening  in  the  memliranes, 

Encephalocele  is  a  meningocele  containing  a  portion  of  the  brain.  The 
signs  are  the  same  as  those  of  meningocele,  except  that  the  tumor  is  opaque, 
pulsates  but  does  not  tluctuate,  and  causes  symptoms  of  pressure  when  re- 
duced. Occasionally  the  brain  tissue  retracts  within  the  skull  and  the  tumor 
becomes  a  meningocele,  which  in  rare  instances  may  undergo  spontaneous 
cure  owing  to  the  closure  of  the  opening.  The  In-almmi  is  excision  of  the 
sac  and  brain  tissue,  providing  no  important  center  is  involved. 

Hydr encephalocele  is  the  same  as  encephalocele,  except  that  the  herni- 
ated brain  tissue  contains  a  cavity  which  communicates  with  the  ventricles. 
The  swelling  is  large,  lobulated,  somewhat  translucent,  and  rarely  peduncu- 
lated or  reducible;  and  it  fluctuates*  pulsates,  ami  has  a  slight  impulse  on 
coughing.  If  the  tumor  contains  motor  centers  there  may  be  paralysis. 
Hydrencephalocele  is  not  amenable  to  treatment  and  is  always  fatal. 

Poeumatocele  is  a  collection  of  air  between  the  pericranium  and  the 
skull,  the  result  of  a  spontaneous  or  pathological  perforation  of  the  frontal 
sinus  or  mastoid  cells.  Of  thirty-three  cases  reported,  twenty- three  were 
occipital  and  ten  frontal  The  tumor  is  elastic,  pseudo-iluctuant,  and  often 
partly  reducible.  The  ireatment  is  puncture  and  compression;  or  better 
incision,  and  plugging  of  the  opening  in  the  bone  with  antiseptic  wax. 

Hydrocephalus  is  an  excess  of  lluid  in  the  ventricles  (itUernai  hydrofcpk' 
alus)  or  in  the  subarachnoid  spaie  (exterftal  hydrocephahis)\  the  latter  is 
usually  secondary  to  the  former.  It  may  be  acute  (e.g.,  in  meningitis,  which 
is  described  below)  or  chronic.  Ckrtmic  hydroeepkaitis  may  be  congenital 
or  acquired,  Catt genital  hydroiephalus  is  of  unknown  origin.  The  cranium 
becomes  very  much  enlarged,  the  superficial  veins  are  distended,  the  face 
looks  small,  the  sutures  and  fontanelles  are  wide  and  bulging,  and  the  child  is 
defective  mentally.  Convulsions  and  paralyses  may  occur,  and  death  usually 
takes  place  early.  Sometimes  a  cracked  pijt  sound  may  be  obtained  on 
percussion,  sometimes  fluctuation  may  be  felt,  and  occasionally  the  head  is 
translucent.  The  acquired  form  results  from  meningitis,  closure  of  the  fora- 
men of  Majendie,  or  pressure  by  a  tumor  upon  the  veins  of  Galen  or  the 
straight  sinus.     It  sometimes  follows  operation  for  spina  bifida. 


HEAD. 

The  treatment  uf  acute  hydrocephalus  is  that  ul  meningitis.  Chrwrk 
hydrocephalus  depending  upon  tumor  should  be  treated  by  removal  of  the 
tumor;  If  this  is  impossible,  relief  from  pressure  may  be  maintained  by 
making  a  large  opening  in  the  skull.  Congenital  hydrocephalus  cannot  be 
cured.  Elastic  pressure,  the  injection  of  Morton's  fluid  (p,  565),  tapping  the 
ventricles,  and  spinal  puncture  are  practically  useless.  The  lateral  veniride 
may  he  punctured  either  at  one  side  of  a  large  anterior  fontanelle,  or  by  making 
a  small  trephine  opening  one  and  one-fourth  inches  above  and  behind  the 
external  auditory  meatus,  and  pushing  the  needle  inwards  two  and  one- 
fourth  inches,  towards  a  point  two  and  one-half  inches  above  the  opposite 
meatus  (Keen).  The  most  encouraging  results  have  been  obtained  by  meajis 
of  horse  hair  or  catgut  strands,  one  end  of  which  is  introduced  into  the  lateral 
ventricle  and  the  other  placed  beneath  the  dura  or  beneath  the  skin,  thus 
providing  permanent  drainage  of  the  ventricular  fluid  to  a  situation  where  it 
may  be  absorbed. 

Microcephalus^  or  abnormal  smaOuess  of  the  cranium,  is  due  to  def ecti\T 
development,  and  is  usually  associated  with  idiocy.  The  patient  should  Ik 
referred  to  a  school  for  the  feeble  minded.  Linear  craniotomy  is  useless  and 
will  not  be  descnbed. 

Intracranial  infiammation  may  involve  the  dura  {pachymeningitis)^ 
the  arachnoid  and  pia  {leptomeningitis) ^  or  the  brain  (encephalitis).  In  most 
instances  both  the  membranes  and  the  brain  are  involved  and  the  condition 
is  called  meningitis  or  ai cephalitis,  although  meningoencephalitis  would 
perhaps  be  the  best  term.  Under  this  heading  should  be  included  also  infec- 
tive sinus  thrombosis. 

Pachjnueningitis  externa,  i.e.,  inflammation  of  the  outer  layer  of  the 
dura,  is  due  to  injury,  syphilis,  or  to  diseases  of  the  cranial  Ixmes,  particularly 
of  the  osseous  tissue  surrounding  the  middle  ear.  In  the  simple  form  the 
membrane  is  thickened,  perhaps  causuig  a  persistent  localized  headache. 
In  the  suppurative  variety  pus  collects  between  the  dura  and  the  bone,  and  the 
symptoms  and  treatment  are  identical  with  those  of  extradural  abscess. 

Pachymeningitis  interna  may  be  due  to  extension  from  the  outer  layer 
of  the  dura  or  from  the  pia  and  arachnoid.  Pachymeningitis  iniema  hemor- 
rhagica {hematoma  of  the  dura  matrr)  is  caused  by  the  rupture  of  vessels  in  a 
vascular  layer  which  forms  on  the  inner  surface  of  the  dura.  The  condition 
is  generally  bilateral,  and  is  found  most  frequently  in  the  insane,  alcoholic, 
syphilitic,  and  in  the  aged,  although  it  may  be  associated  with  infectious  fevers 
and  diseases  of  the  blood.  The  symptoms  are  those  of  cerebral  irritation  and 
slowly  progressing  compression,  perhaps  with  localizing  phenomena.  The 
treatment  is  trephining  on  both  sides  and  removal  of  the  subdural  clot- 

Leptomeningitis,  or  inflammation  of  the  pia-arachnoid,  may  be  acute  or 
chronic,  localized  or  diffused. 

Acute  leptomeningitis  may  be  primary,  e.g.,  in  wounds  (pyogenic  organ- 
isms) and  in  epidemic  cerebrospinal  meningitis  (diplococcus  intracellularis 
meningitidis)*  but  it  is  most  frequently  secondar>'  to  infective  diseases  of  the 
scalp,  cranium,  and  face,  e.g.,  erysipelas,  carbuncle,  caries,  necrosis,  and 
middle  ear  disease,  or  to  pyemia,  pneumonia,  typhoid,  influenza,  diphtheria, 
gonorrhea,  anthrax,  actinomycosis,  tuberculosis,  or  sun-stroke.  It  occurs 
too  as  a  terminal  infection  in  many  chronic  maladies,  including  chronic 
alcoholism  (pyogenic  organisms).  Thus  a  great  variety  of  bacteria  may  be 
responsible  for  the  condition.     The  inflammatitm  is  essentially  the  same  as 


THROMBOSIS   OF   THE  SINUSES. 


549 


in  other  parts  of  the  l>ody.  The  subarachnoid  space  becomes  distended  with 
a  cloudy  or  purulent  fluid,  and  the  brain  becomes  edematous  and  covered 
with  lymph  ami  frequently  shows  small  hemorrhages.  Extension  to  the 
meninges  of  the  cord  is  yery  apt  to  follow.  Should  recovery  occur^  the  patient 
is  liable  to  suffer  from  the  changes  whii  h  occur  in  the  l>rain  tissue,  or  from 
adhesions  which  shut  oil  the  ventricles  (hydrocephalus)  or  which  form 
at  the  cortex  or  base  of  the  brain  (epilepsy,  paralyses  of  the  cranial 
nerves,  etc.). 

The  symptoms  in  traumatic  cases  usually  come  on  within  two  or  three 
days,  although  there  is  a  subacute  form  in  which  the  onset  may  be  delayed 
for  a  number  of  days  or  even  weeks,  probably  the  result  of  a  late  infection 
by  way  of  the  blood  or  lymph  vessels.  The  symptoms  are  those  of  { i)  sepsis, 
viz.,  chills,  irregular  fever»  and  the  changes  associated  with  fever;  (2)  those 
of  irritation  of  the  lira  in,  which  occur  in  the  early  stages,  \'iz.,  severe  head- 
ache, vomiting,  stiff  neck,  rigidity  of  other  muscles  (producing  in  the  leg 
Kernig^s  sign),  delirium,  photophobia,  contracted  pupils,  hyperesthesia,  and 
conxiilsions;  and  (3)  those  due  to  pressure,  which  oi^cur  during  the  terminal 
stage,  viz..  coma,  dilated  unequal  pupils,  optic  neuritis,  strabismus,  paralyses 
in  other  parts  of  the  body,  slow  pulse,  and  stertorous  respirations.  Upon 
lumbar  puncture  the  cere l>ro spinal  ffuid  spurts  out;  it  contains  many  poly* 
morphonuclear  leukocytes  in  septic  cases,  many  lymphocytes  in  tuberculous 
cases,  and  ihe  causative  bacteria. 

The  treatment  is  to  place  the  patient  in  a  quiet  darkened  room,  put  ice  to 
the  head,  administer  laxatives  and  hexamethylenamine,  and  apply  wet  cups 
to  the  mastoid  (to  drain  the  mastoid  vein)  and  back  of  the  neck.  Sedatives, 
such  as  l>romid  of  potassium,  are  used  in  the  early  stages,  stimulants  in  the  hnal 
stage.  Mercury  and  potassium  iodid  are  often  employed.  Lumbar  punc- 
ture may  be  used  to  rcmtjve  pressure  temporarily;  ihe  ventricles  also  have 
been  tapped  for  the  same  indication.  Trephining  for  drainage  is  indicated  if 
the  process  is  localized,  and  has  been  employed  in  even  the  diiTuse  form,  with, 
however,  very*  little  encouragement,  the  opening  being  made  in  the  occipital 
bone  towards  the  base  of  the  brain. 

Chronic  leptomeningitis  may  foIlow^  trauma  and  is  not  infrequently  seen 
in  syphililics  and  alcohobcs.  The  membranes  are  thickened  and  are  adhe- 
rent to  the  brain,  »^ausing  persistent  localized  headache,  tenderness,  and  some- 
times epilepsy.  The  treatment  is  the  administration  of  sedatives  and  p>otas- 
sium  iodid,  or  if  these  fail  trephining. 

Infective  thrombosis  of  the  venous  sinuses  may  be  due  to  primary^  in- 
fection in  compound  fractures  of  the  skull  or  in  the  acute  infective  fevers,  but 
is  usually  secondary  to  infections  of  the  ear,  nose,  pharynx,  face,  orbit,  or 
scalp,  the  primary  inflammation  spreading  by  contiguity,  or  by  setting  up  a 
phlebitis  which  extends  inwards  to  the  sinuses.  In  two-thirds  of  the  cases  the 
cause  is  disease  of  the  middle  ear,  and  the  lateral  sinus  is  the  one  affected. 
Meningitis  and  brain  abscess  are  not  infrequent  complications. 

The  symptoms  are  due  to  (i)  the  infective  process  and  (2)  to  the  throm- 
bosis. I.  The  infective  symptoms  are  those  of  septicemia  or  more  frequently 
pyemia;  some  cases  resemble  typhoid  fever,  in  others  pulmonary*  symptoms 
are  prominent  owing  to  infection  of  the  lungs  with  em  boh*.  If  the  infection 
spreads  to  the  meninges,  there  will  be  irritation  or  compression  of  the  brain, 
as  indicated  under  meningitis.  2.  The  symptoms  due  to  the  thrombosis 
vary  with  the  sinus  affected.     Thrombosis  of  the  ktt^ral  sinus  cau?«s»  ^^im. 


% 


3  so  ^'^l^^  HK.VD. 

tenderness,  and  edema  along  the  line  of  the  sinus,  over  the  mastoid? 
along  the  jugular  if  the  latter  is  invaded.  There  will  be  a  history  of  suppun* 
tive  middle  ear  disease,  with  perhaps  an  offensive  discharge  which  haiv.  r 
with  the  onset  of  the  symptoms  of  sinus  thrombosis.  The  pneumog.: 
glossopharyngeal,  and  spinal  accessory  ner\'es  may  be  paralyzed  by  pre!s?.ure 
in  t  h  e  j  u  gul  a  r  f  ora  men.  T  h  ro  m  bosis  o  f  t  h  e  v  upcr  wr  Ion  git  ud  inaJ  s  inus  causes 
pain,  tenderness,  and  edema  along  the  sinus  and  over  the  forehead,  episiaxi.s 
ajtid  possibly  convulsions  from  irritation  of  the  motor  area.  Thrombosis  of 
the  cavernous  sinus  causes  exophthalmos,  edema  of  the  orbit  and  eyelids, 
choked  disc,  and  paralysis  of  the  third,  fourth,  ophthalmic  branch  of  the  fifth, 
and  sixth  cranial  nerves.  Thromljosis  of  the  petrosal  sinus  gives  no  localizing 
symptoms. 

The  treatment  of  thrombosis  of  the  lateral  sinus  due  to  middle  ear  disease 
is  to  clean  out  the  mastoid  (p.  377),  and  then  expose  the  sinus  by  gouging 
or  chiseling  away  the  bone  at  the  posterior  part  of  the  opening.  ^\ny  pus  in 
the  groove  of  the  sinus  is  washed  away,  and  an  attempt  is  made  to  confirm 
the  diagnosis  by  palpating  the  sinus  and  by  introducing  a  hollow^  needle. 
If  no  bIcMjd  flows  through  the  needle  thrombosis  is  present.  If  blood  flows 
through  the  needle  it  should  lie  withdrawn  until  the  point  is  just  within  the 
sinus,  to  make  sure  there  is  no  mural  thrombus.  After  the  diagnosis  has 
been  confirmed,  the  internal  jugular  vein  should  l>e  tied  below  any  existing 
thrombus  to  prevent  septic  dissemination.  The  sinus  is  then  opened,  and 
the  clot  removed  by  curetting  until  free  l>leeding  is  obtained,  which  is  easily 
controlled  by  forcing  gauze  lietwecn  the  sinus  and  the  bone.  If  the  jugular 
is  involved  it  should  be  excised  above  the  ligature  which  has  been  placed  on  it, 
and  irrigation  practised  from  the  opening  in  the  skull  through  to  that  in  th< 
neck>  Both  wounds  should  be  packed  with  sterile  gauze.  Death  is  prai 
lically  certain  without  operation,  while  the  mortality  after  operation  is  abo 
50  per  cenL  Inflammation  of  the  longitudinal  sinus  should  be  dealt  with  in 
a  similar  way,  but  the  remaining  sinuses  of  the  head  are  practically  inacc 
sible,  although  attempts  have  been  made  to  drain  the  cavernous  sinus  throu 
an  opening  in  the  temporal  fossa,  somewhat  like  that  used  to  expose  the 
Gasserian  ganglion. 

Intracranial  abscesses  may  lie  between  the  dura  and  the  skull  {exira- 
durai),  between  the  dura  and  the  brain  (subdural) ^  or  in  the  brain  substan 
{cerebral  or  cerebellar).     The  causes  are  those  already  indicated  under  int 
cranial  intlammation,  50  per  cent,  being  due  to  chronic  suppurative  oti 
media. 

Extradural  abscess  causes  fever  with  or  without  chills,  edema  of  the 
scalp  over  the  abscess,  a  discharging  sinus  if  due  to  bone  disease  or  com- 
pound fracture,  locab^zed  headache  and  tenderness,  and  pressure  sy^mptoms, 
e.g.,  spasm  or  paralysis  if  over  the  motor  area,  optic  neuritis  or  dilated  pupil 
if  near  the  base,  etc.  Coma  finally  occurs,  owing  to  the  growth  of  the  absce-Si 
or  to  the  extension  of  the  inflammation  to  the  meninges  and  the  brain,  T 
treahncnt  is  drainage  by  enlarging  a  sinus,  if  such  exists,  or  by  trephinin 
If  due  to  middle  ear  disease,  the  mastoid  is  opened  and  the  abscess  usualf 
found  by  following  a  sinus. 

Subdural  abscess  and  abscess  of  the  brain  cannot  be  differentiated 
Excepting  thfjse  due  to  tubcrt  ulosis  and  pyemia,  the  abscess  is  usually  sing! 
In  traumatic  cases  it  is  generally  under  that  portion  of  the  scalp  which  h 
been  struck,  but  it  may  be  on  the  opposite  sitle  of  the  brain  just  like  coniusiu] 


^ 


1^^ 


upil 
ally™ 


ABSCESS   OF  Tni:    BRAIN'. 


351 


and  lacerations.  Abscesses  due  to  middle  ear  disease  are  most  common  in 
the  temporosphcnoidal  lobe  and  next  in  the  cerebellum,  nine-tenths  being 
within  a  circle  whose  center  is  one  and  one-fourth  inches  above  and  behind 
the  external  auditory  meatus,  and  whose  radius  is  one  and  one-fourth  inches. 
The  abscess  may  be  just  beneath  the  membranes,  or  it  may  lie  some  distance 
below  the  surface  of  the  brain,  the  infection  having  traveled  along  the  blood 
or  lymph  vessels. 

The  symptoms  may  be  either  acute  or  chronic,  and  are  due  to  the  absorp- 
tion of  septic  products  and  to  compression  of  the  brain.  In  acute  cases,  the 
best  example  of  which  is  seen  a  few  days  after  a  compound  fracture  of  the 
skull,  there  are  severe  headache,  fever,  perhaps  chills,  and  the  rapid  develop- 
ment of  pressure  symptoms,  in  a  word  the  symptoms  of  men  in  go= en  cephali- 
tis, from  which  the  condition  cannot  be  distinguished  unless  there  are  localiz- 
ing s)Tnptoms.  In  the  course  of  a  chronic  abscess  the  same  group  of  symp- 
toms may  suddenly  arise,  owing  to  the  bursting  of  the  abscess  into  the  lateral 
ventricle  or  on  the  surface  of  the  brain.  Chnmic  aburss  seldom  begins  within 
one  week  of  an  injury,  and  it  may  not  apf>ear  fc^^  months  or  even  years.  In  a 
typical  case  the  signs  of  septic  absorption  are  slight  or  absent,  thus  there  may 
be  an  initial  rise  in  the  temperature^  but  it  soon  falls  to  normal  or  subnormal, 
although  the  local  temperature  over  the  abscess  remains  elevated.  The 
symptoms  of  compression  come  on  slowly  in  the  course  of  weeks  or  months. 
They  are  persistent  headache,  often  most  marked  (and  associated  with 
tenderness)  over  the  abscess;  cerebral  vomiting,  which  is  distinguished  by  its 
explosive  character,  the  absence  of  nausea,  the  presence  of  a  clean  tongue,  and 
by  the  fact  that  it  has  no  reladon  to  the  ingestion  of  food;  slow,  full  pulse; 
mental  hebetude  merging  into  coma,  with  Cheyne-Stokes  respiration  in  the 
final  stages;  optic  neuritis,  which  if  l>ilateral  is  more  marked  on  the  alTected 
side;  dilated  fixed  pupil  tm  the  diseased  side;  ptosis  or  strabismus;  convul- 
sions or  paralyses  of  the  face,  arm,  or  leg;  interference  with  the  special  senses; 
and  vertigo,  ataxia,  etc.,  according  to  the  portion  of  brain  involved 
(p.  ;i$2).  Localizing  symptoms  in  abscess  of  the  temporosphcnoidal  lobe 
lire  often  absent. 

The  diagnosis  of  chronic  abscess  from  ofnfr  meningiiis  is  made  by  noting 
that  the  latter  commences  a  few  days  after  injury,  that  it  is  associated  with 
fever,  delirium,  contracted  pupils,  pihotophobia,  and  stiff  neck,  and  that  the 
whole  course  is  very  acute.  Mastoid  disrasr  ahme  may  cause  cerebral  symp- 
toms, but  opening  the  masttn'd  will  cause  these  symptoms  to  subside.  Throm- 
bosis of  the  later  at  sinus  is  associatetl  with  chills,  fev^r,  and  sweats,  and  there 
are  local  evidences  of  thrombosis.  Tumor  />/  the  brain  comes  on  more  slowly 
than  abscess,  but  presents  earlier  localizing  symptoms.  Uremia  may  cause 
symptoms  very  much  like  those  of  abscess. 

The  treatment  is  trephining,  according  to  the  localizing  symptoms,  and 
drainage.  The  dura  may  Ix*  opened  by  a  crucial  incisimt,  which  will  be  all 
that  is  needed  if  the  abscess  is  subdural.  If  it  lies  beneath  the  cortex  the 
li\id  and  edematous  brain  will  bulge  into  the  opening  and  there  will  be  absence 
of  pulsation.  The  exact  site  of  the  abscess  should  he  determined  by  a 
grooved  director  or  trocar  and  cannula,  when  a  pair  of  hemostatic  forceps 
may  l>e  pushed  along  the  exploring  instrument  \r\Xn  the  afjscess,  opened,  and 
withdrawn.  The  cavity  is  gently  irrigated  with  salt  solution,  sloughs  re- 
moved, and  a  double  rubber  dndnage  tulie  inserted;  gauze  may  be  paiketl 
around  the  projecting  i><irtion  of  the  tubrs  to  protect  the  meningeal  cavity^ 


1 


HEAD. 


t« 


In  abscess  due  to  middle  ear  disease  the  mastoid  should  first  be  opened  {p. 
377)  and  any  sinus  foOowedj  thus  perhaps  evacuating  an  extradural  or  e^*en 
a  subdural  collection  of  pus.  If  the  abscess  k  in  the  temporosphenoidal  lobe, 
the  incision  in  the  soft  parts  may  be  extended  upwards,  and  the  skull  opened 
about  three-fourths  of  an  inch  above  the  posterior  root  of  the  zygoma,  on  a 
line  with  the  posterior  border  of  the  bony  auditory  meal  us.  Barker  adWses 
trephining  one  and  one-fourth  inches  above  and  behind  the  external  audi- 
tor)^ meatus.  For  al>scess  of  the  cerebellum  the  trephine  opening  is  made 
beiow  the  lateral  sinus,  midway  between  the  inion  and  the  mastoid,  although 
it  may  sometimes  be  reached  by  deepening  and  enlarging  the  opening  which 
has  been  made  in  the  mastoid. 

Intracranial  tumors  may  spring  from  the  interior  of  the  skull  or  from 
any  of  the  intracranial  tissues,  or  they  may  be  metastatic,  the  priniar>'  tumor 
existing  in  some  other  portion  of  the  body.  In  this  region  the  term  tumor  is 
used  in  a  broatl  sense,  and  includes  not  only  neoplasms,  but  cysts  and  growths 
due  to  parasites  and  the  infectious  granulomata.  Speaking  in  round  numbers 
33J  per  cent,  are  sarcomata  (including  endothelioma  and  glioma),  25  per 
cent,  tuberculous,  10  per  cent,  cysts  (usually  resulting  from  old  blood  dots; 
dermoids,  hydatids,  and  cysticerci  are  very  rare),  5  per  cent,  secondarj'  car- 
cinomala.  and  3  per  cent,  gummata.  Benign  tumors  of  the  connective  tissue 
type  are  exceptional;  adenoma  is  occasionally  found  in  the  pituitary  body. 
About  twu-thirds  of  all  tumors  are  situated  in  the  cerebrum,  one- third  in  the 
cerebellum.     They  are  more  frequent  in  males  than  in  females. 

The  sjrmptoms  are  those  (i)  of  general  ami  (2)  of  local  compression,  (i) 
The  geniTai  symp{ofns  are  constant  severe  headache,  which  may  be  localized 
to  the  site  of  disease,  and  associated  with  tenderness  if  the  tumor  be  super- 
ficial; cerebral  vomiting  (p.  351);  in  80  per  cent,  generalixed  convulsions; 
optic  neuritis,  which  is  usually  double  and  more  marked  on  the  affected 
side  (unilateral  choked  disc  indicates  a  tumor  near  the  back  of  the  orbit  on 
the  same  side);  vertigo,  particularly  in  cerebellar  tumors;  inequality  of  the 
pupils;  and  stupor  or  other  menial  symptoms,  finally  merging  into  coma,  with 
slow  pulse  anil  Cheyne- Stokes  respirations.  The  temperature  is  normal  or 
subnormal  unless  there  is  a  complicating  meningitis.  (2)  The  localizing 
symptoms  are,  according  to  the  location  of  the  tumor,  interference  with  the 
special  senses,  spasm  or  paralysis  of  any  of  the  eye  muscles  or  of  muscles  in 
other  portions  of  the  body,  anesthesia  (rare  unless  the  internal  capsule  is  in- 
volved), etc.  (p.  332).  Localizing  symptoms  are  absent  if  the  tumor  lies  in 
a  silent  region.  Tumors  in  the  cerebcllo-pontinc  angle  may  cause  irritation 
or  paralysis  of  the  third,  fifth,  sixth,  seventh,  and  eighth  nerves.  The  symp- 
toms of  pituitary  tumors  are  given  on  p.  353. 

The  diagnosis  from  ahscess  is  given  on  page  351.  Chrmtic  uremia,  and 
occasionally  had  poisoning,  may  cause  headache,  vomiting,  convulsions,  and 
optic  neuritis,  so  that  a  careful  examination  should  be  made  for  these  condi- 
tions. The  situation  of  a  tumor  is  determined  by  the  localizing  symptoms 
and  occasionally  by  the  X-ray.  A  cortical  tumor  often  causes  tenderness 
over  the  growth  and  a  local  rise  in  the  temperature,  and  is  not  associated  with 
anesthesia.  Multiple  tumors,  of  which  the  most  frequent  are  the  tubercu- 
lous, metastatic,  and  gummata,  may  be  suspected  if  widely  separated  centers 
are  involved.  The  size  of  the  tumor  may  be  indicated  by  the  number  of  cen- 
ters involved  and  the  degree  of  compression.  The  nature  of  the  tumor  can' 
rarely  be  foretold.     Those  which  most  frequently  follow  injury  are  sarcoma- 


EPILEPSY.  353 

tous.  Tuberculous  masses  are  apt  to  occur  before  the  twentieth  year,  and  to 
be  associated  with  tuberculosis  elsewhere,  and  the  patient  may  react  to  one 
of  the  tuberculin  tests.  The  history  of  syphilis  or  of  a  primary  malignant 
tumor  in  some  other  portion  of  the  body  may  aid  in  arriving  at  a  correct 
diagnosis,  as  may  also  the  Wassermann  test. 

The  prognosis  is  exceedingly  gloomy.  Excepting  the  gummata,  death  is 
inevitable  without  operation,  and  almost  95  per  cent,  are  inoperable.  In  25 
per  cent,  of  those  subjected  to  exploration  the  tumor  is  not  foimd,  and  the 
operative  mortality  is  about  33  J  per  cent,  for  cerebral  tumors  and  60  per  cent. 
for  cerebellar  tumors.  Of  those  which  survive  the  removal  of  a  malignant 
growth,  practically  all  will  be  the  victims  of  recurrence.  The  damage  to  the 
nervous  centers  caused  by  the  tumor,  even  if  it  has  been  safely  removed,  is 
usually  permanent. 

The  treatmenti  at  first,  is  usually  the  administration  of  potassium  iodid, 
with  the  hope  that  the  growth  may  be  syphilitic.  If  no  improvement  is 
noticed  within  six  weeks,  operation  should  be  undertaken.  If  the  Wassermann 
reaction  is  absent,  one  may  dispense  with  this  preliminary  treatment.  The 
skull  over  the  area  indicated  by  the  symptoms  is  opened  by  an  osteoplastic  flap 
at  least  three  or  four  inches  in  diameter.  If  the  patient's  condition  is  poor,  the 
flap  may  be  replaced  and  the  operation  completed  after  several  days  {operation 
in  two  stages).  The  dura  is  opened  as  indicated  in  the  chapter  on  technic, 
and  the  tumor  enucleated  with  the  finger  or  handle  of  a  knife,  after  incising 
the  brain  tissue  if  the  tumor  be  subcortical.  If  the  tumor  cannot  be  removed, 
the  dura  should  be  allowed  to  gap,  and  the  scalp  sutured  after  stripping  the 
bone  from  the  inner  side  of  the  osteoplastic  flap,  so  that  at  least  relief  from 
pressure  may  be  obtained.  When  the  growth  cannot  be  localized  or  is 
known  to  be  irremovable  decompression  may  be  deliberately  undertaken  to 
relieve  headache  and  vomiting,  prevent  blindness,  and  prolong  life.  In 
such  cases,  if  the  tumor  be  cerebral,  the  bone  and  dura  beneath  the  right 
temporal  muscle  (the  speech  center  is  on  the  left  side)  should  be  removed, 
through  a  straight  longitudinal  incision.  Cerebellar  decompression  is  made 
by  removing  the  bone  and  dura,  on  each  side,  from  the  superior  curved 
line  of  the  occipital  bone  to  the  foramen  magnum,  after  reflecting  the  soft 
tissues  as  a  flap. 

Tumors  of  the  pituitary  body  (hypophysis  cerebri),  in  addition  to  the 
general  symptoms  of  brain  tumor,  may  cause  bitemporal  hemianopsia 
(primary  atrophy  of  the  nasal  half  of  each  optic  disc)  from  pressure  on  the 
optic  chiasm,  and,  as  shown  by  the  X-ray,  excavation  of  the  sella  turcica. 
As  with  tumors  of  the  thyroid  gland  the  function  of  the  hypophysis  may  be 
increased  or  decreased.  Hyperpituitarism  causes  gigantism  in  youth, 
acromegaly  (p.  294)  in  adults.  Hypopituitarism  causes  dystrophia  adiposo- 
genitalis,  i.e.,  small  stature,  infantile  genitalia  (with  impotence  in  men, 
amenorrhea  in  women),  hypotrichosis,  obesity,  sometimes  polyuria,  and 
occasionally  glycosuria.  In  a  few  cases  the  tumor  has  been  successfully 
removed,  either  from  the  side,  as  in  the  operation  for  resection  of  the  Gasserian 
ganglion,  or  through  the  body  of  the  sphenoid,  after  reflecting  the  nose  to 
one  side  and  removing  the  turbinate  bodies  and  vomer.  Care  is  taken  not  to 
excise  the  entire  gland,  as  complete  ablation  results  in  cachexia  hypophyseo- 
priva  and  death. 

Epilepsyi  from  an  etiologic  and  therapeutic  standpoint,  may  be  divided 
into  two  forms,  the  idiopathic  and  the  symptomatic.     When  no  cause  ca.xv 

'J 


3S4 


SPINE. 


be  determined  the  disease  is  called  iJiopafkif,  or  essett^iah  and  surgical  treat- 
ment is  not  indicated.  It  is  true,  however,  thai  operations,  e.g.,  ligation  of  the 
vcrteliral  artery  and  removal  of  the  cerncal  sympathetic  ganglia,  have  been 
recommended  for  this  disease,  but  such  are  generally  regarded  in  the  same 
light  as  an  accident,  a  severe  shock,  or  in  fact  an  operation  in  any  portion  of 
the  body,  which  is  occasionaily  followed  by  a  temporary  improvement  in  the 
convulsions.  Secondary,  or  symptomalir  epikpsy,  may  be  divided  into  four 
varieties,  (i)  Syphilitic  and  (2)  toxic  epilepsy  (e.g.»  due  to  plumbism, 
nephritis,  diabetes,  akohoHsm)  must  be  treated  medically,  (3)  Peripheral 
sources  of  irritation,  such  as  phimosis,  carious  teeth,  ovarian  disease,  etc*, 
should  be  removeci  with  the  hope  that  the  disease  may  be  reflex,  (4)  Those 
cases  depending  upon  a  dcfmite  lesion  of  the  brain  or  its  coverings,  e.g., 
injury  to  the  scalp,  skull,  or  brain,  or  tumor,  abscess,  hemorrhage,  localized 
meningitis,  foreign  tiodies,  adhesions  of  the  membranes,  cicatrices  in  the  brain, 
degenerarive  changes  in  the  cortex,  etc.,  arc  usually  focal,  or  Jacksonian,  in 
type,  i.e.,  the  spasm  affects  one  group  of  muscles  only  and  is  not  assficiated 
with  unconsciousness,  or  it  begins  in  one  group  of  muscles  and  terminates  in 
a  generalized  convulsion  with  unconsciousness*  Such  cases  always  demand 
exploration  and  removal  of  the  source  of  irritation.  Occasionally  simple 
excision  of  a  scar  in  the  scalp,  particularly  if  it  be  tender,  the  seat  of  an  aura, 
or  if  pressure  upon  it  proiluces  a  ht,  will  result  in  cure,  even  when  the  con- 
vulsions are  not  focal  in  character.  If  on  exploration  no  lesion  can  be  found, 
the  center  which  initiates  the  convulsion  may  be  accurately  localized  by 
electricity  and  excised.  The  resulting  paralysis  may  involve  neighboring 
centers  from  edema,  fjut  such  is  only  temporary,  and  even  the  parts  supplied 
by  the  excised  center  often  resume  their  functions.  The  means  for  pre- 
venting adhesions  after  operations  of  this  character  have  already  been  men- 
tioned. When  indicated,  operation  should  be  performed  early,  as  in  late 
cases  the  convulsions  may  continue  from  the  development  of  an  epileptic 
habit,  even  after  the  cause  has  been  removct!.  Apart  from  this,  recurrences 
may  be  due  to  the  redevelopment  of  ailhesions  or  cicatrices,  so  that  recovery 
15  seldom  permanent,  although^  as  indicated  above,  temporary  jmproveraenl 
may  follow  any  operation. 

In¥eterate  headache^  particularly  when  localized  and  severe,  may  be  due 
to  one  of  the  causes  mentioned  above  under  focal  epilepsy.  If  unreDeved 
after  a  thorough  trial  of  medicinal  measures,  trephining  and  exploration 
is  indicated. 

Insanity  and  arrest  of  development,  when  of  traumatic  origin,  may 
occasionaily  be  l>enelited  by  removal  of  any  existing  lesion  if  such,  e.g.,  a  de- 
pression in  the  skull,  can  be  localized. 


) 


CHAPTER  XX 11, 

SPINE. 

Spinal  Localization. ^The  hrst  Inmy  prominence  which  tan  be  fef 
beneath  the  o(  cijiut  is  the  forked  spine  of  the  axis.  The  next  prominent 
spine  is  the  seventh  cervical,  although  frequently  tiie  sixth  cervical  or  ihe  first 
dorsal  is  equally  prominent,  and  in  the  infant  the  tirst  dorsal  is  regularly  more 


SPINAL  LOCALIZATION* 


^"^ 


>: 


y- 


""> 


r 


prominent.  Generally  the  third  lumbar  spine  is  a  little  more  prominent  than 
its  neighbors.  A  line  passing  through  the  inner  extremities  of  the  spines  of  the 
scapuke  crosses  the  third  dorsal  spine;  through  the  inferior  extremities  of  the 
scapula.',  the  seventh  dorsal;  through  the 
highest  points  of  the  iliac  crests,  the  fourth 
lumbar;  through  the  posterior  superior 
spines  of  the  ilia,  the  first  sacral  spine. 
The  bodies  of  the  vertebce  may  be  pal- 
pated as  far  as  the  tifth  cervical  and  occa- 
sionally lower,  through  the  mouth;  the 
anterior  surface  of  the  sacrum  and  coccyx 
through  the  rectum.  That  section  of  the 
core!  from  which  spring  the  fibers  forming 
a  single  spinal  nerve  is  called  a  segment; 
it  corresponds  to  the  nerve  to  which  it 
gives  origin*  Imt  does  not  lie  ot>posite  the 
vertebra  of  like  name  and  number,  owing 
to  the  fact  that  the  cord  is  much  shorter 
than  the  spinal  canal  (Fig.  250).  A  lesion 
involving  all  the  contents  of  the  spinal 
canal  at  a  given  level  destroys  not  only 
the  segment  at  that  levcL  but  also  the 
nerves  which  run  alongside  of  it,  thus  a 
fracture  a  I  the  level  of  the  twelfth  dorsal 
vertebra  might  destroy  not  only  the  cord 
at  that  level,  but  also  the  spinal  nerves 
as  high  as  the  twelfth  dorsal.  A  lesion 
in  the  cord  is  localized  by  the  sensory, 


(I 


"^y  — 


m 


m- 


Fig.  359, — ReUtions  of  the  corH.  the  mem- 
branes, anci  the  nerves  with  the  spinous  processes 
(after  Marion),  The  spinal  cord  cxteofls  lo  the 
level  of  the  spinous  proress  of  the  first  lumbar 
verlehra  in  meOj  to  the  second  in  women,  lo  ihe 
ihtrrj  in  infants,  llie  cervical  cord  terminates  at 
the  sixth  tnterspiinous  space,  the  dorsal  cord  at 
the  ninth  dorsal  spine,  the  lumbar  corti  at  the 
twelfth  dorsal  spine. 

The  dura  terminates  at  the  first  sacral  spine. 
I  The  level  of  ihc  spinal  segments  is  determined 
As  follows:  In  the  cerv^ical  region ^  add  one  to  the 
number  of  a  given  spinous  process,  thus  the  third 
cervical  segment  lies  opposite  the  second  cervical 
»pinc;  in  the  supierior  dorsal  region,  add  two; 
from  the  sixth  to  the  eleventh,  add  three;  the  in- 
ferior part  of  the  eleventh  dorsal  spine,  the  sub- 
jacent interspace,  and  the  twelfth  spine  cor- 
respond to  the  last  three  lumbar  segmenis;  the  subjacent  interspace  and  ihc  first  luml>ar 
spine  correspond  to  the  sacral  segments. 

In  the  cervical  region,  the  nerves  emerge  above  ihe  corresponding  vertebra-  (the 
seventh  nerve  emerges  at>ove  the  seventh  cer\4cal  vertebrah  in  the  dorsal  and  lumbar 
regions  they  emerge  helow  the  corresjijonding  vertebnc.  In  the  cervical  and  lumbar 
regions,  the  foramina  are  on  a  level  with  the  spiiieof  the  vertebra  which  limits  them  atwve. 
In  the  dorsal  region,  they  aR*cm  a  tevcl  with  the  spine  of  the  vertebra  next  above  thai  which 
limits  them  su|>enorfy» 


'  Tt«MW*TW(l  J 

or  DuM  ■ 


K--As^ 


SPINE. 


FXONT, 


'j'2ani>3S' 


Flo,  260.  -^Sensor)'  distribution  of  the  spinal  segments,  combinerl  principally  from 
diagrams  of  Bolk.  The  zones  corresponriirig  to  the  dislributiori  of  the  ccnical  and  lum 
segments  are  mEirkcd  in  red.  Ever)'  culaneous  area  is  supplied  ni>t  by  one,  but  by  llj 
segments,  so  that  an  injurj'  to  one  sensor}'  root  mighl  be  followe<l  by  but  little  scnsoiy  4 
lurbance.  Il  is  therefore  neccssar)'  lo  localise  a  lesion  at  the  level  of  the  highest  ncr\*c  p 
corresponding  with  the  highest  culaneoits  jtonc  attacked. 


SPINAL   LOCALIZATION.  357 

motor,  and  trophic  symptoms,  and  by  the  alterations  in  the  reflexes. 
These  symptoms  correspond  to  an  exaltation  (hyperesthesia,  spasms, 
increased  reflexes)  or  an  abolition  of  the  functions  of  the  spinal  segments 
(anesthesia,  paralysis,  loss  of  reflexes),  according  to  the  nature  and  degree  of 
the  lesion.  Total  destruction  of  one  segment  causes:  anesthesia  of  the  skin 
supplied  by  that  segment  and  all  lower  segments,  with  frequently  a  narrow 
band  of  hyperesthesia  immediately  above,  from  irritation  of  the  nerve  roots 
at  that  level ;  paralysis  of  the  muscles  supplied  by  the  destroyed  segment  and 
all  lower  segments;  trophic  changes  in  the  parts  supplied  by  the  destroyed 
segment,  and  as  a  rule  in  the  parts  supplied  by  the  lower  segments  owing  to 
descending  degeneration  (in  the  absence  of  descending  degeneration  trophic 
changes  in  the  parts  supplied  by  the  lower  segments  need  not  occur) ;  and  ab- 
sence of  the  superficial  and  deep  reflexes j  which  may,  however,  reappear  if  the 
cord  below  the  lesion  remains  intact.  Priapism  from  vasomotor  paralysis 
may  occur  in  lesions  of  any  part  of  the  cord;  it  occurs  also  from  irritation  of 
the  erection  center  in  the  sacral  cord.  Diabetes  likewise  may  occur  after  a 
total  transverse  lesion  of  any  portion  of  the  cord.  Complete  unilateral 
lesions  cause  paralysis  upon  the  same  side  and  anesthesia  upon  the  opposite 
side  {Brawn-S^quard  paralysis). 

A  study  of  Fig.  260  will  aid  in  the  localization  of  a  cord  lesion  according  to 
the  sensory  symptoms.  Practically  all  muscles  are  innervated  not  by  one 
but  by  several  segments.  In  the  following  table  the  muscles  and  reflexes  are 
listed  with  the  highest  segment  concerning  them,  since  it  is  in  that  segment 
a  lesion  must  be  localized  if  the  muscle  is  completely  paralyzed. 


Segment.  Muscles.  Reflex. 

C.  I  Rectus  capitis  anticus  major  (C.  1-4). 

Rectus  capitis  anticus  minor. 
Rectus  capitis  posticus  major  and  minor. 
Geniohyoid  (C.  1-2). 
Superior  and  inferior  oblique  (C.  1-2). 
Complexus  (C.  1-3). 


C.  2  Longus  colli  (C.  2-8). 

Sternomastoid. 
Subhyoids  (C.  2-3). 
Splenius. 

-  — !  .      - 

C.  3  Levator  angulae  scapulae  (C.  3-5). 

'     Trapezius  (C.  3-4). 
Diaphragm  (C.  3-5). 

Total  lesions  at  or  above  this  level  are  usually 
immediately  fatal,  as  respiration  can  be  main- 
tained only  by  the  stemomastoids  and  supe- 
rior part  of  the  trapezii. 


C.  4  Scaleni  (C.  4-D.  i).  Pupillar>' 

(C.  4-D.  i). 
Teres  minor  (C.  4-5).) 
Rhomboid  (C.  4-5).  ' 


3S8 


SPINE. 


Skgment. 


Muscles. 


Keflex. 


C.  ^  Supra-  and  infraspinatus  (C.  5-6). 

Deltoid  (C.  5-7). 

Serratus  magnus  (C.  5-8). 

Subclavius  (C.  5-6). 

Brachialis  amicus  (C.  5-6). 

Supinator  longus  and  brevis  (C.  5-7). 

Biceps. 

In  total  lesions  just  below  this  level  the  dia- 
phragm is  not  paralyzed  but  coughing  is  im- 
possible so  that  a  bronchitis  quickly  proves 
fatal;  the  upi>er  extremities  assume  a  char- 
acteristic position,  abduction  and  external 
rotation  of  the  arm  with  flexion  and  supina- 
tion of  the  forearm,  owing  to  the  unapix>scd 
action  of  the  muscles  just  enumerated. 


Scapular 

(C.  5-D.  I). 
Supinator  longus. 
Biceps. 


C   7 


('.6  Pect«)ralis  major  (C.  6-1).  2).  Triceps 

j     Pronator  radii  teres. 

I     Extensors  of  wrist  (C.  6-8).  Posterior  wrist. 

i     Triceps  (C.  6-7). 
!     Teres  major  (C.  6-7). 
I^ti.ssimus  dorsi  (C.  6-8). 
Subscapularis  (C  6-7). 

l^ecloralis  minor  {C.  7-I).  2). 

Conu'o-bnichialis  and  anct)neus  (('.  7  -S)  Anterior  wrist. 

j     Superficial  flexors  of  lingers. 
I     Pronators  of  wrist. 
I     Kxtensors  of  lingers. 

I     Musdt's  of   thenar  and   hvjKUhciiar   eminences 
!         (C.  7-1).  I). 

In  a  total  lesion  just  below  this  sej^ment  the 
flexors  of  the  wrist  an<l  intrinsic  must  les  of 
the  hatnl  .ire  the  only  nius«  les  i»f  the  ui>|)er 
exl remit y  paralyzcfl. 

('.  S  Klexors  of  wrist.  Palmar. 

Interossei  and  hunhricales  (C.  S-D.  i). 


1).  r 


I).  2    12 


L. 


liitenostals  (I),  i  -  12). 

Kre<  tor  spina*  (1).  i    L.  5). 

Helow  this  level  the  arms  eM  ape  paralysis. 

Ret  tusalxlonnnisand  external  ohliijue  {1>.  5    12). 
Internal  obKujue  and  transvers;dis  (1).  7    I.,  i.) 

Paralysis    of    these    must  les    interferes    with 
(()U)i;hing,  tlefecation  and  all  straining;  move- 
ments.    Severe   metcori.sm   may  devel<»p  and 
interfere  with  res[>iration. 

(^ua<lratus  himl)orum  (L.  1-2). 
C'remaster. 

I*soas  magnus  (L.  i-.O- 


Epigastric  (I).  4-7). 
.\bdominal 


Cremasteric 

(L.  1-2). 


LAMINECTOMY. 


359 


Se<;ment. 


Muscles. 


Reflex. 


L.  2  Iliacus. 

Quadriceps  (L.  2-4). 
Peclineus. 
Sartorius  (L.  2-3). 
I     Adductors  of  thigh  (L.  2-4). 

In  lesions  below  this  level  the  lower  limbs  are 
not  completely  paralyzed. 


L.  3  Internal  rotators  of  thigh. 

Adductors  of  thigh  (L.  3-4). 

L.  4  Flexors  of  knee  (L.  4-5). 

Extensors  of  ankle  (tibialis  anticus,  etc), 
(jluteus  medius  and  minimus  (L.  4-5). 
Flexors  of  ankle  (calf  muscles)  (L.  4-S.  2). 
'     Extensors  of  toes  (L.  4-S.  i). 

L.  5  External  rotators  of  thigh. 

Gluteus  maximus  (L.  5-S.  i). 
Peronei  (L.  5-S.  3). 
Flexors  of  toes  (L.  5-S.  2). 


Patellar. 


Gluteal. 


S.  1-2 


3-5 


Small  muscles  of  foot. 


Levator  and  sphincter  ani  (S.  3-4). 

Bladder  (S.  3-4). 

Perineal  muscles  (S.  4-5). 

In  all  total  lesions  of  the  spinal  cord  and  of  the 
Cauda  equina  the  bladder  and  rectum  are 
paralyzed,  causing  retention  and  later  drib- 
bling of  overflow  m  the  former,  and  inconti- 
nence in  the  latter. 


Ankle  clonus. 
Plantar. 


Anal. 
j  Vesical. 
Erection  of  p>enis. 


Laminectomy,  or  removal  of  the  laminae  of  the  vertebrae,  may  be  per- 
formed for  exploration,,  wounds  or  compression  of  the  cord,  or  for  diseases  of 
the  bones.  A  straight  incision  is  made  over  the  spinous  processes;  the  lam- 
inae exposed  by  separating  the  muscles  from  the  bone  with  a  rougine;  the 
l)leeding  controlled  by  gauze  sponges,  held  beneath  the  retractors  which  sep- 
arate the  wound;  the  spinous  processes  removed  with  rongeur  forceps ;  the 
laminae  excised  with  bone-cutting  forceps,  chisel,  or  saw;  the  contents  of  the 
spinal  canal  examined;  the  dura  opened,  if  necessary,  by  a  longitudinal 
incision,  using  the  same  precautions  as  in  opening  the  dura  of  the  brain; 
the  cord  examined,  being  very  careful  not  to  exert  undue  compression;  the 
dura  sutured  with  fine  catgut,  without  drainage  whenever  possible;  and  the 
muscles  approximated  with  catgut  and  the  skin  with  silkworm  gut,  superficial 
drainage  being  employed  for  twenty-four  hours,  or  longer  if  there  is  infection. 
Osteoplastic  resection,  with  the  base  of  the  flap  above  or  on  one  side,  is  more 
laborious  and  no  more  useful.  One  need  not  fear  to  make  a  large  exposure, 
as  such  does  not  permanently  weaken  the  spine.  Braces  or  casts  are  seldom 
required  after  operation.     The  dangers  of  infection  are  no  greater  than  in 


360  SPINE. 

the  skull,  chest,  or  abdomen,  and  the  escape  of  cerebrospinal  fluid  seems  to 
do  no  harm. 

Spinal  puncture  (subarachnoid)  has  been  employed  for  anesthetic  (p.  24), 
therapeutic,  and  diagnostic  purposes.  As  a  therapeutic  measure  for  the 
relief  of  pressure  (hydrocephalus,  brain  tumors,  meningitis,  etc.),  or  for  the 
injection  of  medicaments  (iodoform,  tetanus  antitoxin,  etc.),  it  is  of  little 
value.  Its  diagnostic  value,  however,  has  been  proved.  The  fluid  may  be 
examined  microscopically  for  cells  (cytodiagnosis),  bacteria,  and  blood 
(fracture  of  the  skull  or  spine,  hemorrhagic  i^eningitis).  In  the  last  instance 
the  fluid  should  be  collected  in  two  tubes  and  only  the  second  one  examined. 
The  puncture  may  be  made  anywhere  between  the  lower  end  of  the  cord  and 
the  lower  end  of  the  dural  sac  (Fig.  259),  but  the  favorite  spot  is  just  below 
the  fourth  lumbar  vertebra.  The  back  is  bent  forward,  the  left  index  finger 
placed  on  the  selected  spinous  process,  and  the  needle,  three  or  four  inches 
long,  entered  just  below  and  to  the  outside  of  the  finger  and  pushed  slightly 
inwards  and  upwards  for  from  one-third  to  three  inches,  according  to  the 
age  of  the  patient  and  the  thickness  of  the  tissues. 


INJURIES  OF  THE  SPINE. 

Sprains  of  the  spine  are  caused  by  falls,  twists,  and  violent  shocks  when, 
as  in  a  railway  accident,  the  muscles  are  not  on  guard.  The  pathology  is 
that  of  sprains  elsewhere.  The  symptoms  are  pain,  tenderness,  and  rigidity. 
Fracture  without  displacement  and  without  nervous  symptoms  might  give 
identical  symptoms,  and  the  author  has  seen  several  cases  in  which  a  correct 
diagnosis  could  be  made  only  by  an  X-ray  examination.  In  a  strain  of  the 
back,  such  as  is  produced  by  heavy  lifting,  the  lesion  is  in  the  muscles,  not 
in  the  joints.  Sprains  are  rarely  serious,  although  they  are  occasionally 
followed  by  bleeding  into  the  spinal  canal,  extension  of  the  inflammation  to 
the  meninges,  traumatic  neuroses,  or,  in  those  so  predisposed,  by  spinal 
caries.  The  treatment  is  local  applications  as  in  sprains  in  other  parts  of 
the  body,  and  rest  in  bed  in  the  severer  cases. 

Concussion  of  the  spinal  cord  is  caused  by  blows  or  falls  which  shake 
or  jar  the  cord.  Theoretically  at  least,  no  anatomical  change  is  produced. 
When  minute  hemorrhages  or  like  lesions  occur,  the  term  contusion  is  appli- 
cable. Concussion  is  becoming  rarer  with  improved  methods  of  investiga- 
tion, and  some  have  doubted  even  its  existence.  The  author,  however,  has 
seen  two  cases  of  gunshot  wound,  close  to  but  not  involving  the  dorsal  cord, 
in  which  there  were  typical  symptoms  of  a  total  transverse  lesion,  but  in 
which  autopsy  revealed  no  anatomical  changes  in  the  cord.  The  symptoms 
are  those  of  shock,  and  usually  a  limited,  incomplete,  and  transient  inter- 
ference with  sensation  and  motion,  although,  as  noticed  above,  they  may 
be  those  of  a  total  lesion.  After  any  injury  to  the  cord  the  reflexes  may  be 
absent,  at  least  for  a  Jime.  The  prognosis  in  the  mildest  cases  is  good,  the 
symptoms  disappearing  within  a  few  hours  or  days.  If  the  symptoms  are 
severe  and  persist,  the  condition  is  probably  one  of  contusion  or  compression 
rather  than  concussion.  Neurasthenia,  hysteria,  or  organic  cord  disease  may 
follow  even  the  slightest  cases.  The  treatment  is  reaction  from  shock  and 
rest  in  bed.     If  compression  is  suspected,  laminectomy  may  be  indicated. 

Traumatic  neuroses  may  occur  after  any  injury  or  severe  mental  shock. 


IjuI  arc  mo>t  fretftieiilly  the  result  t>f  sprains  uf  the  spine  or  coin^ussion  of  the 
cord  due  to  railway  ace  idents,  hence  the  term  'Railway  spine";  when  foUow- 
ing  an  injury  to  the  head  the  condition  has  heen  termed  "railway  brain," 
The  symptoms,  which  may  closely  follow  the  accident*  or  be  delayeil  for  hours 
or  even  days,  are  those  of  neurasthenia  (trau malic  nettrayihenia),  hysteria 
(traumaik  hysteria],  or  hystero-neurasthenia,  and  are  identical  with  those 
ociurring  in  non-traumatic  cases,  for  which  the  reader  is  referred  to  a  text- 
book on  medicine,  Other  functional  nervous  affections,  such  as  neurotic 
diabetes,  paralysis  agitans,  chorea*  exophthalmic  goiter,  etc.,  and  even  organic 
diseases^  such  as  tabes,  myelitis,  and  other  inflammatory  and  degenerative 
processes,  may  follow  accidents  such  as  have  been  described  above.  The 
diagnmis  of  traumatic  neuroses  requires  great  care*  tirst  to  rule  out  organic 
disease,  secondly  to  detect  malingerers  who  feign  disease  in  order  to  secure 
damages.  The  prognosis  is  generally  favorable.  The  (raUment  is  that  of 
non- traumatic  neurasthenia  and  hysteria. 

Compression  of  the  spinal  cord  develops  suddenly  in  fractures,  dis- 
locatiuns,  foreign  bodies,  and  intramedullary  hemorrhage;  more  slowly  in 
extramedullary  hemorrhage  (within  twenty-four  or  forty-eight  hours), 
inflammatory  exudate,  e.g.^in  acute  spinal  meningitis  (in  the  course  of  several 
days),  and  pachymeningitis  (a  week  or  longer) ;  and  very  gradually  in  tumors, 
cysts,  aneurysms,  callus  formation,  cicatrices^  etc.  The  symptoms  and  the 
means  of  determining  the  level  of  the  lesion  have  alreaily  been  considered 
under  spinal  localization.  The  trcatmmt  varies  with  the  nature  and  cause 
of  compression,  and  will  be  given  when  the  imbvidual  forms  are  discussed. 

Fracture  of  the  spine  is  caused  by  tlirect,  or  much  more  frequently  by 
indirect  violence.  In  the  former  the  break  is  situated  at  the  point  struck  and 
the  arches  are  particularly  liable  to  sulTer,  a  spicule  of  Ijone  often  being  driven 
into  the  cord.  In  the  latter  the  injury  is  usually  due  to  hyperllexion  of  the 
spine,  such  as  occurs  w  hen  a  man  dives  into  shallow  water,  falls  from  a  height 
on  the  feet  or  buttocks,  or  is  doubled  up  by  the  caving  in  of  an  embankment, 
the  vertebral  column  generally  breaking  at  the  junction  of  a  freely  movable 
w^ith  a  comparatively  fixed  portion,  i.e.,  in  the  cenico-dorsal  (most  frequent) 
or  dorso-lumbar  region;  the  bodies  of  the  verteline,  with  or  without  the 
arches,  are  broken,  and  the  upper  segment  usually  displaced  forwards  (/ror- 
lure-dislocation) ,  thus  contusing  or  compressing  the  cord.  The  muscles,  liga- 
ments, and  membranes  may  be  torn,  and  l>!ood  may  collect  between  the  bone 
and  the  membranes,  or  between  the  membranes  and  the  cord. 

The  symptoms  are  (i)  shock  of  varying  degree;  (2)  loca!  evidences  of  frac- 
ture, such  as  pain,  swelling,  tenderness,  usually  deformity,  and  possibly 
crepitus;  and  (3)  interference  with  tht  functions  of  the  c^rrf,  due  to  concussion, 
contusion,  or  compression,  i.e.,  more  or  less  complete  paralysis  and  anesthe- 
sia below  the  injur}%  with  decrease  or  abolition  of  the  reflexes,  and  trophic 
changes  (p.  355).  Without  displacement,  cord  symptoms  may  be  absent, 
and  in  some  cases  the  diagnosis  can  be  made  only  by  the  X-ray.  Paralysis 
coming  on  after  a  short  interval  may  be  due  to  edema  of  the  cord,  extramedul- 
lary hemorrhage,  inflammatory  exudate,  or  secondary  displacement  of  bone. 
The  symptoms  of  complete  transverse  destruction  of  the  cord  have  already 
been  given.  Incomplete  destruction  may  be  diagnosticated  when  there  is 
incomplete  paralysis,  partial  anesthesia,  and  retention  of  the  retlexes  in  the 
parts  supplied  by  the  cord  below  the  injur)';  not  infrequently,  however,  the 
symptoms  will  be  identical,  sometimes  for  several  days  or  longer,  with  those 


J 


362 


SPINE. 


of  a  total  transverse  lesion.  The  prognosis  in  all  cases  with  total  paralysis 
and  complete  anesthesia  is  distinctly  unfavorable,  both  regarding  life  and 
return  of  function.  The  higher  the  lesion  the  worse  the  prognosis.  Death 
occurs  immediately  from  shock  or  interference  with  respiration  (in  the  upper 
cervical  region) ;  during  the  first  week  from  suffocation  with  mucus  (in  the 
lower  cervical  region)  or  from  meningitis;  or  after  weeks  or  months  from  ex- 
haustion and  sepsis  the  result  of  extensive  bed  sores,  cystitis,  or  pyonephrosis. 
With  even  a  completely  divided  cord,  however,  life  may  be  prolonged  for 
years  if  the  injury  is  in  the  dorsal  or  lumbar  region. 

The  treatment  is  first  reaction  from  shock.  Whether  or  not  operation  has 
been  decided  upon,  the  patient  should  be  placed  on  an  air  or  water  bed  and 
most  carefully  nursed  to  prevent  bed  sores.     The  bladder  should  be  cathe- 

terized  every  eight  hours,  or  more  often,  with 
the  most  rigid  aseptic  precautions  to  prevent 
cystitis.  Massage  and  electricity  should  be 
employed  to  maintain  the  nutrition  of  the 
paralyzed  parts.  Attempts  to  effect  reduc- 
tion by  extension  and  pressure,  without 
operative  exposure  of  the  parts,  are  too 
dangerous  to  be  recommended.  Excepting 
fractures  in  the  cervical  region,  sand  bags, 
plaster  casts,  etc.,  are  seldom  required  to 
immobilize  the  parts.  There  is  no  general 
agreement  as  to  the  indications  and  time  for 
operation.  Many  neurologists  and  a  few 
surgeons  doubt  the  value  of  laminectomy  in 
any  case.  This  condition  of  affairs  is  due  to 
the  difficulty  of  differentiating  concussion 
from  compression,  and  to  the  teaching  that 
the  tissues  of  the  cord  are  incapable  of  regen- 
eration ;  the  latter  is  true  with  regard  to  the 
brain,  however,  but  does  not  deter  surgeons 
from  operating  early  and  radically  in  frac- 
tures of  the  skull.  The  author's  views, 
which  are  not  those  generally  adopted,  are 
as  follows:  Fractures  of  the  spine  should  be  treated  like  fractures  of  the 
skull,  i.e., for  (i)  disinfection;  (2)  depression,  and  (3)  compression,  i.  All 
compound  fractures  must  he  disinfected,  including  irrigation  with  salt  solu- 
tion of  the  cord  itself,  if  the  membranes  have  been  opened.  2.  Obvious 
depression  of  the  laminie  will  often  be  associated  with  symptoms  of  com- 
pression, but  even  in  the  absence  of  such  symptoms,  the  depressed  bone 
should  be  removed,  because  of  the  danger  of  injury  to  the  cord  by  displace- 
ment of  the  fragments  during  subsequent  treatment,  and  because  of  the  dan- 
ger of  pressure  from  callus  on  the  cord  or  nerve  roots  at  a  later  period.  3. 
All  fractures,  whether  simple  or  compound,  with  symptoms  of  compression 
re([uire  laminectomy  (p.  359)  as  soon  as  shock  has  subsided,  unless  in  the 
meantime  the  symptoms  have  distinctly  ameliorated.  The  more  severe  the 
symptoms  the  more  imperative  the  operation.  It  is  true  that  at  this  period 
one  cannot  always  be  sure  whether  the  symptoms  are  those  of  concussion, 
contusion,  or  compression,  but  pure  concussion  is  rare,  and  contusion  with 
its  subse([uent  edema  can  only  be  benefited  by  the  drainage  of  operation. 


I 


I 


Fig.  261. — Diagram  of  fracture- 
dislocation  of  the  spine,  showing 
compressi(in  of  the  cord  by  the 
laminie  of  the  9th  dorsal  vertebra 
(A),  and  by  the  btnly  of  the  loth 
dorsal  vertebra  (B).  C.  Spines  in 
same  case  «is  feh  from  the  rear. 


tllSI-OCATIONS  OF  THF  VERTF.BHjB. 


303 


pTIu'  tumprussing  agent  (bone,  Ijkiod  dai,  foreign  f>o(Iy)  sh<ml«l  In:  rcmovt'd 
hefore  the  onset  of  secondary  degenenilioji.  Kem(»vul  of  the  posterior  arthes 
may  We  all  that  is  rcfjuired^  or  compression  may  be  caused  likewise  by 
the  body  of  a  vertebra  (Fig.  261),  in  which  case  reduclion  may  be  attempted 
by  extension  and  direct  pressure,  or  failing  in  this,  the  projecting  edge  of 
bone  should  \m:  bitten  away  with  rongeur  forceps,  taking  care  not  to  contuse 
the  cord.  If  the  dura  is  distended  or  bluish  and  no  pulsation  can  be  detected, 
a  subdural  clot  exists,  and  such  should  fje  removeib  If  the  spinal  sheath 
seems  empty,  the  dura  should  likewise  be  opened  and  the  di nded  cord,  for 
such  will  probably  be  found,  sutured  with  catgut  (see  also  wounds  of  the 
cord).  Operation  is  not  indicated  in  simple  fractures  without  obvious  depres- 
sion or  cord  symptoms,  or  in  simple  fractures  with  cord  symptoms  which  are 
improving. 

DislocetionB  of  the  vertebrae  without  fracture  are  extremely  rare  and 
confined  almost  exclusively  to  I  he  cervical  region,  usually  the  lower  half. 
The  upper  vertebra  is  called  the  dislocated  one,  contrary  to  the  custom  when 
speaking  of  dislocations  elsewhere.     The  usual  cause  is  hyperflexion,  fioth 


FiG-  262, — Complete  dislocation. 
(Marion.) 


Fig.  263. 


-Incomplete  dislocation. 
(Marion.) 


articular  processes  of  the  upper  vertebra  passing  in  front  of  those  of  the  lower 
vertebra,  i.e.,  a  complete  biliiteral  anterior  didoiatimi  (Fig.  262).  BUakrai 
posterior  dislocathm  may  be  caused  by  hyperextension,  unilateral  dishuation 
by  forcible  approximation  of  the  head  and  shoulder  combined  with  rotation. 
Inromplde  disloeaiion  also  may  occur  (Fig.  263).  The  ligaments  and  inter- 
vcrlebral  discs  are  torn,  and  in  complete  bilateral  cases  the  ctjrd  is  almost 
iways  compressed,  usually  causing,  in  the  upper  cervical  region,  immetiiate 
death.  In  many  incomplete  or  unilateral  cases,  the  cord  may  escape  pres- 
sure by  hone,  although  it  may  still  be  compressed  by  blood  clot,  and  the  nerve 
roots  may  be  stretched  or  torn,  causing  neuralgia,  etc.  In  forward  disloca- 
tions the  heail  is  displaced  forwards  and  l>ent  towards  the  chest.  In  back- 
ward dislocations  the  heail  is  displaced  liackwards  and  the  face  turned  up- 
wards.  In  unilateral  dislocations  the  head  is  bent  towards  the  s«:>und  shoul- 
der.  The  deformity  may  be  felt  externally  or  through  the  pharynx,  and  in 
any  case  there  will  likely  be  dilTiculty  in  swallowing. 

The  treatment  of  unilateral  and  incomplete  dislocations  is  reduction, 
under  an  anesthetic,  by  traction  and  appro.ximation  of  the  head  towards  the 
sound  shoulder  to  unlock  the  processes,  then  rotation  of  the  heafl,  the  ear  on 
the  sound  side  moving  forwards.  In  long  standing  cases  reduction  cannot  be 
effected,  Imt  operation  may  be  undertaken  to  relieve  pressure  on  the  spinal 
nerves.  Bilateral  dislocations  may  be  reduced  by  bending  the  head  towards 
the  right  shoulder  and  rotating  the  head  (the  right  car  being  carried  forward), 
thus  converting  the  dislocation  into  a  unilateral  one,  which  may  be  reduced  by 


364  SPINE. 

reversing  the  movements  just  described.  These  manipulations  are  so  dan- 
gerous, that  it  is  probably  best  to  relieve  pressure  by  at  once  removing  the 
lamina;  of  the  dislocated  vertebra,  and  then  reducing  the  bones  under  the 
guidance  of  the  finger  and  eye.  If  sufficient  traction  cannot  be  exerted  to 
unlock  the  processes,  as  little  as  possible  of  the  upper  margin  of  the  upper 
articular  processes  of  the  lower  vertebra  should  be  removed  to  permit  reduc- 
tion. Removal  of  the  whole  process  would,  of  course,  permit  recurrence. 
The  dura  may  be  opened  to  remove  coagulated  blood. 

Wounds  of  the  spinal  cord  are  usually  the  result  of  stabs  or  gunshot 
injuries.  There  may  be  complete  paralysis  below,  or  if  half  of  the  cord  is 
divided,  loss  of  motion  on  the  same  side  and  anesthesia  on  the  opposite  side, 
or  again  the  injury  may  be  limited  to  the  nerve  roots.  Although  it  is  gener- 
ally taught  that  regeneration  of  the  cord  never  occurs,  the  author  has  had  a 
case  in  which  a  severed  spinal  cord  was  sutured  and  in  which  partial  return 
of  function  followed.  The  treatment  is  laminectomy,  removal  of  foreign 
bodies  and  comminuted  bone,  irrigation  with  salt  solution,  and  suture  of  the 
wound  of  the  cord  and  of  the  severed  spinal  nerves  with  catgut.  The  dura 
should  be  closed  whenever  possible.  Probes  should  never  be  employed  to 
explore  the  wound.  In  the  cervical  region  it  may  be  necessary  to  tie  the  ver- 
tebral artery. 

Intraspinal  hemorrhage  may  be  extradural,  subdural,  or  intramedullary. 
It  is  usually  the  result  of  injury,  but  may  be  due  to  other  causes,  e.g.,  acute 
infectious  fevers,  convulsions,  rupture  of  aneurysms,  etc. 

In  extra-  and  subdural  hemorrhage  {hematorrhachis)  the  symptoms  are 
pain  in  the  back  and  irritation  of  the  nerve  roots  (pain,  hyperesthesia,  and 
spasms  in  the  parts  supplied  by  the  affected  nerves),  followed  by  symptoms  of 
compression,  the  paralysis  and  anesthesia  coming  on  suddenly,  or  perhaps 
slowly  from  below  upwards  as  the  blood  increases  in  amount.  Complete  re- 
covery may  occur  in  traumatic  cases.  The  treatment,  excepting  the  milder 
forms,  is,  in  the  early  stages  when  the  blood  is  still  fluid,  spinal  puncture,  and 
at  a  later  period  laminectomy  and  removal  of  the  clot. 

Intramedullary  hemorrhage  {hematomyeUa)  is  most  frequent  in  the 
lower  cervical  region.  The  symptoms  are  sudden  paralysis  and  anesthesia 
of  the  parts  below,  and  intense  pain  in  the  back.  The  lesion  may  be  unilat- 
eral (paralysis  on  one  side,  anesthesia  on  the  other),  or  if  the  bleeding  is  slight, 
signs  of  irritation  may  be  present,  but  are  not  so  common  as  in  extramedul- 
lary  hemorrhage.     The  usual  treatment  is  that  of  concussion. 

DISEASES  OF  THE  SPINE. 

Spina  bifida  (rachischisis),  or  failure  of  the  spinal  laminae  to  imite,  is 
present  in  about  one  in  every  1,000  children  bom.  Sometimes  there  is  a 
small  congenital  gap  in  the  spine,  the  cord  and  membranes  remaining  in  the 
canal  {spina  bifida  occulta);  the  skin  is  frequently  indented  over  this  defect 
and  the  dimple  filled  with  hair.  These  cases  need  no  treatment  unless  there 
are  symptoms  of  pressure  on  the  cord,  when  the  removal  of  such  compres- 
sion, which  may  be  due  to  hypertrophy  of  the  skin  and  subjacent  soft  parts, 
would  be  indicated.  In  2  per  cent,  of  the  cases  the  cleft  is  wide,  the  skin  is 
absent,  and  the  cord  protrudes  through  the  opening,  its  central  canal  com- 
municating with  the  surface  of  the  body  {myelocele).  This  condition  is  not 
compatible  with  existence.     In  10  per  cent,  the  membranes  alone*  escape 


SPINA  BIFIDA. 


365 


v^ 


so 

m 

Vsh 


through  the  opening  {me?tingocele),  but  in  the  vast  majority  (about  75  per 
cent.)  there  is  also  a  portion  of  the  cord  in  the  protuberance  (meningomydo- 
c€k)f  and  very  rarely  the  tumor  is  the  result  of  a  dilatation  of  the  central  canal 
of  the  cord  Isyringomyeiocek).  The  last  variety  is  often  situated  laterally. 
More  than  one  vertebra  is  usually  fissured^  and  cases  have  been  reported  in 
which  all  the  vertebne  were  involved.  Rarely  the  body  of  the  vertebra  is 
implicated  (anterior  spina  bifnia).  One-half  of  all  cases  occur  in  the  lumbar 
region,  and  more  than  one-third  in  the  lumbosacral  or  sacra!  portion  of  the 
spine. 

Diagnosis. — The  swelling  is  congenital,  almost  always  central,  and  partly 
reduiible,  pressure  causing  the  fonlanelles  to  bulge  and  sometimes  producing 
convulsions  or  other  nervous  symptoms.  Palpation 
reveals  the  cleft,  and  bulging  on  crying  or  coughing. 
Transluccncy  may  be  detected,  with  the  cord  or  nen'es 
represented  as  shadows.  There  may  be  other  develop- 
mental defects,  such  as  hare  lip  and  talipes  (Fig.  264), 
and  as  the  result  of  compression  or  abnormalities  of  the 
nervous  elements,  anesthesia,  paralysis,  or  trophic  changes 
may  be  found  lielow^  the  cloven  spine. 

The  prognosis  is  bad,  although  spontaneous  recovery 
may  occur  in  rare  instances  when  the  opening  is  small 
and  the  skin  thick  and  healthy.  Death  is  due  to  maras- 
mus, to  the  sequela.^  of  paralyses,  or  to  meningitis  follow- 
ing rupture  or  intlamraation  of  the  sac. 

The  treatment,  if  operation  is  not  decided  on,  is  pro- 
tection of  the  sac  by  collodion  or  a  suitable  cap,  in  order 
to  prevent  rupture,  Morton's  lluid  (iodin  gr.  10,  potas- 
sium iodid  gr.  30,  glycerin  1  oz.)  may  be  injected  in  the 
I  lose  of  2  dr.,  repeated  in  ten  days  if  necessary,  care  being 
taken  during  the  injection  to  obliterate  the  neck  of  the 
sac  as  much  as  possif>le  !>y  compression.  This  plan  has 
so  often  !>een  followed  by  sloughing  and  rupture  of  the  sac,  by  convul- 
ons  and  meningitis^  and  by  paralysis  and  hydroeephalus  (mortality 
.0  per  cent.),  that  most  surgeons  prefer  excision  [mortality  25  per  cent,). 
he  lumbar  region  in  infants  is  so  difficult  to  keep  clean  that  operation 
should  be  postponed  as  long  as  possible.  If  the  skin  is  thin,  or  threatens  to 
ulcerate,  or  if  the  tumor  is  enlarging,  operation  becomes  imperative.  An 
elliptical  incision  is  made  about  the  tumor,  and  the  sac  opened  laterally  by 
a  small  transverse  cut,  in  order  to  avoid  the  cord,  which  may  be  adherent  in 
the  middle  lijie,  and  the  nerves  which  run  at  right  angles  to  it.  If  no  nervous 
tissues  are  present,  the  sac  is  removed  and  the  opening  sutured  with  catgut. 
If  nervous  structures  are  present,  they  are  separated  from  the  sac;  if  inti- 
mately adherent,  that  portion  of  the  sac  in  which  ihey  are  incorporated  may 
be  reduced  with  them  into  the  spinal  canal.  The  muscles  i>n  each  side  are 
then  loosened,  sutured  together,  and  the  skin  closed.  The  bony  defect  has 
l>een  closed  by  drawing  the  remnants  of  the  lamina?,  if  present,  over  the  gaf>; 
by  swinging  a  flap  of  bone,  attached  by  its  periosteum,  from  the  outer  table 
of  the  ilium;  liv  a  bcme  graft,  such  as  the  scapula  of  the  rabbit;  and  by  foreign 
substances,  such  as  a  plate  of  celluloid;  j^rocedures  of  this  character  are 
rarely  necessary.  Recurrences  sometimes  iKeur  and  hydrocephalus  may 
follow. 


Frci.  264 — Spina 
\i\fiflii,  and  rlub  f I >tn 
(Kirmisson.) 


I 


Congenital  sacrococcygeal  tumors  occur  on  the  dorsal  or  ventral 
surface.  Llpomata  may  communicate  with  the  interior  of  the  spinal  canal, 
dermoids  with  the  rectum,  bladder,  or  spinal  meninges.  C^ystic  tumors  con 
taining  a  myxomatous  material  and  developing  between  the  rectum 
sacrum  originate  in  the  remains  of  the  postanal  gut,  or  neurenleric 
(the  canal  which  connects  the  neural  and  enteric  tracts  in  early  fetaJ 
Teraiomala  (Fig,  265),  sanomatiK  and  spina  bifida  constitute  the  remaimiig 
congenital  tumors  in  this  region.  The  treaimmt  is  removal;  it  may  Xx 
necessary  to  excise  a  portion  of  the  sacrum  or  split  the  pt»sterior  wall  of  the 
rectum. 


Fig,  265.— Sacrocwcygeal  teratoma.      (Pennsylvania  HospitnL) 


Sacrococcygeal  fistulse  arc  the  result  of  imperfect  coalescence  of  the 
skin,  or  persistence  of  the  fjostanal  gut.  The  simplest  form  is  the  postanal 
dimple.  Others  may  communicate  with  the  rectum  or  spinal  canal.  The 
treat  mail  is  excision  unless  the  condirion  gives  no  trouble. 

Spinal  curvatures  include  scoliosis,  kyphosis,  and  lordosis. 

Scoliosis j  or  lateral  curvature,  rarely  involves  the  spine  in  one  cun'e 
(tiHal  sfoliosis);  as  a  rule  there  are  two  or  more  lateral  ( urves  with  their  con- 
vexities in  opposite  directions  (Fig.  266),  Lateral  deformities  of  the  spine 
due  to  caries,  fracture,  tumors,  etc.,  are  not  placed  under  this  heading.  The 
fattsfs  arc  rickets;  asynwietr\\  the  result  of  shortness  of  one  leg,  empyema,  tor- 
ticollis, tlc.\  Jauiiy  poatures,  the  result  of  habit  (e.g.*  standing  on  one  leg), 
occupation  (e.g.,  constantly  working  a  lever  with  one  hand  or  foot),  or  dis- 
ease (e.g.,  sacroiliac  (h'sease);  and  rmtral  nen'ous  diseases,  producing  unilat- 
eral atrophy  or  spasms  of  the  muscles,  The  most  common  form  is  the  scoHo- 
sis  of  adotescente,  due  to  relaxed  muscles  and  ligaments  which  do  not  develop 
as  rapidly  as  the  spine.  One  of  the  causes  mentioned  above  may  be  a  con- 
tributing factor.  The  patients  are  usually  anemic  girls,  easily  fatigued,  and 
frequently  assuming  altitudes  of  rest,  e.g.,  standing  with  the  weight  resting 
on  one  leg  or  lounging  in  a  faulty  position. 

Sjrmptoms  and  Pathological  Anatomy-  -  In  the  usual  variety  the 
lumbar  spine  becomes  convex  towards  the  left,  and  later  a  compensator)' 
dorsal  curve  with  the  convexity  to  the  right  develops;  there  may  or  may  not 
be  an  associated  kyphosis.     The  vertebral  column  not  only  denates  laterally, 


SCOLIOSIS, 


Jf'/ 


Fig.  366.— Scoliosis.     (Philadelphia  College  of  Physicians.) 


368  SPINE. 

but  is  twisted  in  a  spiral  direction,  the  spines  rotating  towards  the  concavity, 
so  that  they  do  not  give  an  accurate  indication  of  the  degree  of  curva- 
ture. The  ribs  on  the  right  side  are  separated,  more  horizontal,  and  bent 
at  their  angles;  the  shoulder  is  raised,  the  scapula  more  prominent,  and  the 
front  of  the  chest  flattened.  On  the  left  side  the  ribs  are  crowded  together 
and  their  angles  are  more  obtuse,  so  that  the  shoulder  is  lower,  the  scapuli 
less  prominent,  and  the  chest  projects  anteriorly.  The  sternum  moves  to- 
wards the  concavity  and  faces  the  convexity.  In  the  worst  cases  the  thoracic 
and  abdominal  \iscera  are  displaced.  The  left  hip  projects  and  the  waist  on 
the  right  side  is  more  marked.  In  the  initial  stages  the  deformity  disappears 
on  bending  forward,  or  on  hanging  from  a  bar,  but  in  the  fixed  stage  when  the 
bones  have  become  altered  in  shape  this  is  impossible.  Malaise,  backache, 
intercostal  neuralgia,  dyspnea,  and  dyspepsia  may  annoy  the  patient.  The 
prognosis  is  good  if  the  cause  can  be  removed  and  the  spine  straightened 
by  extension.  In  the  later  stages  improvement  may  be  obtained  or  at  least 
the  progress  of  deformity  interrupted. 

i'he  treatment  is  removal  of  the  cause  when  such  is  possible,  the  correc- 
tion of  vicious  attitudes,  massage  and  electricity  to  the  weakened  muscles, 
and  gymnastic  exercises,  such  as  swinging  from  a  bar,  riding  a  bicycle  with  an 
inclined  seat,  balancing  a  light  weight  on  the  head,  placing  the  hands  together 
above  the  head  and  bending  forwards,  etc.  The  general  health  should 
receive  attention  and  the  patient  should  rest  in  the  recumbent  posture  daily. 
Braces  and  supports  tend  to  weaken  the  muscles,  and  are  employed  only  when 
deformity  is  advancing  despite  other  treatment. 

Kyphosis,  or  dorsal  convexity  of  the  spine,  may  involve  the  whole  column, 
as  is  physiological  in  infants,  but  is  usually  confined  to  the  dorsal  region  and 
may  or  may  not  be  associated  with  a  compensatory  lumbar  lordosis.  The 
causes  are  r'ukcts:  faulty  postures,  the  result  of  habit  (as  in  piano  playing), 
()( cupation  (cobblers,  tailors,  etc.),  or  disease  (myopia,  dyspnea,  asthma, 
emphysema  and  chronic  abdominal  disease):  affections  of  the  spine,  such  as 
tuberculosis,  syphilis,  mali^^nant  growths,  aneurysmal  erosion,  osteoarthritis. 
ostitis  deformans,  osteomalacia,  hypertrophic  pulmonary  osteoarthropathy. 
and  acromegaly;  fractures;  and  senile  atrophy.  The  round  shoulders  of 
adolescence  occ  urs  in  the  same  type  of  jiatients  as  the  .scoliosis  of  adolescence. 

The  treatment  varies  with  the  cause;  many  of  the  forms  mentioned  above 
cannot  be  remedied.  In  adolescence  round  .shoulders  may  require  the  cor- 
rection of  myopia  or  the  removal  of  adenoids.  Vicious  postures  should  be 
corrected,  and  the  musiles  strengthened  by  massage,  electricity,  and  exercises; 
rest  should  be  taken  on  a  hard  mattress,  with  a  pillow  beneath  the  deformity. 
If  the  deformity  is  progressive,  a  brace  may  be  required. 

Lordosis,  or  ajiterior  curvature  of  the  luml)ar  spine,  is  comjjensatory  in 
kyphosis,  large  abdominal  tumors,  pregnancy,  etc.  The  most  common  cause 
is  fixation  of  the  hip  in  flexion,  e.g.,  in  congenital  or  unreduced  dislocations 
and  in  hip  disease  or  ankylosis.  It  occurs  also  in  rickets,  caries  of  the  poste- 
rior part  of  the  vertebral  bodies,  progressive  muscular  atrophy,  pseudohy- 
pertrophic paralysis,  and  spondylolisthesis.  The  treatment  is  removal  of 
the  c  ause  when  such  is  possible. 

Spondylolisthesis  is  a  rare  conditi<m  confined  almost  exclusively  to  the 
lumbosacral  joint.  As  the  result  of  imperfect  development  or  fracture  of 
the  arlit  ular  processes,  the  spinal  colurhn  slips  downward  and  forward  from 
the  sacrum,  thus  causing  marked  lordo.sis  and  .shortening  of  stature.     The 


TUBERCULOSIS   OF   THE   SPIITE. 


treaiment  is  extension  in  the  recumbent  posture.  II  the  patient  sits  up  or 
walks,  a  brace  will  be  needed  to  convey  the  weight  of  the  body  tt>  the  pehis. 

Spondylitis  defonnans  is  osteoarthritis  of  the  spine  which  results  in 
locking  of  the  vertebrae  by  osteophytes.  There  are  pain  and  tenderness, 
with  kyphosis  and  perhaps  pressure  on  the  nen-e  roots.  The  treatment  is 
that  of  osteoarthritis  elsewhere.  Braces  are  occasionally  required  to  prevent 
increase  of  deformity. 

Typhoid  spine  is  a  term  applied  to  a  periostitis  or  ostitis  following  typhoid 
fever  There  are  pain,  tenderness,  and  weakness  of  the  spine,  with  muscular 
rigidity.  Suppuration  rarely  occurs.  The  treatment  is  a  plaster  cast  or 
leather  jacket,  and  later  massage  and  electricity. 

Acute  osteomyelitis  of  the  vertebne  is  uncommon  and  is  due  to  the  same 
causes  as  osteomyelitis  elsewhere.  When  the  arches  are  involved  the  condi- 
tion is  easily  recognized,  but  when  the  bodies  are  affect e{l  the  diagnosis  is 
often  difficult,  the  condition  being  mistaken  for  typhoid  fever,  peritonitis, 
etc.  The  infection  may  spread  to  the  meninges/the  symptoms  then  being 
those  of  meningitis.  The  symptoms  are  acute  pain  and  tenderness,  rigidity 
of  the  spinal  muscles,  and  the  constitutional  symptoms  of  sepsis.  The  al>scess 
may  appear  posteriorly  or  anteriorly  (retropharyngeal,  mediastinal,  lumbar, 
or  pelvic).  The  tr^atmmt  is  that  of  osteomyelitis  elsewhere,  viz.,  incision 
and  drainage,  and  at  a  later  period  removal  of  the  sequestrum. 

Tubercuiiosis  of  the  spine  (PoiVs  disease,  angular  cunaiure,  spimdyltlis) 
may  occur  at  any  period  of  life,  but  is  most  frefjuenl  l>L"tween  the  sixth  and 
tenth  year.  Heredity,  impaired  health,  poor  hygienic  surroundings,  and  in- 
juries, often  slight  in  nature,  provide  a  favorable  soil  for  the  tubercle  bacillus. 
The  disease  may  occur  in  any  portion  of  the  spine,  but  is  most  frequent  in 
the  lower  dorsal  region. 

The  pathology  is  that  of  tuberculous  bone  disease  elsewhere.  The 
starting  point  is  usually  on  the  anterior  surface  of  the  body  just  beneath  the 
periosteum,  or  at  the  upper  or  lower  epiphyseal  line;  the  posterior  arches  arc 
rarely  involved  primarily.  The  cancellous  bone  of  the  body  is  gradually  tle- 
stroyed,  and  the  disease  spreads  to  neighboring  vertebra;  beneath  the  anterior 
common  ligament,  or  by  disintegrating  the  intervericbral  cartilages.  Caseous 
changes  occur,  and  pus  forms,  and  burrows  in  the  direction  of  least  resistance. 
Caries  without  suppuration  {cartes  sicca)  and  caries  with  the  formation  of 
sequestra  (caries  necrotica)  occasionally  occur.  Owing  to  the  destruction  of 
the  bodies  of  the  vertebne,  the  spine  bends  and  a  posterior  angular  deformity 
is  produced  {Fig.  267).  The  spinal  cord  is  occasionally  involved.  Cure  is 
effected  by  the  formation  of  new^  bone,  ankylosis  of  the  vertebne,  and  the 
organization  or  calcilkation  of  the  surrounding  inflammatory  tissue. 

The  local  symptoms  are  pain,  rigidity,  deformity,  abscess,  paralysis. 
Pain  is  rarely  severe,  indeed  may  be  absent.  It  is  increased  by  local  pres- 
sure, movements,  and  jarring  of  the  spine.  When  the  nerve  roots  are  irritated 
the  pain  is  referred  to  the  area  supplied  by  these  nerves.  Rigidity  in  the  eariy 
stages  is  due  to  muscular  spasm,  which  is  nature's  effort  to  protect  the  dis- 
eased part.  In  the  convalescing  stage  immobibty  of  the  spine  is  due  to  anky- 
losis. Movements  of  the  spine  are  instinctively  resisted.  The  patient  walks 
like  a  marionette,  refuses  to  jump,  stoops  by  bending  the  knees  and  hips  and 
not  the  back,  turns  around  by  moving  the  whole  body  as  a  unit  instead  of 
rotating  ihe  spine  (particularly  in  cervical  caries),  and  when  sitting  takes 
the  weight  of  the  upper  part  of  the  trunk  from  the  diseased  vertebra:  '(lower 


iPINK. 


I.»:.:r^^v 


-icT  ":■;»  |:r^-p»in^  the  arms  of  ihe  chair.  The  hanjenins: 
!y  -I'lTfi^'-Ie  :«"i  the  imger?.  Z)r/if>rw;//v  varies  irs  nature 
c  :  •  :hc  '.'.^'.ion  and  extent  of  the  disease.  In  the c^:'} 
-ir  :r.  :r.t-  enival  or  lumbar  region  may  l)e  caused  b) 
ry  r-rtly  •  y  caries  of  the  posterior  part  of  the  venebri 

:hf  jr  ht>  ':«»e>  not  prc^duce  deformity.  When  the 
*:  :c  :r.  re  -.r.Jin  the  other  and  lateral  cur\-ature  iKcur>, 
re-  r.t-  i-  :r.  :he  ••p»pv:>siie  direction  to  that  of  scohosis.  i.e.. 

:ht  ■:.  avr  -i-ie  of  the  curve.  Posterior  angular 
:  u!    no.  :hv  rr. -re  vcnehnv  involved  the  more  oblu^eIbc 


"     f  verteSne  shouini|j  ab-urpliiir, 


-II  ri" 


;  If 
.  Ill 


UpiKT     . 

;ii  iiu"  !' 
If  jM-irn 


■  ■  r-' 

ivit.ilr 
in-  l.rl 


.  . . : ::  . ; r  r ..::•. -  : :i e  spine  n ecessa ril y  1  >ecii me> 
r  ■  ■  —r'.y  ..:  .«  ::r:  \n  the  former  situaticm  it  i> 
•v  ■-.;■.  :y  ...:...>  :  r::'.  :::  the  remaining  parts  of  the 
■"- ..  \i  r.i  !  -:   ..'i.  "  ,.  :!y  -.liMormed  secondarv  changes 

r.-x    ■     v.r.      r     '. .  ur  in  the  later  stages,  and 

:^'i:.   .; -;..;!!■*  ..::..:;.  ..  \..r^v  -i/.c  and  travel  a  long  dis- 

•  iT. :.  al  redon  the  pus  collects  be- 

■*::    n:r  .'^^uiryngral  abscess,  p.  4;5). 

--  ;:-i;..:I\   perforates  the  intercostal 

r-  pu-.!iri»'rly    ,:,if-.L    ;■  .  ■    v  ;  rarely  it  comes  to  the 

ihf  lut  k.     I;i  \hv  ].».'. I  r  .i«.r-.il  nr  the  lumliar  region  the 

-    //?"•'• /r  ,^^.,,^...  ,.r  i;:ir-  the  psoas  .^^heaih   \psoa> 

^  «|i«'An\\.ir'U.  riiiuT  :i.r::ii:'L:  a  laru'c  swelling  in  the  iliai 

luu  Ttiupan'^  h'.uMnuni.  ii-ualiy  cxiernal  \o  the  femoral 


:.i.x.i.      In 

•u-tiTi'Tiv 


TUBEHCFLOSIS    OF   THE   SPINE. 


371 


vessels.  A  psoas  abscess  may;  however,  come  to  the  surface  on  ihe  inner  side 
of  the  vessels,  on  the  inner  side  of  the  thigh,  or  even  as  low  as  the  heel; 
occasionally  it  bursts  into  the  rectum,  bladder,  vagina,  or  on  the  perineum. 
Paraiysis  is  not  frequent  (about  7  per  cent.)  and  occurs  only  in  the  later 
stages.  It  is  rarely  sudden  in  onset,  and  is  then  probably  due  lo  displace- 
ment of  bone.  As  a  rule  il  appears  slowly  as  the  result  of  c  ompression  of  the 
cord  by  tuberculous  masses  or  pus,  or  most  commonly  pachymeningitis 
Sensation  is  affected  later.  The  cmsiilutional  symptoms  are  those  of 
tuberculosis  elsewhere. 

The  diagnosis  may  be  difficult  before  the  onset  of  deformity*  Localized 
tenderness  and  rigidity  are  the  most  important  symptoms  in  this  stage.  The 
reflected  pains  may  be  mistaken  for  pleurisy,  abdominal  disease^  neuralgia, 
rheumatism,  etc.  Angular  deformity  may  be  caused  also  by  syphilis^  malig- 
nant growths,  and  aneurysmal  erosions.  In  kyphosis  due  lo  other  causes, 
the  deformity  is  usually  a  Jong  curve  rather  than  a  limited  angular  projection, 


VtU's  disease.     (VVmng.) 

and  rigidity  is  generally  absent.  Flexion  of  the  hip  due  to  psoas  abscess 
should  not  be  mistaken  for  hip  joint  flisease,  and  it  should  lie  recalled  that 
psoas  abscess  may  be  due  to  other  causes  than  tubercuhjsis,  as  may  also 
abscesses  in  the  other  regions  indicated  above.  In  doubtful  cases  the  X-ray 
and  the  tuberculin  tests  may  be  of  service. 

The  prognosis  is  good  in  children  who  are  efficiently  treated  from  the 
beginning.  The  higher  the  disease,  the  more  vertebne  involved,  and 
the  older  the  patient,  the  worse  the  prognosis.  Abscesses  which  become  in- 
fected with  pyogenic  organisms  cause  hectic  fever  an<l  eventuate  in  amyloid 
disease  unless  the  infection  tan  be  controlled.  Paralysis  is  a  grave  complica- 
tion, but  with  suitable  treatment  may  entirely  disappear.  Death  is  usually 
the  result  of  exhaustion,  sepsis,  tubercuh)sis  elsewhere,  involvement  of  the 
cord  or  meninges,  or  an  intercurrent  malady.  Sudden  death  from  dislocation 
may  occur  in  disease  of  the  atlas  or  axis. 

The  treatment  is  local  and  constitutional.  For  the  latter  see  page  135, 
The  iofol  Irtatmetti  is  (1)  rest.  (2)  correction  of  deformity,  (3)  evacuation  of 
aliscesses  anti  jxissibly  removal  of  tliseaserl  bone,  anti  {4)  the  care  of  paralysis 
if  it  should  incur.  Local  appHcations  are  useless,  and  blisters  and  the  actual 
I  autery  may  be  harmful  in  fjredisposing  to  lied  sores,     i .  Rest  h  best  obtained 


d 


372  * 


SFINE. 


by  the  recumbent  posture  and  the  application  of  extension.  In  cervical 
caries  extension  is  applied  to  the  head  only  (Fig.  268),  the  head  of  the  bed 
being  slightly  elevated,  and  sand  bags  being  used  to  prevent  lateral  motions. 
In  the  lower  dorsal  or  lumbar  region  extension  should  be  applied  also  to  the 
legs.  Restless  children  may  be  fastened  in  a  specially  constructed  box  or 
trough  in  which  an  opening  has  been  provided  for  the  discharges  from  the 
bowels.  After  a  number  of  months  when  the  pain  and  acute  symptoms 
have  subsided,  or  even  before  in  adults  or  in  children  who  do  not  stand 
bed  treatment  wed,  a  plaster  cast  or  a  leather  brace  should  be  applied  and 
the  patient  allowed  to  walk  about.  Sayre's  plaster  jacket  is  applied  as  follows : 
An  armless  woolen  undershirt,  reaching  below  the  iliac  crests,  is  put  on  the 
patient,  who  is  suspended  from  a  tripod  (Fig.  269)  with  the  toes  just  reach- 


FiG.  269.^Sjiyrc's  triporl. 


Fig.  270. — Sa/rc's  jury  miust. 


ing  the  ground-  instead  of  using  the  axillary  straps  the  patient  may  grasp  the 
cross  bar  above.  In  some  cases  the  cast  should  be  applied  in  the  recumbent 
posture  while  extension  is  being  made.  A  folded  towel  is  placed  over  the* 
epigastrium,  and  this  '* dinner  pad**  is  withdrawn  after  the  plaster  has  set; 
padding  is  placed  also  over  the  posterior  deformity,  the  iliac  crests,  and  the 
breasts.  Plaster  bandages  are  now  applied  alxmt  the  trunk  from  the  axilke 
to  below  the  iliac  crests.  In  disease  above  the  middorsal  region  it  will  be 
necessary  to  apply  a  jury  mast  (Fig.  270),  or  to  include  the  neck  in  the 
piaster  bandage,  so  as  to  take  the  weight  of  the  head  from  the  body.  The 
cast  may  be  split  down  the  front  and  provided  with  hooks  for  lacing,  so  that  it 
may  be  removed  and  reapplied  from  time  to  time,  or  a  new  cast  may  be  ap- 
plied every  two  or  three  months.  The  cast  or  a  suitable  leather  or  felt  jacket 
should  be  worn  for  at  least  six  months  after  the  patient  is  apparently  cured, 
2,  Deformity  when  recent  may  be  gradually  corrected  by  extension,  and 
gentle  pressure  over  the  gibbosity,  either  by  means  of  a  pad  left  in  place  or  by 
daily  pressure  with  the  hand.     In  nld  cases  after  ankylosis  has  occurred, 


removal  of  the  spinous  processes  may  be  indicatetl.  Forcible  correction  at 
one  sitting,  first  proposed  by  Chipault^  who  also  wires  the  spinous  processes 
together  to  maintain  the  reduction,  is  often  called  Calot's  method  because  of 
the  enthusiasm  with  which  he  has  advocated  it.  Most  surgeons  consider  the 
method  dangerous. 

3.  Abscesses  should  be  evacuated  when  detected.  The  general  treatment 
of  chronic  abscesses  has  been  considered  on  p*  73,  and  the  treatment  of  retro- 
pharyngeal abscess  will  be  described  under  diseases  of  the  pharynx.  In  ab- 
scesses due  to  disease  of  the  posterior  arches,  a  free  incision  should  be  made, 
the  diseased  bone  removed,  and  the  cavity  disinfected  and  packed  with  iodo- 
form gau^se.  Dorsal »  lumbar,  and  psoas  abscesses  should  be  incised  at  the 
point  where  they  are  nearest  the  surface,  the  pyogenic  membrane  and  cheesy 
masses  removed  by  curetting  with  a  piece  of  gauze  on  a  long  pair  of  forceps, 
the  cavity  irrigated  with  salt  solution  and  injected  with  iodoform  emulsion 
(p.  74),  and  the  wound  closed  with  sutures.  Some  surgeons  prefer  to  tap 
with  a  trocar  and  cannula,  but  irrigation  is  unsatisfactory  through  a  cannula 
and  removal  of  the  debris  is  impossible.  These  operations  may  have  to  be 
repeated.  If  diseased  bone  is  found  it  should  be  removed.  Treves^  opera- 
tion may  be  performed  in  disease  of  the  twelfth  dorsal  or  any  of  the  lumbar 
vertebne.  An  incision  is  made  along  the  outer  edge  of  the  erector  spina^  from 
the  last  rib  to  the  crest  of  the  ilium,  and  the  tissues  divided  until  the  quadratus 
lumborum  is  excised,  which  with  the  underlying  fascia  is  cut  transversely  to 
avoid  the  lumbar  arteries.  The  psoas  is  opened,  .irrigated  with  liichlorid  1 
to  5,000,  the  pyogenic  membrane  scraped  off  with  the  finger,  diseased  bone 
removed  with  forceps  or  curette,  and  the  wound  closed  with  sutures.  Similar 
operations  have  been  performed  in  the  cervical  and,  after  resection  of  the  ribs » 
in  the  dorsal  regions. 

4.  Paralysis  is  treated  by  extension  and  gentle  pressure  to  correct  the 
deformity,  care  being  taken  to  preserve  nutrition,  prevent  bed  sores,  cystitis, 
etc.,  as  indicated  under  fracture  of  the  spine.  As  compression  of  the  cord  is 
usually  caused  by  pachymeningitis,  and  as  recover)'  frequently  follows  this 
treatment »  laminectomy  is  employed  only  when  the  symptoms  persist  or 
increase  after  months  or  even  a  year  of  extension,  when  the  patient's  life  is 
threatened  by  sepsis  the  result  of  cystitis  or  bed  sores,  when  the  posterior 
arches  are  diseased,  or  when  the  compression  is  acute  in  onset,  indicating 
bony  displacement. 

Spinal  meningitis  extends  from  the  membranes  of  the  brain  or  begins 
as  a  local  alTection.  PachymeningUis  may  follow  disease  or  injury  of  the  vcr- 
tebne  and  is  often  syphilitic  or  tuberculous  in  nature,  A  hemorrhagic  pachy- 
meningitis interna  analogous  to  that  found  in  the  head  occurs,  chiefly  in 
the  cervical  region.  The  symptoms  of  pachymeningitis  are  first  those  of 
irritation  of  the  nerve  roots,  i.e.,  shooting  pains  and  perhaps  spasms  in  the 
parts  supplied  by  the  nerves,  and  later  those  of  a  gradually  oncoming  com- 
pression of  the  cord.  The  treaimmt  is  removal  of  the  cause,  rest,  and  potas- 
sium iodid.     Laminectomy  may  be  indicated  m  the  later  stages. 

Acute  kptomeningUis  may  follow  disease  or  injury^  of  the  spinal  column, 
or  wounds  of  the  membranes.  It  usually  extends  to  the  cerebral  meninges, 
and  then  presents  the  symptoms  described  under  inflammation  of  the  latter 
structure,  and  is  treated  by  the  same  means.  Chronic  leptomeningitis  may 
follow  the  acute  form.  When  chronic  from  the  beginning  it  is  usually  local- 
ized, and  is  prone  to  attack  the  syphilitic  and  alcoholic.     The  symptoms  arc 


M 


luializeil  pain  in  the  Jiatk,  rigidity  of  the  spinal  musrles,  and  evklcnces 
irritation  of  the  nerve  roots  as  ilestrihetj  above.  If  granulations  form,  the 
symptoms  will  be  similar  to  (hose  of  tumor.  The  irealment  is  rest,  counter* 
irritation,  scilatives,  potassium  iodic! ,  and  laminectomy  if  pressure  symptoms 
ensue. 

Intraspinal  tumors  are  generally  glioma  ta,  gum  mala,  or  tuberculous 
masses.  Lipoma  (usually  congenital),  fibroma,  angioma,  myxoma,  choD- 
droma,  hydatid  and  dermoid  cysts,  secondary  carcinoma,  and  sarcoma  also 
occur  The  tumor  may  be  extradural,  subdural ^  or  intramedullar)%  The 
symptoms  are  those  of  a  gradually  oncoming  compression  with  perhaps 
localized  pain  and  tenderness  over  the  segment  involved.  The  disturbances 
of  motion,  sensation,  and  of  the  retlexes,  develop  from  lielow  upward  and  arc 
often  at  first  unilateral.  In  the  beginning  the  symptoms  are  those  of  irrita- 
tion, i.e.,  shooting  pains,  hyperesthesia,  localized  spasms  (perhaps  causing 
lateral  cun'ature,  the  concavity  being  on  the  side  of  the  tumor),  and  increased 
redexes.  Later  there  are  paresis,  hypesthesia,  and  decrease  of  retlexes,  and 
finally  paralysis,  anesthesia,  loss  of  reflexes,  and  trophic  disturbances* 
Motion  is  usually  alTected  before  sensation,  but  this  will  necessarily  depend 
somewhat  on  the  situation  of  the  growth.  7'he  pupils  may  be  affected  if  the 
lesion  is  above  the  second  dorsal  segment.  Th^  diagnosis  of  the  nature  of  the 
growth  is  usually  impossible,  although  a  previous  history  of  syphilis,  tuber- 
culosis, or  a  malignant  growth  elsewhere,  should  be  sought;  a  tumor  occur- 
ring soon  after  birth  would  probably  be  a  lipoma.  The  seat  of  the  tumor  is 
determined  by  the  localizing  symptoms  (p.  354).  Intramedullary  growths 
usually  produce  bilateral  symptoms  and  earlier  signs  of  compression.  Extra- 
medullary  growths  are  apt  to  cause  earlier  and  more  severe  signs  of  irritation. 
Chronic  inflammation  of  the  meninges  or  cord  may  produce  similar  symp- 
toms. The  ftrtrgnosis  is  much  more  favorable  than  in  cerebral  tumors. 
AlMJUt  one- half  are  opera !>le  and  about  one-half  of  those  operated  upon  are 
benefited.     The  mortality  of  operation  is  10  per  cent. 

The  treatment  is  usually  potassium  iodid  and  mercury  for  six  weeks,  to 
e.xclude  syphilis.  If  no  improvement  is  noted,  the  tumor  should  be  removed 
by  laminectomy* 

Infantile  paralysis  (aadc  anterior  poVwmyrUtis)  usually  occurs  within 
the  first  three  years  of  life,  is  mildly  contagious,  and  probably  due  to  a  specific 
microorganism.  It  is  characterized  by  slight  fever,  and  sudden  paralysis 
of  a  group  of  muscles,  followed  by  rapid  atrophy  because  of  the  destruction 
of  their  trophic  centers  in  the  anterior  horns  of  the  cord.  The  face  and 
neck  are  very  rarely  involved,  but  the  muscles  of  the  back  and  abdomen 
may  be  affected.  In  the  upper  extremity  the  deltoid,  brachialis  anticus, 
biceps,  supinator  longus,  extensors  or  flexors  of  the  wrist  or  fingers  may  be 
attacked;  in  the  leg,  the  favorite  site,  the  tibialis  anticus  and  other  muscles 
on  the  front  of  the  leg;  and  in  the  thigh  the  quadriceps  and  the  adductors. 
The  stirgi^aUreaimatt,  in  the  early  stages,  is  to  prevent  deformity  and  increase 
the  nutrition  of  the  muscles  by  massage,  electricity,  passive  and  active  motions, 
and  special  shoes  or  braces^  either  during  the  night,  or  in  bad  cases  also 
during  the  day.  When  deformity  has  developed,  various  measures  may  be 
indicated  in  addition  to  the  above:  forcible  correction  under  an  anesthetic, 
tenotomy,  fasciotomy,  myotomy,  tendon  transplantation,  nerve  transplanta- 
tion, osteotomy,  arthrodesis,  or  rarely  amputation  when  a  limb  is  absolutely 
useless. 


i 

li 

\ 

■ 
■ 


FOREIGN   BOBrFS   TN   TtTE   EAR. 


375 


CHAPTER  XXIII. 

EAR,  NECK,  THYROID  GLAND. 

THE  EAR. 

Only  those  condilioiis  peculiar  lo  the  ear  which  more  or  less  directly  con- 
cern the  surgeon  will  lie  consideretl  in  this  chapter. 

The  external  ear  may  be  abnormally  small  (microtia),  or  it  may  be 
completely  or,  mcjte  rommonlyj  partly  absent,  and  such  defects  can  rarely 
be  benefited  by  plastic  surgery.  Accessory  auricles  should  be  amputated. 
Congenital  fistulas  and  fissures  are  the  result  of  incomplete  closure  of  the 
first  liranchial  ciefl;  the  former  may  be  excised*  the  latter  sutured  after  par- 
ing the  edges.  Very  large  ears  (macrotia)  have  been  reduced  in  siise  by  the 
removal  of  a  wedge-shaped  section  from  the  upper  part  of  the  pinna  with 
subsequent  suture.  Prominent  ears  may  be  brought  closer  to  the  head 
by  the  excision  of  an  elbptiial  portion  of  the  skin  on  the  posterior  aspect 
with  subsequent  suture,  or  by  denuding  the  groove  between  the  ear  and  the 
skull  and  closing  the  wound  with  sutures,  'Wounds  of  the  auricle  are  often 
slow  in  healing  and  are  occasionally  followed  lay  necrosis  of  the  cartilage;  if 
the  meatus  is  involved  it  may  be  necessar>^  to  graft  skin  to  prevent  atresia. 
Loss  of  a  portion  of  the  ear  may  be  supplied  by  a  pedunculated  tlap  from  the 
neighboring  skin,  the  pedicle  being  cut  after  union  has  taken  place  [otoplmty) ; 
artificial  ears  of  papier-mache  or  metal  are  usually  more  sightly  than  the 
shapeless  mass  which  generally  follows  an  attempted  otoplasty  when  the 
entire  auricle  has  been  lost.  Hematoma  of  the  ear  {oiliemaionia)  generally 
occupies  the  concavity  of  the  auricle,  the  bltMxl  separating  the  perichondrium 
from  the  cartilage.  It  follows  injury  (boxers  ear),  or  occurs  spontaneously, 
most  frequently  in  the  insane,  and  is  then  apt  to  be  followed  by  great  thicken- 
ing and  distortion.  The  ireatment  is  aspiration,  and  pressure  by  means  of  a 
bandage.     Should  suppuration  occur,  a  free  incision  will  be  needed. 

Inflammatory  atTcctions  and  tumors  of  the  external  ear  present  the  same 
features  and  requirt  the  same  treatment  as  else w  here. 

Atresia  of  the  meatus,  congenital  or  acquired,  when  membranous  in 
characte:  may  be  treated  by  excision  of  the  mem  lira  ne  and  skin  grafting. 

Impacted  cerumen  (jjiugs  of  wax)  causes  diminution  in  hearing,  tinnitus, 
and  sometimes  vertigo  and  intlammatory  troubles.  The  diagnosis  is  made 
by  the  speculum.  The  irralmrtti  is  removal  by  syringing  with  warm  bicar- 
lK>nate  of  soda  solution.  The  wax  may  tirsl  be  softened  by  having  the  patient 
retain  in  the  ear  for  tlftecn  minutes  or  longer  a  mixture  of  glycerin  and  water. 

Foreign  bodies  also  are  removed  by  syringing.  Live  insects  may  be 
killed  with  sweet  oil;  if  fastened  to  the  wall  of  the  canal  it  will  be  necessary 
lo  use  angular  forceps  to  remove  them,  the  ear  being  illuminated  with  a  head 
mirror.  Vegetable  bodies  which  swell  should  be  removeil  at  once  l>y  in- 
strumental means  if  syringing  fails.  If  unskilled,  one  may  do  much  harm 
with  instruments  in  the  ear,  hence  if  syringing  fails  the  case  should  be  referred 
to  an  otologist.  Rarely  will  it  be  necessary  to  turn  the  auricle  forwards 
and  enter  the  meatus  from  behind. 


376  EAR,   NECK,   THYROID  GLAND. 

The  surgical  complications  of  suppurative  otitis  media  are  often  of 
the  gravest  nature,  consequently  this  condition  should  never  be  neglected. 
Pyemia  without  even  local  complications  may  occur,  and  miliary  Mer- 
culosis  occasionally  develops  when  the  affection  is  tuberculous  in  nature. 
The  local  complications  may  be  (i)  extracranial,  (2)  cranial,  or  (3)  in- 
tracranial. 

1.  The  extracranial  complications  are  eczema  sjid  furuncles  of  the 
meatus,  cervical  adenitis^  and  suppuralive  arthritis  of  the  temporomazillaiy 
joint. 

2.  The  cranial  complications. — Carious  or  necrotic  ossicles  may 
be  removed  through  the  meatus,  and  disease  of  adjacent  bone  is  occasionally 
treated  in  the  same  way,  but  more  frequentiy  a  mastoid  operation  will  hie 
required  and  the  disease  can  then  be  dealt  with  from  behind. 

Granulations  and  polypi  may  dam  up  the  discharge,  and  are  removed 
by  the  currette,  forceps,  or  snare. 

Suppuration  of  the  labyrinth  can  be  treated  only  by  providing  free 
drainage  of  the  tympanum;  there  is  considerable  danger  of  extension  to  the 
brain. 

Facial  paralysis  is  due  to  neuritis,  pressure  being  exerted  by  the  increase 
in  the  size  of  the  nerve  and  the  thickening  of  its  osseous  canal.  The  nutri- 
tion of  the  facial  muscles  should  be  maintained  by  electricity  and- massage, 
and  if  no  signs  of  recovery  appear  after  six  months,  the  nerve  may  be  anasto- 
mosed with  the  spinal  accessory  or  the  hypoglossal  (p.  229). 

Fatal  hemorrhage  from  erosion  of  the  internal  carotid,  internal 
jugular,  middle  meningeal,  or  lateral  or  petrosal  sinus  is  a  rare  but  pos- 
sible complication. 

Mastoiditis  of  some  degree  is  probably  associated  with  every  acute  sup- 
puralive otitis  media,  but  if  the  tympanum  is  promptly  drained,  no  ill  effects 
need  follow.  The  mucous  membrane  alone  may  be  involved,  but  what  is 
recognized  clinically  as  mastoiditis  is  usually  an  osteomyelitis.  There  may 
be  a  desquamative  inflammation  which  fills  the  cavities  with  cholesteato- 
matous  material.  Although  the  mastoid  antrum  is  present  at  birth,  the 
mastoid  cells  and  the  mastoid  process  are  not  well  developed  until  after 
puberty.  These  cells  surround  and  communicate  with  the  antrum  and  are 
very  variable  in  extent;  they  may  extend  forwards  above  the  meatus,  back- 
wards to  the  occipital  bone,  upwards  to  the  parietal  bone,  and  downwards 
to  the  apex  of  the  mastoid. 

The  Sjrmptoms  are  pain  and  tenderness,  both  of  which  may,  however,  be 
absent  in  chronic  cases  with  a  thick  cortex  or  limited  disease.  In  acute  cases 
there  may  be  fever  and  leukocytosis.  The  most  important  sign  is  edema 
and  bulging  of  the  upper  posterior  wall  of  the  auditory  meatus.  If  the  in- 
fection spreads  outwards  there  will  be  redness  and  edema  of  the  skin  over  the 
mastoid  and  possibly  the  formation  of  a  subperiosteal  abscess,  which  may 
perforate  and  form  a  subcutaneous  collection  of  pus,  or  spread  downwards 
and  give  rise  to  a  cellulitis  of  the  neck.  Extension  inwards  through  the  teg- 
men  tympani  may  cause  inflammation  of  the  external  semicircular  canal  or 
the  facial  nerve;  upwards,  abscess  on  either  side  of  the  dura,  septic  menin- 
gitis, or  cerebral  abscess;  downwards,  deep  cellulitis  of  the  neck;  forwards, 
a  sinus  of  the  meatus;  and  backwards,  thrombosis  of  the  lateral  sinus  or 
abscess  of  the  cerebellum.  Often  the  discharge  from  the  ear  abates  when  the 
mastoid  symptoms  are  active.     A  skiagraph  is  often  of  value  in  diagnosis. 


iTomms. 


377 


Thu  treatment  in  atule  cases  with  pain  and  tentlemess  only,  is  drain iiii< 
and  cicansiiig  of  the  t}Tnpanum,  cold  to  the  mastoid,  and  the  artiticiaJ  leech. 
If  the  symptoms  persist  for  several  days,  or  if  there  is  external  edema,  con- 
tinuous headache^  or  constitutional  symptoms,  the  mastoid  should  be  opened 
and  drained.  A  mastoid  operation  is  indicated  likewise  in  cases  of  incurable 
chronic  otorrhea,  even  when  there  are  no  symptoms  of  mastoiditis.  In  acute 
mastoiditis  the  Schwa rtzc  operation,  or  simple  opening  of  the  antrum  with 
|drainage,  may  he  ail  that  is  required.  In  chronic  cases  it  will  be  necessary 
*to  clean  out  and  convert  into  one  cavity  the  antrum,  attic,  tympanum,  and 
meatus  (Schwartze-Slacke  operation). 

In  the  Schwartz e  operation  the  antrum  may  be  opened  with  a  trephine, 
awl,  gimlet,  or  with  a  bur  propelled  by  a  surgical  engine,  but  probably  most 


KiG,  271,— C,  F,  E  (X).  Supnimealal  nr  M;uevven'^  irianKU--  A.  B,  l>pt.T  two- 
ihirds  of  ihis  line  overlies  Ihe  stj^moid  sjnij<;.  C  D.  Overlie*  sigmoid  pinus  from  knee 
to  «:(^mmrn cement,     (Binnie.l 

surgeons  use  a  gouge  or  a  chisel.  A  curved  incision  is  made  about  one-fourth 
inch  posterior  to  and  parallel  with  the  insertion  of  the  auricle,  from  above  the 
ear  to  the  tip  of  the  mastoid,  the  flap  including  the  periosteum  pushed  for- 
wards, and  the  mastoid  vein  examined  for  thrombosis  (indicating  thromlxjsisof 
the  lateral  sinus)  and  the  bone  for  sinuses.  In  the  absence  of  a  sinus,  which 
should  be  followed  if  present,  the  antrum  is  opened  in  Macewen's  supra- 
meatal  triangle  (Fig.  271),  which  is  bounded  above  by  the  posterior  root  of  the 
zygoma,  in  front  by  the  posterior  wall  of  the  external  meatus,  and  behind 
by  a  line  joining  these  two.  With  the  ear  pulled  well  forward  this  triangle 
can  be  recognized  as  a  depression  in  the  bone.  In  young  children  the 
antrum  may  be  perforated  with  a  curette.  In  adults  the  chisel  or  gouge,  one- 
fourth  inch  in  width,  may  be  used,  thin  slices  of  bone  being  removed  in  a 
direction  downwards,  forwards,  and  slightly  inwards.  Unless  the  bone  is 
thickened  the  mastoid  cells  will  be  encountered  just  below  the  surface.  The 
I  anlnim  too  is  superficial  in  the  child,  but  in  the  adult  its  depth  beneath  the 
surface  of  the  bone  varies  from  one-eighth  to  three-fourths  of  an  inch.     One 


i 


Fu.  272.~l.clt  icm|njrai  ijnm*:.  Amrum  an<i  mn^i  nl  tnc  ma*iinfi  ivlh  ohjiierated. 
I  ScmidrtuUr  «anah-  2.  Ixjcation  of  facial  nerve  in  aquciluct  uf  Fallopius,  which 
has  ^jci;xi  opened.     3.   Location  < if  sigmoid  sinus.     (Binnie.) 


removed  almost  as  far  as  the  lloor  of  the  meatus,  but  skiping  upwards  in  the 
deeper  parts  to  avoid  the  facial  nerve.  The  remains  of  the  tympanic  mem- 
brane, malleus,  and  incus  are  removed.  A  probe  may  lie  passed  through  the 
operiinji;  helvvcen  the  antrum  and  attic,  to  protect  the  facial  nen-e  and  the  ex- 
ternal semicircular  canal,  which  lie  behind,  while  the  bone  in  front  including 
the  4)uter  wall  of  the  attic  is  removed.  The  inner  wall  and  »loor  of  the  antrum 
shc^dd  n*)i  !)e  disturbed,  because  of  the  danger  of  injury  to  the  fac^ial  nerve  or 
external  semicin  ular  tanal  (Fig.  272).  After  smoothing  the  walls  of  the 
cuvily  and  irrigating  with  salt  solution,  the  posterior  wall  of  the  cartilaginous 
meatus  is  split  hjngitudinally,  and  the  daps  thus  formed  stitched  to  the  pos- 
terior margin  of  the  skin  wound,  so  that  the  whole  cavity  can  be  inspected 
ihrough  the  meatus.  The  operatioji  is  compkled  by  tilling  the  cavity  with 
gau/A%  introduced  through  the  meatus  and  posteriorly,  and  by  partly  dosing 


CYSTS   OF   THE  NECK. 


379 


the  wfiund  in  \hv  skin.     When  ^ranulalions  have  covered  the  tjone,  healing 
may  lie  fadlitate*!  I>y  the  use  o^  rhiersi  h's  skin  grafts. 

3.  The  intracranial  complications  of  otorrhea  are  ihromhosis  of  ihc 
lateral  sinus,  numhigiiis,  and  extradural ^  (crtbral,  or  cerebdlar  abscess  (see 
chapter  on  the  Heail). 


THE  NECK. 


In  the  development  of  the  face  and  oerk  four  processes  {branchial  arches) 
are  formed  on  each  side»  and  between  these  arches  are  the  bramhlal  defts. 
The  tirst  arch  joins  its  fellow  in  the  midtlle  line  to  form  the  tower  jaw,  the 
malleus  developing  from  its  upper  end.  A  process  from  the  l>ase  of  this  arch 
extends  forward  to  join  the  fronto-nasal  process  jutting  down  from  above, 
and  forms  the  upper  jaw;  when  these  processes  fail  to  unite,  cleft  palate  and 
harelip  result.  The  second  arch  forms  the  incus^  stapes,  styloid  process, 
stylohyoid  ligament,  and  lesser  comu  of  the  hyoid  bone.  The  remains  of  the 
tleft  lietween  the  first  and  the  second  arch  is  seen  as  the  Glasserian  fissure, 
external  auditory  meatus,  tympanum,  and  Eustachian  canal.  7'he  third 
arch  forms  the  body  and  greater  cornu  of  the  hyoid  bone,  while  the  rest  of  the 
neck  develops  from  the  remaining  arch. 

Branchial  fistulae  result  from  imperfect  closure  of  the  liranchial  clefts; 
they  open  on  the  skin,  in  the  pharynx,  or  in  both  places.  Fistula*  and  hssures 
in  the  neighlx>rhood  of  ihe  ear  are  vestiges  of  the  ttrst  branchial  cleft.  Con- 
genital tistulie  of  the  neck  are  most  frequent  in  the  neighborhood  of  the  fourth 
cleft,  and  open  externally  at  the  anterior  edge  of  the  sternomastoid  close  to  its 
lower  end.  Fistula^  at  the  anterior  or  posterior  tti^^  of  the  sternomastoid  at 
the  level  of  the  larynx  are  the  remains  of  the  second  or  third  cleft.  The 
iniernal  opening  is  usually  in  the  lower  part  of  the  pharynx  or  behintl  the 
tonsil.  An  incomplete  internal  fistula  may  cause  a  congenital  diverticulum 
of  the  esophagus.  Of  similar  origin  are  some  median  tistuk%  which  may 
open  into  the  trachea  or  larynx,  and  which  when  incomplete  internally 
may  beget  air  tumors  (laryttgoceie  or  trachfocdf).  Other  median  tistuke  are 
due  to  a  patent  thyrogiossai  dud,  which  in  the  embryo  passes  from  the  isthmus 
of  the  thyroid  gland  up  in  front  of  the  trachea  and  larynx,  then  behind  the 
body  of  the  hyoid  bone,  to  open  at  the  foramen  cecum  of  the  tongue.  Acces- 
sory thyroids  may  spring  from  any  pijrtion  of  this  duct.  All  these  tistuke  are 
lined  by  mucous  membrane  and  hence  give  rise  to  a  mucoid  discharge- 
Cysts  of  the  neck  may  be  congenital  or  acquired. 

Congenital  cysts,  which  may  not  appear  for  some  years  after  birth,  in- 
clude the  branchial,  thyrogiossai  (either  of  which  may  be  mucoid  or  der- 
moid), and  bloo<i  cysts,  and  cystic  lymphangioma.  Branchial  cysts  arise 
from  unobliterated  portions  of  the  branchial  clefts,  and  usually  lie  lieneath 
the  muscles  of  the  tongue  or  behind  the  sternomastoid;  In  the  former 
situation  they  may  be  mistaken  for  ranula?,  in  the  latter  they  are  often 
closely  connected  with  the  great  vessels.  7'hey  are  lined  by  epithelium  and 
contain  a  serous  or  mucoid  material  {hygroma,  hydrocdc  of  thcncck — Pig. 
273)»  or  sebum,  hair,  teeth,  etc,  (dermoids).  Thyrogiossai  cysts  arise  from 
any  portion  of  the  thyrogiossai  duct,  hence  are  median  in  position ;  they 
may  contain  mucus  or  dermoid  material.  Subihtgual  dermoids  and  subhyoid 
cysts  belong  to  this  class.    Blood  cysts  probably  arise  from  a  congenital 


380 


KAK,    NKCK,    THYROID    GL.\ND. 


diverticulum  of  one  of  ihe  large  veins  of  the  neck;  if  the  communitatioii 
persists,  they  may  be  reduced  by  pressure,  and  vary  in  size  during  respira* 
tion.  Cystic  l3nnphaiigioma  (Fig,  87},  sometimes  improperly  caJled 
cystic  hygroma,  is  due  to  dilated  lymph  vessels  and  spaces,  hence  is  muld- 
locular  and  iobulated;  it  may  spread  to  the  face  and  into  the  thorax  and 
is  then  beyond  operative  aid. 

Acquired  cysts  may  be  sebaceous  (p.  163),  hydatid  (  p.  149)^  thyroid 
(see  cystic  goiter),  bursab  or  malignant.  Bursal  cysts  may  develop  over 
the  thyroid  cartilage,  or  between  it  and  the  hyoid  Ijone,  Occasionally  one 
encounters  a  carcinoma  deep  in  the  cervical  tissues  without  finding  a  pri- 
mar)^  growth  elsewhere.     These  cases  may  be  regarded  as  branchial  rar- 

cinomata;  after  a  time  they^  undergo 
cystic  degeneration  (malignant  cysts 
of  the  neck),  or  break  down  into  a 
puruloid  material,  and  may  superfi' 
cially  resemble  a  chronic  celluUtis  of 
I  he  neck.  Sarcoma  of  the  neck  likewise 
may  undergo  cystic  degeneration.  The 
Irealmenl  uf  all  the  conditions  mentioned 
a!>ove  is  e.vcision,  which  is  often  a  diffi- 
cult matter.  KistuLe  and  cysts  which 
cannot  be  excised  may  be  opened,  and 
the  lining  membrane  destroyed  by 
cauterization.  Blood  cysts  may  neces- 
sitate suture  or  ligature  of  the  jugular  or 
suliclavian  vein. 

Torticollis,  or  wry  neck,  is  a  de- 
formity in  which  the  head  is  bent  to- 
wards I  he  shoulder »  and  the  face  turned 
towards  the  opposite  side.  False  torticollis  is  seen  m  cases  like  fracture 
of  the  clavicle,  and  tumors  and  intiammations  of  the  neck;  it  results  also 
from  rheumatism  or  cold  (stiff  neck)  and  hysteria.  The  treatment  is 
directed  to  the  cause. 

True,  or  chronic  torticollis,  may  be  (i)  spasmodic  or  (2)  permanent. 
I.  Spasmodic  torticollis  (tonic  or  clonic)  usually  affects  one  stemomastoid 
only,  but  occasionally  that  of  the  i:«pposite  side  as  well  as  the  posterior  deep 
cervical  muscles  also  are  involved,  so  that  the  head  is  drawm  backw^ards 
{rctrocollis) .  The  spasm  may  be  persistent,  or  it  may  intermit  for  days  or 
weeks,  but  in  either  event  it  is  usually  al>sent  during  sleep.  It  may  result  from 
direct  irritation  of  the  nene  supplying  the  muscles,  e.g.,  by  tumors,  enlarged 
glands^  cervical  caries;  or  from  reflex  irritation,  such  as  carious  teeth,  worms, 
and  pehic  troubles;  but  is  usually  seen  in  the  neurotic  and  hysterical  and  may 
possibly  be  due  to  irritation  of  tiie  motor  centers.  The  treatment  is  removal 
of  any  source  of  irritation,  the  treatment  of  any  associated  neurosis,  and  the 
administration  of  antispasmodics.  If  these  measures  faib  the  spinal  acces- 
sory nerve  may  be  stretched  or  severed;  the  posterior  cervical  nerves  may  be 
similarly  treated  if  the  posterior  cervical  muscles  also  are  affected. 

2.  Permanent  torticollis  is  the  result  of  malformation,  vidous  intrau- 
terine position,  or  prenatal  disease  of  the  muscle  or  nenes  (amgenUal  torti- 
collis); it  may  be  caused  also  by  strabismus,  scoliosis,  paralysis  of  the  opposite 
muscle,  or  by  cicatricial  shortening  of  the  muscle  or  surrounding  tissues, 


Fig.    273.— Hydrocele  of   neck. 
(Pennsylvania   Hospliabj 


CELLULITIS    OF    TirE    NECK. 


38t 


following  laceration  at  birth  or  subsequent  injuries  or  inllammations.  The 
stemomastoid  alone  may  be  at  fault,  or  the  trapezius  and  deeper  muscles  also 
may  be  implicated  and  the  deep  cervical  fascia  shortened*  In  congenital 
cases  or  those  arising  soon  after  birth,  the  face  of  the  atletted  side  fails  to  de- 
velop as  rapidly  as  the  sound  side.  A  rompensatory  lateral  curve,  concave 
towards  the  affected  side,  develops  in  the  cervical  spine,  and  a  secondary 
dorsal  cur^e^  concave  in  the  opposite  direction,  is  formed,  leading  to  changes 
in  the  shape  of  the  vertebra?.  The  treatment  in  early  cases  is  massage,  manip- 
ulations  to  straighten  the  head,  and  a  Iirace  or  support  to  maintain  the 
corrected  position.  Any  contributory  lesion,  such  as  strabismus,  scoliosis, 
etc,  likewise  should  receive  attention.  In  most  rases,  however,  Httle  prog- 
ress can  be  made  until  the  stemomastoid  muscle  has  been  divided.  The 
subcutaneous  operation  for  this  purpose  is  unsafe  and  incomplete  and  will 
not  l>e  descriljetl  In  the  open  method  the  muscle  is  isolated  and  divided 
through  a  transverse  incision  about  one-half  inch  above  the  clavicle,  the  skin 
is  then  sutured,  and  the  head  fixed  in  the  corrected  position  by  plaster-of- 
Paris  or  other  apparatus.  Mikulicz  removes  the  entire  muscle  as  far  as  the 
spinal  accessory  nerve. 

Cervical  rib  springs  from  the  anterior  transverse  process  of  the  seventh 
cervical  vertebra.  It  is  bilateral  in  about  two-thirds  of  the  cases;  rarely  a 
second  cervical  rib  may  arise  from  the  sixth  cervical  vertebra.  The  anterior 
extremity  is  usually  free,  but  it  may  unite  with  the  first  rib  or  with  even  the 
sternum.  The  brachial  plexus  and  subclavian  artery  pass  over  it,  and  with 
the  growth  of  the  rib  or  its  ossification  these  structures  are  compressed,  caus- 
ing pam,  weakness  of  the  arm,  trophic  troubles,  or  even  obliteration  of  the 
pulse  and  gangrene.  There  is  no  edema  of  the  arm,  because  the  subclavian 
vein  lies  in  front  of  the  middle  scalene  muscle  and  escapes  pressure.  The 
rib  forms  a  prominence  in  the  neck,  which  has  been  mistaken  for  aneur}^sm, 
because  it  pushes  the  subclavian  artery  forwards  and  upwards.  The  X-ray 
will  dispel  all  doubt.  If  there  are  pressure  symptoms,  the  rib  may  be  removed 
through  a  transverse  incision  after  separating  the  nerves  and  vessels. 

Cellulitis  of  the  neck  is  usually  secondar>^  to  infections  in  the  area 
drained  by  the  cervical  lymph  glands,  but  may  follow  also  cold,  injury,  and 
acute  infectious  fevers.  I'he  process  varies  greatly  according  to  its  situation, 
the  virulency  of  the  infection,  and  the  resistance  of  the  individual;  thus  it 
may  be  superficial  or  deep  (with  reference  to  the  cervical  fascia),  circum- 
scribed or  diffuse,  acute  or  chronic,  Superpdai  in(lammator>'  trt>ubles  of 
the  neck  differ  little  from  like  lesions  elsewhere  and  require  no  special  mention. 
Deep  cellulitis  or  abscess  is  often  of  the  gravest  nature,  because  of  the  danger 
of  extension  to  the  axilla,  mediastinum,  or  pleura,  or  rupture  into  the  trachea 
or  esophagus.  External  fluctuation  and  pi>inting  are  the  exception.  In 
addition  to  the  general  septic  symptoms  the  neck  is  swollen  and  hardened 
and  the  skin  red  and  edematous.  The  head  is  bent  towards  the  affected 
side,  and  there  may  be  dysphagia,  dyspnea,  and  symptoms  of  pressure  on 
the  vessels  or  nerves.  A  streptococcic  celliditis  of  the  subma.xillary  region 
is  called  angina  Ludovki.  A  chronic  form  of  cellulids  of  the  neck  with  little 
or  no  pain  and  fever,  and  presenting  a  board -like  inflammatory  hardness, 
has  been  described  by  Reel  us  untler  the  term  phligtnont  ligneusc  dit  cou^  or 
woody  phlegmon  of  the  neck,  .\fter  a  time  a  small  abscess  forms  and  healing 
ensues,  although  in  one  case  death  was  due  to  edema  of  the  glottis.  These 
rases  resemble  a  carcinomatous  infiltration  of  the  nee  k. 


382  EAR,   NECK,    THYROID   GLAND. 

The  treatment  in  acute  cases  is  prompt  incision,  never  waiting  for  fluctua- 
tion. An  abscess  may  be  opened  by  Hilton's  plan  (p.  72).  Tracheotomy 
is  sometimes  necessary.  The  constitutional  symptoms  of  sepsis  should  be 
combated. 

Cut  throat  may  be  homicidal  or  suicidal.  In  the  latter  the  wound  is 
usually  between  the  hyoid  bone  and  the  larynx  and  deepest  on  the  side 
opposite  to  the  hand  employed.  In  either  case,  however,  the  wound  varies 
both  as  to  depth  and  to  situation,  and  any  of  the  structures  of  the  neck  may  be 
involved.  The  effects  of  division  of  the  nerves  have  already  been  mentioned. 
The  diagnosis  of  a  wound  of  the  air  passages  is  easily  made.  Injury  to 
the  esophagus  is  much  less  common  and  may  be  accompanied  by  hematemesis, 
dysphagia,  and  the  escape  of  mucus  or  food  through  the  wound.  The  imme- 
diate dangers  are  shock,  hemorrhage,  air  embolism,  and  asphyxia  due  to 
blood  or  displaced  structures.  The  secondary  dangers  are  cellulitis,  sep- 
ticemia, pyemia,  edema  of  the  glottis,  secondary  hemorrhage,  inspiration 
pneumonia,  and  emphysema  of  the  cellular  tissues. 

The  treatment  is  arrest  of  hemorrhage,  even  the  smallest  bleeding  point 
being  attended  to,  because  of  the  danger  of  blood  trickling  into  the  air  passages; 
removal  of  clots  from  the  trachea;  saline  infusion  and  other  means  to  combat 
shock;  disinfection  of  the  wound;  and  suture  of  divided  nerves,  esophagus, 
trachea,  larynx,  and  muscles.  Drainage  should  be  employed  in  order  to  pro- 
vide a  vent  for  blood,  air,  or  esophageal  secretions.  In  an  extensive  trans- 
verse wound  of  the  trachea  the  sutures  almost  invariably  tear  out.  If  the 
larynx  has  been  opened,  safety  demands  the  performance  of  a  high  tracheot- 
omy, as  breathing  is  sure  to  be  obstructed.  The  neck  is  dressed  with  the 
head  flexed  on  the  chest,  and  the  patient  fed  per  rectum  or  through  a  tube 
in  the  esophagus,  if  that  structure  has  not  been  wounded. 

Among  the  sequelcp  may  be  mentioned  stenosis  of  the  larynx,  esophagus, 
or  trachea  (p.  397);  esophageal  fistula,  which  usually  closes  after  a.  time; 
aerial  fistula,  which  if  persistent  may  be  closed  by  freshening  and  suturing  the 
opening  in  the  air  passages,  care  l)eing  taken  first  to  make  sure  that  there  is 
no  stenosis  above;  and  lesions  which  may  follow  division  of  nerves,  e.g., 
aphonia  from  a  severed  recurrent  laryngeal  nerve. 


THE  THYROID  GLAND. 

The  parathyroid  glands  are  four  in  number.  They  are  brownish  red, 
oval  bodies,  about  one-fourth  inch  in  length,  lying  upon  the  posterior  surface 
of  the  capsule  of  the  thyroid  gland,  one  near  the  pole  of  each  lobe.  Each 
parathyroid  has  a  terminal  artery,  usually  derived  from  the  anastomotic 
branch  between  the  superior  and  inferior  thyroid  arteries.  A  knowledge  of 
the  existence  and  situation  of  these  bodies  is  of  great  importance  to  the  sur- 
geon, as  their  destruction  results  in  tetany,  severe  and  fatal  if  none  is  left, 
milder  if  one  or  two  remain.  The  symptoms  of  this  tetany  par  atliyreopriva,  as 
it  is  called,  are  those  of  other  forms  of  tetany,  for  which  the  student  is  referred 
to  a  text-book  on  medicine.  The  treatment  is  administration  of  parathyroid 
extrait  or  serum,  and  calcium  lactate,  in  a  5  per  cent,  solution,  by  mouth, 
rectum,  or  intravenously;  transplantation  of  j)aralhyroids  from  animals  also 
has  been  tried. 

Wounds  of  the  thyroid  cause  severe  bleeding,  which  may  be  checked  by 


TUMORS   OF   Tire    TllYROin    GIANT>. 


383 


sutures  or  by  gauze  packing.     In  some  cases  il  may  be  necessary  to  extirpate 
the  gland. 

Accessory  thyroids  may  be  found  about  the  thyroid  gland*  in  the  upper 
porliun  of  the  chest,  or  along  the  course  of  a  thyroglossal  duct  (p.  370)  as  far 
as  the  base  of  the  tongue  (lingual  goiter).  If  increasing  in  size  or  causing 
pressure  symptoms,  medical  treatment  as  described  below  may  be  tried  for  a 
time,  but  will  usually  faiL  and  then  extirpation  should  be  performed,  first 
making  sure  that  the  normal  thyroid  is  present,  as  the  accessory  gland  may 
be  the  only  one  the  patient  has  and  its  removal  would  then  be  fallowed  by 
myxedema.  The  presence  of  an  accessory  thyroid  explains  the  absence  of 
myxedema  in  some  cases  of  complete  thyroidectomy.  The  occurrence  of  a 
nonint^ammatory  tumor  along  the  course  of  the  thyroglossal  duct,  particu* 
larly  in  a  woman,  should  always  make  ojie  think  of  the  possibility  of  an 
accessory  thyroi<L 

Absence  or  dericiemy  of  the  internal  secretiun,  the  result  of  atrophy  or 
absence  of  the  thyroidj  causes  a  peculiar  group  of  symptoms,  which  is  called 
crdinism  when  developing  soon  after  birth,  myxedema  when  occurring  in 
adults,  and  caificxia  strumipriva  when  following  extirpation  of  the  gland. 
The  essential  features  of  these  conditions  are  a  non-pitting  edema  of  the  sub- 
cutaneous tissues,  due  to  infiltration  with  a  mucindike  substance  (myxedema), 
pallor  and  dryness  of  the  skin,  loss  of  hair,  and  in  children  dwarfing  of  the 
body  and  idiocy,  and  in  adults  marketi  impairment  of  the  intellectual  facul- 
ties and  loss  of  sexual  power.  The  treaimeni  is  thyroid  extract,  one  grain 
three  times  a  day,  gradually  increased  to  10  or  more  grains,  watching  (or 
s y m  |> t o m s  of  t  h y ro  1  d  i  s m ,  i . e . ,  t a c  h y ca  rd ia ,  n er\'o us n es s ,  d el  i  ri  u m ,  et  c .  \\  h en 
cure  has  been  effected,  it  will  usually  be  necessary  to  administer  small  doses, 
perhaps  for  the  rest  of  the  palienTs  life. 

Congestion  of  the  thyroid,  evidenced  by  slight  enlargement,  may  l>e 
due  to  cardiac  disease,  obstruction  to  the  veins  in  the  mediastinum,  anemia, 
overexertion,  or  emotion;  in  women  il  may  occur  at  puberty,  or  during  preg- 
nancy or  menstruation.     No  surgical  treatment  is  required. 

Thyroiditis  is  usually  a  complitation  of  one  of  the  acute  infectious  dis- 
eases,  but  may  f<»llow  also  injury.  In  adtlition  to  the  ordinary  signs  of  inflam- 
mation there  may  be  pressure  symptoms  much  like  those  whit  h  octur  in 
orflinary  goiter.  Inflammation  of  a  goiter  is  called  strumitis.  The  treat- 
ment is  that  of  inllammatton  elsewhere,  inclutiing  indsion  should  suppura- 
tion occur.  Tracheotomy,  preceded  by  <ii vision  of  the  isthmus  or  in  some 
cases  extirpation  of  the  organ,  may  he  required  if  l>reathing  is  seriously 
embarrassed. 

Tuberculosis,  gummata,  actinomycosis,  and  hydatid  cysts  a  re  treated 
as  are  such  conditiuns  elsewhere. 

Tumors  of  the  thyroid  are  sometimes  tailed  malignant  goittrs,  and 
indeed  it  is  often  difficult  to  make  a  sharp  distinction  between  certain  goiters 
and  some  neijplasms.  An  adenoma  theoretically  is  distinguished  from  an 
adenomatous  goiter  l^y  its  typical  microscopic  picture,  and  by  the  fat  t  that 
the  lumor  is  circumscril>ed  and  separated  from  the  healthy  glan*!  tissue.  It, 
however,  together  with  carcinoma  and  sarcoma  (l*ig.  274),  may  give  rise  to 
metastases,  hence  all  tumors  of  the  thyroid  gland  should  he  regarded  as  ma- 
lignant and  be  extirpated  at  the  earliest  ptissible  mt^ment.  They  usually 
develop  after  forty,  often  from  a  simjile  guiier,  are  lianl,  fixed,  and  irregular 
in  contour;  gnjw   rapidly,  quickly  pnitKk  e   pressure  symptoms,  and  (vften 


3«4 


EAR,    XECK,   THYROID   GLAND. 


come  under  ol)servatioii  only  when  they  have  invaded  the  surrounding  tissae^ 
and  are  inoperable.  If  the  entire  gland  is  removed,  the  patient  should  be 
fed  on  thyroid  extract  subsecjuent  to  operation. 

Goiter,  struma,  or  bronchocele  is  a  hyperplasia  of  the  thyroid  ^and 
not  of  infectious  or  neoplastic  origin.  The  disease  may  involve  any  pan  or 
all  of  the  ghuui,  but  is  most  common  in  the  right  lobe,  and  occurs  more 
frequently  in  females,  usually  after  the  tenth  year.  The  cause  is  not  known. 
The  theory  that  it  is  due  to  magnesium  or  calcium  salts  or  some  other  sub- 
stance   in    the    drinking  water 


probably  has  the  most  advo- 
cates. It  occurs  sporadically  in 
all  parts  of  the  world,  and  is 
endemic  in  Central  Asia,  Switz- 
erland and  the  contiguous  por- 
tions of  France,  Italy,  Austria, 
and  Germany;  in  England  it 
has  been  called  Derbyshire  neck 
owing  to  its  prevalence  in  that 
locality;  in  this  country  it  is  most 
common  in  certain  parts  of 
Michigan  and  in  the  mountain- 
ous regions  of  Pennsylvania. 

The  varieties  of  goiter  are: 
I .  The  parendtymaious,  in  which 
the  whole  gland  is  involved, 
although  one  lobe  may  be  larger 
than  the  other.  The  swelling  is 
soft,  clastic,  and  painless.  Allien 
tluTc  is  an  excessive  develop- 
ment of  the  stroma,  the  gland  is 
Iianlcr  and  perhaps  lobulated 
[fibrous  goiter);  when  the  con- 
lu'i  live  tissue  is  small  in  amount 
and  the  acini  are  distended  with 
(olloid  material,  the  gland  is 
softer  { follicular  or  colloid  goiter), 
J.  (  \'stii  i^oitrr  is  clue  to  the  lontlueme  i)f  the  ai  ini.  The  cysts  may  be  single 
or  nuilliple,  vary  f^really  in  size,  and  (ontain  a  colloid  or  serous  material, 
wln'(  h  mav  he  hrown  or  black  from  the  presence  o\  altered  blood.  Intracys- 
lic  papilloniata  are  sometimes  foun<i.  7,.  Ailniomatous  goiter  (Fig.  2 y ^)  re- 
semhles  an  adenoma  in  st rue  lure;  it  may  develop  in  one  portion  of  a  normal 
gland  and  sul)se<|uenily  involve  the  whole  thyroid,  or  it  may  be  a  secondare* 
( liange  in  a  parenc  hymatous  goiter,  and  not  infre<|uenlly  it  is  followed  by  the 
formation  of  cysts.  A  sharp  distinction  cannot  be  made  between  adenoma- 
tous goiter  and  adenoma  of  the  thyroi<i.  4.  I  \iscular  goiter  is  most  commonly 
seen  in  (Jraves'  <lisease,  which  is  dcscrii)cd  un<ler  a  separate  heading.  The 
bulk  of  the  mass  is  made  up  of  dilated  blood  vessels,  so  that  pulsation,  thrill, 
and  bruit  may  be  detected.  In  any  of  these  varieties  certain  secondary 
changes  may  o»  <  ur,  e.g.,  inflammation,  abscess,  hemorrhage  into  the  gland, 
cab  ification.  or  malignant  disease. 

'I'he  symptoms  are  (i)  the  presence  of  a  tumor,  (2)  eviflencesof  pressure. 


J 


lI-.-l-iMlJ 


t»!"    I  he    tliyrnid    Ljl.inil 
Niilr  i-nlariji-il  vi-iiw. 


GOITER. 


.?85 


and  (3)  signs  of  excess  or  defidency  of  the  thjToid  seLredun*  i.  The  tumor 
is  horseshoe-shaped  or  oval,  varies  greatly  in  size,  sometimes  being  as  large 
as  a  man*s  head,  develops  insidiously,  rises  and  falls  during  swallowing,  is 
painless,  and,  exrepting  the  trachea,  is  not  adherent  to  the  surrounding 
tissues.  1 11  darned,  malignant,  and  very  large  goiters,  however,  may  not 
move  with  deglutition,  and  other  remail  swellings,  e.g.,  thyroglossal  cysts, 
subhyoid  bursie,  and  abscesses,  lymph  glands,  and  malignant  growths  that 
are  adherent  to  the  larynx,  trachea,  or  esophagus,  may  move  with  degluti- 
tion,  2,  The  pressure  symptoms  depend  upon  the  situation  of  the  growth, 
thus  a  retrosternal  goiter  quickly  produces  symptoms,  and^^ey  may  be 
absent  in  even  the  largest  goiters.  The  larynx  and  trachea  may  be  pushed 
from  the  mirldle  line,  or  the  latter  may  be  flattened  from  sifle  to  side, 
causing  dyspnea  and  cough  if  both  lolies  are  equally  enlarged.  Pressure 
on  the  esophagus  causes  dysphagia;  on  the  vessels  of  the  neck  headache, 
flushing  of  the  face,  and  epis 
taxis;  on  the  recurrent  laryngeal 
nerve  alteration  in  the  voice  or, 
if  both  are  involved,  bilateral 
paralysis  of  the  muscles  of  the 
larynx  and  death:  on  the  pneu- 
mogastric  alteration  of  the 
heart's  action;  and  on  the  sym 
pathetic  dilatation  of  the  pupil, 
etc.  (p,  234).  3.  Signs  of  txcess 
or  deficiency  of  iJie  thyroid  sftre^ 
Hon  also  may  be  encountered; 
the  former  are  given  under  ex- 
ophthalmic goiter»  the  latter 
under  absence  of  the  thyroid. 

The  treatment  in  the  early 
stages  may  be  medical,  nz,,  iodid 
of  potassium  internally,  ami  red  oxid  of  mercury  ointment  or  iodin  locally. 
Thyroid  extract  is  of  value,  particularly  if  there  are  any  sigiis  of  myxedema. 
Electrolysis  and  the  X-ray  have  temporarily  heiietlted  a  few  cases.  Medit  al 
treatment  is  of  most  value  in  parenchymatous  goiter.  If  the  goiter  increases 
in  size  or  there  are  pressure  symptt*ms,  uperalion  is  indicated.  Ligation  of 
the  thyroid  arteries,  and  exothyreopexy,  be.,  drawing  the  thyroid  into  a  wound 
in  the  neck  so  that  it  may  atrophy,  have  been  employed,  while  as  a  palliative 
or  emergency  operation  in  cases  of  severe  dyspnea,  the  riblmn  musrlcs  of  the 
neck  or  the  isthmus  of  the  gland  have  been  divided.  The  usual  operations 
are  intra  glandular  enuckalioit,  which  is  indicated  in  a  localized  adenoma  or 
a  single  cyst,  or  in  a  small  collection  of  cysts,  and  partial  excision,  or 
Utyroidectomy^  which  is  indicated  in  all  other  varieties,  care  being  taken 
to  leave  at  least  one-fourth  of  the  gland  in  order  to  prevent  myxedema. 
Local  anesthesia  is  strongly  recommended  by  many  surgeons,  in  order  to 
prevent  the  congestion  of  the  neck  incident  to  ether  and  chloroform »  to 
avoid  postoperative  vomiting,  which  may  start  bleeding,  and  in  order  to 
have  the  patient  speak  during  the  operation,  so  that  the  surgeon  may  know 
when  he  is  in  the  vicinity  of  the  ret  urrent  laryngeal  nerve. 

Intragiandular  enucleation  is  performed  by  exposing  the  gland  by  a 
transverse  or  oblique  incision,  incising  the  gland  down  lo  the  tumor,  and  shell- 


Fig,   275, — Afk'nt>rnittous  ^oilcr, 
(Pennsylvania  Mospiuil . ) 


i 


366  EAR.   NECK.   THYEOn)  GLAND. 

ir.:£  out  \h*:  tumor  Ahh  the  fingers  or  a  dirertor;  the  wound  is  then  qnkklT 
p'4,f  i:*-A  v. i:h  i^auzt  ^x:f  ause  of  the  free  bleeding,  and  as  the  gauze  is  graduaHj 
r'rmovt'J.  the  bieedirijf  points  are  ligated  or  siurounded  by  sutures.  The 
'^ivity  i-  f\tj:^:f\  by  ratgut  sutures  and  the  skin  appioximated.  leaving  spict 
;or  a  ;;auze  'irain  for  tA*eniy-four  hour?. 

Partial  thyroidectomy  usually  means  removal  of  one  lobe.    A  currcd 
t  ran -verse  in'  i.*ion.  with  the  concanty  upwards,  is  made  over  the  tumor  from 
the  outer  UipJer  of  one  stemoraastoid  to  be^-ond  the  middle  line,  the  skin  and 
platy-ma  rjividerl,  the  nblxjn  muscles  separated  in  the  median  line  or  divided 
transversely,  and  the  fibrous  capsule  opened.     .\11  bleeding  is  checked,  the 
\t,\,t:  4\\A<n  ated  from  its  ribrous  envelope,  the  superior  thyroid  vessds  divided 
1/eiv.een  f.vo  lijratures.  and  the  inferior  thvToid  vessels  tied  close  to  the  gland 
in  order  to  avoid  the  re*  urrent  laryngeal  ner>e.     The  thyroidea  ima  if  present 
airo  is  tied.     The  parathyroid>  are  avuided  by  t^ing  ail  vess^  close  to  the 
'  ap-ijje,  or.  as  •uj;:re^ied  liy  Mayo.  Iea\ing  that  portion  which  covers  thepos- 
t*rior  -una'  e  of  the  jjland.     The  isthmus  of  the  gland  is  crushed  with  strong 
fonep-  and  li;faled  in  sections,  or  it  may  Ije  divided  and  the  Ueeding con- 
trolled by  -uiure-i.     Any  aiiat  hments  to  the  cricoid  are  separated,  or  perhaps 
better,  a  thin  -li«  e  of  the  ^land  \<  left  in  place  in  this  situation  to  avoid  injuiy 
to  the  re'  urrent  laryngeal  nerve.     The  wound  is  irrigated  with  salt  scriution. 
and  'I'ise'l  after  -uiuring  the  divided  muscles,  a  small  space  being  left  for 
g.iu/e  'J  rain  age  f'^r  tweniy-four  hours.     The  normal  anatomy  is  necessanlr 
'li-TijrIied  jr,  large  grov.ths:  lhu>  the  jugular  vein,  which  has  branches  coming 
fr'/jTi  thf;  tumor,  m'ive<  i'»r.var(l  with  the  growth,  while  the  arteiy,  which 
h;i-  u*}  -ij' h  rfonne'.tion-.  is  pushed  l^ackward  and  outwards  and  may  lie 
exl'r.'i.'jl   t'/  the   vein.     The  tracheal   rings  may  be  absorbed  or  softened, 
h':fi"-  rrj'/f  easily  injured :  in  -ome  <  ases  the  trachea  collapses  as  soon  as  the 
-•'\\t\tun  of  tfie  ium'»r  is  removed,  the  patient  dWng  of  asphyxia  unless  a  lul)C 
i    \'.i  '  r!'fi.     -u'l'l'-n  'j«;iith  may  o«  cur  also  from  reflex  inhibition  of  the  heart, 
f}:«-    t.'.tij-  !yjrjiili;iti'  U-.  'ir  from  the  absorption  of  thyroid  secretion  from  the 
■o.jj.')     I;.  oih'T  •  a-'--  thyr'iio  intoxiv.ati<.»n  will  cause  high  fever,  rapid  pulse. 
.ii.'i  <\y  \,\:*-.\  -ijl^-'-^jii'-utly  Vt  operation.    If  io<.)  much  of  the  gland  is  removed. 
ff.;.  ■•.'-'I'-rna  may  f'iliov.-:  ii:i'!  if  the  parathyroi'ls  are  excised  tetany  develops. 
li'/'  [j't'-  moriality  in  over  ^ooo  ( ases  is  less  than  i  per  cent. 

Exophthalmic  goiter  ((iniirs'  (lipase.  Ba<oiira.'*s  disease)  is  probably 
'li':  io  j":.' fa-iMl  al^-'iFpli'in  of  ihyroiri  se»reiion.  Ninety  per  cent,  of  the 
•  a  .'■  an  J'  fiial*-.  grnerally  liolween  the  ages  of  fifteen  and  thirty.  It  may 
folio  .V  «  ■.  'pr  (fmoti'>nal  j>torms  or  ordinary  goiter,  and  sometimes  terminates 
ifi  rnyv'-'i'-rna.  Ijilargemeni  of  the  thymus  is  f«)und  in  many  cases.  The 
'  anlirial  .  w/jIow.  an-  the  presem  e  of  a  goiter,  which  is  usually  of  the  vascular 
vari'ty.  Ij«ii'  «•  j>iil-ati'>n.  thrill,  and  bruit  are  (ommcmly  foimd;  exopfitftalmos 
f'lu'-  u,  iiH  n-a-«'  'A  the  orliital  fat),  causing  a  widening  of  the  palpebral  fissure 
f  Mill.'.ag'-  M'gn;  an'l  retanlation  ')f  the  movement  of  the  upper  lid  when  the 
<y«l>all  i-  r'>tated  'lownwanls  (von  Graefe's  sign):  /aWnrar<f fa,  often  with 
|ial|;itati';n  and  dy.^pnea;  and  a  line  tremor.  Many  other  symptoms  referable 
t'l  ill'-  n'Tvou^  .sy.-t<.-m,the  gastn)intestinal  tract,  orthe anemia,  are  described. 
Ko' li'-r  -ay-^  there  is  leuk<)i)enia,  particularly  of  the  polymorphonuclears, 
ari'i  IvMiplio*  yt'^si-i. 

'I  \\r  tniitmrjit  in  the  lu'ginning  is  medical.  Absolute  rest,  cardiac  sinla- 
live-,  an  i' e  bag  to  the  heart,  ergot,  bellacliinna,  and  phosphate  of  soda,  are 
re«  oMimen'Icd.     IClei  trolysis  and  the  X-rays  have  been  employed.     Recently 


DEFORMITIES  OF  THE   NOSE. 


387 


encouraging  results  have  been  obtained  with  a  serum  obtained  fronx  animals 
injected  with  increasing  doses  of  human  thyroid  extract.  Iodides  and 
thyroid  extract  are  coiitraindicated,  but  extract  of  the  thymus  or  suprarenals 
is  said  la  be  beneficial.  As  soon  as  medical  treatment  has  failed,  i.  e.,  after  a 
few  months^  operation  should  be  proposed  Ijefore  the  condition  of  the  patient 
has  markedly  deteriorated.  Partial  thyroidtrtomy  is  the  operation  of  choice. 
The  average  results  are  "71  per  cent,  cured;  9.6  per  cent,  improved;  6.4  per 
cent,  unimproved,  failures,  lost  sight  of,  or  partly  benefited;  and  12.6  percent, 
died"  (Hartley).  The  dangers  have  been  mentioned  under  partial  thy- 
roidectomy. Improvement  is  immediate,  but  the  exophthalmos  may  persist 
for  months,  and  recurrences  have  been  noticed  in  a  few  instances.  BUaieral 
resection  of  the  cervkal  sympathetic  ganglia  gives  less  favorable  statistics,  but 
may  be  indicated  in  Graves^  disease  vvithout  goiter,  or  possil>ly  in  cases  in 
which  the  ophthalmic  symptoms  predominate.  The  other  operations  men- 
tioned under  the  treatment  of  goiter  also  have  been  employed  for  Graves^ 
disease. 

Enlargentent  of  the  thymus  gland  has  been  referred  to  above  and  also 
in  discussing  the  status  iymphaticus  ((j,v.). 

The  carotid  gland  or  body,  when  present,  is  attached  to  the  carotid 
sheath  at  or  near  the  bifurcation  of  the  artery.  It  is  about  the  size  of  a  grain  of 
corn  and  is  composed  chiefly  of  endothelial  cells.  Its  nature  is  unknown. 
Keen  (1906)  has  collected  twenty- seven  endotheliomata  arising  from  this 
gland.  These  ''potato  tumors  of  the  neck*'  are  located  at  the  bifurcation  of 
the  carotid  under  the  sternomastoid,  are  slightly  movable  transversely  but 
not  vertically*  transmit  pulsation,  thrill,  and  bruit  from  the  carotid  artery, 
and  often  exist  for  a  number  of  years  before  taking  on  malignant  features* 
They  should  be  e.xtirpated,  an  operation  which  will  sometimes  necessitate 
excision  of  the  carotid  artery. 


CHAPTER  XXIV. 
RESPIRATORY  SYSTEM: 


THE  NOSE. 

Rhinoscleroma  is  an  infectious  disease  in  which  a  number  of  hard  swell- 
ings appear  on  and  about  the  nose.     It  should  be  excised  in  the  early  stages, 

Rhinophyma  is  a  hypertrophic  form  of  acne  rosacea  in  which  red  greasy 
masses  form  on  the  lower  end  of  the  nose,  producing  a  deformity  which  has 
been  called  hammer  nose  (Fig.  276).  It  may  be  treated  by  excision  with  sub- 
sequent skin  grafting. 

Deformities  of  the  nose  may  be  congenital,  or  result  from  injury,  de- 
structive diseases,  or  operations,  e.g.,  for  the  removal  of  malignant  disease. 
All  operative  efforts  to  rebuild  a  deformed  nose  are  includeil  under  the  term 
rhinoplasty,  whit  h  may  be  f>artial  or  complete,  according  to   its  extent. 

Deformity  i>f  the  Roman  nose  type  is  corrected  by  making  a  small  Icmgi- 
tudinal  incision  in  ihc  middle  line  uf  the  nose,  and  removing  the  redundant 
tissue  with  a  chisel,  if  bune,  or  a  knife,  if  cartilage.  The  wound  is  then  su* 
tured.     Expansion   of  the   bridge,  or  frog  nose,  is  commonly  caused  by 


I 


RESPOUlTOttT  SlSnOL 


btruiaial  growths,  and  the  tfeatmcm  is  < 
OOft  b  trea^  by  removing  a  wtd^^-AMptd  i 
Cltfti  of  the  nose  are  remedved  bjr 

Flj?!!.  ?77  and  278  illustrate  Lanj?rabeck*s  opmtioa  fbra  1 


FlO.  276. — Rhinophytna,  treated  by  cxcisicm. 

mmc.  FIk.  a7r>  illu^itratcft  Wlaion's,  the  raw  surface  left  by  ilie  tmnspositioa 
of  ihf  »lup  bdii^  uncrcfl  with  a  Thiersch  skin  graft.  Figs.  28a  to  283  abo 
lllu»triftlf  thr  repiiir  i*f  a  lateral  defect.  Figs.  284  to  289  iUu&trate  inetbo«l5<rf 
triiiMry*  lln«  a  columna  nasi.  Saddle  nose  may  be  caused  by  injurv,  but 
In  mttni  lrn|yriuly  tlu'  rvsuk  of  byphililk  ukcratfon  of  the  septum.     Various 


Fm.  377.  Fig.  278  Fic    ijg 

Vtc»    ijj  \o  3jg. — 0{M*rations  for  cleft  nose,     (Esninnh  and  Kowmlxig,) 


morr  HF  h  s.  unsatii^fat  tory  prcHcdyrcs  have  been  devised  for  this  deformity, 
Arlir»cial  fpri'l^^cs  of  lelluloicl,  rubber,  silver,  gold,  etc .,  have  been  inserted 
beneath  the  skin  ihrou^'h  an  external  incision  or  from  within  the  nose.  In 
^41  me  iiiM*%  the  nujiul  hones  have  been  broken  or  chiseled  from  their  attach- 


DEFORMTTTKS    OF    THE    NOSE. 


389 


meiUs,  and  lieUl  in  an  elevaletl  position  by  a  speitade  clip,  or  by  pin.s  iuserteil 
beneath  them.  A  transverse  incision  may  be  made  across  the  sunken 
part  of  the  nose,  thus  allowing  the  tip  to  be  pulled  down.  The  resulting  gap 
is  closed  by  a  flap  turned  inward  from  each  cheek,  the  skin  surface  facing 
the  nasal  cavity,  A  llap  from  the  forehead  is  brought  down  to  cover  the  raw 
surfaces  of  the  cheek  tlaps,  and  the  wounds  in  the  forehead  and  cheeks 
sutured.     The  subcutaneous  injection  of  sterile  paraffin  has  been  used  with 


Fig,  280,  Fxa,  j8i.  Fig.  282.  Fig.  283. 

Figs*   280  to  283. — OperaLjon?*  for  lateral  defect  of  the  ntjse.      (Esmarrb  ami  Kowalzig.) 


^^ 

KiG.  284.  Fig.  285.  Fro.  286. 

Fics,  284  to  286. — Methods  of  coa^tructing  the  colurana  nasi.    (Esmarth  arid  KowaUigj 


/- 

Fig.  287.  1  Ki.  j88.  Fig.  289. 

Figs*  387  to  289.— Methods  of  constructing  the  columna  nasi.    (Esmarch  and  Kowalzi^.) 

some  success  in  this  deformity.  The  skin  of  the  nose  should  be  loose,  and 
the  melting  point  of  the  paraffin  (mixed  with  liquid  paraffin  or  vaselin)  above 
115°  F.  The  paraffin  is  melted,  injected  by  a  screw  piston  syringe  in  a 
semi-solid  state,  and  molded  with  the  fingers.  The  complications  are 
abscess,  glazing  and  thickening  of  skin,  diffusion,  and  emboh'sm. 

Absence  of  the  nose  is  rarely  congenital;  it  may  result  from  traumatism, 
but  is  most  frequently  due  to  disease,  e.g.,  syphilis,  lupus,  and  malignant 


iri 


.^QO 


RESPIBATOtY  STSTElf. 


I 


}<n)wths.  Vanous  methocU  of  complete  rhinoplasty  ha%e  hem  used  wili 
more  or  less  sittii^fat  lion.  When  an  operation  for  the  reprrKiUi-ljoo  of  tk 
no?*e  is  tieemetl  inadvisable,  an  artifidal  nose  held  in  plare  hy  spcctack  no» 
may  be  worn.  The  Indian  matiiod  for  complete  rhinoplasty  (Figs,  tf^  jqi) 
I  (insists  in  supplying  the  defect  by  a  flap  from  the  foreheaij.     A  modd  of  tlie 


Hi-^ 


Fros 


ago  and  ac>i. — Indian  method  of  rhinoplasty 


Fig.  291, 

(Esmarch  And  Ki.u  tli-U  1 


Fl«-  29a, — Imlian  meiHij<l  of  rHiitr>|)lasly. 
(Monod  unfi  Vsinvert^i.) 


Fig.   393. — French  meihod  of  rhifiQf|iljistv. 
(Monoci  and  Van  verts.) 


flap  i>  llrst  cut  out  of  oiled  silk.  The  end  of  the  flap  is  so  shaped  as  to  fornix 
when  folded,  the  ake  and  the  septum  of  the  nose,  the  nasal  openings  being 
maintained  by  rubber  tubes.  When  the  osseous  framework  of  the  nose  has 
been  destroyed,  this  methrul  may  be  modified  by  including  in  the  forehead  flap 
the  outer  table  of  the  skull.     In  the  Italian  mtlhod  the  tlap  is  taken  from  ihc 


KPISTAXTS. 


391 


artn  (Fig.  2^2),  which  must  t>e  Hxcd  Ijv  a  suHalile  apparatus  until  union  has 


(I;  the  no* licit 


tht 


ilivideil, 


(I  the  ala 


d  septum  U) 


■il  from 


occur  re 

ihe  lower  portion  of  the  tiap.  In  the  Fremh  method  (rig.  293)  the  llaf>s  ure 
formed  from  the  checks.  Several  sutcessful  attempts  have  been  made  to 
replace  the  bony  framework  of  the  nose  hy  suturing  the  freshened  end  of  a 
finger  into  the  upper  angle  of  the  nasal  defect,  and  when  union  has  occurred, 
amputating  the  finger. 

Crooked  nose  may  be  congenital  or  traumatic,  and  is  usually  associated 
with  tlexion  of  the  septum,  the  correction  of  which  may  straighten  the  nose. 
When  the  nasal  hones  themselves  are  deformed*  they  may  be  molded  into 
sh^pe  after  separating  their  attachments  with  a  chisel,  through  a  small  inci- 
sion at  the  root  of  the  nose. 

Deviation  of  the  septum  may  be  caused  by  injury  or  be  the  result  of 
defective  development.  The  dellection  may  be  vertical,  horizontab  or 
oblique,  liowed  or  angular,  and  the  septum  may  or  may  not  be  thickened. 
A  sigmoi<l  deviation  is  a  double  curve,  one  projecting  into  each  nostril.  The 
cartilaginous  septum  is  the  piirtion  usually  involved.  The  condition  is  very 
common,  but  in  the  sh'ghter  forms  gives  no  trouf>le-  In  more  marked  cases 
there  may  lie  stenosis  of  one  nostrib  and  various  re  Hex  troubles,  such  as  are 
to  be  mentioned  under  p^jlyps.  In  the  presence  of  direct  or  retlex  troubles 
treatment  will  be  re(|mretL  When  there  is  marked  thickening,  or  the 
development  of  cartilaginous  or  Imny  spurs  of  the  septum,  these  should  be 
removed  with  knife  or  saw ,  and  perhaps  no  further  treatment  will  be  needed. 
Warping  of  the  cartilage  itself  is  torrectefl  hy  incisions  along  the  lines  of 
deviation,  in  order  to  lessen  the  resiliency  of  the  septum.  These  incisions 
may  be  made  by  introducing  a  sharp  knife  f)eneath  the  mucous  membrane,  or 
by  special  knives  or  punches,  after  which  it  may  be  possilile  to  correct  the 
deformity  with  the  fingers.  In  other  cases  septal  forceps  are  introcluced,  one 
blade  in  each  nostril,  and  the  cartilage  broken  from  its  attachments  and 
straightened.  It  is  held  in  a  corrected  position  by  nasal  tamfnins  of  gauze,  or 
by  rubber  or  metal  splints.  The  tampons  are  removed  aucl  the  nose  cleansed 
daily  until  union  has  occurred.  Roberts  uses  long  pins  such  as  have  l^een 
descril>ed  under  fracture  of  the  nose. 

Epistaxis,  or  bleeding  from  the  nose,  may  be  traumatic,  e,g.j  from  blow^s, 
fracture  of  the  skull,  picking  the  nose,  foreign  bodies,  etc.,  or  it  may  be  spon- 
taneous, e.g.,  from  plethora,  ulcers,  tumors,  rarefied  air,  vicarious  menstrua- 
tion, varicose  veins,  cardiac  or  pulmonary  disease,  acute  diseases  (notal)ly 
typhoid),  aofl  diseases  in  which  there  is  a  tendency  to  hemorrhage  (hemo- 
philia, scurvy,  purpura,  etc.). 

The  treatment  is  removal  of  the  cause  if  possible.  When  depending  uptm 
an  intracranial  congestion  epistaxis  may  be  benetkial,  and  should  be  stop[»ed 
only  when  it  becomes  excessive.  The  head  should  l»e  elevated,  constric- 
tions alnrnt  the  neck  and  chest  removed,  and  blowing  the  nose  forbidden. 
Compression  of  the  nostrils  will  check  the  lileeding  if  it  l>e  well  forward. 
When  further  back,  the  bleeding  point  may  be  detected  with  the  speculum 
and  head  mirror,  and  touched  with  the  galvanocautery,  or  a  swab  soaked 
in  chromic  aci<l  solution.  Sprays  or  douches  of  ice  w^ater,  adrenalin  solution* 
or  antipyrin,  5-10  per  cent.,  are  sometimes  efficient  and  do  not  possess  the 
disagreeable  features  of  other  styptics.  In  serious  cases,  however,  the 
nostrils  should  be  at  once  plugged  with  gauze  moistened  with  adrenalin.  If 
the  bleeding  comes  from  the  anterior  portion  of  the  nasal  passages,  it  may 


y;2 


RESPIRATORY  SYSTEM. 


I'«- '  'ifitroll«rfl  l>y  par  king  thmugh  the  anterior  nares.  In  otbrrcjaesiEvflbe 
iittf'^.nry  to  jilug  the  fKjsterior  nares  in  additioii.  A  soft  cathrtrr  wiAa 
\nuy,  |;i(:M:  nf  ^j'lk  fiassed  thrrjugh  the  eye  is  pushed  aka^  the  floor  of  die  bok 
urifil  it  Ti.iif\u'.s  the  pharynx,  when  the  silk  is  gasped  widi  IdicsqB  aad  tk 
'ath'!t«rr  v.ithfjrawn,  so  that  the  silk  passes  in  thioagii  die  nose  and  M 
throij^^h  thf:  mouth.  Several  pieces  of  gauze,  gndnaDy  incmsiiig  in  siae^ 
:irf'  f.i  ti'firrj  to  the  mi'ldle  of  the  silk,  which  is  then  «limvii  out  duoo^tk 
no  I'  while  the  hnger  guides  the  tampons  up  behind  die  soft  palate  Tht 
I  fi'l .  of  th<-  -ilk  are  nr>w  tied  together  and  the  anterior  nostzOs  plngj^ed.  Ate 
:i  d;iy  or  t.vo  the  fiosterior  park  may  be  removed  by  «liawiii^  dovnwaid  oa 
iUf  •Anil'/  through  the  mr>uth,  and  the  nostrils  sprayed  widi  a  mild  andsep- 
U'  oliiiion.  I'i^/.  :^fy,i  show.>  a  He]  locq  cannula,  which  may  be  nsed  to  pass  the 
ill  throii^di  thf*  nosr.     An  easy  and  sometimes  efficient  medKMl  for  making 


i  I' 


■'i\ 
■  i,i.  I. 


I    I..        I',.    II'M'I 
III'  ll.       I    .    |l.l 

MI'.iili  ) 


■iiMinl.i.      \  « iirw  I'.iird  wai<  h  spring  \%nih  a  ring  at  the  end, 
I  f|   i    Mi.i'li-  1.1 1  iirl  fnrw.ird  into  the  mouth  after  the  cannula 


|iii  III'-  v.  it  hill  I  hi-  no  .tiil  is  i<>  fasten  a  condom  over  a  rubber  catheter,  and 
■A  |j<  n  ihi    liii    l»«<n  in  rrfrcj,  to  inllate  the  condom  and  tie  the  catheter. 

Foreign  bodies  in  the  nose  arc  most  fre([uent  in  children,  in  whom  a 
iiniLit'i^d  j>iiiul«nl  di..«  \\:\r^r  should  always  suggest  such  accident.  Among 
olhri  vnipioni .  ;irc  p;iin,  (  pistaxis,  and  stenosis.  Removal  may  be  effected 
l»y  f'MMji.,  hool..  loop,  or  snare.  The  forcible  injection  of  water  into  the 
o|»po.ilr  no.liil  i.  not  m  oniincnded.  An  incrustation  of  salts  about  a  foreign 
|,odv  or  jiaiti*  h-  of  inu(  us  is  (  ailed  a  rhinolith,  the  symptoms  and  treatment  of 
whi«  ll  an-  nnn  h  like  those  of  fori-ign  body.  Parasites,  e.g.,  maggots,  may  be 
rcniov<Ml  from  thf  nasal  cavity  by  douching  with  efiual  parts  of  chloroform 
and  water. 

Tumors  of  the  nasal  cavities  inclu<le  many  diiTerent  forms,  both  benign 
and  malignant,  but  a  sufliciently  clear  idea  of  their  behavior  and  treatment 
may  !»<•  obtained  from  a  short  description  of  the  two  common  varieties,  \nz., 
mucous  an<l  fibrous  iK)lypi. 


ADENOIDS.  393 

Mucous,  or  myxomatous  polypi,  most  frequently  arise  in  the  neighbor- 
hood of  the  middle  turbinate  bone,  often  as  the  result  of  disease  of  the  acces- 
sory sinuses.  Cystic,  adenomatous,  or  fibrous  changes  may  occur.  They 
are  movable,  almost  transparent,  and  of  a  bluish  gray  color.  The  symptoms 
are  a  mucopurulent  discharge,  nasal  obstruction,  and  sometimes  epistaxis. 
Cough,  asthma,  headache,  facial  neuralgia,  asthenopia,  anemia,  possibly 
epilepsy,  and  other  reflex  symptoms  may  be  caused  by  polyps.  They  should 
be  removed  by  seizing  the  growth  with  forceps,  and  twisting  the  pedicle  until 
the  growth  is  loose,  or  by  a  wire  loop  or  ^craseur,  with  which  the  pedicle 
is  gradually  cut  through.  In  either  case  the  base  should  be  cauterized  with 
the  galvanocautery  or  some  chemical  caustic. 

Fibrous  polypi  are  much  more  serious  than  mucous  polyps,  as  they 
often  contain  sarcomatous  elements,  progress  steadily,  and  press  on  adjacent 
parts,  causing  exophthalmos,  disfigurement,  etc.  The  so-called  nasopharyn- 
geal polyp  is  always  a  fibrosarcoma.  Fibromata  when  small  may  be  removed 
with  the  snare,  but  such  is  always  attended  with  some  risk  of  hemorrhage. 
When  of  large  size  a  very  formidable  operation  may  be  needed,  such  as  re- 
section of  the  upper  jaw  (temporary  or  permanent)  or  removal  of  a  portion 
of  the  roof  of  the  mouth.  For  anterior  growths  sufficient  exposure  has  been 
obtained  by  incising  the  mucous  membrane  between  the  upper  lip  and  the 
jaw,  cutting  through  the  cartilages  of  the  nose,  and  temporarily  displacing  the 
entire  nose  upwards.  Temporary  osteoplastic  resections  of  the  nose  are  made 
also  by  an  external  incision. 

Synechia,  or  adhesion  between  the  intranasal  structures,  may  be  con- 
genital, but  is  usually  the  result  of  previous  ulceration.  Adhesions  are  most 
frequent  in  narrow  noses,  and  interfere  with  respiration  and  drainage.  They 
are  treated  by  incision  or  excision,  the  raw  surfaces  being  subsequently 
separated  by  a  plug  of  rubber,  metal,  or  cotton. 

Ozena  is  a  term  often  applied  to  any  fetid  discharge  from  the  nose,  but 
it  should  be  restricted  to  cases  of  chronic  atrophic  rhinitis,  a  condition  in 
which  the  nasal  fossae  are  roomy,  the  mucous  membrane  atrophic  and  cov- 
ered with  scabs,  and  in  whi.ch  there  is  a  very  objectionable  odor,  not  appre- 
ciated by  the  patient.  The  reader  is  referred  to  special  text-books  for  a 
full  consideration  of  this  affection  and  its  treatment.  Other  causes  of  a 
foul  discharge  from  the  nose  are  tumors,  foreign  bodies,  rhinoliths,  ulcers 
(syphilitic,  tuberculous,  malignant,  simple),  disease  of  the  accessory  sinuses, 
and  necrosis  of  bone.  A  unilateral  discharge  in  children  is  most  frequently 
caused  by  a  foreign  body,  and  in  adults  by  disease  of  the  accessory  sinuses. 
The  diagnosis  requires  thorough  cleansing  of  the  nose,  and  careful  examina- 
tion of  its  interior  with  the  speculum  and  head  mirror.  The  treatment 
varies  widely  with  the  cause,  and  may  involve  removal  of  necrotic  bone  or 
cartilage. 

Post-nasal  adenoids  is  a  term  applied  to  hyperplasia  of  the  pharyngeal 
lymphoid  tissue,  or,  as  it  is  sometimes  called,  the  pharyngeal  or  Luschka's 
tonsil,  which  is  analogous  to  the  faucial  and  lingual  tonsils.  Adenoids  are 
most  common  in  children  of  a  tuberculous  tendency,  and  are  probably  the 
result  of  repeated  catarrhal  inflammations.  The  symptoms  are  mouth 
breathing,  change  in  the  voice,  headache,  snoring  during  <>leep,  narrowing 
of  the  nostrils,  and  interference  with  nasal  respiration.  The  child  has  a 
stupid  look  and  indeed  the  mental  development  may  be  retarded.  There 
may  be  a  purulent  discharge,  occasionally  mixed  with  blood,  from  the  nose  or 


394  RESPIRATORY  SYSTEM. 

pharynx,  and  deafness  or  middle  ear  disease  may  follow.  The  palate  Is 
often  high,  the  up[)er  incisor  teeth  prominent,  and  the  cervical  glands  en- 
larged. There  may  l)e  impairment  of  taste  and  smell,  and  later  in  life 
deformity  of  the  chest,  the  ribs  being  sunken  and  the  spine  kyphotic  because 
of  interference  with  deep  inspiration.  The  diagnosis  is  made  by  posterior 
rhinoscopy,  or  better,  in  young  children,  by  the  finger  passed  vp  into  the 
pharynx,  when  the  soft,  easily  bleeding  mass  is  readily  detected. 

The  treatment  in  practically  all  cases  is  removal  by  operation,  although 
there  is  a  tendency  for  adenoids  to  decrease  in  size  or  disappear  later  in  life. 
The  patient  is  etherized  and  the  head  allowed  to  hang  over  the  table.  Long 
curved  forceps,  such  as  those  of  Lowenberg,  are  passed  up  behind  the  soft 
palate,  which  is  guarded  with  the  left  index  finger,  and  the  greater  portion  of 
the  mass  removed,  care  being  taken  not  to  grasp  the  septum  or  include  the 
openings  of  the  Eustachian  tubes.  Any  fragments  which  remain  may 
be  removed  with  the  finger  nail  or  the  Gottstein  curette.  Bleeding  is  very 
profuse  but  soon  ceases. 

AFFECTIONS  OF  THE  SINUSES. 

Frontal  Sinuses. — ^Fracture  of  the  anterior  wall  is  common  and  may  lead 
to  emphysema  of  the  face  and  scalp,  or  in  compound  cases  to  necrosis  of  the 
bone.  If  there  is  much  depression  the  bone  may  be  elevated  to  prevent 
deformity,  opportunity  being  afforded  at  the  same  time  to  make  sure  that  the 
posterior  wall  is  not  injured.  In  rare  cases  a  fistula  through  which  air  passes 
may  follow.  Reference  has  already  been  made  to  pneumatocele  (p.  347). 
Foreign  bodies  introduced  from  without,  or  insects  which  have  ascended 
from  the  nose,  may  cause  empyema  of  the  sinus. 

Inflammation  may  be  caused  by  injuries,  foreign  bodies,  disease  of  adja- 
cent hones,  syphilis,  or  tuberculosis,  but  is  usually  secondary  to  rhinitis.  In 
acute  simple  cases  there  is  frontal  headache  which  subsides  with  the  acute 
rhinitis.  If  the  nasofrontal  duct  (infundibulum)  becomes  blocked,  the  sinus 
distends  with  mucus  {hydrops,  or  mnc/>cele)  or  pus  {empyema).  In  the  former 
an  enlargement  in  the  region  of  the  sinus  is  noticed,  with  egg-shell  crackling  in 
the  later  stages  owing  to  thinning  of  the  l)one.  In  acute  empyema  there  may 
be  redness  and  edema  over  the  sinus  with  general  septic  symptoms.  The 
process  sul)si(ies  with  the  discharge  of  pus  from  the  nose,  or  it  may  extend 
and  involve  the  frontal  bone,  meninges,  brain,  or  intracranial  venous  sinuses. 
Chronic  empyema  is  characterized  by  pain,  tenderness,  l^ulging  of  the  sinus, 
pus  and  polypoid  granulations  in  the  anterior  part  of  the  middle  meatus,  and 
sometimes  l^y  disturbances  of  vision  and  exophthalmos.  The  X-ray  shows 
the  sinus  to  be  enlarged  and  opaque;  the  latter  sign  may  l)e  demonstrated  also 
by  transillumination,  an  electric  lamp  being  held  in  the  angle  of  the  orbit. 

The  treatment  of  acute  inflammation  is  that  of  the  accompanying  rhini- 
tis. If  suppuration  occurs,  the  sinus  should  l>e  opened  through  an  incision 
from  the  root  of  the  nose  outwards  through  the  eyebrow  to  the  supraorbital 
notch,  the  anterior  wall  being  perforated  with  a  trephine  or  gouge  just  below 
the  line  joining  the  two  supraorbital  notches  and  a  little  away  from  the 
median  line.  The  sinus  may  be  curetted,  irrigated,  and  packed  with  gauze, 
so  that  it  may  close  by  granulations  and  shut  off  the  nasofrontal  duct,  or  it 
may  be  necessary  to  remove  the  entire  anterior  wail,  but  this  should  l>e 
,  avoided  whenever  possible,  owing  to  the  disfigurement.     Killian  removes  the 


AFFECTIONS    OF    THE    SINUSES. 


395 


anterior  wall  and  iTnor  of  the  sinus,  leaving  a  bridge  of  hone  at  the  inner 
anj^le  of  the  orhit  to  lessen  deformity.  Some  surgeons  push  a  small  tube  into 
the  nasofrontal  <ltict  in  ortfer  lo  drain  the  sinus  intu  I  he  nose,  and  then  close 
the  skin  iniision.  It  may  be  possible  for  a  skiiled  rhinologist  to  enter  the 
infundibulum  from  the  nose  after  removing  the  anterior  tip  of  the  middle 
turbinate,  but  the  duct  cannot  be  enlarged  without  great  danger,  so  that, 
although  catheterization  may  be  useful  from  a  diagnostic  standpoint,  it  should 
not  be  used  as  a  means  of  treatment. 

Tumors,  both  benign  and  malignant,  may  arise  in  the  frontal  sinus. 
When  of  large  size,  they  may  press  on  the  brain  or  on  the  eye,  causing  blind- 
ness and  displacement  of  the  eyeball.     They  should  be  excised. 

Ethmoiditis  may  cause  pain  and  tenderness  at  the  root  of  the  nose, 
disturbance  of  vision,  mentai  hebetude,  anosmia,  and  possildy  relluiilis  of  the 
orbit,  meningitis,  or  abscess  of  the  brain.  There  may  be  a  continuous  dis- 
charge of  pus  from  the  nose  and  polypi  in  the  middle  meatus.  Proliing 
reveals  necrotic  l)one  and  opacity  can  be  demonstrateti  by  the  X-ray.  The 
treatment  is  excision  of  the  anterior  end  of  the  middJe  turbinate,  to  permit 
drainage  and  removal  of  the  cells  by  curettage.  The  best  way  to  reach  the 
ethmoid  cells  by  an  e.xtemal  incision  is  through  the  inner  wall  of  the  orbit, 
and  such  is  particularly  indicated  if  the  pus  has  perforated  in  this  direction. 

The  sphenoidal  sinuses  open  at  the  junction  of  the  roof  of  the  nose  with 
the  wall  of  the  nasopharynx,  and  this  opening  may  be  enlarged  in  a  down- 
ward and  outward  direction  in  cases  of  sphenoidal  empyema.  Sphenoidal 
and  ethmoidal  disease  are  commonly  associated,  and  may  cause  meningitis, 
abscess  of  the  brain,  or  thrombosis  of  the  cavernous  sinus.  Pus  tlows  into 
the  superior  meatus,  necrotic  bone  may  be  detected  with  the  probe,  and  the 
X-ray  shows  abnormal  density.  The  sinus  may  be  opened  through  the  pos- 
terior  ethmoidal  cells  after  the  removal  of  the  middle  turbinate,  through  the 
orbit  and  posterior  ethmoidal  cells,  or  through  the  antrum  of  Highmore  and 
posterior  ethmoidal  cells. 

Empyema  of  the  antnim  of  Highmore  (the  maxillary  sinus)  is  most 
frequently  due  to  carious  teeth,  but  may  result  also  from  infection  of  the  nasal 
cavities,  or  from  the  entrance  into  its  opening  of  pus  from  the  frontal  or  eth- 
moidal sinuses.  Injury  is  responsible  for  a  small  number  of  cases.  The 
symptoms  are  pain,  tenderness,  edema  of  the  cheek,  and  an  intermittent  uni- 
lateral discharge  of  pus  from  the  middle  meatus,  most  marked  when  the 
diseased  side  is  upward  or  when  the  patient  bends  forwards,  and  accom- 
panied by  marked  subjective  feton  If  the  opening  into  the  middle  meatus 
is  obstructed,  the  cavity  becomes  distended,  causing  in  extreme  cases  stenosis 
of  the  nostril,  exophthalmos,  depression  of  the  palate,  and  a  prominence 
beneath  the  malar  eminence  due  to  bulging  of  the  outer  wall,  which  in  old 
cases  may  crackle  under  the  finger.  Acute  cases  may  be  associated  with 
septic  constitutional  symf>toms>  Percussion  over  the  antrum  will  give  a  dull 
instead  of  a  tympanitic  sound,  and  transillumination,  by  placing  a  small 
electric  light  In  the  patient's  mouth  in  a  dark  rocjm,  or  the  X-ray,  will  show 
the  diseased  much  darker  than  the  normal  side.  In  doubtful  cases  in  w  hich 
pus  cannot  be  seen  coming  from  the  antral  opening,  an  exploratory  puncture 
may  be  made  in  the  inferior  meatus,  one  inch  behind  the  anterior  end  of  the 
inferior  turbinate,  or  if  the  nostril  is  blocked,  by  making  a  similar  puncture 
through  the  canine  fossa,  pushing  the  cannula  upwards  at  an  angle  of  45 
degrees. 


i 


396  RESPIRATORY  SYSTEM. 

The  treatment,  when  the  condition  is  due  to  a  carious  tooth,  usually  the 
second  bicuspid  or  the  first  molar,  is  extraction  of  the  tooth,  and  opening 
upwards  through  the  socket  to  the  antrum  by  directing  the  drill  or  gouge  to- 
wards the  supraorbital  notch.  The  cavity  is  irrigated,  and  permanent  drain- 
age  secured  by  a  gold  or  silver  tube,  which  may  be  closed  with  a  stopper  dur- 
ing meals.  Irrigation  may  be  practised  likewise  through  the  natural  opening, 
or  through  an  opening  made  through  the  inferior  meatus  or  canine  fossa. 
Small  openings  of  this  character  are  exploratory  or  palliative  and  are  not 
suited  for  chronic  cases.  The  radical  operation  is  performed  by  making  an 
incision  at  the  junction  of  the  buccal  and  alveolar  mucous  membrane,  and 
opening  the  antrum  with  a  gouge  through  the  canine  fossa,  about  one  inch 
above  the  border  of  the  gum,  on  a  level  with  the  second  bicuspid  tooth.  The 
opening  may  be  enlarged  sufficiently  to  explore  and  curette  the  antrum 
thoroughly,  and  a  counteropening  may  be  made  into  the  inferior  meatus  of 
the  nose.  A  tube  may  be  passed  through  both  of  these  openings  and  the 
cavity  irrigated  daily. 

Tumors  of  various  kinds  may  develop  in  the  antrum ;  about  two-thirds  are 
malignant.  The  so-called  hydrops,  or  dropsy  of  the  antrum^  is  practically  always 
due  to  cystic  degeneration  of  tumors,  or  to  cysts  connected  with  the  tooth 
follicles,  although  a  true  dropsy  from  closure  of  the  natural  opening  of  the 
antrum  is  said  to  occur.  Large  growths  cause  expansion  of  the  walls  of  the 
antrum,  and  when  malignant  soon  spread  to  adjacent  parts.  Transillumina- 
tion and  percussion  will  give  the  same  results  as  in  empyema,  and  the  intro- 
duction of  a  small  cannula  will  determine  the  presence  or  absence  of  fluid  and 
the  density  of  the  growth.  In  doubtful  cases  the  cheek  may  be  reflected  as  for 
excision  of  the  jaw  and  the  anterior  wall  of  the  antrum  removed.  Polyps, 
cysts,  and  other  benign  tumors  may  be  removed  through  this  opening;  if 
malignant  disease  is  found,  the  entire  upper  jaw  should  be  resected. 


LARYNX  AND  TRACHEA. 

Cofigenital  fissures  and  fistidce,  laryngocele  and  tracheocele,  and  wounds  of 
the  air  passages,  have  been  referred  to  in  the  chapter  on  surgery  of  the  neck. 

Foreign  bodies  in  the  air  passages  may  be  of  any  nature,  providing  they 
are  small  enough  to  enter  the  larynx  or  trachea.  Those  most  often  found  are, 
in  the  order  of  their  frequency,  a  grain  of  corn,  watermelon  seed,  bean,  and 
grain  of  coffee.  Congenital  defects  or  destruction  of  the  epiglottis  by  ulcera- 
tion, certain  diseases  like  bulbar  paralysis,  and  unconsciousness  from  any 
cause,  predispose  to  this  accident.  Foreign  bodies  may  be  introduced  through 
the  glottis  or  through  an  artificial  opening  in  the  trachea,  and  they  may  pene- 
trate from  without,  as  a  bullet,  needle,  or  other  sharp  body.  They  may 
ulcerate  into  the  respiratory  tree  from  the  esophagus,  mediastinum,  or  one  of 
the  subphrenic  organs,  stomach,  colon,  liver,  or  spleen,  and  they  may  be 
formed  in  the  lung  itself  (lung  stones). 

If  not  arrestee!  in  the  pharynx  or  larynx,  or  of  such  a  nature  as  to  catch 
in  the  wall  of  the  trachea,  the  foreign  body  usually  descends  into  the  right 
bronchus,  l)erause  of  its  greater  diameter  and  because  the  bronchial  septum 
is  situated  to  the  left  of  the  median  line.  Foreign  bodies  may  be  expelled 
through  the  mouth  or  through  an  artificial  opening;  they  may  be  coughed  into 
the  pharynx  and  swallowed;  and  rarely  may  they  gain  exit  through  the  chest 


FOREIGN   BODIES   IN   THE  AIR   PASSAGES.  397 

wall  by  ulceration.  Vegetable  substances  swell  and  sometimes  sprout. 
Death  is  due  to  asphyxia  from  complete  blocking  of  the  respiratory  channel  or 
from  edema  or  violent  spasm  of  the  glottis,  or  it  occurs  later  from  septic  inflam- 
mation. Rarely  hemorrhage  may  cause  a  fatal  issue,  as  in  a  case  in  which  an 
inhaled  dart  pierced  the  innominate  artery.  If  the  foreign  body  is  not  large 
enough  to  block  the  air  channel  completely,  there  are  great  dyspnea,  violent 
cough,  lividity  of  the  countenance,  writhing  of  the  patient,  and  partial  insen- 
sibility, followed  by  expulsion  of  the  foreign  body  or  a  variable  lull  in  the 
symptoms,  then  by  recurrence  of  the  symptoms,  and  so  on  until  spasm  or 
edema  of  the  glottis  causes  asphyxia,  or  the  body  descends  into  the  limg. 
The  diagnosis  is  usually  made  from  the  history,  but  if  the  patient  be  un- 
conscious or  a  child  from  whom  no  history  can  be  obtained,  the  symptoms 
may  be  mistaken  for  asthma,  pertussis,  epilepsy,  apoplexy,  diphtheria,  cardiac 
disease,  spasmodic  croup,  laryngismus  stridulus,  edema  and  ulceration  of  the 
larynx,  the  laryngeal  crisis  of  locomotor  ataxia,  or  for  worms.  Even  after 
expulsion  doubt  may  arise,  owing  to  the  persistence  of  symptoms  due  to  irri- 
tation. In  children  with  sudden  respiratory  difficulty  one  should  think  al- 
ways of  a  foreign  body.  The  breathing  is  slow  compared  with  that  of  disease, 
inspiration  prolonged  and  difficult  with  retraction  of  the  lower  ribs,  and  the 
respiratory  murmur  diminished  or  absent  on  the  corresponding  side  if  there 
be  impaction  in  the  bronchus,  the  pulmonary  resonance,  however,  remaining 
normal.  The  symptoms  are  intermittent  and  in  the  beginning  there  is  no 
fever.  Sometimes  the  foreign  body  may  be  heard  rising  and  falling  in  the 
trachea  with  each  respiration.  The  pharjmx  may  be  easily  explored  with  the 
finger,  and  the  larynx  and  upper  part  of  the  trachea  may  be  inspected  with 
the  larjmgoscope.  It  should  be  recalled  that  blocking  of  the  esophagus  may 
cause  suffocative  symptoms.  When  the  infective  sequelae  from  irritation  of 
a  foreign  body  have  become  established,  the  diagnosis  may  be  impossible 
without  a  guiding  history.  These  cases  must  be  differentiated  from  inflam- 
matory diseases  from  other  causes,  and  from  chronic  laryngeal,  tracheal, 
or  bronchial  stenosis,  which  may  be  extrinsic  or  intrinsic.  As  extrinsic 
causes  may  be  mentioned  cicatricial  contractures;  localized  emphysema; 
enlarged  thyroid,  thymus,  or  lymphatic  glands;  extensive  pericardial  exudate; 
dilatation  of  the  left  auricle;  disease  or  injury  of  the  clavicle,  sternum,  or 
vertebrae;  and  cervical  or  mediastinal  cyst,  abscess,  neoplasm,  or  aneurysm. 
Among  the  intrinsic  causes  are  malformations;  neoplasms;  inflammatory 
thickening;  intussusception  of  the  trachea;  paralysis  of  the  posterior  crico- 
arytenoids; longitudinal  involution  of  the  trachea  after  tracheotomy ;  adhesions 
of  the  epiglottis,  vocal  bands,  or  arytenoids ;  cicatrices,  syphilitic,  tuberculous, 
or  traumatic;  and  cicatrices  following  diseases  like  scarlatina,  diphtheria, 
variola,  rubeola,  and  enteric  fever.  The  characteristic  inspiratory  dyspnea 
is  sufficient  to  establish  the  diagnosis  of  stenosis.  If  the  voice  is  altered,  with 
pain  and  rhoncus  in  a  larynx  which  rises  and  falls  with  each  respiration, 
the  lesion  is  probably  in  the  larynx,  and  the  diagnosis  may  be  confirmed 
by  examination  with  reflected  light.  Dysphagia  has  been  observed  in  some 
cases,  and  the  head  is  apt  to  be  held  backward  in  lar>Tigeal  constriction,  and 
slightly  depressed  with  extended  neck  in  tracheal  stenosis.  The  respiratory 
murmur  is  diminished  over  both  lungs  in  any  constriction  above  the  tracheal 
bifurcation,  and  the  voice  may  be  weakened  owing  to  the  lessened  column 
of  air  impinging  on  the  vocal  bands.  Fixed  pain  and  rhoncus,  with  visual 
examination  through  the  mouth,  would  locate  the  stricture  in  the  trachea. 


398  ^^^F  RESPIRATORY   SYSTEM. 

The  sound  has  been  abandoned.  Narrowing  of  a  bronchus  may  be  recognized 
by  physical  examination  of  the  chest,  or  by  direct  inspection  through  a  long 
thin  speculum  (brmtehtucope),  introduced  through  the  mouth.  Diminished 
respiratory  dilatation  of  one  lung,  as  evinced  by  inspection,  palpation,  and 
mensuration^  with  diminished  vesicular  murmur  and  vocal  fremitus,  and 
retention  of  resonance,  can  be  caused  only  by  narrowing  of  the  bronchus 
or  pneumothorax.  A  whirring  rhoncus  occupying  the  same  place  and  having 
the  same  character  and  intensity  on  different  examinations,  ^\^th  fixed  pain 
and  thrill  over  the  spot  corresponding  to  a  bronchus,  will  definitely  settle  the 
point  of  constriction.  The  diagnosis  of  a  foreign  body  would  be  made  by 
excluding  the  other  causes  of  obstruction.  An  X-ray  plate  might  facilitate 
the  differentiation* 

The  treatment  in  a  great  emergency  is  to  thrust  a  knife  through  the  cri- 
cothyroid membrane;  if  there  be  less  urgency,  a  low  and  rapid  tracheotomy 
may  be  performed;  and  if  the  patient  is  seen  during  a  quiescent  period,  a 
careful  examination  should  be  made.  When  above  the  vocal  bands  the  body 
may  be  removed  with  the  finger  or  forceps,  but  when  below  this  point  and 
irregular  or  jagged,  permanent  injury  to  the  vocal  bands  may  follow  forcible 
extraction  from  al>ove.  Foreign  bodies  have  been  removed  from  the  bron- 
chi through  a  bronchoscope.  If  impossible  or  injudicious  to  extract  the 
body  from  above,  the  patient  may  be  inverted  and  succussed  with  a  pillow,  a 
procedure  which  is  occasionally  successful,  especially  when  the  alien  is  small, 
round,  and  heavy.  Inversion,  however,  without  adequate  means  for  imme- 
diately opening  the  trachea,  is  dangerous,  because  of  the  possibility  of  death 
from  impaction  or  spasm  of  the  glottis,  the  foreign  body  suddenly  striking 
the  larynx  from  below.  If  inversion  fail,  the  trachea  should  be  opened  low 
down,  though  the  symptoms  are  even  not  urgent,  because  of  the  danger  of 
death  from  impaction  or  convulsive  closure  of  the  glottis,  or  from  subse- 
quent inflammation.  The  body  is  frequently  expelled  as  soon  as  the  trachea 
is  opened;  expulsion  may  be  facilitated  by  turning  the  patient  face  down- 
ward, or  by  inversion  and  succussion.  These  measures  failing,  a  careful 
search  should  be  made,  and  removal  effected  with  finger,  forceps,  scoop, 
hook,  probe,  coin  catcher,  or  wire.  The  bronchi  may  be  inspected  with  a 
bronchoscope,  A  powerful  magnet  may  attract  bodies  like  needles,  and  a 
Bigelow  evacuator  may  be  used  to  aspirate  small  foreign  bo(h'es.  If  all 
efforts  are  unavailing,  the  wound  should  be  kept  open  by  sutures  or  hooks, 
and  a  second  trial  made  the  next  day.  A  tracheotomy  tube  would  hinder 
expulsion  of  the  foreign  body,  Laryngotomy,  because  of  the  danger  of 
injuring  the  vocal  liands,  should  be  performed  only  when  the  foreign  body  is 
in  the  larynx  and  cannot  be  removed  in  any  other  manner.  Several  attempts 
have  been  made  to  remove  foreign  bodies  in  the  bronchi  which  could  not  be 
dealt  with  through  a  low  tracheotomy  wound,  by  splitting  the  sternum  or  by 
opening  the  thorax  posteriorly,  with,  we  believe,  but  a  single  success.  If  a 
foreign  body  causes  pulmonary  abscess  or  gangrene  which  caJi  be  localized, 
these  should  be  opened  and  drained,  when  the  irritating  body  may  be  de- 
tected, or  perhaps  discharged  later. 

Edematous  laryngitis  (edema  of  the  glottis)  may  be  caused  by  other 
forms  of  laryngitis,  l>y  injuries,  such  as  fractures  of  the  larynx,  scalds,  and 
foreign  iHidics,  by  inllammatory  cujiditions  in  the  vicinity,  such  as  cdlulitis 
of  the  neck,  and  liy  Bright's  tliscase,  angicujcurotic  edema,  anti  the  acute 
infectious  fevers.     The  symphms  are  interference  with  brealhing,  particu- 


p. 


TUMORS   OF  THE 


LARYNX. 


399 


larly  mspiralion,  with  cyanosis^  etc.,  as  the  ol>strurtion  becomes  more 
complete.  The  diagnosis  is  made  by  the  laryngoscope  and  by  feeling  the 
swollen  epiglottis  with  the  finger.  The  treatment  in  the  milder  cases  is 
multiple  punctures  or  scarification  of  the  swollen  tissues,  the  inhalation  of 
steam  laden  with  compound  tincture  of  benzoin,  and  ice  to  the  neck.  In 
more  severe  cases  high  tracheotomy  should  be  performed,  not  waiting  until 
the  patient  is  m  extremis.  Intubation  is  to  be  preferred,  providing  the 
swelling  is  not  too  great  to  prevent  the  introduction  of  a  tube. 

Chondritis  is  always  associated  with  perichondritis,  and  may  be  due  to 
trauma,  chronic  laryngitis,  syphilis,  tuberculosis,  epithelioma,  typhoid  fever, 
or  the  exanthemata.  The  cricoid  and  arytenoid  cartilages  are  most  fre- 
quently afTected.  Necrosis  may  occur  and  pus  may  form  (abscess  of  the 
iary'fLx),  which  may  discharge  internally  or  externally;  subsequently  cicatricial 
contraction  is  very  apt  to  cause  stenosis.  The  symptoms  are  pain,  tenderness, 
cough,  hoarseness,  dysphagia,  and  dyspnea.  Swelling  may  be  noticed  exter- 
nal ly^  or  perhaps  detected  only  with  the  laryngoscope.  The  treatment  is 
much  like  that  for  edema  of  the  glottis.  Abscesses  may  [>e  opened  within 
the  larynx  or  externally,  accortMng  to  where  they  point.  In  the  later  stages 
removal  of  necrotic  cartilage  may  be  indicated. 

Syphilis  of  the  larynx  may  appear  in  the  secondary  stage  as  mucous 
patches  or  condylomata,  and  in  the  tertiar)^  stage  as  a  gummatous  degenera- 
tion, causing  extensive  destruction  of  tissue  with  sub.sequent  cicatrization  and 
stenosis.  A  subacute  or  chronic  laryngitis  without  ulceration,  causing  little 
or  no  trouble  beyond  hoarseness,  also  occurs.  In  the  ulcerative  form  the 
symptoms  are  pain,  cough,  hoarseness,  dyspnea,  and  dysphagia.  Syphilitic 
lesions  are  present  elsewhere  and  the  ulcers  revealed  by  the  laryngoscope  are 
usually  symmetrical;  in  the  tertiary  stage  the  epiglottis  is  particularly  apt  to 
be  affected.  The  trealmettt  is  that  of  syphilis,  with  the  insufflation  of 
iodoform  into  the  larynx.  Tracheotomy  may  be  needed  for  edema,  convul- 
sive closure  of  the  glottis,  or  later  for  cicatricial  stenosis. 

Tuberculous  laryngitis  may  be  primary,  but  is  usually  secondary  to 
phthisis.  Tubercles  form,  break  down,  and  become  ulcers,  which  coalesce 
and  often  cause  great  destruction  of  tissue.  The  most  common  situation  for 
these  ulcers  is  about  the  arytenoid  cartilages,  the  vocal  cords,  and  the  under 
surface  of  the  epiglottis  Elevated  granulations  on  the  posterior  wall  of  the 
larynx  arc  strongly  suggestive  of  tuberculosis.  The  subjective  symptoms  are 
those  of  syphilis  of  the  lamix.  Tubercle  bacilli  may  be  found  in  the  expecto- 
ration. The  treatment  is  that  of  tuberculosis  elsewhere,  with  applications  of 
lactic  add  and  insufflations  of  iodoform  or  thymol  iodid.  Tracheotomy  may 
be  needed  for  the  same  conditions  as  in  syphibs  of  the  larynx. 

Tumors  of  the  larynx  may  be  l>enign  or  malignant.  The  papillomata 
are  the  most  common;  they  are  most  frequent  on  the  vocal  cords  and  some- 
times undergo  an  epitheliomatous  change.  The  symptoms  are  hoarseness  or 
aphonia,  cough,  dyspnea,  and  sometimes  pain  and  dysphagia.  In  adults  the 
growth  may  be  seen  with  the  lar)Tigoscope;  the  warty-like  appearance  of  the 
papilloma  is  distinctive.  The  treat mettt  is  inlralaryngeal  removal  by  special 
forceps  or  snare,  or  by  cauterization.  Cysts  may  be  inciseil.  In  children 
and  in  extensive  su1>glottic  growths  it  will  usually  be  necessary  Ui  split  the 
thyroid  cartilage  \i\  the  middle  line  (t/fyroiomy)  and  deal  directly  with  the 
growth. 

Malignant  tumors  may  be  sarcomata,  but  arc  usually  epitheliomata, 


400  RESPIKATORY   SYSTEM. 

which  frequently  result  from  pre^'iously  benign  tumors  and  grow  slowly. 
The  symptoms  are  those  of  benign  tumors,  but  pain  shooting  towards  the 
ears  and  hemoptysis  are  more  frequent,  and  there  is  likely  to  be  emaciation 
and  lymphatic  involvement.  The  diagnosis  in  the  eariy  stages  is  often 
difficult;  in  doubtful  cases  a  piece  of  the  growth  should. if  possible,  be  secured 
for  microscopic  examination.  The  treatment  is  removal  of  the  growth  by 
thyrotomy,  or  by  partial  or  complete  larjTigectomy.  according  to  its  extent. 
Cure  has  h>een  obtained  in  26.6  per  cent,  of  the  cases  (Kocher).  Endo- 
lar}'ngeal  operations  are  not  competent  to  deal  with  malignant  disease.  In 
the  later  stages  tracheotomy  may  be  performed  to  relieve  d}'spnea. 

Ttimors  of  the  trachea  have  in  a  general  way  the  same  features  as 
those  of  the  larjTix,  except  that  respiration  is  more  apt  to  be  affected  than 
phonation.  The  tumor  may  be  of  any  variety,  is  often  recognized  by  the 
lar}ngoscope,  and  may  in  suitable  cases  be  excised  through  a  tracheotomy 
wound. 


OPERATIONS  UPON  THE  AIR  PASSAGES. 

Subhyoid  pharyngotomy  may  be  performed  to  gain  access  to  the  phai^-nx 
or  upper  part  of  the  larynx,  but  the  operation  is  rarely  used.  A  transverse 
incision  is  made  between  the  hyoid  l)one  and  the  thyroid  cartilage  and  the 
pharynx  opened,  the  epiglottis  being  detached  from  the  tongue.  .\  prelimi- 
nar>'  tracheotomy  will  be  necessary  in  removing  growths,  etc.,  which  cause 
much  hemorrhage.  The  structures  are  sutured  at  the  completion  of  the 
operation. 

Transhyoid  pharyngotomy  may  l)e  used  for  the  same  purposes  as  the 
al>ove.  An  incision  is  made  in  the  median  line  from  the  chin  to  the  th}Toid 
not(  h,  the  hyoid  bone  divided,  and  the  pharynx  opened.  A  preliminary* 
lra(  heoiomy  will  usually  he  necessary. 

Thyrotomy  exposes  the  interior  of  the  larynx  in-  splitting  the  thyroid  car- 
tilage in  the  median  line,  after  performing  tracheotomy  and  inserting  a  tam- 
pon ( annula  into  the  windpipe.  The  wound  in  the  thyroid  cartilage  is 
widely  separated  and  the  interior  of  the  larynx  exposed  to  new.  The  wound 
may  subsequently  be  closed  by  sutures. 

Laryngectomy  is  performed  for  malignant  <lisease  and  occasionally  for 
other  conditions,  such  as  extensive  stenosis  or  ulceration.  It  may  be  com- 
plete or  partial  according  to  the  extent  of  disease,  and  in  a  few  cases  adjacent 
portions  of  the  tongue,  pharynx,  and  esophagus  have  been  excised.  After 
unilateral  laryngectomy  the  patient  is  able  to  speak,  after  total  laryngec- 
tomy he  is  able  to  whisper.  \  low  tracheotomy  should  be  performed  a  week 
or  more  before  the  ex(  ision  of  the  larynx,  especially  if  there  is  much  dyspnea, 
in  order  to  accustom  the  patient  to  !)realh  through  the  tube,  to  facilitate 
anesthesia,  and  to  lessen  the  time  of  the  larger  operation.  A  Hahn  or  Tren- 
delenburg tampon  cannula  (p.  402)  is  inserted  into  the  trachea,  and  the 
patient  chloroformed  through  this  opening.  A  median  incision  is  made 
from  the  hyoid  bone  to  below  the  cricoid  cartilage,  a  transverse  cut  made  at 
either  end  of  this  incision,  the  flaps  retlected,  the  larynx  isolated  by  blunt 
<lissection,  and  removed  by  cutting  through  the  thyrohyoid  space  above  and 
the  tra<  hea  below.  The  upper  end  of  the  trachea  is  sutured  to  the  skin  and 
the  wound  pac  ked  with  gauze  and  partly  sutured,  the  patient  being  fed 


TRACHEOTOMY.  4OI 

through  a  tube.  The  cervical  lymphatic  glands  are  of  course  removed  before 
completing  the  operation.  When  healing  is  complete  the  patient  may  wear 
an  artificial  larjmx.  Some  surgeons  prefer  performing  the  tracheotomy  im- 
mediately before  the  laryngectomy,  others  discard  the  preliminary  trache- 
otomy altogether,  and  after  isolating  the  larynx  sever  the  trachea,  suture  it 
to  the  skin,  and  close  the  opening  in  the  pharynx;  this  of  course  prevents 
the  use  of  an  artificial  larynx. 

Laryngotomy  is  an  emergency  operation  in  cases  of  laryngeal  obstruc- 
tion from  any  cause.  A  vertical  incision  is  made  over  the  cricothjnroid  mem- 
brane, the  cricothyroid  membrane  divided  transversely  close  to  the  cricoid 
cartilage,  and  a  tube  introduced.  The  cricothyroid  artery  may  be  injured 
and  require  a  ligature.  In  a  great  emergency  the  whole  operation  may  be 
completed  by  a  single  transverse  incision  made  with  a  penknife,  and  the 
patency  of  the  opening  maintained  with  the  handle  of  the  knife.  The  opera- 
tion is  not  applicable  to  children,  owing  to  the  small  size  of  the  cricoth)rroid 
space;  if  ever  performed  before  puberty,  it  should  be  combined  with  division 
of  the  cricoid  and  possibly  the  first  ring  of  the  trachea  (laryngotracheotomy) . 

Tracheotomy  is  performed  for  serious  obstruction  to  respiration,  for 
the  removal  of  foreign  bodies,  and  as  a  preliminary  to  operations  on  the 
mouth,  pharynx,  or  larynx.  The  high  operation,  i.e.,  above  the  isthmus  of 
the  thyroid  gland,  is  always  selected  when  possible,  because  in  this  situa- 
tion the  trachea  is  superficial  and  the  operation  much  more  simple.  When 
the  obstruction  is  low  down,  however,  or  when  one  desires  to  search  for  a 
foreign  body  in  the  trachea  or  bronchi,  the  low  operation  is  indicated. 

High  tracheotomy  may  be  performed  under  a  general  or  a  local  anes- 
thetic, or  indeed  in  urgent  cases  without  any  anesthetic.  A  pillow  is  placed 
under  the  shoulders  so  as  to  extend  the  head,  and  an  incision,  exactly  in  the 
median  line,  is  made  from  the  cricoid  downwards  for  one  and  one-half  inches, 
dividing  the  skin  and  superficial  and  deep  fasciae.  The  trachea  is  now  exposed 
by  separating,  if  necessary,  the  sternohyoid  muscles.  The  isthmus  of  the 
thyroid  gland  normally  lies  over  the  third  and  fourth  tracheal  rings.  If  it  be 
in  the  way,  it  may  be  depressed  after  dividing  the  deep  fascia  tranversely,  or 
it  may  be  incised  in  the  median  line,  without  ordinarily  giving  rise  to  much 
hemorrhage.  A  tenaculum  is  inserted  below  the  cricoid  to  steady  the  trachea, 
which  is  opened  from  below  upwards,  being  careful  to  guard  the  knife  with 
the  index  finger  so  as  not  to  injure  the  posterior  wall.  Ordinarily  two  or 
three  rings  are  divided,  the  cut  being  exactly  in  the  middle  line.  A  pair  of 
hemostats  should  be  introduced  into  the  trachea  before  the  knife  is  withdrawn 
and  a  tracheotomy  tube  inserted  as  the  blades  of  the  forceps  are  separated. 
The  tenaculum  should  not  be  removed  until  the  tube  is  in  place.  The  tube 
is  held  in  position  by  tapes  tied  around  the  neck.  In  the  absence  of  a  tube 
one  may  suture  the  edges  of  the  tracheal  wound  to  the  skin.  Bleeding  from 
the  small  veins  which  have  been  divided  usually  ceases  promptly  when  the 
trachea  is  opened.  The  wound  is  sutured,  leaving  sufficient  opening  for 
the  tube,  a  couple  of  layers  of  gauze  are  placed  beneath  the  flange  of  the  tube, 
and  one  or  two  layers  moistened  with  boric  acid  solution  over  the  orifice  of 
the  tube. 

In  low  tracheotomy  the  skin  incision  may  reach  the  sternum,  but  the 

lower  part  of  the  wound  should  be  deepened  very  cautiously  because  of  the 

danger  of  wounding  the  innominate  vein  or  the  thyroidea  ima.     Often  the 

inferior  thyroid  veins  arc  large  and  numerous  and  lie  directly  over  the  trachea ; 

26 


402 


RESPIIL\TORY   SYSTEM. 


m 


they  should  he  ligated  or  pushed  aside.  If  need  lie,  the  isthmus  of  the  thy- 
roid gland  may  be  pushed  upwards.  The  rest  of  the  operation  is  precisely  the 
same  as  the  high  operation.  In  rhildreii  the  low  operation  is  extreitiely 
difficult  because  of  the  depth  and  small  size  of  the  trachea,  the  shortness  of 
the  neck,  and  the  large  size  of  the  thymus  gland.  If  the  obstruction  is  stiO 
below  the  tracheotomy  opening  a  long  tube  or  catheter  may  possibly  be  passed 
beyond  it. 

Trachtotomy  tubes  are  made  of  hard  rubber, 
silver,  or  aluminum.  They  are  always  double, 
the  outer  tube  ha%nng  a  flange  with  slots,  through 
which  tape  may  be  passed,  and  the  inner  tube 
lieing  fastened  to  the  outer  by  a  little  catch  un 
the  si(!ej  so  that  it  may  be  removed  and  cleansed 
as  often  as  necessary  (Fig-  295).  Some  of  the5»e 
tubes  are  provided  with  a  long  handle  or  intro- 
duLer  and  a  special  speculum-like  apparatus  or 
dilator  to  facilitate  introduction »  but  such  arc 
commonly  unnecessary.  When  a  tracheotomy 
is  performed  preliminary  to  operations  on  the 
mouthy  larj'nx,  etc.,  a  tampon  cannula  is  often 
entrance  of  the  blood  into  the  lungs.  Tren* 
296)  is  encased  in  a  rubber  sac,  which  may  be 
inflated  m  order  to  (\l\  the  space  between  the  tube  and  the  tracheal  walL 
Hahn's  cannula  (Fig.  297)  is  covercil  with  a  compressed  sponge  which  swells 
when  moistened. 

After  Treatment, — The  room  should  be  kept  at  a  uniform  temperature 
oi  75°  F.,  the  air  moistened  by  steam,  ajid  the  gauiie  over  the  tube  changed  as 


Fig.  295, — Tnuheiiiumy  tube. 

employed  to   prevent   the 
delenburg's  cannula  (Fig. 


FiO.  296. — Trendelenburg's  cannula  in  f//w.  Fir,.  297. — Hahn's  cannuU. 

Figs.  296  and  297. — (Esmarch  and  Kowalzig.) 

often  as  the  patient  coughs,  so  that  the  mucus,  etc.,  will  not  fall  back  inio 
the  tube.  The  inner  tube  should  be  removed  ever)*  two  c^r  three  hours  by 
the  nurse  and  cleansed,  the  outer  tube  may  be  removed  once  a  day  by  the 
physician  for  the  same  purpose.  Mucus  in  the  trachea  may  be  extracted 
by  a  sterile  feather  moistened  with  bicarbonate  of  soda  solution.  20  grains 
to  the  ounce.  The  tube  should  be  removed  permanently  as  early  as  possible, 
but  the  time  that  it  should  remain  in  plate  will  vary  greatly  with  the  condi- 
tion; thus  afler  the  removal  td  a  foreign  body  it  may  be  only  twenty-four 


INTUBATION. 


403 


hours,  in  some  cases  of  stenosis  it  may  be  for  the  rest  of  the  patient's  life. 
Tubes  are  constructed  with  an  opening  in  the  convex  portion,  so  that  part  of 
the  air  will  pass  through  the  larynx;  if  breathing  is  free  when  the  outer 
(»perring  is  plugged^  the  tube  may  be  removed  with  safety.  Among  the  com- 
pikaiicnts  of  tracheotomy  may  be  mentioned  ulceration  of  the  trachea  from 
a  poorly  fitting  tube,  cellulitis,  secondar)'  hemorrhage,  bronchitis,  pneumonia, 
and  stenosis  of  the  larynx  or  trachea.  Stenosis  of  the  lar>^x  may  be  treated 
by  gradual  dilatation  vviih  D'Dwyer's  lubes,  or  in  some  cases  by  removing  the 
cicatricial  tissue  and  .skin  grafting  the  interior  of  the  larynx. 

Intubation  of  the  larynx  may  be  used  for  many  forms  of  stenosis  of  the 
larynjc,  but  is  chiefly  employed  in  that  form  due  to  diphtheria.     It  is  rapidly 


^-^HD 


Fxc»  298, — To  the  left  is  the  mouth  gag^  and  the  scale  for  determining  the  proper  sized 
'  tube  accordine  to  ihe  age  of  the  patient.  Next  is  the  introducer,  next  the  exirat-tor.  On 
the  ripht  arc  the  tuti«s,  which  are  expanded  above  to  rest  on  the  ventricular  bands,  wiiti  a 
prominence  posteriorly  which  rests  between  the  arj'tenuid  rartiiiiges.  The  middle  of  the 
tube  is  enlarged,  the  enlargement  resting  just  t*ehiw  the  vocal  cords,  tt>  prevent  dispkccmcnl 
of  the  tube  upwards  when  it  is  jn  position.  Between  the  tubes  on  the  right  is  the  obturator, 
which  fits  into  the  tube  and  h  strewed  into  the  hohier,  and  which  is  hinged  In  the  middle 
stj  that  it  may  be  wilhdrawn  after  the  tube  is  in  position. 

performed  with  miKh  less  risk  than  tracheotomy,  but  requires  special  instru- 
metits,  and  the  presence  of  the  sorgeon  if  the  tube  should  be  coughed  up. 
The  instruments  are  shown  in  Fig.  2qS.  The  chdd  is  wrappcfl  In  a  blanket 
to  control  the  arms  and  legs,  and  is  held  upright  by  a  nurse  seated  in  a  chair, 
yvhile  an  assistant  holds  the  head  upon  the  nurse's  left  shoulder  and  prevents 
the  mouth  gag  from  shpping.  A  long  piece  of  .silk  is  passed  through  the 
small  opening  in  the  upper  part  of  the  tube,  the  tul»e  fastened  to  the  intro- 
tluier,  and  the  silk  looped  around  the  Male  finger.  The  left  index  linger  is 
passed  into  the  throat,  and  lifts  the  epiglottis  while  the  tube  is  passed  along 
it  into  the  glcdtis.     The  left  index  linger  is  then  made  to  press  upon  the  head 


404  RESPIRATORY  SYSTEM. 

of  the  tube,  which  is  released  by  pulling  the  trigger  on  the  introducer,  which 
is  then  withdrawn.  When  one  is  assured  that  the  tube  is  in  the  right  place 
and  that  the  symptoms  are  relieved,  the  silk  loop  may  be  cut  and  withdrawn 
while  the  finger  is  again  made  to  press  down  on  the  tube.  If  the  tube  is 
coughed  up,  it  is  too  small  and  the  next  larger  size  should  be  introduced.  In 
cases  of  diphtheria  the  membrane  may  be  pushed  before  the  tube  and  cause 
asphyxia,  which,  if  not  immediately  relieved  by  expulsion  of  the  membrane 
after  the  tube  has  been  pulled  out  by  the  string,  will  demand  tracheotomy, 
hence  instruments  for  this  operation  should  always  be  at  hand.  The  patient 
speaks  in  a  whisper,  and  is  apt  to  inhale  food  during  deglutition,  hence  feed- 
ing should  be  per  rectum  or  by  nasal  tube,  although  some  advise  feeding 
with  the  head  lower  than  the  body,  or  the  gi\ing  of  semi-solids,  which  will 
more  easily  pass  over  the  glottis.  The  tube  remains  in  place  several  days, 
and  is  then  removed  with  the  child  in  the  same  position  as  for  introduction, 
by  passing  the  left  index  finger  down  to  the  tube  and  slipping  the  point  of 
the  extractor  into  its  opening,  the  tube  being  engaged  by  pressing  the  spring 
on  the  shank  of  the  extractor. 


SURGERY  OF  THE  CHEST. 

Contusion  of  the  chest  may  cause  superficial  bruising  of  the  skin,  lacera- 
tion of  the  muscles,  fracture  of  any  portion  of  the  wall  of  the  thorax,  or  more 
or  less  extensive  injury  to  the  contained  viscera.  Occasionally  a  severe  blow 
on  the  chest  or  epigastrium  (so-called  solar  plexus  blow)  will  be  followed 
by  severe  shock  or  even  death,  without  causing  any  gross  anatomical  change; 
this  condition  has  ])ecn  termed  concussion  of  the  chest  and  is  probably  due 
to  direct  concussion  of  the  heart  muscle  or  its  nerve  mechanism.  Owing  to 
the  lack  of  functionating  valves  in  the  jugular  and  facial  veins,  forcible 
compression  of  the  chest  of  some  minutes'  duration,  such  as  may  occur  in  a 
struggling  mob,  may  cause  a  bluish  or  black  discoloration  of  the  face  and 
neck,  sui>conjunctival  ecchymosis,  and  hemorrhages  into  the  retina  and 
brain  {traumatic  asp'iyxia).  Rupture  of  the  lung  is  recognized  by  cough, 
dyspnea,  hemoptysis,  subcutaneous  emphysema,  and  hemo-pneumothorax. 
Ruptures  of  the  large  vessels,  trachea,  or  esophagus  are  associated  with  such 
widespread  injury  that  death  quickly  follows.  For  injuries  of  the  heart  see 
p.  1 74,  and  for  rupture  of  the  diaphragm,  p.  445.  The  treatment  of  contu- 
sion of  the  chest  is  reaction  from  shock,  and  immobilization  of  the  thorax  as 
in  frac  ture  of  the  ribs.  In  the  presence  of  marked  evidences  of  internal 
hemorrhage,  thoracotomy  and  efforts  to  check  the  bleeding  are  indicated. 

Wounds  of  the  chest  may  be  penetrating  or  non-penetrating;  the  latter 
arc  treated  as  wounds  elsewhere.  Penetrating  wounds  are  usually  caused  by 
stabs  or  bullets.  The  diagnosis  may  be  made  by  signs  of  injury  to  the  viscera, 
or  by  cxi)loration  of  the  disinfected  wound  with  a  sterile  finger;  the  latter  is 
always  advisable,  particularly  in  wounds  in  the  neighborhood  of  the  heart,  or 
l)elow  the  sixth  rii),  as  in  this  situation  penetration  of  the  diaphragm  and 
injury  to  the  abdominal  viscera  may  easily  occur.  Wounds  of  the  heart 
have  already  been  discussed  and  injuries  of  the  abdominal  viscera  will  be 
considered  in  a  subsetiuent  chapter.  The  possii)le  symptoms  of  a  penetrating 
wound  of  the  lung  arc  those  of  rupture  of  the  lung,  with  a  bleeding  and  a  garru- 
lous external  wound. 


PNEUMOTHORAX. 


The  treatment  in  the  abst^ntc  of  serious  hemorrhage  or  the  lodgement 
of  a  foreign  bodyj  is  disinfection  and  suture  of  the  external  wound  and  im- 
mobilization of  the  aiTected  side  of  the  chest.  Hemorrhage  from  the  htlemai 
mammary  or  iniercoslal  artery  may  be  controlled  by  ligation,  or  Ijv  pushing 
a  gauze  sac  between  the  ribs  and  filling  the  inner  end  of  the  sac  with  gauze 
so  that  when  drawn  upon  it  will  make  pressure  from  within  outwards. 
Excepting  extensive  wounds,  bleeding  from  tlwlungh  rarely  fatal,  as  the  bleed- 
ing is  checked  by  collapse  of  the  lung.  In  the  absence  of  external  hemor- 
rhage, serious  loss  of  blood  is  diagnosticated  by  the  constitutional  signs  of 
acute  anemia  and  a  rapidly  accumulating  hemolh&rax.  Cases  of  this  sort 
have  been  treated  by  the  introduction  of  a  drainage  tube  in  order  to  admit  air 
and  favor  collapse  of  the  limg,  but  in  the  presence  of  serious  symptoms 
one  or  more  ribs  should  be  resected,  and  the  wounded  lung  dealt  with  directly 
by  sutures  or  gauze  packing*  Hemothorajc  of  lesser  degree,  or  that  form  due 
to  hemorrhagic  pleurisy  or  tumors  of  the  lung  or  pleura,  does  not  require 
special  surgical  treatment  unless  it  causes  pressure  symptoms  or  becomes 
infected;  in  the  former  case  aspiration,  and  in  the  latter  resection  of  a  rib  and 
drainage  would  be  indicated.  Foreign  bodies  should  be  removed  if  easily 
accessible,  and  the  same  rules  as  to  the  examination  of  the  vuln crating  instru- 
ment, the  clothing,  etc.,  apply  here  as  elsewhere.  If  the  foreign  body  is  not 
easily  found,  it  should  be  allowed  to  remain,  unless  it  gives  rise  to  subsequent 
trouble,  when  it  may  be  defmitely  localized  by  the  X-ray  and  its  removal 
ejected,  if  such  be  deemed  advisable.  With  the  exception  of  pneumocele, 
the  complications  of  injuries  to  the  chest  are  inflammatory  in  nature,  viz., 
cellulitis,  pleurisy,  empyema^  pneumonia,  abscess  or  gangrene  of  the  lung, 
mediastinal  abscess,  and  peri-,  myo-  or  endocarditis. 

Hernia  of  the  lung  iptieumocele)  is  rare;  it  is  the  result  of  laceration  of 
the  intercostal  structures  without  involvement  of  the  skin,  or  follows  a 
wound  owing  to  stretching  of  the  cicatrix.  It  has  an  impulse  on  coughing, 
crepitates  beneath  the  lingers,  and  a  vesicular  murmur  can  be  heard  on 
auscultation.  It  is  treated  hy  a  pad  or  truss.  In  contradistinction  t\>  a 
hernia,  a  prolapse  of  the  lung  is  a  protrusion  of  the  lung  iJito  an  open 
wound.  It  should  be  reduced  and  the  opening  closed,  or  if  badly  infected 
and  gangrenous,  or  densely  adherent,  it  may  be  amputated. 

Emphysema  of  the  subcutaneous  tissues,  the  result  of  injury  to  the  lung, 
rarely  requires  any  treatment  and  gradually  disappears.  If  excessive  and 
interfering  with  respiration,  multiple  punctures  may  be  mad6. 

Pneuniothoraj[  (air  in  the  pleural  cavity)  is  almost  always  associated  with 
the  presence  of  pus,  blood,  or  serum.  Ninety  per  cent,  of  all  cases  are  due  to 
phthisis.  Air  may  enter  the  pleural  sac  through  a  wound  in  the  chest  wall 
or  lung,  it  may  come  from  the  cohm,  stomach,  or  esophagus  as  the  result  of 
suppurative  or  ^malignant  disease,  and  it  may  be  produced  by  aerogenic 
microbes.  The  symptoms,  when  a  large  amount  of  air  is  suddenly  intro- 
duced, are  pain,  dyspnea,  cyanosis,  and  rapid  weak  pulse.  These  symptoms 
are  seldom  seen  during  operations  involving  the  pleural  cavity,  because  of  the 
frequency  of  pleural  adhesions  and  the  strong  coherence  which  normally 
exists  between  the  pleural  laminae.  The  signs  of  pneumothorax  are  bulging 
and  immobility  of  the  affected  side,  displacement  of  the  heart,  lessening  or 
absence  of  vocal  fremitus  and  breath  sounds,  tympany  on  percussion  (rarely 
dulness),  metallic  tinkling,  and  a  metallic  quality  in  the  voice,  in  the  r4les» 
and  in  the  sound  heard  when  percussing  the  chest  by  using  a  coin  as  a  plexor 


J 


4o6  RESPIRATORY   SYSTEM. 

and  one  as  a  pleximcter  (coin  lest).  There  may  be  signs  of  fluid  in  the 
cavity,  and  a  splashing  souncl  obtained  by  shaking  the  patient.  The  X-ray 
will  give  an  intense  clearness  over  the  air  sac.  Treatment  is  not  required  as 
long  as  respiration  is  not  impeded,  indeed  a  little  pneumothorax  may  be 
beneficial  in  giving  rest  to  an  affected  lung,  but  if  the  breathing  be  difficult 
and  the  heart  displaced,  the  air  may  be  removed  by  aspiration ,  or  if  associated 
with  pus,  by  resection  of  a  rib  and  drainage.  In  cases  resulting  from  an 
external  wound  the  pleural  opening  may  be  sutured  or  plugged,  or  the  lung 
or  diaphragm  may  be  stitched  to  the  chest  wall.  The  Fell-O'Dwyer  appara- 
tus (p.  21)  has  been  suggested  to  anticipate  and  combat  acute  operatiTe 
pneumothorax;  for  the  same  purpose  Sauerbruch  operates  inside  a  cabinet 
in  which  the  air  pressure  is  negative,  the  patient's  head  extending  beyond  the 
cabinet,  an  air  tight  collar  being  fitted  to  his  neck.  Brauer  uses  positive 
pressure,  i.e.,  an  airtight  mask  is  fitted  to  the  patient's  head  and  the  anesthetic. 
at  a  pressure  above  that  of  the  atmosphere,  given  by  a  special  apparatus. 
Although  more  convenient  than  the  Sauerbruch  method,  difficulty  is  encount- 
ered in  adjusting  the  mask  if  the  patient  vomits,  a  disadvantage  which  has 
been  met  by  administering  the  anesthetic  through  a  tracheotomy  wound. 
Some  surgeons,  the  day  before  operations  on  the  lung,  suture  both  layers  of 
the  pleura  together,  or  slowly  induce  a  pneumothorax.  If  none  of  these 
precautions  is  taken,  a  small  opening  may  be  made  in  the  chest  at  the  time  of 
operation  and  the  air  allowed  to  enter  slowly.  Elsberg  states  that  when  the 
patient  is  in  the  dorsal  position  the  heart  falls  backwards  and  pulls  with  it  the 
visceral  pleura  of  the  anterior  mediastinum,  thus  predisposing  to  pneumo- 
thorax; consequently  he  advises  opening  the  pleural  cavity  with  the  patient 
in  the  ventral  position. 

Serous  pleural  effusion  is  usually  the  result  of  pleurisy,  which  may  be 
primary,  or  secondary  to  trauma  or  disease  of  the  lung;  it  may  be  caused  also 
by  tumors  of  the  lung,  or  disease  of  the  heart,  liver,  or  kidney.  Symptoms 
may  be  absent,  or  there  may  be  pain,  cough,  dyspnea,  and  in  inflammatory 
cases  fever  and  leukocytosis.  The  signs  of  lluid  in  the  chest  are  immobility 
and  enlargement  of  the  affected  side,  widening  with  perhaps  bulging  of  the 
intercostal  si)aces,  displacement  of  the  heart,  diminished  or  absent  vocal 
fremitus,  dulness  or  tlatness  on  percussion  which  may  change  with  alteration 
in  the  position  of  the  patient,  tympany  ai)ove  the  fluid,  feeble  or  absent 
breath  sounds  and  vocal  resonance,  and  opacity  as  revealed  by  the  X-ray. 
In  some  cases  there  is  bronchial  breathing  and  egophony.  The  treatment  of 
serous  effusions  when  large  in  amount  or  j)roducing  pressure  symptoms,  or  in 
any  case  not  quickly  relieved  by  medical  treatment,  is  aspiration. 

Pyothorax,  or  empyema  (pus  in  the  pleural  cavity),  may  be  due  to  infec- 
tion of  the  pleural  cavity  by  a  wound,  or  to  extension  of  a  suppurative  proc- 
ess of  the  lung,  neck,  or  abdomen,  but  is  commonly  secondary  to  infection  of 
a  .serous  pleural  effusion.  The  organism  present  will  vary  with  the  cause; 
it  may  be  the  staphylococcus,  streptococcus,  pneumococcus,  colon  bacillus, 
tubercle  bacillus,  typhoid  bacillus,  etc.  The  symptoms  and  signs  are  those 
of  serous  etTusi<m,  with,  in  a  t>'pical  case,  irregular  fever,  possibly  chills  and 
sweats,  leukocytosis,  edema  of  the  chest  wall,  and  absence  of  the  whispered 
pectorihxiuy  which  may  be  heard  in  serous  effusions  {HaccclWs  sign).  The 
diagnosis  is  confirmed  by  exploratory  puncture.  In  some  cases  the  pulsa- 
tions of  the  heart  are  transmitted  through  the  effusion  (pulsating  empyema). 
The  pus  may  be  localized  by  adhesions  {encapsulated  empyema)^  or  fill  the 


PARACENTESIS   THORACIS. 


407 


whole  pleural  cavity  (tt^t a!  empyema).  S|K)ntane(>us  rccovt'ry  is  possible  but 
very  rare.  An  empyema  may  perforate  the  rhest  wall  {empyema  Hacssilatus), 
or  it  may  break  into  the  lung,  esophat^ns,  stomach,  f)erieardiiim,  or  perito- 
neum. Rarely  il  may  form  a  luml>ar  or  psoas  abscess.  In  acute  cases  the 
pleura  is  but  little  altered,  and  although  the  lung  is  compressed,  it  readily 
expands  when  drainage  is  estafilished.  In  chronic  cases,  however,  reexpan- 
sion  is  prevented  by  silerotic  changes  in  the  lung  and  l>y  the  dense  and  thick- 
ened pleura*  In  these  cases  nature  tries  to  obliterate  the  cavity  by  causing  a 
hypertrophy  of  the  opposite  lung,  an  ascent  of  the 
abdominal  viscera  on  the  aflfected  side,  a  sinking  in 
of  the  chest,  a  lateral  curvature  of  the  spine,  and  an 
abun riant  growth  of  granulations  from  the  pleura. 
If  the  cavity  is  large,  healing  can  take  place  only 
with  the  aid  of  surgery.  The  prognosis  is  consider- 
ably modified  by  the  character  of  the  infection,  thus 
a  pneumococcal  empyema  in  the  early  stages  may 
often  hv  cured  by  aspiratitin  alone,  as  the  organisms 
quickly  perish,  while  the  presence  of  other  pyogenic 
bacteria  will  always  indicate  free  drainage,  and  even 
then  extensive  subsequent  operations  may  be  de- 
manded. A  tuberculous  empyema  will  of  course 
present  a  grave  prognosis.  Cultures  in  these  cases, 
as  well  as  in  a  late  pneumococcal  empyema,  may  be 
sterile.  The  earlier  drainage  is  instituted,  the  greater 
the  chance  of  reexpansion  of  the  lung. 

The  trea talent  of  acute  cases  is  aspiration,  in- 
tercostal incision,  or  rib  resection;  chronic  cases  may 
demand  the  Est  lander,  Schede,  or  Fowler  operation. 
The  principle  in  acute  cases  is  to  remove  the  pus,  in 
chronic  cases  to  obliterate  the  cavity  by  causing  the 
chest  wall  to  collapse  or  the  lung  to  expand. 

Paracentesis  thoracis  (tapping)  may  be  per- 
formed with  an  ordinary  trocar  and  cannula,  but  as 
this  permits  the  introduction  of  air,  aspiration  should 
be  employed  whenever  possible.  A  hypodermic  or 
an  antitoxin  syringe  (Fig.  299),  with  a  long  and 
strong  needle  of  large  calil)re,  may  be  used  for 
diagnostic  purposes.  Pig,  300  shows  an  aspirator. 
The  stopper  is  inserted  into  a  large  glass  bottle, 
the  stop-cock  A  closed  and  the  stop-cock  B  opened,  a  vacuum  created  in 
the  glass  bottle  by  the  pump,  and  stop-cock  B  closed;  after  the  needle 
has  been  inserted  into  the  chest,  stop-cock  A  is  opened  and  the  6uid 
in  the  pleural  cavity  enters  the  bottle.  The  skin  and  needle  should 
be  disinfected,  and  the  patient  placed  in  a  semi-recumt>ent  posture, 
unless  such  is  contraindicated.  Local  anesthesia  is  usually  unnecessary^ 
although  it  is  desirable  to  give  a  little  whiskey  before  operation.  The 
puncture  is  generally  made  in  the  eighth  intercostal  space  near  the  angle  of 
the  scapula,  or  in  the  sixth  interspace  in  the  midaxillar)"  line.  A  small 
puncture  is  made  over  the  lower  rib  with  a  knife,  and  the  skin  pulled  upwards^ 
so  that  the  needle,  guarded  by  the  index  finger,  may  be  introduced  close  to  the 
upper  edge  of  the  rib,  in  order  to  avoid  the  intercostal  vessels;  thus  the  open- 


FlG»    J99, 

Antitoxin  syringe. 


^ 


4o8 


RESPIRATORY  SYSTEM. 


ing  is  valvular  and  closes  as  soon  as  the  needle  is  withdrawn.  If  the  tap  be  diy, 
a  stylet  may  be  introduced  into  the  needle  to  make  sure  that  it  is  not  plugged 
and  if  fluid  still  fails  to  come,  the  needle  should  be  partly  withdrawn,  and 
reintroduced  at  a  different  angle.  The  fluid  is  withdrawn  slowly,  and  the 
flow  stopped  for  a  time  if  there  is  faintness,  violent  cough,  or  marked  altera- 
tion in  the  pulse.  The  puncture  in  the  skin  is  covered  with  collodion.  Al- 
though it  is  true  that  aspiration  will  occasionally  cure  a  pneumococcal  empy- 
ema in  a  child,  it  is  generally  regarded  by  surgeons  as  an  exploratory  or  pal- 
liative measure.  For  the  latter  purpose  it  may  be  used  in  cases  of  rapid 
phthisis,  or  as  a  preliminary  measure  to  operation  in  bad  cases  in  which 
the  effusion  is  very  large  or  exists  on  both  sides.  With  these  exceptions, 
thoracotomy  (opening  the  pleural  cav-ity),  with  or  without  resection  of  a  rib, 
is  recommended  in  all  cases.  Thoracotomy  without  resection  of  a  lib  is  in- 
dicated when  the  patient's  condition  is  very  serious,  as  it  is  easOy  performed 


300. — ^Aspirator. 


under  local  anesthesia,  by  making  an  incision  al>out  two  inches  in  length 
along  the  lower  border  of  the  sixth  or  seventh  intercostal  space  in  the  mid- 
axillary  line.  A  small  opening  is  made  in  the  pleura,  in  order  to  allow  the 
pus  to  escape  slowly;  the  opening  is  then  enlarged,  loose  pieces  of  l3rmph  re- 
moved, and  a  short  rubber  tube  introduced.  The  tube  should  be  sutured 
to  the  skin  or  transfixed  with  a  large  safety  pin,  in  order  to  prevent  its  drop- 
ping into  the  ( avity.  Resection  of  a  portion  of  a  rib  is  the  usual  operation, 
as  it  allows  more  room  for  exploration  and  free  drainage.  The  patient  lies 
on  his  back  and  is  brought  to  the  edge  of  the  table.  A  two  or  three  inch 
incision,  with  its  center  in  the  midaxillar}^  line,  is  made  over  the  seventh  rib, 
and  the  periosteum  divided,  and  separated  from  the  entire  circumference 
of  the  rib  with  closed  curved  scissors  or  a  periosteal  elevator.  The  rib  is 
divided  at  each  extremity  of  the  incision  with  bone  forceps  and  removed,  the 
intercostal  vessels  having  been  pushed  aside  with  the  periosteum;  the  opera- 
tion then  proceeds  as  in  thoracotomy  without  resection  of  the  rib.  Irrigation 
of  the  ("avity  should  never  be  employed  in  acute  cases,  as  it  is  occasionally 
followed  by  death.  In  chronic  cases,  however,  in  which  the  adhesions  are 
firm,  irrigation  with  sterile  salt  solution  is  often  advisable,  particularly  if  the 
discharge  is  very  fetid.  The  tube  may  remain  in  place  until  the  purulent 
discharge  ceases,  or,  better,  it  may  be  removed  at  the  end  of  a  wedc,  and  a 


PNEUMOTOMY.  409 

Bier  suction  pump  used  once  or  twice  daily  until  the  lung  is  fully  expanded. 
If  the  sinus  persists  (pleural  fistula),  there  is  caries  of  a  rib  or  non-oblitera- 
tion of  the  cavity.  In  either  case  a  secondary  operation  will  be  required. 
If  the  lung  fails  to  reach  the  chest  wall  after  several  months,  the  chest  wall 
should  be  taken  to  the  lung  by  thoracoplasty  (Estlander  or  Schede  operation). 
One  may  first  try,  however,  injections  of  Beck's  bismuth  paste  (p.  79).  The 
cavity  is  filled  with  mixture  No.  i  (not  more  than  100  grams  being  used)  and 
the  opening  allowed  to  dose.  If  the  temperature  rises  above  loi**  or  severe 
pressure  symptoms  appear,  the  accumulated  fluid  is  evacuated  and  the  open- 
ing again  allowed  to  close.  Repetition  of  the  injection  is  necessary  only 
when  the  paste  is  discharged  with  the  pus. 

Estlander's  operation  consists  of  the  resection  of  a  sufficient  number  of 
ribs,  with  the  periosteum,  to  obliterate  the  abscess  cavity.  The  length  and 
number  of  ribs  to  be  removed  depend  upon  the  size  of  the  cavity.  In  a 
large  cavity  it  may  be  necessary  to  remove  three  or  four  inches  of  all  the 
ribs  from  the  third  to  the  ninth.  This  is  best  done  through  an  I-or  U- 
shaped  incision,  although  separate  incisions  may  be  made  in  every  other  inter- 
costal space,  and  the  rib  above  and  below  removed  through  each  incision. 
The  cavity  is  emptied  of  all  debris  and  packed  with  gauze. 

Schede's  operation  is  more  radical  and  more  severe.  A  U-shaped  inci- 
sion is  made  from  the  origin  of  the  pectoralis  major  at  the  level  of  the  axilla, 
down  to  the  lower  level  of  the  pleural  cavity,  then  up  to  the  level  of  the 
second  rib  between  the  spine  and  the  scapula.  This  flap  is  reflected  upwards, 
and  all  the  ribs  over  the  cavity  from  the  second  down,  and  from  their  tubercles 
to  the  costal  cartilages,  excised  together  with  the  periosteum,  intercostal  struc- 
tures, and  thickened  parietal  pleura.  Bleeding  is  checked,  the  cavity  curetted 
with  gauze,  and  the  flap  sutured  so  as  to  lie  in  contact  with  the  lung,  drainage 
being  provided  by  sterile  gauze.  After  any  operation  for  empyema  pul- 
monary gymnastics  should  be  given  to  expand  the  lung.  The  patient 
should  also  have  been  informed  that  the  resulting  deformity  is  necessary  to 
the  cure. 

Pulmonary  decortication^  or  total  pleurectomy  (Fowler's  operation)  y 
consists  in  excision  of  the  sinus,  resection  of  two  or  more  ribs,  and  stripping  of 
the  entire  pleura,  both  visceral  and  parietal,  from  the  subjacent  parts,  thus 
allowing  the  lung  to  expand.  The  flap  is  replaced  and  the  cavity  drained. 
Further  experience  is  needed  to  determine  the  status  of  this  operation,  al- 
though it  may  be  said  that  at  least  partial  decortication  of  the  limg  is  a  useful 
adjunct  to  either  the  Estlander  or  the  Schede  operation.  Ransohoff  has 
recently  modified  this  operation  by  making  longitudinal  incisions  in  the  pul- 
monary pleura  {discission  of  the  lung), 

Pneumotomy,  or  incision  of  the  lung,  is  indicated  in  pulmonary  gangrene 
or  abscess,  echinococcus  cysts,  and  in  certain  cases  of  bronchiectasis  and 
foreign  bodies.  It  has  been  employed,  but  is  rarely  justifiable,  for  tuber- 
culous ca\ities.  The  trouble  is  first  localized  by  physical  examination, 
the  X-ray,  and  by  the  aspirating  needle.  The  needle  is  left  in  place  as  a 
guide,  and  an  incision  made  exposing  the  pleura.  More  room  may  be  obtained 
by  resecting  the  rib  above  and  below.  Often  the  pleura  will  be  adherent, 
and  the  cavity  may  be  at  once  opened  with  the  thermo-cautery  and  drained 
with  a  soft  rubber  tube.  Loose  particles  of  necrotic  tissue  are  removed,  but 
curettage  and  irrigation  should  be  avoided.  If  the  layers  of  the  pleura  are 
not  adherent,  they  may  be  sutured  together  in  order  to  avoid  pneumothorax 


4IO  DISEASES   OF  THE  BREAST. 

and  infection  of  the  pleural  ca\ity,  and  the  incision  into  the  lung  postponed 
for  twenty-four  hours,  or  longer  if  there  be  no  urgency.  The  positive  and 
negative  pressure  methods  for  preventing  pneumothorax  are  described  on 
p.  406. 

Pneumectomy,  or  excision  of  a  part  of  the  lung,  may  be  indicirted  in 
pneumocele,  or  in  tumors  of  the  chest  wall  which  have  invided  the  superfi- 
cial portion  of  the  lung.  The  operation  has  been  performed  for  tuberculosis 
but  cannot  be  recommended,  because  in  the  localized  form  recovery  fre- 
quently follows  medical  treatment,  and  in  the  diffuse  variety  the  disease 
cannot  be  removed.  The  measures  already  indicated  to  guard  against 
pneumothorax  should  be  taken,  and  after  resection  bleeding  may  be  con- 
trolled by  sutures,  ligatures,  the  cautery,  or  by  gauze  packing. 

Pneumolysis  is  a  term  applied  by  Friedrich  to  an  operation  which  he 
practises  for  unilateral  phthisis  pulmonalis.  After  making  an  incision  like 
that  for  Schede's  operation,  the  ribs,  from  the  second  to  the  tenth,  and  from 
the  costal  cartilages  back  to  and  including  the  heads,  are  removed  without 
opening  the  pleura,  thus  allowing  the  chest  wall  to  collapse,  putting  the 
lung  at  rest,  and  favoring  cicatrization  of  the  cavities.  Murphy  has  injected 
nitrogen  gas  into  the  pleural  cavity  with  the  same  end  in  view.  Pneumolysis 
is  still  in  the  experimental  stage. 

Pulmonary  alveolar  emphysema,  according  to  Freund,  is  the  result,  not 
the  cause,  of  the  dilated,  rigid  thorax  characteristic  of  this  disease.  He, 
therefore,  excises  about  two  inches  of  the  ribs,  from  the  second  to  the  sixth, 
including  the  costochondral  junctures,  with,  he  states,  marked  benefit  in 
some  cases. 

Mediastinal  abscess  may  be  traumatic,  or  secondary  to  a  suppurative 
process  in  the  neck  or  intrathoracic  organs.  The  symptoms  are  those  of 
sepsis  (except  in  chronic  cases),  and  pressure,  as  in  aneurysm,  from  which 
the  condition  may  be  distinguished  by  the  absence  of  thrill,  bruit,  and  expan- 
sile pulsation.  In  doubtful  cases  a  fine  needle  may  be  introduced.  Various 
tumors,  both  benign  and  malignant,  may  originate  in  the  mediastinum  and 
produce  identical  pressure  symptoms.  Abscesses  should  be  drained  after 
localizing  them  with  the  aspirating  needle.  Tumors  are  for  the  most  part 
beyond  the  aid  of  present-day  surgery,  but  in  a  few  instances  operative  relief 
may  be  attempted.  The  anterior  mediastinum  may  he  approached  by  resect- 
ing a  portion  of  the  sternum;  the  posterior  mediastinum  has  been  opened 
cxtrapleurally  by  resecting  the  ribs  near  the  spine.  The  possibility  of  re- 
moving foreign  bodies  impacted  in  the  thoracic  portion  of  the  esophagus,  as 
well  as  resecting  portions  of  the  gullet  for  malignant  disease,  is  presented  by 
the  latter  route. 


CHAPTKR  XXV. 
DISEASES  OF  THE  BREAST. 

Congenital  malformations  such  as  incom})lcte  development  (micro- 
mazia)  or  absence  of  the  breasts  {amazia)  and  supernumerary  nipples  and 
mammie  {polymastia)  require  no  treatment. 

Retracted  nipples  may  be  congenital  or  <iue  to  contraction  from  ulcera- 


MASTITIS. 


4ir 


lion,  mastitis,  or  tumors.  OiTasionally  the  roinlilion  may  hv  Imnvfiit'tl  l>y 
repeatedly  drawing  the  nipple  out  with  the  lingers  or  with  the  breast  pump. 
Nursing  can  ohen  be  aixomplishecl  \\y  means  of  the  nipple  shiekl. 

MaimnilitiSi  or  inllammation  of  the  nipple,  is  almost  invariably  associ- 
ated with  lactation,  the  delicate  epithelium  becoming  macerated  by  milk  and 
saliva,  and  easily  excoriated  {fissured  or  cracked  nippies).  The  inllammation 
may  extend  to  the  surrounding  skin,  or  cause  an  abscess  of  the  breast  by 
spreafling  along  the  milk  durts  or  lymphatics;  occasionally  the  nipple  is  de- 
stroyed by  ulceration.  Nursing  is  painful  and  often  followed  by  bleeding, 
hence  is  often  postponed,  thus  leading  to  engorgement  of  the  breast.  The 
tr e  a  tm  en  t  sh  o  u  I  d  b  egi n  before  t  h  e  t  ro  u  bl  e  i  s  i  n  a  u  gu  rat  ed .  To  w  a  rd  s  t  he  en  d 
of  pregnancy  the  epithelium  may  be  hardened  by  bathing  with  alcohol, 
during  lactation  the  nipples  should  be  washed  before  and  after  nursing  with 
boric  add  solution,  and  carefully  dried.  If  a  small  tissure  forms,  it  may  be 
sprayed  with  peroxid  of  hydrogen,  washed  with  boric  acid  solution,  and 
dusted  with  boric  powder,  a  nipple  shield  being  used  during  nursing.  In 
the  more  severe  forms  the  child  should  be  weaned,  the  secretion  of  milk  sup- 
pressed by  the  application  of  belladonna  ointment  and  a  pressure  bandage, 
and  the  nipple  treated  with  peroxid  of  hydrogen,  boric  acid  solution »  and 
applications  of  silver  nitrate. 

Paget's  disease  (malignani  dfrmcUiiis)  is  a  chronic  destructive  inflamma- 
tion of  the  nipple,  usually  occurring  in  women  past  middle  life.  Some  con- 
sider certain  psorosperms  as  the  cause  of  this  condition,  but  such  has  not 
been  proved.  At  first  there  is  a  moist  desquamation,  later  a  sticky  yellowish 
discharge  \vith  the  formation  of  crusts,  beneath  which  the  surface  is  red  and 
raw*.  The  nipple  may  be  retracted  or  even  destroyed,  and  the  condition 
may  extend  to  the  skin  of  the  breast.  It  is  not  a  simple  eczema,  which, 
however,  may  attack  the  nipple,  but  a  precursor  of  carcinoma  of  the  breast. 
The  treat meni  h,  therefore,  excision  of  the  diseased  area,  and  also  the  lireast 
and  axillary  glands  if  there  are  any  indurations  in  the  breast. 

Abscess  of  the  areola  rer|uires  incision  and  drainage.  It  usually  arises 
from  the  sebat  eous  follirles,  and  is  most  fre(|Uent  in  girls  about  puberty. 

Tumors  of  the  nipple  include  papilloma,  epithelioma,  ribrf>ma,  angei- 
oma,  myxoma,  and  myoma.  Sc])aceous  cysts  may  arise  from  the  nipple  or 
the  areola. 

Neuralgia  of  the  breast  (masiodyfila)  is  usually  associated  with  hyperes- 
thesia of  the  skin  and  deep  tenderness  of  the  gland,  but  no  organic  change  can 
be  detected.  It  is  most  common  in  young  unmarried  women  and  may  Ije 
associated  with  ovarian  disturl>ances.  Local  treatment  should  be  avoided 
and  the  general  health  improved. 

Hypertrophy  is  generally  bilateral,  begins  at  puberty,  and  does  not 
interfere  with  the  general  health ;  occasionally  the  patient  complains  of  neu- 
ralgia. The  growth  is  slow,  but  the  breasts  may  attain  an  enormous  size. 
The  consistency  may  be  normal t  or  there  may  be  a  diffuse  firmness  due  to  an 
increase  in  the  fibrous  tissue,     .imputation  is  the  only  remedy. 

Acute  mastitis,  ormammitis,  is  occasionally  seen  in  women  as  a  metas- 
tatic process  during  the  course  of  mumps.  In  giris  and  sometimes  in  Iwys 
al>out  the  age  of  pul>erty  the  breast  may  become  large  and  tender,  and  after 
persisting  for  weeks  go  on  to  resolution,  although  suppuration  is  occasionally 
seen,  A  somewhat  similar  condition  is  encountered  in  children  soon  after 
birth,  particularly  if  the  nurse  has  tried  to  '* break  the  nipple  string"  by 


i 


412  DISEASES   OF  THE  BREAST. 

pulling  or  rubbing.  Acute  mastitis,  however,  is  most  often  seen  during  the 
puerperium,  usually  as  the  result  of  cracked  nipples,  the  infection  passing 
along  the  milk  ducts  or  the  lymphatics. 

The  Sjrmptoms  are  pain,  tenderness,  swelling,  localized  heat,  hardening  of 
the  breast,  and  the  constitutional  signs  of  fever.  If  abscess  of  the  breast 
follows,  the  skin  becomes  red  and  edematous,  the  pain  more  intense,  and  in 
the  later  stages  fluctuation  appears.  The  pus  may  be  between  the  skin  and 
the  gland  {supramammary  abscess),  in  the  gland  (intramammary  abscess),  or 
beneath  the  breast  (submammary  abscess)  as  the  result  of  extension  from  the 
deep  lobules.  The  last  may  be  due  also  to  disease  of  the  ribs  and  like 
conditions. 

The  treatment  of  acute  mastitis  is  suspension  of  nursing,  depletion  by 
means  of  the  breast  pump,  support  of  the  gland  by  a  sling  or  bandage,  and 
the  application  of  ichthyol  or  an  evaporating  lotion.  Fissures  should  be 
disinfected  and  the  general  health  improved.  In  the  later  stages  resolution 
may  be  hastened  by  gentle  massage.  If  pus  forms,  the  treatment  is  the  same 
as  for  suppuration  elsewhere.  In  an  intramammary  abscess  the  incision 
should  radiate  from  the  nipple,  so  as  to  be  parallel  with  the  milk  ducts,  and  a 
finger  should  be  introduced  to  open  any  adjacent  lobules  which  may  be  dis- 
tended with  pus.  When  the  abscess  is  in  the  upper  portion  of  the  breast,  it 
is  often  desirable  to  make  a  counterincision  below  and  introduce  a  drainage 
tube.     A  retromammary  abscess  is  best  opened  at  the  lower  and  outer  side. 

Milk  fistulas  follow  abscesses  or  incisions,  and  are  treated  as  sinuses  else- 
where. 

Chronic  mastitis  may  be  divided  primarily  into  the  non-suppurative  and 
the  suppurative,  although  the  term  is  often  used  to  designate  the  former  only. 
Chronic  non-suppurative  mastitis  occurs  in  two  forms,  the  circumscribed  and 
the  diffuse.  Chronic  circumscribed,  or  lobarmastitis,  may  follow  trauma 
or  pregnancy,  but  is  most  fre(|uent  in  women  approaching  the  menopause. 
One  or  more  of  the  lobes  become  enlarged,  indurated,  tender,  and  some- 
times the  seat  of  severe  neuralgia,  which  is  apt  to  be  worse  during  menstrua- 
tion. The  condition  may  persist  for  months  or  years,  but  never  terminates  in 
suppuration.  Chronic  diffuse,  lobular,  or  interstitial  mastitis  may  occur 
at  any  time  after  puberty,  but  is  most  frequent  after  lactation  or  at  the  climac- 
teric. There  is  a  marked  increase  in  the  connective  tissue,  which  ultimately 
contracts,  causing  induration,  shrinkage  of  the  breast,  depression  of  the 
nipple,  and  the  formation  of  cysts  owing  to  pressure  on  the  ducts,  which 
prevents  the  escape  of  degenerated  and  li(iuefied  epithelium  which  has  under- 
gone proliferation.  There  may  be  pain,  tenderness,  and  a  watery  discharge 
from  the  nipple.  The  disease  rarely  disappears,  but  usually  terminates  in 
atrophy  of  the  breast,  the  gland  becoming  hard,  nodular,  and  shrunken,  or  in 
general  cystic  degeneration,  or  possibly  carcinoma.  The  diagnosis  from 
carcinoma  may  be  difTicult  or  even  impossible  without  microscopic  examina- 
tion. The  involvement  of  the  opposite  breast,  the  absence  of  a  distinct 
tumor,  the  presence  of  small  cysts,  the  long  duration,  with  preservation  of  the 
general  health,  and  without  infiltration  of  the  perimammary  tissues  or  in- 
volvement of  the  axillary  glands,  all  point  to  interstitial  mastitis. 

The  treatment  of  the  above  forms  of  chronic  mastitis  is  the  removal  of 
any  source  of  irritation,  such  as  badly  fitting  corsets;  support  by  a  bandage; 
local  applications  of  belladonna  and  mercury;  and  the  internal  administra- 
tion of  potassium  iodid.     If  there  be  doubt  as  to  the  nature  of  the  conditition, 


TUMORS    OF   THE    BREAST, 


413 


if  there  be  a  diffuse  cystic  change,  or  if  the  disease  cause  much  pain  or  anxiety, 
the  breast  should  be  amputated. 

Chronic  suppurative  mastitis  is  characterized  by  the  formation  of  pus, 
often  without  symptoms  of  intlammation ;  it  follows  lactation,  probably  as  the 
result  of  infection  of  galactmeles,  or  it  may  be  due  to  syphilis,  tuberculosis, 
or  actinomycosis.  The  abscess  wall  is  often  so  thick  as  to  resemble  a  tumor, 
and  in  several  instances  the  breast  has  l>een  removed  as  the  result  of  an 
incorrect  diagnosis.  A  hollow  needle  or  an  exploratory  incision  will  dispel 
all  doubt.  The  treatment  is  incision,  disiJifection,  and  drainage^  or,  if  the 
breast  is  totally  destroyed,  amputation. 

Tuberculosis  of  the  l>reast  may  be  localized  (cold  abxcess)  or  diffuse,  but 
is  not  common.  In  the  diffuse  form  the  breast  is  riddled  with  sinuses  which 
discharge  caseous  pus.  The  disease  may  be  primary,  or  secondary  to  tuber- 
culosis of  neighboring  parts.  The  Ireahnenl  of  the  diffuse  form  is  amputa- 
tion  of  the  breast.  Sharply  locah*zed  disease  may  lie  treated  by  excision,  or 
by  incision  and  curettage. 

Syphilitic  affections  of  the  breast  include  chancre,  mucous  patches, 
condylomata,  and  gummata,  the  appearances  and  treatment  of  which  have 
already  been  given. 

Tumors  of  the  breast  may  be  of  almost  any  variety,  but  only  the  most 
common  forms  re(|uire  special  description.  In  palpating  a  breast  for  a  tumor, 
the  gland  should  be  pressed  against  the  chest  wall  with  the  flat  of  the  hand,  as 
picking  up  the  tissues  between  the  fingers  gives  a  deceptive  sense  of  a  j\q\\ 
growth. 

Fibroadenoma  is  the  most  common  benign  tumor  of  the  breast.  Pure 
adenoma  and  pure  fibroma  are  ver>'  rare.  Fibroadenoma  usually  originates 
in  women  between  puberty  and  the  thirtieth  year.  It  is  hard,  slightly  nodu- 
lar, freely  movable,  generally  but  not  always  painless,  and  unassociated  with 
impairment  of  the  general  health,  axillary  involvement,  or  retracticm  of  the 
nipple.  Cystic  changes  occur  in  a  few  cases,  but  sarcomatous  or  carci- 
nomatous degeneration  is  rare.  The  trealmettt  is  enucleation  of  the  growth 
from  its  capsule,  the  incision  radiating  from  the  nipple.  In  order  to  conceal 
the  scar,  Thomas  makes  the  incision  along  the  lower  margin  of  the  breast, 
which  is  then  turned  upward,  and  the  growth  removed  from  behind  by  a  V- 
shaped  incision  that  is  subsequently  sutured. 

Cystadenoma,  or  adenocele,  is  characterized  by  dilatation  of  the  acini 
and  small  ducts  of  adenomatous  tissue  into  cysts,  into  which  libropapillo- 
ma  toys  vegetations  project,  hence  the  Itrms  proli/irons  mammary  cyst,  intra- 
canalifular  fibroma,  and  dud  papilloma  (the  last  term  is  often  restricted  to  a 
small  cyst  situated  near  the  nipple  and  containing  a  warty  growth).  The 
tumor  grows  slowly  but  may  attain  a  large  size,  and  in  the  later  stages  ad* 
heres  to  the  skin  and  may  even  break  through  it.  It  is  nodular,  encapsulated, 
movable,  occurs  between  the  thirtieth  and  fortieth  years,  is  generally  painless, 
and  may  be  associated  with  a  bloody  discharge  from  the  nipple,  as  the  result 
of  intracystic  hemorrhage.  It  is  hard,  but  varies  in  consistency  according  to 
the  size  of  the  cysts.  It  does  not  infiltrate  the  surrounding  tissues  or  involve 
the  axillary  glands.  Carcinomatous  and  sarcomatous  degeneration  are 
jK>ssi  hi  lilies.  The  treatment  in  the  early  stages  is  removal  of  the  growth  alone, 
but  in  the  later  stages  it  will  usually  be  necessar}'  to  amputate  the  breast. 

Sarcoma  (Fig.  301)  constitutes  less  than  5  per  cent,  of  all  breast  tumors; 
the  cells  may  be  of  any  type,  authorities  differing  as  to  whether  the  round-  at 


i 


414 


DISKASKS    01'    THE   BREIAST. 


the  spindle-telled  variety  is  the  most  frequent.  Cyst  furmatian  occurs  In 
about  half  the  cases,  as  the  result  of  hemorrhage,  degeneration,  or  obstruction 
to  the  tubules  {cystosarcoma).  Adenosarcoma  is  that  form  which  develops 
from  an  adenoma  or  a  fibroadenoma,  or  in  which  the  tubules  and  acini  prolif- 
erate. Indammation  and  suppuration  are  common,  and  myxomatous,  fatty, 
calcareous,  and  telangiectatic  changes  may  occur.  Sarcoma  usually  appears 
between  the  ages  of  twenty-five  and  thirty,  grows  rapidly,  is  encapsulated*  is 
brm  or  soft  according  to  the  constituent  cell,  causes  distention  of  the  over- 
lying veins,  and  does  not  ijivolve  the  axillary  glands  until  ulceration  has 
occurred;  it  docs,  however,  give  rise  to  early  metastases  in  the  viscera.  Pain 
is  often  severe,  and  discharge  from  the  nipple  frequent.  It  differs  from  car- 
cinoma in  that  it  occurs  at  an  earlier  age,  is  more  movable,  grows  more 


Fjg.  301. — Round-celled  sarcoma  of  ihc  breast  \^hL(.h  jtini  bruken  ihrou^li  ihe  skin  and 
given  rise  to  repealetl  hemorrhages.     (Jefferson  Hoapilal  i 


rapidly,  is  less  uniform  in  consistency,  does  not  retract  the  nipple  or  cause 
enlargement  of  ihe  lymph  glands,  except  in  rare  cases,  and  even  when  ulcer- 
ating does  not  in  fill  rale  or  markedly  thicken  the  skin.  The  prognosis  is 
very  grave.  The  inatment  is  removal  of  the  breast  and  the  a.xillary  glands. 
Carcinoma  constitutes  over  80  per  cent.  o»*  all  breast  tumors,  so  that  any 
lump  in  the  mammary  gland  must  be  regarded  as  mah'gnant  unless  positive 
proof  to  the  contrary  is  forthcoming.  It  attacks  the  male  breast  in  about 
one  per  cent,  of  the  cases.  The  inlluence  of  heredity  is  probably  very  slight, 
but  the  frequency  of  preceding  trauma  or  mtlammation  seems  to  be  more 
than  a  coincidence.  The  importance  of  I^aget*s  disease  as  a  precancerous 
condition  has  already  been  mcnlioned.  Cancer  of  the  breast  is  said  to  be 
more  lommon  in  women  whn  have  l>orne  children,  but  this  statement  is 
greatly   weakened  when  ihe  comparatively  small  number  of  nullipara*  is 


CARCIMOMA    OF    THE    BREAST. 


415 


considered.  It  is  moru  frequent  in  the  left  breast  than  in  the  right,  and  is 
usually  encountered  after  the  age  of  thirlylive,  although  it  may  occur  at  a 
much  earlier  period.  There  are  three  primar}'  varieties,  viz.,  (i)  the  sphe- 
roidal-celled or  acinous,  (2)  the  columnar-celled  or  duct  cancer,  and  (3)  the 
squamous-celled  or  epithelioma  of  the  nipple.  (1)  The  acinmds  form  may 
be  medullary,  simple,  or  scirrhous.  Colloid  or  myxomatous  cancer  is  a 
rare  variety  in  which  one  of  the  former  has  undergone  mucoid  degeneration. 
Meduilary,  atcephaloidj  or  soft  cancer  grows  rapidly,  quickly  ulcerates, 
causes  early  metastases,  and  appears  earlier  in  life;  as  a  rule  the  skin  is 
distended  rather  than  dimpled,  and  the  nipple  is  not  retracted.  As  it  may 
feel  hot,  owing  to  its  vascularity,  and  often  follows  pregnancy,  it  may  lie 
mistaken  for  mastitis  or  an  abscess,  A  simple  cancer  approaches  the  normal 
in  the  relative  amount  of  fibrous  and  epithelial  tissues,  and  is  midway 
between  the  encephaloid  and  the  scirrhous  in  hardness  and  malignancy* 
The  Siirrhous  or  hard  cancer  grows  more  slowly,  and  is  nodular  and  of  a 
stony  hardness;  it  infiltrates  the  glandular  tissue,  and  cannot  be  moved 
without  carrying  the  breast  with  it.  In  the  early  stages,  with  the  breast 
held  firmly,  the  tumor  may  be  moved  perpendicularly  to  but  not  parallel 
with  the  milk  ducts.  Later  it  invades  the  pectoral  muscle,  when  the  whole 
breast  (not  the  tumor)  may  be  moved  up  and  down,  but  not  in  the  direction 
of  the  muscle  fibres;  anti  finally  it  adheres  to  the  chest  wall  and  becomes 
absolutely  immovable.  Owing  to  the  contraction  of  the  fibrous  septa  of  the 
breast,  small  depressions  appear  in  the  skin,  which  has  been  likened  to  pig's 
skin,  or  the  rind  of  an  orange.  The  growth  is  most  frequent  in  the  upper 
and  outer  segment  of  the  gland.  When  it  orginates  in  or  invades  the  tissues 
near  the  nipple,  the  nipple  is  retracted,  shrunken,  and  fixed,  and  occasion- 
ally exudes  a  thin  blcjody  discharge.  Pain  is  absent  at  first,  but  in  the  final 
stages  becomes  agonizing  owing  to  involvement  of  the  axiliary  nerves. 
Cachexia  also  is  a  late  symptom.  Ulceration  is  preceded  l>y  a  reddish  or 
purplish  discoloratitm  of  the  skin.  A  scirrhous  ulcer  is  deep  and  has  an 
offensive  sanious  discharge,  a  sloughing  base,  and  hard,  irregular,  everted 
margins.  Extensive  infiltration  of  the  skin  is  called  cancer  en  cuirasse. 
*  Occasionally  cysts  form,  probal)ly  as  the  result  of  obstruction  of  the  ducts. 
The  axillary  lymph  glands  are  enlarged  in  the  eariy  stages  and  probably 
harbor  cancer  cells  within  even  the  first  few  weeks.  Later  the  supraclavicu- 
lar glands  become  enlarged.  Pressure  on  the  axillary  vein  and  lymph  vessels 
causes  a  solid  edema  of  the  upper  extremity.  When  the  lymphatics  running 
to  the  axilla  are  biocked,  and  when  the  growth  involves  the  sternal  half  of  the 
gland  or  its  costal  surface,  metastases  occur  in  the  chest,  the  lymph  from  the 
inner  half  of  the  gland  entering  the  anterior  mediaslinum  through  the  second 
and  fourth  intercostal  spaces,  and  that  from  its  costal  surface  passing  back- 
wards to  the  pMjsterior  mediastinum.  Occasionally  the  opposite  breast  and 
the  glands  in  the  opposite  axilla  becrjme  enlarged,  becauseof  the  free  lymphatic 
anastomosis  across  the  middle  line.  A  scirrhus  is  never  of  great  si^e,  and 
occasionally  in  old  women  the  contracting  librous  tissue  is  so  abundant  that 
the  tumor  shrinks  rather  than  enlarges  {airophic  or  withering  scirrhus);  these 
cases  may  last  for  many  years.  An  ordinary  untreated  scirrhus  usually 
causes  death  in  from  two  to  three  years,  an  encephaloid  in  from  six  to  twelve 
months.  (2)  Dtat  cancer  springs  fmm  the  duct  walls,  particulariy  in  cystic 
disease  of  the  Ijreast,  but  is  not  common.  It  involves  the  skin  anfl  lymph 
glands  late,  and  is  softer  than  scirrhus.     There  is  often  a  bloody  tlischarge 


41 6  DISEASES   OF  THE   BREAST. 

from  the  nipple.  (3)  Epi(heliom<i  of  the  nipple  presents  the  same  features  as 
epithelioma  elsewhere;  it  is  often  preceded  by  Paget *s  disease  of  the  nipple. 

The  treatment  is  amputation  of  the  breast  and  evacuation  of  the  axilla  as 
soon  as  the  growth  is  detected.  Some  recognize  no  contraindication  to 
operation  excepting  visceral  metastases,  and  remove  portions  of  the  chest  wall 
or  even  the  entire  upper  extremity.  Most  surgeons  exclude  cases  of  cancer 
en  cuirasse  and  those  in  which  there  is  extensive  involvement  of  the  axilla  and 
supraclavicular  glands.  In  an  atrophic  scirrhus  in  an  old  woman  the  prog- 
nosis may  be  better  without  than  with  operation.  Suggestions  for  the  treat- 
ment of  inoperable  cases  will  be  found  on  p.  140.  While  most  surgeons 
have  their  own  method  of  operating,  they  all  imitate  to  a  greater  or  lesser 
extent  Halsted,  to  whom  is  due  the  credit  for  elaborating  the  modem  opera- 
tion for  cancer  of  the  breast.  Halsted* s  operation 
aims  to  remove  in  one  piece  the  entire  breast  and 
overlying  skin,  the  costal  portion  of  the  pectoralis 
major,  the  pectoralis  minor,  and  all  the  fat  and 
glands  of  the  axilla.  The  supraclavicular  glands 
are  removed  in  a  second  piece.  An  indsion  (Fig. 
302)  is  carried  through  the  skin  and  fat,  and  the 
triangular  flap  ABC  turned  back.  The  costal 
portion  of  the  pectoralis  major  is  divided  close 
to  the  ribs  and  separated  from  the  clavicular 
portion,  which  with  the  overlying  skin  is  divided 
up  to  the  clavicle,  exposing  the  apex  of  the  axilla; 
F  — m*    •  these  flaps  are  drawn  upwards  with  a  retractor 

iG.  302.    (  mnie.)  ^^^  separated  from  the  underlying  tissues,  and 

the  muscle  further  split  as  far  as  the  humerus,  where  it  is  severed  close  to  the 
bone.  The  breast,  pectoralis  major,  and  all  fat  arc  stripped  from  the  chest 
wall,  including  the  pectoralis  minor,  which  is  di\ided  at  each  end,  thus  ex- 
posing the  entire  axilla,  which  is  cleansed  of  fat  and  lymphatic  glands  from 
above  and  within,  downwards  and  outwards,  all  small  vessels  being  ligated 
dose  to  the  axillar)'  vessels,  which,  with  the  nerves,  should  alone  remain. 
The  triangular  flap  of  skin  is  drawn  outwards  and  the  lateral  and  posterior 
walls  of  the  axilla  likewise  cleared,  the  subscapular  vessels  being  ligated,  and 
the  subscapular  nerves  preserved  if  possible.  The  mass  is  then  turned  in- 
ward, and  removed  from  the  chest  by  cutting  from  B  to  C.  A  vertical  inci- 
sion is  now  made  along  the  posterior  margin  of  the  stcrnomastoid,  and  the 
supra-  and  infraclancular  fat  and  glands  removed  by  dissecting  from  the 
junction  of  the  internal  jugular  and  subclavian  veins  downwards  and  out- 
wards. The  cer\'ical  wound  is  sutured,  and  the  edges  of  the  chest  wound 
approximated  by  a  buried  purse-string  suture  of  silk,  which  includes  the  base 
of  the  triangular  flap,  the  apex  being  spread  over  the  axilla.  The  rest  of  the 
woun<i  is  covered  with  Thiersch's  skin  grafts.  The  axilla  is  not  drained. 
The  disability  resulting  after  such  an  extensive  operation  is  surprisingly  slight. 
The  author  prefers  a  long  elliptical  incision  extending  from  the  insertion  oi 
the  pectoralis  major  to  the  ensiform  cartilage,  because  the  apex  of  the  trian- 
gular flap  described  above  is  ver}'  apt  to  slough,  and  because  it  is  often 
desirable  to  remove  the  fascia  over  the  upper  part  of  the  rectus  abdominis. 
The  tendons  of  the  pectoralis  major  and  minor  are  then  divided  and,  as 
suggested  by  Gerster,  the  axilla  cleared  l)cfore  removing  the  breast.  Thus 
the  lymphatics  are  secured  at  once  and  difl^usion  of  cancer  cells  prevented. 


HARE-LIP.  417 

the  branches  of  the  axillary  vessels  tied  at  their  origin  and  bleeding  mini- 
mized,  and  the  chest  protected  from  cold  by  the  breast  almost  until  the  end  of 
the  operation.  The  entire  wound  may  be  closed  in  most  cases  by  fashioning 
two  flaps  from  the  lower  lip  of  the  wound  as  is  shown  in  Figs.  337,  338.  A 
small  gauze  drain  should  always  be  placed  in  the  axilla,  preferably  thpugh 
a  small  incision  at  its  posterior  margin,  in  order  to  drain  the  large  quantity  of 
fluid  which  escapes  from  the  severed  lymph  vessels.  The  mortality  of  the 
modem  breast  amputation  is  less  than  3  per  cent.  'The  percentage  of  per- 
manent cures,  i.e.,  after  three  years,  is  about  20  per  cent.,  although  Halsted 
and  Cheyne  show  a  record  of  about  50  per  cent. 

Cysts  of  the  breast  are  to  be  distinguished  from  cystic  degenerations, 
which  may  occur  in  any  form  of  mammary  tumor,  but  particularly  in  sar- 
coma and  cystadenoma  (p.  413). 

Acinous  or  retention  cysts  are  caused  by  blocking  of  the  ducts,  and 
pressure  upon  them  will  often  cause  a  discharge  from  the  nipple.  Such  cysts, 
when  occurring  during  the  nursing  period,  contain  milk  {galaiocele).  A  milk 
or  lacteal  cyst  is  round,  situated  near  the  nipple,  and  usually  painless;  it 
fluctuates,  except  in  old  cases  in  which  the  wall  is  thick  or  the  contents  solid. 
The  treatment  is  incision  and  drainage.  Involution  cysts  {cystic  degeneration 
of  tfie  breast)  occur  in  the  course  of  interstitial  mastitis,  or  after  the  meno- 
pause when  the  breast  is  undergoing  degenerative  changes.  They  are  small 
and  numerous,  and  may  contain  intracystic  fibropapillomatous  vegetations. 
Both  glands  are  usually  affected.  The  treatment  is  amputation  of  the  breast, 
because  of  the  danger  of  carcinoma. 

Interacinous  cysts  are  unconnected  with  the  ducts,  do  not  cause  a  dis- 
charge from  the  nipple,  contain  no  intracystic  growths,  and  are  lined  with 
endothelium  instead  of  epithelium.  They  contain  serum,  and  are  supposed 
to  originate  from  the  lymph  spaces.  They  may  be  single  or  multiple.  The 
diagnosis  may  be  made  in  doubtful  cases  by  the  use  of  the  exploring  needle. 
The  treatment  is  excision  of  the  cyst.  Hydatid  and  dermoid  cysts  also  occur 
in  the  breast,  but  are  rare,  and  are  treated  by  excision. 


CHAPTER  XXVI. 
UPPER  DIGESTIVE  APPARATUS. 

THE  LIPS. 

Hare-lip  is  a  congenital  cleft  in  the  upper  lip  due  to  non-imion  of  the 
frontonasal  and  superior  maxillary  processes  (p.  379).  The  term  is  mislead- 
ing, as  the  cleft  is  not  central  as  in  a  hare's  lip,  although  a  median  hare-lip  is 
a  possibility.  Hare-lip  may  be  single  or  double,  incomplete  or  complete, 
and  it  may  or  may  not  be  associated  with  deft  palate.  It  is  more  frequent  on 
the  left  side,  more  common  in  males,  and  is  sometimes  hereditary.  When 
double,  the  intermaxillary  bones  often  fail  to  unite  and,  with  the  central 
portion  of  the  lip,  project  forward.  In  all  cases  the  nose  is  broadened  and 
flattened. 

The  best  time  for  operation  is  between  the  third  and  sixth  months  of  life, 
i.e.,  before  dentition  begins.     The  principles  of  any  operation  for  hare-lip 

27 


4i8 

are  to  pare  the  edges  of  the  cleft,  hnng  the  flaps  together  without  tension  by 
sepa rating  the  lip  from  the  gum,  and  to  have  the  vermillion  of  the  lip  in  align- 
ment and  a  little  projection  at  the  edge  formerly  occupied  by  the  gap.  The 
suture  material  is  usually  silkworm  gut,  introduced  through  the  entire  thick- 
ness of  the  lip,  and  removed  at  the  end  of  a  week.  In  order  to  avoid  the 
scarring  of  stitches,  chromicized  catgut,  passed  through  all  the  tissues  except 
the  skin  and  tied  within  the  mouth,  may  be  employed,  an  additional  sub- 
cuticular stitch  lieing  used  if  necessary.  In  order  to  prevent  aspiration  of 
blood,  the  patient  should  be  placed  in  the  Trendelenburg  ptjsture,  or  on  the 


y 


'^ 


Fig.  303.  Fig,  304, 

Figs,  303  and  304, — Malgaignc,     (Elsmarth  and  Kowalzig/) 


f*iG.  305.  .    Fia  306. 

Figs.  305  and  306,— NcUton.     (Esmarch  and  Kowalxig.) 


t'»ti.  307.  Fig.  308. 

Figs.  307  and  jo8.— MiraulL     (Ksniarch  and  Kowakig.) 

back  with  the  head  hanging  over  the  end  of  the  table  (Rose's  position).  No 
dressing  need  be  applied  to  the  wound ^  although  some  surgeons  prefer  to  use 
collodion.  Some  measures,  such  as  splinting  the  elbow  joint,  should  be  em- 
ployed to  prevent  disturbance  of  the  wound  by  the  child's  fingers.  The 
child  is  fed  with  a  spoon  or  medicine  dropper,  until  able  to  return  to  the 
breast.  Figs.  303  to  308  illustrate  various  operations  for  incomplete  hare-lip, 
and  Figs.  309  to  ^ig  operations  for  (omplcte  single  hare-lip.  Operations 
for  doulde  uitcnmplicated  hare-lip  are  illustrated  in  Figs.  3^0  to  328.  Double 
harelip  compHcatetl  by  protrusion  of  the  intermaxillary  bone  must  be  treated 
by  removing  or  replaciiig  the  projecting  bone,  the  sc)ft  parts  being  united 


3M  l«» 


Oblique  facial  cleft,  rujiniiig  from  the  Imver  lid  to  the  mouth,  and  result- 
ing from  non-closure  of  the  naso-orbital  iissure,  is  a  rare  deformity.  Cleft 
of  the  lower  lip  or  lower  jaw  is  very  rure,  and  due  to  non-union  of  the  man- 
dibular processes  in  the  midtlle  line.  Macrostoma,  or  enlarged  mouth,  is 
due  to  defective  imioii  of  the  maxillary  and  mandibular  processes;  micro- 
stoma, or  small  mouth,  to  excessive  fusion  of  these  processes.  All  these 
conditions  mity  be  remedied  by  plastic  t>per:ilions. 

Cracked  or  chapped  lips^  the  rc'^ult  of  cold,  and  herpes  hbrnlis,  or  fever 
Misters,  are  treated  by  the  application  of  cold  cream,  i*r  better  a  stnmg  solu- 
tion of  silver  nitrate.     Cracks  and  fissures  radiating  from  the  angles  of  the 


Fig,  .326.  I'Ut.  ^\2j. 

Figs.    u6  to  328, — (Esmarth  anrl  Kowa 

lymphangiectasis,  tertiary  syphilis,  or  a  tuljcrculous  prcdisposidoii  (slrummi^ 
lip).  If  excessive,  a  horizontal  wcilgc  <if  miK  ous  membrane  and  submucoHM 
tissue  may  be  excised.     Mucous   cysts  appear  as    roujided,   transluren^ 


KPITTTELTOMA    OF   TIIK    LTP.  42 1 

swellings.  They  are  caused  by  blocking  of  the  on  Ikes  uf  the  glamb»  and 
are  treated  by  excision.  Warts,  horns,  and  nevi  also  may  be  seen  on  the  lij^. 
Epithelioma  almost  invarial>ly  attacks  the  lower  lip,  and  is  seldom  seen 
in  women.  The  irritation  i>f  a  short  tlay  pipe  is  responsible  for  some  cases. 
It  begins  as  a  small  fissure,  inliliration,  or  warty  growth,  which  ulcerates  and 
is  covered  by  a  scab  (Fig.  329).  The  ulcer  slowly  spreads,  is  situated  on  a 
hard  base,  and  ultimately  invades  the  jaw.  Sooner  or  later  the  cenical 
glands  are  involved,  but  visceral  metastases  are  uncommon.  In  old  men  the 
disease  is  often  very  slow,  and  may  not  cause  death  for  a  number  of  years. 


(i 


Fig.  319,  -  EpilhulknTia  uf  lip. 
(Pcnnsylvama  Hospital) 


l' 


Fig.   ^30.  — DuutI's  tipcration,     (Binnie 


Figs.  331  and  332,— Unin;^.     (Esmarch  and  Kowahdg.) 

The  treatment  is  early  and  thorough  excision,  with  the  glands  in  the  sub 
maxillary  and  submental  triangles.  5Permanent  cure  may  be  obtained  in 
from  50  to  60  per  cent,  of  the  cases  thus  treated.  .\11  incisions  should  Ixe  at 
least  a  half  inch  away  from  the  growth.  Small  growths  may  be  excised  by 
the  classical  V-shaped  incision,  and  the  glands  removed  from  both  sides  of  the 
neck  by  separate  incisions.  In  larger  growths  Dowd's  operation  (Fig.  330) 
may  be  employed.  The  cervical  incisions  are  made  first,  in  order  to  remove 
the  fat,  lymph  glands,  and  submaxillar)^  salivary  glands  before  opening  the 
mouth.  The  incisions,  I  E  and  G  K,  sufficiently  long  for  approximation  of  the 
tiaps,  are  made  by  dividing  the  skin  it  bout  one- third  inch  lower  than  the 


i 


Fig.  339.  Fig.   ho 

Figs.  339  and  340. — Langcnbeck.     (Esmarch  and  Kowalzig.) 


muroiis  membrane,  so  that  the  latter  may  f>c  stitehed  tn  the  skin  of  the  new 
lower  lip.  The  edges  \i  A  and  G  C  are  approximated  after  excising  wedged- 
shajied  pieces  of  skin  at  L  and  M,  Figs.  331  to  340  show  niher  methods  of 
cheiloplasty. 

THE  SALIVARY  GLANDS. 

Parotitis  is  most  often  seen  as  mumps ^  an  acute,  contagious,  self-limited, 
specific  intlammation,  which  may  involve  also  the  submaxillary  and  sublin- 
gual glands.  Suppuration  is  rare,  but  metastasis  to  the  testes,  ovaries,  or 
mamma*  may  occur  A  true  orchitis  is  produced  in  the  testicle,  which  usually 
undergoes  subsequent  atrophy;  the  condition  is  generally  unilateral,  however, 
and  sterility  does  not  follow.  A  nmt-mp pur  alive  paroiUis  may  follow  also 
injury,  salivary  calculi,  and  disease  or  injur)'  of  the  abdomen.  The  symp- 
toms are  pain  and  swelling,  with  perhaps  some  elevation  of  temperature. 
The  trcainwnt  is  the  application  of  ichthyol  or  belladonna  ointment,  and  an 
antiseptic  mouth  wash,  as  oral  sepsis  is  a  factor  in  many  cases. 

Suppurative  parotitis  rarely  follows  the  forms  described  above,  but  is 
commonly  the  result  of  pyemia  or  one  of  the  acute  infectious  fevers.  In 
addition  to  the  swelling,  and  the  redness  and  edema  of  the  skin,  pain  and  con* 
stitutional  symptoms  are  usually  severe,  owing  to  the  firmness  of  the  surround- 
ing fascia.  This  fact  explains  aJso  the  tendency  of  the  pus  to  burrow  deeply 
into  the  surrounding  tissues  rather  than  point  externally.  The  treatment  is 
incision  parallel  with  the  fibers  of  the  facial  nerve  and  in  front  of  the  line  for 
the  external  carotid. 

Salivary  calculi  consist  of  carbonate  and  phosphate  of  lime,  and  may 
form  in  any  of  the  ducts.  The  symptoms  are  those  of  obstruction  to  the  llow 
of  saliva,  which  may  be  caused  likewise  by  cicatrices,  tumors,  etc.  There  are 
swelling  and  tenderness  of  the  gland  during  meals,  and  in  old  cases  a  perma- 
nent thickening  of  the  glandular  tissues.  The  calculus  may  be  detected  with 
the  finger,  probe,  needle,  or  X-ray.  It  may  be  removed  by  dilating  the  duct, 
by  incision  from  within  the  mouth,  or,  in  large  calculi  in  the  submaxillary,  by 
removal  of  the  gland. 

Kanula  is  a  cystic  tumor  due  to  obstruction  of  one  of  the  ducts  of  the  sub- 
lingual glands,  or  more  rarely  the  duct  of  the  submaxillary  gland.  It  contains 
a  mixture  of  mucus  and  saliva.  Similar  in  nature  arc  the  mucous  cysts  which 
may  form  on  the  floor  of  the  mouth  as  the  result  of  obstruction  to  the  ducts 
of  the  mucous  glands.  Dermoid  cysis  in  this  region  frequently  spring  from 
the  thyroglossal  duct,  hence  are  situated  in  the  median  line  and  often  cause  a 
swelling  beneath  the  chin.  The  treatment  of  ranuLx  and  mucous  cysts  is 
removal  of  the  anterior  wall  and  cauterisation  of  the  posterior  wall,  so  that 
the  ca\'ity  will  be  filled  by  granulations.  In  some  cases  cure  can  be  obtained 
only  by  dissecting  out  the  entire  cyst  and  removing  the  salivary  gland. 
Dermoid  cysts  require  an  external  incision  and  careful  dissection. 

Tumors  of  the  parotid  gland  are  usually  of  a  mixed  nature.  A  benign 
parotid  tumor  is  usually  a  mixture  of  chondroma,  fibroma,  myxoma,  and 
adenoma,  hence  it  is  hard  and  nodular  in  certain  parts  and  soft  in  others. 
It  gmws  very  slowly,  and  is  usually  superficial  to  the  important  vessels  and 
nerves,  except  in  the  later  stages.  \  malignant  parotid  tumor  may  be  sar- 
coma, carcinoma,  or  endothelioma.  It  is  often  the  result  of  a  malignant 
change  in  a  benign  tumor,  from  which  it  may  be  distinguished  by  its  immo- 


w 


424  UPPER   DIGESTIVE  APPARATUS. 

bilily,  greater  pain  and  rapidity  of  growth,  more  frequent  association  with 
facial  paralysis,  and  by  its  tendency  to  enlarge  the  lymph  glands,  The  lymph 
gland  lying  near  the  surface  of  the  parotid  may  enlarge  as  the  result  of  inflam- 
mation, tuberculosis,  or  a  neoplastic  change;  it  is  distinguished  from  a  par- 
otid tumor  by  its  imiform  consistency  and  its  more  superficial  situation. 

The  treatment  is  excision.  Benign  tumors  may  be  enucleated  through 
an  incision  parallel  with  the  course  of  the  facial  nerve.  Malignant  tumors 
require  removal  of  the  entire  gland  through  a  vertical  incision,  supplemented, 
if  need  be,  by  a  tranverse  cut  running  forwards  from  the  middle  or  lower  end. 
The  dissection  should  proceed  from  below  upwards,  so  that  the  external  car- 
otid artery  may  be  ligated  in  the  early  part  of  the  operation.  The  facial  nerve 
is,  of  course,  destroyed,  and  of  this  the  patient  should  be  previously  warned. 
The  operation  is  very  diflScult  and  recurrence  almost  inevitable.  Somewhat 
similar  tumors  are  encountered  in  the  other  salivary  glands,  but  such  are 
much  more  easily  excised. 


Fig.  341. — Braun's  operation.     (Binnic.) 

Salivary  fistula  is  usually  caused  by  disease  or  injury  of  Steno's  duct, 
which  is  about  one-eighth  inch  in  diameter,  opens  into  the  mouth  opposite  the 
second  upper  molar  tooth,  and  is  represented  by  a  line  drawn  from  the  lowest 
part  of  the  cartilage  of  the  ear  to  a  point  midway  between  the  angle  of  the 
mouth  and  the  ala  nasi.  If  small,  the  fistula  may  sometimes  be  closed  by 
cauterization  or  by  sutures,  first  dilating  any  existing  stricture  in  the  distal 
portion  of  the  duct.  If  this  method  fails  or  if  the  distal  portion  of  the  duct  is 
obliterated,  the  central  portion  may  be  isolated,  and  its  orifice  sutured  to  the 
mucous  membrane  of  the  mouth,  the  external  wound  being  closed.  Some 
surgeons  make  an  opening  from  the  fistula  into  the  mouth,  and  keep  this 
opening  patent  by  a  rubber  tube  or  seton,  until  it  is  lined  with  epithelium;  the 
external  opening  is  then  closed.  When  the  fistula  is  near  the  gland,  a  new- 
duct  may  he  constructed  from  the  mucous  membrane  as  shown  in  Fig.  341. 

THE  TONGUE. 

Malformations,  such  as  bifid  tongue,  hemiatrophy,  and  total  absence  of 
the  tongue,  are  very  rare.  Tongue-tie,  or  shortness  of  the  frenum,  may 
interfere  with  sucking  and  later  cause  lisping;  the  frenum  may  be  nicked  with 
a  pair  of  blunt  scissors,  and  if  this  does  not  produce  sufficient  mobilization, 
the  rest  of  the  frenum  may  be  torn  with  the  finger,  thus  avoiding  troublesome 
hemorrhage.  The  frenum  may  be  abnormally  long  and  allow  the  tongue 
to  fall  backwards  and  interfere  with  respiration.  Ankyloglossia,  in  which  the 
tongue  is  adherent  to  the  floor  of  the  mouth,  may  be  congenital  or  follow 
ulceration  in  this  region.  The  adhesions  should  be  separated,  a  procedure 
which  may  be  very  difficult  iji  acquired  cases.     Macroglossia,  or  elephantiasis 


ULCERATION  OF  THE  TONGUE.  425 

of  the  tongue,  is  usually  congenital,  and  is  due  to  an  increase  in  the  connective 
tissue  and  lymphangiectasis.  Lymphatic  cysts  and  hypertrophied  papilLe 
may  be  seen  on  the  surface,  and  recurring  glossitis  augments  the  volume  of  the 
organ.  The  tongue  protrudes  from  the  mouth,  becomes  indurated  and 
purplish,  interferes  with  speech  and  swallowing,  and  causes  deformity  of  the 
teeth  and  jaws.  The  treatment  is  removal  of  a  wedge-shaped  portion. 
Enlargement  of  the  tongue  may  be  caused  also  by  stomatitis,  particularly  the 
syphilitic  variety,  and  is  sometimes  seen  in  idiots. 

Wounds  of  the  tongue  are  seldom  serious,  although  in  a  few  cases  death 
from  hemorrhage  has  followed.  Sutures  shoiild  be  of  silk,  as  the  moisture 
and  movements  of  the  tongue  will  quickly  loosen  catgut.  Ordinarily  bleed- 
ing is  controlled  by  closure  of  the  woimd,  although  if  the  ranine  artery  is 
opened  a  ligature  may  be  necessary. 

Acute  parenchymatous  glossitis  is  caused  by  infection  of  the  tongue 
with  pyogenic  organisms.  It  may  arise  from  injuries,  or  from  stomatitis, 
particularly  the  mercurial  form  and  those  varieties  accompanying  low  fevers. 
The  tongue  becomes  red  and  painful,  and  swells  rapidly,  so  that  it  may  pro- 
trude from  the  mouth  and  interfere  with  speaking,  swallowing,  and  breathing. 
Ulceration,  abscess,  or  even  gangrene  may  follow.  There  is  drooling  of 
saliva  and  constitutional  symptoms  of  sepsis.  The  treatment,  in  the  milder 
cases,  is  a  chlorate  of  potassium  mouth  wash  and  the  sucking  of  particles  of 
ice.  If  the  swelling  increases,  a  free  incision  should  be  made  into  the  tongue 
on  each  side  of  the  median  line.  In  the  presence  of  threatening  asphyxia 
tracheotomy  will  be  required. 

Abscess  of  the  tongue  may  be  of  an  acute  nature,  but  is  often  chronic, 
and  encapsulated  by  dense  inflammatory  tissue,  which  often  leads  to  the  diag- 
nosis of  a  neoplasm.  The  treatment  is  incision,  and  disinfection  with  antisep- 
tic mouth  washes. 

Acute  superficial  glossitis  is  but  a  part  of  a  general  stomatitis  and  need 
not  be  described  as  a  separate  affection,  although  a  special  form,  invoking 
one-half  of  the  tongue  {hemiglossUis),  usually  with  herpes,  and  probably  of 
nervous  origin,  occurs. 

Chronic  superficial  glossitis,  or  leukoplakia  (psoriasis  or  ichthyosis 
of  the  tongue),  is  commonly  attributed  to  syphilis,  smoking,  whiskey  drinking, 
chronic  dyspepsia,  or  ragged  teeth.  Thin  bluish-white  or  yellowish  patches 
form  on  the  tongue  (Fig.  342)  and  perhaps  on  the  lips  and  cheeks.  The 
disease  is  very  chronic  and  is  often  followed  by  epithelioma.  In  some  in- 
stances the  patches  are  shed  and  the  tongue  becomes  red  and  glazed  or  cracked 
and  fissured.  The  discomfort  is  usually  slight,  although  in  severe  cases 
there  may  be  marked  tenderness  and  interference  with  speaking  and  eating. 
The  treatment  is  removal  of  all  sources  of  irritation,  such  as  tobacco,  alcohol, 
and  highly  seasoned  food.  The  teeth  should  be  put  in  order  and  an  alka- 
line mouth  wash  used,  such  as  sodium  bicarbonate,  20  grains  to  the  ounce. 
Applications  of  tincture  of  benzoin  or  myrrh  are  useful,  the  benzoin  or  myrrh 
being  precipitated  as  a  varnish.  Caustics  should  be  avoided.  If  the  disease 
is  not  too  extensive,  excision  of  the  patches  is  the  best  treatment. 

Hyperkeratosis  linguae  {black  tongue)  is  a  rare  condition  in  which 
the  mucous  membrane  just  in  front  of  the  circumvallate  papillae  becomes  dark 
or  black  and  covered  with  long,  waving  papillae  resembling  hairs.  The  color 
is  supposed  to  be  due  to  bacteria. 

Ulceration  of  the  tongue  due  to  trauma,  ragged  teeth,  dyspepsia,  and 


UPPER   BIGESTTVE  APPARATUS. 

stnmatilis  reaiHIy  hea!s  an  removal  of  the  cause.  Ifcrpdic  ulcers  follov 
herpes,  and  are  treated  with  applrcations  of  silver  nitrate  and  an  antiseptic 
wash.  Luf^its  and  afiinoniyto^is  are  rare.  TuhercuUms  ulcers  may  be  pn* 
mary,  but  are  usually  secondary  to  disease  of  the  lungs.  As  a  rule  they  are  on 
or  near  the  tip  of  the  tongue  and  have  sharply  defined  irregular  edges,  pale 
llabby  granulations,  and  but  little  induration.  They  are  very  painful  and 
may  reach  a  large  size.  The  treatment  is  excision.  The  most  important 
ulcers  of  the  tongue  are  the  syphilitic  and  the  malignant. 

Syphilis  of  ti^e  tongue  is  seen  as  the  chancre,  mucous  patches,  condylo- 
mata, ulcers,  glossitis,  and  gumma*    SyphilUk  glossHis  may  be  of  the  chronic 


Fig.  342 »— Leukoplakia.     The  patch  is  raised,  nodular,  and  whitish.     (Butlin.) 


I 


superficial  variety,  or  the  whole  tongue  may  be  enlarged,  hardened,  and 
marked  by  deep  fissures,  which  result  from  contraction  of  newly  formed 
fibrous  tissue.  Gumma  is  usually  on  the  dorsum  near  the  median  line  and 
may  be  multiple.  It  is  preceded  by  a  chancre,  associated  with  lesions  in 
other  parts  of  the  body,  is  apt  to  occur  in  the  earlier  half  of  life,  is  more  com- 
mon in  the  female,  and  begins  as  a  submucous  infiltration  which  finally 
ulcerates.  The  ulcer  is  romid  or  oval,  punched  out,  deep,  nearly  painlesS|^ 
and  covered  by  the  characteristic  gummy  matcriab  Induration  is  slight,  the 
submaxillary^  glands  frequently  unailected,  the  tongue  mobile,  articulation 
and  deglutition  but  litUe  disturbed,  and  cachexia  absent.  In  doubtful  cases 
a  piece  may  be  excised  for  microscopic  examination,  a  Wasscnnarm  test 
made,  and  the  effect  of  iodid  of  potassium  internally  tried. 

Cancer  of  the  tongue  is  always  a  squamous  epithelioma.     It  is  most 
frequent  in  men  after  forty,  and  is  often  preceded  by  some  form  of  irritation, 


FlO.  343. — Epilhelioma  of  the  tongue  The  c<1gcs  of  the  ulcer  arc  thick  and  everted; 
rlhe  rest  of  the  tongue  is  covercci  with  a  Ihick  green-black  fur  due  to  ihe  foul  condition  ol 
I  the  mouih  and  the  immobility  of  the  tongue  (Butlin). 

ulation  and  deglutition  difficult.  The  ulcer  is  surrounded  by  an  indurated 
area  and  is  often  exceedingly  painful.  The  edges  are  thick  and  everted,  the 
base  foul  and  sloughing,  and  the  discharge  fetid  (Fig.  34,3)^  There  is  in- 
.  continence  of  saliva,  and  bleeding  occurs  on  slight  provocation.  The  sub* 
'maxillary  glands  are  involved  early  and  cachexia  promptly  supervenes. 
The  condition  is  easily  recognized  in  the  later  stages,  but  at  the  onset  the 


1 


428  UPPER   DIGESTIVE  APPARATUS. 

diagnosis  may  be  impossible  without  a  microscopic  examination,  which 
should  be  promptly  made  in  all  doubtful  cases. 

The  treatment  is  excision  of  the  growth  with  the  lymphatic  area  into 
which  it  drains.  Without  operation  death  generally  occurs  in  from  one 
year  to  eighteen  months;  with  early  and  thorough  operation  20  per  cent., 
according  to  Butlin,  remain  free  from  recurrence  after  three  years.  Very 
small  growths  may  be  removed  by  a  V-shaped  or  ellipitcal  incision  which  is 
subsequently  sutured,  but  in  most  instances  it  will  be  necessary  to  remove 
half  or  all  of  the  tongue.  The  teeth  should  first  be  cleansed  by  a  dentist,  and 
the  mouth  rinsed  every  three  or  four  hours  with  an  antiseptic  mouth  wash. 
The  mortality  of  excision  is  about  5  per  cent.,  most  deaths  occurring  from 
septic  pneumonia,  the  result  of  inhalation  of  blood  and  wound  discharges, 
hence  the  patient  should  be  put  in  the  Trendelenburg  or  the  Rose  posture  dur- 
ing operation.  Some  surgeons  perform  a  preliminary  tracheotomy,  and  pack 
the  pharynx  with  gauze  at  the  time  of  operation.  Crile  administers  the 
anesthetic  through  a  rubber  tube  which  passes  through  the  nose  into  the 
upper  part  of  the  larynx  and  which  is  surrounded  by  gauze  packing. 

Whitehead's  operation  consists  in  removal  of  the  tongue  through  the 
mouth.  The  jaws  are  separated  by  a  gag  and  the  tongue  drawn  forward 
by  a  ligature  passed  through  its  tip.  The  tongue  is  then  separated,  with 
the  sublingual  gland,  from  the  floor  of  the  mouth  by  scissors,  the  lingual  arter- 
ies being  seized  with  forceps  before  they  are  cut.  A  ligature  is  now  passed 
through  the  glosso-epiglottic  fold,  and  the  tongue  severed  in  front  of  the 
ligature.  The  ligature  is  left  in  place  twenty-four  hours,  in  order  to  pull  the 
epiglottis  forward  if  there  be  bleeding  or  trouble  with  breathing.  The 
wound  is  painted  with  Whitehead's  varnish  (Friar's  balsam  in  which  die  alco- 
hol is  replaced  by  a  saturated  solution  of  iodoform  in  ether).  The  cervical 
lymph  glands  are  then  removed.  Most  surgeons,  however,  prefer  to  excise 
the  glands  first,  as  this  permits  ligation  of  the  lingual  artery  and  postpones 
invasion  of  the  mouth  until  the  clean  part  of  the  operation  is  fiinished.  The 
patient  sits  up  as  soon  as  the  effects  of  the  anesthetic  have  passed,  and  is  fed 
l)y  mouth  from  the  beginning,  or,  if  need  be,  by  the  nasal  tube  or  by  the 
rectum.  Removal  of  half  of  the  tongue  is  accomplished  in  the  same  manner, 
except  that  the  organ  is  split  in  the  middle  line. 

Kocher's  operation  is  indicated  in  cases  in  which  the  floor  of  the  mouth 
or  the  jaw  is  involved.  An  incision  is  made  from  below  the  symphysis  to 
above  the  hyoid  bone,  then  to  the  anterior  margin  of  the  sterno-mastoid,  and 
lastly  upwards  to  the  mastoid  process.  The  flap  is  turned  upwards  and  all 
the  lymphatic  glands  in  this  region,  with  the  submaxillary  salivary  gland,  ex- 
cised, the  lingual  and  facial  arteries  or,  perhaps  better,  the  external  carotid 
being  ligated.  The  hyoglossus  and  mylohyoid  muscles  are  divided  and  the 
mouth  entered;  the  tongue  is  drawn  through  this  opening,  and  divided  close 
to  the  epiglottis  and  hyoid  bone.  The  same  precautions  as  in  the  Whitehead 
operation  should  be  taken  in  regard  to  the  stump  of  the  tongue.  The  incision 
in  the  neck  is  partly  closed,  and  the  cavity  packed  with  gauze.  The  patient 
is  fed  through  the  nose  or  per  rectum,  until  the  power  of  deglutition  returns. 
The  mouth  and  the  wound  should  be  irrigated  frecfuently  with  boric  acid  or 
salt  solution. 

Sedillot's  operation  is  performed  by  dividing  the  lower  lip  in  the  median 
line  and  extending  the  incision  to  the  hyoid  bone.  The  lower  jaw  is  sawed 
through  in  the  middle  line  and  the  two  halves  retracted.     The  tongue  is  then 


CYSTS   OF   THE  JAWS.  429 

removed  with  scissors  or,  as  performed  by  Kocher,  who  has  recently  adopted 
this  operation,  with  the  cautery.  A  small  amount  of  xeroform  is  rubbed  into 
the  wound,  the  divided  jaw  wired,  and  the  wound  in  the  soft  parts  closed 
except  below,  where  a  gauze  drain  finds  exit. 

Sarcoma,  benign  tumors,  and  cysts  occur  in  the  tongue  but  are  very  rare. 


THE  MOUTH,  JAWS,  AND  PHARYNX. 

Stomatitis,  or  inflammation  of  the  mouth,  may  be  caused  by  mechanical 
or  chemical  irritants,  dyspepsia,  fevers,  and  by  a  specific  fungus,  oidium 
albicans  {tJirush),  The  simple  catarrhal  form  presents  the  ordinary  phenom- 
ena of  inflammation,  and  quickly  subsides  when  the  cause  is  removed. 
AphUious  stomatitis  occurs  as  small  whitish  vesicles,  which  form  ulcers  sur- 
rounded by  a  red  areola.  It  is  seen  in  children  with  digestive  disturbances. 
Ulcerative  stomatitis  occurs  in  debilitated  children,  and  in  adults  with  dia- 
betes or  Bright*s  disease.  Attention  has  already  been  called  to  gangrenous, 
syphilitic,  and  mercurial  stomatitis.  Certain  forms  of  skin  eruptions  also  may 
attack  the  mucous  membrane  of  the  mouth.  The  treatment  of  stomatitis  is 
removal  of  the  cause,  attention  to  the  general  health,  proper  feeding,  and  the 
use  of  a  mouth  wash  containing  chlorate  of  potash.  Ulcers  may  be  touched 
with  silver  nitrate. 

Pyorrhea  alveolaris  (Riggs^  disease)  is  characterized  by  a  collection  of 
tartar  and  chronic  suppuration  beneath  the  margins  of  the  gums,  which 
atrophy  and  recede  from  the  teeth,  leaving  them  loose.  It  may  be  responsible 
for  fetid  breath,  dyspepsia,  anemia,  and  various  forms  of  so-called  crypto- 
genic sepsis.  The  treatmenty  which  can  be  carried  out  only  by  a  dentist, 
consists  in  removal  of  the  tartar  and  frequent  antiseptic  douches. 

Alveolar  abscess  is  due  to  irritation  from  a  decayed  tooth.  When 
superficial  it  is  known  as  gum  boil.  Occasionally  the  pus  passes  beneath  the 
periosteum  and  causes  necrosis  of  the  jaw.  In  the  upper  jaw  the  antrum 
may  be  opened,  in  the  lower  jaw  the  pus  may  point  in  the  neck.  The  treat- 
ment is  drainage  of  the  abscess  cavity,  and  generally  extraction  of  the  tooth. 
If,  however,  the  tooth  is  but  slightly  diseased,  it  may  be  saved  by  appropriate 
dental  treatment. 

Necrosis  of  the  jaw  may  be  caused  by  injury,  caries  of  the  teeth,  phos- 
phorus (p.  287),  mercury,  syphilis,  tuberculosis,  and  the  exanthemata.  The 
symptoms  in  the  beginning  are  pain,  swelling  of  the  face  and  gums,  fever,  and 
the  formation  of  an  abscess,  which  may  j)oint  in  the  mouth,  or  externally  on 
the  face  or  neck.  The  discharge  is  offensive,  and  on  probing  dead  bone  can 
be  felt.  An  involucrum  may  form  in  the  lower  jaw,  but  is  uncommon  in  the 
upper  jaw.  The  treatment  is  incision  for  the  purposes  of  drainage,  and  anti- 
septic mouth  washes  until  the  sequestrum  is  loose,  when  it  should  be  removed 
through  the  mouth,  or  if  this  is  not  possible,  by  an  external  incision. 

Cysts  of  the  jaws  generally  arise  in  connection  with  the  teeth,  or  are  the 
result  of  a  cystic  change  in  solid  tumors,  particulary  sarcoma  and  epithelioma. 
Dental  cysts  occurring  in  connection  with  completely  developed  teeth  are  of 
inflammatory  origin,  the  fluid  coUqcting  between  the  root  and  the  peridental 
membrane.  The  treatment  is  extraction  of  the  tooth.  DefUigerous  rysts 
(follicular  odontomata,  p.  145)  arc  caused  by  the  non-eruption  of  a  tooth 
The  swelling  is  at  first  hard,  but  later  egg-shell  crackling  may  be  noted 


43® 


UPPER    DIGES'HVE  APP^VIL\TtTS* 


Oaasionally  suppuration  occurs.  The  permanent  tooth  is  absent,  but  some- 
times the  milk  tooth  persists,  and  may  be  mistaken  for  a  permanent  one 
unless  an  X-ray  examination  is  made.  The  treat tncnl  is  excision  of  the 
anterior  wall  of  the  cyst,  removal  of  the  unerupled  tooth,  and  gauze  packing. 
Fibrocystic  disease  of  the  louder  jaw  (epithelial  odontome)  is  a  multilocular 
cystic  formadon,  which  may  attain  a  great  size,  and  is  most  frequently 
observed  in  the  young.  It  has  been  mistaken  for  sarcoma.  The  treaimefU  is 
excision- 

Tumors  of  the  jaws  comprise  the  fibroma^  en  chondroma,  osteoma^ 
odontoma  (p.  145),  sarcoma,  and  epithelioma.  In  many  tumors  of  the  jaws, 
especially  in  the  young,  one  should  first  make  sure,  by  X-ray  examination, 

puncture,  or  even  incision,  that  the  growth  is 
not  a  benign  cyst,  before  deciding  on  extirpa- 
tion. Epulis  is  a  terra  apph'ed  to  tumors 
originating  in  the  alveolar  periosteum.  A 
simple  epuiis  is  smooth,  round,  re<J,  elastic, 
and  generally  fibromatous  in  nature.  It 
may  ulcerate  or  become  ossified.  A  malig- 
ruinf  epulis  is  a  myeloid  sarcoma,  whic:h  is 
soft  and  purplish,  grows  rapidly,  bleeds 
easily,  and  may  ulcerate.  The  treatment  of 
epulis  is  excision  of  the  alveolar  process  as 
far  as  one  tooth  on  each  side  of  the  growth. 
Fibroma  and  enchondroma  are  more  apt 
to  appear  early  in  life,  grow  slowly,  and 
.sometimes  recur  after  removal,  possibly  be- 
cause of  the  presence  of  some  sarcomatous 
tissue.  The  treatment  is  removal,  ^i-ith  that 
portion  of  the  jaw  to  which  they  are  attached. 
Osteoma  occurs  later  in  life  and  sometimes 
follows  injur}^  or  intlammation  of  the  bone. 
It  should  be  removed.  Sarcoma  (Fig.  344)  may  occur  at  any  period  of 
life,  and  is  the  most  frequent  form  of  tumor  attacking  the  jaws.  It  maybe 
of  any  variety.  The  soft  forms  (containing  round  cells)  grow  rapidly  and 
invade  or  displace  the  surrounding  structures;  thus  in  the  upper  jaw^  there 
may  be  a  projection  beneath  the  cheek,  depression  of  the  palate,  obstruction 
of  the  nose  with  the  discharge  of  blood  or  pus,  epiphora,  exophthalmos,  and 
severe  pain  ouing  to  implication  of  the  nerves.  Epithelioma  occurs  in  the 
later  period  of  life,  and  begins  in  the  mucous  membrane  of  the  mouth,  nose, 
or  antrum.  The  .symptoms  are  much  like  those  of  sarcoma,  but  ulcera- 
tion is  more  frequent  and  the  lymphatic  glands  are  quickly  involved.  The 
treaifnent  of  sarcoma  and  epithelioma  is  partial  or  complete  excision  of  the 
jaw%  according  to  the  extent  of  the  growth. 

Excision  of  the  upper  jaw  may  be  refjuired  for  the  removal  of  growths 
within  or  behind  the  liune.  Inspiration  of  l)Iood  is  prevented  in  the  same  way 
as  in  excision  of  the  tongue  (p.  428),  Bleeding  may  be  lessened  by  ligation 
of  the  external  carotirl,  or  by  temporary  occlusion  of  the  commoif  carotid  by 
means  of  Crilc's  clamp.  .^\n  iru  ision  is  made  from  the  malar  bone  along  the 
margin  of  the  orbit  to  half  inch  bdow  the  inner  canlhus.  then*  e  downwards 
along  the  siile  of  the  nose  and  around  the  ala  to  the  median  line,  at  which 
^MJint  the  upper  lip  is  divided.     The  llap  is  reflected,  and  the  malar  bone  and 


Fig.  344. — Sartoma  of  lower  jaw. 
(Pennsylvania  Hospital.) 


CLOS 


♦31 


nasal  process  divided  with  a  saw,  after  the  infraorbital  periosteum  has  been 
separated  and  carefully  retracted  upwards.  The  central  incisor  tootli  of  the 
affected  side  is  extracted,  and  the  mucous  membrane  of  the  roof  of  the  mouth 
divided  In  the  median  line  as  far  as  the  soft  palate,  and  then  transversely 
between  the  hard  and  soft  palates.  A  narrow  saw  is  now  passed  into  the  nose, 
ami  the  alveolus  and  hard  palate  divided  from  before  backwards.  The  bone 
is  seized  with  lion- jawed  forceps  (Fig.  220)  and  twisted  from  its  bed  \iy  frac- 
turing the  pterygoid  processes  and  the  lateral  mass  of  the  ethmoid.  The 
bleeding  vessels  are  caught  and  tied,  and  the  cavity  tilled  with  gauze  packing. 
The  entire  skin  wound  is  sutured,  the  gauze  being  subsequently  removed 
and  irrigations  practised  through  the  mouth.  The  patient  is  at  first  fed  by  the 
rectum  or  by  an  esophageal  tube.  The  resulting  deformit}^  may  be  corrected 
by  means  of  an  obturator  and  cheek-plate. 

Temporary  resection  of  the  upper  jaws  (Kocher)  is  useful  in  exposing 
certain  nasopharvngeal  growths.  The  upper  lip  is  split  into  one  nostril  and 
both  ^aps  separated  from  the  bone.  The  alveolar  process  and  palate  are 
then  split  in  the  middle  line  with  a  chisel,  and  both  upper  jaws  divided 
horizonially  on  a  level  with  the  lower  portion  of  the  nasal  processes,  thus 
permitting  retraction.  At  the  completion  of  the  operation  the  lx>nes  are 
wired  in  place. 

Excision  of  the  lower  jaw  is  performed  for  tumors  and  necrosis.  Small 
portions  of  the  jaw  can  often  be  resected  through  the  mouth.  If  the  symphysis 
is  remove<l,  the  muscles  attached  to  the  genial  tubercles  are  divided,  and  a 
ligature  must  be  passed  through  the  tongue  to  prevent  its  falling  backwards. 
The  periosteum  should  lie  preserved  wh&never  possible.  Resection  of  the 
entire  lower  jaw  is  performed  liy  dividing  the  bone  in  the  median  line  and 
dealing  with  each  half  separately.  The  incision  for  removal  of  one-half  the 
lower  jaw  is  made  from  below  the  free  margin  of  the  lower  lip  downwards 
in  the  median  line,  then  along  the  under  surface  of  the  jaw  and  upwards 
along  the  posterior  border  of  the  ramus  to  below  the  line  for  the  facial  nerve. 
The  facial  vessels  are  tied,  the  soft  parts  separated  from  the  bone,  the  central 
incisor  tooth  extracted,  and  the  jaw  sawed  through  the  empty  socket,  thus 
avoiding  the  genial  tubercles.  By  pulling  the  bone  outwards  the  internal 
soft  parts  can  be  separated  and  the  inferior  dental  artery  tied.  The  jaw  is 
now  depressed  and  the  coronoid  process  and  the  condyle  separated  ljy  cut- 
ting  close  to  the  bone,  recalling  that  the  internal  maxillary  lies  very  near  the 
condyle.  The  buccal  mucous  membrane  is  sutured  to  that  of  the  Jloor  of  the 
mouth  and  the  external  wound  closed.  In  order  to  correct  the  resulting  de- 
formity, which  is  increased  by  the  passage  of  the  remaining  half  of  the  bone 
towards  the  affected  side,  splints  of  aluminium,  hard  rubber,  and  even  bone 
grafts  have  been  inserted. 

Closure  of  the  jaws  may  be  caused  by  ankylosis  of  the  temporomaxillar)^ 
joint  the  result  of  injury  or  in^a.mmii\ion\  cicairkidl  contraci ton  of  the  soft 
parts  following  noma,  burns,  etc;  trismus  (spasm  of  the  muscles),  the  result 
of  tetanus,  hysteria,,  or  local  causes,  such  as  an  unerupted  wisdom  tooth  or 
caries  of  the  teeth;  and  by  inflmnmatory  or  tm>plasiic  lesions  which  mechani- 
cally interfere  with  opening  of  the  mouth,  e.g.,  mumps  and  malignant 
growths. 

The  treatment  of  temporary  chisure  of  the  jaws  depends  upon  the  cause. 
Permanent  closure  due  to  bony  or  fibrous  ankylosis  of  the  temporomaxillary 
joint  is  best  treated  by  resection  of  the  condyle,  with  the  interposition  of  a 


43^ 


UPPER  DIGESTIVB  APPAI 


rus. 


P 


flap  from  the  temporal  or  masseter  muscle.  The  dangers  are  injury  to  the 
facial  nerve  and  internal  maxillar}'  arterj'.  WTieo  the  jaws  are  bound  together 
by  extraarticular  cicatrices,  a  wedge-shaped  section  of  bone,  with  the  apex 
towards  the  alveolar  process,  should  be  excised  in  front  of  the  cicatrix*  and 
a  false  joint  established  by  the  interposition  of  muscle  or  fascia. 

Cleft  palate  is  a  congenital  deformity  caused  by  failure  of  the  palatine 
processes  to  unite.  Beginning  posteriorly  the  cleft  may  extend  a  variable  dis- 
tance, the  mildest  form  presenting  itself  as  a  bitld  uvula,  and  the  severest 
form  as  a  wide  cleft  involving  the  whole  palate  and  dividing  anteriorly  to 
embrace  the  os  incisivum  and  the  middle  segment  of  the  upper  lip.  The 
septum  of  the  nose  may  be  free  or  it  may  have  united  with  one  of  the  palatine 
processes,  usually  the  right.  Cleft  palate  inter- 
feres with  sucking  and  in  later  life  with  swallow- 
ing and  articulation. 

Operation  should  be  performed  lietween  the 
third  and  fourth  year  before  faulty  habits  of  artic- 
ulation have  developed,  the  patient  being  fed  in 
the  meantime  with  a  spoon  or  tube  with  the  head 
thrown  well  back.  If  there  is  an  associated  hare- 
It,,        t     ;  ^     ;  lip  the  cleft  palate  should  be  closed  tirst.     At  the 

Ij^pi^lllll    ^y^;*^  ^^^  ^f   operation*   preferably  in   the  spring  or 

summer^  the  child  should  be  free  of  local  and 
general  disease.  The  nose  and  mouth  should  be 
cleansed  for  a  few  days  before  operation  with  a 
solution  of  boric  acid.  The  child  is  anesthetized 
with  chloroform,  placed  in  the  Rose  or  the 
Trendelenburg  posture,  and  a  mouth  gag  intro- 
duced. 

Staphylorrhaphy,  or  suture  of  the  soft  palate  alone,  is  performed  by 
paring  the  edges  of  the  cleft,  which  is  then  united  with  silk  sutures.  If  this 
cannot  be  done  ^^ithout  too  great  tension,  relaxation  may  be  secured  by 
dividing  the  tissues  which  attach  the  soft  to  the  hard  palate,  excepting  the 
oral  mucous  membrane,  and  by  undermining  the  muco-periosteum  of  the 
hard  palate  (Fig.  345).  Division  of  the  muscles  of  the  soft  palate  is  not 
advisable. 

Uranoplasty,  or  suture  of  the  hard  palate,  may  be  performed  as  follows: 
The  edges  of  the  cleft  are  pared  with  a  tenotome  (Fig.  346),  and  the  muco- 
periosteum  separated  from  the  hard  palate  with  a  periosteal  elevator  (Fig.  347) 
as  far  as  the  alveolar  process,  being  careful  to  avoid  injur)'  to  the  vessels 
passing  through  the  anterior  and  posterior  palatine  canals.  The  soft  palate 
is  separated  from  the  hanl  palate  as  in  staphylorrhaphy.  The  edges  are  now 
united  with  interrupted  sutures  of  silkworm  gut.  If  the  edges  do  not  come 
together  without  tension,  an  incision  on  one  or  both  sides  is  made  through 
the  muco-periosteum  near  the  alveolus,  from  the  lateral  incisor  tooth  to  the 
posterior  edge  of  the  hard  palate.  Tension  may  further  be  relieved  by 
dividing  the  hamular  process  with  a  chisel.  Some  surgeons  chisel  also 
through  the  hard  palate  on  each  side,  prj'  the  bone  inwards,  and  pack  the 
resulting  gap  with  gauze.  Although  special  needles  are  recommended  for 
this  operation,  a  shar^^ly  curved  needle  and  a  needle  holder  arc  sufHcient  for 
every  purpose.  The  sutures  remain  in  place  ten  days,  during  which  time 
liquid  or  soft  foot]  only  should  be  given.     Antiseptic  sprays  may  be  employed. 


Fig.  J45. — ZanflQ.  Line 
of  sepi ration  of  attachments 
of  velum  lo  hard  |>aUte.  X, 
Y,  Z,  (^,  .\rea  in  which  muco- 
periosteum  (continuous  with 
the  velum)  is  scparatc<l  from 
the  bone,     (Binnie. ) 


a  6 

Fig.  351, — (Binnie,) 


Lxillaty 


bones  t  age  the  r,  the  edges  of  the  tleft  having  previously  been 
pared.  Fig.  348  illustrates  a  plan  in  which  the  lower  part  of  the  septum  is 
used  to  dose  a  unilateral  cleft  palate.  The  septum  is  severed  at  X,  and  the 
lower  portion  sutured  to  the  pared  edge  of  the  free  palatine  process.  Figs. 
^^49,  350,  and  351  illustrate  other  operations  for  cleft  palate.  In  about  one- 
half  of  the  cases  a  second  operation  is  required.  A  cleft  may  be  closed  also 
by  means  of  an  obturator,  fitted  by  a  dentist. 
28 


1 


434 


UPPER  DIGESTIVE  APPAR^VTUS. 


Perforation^  of  the  palate  are  usually  caused  by  >yphilis,  uc  a^t  :i:: 
by  traumatism  or  lupus.  If  the  local  disease  is  cured,  the  fHjrforaii-n:-  ri; 
be  closed  by  a  plastic  operation,  although  in  most  syphilitic  ca.*e>  l«3c 
results  are  obtained  by  the  use  of  obturators. 

Elongation  of  the  uvula  when  troublesome  may  be  remedied  by  tct... 
ing  the  lower  portion  with  scissors. 

Suppurative  tonsillitis,  or  quinsy,  may  follow  exposure  to  u>I<ior:«'. 
luteil  air.  Certain  individuals  are  predisposed  to  this  aflFei  tion,  partiruiT' 
during  adolescence.  The  tonsils,  the  fauces,  and  the  soft  palate  are  *vr.;> 
and  edematous,  causing  interference  with  breathing,  swallowing,  and  spcA- 
ing.  There  are  pain  in  the  throat,  enlargement  of  the  cervical  gland?,  r: 
marked  constitutional  symptoms.  Both  tonsils  may  be  involved.  an«i  if 
patient  may  l)e  unable  to  open  the  mouth.  The  ireatmcptt  in  the  iniria!  ^m^ 
is  an  ice  bag  externally,  scarification  of  the  tonsil,  a  chlorate  of  potash  sirit. 
and  symptomatic  internal  treatment.  When  pus  forms,  the  abscess  ma; '/. 
opened  with  a  sharj)  pointed  tenotome,  the  incision  being  parallel  with  'h 
anterior  pillar  of  the  fauces  and  directed  towards  the  middle  line. 

Hypertrophy  of  the  tonsils  is  most  frequent  in  children  and  intice^ir:' 
be  congenital.  It  may  follow  repeated  acute  attacks  of  inflammation  dn::- 
t>ften  a  manifestation  of  a  tuberculous  diathesis.  It  is  usually  asso-.iarci 
with  adenoids  and  hence  presents  the  same  symptoms  as  the  latter.  Ca>e"> 
and  calcareous  concretions  may  form  in  the  crypts  of  the  tonsils,  and  i;..".- 


(>■  . M-iiHially  'lr\(!.)i)  from  bloiking  of  the  oritices  of  the  l\>ilii!e-.  1 : 
/;'  it'tunt  \-  ;ittt'!::ii>;i  U)  ihc  general  health  and  removal  of  a  portion  :"■  * 
ifi<»ni\  :•  <»r  (»t"  tin-  ulioli'  .i^Haii'l  u-nu^  Ication).  ("auslics  are  slow  an«i  y^-.v  ' . 
\  !u'  i^alv.iiioi  ;ii]:ir\  i-  oi'tni  hm  ommended  in  adults  bccau>f  of  the  cr' •••" 
li-K  i»i'  -I'Xt-n-  In  ;ii.irrh;!L:i'  ai  thi.^  t  inn- of  life.  Tonsillotomy  may  I »t' pcrf«  :"' - 
V.  i''i  .1  l)i-t(.iir\  iT  with  the  Liuilloiinc.  In  the  first  instance  the  tonsil  i-  '.::.•.  • 
Ii; .'.  aril-  wiih  a  it!ia«  uluin.  ami  removed  by  cutting  from  below  upwar<!  •'•■■ 
a  i.linif  |»«)iiittii  j.i-iourv.  ih<'  l»la(i<'  (A  which  is  wrapped  to  within  an  iv 
i»r  tin-  jM)im  witli  a<llie-i\f  i)la-ier.  The  guillotine,  or  tonsillotome  \¥\\:  \>- 
ta»  ililaie>  thr  ojxratinii.  The  rim;  of  the  instrument  is  pa>sed  over  :!". 
;o:i-iI,  uhiiii  i^  pn-.-til  iii\var«U  wiih  tht-  lingers  behind  the  angle  of  the ':i- 
i}i(  11  by  ai»|»n>\imaiinL:  ihe  iinm-rs  and  thumb  the  tonsil  harpooned.  an«!  ..r 
[••.iiainl  wiih  ihf  riiiii  --haptd  kiiiff.  H('for<'  either  t»perati<»n  adhe^in:.- ■ 
ihe  art  lie^  of  liie  j)alaif  -houM  be  ^rjiaraled.      /.nitrlaition  is   imw    pr<-:Vr:i 


Ki-  ESOPHAGEAL   DIVERTICULA.  435 

t*:n>"tonsillotomy,  as  after  the  latter  the  portion  of  gland  left  behind  may  lead 
^?lO  recurrence.  With  a  finger  or  blunt  dissector  the  tonsil  is  shelled  from  its 
SFOed,  and  then  expressed  from  between  the  faucial  pillars  with  an  ^craseur 
ar  blunt  tonsillotome.  Hemorrhage  after  these  operations  usually  ceases 
rif»ioinptly,  but  occasionally  persists,  the  blood  coming  from  the  tonsillar  branch 
<rf  the  facial.  If  it  cannot  be  controlled  by  adrenalin  and  pressure,  the 
^ivound  should  be  united  by  deep  sutures;  rarely  will  it  be  necessary  to  tie 
ri^Hie  external  carotid. 

:t  Tomors  of  the  tonsils  are  generally  malignant,  lympho-sarcoma  being  the 
.4jBK>0t  frequent  variety.  Epithelioma  is  usually  secondary.  Both  diese 
:4'g^wibs  cause  enlargement  of  the  lymph  glands,  interfere  with  deglutition 
.  mnd  respiration,  and  undergo  ulceration,  which  often  causes  a  serious  or  fatal 
r .  faemorrhage.  The  treatment  is  extirpation.  A  small  encapsulated  sarcoma 
.  may  be  enucleated  through  the  mouth,  but  most  malignant  growths  will  have 
\  to  be  dealt  with  from  the  neck.  An  incision  is  made  along  the  anterior  bor- 
.  4ier  of  the  stemomastoid,  the  lymphatic  glands  removed,  the  external  carotid 
tiedy  and  the  growth  excised.  It  may  be  necessary  to  divide  the  lower  jaw, 
or  to  incise  the  cheek  from  the  angle  of  the  mouth  backwards. 

-Retropharyngeal  abscess  may  be  acute  or  chronic,  and  is  most  frequent 
in  children.  Acute  abscesses  may  be  caused  by  foreign  bodies,  or  by  infection 
cl  the  lymph  glands  in  this  region,  which  drain  the  nose  and  nasopharynx. 
The  chronic  form  is  usually  the  result  of  caries  of  the  spine  or  base  of  the  skull, 
and  is  not  associated  with  the  fever  and  inflammatory  phenomena  character- 
btic  of  the  former.  In  either  case  the  posterior  wall  of  the  pharynx  bulges 
forward,  exhibits  fluctuation,  and  may  interfere  with  deglutition  and  respira- 
tion. If  imopened,  the  abscess  will  break  into  the  pharynx,  point  externally 
in  the  neck,  or  gravitate  into  the  posterior  mediastinum.  The  treatment  is 
evacuation  through  the  mouth  in  acute  cases,  and  through  the  neck  in  chronic 
cases,  as  in  the  latter  secondary  infection  should  be  prevented.  When  the 
abscess  is  to  be  opened  through  the  mouth,  the  head  should  hang  over  the 
edge  of  the  table  in  order  to  prevent  the  entrance  of  pus  into  the  air  passages, 
and  the  abscess  opened  with  a  knife,  the  edge  of  which  is  covered  with  adhe- 
sive plaster  to  near  the  point.  Anesthesia  is  dangerous.  When  the  abscess 
is  opened  through  the  neck,  an  incision  is  made  along  the  posterior  border  of 
the  stemomastoid  from  the  apex  of  the  mastoid  downwards,  unless  the  ab- 
scess points  in  some  other  region.  The  finger  or  a  pair  of  forceps  is  passed 
along  the  anterior  surface  of  the  bodies  of  the  vertebrae  and  a  drainage  tube 
inserted. 

THE  ESOPHAGUS. 

Congenital  malformations  include  fistula;,  diverticula,  and  cystic 
growths,  such  as  have  already  been  mentioned  in  speaking  of  the  branchial 
clefts.  Stenosis,  atresia,  and  absence  of  the  esophagus  also  have  been  noted, 
as  well  as  double  esophagus  and  opening  of  the  esophagus  into  the  trachea. 

Diverticula  occur  in  three  forms.  Pulsion  or.  pressure  diverticula  most 
frequently  originate  in  the  posterior  wall  at  the  junction  of  the  pharynx  and 
esophagus.  When  consisting  of  mucous  membrane  alone,  they  are  some- 
times called  pharyngoceles,  A  sacculation  may  be  formed  from  the  pressure 
of  food  also  above  a  stricture.  Traction  diverticula  arc  due  to  the  contraction 
of  scar  tissue,  such  as  may  follow  inflammation  of  the  bronchial  glands,  hence 


434 


UPPER  DrOESTIVE  APPAItATUS. 


Perforationsi  of  tlie  palate  are  usually  caused  Ijy  syphilis,  occasionally 

by  traumatism  or  lupus.  If  the  local  disease  is  cured,  the  perforation  may 
be  closed  by  a  plastic  operation,  although  in  most  syphilitic  cases  better 
results  are  obtained  by  Ihe  use  of  of)lurators. 

Elongation  of  the  uvula  when  troublesome  may  be  remedied  by  remov- 
ing the  lower  portion  with  scissors. 

Suppurative  tonsillitis,  or  quinsy,  may  follow  exposure  to  cold  or  pol- 
luted air;  Certain  individuals  are  predisposed  to  this  aflfection,  particularly 
during  adolescence.  The  tonsils,  the  fauces,  and  the  soft  palate  are  swollen 
and  edematous,  causing  interference  with  breathing,  swallowing,  and  speak- 
ing. There  are  pain  in  the  throat,  enlargement  of  the  cervical  glands,  and 
marked  constitutional  symptoms.  Both  tonsils  may  be  involved,  and  the 
patient  may  be  unable  to  open  the  mouth.  The  ireatmeni  in  the  initial  stage 
is  an  ice  bag  externally,  scarification  of  the  tonsil,  a  chlorate  of  potasJi  gargle, 
and  symptomatic  internal  treatment.  Wlien  pus  forms,  the  abscess  may  he 
opened  with  a  sharp  pointed  tenotome^  the  incision  being  parallel  with  the 
anterior  pillar  of  die  fauces  and  directed  towards  the  middle  line. 

Hypertrophy  of  the  tonsils  is  most  frequent  in  children  and  indeed  may 
be  congenitab  It  may  follow  repeated  acute  attacks  of  inllammation  and  is 
often  a  manifestation  of  a  tuberculous  diathesis.  It  is  usually  associated 
with  adenoids  and  hence  presents  the  same  symptoms  as  the  latter.  Caseous 
and  calcareous  concretions  may  form  in  the  crypts  of  the  tonsils,  and  cysts 


I 


Fig.  353. — Tonsitlotome.     (Zuckerkandl.) 


occasionally  develop  from  blocking  of  the  orifices  of  the  follicles.  The 
treatment  is  attention  to  the  general  health  and  removal  of  a  portion  (tonsil- 
lotomy) or  of  the  whole  gland  (enucleation).  Caustics  are  slow  and  painful. 
The  galvanocautery  is  often  recommended  in  ailults  because  of  the  greater 
risk  of  severe  hemorrhage  at  this  time  of  life.  TonsiUoiomy  may  be  performed 
with  a  bistoury  or  with  the  guillotine.  In  the  first  instance  the  tonsil  is  dravm 
inw^ards  with  a  tenaculum,  and  removed  by  cutting  from  below  upward  mlh 
a  blunt  pointed  bistoury,  the  blade  of  which  is  wrapped  to  within  an  inch 
of  the  point  with  atlhesive  plaster.  The  guillotine,  or  lonsillotome  (Fig.  552), 
facilitates  the  operation.  The  ring  of  the  instrument  is  passed  over  the 
tonsil,  which  is  pressed  inwards  with  the  fingers  Ijehind  the  an^le  of  the  jaw; 
then  by  approximating  the  fingers  and  thumb  the  tonsil  harpooned,  and  aiu- 
putated  with  the  ring-shaped  knife.  Before  cither  operation  adhesions  Ip 
the  arches  of  the  palate  should  J>e  separated     Emu  hat  ion  is  now  preferred 


ESOPHAGEAt   DINTORTICULA. 


435 


to  tonsillDtomy^  as  after  tlie  latter  the  portion  of  gland  left  behind  may  lead 
to  recurreni  c.  With  a  tmger  or  blunt  dissector  the  tonsil  is  shelled  from  its 
bed,  and  then  expressed  from  between  the  faucial  pillars  with  an  <5craseur 
or  blunt  tonsillotome.  Hemorrhage  after  these  operations  usually  ceases 
promj)tly,  but  occasionally  persists,  the  blood  coming  from  the  tonsillar  branch 
of  the  facial.  If  it  cannot  be  controlled  by  adrenalin  and  pressure,  the 
wound  should  be  united  by  deep  sutures;  rarely  will  it  be  necessary  to  tie 
the  external  carotid. 

Tumors  of  the  tonsils  are  generally  malignant,  lympho- sarcoma  being  the 
most  frequent  variety.  Epithelioma  is  usually  secondary.  Both  these 
growths  cause  enlargement  of  the  lymph  glands,  interfere  with  deglutition 
and  respiration,  and  undergo  ulceration,  which  often  causes  a  serious  or  fatal 
hemorrhage.  The  treaimmi  is  extirpation.  A  small  encapsulated  sarcoma 
may  be  enucleated  through  the  mouth,  but  most  malignant  growths  will  have 
to  be  dealt  witli  from  the  neck.  An  incision  is  made  along  the  anterior  bor- 
der of  the  sternomastoiib  the  lymphatic  glands  removed,  the  external  carotid 
tied,  and  the  growth  excised.  It  may  be  necessary  to  divide  the  lower  jaw, 
or  to  incise  tJie  cheek  from  the  angle  of  the  mouth  backwards. 

Retropharyngeal  abscess  may  be  acule  or  chronic,  and  is  most  frequent 
in  i^hildren.  Acuir  abscesses  may  be  caused  by  foreign  bodies,  or  by  infection 
of  the  lymph  glands  in  this  region,  which  drain  the  nose  and  nasopharjmx. 
The  thrmiic farm  is  usually  the  result  of  caries  of  the  spine  or  base  of  the  skull, 
and  is  not  associated  with  the  fever  and  inflammator}^  phenomena  character- 
istic of  the  former.  In  either  case  the  posterior  wall  of  the  phar>'nx  bulges 
forward,  exhibits  iluctuation,  and  may  interfere  with  deglutition  and  respira- 
tion. If  unopened,  the  abscess  will  break  into  the  pharynx,  point  externally 
in  the  neck,  or  gravitate  into  the  posterior  mediastinum.  The  Ircaimcnt  is 
evacuation  through  the  mouth  in  acute  cases,  and  through  the  neck  in  chronic 
cases,  as  in  the  latter  secondar}^  infection  should  be  prevented,  WTien  the 
abscess  is  to  be  opened  through  the  mouth,  the  head  should  hang  over  the 
edge  of  the  table  in  order  to  prevent  the  entrance  of  pus  into  the  air  passages, 
and  the  abscess  opened  witli  a  knife,  the  edge  of  which  is  covered  with  atlhe- 
sivc  plaster  to  near  the  point.  Anesthesia  is  dangerous.  WTien  the  abscess 
is  opened  through  the  neck,  an  incision  is  made  along  the  posterior  border  of 
the  sternomastoid  from  the  apex  of  the  mastoid  downwards,  unless  the  ab- 
scess points  in  some  other  region.  The  finger  or  a  pair  of  forceps  is  passed 
along  the  anterior  surface  of  the  bodies  of  the  verlebric  and  a  drainage  tube 
inserted. 

THE  ESOPHAGUS. 

Congenital  malformations  include  tistuhe,  diverticula,  and  cystic 
growths,  suth  as  have  already  l»ecn  mentioned  in  speaking  of  the  branchial 
clefts.  Stenosis,  atresia,  and  absence  of  the  esophagus  aJso  have  been  noted, 
as  well  as  double  estiphagus  and  opening  of  the  esophagus  into  the  trachea. 

Divertictila  occur  in  three  forms.  Pulsion  or  pressure  divertiadu  most 
frequently  originate  in  the  posterior  wall  at  the  junction  of  the  pharynx  and 
es*3phagus.  UTien  consisting  of  mucous  membrane  alone,  they  are  s(»me- 
times  called  pharyn^oteles,  A  sacculation  may  be  formed  from  the  pressure 
of  food  also  aliove  a  stricture.  Tratfhm  divertuula  are  due  to  the  contraction 
of  scar  tissue,  sucJi  as  may  follow  inflammation  of  the  lironchial  glands,  hence 


IP 


UPPER   DIGESTIVE  APPARATtTS. 


they  are  most  frequent  on  the  anterior  wall  near  the  bifurcation  of  the  trachea. 
They  are  usually  small,  seldom  cause  trouble,  and  are  recognized  post  mor- 
tem only.  Pseudodiverliada  are  formed  by  the  cavity  of  an  abscess  or  cyst 
which  has  emptied  into  the  esophagus. 

The  symptoms  of  pressure  diverticula  are  dysphagia,  swelling  of  the  neck 
after  taking  food,  and  regurgitation  after  taking  more  food,  owing  to  the 
pressure  of  the  disteniled  sac  on  the  esophagus^  or  when  the  sac  Is  pressed 
upon  witli  the  fmgers.  A  bougie  may  enter  the  sac  at  one  lime  and  pass 
along  the  esophagus  at  another.  After  taking  bismuth  (p,  458)  the  sac  nnay 
be  outlined  with  the  X-rays,  Examination  with  the  esophagoscope  may 
reveal  the  opening  in  the  sac.  The  inaimntl  is  incision  along  tlie  anterior 
edge  of  the  left  sternomastoi*l  {the  esophagus  inclines  towards  the  left),  retrac- 
tion of  the  muscle  and  the  carotid  packet  to  the  left  and  the  trachea  to  the 
right,  isolation  and  amputation  of  the  diverticulum  (which  may  be  identiticd 
with  a  bougie),  suture  of  the  opening  in  the  esophagus,  and  gauze  drainage. 

Idiopathic  dilatation  of  the  esophagus  icartiiospasm)  is  characterized 
by  atony  and  dilatation  of  the  gullet  with  spasm  of  the  canlia;  which  of  these 
is  the  primary  lesion  is  a  matter  of  dispute.  It  may  be  associated  with 
esophagitis  or  disease  of  the  stomach  or  l(verj>ut  in  many  instances  no  cause  j 
for  the  spasm  can  be  found  beyond  the  fact  that  the  patient  is  nen^ous. 
Th^  sympioms  are  lirst  those  of  spasmodic  stricture   (p.  4.^0).  *i"<l*  2U5  the 


FlO,  JS3. — Skmgrjiph  showing  liKaliun  of  penny  in  eusophagus  afK>vi?  a  stricture,  the 
result  of  swallowing  lyc.     (PolycliTiic  Hospital.) 

spasm  becomes  continuous^  those  of  organit  strictu re  (p.  4^8} .  The  ireaimerU 
is  the  passage  of  large  bougies;  forcible  dilatation  hy  means  of  a  rubber  bag 
attached  to  a  tube,  and  distended  after  it  is  in  place;  or  divulsion  of  the  cardia 
with  the  lingers  or  a  uterine  dilator,  after  opening  the  stomach. 

Wounds  of  the  esophagus  from  without  have  already  been  referred  to 
under  cut  throat.  Internal  injuries,  e.g.,  from  foreign  bodies,  bougies,  and 
die  swallowing  of  caustics,  cause  painful  dysphagia,  bleeding,  and  emphy- 
sema if  the  wall  is  perforated.  The  patient  is  fed  by  rectum  for  a  week  or 
more,  and  sounds  used  when  healing  has  occurred,  in  order  to  prevent  the 
development  of  a  stricture.  After  the  swallowing  of  a  caustic  the  proper 
antidote  should,  of  course,  be  administered. 

Foreign  bodies  in  the  esopbagus  are  most  frequent  in  children  and 
lunatics.     They  are  apt  to  be  arrested  at  the  narrowest  poriions  of  the  lube. 


FOREIGN    BODIES   IN   THE   ESOPHAGUS. 


437 


^posite  the  cricoid  cartilage  (six  inches  from  the  teeth),  at  the  level  of 
ft  bronchus  (12  inches  from  the  teeth),  and  at  the  diaphragmatic 
ig  ( 16  to  18  inches  from  the  teeth).  The  symptoms  are  dysphagia,  pain, 
)metimes  dyspnea.  Sharp  or  rough  bodies  may  cause  hemorrhage; 
ged  impaction  may  lead  to  perforation  and  death.  Owing  to  the 
on  which  is  produced,  the  symptoms  sometimes  persist  for  a  time,  even 
he  foreign  body  has  been  removed.  Foreign  bodies  may  be  detected 
[le  bougie,  the  esophagoscope,  or,  if  dense,  with  the  X-ray  (Fig.  353.) 


t 


•• 


A  4 


''k;.  .^54. — Expanding 
horsehair  prohang. 


Fig.  355— C 
catcher. 


Fig.  356. — Esophageal 
bougies. 


lodged  in  the  cervical  portion  of  the  tube,  external  palpation  may  be  of 
value.  The  patient  is  usually  able  to  indicate  the  site  of  impaction. 
'catmcnt  varies  with  the  size,  shape,  situation,  and  nature  of  the  body, 
t  these  facts  should  be  ascertained  whenever  possible.  Bodies  like  pins 
sh  bones  may  be  extracted  with  the  expanding  horsehair  probe  (Fig. 
discs  and  coins  with  the  coin-catcher  (355).  Round  and  smooth  ot- 
nay  sometimes  be  pushed  into  the  stomach.  When  in  the  cervical 
n  of  the  esophagus,  the  offending  substance  may  often  be  remove^ 


I 


with  long  cunctl  funcps.  ICxtrartion  umler  the  eye  may  sometimes  \ic 
smcessfuUy  atcompJisiiecl  hy  means  of  long  slender  forceps  introduced 
through  an  esophagaseope..  Esophagohmty  is  indicated  when  a  body  is 
impacted  in  the  upper  part  of  the  tube,  the  esophagus  Ijeing  exposed  in  the 
neck  as  described  in  the  treatment  of  diverticula,  and  sutured  after  extraction 
of  the  foreign  liody'  Impaction  in  the  lower  part  of  the  esophagus  may 
demand  gastrotomy,  and  extraction  of  the  foreign  body  by  the  finger  or  fore- 
ceps  introduced  through  the  cardiac  orifice  of  the  stomach* 

Stricture  of  the  esophagus  may  be  (i)  organic  or  (2)  inorganic. 

I,  Organic  stricture  is  usually  (a)  cicatricial  or  (b)  malignant,  although 
it  may  be  congenital  or  be  caused  by  foreign  bodies  or  the  pressure  of  aneu- 
r>'sms,  tumors,  etc.  (a)  Fibrous  or  cicatricial  stricture  is  generally  the 
result  of  the  swallowing  of  corrosives,  but  may  follow  also  other  injuries  and 
ulcerations.  It  is  most  frequent  in  the  young  and  often  situated  opposite  to 
the  cricoid  cartilage.     In  some  cases  there  are  multiple  strictures. 

The  symptoms  come  on  slowly^  there  first  being  difficulty  in  swallowing 
solids  and  finally  in  swallowing  liquids.  WTicn  the  stricture  is  near  the 
stomach*  food  may  not  be  returned  immediately,  but  may  collect  in  the  pouch 
which  forms,  and  be  regurgitated  after  an  interval,  the  reaction  being  alkalin, 
not  acid  as  would  be  ihe  stomach  contents.  Pain  is  slight  or  absent  an4 
as  a  rule,  the  patient  is  able  to  locate  the  site  of  obstruction.  In  the  later 
stages  there  is  marked  emaciation  from  stan-ation.  The  diagnosis  is  con* 
firmed  and  the  stricture  located  with  an  esophageal  bougie  (Fig,  sS^h  which 
in  the  adult  should  normally  enter  the  stomach  16  to  18  inches  from  the 
teeth.  The  patient  is  sealed  with  the  head  forward  and  the  jaws  open;  the 
bougie  is  warmed,  lubricatctl  with  glycerin,  and  passed  downw^ard  into  the 
esophagus  while  the  left  forefinger  depresses  the  tongue  and  guards  the  orifice 
of  the  larynx.  Great  force  should  never  be  employed,  particularly  if  cancer 
is  suspected,  as  perforation  and  death  may  follow.  Furthermore,  it  is  well  to 
rule  out  the  presence  of  aneurysm  before  passing  a  bougie.  In  all  cases  there 
is  a  delay  in  the  swallowing  sound,  which  is  normally  about  four  seconds  in 
length,  i.e.,  from  the  time  the  patient  begins  to  swallow  a  mouthful  of  water 
until  the  last  gurgle  into  tlie  stomach  is  heard;  the  ear  is  applied  to  the  verte* 
bral  groove  near  the  angle  of  the  left  scapula.  Finally  the  esophagoscope 
may  be  used  to  determine  the  nature  and  site  of  the  stricture,  and  the  seat 
of  narrowing  may  be  graphically  depicted  by  a  radiogram,  after  the  ingestion 
of  bismuth  (p.  458). 

The  treatment  is  gradual  dUaialimt  by  passing  increasing  sizes  of  bougies 
every  second  or  third  day.  In  order  safely  to  penetrate  a  minute  stricture 
Plummer  has  the  patient  swallow  six  yards  of  fine  silk,  three  in  the  evening 
and  three  the  following  morning.  The  portion  first  swallowed  passes  into 
the  intestine,  so  that  die  thread  hanging  from  the  mouth  may  be  pulled  taut. 
A  bougie  with  a  perforated  olive  tip  is  then  threaded  on  the  silk,  which  acts  as 
a  guide  to  the  orifice  of  the  stricture.  In  cases  in  which  dilatation  cannot  be 
practiced  a  Symond's  hibc  may  be  used.  This  is  a  rubber  tube,  funnd- 
shaped  at  the  upper  end  where  it  rests  against  the  stricture.  It  is  inserted  by 
a  whalebone  introduc  er,  and  removed  every  two  or  three  weeks  by  means  of 
a  piece  of  silk  attached  to  its  upper  end  and  issuing  from  the  mouth,  Reiro- 
grade  dUatatkm  by  means  of  the  finger  or  bougie  may  be  practiced  after 
opening  the  stomach  when  the  lesion  is  near  the  cardiac  orifice.  Abbe's 
operaihn  is  applicable  to  strictures  in  the  thoracic  portion  of  the  esophagus 


^ 


STRTCTtTRE   OF   THE   ESOFHAGUS. 


439 


which  have  resiste<l  other  means  of  treatment.  A  shot  i  lamped  to  the  end 
of  a  tine  piece  of  silk  is  swallowed  by  the  patient.  The  stomarh  is  then 
opened,  and  coarse  silk  attached  to  the  thread  and  pulled  through  the  stricture^ 
which  is  then  divided  by  sawing  movements,  while  it  is  made  tense  by  the 
pressure  of  a  bougie  passed  from  below.  In  some  cases  the  silk  is  brought 
out  through  an  esophagotomy  wound  in  the  neck  instead  of  through  the 
mouth.  The  calibre  of  tlie  esophagus  is  maintained  by  the  passage  of 
bougies.  Odtsneys  method  consists  in  opening  the  stomach,  and  passing  a 
long  loop  of  silk  through  the  stricture  by  means  of  a  w^halebone  probe.  A 
small  rubber  tube  is  passed  through  tliisloop,  and  drawn  through  the  stricture 
while  on  the  stretch.  When  released  the  rubber  swells  and  dilates  the  stric- 
ture. Increasing  sizes  of  tubes  are  thus  employed.  Internal  esophagotmny 
by  means  of  an  instrument  with  a  concealed  knife,  2Ji(\  forcible  dilatation  by 
special  divulging  instruments,  are  ver>^  dangerous.  External  esophagoiomy 
has  been  employed  in  high  strictures,  the  contraction  being  divided,  dilated, 
or  even  excised.  Esophagastomy  consists  in  suturing  the  mucous  memf>rane 
of  the  esophagus  below  the  stricture  to  the  skin,  thus  making  an  artificial 
mouth.  Gastroslomy  is  indicated  when  swalJowing  is  impossible,  in  order  to 
feed  the  patient.  A  stricture  which  is  thus  rested  may  after  a  time  become 
passable  to  bougies. 

(b)  Malignant  stricture  is  most  frequent  in  men  after  the  age  of  forty » 
and  most  common  at  the  narrow^est  portions  of  the  esophagus,  vi^.,  opposite 
the  cricoid,  at  the  level  of  the  left  bronchus  (being  epitheliomatous  in  both 
instances),  and  at  the  cardia,  when  it  is  a  columnar-celled  carcinoma. 
The  symptoms  are  those  of  cicatricial  stenosis,  but  there  are  greater  pain, 
more  rapid  emaciation,  and  often  cough,  and  regurgitation  of  blood-stained 
food.  The  tumor  may  be  fell  when  the  cer\^ical  portion  is  involved.  Other 
symptoms  may  arise  owing  to  invasion  of  surrounthng  structures.  The 
treatment  in  the  early  stages  is  the  passage  of  a  soft  rubber  bougie  to  keep 
the  canal  open.  Symond's  tube  has  been  used  in  some  cases.  The  best 
treatment,  however,  when  swallowing  is  diffirult,  is  gastrostomy.  Excision 
of  limited  growths  in  the  cervical  portion  of  the  cstDphagus  has  been  success- 
fully accomphshed,  but  all  attempts  thus  far  to  resect  a  portion  of  the  thoracic 
gullet  have  been  fatal. 

2.  Inorganic  or  spasmodic  stricture  (esophagismtis)  is  usually  hysterical 
in  origini  the  spasm  beginning  below  and  ascending  (ghims  kysterieus),  but 
occasionally  occurs  in  tetanus,  and  as  the  result  of  retlex  irritation  in  diseases 
of  the  larynx  (opposite  the  larynx),  liver,  and  stomach  (at  the  cardia).  In  the 
last  situation  it  may  become  permanent  and  give  rise  to  the  so  called  idio* 
pathic  dilatation  of  the  esophagus  (p.  436).  The  symptoms  are  sudden  in  on- 
set, intermittent  in  character,  and  associated  wnth  evidences  of  the  causative 
lesion.  There  is  a  spasmodic  choking  sensation,  with  dysphagia  and  some- 
times regurgitation  of  food.  Anesthesia  relaxes  the  spasm  and  permits  the 
passage  of  a  full-sized  bougie.  The  treatment  is  directed  to  the  cause.  The 
passage  of  bougies  will  do  more  harm  than  good  in  hysterical  cases. 


J 


440  ABDOMEN. 


CHAPTER  XXVII. 
ABDOMEN. 

Abdominal  section  {celiotomy ,  laparotomy)  is  incision  into  the  abdomen 
for  surgical  purposes.  The  preparation  and  after  care  of  the  patient,  the  pre- 
cautions in  reference  to  instruments  and  sponges,  and  the  indications  for  and 
dangers  of  drainage,  are  given  in  the  chapter  on  Surgical  Technic;  the  pos- 
tures different  operations  may  require  and  the  situation  of  the  incisions  for  ex- 
posure of  various  organs,  in  the  description  of  the  operations  on  the  viscus  con- 
cerned. In  order  to  give  an  idea  of  the  way  in  wldch  the  abdomen  is  opened 
and  closed,  we  shall  here  describe  only  the  median  incision,  since  it  is  often 
selected,  not  only  because  it  causes  comparatively  little  bleeding,  but  also  be- 
cause it  permits  exploration  of  both  sides  of  the  abdominal  cavity.  When  it  is 
necessary  to  pass  the  umbilicus,  the  left  side  is  chosen  to  avoid  die  round  liga- 
ment of  the  liver,  although  some  operators  excise  the  umbilicus  because  it  is 
often  infected  and  is  difficult  to  suture.  After  incising  the  skin  and  subcutan- 
eous tissues,  instead  of  locating  the  linea  alba  with  nicety,  the  anterior  sheath  of 
the  rectus  is  split,  the  muscular  fibres  separated  with  Uie  finger  or  the  handle 
of  the  knife,  and  the  posterior  sheath  and  transversalis  fascia  divided.  The 
peritoneum,  which  is  recognized  by  the  presence  of  fatty  tissue  in  front  of  it, 
is  now  elevated  from  the  viscera  with  forceps  and  opened  sufficiently  to  admit 
the  finger,  which  guards  the  intestines  while  the  opening  is  enlarged  with  the 
scissors.  After  the  operation  has  been  completed  the  wound  is  closed  with 
great  care  in  order  to  prevent  the  development  of  a  hernia.  Figs.  357  to  364 
illustrate  various  methods  of  dosing  the  abdominal  wound.  Buried  sutures 
should  be  of  catgut,  sutures  which  are  subsequently  removed  of  silkworm  gut. 
Through  and  through  sutures  (Fig.  357),  which  are  introduced  about  one- 
fourth  inch  from  the  ^dge  of  the  wound  and  about  one-half  inch  apart, 
obliterate  all  dead  spaces,  stop  oozing,  give  firm  support,  and  permit  rapid 
work.  Suture  of  the  individual  layers  of  the  abdominal  wall  (Fig.  364)  is 
anatomically  more  accurate,  and,  owing  to  the  smaller  amount  of  tension 
on  each  suture,  less  apt  to  cause  necrosis.  The  various  ways  of  closing  the 
skin  incision,  when  the  tier  suture  is  employed,  arc  given  in  the  chapter  on 
Wounds.  The  author,  whenever  possible,  puts  a  purse-string  suture  of 
catgut  in  the  peritoneum,  thus  making  a  dot  instead  of  a  line  of  scar  tissue 
and  lessening  the  chances  of  adhesions;  passes  through  and  through  sutures 
of  silkworm  gut  through  the  remaining  layers;  closes  the  fascia  with  a  con- 
tinuous suture,  using  the  same  thread  that  was  placed  in  the  peritoneum, 
thus  drawing  the  peritoneum  up  under  the  fascia  and  preventing  the  formation 
of  a  dead  space;  and  finally  ties  the  silkworm-gut  sutures.  The  wound  is 
dressed  with  aseptic  gauze,  retained  in  place  by  adhesive  j)Iaster  and  a  firm 
binder.  The  patient  is  not  allowed  to  sit  up  for  from  ten  days  to  three 
weeks  or  longer,  according  to  the  situation  and  length  of  the  incision  and 
the  presence  or  absence  of  drainage  or  infection.  In  most  instances  the 
patient  should  wear  an  abdominal  support  for  some  time  after  leaving  bed. 

Contusions  of  the  abdomen  vary  from  a  superficial  ecchymosis  to  the 


CONTUSIONS  OF  THE  ABDOMEN. 


441 


most  extensive  shattering  of  the  viscera.  Sudden  and  immediate  death 
following  a  blow  on  the  abdomen,  without  gross  injury  to  the  viscera,  has 
been  attributed  to  shock,  or  disturbance  of  the  solar  plexus,  but  is  probably 
the  result  of  violence  to  the  heart  or  to  its  nerve  mechanism.  Hematoma 
and  suppuration  of  the  abdominal  wall  may  follow  a  contusion  as  elsewhere. 
Muscular  rupture  follows  a  violent  force  to  a  normal  muscle  in  extreme 
tension,  or  a  trivial  injury  to  a  degenerated  muscle.  The  rectus  tends  to 
rupture  more  frequently  than  the  broad  muscles  of  the  parietes.  A  ruptured 
muscle  should  be  sutured  because  of  the  subsequent  danger  of  hernia.     When 


Fig.  357. 


Fig.  358. 


Fig.  359. 


Fig.  360. 


Fig.  361. 


Fig.  362. 


Fig.  363- 


Figs.  357  to  364. — (Binnie.) 


Fig.  364. 


a  blow  is  expected,  the  body  is  bent,  the  muscles  contracted,  and  the  force 
expended  on  the  abdominal  wall,  but  a  blow  received  when  the  muscles  are 
flaccid  is  very  apt  to  injure  the  viscera.  The  most  serious  intraabdominal 
injury  may  be  present  without  any  evidence  of  injury  to  the  skin  or  muscles. 
The  effects  of  visceral  injury  are  manifested  immediately,  as  shock,  hemor- 
rhage, or  peritonitis;  inler mediately,  as  when  peritonitis  follows  a  perforation 
through  a  contused  necrotic  patch  in  the  intestine,  the  patient  having  been 
apparently  well  for  one  or  more  days;  or  remotely,  as  adhesions,  stricture  of 
the  bowel,  aneurysm,  etc.,  developing  after  a  prolonged  period. 


Il 


ABDOMEN, 

Ruptures  of  mast  of  the  large  intraabdominal  vessels  have  !>een 
rccordeti.  Provifling  there  lie  time,  the  alHliimeii  shoulcl  be  opened  arui  the 
hemorrhage  t  heiketl.  If  the  vessel  be  severely  tonluscd,  hlet*ding  may  lie 
postponed  until  sloughing  of  the  arterial  wall  ensues,  or  thrombofsis,  emlx>lism, 
stenosis,  or  aneurysm  may  develop,  and  the  parts  supplied  by  the  artery  l 
become  gangrenous. 

From  its  elasticity  and  more  protected  position  beneath  the  ribs,  the 
stomach  is  less  liable  to  be  affected  by  trauma  than  the  intestines.  The  ante- 
rior wall  is  the  most  frequent  site  for  rupture.  One  or  all  the  coats  may  be 
torn.  Shock,  peritonitis,  and  hematemesis  are  the  symptoms.  The  stomach 
should  be  sutured  and  the  treatment  for  peritonitis  instituted. 

Rupture  of  the  intestine  is  frequendy  the  result  of  a  horse-kick,  a 
man-kick,  or  a  run-over  accident,  the  intestine  being  crushed  between  the 
vulnerating  body  and  the  l>ony  parts  behind.  A  fall  from  a  height  or  a  blow 
upon  the  bark  also  may  tear  the  intestine,  particularly  where  it  is  firmly  fixed, 
e.g.,  the  duodenum.  The  most  important  symptoms  are  pain,  tenderness, 
rigidity  of  the  abdominal  wall,  and  an  anxious  facial  expression.  Shock 
is  slight  or  absent  in  25  per  cent,  of  the  cases.  Absence  of  liver  dulness  with 
a  flat  abdomen  is  a  valualile  sign.  Cellular  emphysema  is  rare  and  indicates 
a  lesion  of  the  bowei  beyond  the  limits  of  the  peritoneal  space.  Movable 
dulness  in  the  tlanks  is  a  sign  of  l^uid  in  the  peritoneal  cavity,  which  may  be 
serous,  sanguineous^  or  fecal.  Fecal  extravasation  is  rarely  great  in  rupture 
of  the  bowel,  owing  to  the  contraction  of  the  muscular  coat,  whiJc  hemorrhage 
is  slight  unless  the  mesentery  or  other  vascular  structure  is  torn.  Abdominal 
distention,  fever,  and  other  symptoms  of  widespread  peritonitis  are  later 
symptoms,  and  usually  mean  that  the  favorable  time  for  operation  is  past. 
Vomiting  immediately  after  the  accident  is  unimportant,  but  recurring  vomit- 
ing is  ominous.  There  may  be  absence  of  peristalsis  and  a  friction  sound  On 
auscultation,  and  tenesmus  with  a  frequent  desire  to  defecate  is  sometimes 
encountered.  Rectal  examination  in.  some  instances  may  detect  resistance 
in  the  vicinity  of  the  rupture,  due  to  the  formation  of  adhesions  around  the 
laceration.  Bright  blood  in  the  stools  points  to  a  rent  in  the  large  bowel, 
tarry  movements  to  a  lesion  higher.  The  temperature,  pulse,  and  respirations 
augment  with  the  spread  of  the  peritonitis,  which  will  cause  also  a  leukocytosis 
and  a  rise  in  the  blood  pressure.  The  rectal  insufflation  of  hydrogen  or  ether 
to  detect  the  perforation  is  too  dangerous  to  be  employed. 

The  treatinent  is  laparotomy,  suture  of  the  perforation,  cleansing  of  the 
j)eritonea]  <  avity,  and  drain Lige  as  described  under  peritonitis.  Death 
is  almost  inevitable  without  operation;  with  operaton  20  per  cent,  re- 
cover. The  difficulty  is  to  make  an  early  diagnosis.  In  the  presence  of 
the  tlrst  four  signs  mentioned  above,  exploration  is  urgently  demanded.  Asj 
a  rule  a  median  incision  is  made  below  the  umbilicus,  and  the  rupture  found 
between  the  seat  of  the  surface  injury  and  the  spine;  the  possibility  of  more 
than  one  perforation  should  be  kept  in  mind  and  discolored  spots  treated  as 
ruptures.  Resection  or  extraperitoneal  isolation  of  the  injured  bowel 
(according  to  the  condition  of  the  patient)  may  be  indicated,  because  of  the 
severity  of  the  contusion,  the  extent  of  the  laceration^  or  because  of  detach- 
ment or  injur}'  of  the  mesentery. 

In  tears  of  the  omentum  and  mesentery  the  immediate  danger  is  hemor- 
rhage. Later  an  intlammatory  mass  or  embarrassing  ailhesions  may  develop. 
When  the  mesenter)^  is  violently  contused,  or  stripped  from  the  bowel,  in- 


teslinal  gaiigrem.^  follows.  The  intestine  may  herome  strangylatecl  through 
a  slit  in  the  mesentery.  Sanguineous  mesenleric  cysts  al^i  may  (1eveh>p. 
The  treaiment  is  ligation  of  the  hleeding  vessels,  and  excision  of  omentum 
or  intestine,  if  such  be  needed. 

The  liver  is  frequently  lacerated,  particularly  the  right  lobe.  One-half 
of  the  cases  die  within  twenty-four  hours  from  hemorrhage.  Pain  is  severe 
and  shock  profound,  and  there  are  symptoms  of  internal  bleeding,  with  mov- 
able dubiess  in  ihe  Oanks.  Hepatic  dulness  is  increased.  Jaundice  some- 
times develops  after  twenty-four  hours,  and  bile  and  sugar  may  appear  in  the 
urine.  Peritonitis  frequently  occurs  in  those  who  sur\nve  the  initial  shock 
and  subsequent  hemorrhage.  Operation  is  imperative  to  check  hemorrhage, 
which  may  be  controlled  by  suture,  ligature,  cautery,  or  tampon.  Sutures 
should  be  given  the  preference^  but  if  they  tear  out,  fail  to  stop  the  bleeding, 
or  if  the  wound  is  inaccessible,  gauze  packing  should  be  ulilized  Cauteriza- 
tion  is  not  suitable  for  large  wounds  and  is  liable  to  be  followed  by  secondary 
hemorrhage. 

Ruptures  of  the  gall-bladder,  cystic,  hepatic,  and  common  bile  ducts 
have  occurred.  The  symptoms  are  pain,  shock,  biliar>^  ascites,  and  later  in 
some  cases  peritonitis,  as  the  bile  is  irritating  even  if  sterile.  In  a  complete 
rupture  of  the  hepatic  or  common  duct  there  would  f>e  jaundice,  cholemia,  and 
inanition.  The  gall-bladder  may  be  sutured  or  removed,  according  to  the 
degree  of  laceration.  Drainage  is  the  treatment  when  the  ducts  are  damaged, 
although  in  a  suitable  case  anastomosis  would  be  the  ideal  procedure. 

The  spleen  is  not  as  frequently  ruptured  as  the  liven  Enlargement  of 
the  organ  predisposes  to  ^nju^)^  Hemorrhage  is  the  great  danger,  but  is  not 
as  quickly  fatal  as  one  would  suppose,  owing  lo  the  elasticity  of  the  organ, 
and  lo  the  fact  that  the  blood  coagulates  rapidly  because  of  the  large  number 
of  leukocytes  present.  Abscess  or  peritonitis  may  follow.  The  sympioms 
are  those  of  internal  hemorrhage,  with  pain  and  tenderness  over  the  spleen. 
Splenic  dulness  is  increased,  and  frequently  docs  not  disappear  when  the 
patient  is  turned  on  die  right  side,  because  the  blood  is  often  clotted.  Opera- 
tion should  be  immediate;  its  nature  depends  upon  the  condition  of  the  patient 
and  of  the  spleen.  If  the  patient  has  lost  much  blood,  if  the  spleen  is  large 
and  extensively  adherent,  and  if  the  tear  is  favorably  situate*!,  suture  is  to  be 
chosen.  If  the  capsule  is  thin,  the  spleen  soft,  and  the  tear  inaccessible, 
packing  is  to  be  considered.  Ordmarily  a  large  laceration  in  a  normal 
spleen  is  best  treated  by  splenectomy.  Of  thirty-four  cases  of  splenectomy 
for  rupture,  41.2  per  cent,  were  fataL 

The  pancreas  is  seldom  ruptured  alone.  In  the  absence  of  fatal  hemor- 
rhage, gangrene,  suppuration,  or  chronic  pancreatitis  may  ensue.  The  so- 
called  traumatic  cysts  of  the  pancreas  are  probably  collections  of  blood  and 
pancreatic  fluid  in  the  lesser  peritoneal  cavity,  the  foramen  of  Winslow  hav- 
ing  been  closed  by  adhesions.  The  sympioms  are  those  of  shock  and  internal 
hemorrhage.  The  bleeding  is  checked  by  ligature,  suture,  packing,  or  partial 
excision,  being  careful  to  preserve  the  canal  of  Wirsung.  Posterior  drainage 
through  the  left  lumbar  fossa  is  lo  be  employed,  to  drain  off  any  leakage  of 
pancreatic  juice,  which  may  cause  peritonitis  or  fat  necrosis. 

The  kidney  is  well  protected  by  its  position  and  by  an  enveloping  bed  of 
fat,  yet  it  is  not  infrequently  injured.  The  rupture  is  usually  transverse  to 
the  long  axis  of  the  kidney.  If  the  capsule  remains  intact,  hemorrhage  takes 
place  into  the  organ ;  if  it  is  torn,  blood  and  urine  collect  in  the  perinephritic 


444  ABDOMEN. 

tissues.  If  the  peritoneum  is  lacerated,  urine  and  blood  accumulate  in  the 
abdominal  cavity.  Bilateral  and  occasionally  unilateral  injuries  of  the  kid- 
ney may  be  fatal  from  anuria,  in  the  latter  instance  the  sound  kidney  refusing 
to  act  from  reflex  inhibition.  The  symptoms  are  shock,  pain,  and  hematuria. 
Hematuria  may  be  absent  if  the  kidney  is  separated  from  the  renal  vessels  or 
the  ureter,  or  if  there  be  a  clot  in  the  ureter,  or  an  extensive  laceration  of  the 
pelvis  of  the  kidney.  Absence  of  hematuria  has  been  caused  also  by  throm- 
bosis of  the  renal  vessels  and  a  preexisting  stricture  of  the  ureter.  Hemorrhage 
and  sepsis  are  the  dangers.  Symptoms  of  internal  hemorrhage,  with  an  in- 
creasing tumor  in  the  loin,  demand  immediate  exploration.  If  the  kidney  is 
hopelessly  destroyed,  or  if  ligation  of  the  renal  vessels  be  necessary  to  control 
the  bleeding,  the  organ  should  be  removed,  taking  the  chances  of  the  existence 
and  integrity  of  the  opposite  kidney.  If  but  moderate  laceration  is  present, 
disinfection  and  drainage,  with  suture  or  partial  nephrectomy,  is  indicated. 
The  possibility  of  injury  to  the  intraperitoneal  organs  should  not  be  forgotten. 
MOd  cases  are  treated  by  ice  to  the  loin,  internal  astringents,  urinary  antisep- 
tics, and  rest. 

Rupture  of  the  ureter  is  caused  by  its  being  crushed  against  the  trans- 
verse process  of  the  third,  fourth,  or  fifth  lumbar  vertebra,  or  by  traction  on 
the  ureter.  All  ruptures  are  above  the  pelvic  brim.  Shock  is  neither  pro- 
found nor  persistent,  unless  there  be  some  injury  to  the  other  abdominal 
organs.  A  few  drops  of  blood  in  the  urine,  with  persistent  pain  and  tender- 
ness in  the  side,  point  to  injury  of  the  ureter.  If  the  duct  be  completely 
ruptured,  a  retroperitoneal  accumulation  of  urine  and  blood  will  appear  after 
several  days.  Complete  obstruction  of  the  ureter  will  cause  atrophy  of  the 
kidney;  partial  obliteration  may  result  in  a  pyo-  or  hydronephrosis.  If  the 
injury  be  uncomplicated,  the  danger  to  life  is  slight,  although  there  is  little 
tendency  towards  spontaneous  repair.  A  tear  in  the  peritoneum  may  lead  to 
a  fatal  peritonitis.  Immediate  anastomosis  is  the  ideal  treatment.  Lumbar 
incision  and  drainage  are  indicated  after  infection  has  taken  place;  if  a 
ureteral  fistula  follows  it  should  be  treated  as  described  on  page  528. 

Rupture  of  the  bladder  is  extraperitoneal,  intraperitoneal,  or  combined 
extra-  and  intraperitoneal.  Laceration  of  the  mucous  membrane  alone,  with 
hematuria,  may  follow  a  blow  on  the  hypogastrium.  Extraperitoneal  rupture 
is  usually  associated  with  fracture  of  the  pelvis.  Intraperitoneal  rupture  is 
generally  caused  by  a  forcing  backward  of  the  distended  viscus  against  the 
promontory  of  the  sacrum,  although  in  some  cases  it  may  result  from  centre 
coup.  In  uncomplicated  cases  the  rent  is  vertical  and  occurs  at  the  uppter 
and  posterior  part  of  the  bladder.  Normal  urine  may  come  in  contact  with 
the  peritoneum  without  causing  inflammation,  but  when  bacteria  are  present 
inflammation  (juickly  ensues.  The  injury  is  fatal  without  operation.  With 
operation  over  one-half  die  from  shock,  hemorrhage,  or  peritonitis.  The 
symptoms  are  shock,  hypogastric  pain,  a  sensation  of  something  having  given 
way,  rectal  tenesmus,  and  an  urgent  desire  but  inability  to  urinate.  The 
catheter  reveals  a  little  bloody  urine  or  no  urine  at  all;  it  may  pass  directly 
into  the  abdominal  cavity.  Cases  have  occurred  in  which  unstained  urine 
has  been  withdrawn  from  a  torn  bladder.  A  measured  quantity  of  boric  acid 
solution  may  be  injected  into  the  bladder;  if  the  same  amount  returns,  the 
bladder  is  probably  intact.  Air  or  hydrogen  may  be  pumped  into  the  blad- 
der, and  if  the  viscus  is  intact,  it  will  rise  above  the  pubes  as  a  symmetrical 
tumor,  tympanitic  on  percussion,  and  the  air  will  rush  out  again  when  allowed 


to  do  so.  WT^en  the  tear  involves  the  peritoneum,  the  gas  will  cause  a  general 
distention  of  the  belly;  when  the  rent  is  extraperitoneal,  an  emphysema  of  the 
extra  vesical  connective  tissue.  These  injection  tests  are  not  infallible,  and 
may  spread  infection.  Movable  dulness  in  the  Hanks  suggests  intraperitoneal 
rupture,  unilateral  tentleroess  ajid  tumor  extraperitoneal  rupture.  A  ditler- 
ential  diagnosis  is»  however,  unimportant  before  operation.  Wlien  symp- 
toms of  rupture  are  present,  the  prevesical  space  should  be  opened  through 
a  suprapubic  incision,  and  if  this  be  healthy,  indicating  the  absence  of  extra- 
peritoneal rupture,  the  incision  may  be  continued  upwards  and  the  abdom- 
inal cavity  opened.  An  intraperitoneal  rupture  should  be  sutured  and  the 
peritoneal  cavity  cleanserl  iind  drained.  As  a  rule  in  extraperitoneal  rup- 
ture, drainage  is  all  thai  t  an  be  done. 

Rupture  of  the  diaphragm  is  usually  on  llie  left  side,  because  the  dia* 
phragm  is  weaker  at  this  point,  and  because  the  liver  is  on  the  right  side. 
Dyspnea,  intense  pain,  cough,  thirst*  and  hiccough  are  mentioned  as  symp- 
loms.  The  physical  signs  rescml^le  those  of  pneumothorax.  A  tympanitic 
note  over  the  chest,  due  to  the  prolapsed  gut  or  stomach,  amphoric  tinkling, 
and  sometimes  a  succussion  sound  are  present.  There  may  be  symptoms  of 
obstruction  if  the  stomach  or  bowel  is  strangulated.  The  diagnosis  is  very 
rarely  made  before  operation  or  death.  The  treat  men  I  is  laparotomy  and 
suture  of  the  diaphragm.  In  old  cases  (diaphragmatic  herftia,  p.  512)  the 
transpleural  route  is  preferable,  owing  to  the  dithculty  of  reducing  the  gut, 
ligating  the  sac,  and  closing  the  rent  in  the  diaphragm  from  below. 

Wounds  of  the  abdomen  may  he  penetrating  or  non-penetrating;  Non- 
penetrating wounds  are  treated  as  wounds  elsewhere,  care  being  taken  to 
approximate  the  must  les,  if  such  have  been  divided,  in  order  to  guard  against 
hernia.  Penetrating  wounds,  including  those  produced  by  gunshots  and 
stabs,  are  readily  recognized  if  the  viscera  or  the  contents  of  the  viscera 
escape  through  the  wound.  The  symptoms  and  the  dangers  of  visceral 
injury  are  those  of  contusions  of  the  abdomen.  The  ireatnumi.  even  without 
symptoms  of  viscer;il  injury,  is  immediate  enlargement  of  the  wound,  in  order 
lo  explore  the  abdomen,  check  hemorrhage,  and  close  such  visceral  perfora- 
tions as  may  be  found.  The  abdomen  is  then  flushed  with  salt  solution,  and 
closed  or  draine<l  acconling  to  the  amount  of  soiling  present.  If  the  c>men- 
lum  protrudes  it  should  be  Hgated  and  removed,  while  coils  of  intestine 
should  be  carefully  washed  with  salt  solution  and  returnerl  to  the  cavity.  In 
cases  in  which  there  is  doubt  as  to  whether  or  not  a  wound  enters  the  perito- 
neal cavity,  such  wound  should  be  enlarged  and  the  diagnosis  positively  made, 
being  prepared  at  the  same  time  to  treat  any  visceral  injuries  that  may  be 
found.  In  gunshot  wounds  on  the  battle  fjeld  an  exception  has  been  made  to 
the  rule  of  immediate  exploration,  because  it  has  been  found  that  the  chances 
of  recovery  are  somewhat  better  without  than  with  operation  undertaken  in 
the  absence  of  proper  facilities.  Symptoms  of  internal  hemorrhage  or  of 
injur)'  to  the  viscera,  untler  even  these  circumstances,  retjuire  laparotomy. 

Phantom  tumor  of  the  abdomen  generally  occurs  in  hysterical  females. 
It  is  tlue  to  eitiier  a  localiised  contraction  of  the  abdominal  muscles,  usually 
a  section  of  the  rectus,  or  a  tetanic  spasm  of  the  intestine.  The  swelling  may 
be  as  harii  as  bone,  but  as  a  rule  varies  in  consistency  on  different  examina- 
tions,  and  disappears  under  anesthesia,  with  gurgling  if  it  be  intestinal.  The 
treatment  is  that  of  hysteria. 


I 


Inflammation  and  abscess  are  commonly  the  result  of  yncleanJiness, 
especially  after  separation  of  the  cord,  or  in  corpulent  adults  in  whom  the 
umbilicus  is  deep.  Eczema  likewise  is  observed.  Tetanus  neonatorum  and 
er}'sipelas  may  be  caused  by  infection  of  the  umbilicus  soon  after  birth. 
Benign  and  malignant  tumors  may  occur  in  this  region,  but  are  rare. 
Among  the  cysts  may  be  mentioned  the  dermoid,  sebaceous,  vitelline  (devel* 
oping  from  an  unobi iterated  portion  of  the  vitelline  duct),  serous  (due  to  a 
shutting  off  of  an  empty  hernial  sac),  and  the  urachal.  The  last  are  caused 
by  distention  of  an  unobliterated  portion  of  the  urachus,  which  normally 
extends  from  the  1j! adder  to  the  umbilicus;  they  are  properitoneai,  median 
in  situation,  sometimes  of  large  size,  and  may  open  botli  into  the  bladder  and 
at  the  umbilicus.  The  treatment  of  cysts  is  excision.  In  some  urachal 
cysts  this  is  not  possil>le,  and  incision  and  drainage  are  all  that  can  be 
accomplished. 

Umbilical  fistula  may  l>c  congenital  or  acquired.  Fecai  fistuJit  resulting 
from  non-closure  of  the  omphalo-mesenlenc  duct  ( Meckel's  diverticulum) 
are  first  observed  after  the  umbilical  stump  has  separated.  The  mucous 
membrane  may  !)ecome  everted  and  form  a  red  tumor,  which  has  been  called 
a  po!ypt4:i  ar  adenoma  when  the  communication  with  the  intestine  has  become 
obliterated.  VVTien  Uie  duct  is  wide  and  short  a  portion  of  the  intestine  may 
protrude  through  the  opening.  Fecal  tistuLT  in  the  newborn  have  been 
caused  also  by  including  mthin  the  ligature  which  surrounds  the  cord  a 
small  umbilical  hernia.  Acquired  fecal  llstuke  follow  conditions  like  strangu- 
lated hernia  and  lulierculous  peritonitis.  Urmary  fisluiw  are  caused  by  non- 
obliteration  of  the  urachus.  mucous  ftsiula  by  the  omphalo- mesenteric  duct 
or  the  urachus  which  has  become  closed  at  the  visceral  efid.  A  fistula  should 
be  excised  and  the  opening  into  the  viscus  closed,  Umhilkal  sinuses  are  the 
result  of  abscesses,  and  require  incision  and  packing. 

Umbilical  hernia,  p.  509. 


THE  PERITONEUM,  OMENTUM,  AND  MESENTERY. 


Peritonitis,  or  inflammation  of  the  peritoneum,  is  practically  always 
bacieriai  in  origin.     It  is  divided  primarily  into  the  acute  and  chronic  forms. 

Acute  peritonitis  is  caused  by  perforations  of  the  hollow  viscera,  wounds 
of  the  abdomen,  extension  of  inflammatory  processes  from  the  abdominal 
organs  by  contiguity  or  continuity  (e.g.,  from  the  Fallopian  tubes),  and  by  in- 
fection coming  through  the  blood  or  lymph  vessels.  Idiopathic  peritonitis  does 
not  exist;  rheumatic  peritonitis  probably  seldom  or  never  occurs,  A  great 
variety  of  micro-organisms  have  been  cultivated  from  cases  of  peritonitis,  and 
in  most  instances  the  infection  is  a  mixefl  one.  The  streptococcus  pyogenes 
is  responsiljle  for  the  most  severe  forms;  the  staphylococcus  pyogenes  is  less 
virulent.  The  colon  bacillus  is  usually  found  in  cases  secondary  to  intestinal 
lesions.  The  diplococcus  of  pneumonia  and  the  gonococcus  are  much  less 
virulent  in  this  situation  than  are  other  organisms.  Two  forms  of  acute 
peritonitis  are  described,  (i)  the  localized,  and  (2)  the  diffuse,  or  generalized. 

I.  Acute  localized  peritonitis  is  most  frequent  in  the  vicinity  of  the 
Fallopian  tubes  and  appendix.  There  is  a  sui>periloneal  collection  of  round 
cells,  and  the  peritoneum  becomes  congested,  loses  its  luster,  sheds  its  endo- 


I 


PERITONITIS.  447 

thclium  (especially  in  virulent  infections),  and  exudes  a  sero-fii>ririaus 
malerial,  which  surrounds  the  afTecled  area,  and  which  may  become  purylent, 
forming  a  localized  abscess.  The  pus  may  break  tJi rough  the  barrier  of 
adhesions  and  cause  a  generalized  peritonitis^  or  it  may  break  intooneof  the 
hollow  viscera.  In  rare  cases  it  points  externally,  and  in  a  few  instances  in 
which  it  is  well  encapsulated,  it  becomes  inspissated  or  even  calcareous.  The 
fibrinous  material  which  glues  adjacent  peritoneal  surfaces  together  may  lie 
absorbed,  or  become  organized  into  fibrous  adhesions.  The  svfnpioms  are 
localized  pain,  tenderness,  and  muscular  rigidity,  with  fever,  increase  in  the 
pulse  rate,  vomiting,  and  constipation.  Later  the  inflammalor)^  mass  may 
be  palpated,  giving  either  a  dull  or  tympanitic  note  on  percussion.  When 
near  the  surface,  redness  and  edema  of  the  abdominal  wall  may  be  noted. 
Unless  the  infection  is  well  encapsulated,  leukocytosis  is  present.  The  treat- 
ment is  given  under  the  conditions  which  give  rise  to  the  localized  peritonitis, 
as  it  varies  somewhat  according  to  the  region  affected  and  the  cause,  thus 
acute  pelvic  peritonitis  caused  by  the  gonococcus  is  usually  treated  sympto- 
matically  until  quiescent,  while  localized  peritonitis  the  result  of  appendicitis 
requires  early  operation.  It  should  not  be  forgotten,  however,  that  a  ditTusc 
peritonitis  always  begins  as  a  more  or  less  localized  process,  and  that  in  many 
instances  prompt  and  ctTicient  treatment  of  the  infection  while  still  limited 
may  prevent  its  generalization. 

2.  Acute  diCFuse  or  generalized  peritonitis  is  generally  the  result  of  an 
extension  of  a  localized  peritonitis,  although  a  large  area  of  the  peritoneum 
may  be  Hooded  with  infective  material  from  the  bursting  of  a  localized  ab- 
scess, or  the  perforation  of  a  hollow  viscus.  The  peritoneum  is  congested 
and  lusterless  and  in  fulgurant  cases  dcatli  may  o(  cur  from  toxemia  before 
further  changes  take  place.  As  a  rule,  however,  there  is  some  serous  exuda- 
tion,  and  fibrinous  patches  form  on  the  area  from  which  the  endothelium  has 
been  shed.  At  a  later  period  the  exudate  becomes  purulent  and  occasionally 
bloody. 

The  symptoms  at  the  onset  are  those  of  localized  peritonitis,  or  when  a 
large  amount  of  infective  material  has  been  suddenly  diffused,  as  in  perfora- 
tion, there  will  be  sudden  violent  pain,  profound  shock,  and  in  some  cases 
death  within  a  few  hours.  The  patient  usually  survives  the  shock,  however, 
and  the  temperature  ascends  to  and  then  above  normal,  and  finally  falls  to 
subnormal  as  death  approaches,  but  the  pulse  remains  qui<  k,  and  becomes 
hard  and  wiry  owing  to  the  rise  in  blood  pressure,  though  in  the  final  stages 
it  is  running  and  compressible.  Chills  are  uncommon  except  in  puerperal 
cases.  The  alidomen  is  rigid,  tender,  and  later  tensely  distended  and  tyra* 
panitic,  with  an  amelioration  in  the  pain.  Vomiting  is  early  and  persistent, 
and  in  the  final  stages  stercoral  eo us  material  is  regurgitated  without  effort. 
The  patient  lies  on  the  back  with  the  knees  drawn  up,  and  the  face  has  a 
characteristic  anxious  and  pinched  look.  Movable  dulness  in  the  flanks 
may  sometimes  be  observed  when  the  effusion  is  great.  The  abdomen  is 
motionless,  the  breathing  being  quick,  shallow,  and  entirely  thoracic.  Hic- 
cough is  not  uncommon.  There  is  usually  obstinate  constipation,  although 
diarrhea  may  be  present.  Leukocytosis  is  present  unless  the  infection  is 
overwhelming,  lliere  may  be  afjsence  of  liver  dulness  in  cases  due  to  per- 
foration of  the  gastrointestinal  canal 

Treatment  with  poultices  or  ice  to  the  abtlomen  may  make  the  patient 
more  comfortable,  but  do  not  influence  the  disease.     Purgation  is  contrain- 


448  ABDOMEN. 

dicated,  but  the  lower  bowel  may  be  emptied  by  an  enema.    Opium  theoretic- 
ally discourages  diffusion  of  the  inflammation  by  quieting  peristalsis.     Most 
surgeons  advise  immediate  operation  in  all  cases,  excepting  puerperal  perit- 
onitis, unless  the  patient  is  moribund;  all  advise  immediate  operation  in 
perforative  peritonitis;  and  a  few  in  the  non-perforative  variety  adopt  the 
Ochsner  me^iody  which  consists  in  gastric  lavage,  no  food,  water,  or  purga- 
tives by  mouth,  and  operation  when  the  process  becomes  localized.     The 
Ochsner  method  undoubtedly  lowers  the  operative  mortality,  but  that  it 
lessens  the  number  of  deaths  from  peritonitis  remains  to  be  proved.     The 
most  important  principles  involved  in  any  operation  for  peritonitis  are 
rapidity  and  gentleness.     Unless  the  starting  point  of  the  inflammation  can 
be  localized,  &e  incision  should  be  made  in  ^e  middle  line  below  the  umbili- 
cus, and  the  cause  of  the  peritonitis,  e.g.,  a  gangrenous  appendix,  surrounded 
with  gauze  and  quickly  removed.     The  gauze  packing  prevents  further  dis- 
semination of  the  infection  and  absorbs  a  large  quantity  of  the  peritoneal 
exudate.     The  peritoneal  cavity  should  then  be  thoroughly  douched  with 
hot  (115°  F.)  salt  solution  by  means  of  a  large  rubber  tube  passed  first  to  the 
least  infected  parts  of  the  abdomen,  especial  attention  being  given  to  each 
kidney  pouch  and  the  pelvis,  and  the  flow  continued  until  the  water  returns 
dear.    A  tube  or  a  piece  of  gauze  should  next  be  passed  into  the  lowest  portion 
of  the  pelvis  for  drainage  (gaining  exit,  in  the  female,  through  the  vagina); 
a  separate  incision  may  be  made  in  each  loin  for  the  same  purpose.     The 
patient  may  then  be  put  in  the  semi-sitting  posture,  or  the  head  of  the  bed 
raised  two  or  three  feet  (Fowler's  position),  in  order  to  drain  the  fluids  into 
the  pelvis  and  away  from  the  diaphragm,  in  which  region  absorption  is  said 
to  be  most  active.     In  the  gravely  ill,  however,  the  depressing  effects  of  the 
upright  posture  upon  the  heart  far  outweigh  the  theoretical  advantages  just 
mentioned.     The  writer  prefens  to  place  the  patfent  in  the  Sims  position, 
i.e.,  almost  on  the  abdomen,  on  the  right  side  if  the  incision  is  right-sided 
or  median,  on  the  left  side  if  the  incision  is  on  the  left  side.     Salt  solution 
should  be  given  by  bowel,  eight  ounces  every  three  hours,  or  by  continuous 
proctolysis  {Murphy  method) y  i.e.,  by  means  of  a  fountain  syringe,  the  reservoir 
of  which,  surrounded  by  hot  water  bags,  is  but  slightly  higher  than  the  rec- 
tum, so  that  the  water  shall  enter  no  faster  than  al)sorption  takes  place,  the 
patient  getting  perhaps  a  pint  or  two  in  the  course  of  an  hour.  This  stimulates 
the  heart  and  kidneys,  eliminates  septic  material  which  has  entered  the  circu- 
lation, and  reverses  the  current  in  the  lymphatics  of  the  peritoneum,  making 
that  membrane  a  secreting  instead  of  an  absorbing  one.    Occasionally  proc- 
tolysis  seems   to   increase  the  distention  and  provoke  vomiting,  in  which 
event  salt  solution  may  be  given  intravenously  or  subcutaneously.     Nothing 
is  given  by  mouth  until  the  stomach  is  retentive,  stimulants  are  freely  ad- 
ministered, and  an  early  movement  of  the  bowels  is  secured.     When  there 
is  great  distention  which  cannot  be  relieved  by  purgatives,  enemata,  or  the 
re(  tal  tube,  an  artificial  anus  may  be  established.     The  prognosis  will  depend 
upon  the  iharac  ter,  duration,  and  extent  of  the  infection,  and  the  resistance  of 
the  individual.     Including  all  forms,  irrespective  of  the  cause,  the  mortality 
is  from  15  to  20  per  cent,  in  cases  which  are  in  fair  condition  at  the  time  of 
operation,  and  50  per  cent,  or  more  in  those  in  bad  tondition.     Some  surgeons 
omit  irrigation,  others  drainage,  and  both  (lasses  claim  good  results. 

Chronic  peritonitis  may  be  (i)  simple  or  (2)  tuberculous. 

r.  Simple  chronic  peritonitis  may  be  localized  or  difTuse.     It  generally 


r 


PAEACENTESIS  ABDOMINIS. 


449 


follows  the  acute  form,  but  may  in  mild  infections  be  chronic  from  the  start. 
The  peritoneum  is  thickened,  and  the  adjacent  surfaces  fastened  together 
by  more  or  less  firm  adhesions.  Sacculated  effusions  are  sometimes  en- 
countered.  Syphilis  is  said  to  be  responsible  for  some  cases.  The  treatment 
is  directed  to  the  cause.  Adhesions  may  be  separated  if  they  give  rise  to 
symptoms,  e.g.,  pain  or  obstruction. 

2,  Tuberculous  peritonitis  may  be  primar}%  but  is  usually  secondary  to 
disease  in  a  distant  organ,  or  to  tuberculosis  of  some  other  abdominal  structure, 
particularly  the  lymph  glands,  the  intestine,  or  the  Fallopian  tubes.  It  is 
more  common  in  females,  and  is  rarely  seen  before  the  third  or  after  the 
liftieth  year.  Three  forms  are  described:  (a)  The  asfiiic  form  presents 
itself  as  a  free  or  sacculated  serous,  sero-librinous,  or  occasionally  purulent 
exudate,  as  the  result  of  a  diffuse  miliary  invasion  of  the  peritoneum;  it  is 
sometimes  complicated  by  t  irrhosis  of  the  liver,  (b)  The  fibrous  or  adhesive 
variety  is  characterized  liy  a  slow  course  and  the  absence  of  tluid.  The  ab- 
dominal organs  are  glueil  together,  and  gray  or  yellow  tulierclcs  are  found 
among  the  adhesions.  Not  unusually  the  omentum  is  rolled  upon  itself  and 
is  palpable  as  a  transverse  mass  in  the  upper  part  of  the  abdomen,  (c}  The 
i'dseous  or  supf>urative  form  is  a  later  stage  of  the  adhesive  variety.  The 
tubercles  caseate  and  give  rise  to  abscesses,  which  may  point  externally, 
especially  at  the  naveb  and  lead  to  fecal  fjstul*e,  the  bowel  often  being  opened 
by  ulceration. 

I'he  local  symptoms  may  arise  suddenly  and  resemble  those  of  acute 
appendicitis  or  other  acute  intraabdominal  condition,  or  the  general 
symptoms  may  predominate  and  typhoid  fever  be  simulated.  Most  of 
the  cases,  however,  are  chronic.  Pain  and  tenderness  are  rarely  severe 
and  may  be  entirely  absent.  Dysuria  is  not  uncommon,  particularly  in 
women.  The  digestion  is  disturbed,  although  vomiting  is  rare,  and  diarrhea 
is  absent  unless  there  is  disease  in  the  intestine.  The  temperature  rises 
one  or  two  degrees  in  the  evening,  night  sweats  may  occur,  and  there  is  a 
gradual  loss  of  weight.  The  subcutaneous  abdominal  veins  are  generally 
distended,  and  free  or  encapsulated  (luitl  may  be  detected  in  the  peri- 
toneal cavity.  The  rolled  up  omentum,  masses  of  adherent  intestine,  or 
enlarged  lymph  glands  may  be  found  on  palpation.  Symptoms  of  .stenosis 
of  the  intestine  may  be  present,  the  liver  and  spleen  are  often  enlarged, 
and  tuberculosis  may  be  detected  in  distant  parts  of  the  body. 
.  The  treatment  may  be  medical  or  surgical.  Medkal  /r^a/mm/ includes 
the  general  measures  employed  for  tuberculosis  elsewhere  and  local  applica- 
tions of  green  soap,  mercurial  ointment,  iodin,  elastic  collodion,  or  guaiacol. 
The  X-ray  and  intraperitoneal  injections  of  a  weak  solution  of  iodin  al.so  have 
been  used.  Surgical  trealmmi  is  of  the  greatest  value  in  the  ascitic  form,  in 
which  laparotomy  is  followed  by  at  least  50  per  cent  of  permanent  cures. 
All  that  is  needed  is  to  open  the  abdomen,  evacuate  the  fluid,  and  close  without 
drainage.  If  the  cause  of  the  disease,  e.g.,  a  tuberculous  appendix  or  Fallo- 
plan  tube,  be  discovered,  this  may  be  removed.  Separation  of  adhesions  is 
not  infrequently  followed  by  fecal  fistula;.  The  reason  for  the  beneficial 
elTect  of  a  simple  laparotomy  is  not  knowm.  It  has  been  supposed  that  the 
o[>eration  causes  hyperemia,  and  the  outpouring  of  an  antitoxic  serum.  If 
lluid  reuillet  ts.  it  may  be  aspirated  or  a  second  laparotomy  performed. 

Paracentesis  abdominis  is  performed  for  the  removal  of  fluid  from  the 
peritoneal  cavity.     The  bladder  should  be  emptied,  and  a  spot  of  absolute 
29 


450 


ABDOMEN. 


L,L. 


r.L. 


C.^dRL 


dulness  selected  in  the  median  line  below  the  umbilicus.  The  patient  sits  up. 
and  a  broad  flannel  binder  with  an  opening  in  front  is  passed  around  the 
abdomen  and  held  by  an  assistant  behind,  so  as  to  make  pressure  upon  the 
abdomen.  The  skin  is  then  sterilized,  a  small  incision  made  in  the  skin 
^-ith  a  scalpel,  the  trocar  and  cannula  inserted,  and  the  trocar  withdrawn. 

Subphrenic  abscess  is  an  abscess  just  beneath  the  diaphragm.  About 
one-third  of  the  cases  are  due  to  ruptured  gastric  or  duodenal  ulcer,  one- 
fourth  to  appendicitis,  one-fifth  to  infections  of  the  liver  and  biliary  ducts, 
and  the  remainder  to  perforation  of  the  intestine,  trauma,  pyemia,  and 
suppurative  processes  in  the  female  generative  organs,  spleen,  pancreas,  kid- 
ney, ribs,  vertebrae,  or  pleura,  hence  the 
abscess  may  be  (a)  intraperitoneal  or  (b) 
retroperitoneal,  (a)  In  the  intrapcrUoneal 
variety  (83  per  cent,  of  890  cases  collected 
by  Piquand)  the  infection  is  transmitted 
from  the  primary'  focus  by  the  intraperi- 
toneal lymph  stream,  which  flows  to- 
wards the  diaphragm,  or  by  a  spreading 
peritonitis.  Its  situation  depends  upon 
the  location  of  the  causative  lesion  and 
the  arrangement  of  the  subphrenic  perito- 
neal fossa%  which  are  five  in  number,  four 
phreno-hepatic,  formed  by  the  cruciform 
reflection  of  the  peritoneum  from  the  liver 
to  the  diaphragm,  and  one  phreno-splenic 
(f'ig-  3^5)-  (0  ^'^^'^  anterior  phreno- 
hepatic  abscess  is  the  most  frequent  (36 
per  cent.) ;  it  lies  between  the  right  lobe  of 
the  liver  and  the  diaphragm,  to  the  right 
of  the  falciform  ligafnent,  and  in  front  of 
the  coronary  and  right  lateral  ligaments. 
(2)  The  right  posterior  form  (10  per  cent.) 
is  !)chin(l  the  coronar}'  ligament,  extends  down  towards  the  right  kidney,  and 
is  often  associated  with  the  right  anterior  form.  (3)  Left  anterior  abscess 
(30  per  cent.)  presents  in  the  epigastrium,  adhesions  limiting  it  below.  (4) 
.'\  left  posterior  collection  (3  per  cent.)  distends  the  lesser  peritoneal  cavity, 
consecjuently  is  l)ehin(l  the  stomach.  (5)  Phreno-splenic  or  perisplenic 
abscess  (4  per  cent.)  occupies  the  .space  above  and  al)Out  the  spleen,  (fi) 
In  retroperitoneal  abscess  the  infection  travels  by  way  of  the  lymph  vessels  or 
by  a  spreading  cellulitis,  (i)  Right  retroperitoneal  abscess  (15  per  cent.) 
may  extend  forwards  between  the  layers  of  the  coronary  and  falciform  liga- 
ments and  point  in  the  epigastrium,  or  downwards  and  point  in  the  right  loin; 
(2)  lejt  retroperitoneal  (2  per  cent.)  forwards  between  the  layers  of  the  left 
lateral  ligament  and  downwards  to  the  left  loin.  A  subphrenic  abscess  often 
contains  gas,  owing  to  the  presence  of  the  colon  bacillus,  or  to  perforation  of 
the  gastrointestinal  canal  or  lung.  It  may  cause  empyema,  rarely  pyoperi- 
canlium,  by  breaking  into  the  pleural  cavity  or  pericardium,  or  by  extension 
of  the  infection  along  the  lymphatics  through  the  diaphragm  without  per- 
foration. It  may  break  also  into  the  lung,  the  general  peritoneal  cavity,  the 
stomach,  the  intestine,  the  mediastinum,  or  in  rare  instances  e.xternally 
(hypochondrium,  epiga.strium,  loin). 


Fig.  365.-  -Diagram  showing  the  vari- 
ous locations  of  subphrenic  abscess. 
I -river  and  spleen  shaded.  Peritoneal 
reflection  to  diaphragm  in  re<l.  V.  Vena 
cava.  A .  Aorta.  F.  L.  Falciform  liga- 
ment. L.  L.  I^ft  lateral  ligament,  (i) 
Right  anterior,  (2)  right  jwstcrior,  (3) 
left  anterior,  and  (4)  left  fxjsterior 
phrenohepatic  sfwices.  (5)  Phreno- 
splenic  or  jK'risplenir  space.  (6)  Right 
and  (7)  left  retro|K*ritoneal  spaces. 


TUMORS   OF   TTIE    OMENTUM. 

The  symptoms  are  usually  preceded  or  accompanied  by  those  of  the 
causative  lesion.  The  general  phenomena  are  those  of  sepsis.  Locally 
there  are  pain  and  tenderness,  muscular  rigidity,  perhaps  swelling  and 
edema,  and,  on  percussion^  a  tympanitic  area  which  moves  with  the  position 
of  the  patient,  or  dulness.  Friction  sounds  are  occasionally  heard  anil  when 
the  abscess  contains  gas  ail  the  signs  of  pneumotliorax  may  be  present, 
hence  the  term  false  pneumothorax.  Muoroscopit:  examination  reveals 
elevation  and  possibly  immobility  of  the  diaphragm  on  the  affected  side, 
below  which  is  a  clear  area  if  the  abscess  contains  gas.  The  liver  or  the 
spleen  is  depresse<l.  Exploratory  aspiration  may  Ije  made  in  the  tenth, 
ninth,  eighth,  and  seventh  interspaces,  in  the  order  named,  first  below  the 
scapula,  and  then,  if  no  pus  is  found,  in  tJie  midaxillary  iine,  but  never 
through  the  peritoneum,  and  only  when  all  preparations  have  been  made  for 
immediate  operation  in  case  the  abscess  is  locatetL  The  diagnosis  of  sub- 
phrenic a()scess  is  often  difficult*  and  the  conditions  which  it  reseml*les  are 
often  associated  with  it.  In  hepatic  abscess  there  may  be  jaundice  ajid  gas 
is  never  present.  Pancreatitis  may  reveal  itself  by  the  laboratory  tests  for  this 
condition.  In  empyema  the  pulmonar}*  symptoms  are  more  marked,  the 
upper  level  of  the  fluid  is  concave  insteatl  of  convex,  the  heart  is  pushed  to  one 
si  tie  rather  than  upwards,  the  liver  is  not  depressed »  the  obliquity  of  the  ribs 
is  increased  (being  decreased  in  subphrenic  abscess),  the  level  of  the  dia- 
phragm as  shown  by  the  X-ray  is  not  disturbed,  the  Lit  ten  phenomenon  (vis- 
ibility of  the  excursions  of  the  diaphragm  in  the  intcn  osial  spaces)  is  absent, 
and  Traube*s  space  is  rarely  obliterated,  a  sign  whirh  may  occur  in  left 
subphrenic  aljscess.  Bronchial  breathing,  owing  to  compression  of  the  lung, 
is  sometimes  heard  in  subphrenic  abscess,  but  never  egophony.  In  empyema, 
on  exploratory  puncture,  the  pus  is  more  superficial ,  escapes  under  greater 
pressure  during  expiration  (the  reverse  being  true  in  sul>phrenic  abscess), 
and  the  needle  does  not  oscillate.  WTien  the  needle  passes  through  the 
diaphragm  its  outer  end  ascends  on  inspiration,  descends  on  expiration. 
When  a  serous  pleural  effusion  and  a  subphrenic  abscess  are  both  present, 
one  may  obtain  serous  (luitl  supcrlicially  anrl  fetid  pus  at  a  deeper  level,  or 
serum  in  the  sixth  or  seventh  interspace  and  pus  in  the  ninth  or  tenth.  The 
mortality  of  subfihreriic  abscess  is  almost  loo  per  cent,  without  operation,  50 
per  cent,  with  ojieralion. 

The  treatment  is  evat  Uiiiion.  Ai  cording  to  the  situation  of  the  abscess, 
the  incision  will  be  made  in  the  epigastrium,  the  hypochondrium,  the  loin,  or 
through  the  diaphragm  after  resecting  the  ninth  or  tenth  rib  and  pushing 
the  pleura  upwards  (subpleural  route),  or  sewing  the  diaphragm  lo  the  parie- 
tal pleura  (Iranspleural  route). 

The  omcDtiim  has  been  called  *'  the  policeman  of  the  abdomen,"  because 
of  its  tendency  to  adhere  to  and  surround  diseased  processes  and  prevent  their 
diffusion;  it,  therefore,  participates  in  diseases  common  to  the  peritoneum. 

Volvulus  of  the  omentmn  in  most  instances  is  caused  by  forcible  taxis  of 
an  epiplocele,  although  it  may  occur  without  the  presence  of  a  hernia.  The 
omentum  becomes  gangrenous,  and  the  patient  is  usually  operated  upon  with 
the  idea  that  he  has  a  strangulated  hernia  or  appendicitis.  A  doughy  abdom- 
inal tumor  coming  on  after  attempts  to  reduce  a  hernia  shouhl  make  one  sus- 
picious of  an  omental  torsion.     The  involved  portion  should  be  excised. 

Tmuors  of  the  omentum  and  mesentery  are  uncommon,  and  are  gener- 
aily  sarcomatous  in  nature,  although  benign  growths  and  secondary  carci- 


452  ABDOMEN. 

noma  may  occur.  Free  fatty  tumors  in  the  peritoneal  cavity  represent  lipo- 
mata  of  the  omentum  or  epiploic  appendages,  the  pedicle  of  which  has  broken. 
The  rolled  up  tuberculous  omentum  has  already  been  described.  Cysts  of 
the  omentum  and  mesentery  also  are  rare,  and  are  frequendy  caused  by  the 
echinococcus  or  by  cystic  degeneration  of  malignant  disease.  In  the  mesen- 
tery serous,  sanguineous,  chylous  (Fig.  366),  and  dermoid  cysts  have  been 
observed.  These  tumors  and  cysts  are  freely  movable,  surrounded  by  tym- 
pany on  all  sides,  and  are  not  connected  with  the  pelvis.  The  treatment  is 
extirpation;  when  this  is  impossible  with  cysts,  they  may  be  opened  and 
stitched  to  the  abdominal  wall. 

Retroperitoneal  tumors,  excluding  those  of  the  kidney  and  the  pan- 
creas, are  usually  sarcomata,  lipomata,  or  dermoids.     Secondary  tumors  of 

the  lymph  glands,  and  chronic  abscesses, 
most  frequently  originating  in  a  tuber- 
culous spondylitis  or  lymphadenitis,  also 
are  observed.  The  tumor  is  behind  the 
stomach  and  intestines,  as  is  shown  by  its 
immobility  and  the  presence  of  tympany. 
The  possibility  of  aneurysm  should  not 
be  forgotten.  Retroperitoneal  tumors 
may  be  extirpated  from  the  front,  thus 
going  through  the  anterior  and  posterior 
parietal  peritoneum.  Abscesses  should 
be  drained  extraperitoneally,  by  an  in- 
cision in  the  loin  or  above  Poupart*s 
ligament. 

Thrombosis  of  the  mesenteric  veins 
,       ,,     ,,       r  ,  ,,      and  embolism  of  the  mesenteric  arter- 

.  iivlc.us.  '  (i'.,iv<  linic  Ilnspiial.)    '     ^^s  causc  gangrene  of  that  portion  of  the 

intestine  supplied  by  the  vessel  involved. 
Kmbolism  is  frequenlly  the  result  of  cardiac  disease,  and  is  sometimes 
associated  with  the  j)resence  of  emboli  in  other  portions  of  the  body. 
Tlirombosis  is  ( aused  I>y  acute  or  chronic  phlebitis,  the  result  of  infection 
from  the  intestine  or  other  organ.  I'he  symptoms  are  sudden  intense 
j)ain,  bloody  diarrhea  in  half  the  cases,  vomiting,  subnormal  temperature, 
rapid  pulse,  meteorism,  and  abdominal  rigidity.  The  treatment  is  resection 
of  the  gangrenous  intestine,  if  the  process  be  sufficiently  limited.  If  the 
superior  mesenteric  artery  is  occluded  near  its  origin,  the  entire  small  in- 
testine, with  the  ascending  and  transverse  colon,  will  be  gangrenous  and  no 
treatment  applicable. 

THE  STOMACH. 

Congenital  stenosis  of  the  pylorus  is  due  to  spasm  or  to  what  is  prob- 
ably the  result  of  persistent  spasm,  hypertrophy  of  the  sphincter  with  fibrous 
overgrowth  of  the  submucous  tissues.  The  symptoms,  which  usually  begin 
a  few  days  after  birth,  are  vomiting,  intermittent  if  caused  by  spasm  of  the 
I)ylorus,  persistent,  regular,  and  not  bile  stained  if  the  result  of  complete 
stenosis;  distention  of  the  upper  abdomen,  due  to  dilatation  of  the  stomach ; 
retrai  tion  of  the  lower  abdomen,  due  to  collai)se  of  the  bowel ;  palpable  pyloric 
tumor  in  two-thirds  of  the  cases;  visible  gastric  peristalsis,  passing  from  left 


GASTRIC   ULCER. 


453 


lo  right;  emaciation,  progressive  in  complete  stenosis;  ami  constipation,  alter- 
nating with  diarrhea  in  pylorospasm,  and  extreme  in  complete  stenosis,  an  ad- 
ditional sign  of  which  is  the  failure  of  methylene  blue  to  appear  in  the  stools 
after  its  administration  by  mouth. 

The  treatment  of  spasmodic  or  incomplete 
stenosis  is  daily  gastric  lavage;  small  quantities  of 
peptonized  milk  or  beef  juice  by  mouth,  supple- 
mented by  nutrient  enemata  and  cod-liver  oil 
inunctions;  heat  to  the  abdomen;  and  small  doses 
of  the  bromides  or  opium  per  rectum.  If  vomit- 
ing and  emaciation  continue,  or  if  there  are  signs 
of  complete  occlusion,  gastroenterostomy  should 
be  performed,  an  operation  which  saves  50  per 
cent,  of  the  cases. 

Rupture  of  the  stomach  (p.  442). 

Foreign  bodies  which  are  swallowed  may  give 
no  trouble,  and  finally  be  expelled  through  the 
anus.  Balls  of  hair,  etc.,  which  have  formed  as 
the  result  of  the  habit  of  swallowing  small  particles 
of  such  material,  may  reach  a  great  size  and  be 
mistaken  for  a  neoplasm.  In  Siese  cases,  or  in 
case  a  small  foreign  body  lodges  and  causes  mis- 
chief, gastrotomy  may  be  performed  and  the 
offending  materiai  removed.  The  X-ray  will  often 
be  of  value  for  diagnostic  purposes. 

Peptic  ulcer  of  the  stomach  is  due  to  auto- 
digestion  of  the  gastric  wall  as  the  result  of  exces- 
sively acid  gastric  juice  {hyperchlorhydria)^  the 
resistance  of  the  mucous  membrane  often  being 
lowered  by  anemia.  The  disease  is  common  in 
both  sexes,  acute  ulcer  being  more  frequent  in 
young  females,  chronic  ulcer  in  males  between  the 
ages  of  thirty  and  fifty.  The  ulcer  may  be  soli- 
tary, but  sometimes  there  are  multiple  ulcers, 
which  may  involve  not  only  the  stomach,  but  also 
the  duodenum  and  occasionally  the  lower  end  of 
the  esophagus.  The  posterior  wall  of  the  pyloric 
region  near  the  lesser  curvature  is  the  favorite  site. 
In  the  early  stages  (acute  ulcer)  the  ulcer  is  round, 
smooth,  and  funnel-shaped,  with  the  base  towards 
the  cavity  of  the  stomach.  Chronic  ulcers  are 
usually  solitary,  have  indurated  edges,  and  may 
be  large  and  irregiilar.  The  ulcer  may  perforate 
or  it  may  heal.  Symptoms  may  be  entirely 
absent  {latent  ulcer).  In  a  t)rpical  case  there  are  flatulence,  acid  eructa- 
tions, and  pain  and  tenderness  in  the  region  of  the  ulcer  (Fig.  367),  often 
passing  to  the  back  and  relieved  by  vomiting,  which  occurs  a  variable 
time  after  taking  food,  according  to  the  situation  of  the  ulcer.  Hematem- 
esis  exists  in  less  than  half  the  cases,  the  quantity  of  blood  varying  from 
a  few  drops  to  a  pint  or  more.  In  some  cases  visible  or  occult  blood  may  be 
found  in  the  stools.     In  chronic  cases  a  tumor  may  sometimes  be  felt,  and 


Fig.  367. — Tender  points 
in  some  abdominal  afTec- 
tions.  I.  Ulcer  on  lesser 
curvature  of  stomach  to  the 
left  of  the  median  line;  pain 
may  radiate  up  beneath  the 
sternum  and  to  the  heart. 

2.  Ulcer  near  the  pylorus. 

3.  Duodenal  ulcer.  In  i, 
2,  and  3,  pain  may  strike 
through  to  the  back.  4. 
Affections  of  the  gall-blad- 
der (Robson's  point);  pain 
may  radiate  to  epigastrium, 
around  the  right  side  to  the 
back,  and  up  to  the  right 
shoulder.  5.  Chronic  pan- 
creatitis (Desjardin's  point) ; 
pain  radiates  to  the  epigas- 
trium and  sometimes  to  the 
left  shoulder.  6.  Appendi- 
citis (McBumey's  point); 
I)ain  often  begins  in  the  ei)i- 
gastrium  or  about  the  um- 
bilicus. 7.  Diverticulitis. 
8.  Ovaritis;  pain  may  radiate 
down  the  thigh.  9.  Renal 
colic;  pain  radiates  from  the 
loin,  along  the  ureter,  to  the 
genitals.  10.  Direction  of 
pain  radiated  from  incipient 
inguinal  hernia,  affections 
of  the  testicle  and  spermatic 
cord,  vesiculitis. 


I 


L 


Inflainmatioii  and  abscess  are  commooly  the  result  of  undeanliness, 
espet  idly  after  separation  of  the  cord»  or  in  corpulent  adults  in  wh<ym  the 
umbilicus  is  deep.  Ecisema  likewise  is  observed.  Tetanus  neonatorum  and 
er}'sipelas  may  be  caused  hy  infection  of  the  umbilicus  soon  after  birlh. 
Benign  and  malignant  ttimors  may  occur  in  this  region,  but  are  rare. 
Among  the  cysts  may  be  mentioned  the  dermoid,  sebaceous,  vitelline  (devel- 
oping from  an  unobliterated  |x>rlion  of  the  vitelline  duct),  serous  (due  to  a 
shutting  off  of  an  empty  hernial  sat),  ami  the  urachal.  The  last  are  caused 
by  distention  of  an  unobliterated  portion  of  the  urachus,  which  normally 
extends  from  the  bladder  to  the  umliilicus;  they  are  properitoneal,  median 
in  situation,  sometimes  of  large  size,  and  may  open  both  into  the  bladder  and 
at  the  umbilicus.  The  treatment  of  cysts  is  excision.  In  some  urachal 
cysts  this  is  not  possible,  and  incision  and  drainage  are  all  that  can  be 
accomplished. 

Umbilical  fistulee  may  be  rongenilal  or  acquired.  Fetal  fishdo'  resulting 
from  mm-closurc  of  the  omphalo-mcsenteric  duct  (Mecke!*s  diverticulum) 
are  first  observed  after  the  umbilicaJ  stump  has  separaterK  The  mucous 
memlirane  may  become  everteil  and  form  a  red  tumor,  which  has  been  called 
a  polypus  or  adiftmna  when  the  communication  with  the  intestine  has  become 
obHterated.  Ulien  the  duct  is  wide  and  short  a  portion  of  the  Intestine  may 
protnide  through  the  opening.  Fecal  tistula?  in  the  new-born  have  been^ 
caused  also  hy  including  wthin  the  ligature  which  surrounds  the  cord  a] 
small  umbilical  hernia.  Acquired  fecal  tistulae  follow  conditions  like  strangu* 
latcd  hernia  and  tuberculous  peritonitis.  Urinary  fistula'  are  caused  by  non- 
obbteration  of  the  urachus,  mucam  fistula-  by  the  omphalo- mesenteric  duct 
or  the  urachus  which  has  become  closed  at  the  visceral  ehd.  A  fistula  should 
be  excised  and  the  opening  into  the  viscus  closed,  Umbilkal  sinuses  are  the 
result  of  abscesses,  and  require  incision  and  packing. 

Umbilical  hernia^  p,  509. 

THE  PERITOKEUM,  OMENTUM,  AND  MESENTERY. 

Peritonitis,  or  inJlammation  of  the  peritoneum,  is  practically  always 
bacterial  in  origin.     It  is  divided  primarily  into  the  acute  and  chronic  forms. 

Acute  peritonitis  is  caused  by  perforations  of  the  hollow  viscera,  wounds 
of  the  aLjdomen,  extension  of  intlammatory  processes  from  the  abdominal 
organs  by  contiguity  or  continuity  (e.g.,  from  the  Fallopian  tubes),  and  by  in- 
fection coming  through  the  blood  or  lymph  vessels.  Idiopathic  peritonitis  does 
not  exist;  rheumatic  peritonitis  probably  seldom  or  never  occurs,  A  great 
variety  of  micro-organisms  have  been  cultivated  from  cases  of  peritonitis,  and 
in  most  instances  the  infection  is  a  mixed  one.  The  streptococcus  pyogenes 
is  responsible  for  the  most  severe  forms;  the  staphylococcus  pyogenes  is  less 
virulent.  The  colon  bacillus  is  usually  found  in  cases  secondary  to  intestinal 
lesions.  The  diplococcus  of  pneumonia  and  the  gonococcus  are  much  less 
viruJent  in  this  situation  than  are  other  organisms.  Two  forms  of  acute 
peritonitis  are  descrilicd,  ( i)  the  localized,  and  (2)  the  diffuse,  or  generalized, 

I,  Acute  localized  peritonitis  is  most  frequent  in  the  vit  inily  of  the 
Fallopian  tuftes  and  appendix.  There  is  a  subiieritoneal  tolleciion  of  round 
cells,  and  the  peritoneum  becomes  congested,  loses  its  luster*  sheds  its  endo- 


I 


ihelium  (especially  in  virulent  infections),  and  exudes  a  sem-fihrinous 
material,  which  surrounds  the  affected  area,  and  which  may  liecome  purulent, 
forming  a  localized  abscess.  The  pus  may  lireak  di rough  the  l>arrier  of 
adhesions  and  cause  a  generalized  peritonitis,  or  it  may  break  into  one  of  the 
hollow  viscera*  In  rare  cases  it  points  externally,  and  in  a  few  instances  in 
which  it  is  well  encapsulated,  it  becomes  inspissated  or  even  calcaretjus.  The 
fibrinous  material  which  glues  adjacent  peritonea[  surfaces  together  may  be 
absorbed,  or  l>ecome  organized  into  fibrous  adhesions.  The  symptoms  are 
localized  pain,  tenderness,  and  muscular  rigidity,  with  fever,  increase  in  the 
pulse  rate,  \^omiting,  and  constipation.  Later  the  inflammatory'  mass  may 
be  palpated,  giving  either  a  dull  or  tympanitic  note  on  percussion.  When 
near  the  surface,  redness  and  edema  of  the  abdonunal  wall  may  be  noted* 
Unless  the  infection  is  well  encapsulated,  leukocytosis  is  present.  The/rra/- 
meni  is  given  under  the  conditions  which  give  rise  to  the  localized  peritonitis, 
as  it  varies  somewhat  according  to  the  region  affected  and  the  cause,  thus 
acute  pelvic  peritonitis  catised  by  the  gonococcus  is  usually  treated  sympto- 
maticaliy  until  quiescent,  while  localized  peritonitis  the  result  of  appendicitis 
requires  early  operation.  It  should  not  be  forgotten,  however*  that  a  diffuse 
peritonitis  always  begins  as  a  more  or  less  localized  process,  and  that  in  many 
instances  prompt  and  efficient  treatment  of  the  infection  while  still  limited 
may  [>revent  its  generalization. 

2.  Acute  diffuse  or  generalized  peritonitis  is  generally  the  result  of  an 
extension  of  a  localized  peritonitis,  although  a  large  area  of  the  peritoneum 
may  be  flooded  with  infective  material  from  the  bursting  of  a  iocalized  ab- 
scess, or  the  perforation  of  a  hollow  viscus.  The  peritoneum  is  congested 
and  lusterless  and  in  fulgurant  cases  death  may  occur  from  toxemia  before 
further  changes  take  place.  As  a  rule,  however*  there  is  some  serous  exuda- 
tion, and  fibrinous  patches  form  on  the  area  from  which  the  endothelium  has 
been  shed.  At  a  later  period  the  exudate  becomes  purulent  and  occasionally 
bloody. 

The  symptoms  at  the  onset  are  those  of  localized  peritonitis,  or  when  a 
large  amount  of  infective  material  has  been  suddenly  diffused,  as  in  perfora- 
tion, there  will  be  sudden  violent  pain,  profound  shock,  and  in  some  cases 
death  within  a  few  hours.  The  patient  usually  survives  the  shock,  however, 
and  the  temperature  ascends  to  and  then  above  normal,  and  finally  falls  to 
subnormal  as  death  approaches,  but  the  pulse  remains  quick,  and  becomes 
hard  and  wiry  owing  to  the  rise  in  blood  pressure,  though  in  the  final  stages 
it  is  rtinning  and  compressible.  Chills  are  uncommon  except  in  puerperal 
cases.  The  abdomen  is  rigid,  tender,  and  later  tensely  distended  and  tym- 
panitic, with  an  amelioration  in  the  pain.  Vomiting  is  early  and  persistent, 
and  in  the  final  stages  stercoraceous  material  is  regurgitated  without  etiurt. 
The  patient  lies  on  the  Imck  with  the  knees  tirawn  up,  and  the  face  has  a 
characteristic  anxious  and  pinched  look.  Movaliie  dulness  in  the  Hanks 
may  sometimes  be  observed  when  the  etTusion  h  great.  The  abdomen  is 
motionless,  the  breathing  being  quick,  shallow,  and  entirely  thoracic.  Hic- 
cough is  not  uncommon.  There  is  usually  obstinate  constipation,  although 
diarrhea  may  be  present.  Leukocytosis  is  present  unless  the  infection  is 
overwhelming.  There  may  be  absence  of  liver  dulness  in  cases  due  to  per* 
foralion  of  the  gastrointestinal  canal. 

Treatment  with  poultices  or  ice  to  the  abilomen  may  make  the  patient 
more  comfortable,  but  do  not  influence  the  disease.     Purgation  is  contrain- 


456 


ABDOMEN. 


dilatation  of  the  stomach  (q.v.),  plus  in  some  cases  the  detection  of  a  tumor 
at  the  pylorus.  The  treaimerU  of  the  extrinsic  cases  is  removal  of  the  cause, 
or,  if  such  be  impossible,  gastroenterostomy.  Cicatricial  stenosis  and 
pylorospasm  are  best  treated  by  gastroenterostomy.  Digital  and  instru- 
mental dilatation  of  the  pylorus,  after  gastrotomy,  have  been  abandoned,  but 
pyloroplasty  is  still  employed  by  a  few  surgeons.  Pylorectomy  is  indicated 
in  malignant  cases,  or  when  there  is  suspicion  of  malignancy. 

Stenosis  of  the  cardiac  orifice  (see  stricture  of  the  esophagus). 

Bilocular  stomach  {hour-glass  stomach)  may  be  congenital,  but  is  usually 
due  to  cicatricial  contraction  of  a  healing  ulcer;  it  may  be  caused  also  by 


Fig.  368. 


Fig.  370. 


Fig.  371. 


Fig.  372. 

Figs.  368  to  373.- 


-(Moynihan.) 


^'i^'-  373- 


perigastric  adhesions  and  cancer.  The  symptoms,  when  the  constriction  is 
small,  are  those  of  dilatation  of  the  stomach,  the  cardiac  pouch  being  dilated 
owing  to  interference  with  the  onward  passage  of  food.  Occasionally  the 
sulcus  may  he  seen  or  felt  through  the  abdominal  wall,  and  an  X-ray  picture 
taken  after  the  ingestion  of  bismuth  (p.  458)  will  show  the  outlines  of  the 
stomach,  or  at  least  the  cardiac  pouch.  If  the  cardiac  pouch  is  filled  with 
fluid,  a  swelling  on  the  left  side  of  the  abdomen  may  be  seen,  which  gradually 
passes  to  the  right  side,  perhaps  with  an  audible  gurgle,  as  the  fluid  passes 
through  the  constriction.  In  some  cases  fluid  injected  into  the  stomach 
can  only  partly  be  recovered,  although  a  spla.shing  sound  persists,  and  after  a 


PAItACKNTESIS   ABDOMINIS. 


AM) 


'ollows  the  acute  form,  but  may  in  mild  infections  be  chronic  from  the  start. 

e  peritoneum  is  thickened,  and  the  adjacent  surfaces  fastened  together 
rby  more  or  less  firm  adhesions.  Sacculated  effusions  are  sometimes  en- 
countered.  Syphilis  is  said  to  be  responsible  for  some  cases.  The  treatment 
is  directed  to  the  cause.  Adhesions  may  be  separated  if  they  give  rise  to 
symptoms,  e.g.,  pain  or  obstruction, 

2.  Tuberculoug  peritonitis  may  l>e  primar>%  but  is  usually  secondary  to 
disease  in  a  distant  organ,  or  to  tuberculosisof  some  other  abdominal  structure, 
particularly  the  lymph  glands,  the  intestine,  or  the  Fallopian  tubes.  It  is 
more  common  in  females,  and  is  rarely  seen  before  the  third  or  after  the 
fiftieth  year.  Three  forms  are  described:  (a)  The  asciik  form  presents 
itself  as  a  free  or  sacculated  serous,  sero- fibrinous,  or  occasionally  purulent 
exudate,  as  the  result  of  a  diffuse  miliary  invasion  of  the  peritoneum;  it  is 
sometimes  complicated  by  cirrhosis  of  tlie  liver,  (b)  The  jjibrous  or  adhesive 
variety  is  characterized  by  a  slow  course  and  the  absence  of  tluid.  The  ab- 
dominal organs  are  gJued  together,  and  gray  or  yellow  tuliercles  are  found 
among  the  adhesions.  Not  unusually  the  omentum  is  rolled  upon  itself  and 
is  palpable  as  a  transverse  mass  in  the  upper  part  of  the  abdomen,  (c)  The 
lasemis  or  suppurative  form  is  a  later  stage  of  the  adhesive  variety.  The 
tubercles  caseate  and  give  rise  lo  abscesses,  which  may  point  e.xternally, 
especiEdly  at  the  naveb  and  lead  to  feral  fistulas,  the  bowel  often  being  opened 
by  ulceration. 

The  local  symptoms  may  arise  suddenly  and  resemble  those  of  acute 
appendicitis  or  other  acute  intraabdominal  condition,  or  the  general 
symptoms  may  predominate  and  typhoid  fever  be  simulated.  Most  of 
the  cases,  however,  are  chronic.  Pain  and  tenderness  are  rarely  severe 
antl  may  be  entirely  absent.  Dysuria  is  not  uncommon,  particularly  in 
women.  The  digestion  is  disturbed,  although  vomiting  is  rare,  and  diarrhea 
is  absent  unless  thefe  is  disease  in  the  intestine.  The  temperature  rises 
one  or  two  degrees  in  the  evening,  night  sweats  may  occur,  ancl  there  is  a 
gradual  loss  of  weight.  The  subcutaneous  abdominal  veins  are  generally 
distendeib  and  free  or  encapsulated  fluid  may  be  detected  in  the  peri- 
toneal cavity.  The  rolled  up  omentum,  masses  of  adherent  intestine,  or 
enlarged  lymph  glands  may  be  found  on  palpation.  Symptoms  of  stenosis 
of  the  intestine  may  be  present,  the  liver  and  spleen  are  often  enlarged, 
and  tuberculosis  may  be  detected  in  distant  parts  of  the  body. 

.  The  treatment  may  be  medical  or  surgical.  Medkal  treatment  mdxxdt^ 
the  general  measures  employeil  for  tuberculosis  elsewhere  and  local  applica- 
tions of  green  soap,  mercurial  ointment,  iodin,  elastic  collodion,  or  guaiacol. 
The  X-ray  and  intraperitoneal  injections  of  a  weak  solution  of  iodin  also  have 
been  used.  Surgical  in  aim  nit  is  of  the  greatest  value  in  the  ascitic  form,  in 
which  laparotomy  is  followed  by  at  least  50  per  cent,  of  permanent  cures. 
All  thai  is  needed  is  to  open  the  abdomen,  evacuate  the  fluid,  and  close  i^ithout 
drainage.  If  the  cause  of  the  disease,  e.g.,  a  tuberculous  appendix  or  Fallo- 
pian tube,  be  discovered,  this  may  be  removed.  Separation  of  adhesions  is 
not  infrequently  folloived  by  fecal  fistula?.  The  reason  for  the  beneficial 
effect  of  a  simple  laparotomy  is  not  known.  It  has  been  supposed  that  the 
operation  causes  hyperemia,  and  the  outpouring  of  an  antitoxic  serum.  If 
lluid  recollects,  it  may  be  aspirated  or  a  second  laparotomy  performed. 

Paracentesis  abdominis  is  performed  for  the  removal  of  fluid  from  the 
peritoneal  cavity.     The  bladder  should  be  emptied,  and  a  spot  of  absolute 
2y 


4S8 


ABDOJIEN. 


k 


abtJominal  vvalL  Peristalsis  passing  from  left  to  right  likewise  may  be  seen 
at  time:s.  On  palpation  the  Lushion-Hke  resistance  of  the  stomach  may  be 
felt*  a  splashing  sounil  often  eliciietl,  and  in  some  cases  a  tumor  delected  in 
the  pyloric  region.  The  size  of  the  stomach  is  determined  by  percussion, 
after  filling  the  stomach  with  air  or  water;  by  measuring  the  quantity  of  Huid 
which  the  stomach  will  hold;  or  by  gastrodiaphany  (transillumination  by 
means  of  an  electric  !amp  passefl  into  the  stomach).  If  the  patient  takes  lo 
grains  of  salol,  which  is  decomposed  and  absorbed  in  the  intestine  only, 
salicylic  acid  may  not  appear  in  the  urine  for  many  hours;  normally  it  should 
be  detected  within  one  hour.  The  absorptive  power  of  the  stomach  is  deter- 
mined by  giving  several  grains  of  potassium  iodid  and  testing  the  saliva  for 
iodin^  which  should  be  found  normally  in  from  ten  to  fifteen  minutes.  The 
size,  shape,  position,  and  activity  of  the  stomach  may  be  shown  also  by  the 
X-rays,  after  administering  two  ounces  of  bismuth  subnitrate  or  subcarbonatc 
in  a  pint  of  milk  or  koumyss.  Normally  the  stomach  should  l»e  free  of  the 
bismuth  in  three  hours.  With  the  tluoroscope  the  peristaltic  movements 
can  be  kept  under  continuous  observation. 

The  treatment  in  atonic  cases  is  medical,  i.e.,  lavage.  regtUation  of  the 
diet,  electricity,  etc.  If  medical  treatment  fails,  gaslropbVation  may  be  per- 
formed. In  those  cases  depending  upon  obstruction  to  the  outlet  of  the 
stomacJi,  the  treatment  is  that  of  pyloric  stenosis. 

Gastroptasis,  or  prolapse  of  the  stomach,  is  usually  secondary  to  gastric 
dilatation,  when  the  symptoms  and  treatment  will  be  those  of  gastrectasia* 
It  forms  part  also  of  the  general  visceral  ptosis  called  Gl<5nard's  disease. 
Primary  or  essential  gastroptosis  is  prolialily  very  rare,  and  is  constantly  linked 
wnlh  dilatation,  from  kinking  of  the  pylorus^  or  from  pylorospasm  the  result 
of  hyperacidity.  The  symptoms  are  therefore  usually  those  of  chronic  indi- 
gestion and  gastric  stasis.  The  position  of  the  stomach  may  be  determined 
by  percussion,  after  filling  the  stomach  with  air  or  water^  or  by  the  X-ray 
(vide  supra).  The  treatment  of  the  essential  form  is  gastroenterostomy,  with 
or  without  gasiropexy. 

Carcinoma  of  tie  stomach  is  verv'  frequent,  sarcoma  and  innocent 
tumors  are  rare.  Carcinoma  may  involve  any  portion  of  the  stomach, 
but  most  often  alTects  the  pylorus  (60  per  cent.),  often  starting  from  an  old 
ulcer.  It  is  more  frequent  in  the  male,  and  is  unusual  before  the  fortieth 
year.  It  may  be  of  any  variety,  but  is  usually  scirrhous  in  nature.  It  alwa)*s 
begins  in  the  mucous  membrane,  infiltrates  the  remaining  coats  of  the  stomadi, 
and  tinally  invades  the  surrounding  organs,  particularly  the  liver  and  pan- 
creas. Perforation  of  the  stomach  occasionally  occurs.  The  lymphatic 
glands,  particula Hy  those  along  the  lesser  curvature,  arc  invaded  at  an  early 
period,  and  distant  metastases  aJso  may  occur  The  '*  leather  bottle  stomach'* 
is  a  diffuse  carcinomatous  infiltration  of  the  whole  organ.  The  disease 
is  fatal  in  from  a  few  months  to  two  years  or  longer,  according  to  the  nature 
and  situation  of  the  growth. 

The  symptoms  at  first  are  those  of  chronic  gastritis  or  nervous  dyspepsia, 
i.e.,  interference  with  the  appetite,  thirst,  a  sense  of  ftdness,  eructations, 
nausea,  vomiting,  and  usually  constipation.  If  in  spite  of  carefid  medical 
treatment,  symptoms  of  this  character  persist  for  a  month  or  longer,  and  arc 
associated  with  a  progressive  loss  of  weight,  in  a  patient  past  forty,  one  should 
always  suspect  carcinoma,  and  advise  an  exploratory  incision,  which  is  the 
most  reliable  diagnostic  measure.     This  is  the  lime  for  successful  surgical 


GASTRIC   L.\VAGE. 


450 


irealmeiiL  Among  the  ialer  symptoms  are  coffee-ground  vomit  (decomposed 
blood),  cachexia,  enlargement  of  the  lymph  glamh  at  the  base  of  the  neck 
(rare),  palpable  Inmor  (absent  in  40  per  tent.)*  ascites,  distention  of  the 
superficial  abdominal  veins,  swelling  of  the  legs,  and  jaundice  owing  to  in- 
volvement of  the  common  bile  duct.  Pain  in  tlfie  epigastrium  and  back  may 
be  an  early  symptom,  but  is  sometimes  al>sent  in  even  the  later  stages;  it  may 
be  increased  or  relieveil  by  food.  The  laboratory  methods  of  diagnosis  are 
unreliable  in  the  early  stages,  and  are  of  the  greatest  value  only  when  the 
growth  is  inoperable.  At  this  time  examination  of  the  gastric  contents  shows 
an  absence  of  free  hydrochloric  acid  and  an  increase  in  the  amount  of  lactic 
add,  both  of  which  conditions  may  be  found  in  other  gastric  diseases.  Mi- 
croscopic examination  of  the  stomach  contents  may  show  small  portions  of  the 
neoplasm  and  the  Oppler-Boas  bacilli,  and  these  bacilli  and  occu!t  blood  may 
be  found  in  the  stools.  The  motor  and  al^sorptive  powers  of  the  stomach 
are  lessened.  Blood  examination  shows  a  reduction  in  the  hemogloliin  and 
an  absence  of  the  digestive  leukocytosis.  Finally  may  be  mentioned  the 
possibility  of  making  a  diagnosis  by  the  esophagoscope,  introduced  into  the 
stomach;  by  transillumination  with  an  intragastric  lamp,  showing  a  tumor 
on  the  anterior  wall;  and  by  the  X-rays,  after  the  ingestion  of  an  emulsion  of 
bismuth  (p.  458),  the  tumor  appearing  as  a  marked  indentation  in  the  outline 
of  the  stomach.  The  situation  of  the  growth  has  a  marked  intluence  on  the 
symptoms.  WTien  the  cardiac  orifice  is  involved,  the  symptoms  are  those  of 
stricture  of  the  esophagus,  and  a  tumor  cannot  be  felt.  When  the  growth  is 
at  the  pylorus,  the  symptoms  are  those  of  dilatation  of  the  stomach,  and  the 
tumor  is  more  apt  to  be  palpated.  WTien  neither  orifice  is  involved,  vomiting 
may  be  absent,  and  a  tumor  may  or  may  not  be  felt,  according  to  its  size  and 
situation. 

The  treatment  is  e.^ploratory  incision,  and  if  possible,  removal  of  the 
growth  l)y  partial  or  complete  gastrectomy.  Kocher  claims  8  per  cent,  of 
permanent  cures  from  operation.  If  the  cardiac  oritice  is  involved,  gastros- 
tomy will  be  indicated  for  the  purposes  of  feeding.  In  inoperable  cancer  of  the 
pylorus  gastroenterostomy  may  be  performed,  in  order  to  allow  the  passage 
of  food  into  the  boweb  WTien  the  entire  stomach  is  hopelessly  invaded,  the 
only  possible  measure  which  promises  relief  is  jejunostomy,  or  the  making 
of  an  artiticial  opening  into  the  jejunum  in  order  to  feed  the  patient. 

Gastrttis  obliterans  (piasiic  Ihtiiis)  is  a  rare  affection,  diaracterizeil  by 
great  thickening  of  the  walls  of  the  stomach  as  the  result  of  hyperplasia  of  the 
Hubmurcjisa,  ami  a  f>rogressivc  diminution  in  die  size  of  the  stomach.  It  is  a 
cirrhotic  inflammation,  the  cause  of  which  is  unknown.  The  symptoms  are 
pain,  vomiting  immediately  after  talcing  food,  and  emaciation.  The  if  eat- 
meni  is  pyloroplasty  or  gastroenterostomy,  when  the  pyloric  portion  is  chiefly 
invoIve(l;  or  partial  or  complete  gastrectomy. 

Vol  villus  of  the  stomach  also  is  rare.  It  may  be  associated  with  dia* 
phragmaUc  hernia.  The  symptoms  are  pain,  shock,  and  distention  of  the 
upper  atidomen.  V^omiting  cannot  occur  The  ireatmcnt  is  laparotomy, 
reduction  of  the  tuist,  and  shortening  of  the  gastrohepatic  omentum. 

OPERATIONS  ON  THE  STOMACH, 

Gastric  lavage  is  required  in  cases  of  poisoning,  as  a  preliminary  to  opera- 
tions on  the  stomach,  and  as  a  therapeutic  measure  in  many  gastric  diseases, 


v^ 


ABDOMEN. 


partif  ulariy  ^liJatation.  The  stumaiJi  tube  i>  lubricateil  with  glyceiin,  guided 
over  the  epiglottis  by  the  foretinger.  and  pushed  into  the  stomach  while  the 
patient  makes  efforts  at  swallowing.  Water  or  other  fluid  15  then  poured  into 
the  funnel  end  of  the  tube  until  the  requisite  amount  has  been  introduced, 
when  it  is  carried  to  a  lower  level  than  the  stomach  while  still  full  of  liquid^ 
thus  syphoning  off  the  contents  of  the  stomach.  The  washing  may  be  con- 
tinued until  the  stomach  is  clean. 

Gastrotomjy  or  incision  into  the  stomach,  may  be  performed  for  explor- 
atory purposes,  gastric  hemorrhage,  the  removal  of  foreign  bodies  from  the 
esTiphagus  or  stomach,  and  for  the  dilatation  of  stricture  of  either  orifice  of  the 
stomach.  A  median  abdominal  incision  is  made,  and  the  stomach  drawn 
into  the  wound,  isolated  ^ith  gauze,  and  incised  at  the  desired  point.  The 
wound  is  sutured  with  catgut,  passing  through  all  the  coats,  and  over  this  is 
placed  a  layer  of  Lembert  sutures  of  silk.  The  operative  field  is  then 
cleansed  with  salt  solution,  and  the  abdomen  closed  without  drainage.  The 
patient  begins  to  take  water  after  the  vomiting  has  ceased,  and  solid  food 
at  the  end  of  two  or  three  weeks. 

Gastrostomy  is  the  making  of  a  permanent  opening  into  the  stomach, 
for  the  purpose  of  feeding  a  patient  ^ith  inoperable  stricture  of  the  esopha- 
gus, llie  opening  should  permit  feeding,  prevent  the  external  leakage  of  the 
gastric  contents,  and  be  as  near  the  cardiac  orifice  as  possible.  Hartnuum 
and  others  make  a  vertical  incision  through  the  outer  border  of  the  left  rectus, 
retract  the  inner  portion  of  the  muscle  towards  the  right,  and  open  the  pos- 
terior sheath  and  peritoneum  near  the  middle  line.  A  cone  of  the  stomach 
is  pulled  through  the  wound,  and  sutured  to  the  parietal  peritoneum  and  the 
skin.    The  apex  of  the  cone  is  opened,  and  the  patient  fed  with  a  rubber  tube. 


p 

)  i 

f  i 

Pariefe9  Jl 

I      Ari^003 

S74 


Witzcl's  j^astrostoiny. 
(Hinnif.) 


Fig.  ;^75. — The  Stamm-Kaxier   gas- 
trostomy.    (Binnie.) 


Frank's  operation  is  recommended  when  the  stomach  is  not  too  small; 
a  two  inch  incision  is  made  below  and  parallel  with  the  left  costal  margin, 
thru  a  (one  of  the  .stomach  is  drawn  through  this  incision,  and  passed  up- 
wards under  the  skin  to  a  second  incision,  about  one  inch  in  lengdi,  situated 
over  the  ( ostal  margin.  The  stomach  is  sutured  to  the  muscles  of  the  first 
incision,  and  to  the  skin  of  the  second  incision,  where  it  is  opened  and  a  tube 
inserted. 

In  Witzel's  operation  the  abdomen  is  opened  through  the  left  rectus, 
a  catheter  passed   into  the  stomach  through  a  small  opening  and  there 


Fig,  376. ^B.  Proper    positiun    for   opening    in   stumach.     A,  Improper   position, 
allowing  formation  of  intragastric  pouch.     (Mayo,) 

Gastropexy  also  is  of  doubtful  value.  The  stomach  has  been  sutured 
to  the  anterior  abdominal  wall  and  lo  ihe  liver.  Beyea  shortens  the  gaslro- 
hcpatic  and  gastrophrenic  ligaments  by  the  introduction  of  reefing  sutures. 

Gastrectomy  may  be  partial  or  complete.  Partial  gastrectomy  is  per- 
formed for  ulcer  or  for  localized  tumors  of  the  stomach  wall  Pylorcctomy 
js  really  a  partial  ga.strectomy»  but  is  considered  later  under  a  separate  head- 
ing. The  diseasetl  portion  of  ihe  stomach  wall  is  excised,  and  the  wound 
closed  as  in  gastrolomy.     Complete  gastrectomy,  or  removal  of  the  whole 


J 


Fl«;.  .^77. — Showing  |wvsitcri<>r  wall  of  the  stomiu  fi  <ir;i\vn  through  a  rrni  in  the  trail 
vcrsr  mrs«Hok>n.  Note  flight  scptiraliriin  of  ga.strrjrolir  omentum  from  it's  attachment  la 
ihc  Hluniut  h»  |j<*rmuiing  anlcnur  wall  of  stomach  to  appear,  and  insuring  dminage  al  lower- 
miM»t  Icvch  Blark  linrs  mark  site  of  proposeri  anastomosis ;  the  jejunum  shows  at  its 
origin.     (May<*-) 


Anterior  gastroenterostomy,  or  Wolfler's  operatioo  (Fig.  376),  is  to- 
<licrtte(l  in  lascs  in  which  the  posterior  operation  is  not  applicable  because  of 
the  prt-'M'jiie  of  adhesions,  etc.^  and  in  cases  of  malignancy  when  every 
minute  should  be  saved.  Its  disadvantages  are  the  presence  of  a  long  IcKip 
of  intrslinc  attached  to  the  stomacii,  which  may  cause  obstruction  by  pressure 
on  the  iransverse  colon  or  by  allowing  adjacent  coils  of  intestine  to  slip  into 
the  noose,  ll  alst*  puts  out  of  commission  a  long  segment  of  intestine  which 
is  of  great  imporhmce  for  the  purposes  of  digestion  and  absorption.      After 


GASTROENTEROSTOMY. 


463 


openjQg  the  abdomen  in  the  niiddle  line  above  the  umf>iIiLUS,  the  omentum  is 
pulle<l  upwards,  and  a  loop  of  jejunum,  about  a  foot  from  the  duodenum, 
brought  up  o^'er  the  transverse  colon  and  anastomosed  with  the  lowest  point 
on  the  anterior  wall  of  the  stomach,  by  sutures,  the  Murphy  button,  or  the 
McGraw  elastic  ligature  (see  section  on  intestinal  anastomosis).  The  loop 
of  intestine  and  that  portion  of  the  stomach  to  he  opened  arc  first  secured  by 
clamps,  the  blades  of  which  are  covered  with  rubljer  tubing,  in  order  to 
prevent  leakage  and  lileeding.  It  (s  usually  desiraf>le  to  unite  the  stomach  to 
tlie  bowel  with  a  few  additional  sutures  on  each  side  of  the  opening  in  onler 
to  prevent  a  sharp  kink.  Kocher  places  the  afferent  limb  of  intestine  poste- 
riorly and  invaginates  its  wall  transversely,  in  order  to  form  a  valve  which  will 
direct  the  stomach  contents  into  the  efferent  limb  of  intestine. 


Fig.  378. — Forceps  in  place  &nd  anastomosis  half  completed  by  suturi:.     uMayo.) 


Posterior   gastrcenterostoniy,    or    Von    Hackers    operation,    has 

advanced  to  its  present  state  of  efficiency  largely  through  the  labors  of 
Peterson,  Czerny,  Mikulicz,  Moynihan,  and  Mayo,  The  ga^stric  opening 
should  lie  at  the  lowest  point  of  the  posterior  wall  of  the  stomach,  in  the  same 
plane  as  the  canhat  orilke,  and  directed  obliquely  from  above  downward  and 
from  left  Lo  right  (Fig.  377}.  Mayo  (1906)  has  recently  been  making  this 
opening  from  right  lo  left,  in  order  to  avoid  angulation  of  the  jejunum,  which 
normally  passes  in  this  direction.  The  opening  in  the  intestine  should  be 
longitudinal  and  opposite  the  mesentery,  as  near  the  origin  of  the  jejunum 
as  possil>le,  usually  from  two  to  four  inches,  thus  utilizing  thai  portion  which 
normally  lies  immediately  behind  the  stomach  and  avoiding  a  loc>p.     Clamps 


i 


464  ABDOMEN. 

should  be  used,  both  on  the  intestine  and  the  stomach,  to  prevent  extravasa- 
tion of  contents  and  bleeding  during  the  operation.  The  operation  is  per- 
formed as  follows:  The  abdomen  is  opened  by  a  four  inch  incision^  sq»- 
rating  the  fillers  of  the  right  rectus  muscle.  The  transverse  colon  and  omen- 
tum are  turned  up  over  the  epigastrium,  and  the  mesocolon  torn  through  at  a 
blorxlless  spot  within  the  loop  of  the  middle  colic  artery.  A  fold  of  the  poste- 
rior wall  of  the  stomach  is  drawn  through  this  opening  and  damped  with  long 
Doyen  forceps,  the  blades  of  which  are  covered  with  rubber  tubing.  The 
forceps  should  include  a  portion  of  the  greater  cur\'ature,  the  great  omentum 
l>eing  separated  slightly  for  this  purpose  (Fig.  377).  The  fold  extends  from 
alx>ve  downwards  and  from  left  to  right.  The  jejunum  just  below  its  origin 
is  now  brought  to  the  surface  and  clamped.  The  origin  of  the  jejunum  may 
liC  found  by  carrying  the  finger  along  the  root  of  the  transverse  mesocolon  to 

the  left  of  the  spine.  The  damps  are  laid 
side  by  side  and  surrounded  by  gauze  pads. 
With  a  continuous  Lembert  suture  of  silk  or 
celluloid  thread  the  stomach  is  sutured  to  the 
intestine  for  at  least  two  and  one-half  inches. 
Both  the  stomach  and  intestine  are  now  in- 
cised down  to  the  mucous  membrane,  about 
one-fourth  of  an  inch  in  front  of  the  suture 
line.  The  mucous  membrane  exposed  by 
the  retraction  of  the  outer  coats  is  excised, 
and  the  stomach  united  to  the  intestine  all 
around  the  anastomotic  opening  by  a  con- 
tinuous catgut  suture,  passing  through  all 
the  coats  in  order  to  give  firm  apposition 
and  stop  bleeding  (Fig.  378).  The  clamps 
\'u..  ,,-]()  Roux'smcihorr-en  V."  ^^^  '^^^^'  removed  and  the  continuous  Lem- 
LMonod  jinl  Vanvcrts.)  bert  suturc  continued  around  the  opening 

to  its  i)()int  of  origin.  The  edges  of  the 
tear  in  the  mesocolon  are  fastened  to  the  stomach  lo  prevent  hernia,  and 
the  abdomen  closed  without  drainage.  After  operation  the  patient  is  put 
in  the  semi-sitting  posture  and  fed  as  after  gastrotomy.  The  Murphy 
button  or  other  means  of  anastomosis  may  be  employed  instead  of  simple 
suture,  which  is,  however,  the  preferable  method  in  most  instances.  The 
Muri)hy  button  is  of  great  value  as  a  time  saver,  but  it  may  drop  back 
into  the  st()ma(  h,  f)roduce  obstruction  lower  in  the  intestine,  or  be  followed 
by  leakage,  the  result  of  a  .spreading  of  the  necrosis  which  it  necessarily  in- 
< luces.  It  is  used  chietly  in  the  anterior  method  in  malignant  cases.  The 
M(  (Jraw  ligature  is  never  indicated  when  immediate  feeding  is  desired;  it  is 
more  rapid  than  suturing  and  slower  than  the  button. 

The  vicious  circle  is  a  term  applied  to  the  passage  of  stomach  contents 
into  the  afferent  limb  of  gut,  thence  back  into  the  stomach,  which  is  emptied 
by  vomiting.  Kocher*s  method  for  preventing  this  accident  has  already  been 
mentioned.  In  operations  with  a  loop  an  anastomosis  may  be  made  between 
the  lowest  f)ortion  of  the  loop  and  the  jejunum.  In  addition  to  this  measure 
the  afferent  looj)  may  be  ligated  with  silk  or  silver  wire,  between  the  two 
points  of  anastomosis.  In  Roux's  method  "en  V"  (Fig.  379)  the  jejunum  is 
tlivided,  the  lower  .segment  anastomosed  with  the  stomach,  and  the  upper 
segment  with  the  side  of  the  lower  segment  several  inches  below  the  stom- 


PYLOROPLASTY.  4^5 

ach.  The  posterior  operation  without  the  loop  is  very  rarely  if  ever 
followed  by  the  vicious  circle.  When  vomiting  occurs  after  these  cases,  it  is 
due  to  the  passage  of  bile  into  the  stomach  through  the  anastomotic  opening, 
kinking  of  the  bowel,  or  contraction  of  the  anastomotic  opening.  Persistent 
vomiting  unrelieved  by  gastric  lavage  requires  a  secondary  operation  for  the 
relief  of  the  obstruction. 

Peptic  ulcer  of  the  jejunum  may  follow  gastroenterostomy,  owing  to  the 
corrosive  action  of  the  gastric  juice.  It  is  probably  more  frequent  than  is 
generally  thought,  many  cases  being  unrecognized.  Roojen  (1910)  has 
collected  89  cases,  most  of  which  occurred  after  the  anterior  operation,  the 
reason  for  this  being  that  the  upper  portion  of  the  jejunum,  such  as  is  utilized 
in  the  posterior  operation,  is  more  resistant  to  the  digestive  action  of  the  gas- 
tric juice,  owing  to  the  presence  of  bile 
^ — P^  ^v  and  pancreatic  fluid.     The  onset  of 

'T*^  \  \ \  symptoms  varied  from  ten  days  to 

^^       \^^^^  \        nine  years  after  the  gastroenterostomy. 

The  ulcer  is  usually  in  the  descend- 
ing limb  of  bowel,  but  may  attack  the 


y^ 


Fig.  380.=— Heineke-Mikulicz  pylor-  Fig.  381. — ^Finney  pyloroplasty,  the 

opiasty.     A.  Direction  of  incision  in  posterior  sutures  of  silk  and  catgut  and 

pylorus.     B.  Incision  sutured.  the  first  anterior  sutures  of  catgut  in- 

serted. 


anastomosis  itself  or  the  afferent  limb;  in  several  cases  there  were  multiple 
ulcers.  Not  one  occurred  after  gastroenterostomy  for  cancer,  hydrochloric 
acid  generally  being  absent  in  these  cases.  The  ulcer  may  perforate  into  the 
transverse  colon,  into  the  general  peritoneal  cavity,  or  it  may  cause  a  localized 
peritonitis.  These  cases  emphasize  the  importance  of  treatment  after  gas- 
troenterostomy, particularly  in  the  presence  of  hyperacidity.  Cases  of  acute 
perforation  may  be  saved  by  operation.  In  chronic  cases  a  new  gastroen- 
terostomy may  be  made  as  far  from  the  pylorus  as  possible,  in  order  to  avoid 
the  acid- forming  portion  of  the  stomach. 

Operations  for  Hour-glass  Stomach  (see  Figs.  368  to  373). 

Pylorodiosis,  or  stretching  the  pylorus  by  means  of  a  finger  introduced 
through  a  wound  in  the  stomach  (Loreta's  method),  or  by  invaginating  the 
anterior  wall  of  the  stomach  through  the  pylorus  without  making  an  incision 
(Holm's  method),  has  been  abandoned. 

Pyloroplasty  is  used  by  a  few  surgeons  for  benign  pyloric  stenosis.  The 
1 1  eineke- Mikulicz  operation  consists  in  making  a  longitudinal  incision 
through  the  stricture  and  suturing  the  wound  transversely  (Fig.  380).  This 
30 


ABDOMEN.' 

has  been  superseded  l*y  Finney's  pyhroplasly,  which  not  only  enlarges  the 
pylorus,  Ijut  also  lowers  the  outlet  of  the  stomach.  After  applying  clamps  to 
the  stomach  and  duodenum  the  greater  curvature  of  the  stomach  is  sutured 
to  the  posterior  surface  of  the  duodenum  with  silk.  An  incision  is  then 
made  in  front  of  these  su lures  on  the  inferior  surface  of  the  pylorus  an<l 
continued  into  the  stomach  and  duodenum.  The  posterior,  then  the  ante- 
rior, lips  of  this  incision  are  united  by  catgut,  the  clamps  removed,  and  the 
Lembert  suture  continued  anteriorly  as  in  gastroenterostomy  (Fig.  381). 

Pylorectomy  is  usually  performed  for  carcinoma,  occasionally  for  pep- 
tic ulcer.     Rodman  urges  the  more  frequent  use  of  this  procedure  in  gastric 


I 


Ct 


KiG.  382, — (Mayo.) 


uker,  in  order  to  remove  the  ulcer  bearing  portion  of  the  stomach  and  pre- 
I'ent  the  development  of  carcinoma.  After  the  pylorus  has  been  removed 
there  are  several  ways  of  restoring  the  continuity  of  the  gastrointestinal  canal. 
In  Bill  roth's  first  method  the  open  end  of  the  duodenum  was  sutured  to  ihe 
lower  end  of  the  wound  in  the  stomach,  the  supierlluous  part  of  the  stomach 
wound  being  closed  by  sutures;  leakage  often  occurred  where  the  three  lines 
of  suture  met.  In  Kocher's  method  the  stomach  wound  is  closed  and  the  end 
of  the  duodenum  anastomosed  to  the  posterior  gastric  walL  In  Billroih^s 
second  method,  the  procedure  now  generally  employe<b  both  the  wound  in 
the  stomach  and  that  in  the  fluodenum  are  closeil  and  a  gastrojejunostomy 


PYLORECTOMY, 

performed ►  Mayo  petforms  the  operation  as  follows:  **  Open  the  abdomen 
by  a  longitudinal  incision  from  the  ensiform  cartilage  to  the  umbilicus;  ligate 
and  divide*  the  gastric  arterv'  near  the  stomach,  ligate  and  divide  the  gastro- 
hepatic  omentum  close  to  the  liver  and  tie  the  superior  pyloric  artery.  Free 
the  upper  part  of  the  duodenum  and,  with  the  finger  as  a  guide  beneath  the 
pylorus  in  the  lesser  peritoneal  cavity,  ligate  the  right  gastroepiploic  or 
gastroduodenal  artery,  1  ie  and  sever  the  gastrocolic  omentum  near  the 
colon  as  far  as  the  desired  point  on  the  greater  cun  ature,  and  here  secure  the 
left  gastroepiploic  vessels.  Apply  two  short  damps  to  the  duodenum,  sever 
the  duodenum  between  the  clamps  with  the  cautery,  and  close  it  by  a  con- 
tinuous catgut  suture  which  is  buried  by  a  purse-string  suture  of  silk. 
Double  clamp  the  stomach  along  the  Mikulicz-Hartmami  line  (Fig.  382)  and 


sever  betw*een  the  clamps  with  the  vauter>\  Close  the  stomach  by  a  con- 
tinuous suture  of  catgut  and  a  continuous  Lembert  suture  of  silk.  Perform 
a  gastrojejunostomy  (Fig.  383)."  This  operation  removes  the  growth  and 
the  lymphatic  glands  into  which  it  drains,  i,e,»  those  along  the  lesser  curvature, 
and  those  along  the  greater  cur\'ature  near  the  pylorus.  The  latter  group  of 
glands  drains  the  adjacent  third  of  the  stomach,  the  lymph  stream  (lown'ng 
from  left  to  right,  hence  the  absence  of  involvement,  in  pyloric  carcinoma, 
of  the  lymph  glands  along  the  left  two- thirds  of  the  greater  curvature.  The 
mortality  of  pylorectomy  for  cancer  is  lietween  10  and  20  per  cent.,  while 
permanent  cures  may  be  obtained  in  from  5  to  ro  per  cent*  of  the  cases. 


468  ABDOMEN. 

THE  INTESTINES. 

Ulcer  of  the  duodenum  is  usually  on  the  anterior  wall  within  two  or 
three  inches  of  the  pylorus,  is  due  to  the  same  causes  and  is  probably  as 
frequent  as  ulcer  of  the  stomach,  and  is  more  common  in  men.  The  symp- 
toms  are  much  like  those  of  gastric  ulcer,  but  vomiting  is  later,  blood  is  more 
apt  to  be  passed  by  bowel  than  vomited,  the  pain  occurs  several  hours  after 
eating,  often  being  relieved  by  food  (hunger  pain),  and  the  tender  point  is 
just  above  and  to  the  right  of  the  umbilicus  (Fig.  367).  Perforation  and 
fatal  hemorrhage  may  occur.  The  treatment  is  that  of  gastric  ulcer.  (Sec 
also  Curling's  ulcer  of  the  duodenum,  p.  97.) 

Wounds  of  the  intestine  (see  contusions  and  wounds  of  the  abdomen). 

Congenital  stenosis  of  the  intestine  may  occur  near  the  common  bile 
duct,  and  in  the  lower  ileum  at  a  point  corresponding  to  the  situation  of 
Meckel's  deverticulum.  Imperforate  anus  is  considered  on  a  later  page. 
Meckel's  diverticulum  is  a  persistent  omphalo-mesenteric  duct,  which  gener- 
ally arises  from  the  ileum  about  three  feet  above  the  ileocecal  valve.  It  may 
open  at  the  umbilicus  (congenital  fecal  fistula,  p.  446),  or  be  obliterated  in 
whole  or  part,  the  obliterated  portion  persisting  as  a  cord  attached  to  the 
umbilicus,  the  mesentery,  or  other  viscus.  In  many  cases  the  diverticulum 
hangs  free  in  the  peritoneal  cavity,  its  interior  being  lined  with  mucous  mem- 
brane and  communicating  with  the  intestine.  The  structure  may  become 
inflamed,  the  symptoms  and  treatment  being  the  same  as  those  of  appendicitis, 
or  it  may  cause  intestinal  obstruction  by  kinking  or  twisting  the  bowel,  by 
invaginating  into  the  bowel  (intussusception),  or  by  acting  as  a  band  or  noose 
whidi  constricts  or  ensnares  a  coil  of  intestine.  Obstruction  is  most  common 
in  early  life  and  the  patient  may  exhibit  other  deformities,  but  there  is  noth- 
ing distinctive  in  the  symptoms.  When  inflamed  or  giving  rise  to  obstruction, 
the  diverticulum  should  be  excised,  and  the  opening  in  the  bowel  closed 
with  Lembert  sutures. 

Acquired  diverticula  are  most  frequent  in  the  descending  colon  and 
sigmoid  of  fat  constipated  men  past  middle  life.  They  are  usually  multiple, 
may  be  ver>'  minute  or  as  large  as  a  cherry,  and  represent  hernial  protrusions 
of  the  mucosa  through  the  muscularis,  often  at  the  points  where  vessels 
pierce  the  bowel  wall  to  enter  the  appendices  epiploic^.  Diverticulitis 
often  results  from  the  irritation  of  a  fecal  concretion.  The  symptoms  of  the 
acute  form  are  those  of  appendicitis,  except  that  the  trouble  is  in  the  left 
abdomen  (Fig.  367).  Perforative  peritonitis  or  localized  abscess  may  follow. 
In  the  chronic  variety  the  colon  about  the  divertic  ulum  participates  in  the 
inflammation  and  finally  becomes  thick,  hard,  and  contracted,  causing 
symptoms  of  chronic  obstruction,  and  closely  mimicking  scirrhous  carcinoma. 
The  treatment  of  perforation  is  suture;  of  abscess,  drainage;  of  stricture, 
excision. 

Idiopathic  dilatation  of  the  colon  (Hirschsprung's  disease)  may  occur 
at  any  period  of  life,  but  is  usually  of  congenital  origin  and  most  frequent  in 
male  infants.  .Although  mild  cases  may  remain  stationary,  the  disease 
generally  progresses  and  terminates,  in  from  a  few  weeks  to  many  years,  in 
death  from  i)critonitis,  to.xemia,  or  pneumonia.  The  whole  colon,  or  only 
a  part,  usually  the  sigmoid,  may  be  involved.  The  })oweI  is  greatly  dilated 
(the  circumference  in  one  case  reaching  30  inches),  hypertrophied,  sometimes 
elongated,  often  kinked,  and  frequently  contains  stercoral  ulcers,  which  on 


TYPHOroAL  PERFOHATIC 

liealing  may  lead  lo  stenosis.  The  sympioftn  are  t*l)stiiialr  t  unstipaUon  (the 
bowels  may  not  move  for  weeks),  sometimes  alternating  with  diarrhea; 
emaciation ;  possibly  convulsions  or  tetany;  ballooning  of  the  abdomen ;  visible, 
audible,  and  palpable  peristalsis;  foreshortening  of  the  thorax;  flaring  of 
the  costal  margins;  and  interference  widi  the  action  of  the  heart  and  lungs 
from  pressure.  The  treatment  is  at  first  medical,  viz.,  liqiiitl  diet,  tonics, 
strychnin,  colonic  lavage,  electricity  locally,  and  abdominal  massage.  If 
these  measures  fail  appendicostomy  (p.  4^^)  and  daily  irrigations  of  the  colon, 
short  circuiting  of  the  colon  by  ileosigmoidostomy,  or  excision  of  the  colon  or 
its  most  affected  part  may  be  performed.  In  desperate  cases  right  inguinal 
colostomy  is  indicated,  more  radical  measures  l»eing  adopted  after  im- 
provement has  occurred 

Typhoidal  perforation  of  the  intestine  is  probal>ly  responsible  for  one- 
third  of  the  fatalities  in  enteric  fever.  The  accident  usually  occurs  during  the 
third,  fourth,  or  tifth  week,  although  it  may  happen  at  any  stage  of  the  disease. 
As  a  rule  the  pain  is  sudden  in  onset,  begins  in  the  right  lower  quadrant  of  the 
abdomen,  quickly  becomes  generalized,  and  persists  despite  the  hebetude  of 
the  patient.  Tenderness  is  most  marked  in  the  region  of  the  perforation, 
usually  the  right  iliac  fossa,  and  may  be  elicited  also  on  rectal  or  vaginal 
examination.  Rigidity  of  the  abdominal  muscles  is  the  most  valuable  sign; 
it  is  at  first  localized  over  the  area  of  perforation,  thence  becoming  generalized 
with  the  spread  of  the  infection.  The  hardening  of  the  belly  wail  due  to 
meteorism,  to  emaciation,  to  the  application  of  cold  water,  or  lo  associated 
pulmonary  disease  should  not  mislead  the  surgeon.  The  remaining  symp- 
toms are  identical  with  those  of  diffuse  peritonitis  (q.v.).  Typhoidal  per- 
foration may  be  confounded  with  almost  any  other  lesion  producing  a  periton- 
itis, with  any  form  of  intestinal  obstruction,  and  with  spontaneous  rupture 
of  the  spleen,  but  as  the  treatment  of  all  these  cases  is  laparotomy,  a  failure 
to  differentiate  them  is  not  productive  of  harm.  One  must  be  most  careful, 
however,  to  exclude  constipation,  distention  of  the  urinary  bladder,  catarrhal 
cholecystitis,  pleurisy,  iliac  phlebitis,  and  epididymitis,  all  of  which  may  sim- 
ulate perforation,  and  none  of  which  requires  operation.  The  most  difficult 
differential  diagnosis  is  that  between  intestinal  hemorrhage  and  perftiration, 
as  the  symptoms  are  sometimes  identical;  to  mistake  hemorrhage  for  per- 
foration means  an  unnecessary  operation  at  a  very  critical  period,  to  mistake 
perforation  for  hemorrhage  means  death.  Blood  in  the  stools  is  not  con- 
clusive, since  the  two  conditions  may  coexist.  A  reduction  in  the  number  of 
red  cells  and  in  the  hemoglobin  would  point  towards  hemorrhage,  leukocy- 
tosis and  a  rise  in  the  blood  pressure  towards  perforation.  Opium  should  be 
iJ^^thheld  in  cases  of  hemorrhage  in  which  perforation  is  suspected,  because 
of  the  danger  of  clouding  the  symptoms. 

The  treatnient  is  immediate  operation.  Pain,  rigidity,  and  tenderness 
always  demand  exploration,  which  may  be  conducted  under  local  anesthesia. 
If  the  diagnosis  is  confirmed,  ether  should  be  employed,  as  the  operation  can 
be  performed  more  quickly  and  the  abdominal  cavity  cleansed  more  thor- 
oughiy  without  subjecting  the  patient  to  the  deleterious  effects  of  fright  and 
struggling.  If  shock  is  present  the  danger  of  delay  far  outweighs  the  danger 
of  a  rapid  operation  The  incision  is  made  in  the  right  iliac  region,  as  90 
per  cent,  of  all  perforations  are  found  u\  the  last  twenty  or  thirty  inches  of  the 
ileum  or  in  the  cecum  or  appendix.  If  the  perforation  is  not  found  in  the 
ileum  and  there  are  evidences  of  peritonitis,  the  sigmoid,  the  colon,  and  the 


* 


he 


k 


remaining  portion  of  ihc  small  intcstiiie  sliou!<i  Ijc  explored  in  ihe order 
mentioned.  The  perforation  should  he  sutured  with  a  double  row  of  Lembert 
suturei5  of  siik,  without  extising  the  ulcer  A  large  perforation  may  be 
sutured  obliquely,  so  as  not  to  interfere  with  the  fecal  current.  Search  for  a 
second  perforation  should  always  be  made,  as  in  i8  per  cent,  of  the  cases  the 
openings  are  multiple.  All  suspicious  spots  should  be  treated  as  perforations. 
In  some  cases  suture  is  impossible  because  of  the  size  of  the  opening,  the 
number  of  openings,  or  because  of  gangrene  of  the  bowel.  Resection  in  these 
cases  consumes  so  much  time  that  surgeons  have  been  afraid  to  trj^it.  Plu, 
giiig  the  hole  with  omentum,  or  suturing  the  omentum  over  the  perforation 
has  been  suggested,  and  isolation  of  the  affected  portion  of  bowel  by  gauze 
packing  may  sometimes  be  used.  The  safest  plan  is  to  anchor  the  intestinal 
loop  outside  the  al>dominal  cavity,  in  order  to  make  the  isolation  more  com- 
plete; this  will  also  relieve  the  distention  and  permit  local  treatment  of  the 
remaining  typhoid  ukers.  After  dealing  with  the  perforation,  the  treatment 
is  that  of  the  diffuse  peritonitis  (q.v,).  The  writer  has  operated  upon 
thirty- six  cases  with  twelve  recoveries. 

Tuberculosis  of  the  intestine  is  most  frequent  jn  the  lower  ileum  and  in 
the  cecum,  probably  because  the  slow  fecal  current  in  this  region  permits  the 
deposition  of  the  bacilli.  There  are  two  forms.  The  enkro- peritoneal  form 
is  the  result  of  active  caseation.  There  is  liule  or  no  tendency  towards  heal- 
ing, hence  stricture  does  not  occur.  A  subacute  abscess  forms  in  the  right 
iliac  fossa  and  tliis  may  llnally  break  externally,  often  through  one  of  the 
hernial  rings,  and  eventuate  in  a  fecal  listula.  Diarrhea  with  blood  and 
mucus  in  the  stools  is  caused  by  ulceration  of  the  mucosa,  and  phthisis  is 
frequently  present.  The  hyper plastk  form  arises  when  the  reparative  forces 
are  in  excess.  The  tubercles  are  encased  in  dense  tibrous  tissue,  which  con- 
verts the  gut  into  a  thick,  rigid,  contracted  tube.  The  mucous  membrane 
is  ulcerated  and  Oie  lymph  glands  enlarged.  The  symptoms  are  those  of 
chronic  obstruction,  with  a  hard,  movable,  cylindrical  mass  in  the  right  iliac 
fossa.  The  treatmetit  is  excision.  WTien  this  is  impossilile  the  affected  seg- 
ment may  be  short  circuited  by  il  en  sigmoid  ostomy. 

Splanchnoptosis,  or  Gienard^s  disease,  is  a  displacement  downwards  of 
the  abdominal  viscera,  and  includes  gastroptosis,  enteroplosis.  hepatoptosis, 
splenoptosis,  nephroptosis,  retrodisplacement  or  prolapse  of  the  uterus,  and 
sometimes  cardioptosis  owing  to  displacement  of  the  diaphragm.  The  most 
important  cause  is  relaxation  of  the  abdominal  wall,  which  may  be  congeni- 
tal, or  tlie  result  of  trophic  changes,  pregnancy,  ascites,  and  like  conditions. 
Traumatism,  corsets,  and  kyphosis  also  have  been  held  responsible  for  this 
condition.  It  is  much  more  common  in  women  than  in  men.  The  symp-  i 
toms  are  usually  those  of  dyspepsia  and  neurasthenia,  although  they  vary  ^^H 
according  to  the  organ  which  is  most  affected.  The  abdomen  is  flat  above  ^^ 
and  prominent  below,  the  wall  flabby,  and  the  recti  often  widely  separated. 
The  displaced  organs  may  be  palpated,  or  outlined  by  percussion.  The 
gastrointestinal  canal  is  often  narrowed  at  its  most  fixed  points.  Stiller's 
sign  is  aljnormal  mobility  of  the  tenth  rib.  The  treatment  is  the  application 
of  an  abdominal  support,  massage,  electricity,  tonics,  and  often  lavage  of  the 
stomach.  If  these  measures  fail,  the  fascia  between  the  recti  may  be  excised 
and  these  muscles  sutured  together,  in  order  to  lessen  the  size  of  the  peritoneal 
cavity  and  tighten  the  abdominal  wall.  One  or  more  of  the  displaced 
structures  may  be  fastened  in  place.     In  enteroptosis  the  splenic  and  hepatic 


4 


TNTESTIXA1,   OBSTRITCTIOX 


llexures  of  ihe  coUiii  have  been  fasleiied  to  ihe  aiKlominal  whIL  Operations 
for  tlie  fixation  of  other  organs  arc  mentioncti  in  the  sections  treating  of  these 
organs. 

Intestinal  obstruction!  ^J''  il^ws,  is  caused  by  the  following  conditions: 

1.  Bands,  adliesions,  and  apertures  are  a  common  cause  of  intestinal 
obstruction.  Bands  or  cord-like  structures  result  from  the  stretching  of  perit- 
oneal adhesions  or  are  formed  by  adherent  omentum,  appendix,  appendices 
epiploiciE,  Fallopian  tubes,  or  Meckers  diverticulum.  A  coil  of  bowel  slips 
into  the  noose  thus  formed  and  may  become  strangulated,  or  occasionally  it 
is  constricted  by  hanging  over  the  band  instead  of  passing  under  it.  Con- 
tracting adlu'sions  may  kink  or  constrict  the  gut.  Apertures  are  responsible 
for  all  forms  of  hernia  (p.  4q8).  Abnormal  openings^  either  congenital  or 
traumatic,  may  be  found  also  in  the  omentum  and  mesentery. 

2.  Volvulus,  or  torsion  of  the  intestine,  is  most  common  in  the  sigmoid 
tlexure,  then  in  the  small  intestine,  then  in  the  cecum  and  ascending  colon. 
The  bowel  may  be  twisted  on  its  mesenteric  axis,  the  usual  variety  (Fig.  384), 
on  its  own  axis,  or  two  coils  of  intestine  may  be  twisted  together.  \\Tien 
the  twist  is  tight  the  circulation  is  suppressed  and  gangrene  follows. 


Fig.  384-— Volvulus  of  the 
inlestine.  Note  rtislcnlion  of 
I  he  loop  and  of  the  bowel 
above  ihr  obsiructii>n. 


j^fPiiM 


Fig.  385. — Diagram  of  intyssusception. 
A.  Apex.  <P.  Neck.  C  Entering  layer  and 
/>.  returning  layer  of  intussusceplunL  £. 
Inlussuscipiens.  F.  Peritoneum.  C.  Mus- 
cularis,     //.  Mucosa. 


3.  Foreign  bodies  may  be  gall-stones  which  have  ulceratetl  their  way  into 
the  intestinal  tract;  intestinal  concretions  (enieraliihs),  composed  of  phosphate 
of  lime  and  hardened  feces,  often  with  some  indigestible  material  as  a  nucleus; 
and  foreign  bodies  which  have  been  swallowed.  The  scat  of  obstruction  is 
usually  in  the  lower  ileum,  because  of  tlK*  smaller  cab1)re  of  this  portion  of 
the  boweL     Impackd  Jtccs  also  may  be  included  under  this  heading. 

4,  Intussusception  is  the  telescoping  of  one  part  of  the  intestine  into  the 
segment  l>eIow,  The  swallowe<l  portion  is  called  the  intussuseeptum,  the 
swallowing  segment  the  iniussuscipiens  (Fig.  385).  The  cause  is  irregular 
peristalsis^  &(^metimes  induced  by  polypoid  tumors  or  other  form  of  irrita- 
tion.  The  author  has  had  two  cases  of  traumatic  origin.  As  the  peritoneal 
surfaces  of  the  entering  and  returning  layers  of  the  intussusccplum  tend  to 
adhere,  and  the  mucous  surface  of  the  returning  layer  readily  slips  over  the 
mucous  surface  of  the  intussuscipiens,  the  intussusception  elongates  at  the 
expense  of  the  intussuscipiens  and  the  apex  is  always  represented  by  the 
same  piece  of  bowel.  The  mesenter>^  is  drawn  down  between  the  layers 
of  the  intussusceptum,  hence  is  stretched,  bunched^  and  constricted.     The 


472  ABDOMEN. 

circulation  is  further  impeded  by.  inflammatory  exudation,  and  this  leads 
to  desquamation  of  the  mucous  membrane  ^ence  blood  and  shreds  in 
the  stools),  and  finally  to  strangulation  and  gangrene.  Intussusception 
is  responsible  for  39  per  cent,  of  tiie  cases  of  intestinal  obstruction.  There 
are  two  clinical  varieties,  the  acute  (sudden  and  complete  obstruction), 
which  is  most  frequent  in  young  children,  and  the  chronic^  which  is  more 
common  in  adults.  The  anatomical  varieties,  in  the  order  of  their  frequency, 
are  the  ileocecal  (44  per  cent.),  in  which  the  ileocecal  valve  and  ileum  pass  in- 
to the  colon,  the  enteric  (30  per  cent.),  usually  involving  the  jejunum,  the 
colic  (18  per  cent.),  involving  the  colon  alone,  and  the  ileocolic  (8  per  cent.). 
in  which  the  ileum  passes  through  the  ileocecal  valve. 

5.  Stricture  of  the  intestine  may  be  congenital  (p.  468)  or  acquired 
(cicatricial,  neoplastic,  compression,  or  spastic).    Cicatricial  strichire  of  the 
small  intestine  is  usually  caused  by  tuberculous  ulcers,  that  of  the  colon  by 
dysentery,  that  of  the  rectum  by  syphilis  or  pelvic  cellulitis.     Cicatricial 
stenosis  may  occur  also  after  injury,  diverticulitis,  strangulated  hernia,  or 
intestinal  anastomosis.     It  is  rare  after  typhoid  fever,  as  the  ulcers  in  this 
disease  are  longitudinal.     Intestine^  tumors  when  benign  (fibroma,  myxoma, 
lipoma,  or  adenoma),  often  project  into  the  intestine  as  polyps,  but  seldom 
cause  obstruction,  imless  there  is  a  Idnk  in  the  bowel  or  unless  they  induce  an 
intussusception.     Sarcoma  is  rare  and  usually  attacks  the  small  intestine. 
Carcinoma  is  the  most  frequent  tumor  and  occurs  more  often  in  the  large 
bowel  (95  per  cent,  of  the  cases),  especially  at  the  flexures  and  in  the  rectum. 
It  is  cylindrical-celled,  usually  annular,  and  involves  the  lymph  glands  later 
than  carcinoma  elsewhere.     Tumors  of  the  intestine  are  seldom  suspected 
until  there  is  partial  or  complete  interruption  of  the  fecal  circulation.     Com- 
pression of  the  bowel  is  caused  by  extraintestinal  lesions,  such  as  tumors,  C3rsts, 
abscesses,  etc.,  by  prolapse  of  other  abdominal  viscera,  or  by  the  superior 
mesenteric  vessels  (see  acute  dilatation  of  the  stomach).    Spastic  ileus  is  due 
to  tetanic  contraction  of  a  segment  of  intestine.     It  may  be  caused  by  lead 
poisoning,  irritating  intestinal  contents,  hysteria  (see  phantom  tumor),  and 
trauma,  hence  occasionally  follows  abdominal  operations.     It  is  the  first 
step  in  the  development  of  many  cases  of  intussusception. 

Intestinal  paralysis,  adymamic  ileus,  or  pseudoobstructiony  is  most  fre- 
quently caused  by  peritonitis,  but  it  occurs  also  in  enteritis,  acute  pancre- 
atitis, thrombosis  or  embolism  of  the  mesenteric  vessels,  biliary  and  renal 
colic,  strangulation  of  the  omentum,  injury  to  the  ovary  or  testicle,  in  diseases 
of  the  central  nervous  system,  and  as  a  terminal  event  in  other  maladies, 
particularly  those  accompanied  by  delirium  or  coma.  That  form  occurring 
after  abdominal  section,  not  due  to  peritonitis,  is  caused  by  the  sudden  relief 
of  chronic  pressure  (e.g.,  the  removal  of  a  large  tumor)  or  by  undue  handling 
of  the  intestines. 

The  pathological  changes  in  the  bowel  above  the  obstruction  are  dilata- 
tion, congestion,  and,  if  the  obstruction  lasts  long  enough,  hypertrophy  of  the 
muscular  coat  and  ulceration  of  the  mucosa,  the  last  of  which  may  lead  to 
perforative  peritonitis,  abscess  formation,  or  fecal  fistula.  Below  the  obstruc- 
tion the  gut  is  pale,  empty,  and  contracted.  At  the  site  of  obstruction  the 
intestine  may  be  gangrenous  from  strangulation  (see  strangulated  hernia), 
ulcerated  from  the  pressure  of  foreign  bodies,  bands,  ptc,  or  exhibit  simply 
the  changes  incident  to  the  causative  lesion,  e.g.,  in  neoplastic  and  cicatricial 
stricture. 


DIAGNOSIS   OF   OBSTRUCTION. 


473 


The  symptoms  of  iatestinal  obstruction  differ  somewhat  according 
to  whether  the  obstruction  is  acute  or  chronic.  In  acute  obstruction,  in 
which  the  lumen  of  the  bowel  is  suddenly  and  completely  closed,  e.g.,  in 
volvulus,  acute  intusi^usception,  and  strangulation  by  bands,  ailhesions,  or 
apertures,  there  are  sudden,  severe,  colicky,  abdominal  pain,  which  is  some- 
limes  relieved  by,  but  is  often  worse  after,  pressure;  shocky  which  is  more 
severe^  the  more  sudden  the  onset,  the  higher  the  obstruction,  the  tighter  the 
strangulation,  and  the  greater  the  amount  of  bowel  involved;  vomiting,  first  of 
the  contents  of  the  stomach,  then  of  bilious  material,  ami  finally  of  stercor- 
aceous  tluid;  and  consiipalioftf  which,  if  the  lower  bowel  is  empty^  becomes 
absolute,  not  even  gas  being  expelled.  The  intestine  above  the  obstruction 
becomes  greatly  distended,  and  is  the  seat  of  violent  peristaltic  movements, 
whicJi  may  often  be  seen,  felt,  and  heard.  Rigidity  of  the  abdominal  muscles 
is  absent  until  the  advent  of  peritonitis.  The  urine  is  lessened  in  amount  and 
contains  an  excess  of  indican.  The  shock  passes  after  a  time,  but  the  pulse 
remains  rapid,  and  the  temperature  does  not  rise  above  normal  until  perit- 
onitis supervenes,  when  all  the  symptoms  of  this  affection  ensue.  If  un- 
relieve*!,  acute  obstruction  usually  causes  death  within  a  week,  as  the  result  of 
peritonitis  {gangrene  or  perforation  of  intestine),  exhausdon,  or  interference 
with  the  intrathoracic  organs  from  tympanites.  Although  rare,  spontaneous 
recovery  is  possible;  thus  a  fistula  may  connect  the  bowel  above  and  below  the 
oljstruction  or  empty  externally,  a  foreign  body  may  pass,  a  kink  be  straight- 
ened, or  the  invaginated  portion  of  an  intussusception  may  slough  and  sepa- 
rate. In  chronic  obstruction  there  is  gradually  increasing  constipation 
and  abdominal  uneasiness,  which  is  often  attributed  to  intestinal  indigestion. 
At  irregular  intervals  there  are  colicky  pain,  obstinate  constipation,  ab- 
dominal distention,  visible,  audible,  and  palpable  peristalsis,  anil  vomiting; 
the  last,  however,  is  often  absent  in  stricture  of  the  colon  until  the  obstruction 
becomes  complete.  Purgatives  often  dislodge  the  impacted  food  or  feces 
resportsible  for  the  transient  obstruction.  Diarrhea  may  thus  alternate  with 
constipation.     Finally  acute  and  complete  obstruction  ensues. 

The  diagnosis  is  seldom  difficult,  but  the  seat  and  cause  are  often  un- 
determined until  an  explorator>^  incision  has  been  made.  Intestinal  paraly- 
sis differs  from  obstruction  in  the  absence  of  peristalsis,  and  the  presence  of 
the  symptoms  of  the  causative  lesion,  both  before  and  after  the  onset  of  ob- 
structive symptoms;  thus  in  peritonitis  there  will  be  fever,  rigidity,  leukocyto- 
sis, etc.  The  srai  of  obsiructitm  may  occasionally  be  located  by  the  paJpation 
of  a  mass  through  the  rectum,  vagina,  or  abdominal  wall,  or  by  the  situation 
of  the  pain  or  tenderaess.  The  greater  the  distention,  the  later  the  vomiting 
of  stercoraceous  material,  and  the  larger  the  amount  of  urine  excreted,  the 
lower  in  the  intestine  is  the  obstruct  ion.  When  the  central  portion  of  the 
abdomen  alone  is  distended,  the  lesion  is  above  the  ileocecal  valve;  when  both 
loins  also  are  distended,  the  obstruction  is  in  the  sigmoid  or  rectum;  and 
when  the  right  loin  is  greatly  distended  the  transverse  colon  is  involved.  Ten- 
esmus generally  indicates  a  lesion  of  the  large  bowel.  Rectal  injections  of 
air  or  water  for  the  purpose  of  diagnosis  are  not  recommended.  It  is  said  thai 
if  six  quarts  of  water  can  be  introduced,  the  obstruction  is  m  the  small  intes- 
tine; if  but  a  pint  or  quart,  in  the  rectum  or  sigmoid.  The  cause  of  ohslruc- 
Hon  may  be  an  external  hertiia,  which  must  first  be  excluded  in  all  cases;  if 
such  be  found  and  be  irreducible,  it  should  be  investigated  by  incision.  If  a 
hernia  has  been  replaced  and  the  symptoms  continue,  the  possibility  of  a 


ABDOMEN, 

reductwn  m  bhr,  i.e.,  reduction  without  ihc  rdief  of  strangulation,  shou 
recallet-L  Severe  collapse  indicates  a  light  strangulation.  The  prcv 
histor>'  should  be  elicited,  particularly  with  reference  to  biliary  colic,  chronic 
constipation y  peritonitis,  abdominal  operations,  tuberculosis,  syphilis, 
dysentery,  and  pelvic  disorders.  Volvulus  is  tnost  common  in  later  life,  is 
generally  ver>'  sudden  in  onset,  is  often  preceded  by  chronic  const ipadoo, 
and  may  sometimes  be  recognized  by  the  presence  of  a*  rounded  tympanitic 
tumor  in  the  region  of  the  sigmoid  when  this  structure  is  involved.  Foreign 
bodies  generally  cause  intermittent  or  chronic  obstmction  at  first,  an<i  may  in 
some  instances  be  localized  by  palpation  and  the  X-ray.  FecaJ  impacii&m  b 
most  common  in  old  ladies  with  chronic  constipation.  The  mass  is  generally  id 
the  colon,  and  may  sometimes  be  felt  and  indented  with  the  fingers.  Intui- 
suscepiioft  is  most  common  in  children,  sometimes  follows  a  straining  diarrhea, 
and  is  usually  associated  with  tenesmus  and  the  passage  of  blood  and  mucus 
It  can  often  be  felt  in  the  region  of  the  ascending  colon,  as  an  elongated 
tumor  which  becomes  harder  and  more  prominent  with  each  recurrence  of 
the  griping  pain.  In  some  cases  the  apex  of  the  intussusceptum  may  be 
felt  in  the  rectum.  Distention  is  not  marked,  and  stercoraceous  vomiting  b 
not  as  common  as  in  some  other  forms  of  obstruction.  The  right  iliac  fossa 
may  feel  empty,  the  bowel  in  this  region  having  passed  along  the  colon.  In 
stfkhire  the  symptoms  are  at  first  those  of  chronic  obstruction;  as  the  con- 
tents of  the  small  bowel  are  liquid,  however,  the  fecal  current  may  suffer  no 
interruption  until  its  lumen  is  almost  totally  occluded.  In  stricture  of  the 
large  bowel,  the  stools  may  be  deformed  or  diminished  in  calibre.  After 
giving  bismuth  by  mouth  or  rectum  (p.  458)  the  stricture  may  show  in  askia* 
graph;  with  the  tluoroscope  its  progress  along  the  intestine  can  be  kept 
un  tier  co  n  1 1  n  uo  u  s  ol  j  s  e  r  v  atio  n ,  Incarc  ino  m  a  bl  00  d ,  m  uc  u  s,  a  nil  o  c  c  asio  n  ally 
fragments  of  the  growth  may  be  found  in  the  stools;  the  tumor  can  be  felt  in 
40  per  cent,  of  tlie  cases;  the  patient  is  usually  over  40,  but  it  should  be  re- 
called that  before  30  carcinoma  is  more  frequent  in  the  colon  than  in  other 
situations,  and  that  cachexia  is  often  aljsent  until  the  growth  diffuses  itself 
over  the  abdominal  cavity. 

The  treatment  is,  with  few  exceptions,  abdominal  section.  While  prep- 
arations are  being  made  for  operation,  morphin  should  be  given  hypoder- 
matically  to  quiet  peristalsis,  the  stomach  emptied  by  lavage,  and  the  rectum 
evacuated  by  an  enema  unless  such  has  alread)-  l>een  done.  Purgatives  are 
contraindicated.  In  tlie  absence  of  a  definite  diagnosis  as  to  the  point  of 
obstruction,  the  abdomen  should  be  opened  in  the  median  line  below  the 
umbilicus.  If  the  cecum  is  distended,  explore  the  sigmoid;  if  the  sigmoid  is 
collapsed,  the  obstruction  is  in  the  large  bowel  between  it  and  the  cecunit 
If  the  cecum  is  collapsed,  it  will  be  necessary  to  follow  the  small  bowel  until 
the  obstruction  is  found.  Another  rule  is  to  select  the  most  dilated  and  con- 
gested coil  of  liowel  and  follow  it  in  the  direction  of  the  increasing  congesuon 
and  distention.  In  the  most  urgmt  cases  no  attempt  should  be  made  to  find 
the  seat  of  obstruction,  but  tlie  abdomen  shotdd  be  opened  under  local 
anesthesia,  and  an  artificial  anus  established  in  the  llrst  presenting  distended 
coil  of  intestine.  Before  or  after  dealing  with  the  obstruction,  particularly 
in  late  cases  in  which  peristalsis  is  feeble  or  absent,  the  great  distention  should 
be  relieved  by  incising  one  or  more  coils  of  intestine  and  allowing  the  con- 
tents to  escape,  subsequently  suturing  the  wounds.  The  obstruction  itsdf 
is  dealt  with  according  to  its  cause.     AiUteswns  are  separated,  and  bands 


TNTESTINAt   LOCALIZATTON. 


47$ 


divided  between  ligatures,  making  sure  that  such  liand  is  not  a  Mtikers 
diverlkuiiifti,  which  should  be  excised  in  the  same  way  as  the  appendix,  A 
vokmlus  should  be  untwisted,  and  foreign  bodies  removed  by  enterotomy 
after  displacing  the  body  upwards  to  a  more  healthy  portion  of  the  IjoweL 
Gangrene  of  the  bowel  necessitates  resection  or  extraperitoneal  isolation  of 
the  aflfected  segment.  Fecai  impaiiioti  is  treated  by  copious  enemata.  mas- 
sage, and  laxatives.  When  situated  in  the  rectum  the  mass  may  be  broken 
up  with  the  finger  Purgatives  are  rontraindicated  if  the  Ijowel  is  inliamed. 
During  the  first  twenty -four  hours  intussuscepimt  may  be  treated  by  the 
administration  of  opium  and  belladonna',  and  the  injection  of  air  or  water 
into  the  rectum.  If  water  is  used,  the  reservoir  should  be  about  two  feet 
above  the  pelvis,  which  also  is  elevated  about  a  foot,  the  patient  being  anes- 
thetized. At  a  later  period  this  treatment  may  be  flangerous  because  of 
the  presence  of  gangrene  of  the  bo  web  If  injections  fail  or  if  the  patient 
comes  under  observation  after  twenty-four  hours,  operation  should  be 
performed  at  once.  The  intussusception  is  reduced,  not  by  traction,  but  by 
milking  or  pressing  the  intussusceptum  upwards.  It  has  been  suggested, 
both  in  intussusception  and  volvulus,  to  shorten  the  mesentery  or  suture  the 
bowel  to  the  abdominal  wall,  in  order  to  prevent  recurrence,  When  reduc- 
tion is  impossible,  i.e.,  in  half  tihe  cases,  the  bowel  may  be  resected  (see 
MaunselPs  method),  a  lateral  anastomosis  made  between  the  bowel  above 
and  below  the  intussusception,  or  an  artificial  anus  established.  In  children 
the  mortality  is  between  30  and  40  per  cent,  when  reduction  is  easy,  and 
over  go  per  cent,  when  reduction  is  impossihle.  Strkture  qf  i/if  inksthte  is 
treated  by  enterectomy,  with,  if  tJie  disease  be  malignant,  a  V-shaped  por- 
tion of  the  mesenter)'  and  the  lymph  glands.  In  urgent  cases  an  artificial 
anus  should  be  established,  and  the  excision  performed  at  a  later  period. 
When  the  growth  is  irremovable,  the  intestine  aljove  and  below  may  be  united 
by  lateral  anastomosis;  the  bowel  may  be  divided  above  the  gro%^  and 
implanted  in  the  gut  below,  the  lower  end  of  the  divided  bowel  being  closed 
by  sutures;  or  the  diseased  bowel  may  be  excluded  from  the  fecal  circulation 
(see  exclusion  of  iniestinc).  Inksiinai  paralysis  when  of  severe  tlegree  is 
generally  fatab  An  artificial  anus  may  be  established,  but  usually  does  not 
drain  more  than  the  coiJ  in  which  it  is  made.  The  stomach  should  be  washed 
out,  a  tube  passed  into  the  colon,  and  str}'chnin  and  eserin  given  hypoder- 
matically.  Large  doses  of  atropin  may  be  of  .some  value  in  this  aflection,  as 
well  as  in  spastic  Urns, 


OPERATIONS  ON  THE  INTESTINES. 


Intestinal  Localization. — The  large  intestine  is  differentiated  from  the 
small  intestine  by  its  mesenteric  atlachment,  greater  size,  longitudinal  bands, 
sacculations,  and  by  its  appendices  epiploica*.  The  method  for  finding  the 
upper  end  of  the  jejunum  is  given  on  page  464.  In  order  to  determine  the 
situation  and  direction  of  a  loop  of  intestine,  the  following  facts,  according  to 
Monks,  are  of  great  value:  The  average  length  of  the  small  intestine  is 
twenty-one  feet.  The  upper  third  occupies  the  left  hypochondrium  {duode- 
num excluded);  the  middle  third,  the  middle  section  of  the  abdomen;  the 
lower  third,  the  pehic  and  right  iliac  regions.  The  intestine,  from  above 
downwards,  decreases  in  size  and  thickness,  becomes  le  opssaque,  has  smaller 


476  ABDOMEN. 

vessels,  which  are  nearer  together,  and  changes  in  color  from  bright  pink  or 
red  to  pinkish  or  yellowish  gray.  In  the  upper  jejunum  large  and  numerous 
valvulae  conniventes  may  be  felt,  but  are  imperceptible  beyond  the  fourteenth 
to  the  sixteenth  foot.  The  fixation  of  the  two  ends  of  the  intestine  may  be 
felt;  and  the  consistency  of  the  contents  increases  from  above  downwards. 
The  mesentery  is  thin  and  transparent  at  the  upper  part,  thick  and  opaque  in 
the  lower  third.  The  lunettes  between  the  vessels  are  perceptible  in  the 
upper  eight  feet  or  more,  but  cannot  be  seen  in  the  lower  third.  Tabs  of  fat  ex- 
tending onto  the  intestine  begin  to  appear  at  about  the  fourteenth  foot  and 
become  more  and  more  prominent.  In  the  upper  third  the  mesenteric  ves- 
sels are  large  and  far  apart,  form  primary  loops  as  far  as  the  fourth  foot 
when  secondary  loops  appear,  and  give  off  long,  regular,  unbranching  vasa 
recta  to  the  intestine.  In  the  lower  third  the  mesenteric  vessels  are  small 
and  close  together,  have  many  loops  often  obscured  by  fat,  and  give  off 
small,  short,  and  irregular  vasa  recta.  The  root  of  the  mesentery  is  to 
the  left  of  the  median  line  above,  to  the  right  below.  If  a  loop  of  bowel  is 
placed  parallel  with  the  root  of  the  mesentery,  the  upper  end  will  be  nearer 
the  duodenum,  providing  there  is  no  twist  in  the  mesentery. 


Fig.  386. — Lembcrt  suture.  Vic  387. — Czemy-Lembcrt 

(Binnie.)  suture.     (Binnie.) 

Enterotomy  signifies  an  incision  into  the  intestine  for  the  purpose  of  re- 
moving a  foreign  body  or  for  exploration.  A  longitudinal  incision  is  made 
opposite  the  mesentery,  and  the  wound  closed  with  Czemy-Lembert  sutures. 

Enterorrhaphy,  or  suture  of  the  intestine,  is  performed  with  a  fine 
straight  round  needle  and  fine  silk  or  celluloid  thread.  It  is  essential  that 
the  wound  be  air-tight,  and  that  the  edges  be  inverted  so  that  serous  mem- 
brane shall  come  in  contact  with  serous  membrane.  The  Lembert  suture 
(Fig.  386)  is  placed  at  right  angles  to  the  wound.  The  needle  is  inserted 
about  one-fourth  inch  from  the  edge  of  the  wound,  goes  down  to  and  throu^ 
the  submucous  coat  but  not  through  the  mucous  membrane,  is  brought  out 
one-eighth  inch  from  the  edge  of  the  wound,  and  is  inserted  in  a  similar  man- 
ner on  the  opposite  side,  so  tifiat  when  tied  the  edges  of  the  wound  are  inverted. 
The  stitches  are  about  one-eighth  of  an  inch  apart.  The  Czemy-Lembert 
suture  (Fig.  387)  consists  of  a  deep  suture  going  through  all  the  coats  of  the 
bowel  and  a  superadded  Lembert  suture.  Either  or  both  of  these  sutures  may 
be  interrupted  or  continuous.  When  using  a  suture  going  through  all  coats 
it  is  belter  to  place  the  knot  within  the  lumen  of  the  bowel  and  to  use  catgut. 
The  Ilalstead  mattress  suture  is  shown  in  Fig.  388  and  the  Gushing  right  angle 
suture  in  Fig.  389;  both  these  sutures  are  inserted  with  the  precautions  u^ 
in  employing  the  Lembert  suture. 

Enterostomy  is  the  making  of  an  opening  into  the  intestine  in  order  to 


COLOSTOMY. 


*477 


feed  a  patient  or  to  drain  away  the  contents  of  the  intestine  {arlificml  anus) ; 
according  to  the  situation  of  the  opening  the  operation  is  called  duodenos- 
tomy,  jejunoslomy,  or  colostomy. 

Duodenostomy  or  jejunostomy  is  OLcasionally  performed  to  give  rest 
to  the  stomach  in  cases  of  gastric  hemorrhage,  and  to  feeii  the  patient  in 
gastric  cancer  when  a  gastroenterostomy  is  inappiicai>le.  As  the  idea  is  to 
introduce  food  and  prevent  the  escape  of  intestinal  contents,  the  principles 
used  in  the  Stamm-Karler  gastrostomy  should  be  employed. 

Coiostomy,  or  colotomy,  as  it  is  sometimes  called,  is  commonly  em- 
ployed for  the  relief  of  obstruction,  and  occasionally  for  the  purpose  of  giv- 
ing the  large  bowel  rest  and  allowing  irrigation  in  cases  of  chronic  dysentery 
or  other  severe  ulcerative  lesions.  Irrigation  of  the  colon,  without  diversion 
of  the  fecal  current,  is  best  performed  through  the  appendix  after  append i- 
costomy  (p.  488),  or  when  this  is  not  possible,  because  of  stricture  of  the 
appendix,  through  a  valvular  opening  in  the  colon,  which  is  made  in  the 
same  way  as  the  Stamm-Kader  gastrostomy,  but  which  in  this  region  is 


n 


^^ 


Fig .  38*^ .      ]  J , ; !  - ;  r .Lil  mat t res-s  sutu re 
(M'iuimI  .I'll!  Van  verts.) 


Frc.  389.— Cushing's  suture. 
(Binnic.) 


called  Gibson^ s  operaihm.  An  artificial  anus  should  never  be  made  in  the 
small  intestine  when  such  can  possibly  be  avoided,  because  of  the  inter- 
ference  witli  nutrition,  which  is  more  marked  the  higher  the  opening,  and 
because  of  the  digestive  effect  of  the  intestinal  juices  on  the  skin.  The 
operation  is  performed  in  the  same  manner  as  colostomy.  The  large  bowel 
may  be  opened  in  either  inguinal  region  or  in  either  lumbar  region.  In  lum- 
bar  colostomy  the  large  bowel  is  approached  extraperitoneally  through 
the  loin.  1  he  operation  has  been  abandoned,  liecause,  as  compared  with 
iliac  colostomy,  it  is  more  ditlScult,  does  not  completely  divert  the  feces,  and 
the  resulting  opening  is  not  well  situated  for  cleanliness. 

Inguinal  colostomy  {Litire-Maydi  o^craiion)  may  be  done  on  either  side, 
but  the  left  side  is  chosen  whenever  possible.  An  incision,  two  or  three 
inches  long,  is  made  at  right  angles  to  a  line  drawn  from  the  anterior  superior 
spine  to  the  umbilicus,  its  middle  crossing  this  line  at  the  junction  of  the  outer 
and  middle  thirds.  A  loop  of  the  colon  is  pulled  into  the  wound,  the  upper 
limb  of  the  loop  being  made  taut  in  order  to  prevent  subsequent  prolapse, 
and  the  gut  fastenefl  by  passing  a  glass  rod  through  the  mesenter}^  and  sutur- 
ing the  parietal  peritoneum  and  then  the  skin  to  the  bowel.     Instead  of  the 


ABDOMEN. 


glass  rod,  gauze  or  other  material  may  be  used,  or  the  middle  of  the  skin 
incision  may  be  united  beneath  the  bowel  The  bowel  is  opened  with  scis- 
sors or  cauter>%  at  the  end  of  two  or  three  days,  after  protecting  adhedon> 
have  formed;  no  anesthetic  is  required.  If  the  artificial  anus  is  to  be  tern- 
porar>'  the  incision  should  be  longitudinal;  if  permanent,  transverse^  but 
the  gut  should  not  be  completely  divided  for  a  week  or  ten  days,  UTicn 
immediate  opening  of  the  intestine  is  mandatory,  there  is  considerable  risk 
of  infecting  the  peritoneal  cavity  with  fcies.  The  author  prevents  this  in  the 
following  manner:  The  loop  of  bowel  is  emptied  by  pressure,  and  a  damp 
placed  at  each  extremity,  the  whole  being  surrounded  by  gauze.  One- half 
of  a  Murphy  button  is  inserted  into  the  empty  loop  of  intestine  through  a 

small  incision,  and  the  other  half 
is  squeezed  into  the  end  of  a  long 
rublier  tube  whose  calibre  b 
slightly  smaller  than  that  of  the 
Oange  of  the  button,  thus  mak* 
ing  a  tight  joint  (Fig.  39c).  The 
two  halves  of  the  button  arc  then 
pressed  together,  or  in  other 
words  a  lateral  implantation  is 
made  between  the  rubber  lube 
anrl  the  boweL  The  feces  drain 
through  the  rubber  tube  into  * 
ret  cptacle  on  the  floor.  By  the 
lime  the  button  has  sloughed 
through  the  bowel,  i.e.,  at  the 
end  of  two  or  three  days,  adhe- 
sions will  have  closed  the  perito- 
neal cavity.  The  bowels  should 
move  once  or  t^ice  a  day»  Que 
anus  being  closed  at  other  times 
by  a  hollow  rubber  bulb,  shaped 
somewhat  like  a  dumb-bell;  one 
end  is  placed  in  the  intestine  and  the  bulb  is  then  distended  with  air. 
The  opening  may  be  provided  with  a  more  or  less  satisfactorv^  sphincter 
by  drawing  the  bowel  through  the  split  rectus  muscle  or  through  a  McBumcy 
incision  (p.  487), 

Operative  closure  of  the  artificial  anus  will  be  required  in  those  cases 
in  which  the  condition  for  which  it  has  been  established  has  been  remove<b 
The  opening  in  the  bowel  is  disinfected  with  carbolic  acid,  stuffed  with  gauze, 
and  closed  unth  sutures.  The  abdomen  is  then  carefully  scrubbed,  and  opened 
by  an  ellipitcal  incision  surrounding  the  anus,  the  involved  segment  of 
bowel  being  reset  ted,  and  the  fecal  circulation  re-established  by  an  end-to-end 
anastomosis.  In  many  cases  the  lower  segment  will  be  so  contracted  that 
the  surgeon  will  prefer  a  lateral  anastomosis.  An  old  and  dangerous  method 
is  to  apply  a  clamp  to  the  spur  between  the  segments  and  leave  it  in  position 
until  the  spur  sloughs,  the  external  opening  then  being  closed  by  suture,  A 
fecal  listula  differs  from  an  artilkial  anus  in  that  only  a  portion,  and  not 
all,  of  the  intestinal  contents  escape  through  the  abnormal  opening.  It 
may  follow  injun%  ulceration,  strangulation,  and  malignant  tumors  of  the 
Ijowel,  f>r  inflammatory  lesions  of  the  abdominal  cavity  secondarily  inv*oI\iiig 


Fig.  5go. — Immediate  entemslomy. 


INTESTINAL  ANASTOMOSIS. 


479 


the  bowd.  Occasionally  a  fecal  fistula  is  deliberately  established  by  the 
surgeon.  \\Tien  of  large  size  it  requires  the  same  treatment  as  artificial 
anus.  Smaller  fistulfts  particularly  in  the  large  Ijowel,  often  close  sponta- 
neously. If  the  tract  is  lined  i>y  mucous  membrane,  this  should  be  destroyed 
with  the  cauter)\  Wlien  opening  into  the  small  bowel,  even  minute  fistulie 
sometimes  refuse  to  heal,  In  these  cases  the  external  opening  should  be 
treated  as  mentioned  above  for  artificial  anus,  the  tract  dissected  out,  and 
the  opening  in  the  bowel  closed  by  suture.  When  the  above  methods  are 
inapplicable  or  inadnsable,  exclusion  of  the  intestine  may  be  performc<l 
{?■  483), 

Enterectomy,  or  resection  of  the  intestine,  is  performed  for  many  condi- 
tions, of  which  the  follo^\ing  are  the  most  important:  gangrene,  extensive 
injury,  tumors,  artificial  anus,  cicatricial  stenosis,  tuf>erculosis.  and  injury 
to  the  vessels  supplying  the  segment  of  bowel  The  portion  of  gut  to  be 
removed  is  drawn  from  die  body,  and  the  peritoneal  cavity  protected  by 
gauze  packing.  The  loop  is  emptied  by  stripping  widi  the  fingers,  and 
rubber-coated  clamps  placed  on  the  bowel  on  each  side  of  the  proposed  inci- 
sions, i.e.,  four  clamps  are  used.  In  the  absence  of  intestinal  clamps,  gauze 
or  rubber  tubing  may  be  tied  around  the  bowel.  The  mesentery  is  then 
ligated  in  sections,  a  short  distance  from  the  bowel,  and  divided;  in  malig- 
nant disease  particularly,  a  V- shaped  portion  of  the  mesentery  is  removed, 
great  care  being  exercisetl  not  to  cut  off  the  filood  supply  of  the  bowel  which 
is  to  remain.  The  bowel  is  divided  somewhat  obliquely,  removing  more  at 
the  free  than  at  the  mesenteric  border^  in  order  to  give  a  greater  circumference, 
and  to  assure  a  gooti  blood  supply  to  the  antimesenteric  portion.  The  ends 
are  united  by  end-lo-end  anastomosis,  or  they  are  closed  by  sutures  and  a 
lateral  anastomosis  performed.  The  opening  in  the  mesentery  is  closed, 
an<l  any  excess  folded  and  held  in  place  by  sutures. 

End-to-end  anastomosis,  or  rircsilar  enicrorrhaphy,  may  be  performed 
by  simple  suturing  or  witli  the  aid  of  special  apparatus.  Simpk  suturing  is 
always  to  be  preferred  when  time  is  not  too  pressing.  The  best  [>lan  is  to 
bring  the  clamps  together  as  in  gastroenterostomy  (Fig.  378I,  suture  the 
apposed  peritoneal  surfaces,  paying  s[>ecial  attention  to  the  mesenteric 
border  as  describetl  below,  and  then  to  finish  the  operation  like  a  gas- 
troenterostomy. If  this  is  not  done  the  ends  of  the  intestine  may  be 
brought  together  and  two  sutures  inserted  on  opposite  sides  of  the 
bowel,  each  midway  between  the  free  border  and  the  mesenteric  attach- 
ment. These  sutures  are  left  long  and  hehl  liy  an  assistant,  in  order 
to  act  as  guides.  A  third  suture  is  now  inserted  at  the  mesenteric  bor- 
der (Fig.  391),  so  as  to  obliterate  the  space  normally  present  between 
the  layers  of  the  mesenter>'  at  this  point.  The  two  segments  are  now  united 
by  a  continuous  suture  of  catgut,  passing  through  all  the  coats  in  order  to 
secure  firm  apposition  and  stop  bleeding-  xAfter  the  posterior  margins  have 
been  unitetl,  the  suture  may  be  instated  like  a  Cushing  right  angle  suture, 
except  that  it  passes  through  all  the  coats  (Fig.  392).  This  layer  of  sutures 
is  buried  by  a  continuous  Lembert  or  Cushing  suture  of  silk,  extending 
around  the  whole  circumference  of  the  anastomosis.  It  is  well  to  insert  an 
extra  suture  at  the  mesenteric  insertion  as  shown  in  Fig.  393.  WTien  the 
ends  of  the  bowel  are  of  unequal  size,  the  larger  opening  may  be  partly  closed 
by  sutures,  or  the  smaller  end  may  be  cut  obliquely  and  the  larger  transversely; 
under  these  circumstances,  however,  it  is  much  belter  to  close  both  ends  and 


480  ABDOMEN. 

perform  a  lateral  anastomosis.  In  MaunseWs  operation  the  ends  of  the  gut 
are  first  united  by  two  sutures,  one  at  the  mesenteric  and  one  at  the  free 
border,  the  knots  being  placed  within  the  lumen  and  the  sutures  left  long. 
A  longitudinal  incision  is  then  made  in  the  free  margin  of  the  segment  of 
bowel  with  the  larger  diameter,  about  an  inch  from  its  end.  These  sutures 
are  drawn  out  through  the  lateral  opening  (Fig.  394)  and  by  traction  an 
artificial  intussusception  is  produced  (Fig.  395).  The  edges  of  the  protruded 
intussusception  are  united  by  sutures  passing  through  all  the  coats  of  the 


Fig.  391.  -MescnUTic  stiUh. 


Fig.  392. 


-wpat>JTeHV 


SUTURES 


Fk;.  .^93. 


Fir.s.  394  and  395. — Maunscir> 
operation. 


bowel,  the  intussusception  reduced,  and  the  longitudinal  opening  closed  by 
Lembert  sutures.  The  union  may  be  reinforced  by  an  extra  layer  of  Lembert 
sutures. 

Of  the  many  forms  of  special  apparatus  which  have  been  suggested  to 
facilitate  end-lo-cnd  anastomosis,  the  Murphy  l)Ulton  remains  the  premier 
and  alone  will  be  described.  The  button  consists  of  two  hollow,  flangeil. 
metallic  cylinders.  When  one  cylinder  is  in.serted  into  the  other  and  pressed 
home  the  llanges  cannot  be  separated  except  by  unscrewing,  there  being  two 
spring  catches  (S.  S.  Fig.  396)  on  opposite  sides  of  the  smaller  cylinder,  and 
a  screw  thread  in  the  interior  of  the  larger.  In  one-half  of  the  button  there 
is  an  additional  llange  (P.  Fig.  396)  separated  from  the  first  by  a  spring 
(C\  Fig.  396).  which  exercises  constant  pressure  on  the  bowel,  and  thus  in- 
duces necrosis  and  liberates  the  button,  the  segments  of  bowel  having  in  the 
meantime  united.  A  purse-string  suture  is  inserted  into  each  end  of  the 
divided  intestine  as  shown  in  Fig.  397.  special  attention  l)eing  given  to  the 
mesenteric  insertion  so  that  it  will  be  included  within  the  grasp  of  the  button. 


INTESTINAL  ANASTOMOSIS. 


4S1 


One-half  of  the  button  is  inserted  Into  the  open  ^nd  of  each  segment  of 
bowel  and  the  pyrse-string  suture  drawn  tight  and  tied  (Fig.  398).  Any 
excess  of  mucous  membrane  is  cut  off  and  the  two  halves  of  the  button  pressed 
together.  The  button  should  be  passed  with  the  feces  in  from  two  to  three 
weeks.  The  disadvantages  of  the  button  are  that  it  is  a  foreign  body  which 
may  become  impacted  or  retained,  producing  obstruction  or  ulceration  of  the 
bowel,  and  that  its  use  may  be  followed  by  leakage,  the 
result  of  a  sprea<iing  of  the  necrosis  which  it  necessarily 
induces.  The  button  should  always  be  tried  before  oper- 
ation, as  many  are  defective  in  construction.  For  the 
above  reasons  it  should  be  used  only  when  great  speed  is 
desired. 

Lateral  anastomosis  is  performed  to  short -circuit  a 
portion  of  the  intestinal  canal,  and  sometimes  instead  of 
end-to-end  anastomosis  after  resection  of  the  Ijowel, 
The   advantages  over  end-to-end   anastomosis  are  that 


Fio.  396.— Murphy  button.     .\.  Malt-  half;  H,  female  half. 
The  rmiud  holes  are  for  drainage. 


Fli;.  ^ty;.— Pursr- 
^tring  -siiturc  (6)  run- 
ning  over  edjj^e  of 
btnvel  and  closing 
spare  between  mc*- 
enlerir'  {c)  at  a. 


broader  contact  of  the  serous  surfaces  can  be  secured  without  narrowing  the 
lumen;  that  necrosis  is  less  apt  to  occur,  as  the  mesenteric  vessels  are  not 
involved  in  the  suture;  that  the  opening  can  be  made  as  large  as  desired, 
hence  post-operative  contraction  may  be  discounted;  and  that  a  diflference  in 
the  size  of  the  segments  makes  the  operation  no  more  difficult  or  dangerous. 
The  disadvantages  are  that  the  feces  are  apt  lo  be  propelled  past  the  opem'ng 


Fig.  jg8, — Button  ready  to  he  appmjtimatcfL 


into  the  blind  end  of  the  proximal  segment,  which  may  give  w^ay  under  the 
pressure;  that  the  circular  fibres  are  cut,  thus  predisposing  to  impaction  at 
the  site  of  anastomosis;  and  that  the  blind  end  of  the  distal  segment  may 
invaginate,  WTiile  surgeons  differ  as  to  the  importance  to  be  attached  to  the 
ai)ove  considerations,  all  agree  that  lateral  anastomosis  is  safer  when  the 
Iwwel  is  not  completely  surroun^led  by  peritoneum,  e.g..  in  the  ascending  and 


472  ABDOMEN. 

circulation  is  further  impeded  by.  inflammatory  exudation,  and  this  leads 
to  desquamation  of  the  mucous  membrane  (hence  blood  and  shreds  in 
the  stools),  and  finally  to  strangulation  and  gangrene.  Intussusception 
is  responsible  for  39  per  cent,  of  €ie  cases  of  intestinal  obstruction.  There 
are  two  clinical  varieties,  the  acute  (sudden  and  complete  obstruction), 
which  is  most  frequent  in  young  children,  and  the  chronic,  which  is  more 
common  in  adults.  The  anatomical  varieties,  in  the  order  of  their  frequency, 
are  the  ileocecal  (44  per  cent.),  in  which  the  ileocecal  valve  and  ileum  pass  in- 
to the  colon,  the  enteric  (30  per  cent.),  usually  involving  the  jejunum,  the 
colic  (18  per  cent.),  involving  the  colon  alone,  and  the  ileocolic  (8  per  cent), 
in  which  the  ileum  passes  through  the  ileocecal  valve. 

5.  Stricture  of  the  intestine  may  be  congenital  (p.  468)  or  acquired 
(cicatricial,  neoplastic,  compression,  or  spastic).  Cicatricial  stricUtre  of  the 
small  intestine  is  usually  caused  by  tuberculous  ulcers,  that  of  the  colon  by 
dysentery,  that  of  the  rectum  by  syphilis  or  pelvic  cellulitis.  Cicatricial 
stenosis  may  occur  also  after  injury,  diverticulitis,  strangidated  hernia,  or 
intestinal  anastomosis.  It  is  rare  after  typhoid  fever,  as  the  ulcers  in  this 
disease  are  longitudinal.  Intestinal  tumors  when  benign  (fibroma,  myxoma, 
lipoma,  or  adenoma),  often  project  into  the  intestine  as  polyps,  but  seldom 
cause  obstruction,  unless  there  is  a  kink  in  the  bowel  or  unless  they  induce  an 
intussusception.  Sarcoma  is  rare  and  usually  attacks  the  small  intestine. 
Carcinoma  is  the  most  frequent  tumor  and  occurs  more  often  in  the  large 
bowel  (95  per  cent,  of  the  cases),  especially  at  the  flexures  and  in  the  rectum. 
It  is  cylindrical-celled,  usually  annular,  and  involves  the  lymph  glands  later 
than  carcinoma  elsewhere.  Tumors  of  the  intestine  are  seldom  suspected 
until  there  is  partial  or  complete  interruption  of  the  fecal  circulation.  Com- 
pression of  Hie  bowel  is  caused  by  extraintestinal  lesions,  such  as  tumors,  cysts, 
abscesses,  etc.,  by  prolapse  of  other  abdominal  viscera,  or  by  the  superior 
mesenteric  vessels  (see  acute  dilatation  of  the  stomach).  Spastic  ileus  is  due 
to  tetanic  contraction  of  a  segment  of  intestine.  It  may  be  caused  by  lead 
poisoning,  irritating  intestinal  contents,  hysteria  (see  phantom  tumor),  and 
trauma,  hence  occasionally  follows  abdominal  operations.  It  is  the  first 
step  in  the  development  of  many  cases  of  intussusception. 

Intestinal  paralysis,  adynamic  ileus,  or  pseudoobstruction,  is  most  fre- 
quently caused  by  peritonitis,  but  it  occurs  also  in  enteritis,  acute  pancre- 
atitis, thrombosis  or  embolism  of  the  mesenteric  vessels,  biliary  and  renal 
colic,  strangulation  of  the  omentum,  injury  to  the  ovary  or  testicle,  in  diseases 
of  the  central  nervous  system,  and  as  a  terminal  event  in  other  maladies, 
particularly  those  accompanied  by  delirium  or  coma.  That  form  occurring 
after  abdominal  section,  not  due  to  peritonitis,  is  caused  by  the  sudden  relief 
of  chronic  pressure  (e.g.,  the  removal  of  a  large  tumor)  or  by  undue  handling 
of  the  intestines. 

The  pathological  changes  in  the  bowel  above  the  obstruction  are  dilata- 
tion, congestion,  and,  if  the  obstruction  lasts  long  enough,  hypertrophy  of  the 
muscular  coat  and  ulceration  of  the  mucosa,  the  last  of  which  may  lead  to 
perforative  peritonitis,  abscess  formation,  or  fecal  fistula.  Below  the  obstruc- 
tion the  gut  is  pale,  empty,  and  contracted.  At  the  site  of  obstruction  the 
intestine  may  be  gangrenous  from  strangulation  (see  strangulated  hernia), 
ulcerated  from  the  pressure  of  foreign  bodies,  bands,  ptc,  or  exhibit  simply 
the  changes  incident  to  the  causative  lesion,  e.g.,  in  neoplastic  and  cicatricial 
stricture. 


DUGNOSIS   OF   OBSTRUCTION. 


473 


The  symptoms  of  iotestinal  obstnictioti  differ  somewhat  according 
to  whether  the  obstruction  i.s  acute  or  chronic.  In  acute  obstruction,  in 
which  the  lumen  of  the  bowel  is  sutldenly  aad  completely  closed,  e.g.,  in 
%'oh^ulus^  acute  intussusception,  and  strangulation  by  bands,  afJhesions^  or 
apertures,  there  are  sudden,  severe,  colicky,  abdominal  pain,  which  h  some- 
time?^ relieved  by,  but  is  often  worse  alter,  pressure;  shock,  which  is  more 
severe,  the  more  sudden  the  onset,  the  higher  the  obstruction,  the  tighter  the 
strangulation,  and  the  greater  the  amount  of  bowel  involved;  iwmiiing^  tirst  of 
the  contents  of  the  stomach,  then  of  bilious  material,  and  finally  of  stercor- 
aceous  tluid;  and  consiipaiwn,  which ^  if  the  lower  Ijowel  is  empty,  becomes 
absolute,  not  even  gas  being  expelled.  The  intestine  above  the  obstruction 
becomes  greatly  distended,  and  is  the  seat  of  violent  peristaltic  movements, 
which  may  often  be  seen,  felt,  and  heard.  Rigidity  of  the  abdominal  muscles 
is  absent  until  the  advent  of  peritonitis.  The  urine  is  lessened  in  amount  and 
contains  an  excess  of  indican.  The  shock  passes  after  a  lime,  but  the  pulse 
remains  rapid,  and  the  temperature  does  not  rise  above  normal  until  perit- 
onitis supervenes,  when  all  the  symptoms  of  this  affection  ensue.  If  un- 
relieved,  acute  obstruction  usually  causes  death  within  a  week,  as  the  result  of 
peritonitis  (gangrene  or  perforation  of  intestine),  exhaustion,  or  interference 
with  the  intrathoracic  organs  from  tympanites.  Although  rare,  spontaneous 
recover)'  is  possible;  thus  a  fistula  may  connect  the  bowel  above  and  below  the 
obstruction  or  empty  externally,  a  foreign  body  may  pass,  a  kink  be  straight- 
ened, or  the  invaginated  portion  of  an  intussusception  may  slough  and  sepa- 
rate. In  chronic  obstruction  there  is  gradually  increasing  constipation 
and  abdominal  uneasiness,  which  is  often  attributed  to  intestinal  indigestion* 
At  irreguliir  intervals  there  are  colicJcy  pain,  obstinate  constipation,  ab- 
dominal *listention,  visible,  audible,  and  palpable  peristalsis,  and  vomiting; 
the  last,  however,  is  often  absent  in  stricture  of  the  colon  until  the  obstruction 
becomes  complete.  Purgatives  often  dislodge  the  impacted  food  or  feces 
responsible  for  the  transient  obstruction.  Diarrhea  may  thus  alternate  with 
constipation.     Finally  acute  and  complete  obstruction  ensues. 

The  diagnosis  is  seldom  difficult,  but  the  seat  and  cause  are  often  un- 
determined until  an  exploratory  incision  has  been  made.  Intestinal  paraly- 
sis differs  from  obstruction  in  the  absence  of  peristalsis,  and  the  presence  of 
the  symptoms  of  the  causative  lesion,  both  before  and  after  the  onset  of  ob- 
structive symptoms;  thus  in  peritonitis  there  will  be  fever,  rigidity*  leukocyto- 
sis, etc.  The  seal  of  obstmclmi  may  occasionally  be  located  by  the  palpation 
of  a  mass  through  the  rectum,  vagina,  or  abdominal  wall,  or  by  the  situation 
of  the  pain  or  tenderness.  The  greater  the  distention,  the  later  the  vomiting 
of  stercoraceous  material,  and  the  larger  the  amount  of  urine  excreted,  the 
lower  in  the  intestine  is  the  obstruction.  When  the  central  portion  of  the 
abdomen  alone  is  distended,  the  lesion  is  above  the  ileocecal  valve;  when  both 
loins  also  are  distended,  the  obstruction  is  in  the  sigmoid  or  rectum;  and 
when  the  right  loin  is  greatly  distended  the  transverse  colon  is  involved.  Ten- 
esmus generally  indicates  a  lesion  of  the  large  bowel  Rectal  injections  of 
air  or  water  for  the  purpose  of  diagnosis  are  not  recommended.  It  is  said  that 
if  six  quarts  of  water  tan  be  introduced,  the  obstruction  is  in  the  small  intes- 
tine; if  but  a  pint  or  quart,  in  the  rectum  or  sigmoid.  The  cause  of  obstruc- 
tion may  be  an  external  hernia,  which  must  first  be  excluded  in  all  cases;  if 
such  be  found  and  be  irreducible,  it  should  be  investigated  by  incision.  If  a 
hernia  has  been  replaced  and  the  symptoms  continue,  the  possibility  of  a 


484  ABDOMEN. 

tis  (including  intestinal  indigestion,  typhoid,  dysentery,  etc.)  which  spreads 
to  the  appendix,  traumatism,  exposure  to  cold,  and  foreign  bodies.  Foreign 
bodies,  such  as  intestinal  parasites,  seeds,  stones,  etc.,  are  uncommon,  but 
fecal  concretions  are  often  encountered.  Tuberculosis,  actinomycosis,  and 
certain  neoplasms  also  may  involve  the  appendix,  and  inflammation  of 
neighboring  structures,  e.g.,  the  uterine  appendages,  may  cause  a  secondary 
appendicitis.  No  matter  what  the  source  of  irritation,  however,  the  most 
important  factor  is  infection  of  the  walls  with  micro-organisms,  es]>ecially 
the  colon  bacillus.  The  ordinary  pyogenic  bacteria,  particularly  the  strepto- 
coccus pyogenes  and  less  frequently  other  organisms,  also  are  found,  either 
alone  or  as  a  mixed  infection.  The  appendix  is  normally  inhabited  by  hordes 
of  bacteria,  which  become  vicious  only  when  they  enter  the  wall  of  the  ap- 
pendix through  an  abrasion,  e.g.,  by  a  fecal  concretion,  or  through  the 
lymphatics  without  an  abrasion,  e.g.,  when  the  drainage  of  the  organ  is  de- 
fective as  the  result  of  kinks,  adhesions,  tumors,  concretions,  foreign  bodies, 
swelling  of  the  mucous  membrane  of  the  cecum,  etc. 

The  pathological  anatomy  varies  with  the  virulence  of  the  infection, 
the  depth  of  the  inflammation,  the  duration  of  the  process,  and  the  complica- 
tions.    In  catarrhal  appendkitis  the  mucous  membrane  is  swollen  and  con- 
gested and  sometimes  presents  hemorrhagic  foci;  the  process  may  subside 
if  drainage  is  free,  or  it  may  extend  to  the  outer  walls  {interstitial  appendicitis), 
the  entire  organ  then  being  swollen  and  congested,  and  containingpus  (empyema 
of  the  appendix)^  blood,  or  feces.    Interstitial  abscesses  also  may  be  found'.     If 
the  appendix  empties  itself  into  the  cecum,  the  patient  may  recover  from  the 
attack,  but  the  organ  is  permanently  crippled  and  a  chronic  or  recurring  in- 
flammation ensues.     More  often  the  disease   progresses  to  ulceration  or 
gangrene.     Ulcerative  appendicitis  may  arise  also  primarily,  e.g.,  in  typhoid 
fever  or  dysentery,  or  from  a  foreign  body.     One  or  more  of  these  ulcers 
may  perforate  {perforative  appendicitis),  either  into  the  free  peritoneal  ca\ity. 
or  much  more  commonly  after  the  general  peritoneal  cavity  has  been  pro- 
tected by  inflammatory  adhesions.     In  the  latter  instance  a  localized  abscess 
will  be  formed.     Ulcers  which  do  not  perforate,  but  cicatrize,  cause  strictures 
and  deformities  of  the  appendix.     When  such  contraction  is  universal,  the 
entire    cavity    may    disappear    {obliterating   appendicitis).     The    appendi.x 
occasionally  becomes  distended  with  mucus  distal  to  a  stricture  {hydrops  or 
mucocele  of  the  appendix).     Gangrenous  appendicitis  may  follow  any  of  the 
preceding  varieties,  or  it  may  be  caused  by  a  sudden  and  overwhelming  in- 
fection, or  by  a  cutting  off  of  the  blood  supply  as  the  result  of  thrombosis,  or 
obstruction  of  the  vessels  by  kinks,  etc.     This  variety  may  develop  within  a 
few  hours  {fulminating  appendicitis).     The  organ  undergoes  moist  gangrene, 
being  soft,  swollen,  and  green  or  black  in  color,  and  soon  separating  from 
the  healthy  tissues.     In  fulminating  cases  it  may  lie  free  in  the  peritoneal 
cavity.     In  any  case,  however,  in  which  the  inflammation  progresses  beyond 
the  mucous  membrane,  adhesions  are  apt  to  form  about  the  appendix,  thus 
serving  as  a  protective  barrier  in  the  event  of  gangrene  or  perforation.     The 
exudate  thus  formed  may  become  purulent,  even  in  the  absence  of  perfora- 
tion and  gangrene.     The  situation  of  the  appendix  determines  the  location 
of  the  a!)scess,  which  may  rupture  through  the  abdominal  wall,  into  a  neigh- 
boring hollow  viscus,  or  into  the  general  peritoneal  cavity.     Among  the  other 
complications  of  suppuration  about  the  appendix  may  be  mentioned  perfora- 
tion of  the  iliac  vein  or  arter>',  psoitis,  lymphangitis  or  lymphadenitis,  phlel>- 


APPENDICITIS. 


485 


it  is  (iliac,  fu  moral,  mcscnterii,  orporlalj^  abscess  of  the  liver,  kidney,  spleeji, 
or  lung,  suhphrenit  abscess^  empyema,  endocarditis,  meningiUs,  parotitis, 
and  pyemia. 

The  symptoms  may  be  described  under  two  headings^  according  to 
whether  the  disease  is  acute  or  chronic.  The  most  important  symptoms  of 
oftite  appatdkiih  are  pain,  tenderness,  and  rigidity  of  the  muscles  over  the 
appendix,  which  is  generally  in  the  right  iliac  fossa,  but  may  be  in  the  loin, 
pelvis,  or  any  part  of  the  right  side  of  the  abilomen;  in  rare  instances  it  is  to 
the  left  of  the  median  line.  The  first  symptom  is  pain,  which  usually  develops 
sudtlenly,  is  paroxysmal  in  the  beginning  and  confined  to  the  epigastric  or 
umbtlii  al  region,  and  later  becomes  constant  and  localized  in  the  region  of 
the  appendix.  It  is  increased  by  pressure,  movements  of  the  right  thigh,  ab- 
dominal respiration,  etc.  It  may  disappear  entirely  after  the  onset  of  gan- 
grene or  suppuration.  The  situation  of  the  most  marked  tenderness  also 
varies  with  the  situation  of  the  appendix,  hence  may  require  rectal  or  vaginal 
examination  for  its  development;  In  most  instances,  however,  it  is  at  McBur- 
ney's  point  (one  and  one-half  to  two  inches  from  the  anterior  superior  spine 
of  the  right  ilium  on  a  line  running  to  the  umbilicus.  Fig.  367}*  The  skin 
over  the  inllamctl  area  also  may  be  hyperesthetic.  Rigidity,  often  lM)ard-like 
in  character,  likewise  is  most  intense  over  the  appendix,  and  its  degree  and 
extent  usually  indicate  the  degree  and  extent  of  the  underlying  inllammation. 
Vomiting  occurs  with  the  epigastric  pain,  then  subsides,  and  recurs  w^iih 
the  development  of  peritonitis.  Constipation  is  present  in  about  two-thirds 
of  the  cases.  The  tem[*crature  usuall-y  rises  two  or  three  degrees,  but  in 
many  cases  there  is  no  fever  until  abscess  or  peritonitis  or  other  septic  com- 
plications ensue.  Chills  are  rare  and  generally  indicate  gangrene  of  the 
appendix  or  metastatic  abscesses.  The  pulse,  in  the  absence  of  complica- 
tions, may  be  normal  or  but  slightly  accelerated;  it  becomes  rapid  with 
the  develop mi?nt  of  peritonitis.  The  respirations  are  costal,  but  the  rate 
is  not  intluenced  to  any  great  extent  until  peritonitis  develops.  The 
facial  expression  may  be  that  of  pain,  but  is  not  characteristic  in  the 
absence  of  peritonitis.  The  tongue  is  usually  coated.  The  late  symp- 
toms, in  a  progressive  case,  are  those  of  peritonitis.  In  the  early  stages 
the  underlying  structures  cannot  be  palpated  because  of  the  muscular 
rigidity,  but  with  the  formation  of  an  abscess  or  a  (ibrinous  exudate 
about  the  appendix,  a  mass  may  be  feh  and  sometimes  seen.  This  tu- 
mor is  smooth,  fixed,  usually  tympanitic,  and  rarely  tluctuaiing.  After 
the  infected  focus  has  become  well  encapsulated,  the  rigidity  often  dis- 
appears. Rough  or  powerful  pressure  should  never  be  used  in  acute 
cases  because  of  the  danger  of  rupturing  the  appendLx  or  an  environing 
abscess-  Leukocytosis,  increasing  with  the  extent  of  the  infection,  unless 
such  be  overwhelming,  is  a  sign  of  some  value  when  considered  with  die 
clinical  phenomena.  The  progress  of  the  disease  varies  greatly  in  different 
instances.  In  the  mildest  forms  in  which  the  infection  does  not  extend  be- 
yond the  appendix,  complete  recovery  may  follow  in  a  few  days,  but  subse- 
quent attacks  are  the  rule  {recurring  appendicilis).  In  fulminating  cases  the 
peritoneum  may  be  involved  within  a  few  hours.  Unfortunately  it  is  im* 
possible  to  foretell  from  the  character  of  the  symptoms  which  cases  will 
recover  and  which  will  progress  to  perforation,  gangrene,  or  abscess  formation. 
In  tiie  midst  of  even  the  mildest  symptoms,  sudden  perforation  or  gangrene 
with  their  disastrous  sequela;  may  occur    Chronic  appendicitis  may  be  such 


J 


486  ABDOMEN. 

from  the  beginning  or  it  may  follow  an  acute  attack.  The  symptoms  are 
pain  and  tenderness  in  the  region  of  the  appendix  with  chronic  indigestion. 
Occasionally  a  thickened  appendix  may  be  felt.  Chronic  appendicitis  in 
which  acute  attacks  occur  at  intervals  is  called  relapsing  appendicitis. 

The  diagnosis  is  generally  easy,  but  may  be  very  difficult  or  impossible. 
In  many  cases  a  failure  to  make  a  definite  diagnosis  entails  no  serious  con- 
sequences, because  the  surgeon  recognizes  the  necessity  for  operation  in 
order  to  deal  with  some  intraabdominal  catastrophe.     Pain,   tenderness, 
and  rigidity  are  prominent  features  in  this  group  of  cases,  which  includes 
among  other  conditions  the  following:     Perforation  of  any  portion  of  the 
gastrointestinal   canal,    intestinal   obstruction,   inflammation    of    Meckel's 
diverticulum,  volvulus  of  the  omentum,  acute  infections  of  the  gall-bladder, 
abscess  of  the  kidney,  floating  kidney  with  twisted  ureter,  extrauterine  preg- 
nancy, inflammatory  lesions  of  the  right  tube  or  ovary,  ovarian  cyst  widi 
twisted  pedicle,  acute  pancreatitis,  thrombosis  of  the  mesenteric  vessels,  and 
tuberculous  peritonitis.     In  a  second  group  of  cases  a  mistake  in  diagnosis 
may  lead  to  an  unnecessary  operation.     A  partial  list  of  these  cases  is  as 
follows:     Acute  indigestion,  intestinal  colic,  acute  enteritis,  typhoid  fever, 
gastric  ulcer,  dysentery,  hepatic  colic,  renal  colic,  movable  kidney,  ureteritis, 
epididymitis,    dysmenorrhea,    lead    poisoning,    incipient    inguinal    hernia, 
pneumonia,  pleurisy.  Pott's  disease,  cerebrospinal  meningitis,   abdominal 
crisis  of  locomotor  ataxia,  and  distention  of  the  urinary  bladder.     A  mass  in 
the  right  iliac  region  may  be  due  to  fecal  impaction,  neoplasm  of  the  struc- 
tures in  this  region,  cysts,  lymphadenitis,  foreign  body  in  the  intestine,  in- 
tussusception, aneurysm,  abscess  (from  the  vertebrae  or  pelvic  bones,  ilio- 
psoas or  abdominal  muscles),  pelvic  cellulitis,  inflamed  undescended  testicle, 
properitoneal  hernia,  enlarged  gall-bladder,  displaced  kidney,*  and  phantom 
tumor.     Space  cannot  be  spared  in  this  place  to  give  a  separate  enumeration 
of  the  symptoms  of  the  above  conditions,  but  in  most  instances  the  differen- 
tial diagnosis  is  possible  if  care  is  taken  to  obtain  a  full  history  and  make  a 
complete  examination. 

The  treatment  is  operation  as  soon  as  the  diagnosis  is  made.  There  are 
certain  exceptions  to  this  rule,  e.g.,  the  presence  of  some  other  grave  malady 
which  will  render  operation  extremely  dangerous,  or  the  absence  of  a  com- 
petent surgeon.  Under  these  circumstances  or  when  operation  is  refused,  the 
patient  should  be  confined  to  bed  and,  if  seen  early  in  the  attack,  given  a 
laxative.  Purgatives  are  contraindicated  at  a  later  period,  because  of  the 
danger  of  causing  perforation,  or  spreading  the  infection  if  such  be  outside 
the  appendix;  in  these  cases  the  bowels  should  he  moved  by  enemata.  The 
diet  should  be  liquid;  if  vomiting  persists,  the  stomach  ^ould  be  washed 
out  and  the  patient  fed  by  rectum.  An  ice  hag  or  hot  water  bag  may  be 
applied  over  the  appendix.  Opium  may  he  given  to  quiet  peristalsis  and 
relieve  pain,  hut  under  no  circumstances  before  a  positive  diagnosis  is  made, 
because  of  the  danger  of  clouding  the  symptoms.  The  mortality  with  medi- 
cal treatment  is  said  to  he  25  per  cent.,  that  of  early  operation  while  the  infec- 
tion is  still  confined  to  the  appendix  is  le.'^s  than  i  per  cent.;  in  cases  in  which 
a  localized  abscess  has  formed  the  mortality  of  operation  is  from  5  to  10  per 
cent.,  in  those  with  diffuse  peritonitis  between  10  and  25  per  cent.  The 
practitioner  is  sometimes  advised  to  wait  for  an  interval  before  operating  in 
cases  with  mild  or  subsiding  symptoms,  but  operation  in  these  cases  is  just  as 
safe  as  in  an  interval,  and  the  danger  of  a  sudden  exacerbation  is  precluded. 


APPENBICmS. 

In  appendkiLis  with  punU>nitis  a  few  surguiuLs  adopt  the  Ochsncr  melhui) 
of  treatment  (p.  448).  If  a  patient  has  passed  through  one  attack  of  un- 
doubted appendicitis^  removal  of  the  organ  is  recommendetl  because  of  the 
danger  of  subsequent  attacks;  this  advice  becomes  progressively  stronger 
with  the  number  of  attacks  which  have  been  experienced, 

Operatiotl  in  clean  cases,  ix\,  early  in  an  attack  or  in  interval  cases,  is 
as  follows:  The  abdomen  is  opened  l>y  an  incision  through  the  outer  border 
of  the  right  rectus  muscle,  beginning  at  the  level  of  the  umbilicus  and  ex- 
tending downwards  two  or  more  inches,  according  to  the  amount  of  room 
desired.  WTien  one  is  positive  there  is  no  extraappendiceal  infection,  the 
McBurney  method  of  opening  the  abdomen  is  ideal,  because  no  nerves  are 
severed  and  subsequent  hernia  is  practically  impossible.  A  two  or  three 
inch  skin  incision  is  made  in  the  direction  of  the  fibers  of  the  external  oblique, 
the  center  of  the  incision  being  aliout  one  and  one-half  inches  from  the  ante- 
rior superior  spine  of  the  ilium  on  a  line  to  the  umbilicus.  The  fibers  of 
the  external  oblique  are  separated  and  retracted,  h*kewise  the  liljers  of  the 
internal  oblique  and  transversalis  muscles,  which  run  almost  at  right  angles 
to  the  superficial  wound.  The  transversalis  fascia  and  peritoneum  are 
severed  in  the  same  direction  as  the  internal  oblique.  At  the  completion 
of  the  operation  each  of  these  layers  is  separately  sutured  with  catgut.  The 
appendix  may  be  found  as  soon  as  the  abdomen  is  opened.  In  other  cases  it 
wdll  be  necessary  to  identify  the  cecum,  and  follow^  the  anterior  longitudinal 
band»  which  alw^ays  leads  to  the  liase  of  the  appendix.  If  adhesions  are  en- 
countered, they  should  never  be  separated  without  protecting  the  general 
peritoneal  cavity  with  gauze,  as  they  may  harbor  a  focus  of  suppuration. 
The  mesoappendix  is  perforated  close  to  the  cecum  with  an  aneurysm  needle, 
armed  \nth  catgut,  ligated,  and  divided.  There  are  numerous  ways  of  ampu- 
tating the  appendix,  but  the  best  method,  when  the  cecum  can  be  drawn 
into  the  wound,  is  to  grasp  it  on  each  side  of  the  base  of  the  appendix  with 
the  thumb  and  forefinger  of  the  left  hiind,  remove  the  organ  with  scissors  by 
cutting  (iush  with  the  cecum,  and  close  the  opening  in  the  bowel  by  a  double 
row  of  Lembert  sutures  of  silk.  When  the  cecum  caimot  be  delivered,  the 
appendix  may  lie  tied  close  to  its  f>ase,  ampuiatetl  l^eyond  the  ligature^  and 
the  stump  buried  in  the  head  of  the  cecum  with  Lembert  sutures,  after  the 
exposed  mucous  membrane  has  been  touched  with  carbolic  acid.  The  wound 
in  rhe  abdominal  w^all  is  closed  without  drainage. 

Operation  for  appendiceal  abscess  is  performed  through  an  incision 
made  over  the  mass.  If  edema  of  the  abdominal  w^all  be  found,  the 
abscess  is  probably  adherent  to  ihe'parietes,  and  w^iJl  be  opened  on  cau- 
tiously  deepening  the  wound.  All  that  is  then  needed  is  to  insert  a  drainage 
tube  and  allow^  the  cavity  to  heal  by  granulation.  If,  however,  the  appendix 
is  loose  in  the  abscess  cavity,  or  can  be  removed  without  opening  the  general 
peritoneal  cavity,  such  should,  of  course,  be  done.  In  other  cases  the 
appendix  may  be  removed  after  the  abscess  has  healed,  when  there  is  no 
longer  danger  of  infecting  the  peritoneum.  If,  on  incising  the  abdominal 
wall,  the  abscess  is  not  adherent  to  the  parietcs,  it  should  be  carefully  isolated 
from  the  general  peritoneal  cavity  by  gauze  packing.  A  small  opening  is 
then  made  into  the  abscess  by  separating  the  adhesions  with  the  finger,  and 
the  pus  removed  with  gauze  pads  as  quickly  as  it  appears.  W^hen  the  pus 
ceases  to  flow,  the  opening  is  enlarged  with  the  finger*  the  cavity  dried  with 
gauze,  anti  the  appendix  removed  by  one  of  the  methods  already  mentioned, 


488  ABDOMEN. 

using  catgut,  however,  for  the  appendix  if  it  is  to  be  removed  by  the  simple 
ligature  method ;  sUk  in  these  cases  may  give  rise  to  a  troublesome  sinus.  The 
cavity  is  mopped  with  salt  solution,  dried,  and  drained  with  gauze;  the  author 
uses  the  Mikulicz  drain,  as  described  on  p.  42.  After  the  outer  packing  is 
removed,  the  superfluous  portion  of  the  wound  is  closed  with  sutures.  If 
the  protecting  gauze  packing  has  been  efliciently  arranged  during  the  op- 
eration, the  abscess  cavity  may  be  safely  washed  with  salt  solution  after  the 
pus  has  been  removed. 

For  operation  for  diffuse  peritonitis  following  appendicitis  see  p.  448. 

The  sequels  of  operation  in  abscess  cases,  or  in  those  complicated  by  per- 
itonitis, are  secondary  abscess,  intestinal  obstruction,  fecal  fistula,  suppura^ 
tion  of  the  superficial  wound,  and  hernia. 

Appendicostomy  (Wier's  operation)  is  employed  to  permit  irrigation  of 
the  colon  in  chronic  dysentery  and  other  ulcerative  lesions  of  the  large  bowel. 
The  abdomen  is  opened  by  a  McBurney  incision  (p.  487),  the  mesoappendix 
ligated  and  severed,  the  appendix  sutured  to  the  parietal  peritoneum  and  skin, 
the  superfluous  portion  of  the  wound  closed,  the  appendix  opened  to  make 
sure  that  it  is  patulous  (if  strictured  a  Gibson  operation,  p.  477,  is  indicated), 
a  ligature  applied  to  prevent  leakage,  and  after  several  days  the  protruding 
part  of  the  appendix  amputated.  The  colon  may  now  be  irrigated  daily 
with  salt  solution,  silver  nitrate,  1-5000,  bismuth  and  starch  water,  i  dram  to 
the  ounce,  etc.,  by  passing  a  catheter  through  the  appendix  and  introducing 
a  tube  into  the  rectum.  WTien  the  fistula  is  no  longer  needed  it  may  be 
closed  by  cauterizing  the  mucous  membrane. 

THE  LIVER. 

For  injuries  of  the  liver  see  contusions  and  wounds  of  the  abdomen. 

Abscess  of  the  liver  is  most  frequent  in  the  inhabitants  of  tropical  coun- 
tries and  in  alcoholics.  Infection  may  be  direct,  as  in  w^ounds  or  when  it  ex- 
tends from  neighboring  organs;  it  may  travel  up  the  bile  ducts,  particularly 
when  they  are  obstructed;  and  it  may  be  carried  by  the  blood  stream,  either 
hepatic,  as  in  general  pyemia,  or  portal,  as  in  abscesses  following  infective 
lesions  in  the  area  drained  by  the  portal  vein,  e.g.,  appendicitis,  and  dysentery 
or  other  forms  of  intestinal  ulceration.  Hydatid  cysts  may  suppurate,  and  in 
tropical  countries  a  contusion  may  be  followed  by  an  abscess.  The  organisms 
most  frequently  found  are  streptococci,  staphylococci,  and  the  colon  bacillus. 
In  that  form  following  amebic  dysentery  {tropical  abscess)  the  pus  is  fre- 
(juently  sterile,  the  organisms  probably  having  perished  as  the  result  of  the 
chronicity  of  the  case.  Ascarides,  distoma,  and  coccidia  are  possible  but 
rare  causes  of  hepatic  suppuration.  Tropical  and  traumatic  abscesses  are 
usually  solitary  and  occupy  the  right  lobe;  pyemic  abscesses  small,  multiple, 
and  hence  rarely  amenable  to  treatment. 

The  symptoms  in  acute  and  pyemic  abscesses  are  pain  reflected  to  the 
right  shoulder,  tenderness  and  enlargement  of  the  liver,  occasionally  friction 
sounds  owing  to  involvement  of  the  peritoneum,  rarely  edema  of  the  skin  or 
fluctuation,  chills,  fever,  sweats,  leukocytosis,  perhaps  slight  jaundice,  and 
sometimes  cough  from  irritation  of  the  phrenic  nerve  or  invasion  of  the  lung. 
Chronic  and  tropical  abscesses  may  give  few  or  no  symptoms.  In  the  latter 
the  ameba  may  be  found  in  the  stools.  The  abscess  may  break  into  the 
peritoneal  cavity,  one  of  the  hollow  viscera,  the  pleura,  the  lung,  the  peri- 


CYSTS   OF   THE   LI\^R. 


tiirdium,  or  inia  the  vena  tava  or  portal  vein;  or  it  may  poiiil  externally 
through  the  abdominal  wall.  The  diagnosis  may  be  confirmed  by  aspiration, 
the  needle  being  inserted  in  the  seventh  or  eighth  intercostal  space  between  the 
axillar}'  lines,  below  the  costal  arch  in  the  right  nipple  line,  or  posteriorly  in 
the  ninth  or  tenth  interspace  vertically  below  the  angle  of  the  scapula.  One 
should  lie  prepared  to  proceed  immediately  with  operation  if  pus  is  found. 

The  treatment  hhepoloiomy  by  the  abdominal  or  thoracic  route,  depend- 
ing upon  the  situation  of  the  abscess.  If  the  former  is  chosen,  the  abdomen 
is  opened  usually  by  a  longitudinal  incision  below^  the  costal  arch.  If  the 
liver  is  adherent  to  the  abdominal  wall,  the  abscess  may  be  opened  without 
danger  of  contaminating  the  peritoneal  cavity.  In  the  absence  of  adhesions 
the  peritoneal  cavity  must  be  protected  by  gauze  packing.  The  abscess  is 
located  wi'th  a  hollow  needle,  and  opened  by  passing  a  knife  or  a  cautery  blade 
along  the  needle.  The  abscess  is  irrigated,  and  drained  with  a  rubber  tube, 
the  free  portion  of  the  cavity  being  lightly  packed  with  gauze.  After  re- 
moving the  gauze  whicji  protects  the  peritoneal  cavity,  the  liver  below  the 
opening  of  the  abscess  may  be  sutured  to  the  abdominal  wall.  WTien  the 
abscess  is  high  on  the  dome  of  the  liver,  the  transpleural  or  thoracic  operation 
is  indicated.  The  abscess  is  located  with  the  needle  as  directed  above,  the  rib 
Ijelow^  the  needle  excised,  and,  if  the  pleural  cavity  is  obliterated  at  this  point 
by  adhesions,  the  abscess  opened  as  previously  described.  If  there  are  no 
aiihesion*?,  the  tw^o  layers  of  the  pleura  should  be  stitched  together  with 
catgut. 

Cysts  of  the  liver  arising  from  dilatation  of  the  lymph  spaces  are  called 
simple  sirous  cysis\  They  may  be  single  or  multiple,  large  or  small,  i>ut 
seldom  cause  symptoms.  Polycystic  disease  of  the  liver  is  usually  congenital 
and  often  associated  with  cystic  disease  of  the  kidneys;  almost  the  whole 
organ  is  converted  into  serous  cysts  of  various  sizes.  Both  these  varieties 
as  well  as  cystic'  adcfioma  and  dermoids  are  very  rare.  Hydatid  cysls  are 
considered  in  the  next  paragraph. 

Hydatid  cysts  are  found  more  frequently  in  theliver  than  in  any  other  por- 
tion of  the  body.  The  general  facts  concerning  these  cysts  and  the  com- 
position of  hydatid  tluid  are  given  on  page  149. 

The  symptoms  develop  slowly.  The  swelling  moves  with  respiration 
antl  is  seldom  painful.  When  superficial,  tluctuation  and  hydatid  fremitus, 
or  thrill,  may  be  obtained;  the  latter  is  due  to  the  rubbing  together  of  the 
daughter  cysts,  WTien  deeply  situated  the  cyst  may  be  mistaken  for  a 
neoplasm.  Pressure  on  the  lung  causes  dyspnea;  on  die  stomach  or  bowel, 
vomiting  and  indigestion;  on  the  blood  vessels,  ascites  and  edema  of  the 
legs;  on  tlie  bile  ducts,  jaundice,  which  is  rare.  Hydatid  urticaria  and  toxe- 
mia occur  most  often  after  rupture  into  the  peritoneal  cavity.  Examination 
of  the  blood  reveals  cosinophilia.  Aspiration  may  be  used  for  diagnostic 
purposes,  but  only  immediately  before  operation.  The  cyst  may  shrink  and 
the  contents  become  inspissated,  or  it  may  enlarge,  with  or  wi'thout  suppura- 
tion, and  burst  in  one  of  the  situations  just  mentioned  under  abscess  of  the 
liver. 

The  treatment  is  much  like  that  of  abscess.  After  protecting  the  abdom- 
inal cavity,  the  cyst  is  aspirated,  opened  wa'th  the  cautery  or  knife,  the  daugh- 
ter cysts  removed,  and  the  cavity  drained  after  stitching  the  edges  of  the  open- 
ing to  the  abdominal  wall.  Small  cysts  raay  be  completely  excised.  Simple 
aspiration  and  aspiration  followed  by  injections  are  not  recommended. 


490  ABDOMEN. 

Tumors  of  the  liver  arc  usually  secondary,  hence  multiple.  Among 
the  primary  tumors  are  carcinoma,  sarcoma,  endothelioma,  angioma,  fibroma, 
adenoma,  lipoma,  and  myxoma.  Gummata  and  thick-walled  hydatid  cysts 
may  closely  simulate  neoplasms.  In  suitable  cases  the  growth  may  be 
resected  with  the  knife  or  thermocautery,  after  surrounding  it  with  a  series 
of  interlocking  ligatures  of  silk  or  catgut,  introduced  with  a  blunt  needle. 
In  certain  cases  the  growth  may  be  secured  extraperitoneally  by  passing  pins 
through  the  pedicle,  and  then  removed  after  constricting  the  pedicle  with  an 
clastic  ligature,  which  is  left  in  place. 

Hepatoptosis,  or  floating  liver,  is  generally  a  part  of  splanchnoptosis. 
There  may  he  pain,  vomiting,  and  general  weakness,  with,  in  some  cases, 
jaundice  and  a.scites.  The  prolapsed  organ  may  be  outlined  by  palpation. 
The  treatment  is  that  of  splanchnoptosis.  When  other  measures  fail,  the 
liver  may  l)e  sutured  to  the  anterior  abdominal  wall  with  a  blunt  needle  and 
silk  or  catgut  (hepatopexy) .  In  partial  ptosis,  or  floating  lobe,  e.g.,  the  result  of 
tight  lacing  or  cholelithiasis  {RiedeVs  lobe),  the  cause  should  be  removed,  and 
the  floating  lobe  supported  by  suturing  the  ligamentum  teres  or  gall-bladder 
to  the  alxlominal  wall.  Kxcision  of  a  linguiform  projection  also  has  been 
done, 

In  atrophic  cirrhosis  of  the  liver  with  ascites,  attempts  have  been 
made  to  establish  a  collateral  circulation  between  the  portal  and  systemic 
vessels  {Talma^s  operation,  or  epiplopexy).  The  fluid  is  drawn  oflF  by  a  punc- 
ture above  the  pubes  and  the  abdomen  opened  alx)ve  the  umbilicus.  The 
external  surface  of  the  liver  and  spleen  and  the  parietal  peritoneum  are 
scrubbed  with  gauze,  after  which  the  omentum  is  sutured  to  the  abdominal 
wall.  The  wound  is  then  closed,  and  the  freshened  intraperitoneal  surfaces 
hehl  together  hy  a  tight  bandage  or  adhesive  plaster  applied  to  the  upper 
abdomen.  A  few  cases  have  been  cured  in  this  way.  Biliary  cirrhosis  with- 
out ascites  has  been  treated  bv  oholcrvstostomv. 


THE  BILIARY  PASSAGES. 

Cholangitis,  or  inflammation  of  the  I)iliar\'  ducts,  may  be  acute  (catar- 
rhal or  suppurative)  or  chronic.  Acute  catarrhal  cholangitis  (caiarrhal 
jaundice)  is  usually  due  to  an  ascending  infection  from  the  duodenum;  it  is 
dealt  with  by  the  physician  and  need  not  be  discussed  here.  Suppurative  of 
phlegmonous  cholangitis  is  caused  by  pyogenic  organisms  which  ascend  from 
the  duodenum  or  are  excreted  with  the  bile.  Any  lesion  interfering  with  biliary 
drainage  predisposes  to  this  condition,  and  it  may  be  caused  by  general  infec- 
tions, e.g.,  pyemia,  typhoid  fever,  influenza,  etc.  The  symptoms  are  those  of 
septicemia  or  pyemia,  with  an  enlarged  and  tender  liver  and  a  varying  degree 
of  jaundic  e.  The  treatment  is  that  of  pyemia,  with  the  removal,  if  possible, 
of  any  obstruction  to  the  flow  of  bile,  and  drainage  of  the  gall-bladder. 

Chronic  catarrhal  cholangitis  may  follow  the  acute  form,  but  is 
usually  the  result  of  obstruction  of  the  bile  ducts  (gall-stones,  parasites, 
tumors,  aneurysm,  pancreatitis,  adhesions,  prolapse  of  the  kidney  or  liver, 
pseudomcmbrane,  strictures,  and  inflammator\'  swelling  of  the  mucosa).  In 
rare  instances  obstruction  is  due  to  congenital  absence  or  atresia  of  one  or 
more  of  the  ducts.  The  symptoms  are  persistent  jaundice,  and  in  many 
cases  recurring  attacks  of  fever  associated  with  sweats  (Charcot's  intermittent 


aiOLKLITinASIS. 


4QT 


fever).  There  is  usually  enlargement  and  tenderness  of  ihe  liver  with  aslhe- 
nia  and  emaciation.  The  complitations  are  suppurative  cholangitis,  dif- 
fuse hepatitis,  alyscess  of  the  livett  cirrhosis  of  the  liver,  pylephlebitis,  chole- 
cystiliSy  perforation  of  the  ducts,  pancreatitis,  endocarditis,  pleurisy,  pneu- 
monia, and  other  septic  maladies.  The  trealmeni  is  removal  of  the  cause 
when  possible^  and  drainage  of  the  biliary  tiucts  by  one  of  the  operations  to  be 
described  later. 

Cholecystitis,  or  inllammation  of  the  gall-bladder,  may  be  catarrhal, 
pseudomembranous,  suppurative,  or  gangrenous.  The  infection  may 
ascend  from  the  duodenum  or  descend  from  the  liver.  The  organisms  most 
frequently  found  are  the  colon  bacillus,  the  typhoid  bacillus,  and  the  ordinary 
pyogenic  organisms.  The  causes  are  those  of  cholangitis,  the  most  frequent 
etiological  factor  being  gal b stones.  The  cystic  duct  is  often  blocked,  if  not 
by  a  calculus,  by  inflammatory  swelling  or  a  plug  of  mucus  or  membrane;  as 
a  consequence  the  gall-bladder  is  distended  with  hlle  mixed  with  mucus 
(catarrhal  variety),  pus  {cmpyrma  of  the  gallhladder),  or  blood  (gangrenous 
variety).  In  the  severer  grades  there  is  always  a  pericholecystitis,  which 
may  result  in  suppuration  or  the  formation  of  adhesions.  The  gall  bladder 
may  perforate  into  these  adhesions,  into  the  stomach  or  Ixiwel,  into  the  free 
peritoneal  cavity,  or  rarely  through  the  al>dominaI  walb  As  the  result  of 
.  repeated  attacks  of  inflammation,  the  gall-bladder  may  be  reduced  to  a 
tibrous  cord  (Mlierufinj^  chaifrystitis).  Prolonged  obstruction  of  the  cystic 
duct,  without  serious  infection,  leads  to  distention  of  the  gall-bladder  with 
mucoid  flui<l,  the  bile  having  disappeared  [hydrops  cyslidis  Jdkw).  The 
symptoms  are  pain  and  tenderness  in  the  region  of  the  gall-bladder,  with,  in 
the  more  severe  forms,  fever,  rapid  pulse,  vomiting,  rigidity  of  the  abdominal 
muscles,  and  leukocytosis.  In  many  instances  the  distended  galb bladder 
may  be  palpated  below  the  edge  of  the  ribs.  Jaundice  is  absent  if  the  gall- 
bladder alone  is  involved. 

The  treatment  is  operation  in  all  cases,  with  the  exception  of  the  non- 
obstructive catarrhal  variety.  In  this  form,  especially  when  arising  in  the 
course  of  some  general  disease  like  enteric  fever  and  not  associateci  with 
severe  symptoms,  medical  treatment  is  efficacious.  Should  the  symptoms 
persist,  however,  or  become  severe,  operation  will  l>e  indicated.  In  catarrhal, 
pseudomembranous,  and  suppurative  cholecytitis,  cholecystostomy  is  the 
proper  treatment,  gall  stones  being  removed  if  present.  In  hydrops  and 
gangrene  cholecystectomy  is  demanded. 

Cholelithiasis  (gall-stones)  is  said  to  affect  nearly  lo  per  cent,  of  all  adults, 
75  per  cent,  of  the  cases  being  females.  It  is  most  common  in  individuals 
past  forty,  f  jther  predisposing  factors  are  sedentary  habits,  tight  lacing, 
abdominal  tumors  (all  of  which  hinder  abdominal  respiration,  hence  the  free 
flow  of  bile),  constipation,  excess  of  cariiohydrates  in  the  diet,  catarrh  of  the 
stomach  and  duodenum,  and  lesions  which  interfere  with  biliary  drainage. 
Thetaw^f  of  gall-stone  formation  is  catarrhal  inflammation  induced  by  micro- 
organisms. The  nucleus  of  the  stone  is  generally  a  mass  of  bacteria,  rarely 
a  blood  clot,  particle  of  mucus,  or  other  foreign  body.  The  stones  are  com- 
posed of  cholesterine  and  calcium  salts,  and  vary  in  color  according  to  the 
quantity  of  bile  pigment  present.  They  vary  greatly  also  in  number  and 
size,  and  when  multiple  are  faceted  from  mutual  pressure.  The  organisms 
most  frequently  found  are  the  colon  bacillus  and  the  typhoid  bacillus,  hence 
in  many  cases  a  previous  history  of  typhoid  fever  may  be  obtained.     The 


492  ABDOMEN. 

Stones  are  almost  always  formed  in  the  gall-bladder,  rarely  in  the  bilianf 
ducts,  although  they  are  often  transported  to  the  latter  situation.  Symptoms 
sufficiently  severe  to  demand  treatment  are  present  in  about  5  per  cent,  of  the 
cases,  although  many  of  the  so-called  digestive  disturbances  are  in  realitj 
due  to  gall-stones.  The  symptoms  are  caused  by  the  passage  of  a  stone 
along  the  ducts,  by  inflammation,  or  by  obstruction  to  the  flow  of  bile.  When  a 
stone  passes  along  the  ducts  (biliary  or  hepatic  colic),  there  is  in  most  instances 
excruciating  pain  in  the  region  of  the  gall-bladder  which  radiates  to  the  epigas- 
trium and  right  shoulder,  and  is  accompanied  by  vomiting,  sweating,  and 
sometimes  collapse.  The  attack  lasts  from  a  few  hours  to  several  days: 
it  may  be  followed  by  jaundice  from  obstruction  of  the  common  or  hepatic 
duct  by  the  stone  or  by  inflammatory  swelling.  Jaundice  is  a  symptom 
of  gall-stones  in  only  20  per  cent,  of  the  cases.  The  calculus  may  be  passed 
with  the  feces,  but  in  most  instances  the  colic  is  unsuccessful,  the  stone  drop- 
ping back  into  the  gall-bladder  or  lodging  in  one  of  the  ducts.  Should  a 
faceted  stone  be  found,  the  evidence  is  positive  that  other  stones  are  present 
In  the  majority  of  cases  there  is  no  typical  biliary  colic,  but  the  patient  com- 
plains of  indigestion,  a  dull  pain  radiating  towards  the  epigastrium  and  the 
right  shoulder,  and  tenderness  between  the  ninth  costal  cartilage  and  the  um- 
bilicus {Rohson's  point,  Fig.  367).  With  these  there  may  be  enlargement  of 
the  liver  and  swelling  of  the  gall-bladder.  In  rare  instances  crepitus  may  be  . 
obtained  by  manipulating  the  gall-bladder.  Under  favorable  conditions 
the  stones  may  be  shown  in  a  skiagraph.  The  following  synopsis  concerning 
the  position  of  the  stones  and  the  condition  of  the  biliary  apparatus  is  taken 
largely  from  Kehr:  i.  Oall-bladder  containing  stones  with  free  c\-stic 
duct  and  little  alteration  in  the  walls. — Symptoms  usually  wanting,  occasion- 
ally pains  in  the  stomach  due  to  transitory'  obstruction  of  the  cysticus.  Pal- 
pation negative  or  only  .slight  tenderness  in  region  of  gall-bladder.  Confusion 
with  gastric  ulcer,  intestinal  colic,  movable  kidney,  and  hernia  of  linea  alba 
frequent.  2.  Stones  in  gall-bladder  in  which  inflammatory  processes  have 
already  been  present  resulting  in  pericystic  adhesions. — Severe  colic  caused 
by  kinking  of  cystic  duct  after  full  meal  or  complete  distention  of  the  gall- 
bladder; vomiting,  tenderness,  and  palpable  gall-bladder.  Between  attacks 
there  may  be  complete  relief.  3.  Acute  cholecystitis  due  to  stone  in  neck 
of  gall-bladder. — Pain,  swelling,  tenderness  in  the  region  of  the  gall-bladder, 
and  symptoms  of  general  infection;  rarely  jaundice  or  expulsion  of  stone;  in  the 
latter  event  symptoms  of  acute  obstruction  of  the  choledochus  arise.  Lingui- 
form  projection  of  the  anterior  edge  of  the  liver  over  gall-bladder  (Riedel's 
lo!)e);  occasionally  mistaken  for  appendicitis.  When  the  general  infection 
is  severe,  the  condition  may  be  mistaken  for  malaria,  typhoid,  or  sepsis.  4. 
Hydrops  of  the  gall-bladder. — Symptoms  may  be  wanting,  the  tumor  being 
the  only  sign  of  disease,  although  Riedel's  lobe  and  pain  may  be  present. 
The  tumor  may  be  taken  for  a  floating  kidney,  but  is  more  movable  from 
side  to  side,  and  when  depressed  towards  the  back  immediately  returns. 
5.  Empyema  of  the  gall-bladder. — .Symptoms  same  as  cholecystitis.  6.  Car- 
cinoma of  the  stone-containing  gall-bladder. — Digestive  disturbances  at  first 
later  cachexia,  and  jaundice  and  ascites  from  the  invasion  of  portal  glands. 
The  tumor  is  hard,  uneven,  and  only  slightly  painful.  7.  .\cute  obstruction 
of  common  duct  by  stone. — Typical  biliar}'  colic.  8.  Chronic  obstruction 
of  the  common  duct. — Jaundice  of  varying  intensity  according  to  degree 
of  obstruction.     Intermittent  fever,  pain  and  tenderness  nearer  the  middle 


CHOLECYSTOSTOMY. 


493 


line;  liver  and  often  spleen  enlarged.  This  is  in  marked  contrast  to  obstruc- 
tion of  the  common  duct  by  carcinoma  or  other  tumor,  in  whicJi  there  is 
persistent  deep  jaundice,  no  fever,  and  slight  pain.  In  the  latter  the  gall- 
bladder is  usually  distended,  in  chronic  stone  obstruction  tt  is  shrunken 
{Cmiri'oisier's  law).  Robson  gives  the  following  list  of  comfiikafums  of 
cholelithiasis:  '*  Intestinal  obstruction  due  to  localized  peritonitis,  vol vulusi 
adhesions,  or  large  gall -stones  which  have  ulcerated  into  the  bowel;  general 
hemorrhages  the  result  of  chronic  jaundice;  ailhesions  causing  pain,  even 
after  gall-stones  have  been  removed,  or  dilatalion  of  the  stomach;  fistula  into 
neighboring  viscus  or  to  the  surface  of  the  body;  stricture  of  cystic  or  com- 
mon duct;  abscess  (liver,  kidney,  pericystic,  abdominal  wall,  subphrenic, 
pancreas);  cholangitis,  simple  or  suppurative;  septicemia  or  pyemia;  phleg- 
monous or  gangrenous  cholecystitis;  perforative  peritonitis;  cancer  of  the 
gall-bladder  or  ducts;  pneumonia  of  the  right  lung  or  empyema  of  the  right 
pleura;  acute  or  chronic  pancreatitis;  cirrhosis  of  liver.'^ 

The  treatment  of  hepatic  cobc  is  the  application  of  heat  and  the  subcuta- 
neous at! ministration  of  morphin  and  atmpin.  For  the  medical  treatment  of 
cholelithiasis  the  reader  is  referred  to  a  textbook  on  medicine.  Gall-stones 
are  unaffected  by  drugs  and  the  aim  of  the  physician  is  to  cure  the  catarrhal 
intlammalion  and  prevent  the  formation  of  other  stones.  Medical  treatment 
is  intlicated  when  the  attacks  are  mild  and  widely  separated,  and  in  cases  in 
which  operation  would  he  dangerous  because  of  the  presence  of  some  inde- 
pendent aflfection.  In  the  early  stages  operation  is  easy  and  safe;  after  the 
flevclopment  of  complications,  both  the  difficulties  and  I  he  danger  are  vastly 
increased. 

Operations  on  the  biliary  passages  are  greatly  faciiitated  by  pJai  ing  a 
sand  f>ag  licneath  the  spine,  in  order  to  push  the  liver  and  ducts  forward  anfl 
allow  the  intestines  to  fall  away  from  the  field  of  operation.  In  the  presence 
of  chronic  jaundice  there  is  great  danger  of  persistent  and  uncontrollable 
hemorrhage.  In  order  to  avert  this  catastrophy,  Robson  gives  30  grains  of 
calcium  chlorid  daily  for  several  days  preceding  operation,  and  60  grains  per 
rectum  for  a  few  days  after  operation.  The  same  author  opens  the  abdomen 
through  the  middle  of  the  right  rectus  muscle,  continuing  the  incision  upwards 
and  inwards  along  the  costal  margin  as  far  as  the  ensiform  if  more  room  is 
desired.  After  separating  any  adhesions  which  may  be  present  and  packing 
otT  the  stomach  and  intestines,  the  gall-hladder  and  cystic  duct  may  he  pal- 
pated, and  a  finger  passed  through  the  foramen  of  Winslow,  in  order  to  ex- 
plore the  supraduodenal  segment  of  the  common  duel.  The  rest  of  the 
operation  depends  upon  the  conditions  found. 

Cholecyst ostomy,  or  cholccystotomy  as  it  is  sometimes  called,  is  intlicated 
in  (1)  cases  in  which  the  gall-bladder  is  sufficiently  large  to  permit  of  drainage, 
after  gall-stones  have  been  removed;  (2)  cases  in  which,  although  there  are 
gall-stones  in  the  ducts,  the  patient  is  too  ill  to  liear  a  prolonged  operation,  the 
gallstones  being  tieliberately  left  for  subsequent  treatment;  (3)  empyema  of 
the  gall  bladder,  if  the  viscus  is  not  too  much  disorganized  to  l>e  permitted  to 
remain;  (4)  certain  cases  of  chronic  catarrh  of  the  gall-bladder  or  bile  ducts; 
(5)  infective  and  suppurative  cholangitis;  (6)  obstruction  of  the  ducts  due  to 
hydatid  disease  ;  (7)  dropsy  of  the  gall-bladder  after  removal  of  obstruction; 
(8)  rupture  or  laceration  of  the  gall-bladder  or  ducts,  when  cholecystectomy 
is  undesirable;  (9)  choledochotomy,  in  order  to  avoid  tension  in  the  sutured 
duct;  (10)  certain  cases  of  obstructive  jaundice  dependent  on  malignant 


494  ABDOMEN. 

tumor  which  is  occluding  the  ducts;  (ii)  phlegmonous  cholecystitis  when 
the  patient  is  too  ill  to  bear  cholecystectomy;  and  (12)  in  chronic  pancreatitis, 
in  which  both  the  bile  and  pancreatic  ducts  are  drained  (Robson).  The 
gall-bladder  is  drawn  into  the  wound,  aspirated,  an  incision  made  in  the 
fundus,  and  the  stones  removed  with  a  scoop.  The  opening  in  the  gall- 
bladder is  sutured  to  the  transversalis  fascia  at  the  upper  angle  of  the  wound, 
and  the  gall-bladder  drained  with  a  rubber  tube.  A  better  plan  is  to  suture 
the  rubber  tube  in  the  gall-bladder  with  catgut,  depress  it  so  as  to  invert  the 
edges,  and  apply  a  purse-string  suture  (Fig.  404),  thus  making  a  tight  joint 
The  tube  should  be  long  enough  to  drain  into  a  receptacle  at  the  side  of  the 
bed.  When  the  catgut  has  been  absorbed  the  tube  is  ready  to  be  removed. 
The  mortality  of  cholecystostomy  for  gall-stones  is  i  to  2  per  cent.  The 
biliary  fistula  left  after  removing  the  tube  should  close  spontaneously. 

A  persistent  fistula  discharging  bile  is  due  to 
obstruction  of  the  common  duct;  dischai^g 
mucus  to  blocking  of  the  cystic  duct;  in 
either  case  a  secondary  operation  is  re- 
quired. In  former  days  a  biliary  fistula 
sometimes  followed  suturing  of  the  gall- 
-Purse-Strioi  bladder  to  the  skin. 

Suture  Cholecystectomy  may  be   required  in 

(i)    wounds  of  the  gall-bladder  in  whidi 
suture  is  impracticable;  (2)  stricture  of  the 
Fig.  404.— (Binnic.)  ^T^tic  duct;   (3)  phlegmonous  cholecystitis 

and  gangrene  of  the  gall-bladder;  (4)  multi- 
ple or  perforating  ulcers;  (5)  chronic  cholecystitis  in  which  the  gall-Madder 
is  too  small  to  drain,  or  in  which  it  is  enlarged,  thickened,  and  ulcerated,  the 
common  duct  being  free  from  obstruction;  (6)  mucous  fistula  due  to  stricture 
of  the  cystic  duct;  (7)  hydrops  due  to  stricture  of  the  cystic  duct;  (8)  empyema 
in  which  the  walls  of  the  gall-bladder  are  seriously  damaged;  (9)  cancer 
limited  to  the  gall-bladder  or  to  the  immediately  adjoining  parts;  (10)  other 
solid  tumors  of  the  gall-bladder,  whether  inllammatory  or  neoplastic,  and  (11) 
in  calcareous  gall-bladder  (Robson).  It  is  contraindicated  when  there  is 
obstruction  of  the  common  duct.  The  cystic  duct  and  artery  are  ligated, 
the  duct  grasped  with  hemostatic  forceps  between  the  ligature  and  the  gall- 
bladder, and  severed  between  the  forceps  and  the  ligature,  the  peritoneal  re- 
Hection  from  the  liver  split  on  each  side  of  the  gall-bladder,  and  the  gall- 
bladder removed  from  within  outwards  by  blunt  dissection.  The  peritoneal 
flaps  are  then  stitched  together,  any  oozing  from  the  liver  being  checked  bv 
sutures  or  gauze  packing.  If  bleeding  is  controlled  absolutely,  drainage 
may  be  omitted.  If  drainage  of  the  biliar>'  apparatus  is  required,  the  cvslic 
artery  alone  should  be  ligated,  and  a  rubber  tube  sutured  to  the  end  of  the 
open  cystic  duct  with  catgut.  The  mortality  of  cholecystectomy  for  gall- 
stones is  5  per  cent.  When  cholecystectomy  is  indicated  but  is  impracticable, 
e.g.,  because  of  dense  adhesions,  the  fundus  may  l>e  amputated  and  the 
lining  mucous  membrane  removed  {Mayo's  operatiofj). 

Cholecystenterostomy  consists  in  the  formation  of  a  fistula  between  the 
gall-bladder  and  duodenum,  jejunum,  or  colon.  Robson  employs  the 
operation  in  biliary  fistula*  dcj)en(ling  on  stric  ture  or  other  permanent  occlu- 
sion of  the  common  duct;  occasionally  in  cancer  of  the  head  of  the  pancreas 
or  common  duct  leading  to  chronic  jaundice;  and  rarely  in  gall-stone  im- 


PANCREATITIS. 


495 


pacted  in  the  ductSj  when  the  common  duct  cannot  be  exposed  and  the  patient 
is  in  no  condition  to  stand  a  prolonged  operation.  The  operation  is  per- 
formed by  means  of  the  Murphy  button  or  by  simple  suturing; 

Cysticotomy  is  incision  into  the  cystic  duct,  usually  for  the  removal  of  a 
calculus  which  catinot  be  pushed  backwards  into  the  gall-bladder.  The 
duct  may  be  sutured  with  catgut  or  drained  with  a  rubber  tulsc. 

Choledochotomy  is  incision  into  the  commuri  bile  duct,  for  the  removal 
of  a  stone  {ciwkdodwUthotomy),  or  for  the  purpose  of  drainage  in  cholangitis. 
WTien  the  stone  ties  in  the  supraduodenal  portion  of  the  duct,  which  is 
about  three-fourths  of  an  inch  in  length  and  runs  in  the  right  edge  of  the 
gastro-hepatic  omentum,  it  is  brought  forward  by  a  finger  in  the  foramen  of 
Winslow,  and  the  operation  completed  as  in  cysticotomy.  The  portal 
vein  and  hepatic  artery  lie  to  the  left.  The  sutures  may  be  inserted  before 
the  stone,  which  acts  as  a  guide,  is  removed.  Before  tying  the  sutures^  the 
ducts  should  be  explored  with  the  finger  or  with  the  probe.  CTUshing  of 
the  stone  without  opening  the  duct  {ihoiedochoUtlwirity) ,  or  breaking  it  up  by 
the  insertion  of  a  needle,  is  unsatisfactor>^  because  fragments  are  often  left 
behind^  Occasionally  a  stone  in  the  common  duct  may  be  manipulated  back 
into  the  gall-bladder;  it  should  never  be  forced  towards  the  duodenum.  The 
retroduodenal  portion  of  the  common  duct  is  about  two  inches  in  length, 
runs  in  or  on  the  pancreas,  and  cannot  be  palpated  without  loosening  the 
duodenum  and  turning  it  inwards.  Stones  in  this  situation  may  be  removed 
by  an  incision  in  the  upper  portion  of  tlie  duct,  or  when  occupying  the 
lower  third  of  the  choledochus,  especially  if  impacted  in  the  diverticulum  of 
Vater,  the  operation  of  duodeno-choledmhoiomy  may  ij>e  performed.  The 
anterior  wall  of  the  duoilenum  is  opened,  and  the  stune  removed  by  enlarging 
the  papilla,  or  by  incising  directly  down  upon  it  through  the  posterior  wall  of 
the  gut.  The  incision  in  the  anterior  wall  of  the  duodenum  is  then  sutured; 
it  is  not  necessary  to  place  sutures  in  the  posterior  wall.  The  mortality  of 
choledocholithotomy  is  lo  per  cent. 

HepaticGtomy,  or  incision  into  the  hepatic  duct,  has  the  same  indi- 
cations as  choledochotomy,  but  is  seldom  performed. 

Hepatico-cholaogio-enterostomy  consists  in  anastomosing  the  intes- 
tine to  an  incision  in  the  liver,  wh^n  there  is  an  irremovable  obstruction  in  the 
hepatic  duct.  Clwlani^wsiomy  is  the  establishment  of  a  fistula  between  the 
liver  and  the  skin,  chokdo<lwst&my  between  the  common  duct  and  ihe  skin, 
and  fhakdoch&*ent€foslom\  between  the  common  duct  and  the  intestine. 


THE  PANCREAS. 


For  injuries  of  the  pancreas  see  injuries  of  the  abdomen. 

Pancreatitis  is  due  to  trauma,  general  infective  thseases,  direct  extension 
from  neighboring  inflammatory  lesions,  and  most  frequently  to  infection 
by  way  of  the  duct,  as  the  result  of  catarrhal  intlammation  of  the  duodenum 
or  cholelithiasis.  Obstruction  of  the  duodenal  papilla  by  a  stone  may  cause 
pancreatic  stasis  and  regurgitation  of  infected  bile,  and  a  stone  lodged  in  the 
pancreatic  segment  of  the  common  duct  may  compress  the  canal  of  Wirsung 
and  lead  lo  pancreatic  retention,  thus  predisposing  to  infection.  Although 
the  {lisease  may  occur  at  any  age,  it  is  most,  common  during  or  after  middle 
life.     Three  forms  are  described,  the  acute,  the  suliacutc,  and  the  thronic. 


496  ABDOMEN. 

Acute  or  hemorrhagic  pancreatitis  is  characterized  by  sudden  onset 
and  rapid  progress.  The  symptoms  are  violent  epigastric  pain  and  tender- 
ness, vomiting,  constipation,  often  slight  jaundice,  frequently  distention  of  the 
abdomen,  and  the  usual  signs  of  collapse.  Death  occurs  in  from  twenty-four 
hours  to  one  week.  The  gland  is  swollen,  hyperemic,  and  often  infiltrated 
with  blood.  In  many  cases  there  are  small  yellowish-white  patches  (/fl/ 
necrosis)  on  the  pancreas,  in  the  omentum  and  mesentery,  and  occasionallj 
in  more  remote  situations,  due  to  the  escape  of  pancreatic  ferments,  which 
split  up  the  fat  into  glycerin  and  fatty  acids,  the  former  being  absorbed,  and 
the  latter  precipitated  with  calcium  salts.  Acute  pancreatitis  may  be  mistaken 
for  intestinal  obstruction,  perforation  of  the  stomach  or  duodenum,  acute 
cholecystitis  (which  it  may  accompany),  appendicitis,  and  acute  gastritis  the 
result  of  swallowing  irritant  poisons.  The  urine  may  contain  sugar,  leudn 
and  tyrosin.  lypolytic  substances,  or  derivatives  of  glycerin  (Cantmidge's 
tesi),  but  the  disease  is  so  rapid  that  urinary  changes  are  often  absent. 

The  treatment  is  drainage.  The  abdomen  will  usually  be  opened  in  the 
median  line  above  the  umbilicus  for  exploration.  The  pancreas  itself  may 
be  exposed  either  above  or  below  the  stomach,  preferably  by  the  latter  route, 
after  tearing  through  the  gastrocolic  omentum.  A  gauze  drain  may  then  be 
inserted  into  the  lesser  peritoneal  cavity.  It  is  seldom  necessary  to  tie  the 
vessels  in  the  pancreas,  as  the  loss  of  blood  is  not  the  cause  of  death.  The  pan- 
creas may  be  drained  also  by  an  incision  in  the  loin,  the  drain  gaining  exit 
below  the  lower  pole  of  the  kidney,  preferably  the  left.  Drainage  of  the  gall- 
bladder also  is  indicated  if  there  be  gall-stones  or  cholecystitis.  A  few  cases 
have  recovered  with  this  form  of  treatment. 

Subacute  pancreatitis  is  such  from  the  beginning,  or  follows  the  acute 
form  if  the  patient  survives,  the  symptoms  at  first  being  much  the  same  but 
less  severe.  At  a  later  period  suppuration  (suppurative  pancreatitis)  or  gan- 
grene {gangrenous  pancreatitis)  occurs  and  septic  symptoms  develop,  viz., 
chills,  fever,  sweats,  rapid  emaciation,  and  frequently  diarrhea  with  foul 
smelling  or  bloody  stools.  If  an  abscess  forms,  the  swelling  may  be  detected 
in  the  epigastrium  or  in  the  loin,  or  the  pus  may  gravitate  to  either  iliac 
region.  The  prognosis  is  somewhat  less  gloomy  than  in  the  hemorrhagic 
form.  The  treatment  is  drainage  by  one  of  the  routes  mentioned  above,  with 
the  removal  of  gall-stones  and  drainage  of  the  biliary  passages  if  there  be 
cholelithiasis. 

Chronic  pancreatitis  is  characterized  by  a  marked  increase  in  the  con- 
nective tissue,  which  causes  the  pancreas  to  become  large  and  hard.  The  con- 
nective tissue  may  be  more  marked  between  the  lobules  {interlobular  pan- 
creatitis) or  in  the  lobules  {interacinar  pancreatitis) ;  in  the  latter  form,  which 
is  less  common  than  the  interlobular  variety,  the  islands  of  Langerhans  are 
involved  and  glycosuria  is  present.  The  islands  of  Langerhans  are  supposed 
normally  to  manufacture  an  internal  secretion  which  prevents  glycosuria. 
The  symptoms  are  emaciation,  pain  after  eating,  paroxysms  of  pain  and 
vomiting,  and  tenderness  in  the  epigastrium.  The  pain  radiates  to  the  inter- 
scapular region  and  towards  the  left  shoulder.  The  pancreatic  point  oj 
Desjardin,  which  corresponds  with  the  opening  of  the  canal  of  Wirsung  into 
the  duodenum  and  which  is  .supposed  to  be  the  point  of  greatest  tenderness, 
is  situated  from  5  to  7  cm.  from  the  umbilicus  on  a  line  running  to  the  right 
axilla  (Fig.  .^67. )  ( liolelithiasis.is  frequently  present,  and  there  may  be  jaun- 
dice from  this  cause,  or  as  a  result  of  the  pressure  of  the  contracting  pan- 


SPLENOPTOSIS. 


497 


creatic  tissue  on  the  common  bile  duct.  Rarely  is  it  possible  to  outline 
the  pancreas  by  palpation.  The  urine  may  contain  sugar  (if  the  islands 
of  Laogerhans  arc  involved),  fat,  glycerin  derivatives,  or  leudn  and  ty rosin. 
An  excess  of  fat  and  muscle  liber  may  be  demonstrated  in  (he  feces,  which 
are  often  clay  colored,  even  when  bile  is  present*  WTien  salol  is  adminis- 
tered by  mouth  it  is  not  decomposed,  and  carbolic  and  saiicyluric  acids  do 
not  appear  in  the  urine  {Sa/iU's  sign).  The  treatment  is  removai  of  gall- 
stones, if  present,  and  indirect  drainage  of  the  pancreas  by  choiecystostomy. 
The  mortality  of  operation  is  about  12  per  cent. 

Pancreatic  calculi  are  formed  much  in  the  same  manner  as  gall-stones, 
and  pancreatic  colic  is  much  like  gall-stone  coHc,  except  that  the  pain  is 
below  and  to  the  inner  side  of  the  gall-bladder  and  may  be  reflected  to  the 
left  shoulder.  Pancreatic  calculi  may  be  associated  with  gall-stones  or  with 
the  various  forms  of  pancreatitis,  and  sometimes  cause  a  retention  cyst  by 
damming  up  the  secretion  of  the  gland.  In  a  few  instances  they  have  been 
removed  by  operation. 

Tumors  of  the  pancreas  include  carcinoma,  sarcoma,  adenoma,  and 
syphiloma.  Primary  growths  are  rare.  Carcinoma  is  the  most  frequent, 
and  chieily  afifects  the  head  of  the  glajitl.  The  symptoms  are  indigestion, 
epigastric  pain,  emaciation,  and  in  the  later  stages  jaundice^  painless  swet- 
ling  of  the  galbltladden  enlargement  of  the  liver,  and  the  appearance  of 
a  tumor.  The  signs  of  interference  with  the  functions  of  the  pancreas 
alrea<ly  mentioned  also  may  be  found.  The  treatment  is  symptomatic, 
although  if  detected  at  any  early  period,  excision  would  be  indicated. 

Pancreatic  cysts  are  uncommon,  generally  arise  after  middle  age,  and 
may  be  true  or  false.  True  cysts  arise  within  the  gland  and  include  reten- 
tion  cysts  (pancreatic  ranula),  congenital  cystic  disease,  rysladenoma, 
hydatids,  and  hemorrhagic  cysts.  Pseudocysts  are  usually  elTusions  into  the 
lesser  peritoneal  cavity,  the  result  of  injur>^  or  inflammation,  but  may,  how- 
ever^  communicate  with  the  pancreas  and  contain  a  proteolytic  anrl  an  emulsi- 
fying ferment.  The  symptoms  are  indigestion,  vomiting,  and  frequently 
epigastric  pain.  Other  symptoms  are  due  to  pressure  on  environing  organs, 
or  to  interference  with  the  functions  of  the  pancreas,  such  as  have  already 
been  mentioned.  The  patient  usually  emaciates  and  beroraes  sallow  and 
weak.  When  of  large  size  the  cyst  reaches  the  alnlomina!  wall  between  the 
stomach  and  the  colon,  although  it  may  be  above  the  stomach  or  distend 
the  layers  of  the  mesocolon.  It  is  usually  immovable  and  at  least  partly 
covered  by  stomach  tympany.  The  treatment  in  suitable  rases  is  extirpation. 
In  most  instances  this  will  be  impossible  l)ecause  of  adhesions,  and  it  will 
then  be  necessary  to  stitch  the  cyst  to  the  anterior  abdominal  wall  and  drain  it. 


THE  SPLEEN. 

For  injuries  of  the  spleen  see  contusions  of  the  abdomen. 

Splenoptosis  (wandering  or  mcn*ab(e  spleen)  is  usually  a  part  of  Gl^nard's 
disease^  or  is  caused  by  enlargement  of  the  spleen.  The  sytnptoms  are  indi- 
gestion, vomiting,  dragging  pain,  absence  of  normal  splenic  dulness,  and  the 
presence  in  the  abdomen  of  a  movable  tumor  with  a  marked  notch.  The 
chief  danger  is  twisting  of  the  pedicle,  which  may  lead  to  gangrene  of  the 
organ.  The  treatmaU  is  the  application  of  a  pad  or  belt.  If  this  is  unsur- 
ce.ssful,  the  spleen  may  be  removed,  or  sutured  to  the  al>ilominal  wall  (spieno- 

J2 


498  ABDOMEN. 

pexy).  As  sutures  are  apt  to  cut  out  and  cause  profuse  bleeding,  a  better 
meUiod  is  to  slip  the  spleen  into  a  pocket  formed  by  separating  the  parietal 
peritoneum  from  the  abdominal  wall,  the  peritoneum  being  sutured  to  the 
abdominal  wall  at  the  bottom  of  the  pouch  (Rydygier's  method).  Torsion 
of  the  pedicle  and  gangrene  require  splenectomy. 

Abscess  may  be  caused  by  trauma,  extension  from  neighboring  organs. 
acute  infectious  diseases,  chronic  malaria,  and  pyemia.  Chronic  suppuratkn 
may  be  due  to  syphilis,  tuberculosis,  or  actinomycosis.  The  symptoms  are 
pain,  tenderness,  and  enlargement  of  the  spleen,  with  the  general  symptoms 
of  sepsis.  The  treatment  is  the  same  as  for  abscess  of  the  liver,  or  ^lenec- 
tomy  if  much  of  the  organ  is  disorganized. 

Splenectomy  has  been  performed  for:  (i)  Injuries;  (2)  spontaneous 
rupture  in  typhoidal  and  other  splenic  enlargements;  (3)  splenoptosis;  (4) 
abscess;  (5)  tumors,  which  are  rare,  the  most  frequent  being  sarcoma;  (6) 
cysts,  hemorrhagic,  serous,  lymph,  or  most  frequently  hydatid ;  (7)  malarial 
hypertrophy;  (8)  idiopathic  splenomegaly;  (9)  splenic  anemia  (splenic  pseu- 
doleukemia), in  which  there  is  enlargement  of  the  spleen,  with  diminution 
in  the  number  of  white  and  red  blood  cells  and  a  reduction  in  the  percentage 
of  hemoglobin;  (10)  Banti\s  disease  (hypertrophy  with  drrhosis  of  the  liver); 
and  (11)  certain  other  affections,  such  as  tuberculosis,  syphilis,  and  amyloid 
di.sease.  I'he  operation  is  contraindicated  in  leukemia  and  in  the  presence  of 
marked  cachexia  and  dense  universal  adhesions.  An  incision  is  made  in  the 
left  semilunar  line,  the  phrenosplenic  ligament  tied  and  divided,  the  spleen 
delivered  through  the  wound,  and  each  vessel  of  the  pedicle  severed  between 
ligatures.  The  mortality  of  the  operation  for  all  conditions  is  26  per  cent. 
(Carstens).  Sui>se(|uent  to  splenectomy  there  is  a  reduction  in  the  number 
of  red  cells  and  in  the  percentage  of  hemoglobin,  an  increase  in  the  number 
of  white  cori)us<  les,  and  often  enlargement  of  the  lymph  glands,  with  head- 
ache, emaciation,  and  sometimes  rapid  pulse  and  fever.  These  symptoms 
may  last  weeks  or  months  before  good  health  is  obtained. 

ABDOMINAL  HERNIA,  OR  RUPTURE. 

The  word  hernia  is  sometimes  employed  in  connection  with  the  brain, 
lung,  muscle,  or  other  parts,  but  when  used  without  qualification  means  a 
protrusion  of  a  portion  of  the  contents  of  the  abdomen  through  a  normal  or 
artificial  opening  in  the  abdominal  wall,  the  protruded  parts  being  contained 
in  a  sac.  When  the  abdominal  contents  escape  through  a  wound,  the  condi- 
tion is  called  prolapse  and  not  hernia. 

The  causes  of  hernia  are  congenital  and  accjuired.  Among  the  congeni- 
tal causes  are  (i)  non-obliteration  of  a  normal  peritoneal  diverticulum,  e.g.. 
the  funicular  process,  which  i)recedes  the  testicle  in  its  descent,  and  passes 
along  the  spermatic  cord  or,  in  the  female,  the  round  ligament;  (2)  abnormal 
congenital  apertures,  e.g.,  in  the  mesentery,  diaphragm,  linea  ailba,  or  linea 
semilunaris;  (.^)  unusually  large  normal  apertures,  e.g.,  the  umbilical. 
inguinal,  and  femoral  rings;  (4)  weakness  of  the  abdominal  muscles  (often 
inherited);  (5)  abnormal  length  of  the  mesenter}'  or  omentum;  and  (6)  imper- 
fectly (les(  ended  testicles.  Among  the  acquired  causes  are  (i)  those  which 
weaken  the  alxlominal  wall,  e.g.,  prolonged  illness,  operations,  injuries,  and  in- 
traabdominal tumors  and  pregnancy,  which  weaken  the  walls  by  stretching; 
(2)    those    whi<h    increase    the  intraabdominal  pressure,  e.g.,  ascites    in- 


HEUNIA. 


499 


traalxlominal  tumors,  obesily,  tight  belts,  and  all  conditions  whidi  necessitate 
straining,  such  a^  laborious  occupations,  phimosis,  enlarged  prostate,  con- 
stipation, antl  diseases  of  the  air  passages  associated  with  persistent  cough ;  and 
(j)  tho^e  which  drag  on  the  peritoneum,  suih  as  ricat rices  and  tumors, 
particularly  the  subperitoneal  bpoma.  Hertiia  is  most  frequent  in  the  first 
year  of  life,  iq,  6  cases  in  even*  looo  iotJividuals  according  to  Berger;  it  then 
decreases  in  frequency  until  the  minimum  is  reached  in  the  twentieth  to  the 
twenty- fourth  year,  and  gradually  increases,  owing  to  degeneration  of  the 
muscles,  as  age  advances.  Hernia  is  three  times  more  frequent  in  males 
than  in  females. 

In  structure  a  hernia  consists  of  (i)  a  mouth,  (2)  a  sac,  (3)  the  coverings 
of  the  sac,  and  (4)  the  contents,  i.  The  mouth  is  the  opening  in  the  parietes 
which  is  usually  called  the  ring;  in  certain  situations,  as  in  the  inguintd  region, 
the  opening  is  more  or  less  canalicular  and  diere  are  an  internal  and  an 
external  ring.  2.  The  sac  is  the  peritoneal  pouch  covering  the  contents  of 
the  hernia.  In  the  early  stages  of  an  acquired 
hernia  die  sac  is  thin  and  funncl-shapcrl;  later 
it  Ijecomes  larger^  thicker,  and  more  globular. 
It  consists  of  a  neck,  a  body,  and  a  fundus^  and 
is  formed  hy  stretching  and  sliding  of  the  peri- 
toneum, hence  when  a  hernia  appears  sud- 
denly, excluding  actual  ruptures  of  the  aljdom- 
inal  muscles  {iraumatk  hcrniu),  there  must  have 
been  a  preformed  (congenital)  sac.  As  the 
result  of  irritation  or  inflammation,  from  pres- 
sure or  injurj%  the  sac  may  become  adherent 
to  the  contents,  or  be  divided  into  two  {hmif- 

glass)  or  more  saccules  or  diverticula.  It  is  always  adherent  to  its 
coverings,  hence  is  irreducible,  although  the  contents  may  be  reducible. 
(Occasionally  the  sac  or  a  saccule  becomes  completely  shut  off  and  filled 
with  fluid  {hydrocele  of  Ihc  sac).  As  the  sac  is  merely  a  peritoneal  diver- 
ticulum it  may  participate  in  any  of  the  affections  of  the  peritoneal  cavity, 
e.g.,  ascites,  carcinomatosis,  tuberculosis,  acute  peritonitis.  T'he  exceptions 
to  the  rule  that  a  hernia  must  have  a  peritoneal  sac  are  certain  sliding  hernias, 
certain  hernias  following  abdominal  operations  or  injuries,  diaphragmatic 
hernia,  and  retroperitoneal  hernias.  SHdlng  hernia  is  a  term  applied  to 
hernias  of  the  ascending  and  descending  colon.  These  structures  usually 
have  no  mesentery  anri  when  they  slip  down  through  the  inguinal  canal  the 
normal  arrangement  of  the  peritoneum  is  preserved,  hence  the  posterior  portion 
of  the  sac  is  absent  (Fig.  405 ) .  3 .  The  coverings  of  the  sac  vary  with  the  situa- 
tion of  the  hernia  and,  excepting  the  skin,  are  usually  indistinguishable  as 
separate  structures.  4,  The  contents  may  l>e  any  abdominal  viscus,  hut  is 
usually  the  small  intestine  (entrnneie),  omentum  (e pi  pi  ocek),  or  both  (etitero- 
cpiplocdc).  When  only  a  portion  of  the  circumference  of  the  intestine  lies 
within  the  sac  (partial  entrrocelt,  or  Richter's  hernia),  the  hernia  is  ver>'  small, 
and  if  strangulation  occurs,  the  symptoms  of  obstruction  are  not  complete. 
Lillri's  hernia  is  a  hernia  of  Meckel's  diverticulum.  The  cecum,  with  or 
without  the  appendix,  has  been  found  in  even  a  left  femoral  hernia  (cccoceit). 
As  it  usually  has  a  mesentery,  it  generally  lies  within  the  hernial  sac;  but 
when  the  mesentery  is  absent,  the  cecum  may  be  partly  within  and  partly  with- 
out the  hernial  sac,  the  soralled  sliding  hernia  of  the  cecum.     The  bladder  may 


Fig.  405. — ^Diagram  of  slid- 
ing hernia  of  the  colon.  A . 
Peritoneum. 


500  ABDOMEN. 

be  encountered  in  a  direct  inguinal  hernia  (cystoceU).  As  a  rule,  the  herniated 
portion  of  the  bladder  is  acUierent  to  the  sac  and  hence  partly  covered  with 
peritoneum  and  partly  extraperitoneal,  but  it  may  be  wholly  within  or  with- 
out the  sac.  The  condition  may  be  suspected  if  the  bladder  is  irritable,  if  the 
hernia  increases  in  size  when  the  bladder  is  filled  and  lessens  in  size  when  it  is 
emptied,  and  if  pressure  upon  the  hernia  causes  a  desire  to  urinate.  In 
many  cases  the  bladder  has  been  opened  for  the  sac  of  the  hernia;  in  the 
event  of  such  an  accident  the  wound  should  be  sutured  like  a  wound  in  the 
intestine,  and  a  retention  catheter  passed  into  the  bladder  through  the  urethra. 
The  bladder  lies  to  the  inner  side  of  and  behind  the  other  contents  of  the 
rupture,  and  is  usually  covered  by  a  large  quantity  of  fat.  If  its  presence  is 
suspected  during  an  operation,  the  bladder  should  be  distended  or  a  sound 
passed  into  it.  Loose  bodies,  sometimes  as  large  as  marbles  and  probably 
representing  detached  appendices  epiploicie,  are  occasionally  found  in  the 
sac  of  a  hernia. 

The  signs  of  an  uncomplicated  enterocele  are  (i)  a  soft  swelling^  (2) 
which  is  in  the  usual  situation  of  a  hernia,  (3)  is  inseparable  from  the  ab- 
dominal wall,  (4)  has  an  expansile  impulse  on  coughing,  (5)  is  tympanitic  on 
percussion,  (6)  disappears,  often  suddenly  and  with  a  gurgle,  on  recumbency 
or  pressure,  (7)  when  the  hernial  orifice  may  be  felt,  and  (8)  which  reap- 
pears when  the  patient  stands  or  strains.  An  epiplocele  is  dull  on  per- 
cussion, feels  more  doughy,  has  a  less  marked  impulse,  and  reduction  is 
more  difficult  and  unaccompanied  by  a  gurgle.  The  patient  may  complain 
of  pain,  indigestion,  and  constipation. 

The  treatment  may  be  palliative  (trusses)  or  radical  (operation),  but 
such  is  best  considered  with  the  special  forms  of  hernia?. 

SPECIAL  HERNIiE. 

Inguinal  hernia  constitutes  about  80  per  cent,  of  all  hernije,  is  much 
more  common  in  males,  and,  owing  to  the  later  descent  of  the  right  testicle, 
which  keeps  the  inguinal  canal  patent  for  a  longer  period,  is  more  frequent 
on  the  right  side.  A  classification  of  the  principal  forms  of  inguinal  hernia 
is  given  in  the  subjoined  table. 

^  .     .     I      J  a.  Incomplete 

'  ^^  [  1).  Complete  (scrotal  or  labial) 

w    1.  If.         )  I  a.  Vai<inal 

I.     Indirect  or  oblique  \  ^       Congenital  J  b.  Funicular 


c. 


infantile 


(1.     Kncvsted  infantile 


II.     Direct  (always  acquired) 


f,.     Intra,>arietal{\"„\;^^'J";.^, 
111.     Interstitial  (usually  congenital)       {2.     Interparietal    I '^"^^^^^»<-ai 

■  3.     IC.xtraparictal 

I. — The  indirect  or  oblique  is  called  also  external  inguinal  hernia, 
from  the  fact  that  it  enters  the  internal  ring  in  the  external  inguinal  fossa, 
external  to  the  deep  epigastric  arter}'. 

I.  Acquired  indirect  inguinal  hernia  (Fig.  40S),  in  which  the  sac  is 
gradually  formed  from  the  parietal  peritoneum,  may  (a)  distend  the  inguinal 
( anal  ()nly  {ituomplete  in ^^uinal hernia  or  bubonotde),  or  it  may  (b)  pa.ss  into  the 


INGUINAL   NERNtA. 


!;ot 


Fig.  406. — Complete  oblique  hernia  on 
the  left  J  bubormxrele  on  the  right. 


scrotum  (stmtal  hfrtiia)  or^  in  the  femaJt%  inio  thf  labium  majus  (hhial 
hemia),  when  it  constitutes  a  complete  inguinal  hernia  (Fig,  406).  The  cover- 
ings of  a  complete  indirect  inguinal  hernia  are  the  sac,  with  subperitoneal  fat; 
infundibulilorm  fascia,  derived  from  the  _ 

transversal  is  fascia;  cremasteric  fascia 
and  muscle,  derivtxl  from  the  internal 
oblique;  intercolumnar  fascia,  derived 
from  the  external  oblique;  deep  and 
superficial  fasciie;  and  the  skin.  In  old 
cases  the  internal  ring  may  lie  directly 
behind  the  external  ring,  simulating  very 
closely  a  direct  hernia.  The  sac  always 
lies  in  front  of  the  spermatic  cord. 

2.  Congenital  indirect  inguinal  litr- 
nia  owes  its  existence  to  nonobliteration 
of  the  funicular  process  of  peritoneum. 
It  usually  appears  at  or  soon  after  birth, 
although  it  is  not,  as  the  term  congenital  implies,  always  present  at 
this  time,  but  may  occur  at  any  period  of  life  as  the  result  of  a  sud- 
den strain  forcing  apart  the  apposed  peritoneal  layers,  indeed,  some  au- 
thors go  so  far  as  to  attribute  prac- 
tically all  hernias  to  a  persistent  ante- 
natal sac.  It  is  never  gradual  in 
onset  but  becomes  complete  at  once^ 
and  the  sac  is  invariably  densely  ad- 
herent to  the  cord.  Inguinal  hernia  in 
the  female  is  almost  always  congen- 
ital, the  patent  tube  of  peritoneum 
(canal  of  Nuck)  following  the  round 
ligament,  (a)  In  the  vaginal  form 
(Figs.  407  and  409)  the  bowel  passes^ 
directly  into  the  tunica  vaginalis,  sur- 
rountling  and  concealing  the  testicle. 
(I>)  In  Junictdar  hernia  (Fig.  410)  the 
funicular  process  remains  patent  for  a 
variable  distance,  but  is  always  shut 
oflf  from  the  tunica  vaginalis,  (c)  In 
injani He  hernia  (Fig.  411)  the  funicular 
process  is  closed  at  its  abdominal  end 
only,  the  hernia  (in  a  special  sac) 
passing  downwards  behind  the  process 
or  (d)  in  vagina  ting  it  (encysted  infan- 
!ik  /ternia) ;  thus  there  are  three  layers 
of  peritoneum  in  front  of  the  hernia 
(Pig.  412).  Any  inguinaJ  hernia,  but 
more  particulariy  the  congenital  forms, 
may  be  associated  with  a  hydrocele  of 
the  cord  or  testicle. 
II.— Direct  inguinal  hernia  (Fig.  413)  is  always  acquired,  and  generally 
appears  late  in  life.  It  originates  in  the  internal  inguinal  fossa,  to  the  inner 
side  of  the  deep  epigastric  artery,  i.e.,  in  Hesselhach's  triangle.     The  sper- 


Fio. 


407. — Double  CDngemtal  hernia, 
(Pennsylvania  Hospital.) 


:^02 


ABDOMEN. 


matic  cord  generally  lies  to  the  outer  side  of  the  hernia,  which  emerges  at  the 
outer  side  of  the  conjoined  tendon,  or  splits  or  pushes  that  structure  before  it 
thus  entering  the  inguinal  canal  and  appearing  at  the  external  ring.  When 
passing  to  the  outer  side  of  the  conjoined  tendon  its  coverings  are  the  same 
as  those  of  indirect  inguinal  hernia,  except  that  the  transversalis  fasda  b 
substituted  for  the  infundibuliform  fascia;  the  conjoined  tendon  also  is 
added  to  the  coverings  when  the  hernia  pushes  that  structure  before  it. 

III. — Interstitial  hernia,  instead  of  passing  regularly  through  the  in- 
guinal canal,  insinuates  itself  between  the  layers  of  the  abdominal  wall. 
Over  one-half  of  the  cases  are  cryptorchids.  Three  forms  are  described: 
(i)  In  properitoneal  or  intraparietal  hernia,  the  sac  lies  between  the  peritoneum 
and  the  transversalis  fascia,  either  extending  outwards  (intrailiac)  or  inwards 


Fig.  408. 
Acquired  ingui- 
nal hernia. 


V  V 

Fk;.  409.          Fig.  410.  Fig.  411.               Fig.  412. 

Vaginal  form    Hernia  into  Infantile  Encysted  infan- 

of  congenital      funicular  hernia.                  tile  hernia. 

inguinal  hernia,     process. 


Diagram  nf  hernia*.     C.  Conl.     S.  Sac.     T.  Testiile.     V.  Tunica  vaginalis. 

(anteveskal),  U  there  i.s  also  a  sac  in  the  scrotum  the  condition  is  called 
hernia  en  bissac.  (2)  In  interparietal  hernia  the  sac  may  be  between  the  trans- 
versalis muscle  and  fascia,  the  external  and  internal  oblique,  or  between  the 
external  oblique  and  the  transversalis  fa.scia,  the  other  muscles  having  been 
pushed  aside.  (3)/"  superficial  inguinal  hernia  {extra parietal)  the  sac  lies  be- 
tween the  external  oblique  and  the  skin.  In  any  strangulated  interstitial 
hernia  in  which  the  sac  is  bilocular,  the  bowel  may  be  pushed  from  the 
superficial  into  the  deeper  sac,  and  the  symptoms  of  strangulation  persist 
after  apparent  reduction;  this  is  the  explanation  of  the  so-called  reductum 
en  masse,  or  en  bloc,  it  being  very  doubtful  whether  a  hernial  sac  is  ever  torn 
from  its  attachments  and  reduced  with  the  contents. 

The  signs  of  an  inguinal  hernia  are  those  already  mentioned  in  describ- 
ing the  general  features  of  hernia  (p.  500).  The  swelling  increases  in  sise 
from  above  downwards  and  the  testicle  lies  below  and  behind.  In  the  male 
the  external  inguinal  ring  may  be  felt  by  invaginating  the  skin  of  the  scrotum 
with  the  index  finger;  if  it  enters,  the  ring  is  abnormally  large. 

The  diagnosis  is  usually  easy,  but  may  be  diflicult  or  impossible  without 
operation.  In  oblique  hernia  the  canal,  at  least  in  the  beginning,  passes 
upwards  and  outwards,  and  in  rare  instances  the  deep  epigastric  artery  may 
be  felt  to  the  inner  side.  Direct  hernia  occurs  in  adults,  usually  stops  at 
the  root  of  the  scrotum,  has  the  deep  epigastric  arter>'  to  its  outer  side,  and 
passes  directly  backwards  through  the  abdominal  wall.  The  conditions 
which  may  be  mistaken  for  inguinal  hernial  are: 


INGUINAL  HBKNIA. 


cavity    fluctuates,   may    be    on   i 
of  the  femoral  vessels,  and  may   \J 
ed  with  other  signs  indicatinfi:  its 


Dirctt  i Inguinal  hernia. 


I. — Reducible  swellings  which  give  (a)  an  expansilt-  or  (b)  a  nonexpansile 
(lifting)  impulse  on  coughing. 

(a)  Reducible  swellings  w^ith  an  expansile  impulse:  (i)  In  femoral  hernia 
the  orifice  is  below  Poupart's  ligament  and  to  the  outer  side  of  the  pubic 
spine;  in  inguinal  hernia  above  Poupart's  ligament  and  internal  to  the  pubic 
spine  (Fig.  423);  in  the  former  the  inguinal  canal  remains  empty.  In  in- 
guinal hernia  retiuction  is  efTected  i>y  pushing  upwards,  outwards,  and 
backw^ards,  and  in  femoral  hernia,  downwarils  and  then  upwards  and  back- 
wards, (2)  C&ngettiiai  hydroiek  is  translucent,  and  slowly  reducible  without 
a  gurgle,  but  is  very  apt  to  be  associated  with  a  hernia.  (3)  Varkocek  feels 
like  a  **bag  of  worms/'  and  reappears  from  below  upw^ards  after  compres- 
sion, even  when  the  fmger  blocks  the  inguinal  canal.  (4.)  A  psoas  or  other 
chromic  abscess  communicating  wnth  the 
abdominal 
either  side 

be  associated  witti  other  signs  indicatmg  : 
nature,    e,g,,      vphosis,   mass   in    the   iHac 
region,   etc. 

(b)  Reducible  swellings  with  a  nonex- 
pansile  impulse:  (i)  Subperitoneal  lipoma 
always  has  the  same  shape  and  consistency; 
it  may,  however,  be  the  pilot  of  a  hernial 
sac.  (2.)  In  utidescemird  iesiicle  the  scrotum 
is  empty;  the  swelling  is  elastic,  more  or  less 

circumscribed,  and  gi%^es  the  testicular  sensation  on  pressure.  There  is 
usually,  however,  a  hernia  above  the  testicle.  An  inflamed  or  twisted 
undescended  testicle  may  give  symptoms  almost  identical  with  those  of 
strangulated  hernia. 

IL — ^Irreducible  swellings,  all  of  w^hich  may  have  a  lifting,  but  never 
an  expansile,  impulse:  (1)  Enlarged  inguinal  glands  are  bbulated,  caused 
by  irritation  in  the  area  ivhicJi  ihey  drain,  and  the  inguinal  canal  is  free.  (2) 
Encysted  hydroeclt  of  the  cord  is  translucent,  elastic,  circumscribed,  and 
cannot  be  reduced  when  traction  is  made  on  the  cord.  (3)  In  hydrocele  of 
tlie  testis  the  swelling  develops  slowly,  beginning  below  and  spreading  up- 
wards; stands  out  from  the  abdomen,  from  w^hich  it  may  be  separate*!  by  the 
fingers;  is  translucent  (unless  the  walls  are  vltv  thick,  or  blood  or  spermatic 
fluid  be  the  contents),  dull  on  percussion,  and  not  reducible  (excepting  those 
which  communicate  with  the  abdomen  or  with  a  second  sac).  (4)  Hrm- 
atocele  of  the  cord  follow^s  injur)'  and  is  associated  with  pain  and  ecchymosis.  ( 5) 
Swell  in  gs  in  the  Imcer  scroium,  e.g.,  spermatocele,  hematocele,  orchitis,  tumors 
of  the  testicle,  etc.,  are  generally  readily  difirerentiate<l  from  hernia  by  the 
freedom  of  the  cord  above,  and  the  absence  of  a  swelling  in  the  inguinal  canal. 

The  treatment  may  be  palliative  or  radical. 

Palliative  treatment  consists  in  tlie  application  of  a  truss  and  the  re- 
moval of  all  sources  of  straining.  A  year  or  tw^o  of  this  treatment  in  children 
will  often  result  in  cure.  The  younger  the  child,  the  greater  the  chances  of  cure. 
A  truss  consists  of  a  pad  for  the  hernia,  held  in  place  by  a  steel  spring,  which 
passes  backward  on  the  same  side,  midway  between  the  crest  of  the  ilium  and 
the  top  of  the  trodianter,  to  just  behind  the  anterior  superior  spine  of  the 
opposite  side,  whence  it  is  continued  with  a  strap,  w^hich  is  fastened  to  the 
pad.     A  second  strap  passing  beneath  the  thigh  may  be  necessary  to  hold  the 


504  ABDOMEN. 

truss  ill  place.  The  measure  to  be  given  to  an  instrument  maker  is  thai  ot 
the  line  for  the  truss  just  described;  the  size  of  the  hernia  and  of  the  orifice 
also  should  be  mentioned.  The  pad  may  be  of  vulcanite,  rubber,  etc.,  and 
should  rest  over  the  internal  ring  in  oblique  hernia,  over  the  external  ring  in 
direct  hernia.  It  should  rest  on  the  soft  tissues  only,  and  should  not  be  so 
small  or  so  convex  as  to  project  into  and  dilate  the  opening;  the  spring  should 
be  strong  enough  to  retain  the  hernia  under  all  strains,  but  without  injurious 
pressure.  In  adults  the  truss  is  ordinarily  worn  during  the  day,  being  putim 
before  rising  and  removed  after  retiring.  In  young  children,  in  whom  there 
is  a  chance  of  cure,  the  truss  should  be  worn  also  at  night,  as  a  single  escape 
of  the  hernia,  even  after  months  of  treatment,  wHl 
I  I         cancel  all  the  good  which  has  been  done.     In 

i ^'>V  -W      irreducible  herniae  cup  or  bag  trusses  are  some- 

fr*" '&^f3l      t™^s  employed.    Fig.  414  shows  the  applicatiOD 

/^^  ;/  ^^\      of  a  skein  of  wool  as  a  truss  in  the  treatment  of 

I  ^^fcj^    ^\j^     1      hernia  in  children.     The  wool  is  changed  twice  a 
I        ^^g^jy  day  or  whenever  soiled. 

\  %B  \  ^^^  radical  treatment  of  inguinal  hernia 

\  \^  \      ^^  become  so  safe  and  sure  that  it  is  recom- 

\  if  /       mended  in  all  cases  after  the  age  of  three,  if  truss 

\  \\  I       treatment  has  failed,  and  up  to  the  age  of  sixty, 

Fig.  414. -WcMjl  truss  for  providing  there  is  no  visceral  disease  to  contrain- 
hernia  in  chilflren.  (Rose  dicatc  operation.  The  mortality  is  less  than  one 
and  Carlcss.)  per  cent.,   recurrences  less  than    two   per  cent. 

(Coley) ;  80  per  cent,  of  the  latter  occur  within  the 
first  year.  These  statements  do  not  apply  to  enormous  hemiae,  in  which  the 
danger  of  operation  is  by  no  means  small,  and  the  chances  of  recurrence 
ver>'  great.  Direct  hernias  also  arc  prone  to  recur,  because  of  the  flabbiness 
of  the  muscles,  the  large  size  of  the  orifice,  the  absence  of  a  canal,  and 
because  the  sac  is  often  formed  partly  by  the  bladder  and  therefore  cannot 
be  completely  removed.  While  a  patient  with  a  reducible  hernia  and  a 
comfortable  truss  may  be  offered  operation,  one  with  a  hernia  which  is 
irreducible,  which  a  truss  does  not  retain,  which  occasionally  becomes 
incarcerated  or  iiitlamed,  or  which  is  associated  with  an  undescended  testicle 
or  a  reducible  hydrocele,  should  be  ur^ed  to  accept  radical  treatment.  The 
operations  whit  h  have  been  advocated  for  this  purpose  are  many  and  space 
can  be  given  only  to  the  most  important. 

Bassini's  operation  is  performed  as  follows:  An  incision  is  made 
parallel  with  and  one-half  inch  above  Poupart's  ligament,  from  the  external 
to  just  above  the  internal  ring.  The  superficial  epigastric  and  the  superficial 
external  pudic  vessels  are  secured,  and  the  aponeurosis  of  the  external  oblique 
divided  in  the  direction  of  its  fibers,  from  the  external  ring  upwards  and 
outwards,  the  flaps  being  separated  from  the  subjacent  tissues.  The  sac  is 
now  separated  from  the  spermatic  cord  by  blunt  dissection,  opened  to  make 
sure  there  are  no  adherent  structures,  ligated  as  high  as  possible,  either  with 
silk  or  catgut,  and  severed  beyond  the  ligature,  the  stump  retracting  into  the 
abdominal  cavity.  The  spermatic  cord  is  separated  from  its  bed,  and  held 
aside  by  a  blunt  hook  or  loop  of  gauze,  while  the  internal  oblique  and  trans- 
versalis  muscles,  as  one  layer,  are  sutured  to  Poupart's  ligament  beneath  the 
cord.  A  suture  should  be  placed  also  above  the  cord  (Fig.  415).  The  cord 
is  now  placed  on  this  suture  line  and  the  incision  in  the  external  oblique 


INGUINAL   HERNIA, 


505 


closed.  The  skin  is  sutured  with  silkworm  gut,  after  ligalijig  all  bleeding 
points.  Chromidzcd  catgut  or  kangaroo  tendon  is  used  for  the  buried 
sutures.  In  children  it  is  well  to  sea!  the  wound  uith  collodion  before  apply- 
ing the  spica  of  the  groin.  The  scrotum  is  supported  for  the  first  week. 
The  patient  remains  in  bed  for  two  or  three  weeks,  and  should  undertake  no 
straining  efforts  for  six  months.     A  truss  is  not  needed  after  operation. 

In  the  vaginal  form  of  congenital  /n'rnia  the  sac  must  be  divided  below^, 
the  portion  which  remains  being  sutured  to  form  the  tunica  vaginalis.  In 
the  female  it  is  unnecessary  to  transpose  the  round  ligament^  which  should 
be  allowed  to  emerge  from  the  lower  end  of  tlic  wound  in  the  muscles. 

In  Halsted*s  operation  the  skin  and 
external  oblique  are  incised  as  in  the 
Bassini  operation.  The  cremaster  mus- 
cle and  fascia  are  spht  above  the  center 
of  the  cord  and  reflected  downwards. 
The  veins  of  the  cord,  if  large,  are  ligatcd 
and  removed.  The  sac  is  treated  as  in 
Bassiiii^s  operation,  leaving  the  ends  of 
the  ligature  long,  so  that  they  may  be 
passed,  by  means  of  needles,  upwards 
and  outw^ards  through  the  internal 
oblique,  w^here  they  are  tied.  The  vas 
deferens  is  not  disturbed.  The  flap  of 
cremaster  muscle  and  fascia  is  now* 
sutured  to  the  under  surface  of  the 
internal  oblique  (Fig.  416),  and  the  inter- 
nal oblique  to  Poupart*s  ligament.  If 
necessary  the  anterior  sheath  of  the  rectus  muscle  is  incised  to  mobilize 
sufficiently  the  internal  oblique  and  conjoined  tendon.  The  flaps  of  the 
external  oblique  are  overlapped  as  shown  in  Fig.  417,  and  the  skin  wound 
closed.  Fig*  418  shows  the  use  of  a  flap  from  the  anterior  sheath  of  the 
rectus,  whicJi  is  sutured  to  Poupart's  ligament,  in  cases  in  which  the  hernial 
orifice  is  large  and  the  muscular  structures  atrophied. 

The  chief  objection  to  the  Bassini  operation  is  that  edema  of  the  cord, 
hydrocele,  and  orchitis  occasionally  follow,  owing  to  the  handling  of  the  cord 
and  its  compression  bctw^een  the  layers  of  the  abdominal  wall.  This  is 
avoided  in  the  Halsted  operation,  but  there  is  some  danger  of  injuring  the 
femoral  vessels  in  suturing  the  upper  down  over  the  lower  flap  of  the  external 
oblique. 

The  author*s  method  combines  some  of  the  features  of  the  foregoing 
ahd  the  Ferguson  operations,  with  imbrication  of  the  layers  of  the  abdominal 
wall  in  a  mariner  which,  although  tlevised  independently,  is  much  like  that 
previously  suggested  by  Andrews.  After  incising  Oie  skin  and  the  external 
oblique  die  ilioinguinal  ner^^e  is  retracted,  the  cremasteric  muscle  and  fascia 
raised  from  the  cord  and  divided  longitudinally,  and  the  sac,  which  lies 
immediately  beneath,  isolated  by  gentle  gauze  dissection,  so  as  to  injure  the 
cord  as  little  as  possible,  and  opened.  Ailhcrent  omentum  is  divided  between 
ligatures;  adherent  intestine  gently  separated,  unless  the  adhesions  are  dense, 
when  it  is  better  to  leave  a  portion  of  the  sac,  thus  preventing  the  raw^  sur- 
faces which  would  otherwise  result.  A  finger  is  passed  into  the  abdo- 
men and  the  internal  ring  of  the  opposite  side  palpated;  if  it  is  large  or  a  sac 


Fig,  415- — Bassini '5  operation. 


Fig.  4[6.— (HaUicrJ.) 


Fig.  417, — (ilakted  ) 

oneal  hernia,  and  laxity  of  the  pentoneuin  to  the  inner  side  of  the  deep  epigas 
trie  vessels  (potential  direct  hernia).  The  neck  of  the  sac,  which  is  recog- 
nized by  following  the  peritoneum  until  it  expands  beneath  the  parictes, 


INGUINAL  HERNIA. 


507 


where  it  is  covered  with  properiLoneal  fal,  and  by  identifying  aia!  pushing 
aside  the  deep  epigastric  vessels,  is  palpated  for  ihickening.  If  the  thicken- 
ing is  soft  one  should  suspect  hernia  of  the  blatltler  or  sliding  hernia  of  the 
colon,  conditions  in  which  the  affected  viscos  may  readily  be  injured  in  Hgat- 
ing  the  sac.  The  parietal  peritoneum  abozfc  the  neck  qf  tlie  sat'  is  now  trans- 
fixed and  ligated  with  catgut,  and  the  stump  transplanted  upwards  and  out- 
wards beneath  the  trans versalis  fascia,  ljy  carrying  the  ends  of  the  ligature 
through  the  fascia  and  muscles  and  tying  Ihem.  This  transplantation  is 
particularly  indicated  in  sliding  hernias  and  in  cases  in  which  the  peritoneum 
to  the  inner  side  of  the  epigastric  vessels  is  lax.  The  internal  ring  is  made 
snug  by  passing  one  or  two  sutures  through  the  transversalis  fascia  above  the 


^xr  nW  *^J 


^^;i:-^ 


l^r 


Fio.  418.— (HalstHO 


cord.  The  canal  is  closed  over  the  cord,  by  suturing  all  the  structures  on 
the  inner  side  (transversalis,  internal  oblique,  external  oblique)  to  Poupart's 
ligament,  beginning  below^  and  extending  up  as  far  as  the  attachment  of  the 
muscles  to  Poupart's  ligament  (Fig.  419)-  'Th*^  fascia  of  the  external 
oblique  thus  acts  as  a  splint  for  the  muscular  fibres,  which,  if  sutured  alone, 
tend  to  separate.  The  needle  should  be  passed,  from  without  inwards, 
through  the  structures  on  the  inner  side  of  the  canal,  then,  from  within  out- 
wards, through  Poupart's  ligament,  while  a  finger  protects  the  femoral 
vessels.  In  order  to  secure  accurate  coaptation  alternate  deep  and  super- 
licial  sutures  are  employed;  this  also  prevents  the  tearing  apart  of  the 
muscular  and  fascial  bundles  that  sometimes  follows  when  all  the  sutures  are 
inserted  in  the  same  plane  (Fig.  420).  The  lower  is  now  sutured  up  over 
the  upper  tlap  of  the  external  oblique  (Fig.  421)  and  the  skin  closed.  The 
operation  for  direci  hernia  is  identical,  except  that  the  sac  is  exposed  by  in* 
cising  the  transversalis  fascia  to  the  inner  side  of  the  cord,  the  fascia  subse- 


5o8 


ABDOMTSN. 


qucnOy  Ijeing  sutured.  The  ijilenml  ring  is,  of  course,  nut  concernc^d  in 
direct  hernia,  but  it  .shouhl  be  treated  as  in  oblique  hernia  if  it  seeob 
loo  large. 

Femoral  hernia  (Fig.  422)  constitutes  10  per  cent,  of  all  hemiaE?,  and  is 
more  frequent  in  females  owing  to  the  larger  size  of  the  cmral  canaJ,  consc- 


m.muoift  s  ¥it4m¥iii5Mus 


rjv 


--^r^ 


iXLQBUQyi 


'  /*o(fP4nrs  acx 


Fig.  41Q. — The  irdnsvcrsalis,  internal 
oblique,  and  external  oblique  muscles,  as 
one  layer,  are  sutured  to  Poupart*s  ligament. 


KiG.  420. — ^Altcrnaie  deep  and  super- 
dcial  sutures  iniierted. 


quent  upon  the  wider  pelvis,  but  even  in  females  it  is  less  common  than  the 
inguinal  variety.  The  hernia  passes  along  the  femoral  canal  and  protrudes 
through  the  saphenous  opening.  The  interna!  iing  is  formed  by  Poupart's 
ligament  in  front,  the  pectineal  line  and  fascia  Ijchind,  Gimbernat's 
ligament  on  the  inside,  and  the  inner  septum  of  the  femoral  sheath  on  the 
outside.     The  external  ring  is  formed  by  the  saphenous  opening.    Occasion - 


sicm 


Flc,  431. — Imbrication  of  the  external 
oblique. 


Fig.  422. — Femoral  hernia. 


ally  the  obturator  artery  arises  from  the  deep  epigastric  and  passes  ale 
the  edge  of  Gimbernat's  ligament.  The  coverings  of  a  femoral  hernia  are 
peritoneum,  septum  cm  rale,  anterior  layer  of  the  femoral  .sheath,  cribriform 
fascia,  deep  and  superficial  fascia;,  and  the  skin.  After  the  hernia  has  passed 
through  the  saphenous  opening,  it  is  bent  at  an  angle,  and  usually  passes 


ITMBIUCAL  HERNU, 


509 


upward,s  and  outwards,  because  of  the  attachment  of  the  deep  layer  of  the 
superficial  fascia. 

The  signs  are  those  of  other  hernia?  (p.  500).  The  swelling  is  seldom 
large,  and  is  usually  more  or  less  lobular.  The  neck  lies  to  the  inside  of  the 
femoral  vessels,  to  the  outer  side  of  the  pubic  spLne,  and  below  Poupart's 
tigamenl  (F'ig,  423).  The  diagnosis  is  facilitated  by  determining  the  exact 
situation  of  the  swelling  {Fig,  423).  Inguinal  hernia,  enlarged  glands,  lipoma^ 
and  psoas  abscess  may  be  differentiated  l>y  considering  the  points  given  under 
the  diagnosis  of  inguinal  hernia.  An  iliopsoas  bursa  limits  extension  of  the 
hip  and  appears  outside  the  femoral 

4MI  cmaAL  Hm¥L 

/  fiMORiL  VESSELS 

sAPHfmm  vm 


'ih 


^■-^ 


vessels.  Varix  of  the  sapkmmts  vein  )  eo(/F4RIS  //tf 
at  the  saphenous  opening  may  be  re- 
duced, but  with  a  thrill  instead  of  a 
gurgle,  and  it  reappears  from  below 
upwards,  even  when  the  linger 
blocks  the  femoral  canal  The 
veins  below  are  often  dilated. 
Ohluraior  hernia  lies  deep  under  the 
adductor  muscles  and  is  very  rare 
(seep.  511). 

The  treatment  may  be  pallia- 
tive^  a  truss  somewhat  similar  to 
that  used  for  inguinal  hernia  being 
employed,  except  that  the  pad  rests 
over  the  femoral  canal  at  the  level 
of  (iimbcrnal's  ligament. 

The  operative  treatment  is 
simple,  safe,  and  satisfactory'. 
Bassini's  operation  is  as  follows: 
An  incision,  parallel  with  and  below 
Poupart^s  ligament,  is  made  over 
the  sac,  which  is  isolated,  opened, 
and  ligated  as  in  inguinal  hernia. 
Poupart's  ligament  is  then  sutured 
to  the  pectineal  fast  i a,  to  close  the 
internal  ring,  and  the  plica  falci- 
formis  of  the  fascia  lata  is  suturerl  to  the  pectineal  fascia,  thus  closing 
the  canal  (Fig.  424).  Care  should  be  taken  not  to  injure  or  compress  the 
femoral  vein. 

Umbilical  hernia  represents  5  per  cent,  of  all  herniie.  There  are  three 
forms; 

K  Congenital  umhilical  hernia,  or  ex  omphalos,  is  the  result  of  im- 
perfect (Itjsure  of  the  alu luminal  wails,  the  contents  varying  from  a  small 
loop  of  bowei  to  a  large  part  of  the  viscera  (eclopin  viscenwt).  The  hernia 
is  covered  by  a  transparent  membrane  composed  of  peritoneum  and  dssues 
of  the  umbilical  cord.  The  condition  is  rare,  and  if  overlooketl  the  bowel 
may  he  tied  with  the  cord.  The  treatmefil  in  small  hemiiu  is  an  aseptic  dress- 
ing, w^ith  pressure.  In  larger  prolusions  the  contents  should  be  reduced, 
the  sac  removed,  and  the  opening  closed  wnth  sutures,  as  untreated  cases  are 
quit  kly  fatal  from  sloughing  of  the  sac. 

2.  Infantile  umbilical  hernia  is  Hue  to  stretching  of  the  umlnTica!  cica* 


Ftc.  423  — Siiualion  of  swelling?;  in  the 
Kfoin.  (i)  Inguinal  hernia.  (2)  Femoral 
hernia;  saphenous  opening.  (3)  Obdirator 
hernia.  (4)  Iliopsoas  bursa.  (5,  5,  5) 
Ingiiinal  lymph  gUnrls,  (2  and  6)  Femoml 
lymph  glands. 


Sio 


ABDOMEN. 


trix.  The  hernia  is  usually  of  small  size  and  tends  towards  spontaneous 
recovery.  Operation  is  therefore  seldom  required,  unless  the  rupture  persists 
after  puberty.  All  sources  of  straining,  e.g.,  constipation,  phimosis,  etc.. 
should  be  removed,  and  reduction  maintained  by  a  flat  pad,  larger  than  the 
ring  (a  covered  penny  is  often  employed),  held  in  place  by  a  broad  stn4)  of 
adhesive  plaster. 

3.  Umbilical  hernia  of  adults  is  caused  by  stretching  or  rupture  of  the 
tissues  in  the  immediate  vicinity  of  the  umbilicus,  as  the  result  of  increased 
intraabdominal  pressure,  hence  is  most  frequent  in  women  who  have  home 


P0yPAftT5  UG 


FEMORAL  VC5SELS 


PCCTINCU5 


ICA  FALCIFORMIS 
3AIWCN0US   VEIN 


Fig.  424.— Bassini's  operation  for  femoral  hernia. 

many  children.  The  coverings  are  peritoneum,  transversalis  fascia,  and 
skin.  The  hernia  often  attains  a  large  size,  and  as  it  is  exposed  to  various 
forms  of  irritation,  the  contents  are  prone  to  become  adherent  to  one  another 
and  to  the  sac.  Not  infrequently,  therefore,  the  sac  is  divided  into  several 
parts,  and  the  hernia  is  often  irreducible,  thus  predisposing  to  strangulation. 
The  treatment  should  be  palliative,  unless  complications  ensue,  if,  as  is 
often  the  case,  the  patient  is  advanced  in  years  and  extremely  fat,  or  the  her- 
nia is  of  large  size.  A  pad  truss  should  be  worn,  unless  the  rupture  is  ir- 
reducible, when  some  form  of  cup  or  bag  truss  may  be  needed. 


SKIN 

SUTURED 
PCRITONCUN 

APONEUROSIS 


Fig.  425. — Mayo's  o])cratiun. 

The  Mayo  operation  is  the  most  satisfactor}'  in  cases  suitable  for  radical 
treatment.  The  hernia  is  surrounded  by  transverse  elliptical  incisions  and 
the  aponeurotic  structures  about  the  ring  exposed.  The  sac  is  opened,  and 
divided  at  its  neck,  adherent  intestines  separated  and  reduced,  and  omentum 
ligated,  and  removed  with  the  sac  and  skin.  The  peritoneum  is  separated 
from  the  edges  of  the  ring  and  sutured  transversely.  Mattress  sutures  of 
silver  wire  or  chromicized  catgut  are  now  introduced  an  inch  or  more  above 
the  edge  of  the  upper  flap,  catching  the  margin  of  the  lower  flap  en  route,  thu> 
sliding  it  into  the  space  between  the  peritoneum  and  upper  ^ap  (Fig.  425). 
The  lower  edge  of  the  upper  flap  is  now  sutured  to  the  aponeurosis  below. 


FERINBL^L  HERNIA. 


511 


Very  large  hernial  orifices  have  l>een  closed  by  the  implantation  of  a  perfo- 
rated celluloid  plate  or  a  network  of  silver  wire. 

Ventral  hernia  is  a  hernia  in  any  portion  of  the  anterior  abdominal 
wall,  excepting  those  mentioned  above.  It  may  be  median  or  lateral.  Of 
the  median  hemiae  there  are  two  principal  forms:  i.  Hernia  of  the  linea 
aiba  is  most  frequent  about  midway  between  the  umbilirus  and  the  ensiform 
(epigastric  hernia) ;  it  is  usually  caused  by  a  suliperitoneal  lipoma,  which 
insinuates  itself  between  the  meshes  of  the  linea  alba  and  draws  a  sac  of 
peritoneum  after  it.  It  is  most  common  in  healthy,  hard  working  men,  and 
is  frequently  insignificant  in  size,  so  that  it  may  readily  be  overlooked.  Con- 
genital apertures  in  the  linea  alba  are  very  rare.  These  hernia?  often  cause 
epigastric  pain,  vomiting,  and  other  gastric  symptoms.  Truss  treatment  is 
inapplicable  as  the  hernia  is  seldom  reducible.  The  lipoma  should  be 
excis-^l  with  the  sac,  and  the  opening  in  the  abdominal  wall  closed  with 
sutures.  The  stomach  and  adjacent  organs  should  always  be  explored  at  the 
same  time,  to  make  sure  that  the  symptoms  are  not  due  to  some  graver  disease, 
2.  Diastasis  0/  the  recti  muscles  is  most  commonly  observed  in  multipara; 
it  causes  a  stretching  of  the  linea  alba,  which  encourages  a  prolapse  of  all 
the  abdominal  viscera.  The  diagnosis  is  readily  made  by  having  the  patient, 
when  lying  dow^n,  fold  the  arms  and  raise  the  head  and  shoulders,  the  whole 
linea  alba  bulging  forwards  in  a  long  mound- like  eminence,  reaching  from 
the  ensiform  to  the  pubes.  The  treatment  is  that  of  tildnard's  disease.  In 
some  cases  marked  benefit  has  been  ol>tained  by  suturing  the  recti  together, 
or,  better,  by  overlapping  them,  with  the  redundant  linea  alba.  Lateral 
ventral  hernia  is  most  frequent  in  the  semilunar  line  at  a  point  where  it  is 
crossed  by  the  omphalo- spinous  line,  owing  ti>  the  fact  that  a  liranch  of  the 
epigastric  artery  pierces  the  wall  in  this  situation.  It  is  the  result  of  in- 
creased intraabtlominal  pressure.  Postoperative  or  postincisimialherni(t  may, 
of, course,  occur  in  any  portion  of  the  abdomen^  and  are  particularly  prone 
to  develop  if  the  wound  suppurates  or  if  drainage  has  been  employed.  They 
arc  treated  by  separately  suturing  the  individual  layers  of  the  abdominal 
Willi  or,  better,  by  overlapping  these  layers. 

Among  the  rarer  forms  of  hernia  are  the  following:  Obturator  hernia 
passes  through  the  obturator  foramen  witJi  the  obturator  vessels,  appearing 
deep  in  the  thigh  on  the  inner  side  of  the  femoral  vessels  (Fig.  423).  It  is 
more  common  in  women,  because  of  the  larger  size  of  the  foramen.  There 
may  be  pain  in  the  hip  and  along  the  inside  of  the  thigh  and  knee,  due  to 
pressure  on  the  obturator  nerve.  Bimanual  examination  may  reveal  a  cord- 
like mass  extending  to  the  foramen.  The  diagnosis  is  seldom  made,  even 
when  the  hernia  is  strangulated,  in  which  event  the  sac  should  be  exposed  by 
an  incision  in  the  upper  and  inner  angle  of  Scarpa's  triangle,  and  the 
constriction  relieved  by  cutting  upwards,  since  the  obturator  artery  usually 
lies  below  and  to  the  outer  side. 

Lumbar  hernia  occurs  in  Tetit's  triangle,  and  is  treated  as  a  ventral 
hernia. 

Sciatic  hernia  emerges  from  the  pelvis  through  one  of  the  sciatic  for- 
amina, and  appears  in  the  gluteal  region. 

Perineal  hernise  are  those  passing  through  the  pelvic  diaphragm,  and 
appearing  in  the  perineum,  towards  the  rectum  (reclai  hernia)^  vagina  (vag- 
inal hernia),  or  in  the  lower  part  of  the  labium  { pudendal  hernia).  Inguinal 
perineal  hernia  is  one  which  follows  an  aberrant  tesiicte  into  the  perineum. 


512  ABDOMEN. 

Diaphragmatic  hernia  is  usually  congenital,  but  may  be  caused  also  by 
wounds  of  the  diaphragm  (p.  445).  It  is  more  frequent  on  the  left  side,  owing 
to  the  situation  of  the  liver  on  the  right,  and  seldom  has  a  sac.  Although 
any  of  the  abdominal  viscera  may  pass  into  the  thorax,  the  stomach  and 
transverse  colon  are  the  organs  usually  herniated.  The  signs  are  those  of 
pneumothorax,  with  displacement  of  the  heart  and  gastric  disturbances. 
In  traumatic  cases  these  signs  are  accompanied  by  shock,  dyspnea,  and 
cyanosis.  The  diagnosis  is  rarely  made,  but  in  a  few  cases  in  which  strangu- 
lation has  occurred,  the  abdomen  has  been  opened,  the  hernia  reduced,  and 
the  diaphragm  sutured.  A  similar  operation  may  be  performed  by  opening 
the  lower  part  of  the  thorax,  and  dealing  with  the  diaphragm  from  above.. 

Internal  or  retroperitoneal  hemise  are  observed  in  the  following  situa- 
tions: I.  Foramen  of  Winslow.  2.  Recessus  duodeno-jejunalis ;  the 
margin  of  this  fossa  contains  the  inferior  mesenteric  vein  or  colica  sinistra 
artery,  a  fact  to  be  remembered  if,  in  a  case  of  strangulated  hernia  in  this  vi- 
cinity, enlargement  of  the  opening  is  necessary.  3.  Pericecal  fossae,  of 
which  there  are  three,  the  retrocecal,  behind  the  cecum  and  external  to  the 
mesoappendix;  the  superior  ileocecal^  in  the  upper  angle  formed  by  the 
junction  of  the  ileum  and  cecum;  and  the  inferior  ileocecal,  in  the  lower  angle 
formed  by  the  ileum  and  cecum.  4.  Intersigmoid  fossa,  at  the  root  of  the 
mesocolon  on  the  left  side.  5.  Retrovesical  fossa.  Hernias  into  these 
fossae  rarely  cause  trouble  unless  they  become  strangulated,  when  the  symp- 
toms are  those  of  intestinal  obstruction.  The  treatment  is  laparotomy  and 
reduction  of  the  hernia.  Obliteration  of  the  hernial  orifice  by  sutures  may 
be  attempted  in  suitable  cases. 


ACCIDENTS  OF  HERNIA. 

Irreducible  hernia  presents  all  the  signs  of  a  reducible  one,  except  that  it 
cannot  be  replaced  within  the  abdomen  and  is  apt  to  be  more  firm  in  consist- 
ence. It  is  always  more  prone  to  become  inflamed,  obstructed,  or  strangu- 
lated. Irreducibility  is  most  frequent  in  umbilical  hernias  (of  adults),  then 
in  femoral,  then  in  large  scrotal  hernias.  The  causes  are:  i.  Adhesions  (a) 
between  the  contents  and  the  sac,  (b)  among  the  contents,  forming  a  mass 
which  will  not  pass  through  the  ring,  (c)  giving  rise  to  cystic  accumulations, 
or  (d)  causing  thickening  of  the  neck  or  other  portion  of  the  sac.  2.  Exces- 
sive deposit  of  fat,  either  in  the  herniated  omentum  or  mesentery,  or  within 
the  abdomen;  in  the  latter  instance  the  hernia  cannot  be  returned  because 
of  want  of  room. 

The  treatment  in  most  cases  is  operation ;  -when  this  is  inadvisable  be- 
cause of  the  general  condition  of  the  patient,  the  hernia  may  be  supi>orted 
by  a  bag  truss.  Wlien  due  to  fat,  the  hernia  may  again  become  reducible 
after  strict  dieting. 

An  inflamed  hernia  is  one  in  which  there  is  a  localized  peritonitis,  involv- 
ing the  sac  and  possibly  the  peritoneal  covering  of  the  contained  viscera.  It 
arises  from  blows,  badly  fitting  trusses,  and  strenuous  taxis;  also  from  in- 
carceration and  strangulation,  but  these  are  considered  in  separate  classes. 
The  symptoms  are  pain,  tenderness,  swelling,  increased  heat,  and  sometimes 
redness  and  edema  of  the  .skin;  in  addition  there  are  general  fever  and  often 
vomiting  and  constipation.     The  hernia  is  likely  to  be  irreducible  and  hence 


STRANGULATED   HERNIA.  513 

strangulation  is  strongly  suggested,  but  in  the  latter  there  are  shock  instead 
of  fever,  absence  of  an  impulse  on  coughing,  absolute  constipation,  and 
fecal  vomiting.  The  treatment  is  rest  in  bed,  elevation  of  the  hernia,  the 
application  of  lead  water  and  laudanum,  opium  internally,  and  liquid 
diet.  Suppuration  calls  for  incision.  After  the  inflammation  has  subsided, 
the  radical  operation  should  be  performed. 

Incarcerated  or  obstructed  hernia  is  an  irreducible  hernia  in  which  the 
fecal  (not  the  blood)  circulation  is  interrupted.  It  is  generally  due  to  un- 
digested food  or  impacted  feces.  It  is  most  common  in  umbilical  hernias, 
because  of  the  frequency  of  adhesions,  which  interfere  with  peristalsis,  and 
because  of  the  presence  of  the  transverse  colon,  which  contains  solid  feces. 
The  symptoms  are  those  of  an  irreducible  hernia  which  becomes  tender  and 
painful,  harder  and  larger  than  usual,  and  dull  on  percussion;  it  may  be 
diminished  in  size  by  pressure,  and  has  an  impulse  on  coughing.  The 
abdomen  becomes  distended  and  there  are  vomiting  (not  fecal),  constipation 
(not  absolute),  and  colicky  pain.  The  hernia  may  become  inflamed  or 
strangulated.  The  treatment  is  opium,  gentle  taxis,  and  the  local  application 
of  heat  or  cold.  If  this  treatment  is  not  quickly  successful,  or  if  symptoms  of 
strangulation  ensue,  operation  should  be  performed. 

Strangulated  hernia  is  one  in  which  the  contents  are  so  firmly  con- 
stricted that  the  circulation  of  blood  is  cut  oflF.  Interference  with  the  fecal  cir- 
culation is  usual  but  not  essential,  since  the  hernia  may  be  an  epiplocele  or  a 
Richter's  hernia. 

The  cause  of  strangulation  is  sudden  augmentation  in  the  size  of  the  hernia, 
from  the  extrusion  of  additional  contents,  from  congestion  or  inflammation, 
or  from  fecal  or  gaseous  accumulations.  The  site  of  constriction  is  usually 
the  hernial  orifice,  but  it  may  be  in  the  neck  of  the  sac  alone,  or  elsewhere 
in  the  sac  as  the  result  of  adhesions  or  constrictions.  The  venous  circulation 
is  first  aflfected,  causing  swelling  of  the  hernial  contents,  and  finally  arrest 
of  the  arterial  current,  thus  leading  to  mqist  gangrene.  The  sac  is  in- 
flamed, owing  to  the  passage  of  bacteria  through  the  intestinal  walls,  and 
usually  contains  fluid,  which  is  at  first  clear,  but  in  the  later  stages  becomes 
bloody  and  finally  dark  brown  in  color  and  offensive  in  odor.  The  parts  about 
the  sac  are  usually  unaffected,  but  occasionally  in  unrelieved  cases  they  become 
inflamed  and  break  down,  thus  leading  in  rare  instances  to  spontaneous 
cure  by  the  formation  of  an  artificial  anus.  The  intestine  is  furrowed  at  the 
point  of  constriction,  in  which  situation  it  is  very  liable  to  ulcerate.  At  first 
it  is  dark  red,  smooth,  and  glistening,  and  may  completely  recover  if  the 
constriction  is  relieved;  but  later  it  becomes  black  and  lusterless  (gangrene). 
Above  the  point  of  constriction  the  bowel  wall  is  edematous  for  a  variable  dis- 
tance and  the  intestine  distended  with  retained  fecal  material.  Even  when 
obstruction  is  not  complete,  e.g.,  in  a  Richter's  hernia,  the  bowel  may  be  para- 
lyzed. Retrograde  strangulation  is  a  condition  in  which  the  end  of  a  piece 
of  bowel  or  omentum  in  a  hernia  passes  back  into  the  abdomen,  becoming 
strangulated  at  the  hernial  orifice,  the  remaining  portion  of  the  hernia  being 
uninvolved.  Doubtless  some  of  the  cases  of  so-called  retrograde  strangula- 
tion are  due  to  the  reduction  of  a  strangulated  segment,  the  sac  then  fill- 
ing with  healthy  bowel  or  omentum,  or  to  twisting  of  the  end  that,  reenters 
the  abdomen. 

The  symptoms  are  those  of  intestinal  obstruction,  viz.,  shock;  abdominal 
pain,  tenderness,  and  distention;  vomiting  which  finally  becomes  stercora- 

3i 


-     5^4  ABDOMEN. 

ceous;  and  absolute  constipation.  In  the  final  stages  the  picture  is  that  of 
generaliaed  peritonitis.  In  even  a  strangulated  Rid&ter's,  Littre's;  or  omen- 
tal hernia,  there  may  be  complete  obstruction,  possibly  from  reflex  paralysis 
of  the  intestine.  The  hernia  is  irreducible,  tense,  tender,  and  painful,  and 
has  no  impulse  on  coughing.  With  the  onset  of  gangrene  pain  and  tender- 
ness disappear,  and  the  hernia  becomes  softer  and  sometimes  crepitates. 
Two  facts  must  be  emphasized.  First,  the  symptoms  may  be  mild  and  the 
cause  overlooked,  especially  in  old  women  who  have  long  had  a  small 
irreducible  femoral  hernia  that  they  deem  of  no  importance  and  do  not 
mention  to  the  physician.  In  all  doubtful  cases  one  should  inqmre,  or,  better, 
look  for  hernia.  Secondly,  gangrene  depends,  not  so  much  on  the  duration, 
as  on  the  tightness  of  the  strangulation,  hence  may  occur  in  a  few  hours. 

The  treatment  is  reduction  by  taxis  or  operation. 

Taxis,  or  the  manipulations  for  the  reduction  of  a  hernia,  should  always 
be  gentle,  and  should  rarely  be  tried  for  more  than  five  or  ten  minutes,  because 
of  the  danger  of  rupture  of  the  bowel.  It  should  not  be  employed  in  the 
presence  of  inflammation  or  gangrene.  Reduction  is  facilitated  by  having 
the  patient  recumbent,  the  thighs  flexed  (and  that  of  the  affected  side  ad- 
ducted  in  femoral  or  inguinal  hernia),  and  the  pelvis  raised.  The  administra- 
tion of  opium  and  belladonna  and  the  application  of  heat  or  cold  also  are 
useful  in  securing  relaxation.  One  hand  is  used  to  steady  the  neck  of  the  sac, 
while  with  the  other  the  hernia  is  compressed  and  pushed  back  into  the 
abdomen.  In  direct  inguinal  and  umbilical  hemiae  the  pressure  is  back- 
wards; in  oblique  inguinal  hernia  it  is  upwards,  outwards  ,and  backwards; 
in  femoral  hernia  it  is  at  first  downwards  and  inwards,  then  upwards  and 
backwards.  The  successful  reduction  of  bowel  is  sudden  and  accompanied 
by  a  gurgle;  omentum  is  forced  back  slowly  without  gurgling.  The  can- 
tinuance  of  symptoms  after  apparent  reduction  may  be  due  to  (i)  incomplete 
reduction,  (2)  reduction  en  masse  (p.  502),  (3)  recurrence  of  the  hernia,  (4) 
the  presence  of  some  other  form  of  intestinal  obstruction,  (5)  paralysis  of  the 
bowel,  (6)  peritonitis,  (7)  reduction  of  gangrenous  or  perforated  bowel,  (8) 
reduction  of  bowel  which  is  obstructed  by  adhesions  or  through  a  slit  in  the 
omentum,  or  to  (9)  the  effects  of  an  anesthetic  if  used.  With  the  exception  of 
the  last  named  condition,  the  persistence  of  symptoms  after  apparent  reduc- 
tion calls  for  operation. 

The  operative  treatment,  or  herniotomy,  consists  in  reduction  of  the 
bowel  after  division  of  the  constriction.  It  is  indicated  as  soon  as  taxis  fails, 
and  should  be  employed  instead  of  taxis,  if  the  strangulation  has  existed  for 
more  than  a  few  hours,  or  if  there  is  the  slightest  suspicion  of  gangrene.  If 
the  vomiting  is  fecal,  the  stomach  should  first  be  washed  out,  and  if  the 
patient  is  in  poor  condition,  local  anesthesia  may  be  employed.  When  a 
general  anesthetic  is  administered  and  the  strangulation  is  recent,  taxis  may 
again  1)C  tried  when  the  patient  is  fully  relaxed.  The  sac  is  exposed  by  a 
suitable  incision  {vide  radical  operations)  and  opened ;  it  is  recognized  by  its 
bluish  color,  the  presence  of  subperitoneal  fat,  and  by  its  gliding  over  the 
contained  viscera.  The  sac  almost  always  contains  fluid,  hence,  as  a  rule, 
there  is  little  danger  of  injuring  the  bowel  in  opening  it.  The  contents  of  the 
hernia  are  now  examined,  and  the  constriction  divided  by  blunt  pointed 
scissors  or  a  hernia  knife  (curved  blunt-ended  bistoury),  introduced  along  the 
left  forefinger,  the  nail  of  which  is  passed  into  the  stricture.  The  constriction 
js  nicked  sufficiently  to  relieve  the  strangulation.     In  inguinal  hernia  the 


CONGENITAL   MALFORMATIONS   OF   THE   RECTUM.  5x5 

direction  of  the  nick  is  directly  upwards,  in  femoral  hernia  directly  inwards. 
Many  surgeons  divide  the  constricting  tissues  from  the  surface  towards  the 
hernia,  so  that  if  any  important  vessels  are  cut  they  may  be  caught  at  once 
and  tied.  The  bowel  should  be  withdrawn  a  little  from  the  abdomen,  in 
order  to  determine  its  condition  at  the  point  of  constriction  and  to  make  sure 
there  is  no  retrograde  strangulation  or  torsion;  the  omentum  should  be  treated 
in  a  like  manner.  If  the  hernial  contents  are  healthy,  they  should  be  re- 
placed, and  the  radical  operation  performed  if  the  patient's  condition  per- 
mits. If  the  bowel  is  gangrenous  (black  and  lusterless),  it  should  be  re- 
sected. In  femoral  hernia  it  will  usually  be  necessary  to  make  a  second 
incision  above  Poupart's  ligament  for  this  purpose.  If  the  patient's  con- 
dition forbids  resection,  the  bowel  may  be  opened  and  an  artificial  anus 
established;  this  is  dealt  with  at  a  later  period  as  described  elsewhere.  If  the 
condition  of  the  bowel  is  doubtful,  it  may  be  surrounded  with  gauze  and  the 
wound  left  open.  Should  gangrene  or  perforation  follow,  the  intestinal  con- 
tents will  be  discharged  through  the  wound;  if  gangrene  does  not  supervene, 
the  bowel  may  be  replaced,  and  the  wound  closed  at  a  later  period.  If  the 
bowel  is  dark,  but  retains  its  luster  and  elasticity,  and  improves  in  color  on 
the  application  of  hot  water,  it  is  viable,  but  may  become  gangrenous  from 
subsequent  inflammatory  reaction.  When  the  condition  of  the  omentum  is 
doubtful,  it  should  be  removed. 


CHAPTER  XXVIII. 
RECTUM  AND  ANUS. 


Congenital  Malformations. — Normally,  in  the  early  stages  of  develop- 
ment the  hind-gut  communicates  in  front  witii  the  allantois  and  behind  with 
the  neurenteric  canal.  At  a  later  period  the  gut  and  genitourinary  canal 
open  externally  in  a  common  passage,  called  the  cloaca.     By  the  growth  of  a 


Fig.  426.— Imperforate  anus.  Fig.  427.— Imperforate  rectum. 


posterior  and  two  lateral  folds,  the  perineum  is  formed,  and  the  gut  separated 
from  the  genitourinary  cavity.  A  pit  called  the  proctodeum  extends  inward 
from  the  perineum,  until  finally  it  meets  and  communicates  with  the  rectum. 
According  to  the  extent  to  which  development  has  progressed,  the  following 


Si6 


RECTUM  AND  ANUS. 


malformations  may  be  encountered.  Anal  stricture  may  be  enlarged  by 
cutting  backwards  towards  the  coccyx,  and  the  opening  maintained  by  the 
subsequent  passage  of  bougies.  Imperforate  anus  (Fig.  426)  is  a  condition 
in  which  the  rectum  is  developed,  but  there  is  no  proctodeum.  When  the  in- 
fant cries,  the  rectum  is  felt  to  bulge  at  the  point  where  the  anal  orifice  should 
be.  Imperforate  rectimi  (Fig.  427),  in  which  both  the  rectum  and  the  proc- 
todeum are  developed,  but  have  not  united,  is  the  most  common  malforma- 


Fic.  428. — Absent  rectum. 


Fig.  429. — Atresia  ani  vesicalis. 


tion,  the  septum  being  about  an  inch  above  the  anus.  Absent  rectum  (Fig. 
428)  is  a  malformation  in  which  the  rectum  ends  blindly  high  up,  perhaps 
above  the  pelvic  brim.  The  proctodeum  may  or  may  not  be  present.  Atre- 
sia ani  vesicalis  (Fig.  429),  urethralis  (Fig.  430),  and  vaginalis  (Fig.  431) 
are  due  to  defective  development  of  the  septum  which  should  divide  the 
cloaca. 

The  treatment  in  all  cases,  except  atresia  ani  vaginalis,  must  be  prompt, 
otherwise  the  patient  dies  of  intestinal  obstruction.     If  no  anus  is  present,  an 


Kit;.   4.^0.     AlrcMa  ani  urethralis. 


Atresia  ani  vaginalis. 


incision  is  made  in  the  midline  of  the  perineum  and  deepened  until  the 
rectum  is  encounlered,  care  being  taken  not  to  injure  the  bladder.  One  may 
follow  the  concavity  of  the  sacrum  as  high  as  its  promontory,  excising,  when 
necessary,  the  co((yx  and  lower  segment  of  the  sacrum;  when  the  rectum  is 
found,  il  is  pullrd  down  to  the  oxlernal  opening,  incised,  and  stitched  to  the 
skin.  If  the  rectum  cannot  be  found,  the  sigmoid  may  be  brought  down  into 
the  wound  or  an  artificial  anus  made  in  the  inguinal  region.     When  the  anus 


PERrPROCTlTig, 


S»7 


is  (>R'Siiil,  the  st^ptum  st'paraljnf;  il  from  the  rtn  lum  shouliJ  bt*  im  tsed  or  ex- 
cised, the  opeiTing  thus  farmed  lieing  maintained  by  the  passage  of  bougies. 

Prurittis  ani,  or  itching,  is  a  symptom  whith  may  be  eaused  by  local 
conditions,  such  as  piles,  fissure,  fistula,  worms,  eczema,  and  diseases  of  the 
urethra,  1j1  adder,  uterus,  or  ovaries,  or  by  general  conditions  like  gout,  dis- 
orders of  digestion,  nephritis,  diabetes,  jaundice,  constipation,  mental  anfl 
nervous  disorders,  and  the  opium,  aUohob  tea,  or  tobacco  habits.  The 
treatment  is  removal  of  the  cause  and  attention  to  the  general  health.  The 
parts  should  be  kept  scrupulously  clean.  The  itching  may  be  relieved  by 
lotions  or  ointments  containing  carbolic  acid  (1-15)  or  menthol  (i  30). 
Painling  the  skin  with  silver  nitrate  (i-io)  also  is  recommended;  in  the 
worst  cases  division  of  the  sensory  nerves  supplying  the  part  has  been  prac- 
ticed, or  the  affected  skin  excised. 

Fissure  of  the  anus  is  caused  by  the  passage  of  hardened  fece^,  and  not 
infrequently  accompanies  hemorrhoids  and  other  diseases.  There  is  often  a 
""sentinel"  external  pile  at  its  outer  extremity.  The  principal  symptom  is 
burning  pain  on  defecation,  and  sometimes  on  walking  or  coughing.  Con* 
stipation  is  thus  encouraged,  and  when  the  hardened  feces  pass,  they  may  be 
streaked  with  pus  or  blood.  The  ulcer  is  seen  on  separating  the  folds  of  the 
anus  and  the  sphincter  is  found  spasmodically  contracted.  The  trtafmmt  is 
laxatives  and  the  application  of  silver  nitrate;  if  this  fails,  the  patient  should 
be  anesthetized,  and  the  sphincter  stretched  with  the  thumbs,  thus  causing 
a  paralysis  for  from  five  to  ten  days,  during  which  time  the  ulcer  heals.  Piles 
should,  of  course,  be  removed  at  the  same  time.  Large  ulcers  may  be 
excised. 

Proctitis,  or  inflammatioo  of  the  rectum^  arises  from  foreign  bodies, 
polypi,  piles,  parasites,  gonorrhea,  dysentery,  etc.  The  symptoms  are  tenes- 
mus, frequent  bowel  movements,  with  mucus,  pus,  or  blood,  and  a  sensation 
of  heat  and  fullness.  The  bladder  also  may  be  irritable.  The  rectal 
mucous  membrane  may  prolapse,  and  in  chronic  cases  there  may  be  ulcera- 
tion followed  by  stricture  formation.  The  trmfmait  is  removal  of  the  cause, 
rest  in  bed,  liquid  diet,  suppositories  of  opium  and  belladonna,  hot  sitz  baths, 
and  irrigation  with  ver>^  weak  solutions  of  silver  nitrate. 

Periproctitis  (cellulitis)  is  usually  caused  by  infection  from  the  rectum, 
as  the  result  of  disease  (piles,  fissure,  fistula,  cancer,  etc.)  or  injury  (hardened 
feces,  swallow^ed  fish  bone,  etc).  It  may  be  caused  also  by  abrasions  of  the 
skin  and  affections  of  the  surrounding  tissues,  including  the  bladrler,  urethra, 
prostate,  and  female  pelvic  organs.  The  dijfusr  form  spreads  rai>idly,  results 
in  extensive  sloughing,  is  usually  seen  in  the  old  and  asthenic,  and  is  ver\'  apt 
to  cause  death.  It  is  treated  by  free  drainage  and  vigorous  stimulation.  In 
the  circumscribed  variety  an  abscess  forms,  which  liursts  and  gives  rise  to  a 
sinus.  Superticial  abscesses  may  be  situated  just  beneath  the  mucous  mem- 
brane or  just  beneath  the  skin  of  the  anus  [anal  abscess).  The  latler  are 
often  caused  by  inilammation  of  the  sebaceous  glancls,  and  are  treated  by 
incision  and  drainage.  The  most  frequent  deep  aliscess  is  that  occurring  in 
the  ischiorectal  fossa. 

Acute  ischiorectal  abscess  arises  from  the  causes  given  above,  and  is 
characterized  by  pain,  sw^elling,  heat,  redness,  and  braw^ny  fndu ration  to  the 
side  of  the  anus.  The  treat fnettt  should  be  prompt,  in  order  to  avoid  the 
formation  of  a  fistula.  A  free  incision  is  made,  and  the  cavity  irrigated  with 
creolin  solution  and  packed  with  iodoform  gauze.     Chronic  ischiorectal 


Si8 


RECTUM  AND   ANUS. 


abscess  is  usually  tuberculous.     There  is  at  first  a  painless  induratioo," 
wJiidi  subsequently  softens;  in  the  later  stages  it  is  often  infected  with  pyo- 
genic organisms,  the  symptoms  then  being  those  of  an  acute  abscess.     The 
treatment  is  that  of  acute  abscess. 

Fistula  in  ano  is  caused  by  the  breaking  of  abscesses  into  and  about  the 
rectum,  although  in  rare  instances  a  non-inflammatorj^  fistula,  lined  by 
epitlielium  and  possibly  due  to  a  small  pressure  diverticulum,  is  seen. 
There  arc  three  varieties,  i.  The  blind  external  opens  externally ,  but  does 
not  communicate  with  the  bowel.  2.  The  blind  internal  opens  into  the 
bowel,  usually  just  above  the  anus,  but  has  no  external  opening.  3,  The 
complete  or  true  fistula  opens  both  externally  and  internally.  The  internal 
opening  is  usually  between  the  two  sphincters,  but  may  be  a  considerable 


Fic.  43a.— Multiple  fijituk'  in  ano.     (Pennsylvania  HospilalO 

distance  al>ove  the  internal  sphincter,  or  when  follov^ing  an  anal  abscess,  out- 
side the  external  sphincter.  There  may  be  numerous  side  tracts  extending 
in  various  directions  (Fig.  432).  A  horseshoe  fistula  is  one  which  extend 
around  the  bowel  and  opens  on  each  side.  The  sjrmptoms  are  pain  durin 
defecation,  a  mucopurulent  discharge,  and  in  the  complete  variety  the  passage 
of  feces  and  gas  through  the  fistula;  recurring  abscesses  may  form,  owing  to 
healing  or  blocking  of  the  openings.  Wlien  there  is  an  external  opening. 
the  diagnosis  is  readily  made  by  inspection  and  the  use  of  a  probe.  Wlien 
there  is  no  external  opening,  it  will  be  necessary  to  use  a  speculum  in  order 
to  expose  the  orifice,  although  such  can  sometimes  be  felt  by  the  finger 
The  lungs  should  always  be  examined  for  evidences  of  phthisis. 

The  treatment  is  the  conversion  of  the  fistula  into  an  open  wound,  so  thai 
it  may  heal  from  the  bottom.     A  grooved  director  is  passed  through  the  fistula 


HEMORRHOIDS.  5 1 9 

into  the  rectum,  and  the  overlymg  tissues  severed  with  a  bistoury.  The 
sphincter  should  never  be  cut  more  than  once,  because  of  the  danger  of 
incontinence.  All  branching  sinuses  likewise  should  be  opened,  and  ail 
fibrous  tissue,  with  undermined  skin,  cut  away  with  scissors.  The  bleeding 
is  then  checked,  and  the  wound  packed  with  iodoform  gauze.  If  the  fistula 
is  lined  with  mucous  membrane  it  must  be  completely  excised.  A  blind 
external  fistula  may  be  excised  and  the  wound  sutured.  A  blind  internal 
fistula  may  be  converted  into  a  complete  one  and  treated  as  above.  The 
bowels  are  confined  for  the  first  three  or  four  days,  and  the  wound  dressed 
after  each  defecation,  being  irrigated  with  creolin  and  repacked  with  iodo- 
form gauze. 

Hemorrhoids,  or  piles,  are  swellings  due  to  varicose  veins  about  the 
lower  end  of  the  rectum.  The  causes  are  those  which  induce  congestion  in 
this  region,  such  as  sedentary  habits,  constipation,  rectal  disorders,  tumors, 
inflammatory  affections  in  the  pelvis,  cirrhosis  of  the  liver  and  other  condi- 
tions which  interfere  with  the  portal  circulation,  and  diseases  of  the  heart  and 
lungs.  The  hemorrhoidal  veins  run  between  the  mucous  membrane  and  the 
muscle  in  a  longitudinal  direction,  forming  a  plexus  around  and  above  the 
anus;  they  have  but  little  support,  possess  no  valves,  and  form  one  of  the 
principal  communications  between  the  portal  and  systemic  circulations. 
There  are  two  varieties  of  hemorrhoids,  the  external  and  the  internal,  which, 
however,  often  coexist. 

External  hemorrhoids  occur  at  the  margin  of  the  anus,  are  covered  with 
skin,  originate  from  the  inferior  hemorrhoidal  plexus,  and  consist  of  dilated 
veins  surrounded  by  fibrocellular  tissue.  They  cause  no  symptoms,  except 
possibly  itching  or  a  little  irritation,  unless  they  are  inflamed,  when  the  veins 
become  thrombosed,  painful,  and  tender,  and  appear  as  tense  bluish  masses 
which  cannot  be  emptied  by  pressure.  When  the  attack  subsides,  the  piles 
are  harder  and  thicker  than  before.  The  treatment  is  the  relief  of  constipa- 
tion, cleanliness,  and  the  use  of  soft  paper  or  cotton,  after  defecation.  The 
parts  may  be  washed  with  a  lotion  containing  witch-hazel.  Operation  is 
rarely  required  unless  the  piles  become  inflamed,  when  they  should  be 
incised,  the  clot  turned  out,  and  the  cavity  filled  with  iodoform  gauze.  When 
operating  on  internal  hemorrhoids  it  is  advisable  to  remove  any  coexisting 
external  piles  with  scissors,  the  cuts  radiating  from  the  anus.  If  too  much 
skin  is  removed,  however,  stenosis  may  follow. 

Internal  hemorrhoids  are  covered  with  mucous  membrane,  originate 
from  the  superior  hemorrhoidal  plexus,  and  consist  of  dilated  veins,  arterial 
twigs,  and  connective  tissue.  They  cause  pain,  a  sense  of  fullness,  and  often 
bleeding  and  a  mucous  discharge.  They  may  protrude  through  the  anus,  and 
in  some  cases  become  strangulated  from  the  grip  of  the  sphincter  and 
undergo  sloughing.  When  inflamed  (attack  of  piles),  they  swell  and  become 
intensely  painful.  Ulceration  or  suppuration,  and  occasionally  abscess  of  the 
liver  or  pyemia  may  follow.  The  diagnosis  is  easily  made  with  the  aid  of 
a  speculum,  but  digital  examination  should  always  be  employed  to  exclude 
carcinoma. 

The  treatment  is  removal  of  the  cause,  if  such  be  possible.  The  bowels 
should  be  moved  daily,  alcohol  and  spices  avoided,  and  regular  exercise 
taken.  The  parts  should  be  kept  dean,  bathed  with  cold  water  after  def- 
ecation, and  dried  with  a  soft  rag.  Ointments  or  suppositories  containing 
hamamelis  and,  if  there  is  much  pain,  opium  and  belladonna  may  be  used. 


520  RECTUM  AND  ANUS. 

Adler  has  the  following  frequently  applied:  ex.  hamamelis  fl.,  one  fluid  ounce, 
ex.  hydras,  fl.,  tincture  of  benzoin  comp.,  each  one-half  ounce,  tincture  of 
belladonna,  one  dram,  ol.  olive  (carbol.  5  per  cent.)  q.s.  three  fluid  ounces. 
Strangulated  piles  should  be  reduced  after  anointing  them  with  oil,  or  if 
this  is  unsuccessful,  they  should  be  removed  by  operation.  Operation  is 
indicated  also  when  there  is  prolapse,  ulceration,  recurring  hemorrhages, 
attacks  of  inflammation,  or  pain  requiring  the  frequent  use  of  opium.  The 
liver  should  always  be  examined  before  operation,  as  in  some  cases  the 
bleeding  is  beneficial  rather  than  harmful.  A  laxative  should  be  given 
forty-eight  hours  before,  and  an  enema  the  day  before  operation,  thus 
preventing  soiling  on  the  table.  Many  operators  omit  shaving.  The  patient 
is  anesthetized  and  put  in  the  lithotomy  position,  and  the  anus  thoroughly 
stretched.     There  are  three  principal  methods  of  operating  on  hemorrhoids: 

Ligation  is  easy,  safe,  and  sure.  The  hemorrhoid  is  picked  up  with 
forceps  and  an  incision  made  through  the  mucous  membrane  around  the 
pile;  the  base  is  then  transfixed  with  a  double  silk  ligature,  which  is  tied  on 
each  side,  and  the  mass  cut  away. 

Operation  by  the  clamp  and  cautery  is  favored  by  many  surgeons. 
The  pile  is  caught  with  forceps,  and  a  Smith's  clamp,  the  blades  of  which,  in 
order  to  prevent  burning,  are  covered  with  ivory  on  the  side  which  rests 
against  the  mucous  membrane,  applied  to  the  base  of  the  pile,  in  the  long 
axis  of  the  rectum.  The  pile  is  then  removed  with  scissors,  and  the  base 
seared  with  the  cautery  at  a  dull  red  heat,  after  which  the  clamp  is  removed. 

Whitehead's  operation  consists  in  removal  of  the  entire  pile  bearing 
area,  and  is  indicated  when  there  are  ma.sses  of  varicose  veins  which  occupy 
the  whole  of  this  region.  A  circular  incision  is  made  at  the  junction  of  the 
skin  and  mucous  membrane;  the  tube  of  mucous  membrane  containing  the 
varico.se  veins  is  then  dissected  up  and  amputated,  and  the  divided  mucous 
membrane  sutured  to  the  skin.  Stricture  and  incontinence  occasionally 
follow  this  operation. 

After  any  of  these  operations  bleeding  and  tenesmus  may  be  prevented, 
and  the  painless  escape  of  flatus  permitted,  by  introducing  into  the  rectum  a 
rubber  tube  surrounded  by  gauze  and  transfixed  externally  by  a  safety  pin. 
The  parts  are  protected  with  a  sterile  gauze  pad,  and  washed  each  day  with 
creolin  solution.  The  bowels  are  opened  on  the  third  or  fourth  day.  It 
will  often  be  necessar>'  to  catheterize  the  patient  for  the  first  day  or  two, 
owing  to  reflex  retention  of  urine. 

Piles  have  l)een  treated  also  by  excision  of  the  individual  tumors,  preceded 
l)y  the  application  of  a  crushing  clamp,  or  followed  hy  suture  of  the  wound; 
by  ignipioicture;  and  hy  the  injection  of  carbolic  acid,  one  or  two  drops  of 
a  10  per  cent,  solution  being  injected  into  each  pile  at  intervals  of  a  week. 

Prolapse  of  the  rectum  may  involve  the  mucous  membrane  only  {incom- 
plete prolapse,  or  prolapsus  ani),  or  the  entire  rectal  wall  {complete  prolapse, 
or  prolapsus  recti).  The  causes  are  relaxation  of  the  tissues,  such  as  is  seen 
in  the  debilitated,  and  conditions  which  give  rise  to  repealed  and  violent 
straining,  e.g.,  constipation,  diarrhea,  various  forms  of  rectal  irritation, 
enlarged  prostate,  urethral  strictures,  stone  in  the  bladder,  and  phimosis. 
In  the  early  stages  the  prolapse  appears  as  a  reducible,  red  or  purplish  cuff 
of  mucous  membrane.  In  complete  prolapse  the  mass  may  be  of  large 
size,  irreducible,  dry,  and  sometimes  ulcerated  or  even  strangulated. 

The  treatment  is  removal  of  the  cause,  and  reduction  of  the  prolapse  by 


TITMORS    OF    THE   RFCTUM. 


S2t 


pressing  the  finger  in  the  orilice  after  the  parts  have  been  oiled;  recluction  is 
maintained  liy  strapping  the  F>uttocks  together  with  adhesive  plaster,  leaving 
an  opening  for  the  passage  of  feres.  In  t  hihlren  nire  is  oflen  thus  t>l>laine<K 
if  care  is  taken  to  prevent  lonstipation.  In  adults  the  parts  may  be  kept  in 
place  by  a  T-bandage,  and  a  daily  movement  of  the  l>owe!s  secureil  while  the 
patient  h'es  on  one  side.  An  enema  of  cold  water  containing  an  astringent, 
such  as  tannin  or  fluid  extract  of  hyrirasiis,  alstj  is  useful.  When  these 
measures  fail  in  the  incomplete  variety,  longitudinal  strips  of  mucous  mem- 
brane may  be  excised  and  the  wounds  sutured,  or  the  same  result  ob- 
tained by  the  use  of  caustics  or  the  cautery.  Paraffm  has  been  injected 
about  the  anus  in  order  to  narrow  the  opening,  In  recurring  complete  pro- 
lapse the  rectum  or  sigmoid  may  be  fastened  to  the  abdominal  wall  through 
an  incision  in  the  iliac  region  (proff&pexy  or  iohpexy).  In  other  cases,  par* 
ticularly  when  irreducible,  the  prolapsed  gut  may  be  amputated,  its  con- 
tinuity being  restored  by  sutures. 

Ulcer  of  the  rectum  may  be  simple  (due  to  foreign  body,  abrasion  of 
feces,  etc.),  syphilitic,  tuberculous,  malignant,  gonorrheal,  dysenterii ,  or 
typhoidal  The  sym plants  are  those  of  rectal  irritation,  with  constipation 
or  diarrhea,  and  the  discJiarge  of  mucus,  pus,  or  blood.  The  diagnosis  is 
made  \>y  digital  examination  and  the  speculum.  The  nature  of  the  ulcer 
may  be  ascertained  from  the  history  and  the  local  characteristics,  which  are 
much  the  same  here  as  elsewhere.  The  treatment  in  non- malignant  cases  is 
local  applications  of  silver  nitrate,  20  or  30  grains  to  the  ounce,  after  cleans- 
ing the  rectum  witli  hot  water.  Iodoform  is  useful,  particularly  in  tuber- 
culous cases.  The  general  health  should  receive  attention,  and  in  syphilitic 
cases  appropriate  inlenial  treatment  administered. 

Stenosis  or  stricture  of  the  rectum  may  he  caused  by  pelvic  neoplasms 
or  cellulitis,  and  by  the  cicatrization  of  wounds  or  ukers  of  the  rectum.  It 
may  be  also  congenital  or  due  to  malignant  tumors  in  this  region;  the  latter 
will  he  considered  separately.  The  bowel  is  dilated  above  the  stricture  and 
secondary  tistula^  may  form.  The  symptoms  are  pain,  discharge  (mucus, 
pus,  or  blood),  constipation,  deformity  of  the  stools  (ribbon  or  pipe-stem), 
occasionally  attacks  of  diarrhea,  due  to  enteritis  from  the  irritation  of  re- 
tained feces,  and  finally  in  some  cases  comjjlete  obstruction.  The  diagnosis 
is  made  with  the  finger  and  the  speculum.  The  irtatment  in  the  cicatricial 
variety  is  gradual  dilatation  with  bougies.  When  in  the  lower  part  of  the 
rectum,  the  stricture  may  be  incised  posteriorly.  In  suitable  cases  the 
stricture  may  be  excised,  and  the  ends  of  the  bow^el  united  by  suture.  In 
ex  ten. si  ve  and  intractable  cases  colostomy  may  be  the  only  possible  remedy. 
Any  (onstilutional  disease,  e.g.,  syphilis  or  tuberculosis,  shouhl  receive 
treatment. 

Ttimors  of  the  anus  are  uncommon.  Epithelioma  in  this  region  pre- 
sents its  usual  features,  antl  causes  enlargement  of  the  inguinal  glands. 
Cancer  of  the  anus,  however,  is  usually  secondary  to  that  of  the  rectum.  The 
treatment  is  excision,  with  the  inguinal  glands. 

Tumors  of  the  Rectum. — Polypus  recti  is  the  most  common  benign 
tumor,  is  most  frequent  in  chihlren,  and  is  an  adenoma  with  a  long  ped- 
icle. The  symptoms  are  rectal  irritation,  the  passage  of  blood  or  mucus, 
antl  occasionally  prolapse  or  intussusception.  The  treatmmt  is  removal 
after  ligating  or  twisting  the  pedicle.  Papilloma  is  rare,  but  may  occur 
as  a  cauliflower  mass,  the  chief  symptoms  of  which  are  hemorrhage  and 


522  RECTUM  AND  ANUS. 

rectal  irritability.  The  trecUment  is  removal  by  ligature  or  snare.  A  micro- 
scopic examination  should  always  be  made  to  exclude  malignant  disease. 
Sarcoma  also  is  rare;  it  occurs  as  a  large  fleshy  mass,  without  primary  ulcera- 
tion. The  symptoms  are  the  same  as  those  of  cancer,  but  occur  at  an  earlier 
age.     The  treatment  is  extirpation. 

Cancer  of  the  rectum  is  usually  of  the  tubular  or  cylindrical-celled 
variety,  and  is  occasionally  the  result  of  a  malignant  change  in  an  adenoma. 
The  disease  may  begin  as  an  ulcer,  or  as  a  nodule  beneath  the  mucous  mem- 
brane which  reaches  a  large  size  before  ulcerating.  In  the  former  instance 
the  growth  usually  extends  annularly  around  the  rectum,  in  the  latter  it 
increases  equally  in  all  directions.  The  consistency  varies  with  the  amount 
of  fibrous  tissue  present;  thus  the  mass  may  be  soft,  f ungating,  and  friable,  or 
extremely  dense  yniYi  an  ulcerated  surface,  the  margins  of  which  are  hard  and 
everted.  The  softer  varieties  are  the  more  malignant.  Metastases  may 
occur  in  the  lumbar  glands,  liver,  and  peritoneum,  but  are  comparatively 
rare  and  late.  The  disease  is  most  common  in  middle  life,  but  it  may  occur 
earlier  and  has  been  seen  even  in  childhood.  The  symptoms  may  be  slight  or 
absent,  until  the  disease  is  far  advanced.  There  may  be  pain,  a  sense  of 
fullness  in  the  rectum,  tenesmus,  and  the  passage  of  pus,  blood,  or  mucus. 
In  the  later  stages  the  signs  of  stricture  are  evident  and  cachexia  develops. 
Secondary  fistulas  into  the  bladder,  vagina,  or  opening  externally  may  form. 
The  diagnosis  is  made  with  the  finger  and  the  speculum.  If  the  growth  is 
high  up,  it  may  sometimes  be  detected  by  having  the  patient  bear  down  while 
in  the  standing  position.  Death  occurs  in  from  one  to  ^\\t  years,  from  exhaus- 
tion, obstruction,  hemorrhage,  or  peritonitis. 

The  treatment  may  be  palliative  or  radical.  Palliative  treatment 
is  indicated  when  the  growth  cannot  be  removed.  The  rectum  is  irrigated 
daily  with  salt  solution,  opium  given  for  pain,  and  colostomy  performed 
at  an  early  period  and  not  postponed  until  obstructive  symptoms  supervene, 
as  it  diverts  the  fecal  current  and  thus  diminishes  pain  and  retards  the 
progress  of  the  disease. 

Radical  treatment,  or  excision  of  the  rectum,  is  indicated  when  the 
growth  is  movable  and  metastases  are  not  present.  If  the  sacrum,  base  of  the 
bladder,  or  uterus  is  involved,  operation  is  useless.  The  mortality  of  com- 
plete excision  of  the  rectum  is  about  25  i)er  cent.,  and  cure  results  in  al>out 
the  same  proportion.  Before  any  operation  the  bowels  should  be  thoroughly 
evacuated,  the  rectum  Hushed  with  salt  solution,  and  the  patient  fed  only  on 
wholly  digestible  food.  Surgeons  differ  as  to  the  necessity  of  a  preliminar}' 
inguinal  colostomy.  Its  chief  advantages  are  that  the  rectum  can  be  thor- 
oughly irrigated  before  operation,  that  the  field  of  operation  can  be  kept 
clean  after  operation,  and  that  the  limits  of  the  growth  above  and  the  pres- 
ence or  absence  of  abdominal  metastases  can  be  determined  at  the  lime  the 
artificial  anus  is  made.  The  chief  objections  are  the  additional  risk  involved 
in  closing  the  artificial  anus,  if  such  be  desirable,  and  the  interference  with 
thorough  mobilization  of  the  rectum  at  the  time  of  excision;  the  latter  objec- 
tion loses  its  force  if  the  sigmoid  is  pulled  well  down  at  the  time  of  the 
colostomy.  The  following  are  the  routes  by  which  the  rectum  may  be 
excised: 

The  vaginal  route  is  indicated  when  a  small  growth  exists  on  the  ante- 
rior wall.  The  posterior  wall  of  the  vagina  is  split,  the  growth  excised,  and 
the  vagina  and  rectum  sutured. 


CONGENITAL  ABNORMAUTIES   OF   THE   KIDNEY.  523 

The  anal  route  is  indicated  when  the  growth  is  very  low.  The  anus  is 
dilated,  a  circular  incision  made  through  die  rectal  wall  above  the  external 
sphincter,  the  rectum  pulled  out  through  the  anus  and  amputated,  and  the 
two  ends  sutured.  If  the  anus  is  involved  it  also  must  be  removed,  the  pri- 
mary incision  then  being  made  around  the  anus  externally. 

The  perineal  route  is  indicated  in  growths  occupying  the  lower  two  or 
three  inches  of  the  rectum,  and  is  much  the  same  as  the  preceding,  except  that 
the  incision  extends  back  to  the  coccyx  and,  if  necessary,  as  far  forward  as  the 
scrotum.     In  some  cases  the  external  sphincter  may  be  preserved. 

The  sacral  route  (Kraske*s  operation)  is  indicated  in  higher  growths. 
With  the  patient  on  the  right  side,  an  incision  is  made  from  the  posterior 
margin  of  the  anus,  upwards  in  the  middle  line,  to  the  second  piece  of  the 
sacrum.  The  coccyx  is  excised,  the  left  side  of  the  sacrum  below  the  third 
foramen  (the  third  sacral  nerve  sends  a  branch  to  the  bladder)  removed  with 
the  chisel,  and  the  rectum  extirpated.  If  the  sphincter  is  not  involved,  the 
upper  segment  may  be  sutured  to  the  lower.  When  this  is  imi>ossibIe,  the 
upper  segment  of  bowel  may  be  sutured  in  the  sacral  wound,  or  the  end  may 
be  closed  by  sutures,  providing,  of  course,  a  preliminary  colostomy  has  been 
made.  In  the  Kraske  operation  the  peritoneum  is  often  opened,  subse- 
quently being  sutured,  or  packed  with  gauze.  There  are  several  modifications 
of  this  operation,  involving  more  extensive  removal  of  bone  or  osteoplastic 
resection. 

The  abdomino-perineal  route  is  indicated  in  cases  in  which  the  growth 
extends  too  high  to  be  removed  by  any  of  the  preceding  methods.  In  Quinu's 
operation  the  abdomen  is  opened  in  the  middle  line,  both  internal  iliac  arteries 
tied,  the  sigmoid  divided,  die  upper  segment  of  the  bowel  brought  out  through 
an  incision  in  the  left  iliac  region,  thus  making  a  permanent  artificial  anus, 
and  the  lower  segment  separated  as  far  down  as  possible.  The  abdominal 
wound  is  then  dosed,  and  the  rectum  removed  through  the  perineum.  In 
Weir's  operation  the  abdomen  is  opened,  the  gut  divided  above  the  tumor,  the 
upper  end  of  the  lower  segment  invaginated  and  pulled  out  through  the  anus, 
and  the  involved  segment  amputated.  The  lower  end  of  the  upper  segment 
is  then  drawn  through  the  anus,  and  united  to  the  lower  segment  by  sutures 
(Maunseirs  method). 


CHAPTER  XXIX. 

URINARY  ORGANS. 

KIDNEY  AND  URETER. 

Congenital  abnormalities  of  the  kidney  include  (a)  absence  or  atrophy 
of  one  organ,  the  other  being  hypertrophied  (single  kidney) ;  (b)  fusion  of  the 
kidneys  {solitary  kidney),  constituting  a  disc  shaped  mass  lying  in  the  middle 
line,  or  if  the  lower  poles  are  joined,  the  horseshoe  kidney;  (c)  lobulation , 
which  is  normal  in  fetal  life  and  in  some  animals;  (d)  doubling  of  the  ureter 
in  whole  or  in  part;  (e)  stricture  of  the  ureter;  (f)  tu^o  or  more  renal  arteries  for 
the  same  organ;  and  (g)  displacement  of  the  kidney,  which  may  be  freely 
movable  and  supplied  with  a  mesonephron   (congenital  floating  kidney), 


URINARY    ORGANS. 


or  fixeil  at  any  pc»iiit  as  low  a*  the  internal  abdoininal 

whk  h  situation  il  is  probably  drawn  by  the  de!?-cem  oi  ihe  le-Oid 

hydrfmrphr&sis\  and  ryuiir  disease  also  may  l>c  cong^itiL  J 


Fig.  433.— Skiagraph  made  after  injecting  coll 
pelvis  {pyelography),  showing  the  size,  shape  anrf""^^  -^'^  ^^''  ^t 
ureter  (Jefferson  Hospital).  Irregularities  in  the*^  P^ition  of  th 
pyelitis,  tumors,  tuberculosis,  hydronephrosis,  and  ^"""'^  0/  ^^/k 
shadow  will  aid  in  the  differentiation  of  abdominaj  t  °''^'*'*^^'®'*-  7u' 
ectopic,  and  horseshoe  kidney,  and  in  the  locaiizati**'''*^'^'  '''  ^^^d  ^ 
cortex  will  appear  distinct  from  the  pelvic  shadow)  ^  ^  ''caaj  t^^^ 
tion  and  dilatation  also  can  be  demonstrated.  *ious  /Qriu,^^* 

Examination  of  the  Kidney. — (i)  ^o  palpate  th 
placed  under  the  loin  and  the  other  in  front  bene^  ^^^ey  ^ 
patient  breathes  deeply.     The  patient  should  be  on  the  h  *^  '^ 


FUNCTIONAL   TESTS    FOR    THE    KmNEY. 


5^5 


side,  or  in  some  cases  standing  up.  The  normal  kidney  descends  sHghtly 
on  deep  inspiration  but  ordinariiy  cannot  be  palpated.  An  enlarged  ureter 
can  sometimes  be  felt  through  the  rectum,  vagina,  or  abdominal  wall.  (2) 
The  chief  value  of  perfussion  is  in  determining  the  relations  of  a  swelling  in 
the  loin  to  the  colon;  the  kidney  is  always  behind  the  colon.  (3)  The  X-rays 
may  show  the  normal  kidney,  enlargements  of  various  sorts^  tuberculous 
foci,  stones  (Fig.  436),  the  ureters  (after  the  passage  of  styleted  catheters — 
Fig»  437),  and  the  renal  pelvis  (after  the  injection  of  collargol  5  to  15  per 
cent. — pydography,  Fig.  433).  As  food,  fecal  matter,  and  gas  within  the 
intestines  produce  confusing  shadows,  the  diet  should  be  limited  to 
liquids  for  24  hours  before  the  plate  is  taken  and  the  bowels  cleared  by 
purgation.  The  patient's  back  is  brought  in  close  contact  with  the  plate 
by  drawing  up  the  knees  ami  raising  the  shoulders,  and  the  respiratory 
movements  restricted  and  the  thickness  of  the  abdomen  reduced  by  com- 
pressing the  abdomen  with  a  canvas  band  or  a  wooden  ring.  (4)  Of  great 
importance  is  the  ihcmical,  microstopkai,  and  bacttTUflogudl  exam i nation 
of  the  urine,  with  the  quantity  secreted.  (5)  Cystescopy  allows  dirct  inspec- 
lion  of  the  ureterd  orifices  (p.  539)  and  catheterization  of  the  ureters  (\ide 
infra).  (6)  The  J'unriwnai  caparily  of  ilw  ki^ineys  is  considered  below, 
(7}  F^ploratory  incision  is  indicated  when  all  other  methods  fail  to  give  the 
desired  information,  but  onJy  in  cases  in  which  the  symptoms  are  sufficiently 
grave  to  demand  operation. 

CatheterizEtion  of  the  ureter  permits  the  collection  of  unmixed  urine 
from  each  kidney,  and  is  of  great  value  in  determining  the  presence  of  both 
kidneys,  the  location  of  disease  In 
one  or  both  organs,  the  patency  of 
the  ureter,  the  size  of  the  pelvis,  and 
like  conditions.  The  technic  is  given 
on  p.  540.  In  order  to  overcome  the 
difficulties  of  ureteral  catheterization 
several  forms  of  urine  si\^regaiors  have 
been  devised.  The  Harris  segregator 
separates  the  bladder  into  two  com- 
partments by  a  lever  in  the  rectum  or 
vagina  the  urine  l>eirig  drained  from 
each  compartment  by  a  small  catheter 
In  another  form  of  instrument  (Luys 
and  Cathlin)  the  bladder  is  separate*! 

into  two  portions  by  means  of  a  thin  ruliber  diaphragm  which  is  expanded 
after  it  is  passed  into  the  bladder;  the  urine  is  then  withdrawn  by  separate 
catheters  passed  through  the  instrument  into  each  half  of  the  bladder 
(Fig.  434).  Segregation  of  urine  is  easier  and  safer  than  catheterization  of 
the  ureters,  but  the  sources  of  error  are  greater. 

The  functional  capacity  of  the  kidneys  is  determined  before  perform- 
ing a  serious  operation  on  one  organ,  and  it  is  important  to  ascertain  that 
the  other  kidney  is  not  only  present  and  heaithvt  but  also  sufficiently  active 
to  preserve  the  patient.  The  urine  from  each  organ  is  collected  separately 
and  simultaneously,  and  one  or  more  of  the  following  methods  employed. 

(1)  The  amount  and  iom position  of  the  urine  secreted  by  each  kidney  in 
a  given  time  is  determined.  The  normal  output  of  each  kidney  in  twenty- 
four  hours  is  500  to  750  cc.  of  urine,  10  to  15  grams  of  urea,  5  to  6  grams  of 


.^ 


Fig.  434.— Caihlin's  s^'gregaior  in  posi- 
tion, with  lubes  attached  for  coileciing 
the  urine 


JaO  UMNAHY  ORGANS. 

chlorids.     A  decrease  of  one-third  in  these  quantities  indicates  that  the 
kidney  is  incompetent  to  sustain  life* 

{2)  The  phhridzin  kst  consists  in  the  subcutaneous  administration  of 
5  milligrams  of  phtoridzin,  which  ts  transformed  into  sugar  by  the  secreting 
cells  of  tlie  kidney.  If  these  cells  are  normal,  sugar  should  appear  in  the 
urine  in  from  fifteen  to  thirty  minutes,  and  continue  to  be  excreted  for 
four  hours.     Delayed  or  prolonged  elimination  points  to  renal  insufficiency. 

(3)  Chromocystoscopy  consists  in  watching  the  ureteral  orifices  for  the  tx- 
cretion  of  blue  urine,  after  the  intramuscular  injection  of  methylene  blue 
(15  minims  of  a  5  per  cent,  solution)  or  indigocarmin  (4  cc.  of  a  4  per  cent. 
solution).  A  simpler  plan  is  to  insert  ureteral  catheters  and  note  when  the 
blue  urine  appears  externally.  Normally  this  should  occur  in  from  10  to 
20  minutes  and  continue  24  to  48  hours.  If  the  blue  is  late  in  appearing 
or  disappearing  the  renal  parenchyma  is  diseased.  Roundtree  and  Geraghty 
have  recently  suggested  the  intramuscular  injection  of  6  milligrams  of 
phenol sulpbonephthalein.  The  urine  drains  from  the  catheter  into  a  test* 
tube  containing  i  drop  of  a  25  per  cent,  sodium  hydroxid  solution,  which 
becomes  pinkish  when  the  drug  appears  in  the  urine.  As  acid  urine  shows 
only  a  faint  orange  tinge,  it  is  made  decidedly  alkaline  by  adding  more 
sodium  hydroxid  solution,  w^hen  it  turns  to  a  brilliant  red.  The  sample  is 
now  diluted  to  i  liter  with  distilled  water,  and  a  small  tiltered  portion  com- 
pared,  by  means  of  a  Duboscq  colorimeter,  with  a  standard  consisting  of  5 
milligrams  of  phenolsulphonephthalein  and  1  or  2  drops  of  sodium  hy- 
droxid solution  (25  per  cent)  in  i  liter  of  water.  Normally  the  drug 
appears  in  the  urine  in  from  5  to  10  minutes,  50  per  cent,  being  eliminated 
during  the  first  hour,  15  to  25  per  cent,  during  the  second  hour. 

(4)  Cryoscopy  is  the  determination  of  the  freezing  point  of  the  blood  and 
urine.  It  requires  special  apparatus  and  is  regarded  by  most  surgeons  as 
untrustworthy.  The  greater  the  number  of  molecules  in  a  fluid,  the  lower 
its  freezing  point,  hence  tf  the  kidneys  are  diseased,  the  urine  w^ill  contain 
less  solids  and  will  freeze  at  a  high  temperature,  while  the  blood  will  contain 
more  solids  and  freeze  at  a  low^  point.  The  normal  freezing  point  of  the 
blood  is-. 56  C,  of  urine -.9  C.  When  the  freezing  point  of  the  blood 
i&-.58  C  or  lower,  and  that  of  the  urine  is-,8  C  or  higher,  operations  on 
the  kidney  are  dangerous. 

The  presence  of  two  kidneys  may  be  determined  by  the  cystoscopc 
(presence  of  two  ureteral  oridces),  by  the  segregator,  by  palpation  externally 
(occasionally)  or  through  an  incision,  and  in  some  instances  by  the  X-ray. 

Hematuria,  or  blood  in  the  urine,  may  be  due  to  local  or  general  causes. 
Among  the  local  causes  are  inflammation,  congestion,  traumatism,  embolism, 
thrombosis,  calculus,  tumors,  ulceration,  and  parasites  in  any  portion  of  the 
urinar)"  tract.  The  most  important  parasite  is  the  Bilharzia  hematobia, 
which,  in  portions  of  Africa,  enters  the  body  with  the  drinking  w^ater  and 
later  develops  in  the  veins  of  the  intestine  or  urinar}^  apparatus.  The  hemor- 
rhage is  caused  by  the  discharge  of  ova  through  die  mucous  membrane 
Bleeding  may  be  produced  also  by  the  passage  of  an  instrument,  and  in  the 
female  bloody  urine  may  be  the  result  of  contamination  with  the  menstrual 
fluid.  Among  the  general  causes  are  certain  infectious  diseases,  e.g.,  variola, 
measles,  scarlet  fever,  enteric  fever,  yellow  fever,  malaria,  plague,  and  pneu- 
monia; certain  blood  diseases,  e.g.,  scurvy,  leukemia,  purpura,  and  hemophilia; 
intoxications,  such  as  jaundice  or  those  due  to  mercury,  lead,  arsenic,  can- 


WOUNDS    OF   THE    URETER.  527 

tharides,  turpentine,  and  quinin;  hysteria;  and  vicarious  menstruation.  The 
color  of  the  urine  varies  from  red  to  black.  It  should  be  recalled  that  senna, 
rhubarb,  beet  root,  and  sorrel  make  the  urine  red;  and  carbolic  and  salicylic 
acids,  brown  or  black.  Hemoglobinuria  is  characterized  by  the  absence  of 
corpuscles.  It  may  be  due  to  any  of  the  causes  mentioned  above,  or  to  exten- 
sive burns,  transfusion  of  blood,  infusion  of  salt  solution,  or  paroxysmal 
hemoglobinuria.  In  renal  hematuria  the  blood  is  intimately  mixed  with  the 
urine,  and  may  contain  blood  casts. of  the  renal  tubules  or  ureter.  By 
cystoscopic  examination  blood  may  be  seen  issuing  from  the  ureter.  In 
ureteral  hemorrhage  bleeding  is  often  slight  and  detectable  only  by  micro- 
scopic examination.  In  vesical  or  prostatic  hematuria  the  urine  is  often  alka- 
line, contains  clots,  and  most  of  the  blood  is  passed  at  the  end  of  micturition. 
In  urethral  hematuria  blood  drips  from  the  urethra  independently  of  micturi- 
tion, and  the  final  urine  passed  may  be  quite  clear. 

Pyuria,  or  pus  in  the  urine,  may  be  due  to  inflammation  of,  or  rupture  of 
an  abscess  into,  any  portion  of  the  urinary  tract.  When  of  renal  origin  the 
urine  is  usually  acid,  when  from  the  bladder  generally  alkaline.  Pus  from 
the  prostate  may  be  expressed  into  the  urethra  by  pressure  through  the 
rectum,  and  pus  from  the  urethra  appears  in  the  first  portion  of  urine  passed. 
The  source  may  often  be  located  with  the  cystoscope  or  the  urethroscope. 

Chyluria  is  usuMly  caused  by  filariasis. 

Anuria  (not  to  be  confuted  with  retention,  p.  542)  is  the  condition  in 
which  no  urine  is  passed  and  the  bladder  is  empty.  It  may  be  obstructive 
or  non-obstructive.  Obstructive  anuria  may  be  caused  by  obstruction  of 
the  ureter  of  the  only  existing  or  only  functionating  kidney,  or  in  rare  in- 
stances by  obstruction  of  both  ureters  simultaneously.  The  causes  of  ureteral 
obstruction  are  given  under  hydronephrosis  (p.  529).  In  this  variety  of 
anuria  uremia  may  not  supervene  for  a  number  of  days,  even  though  no  urine 
is  passed.  The  treatment  is  nephrotomy  upon  the  obstructed  side,  in  order 
to  allow  the  urine  to  escape.  The  side  to  be  operated  upon  will  usually  be 
indicated  by  pain,  tenderness,  muscular  rigidity,  and  possibly  by  enlarge- 
ment of  the  kidney.  Removal  of  the  cause  of  obstruction,  unless  very  easy, 
should  be  undertaken  at  a  later  date.  Non-obstructive  anuria  (suppression 
of  urine)  may  be  reflex  or  due  to  degenerative  changes  in  the  kidneys. 
Among  the  reflex  causes  are  operations  on  or  injuries  to  any  portion  of  the 
genitourinary  apparatus,  obstruction  to  one  ureter  the  other  remaining  free, 
hysteria,  and  extensive  burns;  in  this  group  also  uremia  may  be  postponed 
for  some  days.  The  treatment  is  at  first  medical,  and  later  nephrotomy  upon 
one  or  both  kidneys.  Degenerative  changes  in  the  kidneys  may  be  caused  by 
nephritis;  acute  infectious  diseases,  including  septicemia;  poisons,  such  as  phos- 
phorus, turpentine,  carbolic  acid,  cantharides,  ether,  and  chloroform;  and 
by  lesions  like  tumors,  tuberculosis,  and  cystic  disease  of  both  kidneys.  In 
these  cases  uremia  accompanies  or  precedes  the  anuria.  The  treatment  is 
usually  medical,  although  in  a  few  instances  favorable  results  have  followed 
nephrotomy. 

For  rupture  of  the  kidney  and  ureter  see  contusions  of  the  abdomen. 

Wounds  of  the  kidney  give  the  same  symptoms  as  ruptures,  plus  an 
external  wound,  from  which  blood  and  urine  may  escape.  The  treatment  is 
that  of  ruptures. 

Wounds  of  the  ureter  may  be  produced  by  stabs,  bullets,  and  most 
frequently  by  the  surgeon  during  abdominal  operations,  especially  hysterec- 


528  URINARY   ORGANS. 

tomy.  The  result  is  peritonitis,  localized  or  generalized,  and  if  the  patient 
survive,  a  urinary  fistula.  The  immediate  treatment  of  a  lateral  wound  is 
suture;  of  complete  division,  anastomosis  (p.  538). 

Ligation  of  the  ureter^  which  is  sometimes  unintentionally  performed,  par- 
ticularly during  gynecological  operations,  causes  atrophy  of  the  kidney  or, 
owing  to  ulceration  of  the  ligature  through  the  ureteral  walls,  an  abscess, 
which  on  breaking  leaves  a  fistula. 

Ureteral  fistulse,  in  addition  to  ruptures,  wounds,  and  ligation,  may  be 
caused  by  sloughing  following  labor,  or  ulceration  the  result  of  conditions  like 
tuberculosis,  carcinoma,  and  calculus.  The  fistula  may  open  into  one  of  the 
hollow  viscera,  the  vagina,  or  on  the  skin.  The  diagnosis  from  vesical  fistula 
can  be  made  by  injecting  colored  fluid  into  the  bladder  and  by  cystoscopy. 
The  first  step  in  treatment  should  be  the  passage  of  a  catheter  along  the 
ureter,  from  the  bladder,  in  order  to  determine  whether  the  defect  is  lateral 
or  complete  and  to  make  sure  the  canal  below  the  fistula  is  per\nous.  If  the 
defect  is  lateral  and  no  obstruction  exists  spontaneous  healing  may  occur. 
Cutaneous  fistula;  in  which  spontaneous  closure  is  unlikely  should  be  treated 
by  some  form  of  ureteral  anastomosis  (p.  538),  vaginal  fistulas  as  described 
on  p.  580. 

Movable  kidney,  or  nephroptosis,  is  to  be  distinguished  itoia  floating 
kidney;  in  the  latter  condition,  which  is  said  to  be  always  congenital,  the 
kidney  passes  forward  into  the  abdominal  cavity^and  is  completely  surrounded 
by  peritoneum,  being  attached  to  the  posterior  abdominal  wall  by  a 
mesonephron.  In  movable  kidney  the  organ  is  excessively  mobile  behind 
the  peritoneum.  Eighty  per  cent,  occur  in  women,  and  the  right  kidney  is 
involved  in  about  the  same  proportion.  It  is  most  common  between  twenty 
and  forty,  but  may  be  seen  at  any  time  of  life.  The  causes  are  conditions 
which  render  the  abdominal  walls  flaccid,  such  as  pregnancy,  emaciation, 
removal  of  abdominal  tumors,  etc.;  Olenard's  disease;  tight  lacing;  trauma: 
and  conditions  which  increase  the  size  or  weight  of  the  kidney. 

According  to  the  symptoms  the  cases  may  be  divided  into  four  classes. 
( i)  In  most  cases  symptoms  arc  absent.  (2)  In  others  there  is  dragging  pain 
in  the  loin,  with  indigestion  and  nervousness.  (3)  In  this  class  complica- 
tions arise.  If  the  ureter  becomes  kinked  or  twisted,  there  is  transient 
hydronephrosis,  with  violent  j)ain  in  the  kidney  and  epigastrium,  vomiting, 
collapse,  and  subsequently  elevation  of  temperature  and  the  discharge  of  a 
large  quantity  of  urine  {DietVs  crisis) ;  if  the  pedicle  becomes  twisted  gan- 
grene of  the  kidney  may  ensue.  Dragging  on  the  duodenum  or  bile  ducts 
may  cause  gastric  and  biliary  disturbances  and  even  jaundice,  and  the  condi- 
tion is  not  inf  recjuently  associated  with  chronic  appendicitis  or  mucous  colitis. 
.Vlbuminuria,  pyuria,  and  occasionally  hematuria  may  occur,  from  congestion 
of  the  kidney  or  pyelitis.  (4)  In  this  group  the  prolapse  is  secondare'  to 
tuberculosis,  tumor,  hydronephrosis,  or  some  similar  malady,  hence  presents 
the  same  symptoms  as  the  primary  trouble.  In  all  cases  the  symptoms  are 
intensified  by  exercise  or  by  lying  on  the  sound  side,  and  are  usually  relieved 
by  lying  on  the  back.  The  diagnosis  is  made  by  feeling  the  kidney  descend 
below  its  normal  level  on  deep  inspiration.  In  the  .severer  forms  the  hands 
(an  be  ap[)roximate(l  above  the  kidney,  and  in  the  worse  ca.ses  the  kidney 
may  be  found  in  the  pelvis;  percu.s.sion  over  the  loin  is  said  to  give  resonance, 
but  the  .^ign  is  fallacious.  The  X-ray  may  show  the  position  of  the  kidney 
and  reveal  unsu.spected  conditions,  e.g.,  a  calculus. 


PYELITIS.  529 

No  treatment  is  required  in  class  i ;  above  all  the  patient  should  not  be 
told  that  the  kidney  is  movable.  The  treatment  in  class  2  is  the  application 
of  a  straight  front  corset,  adjusted  while  the  patient  is  lying  down,  forced 
feeding,  tonics,  and  rest;  in  class  3,  nephorrhaphy;  in  class  4,  that  of  the 
cause. 

Hydronephrosis,  or  uronephrosis,  is  distention  of  the  pelvis  and 
calices  with  urine,  as  the  result  of  gradual  or  intermittent  obstruction  of  one 
of  the  passages  below.  Sudden  and  complete  obstruction  to  a  ureter  results 
in  cessation  of  the  urinary  secretion  as  soon  as  the  back  pressure  is  sufh- 
cientiy  high,  and  after  a  time  in  renal  atrophy;  if,  however,  the  obstruction 
is  removed  within  a  few  weeks  restoration  of  the  function  of  the  kidney  may 
follow.  The  causes  are  congenital  and  acquired.  Congenital  hydronephrosis 
is  due  to  atresia  of  some  portion  of  the  urinary  passages;  acquired  hydrone- 
phrosis to  obstruction  of  the  ureter  by  calculus,  blood  clot,  parasites,  plugs  of 
mucus  or  pus,  or  stricture;  by  tumors,  abscesses,  cysts,  pregnant  uterus,  or 
other  forms  of  external  pressure;  by  valve  formation  at  the  junction  of  the 
pelvis  and  ureter  owing  to  oblique  insertion;  by  kinking,  e.g.,  over  an  acces- 
sory renal  artery  or  from  excessive  mobility  of  the  kidney;  and  less  commonly 
to  obstructions  in  the  urethra.  In  the  last  instance  the  hydronephrosis  may 
be  double.  As  the  result  of  the  accumulation  of  urine  in  the  pelvis  of  the 
kidney  the  cortex  becomes  thin  and  in  the  final  stages  disappears,  the  kidney 
being  converted  into  a  large,  thin  walled,  irregular  cyst.  At  this  time  the 
fluid  may  not  contain  urea  or  other  urinary  solids.  Infection  and  conse- 
quent pyonephrosis  may  occur  at  any  time. 

The  symptoms  are  combined  with  those  of  the  causative  lesion.  Disten- 
tion of  the  kidney  gives  rise  to  pain  and  a  tumor  in  the  loin,  which  fluctuates, 
is  dull  on  percussion,  lies  behind  the  colon,  and  may  disappear  with  the  pas- 
sage of  a  large  amount  of  urine.  Alternating  ischuria  and  polyuria  is  known 
as  ih^ flush-tank  symptom.  The  cystoscope  will  show  absence  of  urine  on  the 
affected  side,  and  the  ureteral  catheter  may  reveal  the  obstruction.  If  the 
catheter  passes  the  obstruction  the  size  of  the  pelvis  may  be  determined  by 
measuring  the  quantity  of  water  (colored  with  methylene  blue  or  coUargol, 
2  per  cent.)  which  can  be  injected  before  it  escapes  from  the  ureter  along- 
side of  the  catheter  (the  normal  pelvis  holds  from  5  to  20  cc),  or  by  taking  a 
skiagraph  after  the  pelvis  is  filled  with  the  coUargol  solution  (Fig.  433). 
Calculi  also  may  be  detected  with  the  X-ray.  Death  occurs  from  uremia, 
sepsis,  pressure  on  important  organs,  or  rupture  into  the  peritoneal  cavity. 

The  treatment  is  removal  of  the  cause  if  possible.  Aspiration  is  only  a 
palliative  measure.  In  most  instances  the  kidney  is  exposed  by  an  explora- 
tory incision,  opened,  and  drained  {nephrotomy) ;  it  is  then  sometimes  possible 
to  find  and  remove  the  cause.  If  the  kidney  is  totally  destroyed,  or  if  the 
obstruction  cannot  be  removed  and  a  permanent  sinus  follows  nephrotomy, 
nephrectomy  should  be  performed  if  the  other  kidney  is  sufficiently  active  to 
maintain  life. 

Pyelitis,  or  inflammation  of  the  pelvis  of  the  kidney,  is  caused  by  the 
colon  bacillus  in  75  per  cent,  of  the  cases,  either  alone  or  mixed  with  other 
pyogenic  organisms,  the  most  frequent  of  which  are  the  streptococcus  and 
the  staphylococcus.  The  bacteria  reach  the  renal  pelvis  by  one  of  four 
routes.  ( i)  Ascending  infection  travels  up  the  ureter  by  continuity,  by  means 
of  regurgitated  urine  (urogenous),  or  by  way  of  the  lymphatics.  It  is 
the  result  of  obstruction  or  inflammation  in  the  lower  urinary  passages 
34 


530  URINARY  ORGANS. 

(ureter,  bladder,  urethra).  (2)  Hematogenous  infection  occurs  in  acute 
fevers,  such  as  the  exanthemata,  typhoid,  diphtheria,  pyemia;  and  possibly 
in  those  cases  depending  primarily  upon  localized  forms  of  irritation,  e.g., 
calculus,  parasites  (the  chief  of  which  is  the  Bilharzia  hematobia),  tuber- 
culosis, tumor,  contusion,  and  the  excretion  of  drugs  like  turpentine  and 
cantharides.  It  may  be  stated  that  ordinarily  bacteria  excreted  by  the  kid- 
neys produce  no  evil  eflFects,  unless  there  is  some  local  irritation  or  some 
obstruction  to  the  free  discharge  of  urine.  (3)  Direct  infection  is  the  conse- 
quence of  wounds  or  fistulae.  (4)  Infection  by  contiguity  is  due  to  inflamma- 
tion extending  from  the  surrounding  structures. 

The  symptoms  are  pain  and  tenderness  in  the  kidney,  frequent  micturi- 
tion, intermittent  pyuria,  and  fever  during  the  absence  of  the  pus  from  the 
urine,  which  is  acid  unless  there  is  a  coexisting  cystitis  with  decomposition  of 
the  urine.  Owing  to  the  obstruction  to  the  urinary  flow  caused  by  swelling 
of  the  mucous  membrane  or  other  lesion,  a  pyonephrosis  may  develop  and 
extension  to  the  kidney  occur  (pyelonephritis) ;  suppuration  may  extend  also 
to  the  surrounding  tissues. 

The  treatment  is  hot  fomentations,  alkaline  waters,  diuretics,  and 
urinary  antiseptics.  Lavage  with  a  weak  solution  of  one  of  the  silver  salts, 
introduced  through  a  ureteral  catheter,  is  beneficial  in  some  cases.  If  the 
condition  be  caused  by  an  ascending  infection,  the  bladder  should  receive 
appropriate  treatment.  Other  causes  if  evident  should  be  removed.  If  no 
cause  can  be  ascertained  and  the  symptoms  persist,  the  kidney  should  be 
explored. 

Pyelonephritis  is  pyogenic  inflammation  of  the  pelvis  of  the  kidney  and  of 
the  renal  parenchyma,  and  is  due  to  the  same  causes  as  pyelitis.  The  symp- 
toms are  chills,  fever,  pain  and  tenderness  in  the  kidney,  vomiting,  headache, 
and  later  signs  of  exhaustion  and  uremia.  The  urine  is  small  in  amount, 
usually  contains  pus,  and  sometimes  blood.  The  treatment  is  that  of  pyelitis. 
If  both  kidneys  are  affected  the  prognosis  is  extremely  grave. 

Pyonephrosis,  or  distention  of  the  pelvis  of  the  kidney  with  pus,  is  the 
result  of  infection  of  a  hydronephrosis,  or  retention  of  pus  in  pyelitis.  The 
cortex  is  invaded  and  the  kidney  finally  represented  by  a  large  multilocular  pus 
sac  (Fig.  435),  surrounded  by  adhesions,  through  which  the  pus  may  break, 
establishing  a  fistulous  communication  with  the  bowel  or  the  skin,  or  setting 
up  a  fatal  peritonitis.  The  symptoms  are  those  of  hydronephrosis,  plus  those 
of  sepsis.  The  quantity  of  pus  in  the  urine  depends  upon  the  degree  of  ob- 
struction. It  may  be  intermittent  or  entirely  absent.  Death  occurs  from 
sepsis  or  uremia.  The  treatment  in  unilateral  cases  is  nephrotomy^  removal  of 
the  cause  if  possible,  and  drainage,  or  if  the  kidney  is  hopelessly  disorgan- 
ized, nephrectomy.  If  both  organs  arc  involved  treatment  is  usually  hope- 
less, although  double  nephrotomy  may  be  employed  in  suitable  cases. 

Abscess  of  the  kidney  is  due  to  the  same  causes  as  pyelitis.  Pyemic 
abscesses  are  always  small  and  multiple.  Chronic  abscesses  are  usually 
tuberculous.  The  symptoms  are  pain,  tenderness,  and  muscular  rigidity 
on  the  affected  side,  and  the  constitutional  symptoms  of  sepsis.  The  abscess 
cannot  be  detected  by  palpation  unless  it  is  of  large  size.  Pyuria  may  be 
present  or  absent.  The  treatmmt  is  nephrotomy  and  drainage,  or,  if  the  whole 
kidney  is  destroyed,  nephrectomy. 

Perinephritis,  or  inflammation  of  the  perinephritic  fat,  may  be  caused 
by  trauma,  infection  from  the  blood,  and  extension  from  environing  parts 


TUBERCULOSIS   OF   THE   IQDNEY.  JJt 

(spine,  pleura,  ribs,  liver,  intestine),  but  is  usually  secondary  to  suppurative 
processes  in  the  kidney*  The  symptoms  are  pain,  tenderness,  muscular 
rigidity,  and  if  suppuration  occurs,  fever,  and  the  presence  of  a  mass  in  the 
loin.  A  perinepliritic  abscess  usually  points  alongside  of  the  erector 
spinae,  but  may  descend  into  the  iliac  fossa  or  burst  into  the  pleura,  peritoneum, 
or  intestine.  The  irealmmi  of  perinephritis  in  the  absence  of  suppuration 
is  hot  fomentations,  sedatives,  and  attention  to  the  general  health;  a  peri- 
nephritic  abscess  should  be  opened  and  drained.  In  all  cases  the  cause 
should,  if  possible,  be  determined  and  removed. 

Ureteritis,  or  intlammation  of  the  ureter,  is  practically  always  secondary 
to  pyelitis  or  cystitis.  Primary  ureteritis  is  possible,  e.g.,  from  calculus  or 
injur)^  but  is  very  rare.  In  the  acufc  variety  there  is  a  pyogenic  inflamma- 
tion of  the  mucosa.  Chronic  ureteritis  presents  itself  in  two  forms.  (i) 
In  the  dilated  form  the  ureter  is  dilated  and  tortuous  from  obstruction,  the 
muscular  coat  undergoing  h)T)ertrophy  and  the  mucosa  cysdc  ciianges.  (2)  In 
the  fibroid  form  the  ureter  is  straight,  thickened,  shorlened,  densely  adherent^ 
and  strictured  in  numerous  places. 

The  symptoms  are  usually  masked  by  the  causative  pyelitis  or  cystitis. 
Occasionally  tenderness  can  be  elicited  through  the  abdominal  wall,  and  the 
thickened  ureter  can  often  be  felt  through  the  vagina  and  sometimes  through 
the  rectum.  The  ureteral  orifice,  as  seen  with  the  cystoscope,  is  dilated  or 
contracted,  retracted  or  pouting,  and  almost  always  rigid  (noncontracting) 
and  reddened.  Strictures  are  revealed  by  the  ureteral  catheter.  The 
treatment  is  that  of  the  cause. 

Tuberculosis  of  the  kidney  may  be  ascending  or  descending.  In  the 
former  the  itifection  ascends  from  tlie  lower  urinary  passages,  spreads  from 
the  pelvis  to  the  parenchyma,  and  both  organs  are  generally  affected.  In  the 
descending  type,  which  represents  about  two -thirds  of  the  cases,  the  bacilli 
are  deposited  from  the  blood  and  the  disease  is  called  primary,  i.e.,  it  is 
primary  as  far  as  the  urinar)^  organs  are  concerned,  but  generally  secondary 
to  a  lesion  in  some  other  portion  of  the  body,  notably  the  lungs.  This 
type  is  usually  unilateral,  commences  in  the  parenchyma,  extends  to  the 
peh^s  and  ureter,  and  in  about  half  the  cases  to  the  bladder  and  the  other 
kidney.  The  changes  are  those  of  tuberculosis  elsewhere.  Caseation  occurs 
and  the  abscesses  open  into  the  pelvis  or  exceptionally  through  the  capsule. 
In  tlie  later  stages  the  kidney  is  densely  adherent  from  perinephritis,  dius 
rendering  nephrectomy  difficult  and  dangerous.  The  sytnpiotfts  are  frequent 
micturition  with  dysuria,  slight  pain  or  from  transient  blocking  of  the  ureter 
severe  colic,  tenderness  and  enlargement  of  the  kidney,  pyuria,  occasionally 
hematuria,  and  in  the  later  stages  chills,  fever,  and  sweats,  due  to  secondary 
infection  with  pyogenic  organisms.  Nodules  may  be  detected  in  the  epidid- 
ymis, vas,  or  seminal  vesicle.  Tubercle  bacilli  are  sometimes  found  in  the 
urine.  The  cystoscope  reveals  a  dilated,  rigid  (noncontracting),  and,  owing 
to  the -thickening  and  shortening  of  the  ureter,  retracted  ureteral  oritke, 
w^hich  is  often  surrounded  by  ulcers  or  tubercles  (Fig.  444).  The  thick- 
ened ureter  can  be  felt  through  the  vagina  and  sometimes  through  the  rectum 
or  abdominal  wall,  l^he  X-ray  may  show  the  tuberculous  focus,  which, 
o\Wng  to  calcareous  infiltration,  sometimes  casts  a  dense  shadow  closely  re- 
sembling that  of  a  calculus.  The  Ireatmmi  is  medical  if  both  kidneys  are 
involved.  Pcrinephritic  abscesses  should  of  course  be  incised.  If  the  disease 
is  unilateral  the  kidney  should  he  explored.     If  the  focus  is  strictly  limited,  a 


S32 


INARY  ORGANS. 


partial  nephrectomy  with  subsequent  suture  of  the  wound  may  be  tried,  bu! 
in  most  instances  the  disease  will  be  found  so  extensive  that  the  entire  organ, 
with  the  ureter,  will  require  removal. 

Nephrolithiasis  {renal  cakuli)  is  caused  by  the  precipitatiori  of  urinary^ 
salts  from  highly  concentrated  urine,  the  result  of  lithemia,  gout,  lack  of  exj 
ercise,  and  high  living.  The  condition  is  favored  by  obstruction  of  the  ureter" 
and  inflammation  of  the  kidney  or  its  pelvis.     There  may  be  one  or  many 

stones,  the  size  of  whicii  varies  from 
fine  granules  (gravel)  to  a  mass  almost 
as  large  as  the  kidney  itself  (Fig.  435^^ 
They  consist  of  uric  acid  or  uraleL>. 
sometimes  of  oxalate  or  phosphate  of 
lime,  and  less  frequently  of  carbonates, 
cystin,  or  xanthin.  There  is  often  a 
nucleus,  which  may  be  epithelial^ 
parasitic,  or  bacterial  in  origin. 

The  symptoms  vary  ^ith  the  situ- 
ation of  the  cakulus.  If  it  is  situated 
in  the  parenchyma  and  is  smooth  there 
may  be  no  symptoms.  As  a  rule, 
however,  there  is  pain  in  the  loin,  which 
is  increased  by  jolting,  and  which  may 
be  felt  also  in  the  groin,  thigh,  testicle 
{sometimes  with  retraction  of  this 
organ),  and  occasionally  along  the 
back  of  the  lower  limb  as  far  as  the 
heel  In  rare  instances  it  is  referred 
to  the  other  kidney.  There  may  be 
no  urinary  changes.  Tenderness  on 
pressure  can  almost  always  be  elicited. 
Abscess  of  the  kidney  may  follow. 
When  the  stone  lies  in  the  pelvis  of  the 
kidney  it  usually  causes  pyelitis  (pyuria, 
hematuria,  frequent  micturition,  etc). 
If  the  stone  passes  dmim  the  urelcr 
symptoms  of  ren<il  colic  follow%  viz., 
sudden,  excruciating,  paroxysmal  pain, 
passing  from  the  loin  along  the  ureter 
to  the  testicle,  which  is  retracted; 
hematuria,  which  is  often  detectable 
The  pain  ceases  if  the  calculus  slips  back 
reaches  the  bladder.  The  stone  may  lodge 
the  bladder,  or  at  the  brim  of 
Sudden 


Fig.  435, — Calculous  pyonephroisis 
(Pennsylvania  HospitaL) 


vomiting;   collapse;   strangury;   and 
only    by    the    microscope, 
into    the    pelvis^    or    if    it 
near  the  pelvis  of  the  kidney,   close  to 

the  bony  pehis,  the  point  of  impaction  being  excessively  tender, 
and  complete  obstruction  is  followed  by  suppression  of  urine  on  the  corre- 
sponding side  and  atrophy  of  the  kidney,  or  by  death  if  the  other  kidney  is 
not  functionally  active.  Occasionally  the  other  kidney,  even  when  healthy, 
suddenly  ceases  to  secrete  urine  {reflex  anuria ^  p,  527),  Incomplete  or  inter- 
mittent obstruction  causes  hydronephrosis  or  pyonephrosis.  In  some  cases 
tlie  stone  ulcerates  through  the  wall  of  the  ureter  into  the  abdomen  or  re- 
troperitoneal  tissues.     Having  passed  through   the  ureter  the   stone  may 


remain  in  the  bladder  as  a  vesical  calculus,  lie  passed  with  the  urine,  or, 
particularly  in  male  children,  become  impacted  in  the  urethra.  A  calculus 
in  the  lower  portion  of  the  ureter  may  occasionally  be  palpated  through  die 
vagina  or  rectum.  The  cystoscope  may  show  edema  of,  or  a  stone  in,  the 
ureteral  meatus,  a  difference  in  the  urine  on  the  two  sides,  or  absence 
of  the  urine  on  the  affected  side.  As  a  catheter  sometimes  passes  a  stone, 
Kelly  suggests  the  use  of  a  wax-lipped  ureteral  bougie,  upon  which  scratches 
will  be  made  if  a  calculus  is  present.  The  X-rays  (Fig.  436)  furnish  the 
most  reliable  means  of  diagnosis,  but  are  not  inf alible.  They  may  fail  to 
show  very  small  stones,  pure  uric  acid  stones,  and  stones  hidden  beneath 


Fic.  4j6. — Skiagraph  of  multiple  renal  calculi,     t Pennsylvania* HospitaL) 


the  twelfth  rib.  Failure  in  the  last  instance  may  be  avoided  by  taking  two 
plates  at  different  angles.  They  may  apparently  show  a  stone  when  none 
exists,  the  source  of  error  being  a  defective  plate,  or  shadows  cast  by  phle- 
boliths,  atheromatous  plates,  appendiceal  concretions,  gall  stones,  tubercu- 
lous foci,  calcified  lymph  glands,  centers  of  ossilication  in  the  pelvic  ligaments, 
dermoids,  foreign  bodies,  and  fecal  masses  (hence  the  necessity  of  preliminary 
purgation,  p.  525).  The  shadows  of  ureteral  calculi  are  generally  oval,  with 
the  long  axis  in  the  line  of  the  ureter.  In  doubtful  cases  a  styleted  catheter 
may  be  passed  into  the  ureter  (Fig.  437)  and  two  plates  taken  at  different 
angles.  Extraureteral  shadows  will  thus  appear  out  of  alignment  with  the 
catheter.  As  calculi  are  bilateral  in  30  per  cent,  of  the  cases  the  skiagraph 
should  always  include  both  kidneys  and  Ijoth  ureters. 


URlNAitY   ORGANS. 


The  treatment,  if  tlie  stone  is  small,  quiescent,  aiid  in  ihe  parenchr^ 
may  be  directed  to  the  litliemia,  in  order  to  prevent  augmentation  of  the  stone  %r 
the  formation  of  others;  this  consists  in  exercise,  regulation  of  the  diet,  attcn 


oneor^^l 


I'^t*-  437- — i^tiagraph  of  a  ureteral  calculus  impacted  near  tbe  bladder  (Jefferson 
Hospital).  A  styleled  catheter  was  passed  into  each  ureter;  on  the  affected  side  tlie 
catheter  met  with  ohstruclion  three-fourths  of  an  inch  from  the  ureteral  orifice;  on  the 
opposite  side  the  catheter  passed  up  the  ureter  without  difficulty.  The  stone,  which 
was  removed  cxtraperitoneally,  through  an  incision  above  and  parallel  with  Poupftrt's 
ligament,  is  shown,  actual  size,  in  the  right  lower  corner  of  the  illustration. 

tion  to  the  bowels,  plenty  of  water,  alkaline  diuretics,  and  piperazin.  Under 
even  these  circumstances^  however,  the  possibility  of  c\il  effects  is  by  no 
means  small,  and  unless  there  are  serious  contraindications  nephrolithotomy 


OPERATION 

(P*  537)  ^^  probably  the  safer  course,  an  operatian  which  becomes  imperative 
if  symptoms  or  complications  arise.  A  stone  in  the  pelvis  practically  always 
causes  trouble,  and,  unless  minute  enough  to  pass  down  the  ureter,  should  be 
removed  by  pyclolithotomy  (p.  537)*  A  stone  moving  down  the  ureter 
causes  renal  colic,  which  requires  hot  fomentations,  hot  drinks^  and  the 
hypodermatic  administration  of  atropin  and  morphin.  If  impaction  with 
complete  obstruction  occurs  immediate  operation  is  demanded  to  save 
the  kidney,  or  if  there  is  anuria  (p*  527)  to  save  life.  In  impaction  with  In- 
complete obstruction  large  quantities  of  water  by  mouth  and  injections  of 
sweet  oil  into  the  ureter  through  a  catheter  may  be  tried.  If  these  fail  to 
dislodge  the  stone  it  should  be  removed  by  one  of  tJie  forms  of  uretero- 
lithotomy (p.  538)  or,  in  some  cases,  when  situated  near  the  kidney,  by  pyelot- 
omy  after  it  has  been  pushed  back  in  I  o  the  pelvis.  Nephrectomy  is  indicated 
only  when  the  kidney  is  totally  destroyed  and  the  other  organ  is  healthy. 

Tumors  of  the  kidney  include  cancer^  sarcoma,  and  hypernephroma,  the 
last  being  the  most  frequent.  Sarcomata  are  most  common  in  childhood. 
Angioma,  papilloma,  adenoma,  and  rarely  other  benign  tumors  also  have  been 
observed.  The  sympioms  are  pain,  hematuria,  and  the  presence  of  a  growth 
in  the  loin^  the  tumor  lying  behind  the  colon,  moving  slightly  with  respiration, 
and  having  the  shape  of  the  kidney-  In  malignant  cases  acute  varicocele 
may  occur  from  the  pressure  of  enlarged  glands  on  the  root  of  the  spermatic 
vein,  and  cachexia  sooner  or  later  develops.  Pigmentation  of  tlie  skin 
indicates  invasion  of  ^  the  suprarenal  body.  Sarcoma,  including  hyper- 
nephroma,  may  give  rise  to  metastases  in  the  lungs,  liver,  and  bones,  indeed 
the  last  may  be  the  first  sign  of  trouble.  Papilloma  of  the  renal  pelvis  is 
very  likely  to  become  malignant;  it  may  cause  death  from  hemorrhage,  and 
occasionally  some  of  the  villous  tufts  become  detached  aiul  appear  in  the 
urine.  The  ireatmeki  is  nephrectomy,  unless  the  growth  is  benign  and  small, 
when  it  alone  should  be  removed. 

Cysts  result  from  interstitiol  nephritis  (small  and  not  treated  surgically), 
from  obstruction  to  one  of  die  ducts,  or  from  hydatid  disease.  Dermoid 
cysts  also  have  been  observed.  When  of  large  size  ihey  may  be  detected  by 
palpation.  In  hydatid  disease  the  hooklets  may  sometimes  be  found  in  the 
urine.  The  ircalment  is  enucleation,  or  in  the  worst  cases  nephrectomy. 
Congenital  cystic  disease  of  the  kidney  is  characterized  by  large  multi- 
locular  cysts,  probably  die  result  of  defective  development  of  the  Wolffian 
body.  Both  kidneys  are  generally  involved.  The  symptoms  are  the  presence 
of  a  tumor,  and  occasionally  pain,  albuminuria,  and  hematuria,  WQien 
bilateral  the  disease  is  not  amenable  to  treatment.  When  one  organ  alone 
is  involved,  it  may  be  excised. 


OPERATIONS  ON  THE  KIDNEY  AND  URETER. 

The  kidney  may  be  exposed  through  the  abdomen  or  through  the  loin. 
The  abdominal  route  is  selected  if  a  ven^  large  tumor  is  to  be  attacked. 
The  incision  is  made  through  the  semilunar  line^  the  peritoneal  cavity  opened » 
and  the  organ  exposed  by  an  incision  tli rough  the  posterior  parietal  perito- 
neum at  the  outer  side  of  the  colon.  The  lumbar  route  is  chosen  whenever 
possible.  The  patient  may  be  placed  upon  the  sound  side  with  the  thighs  and 
knees  flexed  and  a  sand  bag  or  air  cushion  under  the  loin,  or  on  the  abdomen 


536 


URTNARV    ORGANS. 


with  the  air  cushion  beneath,  in  order  to  widen  the  costoiirac  : 
the  kidney  up  into  the  wound.  The  incision  may  be  vertical  or  oliliquc 
The  vtrtiaii  indsimi  runs  close  lo  the  outer  border  of  the  erector  spina?,  fmm 
one  half  int  h  helow  ihe  last  rib  to  the  crest  of  the  ilium.  7^he  tibers  of  the 
latissimus  dorsi  are  separated,  the  lumbar  fascia  Indsed,  and  the  quadratus 
lumborum  and  the  erector  spina*  retracted  inwards.  The  last  thoracic,  the 
iliohypogastric,  and  the  ilioinguinal  nerves  lie  beneath  the  quadratus  and 
should  be  drawn  aside,  or,  if  severed,  sutured  at  the  end  of  the  operation. 
The  kidney  is  exposed  by  tearing  through  the  perirenal  fat.  If  more  room 
is  needed,  the  incision  may  he  extended  outw^ards  in  a  transverse  direction 
afjove  the  crest  of  the  ilium.  The  oblitjue  incision  extends  fronn  the  outer 
border  of  the  erector  spiiia.\  one-half  inch  below  the  twelfth  rib,  downwards 
and  outwards  towards  the  anterior  spine  of  the  ilium.  The  latissimus 
dorsi»  external  obhque,  internal  oblique,  and  the  transversal  is  muscle  and 
fascia  are  dirided.  * 


r 


Nephropexy,  or  nephrorrhaphy,  has  been  performed  in  many  different 

ways.  The  simplest  method  consists  in  passing  three  silk  sutures  throug 
the  lips  of  the  wound  and  the  kidney  parenchyma,  one  at  the  upper,  one  in  1 
middle,  and  one  at  the  lower  end;  the  sutures  are  gendy  tied  after  the  wound 
is  closed.  Some  surgeons  remove  the  capsule  from  the  posterior  surface  of 
the  kidney  before  passing  the  sutures,  in  order  to  make  a  raw^  surface. 
Edebohis  <lelivers  the  kidney  through  the  wound,  excises  the  fatty  capsule, 
makes  an  incision  through  the  fibrous  capsule  along  the  convex  border  of  the 
kidney,  turns  the  capsule  back  towards  the  pelvis,  and  passes  sutures  throug 
tJie  capsule  as  shown  in  Fig.  438.  The  kidney  is  reduced,  and  the  sutur 
passed  from  within  outwards  through  the  muscles  and  tied.  The  wound  is 
then  dosed.  Senn  excises  the  fatty  capsule,  passes  a  sling  of  gauze  around 
each  pole  of  the  kidney,  ties  the  ends  of  the  slings  over  additional  gauze  w^hich 
fills  the  wound  superficial  to  the  kidney,  and  removes  the  gauze  in  ten  days. 


bi 


OPERATIONS    ON   THE   XIDNEY  ANB   XTEETER, 


537 


Nephrotomyj  or  incision  of  the  kidney,  is  performed  after  delivering  Lhc 
kidney  through  the  wound,  whenever  possible.  The  length  and  dirertion 
of  the  incision  will  var>'  mth  the  condition  to  he  treated.  UTien  done  for 
exploratory  purposes,  the  incision  is  made  along  the  convex  border,  just 
behind  the  mesiaJ  plane,  al  which  place  the  venlral  and  dorsal  vessels  meet 
and  the  least  bleeding  occurs.  If  necessary  the  whole  kidney  may  be  split 
and  laid  open  like  a  book.  An  assistant  should  compress  the  renal  vessels 
during  this  procedure  in  order  to  prevent  hemorrhage.  Through  the  inci- 
sion'the  interior  of  the  kidney  and  the  pelvis  can  be  explored  and  bougies 
passed  down  the  ureter.  The  wound  may  be  dosed  with  mattress  sutures 
of  catgut.  If  this  does  not  entirely  control  the  hemorrhage,  drainage  will  be 
needed.  Nephrolithotomy  is  nephrotomy,  plus  the  removal  of  stones  with 
the  linger  or  forceps.  The  calcidi,  if  not  accurately  localized  by  the  X-ray, 
may  be  found  by  palpation,  or  by  puncturing  the  organ  with  a  needle. 
Drainage  will  usually  lie  required. 

Pyelotomy,  or  in<  ision  of  the  pelvis  of  the  kidney,  is  called  pyelolithot- 
omy  when  done  for  stone.  The  kidney  is  delivered,  the  pelvis  opened  trans- 
versely to  avoid  the  vessels,  and  the  wound  subsequently  sutured  or  drained, 
according  to  indications.  Urinary  fistula  is  more  apt  to  follow  than  after 
nephrotomy. 

Nephrectomy,  or  removal  of  the  kidney,  should  not  be  performed  until 
the  presence  and,  if  possible,  the  functionating  capacity  of  the  other  kidney 
have  been  ascertained.  The  kidney  may  be  removed  through  the  al>domen 
or  l>y  the  lumbar  route.  The  advantages  of  the 
abdominal  route  are  that  the  pedicle  can  be  more 
easily  controlled  and  the  other  kidney  palpated;  the 
latter  maneuver  may  be  accomplished  also  in  the 
lumbar  operation,  after  incising  the  peritoneum  on  the 
outer  side  of  the  colon.  The  great  objection  is  that  the 
peritoneum  is  opened,  hence  it  is  employed  only  when 
the  organ  is  too  large  to  be  dealt  with  through  the  loin. 
In  either  method  the  kidney  is  shelletl  from  its  bed. 
and  the  ureter  and  renal  vessels  tied  separately.  It 
should  be  recalled  that  accessory  renal  vessels  exist  in  20 
per  cent,  of  the  cases.  When  the  operation  is  done 
for  malignant  disease,  the  fatty  capsule  also  should  be 
removed;  if  for  tuberculosis,  the  ureter,  when  involved, 
likewise  should  be  excised.  Partial  nephrectomy  is 
performed  by  removing  a  wefJgeshaped  portion  of  the 
kidney  and  suturing  the  wound. 

Decapsulation  of  the  kidneys  for  chronic  nephritis  consists  in  expos- 
ing the  kidneys,  peeling  off  the  fibrous  capsules,  and  dropping  the  kidneys 
back  into  place.  Improvement  follows  in  some  cases,  but  the  exact  value 
of  the  operation  has  not  yet  been  determined. 

The  ureter  may  be  palpated  through  an  abdominal  incision,  but  should 
not  be  opened  by  this  route  because  of  the  danger  of  peritonitis.  The  whole 
ureter  may  be  explored  extraperitoneaJly  by  the  incision  shown  in  Fig.  459. 
The  peritoneum  is  exposed,  and  stripped  from  the  parietes  until  the  ureter  is 
reached.  The  lower  end  of  the  ureter  may  be  attacked  also  through  the 
bladder,  vagina,  perineum,  or  by  a  modified  Kraske  operation. 

Ureteropyelostomy,  or  anastomosis  between  the  ureter  and  the  pelvis 


Fin.  439.^ — (MoiifKl 
and  ViinvTrtsJ 


538 


URINARY   ORGANS. 


of  the  kidney,  has  been  performed  in  cases  of  hydronephrosis  due  to  imper- 
meable stricture  of  the  upper  end  of  the  ureter  or  kinking  of  the  ureter  over 
the  renal  vessels.  The  same  result  has  been  obtained  by  an  operation  similar 
to  pyloroplasty,  or  by  excising  the  valve  which  is  sometimes  found  betweoi 
the  hydronephrotic  sac  and  the  ureter. 

Ureterolithotomy  consists  in  opening  the  ureter  by  a  longitudinal  inci- 
sion and  removing  the  calculus,  after  the  ureter  has  been  exposed  by  one  of 
the  routes  mentioned  above.  The  wound  may  be  sutured  with  fine  catgut, 
or  drained,  and  allowed  to  close  at  a  later  period. 

Ureteral  anastomosis  may  be  performed  in  the  same  manner  as  lateral 
anastomosis  of  the  intestine  (Fig.  440).  Lateral  implantation  (Van  Hook's 
operation)  is  shown  in  Fig  441.     The  end  of  the  lower  segment  of  the  ureter 


Fig.  440.  -  (Binnie.) 


Fig.  441. — (Binnie.) 


is  ligated,  and  an  opening  made  below  the  ligature,  into  which  the  lower 
end  of  the  upper  segment  is  drawn  by  a  calgut  suture,  the  end  of  the  upper 
segment  having  been  i)reviously  split  in  a  longitudinal  direction  to  prevent 
stenosis.  When  this  operation  is  not  feasible,  the  ureter  may  be  anastomosed 
to  the  bladder  {urctcrocystostomy)^  to  the  pelvis  {ureteropyelostomy ,  p.  537)* 
or  even  to  the  intestine  {iiretcroenter ostomy);  the  last  method,  however  is 
very  likely  to  he  followed  by  peritonitis  or  infection  of  the  kidney.  When  a 
great  length  of  the  ureter  has  been  injured  or  destroyed,  it  may  be  necessar}* 
to  suture  the  ureter  to  the  skin  or  to  remove  the  corresponding  kidney. 


THE  BLADDER. 

Attention  has  already  been  called  to  congenital  umbilical  and  rectal  fistu- 
lie  communicating  with  the  bladder. 

Ectopia  vesicae,  or  extroversion  of  the  bladder,  is  a  congenital  absence 
of  the  anterior  wall  of  the  bladder,  the  soft  tissues  which  should  overlie  it,  and 
of  the  symphysis  pubis.  It  is  most  common  in  males,  the  upper  wall  of  the 
urethra  also  being  wanting  {complete  epispadias).     The  posterior  wall  of  the 


CYSTOSCOPY. 


539 


Fiap\ 


Bt adder   \\ 


I 


l)ladder  with  the  ureteral  openings  is  pressed  forwards  and  becomes  inilamed 
owing  to  exposure-  The  urine  dribbles  away  constantly  and  the  inflam- 
mation  may  spread  up  the  ureters  to  the  kidneys.  The  treatment  is  very 
unsatisfactory.  The  patient  may  wear  a  urinal  or  be  subjected  to  operation, 
Trendelcnhurg's  operathn  consists  in  dividing  the  sacroiliac  ligaments, 
approximating  the  cleft  in  the  pubes  by  forcible  compression,  and  closing  the 
defect  in  the  soft  parts  at  a  later  period  by  ilaps  from  the  neighboring  skin. 
Wood's  operation  is  sho^\ii  in  Fig.  442.  Flap  A  is  turned  down  over  the 
bladder,  the  portion  D  lieing  used  to  construct  the  upper  wall  of  the  urethra. 
The  raw  surface  of  flap  A  is  covered  by  sliding  flaps  B  and  C  inwards.  The 
remaining  raw  surface  is  skin  grafted. 

Sonnailmrg  transplants  the  ureters  to  \  \ 

the  urethra,  removes  the  mucous  mem- 
brane of  the  bladder,  and  covers  the 
raw  surface  with  flaps*  Probably  the 
best  operation  is  that  of  Maydl,  in 
which  the  ureters  with  the  trigone  are 
implanted  into  the  sigmoid.  The 
valvular  openings  of  the  ureters  are 

thus  preserved  and  bacteria  prevented  (         1   /^  x  1 

from  ascending  to  the  kidney;  urine 
collects  in  the  sigmoid  and  is  voided 
at  inter\^als. 

For  injuries  of  the  bladder  see 
contusions  of  the  abdomen. 

Examination  of  the  bladder  may 
be  made  by   palpation    through   the 

hypogastrium,  rectunij  or  in  die  female  ^SHBh^  ^t^^jjjHjp? 

through  the  vagina  or  even  the  dilated 
urethra.  Percussion  and  inspection 
of  the  hypogastrium  also  may  give 
information.  The  introduction  of  a 
sound  through  the  urethra  may  detect 
a  calculus  or  tumor  The  X-ray  is  of 
value  chietly  for  the  detection  of  stones  and  foreign  bodies.  Cystoscopy  is 
described  below.  In  cases  in  which  a  diagnosis  cannot  be  reached  by  the 
above  means,  the  bladder  may  be  opened  above  the  pubes  or  through  the 
perineum  for  exploration. 

Cystoscopy  is  the  most  important  and»  indeed,  excluding  exploratory 
incision,  sometimes  the  only  metliod  for  diagnosticating  endo vesical  condi- 
tions. It  permits  inspection  also  of  the  prostate  and  ureteral  oriflces,  the 
introduction  of  catheters  into  the  ureters,  lavage  and  medication  of  these 
ducts  and  of  the  renal  pelvis,  topical  applications  to  the  bladder,  and  the 
removal  of  small  intravesical  growths,  stones,  and  foreign  bodies.  It  cannot 
be  used  w^hen  the  urethra  is  too  small  to  admit  the  instrument,  e.g.,  in  stric- 
ture and  in  children,  and  when  the  bladder  will  not  hold  the  requisite  amount 
of  fluid;  and  it  is  generally  contraindicated  in  acute  inflammator>^  troubles 
of  the  urethra,  bladder,  and  prostate;  in  tuberculosis  of  the  bladder,  unless 
the  diagnosis  cannot  be  made  by  other  means;  and,  because  of  the  danger  of 
suppression  of  urine,  in  acute  nephritis. 

The  cysioscope  consists  of  a  hollow  shaft,  shaped  like  a  stone  sound, 


Fig.  441 — (Binnie,) 


540  URINARY  ORGANS. 

with  an  electric  light  at  the  end,  and  one  or  more  telescopes  which  slide  into 
the  shaft.  The  lens  system  in  the  telescope  is  so  arranged  as  to  enable  the 
examiner  to  see  that  part  of  the  bladder  toward  whidi  the  instrument  is 
directed  (direct  system),  or  the  part  at  right  angles  to  the  instrument  (indi- 
rect system).  In  some  cystoscopes  both  systems  may  be  used  with  the  same 
shaft,  which  also  contains  channels  for  the  passage  of  ureteral  catheters  and 
channels  for  irrigating  the  bladder.  When  the  indirect  system  is  used 
for  catheterizing  the  ureters,  the  catheter  is  directed  towards  the  ureteral 
orifice  by  a  lever  on  the  end  of  the  cystoscope,  which  is  raised  or  lowered  by  a 
screw  on  the  external  end.  A  special  cystocope  is  required  for  endovesicil 
operations.  The  male  cystoscope  answers  equally  well  in  the  female.  The 
cystoscope  and  ureteral  catheters  may  be  sterilized  by  immersion  in  a  solu- 
tion of  carbolic  acid  (5  per  cent.)  or  formalin  (2  per  cent.)  for  thirty  minutes, 
after  which  all  traces  of  the  antiseptic  should  be  removed  with  sterile  water. 
For  ordinary  examinations  anesthesia  is  not  required;  if  the  urethra  is  sensi- 
tive, however,  about  10  drops  of  a  5  per  cent,  jsolutlon  of  cocain  may  be 
instilled  into  its  posterior  portion  by  a  Keyes-Ultzmann  syringe  or  a  catheter; 


Kk;.   44  ^ — Cystoscope  in  iM)siii()n.     (T)uplay  and  Reclus.) 

occasionally  in  nervous  patients  a  general  anesthetic  must  be  employed. 
The  buttocks  are  elevated  and  brought  over  the  end  of  the  table,  the  thighs 
being  separated  and  slightly  flexed,  the  feet  resting  on  chairs;  a  special  table 
is  convenient  but  not  essential.  The  external  genitals  are  disinfected  and 
washed  with  sterile  water.  The  light  is  then  turned  on  for  a  moment  to 
test  the  lamp;  the  instrument  lubricated  with  glycerin  or  liquid  vaselin  and 
passed  into  the  bladder  like  a  sound;  the  bladder  irrigated  with  cool  sterile 
water  until  it  is  clean,  adding,  however,  adrenalin  chlorid  in  the  proportion  of 
I  to  10,000,  if  there  is  bleeding;  at  least  5  ounces  of  the  fluid,  but  preferably 
10  or  12,  allowed  to  remain  in  the  bladder,  so  as  to  distend  it  and  prevent 
burning;  the  telescope  slipped  into  the  sheath;  and  the  light  turned  on  (Fig. 
443).  If  the  fluid  quickly  becomes  turbid  the  examination  may  be  made 
under  continuous  irrigation. 

If  callietcrization  of  the  ureters  is  desired  the  instrument  is  brought  to  the 
middle  line  and  slowly  withdrawn  until  the  interureteral  bar  (which  forms  the 
posterior  boundar>' of  the  trigone)  comes  into  view;  this  is  followed  laterally 
until  the  slit-like  ureteral  meatus  appears  (Fig.  445),  which  is  usually  on  the 
summit  of  a  little  teat,  and  may  be  identified  by  noting  that  at  intervals,  gen- 
erally var}ing  from  30  to  60  seconds  or  more,  it  opens  like  a  fish  mouth, 
ejects  a  swirl  of  urine,  and  closes  again.     The  catheter  is  protruded  from 


446.  Fig. 

Figs.  444  to  447.— Cystoscopic  piciure!*. 

Fig.  444. — iJiliitcfl,  rigid  (noiicontractingK  retracier!  urelcral  meatus,  surrounded  by 

ulcers  and  tubcrcJrs,  characlcnstic  of  renal  tubercu!oi*i«».     Fig.  445,  — Nomiiil  urrtenil 

mcutytk.     Fig.  446. — Jet  of  [>us  coming  fntm  ureter      Fig.  4  17.— Catheter  rnteniij!;  unncr. 

that  110  confusion  as  to  which  h  which  can  arise.  As  a  rule,  e%'cn  with  thu 
ji^entlest  manipuiatiunj  some  blood  will  be  founcl  in  the  samples,  hence  it  is 
advisable  to  collect  the  urine  from  each  side  in  two  or  three  tubes,  allowing 
each  to  remain  in  position  one-half  hour  or  longer,  according  to  the  amount 
of  urine  excreted.  If  a  catheter  does  not  drain,  gentle  suction  with  a  syringe 
should  be  tried;  failing  this  not  more  than  2  lluid  drams  of  sterile  water 
may  In*  injected.  Urine  segregators  are  considered  on  p.  525,  the  functional 
capacity  of  the  kidneys  and  ch  ro  mo  cystoscopy  on  p.  525,  !he  means  of  meas- 
uring the  pelvis  on  p.  52Q,  the  use  of  styleted  catheters  on  p.  533. 


542  URINARY  ORGANS. 

Incontinence  of  urine  is  the  involuntary  escape  of  urine,  (i)  In  Irue  or 
passive  incontinence  the  urine  flows  out  of  the  bladder  as  soon  as  it  flows  in 
and  the  bladder  is  never  distended.  It  is  seen  in  conditions  like  ectopia 
vesicae,  fistuhe  leading  into  the  bladder,  and  paralysis  of  the  sphincter  vesicae 
the  result  of  disease  or  injury  of  the  vesical  sphincter  or  of  its  center  in  the 
spinal  cord;  it  occurs  also  from  propping  open  of  the  internal  meatus  by  a 
growth  or  calculus.  (2)  Active  incontinence  is  due  to  exaggeration  of  the 
vesical  reflex.  It  is  most  common  in  children,  occurring,  as  a  rule,  only 
during  sleep.  It  may  be  symptomatic ^  i.e.,  due  to  phimosis^  stone,  hi^y 
acid  urine,  seat  worms,  spinal  disease,  etc.,  but  in  most  cases  it  is  tdiopaihic, 
i.e.,  no  cause  can  be  foimd,  except  perhaps  that  the  child  is  neurotic  These 
cases  are  treated  by  removing  any  existing  irritation,  administering  bella- 
donna and  tonics,  waking  the  diild  at  night  to  pass  water,  and  by  sending  the 
patient  to  bed  thirsty.  Imperative  urination,  coming  on  every  few  minutes, 
and  due  to  inflammation  or  other  form  of  irritation,  is  sometimes  called 
false  incontinence.  (3)  The  incontinence  of  retentiofi  is  the  overflow  of  a  dis- 
tended bladder,  due  to  some  obstruction,  such  as  stricture  or  enlarged  pros- 
tate, or  to  paralysis  of  the  detrusor,  such  as  may  occur  in  spinal  diseases  and 
injuries. 

Retention  of  urine  is  distention  of  the  bladder  owing  to  inability  to  pass 
urine.  The  causes  of  retention  are:  i.  Obstruction,  such  as  phimosis; 
ligature  about  the  penis;  tumor  or  abscess  of  the  perineum;  stricture,  calculus, 
rupture,  tumor,  abscess,  or  congenital  occlusion  of  the  urethra;  inflammation, 
abscess  tumor,  hypertrophy,  or  calculus  of  the  prostate;  and  external  pressure, 
such  as  fecal  impaction  and  uterine  tumors.  2.  Non-obstructive  lesions, 
such  as  atony  or  paralysis  of  the  bladder,  reflex  inhibition  (e.g.,  after  opera- 
tions on  the  rectum),  hysteria,  fevers^  shock,  and  drugs  like  belladonna, 
opium,  and  cantharides.  The  most  common  cause  in  the  new  bom  is  oc- 
clusion of  the  urethra,  in  infants  phimosis,  in  children  impacted  calculus,  in 
youth  one  of  the  complications  of  gonorrhea  (male)  or  hysteria  or  foreign 
body  in  the  bladder  (female),  in  men  stricture,  in  women  pelvic  disease,  and 
in  old  age  prostatic  hypertrophy. 

The  symptoms  in  obstructive  rases  are  pain,  intense  desire  but  inability 
to  urinate,  and  frequent  straining  efforts.  The  bladder  may  be  seen  and 
felt  above  the  pubes  as  a  median,  symmetrical,  pyriform,  fluctuating  tumor, 
which  is  dull  on  percussion,  and  pressure  upon  which  increases  the  desire 
to  urinate.  It  may  be  palpated  also  through  the  rectum  or  vagina.  The 
obstruction  is  encountered  on  attempting  to  pass  a  catheter.  The  distention 
increases  until  some  urine  is  forced  through  the  obstruction,  or  until  the 
hack  pressure  induces  suppression  of  urine.  The  bladder  does  not  burst 
unless  injured  or  ulcerated,  although  the  posterior  urethra  may  give  way  if 
the  obstruction  is  lower  down.  In  non-obstructive  retention  the  patient 
may  make  no  complaint,  and  as  the  urine  begins  to  dribble  away  when  the 
bladder  can  hold  no  more,  the  condition  may  be  mistaken  for  inconti- 
nence. Retention  is  to  be  distinguished  also  from  suppression,  as  in  each 
no  urine  is  voided.  In  the  former  the  signs  of  a  distended  bladder  are  in 
evidence,  and  the  introduction  of  a  catheter  is  impossible,  or  results  in  the 
withdrawal  of  a  large  quantity  of  urine.  In  the  latter  the  bladder  is  empty 
and  no  urine  is  obtained  by  the  catheter. 

The  treatment  consists  in  emptying  the  bladder  as  soon  as  possible  by  the 
use  of  a  catheter,  or  if  this  fails  by  paracentesis  vesiccFj  i.e.,  the  plunging  of  a 


TUBERCULOSIS   OF   THE   BLADDER.  543 

fine  trocar  into  the  bladder,  in  the  middle  line  immediately  above  the  pubes. 
The  details  of  the  treatment  of  retention,  which  is  simply  a  symptom,  vary 
with  its  cause. 

Atony  of  the  bladder  (loss  of  tone  of  the  muscular  walls)  is  caused  by 
acute  or  chronic  retention,  and  is  physiological  m  old  age.  It  is  to  be  distin- 
guished from  paralysis  of  the  bladder,  which  is  due  to  some  lesion  of  the 
nervous  system  and  results  in  true  mcontinence.  The  symptoms  are  difficulty 
in  starting  micturition,  lessened  force  of  the  stream,  and  dribbling  at  the 
completion  of  the  act.  There  is  always  some  residud  urine,  which  is  apt  to 
decompose  and  set  up  a  cystitis.  The  treatment  is  removal  of  any  obstruc- 
tion to  the  urinary  flow,  and  catheterization  to  draw  off  the  residual  urine. 
The  catheter  is  to  be  used  once  per  day  for  every  two  oimces  of  residual 
urine,  thus  if  there  are  eight  ounces  of  residual  urine,  the  catheter  should  be 
used  every  six  hours.  Urinary  antiseptics,  strychnin,  and  electricity  also 
may  be  employed. 

Cystitis,  or  inflammation  of  the  bladder,  may  be  acute  or  chronic.  The 
morbid  anatomy  and  the  varieties  are  the  same  as  those  of  inflammation  in 
other  mucous  membranes.  The  causes  are  cold,  injuries,  foreign  bodies, 
calculi,  gonorrhea,  the  introduction  of  filthy  instruments,  irritating  drugs  (e.g., 
turpentine  and  cantharides),  acute  infectious  fevers,  and  any  condition  which, 
causing  obstruction  to  the  urinary  flow,  results  in  retention  and  decomposi- 
tion of  urine.  The  bacteria  usually  present  are  the  colon  bacillus,  staphy- 
lococcus, streptococcus,  and  less  commonly  the  gonococcus,  typhoid  bacillus, 
and  the  tubercle  bacillus.  These  organisms  reach  the  bladder  through 
wounds,  through  the  ureter  or  urethra,  or  by  the  lymph  or  blood  stream. 

The  symptoms  of  acute  cystitis  are  pain,  frequent  micturition,  tenesmus, 
and  in  some  cases  fever;  the  bladder  is  tender  to  pressure,  and  the  urine 
is  usually  acid  and  contains  mucus,  pus,  and  sometimes  blood.  Recovery 
is  the  rule,  but  the  inflammation  may  become  chronic,  or  rarely  cause  death 
from  toxemia,  peritonitis,  or  pyelonephritis. 

The  treatment  is  removal  of  the  cause,  rest  in  bed  with  the  hips  elevated, 
hot  applications  to  the  hypogastrium,  hot  hip  baths,  liquid  diet,  alkaline  diu- 
retics, urinary  antiseptics  such  as  hexamethylenamine  or  salol,  opium  and 
belladonna  suppositories  when  needed,  and  daily  irrigations  of  the  bladder 
with  boric  acid  solution  or  nitrate  of  silver  (i  to  10,000). 

Chronic  cystitis  follows  the  acute  form  or  is  such  from  the  beginning. 
The  symptoms  are  those  of  the  acute  form,  but  much  milder  in  degree.  The 
urine  may  be  acid,  but  is  much  more  commonly  alkaline,  ammoniacal,  fetid, 
and  turbid  with  phosphates,  mucus,  and  pus;  phosphatic  calculi  are  fre- 
quently formed.  The  general  health  becomes  impaired  and  there  is  constant 
danger  of  septic  pyelonephritis.  The  bladder  walls  are  thickened  and 
sometimes  sacculated.     Ulcers  may  form  and  occasionally  perforation  ensues. 

The  treatment  is  conducted  on  the  same  lines  as  in  acute  cystitis.  Con- 
finement to  bed  is  usually  unnecessary,  and  the  injections  may  be  stronger. 
In  some  cases  balsamics,  such  as  sandalwood  oil,  turpentine,  and  copaiba, 
are  employed.  When  the  cause  cannot  be  ascertained  and  no  improvement 
follows  treatment  like  the  foregoing,  the  bladder  may  be  opened  through  the 
perineum  or  suprapubicly,  carefully  explored,  and  drained. 

Tuberculosis  of  the  bladder  may  be  primary,  but  is  usually  secondary  to 
tuberculosis  of  the  kidney,  prostate,  testicle,  or  lungs.  It  is  more  frequent  in 
men  than  in  women.     The  tubercles  break  down  and  form  ulcers.     The 


544  URINARY  ORGANS. 

symptoms  are  those  of  chronic  cystitis,  there  being  marked  irritability  of 
the  bladder,  and  pus  and  blood  in  the  urine.  The  diagnosis  is  made 
by  finding  the  tubercle  bacillus  in  the  urine  and  by  the  cystoscope.  The 
prognosis  is  unfavorable. 

The  treatment  is  attention  to  the  general  health  as  in  tuberculosis 
elsewhere,  and  local  treatment  as  in  other  forms  of  chronic  cystitis.  The 
injection  of  iodoform  emulsion  has  been  advised.  When  these  measures 
fail  the  bladder  should  be  opened  above  the  pubes  and  drained,  and  perhaps 
the  ulcers  curetted,  or  touched  with  carbolic  acid. 

Ulcers  of  the  bladder,  apart  from  tuberculosis  and  other  forms  of*  cysti- 
tis, may  be  due  to  injury,  burning  with  the  cystoscope,  or  malignant  growths. 
Under  the  heading  simple  ulcer  has  been  described  a  solitary  ulcer  usually 
situated  at  the  base  of  the  bladder.  It  is  most  frequent  in  anemic  women, 
occasionally  perforates,  and  has  been  compared  to  a  peptic  ulcer.  The 
symptoms  of  ulcer  of  the  bladder  are  those  of  chronic  cystitis,  the  diagnosis 
being  made  by  the  cystoscope.  The  treatment  is  that  of  chronic  cystitis. 
Ulcers  have  been  curetted  and  local  applications  made  through  an  operating 
cystoscope.  In  progressing  cases  the  bladder  should  be  opened,  the  ulcers 
curetted  and  cauterized,  and  drainage  established;  perforation  is  treated 
in  the  same  way  as  rupture  of  the  bladder. 

Tumors  of  the  bladder  are  uncommon,  and  are  more  often  encountered 
in  men  than  in  women.  The  most  frequent  variety  is  papilloma;  it  has  project- 
ing fimbriae,  and  is  apt  to  undergo  carcinomatous  degeneration.  Carcinoma 
also  is  comparatively  frequent,  while  sarcoma,  angioma,  myoma,  and 
fibroma  are  very  rare.  The  base  of  the  bladder  is  the  portion  usually 
attacked.  The  symptoms  are  those  of  chronic  cystitis,  with  attacks  of  pro- 
fuse hematuria,  which  is  most  marked  at  the  end  of  micturition;  occasionally 
a  portion  of  the  tumor  is  passed  with  the  urine.  Sudden  interruption  of  the 
urinary  stream  may  occur  from  transient  blocking  of  the  internal  meatus, 
hydronephrosis  from  obstruction  to  the  ureter.  The  diagnosis  is  made 
with  the  cystoscope,  the  use  of  which  may  be  difficult  on  account  of  hemor- 
rhage. Large  tumors  may  be  palpated  by  bimanual  examination,  between 
the  hand  above  the  pubes  and  a  finger  in  the  rectum.  Malignant  growths 
may  often  be  felt  with  the  sound,  particularly  if  incrustated  withphos- 
phatic  deposits.  The  prognosis  is  bad,  even  benign  growths,  if  unmo- 
lested, may  be  fatal  from  bleeding. 

The  treatment  is  suprapubic  cystotomy.  If  the  growth  is  pedunculated, 
it  may  be  removed  with  the  curette  and  the  base  cauterized.  If  it  is  malig- 
nant and  of  small  size,  a  portion  of  the  bladder  wall  should  be  removed  and 
the  wound  sutured.  Partial  cystectomy  may  be  done,  as  suggested  by 
Harrington,  through  the  peritoneal  cavity.  Removal  of  the  entire  bladder, 
with  implantation  of  the  ureters  into  the  vagina  or  rectum,  has  been  success- 
fully performed.  If  the  growth  is  found  to  be  inoperable,  drainage  should 
be  established  for  palliative  purposes. 

Foreign  bodies  usually  gain  entrance  to  the  Ijiadder  through  the  urethra, 
being  introduced  by  the  patient,  or  resulting  from  the  breaking  of  instru- 
ments, but  they  may  find  their  way  into  the  viscus  also  through  ulceration 
or  injury  of  its  walls.  The  symptoms  are  those  of  cystitis.  If  allowed  to 
remain,  the  foreign  body  is  apt  to  become  the  nucleus  of  a  calculus.  The 
diagnosis  may  be  made  by  means  of  the  sound,  the  cystoscope,  and  the  X-ray. 
They  should  be  removed  with  the  lithotrite,  with  the  finger  or  forceps  after 


VESICAL   CALCULUS.  545 

dilatation  of  the  urethra  (in  the  female),  or  by  suprapubic  or  perineal 
cystotomy. 

Vesical  calculus,  or  stone  in  the  bladder,  may  be  composed  of  uric 
acid,  urates,  or  the  oxalate,  phosphate,  or  carbonate  of  calcium.  Cystin  and 
xanthin  calculi  are  very  rare.  Uric  acid  calculi  are  oval,  smooth,  brownish, 
and  very  dense.  Those  composed  of  urates  are  lighter  in  color,  less  dense, 
and  not  as  distinctly  laminated.  The  oxalate  of  lime  or  mulberry  calculus 
is  irregular,  very  dense,  distinctly  laminated,  and  dark  brown  or  greenish  in 
color.  Phosphatic  calculi  are  whitish,  soft,  friable,  usually  fetid,  and  rarely 
laminated.  Any  stone  or  foreign  body  which  causes  chronic  cystitis  is  apt  to 
have  a  phosphatic  coating.  Stones  vary  greatly  in  size  and  number.  When 
multiple  they  are  usually  faceted.  The  causes  are  lithemia  and  any  condition 
which  increases  the  density  of  the  urine  or  leads  to  chronic  cystitis.  Calculi 
are  frequent  in  India  and  Egypt,  owing  to  the  character  of  the  drinking 
water,  and  the  greater  amount  of  sweat  excreted.  Stone  is  common  in 
young  boys  because  of  the  small  caliber  of  the  urethra,  and  in  old  men  because 
of  the  frequency  of  residual  urine  and  cystitis.  Women  are  comparatively 
free  from  the  affection,  as  <he  urethra  is  short  and  of  large  caliber,  thus  per- 
mitting the  ready  passage  of  small  stones.  The  nucleus  of  a  calculus  may  be 
a  renal  stone,  a  foreign  body,  a  blood  clot,  or  a  particle  of  mucus  or  colloid 
material. 

The  symptoms  are  pain,  which  is  worse  just  after  urination  and  which 
may  be  referred  to  the  perineum,  back,  down  the  thighs,  and  especially  to 
the  glans  penis;  frequent  micturition;  often  hematuria,  particularly  at  the 
end  of  micturition;  and  sometimes  sudden  cessation  of  the  flow  of  urine, 
caused  by  the  stone  falling  against  the  internal  meatus.  The  symptoms  are 
intensified  by  exercise  or  jolting,  and  vary  in  degree  according  to  the  size  and 
shape  of  the  stone  and  the  sensitiveness  of  the  mucous  membrane.  Occa- 
sionally the  history  of  "gravel"  or  of  renal  colic  may  be  obtained.  Cystitis 
may  either  precede  or  follow  stone  formation.     Hernia,  hemorrhoids,  or 


Fig.  448. — Stone  sound. 


^ 


prolapse  of  the  rectum  may  be  induced  by  straining,  and  priapism  is  sometimes 
observed.  In  children  incontinence  or  constant  pulling  at  the  foreskin 
should  always  suggest  calculus.  The  diagnosis  is  made  by  sounding,  by 
the  cystoscope,  and  by  the  X-ray,  and  occasionally  a  stone  may  be  felt  through 
the  vagina  or  rectum.  The  sound  (Fig.  448)  is  introduced  with  the  patient 
in  the  recumbent  posture,  the  bladder  being  partly  filled  with  urine  or  boric 
solution.  The  handle  should  be  marked  on  the  side  towards  which  the  beak 
of  the  instrument  projects.  The  instrument  is  drawn  backwards  and  for- 
wards, rotated  to  each  side,  and  finally  turned  downwards,  thus  exploring 
the  whole  bladder.  The  stone  is  detected  by  a  click,  which  may  be  felt  and 
sometimes  heard.  The  sound  may  fail  to  discover  a  stone  which  is  encysted 
in  the  bladder  wall,  lies  behind  a  large  prostate,  or  is  coated  ^  '^^ 
The  size  of  the  stone  can  be  measured  with  a  lithotritec 

35 


546 


URINARY  ORGANS. 


eludes  the  sound  may  be  discovered  by  using  a  Bigelow  evacuator;  the  suction 
causes  the  stone  to  strike  against  the  end  of  the  instrument.  As  vesical  and 
renal  stones  coexist  so  frequently,  the  examination  should  not  be  regarded 
as  complete  until  both  kidneys  and  both  ureters  have  been  investigated. 

The  treatment  is  removal  of  the  stone  by  litholapaxy,  or  by  suprapubic 
or  perineal  lithotomy. 

Litholapazy  {Bigelow* s  operation)  is  crushing  of  the  stone  and  removal 
of  the  fragments  at  the  same  sitting.  Lithotrity,  which  consists  in  crushing 
the  stone  at  intervals  and  allowing  the  patient  to  evacuate  the  fragments 
through  the  urethra,  has  been  abandoned.     Litholapaxy  is  to  be  chosen  in  all 


Fig.  449. — Thompson's  modification  of  Civiale's  lithotrite. 


cases  in  which  the  following  contraindications  are  not  present:  Obstructions 
to  the  passage  of  the  instrument  (e.g.,  stricture  and  enlarged  prostate), 
severe  cystitis,  sacculated  bladder,  greatly  contracted  bladder  (holding  less 
than  four  ounces),  great  irritability  of  the  urethra  (as  shown  by  chills  after 
instrumentation),  and  large  (above  two  inches  in  diameter),  very  hard,  or 
encysted  calculus.  Recurrence  is  more  frequent  after  this  operation  than 
after  lithotomy,  the  nucleus  of  the  new  stone  being  formed  by  a  fragment 
which  has  been  left  behind.  The  mortality  is  between  three  and  four  per 
cent,  in  the  hands  of  the  most  skilled.  The  patient  is  placed  on  the  back 
with  the  thighs  separated,  and  the  bladder  irrigated  with  boric  solution, 

six  ounces  of  which  should  be  allowed 
to  remain  in  the  viscus.  The  litho- 
trite (Fig.  449)  is  introduced,  and*  the 
stone  caught  and  crushed  between  the 
blades,  which  are  pressed  together  by 
screwing  the  handle.  The  larger  frag- 
ments are  crushed  in  the  same  man- 
ner. The  crushing  is  always  done  in 
the  middle  of  the  bladder,  with  the 
blades  up,  in  order  to  avoid  injury  to 
the  bladder  wall.  The  evacuator  (Fig. 
450)  is  next  introduced,  and  the  debris 
removed  by  alternate  pressure  and  re- 
laxation of  the  rubber  bulb,  the  fragments  falling  into  the  glass  receptacle 
attached  to  the  apparatus.  If  fragments  remain  which  are  too  large  to  pass, 
the  lithotrite  must  be  reintroduced.  Severe  bleeding  may  be  checked  by 
the  introduction  of  adrenalin  solution  i  to  10,000.  If  the  blades  lock,  it 
may  become  nccessar}^  to  open  the  bladder  through  the  perineum  or  above 
the  pubcs.  The  after  treatment  consists  in  rest,  warmth,  plenty  of  fluid, 
and  urinary  antiseptics.  Morphin  may  be  given  for  pain,  quinin  for  chills, 
and  irrigations  for  cystitis. 

Suprapubic  cystotomy,  when  performed  for  the  removal  of  stones,  is 


Fk; 


450.     Kvac  uator  in  position  in  the 
bladder.     (Ro-e  and  Carless.) 


PERINEAL   CYSTOTOMY. 


547 


called  suprapubic  lithotomy,  and  is  the  operation  of  choice  when  litho- 
lapaxy  is  contraindicated,  or  when  the  surgeon  lacks  the  necessary  instruments 
or  skill.  The  patient  is  prepared  as  for  any  abdominal  operation,  including 
shaving  of  the  pubes.  The  capacity  of  the  bladder  should  have  been  pre- 
viously tested,  and  at  the  time  of  operation  the  bladder  should  be  irrigated 
and  filled  with  boric  acid  solution,  or,  as  some  surgeons  prefer,  filled  witii  air. 
A  catheter  is  tied  about  the  penis,  in  order  to  prevent  the  escape  of  fluid,  and 
the  patient  placed  in  the  Trendelenburg  position.  These  maneuvers  displace 
the  vesical  fold  of  the  peritoneum  upwards,  and  thus  permit  extraperitoneal 
exposure  of  the  bladder.  The  bladder  may  be  pushed  upwards  against  the 
belly  wall  by  introducing  a  rubber  bag  into  the  rectum  and  distending  it  with 


Fio.  451. — Stone  forceps. 

air  or  water  (Fig.  118),  but  this  is  unnecessary  and  sometimes  dangerous.  A 
three  inch  incision  is  made  in  the  median  line  from  the  symphysis  pubis  up- 
wards, the  prevesical  fat  separated,  and  the  bladder  recognized  by  its  longi- 
tudinal muscular  fibers  and  its  globular  form.  Two  sutures  are  passed 
through  the  bladder  wall  to  act  as  tractors  and  a  longitudinal  incision  made 
between  them.  Stones  may  be  removed  with  the  finger,  forceps  (Fig.  451), 
or  scoop  (Fig.  452),  or  if  the  bladder  has  been  opened  for  other  reasons,  the 
lesion  should  be  dealt  with  as  described  elsewhere.  If  the  bladder  is  not  in- 
fected, the  wound  may  be  closed  by  two  layers  of  Lembert's  sutures  of  catgut, 
the  incision  in  the  soft  parts  approximated,  leaving  space  for  a  small  gauze 
drain  running  down  to  the  bladder,  and  a  retention  catheter  passed  into  the 


Fig.  452. — Stone  scoop. 


bladder  through  the  urethra.  If  the  bladder  is  infected,  the  wound  in  its 
wall  may  be  sewed  to  the  fascia,  or  it  may  be  closed  with  catgut  sutures  which 
invert  it  about  a  rubber  tube,  several  of  the  sutures  passing  through  the  tube, 
which  should  be  long  enough  to  syphon  the  urine  to  a  receptacle  beneath  the 
bed. 

Perineal  cystotomy  (perineal  section)  is  performed  for  exploration, 
drainage,  the  removal  of  growths,  prostatic  enlargement,  and  the  extraction 
of  calculi;  in  the  last  instance  it  is  called  perineal  lithotomyi  median  or 
lateral,  according  to  the  position  of  the  incision.  The  perineum  is  shaved 
and  disinfected  and  the  patient  placed  in  the  lithotomy  posUion^  i.e.,  on  the 
back  with  the  pelvis  raised  and  the  thighs  flexed  on  the  abdomen.    The  bla4- 


548  GENITAL   ORGANS. 

(ler  is  irrigated  and  left  parUy  distended  with  the  solution.  In  median  lUhot- 
amy  a  staff  with  a  median  groove  on  its  convex  side  is  passed  into  the  bladder, 
and  a  median  incision  made  from  just  behind  the  scrotum  to  within  one  inch 
of  the  anus.  The  membranous  urethra  is  opened  on  the  sta£f,  and  the  finger 
passed  into  the  bladder  by  dilating  the  prostatic  urethra.  If  more  room  is 
required  the  prostate  may  be  incised  in  the  middle  line  posteriorly.  A  cal- 
culus may  be  removed  with  forceps  or  scoop,  or  if  too  largie  to  be  withdrawn 
whole,  it  may  first  be  fragmented  with  the  lithotrite.     A  drainage  tube  is  then 

introduced  into  the  bladder  through  the 
•r-'rllSS^^^jSii!^  wound.  If  a  rubber  tube  is  employed  it 
should  be  sutured  to  the  skin;  the  special 
metal  perineal  tube  shown  in  Fig.  453  is 
fastened  in  place  by  tapes.  Ordinarily  the 
drainage  tube  may  be  removed  in  forty- 
eight  hours.  The  wound  is  covered  with 
dressings,  held  in  place  by  a  T-bandage. 
Lateral  lithotomy  is  rarely  performed  at  the 
Fig.  453— Wats<in's  perineal  lube      present  time,  having  been  displaced  by  the 

operations  previously  described.  A  staflF 
with  a  groove  on  the  left  side  is  introduced  into  the  bladder.  The  incision 
begins  one  and  one-half  inches  above  the  anus,  just  to  the  left  of  the  middle 
line,  and  extends  downwards  and  outwards  to  a  point  just  outside  of  the 
middle  of  a  line  from  the  anus  to  the  tuber  ischii.  The  knife  enters  the  groove 
on  the  staff  in  front  of  the  prostate  and  severs  the  left  lobe  of  that  organ.  The 
rest  of  the  operation  is  much  the  same  as  median  lithotomy. 

Calculus  in  the  female  is  rare,  and  is  usually  due  to  phosphatic  deposits 
on  a  foreign  body,  often  introduced  by  the  patient.  If  small  it  may  be 
removed  by  the  finger  or  forceps,  after  dilating  the  urethra.  If  this  is 
injudicious,  litholapaxy  should  be  performed.  Very  large  stones  may  be 
removed  by  suprapubic  cystotomy.  Vaginal  cystotomy  is  inadvisable  l>ecause 
of  the  danger  of  vesicovaginal  fistula. 


CHAPTER  XXX. 

GENITAL  ORGANS. 

URETHRA  AND  PENIS. 

Congenital  Malformations. — Narrow  meatus  rarely  causes  symptoms 
and,  as  a  rule,  is  brought  to  the  surgeon's  attention  only  when  it  is  desirable 
to  introduce  instruments  for  other  reasons.  When  needed  the  meatus  may 
be  enlarged  by  cutting  downwards  with  a  blunt  pointed  bistoury  (meat<ftomy), 
the  parts  being  separated  each  day  by  a  probe  in  order  to  prevent  union. 
Congenital  stricture  may  occur  at  the  outer  end  of  the  fossa  navicularis 
and  in  the  membranous  urethra.  Occlusion  of  the  urethra  may  be  due  to  a 
septum,  which  should  be  perforated.  The  urethra  may  be  absent|  leading  to 
early  death  unless  there  is  a  congenital  urinar>'  fistula  at  the  umbilicus  or  into 
the  rei  turn  or  perineum.  Epispadias  (Fig.  454)  is  a  congenital  deformity  in 
which  the  urethra  opens  on  the  dorsum  of  the  penis.  Complete  epispadias, 
i.e.,  when  the  whole  urethra  is  exposed  on  the  dorsum  of  the  penis,  is  always 


KUPTtTKK    OF    THE    URETHR.^. 


asstHjalecl  with  exlruvLTsion  of  ihe  Ijladder.  The  worst  feaUirt*  of  (he 
ikiverer  casies  \^  incontineiKe  of  urine.  In  lltkrsth's  operation  the  balanic 
and  penile  urelhrse  are  iirst  constructed  by  lateral  flaps  (Fig.  455),  and  at  a 
later  period  the  defect  at  the  foot  of  tlie  penis  and  that  at  the  corona  are  closed 
as  shown  in  Fig.  456.  Hypospadias^  a  congenital  condition  in  which  the 
floor  of  the  urethra  is  defective,  is  much  more  common.  There  are  three 
types:  In  the  batanitk,  the  urethra  opens  just  behind  the  glans;  in  the  pmilr, 
on  the  under  surface  of  the  penis;  in  the  perineal,  in  the  perineum,  the  scrotum 
being  cleft,  and  the  penis  rudimenlar>^  In  the  last  form  the  testicles  may 
remain  within  the  abdomen  and  the  child  be  mistaken  for  a  female.  Hypo- 
spadias does  not  cause  incontinence  of 
urine.  When  the  opening  is  a  short  dis- 
tance behind  the  glans,  the  urethra  may 
be  freed  from  its  surroundingsand  drawn 
through  a  perforation  in  the  glans.  where 
it  is  sutured  (Beck's  operation).  In 
other  cases  the  defect  may  be  reme<lied 
l}y  an  operation  similar  to  thai  of  Thiersch 
for  epispadias.  The  fibrous  hantls  whii  h 
curve  the  penis  downwards  should  be 
ilivided  previous  to  any  operation  for 
hypos]  ladi  as. 

Rupture  of  the  urethra  usually 
takes  place  at  the  bulb,  as  the  result  of 
falling  astride  of  some  hard  object.  The 
membranous  urethra  may  be  lorn  Iw 
fracture  of  the  peKis,  the  penile  urethra 
in  fracture  of  the  penis  during  erection. 
The  urethra  may  give  way  also  behind  a 
stricture,  as  the  result  of  ulceration  or 
straining.     The  rupture  may  be  complete 

or  partiaL  The  S3miptoms  are  shock,  pain,  tenderness,  bleeding  from  the 
urethra,  inability  to  urinate,  and  swelling  caused  by  blood  and  urine.  At 
a  later  period  the  phenomena  of  se|>ticemia  ensue,  owing  to  the  gangrenous 
cellulits  induced  !>y  the  extravasated  urine.  Kxtravasation  of  urint-  is 
influenced  by  the  situation  of  the  rupture.  When  the  rupture  is  above  the 
upper  layer  of  the  triangular  ligament,  the  urine  extravasates  as  in  extra- 
peritoneal rupture  of  the  Idadder;  when  between  the  two  layers,  the  urine 
remains  localized  and  causes  an  abscess;  when  below  the  lower  layer,  the 
usual  situation,  the  urine  distends  the  scrotum,  penis,  and  abdominal  wall,  but 
does  not  pass  backwards,  owing  to  the  attachment  of  the  fascia  of  Colles. 
The  condition  is  to  be  distinguished  from  contusion,  in  which  extravasation 
does  not  occur,  and  in  which  urination  is  usually  possible.  In  severe  lacer- 
ations a  catheter  cannot  be  introduced. 

The  treatment  is  exposure  and  suture  of  the  torn  urethra,  a  retentitm 
catheter  being  passeil  into  the  bladder  tiirough  the  urethra.  The  perineal 
urethra  is  exposed  by  an  incision  identical  with  that  for  median  lithotomy. 
The  wound  should  be  drained  with  gauze;  additional  incisions  will  be  neces- 
sary for  drainage  if  the  urine  has  in  filtrated  the  surrounding  tissues.  Vigorous 
constitutional  treatment  will  be  needed  if  the  parts  have  become  septic. 
Traumatic  stricture,  which  is  almost  inevitable  after  this  injury,  should  be 


Kn;.  454.~EpLspadi4is.     |Pt4ytUnic 
tIfjspHal.) 


anticipated  by  the  passage  of  sounds  every  second  day  after  the  retendoD 
catheter  has  been  removed,  i.e,,  at  the  end  of  a  week.  Confusions  of  the 
urethra  are  treated  by  external  applications  of  cold^  rest  in  bed,  and  urinan' 
antiseptics.  The  catheter  should  not  be  used  unless  there  is  retention  of  urine. 
Foreign  bodies^  such  as  a  portion  of  a  catheter,  pencil,  etc..  when  lodged 
in  the  uretlira,  partly  or  completely  obstruct  the  lumen,  and  may  cause  ulcera- 
tion,  periurediral  abscess,  and  extravasation  of  urine.  They  may  be  detected 
by  the  sound,  the  urethroscope  (p,  553),  die  X-ray,  and  sometimes  by  external 
palpation.  Removal  is  effected  by  forceps  v^hen  the  foreign  body  is  in  the 
penile  urethra,  or,  when  this  is  not  possible,  by  external  incision.  In  the  latter 
instance  the  urethral  wound  should  be  sutured.  A  pin  which  has  been 
pushed  into  the  urethra  head-first,  may  be  removed  by  forcing  the  point 


Fig. 


455- 


Fig.  456. 


Figs.  455  and  456. — Thiersch's  operadon.  cc.  (Fig.  455),  Tndsion  in  prepuce  ihmugh 
which  glans  is  thrust  (Fig.  456),  so  ihal  prepuce  may  be  used  as  flap  to  clcvse  defect  lietween 
the  balanic  and  ffenilc  urelhra?,     (Esmarch  and  Kowalzig.) 


i 


through  the  Soorof  the  urethra,  reversing  the  direcliun  of  the  pin,  and  pushing 
it  out  through  the  meatus.  An  impacted  cakulus  is  treated  as  a  foreign  body. 
tJrethritis  may  be  simple  or  specific.  Simple  urethritis  is  inflamraatlon 
of  the  urethra  not  due  to  tlie  gonococcus.  It  may  be  caused  by  injur}%  e.g., 
contusions^  wounds,  foreign  bodies^  rough  instrumentation,  and  caustic  injec- 
tions; certain  substances  taken  into  the  stomach,  e.g.,  alcohol  in  excess,  can- 
tharides,  turpentine^  and  potassium  iodid;  gout  or  rheumatism;  certain  skin 
diseases,  e.g.,  herpes  and  eczema;  urethral  chancre  or  chancroid;  highly 
acid  urine;  contact  with  lochial,  Icukorrheab  or  menstrual  fluid;  infectious 
diseases;  tuberculous  ulceration;  masturbation;  sexual  excess;  and  polypi. 
The  sympioms  are  the  same  as  those  of  gonorrhea,  but  usually  milder.  The 
treatmeni  is  removal  of  the  cause,  diuretics,  urinary  antiseptics,  and  in  some 
cases  mild  astringent  injections. 


GONORRHEA.  551 

Specific  urethritis,  gonorrheal  or  clap,  is  inflammation  of  the  urethra 
caused  by  the  gonococcus.  The  gonococcus  is  a  diplococcus  looking  some- 
what like  a  coffee  bean,  and  occurring  both  within  and  without  the  leidcocytes 
and  epithelial  cells.  It  may  be  stained  with  methyl  or  gentian  violet,  and 
does  not  take  the  Gram  stain,  a  point  to  be  remembered  in  differentiating  it 
from  pseudogonococci.  In  doubtful  cases  cultural  methods  may  be  necessary 
to  establish  a  diagnosis.  The  disease  is  acquired  by  direct  contact,  but  no 
breach  of  the  mucous  surface  is  necessary.  The  organism  enters  the  epithe- 
lial cells  and  occasionally  the  subepithelial  tissues,  causing  a  purulent  inflam- 
mation. 

The  symptoms  begin  after  a  period  of  incubation  varying  from  one  to 
fourteen  days.  At  first  there  is  itching  and  burning  in  the  fossa  navicularis, 
with  gluing  together  of  the  lips  of  the  meatus.  During  the  acute  stage  the 
meatus  is  red  and  swollen,  the  discharge  thick  and  yellow.  There  is  burning 
pain  on  micturition  {ardor  urina),  which  may  pass  to  the  groin  or  perineum. 
The  urinary  stream  may  be  forked,  owing  to  the  swelling  of  the  mucous 
membrane,  but  retention  is  uncommon.  Owing  to  the  infiltration  of  the 
corpus  spongiosum,  erection  may  be  exceedingly  painful  and  the  penis 
markedly  curved  (chordee).  After  from  two  to  six  weeks  in  a  favorable  case, 
the  discharge  becomes  serous  and  finally  disappears.  In  the  female  the  vulva 
and  vagina  as  well  as  the  urethra  are  involved,  but  the  symptoms  are  usually 
less  acute  than  in  the  male.  Gonorrhea  varies  in  duration  and  intensity ;  thus 
the  discharge  may  persist  but  a  week  or  ten  days  (abortive  gonorrhea)  f  or  the 
manifestations  may  be  comparatively  mild  (subacute  gonorrhea)^  partic- 
ularly in  those  who  have  had  previous  attacks.  In  a  certain  proportion  of 
cases  the  inflammation  extends  backwards  and  involves  the  membranous 
and  prostatic  portions  of  the  urethra  (posterior  urethritis) ^  whence  it  may 
spread  to  the  bladder,  prostate,  seminal  vesicles,  or  testicles.  Posterior  ure- 
thritis is  usually  announced  by  frequent  and  painful  micturition  and  often  by 
perineal  pain.  If  the  patient  urinates  into  two  glasses,  the  first,  holding 
about  two  ounces,  will  contain  the  washings  of  the  entire  urethra,  while  the 
second,  if  turbid  with  pus,  will  indicate  posterior  urethritis,  the  pus  from 
which  flows  back  into  the  bladder.  Another  test  is  to  wash  out  the  anterior 
urethra  with  a  catheter,  after  which  purulent  urine  w^ould  point  to  posterior 
urethritis. 

Chronic  gonorrhea  may  involve  the  anterior,  the  posterior,  or  the  whole 
urethra.  In  the  first  and  last  instances  the  most  important  symptom  is 
gleet,  i.e.,  a  slight  mucopurulent  discharge,  which  may  be  observed  only  in  the 
morning.  If  posterior  urethritis  alone  exists,  there  may  be  no  discharge, 
but  pus  or  threads  (Tripperfdden)  will  be  found  in  the  urine.  Chronic 
anterior  urethritis  is  usually  perpetuated  by  a  stricture,  a  suppurating 
follicle,  or  a  spot  of  ulceration;  posterior  urethritis  by  infection  of  the 
prostatic  ducts. 

The  complications  of  gonorrhea  are  due  to  (i)  extension  by  continuity 
— balano-posthitis,  phimosis,  pafaphimosis,  folliculitis,  periurethral  abscess, 
Cowperitis,  prostatitis,  vesiculitis,  epididymitis,  cystitis,  pyelonephritis  (rare), 
abscess  of  Bartholin's  glands,  endometritis,  salpingitis,  ovaritis,  pelvic  perit- 
onitis; (2)  extension  by  contiguity — cellulitis  (rare);  (3)  extension  by  the  lym- 
phatics— lymphangitis,  buboes;  (4)  transmission  of  Qie  infection — proctitis, 
rhinitis,  conjunctivitis  (gonorrheal  ophthalmia),  stomatitis;  (5)  extension 
by  the  blood — arthritis  (gonorrheal  rheumatism),  gonorrheal  sclerotitis  or 


552  GENITAL   ORGANS. 

iritis  (independent  of  gonorrheal  ophthalmia),  and  intlammation  of  the  ten- 
(ion  sheaths,  muscles,  pleura,  pericardium,  endocardium,  blood  vessels,  and 
it  is  said  even  of  the  meninges,  nerves,  or  spinal  cord. 

The  treatment  of  acute  gonorrhea  is  greatly  facilitated  by  keeping  the 
patient  as  quiet  as  possible,  and  in  severe  cases  by  rest  in  bed.  The  bowels 
should  move  regularly  and  large  quantities  of  water  taken.  The  diet 
should  be  plain  and  unstimulating,  alcohol,  coffee,  tea,  and  condiments 
being  especially  interdicted.  The  patient  should  wear  a  suspensory,  and 
some  form  o\  gonorrhea  bag  to  catch  the  discharge;  a  piece  of  cotton  held 
in  place  by  pulling  down  the  foreskin  over  it,  is  useful  for  the  latter  purpose. 
Sexual  excitement  of  all  forms  must  be  prohibited,  and  the  penis  cleansed 
twice  a  day  by  soaking  in  warm  salt  solution.  A  hot  hip  bath  once  or  twice 
a  day  is  beneficial.  The  patient  should  be  warned  of  the  contagiousness 
of  the  discharge,  and  particularly  of  the  danger  of  gonorrheal  ophthalmia; 
the  hands  should  be  kept  clean,  and  all  towels  used  by  the  patient  kept  apart 
from  those  used  by  others.  The  so-called  abortive  treatment^  in  which  strong 
antiseptic  solutions  are  injected  into  the  urethra,  is  dangerous.  Infernal 
treatment  usually  consists  in  the  administration  of  urinary  antiseptics,  e.g., 
hexamethylenamine  (grains  5  t.  d.),  salol  in  the  same  dose,  or  methylene  blue 
(grains  2  t.  d.);  alkalies,  particularly  when  ardor  urinae  is  marked,  e.g.,  car- 
bonate of  soda,  or  potassium  citrate  or  acetate;  and  balsamics,  e.g.,  oleoresin 
of  copaiba,  oleoresin  of  cubebs,  and  oil  of  sandalwood,  each  of  which  may  be 
given  in  from  5  to  10  minim  doses  t.  d.  in  capsules.  The  balsamics  may 
upset  the  stomach  and  copaiba  may  cause  an  urticarial  erythema;  they  are 
most  useful  towards  the  end  of  an  attack  or  in  chronic  cases.  Bromid  of 
potassium  or  lupelin,  20  to  40  grains  on  retiring,  is  the  most  effective  remedy 
for  chordee;  the  painful  erection  itself  may  be  relieved  with  ice  water.  In- 
jections may  be  antiseptic  or  astringent;  the  former  may  be  used  from  the 
beginning,  the  latter  in  the  declining  stages.  Any  injection  which  causes 
much  pain  is  too  strong  and  must  be  diluted  or  discarded.  The  syringe 
should  be  blunt  pointed  and  hold  about  three  or  four  drams.  The  injection 
should  be  given  after  each  urination,  and  the  fluid  held  in  the  urethra  for 
three  minutes  by  compressing  the  meatus.  Of  the  antiseptic  injections  may 
be  mentioned  argyrol  (silver  vitellin)  i  to  5  per  cent.,  protargol  J  to  i  per 
cent.,  and  potassium  permanganate  from  i  to  10,000  to  1  to  1000.  The 
following  are  astringent  injections;  zinc  sulphate,  grains  10,  bismuth  sub- 
nitrate,  powdered  acacia,  each  i  dram,  and  water  3  ounces;  tincture  of 
catechu,  10  minims  to  the  ounce  of  water;  and  liq.  plumbi  subacetat.  dil. 
JaneCs  irrigation  method  consists  in  washing  out  the  urethra  by  means  of  a 
fountain  syringe,  which  is  connected  with  a  blunt  nozzle  to  be  applied  to  the 
meatus.  Permanganate  of  pota.ssium  i  to  4000  or  weaker,  is  used  at  first, 
the  reservoir  being  two  feet  above  the  penis,  and  the  irrigations  given  twice 
a  day.  Later  the  strength  of  the  solution  is  increased,  and  the  irrigations 
given  once  a  day.  The  posterior  urethra  may  be  irrigated  by  raising  the 
reservoir  to  the  height  of  five  feet,  the  fluid  entering  the  bladder,  which,  when 
full,  is  emptied  by  urination.  When  the  acute  symptoms  subside  the  irriga- 
tions are  abandoned  and  astringent  injections  employed.  The  method  is 
highly  recommended  by  some,  and  condemned  by  others,  who  believe  that 
it  increases  the  danger  of  complications.  Gonorrhea  in  the  female  is  treated 
on  the  same  principles  as  in  die  male  (see  vulvitis,  vaginitis,  etc.).  Gonor- 
rhea is  cured  when  there  are  no  clinical  evidences  of  the  disease  for  two 


GONORRHEA.  553 

weeks,  and  when  goiiococci  cannot  be  found  in  the  mucus  expressed  from 
ihe  prostate,  the  seminal  vesicles,  and  the  urethra. 

The  treatment  of  chronic  gonorrhea  involves  a  careful  examination  to 
determine  the  cause  of  the  persistence  of  the  discharge.  Any  constitutional 
malady,  particularly  gout  or  rheumatism,  should  receive  appropriate  treat- 
ment. Localized  patches  of  inflammation  will  prove  to  be  very  sensitive 
on  the  introduction  of  a  bulbous  bougie,  which  will  detect  also  any  narrowing 


Fig.  457. — ^Valentine's  urethroscope. 

of  the  urethra,  and  will  give  some  information  by  the  character  of  the  dis- 
charge which  is  brought  out  in  front  of  the  bulb.  The  urethroscope  (Fig.  457), 
which  is  a  cylindrical  speculum  with  a  small  electric  lamp  at  the  end,  allows 
visual  inspection  of  the  entire  urethra,  the  walls  of  the  canal  prolapsing  over 
the  end  of  the  tube  as  it  is  withdrawn.  It  is  inserted  after  disinfecting  the 
external  genitals  and  injecting  one  fluid  dram  of  a  5  per  cent,  solution  of 
novocain.  The  prostate  and  seminal  vesicles  also  should  be  investigated. 
Localized  patches  of  inflammation  are  treated  by  the  application  of  silver 


VJEKVLVSGMS 


V- 


Fig.  458. — Keycs-Ullzman  syringe. 

nitrate  (i  per  cent.),  either  through  the  urethroscope  or  by  means  of  a  deep 
urethral  syringe  (Fig.  458),  every  two  or  three  days.  Irrigations  and  in- 
jections, as  in  acute  gonorrhea,  also  are  useful.  When  the  discharge  depends 
upon  stricture,  or  some  complication  like  prostatitis,  folliculitis,  etc.,  the 
treatment  is  that  of  the  complication.  Even  in  the  absence  of  stricture,  the 
passage  of  a  sound  once  or  twice  a  week  is  beneficial,  in  that  it  is  a  form  of 
massage  which  expresses  from  the  follicles  any  retained  secretions.     Anti- 


554  GENITAL  ORGANS. 

gonococcal  serum  and  gonococcal  bacterin  (see  p.  30)  have  been  employed 
in  the  treatment  of  gonorrhea  and  its  complications,  but  their  value  is  not 
yet  determined.  The  dose  of  the  bacterin  varies,  according  to  different 
observers,  from  5  to  50  millions  dead  bacteria  every  third  to  every  seventh  day. 

Urethrorrhea  is  a  slight  discharge  of  a  non-purulent  mucoid  fluid  from 
the  urethra,  most  marked  in  the  morning  and  after  straining  at  stool,  and 
due  to  hyperactivity  of  the  urethral  glands.  The  discharge  stains  but  does 
not  stiffen  linen.  The  causes  are  sexual  excess,  masturbation,  ungratified 
sexual  desire,  and  like  conditions  which  induce  urethral  congestion.  It  is 
sometimes  accompanied  by  sexual  neurasthenia  and  false  impotence.  The 
treatment  is  tonics  and  removal  of  the  cause. 

Folliculitis,  or  inflammation  of  one  of  the  urethral  follicles,  is  caused  by 
urethritis,  usually  of  gonorrheal  origin.  A  tender,  painful,  shot-like  swelling 
may  be  felt  beneath  the  skin  along  the  floor  of  the  urethra.  If  suppuration 
occurs  {periuretiiral  abscess),  the  abscess  may  discharge  into  the  urethra, 
through  the  skin,  or  in  both  directions,  thus  forming  a  urinary  fisiula.  The 
treatmetit  is  the  application  of  ichthyol.  If  pus  forms,  it  may  be  evacuated 
through  the  urethra  by  means  of  a  fine  knife  and  the  urethroscope,  or  exter- 
nally if  the  suppuration  is  diffuse  under  the  skin.  A  urinary  fistula  which 
refuses  lo  heal  should  be  cauterized,  or  failing  in  this,  closed  by  a  plastic 
operation. 

Cowperitis,  or  inflammation  of  Cowper's  gland,  is  identical  in  cause  and 
symptoms  with  folliculitis,  except  that  the  swelling  is  felt  in  the  perineum, 
to  one  or  the  other  side  of  the  median  raphe.  If  pus  forms,  it  should  be 
evacuated  by  a  perineal  incision. 

Stricture  of  the  urethra,  or  narrowing  of  the  lumen  of  the  canal,  may 
be  inflammatory,  spasmodic,  or  organic. 

Inflammatory  stricture  is  due  to  inflammatory  swelling  of  the  mucous 
membrane,  which  in  itself  is  scarcely  ever  great  enough  to  interfere  seriously 
with  the  passage  of  urine,  but  which  may  cause  acute  retention  if  engrafted 
on  an  organic  stricture. 

Spasmodic  stricture  occurs  in  the  membranous  urethra  as  the  result  of  a 
spasmodic  contraction  of  the  compressor  urethras.  The  causes  are  organic 
stricture,  particularly  after  exposure  to  cold  or  after  drinking  alcohol;  opera- 
tions on  or  injuries  of  the  perineum,  rectum,  or  spermatic  cord;  and  ner\'ous 
and  emotional  disturbances.  Retention  due  to  spasmodic  stricture  is  treated 
by  a  hot  sitz  hath  and  an  opium  suppository,  and,  if  these  fail,  by  the  in- 
troduction of  a  large  catheter,  which,  if  pressed  gently  but  firmly  against  the 
stricture,  will,  after  a  time,  tire  the  muscle  and  slip  into  the  bladder. 

Organic  stricture  may  be  congenital  (p.  548)  or  acquired.  Acquired 
organic  stricture  is  due  to  cicatricial  contraction,  the  result  of  gonorrhea  or 
other  form  of  urethral  inflammation,  or  injury,  such  as  rupture  or  laceration 
of  the  urethra.  Strictures  may  be  single  or  multiple.  The  usual  situation 
of  gonorrheal  stricture  is  in  the  bulb,  of  traumatic  stricture  in  the  membran- 
ous urethra.  Stricture  of  the  prostatic  urethra  is  extremely  rare.  According 
to  its  shape  the  stricture  may  be  annulary  bridle  (involving  only  a  portion  of 
the  circumference),  tubular  (when  very  long),  or  tortuous;  according  to  its 
consistency,  fibrous y  soft,  cartilaginous,  or  elastic  or  resilient  (rapidly  recontracts 
after  dilatation);  and  according  to  the  degree  of  narrowing,  impermeable 
(does  not  permit  the  passage  of  urine)  or  impassable  (when  instruments  can- 
not be  introduced).     A  stricture  of  small  calibre  is  one  through  which  a 


STRICTURE    OF   THE   URETHRA. 


5SS 


immber  15  French  sound  cannot  be  passed^  a  stricture  of  large  calibre  one 
which  will  admit  a  Jarger  instrument. 

The  results  are  dilatation  of  the  urethra  behind  the  stricture,  with  chronic 
inllammation  and  sometimes  ulceration.  If  the  ulcer  extends  deeply,  a 
perijical  abscess  and  subsequently  perineal  fistula?  develop;  the  latter  are 
treated  by  external  urethrotomy,  with  incision  or  excision  of  the  tracts.  WTien 
the  obstruction  becomes  complete  the  uredira  may  give  way,  leading  to  ex- 
travasation of  urine  (p.  549).  The  bladder  hypertropliies  and  ultimately 
becomes  in  11  am ed  and  sometimes  ulcerated,  while  stone  may  form  owing  to 
the  alkaline  changes  in  the  urine.  In  some  cases  the  bladder  walls  are 
stretched  and  thinned  instead  of  thickened.  Hydronephrosis,  pyonephrosis, 
and  pyelonephritis  also  may  ensue. 

The  symptoms  are  gradually  increasing  diffiiulty  in  urination,  the 
stream  becoming  forked,  progressively  smaller,  and  dribbling  at  the  end. 
Micturition  lakes  more  and  more  time,  and  finally  retention  occurs,  usually 
as  the  result  of  spasm  or  congestion  following  exposure  to  cold  or  an  alcoholic 
debauch.  The  diagnosis  may  be  made  with  the  urethroscope  or  the  bougie 
a  boule  (Fig.  459);  occasionally  the  induration  can  be  felt  tlirough  the  skin. 
If  the  largest  bougie  whi^  the  meatus  admits  meets  with  obstruction,  there 


FiG.  459- — BouKiP  i  boulc. 


I  [c;.  460.^ — Conical. 
Tig.  461. — (>livan\ 
Fici.  46 J. — Cyiindrical. 


Fig,  40 jJ. — Merrier     double 
elbow  (bictiude). 

Fig.  464,— ElWw   (coud^). 


Figs.  460  to  464. — Flexible  ralhelers. 


is  a  stricture,  as  the  meatus  is  normally  the  narrowest  part  of  the  canal. 
Smaller  sixes  should  then  be  used  until  one  finally  passes.  The  exact  situa- 
tion of  the  stricture  may  be  determined  by  noting  the  depth  at  which  a  large 
sound  meets  with  obstruction,  and  l)y  the  catching  of  the  bulb  of  a  smaller 
instrument  upon  withdrawal.  The  patient  should  be  recumbent  and  the 
thighs  separated.  The  glans  should  be  cleansed  with  bichloriti  of  mercury 
solution »  then  with  sterile  water,  the  hands  disinfected,  and  the  bougie 
sterilized,  and  anointed  with  lubrichondrin  or  sterile  oil.  Flexible  instru- 
ments (Fig.  460  to  464)  will  sometimes  pass  an  obstruction  if  a  screwing 
motion  is  used.  Non-tlexible  (Fig.  465)  instruments  should  be  allowed  to 
lind  their  own  way  along  the  urethra  without  the  use  of  force.  The  penis  is 
held  in  one  hand  and  the  instrument  manipulated  with  the  other.     Th"^ 


556  GENITAL   ORGANS. 

shank  of  the  instrument  is  hehi  near  the  skin  of  the  groin,  ajid  the  end  intro 
duced  into  the  meatus,  imtil  the  curve  disappears  within  the  urethra.  The 
handle  is  then  carried  across  the  abdomen,  still  close  to  the  skin,  to  the  median 
line,  the  penis  pulled  up  on  the  instrument,  and  the  handle  raised  to  the 
vertical  and  finally  depressed  between  the  thighs.  The  pocketing  of  a  small 
instrument  in  the  lacuna  magna  may  be  prevented  by  carrjdng  the  point 
along  the  floor  of  the  urethra  as  far  as  the  perineum,  obstruction  at  the 
opening  of  the  triangular  ligament  and  at  the  sinus  pocularis  by  carrying  the . 
point  along  the  upper  wall  of  the  rest  of  the  urethra.  The  dangers  of  the 
introduction  of  an  instrument  into  the  urethra  are  shock,  when  the  urethra  is 


^ 


Fig.  465. — Conical  steel  bougie. 

hypersensitive,  a  condition  which  may  be  prevented  by  distending  the  urethra 
with  a  5  per  cent,  solution  of  novocain ;  hemorrhage,  which  may  be  avoided 
by  gentleness;  false  passages  (p.  558);  and  septic  processes,  e.g.,  prostatitis, 
epididymitis,  cystitis,  and  urinary  fever. 

The  treatment  of  stricture  is  (i)  dilatation,  (2)  urethrotomy,  or  (3) 
urethrectomy.  i.  Dilatation  may  be  gradual,  rapid,  or  continuous.  Grad- 
ual dilatation  is  the  best  treatment  for  all  non-resilient  strictures  through 
which  an  instrument  can  !)e  passed.  The  largest  sound  which  the  stricture 
will  admit  is  introduced  and  allowed  to  remain  a  few  minutes;  this  is  repeated 
twice  a  week  with  larger  instruments,  until  the  stricture  is  as  large  as  the 
meatus  (from  27  to  32  F.).  The  patient  should  take  a  urinary  antiseptic 
during  the  treatment,  which  should  always  he  suspended  if  there  is  much 
irritation.  Rapid  dilatation  is  less  desirable,  even  though  it  saves  time;  it  con- 
sists in  the  introduction  of  larger  bougies,  one  after  the  other,  at  the  same  sit- 
ting, until  the  full  size  is  reached.  Continuous  dilatation  is  useful  in  very  small 
strictures.  The  patient  is  confined  to  bed,  and  a  fine  bougie  introduced  and 
kept  in  place  for  a  day  or  two,  when  it  will  be  found  that  a  larger  instrument 
ran  be  passed.  This  is  continued  until  a  large  in.strument  can  be  passeil. 
when  gradual  or  rapid  dilatation  may  be  substituted.  Filiform  l>ougies 
(less  than  i  mm.  in  diameter)  are  made  of  whalebone  and  used  for  the  finest 
strictures.  A  filiform  bougie  is  apt  to  enter  one  of  the  crypts  in  the  urethra, 
in  which  case  it  should  !>e  partly  withdrawn,  then  pushed  onward  with  a 
rotary  movement.  If  a  filiform  fails  to  enter  a  stricture,  the  urethra  should 
be  filled  with  these  fine  instruments,  when  it  will  be  found  that  one  will 
engage  in  the  orifice  of  the  stricture;  it  may  then  !)e  left  in  place  for  continuous 
dilatation,  or  a  tunneled  sound  or  catheter  (Fig.  466)  may  be  slipped  over  it. 
Forcible  dilatationy  or  diimlsiony  in  which  the  stricture  is  torn  by  means  of  an 
instrument  working  on  the  same  principle  as  a  glove  stretcher,  is  not  recom- 
mended. After  any  method  of  dilatation  an  instrument  should  be  passed  at 
first  once  a  week,  then  at  increasing  intervals,  to  make  sure  there  is  no 
recontraction. 


URETHROTOMY. 


557 


2.  Urethrotomy,  or  cutting  of  the  stricture,  may  be  employed  in  cases 
which  resist  dilatation.  Internal  urethrotomy  is  indicated  in  very  dense  or 
resilient  strictures  in  the  pendulous  urethra.  Strictures  near  the  meatus  may 
be  incised  with  a  blunt  pointed  bistoury  (see  meatotomy) ;  in  deeper  strictures 
a  special  instrument  is  required.     Civiale's  urethrotome  is  used  by  passing 


KiG.  466. — Filiform  bougie  threaded  on  a  Gouley  tunnelc<l  catheter. 

it  through  the  stricture,  protruding  the  blade  by  a  mechanism  in  the  handle, 
and  cutting  the  stricture,  from  behind  forwards,  on  the  roof  of  the  urethra  if 
in  the  bulb,  on  the  floor  if  in  the  penile  portion.  Maisonneuve's  urethrotome 
(Fig.  467)  cuts  from  before  backwards,  and  is  useful  when  the  stricture  is 
very  small,  as  a  filiform  bougie  screwed  to  its  end  acts  as  a  guide  to  the 


^ 


* 


Fig.  467. — Maisonneuve's  urethrotome. 


stricture.  The  operation  may  be  performed  under  general  anesthesia,  or 
after  distending  the  urethra  with  a  5  per  cent,  solution  of  novocain.  The 
urethra  is  irrigated  previous  to  operation,  and  a  full  sized  bougie  subse- 
quently passed  twice  a  week,  until  the  tendency  to  recontraction  is  over- 
come. 


Fig.  468.— Syme's  staff. 

External  urethrotomy  has  the  same  indications  as  internal  urethrotomy, 
when  the  stricture  is  in  the  posterior  third  of  the  urethra,  (a)  Syme's  opera- 
tion is  performed  by  introducing  a  shouldered  grooved  staff  (Fig.  468)  into 
the  bladder,  and  opening  the  urethra  just  behind  the  shoulder  of  the  staff, 
which  corresponds  to  the  stricture,  by  a  median  perineal  incision.     The 


558  GENITAL  ORGANS. 

Stricture  is  then  divided,  and  a  large  catheter  passed  into  the  bladder  through 
the  urethra,  and  fixed  there  by  adhesive  plaster,  running  from  the  catheter 
to  the  penis.  The  perineal  wound  is  drained.  The  catheter  is  washed 
daily,  and  removed  at  the  end  of  a  week,  after  which  sounds  are  passed 
twice  a  week,  the  perineal  wound  gradually  closing. 

(b)  Wheeihouse's  operation  is  indicated  in  impassable  strictures.  A 
Wheelhouse  staff  (Fig.  469)  is  passed  down  to  the  stricture,  the  urethra 
opened  just  in  front  of  the  stricture  by  a  median  perineal  incision,  and  a 
probe  gorget  (Fig.  470)  pushed  through  the  opening  and  the  stricture  divided. 
The  after  treatment  is  Aat  of  Syme's  operation. 


FiG.  469. — Wheeihouse's  staff. 

(c)  Cock's  operation  is  performed,  without  a  guide,  for  the  relief  of  reten 
tion  of  urine  (Fig.  471).  The  left  index  finger  is  passed  into  the  rectum  to  the 
apex  of  the  prostate,  and  the  urethra  opened  behind  the  stricture  by  a  me- 
dian perineal  incision.  The  stricture  may  be  divided  at  the  same  time,  or 
the  bladder  may  be  drained  through  the  perineum,  and  the  stricture  dealt 
with  at  a  later  period. 

3.  Urethrectomy,  or  excision  of  the  stricture  with  subsequent  suture  of 
the  urethra,  has  been  successfully  performed. 

False  passages,  or  channels  in  the  submucous  or  periurethral  tissues, 
may  result  from  attempts  to  introduce  an  instrument  into  the  bladder.  The 
instrument  lurches  onward  with  a  grating  sensation,  is  deflected  from  the 
middle  line,  and  the  point  cannot  be  rotated  as  it  should  be  if  it  had  entered 
the  bladder.     No  urine  flows  unless  the  instrument  reenters  the  urethra  or 


Vic.   470.  -Tcjilf's  prolK'  gnrgrt. 

bladder  behind  the  obstruction,  and  there  are  pain  and  hemorrhage.  No  e\il 
results  may  follow,  but  in  some  cases  there  will  be  urinar}'  fever  or  extravasa- 
tion of  urine  and  l)lood.  The  treatmnit  is  expectant  if  the  patient  can  pass 
urine.  If  there  is  acute  retention  of  urine  and  the  stricture  is  impassable,  or 
if  there  is  leakage  of  urine  into  the  perineal  tissues,  external  urethrotomy  yn\\ 
be  mandatory.  If  an  old  false  passage  interferes  with  catheterization,  it  may 
be  tilled  with  filiform  bougies,  when  an  additional  filiform  will  pass  into  the 
bladder. 

Urinary,  urethral,  or  catheter  fever  may  be  acute  or  chronic.  The 
acute  form  quickly  follows  the  introduction  of  an  instrument,  and  is  charac- 
terized l)y  a  chill  with  a  subsequent  rise  of  temperature.     It  is  of  ner\'ous  or 


PHIMOSIS. 


SS9 


possibly  septic  origin,  and  subsides  promptly  willi  the  use  of  opium,  quinin, 
and  urinary  antiseptics.  The  chronic  form  is  always  due  to  infection^  and 
usually  begins  several  days  after  the  introduction  of  an  instrument.  The 
symptoms  are  those  of  septicemia^  with  in  the  later  stages  those  of  uremia. 
The  pathological  findings  are  those  of  cv^stitis  and  pyelonephritis.  The 
treatment  is  first  prevenlionj  ix\,  the  strictest  antiseptic  precautions  and 
the  greatest  gentleness  during  instrumentation.  Mlien  once  developed  the 
condition  is  treated  on  the  same  principles  as  septicemia  and  uremia,  with 
urinary  antiseptics,  frequent  irrigations  of  the  bladder,  and  in  some  cases 
drainage  by  permanent  catheterization,  cystotomy,  or  nephrotomy. 

Chancroid,  or  soft  chancre,  is  a  non-syphilitic  sore  acquired  during 
coitus,  and  caused  by  the  baciUus  a/  Ducrey,  The  period  of  incubation  is 
from  one  to  five  days.  ChancroUs  are 
usually  found  on  the  glans,  the  pre- 
puce, or  the  labia,  and  very  rarely  in 
any  extragenital  situation.  A  soft 
chancre  first  appears  as  a  red  papule, 
which  quickly  changes  to  a  vcside, 
then  a  pustule,  and  finally  a  painful 
ulcer  with  sharp  undermined  edges 
and  a  yellowish  base,  which  secretes  a 
large  quantity  of  highly  contagious 
pus.  As  a  rule  there  is  more  than 
one  ulcer,  the  pus  being  autoinocula- 
ble,  and  the  surrounding  parts  are 
infiamed.  The  inguinal  lymph  glands 
are  \'ery  apt  to  suppurate  {so/i  bubo), 
but  the  infection  never  becomes  generalized.  If  neglected  or  if  occurring 
in  those  with  poor  resistance,  chancroid  may  spread,  with  or  without 
sloughing,  and  cause  great  destruction  of  tissue  (phagedena).  For  the 
diflferential  diagnosis  between  chancre,  chancroid,  and  herpes  see  p.  124. 
The  treatment  is  spraying  with  peroxid  of  hydrogen,  washing  with  bichlorid 
of  mercury  i  to  t,ooo,  and  dusting  the  sore  with  iodoform  or  thymol  iodid. 
Healing  usually  takes  place  within  two  or  three  weeks.  Phagedena  is 
treated  as  described  on  p.  77,  while  the  bubo  is  dealt  with  in  the  same  w^ay 
as  other  forms  of  adenitis.  If  phimosis  exists  and  interferes  with  cleanli- 
nessj  the  prepuce  may  be  split  along  the  dorsum,  and  the  raw  edges  touched 
with  carbolic  acid;  circumcision  is  generally  inadvisable,  as  the  entire 
wound  is  apt  to  become  infected. 

Venereal  warts  are  papiJlomatous  masses  which  appear  on  the  genitals 
as  the  result  of  irritating  discharges  or  uncleanliness,  and  occasionally  spon- 
taneously, hence  the  terra  venereal  is  a  misnomer.  They  may  be  snipped  off 
with  scissors  and  the  raw*  surfaces  cauterized  with  silver  nitrate. 

Pllimosis,  or  stenosis  of  the  orifice  of  a  long  prepuce,  is  usually  congenital 
In  origin,  but  occasionally  results  from  cicatricial  contraction.  It  interferes 
with  cleanliness,  thus  predisposing  to  local  inflammator}^  disorders,  and 
later  in  life  to  venereal  disease  and  epithelioma;  adhesions  may  form  betw^een 
the  glans  and  the  prepuce,  causing  retention  of  smegma  or  the  formation  of 
preputial  stones.  Wlien  of  extreme  grade  it  interferes  with  urination,  thus 
causing  straining  and  predisposing  to  hernia  and  prolapsus  ani.  Retention 
of  urine  occasionally  occurs,  and  irritability  of  the  bladder,  masturbation, 


Fig.  47  r — Cixk's  oj>craiion. 


560 


GENITAL   ORGANS. 


Fig,  473. — Method  of  reducing  piiraphimofiis. 
(HiTsch.) 


and  reflex  nervous  disorders  may  be  induced.  The  treatment  is  cir 
cisjon,  whlcli  may  be  performed  by  splitting  the  prepuce  up  the  dorsum,  sepa- 
rating adhesions,  trimming  the  l!aps  flush  with  the  corona  glandis,  and 
suturing  the  skin  to  the  mucous  membrane  with  catgut.  The  wound  b 
dressed  with  gauze,  which  should  be  changed  as  often  as  soiled.  When  cir- 
cumcision forceps  are  used,  adhesions  are  first  separated  with  a  probe,  the 
foreskin  drawn  down,  and  the  forceps  applied  parallel  with  the  corona,  care 
being  taken  not  to  include  the  glans.  The  prepuce  is  then  amputated  just 
beyond  the  forceps,  and  sutures  applied  after  the  forceps  have  been  removed. 
Paraphimosis  is  the  condition  existing  when  a  narrowed  preputial  orifice 

is  pushed  back  over  the  glans 
and  cannot  be  replaced.  The 
parts  are  edematous,  sometimes 
ulcerate  at  the  point  of  const ric- 
tion,  and  occasionally  become 
gangrenous  distal  to  the  constric- 
tion. The  treatment  is  reduc- 
tion hy  encircling  the  penis  be- 
hind the  constriction  with  the 
separated  index  and  middle  finger 
of  each  hand,  and  making  pres- 
sure on  the  glans  with  both 
thumbs,  a  maneuver  which 
presses  the  blood  from  the  glans 
and  pulls  the  foreskin  down  over 
it  (Fig.  472).  Reduction  maybe 
facilitated  by  multiple  punctures  to  relieve  the  edema,  by  anointing  the  parts 
with  sweet  oil,  and  by  general  anesthesia,  UTien  reduction  is  impossible, 
the  constricting  banil  may  be  divided  on  the  dorsum  of  the  penis. 

Balanitis^  or  inflammation  of  the  glans,  is  usually  associated  with  posthi- 
tis, or  inflammation  of  the  prepuce  (haianoposl/tiJis).  The  condition  is 
favored  by  phimosis,  and  is  usually  the  result  of  un cleanliness,  or  other  forms 
of  irritation,  such  as  chancroid,  gonorrhea,  and  diabetes.  The  prepuce  is 
edematous  and  a  purulent  discharge  escapes  from  its  orifice.  The  prepuce 
may  ulcerate  and  the  inguinal  glands  are  often  enlarged  and  lender.  The 
treattneot  is  frequent  washings  with  peroxid  of  hydrogen  and  bichlorid  of 
mcrcur}'  1  to  5,000,  the  glans  being  separated  from  the  foreskin,  between  the 
washings,  by  lint  moistened  with  the  bichlorifl  solution.  "WTien  the  prepuce 
cannot  be  retracted,  it  will  often  be  necessary  to  spIil  it  up  the  dorsum,  after 
which  cleanh'ness  may  be  maintainetl 

Epithelioma  of  the  penis  usually  l»egins  close  to  the  corona  glandis, 
most  frequently  in  tliosc  with  long  foreskins,  hence  it  may  be  concealed  for  a 
time,  the  only  evidence  of  its  existence  being  some  swelling  and  a  discharge 
containing  blood  and  pus.  The  growth  has  the  usual  characteristics  of 
cancer  elsewhere,  and  early  implicates  the  inguinal  glands.  The  treatment 
is  amputation  of  the  penis  and  removal  of  the  inguinal  glands.  VVlien  the 
disease  is  localized  to  the  distal  end,  the  section  may  be  made  through  the 
body  of  the  penis.  The  skin  flap  may  be  circular,  or  a  long  dorsal  and  a 
short  ventral  flap  may  be  employed.  The  corpus  sf>ongiosum  is  cut  a  little 
longer  than  the  corpora  cavernosa,  and  the  end  of  the  urethra  sutured  to  the 
edges  of  the  flaps,  after  being  split  to  avoid  stricture.     The  dorsal  arteries  of 


UNDESCENBED   TESTICLE. 


Sm 


the  penis  and  the  arteries  of  the  corpora  cavernosa  will  require  ligation. 
Extirpation  of  the  penis  may  be  required  if  the  disease  is  more  exteosive. 
With  the  patient  in  the  lithotomy  position,  the  root  of  the  penis  is  encircled 
by  an  incision  which  is  carried  downward  along  the  median  raphe  of  the 
scrotum  to  Llie  perineum.  The  divided  scrotum  is  separated,  and  the  corpus 
spongiosum  severed  in  front  of  the  triangular  ligament,  a  catlieler  having 
been  passed  down  to  this  point  as  a  guide.  The  suspensory  ligament  is  then 
divided,  and  the  crura  severed  close  to  llie  bone.  The  end  of  the  urethra 
is  split,  and  sutured  to  the  posterior  angle  of  the  perineal  incision,  and  the 
rest  of  the  w^ound  is  dosed,  with  ample  provision  for  drainage. 


TESTIS,  CORD,  AND  SEMmAL  VESICLES. 

The  ttsticle  may  he  absent  (anorfhism),  fused  with  its  fellow  {synoniiism), 
undescended  {cryptorrhism),  out  of  place  (tetopia)^  or  inverted  in  the  scrotum^ 
while  at  least  one  case  of  supernumerary  testis  (polyorchism)  has  been 
reported. 

Undescended  testicle  (trypfon-hism)  may  be  caused  by  "an  unusual 
length  of  the  mesorchium,  which  permits  so  free  a  movement  of  the  organ 
that  it  fails  to  enter  the  mouth  of  the  vaginal  process,  or  the  mesorcJiium 
becomes  aiiberent  to  adjacent  structures;  the  abnormal  persistence  of  the 
plica  vascularis;  certain  malformations  of  the  testicle  and  its  component 
parts,  such  as  a  short  vas  deferens  and  an  abnormally  large  epididymis;  cer- 
tain forms  of  hermaphroditism;  retraction  of  the  c remaster  and  absence  of 
the  internal  fibers  of  the  cremaster  before  the  testicle  has  entered  the  inguinal 
canal;  want  of  development  of  the  inguinal  canab  of  the  superficial  ab- 
dominal ring,  and  of  the  scrotum;  and  other  rare  causes,  such  as  the 
wearing  of  a  truss*'  (P^ccels).  The  organ  may  l>e  retained  within  the 
abdomen,  in  the  inguinal  canal,  or  just  outside  of  the  external  ring.  An 
ectopic  testicle  may  be  foujid  in  the  perineum,  Scarpa's  triangle,  at  the  root 
of  the  penis,  or  upon  the  aponeurosis  of  the  external  oblique.  It  is  pulled 
into  one  of  these  positions  by  the  gubernaculum  or  pushed  there  by  a  hernia. 
Imperfectly  descen<led  and  misplaced  testicles  are  almost  always  small  and 
soft  and  do  not  produce  spermatozoa.  They  are  often  subject  to  attacks  of 
inllammation  and  may  undergo  cystic  or  malignant  degeneration,  while 
hydrocele  and  hernia  are  frequent  complications,  and  gangrene  may  be  in- 
duced by  torsion  of  the  spermatic  cord. 

Treatment  by  massage  is  dangerous  l>ecause  of  the  irritation  which  it 
produces.  If  the  organ  has  not  descended  by  the  sixth  year,  the  best  treat- 
ment is  Beimn's  operation,  The  inguinal  canal  is  opened  as  in  Bassini*s  oper- 
ation, an<l  the  peritoneal  pouch  separated  from  the  cord  and  divided  between 
two  ligatures,  thus  blocking  the  hernial  sac  and  forming  a  tunica  vaginalis. 
The  cord  is  lengthened  by  separating  it  from  the  surrounding  tissues  and 
peritoneum,  and  by  separating  the  vas  from  the  spermatic  vessels.  If  this 
does  not  produce  sufficient  lengthening,  the  spermatic  vessels  are  ligated  and 
divided,  the  testicle  generally  being  amply  nourishefl  by  the  artery  of  the  vas, 
although  the  author  has  had  two  cases  in  which  the  testicle  suljsequcntly 
became  gangrenous.  A  pocket  is  then  made  in  the  the  scrotum  by  the  fingers, 
the  testicle  placed  therein,  and  the  mouth  of  the  pocket  closed  fjy  a  purse- 
string  suture.     The  wound  is  closed  as  in  Bassini's  operation,  except  that 

3^ 


S62 


GENITAL   ORGANS. 


the  cord  is  not  displaced,  but  allowed  to  emerge  at  the  lower  angle  of  the 
wound.  Castration  is  advised  by  many  surgeons,  but  should  never  be  done 
if  the  condition  is  bilateral,  for  though  the  patient  is  even  steiile,  he  may  be 
potent,  and  removal  of  both  organs  has  a  serious  effect  upon  development, 
owing  to  the  absence  of  the  internal  secretion  of  the  testicle. 

Torsion  of  the  spermatic  cord  may  occur  during  severe  exertion  if  there 
is  a  long  mesorchium.  In  about  half  the  cases  the  testicle  is  imperfectly  de- 
scended. The  symptoms  resemble  strangulated  hernia,  in  that  there  are 
sudden  pain,  swelling,  tenderness,  and  vomiting,  but,  unlike  strangulated 
hernia,  there  is  apt  to  be  fever  and  no  intestinal  obstruction.  In  some  cases 
the  twisting  of  the  cord  and  the  rotation  of  the  testicle  may  be  made  out  by 
palpation.  In  the  severer  forms  the  testicle  becomes  gangrenous.  The 
treatment  in  recent  cases  is  exploratory  incision,  with  imtwisting  of  the  cord 
and  suturing  of  the  testicle  to  the  scrotum.  A  gangrenous  testicle  should  be 
removed. 

Acute  orchitis,  or  inflammation  of  the  secreting  part  of  the  testicle,  may 
be  due  to  injury,  gout,  rheumatism,  mumps,  typhoid  fever,  and  less  fre- 
quently to  other  infectious  diseases;  or  it  may  be  secondary  to  epididymitis. 


Vic.  47  ^  — Diaj^rammiitic  st^ctions  of  (A) 
orcliitis  (li)  epididNinitis.  and  (C)  hydnxrclc  of 
the  tunic  a  \  aj^inalis.  Ho,  Testis,  X,  epitlidy- 
mis;   II y,  livdnx  ele.     (Tillmanns.) 


Fig.  474. — Adhesive  plaster 
strapping  for  testicle.   (Heath.) 


The  symptoms  are  sickening  pain  extending  upward  along  the  cord  and  often 
to  the  loin,  great  tenderness,  uniform  swelling  of  the  testicle  (Fig.  473),  fever» 
redness  and  edema  of  the  scrotum,  and  often  acute  hydrocele.  Atrophy 
commonly  follows,  but  abscess  and  gangrene  are  rare. 

Acute  epididymitis  may,  in  rare  instances,  be  due  to  the  same  causes  as 
orchitis,  hut  is  almost  always  the  result  of  infection  spreading  from  the  deep 
urethra,  usually  arising  from  gonorrhea,  and  occasionally  from  prostatitis, 
the  passage  of  instruments,  or  other  forms  of  irritation.  The  process  often 
extends  to  the  testicle.  The  symptoms  usually  arise  in  the  latter  stages  of 
gonorrhea  and  are  those  of  orchitis,  but  the  character  of  the  swelling  is  some- 
what (litlerent  (Fig.  473)  and  the  vas  is  generally  swollen  and  tender.  Acute 
hydrocele  is  common,  a!)scess  and  gangrene  rare.  In  bilateral  cases  there 
may  be  sterility  from  blocking  of  the  ducts,  but  .sexual  potency  is  retained 
unless  the  testicle  atrophies,  which  is  not  usual. 

Chronic  orchitis  and  epididymitis  may  follow  the  acute  form;  those 
cases  which  are  chronic  from  the  beginning  are  generally  due  to  syphilis  or 
tuberculo.sis. 

The  treatment  of  acute  orchitis  or  epididymitis  is  rest  in  bed,  elevation 
of  the  scrotum,  the  application  of  lead-water  and  laudanum  or  poultices, 
and,  in  the  declining  stages,  pressure  by  a  rubber  bandage  or  by  strapping 
the  testicle  with  adhesive  plaster  (Fig.  474).     Local  treatment  to  the  urethra 


HERNIA   OF   THE   TESTICLE.  563 

is  abandoned;  this  does  not  worry  the  patient  as  the  discharge  has  prob- 
ably disappeared  with  the  onset  of  the  inflammation.  In  acute  orchitis  with 
excessive  pain  or  threatened  gangrene,  the  tunica  albuginea  may  be  cut 
subcutaneously  with  a  tenotome.  Recurring  epididymitis  has  been  success- 
fully treated  by  ligation  of  the  vas  deferens  (Chetwood).  Chronic  infiamma- 
tion  of  the  testicle  is  treated  by  strapping,  or  by  inunctions  of  ichthyol  and 
mercury  and  the  internal  administration  of  potassium  iodid. 

Tuberculosis  of  the  testicle  usually  begins  in  the  globus  major  of  the 
epididymis,  as  the  result  of  a  deposition  of  the  tubercle  bacilli  from  the  blood, 
or  a  descending  infection  from  the  seminal  vesicles  or  prostate.  As  in  other 
affections,  the  left  testicle  is  more  frequently  involved  owing  to  its  more 
sluggish  circulation.  The  disease  is  most  common  between  the  fifteenth  and 
thfrtieth  years,  in  those  who  are  predisposed  to  tuberculosis,  and  it  is  often 
preceded  by  inflammation  or  a  slight  injury.  The  process  spreads  to  the 
body  of  the  testicle  and  up  the  vas  deferens,  affecting  the  other  genitourinary 
organs,  including  in  many  cases  the  opposite  testicle.  In  favorable  cases 
the  tuberculous  mass  may  become  encapsulated  and  calcify,  but  more  often 
it  undergoes  caseation,  forms  abscesses,  and  later  gives  rise  to  fistulas. 

The  symptoms  may  be  acute,  resembling  an  acute  epididymitis  which 
fails  to  subside  and  is  followed  by  abscesses.  As  a  rule  the  onset  is  insidious, 
and  perhaps  the  nodular  enlargement  of  the  epididymitis  is  discovered  acci- 
dentally. At  a  later  period  the  whole  organ  is  enlarged,  effusion  into  the 
tunica  vaginalis  is  apt  to  occur,  the  vas  deferens  is  thickened  and  knotty,  and 
finally  symptoms  referable  to  the  other  genitourinary  organs  appear,  while 
evidences  of  the  disease  in  the  lungs  may  be  detected.  Pain  and  tenderness 
are  not  marked  until  fistulae  of  the  scrotum  form.  The  sexual  power  is  un- 
impaired unless  both  organs  are  destroyed. 

The  treatment  is  the  wearing  of  a  suspensory,  and  general  treatment  as 
for  tuberculosis  elsewhere.  Injections  of  iodoform  or  zinc  sulphate  are  not 
recommended.  If  the  disease  progresses,  epididymectomy  should  be  per- 
formed, with  removal  of  the  vas  if  it  is  thickened;  this  operation  does  not 
cause  atrophy  of  the  testicle  or  impotency.  When  the  testicle  is  extensively 
diseased,  castration  should  be  performed  when  the  process  is  unilateral;  when 
bilateral,  the  worse  testicle  should  be  removed,  and  at  least  a  portion  of  the 
other  preserved.  Tuberculosis  in  other  portions  of  the  genitourinary  appa- 
ratus sometimes  subsides  after  removal  of  the  testicular  foci,  and  should  not, 
therefore,  be  attacked  at  the  same  time. 

Syphilis  of  the  testicle  during  the  secondary  period  appears  as  a  bilat- 
eral, painless  epididymitis ^  affecting  principally  the  globus  major;  it  is  some- 
times associated  with  hydrocele,  and  disappears  with  antisyphilitic  treatment. 
During  the  tertiary  period  syphilitic  orchitis,  or  sarcocele,  occurs  as  a  diffuse 
overgrowth  of  the  connective  tissue,  causing  atrophy  of  the  tubules,  or  as  a 
nodular,  gummy  degeneration.  The  symptoms  are  a  painless  enlargement, 
the  testicle  being  hard  and  smooth  or  perhaps  nodular;  hydrocele  may  occur, 
and  if  a  gumma  opens  on  the  surface,  it  will  present  the  characteristic  features 
of  a  syphilitic  ulcer.  The  treatment  is  a  suspensory  bandage  and  the  internal 
administration  of  mercury  and  potassium  iodid. 

Hernia,  or  fungus  of  the  testicle,  is  a  protrusion  of  the  interior  of  the 
testicle  or  a  fungus  growth  therefrom,  through  the  skin  of  the  scrotum.  It 
may  be  due  to  a  wound,  malignant  disease,  abscess,  syphilis,  or  tuberculosis. 
The  treatment  is  that  of  the  cause.     In  cases  following  abscess  or  trauma,  the 


564 


GENITAL  ORGANS. 


fungus  may  be  cauterized  and  pressure  applied,  or  amputated  and  the  skin 
sutured  over  the  stump. 

Tumors  of  the  testicle  are  usually  malignant  and  of  a  niixed  t3rpe.  The 
most  common  non-malignant  tumor  is  cystic  fibroma,  or  adenoma,  which  con- 
sists of  fibrous  tissue  with  multiple  serous  cysts;  it  may,  however,  contain 
other  forms  of  tissue,  and  in  the  later  stages  is  apt  to  become  malignant. 
Dermoid,  teratoma,  chondroma,  osteoma,  fibroma,  and  myxoma  also  have  been 
observed.  Of  the  malignant  tumors  sarcoma  is  the  more  frequent;  carcinoma 
is  almost  always  of  the  medullary  variety.  Malignant  disease  may  be  second- 
ary to  benign  tumors  and  is  often  cystic  in  character.  Both  sarcoma  and 
carcinoma  spread  along  the  cord,  invade  the  lumbar  glands,  break  through 
the  scrotum,  and  then  involve  the  inguinal  glands. 

The  diagnosis  of  the  exact  nature  of  a  neoplasm  of  the  testicle  is  seldom 
possible  before  exploratory  incision.  The  clinician  is  usually  content  to 
distinguish  a  neoplasm  from  other  lesions  not  requiring  castration.  The 
following  table,  modified  from  Keyes,  shows  the  main  points  in  the  diagnosis 
of  chronic  diseases  of  the  testicle. 


Histor)' 

Simple 
Chronic  Epi- 
didymitis. 

(ionor  rhea, 
stricture,  or 
hypertrophy 
of  prostate. 

I'nc ommon  .  .  . 

Small  between 
attacks. 

Tuberculosis. 

\  Tuberculosis, 
family  or  per- 
somil. 

Frequent 

1  )()es  not  reach 
any  great  size. 

Syphilis. 

Syphilis    inherit- 
wl  or  acquired. 

Tumor. 
Periiaps  trauma. 

Freijuency 

Frequent 

Rare. 

Size 

Does  not   reach 
any    great    size. 

May  reach  any 
size. 

Tenderness 

Ves 

Ves 

Epididymis 
mKlular.  Tes- 
tis    not     in- 
volved unless 
acute    or    an- 
cient. 

No 

No. 

Shape   

Between       at- 
tacks      testis 
normal,     epi- 
<lidymis  nod- 
dular. 

May  he  slight- 
ly  thickened. 

I'sually    dis- 
tended. 

Testis  evenly  en- 
larged,   .slightly 
nodular    "clam 
shell"    epididy- 
mis. 

Free 

Uninfluenced    .  .  . 

Cninrtuenced   .  . 

Testis  greatly  en 
larged,  no  char- 
acteristic      i  n  - 
volvement  of 
epididymis. 

Cord   

P^nlarged    and 
nodular. 

Tuberculous  .  . 

Congested     or 
tuberculous. 

Free. 

Seminal  vc'^icles.  . 

Uninfluenced. 

Prostate   

Posterior    ure- 
thra inflamed. 

U'ninfluence<l. 

Trine 

Cloudy   

I'nusual 

I'suallv  a(  ute. 

Cloudy,     may 
contain  })acilli. 

Clear 

Nearly  always.  .  . 
Cliroiiit 

Clear. 

Hydnxele 

Often 

I'suallv  chronic 

Unusual. 

()iis<;t 

Chronic. 

HYDROCELE. 


565 


Simple 
Chronic  Epi- 
I       didymitis. 


Tuljerculosis.    1  Syphilis. 


Tumor. 


■Vge 

Adult  life 

Not  often  after 
30- 

Middle  life 

Any  age. 

Origin 

Epididymis  . . . 

Epididymis  . .  . 

Testicle 

Testicle. 

Course 

1 

1  Recurring     a- 
cute    attacks. 

Chronic 

V^ery  chronic  .  . . . 

Usually  rapid. 

Suppuration 

Unusual 

1 

Common 

Rare 

None,but  fungus 
common  in  later 
stages. 

Atrophy  of  testis. 

Rare,   potency 
unimpaired. 

Rare,   potency 
somewhat  im- 
paired. 

Common,  poten- 
cy  somewhat 
impaired. 

Never,    potency 
unimpaired. 

■  1 

/■\/«_     :    —   1 1 

TT 11..      :- 

•c_   _ 

•W7>        _ 

Opposite  testicle. .    Often  involved    Usually    in-        Free. 
I  simultaneously.!    volved  sub- 
sequently. 


Free. 


Malignant  disease  is  the  onJy  condition  likely  to  cause  enlargement  of  the 
iliac,  lumbar,  and  inguinal  glands.  The  aspirator  and  antisyphilitic  reme- 
dies may  be  of  value  in  diagnosis,  also  the  laboratory  tests  for  syphilis  and 
tuberculosis. 

The  treatment  of  tumors  of  the  testicle  is  castration. 

Castration  is  best  performed  through  an  incision  over  the  external 
inguinal  ring.  The  cord  is  isolated,  crushed  with  forceps,  tied  en  masse, 
severed  below  the  ligature,  and  each  vessel  secured  by  an  individual  ligature. 
The  testicle  is  next  pushed  up  through  the  wound,  stripped  from  the  scrotum, 
and  removed,  any  bleeding  points  being  ligated.  This  incision  may  be 
modified  to  include  fistulae  or  diseased  skin.  When  the  operation  is  done 
for  tuberculosis y  the  inguinal  canal  should  be  opened,  and  the  vas  followed 
until  it  may  be  tied  and  cauterized  close  to  the  seminal  vesicle.  Id  malig- 
nant disease  too  the  vessels  should  be  secured  as  high  as  possible,  and  any 
accessible  lymph  glands  removed.  If  the  scrotum  is  invaded,  the  inguinal 
glands  should  be  excised  whether  they  are  enlarged  or  not. 

Neuralgia  of  the  testicle  may  be  caused  by  ungratified  sexual  desire, 
sexual  irregularities,  incipient  inguinal  hernia,  or  by  some  local  or  remote 
disease,  e.g.,  varicocele;  prostatic  engorgement,  and  vesical  or  renal  calculus. 
The  treatment  is  removal  of  the  cause. 

Hydrocele  is  a  collection  of  serous  fluid  in  the  tunica  vaginalis,  or  in 
connection  with  the  cord  or  testicle.  Vaginal  hydrocele  (Fig.  475),  or  a 
collection  of  fluid  in  the  tunica  vaginalis,  may  be  symptomatic  or  idiopathic. 
Symptomatic  hydrocele  (serous  vaginalitis)  is  often  acute,  and  may  be  caused 
by  any  disease  of  the  testicle  or  epididymis.  Idiopathic  hydrocele  is  always 
chronic,  is  most  common  in  the  middle  aged,  and  is  of  unknown  origin. 
The  fluid  is  straw  colored,  and  contains  albumin,  fibrinogen,  inorganic  salts, 
often  cholesterin  crystals,  and  occasionally  fibrous  bodies  containing  phos- 
phates, carbonates,  and  fibrin.     The  tunica  vaginalis,  in  old  cases,  becomes 


566  GENITAL  ORGANS. 

thickened  and  fibrous,  or  even  cartilaginous  or  calcified.     Warty  growths 
may  arise  from  the  tunic  or  the  testicle. 

The  signs  of  a  vaginal  hydrocele  are  a  tense,  pear-shaped,  fluctuating 
swelling,  which  grows  from  below  upward,  and  which  is  usually  situated  in 
front  of  the  testicle,  but  occasionally  lies  behind  or  envelopes  this  organ.  It 
is  fiat  on  percussion,  and  has  no  impulse  on  coughing  unless  it  extends  into 
the  inguinal  canal.  By  placing  a  light  on  one  side  of  the  swelling,  translu- 
cency  will  be  demonstrated,  unless  the  tunica  vaginalis  is  very  thick  or  the 
fluid  bloody  or  mucoid.  The  situation  of  the  testicle  may  be  determined 
by  the  light  test,  and  by  the  peculiar  sensation  experienced  by  the  patient 
when  the  organ  is  squeezed. 

The  treatment  may  be  palliative  or  radical.  Palliative  treatment 
consists  in  tapping,  the  needle  being  entered  at  the  front  and  lower  part  of 
the  swelling.  The  position  of  the  testicle  should  always  be  ascertained 
just  before  the  operation.  Tapping  is  often  curative  in  children,  and  some- 
times in  symptomatic  hydrocele,  but  practically  never  in  the  idiopathic 
variety,  the  sac  refilling  after  the  lapse  of  a  few  months.  Radical  treatment 
may  be  carried  out  by  injections  or  by  an  open  operation.  Of  the  many 
substances  recommended  for  injection  pure  carbolic  acid  is  the  best,  from  lo 
m.  to  a  dram  being  injected  into  the  sac  and  diffused  by  manipulation,  after 
all  the  fluid  has  been  withdrawn.  There  is  some  inflammatory  reaction, 
and  retapping  may  be  necessary  if  there  is  much  effusion.  Open  operation 
possesses  the  advantage  of  allowing  inspection  of  the  testicle,  and  is  always 
indicated  if  the  sac  is  thickened.  The  patient's  permission  to  deal  with  any 
testicular  lesion  which  may  be  present  should  always  be  obtained,  particu- 
larly if  the  hydrocele  has  formed  rapidly.  Open  operation  may  be  by  inci- 
sion, excision,  or  eversion  of  the  sac.  Incision,  or  Volkmann's  operation, 
consists  in  incising  the  sac  and  packing  it  with  iodoform  gauze.  Excision^  or 
von  Bergmann's  operation,  consists  in  removing  the  entire  parietal  layer  of 
the  tunica  vaginalis.  Eversion  of  the  sac  is  the  best  operation.  The  sac  is 
opened  by  a  small  incision,  turned  inside  out,  and  so  held  by  a  few  catgut 
sutures  passed  through  its  edges,  above  the  testicle  and  behind  the  cord. 
The  testicle  is  then  replaced  within  the  scrotum  and  the  wound  closed. 

Congenital  or  reducible  hydrocele  (Fig.  476)  is  one  which  communi- 
cates with  the  peritoneal  cavity  through  an  unclosed  funicular  process, 
hence  is  often  associated  with  hernia.  The  treatment  is  that  of  congenital 
inguinal  hernia.     Injections  should  never  be  used. 

Infantile  hydrocele  (Fig.  477)  is  one  which  distends  the  tunica  vaginalis 
and  the  funicular  process,  the  latter,  however,  not  communicating  with  the 
peritoneal  cavity.  The  treatmetit  is  tapping,  the  walls  of  the  sac  being 
scratched  with  the  end  of  the  needle. 

Bilocular  or  abdominal  hydrocele  (Fig.  478)  is  an  infantile  hydrocele 
in  which  the  upper  end  of  the  funicular  process,  distended  with  fluid,  lies 
between  the  peritoneum  and  the  abdominal  wall.     The  treatment  is  excision. 

Inguinal  hydrocele  is  one  about  a  retained  testicle;  it  is  dealt  with  by 
excision  or  eversion,  and  the  organ  brought  down  into  the  scrotum. 

Encysted  hydrocele  of  the  testis  is  a  cyst,  or  collection  of  cysts,  occur- 
ring in  or  about  the  epididymis  (cysts  of  the  epididymis),  or  rarely  in  the  tes- 
ticle. There  are  two  varieties:  (i)  Small  cysts  occur  late  in  life,  rarely 
contain  spermatozoa,  and  cause  little  or  no  disturbance;  they  are  said  to  be 
due  to  senile  changes  causing  a  dilatation  of  the  tubules.     (2)  Large  cysts 


HEMATOCELE. 


567 


occur  before  midcUe  age  and  contain  a  milky  fluid  flUed  with  spermatozoa 
{spermatocele) ;  they  are  due  to  dilatation  of  the  vasa  eflferentia,  or  to  cystic 
changes  in  persisting  fetal  remains,  being  in  this  respect  similar  to  parovarian 
cysts.     The  treatment  is  injection  or  excision. 

Diffuse  hydrocele  of  the  cord  is  a  smooth  boggy  enlargement  of  the 
cord,  which  may  be  due  to  edema,  spermatocele,  multilocular  encysted 
hydrocele  of  the  cord,  lymphangioma,  cysts  of  fetal  remains,  or  echinococcus 
cysts.     The  treatment y  excepting  edema,  is  excision. 

Encysted  hydrocele  of  the  cord  (Fig.  479)  is  due  to  distention  of  the 
funicular  process  which  has  been  closed  for  a  variable  distance  above  and 
below,  or  rarely  to  an  accumulation  of  fluid  in  an  old  hernial  sac  which  has 


Fig.  475.  Fig.   476.  Fig.  477.  Fig.  478.  Fig.  479. 

Vaginal  Congenital  Infantile  Bilcxrular  Encysted  hydro- 

hydrocele.  hydrocele.  hydrocele.  hydrocele.  cele  of  cord. 

Diagram  of  various  forms  of  hydrocele.     H,  hydrocele;  T,  testicle;  E,  epididymis;  F,  funic- 
ular process;  C,  cord. 


been  shut  off  above.  In  the  female  the  canal  of  Nuck  may  be  likewise  af- 
fected, constituting  a  hydrocele  of  the  round  ligament.  The  condition  may 
be  mistaken  for  hernia,  owing  to  the  fact  that  it  may  enter  the  inguinal  canal, 
but  if  the  cord  is  drawn  downwards,  the  cyst  is  fixed,  and  presents  the  fea- 
tures of  a  hydrocele  elsewhere.     The  treatment  is  injection  or,  better,  excision. 

Chylocele,  or  chylous  hydrocele,  is  a  collection  of  lymph  in  the  tunica 
vaginalis,  due  to  the  rupture  of  dilated  lymph  vessels,  and  often  associated 
with  filariasis.  The  treatment  is  that  of  hematocele,  with  possibly  ligation 
or  excision  of  the  dilated  lymph  vessels. 

Hematocele  is  a  collection  of  blood  in  or  about  the  testicle  or  cord.  It 
follows  injury  or  operations,  and  occasionally  occurs  spontaneously,  e.g.,  in 
malignant  disease  and  hemophilia.  According  to  its  situation  it  may  be  a 
vaginal  hematocele,  i.e.,  in  the  tunica  vaginalis,  an  encysted  or  diffuse  hemat- 
ocele of  the  cord,  or  an  encysted  hematocele  of  the  testicle.  The  signs  are  those 
of  hydrocele,  except  that  the  swelling  is  doughy  or  solid  and  not  translucent 
and  there  is  apt  to  be  ecchymosis  of  the  skin.  The  treatment  is  rest  and  the 
application  of  cold,  or  in  the  presence  of  continued  bleeding  incision  and 
ligation  or  packing.  In  old  cases  in  which  the  blood  has  not  been  absorbed, 
incision  and  evacuation  may  be  indicated. 


568  GENITAL  ORGANS. 

Rupture  of  the  vas  deferens,  as  the  result  of  operations  or  injuries, 
should  be  treated  by  anastomosis  in  a  manner  similar  to  anastomosis  of  the 

ureter. 

Varicocele  is  a  condition  in  which  the  veins  of  the  pampiniform  plexus 
are  dilated,  thickened,  and  tortuous.     It  is  very  common,  and  is  most  fre- 
quent in  young  men.     It  is  almost  always  on  the  left  side,  because  the  left 
testicle  hangs  lower,  because  the  left  spermatic  vein  opens  into  the  renal 
vein  at  right  angles  and  has  no  valves,  while  that  on  the  right  has  valves  and 
opens  obliquely  into  the  vena  cava,  and  because  the  left  vein  lies  behind  the 
sigmoid  flexure  and  is  apt  to  be  compressed  when  the  latter  is  distended. 
The  cause  is  said  to  be  unrelieved  sexual  desire.     It  may  be  due  also  to  the 
pressure  of  a  truss  or  abdominal  tumors,  and  is  then  usually  acute,  and 
occurs  on  either  side  at  any  time  of  life.     The  condition  is  readily  recognized, 
the  veins  feeling  like  a  ^'bag  of  earth  worms;"  it  has  a  slight  impulse  on 
coughing,  disappears  on  lying  down,  and  refills  from  below  upwards  if  pressure 
is  made  over  the  external  ring  and  the  patient  is  asked  to  stand.     The  symp- 
toms, when  they  exist,  are  neuralgia  and  hypochondria.     The  treatment 
is  the  use  of  a  suspensory  bandage,  and  the  application  of  cold  water  night 
and  morning.     There  is  no  danger  of  impotence.     Operation  is  indicated 
when  the  condition  is  the  source  of  constant  anxiety.    An  incision  is  made 
over  the  external  inguinal  ring,  the  testicle  pulled  up  into  the  wound,  and  the 
veins  separated  from  the  vas  and  its  vessels  and  excised,  the  cremaster  muscle 
being  shortened  if  the  cord  is  very  long.     The  wound  is  closed  without  drain- 
age.    If  the  inguinal  canal  has  been  dilated  by  the  varicocele,  it  should  be 
ol)literated  as  in  the  operation  for  hernia,  since  removal  of  the  veins  leave 
an    open    canal.      The   subcutaneous   operation   and   injections   are   not 
recommended. 

Acute  seminal  vesiculitis  is  caused  by  posterior  urethritis,  usually 
f^onorrheal  in  nature.  The  symptoms  are  pain  in  the  perineum,  rectum, 
hip,  or  bark,  increased  by  urination  and  defecation;  frequent  micturition: 
and  sometimes  priapism  and  painful,  bloody  emissions.  There  is  fever,  and 
the  distended,  tender  vesicle  can  be  felt  by  rectal  examination,  above  and 
to  the  outer  side  of  the  prostate.  The  treatment  is  that  of  acute  prostatitis. 
If  suppuration  occurs,  the  abscess  should  be  opened  through  the  perineum. 

Chronic  seminal  vesiculitis  follows  the  acute  form,  when  it  constitutes 
one  of  the  causes  of  gleet,  or  it  is  due  to  sexual  irregularities  or  prostatic 
disease.  The  symptoms  are  those  of  the  acute  form,  but  much  milder  in 
degree.  There  is  sexual  feebleness  but  increased  desire,  and  usually  marked 
depression  of  the  spirits.  Recurring  epididymitis  is  common.  We  have  seen 
several  cases  in  which,  because  of  backache  and  hematuria,  the  diagnosis  of 
renal  cah  ulus  had  been  made.  The  treatment  is  a  hot  rectal  douche  daily, 
and  massage  of  the  vesicles  once  a  week.  Ma.ssage  is  performed  while  the 
bladder  is  full  and  the  patient  bends  over  a  chair.  A  finger  is  inserted  into 
the  rectum  and  the  vesicles  gently  stripped  from  above  downwards.  The 
accompanying  neurasthenia  and  posterior  urethritis  also  should  receive  atten- 
tion. In  inveterate  cases  excision  of  the  vesicles,  by  one  of  the  routes  men- 
tioned below,  should  be  considered. 

Tuberculosis  of  the  seminal  vesicles  may  be  primary,  or  secondar}' 
to  the  same  disease  in  the  prostate  or  epididymis,  the  symptoms  of  which 
usually  l)ring  the  patient  to  the  surgeon.  On  rectal  examination  the  vesicles 
are  found  tender  and  dilated,  or  even  nodular.     The  bacilli  may  occasionally 


HYPERTROPHY   OF   THE   PROSTATE.  569 

I)c  found  in  the  fluid  expressed  from  the  vesicles  by  massage.  The  Ireat- 
ment  includes  the  general  measures  suitable  for  tuberculosis  elsewhere, 
with  the  removal  of  more  accessible  foci,  e.g.,  in  the  epididymis.  If  the 
disease  continues  to  progress,  the  vesicles  may  be  removed  through  the  per- 
ineum, by  the  transsacral  route  as  in  Kraske's  operation  on  the  rectum,  or 
!)y  a  suprapubic  or  inguinal  incision,  through  which  the  vesicles  are  reached 
extraperitoneally. 

PROSTATE  GLAND. 

Acute  prostatitis  is  caused  by  posterior  urethritis,  usually  gonorrheal 
in  nature,  but  occasionally  following  the  passage  of  instruments  or  calculi. 
The  symptoms  are  frequent  micturition;  prostatic  shreds  or  pus  in  the  urine; 
pain,  tenderness,  heat,  and  weight  in  the  perineum,  increased  by  defecation 
and  urination;  chills  and  fever;  and  sometimes  retention  of  urine.  On 
rectal  examination  the  prostate  feels  hot,  swollen,  tender,  and,  if  suppuration 
has  occurred,  boggy  or  fluctuating.  A  prostatic  abscess  usually  opens  into  the 
urethra,  sometimes  into  the  rectum  or  through  the  perineum,  and  rarely 
into  the  bladder.  The  treatment  consists  of  laxatives,  hot  rectal  douches^ 
opium  suppositories,  and  poultices  to  the  perineum.  If  suppuration  occurs, 
the  abscess  mayjsometimes  break  into  the  urethra  on  the  passage  of  a  catheter; 
if  this  does  not  occur,  or  if  the  abscess  is  large,  it  should  be  opened  by  a 
median  perineal  incision. 

Chronic  prostatitis  may  follow  the  acute  form,  but  is  usually  chronic 
from  the  beginning.  The  symptoms  are  enlargement  and  tenderness  of  the 
prostate,  pain  on  urination  and  defecation,  and  the  discharge  from  the  urethra 
of  a  thin,  milky  fluid  containing  prostatic  casts  (prostatorrhea)^  especially 
after  defecation.  Prostatorrhea  may  occur  also  without  prostatitis,  and 
then  has  the  same  causes  and  the  same  treatment  as  urethrorrhea.  The 
treatment  is  tonics,  gentle  massage  of  the  prostate,  the  passage  of  a  large 
sound  twice  a  week,  and  instillations  of  a  few  drops  of  a  5  per  cent,  solution 
of  silver  nitrate  into  the  posterior  urethra.  Hot  rectal  doudies,  suppositories 
of  ichthyol,  and  counterirritation  to  the  perineum  also  have  been  recom- 
mended.    Should  an  abscess  form,  it  is  treated  as  described  above. 

Tuberculosis  of  the  prostate  is  usually  secondary  to  that  of  the  seminal 
vesicles  and  epididymis.  The  prostate  becomes  nodular,  and  later  suppura- 
tion ensues.  The  symptoms  are  painful  and  frequent  micturition,  hema- 
turia, pyuria,  and  pain  in  the  back  and  perineum.  Tubercle  bacilli  may  be 
found  in  the  urine.  The  treatment  is  that  of  tuberculosis  elsewhere.  In 
suitable  cases  the  prostate  may  be  removed  through  the  perineum,  or  abscesses 
opened,  curetted,  and  packed  with  iodoform  gauze. 

Prostatic  calculi  are  caused  by  the  deposition  of  phosphates  or  in- 
spissated prostatic  secretion.  They  may  cause  prostatitis,  abscess  of  the 
prostate,  or  retention  of  urine.  Occasionally  they  may  be  felt  with  a 
urethral  sound  or  by  rectal  examination.  When  producing  trouble,  they 
should  be  removed  by  a  median  perineal  section. 

Hjrpertrophy  of  tiie  prostrate  is  a  senile  enlargement  of  the  gland, 
the  cause  of  which  is  not  known.  It  is  very  rare  before  fifty,  but  is  said 
to  be  present  in  one-third  of  all  men  who  have  reached  the  sixtieth  year, 
producing  symptoms,  however,  in  only  one-half  of  these.  All  the  elements 
of  the  gland  hypertrophy,  but,  according  to  the  tissue  which  predominates. 


570 


GENITAL  ORGANS. 


the  growth  may  be  hard  and  fibrous,  or  soft  and  adenomatous^  As  a 
rule  die  changes  are  more  marked  in  certain  portions  of  the  gland,  so  that  the 
specimen  consists  of  a  number  of  encapsulated  tumors,  which  may  be 
fibroadenomatous  or  adenofibromataus,  depending  upon  which  tissue  is  in  ex- 
cess. In  about  20  per  cent,  of  those  removed  at  operation  carcinomatous 
elements  are  found.  Prostatic  h)rpertrophy  lengthens  the  prostatic  urethn, 
and  sometimes  gives  it  a  tortuous  course,  owing  to  the  irregular  enlaigemeot 
of  different  portions  of  the  gland.  The  outlet  of  the  bladder  is  always 
elevated,  thus  creating  a  pouch  behind  the  prostate  and  preventing  complete 
evacuation  of  the  bladder  (Fig.  480).     In  some  cases  the  commissure  between 

the  lateral  lobes  may  constitute  a  bar 
across  the  urethra,  or  a  pedunculated 
growth,  the  so-called  third  lobe,  which 
obstructs  the  internal  urinary  meatus 
like  a  ball-valve.  The  anterior  com- 
missure is  rarely  involved. 

The  symptoms  are  frequent  uri- 
nation, especially  at  night,  and  diffi- 
culty in  urination.  The  stream  is 
hard  to  start,  has  little  force,  and,  is 
terminated  by  dribbling.  The  diffi- 
culty is  increased  rather  than  lessened 
by  straining,  which  may  be  so  great  as 
to  cause  hematuria,  hernia,  or  prolapse 
of  the  anus.  There  may  be  pain  and 
a  sense  of  fulness  in  the  perineum, 
and  priapism  sometimes  occurs  owing 
to  the  congestion  about  the  neck  of 
the  bladder.  These  symptoms  are 
insidious  in  onset  and  gradually  grow 
worse,  the  residual  urine  progressively  increasing  in  amount.  At  this  period 
indulgence  in  alcohol  or  catching  cold  is  apt  to  increase  the  congestion  and 
lead  to  retention  of  urine,  which,  unless  relieved  by  the  catheter,  results  in 
overflow  (the  incontinence  of  retention).  The  patient  may  have  several  of 
these  attacks,  until  finally  the  bladder  remains  full  all  the  time,  the  urine  con- 
stantly dribbling  away.  The  bladder  is  now  dilated,  atonic,  and  fasciculated, 
and  the  back  pressure  of  the  urine  leads  to  dilatation  of  the  ureters  and  pelves 
of  the  kidneys.  Juther  spontaneously  or  as  the  result  of  instrumentation 
the  bladder  and  prostate  become  inflamed,  and  the  urine  ammoniacal  and 
purulent,  the  patient  finally  dying  from  an  ascending  infection  of  the  kidneys. 
Phosphatic  vesical  calculi  may  form,  and  epididymitis  may  occur,  particu- 
larly after  the  passage  of  a  catheter.  The  diagnosis  is  confirmed  by  rectal 
examination,  the  finger  readily  detecting  the  enlarged  lateral  lobes  of  the 
gland.  In  about  20  per  cent  of  the  cases  rectal  examination  is  fallacious, 
because  the  chief  enlargement  is  forwards  and  not  backwards.  In  these 
cases  the  obstruction  at  the  neck  of  the  bladder  will  be  appreciated  by 
the  passage  of  a  catheter,  which  may  be  used  to  ascertain  also  the  length 
of  the  urethra  and  the  amount  of  residual  urine,  i.e.,  the  quantity  of  urine 
which  may  be  drawn  off  immediately  after  the  patient  has  passed  water. 
The  bladder  should  always  be  searched  for  stones.  In  cases  in  which 
it  can  be  used,  the  cystoscopc  may  be  employed  to  outline  accurately  the 


Fig.  480.- -Hypertrophy  of  the  pros- 
tate. Note  retroprostatic  pouch  and 
residual  urine,  the  marked  anterior  curve 
and  increased  length  of  the  prostatic 
urethra. 


PROSTATOTOMY.  5  7 1 

nature  of  the  obstruction.  '*When  there  are  symptoms  of  prostatic  re- 
tention without  any  hypertrophy  of  the  prostate,  the  essential  lesion  is  a 
contracture  of  the  neck  ofUie  bladder^*  (Keyes).  This  is  usually  due  to  posterior 
urethritis  and  is  curable  by  perineal  cystotomy. 

The  treatment  in  the  early  stages  consists  in  attention  to  the  general 
health,  the  drinking  of  plenty  of  water,  and  the  avoidance  of  cold,  wet, 
alcohol,  and  overeating.  When  the  residual  urine  amounts  to  two  oimces, 
the  bladder  should  be  catheterized  every  evening  before  retiring;  each  addi- 
tional two  ounces  of  residual  urine  will  require  an  additional  catheterization, 
the  intervals  always  being  regular.  This  the  patient  must  be  taught  to  do 
in  a  surgically  clean  manner,  laying  emphasis  upon  the  ease  with  which 
infection  occurs,  and  the  great  dangers  which  follow.  Hexamethylenamine, 
grains  5  three  times  a  day,  or  other  urinary  antiseptics  should  be  admin- 
istered, and  the  bladder  irrigated  with  hot  boric  acid  solution  once  daily. 
If  the  ordinary  soft  catheter  cannot  be  passed,  and  this  applies  equally  in 
cases  of  acute  retention,  a  soft  coud6  or  bicoud^  (Figs.  463  and  464)  catheter 


Fig.  481. — ^Prostatic  catheter. 

may  mount  the  obstruction  and  enter  the  bladder;  if  these  fail,  it  will  be 
necessary  to  use  a  silver  prostatic  catheter  (Fig.  481),  which,  owing  to  its 
greater  length  and  larger  curve,  may  reach  the  bladder  when  pressed  well 
down  between  the  thighs.  If  catheterization  is  difficult,  if  there  is  marked 
irritability  of  the  bladder,  if  the  residual  urine  steadily  increases  in  quan- 
tity, or  if  there  is  stone  or  persistent  cystitis,  catheterization  should  be 
abandoned  and  operation  advised.  Seriously  damaged  kidneys  or  the  pres- 
ence of  septicemia  is  an  indication  that  operation  has  been  postponed  too 
long.  Operations  designed  to  cause  atrophy  of  the  gland  by  indirect  means, 
such  as  ligation  ofUie  internal  iliac  arteries,  castratiany  and  vasectomy ,  are,  at 
the  present  time,  practically  abandoned  in  favor  of  incision  or  excision  of 
the  prostate. 

Prostatotomy,  or  incision  of  the  prostate,  may  be  performed  with  the 
knife  or  the  cautery,  either  through  the  perineum,  or  after  the  bladder  has 
been  opened  above  the  pubes,  the  situation  of  the  cut  varying  according  to 
which  lobe  is  chiefly  enlarged;  but  these  operations  are  seldom  employed, 
and  the  only  form  of  prostatotomy  claiming  serious  attention  at  the  present 
time  is  that  devised  by  Botdni.  Bottini's  operation  consists  in  incising 
the  prostatic  obstruction  with  a  galvano-cautery  introduced  through  the 
urethra.  The  instrument  is  shaped  like  a  lithotrite,  the  male  blade  of  which 
is  a  galvano-cautery  knife,  and  die  female  blade  of  which  is  provided  with  a 
double  channel,  through  which  cold  water  runs  during  the  operation.  Either 
general  or  local  anesthesia  may  be  employed.     The  bladder  is  first  irrigated 


572  GENITAL  ORGANS. 

and  then  filled  with  air  or  water.  The  amount  of  electricity  required  u< 
heat  the  cautery  to  a  bright  glow  is  ascertained,  and  after  the  Made  ]u« 
cooled  the  instrument  is  introduced  into  the  bladder,  the  beak  turned  down- 
ward and  pulled  against  the  prostate,  the  cooling  apparatus  set  in  motioo. 
the  electricity  turned  on,  the  blade  extruded  and  then  returned  by  turaing 
the  screw  in  the  handle,  the  electricity  turned  off,  and  the  instrument  widi- 
drawn.  A  similar  incision  may  be  made  also  in  the  sides  of  the  urethn 
Freudenberg  (1905),  the  chief  advocate  of  Bottini's  operation,  reports  152 
cases  with  7.2  per  cent,  mortality,  84.9  percent,  good  results,  and  7.9  percent 
negative  results.  He  advises  the  operation  in  the  very  old  and  debilitated 
and  in  the  young,  as  it  preserves  the  sexual  fimction,  and  says  it  is  prefer- 
able in  the  small  prostate  and  where  there  is  a  bar.  It  is  contraindicated 
in  large  prostates,  in  a  sessile  or  pedunculated  tumor,  and  in  cases  in  wliidi 
there  is  fever,  or  ammoniacal  cystitis,  because  of  the  danger  of  incrustadoo 
of  the  eschar.  If  the  cut  is  made  too  deep,  there  will  be  infiltration  of  urine, 
and  if  too  shallow,  the  symptoms  will  soon  recur.  The  operation  is  regarded 
as  blind  and  dangerous  by  most  surgeons,  who  think  prostatectomy,  as 
complete  as  possible,  to  be  the  operation  of  choice. 

Prostatectomy,  or  removal  of  the  prostate,  may  be  complete  or  partial, 
and  effected  either  through  the  perineum  (intra-  or  extravesically)  or  by  the 
suprapubic  route.  The  mortality  is  from  10  to  20  per  cent.,  but  the  yzsi 
majority  of  those  who  recover  are  cured.  Among  the  sequelae  are  impo- 
tence, incontinence  of  urine,  epididymitis,  urinary  fistula,  rectal  fistula,  and 
stricture. 

Suprapubic  prostatectomy  is  performed  by  opening  the  bladder  as  in 
suprapubic  cystotomy,  tearing  through  the  mucous  membrane  over  the 
prostate  with  the  finger-nail  or  blunt  scissors,  and  enucleating  the  gland  by 
working  between  the  true  and  false  prostatic  capsules,  while  the  prostate  L^ 
pushed  upwards  by  a  finger  in  the  rectum.  If  the  lateral  lobes  are  removed 
separately,  the  ejaculator>'  ducts  may  occasionally  be  preser\'ed.  The 
hemorrhage  is  controlled  by  irrigation  with  hot  water,  and  the  bladder 
drained  as  after  suprapubic  cystotomy.  The  operation  is  easy,  quick, 
requires  no  special  instruments,  permits  full  exploration  of  the  bladder,  does 
not  injure  the  rectum,  is  rarely  followed  by  a  permanent  fistula,  and  does 
not  always  destroy  the  sexual  function. 

Perineal  prostatectomy  may  be  performed  through  a  cur\'ed  transverse 
incision,  convexity  forward,  reaching  from  one  ischial  tuberosity  to  the  other, 
or  one  of  its  modifications,  but  the  easiest  and  simplest  is  the  median  incision 
as  in  perineal  cystotomy.  The  membranous  urethra  is  opened,  and  the 
prostate  pulled  downwards  by  a  sound  passed  into  the  bladder,  or  by  special 
tractors  devised  for  this  purpose,  and  enucleated  after  incising  its  fibrous 
sheath.  The  bladder  is  (irained  by  a  tube  emerging  through  the  perineum, 
and  the  wound  packed  with  gauze.  The  drain  may  be  removed  in  a  few 
days,  the  after  treatment  being  the  same  as  that  of  perineal  cystotomy. 
Young  incises  the  capsule  outside  of  the  seminal  ducts,  in  order  to  presen'c 
these  structures,  and  removes  the  rest  of  the  gland.  Dittel,  Rydygier,  and 
others  make  a  transverse  perineal  incision,  and  excise  V-shaped  portions  of 
the  lateral  lobes  without  opening  the  urethra  or  bladder  {exiravesical  prostatec- 
tomy). The  perineal  operation  is  more  difficult  than  suprapubic  prostatec- 
tomy, and  has  the  special  danger  of  injury  to  the  rectum. 

If  the  symptoms  are  severe,  and  prostatectomy  cannot  be  practiced  be- 


r 


EXAMINATION    OF   THE    FEMALE    GENERATIVE    ORGANS. 


573 


cause  of  the  poor  general  condition  of  the  patient,  the  only  operation  which 
promises  relief  is  cystotomy,  either  suprapubic  or  perineal,  for  the  purpose  of 
drainage. 

Carcinoma  of  the  prostate,  as  previously  mentioned,  is  found  in 
about  20  per  cent,  of  the  glands  removed  for  supposed  benign  hypertrophy. 
Sarcoma  is  rare,  and  may  occur  in  eady  life.  The  sympioms  of  carcinoma 
are  much  like  those  of  hypertrophy  of  the  prostate,  but  the  paiti  is  greater, 
the  growth  more  rapid,  hematuria  more  common,  and  the  gland  stony 
hard  and  nodular.  In  the  later  stages  the  tumor  breaks  through  the  capsule, 
invades  the  bladder,  urethra,  and  rectum,  causes  metastases  in  the  pelvic 
and  inguinal  lymphatic  glands,  and  induces  cachexia.  The  treatment,  if 
the  case  is  seen  early  enough,  is  remoi^al  of  the  entire  prostate,  the  seminal 
vesicles,  and  the  anterior  two-thirds  of  the  trigone,  through  the  perineum, 
the  bladder  being  anastomosed  with  the  membranous  urethra.  Young  has 
performed  this  op^eration  six  times,  one  patient  being  well  at  the  end  of 
five  years.  WTien  excision  is  out  of  the  question,  some  relief  may  be  ob- 
tained by  suprapubic  cystotomy. 


FEMALE  GENITAL  ORGANS. 

Examination  of  the  female  generative  organs  is  usually  made  with 
the  patient  in  the  dorsal  position,  the  knees  being  drawn  up  and  the  thighs 
abducted,  and  the  bladder  and  rectum  having  previously  been  emptied. 
The  external  genitals  should  hrst  lie  inspected.  By  separating  the  labia  the 
urethra,  the  hymen  or  its  remains,  and  the  perineum  may  be  seen,  and  if 
the  patient  strains,  a  cystocele  or  rectoccle  may  be  detected.  For  inspect- 
ing the  inner  parts  a  speculum  is  necessary,  the  most  serviceable  of  which 
is  one  of  the  bivalve  variety  (Fig.  482).     The  instrument  is  warmed  and 


Flc.  48  a* — GocKtcirs  sj>etulum, 

lubricated,  and  introduced  with  the  blades  closed  and  facing  laterally;  it  is 
then  turned  so  that  the  edges  are  lateral,  and  the  blades  separated.  The 
Sims  speculum  is  used  with  the  patient  in  \he  Sims  positimi  (Fig>  483),  i.e., 
lying  upon  the  left  side,  with  the  left  arm  behind  the  back,  the  right  shoulder 
near  the  table,  and  the  hips  (lexed,  the  right  more  than  the  left.  The  specu- 
lum is  introduced,  then  turned  transversely,  so  as  to  retract  the  posterior 
vaginal  wall,  the  right  buttock  being  lifted  with  (Jie  disengaged  hand.  The 
cylindrical  speculum  of  Fergusson,  consisting  of  glass  or  hard  rubber,  and 
having  tlie  inner  extremity  bevel erl,  is  seldom  employed.  By  vaginal  palpa- 
tion may  be  determined  the  condition  of  tlie  perineum,  whether  or  not  the 
vulvovaginal  glands  are  enlargeib  the  presence  of  spasm  and  tenderness,  the 


574 


GENITAL  ORGANS. 


amount  of  heat  and  moisture,  the  condition  of  the  vaginal  walls,  the  presence 
or  absence  of  tumors  or  masses,  and  the  size,  shape,  position,  mobflity,  and 
consistency  of  the  cervix  and  uterus.  Either  the  index,  or  the  index  and 
middle  fingers,  according  to  whether  the  patient  is  single  or  married,  are 
lubricated  and  passed  into  the  vagina  over  the  perineum;  by  placing  the 
other  hand  over  the  lower  abdomen  (bimanual  examination)  the  uterus,  tubes, 
and  ovaries  may  be  palpated  between  the  fingers  and  their  condition  deter- 


Fig.  483. — Sims'  position.     (Montgomery'.) 

mined.  The  right  side  of  the  pelvis  is  best  examined  with  the  right  hand 
internally,  the  left  with  the  left  hand  internally.  In  virgins,  instead  of  a 
vaginal  examination,  and  often  in  others  as  supplemental  to  a  vaginal  exami- 
nation, it  is  desirable  to  pass  a  finger  into  the  rectum  and  examine  the  parts 
bimanually.  This  examination  is  facilitated,  if  at  the  same  time  the  cer\ix 
is  drawn  downward  by  volsella  forceps  (Fig.  484).  Before  or  after  the 
internal  examination  the  abdomen  should  always  be  examined  externally 


Fn;.  484.-  -\'()lsc*llii  foneps. 

by  inspection,  palpati(m,  and  percussion,  and  sometimes  by  auscultation. 
\\Tien  these  examinations  are  unsatisfactory,  it  may  be  necessary  to  anesthe- 
tize the  patient  in  order  to  secure  complete  relaxation.  The  uterine  sound 
(Fig.  485)  may  be  used  to  determine  the  length,  permeability,  and  direction 
of  the  uterine  canal,  the  presence  of  growths,  the  condition  of  the  endome- 
trium, and  occasionally  to  replace  a  displaced  uterus.  It  is  seldom  employed, 
however,  because  of  the  dangers  of  sepsis,  perforation,  or  abortion,  and  it  i.< 


THE   VULVA.  575 

absolutely  contraindicated  in  acute  inflammatory  troubles,  in  cancer,  during 
the  menstrual  period,  and  in  cases  in  which  there  is  the  slightest  suspicion 
of  pregnancy.  The  vagina  and  the  sound  should  be  thoroughly  stenlized, 
and  the  instrument,  properly  curved,  introduced  under  the  guidance  of  the 
eye,  the  position  of  the  uterus  having  been  previously  determined.  The 
interior  of  the  uterus  may  be  explored  also  with  the  finger,  after  the  cervix 
has  been  dilated,  or  a  portion  of  the  endometrium  may  be  removed  with  a 
curette  for  microscopic  examination. 


Fig.  485. — Sims'  uterine  sound. 

THE  VULVA. 


Any  or  all  parts  of  the  vulva  may  be  absent,  rudimentary,  or  hyper- 
trophied.  Enormous  hypertrophy  of  the  labia  minora  is  seen  in  the  Hottentot 
apron.  Epispadias  and  hypospadias  also  occur.  True  hermaphrodism 
(presence  of  both  ovaries  and  testicles)  does  not  occur,  but  pseudoher- 
maphrodism,  in  which  the  external  genitals  resemble  those  of  both  sexes, 
is  sometimes  seen. 

The  vulva  is  subject  to  the  same  diseases  and  injuries  as  other  parts 
covered  by  skin  and  mucous  membrane,  and  only  a  few  of  these  need  special 
description. 

Vulvitis  is  usually  gonorrheal  in  origin,  but  may  be  caused  by  irritating 
discharges,  uncleanliness,  diabetic  urine,  parasites,  infectious  fevers,  trau- 
matism, caustics,  pregnancy,  and  excessive  masturbation  or  coitus.  Follic- 
ular vulvitis  is  acne.  Cellulitis  of  the  vulva  is  called  phlegmonous  vulvitis. 
During  the  acute  exanthemata  or  other  debilitating  diseases  the  parts  may 
become  gangrenous  {gangrenous  vulvitis y  noma  pudendi),  or  covered  with 
a  false  membrane  {croupous  vulvitis)]  true  diphtheria  also  occurs.  The 
symptoms  are  localized  pain  and  burning,  more  marked  on  walking  or 
during  micturition.  The  parts  are  swollen,  reddened,  and  covered  with  a 
mucopurulent  discharge.  The  treatment  is  removal  of  the  cause,  and 
cleanliness.  Rest  in  bed,  sitz  baths,  and  local  applications  of  the  medica- 
ments recommended  for  injection  in  gonorrhea  are  indicated.  In  the 
severer  forms  tonics  and  stimulants  are  needed,  while  cellulitis  will  call 
for  incision,  and  gangrene  for  excision  and  cauterization. 

Abscess  of  the  vulvovaginal  or  Bartholin's  gland  is  caused  by 
vulvitis,  and  presents  the  usual  signs  of  an  abscess.  The  treatment  is  incision, 
or  excision  with  partial  closure  of  the  wound  and  drainage.  A  cyst  of  the 
vulvovaginal  gland  caused  by  occlusion  of  its  duct  likewise  is  treated  by 
excision. 

Pruritus  vulvae,  or  intense  itching  of  the  vulva,  is  a  symptom  rather 
than  a  disease,  and  may  be  caused  by  uncleanliness,  local  skin  diseases, 
irritating  discharges,  diabetic  urine,  parasites,  masturbation,  rectal  diseases, 
digestive  disorders,  gout  and  rheumatism,  pregnancy,  the  menopause,  dis- 
eases of  the  internal  generative  organs,  and  kraurosis  vulvae.     The  itching 


576  GENITAL  ORGANS. 

is  worse  after  exercise  and  at  night,  and  leads  to  excoriation  and  troph'u 
changes  in  the  skin;  melancholia  sometimes  follows.  The  treatment  is  re- 
moval of  the  cause,  attention  to  the  general  health,  and  local  cleanliness. 
The  itching  may  be  relieved  by  lead-water  and  laudanum,  carbolic  solution 
(5  per  cent.),  cocain  (5  per  cent.),  or  by  painting  the  parts  with  silver  nitrate 
(10  grains  to  the  ounce).  Excision  of  the  affected  skin,  or  resection  of  the 
nerves  supplying  it  with  sensation  has  been  performed  in  inveterate  cases. 

Kraurosis  vulvae  is  an  atrophic  change  in  the  vulvar  skin  leading  to 
shrinking  and  thickening  of  the  parts,  which  become  white  and  smooth. 
The  cause  is  unknown,  and  the  symptoms  are  usually  pruritus  and  some- 
times intense  hyperesthesia.     The  treatment  is  that  of  pruritus. 

Urethral  caruncle  is  a  dark-red  tumor  growing  from  the  mucous  mem- 
brane in  or  near  the  urethral  meatus.  The  growth  is  a  papilloma,  angioma. 
or  adenoma,  and  is  exceedingly  sensitive,  causing  dysuria,  pain  on  walking 
or  intercourse,  and  marked  nervous  symptoms.     The  ireatmeni  is  excision. 


LTHE  VAGINA. 

The  vagina  may  be  double  owing  to  failure  of  union  of  the  lower  portions 
of  Miiller*s  ducts,  lateral  if  one  of  the  ducts  fails  to  develop,  or  absent  or  ntdi- 
mentary,  in  whole  or  in  part  (see  also  atresia  ani  vaginalis,  p.  516). 

Atresia  of  the  vagina  (complete  closure)  occurs  at  the  hymen  (atresia 
hymenalis)  or  at  a  higher  level  {atresia  vaginalis).  It  may  be  congenital,  or 
be  caused  by  cicatricial  contraction  the  result  of  traumatism,  operations. 
caustics,  or  the  severer  forms  of  vaginitis.  The  symptoms  are  caused  bv 
retention  of  menstrual  fluid.  At  the  time  of  the  periods  there  are  all  the 
symptoms  of  menstruation  except  the  appearance  of  blood.  The  vagina 
becomes  (iistendecl  (hematocolpos),  and  after  a  time  the  uterus  {hematometra), 
and  then  the  tubes  {hematosalpinx).  When  the  distention  becomes  extreme, 
the  blood  may  burst  through  any  portion  of  the  genital  tract,  or  through  the 
atresia,  an  accident  which  is  often  followed  by  infection  and  death. 

The  treatment  is  puncture  or  incision  of  the  obstruction,  in  order  10 
allow  the  blood,  which  may  be  as  thick  as  tar,  to  escape  slowly.  The  opening 
is  then  enlarged,  the  cavity  irrigated  with  a  mild  antiseptic  solution,  and  the 
opening  maintained  by  gauze,  or  by  a  rubber  or  glass  plug.  If  the  tubes 
are  distended,  they  are  probably  adherent,  hence  collapse  of  the  uterus  and 
vagina  often  results  in  their  rupture  and  peritonitis;  the  condition  of  the 
tubes  should  therefore  be  investigated  before  operating  on  the  atresia,  anH 
if  distended,  they  should  I'lrst  be  removed  by  abdominal  section.  In  ahsenve 
or  obliteration  of  the  vagina  efforts  have  been  made  to  con.struct  a  canal  by 
llaps  from  the  lal)ia,  by  skin  grafting,  and  by  the  substitution  of  a  portion  of 
the  rectum. 

Stenosis  of  the  vagina  (incomplete  closure)  results  from  the  same 
i  auses  as  atresia,  and  may  interfere  with  intercourse,  drainage  of  the  vagina, 
and  labor.  The  treatment  is  gradual  dilatation  with  bougies,  or  a  plasiii 
operation. 

Injuries  of  the  vagina  may  be  caused  in  a  great  variety  of  ways,  e.g.. 
by  coitus,  !)ullets,  falls  astride  some  sharp  objei  t,an<l  rough  instrumentation. 
They  are  treated  on  general  surgical  princi|)les.  If  the  peritoneal  cavity  has 
been  j)enet rated  by  .some  pointed  object,  the  abdomen  should  be  openeii  in 


LACERATION    OF    THE    PERINEUM. 


577 


order  to  search  for  wouiuls  of  the  intestines.     By  far  the  most  frequent  and 
important  injuries  are  those  occurring  during  labor, 

Laeeration  of  tlie  permeum  is  usually  caused  by  childbirth,  rarely  by 
external  injuries.  According  to  position  the  laceration  may  be  taieral,  the 
fibers  of  the  levator  ani,  on  one  or  both  sides,  being  torn;  median;  or  eenlral, 
a  rare  form  in  which  the  child  is  bom  through  a  perforation  of  the  perineum, 
the  vulva  remaining  intact.  According  to  degree  the  laceration  may  be 
hitomplde  or  rompiek\  the  latter  passing  through  the  sphincter  ani-  Perineal 
rtiaxation  is  a  term  used  for  those  cases  in  which  there  has  been  a  submucous 
tear  of  the  levator  ani  fibers. 


Fic..  4S6. — Lacenilion  of  fieri ncum 
and  large  rectocele.  (Pennsylvania. 
Huspital.) 


Fig.  487. — Uiagram  of  cystocclc  and 
rcclocele.  Dotte*!  lines  represent  residual 
urine.  The  uteru:^  is  displaced  downwards 
and  backwards. 


The  symptoms  are  a  feeling  of  insecurity  in  the  parts,  dragging  pain, 
and  retlex  nervous  disorders.  Incomplete  median  tears  may  give  no  symp- 
toms. When  the  levator  ani  is  torn,  the  anus  fails  backwards,  the  rectum 
bulges  forward  as  a  tumor  {redorde — Fig.  486),  causing  constipation,  and 
the  stretc»iing  of  the  posterior  wall  leads  to  retroversion  and  prolapse  of  the 
uterus.  These  conditions  cause  congestion,  and  hence  hemorrhoids  and 
endometritis.  The  anterior  vaginal  wall  also  may  prolapse  from  lack  of 
support  of  the  posterior  wall,  or  from  descent  of  the  uterus,  causing  a  bulging 
downwanJs  and  outw^ards  of  the  bladder  {cysioceh),  a  condition  which  may 
exist  likewise  %vithout  laceration  of  the  perineum,  owing  to  the  submucous 
stripping  of  the  anterior  vaginal  wall  from  the  underlying  parts  during  labon 
A  cystocele  causes  dysuria,  and  sometimes  cystitis  from  the  decomposition 
of  residual  urine  (Fig.  487).  A  complete  tear  causes  incontinence  of  feces 
and  gas.  The  gaping  of  the  vaginal  orifice,  the  backward  displacement  of 
the  anus,  and  the  rectocele  or  cystocele  are  readily  detected  by  inspection, 
especially  when  the  patient  strains.  By  palpation  with  a  finger  in  the  vagina 
and  the  thumb  externally  or  in  the  rectum,  the  gap  in  the  muscles  may  be 
felt. 

The  treatment  should  be  immediate  repair  after  labor  {perineorrhaphy, 
or  posterior  eolporrhaphy),  the  divided  structures  being  approximated  with 
silk  or  twenty-day  catgut.  Non-chromicized  catgut  is  absorbed  verj'  rapidly 
in  these  cases  and  should  not  be  employed.     Of  the  secondary  operations, 

J7 


578 


GENITAL   ORGANS. 


i.e.,  those  in  which  the  laceration  is  repaired  after  the  completion  of  cica- 
trization, the  most  important  are  described  below.  *" 

Lateral  tears  are  best  repaired  by  the  Emmei  operation.  With  the 
patient  in  the  lithotomy  position,  guide  sutures  or  tenacula  are  passed  through 
the  apex  of  the  rectocele,  and  dirough  each  labium  majus  at  the  lowest 
camuculae  myrtiformes.  By  drawing  on  the  lateral  suture  and  pulling  the 
central  suture  downward  and  to  the  opposite  side,  the  lateral  sulcus  appears 
as  a  triangle  with  the  apex  up  in  the  vagina.  This  triangle  is  denuded  of 
mucous  membrane  by  cutting  off  long  strips  by  means  of  forceps  and  scissors, 
or  by  dissecting  the  mucous  membrane  off  in  one  piece.  The  triangle  on  the 
opposite  side  is  treated  in  the  same  manner,  and  the  denudation  completed 
by  removing  the  mucous  membrane  between  the  bases  of  the  triangles  and 
below  the  central  suture  (Fig.  488).  Each  lateral  triangle  is  closed  by 
interrupted  sutures  of  chromicized  catgut  or  silkworm  gut,  the  latter  being 


Fk;.  48S.  Emmet's  operation,  showing 
area  of  denudation.  A,  A,  A,  (iui<lc  sutures: 
H,  uj)per  suture  passed  in  lateral  sulcus 


Fig.  489.— Sulci  closed.     A,  Crown  stitch. 


shotted.  The  needle,  which  should  be  curved,  is  entered  near  the  margin 
of  the  wound  on  the  outer  side,  passed  deeply  to  c  atch  the  fibers  of  the  levator 
ani,  and  brought  out  at  the  bottom  of  the  sulcus,  at  a  point  nearer  the  operator; 
it  is  then  reinserted  at  the  bottom  of  the  sulcus,  and  passed  upwards  and 
backwards  in  the  rectocele,  to  emerge  opposite  the  point  of  the  original 
insertion.  The  opposite  triangle  is  treated  in  the  same  manner,  which  leaves 
a  small  raw  area  externally  to  be  closed  (Fig.  489).  The  upper  or  "crown 
stitch"  passes  through  the  skin  of  the  perineum  below  the  lateral  guide 
suture,  then  through  the  rectocele  below  the  central  guide  suture,  and  finally 
through  the  tissues  below  the  opposite  guide  stitch.  As  many  sutures  as 
may  be  necessary  are  inserted  below  this.  If  silkworm  gut  is  used,  the 
stitches  should  be  removed  on  the  tenth  day.  The  external  genitals  are 
irrigated  with  weak  bichlorid   of   mercury  solution   after  each  urination; 


ANTERIOR   COLPORRH.\PHY, 


579 


catheterkadon  should,  if  possible,  be  avoided.  The  bowels  are  moved  on 
the  second  day.  Internal  douches  are  not  needed  unless  there  be  infection. 
The  patient  should  be  kept  in  bed  two  weeks,  and  hea\7  work  and  sexual 
in|ercourse  forbidden  for  three  months. 

Hegar's  operation  (Fig,  490)  is  indicated  in  median  tears.  Lateral 
guide  sutures  are  placed  as  in  the  Emmet  operation,  and  a  central  guide 
suture  is  inserted  in  the  middle  line  of  the  posterior  vaginal  wall  as  high 
as  may  be  necessary.  The  triangle  thus  outlined  is  denuded,  and  the  raw 
surface  closed  by  interrupted  sutures  passing  beneath  the  entire  denuded 
area  J  care  being  taken  to  catch  the  transverse  perineal  muscle. 

The  flap -splitting  method  may  be  employed  in  either  lateral  or  median 
tears.  An  incision  is  made  around  the  lower  margin  of  the  vulva,  joining 
the  terminations  of  the  nymphie;  the  flap  separated  from  the  rectum  and 
drawn  upwards;  the  levator  ani  on  each  side  clearly  defined^  and  the  muscular 


->-J 


Fig.  490. — Hegar's  operation. 


FiC.  491, — Flap-splitting  method  of 
perineorrhaphy  Flap  elcvaicti  and 
sutures  passed  through  the  levator  ani 
on  each  side. 


united  with  catgut  (Fig,  491);  the  sktn  and  tissues  over  the  muscles 
brought  together  with  silkworm  gut;  and  the  flap  fixed  in  position  with  a 
few^  catgut  sutures. 

In  the  operation  for  complete  laceration  the  rectovaginal  septum  is 
split  laterally,  tlius  separating  the  vagina  from  the  rectum  for  a  short  distance 
and  thoroughly  exposing  the  ends  of  the  sphincter  ani.  The  wound  in  the 
rectum  is  then  closed  by  iwo  layers  of  chromicLzed  catgut  sutures,  one  for 
the  mucous  membrane  and  a  second  for  the  outer  coats.  The  sphincter 
ani  h  approximated  by  two  or  three  arlditional  catgut  sutures.  The  operation 
is  then  completed  by  any  one  of  the  methods  just  described,  the  lowest 
external  suture  being  passed  through  the  sphincter  ani. 

Anterior  colporrhaphy,  or  the  operation  for  cystocele,  consists  in  remov- 
ing an  elh'ptical  piece  of  mucous  membrane  from  the  anterior  vaginal  wall. 


I 
I 


1^  vagi 


extending  from  just  behind  the  urinar)^  meatus  almost  to  the  cervix,  the 
\^idth  depending  upon  the  degree  of  relaxation.  The  cervix  is  pulled 
down  with  a  tenaculum  and  the  mucous  membrane  removed  with  scissors 
and  forceps.  The  wound  is  then  closed  by  two  or  three  layers  of  continuous 
catgut  sutures. 

Fistulse  are  usually  caused  by  sloughing  following  a  long  labor,  but  are 
occasionally  due  to  other  injuries,  and  sometimes  to  disease,  such  as  syphilis, 
tuberculosis,  or  cancer.  Those  due  to  disease  are  not*  as  a  rule,  suitable 
for  plastic  operations.  Urinary  fishilae  may  be  ureihrovaglnaJ,  vesiravag- 
inai  (the  most  common),  vesifouterine  ureterovaginal^  or  uret^routerinr.  A 
The  most  common  fecal  fistula  is  the  rectovaginal,  but  occasionally,  as  a  ™ 
result  of  a  vaginal  operation  or  injur)^  the  vagina  communicates  with  the 
small  howeb  These  fistula?  cause  an  involuntar}^  escape  of  urine,  feces,  or 
gas  from  the  vagina,  and  consequent  irritation  of  the  parts.  Urinary  ^stuk 
may  be  complicated  by  cystitis,  ureteritis,  and  pyelonephritis.  The  diag- 
nosis is  made  by  passing  a  probe  or  finger  through  the  Jistula»  or,  when  the 
orifice  is  very  small,  by  injecting  a  colored  fluid  into  the  bladder  or  rectum 
and  watching  for  its  escape  through  the  tlstula.  In  ureteral  fistuUe  a  small 
quantity  of  urine  constantly  dribbles  from  the  vagina,  despite  the  fact  thai 
micturition  is  normal,  and  the  color  and  quantity  of  the  fluid  escaping  from 
the  fistula  is  not  influenced  by  the  injection  of  a  colored  solution  into  the 
bladder. 

The  treatment  of  recent  small  hstula:  is  daily  irrigation  of  the  vagina 
with  boric  acid  solution  or  salt  solution,  never  with  strong  antiseptics; 
if  spontaneous  healing  does  not  occur  after  three  months,  operation  should 
f>e  advised.  Large  or  old  fistuke,  with  the  exceptions  noted  above,  always  M 
require  operation.  Often,  however,  it  is  first  necessary  to  remove  phosfihatic  m 
deposits,  to  coml>al  cystitis  and  ulcerations,  and  to  improve  the  general  health 
A  veskovaginal  psiula  may  be  closed  by  paring  the  edges  of  the  oriticet  and 
then  unidng  them  with  silkworm  gut  sutures,  which  penetrate  to,  but  iK>t 
through,  the  bladder  mucous  membrane.  The  patient  is  usually  placed 
in  the  Sims  position  during  the  operation,  and  a  retention  catheter  remains 
in  the  bladder  after  operation.  The  sutures  are  removed  in  ten  days.  If 
the  edges  do  not  come  together  without  tension^  a  longitudinal  incision,  which 
is  subsequently  sutured  transversely,  may  be  made  on  each  side  of  the 
opening.  In  some  cases  it  may  be  necessary  to  separate  the  bladder  from 
the  vagina  for  some  distance,  and  suture  each  cavity  separately.  In  the 
worst  cases  which  cannot  be  remedied  by  other  means,  the  vagina  may  be 
closed  below  the  opening  {coipockisis),  thus  converting  the  bladder  and 
vagina  into  one  cavity,  U reihrovaginal  and  rectovaginal  fiatuld  are  treated 
in  a  similar  manner,  A  rectovaginal  fistula  close  to  the  vulva  may  be  indsed 
like  a  fistula  in  ano,  and  then  treated  like  a  complete  laceration  of  the  peri- 
neum. A  veskaulerine  fistula  may  be  reached  by  dilating  or  splitting  the 
cer\ix.  Probably  the  best  operation  is  to  make  an  incision  in  front  of  the 
cervix,  separate  the  bladder,  and  close  the  opening  in  it  by  catgut  sutures. 
Urtieral  fistula:  may  be  treated  by  establishing  a  vesicovaginal  fistula  along- 
side the  opening  in  the  ureter,  and  later  closing  the  vesicovaginal  fistula, 
which  now  includes  the  ureteral  opening,  by  denuding  the  vaginal  mucous 
membrane  about  the  oritice  of  the  fistula,  and  subsequently  suturing  the  raw 
surfaces.  The  ureter  may  be  dissected  from  its  bed,  either  through  the 
vagina  or  abdomen,  and  anastomosed  with  the  bladder.     Anastomosis  with 


I 
I 


MALFORMATIONS    OF   UTE    UTERUS* 

the  bowel  is  not  advisable.  When  all  other  plans  have  failed  or  caniiol  be 
used,  and  the  opposite  kidney  is  healthy,  the  ureter  may  be  tied.  WTien  the 
kidney  of  the  affected  side  is  extensively  damaged  from  an  ascending  infec- 
tion, it  may  be  removed* 

Vaginitis  is  usually  caused  by  gonorrhea^  but  may  be  due  to  foreign 
bodies,  or  other  conditions  mentioned  under  vulvitis.  In  old  age  the  epithe- 
lium is  prone  to  desquamate,  leaving  ulcers  {senile  or  air er alive  vaginiiis), 
which  may  residl  in  stenosis  or  atresia.  As  in  vulvitis,  gangrenous  and 
croupous  intlammation  may  occur,  but  cellulitis  (paracolpiiis)  is  rare. 
The  symptoms  of  the  acukform  are  pain  and  heat  in  the  vagina  and  pelvis, 
vesical  and  rectal  irritability,  a  mucopurulent  discharge,  and  reddening 
of  the  mucous  membrane,  which  is  frequently  studded  with  enlarged  papilla*. 
Chronic  vaginitis  may  have  nothing  but  a  leukorrhea  to  indicate  its  existence. 
Gonorrheal  vaginitis  can  be  diagnosticated  with  certainty  only  by  finding 
the  gonococci,  although  its  symptoms  are  often  very  acute,  and  it  is  more 
apt  to  be  associated  with  vulvitis,  urethritis,  and  infection  of  the  vulvo- 
vaginal glands.  Extension  to  the  uterus,  tubes*  ovaries,  and  peritoneum 
also  is  common. 

The  treatment  of  acute  vaginitis  is  rest  in  lied  and  the  general  measures 
advised  in  tlie  treatment  of  gonorrhea.  Douches  of  bichloritj  of  mercury 
(i  to  5tOCX3)  or  permanganate  of  potassium  (i  to  10,000)  may  be  given  several 
times  a  day,  while  applications  of  a  5  per  cent,  argyrol  solution  may  be 
made  through  a  speculum  once  daily,  and  the  vagina  lighUy  packed  with 
gauze  between  treatments.  In  the  later  stages,  or  in  chronic  cases,  the 
vaginal  mucous  membrane  may  be  painted  with  silver  nitrate  (gr.  30  to  the 
ounce)  several  times  a  week,  and  an  astringent  douche  of  zinc  sulphate 
and  powdered  alum  (each  half  an  ounce  to  a  quart  of  water)  may  be  ordered. 
Ulcerations  are  treated  by  the  application  of  silver  nitrate. 

Vaginismus  is  a  spasmodic  contraction  of  the  perivaginal  muscles, 
preventing  coitus  and  associated  with  excessive  hyperesthesia  of  the  struc- 
tures about  the  vulva.  It  may  be  caused  by  a  urethral  caruncle  or  other 
local  disease,  and  is  most  common  in  the  neurasthenic. 

The  treatment  is  the  correction  of  any  local  disease,  and  gradual  dilatation 
by  means  of  bougies,  or  forcible  dilatation  under  a  general  anesthetic. 
Inveterate  cases  have  been  treated  by  excising  the  hymen,  or  by  incising 
the  perineum  in  a  longitudinal  direction  ami  closing  the  wound  transversely. 


THE  UTERUS. 

Malformations  of  the  Utenis.^The  uterus  may  l>e  absent  or  rudimen- 
tary, in  the  latter  case  existing  as  a  thin  band  of  muscle  and  connective 
tissue. 

Congenital  atrophy  of  the  uterus  is  a  condition  in  which  the  uterus 
is  exceedingly  small,  the  size  of  the  cervix  being  proportionate  to  that  of  tlie 
body.  An  infantile  uterus  is  small,  but  the  cenix  is  two  or  three  times 
longer  than  the  body,  a  condition  which  is  normally  present  at  birth. 

The  remaining  malformations  of  the  uterus  are  due  to  non-union  or 
imperfect  fusion  of  the  ducts  of  MiUler.  Uterus  septus  is  one  in  which 
the  uterus  is  divided  longitudinally  by  an  antero- posterior  septum.  Uterus 
blcorais  is  one  in  which  the  uterus  is  divided  into  two  horns  by  an  antero- 


582  GENITAL   ORGANS. 

posterior  groove  across  the  fundus.  When  this  deft  extends  to  the  vagina 
there  are  two  uteri,  each  with  a  tube  and  ovary  (uterus  didelphys).  When 
one  of  the  canals  of  Muller  develops  and  the  other  remains  nidimentan', 
the  uterus  is  deflected  to  one  side  (uterus  unicornis).  In  the  uterus 
bipartitus  both  horns  are  rudimentary,  but  may  be  hollow  and  connected 
with  the  vagina  and  with  each  other  by  the  cervix.  Some  of  these  malforma- 
tions cause  sterility,  others  miscarriages  or  great  difficulty  in  labor.  When 
the  uterus  is  so  poorly  developed  ^at  menstruation  amounts  to  agony, 
the  ovaries  may  be  removed.  When  the  uterus  is  divided  by  a  septum, 
such  may  be  crushed  with  forceps,  which  are  left  in  place  until  they  come 
away  of  themselves.  When  conception  takes  place  in  a  rudimentary 
horn,  the  condition  resembles  ectopic  pregnancy,  in  that  the  walls  may 
break  and  a  fatal  hemorrhage  occur;  in  such  a  case  the  rudimentary  horn 
should  be  removed.  The  uterus  didelphys  has  been  mistaken  for  pus  tubes 
and  one  of  the  organs  removed  before  the  mistake  was  discovered;  excision 
is  the  proper  procedure  if  there  is  a  unilateral  hematometra  or  pyometra. 
Atresia  of  the  cervix  (complete  closure)  may  be  congenital,  or  it  may 
be  acquired  as  the  result  of  tumors  of  the  cervix,  or  cicatrization  following 
the  application  of  caustics,  ulceration  due  to  infectious  fevers,  injuries  of 
childbirth,  or  a  badly  performed  trachelorrhaphy.  There  is  retention  <rf 
menstrual  blood  {hematometra),  mucus  {hydromelra),  pus  {pyofnelra)j  or,  in 
cases  infected  by  saprophytes  or  the  gas  bacillus,  gas  {physometra).  There 
is  amenorrhea  with  the  subjective  symptoms  of  menstruation  at  the  regular 
periods,  except  in  hydrometra,  which  usually  occurs  after  the  menopause. 


F'iG.  492. — (ioodcU's  uterine  dilator. 

In  pyometra  and  physometra  septic  phenomena  are  in  evidence.  The 
uterus  is  enlarged  and  cystic  in  fluid  accumulations,  tympanitic  or  crepitating 
if  there  is  a  collection  of  gas.  The  treatment  is  puncture  or  incision  of  the 
cervix,  irrigation  of  the  uterine  cavity  with  salt  solution,  and  the  subsequent 
passages  of  bougies  to  maintain  the  patency  of  the  canal.  The  condition 
of  the  lubes  should  be  ascertained  before  operation,  and  if  they  also  are 
distended,  they  should  be  removed  by  abdominal  section  before  empt>ing 
the  uterus,  as  such  is  apt  to  rupture  them  and  cause  peritonitis. 

Stenosis  of  the  cervix  (partial  closure)  may  be  due  to  the  same  causes  as 
atresia.  In  the  congenital  form  the  cervix  is  conical  and  the  uterus  small  and 
anteflexcd.  The  symptoms  are  dysmenorrhea  and  sterility,  the  latter  usually 
being  caused  by  an  endocervicitis,  which  induces  also  leukorrhea.  The 
treatment  is  dilatation  of  the  cervical  canal  by  a  glove-stretcher  dilator  (Fig. 
492),  and  the  subsequent  passage  of  bougies  at  regular  intervals.  The 
operation  is  performed  by  seizing  the  anterior  lip  of  the  cernx  with  a  double 
tenaculum,  and  gently  passing  into  the  uterus  a  small  dilator,  the  blades 


LACERATION    OF    THE   CERVIX.  583 

of  which  are  separated  laterally,  and  then  in  other  directions,  so  as  not  to 
tear  the  cervix.  A  larger  and  more  powerful  dilator  may  then  be  used  if 
needed.  Dilatation  by  means  of  tents  (sponge,  laminaria,  tupelo,  corn 
stalk,  etc.)  which  expand  by  absorbing  moisture  after  their  introduction 
into  the  cervix,  is  slow,  painful,  and  dangerous  because  they  are  difficult 
to  render  and  keep  sterile.  Dilatation  may  be  effected  also  by  repeated 
packings  with  gauze,  or  by  the  Barnes  bag;  the  latter  consists  of  india  rubber 
and  is  introduced  into  the  cervix  collapsed,  after  which  it  is  slowly  distended 
with  air  or  water.  In  rare  instances  it  may  be  necessary  to  incise  the  cervix. 
Hypertrophy  of  the  cervix  may  involve  the  supravaginal  or  infravaginal 
portion ;  the  former  is  associated  with  prolapse  of  the  uterus  and  eversion  of 
the  vaginal  mucous  membrane,  the  latter  is  congenital  and  is  not  associated 
with  displacement  of  the  fundus  of  the  uterus  or  obliteration  of  the  vaginal 
fornices.  In  the  congenital  variety  the  os  is  small  and  the  cervix  long  and 
conical.  It  may  cause  leukorrhea,  sterility  and  dysmenorrhea,  and  when 
protruding  from  the  vulva,  it  may  become  ulcerated  and  interfere  with  loco- 
motion. The  treatment  is  amputation  of  the  cervix.  The  anterior  and 
posterior  lips  of  the  cervix  are  seized  with  double  tenacula,  the  cervix  split 


Fig.  493.— (Auvard.)  Fic.  494. 

transversely,  each  lip  amputated  by  a  wedge-shaped  incision,  and  the  wound 
closed,  by  sutures  as  shown  in  Fig.  493.  Shroeder^s  method,  which  is  indicated 
when  the  cervical  mucous  membrane  is  badly  diseased,  is  shown  in  Fig.  494. 
The  cervix  is  split  as  in  the  previous  operation,  and  each  flap  amputated 
in  a  manner  similar  to  removal  of  the  distal  phalanx  of  the  finger  when  a 
long  palmar  flap  is  used.     Chromicized  catgut  is  the  l)est  suture  material. 

Laceration  of  the  cervix  is  usually  the  result  of  childbirth,  but  occasion- 
ally follows  attempts  at  abortion  or  dilatation  of  the  cervix.  The  laceration 
may  be  partial  or  completCy  the  latter  extending  through  the  whole  cervix. 
The  line  of  cleavage  is  apt  to  correspond  with  the  right  oblique  diameter 
of  the  pehis,  because  the  most  frequent  presentation  is  the  left  occipito- 
anterior. The  laceration  may  be  unilateral,  bilateral ,  or  stellate^  i.e.,  having 
more  than  two  branches  radiating  from  the  cervical  canal.  Extensive 
lacerations  may  open  the  cellular  tissue  of  the  broad  ligaments  or  even  the 
peritoneum,  and  be  followed  by  cellulitis  or  peritonitis.  Symptoms  may 
be  absent,  particularly  in  unilateral  lacerations.  In  a  bilateral  laceration 
the  lips  are  separated,  exposing  the  cervical  mucous  membrane  {ectropion 
or  eversion)  J  which  becomes  raw  and  inflamed  (erosion  of  the  cervix)  ^  and 


584 


GENITAL    ORGANS. 


frequently  studded  widi  small  retention  cysts^  owing  to  obstruction  of  the 
mouths  of  the  cervical  glands  (cysts  or  ot^es  of  Naboth).  These  chaiigts. 
with  the  irritation  of  the  cicatrices,  lead  to  subinvolution  and  chronic  in- 
flammation of  the  uterus,  and  predispose  to  its  displacement,  sterility,  abor- 
tion, and  epithelioma.  The  most  prominent  symptoms  are  usually  a  fcding 
of  weight  and  discomfort  in  the  pelvis,  menorrhagia,  leukorrhea,  suboccipital 
headache,  and  neurasthenia.  The  diagnosis  is  readily  made  by  palpation, 
and  by  inspection  with  the  aid  of  a  speculum. 

Treatment  at  the  time  of  laceration  is  not  advisable  unless  there  is 
excessive  hemorrhage,  when  the  laceration  should  be  closed   by  suture*. 

After  the  puerperium  erosions  may  be 
touched  ever}'  other  day  mth  silver 
nitrate  (grains  20  to  the  ounce),  the 
cysts  of  Naboth  punctured,  tam|>oD5 
saturated  with  boroglycerid  inserted 
Into  the  vagina  every  other  day^  and 
copious  douches  of  hot  water  given 
daily.  If  this  treatment  fails  10  re- 
lieve, operation  is  indicated. 

EmmeVs  trachelorrhaphy,  or  suture 
of  the  laceration,  is  performed  as  fol- 
lows: The  cer\ix  is  exposed  by 
retracting  the  perineum  with  a  specu* 
lum,  and  each  Up  caught  with  a  double 
tenaculum,  The  edges  of  the  laccra* 
tion  are  denuded  with  scissors  or« 
knife,  leaving  a  strip  of  mucous  men 
brane  in  the  center  for  the  cervic 
canal,  all  the  scar  tissue  excised, 
sutures  of  chromic  catgut  inserted  i 
tied  (Fig.  495)*  It  is  usually  ad\isablc  to  precede  this  operation  by  curettinjl 
the  uterus.  In  stellate  tears  with  much  scar  formation  and  hypertrophy 
of  the  cer%ix,  amputation  is  generally  the  belter  operation. 

Endometritis,  or  inllammation  of  the  mucous  membrane  lining  the 
uterus,  may  be  acute  or  chronic. 

Acute  endometritis  involves  both  the  cervical  and  corporeal  endome- 
trium and  extends  to  the  underl)ing  tissues.  It  is  usually  caused  by  infec- 
tion following  labor  or  abortion,  by  gonorrhea^  or  by  the  use  of  infectcfi 
instruments,  but  it  may  be  due  also  to  acute  infectious  fevers,  and  exposure  to 
cold  during  menstruation.  The  mucous  membrane  is  swollen,  softened, 
and  intensely  hyperemic.  There  may  be  extravasations  of  blood  into  the 
uterine  walls  and  the  formation  of  abscesses.  The  symptoms  in  mild 
cases  are  a  mucopurulent  discharge,  often  bloodstained,  pain  in  the  baci 
and  pehis,  irritability  of  the  bladder,  and  a  little  fever  The  uterus 
slightly  enlarged  and  tender,  the  cervix  softened,  and  the  os  frequenllj 
surrounded  by  an  area  of  erosion.  In  the  severer  forms  the  discharge 
very  foul,  the  tenderness  more  marked,  and  the  general  symptoms  thosel 
of  sapremia  or  septicemia.  The  infection  often  spreads  to  the  Fallopian 
tubes  and  peritoneum;  in  other  instances  it  involves  the  body  of  the  uterus, 
or  causes  a  phlebitis  of  tlie  pelvic  or  other  veins;  and  finally  it  may  spread 
through  the  lymphatics  and  cause  a  pelvic  cellulitis. 


Fr«.  495, — Trachelorrhaphy. 


I 


\ 


ENDOMETRITIS. 


5»5 


The  treatment  is  rest  in  bed,  liquid  diet,  saline  laxatives,  hot  vaginal 
douches  of  bichlorid  (i  to  5,000)  twice  daily,  and  an  ice  cap  to  the  hypo- 
gastrium.  In  the  more  severe  forms  the  uterine  cavity  itself  may  be 
irrigated  with  a  solution  of  bichlorid  (i  to  10,000)  or  normal  salt  solution. 
When  occurring  after  labor  or  abortion,  the  uterine  cavity  should  be  ex- 
plored with  the  tinger  and  any  decomposing  secundines  or  blood  clot 
removed.  Curettage  is,  as  a  rule,  contraindicated.  Septicemia  will  require 
appropriate  general  treatment.  In  the*  worst  cases,  particularly  if  abscesses 
form  in  the  uterine  wall,  hysterectomy  may  be  indicated. 

Chronic  endometritis  may  involve  the  entire  endometrium,  Imt  is 
often  localized  to  the  cervical  or  corporeal  portion. 

Chronic  cervical  endometritis  or  catarrh  (endocervkiiis)  may  be 
due  to  any  of  the  conditions  producing  a  vaginitis  or  endometritis,  the 
intlammation  spreading  to  the  cervix  from  these  regions.  Lacerations 
and  gonorrhea  are  the  most  frequent  causes.  It  may  be  due  also  to  stenosis 
of  the  cervix.  The  entire  cervix,  including  the  epithelium,  the  glands, 
and  the  connective  tissue,  is  involved.  The  cylindrical  epithelium  lining 
the  cervix  spreads  out  over  the  vaginal  portion,  giving  it  a  raw  appearance, 
which  is  called  an  erosion,  and  sometimes  erroneously  an  ulceration. 
True  ukeraiim  of  ike  cen>Lx  is  seen  in  chancre,  chancroid,  tuberculosis, 
neoplasms^  prolapse  of  the  uterus,  and  after  traumatism.  In  endocervicitis 
the  mucous  membrane  is  often  thrown  into  transverse  folds,  and  the  blood 
vessels  may  be  so  dilated  as  to  resemble  hemorrhoids.  The  enlarged  glands 
are  often  constricted  by  the  increased  amount  of  connective  tissue,  thus 
forming  retention  cysts  (ovules  of  Naboth).  The  symptoms  are  pain 
in  the  back,  irregular  menstruation,  and  leukorrhea.  The  discharge 
from  the  cervix  is  thick  and  viscid,  and  this  is  often  sufficient  to  prevent 
conception.  The  cervix  is  usually  enlarged  and  tender.  The  changes 
described  above  may  be  made  out  by  palpation  and  by  the  use  of  the 
speculum. 

The  treatment  is  attention  to  the  general  health,  and  the  use  of  hot 
vaginal  douches  containing  sulphate  of  zinc  (one  dram  to  the  pint)  or  corros- 
ive sublimate  (i  to  5.000).  If  stenosed,  the  cervix  should  be  dilated;  if 
lacerated,  sutured.  Cysts  should  be  punctured,  and  the  cervix  may  be 
scarified  if  there  is  much  congestion.  In  some  cases  it  may  be  necessary 
to  apply  tincture  of  iodin,  ichthyol  (25  per  cent,  in  lanolin),  or  silver  nitrate 
(gr.  30  to  the  ounce)  to  the  cervical  canal ,  following  the  application  by  a  glycerin 
tampon.  Displacement  of  the  uterus  or  other  compiication  should  of 
course  be  corrected.  In  inveterate  cases  the  uterus  should  be  curetted 
and  packed  with  gauze,  or  Schroeder^s  operation  (p.   583)  performed. 

Chronic  corporeal  endometritis  may  follow  the  acute  form,  but  is 
more  often  chronic  from  the  beginning;  in  the  latter  instance  it  is  due  to 
the  extension  of  an  endocervicitis  or  vaginitis,  or  to  any  condition,  w^hich 
induces  congestion,  e.g.,,  excessive  coitus,  displacements  of  the  uterus, 
pelvic  tumors,  and  in  fact  almost  any  pelvic  disease,  as  well  as  tight 
lacing,  and  chronic  disease  of  the  heart,  lungs,  liver,  or  blood.  In  many 
of  these  cases  no  bacteria  can  be  recovered  from  the  endometrium. 
According  to  the  tissue  more  involved  the  intlammation  is  designated 
glandular  or  irttersliltaL  When  the  changes  are  equally  distributed, 
the  mucous  membrane  is  thick,  soft,  and  smooth;  when  some  portions 
are  more  involved  than  others,  the  surface  presents  vascular  or  glandular 


586  GENITAL   ORGANS. 

vegetations  (villous  or  fungous  endometritis).  As  in  the  cervix,  the  orifices 
of  the  glands  may  be  occluded  and  cysts  formed.  In  ex/aiiaiive  endo- 
metritis j  or  membranous  dysmenorrhea,  at  each  menstruation  the  epithelium 
is  thrown  off  in  shreds,  or  in  one  whole  piece  as  a  cast  of  the  utenis. 
The  symptoms  are  pain  in  the  pelvis  and  back,  mucopurulent  leukor- 
rhea,  menorrhagia  or  metrorrhagia,  dysmenorrhea,  reflex  nervous  distur- 
bances, and  often  sterility  or  abortions.  The  uterus  is  usually  enlar^ged 
and  slightly  tender.  When  the  disease  occurs  after  the  menopause  {senile 
endometritis),  the  discharge  may  be  retained,  giving  rise  to  an  offensiw 
odor  which  suggests  malignant  disease,  a  suspicion  which  may  be  dispelled 


Fig.  496. — Sims*  sharp  curette. 

by  a  microscopic  examination  of  the  tissue  removed  by  the  curette.  As 
in  acute  endometritis,  the  inflammation  may  spread  to  the  extrauterine 
structures. 

The  treatment,  in  the  absence  of  acute  inflammation  in  Ae  periuterine 
structures,  is  curettage.  With  the  patient  in  the  lithotomy  position,  the 
anterior  lip  of  the  cervix  is  grasped  with  tenaculum  forceps,  and  the  canal 
dilated  with  the  glove-stretcher  dilator.  The  curette  (Fig.  496)  is  then 
introduced  and  the  walls  of  the  cavity  systematically  gone  over  several 
times,  a  grating  sensation  being  imparted  to  the  hand  when  the  mucous 
membrane  has  been  removed.  For  curettage  of  the  fundus  and  comua 
the  Martin  curette  (Fig.  497)  should  be  employed.  The  uterine  carit>' 
is  irrigated  with  bichlorid  of  mercury  solution  (i  to  10,000)  and  the  vagina 
fdled  with  sterile  gauze.  The  uterus  should  not  be  packed  unless  there 
is  free  blee.Hng,  as  the  gau7.e  plug  interferes  with  drainage.     All  gauze 


O ■      -T=n[B!ii!iili'!llli!i!l|i!il 


Fk;.  497.  — Martin's  curette. 

should  ho  removed  at  the  end  of  twenty-four  hours,  and  a  daily  vaginal 
douche  of  bichlorid  of  mercury  (i  to  10,000)  given  thereafter.  The  dangers 
of  the  operation  are  perforation  of  the  uterus,  inflammation  of  the  adnexa, 
and  peritonitis.  The  patient  should  remain  in  bed  one  week.  The  cause 
of  the  endometritis,  e.g.,  lacerations,  displacements,  etc.,  should,  if  possible, 
be  removed  at  the  lime  of  the  curettage.  Strychnin  and  ergot  may  be  given 
after  operation,  in  order  to  encourage  contraction  of  the  uterus. 

Acute  metritis,  or  inflammation  of  the  uterine  muscle,  is  due  to  the 
same  causes  as  acute  endometritis,  with  which  it  is  always  associated,  and 
from  which  it  cannot  be  differentiated  clinically.  The  symptoms  and  treat- 
ment are,  therefore,  those  of  endometritis. 

Chronic  metritis,  chronic  parenchymatous  inflammation  o/theutrrus,  diffuse 
interstitial  metritis,  or  subinvolution,  as  it  is  called  when  following  labor, 
may  be  due  to  (a)  causes  which  interfere  with  normal  involution  of  the  puer- 


DISPLACEMENTS    OF   THE   UTERUS.  587 

peral  uterus,  e.g.,  retained  secundines,  cervical  laceration,  acute  endome- 
ritis,  pelvic  inflammation,  rising  too  soon  after  confinement,  nonlactation, 
and  repeated  miscarriages;  and  to  (b)  causes  which  produce  repeated  or  pro- 
tracted congestions,  such  as  chronic  endometritis,  uterine  displacements, 
pelvic  tumors,  excessive  coitus  or  masturbation,  tight  lacing,  and  chronic 
disease  of  the  heart,  lungs,  or  liver.  At  first  the  uterus  is  large,  soft,  tender, 
and  hyperemic,  later  the  connective  tissue  gradually  increases  in  amount  and 
compresses  the  blood  vessels,  rendering  the  organ  hard  and  anemic.  The 
symptoms  are  those  of  the  complicating  chronic  endometritis,  with  a  feeling 
of  weight  in  the  pelvis,  chronic  invalidism,  and  neurasthenia.  The  increase 
in  the  size,  weight,  and  firmness  of  the  uterus  is  readily  detected  by  bimanual 
examination.  The  cervical  canal  is  dilated  aQd  the  uterine  cavity  uniformly 
enlarged.  The  complications  are  displacement  of  the  uterus,  chronic  endo- 
metritis, and  extension  of  the  inflammation  to  the  appendages  and  the 
peritoneum. 

The  treatment  is  removal  of  the  cause  (displacements,  lacerations,  tumors, 
etc.),  curettage  for  the  chronic  endometritis,  copious  hot  vaginal  douches, 
glycerin  tampons,  the  internal  administration  of  ergot  and  strychnin,  and 
the  general  treatment  for  neurasthenia.  The  cervix  may  be  scarified,  or 
painted  with  iodin,  or,  if  it  is  much  enlarged,  it  may  be  amputated. 

Atrophy  of  the  uterus  is  normal  after  the  menopause.     It  may  follow 
destruction  or  removal  of  the  ovaries,  exhausting  general  diseases,  and  cer- 


FiG.   498. — Anteversion  of  uterus.  Fig.   499. — Acute  anteflexion. 

(Montgomery.)  (Montgomery.) 

tain  nervous  affections.  When  following  labor,  it  is  called  superinvolution. 
The  symptoms  are  amenorrhea,  sterility,  and  reflex  nervous  disorders.  The 
treatment  is  unsatisfactory.  Attention  to  the  general  health  and  electricity 
locally  may  be  useful. 

Displacements  of  the  uterus  are  pathological  when  they  are  more  or 
less  permanent  and  interfere  with  the  normal  mobility  of  the  organ.  The 
uterus  may  be  displaced  upwards  {ascent)  or  downwards  (prolapsus) ;  it  may 
be  tilted  {version)  or  bent  {flexion)  forwards  {anteversion  or  anteflexion), 
backwards  {retroversion  or  retroflexion),  or  laterally  {lateroversion  or  latero- 
flexion) ;  it  may  be  turned  inside  out  {inversion) ;  and  the  body  may  be  twisted 
on  the  cervix  {torsion  of  the  uterus).  Dislocation  of  the  uterus  is  a  displace- 
ment of  the  whole  organ,  with  little  or  no  change  in  its  axis;  it  may  be  for- 
wards  {anteposition)y    backwards  {retro position),  or  lateral  (IcUeroposition). 


588 


GENITAL  ORGANS. 


Ascent,  lateroversion,  lateroflexion,  torsion,  and  dislocation  of  the  uterus  arc 
due  to  exudates  or  neoplasms  which  push  the  uterus,  or  to  adhesions  whidb 
pull  the  uterus,  into  its  abnormal  position;  the  treatment  is  that  of  the  causa- 
tive lesion. 

Anteversion  (Fig.  498)  may  be  caused  by  any  condition  which  increases 
the  weight  of  the  uterus  (e.g.,  metritis  and  tumors),  and  by  adhesions  which 
draw  the  fundus  forward  or  the  cervix  backward.  The  sympUmis  are  those 
of  the  causative  lesion,  with  those  of  pressure  on  the  bladder,  i.e.,  frequent 
micturition  and  hypogastric  pain.  The  treatment  is  directed  to  die  condi- 
tion producing  the  displacement. 

Aateflezion  (Fig.  499)  is  an  exaggeration  of  the  normal  forward  bend  in 
the  uterus,  with  rigidity  at  the  point  of  flexion.  It  may  be  congenital,  or  the 
result  of  metritis,  inflammation  of  the  uterosacral  ligaments  which  draws 
the  upper  part  of  the  cervix  upwards  and  backwards,  irregular  involution 
after  labor,  or  tumors  of  the  fundus.  In  some  cases  the  uterus  faUs  back- 
wards {retroversion  with  anteflexion).  The  symptoms  are  d3rsnienonhea, 
sterility,  frequent  micturition,  leukorrhea,  and  the  symptoms  of  any  accom- 
panying inflammation.  The  cervix  is  often  conical,  with  a  small  os,  and  lies 
in  the  axis  of  the  vagina,  while  the  fundus  may  be  felt  anteriorly.  The  con- 
dition is  differentiated  from  tumors  and  exudates  in  front  of  the  uterus,  by 
definitely  locating  the  fundus  by  bimanual  or  rectal  examination.  The 
sound  should  rarely  be  employed  to  determine  the  direction  of  the  canal 
and  the  position  of  the  fundus. 

The  treatment  is  dilatation  of  the  cervix,  curettage  of  the  uterus,  and 
the  maintenance  of  dilatation  by  the  passage  of  graduated  sounds  weekly  for 

a  month  or  more.  Stem-pessaries  and  tents  are 
dangerous.  Any  extrauterine  inflammation 
should  of  course  receive  appropriate  treat- 
ment. Dudley  splits  the  posterior  lip  of  the 
cervix  and  removes  a  wedge-shaped  piece  from 
each  margin  of  the  incision,  subsequently  unit- 
ing the  diamond-shaped  wound  with  transverse 
sutures,  thus  enlarging  the  os  posteriorly. 
Noursc  splits  the  cervix  laterally,  and  attempts 
to  straighten  the  uterus  by  pulling  on  the 
posterior  lip,  which  is  then  sutured  in  its  new 
position.  Others  have  divided  the  uterosacral 
ligaments,  or  removed  a  wedge-shaped  'portion 
of  the  posterior  wall  of  the  uterus  opposite  the 
flexion,  the  canal  being  straightened  by  sutur- 
ing the  incision. 
Retroflexion  and  retroversion  are  commonly  associated,  constituting 
the  condition  called  rdrovcrsio-flexio  (Fig.  500).  As  a  rule  the  uterus  first 
retroverts,  and  is  later  bent  backwards  by  the  action  of  the  intraabdominal 
pressure  upon  the  anterior  face  of  the  fundus.  The  causes  are  subinvolution 
and  relaxation  of  the  ligaments  following  labor,  particularly  if  the  patient 
gets  up  too  early;  violent  jars  or  severe  straining;  salpingitis,  the  tubes 
falling  backwards  and  carr>'ing  the  fundus  \\\i\i  them;  pdvic  adhesions; 
tumors  of  the  uterus  or  tissues  in  front  of  it;  lacerations  of  the  perineum;  and 
habitually  allowing  the  bladder  to  become  overdistended.  Some  cases  are 
said  to  be  congenital,  the  posterior  wall  of  the  vagina  failing  to  elongate,  thus 


I''i(;.  500.--  Rt'trovrrNio-flcxio. 
(Montgomery.) 


DISPIJICEMENTS    OF   HffE    UTERUS* 


^  rW 


pulling  die  uterus  backward.  The  uterus  is  usually  enlarged  and  congested, 
and  there  is  practically  always  a  complicating  endometritis.  Symptoms, 
in  the  absence  of  complications,  are  often  absent.  In  a  typical  case  there  is 
lumbosacral  pain,  occipital  headache^  a  feeling  of  weight  in  the  pelvis* 
leukorrhea,  menorrhagia,  dysmenorrhea^  frequent  micturition  from  pressure 
of  the  cervix  on  the  bladder  constipation  and  hemorrhoids  from  pressure 
on  the  rectum  J  sterility  or  abortions,  and  neurasthenia  or  hysteria.  On  ex- 
amination the  uterus  is  found  low  in  the  pelvis^  the  cervix  often  pointing 
forward,  and  the  fundus  is  found  posteriorly.  In  tumors  or  exudates  in 
Douglas's  ad  de  sai\  and  in  feces  in  the  rectum,  the  fundus  is  found  anteri- 
orly, a  fact  which  may,  if  necessar>^  be  verified  with  the  sound.  The  direc- 
tion of  the  cervix  is  not  of  much  value  in  differential  diagnosis.  Feces  have 
a  doughy  feel  and  can  be  identified  by  passing  a  tinger  into  the  rectum. 

The  treatment  varies  according  to  whether  the  retroversion  is  acute  or 
chronic,  and  according  to  the  presence  or  absence  of  complications.  Acute 
retroiTrsion^  ix.,  occurring  after 
labor,  miscarriage,  or  an  accident, 
should  be  treated  by  replacing  the 
uterus,  and  the  assumption  of  the 
knee  chest  posture  (Fig.  501)  for 
live  minutes  night  and  morning. 
WTien  involution  is  complete  (six 
weeks  after  labor),  a  pessary  may 
be  inserted  and  worn  for  several 
months.  About  one- third  of  the 
cases  are  thus  cured.  If  the  dis- 
placement recurs  after  the  removal 

of  the  pessar}%  the  patient  should  be  allowed  to  choose  between  an  opera- 
tion and  the  permanent  use  of  a  pessary.  A  chronic  relroversion  without 
symptoms  or  complications  requires  no  treatment.  If  there  are  symptoms, 
the  patient  may  choose  between  operation  and  the  permanent  use  of  a 
pessary,  if  such  can  be  worn  with  comfort.  The  pessary  in  chronic  cases 
is  to  be  regarded  as  a  crutch,  as  it  is  very  rarely  curative.  Retroversion 
with  complications  (lacerations  of  the  cervix  or  perineum,  endometritis, 
salpingitis,  adhesions,  etc.)  requires  operation  primarily  for  the  complica- 
tions, the  uterus  being  brought  forward  and  held  in  place  by  some  operative 
procedure  at  the  same  sitting. 

Reposition  of  a  retroverted  uterus  may  be  effected  by  placing  the 
patient  in  the  dorsal  position,  and  pressing  the  fundus  upwards  v\ith  two 
fingers  in  the  vagina  until  it  can  l>e  caught  by  the  external  hand,  w^hen  the 
vaginal  fingers  press  backwards  on  the  cer\dx.  If  the  fundus  is  caught 
behind  the  promontory  of  the  sacrum,  the  cernx  may  first  be  drawn  dow^n- 
wards  with  tenaculum  forceps.  Another  methotl  is  to  place  the  patient  in 
the  Sims  or  knee  chest  posture*  and  then  to  press  the  fundus  upwards  and 
forwards  with  two  fingers  in  the  vagina  until  it  passes  the  sacral  promontory, 
when  the  vaginal  fingers  draw  the  cervix  backwards.  Reposition  by 
introducing  a  sound  into  the  cavity  of  the  uterus  and  using  it  as  a  lever  is 
dangerous  and  should  not  be  employed.  WTien  the  uterus  is  fixed  by  adhe- 
sions, abdominal  section  is  the  best  treatment.  If  the  patient  refuses 
this  and  the  surgeon  can  assure  himself  that  there  are  no  pus  collections, 
gradual  reposition  may  be  tried,  the  adhesions  being  stretched  by  gently 


Fig,  501.— Genupc?ctoral  position. 
(Montgomer)'.) 


S90 


GENITAL   ORGANS. 


Fig.  502. 
Hodge 
pessary. 


Fig.  503. 

Smith  ' 

{Missary. 


Fig.  504. 
Thomas 
pessary. 


pushing  the  fundus  upward,  and  the  posterior  vaginal  fornix  then  packet 
with  a  tampon.  This  is  repeated  every  forty-eight  hours,  and  when  tb 
fundus  has  ascended  well  into  the  abdomen,  the  tampon  is  packed  into  th 
anterior  fornix,  in  order  to  press  the  cervix  backwards.  Schiiltze's  metho 
of  forcibly  breaking  up  the  adhesions  under  an  anesthetic  is  too  dangeiou 
to  be  recommended. 

Pessaries  are  used  to  hold  the  uterus  in  a  forward  position  after  it  ha 
been  replaced.  They  should  be  made  of  hard  rubber,  and  various  sizes  vi] 
be  needed  for  individual  cases.  Those  most  commonly  employed  ar 
shown  in  Figs.  502,  503,  504.  The  advantage  of  the  Smith  pessary  is  thi 
bend  of  the  anterior  bar,  which  prevents  pressure  on  the  urethra;  the  Hodgi 
pessary  does  not  possess  this  bend,  but  is  more  useful  in  a  relaxed  vagina 
the  Thomas  pessary  possesses  a  broad  posterior  bar,  which  more  equall] 

distributes  pressure,  thus  avoidinf 
ulceration.  A  pessary  acts  bi 
stretching  the  posterior  vaginal  wall 
and  pulling  the  cervix  backwards 
and  not  by  supporting  the  funduf 
of  the  uterus.  It  is  contraindicated 
in  the  presence  of  acute  inflamma- 
tion, and  should  be  employed  on]} 
after  the  uterus  has  been  replaced. 
It  may  be  impossible  to  retain  a 
pessary  if  the  cervix  is  very  short  01 
the  perineum  extensively  torn;  in 
the  latter  instance  the  difficult) 
may  be  remedied  by  perineorrhaphy,  but  it  is  better  to  perform  an  operation 
for  the  cure  of  the  retrodisplacemcnt  at  the  same  sitting.  The  length  and 
breadth  of  the  pessary  needed  may  be  ascertained  by  passing  two  fingers 
well  up  into  the  posterior  fornix  and  separating  them.  The  sha{>e  of  the 
pessary  may  be  modified  after  oiling  it  and  heating  it  over  a  lamp;  it  is  then 
rendered  firm  by  plunging  it  into  cold  water.  The  pessary  is  introduced  as 
follows,  the  patient  being  in  the  dorsal  or  the  Sims  position:  It  is  held  by 
its  smaller  end  and  the  broader  extremity  passed  into  the  vagina  parallel 
with  the  labia,  pressure  being  made  downwards  against  the  perineum.  It 
is  then  turned  transversely,  the  broader  extremity  curving  upwards  and  the 
narrow  end  downwards.  The  index  finger  of  the  disengaged  hand  is  passed 
beneath  the  pessar}-  and  over  its  inner  end,  which  is  thus  guided  upwards  and 
backwards  behind  the  cervix.  The  lower  end  of  the  pessary  should  reach 
the  middle  of  the  urethra,  and  it  should  be  possible  to  pass  the  finger-tip 
between  the  pessary  and  vaginal  wall  at  all  points;  if  the  pessary  is  too  large, 
ulceration  may  follow.  The  patient  should  take  a  daily  douche,  and  the 
pessary  should  be  removed,  cleansed,  and  reinserted  every  month  or  two. 

Operations  for  retroversion  arc  ver>'  numerous  and  none  is  ideal.  Those 
which  are  most  frecjuenlly  employed  are  Alexander's  operation,  hysteropexy, 
and  intraabdominal  shortening  of  the  round  ligaments.  Alexander's 
operation  ( onsists  in  opening  each  inguinal  canal  as  in  a  hernia  operadon. 
and  drawing  out  the  round  ligaments  until  the  fundus  reaches  the  anterior 
abdominal  wall,  the  peritoneum  being  stripped  from  the  ligament  as  it  is 
pulled  outwards.  The  wounds  are  closed  as  in  the  Bassini  operation,  the 
sutures  including  the  round  ligament,  the  excess  of  which  is  cut  off.     The 


DISPLACEMENTS    OF   THE   UTERUS.  59I 

operation  is  indicated  in  cases  in  which  the  uterus  is  freely  movable,  and 
in  which  there  are  no  intraabdominal  complications.  The  disadvantages 
are  its  limited  field,  the  difficulty  sometimes  encountered  in  finding  the  liga- 
ments, the  occasional  breaking  of  a  ligament,  and  the  possibility  of  hernia 
from  the  pulling  out  of  a  pouch  of  peritoneum,  an  accident  which  can 
always  be  avoided. 

Hysteropexy,  hysterorrhaphy,  or  ventral  suspension^  is  performed  through 
a  small  median  abdominal  incision.  The  uterus  is  brought  forward  and 
the  fundus  sutured  to  the  lower  angle  of  the  wound  by  two  silk  sutures,  each 
passing  through  the  peritoneum  and  subperitoneal  connective  tissue  and  the 
fundus,  the  first  on  a  line  with  the  Fallopian  tubes,  and  the  second  about  one- 
third  inch  posteriorly,  thus  anteverting  the  uterus.  The  fundus  should  be 
secured  also  by  the  lowest  suture  closing  the  abdominal  wound.  In  time 
the  uterus  recedes  from  the  abdominal  wall  by  stretching  the  bond  of  union, 
thus  forming  an  artificial  ligament.  The  operation  allows  the  separation 
of  adhesions  and  the  treatment  of  other  intraabdominal  complications, 
but  has  the  disadvantages  of  occasionally  interfering  with  labor,  and  of 
forming  a  band,  about  which  intestinal  strangulation  may  occur.  Ventrofix- 
ation is  a  term  applied  to  the  same  operation  when  the  sutures  fixing  the 
uterus  pass  through  the  muscles  and  aponeurosis  of  the  abdominal  waJl;  it 
should  never  be  employed  unless  the  ovaries  have  been  removed  or  the 
menopause  has  arrived. 

Intraabdominal  shortening  of  the  round  ligaments  possesses  the 
advantages  of  hysterorrhaphy  and  the  Alexander  operation  and  the  dis- 
advantages of  neither.  Operations  which  shorten  these  ligaments  by  fold- 
ing them  on  themselves,  by  fastening  them  to  the  anterior  surface  of  the 
uterus,  or  by  drawing  them  through  the  broad  ligament  and  fastening  them 
together  behind  the  uterus,  are  objectionable  in  that  the  greatest  strain  is 
brought  to  bear  upon  the  weakest  portion  of  the  round  ligament  in  the  in- 
guinal canal.  The  Gilliam-Ferguson  operation  utilizes  the  strongest  part 
of  the  ligament.  After  opening  the  abdomen  in  the  median  line  a  pair  of 
forceps  is  pushed  through  the  outer  edge  of  the  rectus  muscle,  and  the  round 
ligament  grasped  about  two  inches  from  its  uterine  end;  the  forceps  is  with- 
drawn, and  the  ligament  sutured  to  the  fascia  covering  the  rectus  muscle. 
Montgomery  has  modified  the  Simpson  operation.  A  silk  ligature  is  passed 
beneath  each  round  ligament  about  one  and  one-half  inches  from  the  uterus. 
The  two  ends  of  the  ligature  are  threaded  into  a  pedicle  needle,  which  is 
introduced  between  the  layers  of  the  broad  ligament,  and  carried  forward 
extraperitoneally  until  it  reaches  the  outer  border  of  the  rectus  muscle, 
through  which  it  is  thrust,  the  round  ligament  being  rendered  taut  to  facili- 
tate this  maneuver.  The  ligature  is  withdrawn  from  the  needle,  and  serves 
to  pull  the  ligament  through  the  abdominal  wall,  where  it  is  fastened  by 
catgut  sutures.  As  there  is  some  danger  of  hernia  occurring  at  the  point 
where  the  round  ligament  passes  through  the  rectus,  we  have  further  modi- 
fied this  operation  by  carrying  the  ligament  between  the  rectus  and  its  super- 
ficial sheath,  to  the  median  line,  where  it  is  sutured  to  its  fellow. 

Prolapse  or  descent  of  the  uterus  is  divided  into  three  degrees,  (i) 
retroversion  with  sinking  of  the  organ  in  the  pelvis,  (2)  presentation  of  the 
OS  at  the  vulva,  and  (3)  prolapse  of  the  uterus  between  the  thighs.  The 
first  and  second  are  called  incompletey  the  last  complete  prolapse,  or  procidentia. 
The  causes  are  (i)  lack  of  support  due  to  relaxation  of  the  uterine  ligaments 


592  GENITAL   ORGANS. 

or  of  the  pelvic  floor,  particularly  following  laceration  of  the  perineum: 

(2)  increased  weight  of  the  uterus,  especially  subinvolution  after  labor;  and 

(3)  increased  intraabdominal  pressure,  such  as  is  produced  by  straining, 
lifting  heavy  weights,  improper  clothing,  and  abdominal  tumors.  Oca- 
sionally  prolapse  is  suddenly  produced  by  a  severe  injury,  such  as  a  crush, 
or  a  fall  from  a  height.  The  symptoms  in  an  acute  case  are  severe  pain, 
and  possibly  internal  hemorrhage  and  peritonitis.  In  the  ordinary  chronii 
form  there  are  first  rectocele  and  cystocele,  then  retroversion  and  gradual 
descent  of  the  uterus,  which  causes  a  dragging  sensation  in  the  pelvis  and 
back,  dysuria,  and  constipation;  in  complete  prolapse  there  may  be  difficulty 
in  walking,  and  ulceration  of  the  protruding  mass  is  not  uncommon.  As 
chronic  endometritis  is  always  present  the  symptoms  of  this  affection  are 
added  to  those  just  mentioned.     In  pseudoprolapse,  or  hypertrophy  of  the 


Fig.  505. — GcKldard  pessar}*. 

cervix,  the  fundus  is  found  in  its  normal  situation  and  the  vaginal  walls  are 
not  displaced.  Inversion  of  the  uterus  presents  no  os,  but  shows  the  orifices 
of  the  Fallopian  tubes;  it  is  smaller  above  than  below,  and  on  bimanual 
examination  a  depression  is  found  in  the  region  where  the  fundus  ought  to  be. 
The  treatment  is  reduction  of  the  prolapse,  and  maintenance  of  the 
uterus  in  its  normal  position  by  pessaries  or  by  operation.  Reduction  is  occa- 
sionally (lifhcult  because  of  edema;  strangulation  with  gangrene  of  the  uterus 
has  occurred  in  rare  cases.  If  edema  prevents  reduction,  multiple  punctures 
should  be  made,  cold  compresses  applied,  and  the  foot  of  the  bed  elevated 
for  some  hours.  Pessaries  are  not  curative,  but  may  be  employed  if  the 
patient  refuses  operation,  or  if  operation  is  contraindicated.  If  the  perineum 
is  intact,  a  retroversion  pessary  may  be  tried,  or  if  this  fails,  a  ring  pessar}'. 
When  pessaries  of  this  character  cannot  be  retained,  the  uterus  may  be  held 
up  by  a  cup  and  stem  pessary  (Fig.  505)  which  is  fastened  to  an  abdominal 
belt.  The  operative  treatment  consists  in  curettage,  amputation  of  the  cer>'ix 
to  lessen  the  weight  of  the  uterus,  anterior  colporrhaphy  and  perineorrhaphy 
to  narrow  the  vagina  and  support  the  uterus,  and  intraabdominal  shortening 
of  the  round  ligaments  before,  and  ventrofixation  after,  the  menopause.  If 
the  uterus  is  badly  diseased  or  contains  ''fibroids"  a  supravaginal  hysterec- 
tomy may  be  performed  and  the  stump  sutured  to  the  abdominal  wall. 
Watkins  and  Wertheim  have  recently  revived  vaginal  fixation  of  the  uterus 
in  the  treatment  of  prolapse  after  the  menopause.  The  anterior  vaginal 
wall  is  incised  longitudinally,  the  bladder  separated  from  the  vagina  and 
the  uterus  by  blunt  dissection,  and  the  vesicouterine  fold  of  peritoneum 
opened.     The  fundus  of  the  uterus  is  then  brought  down  into  the  vagina. 


FIBROMYOBiA    OF   THE   UTERUS. 


593 


the  vesical  fold  of  peritontum  sutured  to  the  posterior  surface  of  the  uterus 
near  the  cen^Lx,  and  the  fundus  attached  to  the  vaginal  flaps  near  the 
urethra.  The  incision  in  the  vagina  is  now  closed  by  suturing  the  tlaps 
together.  Thus  the  uterus,  turned  upside  down,  lies  between  the  bladder 
and  the  anterior  wall  of  the  vagina. 

Inversion  of  the  uterus  is  a  condition  in  which  the  uterus  is  partly  or 
completely  turned  inside  out.  There  are  three  degrees,  (i)  the  intrauterine* 
in  which  the  depressed  fundus  does  not  protrude  from  the  cer\ix,  (2)  the 
intravaginal,  in  which  the  fundus  protrudes  through  the  cervix,  and  (3)  the 
extra  vaginal,  in  which  the  inverted  uterus  protrudes  from  the  vulva.  It 
arises  during  the  puerperium  as  the  result  of  traction  on  the  cord,  or  pressure 
on  the  fundus  of  the  uterus  (acute  inversimi),  or  in  non-puerperal  cases  as  the 
result  of  the  dragging  of  a  pedunculated  intrauterine  tumor  {chrmtir  in- 
version). An  intussusception  is  thus  formed,  the  depressed  portion  being 
swallow^ed  by  the  undepressed  portion.  The  lubes  and  o%^aries  may  or  may 
not  lie  within  the  inverted  uterus.  The  symptoms  of  acute  inversion  are 
pain,  shock,  hemorrhage,  and  the  detection  of  a  mass  in  the  vagina.  Chronic 
cases  develop  gradually  and  are  associated  with  metrorrhagia,  leukorrhea, 
dragging  pains  in  the  pelvis  and  back,  and,  from  pressure  on  the  bladder  and 
rectum,  dysuria  and  constipation.  In  intrauterine  or  partial  inversion  a 
cupping  of  the  fundus  may  be  felt  on  bimanual  examination,  and  the  de- 
pressed portion  may  be  detected  by  a  sound  in  the  uterus.  When  the  inver- 
sion is  complete,  the  mass  is  detected  in  the  vagina  or  outside  the  vulva,  the 
uterus  cannot  be  found  in  its  normal  situation,  and  the  cup-shaped  depression 
may  be  felt  on  bimanual  examination.  A  sound,  or^  belter,  the  finger,  may 
be  passed  around  the  tumor,  but  will  enter  the  cervbt  for  a  short  distance  only, 
or  not  at  all.  The  mass  is  sensitive,  bleefls  easily,  is  larger  below^  than  above, 
and  may  show  the  orifices  of  the  Fallopian  tubes.  The  condition  must  be 
differentiated  from  prolapse  (p.  592)  and  from  polypi.  In  the  latter  the 
uterus  is  in  its  normal  situation,  and  a  sound  cannot  be  passed  al!  around  the 
base  of  the  tumor,  but  enters  the  uterine  cavity  at  one  side  and  reveals  it  to  be 
of  normal  or  increased  depth. 

The  treatment  is  reduction,  usually  with  the  aid  of  a  general  anesthetic. 
Emmet's  method  consists  in  passing  the  fingers  arouml  the  tumor  and  into 
the  cervix,  in  order  to  press  upon  the  fundus  with  the  palm  of  ihe  hand  w*hi!e 
the  fingers  dilate  the  cervical  ring,  counterpressure  being  made  with  the  other 
hand  through  the  abdominal  w^alb  Xoeggerath  pushes  on  one  hom  of  the 
uterus  with  the  finger,  thus  reinverting  the  fundus  and  tinally  the  body. 
Prolonged  pressure  on  the  fundus  may  be  employed  by  gauze  packing  or  an 
elastic  vaginal  bag.  Special  apparatus  also  has  been  invented  to  make 
pressure  on  the  fundus  and  pull  down  the  cervix.  If  these  measures  fail  the 
posterior  lip  of  the  cervix  may  be  cut  through  in  the  median  line,  the  uterus 
reduced,  and  the  cepiical  wound  sutured.  Other  operations  for  this  condition 
are  stretching  of  the  cervical  ring  through  an  alidominal  incision,  and  reduc- 
tion by  traction  on  the  fundus;  opening  the  peritoneal  ca\Tty  through  the 
mass,  follow^ed  by  dilatation  of  the  cervical  ring,  suture  of  the  wound,  and 
reposition  of  the  uterus;  and  vagina!  hysterectomy. 

Flbromyomata  or  **fibroids**  of  the  uterus  are  slow-growings  encapsu- 
lated tumors  composed  of  fibrous  and  muscular  tissue,  Hie  fibrous  tissue 
being  in  excess.  WTien  the  muscular  tissue  predominates,  the  term  myo- 
fihroma  is  applicable.     Pure  myomata  are  rare,  grow  rapidly,  and  are  not 

38 


594  GENITAL   ORGANS. 

encapsulated.  Fibroids  arise  during  the  period  of  sexual  activity,  and  ne\'er 
before  puberty  or  after  the  menopause,  in  fact,  subsequent  to  the  climacteric 
they  usually  remain  stationary  or  atrophy.  They  are  most  frequent  in  the 
colored  race  and  in  the  married,  sexual  excitement  and  pregnancy  both  in- 
creasing the  rate  of  growth.  Twenty  per  cent,  of  all  women  who  have 
reached  the  age  of  thirty-five  are  said  to  have  fibroids.  These  tumors  are 
almost  always  multiple  and  vary  greatly  in  size.  The  body  of  the  uterus, 
particularly  the  posterior  wall,  is  the  favorite  situation.  According  to  their 
relations  with  the  uterine  wall,  they  may  be  inter stiiM^  submucous,  or  sub- 
peritoneal  (Fig.  506) ;  the  second  and  third  varieties  may  be  sessOe  or  pedun- 

culated.    A  pedunculated  submucous  growth 

smt^mr^/fiML       /  ^^  ^^'^^  ^  ^^^^^  ^^^^^*     '^^  uterus  is  cn- 

■  ^ "  '  "       '  larged,  and  the  mucous  membrane  hypcrtro- 

phied  and  sometimes  ulcerated.  According 
to  the  situation  of  the  growth,  the  uterus 
may  ascend,  descend,  or  be  pushed  towards 
ifiri^sfim^S?'^^('^^^^^\  one  of  the  walls  of  the  pelvis,  while  a  sub- 
mucous growth  may  cause  inversion.  In  4c 
per  cent,  of  the  cases  (Fleck)  there  is  brown 
atrophy  of  the  heart,  a  fact  accounting  for 
mB»mms/    )^K!SfflE  some  of  the  sudden  deaths  after  operation. 

In  5.1  per  cent.  (Tait)  there  are  inflam- 
matory changes  in  the  tubes  or  ovaries.  The 
changes  which  may  occur  in  the  tumor  itsdf 
FIG.  so6.-l)iagram  showing  the  '^'^  edema  necrobiosis,  suppuration,  gan- 
varieties  of  uterine  fibromyomata.     ^rene,  calcification,  atrophy  (espeaally  after 

•  castration  or  the  menopause),  and  fatty, 
amyloid,  myxomatous,  cystic,  or  sarcomatous  degeneration  (1-2  per  cent.). 
The  growth  may  be  associated  also  with  chondroma  or  osteoma,  or  car- 
cinoma of  the  endometrium. 

The  symptoms  are  (i)  hemorrhage  (menorrhagia,  metrorrhagia,  and 
delayed  menopause),  especially  in  the  submucous  variety;  (2)  pain  due  to 
dysmenorrhea,  particularly  in  submucous  growths,  or  caused  by  peritonitis 
or  pressure  on  the  pelvic  nerves;  (3)  sterility  or  miscarriages;  and  (4)  those 
due  to  pressure  on  the  urethra  or  bladder  (dysuria,  frequent  micturition,  re- 
tention, cystitis),  on  the  ureter  (hydronephrosis,  pyonephrosis),  on  the  rectum 
(constipation,  tenesmus,  obstruction,  hemorrhoids),  on  the  pelvic  nerves 
(pain  or  numbness),  on  the  pelvic  veins  (varicosities  and  edema  of  the  leg, 
phlebitis),  and  during  labor  (dystocia).  Symptoms  may,  however,  be  ab- 
sent in  even  large  growths.  The  uterus  is  irregularly  enlarged  and  often 
tilled  with  hard  masses.  A  submucous  fibroid  may  be  recognized  with  the 
sound,  or  with  the  finger  after  dilatation  of  the  cervix.  Pregnancy,  partic- 
ularly when  associated  with  bleeding,  may  be  mistaken  for  a  fibroid.  In 
these  cases  the  cervi.x  is  softened  and  the  positive  signs  of  pregnancy  will 
sooner  or  later  be  detected.  It  should  be  remembered  that  the  uterine 
souflle  may  often  be  heard  in  large  fibroids  and  that  intermittent  contraction? 
of  the  uterus  can  sometimes  be  felt.  In  doubtful  cases  the  best  diagnostic 
agent  is  time.  It  is  not  unusual  to  mistake  other  tumors  or  chronic  inflam- 
matory troul;les  of  the  pelvis  for  a  fibroid.  A  subperitoneal  fibroid  with  a 
long  pedicle  may  easily  simulate  a  growth  of  a  neighboring  organ. 

Treatment  is  not  needed  in  the  absence  of  symptoms.     If  symptoms  are 


VAGINAL  HYSTERECTOMY.  $95 

present  the  treatment  may  be  palliative  or  radical.  Palliative  treatment 
may  be  indicated  if  the  symptoms  are  slight,  complications  absent,  and  the 
menopause  near.  Drugs  like  ergot,  hamamelis,  hydrastis,  thyroid  extract,  and 
adrenalin  may  be  given  internally  for  hemorrhage,  and  such  occasionally 
lessen  the  size  of  the  growth.  Hygienic  treatment  includes  rest  in  bed  for  a 
portion  of  each  day,  and  the  avoidance  of  constipation,  coitus,  tight  corsets, 
prolonged  walking,  and,  in  short,  anything  which  induces  pelvic  congestion. 
Electrical  treatment  requires  special  apparatus,  is  not  free  from  risk,  and 
should  never  be  used  in  complicated  cases;  it  is  said  to  reduce  the  size  of  the 
tumor,  but  is  of  most  value  as  a  hemostatic.  The  positive  pole  is  attached 
to  a  uterine  sound,  which  is  passed  into  the  uterus,  while  the  negative  pole  is 
placed  on  the  abdomen,  the  current  is  then  gradually  turned  on  to  the  point 
of  tolerance  and  so  maintained  for  five  minutes ;  this  may  be  repeated  once  or 
twice  a  week.  Curettage  followed  by  packing  with  iodoform  gauze  is  a  val- 
uable measure  for  controlling  hemorrhage.  Intrauterine  applications  of 
iodin,  carbolic  acid,  and  other  hemostatics  also  have  been  used  for  the  metror- 
rhagia. Salpingo-oOphorectomy  checks  the  bleeding  and  diminishes  the  size 
of  the  growth,  and  may  be  employed  in  cases  in  which  hysterectomy  is  con- 
traindicated,  because  of  its  difficulty  or  the  general  condition  of  the  patient. 
Ligation  of  the  uterine  arteries  throu^  the  vagina  is  uncertain  in  its  effects  and 
rarely  indicated. 

Radical  treatment  is  indicated  if  the  tumor  is  growing  rapidly,  if  the 
bleeding  is  severe,  or  if  there  are  dangerous  pressure  symptoms  or  serious 
complications.  Generally  speaking,  the  nearer  the  menopause,  tjie  less  the 
'  necessity  for  radical  operation.  An  operation  which  may  be  advisable  in  a 
working  woman  who  cannot  afford  to  be  an  invalid,  might  be  postponed  or 
avoided  in  a  woman  of  means.  Radical  treatment  consists  in  removal  of  the 
growth  alone,  or  the  entire  uterus,  either  through  the  vagina  or  through  the 
abdomen. 

Removal  of  fibrous  polypi  when  small  may  be  effected  with  the  curette; 
growths  of  larger  size  may  be  twisted  off,  or  the  pedicle  may  be  cut  with 
scissors  or  with  the  wire  ^craseur.  Hemorrhage  following  any  of  these  opera- 
tions is  controlled  by  gauze  packing. 

Vaginal  enucleation  of  submucous  fibroids  may  be  performed  after  dila- 
tation or  incision  of  the  cervix,  the  capsule  being  incised,  and  the  tumor 
shelled  out  with  the  finger  or  a  blunt  instrument.  If  the  tumor  is  too  large 
to  be  delivered,  it  may  be  reduced  in  size  by  cutting  sections  out  of  it 
(morcellement) . 

Vaginal  hysterectomy  is  rarely  indicated  for  fibromyomata,  as  a  tumor 
large  enough  to  demand  radical  treatment  is  better  dealt  with  through  the 
abdominal  wall.  The  patient  is  placed  in  the  lithotomy  position,  and  the 
cervix  exposed  by  perineal  and  lateral  retractors,  and  seized  with  strong  ten- 
aculum forceps.  The  peritoneal  cavity  is  opened  by  a  curved  incision  behind 
the  cervix  and  by  a  curved  incision  in  front  of  the  cervix,  care  being  taken  not 
to  injure  the  bladder.  The  uterine  artery  on  each  side  is  then  ligated,  making 
sure  that  the  ureters  are  not  included  in  the  ligature.  The  broad  ligament 
between  the  ligature  and  the  uterus  is  cut,  the  uterus  drawn  further  down, 
and  the  broad  ligament  ligated  in  sections  and  cut  until  the  uterus  is  freed. 
The  final  ligature  is  placed  to  the  outer  or  inner  side  of  the  ovary,  according 
to  whether  it  is  desirable  or  not  to  remove  that  organ.  After  separating  the 
cervix  from  the  vagina  some  operators  turn  the  uterus  upside  down,  thus 


bringing  the  fundus  into  the  vagina,  and  ligate  and  cut  the  broad  ligament 
from  above  downward.  Others,  instead  of  ligatures,  use  clamps  which  are  ^^ 
moved  at  the  end  of  two  or  three  days;  this  method  facilitates  the  operatidQ, 
but  increases  the  danger  of  secondary  hemorrhage,  Wlien  the  uterus  is  too 
large  to  be  delivered  through  the  vagina,  it  may  be  divided  into  halves  in  the 
median  line  and  each  half  removed  separately,  or,  if  it  is  still  too  large,  wedge- 
shaped  portions  may  be  excised  (morceUement)  from  its  center.  After  re 
moval  of  the  uterus,  the  peritoneum  and  vagina  may  be  sutured  or  the  wouml 
filled  with  gauze. 

Abdominal  myomectomy  consists  in  exposing  the  tumor  through  an 
abdominal  incision,  incising  its  capsule,  enucleating  the  growiJi,  and  dosing 

the  uterine  wound  with  catgut  su- 
tures. The  operation  is  particularly 
indicated  m  the  young  in  whom  the 
growths  are  few  and  easily  accessi- 
ble. In  pedunculated  subperitoneal 
tumors,  tlie  pedicle  may  be  ligaied 
if  small,  or  it  may  be  excised  by 
a  wedge-shaped  incision  and 
wound  in  the  uterus  closed  wi 
sutures. 

Abdominal  hysterectomy  ma; 
be  partial  or  complete.  PaHi(U 
supravaginal  hysterectomy  is  die 
operation  of  choice  in  the  majority 
of  cases,  particularly  in  large 
tumors,  in  the  presence  of  degenera- 
tive changes,  and  w^hen  the  tubes  or 
ovaries  are  diseased.     If  the  ovaries 


Fig*  507. — ^Dlagram  of  supravaginal  hys- 
terectomy,  shoeing  Jigatures,  from  above 
downwards,  on  I  he  ovarian  artery,  the  round 
ligament,  and  the  uterine  artery.  The 
bladder  has  been  pashed  downwards,  and 
the  uterus  ampul  a  ted  by  a  wedge-shaped 
incision.  The  dotted  Jines  indicate  the 
situation  of  the  ureters,  which  pass  under 
the  uterine  arteries  about  three-fourths  of 
an  inch  from  the  cervix. 


the^ 
■itifl 

"J 


L 


are  healthy  and  the  patient  voun^ 
at  least  one  should  be  preser^'ed,  in  order  to  avoid  the  nervous  s^^mptoins 
induced  by  an  artificial  menopause.  A  median  incision  is  made  below  ihe 
umbilicus,  ailhesions  separated,  the  uterus  delivered  through  the  wound, 
the  foot  of  the  table  raised  (Trendelenburg  posture),  the  intestines  pushed 
upwards  and  held  in  place  with  gauze  pads,  and  each  broad  hgament  severed 
after  tying  the  ovarian  artery,  the  round  ligament,  and  the  uterine  arten\ 
clamps  or  ligatures  being  placed  on  the  uterine  edge  of  the  broad  ligament  to 
prevent  rellux  hemorrhage.  The  ligatures  are  passed  through  the  broad  hga- 
ment by  an  aneurysm  or  pedicle  needle  and  may  be  of  silk  or  catgut.  The 
ovarian  artery  may  be  tied  to  the  outer  or  the  inner  side  of  the  ovary »  accord- 
ing to  whether  this  organ  is  to  be  removed  or  retained.  In  securing  the  uler 
ine  artery,  the  needle  must  be  passed  close  to  the  cervix,  in  order  to  avoid  the 
ureter.  The  two  incisions  in  the  broad  ligaments  are  now^  joined  by  cutting 
the  peritoneum  across  the  uterus  just  above  the  bladder,  which  is  pushed 
downward  w4ih  the  handle  of  the  knife.  A  similar  incision  is  made  poste- 
riorly, and  the  uterus  amputated  at  the  level  of  the  internal  os  by  a  wedge- 
shaped  incision  (Fig,  507).  The  cervix  is  now^  closed  with  catgut  sutures, 
and  the  peritoneum  appro.ximated  over  the  stumps  of  the  arteries  and  the  cer- 
vix by  a  continuous  catgut  suture.  The  abdomen  is  closed  \vithout  drainage. 
Compktc  hyslerechmy,  or  panhy stent iorny,  is  to  be  preferred  if  tliere  is  asso* 
dated  malignant  disease  or  infection  of  the  tumor,  or  fibroid  growths  in  the 


I 
I 


CARCINOMA    OF  THE    tJTERUS. 


597 


cervijt-  The  broad  ligaments  are  ligated  and  divided  and  the  bladder 
stripped  from  the  cenix,  as  in  the  previous  operation.  An  incision  is  then 
made  into  the  vagina  through  Douglas's  cui  de  sac,  and^  aided  by  a  finger 
passed  through  this  opening  into  the  vagina,  the  incision  is  continued  all 
around  the  cervix  and  ihe  uterus  removed.  The  opening  in  the  vagina  is 
then  dosed  by  sutures,  or  it  may  give  exit  to  a  gauze  drain  if  such  be  needed. 
WTien  there  are  intraligamentar>'  fibroids,  it  is  often  better  to  sever  first  the 
broad  ligament  on  the  unaffected  side,  then  to  cut  through  or  around  the 
cervix,  and  Hgate  and  divide  the  opposite  broad  ligament  from  below  upwards 
while  the  uterus  is  rolled  strongly  towards  the  affected  side;  by  this  procedure 
an  in  trail  game  ntary  growth  is  turned  out  of  its  bed  and  the  danger  of  injury 
to  the  ureter  minimized. 

Polypi  of  the  uterus  are  pedunculated  tumors  springing  from  the  mu- 
cous membrane  of  the  body,  or  more  frequently  the  neck  of  the  uterus.  Fi- 
braus  polypi  have  been  considered  above.  Mucous  polypi  are  soft  red  growths 
composed  of  mucous  membrane.  Pedunculated  Naboihian  failides  are 
retention  cysts  of  the  cervical  glands  which  have  acquired  pedicles.  Placental 
polypi  are  undetached  portions  of  the  placenta  which  retain  a  vascular  con- 
nection with  the  uterus.  .4  papillomatous  polypus  may  spring  from  the  cervix, 
and  is  ver>'  apt  to  become  malignant.  The  symptoms  are  bleeding,  leukor- 
rhea,  cramp-like  pains  due  to  the  expulsive  efforts  of  the  uterus,  dysmenor- 
rhea, and  sterility.  When  the  polypus  protrudes  from  the  os,  it  is  easily  de- 
tected with  the  finger  and  the  speculum.  Before  this  lime  it  may  be  over- 
looked, but  may  be  recognized  either  with  the  sound,  or  with  the  finger  after 
dilatation  of  the  cervix.  The  treatment  is  removal  by  seizing  the  tumor  with  a 
pair  of  forceps,  and  twisting  it  until  the  pedicle  gives  way,  or  the  pedicle  may 
be  cut  with  scissors,  the  galvano^cautery,  or  the  wire  ^craseur.  Small  soft 
polypi  may  be  removed  with  the  curette^  In  all  cases  the  growth  should  be 
studied  microscopically  to  exclude  malignant  disease, 

8arcoma  of  the  uterus  is  uncommon,  is  most  frequent  in  the  body  of  the 
uterus,  and  is  often  a  degenerative  process  in  a  fibromyoma.  It  is  usually 
of  the  spindle-celled  variety,  and  has  the  same  tendencies  here  as  elsewhere. 
The  symptoms  are  pain,  uterine  hemorrhages,  watery  leukorrhea,  emaciation, 
a  rapidly  growing  tumor,  and  in  some  cases  ascites.  A  fibroid  which  grows 
rapidly,  continue^j  to  increase  in  size  after  the  menopause,  or  which  recurs 
after  removal,  strongly  suggests  sarcomatous  degeneration.  The  treaimeftt 
is  complete  hystereclomy. 

Caxcinoma  of  the  uterus  is  the  most  frequent  form  of  malignant  disease 
in  the  human  body.  It  is  most  common  after  the  fortieth  year,  but  may  arise 
in  early  life.  The  intluence  of  heredity  is  douljtful,  but  any  local  irritation, 
such  as  laceration  of  the  cervix^  polypus^  and  chronic  endometritis^  favors  its 
development.  In  over  80  per  cent,  of  the  cases  the  disease  originates  in  the 
cervix.  It  may  be  squamous- eel  led  (epithelioma)  when  springing  from  the 
vaginal  portion  of  the  cervk,  or  cylindrical-celled  (adaiocarcinoma)  when  at- 
tacking the  cervical  canal  or  corporeal  endometrium.  Epithelioma  of  the 
ccri^ix  begins  as  a  nodule  in  the  vaginal  portion  of  the  mucosa,  from  which, 
after  a  time,  finger-like  projections  spring,  forming  a  caulitlower-like  mass; 
or  as  the  resultof  necrosis,  the  growth  appears  as  an  excavated  ulcer  with  hard- 
ened everted  edges.  Extension  is  most  rapid  in  the  direction  of  the  vagina, 
and  the  growth  involves  the  bladder  at  an  early  period.  Adatocarcinoma  of 
the  cervical  endomelrium  soon  causes  enlargement  of  the  cervical  canal,  either 


59S  GKXITAL   ORGANS. 

by  ulcerdiiuii.  ur  ijv  prc??urc  from  papiUan-  growths.  The  disease  is  proi 
to  extend  outward  into  the  parametrium  sdong  the  bases  of  the  broad  lig 
meni?,  and  upward  into  the  body  of  the  uterus,  long  before  it  invades  tj 
vaginal  portion  of  the  cenLx:  the  bladder,  and  less  frequently  the  rectum. m; 
be  involved  in  the  later  stages.  Cancer  of  the  fundus  projects  into  the  uteri 
cavity  as  a  fungous  mass,  which  ulcerates,  and  extends  through  the  uteri 
wall  to  the  environing  structures.  Cancer  of  the  uterus  in  most  instanc 
involves  the  regional  lymph  glands,  only  after  it  has  extended  to  the  pai 
metrium:  this  is  said  to  be  due  to  the  small  size  of  the  lymph  vessels  of  t 
uterus  and  the  large  size  of  the  epithelial  cells.  Metastases  to  distant  jx 
tions  of  the  lx)dy  are  therefore  comparatively  infrequent.  Unchecked,  t 
disease  is  usually  fatal  in  from  six  months  to  two  years. 

The  symptoms,  in  the  usual  order  of  their  appearance,  are  hemorrhaj 
offensive  discharge,  pain,  and  cachexia.  Pain  is  often  absent  until  the  per 
oneum  or  parametrium  is  involved,  while  cachexia  is  often  postponed  un 
near  the  end:  consequently  to  wait  for  these  signs  before  making  a  diagnoi 
is  usually  to  wait  until  the  case  is  inoperable.  Pressure  symptoms  similar 
those  induced  by  fibromyomaia  (p.  594),  and  urinary  or  fecal  fistulx  fro 
ulceration  invjjlving  the  bladder  or  rectum  maV  arise  in  the  final  stagt 
Epithelioma  of  the  vaginal  portion  of  the  cenix  can  be  recognized  with  il 
hnger  or  speculum,  as  a  friable,  fungating,  easily  bleeding  mass.  In  can 
noma  of  the  cervical  canal  the  cervix  is  enlarged,  firmer  than  normal,  and  som 
times  infiltrated  with  nodules,  and  the  growth  may  be  felt  by  insening  tl 
finger  into  ihe  cervical  canal.  Cancer  of  the  fundus  causes  enlargement  i 
the  uterus  ami  may  be  felt  with  the  sound.  In  doubtful  cases  a  portio 
should  be  removed  for  microscopic  examination,  by  excision  when  the  disea: 
is  in  the  ( crvi.x,  ami  by  the  curette  when  in  the  l>ody  of  the  uterus.  Menoi 
rhajria  at.  or  metrorrhagia  subscijuenl  to  the  menopause,  is  so  strongly  sus 
•festive  of  taniLT,  a>  to  demand  a  m«^st  careful  investigation,  inclmiin 
micro?cr)j)ic  examination  of  suspected  tissue. 

The  treatment  is  palliative  or  radical.  Palliative  treatment  isindi 
(aled  in  innj>LTable  cases,  which,  unfortunately,  constitute  the  vast  majoriiyo 
tho-c  ( «)niiii;:  under  <)ij>ervation.  When  the  uterus  is  fixed  in  the  pelvis,  in 
dilating  in\a><i«)n  «>f  the  i)arametrium,  or  when  the  bladder  or  rectum  i 
involved,  radical  <»pcrati«»n  i>  i^cnerally  c«)nlraindicated,  although  attempi 
are  M>m(iinu>  made  to  remove  a  portion  of  all  these  structures  with  the  utenii 
llemorrhaize  and  di<diar«^e  are  greatly  lessened,  and  life  prolonged,  by  re 
moviiii;  a>  mmh  of  the  j^rowih  as  possible  with  a  curette,  and  cauterizing  th< 
raw  surfac  e>  w  itli  the  Pacjuelin  cautery ;  the  cavity  is  filled  with  iodoform  gauze 
which  i-  removed  at  the  en<lof  twenty-four  hours,  and  douches  of  perman 
;^anaie  of  j>oia->ium,  i  reolin,  or  other  antiseptic  deodorant  given  daily.  Can 
>hould  In-  taken  not  to  perforate  the  uterus  during  this  operation.  Instead  of 
or  in  addition  t<»  the  Pa([uelin cautery,  some  surgeons  insert  into  the  cavity: 
tamp<»n  oniaining  a  50  per  cent,  solution  of  chlorid  of  zinc,  which  is  allowe< 
to  remain  xveral  days.  The  vagina  should  I'lrst  be  coated  with  an  ointmeni 
con.si-tini:  <>f  <>ne  part  of  xxlium  bicari)onate  to  three  parts  of  vaselin.  Noth 
ing  short  of  opium  is  of  value  for  the  excruciating  pain  in  the  later  stages. 

Radical  treatment  consists  in  removal  t)f  the  uterus  through  the  vagina 
throujzh  llie  alxiomen,  or  by  the  combined  method.  Vaginal  hysterectomy 
may  i)e  emj)loye<l  when  the  vagina  is  large,  the  uterus  small,  and  the  patieni 
very  stout.     'I'he  operation  is  similar  to  that  already  described  for  libro- 


DISORDERS    OF   MENSTRUATION.  599 

myoma,  except  that  any  protruding  carcinomatous  tissue  should  first  be  re- 
moved with  the  curette  and  the  cervix  closed  with  sutures,  and  hemisection 
of  the  uterus  or  morcellation  should  never  be  employed.  Complete  abdo- 
minal  hysterectomy  is  the  operation  of  choice,  as  it  allows  the  wide  removal 
of  the  parametrium  and  of  any  enlarged  retroperitoneal  lymph  glands. 
The  operation  is  identical  with  that  described  for  fibroids,  except  that  the 
uterus  should  first  be  curetted,  packed  with  gauze,  and  the  cervix  dosed  with 
sutures,  in  order  to  prevent  infection  of  the  peritoneum  when  the  vagina  is 
opened,  and  the  uterine  arteries  should  be  ligated,  not  close  to  the  cervix,  but 
to  the  outer  side  of  the  ureters.  Combined  vaginal  and  abdominal  hysterec- 
tomy is  preferred  by  some  operators.  The  cervix  may  be  isolated  from 
the  vagina  and  the  operation  completed  through  the  abdomen;  or  the  broad 
ligaments  may  be  tied  and  divided  from  above,  the  abdomen  closed,  and 
the  operation  completed  through  the  vagina.  The  mortality  of  hysterec- 
tomy for  carcinoma  is  from  10  to  20  per  cent.  The  chances  of  per- 
manent cure  are  about  5  per  cent,  in  carcinoma  of  the  cervix,  and  about 
75  per  cent,  in  carcinoma  of  the  fundus. 

Endothelioma  of  the  uterus  is  rare  and  cannot  be  differentiated  clinic- 
ally from  carcinoma.     The  treatment  is  complete  hysterectomy. 

Chorio-epithelioma,  deciduoma  mcUignum^  or  syncytioma  malignum^  is  a 
malignant  growth  springing  from  the  chorionic  epithelium  following  preg- 
nancy. The  growth  resembles  placental  tissue  infiltrated  with  blood.  The 
symptoms  usually  arise  a  few  weeks  or  months  after  a  normal  labor  or  an 
abortion,  particularly  if  there  has  been  a  hydatidiform  mole.  There  are 
metrorrhagia  and  a  foul  smelling,  watery  discharge,  and  later  pain.  The 
OS  is  dilated,  and  the  uterus  large  and  its  cavity  filled  with  a  friable,  pur- 
plish mass,  which  recurs  after  removal,  extends  to  the  surrounding  parts, 
and  quickly  gives  rise  to  distant  metastases.  The  diagnosis  is  made  with 
the  microscope.     The  treatment  is  immediate  complete  hysterectomy. 


DISORDERS  OF  MENSTRUATION. 

Amenorrhea,  or  absence  of  menstruation,  is  normal  before  puberty, 
after  the  menopause,  and  during  pregnancy  and  lactation.  The  pathological 
causes  are  atresia  of  the  genital  canal  {concealed  menstruation)  y  non-develop- 
ment or  atrophy  of  the  generative  organs,  destruction  of  the  ovaries  and  tubes 
by  disease  or  their  removal  by  operation,  obesity,  emotional  disturbances, 
hysteria,  neurasthenia,  debilitating  diseases,  change  of  climate,  catching 
cold  during  menstruation,  opium  and  other  drug  habits,  and  most  frequently 
of  all  chlorosis.  The  treatment  is  that  of  the  cause.  Suppression  of  the 
menses  due  to  cold  is  treated  by  hot  drinks  and  hot  applications.  Emmena- 
gogues  are  rarely  indicated,  and  should  never  be  employed  unless  pregnancy 
can  be  positively  excluded. 

Vicarious  menstruation  is  the  periodic  discharge  of  blood  from  some 
other  part  of  the  body  than  the  uterine  mucosa.  It  may  occur  from  any 
mucous  membrane,  the  skin,  or  from  an  ulcer,  and  is  usually  associated  with 
amenorrhea  or  scanty  menstruation.  Attempts  may  be  made  to  induce 
normal  menstruation  by  hot  douches,  electricity  locally,  and  the  internal  use 
of  emmenagogues,  such  as  iron,  oxalic  acid,  aloes,  apiolin,  or  the  salicylates. 
Irritating  applications  to  the  endometrium  are  dangerous. 


6CK)  ^^^^  GENITAL    ORGANS. 

Menorrhagia  is  prolonged  or  increased  menstrual  bleeding.  Metror- 
rliagia  is  bleeding  from  the  uterus  between  the  menstniaJ  periods.  Among 
the  local  causes  are  inflammatory  diseases,  displacements,  injuries,  and  ne^- 
plasms  of  the  uterus  or  appendages,  foreign  bodies  in  the  uterus,  pd^ic 
tumors  not  connected  with  the  uterus,  placenta  preWa,  detachment  of  Qie 
placenta,  hydatidiform  degeneration  of  the  chorion,  ectopic  pregnancy*. 
abortion,  sclerosis  of  the  uterine  vessels,  and  most  common  of  all  fungous 
endometritis.  Among  the  general  causes  are  anemia,  hemophilia,  acute 
infectious  diseases,  emotional  disturbances,  gout,  scurvy,  malaria,  lead 
poisoning,  and  diseases  of  the  heart,  lungs,  and  liver. 

The  treatment  is  that  of  the  cause.  In  an  emergency  the  bleeding  mkj 
be  checked  by  packing  the  uterus  tightly  with  gauze,  while  ergot,  hydrasds, 
or  suprarenal  extract  may  be  given  internally.  Uncontrollable  bleeding  U 
the  menopause  may  demand  hysterectomy. 

Dysmenorrhea  is  excessive  pain  just  before,  during,  or  immediatdj 
after  the  menses.  Like  amenorrhea,  menorrhagia,  and  metrorrha^a, 
dysmenorrhea  is  a  symptom,  not  a  disease.  The  following  varieties  are 
described : 

Neuralgic  dysmenorrhea  is  most  frequent  In  the  anemic  and  nervous, 
and  may  or  may  not  be  associated  with  disease  of  the  pelvic  organs.  The 
pain  is  neuralgic  in  character,  and  may  be  referred  to  the  uterus,  to  the 
ovaries,  or  elsewhere.  It  is  apt  to  be  most  severe  before,  and  is  occasionally 
relieved  by  the  flow*  There  may  be  neuralgia  in  other  parts  of  the  body. 
The  treatment  is  attention  to  the  general  heahh,  anemia,  gout,  rheumatism, 
or  indigestion  being  relieved  by  appropriate  remedies.  Any  local  disease 
should  be  removed,  and  the  pain  itself  relieved  by  hot  applications  and  the 
administration  of  an ti neuralgic  remedies  like  acetphenetidin,  cannabis  indica^ 
and  belladonna;  elixir  of  %'alerianate  of  ammonium  (fo  ii)  or  fluid  extract 
of  viburnum  prunifolium  (f3  i),  every  three  or  four  hours,  is  frequently 
employed.  In  cases  which  resist  all  other  forms  of  treatment,  removal  of 
the  ovaries  may  be  indicated. 

Congestive  dysmenorrhea  is  due  to  exposure  to  cold,  uterine  displace- 
ments, pelvic  tumors,  and  inflammations  of  the  uterus,  the  appendages,  or 
the  environing  structures.  These  conditions,  excepting  the  first,  cause 
intermenstrual  symptoms  and  may  be  recognized  by  pelvic  examination. 
The  symptoms  are  worst  at  the  beginning  of  menstruation,  and  are  often 
relieved  by  a  free  flow\  The  treatment  during  the  attack  is  hot  applications, 
hot  sitz  baths,  diuretics,  and  diaphoretics.  Between  attacks  the  cause  should 
be  removed. 

Mechanical  or  obstructive  dysmenorrhea  is  due  to  some  obstruction 
to  the  egress  of  menstrual  fluid,  such  as  stenosis  of  the  cervix,  flexions  of  the 
uterus,  tumors  (particularly  polyps),  and  spasmodic  contraction  of  the  inter- 
nal OS.  There  are  severe,  cramp-like  pains  {uterine  colic)  ^  follow^ed  by  a 
gush  of  blood  or  tlie  expulsion  of  clots,  w^hich  usually  gives  relief.  Between 
the  periods  the  passage  of  a  sound  may  reveal  hyperesthesia  of  the  endome- 
trium, particularly  about  the  internal  os.  The  treatment  is  dilatation  of  the 
cervical  cana!  if  there  be  stenosis,  and  curettage  of  the  uterus  if  there  be 
endometritis.  Polypi  should,  of  course,  be  removed.  The  treatment  of 
flexions  has  already  been  considered.  Obstructive  dysmenorrhea  is  often 
cured  by  labor,  which  permanently  dilates  the  cervical  canal. 

Ovarian  dysmenorrhea  is  associated  with  disease  of  the  ovaries,  the 


k 


SALPINGITIS. 


6oi 


symptoms  referable  to  these  organs  being  intensified  during  the  menstrual 
period.     The  irealmefti  is  that  of  the  causative  lesion. 

Membranous  dysmenorrhea  is  characterized  by  the  expulsion  of  a 
membrane,  the  decidua  menstrualis,  either  in  shreds  or  as  a  cast  of  the  uterus. 
It  is  differentiated  from  an  early  abortion  by  its  regular  occurrence,  and  by 
the  absence  of  chorionic  vilJi  in  the  memljrane.  It  is  a  form  of  endometritiSj 
and  is  usually  associated  with  sterility.  The  Ir^almeni  is  dilatation  and 
curettage,  which  may  require  repetition. 

Sterility  in  the  female  is  normal  before  puberty,  after  the  menopause, 
and  during  lactation,  although  conception  may  ociur  during  any  of  these 
periods.  At  other  times  it  may  be  due  to  i>reventive  measures,  vaginismus, 
displacements  or  atrophy  of  the  uterus,  laceration  of  the  perineum  suffici- 
ently severe  to  interfere  with  retention  of  semen,  or  to  congenital  defects, 
stenosis,  atresia,  fistuke,  neoplasms,  or  inflamraator}^  diseases  of  any  portion 
of  the  genital  tract.  Among  the  general  conditions  which  may  be  responsible 
are  anemia,  debilitating  diseases,  obesity,  gout,  syphilis,  chronic  alcohol isra, 
and  lack  of  affinity  between  the  male  and  female.  It  should  be  recalled 
that  in  about  one-fifth  of  the  cases  the  fault  lies  with  the  male,  hence  in 
order  to  be  complete,  an  investigation  for  the  cause  of  sterility  should  in- 
clude an  examination  of  the  male  sexual  organs,  the  microscopic  examina- 
tion of  the  semen  for  spermatoaoa.  and  an  inquiry  into  the  potency  of  the 
male.     The  trmtmeni  is  that  of  the  cause. 


THE  FALLOPIAN  TUBES. 

Congenital  Anomalies. — ^The  tubes  may  be  absent  or  rudimentary, 
they  may  have  accessor)^  fimbriated  extremities,  and  the  tubal  ducts  may  be 
doubled  on  one  or  both  sides. 

Displacements  are  usually  downwards  and  backwards  as  the  result  of 
inflammatory  trouble.  The  tubes  accompany  displacements  of  the  uterus 
or  ovaries,  and  may  be  pushed  in  any  direction  by  tumors. 

Salpingitis,  or  indammation  of  the  Fallopian  tube,  is  usually  the  result  of 
extension  upwards  of  an  endometritis;  its  causes,  therefore,  include  those 
of  endometrids,  particularly  gonorrhea,  the  use  of  septic  instruments,  and 
sepsis  following  labor  or  abortion;  occasionally  the  inflammation  extends 
from  the  peritoneum  or  neighboring  organs  other  than  the  uterus,  and 
infection  is  sometimes  conveyed  to  the  tube  by  the  blood  or  lymph  vessels. 
The  organism  most  frequently  found  is  the  gonococcus,  and  next,  in  the 
order  of  their  frequency,  the  streptococcus,  tubercle  bacillus,  colon  bacillus, 
staphylococcus,  and  pneumococcus.  In  most  of  the  tubes  removed  at  opera- 
rion,  cultures  are  negative,  the  organisms  having  perished.  The  inflamma- 
tion first  involves  the  mucous  membrane,  then  spreads  through  the  outer 
walls  to  the  peritoneum  and  closes  both  ends  of  the  tube.  TJie  secretions 
accumulate  and  distend  the  tube,  particulariy  the  outer  two-thirds.  The 
walls  may  be  either  thinned  or  thickened.  The  tube  is  distorted,  affherent 
to  adjacent  structures,  and  commonly  displaced  downwards  and  backwards, 
although  it  may  remain  in  its  normal  situation  or  be  displaced  even  forwards. 
Hydrosalpinx,  or  distention  of  the  tube  with  serum  or  mucus,  is  the  result 
of  a  catarrhal  infiammadon;  such  a  sac  may  empty  itself  intermittently  into 
the  uterus  {kydrofis  tubiT  profluens).  Hematosalpinx  is  distention  of  the  tube 
with  blood,  as  the  result  of  infiammation,  tubal  pregnancy,  torsion  of  the  tube, 


602  GENITAL   ORGANS. 

or  atresia  of  any  portion  of  the  genital  tract.  Pyosalpitix  is  distention  of  the 
tube  with  pus,  which  may  rupture  into  the  bowel,  bladder,  vagina,  or  into 
the  peritoneal  cavity,  in  the  last  instance  causing  a  pelvic  abscess  or  a  general- 
ized peritonitis.  Leakage  of  the  pus  from  the  abdominal  ostium  also  may 
occur,  and  rarely  the  infection  spreads  downwards  between  the  layers  of 
the  broad  ligament,  giving  rise  to  pelvic  cellulitis  or  abscess  of  the  broad 
ligament. 

The  Sjrmptoms  are  pain  in  the  lower  abdomen,  most  marked  just  above 
Poupart's  ligament,  and  increased  by  walking,  jolting,  or  straining;  leukor- 
rhea;  dysmenorrhea;  menorrhagia;  sometimes  metrorrhagia;  usually  sterility; 
and  disturbances  of  the  general  health.  There  are  often  backache,  rectal 
pain  intensified  at  stool,  and  sometimes  pain  in  distant  parts,  such  as  the 
head,  the  breast,  the  epigastrium,  or  the  thighs.  In  pyosalpinz  there  may  be 
repeated  attacks  of  pelvic  peritonitis  with  septic  symptoms.  On  bimanual 
examination,  pressure  on  the  uterus,  or  in  the  lateral  or  posterior  fornix, 
causes  pain;  the  uterus  is  usually  retroverted  and  adherent,  and  the  distended 
tubes  are  felt  behind  or  to  the  sides  of  the  uterus. 

The  treatment  may  be  medical  or  surgical.  Medical  treatment  is  indi- 
cated during  the  acute  stage,  during  acute  exacerbations  of  a  chronic  inflam- 
mation, and  in  chronic  cases  in  the  absence  of  suppuration.  In  the  presence 
of  acute  symptoms  with  fever,  the  patient  should  be  confined  to  bed  and  be 
given  a  liquid  diet.  An  ice  bag  should  be  applied  to  the  hypogastrium. 
copious,  hot  vaginal  douches  given  twice  a  day,  and  the  bowels  thoroughly 
moved  with  salts.  Depletion  may  be  secured  also  by  scarification  of  the 
cervix  and  glycerin  tampons.  In  severe  cases  anodynes  and  stimulants 
N^ill  be  required.  UTien  the  acute  symptoms  have  subsided,  absorption  of 
the  exudate  may  be  encouraged  by  the  application  of  iodin  to  the  vaginal 
fornices,  and  !;y  the  pressure  of  tampons  containing  glycerin  or  icfathyol. 
which  should  be  removed  in  forty-eight  hours,  a  copious  hot  douche  taken, 
and  the  tampons  reinserted.  In  selected  cases  curettage  of  the  uterus  is 
beneficial,  although  it  occasionally  stirs  the  chronic  inflammation  to  renewed 
activity. 

The  surgical  or  radical  treatment  of  salpingitis  is  indicated  in  the 
presence  of  pus,  and  in  ( ases  in  which  medical  treatment  fails  to  give  relief: 
in  other  words  in  the  large  majority  of  cases.  The  tubes  may  be  exposed 
for  operative  attack  through  the  vagina  or  through  the  abdomen.  In 
VQi^hial  section  the  intestines  and  ureters  arc  more  apt  to  be  damaged,  bleed- 
ing is  more  diffu  ult  to  control,  secondar\'  hemorrhage  is  more  frequent,  the 
general  peritoneal  cavity  cannot  be  protected,  and  disease  of  en\'ironing 
organs,  particularly  the  appendix,  cannot  be  treated  satisfactorily;  it  is, 
therefore,  seldom  indicated.  Abdominal  section  is  always  more  or  less 
exploratory  in  these  cases,  and  the  surgeon  should  secure  permission  to  do 
that  which  in  his  judgment  seems  best.  The  abdomen  is  opened  by  a 
median  incision  below  the  umbilicus,  the  table  raised  to  the  Trendelenburg 
posture,  and  the  operative  field  isolated  with  gauze.  After  identifying  the 
fundus  of  the  uterus,  two  fingers  are  insinuated  downwards  along  its  |X)stenor 
surface  and  adhesions  separated  in  the  lines  of  least  resistance,  the  fingers 
passing  outwards  and  usually  unrolling  the  tube  from  below  upwards.  Ad- 
hesions may  recjuire  the  use  of  scissors  and  the  application  of  ligatures. 
.Should  pus  appear  at  any  time,  it  is  caught  with  sponges  and  the  table  immedi- 
ately lowered,  while  any  unavoidable  injury  to  the  bowel  should  be  closed 


SALPINGITIS. 


603 


at  once  with  sutures.  As  a  rule  both  tubes  and  ovaries  will  be  so  extensively 
diseased  as  to  require  removal  (salpingo-odphorectomy).  This  may  be  done 
by  passing  a  pedicle  needle  armed  with  silk  or  catgut  through  the  broad 
ligament  and  below  the  round  ligament  (Fig.  508);  the  loop  of  the  ligature 
is  cut,  one-half  tied  around  the  tube  close  to  the  uterus,  and  the  second 
beneath  the  ovary.  The  ends  of  one  of  these  ligatures  may  be  left  long 
and  again  carried  around  the  pedicle  and  tied,  always  using  a  surgeon's 
knot  first  and  then  a  single  knot.  The  tube  and  ovary  are  then  amputated 
above  the  ligatures,  leaving  suflScient  tissue  to  prevent  slipping.  This 
method  is  easy  and  quick,  but  may  be  followed  by  secondary  hemorrhage, 
as  the  ligatures  are  apt  to  loosen  from  shrinkage  of  the  stump  or  to  cut 
through  the  friable  tissues;  more- 
over, the  large  area  left  uncovered 
by  peritoneum  predisposes  to  adhe- 
sions and  intestinal  obstruction.  A 
better  way  is  to  pass  a  ligature 
through  the  broad  ligament  to  the 
outer  side  of  the  ovary,  thus  includ- 
ing the  infundibulo-pelvic  ligament 
and  the  ovarian  artery.  A  second 
ligature  is  then  placed  in  the  angle 
between  the  round  ligament  and  the 
uterus,  securing  the  upper  end  of 
the  uterine  artery  (Fig.  508).  The 
tube  and  ovary  are  removed  by 
cutting  close  to  them  with  scissors, 
the  uterine  end  of  the  tube  being 
amputated  by  a  wedge-shaped  in- 
cision. The  wound  in  the  uterus  and  broad  ligament  is  now  closed  with  a 
continuous  catgut  suture.  When  both  tubes  and  ovaries  are  excised,  some 
operators  advise  a  supravaginal  amputation  of  the  uterus,  in  order  to  remove 
all  the  infected  structures,  and  likewise  prevent  the  adhesions  which  neces- 
sarily form  between  the  intestines  and  the  raw  posterior  surface  of  the  uterus. 
If  the  ovaries  are  normal  they  should  be  allowed  to  remain,  the  ligature 
securing  the  ovarian  artery  being  placed  to  the  inner  side  of  the  ovary. 
Occasionally  only  the  outer  two-thirds  of  the  tube  will  require  removal,  the 
mucous  membrane  of  the  remaining  portion  being  sutured  to  the  peritoneum, 
in  order  to  allow  the  passage  of  ova.  In  cases  of  sterility  due  to  closure  of 
the  abdominal  ostium,  salpingostomy  may  be  performed  if  the  tube  is  fairly 
healthy.  The  outer  end  of  the  tube  is  opened,  and  its  mucous  membrane 
sutured  to  the  peritoneum  with  catgut.  When  the  tubes  are  neither  seriously 
altered  in  structure  nor  occluded,  but  simply  prolapsed  and  adherent,  the 
adhesions  may  be  separated,  and  the  tubes  retained  in  their  normal  position 
by  shortening  the  infundibulo-pelvic  ligaments,  or  by  performing  one  of  the 
operations  for  retroversion.  Drainage  is  rarely  needed  after  operations  for 
salpingitis,  but  may  be  required  for  continued  oozing  from  adhesions,  or  in 
cases  in  which  the  infection  is  active.  The  best  drain  for  these  cases  is 
gauze  surrounded  by  rubber  tissue,  the  drain  gaining  exit  through  the 
abdominal  wound,  or  better,  through  the  posterior  vaginal  fornix. 

Tuberculous  salpingitis  is  the  most  frequent  form  of  genital  tuberculo- 
sis; it  is  usually  bilateral  and  secondary  to  tuberculosis  elsewhere,  but  may 


Fig.  508. — Methods  of  ligation  in  salpingo- 
oophorectomy.  On  the  right  mass  ligation 
of  the  broad  ligament.  On  the  left  ligation 
of  the  individual  vessels,  with  wedge-shaped 
amputation  of  the  tube;  the  wound  in  the 
uterus  and  broad  ligament  is  closed  with  a 
continuous  catgut  suture. 


604  GENITAL   ORGANS. 

be  primary,  the  bacilli  being  conveyed  to  the  tubes  from  the  endometrium  o 
peritoneum,  or  through  the  blood  or  lymph  vessels.  The  tubes  are  usuall 
distended  with  pus  or  cheesy  material,  and  give  rise  to  symptoms  similir  t 
those  of  other  forms  of  salpingitis.  The  condition  may  be  suspected  i 
there  is  tuberculosis  elsewhere  in  the  body,  if  evidences  of  other  forms  c 
infection  are  absent,  if  there  is  an  encysted  ascites,  and  if  on  bimanw 
examination  the  tubes  are  nodular  and  only  slightly  sensitive.  Tuberd 
bacilli  have  been  found  in  the  discharge  from  the  uterus.  The  treatment : 
salpingo-oophorectomy. 

Neoplasms  of  the  tubes  include  papilloma,  carcinoma,  fibromyomj 
lipoma,  dermoids,  lymphangioma,  enchondroma,  and  sarcoma.  The 
growths  are  rarely  recognized  until  after  abdominal  section  for  the 
removal. 

Extrauterine  or  ectopic  pregnancy  occurs  about  once  to  every  50 
intrauterine  pregnancies.  The  causes  are  not  dear,  but  it  is  supposed  to  h 
due  to  an  unusually  large  ovum,  or  to  conditions  which  narrow,  elongate,  0 
twist  the  tube,  or  destroy  the  cilia  of  the  mucosa,  thus  interfering  with  it 
peristalsis.  Among  these  conditions  are  salpingitis,  peritoneal  adhesioiu 
neoplasms,  stenosis  or  atresia,  and  tubal  diverticulum.  According  to  it 
situation  the  pregnancy  may  be  (i)  tubal,  usually  in  the  free  portion  {kM 
proper),  but  occasionally  in  that  part  embraced  by  the  uterine  wall  {tube 
uterine  or  interstitial),  or  between  the  tube  and  the  ovary  {tuho-avarian);  {2 
ovarian,  which  is  very  rare;  or  (3)  abdominal,  the  ovum  being  fertilized  in< 
developing  in  the  peritoneal  cavity  {primary  abdominal  pregnancy)  y  an  even 
which  many  believe  cannot  occur,  or  escaping  from  one  of  the  previous!} 
mentioned  situations  and  continuing  its  growth  in  the  abdominal  cavi^ 
{secondary  abdominal  pregnancy).  It  is  possible  for  an  enlarging  ovum  11 
the  uterine  cavity  to  break  through  an  old  scar  in  the  uterus  and  thus  become 
abdominal. 

Pathology. — In  tubal  pregnancy  the  walls  of  the  tube  at  first  thicken 
and  later  become  thin  and  weak  owing  to  distention  and  to  the  ingrowth  ol 
chorionic  villi.  The  abdominal  ostium  narrows,  and  finally  closes  about  th< 
eighth  week.  Prior  to  this  time  the  ovum  may  be  extruded  from  the  fim- 
briated extremity,  constituting  a  tubal  abortion.  If  this  does  not  occur, 
he  tube  usually  ruptures,  most  often  between  the  eighth  and  twelfth  weeks, 
either  into  the  peritoneal  cavity  or  between  the  layers  of  the  broad  ligament. 
In  the  former  event  the  hemorrhage  may  be  quickly  fatal,  or,  if  the  ruptiu^  if 
small,  the  bleeding  may  be  checked  by  the  bulging  ovum  and  a  new  sac  be 
formed,  which  in  turn  is  ruptured,  either  causing  a  fatal  hemorrhage,  or  again 
forming  a  new  sac.  In  rupture  between  the  layers  of  the  broad  ligament, 
the  bleeding  is  limited  and  seldom  directly  fatal,  unless  the  broad  ligament 
becomes  overdistended  and  also  gives  way.  Hemorrhage  is  frequently  the 
result  of  perforation  of  the  tube  by  developing  villi,  instead  of  rupture.  In 
interstitial  pregnancy  rupture  is  often  postponed  until  the  end  of  the  fourth 
month,  and  occasionally  takes  place  into  the  uterine  cavity.  The  ovum 
develops  normally  until  the  first  hemorrhage,  when  the  fetus  usually  dies; 
if  the  patient  survives,  the  ovum  may  be  absorbed  or  converted  into  a  tubal 
mole,  or  it  may  cause  suppuration.  Occasionally  the  fetus  survives,  and, 
particularly  in  extraperitoneal  ruptures,  may  reach  even  full  development. 
If  the  fetus  dies  after  it  has  attained  a  large  size,  it  may  mummify,  calcify 
(lithopedion),  be  converted  into  adipocere,  or  suppurate,  the  resulting  abscess 


ECTOPIC   PREGNANCY. 


breaking  into  the  peritoneal  cavity,  rectum,  vagina^  bladder,  or  through  the 
abdominal  wall.  It  has  been  asserted  Ihat  the  placenta  may  continue  to 
develop  after  the  death  of  the  fetus,  but  this  is  doubtful  W^en  the  ovum 
is  impregnated,  the  endometrium  forms  a  decidua,  which  is  often  expelled 
at  the  time  of  the  tubal  abortion  or  rupture.  Bilateral  ectopic  gestation, 
coincident  intra-  and  extrauterine  pregnancy,  and  twin  or  triplet  extrauterine 
pregnancy  have  all  been  observed. 

Symptoms  are  often  aljsent  until  the  time  of  rupture.  There  is  frequently 
a  history  of  sterility  or  salpingitis,  followed  by  amenorrhea  and  the  early  signs 
of  pregnancy.  Tubal  abortion  or  rupture  is  announced  by  severe,  sharp, 
often  excruciating  pain,  with  shock  or  syncope,  and  the  symptoms  of  in- 
lernal  hemorrhage.  At  this  time  there  ^ill  likely  be  metrorrhagia  with 
discharge  of  the  uterine  decidua,  either  in  shreds  or  as  a  cast  of  the  uterus. 
If  the  patient  survives,  other  attacks  usually  follow;  If  the  gestation  goes  to 
term,  spurious  labor  occurs,  and  the  fetus  dies  and  undergoes  the  changes 
mentioned  above.  The  uterus  is  enlarged,  the  cervix  soft,  and  prior  to  rup- 
ture the  tube  is  slightly  distended.  Subsequent  to  rupture  the  local  signs  are 
those  of  pelvic  hematocele  or  hematoma  (q.v.).  The  conditions  which  must 
be  differentiated  from  ectopic  gestation  may  be  grouped  under  four  headings: 
(i)  Uterine  pregnancy,  pregnancy  in  a  bicornate  uterus,  and  spurious  preg- 
nancy; (2)  any  condition  giving  rise  to  a  pelvic  mass;  (3)  conditions  associated 
with  acute  pain,  such  as  appendicitis  and  other  acute  intraabdominal  diseases; 
and  (4)  conditions  associated  with  metrorrhagia,  especially  abortion,  which 
perhaps  is  the  most  frequent  condition  mistaken  for  ectopic  pregnancy  by  the 
general  practitioner,  because  both  are  preceded  by  amenorrhea,  and  in 
each  a  decidual  membrane  is  discharged. 

The  treatment  before  rupture  is  abdominal  section  and  removal  of  the 
afifected  tube,  providing  the  diagnosis  can  fie  made  at  this  time.  Electricity, 
injections  into  the  sac,  and  other  measures  of  like  character  for  tJie  purpose 
of  destroying  the  embrj'o  should  never  be  employed.  If  rupture  occurs  into 
the  peritoneal  cavity,  the  abdomen  should  be  opened  immediately,  the  tube 
and  ovary  on  the  affected  side  removed  as  quickly  as  possible,  liquid  and 
clotted  blood  washed  from  the  abdominal  cavity  with  salt  solution,  the  abdo- 
men closed  without  drainage,  and  the  patient  treated  for  shock  and  loss  of 
blood.  In  interstitial  pregnancy  it  may  be  necessary  to  perform  hysterectomy 
in  order  to  control  the  bleeding.  When  rupture  occurs  between  the  layers 
of  the  broad  ligament,  if  the  hematoma  is  small  and  there  are  no  consti- 
tutional symptoms  of  hemorrhage,  the  patient  should  be  put  in  bed,  an  ice 
cap  api>lied  to  the  lower  abdomen,  and  expectant  treatment  adopted,  w^ith 
the  hope  that  absorption  will  occur  If  the  hematoma  is  large,  or  if  con- 
stitutional symptoms  of  hemorrhage  are  present,  operation  is  indicatefb 
If  a  hematoma  treated  expectantly  suppurates,  it  should  be  opened  through 
the  vagina  and  drained.  In  ad  van  red  extrauterine  pregnancy,  if  the  felus  is 
alive,  operation  may  l>e  delayed  until  just  short  of  term,  with  the  hope  of 
saving  the  life  of  the  child.  The  entire  fetal  sac  should  be  removed  if 
possible;  when  this  is  inadvisable,  it  should  be  sutured  to  the  skin  and 
drained.  The  placenta  should,  however,  be  removed  if  such  can  be  done 
with  safety.  Often  the  fear  of  a  fatal  hemorrhage  w^l  cause  the  operator 
to  tie  the  cord  close  to  the  placenta  and  allow  it  to  come  aw^ay  at  a  later 
period.  In  advanced  cases  in  which  the  child  is  dead,  the  entire  sac  should 
be  removed  or  drained,  according  to  indications. 


6o6 


GENITAL  ORGAKS. 


THE  OVARY. 


The  ovaries  may  be  absent  or  rudimentary,  and  accessory  ovaries  have 
occasionally  been  observed. 

The  ovary  may  be  displaced  by  changes  in  the  position  of  the  FallopiaD 
tube  or  uterus,  by  tumors,  and  by  peritoneal  adhesions.  It  may  be  fixed  at  a 
hi^h  level,  thus  corresponding  to  an  undescended  testicle,  or  it  may  be  found 
in  the  sac  of  a  hernia.  The  most  important  displacement  is  prolapse  of  the 
ovary  downward  into  Douglas's  pouch.  It  may  be  caused  by  relaxadonof 
the  ligaments,  especially  after  childbirth,  increased  intraabdominal  pressure. 
rctroiicviations  of  the  uterus,  salpingitis,  and  byany  condition  which  increases 
the  weight  of  the  ovary,  e.g.,  neoplasms  and  inflammatory  aflfections.  The 
symptoms  are  those  of  the  causative  lesion,  with  those  of  pressure  on  the 
ovary,  viz.,  dyspareunia,  painful  defecation,  and  pain  on  standing  or  walking. 
The  diagnosis  is  made  by  bimanual  examination.  The  treatment  is  that  of 
the  condition  which  has  caused  the  prolapse.  When  due  simply  to  relaxation 
of  the  ligaments,  without  serious  changes  in  the  ovary,  the  infundibulo- 
pelvic  ligament  may  he  shortened,  or  the  ovary  sutured  to  a  fixed  portion 
of  the  broad  ligament. 

Ovaritis,  or  inflammation  of  the  ovary,  may  be  acute  or  chronic. 
Acute  ovaritis  may  occur  in  mumps  or  other  acute  infectious  fevers,  and 
after  the  ingestion  of  metallic  poisons,  such  as  arsenic  and  phosphorus,  but 
it  is  most  fre(|uenily  secondary  to  salpingitis,  hence  due  to  the  same  causc>. 
The  ordinary  plienomena  of  inflammation  are  pre.sent.  The  disease  mav 
terminate  in  resolution  or  in  abscess  formation,  or  it  may  become  chronic. 
The  svmplonis  are  those  of  the  salpingitis  with  which  it  is  usually  associated: 
pain,  however,  is  nnuh  more  intense.  Pelvic  peritonitis  and  the  constitu- 
tional synij)toms  of  sepsis  are  present  in  the  severer  forms.  Occasionally 
the  enlarged  ovary  may  be  mapped  out  on  bimanual  examination,  but  as  a 
rule  all  that  can  he  felt  is  a  sensitive  mass  behind  or  to  the  side  of  the  uterus. 
consisting  of  tube,  ovary,  and  pelvic  exudate.  The  treaiment  is  that  of 
salj)ingins. 

Chronic  ovaritis  may  follow  the  acute  form,  or  it  may  be  caused  hy 

repeated  or  (ontinued  congestion  the  result  of  excessive  venery,  menstrual 

sUj)j)ression.  displacements  of  the  uterus,  pelvic  tumors,  or  inllammator}' 

alTec  tions  of  adjac  ent  organs.     In  the  early  stages  the  ovaries  are  enlarged 

imd  lirni  [liypcrphi^tir  ovaritis)  and  are  apt  to  prolapse  behind  the  uterus. 

\l  a  later  period  ruj)ture  of  the  (iraatian  follicles  is  hindered  by  the  thickened 

tunica  albuginea  and  the  ovary  is  filled  with  small  cysts  {cystic  ovaries).     In 

the  final  stages  the  connective  tissue  contracts  and  renders  the  ovary  small. 

jiard,  and  fissured  {cirrhosis  of  the  ovaries).     The  symptoms  are  pain  in  the 

iv.rion  of  iheovar}',  increased  by  walking,  defecation,  coitus,  or  jolting,  and 

worse  at  the  menstrual  periods,  which  arc  apt  to  be  profuse  and  prolongcxl. 

Sterilit'v  i-  common,  and  when  the  ovaries  become  cirrhotic,  there  may  be 

.norrhea      Hvsteria,  neurasthenia,  and  various  reflex  neuroses  are  fre- 

'*'!'!,,/  comphcations.     The  diagnosis  is  made  by  bimanual  examination, 

'.:....  ic  often  rendered  easier  by  descent  of  the  ovaries. 


CYSTS   OF   THE   OVARY. 


607 


eased  portion  of  the  ovary  by  a  wedge-shaped  incision  followed  by  suture, 
puncturing  of  cysts,  and  shortening  of  the  infundibulo-pelvic  ligameht  may 
be  beneficial,  but  such  measures  are  uncertain. 

Tuberculosis  of  the  ovary  is  almost  always  secondary  to  tuberculosis 
of  the  Fallopian  tube  or  peritoneum,  and  the  infected  ovary  should  be 
removed  when  the  disease  in  these  situations  is  attacked. 

Atrophy  of  the  ovary  prior  to  the  menopause  may  be  caused  by  the  pres- 
sure of  tumors,  chronic  inflammation,  ovarian  hemorrhage,  varicocele  of  the 
broad  ligament,  superinvolution  of  the  uterus,  obesity,  diabetes,  myxedema, 
acromegaly,  and  by  certain  neu- 
roses and  exhausting  diseases. 
There  is  amenorrhea  with  sterility. 
The  treatment  is  directed  to  the 
cause. 

Ovarian  hemorrhage  may  take 
place  into  the  follicles  or  stroma  of 
the  ovary,  as  the  result  of  conges- 
tion or  inflammation,  and  is  called 
ovarian  apoplexy.  When  the 
hemorrhage  is  diffuse,  the  whole 
organ  may  be  converted  into  a 
blood  sac  {hematoma  of  the  ovary), 
which  may  rupture  into  the  perit- 
oneal cavity,  resulting  in  the  forma- 
tion of  a  hematocele,  or  occasionally 
causing  death  from  hemorrhage. 
These  cases  are  usually  mistaken 
for  ectopic  pregnancy.  Small 
hemorrhages  are  of  little  impor- 
tance, but  profuse  bleeding  demands  abdominal  section  and  removal  of  the 
ovary. 

Ttunors  of  the  ovary  include  the  fibroma,  myoma,  fibromyoma,  sarcoma, 
papilloma,  carcinoma,  and  endothelioma.  All  of  these  growths  are  compara- 
tively rare,  and  the  malignant  are  more  frequent  than  the  benign  varieties. 
Carcinoma  is  usually  secondary,  but  may  be  primary,  and  is  commonly  of  the 
medullary  variety.  Sarcoma  (Fig.  509)  is  the  most  frequent  neoplasm,  is 
usually  of  the  spindle-celled  variety,  and  may  occur  in  childhood.  The  ovary 
rapidly  enlarges,  sometimes  reaching  an  enormous  size,  but  retains  its  shape 
and  presents  a  smooth  surface.  Ascites  is  common  and  the  other  ovary  is 
usually  involved.  The  symptoms  of  tumors  are  those  of  cysts  of  the  ovary. 
Rapid  growth  and  ascites  always  suggest  malignancy.  The  treatment  is 
removal  of  the  ovary;  the  opposite  organ  should  always  be  excised  in  sarcoma, 
as  it,  too,  is  generally  sarcomatous. 

Cysts  of  the  ovary  and  parovaritun  may  be  found  at  any  time  of  life,  but 
are  most  frequent  between  die  ages  of  twenty  and  fifty.  The  etiology  is  ob- 
scure; some  are  undoubtedly  the  result  of  inflammation.  Fig.  510  shows  the 
areas  in  and  about  the  ovary  in  which  cysts  develop.  The  hydatid  of  Mor- 
gagni,  representing  the  closed  extremity  of  MuHer's  canal,  is  a  small  cyst 
which  may  be  regarded  as  normal. 

'  c  oophoron,  or  egg  bearing  portion  of  the  ovary,  are  of  several 
VI  le  or  follicular  cysts  {hydrops  follictdrtrum)  are  dilated  Graafian 


Fig.  509. — Showing  outline  of  sarcoma  of 
right  ovary.     (Polyclinic  Hospital.) 


6o8 


GENITAL   ORGANS. 


follicles;  they  are  unilocular,  multiple,  and  usually  bilateral  and  of  small  size, 
but  occasionally  may  be  as  large  as,  or  larger,  than  a  man's  head.  The  cyst 
replaces  the  ovary,  and  has  a  thin  wall  and  serous  contents.  Cysts  of  the  cor- 
pus luteum  are  unilocular  and  rarely  larger  than  an  orange.  Microscopic  a- 
amination  of  the  wall  demonstrates  the  bud-like  papillae  characteristic  of  the 
corpus  luteum.  Cystadenoma  {glandular  proliferating  cyst)  springs  from  the 
parenchyma  of  the  ovary  and  may  attain  an  enormous  size.  It  is  always 
multilocular,  and  sometimes  resembles  a  honeycomb  on  section,  the  waQs 
being  made  up  of  altered  glandular  tissue.  Unilocular  cysts  of  this  variety 
are  due  to  absorption  of  the  partition  walls.  The  contents  may  be  thin  or 
gelatinous,  and  light  yellow,  green,  purple,  or  black  in  color;  the  contents  of 
the  dififerent  loculi  in  the  same  cyst  usually  vary  in  color  and  consistency. 
Occasionally  the  cysts  contain  papillary  growths.     Dermoids  containing 


MVOATID  or 
MOR«A6NI    OM 
'C^OSCO  END  or 
MULLCR9  DUCT 


Vu'..   510.— Diagram  showing  structures  from  which  cysts  arise. 


epihlastic  derivatives,  such  as  hair,  teeth,  etc.,  occur  in  the  ovaries,  as  well 
as  teratomata,  which  contain  tissues  from  all  the  blastodermic  layers.  Der- 
moids have  dense  walls,  and,  because  of  their  weight,  are  more  prone  to 
rotate  on  the  pedicle  than  other  cysts.  Rupture  or  aspiration  of  a  dermoid 
may  result  in  peritonitis,  owing  to  the  irritating  character  of  its  contents. 

Cysts  of  the  paroophoron,  or  hilum  of  the  ovary,  which  consists  of  con- 
nective tissue  and  blood  vessels,  are  usually  unilocular,  do  not  afiFect  the  shape 
of  the  ovary  unless  of  large  size,  burrow  between  the  layers  of  the  mesosal- 
pinx and  broad  ligament,  and  generally  contain  papillomatous  masses 
(proliferating  papillary  cysts),  which  may  spread  to  and  infect  the  peritoneum, 
causing  ascites  and  the  growth  of  papillomata  all  over  the  abdominal 
cavity. 

Cysts  of  the  parovarium  arising  in  the  vertical  tubes  are  generally  uniloi- 
ular,  filled  with  a  clear  fluid  of  low  specific  gravity,  and  burrow  between  the 
layers  of  the  broad  ligament.  They  neither  contract  adhesions  nor  suppurate, 
and  never  occur  before  puberty.  The  ovary  is  attached  to  one  side  of  the 
cyst,  over  which  is  stretched  the  Fallopian  tube.  Cysts  of  Gdrtner^s  duct 
may  project  down  into  the  vagina.  Cysts  of  Kohelt\s  tubes  are  small,  pedun- 
culated, and  of  no  clinical  importance. 


OVARY. 


Tubo-ovaiian  cysts  are  retort-shaped  and  due  to  fusion  of  the  tube  with 
an  ovarian  cyst,  or  to  the  communication  of  the  tube  with  an  abnormal  pent* 
oneal  investment  of  the  ovary  {ovariays  hydroctk).  In  some  of  these  cases 
the  fluid  is  evacuated  through  the  tube  into  the  uterus. 

The  Sjrmptoins  of  ovarian  cysts  are  mainly  those  of  pressure,  such  as  have 
been  listed  under  fibrorayomata  of  the  uterus,  and  those  due  to  accidental 
complications.  Menstruation  may  he  unadected ,  or  there  may  be  amenorrhea 
from  destruction  of  the  ovaries,  or  menorrhagia  from  pressure  on  the  pelvic 
veins.  When  the  tumor  is  very  large  it  interferes  with  respiration,  presses  on 
the  stomach  and  intestines,  causing  emaciation  and  a  peculiar  facial  expres- 
sion (Jades  ovariana),  and  leads  to  umbilical  hernia,  dilated  superficial  veins, 
and  to  the  formation  of  linea*  albican tes.  Sometimes  the  breasts  enlarge,  be- 
come pigmented  and  painful,  and  secrete  colostrum.  Death  is  usually  the 
result  of  exhaustion,  uremia,  or  some  complication. 

The  complications  are  ascites,  intlammation  (adhesions^  suppuration), 
torsion  of  the  pedicle  (hemorrhage,  gangrene),  and  rupture. 

Ascites  is  most  frequent  in  malignant  growths,  fibromata,  and  papillo- 
matous cysts. 

laflaimnation,  causing  symptoms  of  localized  peritonitis,  may  be  caused 
by  tappings  or  by  infection  derived  from  the  tubes,  bladder,  intestines,  or  from 
the  bloofi  or  lymph  vessels.  Circumscribeil  or  universal  adhcsimts  are  thus 
formed  between  the  cyst  wall  and  adjacent  structures,  which  may  be  vascular 
enough  to  keep  the  cyst  alive,  even  after  it  has  been  separated  from  its  pedicle. 
Suppuration  is  most  frequent  in  dermoids,  and  is  manifested  by  the  signs 
of  a  severe  localized  peritonitis,  with  the  constitutional  symptoms  of 
sepsis.  The  treatment  of  these  cases  is  immediate  removal  of  the  cyst, 
or,  when  this  is  impossible,  suture  of  the  cyst  to  the  aljdominal  wall  and 
drainage.  Left  to  itself  the  abscess  may  rupture  into  the  peritoneal  cavity, 
into'  one  of  the  hollow  viscera,  into  the  vagina,  or  externally  through  the 
abdominal  wall. 

Torsion  of  the  pedicle  is  most  apt  to  occur  vt'hen  the  pedicle  is  long,  when 
the  tumor  is  small  and  heavy,  e.g.,  dermoids,  and  during  pregnancy.  If  the 
twist  takes  place  slowly,  the  cyst  may  be  gradually  separated  from  its  pedicle 
and  be  nourished  by  adhesions.  WTicn  the  torsion  is  acute  and  tight,  strangu- 
lation ensues,  the  cyst  increasing  in  siise  from  effusion  of  blood  and  later  be- 
coming gangrenmis.  There  are  severe  pain,  shock,  rigidity  of  the  abdominal 
muscles,  and  symptoms  of  internal  hemorrhage  if  there  is  much  loss  of  blood. 
Intracystic  hemorrhage ^  causing  sudden  enlargement  of  the  tumor,  may 
follow  also  injury  or  tapping,  or  it  may  arise  spontaneously  from  dilated  veins 
or  papillomatous  masses.  Torsion  of  the  pedicle  calls  for  immediate  re- 
moval of  the  cyst. 

Rupture  of  the  cyst  may  follow  traumatism  of  any  character,  twisting  of 
the  pedicle,  or  simple  overdistention.  It  is  most  prone  to  occur  in  the  thin- 
walled  parovarian  cyst.  The  swelling  suddenly  diminishes  in  size  or  disap- 
pears, and  free  fluid  is  found  in  the  abdomen.  This  may  be  rapidly  absorbed, 
leading  to  free  sweating  and  the  passage  of  large  quantities  of  urine.  In 
rare  instances  symptoms  of  intraabdominal  hemorrhage  appear.  The  pas- 
sage of  serous  duids  into  the  peritoneal  cavity  docs  no  harm  unless  the  cyst 
is  indamed.  Rupture  of  a  dermoid  is  generally  followed  by  peritonitis;  if 
the  cyst  be  papillomatous,  these  growths  may  be  widely  implanted  throughout 
the  abdominal  cavity.     Immediate  operation  is  not  imperative  for  rupture 

3*^ 


6io 


GENITAL   ORGANS. 


of  the  cyst,  unless  it  be  dermoid  or  papillary  in  nature,  or  unless  there  be 
symptoms  of  internal  hemorrhage  or  peritonitis.  , 

The  diagnosis  of  small  qrsts  is  made  by  bimanual  examination.  Inflam- 
matory masses  are  fixed,  more  painful,  intimately  connected  with  the  uteras, 
and  are  preceded  by  a  history  of  infection.  Solid  tumors  are  much  harder, 
are  often  accompanied  by  ascites,  and  grow  rapidly  if  malignant.  The  pres- 
ence  or  absence  of  fluctuation  depends  upon  the  thickness  of  the  cyst  wall, 
the  number  of  loculi,  and  the  contents  of  the  cyst.  Dertnoids  have  a  dough? 
feel  and  the  X-ray  may  show  the  presence  of  bone.  A  large  cyst  ascends 
into  the  abdomen,  pushes  the  uterus  to  one  side,  and  elongates  the  vagina: 

it  may  be  mistaken  for  condition^ 
like  ascites,  pregnancy,  hematometra. 
hydramnios,  and  distended  bladder. 
In  ascites,  when  the  patient  is  recum- 
bent, the  flanks  bulge  and  are  dull  on 
percussion,  while  the  central  portion  of 
the  abdomen  is  tympanitic  (Fig.  511); 
when  the  pelvis  is  elevated  the  area 


Kk;. 


Fig.  512. 


Vh..  51  t.  \rvA  of  (lulnoss  in  a>cUes  (shaded)  and  in  ovarian  cyst  (dotted  line 
when  the  j)atitnt  is  ro(:um!)L'nl.  Note  that  the  former  is  symmetric,  with  a  concave 
upper  bonier;  thai  the  laltrr  is  asymmetric  and  convex.  The  shipe  of  the  dull  area  in 
ascites  than^^es  with  the  j)osition  of  the  yxitient,  that  of  a  cyst  is  always  the  same. 

Vu;.  5  I  J.  Lateral  view  of  abdomen  in  ascites.  Dotted  line  indicates  ovarian  cys*. 
and  its  ftfe(  I  on  the  y)roriie  of  the  abdomen.  Note  that  in  ascites  the  greatest  circum- 
ference is  at.  in  ovarian  cv>t  !)ei«nv,  the  umbilicus. 


of  dulncss  in  ihc  loins  is  iiurea.sed;  when  the  patient  turns  on  one  side  the 
u|)pi.T  llank  is  tympanitir;  the  greatest  circumference  of  the  abdomen  is  at 
the  umbilicus,  not  below  as  in  ovarian  cyst  (Fig.  512);  the  fluctuation  wave 
is  very  (iistinct  and  extends  all  over  the  abdomen;  the  vagina  is  not  lengthened. 
indeed  may  be  shortened  from  descent  of  the  uterus  and  bulging  of  the 
fornices;  the  uterus  is  in  the  midline  and  freely  movable;  and  disease  of  the 
heart,  liver,  or  kidneys  may  be  found.  In  ovarian  cyst  the  patient  may  have 
noticed  that  the  swelling  was  at  first  unilateral.  In  localized  peritoneal  effu- 
sions^ such  as  are  most  often  .seen  in  connection  with  tuberculous  peritonitis. 
the  diagnosis  may  i)e  impossible  without  exploratory  incision.  A  pregnant 
ntvrus  is  more  central,  le.ss  Iluctuating,  and  is  associated  with  softening  of 
the  cervix,  amenorrhea,  and  the  positive  signs  of  pregnancy;  the  parts  of  the 
fetus  may  be  reiogni/ed,  and  the  growth  is  more  rapid  than  ovarian  cj'si. 


PELVIC    PERITONITIS.  6ll 

In  hcmatometra  the  menses  are  absent,  atresia  of  the  genital  canal  is  present, 
the  tumor  is  central  and  formed  by  the  uterus,  and  Ae  menstrual  molimina 
appear  each  month.  Hydramnios  will  show  the  signs  of  pregnancy.  A  dis- 
tended bladder  will  collapse  upon  the  introduction  of  a  catheter. 

The  treatment  is  ovariotomy,  or  removal  of  the  cyst.  Tapping  is  never 
indicated,  unless  the  patient's  condition  forbids  abdominal  section.  A 
coexisting  pregnancy  is  not  a  contraindication  to  operation,  indeed,  as  com- 
plications are  likely  to  arise  at  this  time  and  during  labor,  it  makes  operation 
more  urgent.  Ovariotomy  is  performed  through  a  median  abdominal  incision 
below  the  umbilicus.  A  hand  is  introduced  into  the  abdomen  and  any  light 
adhesions  broken,  care  being  taken  not  to  mistake  the  peritoneum  for 
the  cyst  wall.  The  cyst  is  punctured  with  a  trocar  to  which  a  rubber  tube 
is  attached,  the  contents  draining  into  a  bucket  at  the  side  of  the  table. 
An  assistant  makes  pressure  on  the  abdominal  wall  to  keep  it  closely  applied 
to  the  cyst,  which  is  seized  with  forceps  and  drawn  from  the  abdomen  as 
it  collapses.  Adhesions  to  the  deeper  parts,  if  present,  may  now  be  separated, 
or  tied  and  cut,  according  to  their  nature,  oozing  from  large  raw  surfaces 
being  controlled  by  pads  soaked  in  hot  water,  or  by  sutures  or  gauze  packing. 
The  pedicle,  consisting  of  the-  broad  ligament,  the  ovarian  ligament,  and  the 
Fallopian  tube,  and  containing  the  anastomosis  between  the  ovarian  and 
uterine  arteries,  is  transfixed  and  ligated  as  in  salpingo-oophorectomy,  and 
divided  about  one-half  inch  beyond  the  ligature.  The  other  ovary  should 
be  removed  if  it  is  diseased,  if  Uie  woman  is  near  the  menopause,  or  if  the 
ovarian  growth  is  malignant  or  papillomatous.  In  dermoids,  papillomatous 
cysts,  and  in  cysts  which  are  inflamed  or  suppurating,  the  growth  should  be 
removed  without  tapping  whenever  possible.  Intraligamentary  cysts  are 
enucleated  after  incising  the  layers  of  the  broad  ligament,  and  usually 
after  tying  the  ovarian  and  occasionally  the  uterine  artery.  The  raw  cavity 
left  is  closed  by  sutures,  and  sometimes  drained  through  the  vagina.  The 
abdominal  wound  is  closed  in  the  usual  manner.  When  adhesions  are 
dense  and  universal,  particularly  if  the  condition  of  the  patient  is  poor,  the 
cyst  may  be  sutured  to  the  abdominal  wound  and  drained  (marsupialization). 
The  mortality  of  uncomplicated  ovariotomy  is  about  5  per  cent. 


PELVIC  PERITONEUM  AND  CONNECTIVE  TISSUE. 

Pelvic  peritonitis  is  usually  secondary  to  salpingitis,  but  may  follow  in- 
flammation or  perforation  of  any  of  the  pelvic  organs,  or  the  leakage,  through 
the  tube  into  the  peritoneal  cavity,  of  fluid  which  has  been  injected  into  the 
uterus.  It  may  be  caused  also  by  the  irritation  of  pelvic  tumors,  and  is  a  part 
of  a  generalized  peritonitis  caused  by  lesions  of  any  of  the  abdominal  viscera. 
The  Sjrmptoms  are  pain  and  tenderness  in  the  lower  part  of  the  abdomen, 
rigidity  of  the  overlying  muscles,  constipation,  tympany,  vomiting,  irritability 
of  the  bladder,  fever,  and  a  rapid,  wiry  pulse.  The  patient  lies  on  the  back 
with  the  knees  drawn  up.  The  vagina  is  hot  and  dry,  the  vaginal  fornices 
exceedingly  tender,  and  the  pelvis,  particularly  the  pouch  of  Douglas,  filled 
with  exudate  (Fig.  513),  which  may  be  hard  or  soft,  according  to  the  presence 
or  absence  of  pus. 

The  treatment  of  acute  pelvic  peritonitis  due  to  salpingitis  is  rest  in  bed, 
fluid  diet,  an  ice  bag  to  the  lower  abdomen,  saline  purgatives,  hot  vaginal 


6l2 


GENITAL    ORGANS. 


Fig.  513. — Induration  from 
pc ri lonit is.  ( M o n i gi>mf  r}\ ) 


douches,  sedatives  for  pain,  aiid  stimulants  if  needed.  If  suppuration  1 
and  fluctuation  can  be  detected  in  Douglas's  pouch,  the  abscess  should  be 
opened  in  this  situation  and  a  drainage  tube  inserted,  particularly  if  thecoih 
dition  of  die  patient  is  poor.  Even  after  an  abscess  has  been  drained  through 
the  vagina,  it  will  usually  be  necessary  to  remove  the  tubes  and  ovaries  at  a 
later  period,  when  the  condition  of  the  patient  has  improved.  In  all  oilier 
cases  abdominal  section  with  removal  of  the  cause  of  trouble  is  the  proper 
treatment. 

Chronic  pelvic  peritonitis  is  adhesions  and  organizing  exudate  foUov-ing 
the  acute  form,  and  results  in  displacements  of 
the  uterus  and  appendages.  Its  trenimait  has 
been  considered  with  these  subjects  and  w"i|j 
salpingitis. 

Pelvic  cellulitis  is  iniiamraalion  of  the  con" 
nective  tissue  of  die  pelvis,  and   may  exist  alxmt 
the  bladder,  uterus,  vagina,  or  rectum  (p.  517),  or 
.     in  any  of  the  pelvic  ligaments.     It  is  comparatively 
^^^^^^^  rare,   and   almost  always  associated   with   pehic 

^^^^HHHB|^^  peritonitis.  Parametriiis  is  that  form  invoking 
^^^^^^^^^^HB  the  connective  tissue  of  the  broad  ligaments.  It 
^^mi^Hpi^^  is  usually  of  puerperal  origin,  the  infection  enter- 
ing  through  lacerations  or  abrasions  of  the  en- 
dometrium, cervix,  or  vagina,  but  it  may  be  cau^^'d 
also  by  inllammation  of.  or  operations  on,  any  of 
the  pelvic  organs.  The  pathology^  is  that  of  cellu- 
litis elsewhere.  Suppuration  is  the  common  result,  the  abscess  rupturing 
into  the  vagina,  rectum,  or  bladder,  or  through  the  abdominal  wall  above 
Poupart's  ligament,  through  one  of  the  hernial  canals,  or  through  the 
sciatic  or  obturator  foramen;  occasionally  it  opens  into  the  peritoneal  cavity. 
The  exudate  may  be  wholly  absorbed,  or  it  may  organize  and  result  in  chronic 
pelvic  congestion,  displacements  of  the  uterus,  or  stricture  of  the  rectum. 

The  symptoms  in  the  mildest  cases  are  diose  of  the  causative  salpingitis 
or  endometritis.  In  the  severe  form  there  are  chills,  fever,  and  the  generaij 
symptoms  of  septicemia.  Locally  there  are  pain,  metrorrhagia,  and  of  ten] 
irritability  of  the  bladder  or  bowel, 
when  the  connecti%'e  tissue  about 
these  structures  is  involved.  Digital 
examination  reveals  the  exudate  in  the 
broad  ligaments,  more  commonly  on 
the  left  side,  and  possibly  about  the 
rectum,  bladder,  or  above  Pou part's 
ligament,  if  the  inllammation  spreads 

so  far.  If  suppuration  occurs,  the  septic  symptoms  continue  and  the 
mass  softens.  Pelvic  cellulitis  can  seldom  be  diflerentiated  from  pelvic 
peritonitis,  indeed,  the  two  are  commonly  associated-  Cellulitis,  however. 
when  existing  alone^  is  less  painful,  more  often  unilateral,  and  more  prone 
to  suppurate,  and  it  bulges  into  the  vagina,  displaces  the  uterus  laterallv, 
and  presents  no  exudate  in  the  peritonea!  pouches  in  front  of  and  behind 
the  uterus  (Figs.  51J?,  514). 

The  treatment  is  that  of  pelvic  peritonitis.     If  suppuration  occurs,  the 
abscess  should  be  incised  eitJier  through  the  vagina  or  above  Poupart's  liga- 


T. 


>*t 


Fig.  5i4-'lRfluration  from  jxdvic 
rellutilis.     (Montgomery  J 


4 


i 


k 


NEOPLASMS    OF    THE    PELA^C    CONKECTTV^    TrSSUE. 


613 


meat,  according  to  ils  situation.  In  doubtful  cases  the  abdomen  may  be 
opened  in  the  median  line,  the  relations  of  the  mass  determined,  and  in  the 
absence  of  disease  of  the  appendages  the  abdomen  closed  and  the  abscess 
opened  through  the  vagina.  Organized  exudate  is  treated  by  hot  sitz  baths» 
hot  vaginal  douches,  pressure  by  boro-glycerid  tampons  in  the  vagina  and 
shot  hags  on  the  lower  abdomen,  and  by  the  internal  administration  of 
potassium  iodid  and  tonics. 

Pelvic  hematocele  is  an  efTusion  of  blood  into  the  cavity  of  the  pelvic 
peritoneum.  It  is  almost  always  due  to  a  ruptured  ectopic  pregnancy  or  a 
tubal  abortion,  but  may  be  caused  also  by  rupture  of  an  ovarian  hematoma, 
excessive  bleeding  following  rupture  of  a  Graafian  follicle,  rupture  of  perit- 
oneal adhesions  from  traumatism,  regurgitation  of  blood  in  atresia  of  the 
genital  canal,  malignant  tumors  of  the  pelvis*  and  by  operations  on,  or  in- 
juries of,  any  of  the  abdominal  viscera.  The  blood  gravitates  into  the  pouch 
of  Douglas,  where,  after  a  time,  it  coagulates  and  becomes  encapsulated  by 
adhesions.  Finally  it  may  undergo  absorption,  organisation,  or  suppuration. 
The  symptoms  are  sudden  sharp  pain,  followed  by  evidences  of  internal 
bleeding  if  there  be  much  loss  of  blood.  When  the  blood  coagulates^  there 
may  be  signs  of  pressure  on  any  of  the  pelvic  organs.  At  tlrst  tliere  is  only  an 
indefinite  ftilness  in  the  posterior  fornix,  but  as  the  blood  clots,  this  becomes 
firmer  and  may  crepitate  on  pressure. 

PelvlQ  hematoma  is  an  extraperitoneal  effusion  of  blood,  usually  between 
the  folds  of  the  broad  ligament.  It  is  generally  due  to  the  rupture  of  an 
ectopic  pregnancy,  but  may  be  caused  also  by  spontaneous  or  traumatic 
rupture  of  any  of  the  pelvic  vessels,  especially  varices  of  the  broad  liga- 
ment. The  S3^ptom5  are  similar  to  those  of  hematocele,  though  fatal 
hemorrhage  is  less  common  and  coagulation  occurs  more  quickly.  The 
hematoma  is  felt  to  the  side  of  and  behind  the  cervix,  displacing  the  uterus 
forward  and  to  one  side,  and  may  be  detected  above  Poupart's  ligament 
when  of  large  size.  It  may  rupture  into  the  peritoneal  cavity,  vagina,  or 
rectum,  and,  like  hematocele,  it  may  undergo  absorption,  organization,  or 
suppuration. 

The  treatment  of  hematocele  and  hematoma,  the  result  of  ectopic 
pregnancy,  has  already  been  given.  When  due  tu  other  causes,  the  patient 
should  be  confined  to  bed  and  ice  applied  to  the  lower  abdomen.  If  the 
mass  steadily  increases  in  size,  or  is  accompanied  l>y  symptoms  of  internal 
bleeding,  the  abdomen  should  be  opened  and  the  hemorrhage  controlled.  If 
suppuration  occurs,  the  abscess  should  be  opened  through  the  vagina. 

Varicocele  of  the  broad  ligament  is  usually  the  result  of  displacements, 
tumors,  or  chronic  inflammation  of  the  pehic  organs,  or  other  conditions  pro- 
ducing chronic  congestion,  such  as  constipation,  sedentary  life,  and  chronic 
diseases  of  the  heart,  lungs,  or  liver.  As  in  the  mate,  the  left  side  is  more 
frequendy  affectetl.  The  symptoms  are  those  of  the  causative  lesion,  with 
dull  aching  pelvic  pain,  which  is  worse  on  standing  and  relieved  by  the 
recumbent  posture.  The  treatment  is  removal  of  the  cause  and  attention  to 
the  general  health.  When  tlie  abdomen  is  opened  for  other  reasons,  the  veins, 
as  well  as  any  calcified  thrombi  (pkirboiiths),  may  be  excised. 

Neoplasms  of  the  pelvic  connective  tissue  require  no  special  descrip- 
tion. When  intraligamenlary  they  may  be  removed  in  the  same  way  as  par- 
ovarian cysts  or  intraligamentary  fibroids  of  the  uterus. 


; 


6l4  EXTREMITIES. 


CHAPTER  XXXI.       . 

EXTREMITIES. 

As  most  of  the  diseases  and  injuries  of  the  extremities  have  been  dealt 
with  in  the  preceding  pages,  little  need  be  considered  in  this  chapter  except 

deformities  and  amputations. 

Congenital  elevation  of  the  scapula  {Sprengers  deformity)  is  rare. 
The  scapula  is  elevated,  and  its  lower  angle  rotated  towards  the  spine.  Ix 
may  be  associated  with  scoliosis,  and  asymmetry  of  the  head.-  The  supra- 
scapular  muscles  are  shortened  and  sometimes  ossified.  When  seen  early  in 
life  the  contracted  muscles  should  be  divided. 

Scapulum  alatum,  or  winged  scapula,  was  formerly  supposed  to  be  due 
to  slipping  of  the  lower  angle  of  the  bone  from  beneath  the  fibers  of  the  latis- 
simus  dorsi,  hence  the  term  dislocatioti  of  the  lower  angle  of  the  scapula;  it  is 
now  known  to  be  due  to  paralysis  of  the  serratus  magnus  following  polio- 
myelitis, or  neuritis,  rupture,  or  contusion  of  the  long  thoracic  nerve.  The 
treatment  is  electricity,  massage,  str>'chnin,  and  in  some  cases  a  brace. 
Suture  of  the  divided  nerve,  or  its  anastomosis  to  the  posterior  cord  of  the 
brachial  plexus,  may  be  considered  in  cases  depending  upon  section  of  the 
nerve.  Tubi)y  transplants  the  lower  portion  of  the  pectoralis  major  to  the 
digitations  of  the  serratus  magnus,  after  splitting  it  to  correspond  to  these 
serrations.  When  bilateral  the  scapula?  may  be  sutured  together  (von 
Kisclbcrg).  Duval  sutures  the  inner  border  of  the  scapula  to  the  sixth  and 
seventh  ribs. 

Club-hand  may  be  palmar,  dorsal,  radial,  or  ulnar,  depending  on  the 
direction  of   the   deviation.     In  congenital  absence  of  the  radius  there  is  a 

pronounced  radial  club-hand.  The 
mildest  cases  may  be  remedied  by 
massage  and  passive  motion;  in 
others  tenotomy  w^ill  be  required. 
When  the  bones  are  much  altered, 
osteotomy  of  one  of  the  bones  of 
515.  -Madrlung's  deformiiy.         the    forearm    or   removal    of    one   or 

more  of  the  carpal  bones,  according 
to  the  tyj)e  of  deformity,  may  i)e  needed. 

Madelung's  deformity  (Fig.  515)  is  a  progressive  forward  (rarely  back- 
ward) subluxation  of  the  radiocarpal  joint,  due  to  relaxation  of  the  ligaments 
or  to  disturbance  in  the  growth  of  the  radial  epiphysis.  Eighty  per  cent,  of 
the  cases  occur  in  girls  during  adolescence.  The  lower  end  of  the  ulna  is 
prominent,  the  radius  often  curved,  and  the  hand  usually  adducted  but 
occasionally  abducted.  Extension  and  sometimes  flexion  of  the  wrist  are 
impaired.  The  treatment  in  the  early  stages  is  a  retentive  apparatus,  e.g., 
a  leather  cull.  At  a  later  period  tenotomy,  reduction  through  an  incision, 
or  cuneiform  osteotomy  of  the  radius  may  be  indicated. 

Polydactylism,  or  supernumerary  fingers  or  toes,  requires  amputation  of 


dupuytren's  contraction. 


615 


the  accessory  digits  if  they  are  useless  or  troublesome.  Macrodactylism, 
or  congenital  hypertrophy  of  one  or  more  fingers  or  toes,  also  may  require 
amputation.  Ectrodactylism  is  the  absence  of  one  or  more  digits.  Syn- 
dactylism, or  webbed  fingers,  is  treated  by  incising  the  web  in  such  a  way 
as  to  form  a  flap  which  is  used  to  cover  the  raw  surface  between  the  roots  of 
the  fingers,  or  by  raising  two  flaps  of  skin  by  an  incision  along  the  middle 
of  the  palmar  surface  of  one  finger  and  another  along  the  middle  of  the 
dorsal  surface  of  the  other  finger,  the  flaps  being  wrapped  around  the  digits 
after  they  have  been  separated. 

Congenital  contraction  of  the  fingers  is  most  often  seen  in  the  little 
finger,  and  corresponds  to  congenital  hammer-toe,  with  which  it  is  sometimes 
associated.     The  first  phalanx  is  hyperextended  and  the  second  and  third 
flexed,  thus  differing  from  Dupuytren's  con- 
traction,   in    which    the   first   and   second 
phalanges  are  flexed  and  the  third  extended. 
In  the  former  the  middle,  and  in  the  latter 
the  lateral  digital  processes  of  the  palmar 
fascia    are    shortened.      The  treatment  is 
forcible  correction  and  the  application  of  a 
splint,  or  division  of  the  contracted  fascia. 

Snap-  or  trigger-finger  is  an  acquired 
deformity  in  which  one  or  possibly  two 
fingers  can  be  extended  only  by  great  effort 
or  by  using  the  other  hand,  when  the  finger 
flies  out  like  the  blade  of  a  penknife.  It 
is  caused  by  any  lesion  which  offers  a 
limited  obstruction  to  the  play  of  the  tendon 
in  its  sheath,  e.g.,  contraction  of  the  sheath, 
enlarged  sesamoid,  ganglion,  or  a  growth 
on  the  tendon,  hence  ifi  most  instances 
cure  can  be  obtained  only  by  incision  and 
removal  of  the  obstruction. 

Mallet  finger  is  a  drooping  of  the  distal  phalanx  as  the  result  of  rupture 
or  overstretching  of  the  end  of  the  extensor  tendon,  such  as  may  be  caused 
by  sudden  and  violent  hyper  flexion  of  the  end  of  the  finger.  In  the  early 
stages  it  is  treated  by  the  application  of  a  splint.  If  the  deformity  persists, 
the  tendon  may  be  sutured  to  the  periosteum. 

Dupuytren's  contraction  (Fig.  516)  is  a  shortening  of  the  palmar 
fascia  the  result  of  a  chronic  cirrhotic  inflammation,  which  begins  as  an  in- 
duration in  the  palm,  and,  as  it  progresses,  gradually  puckers  the  skin  and 
causes  a  permanent  flexion  of  the  little  and  ring  fingers,  and  less  frequently 
of  the  remaining  fingers.  It  is  most  common  in  middle  aged  men  and  may 
be  bilateral.  Occasionally  it  follows  long  continued  pressure,  such  as  is 
necessitated  by  the  use  of  certain  tools,  and  a  gouty  or  rheumatic  history  is 
often  obtainable.  On  seeing  his  first  case,  the  student  feels  the  tense  bands 
of  fascia  and  almost  invariably  makes  a  diagnosis  of  contracted  tendon,  a 
condition  which  may  readily  be  differentiated  by  noting  that  the  finger  can 
be  extended  when  the  wrist  is  flexed.  The  treatment  is  excision  of  the 
contracted  fascia,  either  through  longitudinal  incisions,  or  after  dissecting 
off  the  skin  in  the  form  of  a  flap.  Subcutaneous  section  of  the  tense  bands  is 
unsatisfactory. 


f'lG.  516. — Dupuytren's  con- 
traction. 


6i6 


EXTREBOTIES. 


Coxa  vara  is  a  downward  bending  of  the  neck  of  the  femur,  which  may 
form  an  angle  of  90^  or  even  less  with  the  shaft  of  the  bone.  It  may  affect 
one  or  both  sides  and  is  frequent  in  young  males,  although  it  may  occur  in 
either  sex  and  at  any  period  of  life;  indeed  it  is  physiological  in  old  age  and 
may  be  congenital.  Diseases  which  soften  the  osseous  tissue,  such  as 
rickets,  osteomalacia,  ostitis  deformans,  and  chronic  inflammatory  affec- 
tions of  bone,  as  well  as  fracture  of  the  neck  of  the  femur,  may  result  in 
coxa  vara.  The  symptoms  are  pain  and  lameness.  The  limb  is  shortened, 
the  trochanter  above  Ndaton's  line,  and  abduction  limited.  The  foot  may 
be  everted  and  internal  rotation  restricted,  if  the  neck  "is  twisted  backwards, 

and  less  commonly  inverted  with  the 
restriction  of  external  rotation,  if  the 
neck  is  twisted  forward.  Careful  ex- 
amination, with  a  radiogram,  will  usu- 
ally permit  easy  differentiation  from 
coxalgia  or  congenital  dislocatiffli. 
The  treatment  in  the  developing 
stages  is  rest  in  bed  with  extension,  or 
the  use  of  some  form  of  hip  splint,  for 
a  number  of  months,  in  order  to  pre- 
vent further  deformity,  the  nutrition 
of  the  limb  being  maintained  by  mas- 
sage and  electricity.  Persistent  de- 
formity when  disabling  may  be  cor- 
rected by  osteotomy,  either  linear  or 
cuneiform  (Fig.  517). 

Coxa  valga  is  an  increase  in  the 
angle  between  the  neck  and  shaft  of  the 
femur.  As  in  coxa  vara  the  neck  may 
be  twisted  forwards  or  backwards. 
The  limi)  is  lengthened,  the  trochanter  below  N^laton'sline,  and  adduction 
restricted.  It  has  been  found  associated  with  diseases  like  those  mentioned 
under  coxa  vara.  Osteotomy  and  correction  of  the  deformity  may  possibly 
be  indicated  in  some  cases. 

Genu  valgum,  or  knock-knee,  is  an  abnormal  outward  deflection  of  the 
leg,  the  feet  being  separated  when  the  knees  are  together  in  the  extended 
position.  One  or  both  limbs  may  be  ailected.  According  to  the  cause, 
the  cases  may  be  grouped  in  three  classes: 

T.  Genu  valgum  rhachiticum  appears  soon  after  the  child  begins  to  walk, 
the  normal  angle  i)etwecn  the  thigh  and  the  leg  being  exaggerated  as  the 
result  of  lengthening  of  the  internal  condyle,  or  bending  of  the  femur  above, 
or  the  tibia  below,  the  knee.  The  internal  lateral  ligament  is  stretched,  and 
the  joint  is  often  abnormally  movable  in  all  directions  Qoose  knees),  2.  Genu 
valgum  staticum  is  most  common  during  adolescence  in  those  of  poor  physique, 
or  in  those  who  are  compelled  to  stand  much  or  to  carry  heavy  weights.  It 
is  supposed  by  some  to  be  due  to  a  latent  form  of  rickets.  Owing  to  the  normal 
obliquity  of  the  femur,  most  of  the  weight  of  the  body  is  transmitted  to  the 
tibia  through  the  external  condyle  of  the  femur,  and  knock-knee  is  pre- 
vented by  the  action  of  the  muscles  on  the  inner  side  of  the  limb.  In  the  weak 
or  overworked  these  muscles  tire  and  the  individual  assumes  an  attitude  of 
rest  with  the  feet  separated  and  the  knees  extended,  thus  relaxing  the  muscles. 


Fig.  517. — I.  Normal  femur.  2.  Coxa 
vara — cuneiform  osteotomy.  3.  Abduc- 
tion of  limb  fixes  the  upper  fragment 
against  rim  o{  acetabulum  and  doses 
opening  in  bone.  4.  Replacement  of  limb 
after  union  is  complete  elevates  the  neck 
to  its  former  position.     (Whitman.) 


TALIPES. 


5i7 


stretching  ihe  inlernal  lateral  ligament^  and  ultimatdy  tausiog  atrophy  of 
the  external  condyle  and  hypertrophy  of  the  internal  condyle.  The  patella 
passes  externally,  the  tissues  on  the  outside  of  the  limb  are  contracted,  and  the 
tibia  is  usually  rotated  outwards.  The  patient  has  a  rolling  gait,  and  sco* 
liosis  may  follow  in  unilateral  cases.  As  the  enlargement  of  the  internal 
condyle  is  chiefly  in  the  vertical  and  transverse  directions,  the  deformity 
disappears  when  the  knee  is  t^exed  to  a  right  angle,  unless  the  tibia  is  curved. 
^.  Other  causes  of  knock -knee  are  infantile  or  other  forms  of  paralysis, 
fracture  or  dislocation  of  the  knee,  and  destructive  int^ammatory  affections 
of  the  joint  or  neighboring  bones.  Flat-foot  may  be  either  the  cause  or  the 
result  of  knock-knee. 

The  treatment  during  the  early  stages  consists  in  keeping  the  patient 
off  the  feet  and  employing  massage  and  daily  rorredive  manipidatims,  the 
knee  being  pressed  outward  and  the  tibia  inward.  Constitutional  measures 
for  rickets,  or  in  static  cases  for  the  feeble  general  health,  should  be  employed. 
At  a  later  period  brares  consisting  of  an  outside  steel  rod  running  from  the 
trochanter  to  the  foot,  and  supplied  with  straps  for  pulling  the  knee  outward, 
are  indicatecL  When  the  bones  have  become  thoroughly  ossified  (at  the  age 
of  three  or  four  in  children),  cure  can  be  obtained  only  by  opera  live  treat  menl. 
Mactwan^s  osteotomy  is  the  usual  operation.  The  outer  side  of  the  knee 
is  placed  on  a  sand  bag,  and  a  small  longitudinal  incision  niade  on  the  inner 
side  just  above  the  adductor  tubercle.  Through  this  an  osteotome,  which 
differs  from  a  chisel  in  Imng  beveled  on  both  sides  (Fig.  220),  is  passed 
down  to  the  bone,  turned  transversely,  and  driven  three-fourths  of  the  way 
through  the  bone.  It  is  then  withdrawn,  the  remaining  portion  of  the  bone 
broken,  the  wound  sutured,  and  the  limb  put  up  in  plaster  in  a  corrected 
position.  Rarely,  and  only  in  the  worst  cases,  is  it  necessar)^  to  remove  a 
wedge  of  bone  (cuneiform  osteotomy).  The  cast  is  removed  in  six  weeks 
and  the  patient  allowed  to  walk  at  the  end  of  two  months. 

Genu  varum j  or  bow-leg,  is  the  reverse  of  genu  valgum,  the  extended 
knees  being  separated  when  the  feet  are  together.  It  is  almost  always  due  to 
rickets, which  permits  the  tibiae  to  bend  outward.  Occasionally  the  deform- 
ity is  produced  by  a  bending  of  the  femur  or  an  enlargement  of  the  external 
condyle.  Anterior  btrw-leg  is  a  forward  curve  of  the  tibia,  usually  near  one 
extremity  of  the  bone,  and  generally  associated  with  some  lateral  deviation, 
thus  differing  from  the  sabre  blade  deform iiy  of  syphilis,  which  is  due  to  a 
hyperplasia  rather  than  a  bending  of  the  bone,  and  which  is  generally  regular 
and  without  a  twist.  Posterior  bouf4eg  or  genu  recurvaium,  is  the  reverse  of 
anterior  bow-leg.  The  treatment  is  correction  by  daily  manipulations  or  the 
use  of  braces,  up  to  the  age  of  three  or  four,  after  which  operative  treatment 
offers  the  only  hope  of  success.  Osteotomy  of  the  tibia  is  performed  at 
the  point  of  greatest  curvature,  in  tlie  same  manner  as  osteotomy  for  knock- 
knee,  the  fibula  being  broken  manually.  The  cast  is  removed  in  four  weeks 
and  the  patient  allowed  to  walk  at  tiie  end  of  six  weeks.  Osteodasis,  or 
fracture  of  the  bone  by  a  special  apparatus,  the  osteoclast,  is  preferred  by 
some  surgeons,  but  should  not  be  employed  when  the  cunx  is  near  a  joint  or 
the  bone  ver)'  strong* 

Talipes,  or  club-foot,  is  an  abnormal  and  permanent  deviation  of  the 
foot  in  the  direction  of  extension  (T,  equinus),  flexion  (T,  calcaneus),  adduc- 
tion (T.  varus),  or  abduction  (T.  valgus).  Combinations  of  these  forms 
occur,  such  as  T.  equi no- valgus  or  varus,  and  T.  calcaneo -valgus  or  varus. 


^ 


6l8  EXTREMITIES. 

The  causes  are  congenital  and  acquired.  Congenital  club-foot 
may  be  clue  to  abnormal  intrauterine  pressure,  to  defective  devdopment 
of  the  bones  of  the  leg,  or  to  some  nerve  lesion,  e.g.,  when  associated  wiik 
spina  bifida.  It  is  often  bilateral,  sometimes  hereditary,  and  usually  not 
associated  with  the  wasting,  trophic  changes,  and  impaired  electrical  re- 
actions observed  in  the  acquired  paralytic  form.  Acquired  club-foot  nuj 
arise  from  paralysis  from  any  cause,  but  particularly  that  form  followiof 
anterior  poliomyelitis  (paralytic  talipes),  from  spasmodic  affections  of  certain 
groups  of  muscles  (spastic  talipes) ,  cicatricial  contraction  of  the  soft  pins 
following  injury  or  disease,  rupture  of  tendons  or  muscles,  fractures  about 
the  ankle  {traumatic  talipes),  and  epiphysitis.  Shortening  of  the  lower  a- 
tremity  from  any  cause  is  often  followed  by  a  compensatory  talipes  equinus, 
while  prolonged  fixation  of  the  foot  in  any  position  may  lead  to  defonnitr, 
e.g.,  the  pointed  foot  following  prolonged  confinement  to  bed  (talipes  de- 
cubitus) j  or  the  improper  application  of  a  plaster  cast.  The  anaUmicii 
changes  vary  with  the  degree  and  type  of  deformity.  The  midtarsal  joint 
(os  calcis  with  cuboid,  and  astragalus  with  scaphoid)  is  the  one  most  fr^ 
quently  and  most  extensively  involved,  the  ankle  joint  being  most  affected 
in  equinus  and  calcaneus.  In  severe  cases  the  bones  are  altered  in  shape. 
the  tendons  run  in  abnormal  directions,  the  weak  or  paralyzed  muscles  are 
stretched  or  atrophied  while  their  opponents  are  shortened,  the  ligaments 

and  fasciae  are  contracted  or 
stretched,  and  the  skin  is  thick- 
ened, perhaps  with  corns  or  ulcers. 
at  the  points  where  the  foot  rests 
on  the  ground.  Abnormal  bursac 
also  may  form. 

The  treatment  is  (i)  me- 
chanical, i.e.,  manipulatioii. 
pi  aster-of -Paris  bandages,  and 
braces,  or  (2)  operative,  i.e., 
tenotomy,  tendon  lengthening.* 
shortening,  or  transplantation, 
syndesmotomy  or  fasciotomy, 
myotomy  (rare),  brisemeni  force, 
open  incision,  tarsotomy  or  tar- 
Fic.  5i8.--Talii)c>c(|uinn-varus.  sectomy,    nerve    transplantation, 

ii'iiiiiMlvania  Hospital.)  arthrodesisj    and    in    the    worst 

cases  amputation.  Manipulation 
consists  in  holdin<;  the  foot  in  a  corrected  position  for  a  few  minutes  several 
limes  daily;  it  is  indicated  in  recent  cases  of  mild  degree.  An  extension  of 
this  method  is  the  aj)plication  of  plastcr-of-Paris  bandages,  after  the  deformity 
has  been  corrected  as  much  as  possii)le.  When  the  cast  becomes  loose. 
further  correction  is  made  and  a  second  bandage  applied,  and  so  on,  until 
the  foot  returns  to  its  normal  position.  Braces  and  shoes  are  employed, 
not  so  much  for  correction,  as  for  the  maintenance  of  the  normal  position 
after  the  deformity  has  been  reduced  by  other  means. 

Operative  treatment  of  some  form  is  required  in  all  but  the  mildest 
cases,  and  varies  with  the  type  of  deformity.  Talipes  equino-varus 
(Fig.  51S)  is  the  commonest  form  of  club-foot,  and  when  bilateral  is  called 
reel-feet,  owing  to  the  fact  that  the  feet  are  lifted  one  over  the  other  when 


TALIPES. 


619 


the  patient  walks. ,  The  heel  is  dra>yn  up  and  the  foot  twisted  and  folded 
on  itself,  so  that  the  toes  point  inwards  and  the  patient  walks  on  the  outer 
border  or  dorsum.  When  the  measures  mentioned  above  have  failed 
or  are  inadvisable,  the  varus  may  be  corrected  after  tenotomy  of  the  tibialis 
anticus,  tibialis  posticus,  and  plantar  fascia  (fasciotomy),  and  the  equinus 
may  then  be  overcome  by  section  or  lengthening  of  the  tendo  Adiillis. 
Division  of  the  contracted  ligaments  on  the  inner  side  of  the  foot  (syndesmot- 
omy)  also  may  be  needed.  In  any  operation  for  club-foot  the  deformity 
should  be  overcorrected  and  the  foot  and  leg  put  up  in  plaster,  which  should 
not  be  disturbed  for  two  or  three  months.  After  the 
plaster  has  been  removed,  braces  will  be  needed  until  there 
is  no  longer  any  tendency  towards  recurrence,  usually  a 
matter  of  some  years.  In  paralytic  cases  a  permanent 
brace  may  be  required.  Brisement  ford  is  immediate 
forcible  correction  by  the  hands  or  by  instruments  (Fig. 
519).  Open  incision,  or  Phelps'  operation,  consists  in 
dividing  all  the  tissues  on  the  inner  side  of  the  foot,  down 
to  the  bone,  by  an  incision  extending  from  the  internal 
malleolus  to  one-fourth  of  the  distance  across  the  sole  of 
the  foot.  The  wound  is  packed  with  gauze,  and  the  foot 
put  up  in  plaster  in  an  overcorrected  position.  Jones  raises 
a  triangular  flap,  thus  lessening  the  gap  after  correction 
of  the  deformity.  When  the  bones  are  so  altered  in  shape 
as  to  prevent  reduction,  the  osseous  tissue  itself  must  be 
attacked.  According  to  the  situation  of  the  obstruction, 
osteotomy  may  be  performed  upon  the  neck  of  the  astragalus 
through  an  incision  below  the  internal  malleolus,  upon  the 
head  of  the  os  calcis  through  an  incision  below  the  ex- 
ternal malleolus,  or  upon  the  scaphoid  through  an  incision 
in  the  sole;  osteotomy  of  the  tibia  and  fibula  above  the 
ankle  is  seldom  employed.  Tarsectomy  has  been  performed 
in  various  ways,  one  or  more  of  the  tarsal  bones  being 
removed,  according  to  different  operators.  Perhaps  the  best  plan  is  to 
remove  a  wedge  of  bone  with  the  base  outwards  and  of  sufficient  size  to 
correct  the  deformity.  An  incision  is  made  over  the  most  prominent 
portion  of  the  tarsus,  the  tendons  and  soft  parts  retracted,  and  the  bone 
removed  with  a  chisel,  without  respect  to  the  individual  bones  or  joints. 
In  paralytic  cases  tendon  or  nerve  transplantation  may  be  indicated.  "The 
outer  half  of  the  tendo  Achillis  may  be  inserted  into  the  distal  end  of  both 
peronei.  The  extensor  longus  hallucis  or  the  outer  half  of  the  tibialis 
anticus  may  be  passed  across  the  foot  under  the  other  tendons  to  be 
fastened  to  the  periosteum  of  the  cuboid  bone''  (Le  Breton).  The  anterior 
tibial  nerve  and  the  branches  to  the  tibialis  anticus  may  be  transplanted 
into  the  musculo-cutaneous.  Arthrodesis  of  the  calcaneocuboid  joint  also 
may  be  used  in  these  cases. 

Talipes  equinus  is  usually  the  result  of  paralysis  of  the  extensor  muscles, 
and  is  rare  as  a  congenital  deformity;  the  patient  walks  on  the  toes,  and  in 
the  worst  cases  on  the  dorsum  of  the  foot.  The  tendo  Achillis  and  the 
tissues  of  the  sole  of  the  foot  are  shortened.  The  operative  measures  for 
its  correction  are  division  or  lengthening  of  the  tendo  Achillis,  or  in  more 
severe  cases  removal  of  the  astragalus  or  a  wedge-shaped  section  of  the 


Fig.  sip. 

Thomas  club-foot 

wrench. 


620 


EXTREMITIES. 


tarsus.  Nerve  transplantation  as  for  equino- varus,  or  the  traii^plam*:  - 
of  a  portion  of  the  tendo  A  chill  is  to  the  tibialis  anticus  or  extensor  coinBk^ 
digitorum  may  be  employed.  After  correction  arthrodesis  of  the  vtik 
joint  may  be  performed. 

Talipes  calcaneus  may  be  congenital  or  acquired.  The  foot  isdivn 
upwards  and  the  patient  walks  on  the  heel  It  may  require  division oltk 
extensor  tendons,  shortening  of  the  tendo  AchiUis,  transplantation  d  ^ 
peronei  into  the  os  calcis,  astragalectomy,  or  arthrodesis  of  the  ankle  )«* 

Talipes  valgus  (Fig.  520)  is  an  abduction  and  aversion  of  die  iW 
with  flattening  of  the  sole.     It  may  be  combined  with  equinus  or  calcaauft 


FiC,  520.     Talipes  valguii.     (Gould.) 


Fig.  521.— Talipes  \*aru&.     (Gcmkil 


The  acquired  form  is  synonymous  with  flat-foot,  under  which  the  treatnal 
will  !>e  discussed. 

Talipes  varus  (Fig.  521),  or  adduction  and  inversion  of  the  foot,  l* 
treated  as  equino-varus»  excepting  the  division  of  the  tendo  AchiUis. 

Flat-foot,  or  pes  planus  {sp!a\'/oot,  acquired  or  spuriaus  vatgm),  is  1 
tialtening  of  the  arch,  usually  with  abduction  and  eversion  of  the  foot 
The  cattses  include  all  those  conditions  which  induce  a  disproportion  betveci 
the  weight  of  the  l>ody  and  the  strength  of  the  muscular  and  Ugameotcrad 
tissues  controlling  the  fool,  and  diseases  or  injuries  w^hicli  alter  the  reUoon 
or  shape  of  the  bones.  Among  these  conditions  are  improperly  fitting  sboek 
prolonged  standing,  rajjid  increase  in  weight,  general  ill  health,  prolong 
disuse  of  the  foot  resulting  in  muscular  weakness,  infantile  or  other  fom 


Fjg.  522.— Flat-foot  plate. 

of  paralysis,   rickets,   injurv'   (particularly   Poll's  fracture),   and   arth 
especially  of  gonorrheal  origin. 

Symptoms  may  lie  alisent  in  a  well-marked  case,  severe  in  a  case  in 
which  the  deformity  is  slight  or  absent.  Pain,  particularly  after  using  iht 
foot,  is  most  marked  in  the  sole  and  the  midtarsal  joint,  but  occurs  also 
in  other  portions  of  the  fool,  occasionally  being  reflected  up  the  limb 
even  to  the  lumbar  region,  and  sometimes  associated  with  muscular  spasnt 
The  foot  loses  its  normal  flexibility,  and  tenderness  exists  over  the  points 
of  the  ligamentous  attachments.  The  gait  is  shuffling  and  there  may  be 
some  sw^elling,  which  frequently  leads  to  an  incorrect  diagnosb  of  rheuma- 
tism.    The  deformity  (Fig.  520)  is  quite  obvious  in  well-marked  cases  and 


METATARSALGU, 


621 


is  accentuated  when  die  patient  slands,  The  inner  border  of  the  foot  is 
lengthened  and  rests  on  the  ground,  and  the  internal  malleolus  and  head  of 
the  astragalus  are  more  prominent  than  usual.  The  plantar  ligaments  and 
muscles  are  stretched,  the  tibialis  posticus  weakened,  and  the  per  one! 
contracted.  An  impression  of  the  weight  bearing  portion  of  the  sole  may 
be  obtained  by  having  the  patient  step  on  cardboard  covered  with  lamp 
black. 

The  treatment  in  static  cases,  i.e.,  those  due  to  disproportionate  weight, 
is  the  application  of  a  flat-foot  plate  (Fig.  522),  and,  to  strengthen  the  mus- 
cles, massage,  electricity,  and  exercises,  such  as  rising  on  the  toes,  and 
w^alking  with  the  foot  in  a  varus  position.  WTien  the  symptoms  have  dis- 
appeared  the  p!ate  should  be  gradually  discontinued.  When  the  foot  is 
too  tender  for  the  use  of  a  plate,  the  patient  may  rest  in  bed  or  have  a 
plaster  cast  applied.  In  some  cases  the  e version  is  so  marked  as  to  require 
a  steel  bar  running  up  the  outer  side  of  the  leg,  and  supplied  w^ith  a  strap^ 
which  passes  around  the  internal  malleolus  and  pulls  the  ankle  out.  Plates 
and  supports  are  generally  useless  unless  the  deformity  can  be  corrected. 
Wlien  the  foot  is  fixed  in  deformity,  the  patient  should  be  anesthetized, 
the  deformity  overcorrected  with  the  hands  or  the  club-fool  wrench,  and  a 
plaster  cast  applied,  a  support  being  used  when  the  pain  has  disappeared. 
In  paralytic  cases  nerves  may  be  transplanted  as  in  equino- varus.  The 
peroneus  brevfs  may  be  passed  un<ier  the  tendo  Achillis  and  attached  to 
the  scaphoid,  while  the  peroneus  tertius  may  !>e  attached  to  the  same  point 
after  being  passed  beneath  the  anterior  tendons.  The  extensor  longus 
poUicis  or  the  tibialis  anticus  may  be  passed  through  a  hole  Ijored  in  the 
scaphoid  and  turned  back  and  sutured  to  the  periosteum.  The  peroneus 
longus  has  been  transplanted  to  the  tibiaiis  posticus.  When  the  obstacle 
to  reduction  is  osseous,  a  wedge  of  bone  may  be  removed  from  the  inner 
side  of  the  tarsus.  Other  bone  operations  are  osteotomy 
of  the  neck  of  the  os  cakis  and  astragalus,  removal  of 
the  scaphoid,  supramalleolar  osteotomy,  and  longitudinal 
section  of  the  os  calcis  with  displacement  downwards 
of  the  posterior  fragment. 

Pes  cavus,  or  hollow  foot  (Fig.  523),  is  the  reverse 
of  tlat-foot.  It  is  rarely  congenital,  being  usually  the 
result  of  anterior  poliomyelitis  or  the  wearing  of  short 
or  ill  fitting  shoes.  The  most  marked  cases  occur  in 
Chinese  women,  from  bandaging.  The  treatment  is 
the  use  of  a  properly  fitting  shoe,  with  a  ilat  steel  plate 
in  the  sole  and  a  strap  running  over  the  arch  of  the  foot, 
forms  require  division  of  the  plantar  fascia. 

Metatarsalgia^  or  Morton's  disease^  h  severe  neuralgic  pain  beginning 
on  either  side  of  the  distal  €nd  of  the  fourth  metatarsal  bone  and  passing  up 
the  foot  and  often  up  the  leg.  It  is  caused  by  a  pinching  of  the  digital 
nerves  between  the  beads  of  the  third  and  fourth,  or  fourth  and  fifth  meta- 
tarsal bones,  which  have  become  displacerl  as  the  result  of  badly  fitting 
shoes.  The  transverse  arch  formed  by  the  distal  ends  of  the  metatarsal 
bones  is  flattened  and  the  foot  broadened;  there  may  or  may  not  be  flat- 
foot.  The  pain  usually  comes  on  when  walking  and  is  often  so  severe 
that  the  patient  immediately  removes  the  shoe  and  rubs  the  foot;  it  can 
often  l>c  induced  by  rolling  the  metatarsal  bones  one  over  the  other.     The 


Fig 


S23. — Pcscavus, 
(Goukl.) 

The  severer 


622  EXTREMITIES. 

treatment  is  the  application  of  a  flat-foot  brace,  if  such  is  needed,  and  the 
use  of  properly  fitting  shoes;  the  pain  may  often  be  relieved  by  a  pad  to 
brace  up  the  transverse  arch  of  the  metatarsus,  or  by  the  application  of  a 
tight  bandage  to  the  anterior  segment  of  the  foot.  Intractable  cases  can 
be  cured  only  by  resection  of  the  head  of  the  fourth  metatarsal  bone,  or  by 
excision  of  the  superficial  branch  of  the  external  plantar  nerve. 

Hallux  valgus  is  an  outward  deviation  of  the  great  toe  produced  by 
short,  tight,  or  pointed  shoes  and  stockings.  It  exists  in  a  ^ght  degree 
in  most  civilized  people  and  the  most  severe  forms  are  commonly  seen  in 
later  life.  The  head  of  the  first  metatarsal  is  uncovered,  and  often  becomes 
enlarged  as  the  result  of  chronic  periostitis.  A  bursa  may  form  in  this 
situation  (bunion) y  which  may  become  inflamed;  should  suppuration  occur 

the  joint  may  be  invaded  and 
disorganized.  The  treatment 
in  early  cases  is  the  application 
to  the  inner  side  of  the  foot  of  a 
hard  rubber  splint,  to  which  the 
toe  is  bandaged,  or  the  use  of  a 
metal  partition  attached  to  the 
sole  of  the  shoe  and  projecting 
])etween  the  first  and  sec(Mid 
,toes.  An  inflamed  bunion  is 
treated  like  acute  bursitis;  a 
bunion  plaster,  i.e.,  a  pad  with 
Fig.  524.— (Weir,  "Annals  of  Surgery.")  a  central  opening,  may  be  ap- 
plied to  relieve  pressure.  Perma- 
nent relief  is  obtained  by  excision  of  the  bursa,  and  correction  of  the  hallux 
valgus,  which  in  advanced  cases  can  be  accomplished  only  by  operation. 
This  may  be  an  osteotomy  of  the  metatarsal  hone,  an  excision  of  the  meta- 
tarso-phalangeal  joint,  or  a  shaving  off  of  the  exostosis  on  the  inner  side 
of  the  head  of  the  metatarsal  bone.  In  addition  to  the  last  procedure, 
Weir  divides  the  outer  portion  of  the  capsular  ligament  and  transfers  the 
dorsal  tendon  to  the  periosteum  on  the  inner  side  of  the  base  of  the  first 
phalanx   (Fig.    524). 

Hallux  rigidus  is  an  arthritis  of  the  metatarsophalangeal  articulation, 
the  result  of  tlat-foot,  defective  shoes,  or  injury,  and  terminating  in  ankylosis. 
The  treatment  is  removal  of  the  cause,  with  local  applications  as  for  arthritis. 
In  old  cases,  particularly  if  ankylosis  occurs  in  a  vicious  position,  excision 
of  the  joint  may  be  needed. 

Hammer-toe  is  a  permanent  hyperextension  of  the  first,  and  flexion  of 
the  second  and  third  phalanges.  The  congenital  form  is  probably  due  to 
shortening  of  the  lateral  digital  processes  of  the  plantar  fascia.  It  may 
be  caused  by  short  shoes  or  be  associated  with  hallux  valgus,  talipes  equinus, 
or  pes  cavus.  It  also  follows  paralysis  of  the  interossei  and  lumbricales, 
corresponding  to  a  similar  deformity  of  the  lingers,  after  ulnar  paralysis. 
Corns  or  bursa?  may  form  over  the  points  exposed  to  pressure,  and  walking 
becomes  painful  and  difficult.  The  treatment  in  the  mildest  form  is  the 
application  of  a  splint,  preceded,  if  necessary,  by  division  of  the  contracted 
fascia  and  forcii)le  correction.  When  more  severe,  it  will  be  necessary  to 
excise  the  distal  end  of  the  first  phalanx  and  divide  the  extensor  tendon.  In 
the  worst  cases  amputation  will  be  required. 


MAL   PERFORANT.  623 

Achillodjmia  is  a  term  which  has  been  ap{^ied  to  two  separate  conditions, 
(i.)  Post-calcaneal  bursitis,  or  Albert's  disease,  causes  a  tender  swell- 
ing between  the  os  calcis  and  tendo  Achillis,  and  may  follow  an  injury,  a 
strain,  or  prolonged  walking  or  skating.  Some  cases  are  due  to  an  exostosis 
of  the  OS  calcis.  The  treatment  is  rest  of  the  foot  and  the  use  of  the  measures 
indicated  in  bursitis.  Operation  may  be  required  for  an  exostosis.  (2.) 
Synovitis  of  the  tendo  Achillis  may  follow  the  same  conditions,  or  arise 
spontaneously  in  the  gouty  or  rheumatic.  Pain  and  swelling  are  most  marked 
at  the  level  of  the  top  of  the  shoe,  and  soft  crepitus  may  sometimes  be  obtained 
on  flexing  or  extending  the  foot.  The  treatment  is  that  of  tenosynovitis, 
with  the  use  of  the  salicylates  in  the  rheumatic. 

Painful  heel  (policeman's  heel)  is  characterized  by  pain  and  tenderness 
on  the  under  surface  of  the  heel.  It  may  be  caused  by  strain,  periostitis, 
flat-foot,  inflammation  of  the  bursa  beneath  the  os  calcis,  or  an  exostosis, 
hence  the  necessity  for  a  radiograph  in  all  doubtful  cases.  The  treatment 
necessarily  varies  with  the  cause. 

In  addition  to  the  various  conditions  mentioned  above,  painful  feet  may 
be  caused  by  gout,  rheumatism,  cardiac  or  renal  disease,  neurasthenia, 
neuritis,  neuroma  or  other  tumors,  inflammatory  aflFections  of  the  bones, 
and  diseases  of  the  ovary,  prostate,  or  rectum.  Non-deforming  club-foot 
causes  pain  in  the  foot,  leg,  and  ankle,  and  is  supposed  to  be  due  to  an  altera- 
tion in  the  articular  surfaces,  the  result  of  injury,  arthritis,  habitual  mal- 
position, or  anterior  poliomyelitis.  The  foot  cannot  be  flexed  beyond  a 
right  angle.  Erytfiromelalgia  is  a  curious  nervous  disorder  in  which  there 
are  redness,  swelling,  and  burning  pain,  increased  by  heat  and  immediately 
relieved  by  cold. 

Perforating  ulcer  of  the  foot  {mal  perforant)  is  most  frequently  seen  be- 
neath the  head  of  the  first  or  fifth  metatarsal  bone.  As  a  rule  a  com  or  callos- 
ity first  appears,  suppuration  takes  place  beneath  this,  and  a  sinus  results,  the 
opening  being  surrounded  by  thickened  epidermis;  the  sinus  deepens,  and 
if  allowed  to  progress  imchecked,  the  bones  and  joints  may  be  destroyed. 
The  discharge  is  scanty  and  pain  frequently  slight  or  absent.  The  cause  of 
perforating  ulcer  is  usually  anesthesia  of  the  sole  of  the  foot,  which  permits 
repeated  or  long  continued  irritation  without  the  individual's  knowledge. 
It  may  be  found  in  many  diseases,  conspicuous  among  which  are  leprosy, 
tabes  dorsalis,  and  peripheral  neuritis  the  result  of  alcohol,  syphilis,  or  diabe- 
tes; it  may  result  also  from  injury  of  the  spinal  cord  or  nerves.  In  rare  in- 
stances it  may  follow  epithelioma,  a  neglected  com,  or  other  purely  local 
lesion,  and  in  these  cases  pain  may  be  severe. 

The  treatment  is  relief  of  pressure  by  confining  the  patient  to  a  chair,  re- 
moval of  the  thickened  epidermis  after  poulticing  or  soaking  the  foot  in 
warm  water,  and  disinfection  and  drainage  of  the  sinus ;  the  wound  may  then 
be  stimulated  by  balsam  of  Peru,  or  weak  solutions  of  silver  nitrate  or  cop- 
per sulphate.  Good  results  have  followed  stretching  of  the  tibial  or  the  plan- 
tar nerves.  In  recalcitrant  cases  the  ulcer  should  be  excised  and  necrotic 
bone  removed.  When  the  foot  is  extensively  involved  amputation  may  be 
necessary.  The  cause  of  the  condition  should,  of  course,  be  removed  if 
possible. 


EXTREMITIES, 


AMPUTATIONS. 


Amputation  as  applied  to  tlie  extremities  signifies  the  reraaval  in  coxt 
tinuity  of  the  whole  or  portion  of  a  limb.     If  through  a  joint  it  Is  known  is 

I  a  disarlktdaiimt. 
The  indications  for  amputation  are  (i)  to  save  life,  e.g.,  in  exteDSive 
crushes,  virulent  infections,  gangrene,  septic  diseases  of  bone,  tumors,  and 
aneurysms;  and  (2)  to  provide  for  the  fitting  of  useful  artilicial  supports  when 
the  limb  is  functionless  from  disease  or  deformity.  To  amputate  or  not  to 
amputate  is  a  question  which  often  taxes  the  surgeon's  judgment  lo  the 
utmost,  as  absolute  rules  cannot  be  formulated-  The  age  and  general 
condition  of  the  patient  may  be  such  as  to  necessitate  amputation,  which 
under  other  circumstances  would  be  inadvisable.  Furthermore^  a  la* 
borer  who  must  support  a  large  family  can  often  be  more  quickly  and 
better  prepared  to  meet  life*s  responsibilities  with  an  artificial  limb  thin 
with  a  badly  crippled  ejitremity,  which  lo  his  more  fortunate  brother  is  an 
inconvenience  only.  In  injuries  the  principal  questions  to  be  answered  are: 
(i)  Will  the  blood  supply  be  adequate  to  pre%'ent  gangrene;  (2)  Ls  the  injury 
lo  the  nerves  and  muscles  sci  great  that  a  useful  limb  cannot  be  obtained; 
(3)  can  infection  be  presented  or  kept  under  control  ?  i.  Laceration  of  the 
main  artery  or  vein  alone  is  not  an  imperative  indication  for  amputation, 
as  either  may  be  sutured  or  even  tied  without  gangrene  following,  providing 
the  collaleral  vessels  are  intact.  If  both  arter>^  and  vein  require  ligation, 
however,  amputation  must  be  performed,  unless  the  injury,  a  gunshot 
wound  for  example,  has  not  compromised  the  collateral  circulation.  Mosz- 
kowitz  tests  the  efficiency  of  the  circulation  by  elevating  the  limb,  applying 
a  tourniquet,  then  lowering  the  limb  and  after  five  minutes  removing  the 
constrictor.  If  the  circulation  is  active,  the  whole  limb  becomes  hy^eremic 
in  a  few  seconds.  Parts  which  remain  anemic  are  devitalized,  those  which 
improve  in  color  very  slowly  will  probably  become  gangrenous.  Matas* 
in  order  to  ascertain  the  condition  of  the  collateral  circulation,  maintains 
the  pressure  on  the  artery  after  removing  the  tourniquet.  2.  Nerves  and 
muscles  may  be  sutured  in  suitable  cases,  but  they  are  often  so  extensively 
damaged  that  they  either  cannot  be  approximated  or  repair  cannot  be  ex- 
pected. Extensive  loss  of  skin  in  itself  is  rarely  an  indication  for  amputation. 
3.  Infection  is  practically  never  an  indication  for  primary  amfrntatlon;  a 
finger  may,  however,  be  amputated  immediately  after  a  bite  by  a  venomous 
snake  or  after  a  known  infection  with  very  virulent  organisms.  Unless 
amputation  is  positively  demanded,  e.g.,  in  pulpiiication  of  the  whole  limb 
or  a  segment  thereof,  or  in  cases  In  which  the  main  arter)^  and  vein  are  de- 
stroyed, one  is  always  justified  in  making  an  effort  to  preserve  the  part  by 
careful  disinfection  and  free  drainage.  If  gangrene  or  extensive  cellulitis 
follow  within  a  few  days,  the  limb  may  then  be  removed  (mlermediait 
amputalion).  Secmidary  ampulation,  i.e.,  after  a  number  of  days,  may  be 
required  for  secondary  hemorrhage,  osteomyelitis,  chronic  sepsis,  exhaus- 
tion, or  amyloid  disease,  or  to  remo%^e  a  useless  limb  after  healing  has  occurred. 
As  a  rule,  in  accident  cases,  operation  should  be  postponed  until  shock  has 
subsided,  the  hemorrhage  being  temporarily  stayed  by  applpng  a  tourniquet 
as  close  as  possible  to  the  point  at  which  the  muscles  and  bone  are  crushed. 
The  tissues  thus  compressed  are  already  so  devitalised  that  they  would,  in 
any  event,  be  removed  with  the  limb,  hence  the  tourniquet  is  harmless  and 


I 
I 


i 


AMPUTATIONS. 


62s 


should  remain  in  place  until  after  the  amputation,  a  second  one  being 
adjusted  at  a  higher  level  to  control  bleeding  during  the  operation.  Dis- 
infection, in  these  cases,  can  be  thoroughly  performed  only  after  the  induc- 
tion of  anesthesia*  The  operator  stands  to  the  right  of  the  limb,  which  is 
brought  to  the  edge  of  the  table  and  held  by  an  extra  assistant. 

PrelUninary  control  of  hemorrhage  is  secured  liy  elevating  ihe  limb 
for  several  minutes,  in  order  to  allow  the  blood  to  drain  into  the  vessels  of  the 
body,  and  applying  an  Esmarch  l»and  (Fig.  1 20)  or  other  form  of  tourniquet 
(Figs.  121,  122)  above  the  site  of  amputation.  In  certain  regions  (hip  and 
shoulder)  slipping  downwards  may  be  prevented  by  long  pins  thrust  through 
the  tissues  below  the  band,  by  sutures,  or  by  a  bandage  passing  beneath 
the  band  and  around  the  trunk.  When  elastic  constriction  is  inadvisable 
(atheroma,  etc.)  or  inapplicable  (interscapulo-thoracic  amputation,  etc.), 
the  main  vessels  may  be  occluded  by  digital  pressure  (p*  igg),  or  exposed 
by  a  preliminary  incision  and  clamped  or  tied. 

Division  of  the  tissues  must  be  so  made  that  there  wnll  be  sufficient  peri* 
osteum  to  cover  the  bone,  enough  muscle  to  cover  the  periosteum,  and  ample 
skin  to  cover  the  muscles,  the  scar  being  so  situated  as  not  to  be  exposed 
to  pressure.  As  the  tissues  subsequently  contract,  flaps  which  fit  snugly  are 
too  short.     Formerly  made  by  entering  a  long  knife  close  to  the  Iwne  and 


Fig.  535. — CircuLir  ampolalton,  showing  iwo-tailed  muslin  retractor, 
(E*4indrch  and  Kowalzig/j 

cutting  from  within  outwards  {transfixion)^  flaps,  at  the  present  time, 
are  dissected  from  without  inwards,  as  anesthesiahas  removed  the  necessity  for 
great  haste,  and  it  is  important  to  divide  the  vessels  and  nerves  transversely 
rather  than  obliquely.  According  to  the  shape  of  the  llap  or  tiaps.  the 
amputation  may  be  circular,  oval,  racquet,  or  by  lateral  or  a ntero- posterior 
flaps,  or  a  combination  of  these  methods  may  be  employed.  The  circular 
amputation  is  seldom  employed  except  for  the  arm,  as  the  cicatrix  is  opposite 
the  end  of  the  bone  and  the  stump  is  apt  to  become  conical.  The  skin  and 
subcutaneous  tissues  are  divided  around  the  whole  circumference  of  the  limb 
by  a  circular  sweep  of  the  knife  and  dissected  back  like  a  cuff,  when  the  super- 
ficial and  then  the  deep  muscles  are  similarly  dividetl  at  a  higher  level,  so 
40 


626  EXTREMITIES. 

that  the  cut  surfaces  resemble  a  funnel;  the  periosteum  is  then  reflected  as  a 
cuff,  and  the  bone  severed  with  the  saw,  after  retracting  the  soft  parts  with  a 
split  piece  of  muslin  (Fig.  525).  The  cutaneous  incision  should  be  at  least 
two-thirds  of  the  diameter  of  the  limb  (at  the  point  of  section  of  the  bone) 
below  the  level  of  the  plane  in  which  the  bone  is  sawed.  In  the  oval  method 
(Fig.  528)  an  elliptical  incision  is  made  around  the  limb,  the  distal  portion 
dissected  up,  the  muscles  divided  circularly  a  little  below  the  proxinLal  por- 
tion of  the  incision,  and  the  free  convex  border  sutured  to  the  concave  margin. 
The  racquet  method  (Fig.  533)  consists  of  a  straight  incision  in  the  axis  of 
the  limb  (handle  of  the  racquet)  and  a  circular  or  oval  incision  around  the 
limb  (rim  of  the  racquet).  A  short  skin  and  subcutaneous  flap  is  usuaUy 
made  and  the  muscles  divided  obliquely.  Lateral  or  antero-posterior  flaps 
(Fig.  546)  are  now  generally  used  in  amputating  through  the  shafts  of  long 
bones.  The  flaps  consist  of  the  skin,  subcutaneous  tissues,  and  deep  fascia 
with  a  little  muscle  toward  the  base,  and  may  be  single  or  double  and  of 
various  sizes  and  shapes,  according  to  the  exigencies  of  the  case.     The 


Fig.  526. — Modified  flap  and  circular  amputation.     (Bryant.) 

flaps  should  be  half  the  circumference  of  the  limb  in  width,  and  the  com- 
bined length  of  both  flaps  should  be  at  least  five-eighths  of  the  circumference 
of  the  limb  at  the  point  of  section  of  the  bone.  The  modified  flap  and  cir- 
cular method  (Fig.  526)  consists  of  two  rectangular  flaps,  with  rounded 
corners,  made  on  opposite  sides  of  the  limb.  The  skin,  subcutaneous  tis- 
sues, and  fascia  are  reflected,  and  the  muscles  divided  circularly  at  the  level 
at  which  the  bone  is  sawed.  Osteoplastic  flaps  are  made  by  Bier,  Gritti,  and 
others  {vide  infra),  thus  closing  and  protecting  the  medullary  canal  and  pro- 
viding for  a  freely  movable  integumentary  stump,  but  they  are  tedious 
and  require  special  instruments. 

Permanent  Control  of  Hemorrhage. — The  large  vessels  are  recognized, 
caught  with  hemostals,  and  ligated  with  silk  or  chromicized  catgut;  the  tour- 
nifjuet  is  then  removed,  and  the  smaller  vessels  caught,  and  ligated  with 
catgut.  Capillar}'  oozing  may  be  controlled  by  pressure  with  gauze  or 
by  very  hot  water.  Nerves  and  tendons  should  be  drawn  out  a  little  way 
and  cut  off  short,  and  any  bony  irregularities  trimmed  with  rongeur  forceps. 

Drainage  should  he  provided  for  the  oozing  surfaces,  by  gauze  or  rubber 
tui)ing,  emerging  at  the  most  dependent  part  of  the  wound.  The  periosteal 
flaps  and  the  muscles  are  stitched  over  the  ends  of  the  bones  with  catgut 
and  the  skin  a{)proximated  with  silkworm  gut.  After  applying  the  dress- 
ing, the  stump  is  flrmly  bandaged,  and  then  elevated  on  a  pillow  or  splint 
in  order  to  minimize  oozing.  If  there  is  no  infection  the  drain  may  be  per- 
manently removed  in  forty-eight  hours. 

A  stump  when  healed  should  be  round,  freely  movable,  and  painless  even 
when  subjected  to  considerable  pressure.  The  scar  should  be  out  of  the  line 
of  pressure  and  not  adherent  to  the  bone.     All  of  the  tissues  of  a  stump 


AMPUTATIONS    OF    THE    FINGERS. 


627 


necessarily  atrophy.  The  end  of  the  bone  becomes  smooth,  and  the  medul- 
lary cavity  is  often  closed  by  osseous  tissue.  Necrosis  of  the  end  of  the  bone 
may  be  caused  by  stripping  up  of  the  periosteum,  especially  when  followed 
by  infection.  Diffuse  septic  osteomyelitis  (p.  285)  and  secondary  hemorrhage 
(p.  196)  are  uncommon  complications  at  the 
present  time.  Sloughing  of  the  flaps  results  from 
amputating  too  close  to  the  lesion,  too  thin  flaps, 
arterial  disease  (atheroma),  or  from  some  debili- 
tating constitutional  malady,  especially  diabetes. 
If  extensive,  reamputation  may  be  needed. 
Conical  stump  is  caused  by  too  short  flaps, 
cicatricial  contraction  following  septic  processes, 
and,  in  the  young,  from  continued  growth  of  bone 
(Fig.  527).  In  the  worst  cases  the  end  of  the  bone 
is  exposed.  The  treatment  is  reamputation. 
Neuralgia  of  a  stump  is  due  to  encarceration  of  a 
nerve  in  the  cicatrix  or  to  the  formation  of  a 
neuroma,  either  of  which  may  be  excised,  or  the 
nerve  may  be  cut  at  a  higher  level,  or  reamputa- 
tion performed.  Senn  removes  the  bulbous  end 
of  the  nerve  by  a  V-shaped  incision  and  sutures 
the  flaps  of  the  nerve  together,  thus  preventing 
recurrence.  Spasmodic  stump  may  complicate 
the  last  named  condition  and  is  then  curable 
by  the  same  treatment.  When  of  central  origin, 
relief  is  usually  not  obtained.  Ulceration  of 
the  scar  is  prone  to  develop  if  it  is  thin  and 
adherent  or  exposed  to  pressure,  although  it  may 
depend  upon  some  constitutional  disease  (syphilis, 
etc.).  The  worst  cases  require  reamputation. 
Occasionally  epithelioma  develops. 


Fig .  5  27 . — Conical  stump 
from  continued  growth  of 
bone.     Reamputation. 


SPECIAL  AMPUTATIONS. 

In  many  cases,  particularly  after  injuries,  no  set  amputation  is  applicable; 
one  must  remove  the  devitalized  or  diseased  tissues  and  fashion  impromptu 
flaps  from  that  which  remains,  hence  the  following  methods  must  be  regarded 
as  suggestive  only. 

In  amputations  of  the  fingers  and  hands,  usefulness 
and  symmetry  are  the  objects  to  be  obtained.  Amputation 
of  the  distal  phalanx  may  be  performed  by  opening  the 
joint  on  the  dorsal  aspect,  dividing  the  lateral  ligaments, 
and  cutting  a  long  palmar  flap  from  the  pulp  of  the  finger 
(Fig.  528).  Symmetry  at  times  indicates  an  amputation 
through  the  first  inter  phalangeal  articulation,  but,  as  the 
tendons  are  not  attached  to  the  proximal  phalanx,  it  is 
necessary  to  suture  them  to  the  periosteum.  If  in  doubt  as 
to  the  necessity  of  amputation  of  the  fingers,  do  not  ampu- 
tate; the  reverse  is  true  of  the  toes.  When  amputating 
through  a  phalanx  the  section  should  be  made,  not  with  cutting  forceps, 
which  are  apt  to  splinter  the  bone,  but  with  a  Gigli  saw. 


Fig.  528. 


628 


EXTREMITIES. 


Amputation  at  the  metacarpo-phalangeal  joint  is  best  done  by  a 
racquet  shaped  incision,  which  starts  over  the  knuckle  and  is  carried  obli- 
quely around  the  phalanx  at  the  level  of  the  web  of  the  finger  (Fig.  528). 
The  articulation  is  opened  from  the  dorsal  side.  Lateral  tlaps  taken  from 
the  outer  side  may  be  used  in  amputations  of  the  thumb,  index,  and  little 
fingers.  WTiile  removal  of  the  head  of  the  metacarpal  bone  increases  sym- 
metry by  allowing  the  adjoining  (mgcrs  to  fall  together,  it  impairs  the  strength 


7n,a 


m,t/ 


U.€t 


aarJ- 


a.i,n 


€Li,a 


p.tM 


pea 


Frc.  529.— Section  throu^'h  the  foreanii  atxjvc  the  middle.  (After  Bniune,  aiul  Ksm&rch 
and  Koualzig)  r.  Radius,  w.  Ulna.  i.m.  Inierosseous  membrane.  Muscles:  s>L  Su' 
pirxator  longus.  p.r.t.  Pronator  radii  teres.  ex.r.L  Extensor  carpi  radialis  longior- 
e.c.tAk  Extensor  carpi  radialis  brevior.  e.c.d.  Extensor  communis  digitoriim,  e.o.m.f. 
Extensijr  ossis  mctacarpi  pollkis.  e:m.d.  Extensor  minimi  digiti.  fxM.  Extensor  cmrpd 
ulnaris.  /  /  />.  Flexor  longus  pKillicis.  f.p.d.  Flexor  profundus  digitorum.  f.s.d.  Flexor 
subUmis  di^torum.  /,cm.  Fiexor  carpi  ulnaris.  pJ.  Palmaris  Inngus,  /x.f  Flcj^or  airpi 
radialis.  V'e^sels:  r.a.  Radial  artery  and  veme  comiles.  it  a.  l^nar  arter>'.  ntM.  Median 
artery,  hJm,  Anterior  interosseous  artery.  pJ,a^  Posterior  interosseous  arlcry. 
s.r.v.  Superficial  radial  vein.  m.v.  Median  vein.  Nerves:  Wf,«.  Median  nerve,  iiJi. 
Utnar  nerve.  o.t.«.  Anterior  interosse<iiis  ner^'c.  ^,j\«.  Posterior  interosseous  nerve,  rM. 
Radial  nerve.     (Walsh am.) 


i 


of  the  hand,  hence  is  contraindicated  in  a  laboring  man.  The  metacarpil 
bone  can  be  removed  by  extending  the  incision  corresponding  to  the  handle 
of  the  racquet  upwards  (Fig.  528). 

Amputation  at  the  wrist  joint  may  be  performed  by  an  eUipikaJ 
incision  (Fig.  528),  which  is  one-half  inch  below  the  articulation  oa  the 
dorsal  side,  and  two  inches  lower  on  the  palmar  side;  it  passes  between  the 
pisiform  and  the  base  of  the  fifth  metacarpal  on  the  ulnar,  and  crosses  the 
carpometacarpal  joint  on  the  radial  side.  The  joint  is  opened  from  the 
dorsal  surface.    An  externa!  laitral  flap  (Dttbreuif^  metho^i)  may  be  made 


AMPUTATION   THROITGH   THE   FOREARM. 

by  an  incision  whicli  slarts  on  the  dorsal  surface  at  the  junction  of  the  middle 
and  outer  third  of  the  wrist,  curves  downward  to  the  head  of  the  metacarpal 
bone  of  the  thumb,  and  then  passes  upward  on  the  palmar  surface  to  a  point 
immediately  opposite  its  commencement.  Some  of  the  muscular  tissue 
of  the  thenar  eminence  should  he  included  in  the  flap.  The  ends  of  the 
flap  are  connected  by  a  circular  incision  on  the  ulnar  side  and  the  wrist 
disarticulated.  A  Img  palmar  flap  reaching  to  the  middle  of  the  metacarpal 
bones  may  be  similarly  employed. 


lu.ei^  er,/2  /;rglt. 


rn 


'i. 


aMM 
,  ten 


.m,n 


^pr*b 


cli 


M 


.VV». 


/I  '. 


V  *w  u 


^/cr 


i* 


>*<  / 


'It* 


^< 


^ftr 


I  #••••. 


•  • 


>^. 


J// 


/>■< 

p.U.1/ 


fj 


-C.6 


Fig.  530, — Set  liim  ihrou^^h  the  cltxnv  joint.  (.Vftcr  Brauntv  and  Esm.irch  and  Kowal- 
zig.)  Bones,  ligaments,  and  synovial  membrane:  h.  Humerus,  tx.^  i.e.  External  and 
internal  condyle.  0.  Olecranon,  ej.,  ej.  Elbow  joint,  o.ft.  Olecranon  bursa.  eJJ.^  iJJ. 
External  and  internal  lateral  ligament-  Muscles:  s.L  Supinator  longus.  e.c.r.  Extensor 
carpi  radlalis.  ts.n^  Anconeus,  i.  Triceps,  fx.r.  Flexor  carpi  radialls,  p,rJ.  Pronator 
radii  teres.  6.a.  Brachialia  amicus,  j^.  Biceps.  Vessels:  6.0,  Brachial  arter\'  with  vena* 
comites.  i.p.a.  Inferior  profunda  arter)'.  m.c.v.  Median  cephalic  vein,  m.b.v.  Median 
basilic  vein,  a.H.i\  Anterior  ulnar  vein,  p.u.v.  Posterior  ulnar  vein.  Nerves:  m.n, 
Median  nerve,  ujt.  Ulnar  nerve,  r.n.  Radial  nerve,  pi-fi'  Posterior  interosseous  nerve. 
m.h.m.sj$.  Muscular  brancb  of  the  musculo-spiml  nerve,  i,CM.  Internal  cutaneous  nerve. 
(Walsh  am.) 


Amputation  through  the  foreann  (Figs.  526,  529)  may  he  effected  by 
any  of  the  llap  methods.  The  muscles  should  be  divided  circularly,  the 
interosseous  membrane  severed,  a  three-tailed  muslin  retractor  applied, 
and  both  bones  sawed  through  at  the  same  time,  after  making  a  guiding 
groove  in  the  radius. 

Cinematic  amptitalwn  (VangheUPs  operation)  has  been  employed  in  the 
forearm.  The  tendons  are  cut  longer  than  the  bones,  and  loops  formed  by 
suturing  the  ends  together  or  by  turning  the  tendons  back  upon  themselves, 
or  knobs  made  by  t)^ing  the  ends  in  knots  or  by  chiseling  off  the  bony  inser- 
tion.    The  loops  or  knobs  are  enveloped  in  skin  ilaps.  so  that  after  healing 


630 


EXTREMITIES. 


takes  place  they  may  be  attached  to  hooks  or  strings  and  thus  convey 
movement  to  an  artificial  limb. 

Disarticulation  at  the  elbow  joint  (Fig.  530)  is  unsatisfactory,  amputa- 
tion above  or  below  the  joint  being  preferable.  A\Tien  undertaken,  the  ellip- 
tical or  long  anterior  flap  method  should  be  used. 


m.an 


€tA.S^. 


i^p.€x. 


Fig.  5.^ I. --Section  through  the  ami  below  the  micldle.  (After  Braune,  and  Esmarch 
and  Kowiilzig.)  Muscles:  /;.  Hie eps.  ha.  Brachialis  anticus.  le.  External  head  of  triceps. 
//.  Long  head  of  triceps.  //.  Inner  head  of  tricej)?.  \'essels:  h.a.  Brachial  artery  with  vena 
comites.  i.p.a.  Inferior  profun<la  artery,  s.p.a.  Superior  profunda  artery.  a.b.s.p.a. 
Articular  branch  of  the  superior  profunda  arterj'.  b.v.  Basilic  vein.  c.v.  Cephalic  vein. 
Nerves:  ;;/.«.  Median  nerve,  i.ot.  Internal  cutanet)us  nerve,  u.n.  Ulnar  nerve,  m.c.n. 
Musculocutaneous  nerve,     m.s.n.  Musculo-sf>iral  nerve.     (Walsham.) 

Amputation  through  the  arm  (Figs,  531,  532)  may  be  accomplished 
by  any  of  the  methods   as  indicated  by  the  conditions. 

Amputation  at  the  shoulder  joint  may  be  performed  while  the  sub- 
clavian ves.sels  are  controlled  by  direct  pressure  (p.  199),  or  the  axillary  ves- 
sels may  be  ligated  as  a  preliminary  step.  Elastic  constriction  by  Wyeth's 
method  (see  amputation  of  hip)  has  the  objection  that  hemorrhage  may 
occur  when  the  bone  is  removed.  The  posterior  pin  enters  at  the  middle 
of  the  lower  margin  of  the  posterior  axillary  fold,  and  emerges  just  behind 
and  one  inch  within  the  acromion  process.  The  anterior  pin  is  introduced 
at  the  middle  of  the  lower  margin  of  the  anterior  axillary  fold  and  emerges 
one  inch  to  the  inner  side  of  the  acromion.  The  constricting  band  is  ap- 
plied above  the  pins.  The  classical  operations  are  those  of  Spence,  Larry, 
and  Dupuytren. 

Spnicc's  operation  (^anterior  racquet,  Fig.  533)  is  begun  by  making  an 
incision    down    to    the   bone,    from    midway    between    the  coracoid  and 


AMPUTATION  AT  THE  SHOULDER. 


631 


acromion  processes,  down  wards  and  outwards  for  three  or  four  inches; 
if  desirable  the  joint  may  l>e  opened  al  once  for  examination.  The  knife 
is  then  carricil  downward  and  inwards  across  the  axillary  fold  and  around 
the  arm  10  the  end  of  the  primary  incision.  The  skin  is  reflected  for  an  inch 
or  more  and  the  muscles  on  the  inner  aspect  divided  obliquely,  thus  exposing 
the  axillar)^  vessels,  which  are  ligated  and  tlivided.  The  soft  parts  on  the 
outer  side  are  separated  from  the  bone,  the  inner  half  of  the  capsule  ami  the 


,  c  t/ 


-../■ 


/''I 


'  N;-, 


l,.l 


,m. 


}Ja 


V^ 


t.m^ 


Fig.  533. — Section  above  the  middle  of  the  arm.  (After  Braune,  and  Esm^^rch  and 
Kowaliig.)  Muscles:  p,m,  Pcctoralis  major,  hM.  Brathialis  iinlicus.  d.  Deltoid,  t.e, 
Eatteraal  ticad  of  triceps.  iJ.  Long  head  of  Irkeps.  I  A.  Latissimus  dorsi.  i.m.  Tt-rcs 
major,  c.h,  Coraco-brachialis.  hh.  Short  head  of  biceps.  hX.  Long  bead  of  biceps. 
Vcssek:  b.a.  Brachial  artery  with  vena:  coniites,  i-pf^^  Superior  profunda  arter)\  h.v. 
Basilic  vein,  cak  Cephalic  vem.  Nen'cs:  m.n.  Median  nerve,  u.n,  Uhiar  nerve.  m.sM, 
Musculo-spiral  ner\'e.  ixM.  Internal  cutaneous  nerve.  mxM.  Musculocutaneous  nerve, 
(Walshara.) 

subscapularis  divided,  the  head  of  the  humerus  drawn  outwards,  the  division 
of  the  capsule  completed,  and  the  remaining  tissues  cut  by  carrying  the  knife 
downwards  dose  to  the  inner  side  of  the  bone,  to  avoid  injurv'  to  the  posterior 
trunk  of  the  circumflex  arter}'. 

Larry's  operation  is  an  external  racquet  amputation  (Fig.  534).  A  six 
inch  vertical  incision  is  made  from  the  tip  of  the  acromion  down  the  outer 
side  of  the  arm.     The  oval  incision  begins  at  the  center  of  the  vertical  and 


632 


EXTREMITIES. 


is  carried  obliquely  around  the  arm.  The  flaps  are  reflected  from  the 
outer  aspect  of  the  joint  and  the  extremity  removed  as  in  the  Spence 
operation. 

Dupuytren^s  amputation  consists  of  a  U-shaped  flap  extending  from  the 


Fig.  533. — Spence's  amputation. 
(MouUin.) 


Fig.  534. — I.  Larry's  amputation.  2. 
Dupu3rtren's  amputation.  (After  £s- 
march  and  Kowalzig.) 


coracoid  to  the  root  of  the  acromion,  the  lowest  point  reaching  to  the  insertion 
of  the  deltoid  (Fig.  534).  The  inner  flap  is  made  by  an  incision  joining  the 
ends  of  the  former  and  extending  two  inches  below  the  axilla.  Disarticula- 
tion is  accomplished  as  in  other  methods. 


Fig.  535.— Interscapulo-thoracic  amputation.  Fig.  536. — Incisions  for  (i)  Lisfranc's, 

(.After  Esmarch  and  Kowalzig.)  (2)  Chopart's,  (3)  Subastragaloid,    (4) 

PirogofT's,  and  (5)  Syme's  amputations. 

Interscapulo-thoracic  amputation  is  the  removal  of  the  entire  upper 
extremity,  arm,  scapula,  and  the  whole  or  a  portion  of  the  clavicle.  An 
incision  is  made  along  the  clavicle,  and  the  preliminary  control  of  hemorrhage 
secured  by  ligation  of  the  subclavian  vessels,  after  resecting  the  middle  third 


AMPUTATIONS    OF   THE   FOOT.  633 

of  the  clavicle  (Berger),  or  after  disarticulating  its  sternal  end  (Le  Conte), 
care  being  taken  not  to  open  the  pleura.  The  anterior  flap  is  outlined  by 
carrying  the  knife  from  the  center  of  the  clavicular  incision  downwards  and 
outwards  across  the  anterior  axillary  fold  and  backwards  to  the  lower  angle 
of  the  scapula  (Fig.  535).  The  muscles  are  severed,  thus  exposing  the 
brachial  nerves,  which  are  cut  on  the  same  level  as  the  subclavian  vessels. 
The  limb  is  then  carried  across  the  chest,  and  a  posterior  flap  made  by 
joining  the  ends  of  the  two  previous  incisions.  The  scapular  muscles  are 
detached  and  the  whole  extremity  removed. 

Amputations  of  the  toes,  excepting  the  great  toe,  are  never  made  except 
at  the  metatarso-phalangeal  articulation,  the  operation  then  being  identical 
with  that  described  for  the  fingers,  remembering,  however,  that  the  joint 
is  the  same  distance  behind,  as  the  tip  of  the  toe  is  in  front  of  the  web. 

Disarticulation  at  the  tarso-metatarsal  joint  (Lisfranc  amputation) 
is  performed  by  making  a  curved  incision  from  the  base  of  the  first  metatarsal 


Fig.  537. — Diagram  of  amputations  of  foot. 

across  the  dorsum  of  the  foot  to  the  base  of  the  fifth  (Fig.  536).  The  plantar 
flap  curves  convexly  to  the  root  of  the  toes,  and  includes  all  the  tissues  of 
the  foot  to  the  bones.  To  disarticulate  (Fig.  537),  the  knife  is  passed 
behind  the  projecting  end  of  the  fifth  metatarsal  and  directed  toward 
the  base  of  the  great  toe;  the  fourth  metatarsal  is  separated  by  cutting 
toward  the  middle  of  the  fifth  metatarsal,  and  the  third  by  cutting  towards 
its  base;  the  knife  then  glides  over  the  second  metatarsal,  and  enters  the 
joint  of  the  first  metatarsal.  The  second  metatarsal  is  separated  by  incising 
its  dorsal  ligament  transversely  and  then  cutting  upwards  between  the 
first  and  second  metatarsals.  By  strongly  depressing  the  foot  any  remain- 
ing attachments  may  be  severed  and  the  disarticulation  completed.  In  the 
Hey  operation  the  diflficulty  of  disarticulating  the  second  metatarsal  is  over- 
come by  sawing  through  the  projecting  internal  cuneiform.  In Skey^s  method 
the  second  metatarsal  is  sawn  through  at  its  base.  Baudens  advised  dis- 
articulating the  first  metatarsal  and  sawing  through  the  remaining  ones  at 
the  same  level. 

Disarticulation  at  the  Mid-tarsal  Joint  {ChoparVs  Amputation, 
Figs.  536,  537). — The  long  plantar  incision  begins  on  the  inner  side  at  the 
tubercle  of  Qie  scaphoid,  curves  forward  to  within  one  inch  of  the  ends  of 
the  metatarsal  bones,  and  terminates  on  the  outer  side  at  a  point  midway 


634  EXTREMITIES. 

between  the  malleolus  and  base  of  the  fifth  metatarsal.  The  dorsal  indsion 
curves  slightly  forward  and  unites  the  ends  of  the  plantar.  The  astragalo- 
scaphoid  and  the  calcaneo-cuboid  articulations  are'  is  opened  from  the 
dorsal  side.  The  anterior  part  of  the  arch  of  the  foot  is  removed,  leaving 
the  posterior  without  any  support,  so  that  the  os  calcis  is  often  subsequently 
drawn  upwards,  the  patient  walking  on  the  astragalus,  thereby  causing  con- 
siderable pain  and  perhaps  ulceration.  Forbes  separated  ihe  cuneiform 
bones  from  the  scaphoid  and  sawed  through  the  cuboid. 

Subastragaloid  amputation  of  the  foot  makes  a  useful  stump  covered 
by  the  skin  of  the  heel.     A  racquet-shaped  incision  (Fig.  536)  is  made, 


Fig.  538. — Syme's  amputation,  showing  the  structures  divided.  /.  Fibula.  /.Tibia,  i.a. 
Tibialis  anticus  tendon,  f. /.A.  Extensor  longushallucis.  a./.a.  Anterior  tibial  arter>'.  a.t.v. 
Anterior  tibial  vein,  f.c.d.  E.\tensor  communis  digitorum.  pn.l.  Peroneus  longus.  pn.  b. 
Peroneus  brevis.  /.l.h.  Flexor  longus  hallucis.  /.  Ach.  Tendo  Achillis,  beneath  which  is 
a  bolster  of  fat.  t.p.  Tibialis  posticus,  /.l.d.  Flexor  longus  digitorum.  pj.a.  Posterior 
tibial  arter\'  dividing  into  e.p.a.  and  i.p.a.  external  and  internal  plantar  artery,  e.c.a.  and 
i.c.a.  External  and  internal  calcaneal  branches  fonning  the  blood  supply  of  the  thick 
heel-flap.     (Walsham.) 

commencing  at  the  insertion  of  the  tendon  of  Achillis,  and  extending  along 
the  outer  side  of  the  foot  to  a  point  just  above  the  base  of  the  fifth  metatarsal, 
where  it  encircles  the  foot.  The  dorsal  flap  is  reflected,  the  tendon  of 
Achillis  divided,  the  astragalo-scaphoid  joint  opened,  the  foot  twisted 
inwards,  and  the  astragalus  separated  from  the  os  calcis,  which  is  then 
cleared  and  the  foot  removed. 

Amputation  at  the  Ankle  Joint. — Syme's  amputation  (Figs.  536,  537, 
538)  is  a  disarticulation  at  the  ankle  joint,  with  removal  of  the  malleoli 
and  the  articular  surface  of  the  tibia.  An  incision  is  made  down  to  the  bone 
at  the  tip  of  the  external  malleolus,  and  is  carried  under  the  heel  to  a  point 


AMPUTATIONS   OF   THE   FOOT. 


635 


one-half  inch  below  and  behind  the  inner  malleolus.  This  flap  is  dissected 
from  the  os  calcis,  keeping  close  to  the  bone  to  avoid  the  calcaneal  vessels. 
The  dorsal  incision  unites  the  ends  of  the  first  and  is  slightly  convex  down- 
ward.    The  ankle  joint  is  then  opened  from  the  dorsal  aspect,  the  posterior 


m.cft 


a,Ln 


-pJ.a 


e.s.i/ 


s.^.n 


Fig.  539. — Section  through  the  lower  third  of  the  leg.  (After  Braune,  and  Esmarch  and 
Kowalzig.)  /.  Fibula.  ^  Tibia,  i.m.  Interosseous  membrane.  Muscles  and  tendons:  t.a 
Tibialis  anticus.  e.lh.  Extensor  longus  hallucis.  e.l.d.  Ejrtensor  lonsus  digitonim.  pn,l. 
Peroneus  longus.  pn.h.  Peroneus  brevis.  t.p.  Tibialis  posticus.  f.lJi.  Flexor  longus  hal- 
lucis. g.  s.  Gastrocnemius  and  soleus  forming  the  tendo  AchilHs.  pU.  Plantaris  tendon. 
/.l.d.  Flexor  longus  digitonim.  Vessels:  aJ.a.  Anterior  tibial  artery,  pn.a.  Peroneal  artery. 
p.t.a.  Posterior  tibial  artery,  i.s.y.  Internal  saphenous  vein,  e.s.v.  External  saphenous 
vein.  Nerves:  aJ.n.  Anterior  dbial  nerve,  m.c.n.  Musculo-cutaneous  nerves,  pj.n. 
Posterior  tibial  nerve,  s.s.n.  Short  saphenous  ner\'e.  l.s.n.  I-.ong  saphenous  nerve.  (Wal- 
sham.) 

ligaments  and  the  tendon  of  Achillis  divided,  and  the  lower  ends  of  the  tibia 
and  fibula  removed  vnih  the  saw. 

Pirogofif's  amputation  differs  from  Syme's  in  that  the  posterior  por- 
tion of  the  OS  calcis  is  sawn  off  and  approximated  to  the  sawn  ends  of 


•^^ 


Fig.  540. 


Fig.  541. 


Teale's  amputation.     (MouUin.) 


the  tibia  and  fibula,  the  plantar  incision,  forming  a  right  angle  with  the 
dorsal,  being  carried  obliquely  forward  instead  of  vertically  downwards 
(Fig.  536).  The  lower  ends  of  the  tibia  and  fibula  are  sawn  obliquely 
and  almost  parallel  with  the  sawn  surface  of  the  os  calcis  (Fig.  537).    The 


636 


EXTREMITIES. 


bones  are  then  approximated  and  held  in  place  by  wire,  or  by  catgut  suli 
passing  through  the  periosteum.    LcForl  modifies  this  operation  by  sat 
the  tibia  and  os  calcis  horizontally.     Ferguson  allowed  the  malleoli  to  renuun 
and  brought  the  fragment  of  the  os  calcis  up  between  the  two. 

Amputation  of  the  leg  may  be  made  at  any  level,  the  so-called  point  of 
election,  i,e.,  just  below  the  tubercle  of  the  tibia,  no  longer  being  recognized. 
The  fibula  should  always  be  divided  at  a  higher  level  than  the  tibia,  the 
sharp  anterior  edge  of  which  should  be  beveled.  As  in  the  forearm,  a  three- 
tailed  retractor  will  be  needed  to  keep  the  soft  parts  out  of  harm's  way  when 


ijn 


pn.n 


Fig.  542. — Section  throy^h  ihe  middle  of  ihe  leg.  (After  Braune,  ami  Esmarcli 
Kowakig.)  /  Fibula*  L  Tibia.  i,m.  Interosseous  membrane.  Muscles;  t.Q.  TihUIis 
anticus.  e.Ld.  Extensor  longus  digitomm.  p,L  Peroneus  longtis.  t.p.  Tibialis  p»*5ticu5-  s, 
Solciis.  g,^.  Gastrocnemius-  pU.  Pianiaris,  V'^esseb:  aJ.a,  Anterior  tibiaJ  artery  with 
venfc  comiles.  pJ.a.  Posterior  tibial  artery.  pn,a.  Peroneal  arter>'.  i.s.v.,  e.sx'.  Internal 
and  ejttemal  saphenous  vein.  Nerves:  ai.n.  Anterior  tibial  nerve,  pn.n.  Peroneal  nerve 
pj,n.  Posterior  libial  nen^e.  Ls.n.  Long  saphenous  nerve,  s.sm.  Short  saphenous  nerw 
(Walsham.) 

the  saw  is  used.  In  the  l<riVer  third  (Fig.  539)  lateral  flaps  of  equal  h 
are  perhaps  the  best,  Osieopiastk  flaps  (Moschcowitz)  may  be  obi 
from  the  malleoli  and  made  lo  cover  the  ends  of  the  two  bones;  they  should 
be  on  the  same  plane  as  the  articular  cartilage  of  the  tibia.  Teal's  mtihod 
(Figs.  540,  541)  consists  of  two  rectangular  flaps  including  all  the  structure* 
down  to  the  bone.  The  length  and  breadth  of  the  long  flap,  which  is  taken 
from  the  surface  where  the  bone  is  most  superficial,  should  be  equal  to  one- 
half  the  circumference  of  the  leg  at  the  proposed  site  of  amputation.  The 
short  flap,  containing  the  main  blood  vessels,  is  one-quarter  the  length  of  the 
long  flap.  In  the  middle  and  upper  thirds  likewise  (Fig.  542),  two  lateral  flaps 
of  equal  length  are  satisfactoryi  or  the  external  flap  may  be  long  and  the  in- 


IMPUTATION    OF   THE    THIGH. 


537 


ternal  short.  In  the  latter  care  should  be  taken  to  cut  the  anterior  tibial  artery 
long,  and  not  to  injure  it  in  separating  the  interosseous  membrane.  Osteo- 
plastic flaps  have  been  suggested  by  Bier  and  von  Eiselberg.  An  oblong  flap 
of  periosteum  and  bone  is  made  from  the  anterior  portion  of  the  tibia^  and 
turned  upward  by  fracturing  ils  upper  border,  the  periosteum  forming  a 
hinge  (Figs,  543,  544);  the  remainder  of  the  bone  is  then  divided,  and  the 
bone  flap  applied  over  the  medullary  cavity  and  held  in  place  by  chromicized 
catgut  sutures  passing  through  the  periosteum.  The  advantages  claimed 
are  the  closure  and  protection  of  the  medullary  canal,  increased  stability 
of  the  bone,  and  a  movable  skin  flap.  Another  method  (Bier)  Is  to  remove 
a.  wedge  of  bone  a  short  distance  above  the  line  of  amputation,  and  close  the 


Fig.  545.  Fig.  544. 

Bier's  osteoplastic  amputation  of  leg.     (Esmarch  and  Kowalzig.) 


wedge  at  the  completion  of  the  operation,  thus  changing  the  position  of  the 
scar  and  closing  the  medullar)^  cavity, 

DlsarticulaUon  at  the  knee  joint  (see  Fig.  545  for  relations)  may  be 
effected  after  making  bilateral  flaps.  Two  semilunar  incisions,  starting  at 
a  point  just  below  the  tibial  tubercle,  curv^e  around  each  side  of  the  leg, 
meeting  again  posteriorly  in  the  midline  on  a  level  with  the  joint.  As  the 
internal  condyle  is  the  larger,  the  inner  flap  should  be  longer.  The  liga- 
mentum  patelhe  is  dividetl  and  the  joint  opened  and  disarticulated.  A 
hng  anterior  flap  may  be  made  by  an  incision  from  one  condyle  lo  the  other, 
and  extending  to  a  point  Ave  inches  below  the  patella;  a  short  curved  incision 
unites  the  ends  of  the  former.     The  patella  may  or  may  not  be  removed. 

Stipracondjlotd  Amputation  of  the  Femur  (Garden's  Method), -- 
An  anterior  semilunar  flap  of  skin  and  subcutaneous  tissues  is  outlined  by 
an  incision  passing  from  one  condyle  to  the  other,  and  reaching  downward  to 
two  inches  below  the  patella;  the  posterior  flap  is  made  by  an  incision  connecting 
the  ends  of  the  anterior  and  passing  through  all  the  soft  tissues  (Figs.  546, 
547).  The  condyles  are  divided  just  below  the  epiphyseal  line.  GrittVs 
osteoplastic  mtthod. — An  anterior  semilunar  flap  extends  from  the  condyles 
of  the  femur  to  the  tibial  tubercle  and  includes  the  quadriceps  extensor 
tendon  and  the  patella;  the  posterior  is  made  by  an  incision  connecting  the 
ends  of  the  anterior.  The  condyles  of  the  femur  arc  divided  just  alwve  the 
articulation.  The  posterior  surface  of  the  patella  is  then  removed  wdth  a 
fine  saw,  and  the  remaining  portion  sutured  to  the  sawn  surface  of  the  femur 


638 


EXTREMITIES. 


with  catgut  passing  through  the  periosteum,  or  with  wire  (Figs.  548,  549). 
Sabanejeff  covers  the  end  of  the  femur  with  a  bone  flap  from  the  tibia  (Figs. 

55o»  551)- 

Amputation  of  the  thigh  (Fig.  552)  may  be  performed  by  any  of  the 
usual  methods,  the  modified  flap  and  circular  being  perhaps  the  best. 

Amputation  at  the  hip  joint  (Fig.  553)  is  accompanied  by  unusual 
risks  from  hemorrhage,  shock,  and  sepsis.     Hemorrhage  may  be  controlled 


ell^ 


OTKU 


pau 


t.pvn 


€.3.1/ 


Fig.  545.— Section  through  the  condyles  of  the  femur,  to  show  the  relations  of  the  struc- 
tures. (After  Braune,  and  Esmarch  and  Kowalzig.)  /.  Femur,  p.  Patella.  Muscles: 
g.i.,  R.e.  External  and  internal  head  of  the  gastrocnemius,  s.  Sartorius.  sm.  Semi- 
membranosus, RT.  (}racilis.  st.  Semi-tendinosus.  h.  Biceps,  k.j.  Knee  joint.  i.l.L, 
e.l.l.  Internal  and  external  lateral  ligament,  p.c.l.  Posterior  and  crucial  ligaments. 
Vessels:  po.a.  Poj)litcal  arter}-.  ar.a.  Articular  branch,  an.a.  Anastomotic  arter}-.  po.w 
Popliteal  vein,  i.s.v.  Internal  saphenous  vein,  e.s.v.  ?'xtemal  saphenous  vein.  Ner\eii: 
e.po.n.  External  popliteal  nerve,  i.po.n.  Internal  popliteal  nerve.  -I.s.n.  Long  saphenous 
nerve.     (Walsham.) 


by  (i)  preliminary  exposure  and  ligation  of  the  femoral  vessels,  with  subse- 
quent clamping  of  the  smaller  ones  as  they  are  divided  (the  best  method); 

(2)  pressure  upon  the  aorta  by  various  forms  of  tourniquets  (dangerous); 

(3)  pressure  upon  the  external  iliac  vessels  with  Davy's  rectal  lever  (danger- 
ous); (4)  direct  digital  pressure  on  these  vessels  through  an  abdominal 
incision  (McBurney) ;  or  (5)  by  a  rubber  tourniquet  held  close  to  the 
l)rim  of  the  pelvis  by  two  long  steel  pins  (Wyeth),  by  sutures,  or  by  a  loop 
passing  around  the  abdomen.  In  Wycth's  bloodless  method,  "after 
exsanguinating  the  limb  one  pin  is  introduced  one-fourth  of  an  inch  below 
and  within  the  anterior  superior  spine  of  the  ilium,  and  after  traversing 


AMPUTATION  AT   THE  HIP. 


639 


the  muscles  and  fascia  on  the  outer  side  of  the  hip,  emerges  on  a  level 
with  the  point  of  entrance.  The  point  of  the  second  pin  is  thrust  through 
the  skin  and  tendon  of  the  origin  of  the  adductor  longus  muscle  one-half 
inch  below  the  crotch,  the  point  emerging  one  inch  below  the  tuber  ischii. 


Fig.  546.  Fig.  547- 

Garden's  amputation.     (MouUin.) 


/ 


Fig.  548. 


Fig.  549- 


Gritti*s  amputation. 


Fig.  550.  Fig.  551. 

Sabanejcff's  amputation. 


The  points  should  be  shielded  at  once  with  corks  to  prevent  injury  to  the 
hands  of  the  operator.  No  vessels  are  endangered  by  these  skewers.  A 
piece  of  strong  white  rubber  tubing,  one-half  inch  in  diameter  when  un- 
stretched,  and  long  enough  when  in  position  to  go  five  or  six  times  around 


EXTREMITIES. 


the  thigh  J  is  now  wound  tightly  around  abovx  the  fixation  needles."  The 
thigh  is  amputated  by  an  external  racquet  incision,  the  external  portion 
of  which  extends  from  the  rubber  band  downwards  for  six  inches,  ihcn 
being  completed  by  a  circular  incision  around  the  thigh.  The  skin  and 
subcutaneous  tissues  are  reflected  to  the  lesser  trochanter  and  the  muscles 
cul  at  this  level.  The  capsule  of  the  joint  is  opened  and  the  thigh  carried 
upward,  inward ^  and  forward,  tlius  forcing  the  head  of  the  bone  from  the 
socket.  The  round  ligament  is  then  severed  and  the  limb  removed, 
Senn  perforates  the  thigh  close  to  the  head  of  the  femur  with  a  double 


l.SM 


d/ap^ 


t 


YiQ.  552, — Section  of  the  thigh  at  the  junction  of  the  middle  iind  lower  third.  (After 
Brautic,  and  Esmarch  aod  Kowabig.)  /.  Femur,  Muscles:  vA.  Vastus  intemus.  r./. 
Rectus  fcmoris,  rr.  Crurcus.  v.t.  Vastus  externum,  b.h,^  IkL  Short  and  tong  head  of  ihe 
liiiccps.  St.  Semi-tendinosus.  sm.  Semi-mem  bra  it  f3$us,  ^r.  (iradlis.  j.  Sartorius.  a.m, 
Adduclr^r  magnus,  artery  abtjut  to  pass  through.  Vessels:  s,/.a.  Superficial  femoral  artciy. 
an.a.  Anastomotic  artery-  d,J,a.p.  Deep  femoral  arter>'  perforating,  sm.  Sciatic  arlcn'. 
s.f.iK  Superficial  femoml  vein.  %,sa.k  Internal  saphenous  vein.  Nerves:  s.n.  Sciatic  nenre, 
Lsn.     Long    saphenous    nerve.     (Walsham,) 

ruljber  tube,  one-half  of  which  is  tied  in  front  and  the  other  half  behind. 
Es march  divides  the  femur  at  the  level  of  the  circular  incision,  ties  all  blood 
vessels,  removes  the  constrictor,  and  then  enucleates  the  upper  end  of  the 
femur.  Perhaps  the  best  method,  when  applicable,  is  the  anterior  racquft 
amputation  without  the  use  of  a  constrictor.  A  longitudinal  incision  is 
made  from  the  middle  of  Poupart^s  ligament  downwards  for  three  inches. 
The  common  femoral  vessels  are  divided  between  ligatures,  and  the  incision 
continued  downwards  and  inwards  across  the  inner  side  of  the  thigh  about 


INTEMLIO-ABDOMINAL  AMPUTATION. 


641 


four  inches  below  the  crotch,  thence  continuing  around  the  thigh  to  join 
the  primary  incision.  The  outer  flap,  including  the  muscles,  is  separated 
from  the  femur,  any  bleeding  vessels  being  caught  and  tied  as  they  are 
encountered.  The  limb  is  then  rotated  outwards  and  the  process  repeated 
on  the  inner  side.    The  capsule  is  now  opened,  the  head  of  the  bone  dis- 


FiG.  553. — Section  of  the  upper  third  of  the  thigh  to  show  the  relation  of  the  structures 
divided  in  amputation  of  the  hip.  (After  Braune,  and  Esmarch  and  Kowalzig.)  /.  Femur. 
Muscles:  s.  Sartorius.  r.f.  Rectus  femoris.  t.f.  f.  Tensor  fasciae  femoris.  v.  Vastus,  g.m. 
Gluteus  maximus.  j/.  Semi-tendinosus.  jm.  Semi-membranosus.  a.m.  Adductor  magnus. 
a.b.  Adductor  brevis.  gr.  Gracilis,  a.l.  Adductor  longus.  Vessels:  s.f.a.  Superficial 
femoral  artery,  d.f.a.  Deep  femoral  artery,  d./.p.a.  Deep  femoral  perforating  artery. 
g.a.  Gluteal  artery,  s.a.  Sciatic  artery,  s.f.v.  Superficial  femoral  vein,  d./.v.  Deep 
femoral  vein.  i.s.v.  Internal  saphenous  vein.  Nerves:  a.c.n.b.  Anterior  crural  nerve 
branches,  s.n.  Sciatic  nerve,  s.o.n.  Superficial  obturator  nerve,  d.o.n.  Deep  obturator 
nerve.     (Walsham.) 

articulated  forward,  the  ligamentum  teres  divided,  and  the  tissues  on  the 
posterior  surface  severed  by  carrying  the  knife  downwards  and  outwards 
behind  the  bone. 

Interilio-abdominal  amputation,  in  which  the  entire  lower  extremity, 
including  the  whole  or  a  portion  of  the  innominate  bone,  is  removed,  has 
been  performed  thirty -four  times  with  ten  recoveries  (Ransohoflf). 


41 


INDEX 


N.  B.    The  most  important  reference  is  placed  first. 


Abbe's  string  saw,  for   esophageal    stric- 
ture, 438 
operation  on  the  fifth  nerve,  228 
Abdomen,  affections  of,  440 
contusions,  440 
phantom  tumor  of,  445 
wounds  of,  445 
Abdominal  aorta,  compression  of,  200 
ligation  of,  212 
hemorrhage,  203 
hernia,  498 
hydrocele,  566 
hysterectomy,  596 

operations,  general  remarks  on,  440 
pregnane)',  604 
section,  440 
surgery,  440 
tonsil,  483 

tumor,  see  special  organs 
walls,  injuries  of,  440 
Abducens  nerve,  affections  of,  229 
Abrasion,  87 
Abscess,  70 
acute,  70 

diagnosis  of,  7 1 
pathology  of,  70 
symptoms  of,  7 1 
treatment,  71 
varieties  of,  70 
see  also  special  regions 
chronic,  72 

diagnosis  of,  73 
pathology  of,  7  2 
symptoms  of,  7  2 
treatment,  73 
see  also  special  regions 
tuberculous,  see  chronic 
Absorptive  p)ower  of  stomach,  testing,  458 
Accessory  auricles,  375 

th)Toids,  383 
A.  C.  E.  anesthetic  mixture,  19 
Acetabulum,  fracture  of,  27 1 


Acetanilid,  34 
Acetone,  10,  82 
Acetonemia,  103,  7 
Acetonuria,  103 
Achillodynia,  623 
Achondroplasia,  292 
Achorion  Schonleinii,  31 
Acid  bums,  99 
Acinous  adenoma,  138 

carcinoma,  139 
Acne,  Rontgen  rays  in  treatment  of,  1 
Acquired  dermoids,  149 

dislocation,  297 

diverticula,  468 

inguinal  hernia,  500 

valgus,  620 
Acromegaly,  294 
Acromicria,  294 
Acromion,  dislocation  of,  301 

fracture  of,  260 
Actinomycosis,  119,  31 
Acupressure,  200 
Acupuncture  for  aneurysm,  191 

neuritis,  222 
Adams'  osteotomy,  325 
Address,  in  diagnosis,  2 
Adenitis,  femoral,  219 

inguinal,  219 

cervical,  219 
Adenoids,  393 
Adenoma,  138 

see  also  special  regions 
Adenocarcinoma,  138 
Adenomatous  goiter,  384 
Adenomyxoma,  138 
Adenosarcoma,  138 
Adhesive  inflammation,  59 

plaster,  sterilized,  88 
Adrenalin  chlorid,  23,  197 
Adventitious  bursae,  245 
Adynamic  inflammation,  59 

ileus,  472 


643 


644 


INDEX. 


Atrial  fistula,  382 

Aerobes,  27 

Age,  in  diagnosis,  i,  2 

Agglutination,  29 

Agnew's  splint,  261 

Agraphia,  S33 

Ainhum,  82 

Air  bed,  362 

Air  embolism,  173,  183,  382 

hunger,  196 
Air-passages,  foreign  bodies  in,  396,  2 

operations  upon,  400 
Albert's  disease,  623,  245 
Albuminoid  degeneration,  73 

disease,  73 
Alcohol,  $^ 
Alcoholism,  340 
Aleppo  boil,  159 
Alexander's   operation    of   shortening    the 

round  ligaments,  590 
Alexia,  334 
Alexins,  29 
Allantois,  515 
Allis'  inhaler,  16 

method  of  reduction  of  dislocation  of 
hip  joint,  308 
Alopecia  in  syphilis,  1 26,  1 25 
Aluminium  bronze  u-ire,  36 
Alveolar  processes,  affections  of,  429 

sarcoma,  147 
Amazia,  410 
Amboceptor,  29 

Ambulatory  treatment  of  fractures,  251 
Ameba  coli,  69,  31 
Amenorrhea,  599 
Amnesia,  334 
Amputation  stump,  626 

affections  of,  627 
Amputations,  624 

see  also  special  regions 
Amyloid  disease,  73 
Anacrol)es,  91,  27 
Anal,  see  anus 
Anaphylaxis,  30 
Anastomosis,  arterial,  202 

intestinal,  end  to  end,  479 
lateral,  481 

neural,  225 

ureteral,  538 
Anatomical  tubercle,  161 
Anchylostomiasis,  10 
Anel's  operation  for  aneurysm,  192 
Anemia,  () 

acute,  following  hemorrhage,  196 
Anesthesia,  14,  221, 

after  rt"fc(  is,  22 

Hicr's  intravenous,  24 

( oniplitations  during,  20 

( ontraindic  ations,  14 

death  rate.  14 

general,  14,  251 
Mil:uli(  z's  law,  <j 

indications,  14 


Anesthesia,  local,  22,  23 
technic  for,  24 
massage  of  heart  in  collaftse  during, 

preparation  of  anesthetist,  16 
patient,  15,  16 

primary,  17 

Ransohoff's  arterial  anesthesia,  24 

recovery  from,  22 

rectal,  18 

scopolamin-morphin,  20 

spinal,  24 
Anestnetics,  16 

administration  of,  16 

adrenaUn  chlorid,  23 

Barker's  solution,  25 

carbolic  acid,  85 

chloroform,  18,  15,  20,  22,  335 

choice  of,  14,  15 

cocain  hydrochlorid,  23 

contraindications  for,  15,  19 

ether,  16,  15,  17,  18,  22,  97,  335 

ethyl  bromid,  19 

chlorid,  14,  19,  22,  97,  222 

eucain  hydrochlorid,  23 

ice  and  salt,  22 

inhalers  for  administration  of 
Allis,  16 
Clover,  19 
Esmarch,  18 
Rupert,  17 
Skinner,  18 

liquid  air,  22 

methyl  chlorid,  22 

mixtures,  19 

nitrous  oxid,  19,  14,  20,  22 

novocain,  23,  25 

rhigolene,  22 

Schleich's  solution,  23 

scojx)lamin-morphin,  20 

stovain,  23,  25 

tropacocain,  23,  25 
Aneur}'sm,  187 

causes  of,  188 

diagnosis  of,  190 

diffuse  traumatic,  186 

duration  of,  189 

parts  of,  187 

rupture  of,  189 

symptoms  of,  188 

treatment  of,  190 

varieties  of,  188 
Aneurysm  by  anastomosis,  186,  144 
Aneun>'smal  erosion,  371 

varix,  i()4,  344 
Angina  Ludoviei,  381 
Angioma,  144 
Angioneurotic  edema,  398 
Angiorrhaphy,  201 
Angiosarcoma,  14S 
Angiosclerosis,  1S4 
Angiotril>e.  200 
Angle's  hands,  255 


INDEX. 


645 


Angular  curvature  of  spine,  369 

convolution,  332 
Animal  bites,  115 

tuberculosis,  133 
Ankle  joint,  amputation  at,  634 

dislocation  of,  311 

effusion  into,  314 

erasion  of,  321 

excision  ojf,  328,  321 

fracture-dislocation  of,  282,  311 
Ankle  ioint,  gonorrheal  infection  of,  315 

tuDerculous  disease  of,  321 
Ankyloglossia,  424 
Ankylosis,  324 
Anorchism,  561 
Anosmia,  226 
Anteflexion  of  uterus,  588 
Anterior  crural  nerve,  injury  of,  234 

gastroenterostomy,  462 

poliomyelitis,  374 

tibial  artery,  compression  of,  200 
ligation  of,  216 
Anteversion  of  uterus,  588 
Anthrax,  117 
Antibacterial  serums,  104 
Antigens,  29 

Antigonococcus  serum,  316 
Antiphthisin,  136 
Antiseptics,  31 

Antistaphylococcic  serum,  30 
Antistreptococcic  serum,  107,  30 
Antitetanic  serum,  115,  30 
Antitoxins,  29,  107,  115,  135,  315 
Antitoxin  syringe,  407 
Antivenene,  96,  30 

Antrum  of  Highmore,  affections  of,  395 
Antyllus's  operation  for  aneurysm,  193 
Anuria,  527 

calculous,  532 

non-obstructive,  527 

obstructive,  527 

reflex,  527.  S3 2 
Anus,  abscess  of,  517 

absence  of,  516. 

artificial,  477 

chancre  of,  1 24 

condyloma  of,  1 26 

epithelioma  of,  521,  139 

fissure  of,  517 

fistula  of,  518 

imperforate,  516,  2 

prolapse  of,  520,  2 

pruritus  of,  517 

stricture  of,  516 
Aorta,  aneurysm  of,  192,  188 

compression  of,  198 

ligature  of,  212 
Aphasia,  $$$ 
Aphonia,  176,  382,  399 
Apnea,  see  asphyxia 
Apoplexy,  340 
Appendectomy,  487 
Appendiceal  abscess,  487 


Appendicitis,  483 

abscess  in,  487 

causes  of,  483 

complications  of,  484 

diagnosis  of,  486 

operation  for,  487 
sequels  to,  488 

pathology  of,  484 

symptoms  of,  484 

treatment  of,  486 

varieties  of,  484 
Appendicostomy,  488 
Appendix    vermiformis,    in    hernial    sac, 

483 
use  of,  in  treatment  of  colitis,  488 

Apraxia,  334 

Ardor  urinar,  551 

Arm,  amputation  through,  630 

Arsenical  neuritis,  221 

Arterial  anastomosis,  202 

hemorrhage,  186,  195 
control  of,  201,  202 

suture,  201 

thrombosis,  185,  170,  83 

varix,  186,  144 
Arteries,  digital  compression  of,  198,  199, 
191 

diseases  of,  183 

injuries  of,  185 

ligation  of,  203,  200 
gangrene  following,  83 
Arteriocapillary  fibrosis,  184 
Arteriomesenteric  occluaon,  457 
Arteriorrhaphy,  202 

Carrel's  method,  202 
Arteriosclerosis,  184,  178 
Arteriosclerotic  colic,  185 
Arteriovenous  aneur>'sm,  194,  330 

wounds,  194 
Arteritis,  183 

syphilitic,  185 
Arthrectomy,  see  erasion 
Arthritis,  acute,  315 

chronic,  315 

deformans,  see  osteoarthritis 

erysipelatous,  315 

gonorrheal,  315 

gouty,  322,  315 

gummatous,  316 

infantile,  285 

neuropathic,  323,  315 

pneumococcal,  315 

pyemic,  315 

rheumatic,  321 

scarlatinal,  315 

syphilitic,  316,  315 

traumatic,  315 

tuberculous,  316,  286 

typhoid,  315 
Arthrodesis,  326,  374 
Arthrolysis,  326 
Arthroplasty,  326 
Arthrotomy,  314,  324 


646 


INDEX. 


Artificial  anus,  477 

closure  of,  478 

larynx,  401 

leech,  61,  377 

respiration,  see  respiration 
Ascites,  operation  for,  490 
Asepsis,  31 
Aseptic  operation,  40 

fever,  103 
Asphyxia,  traumatic,  404 
Aspiration,  406 

for  hydronephrosis,  529 

of  bladder,  542 
chronic  abscess,  73 
empyema,  407 
joints,  313,  314 
pericardiimi,  176 
Astereognosis,  335 
Asthenic  fever,  see  fever 

inflammation,  ^9 
Astragalus,  dislocation  of,  311 

excision  of,  619 

fracture  of,  284 

tuberculous  disease  of,  321 
,   Ataxia,  335,  351 
Atheroma,  184 
Atony  of  bladder,  543 
Atrophic  scirrhus,  415,  139 
Atrophy,  see  special  regions 
Auditory  nerve,  injury  of,  229 
Auricle  of  ear,  accessory,  375 

wounds  of,  375 
Auriculotemporal  nerve,  excision  of,  228 
Auscultation,  in  diagnosis,  7 
Autointoxication,  103,  106 
Autoprints,  4 
Autotransfusion,  102 
Avulsion  fracture,  247 
Axillary  arter)',  compression  of,  200 

ligature  of,  210 

Bacelli's  sign,  406 

treatment  of  tetanus,  115 
Bacillus  aerogenes  capsulatus,  85,  70 

anthracis,  118,  69 

coli  communis,  69,  70,  285,  406 

Ducrey,  J24,  559 

edematis  maligni,  85,  70 

lepne,  121 

mallei,  119 

Oppler-Boas,  459 

prodigiosus,  148 

pyocyaneus,  69,  70 

tetani,  112,  91 

tuben:uli,  132,  70 

typhosus,  29 
Bacteremia,  104 

Bacteria,  25,  see  also  individual  bacteria 
Bactericidal  serum,  30 
Bacterial  infection,  27,  28 

products,  27 
Bacterin,  30,  107 
Bacteriology,  25 


Bacteriolysin,  29 
Bacteriolysis,  29,  104 
Baking  apparatus,  64,  314 
Balanitis,  560 
Balanoposthitis,  560 
Bamberger's  sign,  176 
Bandages,  45 

see  also  special  bandages 
Bands,  peritoneal,  471 
Band's  disease,  498 
Barbadoes  leg,  218 
Bardenheuer's  method  of  treating  fractures, 

277 
Barker's  operation  for  fractured   patella, 
280 

for  temporosphenoidal  abscess,  35a 

of  excision  of  hip,  328 

solution  for  spinal  anesthesia,  25 
Barnes  bag  for  (tilatation  of  the  os  uteri, 

583 
Bartholin's  glands,  abscess  of,  575 
Barton's  bandage,  47 

fracture,  268 
Basal  meningids,  see  brain 
Base  of  skull,  fracture  of,  342 
Basedow's  disease,  386 
Bassini's    operation    for   femoral    hernia, 

509 

inguinal  hernia,  504 
Battle's  sign,  343 

Bauden's  method  of  amputating  foot,  633 
Beatson's  operation  (o5piiorectomy),  140 
Beck's  operation  for  hypospadias,  549 
Beck's  bismuth  paste,  79,  74,  320 
Bed  sores,  84 

in  spinal  injuries,  362 
Bell's  induction  balance,  92 

palsy,  229 
Bellocq's  cannula,  392 
Benign  tumors,  137 
Bennet's  fracture  of  the  thumb,  270 
Bcri-beri,  neuritis  in,  221 
Bevan's  operation  for  undescended  testicle, 

561 
Beyea's  operation  for  gastroptosis,  461 
Biceps  femoris,  tcntomy  of,  243 
Bichat,  fissure  of,  331 
Bier's  osetoplastic  amputation,  637 

treatment,  62,  135,  74,  317 

danger  of,  in  arteriosclerosis,  185 
of  delayed  union  of  fractures,  253 
Bifid  tongue,  424 

Bigelow's  method  of  reducing  dislocation 
of  hip  joint,  307 

evacuator,  546,  398 

operation  of  litholapaxy,  546 
Bilharzia  hematobia,  526,  2 
Biliary  colic,  492 

fistula,  494 

passages,  affections  of,  490 
ojjerations  on,  493 
Billroth's  operation  of  pylorectomy,  466 
Bilocular  hydrocele,  566 


INDEX. 


647 


Bipartite  scaphoid,  270 
Birth  mark,  144 

palsy,  231 
Bismuth  paste,  79,  74,  320 
Bites,  dog,  115 

insect,  95 

snake,  96,  195 
Blackness,  in  diagnosis,  4 
Bladder,  affections  of,  538, 

aspiration  of,  542 

atony  of,  543 

carcinoma  of,  544 

examination  of,  539 

foreign  bodies  in,  544 

hernia  of,  499 

inflammation  of,  543 

rupture  of,  444,  271 

sounding  for  stone,  545 

stone  in,  545 

tuberculosis  of,  543 

tumors  of,  544 

ulcers  of,  544 
Blank  cartridge  wounds,  93,  113 
Blastomycosis,  158,  31 
Blind  boil,  159 
Blisters,  65 
Blood  clot,  healing  by  organization  of,  67 

coagulation  time,  10 

cysts,  149 

examinations  in  diagnosis,  8 
in  diagnosis  of  tumors,  157 

freezing  point,  526,  10 

poisoning,  103 

pressure,  10 

in  cerebral  surgery,  335 

in  compression  of  brain,  340 

tranfusion  of,  182 

vessels,  injuries  of,  249 
Blueness,  in  diagnosis,  4 
Boils,  158 
Bond  splint,  267 
Bone,  atrophy  of,  293,  247 

contusions  of,  285 

cysts  of,  296 

decalcified,  288 

diseases  of,  284 

felon,  238 

gangrene  of,  287 

grafting  of,  289 

gumma  of,  291 

hydatid  cysts  of,  296 

hypertrophy,  293 

inflammation  of,  284 

injuries  of,  246 

necrosis  of,  287 

Rontgen  ray  in  diagnosis  of  disease  of, 
12,  295 
Bone,  sarcoma  of,  294 

syphilis  of ,  291,  127,  132 

tuberculosis  of,  290 

tumors,  294 
Boric  (boracic)  acid,  ^^ 
Borsch's  eye  bandage,  49 


Bottini's  operation  for  hypertrophied  pros- 
tate, 571 
Bougies,  urethral,  555 

esophageal,  437 
Bowel,  see  intestine 
Bow-legs,  617 
Boxer's  ear,  375 

Brachial  artery,  compression  of,  200 
ligation  of,  211 

birth  palsy,  23 1 

neuritis,  231 

plexus,  injury  of,  230,  259,  262 
Bradjford  frame,  277 

Brain  and  membranes,  see  also  cerebral, 
cerebellar,  skull,  head 

affections  of,  347 

abscess,  350. 

compression  of,  339,  341,  344,  345 

concussion  of,  338,  341,  343.  254 

cysts  of,  339,  352 

foreig'n  bodies  in,  339 

gumma  of,  339,  352 

hernia  of,  346 

injuries,  effects  of,  338 

irritability  of,  339 

laceration  of,  338 

localization,  334,  331 

prolapse  of,  346 

wounds  of,  345 

tumors,  352 

decompression  operation  for,  353 
Branchial  carcinomata,  380 
Branchial  clefts,  379 

cysts,  379 

fistula?,  379 
Brasdor's  operation  for  aneur>'sm,  193 
Brauer's  apparatus  for  prevention  of  pneu- 
mothorax, 406 
Braun's  operation  for  salivary  fistula,  424 
Breast,  abscess  of,  412 
varieties  of,  412 

amputation  of,  416 

diseases  of,  410 

carcinoma  of,  414 

congenital  malformations,  410 

chancre  of,  124 

cysts,  417 

hypertrophy  of,  411 

inflammation  of,  412 

neuralgia  of,  411 

nipples,  affections  of,  410 

syphilitic  affections  of,  413 

tuberculous  disease  of,  413 

tumors  of,  413 

ulceration  of,  415 
Brisement  forc^,  618 
Broadbent's  sign,  177 
Broad  ligament,  varicocele  of,  613 
Broca's  convolution,  ^^^ 

points  on  skull,  331 
Brodie's  abscess,  290 
Bronchiectasis,  409 
Bronchocele,  see  goiter 


648 


INDEX. 


Bronchoscope,  398 

Bronchus,  foreign  bodies  in,  396 

stenosis  of,  397 
Bronze  patches,  in  diagnosis,  4 
Brophy's  operation  for  cleft  palate,  433 
Brown-Sequard's  paralysis,  357 
Bruise,  S6 
Brush  bum,  87 

Bryant's  dressing  for  fractured  femur  in 
children,  277 

sign  for  dislocation  of  shoulder,  302 

triangle,  273 
Bubo,  123,  219 

soft,  559 
Bubonocele,  500 
Buccal  nerve,  excision  of,  228 
Buck's  extension  apparativs,  273 
Bullet  wounds,  see  gunshot  wounds 
Bunion,  622,  245 
Burns,  97,  98 

following  Rontgen  ray,  13,  14 
Bursse,  affections  of,  245 
Bursitis,  245 
Buska  button,  159 
Butchers  wart,  161 

Cachexia,  in  diagnosis,  8,  157 

hypophyseopriva,  353 

strumipriva,  383 
Calcaneum,  see  os  calcis 
Calculus,  see  special  regions 
Callosity,  160,  3 
Callus,  250 

compression  of  nerves  by,  223,  361 

excessive,  250 
Calloway's  sign,  302 
Calmette's  antivenene  serum,  96 

tuberculin  test,  135 
Cammidge's  test  for  pancreatitis,  496 
Cancer  en  cuirasse,  415 
Cancer,  see  carcinoma 
Cancerous  cachexia,  138 
Cancrum  oris,  86 
Cannula  a  chemise,  198 
Capillar\'  hemorrhage,  195 

thrombi,  170 
Caput  succedaneum,  329 
Carbolic  acid,  32 

gangrene,  85 

poisoning,  ;^^,  108 
Carboluria,  32 
Carbuncle,  159 
Carcinoma,  138,  see  also  special  regions 

use  of  Rontgen  rays  in,  162 
Carcinomatosis,  138 
Carden's    supracondyloid    amputation    of 

thigh,  637 
Cardiolysis,  177 
Cardiospasm,  436 
Cargile  membrane,  37 

Caries,  2()o,  74,  2H4,  see  also  special  regions 
Carnochan-Chavasse  operation  of  resection 
of  superior  maxillar}'  nerve,  227 


C&mot's  solution,  197 
Carotid  artery,  compression  of,  199 
ligature  of,  206 

gland,  387 
Carpal  bones,  dislocation  of,  305 

fracture  of,  270 
Carrel's  method  of  suture  of  arteries,  202 
Carron  oil,  98 
Carrying  angle,  264 
CartUage,  inflammation  of,  59 

semilunar,  displacement  of,  310 
Cartilagmous  tumors,  see  chondroma 
Caseation,  134 
Caseous  necrosis,  134 
Castration,  565 
Catalepsy,  114 
Cataplasm,  64 
Catarrhal  inflanunation,  60,  see  also  special 

regions 
Catgut,  35 
Catheters,  555,  556,  571 

fever,  558 

steriUzation  of,  37 
Catheterization,  555,  42,  571 

dangers  of,  556 

for  enlarged  prostate,  571 

of  ureters,  525,  540 
Cavernous  angioma,  144 

lymphangioma,  145 

sinus,  infection  of,  159 
injury  of,  229 
thrombosis  of,  350,  395 
Cecocele,  499 
Cecum  in  herniae,  499 
Celiotomy,  see  abdominal  section 
Cellular  theory  of  immunity,  28 
Cellulitis,  III,  see  special  regions 
Celluloid  thread,  36 
Cementoma,  145 
Central  sarcoma,  294 
Cephalhematoma,  329 
Cephalotetanus,  113 
Cerebellar  abscess,  350,  379 

decompression,  353 
Cerebral  abscess,  350 
Cerebral  compression,  see  compression 

hemorrhage,  344,  33°y  339 

hernia,  346,  330 

irritability,  339,  348 

localization,  331 

sinuses,  hemorrhage  from,  338,  343 
thrombosis  of,  349 

surger>',  335 
Cerebral  tumors,  352,  see  also  brain,  cere- 
bellum, head,  skull 

vomiting,  351 

wounds,  345 
Cerebro-spinal  fluid,  escape  of,  in  fracture 
of  base,  343 

meningitis,  epidemic,  348 
Cerebrum,  see  brain 
Cervical  adenitis,  219 

caries,  372 


INDEX. 


649 


Cervical,  endometritis,  585 
plexus,  injury  to,  230 
rib,  381 
sympathetic  ganglia,  excision  of,  234, 

387.354  ^     ^ 

vertebra,  dislocation  of,  363 
fracture  of,  see  fracture  of  spine 
Chancre,    23,  124 
Chancroid,  S5q,  124 
Change  of  color,  in  diagnosis,  4 
Chapped  lips,  419 
Charbon,  117 
Charcot's  disease,  323,  298 

intermittent  fever,  490 

joint,  J23 
Chciloplasty,  42' 
Chemical  injuries,  97,  98 

gangrene  following,  85 
Chemotaxi*,  rf 
Chest,  concussion  of,  404 

contusion  of,  404 

hemorrhage  into,  404 

surgery  of,  404 

wounds  of,  404 
Cheyne*StQkcs  respinition,  339,  351,  352 
Chicken  breast,  iga 
Chilblain,  99 
Chloroform*  iS,  15,  20,  22,  335 

poisoning,  31  ^ 

Chbroma,  146,  4 
Choked  disk,  231 
Cholangi  ostomy,  495 
Cholangitis,  4QO 
Choiecj'stcctomy,  494 
CholecyaienteroMomyt  494 
Cholecystitis,  4qi 
Cholecysiosiomy,  493 
Choled'ocholithotomy,  495 
Choledochoenlero^tomy,  495 
Choledochostomy,  495 
Choledochotomy,  495 
C  h<  I  It  < !  IK  h  ol  J  t  hotri  ty ,  495 
Choleiiihiasis,  491 
Cholera,  30,  217 
Cholesteatoma,  147 
Chondroarihritis,  316 
Chondrodysiropia  fetalis,  292 
Chondroma,  143,  237,  294 
Chopari's  amputation,  633 
Chordee,  551 
Chorea,  361 

Chorioepithelioma,  599,  140 
C  h  rom  (,Ky5!osco  py ,  5  26 
Chylocele,  567 
Chylothorax,  218 
Chylous  ascites,  318 

diarrhea,  218 

hydrocele,  567,  218 
Chyluria,  218,  527 
Cicatrices,  affections  of,  68 
Cicatrix  aifter  amputation,  626 
Cinematic  amputation,  Vanghetti's    opera- 
tion, 629 


Circular  amputation,  625 

en  tenorrhaphy,  479 
Circumcision,  560 
Circumflex  nen^e,  injur)^  of,  231 
Cirrhosis  of  liver,  operation  for,  490 
Cirsoid  aneurysm,  186,  144,  330 
CiviaJe'a  urethrotome^  557     . 
Clap,  sec  gonorrheal  urethritis 
Classic Ic,  dislocation  of,  joo 

fracture  of,  258,  52 
Clavus,  see  com 

Claw  hand  in  ulnar  paralysis,  233 
Cleft  palate,  432,  417 
Cloaca,  288,  515 
Closed  dislocation,  298 

fracture,  346 
Clot  cmtwlism,  170,  183,  249 
Clover's  Inhaler   16,  19 
Club-foot,  see  talipes 

hand,  614 
Coagulation  time,  10 
Cocain  hydrochlorid,  23,  108 

poisoning,  23 
Cocci,  25 

Coccygeal  tumors,  366 
Ctx:cygodynia,  272 
Coccyx,  excision  of,  27  2 

fracture  of,  272 
Cock's  operation  uf  perineal  section,  558 
Coffee  ground  vomit,  459 
Cohnheim's  iheorv' of  the  origin  of  tumors, 

136 
Coils,  high  frequency,  10 

induction,  10 
Coin  catcher,  437 
Cold  abscess,  72 

effects  of,  QQ,  1 97 ,  249 

gangrene  following,  100 

in  treatment  of  hemorrhage,  197 
inflammation,  62 
sprains,  3^6 
Coley's  fluid,  148,  ib^,  30,  140 
Colic,  see  special  regions 
Collapse,  loi 

Collateral  circulation,  see  ligations 
Collet'  fracture,  268,  304,  322 

immuniiv     22 
Collodion,  88,  97 
Colloid  carcinoma,  140 

dej^eneniiion,    3 

goiter,  384 
Colon,  idiopathic  dilatation  of,  468 
Colopexy,  521 

Color,  abnormal,  in  diagnosis,  4 
Colostomy,  477 
Colpeuiynter,  igS 
ColpotleLSLS,  580 
Colporrhaphy,  577,  579 
Columnar  rartinoma,  139,  see  also  si)ecial 
regions 

celled  epithelioma,  139 
Coma,  diabetic  340,  82 

diagnosis  of,  339,  340 


6so 


INDEX. 


Coma,  in  acute  leptomeningitis,  349 
cerebral  abscess,  339,  350,  351 
injury,  340 
tumor,  352 
renal  disease,  340 
Combined  abdominal  and  vaginal  hysterec- 
tomy, 599 
Comedo,    Rontgen   ray   in    treatment   of. 

Comminuted  fracture,  246 
Common  carotid   artery,   compression  of, 
199 
ligation  of,  206,  227,  344 

iliac  artery,  Ugation  of,  212 
Complement,  29 
Complementophile,  29 
Complete  dislocation,  298 

fracture,  246 

hysterectomy,  596 

inguinal  hernia,  501 
Complicated  fracture,  246 

dislocation,  298 
Complications  of  fractures,  249 
Composite  odontoma,  145 
Compound  dislocation,  299 
Compound  follicular  odontoma,  145 

fracture,  246,  252 

ganglion,  239 
Compression,  cerebral,  339,  341,  344,  345 

for  cure  of  aneurysm,  191 

fracture,  247 

in  sprains,  296 

in  treatment  of  hemorrhage,  198 

in  treatment  of  inflammation,  63 

in  treatment  of  synovitis,  314 

of  the  heart,  174 

of  nerves,  223 

spinal  cord,  361,  360 
Concealed  menstruation,  599 
Concussion,  338,  see  special  regions 

of  the  heart,  174 
Condensing  ostitis,  284 
Condition,  social,  in  diagnosis,  2,  3 
Condy's  fluid,  33 
Condylomata,  126,  138,  3gc) 
Congenital  affe(  tions,  see  special  regions 

fractures,  247 

syj)hilis,  131 
Congestive  dysmenorrhea,  600 
Conical  stump,  627 
Conjunctivitis,  gonorrheal,  551 
Connective    tissue,    inflammation    of.    sec 
cellulitis 

tumors,  140 
Consecutive  hemorrhage,  195 
Consistency  of  tissues,  in  diagnosis,  5 

of  tumors,  155 
Contraction,  Dupuytren's,  615 

Volkmann's,  236 

see  special  regions 
Con t re  coup,  343 
Contused  wounds,  86,  go 
Contusions,  S6,  6,  175,  see  special  regions 


Cooper's  method  of  reducing  dislocations  of 
elbow  joint,  303 
shoulder  joint,  303 
Coracoid,  fracture  of,  260 
Cornea,  inflammation  of,  132 

ulcer  of,  133,  2^ 
Corns,  160 

Cornu  culaneum,  160 
Coronary  artery,  compression  of,  199 
Corporeal  endometritis,  585 
Corradi's  method   of    treating    aneurysms, 

192 
Corrosive  sublimate,  32 

poisoning,  32 
Costal  cartilage,  dislocation  of,  306 

fracture  of,  257 
Counterirritation,  64 
Courvoisier's  law,  493 
Coverings  of  hernia,  498,  see  also  special 

herniae 
Cowper's  glands,  inflammation  of,  554 
Coxa  valga,  616 

vara,  616,  273,  8 
Coxalgia,  318,  61,  6 
Coxitis,  see  coxalgia 
Cracked  lip,  419 

nipples,  411 

pot  sound,  341,  347 
Craniectomy,  linear,  348 
Craniocerebral  topography,  331 
Craniotabes,  291 
Craniotomy,  348 
Cranium,  affections  of,  338,  see  head,  skull, 

brain,  cerebral 
Creolin,  ^^^^ 
Crepitus,  6,  249 
Cretinism,  ^8^,  2 
Crile's  clamp,  102,  430 

method    for     transfusion     of     blood, 
182 

pneumatic  rubber  suit,  102 

treatment  of  shock,  102 
Crisis,  Dietl's,  528 
Crookes  tube,  10 
Crossed  embolism,  170 

paralysis,  229,  t:,t,7, 
Croupous  inflammation,  60 
Crude  tubercle,  134 
Crutch  palsy,  250,  223,  230 
Cr>'oscopy,  526 
Crj'ptogenic  septicemia,  104 
Cr>'ptorchism,  561 
Cubitus  valgus,  264 

varus,  264 
Cultures,  see  bacteria 
Cuneiform  osteotomy,  617 
Cupping,  61 

Curettage  of  uterus,  586 
Curling's  ulcer,  97 
Curvature     of     legs,     see      genu      varum 

of  spine,  angular,  369 
lateral,  366 
rachitic,  ^66 


INDEX. 


651 


Cushing's  decompression  operation  for  in- 
tracranial pressure,  343 
operation  for  the  removal  of  the 

Gasserian  ganglion,  228 
suture,  476 
Cut  throat,  382 
Cutaneous    gangrene,    multiple   areas  of, 

159 
Cylindrical-celled  epithelioma,  139 
Cylindroma,  148 
Cyrtomcter,  Horsley's,  332 
Cystadenoma,  138,  see  special  regions 
Cystic  duct,  impaction  of    gall-stones  in, 

494 

goiter,  384 
ygroma,  379 

lymphangioma,  380 
Cysticercus  cellulose,  151 
C3rsticotomy,  495 
Cystitis,  543 

in  gonorrhea,  552 

in  spinal  affections,  373 
Cystocele,  577,  499 
Cystoscope,  539 
Cystoscopic  pictures,  541 
Cystoscopy,  539 
Cystotomy,  perineal,  547 

suprapubic,  546 
Cysts,  I4Q 

blood,  149 

branchial,  149 

bursal,  380 

degeneration,  151 

dental,  429,  145 

dentigerous,  145 

dermoid,  149 

distention,  149 

extravasation,  149 

exudation,  149 

foreign  body,  149 

hydatid,  149 

implantation,  149 

involution,  417 

malignant,  380,  137 

mucous,  149 

retention,  149 

sebaceous,  163,  149 

traumatic,  149 

see,  also,  special  regions 
Cytodiagnosis,  360,  134 
Cytophiie,  29 
Czemy-Lembert  sutures,  476 

Dactylitis,  syphilitic,  132,  291 

tuberculous,  290 
Davy's  rectal  lever,  638 
Dawbarn's  ojxjration  for  inoperable  growths 

about  the  face,  140 
Decalcified  lx)ne,  use  of,  288 
Decapsulation  of  kidney,  537 
Deciduoma  malignum,  599,  140 
Decompressive  trephining,  343 
Decortication,  pulmonar>',  409 


Decubital  gangrene,  84 
Deformities,  see  special  regions 
Degeneration,  amyloid,  73 

cysts  of,  151 

gummatous,  127 
Delayed  union  of  fractures,  252 
Delhi  sore,  159 
Delirium,  108,  97,  348 

nervosum,  109,  249 

of  collapse,  109 

traumatic,  109 

tremens,  108,  3,  8,  249 
Deltoid  bursa,  246  . 
De  Morgan's  spots,  163 
Dental  cysts,  429,  145 

nerve,  inferior,  resection  of,  228 
Dentate  fracture,  246 
Dentigerous  cyst,  145,  429 
Deodorizer,  31 
Depressed  fracture,  246 
of  skull,  339,  341 
Dermatoses,  precancerous,  163 
Dermoid  cysts,  149 

see,  also,  special  regions 
Desault's  bandage,  53,  259,  260 
Desjardin's  pancreatic  point,  496 
Desmoid,  237 

Diabetes,  81,  7,  8,  15,  58,  74,  86,  158,  159, 
184,  357,  361,  5i7»  575 

traumatic,  103 
Diabetic  coma,  340,  82 

gangrene,  81 
Diacetic  acid,  82 
Diagnosis,  general  remarks  on,  i 

of  tumors,  151 
Diapedesis,  59 
Diaphany,  6 

Diaphragmatic  hernia,  512 
Diaphragmatic  rupture,  445 
Diaphysitis,  285 
Diarrhea,  chylous,  218 
Dietl's  crisis,  528 
Differential  blood  count,  9 
Diffuse  aneur>'sm,  188 

hydnx'ele  of  the  cord,  567 

j)hlegmon,  iii 

septic  osteomyelitis,  285 
Digital  compression  of  arteries,   198,   199, 
191 

chancre,  124 
Dilatation,  see  special  regions 
Diphtheria,  403,  27,  348,  397 

antitoxin,  107,  113 
Diphtheritic  inflammation,  60 

neuritis,  221 
Diplococci,  25 
Diplotixxus  gonorrheae,  551 

intracellularis  meningitidis,  348 
Direct  fracture,  247 

gangrene,  84 

inguinal  hernia,  501 
Disarticulations,  sec  amputations 
Discission  of  lung,  409 


652 


INDEX. 


Discoloration  in  diagnosis,  4 
Disinfection,  see  sterilization 
Dislocations,  297 

see  also  special  regions 
Dissecting  aneurysm,  188 
Dissection  wounds,  95 
Distal  ligature  for  aneurysm,  193 
Distention  cysts,  149 

of  bladder  with  overflow,  542,  570 
Disunited  fracture,  253 
Diverticulitis,  468 
Diverticulum  of  esophagus,  435 

of  Meckel,  468 
Dorrance  and  Ginsburg's  method  for  trans- 
fusion of  blood,  182 
Dorsal  abscess,  373,  370 

dislocation  of  hip,  307 
Dorsalis  pedis  artery,  ligature  of,  217 
.  Double  inclined  plane,  276 
Douche,  64 

Dowd's  operation  for  cancer  of  lip,  421 
Drainage  materials,  42 

of  wounds,  42 

tubes,  42 
Dressings,  37 

fixed,  56,  57,  251 
Dry  gangrene,  80 
Dubreuil's  amputation  at  the  wrist  joint, 

628 
Duchenne-Erb  paralysis,  230 
Dudley's  operation  for  anteversion  of  uterus, 

588 
Duga's  sign,  301 
Dum-Dum  bullet,  94 
Duodenal  ulcer,  468,  97 
Duodenocholedochotomy,  495 
Duodenojejunal  hernia,  512 
Duodenoslomy,  477 
Duodenum,  stenosis  of,  468 

ulcer  of,  468,  97 
Dupuytren's  amputation,  632 

classification  of  burns,  97 

contraction,  615 

fracture,  282,  311 

splint,  282 
Dural  separator,  Horsley's,  335 
Dura  mater,  inflammation  of,  348 

injuries  of,  342 

thickening  of,  causing  epilepsy,  349 
Dysenler>',  69,  30,  31,  472,  477,  483,  488, 

517 
Dysmenorrhea,  600 
Dyspeptic  ulcer  of  tongue,  425 

Ear,  affections  of,  375 

hemorrhage  from,  343 

sterilization  of,  39 
Eburnated  osteoma,  143 
Echinococcus,  149 

see  also  special  regions 
Ecchondroma,  143 
Ecchymosis,  87,  4,  5 
Ecthyma  syphilitic,  126 


Ectopia  testis,  561 

vesica,  538 

viscerum,  509 
Eictopic  kidney,  351 

pregnancy,  604 
Eictrodactylism,  615 
£k:zema,  133,  219 

of  nipple,  411 

of  umbiUcus,  446 
Elczeniatous  ulcer,  77 

Edebohl's  operation  for  floating  kidney,  536 
Edema,  5 

angioneurotic,  398 

hysterical,  5 

lymphatic,  218 

malignant,  85 

see  special  regions 
Effusion  into  joints,  314 
Ehrlich's  theory  of  immunity,  see  immu- 
nity 
Ehrlich's  "606,"  130 
Eighth  nerve,  injuries  of,  229 
Elbow  joint,  ankylosis  of,  265 

disarticulation  of,  630 

dislocation  of,  303 

effusion  into,  314 

examination  of,  263 

excision  of,  327 

fractures  of,  263 

tuberculosis  of,  317 
Electrical  injuries,  100 
Electricity  for  affections  of  ntfrves,  224 
muscles,  235 

for  atrophy  of  uterus,  587 
Electrohemostasis,  197 
Electrolysis  for  aneurysm,  192 

for  angioma,  144 

for  cirsoid  aneurysm,  187 

for  goiter,  385 

for  keloid,  163 

for  uterine  fibroids,  595 
Elephantiasis,  218,  2 

Arabum.  218 

Grajcorum,  see  leprosy 

of  tongue,  424 

pseudo,  218 
Elephantoid  fever,  218 
Elevation  in  hemorrhage,  197 
Elliptical  method  of  amputating,  626 
Embolic  gangrene,  82 
Embolism,  170,  171.  105,  287,  389 
Embr>'onic  tissue,  59,  66 
Emmet's  method  for  treating  inversion  oi 
uterus,  593 

perineorrhaphy,  578 

trachelorrhaphy,  584 
Emphysema,  405 
Emphysematous  gangrene,  85 
Emprosthotonos,  8,  113 
Empyema,  aspiration  of,  407 

of  antrum,  395 

of  appendix,  484 

of  frontal  sinuses,  394 


INDEX. 


(>53 


Empyema,  of  gall-bladder,  491 

of  pericardium,  176 

of  pleural  cavity,  406 

necessitatus,  407 
Enantobiosis,  28 
Encephalitis,  348 
Encephalocele,  347,  33^ 
Encephaloid  carcinoma,  139 
Enchondroma,  143 
Encysted  hydrocele  of  cord,  567, 503 

testis,  566 
Endarteritis,  184 
Endoaneurysmorrhaphy,  193 
Endoccrvicitis,  585 

End-to-end  anastomosis,  of  blood-vessels, 
194 

of  bowel,  479 

of  nerves,  225 

of  ureter,  538 

of  vas  deferens,  568 
Endometritis,  584 
Endostosis,  143 
Endothelial  cancer,  147 
Endothelioma,  147 
Enlarged  prostate,  569 
Enterectomy,  479 
Enteroanastomosis,  479 
Enterocele,  499 
Enteroclysis,  183 
Enteroepiplocele,  499 
Enteroliths,  471 
Enteroptosis,  470 
Enterorrhaphy,  476 

circular,  479 
Enterostomy,  476 
Enterotomy,  476 
Enucleation  of  thyroid  tumors,  385 

uterine  fibroids,  vaginal,  595 
Enzymes,  bacterial,  27 
Eosinophilia,  10,  151 
Epicritic  nerve  fibers,  224 
Epidemic  cerebrospinal  meningitis,  348 
Epididymitis,  562 

syphilitic,  563,  127 

tuberculous,  563 
Epididymis,  cysts  of,  566 
Epigastric  hernia,  511,  143 
Epiglottis,  ulceration  of,  396 
Epilepsy,  353,  342,  234,  393 
Epiphyses,  separation  of,  247 
Epiphysitis,  285 

syphilitic,  291 

tuberculous,  290 
Epiplocele,  499 

Epiplopexy,  operation  of,  for  ascites,  490 
Epispadias,  548,  575 

complete,  538 
Epispastics,  65 
Epistaxis,  391,  196 
Epithelial  odontoma,  145 
Epithelioma,  138,  125,  161,  see  also  special 

regions 
Epulis,  430,  141,  147 


Equinia,  119 

Erasion,  326,  317,  318,  321 
Erethistic  shock,  loi 
Ergot,  gangrene  from,  82 
Ergotism,  5,  82 
Erosion,  aneurysmal,  371 
Erysipelas,  109 

curative  action  of,  in  sarcoma,  148,  no 
Erysipelatous  arthritis,  315 
Erysipeloid,  in 
Erythema  contusiformis,  158 

nodosum,  158 

syphilitic,  126 
Erythromelalgia,  623 
Esmarch  band,  199 

cold  coil,  62 

inhaler,  18 

method  of  amputation  of  the  hip,  640 
Esophageal  bougies.  437 
Esophagismus,  439 
Esophagoscope,  437 
Esophagostomy,  439 
Esophagotomy,  438,  439 
Esophagus,  affections  of,  435 

atresia  of,  435 

bums  of,  99 

congenital  malformations  of,  435 

dilatation  of,  438 

dilatation  of  idiopathic,  436 

diverticula  of,  435 

excision  of,  439,  410 

fistula  of,  435,  382 

foreign  bodies  in,  436 

rupture  of,  404 

stricture  of,  438,  382 

tumors  of,  439 

wounds  of,  436 
Estlander's  operation  of  thoracoplasty,  409 
Ether,  16,  15,  17,  18,  22,  S3^  97»  335 
Ethmoid,  diseases  of,  395 
Ethyl  bromid,  19 

chlorid,  14,  19,  22,  97,  222 
Eucain  hydrochlorid,  uses  of,  23 
Evacuator,  Bigelow's,  546,  398 
Evaporating  lotions,  62 
Ewarl's  sign,  176 
Examination,  general,  7,  8 

physical,  in  diagnosis,  i 

local,  4 
Excessive  callus,  250,  253 
Excision   of   joints,   326,    see   also   special 
joints 

of  tumors  for  microscopic  examination, 

157 
Exclusion  of  intestine,  4S3 
Excoriation,  87 
Exfoliative  endometritis,  586 
Exhaustion,  loi 
Exomphalos,  500 
Exophthalmic  goiter,  386 
Exophthalmos,  386 
Exostoses,  143,  2H5,  322,  330 
Exothyreopex}',  385 


6S4 


INDEX. 


Exploratory  incision,  5,  157 
Extension,  Bucks',  273 

of  limb  in  hip  joint  disease,  320 
External  carotid  artery,  li^tion  of,  207 

iliac  artery,  compression  of,  200 
ligation  of,  213 

hemorrhage,  196 

inguinal  hernia,  500 

popliteal  nerve,  siffections  of,  234 

urethrotomy,  557 
Extirpation  of  aneurysm,  see  aneurysm 
Extraarticular  fractures,  246 
Extracapsular  fracture  of  femur,  274 
Extracranial  complications  of  otitis  media, 

376 
Extradural  abscess,  350,  379 

hemorrhage,  343 
Extragenital  chancres,  124 
Extramedullary  hemorrhages,  spinal,  364, 

361 
Extraperitoneal  rupture  of  bladder,  444 

of  tubal  gestation,  604 
Extrauterine  pregnancy,  604 
Extravasation  cysts,  149 

of  blood,  87 

of  urine,  549 
Extra  vesical  prostatectomy,  57  2 
Extremities,  614 
Extroversion  of  bladder,  538 
Exuberant  granulations,  67 
Exudation  cysts,  149 

Facial  artery,  compression  of,  199 
ligation  of,  208 

cleft,  4i9»  149 

nerve,  affections  of,  229 

neuralgia,  226,  393 

paralysis,  229,  376 

vein,  thrombophlebitis,  105,  159 
Facies,  Hippocratica,  8 

in  diagnosis,  8 

ovariana,  609 
Fallopian  tubes,  affections  of,  601 

congenital  abnormalities  of,  601 

displacements  of,  601 

inflammation  of,  601 

pregnancy  in,  604 

tuberculosis  of,  603 

tumors  of,  604 
False  ankylosis,  326 

incontinence  of  urine,  542 

joints,  253 

keloid,  141 

neuroma,  141,  223 

passages,  558 
Farcy,  see  glanders 
Fasciotomy,  6iq,  374 
Fat  embolism,  173,  24() 

necrosis,  496 
Fatty  hernia,  499,  511 

tumors,  see  li|x)ma 
Favus,  31 

Rontgen  rays  in  treatment  of,  13 


Fecal  fistula,  478,  488 
umbilical,  446 

impaction,  471,  474 

vomiting,  447 
Feeding,  nasal,  115 
Fell-O'Dwyer  apparatus,  21,  406 
Fell's  method  of  artificial  respiration,  21 
Felon,  237 
Female  genital  organs,  examination  of,  573 

surgery  of,  573 
Femoral  adenitb,  219 

artery,  compression  of,  200 
Ugation  of,  214 

hernia,  508 
operation  for  radical  cure,  509 
strangulated,  515 

vein,  inflammation  of,  177 
Femur,  fracture  of,  27  2 

separation  of  lower  epiphysis,  278 
upper  epiphysis,  275 

supracondyloid  amputation,  637 
Fergusons'  amputation  at  the  ankle  joint,636 

speculum,  573 
Ferments,  bacterial,  27 
Fever,  104 

adynamic,  104 

aseptic,  103 

asthenic,  104 

catheter,  558 

Charcot's  intermittent,  490 

cocain,  23 

elephantoid,  218 

fracture,  249 

hectic,  73 

hemorrhagic,  196 

hepatic,  488 

inflammatory,  61,  103 

iodoform,  34 

mercurial,  32 

post-operative,  43 

reactionar>',  103 

resorption,  103 

septic,  104 

simple,  103 

sthenic,  104 

syphilitic,  125 

thyroid,  386 

traumatic,  103 

urethral,  558 
Fibrinous  inflammation,  59 
Fibroadenoma,  138 
Fibroblasts,  59,  66,  250 
Fibrocystic  disease  of  jaw,  145,  430 
Fibroids,  see  fibromyomata  of  uterus 
Fibromata,  140 
Fibromyoma,  144,  593 

of  uterus,  593 
Fibrosarcoma,  147,  393 
Fibrosis,  artericKapillar>',  r84 
Fibrous  epulis,  141 

odontoma,  145 

goiter,  3S4 

union  of  fractures,  253 


INDEX. 


655 


Fibula,  dislocation  of,  310 

fracture  of,  281 
Fifth  nerve,  operations  on,  227 
Filaria  sanguinis  hominis,  218,  170,  527, 

10,  2 
Fingers,  amputations  of,  627 

chancre  of,  124 

deformities  of,  615 
Finney's  operation  of  pyloroplasty,  466 
Finsen  light  in  treatment  of  epithelioma,  162 
lupus,  161 
tuberculosis,  135 
Fissure  of  Bichat,  331 

parietooccipital,  332 

Rolando,  331 

Sylvius,  331 
Fissured  fracture,  246 

of  skull,  341 
Fissures  of  nipple,  411 
Fistula,  79,  see  also  special  regions 
Flagella,  see  bacteria 
Flail  joint,  326,  286 
Flaps  in  amputations,  625 
Flat-foot,  620,  3 
plate,  620 
Floating  kidney,  528 

spleen,  497 
Fluctuation,  5 

Fluhrer's  aluminium  probe,  92,  346 
Fluoroscope,  11,  12 
Flush  tank  symptom,  529 
Follicular  goiter,  384 

odontoma,  145 
Fomentation,  63 
Foudroyant  gangrene,  85 
Foot,  amputations  of,  633 

deformities  of,  613,  3 

drop,  234 

hollow,  621 

perforating  ulcer  of,  623 
Forbes'  amputation  of  foot,  634 
Forcipressure  treatment  in  hemorrhage,  200 
Forearm,  amputation  through,  629 

dislocation  of,  303 

fracture  of  both  bones,  269 
Foreign  bodies,  see  special  regions 

Rdntgen  rays  in  diagnosis  of,  12,  13 
Formaldehyd,  ^^ 
Fourth  nerve,  paralysis  of,  226 
Fowler's  operation  of  puhnonary  decorti- 
cation, 409 

position,  448 
Fracture  box,  261 

dislocation,  252,  282,  298 

fever,  24Q 
Fractures,  246,  see  also  special  bones 

causes  of,  247 

complications  of,  249 

repair  of,  250 

Rontgen  ray  in  diagnosis  of,  1 2 

signs  of,  247 

treatment  of,  250 

varieties  of,  246 


Fragilitas  ossium,  293,  247 

Frank's  operation  of  gastrostomy,  460 

Freezing  anesthesia,  22 

point  of  blood,  526,  10 
Friedreich's  sign,  177 

operation  for  phthisis  pulmonalis,  410 
Frontal  sinuses,  affections  of,  394 

empyema  of,  394 

hydrops  of,  394 

trephine  of,  394 

tumors  of,  395 
Frost  bite,  99,  85,  4 
Fulminating  appendicitis,  484 
Fulgu  ration,  140 
Fungi,  see  bacteria 
Fungus  cerebri,  346 

hematodes,  139 

testis,  563 
Funicular  inguinal  hernia,  501 
Furbringer's    method    of    sterilization    of 

hands,  38 
Furuncle,  158 
Fusiform  aneurysm,  188 

Gait  in  diagnosis,  8 
Galactocele,  417 
Gall-bladder,  affections  of,  491 

rupture  of,  443 

typhoid  bacilli  in,  287 
Gall-stones,  491 

complications  of,  493* 

etiology  of,  491 

impaction  of,  494 

in  intestine,  471 

operations  for,  493 

pancreatitis  due  to,  493 

symptoms  of,  492 

treatment  of,  493 
Ganglion,  238 

compound  palmar,  239 
Gangrene,  79 

signs  of,  79,  80,  85 

symmetrical,  see  Raynaud's,  82 

termination  of,  80 

treatment  of,  81,  86 

varieties  of,  80 

X-ray,  13,  85 
Gangrenous  appendicitis,  484 

cellulitis.  III 

inflammation,  60 

pancreatitis,  40 

stomatitis,  86 

urticaria,  159 
Gartner's  duct,  cyst  of,  608,  149 
Gasserian  ganglion,  removal  of,  228 
Gastrecta.sia,  457 
Gastrectomy,  461 
Gastric  fistula,  460 

hemorrhage,  455 

lavage,  459,  42,  40 

ulcer  and  its  effects,  453 
(lastritis  obliterans,  459 
(iastrodiaphany,  458 


6s6 


INDEX. 


Gastroenterostomy,  462 

indications  for,  462 

vicious  circle  after,  464 
Gastrolysis,  455 
Gastromesenteric  ileus,  457 
Gastropexy,  461 
Gastroptosis,  458 
Gastroplication,  461 
Gastrorrhagia,  454 
Gastrostomy,  460,  193 
Gastrotomy,  460,  438 
Gelatin  as  a  hemostatic,  197 

injection  of  aneurysms,  190 
Gelatinous  carcinoma,  140 
General  anesthesia,  14 

lymphadenosis,  220 
Genital  chancre,  123 

organs,  female,  573 
male,  548 
Genitourinary  canal',  515 
Genupectoral  position,  589 
Genu  recurvatum,  617 

rhachiticum,  616 

staticum,  616 

varum,  617 

valgum,  616 
Germicide,  31 
Gerster's    operation    for    amputation    of 

breast,  416 
Giant-celled  sarcpma,  147,  294 
Gibson's  bandage,  47 

operation,  477 
Gigli  saw,  335 
Gilliam-Ferguson  operation  of  shortening 

the  round  ligaments,  591 
Girdner's  telephonic  probe,  92 
Glanders,  119 
Glands,  lymphatic,  affections  of,  219 

malignant,  220 

mesenteric,  452 

syphilitic,  123,  220 

tuberculous,  219' 
Glandular  carcinofna,  139 
Glaucoma,  235 
(}leet,  551 

Glenard's  disease,  470 
Glioma,  146,  147 
(iliosarcoma,  146 
Gliosis,  146 
Globus  hystericus,  439 
Glossitis,  425 

Glossopharyngeal  nerve,  affections  of,  229 
Glottis,  edema  of,  3(^8,  397,  99,  381 

sj)asm  of,  3(j7 
Glover's  stitch,  S<; 
Gluteal  artery,  ligation  of,  213 
(ilutol,  33 
(ioitcr,  3S4 
(ion<H  (Kcus,  551 
(ionorrhea.  551,  3^8 
Gonorrheal  arthritis.  315.  313 

( onjunc  liviiis.  551 

cystitis,  551 


Gonorrheal,  epididymitis,  551 

iritis,  552 

proctitis,  551 

rheumatism,  315,  286 

rhinitis,  551 

sclerotitis,  551 

synovitis,  313 

tenosynovitis,  237 
Gooch's  flexible  wooden  splints,  251 
Goodell's  uterine  dilator,  582 
Gottstein's  curette,  394 
Gouley  catheter,  557 
Gouty  arthritis,  322 

deposits  in  burse,  245 

neuritis,  221 
Grafting,  bone,  289 

nerve,  225    • 

skin,  168 

tendon,  243 
Granny  knot,  90 
Granulation  tissue,  67 

exuberant,  67,  78 
Gravel,  532 

Graves*  disease,  386,  384 
Great  sciatic  nerve,  affections  of,  234 
Greenish  discoloration,  in  diagnosis,  4 
Greenstick  fracture,  246,  2 
Gritti's  supracondyloid  amputation,  637 
Grossich  method  of  disinfection;  39 
Growth  of  tumors,  152 
Gum  boil,  429 

Gumma,  127,  see  also  special  regions 
Gummatous  arthritis,  316 

degeneration,  127 

osteomyelitis,  291 

synovitis,  127,  316 
Gums,  epithelioma  of,  430,  139 
Gun  powder  stains,  93 
Gunshot  fracture,  247 

wounds,  92 
Gutta-percha,  uses  of,  in  bone  cavities,  288 
Gutter  fracture,  341 

Hahn's  tracheotomy  tube,  400,  402 
Hallux  rigidus  (H.  flexus),  622 

valgus,  622 
Halstcad's    operation    for    amputation    of 
breast,  416 
for  inguinal  hernia,  505 

subcuticular  stitch,  90 

suture,  intestinal,  476 
Hammer  nose,  387 

toe,  622,  160 
Hammond's  wire  splint  for  fracture  of  lower 

jaw,  255 
Hand,  ami)utation  of,  627 

deformities  of,  614 

epithelioma  of,  162 
Hands,  sterilization  of,  37 
Haptophore,  29 
Hare-li|),  417 
Harris'  segregator,  522 
Harrison's  sulcus,  292 


INDEX. 


6S7 


Hartley-Krausc  operation  for  removal  of 

Gasserian  ganglion,  228 
Hartman's  operation  for  gastrostomy,  460 
Head,  329,  see  fractures  of  skull 

injuries  of  brain,  cerebral 
Healing  of  wounds,  see  repair 
Heart,  concussion  of,  404 

fetal  sounds  in  diagnosis,  7 

massage  of,  175,  21 

surgery,  174 

wounds  of,  174 
Heat  in  hemorrhage,  197 

inflammation,  58 

treatment  of  inflammation,  63 
Heberden's  nodes,  322 
Hectic  fever,  73,  104 

flush,  73 
Hegar's  operation  for  laceration  of  peri- 
neum, 579 
Height,  in  diagnosis,  8 
Heineke-Mikuiicz    operation     of     pyloro- 
plasty, 465 
Hemangioma,  144 
Hemianopsia,  ^^$ 
Hemarthrosis,  324 
Hematemesis,  454,  196,  382 
Hematocele,  pelvic,  613 

scrotal,  567 
Hematocolpos,  576 
Hematogenous  jaundice,  105 
Hematoma,  67,  149 

of  abdominal  walls,  441 

of  dura  mater,  348 

of  ear,  375 

of  scalp,  329,  341 
Hematometra,  576,  582 
Hematomyelia,  364 
Hematorrhachis,  364 
Hematosalpinx,  576,  601 
Hematuria,  526,  171 
Hemoglobin,  9 
Hemoglobinuria,  527 
Hemolysis,    danger   of    in    transfusion   of 

blood,  182 
Hemolytic  tests,  10 
Hemopericardium,  176 
Hemophilia,  203 

joints  in,  324 
Hemopneumothorax,  404 
Hemopwsis,  455.  404,  171 
Hemorrhage,  195,  171 

causes,  195 

control  of,  196 

diagnosis,  197 

symptoms,  196 

treatment,  197 

varieties,  195 

see  also  special  regions 
Hemorrhagic  diathesis,  203 

fever,  196 

inflammation,  59 

pancreatitis,  49^5 

ulcers,  78 

42 


Hemorrhoids,  519 

external,  519 

treatment  of,  519 

internal,  519 

treatment  of,  519 
Hemostasis,  196 
Hemostatic  forceps,  200,  45 
Hemostatics,  197 
Hemothorax,  405,  257,  196 
Hepatic  abscess,  488,  7 

colic,  492 

cysts,  489 
Hepaticocholangioenterostomy,  495 
Hepatopexy,  490 
Hepatoptosis,  490 
Hepatotomy,  489 
Hermaphrodism,  575 
,  Hernia,  498,  see  also  special  regions 

accidents  of,  512 

appendix  in,  499 

bladder  in,  499 

causes  of,  498 

cecum  in,  499 

cerebri,  346 

contents  of,  498 

coverings  of,  498 
•    en  bissac,  502 

foreign  bodies  in,  500 

hydrocele  of  sac,  499 

incarceration  of,  513 

inflammation  of,  512 

intestine  in,  499 

mouth  of,  499 

obstructed,  513 

sac  of,  499 

signs  of,  500 

sliding,  499 

special,  500 

strangulated,  513,  83 

complications  after  taxis  for,  514 
operative  treatment  of,  see  special 

regions 
signs  and  symptoms  of,  513 
taxis  in,  514 

structure  of,  499 

traumatic,  499 

treatment  of,  see  special  regions 

varieties  of,  500,  509,  511 
Herniotomy,  514 
Herpes,  gangrenous,  1 59 

labialis,  419 
Herp>etic  ulceration,  124 
Hessdbach's  triangle,  501 
Hey's  amputation,  633 
Hiccough,  189 
Hilton's    method    of    opening    abscesses, 

72,382 
Hind  gut,  516 
Hip  disease,  318,  61,  6 

diagnosis  from  sacroiliac  disease,  3 1 8 

joint,  amputation  at,  638 

ankylosis  of,  320 

diagnosis  of  injuries  about,  275,  319 


6s8 


INDEX. 


Hip    disease,    dislocation    of,    congenital, 
297,  8 
traumatic,  306,  320 

effusion  into,  314 

excision  of,  328,  320 
Hip  joint,  osteoarthritis  of,  322 

tuberculous  disease  of,  318 
Hippocratic  face,  8 
Hirschsprung's  disease,  468 
History  in  diagnosis,  i 
Hodgen's  splint,  276 
Hodgkin*s  disease,  220,  10 
Hoffa's  operation  for  congenital  displace- 
ment of  hip,  298 
Hollow  foot,  621 

Hopkin's  dressing  for  fractured  patella,  279 
Horn,  160 

of  scalp,  330 

sebaceous,  164 
Horse  hair,  36 

probang,  437 

shoe  kidney,  523 
Horsley's  cyrtometer,  332 

dural  separators,  335 

operation  for  the  removal  of  the  Gas- 
serian  ganglion,  229 

wax,  338 
Hospital  gangrene,  86 
Hot  air  apparatus,  64,  314 
Hottentot  apron,  575 
Hour  glass  stomach,  456 

hernia,  499 
Housemaid's  knee,  245 
Howship's  lacunae,  290 
Hudson's  burrs,  336 

modification  of  the  De  Vilbiss  forceps, 

337 
Humerus,  dishxration  of,  301 

fractures  of,  260 

separation  of  epiphysis,  lower,  266 
upper,  262 
Humoral  theor)'  of  immunity,  29 
Hunterian  chancre,  123 
Hunter's  canal,   ligation  of  femoral  artery 
in,  214 

operation  for  aneurysm,  192 
Huntington's   operation    for    transplanting 

bone,  28g 
Hutchinson's  teeth,  132,  5 
Hydatid  cysts,   149,  sec  also  special  regions 

moles,  14^ 

of  Morgagni,  607 
Hydrargyrism,  i2q 
Hydrarthrosis,  see  hydrops  articuli 
Hydrencephaloccle,  347 
Hydn)cele,  565,  see  also  special  regions 

bilocular,  566 

congenital,  566 

chylous,  567,  218 

encysted,  of  cord,  567,  503 
testis.  566 

idiopathic,  565 

infantile,  566 


Hydrocele,  inguinal,  566 

of  hernial  sac,  499 

tapping,  method  of,  566 

treatment  of,  566 

varieties  of,  565,  566 
Hydrocephalus,  347 
Hydrogen,  peroxid  of,  33 
Hydrometra,  582 
Hydronephrosis,  529 
Hydrophobia,  115,  114 
Hydrops  antri,  396 

articuli,  341 

cystidis  fellese,  491 

of  appendix,  484 

of  frontal  sinus,  394 

tubae  profluens,  601 
Hydrosalpinx,  601 
Hygroma,  379,  149 
Hyoid  bone,  fracture  of,  256 
Hyperchlorhydria,  453 
Hyperemia,  58,  4 

reduction  of,  61 
Hyperkeratosis  linguae,  425 
Hypernephroma,  148,  535 
Hyperpituitarism,  353 
Hypertrichosis,  Rdntgen  nys  in  treatment 

of,  13 
Hypertrophic  osteoarthropathy,  285 
Hypertrophy,  see  special  regions 
Hypodermoc  lysis,  183,  102 
Hypoglossal  nerve,  injuries  of,  230 
Hypomycetes,  31 
Hypopituitarism,  353 
Hypospadias,  549,  575 
Hysterectomy,  abdominal,  596 

combined,  599 

complete,  596 
Hysterectomy,  vaginal,  595 
Hysteria,  in  spinal  injuries,  361 
Hysterical  edema,  5 

joints,  323 
Hysteroneurasthenia,  361 
Hysteropexy,  591 
Hysterorrhaphy,  591 

Icterus,  see  jaundice 

Icthyosis  lingua?,  425 

Idiocy,  383 

Idiopathic  dilatation  of  the  colon,  468 

Idiopathic  erj-sipelas,  109 

fragilitas  ossium,  293,  247 

hydrcKele,  565 

inflammation,  59 

multiple  hemorrhagic  sarcoma,  163 

tetanus.  113 
Ileus,  see  intestinal  obstruction 
Iliac  colostomy,  477 

veins,  inflammation  of,  177 

vessels,     ligation     of,     see     comm(m, 
external  and  internal 
Iliopectineal  bursa,  246 
Ilium,  fractures  of,  271 
Immune  bodies,  29 


INDEX. 


6S9 


Immunity,  28 

Colles',  122 
Impacted  calculus,  in  ureter,  529,  532 

feces,  471,  474 

fracture,  246 

gall-stones,  effects  of,  492 

urethral  calculus,  550 
Impaction    of    foreign    bodies    in  bowel, 

471 
Impassable  stricture,  of  urethra,  554 
Imperforate  anus,  516 
Impermeable  stricture  of  urethra,  554 
Impetigo,  syphilitic,  126 
Implantation  dermoids,  149 
Incarcerated  hernia,  531 
Incised  wounds,  88 
Incision,  exploratory,  5 
Incomplete  dislocation,  298 

fracture,  246 

inguinal  hernia,  500 
Incontinence  of  urine,  542 

retention,  569,  542 
Indifferent  tissue,  59 
Indirect  fracture,  247 

gangrene,  80 

inguinal  hernia,  500 
congenital,  501 
Induction  balance.  Bell's,  92 
Infantile  arthritis,  285 

hydrocele,  566 

inguinal  hernia,  501 

palsy,  374,  319.  2 

scurvy,  292,  286 

umbilical  hernia,  509 
Infarct,  171,  see  also  emboli 
Infection,  27 
Infective  arthritis,  315 

inflammation,  59 

osteomyelitis,  acute,  see  osteomyelitis 

phlebitis,  177 

thrombophlebitis,  178 

thrombosis    of    cerebral    sinues,   349, 

178 

Inferior  dental  nerve,  operations  on,  228 

maxilla,  see  lower  jaw 

thyroid  artery,  compression  of,  199 
ligation  of,  210 

maxillary  nerve,  operations  on,  228 
Inflamed  hernia,  512 
Inflammation,  58,  see  also  special  regions 

causes  of,  58 

extension  of,  59 

pathology,  58 

symptoms  of,  60 

termination  of,  59 

treatment  of,  61 

Bier's,  62,  135,  74,  317 

varieties  of,  59 
Infraction,  246 
Infrapatellar  bursa,  245 
Infraorbital  nerve,  op>eration  on,  227 
Infusion  of  salt  solution,  182 
Ingrowing  toe  nail,  166 


Inguinal  adenitis,  219 
bubo,  123,  219,  559 
colostomy,  477 
hernia,  500 

diagnosis  of,  502 
treatment  of,  503 
varieties  of,  500 
hydrocele,  56(3 
perineal  hernia,  511 
Inherited  syphilis,  131 

bone  affections  in,  291,  132 
Injections  for  cure  of  hydrocele,  566 

in  gonorrhea,  552 
Injuries,  see  special  regions 
Innominate  artery,  ligature  of,  205 
Inoperable  malignant  disease,  treatment  of, 

148,  140 
Insanity,  354,  22,  109,  342 
Insect  biles  and  stings,  95 
Inspection,  in  diagnosis,  4 
Instruments,  preparation  of,  for  operations, 

34 
Intercostal  artery,  hemorrhage  from,  405 
Interdental  splints,  255 
Interilio-abdominal  amputation,  641 
Iptermaxilla,  in  hare-lip,  417 
Intermediate  hemorrhage,  195 
Internal  carotid  artery,  hemorrhage  from, 
376 
ligation  of,  207 
wounds  of,  344 
derangement  of  knee  joint,  310 
hemorrhage,  196 
hernia,  512 

iliac  artery,  ligation  of,  213 
mammary  artery,  hemorrhage  from, 

405 
ligation  of,  210 

popliteal  nerve,  affections  of,  234 

pudic  artery,  ligation  of,  213 

urethrotomy,  557 

jugular  vein,  hemorrhage  from,  376 
Interpretation  of  X-ray  pictures,  11,  12 
Interscapulothoracic  amputation,  632 
Intersigmoid  fossa,  hernia  into,  512 
Interstitial  appendicitis,  484 

hernia,  inguinal,  502 

inflammation,  59 

keratitis,  132 

mastitis,  412 
Intestinal  adhesions,  471 

anastomosis,  479 

bands,  471 

calculi,  471 

exclusion,  483 

localization,  475 

obstruction,  471 

paralysis,  472 

sutures,  476 
Intestines,  affections  of,  468 

anastomosis  of,  479 

carcinoma  of,  472,  474 

congenital  malformations  of,  468 


66o 


INDEX. 


Intestines,  entcroptosis,  470 

exclusion  of,  483 

foreign  bodies  in,  471 

gangrene  of,  513,  452 

lateral  implantation  of,  483 

operations  on,  475 

perforation  of,  typhoid,  469 

rupture  of,  442 

segregation  of,  483 

stricture  of,  472 

tuberculosis  of,  470 

tumors  of,  472 

wounds  of,  442,  445 
Intraarticular  fracture,  246 
Intracanalicular  fibroma,  413 
Intracapsular  fracture  of  femur,  272 

humerus,  262 
Intracranial  abscesses,  350,  379,  see  also 
cerebral,  head,  skull,  brain 

blood  vessels,  injuries  of,  343 

complications  of  otitis  media,  379 
Intracranial  hemorrhage,  343,  344, 340, 33^ 

in  the  new-born,  344 

inflammation,  348 

tumors,  352,  see  also  head,  skull,  brain, 
cerebral  , 

Intramammary  abscess,  see  breast 
Intramedullary  hemorrhage  of  spinal  cord, 

364,  361 
Intraperitoneal  abscess,  450 

hemorrhage,  203 
Intraspinal  tumor,  374 
Intrauterine  fractures,  247 
Intravenous  infusion,  182 
Intubation  of  larynx,  403 
Intussusception,  471 

congenital,  468 

varieties  of,  471 
Inunction  of  mercury,  129 
Inversion  of  testis,  561 

uterus,  593 
Involucrum,  288 
Involution  cysts,  417 
lodin,  tincture  of,  ^3 
Iodoform,  3,^ 

emulsion,  74,  t^^,  317 

gauze,  37 

jx)isoning,  34,  108 
lodophilia,  g,  106 
Iritis,  60,  125,  127,  552 
Iron  wire,  36 
Irreducible  swellings,  503 

hernia,  512 
Irrigation,  constant,  112 

of  chronic  abscesses,  74 

of  j)eritoneal  cavity,  448 
Ischiorectal  abscess,  517 
Iterilioalxioniinal  amputation,  641 

Jacksonian  epilepsy,  354 

Jacob's  ulcer,  162 

Janet's   methcKl  of  irrigating   the  urethra. 


Jaundice,  hematogenous,  105 
Jaw,  lower,  cleft  of,  419 

closure  of,  431 

cysts  of,  429 

dislocation  of,  300 

epulis,  430 

excision  of,  431 

fibrocystic  disease  of,  430,  145 

fracture  of,  255 

necrosis  of,  429,  287 

tumors  of,  430 
Jaw,  upper,  cysts  of,  429 

epulis,  430 

excision  of,  430 

fracture  of,  254 

necrosis  of,  429 

timiors  of,  430 
Jejunostomy,  477 
Jejunum,  peptic  ulcer  of,  465 
Joints,  296 

affections  in  syringomycUa,  323 

ankylosis  of,  324 

aspiration  of,  313 

Charcot's,  323 

diseases  of,  312 

dislocations  of,  297 

effusion  into,  evidences  of,  314 

examination  of,  313 

excision  of,  326 

false,  299,  253 

gonorrheal  affections  of,  315 

gout>',  322 

hemophilic  disease  of,  see  hemarthroas 

hysterical,  323 

incision  of,  313 

injuries  of,  296 

involvement   of   in   infectious    fevers, 
312,  298 

lipoma  aborescens,  141,  324 

lo<jse  bodies  in,  324,  317 

mice,  324,  317 

neuralgic,  323 

pyemic,  312 

rheumatic,  321,  312 

ruptured  semilunar  cartilages  in,3io,3i5 

sprains  of,  296. 

syphilis  of,  316,  313,  127 

tuberculous  disease  of,  317,  316 

wounds  of,  276 
Jones'  position,  265 
Jonnesco's  operation   for   excision   of   the 

cer\ical  sympathetic,  235 
Jugular  vein,  hemorrhage  from,  376 

ligation  of,  178,  380,  350 
Jur>'  mast,  Sayre's,  372 

Kader's  gastrostomy,  461 

Kangaroo  tedon,  36 

Kar>'okinesis,  66 

Kelly's  method  of  sterilization  of  hands,  38 

Keloid,  false,  163,  141 

spontaneous,  163 

true,  163,  141 


INDEX. 


66l 


Keratitis  interstitial,  132 
Keratosis  senilis,  163 
Kemig's  sign,  349 
Keyes-Ultzman  syringe,  553 
Kidneys  and  ureter,  affections  of,  523 

abscess  of,  530 

amyloid  disease  of,  73 

calculus,  532 

carcinoma,  535 

congenital  affections  of,  523 

c)rstic  disease  of,  535,  149 

cysts,  535 

decapsulation,  537 

examination  of,  524 

exploration  of,  535 

floating,  528 

functional  capacity  of,  525 

horse  shoe,  523 

hydronephrosis,  529,  424 

hypernephroma,  535 

injuries  of,  443 

movable,  528 

nephritis,  operation  for,  537 

operations  on,  535 

pyelitis,  529 

pyelonephritis,  530 

pyonephrosis,  530 

rupture,  443 

sarcoma,  535,  524 

solitary,  523 

surgical,  530 

tuberculous  disease  of,  531 

tumors  of,  535 

twisting  of  pedicle,  528 
Killian's  operation   for  empyema  of   the 

frontal  sinus,  394 
Klumpke  paralysis,  230 
Knee-chest  posture,  589 
Knee-joint,  amputation  through,  637 

ankylosis  of,  325 

dislocation  of,  308 

effusion  into,  314 

erasion  of,  321 

excision  of,  328,  325,  321 

gonorrheal  infection  of,  315 

housemaid's  245 

internal  derangement  of,  310 

semilunar  cartilage,  dislocation  of,  3 10 

tuberculous  disease  of,  321 
Knock-knee,  616 
Knots,  90 

Kobelt's  tubes,  cysts  of,  608,  149 
Kocher's  method  of  gastroenterostomy,  463 

method  of  treating  dislocation  of  the 
humerus,  302 

operation  of  pylorectomy,  466 
for  excision  of  the  hip,  328 
for  removal  of  the  tongue,  428 

temporary  resection  of  upper  jaws  for 
exposing  nasopharyngeal  growths, 

Koch's  postulates,  28 
tuberculin,  135 


Kopf  tetanus,  113 

Kraske's  method  of  excision  of  rectum,  523 

Kraurosis  vulvae,  576 

Kronlein's  method  of  craniocerebral  to- 
pography, 332 

Kuettner's  infusion  of  salt  solution  with 
oxygen,  183 

Kussmaul's  sign,  177 

Kyphosis,  368,  393,  294 

Labial  abscess,  575 

artery,  compression  of,  199 

chancre,  124 

hernia,  501 
Laborde's  method  of  artificial  respiration, 

21 
Lacerated  wounds,  90 
Laceration,  see  special  regions 
Lachrymal  bone,  fracture  of,  254 
Lacteal  cysts,  417 
Lacunar  abscess,  70 
Lamina,  fracture  of,  see  spine 
Laminectomy,  359,  362,  364,  374 
Langenbeck's  operation  of  excision  of  ankle, 

329 
elbow,  327 
hip,  328 
wrist,  327 

on  nose,  388 
Laparotomy,  see  abdominal  section 
Lardaceous  disease,  73 
Larrey's  amputation  at  shoulder  joint,  631 
Lar>'ngeal  cartilage,  fracture  of,  256 

crises,  397 

stenosis,  397 
Lar)'ngectomy,  400 
Laryngitis,  edematous,  398 
Laryngismus^stridulus,  397 
Laryngocele,*379 
Laryngoscope,  397,  5 
Lar>'ngotomy,  401 
Laryngotracheotomy,  401 
Larynx,  abscess  of,  399 

acute  edema  of,  397,  see  also  edema 
of  glottis,  398 

artificial,  401 

chrondritis,  399 

congenital  fissures,  396 
fistulse,  396 

diseases  of,  397 

epithelioma  of,  399,  139 

foreign  bodies  in,  396,  398 

fractures  of,  256,  398 

gumma  of,  399 

injuries  of,  398 

intubation  of,  403 

papilloma  of,  399 

paralysis  of,  230 

stenosis,  of  397 

syphilis  of,  399 

tuberculous  disease  of,  399 

tumors  of,  399 

ulceration  of,  397 


662 


INDEX. 


Lateral  anastomosis  of  intestine,  481 
curvature  of  sjnnc,  366,  374 

in  hip  disease,  319 
implantation  of  intestine,  483 
ligature,  201 
lithotomy,  548 
sinus,  drainage  of,  350,  178 

hemorrhage  from,  376 

thrombophlebitis  of,  350,  105,  107, 

178.  377.  379 

ventricle,  puncture  of,  348 
Lavage  of  stomach,  459,  15,  42,  40 
Lead  poisoning,  352 
Lead-water  and  laudanum,  62 
Leaking  aneurysm,  189 
Leather-bottle  stomach,  458 
Leech,  artificial,  61,  377 
Leeching,  61 
Le  Fort's  amputation  at  the  ankle-joint, 

636 
Leg,  amputation  of,  636 

fracture  of  both  bones,  283 
Leiomyoma,  144 
Leiter's  tubes,  62 
Lembert's  intestinal  suture,  476 
Lenticular  carcinoma,  162 
Leontiasis  leprosa,  121 

ossea,  293,  143 
Leprosy,  121 
Leptothrir,  see  bacteria 
Leptomeningitis,  348,  349*  373 
Leukemia,  10,  195,  498 
Leukemic  tumors,  163 
Leukocytes,  enumeration  of,  9 

migration  of,  in  inflammation,  58 

phagocytic  action,  29 
Leukocytosis,  9,  29,  59,  104,  106,  175,  220, 
376,  406 

in  abscess,  71 

in  inflammation,  59 

stimulation  of,  29 
Leukopenia,  10 
Leukoplakia,  425,  4,  163 
Levis  apparatus  for  reduction  of  dislocation 
of  phalanges,  306 

splint,  26g 
Ligation  of  arteries,  effects  of,  201 

for  aneurysm,  iq2 

enlarged  prostate,  204,  571 
epilepsy,  204,  354 
hemorrhage,  200 
malignant  growths,  140,  203 
trigeminal  neuralgia,  204,  226 
gangrene  following,  83 

in  continuity,  203 

technic  for,  205 
Ligatures,  materials  for,  35 

preparation  of,  35 
Light,  electric,  5 
Lightning  stnAe,  100,  5 
Lilienthal's  electric  probe,  92 
Linear  craniectomy,  348 

discoloration,  in  diagnosis,  4 


Lingual  artery,  ligature  of,  208 

goiter,  383 

nerve,  operation  on,  228 
Lipoma,  141,  71,  237 

arborescens,  141,  324 

diffuse,  143 

fibrolipoma,  141 

intermuscular,  142 

nevolipoma,  141 

subcutaneous,  141 

subserous,  141 
Lips,  affections  of,  417 

chancre  of,  123 

cleft  of,  417 

cysts  of,  420 

epithelioma  of,  421,  139,  162 

horns  of,  421 

strumous,  420 

warts  of,  421 
Liquid  air,  22 

Lisfranc's  amputation  of  foot,  633 
Lister's  modified  flap  and  circular  ampu- 

tadon,  626 
Litholapaxy,  546 
Lithopedion,  604 
Lithotomy,  perineal,  547 

position,  547 

suprapubic,  547 
Lithotrites,  546 
Lithotrity,  546 
Littre's  hernia,  499 

Littre-Maydl  operation  of  colostomy,  477 
Liver,  abscess  of,  488 

affections  of,  488 

cirrhosis  of,  490,  2 

hemorrhage  from,  442 

hydatid  cysts,  489 

laceration  of,  443 

tumors  of,  490 

see  also  hepatic 
Local  anesthesia,  see  anesthesia 
Localization,  in  cerebral  injuries,  331 

intestinal,  475 

spinal,  354 
Lock  jaw,  112 

Locomotor  ataxia,  7,  74,  623,  293,  323,  397 
Longitudinal  fracture,  246 
Loose  bodies  in  joints,  324,  314 
Lordosis,  368 

Lorenz's  method  of  treating  congenital  dis- 
location of  hip,  298 
Ivowenberg's  forceps,  394 
Lower  jaw,  see  jaw 
Lud wig's  angina,  381 
Lumbago,  318 
Lumbar  disease,  373,  369,  370 

caries,  373 

colostomy,  477 

hernia,  511 

incision  for  exposing  kidney,  535 

plexus,  injury  of,  233 

puncture,  360,  343,  349,  364 
Lumpy  jaw,  1 19 


INDEX. 


663 


Lungs,  abscess  of,  409,  398,  405 

cysts  of,  409 

discission  of,  409 

decortication  of,  409 

foreign  bodies  in,  397,  405 

gangrene,  409,  39^,  405 

hemorrhage  from,  405 

hernia  of,  405 

operations  upon,  409 

prolapse  of,  405 

rupture  of,  404 

stones,  396 

wounds,  404 
Lupoid  ulcer,  161,  75 
Lupoma,  161 
Lupus,  161,  389 

treatment  of,  by  Finsen  light,  161 
X-rays,  161 
Luschka*s  tonsil,  393 
Luxatio  erecta,  301 

Luxation  of  joints,  see  dislocation,  297 
Luys*  segregator,  525 
Lymphadenitis,  acute,  219,  237 

chronic,  219 

syphilitic,  220 

tuberculous,  219 
Ljrmphadenoma,  221,  145 
Lymphangiectasis,  217,  145 
Lymphangioma,  145,  218 
Lymphangitis,  218,  4,  237 
Lymphatic  glands,  affections  of,  219 

nevus,  218 

secondary  growths  in,  see  sarcoma  and 
carcinoma 

simulating  hernia,  503 

syphilis  of,  220,  125 

tuberculosis  of,  219 

vessels,  diseases  of,  217 

warts,  218 

leukemia,  220 

system,  217 

edema,  218 

fistula,  218 
Lymphatism,  221 
Lymphedema,  218 
Lymphoma,  145,  221 
Lymphorrhea,  218 
Lymphosarcoma,  146,  220 
Lysol,  S3 
Lyssophobia,  117 

McBumey's  operation  for  appendicitis,  487 

point,  484 
Macewen's  operation  for  knock-knee  (os- 
teotomy), 607 

treatment  of  aneurysm,  191 

triangle,  377 
Macrocheilia,  420,  145,  218 
Macrodactylia,  615,  293 
Macroglossia,  424,  145,  218 
Macrostoma,  419 
Macrotia,  325 
Madelung's  deformity,  614 


Madura  foot,  120,  31 

Magnet  for  the  removal  of  iron  bodies,  398 

Mahler's  symptom,  178 

Maisonneuve's  urethrotome,  557 

Malar,  fracture  of,  254 

Malaria,  9,  31,  106,  195 

Male  genital  oigans,  548 

Malignant  cysts  of  neck,  380 

dermatitis,  411 

edema,  85 

epulis,  430 

pustule,  117 

tumors,  137 

ulcers,  74 
Mallein,  119 
Mallet  finger,  615 
Malleus,  119 
Mai  perforant,  623 
Malpositions  of  testis,  561 
Malum  senile,  see  osteoarthritis 
Mamma,  see  breast 
Mammilitis,  411 
Mandible,  see  lower  jaw 
Mangoldt's  method  of  skin  grafting,  168 
Mania  a  potu,  108 
Marie's  disease,  285 
Marjolin's  ulcer,  68,  139 
Marsupialization  of  ovarian  cyst,  611 
Martin's  rubber  bandage,  77 

uterine  curette,  586 
Mason's  pin,  254 
Massage,  63 

danger  of,  63 

in  treatment  of  fractures,  251 

of  heart,  175,  21 
Mastitis,  411 
Mastodynia,  411 

Mastoid  antrum,  suppuration  in,  376 
Mastoiditis,  376,  351 
Matas  operation  for  aneurysm,  193 

splint  for  fracture  of  lower  jaw,  256 

test  for  efficiency  of  collateral  circula- 
tion, 624,  193 
Maunsell's  method  of  end-to-end  anasto- 
mosis, 480 
Maxillary  nerves,  operation  upon,  227 

sinus,  empyema  of,  see  antrum  of  High- 
more 
Maydl  operation  for  ectopia  vesicae,  539 
Mayo's  operation  for  partial  excision  of  gall- 
bladder, 494 
for  partial  thyroidectomy,  386 
for  umbilical  hernia,  510 
of  pylorectoray,  467 
McG raw's  elastic  ligature,  482 
Mclntyre  splint,  276 
Meatotomy,  548 
Mechanical  dysmenorrhea,  600 

sterilization,  31 
Meckel's  diverticulum,  468 

ganglion,  227 
Median  cervical  fistula,  379 

lithotomy,  548 


664 


INDEX. 


Median  nerve,  affections  of,  232 
Mediastinopericarditis,  177 
Mediastinum  abscess,  410,  397,  403 

tumors,  410,  397 
Medulla  of  bone,  inflammation  of ,  see  os- 
teomyelitis 
Medullary  carcinoma,  139 

narcosis,  24 
Melanotic  sarcoma,  147,  4,  220 
Melon-seed  bodies,  238,  245,  see  also  rice 

bodies 
Membrana  tympani,  rupture  of,  343 
Membranous  dysmenorrhea,  601,  586 
Meningeal  hemorrhage,  cerebral,  343 

spinal,  364 
Meningitis,  cerebral,  acute,  348,  395 

cercbro-spinal,  epidemic,  348 

chronic,  349 

tuberculous,  349 

spinal,  373 
Meningocele,  347,  3^5 

spurious,  330,  341 

traumatic,  330 
Meningoencephalitis,  348,  351 
Meningoencephalocele,  see  encephalocele 
Meningomyelocele,  365 
Menorrhagia,  600 
Menstruation,  disorders  of,  599 
Mercurial  inunction,  129 

necrosis  of  jaw,  429,  287 
Mercurialism,  129 
Mesarteritis,  183 
Mesenter>%  affections  of,  442,  451 

cysts,  452 

embolism  of  arteries  of,  452 

thrombosis  of  veins,  of,  452 
Mesoblastic  tumors,  140 
Metacarpal  lx)nes,  dislocations  of,  305 

fractures  of,  270 
Metacarpophalangeal  joint,  amputation  at, 
628 
disl<Kation  at,  305 
Metastatic  abscess,  71,  105,  171 

gn)\vths,  157 

inflammation,  60 
Metasyphilis,  128 
Metatarsal  bones,  dislocation  of,  312 

fracture  of,  284 
Mctatarsalgia  (Morton's  disease),  621 
Mctschnikoff's  theory  of  immunity,  29 

prophylaxis  for  syphilis,  128 
Methyl  chlorid,  22 
Metritis,  586 
Metrorrhiigia,  600,  ig6 
Michel  clamps,  88 
Microbic  gangrene,  85 
M  ic  rocephalus,  348 
Micrcx"oc(us  tetragenus,  6() 

pyogenes  tenuis,  69 
Micnmiazia,  410 
Micn)mclia,  2(;2 
Microstoma,  4i(^ 
Microtia,  7,-j^ 


Middle-ear  disease,  see  otitis  media 
Middle  meningeal  artery,  hemorrhage  from. 

•343 
Midtarsal  joint,  amputation  through,  633 
Mikulicz-Hartmann  line,  467 
Mikulicz's  law,  9 

operation  for  torticollis,  381 
Miliary  tubercle,  133 

tuberculosis,  134 
Milk  fistula,  412 
Milk  leg,  177 
Milzbrand,  117 
Miner's  elbow,  246 
Mirault's  operation  for  hare-lip,  418 
Mixed  chancre,  123 

infection,  28 

parotid  timior,  423 

treatment  of  syphilis,  129 

tumors,  137,  148 
Moeller-Barlow  disease,  292 
Moist  gangrene,  80 
Mole,  160,  4,  147,  330 
MoUities  ossium,  see  osteomalacia 
MoUuscum  contagiosum,  31 

fibrosum,  141,  223 
Monsel's  solution,  197,  144 
Montgomery    method    ol    shortening    the 

round  ligaments,  591 
Moore's  method  of  treatment  of  aneurysm, 

191 
Moore-Corradi    treatment    of     aneurysm, 

192 
Moorhof 's  wax,  288 
Morbus  coxae,  318 

senilis,  322 
Morcellement  of  uterus,  595 
Morgagni,  hydatid  of,  cysts  from,  607 
Moriarty's  sphnt  for  fracture  of  jaw,  256 
Mormorek's  serum,  in 
Moro's  tuberculin  test,  135 
Morphea,  163 
Mortification,  see  gangrene 
Morton's  disease,  see  metatarsalgia 

fluid,  365,  348 

operation  for  transplanting  bone,  289 
Morvan's  disease,  237 
MoschcowiLz    osteoplastic    amputation    of 

leg,  636 
Moszkowitz  test  for  gangrene,  624 
Mother's  mark,  144 
Motion,  absence  of,  in  diagnosis,  5 
Motor  aphasia,  t^t^^ 

area,  topography  of,  332 

oculi  nerve,  affections  of,  226 
Mouth,  affections  of,  429 

chancre  of,  124 

sterilization  of,  39 
Movable  kidney,  528 

spleen,  497 
Mucocele  of  appendix,  484 
Mu(()us  patches,  126 
Miiller's  law,  1  ^6 
Multiple  fracture,  246 


INDEX. 


665 


Mummification,  see  dry  gangrene 
Mumps,  see  parotitis 
Murphy's  button,  480 

treatment  of  peritonitis,  448 
of  pulmonary  tuberculosis,  410 
Muscles,  affections  of,  236 

carcinoma  of,  237 

contusion  of,  235 

hernia  of,  235 

injuries  of,  235 

massage  of,  236 

ossification  of,  237 

suppuration  of,  236 

tumors  of,  237 
Musculospiral  nerve,  injury  of,  231,  262 
Mycetoma,  120,  31 
Mycosis  fungoides,  147,  163 
Myelocele,  364 
Myeloid  sarcoma,  147,  294 
Myoma,  144,  237 

cavernosum,  144 
Myomectomy,  596 
Myopia,  368 
Myositis,  236,  250 

ischemic,  236 

ossificans,  236,  143 
Myxedema,  383,  3,  5,  294,  386 
Myxoma,  143,  236,  294,  296 
Myxter's  operation  on  fifth  nerve,  228 

Nabothian  c)rst,  584 
Nails,  affections  of,  164 
Nares,  packing  of,  391 
Nasal  bone,  fracture  of,  253 

feeding,  115,  255 

polypi,  393 

septum,  deviation  of,  391 
fracture  of,  253 

spurs,  391 
Nasofrontal  duct,  catheterization  of,  395 
Nasoorbital  fissure,  419 
Nasophar>'ngeal  polypus,  393 
Natiform  skull,  132 
Nationality  in  diagnosis,  2 
Neck,  abscess  of,  381,  397 

affections  of,  379 

cellulitis  of,  381 

cysts  of,  379,  397,  399 

development  of,  379 

fistulae  of,  379 

hydrocele  of,  379 

tuberculous  glands  of,  219 

tumors  of,  220,  397,  380 
Necrosis,  acute,  284 

after  compound  fracture,  250 

fat,  496 

mercurial,  287 

quiet,  287 

syphilitic,  291 

tuberculous,  290 

typhoid,  287 
Needle  wounds,  92 
Negri  bodies,  116 


N^laton's  line,  273 

operation  on  nose,  388 

probe,  92 
Neoplasms,  136 
Nephrectomy,  537 
Nephritis,  operation  for,  537 
Nephrolithiasis,  532 
Nephrolithotomy,  537 
Nephropexy,  536 
Nephroptosis,  528 
Nephrorrhaphy,  536 
Nephrotomy,  537 
Nerve  anastomosis,  225 

grafting,  225 

stretching,  225 

suture,  225 
d  distance,  225 

transplantation,  225 

tubulization,  225 

Nerves,  affections  of,  221 

s|)ecial,  225 

compression  of,  223 

contusions  of,  223 

degeneration  of,  224 

infiammation  of,  221 

injuries  of,  223,  249 

regeneration  of,  225 
Nerves,  rupture  of,  223 

changes  following,  223,  224 

suture  of,  225 

tumors  of,  222 

see  also*  the  special  nerves 
Neuber's  operation  for  filling  bone  cavi- 
ties, 288 
Neuralgia,  222,  6,  250 

see  also  special  regions 

of  stumps,  627 

trifacial,  226 
Neuralgic  dysmenorrhea,  600 

ulcers,  77,  75 
Neurasthenia,  traumatic,  361 
Neurectasy,  222 
Neurectomy,  222 
Neurenteric  canal,  366,  515 
Neuritis,  221 

peripheral,  623 
Neurofibromatosis,  223 
Neurolysis,  223 
Neuroma,  222,  145,  141 
Neuropathic  arthritis,  323 
Neun)rrhaphy,  225 
Neurotomy,  222 
Ne\'us  flamens,  144 

lymphatic,  145,  218 

pigmentosus,  see  mole 

prominens,  144 

simple,  144 

venous,  144 
Nichol's  operation  for  resection  of  bone,  289 
Night  cries,  317,  319 

pains,  127 

sweats,  73 
Nipple,  affections  of,  410 


666 


INDEX. 


Nitrous  oxid  gas,  19,  14,  20,  22 
Nodes,  gouty,  322 

Heberden*s,  322 

Parrot's,  291 

syphilitic,  291,  330,  132 
Noeggerath's    treatment    of    inversion    of 

uterus,  593 
Noguchi  serum  reaction  for  S3rphilis,  see 

Wassermann  reaction 
Noma,  86,  2,  80 

pudendi,  86 
Non-pathogenic  oiganisms,  28 
Non-union  of  fractures,  252,  250,  262 
Normal  salt  solution,  37 
Nose,  surgery  of,  387 

adenoids,  393 

chronic  atrophic  rhinitis,  393 

deformities,  387 

epithelioma  of,  139 

fibromata  of,  393 

foreign  bodies  in,  392 

lupus  of,  161,  389 

ozena  of,  393 

plastic  operation  on,  388 

polypi  of,  393 

sterilization  of,  39 

synechia  of,  393 

S3rphilis  of,  389,  161 

tuberculosis  of,  393 
Nourse,  operation  for  anteflexion  of  uterus, 
588 

Objective  sy-mptoms,  in  diagnosis,  i 
Oblique  facial  cleft,  419 

fractures,  246 

inguinal  hernia,  500 
Obliterating  appendicitis,  484 
Obliteration  of  arteries,  184 
Obstructed  hernia,  513 
Obstruction,  intestinal,  471 

venous,  4,  5,  see  thrombosis 
Obstructive  dysmenorrhea,  600 
Obturator  dislocation  of  hip,  306 

hernia,  511,  509 

nerves,  affections  of,  234 
Occipital  after}',  compression  of,  199 

ligation  of,  209 
Occupation,  in  diagnosis,  2,  3 
Ochsner's  operation  for  esophageal  stric- 
ture, 43Q 

treatment  of  peritonitis,  448 
Odontomata,  145 
O'Dwyer's  intubation  tubes,  403 
Oil  of  cade,  4 
Oiled  silk,  37 
Oidium  albicans,  31,  429 
Olecranon  bursii,  246 

fra(  ture  of,  266 
Olfactory  nerve,  affections  of,  226 
Oligocythemia,  8,  g 
Omental  hernia,  see  ej)iplocele 
Omentum,  atTe(  tions  of,  451 

cysts  of,  452 


Omentum,  tears  of,  442 

tumors  of,  451 

volvulus  of,  451 
Omphalomesenteric  duct,  468 
Onset,  in  diagnosis  of  tumors,  151 
Onychia,  164,  126 

maligna,  165 
Onychauxis,  165 
Onychocryptosis,  166 
Onychogryposis,  165 
06phorcctomy,  603 

for  cancer  of  breast,  140 

for  fibroids  of  uterus,  595 

for  osteomalacia,  293 
see  also  ovary 
Odphoron,  cysts  of,  607 
Open  fractures,  246 
Operating  room,  essentials  of,  34 

techmc,  40 
Operation  in  private  house,  43 
Operative  treatment  of  fractures,  252 
Opisthotonos,  113,  8 
Opium,  108 

poisoning,  340 
Opsonic  index,  30 
Opsonins,  29,  104 
Optic  atrophy,  226 

nerve,  affections  of,  226 

neuritis,  226,  351,  352 
Orbital  celluUtis,  395 
Orbitonasal  cleft,  419 
Orchitis,  acute,  562 

chronic,  562 

complicating  parotitis,  423 

syphilidc,  563,  127 

tuberculous,  563 
Organic  stricture  of  urethra,  see  urethra 
Organization  of  blood  clot,  67 
Oriental  boil,  159 
Origin  of  timiors,  136 
Orthopnea,  8 
Orthotonos,  113 
Os  calcis,  fracture  of,  284 

see  talipes  for  osteotomy  of,  police- 
man's heel,  ostitis  of,  in  flat-foot, 
etc. 

magnum,    dislocation    of,    see    tarsal 
bones 
Osmic  acid,  injection  for  neuralgia,  227 
Ossicles  of  ear,  necrosis  of,  376 
Ossification  of  muscle,  236,  143 
Ostitis  deformans,  see  osteoarthritis 

tuberculous,  290 

typhoid,  287 
Osteoarthritis,  322,  316 
Osteoarthropathy,  hypertrophic,  pulmonar\', 

285 
Osteoblasts,  250 
Osteochondritis,  sj-philitic,  291 
Osteoclasis,  617 
( )stC{H  lasts,  290 
( )stco(.()pic  pains,  127,  291 
Osteoma,  43,  see  also  special  regions 


INDEX. 


667 


Osteomalacia,  293,  247,  2,  3,  296 
Osteomyelitis,  285,  3 

acute  infectious,  285,  2,  287 

chronic,  286 

gummatous,  291 

multiple,  286 

recidiva,  286 

septic,  285 

syphilitic,  291,  287,  132 

tuberculous,  290 

typhoidal,  287 
Osteoperiostitis,  285 
Osteophytes,  322,  285,  324 
Osteoplastic  amputations,  Bier's,  637 
Moschcowitz,  636 
SabanejefPs,  638 

resection  of  nose,  393 

skull,  335 

spine,  ^59 
Osteoporosis,  200,  284 
Osteopsathyrosis,  293 
Osteosarcoma,  294^  147 
Osteosclerc>sis,  287,  284 
Osteotomy,  Adam's,  325 

cuneiSform,  617 

for  bow-legs,  617 

CoUes  fracture,  268 

flat-foot,  621 

hallux  valgus,  622 

knock-knee,  617 

talipes,  619 

Macewen's,  617 

subtrochanteric,  325 
Osteitis,  chronic, 287 

condensing,  284,  287 

deformans,  294,  247,  296 

rarefying,  290,  284 

tuberculous,  290,  316 
Othematoma,  375 
Otitis,  complications  of,  376,  379 
Ovaries,  606 

apoplexy  of,  607 

atrophy  of,  607 

cirrhosis  of,  606 

congenital  malformation,  606 

cysts  of,  607,  149 

hematoma  of,  607 

hemorrhage  from,  607 

inflammation  of,  606 

prolapse  of,  606 

removal  of,  603,  293 

tuberculosis  of,  607 

tumors  of,  607 
Ovarian  cysts,  607 

complications  of,  609 
diagnosis  of,  610 
symptoms  of,  609 
treatment  of,  6n 

dermoids,  608,  610,  149 

dysmenorrhea,  600 

hydrcx:ele,  6og 

pregnancy,  604 
Ovaritis,  606 


Ovariotomy,  611,  293 
Oxybutyric  acid,  82 

Oxygen  combined   with  ether  or  chloro- 
form, 18 
Ozena,  393 

Pachydermatocele,  141,  330 
Pachymeningitis,  348,  373 
Pagenstecher's  thread,  36 
Paget's  abscess,  71 

disease  of  nipple,  411,  163 
bone,  see  ostids  deformans 
Pain  in  diagnosis,  6 

referred  in  diagnosis,  6 
Painful  heel,  623 

scars,  68 

stump,  627 

subcutaneous  tubercle,  223 
Palate,  cleft,  432 

perforation  of,  434 
Palmar  abscess,  237 

fascia,  contraction  of,  615 

ganglion,  compound,  238 

sac,  237 
Palpation  in  diagnosis,  5 
Panaritium,  see  paronychia 
Pancreas,  affections  of,  495 

calculi  of,  497 

cysts  of,  497 

inflammation  of,  495,  443 

rupture  of,  443 

tumors  of,  497 
Pancreatic  point  of  Desjardin,  497 
Pancreatitis,  495,  2,  443 

varieties  of,  496 
Panhysterectomy,  596 
Panostitis,  acute,  285 
Papillomata,  137 

malignant,  137 
Papillitis,  226 
Paquelin  cautery,  65 
Paracentesis  abdominis,  449 

auriculi,  174 

pericardii,  176 

thoracis,  407 

vesicae,  542 
Paracolpitis,  581 
Paraffin,  use  of,  for  cure  of  deformed  nose, 

389 
prolapse  of  rectum,  521 
Paralysis,  agitans,  361 

after  injur)'  to  brain,  339,  et.  seq. 
spinal  disease,  373 
spinal  injuries,  361 
following  injur}'  to  nerves,  223 
infantile,  374,  2,  319 
intestinal,  472 
p<)st-anesthciic,  22,  231 
Paralytic  torticollis,  380 
Parametritis,  612 
Paraphimosis,  560 
Parasitic  cysts,  14Q 
organisms,  27 


$68 


INDEX. 


Parasyphilis,  128 
Parathyroid  glands,  382 

tetany,  382 
Parench>Tnatous  goiter,  384 

hemorrhage,  195 

inflammation,  59 
Paresis,  222 

Parietooccipital  fissure,  332 
Paronychia,  164,  126 
Paroophoron  cysts,  608 
Parotid  gland,  excision  of,  424 

lymph  gland,  affections  of,  424 

tumors,  423,  143 
Parotitis,  423 
Parovian  cysts,  608 
Parrot's  nodes,  291 
Passage  of  urethral  bougies,  555 
Passive  incontinence  of  urine,  542 
Pasteur's  treatment  of  hydrophobia,  117 
Patella,  dislocation  of,  309 

fractures  of,  278 
Pathetic  nerve,  affections  of,  226 
Pathogenic  organisms,  27 
Pathological  dislocations,  298 

fracture,  246 
Payr's  treatment  of  inoperable  angioma,  145 
Pelvic  cellulitis,  612 

hematocele,  613 

hematoma,  613 

peritonitis,  611 
Pelvis,  dislocation  of,  306 

fracture  of,  271 
Penis,  afiFections  of,  548 

amputation  of,  560 

balanitis  of,  560 

congenital  malformation,  548 

chancre  of,  122 

chancroid  of,  559 

epithelioma  of,  560,  139,  162 

extirpation  of,  561 

herpes  of,  1 24 

paraphimosis  of,  560 

phimosis  of,  559 

warts  of,  559 
Peptic  ulcers,  453 

of    jejunum    following    gastroenteros- 
tomy, 465 
Percussion  in  diagnosis,  7 
Perforating  ulcer  of  duodenum,  468,  97 
of  foot,  673,  75 
of  stomach,  454 

typhoid  ulcer,  469 
Perforative  appendicitis,  484 

peritonitis,  447,  4 
Periarteritis,  183 
Pericardial  effusions,  176 
Pericarditis,  175,  405 
Pericardium,  174 
Pcricanlotomy,  176 
Perigastric  adhesions,  455 

inflammation,  455 
Perineal  cystotomy,  547 

fistula,  555 


Perineal  hernia,  511 

lithotomy,  547 

prostatectomy,  572 
-  relaxation,  577 

section,  547 
Perineorrhaphy,  577 
Perinephritic  abscess,  531 
Perinephritis,  530 
Perineum,  laceration  of,  577 
Periosteal  nodes,  291 

sarcoma,  294 
Periostitis,  285,  287 
Peripheral  neuritis,  623 
Periphlebitis,  177 
Periproctitis,  517 
Perirectal  suppuration,  517 
Peritoneal  bands,  471 
Peritonitis,  446 

acute  diffuse,  447 

acute  localized,  446 

chronic  simple,  448 

pelvic,  611 

perforative,  446,  4 

tuberculous,  449,  2 
Periurethral  abscess,  554 
Permanent  torticollis,  380 
Permanganate  of  pota^,  33 
Pernicious  anemia,  195 
Pernio,  99 

Peroneal  artery,  ligation  of,  217 
Peronei  tendons,  tenotomy  of,  241 
Peroxid  of  hydrogen,  33 
Pertussis,  397 
Pes  cavus,  621 

planus,  620 
Pesquin's  operation  for  aneurysm,  193 
Pessaries,  590,  592 
Petechias,  87,  4,  105 
Petit's  tourniquet,  199 
Petrosal  sinus,  hemort-hage  from,  376 

thrombosis  of,  350 
Phagedena.  77,  123,  559 
Phagocytosis,  29 
Phalanges,  amputation  of,  627,  633 

dislocation  of,  305 

fracture  of,  284,  270 
Phantom  tumor  of  abdomen,  445 
Pharyngocele,  435 
Phar\'ngotomy,  subhyoid,  400 

transhyoid,  400 
Phar>'nx,  epithelioma  of,  139 
Phelps'  operation  for  talipes,  619 

for  varicose  veins,  181 
Phenol,  see  carbolic  acid 
Phimosis,  559,  2,  354 
Phlebectasia,  179 
Phlebitis,  177 
Phleboliths,  170 
Phleborrhaphy,  202 
Phlebosclerosis,  178 
Phlebotomy,  181 
Phlegmasia  alba  dolens,  177 
Phlcgmone  ligneuse  du  cou,  381 


INDEX. 


669 


Phlegmonous  erysipelas,  109 

inflammation,  60 

suppuration,  11 1 
Phloridzin  test  of  kidney  function,  526 
Phosphorous  bums,  99  • 

poisoning,  195,  3 
■  Phosphorus  necrosis  of  jaw,  287,  429 
Photophobia,  348 
Phrenic  nerve,  injury  of,  230 
Physical  examination,  in  diagnosis,  i 
Physometra,  582 

Picric  acid  in  treatment  of  bums,  98 
Piles,  see  hemorrhoids 
PirogofTs  amputation,  635 
Pituitary  body,  tumors  of,  353 
Placenta,  retained,  104 
Plague,  30 

Plantar  fascia,  tenotomy  of,  242 
Plantaris  muscle,  mpture  of,  236 
Plasmodium  malarise,  31 
Plaster-of-Paris  splints,  56,  251 
Plastic  inflammation,  59 

linitis,  459 

surgery,  167 
Pleiad  of  Ricord,  123 
Pleural  cavity,  affections  of,  405 
aspiration  of,  407 
effusion  into,  406 
tapping  of,  407 
Pleurectomy,  409 
Pleuropneumonia,  172 
Pleurosthotonos,  113,  8 
Pleurisy,  405,  5,  257 
Plexiform  angioma,  144,  186 

neuroma,  223 

sarcoma,  148 
Pneumatocele,  347 
Pneumectomy,  410 
Pneumocele,  405 
Pneumococcal  arthritis,  315 

empyema,  407 
Pneumococcus,  69,  285,  406 
Pneumogastric    nerve,  affections   of,    229, 

38s 

Pneumohemothorax,  174,  404 

Pneumolysis,  410 

Pneumonia,  10,  30,  106,  108,  175,  257,  348, 

405,  382 
Pneumothorax,  405,  257 
Pneumotomy,  409 
Points  douloureux,  222,  227 
Poisoned  wounds,  95 
Poisoning,  alcohol,  340,  221 

arsenic,  221 

bichlorid  of  mercur>',  32 

blood,  103 

carbolic  acid,  ^^ 

chloroform,  20,  108 

cocain  hydrochlorid,  23 

er»ot,  82,  4 

iodin,  ^^ 

iodoform,  34,  108 

lead,  352 


Poisoning,  opium,  340 

phosphorous,  195,  3 

snake,  96,  5 

strychnia,  114,  9 
Policeman's  heel,  623 
Polycythemia,  8,  97 
Polydact}'lism,  614 
Polymastia,  410 

Polymorphonuclear  leukocytes,  9 
Pol)Tnyositis,  236 
Polyorchism,  561 
Polypi,  141,  393 

see  special  regions 
Pond-shaped  fracture,  341 
Popliteal  artery,  compression  of,  200 
ligature  of,  215 

bursa;,  245 

nerve,  injury  of,  see  intemal  and  ex- 
ternal 
Post-anal  dimple,  see  spina  bifida  occulta 

gut,  366 
Post-anesthetic  paralysis,  221,  231 
Post-calcaneal  bursitis,  623 
Posterior  gastroenterostomy,  463 

thoracic  nerve,  injury  of,  231 

tibial  artery,  compression  of,  200 
ligature  of,  215 
Post-febrile  gangrene,  82 
Post-mortem  wounds,  95 
Post-nasal  adenoids,  see  adenoids 
Post-operative  backache,  43 

dressings,  43 

fever,  43 

hemorrhage,  43 

hernia,  511 

intestinal  obstmction,  43 

phlebitis,  177 

retention  of  urine,  42 

shock,  42 

sepsis,  43 

thirst,  42 

treatment,  42 

vomiting,  42 
Post-pharyn^eal  abscess,  435,  373,  2 
Posture  in  diagnosis,  8 
Potassium  permanganate,  ^^ 
Pott's  disease,  369 

fracture,  281,  311 

gangrene,  80 
Poultice,  64 

Precancerous  dermatoses,  163 
Precentral  sulcus,  332 
Precipitins,  29 
Pregnancy,  610,  179,  368 

abdominal,  604 

ectopic,  604 
Preliminary  colostomy,  522 

tracheotomy,  400 
Preparation  of  instruments,  34 

patients  for  operation,  38 
Prepatellar  bursa,  245 
Prepuce,  incision  of,  560 
Presenile  gangrene,  81 


670 


INDEX. 


Pressure,  gangrene  following,  84,  80,  249, 
199,  63,  46 

ulcers,  74,  75 
Priapism,  359 
Primary  anesthesia,  17 

hemorrhage,  195 

union  of  wounds,  67 
Private  house,  operation  in,  43 
Probes,  telephonic,  92 
Proctectomy,  522 
Proctitis,  517,  6 

gonorrheal,  351 
Proctodeum,  515 
Proctolysis,  448 
Proctopexy,  521 
Profeta's  law,  122 
Progressive  muscular  atrophy,  368 

pernicious  anemia,  195 
Prolapse,  see  special  organs 
Proliferous  mammary  cyst,  413 
Proptosis,  see  exophthalmos 
Prostate,  aflFections  of,  569,  6 

carcinoma  of,  573 

hemorrhage  from,  527 

hypertrophy  of,  569 
Prostatectomy,  572 
Prostatitis,  569 
Prostatorrhea,  569 
Prostatotomy,  571 
Protopathic  nerve-fibers,  224 
Protozoa,  31 
Proud  flesh,  67,  78 
Pruritus  ani,  517 

vulvae,  575 
Psammoma,  147 
Pseudoarthrosis,  299,  253 
Pseudoelephantiasis,  180 
Pseudohermaphrodisra,  575 
Pseudohydrophobia,  117 
Pseudohypertrophic  paralysis,  368 
Pseudoleukemia,  220,  498 
Pseudomembranous  inflammationj  60 
Pseudotrichinosis,  236 
Psoas  abscess,  370,  373,  246 
Psoriasis  linguai,  425 

syphilitic,  127 
Ptomains,  27 
Ptosis,  226,  351 
Ptyalism,  129 

Pubic  dislocation  of  hip,  306 
Pudendal  hernia,  511 
Puerperal  f)eritonitis,  see  p)eritonitis 
Pulmonar)'  alveolar  emphysema,  410 

decortication,  409 

embolism,  172 

g\Tnnastics,  409 

hemorrhage,  405 

hypertrophic  osteoarthropathy,  285 
Pulpv  degeneration  of  synovial  membrane. 

Pulsating  empyema,  406 
tumors  of  bone,  2g4 
tumors  of  scalj),  330 


Pulsation,  in  diagnosis,  5 
Pulse  in  diagnosis,  8 
Pulsus  paradoxus,  175 
Punctured  fracture,  247 

•  wounds,  91 
Purpura  hemorrhagica,  195,  391 
Purulent  infiltration,  iii 

inflammation,  60 
Pus,  69 

Pusey's  treatment  for  nevi,  145 
Pustule,  malignant,  117,  118 
Pyelitis,  529  , 

I^elography,  524,  525 
I^lonejmntis,  530 
Pyelotomy,  537 

I^emia,  105,  5,  iii,  175, 177,  183,  236,  349, 
382 

actinomycotic,  120 

acute,  106 

chronic,  106, 

in  dbeases  of  bones,  285 
of  the  ear,  376 

in  joint  diseases,  313,  315 

lateral  sinus,  349,  178 
Pyemic  abscess,  71 

synovitis,  313 
Pylephlebitis,  105 
Pylorectomy,  466 
Pylorodiosis,  465 
Pyloroplasty,  465 
Pylorospasm,  456 
Pylorus,  stenosis  of,  455 

congenital,  452 

tumors  of,  456 
Pyogenic  bacteremia,  104 

bacteria,  68.  348 

infections,  103 

membrane,  72 

toxemia,  104 
Pyometra,  582 
Pyonephrosis,  530,  362 
Pyo  pericarditis,  176 
Pyorrrhea  alveolaris,  429 
Pyosalpinx,  602 
Pyothorax,  406 
Pyrexia,  104 
Pyuria,  527 

Quenu's    operation    for    excision    of    th< 

rectum,  523 
Quiet  necrosis,  287 
Quinsy,  434 
Quilled  suture,  89 

Rabic  tubercles  of  Babes,  116 
Rabies,  115 

Racemose  adenoma,  138 
aneurysm,  144,  186 
Rarhisrhisis,  364 
Rachitic  msary,  292 
Rachitis,  see  rickets 
Racquet  method  of  amputation,  626 


INDEX. 


671 


Radial  artery,  compression  of,  200 

ligation  of,  212 
Radicular  odontoma,  145 
Radiograph,  11 
Radiography,  10 
Radius,  congenital  absence  of,  614 

dislocation  of,  304 

fractures  o^  267 

separation  of  lower  epiphysis,  269 

subluxation  of  head  of,  304 
Radius  and  ulna,  fractures  of,  269 
Railway  brain,  361 

spine,  361 
Randolph  bandage,  77 
RansohofiF's  arterial  anesthesia,  24 

discission  of  the  lungs,  409 
Ranula,  423,  149 
Rarefaction  of  bone,  290,  284 
Rashes  of  bichlorid  of  mercury,  106 

carbolic  acid,  106 

ether,  106 

iodoform,  106 

septic  105,  106 

syphilis,  125,  127 
Ray  fungus,  1 19 
Raynaud's  disease,  82,  2.  4,  80 

gangrene,  82 
Reactionary  fever,  103 

hemorrhage,  195 
Reactions  of  degeneration,  224 
Receptors,  29 

Recklinghausen's  disease,  223 
Rectal  anesthesia,  18 

hernia,  511 

lever,  Davy's,  638 
Rectocele,  577 
Rectovaginal  septum,  laceration  of,  577 

fistula,  580 
Rectovesical  fistula,  580 
Rectum,  absence  of,  516 

affections  of,  515,  6 

atresia  of,  516 

carcinoma  of,  522,  2 

cellulitis  about,  517 

colostomy  in  carcinoma  of,  522 

congenital  malformation  of,  515 

control  of  hemorrhage  form,  198 

excbionof,  522 

imperforate,  516 

inflammation  of,  517 

polypi,  521,  2 

prolapse,  520 

sterilization  of,  39 

stricture  of,  521 
Rectum,  syphilis  of,  521 

tuberculous  disease  of,  521 

tumors  of,  521 

ulcers  of,  521 
Rectus  abdominis  muscle,  diastasis  of,  511 
Recurrent  appendicitis,  485 

hemorrhage,  195 

laryngeal   nerve,   pressure  upon,  385, 
189 


Red  blood  corpuscles,  8 

basophilic  granulations  in,  10 
in  inflammation,  59 
Redness  in  inflammation,  60 
Redness,  in  diagnosis,  4 
Reducible  hydrocele,  566 

swellings,  503 
Reduction  en  bloc,  of  a  hernia,  502,  474 
en  masse  of  a  hernia,  502 
of  fracture,  250 
Reef  knot,  90,  205 
Reel  feet,  618 
Referred  pain,  6 

in  hip  disease,  318 
renal  disease,  532 
spinal  caries,  369 
vesical  calculus,  545 
Reflex  anuria,  527,  532 

inflammation,  60 
Regeneration,  66 
of  brain,  345,  68 
glandular  organs,  68 
lymphatic  tissue,  68 
nerves,  225,  68 
spinal  cord,  68,  362,  364 
Rehn's  method  of  controlling  hemorrhage 

whUe  suturing  the  heart,  175 
Reid's  method  of  compressing  aneurysms, 

191 
Relapsing  appendicitis,  486 
Renal  calculus,  532,  see  kidneys 
colic,  532 
hematuria,  526 
Repair,  66 

granulation,  66 
healing  by  first  intention,  66 
second  intention,  66 
third  intention,  66 
of  bone,  250,  68 
blood  vessels,  68 
fractures,  250 
muscles,  68 
tendons,  68 
primary  union,  67 
phenomena  of,  66 
Reposition  of  a  retroverted  uterus,  589 
Resection,  see  special  regions 
Residual  abscess,  7 1 

urine,  570,  571,  543 
Resolution  in  inflammation,  59 
Respiration,  artificial,  20,  21 

Cheyne-Stokes,  339,  351,  352 
Respiratory  system,  surgery  of,  387 

difficulties  during  anesthesia,  20 
Restoration   of   function   in    treatment   of 

fractures,  251 
Retained  placenta,  104 

testis,  561 
Retention  cysts,  149 
of  fractures,  251 
of  urine,  542,  42 
Retinal  hemorrhage,  404 
Retinochoroiditis,  127 


672 


INDEX. 


Retrocalcaneal  bursa,  623 
RetrocoUis,  380 
Retroflexion  of  uterus,  588 
Retrograde  embolism,  171 
Retrograde  strangulated  hernia,  513 
Retroperitoneal  abscess,  450 

hernia,  512 

tumors,  452 
Retropharyngeal  abscess,  435,  370 
Retroversion  of  uterus,  588 
Reverdin's  method  of  skin  grafting,  168 
Rhabdomyoma,  144 
Rhagades,  132 
Rheumatic  arthritis,  321 

gout,  see  osteoarthritis 

synovitis,  313 

torticollis,  380 
Rheumatism,  gonorrheal,  315,  286 
Rheumatoid  arthritis,  see  osteoarthritis 
Rhigolene,  22 
Rhinitis,  3g3 

gonorrheal,  551 
Rhinolith,  392 
Rhinophyma,  387 
Rhinoplasty,  387 
Rhinoscleroma,  387 
Rhinoscopy,  393 
Ribs,  cervical,  381 

dislocation  of,  306 

fracture  of,  256,  7 

resection  of,  408 
Rice  bodies,   238,   245,  317,  324,  see  also 

melon-seed  IxKlies 
Richter's  hernia,  499 
Rickets,  291,  2,  221,  247 
Rickety  rosar)',  292 
Rider's  bone,  236 
Riedel's  lobe  of  liver,  490 
Rigg's  disease,  429 
Risus  sardonicus,  113,  8 
Riziform  bcxlies,  see  rice  bodies 
Roberts'  operation  for  frarturc  of  patella, 

280 
Roberts'  pins,  254,  391 
Robson's  point,  492 
Rodent  ulcer,  162,  139,  13 
Rolando,  fissure  of,  331 
Rontgen  rays,  10 

burns,  acute,  14 
chronic,  14,  163 

danger  from,  13,  14 

detection  of  foreign  Ixxlies,  12,  92,  346 
renal  calculus,  533,  12 
vesical  calculus,  12 
ureteral  calculus,  534 

diagnosis,  12 

of  diseases  of  bone,  295 
fractures,  12,  249 
pericanlial  effusions,  176 

gangrene  following,  13,  85 

interpretation  of  pictures,  11,  12 

stereoscopic  plates,  13.  14 
therapeutic  effects  of,  13 


Rontgen,  treatment  of  acne,  13 
actinomycosis,  120 
blastomycosis,  158, 13 
carcinoma,  13,  162,  140 
comedo,  13 
favus,  13 

foiter,  449»  13 
lodgkin's  disease,  221 
hypertrichosis,  13 
keloid,  163 
lupus,  13,  135,  161 
rodent  ulcer,  13,  140,  i6a 
sarcoma,  148,  13 
sarcoma  of  skin,  163 
tenia  barfoe,  13 
tonsurans,  13 
Rosary,  rachitic,  292 
Rose  position,  418 

operation  for  the  removal  of  tfai 
serian  ganglion,  228 
Rotch*s  sign,  176 
Round-cefied  sarcoma,  146,  294 
Round  ligament,  hydrocele  of,  567 

shortening  of,  590,  591 
Roux's  gastroenterostomy,  464 
Rubber  gloves,  38 

sterilization  of,  38 
Rubefacients,  65 
Run  around,  164 

Rupert  apparatus  for  anesthesia,  17 
Rupia,  126 
Rupture,  see  hernia 
Ru])ture  of  organs  and  tissues,  see 

regions 
Rydygier's  method  of  splenopex>',  4 

Sabre  blade  deformity,  617 
Saccharomyceles,  3 1 
Sacculated  aneurysm,  188 
Sac  of  hernia,  499 
Sacral  cysts,  366 

I)lcxus,  injuries  to,  234,  271 

tumors,  congenital,  366 
Sacrococcygeal  fistuUe,  366 

tumors,  366 
.  Sacroiliac  joint,  tuberculosis  of,  3 
366 
Sacrum,  fractures  of,  271 

s;ircoma  of,  366 
Sahli's  sign  of  pancreatitis,  497 
Saline  infusion,  182 
Salivary  calculus,  423 

fistula,  424 

glands,  affections  of,  423 
Salivation,  see  ptyalism 
Salpingitis,  Ooi 

Salpinj^o-oophorectomy,  see  oopho 
Salpingostomy,  603 
Salt  solution,  normal,  37 
Salvarsan,  130 
Saprcmia,  104 
Saprophytes,  27,69 
Sarcinie,  sec  ba<  teria 


INDEX. 


673 


,  syphilitic,  563,  127 
146 

>lar,  147,  160 
dve  action  of  erysipelas  on,  148 

'63 

see  also  special  regions 

osis,  146 

ch*s  operating  cabinet,  406 

iiy  mast,  372 

cr  jacket,  372 

ment  of  fracture  of  clavicle,  259 

:ectionsof,  329 
lethods  of  holding,  41 
bone,  bipartite,  270 
cision  of,  270 
icture  of,  270 
alatum,  614 
enital  elevation  of,  614 
cation  of,  614 
lire  of,  259 
;ed,  614,  301 
a,  surgical,  106 
al  arthritis,  315 

triangle,  ligation  of  femoral  artery 
in,  214 
'ections  of,  68 

operation  for  varicose  veins,  181 
thoracoplasty,  409 
rcetes,  see  bacteria 
s  local  anesthesia,  23 
treatment  of  ulcers,  77 
e*s  operation  for  mastoid  disease, 

377 

«-Stacke    operation    for    mastoid 

disease,  378 

'tery,  ligation  of,  213 

islocation  of  hip,  306 

lia,  511 

e,  operation  on,  234 

234,  3i« 

,  carcinoma,  139,  415 

r,4i5 

e  special  i^gions 
treatment  of  anthrax,  119 
of  bone,  287 
s,  gonorrheal,  551 
366,  3,  380 

lin-morphin  anesthesia,  20 
:  ulcers,  75 
ouche,  64 

133 

lerma,  161 

imors,  general  diagnosis  of,  564 
lia,  501 
/  bandage,  53 
nfantile,  292 
ets,  292 

IS  cysts,  149,  163 
I,  164 

ry  hemorrhage,  1 96 
ction,  28 


Secondaiy,  neurorrhaphy,  225 

perineorrhaphy,  577 

sarcoma  of  bone,  294 

syphilis,  125 

union  of  wounds,  67 
Section,  abdominal,  440 

of  nerves,  223 

perineal,  547 
SediUot's  excision  of  tongue,  428 
Segregation  of  the  intestine,  483 
Segregators,  urine,  525 
Semilunar  cartilage,  displacement  of,  310 
Semimembranous  tendon,  tenotomy  of,  243 
Seminal  vesicles,  affections  of,  568 
Semitendinosus  tendon,  tenotomy  of,  243 
Senile  atrophy  of  bone,  293 

enlargement  of  prostate,  569 

gangrene,  80 

tuberculosis,  133 
Senn's  decalcified  bnone  chips,  338,  288 

method  of  amputation  of  the  hip,  640 

operation  for  floating  kidney,  536 
Sentinel  pile,  517 
Separation  of  epiphyses,  247 
Sepsis,  103 

diagnosis  of,  106 
Septic  arthritis,  315 

emboli,  see  pyemia 

intoxication,  104   106,111,315 
chronic,  73,  104 
Septicemia,  104 
Septum,  lateral  deviation  of,  391 

nasi,  fracture  of,  253 
Sequestration  dermoids,  149 
Sequestrotomy,  288 
Sequestrum,  287 
Serotherapy,  29 
Serous  cysts,  149 

inflammation,  59 

membranes,  inflammation  of,  6 

synovitis,  313 
Serum,  antidiphtheritic,  66,  107 

antistreptococcic,  107 

disease,  30 
Seventh  nerve,  affections  of,  229 
Sex,  in  diagnosis,  2 
Shape  of  lesion  in  diagnosis,  4 
Shock, loi 

Short-circuiting  operation  on  intestine,  483 
Shoulder,  amputation  through,  630 

ankylosis  of,  3  25 

congenital  elevation  of,  614 

dislocation  of,  301 

effusion  into,  3 14 

excision  of,  3  27 

osteoarthritis  of,  322 

tuberculosis  of ,  317 
Side-chain  theory  of  Ehrlich,  29 
Silicate  of  soda  dressing,  56 
Silk,  35 

Silkworm  gut,  35 
Silver,  sahs  of,  34 

wire,  36 


674 


INDEX. 


Simple  carcinoma,  139 

dislocation,  298 

fracture,  246 

goiter,  384 

inflammation,  59 

ulcer,  74 
Sims'  position,  573 

speculum,  573 

uterine  curette,  586 
Sinus,  78 

see  also  special  regions 
Sitz  bath,  64 
Situation  of  lesion,  in  diagnosis,  4 

of  tumors  in  diagnosis,  153 
Sixth  nerve,  injuries  of,  22^^ 
Size  of  lesion,  in  diagnosis,  4 
Skey's  method  of  amputating  foot,  633 
Skiagraph,  11 

Skiagraphy,  see  Rontgen  rays,  10 
Skin,   anesthesia  of,   following   section   of 
nerves,  224 

color  of,  changes  in,  4 

grafting,  168 

preparation  of,  for  operation,  39 

surgery  of,  158 

tuberculosis  of,  160 

tumors  of,  162 
Skinner's  inhaler,  18 
Skull,  atrophy  of,  293,  291 

fracture  of,  339,  229,  391,  345 
base,  342,  255 
vault,  341 

gunshot  injuries  of,  345,  342,  92 
Skull,  natiform,  132 

trephining  of,  335 
Sleeping  sickness,  31 
Sliding  hemia,  499 
Slough,  79 
Sloughing,  7Q 

Small  sciatic  nerve,  affections  of,  234 
Smell,  sense  of,  in  diagnosis,  7 
Smith's,  Nathan  R,  splint,  276 

Stephen,  clamps  for  hemorrhoids,  520 
treatment  of  dislocation  of  shoulder, 

Snake  bites,  96,  195 

Ix)isoning,  96,  5,  33 
Snap-tinger,  615 
Snare,  393 

Snutfles  in  syphilis,  132 
Social  condition,  in  diagnosis,  2 
Soft  carcinoma,  139 

chancre,  see  chancroid 
Sodium  cacodylate  for  syphilis,  130 
Solar  }jlexus  blow,  404 
Sole,  perforating  ulcer  of,  623 
Solitary  kidney,  523 
Sonncnburg's  operation  for  ectopia  vesica". 

Soot  warts,  163 
Sounds,  sec  special  regions 
SournHng  the  urinary  bladder,  method  of, 
545 


Spasmodic  croup,  397 

stricture  of  urethra,  554 
stump,  627 
torticollis,  380 
Spasm  of  esophagus,  439 

intestine,  472 
Spastic  ileus,  472 
Specific  inflainmation,  59 

ulcer,  74 
Spence's  amputation  at  shoulder  joint,  630 
Spermatic  cord,  hematocele  of,  567 
hydrocele  of,  567 
torsion  of,  562 
Spermatocele,  567 
Sphacelus,  79 
Sphacelation,  79 

Sphenoidal  sinuses,  diseases  of,  395 
Sphygmomanometer,  10 
Spiller-Frazier  operation  for  the  removal  of 

the  Gasserian  ganglion,  229 
Spina  bifida,  364 

anterior,  365 
occulta,  364 

ventosa,  see  tuberculous  dactylitis 
Spinal  accessory  nerve,  afFections  of,  230 
stretching  of,  380 
anesthesia,  24 
caries,  369 
curvature,  366 
hemorrhage,  364,  360,  361 
localization,  354 
membranes,  tumors  of,  374 
meningitis,  373 
neurasthenia,  360 
puncture,  see  lumbar  puncture 
rickets,  366,  292,  368 
traumatic  neurosis,  360 
cord,  compression  of,  361,  360 
concussion  of,  360,  361 
contusion  of,  360 
diseases  of,  374,  8 
edema  of,  361 

hemorrhage'into,  364,  361,  360 
injuries  of,  360 

pressure  on,  in  Pott's  disease,  371 
total  transverse  lesion  of,  355 
tumors  of,  374 
wounds  of,  364 
Spindle-celled  sarcoma,  147 
Spine,  abscess  from,  373 

aneurysmal  erosion  of,  368 

ankylosis  of,  322 

caries  of,  369 

concussion  of,  360 

congenital  malformation  of,    364,  366 

curvatures  of,  366 

deformities  of,  366,  3 

diseases  of,  364 

dislocations  of,  363 

fracture  of,  361 

fracture-dislocation  of,  361 

injuries  of,  360 

osteoarthritis  of,  369 


INDEX. 


675 


Spine,  osteomyelitis  of,  369 

sprains  of,  360 

surgery  of,  354 

tuberculosis  of,  369 

tumors  of,  366,  6 
Spiral  fracture,  246 
Spirilla,  see  bacteria 
Spirocheta  pallida,  121,  31,  124 
Splanchnoptosis,  470 
Splay  foot,  see  flat-foot 
Spleen,  affections  of,  497 

rupture  of,  443 
Splenectomy,  498 
Splenic  anemia,  498 

fever,  117 
Splenomegaly,  498 
Splenopexy,  498 
Splenoptosis,  497 
Splint  pressure,  causing  gangrene,  250,  251, 

80,  84 
Splintered  fracture,  246 
Splint,  251 

Agnew,  261 

Bond,  261 

Dupuytren,  261 

Hodgen,  276 

intci^ental,  255 

Gooch,  251 

Hammond,  255 

Levis,  269 

Matas,  256 

Mc  Intyre,  276 

Moriarty's,  256 

Smith,  276 

Stromeyer,  265 

Thomas,  hip,  274 
knee,  321 

Van  Arsdale,  277 
Spondylitis,  369 

deformans,  369 
Spondylolisthesis,  368 
Spondylosis  rhizomelique,  322 
Six)nges,  preparati<m  and  sterilization  of, 

37 
Spontaneous  dislocation,  297 

fracture,  246 

gangrene,  81 

hemorrhage,  195 

hemostasis,  196 
Spores,  see  bacteria 
Sprains  of  joints,  296 
Sprengel's  deformity,  614 
Spurious  meningocele,  330 

valgus,  see  flat-fot:)t 
Squamous  epithelioma,  139 
SabanejelT's  amputation  of  femur,  638,  639 
Stab  wounds,  91 
Stiic  kc's    operation    for    mastoid    disease, 

Stains,  gunpowder,  93 

Stamm-Kader  operation   of    gastrostomy, 

460 
St.  Anthony's  fire,  109 


Staphylococcic  infections,  25,  285,  406 
Staphylococcus  pyogenes,  albus,  68 

aureus,  68,  159 

cereus  albus,  68 

citreus,   68 

epidermidis  albus,  68,  90 

flavescens,  69 
Staphylorrhaphy,  432 
Starch  bandages,  57 
Starting  pains,  317,  319 
Static  machine,  10 
Status  lymphaticus,  221,  386 
Status  presens,  2 
Stay  knot,  205 
Stellate  fracture,  246 
Stellwag's  sign,  386 
Stercoraceous  vomiting,  473 >  7 
Sterility,  60 1 

Stereoscopic    plates,    in    X-ray  diagnosis, 
12,  13,  249,  533 

localizing  foreign  bodies,  12 
Sterilization,  31  ' 

chemical,  32 

fractional,  35 

mechanical,  31 

of  bladder,  39 

of  Cargile  membrane,  37 

of  catheters,  37 

of  cotton  goods,  37 

of  dressings,  37 

of  ear,  39 

of  enamel  ware,  37 

of  gloves,  38 

of  glass,  37 

of  hands,  37 

of  hard  rubber,  37 

of  instruments,  34 

of  mouth,  39 

of  normal  salt  solution,  37 

of  oiled  silk,  37 

of  paraffin  paper,  37 

of  patient,  skin  of,  39 

of  rectum,  39 

of  rubber  tissue,  37 

of  silver  foil,  37 

of  soft  rubber,  37 

of  sutures  and  ligatures,  35 

of  syringes,  37 

of  vagina,  39 

of  water,  37 

thermal,  31 
Sternomastoid  in  torticollis,  380 

division  of,  381 
Sternum,  dislocation  of,  306 

fractures  of,  258 

necrosis  of,  258 
Stertorous  respiration,  340,  349 
Stewart's  enterostomy,  478 

operation  for  inguinal  hernia,  505 
Sthenic  inflammation,  59 
Stimson  and  Weir's  method  of  sterilization 

of  hands,  38 
Stings  of  insects,  95 


676 


INDEX. 


Stomach,  absorptive  power  of,  testing,  458 

affections  of,  452 

bilocular,  456 

carcinoma  of,  458 

congenital  stenosis  of  pylorus,  452 

dilatation  of,  457 

foreign  bodies  in,  453 

hourglass,  456 

lavage  of,  459 

operations  on,  459 

peristaltic  movements,  of  458 

rupture  of,  442 

ulcer  of,  453,  2 
perforation  of,  453 

volvulus  of,  459 
Stomatitis,  429 

gangrenous,  see  noma 

mercurial,  129 
Stone„  see  calculus 
Stovain,  23 

Strabismus,  349,  351,  380 
Strains,  237 

Strangulated  hernia,  513,  83 
Strangulation  of  intestine  by  bands,  471 
Streptobacillus,  see  bacteria 
Streptococcic  infections,  25,  285,  406 
Streptococcus  erysipelatis,  109,  69,  148 

pyogenes,  69,  85,  109 
Streptothrix  madurae,  120 
Stricture,  see  special  regions 
Stromeyer  splint,  265 
Struma,  see  goiter 
Strumous,  133 

lip,  420 
Strumitis,  383 
Strychnin  poisoning,  114,  8 
Stumps,  amputation,  affections  of,  626 
Stupe,  63 
Styptics,  197 
Subaponeurotic  abscess,  330 

hematoma,  329 

lipoma,  330 
Subastragaloid  amputation,  634 

dislocation,  311 
Subclavian  arter}',  compression  of,  199 
ligation  of,  209 

vein,  ligation  of,  380 

vessels,  injuries  of,  259 
Subclavicular  dislocation  of  shoulder,  301 
Subconjunctival  ecchymosis,  404,  342 
Subcoracoid  dislocation  of  shoulder,  301 
Subcutaneous  injection  of  paraffm,  389 
Subdeltoid  bursa,  affection  of,  246 
Subdural  abscess,  350 

hemorrhage,  344 
Subglenoid  dislocation  of  shoulder,  301 
Subhyoid  phar>'ng<>toniy,  400 
Subinvolution  of  uterus,  586 
Subjective  symptoms  in  diagnosis,  i 
Subluxation,  298 

of  head  of  radius,  304 

of  hunuTus,  302 

of  knee,  ^10 


Submammar>'  abscess,  see  breast 
Submaxillary  cellulitis,  see  angina  Ludovici, 
Subphrenic  abscess,  450 
locations  of,  450 
Subperiosteal  fracture,  246 

gummata,  291 

resection  of  joints,  327 

whitlow,  238 
Subserous  lipoma,  see  lipoma 
Subspinous  dislocation  of  shoulder,  301 
Subungual  exostosis,  143 
Suffusion,  87 
Sugillation,  87 
Sulcus,  intraparietal,  332 

precentral,  332 
Sun  stroke,  348 
Superin volution  of  uterus,  587. 
Superior  gluteal  nerve,  affections  of,  234 
Superior  longitudinal  sinus,  thrombosis  of, 

350 

thyroid  artery,  ligation  of,  208 

maxilla,  affections  of,  see  upper  jaw 

maxillary  nerve,  resection  of,  227 
Supernumerary  digits,  614 
Supersensiliveness,  see  anaphylaxis 
Suppression  of  urine,  527 
Suppuration,  68 

pathology  of,  69 

see  also  special  regions 
Supracondyloid  amputation  of  thigh,  637 

fracture  of  femur,  277 
humerus,  263 
Supracoracoid  dislocation  of  humerus,!  301 
Supramammary  abscess,  see  breast 
Supramarginal  convolution,  332 
Suprameatal  triangle,  377 
Supraorbital  ner\'e,  operations  on,  227 
Suprapubic  aspiration  of  bladder,  542 

cystotomy,  546 

lithotomy,  547 

prostatectomy,  572 
Suprarenal  extract,  387,  see  adrenalin 
Supratrochlear     nerve,     operation     upon, 

227 
Supravaginal  hysterectomy,  596 
Surgeon's  knot,  90 
Surgical  emphysema,  405 

kidney,  530 

scarlatina,  106 

technic,  34 
Suture  k  distance,  225 
Suture  of  blood  vessels,  201 
Suture-ligature,  201 
Sutures,  35,  8q 

see  also  special  regions 
Sweep's  cancer,  163 
Sylvester's  artificial  respiration,  20 
Sylvius,  fissure  of,  331 
Symbiosis,  28,  112 
Symc's  amputation.  634 

external  urethn)tomy,  557 

staff,  557 
Symmctrit  al  gangrene,  82 


INDEX. 


677 


S\inond*s   tube   for   esophageal   stricture, 

438 
Sympathetic  ganglia,  cervical,   excision  of, 

387»  354 

inflammation,  60 

nerve,  affections  of,  234 
Symptomatic  hydrocele,  565 
Symptoms,  objective,  i 

subjective,  i 
Sjmcope,  21 

Syncytioma  malignum,  140,  599 
Syndactylism,  615 
Syndesmotomy,  619 
Synechia,  393 
Synorchism,  561 
Synovial  membrane,     pulpy     degeneration 

of,  316 
Sjrnovitis,  acute,  313 

chronic,  314 

gonorrheal,  313 

gummatous,  316 

lipomatosis,  141 

pyemic,  313 

rheumatic,  313 

serous,  313 

syphilitic,  313,  127 

tuberculous,  see  joints 

typhoid,  313 
Syphilides,  125 
Syphilis,  121 

see  also  special  regions 
Syphilitic  arteritis,  185 

fever,  125 
Syphilodermata,  see  syphilides 
Syringes,  sterilization  of,  37 
Syringomyelia,  joint  affections  in,  323 
Syringomyelocele,  365 

T-fracture,  246 

Tachycardia,  386 

Talipes,  617 

Talma's  operation  for  ascites,  490 

Tamponage  of  heart,  175 

Tampons,  vaginal,  602 

Tapping,  see  special  regions 

Tarsectomy,  6iq 

Tarsometatarsal  joints,  amputation  through. 

Tarsus,  amputation  through,  633 

dislocation  of,  312 

fracture  of,  284 

tuberculous  disease  of,  321 
Taxis,  514 
Teale's  amputation  of  leg,  636 

probe  gorget,  558 
Technic  of  modem  surgery,  34 

see  also  special  regions 
Teeth,  carious,  354,  396,  219 

Hutchinson,  132 

in  congenital  syphilis,  132,  4 

in  rickets,  292 

tumors  ill  connection  with,  see  odon- 
toma 


Telangiectatic  sarcoma,  148 
Telephonic  probe,  92 
Temperature,  local,  in  diagnosis,  7 
Temporal  artery,  compression  of,  199 

Ugation  of,  209 
Temporomaxillary  joint,  ankylosis  of,  431 

joint,  arthritis,  suppurative,  376 
dislocation  of,  300 
excision  of,  431,323 
Temporosphenoidal  abscess,  351 
Tenia  barbae,  treatment  with  R6ntgen  rays, 

14 
Tenia  echinococcus,  149 

saginata,  151 

solium,  151 
Tenia  tonsuranus,  treatment  with  R5ntgen 

ra>'s,  i^ 
Tenderness  in  diagnosis,  6 
Tendo-Achillis,  synovitis  of,  623 

tenotomy  of,  240 
Tendons,  affections  of,  237 

displacement  of,  236 

lengthening  of,  243 

operations  on,  239 

rupture  of,  235 

shortening  of,  245 

suppurative,  237 

transplantation  of,  245,  374 
Tendon  sheaths,  diseases  of,  237 
Tenesmus,  6 
Tenoplasty,  243 
Tenorrhaphy,  243 
Tenosynovitis,  237 

tuberculous,  238 
Tenotomy,  239,  56,  251 

see  also  individual  tendons 
Tents  for  dilatation  of  os  uteri,  583 
Teratomata,  148,  149 

of  sacrum,  366 
Testis,  affections  of,  561,  7 

atrophy  of,  565,  561,  562 

congenital  malformation  of,  561 

cysts  of,  566,  149 

ectopic,  561 

fungus  of,  563 

hematocele  of,  567 

hernia  of,  563 

hydrocele  of,  565 

malposition  of,  561 

neuralgia  of,  565 

retained,  561 

syphilis  of,  563 

torsion  of,  562 

tuberculosis  of,  563 

tumors  of,  564,  143 

undescended,  561 
Tetanotoxin,  113,  114 
Tetanus,  112 

risus  sardonicus  of,  8,  1 13 
Tetany,  114 

parathyreouriva,  38a 
Tetracocci,  see  bacteria 
Thecal  whitlow,  237 


078 


INDEX. 


Thecitis,  237,  250 
Thermal  injuries,  97 
*  sterilization.  31 
Thiersch's  fluid,  33 

method  of  skin  grafting,  168 

operation  for  epispadias,  549 
Thigh,  amputation  of,  638 
Third  nerve,  affections  of,  226 
Thomas's  hip  splint,  274,  320 

knee  splint,  321 

wrench,  6iq 
Thoracic  duct,  ligation  of,  217  . 

obstruction  of,  8 

wounds  of,  217 
Thoracoplasty,  409 
Thoracotomy,  408,  404 
Thorax,  surgery  of,  404 
Thrill,  6,  194,  384 
Throat  cut,  382 

Thrombophlebitis,  177,  105,  107, 180 
Thrombosis,  169,  177,  250,  395 

arterial,  185 

gangrene  from,  83,  184 

of  cerebral  sinuses,  349 
cavernous  sinus,  350 
lateral  sinus,  349,  178,  351 
mesenteric  vessels,  452 
petrosal  sinus,  350 
superior  longitudinal  sinus,  350 

venous,  169 
Thrush,  429,  31 
Thumb,  amputation  of,  628 

dislocation  of,  305 

fracture  of,  270 
Thymol  iodid,  34 

Thymus  gland,  enlargement  of,  221 
Thymus  gland,  enlargement  of,  221,  397, 

386 
Thyroglossal  cyst,  379,  149 

fistula,  379 
Thyroid  cysts,  283,  149 
Thyroid  gland,  accessory,  283 

affections  of,  382 
Th>Tcid  dislocation  of  hip,  359,  306 
Thyroidectomy,  385 
Thyroid  extract,  383,  385 
Thyroidism,  383 
Thyroiditis,  383 
Thyroid  tumors,  383 
Thyroid  vessels,  ligation  of,  385,  208 
Thyrotomy,  400 
Tibia,  and  fibula,  fracture  of,  281 

fracture  of,  280 
Tibia,  osttx)iomy  of,  617 

rachitic,  617 

syphilitic,  617 
Tibial  arteries,  see  anterior  and  posterior 
Tibialis  amicus,  tenotomy  of,  240 

posticus,  tenotomy  of,  241 
Tic  convulsif.  226 

douloureux,  226 

facial,  226 
Tinnitus  aurium,  196 


Toe-nail,  ingrowing,  166 
Toes,  amputation  of,  633 

deformities  of,  621 

dislocation  of,  312 
Tongue,  affections  of,  424 

abscess  of,  425 

cancer  of,  426 

chancre  of,  426 

epithelioma  of,  427 

gumma  of,  426 

removal  of,  428 

ulceration  of,  425 
TonsiUotome,  434 
Tonsillotomy,  434 
Tonsils,  affections  of,  434 
Tophi,  322,  245 

Topography,  craniocerebral,  331 
Torsion  fracture,  247 

in  treatment  of  hemorrhage,  200,  42 

of  omentum,  451 

of  ovarian  cyst,  609 

of  spermatic  cord,  562 
Torticollis,  380,  366 
Tourniquets,  199 
Toxemia,  27,  107 
Toxins,  27 
Toxophore,  29 
Trachea,  cicatrices  in,  397 

diseases  of,  396 

foreign  bodies  in,  396 

intussusception  of,  397 

rupture  of,  404 

stenosis  of,  397 

tumors  of,  400 

ulceration  of,  403 

wounds  of,  382 
Tracheotomy,  401 

high,  401 

low,  401 

preliminary,  400 

tubes,  402,  400 
Trachelorrhaphy,  584 
Trachoma,  133 
Transfusion  of  blood,  182 
Transhyoid  phar>'ngotomy,  400 
Transillumination  of  antrum,  395 

stomach,  458 
Transplantation  of  mucous  membrane,  168 
Transverse  fracture,  246 
Traumatic  aneurysm,  186,  188 

arteritis,  184 

asphyxia,  404 

delirium,  109 

dermoid  cysts,  149 

diabetes,  103 

dislocations,  298 

epilepsy,  354 

fever,  103 

fracture,  246 

gangrene,  85 

hemorrhage,  195 

hernia,  499 

hysteria,  361 


INDEX. 


679 


Traumatic,  inflammaiion,  60 
insanity,  354 
meningocele,  330 
neurasthenia,  361 
neuritis,  223 
neuroses,  360 
ulcers,  74 
Trendelenburg's     operation     for     ectopia 
vesicae,  539 

varicose  veins,  181 
position,  596 

tracheal  tampon,  402,  400 
Trephining,  335 

for  epilepsy,  354 

fracture  of  skull,  342,  343 

insanity,  354 

intracranial  abscess,  351 

intrameningeal  hemorrhage,  344 

inveterate  headache,  354 

lateral  sinus  thrombosis,  350 

meningitis,  349 

middle  meningeal  hemorrhage,  344 

332 
puncture  of  lateral  ventricle,  348 
tumors  of  brain,  353 
Treponema  pallida,  121 
Treves'  operation  for  lumbar  caries,  373 
Triangle  of  election,  206 

of  necessity,  206 
Trichiniasis,  236,  10 
Trident  hand,  293 
Trifacial  nerve,  affections  of,  226 

neuralgia,  226 
Trigeminal  ner\'e,  see  trifacial 
Trigger  finger,  615 
Tripod,  Sayre's,  372 
Tripolith  bandage,  56 
Tripperfaden,  551 
Trismus,  113,  431 

nascentium,  114 
Trochanter,  fracture  of,  275 
Tropacocain,  23 
Trophic  gangrene,  84 

changes  following  section  of   nerves, 
224 
Tropical  abscess  of  liver,  488 
True  keloid,  163,  141 
Trusses,  503 

see  special  herniae 

wool,  504 
Trj'panosomiasis,  31 
Tubal  abortion,  604 

gestation,  604 
rupture  of,  604 
Tube,  Crookes,  10 
Tubercle,  133 

anatomical,  161 

bacilli,  see  bacillus 
Tuberculin,  134,  30 
Tuberculocidin,  136 
Tuberculosis,  132 

see  also  special  regions 
Tubes,  Fallopian,  disease  of,  601 


Tubo-ovarian  cysts,  609 
Tubular  adenoma,  138 
Tubulated  aneurysm,  188 
Tubulo-dermoids,  149 
Tuf  nell's  treatment  of  aneurysm,  190 
Tumors,  136 

see  also  various  regions 

diagnosis  of,  151 
Tunica  vaginalis,  hydrocele  of,  565 
Turpentine  stup)e,  63 
Twelfth  nerve,  injuries  of,  230 
Tympanum,  rupture  of,  343 
Typhoid  arthritis,  315 

bacillus,  see  bacillus 
in  gaU-bladder,  287 

osteomyelitis,  287 

spine,  369 

state,  104,  105 

ulcer,  perforation  of,  469 

Widal  reaction,  10,  29 

Ulceration,  74 

see  also  special  regjions 
Ulcerative  appendicitis,  484 
Ulcers,  acute,  75 

caUous,  75,  77 

chancroid,  559,  74 

chronic,  75,  77 

Curling's,  97 

diagnosis  of,  74 

dyspeptic,  425 

eczematous,  77 

embolic,  75 

epitheliomatous,  see  epithelioma 

erethistic,  75,  77 

following  Rdntgen  ray  bums,  14 

glandular  involvement,  76 

gimimatous,  127 

healing,  75 

hemorrhagic,  78 

indolent,  75,  77 

inflamed,  76 

irritable,  77 

Jacob's,  162 

lupoid,  161,  75 

malignant,  74,  75 

Mar  John's,  139,  68 

neuralgic,  75,  77 

of  anthrax,  74 

of  congenital  syphilis,  13a 

of  glanders,  74 

of  leprosy,  74 

pathology  of,  74 

perforating,  of  sole  of  foot,  75 

phagedenic,  77,  75 

pressure,  74,  75 

rodent,  162,  139,  13 

scirrhous,  415 

scorbutic,  75 

simple,  74 

specific,  74 

syphilitic,  127,  74,  75,  161 

traumatic,  74i  75 


63o 


INDEX. 


Ulcers,  treatment  of,  76 

trophic,  75 

tuberculous,  75,  74,  125,  160,  161 

typhoid,  469 

varicose,  180,  74,  75,  77 
see  also  special  regions 
Ulna,  dislocation  of,  304 

fracture  of,  266 
Ulnar  art^y,  compression  of,  200 
ligation  of,  211 

nerve,  dislocation  of,  233 
injury  of,  232,  266 
Umbilical  6stula,  446 

hernia,  509 

sinuses,  446 
Umbilicus,  affections  of,  446 
Undescended  testis,  561 
Ungual  whitlow,  164 
Union  of  fractures,  250,  252 

wounds,  67 
Unna's  treatment  of  ulcers,  77 
Ununited  fractures,  252 
Upper  digestive  apparatus,  417 

extremity,  deformities  of,  614 

jaw,  see  jaw 
Urachal  cysts,  446,  149 
Uranoplasty,  432 
Unreduced  dislocation,  300 
Ureteral  anastomosis,  538 

bougie,  534 

calculus,  532 

fistulae,  528,  580 
Ureteritis,  610 
Ureters,  calculus  in,  532 

impacted,  529 

catheterization  of,  525,  540 

exploration  of,  537 

hemorrhage  from,  527 

ligation  of,  528 

operation  on,  535 

rupture  of,  444 

wounds  of,  527 
Ureterocystostomy,  538 
Uretcroenterostomy,  538 
Ureterolithotomy,  538 
Ureteropyelostomy,  537 
Utero  uterine  fistula,  580 

vaginal  fistula,  580 
Urethra,  abscess  of,  554 

affections  of,  548 

calculus,  impacted  in,  550 

chancroid,  559 

caruncles,  576 

chancre,  124 

congenital  malformation  of,  548 

contusions  of,  550 

false  passage  of,  558 

folliculitis  of,  554 
^foreign  bodies  in,  550 

hemorrhage  from,  527 

irrigation  of,  552 

rupture  of.  549 

stricture  of,  554 


Urethral  bougies,  555 

fever,  558 

syringe,  553 
Urethrectomy,  558 
Urethritis,  550 
Urethrorrhea,  554 
Urethroscope,  553 
Urethrotome,  557 
Urethrotomy,  external,  557 

internal,  557 
Urethrovaginal  fistulae,  580 
Urinary  fever,  558 

fistula,  554,  5^»  446 

organs,  diseases  of,  523 

segregator,  Luys',  525 
Harris',  525 
Urine,  extravasation  of,  549 

incontinence  of,  542 
retention  of,  542 

pus  in,  527 

residual,  570,  571,  543 

retention  of,  542,  42 

suppression  of,  527 
Uronephrosis,  529 
Uterine  colic,  600 
Uterine  sound,  575 
Uterus,  abscess  of  wall,  584 

affections  of,  581 

amputation  of  cervix,  583 

atrophy  of,  587 

carcinoma  of,  597 

congenital  malformations,  581 

curettage  of,  586 

deciduoma  malignum,  599,  140 

dilatation  of  cervix,  582 

dislocation  of,  587 

displacements  of,  587 

erosion  of  cervix,  583 

eversion  of  cervix,  583 

fibroids  of,  593 

hypertrophy  of  cervix,  583 

inflammation  of,  584,  586 

inversion  of,  593 

laceration  of  cervix,  583 

morcellement  of,  595 

myoma  of,  593,  144 

jx)lypi  of,  594,  597 

prolapse  of,  591 

reposition  of,  589 

subinvolution  of,  586 

supcrinvolution  of,  587 

stenosis  of  cervix,  582 

sync}'tioma  malignum,  599,  140 

tumors  of,  593 
Uvula,  elongation  of,  434 


\' -shaped  fracture,  246 
Vaccin,  sec  bacterin 
Vaccination,  30,  114 
Vagina,  affections  of,  576 

sterilization  of,  39 
Vaginal  hematocele,  567 


4^JinvV. 


f^i 


'Vapina.l  keiuM. .  511.  5^1 
iiTdhroceie.  5^*5 
iiyMgrectnmy.  505 

TagxDalitk.  «erniii&.  5^5 

Tafrinitk.  ^i 

TTakexitixie'fi  urethrosmpc,  55k> 

Va%i&,  acquired,  o^c 

ITan  Arsdaic'ii  spiini,  -277 

Vax^hetii's  apeimiion.  sff  rincmalk  amfHi- 

tBtioii 
Van  Hook's  openttion  im  urrrwal  anast^- 

mosiE.  55S 
Varicocele,  566,  170 
Vaxicosc  aneurysm,  104 

ulcers,  i8d,  74.  75-  T7 

veins,  T7Q,  ^Oto 
Varix,  lyq 

aneurysmal  1Q4,  544 

arterial  186,  144 
Vascular  goiter,  3  84 
Vas  deferens,  anastomosis  of,  5f»8 

ligation  of,  for  recurring  rpidiHx'rrtiti^ 

rupture  of.  5t>8 

tuberculous  disease  of,  5ft3 
Vasectomy  for  enlarged  pnisiatc,  571 
Vasoiribe'  200 
Veins,  affections  of,  177 

canalization  of,  i6q 

entrance  of  air  into,  173 

ligation  of,  200 

\'aricose,  179 

wounds  of,  183 
Velpeau's  bandage,  52 
Venereal  ^^-arts,  559,  137 
Venesection,  181,  107 
Venous  hemorrhage,  195 

nevus,  144 

obstruction,  170,  4,  5 

sinuses,  thromlK)si.H  of,  »cc  ihrtMtltHMU 
and  sinuses 

thrombosis,  170 
Venous  wounds,  183 
Ventral  hernia,  571 

suspension,  591 
Ventrofixation,  591 
Vermiform  api>cndix,  jmtc  A\t\mnt\\n  ^€tm\ 

formis,  483 
Verruca,  sec  wart* 

necrogenif>a,  tOi 
Venebne,  sec  »j>in« 
Vertebral  aruny,  </>mf>f*t**'yw  '4^  $0^^ 

hy^xym  'A.  210,  ^f^ 
VesicaJ  calculu*,  5.45 

hwiiaiwia.  tj^t,  ^4 1 

V«iicuia^  ti*:Auut*Jrt?i .  ^ffjfjf^  '4^  ^A 
1k*il»rivt  ji^jf  Uifc^Vrf* 


n>rV"  «f^^!-  fWM'rry^twvUw^mv.  4^ 
VOIr^T^  nim^rM  M*^vMer.>^^^  fmfVlfOTWi 

law^i.  7-" 

ofNemtVvn  fAv  hAMrftcfV.  >!^ 
Va)<«<MIk  foiy«iep«k,  574 
VoMil«N,  <\\  fnt^t?n^,  471.  474 

AmM>h»m.  4-^1 

X'AmiHnji.  iN^fv^ml,  ;^5^ 
>»t<»fHV>mtyyMf%.  473.  7 

<^^ 

X'on  <»r««^r\  ^ign.  3)^ 

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«»«1«M.   1A3 

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WHi^W*.  )t»  '|}K|etf/H!)«;.  <l 


682 


INDEX. 


White  patches,  in  diagnosis,  4 

swelling,  316,  72,  321 
Whitlow,  237 

thecal,  237 

ungual,  164 
Widal  reaction,  10,  29 
Wire,  aluminium  bronze,  36 

iron,  36 

silver,  36 
Witzel's  method  of  gastrostomy,  460 
Wolf's  method  of  skin  grafting,  168 
Wolfler's  method  of  gastroenterostomy,  462 
Wooden  phlegmon,  445 
Wood's  operation  for  ectopia  vesicae,  539 
Woolsorter's  disease,  117 
Wool  truss,  583 
Wound  phagedena,  86 
Wounds,  87 

drainage  of,  47 

repair  of,  66 

see  also  special  regions 
Wrist  drop,  232 
Wrist  joint,  amputation  at,  628 


Wrist  joint,  dislocation  at,  304 

emision  into,  314 

excision  of,  327 

gonorrheal  infection  of,  315 

tuberculous  disease  of,  318 
Wry  neck,  see  torticollis 
Wyeth's  method  of  controlling  hemorrhage, 
in  amputation  at  hip,  638 

at  shoulder,  630 

X-ray,  10 

see  Rontgen  ray 
Xeroderma  pigmentosum,  163 

Yeasts,  31 

Yellow  tubercle,  166 
Yellowish  discoloration  in  diagnosis,  4 
Young's  method  of  perineal  prostatectomy, 
655 

Zoolglea,  33 

Zygoma,  fracture  of,  254 


M31      Stewart,   J?.T.        54345 
884         A  manual  of  surgery. 


« 


1911 


NAME  OATB  DUB 


r 

4