Surgery From an Osteopathic Standpoint

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SURGERY

OSTEOPATHIC STANDPOINT,

F. P. YOUNG, B. S., M. D., D. O.,

PROFESSOR OF SURGERY AND PRACTICAL ANATOMY IN THE AMERICAN SCHOOL

OF OSTEOPATHY AND FORMERLY LECTURER ON HISTOLOGY IN

THE LOUISVILLE MEDICAL COLLEGE, ETC.

COLLABORATED

CHARLES E. STILL, D. O.,

Chief of the operating staff of the a. t. still infirmary and vice
president of the american school of osteopathy,

WITH

One hundred and fifty-six Illustrations in Etchings and Halftones.

UJS 94d
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C0PYRI3HT 1904.

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PREFACE

TN THIS volume an endeavor has been made to present the
essential facts of practical Surgery, modified by the science of
Osteopathy, as taught and practiced by its discoverer, Andrew
Taylor Still. That Osteopathic practice has revolutionized
Modern Surgery may be evidenced by a perusal of the following
pages. In the preparation of this work the writer has attempted
to be as brief as is compatible with clearness^ But few operative
methods have been detailed, since it is believed that these prop-
erly belong to works on operative surgery. For the Osteopathic
treatment of the various surgical affections the writer has fol-
lowed the teachings of Dr. Andrew Taylor Still and the
instructions of Dr. Charles E. Still, collaborator of the text.
Special credit is due Dr. George M. Daughlin for valuable
advice in the preparation of this work, and also for the radiographs
made by him and kindly loaned for the purpose of illustration.

The illustrations in this text, with the exception of the radi-
ographs, were made from original drawings by Miss Agnes
Dandy and Mr. William Richardson, students at the American
School of Osteopathy. Credit is given the various standard
works on surgery to which the author has had occasion to
Credit is also due Dr. Harriet F. Rice for valuable assis
in the preparation of the manuscript.

F.J^ ^OUN
June 1st, 1904. f\ \KiriSvLlle, Mo

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table: of contents

PART I.

GENERAL SURGICAL PATHOLOGY AND
SURGICAL DISEASES.

Inflammation 1

Surgical Bacteria 8

Antiseptics , 16

Asepsis 20

Suppuration, Abscess, Ulcer, Fistula and Sinus 23

Gangrene 37

Septic and Infective Diseases 48

Wound Fever 49

Sapremia 49

Septicemia 50

Pyemia 53

Wound Diphtheria 55

Erysipelas , 56

Tetanus 60

Hydrophobia 64

Actinomycosis 66

Malignant Pustule 66

Tuberculosis 67

Glanders 75

Syphilis " 76

Gonorrhea 85

Rachitis 87

Scurvy 88

Tumors 88

Cysts 100

Bandaging 103

Anesthesia 110

Process of Repair 113

Wounds 118

Shock 119

Burns and Scalds 143

PART II.

DISEASES AND INJURIES OF SPECIAL TISSUES.

Heart an d Pericardium 146

Arteries 146

Aneurysm 148

Ligation of Arteries 161

Veins 171

Embolism 175

Thrombosis ^76

Lymphatics 179

Skin 183

Nerves 186

Bones and Joints 190

Fractures 202

Diseases of Joints 252

Dislocations 273

Diseases and Injuries of the Spine 306

Diseases and Injuries of the Head 324

Diseases and Injuries of Muscles, Tendons, Fascia and Bursae 338

Club-foot 346

PART III.

DISEASES AND INJURIES OF REGIONS.

Face, Lips, Tongue, Mouth and Throat 351

Chest 359

Digestive Tract, Abdomen and Pelvis 361

Rectum and Anus 389

Urinary Organs 394

Male Genitalia 405

Female Genitalia • 413

Mam mary Gland 417

OSTEOPATHIC SURGERY,

-ITS-

Principles and Practice.

PART I.

GENERAL PATHOLOGY AND SURGICAL DISEASES.

INFLAMMATION.

Definition. — Inflammation may be defined as the reaction of the
tissues to an actual or referred injury, providing that injury is not t-o
great as to produce death. Contrary to what was formerly believed,
inflammation is essentially a reparative process, instead of a disease
producing entity. It is a disease process which varies according to the
nature of the injury and condition and character of the tissues. It has
been defined as "nature's effort at the process of repair."

Pathology.

The changes taking place in inflammation may be grouped in the
following manner: — Vascular and circulatory changes. (2) Exudation
of fluids and the migration of leukocytes through the blood vessels,
and (3) Changes in the perivascular tissues.

Vascular and Circulatory Changes. — When an irritant is applied
to a vascular area, a momentary contraction of the blood vessel^ may
or may not occur, but this is quickly followed by a dilatation of the capil-
laries, arterioles, and venules. The blood flows more swiftly to the
injured area, hence we have "determination of the blood to the part."
This engorgement with flowing blood is called active hyperemia, or
congestion. If the blood current be slowed and the engorgement still
continues, it is then termed passive congestion. This is usualhy due to
some obstruction to the return circulation, perhaps, also, to a lack
of tonicity to the vessel walls, or to a, weak heart. But the active
hyperemia continues and perhaps pulsation may occur in the venules
and other smaller vessels. Capillaries previously . invisible become
highly distended. During this stage no exudation of fluid takes place.
If the irritant be removed the blood vessels promptly return to their
normal size and all evidences of hyperemia disappear. This is what
often occurs in hives. If the irritation continues, certain changes will
occur in the blood; white corpuscles will become separated from the

2 I NFL A MM A TION.

general blood stream and will align themselves along the vessel Avail,
the red corpuscles still continuing in the centre of the stream. Pres-
ently it will he noticed that the leukocyte finds an opening (stoma) in
the vessel wall, through which it succeeds in escaping (diapedesis). In
violent inflammation numbers of the red corpuscles may also escape at
the same time (rhexis). It must he remembered that the leukocyte

Inflammatory changes in a small vessel: a, normal circulation; b, dilatation; ^leu-
kocytosis; d, migration of the leucocytes.

is an ameboid cell, which explains its ability to escape through the
stomata in the vessel wall, which act, it readily and quickly accom-
plishes— variously estimated by different observers at from one-half to
one and one-half hours. But during this time the blood current is
slowed perceptibly until finally it actually stops (stasis), then the liquid
elements of the blood pour out through and between the cells in the
vessel wall, while the leukocytes swarm out in vast numbers, the num-
ber depending largely upon the severity of the inflammation. Migra-
tion of the leukocytes to the inflamed area next occurs. It is believed
that the leukocytes are attracted by certain chemical substances (posi-
tive chemotaxis). It is also believed that they are repelled by other
substances (negative chemotaxis). Certain it is that they are attracted
to the inflamed area from the blood vessels from whence they come.

Phagocytosis. — It is known also that the leukocyte has the power to
eat up, as it were, certain offending materials, such as portions of dead

CHANGES IN THE PERIVASCULAR TISSUES.

Fig. 2.

Fig. 3.

Fig. .4.

a

A. B and C illustrating- the various stages of diapedesis
and migration of the leucocyte.

cells or effete materials, but more important than all, bacteria which
may have gained entrance into bhe body. The white corpuscle is able
to destroy the bacteria by means of certain chemical compounds which
it contains (phagocytosis), and it is also believed that certain connec-
tive-tissue cells and endothelial cells also have the same phagocytic
properties, but to a
less degree. If the
inflammation is very
severe the exudation
of the fluids into the
tissues ma}^ occasion
great swelling. The
blood vessels are
g r e a 1 1 3^ distended
and, if the stasis is
complete and extends
to the arterioles, os-
cillation will take
place in the blood
stream, occasioning a
throbbing sensation
to the patient. Eed-
ness will be marked,
and in severe inflam-
mations where r e d

corpuscles escape from the vessels, the area will be of a dark bluish color.
The skin is often stretched to the utmost where the affection is super-
ficial, presenting a shiny appearance. Considerable local heat is
manifest.

Changes in the Perivascular Tissues. — In addition to the exudation
of the fluids and the migration of the leukocytes, there are other impor-
tant changes in the tissues. Eapid proliferation of the resident connec-
tive-tissue cells takes place ; these cells, with the assistance of the leuko-
cytes, form more or less of a wall or barrier around the source of in-
flammation, or irritant, as if to prevent it spreading or extending to
other tissues. These new cells are embryonal in character, but- if the
irritation continues some length of time they will become differen-
tiated into other forms, chiefly fibrous tissue, and then if the
irritation should be removed without the destruction of any
cells-, the part would perhaps be permanently altered by the
formation of this new tissue. Where any tissue is destroyed, as
in case of abscess formation, ulceration, or wounds, these proliferated
resident tissue cells take the place of the destroyed tissue and
will always remain as an evidence of the inflammation. In open
wounds it constitutes the scar tissue or cicatrix. The changes taking
place in the tissues depend largely upon the nature and cause of the
inflammation.

4 TERMINATIONS OF INFLAMMATION.

Causes of Inflammation.

(A) Predisposing and (B) Exciting.

Predisposing Causes. — (1) Abnormal blood supply; abnormal in
quantity as in obstruction to arterial, venous, or lymphatic circulation
by bony lesions, contractions of fascia or muscles, or because of insuffi-
cient food, lack of fresh air, hemorrhage, anemia, etc. Abnormal in
quality because of certain poisons circulating in the blood as occurs in
chronic alcoholism, Bright's disease, diabetes, gout, syphilis, lead, mer-
cury and phosphorus poisoning, etc.

(2) Abnormal nerve influence because of pressure on the nerve or
disease of the nerve trunk supplying the part affected.

Exciting- Causes. — These may be best considered as (1) chemical
and (2) mechanical. By mechanical cause is meant any trauma, as a
bruise, cut or other injury. The chemical causes consist of irritating
chemical compounds and micro-organisms. These irritating chemical
compounds consist of caustic alkalis and acids and toxic animal and
vegetable substances. Micro-organisms cause irritation by means of
certain chemical compounds which they produce either by the meta-
bolism of their own bodies or by their action upon the tissue cells. It
is a recognized fact that some of the most toxic substances known are
produced by bacteria, further, that micro-organisms are perhaps the
most important factor in the majority of inflammations, being always
present, the injured cells give them an opportunity of entering the tis-
sues, when inflammation will result. In the treatment of inflammation
this cause should always be kept in mind.

Terminations of Inflammation.

Inflammation terminates in (1) resolution, (2) new formation, (3)
ulceration and abscess formation, and (4) necrosis.

Resolution. — By resolution is meant that when the cause of the
morbid process is removed or ceases, the tissues return to the normal
condition.

New Formation.. — This consists of inflammatory tissues, the result
of proliferation of the resident connective-tissue cells ; especially is this
true of inflamed joints where injury, attended by long continued irri-
tation brought about by efforts to use the member, results in the forma-
tion of fibrous tissue about the joint, binding down the tendons and liga-
ments, destroying bursae, lessening the range of motion, whilst termi-
nal nerves are compressed, which results in more or less constant pain.
Wherever injury or disease destiws any tissue, the tissue taking the
place of that destroyed consists of regenerated nerves, muscles or other
tissues as the case may be. Tissue the result of proliferation and devel-
opment of the connective tissue cells is called a scar or cicatrix.

For other terminations of inflammation see Ulceration and Abscess
Formation and jSTecrosis.

VARIETIES OF INFLAMMATION. 5

Varieties of Inflammation.

The varieties of inflammation are acute, when the tissue changes are
active, and chronic, when the tissue changes are slow and the cause is
long standing.

Chronic Inflammation. — The causes of chronic inflammation, are, as
in acute inflammation, local and constitutional, but there is more fre-
quently some constitutional cause operating. The color usually indi-
cates venous congestion due to continued dilatation of the veins from
obstruction or the return circulation. The pain, which is less severe
than in acute inflammation, is usually of a dull, aching character, is
more or less constant and is often severest at night. Swelling is often
one of the most pronounced of the symptoms. The increased heat is
often not perceptible when the inflammation is on the surface of the
body. When an important organ is affected a slight rise of temperature
may occur. The changes taking place in chronic inflammation are the
same as those which occur in acute, except they are less rapid.

Other forms of inflammation are traumatic, that which is due to
injury; infective or specific when produced by specific micro-organisms;
sthenic when happening in full blooded people; asthenic when occur-
ring in the old or debilitated; parenchymatous when affecting the paren-
chyma of an organ; interstitial when it involves the connective tissue of
an organ; serous when accompanied by a serous exudate; purulent when
attended by the formation of pus; fibrinous when the exudate is coag-
uable ^hemorrhagic when the exudate contains red blood cells; croup-
ous when a membrane forms over the inflamed area; diphtheritic when
the membrane formed resembles that in diphtheria; gangrenous when
the inflammation is accompanied by death of a mass of tissue; simple
when due to no specific cause; catarrhal when it affects mucous mem-
branes; idiopathic, a term formerly used to indicate an inflammation
without a cause; neuropathic when there is an impairment of the
trophic nerves to the part; sympathetic when inflammation takes place
in one part because of an irritation in another part, as sometimes hap-
pens in the eye.

Signs and Symptoms.

The symptoms of inflammation are (1) pain, (2) heat, (3) redness,
(4) swelling, (5) interference in function.

Pain is due to pressure upon the peripheral sensory nerves of the
part.

Heat is produced by local irritation and by the circulation of certain
products in the body which disturb the heat producing and heat regu-
lating mechanism.

Redness may vary from a bright red, in acute inflammation,
to a dark blue, in chronic inflammation, or in abscess formation to a
dusky or very dark bluish color.

6 TREA TMENT OF IN FLAM MA TION.

Swelling.— This varies with the part involved. In some loose cellu-
lar tissues the swelling mayvbe very great. In the inflammation of bone
little swelling may be evident, yet the pain may be extremely severe.

Interference in Function will largely depend upon the part involved.,
the severity of the inflammation and the violence of the other symp-
toms. As a general rule the severity of the symptoms varies with the
violence of the inflammation.

Treatment of Inflammation.

(A) Osteopathic measures, and (B) Other measures.

Osteopathic Measures. — The results of inflammation depend largely
upon the freedom of the circulating fluids and their quantity and qual-
ity. Degenerations, ulcerations, and necrosis are the result of impaired
nutrition or its sudden arrest, therefore it should be the first duty of
the physician to remove any obstruction to the lymphatic or venous
circulation so as to prevent congestion, or anjr obstruction to the arter-
ial circulation so that the tissues may receive their proper quota of
fresh blood. Unless stasis occurs, destructive changes will not happen,
hence it is of the utmost importance to prevent a stopping of the circu-
lation. This may be done by encouraging the circulation through the
agency of the vasomotor system. Furthermore, the metabolism and
the tissue changes may be directly influenced by relieving the pressure
on a nerve to a part, or reflexly by stimulating or inhibiting them as
may be required. Bacteria constitute the most important factor in
inflammation. Years ago Dr. A. T. Still contended that the most effi-
cient germicide within the body was a free flow of fresh blood; this is
now generally admitted. It is a recognized fact that under all circum-
stances nature heals the sore if given a chance. No salve, medicine, or
other application has such properties. No chemical reagent will destroy
the germs without destroying tissue as well. Bacteria are only destroyed
by nature's forces, therefore it is of the utmost importance that a good
free flow of fresh blood should be secured. This can be done by remov-
ing any obstruction to the arterial flow or to the return circulation,
either lymphatic or venous. An increased flow of fresh blood can best
be secured by stimulating the vasomotor nerves to the part. Lesions
affecting the inflamed area may be found in the planes of fascia, in con-
tracted muscles, or in the partial displacement of bones.

Other Measures. — The local treatment of inflammation consists of
(1) removing the irritant, (2) cleanliness and asepsis, (3) antisepsis, (4)
rest, (5) elevation of the part, (6) cold, (7) heat, (8) incisions, and (9)
manipulation.

Removing the Irritant consists, in case of wounds, in searching for
foreign bodies or the removal of any noxious chemical product.

Cleanliness and Asepsis. — Asepsis means not only that the part be
apparently clean, but that it be surgically clean, which means that it

TREA TMENT OF IN FLA MM A TION. 7

must be germ free. This can best be obtained by the methods detailed
under "Asepsis." . .

Antisepsis in inflammation consists in using those agents which in-
hibit the growth of. or destroy, the micro-organisms which play such an
important part in inflammation; this, however, is but another means of
removing the cause of inflammation. The kind of antiseptics used and
the method of their application is given elsewhere.

Rest must be both functional and physiological; it may be obtained
by position or by immobilizing a joint. Physiological rest, in case of
ulcer of the stomach, can best be obtained by fasting for a time.

Elevation of the Part is of great importance in inflammation of the
lower extremity. Here elevation assists return circulation and secures
a better blood supply to the inflamed area, which is of the greatest im-
portance in chronic inflammation or in old ulcerations or varicose ulcers
of the leg or foot.

Cold is of the greatest value in the early stages of inflammation and
is best applied by means of an ice-pack or cold water coil; intense cold
should be used. It is especially serviceable in sprains.

Heat applied early in inflammation is said to cause dilatation of the
arterioles and to assist the circulation. In the later stages it hastens and
localizes pus formation. It is best applied in the form of hot stupes,
hot fomentations, hot water bags, poultices, and dry heat. . Hot stupes
may be applied by rinsing flannel, doubled so as to make three or four
thicknesses, in boiling water. That this may be done without scalding
the hands, a strip of flannel six inches wide and two feet long, the two
ends being sewed together, is necessary. Now with two sticks about a
foot long; this flannel mny be dipped into the boiling water, when the
sticks may be quickly twisted and the flannel thoroughly wrung out.
While the flannel is very hot a few drops of turpentine may be dropped
on the cloth, when a turpentine stupe is made. This is very effective in
deep seated inflammations and where there is not a broken surface.
The turpentine is an active antiseptic but is too irritating to be used on
an open wound. Hot cloths may be wrung from a boiling saturated
solution of boracie acid and placed over the inflamed area, when, in ad-
dition to heat, antisepsis is also secured. In the application of these
hot stupes or fomentations, sheet-rubber should be applied over the hot
cloths until they are changed, which should be every five or ten minutes
to be effective. A poultice may be made of ground flaxseed, elm bark,
starch, bread and milk, potatoes, etc. To make a flax-seed poultice, stir
the ground flax-seed in a basin with a little boiling water; keep adding
the flax-seed and stir constantly until it is of the consistency of thick
mush. It can now be spread, upon, a piece of aseptic or antiseptic gauze,
which can be doubled over the poultice to prevent its sticking to the
surface of the body. It may then be applied to the inflamed area with a
piece of sheet-rubber or oil-silk covering to retain the heat. The func-
tion of the poultice being heat and moisture, as soon as the heat has dis-

8 SURGICAL BACTERIA.

appeared a new poultice should be applied, which, will be from every quar-
ter to a half hour. In violent and very painful inflammations a sedative
poultice is of- value. Tins can be made by adding from ten to twenty
drops of laudanum to the poultice — being well stirred in previous to
spreading on the cloth. An antiseptic poultice may be made by rinsing
several thicknesses of gauze in a saturated boric acid solution and ap-
plying to the inflamed area, placing over it oiled silk or sheet rubber, and
then applying a hot water bag; by this means heat and antisepsis are
likewise obtained. Dry heat may be applied in the form of hot water
bag or hot sand bag, which is often times of service in deep seated
inflammations, as of joints. When suppuration is imminent the appli-
cation of heat gives great relief and should be applied until pus forma-
tion is evident, then a free incision should be made, the pus discharged
and rigid antisepsis maintained.

Incisions are sometimes useful to relieve congestion in the case of
tonsilitis and. edema of the glottis.

General Treatment. — The old idea in the treatment of inflammation
was diet, drugs, and blood letting. The drugs used were diuretics, dia-
phoretics, purgatives, emetics, anodynes, and other remedies, such as
aconite, quinine, salicylic acid, mercury, etc. These have been elim-
inated and are no longer necessary. Phlebotomy and leeching are relics
of the days of barber surgery. In the general treatment of inflammation
diet, attention to the secretions, and the relief of the various symptoms
arising are of importance. In severe inflammation the diet should be
restricted to milk, gruel, soup, beef-tea, barley water, toast, and other
easily digested foods. The urinary secretions should be kept free, the
bowels open, and the liver acting. The secretions of the mouth should
not be allowed to become foul. In severe cases of erysipelas and typhoid
fever the mouth should be rinsed with Listerine or boric acid solution
to prevent sordes forming on the teeth. The secretions of the skin
should be kept active by baths. Symptoms arising may easily be com-
bated; pain, the chief symptom, is an evidence of pressure on the
nerve; by manipulation this pressure may be removed. In the treat-
ment of chronic inflammation it is very essential to determine whether
or not there are any constitutional causes operating, whether it is be-
cause of vicious habits of the individual or because he lives in unhealthy
surroundings. Whatever the cause is, this should be corrected^ the
mode of life changed, the person should be well nourished, and the
inflamed area protected from further irritation. Eecovery from an old
inflammation ofttimes takes place slowly and many times the prog-
nosis is unfavorable.

SURGICAL BACTERIA.

Definition — A bacterium is a minute, one-celled vegetable organism.
They belong to the class of moulds or fungi. Fungi may conveniently
be divided into three classes:

1. Saccharomycetes, or yeast fungi.

MORPHOL OGY OF BA CTERIA . 9

2. Hyphomycetes, or moulds.

3. Schizomyeetes, fission fungi, or bacteria.

Of these three classes of fungi the last is of the greatest import-
ance to the physician, inasmuch as many of them produce disease, while
not many of the moulds or yeast fungi are harmful.

Morphology of Bacteria.

Bacteria may be divided into three general classes — cocci, bacilli,
and spirilla. Cocci are spherical shaped organisms and may, or
may not have flagella. Flagella are small hair-like processes
which project out from the bodies of the bacteria and furnish
them means by which they may move. They are similar to the
cilia upon ciliated epithelial cells. Bacilli are rod shaped organisms
which may be joined end on end, forming a delicate thread called lep-
tothrix. Spirilla are spiral shaped organisms, which, when joined end
to end and showing no evidence of division are called spirochetae.
Cocci vary in size from .15 to 2.8 mikrons. Bacilli vary from .2 by
1 mikron to 1.5 by 5 mikrons, while some of the spirilla may be as long as
40 mikrons. The weight of a bacterium has been estimated by Xageli
to be 1-10,000,000,000 of a milligram.

Motion.

As before mentioned, some of the bacteria are capable o?
motion (motile), while others are not (non-motile), while some have
flagella and others have not. In some cases bacteria may be capable
of exceedingly rapid motion, while others move more slowly and are
loss active.

Reproduction.

Bacteria are capable of reproducing themselves by at least three
different ways; by fission, endospores, and arthrospores. It has been
estimated by Buchner that under favorable circumstances a bac-
terium can reproduce itself in from fifteen to forty minutes. At
this rate he estimates that it would be possible for one bacterium, under
favorable circumstances, to be the origin of sixteen million in twenty-
four hours. It has been estimated that if bacteria were supplied with a
sufficient amount of food, within three days one would develop a mass
weighing 4752 tons; but fortunately the conditions are rarely present
for such appallingly rapid reproduction. This likely accounts for the
fact that bacteria produce disease less often than might be expected,
also that many times when conditions are favorable it likely accounts
for the rapidity of the course which the disease runs.

Bacteria group themselves in many different ways. Diplococci are
cocci existing in pairs, as the diplococcus lanceolatus, or the diplococcus
Xeisseri. Tetrads are cocci grouped in fours, as happens with the micro-

10 DISTRIBUTION IN NATURE.

coccus tetragenus. Sarcina is where the bacteria increase in all direc-
tions alike and where they present the formation of groups or blocks.
Streptococci is where the bacteria exist in chains, which may be short
or long. Staphylococci is where the bacteria form an irregular group
or mass. Leptothrix is a condition where the bacilli form in long
chains and where the division between the individual bacilli can not be
readily made out. Spirochetae is where the spirilla form in
long spiral-Hke threads. These are the commonest forms of bacteria.
For a more extensive description, works on Bacteriology should
be consulted.

Distribution in Nature.

Air. — Bacteria are found almost everywhere in nature, in the
dust of the air, in water and in the soil. In 1686 Francesco
Bedi proved that maggots arising in putrid meat did not arise
de novo, but that they came from the flies buzzing around the
meat and frequently alighting thereon. It has been proven that
fermentation, wherever found, comes from bacteria which may
have gotten into the fermenting substance or liquid. Bacteria exist
almost evenw/here in nature except perhaps in mid-sea or at very high
altitudes. John Tyndall proved that practically no bacteria were found
at high Alpine altitudes. He furthermore proved that the bacteria
causing decomposition very often come from the dust particles in the
atmosphere. He proved that meat lying in a dust-proof chamber would
keep for a long time, while that exposed. to the dust particles of the air
would quickly decompose. By experiment it has been shown that there
are from 100 to 1000 bacteria of various kinds to each cubic meter of
air. In crowded houses and in cities this number would be much
greater, whereas in rural districts it likely is much smaller.

Water. — Bacteria are found extensively in all water, especially is it
true of infected river water. In good pump water the number varies
from 100 to 200 per cubic centimeter; in unfilterecl river water from
6,000 to 20,000 per cubic centimeter. Contrary to what is popularly
believed bacteria may frequently live in ice. Prudden proved that the
average Hudson river ice contained 398 micro-organisms per cubic cen-
timeter.

Soil. — It has been estimated that virgin soil contains 100,000 germs
per cubic centimeter. These germs exist only in the upper strata of
the soil, perhaps in the first two feet only, except where water contain-
ing a considerable amount of decomposing animal or vegetable matter
is percolating through the ground, at which place the bacteria may be
found at a depth of several feet. It would seem from these statements ]
that one might be readily infected with disease germs, but it must be
remembered that for the most part these germs are harmless sapro-
phytes and will not produce disease. It is only when water or soil
becomes infected with disease producing germs that infection spreads.

CONDITIONS AFFECTING GROWTH. 11

Human Body. — It is a known fact that about liuman habitations
and about the animal body bacteria exist in large numbers, apparently
living on the effete material or the excreta. They are found in the
secretions of the mucous membranes, in the various mucous membranes
and in the superficial layers of the surface epithelium. On the parts of
the body covered with hair and in the flexures they are found in very
large numbers, hence wounds in these regions are much more liable to
infection. One thing is certain, that the fluids of the body are free
from bacteria under normal conditions, and when bacteria are found
in the body-juices it is an evidence of disease. In the salivary secretions
large numbers of bacteria are found, likewise in the lachrymal secre-
tions. Large numbers of bacteria are constantly being taken into the
respiratory tract, lodging in the crypts of the tonsils and in the crevices
of the pharynx, hence this cavity is teeming with them. Many of them
are carried on into the stomach, escaping the gastric secretion they
thrive in the intestines, so the contents of the intestines are exceed-
ingly septic. Bacteria are not generally found in the urine within the
bladder, but in diseased conditions they frequently get into the urine in
large numbers.

Conditions Affecting Growth.

Oxygen. — Some bacteria live best without oxygen; these are called
anaerobic; others grow best in oxygen; these are called aerobic. Some
bacteria grow best without oxygen but can grow with it; these are called
faculative aerobics; likewise some of those growing in oxygen may
thrive without oxygen; these are called faculative anaerobic germs.

Nutriment. — Bacteria are not able to derive their nourishment from
purely inorganic matter, but live for the most part, it seems, on highly
organized compounds. They seem to grow best where diffuse albumins
are present.

Moisture. — A certain amount of water is always necessary for the
growth of bacteria, as with any other form of vegetable life; however,
this does not mean that drying will destroy them, for bacteria may live
upon clothing apparently dry, in some cases for some months, and if the
clothing be damp, even a longer time. Bacteria may also be wafted
great distances in a dried condition by means of dust particles in the
atmosphere and they may live in this condition a considerable length
of time.

Reaction. — The pabulum upon which bacteria thrive, to be most
suitable for their growth, should be faintly alkaline or faintly acid;
strong alkalis or strong acids destroy bacteria.

Light. — Most species of bacteria are not influenced to a great extent,
in their growth, by the presence or absence of light ; however, many of
the bacteria will grow best in a dark room, while there are others whose
growth seems to be retarded by the direct rays of the sun's light. Some
colors, especially blue, are prejudicial to their growth.

12 RESULTS OF VITAL ACTIVITY.

Movement. — A condition of perfect rest seems to be most favorable
for the development of bacteria. Movement of the culture medium, as
sudden agitation, if kept up, will destroy the bacterial growth. It is
this agency acting which seems to be one of" the greatest sources of
destruction of bacteria, and flowing water, especially falls and rapidly
flowing streams, are peculiarly free from bacteria. Other things being
equal, the water from such streams should be best for drinking pur-
poses.

Association. — Very often in disease processes of the body several
forms of bacteria are associated and it is not unusual that this associa-
tion makes one or the other of the bacteria more virulent and active.
Still it is known that in some cases one infection will, to some extent,
render the individual more or less immune to the onslaughts of certain
other bacteria.

Temperature. — Frankel states that bacteria grow best between the
temperatures of 16 and 40 degrees C. Many bacteria will flourish in
a higher temperature than 40 degrees C, many will flourish fairly well
in a temperature lower than 16 degrees C. A temperature from 60 to
75 degrees C. (108 to 135 degrees F.) if continued for some length of
time will arrest the growth of most bacteria. Boiling for a few
minutes will entirely destroy nearly all bacteria. This is of the utmost
importance to the physician, as it furnishes him a harmless method by
which he may secure asepsis.

Results of Vita] Activity.

1. Fermentation. — The various forms of fermentation, wherever
found, are generalhy due to the development of bacteria. Some of
these bacteria may be harmless, while many times they may be exceed-
ingly poisonous.

2. Putrefaction. — The term putrefaction differs from fermentation,
in that it especially refers to the fermentative process taking place in
nitrogenous bodies. The manner in which this takes place seems to be
that the albumins are converted into peptones and these are split up
into gases, acids, bases, and salts. It is in this reaction that many times
some of the most virulent poisons are produced. Ptomains, for instance,
are the result of putrefactive changes taking place in organic matter,
cither animal or vegetable. According to Vaughan and Novy, ice-
cream, meat, and cheese poisoning are really ptomain poisoning, the
ptomains having been produced by putrefactive changes in the food
products.

3. Gases. — It is not unusual for the bacteria to produce noxious
gases. Many times this gas production gives rise to offensive odors.
This is ofttimes seen in foul and infected wounds where the secretions
are teem ins: with bacteria.

INFECTION. 13

4. Enzymes. — That bacteria produce enzymes, or ferments, is well
known and it is also known that many times these enzymes or ferments
are exceedingly poisonous. Whether they result from the secretion of
the bacteria themselves, or the action of the bacteria upon other mat-
ter, is not certainly known. These poisons are sometimes extremely
virulent, as for instance, the purified toxin, tetanin, of the tetanus germ
was found by Brieger and Colm to be fatal to mice in doses of
0.00000005 gram. Lambert holds that this is the most poisonous sub-
stance ever discovered. It is to these enzymes that bacteria owe their
ability to produce disease.

5. Disease. — Bacteria are divided into two general classes, patho-
genic, those capable of producing disease, and non-pathogenic, those
not capable of producing disease. It is believed that their ability to
produce disease depends very largely npon whether the substances pro-
duced by the bacteria are poisonous. These poisonous substances, as
before stated, are either the result of the secretion of the bacterium
itself, or the result of the action of the germ upon the body cell.

Infection.

Ziegler defines infection as "The entrance of bacteria into the
body and their increase there/' This means, of course, the multiplica-
tion of the bacteria within the tissues. Certain conditions are neces-
sary before infection can take place; these are now generally admitted
by most authors to be:

1. The bacteria must be present in sufficient numbers.

2. There must be an avenue of entrance into the tissues.

3. There must be a diminished resistance of the tissues.

There are other conditions, however, which modify infection: —
These are the virulence of the germ and immunity of the subject. It
is known that germs vary in virulence, some species of a certain germ
may be extremely virulent and active, while others may scarcely pro-
duce evidence of disease. The infected subject may be to some extent
immune to the organism in question. These conditions will modify the
development of the bacteria within the tissues. This likely explains
why infection occurs in some cases and not in others.

Avenues of Infection.

Skin. — Inasmuch as bacteria are found in large numbers upon the
surface of the body, wounds are very liable to become infected; and as
the bacteria are much more numerous in the hair, in the sweat glands,
in the sebaceous arlands, and in the roots of the hair, on parts of the
body where these structures are found, infection is much more likely to
happen.

Mucous Membranes. — Abscess of the tonsil likely arises from bac-
teria taken in through the air or by means of food or drink and lodging

14 TOXINS.

in the crypts of the tonsil. The secretions of the mouth cavity are septic
and it is essential in wounds of the mouth that measures be taken to
cleanse the cavity. The lower bowel contains immense numbers of bac-
teria and in constipated conditions poisons of these germs are not in-
frequently absorbed; furthermore, were it not for the resisting power
of the tissues, wounds of the lower bowel would always result in infec-
tion. It seems to be true that it is this resisting power of the tissues
which protects the individual from infection, for often it is that every
individual has sustained small wounds, either on the surface of the body
or in some of the cavities of the body, when bacteria were undoubtedly
present in large numbers, yet infection did not take place. This can
readily be explained by the fact that the tissues prevented the entrance
and multiplication of the bacteria.

Characteristics of Infection.

According to McFarlaud these are (1) phlogistic, (2) toxic, and (3)
septic.

By phlogistic is meant an inflammatory reaction. The toxic effects
consist of local growth with absorption of toxins. The septic effects
are those characterized by the dissemination of the bacteria through
the lymphatic fluids and the blood. In most instances the actual damage
done by these germs and the poisonous effects produced are due to the
ferments developed by the germ.

Toxins.

Bacteriologists seem not to be able as yet to classify the poi-
sons generated by bacteria. They are likely all proteid substances,
most of which probably belong to the class of substances called toxal-
bumins. The poisons of diphtheria and tetanus seem to belong to a
class by themselves, inasmuch as they give no albumin reactions. As a
general rule the poisons are highly organized and are readily destroyed
by temperatures above 108 degrees F., also exposure to air and sun-
light seem to readily destroy them. Some of the substances seem to be
alkaloidal in nature and are readily soluble and quickly diffuse through
the body. It is believed that this explains why some diseases run such
a very rapid course and arc so alarmingly fatal, since the poisons are
readily soluble and are quickly diffused through an animal membrane
and are carried through the body before the germ has actually entered
the tissues.

Ptomains.

Many writers include ptomains under toxins. They are best con-
sidered as putrefactive alkaloids and are the result of the decomposi-
tion or breaking up of organic substances, in contradistinction to the
decomposition or breaking up of organic substances, especially by
bacterial action,

LEUCQM4JNS. 15

leucomains.

Leucomains are alkaloidal substances existing normally in the
body and which arise from retrograde metamorphosis or chemical
changes in the cells. It is not unusual that these substances may
be retained in the body and not eliminated, when autointoxication
occurs. Certain substances found in the urine belong to this class, as
xanthin and hypoxanthin. There are substances which exist normally
in the bowel, but which under certain circumstances are absorbed and
which will produce febrile, circulatory, and other disturbances.

Antitoxins.

The exact nature of antitoxin is unknown. Some maintain
that it is a toxin in a changed form, others that it is a ferment
produced by culture, and still others that it is produced b}^ cellular
activity. This last idea seems to have the most foundation in fact.
Whatever is the nature of antitoxin, it is obvious that after the system
has gotten rid of a certain infection it is not in the same condition that
it was previous to the infection: that many times it is left more or less
immune, for varying periods of time, to subsequent infections. It is
believed by some that this resisting power of the body is contained
largely in the blood and that the resisting power of the blood is due
largely to the chemical changes which have taken place in the leuko-
cytes. It is known that the antiseptic property of the blood from im-
mune individuals is much greater with reference to the bacteria in
question, than the blood from an individual not having such immunity.

Forms of Bacteria.

The forms of bacteria in which the surgeon perhaps is most inter-
ested are the following:

Staphylococcus Pyogenes Albus. — Passet found this germ in pure
culture in four cases of suppuration out of thirty-three examined.

Staphylococcus Pyogenes Aureus. — This is the most common of the
pus germs and is nearly always present in the pus of boils and furuncles.

Streptoccocus Pyogenes. — According to Rosenbach this germ is pres-
ent in eighteen out of thirty-three cases of suppuration. The pus pro-
duced is usually thin, white, and flocculent. It produces diffuse pus for-
mation and its activity is much greater than the other pus germs.

Streptoccocus Erysipelatis or Fehleisen's germ seems to be identical
with the streptoccocus pyogenes of Rosenbach. It often produces pus
and can be obtained in pure culture from serum which oozes from a
puncture made at the margin of an erysipelatous area.

Bacillus Pyocyaneus is the germ of blue or green pus: it likewise
produces disagreeable odors. It is rarely found in pure culture in pus,
but is generally associated with other germs.

16 ANTISEPTICS.

Micrococcus Gonorrhea (Neisser), when inoculated in any mucous
membrane produces a characteristic ulcerative process, attended with
pus formation.

Other germs which are associated with pus formation, but less fre-
quently, are Diplococcus intracellularis meningitidis, Diplococcus pneu-
moniae, B. Tuberculosis, Leprous Bacillus, Streptothrix Actinomycosis,
B. tetanus. B. diphtheriae, Micrococcus tetragenus, B. anthracis, B.
typhi abdonvinalis, B. coli communis, B. pestis bubonicae, and B. mallei.

ANTISEPTICS.

An antiseptic is an agent which retards or inhibits the growth and
development of bacteria. A germicide or disinfectant is an agent which
destroys bacteria. A deodorant is an agent which destroys offensive
odors, but which may not be a very active antiseptic. Chemical anti-
septics are soluble substances which retard or inhibit the growth,
or in some cases destroy the activity, of micro-organisms. It is easy to
develop an antiseptic which will destroy bacteria in a test tube in the
laboratory, but unfortunately it is not so easy to secure an antiseptic
which will not be harmful to the tissues with which it comes in con-
tact. Our best antiseptics are most destructive to the tissues. Perhaps
the best of all known chemical antiseptics for practical use are bichlo-
ride of mercury and carbolic acid. These substances are well known
active poisons and can be used only with certain limitations and under
certain circumstances. The ideal antiseptic is yet to be devised. The
most powerful of these antiseptics is corrosive sublimate and it is per-
haps the most reliable. It is used in the strength of from 1:500 (in
exceptional cases) or 1:1000 to 1:10,000 or 1:20,000 parts of distilled
water. It can not be used in metallic vessels, nor can it be used to dis-
infect instruments. It is irritating to wounds and often causes copious
exudation and in this way does harm. It is perhaps most useful as a
disinfectant for the hands or the surface of the body or certain arti-
cles of clothing. When used on the various parts of the body these
rules must be observed. In the eye it is used in the strength of
1.10,000; in the mouth and throat, never. In the vagina and uterus
in strengths of 1:1000 to 1:5000, depending upon the requirements.
In abscess cavities it may be used where there is free drainage, but under
no circumstances must it be used where it is likely to be retained. In
joints it may be used in strengths of 1:5000 or 1:10,000. It should
not be used in the ear, nose, urinary tract, bowel, or the peritoneal
cavity. In spite of its draw-backs, bichloride of mercury is generally
considered to be the best of the antiseptics. It is prepared m two
forms, a small tablet containing 1.41-50 grains, which when dissolved in
a pint of water makes 1 :4000 solution or in a larger sized tablet contain-
ing 7.5 grains, which when dissolved in a pint of water makes a solution
of 1:1000. These tablets also contain muriate of ammonia, which
hastens their solubility.

CARBOLIC ACID. 17

Carbolic Acid is very valuable as a germicide in strengths varying
from 1:20 to 1:100. It has the advantage that it will not attack metal,
hence the antiseptic: solution can be made in any sort of an aseptic ves-
sel. It is readily absorbed and produces toxic symptoms, hence it mast
not be used in cavities of the body where absorption may take place.
Neither can it be used in the mouth or throat where it is liable to be
swallowed, nor in the bowel, inasmuch as rapid absorption might take
place with collapse and death. It is best used in a liquid form. Liquid
carbolic acid is prepared by heating the crystals and adding five per
cent, of water. For practical purposes a tcaspoonfui of the liquid drug
added to a tin cup of boiling water makes a serviceable antiseptic solu-
tion. If a more active solution is desired, two teaspoonfuls of the drug
should be added to the pint of water. It is irritating in wounds, and
likewise has marked anesthetic properties, often attacking the surgeon's
hands to the extent that it will materially interfere with an operation.
It may be used in the mouth in the strength of one to two per cent.
In tubercular abscesses and suppurating joints it may be used in a five
per cent, solution. In the vagina and uterus it may be used in a two
per cent solution. It should not be used in an abscess cavity where it
is likely to be retained. Pure, it is of great service in cauterizing chan-
croids and sloughing ulcers, also old abscess cavities or old infected
ulcers. It is likewise serviceable as an antiseptic when incorporated
with vaselin. It has the advantage in from 1 to 5 per cent, strengths
with vaselin, that it is a good anesthetic and will often allay itching
and irritation; especially is this true about a wound or open sore.

Creolin is an active antiseptic and is prepared from coal-tar. It has
not the toxic effect^ of carbolic acid or bichloride of mercury and is a'so
not irritating, li is used in strengths of from 1 to 5 per cent, as an
emulsion.

Peroxid of Hydrogen has active oxidizing properties and is a service-
able; cleansing agent. Some preparations are slightly irritating but are
not toxic. It has the advantage that it can be used almost anywhere
and in any location of the body, with the exception of an abscess cav-
ity with a small opening. It oxidizes the dead material and detritus in
the abscess cavity, so that if there is but a small opening from the cav-
itv, the active production of gas will force dead materials into other
parts of the tissues leading to the extension of the infection, whereas,
if the abscess cavity has a free opening the application of the peroxid
of hydrogen loosens up and gets rid of the dead material. It is useful
with other antiseptics, for instance, a pus cavity may be washed out
with peroxid of hydrogen and when cleansed of the dead material it
may then be washed out with bichloride of mercury or carbolic acid,
which are much more active antiseptics. Furthermore, its long con-
tinued use is prejudicial in many ways. It prevents wounds healing.
It should not be used in bed-sores, except occasionally for cleansing pur-
poses. If used regularly the bed-sores will refuse to heal. It should
not be used in large abscesses on the neck, inasmuch as the formation

18 BORACIC ACID.

of gas might dissect through the connective tissue planes and press
upon the air passages. It is used in the strengths found on the market,
or diluted, one part of the solution to one, two, three or more parts of
boiled water, as is reo(uired. It may be used in suppuration of the middle
ear. In weak solutions it is useful for cleansing the throat and mouth
and the nasal mucous membrane.

Boracic Acid is mildly antiseptic, and while irritating in a fresh
wound, or a granulating sore, it is of great advantage in many cases.
It is useful as a dry powder sprinkled over an ulcer, or as a saturated
solution for syringing out cavities. It has the advantage that it is not
toxic, no poisonous effects resulting from its use. In the eye it is used
in the strength of ten grains to the ounce and is perhaps the best of all
antiseptic solutions for such use. When it is very irritating there may
be combined with it cocaine (two grains to the ounce). In abscess of
the middle car, a saturated solution is of service in a fountain syringe
with an ear-nozzle, the stream being directed into the external meatus.
It washes out the pus and destroys the micro-organisms. It is useful
for washing out the bladder in cases of cystitis or purulent inflamma-
tion of the bladder. Here it is useful in a saturated solution.

Permanganate of Potassium is an active oxidizing agent. It is irri-
gating and will stain the skin or tissues, but yet it is useful in the
strength of 1 :200 or 1 :400 to 1 :3000 or 1 :4000 in distilled water for
washing out foul ulcers or old abscesses and many times it acts with a
happy result where other antiseptics apparently failed. It is useful
as a disinfectant in stronger solutions in gangrene after the tissues
have died.

Nitrate of Silver, introduced by Crede, is used in strengths of 1 :300
to 1:1000. It is valuable in gonorrheal affections in the strength of
1 :1000 and in from V2 to 1 grain to the ounce it is a valuable antiseptic
in purulent inflammation of the eye, e. g., gonorrheal ophthalmia and
old cases of trachoma. It is of advantage in from 10 to 30 per cent,
solutions in cauterizing sores, mucous patches in the mouth, ulcers
of the gums, or old ulcers of the leg which refuse to heal.

Salicylic Acid exists in the form of small, needle-shaped crystals
which are slightly soluble in water. It is best used as a powder or as an
ointment, being most useful as a dusting powder in wounds. It is use-
ful in ointments in skin affections to allay itching. It is valuable as a
deodorant and disinfectant in eczema of the feet.

Iodoform is a bright yellow powder and is extensively used in the
treatment of wounds. Its offensive odor is the greatest objection to its
use. It is a valuable powder in the treatment of fresh wounds ; however,
poisoning has followed in numerous cases. It is especially valuable in
tubercular cases. It may be used as a dry powder or as a ten per cent,
emulsion with glycerin. This may be injected into the abscess cavity
or tubercular joint. Many substitutes for iodoform have been pre-
pared. The best of these are iodol, salol, aristol, and dermatol. These

OINTMENTS. 19

may be of advantage used as a dry powder on wounds. Aristol is odor-
less and non-poisonous and is valuable in various skin diseases. It is
also useful in the treatment of sores in the form of an ointment (5 or
10 per cent.) or as a dusting powder.

Ointments.

Ichthyol Ointment is a valuable antiseptic in inflammations, such
as erysipelas, in strengths of 5 to 10 per cent.

Boracic Acid Ointment is an excellent preparation and is best pre-
pared as three parts boracic acid, five parts vaselin, and ten parts par-
affin, or, three parts boracic acid, four parts white wax, and twenty
parts olive oil, or, a saturated solution of boracic acid and glycerin.
These are excellent preparations as the case may require.

Salicylic Acid Ointment consists of one part salicylic acid, six parts
white wax, twelve parts paraffin, and twelve parts olive oil.

Protonuclein is of advantage as a dusting powder in the treatment
of ulcers.

Formalin is a valuable antiseptic and is useful for the disinfection
of instruments and hands of the operator, but is too irritating and poi-
sonous to be of use in wounds. It is used in strength of two per cent.

Surgical Dressings.

Surgical dressings consist of gauze, cotton, lint, lamb's wool, or
other substances which have the property of absorbing moisture or
secretions from wounds or abscess cavities. Surgical dressings have
the following objects in view: First, protection of the part from fur-
ther infection; second, to absorb the secretions and keep the wound
thoroughly dry to prevent further development of any noxious material
which may be already present in the wound. Formerly, during the era
of antiseptics, antiseptic gauzes were very popular and in most cases
were very excellent dressings, but it is a recognized fact that many
times these gauzes are irritating because of the chemical antiseptics and
do harm rather than good. This has led to the production of aseptic
dressings. Aseptic dressings are produced by superheating the article
for some length of time at different periods until all germ life has
been destroyed. Things prepared in this manner probably furnish the
best surgical dressings in any form of fresh wound. Where the wound
is septic and foul, antiseptic dressings are needed. In such conditions,
bichloride gauze in the strength of 1 :1000, carbolic acid 5 per cent.,
borated gauze 10 per cent., or iodoform gauze 10 per cent, may be used.
These gauzes are prepared by impregnating aseptic cheese cloth with
the drug. Cotton is a very useful article for the protection of a wound
and for absorption of the secretions. Surgeon's absorbent cotton is the
kind used. This is prepared by removing the oil from the cotton, after
which it is asepticized, and is then ready for use. Surgeon's aseptic
or antiseptic lint is useful in inany cases.

20 ASEPSIS.

ANTISEPTIC PROPERTIES OP THE BLOOD.

Different theories are advocated concerning the methods by which
the human blood resists infection. Metschnikoff advocated the theory
of phagocytosis. This has recently been attacked and quite seriously.
Some have maintained that the leukocytes do not have the power of
destroying bacteria, but in all probability they possess such power. The
antiseptic properties of the blood do not come entirely from the leuko-
cytes but come largely from substances imparted to the blood by means
of the red marrow of the bones, adenoid tissues generally, and fibro-
blasts, and perhaps the tissues of certain glands. These tissue cells,
when the occasion demands, produce certain substances named by Hen-
kin as "defensive proteids" and these impart to the blood its antiseptic
properties. Therefore, in the reaction of the tissues to injury the
antiseptic properties of the blood are markedly increased. Because of
such properties a dry method of operation has been devised by certain
operators. This consists in not introducing airy liquids into an aseptic
wound, but allowing the wound surfaces to be bathed with the blood,
only dry sponges being used, so that after closing the wound the cut
ends of the tissues and the margins of the wound are covered with
blood. Some operators maintain that the antiseptic properties of the
blood are equally as great as any safe antiseptic which might be intro-
duced into the wound. Without doubt it is a most excellent method of
operation. Yaughan and others attribute the antiseptic properties of
the blood to nucleins or cell globulins which it contains. He says that
the origin of these substances is in the leukocytes, fibroblasts, and
adenoid tissues generally.

ASEPSIS.

By asepsis is meant surgical cleanliness. "Sepsis" comes from the
Greek and means putrefaction. The term asepsis refers to that condi-
tion where all agents and substances causing putrefaction or decompo-
sition are absent. Inasmuch as sepsis is the condition against which
nearly all the surgeon's efforts are directed, an aseptic condition would
be ideal if it could be obtained. Since Dr. Henle in 1840 propounded
the germ theory of disease, physicians have sought for methods to pre-
vent bacterial growth. Lord Lister, believing that the source of sepsis
was largely through, the atmosphere, devised means whereby the air
and the surfaces of the wound were impregnated with pulverized anti-
septics. The extremes to which this and other antiseptic methods were
carried undoubtedly resulted in great injury many times. The mon-
strous outcome of such applications, however, was the result of an
erroneous idea of the sonrce of infection. It is now known that infec-
tion comes largely from the hands of the operator, from his instru-
ments, from the surface of the body, and foreign bodies coming in
contact with the wound and that very few, if any, pathogenic micro-

ASEPSIS. 21

organisms gain access to the wound by means of the air. Therefore,
because of the irritating qualities of the antiseptics, antiseptic methods
really introduced into the wound irritating substances, destroyed tissue
cells and added this burden to the healthy tissues and did not render
infection less likely. Having recognized the source of infection, more
simple and less harmful means nave been devised for destroying the
pathogenic germs. It bar, led to the theory of asepsis. The most diffi-
cult thing to obtain in a surgical operation, or in any surgical condition,
is a condition approaching asepsis, and yet it is the condition hoped for
by every operator; and every method known to destroy germs without
the use of irritating chemical compounds should be used and is justifia-
ble. Heat is the best of all agents to destroy micro-organisms, therefore
instruments of any description used about the body, under any circum-
stances whatever, wb ether a fresh wound is present or not, universally
such instruments should be boiled. The bands of the operator can
readily be sterilized, at least made sufficiently clean for all practical
purposes, by the following means. The nails should be pared closely
and all dirt removed from beneath them; the hands and arms should
then be thoroughly scrubbed with soap, water, and a brush which has
previously been made sterile by boiling. The best soap, such as green
soap, or castile soap, should be used. After the hands have been thor-
oughly scrubbed, they may be washed in alcobol to remove the oil from
the sebaceous glands and the skm Lastly the hands may be bathed in
1:1000 solution of bichloride of mercury. Under ordinary circum-
stances, after such preparation, the hands will be sufficiently clean. If
the hand is to be introduced into the peritoneal cavity, more elaborate
preparations may be made. The idea of using sterile rubber gloves in
operative procedures was looked upon favorably by many most excellent
surgeons, but they have gradually given way to approved methods of
cleansing the hands. The surface of the body in the neighborhood of
the wound or in the field of operation may be similarly treated. After
having been thoroughly scrubbed it may be washed with an antiseptic
solution, and if the antiseptic causes any uneasiness, it should after-
wards be removed with boiled water. Surgical dressings/ ligatures,
and any other objects going in or about wounds should be sterilized,
not by antiseptics, but by heat. Substances entering into and going
about wounds impregnated with antiseptics are uniformly irritating
and harmful.

Preparations for an Operation.

When an operation is to take place in a room in a dwelling house,
all furniture, tapestries, and curtains should be removed, and the floor
and walls thoroughly scrubbed and cleansed. The table should be an
iron portable one, easily rendered sterile. Where this is not obtainable,
an ordinary wooden table, well scrubbed and washed with an antiseptic,
will do. Other small tables, one for the anesthetist, one for sponges,
one for the instruments of the operator, and another for a basin con-

22 PRE PAR A TION FOR OPERA TION.

taining an antiseptic solution are needed. Previous to the operation the
surgeon should see that he has a goodly number of sterile towels. For an
ordinary operation, say resection of the knee-joint, two or three dozen
towels should be available. These towels may be made sterile by
means of heat, and placed conveniently at hand for use during the oper-
ation. The patient, in any major operation, or where a general anes-
thetic is to he given, requires preparation. Uniformly the bowel should
be evacuated of its contents by means of a high enema previous to the
operation. Under no circumstances, if the operation is to take place
in the morning, should the patient be allowed breakfast, as the stom-
ach should be entirely empt}\ The patient should be free from any
excitement, and stimulants or drugs of any kind should not be allowed.
A general bath should be given. The body should be scrubbed about
the flexures, genitalia, and perineum, and the head shampooed. If the
operation is to be on a part of the body covered with hair, the hair
should be removed by shaving, when the skin may be thoroughly
scrubbed and cleansed. The method of applying antiseptic poultices,
soap poultices, or other such means is needless. The field of operation
may be thoroughly scrubbed and cleansed by means of soap and water,
alcohol and bichloride of mercury, when several layers of sterile or
antiseptic gauze may be strapped to the surface to prevent any contam-
ination of the part so cleansed. There should also be at hand a large
quantity of boiled water or of normal salt solution for the purpose of
thoroughly washing out the wound. This is of the utmost importance.
Water does not act as an antiseptic, but, on the other hand, dilutes and
washes away the substances upon which the bacteria live. Inasmuch
as it is in no case harmful, the wound may be flooded with large quanti-
ties of water and all irritating and harmful substances can be removed
without difficulty. Ten gallons of water ma}^ be run through, and into
all parts of a large abscess cavity with very beneficial results. The
present practice of injecting antiseptics into such cavities with the
hope that they will destroy the bacteria is a most vicious practice. In
operations where the peritoneal cavity is opened and where septic
material becomes diffused between the viscera, large quantities of nor-
mal salt solution should be run through, and into every nook
and cranny so as to wash out all offending materials. The sponges
used in an operation can be made of gauze or cotton enveloped by
gauze. Gauze pads are perhaps the most serviceable, as they are easily
sterilized. Marine sponges are rarely used and formerly in the hands
of many surgeons were the vehicles of infection instead of performing
the function of removing offensive materials. All the sponges entering
into an operation should be counted, so that if it becomes necessary at
any time to account for them, this may be done. The misfortune
of closing a wound in the peritoneal cavity with a sponge in situ has
happened to good operators. The towels just previous to the operation
should be spread over all parts of the table and those parts of the
patient's body in the region of the operation, so that previous to oper-

SUPPURATION, ABSCESS, ULCER, FISTULA, SINUS. 23

ating the operator has a sterile ''field''' before him. This field of opera-
lion should, at all hazards, be maintained aseptic. During the opera-
tion no one should be allowed to touch any septic object and then touch
the field of operation. The instruments selected by the operator should
be those required in the operation. Any useless array of instruments
is needless and certainly looks bad. The instruments should be wrapped
in a towel previous to the operation and'be allowed to boil for fifteen
minutes. If the operator means to Kgate an artery, bone forceps are
hardly necessary. On the other hand a good supply of artery forceps,
which are reliable, should be at hand.

SUPPURATION, ABSCESS, ULCER, FISTULA, AND SINUS.

Pus formation was at one time supposed to be the inevitable out-
come of wounds. It has been proven erroneous. This was followed by
the belief that all pus was produced by micro-organisms, which is like-
wise untrue. Pus, in a large majority of cases, is the result of the oper-
ations of micro-organisms within the tissues. It is not a specific infec-
tive process, but it is a form of reaction which may happen from various
injurious agents. The pustules of croton oil contain true pus, and yet
the pus is free from micro-organisms. Pus may be looked upon as a
termination of inflammation, which may be caused by chemical agents,
or bacterial action. An acute abscess is generally the result of the
development of bacteria within the tissues, and as such, it will be
described. Bacteria get into the tissues in various ways; sometimes at
hair follicles, other times in small abrasions of the skin, and at other
times at the open, mouths of lymphatics in wounds. They circulate
either in a healthy state or in the form of spores until they lodge in
some part of the body where an inflammatory reaction follows. The
beginning of the inflammation does not differ from the inflammation
arising from other causes, but if the bacteria are present in large num-
bers the tissue changes are very rapid and the symptoms and signs of
the process are more intensified. The invasion of the system by bac-
teria or the pus micro-organisms, in the case of suppuration, has been
likened to the invasion of a country by a hostile army. The leukocytes
which swarm to the inflamed area, attracted by chemotactic influences,
pounce upon the germs and attempt to destroy them. The connective-tis-
sue cells increase in number rapidly; these, too, exhibit phagocytic prop-
erties. Nature attempts to destroy the irritant. When this is impossi-
ble the proliferated connective-tissue cells, now called the round-cells
of inflammation, or fibroblasts, and the leukocytes, form a wall around
the bacteria. Inasmuch as the inflamed area is so crowded with leuko-
cytes and round-cells it interferes with the flow of the fluids and the
nutrition is cut off to the center of the inflamed area. Death of this
central area follows. The first change occurring is a coagulation of the
albuminous principles in the cell, the nucleus becomes less distinct, the
protoplasm granular and cloudy (Coagulation Necrosis). Coagulation

24 CASE A riON.

necrosis is the first step in pus formation. Now this central mass which
has undergone coagulation necrosis becomes liquefied by the peptoniz-
ing influence of certain ferments which are developed by the micro-
organism (Liquefaction Necrosis). The result of the liquefying of the
tissues is pus. This pus in ordinary abscess formation is limited
by a membrane. It was called by the old writers a pyogenic membrane,
inasmuch as they thought it produced pus. Now it is called the Limit-
ing Membrane since it is this membrane which prevents the extrava-
sation of the pus into the other tissues. Pus forms only after stasis
occurs, and after the nutrition to the inflamed area has been arrested;
therefore, to prevent pus formation, circulation of the fluids must be
kept up. Pus of abscesses varies largely, depending upon the cause of
its formation and the condition of the tissues.

Laudable Pus. — This term was formerly used by surgeons to indicate
the pus flowing from a wound. It is usually of a specific gravity of
1028, is yellowish, yellowish-white, or a greenish fluid of the consistency
of cream, with or without odor.

Ichorous Pus is a putrid fluid which is thin and watery and contains
large numbers of the micro-organisms of putrefaction.

Foul Pus may be ichorous and may be due to various micro-organ-
isms. Certain abscesses discharge this character of pus. Ischiorectal
abscesses and those following typhoid fever are notoriously foul and
stinking.

Sanious Pus is a term applied to bloody pus or that which contains
coloring matter. Sometimes it is thin, reddish, and corroding.

Fibrinous Pus contains fibrinous masses or coagulated purulent
masses. It is met with in the pus of serous cavities.

Blue or Green Pus is due to the presence of the B. Pyocyaneus.

Serous Pus is a serous-like fluid containing flakes of purulent matter.

Tubercular Pus is generally curdy, containing cheesy-like masses.

Muco-Pus is a term applied to the decomposed or purulent mucus
found in catarrhal conditions.

Caseation is a term applied to the fatty degeneration of pus and
dead tissues. These caseous masses may undergo calcification.

It may then be considered that pus only happens from micro-organ-
isms when their onslaughts are so severe as to overwhelm certain por-
tions of the tissues, thus causing death and destruction. This pus is
confined, as before stated, by a limiting membrane. Pus is an offending
substance nature wishes to get rid of, therefore, by the action of certain
forces it burrows in the direction of least resistance. This is not always
toward the surface. In the case of purulent synovitis of the knee-joint
the pus generally burrows upward on either side of the thigh. Pus
forming on the front of the body of a vertebra in the lumbar region,
along the attachment of the psoas magnus muscle, forms a cavity in
the sheath of this muscle, then burrows along down the sheath and

PHLEGMON. 25

opens beneath Poupart's ligament. Pus may burrow a long distance. Pus
from an abscess of the appendix may rupture at the umbilicus. The
writer operated upon a case of this sort where the abscess had been
of more than a year's standing. A rapid and complete recovery fol-
lowed. In abscess on the thumb or little finger, as happens in whitlow,
the pus may burrow along the sheath of the tendons and open
above the anterior annular ligament of the wrist-joint. Pus may bur-
row from the chest cavity down the arm. Pus forming in the hip-joint
may burrow in several directions. (See hip-joint disease). When it is
toward the surface it gives the appearance of "pointing." This point-
ing is evidenced by a dark-bluish spot which afterwards becomes
necrosed, and as the pus approaches the skin, it shows a yellowish color
through the translucent epithelium. When pus ruptures from an
abscess without the assistance of a knife, the opening is rarely suffi-
ciently large; furthermore, necrosis of the superficial tissues results in
the formation of an ugly scar; hence it should be a uniform practice,
whenever pus formation is detected, to make a free incision and evacu-
ate the pus. Pus formation is attended with an intensification of the
symptoms of inflammation. The pain is more severe and more of a
throbbing nature, the redness becomes more dusky, and the swelling
very often edematous. The loss of function becomes more complete
while the heat is greater and in large abscesses the absorption of the
toxins from the abscess may be such as to cause fever and other sys-
temic disturbances, such as anorexia and partial arrest of the
secretions. Previous to the pointing of the abscess the skin becomes
adherent to the deeper structures. Many times this is an indication
of the formation of pus before fluctuation can be obtained. Fluctuation
is the sensation obtained by holding the finger upon one side of the
abscess and tapping the other side. This causes a wave-like motion in
the fluid, which is transmitted to the finger. If the abscess be of suffi-
cient size, a chill may attend the formation of pus. This chill is the
result of circulatory disturbances brought about by the effect of the
poisons upon the vasomotor centers. Following the chill there is
usually a high fever and a drenching sweat. If the abscess be large
and deep seated and is not soon evacuated of its contents, irregular
chills may occur. This is one of the sure signs of pus formation. If
the diagnosis can not yet be made, a tubular exploring-needle may be
introduced into the abscess cavity, when the character of the contents
may be determined, to a certainty.

Abscess formation is generally of two kinds, Circumscribed and
Diffuse. Circumscribed abscess formation is similar to that which
occurs in a boil or furuncle. Diffuse pus formation is called Phlegmon
or purulent infiltration.

Phlegmon. — This process may involve areas of varying sizes, from a
small patch to the entire limb, and is generally due to the infection of
the streptococcus pyogenes or streptococcus erysipelas. These germs
are very often extremely virulent and active. The barrier set up by

26 VARIETIES OF ABSCESS.

the leukocytes and connective-tissue cells will not restrain them. They
disseminate through the intercellular spaces and lymph channels and
spread rapidly, causing intense inflammation, marked swelling, pain,
and great discoloration. The pain very often is of a burning character.
Necrosis of the superficial areas, because of the arrest of the circula-
tion, is not unusual. Neighboring lymphatic glands become inflamed
and enlarged. Chills may occur at the onset of the inflammation, or
there may be severe chills at short intervals in conditions of rapid
infection. Fever, under such circumstances, is more or less continuous,
but following each chill there is a rapid rise, when it again falls
to a minimum. In severe cases the fever may take on a typhoid charac-
ter. In case of broken-down health, compound fracture with great
destruction and injury to the soft-parts, in extravasation of the urine
through the tissues, or in pus formation following an attack of an acute
infectious disease, it is not unusual for the fever to be of a typhoid
nature. It is a very grave condition, and means a septic intoxication,
and unless evacuation of the pus and cleansing of the abscess cavity can
be made, death is imminent. About the edges of the inflamed area there
are red, fiery lines extending from it in forked directions, indicating
that the inflammation extends along the lymphatics. Like cases may not
suppurate, the leukocytes having destroyed the poisons. As soon as the
tissues assert themselves and win the battle waged against the germ, a
circumscribed abscess will follow, when the pus may be evacuated and
the case recovers. When the pus cavity is evacuated, granulation tissue
fills it up. This cicatrizes and a scar results which permanently marks
the location of the abscess.

Varieties of Abscess.

1. Acute, which is the result of an active inflammatory reaction.

2. Chronic, which is one due to certain conditions of the tissues
rather than germs. They are less active and are sometimes called
strumous, cold, or tubercular.

3. Circumscribed, when the abscess has a well defined limiting mem-
brane.

4. Diffuse, when no limiting membrane occurs.

5. Hypostatic, when it is the result of pus gravitating into a part.

6. Embolic, where the abscess is the result of an infective embolus.

7. Encysted, where the abscess is enclosed by a fibrinous wall.

8. Fecal, when the abscess contains feces.

9. Metastatic, when the abscess is caused by pyogenic cocci from
another abscess.

10. Hematic, which arises from bloodclot.

11. Milk Abscess, an abscess of the breast in nursing women.

12. Psoas, an abscess in the psoas muscle.

ABSCESS OF REGIONS. 27

13. Tropical, an abscess of the liver occurring in hot countries.

14. Thecal, when it occurs in the sheath of a tendon.

15. Urinary, when caused by the extravasation of urine.

16. Brodie's Abscess, is a chronic abscess of bone, most commonly
occurring in the tibia.

17. Deep Abscess, when it occurs beneath the deep fascia.

18. Superficial Abscess, when it is above the deep fascia.

19. Pag'et's Abscess, one occurring from the residue of an old abscess
after several years.

*•

Acute Abscesses of Various Regions.

1. Abscess of the Brain. — See Cerebral Abscess.

2. Abscess of the Appendix "Vermiformis. — See Appendicitis.

3. Abscess of the Liver may follow dysentery, appendicitis, or sup-
purative processes in other locations of the body. Where the abscess
obstructs the gall-duct, jaundice will occur. In addition to the pain and
tenderness over the iiver and the enlargement of the liver, fever of an
intermittent t}rpe is present, and there will be severe pain in the shoul-
der and back. The burrowing of the abscess towards the surface is
announced by edema of the skin. Occasionally the condition is not
diagnosed until late.

4. Subphrenic Abscess, as the term indicates, arises beneath the
diaphragm, and is generally of the lesser peritoneal sac. It may arise
from perforation of some of the hollow viscera, from Pott's disease, or
from infection or injury of some of the viscera.

5. Abscess of the Mediastinum is difficult to diagnose except by the
systemic signs.

6. Abscess of the Lung occurs in conditions of pyemia after pneu-
monia, or after injuries and perforating wounds of the lung.

7. Perinephritic Abscess is difficult to diagnose, but occasionally
causes pain down the back of the leg, simulating hip-joint disease.
Edema and fluctuation in the lumbar region may announce the point-
ing of the abscess.

8. Ischiorectal Abscess is caused by an infection of the cellular tis-
sues of the ischiorectal fossa, by means of micro-organisms which have
migrated from the rectum through the intestinal wall. See fistula in
ano.

9. Abscess of the Antrum of Highmore. — See Abscess of Antrum.

10. Postpharyngeal Abscess may come from caries of the cervical
spine. This may occasion difficulty in swallowing and breathing and
puffiness in the postphar}'ngea! wall. Fluctuation may be felt.

11. Prostatic and Urethral Abscesses are attended by painful and fre-
quent micturition or retention of urine, together with chills and fever.

28 TREA TMEN T OF ABSCESS.

12. Abscess of the Breast is caused by pyogenic micro-organisms
entering from abrasions of the nipple, or is cine to an obstruction of the
milk-ducts, .by pendulous breasts, or by luxations of the ribs, affecting
the return circulation. The symptoms of this abscess are similar to
those of abscesses in other regions.

13. Palmar Abscess and Felons. — See Thecal Abscess.

Symptoms of Acute Abscess.

(A) Local, and (E) Constitutional.

Local Symptoms. — 1. Pain, throbbing or burning. 2. Dusky hue
of the skin. 3. The skin is adherent to the underlying tissues. 4.
Edema. 5. Fluctuation. 6. Great heat.

Constitutional Symptoms. — 1. Chills, varying from a chilly sensa-
tion to distinct rigors. There may be one or several, happening irreg-
ularly, usually at the formation of each new abscess, as in
pyemia. 2. Headache. 3. Muscular soreness. 4. Coated tongue
5. Loss of appetite. 6. Sleeplessness. 7. Fever, varying from
half a degree to a rise of several degrees, 8. Highly colored and
scanty urine. 9. The bowels are confined. 10. Certain nerve symp-
toms which vary from irritability to delirium of a noisy character.
Where the abscess is old and long continued it gives rise to what is
called a hectic fever, which is sometimes attended by a peculiar flush
upon the cheek (hectic flush). This is characteristic of tuberculosis,
the fever in which is produced hy pus formation.

Diagnosis of Acute Abscess.

The diagnosis of acute abscess formation is made by weighing the
symptoms present. Where there is doubt the physician should tempor-
ize, unless urgent measures must be adopted. An exploring-needle
may be introduced, which will determine the character of the con-
tents of the tumefaction.

Abscess may be confounded with Aneurysm, Avhen it is seated over
an artery because it is pulsatile. Tt may be confounded with Cyst; an
exploring needle will determine this. A tubercular abscess is differ-
entiated by means of the absence of the inflammatory signs and the
general condition of the patient. A rapidly growing Sarcoma has
deceived some physicians, but here again an exploring-needle would
determine the nature of the tumefaction. Where the character of the
contents of the cavity is doubtful, cultures may be made to determine
whether micro-organisms are present.

Treatment of Acute Abscess.

(A) Osteopathic and (B) Operative.

The Osteopathic treatment is of great value in the treatment of
abscess when brought into use before pus is formed. Suppuration in

TREATMENT OE ACUTE ABSCESS. 29

almost all foims of abscess may be arrested if seen sufficiently early.
The treatment in general is similar to that of any inflammation, but is
more especially directed toward relieving stasis, which must take place
before pus is formed. Death of tissue anywhere is always the result of
the arrest of nutrition. The treatment consists in relieving any obstruc-
tion to the circulation, whether it is within the fascia, muscles or other
tissues. Eelieving the obstruction and encouraging the circulation pre-
vents stasis and the formation of abscess. In many cases the obstruc-
tion may be from bony displacements. These will be at once recognized
and relief given immediately. By appropriate treatment resorption of
the inflammatory products can be secured by opening up the mouths of
the lymphatics and increasing this circulation. Where the pain is great
it can be relieved by removing the obstruction to the circulation, thus
relieving the tension. The fever may be reduced by appropriate treat-
ment. The urinary secietions may be stimulated so that the poisons
circulating within the body may be eliminated, while the bowels, if
confined, should be freely opened.

Operative. — When suppuration is imminent, heat in the form of hot
fomentations or hot poultices may be applied. In small abscesses it is
perhaps the best practice to hasten pus formation and allow it to rup-
ture of itself, unless the boil occurs on an exposed part of the body,
when an incision by a small tenotome or dermal lancet may be made to
evacuate the pus. Should such incision be made, the abscess should
be washed out with an antiseptic solution and the cavity swabbed out
and thoroughly cleansed so as to prevent further pus formation. In
case of an abscess of large size a free incision should be made. The
abscess cavity should be washed out with an antiseptic solution and
good drainage established. Drainage is best obtained by introducing a
strip of gauze, which is not too large to obstruct the free flow of the
■fluids, to the very bottom of the abscess. If the abscess is of large size
and collapsible and of long standing the gauze should be lightly packed
in so as to keep the abscess cavity distended to permit of drainage from
all its parts. Drainage is the most important feature in the treatment
of an open abscess. In an abscess that has opened of itself, it should
be seen to by the attending physician that the opening is large enough
to permit of free drainage of the fluids from it. If there be no general
cause for the abscess, no systemic ailment, such as a strumous condi-
tion, syphilis, alcoholism, or a diathesis of any kind, and free drainage
and antisepsis is maintained by washing out the abscess at least once
daily, the abscess will readily heal in a short time. Should the abscess
continue for some length of time, the antiseptics used to wash the
cavity should be changed, e. g., carbolic acid one week, bichloride the
next week, etc.

In abscess of the Appendix, the appendix may be removed and the
pus cavity washed, out. A cigarette drain may then be inserted.

In Pelvic Abscess drainage may be had by means of a glass tube. A
fenestrated rubber tube may be serviceable in establishing drainage

30 DANGERS OF ABSCESS.

from an abscess in joints, pleura, or other locations, but Treves' method
of gauze drainage is usually the best.

In opening an abscess care should be taken to make the incision in
the direction of the vessels and so as to not injure any important
structures. Hilton's method of opening an abscess is an excellent one
in case of abscess of the neck. This method consists in making a small
incision or puncture in the abscess with a bistoury or small scalpel,
when a closed arter}r forceps is introduced into the abscess cavity, then
opened and withdrawn. While this operation is painful it is safe, for
the arteries and nerves will not tear as readily as the connective tissues
by which they are surrounded, hence you enlarge the opening at the
least possible risk. After the abscess is evacuated, a small strip of
gauze may be introduced to prevent closing of the opening and to estab-
lish drainage. The abscess should always be opened at the most depen-
dent part so as to secure the benefit of gravit}r in drainage. Where the
abscess is large it may be punctured and a grooved director inserted,
and when it is known that no important structures lie between the
grooved director and the surface the tissues may be readily divided and
a large opening secured. In case of old abscess it is advisable to scrape
out, with a dull curette, the inside of the abscess to get rid of the dead
materia], flocculent pus, and masses of dead tissue, and to permit the
antiseptic solution, with which the cavity must be flooded, to get into
every nook and cranny. The antiseptics used in abscesses should be,
in acute abscesses, corrosive sublimate or carbolic acid solutions where
free drainage can be had and there is no likelihood of the fluids being
retained. Under no circumstances* must peroxid of hydrogen be used
unless there is a large opening and free drainage and plenty of oppor-
tunity for the gas to escape, as sometimes large quantities of gas are
evolved when it comes in contact with pus. In acute abscesses, where
there is not good drainage and there is much absorption of pus, the
cavity should be washed out two or three times daily. Where there is
good drainage once daily is sufficient, depending upon the nature of the
discharge. As the abscess begins to heal the discharge will become
less purulent and at the same time more serous, and as the discharge
becomes less, and as the abscess heals from the bottom up, the gauze or
other drainage material may be left out ; not, however, until there is no
possibility of any pockets forming. Boroglyeericle solution and emul-
sions of iodoform are extensively used in chronic abscesses.

Dangers of Abscess.

1. Hemorrhage. — In certain conditions of pus formation where the
pus burrows about blood-vessels, the walls of the vessels may become
eroded and burst. Fatal hemorrhage has occurred from such cause.

2. Rupture into Large Cavities. — Where an abscess ruptures into a
joint or serous cavity such as the pleura or peritoneal cavity, rapid

CHRONIC ABSCESS. 31

absorption of the pus will take place, inasmuch as these cavities are
but large lymph spaces and furnish opportunity for very rapid absorp-
tion of pus, therefore a rupture into any such cavity is likely to be rap-
idly fatal.

3. The Formation of Sinus or Fistula occurs where foreign bodies
remain at the bottom of the abscess cavity, where bone becomes
necrosed and sequestra are formed or where the pus has burrowed
through a long tortuous tract, where the abscess is poorly drained or
where there is some constitutional disturbance. The fistula occurs
where the pus has burrowed from one normal cavity of the body to
another, or to the surface of the body.

4. General Sepsis takes place in diffuse pus formation where the pus
extends around, through, and along the planes of connective tissue
which extends around and between muscles, over bones, nerves, and
blood-vessels in such a manner that rapid absorption of the toxins may
take place. General sepsis may occur following the rupture of a circum-
scribed abscess into a large serous cavity or into the planes of connective
tissue.

5. Deformity. — Pas formation may result in serious deformity, as
happens in palmar abscess, caries of the spine, and in abscesses of the
neck large and hideous scars may be formed. Abscesses of the middle
ear oftentimes permanently impair the hearing. Such deformities
should be anticipated and the abscess opened early so as to limit the
formation of new tissue, which may bind down important structures,
and the contractions of which may be unsightly.

Chronic or Cold Abscess.

A chronic or cold abscess is one which is not inflammatory, the signs
of active inflammation being absent. It differs from acute abscess, in
that it generally forms slowly ; and, while the signs of inflammation are
present to some extent, only in a minor degree. This abscess does not
depend upon the presence of pyogenic micro-organisms. The contents
of 'a cold abscess differ markedly from that of the acute, being very
often thin and curdy, instead of thick and creamy. There
are cases of superficial chronic abscess where the contents vary
but slightly from the pus of an acute abscess. Its chief char-
acteristics are that it is not inflammatory and the cause more obscure.
It was formerly said to be idiopathic. They generally arise from carious
bone, chronic joint disease, caseating lymphatics, and from retrograde
changes taking place in connective tissue planes. The real causes of
chronic abscess are bon)r, muscular, or fascial lesions affecting the cir-
culation and nutrition. The tissues become debilitated and lose their
resisting power. They easily undergo degeneration and form pus be-
cause of a trivial injury. These lesions may affect a part directly or
reflexly. They not only constitute the most important causative factor
in this disease, but also their removal will be attended by a disappear-

32 CHRONIC ABSCESS.

ance of the abscess. The depraved condition of the tissues local or
general, directly the result of certain lesions, permits of the deposit
of the tubercle bacillus, resulting in the formation of the tubercular
abscess. By' no means are all of these chronic abscesses tubercular. In
the pus from some of them the tubercle bacilli may be demonstrated,
but in many others not only can the tubercle bacilli not be found in the
pus, but (likewise not in the surrounding connective tissues. The prac-
tice of some physicians in calling all of these chronic abscesses "tuber-
cular" is certainly bad. These abscesses may exist for months, and
even years, without rupturing externally, during which time there may
be no febrile reaction. Ofttimes the pus burrows for a long distance,
and the sinuous tract is lined with fibrous tissue which may even, in
some cases, be cartilagenous.

i

Symptoms of Chronic Abscess.

The svmptoms are various, differing according to the location of
the abscess; when it is due to a carious spine it is accompanied by
marked spinal curvature ; when associated with bone abscess it is usually
very painful and accompanied by great thickening of the bone and
in. Juration of the tissues. Prior to the opening of the cold abscess no
constitutional symptoms appear — no chill, no fever, no loss of appetite,
or nervous symptoms, but on the other hand there is a certain amount
of general debility in a large number of cases. After the abscess opens
or is opened, pyogenic infection will most likely take place, when a
general hectic fever follows and many times where the abscess is insuf-
ficiently drained and putrefactive changes take place in the retained
discharge, the patient may growr rapidly worse and the case terminate
fatally. This led old practitioners to avoid opening the abscess as long
as possible, and to attempt to get rid of the diseased condition by other
means. Where a chronic abscess becomes infected and the patient is
debilitated, suppuration may extend over a long period. A hectic fever
with the characteristic evening rise and morning remission, giving the
mental picture of a wasting disease, will follow. The case may be
terminated by exhaustion, renal disease, a diarrhea, or by an abscess
forming in the liver.

Diagnosis of Cold Abscess.

The diagnosis of a cold abscess is somewhat difficult. It may be
taken for blood extravasation, soft tumor, lipoma, cyst, etc. Where the
diagnosis is questionable, a needle may be introduced and some of the
fluid, if any is present, withdrawn.

Terminations of Cold Abscess.

A cold abscess after remaining quiescent for months, or even years,
may again become active, enlarge, and rupture. A cold abscess may
rupture upon mucous surfaces, in a serous cavity, or upon the surface

TUBERCULAR ABSCESS. 33

of the body. The contents may be only watery, containing curdy-like
masses, or the fluids may be absorbed and this cheesy-like material may
undergo, calcification and remain quiescent for years. Perhaps after an
injury or the person has become debilitated an abcess may arise from
this cheesy mass. This is called by some writers, Kesidual Abscess.

Treatment of Cold Abscess.

In the treatment of cold abscess, constitutional derangement or bony
lesions should be looked for. Whatever the derangement is, or what-
ever the lesion is, this should be corrected. The flow of the fluids and
the nutrition in the affected tissues should be encouraged. If a person
is of a constipated habit, this should be corrected. If he is suffering
from general debility, his system must be built up. Every effort should
be made to cure the abscess without opening, unless it enlarges, when
aspiration should at first be resorted to, and the general treatment con-
tinued. In a large chronic abscess a person should lead an ouodoor
life. If the abscess is opened it should be scraped well with a Volk-
mann's spoon to get rid of the detritus and dead material clinging to
the abscess walls. Irrigation of the abscess cavity with antiseptic solu-
tions and the enforcement of the most rigid cleanliness is essential.

Tubercular Abscess.

Tubercular abscess may occur wherever the deposit of the tubercle
bacilli may take place, but this is generally in connection with bones,
joints, lymphatics, an'd connective tissues. It differs from the ordinary
chronic abscess in that the exciting cause of the disease process is the
tubercle bacilli. ^Lesions, as misplaced bone or contracted muscle,
affecting the flow of the fluids and weakening the tissues, render possi-
ble the deposit of the germs. Many of the abscesses which are tuber-
cular, so-called, may not be turbercular, inasmuch as it is quite impossi-
ble to demonstrate the presence of the tubercle bacilli. They often
happen in connection with the spine, where it is called "Pott's disease,"
or the hip-joint, where it is called "Morbus Coxarius," or the knee-
joint, where it is popularlv termed "White Swelling." They are found
in persons who have inherited weakness of some sort, often where the
parents or near relatives have been subjects of tuberculosis.

Symptoms of Tubercular Abscess. — It presents many of the symp-
toms of other forms of tuberculosis with chronic abscess formation. The
pathology of this abscess formation is that of the deposit of the tubercle
in the tissues.

Treatment of Tubercular Abscess. — The treatment of tubercular
abscess has been greatly modified by the practice of osteopathy. The
most important part of the treatment is to relieve any constitutional
derangement or bony lesion which may account for the condition pres-
ent. This latter idea is ridiculed by other practitioners, but the uni-

34 ULCER.

formity with which good results have been obtained by correcting such
lesions and increasing the blood supply to the part, no longer leaves
it open to question. In addition to the osteopathic treatment which
may be instituted according as the case requires, the local treatment of
the abscess may be included under the following heads :

1. Aspiration of the pus will sometimes lead to its disappearance.
Eepeated aspirations, together with other manipulative treatment, as
the case requires, ought, in a large majority of cases, to be suffi-
cient.

2. Tapping and Irrigation consist in removing the fluid and irrigat-
ing the cavity with an antiseptic solution. This treatment is fairly suc-
cessful in some cases.

3. Extirpating the Tubercular Area. — This consists in dissecting out
the abscess and its wall, thoroughly cleansing the wound and closing the
incision or wound without drainage. This has been successful in some
cases.

4. Iodoform Emulsion Treatment. — Iodoform was at one time ex-
tremely popular with surgeons, but the writer has" never, in his experi-
ence, had any success which he felt he could conscientiously attribute to
the action of iodoform emulsion injected in these cases. It may be
useful as an antiseptic, but to inject it subcutaneously in the tubercular
abscess or joint, is not good treatment and is hardly warranted.

5. Simple Drainage With Antiseptics, which is the same method as
is used in the treatment of acute abscess, can be resorted to at any time,
but here it should be understood that the most rigid antisepsis is nec-
essary.

6. Open Method. — This method consists in laying the cavity open and
cauterizing the area freely Avith carbolic acid and allowing the wound
to heal from the bottom.

Ulcer.

An ulcer is an open sore produced by the destruction of surface tis-
sues. The term "ulceration" means molecular destruction of the soft-
parts, in contradistinction to "gangrene," which is death of the soft-
parts by mass. Molecular death of bone is called "caries." "Necrosis"
means death of bone by mass. Soine writers maintain that any open
wound is an ulcer, but this view is hardly a good one. Ulceration is best
considered as a process similar to abscess formation, which takes place
in surface tissue and results in death of certain small masses of tissue
— gangrene — which are cast off, or which soften and break down and are
discharged. The causes of the ulcer are similar to the causes of abscess
formation, viz., an abnormal circulation, deficient nerve supply, obstruc-
tion to the return circulation, deficiency in the quality and quantity of
the blood distributed to the part, or to the circulation of poison within
the body, or to infection, or injury — pressure, or to the application of

VARIETIES OE ULCERS. 35

corroding chemicals, or the existence of some constitutional affection,
viz., syphilis, gout, tuberculosis, etc. Inasmuch as the ulcer is open,
pyogenic cocci always play an important part in the process.

Varieties of Ulcers.— 1. Simple.— A simple or healthy ulcer presents
smooth, shelving edges and a granulating base and has but little dis-
charge.

Treatment. — Promote the nutrition and circulation by proper treat-
ment and wash the ulcer daily with an antiseptic solution. Use a pro-
tective ointment in small ulcers, with several thicknesses of antiseptic
gauze and cotton, the bandage being applied in the direction of the
return circulation. Where the ulcer is on a part of the body where
a scar will produce serious deformity, skin grafting should be resorted
to. This operation will promote cicatrization. There are three meth-
ods generally employed. One (Tiersch's method) is that the ulcer
should be brought into a healthy condition by the use of strong anti-
septics, lastly being washed by boiled normal salt solution. The surface
of the body from which the skin is to be removed is made aseptic and
the superficial layers of the epidermis scraped off, when by means of a
razor or sharp knife, small longitudinal strips of the epidermis only are
removed and laid over the healthy ulcer.

The second method is to remove small bits of skin by sticking a needle
between the true and false skin and then by means of a knife cutting
off a small patch of epithelial cells above the needle. Numbers of these
patches are removed from the part of the body, which has previously
been thoroughly cleansed, and are set around over the ulcer, which has
been previously rendered thoroughly aseptic. The part is then pro-
tected from any irritation or injury, when healing generally takes place
rapidly. From these small "grafts" the epithelium spreads out over
the healthy granulating surface.

The third method, of closing an ulcer is quite successful, when it is
so located that the operation is feasible. This is a sliding flap opera-
tion. A suitable flap can be taken from near the ulcer and
turned over so as to cover it. After the edges of the flap have united
with the margins of the ulcer the pedicle of the flap may be cut off.
The wound from which the flap is removed can be closed by interrupted
sutures.

2. Fung-ating Ulcer. — A fnngating ulcer is generally due to an ob-
struction to the return circulation. This may be due to undue contrac-
tion of the tissues between the ulcer and the heart. The edges of the
ulcer are apparently healthy, but the granulations rise above the surface
and are exuberant, are very red and bleed easily. The discharge is gen-
erally purulent.

Treatment. — Eemove such obstruction, cauterize the fungus growth
with creosote, copper sulphate, or nitrate of silver. Afterwards it may
be treated as a healthy ulcer.

36 VARIETIES OF ULCERS.

3. Edematous Ulcer. — Edematous ulcers happen in a part of the body
where the tissues are weakened and there is an obstruction to the return
circulation.. The person suffers from a condition of general debility
and the tissues about the ulcer are edematous because of the poor circu-
lation. The ulcer is unhealthy. The discharge is watery and quite
free.

Treatment. — Remove the cause, i. e.. obstruction to the circulation,
treat the general condition, enforce cleanliness, and antisepsis. Boracic
acid powdered in the ulcer or equal parts of boracic acid and acetanilid
make an excellent dressing.

4. Inflamed Ulcer. — This term applies to ulcers where the inflamma-
tory reaction is the most marked feature. These ulcers are generally
irregular and ragged, or they may be sharp cut. The skin about is red
and edematous. The discharge is generally quite watery. It is due
to septic conditions where the part is frequently irritated.

Treatment. — Rest, relieve the irritation, elevate the part, and assist
the return circulation and use antiseptic lotions frequently until the
ulcer presents a healthy appearance.

5. Sloughing Ulcer. — This is a severe form of ulceration. It is more
frequently met with in venereal diseases, unclean conditions or in per-
sons who have diminished vitality or suffering from general debility
or some constitutional disease. The ulcer spreads rapidly, the edges
are undermined and inverted ; the surfaces of the ulcer are ash-gray or
black. There is geuerally great pain and a continued fever. If the
person is syphilitic, the syphilis should be treated. The dead tissues
must be removed, the ulcer washed out twice daily with a 1:1000 mer-
curial solution, while the surfaces of the wound should be powdered
with equal parts of boracic acid and acetanilid.

6. Phagedenic Ulcer. — These rarely occur except in very unsanitary
conditions and in connection with venereal diseases, or in persons with
broken-down health, or in those who are intemperate. These ulcers
spread rapidly and are very destructive. In a case treated in the free
clinic in the American School of Osteopathy, an ulcer arising on the
side of the penis extended over the scrotum and around the buttocks.
The ulcer was full of maggots and was extremely foul, yet by the use
of antiseptics and proper osteopathic treatment the patient entirely
recovered and suffers but little inconvenience from the extensive de-
struction of the tissues. The ulcer was washed out with a strong solu-
tion of permanganate potassium twice daily; after a few days a solution
of mercuric chloride (1:1000) was used. It is essential to build up the
person's general health before a satisfactory result can be obtained.

7. Indolent Ulcer. — This is a form of ulcer which simply refuses to
heal and is caused by some local lesion, some, constitutional defect, or
by continued irritation and neglect. It is most common on the inner
side of the lower third of the leec or foot where the circulation is defect-

INDOLENT ULCER. 37

ive. The edges of the ulcer are white and calloused, and often the
ulcer is insensible to touch. The skin is often congested and edema-

Fig. 5.

Chronic Ulcer of the Leg.

tous. The base of the ulcer contains a whitish discharge and shows few,
if anjr, granulations. These ulcers may exist for years. Simple oste-
opathic treatment cured a case of extensive ulceration of both lower
legs which had existed continuously for thirty-eight years. Sometimes
the discharge from these ulcers is very great. There is another peculiar
thing in relation with these ulcers, and that is the system seems to have
accommodated itself to their presence and to the discharge which takes
place. Astringents or other agents arresting the secretions must not
be used, but the ulcer must be allowed to gradually heal while the per-
son's general health is improved. It was formerly thought that the
healing of such ulcers would be accompanied by constitutional disturb-
ances, inasmuch as the discharge could no longer get out of the body.
The discharge from these ulcers is not a humor of any kind, but is a
result of the devitalized condition of the tissues of the part.

Treatment. — Better the Circulation to the Inflamed Area. — Boracic
acid powdered on the ulcer twice daily or washing it with an antiseptic
solution twice daily, and a little carbolized vaselin smeared around the
edges to prevent the gauze dressing from sticking to the ulcer, after
which equal parts of boric acid and acetanilid, or pure boracic acid
powdered over the ulcer, will assist healing. The important points in
treating an indolent ulcer are (1) to remove the source of irritation;
(2) remove the obstruction to the return circulation; (3) stimulation of
the ulcer; (4) antisepsis. Where the circulation is poor the limb affected
must be bandaged from the toes upward by a figure-of-8 bandage. The
bandage should be silk or cotton elastic or a wet woolen bandage.

8. Varicose Ulcer. — A varicose ulcer is an indolent ulcer happening
in a condition of varicose veins. For treatment see "Varicose Veins/'

9. Irritable Ulcer. — The term "irritable ulcer" is applied to two
kinds of ulcers, one opening about the inner surface of the ankle in
women beyond middle life. It involves some of the peripheral nerves.
The other is a small ulcer occurring in the rectum at the margin of the
anus.

38 TREATMENT OF ULCERS.

Treatment. — Improve the general health. Lotions of carbolic acid
or carbolized ointment are generally sufficient.

10. Tubercular Ulcer. — These happen in tubercular subjects and are
peculiar, in that the}^ refuse to heal and are very painful. They occur
in the larynx, mucous membranes, rectum, etc. The treatment should
be directed toAvards relieving the tubercular conditions. Cauterization
is sometimes useful.

11. Syphilitic Ulcer. — These occur in persons who have secondary
or tertiary syphilis. In secondary syphilis small ulcers (mucous patches
or serpiginous ulcers) occur in the mucous membranes of the mouth,
pharynx, arid larynx. The treatment should be directed toward reliev-
ing the syphilitic conditions. In secondary syphilis the ulcers are infec-
tious and should always be cauterized as soon as seen to prevent any
further spread of the infection. In tertiary syphilis the ulcers gener-
ally occur upon the surface of the bo'dy. These ulcers are not infectious.

12. Gouty Uicer. — Gouty ulcers occur in gouty subjects and can
not be cured until the diathesis is relieved.

13. Scorbutic Ulcer. — Scorbutic ulcers happen in subjects afflicted
with scurvy. Proper diet and cleanliness will give relief.

14. Mucous Ulcer. — This is a form of tubercular ulceration of the
skin. The treatment consists in cauterizing the ulcer or thoroughly
scraping it out and then cauterizing the base.

15. Rodent Ulcer or Jacob's Ulcer is a form of epithelioma which
requires cauterization or removal by the knife.

16. Trophic Ulcer is caused by some injury or disease of the central
nervous system or of a nerve trunk, whereby the trophic fibres distrib-
uted to the part are destroyed, thereby cutting off this source of nutri-
tion. These ulcers happen on the bottom of the foot in cases of hemi-
plegia and are frequently called perforating ulcers.

17. Decubital Ulcer or Bed-sore is really a form of gangrene. (See
Gangrene.)

The general treatment of Ulcers consists in treating constitutional
defects which may in any way be the cause of the ulcer, removing any
obstruction to the nerve or blood supply, and removing any source of
irritation whatsoever; to use cleanliness and antisepsis, to dress the
ulcer once or twice daily with antiseptic gauze, first having powdered
over the ulcer protonuclein, boracic acid, equal parts of boric acid and
salicylic acid, aristol, or some other such powder, then over the gauze
is applied a sufficient amount of absorbent cotton to absorb all the dis-
charges. The dressing should be changed daily and the parts bandaged
so as to assist the return circulation. Obstruction to nerve and blood
supply can be relieved by removing whatever lesions are present.

GANGRENE. 39

Sinus.

Sinus is generally the result of pus burrowing through the tissues,
and is an opening which leads from an abnormal cavity to one of the
normal cavities or surface of the body. Examples of sinuses are seen
in caries of the spine, psoas abscess, necrosis of the bone, in the forma-
tion of any deep seated abscess, or in the discharge of pus from the knee
or hip joint. Frequently a sinus is long and tortuous. It may be
lined with a pyogenic membrane or with fibrous tissue, or, in cases of
long standing where the irritation has been severe, it may be lined with
cartilagenous tissue. The origin of a sinus is really an unhealed abscess,
healing having been prevented by bad circulation, irritating discharges,
foreign bodies, general ill health, want of rest, or because of the rigidity
of the walls preventing collapse. Foreign bodies, such as pieces of
dead bone, bits of wood, septic ligatures, etc., may be the cause.

Fistula.

A fistula is an abnormal canal or opening connecting two normal
cavities, or a normal cavity and the surface of the body. There are
three varieties, (1) congenital, (2) traumatic, and (3) suppurative, or
those produced by abscess formation and the burrowing of pus.

Treatment. — The treatment consists in removing the foreign body,
relieving the irritation, and correcting the general health. When this
is not sufficient, scrape out the sinus well and secure good drainage. In
fistula, the walls should be freshened, the fistula thoroughly
cleaned and made to heal from the bottom. Fistula of various parts
will be discussed under "Disease and Injury of Begions."

GANGRENE.

Definition — Gangrene is death of the tissues by mass. It may he
simply a patch of skin, or mucous membrane, or an entire limb. While
this has been given as one of the results of inflammation, it may have
other causes, in fact, gangrene is caused by more or less sudden arrest
of the nutrition to a part, and, inasmuch as this may occur without in-
flammation, gangrene may happen without inflammatory reaction. In
severe cases of inflammation, where the reaction brings about arrest of
the nutrition to a part, gangrene in one of its forms is" sure to develop.

Diabetic.

Gangrene from ergotism.

TAidwig's Angina.

Gangrene from frost-bite.

Post-febrile.

Symmetrical or Raynaud's.

Varieties.

1.

2.
3.

4.
5.
6.

7.

Inflammatory.

Traumatic.

Infective or Hospital.

Phagedenic.

Cancrum oris.

Carbuncle.

Decubital (Bed-Sore. )

8.

9.
10.
11.
12.
13.

40 GANGRENE.

Classification.

- 1. Dry. 2. Moist. 3. Senile. 4. Microbic.

Gangrene is so classified because of the peculiar appearance it pre-
sents under certain circumstances.

Cause.

Gangrene is caused by any means which will interfere with the nutri-
tion to a part as (1) injury, (2) infection, (3) thermal causes — freezing
or scalding will arrest nutrition to the parts, bringing about chemical
changes witbin the tissues thereby causing death. (4) Drugs, such as
eruot, which in large closes causes a contraction of the peripheral arteri-
oles so as to more or less cut off the circulation to a certain area. In the
long continued use of carbolic acid as a lotion or where it is continu-
ously in contact with the tissues, necrosis frequently follows. (5) Em-
bolism and thrombosis. Plugging of an artery, either by a clot form-
ing within the vessel or a clot lodging in the vessel and arresting the
circulation to a part, may cause gangrene.

Signs and Symptoms.

1. Lack of pulsation in the vessels in an apparently dead area.

2. Loss of heat.

3. Anesthesia.

4. Loss of function of the necrosed area.

5. Changes in color.

In inflammatory gangrene in an area which was previously red, the
color is changed into yellowish, yellowish-green, or an earthy hue, or it
may be dark or even black. While approaching death may have caused
pain, the part is now painless and when touched with the finger is cold,
as the heat quickly departs from the dead tissues. If rubbed with the
hand, the epidermis loosens from the true skin, leaving the true skin
a moist surface, or if the epidermis has not been removed the exudation
of the fluids underneath it will cause blebs and these may be filled with
yellowish or reddish fluid, due to the disorganization of the red cor-
puscles and a breaking up of its coloring matter. Small cavities may form
in the deeper tissues, some of these being filled with a dark fluid. When
the tissues are pressed upon with the hand crepitation is felt. This
crepitation is due to the formation of gases from putrefactive changes
which have taken place within the tissues. An emphysematous condi-
tion of the tissues is one of the siirest signs of death. As the condition
proceeds, foul odors will arise, due to the decomposition of the albumins
and the presence of saprophytic bacteria. There will be evidences of
lymphangitis and phlebitis, shown by reddish streaks extending from
the inflamed area into the healthy tissues. Should the tissues arrest
the spread of the gangrene, a bright red line — a line, of demarcation —

SENILE GANGRENE. 41

will be established. On one side of this line is healthy tissue, on the
other side dead tissue. Here nature has arrested the process and. later
attempts at amputation. The tissue changes which lead to leath in
gangrene are similar to those which take place in abscess formation, but
are more extensive. The leukocytes swarm into the inflamed area, active
proliferation of the tissue cells occurs, the micro-organisms have gained
entrance in enormous numbers, the warfare between the micro-
organisms and the tissue cells is extremely severe and in
the effort of the leukocytes and connective-tissue cells to over-
come the micro-organisms they crowd into the inflamed area
in such vast numbers as to obstruct the circulation. Throm-
bosis of the smaller arterioles occurs. This leads to gangrene. Gan-
grene is partly due to the mechanical obstruction of the circulation and
partly to the action of the poisons produced by the bacteria. As the
tissues decompose sulphureted gases are liberated which produce dis-
agreeable odors. If bacteria do not enter the tissues mummification
will likely take place. At the line of demarcation the ulcerative pro-
cess is set up and in the treatment of gano-renc we really have a large
ulcer with which to deal, and when the dead tissues are removed granu-
lations will spring up and cicatrization takes place, as in healing of an
ordinary ulcer. If the gangrene has been at all extensive there will
be absorption of certain toxic products, decomposed albumins, and tox-
ins of bacteria. These produce a condition similar to sapremia, or
septic poisoning. The heart and circulation are markedly depressed,
pulse feeble and quickened, the tongue is dry, furred, and brown, breath
foul, features pinched and drawn, the lips, teeth, and tongue are cov-
ered with sordes, and the appetite is lost. If the necrosed tissues are
not removed death from septic intoxication or exhaustion will -occur.
If the gangrene is of a vital part of the body, as a knuckle of the intes-
tines, the constitutional effects of the gangrene are very great and col-
lapse is certain and rapid. Where it is of the superficial tissues they
may slough off, the ulcers healing with but little care. There are two
distinct types of gangrene, which present different symptoms; these are
dry and moist gangrene. Dry gangrene is the variety where apparently
the fluids seem to depart from the member affected and it
Avithers and dies. The causes of these two forms seem to be the state
of the tissues at the time gangrene occurs. In dry gangrene there is
an obstruction to the arterial flow and none to the venous return and
the fluids already in the part are carried out. In moist gangrene there
is an obstruction to the venous return, as well as an obstruction to the
arterial blood, the liquid being unable to get out of the tissues. It is
not unusual to find conditions where the two forms of gangrene will
run into each other. Moist gangrene also occurs in tissues where there
has been a pre-existing inflammation.

Senile Gangrene is really one form of dry gangrene. It happens in
old people, or persons whose tissues have undergone degeneration be-
cause of the action of some disease or certain pathologic conditions

42 MICROBIC GANGRENE.

brought about by vicious habits. It nearly always happens in the foot
or one of the toes. Close examination will reveal the fact that there
is a condition of atheroma or sclero-endarteritis. There will also be
arcus or annulus senilis. The disease may happen in a person 40 or 50
years of age, but usually occurs in subjects from 70 to 80 or 90. In
hea^y drinkers and syphilitics, the arteries undergo degenerative
changes, the walls become weakened because of endarteritis, calcification
of this inflammatory tissue occurs, the artery is no longer able to
respond to the call of the tissues for an increase in the nutritious mate-
rials. Sometimes the arteries may be so calcified as to be very brittle.
Cases may happen which are due to thrombosis of the superficial femoral
artery. In any case, because of the limited blood suppty, any little in-
jury will lead to destructive changes. It maj- begin as a pin prick, it
may arise from an in grown toe nail, or from a scratch or cut sustained
in trimming the nail, or in paring a corn the skin may be slightly
wounded. The wound becomes extremehr painful and burns terrifi-
cally. Tbe tissues become red and swollen and finally die. The tissues
undergo the same changes as in other forms of gangrene, except that it
is nearly always a dry process. The tissues show no evidence of establish-
ing a line of demarcation or limiting the gangrenous process. There may
be considerable absorption of septic materials from the gangrenous area
which will cause great depression, death generally following quickly.
In some instances the case may continue over a period of some months
or even years. Nature will establish a line of demarcation at that point
where the tissues receive the proper amount of nutrition. When gan-
grene happens in the toe, amputation should be done above the ankle.
If it extends back onto the foot, it is advisable to amputate above the
knee. Amputation should not be performed until there is some indica-
tion of the point where the chief obstruction to the circulation is
located. The operation should be done above this point, if possible.

Microbic or Spreading Gangrene, as it is sometimes called, is that
form whose chief cause is infection by certain micro-organisms; it may
be the Streptococcus pyogenes, or erysipelas, B. edematous maligni,
B. coli communis, etc. Bapid infection in conditions where the blood
supply is limited or where the part has sustained injury and the person
is in a debilitated state, will cause the spreading gangrene accompanied
by an emphysematous condition of the tissues, produced by the develop-
ment of gases from the action of the micro-organisms. Some writers
hold that the gangrene is brought about by the action of the poisons of
the germ, but these poisons only act by limiting the nutrition to the
part. In fact gangrene is always caused by defective nutrition, except
perhaps in cases where the injury is so great as to pulverize or crush the
tissues, so the germs act only by arresting the nutrition. Fortunately
this form of gangrene is rare. It happens in illy-nourished people under
bad hygienic surroundings. It is alarmingly and rapidly fatal. It is
most common after bad fractures with extensive injuries to the soft-
parts. The limb becomes enormously swollen and the pulse below the

HOSPITAL GANGRENE. 43

injury is absent. The member becomes cold within 3G to 48 hours and
it ma;y turn green or a greenish-black hue. Death does not seem ro take
place in a single patch, but an extensive area, in fact sometimes the whole
limb dies apparently almost simultaneously. The products carried back
into the healthy tissues cause extensive inflammation and enlargement
of the lymphatics. No line of demarcation forms, while the patient
suffers from septic intoxication; death quickly follows from collapse.
It is not unusual to find the temperature subnormal. Traumatic or
spreading gangrene must not be confounded with erysipelas. Erysipe-
las shows a red inflamed area. Traumatic or spreading gangrene is at
first purple and finally turns to a dark greenish color. The surgeon is
often at a loss to know when to amputate. If, in his judgment, the in-
jury is so extensive as to cause gangrene, amputation should be done
at once. After spreading gangrene has set in he may amputate higher
up or he may wait for a line of demarcation, which sometimes never
forms. In such cases, death follows quickly. If it is doubtful what
should be done, the conditions presenting in each individual case should
decide that one. If the surgeon feels that it requires an amputation to
save the life of the patient, it is his duty to perform such an operation
with the least possible delay. If he believes it is best to temporize, that
should be done. At all events the conditions should be explained to the
patient or the patient's next friend, so he may appreciate them and his
consent obtained for amputation. In case the person is in an uncon-
scious state and he has no next friend, or any relatives, the surgeon
should do that which he feels is his duty.

Infective or Hospital Gangrene is said by some writers to be the
same as Wound Diphtheria and Sloughing Phagedena." The term
"Hospital Gangrene'"' seems to refer to a kind of gangrene which does
not happen in this age, but formerly occurred in poorly ventilated and
unsanitary and overcrowded hospitals. In short, it occurs under filthy
conditions in debilitated people. It is a rapidly spreading and infec-
tious form of microbic gangrene. Hutchinson says it is Syphilitic
Phagedena.

Treatment of Gangrene. — As soon as the injured member comes
under the observation of the physician, if it is not dead, it should be
enveloped in cotton wool, heat applied, and the part elevated to assist
the return circulation. All efforts should be made to restore life to the
part by assisting the circulation by whatever manipulation may be nec-
essary. The patient should be supported with nourishing food and
stimulants. If there is a wound in the tissues the strictest cleanliness
and asepsis should be maintained. The part should be thoroughly
cleansed and good drainage secured. If the member begins to die it
should be constantly kept moist with a solution of 1:5000 bichloride of
mercury and as- soon as the line of demarcation sets up amputation
should be performed. If the line of demarcation is tardy in forming,
the dead tissues become swollen and edematous and noxious gases are
produced, punctures in the dead tissue should be made by a sharp

U DECUBITAL GANGRENE.

instrument and the member wrapped with cloths saturated with a
1 :1000 solution of bichloride of mercury. Every eifort should be made to
destroy all .micro-organisms in the dead tissues. If this is thoroughly
done the part will not emit any stinking odor; also the tissues will more
likely arrest the spread of the gangrenous process. As soon, then, as
the line of demarcation is set up, amputation can be performed far
enough up so that a healtiry flap can be secured. In cases of hospital
gangrene, stronger antiseptics may be necessary over the sloughing
area. A solution of 1:500 mercuric chloride should be used and the
slough and dead tissues should be trimmed off and the antiseptic solu-
tion be introduced into ali crevices of the slough by means of a swab.
One or two such treatments will be sufficient to stop the destructive pro-
cess, then milder antiseptics may be used. The part should be kept dry by
being powdered over with iodoform or equal parts of boric acid and ace-
tanilid. It should be dressed frequently in order to get rid of the secre-
tions from the slough and to not allow the fluids to decompose in the
dressing. In traumatic gangrene the treatment will largely depend
upon the judgment of the physician as to whether or not he can save
the limb; if he feels be can not, amputation is necessary. After ampu-
tation, the stump should be treated, the same as an ordinary ampatation
stump. If the amputation is done after gangrene has set up, the dead
part should be thoroughly wrapped in cloths saturated in a 1 :5000 solu-
tion of bichloride of mercury so as to permit of no opportunity for
infection or the return of the gangrene in the stump.

Cancrum Oris is sloughing of the inside of the cheek in ill-fed and
ill-nourished children. The course of the disease is extremely rapid
and terribly destructive. If not treated with the utmost vigilance
sloughing will take place through the cheek onto the face. As soon
as the case is seen, the physician should at once cauterize the slough
with carbolic acid or nitric acid. After cauterization the mouth should
be rinsed and cleansed thoroughly and frequently with an antiseptic
solution and the patient should be kept in a well-ventilated and clean
apartment and be given supportive treatment.

Phagedena is described under Hospital Gangrene and Sloughing
Phagedenic Ulcers.

Carbuncle. — Occasionally in debilitated persons where the case is
neglected the formation of a carbuncle, which is evidenced by numerous
small boils over a certain area, may lead to gangrene of a mass of the
tissues. The treatment for the case is to open the boils and wash them
several times daily with a 1:1000 solution of bichloride of mercury.
The patient's general health should be treated and any local or spinal
lesions found sbould be removed. These cases usually terminate favor-
ably.

Decubital Gangrene is a variety of gangrene which occurs from pro-
longed pressure upon an area, cutting off the circulation and causing it
to slough. It happens in persons confined to their beds because of

DECUBITAL GANGRENE. 45

sonic wasting disease, or in paralytics where the tissues are deprived of
nerve supply. The trophic influences being withdrawn, pressure cuts
off the circulation and the part dies. The first sign of decubital gan-
grene is perhaps a little reddish pimple, upon the top of which a little
black spot appears and this gradually spreads to an area of considerable
size, depending upon the state of the tissues. Occasionally, in paralytic
cases, the urine is voided. involuntarily and as it dribbles away and sat-
urates the clothing it adds to the irritation, when a little fold of the
sheet or a small pin scratch or insect bite may be the starting point of
an inflammation which results in the destruction of the tissues,
forming what is popularly known as a aBed-sore." The loca-
tion of these sores is usually over the hack part of the sacrum and the
posterior part of the ilium or over the trochanter or sides of the but-
tock, because of the patient lying continuously upon these bony promi-
nences. A pressure-sore sometimes happens upon the heel or one of the
condyles of the humerus because of the unequal pressure of a splint.
The Treatment of decubital gangrene or bed-sore is first preventive.
The preventive treatment is especially important because in many cases
it is almost impossible to heal the sore after it is once formed, there-
fore if it is prevented an infinite amount of pain and trouble may be
avoided. It is well enough in these cases, as soon as the part shows any
signs of irritation, to rub the surface with alcohol and dust it with
oxid of zinc or talcum powder. When any particular point shows irri-
tation an air-cushion may be used to remove the pressure from that
point. If the person is a paralytic and can afford it, a water-bed
should be used. This equalizes the pressure on all parts of the body
in contact with the bed. Furthermore the strictest cleanliness should
be maintained. If the urine has been in the habit of coming in contact
with the skin it should be collected by means of a urinal. Care should
be exercised in the use of a bed-pan and the parts kept dry and free
from irritation or pressure. After a bed-sore is once formed it should
be treated the same as an ordinary ulcer, pressure being kept off and
the strictest cleanliness enforced. Do not use peroxid of hydrogen
continuously as a cleansing agent, as it will stop cicatrization/ There
are numerous preparations which are of advantage. The history of
these sores will extend over a period of some weeks, perhaps some
months, so that the antiseptic will necessarily need to be varied. The
ulcer should be dressed at least twice daily. The edges of the sore
should be greased with a little carbolized vaselin and several layers of
antiseptic gauze applied after the sore has been dusted with equal parts
of boracic acid and acetanilid. Over the gauze a considerable mass of
cotton should be placed. This will prevent any secretions getting into
the sore and will keep it clean. If pressure is removed, the ulcer may
then be in condition to administer another part of the treatment, which
is of the very greatest importance, that is, to stimulate the nerve and
blood supply to the ulcer. Osteopathic practice has shown that many
very extensive decubital ulcers can be successfully treated. In fact it

46 DIABETIC GANGRENE.

seems to be the only method of curing very bad cases or the only hope
of saving the life of persons whose spines have sustained extensive
injury high up. This manipulation must be varied according to the
cause, but is directed towards seen ring the proper blood and nerve sup-
ply. The method by which these sores may be cleansed is this: Kelly's
rubber-pan should be placed under the buttocks. The sore is washed
out by means of an irrigating apparatus filled with an antiseptic solu-
tion. The irrigating aj^paratus may be either a fountain syringe or a
large glass jar having a small rubber hose leading from it. Protonuclein
or other antiseptic powder may be dusted over the sore, the edge of the
ulcer smeared with earbolized vaselin, and several layers of antiseptic
gauze should be applied twice daily. Sometimes the destruction of the
tissues from these bed-sores is very extensive, but as soon as the dead
tissues slough away, if the part becomes healthy it will show a red or
pink granulating surface. Sepsis under unsanitary and neglected con-
ditions may occur, the gangrenous process extending to the deeper
tissues.

Diabetic Gangrene. — It is a peculiar fact that gangrene happens
with the slightest provocation in diabetes mellitus. The gangrene seems
to be caused by the general defective nutrition, perhaps also by the
presence of sugar in the blood. It may happen in the feet or legs, in
the genitalia, or over the buttocks, back, hands, or face. It may simply
affect a small area or a large mass of the tissues. It may happen at
any time in the clinical history of diabetes. An injury seems to be
necessary, but this may be only trivial. Very often there are some
prodromic symptoms, sometimes not. If it comes from traumatism
there are prodromic symptoms, such as violent pain, together with a
red inflamed condition of the surface. The part turns cold and loses
sensation. This form of gangrene is generally moist. The line of
demarcation is not so readily set up. The case calls for the treatment
of diabetes conjointly with gangrene. It spreads more rapidly than
senile gangrene and is very often covered over with blisters. Opera-
tions should be performed only where nature establishes a line
of demarcation. Diabetes mellitus is best treated by well known
osteopathic methods. Should nature show an effort at arresting the
process, 'the remainder of the treatment is clearly surgical.

Gangrene from Ergotism. — Ergot, when taken internally, among
other things produces a spasm or contraction of the muscular fibres in
the walls of the arteries. This affects the peripheral arterioles more
than the large arteries. The spasm may be sufficiently great to so
arrest the nutrition that gangrene may occur. Osier says that the
gangrene is first preceded by anesthesia, muscular cramp, tingling, pain,
itching, and gradual blood sepsis in certain vascular areas. History
of the taking of ergot, together with the presence of the above named
symptoms, should be sufficient to make a diagnosis. The gangrene is
generally superficial and terminal and is very often symmetrical and
may involve the toes of both feet, or may involve both limbs. Death

GANGRENE FROM FROST-BITE. 17

is said to have occurred in from ten to twelve days in very acute cases.
Where the gangrene is superficial the parts should be washed twice
daily with antiseptic solutions and the dead crusts should be trimmed
off with forceps and scissors.

Ludwig's Angina is hardly a form of gangrene, hut is a form of
abscess of the submaxillary gland. It is said to be a condition of infec-
tion of the gland with the streptococcus pyogenes. Occasionally the
abscess formation is attended by gangrene. The swelling is rapid, and
the pain extremely severe, the person being unable to open the mouth.
Occasionally the swelling may extend back into the pharynx and back
part of the tongue and cause edema of the glottis. As soon as fluctua-
tion can be detected the abscess should be opened and the inside of the
mouth and the abscess cavity should be thoroughly cleansed with an
antiseptic solution and the person given supportive treatment.

Gangrene from Frost-Bite. — Frost-bite is more common on the
exposed parts of the body and is extensive according to the exposure.
It causes contraction of the arterioles, drives the blood out of the tis-
sues, arrests the nutrition and the part becomes stiff, cold, and numb.
After the tissues become warm the vessels dilate because of weak-
ness, and congestion and inflammation follow. If the part has been
Cold sufficiently long to entirely arrest the nutrition, the part will
likely die, but if the tissues have become only seriously devitalized a
severe inflammation may result and this inflammation terminate in
gangrene. The inflammation which is caused by exposure to cold is
attended by a severe burning sensation, followed by great pain. Some-
times the cold is sufficiently great to actually disorganize the tissues.
Especially is this true where the part is very cold, or is cold for a con-
siderable length of time and then quickly brought to its normal tem-
perature. The rapid changes in temperature seem to bring about
destructive chemical changes in the blood and tissues. The area which
has become livid with cold and which is not yet believed to be dead,
should be first treated by friction with snow or towels soaked in ice
water, and the part gradually brought to the normal temperature. This
will frequently avoid serious inflammation. Amputation should be done
only after the line of demarcation has been thoroughly established.
Where the ends of the fingers and toes have died the part should be
treated antiseptically and here it must be borne in mind that if the
tissues slough and a sore results, that this sore will heal very slowly and
that the slough should be removed after it has been loosened by nature.
The ulcer should be treated as an ordinary open sore. If gangrene fol-
lows in a considerable area, the treatment, before the line of demarca-
tion has been set up, is hot fomentations of antiseptic solutions. As in
all cases of gangrene, the support of the patient is of the utmost
importance.

Postfebrile Gangrene is a form following a severe attack of continued
fever. It most frequently follows enteric fever, but may follow typhus
fever, scarlet fever, measles, influenza, etc. It is most usual in the lower

48 SEPTIC DISEASES.

extremities, but may happen in the upper extremities or in the upper
parts. oi' the body. The gangrene is generally believed to be due to
embolism following endocarditis. In young girls gangrene is apt to
occur in the genitalia. It is said that now and then the disease arises
from phlebitis with the formation of thrombi. So in continued fevers
examination of the extremities should be made from time to time to
determine the presence of gangrene. The treatment after gangrene has
set up, is antisepsis until the line of demarcation is established. Sec-
ondly, remove any lesions which will obstruct the return circulation
or interfere with the nutrition of the tissues. This being removed and
the line of demarcation set up, if the gangrene is sufficiently extensive,
surgical interference is demanded.

Symmetrical or Raynaud's Gangrene occurs in Eaynaud's disease.
This disease is said to be a vasomotor neurosis which occurs in children
and }roung adults. Clinical experience shows that there are distinct
spinal lesions which account for the condition. The attacks appear in
the tissues symmetrically, e. g., lingers and toes. The parts become cold,
d^ad and bloodless, following severe mental excitement or injury. In
some cases the part becomes livid and there is local asphyxia similar to
a chilblain. The patient complains of shooting pains and tingling in
the part. After local asphyxia occurs the prognosis should be guarded
for gangrene is likely to happen. When death is about to occur the part
becomes dark and blebs may arise. There is local coldness and anes-
thesia and the line of demarcation is generally quickly set up. The treat-
ment is to restore the circulation and remove the pressure from the
nerves. After the part has died antisepsis and surgical measures are
necessary.

SEPTIC AND INFECTIVE DISEASES.
Classification.

A. Septic Diseases.

1. Septic Inflammation. 3. Sapremia.

2. Traumatic fever.

B. Infective Diseases.

1. Suppuration. 10. Malignant pustule.

2. Cellulitis. 11. Actinomycosis.

3. Septicemia. 12. Tuberculosis.

4. Pyemia. 13. Glanders.

5. Hospital gangrene. 14. Syphilis.

6. Wound diphtheria. 15. Gonorrhea.

7. Erysipelas. 16. Scrofula.

8. Tetanus. 17. Rachitis.

9. Hpdrophobia. 18. Scurvy.

Septic Diseases.

The diseases included under this head are due to the absorption of
certain chemical products of putrefaction which causes local inflamma-
tion and certain systemic disturbances. Fevers following injury are
variously classified by different writers, but the author prefers to
include under septic diseases those conditions due to the absorption of

SAPREM/.l. 49

certain alkaloids or putrefactive substances which are not necessarily
the result of bacterial action, but perhaps may be due to the decomposi-
tion of albuminous products in the wound. The nature of these products
is not known. They do not multiply in the body and when the wound
is freely opened the disease symptoms disappear. The symptoms to
which they give rise are often severe in proportion to the amount of
absorption, as is instanced in poorly drained abscess cavities. The
freer the drainage the less fever and other constitutional symptoms.
Furthermore, the poisons are not infective and the disease process does
not extend to other parts of the body. It is said by some that the poi-
sons are due to the multiplication of saprophytic bacteria in the secre-
tions of the wound or cavity, so that the disease is virtually a toxemia.
There seems to be considerable ground for this belief, inasmuch as in
foul wounds and poorly drained cavities there is generally a considera-
ble amount of dead tissue upon which these otherwise harmless sapro-
phytes may grow. Also, in cases .of gangrene after the member has
died, amputation is many times followed by recovery. Previous to the
amputation there may have been marked systemic disturbances, high
fever, delirium, etc., the symptoms being produced by the absorption
of the poisonous products from the decomposition of the albuminous
fluids in the tissues and by the growth and development of the sapro-
phytic bacteria. The reason for no absorption of poisons afterward is
that the bacteria being saprophytes, live only on the dead tissues.

Septic Inflammation. — The pathological process of septic inflamma-
tion is similar to that of acute suppuration or acute inflammation from
chemical cause.

Traumatic or Wound Fever. —There are various grades of traumatic
fever. Following a major operation it is not unusual, in fact it is the
rule, for the temperature to rise from one-half to one and one-half
degrees. The person is more or less uncomfortable and may manifest
some nervous symptoms. Under other circumstances the temperature
may rise to 103 degrees F., this being accompanied by a general malaise
with delirium. In the milder form the absorption of the broken-up
nitrogenous compounds in the wround probably causes the fever, whereas
in the severe form a certain number of germs may have entered the
wound and these having caused more or less putrefaction the fever and
other symptoms follow. These processes come within twelve to twenty-
four hours after the injury. They disappear without serious damage.
Either the poisonous products are taken up by the lymph channels and
carried elsewhere and gotten rid of by the eliminating organs, or the
products are discharged from the wound, nature having set up a wall
of granulation tissue for the protection of the system from the absorp-
tion of these toxic products. This is traumatic fever or wound fever.

Sapremia.

Sapremia is generally considered to be the expression of the absorp-
tion of the toxic products from retained secretions wdiere bacteria are

50 SEPTICEMIA.

causing active fermentation. In fact, sapremia may be associated with
severe forms of poisoning. It is thought milder grades of sepsis termi-
nate in severer forms, therefore, what first was a sapremia may termi-
nate in septicemia or pyemia. Sapremia calls for quick and vigorous
treatment. If it be from a wound, it demands immediate drainage. If
the wound has been closed it should be opened and thoroughly washed
out, all the poisonous products and germs removed and free drainage
established. Sapremia occurs under three conditions: (1) exten-
sive wounds imperfectly drained which were not previously ren-
dered aseptic; (2) wounds of serous cavities where there is abundant
opportunity for the absorption of poisonous products, and (o) from
granulating abscess cavities where the external opening is too small to
permit of drain as e. Very severe conditions may be fatal — this is
unusual. The poisons act chiefly upon the blood and nerve centers, very
often producing decomposition of the red corpuscles, resulting in a
form of petechia. It sometimes acts upon the nerve centers, producing
delirium, or sometimes thrombosis of some of the capillaries may
occur. Microscopic examination made immediately after death shows
that the tissues contain no micro-organisms.

Symptoms of Sapremia. — Chill or chilly feelings, vomiting or loss of
appetite, headache, malaise, muscular soreness; the pulse is rapid and in
severe cases becomes very weak, the temperature in the severe forms
reaches 103 or 104 degrees F. If the absorption is very rapid, collapse
may take place rapidly. Under such circumstances coma follows uncon-
sciousness and delirium and the patient dies.

Treatment. — The treatment is directed towards the removal of the
source of the poisons. Opening the wound and washing it out freely
with antiseptics is sufficient. In operation cases, sapremia calls for the
removal of part of the sutures and establishing drainage. Peot-up
and decomposed pus or secretions give rise to the disease, hence treat-
ment should, as in the treatment of any ailment, be directed towards
removing the cause.

Suppuration and Cellulitis

have been described under circumscribed and diffuse abscess formation.

Septicemia.

Septicemia or "Blood-poisoning"' is a general infective disease
usually produced by the pyogenic micro-organisms, in contradistinction
to septic processes, which are caused by the products of saprophytic
bacteria. In septicemia these pyogenic micro-organisms develop at such
an appallingly rapid rate and are present in such immense numbers that
they swarm into the tissues, passing by means of the blood and lymph
channels into the planes of connective tissues and producing such viru-
lent poisons that the patient is overwhelmed. Sometimes he
looks as if he had been struck down by some terrible mal-
ady. The disease called "Septicemia" presents a clinical picture

SEPTICEMIA. 51

often seen and easily recognized. In some cases diagnosed as septicemia,
micro-organisms are not found in the blood, but they exist in the tissues
around the wound and the toxic products of the bacteria are produced in
such immense quantities that the clinical picture is the same, whether
the germs exist in the circulation or not. It differs from pyemia, in that
in the latter there is multiple or metastatic abscess formation. It does
not follow that because the bacteria have entered the circulation
that multiple abscess will occur. Death may follow a rapid absorption
of the germs before the formation of multiple abscess can take place.
Conditions of septicemia and pyemia may occur coincidently or septi-
cemia merge into pyemia.

Pathology. — First there is local infection of the pyogenic cocci and
there may be phlegmonous signs of a rapidly spreading inflammation.
The wound, if there be one, is generally foul, coated over with a grayish
covering and looks unhealthy The secretion is yellowish and has a
peculiar odor. The cocci develop within the tissues and spread through
the lymphatics. In some cases they reach the circulation, when they
increase and multiply in the blood. It is not unusual that cultures made
from the blood will show large numbers of streptococci. These travel
into the minutest vessels and finally reach the heart and develop
upon the valves, which condition happens in malignant endo-
carditis. This may finally lead to the formation of infective emboli
and result in pyemia. In other cases thrombi may form in the veins in
the infected area. These clots being dislodged, form infective emboli,
which may finally lead to general pyemia. On post-mortem examination
there is a general congestion of the viscera in the gastro-intestinal
tract. The intestines and peritoneum are frequently covered with flakes
of coagulated lymph. These coagula often represent pure cultures of
the streptococcus pyogenes. The peritoneum and pleura, together with
the nerve centers, are all congested and frequently petechial spots may
be seen. In more prolonged cases peritonitis or pleurisy or pneumonia
or inflammation of other viscera may be present, and it is not
unusual for the serous cavities to contain blood-stained serum. The
spleen and lymphatic glands, in fact, all adenoid tissues, are greatly
enlarged and congested. Doubtless man}?- times micro-organisms enter
the blood and are lost sight of, perish and do no harm. When they lodge
in the parenchyma of the lung, liver, or kidney, they may increase and
multiply and result in pyemia.

Cause. — The cause of septicemia, as has been indicated, is pyogenic
micro-organisms. Sometimes several germs may be associated, bacilli
and micrococci being present. In virulent cases there may be only one
micro-organism doing the damage, but in all cases these germs have
been introduced into the tissues in immense numbers, either through
a wound or the open mouths of vessels, as in cases of puerperal septi-
cemia. Where infection takes place in wounds the result of operation,
it is caused by the septic condition already present in the patient, or

52 SEPTICEMIA.

because of an unelean condition of the field of operation, or the germs
have been derived from the instruments, sponges, ligatures, or the hands
of the operator, or from something introduced into the Avound during
the operation. It is singular how much filth nature will apparently
get rid of sometimes. Still, on the other hand, septicemia
may follow when apparently considerable precaution has been taken.
This may be explained by the fact that while streptococci are present,
they may vary in virulence, in one case not producing serious symp-
toms, whereas in another the infection is obviously fatal at the begin-
ning. The importance and frequency with which streptococci infection
accompanies many of the acute infectious diseases in the puerperal state
and in injuries is probably not sufficiently appreciated. In premature
delivery brought about by measles, whooping cough, and similar dis-
eases, septicemia is very likely to happen and is usually alarmingly
fatal. While other of the pus germs may produce this disease, none
is so rapidly fatal or produces such alarming symptoms as the strep-
tococcus pyogenes or streptococcus erysipelatis. In hospitals where these
cases occur they should be isolated. Clothing infected by them should
be fumigated.

Symptoms. — The disease is generally introduced by a chill or chilly
feelings. The rigor may be very severe. There may be several chills
closely following each other, during the first twelve to twenty-four
hours, but after that, if there are other chills, it usually indicates
renewed absorption of toxic material or the formation of an abscess.
The temperature rises rapidly to 103, 104, or 105 degrees F. There
is at first nausea and vomiting, loss of appetite and the person looks
dazed. The symptoms may take on a typhoid nature . The secretions
are arrested, urine high-colored, and the patient greatly prostrated.
The pulse, at first rapid and thready, becomes soft and weak.
The patient soon becomes unconscious and delirium appears. In some
cases there is great and rapid prostration, so that the person dies in a
few days. The writer once saw a case of puerperal septicemia, following
delivery at term attended by a mid-wife, where death occurred within
forty-eight hours. On autopsy the peritoneum and bowels were
markedly congested and of a reddish-black color. The lymph in the
peritoneal cavity was coagulated in flakes.

Treatment. — The treatment is almost entirely preventive, for little
can be done in the way of cure. The reason is, no agent introduced
into the system is of any use after the poisons have entered the circula-
tion. Antistreptococcic serum has been used, and some have claimed to
obtain good results, but the statements are unreliable. Antistrepto-
coccic serum is worthless. After infection has taken place, free inci-
sion, drainage, and curetting, together with frequent lavage of the in-
fected area, may accomplish some good, but it is hardly likely, for blood
infection is fatal. Nourishment and support of the patient, together
with free use of stimulants, may assist the tissues in overcoming the
onslaughts of the germ.

PYEMIA. 53

Pyemia.

Pyemia is distinguished from septicemia by the formation of metas-
tatic abscesses in other parts of the body. It is but a special stage of
septicemia in which abscesses are formed. Prior to the formation of
the abscesses the clinical history of the two diseases is alike and indis-
tinguishable.

Cause. — Without doubt the cause of the disease is the entrance into
the tissue of pyogenic micro-organisms which have found their
way there through the open mouths of lymphatics or veins.
The disease generally develops amidst unhygienic surroundings
or in ill-nourished and debilitated subjects, in over-crowded hospitals
which are poorly ventilated and drained, and where there exist numbers
of foul wounds. It occurs in alcoholic and diabetic subjects, or in per-
sons with low resisting power. It generally occurs in connection with
a wound. The poisonous chemical products absorbed from the wound
debilitate the person to that extent that the micro-organisms absorbed
circulate through the fluids in the body, lodging, in the parenchyma of
some organ, producing the disease. The abscesses are often caused by
infective emboli. Where these emboli lodge suppuration occurs, and,
inasmuch as this generally takes place in some internal organ, clots form
in the small veins and capillaries. These becoming dislodged, are carried
back to the heart, when they are sent to some distant organ, where
they lodge and, being infected, form another abscess. There are, there-
fore, two chief agents acting, one the poisonous products produced by
the cocci, debilitating the system, and the other the deposit of the
cocci and the formation of abscess. This abscess interferes with the
function of the tissues in which it is located, causing the symptoms to
vary in individual cases. Old writers mention idiopathic pyemia, but
such cases do not occur. Abscesses may arise from various causes. (See
abscess formation.) These abscesses, then, may be the exciting cause of
the pyemia, pus having been absorbed from this cavity. Pyemia may
follow typhoid fever, but in this case absorption takes place from the
septic ulcers in the lower part of the small intestine. It is frequently
associated with bone disease, osteomyelitis, osteitis, or periostitis. In
some cases it arises from hospital gangrene, diffuse cellulitis, or
abscesses of erysipelatous origin, or from gonorrhea. Ulcerative endo-
carditis may happen in rheumatism and many of the acute infectious
diseases. Pyogenic cocci have entered the system through abrasions of
the skin and lodge on the valves because of the weakened and unresisting
condition of the tissues, then because of the clot, infective emboli occur,
pyemia resulting. It has been known to follow dysentery. Trivial
operations seem in some cases to have caused the disease, but here it is
evidently due to infection introduced by the operator.

Pathology. — The post-mortem appearance of the tissues is similar to
that of septicemia, with the addition of collections of pus distributed
through the body in small masses. Thereis the same rapid tendency to the
disintegration of the blood, subserous and subcutaneous extravasation

54 PYEMIA.

and congestion as occur in septicemia. The body is generally greatly
emaciated, of ten jaundiced, and of a dirty or dirty-yellowish color. Puru-
lent collections may be found in the serous cavities or in the joints or
connective tissues generally. The abscesses vary from pin-head foci to
the size of a nut. The lung may be honey-combed with abscesses the
size of a pea. The viscera affected are, in order of frequency, the
lung, liver, spleen, kidney, and brain. The abscesses occurring in the
parenchyma of an organ are caused by thrombosis of the peripheral
arterioles. Where pyemia is caused by wounds in the rectum, visceral
abscesses occur first in the liver, since the blood must pass through the
capillaries of that organ before it enters the general circulation. The
pus is generally of a sweetish odor and is rarely, if ever, fetid, and in
case of abscess in the lung the breath of the patient has a sweetish
odor. As in septicemia, when there is a wound it is unhealthy and is
surrounded by an inflammatory area and covered over by pus or dying
• tissues, or oftentimes by a grayish membrane. The veins leading from
the wound generally contain a large number of thrombi which undergo
purulent softening. The fragments which protrude out into the blood
stream become dislodged and are carried to other parts of the body.
Sometimes these thrombi form in small veins, extending back towards
the heart into large venous trunks. Besides the foregoing condi-
tions, inflammatory masses containing numbers of micro-organisms may
be found in various parts of the body. The conditions present in pyemia
may be caused in several ways. The visceral abscesses are
largely due to embolism of the peripheral arterioles or capillaries, the
septic products having come from venous thrombi, vegetations on
the valves of the heart, or at the beginning of the arteries. In other
cases the micro-organisms may have migrated through the walls of the
vessels and upon entering the circulation may lodge in an organ where
the circulation is weak, or having penetrated a mucous or serous mem-
brane, they get into the lymphatics, finally the general circulation, when
they may be deposited in a joint, causing purulent inflammation. The
diffuse purulent infiltration of a joint is said by some to be due to the
general poisoned condition of the system, and the lodgement at the
joint of poisonous products. In many cases, as is indicated
above, ulcerative endocarditis is caused by the germs getting into the
system. An infected clot is formed upon the valve, when ab-
scesses in various parts of the body are produced, this being the dis-
tributing point from which infectious emboli arise. Follow-
ing typhoid fever, after some months an abscess may arise.
This can only be explained by the fact that the pus micro-organisms get
into the circulation, and not being destroyed, lodge and remain in a
quiescent state for some time, finally forming abscesses. From this
focus general infection may follow.

Symptoms. — The symptoms of pyemia may at first be quite similar
to septicemia, but differ in that at the formation of each new abscess
a separate and distinct rigor occurs, followed by a high temperature and

WOUND DIPHTHERIA. 65

a drenching sweat. The fever is of a mild or severe hectic type. After
the chill the temperature may rise to 105 degrees F., depending upon
the amount of absorption of pus. It will rise in the evening to 103 or
104 degrees F., and drop in the morning to perhaps 100 or
101 degrees F. While the pus is pent up in the system the patient is not
free of fever. In some instances where nature is fairly successful in
walling off the abscess the temperature may almost approach normal.
The pulse is quick and weak, the tongue, at first red and moist, becomes
dry and brown as the case is more prolonged. Sordes form in the mouth,
on the lips and teeth, and the breath becomes foul. The body wastes
rapidly, the skin is frequently jaundiced (hepatogenous) because cf the
formation of an abscess in the liver which obstructs the gall-duct, or
it may be caused by the disintegration of the blood (hematogenous) by
the pyogenic micro-organisms. The face is anxious and pinched, the
features drawn, the temperature high, and the hectic flush usually
marked. It is not unusual for eruptions to take place on the skin or
ulcerations in the fauces. The breath and exhalations from the body
bave a peculiar sweet odor. As the different structures are affected,
peritonitis, pleuritis, or pericarditis may occur. Diarrhea may set in
and this is generally exhausting and followed by delirium. The patient
generally dies of exhaustion during the second or third week of the dis-
ease. It is said there are rare cases where the primary wound may heal.

Prognosis. — The prognosis is extremely unfavorable. It is only when
the disease seems to run a chronic sort of course that there is any hope
of recovery. In this case the viscera do not seem to be affected, but
the connective tissues and joints suffer most. The patient may
die after some weeks of lingering or may finally recover after the
disease has existed for some months.

Treatment. — Little or nothing can be done in the way of treatment,
inasmuch as we must depend upon the system to get rid of the micro-
organisms, and when the infection is rapid this seems impossible. When
abscesses form the pus should at once be evacuated. This is impossible
when it occurs in the lung, brain, or other important organ. Where
the seat of trouble can be reached it should be treated at once. Carious
bone should be removed. If it arises from a wound, this should at once
be irrigated with a solution of 1 :1000 bichloride of mercury. All dead
material should be immediately removed. The disease seems to be gen-
erally caused by the staphylococcus pyogenes aureus. Antistrep-
tococcic serum is of no use. We must depend upon nourishing diet and
support of the patient. If he resists the onset of the disease and the
preliminary abscess formation, it is possible that he can be built up and
the system enabled to get rid of the pus.

Wound Diphtheria.

Wound diphtheria is maintained by some to be a form of
hospital gangrene. It may be due to the Klebs-Loeffler bacillus or

53 ERYSIPELAS.

pyogenic cocci. In any case, it usuall3r occurs in ill-nourished people or
where there is some lesion which markedly devitalizes the tissues, per-
mitting the entrance of the organisms with very little resistance. The
wound looks unhealthy and is coated over with a membrane, which in
some cases is quite thick and tough. The membrane is composed of a
fibrinous mass, in which there are generally dead granulation tissue
cells and leukocytes, together with numerous chains and colonies of pus
micro-organisms and perhaps diphtheria bacilli. If the membrane is
pulled off it leaves a bleeding surface. The onset of the disease is sud-
den. The wound quickly takes on an unhealthy appearance, the temper-
ature rises, and the other constitutional symptoms are quite marked.
The patient does badly. Sigid antisepsis and cleanliness are demanded
at once. The wound should be thoroughly irrigated with a strong anti-
septic solution and the patient given a nourishing and stimulating diet.
All the secretions must be kept active by appropriate treatments. The
disease arises most frequently in unsanitary surroundings, illy-
nourished people, and poorly ventilated quarters surrounded with filth.
Fnder good hygienic conditions, if the patient has reasonably good
health, the prognosis should be favorable, but in diabetic or rheumatic
conditions, or in alcoholics, the prognosis is unfavorable.

Erysipelas.

Erysipelas is an acute, diffuse, infective inflammation (lymphangitis)
of the skin and subcutaneous tissues produced by the streptococcus ery-
sipelatis (Fehleisen.) A wound or abrasion of the skin is also necessary
for the entrance of the organism. In the description of idiopathic erysip-
elas by older writers it was said to arise from no particular cause. Such
a disease does not exist. In facial erysipelas it is believed the organism
often gets into the tissues through abrasions of the nasal mucous mem-
branes. The contagion is likely conveyed by the air or water or the
instruments or imperfectly sterilized dressings or ligatures. The morph-
ology and characteristics of the streptococcus erysipelas do not dif-
fer from the streptococcus pyogenes, which produces diffuse pus forma-
tion. The clinical course of the case depends upon the condition of the
tissues and the rapidity of infection and the virulence of the germs.

General Pathology. — When the virus effects an entrance into the
tissues, it increases and multiplies rapidly and spreads quickly through
the lymphatics and connective tissue spaces. The germ is
found only, or at least in greatest abundance, along the mar-
gins of the inflamed area. If incisions are made through the
skin, the serum which exudes will contain large numbers of the micro-
organisms, whereas, in the center of the erysipelatous area there are
no germs. Apparently the tissues have either gained mastery over the
micro-organisms through the agency of the connective-tissue cells and
the leukocytes or the germs have exhausted their food materials. At
any rate, the germs continue spreading until their progress is arrested

ERYSIPELAS. 57

by the combined efforts of all the tissues to rid themselves of this invad-
ing enemy. The constitutional symptoms of the disease are produced
by the poisons being carried into the general circulation by the lymph-
atics. 5ow and then, where the inflammation is extremely severe, it is
accompanied by exudations of serum beneath the epidermis, producing
blebs or blisters. Sometimes the inflammation will extend into the
larynx, producing edema of the glottis, or through the cribriform plate
of the ethmoid into the brain, producing meningitis. It may produce
middle ear disease and infect the lateral sinus, meningitis or abscess of
the brain following.

Classification.- Erysipelas has been classified by writers generally
into (1) simple or cutaneous, (2) cellulo-cutaneous or phlegmonous, and
(3) cellular, which form is similar to acute diffuse cellulitis. Erysipelas
is sometimes accompanied by pus formation, but not very often. This
rarely, if ever, happens in the simple variety.

Signs and Symptoms. — (A) Local and (B) General.

Local Symptoms — Inasmuch as the pathology of the disease is that
of an effective inflammation, the local symptoms are also similar. The
patient complains of a burning or stinging pain, with stiffness of the
tissues. The area is a rose-red, which in the majority of cases after a
time changes into a dusky hue. The skin has a leathery feel and is hot to
the touch. Generalhr the inflamed area presents sharply defined edges
which fade into the healthy skin. These spread irregularly, frequently
in the direction of the lymphatics, and in severe cases the edges of the
inflamed area are forked. The lymphatic glands in the neighborhood
are swollen, turgid, and painful. The inflammation may spread now
in this direction, now in that, subside here and arise at another point.
This previously has been looked upon as one of the whims of the
disease, it choosing an erratic course, but this is explained by
bony or muscular lesions. The inflamed area may be slightly or con-
siderably raised above the surrounding tissues. If the inflammation is
severe and exists about the eye, scrotum, or other location where there is
an abundance of loose connective tissue, edema may be a marked
symptom.

General Symptoms. — Previous malaise is followed by a distinct chill
and a rapid rise in temperature. This chill generally precedes the
inflammation from twelve to twenty-four hours. The temperature is
high, according to the severity of the attack. In some cases it may be
103 degrees F. and in others 105 degrees F. At first there is more or
less loss of appetite, the secretions are generally affected, and as the dis-
ease becomes more severe, there may be constipation. The urine is less
in amount and highly-colored, tongue coated, breath foul, together with
more or less muscular soreness and weakness. In debilitated states
where the infection is rapid and the disease becomes progressively
worse, the patient may enter a typhoid state, attended with high fever,
albuminuria, and delirium. The pulse is generally very rapid and often.

58 ERYSIPELAS.

in mild cases of facial erysipelas the pulse may be 120 or 130, with but
a slight rise of temperature.

Varieties. —

1. Migratory or wandering erysipelas is a form where it spreads
widely over the body.

2. Bullous erysipelas is a form where the inflamed area is covered
with blebs or blisters.

3. Metastatic erysipelas is a form where it leaves one part of the
body and appears at another or appears on more than one place simul-
taneously.

4. Erythematous erysipelas is a mild form of cutaneous erysipelas
where a red blush spreads over a certain area.

5. Erysipelas neonatorum is a term applied to erysipelas from an
unhealed navel in the new-born.

6. Typhoid erysipelas is a form arising in adynamic conditions in
alcoholics and diabetics and is attended by grave symptoms.

7. Edematous erysipelas where it is accompanied by marked edema
of the skin. Sometimes the edema may be enormous.

8. Phlegmonous erysipelas is a variety where pus formation occurs.

9. Mucous erysipelas, a form which affects the mucous membranes.

10. Venous erysipelas is a term applied where there is marked
venous congestion.

11. Lymphatic erysipelas is a term applied to certain cases where
the inflammation is mostly confined apparently to the lymphatic chan-
nels, showing red lines in various directions.

Clinical Course. — The clinical course of the disease will depend upon,
the tissues affected. In simple erysipelas the inflamed area desqua-
mates after the disease subsides. The disease may subside
abruptly, which may be explained by the fact that the obstruc-
tion has been overcome and the circulation freed. The termina-
tion of simple erysipelas is generally favorable, as it readily responds
to treatment. The parts may be weak for a long time after the disease
subsides. In phlegmonous erysipelas, which is accompanied by abscess
formation, the affected area is generally boggy and edematous and the
redness is changed to a dark purple. Many times blebs appear filled
with blood stained serum. The swelling is brawny. Just before pus
formation happens, secondary chills occur. Sometimes instead of ab-
scess formation there will be a sloughing of a patch of the tissues, leav-
ing a ragged, ugly, and unhealthy sore. Often upon opening the abscess,
the tissues, after the pus is evacuated, will present a white, stringy ap-
pearance. Eepeated abscess formation may happen. Certain other
diseases may set up, such as broncho-pneumonia, septicemia, pyemia,
etc., when death generally follows. The severer forms of erysipelas
are most fatal in case of chronic kidney disease. Phlegmonous erysipe-
las may often cause destruction of bone. In cellular erysipelas or dif-
fuse cellulitis, the disease spreads through the planes of connective tis-

ERYSIPELAS. 50

sue around the muscles and blood-vessels and may be attended by
sphacelus or gangrene of a considerable area. The prognosis in these
cases is not favorable.

Treatment. — Erysipelas is wrongly divided into idiopathic and trau-
matic by most authors. Trauma is responsible for all cases of erysipe-
las. It matters not whether the injury be external or some interference
to the blood flow leading to such an amount of stasis as to deteriorate
the resisting power of the organism, the result is the same. There must
be some injury producing the conditions favorable for the growth of
the germ. We know there are many organisms daily taken into the
body which are capable of producing disease, but they are destroyed
by agencies within, so that any cause which leads to the obstruction of
the circulation through a part, the condition is then existing which
favors the multiplication of the organisms, hence disease. In case of
erysipelas the favorite site is the face, beginning at the upper part of
the nose. It is usually found that some obstruction to the facial vein
exists, e. g., at its junction with the jugular. Belief of this obstruction
at once removes the condition upon which depends the possibility of the
disorder continuing. In this case nature has cured the patient just as
soon as given the power to act. The osteopath must be sure that the
venous channels are free from obstruction and endeavor to flush the
arterial blood to that part, as healthy blood is the greatest germicide.
It must be remembered that while we handle a case of erysipelas with
perfect immunity to ourselves, we may readily carry the organisms on
our hands or clothing; it therefore behooves all who attend such cases
to be scrupulously clean, especially so the one who does surgical and
obstetrical work. Our experience with erysipelas has been sufficient
to satisfy ourselves that all cases are handled successfully by osteopathic
treatment. I do not at the present time recall a case in which we
were not able to give relief in a very short time, and in most cases im-
mediately. The treatment of such cases of course must be governed
according to the location of the disease, as there is nothing to go by,
and each case must be an individual one. If it is erysipelas around
the face it is a facial disturbance, and if some other location it is a
disturbance at that point. Erysipelas is nothing more than the blood
being held in a place until it decomposes and it is nature's effort to
dispose of it that causes the spread. It is a condition of a low grade
of life coming immediately upon death of some structure. I have seen
cases of chronic erysipelas, that have been of as long standing as seven
or eight years, relieved by setting a partially dislocated angle of the
jaw. I have seen cases of erysipelas in the leg caused by an interference
at the saphenous opening or a twist of the hip which caused contraction
of some of the muscles at that point. On some occasions the limb may
be swollen to twice its natural size, when after the first treatment it will
be reduced to almost normal within twenty-four hours. Osteopathic
treatment should cure all cases, and if not, it is on account of the in-

60 TETANUS.

ability of the practitioner in locating the cause. Great stress should
be placed on the examination, and if the cause is found there is no rea-
son why the effect cannot be relieved. Pulling teeth is a common cause
of dislocating the jaw. Inasmuch as eifect follows cause within the sys-
tem, when the cause is removed the effect disappears, therefore it is the
duty of the physician to locate and remove the obstruction. Abscess
formation demands evacuation of the pus and the enforcement of
rigid asepsis.

Tetanus.

Tetanus is a toxemia accompanied by more or less tonic spasm of the
voluntary muscles, beginning in the muscles of mastication and gradu-
ally extending into the muscles of the back and extremities, finally in-
volving nearly the entire muscular system. These more or less tonic
spasms are attended with clonic exacerbations. The toxemia arises
from the infection of a wound by the bacillus tetani (Mcolaier). The
disease is much more common in hot climates and among the negro ra<*e.
It is said that in Jamaica one-fourth of the new born negroes succumb
to tetanus. The disease is likewise more common in men than in
women, also in military than in civil practice. The germ produces the
most exquisitely toxic substance known. The toxin circulating through
the body seems to have an affinity for the nerve tissues. It produces
marked congestion and inflammation of the gray matter of the spinal
cord. The germ is found extensively throughout nature, especially is
it found in dust, garden earth, manure and about stables. It is more
common in some kinds of earth than others and in some countries than
in others. In the islands of the iSlew Hebrides the natives poison their
arrows by dipping thejn in clay containing large numbers of tetanus
bacilli. The wound in which infection takes place may be small or
large, may vary from a pin scratch to a capital operation. It may hap-
pen at the stump of the umbilical cord in the new born child. It may
arise from abrasions of the intestines, as the germ is frequently found
in the contents of the intestines of animals. The so-called idiopathic
tetanus likely arises from infection of a small wound in the mucous
membrane of the intestines. Tetanus infection is especially common
after lacerated or punctured wounds and burns. It has been observed
that infection is more common when there is suppuration. This has
been explained by the fact that the micro-organisms of suppuration
use up the oxygen and as the tetanus bacillus is a saprophyte, it makes
the conditions for its growth more favorable. Tetanus may be inocu-
lated from animal to animal or from animal to man. Deaths have
occurred in persons who have sustained small wounds in holding an
autopsy on an animal which died of tetanus. Exposure to cold and
sudden changes in temperature seem to predispose to tetanus. This
observation may have been made because of the fact that the premoni-
tory symptom of the disease is generally that of stiffness of the muscles,
which the patient often attributes to cold or exposure. It has

TETANUS. <;i

been advocated that since the germ docs not circulate within the
body and lies in the tissues adjacent to the wound, that to remove the
tissues would be a successful way to get rid of the poison. This has led
to the observation that the poison is in the nature of a ferment and
after the symptoms of the disease have appeared, if all the germs were
removed, death would follow just as quickly. The noison, because it is
of the nature of a ferment, sets up such destructive changes in the
tissues that death results. Before the days of asepsis and antisepsis,,
tetanus caused the death of many patients undergoing surgical opera-
tions. It is said that a famous surgeon lost ten successive cases by
lock-jaw following major operations, when he accidentally discovered
his instruments were the source of infection, and having boiled these
he lost no more cases. Illustrating how readily this disease may be
transmitted from animal to man, the terrible, unfortunate, and fatal
experience of the city of St. Louis, Mo., in the manufacture of the
diphtheritic antitoxin shows how, by negligence, the poison could be
dispensed with the diphtheritic antitoxin and injected into the diph-
theria cases, producing death by tetanus. More than a dozen deaths
resulted from the injection of the infected diphtheritic serum.

Pathology. — The pathology of the disease seems to be that of a tox-
emia, as proved, in the cases of death happening as before mentioned in
St. Louis. The germ is not necessary to the production of the disease,
but the toxin only may be injected into the system and all the disease
symptoms produced. The germ, if it gets into the tissues at all, stays
in the margins of the wound and is more virulent when associated with
the common bacillus of the colon and with the pus micro-organisms.
The germ is found about horses, in horse stables, in manure, and in
decomposing substances, hence wounds by a rusty nail cr cut
sustained in such localities should be carefully cleansed with an anti-
septic solution. The opinion held by the laity that the disease is caused
by pain is erroneous. The disease only happens after infection by the
above named germ. The disease may be simulated by muscular con-
tractions from other causes and these may be thought to be tetanus,
but are not. The poison is eliminated, to a considerable extent," by
the urine. The period of incubation of the disease is usually about five
days, but varies from twenty-four hours to two or three weeks, and
in some cases even longer.

Symptoms. — In the beginning the patient believes he has caught cold
and has stiffness of the muscles. This stiffness is most pronounced in
the muscles of mastication. The patient is unable to open his mouth
widely and complains of a soreness in his throat and of the muscles of
his neck. Acute tetanus comes on within ten days, the usual period
being from three to five days. The muscles of deglutition and of the
back, arms, legs, and abdomen become at first stiff and are then thrown
into a tonic spasm. The part of the body upon which the wound occurs
also shows stiffness and tonic spasm. This spasm finally extends to

62 TETANUS.

the facial muscles and causes a spasm of the risorius (Santorini) muscle,
the corners of the mouth are pulled up and the patient's face presents
a horrible grinning expression (risus sardonicus). Often the contrac-
tions of the muscles of the back are sufficiently strong that the patient
will lie upon his head and heels, the spine being markedly curved by
the contraction of the erector spinae mass (opisthotonos). Sometimes
the contraction is most manifest in the muscles of the side of the body
and chest, when the person is turned to one side (pleurothotonos),
while if the anterior muscles are affected the body and head will
be drawn forward between the legs (emprosthotonos). The spasms are
exaggerated by external irritation. The creaking of a door or jarring
of the bed upon which the patient is lying will cause exacerbation of
the spasms. The contractions of the muscles of the jaw may be severe
enough to produce fracture, the teeth may be broken off and where the
muscular spasm affects the upper extremities the finger nails may be
buried in the palm. The mouth is sometimes covered with bloody froth
due to the fact that the person has bitten off a piece of his tongue. The
face expresses terrible suffering. The person is conscious until the
last. The muscles of respiration are frequently affected, causing dysp-
nea. Sometimes the muscles of the glottis are affected, causing ob-
struction to the ingress and egress of air. While an interne in a metro-
politan hospital the writer saw a prominent surgeon do a tracheotomy
"in an unrecognized case of tetanus" to relieve strangulation because
of spasm of the muscles of the larynx. Sometimes the person suffers
from an agonizing girdle pain due to the implication of the diaphragm.
The patient is severely coustipated during the disease because of the
contraction of the sphincters. Swallowing is almost impossible, and
talking is difficult. The temperature may be normal, but is generally
very high. Cases are reported where the temperature has attained a
height of 111 degrees F. The person suffers from insomnia because of
the muscular spasms. Death is due to exhaustion and narcosis from
carbonic acid poisoning, because of the spasms of the respiratory
muscles.

Varieties. — Clinically there are several forms of the disease recog-
nized, viz. :

1. Idiopathic tetanus, described by old writers, is now known to
arise from wounds.

2. Tetanus neonatorum occurs in new-born infants from the in-
fected stump of the umbilical cord.

3. Puerperal tetanus from infection of a woman at the lying-in
period.

4. Cephalic tetanus, resulting from wounds in* the head and accom-
panied by facial paralysis.

5. Acute tetanus conies on early and is attended by great severity
of the symptoms.

TETANUS. 63

G. Chronic tetanus comes on late and successively involves differ-
ent parts of the booty and may extend over a long period of time.

The mortality in all forms of tetanus is about 50 per cent.; in the
acute form 80 to 90 per cent, and in the chronic form about 20 per cent.

Diagnosis. — The diagnosis of tetanus is apparently easy. It must
be differentiated from strychnin poisoning, hydrophobia, and hysteria.
Strychnin poisoning begins with exhilaration and restlessness. The
senses are for a time sharpened. The muscular symptoms develop rap-
idly and generally commence in the extremities. Sometimes it affects
the whole body simultaneously, especially if the dose is large. The jaw
is the last part of the body to be affected. If the convulsions are very
severe the jaw may be set, but after the convulsion it drops. In strych-
nia there is muscular relaxation between convulsions, the patient is
excited and sweats. If there is recovery the convulsions become less
frequent and less severe. Consciousness is preserved during the con-
vulsions. "The slightest breath of air" will produce a convulsion. The
patient may cry out with pain, but his cries are only momentary and
express fear and apprehension of the spasm. The eyes are stretched
and wide-open, the legs extended and the feet turned out.

In hysteria there is often a history of globus hystericus. Muscular
rigidity begins in the neck and spreads over the body. The patient
generally persists in opisthotonos and muscular rigidity between the
convulsions. Consciousness is usually lost and the eyes are closed.
Crying spells often alternate the contractions. There is often a history
of a neurosis in h}rsterical spasms. There may be an immense quantity
of urine excreted, or urination may be frequent or suppressed.

In tetanus the disease begins with pain, stiffness of the jaw, pro-
oluced not from pain (as tetany may be), but because of the toxemia.
This stiffness gradually extends to the umscles of the back, thorax, and
the lower extremities. It may affect the facial muscles and muscles of
the upper extremities. The muscles of the neck and back become hard
and rigid like iron, at no time relaxing. These tonic contractions are
exacerbated by certain clonic spasms; drafts of air, loud noises, light,
shaking of the bed, swallowing fluids, visceral actions, etc., bring on the
spasms. In hysteria the spasms come on without cause, and sometimes
are associated with the choice of the patient.

Treatment. — The treatment of tetanus consists of preventive and
curative.

The preventive treatment is careful antisepsis. Aseptic and anti-
septic methods in surgical operations will eliminate this complication
in operative proceolures. As soon as the disease appears the wound
should be cleansed with 1:500 solution of bichloride of mercury, the
patient kept in a dark, well ventilated room and should have absolute
cjuietude, not even being exposed to drafts of air or rays of light. If
the urine is retained it should be withdrawn by a catheter. If the
bowels refuse to move, enemas should be given of soap-suds or castor oil.

64 HYDROPHOBIA.

After the bowel is cleaned out, the patient being unable to swallow,
predigested food should be injected into the rectum. The patient
should be fed regularly and supported, every effort being made to pre-
vent a recurrence of spasms. Bromide of potassium in gram doses every
three to six hours has been advised, but the writer has failed to observe
where the administration of this drug was attended by favorable results.
Other drugs, such as the application and use of alcohol, fomentations
of tobacco, anesthetics, etc., have been used. So far there seems to be
no remedy for the cure of tetanus. It remains to be proven whether
an antitoxin can be developed which will effect a cure. The antitoxin
serum of Tizzoni is said to be little short of useless. In chronic cases
the antitoxin may be of value. Some recommend hypodermic injections
of iodoform, three to five grains, three times a day. This treatment is
valueless. If death does not occur before the ninth day the patient
may be said to have a fair chance of recovering. Acute tetanus gen-
erally kills before that time. Osteopathic treatment consists in secur-
ing muscular relaxation and relieving the spasms whenever they
appear.

Hydrophobia.

Hydrophobia is an acute specific toxemia, most common in the dog,
wolf, cat, and skunk. It is said by some to have occasionally occurred
in poultry, it may be transmitted to horses, cattle, and other animals,
and often to man. The saliva of the affected animal seems to be the
vehicle by which the poison is transmitted, consequently if the bite is
through clothing the disease is less likely to follow than when the injury
is on some exposed part of the bod}'. I^o micro-organism has ever yet
been discovered to which this disease may be attributed. The peculiar-
ities of the affection leave little or no doubt in the minds of bacteriolo-
gists that one exists, and it is thought if there is a specific micro-
organism that it is present in the saliva. It is believed the micro-
organism flourishes in the tissues about the wound and that its growth
and development result in the production of a toxin which affects the
central nervous system. The masses of gray matter in the medulla,
cerebral hemispheres, and the pia mater are markedly congested, caus-
ing the peculiar symptoms of the disease. The varying period of incu-
bation has caused serious doubts to arise in the minds of many physi-
cians as to whether the disease, rabies or lyssa, as it is sometimes called,
actually exists. The period of incubation varies from a few days to
twelve months. The average duration is said to be six weeks.
Only about 14 per cent, of the bites of supposedly-rabid dogs result in
the production of the disease in man. This is perhaps due to the fact
that the bile very often takes place through clothing. It is said that
bites on exposed parts are productive of the disease in 60 to 80 per
cent, of the cases. Inasmuch as nothing can be done in the way of
treatment, it is necessary to recognize the disease in the animal and
prevent infection. Hydrophobia is not so common in this country as it

H } rDR O PHOBIA . 65

is in Europe. In central Russia, where there are many wolves, the
disease is quite common. The animal when affected begins to droop,
shuns the light and is restless. The disease manifests itself in two
forms, one a furious form, where there is marked frenzy and madness.
The symptoms after the preliminary drooping condition are alarmingly
dangerous. The animal is insensible to pain and its taste is perverted
so that it eats sticks, hay, and any objects it meets. Oftentimes on
autopsy, if the stomach shows such foreign bodies or objects,- it is safe
to make a diagnosis of hydrophobia. There is a profuse secretion of
ropy, sometimes frothy, mucus. Soon there is paralysis of deglutition,
spasms of the muscles of the larynx and pharynx and the bark is
changed. "Respiration is rapid and the pupils dilated. The animal
trembles and runs about wildly, madly biting everything with which it
comes in contact.

The other is a paralytic form where the subject is quiet and the
lower jaw becomes paralyzed early and drops down and the tongue
hangs out of the mouth. If the animal is "suspicious" it should be
kept under surveillance. If the animal has bitten another animal or
a person, they should be kept under surveillance until it is determined
whether they have the disease. If they have, the animal should be
killed at once.

The symptoms in man are first respiratory. There is rapid respira-
tion and more or less halting speech. The person becomes melan-
cholic and anxious and shows great despair. Deglutition is
interfered with because of reliex spasms. The word "Hydrophobia"
indicates that the subject fears water, but this is not true. Any irrita-
tion of the throat will set up a reffex spasm of the pharynx and iarynx,
causing more or less suffocation. There is great palpitation of the heart
and sometimes a breath of air will precipitate a paroxysm. The par-
oxysms are often furious, the delirium wild and muttering, and during
the spasms of the muscles of the larynx the voice is hoarse and unnat-
ural and ofttimes somewhat resembles the bark of an animal. There
is great muscular tremor, followed by paralysis and death. The medulla
nnd hemispheres of the brain, as before mentioned, seem to be the parts
fitfeeted, together with certain areas of gray matter in the spinal cord.
Hyperemia seems to take place, largely in the adventitious tissues of the
nervous system. There are very often hallucinations during the disease.
In the paralytic form the person has preliminary mental anxiety,
and great depression and despair. The muscles of mastication become
paralyzed, the lower jaw drops, the tongue hangs out of the mouth and
the person looks haggard and wild. Paralytic symptoms supervene.
The wound generally heals and the person may have forgotten about it,
but at the time when the disease appears the scar becomes inflamed
and congested.

Treatment. — No drugs seem to have any effect upon the disease,
hence when the wound is made it should at once be relieved of infec-

66 MALIGNANT PUSTULE.

tion. This can best be done, first, by thorough and exhaustive suction
to remove the virus; second, cupping; third, the wound should be
enlarged and allowed to bleed freely. Lastly, it should be washed out
with an antiseptic solution or cauterized with carbolic acid. If the
wound has not been immediately treated and it is believed that the
animal is mad, emulsions should be made of the central nervous system
of the animal and this injected into rabbits to determine whether or
not the animal was the subject of hydrophobia. This will require three
or four weeks' time, so it is essential to determine, if possible, whether
or not the animal has hydrophobia without such experiment, since it
delays treatment. The best treatment seems to be that administered
by the Pasteur institutes, which is done by means of injecting within
the tissues of an animal attenuated virus until the subject becomes
immune, then emulsions are made from the spinal cord of this immune
animal and this is injected into the subject thought to be infected. The
treatment is said to be successful. Mad-stones, which have efficacy
according to the beliefs in the minds of people, are of course one of the
monstrous fallacious fancies handed down from generation to genera-
tion. The disease is always fatal when not treated.

Malignant Pustule.

Malignant pustule is sometimes called "Wool sorter's disease," inas-
much as it is generally contracted by the handling of wool or hides from
infected sheep. The cause of the disease is the anthrax bacillus. The dis-
ease is not so common in this country as it is abroad. The incubation
period appears to be two or three days. The disease generally appears on
the face, hands, or arms and is first manifest by a little papule, after
Avhich follows a small vesicle. This enlarges and a mass of the tissues
dies. The papule is indurated and inflamed, but there is no pain. Necro-
sis is manifest by the fact that a small patch turns black and sloughs
out, leaving a ragged hole. Sometimes where there are several points
of infection it may resemble a bad carbuncle. Sometimes the infection
is pretty general on the body and may extend into the viscera, when
death will result. The anthrax bacillus is extremely virulent and
infectious, hence should be handled with great care. Where the case is
seen early the prognosis is generally favorable.

Treatment. — The treatment is first local, by cautery. The entire
sore should be burned out by means of a thermal cautery or by means
of fuming nitric acid or carbolic acid and then the part treated in an
antiseptic manner.. The general treatment consists of cleanliness and
support. After the necrosed area sloughs away the ulcer should be
washed out twice daily with an antiseptic solution, 1 :1000 bichloride of
mercury, and boracic acid dusted over the sore. Then several layers
of antiseptic gauze and cotton should be applied and held firmly by
suitable bandage.

TUBERCl 'L US IS. 67

Actinomycosis.

This disease is rare in man. It is most common in cattle, where it is
called "lumpy jaw" or "swelled head." The cause of the disease is the ray
fungus. This consists of long, irregular, club-shaped prolongations which
radiate from a common center. The infection is acquired by man from
some of the lower animals. It is generally accompanied by pus format ion
and the pus is peculiar in that it contains yellowish gritty particies. The
disease is more common on the face and neck and may involve the jaw,
the pharynx and even the larynx, producing multiple abscess formation.
It may also involve the bones and glands. The diagnosis can be made
by the history of the case, by small yellow particles in the pus, and lastly
by the microscope. The treatment is extirpation of the infected area.

Tuberculosis.

Tuberculosis is an infective disorder, characterized by its slow
course and the formation of granulomatous masses. The cause of the
disease is the bacillus tuberculosis (Koch), .which varies in size from 1.5
to 3.5 mikrons long, and from .2 to .5 mikron broad. The rod-shaped
organisms are very often undulated or beaded, lying parallel or with the
ends of the bacilli closely approximated. The tubercle bacillus will
affect any of the tissues of the body, and in fact almost all warm
blooded animals. Cold blooded animals are less susceptible, but they may
often contract it. That it is the cause of most of the processes called
tubercular, is a fact beyond dispute, but there are many conditions
which are called tubercular, simply because of the chronicity of the
course and because the disease refuses to abate.

The source of infection to man lies in the dust particles in the air,
in the food supply, and in the water. The germ resists drying,
hence it may readily be carried through the air, where it gets into
clothing, when it may infect the skin, or it may be breathed in, picked
up by some leukocyte and carried to other parts of the body, where it
may be lodged and set up the disease. The germ is readily found on
articles of furniture, in carpets, in the dust, and on the walls of the
apartments of a tubercular patient. Tts infection is rather mild, but
after infection takes place it is extremely fatal.

Pathology. — The characteristic lesions caused by the tubercle bacil-
lus are simply small nodules or tubercles. These small nodules have
been variously described, but consist for the most part of a central area
in which there is a giant cell, containing one or more of the germs,
around which there is an area of what are termed "epitheloid" cells,
which seem to be derivatives of the resident connective tissue cells.
These giant cells are said by some to be the result of fusion together of
more or less wounded or destroyed connective-tissue cells; by others
that their vitality is largely destroyed by the presence of the tubercle
bacillus and the cell is unable to divide, that the nucleus divides with-
out the cell dividing, somewhat resembling an endogenous form of cell

68 TUBER CUL OSIS.

division. Around this there is a peripheral zone of leukocytes or round-
cells. - This forms a mass ahout the size of a millet seed or mustard
seed. Several of these tubercles may be near each other and fuse
together, making a larger mass. These tubercles are avascular, and the
cells crowding in closely, more or less cut off the nutrition to the central
area, when the mass dies and undergoes coagulation necrosis. Some-
times pus is formed, sometimes not. Even if pus is formed the fluids
may be absorbed and the residuum undergoes caseation or may become
calcified, forming a hard calcareous mass which may lie latent in the
body for many years. It may undergo caseation with the tubercle still
present, the mass being surrounded by an inflammatory area, the leuko-
cytes having built up a solid wall or cordon, preventing the bacillus
from getting into the fluids of the body. This may exist for years,
finally, because the body becomes generally debilitated, the tissues inac-
tive, and the resistance diminished, the germ takes on renewed activity
and the patient develops acute tuberculosis. As before mentioned, the
case is generally chronic, but it may run a rapid course. The writer
once treated a man who had taken a large dose of laudanum because
of a love affair. He recovered fairly well from the opium poisoning,
but this seemed to have so weakened the system that it made him a
suitable prey for the tubercle bacilli which were present in quiescent
Pott's disease of the spine. This disease had been quiet for a number
of years and the man enjoyed good health and had worked at hard labor.
After recovering from the opium poisoning he contracted tuberculosis
and died on the eleventh day, after taking the opium, of acute miliary
tuberculosis. The germs, as before stated, lie in the center of the tuber-
cle and because of the resistance of the surrounding tissues are kept
imprisoned there. Some venturesome leukocyte attacks one of the
germs and carries it away into the lymph spaces, only to fall a prey
to its prisoner. Then the bacillus is transported by the lymph into the
general circulation and perhaps into the distant tissues. The edge of
the tubercular zone, or the zone of lymphoid cells, presents a character-
istic inflammatory reaction. As before indicated, the tubercle bacillus
may be walled up within the nodular mass and may remain there
quiescent for a number of years. In some cases the germs may be
entirely destroyed and almost all evidence of the tubercular inflamma-
tion removed by the absorbents. It is peculiar of tuberculosis that
there is little tendency to recovery; that the cells developed fall short
of maturity.

Changes in the Tubercle. — The changes following the deposit of the
tubercle in the tissues are: — (1) Absorption of the bacillus and its con-
sequent destruction, wherein there is no appreciable pathological
change. (2) Caseation. (3) Fibrosis (Encapsulation). (4) Calcification.
(5) Pus formation.

In caseation the tissues undergo coagulation necrosis. True pus is
not formed, or if it is formed, the liquid elements are absorbed and the

TUBERCULOSIS. 09

mass undergoes cheesy degeneration and forms a cheesy mass. This
may later become calcified, or the epitheloid cells which are about the
dead mass may become converted into spindle-shaped cells of fibrous
tissue, when a hard fibrous wall is formed about the tubercle bacilli.
This is the condition of "fibrosis." Calcareous materials may be depos-
ited in this fibrous tissue or the cheesy mass may be converted into a
calcareous mass by the deposit of lime salts, when it is said to undergo
calcification. Now and then in tuberculosis subjects these calcareous
masses or gritty particles may be expectorated. A substance quite akin
to pus may be formed, but true or characteristic pus is rarely, if ever,
formed unless there is infection by means of the pyogenic micro-organ-
isms in addition to the tubercle bacillus. This sometimes happens. The
pus in tuberculosis is more like that of a chronic abscess, and in fact
they so closely resemble each other that some writers have held that all
chronic abscesses are tubercular, which opinion is unwarranted.

Causes. — (A) Predisposing. (B) Exciting.

The predisposing causes of tuberculosis are (1) heredity. By heredity
is meant, not the direct transmission of the disease from the mother
or father to the child, as may happen in syphilis, but a tendency
towards the disease is inherited so that children of consumptive parents
are more prone to the disease than children born of healthy parents.

(2) Strumous diathesis, which means a condition in which there is a
general tendency to the enlargement of the lymphatics and the produc-
tion of adenoid tissue.

(3) Bad hygienic surroundings. The disease happens in persons who
have not had sufficient out-door exercise and who breathe air of poorly-
ventilated rooms. The tissues become devitalized and weakened and
permit the bacillus to gain a foot-hold. More important than all these
predisposing causes, and perhaps the actual cause in chronic conditions
where the tubercle bacillus can not be found, may be stated
Osteopathic Lesions.

(4) Osteopathic lesions. In all forms of infection osteopathic lesions
are of the utmost importance. That a part may not receive its proper
blood supply and proper nerve supply is a fact too well known to be dis-
puted It is generally known that disuse of a part causes a weakening;
furthermore, that when a bone assumes an abnormal position, which
it frequently does, it interferes with the blood supply to a certain area,
also presses upon the nerves so it interferes with the trophic influence.
Other things being equal, the point to which these compressed nerves
and arteries are distributed would be weakest. Now the fact that such
lesions make tubercular infection possible can not be disputed. Further-
more, the irritation set up by the abnormal condition of the bony frame-
work of the body brings about muscular contraction. This interferes
markedly with the circulation, rendering weaker the parts to which
the compressed arteries are distributed. Collateral circulation in some
cases may be thoroughly established, but in other cases this may be

70 TUBXERCUL OSIS.

impossible, when then the part receives a small injury, inadequate to
produce the disease under ordinary circumstances, yet in this weakened
state inflammations are set up and a condition of the tissues suitable
for the development of the germs is produced. This injury, and nearly
always a history of one can be obtained, is of more importance than
has generally been considered, for most likely it very often results in
conditions of subluxation and contractions of muscles, fascia, ligaments,
etc., interfering with the normal blood and nerve supply to the part,
so that the lesions found may be at the joint affected or there may be
spinal lesion affecting the structures upon the side of the body below.
Very often the treatment of this spinal lesion will be attended by a
cessation of the disease symptoms in some distant part. This happens
when the spinal lesion has been the chief predisposing cause of the
disease. The importance of this must not be under-estimated. Under
all circumstances an eager and thorough search should be made for the
above named causes.

The exciting cause, is the Bacillus tuberculosis. It enters the
body in many ways, through the air, food or drink, or may enter through
the skin. They become disseminated in the following manner: (1) In
conditions of lupus and anatomical tuberculosis the disease seems to
be confined to one spot and spreads only by the extension of the inflam-
mation of the skin, not affecting the connective tissues and muscles and
lymphatic glands beyond to any great extent.

(2) They may spread to the lymphatic glands, where they excite
inflammation.

(3) They may enter the lymphatic or hemic circulation and lodge in
some distant organ where the characteristic tubercle is found. The
tubercle bacillus seems to have an affinity for serous membranes. The
organs most prone to be affected are the lungs. Next in frequency are
the testicle, kidney, brain, liver, spleen, adrenals, ovaries, mucous mem-
branes of the larynx and intestines. Bones and joints are affected in
the following order of frequency: Hip-joint, knee-joint, joints of the
ankle, foot, hand, and elbow, while the shoulder and collar bone are
rarely affected; the scapula, ilium, and bodies of the vertebrae may be
affected. The skin is affected less frequently than many other tissues.
The inflammation is set up by apparently slight causes and is progres-
sive, indolent and chronic in its nature, and has little tendency to
recovery.

Tubercular Abscess.

The most important termination of the tubercular process is a cold
abscess. It has the characteristics of an ordinary chronic abscess.
There is present little inflammation. The symptoms of inflammation
may be almost entirely absent. The most characteristic point about
the cold abscess is its limiting membrane. This was formerly called a
pyogenic membrane, as was the membrane lining an ordinary abscess

TUBER CUL OSIS. 7 1

cavity. This limiting membrane is a defence-wall, built up by the tis-
sues to prevent absorption of micro-organisms and the products of
the decomposition and disorganization of the tissues. Strange to say,
the tubercle bacilli are rarely, if ever, found in the contents of a cold
abscess. It is said they exist in the margins of the limiting membrane.
As a general rule the abscess causes but little trouble until it ruptures,
when pyogenic infection follows, causing a severe systemic reac-
tion. The abscess may gravitate and open at a distant point. It may
exist for months, the fluid contents being finally absorbed. The solid
residuum afterwards undergoes cheesy or calcareous degeneration. The
common forms of these abscesses are gravitation abscess, psoas abscess,
retropharyngeal abscess, lumbar abscess, etc., which will be discussed
elsewhere.

Tubercular Gummata.

Tuberculosis is an infectious granulomatous disease similar
to syphilis, leprosy, and glanders, so that the formation of gumma, as
happens in these other diseases, may happen in tuberculosis. Gumma
consists of a fusing together of tubercles which have undergone degen-
eration, together with a large mass of ill-formed and ill-developed
granulation tissue cells. It consists of a mass of fungus granulations
which readily break down and ulcerate. They happen in the cranial
and peritoneal cavities least often, but are common in bones and joints.
The gumma consists of a mass of condensed tissues, often uninfected.
It has a poor blood supply and a tendency to break down and ulcerate.

Scrofula.

Scrofula is not a disease, but a condition of the system
whereby the tissiies become an inviting host to the tubercle bacillus.
It is generally of congenital origin, one or the other of the parents
being tubercular. The lymphatic glands are prone to enlarge and sup-
purate. Joints and bones are liable to be affected. Often there is a
chronic catarrhal inflammation of the mucous membranes or chronic
eye disease, granulated lids, etc., eczema of the scalp or face, all of
which are evidences of bad health, malnutrition, etc. Generally the
patient is a victim of unsanitary surroundings or poorly ventilated
quarters.

Tuberculosis of Various Regions.

Skin.— (1) Lupus is tuberculosis of the skin. ' It usually happens
upon the face, beginning before the age of twenty-five. The nose seems
to be its choice point of origin. Three varieties are described. (a)
Lupus Vulgaris is the most common form and appears as pink nodules,
which ulcerate after a time and then cicatrize. This process of forming
nodules, ulceration and cicatrization keeps up continuously, perhaps
disappearing here, but appearing with renewed activity at another point,
(b) Lupus exedens is characterized by severe ulceration. (c) Lupus

72 TUBERCULOSIS.

hypertrophicus is a form in which very large nodules appear. Lupus
generally begins as a pimple, or group of pimples, which finally break
down and ulcerate, leaving a soft irregular, not shelving, ulcer, which
discharges a yellowish colored fluid. The bottom of the ulcer looks
unhealthy and the skin about the ulcer is more or less inflamed. It is
said the disease is painless, but sometimes it is extremely painful. It
is not unusual that the ulcerating process may entirely heal up, but it
finally recurs. It will heal up at one point and become more active at
another, always destroying tissues over some part of the area. Cicatri-
zation may have occurred, which will draw the surrounding tissues,
often producing deformity. The process may be quite destructive, sim-
ilar to a rodent ulcer, and produce hideous deformity. Scars produced
by lupus are firm and hard, but yet break down easily. One of the char-
acteristics of lupus is that the tuberculous secretions, drying, form yel-
lowish crusts, often more or less scaly. Clinically it may be differen-
tiated from a rodent ulcer, inasmuch as the rodent ulcer presents an
everted appearance and is deep, while in the ulcer numerous vessels
are visible. It does not spontaneously heal and its base and edges are
hard and fibrous.

Treatment. — The best treatment for lupus is a free removal of the
diseased tissues with a knife, curette, or cautery. If possible, the entire
mass should be removed and the wound be made to heal by first inten-
tion. If the wound is allowed to heal hj second intention, it is better
that the cautery or curette be used. Where the curette is used, subse-
quent application of caustic, such as nitrate of silver or chloride of
zinc (5 to 10 per cent.), or the electric cautery, may be made. After the
cauterizing of the lupus the wound should be treated with an ointment
of aristol. Concentrated electric or sunlight from which the heat rays
have been removed seem to have given satisfactory results in some
cases, but the treatment requires a long time, inasmuch as but a limited
area can be exposed at a sitting. The result of the exposure to light
is a sloughing out of the lupoid area.

(2) Anatomical Tubercle. — This lesion of the skin happens in sur-
geons or in operators holding post-mortems where infection takes place
in wounds by means of tuberculous material. The anatomical tubercle
is a red inflamed mass, often pustulating.

(3) Tubercular guminata. — Tubercular gummata of. the skin are
characterized by edematous inflammation and ulceration. The ulcers
have grayish bases, show no tendency to heal and have inverted ^edges.
Sometimes there is a chronic thickening of the skin, called sclero-derma.

Subcutaneous Connective Tissues. — In subcutaneous connective tis-
sues the tubercular process is usually manifest in the form of cold
abscess. It may be manifest by gummata and tubercular nodules.

Lung. — Pulmonary tuberculosis does not belong to the province of
surgery and is best treated by well known osteopathic methods.

TUBERCULOSIS. 7'.i

Alimentary Canal. — Tuberculosis of the mouth, pharynx, esophagus,
stomach, and intestines is very rare. The germ may pass through the
lining membranes of these cavities and set up inflammation in the
deeper structures. The adenoid glands found in the mucous mem-
branes of the intestines may become involved.

Peritoneum and Pleura, — Tuberculosis of these membranes becomes
surgical only when abscesses are formed.

Bone. — Tuberculosis of bone is common in youth and is always pre-
ceded by injury. There exist osteopathic lesions which make the injured
bone a point of least resistance. The deposit of the tubercle causes the
characteristic inflammation, attended with softening of the bone and
even of the production of an abscess. This calls for surgical interven-
tion. (See necrosis of bone).

Joints. — Tuberculosis of joints is popularly termed "White Swell-
ing" and consists of a chronic inflammation and degeneration of the
synovial sac. Children are especially susceptible to the disease. It is
brought about by injury and subluxation. The deposit of the tubercle
may occur in the end of the bone, in the synovial sac or in the con-
nective tissues just outside of the synovial sac or in the epiphyseal
cartilage. Lesions affecting the circulation to the joint are responsible
for the disease.

Lymphatic Glands. — Tuberculosis of lymphatic glands is known as
"Tubercular Adenitis." The frequency with which enlargement of
lymphatic glands occurs in tuberculosis is even popularly recognized.
This enlargement is due to the fact that the inflammatory products
and the tubercle bacillus are carried back through the lymph stream
and lodge in the lymphatic glands. Caseation often occurs.
Residual abscess may follow. Tubercular adenitis is more common
in the neck and mesenteric glands, but may occur anywhere in the
body. It may in some cases become very general. Suppuration arises
from mixed infection. While the disease is generally local, it may
became a source of infection, general tuberculosis folloAving. It must
not be confounded with lymph adenoma, which usually occurs in the
lymphatics of the posterior triangles of the neck, whereas cervical
lymphadenitis generally occurs in the anterior triangles of the neck.
Tubercular glands very often run together and form a large inflamed
mass. In every case obstruction to the local circulation may be noted,
which is responsible for the inflammation.

Testicle. — Tuberculosis of the testicle is not rare. Generally but
one testicle is affected in the beginning, but later both are affected. It
is a form of painless epididymitis and orchitis. The tubercular mass
many times softens and breaks down, forming an abscess which bur-
rows towards the surface. The layers of the tunica vaginalis, the skin,
and subcutaneous tissues become adherent and it may rupture exter-
nally. The diagnosis is made purely by the clinical facts presenting.
The use of the microscope is of no avail, as the bacilli are not in the dis-

74 TREATMENT OF TUBERCULOSIS.

charge. In fact, it is not necessary to make the diagnosis of tubercu-
losis,-for it does not modify the treatment.

Prognosis.— The prognosis varies with the condition of the patient,
the structures involved, the extent of the infiltration and the rapidity
of the process.

Treatment of Tuberculosis.

(1) Hygienic, dietary, and climatic. (2) Osteopathic. (3) Surgical.

Hygienic, dietary, and climatic treatment are of inestimable value in
tuberculosis. The hygienic treatment consists chiefly in an open-air
life in pleasant surroundings, etc. The chief dependence of the tuber-
culous patient seems to be in an appetite satisfied with wholesome and
nourishing food. The patient should be instructed, if he has extensive
tuberculosis, to eat less in amount and more frequently. The diet
should consist of eggs, if they are well borne, from three to six daily,
milk in large quantities, good steak, beans, rice, cereals, etc. If the
person has lost his appetite, or if he has indigestion, predigested foods
should be given, such as beef tea, prepared in the following manner:
Place a piece of minced lean beef in a glass fruit jar which is then sealed
up and put in a pan of water and gradually heated to boiling. The juice
is decanted and the remaining liquid elements pressed from the beef.
This juice may be seasoned to taste and is usually well borne and nour-
ishing. Commercial beef tea is usually of not much value. Fruit
juices are often well borne, encourage an appetite, and are pleasant.

Climate. — The pine covered hills of northern Georgia, the dry atmos-
phere of New Mexico, and the altitude of Colorado are all favorable to
the health of tuberculosis patients. They encourage deep breathing,
secure a better blood supply to the chest and cause the patient to do
what he otherwise would not do, take more lung exercise.

The Osteopathic Treatment consists in increasing the blood supply to
the affected area, adjusting vertebrae, ribs, clavicles, relaxing contracted
muscles, etc., that may have excited or are aggravating the diseased
conditions. Since our only hope of curing tuberculosis is in increasing
the vitality and nutrition of the tissues, osteopathic treatment has this
in view when it removes pressure from artery, vein or nerve or when it
increases the blood supply to a part by means of stimulating the vaso-
motor nerves. It has been advocated by enemies of the practice of
osteopathy that there is danger in manipulating a tubercular joint or
area on account of scattering the germs and causing acute general tuber-
culosis. Clinical practice of the entire osteopathic profession in the
enormous number of these cases treated shows that there is no such
danger in this treatment properly applied. It is unnecessary to state
here that drugs administered internally are of no value in the treatment
of tuberculosis.

The surgical treatment consists in extirpating the tuberculous area

GLANDERS. 75

when it is accessible. Cold abscesses when opened should be thoroughly
cleansed with a solution of bichloride of mercury (1:1000), then the
abscess cavity should be scraped out and free drainage established.
Iodoform emulsion in glycerin (10 parts iodoform to 90 parts glycerin)
may be injected into the cavity, providing the drainage is good, after
it has been thoroughly washed out with an antiseptic solution. The
tuberculous area should be kept as nearly aseptic as possible and like-
wise at rest.

Koch's Tuberculin. — The specific treatment demised by Koch has
been proven worthless and is no longer used.

Bier's method consists in placing an elastic band around the limb
above the tuberculous area and is founded upon the principle of Laen-
nec, that cyanosis was unfavorable to the tuberculous process. The
elastic band causes venous congestion. Surgical interference should be
advised only as a dernier resort, when it is shown that the condition can
not be relieved by osteopathic treatment properly applied.

Glanders.

Glanders is an infectious disease produced by the bacillus mallei. It
manifests itself in acute and chronic forms. It is classified as one of
the infectious granulomatous diseases, because of the granulomatous
masses formed in the mucous membranes and in the skin and connective
tissues at which points the micro-organisms have obtained entrance, or
having gotten into the circulation, have lodged at these points and set
up the characteristic pathological changes. The disease is common in the
horse, but is rarely seen in man, and then only in laborers about stables.
It is contracted by laborers about stables from the fact that the pus
is blown into the face or onto the body, from which point it either gets
into a small wound in the skin or it effects an entrance through the
mucous membranes. In man the disease is characterized by (1) copious,
foul, and sanious discharge from the nose, (2) an eruption over the body
quite resembling small-pox, and (3) enlargement of the lymphatic glands
with formation of nodes, which break down and ulcerate, forming foul
ulcers, which discharge a disagreeable pus. The onset of the disease is
often announced by a chill. The febrile reaction is of a typhoid type, be-
ginning with a slight elevation of temperature, which gradually rises,
and after several days reaches its maximum intensity. The symptoms
of the disease are, in addition to the chill and fever, evidences of pleiir-
isy. pneumonia, or diarrhea. These symptoms will vary, depending upon
the mucous membranes and the tissues most affected. The symptoms
often resemble a septic intoxication like sapremia. Later, after the
forming of foul ulcers, the symptoms may be those of septicemia and
pyemia because of the rapid infection of the pus micro-organisms which
are introduced into the ulcer. Usually death occurs within a week.
In the acute form the mortality is from 85 to 90 per cent. In the
chronic form it is much less severe and the patient may linger for

76 SYPHILIS.

several weeks and even months. The disease runs a slow course and
repeated abscesses form, which rupture, and the pus is discharged.
Finally the patient may wear the disease out or the abscesses may have
been opened and the pus discharged, the patient recovering after symp-
toms of chronic pyemia. Cases have been reported where twenty or
more abscesses have been successively opened and the contents removed.
The mortality in the chronic form is 50 per cent. In the acute form
the pustules form over the face, hands, and arms and exposed parts of
the body. The formation of the pustules in the skin is accompanied by
edematous swelling so that the features are often horribly distorted.
The history of the case and the eruption, together with the lymphatic
enlargement and edematous swelling and evidences of pus forming,
would be sufficient on which to base the diagnosis. The chronic form
quite resembles syphilis, from which the diagnosis can be made by care-
ful inquiry into the history of the case.

Treatment. — The treatment consists of (1) supportive, (2) surgical,
and (3) antiseptic. The person should be given concentrated, highly
nourishing, and digestible foods, and if necessar}^ stimulants may be
administered. Surgical treatment consists in opening the abscess as
soon as it appears, removing the limiting membrane and the dead tis-
sues. Rigid antisepsis should be maintained. All the abscesses, where
they can be reached, should be drained and washed out with 1 :20 solu-
tion of carbolic acid or 1:1000 mercuric chloride.

Syphilis.

Syphilis is an infectious, contagious constitutional disease which runs
a slow course and affects successively mucous membranes, lymphatic
glands, skin, connective tissues, bone, eye, and nervous system. The
cause of this disease is unknown, but it is believed to be due
to a micro-organism. There are those who believe it to be caused by
the absorption of inflammatory products, which seriously damage the
general metabolic process. Others believe that the micro-organisms, or
its products, are absorbed into the body and these circulating through
the fluids bring about the changes characteristic of the affection. Lust-
garten's bacillus was thought to have been the cause of the disease, but
this has been proven not true, inasmuch as the germ is found in gum-
matous formations in the tertiary stage, whereas these are not infec-
tious. It is a well known fact that the disease may linger for years
within the system, finally breaking out and assuming many peculiar
forms. It is hardly likely that the micro-organisms could have existed
in the body during this long period. The symptoms of the disease have
been explained by the absorption of the inflammatory products, the
toxins of which disturb the metabolic process and bring about the pro-
duction of granulomatous tissue, which is prone to break down and ulcer-
ate. Whatever is the cause of the disease, it seems to come in almost

SYPHILIS. 77

all instances in a certain way and seems to run the same peculiar
chronic or slow course. While the eruption may vary, yet it fol-
lows in sequence other symptoms, so that likely, as our bacteriological
methods are improved, the cause of the disease will be determined. It
is characterized by a period of incubation varying from two to four
weeks, usually about twenty clays, at which time a local sore appears,
which is soon folloAved by lymphatic enlargement. This local sore is gen-
erally located on the genitalia, but may be found on the hands of the
accoucheur, or upon the lips, tongue or nipple. Two to three months
from the time of inoculation, or from forty to sixty days after the
appearance of the primary sore, the skin and mucous membranes are
affected. These are secondary manifestations or changes, the chief
characteristics of which are that they are generally symmetrical. The
second stage lasts from two months to two years, depending upon the
treatment the case receives, and upon the habits of the patient and his
surroundings. In some cases no further changes may be manifest. The
disease seems to wear out, or after a few months or a few years, tertiary
changes develop. The}r are usually asymmetrical and attack, besides
the superficial tissues, the deeper structures, such as the connective
tissues, bone, periosteum, muscles, viscera, liver, lungs, etc. The path-
ological formations in this stage consist chiefly of gummata. These
gummata often lead to suppuration or to fibroid changes, perhaps to
necrosis or to contractions of the tissues producing distortions or they
may cause paralysis. Fibroid changes sometimes occur in the nervous
system; these are manifest in various ways. The tertiary stage may
last for life, the person dying of an intercurrent disease, whereas it
may terminate fatally or the person may apparently get' rid of the ail-
ment after some years. Another peculiar fact about syphilis, which
indicates that it is a specific disorder due to a micro-organism, is that
it confers immunity to further attacks. Chancre, which is the pri-
mary sore of syphilis, may be multiple, where two points were infected
simultaneously, but if a chancre has appeared at one point, having been
thoroughly established, repeated efforts at inoculation at another point
on the body have failed. Furthermore, after the chancre has healed
and the patient is then the victim of secondary or tertiary syphilis,
chancre will not again appear, nor can a person, under any circum-
stances, be inoculated. The disease is produced by direct contact with a
chancre or the virus may linger upon a drinking cup or it may be intro-
duced into the system by means of lymph in vaccination. The location
of the chancre, as before mentioned, may be on the fingers, lips, tongue,
tonsils, walls of the pharynx, or genitalia. In the female the chancre
is usually located on the labia minora. It may be on the walls of the
vagina or on the cervix uteri. In the male the chancre is usually found
on the prepuce, but may be found upon the glans or situated in the
skin back of the glans. It ma}r be located in the meatus urinarius
externus or back some little distance along the urethra. The appear-
ances of a chancre are peculiar.

78 CHANCRE.

Chancre — Primary Syphilis. — Primary syphilis is the first stage in
which there appears a chancre with enlargement of the lymphatic
glands. The chancre must not be confounded with venereal ulcer or
chancroid. Chancre exists in three forms:

1. Hunterian chancre is a hard, round, elevated, and inflamed mass
which has ulcerated on the top. It does not suppurate and has a vel-
vety edge or surface and "bleeds easily. Hunter described the ulcerated
surface as looking like raw ham. The discharge from the chancre is
watery. This is not the most common form of chancre.

2. A hard, red, indurated mass which is situated beneath the epi-
dermis, and from which the epidermis ma}r, or may not, have been
peeled off. This seems to be the most common form of chancre.

3. The rarer form is a purplish-red or purple patch situated in the
skin, and which is exposed by removing the epidermis. This chancre
is neither indurated nor ulcerated. Ulceration in a chancre seems to be
brought about by irritation or friction or the presence of filth. A
chancre is nearly always single. ■ In most cases it has well defined mar-
gins which feel like encapsulated cartilagenous masses. These may
be readily picked up between the fingers. The hard base is produced
by inflammatory exudates. If the chancre is not properly treated it
may exist for months, but the induration usually disappears after the
secondary symptoms present themselves.

Chancroid. — A chancroid is a local sore which is very often multiple.
It may be single in the beginning, but if allowed to remain for a few
days will quickly become multiple. It appears in from one to ten days,
never afterwards. The sore begins as a pustule, which ruptures, dis-
charging a fluid which spreads over the surface and causes various other
ulcers. The ulcer has thin undermined edges and is sharp-cut, and
looks like it is punched out from the skin or mucous membrane. It
looks sloughy and has a grayish base. The discharge is offen-
sive. The tissues over which this pus flows will become inoculated. If
the first sore was in the vestibule, other sores will be f otmd along down
the labia minora and labia majora, over which the discharge has run. It
is a soft sore. They do not bleed or cause constitutional symptoms,
but are followed (when situated on the genitalia) by inguinal adenitis
or bubo. The lymphatic enlargement is on the side corresponding to
the side of the genitalia affected. Should the chancroid be in the
middle line, lymphatic enlargements may be manifest on both sides.
This is unusual.

Herpetic Ulceration. — Herpetic ulceration may follow febrile re-
action, but is usually due to an irritation set up by foul discharges or
to filth. It first appears as a vesicle or group of vesicles, which rup-
ture, discharging a clear fluid. These vesicles may run together,
finally forming an ulcer. These ulcers are superficial, having no ten-
dency to spread and are not indurated. They are, like chancroids, pain-
ful. Unless suppuration appears they are not attended by bubo.

SYPHILIS. 79

Mixed Sore. — A mixed sore is a condition where the subject is in-
fected with chancroidal poisoning and at the same time with syphilitic
poisoning, hi these cases the sore has the appearance and characteris-
tics of a chancroid, but later along it comes to have a hard indurated
base. These sores should always be regarded as "suspicious." In no
case should an absolute diagnosis be made by the appearance of the
sore, but in all cases they should be treated alike — cauterized — and then
treated as simple sores. Before the diagnosis of syphilis is made, the
attending physician should await the development of secondary symp-
toms. Instituting treatment before secondary symptoms have devel-
oped will in no way benefit the case, for just as soon as the chancre
appears, just so soon is syphilis a constitutional disease. Amputation
of the chancre, followed by the proper healing of the wound, will in
no way affect the course of the disease. Secondary symptoms will ap-
pear in due time. Chancre may be mistaken for cancer of the tongue.
Chancre of the tongue is brownish red, whereas cancer is bright red.
The discharge from the cancer is bloody, from the chancre it is non-
purulent and free from blood. Cancer appears late in life. The
lymphatic enlargements in cancer are painful, while those of chancre or
syphilis are indolent. At all events, the diagnosis can be made in two or
three months.

Syphilitic Phagedena. — This is a condition existing in persons sur-
rounded by filth and debilitated by disease, in diabetics, drinkers, etc.
Foul and spreading ulcers may happen coincident with the chancre
or afterwards and these are best treated by methods advised for slough-
ing phagedena.

Relapsing Chancre. — After syphilis has been apparently cured for
many years, the scar left by the chancre may become inflamed and en-
larged, the chancre apparently returning.

Bubo. — A bubo is the enlargement from inflammation of the lym-
phatic glands above Poupart's ligament. In syphilis it is generally
bilateral and indolent. They may be small or large, usually freely
movable underneath the skin and rarely ulcerate. In debilitated sub-
jects the glands may enlarge enormously. In cases of "mixed sore the
buboes are very often suppurative. Where the chancre appears in the
mouth the bubo appears below the jaw. They may remain for many
months and finally disappear by absorption or fatty degeneration.
After some months there may be general lymphatic involvement. This
lymphatic enlargement affects all of the lymphatics, but those found in
the posterior triangles of the neck and in the epitrochlear space back
of the humerus are characteristic of syphilis. In syphilis the bubo con-
sists of a chain of enlarged lymphatic glands, whereas in chancroid
the bubo consists of an inflamed mass, seemingly produced by the in-
flamed glands fusing together. Syphilitic buboes grow slowly and are
almost painless and are not red and inflamed. Chancroidal buboes
are extremely painful, are red and inflamed and show a tendency to

80 SECONDARY SYPHILIS.

suppurate. It is maintained by some that a positive diagnosis of syph-
ilis can be made when an indurated sore is followed by bilateral buboes
with involvement of other lymphatic glands. I should not advise the
diagnosis to be made so early, but would wait until the development
of the secondary symptoms.

Secondary Syphilis. — Secondary syphilis consists of certain changes
in the skin and mucous membranes with general lymphatic involvement,
and in some cases it is said to attack the iris. These secondary signs
appear about forty clays after the appearance of the primary sore or
about two months after inoculation. They may be so slight as to be
overlooked or in some cases entirely absent. During the secondary
syphilis the disease is very readily transmitted to the offspring through
the ovum or spermatozoon, or by contact with the sores.

Skin. — The skin eruptions are various. It is peculiar that the erup-
tion in syphilis may simulate the rash of almost any of the exanthe-
mata. Frequently the onset of the rash is attended by a chill, high
fever, and may be scarlatinous. In some cases it may be erythema-
tous, in other cases it may resemble measles, while in still others it
may be mistaken for small-pox. The eruption is usually a roseolous
rash spreading over the back, chest, and abdomen. It is generally
accompanied by a sore throat. The rash seems to be caused by a local
congestion, since it fades under pressure. It usually disappears in
a short time, but if the rash continues, inflammation of the skin will
occur at the points of the rash. Sometimes the epithelium will form
scales; these are called scaly syphilides, the eruption taking on the ap-
pearance of psoriasis. It may manifest itself in a distinctly papular
rash, which is called a 'papular syphilide. In other cases, where it is
still more severe, little vesicles may form on top of the papules, ves-
icular .sypliilides. In a certain class of vesicular syphilides, where
the process seems to be more severe and there is marked exudation of
serum, large bullae are formed; these are called hullous syphilides or
syphilitic pemphigus. In some cases the contents of the vesicles are
converted into pus. pustular syphilides, or syphilitic ecthyma, a condition
where the pustules form scabs, which afterwards dry up and fall off,
leaving no scar. Syphilitic rupia is a condition where marked ulcera-
tion takes place underneath the scabs.

Mucous Membrane. — Following the eruptions, ulcers appear upon
the mucous membrane of the mouth and throat. They are called
mucous patches. The first ulcers are usually symmetrical. They
are usually painless and often temporary and superficial. Sometimes
the mucous patch presents an appearance of condyloma. Mucous
patches may also appear upon the mucous membranes of the genitalia
and rectum. Mucons patches are prominent in smokers or people with
badly neglected teeth. These patches sometimes affect the larynx,
causing hoarseness and even loss of voice. The nasal mucous mem-
branes may be affected so as to produce a discharge and evidence of

SYPHILIS. 81

catarrh. It is not unusual that mucous patches may occur in the
urethra, causing an infectious discharge. It is during this stage that the
disease is communicated as the sores are very infectious.

Hair. — The hair falls out, sometimes rapidly and extensively. It
may he so widespread as to affect the beard and eye-brows, or it may be
limited to the production of bald spots on the scalp. This baldness,
which is known as alopecia, begins about the time of the appearance of
the eruption. The baldness is not permanent, as the hair will again
appear. The bald places are not as smooth as in other forms of alopecia
and the skin is scaly.

Nails. — The nails may be entirely or partially cast off, due to inflam-
mation of the matrix. The new nail formed is often diseased.

Eyes. — Iritis is the commonest eye trouble in secondary syphilis. It
appears about four months after the chancre; in fact, acute iritis devel-
oping is said to be a strong symptom of syphilis. It is shown by a pink
zone around the sclera and a muddy, reddish iris. The pupil is irregular
and there is intense photophobia and pain. The pupil may be hazy.
The patient usually recovers from the syphilitic iritis with good vision.
The retina may become affected by diffuse retinitis or there may be a
choroiditis. The diagnosis of these affections can be made by means
of the ophthalmoscope.

Ear. — Barely temporary impairment of hearing takes place, gen-
erally sjonmetrical. Sometimes it may lead to deafness.

Bones and Joints. — Barely there may be a periostitis set up, but this
is usually a manifestation of tertiary syphilis. Likewise the synovial
sacs may be affected, causing more or less synovitis, but these inflamma-
tions are more or less transitory and not very painful. No destructive
disease either of the bones or joints occurs. Intense headache may
appear because of periostitis of the bones of the skull.

Testicle. — Sometimes the epididymis and testis may become
inflamed. This is sometimes followed by atrophic cirrhosis, while in
others the plastic exudate is absorbed without injury to the organs.

Tertiary Syphilis. — Tertiary syphilis appears after a latent period
which follows the secondary syphilis. This latent period varies in
length; in fact, the secondary syphilis may exist for from four or five
to eighteen months. Tertiary syphilis will appear within six months
or two years. There are some cases in which the tertiary symptoms
are manifest after a few months, in other cases they are greatly
delayed. The tertiary symptoms are announced by chronic inflamma-
tion of the various organs and tissues leading to the formation of gum-
mata. These gummata may vary from the size of a pea to that of a
walnut and are very intimately blended with the surrounding tissues.
These gummatous formations may undergo caseation and break down,
producing, when in the submucous tissues, a characteristic ulcer or they
may continue for some length of time, disappearing under favorable
treatment, or in other cases may leave a hard fibrous mass, contractions

82 TERTIARY SYPHILIS.

of which seriously interfere with function and produce great deformity.
These gummata are formed of granulation tissue and are made up, for
the most part, of three zones, a central zone, indicating degeneration,
principally fatty. This is surrounded by a matrix made up of cells
undergoing fibrillar changes. The outer zone contains numerous rami-
fying vessels between which are the granulation tissue cells.

Tertiary Lesions. — The tertiary lesions are (1) gummatous inflam-
mations of the periosteum and of the bones leading to caries or necrosis
occasioning deformity. When the nasal bones are affected the ulcer-
ative and necrotic process may destroy the entire nose, the nasal septum
and pterygoid bones, producing horrible deformity.

(2) Gummatous inflammations in the skin and mucous membranes
(tubercular syphilides). This is a condition in which tubercles are
formed. These sometimes break down and form serpiginous ulcers.
These are symmetrical, involve the deeper tissues and show no tendency
to heal. When the larynx, pharynx, and rectum are affected, serious
damage may result by the formation of strictures and gummata.

(3) Gummata may form in the muscles, producing paralysis and
injury to the muscles affected. Where this occurs in the tongue, serious
damage from ulceration and cicatrization may take place.

(4) Gummata of the nervous system produce paralysis and when they
involve the anterior or frontal lobes of the brain they produce marked
psychical symptoms. It may lead to fibroid changes in columns of the
cord, medulla, or in the cerebellum.

(5) Gummata of the blood vessels. The arteries are chiefly affected
and this results in the formation of thrombi, emboli, and aneurysm and
rupture of the arteries.

(6) Lastly, gummata may form in the viscera, liver, lung, or kidney,
producing symptoms according to the nature of the organ and the
extent of involvement.

Hutchinson enumerates the lesions of tertiary syphilis in this man-
ner: Diseases of the skin of the nature of rupia or lupus, periostitis
of bone forming nodes, causing hypertrophy, caries or necrosis; gum-
mata in various parts, as of the tongue, causing sclerosis, of the nervous
system introducing structural changes, causing ataxia, ophthalmople-
gia, internal and external; general paresis, paralysis of cerebral nerves,
optic atrophy, myeloid degenerations; and chronic inflammations of
certain mucous membranes, such as the mouth, pharynx, vagina, and
rectum, with ulceration, thickenings, and strictures. It may affect the
spine in the form of spondylitis, at the same time involving the men-
inges of the cord. Unilateral enlargements of the testicle and epididy-
mis may take place. Serpiginous ulcers in tertiary syphilis are preceded
by brown or copper colored spots. These spots break down often, form-
ing crescentic shaped ulcers. They are more common about the lips
and nostrils and on the face. Involvement of the periosteum and con-
nective tissues will lead to severe pains, syphilitic rheumatism, so that

CONGENITAL SYPHILIS.

83

pressure on the front of the tibia will usually occasion considerable
pain. These rheumatic pains are greater when a person becomes warm
after retiring at night. They often involve the ribs, showing tender-
ness throughout the extent of one or more.

Syphilis of the nervous system comes on late and is indicated by
meningitis, atheromatous condition of the vessels, fibrosis, and gum-
matous formation. Syphilitic paralysis is progressive, limited and not
complete. Epilepsy appearing after the thirtieth year, not due to alco-
holism, is likely due to latent syphilis. A syphilitic patient often has
persistent headaches, insomnia, muscular tremor, paralysis, slowness
of utterance, and vertigo. Spinal syphilis is manifested in the form of
sclerosis as in Landry's paralysis. There may be a condition of soften-
ing and tumor. Syphilis sets up a neuritis of a chronic form, accom-
panied by degenerations as in locomotor ataxia.

Congenital Syphilis. — Congenital syphilis occurs in children only
when both of the parents are syphilitic. It is transmitted to the child
by means of the ovum or spermatozoon. The child is born healthy, while
the disease usually appears from the fourth to the sixth wee!: after
birth. There are cases where it is said the child was born with evidence
of syphilis. There are other cases where the development of the dis-
ease seems to be considerably delayed. The symptoms of the affec-
tion in general are those of "snuffles" or a chronic catarrh. Mucous
tubercles and ulcerations are present about the mouth and anus. The
discharge from the nose is generally copious and non-purulent. A rash
appears on the body similar to that in secondary syphilis of the acquired
form, later copper colored spots appear about the genitalia and buttocks
and on the hands and feet. These may be followed by ulcerations.
Eruptions may be papular, vesicular, or pustular. Generally the child
is anemic and wasted . It has a shriveled and shrunken appearance and
looks old, so that a child of a few months has the face of an old man.
The hair falls out and eyes become affected, ulcers and keratitis produc-

ing an opaque condition of the cornea,
while the bones and joints and viscera are
all affected. Where the symptoms appear
late or where the child seems to survive the
secondary symptoms,, changes in the bones
occur, producing a broad bridge of the nose.
Ulcerations take place at the angles of the
mouth. These on healing leave scars
(Hutchinson's lesion). Usually there is
a peculiar conformation of the skull. The
head is square with prominent frontal emi-
nence. The incisor teeth are characteristic;
the edges are serrated and concave, and
sometimes they look as if they were cut
out. Enlargements on the bones sometimes
occur. These are called Parrot's nodes.

Deafness usuallv follows

Fig. 6.

Hutchinson teeth in hereditary
syphilis.

84 TREA TAlENT OF SYPHILIS.

Kiiles governing the inheritance of syphilis may he summed up in the
following :

1. Colles's Law. — Children having inherited syphilis from the father,
the mother never having manifested the disease, the mother is immune
to syphilis so that she will not contract it from the nursing child. A
wet nurse would.

2. If one parent is syphilitic the child may be.

3. Syphilitic parents may bring forth healthy children.

4. If the mother, while enceinte, contracts pox, the child may have
syphilis. Under such circumstances it becomes infected in utero.

5. The more recent the syphilis the more likely it is the child will
be infected, and the more latent the syphilis the more tardy and less
likely will be the development of the syphilis in the child.

6. Syphilitic parents may beget several syphilitic children when
afterward they may bring forth healthy children.

7. Syphilis not having manifested itself for a number of years, the
child may not have syphilis.

8. Syphilis in the mother is much more dangerous to the child. She
often aborts at the fifth month.

Treatment.

A. Osteopathic. B. Other measures.

Osteopathic. — The treatment has not as yet been tested in full to
determine its effects in all forms of this disease. We hold it to be a
nutritive disorder due to the absorption of inflammatory products. In
the lesions of tertiary syphilis osteopathy has been peculiarly successful.
Especially is this true of gummata, paralysis, rheumatism, eye affec-
tions, and ulcerations. In all these conditions we depend upon increas-
ing the blood supply to the diseased part. This enables the young
granulation tissue cells to mature. It further hastens the resorption
of the inflammatory, degenerated, and other products present in the
disease. This treatment if properly applied ought to relieve the various
forms of tertiary syphilis readily and completely. The treatment is the
surest and most powerful method of reconstructing and renovating the
tissues. The poison is eliminated by the excretories while the recuper-
ative powers are replenished by securing a good free flow of fresh and
wholesome blood.

Other Treatment. — Chancre. — As soon as seen a chancre must be
cauterized with fuming nitric acid or carbolic acid. Afterwards it
should be treated as a simple sore — dusted with calomel, and borated
gauze and cotton applied and held in place by a bandage. When on a
mucous surface an antiseptic solution may be used twice daily.

Bubo. — The treatment as advised in inflammation will be found ap-
plicable here. They rarely cause trouble. It will do no good to rub
in salves or apply liniments. If the treatments are persisted in the
inflammatory products may be absorbed.

GONORRHEA. 85

There are three methods now in use which affect very favorably the
course of syphilis. They are the following: 1. The inunction treatment
consists of rubbing into the skin on different parts of the body fifteen
to thirty grains of mercurial ointment daily. liubber gloves are neces-
sary. The treatment is extensively used.

2. Daily hypodermic injections of one-fourth grain of the bichloride
of mercury over the back and buttock for one month is a treatment
said to be very successful. If the disease reappears one-sixth grain of
the drug raaj be similarly injected for a period of one month. If it
again reappears one-eighth of a grain may be injected in the same
manner.

3. Iodid of potassium in a saturated solution is extensively used in
the treatment of old syphilitic lesions. It is begun with ten drops three
times daily in a glass of water and increased one drop at each dose until
two hundred drops are taken three times daily.

Diet and Hygiene. — In syphilis it is of the utmost importance that
the patient eat plain, wholesome, and non-stimulating food. He should
take frequent baths, drink copiously of pure water, avoid stimulants of
all kinds such as tea, coffee, tobacco, and alcoholics. Good clothing
should be worn and the victim should receive a good night's sleep. All
the secretions should be kept active and regular.

Gonorrhea.

Gonorrhea is a specific ulcerative inflammation of the urethra in the
male, and the vagina in the female. This inflammation frequently ex-
tends into other organs, sometimes even affecting the eye, it having
been inoculated by pus transported to it from infected hands or cloths.
There are two forms of urethritis usually described in the male, the
specific and non-specific.

The non-specific form of urethritis is produced by irritating dis-
charges, by injury or by micro-organisms. The symptoms are usually
mild, the inflammatory reaction is not severe and it generally runs a
short course. The sequels are of no consequence.

The specific form of urethritis is produced by infecting the mucous
membrane with the diplococcus Neiseri. This micro-organism finds
its way into the deeper layers of the epithelial cells and into the connec-
tive tissues, setting up an ulcerative process. There may be several
ulcers along the urethra. These may extend partially or entirely around
the canal, usually only upon one side. The inflammation is quite severe,
the inflammatory products being carried through the lymphatic chan-
nels into the glands in the groin set up an inguinal adenitis producing
bubo. In severe forms the dorsal veins may become involved, phlebitis
occurring so that they appear as hard, fibrous, and painful cords. The
corpus spongiosum becomes infiltrated with inflammatory material and
is not capable of distention and stretching, as normally, when
upon erection of the corpora cavernosa it occasions a condition of

86 GONORRHEA.

chordee or Lowing of the organ. The gonococci are found in large num-
bers in the pus discharged from the urethra. The germs inhabit the
pus cells, epithelial cells, and the albuminous fluids. They can be readily
stained with the ordinary anilin stains (dilute methyl blue or methyl
violet). It is claimed that there is a certain proportion of cases where
no gonococci can be found, in which the symptoms are cjuite as severe
as in specific urethritis. The cause in these cases seems to be pus micro-
organisms.

Symptoms. — Gonorrheal urethritis may be divided into three stages.
The first stage is from the time of inoculation until inflammation is set
up. The second stage is the acute inflammatory stage, which lasts about
ten days. The third stage is the defervescence of the inflammation,
and lasts two or three weeks, sometimes less.

The first symptom of gonorrhea is an irritation within the meatus
urinarius externus. The meatus becomes swollen, congested, and a
watery fluid exudes. There is pain on urination and during the inter-
vals a teasing sensation. The discharge becomes purulent within a few
days. The disease, after inoculation, generally appears in from one
to four or five days. The purulent discharge, as soon as the ulceration
is set np, becomes quite copious and is sometimes greenish, due to the
association of some of the pus germs. The organ becomes badly swol-
len, urination causes excruciating pain, while there is a continual ache
extending along the back of the organ and about the rectum, sometimes
being referred over the trochanters. After the acute stage is over the
inflammation gradually subsides, the discharge becomes less free and
thinner — seropurulent and finally seroiis, and eventually disappears.
Cicatricial contractions take place in the ulcer formed within the ureth-
ra. This contraction may narrow the caliber of the urethra, producing
stricture. In chronic cases the ulcer never quite heals, but cicatricial
contraction takes place and because of the obstruction by the stricture
the urethra behind the narrowed pointJbecomes distended by the urinary
flow. It is from this distended portion that the discharge in gleet or
chronic urethritis comes.

Complications. — The complications of gonorrhea are:

1. Balanitis, and inflammation of the glans penis.

2. Posthitis, a condition where the prepuce becomes inflamed. In
balanitis if the prepuce is redundant and becomes inflamed while behind
the glans a condition of paraphimosis may result. If posthitis is set
up a condition of phimosis may be caused, in which condition the pre-
puce cannot be brought back over the glans. (See Phimosis and Para-
phimosis.)

3. Chordee is a condition of bowing of the organ and happens in
many cases. The treatment consists of the application of cold or other
means of preventing erection. The patient should be instructed to
sleep on his side and with but little cover.

4. Stricture of either large or small caliber is a frequent result of

RACHITIS. 87

gonorrheal inflammations because of cicatricial tissue formed in the
urethral wall, the contractions lessening the lumen of the urethra,

5. Prostatitis. In some cases the inflammation extends hack the
urethra into the prostate gland. Prostatitis can he recognized because
of the swollen and inflamed condition of the prostate, and because of
the febrile reaction due to the absorption of pus.

6. Epididymitis. The inflammation may travel back along through
the vesiculae seminales and the vas deferens into the epididymis, caus-
ing epididymitis, or even the testicle itself may become inflamed,
orchitis.

6. Gonorrheal Eheumatism. This is caused by the absorption of
the inflammatory products of gonorrhea, which are carried about over
the s}''stem and lodge in the connective tissues about joints, causing in-
flammation. It is not a rheumatic condition.

Treatment. — The Osteopathic treatment consists in increasing the
urinary flow and lessening its acidit}r as recommended by Dr. A. T. Still.
This will lessen the irritation during urination and quiet the desire for
frequent micturition. The blood supply to the urethra must be stimu-
lated and the penis carried in a sack containing cotton to catch the dis-
charges. The acute inflammation will subside in a week or ten days.
The bowels must be kept regular and the patient instructed to avoid
undue exercise or excitement. He should get good sleep, avoid the use
of stimulants and eat good plain food. By all means avoid injections.
They do harm. Never good. In clxronic gonorrhea or gleet a 1 per
cent, solution of nitrate of silver may be injected gently into the urethra
and held there just two minutes.' If this does not effect a cure, every
other day a 2 per cent, solution of the silver salt may be injected — care
should be taken not to force the fluid into the bladder. The irrigation
treatment is very popular. It consists of daily running through the dis-
eased part of the urethra, or even into the bladder, a 1 :4000 solution of
permanganate of potassium. Two or three' quarts should be allowed to
pass through the urethra at a sitting. The treatment is said to be very
successful. In the female the treatment is similar. When the disease
is chronic the vagina ma}'' be tamponed daily with a boroglyceride tam-
pon and irrigated with a solution of a teaspoonful of acetate of zinc to
a pint or quart of distilled water.

Rachitis, or Rickets,
Is a disease of childhood. It occurs in children from eighteen months
to two and a half years of age. It affects the entire system more or less,
but especially the long bones and the bones of the skull. The cause of
rickets is malnutrition. This malnutrition may be the result of lesions
causing malassimilation or because of an insufficient quantity or quality
of food. It may be caused by the debility of the mother or by the child
being surrounded by bad hygienic conditions. It is characterized by the
formation of embryonic tissues. These embryonic tissues never develop
into the mature cell for which they were originallv intended. Bones

88 TUMORS.

are not properly formed, the cells proliferate, but the ossific process
does not take place.

Symptoms. — The symptoms of the disease are, first, its occurrence in
children eighteen months to two and a half years — or in the late form
it may happen in children from nine to twelve. This is said to be a
recrudescence of the disease. The cbild is at first restless and may have
night sweats. Phosphates are abundant in the urine, and there are evi-
dences of gastro-intestinal disturbance and iiatulence. Swellings occur
on the ends of bones, radius and tibia, beading of the ribs and thickening
of the cranial bones at the sutures. The bones frequently bend, causing
bowing of the legs. There may be bowing of the forearms. There
may be many deformities, the most common being pigeon-breast. The
person is often knock-kneed or bow-legged and there is curvature of
the spine. There are various kinds of deformed pelves. The fontanels
close late and the head is square. Dentition is delayed or may not
occur at all and even if the teeth appear they may decay early and fall
out. Ofttimes there are symptoms of bronchitis. There may be lar-
yngismus stridulus, convulsions, diarrhea, etc.

Treatment. — The treatment of rickets is to locate the cause of the
disease, if there is any. Generally there are Osteopathic lesions which
account for the malnutrition. The reduction of the lesion, together
with the proper food, will be attended by relief.

Scurvy.

Scurvy is a disease of malnutrition and malassimilation from im-
proper food. The cause of the disease is lack of vegetables. It has occur-
red inprolonged sieges or Arctic expeditions. Scurvy was common among
those who visited the Klondike. The pathology of the affection is the
pathology of a condition of malnutrition. Improper food materials
lead to disorganization of the blood and there is degeneration of muscles
and great prostration. The skin becomes jaundiced (hematogenous).
There is malaise, torpor, loss of appetite, and insomnia. The gums be-
come inflamed, of a bluish-purple hue, are friable and break down and
ulcerate. The breath becomes fetid, the skin dry and brittle and be-
cause of the changed condition of the blood there are ecchymoses under-
neath the skin and around through the muscles, even under the perios-
teum. The prognosis is generally good unless the case is in a very bad
condition before the proper treatment can be administered. In pro-
longed and neglected cases death results from marasmus and sepsis. The
treatment is a vegetable diet in small quantities, frequently repeated,
fresh fruits, cranberries, lime juice, buttermilk and cider.

TUMORS.

Definition. — A tumor is an atypical neoplasm or new formation which
is not the result of inflammation. The word "tumor" means a swelling,

TUMORS. 89

but all swellings are not tumors. The term tumor is applied to those new
formations which arise from other than inflammatory causes, although
the tumor may be attended by an inflammatory reaction, and, further-
more, a long continued irritation and inflammation may even operate
as one of the causes of a tumor.

Cause. — "All have agreed long since that tumors and issues mark a
cut-off in an artery, vein, or nerve." (A. T. Still, Philosophy of Oste-
opathy, page 200.) Lesions acting in this manner occasion nutritional
disturbances. These disturbances vary in nature and degree, causing ab-
normal development or destruction of cells from perverted nutrition or
retained secretions. Among the various other causes which seem to have
to do with the origin and development of tumors may be mentioned:

1. Constitutional Dyscrasia. By this is meant a certain morbid con-
dition of the system which predisposes to the development of tumors.

2. External Irritation. External irritation seems in some instances
to assist in the formation of tumor. It is not unusual that a cancer

arises from a crack in the lip which has existed for several months
or years.

3. Embryonic Eemains. During development of the fetus embry-
onic tissue may be included in parts of the body where it should not
be and afterwards in growing or developing forms a tumor. This with-
out doubt explains teratomata, but does not explain sarcomata and
many other tumors.

4. Parasites. Cancers can be readily transmitted. Because of this
some writers maintain that a cancer is due to a parasite. This remains
to be proven. Numerous forms of certain parasites have been described
but they are most likely optical illusions.

5. Spermatic Influence on Cells. It is maintained by some path-
ologists that certain cells have a spermatic influence over others, chang-
ing their method of development and producing abnormal growth.

6. Defective Tissue Resistance. This has been advocated in ex-
plaining cancer. Cancer consists of a condition where the epithelial
cells, instead of groAving towards the surface, grow down amongst the
deeper tissues and in the lymph spaces. Because of a lessened resist-
ance which the connective tissues seem to have for the epithelial tis-
sues, they grow the wrong way. This would not explain some of the
tumors.

7. Certain Predisposing Causes. It is said that in some people there
is a predisposition to the development of cancer. Xot that they have
a dyscrasia, but that they have inherited the condition from a cancerous
mother or father. This remains to be proven.

Structure. — The structure of a tumor varies according to its location
and the issues from which it arises. The tissues of a tumor always resem-
ble the tissues from which they grow and develop. Metaplasia of tissue
never occurs. By that we mean that from connective tissues epithelial
cells never develop. If a tumor is derived from the connective tissues,

90 TUMORS.

it will always be a mesoblastic tumor, not hypoblastic or epiblastic.
Wherever a cancer is found it is always developed from epithelial tissue.
Wherever a sarcoma is found it is developed from mesoblastic tissues, so
that in structure the tumors resemble certain tissue types. Some
tumors differ but very little from the normal tissues, while in others
the cells vary in shape and become so distorted as to render it difficult
to determine their nature. These are atypical. The most atypical of
all tumors and tumor-cells is the cancer. A tumor is independent of
the general nutrition of the body. AVhile the body is becoming poor,
thin and emaciated, a fatty tumor may grow to immense proportions.
While the more emaciated and debilitated the patient becomes, the more
luxuriantly does the cancer grow. Many of the tumors do not have a
distinct blood supply. Many of them grow at the expense of the body.

Shape. — The shape of a tumor ma}' be ragged or irregular, it may be
circumscribed and enclosed within a capsule, or it may be difficult to tell
where the tumor begins and the healthy tissues cease. In such conditions
the tumor seems to infiltrate the surrounding tissues. The tumor may
have a fungiform appearance or it may be papillary, or in some cases it
may present a cauliflower excrescence, as in case of a cancer of the
mucous surface.

Effects on the General Health. — The effect of a tumor on
the general health varies according to the nature of the tumor
and the tissues involved. The mechanical pressure of the tumor
may be such as to markedly interfere with the general health. This
is not the rule. Tumors may grow to enormous size and yet the
person may be apparently healthy. Still, on the other hand, a little
cancer not larger than a hickory nut may cause profound cachexia
and a condition of malnutrition. The effects on the general health
are produced by mechanical irritation and pressure upon an artery,
vein, or ner\e, which sometimes may be serious to a part, or by a cer-
tain form of poisoning whereby noxious chemical products are dis-
charged into the body from the tumor. These carried about produce
general systemic effects. Something like this occurring makes a can-
cer a constitutional affection. The general health is likewise impaired
in malignant tumors by the using up of a great amount of nutritious
material, thereby depriving the tissues generally of their nourishment.

Classification.

Clinical. —

A. Benign.

B. Malignant.
Tissue Types. —

A. Mesoblastic.

I. Simple tissues.

1. Fibroma. 4. Osteoma.

2. Myxoma. 5. Papilloma.

3. Lipoma. 6. Chondroma.

TUMORS.

IT. Complex tissues.

1. Myoma.

2. Angioma.

3. Lymphoma.

4. Lymphangioma.

5.

G.

7.

Neuroma.

Glioma.

Adenoma.

II. Embryonic tissues.

1. Sarcoma.

a. Large round -eel led.
h. Small round-celled,
c. Large spindle-celled.
il. Small spindle-celled.

e.
f.

g-

h.

Giant-celled.
Mixed-celled.
Alveolar sarcoma
Melano-sarcoma.

91

B. Epiblastic and Hypoblastic.
I. Carcinoma, or Cancer.

1. Epithelioma, or squamons-celled carcinoma.

2. Glandular cancer, or cylindrical-celled carcinoma.

3. Acinous cancer, or spherical-celled carcinoma.

A Benign tumor is one which does not affect the general health, but
the symptoms of which are entirely due to the mechanical pressure or
irritation which the tumor may exert upon the surrounding structures.

A Malignant tumor is one which affects the body out of proportion
to its size. It affects the general health. It usually runs a rapid course
and results fatally. It is attended by cachexia, great pain, ulcera-
tion, etc.

A Fibroma is a tumor made up of bundles of wavy fibrous connec-
tive tissues. The varieties seen are (1) hard fibroma, (2) soft fibroma,
(3) molluscum fibrosum, and (4) keloid. In addition to these varieties
there may be intermingled with the fibrous structure of the tissue, fatty
or myxomatous tissues, bone, cartilage, etc., or in other cases a degener-
ated condition of the vessels, making the following additional varieties:
(5) Myxo-fibroma, (6) Fibro-lipomatodes, ■(?') Osteo-fibroma, (8) chondro-
fibroma, and (9) angio-fibroma.

Changes In. — The changes which these tissues very often undergo
are calcification, ulceration, and mucoid degeneration.

Location. — The tumors are located in the connective tissues,
beneatb the mucous and serous membranes. Where they occur
in the periosteum they produce a condition of fibrous epulis. Where
they occur in the uterus a condition of myo-iibroma results. A tumor
may form in the stumps of nerves after amputation. This is improp-
erly called a neuroma, it is really a fibrous tumor or false neuroma.
When fibrous tumors occur in the nose and rectum they are generally
in the form of polypi. In subcutaneous tissues hard and soft fibromata
occur. Soft fibromata are popularly called "wens." These tumors are
never malignant.

Diagnosis. — The diagnosis is usually easy. The tumor is encapsu-
lated, often lobulated, generally pedunculated, and is a hard fibrous
mass. It is a benign tumor, may appear at any age and if removed will
not tend to recur.

92 TUMORS.

Molluscum Fibrosum. —This consists of an overgrowth of the fibrous
structure of the skin and subcutaneous tissues. It may affect one side
of the head or one entire side of the body. The skin may become
enormously thickened. It is said the origin of the tumor is congenital.

Keloid. — This is a rare kind of tumor which occurs in two forms,
spontaneous and cicatricial. The spontaneous consists of a fibrous mass
beneath the epidermis and is more common in the negro.

The cicatricial form arises from scars, frequently from piercing of
the ear. The tumor is benign, but is prone to recur unless every vestige
is removed.

A Myxoma is a tumor consisting of mucoid tissues. The tissues of
the tumor are not matured, but are an undeveloped form of connective
tissue. The contents of the tumor are identical with the tissues sur-
rounding the blood vessels in the umbilical cord. It is made up of
stroma, having within the tissue-spaces a substance similar to Wharton's
jelly. The tumor appears to the naked eye as being made up of a
structureless gelatinous mass. It is a soft, gelatinous, grayish, or red-
dish-white tumor. It conies after middle life and grows slowly. They
do not recur after removal. They are benign tumors. They may un-
dergo fatty degeneration, inflammation, ulceration, or may form cysts.

Location. — They are located in the submucous, subcutaneous, and

subserous tissues.

Treatment. — When easily accessible they should be removed.

A Lipoma is a tumor made up of fatty tissue. Its structure is that
of ordinary adipose tissue. It is usually lobulated, soft, and pseudo-
fluctuating. They are ovoid, spherical, and rarely pedunculated. The
tumor is encapsulated and sometimes becomes slightly attached to the
surrounding tissues so that gravitation may cause these tumors to
migrate, say from the side of the chest to the brim of the pelvis.

Degeneration. — Degenerative changes taking place in these tumors
are ulceration, calcification, and softening. Ulceration is sometimes
serious. Calcification may lead to error in diagnosis.

Location. — The location of these tumors is generally the axilla, back,
buttock, and thigh.

Diagnosis. — These tumors are benign, of slow growth, and variable
in size. They appear at any age, are encapsulated, and if the tumor is
grasped at its base and the skin stretched, dimpling of the surface will
take place because of the fibrous bands extending down through the
tumor.

An Osteoma is a tumor formation developed in bone after inflamma-
tion. It generally occurs at the junction of the bone and its cartilage.
There are three forms usually described, depending upon their struc-
ture. (1) Eburnated osteoma consists of very dense bony structure,
made up of lamellae extending parallel with the surface of the tumor.
They are symmetrical and often multiple. (2) Compact osteoma is a

TUMORS. 93

variety consisting of campact bone. It is found in the outer layers of
long bones. (3) Cancellous, or spongy osteoma is a tumor made up of
cancellous bone. In structure it resembles the spongy bone at the end
of long bones. The tumor may become sarcomatous or it may undergo
necrosis following inflammation. Earely caries takes place.

Diagnosis. — It is a benign tumor of slow growth. It is generally
arrested as age advances and never attains a very large size. If it ex-
hibits malignant characteristics it is a sarcoma.

Papilloma. — The common name of this tumor is a wart and consists
of a fibrous stroma containing blood vessels and lymphatics. It seems
to be an overgrown or hypertrophied papilla of the skin. In some cases
the papilla nmy be short or in other cases long, where it presents a villus-
like appearance. Where the wart is situated in the skin the epithelial
covering is sometimes dense and binds the wart in a solid mass.

Changes In. — Ulceration and hemorrhage; it may become cancer-
ous.

Location. — Skin and mucous membranes.

Diagnosis. — The diagnosis is easy. They occur at any age, may be
simple or multiple. They may disappear without operative interfer-
ence. When they occur on mucous surfaces they are highly vascular,
prone to bleed, and may occasion considerable trouble. Where they
are at a point of irritation they should be removed.

Chondroma, sometimes called enchondroma, is a mass of new tissue
composed of hyaline, white fibrous, or elastic cartilage. They are usually
rounded, smooth, iobulated tumors of dense consistency. They some-
times have a well marked capsule. The cut surface presents a pink
appearance identical with fresh cartilage. They are non-vascular.

Location. — Cartilages of the larynx, trachea, and costal cartilages.

Changes In. — They may undergo fatty, mucoid, or calcareous
changes and are often found in bone developed from cartilage. They
are not uncommon in the metatarsal bones and phalanges, and may
occur in glands such as the testicle, ovaries, and mammae.

A Myoma is a tumor composed of muscle. There are two forms
usually recognized, depending upon the kind of muscular tissue.
That composed of striated muscle is called Ehabdomyoma. That
composed of unstriped, muscle is called Leiomyoma, Rhabdomyoma
is very rare and it is maintained by some to never occur. It is usually
congenital. The muscle fibres are irregularly formed, either spindle
or club shaped. It is a benign tumor and occurs in the heart, uterus,
and kidney. Leiomyoma, the variety made of unstriped muscle, fre-
quently contains more fibrous than muscular tissue. It is most fre-
quently located in the uterus, but may occur in the prostate, esophagus,
stomach, and intestines. As a rule, they vary greatly in size; those
located in the intestines are small, while those located in the uterine
wall may attain an enormous size. Severanu removed one which

94 TUMORS.

weighed 195 pounds. They are frequently the size of a fetal head.
When located in the uterus they may he subserous, interstitial, or in-
tramural. They may be pedunculated in the form of uterine polypi.
They are generally encapsulated and made up of elongated, spindle-
shaped cells with rod-shaped nuclei and have but few blood vessels.
The tumors may undergo inflammatory changes or calcareous degener-
ation. They are benign, but may become sarcomatous.

An Angioma is a tumor made up of blood-vessels. There are three
different forms, capillary, venous, and arterial, or, simple, cavernous
and plexiform.

Simple or capillary angioma is a condition of telangiectasis, or
mother's mark, or birth mark. It generally affects the skin and
may be flat or slightly elevated and may vary in color from a pink or
red to a dark-red or violet. They are generally located on the face,
about the orbit, and on the neck, and are congenital. They may increase
in size after birth. On microscopical section it is found that the walls
of the capillaries and vessels are thin, dilated, and fusiform. They may
be cylindrical or sacculated, or several large vessels may establish com-
munication between the nevus, as it is sometimes called, and the main
artery.

Location.— They are generally located in the skin and subcutaneous
tissues in any of the organs which are vascular.

Arterial angioma, sometimes called cirsoid aneurysm, is really not
a tumor, but a pathological alteration of the vessel wall. The vessels
become distended and convoluted. Pressure upon the nerves and tis-
sues causes atrophy. The vessel walls usually, thicken because of inflam-
matory reaction. The tumor may be congenital or acquired. Both the
venous and arterial angiomata may follow injury of the scalp, frontal
region, and the pudendum.

Lymphoma. — The term "lymphoma" means a tumor of the
lymphatic gland. There are various conditions which may
perhaps be included under this head. Enlargement of the
lymphatic glands in tubercle and syphilis is termed by some
tubercular or syphilitic lymphoma. There is no inflamma-
tory reaction due to the absorption of the products of inflammation,
as in bubo or acute and infectious diseases. Sarcoma may occur in the
lymphatic glands, but it does not differ from a sarcoma in any other
region, except that it arises in the lymphoid tissue. This tumor is
called lymphosarcoma. The lymphatic enlargement in leukemia is said
by some to be malignant. Enlargement of the lymphatic glands with
enormous hypertrophy, as occurs in Hodgkin's disease, is called
lymphadenoma.

Lymphangioma is a tumor of the lymphatic vessels. It is very rare
and consists of dilated and cavernous sacs. It is analogous to a tumor
of the blood-vessels. It occurs most frequently in the tongue or lips,
where it is termed macroglossia or macrocheilia, as the case may be.

SARCOMA TA. 95

A Neuroma is a tumor of the nervous tissue. The existence of these
tumors is denied by some writers. An amputation neuroma is really
a fibrous tumor due to the development of fibrous tissue in the stump of
an amputated nerve. Pathologically there are other neuromata
described in connection with ganglia and masses of nerve matter, but
they are rare and not well understood.

A Glioma is a tumor developed from neuroglia and composed chiefly
of glia cells. The tissue elements vary greatly. These tumors are often
located in tbe eye. Some writers believe that they are true sarcomata.
In the brain the glioma does not involve the membranes, while a sar-
coma does. They are circumscribed, diffuse slowly, and generally affect
the central nervous system (brain and spinal cord). The tumor may
be very soft or firm and elastic and is single. When metastasis occurs
it is believed to be sarcomatous.

An Adenoma is a tumor of the type of glandular tissue. It seems
to be an enlargement of all parts of the gland. It is believed by some
that the origin of the tumor is fragments of glandular tissue included
within the tissues where it is found. Sometimes they are termed
localized hypertrophies. They are benign, and secondary changes are
not liable to occur, but when they do, they are fatty or mucoid in nature.
Where gland tubules are developed, cysts may be formed because of the
retention of the secretion.

Location. — Sebaceous glands, mammary glands, thyroid, prostate,
testicle, liver, spleen, etc.

There are two forms described, depending upon the nature of the
formation or structure. They are tubular and acinous.

A Sarcoma is an embryonic connective tissue tumor. The cellular
elements of the tumor predominate over the interstitial substance. The
cell elements tend to infiltrate the surrounding tissues, so
that it is not always encapsulated.

Microscopical Structure. — The microscopical structure of a sarcoma
is of great importance. It consists of embryonic cells, varying in size
and shape, embedded in a stroma or intercellular substance, which
varies in amount and character. It generally contains but little fibrous
tissue. The cells are often protoplasmic masses and rarely possess a
cell wall. The variety of the tumor depends upon the shape and size of
the cells. The intercellular substance extends around between all the
cells and lies in close connection with the individual cell. The blood-
vessels of the tumor are very numerous and often have no well defined
walls, the blood apparently flowing into cavernous spaces in the tumor,
so that the blood is apparently brought in direct contact with the tumor
cells. Sometimes these embryonic cells which form the vessel wall
become detached and are carried by the blood current to other parts
of the body (metastasis). When the tumor grows slowly there appar-
ently is a condensation of the connective tissues about the tumor, which
gives it the appearance of being encapsulated.

96 CAR CI NOMA TA .

Location. — The round-celled sarcomata are situated in the
periosteum, fascia, eye, antrum of Highmore, breast, testicle, and may
occur in any of the connective tissues. The giant-celled sarcomata
occur in connection with hone. The alveolar sarcoma develops
in the subcutaneous connective tissues and in glands. Melano-sarcomata
occur in the surface connective tissues. Spindle-celled sarcomata
occur in the intermuscular septa, subcutaneoiis tissue, fascia,
periosteum, interior of bones, eye, breast, and testicle.

Characteristics. — The characteristics of sarcomata are (1) Malig-
nancy, (2) Occurrence, (3) Metastasis, (4) Infiltration, and (5) Degen-
eration.

Malignancy. The round-celled and spindle-celled varieties are of
rapid growth and very malignant. Melanotic sarcomata are among the
most malignant of tumors.

Occurrence. The tumor occurs at any age, but most frequently in
early or middle life. They are prone to extend locally and after removal
to recur locally. It is maintained by some surgeons that the tumor has
never been successfully removed.

Metastasis may occur, but always by means of the blood-vessels.
The neighbouring lymphatic glands are not enlarged unless the sar-
coma becomes ulcerated. The tumor is generally localized and sharply
circumscribed.

Infiltration takes place into the surrounding tissues and lymphatic
glands. It disseminates by means of the blood-vessels, secondary
growths occurring in the lung.

Degeneration in these tumors is common. Blood extravasations
are frequent. The tumor rarely ulcerates, but more frequently it under-
goes fatty degeneration or mucoid softening.

Cancer, or Carcinoma. — Definition. — Cancers are malignant tumors,
consisting of masses of epithelial cells contained within alveoli and en-
closed in masses of fibrous tissue. Like the tissue from which it is derived
(epithelium) no stroma or connective tissue extends in between the indi-
vidual cells. Cancers are the most atypical of all the neoplasms. The
epithelial cells vary greatly in shape and size. One of its most peculiar
characteristics is that the cells apparently grow the wrong way.
Epithelial tissues groAV towards the surface normally, but in cancer the
tumor-cells grow down into the connective tissues in the interstices
between the fibres and along the lymph spaces, sometimes forming dis-
tinct cell masses or cell nests, or at other times forming column-like
prolongations. These columnar-like masses and cell nests are sur-
rounded by dense la}^ers of fibrous tissues, for when the cells grow down
into the tissues they act like any other irritant and create a low-grade
inflammation. This fibrous tissue surrounding the columns of epithelial
cells extending into the subcutaneous tissues gives rise to the popular
opinion that the cancer has roots. In some instances the cellular growth
is very rapid and there is little production of fibrous tissue about the

CAR CI NO 31 A TA . 97

cell masses. In this case the tumor is largely cellular. It is then soft
and called encephaloid cancer. In other cases the tumor-cells pro-
liferate less rapidly and there is an immense production of fibrous tissue
about the cell nests, tubules, and columns of cells, when the tumor
feels, because of the contraction of this fibrous tissue, like a hard nod-
ular mass. This is called a seirrhns cancer. The blood-vessels of the
tumor contain thickened walls, so that the wall of the artery is much
thicker than in the normal tissues, whereas in the sarcoma the vessels
have no walls, the blood being in actual contact with the tumor-cells.
The fibrous tissue of the cancer, which is really inflammatory tissue,
undergoes contraction, as happens in scars. This cuts off the nutrition
to masses of the tumor, hence the frequency with which the tumor
breaks down and ulcerates. This ulcerative process often extends into
small blood-vessels, which accounts for the frequency with which can-
cer bleeds. The cancer spreads through the lymphatics and the lymph
spaces and consequently the cells soon spread to the neighbouring
lymphatic glands, causing enlargements. One of the most pronounced
symptoms of cancer is cachexia. This cachexia is partly due to local
ulceration and partly to the dissemination of the growth. The skin
assumes a sallow, peculiar earthy color. The face is anxious and care-
worn and the body emaciated. This emaciation continues until the
strength fails and the patient dies of exhaustion because of the general
interference in nutrition, pain, mental anxiety, local ulceration, and
hemorrhage.

Epithelioma or Squamous-Celled Carcinoma arises from the skin or
mucous membranes. The cells of this tumor much resemble squamous
epithelium. The alveolar characteristics of the tumor are not so marked
as in acinous cancer.

Location. — Especially at points where the skin and mucous mem-
branes meet — lips, nose, tongue, scrotum, or in scars, cheek, chronic
ulcers, etc. In general this variety of cancer consists of solid columns
of epithelial cells which have pushed down through the basement mem-
brane and extend into the connective tissues.

Symptoms. — It usually begins as a warty tubercle which is soon
converted into an ulcer with indurated, everted, and raised edges. It
has a hard, warty, and irregular base. The tissues about are inhltrated
and the neighbouring glands, through which the lymph channels of the
affected area pass, become enlarged. On mucous surfaces the tumor
may present a cauliflower excrescence. Sometimes there is a history of
a crack or fissure of long standing. Unless the epithelioma is removed
while the disease is local it will recur in the neighbouring
lymphatic glands or in some distant organ. Frequently cells become
isolated from the columns which extend into the connective tissues.
These cells multiply and form masses of cells which are moulded,
because of pressure, into roundish columns, or they may extend
as a net-work through the tissues, making it often quite impossible

98 CARCINOMA TA .

to remove all of the cancerous growth. This explains the frequency
with which the tumor reappears after apparently all of the diseased
tissue was removed. After removal, if the tumor recurs, it usually grows
much more rapidly and more seriously affects the general health. The
pain and ulceration, together with the growth of the tumor, hring about
exhaustion, from which death is generally the result.

Glandular Cancer, or Cylindrical-Celled Carcinoma. — This tumor
is derived from glands and surfaces covered with columnar or
cylindrical epithelium. It is of slower growth than the other
varieties. It begins as a warty outgrowth on mucous surfaces. It is
most common in the rectum, but will occur in other parts of the
intestinal tract or in the mammary gland.

Structure. — In structure the tumor consists of irregular tubules
which are lined by columnar epithelium. These tubules are held
together by a stroma or connective tissue which is more or less infil-
trated by certain round-cells. The epithelial cells retain their shape
more closely than any of the other forms of cancer. In very rapidly
i growing tumors the alveoli may become entirely filled with cells, when
under such circumstances the cells are gradually destroyed. They infil-
trate the surrounding tissues and affect the lymphatic glands and
become disseminated into the internal organs. The liver is most fre-
quently affected. With this tumor death occurs from obstruction of
the bowel and from exudation and hemorrhage, due to the interference
in the digestive process and to ulceration extending into the vessels.
The general symptoms are of a malignant tumor.

Acinous Cancer, or Spherical-Celled Carcinoma. — These occur
in three varieties, hard, soft, and colloid. The hard variety is
medium sized, hard and nodular. Later the}' ulcerate and
become disseminated through the body. Upon microscopic examination
the alveoli in the older parts of the tumor contain cells undergoing
fatty degeneration and in many cases the alveoli are shrunken and con-
tain no cells, the ceils having atrophied. It is around the circumference
of the tumor where the characteristic microscopical structure is found.

Location. The usual locations are the breast, pylorus, and rarely in
other situations.

The soft acinous cancers were called by the older writers encepha-
loids because of the resemblance to brain substance. The stroma is
scanty in amount and does not contract like it does in hard cancer.
The cells are prone to undergo fatty degeneration. On section they
appear creamy colored or grayish-white. Frequently the cells may be
diffluent. It is not unusual that ulceration may take place into the
blood-vessels, leaving a fungating bleeding mass called fungits hem-
atodes.

Location. Glands generally, as the breast, ovary, kidney, bladder,
liver, testes. Secondary growths in other organs.

TUMORS.

99

Colloid cancer is a term applied to any form of cancer undergoing
mucoid or colloid degeneration. The colloid degeneration begins with
the development of the cancer-cells; later the alveoli become distended
with colloid material.

Location. The favorite location of this cancer is in the stomach,
intestines, and ovary. It may occur in the breast or even in the. throat.

Differential diagnosis between benign and malignant tumors, sar-
coma, carcinoma, and lupus.

BENIGN TUMORS.

1. Age. Appear at any age.

2. Growth. Generally slow.

Dissemination. Does not infiltrate
the surrounding tissues nor does
it disseminate through the lymph
or blood stream.

Capsule. Generally encapsulated.

Adherent. Not adherent to the
surrounding: tissues.

9,
10,

11.

Ulceration. Rarely break down
and ulcerate.

Retraction. The tissues covering
the tumor are not drawn and re-
tracted.

Lymph glands. Lymphatic glands
in the neighbourhood are net en-
larged.

Pain. Generally not painful.

Microscopical appearance. Closely
resemble the tissues from which
they grow.

Metastasis. Never occurs.

12. Cachexia. No cachexia. Affects
the body mechanically only.

SARCOMATA.

1. Age. Appear at any age.

2. Growth. May be rapid or slow.

3. Dissemination. Surrounding tis-
. sues are more or less infiltrated

and they desseminate by means of
the blood-vessels.

4. Capsule. Sometimes encapsulated.

5. Adherent. Adherent to the sur-

rounding tissues.

6. Ulceration. Rare.

7. Retraction. The tissues over the
tumor are not so contracted as in
cancer.

8. Lymph glands. Not enlarged un-

less the tumor is ulcerating.

9. Degeneration. More common than

in cancer.

MALIGNANT TUMORS.

1. Age. Generally appear late in life,

except sarcoma, which may ap-
pear at any age.

2. Growth. Generally rapid, but may

be slow.

3. Dissemination. Surrounding tis-

sues are infiltrated and dissemina-
tion takes place through the lymph
spaces and blood channels.

4. Capsule. Rarely encapsulated.

5. Adherent. Generally adherent to

the surrounding tissues, and are
more or less fixed

6. Ulceration. Prone to break down

and ulcerate.

7. Retraction. The retraction of the

tissues over the tumor gives it a
ubacon-rind" appearance.

8. Lymph glands. Lymphatic glands

in the neighbourhood are very
often involved, except in sarcoma.

9. Pain. Generally painful.

10. Microscopical appearance. Very

atypical.

11. Metastasis. Secondary tumors usu-

ally occur in situ or in distant
organs.
12. Cachexia. Pronounced cachexia
and emaciation. Affects the body
generally.

CANCER.

1. Age. Rare before thirty-five.

2. Growth. Generally rapid.

3. Dissemination. Infiltrates the sur-

rounding tissues and dissemina-
tion takes place by means of the
lymphatics,

4. Capsule. Never encapsulated.

5. Adherent. Adherent to the sur-

rounding tissues.

6. Ulceration. Very common.

7. Retraction. The tissues overlying

the tumor have "bacon-rind1' ap-
pearance. In cancer of the breast
the nipples are retracted.

8. Lymph glands. Neighboring lym-

phatic glands are enlarged.
9. Degenerations are not common.

100 \CYSTS.

10. Origin. Mesoblastic tissues. 10. Origin. Always from epithelial

cells.

11. Blood-vessels. Have no walls. 11. Blood-vessels. Have distinct and

thickened walls.

12. Stroma. Stroma lies in between 12. Stroma. Is around the cell masses

the individual cells. and not between the individual

cells.

13. Metastasis. Distant metastasis not 13. Metastasis. Distant metastasis is
common. common.

LUPUS.

1. More frequently resembles epi- 8. Never appears like a fungus growth.

thelioma. 9. Its base is level with the surface.

2. Does not precede the first evidences 10. Generally not painful.

of disease-nodules. 11. Cicatrization follows ulceration so

3. Evidences of tubercular ulcer or that while ulcerating at one point

diathesis present. it heals at another.

4. Occurs at more than one point. 12. Hemorrhage is rare.

5. No thickening around the ulcer. 13. It occurs at any age.

6. The areas coalesce. 14. The discharge is generally not

7. Abrupt and irregular borders. Has offensive.

an "■eaten" appearance.

Treatment of Tumors. — The principle of the treatment of tumors
is the removing of mechanical obstructions and irritations which will
occasion nutritional disturbances. Not all cases may be so cured, but
many may be. Where the tumor is small, benign, pedunculated, or
encapsulated and is superficial, it may readily be removed by a minor
surgical operation, but where the tumor is large and can be reached only
with considerable risk to the patient's health and life, manipulative
treatment should be advised. In whatever part of the body the tumor
is located, lesions will be found affecting the lymphatic stream, venous
or arterial blood flow, or impinging upon the trunk or roots of the
nerves of the part. Usually the favorable effect of the treatment will
be evidenced within a short while. The tumor if hard will become
softer, and if adherent, more movable. Absorption will gradually take
place, following the correction of lesions and the removing of obstruc-
tions to the circulation. Not all tumors can be successfully treated.
Many cases have been cured even after master minds have declared
them incurable. This alone should commend the treatment in all cases
before the knife is recommended. Should the tumor not yield to
osteopathic treatment and should it manifest any malignant tendencies,
or should it interfere with the general health, the knife should be
resorted to and all parts of the tumor removed.

CYSTS.

A cyst is a tumefaction made up of an enclosed sac filled with fluid,
semi-fluid, or other material.

Varieties. — 1. Retention. 2. Exudation. 3. Extravasation. 4.
Dermoid. 5. Hydatid.

Retention Cysts. — A retention cyst is generally due to the secretions
of a gland being retained within the tissues, with a consequent

CYS-TS. 101

dilation of the tubules or acini of the gland. The wall of the
cyst is formed of inflammatory or fibrous tissue, while the lining
of the cyst is generally flattened epithelium. There are several forms
of retention cysts described, viz., (a) sebaceous cyst, due to the closure
of the duct of the sebaceous gland, which opens into a hair follicle, and
a consequent dilatation of the gland tubules because of the retained
secretion. The cells continue secreting until the cyst attains enor-
mous size. They are generally semi-fluctuating and movable. They are
adherent to the skin. They can be distinguished from fatty tumors,
inasmuch as the tumor will not slip underneath the fingers. These
tumors may undergo numerous secondary changes. Occasionally when
the tumor is opened, the contents will be found to be extremely offen-
sive, or the more liquid portion of the contents may exude and the
remainder become hardened, or the cyst may become inflamed, causing
suppuration and ulceration, or a sinus may result. Wounds may heal
and cysts reappear, or while the sinus still exists, granulation tissue may
form within the tumor, making the mass resemble an epithelioma. The
treatment is often surgical. The tumor should be laid open and the
contents evacuated and the sac scraped out. The wound is allowed to
heal by granulation.

(b) Mucous Cysts. — These occur frequently in the mouth, or
they may be due to the distension of Bartholin's glands at the
entrance of the vagina. The walls are usually thin and they may
attain great size.

Treatment. — Lay the tumor open and cauterize the interior.

There are other forms of retention cysts, such as those formed by
the closure of Wharton's duct — ranula, encysted hydrocele and galac-
tocele.

Exudation Cysts. — Exudation cysts are produced by the exudation
of fluids into cavities which have no ducts or outlets. Examples of
these cysts may be found in the ovary where distension of the Graafian
follicles may occur, or in the bursae over the olecranon, or about the
knee, or ganglia which happen in connection with extensor tendons on
the back of the hands. These will be described under "Diseases of
regions."

Extravasation cysts are produced by the extravasation of blood into
the closed cavities of the body or into connective tissue spaces. They
are called hematoceles. These may occur in the pelvis, tunica
vaginalis, beneath the scalp or following the rupture of an artery within
the skull.

Dermoid cysts are of congenital origin and are formed by the inclu-
sion of a portion of the epiblastic tissues within the mesoblastic. In
after life these inclusions develop epithelial tissues. There are certain
of the dermoid cysts which can not be explained in this manner, as
those containing hair, bone, cartilage, teeth, etc. These are said to be
produced by the inclusion of blighted ovum in a part of the embryo.

102

CYSTS,

By others it is said to be due to the development of atrophied fetal
structures. Dermoid cysts occur in the tunica vaginalis, in the middle
line of the neck, arising from, the thyro-glossal duct, from the paro-
varium near the ovary, or they may arise from the ovary or testicle.
Other forms of congenital cysts may occur in the axilla and scrotum.
Dermoid cysts are the most common. In these are found all the struc-
tures forming the true skin and its appendages, such as hair, sebaceous
glands, teeth, nails, etc. The contents vary, hut consist for the most
part of secretions of the glands in the cyst wall.

Fig. 7.

Method of applying a spiral reverse bandage.

The treatment of these cysts is most likely surgical, and where possi-
ble they should be removed.

Hydatid or Parasitic Cysts are produced by the tenia echinococcus,
one of the forms of tape-worm or cestoda. The worm normally inhabits
the intestine of the dog, but it sometimes gets into the intestine of the
human from uncooked garden vegetables, the parasites having been
deposited on them from the excreta of the dog. The ova taken into the
system, hatch out and develop and the embryo makes its way by some
channel to the liver or to some other organ, where the development of
the embryo results in the production of a cyst.

The diagnosis of the cyst varies according to the locality in which
the cyst is found.

The treatment is entirely surgical. Puncture of the cyst is sometimes

BANDAGINC. 103

attended by urticaria. Peritonitis and general infiltration of the tissues
will produce death in some cases. Fortunately the disease is rare.

In general, cysts should be treated on the same principle as tumors.

After a fair trial of the treatment, if the cyst does not recede, opera-
tion may be advised.

Fig. 8.

The gauntlet bandage for the fingers and hand.

BANDAGING.

Bandages are used tc hold splints and dressings in place, to support
parts, protect injured structures, and assist the return circulation.
The materials usually used are unbleached muslin, gauze, crinolin,
flannel, or rubber. Fabrics impregnated with plaster-of-Paris and
starch paste, are often used as fixed dressings where support and
immobility must be maintained. To hold surgical dressings in place the
muslin or crinolin bandages are best. To assist the return circulation,
a wet flannel or a rubber bandage should be used. A figure-of-8 bandage

104

BANDAGING.

is best and, if possible, should a" ways bo applied. It gives the most
uniform pressure. The spiral reverse bandage is easy to apply, but is
not so' satisfactory. In applying the bandage, it should always be
rolled out. It should be carried, twice directly around the member at the
beginning to anchor the bandage, after which the figure-of-8 turns may
be made. Care should be taken to keep the lower edges of the turns of
the bandage parallel. A part should always be bandaged, if possible, in
the direction of the return circulation. Each turn of the bandage
should be drawn equally tight and should cover one-half of the previous
turn. To do this the bandages should consist of strips of from one to
nine yards in length and should be rolled up into a single or double
roller. In bandaging the fingers or thumb, a figure-of-8 bandage is
used. Successive tarns may be made over the end of the finger, while
afterwards the bandage is carried around the finger to hold the turns

Fift. 9.

Spica bandage of the thumb.

in position. This same method may be used in amputation stumps.
For the knee or elbow a figure-of-8 bandage is best. The first turn of
the bandage is made opposite the joint with succeeding figure-of-8 loops
above and below. In bandaging a shoulder or thigh, a spica bandage is
applied. The bandage is begun at the middle of the arm or the thigh
and. carried upward by figure-of-8 turns. A head bandage is best applied
by means of a double roller which unrolls in opposite directions. One
roller is carried around the head as successive turns from before back-
ward are made by the second roller. The over-and-over turns may be
made from before backward, or from, side to side. The ends of the
bandage must be firmly anchored by safety pins.

The figure-of-8 bandage is also useful in bandaging up an inflamed
breast. A posterior figure-of-8 bandage is quite serviceable in case of
fracture of the clavicle.

Velpeau's Bandage. — A bandage three inches wide and nine yards
long is required. Pad the axilla on the injured side and place the hand

BANDAGING.

105

on the sound shoulder. The bandage is begun on the scapula of the
sound side and carried across the back over the injured shoulder, down
the front and outside of the arm, turning upward toward the axilla to
the starting point. A second turn is made to fix the bandage. The
third turn is made circularly around the chest and over the arm on the

Fig. 10.

Spica bandage of the shoulder.

injured side, while the fourth turn is as the first. These turns are
alternated so as to resemble an ascending spica (see figure). The turns
of the bandage should be fastened over the arm. In bandaging the foot,
care should be taken to cover all parts of the member by regular figure-
of-8 turns. If there is faulty circulation the bandage should be car-
ried beyond the calf of the leg. Barton's bandage, or a figure-of-8 of
the lower jaw, is useful in case of fracture of the lower jaw. A crossed

106

BANDAGING.

figure-of-8 bandage is useful for both eyes, while single turns are suf-
ficient for one eye.

A many-tailed bandage is made by means of a piece of cloth the
width of the part to be bandaged and in length more than twice its cir-

Fig. 11.

Spica bandage of the groin.

cumference. The ends of the piece of cloth are torn into strips three
inches wide, the torn part of the bandage comprising about half its
length. These opposite strips of the torn ends are then tied together
around the member to be bandaged. This bandage is suitable for the
thigh or abdomen.

The "T" bandage is suitable for the perineum. It consists of a cir-

BANDAGING.

107

cular strip extending around the body and a vertical strip attached
behind, passing between the thighs and fastened to the circular strip
in front.

Fixed Dressing's.

Starch Paste Dressing1. — This bandage is made by means of a many-
tailed bandage, pasteboard, and starch paste made by cooking a little
flour or starch into a paste. The strip of pasteboard is smeared on one
side with the starch paste and then applied to the middle of the many-

FlG. 12.

Head bandage applied by means of a double roller.

tailed bandage. This is then applied to the injured member after it has
been suitably enveloped with cotton for protection. Several strips of
pasteboard may be used and they may be placed on all sides of the
member. If two layers of the pasteboard are used, a bandage of great
strength may be made. The tails of the bandage are tied around the
member. The bandage has the advantage that it can be enlarged to
accommodate swelling. This bandage is preferred by Br. Still.

Plaster-of-Paris Dressing. — A piece of crinolin four yards long
should be torn in strips from three to six inches broad, depending upon
the part of the body upon which the dressing must be applied. If it is

108

BANDAGING.

on the thigh it should be torn in strips six inches wide, but if for the
lower leg or foot, three or four inches wide may be sufficient. Into this
erinolin should be rubbed dry powdered plaster-of -Paris, which can
best be done by heaping the plaster on a table, taking the bandage
before it is rolled up and with a thin board or table knife, the plaster-

Fig. 13.

Figure-of-8 bandage applied to support the breast.

of-Paris may be pushed along over the bandage, an effort being made
to scrape from the bandage as much of the plaster-of -Paris as possible.
As the plaster-of -Paris is scraped off, the bandage is rolled up so that
when the bandage is entirely rolled up it is thoroughly infiltrated with
the dry plaster. This may be wrapped in oiled paper and kept ready for
use. For fracture of the tibia and fibula at least one dozen of such
bandages are required. Providing the limb has been put in proper posi-
tion with the bones in apposition, the limb must be enveloped in lamb's

BANDAGING.

109

wool, surgeon's cotton or lint, and a roller bandage applied evenly over
all. The cotton should be carried higher than the bandage. The
plaster-of -Paris dressing is now immersed in warm water in which there
has been a small quantity of common salt dissolved. Powdered alum
will serve the same purpose, viz., to make the plaster set more quickly.
When the bandage is thoroughly soaked, it may be applied as an ordinary

Fig. 14.

A posterior figure-of-8 bandage. Useful in fracture of clavicle.

bandage. Three or four layers of the plaster bandage should be applied.
In case of fracture of the femur, a counter-extending apparatus may
be applied before the leg is enveloped in cotton-wool. After the dress-
ing is applied, extension and counter-extension should be kept up until
the plaster sets, which may be within an hour. If the plaster bandage
has been applied too tightly and interferes with the return circulation,
as soon as it sets it may be cut along one side and pulled open so as to
allow the blood to circulate freely in the limb. On the outside of this,
a roller bandage may be put on to draw the plaster sufficiently close

110

ANESTHESIA.

to the limb to maintain immobility. In this condition the plaster
bandage forms an excellent adjustable splint. The indications that
the bandage is too tight are signs of obstructed circulation in the
extremity, together with numbness and great pain. These demand
immediate attention. The plaster dressing is of especial advantage in

Fig. 15.

Velpeau's bandage.

what is called the ambulatory method of treatment of fractures. It is
bulky, cumbersome, and many times unclean.

ANESTHESIA AND ANESTHETICS.

Anesthesia means insensibility to pain. The word was coined by
Dr. Oliver Wendell Holmes in November, 1846. It may be local, when
produced b}* applications or injections or sprays of cocain, eucain,

ANESTHESIA.

Ill

Fig. 16.

ethyl chlorid, etc., or general when produced by the inhalations of ether,
chloroform, nitrous oxid, ethyl chlorid, etc. Before the discovery of
these drugs, alcohol and opium, together with the application of cold,
were used for the purpose of deadening the sensibility. Ether was
first discovered by Dr. Morton, a dentist in Boston, in September, 1846,
while chloroform was discovered by .Simpson, of Edinburgh, in 1847.
Ether is the safest of the general anesthetics. The death rate of its
administration is variously estimated by different observers, from 1 in
16,542, to 1 in 23,204, while in chloroform the death rate is 1 in 5,860,
to 1 in 3,258. These proportions are given from more than one-half
million collected cases.
More than fort}^ thou-
sand etherizations have
been collected without a
single death reported.

Ether.— The chief ob-
jections to its use are its
irritating qualities and
inflammability (which
makes it dangerous to
use at night), while it
often produces nausea,
vomiting, and cerebral
excitement. In adminis-
tering an anesthetic it is
best to have a third per-
son present, inasmuch
as curious mental impres-
sions may be retained by
the patient after recov-
ery. In general, the
heart, lungs, kidneys,
great vessels, and the
nervous system should be
observed before -the anes-
thetic is given. The patient should have nothing to eat for four hours
previous. It should be looked to that the patient does not have false
teeth, a chew of tobacco, or other objects within his mouth. The clothing
should be loose about the chest. The anesthetic should always be given
while the patient is in a recumbent position, with the head low. The anes-
thetist should have a mouth gag, and a pair of forceps handy with which
to pull out the tongue if necessary. Ether is best administered by
means of a cone which is made of several thicknesses of newspaper and
a towel.

Chloroform is best administered by means of an Esmarch's inhaler,
or a paper cone, containing within its apex a pledget of gauze, or a
small handkerchief. The vapor of chloroform is more grateful, the

Method of bandaging both eyes.

X

112

ANESTHESIA.

Fig. 17.

patient goes under the anesthetic easier and quicker and if is less irri-
tating. It should be given when an anesthetic is required in children
under ten years of age, or in elderly people over sixty who have no
heart disease. It should he given in kidney diseases, diabetes, and in
bronchial inn animations. It is used in labor because of its quick action.
In operations on the mouth and nose, or in operations for cleft palate,
it is best. Ether should be used in all other cases. In the administra-
tion of ether, the cone should be so held over the patient's face that
the proportion of admixture of gas and air will be five per cent, of the
air to ninety-five per cent, of the vapor, while in chloroform just the
opposite condition is desired — from five to ten per cent, of the vapor of
chloroform should be mixed with ninety-five to ninety per cent of air.
Operable anesthesia is reached just after the conjunctival retlex has

been paralyzed, and before stertor-
ous breathing occurs. The pupils
should always be Watched. Sudden
dilatation of the pupil is grave. It
is more essential to watch the respi-
rations than the circulation. Because
of the irritating qualities of the an-
esthetic, the patient may hold his
breath and thus deceive the anes-
thetist. Especially is this true in the
second stage of anesthesia, which is
accompanied by excitement and
muscular rigidity. It is essential
that the drug should not be pushed
under such circumstances, especial-
ly if the patient is strong and vig-
orous. During the early stage of ex-
citement, the patient may shout,
sing, fight, and swear, and it is necessary to give the drug easily and
carefully, but surely, paying attention strictly to the condition of the
patient. By touching the conjunctiva it will be observed that the
reflex has disappeared. The patient is then ready for operation. Just
enough of the drug should be given to keep the patient in this condi-
tion. Some operators give chloroform first, and after complete anes-
thesia ether is given, inasmuch as it stimulates the circulation. The
face and neck are usually warm, moist, and flushed during the admin-
istration of ether. Not so with chloroform. Accidents may happen
during the administration of anesthetics, the first and most important
of which is the arrest of respiration. The tongue should at once be
pulled out of the mouth, the drug removed, and the head fully extended
in order to raise the epiglottis. At this same time the patient shou'd
be everted and artificial respiration performed by Sylvester's method.
Laborde's method of rythmical traction of the tongue is of advantage.
The tongue should be drawn out of the mouth sixteen times per minute,

The towel and paper cone suitable for ad-
ministering ether or chloroform.

PROCESS OF REPAIR. 113

while in Sylvester's method, the manipulation should be done with the
same frequency. The patient must be placed with the head low, while
the flexed arms are compressed against the chest to expel the air, then
extended above the patient's head to raise the ribs. These alternate
motions must he done so as to simulate respiration. Should the cir-
culation fail, the patient should immediately be suspended by his feet
while the vasomotors are stimulated.

PROCESS OF REPAIR.

The reparative process is, in many respects, similar to the inflam-
matory process. Having removed the irritant from the tissues, as will,
more than likely, sooner or later occur in the history of an inflammation,
the return of the tissues to the normal condition, or as nearly the
normal as is possible, is termed the reparative process. It has been
falsely stated by some writers that it is a process taking place in aseptic
inflammation. Obviously such conditions never exist about the human
body. The reparative process differs according to the nature of
the wound, the tissues involved, and the nature of the irritant in ques-
tion. These differences are minor. Where pus formation occurs, the
reparative process is greatly modified and thwarted because the tissues
must not only repair the injury, but must get rid of the irritant (micro-
organism). In reference to wounds the reparative process has been
divided into healing by first intention, by second intention, and by third
intention.

Healing by First Intention. — In healing by first intention, the repar-
ative process in the open wound begins just as soon as the tissues have
recovered from the injury and. the hemorrhage has been arrested and
the cells are again receiving their proper quota of nutritious materials.
If the edges of the wound are coaptated and the suppurative process is
not set up, the inflammation will be slight and just sufficient to bring
about adhesion of the tissues. During the first day or two, there will
be a little redness extending slightly into the surrounding tissues and
there will perhaps be a little swelling and a slight elevation of the local
temperature, but the wound will be devoid of pain and only slightly
tender to pressure. An effort to pull apart the edges of the wound
will show that adhesion has occurred and in a few days the union is
formed. Along the line of injury there will be a number of new cells
formed which assist in welding together the tissues. It is hardly likely
that in any case there is absolute adjustment of the tissues, as fascia
to fascia, muscle to muscle, etc., therefore, even in healing by first inten-
tion, there would be some need for the formation of new tissue, but as
before mentioned, this new formation is of the slightest amount possi-
ble. The tissue changes occurring in healing by first intention are
worthy of note. Immediately in the surrounding area there is a dilata-
tion of the vessels, stasis occurs, proliferation of the connective-tissue
cells and the escape of the leukocytes and serum from the capillaries.

114 PROCESS OF REPAIR.

They infiltrate the surrounding tissues and fill up the lymph spaces.
Proliferation of the connective-tissue cells results in the formation of
new round cells which crowd into the mass of coagulated fibrin which
fills up the slight spaces between the edges of the injured tissues, so that
in a few days the entire wound is filled with new cells (granulation-tissue
cells). The inflammation extends but a short distance back from the
wound. The coagulated lymph, blood, and serum, which first filled up
the wound and which later have become invaded by the granulation-
tissue cells, now become absorbed. The inflammatory reaction becomes
less and finally ceases, so that if in a few days a section of the part be
made, it will be found that a layer of small round cells unites the
edges of the wound. This mass of small round cells is permeated by
capillaries which have stretched across the wound and serve the pur-
pose of furnishing the new cells with nutrition. These capillary loops
are thrown out coincident with the proliferation of the resident con-
nective-tissue cells. This vascularization of the tissues is one of the
characteristic parts of the process and furnishes the cause for the color
of the scar immediately after the wound has healed. These round-cells
which form the scar now become differentiated into fibrillar connective
tissue which, like other fibrous connective tissue, contracts. The cells,
at first elongated and spindle shaped, become wavy. This contraction
of the scar squeezes the blood out of the capillary loops, when the scar
is changed from a pink color to white. The fibrous tissue formed is
generally in excess of the required amount, but absorption of the excess
of new formation takes place and in a few months or years after, the
scar will depreciate materially, or in some cases apparently disappear.
After union takes place, if the wound be an incised one, only a faint
streak remains to mark its site, and as time goes on this line changes,
at first pink, later becoming white and after awhile it may entirely dis-
appear so far as external appearances are concerned. There are few or
no constitutional 83>rmptoms following or attending the repair of wounds
in this manner. This is the condition which should be aimed at by
every physician in the treatment of wounds. Considering that large
bodies, such as bullets, splinters, thorns, or the penetrating object
which produced the wound, have been removed, the only other agency,
outside of constitutional defects or irregularities of circulation, etc.,
which would prevent the union by first intention, is the presence of
micro-organisms. Other things being equal, the micro-organisms are
the objects which prevent union by first intention, or in other words,
cause immoderate inflammation or produce suppuration, therefore,
before the wound is coaptated it must be rendered as nearly aseptic as
possible. There are cases where coaptation of the wound has never
been obtained and the wound having become filled with blood, heals
up. This is said to be one special form of healing by first intention,
or healing by blood clot. There is another method which properly
belongs to healing by first intention— it is where, after a slight Avound, a
scab is formed and without suppuration the healing takes place under-

PROCESS OF REPAIR. 115

neath the scab. This is properly healing by first intention without any
destruction of the tissues.

The conditions preventing union by first intention may be sum-
marized as follows: — -

1. Extensive contusion and destruction of the tissues.

2. Presence of septic material or foreign bodies.

3. Diminished vitality of the tissues because of debility or the use
of alcohol, or the presence of diabetes, bad hygiene, etc.

4. The parts not having been kept at rest.

5. Insufficient drainage.

All of these conditions operate to permit of infection, and if
infection occurs, the granulation tissues will be converted into pus,
when healing by second intention will be necessary

Healing by Second Intention. — In healing by second intention, either
coaptation of the wound has not taken place or infection has occurred
through the operation of some of the above named conditions. If pus
forms because of insufficient drainage, sepsis, etc., after coaptation of
the wound, there may be a reaction quite similar to septic intoxication.
Many times this will occur and has led to the popular belief that
wounds may heal too quickly. If a wound is completely healed, under
no circumstances may the repair take place too quickly, but the trouble
is, because of the vascularity of the deeper layers of the true skin, it
becomes glued together before the connective tissues beneath
heal. The presence of foreign bodies, or the effusion of fluids which
later become septic, cause pus formation. The tissues become
distended and the wound opens and discharges pus. If the
wound is large and the pus formation great, there may be a severe
systemic reaction. After this change has taken place, the wound must
then heal by second intention. If there has been extensive destruction
of tissue or a mass of the tissue dies because of the injury, as soon as
the hemorrhage is arrested and the wound has been cleansed, the con-
nective-tissue cells begin to proliferate. The area becomes very vas-
cular because of the dilatation and the formation of new vessels. The
round cells, the source of which is the resident connective-tissue cells,
increase and multiply and fill up the wound from the bottom. Capil-
lary loops are formed which extend out into these layers of granulation
tissue which are formed one above the other, extending from the bot-
tom of the wound towards the top. When the wound is filled, the sur-
face epithelium creeps out over the top from the surrounding epi-
thelium. This epithelium is usually dwarfed, most likely because of
an insufficient blood supply, so that the epithelial covering of a scar
is not like that over the surrounding healthy tissues. After healing
has taken place the scar, which is now red and elevated, grows smaller
because of contraction. This cicatricial contraction is due to the differ-
entiation of the round cells, which become spindle-shaped and long, and

116 PROCESS OF REPAIR.

afterwards contract into wavy bundles. Where the scar is extensive, this
cicatricial contraction may produce great deformity, often rendering
a member useless. In wounds through the cheek, cicatricial con-
traction and scar formation, if there is not good coaptation of the
wound, may prevent the person from opening the mouth. Cicatricial
contraction may bind down the tendons of the hand so as to render it
useless. In burns about the face, the cicatricial contraction may distort
the features. Should it happen that there is much destruction of the
tissues, healing will not take place until all of the destroyed tissues are
removed. These are removed by process of ulceration and gangrene.

Healing by Third Intention. — Should it happen that the wound is
so extensive that it may not be coaptated, healing by second intention
will continue and after a time the wound will become comparatively
small. It may then be possible to coaptate the edges. Considering that
the surface of the wound has been rendered aseptic, if the edges of the
wound are brought together and held in apposition by some means,
union of the two granulating surfaces will take place readily and
quickly. This is healing by third intention.

Repair of Special Tissues.

Epithelium. — The repair of epithelium is generally complete. The
new cells are derived from the epithelium at the margins of the injury
by a process of division and subdivision, the cells spreading out over the
basement membrane, but if the injury extends into the subepithelial
tissues, a scar will be formed.

Skin. — Eepair of the skin is accomplished by scar formation.
Fibrous tissues take the place of the other structures. No nerves are
found in the scar. After a time even the blood-vessels disappear. Hair,
sebaceous glands, sweat glands, and the other appendages of the skin
are not reformed. The rete Malphigii is not reformed, which likely
accounts for the fact that the epithelium over the scar in the skin is
imperfect. Inasmuch as a scar contains a poor epithelial covering, few
vessels, few or no lymphatics, and no nerves, it is liable to injury.

Fascia and Tendons. — The repair of fascia means practically regen-
eration, inasmuch as it consists almost entirely of fibrous tissue. The
repair of tendons is not quite so complete, the scar always remains in
evidence, but a scar formation may fill up a considerable gap between
the divided ends of the tendons, producing an excellent result, even
though the tendon is somewhat defective.

Muscle. — Muscular tissue is only repaired by means of scar tissue
derived from the endomysium, perimysium, and epimysium, or from
the endothelial tissue elements. Eegeneration of the muscles may fol-
low to a limited extent, but as a general rule, no highly organized tis-
sues, such as muscle, will regenerate. It is possible where there is
absolute coaptation of muscle fibres, that union by adhesion will take

PROCESS OF REPAIR. 117

place. According to some writers, severed ends of muscle fibres die and
the' ends of the damaged muscle cells break up into spindle-shaped
fragments, which undergo fatty degeneration and totally disappear by
the twenty-first day. The disappearing fibril is then replaced by a bun-
dle of longitudinally striated fibres, which are differentiated from the
muscle nuclei. The growth of the muscle fibre into the granulation
tissue and the disappearance of the destroyed muscle tissue, begin about
the sixth day. The outgrowths of muscle may bifurcate and terminate
in club-shaped extremities. The longitudinal striations may appear
as early as the second week. The new muscle filaments which are
formed, should this occur, interlace and extend in various directions.
The interlacing of the fibres from the opposite side of the wound con-
tinues until the muscle is made thoroughly strong, when the interlacing
fibres are gradually absorbed and the muscle seems to return to the
normal condition.

Blood- Vessels. — The repair of blood-vessels frequently depends upon
the organization of thrombi. A wound of an artery may heal by the
formation of cicatricial or scar tissue. More or less arrest of the blood
current is necessary for this to take place. If a thrombus forms it may
undergo secondary changes. Capillaries are developed by the sprouting
out of the endothelial cells. These outgrowths become united with
other outgrowths, forming loops. The cells of these loops become hol-
lowed out, in some manner, forming capillary loops.

Nerves. — Under proper circumstances the repair of nerves (nerve
fibres) is complete. The immediate union of nerve fibres with the
restoration of their power is said to have occurred clinically, but as
yet has never been done experimentally. When nerve cells are destroyed,
they are not reproduced, but when the fibre is destroyed, it may be
regenerated or reproduced. When the fibre is cut off, the whole distal
end of the nerve dies and degeneration of the proximal end takes place
back to the first node of Ranvier. Regeneration of the nerve then
takes place by the outgrowth of the proximal extremity. Zeigler
maintains that the distal segment takes an active part in the regenera-
tion of the nerve. The process which most likely takes, place is as fol-
lows : In four or five days after section, the myelin sheath becomes seg-
mented and the axis cylinder divides up into fragments in the distal
portion of the nerve. As early as the seventh day, active proliferation
begins in the neurolemma with migration of the newly formed cells,
several occupying one internode. During the following week the
myelin sheath and fragmented axis cylinder become absorbed and are
completely removed by the fourteenth day. The nuclei in the inter-
nodes then acquire an investment of protoplasm. This process con-
tinues until a single-celled protoplasm fibre with imbedded nuclei is
formed. It sometimes happens that more than one sheath and more
than one protoplasmic fibre may occupy the old sheath. The fibre now
grows down through the newly formed sheath and the function begins

118 WOUNDS.

to return by the twenty-first day and is complete in eighty days. These
are the results of experiments upon dogs under favorable circum-
stances.

Bone. — The repair of bone takes place in the same manner as in
soft tissues. Ossification follows in the soft callus, or in other words,
the granulation tissue is converted into bone in much the same manner
as bone is formed in cartilage or in membrane. The union may be suf-
ficiently complete under very favorable circumstances, that it would be
difficult to determine the point at which the fracture occurred.

WOUNDS.

Definition. — A wound is a solution of the continuity of the living
tissues. In general, wounds may be divided into two great classes,
open and closed. Open wounds are those in which there has been a
solution of the continuity of the surface or the skin is broken. Wounds
vary according to the instruments which produce them, the tissues
affected, and the amount of force used. A slight force may produce
an extremely severe wound in some tissues, while in others the effects
would be but slight. The amount of damage inflicted by an object is
by no means apparent by the slight wound at the surface, but on the
other hand, the gravity of the wound will depend largely upon the
nature and extent of the wound and the tissues involved.

Effect. — The effects of wounds are (A) Local and (B) General. The
local effects are (1) pain, (2) hemorrhage, (3) retraction of the edges
of the wound, and (4) more or less interference in function.

Pain, Retraction of Edges, etc. — The pain occasioned by a wound
will depend upon the nature and location of the wound. In contused
wounds, the bruising of the tissues will destroy the sensibility. More
or less contusion attends a gunshot wound, and in moments of excite-
ment, persons may not discover that they have been injured, unless a
nerve trunk or some other vital structure has been injured. The
pain may be quite severe, due to irritation of the peripheral nerves,
or it may subsequently become more severe, due to secondary changes
taking place in the wound, e. g., sepsis. Inflammatory changes will
cause pressure on the terminal nerves. Pain at first acute will perhaps
be converted into a dull ache, and if severe inflammation follows, the
pain may become intense. Sometimes retraction of the edges of the
wound will be very great, especially if muscular tissue has been severed.
If the wound is directed across the cutaneous muscular fibres, instead
of parallel to them, the retraction will be much greater. The interfer-
ence in function will depend upon the extent of the injury and the
structures involved.

The General Effects of wounds are (1) shock, and (2) hemorrhage.

SHOCK. 119

Shock.

Shock constitutes the systemic eifect of severe injury in which vaso-
motion and inhibition are profoundly disturbed.

Cause. — It is produced by the profound effects of afferent impulses
on the centers. There is a marked fall of blood pressure, due to tem-
porary paralysis of the splanchnic area. This results in the engorge-
ment of the abdominal viscera and consequent anemia of the nerve cen-
ters. Where it is suddenly fatal, it is perhaps due to the effect of severe
impressions directly on the centers or to the effect on certain nerves,
such as the pneumogastric. Death is said to result in such cases from
inhibition. Shock is more disastrous in old people and in the debili-
tated or in victims of heart disease, diabetes, or alcoholism. Injury to
the viscera, or even simple exposure of the intestines to the air, as in
the opening of the peritoneal cavity, very often occasions great shock.
Operations on the urethra or injury to the testicle or ovary or uterus
are attended with great shock. Burns over considerable areas, even
though it is but an injury of the epithelium, may cause fatal shock.
Especially is this true where it involves the trunk. Irritant poisons or
profound mental emotions may superinduce fatal shock. Prolonged
anesthesia or the removal of a tumor or a considerable quantity of fluid
from the abdominal cavity may bring about considerable shock. The
constant abstraction of the body heat may occasion great shock. Hem-
orrhage will cause shock according to its severity.

Symptoms. — The onset of shock is sudden and is generally easily
recognized. It may be confounded with hemorrhage. The symptoms
may be thus summarized :

Mental. — The person may be conscious or semiconscious, depending
upon the severity of the shock or upon its prolongation.

Skin. — The person is blue, the lips are blanched, and the skin is
generally covered with a cold, clammy sweat. The extremities are
especially cold.

Circulation. — The heart is quick, pulse feeble and fluttering. Very
often the pulse can not be detected in the extremities. It may not be
appreciable in the radials.

Temperature. — The temperature is generally subnormal.

Eyes. — The eyes are half-closed, lusterless, and glazed. The pupils
are dilated and react slightly to light.

Respiration. — The respiration is shallow, quiet, and slow and may
be of the Cheyne-Stokes character.

Muscular System. — The muscles are usually relaxed. There may
be more or less muscular tremor. The sphincters yield and there may
be involuntary actions of the bowels and bladder. There may be
nausea and vomiting. In severe forms of shock, the urine may be sup-
pressed and the patient subsequently die of uremia. The symptoms

120 SHOCK.

may come on with such sudden onset that the patient will die of syn-
cope, .or if the shock is prolonged, the patient will go into a semicon-
scious or delirious state, followed by collapse. Keaction may be estab-
lished. This will be attended by the color returning, the skin becoming
hot, face flushed, and the temperature rising to normal, or perhaps
slightly elevated. The bowels will be confined, the urine scanty and
high-colored and the patient will feel feverish. The pulse becomes full
and strong. The secretions will be established slowly.

Treatment. — The treatment of shock is to first remove
the cause. If it is hemorrhage, this should be at once
arrested. If it is due to an anesthetic, it should be with-
drawn and the patient given plenty of fresh air. If it is
due to exposure the person should be protected. Often in cases of
operation the shock may be brought about partly by exposure of the
patient, the surface of the body becoming chilled. If the shock is due
to the presence of a dead limb, which may sometimes occur, the limb
should be amputated. If due to the presence of a fracture or disloca-
tion, this should be reduced and the member put in an eas}^ position as
soon as possible. Never administer morphine in case of shock, even if
the shock is largely brought about by pain. Bandage the limbs with
hot flannels; especially should this be done if the shock is brought
about by hemorrhage. Wrap the patient in hot blankets. Hot water
bottles should be applied over the heart and generally about the body.
If the shock is severe, hot fluids, such as hot coffee, etc., may be given.
Artificial respiration should be kept up. The head should be lowered
to allow the blood to get to the centers. Enemata of hot normal saline
solutions may be given. The solutions should be heated to 110
degrees F.

Osteopathic Measures. — It is of the greatest importance that a good
circulation be secured to the nerve centers in the medulla and brain.
This can be done by stimulating the superior cervical ganglion. The
vasomotors to the general body should be stimulated so as to equalize
the general circulation. The heart itself, if weak, will require stimula-
tion. This can be successfully done by manipulation in the upper
dorsal and upper cervical regions. Raising the ribs — especially the upper
ribs on the left side — will be of service.

Prevention of Shock. — Shock may be prevented by protecting the
patient, seeing that he is properly covered and the surface of the body
not too much exposed. Prolonged operations are sometimes the source
of shock, hence it is a great and important factor. Operations should
be clone rapidly. Do not allow purging of the patient previous to under-
going an operation. In shock, hot, strong, black coffee will be found
useful. It is perhaps of advantage before the operation. Where the
shock is from pain, relief may be obtained by pressure upon the
nerve involved. In case of injury to the eye, or at a point where it is
impossible to reach the injured nerve, morphine may be given hypo-

HEMORRHAGE. 121

dermically or opium administered per os. However, there are but few
instances where such remedies are necessary. Osteopathic methods are
sufficient in almost all cases.

Hemorrhage.

Hemorrhage is frequently spoken of as (1) arterial, (2) venous, (3)
capillary, (4) parenchymatous, (5) interstitial, and (G) internal.

By Arterial Hemorrhage is meant bleeding from an artery. This
can usually be told by the bright red color of the blood and the pulsa-
tion or irregularity of the stream, the blood escaping in jets.

In Venous Hemorrhage the blood, while flowing rapidly, is a con-
tinuous stream and is blue or purplish-red in color.

In Capillary Hemorrhage the blood oozes from the tissues and seems
to come from all points in the wound and not from any distinct local-
ity. There are conditions, though, in which venous and arterial hem-
orrhage can not be distinguished. In case of prolonged anesthesia, the
blood is generally purplish, or if the blood has flowed some little
distance and is directly exposed to the air, it ma}' become oxygenated
and very bright red, even though it has come from a vein. Where
bleeding takes place from cavernous tissues or tissue spaces, such as
occurs in the corpora cavernosa or from the spleen, it is called
parenchymatous hemorrhage. Where the hemorrhage takes place in the
tissues of a limb between the muscles and along the fascia, it is called
interstitial hemorrhage. This interstitial hemorrhage may be sufficiently
severe to cause a large puffy tumor and to so press upon the blood-
vessels of a limb as to obstruct the circulation below.

Internal Hemorrhage is a condition where there is bleeding into one
of the large cavities of the body, as the peritoneal or pleural cavity.

Symptoms. — The symptoms of hemorrhage are both local and gen-
eral. The local effects are the presence of large quantities of blood.
When it occurs in the subcutaneous tissues it forms a puffy tumor, or in
a cavity of the body an evidence of fluid. The extravasation of blood
takes place along the tendon and muscle-sheaths, or underneath planes
of fascia, and after a time causes considerable discoloration of the tis-
sues. The general effects of hemorrhage are the following: If the
hemorrhage is rapid, death may follow from syncope. If it is not so rapid,
the pulse will be found weak, at first rapid and then slow and fluttering.
The skin becomes covered with a clammy sweat and it may often have
a greenish tinge. The face becomes pale and the lips blanched. The
patient will often complain of vertigo and the eyes will have a fixed and
glassy stare and the pupils are dilated. In less severe cases one of the
first symptoms is defective sight. The patient complains of objects mov-
ing in the room and of everything suddenly turning black, or there may
he little objects dancing before the eyes (muscae volitantes). The hear-

122 HEMORRHAGE.

ing will be defective and the patient may complain of tinnitus aurium.
The more severe the hemorrhage, the harder the hearing of the patient.
Thirst is inordinate and it is not relieved by frequent draughts of
water. The patient is restless and sometimes there is muscular tremor.
Especially is this true if there is considerable blood lost. Convulsions
generally precede death. Vomiting and regurgitation of the contents
of the stomach are not uncommon. Where the hemorrhage is severe
and rapid, dyspnea is a marked symptom and the patient ofttimes gasps
for air and clutches his chest. A loss of one-half the blood of the body
is usually fatal. This amount will vary according to the individual.
It is said from four to six pounds is fatal. Ofttimes in cases of con-
cealed hemorrhage, the first evidence may be yawning. The patient
complains of a close feeling — not sufficient air and of thirst. An exam-
ination should at once be made to determine if there is hemorrhage.

General Treatment of Primary Hemorrhage.

Position. — To prevent syncope and collapse from hemorrhage, it is
essential to keep the head low and the centers supplied with blood,
hence the affected part should be elevated and the head lowered. In
case of uterine hemorrhage, or hemorrhage from the bowels in typhoid
fever and in similar conditions, the foot of the bed should be elevated
six inches and the pillows taken from under the head of the patient
and absolute quiet enjoined.

Bandaging. — The limbs should be closely bandaged with hot flannel
bandages. This is of the greatest value in that it renders the circula-
tory system smaller in size until the quantity of the blood may be
increased.

Increase of Blood to the Medulla and Other Manipulative Measures.

Manipulation in case of hemorrhage should not be directed toward
increasing the heart's action, since it may cause a greater loss of blood.
The blood flow to the nerve centers may be increased by securing
dilation of the carotids and vertebrals and their branches. This can
be accomplished by stimulating the vasomotors in the neck. Any manip-
ulation should be gentle and not sufficient to disturb the patient.

Heat should be applied to the body by means of hot blankets and hot
water bottles. This should be kept up to relieve the shock incident to
the hemorrhage and to restore the heat which the loss of blood has
taken away.

Hot Saline Enemata are of the greatest advantage. In some cases
intravenous injections of hot saline solutions are used. This is unneces-
sary if the enemata are used sufficiently early. A quart of normal salt
solution should be allowed to run into the bowel and must be retained.
If it is voided by the patient, more should be introduced by means of
a fountain syringe.

HEMORRHAGE. 123

-Diet. — The subsequent effects of hemorrhage may be best treated
by the administration of highly concentrated and digestible foods.
Give water, beef broth or beef juice, eggs, milk, and such other nourish-
ment in small quantities, frequently repeated.

Methods of Arresting Hemorrhage.

Nature's Method. — .Nature's method of arresting hemorrhage is to
bring about a lowering of the blood pressure. This is accomplished
by dilating the blood-vessels in the splanchnic area so that the blood
pressure is markedly lowered in the bleeding artery. Then the flow of
blood from the artery becomes less rapid. Furthermore, the inner coat
of the artery is made up of elastic tissue and when this is torn or injured
it has the property of contracting and curling np. As it contracts it
more or less obstructs the lumen of the vessel and furnishes numerous
points which are favorable to the coagulation of the blood. As the
blood flows more slowly and as it is brought in contact with the atmos-
phere, the lumen of the vessel being reduced, the end of the artery
may become plugged by a clot. This clot will form in the vessel
extending back to where the first branch is given off. In this way nature
endeavors to arrest the hemorrhage. It is not unusual that the hem-
orrhage may become arrested, and then by means of the contractions
of muscles or movements, these clots may become disturbed. With the
rise of blood pressure, as the heart becomes stronger, these plugs are
forced out of the ends of the arteries and a subsequent hemorrhage
occurs. Kepeated hemorrhage of this kind may continue until the
patient dies, so that it is necessary to enjoin the strictest quietude
where the methods are not at hand to stop the hemorrhage and we
must rely upon nature's effort. Where hemorrhage takes place into a
cavity, such as the pleural cavity, it will continue until the pressure
within the cavity is equal to that within the vessels. This, it can be
readily seen, would require a considerable amount of blood. There are
two chief factors which have to do with the formation of clots within
the vessels in the operation of nature's method for the control of the
bleeding vessels. They are (1) enfeeblement of the heart and (2) the
absorption of the watery fluids from the tissues. These seem to assist
the coagulation process. Should the clot remain within the artery, it
will most likely undergo reorganization and the artery will become
permanently plugged. Coagulation of the blood in the wound and
around the sheath of the artery, and its subsequent contraction, pre-
vent the artery from dilating, consequently the clot is not readily dis-
lodged. The internal clot, because of its adherence to the vessel wall,
prevents the escape of blood. Leukoc}d;es migrate from the clot. Pro-
liferation of the connective-tissue cells occurs and the clot becomes
organized. After a short time inflammatory exudates occupy the place
of the clot until finally it becomes changed into granulation tissue and
then into fibrous tissue, forming a hard, fibrous plug. This description

124 HEMORRHAGE.

of the method of arresting hemorrhage applies to injury of smalJ
arteries. When an artery is punctured or when the aorta or one of the
larger vessels is injured, this process may not take place. The hem-
orrhage is likely to be fatal. If the artery is divided in its course, the
distal end heals in the manner described-. The proximal end will heal
in this manner, providing the conditions are favorable and the artery
is not too large, so that hemorrhage will destroy life.

The methods employed by the older surgeons in the treatment of
hemorrhage were in some cases terribly barbarous, as, for instance,
in the amputation of a limb, a red hot knife was used. It was the com-
mon practice, until the days of Ambrose Pare, to pour boiling oil over
an amputation stump to check the hemorrhage. Sometimes the stump,
after amputation, was immersed in boiling pitch, but after nature's
method of arresting hemorrhage became better understood, the methods
of the surgeons were made to comply with and to imitate it. Nature's
method depends upon these conditions: — The fall of the blood pressure,
the contraction of the arterioles brought about by the action of the
muscular coat, the curling up of the internal coat with the terminal
plugging of the vessel, together with the increase of the coagulability
of the blood. This increase of the coagulability, as before mentioned,
is brought about by the slowing of the blood and the increase of its
watery elements and by being brought in contact with the air.

Surgical Methods. — (A) Temporary. The temporary methods of
controlling hemorrhage are (1) direct pressure on the bleeding artery,
which can be at once accomplished by placing the thumb or finger over
the bleeding point and holding it, or pressure may be made upon the
bleeding point by means of surgical dressings and a suitably applied
bandage. (2) Pressure between the bleeding point and the heart, which
may be accomplished in the following ways: — digital pressure, forced
flexion, and the tourniquet. The femoral artery may be compressed
where it passes underneath Poupart's ligament.- The dorsalis pedis
artery may be compressed on top of the foot. The popliteal artery
may be compressed by forced flexion. The posterior tibial artery may
be compressed above the internal malleolus. In severe hemorrhage
from the palmar arch, the brachial artery may be compressed at the
insertion of the coraco-brachialis muscle. The axillary artery may be
compressed by pressing it against the head of the humerus. The sub-
clavian artery may be compressed where it comes over the first rib.
The temporal artery may be compressed anywhere upon the side of the
face and head. The occipital artery may be compressed as it passes
up behind the ear. In this manner hemorrhage can be arrested until
other means can be used. Where a limb is torn and mangled and there
are numerous arteries injured, a tourniquet may be necessary. This
can be applied by taking a handkerchief or piece of cloth and tying it
loosely around the limb, then inserting a stick and twisting it. The
knot in the cloth should be placed over the leading vessel. The tourni-

HEMORRHAGE. 125

quet may be twisted sufficiently tight to arrest the hemorrhage. It
must not be twisted sufficiently tight as to entirely cut off the circula-
tion, or gangrene of the stump will take place, providing the tourniquet
is allowed to remain for any length of time. Even a few hours may be
fatal to the tissue beyond the point of compression. Morton's elastic
bandage or an elastic tourniquet is often very valuable where it is at
band.

(B) Permanent methods. The permanent surgical methods of con-
trolling hemorrhage are the following: — (1) Cold, (2) Heat, (3) Pressure,
(4) Ligature, (5) Torsion, (6) Acupressure, (7) Forcipressure, (8)
Cautery, and (9) Styptics.

Cold may be applied in the form of a cold water coil or ice-pack,
preferably in the form of ice. It seems to cause the muscular coat of
the artery to contract and drives the blood out of the part. Severe
cold favors coagulation of the blood in the smaller vessels. Ice-pack
to the right iliac fossa is of advantage in hemorrhage in typhoid fever.
Ice applied directly to the bleeding surface is of benefit.

Heat. — In the control of venous and capillary hemorrhage, heat is
the most valuable agent, next to ligature, that we have. Water should
be used as hot as can be borne. The water should be at least 120 degrees
F. and in man}r instances water of greater heat is of great advantage.
The best method of application is fry sponges wrung from hot water
and applied to the bleeding surface. This causes the con-
traction of the arterioles and coagulation of the blood in the mouths
of the •vessels. By rapid and constant changing of the sponges, together
with the local pressure, hemorrhage may be quickly staunched. The
success of the method depends upon its rigid application.

Pressure has been mentioned as one of the temporary methods of
controlling hemorrhage. It likewise can be considered as one of the
permanent methods. In injuries where the arteries may be compressed
between the dressing and bone, as in wounds of the temporal or occipital
artery, a mass of gauze and cotton may be placed over the artery and
a tight bandage placed about the head. Here pressure is made directly
upon the artery by the bandage which is sufficient to control the hem-
orrhage and yet will not interfere with the nutrition of the tissues and
the healing of the wound. Pressure can be applied in a similar manner,
by a tight bandage, to stumps. Care should be used in the application
of the bandage, not to interfere with the return circulation. In hem-
orrhage from a varicose ulcer or injury to an artery or vein of the
lower leg, the part may be bandaged snugly from below up. The
bandage may be allowed to remain until nature completes the work by
causing coagulation in the mouths of the vessels, thereby arresting the
hemorrhage. In case of hemorrhage from the uterus, tamponing the
vagina is a valuable method. In hemorrhage from the nose, tamponing
the posterior and anterior nares is of the utmost value and many times
will save life when all other efforts are futile. The posterior nares

126 LIGA TURE.

may be best tamponed in the following manner: — Take a small rubber
catheter and tie to it a string several feet in length. The catheter may
then be pushed back through the nose until it enters the pharynx,
where it may be grasped with forceps and pulled through the mouth.
We now have a string coming out of the mouth and nose. A pledget
of cotton of sufficient size, which when compressed will be about as
large as the patient's thumb, should be used. This is tied to the string
coming out of the mouth, when by means of the string coming out of
the anterior nares, the cotton may be pulled back up into the posterior
nares. This will successfully cut off the hemorrhage in that direction.
The anterior nares may be readily plugged by inserting cotton. The
plug in the posterior nares may be allowed to remain thirty-six hours
or longer, or untii the physician is sure that the mouths of the vessels
have been closed by nature. An instrument may then be pushed in
through the nares and the plug pushed out in the pharynx and removed.

Fig. 18. Fig. 19.

A reef knot, the kind used in A granny knot, the kind not to

the ligature of an artery. use in ligaturing a vessel.

Ligature is the most reliable of all the methods of permanently
arresting hemorrhage and it is one which is frequently used. Material
used for the ligature are chromicized and asepticized catgut, sterilized
silk, and kangaroo-tendon. Of these ligatures, silk is most generally
used because it is more readily rendered aseptic. Before asepsis and
antisepsis were thoroughly understood, it was customary in ligature of
an artery to allow the ends of the ligatures to hang out of the wound.
Each day as the surgeon visited his patient he would pull the ligature
slightly until finally the end of the artery was pulled off and the ligature
pulled out. The wound was then allowed to heal by second intention.
It has now been shown by experience that silk, if aseptic, under reason-
ably favorable circumstances, will remain as an inert body within the
tissues and will not occasion any mischief, but will become encapsulated,
perhaps partly absorbed. Kangaroo-tendon and chromicized catgut
have the advantage that they will after a while become absorbed, but
they have the disadvantage that they can not he so successfully ster-
ilized as silk. In the application of a ligature it should be tied suf-
ficiently tight to prevent its slipping, and none of the tissues surround-
ing the artery should be enclosed with it. The artery should be tied by

HEMORRHAGE. 127

means of a reef knot or a friction knot. When the ligature is applied,
the internal coat is broken, the end retracts and curls up and becomes
crumpled, coagulation of the blood readily takes place and secondary
changes, organization of the clot and encapsulation of the ligature, fol-
low in sequence.

Torsion consists in seizing the end of a bleeding artery with an artery
forceps, drawing it from its sheath and twisting it several times until it
is felt to partly yield. Four or five complete turns will be sufficient.
Where the artery is large it should be pulled out a half inch and grasped
by one artery forceps, while another grasps the end of the artery. The
one forceps holds the artery firm, while with the second forceps, or the
one grasping the end of the artery, torsion is made. This method of
arresting hemorrhage is applicable to arteries the size of the radials,
brachials, and even the superficial femoral, hi this method no foreign
body is left in the wound, hence there is less danger in the wound heal-
ing, likewise less danger of scar. This method can not be itsed if the
artery is diseased. It is said that in some cases necrosis of the artery
has taken place. This method was employed even b}r ancient surgeons.
In small arteries or where suppuration would be especially disastrous,
this method is valuable.

Acupressure is controlling hemorrhage by means of pins. It was
devised by J. Y. Simpson. The pin passes underneath the vessel, leav-
ing as little tissue on either side and between the pin and the vessel
as possible. Silk is then twisted in a figure-of-S over the ends of
the needle. There are other means of applying acupressure needles,
but they need not be mentioned, as they are obsolete.

Forcipressure consists simply of using a hemostatic forceps
to grasp the end of the artery. It is the means used during an opera-
tion to control hemorrhage and in many cases will be permanent. It
is occasionally used to arrest hemorrhage where the artery is deep and
it is impractical to further operate, or where the artery can not be
ligated. Apply the forceps and allow them to remain for twenty-four
hours, when they can be quietly removed, the patient being kept very
quiet and the wound afterwards closely watched. By this time nature
has formed a clot within the artery and the subsequent changes, as
occur in nature's method of arresting hemorrhage, will take place.

Cautery arrests hemorrhage by the coagulation of the blood and
partly by charring the tissues, which form an eschar, preventing
further flow from the vessels. It is best applied by means of the
Paquelin cautery or the Galvano-cautery. The wound or bleeding sur-
face is dried by the application of surgeon's lint or cotton, and the
cautery, which is at a full red heat, should be immediately applied.
Where these cauteries are not at hand a cautery iron which is heated
in the fire may be used. The chief objection to the use of the cautery
is that the charred tissues will separate and subsequent hemorrhage

128 HEMORRHAGE.

result. It is useful to arrest hemorrhage in the nasal mucous mem-
branes or the tonsils or in some location which is not readily accessible.
Styptics should never be used to arrest hemorrhage until all other
methods have been exhausted. Personally the writer considers them
of little value. The drugs produce coagulation of the blood in the
mouths of the bleeding vessels. The agents most frequently used are
the tincture of the chloride of iron, in fairly strong solutions, one-half
to one dram to an ounce of water; tannic or gallic acid, either in a dry
powder or a strong solution. Sloughing of the tissues is often brought
about by the application of these styptics and they should be used with
the utmost care.

Recurrent or Reactionary Hemorrhage.

Recurrent or reactionary hemorrhage occurs because of the slipping
of a ligature or because the clot has been washed out of the mouth
of the vessel. It calls for immediate treatment, some permanent
means being used and the wound redressed. The blood soaked
dressings must be removed or infection will take place. Where there
is oozing from a stump, it is hardly reactionary hemorrhage. The part
should be redressed and perhaps more firmly bandaged.

Secondary Hemorrhage.

Secondary hemorrhage is that which occurs after twenty-four or
thirty-six hours and which is generally the result of defective formation
of the clot within the vessel, or perhaps the result of faulty surgical
means. In some cases it may be because of disease of the vessel wall.
Infection may lead to ulceration; this, extending into the blood-vessels,
may bring about secondary hemorrhage.

Cause. — The causes of secondary hemorrhage may be summarized
as follows: (1) Bad treatment. This bad treatment may consist of
failure to maintain cleanliness and asepsis or ligature improperly
applied.

(2) Infection. When infection follows, necrosis of the end of the
bleeding vessels may occur. The application of modern methods will
prevent infection and secondary hemorrhage.

(3) Disease of the vessel wall. Thrombosis and degeneration of the
vessel walls may be such that the ligature will not hold or the artery
will break, secondary hemorrhage occurring.

(4) Certain constitutional conditions, as in hemorrhagic diathesis,
and in conditions where the patient has a tendency to bleed.

TREATMENT OF WOUNDS. 129

Treatment of Wounds.

The treatment of wounds may be conveniently grouped under the
following heads: —

1. Arrest of hemorrhage, prevention 4. Prevention of sepsis by proper care

of shock, and relief of pain. and the proper dressings rightly

2. Cleansing the wound. applied.

3. Closing the wound and providing 5. Attention to the general health.

proper drainage.

Arrest of hemorrhage, prevention of shock, and relief of pain have
been discussed.

The cleansing of the wound consists in the removal of foreign bodies
and irritants of any kind. If the wound has been made by a septic
object it is presumed that the wound is septic. If the opening is suf-
ficiently large, as in the case of an incised or lacerated wound, in fact,
any wound in which there is an opening sufficient for drainage, the
wound should be washed out with an antiseptic solution, either a 1:1000
solution of bichloride of mercury or 1 :20 carbolic acid solution. After
the wound is thoroughly washed out and cleansed in every part, all for-
eign bodies removed, such as splinters, bullets, dirt, pieces of glass,
etc., provisions may be made to establish drainage and to close the
wound. In some wounds where it is believed that the wound tract is
not very septic and the opening is small, as happens in a gunshot wound
or punctured wound, the surface of the wound only should be cleansed
and hemorrhage should be encouraged by compression and all the
blood expressed out of the wound, if possible. After washing
the surface with an antiseptic solution the wound should be dressed
antiseptically by means of cotton and gauze properly applied. It is
the best policy not to introduce fluids into these wounds unless in the
judgment of the physician they are distinctly septic. It is a well known
fact that the tissues of the body may take care of a considerable quan-
tity of septic material under favorable circumstances so that it is well
enough to temporize with these wounds and permit nature to handle
the case. If evidences of undue inflammation arise, the tract of the
wound may be laid open, disinfected, and drained, and allowed to heal
from the bottom up by granulation.

The establishing of drainage is perhaps, next to asepsis, the most
important factor in the treatment of wounds. Where the wound is
large and tbere is liable to be much exudation, it is of the utmost
importance to establish drainage. Drainage should always be estab-
lished at the most dependent part of the wound. If the wound is on
the head and the person will be lying down during the time the wound
is healing, the drainage should be at the most dependent point, but if
the patient will be in an erect posture most of the time, drainage would
perhaps be best established at some other point. At all events it should
be so arranged that it will take place in the easiest manner possible.

The materials used for drainage may be strips of antiseptic gauze.

130

CLOSURE OF WOUNDS.

Fig. 20.

which are laid in the bottom of the wound, or a fenestrated rubber tube,
which. has been previously sterilized, may be introduced. If the wound
is large, the drainage tube should be transfixed with a safety pin to
prevent it from dropping into the wound beyond reach. The rubber
tube furnishes an additional advantage in that, if the wound is septic,
it affords a means of irrigating the interior of the wound with antiseptic
solutions. In operations upon the abdomen a cigarette drain is best.
The drainage tube or other material should be covered over with a good
sized mass of surgeon's cotton to prevent infection and to absorb the
wound secretions. In ordinary wounds, especially small wounds, gauze

drainage is, perhaps, best. The chief object
of drainage is to permit the free escape
of serum and other materials which may
exude into the wound and which, being re-
tained, would furnish a good pabulum for
the growth and development of micro-or-
ganisms. Furthermore, the exudation of
the serum into the wound prevents union
and renders sepsis more likely, inasmuch
as it causes great tension of the flaps and
interferes with the circulation in the tis-
sues.

Closure of Wounds. — The surfaces of
the divided tissues must be accurately co-
aptated, or brought together, and perma-
nently held in that position until the tis-
sues have had time to establish firm union.
Where the wound involves different layers
of tissues, as fascia, skin, muscle, nerve,
etc., if a good result is obtained the nerves
should be brought in apposition, also
muscle to muscle, fascia to fascia, skin
to skin, so that, when union takes
place, the tissues are in as nearly a
normal position as is possible for them to be. There are numerous
methods of Avound closure. The method which is of the greatest value
and most universally used, and in fact is absolutely necessary, is by
some kind of a suture. The materials used for sutures are silver wire,
silk, horse-hair, silkworm-gut, catgut, and kangaroo tendon. The
qualities, which these different forms of sutures possess, vary. An ideal
suture should be one which is, first of all, aseptic, secondly, that it must
be of sufficient strength to hold the tissues in position, and thirdly, that
it is not absorbent, that is, that it will not absorb the fluids from the
tissues nor from the surface of the body. Silver wire has this advantage,
that it is very easily sterilized, is non-irritating and is not absorbent,
but on the other hand, it is not so easily applied and, after union takes
place, it is more difficult to remove. It causes pain and irritation upon

Cigarette drains.

CLOSURE OF WOUNDS. 131

removal. Silkworm-gut is, in many respects, the ideal suture and is
suitable for closing the abdomen or for use in perineal operations or
in very large wounds, but it is not absorbable and of course must be
removed. It is an animal suture and is best sterilized by boiling for
at least an hour, when afterwards it may be kept in strong alcohol until
used. Sometimes it becomes more or less brittle and breaks easily.
This is one objection to its use. But as a superficial suture, in many
respects, it is superior to any other form. In superficial sutures, horse-
hair is not irritating, is readily removed, and being fine, is of advantage
where a small suture is demanded. It is suitable for superficial suture
in closing wounds on the face. Silk suture is the most universally used.
It can be readily sterilized by boiling or lyv the use of antiseptics. Its
chief objection is that it is absorbent and when used on the surface, a
stitch-abscess may result. But with all its defects, silk is a most excel-
lent suture material. It was formerly believed that silk could not be
used in the tissues where it was allowed to remain, but it has been shown
that if it is sterile it will not act as an irritant, but will become encap-
sulated and be harmless. Silk may be sterilized by boiling, or by
immersing in a superheated strong solution of mercuric chloride, or
1 :20 solution of carbolic acid. The carbolic solution may be heated to
boiling, and when the suture material is immersed in it, in a short time
it will become sterile. After the sutures are sterilized, they should be
kept in an air-tight, thoroughly sterile jar or container made for the
purpose. Catgut has the advantage over the sutures before mentioned
in that it is absorbable, being liquefied by the fluids from the tissues.
The suture is made from the submucosa of the intestine of the sheep.
The method by which it is made is as follows : The mucous membrane
is first rubbed or scraped off, and then the muscular coat is scraped off
until only a thin submucosa is left. This is cut into strips and rolled
and dried. Afterwards it is rendered aseptic by various methods, boil-
ing in cumol or by heating to a certain degree at stated intervals,
for several days, or a week or more. Several of these methods are now
known to be reliable and catgut can be obtained which is aseptic; but
with all that, it is not a suitable superficial suture. Healing of the
wound will not take place readily, since, Avhen the suture becomes
liquefied, it furnishes a pabulum upon which the bacteria will develop,
and infection at the stitch-holes is common; in fact, it may lead to gen-
eral infection of the wound. It is useful as a buried suture where the
wound is closed and subsequent removal of the suture would be impos-
sible without a secondary operation. It is put up in several forms,
carbolated, chromicized, etc. Chromicized gut is rendered harder by
the action of the chromic acid and therefore becomes liquefied much
less rapidly, remaining in the tissues for a long time. Chromicized
gut is used for the ligation of arteries. It will generally become lique-
fied within ten days or two weeks. Three or four days is sufficient for
the liquefaction of the ordinary catgut. Kangaroo tendon is used to
a considerable extent for subcutaneous sutures; it is not used on the

132 SUTURES.

surface. It has the advantage that it is readily absorbed and is not
irritating. The methods by which these sutures can be sterilized are
various and -are only successful when they are thoroughly carried out.
Keliable suture material can be obtained from certain supply houses.
Unless the surgeon is equipped to do his own sterilizing thoroughly
and successfully, it is better to get the sterilized sutures already pre-
pared.

According to the manner of their application, sutures may be classi-
fied into buried and superficial. By buried suture is meant a suture
which has been placed in the tissues for the purpose of coaptating some
of the deeper structures and which is allowed to remain in situ and not
afterwards removed. Superficial sutures may be readily removed at
any time. Of the method of application, the following are some of the
varieties in use:

1. Superficial or coaptation.

2. Deep or relaxation.

3. Interrupted.

4. Continuous.

5. Quilled.

6. Figure-of-8.

7. Halsted's.

8. Lembert's.

9. Button.

The needles in use for the appli-
Fig. 21. cation of these sutures should have

Friction knot, the kind used in tying a sharp point and may be either
sutures- curved or straight. There are two

needles which are in most general use. These are Peaslee's and Hage-
dorn's. The Hagedorn needle has the advantage that the slight cut
made by the needle entering the tissues is parallel with the direction of
the suture or is transverse to the wound, whereas the cut made by the
Peaslee needle is parallel with the wound. In tying a suture introduced
by a Peaslee's needle, the little cut made by the needle is pulled open.
Troublesome hemorrhage has followed such application of suture. This
is not true of the Hagedorn needle, as the thread pulls in the end of
the cut, and the more tightly the suture is drawn the more closely do
the cut surfaces of the needle-hole press against each other and thus
hemorrhage is avoided. The needle, having been previously sterilized, is
threaded with the kind of suture material best suited for the occasion
in question and should be introduced, wherever possible, with the fin-
gers. Numerous needle holders have been invented by mechanics and
by operative surgeons, but no needle holder is so good as deft fingers.
Then, too, the best needle holder is liable to break. Where the needle
is small and where the surgeon is operating in a cavity, it may be neces-
sary to use a needle holder. A suitable automatic one should be at hand.
Unless a surgeon has a number of assistants, the needle holder may
entail useless delay. In the closing of an ordinary wound, the suture
should be introduced dowrn to the bottom of the wound, so that when

SUTURES.

133

it is drawn up snugly and tied, all parts of the wound-margins are
brought in apposition. If this is not done, serum will exude into the
lower part of the wound. A cavity is thus formed, filled with serum,
which furnishes an excellent nidus for the development of bacteria.

Fig. 23.

Fig. 22.

Coaptation and relax-
ation sutures.

Interrupted suture.

Fig. 25.

Suppuration is almost sure to occur unless the wound is closed in all
its parts.

The method of application may be an interrupted or continuous
suture. The interrupted suture is the one most frequently used and has
the advantage that it can be
applied evenly. A moderate Fig. 24.

amount of swelling will not
interfere seriously with the
suture. A continuous suture
will not so readily accomo-
date itself to other condi-
tions than those present at
its introduction. It is not
so easily removed. It is use-
ful for closing large wounds
quickly where the wounds
are upon the surface, or it is
suitable for use in buried
suture in apposing fascia.
Halsted's continuous subcu-
ticular suture is an excellent
superficial suture of silk,
which need not be removed.

By deep or relaxation sutures are meant sutures which are intro-
duced a distance back from the edge of the wound, including all the
deep tissues, and are for the purpose of lessening the tension upon the

A continu-
ous suture
applied.

Method of ending a continuous

134

SUTURES.

sutures which are at the margins of the wound. Coaptation sutures
are those which are put in at the margin of the wound and are for the
purpose of accurately apposing the surfaces. The quilled suture is no
longer used. The figure-of-8 suture is still popular in plastic surgery,
especially in harelip. It is applied by the insertion of silver harelip
pins (an ordinary commercial iron pin may be used). The pins are first
sterilized and then inserted, and a sterilized thread is placed in a figure-
of-8 manner over the ends of the needle. It has the advantage that
there is but little scarring of the skin and it holds the superficial tis-
sues in position. Halsted's suture is a valuable suture under some cir-
cumstances. By the use of this suture, the scars, the result of the
wounds made by the needle, are avoided. The button or shot suture
is still sometimes used. Lembert's suture is useful in suturing wounds
in the small intestines or any of the hollow viscera. Other forms, such
as the mattress suture or Ford suture, may be used if the occasion
demands, but these occasions are few, if they ever arise. In the use of
needles and suture material for the closure of wounds, it is the best
policy to use as small a needle as possible, the finest silk for coaptation

sutures, and for retention
Fig. 26. sutures, the larger silk. The

.,- . ,- . twisted silk is the stronger. In

tying sutures the knot should
not be drawn too tightly. If
the suture is drawn tightly it
will more or less arrest the cir-
culation to the tissues under-
neath it and sloughing of the
skin,orstitchabscessmayfollow. If the suture is aseptic, it will not oper-
ate as an irritant unless it interferes with the physiological process of re-
pair. There are a few other means of wound closure which should be un-
derstood, and which are useful in small wounds where other methods are
not available. These consist of adhesive plaster, collodion, etc., which
have the property of adhering closely to the skin, and if the wound is
small, holding the edges in apposition. Tear the adhesive plaster in very
small strips, dry the surfaces of the wound, heat the adhesive plaster
and as the tissues are held together, the adhesive plaster is applied.
Collodion may be used in a similar manner. Little strips of iodoform
or borated gauze may be laid over the wound, which has been dried,
and the whole painted thoroughly with collodion. Another fairly suc-
cessful method of closing a wound, where sutures are not at hand, is
to stick firmly to the skin strips of adhesive plaster which extend par-
allel with, and not too far distant from the wound. Then by means
of a needle and ordinary thread, apposition can be secured
by bringing the thread through the strips of adhesive plaster and
then tying it. This will be found successful in small wounds
or where suture material is not at hand. After a suture ie ap-
plied, if the tension becomes so great on the flaps that there is

Halsted's sub-cuticular suture.

TREATMENT OF WOUNDS. 135

indication of the suture cutting the tissues, some of the sutures should
be removed.

To remove a suture successfully, it must he done in the following
manner: The part of the suture which is without the tissues is more
than likely septic, so in removal the suture should be cut off below the
skm. While the suture is lifted up with a dressing forceps, the tissues
may be pressed down so that a margin of a quarter of an inch of the
suture, which was formerly within the tissues, may be pulled out and
the suture can be cut off at this point. This will prevent stitch-
abscesses. The length of time sutures are allowed to remain in the
tissues will vary according to the nature of the wound and the nature of
the tissues. In the face, coaptation sutures should not be allowed to
remain longer than thirty-six to forty-eight hours. A retention suture
should be allowed to remain longer, until there is no danger of the
wound being pulled apart. In case of lacerated perineum, the suture
should be allowed to remain ten to fourteen days, providing evidences
of inflammation do not appear, for the reason that the motions of the
body and the evacuation of the bowels may cause the newly united
structures to separate. Ordinarily in a vascular area like the hand,
the suture may be removed on the third, fourth, or fifth day. In an
area, as over the back, or on the thigh, union will not take place as
quickly and the suture should be removed on the sixth or seventh day.

Prevention of Sepsis. — Providing the wound has been thoroughly
cleansed, no drainage being necessary, the wound is coaptated and lastly
washed thoroughly to get rid of all materials which might remain. The
wound may be dressed with or without antiseptics. The object of the
dressings is to prevent sepsis and protect the wound. Dressings then
should be sterilized and should be of a material which will readily soak
up any wound-secretion or discharge. An antiseptic or aseptic gauze
is found to be the most serviceable. Outside of these gauzes may be
placed a considerable amount of aseptic cotton. The cotton prevents
any micro-organisms getting into the wound and will, at the same time,
absorb any of the secretions which are discharged.

Removal of Dressings. — Providing there is but little discharge, the
dressings should not be disturbed until it is necessary to remove the
sutures. If drainage has been established, the dressings should be looked
into within the first twenty-four hours, or sooner. Under no circum-
stances should the dressing be allowed to become saturated. Should
this happen, infection quickly travels into the wound from the outside.
The drainage tube should be removed in from twenty-four to thirty-
six hours, for the reason, if it remains there too long, it will act as an
irritant and cause inflammation in the tissues round about and prevent
the wound healing. The idea which the surgeon should have in mind
is that the wound should not, under any circumstances, be disturbed
unless he feels that it is not doing well, or that it requires change of
dressing because of its having been disturbed or because of an excess of

136 TREATMENT OF WOUNDS.

secretions. The wound should be properly dressed in a manner accord-
ing with the principles of modern surgery, and when once dressed should
be allowed to remain quiet until conditions have arisen which demand
intervention. If there is evidence of sepsis upon removal of the dress-
ing, an antiseptic solution may be thoroughly used. Under clean
conditions, considering that the surface has been thoroughly irrigated
with an antiseptic solution, several thicknesses of sterilized gauze may
be applied to the surface. On top of this is placed a considerable mass
of absorbent cotton. If conditions are not very clean, the surgeon may
apply boracic acid, iodoform, equal parts of boric acid and acetanilid,
salicylic acid, aristoL protonuclein, etc., in fact, any antiseptic drug
which prevents fermentation. The gauze may be carbolated five per
cent., boracic acid ten per cent., iodoform ten per cent., bichloride of
mercury 1:5000 or 1:1000. Any of these gauzes are excellent.
Bichloride of mercury is the strongest antiseptic, but is irritating. The
borated gauze secures mild antisepsis and asepsis and is, perhaps, the
best of all the gauzes. Where there is abundant discharge from the
wound, a dressing quickly becomes saturated and should be renewed
sufficiently often to keep the wound dry. It will then heal more rap-
idly. If the dressings are sodden with secretions of the wound, instead
of operating as a protection, they furnish a bed for the micro-organ-
isms in the same manner as a fiax-seed poultice.

Rest. — Functional and mechanical rest is of the greatest importance
in the treatment of wounds. The process of repair is accomplished by
the reproduction of new cells. These granulation-tissue cells are very
delicate and easily destroyed. Every movement of the injured part
will destroy some cells and call upon the tissues for renewed activity
to produce others. In fact, if the irritation is great, it may either pre-
vent the wound healing or may cause a considerable "formation of
fibrous tissues, which is always detrimental in any location in the body.
At best, the process of repair is difficult, and the tissues have an added
burden in order to properly repair the injury.

Constitutional Treatment. — In the healing of wounds, much depends
upon judicious constitutional treatment. It is necessary that the
bowels act daily, unless there are circumstances which require their
quiescence. The urine should be voided at stated intervals. The per-
son should be fed properly and should get the proper amount of sleep
and rest. After the shock has been combated and the patient has ral-
lied from the operation or from the wound, he should be placed in the
most comfortable position, so that he is as nearly at ease as possible.
The room should be sufficiently ventilated, the patient should not be
exposed to drafts. In the sick room a temperature of 60 degrees
F. is necessary. Many cases will require 70 degrees F. The room
should be kept scrupulously clean and especially should the patient's
bed be kept clean and his clothing changed daily. The bowels should
be kept regular by proper treatment. This treatment will vary accord-

KINDS OF WOUNDS. 137

ing to the condition. Sometimes it ma}' be necessary to resort to the
use of an enema. In the administration of an enema, a little castile
soap diffused in a quart of boiled water should be used. Where the
strength of the patient has been markedly reduced, either by shock,
injury, or operation, or severe loss of blood, a stimulating diet will be
found necessary. Where there is suppuration, it is of the utmost
importance that cleanliness be obtained ; furthermore, that the patient
be given a nourishing diet. The pulse and temperature should be care-
fully watched, in case of severe wounds, and where there is not a rise
of temperature and the patient feels well, it will not be necessary to in-
vestigate the wound at the end of the first twenty-four hours, nor may
it be necessary even at the end of forty-eight hours. In recovery from
old wounds or wounds in the ill-nourished, diabetic, or syphilitic cases,
or conditions of tuberculosis and Bright's disease, proper treatment
should be administered tending towards the support of the patient and
the relief of the exisiting conditions.

Kinds of Open Wounds.

1. Incised. 5. Poisoned.

2. Contused. 6. Gunshot.

3. Lacerated. 7. Fracture.

4. Punctured.

Incised Wound. — An incised wound is one having an evenly divided
edge and smooth surface and generally made by a sharp instrument.
A wound quite similar to an incised wound may be made with the edge
of a hard object, as a brick on the scalp. Often the hemorrhage
is very severe in an incised wound, in fact, it is the chief danger. Pro-
viding the wound is properly cleansed and good apposition secured,
healing takes place by first intention. There is nothing special in the
treatment of this form of wound.

Contused" Wound. — A contused wound is one in which the wound
area and edges are severely bruised and injured. It is made by
objects which distribute the wounding force over a considerable area.
It is usually attended by an extravasation of blood within the tissues.
External hemorrhage is slight, the reason being that the mash-
ing of an artery renders the conditions for coagulation of the blood
more favorable, hence nature arrests the hemorrhage more quickly.
The dangers of this wound are sloughing of the tissues, together with
infection. The bruising of the tissues may so devitalize them that it
renders infection easy. Under all circumstances, if the skin is not
broken, the wound should be handled with the greatest care, so that
the skin may not be broken. Any parts of the skin which may have
become more or less detached should always be preserved. Contused
wounds require more careful measures than incised wounds because of
the devitalization of the tissues as the result of the injury.

Lacerated Wound. — A lacerated wound is one which is torn. Lacer-
ated wounds are in many respects more harmful than others.
Certain of the tissues will be torn and perhaps killed, while others will

138 KINDS OF WOUNDS.

have become so devitalized as to be unable to resist the onset of the
invading bacteria. Furthermore, lacerated wounds contain many crev-
ices and nooks in which septic material may lodge, so that the proba-
bilities are the wound will not be thoroughly cleansed. Apposition can
not be so readily obtained, therefore scar formation is common. The
wounds will frequently heal by second intention. The primary hem-
orrhage is not so great and, as a rule, it should be encouraged.
The clangers in lacerated wounds are infection and deformity from scar
formation. The edges of the wound should be closed and drainage
provided for. Sutures can not be applied as closely as in an incised
wound.

Punctured Wound. — A puneturecLwound is one made by a long sharp
instrument. The margins of the wound are not contused. The depth
of the wound is much greater than its breadth. The chief dangers of
these wounds are hemorrhage and infection. Puncture of the viscera
or large vessels is liable to be fatal. Suppuration is common in
punctured wounds and very often leads to general sepsis. The wound
heals on the surface and the infected secretions being retained, pus is
formed. Punctured wounds in the body-cavity (thoracic and abdominal)
are generally fatal. As a rule these wounds should be caused to unite
by second intention. If the wound gives evidence of sepsis, it should
be thoroughly cleansed with an antiseptic solution and a piece of gauze
introduced to the bottom. Where it is made with a septic instrument, it
is advisable to introduce a drainage tube to the bottom of the wound,
and each day as the wound is dressed, the drainage tube may be drawn
out a half inch or more, until it is finally removed, allowing the wound
to heal from the bottom.

PoisonedWound. — A poisoned wound is one in which some poisonous
product is introduced. These poisonous products may be classified as
bacteria, bacterial toxins, and chemical poisons, such as are.
present in the bite of snakes, sting of bees, etc. Wounds
containing bacteria are called septic and infective. A sep-
tic wound should be washed with peroxid of hydrogen, provid-
ing the opening from the wound. is sufficiently large, and
then washed with a solution of bichloride of mercury (1:1000). If
infection is arrested, the wound should be kept at rest and the most
rigid cleanliness maintained. In post-mortem or dissection wounds we
have an example of poisoned wounds. The result will largely depend
upon the treatment, the amount of poison introduced, and the condi-
tion of the health of the person sustaining the injury. x\s soon as the
wound is infected, it should be washed and treated with suction. Every
effort should be made to have the wound bleed freely. Afterward, the
wound may be cauterized with pure carbolic acid or strong acetic acid.
The hands may then be cleansed with a strong solution of bichloride of
mercury. There is, perhaps, the most danger in holding a post-mortem
on patients who have died of typhoid fever, septicemia, pyemia, peri-
tonitis, erysipelas, etc. The changes which take place following

POISONED WOUNDS. 139

infection are, a pustule may be formed and evidences of lymphangitis
and phlebitis. Antiseptic lotions should be applied to the wound at
once. If the wound is located in the upper extremity, the axillary
glands will enlarge and may suppurate. As soon as there is evidence of
suppuration these should be removed. Where the infection is rapid and
severe, and nature shows an effort at limiting it, an amputation should
be performed. The prognosis, in these wounds, is not favorable when
one can not prevent general infection. Where severe constitutional
symptoms set in, death usually occurs in from ten days to two weeks,
or if recovery takes place, it is only after a long, tedious illness. The
nature of the inflammation is that of a cellulitis or a condi-
tion resembling cellulo-cutaneons erysipelas. As soon as infection is
evident at the wound, incisions may be made in the tissues about,
bleeding encouraged, and the wound thoroughly cleansed with a strong
corrosive sublimate solution (1:500).

Snake-Bite. — The venom of certain reptiles introduces into the cir-
culation, through the wound, substances which may produce alarmingly
fatal results. These poisons, in some cases, are extremely rapid in their
action, depending upon whether the poison is introduced into the circu-
lation or whether it reaches the circulatory system through the con-
nective tissues and the lymphatics. Snake-bite may be likened to a
hypodermic injection of a chemical poison. The poison acts directly
upon the muscular and connective tissues, and when it enters into the
circulation, it affects the nervous tissues generally. Many of the reptiles
reputed to be poisonous, have no special poison. On the other hand,
bites of animals, such as ratsj or even the bite of a person, may
at times be poisonous, depending upon the materials carried into the
tissues by the teeth. The poisonous snakes in this country are the
rattlesnake (of which there are*perhaps eighteen different species), the
water moccasin, copperhead, and, perhaps, the viper, although the ordi-
nary spreading viper or puffing adder is believed to be harmless. There
are also said to be some poisonous lizards. The exact nature of the
poison is not definitely known. It seems to be a collection of compounds
containing peptones, globulins, and, perhaps, toxic alkaloids, which act
like ferments, inducing wide-spread chemical reactions. The effect
of the poison upon the body varies according to the dose and according
to the animal from which the poison was extracted. The poisons of
the various reptiles differ not only in their chemistry, but in their
toxicity. The poison in almost all seems to have a paralyzing effect
upon the wall of the artery, while it brings about disorganization of
the blood. Most of the poisons apparently have an affinity for the
nervous tissues, uniformly bringing about paralytic changes. The
poison of the serpent is introduced by means of a hollow fang, and is
produced by a special gland. The duct of the gland leads to the hollow
tooth, and in the working of the jaws, the poison is compressed out of
the gland through the hollow tooth, and in this manner introduced into

140 POISONED WOUNDS.

the tissues. If the poison-bag and the fangs are removed, the snake will
be harmless.

The Symptoms of poisoning are as follows : The pain is excruciating,
coming on very rapidly after the bite. The part of the limb swells rap-
idly and becomes mottled because of the effect of the poison upon the
blood. It is not unusual that the swelling of the member is
enormous. Consciousness is more or less affected. This varies in degree
from slight lethargy and stupor, to complete unconsciousness. The
symptoms are those of profound shock, which may be attended with
delirium. Death may come on within an hour or it may be delayed
several hours. Where death does not occur during the first twenty-
four to forty-eight hours, gangrene and sepsis frequently arise.

The Treatment for snake-bite is to at once tie a tight band about
the member, above the wound. Several of these bands should be placed
around so as to restrict the return circulation. The wound should be
treated with suction, either by the person himself, when possible, or by
some friend or relative who is not afraid to take the risk. Care should
be taken that the person performing this suction has no wounds on the
lips or mouth, as they likewise may become poisoned. A crucial incision
should be made at the bite and hemorrhage encouraged. As soon as
the wound is thoroughly sucked, it should be cauterized. Hunters fre-
quently cover the bite with powder, which, upon being ignited, chars the
skin. A hot iron may be used for a cautery or pure carbolic acid may
be applied. A strong solution of permanganate of potassium is excel-
lent, inasmuch as it seems to have the property of destroying the
poison. A two per cent, solution is sometimes injected into the tissues
about the wound. The wound and member should be kept soaked in
alcohol. It is said to be more efficient if the alcohol contains one-third
of camphor. Where a surgeon is at hand, amputation of the member is
advised if the bite of the reptile is very poisonous. Strong ammonia-
water applied to the wound seems to be an excellent method of destroy-
ing the poisons.

Bites and Stings of Insects and Certain Animals. — There are certain
lizards whose bites are said to be poisonous. These bites should be
treated in the same manner as a snake-bite. The bites of certain
spiders are productive of severe inflammation, great prostration, and,
in some cases, death. These spider-bites should be treated similarly to
snake-bites. As soon as the bite is made, suction should at once be
applied. If this can not be done, enlarge the wound and encourage
bleeding. Tie a fillet around the member, if it is possible, and cauterize
the wound with strong carbolic acid or strong ammonia and use alcohol
as a local application. The bite of the centipede is not so fatal as is
popularly believed. The effects are, generally, only local. The bite of
the scorpion produces much severer symptoms. Very often there is
great prostration, vomiting, delirium, with local swelling rapidly extend-
ing, and severe burning pain. There may be vertigo or severe head-

G UNSHO T WOIJNDS. 141

ache, together with great sweating and diarrhea. Bee-stings, if multi-
ple, may cause severe symptoms or even death. A bee-sting is in the
nature of a poisoned wound, being made by two little lancets which
are pushed out and the poison is squeezed in between them and then
inserted into the wound. When the wound is over the cellular tissues
of the body, swelling is sometimes very rapid and great. Sometimes
the pain is extremely excruciating. Where there are several stings,
constitutional symptoms, such as delirium, vomiting, diarrhea, and con-
siderable shock, may be manifest. Where death follows these severe
symptoms, it is usually from heart failure. Stings in the mouth may,
without causing these symptoms, bring about edema of the glottis
which may be fatal. Such stings should be looked upon with fear.

Treatment. — Wash the part with a strong solution of soda or salt
and apply ammonia-water. Ice applied is very grateful, as it lessens the
inflammation.

Gunshot Wound. — A gunshot wound is peculiar, in that the open-
ing is very often small, surrounded by a contused area, and the tract
of the bullet very often long, giving an example of a deep wound with
a small opening. Drainage is difficult to obtain. The wounds arising
in military and civil practice vary greatly, inasmuch as projectiles vary
and are discharged in one case with much more force than in the other.
Bullets may sometimes cause fracture of a long bone or they may cut
off a nerve to a part or may button-hole a large artery. They very
often glance around these structures unless hurled with terrific force.

Injury to the Soft Parts. — The course of the bullet in the tissues
varies according to the velocity and nature of the bullet. The bul-
lets may be deflected by fascia, bones, and ligaments. If the skin be
struck at the proper angle, and the bullet be '•spent", it will be only
grazed, or merely a streak left. The opening made by the bullet is
very often, unless fired at close range, accompanied by laceration of the
soft parts. The exit of the bail is in some cases marked by much more
extensive laceration than in the entrance. Especially is this true of the
soft-nosed bullets. There the core projects out and forms a mushroom-
like mass and is terrifically destructive. Ordinary pistol-balls are not
nearly so destructive. They may bury themselves in the ends of the
long bones, but rarely pass entirely through the bone, while the injury
to the bone is generally not so great. In civil practice the injury to the
joints is usually not very extensive. The chief element of clanger seems
to be sepsis. The results of gunshot wounds may be summarized as (1)
hemorrhage. Hemorrhage nnw be very severe, but it is usually speed-
ily arrested by natural processes. Gunshot wounds, even of the internal
jugular, may not prove fatal. Especially is this true' if there is con-
tusion. The contusion causes the middle and inner coats to curl up
and plug the ends of the arteries and veins. Secondary hemorrhage
is not uncommon, and is usually due to sepsis. Where the wound is
aseptic, secondary hemorrhage is not likely to occur.

142 GUNSHOT WOUNDS.

(2) Pain. The pain is variable, depending upon whether a large
nerve is injured. \n ease the injury is within the explosive action of
the ball, the part may be anesthetized more or less because of the con-
tusion. It may be that the anesthesia due to the contusion is great
and, if occurring during mental excitement, a person may not know that
he is struck. In such cases infection is more likely. Where fracture
is caused by the bullet, the pain is very often excruciating. Shock
attending bullet injuries varies greatly. A small wound of the extrem-
ity, although trivial in nature, may be accompanied by general shock.
Perhaps the effect is largely due to mental emotion. On the other hand,
penetrating wounds of the abdomen in many cases occasion but com-
paratively little disturbance. Often pistol wounds of the brain may
cause less disturbance than would be expected.

Treatment. — In civil practice, the treatment of gunshot wounds will
differ from that of military practice. Where the patient can
have the advantage of a hospital and of a clean operating
room, in fact, where asepsis can be secured, it may be the
best policy to uniformly investigate these wounds; but it must
be kept in mind that the presence of the bullet and the little
material which the bullet may have carried into the wound,
are in no wise as serious a menace as will be the septic materials
introduced by unclean hands and instruments, in the effort to
locate the ball. Too many physicians, in treating the bullet wound, seem
to feel that they must get the bullet regardless of the effect of their
operations or methods upon the life of the individual. Miscellaneous
probing of bullet wounds is extremely bad. Of all the objects introduced
into the wound, a clean finger is the least harmful. Where the wound
is too small to permit of the introduction of the finger, and none of
the large cavities of the body has been entered or viscera perforated,
the best treatment seems to be to cleanse the surface thoroughly by
means of antiseptic solutions, encourage bleeding and dress the wound
with antiseptic dressings and await developments. If the bullet causes
subsequent trouble it may be removed by operation. The truth of the
maxim, that "when a bullet has ceased to move it has ceased to do
harm," has but few exceptions. These are perhaps where the bullet may
ulcerate into a large cavity, or when present in the brain, by gravity may
cause pressure symptoms, but generally when located within the tis-
sues, unless especially septic, it will not occasion any very considerable
trouble. The probe used to investigate the wound should be metal
and as large as can be conveniently introduced into the wound. It
should be blunt-pointed so as not to injure the tissues in any way.
Nelaton's porcelain- pointed probe is valuable in some cases in locating
a bullet, inasmuch as the lead will leave a mark on the point. Grird-
ner's telephonic probe is, perhaps, the best of the various electrical
devices, but its virtues are questionable. Where the bullet is super-
ficial it should be removed, but if deep and not readily reached and it
is believed to be in a part of the body where it will not occasion much

BUA'NS AND SCALDS. 143

harm, the surface of the body should be cleansed and the wound treated
in an antiseptic manner and allowed to heal of itself. If it is believed
that a patch of the clothing is carried in with the bullet, an
effort should be made to remove such material. Where it is possible
to use it, the x-rays sheald be utilized in locating the bullet. A bullet
forceps may be used in the extraction of the bullet, or the wound may
be enlarged, when it may be seized with forceps or a scoop, or a Volk-
mann spoon may be of advantage.

Other Foreign Bodies in Wounds. — Bits of glass, needles, and other
objects may be blown, hurled or driven into the tissues and their pres-
ence occasion great harm. Glass can be- located by the x-ray, as can
most of the other objects. Universally these foreign bodies should be
removed. A needle is perhaps the worst of these penetrating foreign
bodies. Especially is this true where the needle enters the palm of
the hand or sole of the foot. The needle should be removed at once.
Muscular contractions will often cause the needle to follow along the
tendon-sheaths or planes of fascia or along through the muscles, so that
each contraction drives the needle farther distant. In removing a
needle it should first be accurately located and a sufficiently large inci-
sion made, so that it can be successfully reached. Under no circum-
stances should a little wound be made and the tissues sep-
arated in an attempt to reach the needle, as the efforts of the surgeon
may push the foreign body further in. After the needle is removed, the
wound may be given ordinary treatment.

Contusions. — Contusions, not attended by an open wound, may, in
some cases, cause considerable damage to the soft-parts and may
require special attention. Where a contusion is small it is commonly
called a bruise. If this bruise breaks blood-vessels beneath the skin,
subcutaneous hemorrhage will occur among the tissues, causing the
surface to become black, as in the case of a blacked eye. These ecchy-
moses may be extensive in some cases. Coagulation of the blood will
follow and afterwards the coagula will break down as the serum and
other elements are removed. The surface changes into a blue-black
or purplish or reddish-black color, while later the skin may assume a
greenish tinge. This extravasation of blood may sometimes extend,
where it occurs at the shoulder, even to the tips of the fingers, follow-
ing the fascia. Muscular action is responsible for this. In muscle-
bruises, very often the extravasation of the blood is quite severe. These
extensive contusions are best treated by rest and a suitably applied
woolen bandage, and later, manipulation to assist in breaking up the
clot and securing absorption of the fluids. Even though a large tumor
be formed by the extravasation of blood, on no account should it be
opened, for if once opened and air admitted an abscess will result. If
allowed to remain, nature will take care of the effused material and the
part will finally return to its normal condition.

Burns and Scalds. — Burns and scalds are merely wounds from ther-
mal causes, but deserve special mention because of the difference in

144 BURNS AND SCALDS.

the symptoms and treatment. Burns differ from scalds in that they
are more destructive. If a barn has been produced by boiling
oil or by molten metal, the destruction of the tissues is sometimes very
great. The effects of burns are both local and constitutional. These
depend sometimes upon the severity of the burn, that is, whether it is
attended by extensive destruction of the tissues in any part, or if the
burn is slight and extends over a large area. Burns of the trunk are
more serious than burns of the extremities. Burns and scalds have
been classified by Dupuytren in the following manner:

1. A burn of the first degree consists of an erythema of the surface
which is not attended by any destruction of tissues and leaves no scar.
This burn is usually not serious unless it affects a large area of the
body, when it may be fatal.

2. A burn of the second degree is where the cuticle is raised from
the cutis and blisters result. Should the blisters burst and the cuticle
be removed, it leaves a red and inflamed true skin. This burn is more
painful and more serious. If it affects a considerable part of the body,
it may seriously interfere with the functions of the skin. These blisters
may become infected and later, ulceration take place.

3. A burn of the third degree is where the cuticle is entirely
destroyed and also part of the true skin is affected. Inasmuch as the
true skin contains the tips of the nerves and capillary tufts, these are
affected. The terminal nerves may be injured or even destroyed, and the
congestion and inflammation which follow, occasion severe pain, and
sometimes, destruction of the tissues.

4. In burns of the fourth degree the cuticle and true skin are
entirely destro}^ed, with perhaps some little of the subcutaneous tissues.

5. In burns of the fifth degree, muscles, connective tissues, and
fascia, together with the skin and subcutaneous tissues, are destroyed.

6. In burns of the sixth degree an entire member is destroyed.
Slight burns involving a limited area, and which do not extendbeyond

the skin, while they occasion considerable pain, are not serious. They
may be immersed in cold water, which will relieve the nervous chill
or rigors and the excruciating pain, or some oil, as sweet oil, may be
applied so as to protect the surface from the air. Where these burns,
simply of the surface, affect a large area, the shock to the nervous sys-
tem may be so great as to bring about collapse and death. In burns
of the first degree, where only the cuticle is involved, if a fatal result
should follow, it will occur within thirty-six hours. Where the effect
upon the nervous system is great, it calls for immediate treatment to
prevent this fatal termination. Within twenty-fonr hours the patient
enters into the stage of reaction: and subsequent trouble, providing
sepsis does not occur, will not be serious unless ulceration should follow
in the duodenum, which complication occurs in some burns. This
ulceration may extend through the wall of the duodenum into the
peritoneum, causing peritonitis. There are other burns of the mucous

BURNS AND SCALDS. 145

membrane, as scalding of the respiratory tract from inhaling steam.
In some cases this will set np edema of the glottis and, in other cases,
bronchitis or pneumonia. These may he fatal.

The first symptoms of burns of any considerable extent are those
of shock. Later there are symptoms of reaction and inflammation,
while lastly there are those of sepis because of infection.

Treatment of Burns. — If the burn is extensive, the clothing should
be removed with great care. The burned area should be cleansed with
a warm, normal salt solution. It may be thoroughly dusted with flour
in emergencies. White lead, ready mixed for house painting, has been
extensively used. The part may be coated over with the lead mixture.
Linseed oil and lime water, equal parts, called carron oil, is more gen-
erally used than any other application. x\bsorbent cotton saturated
with this mixture is applied after cleansing the surface. It is a filthy
application and results in much pus formation. Surgeon's lint clipped
in a two per cent, solution of carbolic acid in olive oil is an excellent
preparation.

Where the burn is small, an ointment of benzoated oxid of zinc may
be used. Picric acid has a great reputation in burns. It is used in the
strength of one per cent, in water. Lint saturated with the solution,
is applied with a thick layer of absorbent cotton over it. The dressing
is reapplied in three or four days and not again until recovery. Later
if there is sloughing and pus formation, the sore must be cleansed daily
with a mercurial solution (1:5000) and then dusted with a powder
composed of three parts of boric acid to one part of salicylic acid.
Healing may be hastened and scar formation lessened by skin grafting.
Exuberant granulations will require cauterizing with nitrate of silver.
Later the cicatricial contractions must be overcome by manipulation.

PART II.

DISEASES AND INJURIES OF SPECIAL TISSUES.

Diseases and Injuries of the Blood Vascular System, Heart and

Pericardium.

There are cases of persisting pericardial effusion which may require
removal. Paracentesis of the pericardial sac may be performed with
an ordinary aspirating apparatus. The surface should be thoroughly
cleansed before the introduction of the needle. The fluid may then
be pumped out and the opening dressed antiseptically. An aspirating
needle should be inserted an inch and a half from the left border of
the sternum in the fourth or fifth intercostal space. This is done to
avoid the internal mammary artery. Wounds of the heart and great
vessels are so quickly fatal that it is hardly necessary to dis-
cuss the injury. Injuries to the pericardium, whether they are by knife
or bullet, are attended by hemorrhage into the pericardial
sac and this blood, clotting around the heart, so interferes with its
action, that death occurs. Very often, where this hemorrhage is not
great enough to produce death, infection and suppurative pericarditis,
which is generally fatal, will follow. Little can be done in the way of
operative treatment. The most essential thing is to keep the person
quiet, with his head low. The wound should be cleansed, but during
the stage of shock, no operative means should be attempted. If the
patient recovers from the shock, the wound in the pericardium may
be closed.

DISEASES OF THE AKTEBJES.

Arteries are subject to acute or chronic inflammation, the result
of injur}-, sepsis, or constitutional disorders.

Acute Arteritis is extremely rare, but is said to be occasionally met
with in septic and infective inflammations, where infective emboli
lodge in the artery and create ulcerative inflammation. Of course,
plastic arteritis occurs in the healing of an artery in an open wound,
but the changes attending infection of the artery from infective emboli
are different in that they are destructive.

Chronic Arteritis is frequently spoken of as atheroma, endarteritis,
or sclero-endarteritis. The tunica intima and media only, are involved.
It is the most common disease of the artery and is present in many
people over forty years of age. It is most common in the large arteries,
especially those of the lower extremities. It is the result of increased
intra-arterial pressure, the arteries becoming overtaxed. It is very

146

ARTERITIS. 147

much more common in men than in women. Excitement, alcoholism,
syphilis, Bright's disease, plethora, gout, together with lesions affect-
ing the integrity of the artery-wall, may be set down as among
the causes of the disease.

The pathology of the disease is that of a chronic inflammation. The
middle coat and the tunica intima become infiltrated with round cells.
These may break down and ulcerate (ulcerative endarteritis), or the
inflamed part may undergo calcification (pipe-stem artery), or the
round cells may form fibrous tissue. Soft inflamed areas may fuse
together, making a hard artery (sclerosis). Sclerosis of the arteries
may become general. The artery feels like a hard, fibrous cord, and at
certain places, the artery-wall may become thickened and calcareous,
when it will feel knotty or beaded. In some cases, the degeneration is
so great that the artery can not be tied and, being grasped with an
artery forceps, it will be found brittle and will break off. The elastic
tissue in the tunica intima is most affected, likewise the large arteries
which are made up largely of elastic tissues, are affected to a greater
extent than the medium sized or smaller arteries. But the inflammation
nearly always extends into the tunica media and impairs the integrity
of the muscular coat, so that the arteries are unable to dilate to answer
the call of the tissues for nutrition.

The degenerative changes which come on later are (1) fatty, (2)
calcareous, and (3) fibrous. The effect of this condition in the arteries
is that the limb below is cold, congested, and often ill-nourished.
The arterv becomes tortuous. Aneurysm frequently results because of
a weakening of the artery. This occurs when the tissues of the tunica
intima break down and ulcerate. Thrombosis may be caused by the
debris from the ulcer within the artery, being carried to other parts of
the body, also, coagulation of blood at this roughened area may occur.
This clot may be detached and carried elsewhere and result in the plug-
ging up of an artery (See Thrombosis and Embolism), or rupture of the
artery sometimes occurs because of fatty or calcareous changes, which
so weaken the artery that muscular effort or excitement results
in apoplexy. Gangrene is not an infrequent result of this endarteritis.
(See Gangrene).

The symptoms of chronic endarteritis are: —

1. Evidences of degeneration generally, arcus senilis, the person
is prematurely aged.

2. History of syphilis, tuberculosis, alcoholism, or Bright's dis-
ease, etc.

3. The presence of atheroma of the superficial vessels.

4. Lesions affecting the integrity of the vessel walls.
Obliterative endarteritis sometimes follows in small arteries where

thrombosis occurs, or if the inflammation is more violent, it results
in the obliteration of the artery and occasions great pain and suffering.
It is fortunate that the disease is rare. Chronic endarteritis may con-

148 ANEURYSM.

tinue for years, and if a person leads a quiet life, he may never know
that his arterial system is fragile and may at any time rupture, caus-
ing his death. Degenerative changes will continue until the larger
arteries are affected, when in excitement, or because of the weakened
artery, at a certain point it dilates and an aneurysm results.

ANEURYSM.

An aneurysm is an abnormal dilatation of the living artery,
or a pulsating tumor filled with blood, connected either directly
or indirectly with an artery. Aneurysms are either spontaneous or
traumatic. The spontaneous aneurysms result from disease, while a
traumatic aneurysm results from an injury of the artery. Spontaneous
aneurysms are the result of obstructions to the circulation, endarteritis,
atheroma, arterio-sclerosis, or any diseased condition which makes the
artery weaker at one point than another.

Aneurysms are further classified into false and true. A false
aneurysm is one having no coat of the artery intact. A true aneurysm
is one which has one or more coats of the artery intact.

Varieties. — Besides (1) false, (2) true, (3) spontaneous, and (4)
traumatic aneurysm, there are (5) fusiform, in which there is a long,
spindle-shaped dilatation of the artery, (6) sacculated, where it is in the
shape of a saccular dilatation of the artery, (7) circumscribed, where it is
outlined by a wall of resisting tissue, (8) diffuse, where it has not such
a definite outline, (9) artero-venous, where the aneurysm occurs in con-
nection with a vein (See traumatic aneurysm), (10) cirsoid, where a num-
ber of arteries are dilated and pulsatile, and (11) cylindrical, where
the dilated artery has the same dimensions for some distance.

Causes. — The causes of aneurysm are, predisposing and exciting.

The predisposing causes are male sex, occupation, excitement, and
the presence of certain diseases, as alcoholism, Bright'" s disease, syphilis,
etc. It happens more frequently in laborers, inasmuch as during violent
muscular contraction, which to some extent will obstruct the circula-
tion, or during the time when the heart's action is increased because
of stimulants, the artery may give way at a weak point. Diseases of
the arteries, as atheroma and the formation of emboli, also operate as
predisposing causes.

The exciting causes are obstructions to the circulation, mechanical
violence or injury to the artery, abnormal heart action, muscular con-
tractions, blows, strains, etc.

Formation. — Aneurysms are formed in several different ways.
When due to atheroma or to an ulcerative endarteritis, the middle and
inner coats usually give way. These diseases do not affect the external
coat, therefore, it only, forms a covering for the artery. The dilatation
may be medium or may be quite great. A'a the artery dilates, inflamma-
tory tissues form which prevent the sa . rupturing. Sometimes it may

ANEURYSM. 149

be the result of a weakened condition of the artery or era-
holism of the vasa vasormn and there may he a general dilatation of
a piece of the artery when none of the coats is absent. The vessel
may rupture at the point of ulceration in the artery, and the flow of
blood into the tissues be slow and may excite inflammation and the for-
mation of fibrous tissue, limiting the diffusion of the blood by a distinct
sac formed of this inflammatory tissue. In other cases, the blood may
extravasate in the middle coat separating the internal and a part of the
middle coat from the external coat, with dilatation of the external
coat following. This form of aneurysm is called dissecting or consecu-
tive aneurysm. It may happen that from ulceration or injury, the
external coat may be weakened so that the middle or internal coat is
pushed out through the opening in the external coat, this forming
the wall of the sacculated aneurysm. This is rare. In structure the sac
may be made up of: —

1. All the coats of the artery.

2. It may be the condensed tissues external to the artery, none of
the coats being intact over the tumor.

3. The walls of the sac may consist of the external coat only.

4. The walls of the sac may be the external and part of the middle
coat (rare). In other cases, still more rare, the inner wall of the sac may
consist of the middle coat, as in dissecting aneurysm.

Contents. — The contents of the aneurysm consists more or
less of clot. Coagulation and organization of the blood within
the aneurysm, seems to be nature's method of obtaining a cure. The
blood flows less swiftly inside the sac, the inner surface of the aneurysm
is rough and the conditions are favorable to coagulation. The
clot in the aneurysm may be white, or it may be partly white and partly
red, or it may be entirely red when it forms quickly. It depends upon
how rapidly the clot forms and under what conditions.

Results. — Spontaneous recovery in an aneurysm occurs because of
the deposit of fibrin in the aneurj^smal sac, layer after layer being
formed until, after a time, the entire sac is filled up. This may become
orpjinized, forming a hard fibrous mass. The artery beyond the
aneurysm may be pervious because of collateral circulation having
been established, or it may become obliterated, the tissues to which
this artery was originally distributed, being nourished from other
channels, when a fibrous cord would be the remains of the artery. In
other cases, a hard, nodular mass the size of the aneurysm, somewhat
shrunken, will remain. The artery above and below being plugged up,
an abscess forms and burrows towards the surface and ruptures, the
disintegrated blood being discharged, and finally, the wound healing,
leaves a mass of fibrous tissue which is the result of the inflammatory
process. The arrest of the circulation in the aneurysmal sac is brought
about by pressure upon the artery between the aneurysm and the heart,
or pressure upon the artery beyond the aneurysm. In other cases, the cir-

150 ANEURYSM.

culation in the artery is slowed and coagulation may set in. If it sets up,
it may continue until the coagula fill up the entire aneurysmal sac.
The clots which are formed are classified by some writers as active and
passive, but whether some of the clots may be more productive of
favorable reults than others is, perhaps, not known. Coagulation of
the blood in the sac seems to be the end sought for in almost all the
operations for aneurysm.

Eupture of the Sac may lead to very disastrous results in the case
of aneurysm. Eupture within a joint or the tissues of a member,
followed by hemorrhage, will result in the obstruction of the circula-
tion to the limb below and gangrene will occur. Eupture of a popliteal
aneurysm within the knee-joint, is an indication for amputation. In
aneurysm of the superficial femoral artery which ruptures within the
tissues, the blood extravasating along the fascia and muscle-planes will
sooner or later obstruct the circulation to the leg, and gangrene will
result. Eupture of an aneurysm within the chest, or on a mucous mem-
brane, or in the peritoneal cavity, or externally, will result fatally.

Sloughing during suppuration, folloAving inflammation in the
aneurysmal sac, may result in serious secondary hemorrhage.

Destructive changes may follow the pressure of the aneurysm upon
other tissues. It is a curious fact that the pressure of an aneurysm
upon hard bone will result in the wearing away, erosion, and absorp-
tion of the bone. Elastic tissues are less aifected by the pressure of
the aneurysm than any other. It may result in the paralysis of nerves
and the obstruction of veins. Aneurysm of the arch of the aorta may
caose absorption and erosion of the sternum and it may appear beneath
the skin on the front of the chest. Aneurysm of the descending por-
tion of the arch of the aorta will cause erosion of the bodies of the
vertebrae and finally, paralysis, due to pressure upon the nerves. In
such cases the intervertebral discs are less affected than the bone,
because of the fact that cartilagenous tissues do not yield to the pres-
sure of the aneurysm as does bone. It may press upon the artery, of
which the aneurysm is itself a part, causing obstruction to the circula-
tion through the aneurysm, or at least an interference with it, to that
extent that coagulation of the blood may occur within the aneurysm,
a spontaneous cure resulting. One of the serious results of the pres-
sure of the aneurysmal sac is pressure upon the accompanying veins of
the artery, thus obstructing the circulation.

Gangrene is one of the serious terminations of an aneurysm. It is
caused by pressure on the main artery, vein, or nerve of a member, or
by rupture of the aneurysm, thus interfering with the nutrition.

The effects upon the general health are various, depending largely
upon the local conditions. The presence of a diseased condition of the
artery affects the nutrition to the tissues generally, and the person is
found to be in a conditiou of bad health.

ANEURYSM. 151

Symptoms. — The symptoms of aneurysm are (1) pulsation. This
pulsation is synchronous with the heart-beat. Aneurysm may be mis-
taken for a tumor which lies immediately over the artery and which
raises up at each heart-beat because of the distension of the artery.
The aneurysm not only raises up, but enlarges in all directions, a point
which must be kept in mind. The pulsation of the tumor is arrested
by pressure on the artery between the aneurysm and the heart. The
pulsation in the tumor is markedly increased by pressure on the artery
beyond the tumor. After a little time, because of pressure on the
artery beyond the tumor, the pulsation in the aneurysm will disappear.

2. Pulse. The pulse be}7ond the aneurysm is very small, weak,
or even absent, while, on the proximal side of the aneurysm, the pulse
is equally as strong as it is in corresponding parts of the body.

3. Bruit. Upon auscultation, an abnormal sound may be heard
over the tumor. It is a swishing sound produced by the liquid rushing
from a smaller into a larger space. This is synchronous with the heart-
beat.

4. Circulatory disturbances are often very marked. In consequence
of pressure upon the venae comites of the artery, there is edema of
the part below or beyond the tumor, and there may be even a varicosity
of the superficial veins in some cases. The pulse beyond the tumor is
less, and if the limb is raised, it may be absent. Upon elevating the limb
in which the aneurysm is located, the tumor will be found less tense
and the circulation to the limb almost arrested, whereas, on lowering
the limb, the tumor becomes more turgid and the return circulation of
the limb is affected.. Sphygmographic tracings show that the dicrotic
wave has disappeared and that the pulse beyond the tumor is some-
what delayed.

5. Changes in arteries and other degenerative changes. The pres-
ence of arcus senilis and degenerative changes in the arteries
generally (atheroma), and a history of the case, of diabetes, syphilis,
Bright's disease, etc., will be sufficient, when taken with the symptoms
present, to make a diagnosis of aneurysm.

Internal Aneurysm. — Internal aneurysm is more difficult to recog-
nise. There is no tumor which can be palpated and the signs are often
obscure. It may be mistaken for valvular heart disease. Pressure upon
the thoracic viscera, producing dyspnea, violent cough, obstruction to
the circulation upon the side of the neck and head, or dilatation of the
pupil, or evidence of pressure upon the large nerves of the neck, will
be important evidences of thoracic aneurysm. \Yhen taken into con-
sideration with the interference with the general circulation, or the
interference in the circulation upon one side of the body and not the
other, together with the abnormal sounds of the heart upon ausculta-
tion, the diagnosis of thoracic aneurysm may be made. Aneurysm of
che abdominal aorta is more easily diagnosed, inasmuch as the tumor is
more readily accessible. The evidences of rupture of an aneurysm

152

ANEURYSM.
Fig. 27.

^SS^&^l^l^ - the aort,
of Osteopath. branc^s.-From laboratory Q • %£*"«££££«**.

ANEURYSM. 153

into one of the serous cavities of the body, are those of internal
hemorrhage with rapid collapse. Where the rupture takes place
within the tissues of a limb, there will he rapid distension of the tissues,
together with an obstruction to the return circulation. The pressure
in the tissues occasions great pain. Oftentimes there will he, from
escape of blood in the tissues, a loss of the pulse beyond and a disap-
pearance of the bruit. The rapid and intense swelling ends in edema
and coldness below. Where the loss of blood in the tissues is not suffi-
ciently great to immediately bring on death, gangrene in the member
below will follow. Where the rupture of the aneurysm is in one of the
large cavities, death results quickly from hemorrhage. The rupture
of a carotid aneurysm may result in almost instant death, whether in
the tissues of the neck or in the pharynx. Eupture of an aneurysm
externally, is so rare, and the symptoms so evident, that it merits no
description. Sometimes an aneurysm is spontaneously cured. Evidence
of spontaneous cure will be the increased hardness of the tumor and
the fact that it diminishes in size. There is loss of pulsation and the
disappearance of the bruit. Sometimes, where the aneurysm involves
a nerve by the formation of fibrous tissue, because of cicatricial
contraction occasioned by the plugging of the aneurysm, great pain
will be experienced.

Diagnosis. — The diagnosis of aneurysm is sometimes difficult. It
may be mistaken, under certain circumstances, for (1) tumor over
the artery, (2) an abscess about an artery, (3) enlarged thyroid, and
(4) valvular heart disease. The diagnosis between aneurysm and unior
can be made upon careful examination. The tumor, while it raises up
with each pulse beat, is not expansile. There is no bruit heard over
the tumor. Very frequently the tumor may be raised up away from
the artery. The history of the case and the absence of atheroma will
be sufficient to form the diagnosis. Furthermore, the pulse beyond the
tumor is not seriously affected.

In abscess, the inflammation is more severe. Traumatic aneurysm,
the result of injury of one or more coats of the artery where inflamma-
tion is excited, may be puzzling. As for instance, a lady
in ironing, while turning around to face She table upon which an iron-
ing board lay, struck the inside of her leg in Scarpa's triangle, against
the side of the table. She experienced some pain from the injury, but
gave it little thought and continued with her duties. Swelling fol-
lowed and within four or five days, an acute inflammation set up. There
was considerable interference with the return circulation. Upon exam-
ination it was found that the tumefaction, which had been diagnosed
as an abscess, was an aneurysm of the superficial femoral artery. The
inflammation was not severe enough for an abscess, and an abscess
would not have occasioned the interference with the return circula-
tion. The bruit heard over the tumor was distinct and upon operation
the diagnosis was confirmed. The aneurysm was removed and the case
recovered without untoward symptoms.

154 ANEURYSM.

Aneurysm of the common carotid artery and an enlarged thyroid
gland, are frequently confounded. In exophthalmic goitre, where the
exophthalmos is not very great and where there is a bruit or abnormal
sound over the gland, together with a cardiac murmur and tumefaction
in the neck, the case is often called aneurysm of the carotid artery. In
these cases the pulse beyond the tumor is found not to be affected. If
the case is inquired into carefully, this mistake need not be made. In
goitre there is tachycardia and Graves's sign is present, that
is, widening of the palpebral fissure. The pulse in the temporal arteries
on either side is alike. This would not be true of aneurysm. Further-
more, the enlarged thyroid gland will move with the larynx on degluti-
tion, the aneurysm will not. In cases where there is no pulsation in
the aneurysm, the diagnosis is extremely difficult. At all events, where
the diagnosis is in cloubt, an opinion should be withheld until every
means of obtaining knowledge of the case is exhausted.

The diagnosis of aortic aneurysm will ofttimes depend upon one's
knowledge of, and skill in, physical diagnosis.

Treatment. — The treatment of aneurysm is (A) Osteopathic, (B)
Operative, and (C) Dietetic and General.

Osteopathic Treatment has for its purpose, to decrease the intra-
arterial tension and to favor coagulation of the blood within the sac.
Should such coagulation take place, the tumor will become organized
and harmless. In brief, it simulates nature's method of spontaneous
cure. When the obliteration of the aneurysm is not possible, as where
the aorta is involved, the sac wall may be strengthened by removing
lesions affecting the trophic and vasomotor nerves distributed to the
arterial wall. For a full discussion of the osteopathic methods of
treatment, lesions, etc, a text book on the Practice of Osteopathy should
be consulted.

The operative treatment consists of (1) pressure. Pressure may be
administered in several ways:— (a) Digital pressure, which is made by
the thumbs, assisted by a shot-bag. Pressure is kept up by means of
intelligent assistants. Pressure is made on the proximal side of the
tumor "in order to lessen the circulation in the tumor, with .the hope that
coagulation of the blood will follow. Cases of good results from this
treatment are reported to have taken, place within a few hours. The
aneurysm having fdled up with a clot, the clot later becomes organized
and the aneurysm cured. This method is not practicable in certain
parts of the bod}', as in the neck, but it is practicable in the gluteal
region or in the femoral, popliteal, or tibial aneurysms. (b) Flexion.
Pressure by flexion may be made in cases of popliteal aneurysm, or a
hollow ball of rubber may be used in case of axillary or subclavian
aneurysm, the arm being held to the side, while pressure is exercised
directly upon the tumor, (c) Direct pressure by tourniquet. This
was formerly used quite extensively, the object being to excite inflam-
mation in the sac and adhesion of its walls or the formation of clot.

ANEURYSM. 155

This method is now rarely used, (d) Pressure by bandage is of ser-
vice and might be tried in aneurysms in the extremities. This con-
sists of applying snugly to the limb an Esmarch's elastic bandage, (in
case of the lower extremity, from the toes up to above the aneurysm.
The bandage must be loosely applied over the aneurysm and rather
tightly above it. This cuts oil' the blood supply to the aneurysm some-
what, making the flow of blood through it slower, rendering coagula-
tion more likely. This method is said to be quite successful. In all
these forms, the pressure should not be kept up continuously. In digital
pressure, the operator may press for a period of ten minutes, when the
assistant takes up the duty and keeps up pressure for the same length
of time. This may be kept up for four or five hours during the day,
on successive clays, and should be left off at night. Esmarch's bandage
may be applied so long as it can be borne by the patient, or so as not
to seriously interfere with the circulation to the limb, or so as not to
cause excruciating pain. It can be applied during the day time and
removed at night. This method, or the method of digital pressure,
may be used before operative means are begun.

(2) Ligature. Ligation of the artery is, perhaps, the best method
of treatment. It should be tried where the aneurysm is a menace,
especially after other methods have failed. Operation for ligature of
the artery varies according to the part of the body in which the
aneurysm is located. Of the methods in use, the following may
be mentioned as being of interest, if not the safest to follow:
(a) Hunter's method. This method consists in ligating.the artery at a
distance from the aneurysm. It was devised by the illustrious John
Hunter, recognizing the fact that the artery adjacent to the aneurysm,
is often diseased, and that ligation some distance above is safer.
If the operation is done within the healthy tissues, it does not entirely
interfere with the circulation to the part below. Pulsation does not
return in the tumor. Secondary hemorrhage is not so common. Col-
lateral branches finally distend and take up the function of the artery
below, the inflammation disappears, and the aneurysm becomes more
or less absorbed. Occasionally it is found that after Hunter's operation,
an abscess, or symptoms like those of an abscess, follow. Should
this happen, as soon as pus is evident, the abscess is opened and drained
and the cavity packed with gauze.

(b) Anel's method. x\nel's method was to ligate the artery imme-
diately above the aneurysm. This operation is no longer used except in
special locations. Furthermore, it has no advantage over the Hunterian
operation.

(c) Antyllus's method. The old operation of Antyllus is no longer
used, inasmuch as abscess or suppuration is likely to occur. This
method consists of ligation of the artery immediately above and below
the aneurysm. It is perhaps valuable for traumatic aneurysms, but is
not a good method for the treatment of a spontaneous aneurysm where

156

ANEURYSM.

there is disease of the artery. This method has given way to extirpa-
tion.

(d) Basdor's method. Basdor's method consists of ligation of the
artery beyond the aneurysm. This prevents blood going from the
aneurysm, but allows it to go in. It arrests pulsation in the tumor,
favors coagulation and the formation of a clot. Tbe clot, of course,
may become organized and the aneurysm disappear.

(e) Wardrop's operation. This consists in ligating the main branch

Fig. 28.

Method of Antyllus for treatment of aneurysm.

of the ■ artery beyond the aneurysm, in an effort to arrest the rapid-
ity of the circulation through the tumor. These operations are hardly
fidvisable.

(3) Excision. Of late years excision has grown into favor. The
objection to excision is that it is a prolonged and difficult operation,
•md that it is frequently necessary to remove the venae comites with
the aneurysm. Where this occurs it may so interfere with the return

Fig. 29.

Anel's method of ligaturing an aneurysm.

circulation through the limb that gangrene will follow. With im-
proved technic and a knowledge of the tissues in which the aneurysm
is located, together with a careful consideration of the condition of
the artery, it is perhaps the. safest operation. Should the patient be
feeble and aged, a prolonged operation should not be undertaken.
Then the .Hunterian operation is, perhaps, tbe best, or Wardrop's or
Basdor's operation may be undertaken. These operations are not so
difficult nor are they attended with such danger. But where the
patient is in good, physical condition, excision may be undertaken. The

ANEURYSM.

157

argument that the artery near the sac is diseased, is not of sufficient
weight to warrant going higher than the end of the aneurysmal sac,
since, if there is a condition of general atheroma, it will be at all points.
In an excision under approved surgical conditions where the ligatures
are absolutely sterile, suppuration will be less likely than by ligation
above and below the tumor.

(4) Galvano-puncture or Electrolysis and Injections are all now ob-
solete. They are attended with too much danger and should never,

Ftg. 30.

Basdor's method of operation.

under any circumstances, be undertaken. Xone of them has been
attended with sufficient success to warrant any such procedure. Irri-
tation of the inside of the sac by McEwen's method, is of no value.

(5) Manipulation is one of the operative methods which may be un-
dertaken in the treatment of aneurysm. It consists in manipulating
the aneurysm, with the idea that a piece of the clot may be dislodged
and plug up the mouth of the sac. This method is not unattended with
danger. In case of aneurysm of the common or external carotid artery,

Fig. 31.

Wardrop's method of operation.

a piece of clot may be dislodged; embolism of one of the cerebral
arteries results, producing hemiplegia. It may be undertaken in
an aneurysm of the lower extremity. Here it would not likely be
attended by any such serious results.

Dietetic and General Treatment.— Absolute physical and mental rest
should be enjoined. The person should be free from excitement and
mental worry. All muscular effort in the member should be stopped.
The patient should be confined to his room, and, at least a part of the
time, in bed. Where it is an unfavorable case, it should be explained to

158 ANEURYSM.

the patient, that he carries his life in his own hands and that a sudden
rupture of the aneurysm would be serious. The diet should he simple
and only sufficient to nourish the hod}', and should consist of plain food
well cooked and not a great variety.

Cirsoid Aneurysm. — The treatment of cirsoid aneurysm is somewhat
different from the treatment of ordinary aneurysm. This variety of
aneurysm consists of a general dilatation and pouching and lengthening
of one artery, or several arteries, with their branches. After the disease
continues for some length of time, it involves even the veins and capil-
laries in the same area. The walls of the vessels become thin, lose their
contractility and there seems to be absorption of the muscular and elas-
tic coats, only the outer coat remaining. Eupture is not unusual. Their
location is on the face and scalp. In some cases, they may em-
brace the whole of one side of the head. They are more common in the
temporal artery. The diagnosis is easy, but differs somewhat from
ordinary cases of aneurysm. The thrill and bruit are somewhat difler-

FiG. 32.

Hunter's method of ligation of an artery for aneurysm,

ent. ligation of the larger arteries which supply the tumor, is a failure.
Subcutaneous ligation seems to be successful in some cases. Direct
pressure is also successful in certain cases and should be tried
in all cases at first. Ligation en masse is the only successful method of
treatment. Where the veins and capillaries are involved, the treatment
is somewhat different. (See Nevus.)

Traumatic Aneurysm. — In this condition, there has been puncture or
rupture of the artery, which results, either in the formation of a sac
with part of the artery for its wall, or an effusion of blood within the
tissues sets up an inflammation and the resulting tissues become con-
densed and form a wall for the slowly flowing blood. In trau-
matic aneurysm, there is a large, and somewhat oblong, fluctuating
tumor. In the limb below the aneurysm, there is no pulse, and it
is cold and perhaps swollen. The skin is purple, and if the
vein is also ruptured, the obstruction to the circulation may be com-
plete or, if there is rupture in a joint, an amputation is indicated.

The most frequent aneurysm produced by injury is the artero-venous
or Pott's aneurysm. This aneurysm is now rare. In former times, when
bleeding was common, an aneurysm was frequently seen on the front of
the elbow. It was produced by wounds of both the vein and artery, the
two healing together. There are two forms of this aneurysm, one the

INJURIES TO ARTERIES. 159

varicose aneurysm, in which the communication between the artery and
vein is through an intervening sac. The second variety is aneurysmal
varix, a condition in which there is no such intervening tumor between
the connecting vein and artery, but the vein dilates and forms a tume-
faction, the blood flowing directly from the artery into the vein. Con-
ditions may still arise in civil practice, in case of punctured
wounds, where the artery and vein are both wounded, the blood flowing
from the artery directly into the vein. Where the opening into the
vein is not so large as that in the artery, more blood will perhaps get
out of the artery than goes into the vein, under which condition
the varicose aneurysm will result, that is, a considerable sac will exist
between the artery and the vein. The vein will not be so dilated.

Symptoms of Artero- Venous Aneurysm. — The symptoms of this form
of aneurysm are a large swelling, with pulsation. On auscultation, a
loud bruit is heard which is transmitted along the veins. The veins
above and below the tumor, are tortuous and pulsatile. The
limb is swollen and congested and the parts painful. There is a dis-
tinct thrill in the tumor, which is lessened on pressure. The diagnosis
between anep.r)rsmal varix and varicose aneunrsm is often very difficult.
When the pressure upon the main artery causes a disappearance of the
tumor, it is said to be one of aneurysmal varix, but when such disappear-
ance does not occur, it is said to be varicose aneurysm. Varicose an-
eurysm may be emptied by direct pressure. Palliative measures should
be used. The vein does not tend to rupture, but becomes
thickened and, after a time, cease to enlarge. Usually some form of
support is necessary. The part is much swollen and very painful. The
artery should be tied abore and below the tumor. Both vessels may
be ligated, providing they can be separated with ease. Ordinary pres-
sure treatment for aneurysm should be used here before any other
kind of treatment is applied. Tf this fails, the artery should be tied.
It is a good plan in these cases, to excise the mass if it can be readily
done.

Indications for Amputation.

Amputation is frequently required in case of aneurysm. The condi-
tions which demand amputation may be summarized as follows:

1. When gangrene of the limb is im- it recurs it often becomes much

minent. worse.

2. Suppuration of the aneurysm after 5. Rupture of the aneurysm into a joint,

other methods have been tried. or the erosion of bones.

3. Where severe secondary hemorrhage 6. Rupture of the aneurysm subcutane-

follows and threatens life. ously, causing rapid effusion of

4. Recurrence of the aneurysm. When blood, may call for amputation.

INJURIES TO ARTERIES.

Wounds of arteries may be classified as wounds of other tissues, or
incised, contused, punctured, gunshot, etc.

Contused Wounds. — A contused wound of an artery may entirely
destroy the vitality of the coats, and sloughing, followed by hemorrhage,

160 INJURIES TO ARTERIES.

result, or the contusion may rupture the blood-vessel, which will he
evidenced by the effusion of blood among the tissues. The evidence
of rupture- of the artery will he plain — a rapidly forming, fluctuating
tumor and absence of the pulse beyond the injury. There will he no
bruit and likely no pulsation over die swelling. The limb will become
cold from effusion of blood causing obstruction to the return
circulation. If collateral circulation is more or less set up and
there is not too much obstruction to the return circulation, swell-
ing will occur only at the site of injury. The swelling may extend to
other parts of the limb. If there is rupture of a large vein, a tumor
occurs at the point of rupture, and if the obstruction to the return cir-
culation is very great, which happens if the main vein of the
part becomes ruptured, edema of the member will be one of the chief
signs. In contusions of an artery, unless it is of a very large artery,
nature will arrest the hemorrhage. The internal coat curls up and
favors coagulation. If collateral circulation is not sufficient after the
formation of the clot which may involve some of the branches of the
artery, gangrene of the member will follow. The results of contusion
might be summed up as gangrene from thrombosis and secondary
hemorrhage.

Irscised Wounds. — Incised wounds of an artery are more apt to be
serious. Hemorrhage is rapidly profuse, but contraction of the middle
coat and a curling of the inner coat will, after a time, occur. A trans-
verse wound causes profuse bleeding, but is not so serious as an oblique
wound. The clot which forms within the artery is called the internal
clot. That which forms on the outside is called the external clot. The
place of the internal clot will be taken up by fibrous tissue. The
external clot will be absorbed. Circulation will take place around this
area. The small arteries will become enlarged and if the circulation is
sufficient, the vitality of the member will be only temporarily held in
abeyance. If the circulation is almost entirely cut off, necrosis will
likely follow.

Lacerated Wounds. — A lacerated wound of an artery causes little
primary hemorrhage, as a rule, since the conditions present favor coag-
ulation. Secondary hemorrhage may come on, which will give consid-
erable trouble sometimes. This should be looked for in all cases of
lacerated wounds affecting arteries.

Punctured Wounds. — Punctured wounds are not immediately
serious, but traumatic aneurysm often follows.

Gunshot Wounds. — Gunshot wounds may, because of contusion a
the artery wall, result in thrombosis, hemorrhage, gangrene, etc., or
may cut the artery entirely off, serious hemorrhage resulting. In some
cases, the wound will be clean-cut, in other cases it will be in the nature
of a contusion. When the wound is adjacent to an artery, in some cases
it may cause laceration. The results of these wounds are similar to
others.

LIGATION OF ARTERIES. 161

LIGATION OF ARTERIES.

The ligature of an artery in continuity is sometimes required in the
treatment of aneurysm, as it may he the only method, other than ampu-
tation, which will give relief. The operation consists in dividing all
the tissues evenly, parallel to the vessel in question, and opening the
sheath of the artery, without disturbing the neighboring structures,
then passing a ligature of silk, chromicised catgut, or some other suita-
ble ligature material about the artery and tying it so as to obstruct the
flow of blood along the artery. The ligature should be tied sufficiently
tight to entirely constrict the lumen of the artery.

Instruments. — The instruments needed are a scalpel and dissecting
forceps, a grooved director, artery forceps (a half dozen or more),
retractors, aneurysm-needles, blunt hooks, ligature material, and ordi-
nary needles for the closure of the wound.

Operation. — In general, the operation consists of the following pro-
cedure. The strictest asepsis must be maintained in every particular.
The ligature material must be not only properly prepared, but
it must be known to be aseptic. After every preparation has been
made, the line of the artery marked out, the muscular guide located,
an incision is made, generally parallel with the artery, and all of the
structures divided in equal length down to the sheath of the artery.
The skin and fascia may be divided with a scalpel. A dissecting forceps
may then be used and the fascia lifted up and divided until the sheath
of the artery presents itself, then the sheath of the artery must be
lifted up and divided and the artery itself entirely separated from the
surrounding structures. Where it is deep seated, a double curved
aneurysm-needle is necessary. The aneurysm-needle may be
threaded with a very fine strand of catgut or silk and passed around
the artery. To the end of this fine strand of silk is attached the
ligature material proper, which is then pulled through, bringing the
ligature beneath the artery. It is said this subjects the artery to less
irritation. Under most circumstances the artery can be so exposed
and the needle so readily passed around the artery to be ligated, that
the above procedure is hardly necessary. In making the incision in the
sheath of the vessel, the back of the knife should be kept towards the
artery. The sheath should be picked up, a delicate incision longi-
tudinal to the artery should be made, when the sheath may be stripped
off by means of dissecting forceps. The opening in the sheath should
be from three-fourths to one inch in length. The sheath of the artery
may then be grasped in forceps and held steacty while the operator
passes an aneurysm-needle around the artery. He should note that he
has no other structures engaged than the artery itself. The ligature
may then be passed through the eye of the needle around the vessel.
It is tied in a direction exactly at right angles to the longitudinal axis
of the artery. Under no circumstances should the artery be dragged
out of the wound, but it should be tied in the position in which it is

162 LIGA TION OF AR TERIES.

found. A reef knot is the one used. It is better than a fric-
tion knot and is not so complicated as other knots. It is a general rule
that, when.passing the needle around the artery, it should be directed
away from the other important structures which may lie adjacent to
the artery. If, by accident, the accompanying vein to the artery is
punctured, the needle must be withdrawn and the opening in the vein
ligatured before further procedure. In case of small arteries, no trou-
ble will arise from the ligation of the accompanying vein along with
the artery, but this should not be done in case of the brachial or
femoral, inasmuch as it will interfere quite seriously with the return
circulation.

The ligature used should be a specially prepared form of chromi-
cized catgut and should be at least a foot or more in length to permit
of the ends being sufficiently long that tying may take place easily
and rapidly. No one should attempt the operation until he is thor-
oughly familiar with the location of the artery and the landmarks or
muscular guides. Both deep and superficial guides should be kept in
mind at all times. Every structure divided in continuity by the surgeon
should be recognized. . When the artery is reached, it can be told by
pulsation. It is more easily recognizable in the living subject than in
the dead.

After Treatment.— The after treatment of the operation consists
in maintaining the strictest asepsis and cleanliness. Under ordi-
nary circumstances, the wound should be healed and the stitches re-
moved in from seven to ten days. A limb must be elevated and kept
quiet. It should be bandaged snugly with a woolen bandage to keep
the limb warm, and if it is necessary, hot water bottles should be
applied. In debilitated conditions, or in elderly people, the patient
should be kept quiet a longer period than ten days, to allow the tissues
to consolidate, so that subsequent inflammation will not arise. Should
the operator be afraid of gangrene, for some little time before the
operation, the limb should be thoroughly washed several times with
antiseptics, while the limb may be elevated and enveloped in aseptic
lamb's wool.

Dangers of Ligation. — The dangers of ligation of an artery are sec-
ondary hemorrhage and gangrene.

Secondary hemorrhage from the ligation of an artery occurs in
sentic conditions, where the arterv sloughs and the clot formed within
the artery is not sufficient to entirely plug it up, or where the ulcera-
tion extends into the accompamnng vein. This secondary hemorrhage,
if it is severe, may necessitate amputation unless the artery can be
liga+cd a second time higher up.

Gangrene may arise from several different conditions; usually it
is simply from a loss of vitality. The maximum amount of blood dis-
tributed to the limb by means of collateral circulation is not sufficient
to keep the tissues alive. Collateral circulation will depend upon the

LIGA TION O-F-A R TERIES. 163

condition of the artery and the location. If arterio-sclerosis or atheroma
is present, collateral circulation will not likely be sufficient. In any
case where gangrene occurs, it will begin in the terminal structures,
e. g., in the ends of the fingers, ends of the toes, or the structures near
the cortex of the brain.

Should primary or secondary hemorrhage occur, the gangrene is
then of the dry form. Gangrene occurs also where there is an
obstruction to the venous return. It frequently happens that, in the
removal of an aneurysm or the ligature of an artery, the accom-
panying vein is caught up with the artery, or because of some other
condition existing, there are inflammatory tissues thrown out. These
form an obstruction to the return circulation. A sufficient amount
of blood enters the limb, but after getting in, it can not get out, there-
fore the tissues die from a lack of nutrition. The kind of gangrene
occurring under such circumstances, is moist. Bandages, too
tightly applied, may operate as an obstruction to the return circulation
with similar effect. Gangrene may also occur because of an attack
of erysipelas, or because of injudicious after-treatment, in the use of
ice-bags, or in not keeping the limb warm, or in too high elevation.
Every precaution should be taken to prevent the occurrence of gan-
grene and when it does appear, every precaution should be taken to
limit it. It is not unusual that in ligating the femoral artery there will
be death of the toes. Gangrene may extend no farther if the patient
is well nourished and the limb is properly treated. Such parts, after
having dried,- may be removed by a secondary operation, when the
circulation seems to have been thoroughly established to the limb.

Position of the Patient During' an Operation. — The position of the
patient during the operation should be that which makes the artery
most easily accessible and exaggerates the outline of the muscular
guides.

Ligation of Special Arteries. — Arteria Innominata. — To ligate the
innominate artery, an incision should be made along the lower one-
third of the anterior border of the sterno-cleido-mastoicl. The incision
is usually extended down across the suprasternal notch. The inner ten-
don of the sterno-mastoid should be divided and the anterior jugular
veins secured. The sterno-hyoid and sterno-thyroid muscles should be
successively divided. The carotid sheath should be located and fol-
lowed and opened, and the artery traced down to where it is given
off from the arteria innominata. At this point the innominate artery
may be ligated. It has been ligated six times successfully out of thirty
or more operations. The tissues to be avoided are the internal jugular
and innominate veins which lie to the outer side of the vessel. The
vagus nerve and the pleura also, are to the outer side, and these should
be carefully separated from the artery. The aneurysm-needle should
be passed from without in. Collateral circulation is established by
means of the vertebral, basilar, circle of Willis, branches of external

164 LIGA TION OF AR TERIES

carotid, superior intercostal, aortic intercostals, deep epigastric, inter-
nal mammary, and phrenic arteries.

Carotid. — The carotid artery is ligated below the omo-hyoid in the
inferior carotid triangle or above the omo-hyoid in the superior carotid
triangle. It should always be ligated in the superior triangle if possible.
The superficial muscular guide is the sterno-mastoid, the deep muscular
guide, the omo-hyoid. The vessel should be uncovered at a point where
this muscle crosses the artery and it may then be ligated above or
below. The course of the artery may be indicated by a line drawn
from the sterno-clavicular articulation, to a point midway between the
angle of the jaw and the mastoid process. An incision, two and one-
half inches long, should be made along the anterior border of the sterno-
mastoid. The edge of the muscle should be uncovered and pulled back,
which exposes the common sheath, including the common carotid
artery, the jugular vein and pneumogastric nerve. The artery is on
the inner side, the vein on the outer side, and the nerve between the
two, but on a plane posterior to both, while in front of the sheath will
be found the filaments from the loop of communication between the
descendens and communicans noni nerves. The sheath should be
opened with care not to destroy these nerves. Preliminary hemorrhage,
incident to uncovering the sheath, should be staunched. After the
sheath is opened, the sheath of the carotid itself should be opened and
separated and the needle passed around the artery. The needle should
be passed from without inward. The sheath should be opened suf-
ficiently, so it will be plain that the pneumogastric nerve is not included
in the ligature. The operation above the omo-hyoid does not differ
in any way from that below, except it may be necessary to pull the
depressors of the os-hyoid inward, while the sterno-mastoid may be
pulled outward. It may be necessary to divide the anterior fibres of
the sterno-mastoid. The effect of the ligature of the common
carotid artery is curious and interesting. Either soon after, or in a few
days, brain symptoms manifest themselves in about twenty-five per
cent of the cases. These symptoms are in the nature of syncope,
because of anemia, and in a few days there are evidences of cerebral
softening, convulsions, coma, and death. In the cases thus affected,
about one-half will terminate fatally. In some cases there may be
congestion of the lungs, perhaps due to irritation of the pneumogas-
tric nerve. In other cases, the sympathetic nerves seem to be affected;
perhaps inflammatory tissue involves the sympathetic trunk. Collateral
circulation is then established chiefly by means of the vertebrals, pro-
funda cervicis, arteria princeps cervicis, inferior thyroid, superficial
cervical, and occipital arteries.

Internal Carotid. — Ligature of the internal carotid artery may be de-
manded, under rare circumstances, for aneurysm and hemorrhage. It
may be done in any part of its course, but preferably, just after the
bifurcation of the common carotid. The operation is similar to that

LIGA TION OF AR TERIES. 165

for ligation of the common carotid, but a trifle higher up. A. three-
inch incision along the anterior border of the sterno-rrrastoid muscle,
(which is the muscular guide), opposite the greater cornu of the os-
hyoid, should be made. The aneurysm-needle is.passed toward the middle
line, away from the internal jugular vein. Collateral circulation is
established chiefly through the circle of Willis.

External Carotid. — The external carotid artery may be ligated in
any part of its course, but the operation seems easiest above the point
where the superior thyroid branch is given off. A three-inch incision
is made along the anterior margin of the sterno-mastoid, when the
muscle is uncovered and drawn backward and the digastric muscle is
exposed. Care should be taken not to injure the hypoglossal nerve.
The sheath should be opened below the hypoglossal nerve, where it
winds around the occipital artery. The ligature is applied below the
cornu of the os-hyoid, and the aneurysm-needle should be passed under
the artery toward the middle line of the neck. Enlarged glands make
the operation difficult. Furthermore, any irregularity in the position
of the anterior branches of the artery, will make the operation more
difficult. It is also necessary to avoid the loop of communication
between the descendens and communicans noni and the superior laryn-
geal nerve which lie in close connection with the external carotid.

Superior Thyroid. — An incision is made as in ligating the external
carotid. The superior thyroid is tied just where it is given off.

Lingual. — Ligature of the lingual artery is sometimes done for
malignant disease or injury of the tongue. The operation is difficult
and requires the utmost care. The artery is preferably ligated beneath
the hyo-glossus in the submaxillary triangle of the neck. It may be
ligated just at its origin in a manner similar to the ligation of the
external carotid. For the technic of the operation, larger works should
be consulted.

Facial. — The facial artery is best ligated where it crosses the lower
jaw in front of the masseter muscle. A vertical incision, an inch long,
dividing the skin and deep fascia, will uncover the artery, when it may
be readily tied.

Temporal. — The temporal artery is best tied where it crosses the
zygoma. At this point it is quite superficial and is covered only by
skin and fascia. Sometimes the auriculo-temporal nerve is in relation
with the temporal artery and care should be taken not to wound it or
to engage it within the ligature.

Occipital. — An incision, two inches long, backward and upward from
the mastoid process of the temporal bone, should be made, uncovering
the posterior fibres of the sterno-mastoid. The fibres of the trachelo-
mastoid and the splenius capitis are divided. This will expose the
artery as it emerges from behind the mastoid process, when the ligature
may be readily applied.

166 LIGA TION OF AR TERIES.

Subclavian. — This artery is most frequently ligated in the third
part of- its course, between the scalenus anticus muscle and the lower
border of the first rib. The operation may be done for the purpose of
controlling hemorrhage after wound of the brachial, or aneurysm of
the subclavian, or because of injury. The patient should be placed in
a recumbent posture and the face turned to the opposite side. The arm
should be depressed and the shoulders drawn close to the edge of the
table. A four-inch incision is made over the clavicle after the skin has
been drawn down, so that on relaxation, the skin is returned over the
clavicle. The deep structures are exposed beneath the sterno-mastoid
and trapezius in the subclavian triangle. The external jugular and
communicating veins are drawn to one side. The connective tissues are
divided, care being taken to avoid severing the suprascapular and the
transversalis cervicis arteries. If the posterior belly of the omo-hyoid
muscle presents itself, it should be drawn upward. The connective tis-
sues are separated, when the linger may be introduced and the
scalenus tubercle on the first rib located. The artery should then be.
isolated from the vein, and the cords of the brachial plexus may be
pulled to one side. Great care is necessary to avoid wounding, injur-
ing, or including any of the cords of the brachial plexus, inasmuch as
one cord is on the inside, one posterior, and one on the outside of the
artery. Serious injury may be done to the veins in the neck, also the
pleura may be wounded. These are the chief dangers of the operation.
Collateral circulation is set up through the branches of the thyroid
axis and subclavian, axillary, and external carotid.

Internal Mammary. — The internal mammary artery is best ligated
on the front of the chest, by removal of a costal cartilage. The costal
cartilage is either incised or removed and the artery exposed without
opening the pleura. It lies a half-inch to an inch from the margin
of the sternum. In case of hemorrhage, it may be necessary to
secure both ends of the artery.

Vertebral. — The vertebral artery can readily be ligated just before
it enters the foramen at the base of the transverse process of the sixth
cervical vertebra. A three and a half -inch incision is made along the
posterior border of the sterno-mastoid. The scalenus anticus muscle
must be located and the phrenic nerve by all means avoided. The
interval between the scalenus anticus and longus colli muscle, should
be noted. It is in this interval in which the vertebral artery is found.
If a few sympathetic nerve branches are included in the ligature, con-
traction of the pupil results.

Inferior Thyroid. — The inferior thyroid artery must be tied by an
operation in the inferior carotid triangle. The operation is difficult.
An incision three inches long is made along the anterior border of the
lower part of the sterno-mastoid muscle, the muscle is drawn back-
ward and the sheath of the carotid vessels drawn upAvard. It may be
necessary to divide the sterno-hyoid and the sterno-thyroid. Behind

LIGA TION OF AR TERiES. 167

the sheath of the common carotid artery, the inferior thyroid is found
as it arches upward and inward. Care should be taken not to injure
the sympathetic trunk. The middle cervical ganglion lies directly on
the artery.

Axillary. — The axillary artery is tied, in preference to the brachial,
when injury or aneurysm require ligature high up. There are two
operations which are practiced, either one of which is good. The arm
should be fully abducted and the operation performed from the axilla,
if possible. The surgeon should stand between the patient's arm and
his body. An incision is made along the course of the vessel, which is
at the junction of the anterior and middle third of the space between
the two folds of the axilla. The coraco-brachialis muscle should be
clearly defined, as it is the muscular guide to the artery. The muscle
should be drawn outward, which exposes the median and external
cutaneous nerves, which are drawn inward. This exposes the artery.
The needle should be passed from the vein accompanying the artery,
after the nerves have been thoroughly separated from it. The anas-
tomosis about the shoulder is free.

Brachial. — The brachial artery requires ligature in wounds of the
palmar arch or for aneurysm or artero-venous wounds at the bicipital
space. The arm should be held away from the side and not supported
on the table, but rather held by an assistant. The surgeon may stand
between the arm and the trunk. The biceps muscle is the muscular
guide. A two-inch incision is made along its border and the skin and
fascia divided, when the biceps is drawn slightly outward and the
median nerve ex.posed. As the nerve, which crosses the artery in the
middle part of its course, is brought into view, it should be drawn
inward. The artery should be separated from its venae comites, care
being taken not to inclose any other structures within the ligature.
Collateral circulation takes place through the free anastomosis of the
profunda, anastomotica magna, and recurrent arteries about the elbow.

Ulnar. — The ulnar artery may be tied in the middle of the fore-
arm or at the wrist. The muscular guide is the tendon of the flexor
carpi ulnaris. An inch incision is made, the flexor carpi ulnaris drawn
inward, and the artery exposed. The venae comites should be sep-
arated. The ulnar nerve will be found, on the inner side of the artery,
which should be avoided in passing the ligature. In the middle of the
forearm, a line drawn from the inner condyle to the pisiform bone, will
mark the line of incision. The incision should be made at the inter-
muscular septum between the flexor carpi ulnaris and the flexor
sublimis digitorum muscles. The artery lies under cover of the flexor
carpi ulnaris, and if one succeeds in finding this intermuscular septum,
the artery is easily discovered and tied. It is said that the most com-
mon mistake which happens is, that the operator will separate portions
of the flexor sublimis digitorum, or that he will get too far to the radial
side between the flexor sublimis digitorum and the palmaris longus.

188 LIGA TIOisT 'OF AR TERIES.

Radial. — The radial artery may be tied at three points, in the
upper one-third of the arm, above the wrist, and at the back of the
wrist. The supinator longus is the muscular guide. An incision is
made along the inner border of this muscle, when it is raised up, expos-
ing the artery. The radial nerve is on the outer side and
separated by a small interval. The artery may be readily tied at this
point.

Above the wrist, the artery lies between the tendons of the flexor
carpi radialis and the supinator longus and is subcutaneous. An in-
cision is made between these two tendons. The artery is readily exposed.

On the back of the wrist, the radial artery is ligated in what is known
as the anatomical snuff-box, or inter-tendinous hollow, below the styloid
process of the radius. The artery is here found directed towards the
first interosseous space underneath the extensor tendons.

Abdominal Aorta. — Ligation of the abdominal aorta, according to
Tillaux, has been done fourteen times. Death is reported in all cases,
although a patient operated upon by Keene lived until the forty-eighth
day. The operation is both difficult and dangerous. Patients usually
die of sepsis. For a description of the operation, the student is referred
to large works on operative surgery.

Common Iliac. — The common iliac arteries may be ligatured by two
methods, one by an extraperitoneal method, where the peritoneum is
not opened, similar to operation for ligation of the external iliac, and
by the trans-peritoneal operation, where the artery is ligated through
the peritoneum. The operation is rather difficult and requires a thor-
ough knowledge of the technic. With strictest asepsis the operation
is not necessarily fatal. The method of procedure will be found dis-
cussed at length in more extensive texts.

Internal Iliac. — Occasionally, the internal iliac artery is ligated for
hernia, hemorrhage, or aneurysm. The trunk is short, hence ligation
is done just after the bifurcation of the common iliac.

Gluteal. — Ligation is necessary in case of gluteal aneurysm. The
gluteal artery emerges from the pelvis through the great sacro-sciatic
notch above the pyriformis muscle. A line drawn from the great
trochanter to the posterior superior iliac spine at the junction of the
upper one-third of this line with the middle one-third, will mark the
point of incision. An incision is made along this line just mentioned,
and the fibres of the gluteal muscles are separated and held apart.
Through the space between the gluteus medius and minimus, the
pyriformis muscle is located. The artery may now be ligated. Some
believe that it is wiser to deal with the trunk of the internal iliac, inas-
j much as the operation is difficult.

Sciatic and Pudic. — The sciatic and pudic arteries are rarely ever
; tied, but are best located opposite the sciatic spine.

LIGA TION OF AR TERIES. 169

External Iliac. — The external iliac artery is accessible in any part
of its course. It has but two branches, the deep epigastric and deep
circumflex iliac, and these come off in the lower portion. A line drawn
from the bifurcation of the aorta to the middle of Poupart's ligament,
will indicate the course of the artery. The following operation is
one of the various operations described, which is generally utilized:
An incision four inches in length extends from a point one and a half
inches above the anterior superior spine, to one-half inch below the
middle of Poupart's ligament. The muscles are successively divided
until the fascia transversalis is reached. At this point, if the trans-
versalis fascia is thick, it should be opened. Sometimes it is not well
developed, when, unless eare is taken, the peritoneum may be opened.
The peritoneum and its contents are now stripped from the pelvic wall
with the hand by careful dissection. The incision should be large
enough and the peritoneum separated sufficiently far back to uncover
the psoas muscle; the artery lies on the inner border of this
muscle. It can be readily found enveloped in fascia, while lying over
it is the genito crural nerve, the vein being on the inner side of the
artery. The sheath is opened and the artery separated from the vein
and the genito crural nerve. The aneurysm needle is passed from
within out. This is Abernathy's method of operation. Collateral cir-
culation is established through the internal mammary, superficial and
deep epigastric, lumbar arteries, lower intercostals, also by means of
the crucial anastomosis on the back of the leg; also, by the anastomo-
sis of the ilio-lumbar and gluteal with the circumflex iliac and external
circumflex arter}^ and with the anastomosis of the obturator artery.

Common Femoral. — This artery is rarely ever ligated, except in hip
amputation. The superficial femoral is usually ligated because it
permits of much better collateral circulation. The artery is located
by a line drawn from the mid point of a line extending from the
anterior superior spine to the symphysis, to the internal condyle of the
femur. If the limb is flexed and abducted, the artery may be readily
picked up at the apex of Scarpa's triangle or in Hunter's canal.

In Scarpa's triangle an incision is made over the direction of the
arter3r, about a hand's breadth below Poupart's ligament. The incision
should be about three or four inches long. The border of the sartorius
muscle is the muscular guide. The middle cutaneous nerve presents,
lying over the sheath of the artery. The muscle is drawn aside and
the sheath may be opened and the artery exposed. The needle may
be passed in either direction, especial care being taken not to enclose
any other structures.

When possible, the artery should be .ligated in Hunter's canal. A
four-inch incision is made over the line of the artery and after the
fascia lata is divided, the sartorius muscle is exposed. The outer border
of the muscle is located and the muscle drawn inward. As it is drawn
inward it discloses the aponeurotic covering of Hunter's canal. This

170 LIGA TION OF ARTERIES,

canal is opened, which exposes the femoral artery and vein and long
saphenous nerve. The nerve to the vastus internus lies on the outer
side of the artery. The long saphenous nerve crosses the artery from
without inward, while the vein lies to the inner side and behind. The
needle may he passed in either direction, hut with great care. ]STo mis-
take need he made in locating Hunter's canal, if it is borne in mind
that it is directly beneath the sartorius muscle, and as the sartorius
muscle is raised up in its sheath, the glistening surface of the.
aponeurotic covering of the canal may he seen.

Popliteal. — The popliteal artery may be ligated just after the
femoral artery has passed through the opening in the adductor mag-
nus, but the operation is more troublesome and has no advantage over
the ligation of the femoral. The artery may also be tied in the lower
part of its course where it lies on the popliteus muscle in the popliteal
space. But this operation has no advantage over the ligation of the
superficial femoral in Hunter s canal.

Posterior Tibial. — Ligature of the posterior tibial artery may be
required in case of hemorrhage. It may be ligated in the calf, in the
lower one-thiid of the leg, or just behind the internal malleolus. An
incision should be made an inch behind the inner border of the tibia.
The incision should be at least four inches long. The internal saphe-
nous nerve is met with and should he pulled to one side. The artery
lies just underneath the soleus muscle. The incision should expose the
tibial origin of the soleus which is severed at the oblique line of the
tibia. The muscle is pulled up and the artery exposed. If possible, the
venae comites should be separated. The nerve should be distinguished
from the artery, which is easily done, and the aneurysm-needle passed
around the artery away from the nerve.

In the lower one-third of the leg, an incision is made midway
between the border of the Achilles tendon and the inner border of the
tibia. The artery is found lying on the flexor longus digitorum muscle.
The nerve is on the outer side and behind. In passing the needle this
nerve should be avoided.

Behind the malleolus the incision is made a finger's breadth behind
the internal malleolus. The deep fascia is divided between the extensor
longus digitorum and the flexor longus hallucis, and the artery is ex-
posed. The sheaths of the tendons should not be opened.

Anterior Tibial. — The anterior tibial artery is located by a line
drawn from a point midway between the outer tuberosity of the tibia
and the head of the fibula, to a point midway between the two malleoli.
It may be tied either in the upper, middle, or lower third of the leg.
In the upper third of the leg the artery lies between the tibialis anticus
arid the extensor longus digitorum muscles, on the interosseous mem-
brane. The anterior tibial nerve is on the outer side.

In the middle one-third of the leg it lies between the tibialis anticus

DISEASES OE- VEINS. 171

and the extensor propius hallucis. The nerve generally lies on the
artery.

In the lower one-third of the leg the artery lies between the tendons
of the tibialis anticus and the extensor propms hallueis. The nerve is
on the outer side.

Dorsalis Pedis. — This artery extends from a point midway between
the two malleoli and the interval between the first two metatarsal
bones. An incision made along this line will uncover the artery which
is found lying between the tendons of the extensor propius hallucis
and the extensor brevis digitorum. Sometimes it is said the artery is
rather difficult to tie, and it will be best to cut the artery and then ligate
the cut ends.

Peroneal. — The peroneal artery will be found lying on the inner
side of the fibula on its postero-internal border. It is in an osseo-
aponeurotic canal and is rather difficult to tie.

DISEASES OF VEINS.

Phlebitis is an inflammation of a vein. Two forms are recognized,
(1) plastic and (2) infective.

Plastic Phlebitis usually results from a wound and often arises
from the reparative inflammation extending into the vein. It may also
result from injury. It is a localized inflammation of the vein, and is
often attended by thrombosis. Continued pressure or irritation of the
vein may set up a plastic phlebitis, thrombosis resulting. It is also
said that inflammation of the perivascular tissues, as occurs in septic
conditions, may induce plastic phlebitis within a vein.

Infective Phlebitis is a much more serious condition, inasmuch as the
thrombus formed is infected and may become a means whereby the
micro-organisms are disseminated through the body. This septic or in-
fective phlebitis was the source of trouble among the older surgeons, as
infection was introduced directly into the veins, and rapid sepsis re-
sulted. Septic phlebitis never occurs now as the result of a surgical op-
eration. In neglected wounds or in suppurating diseases, it may arise,
forming a serious complication. It follows mastoid disease, the infec-
tion traveling through the bone into the lateral sinus. Localized
phlebitis often arises around foul ulcers or in cases of gonorrhea, but
where the infection gets directly into the vein, as occurs in septic
phlebitis, general edema will result.

Symptoms. — The vessels are swollen and hard, forming red and pain-
ful cords underneath the skin. Nodular enlargements corresponding to
the valves may be felt. The skin is edematous and there are areas which
are dusky and congested. When the deeper veins are involved,
the diagnosis is more difficult. It is accompanied by a peculiar
white edema of the tissues. In case the deep veins of the leg are in-
volved, a condition called "milk leg" follows. In this condition per-

172 DISEASES OF VEINS.

haps, lymphatic obstruction operates as a part of the cause of the condi-
tion. The onset of septic phlebitis is attended by a chill with rapid
extension of- the inflammation, unless but a small area is affected, and it
is usually followed by sepsis and rapid invasion of the general system.
Diffuse suppuration sometimes follows. Eepetition of the chills and
acceleration of the temperature would indicate pyemia.

Treatment. — The treatment of phlebitis is absolute rest and eleva-
tion of the part. In the case of a limb, it should be enveloped in
lamb's wool or cotton and well bandaged. The limb should be kept hot
by means of hot water bottles. The limb may be manipulated to assist
the return circulation. Vigorous local manipulation should be avoided
since coagulation may occur in the veins. Dislodging of the clot would-
be followed by embolism. The circulation to the affected part must
be assisted by relieving any obstruction and encouraging the flow of
blood through the agency of the vasomotors. Any spinal or other
lesions affecting the nerves to the inflamed vessels should receive es-
pecial attention. The diet of the patient should be non-stimulating and
nutritious. Septic phlebitis, with the formation of pus, should be treated
the same as an abscess. As soon as pus formation is made evident by
means of fluctuation, the abscess should be opened and freely drained.
In some cases it is possible to ligate the vein above the septic area and
scrape out the inflamed mass. This is very often attended by sepsis.
This method of treatment could only be used where a single trunk is
involved: it is rarely ever feasible.

Varicose Veins, or Varix.

This disease is sometimes called phlebectasis. The vein becomes
very prominently dilated and lengthened and more or less tortuous.
It is said to occur in twenty per cent of adults, more frequently
in men than in women. The locations where they are usually found
are the internal and external saphenous veins (generally the internal);
the spermatic veins which surround the spermatic cord (varicocele) and
in the veins of the rectum, where a condition of hemorrhoids or piles is
produced. Varicocele and hemorrhoids will be considered elsewhere.
Other veins may be affected, as, for instance, the veins over the abdomen
may be dilated in conditions of cirrhosis of the liver. Sometimes vari-
cosities of the veins of the viscera happen, and rarefy they occur in the
deep veins of the extremities. Sometimes congenital varicose veins
occur.

Pathology. — It need hardly be mentioned that the cause of varicose
veins is an obstruction to the return circulation at some point. The
cure of the condition depends upon the physician determining the
point of obstruction. Changes take place within the vein-wall. It
becomes thickened by the formation of inflammatory tissue and when
the vein is cut it will remain distended. Pouch-like dilatations occur

DISEASES OE VEINS. 173

along the course of the vein at the location of the valves. After some
length of time, fibrous changes occurring in the veins, entirely displace
the normal tissues of the intima and media. Superficial varicose veins
are evident on inspection. They appear enlarged, thickened, distended,
and tortuous.

Results. — The results of varicose veins in the leg, as these are the
most common, consist of a general impairment of the circulation. In
severe cases, edema of the limb is common. The tissues of the limb
often become debilitated because of the bad circulation and at
the least possible injury, ulcers result. These varicose ulcers are diffi-
cult to treat and sometimes seriously affect the general health. Where
the skin is subject to irritation, eczema sometimes develops. This ec-
zema oftentimes results in ulceration, and after the ulceration is estab-
lished, the secretions flowing over the tissues may again cause eczema.
Inflammations of the vein frequently occur in this ill-nourished and
distended condition. This phlebitis may result in the formation of
thrombus or it may result in the partial occlusion of the vein or the for-
mation of an abscess. Where the injury to the vein results in the
coagulation of the blood and the formation of thrombus, later the vein
may be more or less absorbed, only a fibrous cord being left. Rome-
times calcareous degeneration of the thromhus occurs, Avhen a phlebolith
results. Persons of rheumatic and gouty tendency who have varicose
veins are very liable to phlebitis. Varicose veins are accelerated by the
formation of what is known as the "vicious circulation." Sometimes
blood from the internal saphenous vein empties into the external or
short saphenous vein and thence into the deep veins, whereas the blood
from the deep veins flows from the femoral vein into the saphenous, so
that a certain amount of blood would, as it were, go round and round
this vicious circuit. Whether this is true is questionable, but it is said to
sometimes occur.

Treatment. — The treatment of varicose veins depends on recogniz-
ing the cause. The obstruction in the leg may be caused by enlarged
lymphatic glands at the saphenous opening. Muscular contractions
may produce tension of the fascia lata and cause impingement of the
return circulation. Partial and complete dislocations of the hip will,
in like manner, directly or indirectly interfere with the return circula-
tion. Prolapsus of the abdominal viscera will produce obstructions in
the pelvis. Pressure on the ascending cava where it passes through the
diaphragm may be the cause. Where there is a general lack of tone,
lesions affecting the vasomotor nerve supply to the vessels of the legs
will be found. These lesions may be at the sacro-iliac joint, between
the sacrum and lumbar spine, or in the lower dorsal or lumbar regions.
Luxations of the lower ribs may operate similarly. A cure in any case
depends upon removing the cause and securing the proper nerve sup-
ply by removing the lesions found, and also in stimulating the vaso-
motors to the veins affected.

174 DISEASES OF VEINS.

Nevus.

Nevus is a condition of dilation of the veins, venules and arterioles
and is classified as one of the tumors. (See Angioma.) The capillaries
are dilated and this dilation may extend into the small veins and
arteries, and large cavernous spaces may be formed. Considerable pig-
mentation of the tissues about may occur, since the blood may flow
in cavernous spaces, and the circulation being weak at this point, it may
be partially obstructed. The disease is very often congenital. It may
wither and disappear after a time or it may enlarge and spread over
a considerable area. Two varieties are usually described.

1. Capillary nevus, or mother's mark, occurs usually as a bright
red or purplish colored mass, slightly elevated above the skin. It con-
sists of a mass of capillaries lined with endothelium. They are small and
often do not extend over a space of more than an inch or two in diame-
ter, but they may, in some cases, cover the side of the head and face.
Where a certain amount of pigmentation occurs, it is called the '"'port
wine" stain. If they are injured, hemorrhage is usually very free, but
is readily stopped by pressure.

2. Cavernous angioma is a condition where the veins are largely in-
volved. They lie in the skin and subcutaneous tissues. They are soft
to the touch, easily compressible, but return to their dilated condition
so soon as the pressure is removed. They are often lobulated, and
when the blood' is pressed from them, they give evidence of sinuses be-
neath the skin. They are generally situated beneath the skin and show
as a blue lobulated mass. In the mucous form, where the capillary and
venous angiomata are mixed, it is usually of a dark red color. Venous
nevi are really masses of venous sinuses lined with endothelium. They
may be associated with injury, may occur spontaneously, because of
local weakness and obstructions, and may be congenital.

Treatment. — The treatment of nevus, where it can be accomplished,
especially the venous form, is (1) excision. The veins are ligated, sep-
arated from the subcutaneous tissues and the skin, and removed. (2)
Subcutaneous ligation ma}*" be used with advantage in some cases, and
if excision cannot be done, it should be tried. (3) Injection of coagu-
lating fluids into the tumor, such as perchloride of iron or a strong solu-
tion of carbolic acid, is no longer practiced. (4) Electrolysis. Where
excision and subcutaneous ligation are impossible, electrolysis forms an
excellent method of treatment of nevus. This treatment is especially
valuable where the nevus occurs upon the face or where it is necessary
to avoid cicatrization. It consists in the passing of a strong current of
electricity through the mass. This produces chemical and physical
changes and brings about coagulation and organization of the tissues.
Both poles of the battery may be introduced into the tumor, but this
is not the wisest plan. It is better to employ a one or two
needled positive electrode and introduce it into the tumor while the
negative pole is applied to a different part of the body. The needle

EMBOLISM. 175

should be made of steel, inasmuch as the treatment corrodes the needle,
which has an advantageous effect upon the tumor. The use
of the negative pole in the tumor is more liable to cause scar. A cur-
rent equal to about two-hundred milliamperes should be passed through
the tumor for about fifteen minutes. Should both poles be applied to
the tumor, a current of only about half this strength is necessary. Gen-
eral anesthesia is required. The immediate effect on the tumor is to
cause it to become hard through the coagulation of the blood. In some
cases the treatment is not successful. It is best to deal with the pe-
riphery of the nevus first. Some scarring will be inevitable. It is wise
not to do too much at one sitting. If the nevus be treated at several
sittings, there will be less scar formation. The nevus should be treated
sufficiently long to permit of complete cicatrization.

Embolism.

An embolus is any floating object in the blood. It may be composed
of the following materials:

1. Thrombi. (2) Parasites. (3) Fat. (4) Air. (5) Glandular Cells.

The method by which thrombi become emboli can best be seen in
forms of valvular heart disease or endocarditis. In valvular heart dis-
ease the valves become roughened and clots are readily formed, when,
because of the action of the heart, these clots become detached and are
whirled away along the blood-stream and finally plug up some artery.
This is the most frequent origin of emboli. Emboli may contain para-
sites and wherever they lodge, an abscess results. In case of fracture,
especially of long bones, particles of fat may be dislodged, and finally
entering the veins, are carried back to the heart. This will cause
dyspnea by plugging up the branches of the pulmonary artery. Air
embolism sometimes occurs where there is a wound of a large vein and
where the intravenous pressure is negative, or it sometimes happens
after giving a hypodermic injection of a drug, where the syringe con-
tains some quantity of air. Embolism by other cells sometimes occurs
in cases of cancer and sarcoma. The cells enter the circulation and
are carried elsewhere, and a secondary tumor results.

Effects of Embolism. — The effect of embolism is to cut off the circu-
lation to the part. If it occurs in the brain, paralysis results. If it hap-
pens in other organs, other symptoms. These effects may depend
somewhat upon the nature of the clot. They may be classified as fol-
lows :

1. Changes in the clot. Subsequent changes in the clot may oc-
cur. Becoming organized, as in case of thrombi, the artery is perma-
nently obliterated. Collateral circulation may be established and
the function of the part restored.

2. Anemia. Where collateral circulation is fairly good, the part may
give evidence only of anemia. This will be recovered from in due time.

3. Necrosis. In terminal arteries, necrosis Avill occur, as in case of

176 THROMBOSIS.

gastric iilcer. In terminal arteries of the brain, necrosis of a portion
of the brain very often happens. This necrosed area becomes lique-
fied, afterwards forming either an abscess or cyst, depending upon
whether the clot is infective.

4. Infarction. Where the embolism is of an organ like the kidney
or spleen, infarcts are formed. This infarct consists in the plugging
of a terminal artery in some such organ as mentioned, and a subsequent
engorgement or swelling in the area to which the artery is distributed.
Inflammatory changes and fibrous tissue changes very often take place
in these infarcted areas. There are two kinds of infarcts — the white,
in which there is no obstruction to the return circulation, and red in-
farcts, where there is more or less obstruction to the return circulation,
or where there is at least some collateral circulation.

Evidences of Embolism. — The evidences of embolism are similar to
those of thrombosis, with the exception that they come on more sud-
denly. The effect on the brain is sudden and complete paralysis of
the area affected. Embolism of the arteria centralis retinae and its
branches would destroy sight in the eye affected. It at once destroys
the function of the area to which the artery, which is plugged, is dis-
tributed. In the organs where infarction takes place, there will be evi-
dences of congestion and edema. Should the blood supply be entirely
cut off, necrosis of a mass of tissue will occur. If the embolus is infec-
tive an abscess results. In any case the symptoms will be obscure and
diagnosis difficult, and it can only be made, in many cases, by elim-
inating other conditions.

Thrombosis.

Thrombosis is the formation of a clot in a living blood-vessel.
Causes. — The causes of thrombosis may be classified as follows :

1. Disease or injury to the vessel wall. Any disease or injury to
the vessel wall, whereby it becomes roughened or thickened or a portion
is removed, may furnish more favorable conditions for coagulation. Ath-
eroma, sclero-endarteritis, etc., are conditions which bring about throm-
bosis.

2. Certain changes in the blood. Changes in the blood, whereby it
becomes more coagulable, favor thrombosis. These changes are, per-
haps, problematical and theoretical, but that the blood is more coagu-
lable under some circumstances than in others, is likely true.

3. Foreign bodies or the presence of micro-organisms. These for-
eign bodies furnish a point upon which the coagula may be deposited or
to which the leukocytes may cling, thereb}'- assisting the formation of
a clot.

4. Eetardation of the blood stream. Eetardation or slowing of the
blood stream may occur under several conditions. It occurs after (a)
ligature of the artery in operations for thrombosis, or from injury to
the artery or vein, from aneurysm, or in any operation where the artery
is tied.

THROMBOSIS.

177

(b) From tight bandage. Pressure of a tight bandage may lead to
such obstruction to the circulation that coagulation will occur.

(c) Diminished force and frequency of the heart-beat, lessening the
vis a tergo, perhaps assist in the formation of the clot.

(d) The pressure of a tumor or luxated bones or other objects upon
the vessel above, may lead to coagulation and the formation of throm-
bi. This occurs, perhaps, in cases of phlegmasia alba dolens or milk leg.
When the clot is formed, it may extend in both directions from the
point of origin, but it usually extends in the direction of the blood
current. If it entirely fills up a branch of the artery it will extend
back only so far as the main trunk. At this point it may stick out and
form a projection into the blood stream of the larger artery. It will
extend in the direction of the blood stream as far as where branches
are given off, or where the blood flow is influenced by

collateral circulation. The thrombi may be occlud- Fig. 33.

ing where they entirely fill up the vessels or they
may be only partial. The effects they produce and
the symptoms of thrombosis will depend upon the
subsequent changes which take place in the throm-
bus, or upon whether it is occluding.

Changes in Thrombosis. — 1. Organization. A
thrombus may become organized; this takes place in
the following manner: As soon as a clot forms in
any vessel, it becomes infiltrated with leukocytes and
proliferated endothelial cells and connective-tissue
cells — in other words, round cell infiltration occurs.
Subsequently the clot becomes displaced by means
of this new formation. Small blood vessels may ex-
tend from the vasa vasorum through the vessel wall
out into the clot. The artery becomes organized and
forms a hard fibrous cord.

2. Softening. Softening of the clot may occur venous thrombus,
because of fatty degeneration of its elements. Fatty
degeneration may be because of. the limited nutrition of the infiltrated
tissue cells or the softening may be the result of bacteria. The clot
may become softened and a portion of it dislodged and carried into the
general circulation, embolism resulting. It may break down, the ele-
ments become liquefied and a small cyst result, or, on the other hand,
fatty degeneration and liquefaction and absorption of the elements
may occur.

3. Calcification. Sometimes the fatty material which is formed
as the result of fatty degeneration of the clot, will become displaced
by means of calcareous material, when the remains of the thrombus and
the artery will be a calcified mass.

4. Absorption and tunnelling of the clot may sometimes occur. This
is accomplished by means of the clot apparently opening up because of
the blood pressure or the liquefying effects of the blood, or perhaps be-

178 THROMBOSIS.

cause of fatty degeneration. The clot becomes tunnelled out and a sin-
uous or tortuous tract is made through the clot and it becomes pervious
to the extent that it will permit of regular circulation taking place
through it.

Effects of Thrombosis. — The effects of thrombosis depend upon
whether it occurs in an artery or vein, or whether it is in a terminal
artery, or upon the extent to which the circulation is cut off from the
tissues to which the vessel is distributed.

1. Swelling and edema. The swelling and edema are usually great.
It will depend upon whether the obstruction is in the vein or artery.
If the obstruction is in the vein, the swelling will be enormous. If the
clot becomes organized in the vein and the collateral circulation is
poorly established, this edema may remain and become hard (solid
edema). This sometimes occurs in phlegmasia alba dolens.

2. Gangrene. It is not unusual for gangrene to result from ob-
struction to the return circulation or from the formation of a thrombus
in an artery or vein. The gangrene following is of a moist vari-
ety, especially where the thrombus is in the vein. The extent of the
gangrene will depend upon the extent to which the circulation is cut off.

3. Fhlebitis. Inflammation of the vein walls will very likely occur,
especially if the clot is infected or if the patient is in a debilitated
condition. It may take on a suppurative form. If it does, it more
than likely arises from an infected clot.

4. Embolism. Embolism consists in the plugging up of an artery
by means of a floating clot or other material which has become de-
tached and loose in the blood. If the material forming the embolus is
not infective, the results are not so serious, but if it is infective, pyemia
will likely result.

Symptoms of Thrombosis. — The symptoms of thrombosis depend
upon the location of the clot. In case it occurs in a vein, it will be
attended by marked edema and dilatation of the veins, together with
phlebitis. Blood extravasations are not uncommon. The pain is severe
and the part to which the arteiw is distributed, or from which the vein
comes, will lose its function. Thrombosis of one of the cerebral arteries
would be attended by paralytic or mental symptoms. If it should occur
in the lower limb, paralysis and edema of the member will follow, to-
gether with more or less pain. In case the vein is affected the symp-
toms of phlebitis will supervene.

Treatment, — The treatment depends upon the conditions present.
In general, it is directed toward securing resorption of the clot and stim-
ulating collateral circulation. Vigorous manipulation to dislodge the
clot is not advisable. Often the clot can be absorbed if the case is seen
early. When gangrene results, operation is necessary. In paralysis,
the result of thrombosis and embolism, an effort should be made to estab-
lish collateral circulation. In this, nature can be assisted. If the part

DISEASES OF LYMPH A TICS. 179

can be prevented from dying, the integrity of the tissues will be restored
in time.

INJURIES TO VEINS.

Injury to veins should be treated in much the same manner as
injury to arteries. It demands prompt methods to arrest the hem-
orrhage, and later, the bleeding points may be ligated. In all cases the
proximal and distal ends of the veins should be ligated, as hemorrhage
may occur from either end. Especially is this true of the external jug-
ular, inasmuch as the valves are imperfect and do not entirely close the
vessel. Operations on veins are done with the same precautions as are
taken in the ligature of arteries. (See Ligature of Arteries.)

DISEASES AND INJURIES OF THE LYMPHATICS.

Lymphangitis.

There are two forms of lymphangitis, acute and chronic.

Acute Lymphangitis is a rapid invasion of the lymphatics by septic-
material or the products absorbed from poisoned wounds.

Cause. — The cause is micro-organisms or other toxic material asso-
ciated with obstruction to the lymph stream.

Pathology, — The wall of the lymphatic is infiltrated and inflamed
as in an ordinary acute inflammation. The tissues round about are
more or less involved. It is said by some that the lymph within the
vessels coagulates and forms a pink clot.

Symptoms. — The symptoms of an acute lymphangitis are fine red
lines, edematous swelling and a violent inflammation closely resembling
erysipelas. There seems to be two forms, one in which the larger lym-
phatics are involved, a tubular form, and the other in which the smaller
lymphatics are involved. Where the small lymphatics only are involved,
it may closely resemble erysipelas. The disease may be attended by
chill, vomiting, and sweats. The pulse is rapid and the fever ranges
from 102 degrees to 104 degrees F. The diagnosis is sometimes difficult,
but it is not so essential. Erysipelas itself is a lymphangitis due to a
special micro-organism. It has more of a rose-red color, the skin is more
brawny, and the onset of the disease more marked than in acute lym-
phangitis.

Treatment. — It is essentially that of erysipelas. (See treatment of
Erysipelas.)

Chronic Lymphangitis. — A chronic inflammation of the lymphatics
resembles a chronic inflammation in any of the connective tissues. It fol-
lows the acute form where recovery is not entire, or it happens in cases of
syphilis and tuberculosis. There are people who seem to have a ten-
dency to the proliferation of connective tissue elements. In these sub-
jects, chronic lymphangitis often develops. There are enlargements
of the lymphatic glands and thickening of the connective tissues gen-
erally.

180 ELEPHANTIASIS.

Treatment. — The treatment is the same as the acute form. Kemove
the obstruction to the lymphatic circulation.

Lymphangiectasis or Lymphangioma.

This is a condition of chronic dilatation of the lymphatic vessels. It
is sometimes congenital and other times acquired. It may be localized
to small areas or involve a considerable part of a member. Chronic
distension of the lymphatics is oftentimes accompanied by overgrowth
of the connective tissue elements of the part, leading to chronic hyper-
trophy, as seen in inacroglossia. Distension of the lymphatics may be
shown by small vesicles which persist and which are not accompanied
by evidences of inflammation. When these vesicles or lymph spaces are
opened, there is a considerable flow of fluid (lymphorrhea). They are
found most frequently on the inner side of the thigh and the genitalia
of the male.

Treatment. — Eemove the fascial obstruction to the lymphatic circu-
lation. This will drain the sodden tissues and give relief.

Lymphatic Obstruction.

Lymphatic obstruction may take place in any of the large lym-
phatics, as the thoracic duct or any of its branches. The obstruction
may be due to muscular contraction, contraction of the fascia, abnormal
position of the bony structures, and to chronic lymphatic obstruction
arising from the deposit of tuberculous material, as occurs in long
standing inflammations of the fascia or connective tissues generally.
Repeated attacks of eczema may cause enlargement of the lymphatic
glands, which operates as an obstruction to the lymphatic circulation
and will sometimes finally result in a thickening of a member. This
lymphatic obstruction and enlargement of the part is called elephan-
tiasis.

Elephantiasis.

There are two forms of elephantiasis: (1) Elephantiasis Arabum
and (2) Pseudo-elephantiasis. It may affect the foot, leg, genitalia, etc.,
where it is known as elephantiasis pedis, elephantiasis cruris, elephan-
tiasis labium, etc. The phenomena of elephantiasis consist of (1)
edema. This edema is lymphatic in origin and solid. The fluid cannot
be pressed out of the tissues and the part appears to be permanently
thickened. (2) Hyperplasia. Hyperplasia of the connective tissues
takes place. The subcutaneous connective tissues become infiltrated
and thickened and increased in amount. The skin becomes coarse and
warty in appearance and ulcers are common. Where injuries or ulcera-
tions occur in the enlarged part, the lymph will seep out (lymph fis-
tula). This continual discharge of lymph is called lymphorrhea.

Pseudo-elephantiasis arises from tuberculous conditions and ulcers.
It is sometimes called Barbados leg. It is a disease of the tropics and
need not be discussed here. It affects the leg, scrotum, vulva, face,
and breast. The disease may persist for years.

DISEASES OF L YMPHA TICS. 181

Lymphadenitis or Adenitis of the Lymphatic Glands.

Canse. — Inflammation of the lymphatic glands is produced by the
absorption of toxic materials and obstruction to the return circulation.
This material is carried back through the lymph channel into the lym-
phatic glands where tissue changes are produced. This inflammation in
the lymphatic glands operates as an obstruction to the flow of lymph.
As soon as the source of the irritating products and the obstructions are
removed, the swelling and inflammation of the gland disappear. If
pyogenic micro-organisms get in, suppuration is very likely to follow.
Suppurative adenitis is a slow process and may be prolonged over a
considerable period. Some writers look upon the lymphatic glands as
filters whereby poisonous products are kept from entering the general
circulation. This perhaps accounts for the fact that when a consider-
able amount of poisonous material finally gets into these glands, suppu-
ration is very apt to occur. Occasionally, acute lymphangitis occurs.
In these cases it is believed that muscular injury, irregularities in the
circulation, and bony lesions, etc., may be set down as the cause.

Pathology. — The pathology of the disease is simply that of an in-
flammation in any of the tissues. If suppuration occurs, it is usually
localized, rarely diffuse. If it becomes diffuse, it may persist for a
considerable length of time.

Symptoms. — The evidences of acute lymphangitis are the symptoms
of inflammation", together with the enlargements of the glands. They
are extremely painful and hard, and the tissues about are sometimes
edematous. As soon as suppuration is evident, the lymphatic gland
should be freely opened and drained. Sometimes the suppurative process
may extend into the neighboring glands and each one in succession
breaks down and ulcerates. The absorption of toxins and disturbance of
the digestion and secretions will follow and the patient becomes debili-
tated, and a chronic abscess results, if the disease is not properly treated
at once. Any obstruction to the nerve or blood supply, or the lymph
stream, should be relieved at once and any anatomical lesions account-
ing for the condition, should be corrected. As soon as suppuration is
evident, the abscess should be opened and freely drained. Not only
should there be free drainage, but the abscess should be frequently
dressed, each time being washed with an antiseptic solution. Before
suppuration takes place, hot fomentations are valuable. The glands
most frequently involved are the axillary, inguinal, and cervical.
Where suppuration occurs, they should be treated as acute abscesses.
It is worthy of note that the osteopathic treatment, which will be indi-
cated in each individual case, is of the utmost importance. Next to this
should be cleanliness, proper diet, and hygiene.

Chronic Lymphadenitis.

Chronic lymphadenitis is a chronic inflammation of the lymphatic
glands and may result from acute inflammation or from constitutional
conditions, but, in all events, the chief underlying cause is anatomical

IS2 DISEASES OF L YMPHA TICS.

derangement. The disease is most common in the neck in scrofulous
children. Sometimes the disease can be traced to exciting causes, such
a? carious teeth, chronically inflamed tonsils, sore mouth, and is said
to be produced in some cases by lice. In every case syphilis and tuber-
culosis should be eliminated. The glands usually enlarge slowly and
become infiltrated with round cells, as in chronic inflammation of other
tissues. The enlargement is first fleshy in nature and usually not pain-
ful. The person may improve in health and the enlargement disappear,
or the inflammation may continue for some length of time. The in-
flammatory reaction becomes apparent, slowly accelerated and may or
may not be painful. Finally the gland undergoes caseation, or it may
even break clown and ulcerate. Other times, the liquid elements of the
caseous mass may be absorbed, leaving a hard mass, which finally
atrophies and disappears. It is claimed by some that general tubercu-
losis may be derived from these chronically enlarged glands. The
glands, which are at first singly enlarged and movable, often become
adhered into a mass. Evidence of suppuration will be shown by the
fact that the skin over the gland becomes red and adherent. After a
lymphatic gland breaks down and suppurates, it leaves a purplish, foul,
undermined, and indolent ulcer. After awhile this may heal. They
leave a peculiar, puckered, white scar. After suppuration has oc-
curred and fluctuation is distinctly felt, the abscess cavity should be
opened and well drained. If the opening is large enough for the finger
to be introduced, all loculi of the cavity should be dug out. A
Yolkmann's spoon is an excellent instrument with which to scrape out
the dead parts of the gland. Strictest asepsis should be maintained to
prevent scarring. The scars are peculiar in these cases, in that they
retain their pink color much longer than ordinary scars. In treating
acute and chronic lymphangitis, painting the glands with belladonna and
glycerin, the application of the tincture of iodine, or the oleate of mer-
cury, or other such drugs, is of no value. The treatment should be
first directed towards restoring the circulation and relieving the obstruc-
tion to the return circulation, not only the lymphatic, but the venous as
well. Besides the cause must be removed, whether it is carious teeth,
anatomical lesions, or a sore. Some surgeons advise a radical treatment
for enlarged lymphatic glands, but this is unwise. This treatment is to
enucleate the gland as soon as it enlarges. If proper attention is paid
to the cause of t.he disease, the treatment will be plain.

Lymphadenoma.

A non-inflammatory enlargement of lymphatic glands may occur
sometimes; this is called a condition of lymphadenoma. Two forms
are described by various writers, (1) benign or the simple form, which
consists in the enlargement of a single lymphatic gland or the lymphatic
glands of a small area, viz., the groin, neck, or axilla. The cause of the
disease is due to lymphatic obstruction or to errors of the nerve and

DISEASES OF THE SKIN. 183-

blood supply. (2) Malignant lymphadenoma, or Hodgkin's disease/ or
pseudo-leukemia, is usually met with in adults and consists in an over-
growth of all the lymphoid tissues of the body — spleen, lymphatic
glands, and the lymphoid tissues in the bowels. The proportion of
white corpuscles is much greater than should be. but not so great as
exists in true leukemia. The subject has one white, to fifty or seventy-
five red, corpuscles. The disease is said to be incurable.

Lymphosarcoma.

This is a condition of sarcoma of the lymphatic glands. (See Sar-
comata.) The disease occurs more often in the tonsil than any place
in the body. It grows rapidly and is painless. It seriously affects the
health and rapidly becomes fatal. The disease usually occurs in adults.
The dissemination of the growth to the viscera results fatally.

Secondary growths of the lymphatic glands and tubercular enlarge-
ments of the lymphatic glands or syphilis of the lymphatic glands, are
discussed elsewhere in the text.

DISEASES OF THE SKIN AND ITS APPENDAGES.

Dermatitis.

One of the most common inflammations of the skin is the toxic form,
the result of poison sumach. There are three forms of the poison
sumach more especially toxic, the poison oak, poison ash, and poison
ivy. Contact with the plant is not always necessary to bring on the
inflammation. The symptoms are a papillary or vesicular inflammation
of the skin. Edema may result. In bad cases there is fever.

Treatment. — Apply sweet spirits of nitre to moisten the surface of
the skin. Oxid of zinc ointment containing ten drops of carbolic acid
to the ounce of ointment is an excellent application. Extract of witch
hazel applied several times daily is of great service many times. A 1 :5000
solution of bichloride of mercury will relieve some cases.

Furuncle.

A furuncle, or boil, is a circumscribed inflammation of the true skin
and the connective tissues beneath it. The cause of a boil is infection
of a hair follicle by the pus germs, generally the staphylococcus py-
ogenes aurus, sometimes the albus. Conditions making inoculation
possible are the same as those operating in other infections. They are
common in disorders of digestion, in constipation, diabetes, Bright's
disease, and conditions of general debility.

Symptoms. — The symptoms of a boil are too well known to require
description. Sometimes boils apparently come in crops or they may
be scattered over the body. In such instances the pus is usually ex-
pressed by the hand and gets onto the body in other locations and in-
fection occurs.

184 CARBUNCLE.

Treatment.— As soon as pus is evident, the boil may be lanced or
allowed to rupture itself. The cavity must be thoroughly cleansed with
an antiseptic solution, as peroxid of hydrogen. Where the boils come
in crops, scrubbing the skin with soap and water and afterwards thor-
oughly washing it with an' antiseptic solution, or fomentations of a weak
solution of bichloride of mercury, or a saturated solution of boracic acid,
is of great service.

Carbuncle.

A carbuncle is really a condition similar to a boil, but which is at-
tended by extensive infiltration of the skin in the neighborhood of the
pus formation. The cause is the staphylococcus pyogenes aurus,
coupled with certain conditions of the body or a devitalized condition
locally. It differs from a boil in that the constitutional symptoms are
severer and the base is hard, indurated, and boggy. Instead of the
pus pointing at one place, several pustules will form with a bloody serum
contained in them. It is not unusual that a considerable mass of
tissue will necrose, pus forming in below this, will burrow out
through it. Where the patient is debilitated and the absorption of pus
is veiw great, general sepsis may follow, when it may result in phlebitis
or lymphangitis. The most usual location for carbuncles is the neck,
back, and buttock.

Treatment. — The treatment is to relieve local lesions and whatever
general ailment the patient may have. The carbuncle should be freely
incised and cauterized with pure carbolic acid. It should then be
treated as a simple sore by washing with antiseptics and sprinkling with
Senn's powder (one-third salicylic acid to two-thirds boric acid). Some-
times a hot saturated solution of boracic acid accomplishes much. This
treatment should be kept up until the sloughs are separated. The
sore should then be dressed with dry antiseptic gauzes.

Clavus or Corn.

A corn is a thickening of the epidermis, due to inflammation of the
skin, brought about by irregular pressure of ill-fitting boots. The
treatment is to remove the pressure by the use of plasters and
then subsequently to remove the corn by scraping. In old persons the
corn should not be cut. but should be soaked in hot water and scraped,
care being taken not to injure the skin. In painful feet, the result o*
corns, direct the patient to soak the feet in hot water and afterwards
wrap them in cloths saturated with a mixture of equal parts of linseed
oil and lime water. Suitable plasters to remove the pressure from the
corn, will relieve the inflammation, when the corn can be removed. The
following formula will be found useful in removing corns: Paint the
corn each night with a mixture of salicylic acid, one and one-half drams,
extract of cannabis indica ten grains, and flexible collodion one dram.

INGROWING NAIL. 185

Chilblains.

Chilblains are circumscribed congestions and inflammations of the
skin, the result of excessive cold. They are more common in young
persons. They consist of localized reddish or bluish-red ery-
thematous areas. They give rise to intolerable itching and burning.
In some cases the skin may be a purplish-red and so congested as to
cause rupture — broken chilblain.

Treatment. — The application of equal parts of spirits of turpentine
imd olive oil, or the oxid of zinc ointment, or the tincture of cantharides
and soap liniment in the proportion of one to six, will give relief.

Onychia.

Onychia is an inflammation of the nail and seems to be due always
to the infection of the matrix with pyogenic organisms. The inflamma-
tion usually starts at the side or base. The common form is perio-
nychia or ungual whitlow. Pus forms beneath the nail and the affection
is extremely persistent and painful.

Treatment, — The treatment consists in removing the nail with fine
scissors and cleansing the sore thoroughly with antiseptics. The
patient is usually run down in health. Strictest antisepsis and care
of the nail is necessary. When suppuration is taking place, hot lotions
of 1:50 carbolic solution are most comforting. All parts of the diseased
nail should be trimmed away with fine scissors
and all exuberant granulations touched with
lunar caustic.

Fig. 34.

Ingrowing Nail.

Ingrowing nail is an ulcerative condition of
the side of the toe (generally the great toe) pro-
duced by the curling up of, and pressure on,
the nail, caused by pressure of ill-fitting boots
and neglect of the feet. Extensive inflammation
and thickening of the tissues alongside of the
nail may result, so that the flesh will, in some
cases, extend out over half the nail.

Treatment.— The treatment is to take the ^Sl"^
condition in hand early and prevent pressure by ar°und the toe and excise

.'.ii .; part of the nail.

correcting the footwear. Then insert a piece

•of surgeon's cotton underneath the edge of the nail to prevent the sharp
edge from cutting into the flesh, also, the middle of the nail should
be scraped thin so as to permit it to bend; also, in trimming the nail, it
should be cut straight across and the corners allowed to grow out.
These should be turned up. The disease seems to be produced by the
nail being thick and the corners having been cut off on the sides. As
the nail grows out the flesh is pushed by the boot against the sharp edge
-of the nail, which causes the inflammation.

ISO INJURIES OF NERVES.

Of the various operations for relief of ingrowing toenail, there is
but one that gives permanent relief. The redundant tissues on the
side of the toe should be cut off and one-fourth of the nail should be
removed, care being taken to destroy the matrix so the nail will not
return. After the operation the wound should be treated antiseptically
and allowed to heal.

Molluscum Contagiosum.

This is an affection which shows itself by small, hemispherical nod-
ules, about the size of a split pea. They are yellowish-white in color and
umbilicated. These masses undergo hyaline or waxy degeneration. The
depression in the center is usually occupied by dried material. They
are common on the face, especially of a child, and may appear upon
the breast of the mother. The nature of the affection is unknown. The
origin seems to be in a hair follicle.

Treatment. — The treatment is to incise the mass, express out the
contents and touch the capsule with a stick of nitrate of silver.

DISEASES AND INJURIES OF NERVES.

Injuries to the nerves consist of:

1. Contusions. 4. Compression.

2. Strains. 5. Puncture.

3. Rupture. C. Division.

Contusions.

Contusions may be transitory in their effect, but in persons subject
to gout, syphilis, rheumatism, or in neurotic individuals, neuritis may
result. Simple contusions cause a tingling sensation as of a pin pricking
the skin. This may wear off in a few hours. In severe cases there may
be complete loss of motion and sensation.

Treatment. — The treatment consists in securing the proper nerve
and blood supply to the affected nerve trunk. Massage and friction will
be found serviceable.

Strains.

Strains are produced by extraordinary muscular efforts during
times of excitement, and the results are similar to contusions. The
treatment is likewise similar.

Rupture.

Rupture of a nerve rarely occurs except in connection with
fractures where there is considerable laceration of the soft parts, or in
connection with dislocations. Entire division of a nerve is very rare.
All of the axis cylinders may be ruptured, with the sheath of the nerve
still intact. The symptoms of the affection are immediate paralysis
of motion and sensation. In case the rupture is complete, the paralysis

INJURIES OF NER VES. 187

of motion and sensation may be permanent, but usually a considera-
ble amount of repair will take place; sometimes it is complete.

Treatment. — The treatment consists in relieving the congestion and
securing the proper blood supply to the injured nerve. Where the
paralysis exists for some length of time, the part should be thoroughly
manipulated io prevent atrophy, until regeneration of the nerve takes
place. Even in old standing cases much improvement may be obtained.

Compression.

Compression of the nerve may result in partial or complete loss of
function. The pressure may serve as an irritation and cause the inflam-
mation and a neuralgic condition. Pressure may be exercised upon a
nerve in the following conditions :

1. Aneurysm. 5. Pressure of a crutch, causing crutch-

2. Tumor. paralysis.

3. Fracture. G. Pressure of a splint.

4. Callus, where it envelops a nerve 7. Chronic osteitis.

some weeks after the fracture. 8. Syphilitic diseases of bones.

y. Displacement of bones.

Displacement of bones consists in partial or complete dislocations.
Partial dislocations, the result of injury or muscular contractions, are
more frequently the cause of compression than all other agencies.
These should be looked for in any given case. When the compression
can be readily removed, recovery will be complete. If secondary changes
have taken place in the nerve and muscles, the prognosis is not so
favorable. lieeovery will be slow.

Puncture.

Puncture of a nerve is usually associated with inflammation and
followed by neuralgic pains. Sometimes the pain is very intense.
Especially is this true in neurotic individuals. The pain will radiate
along up the nerve trunk and cause muscular spasms.

Division.

The immediate effects of division of a nerve are :

1. Paralysis of motion, providing the nerve contains motor fila-
ments.

2. Paralysis of sensation in the part to which the nerve is distrib-
uted. The area of sensation destroyed becomes smaller through the
development of collateral nerve distribution.

3. Vasomotor paralysis will be evident by congestion of the part c.t
first, followed later by the part becoming colder and not sufficiently
supplied with blood.

4. The secretions may be arrested because of secretory fibres having
been destroyed.

5. Trophic changes may take place in the tissues, as ulcerations,
degenerations, etc., because of paralysis of the trophic nerves.

188 INJURIES OF NERVES.

Secondary Effects. — The secondary effects consist in (1) inflamma-
tion aiicl (2) degeneration of the nerve trunk and (3) the reparative
efforts of nature. Immediately upon division of a nerve, the space be-
tween the divided ends becomes filled with blood. After several days
this is absorbed. Round-celled infiltration takes place, so that the
spaces finally become filled up with granulation tissue. If there is not ap-
proximation of the nerve ends, the two stumps become united by means
of cicatricial tissue. From the proximal extremity of the nerve, the axis
cylinders will grow out through the connective tissue, and some of the
fibres will seek out the axis cylinders of the distal end of the nerve, and
will grow down through the myelin sheaths. This results in the partial
restoration of the nerve-function. It is said that such outgrowing of
the nerve trunks ma}'' take place through one and a half inches of cica-
tricial tissue. Sometimes such regeneration does not occur. Even
a small scar may result in the complete loss of the nerve-function. In
case of amputation of a limb, the divided end of the nerve sometimes
develops a tumefaction (amputation neuroma). This consists of a thick-
ening of the connective tissues of the nerve, together with the out-
growth of the axis cjdinders of the trunk of the nerve. These axis cyl-
inders coil up and sometimes form a bulbous extremity. These bulbs
may be the cause of severe neuralgias, and may necessitate the removal
of the end of the nerve trunk. After division of the nerve, in the periph-
eral extremity, Wallerian degeneration occurs. This is set up about
the fourth day. It is said to be caused by a separation of the nerve
trunk from its source of nutrition, the nerve cell. The changes which
occur are such as are described under "Repair of Nerves." The changes
which take place in muscles consist of more or less complete paralysis of
motion. This paralysis is later followed by more or less slowly develop-
ing atrophy, and finally, the muscle undergoes degeneration. Deformity
may result because of the paralysis, atrophy, and degeneration; espe-
cially is this true where the opposing muscles are disturbed. Certain
electrical changes take place in the muscle. These electrical changes
are summed up in the reactions of degeneration. As long as the re-
actions of degeneration are present, there is hope for recovery of the
muscle, providing the nerve can be restored. This is of little practical
use inasmuch as the history of the case, together with the anatomical
conditions present, will enable the physician to determine the amount
of recovery which may be expected. The sensation which has been
destroyed as the result of the nerve division, will be more or less re-
stored. The area of anesthesia will be lessened as anastomosis and col-
lateral nerve supply is established. The blood supply to the part is
lessened. The part looks bluish and may appear congested. Some-
times the skin has a peculiar, shiny appearance, while at other
times it is rough and covered with scales, or even edematous.
Wounds heal badly in a paralytic limb. Exposure to heat and cold may
cause chilblains or vesication. Slight irritants excite ulceration, and
these ulcers persist for a considerable length of time. In paralysis of

DISEASES OEl^NERVES. 189

the fifth nerve, corneal ulceration is common, whereas in hemiplegia,
perforating ulcers arise on the bottom of the foot. The appendages
of the skin may become involved, the hair falling out, or the nails be-
come brittle and rough. The sebaceous glands may become function-
less or may secrete an over abundance of sebaceous material. Atrophy
of some of the smaller bones, as the phalanges, and ankylosis of the
terminal joints, may occur in old cases. When the paralysis occurs
in young people, the development of the member paratyzed is arrested.
Occasionally the division of a nerve is attended by certain changes in
the cortical area. This may result in epileptiform seizures or in severe
cases of dementia. This is not so common unless a foreign body is in
relation with the stump of the nerve. Regeneration of the nerve
will take place according to the method described under "Regeneration
of Xerve Tissue."

Treatment. — In case of division of a nerve, the treatment is nerve
suture. The needle best suited for the purpose is a round one, not hav-
ing cutting edges. A fine Hagedorn needle may be used. The opera-
tion of uniting the nerve ends should be done under the strictest asep-
sis. The suture, which should be of catgut, must be aseptic and only one
or two applied, sufficient to hold the ends of the nerve in position.

Secondary nerve suture has, of late years, given some promise. Even
where a considerable cicatrix has formed between the ends of the nerve,
it can be removed, the nerve ends approximated, and a good result
obtained.

Nerve grafting has been done successfully. It consists in removing
a piece of nerve from a lower animal (preferably from the spinal cord),
and grafting it in between the divided ends of the nerve. This operation
has been done successfully in several instances. It requires the strict-
est asepsis and a thorough acquaintance with operative technic. After
the injury, the parts should be manipulated and massaged in order to
encourage the circulation to the injured part and prevent degeneration
of the muscles. Ankylosis and contractions of any muscles or liga-
ments should be prevented. If sepsis has complicated the original
wound, the prognosis of the case is rather unfavorable.

Neuritis.

Neuritis, or inflammation of a nerve, is not a common condition, but
may occur from subluxations, injury, gout, or rheumatism. It some-
times attends necrosis of hone, carious teeth, etc.

The symptoms vary according to whether the inflammation is acute
or chronic, and according to the nerve affected. The inflammatory con-
dition may be sufficient to lead to degeneration of the nerve. Usually
it results in the formation of fibrous tissue, the slow contraction of
which so impinges upon the nerve that persistent neuralgic pains result.

The causes are due to injury, gout, rheumatism, and subluxations.

The treatment consists in relieving the congestion, improving the
circulation to the nerve, and removing the cause. If it is rheumatism,

190 DISEASES OF BONES.

the rheumatism should he treated; if it is gout, the gout should he
treated; or if it is a dislocated bone, the luxation should be reduced.

Neuralgia.

Neuralgia means ''nerve pain." The term is applied to persistent
pain in a part along the course of a certain nerve. The pain is usually
paroxysmal, intermittent, darting, and stabbing in character. It is
most common in the trigeminus or fifth nerve. The attacks may last
a few minutes, or several days, or even longer. It may be periodical.
The pains may extend over a certain part of the nerve, or all of it.
Trophic changes will take place in the skin. Sensation and motion may
be more or less affected. Frequently the circulation is impaired. It
may be brought on apparently by a draft of air. Pressure on certain
points may relieve or increase the pain. Muscles frequently be-
come contracted and there may be excessive secretions. Over the area
of the distribution of the nerve, an herpetic eruption may break out.
Neuralgic pains ma}' occur in any mixed or sensory nerve or in any of
the organs, such as the breast, ovary, or testis.

Causes and Treatment. — Osteopathy in this affection does what
medicine and surgery have failed to do — accomplishes a cure. The
cause of this troublesome affection is pressure on a nerve by contrac-
tions of the muscles and connective tissues, but more especially by bony
displacements. As for instance, trifacial neuralgia is produced by lux-
ation of the atlas affecting the medulla and sjnnpathetic nerves. Inter-
costal neuralgia is produced by a luxated rib or contractions of the
intercostal muscles which hold the ribs in abnormal position. Operative
interference is never warranted in view of the results obtained by
osteopathic treatment. These operations consist of nerve section and
nerve stretching.

DISEASES AND INJURIES OF BONES AND JOINTS.
Diseases of Bones.

Inflammation of Bone. — Inflammation of bone has for its causes the
same agencies which produce inflammation of any other tissue. The
reaction to injury in bone is quite similar to the reaction in other
tissues. Only the soft tissue of the bone is affected. The inflammation
usually begins in the periosteum or endosteum and then extends along
the Haversian canals, lymphatics, and blood stream into the bone itself.

The results of inflammation of bone are suppuration, caries,
necrosis, and sclerosis, which are similar to the terminations of inflam-
mation in other tissues. When the inflammation occurs chiefly in the
periosteum, it is a periostitis; if the chief changes take place within
the bone itself, it is an osteitis; or within the medulla of the bone,
osteomyelitis. The inflammation may be simple or septic. Simple
inflammations attend fractures and bruises of the bone and 'are repar-
ative in nature and terminate in resolution, whereas the septic variety

DISEASES OE BONES. 191

very often terminates in destructive changes. The septic variety is
brought about by the absorption of micro-organisms. These are car-
ried through the body and finally lodge in the connective tissue spaces
of the bone, setting up inflammation.

Periostitis.

Periostitis, or inflammation of the periosteum, occurs in three
forms, {1) acute simple periostitis, (2) acute infective periostitis, and
(3) chronic periostitis.

Acute Simple Periostitis.

This is usually the result of injury and occurs in the exposed parts
of the body. Its pathology is that of simple inflammation. It termi-
nates in resolution.

Treatment. — The treatment consists in rest, elevation of the part,
and the application of cold. Manipulation to assist the return circula-
tion and to secure a good, free flow of arterial blood, will be found of
great advantage. Pus formation is rare. The disease usually terminates
in resolution. Should evidence of suppuration' appear, hot boracic acid
fomentations should be applied, and as soon as the pus is formed, a free
incision should be made and the pus evacuated. Eigid antisepsis should
be employed to prevent ulceration of the bone.

Acute Infective Periostitis

Is sometimes called diffuse periostitis. It is of a grave nature and
leads to death of a considerable portion of bone, or the disease
may terminate fatally in pyemia or septicemia.

Pathology. — The disease usually occurs in young people who
are debilitated. It often follows an injury, although the injury nnay be
slight. The most probable causes are constitutional conditions and
certain bony lesions affecting the nutrition, which render infection
possible. The disease is often the sequel of a continued fever. The
exciting cause of the affection is. perhaps, the staphylococci or strep-
tococci which have gained entrance into the system at some point made
weak by a deficient nerve and blood supply, the result of subluxations
or muscular contractions. The disease begins as a rapidly
spreading inflammation, which quickly extends into the bone and
reaches the medulla. The pus is formed beneath the periosteum in the
cancellous part of the bone, also in the medulla. In some cases the
entire shaft of the bone may be destroyed. The epiphysis of the bone
escapes injury, as the blood supply to this part is through
another source and is perhaps better. There is no direct connection
between the blood-vessels which supply the epiphysis and those which
supply the diaphysis until after ossification is complete, and for this
reason, neither the epiphysis nor the joint become affected. It is possible

192 DISEASES OF BONES.

for the inflammation to spread to the joint, only through the con-
nection between the capsule of the joint and the periosteum.

Symptoms. — The onset of the disease is usually announced by a
chill and an inflammatory fever, which is sometimes attended by
delirium. The shafts of the long bones, such as the humerus, femur,
and tibia, are more frequently affected. This disease may be over-
looked. It begins as a pain, deep-seated, intense, and agonizing. The
limb can not be handled, which makes it probable that the periosteum
is affected. The soft-parts over the bone become swollen, edematous,
and dusky red (indicating a deep-seated inflammation). It can not
always be differentiated from an abscess, except by incision. If the
joints become involved, the symptoms are more urgent. After sup-
puration occurs and the pus burrows towards the surface, it will be
found, after rupture or opening of the abscess, that a considerable
mass of the bone has died. If the joint becomes involved, bony anky-
losis will frequently result. As soon as the diagnosis is made, an inc-
sion should be made through the periosteum, free drainage established,
and the wound washed with corrosive sublimate solution (1:2000).
Should this not serve to arrest the process, and if small particles of pus
seem to come through the nutrient foramina, an opening should be
made, by means of a bone chisel or trephine, into the middle of the bone,
where, some surgeons believe, is the primary seat of the trouble. The
wound should be washed out twice daily with a 1 :2000 corrosive subli-
mate solution. At least a gallon of antiseptic solution should be thrown
into all parts of the abscess each time. The limb should be kept quiet.
Liquid nourishment should be given regularly at stated intervals.
Should a joint become involved, suppuration occurring, it should be
laid open and freely irrigated with some antiseptic solution. If there
is evidence of general sepsis intervening, amputation should be consid-
ered. An early incision can not be too strongly emphasized, since by
this means the shaft of the bone may be saved. Should necrosis of
bone occur, the dead bone must be removed as soon as it becomes loose.
If the shaft of the bone dies, a short longitudinal incision should be
made, the shaft divided and pulled loose from either epiphysis. If this
is done early, it will save deformity, suppuration, and sepsis. Further-
more, by applying an extension apparatus, new bone will be formed
in place of the old shaft, providing pus has not been present a sufficient
length of time to destroy the vitality of the periosteum.

Chronic Periostitis.

It is associated with changes in the connective tissues about the
bone. It is usually limited and is almost always due to syphilis, tuber-
culosis, or rheumatism. When it is caused by trauma, it arises from a
long continued irritation, or perhaps from the extension of an ulcer
into bone. As in acute periostitis, it may result from continued fevers,
such as typhoid.

DISEASES OF BONES. 193

Pathology. — The pathology is similar to that of acute periostitis,
except the tissue changes are not so rapid. Round cell infiltration takes
place in the periosteum, extending finally into the bone. The inflam-
matory material will, with proper treatment, be absorbed or may be-
come ossified, or a condition of fibrosis may occur. In another case it
may break down, forming pus, caries resulting. The ossifying variety
of the disease forms a hard node of bone. Suppurating chronic perios-
titis of the long bones is usually due to tuberculosis or typhoid fever,
whereas, that occurring in the skail is often the result of syphilis.

Symptoms. — Dull, deep-seated, boring pains, which are worse at
night than by day. Upon examination it will be found that the bone
is thickened, presenting hard, irregular nodules along its surface. On
the head, the tumor is usually soft and fluctuating and looks like a
sebaceous cyst, but there is always a history of syphilis.

Treatment. — The treatment is to lay open the soft mass and clean
out the abscess. If the case is syphilitic, the general condition should
be treated. Where a mass of bone dies, it should be removed. If the
inflammation extends into the medullary cavity, the bone should be
trephined.

Osteomyelitis.

There are three forms of osteomyelitis, (1) Acute simple osteomye-
litis, (2) Acute diffuse osteomyelitis, and (3) Chronic osteomyelitis.

Acute Simple Osteomyelitis is a localized inflammation of the
medulla of the bone and is believed to be of traumatic origin.
It arises from fractures or from sawing of the bone in an amputation.
There may be a localized necrosis, when the sequestrum is small and
conical, because of the spread of the inflammation along up
the medullary canal.

The treatment is to keep the wound aseptic and to remove the
sequestrum, if one forms.

Acute Diffuse or Infective Osteomyelitis is a more grave affliction.
It is said to be often spontaneous in its origin, while, in some
cases there may be a distinct history of trauma. It occurs in debilitated
and strumous subjects, especially in children.

Cause. — The cause of the disease is the streptococci and the staphy-
lococci, which have gained entrance into the system, because of the
lessened resistance of the tissues at some point, or because of the pres-
ence of ulcers. It follows, or attends, attacks of acute infectious dis-
eases or suppurating wounds. It sometimes follows abrasions where
more or less sepsis complicates the condition.

Pathology. — The disease is grave. It usually begins with a chill,
the fever rises rather rapidly, and delirium is common. In children,
after wounds, the disease comes on suddenly and at night. Where
there is no evidence of injury, the patient may give a history of becom-
ing chilled after being apparently over-heated. Locally, there are vio-

194 DISEASES OF BONES.

lent aching pains and acute tenderness over the seat of the inflamma-
tion. The entire medulla of the bone becomes infiltrated and there is
rapid diffusion of the pus germs. The toxins absorbed give symptoms
of sapremia, septicemia, or pyemia. It is not unusual that infective
osteomyelitis is the gravest of the staphylococci infections. The disease
can probably be prevented in many instances, but in others not.
The entire diaphysis of the bone may be destroyed and sometimes the
neighboring joints are involved. In some cases, only a central mass of
bone is destroyed.

Symptoms. — The symptoms are similar to those of periostitis, ex-
cept that the local signs are not evidenced so soon. The systemic dis-
turbances are usually greater and more sudden, but as soon as the
inflammation extends through the bone to the periosteum, the local
symptoms are the same, and perhaps the two diseases can not be differ-
entiated. High fever, rigors, and edematous swelling of the limb are
present. In cases of fractures or amputation, the periosteum recedes,
leaving the dead end of the bone protruding. The granulations about
the dead bone are fungating in character.

Treatment.— In osteomyelitis, not the result of wounds, an early
free incision seems to be the best treatment. Even before pus is formed,
the medulla of the bone should be exposed. In cases, the result of
operation or injury, the wound should be thoroughly cleansed with an
antiseptic solution. Some operators scrape out the medulla of the bone
and follow this curetting process with antiseptic washes. The treat-
ment is similar to that of sapremia or septicemia. Should general sep-
sis supervene, a high amputation is necessary. When septicemia and
pyemia seem to have been established, amputation will be of no use.

Chronic Osteomyelitis can not be differentiated from chronic perios-
titis. It may end, as other chronic inflammations, in the formation of
fibrous tissue in the medullary canal, or it may end in the formation
of pus. The disease is believed to be tubercular. The abscess following
is called Brodie's abscess. The disease may be the result of sj'-philis or
typhoid fever. The medulla of the bone and the tissues within the
Haversian canals, seem to be equally affected. The cancellous part of
the bone suffers most. It is difficult to differentiate this disease from
osteitis until after the diseased tissues have been exposed by operation.

Osteitis.

Osteitis means inflammation of the bone tissues, but this is said
to occur rarely, if ever, without involving the medulla or periosteum,
hence it is difficult to differentiate between it, periostitis and osteomye-
litis.

Cause. — The cause seems to be the same as in other disease of bone.

Pathology. — The pathology is likewise about the same. There is
usually a history of injur}'-, together with lesions affecting the tissues
locally, or certain constitutional conditions. The tissue changes

DISEASES OF BONES. 195

occurring in osteitis, are similar to those occurring in inflammations of
other tissues. The Haversian canals and other spaces in the bone be-
come infiltrated with proliferated bone cells. There are certain large
bone corpuscles formed which bring about a ratification, or thinning,
of the bone. By this process all of the bony spaces are enlarged and
by destroying the septa between the spaces, larger spaces are formed.
The periosteum wdl become more or less inflamed and perhaps sep-
arated by exudations from the bone itself. When the periosteum be-
comes separated, the nutrition i.s cut oft to a portion of the bone mass.
Death of this mass occurs (necrosis). In some cases, resolution of the
inflammation may take place, while in other cases, fibrous tissue and
bone formation will result, the bone becoming permanently thickened
and hardened (sclerosis). In other cases suppuration ma}^ follow and
abscess of the bone occur. This abscess of the bone is attended with
molecular death or caries. Sometimes caseation, may take place in
the abscess. It is said that osteitis will sometimes occur in connection
with periostitis, as the result of strains or traumatism, or will follow
any of the acute infectious diseases. Periostitis, and sometimes osteitis,
will occur at the attachment of the patellar tendon to the tubercle on
the front of the tibia in football players, causing a football knee.

Osteitis may terminate in destruction and absorption of part of the
bone, the process being similar to abscess formation with absorption of
pus. This is called "rarefied osteitis."

Symptoms. — Osteitis can not be differentiated from periostitis. The
signs vary according to the intensity of the inflammation. Pains are
deep-seated and boring, and they are worse at night, and increase on
moving about. The edema is slight, with little redness. If the
periosteum is involved, the redness will be considerable. There may
be no swelling at first, although subsequently, the limb maj^ become
considerably enlarged. The deep-seated character of the pain,
the fact that it has continued for a long time, and that pres-
sure relieves the pain, together with the absence of much redness and
swelling, indicate osteitis. Pain of a more superficial character, and
which is increased upon pressure, would indicate that the periosteum
and superficial tissues are affected. In the chronic form of the disease,
the diagnosis can not always be made.

Treatment. — The treatment should be directed towards increasing
the arterial blood flow, relieving the return circulation, and
any general or svstemic ailment which may be present. Eelief
may not be obtained until the bone is laid bare and a piece chiseled
out. This will let out the engorged blood and pus. If gout, rheumatism,
or tuberculosis exist, special treatment will be required.

Abscess of Bone.
Abscess of bone is always chronic. Acute inflammation of bone
causes necrosis rather than abscess formation. After enteric fever, an
area of suppuration may slowly form at the end of one of the long

196 DISEASES OF BONES.

bones. This is said to be due to the action of the typhoid bacilli. It
may occur after tuberculosis, the end of the bone being the point, of
least resistance. The disease is more commonly found in the tibia
than any other bone. Often great thickening of the bone
covering the abscess occurs. The pus may burrow into the joint,
inasmuch as there is no periosteum there to form a shell of bone to
act as a barrier, [inasmuch as this abscess of the bone may be the
result of any chronic inflammation of the bone, it may be located
within the medullary canal, within the bone itself, or beneath the
periosteum. The process by which pus is formed in bone, is similar to
that occurring in suppuration in the soft tissues. After the central
portion of the inflamed area dies, caries of the surrounding bone
follows until a distinct abscess cavity is formed. This is lined
with a thick, tough, pyogenic membrane. The abscess may be
latent in the bono for years. zVfter the abscess cavity forms, it may
burrow through the periosteum to the surface and discharge most of
its contents. The opening through the outside shell of bone may close
up and the abscess remain quiescent for a considerable period of time,
and when the system again becomes debilitated, or because of injury
or exposure, the abscess takes on renewed activity and pus is again
formed. At the second formation of pus it may burrow through a new
sinus, making an additional opening.

Symptoms. — The symptoms are somewhat obscure and frequently
lead to the diagnosis of chronic rheumatism. The pain is rather a
dull ache and is described by the patient as giving a sensation like
boring into the bone with a gimlet. The pain is said to be worse at
night. Previous to the discharge of pus through the small sinuses lead-
ing down to the cavity, the pain will be intense ; afterwards the patient
may be able to get up and about and suffer no very great inconvenience.
As the abscess approaches the surface, there will be edema and other
evidences of pus formation. The enlargement of the bone, the redness
of the skin, and the character of the pain, will be sufficient to make the
diagnosis. It may be impossible to distinguish whether it is a case of
osteitis, periostitis, or osteomyelitis, but it does not matter with which
of these ailments we have to deal, the treatment is practically the same.
Where there is doubt, exposure of the limb to the x-rays will indicate
the nature of the affection. In a case operated upon by the author in
the clinics of the American School of Osteopathy, an abscess in the
lower part of the tibia was opened. The history of the case extended
over a period of seventeen years. There were two openings leading
through the thick, hard shell of bone Avhich surrounded the abscess
cavity. The cavity itself was perhaps the size of a walnut. The tibia
was several times its natural size. A button of bone was taken out by a
trephine and the abscess cavity well curetted out and then packed with
gauze and afterwards treated antiseptieally. Appropriate osteopathic
treatment afterwards, to restore the general health, resulted in com-
plete recovery.

DISEASES OF BONES. 107

Caries.

Caries in bone is a process similar to ulceration in the soft-parts.
Tt means a limited molecular death of the hone substance. The general
tendency is to inflammatory exudates which are prone to suppurate
and afterwards, perhaps, to caseate.

Cause. — The cause of the disease is deficient nutrition from abnor-
mal blood supply and obstruction to the return circulation. Syphilis
and a general debilitated state of the system are also causes.
Conditions of caries usually give a history of an injury and a period
of failing health. Like abscess, caries is one of the terminations of
chronic inflammations of bone. The process ma3r be tubercular.

Pathology. — The pathological changes taking place are similar to
those of abscess formation, except that the condition is more chronic
and takes place slowly. The bone and periosteum become infiltrated
with granulation-tissue cells, the circulation becomes more or less
arrested at a certain point and coagulation necrosis of a small mass
results. This mass may break down and form pus, or it may undergo
caseation and absorption. Liquefaction necrosis may occur. Some-
times the adjacent trabeeulae of bone become absorbed because of the
destructive process, and a considerable cavity in the bone results. It
is said that the granulation-tissue cells may form distinct masses some-
times. These masses will increase or extend through the soft tissues.
This is called funrjating caries. There are cases where these granula-
tion tissue cells seem to break down and afterwards dry up, or the fluids
are absorbed, but the bone has already been destroyed by their action,
so that there is no pus formation and little evidence of inflammatory
tissue. This is a condition of dry caries (caries sicca). Should a con-
siderable mass die so as to form a sequestrum of bone, and afterwards
the caries follow, as in other instances, the condition is called
caries necrotica. In some instances, it is claimed the tubercle bacilli and
giant cells have been found in among the granulation tissue. This
has led to the claim that all these cases are tubercular. Caries occurs
in cancellous bone, and more often in the vertebrae than in any other
part of the body, whereas necrosis happens in compact bone and more
often in the long bones. The tuberculous variety more frequently under-
goes caseation and is attended by a crumbling away of the bone, with but
little tendency to repair, and the destructive process is more wide-
spread. There seems to be no method of determining whether or not
these cases are tubercular. It matters little, since the treatment is
the same in all cases.

Symptoms. — The symptoms are pain, more or less swelling (some-
times not evident), contraction and rigidity of muscles about the in-
flamed area, redness, and other evidences of inflammation when the
process becomes superficial. If pus forms, it will burrow along the direc-
tion of least resistance until rupturing. The discharge is a peculiar,
foul-smellins; material which contains a considerable number of bone

198 DISEASES OF BONES.

cells. Around the opening of the sinus there is a mass of granulation
tissue which is more or less exuberant and puckered. At the point
where caries occurs, the bone is found to be friable, rough, and yielding.
Treatment. — The surgical treatment is to enlarge the sinus and
cleanse the cavity. If it is possible to reach the carious bone, it should
be scraped out and a healthy ulcerating surface produced. Afterwards,
antiseptics, as boroglyceride solution, may be applied.

Necrosis.

Necrosis is the death of bone en masse, and with reference to bone,
it means the same as gangrene of the soft-parts. Necrosis of bone is
rather frequent and is more common, as before mentioned, in compact
than in cancellous bone. It more frequently follows acute inflamma-
tion. Necrosis is always due to an arrest of the nutrition to a mass of
bone, therefore, any inflammatory process which would interfere with
the nutrition to compact bone, will result in its death.

Cause. — The cause in all cases is arrest of nutrition, that is, the
blood supply is cut off. This may be due to inflammation, injury, tissue-
contractions, or luxations. The cause of the inflammation may be
injury or constitutional disease, or, perhaps, acute, specific febrile pro-
cesses. Fracture of bone and injury of the nutrient artery may result
in death of the bone, or necrosis. Injury of the main artery to the
part, or the main nerve, or vein, or extensive laceration of the soft
parts, or phosphorous or mercurial poisoning, may result in death of the
bone.

Pathology. — The pathological changes, which occur in the death of
bone, consist, for the most part, in depriving the bone of its membrane
(periosteum), and in plugging up the blood-vessels which enter the
bone through the Haversian canals. If undue inflammation occurs,
it will interfere with the nutrition and result in death. In necrosis,
from various causes, different parts of the bone will be affected. In
simple periostitis, the outer lamellae of the bone are usually
affected, whereas, in osteomyelitis, the layers of bone surrounding the
medulla are mostly affected. If, in acute osteomyelitis, the entire bone
is affected, the whole diaphysis will die. If the necrosis is due to ostei-
tis or simple periostitis, it is very often attended with, and followed
by, caries. A piece of dead bone is called a sequestrum. This piece of
bone is devoid of periosteum, and is usually white, hard and bloodless.
Sometimes, after it has been exposed for a length of time to decompos-
ing discharges, it may turn black. The resonance of dead bone and
live bone is different. LI the bone has been inflamed, the surface of the
sequestrum will be rough and irregular. Usually, the surface next
the periosteum is smooth and the margins are ragged and serrated.
In inflammations, where caries has occurred, the sequestrum will be
porous and friable, but where there is more or less fibrosis, the mass
will be found hard and unyielding. After a piece of bone has died it

DISEASES OF BONES. 199

may, of itself, act as a source of inflammation, as it becomes a foreign
body and is therefore irritating. Nature endeavors to get rid of it by
an ulcerating process. In some cases, the ulcerating process may con-
tinue for some considerable length of time and the mass of bone may
be discharged (exfoliation). Often there is caries of the bone
around a sequestrum, forming a cavity. After the discharge
of a piece of bone or after its removal by surgical methods, the cavity
fills up with fibrous tissue, which undergoes ossification. It may
happen that, as the mass of bone dies and becomes separated, the
periosteum, not being destroyed, forms new bone around the outside of
it, so that the sequestrum lies in a mass of pus walled in by bone on all
sides. The sequestrum is then said to be invaginated. Sometimes this
cavity containing a sequestrum and pus, surrounded by a shell of bone,
is called an involucmm. Occasionally, the pus may burrow through this
shell of bone and discharge on the surface. The opening of the sinus
has a drawn appearance and is called a cloaca.

Diagnosis. — The diagnosis between caries and necrosis can not
always be made, nor is it essential. The pus is usually foul smelling,
and the appearance of the opening of the sinus is characteristic. A
probe may be introduced to the bottom of the sinus and the roughened
or loose bone detected. There are cases of necrosis without the
■formation of pus. These somewhat resemble new growths. This form
of the disease can not be diagnosed unless an incision is made. The
dead bone exfoliated in carious conditions is soft and crumbles, whereas
that derived from conditions of necrosis is thick and hard.
The skin over necrosis is more edematous and inflamed. The dis-
charge in caries may be thin and more or less watery, whereas in the
case of necrosis, it is thick and purulent. In case of necrosis,
there may be great thickening of bone, while in caries, there may not
be. In abscess of the bone there likewise may be found great thicken-
ing of the bone and a discharge of pus. The diagnosis can be eorrectly
made only by exploratory incision.

Treatment. — The treatment in diseased bone is to extirpate the
diseased area when it is possible. In case of necrosis, as soon as the
diseased bone is found, it should be removed. The inflammation should
be treated as any acute inflammation. In chronic conditions, an opera-
tion, uncovering the sequestrum and removing it will be found neces-
sary. The presence of several cloacae and a thickened condition of the
bone will be sufficient to warrant a diagnosis of involucrum. A bone
chisel or trephine should be brought into use, the abscess cavity opened
and the sequestrum removed, and all of the dead or diseased bone
scraped out. The abscess cavity may then be cleansed thoroughly and
a boroglyceride solution applied once or twice daily. In case the
abscess cavity is larsre, and severe hemorrhage follows the operation,
the cavity from which the diseased bone has been removed should be
packed with borated gauze. Cleanliness, together with supporting

200 DISEASES OF BOA?ES.

treatment and a correction of any local lesions, malposition of the
limbs, bones, muscles, and contractions of fascia, will effect a cure.

Atrophy of Bone.

Atrophy of bone is often an accompaniment of old age. It
results because of pressure or non-use. It may occur about joints,
because of disease or non-use, or in the stumps of amputated limbs.
This atrophy may be attended by a friable condition of the bone, or
the bone may become considerably smaller, rendering it more liable to
fracture. Fatty degeneration, more or less, attends atrophy of the bone.

Hypertrophy of Bone.

Hypertrophy, as the term indicates, is an overgrowth of the osseous
structures. The general causes of hypertrophy operate. It is the result
of an increased blood supply, excessive use, etc. In case of the removal
of the radius, the companion bone, the ulna, will become enlarged and
hypertrophied. In such cases it depends upon an increased demand
upon the bone. The term "hypertrophy" should not be applied to
fibroid thickening, the result of inflammation.

Syphilis of Bone.

In tertiary syphilis, certain pathological changes take place in the
bones. The nature of these changes are gummatous formations
occurring usually in the periosteum. They are nodes of inflammatory
thickening or infiltration. These extend into the bone itself. Ofttimes
they lead to caries, necrosis, or sclerosis. Ulceration and destruction
of bone may occur because of this low-grade inflammation set up, and
because of the general condition of malnutrition existing in syphilis.

Tuberculosis of Bone.

Tubercular disease of bone refers to that variety of osteitis set up
by the deposit of the tubercle bacillus.

Pathology. — The pathology of the affection is the pathology of the
deposit of the tubercle anywhere, except that it occurs in bone. The
deposit of the tubercle always takes place at a point in the bone where
there is the least blood supply and where the bone is the weakest. It
develops after an injury has set up an inflammation. In the largest
per cent of the cases, tuberculosis of other organs does not occur.
Patients suffering from Pott's disease of the spine, which results in the
formation of psoas or lumbar abscess, may live out a long life, after
apparently extensive destruction of the tissues. There seems to be no
way by which we can determine whether or not a given case is tubercu-
lar, therefore the same treatment should be applied in all cases, viz., to
increase the general nutrition, relieve any constitutional conditions,
support the patient by proper diet, hygiene, and habits, and above all,
correct any lesions which may be found, Avhich might be the cause of the
ailment by interfering with the circulation and nutrition of parts of
the bone.

DISEASES OF BONES. 201

Mollities Ossium, or Osteomalacia.

Mollities Ossium is a disease in which the earthy salts are absorbed,
leaving the bone soft so that it will bend. There may be numerous bones
involved. Usually it comes on late in life, and is said to be more fre-
quent in women than in men. It may occur during pregnane}'. The
medullary structures of the hone increase in size and become more
fatty.

Cause. — The cause of the disease is unknown. Some writers main-
tain that it is produced by the development of lactic acid in the system,
but this is only theory. In some cases the medulla of the bone seems
to be filled with material much resembling spleen pulp.

Symptoms. — The symptoms of the disease are those of rheumatism.
There is a general weakness and obscure pains. This is followed by a
sudden fracture or perhaps a bending and distortion of the bones. The
long bones become misshapen, as do the pelvis and thorax. The urine
is said to contain albumen, phosphates, and lactic acid. Death usually
comes on from exhaustion. If it occurs during pregnancy, the patient
may die during parturition.

Treatment. — Inasmuch as the cause of the disease is unknown, the
treatment is likewise not definite. It is reasonable to suppose, when
we consider the many affections in which Osteopathic treatment has
been eminently successful, where other methods failed, that in these
cases there will be found lesions accounting for the conditions present.
Where this is true, the removal of these lesions and the abatement of
the symptoms would indicate to the physician that he had found the
source of the trouble. At all events, whatever lesions are found, they
should be removed with the hope that a specific treatment may be
found.

Acromegaly.

In this disease there is general, symmetrical enlargement of the
bones and connective tissues of the hands, feet, head, and face. The
nasal and inferior maxillary bones are the most affected. Prognathism
of the lower jaw and prominence and thickening of the nose and supra-
orbital ridges are marked symptoms. The larynx, bones of the shoulder-
girdle, ribs, and vertebrae may also become affected. The cause of the
disease is obscure. It can. most likely, be attributed to some
lesion of the nervous s}rstem.

Virchow's Disease, or Leontiasis Ossium.

This disease consists of hypertrophy of the facial and cranial hones.
It is symmetrical and usually involves the superior maxillary bone.
The hypertrophy is progressive, symmetrical, and causes persistent
headaches. Great deformity results. Where the disease has continued
for some length of time, the removal of a mass of bone may give some
relief.

202 INJURIES OF BONES.

Tumors of Bone.

The tumors of bone are:
1. Osteomata. 2. Enehondromata. 3 Fibromata, -i. Sarcomata.
5. Carcinomata.

Osteomata. — These tumors are reproductions of true bone. They are
circumscribed and diffuse. The diagnosis of the tumor can be made by
eliminating the other forms.

The treatment consists in, removing the tumor by means of a chisel.

Enehondromata. — These are reproductions of cartilage in connection
with bone. They occur more frequently in the bones of the fingers or
at the end of the long bones. They are multiple and often
congenital. Sometimes, in developing within a bone, the}r expand it
into a thin shell, maybe rupturing it. They are thought to arise from
periosteum. They may grow in any direction in the bone, or out
towards the surface. They rarely ossify, but calcification or mucoid
softening may occur.

Diagnosis. — They may be diagnosed by great hardness and their
even attachment to the bone, slow growth, and no glandular enlarge-
ments attending.

Fibromata. — These sometimes occur in connection with the bones at
the base of the skull or lower jaw. They are said to constitute the
nasal polypi and epulis, and rise from the periosteum of the bones of
the naso-pharynx.

The treatment is to remove the tumor.

Sarcomata. — Sarcomata of bone are common. They are of the
mveloid variety, occasionally the round and mix-celled. They are de-
rived from the deeper layers of the periosteum and may surround the
bone or extend to the bony tissues.

Symptoms. — The symptoms of sarcoma are the symptoms of a sar-
coma anywhere on the body. They grow slowly and occasion consider-
able pain, but do not affect the lymphatic glands. Some forms of- sar-
comata may grow rapidly. The pain may not be severe, or it may be
absent. The tumor occurs more frequently in young people and is
attended by great loss of weight and strength. In some cases the tumor
is pulsating and there is considerable redness and edema of
the soft-parts. If possible, the tumor should be removed. Some forms
of the tumor are very malignant.

Carcinomata. — Cancer of bone never occurs primarily. It may
spread to the bone from any of the organs or from any of the surfaces
of the bod)^. Amputation seems to be the only relief.

INJURIES OE BONES.
Fractures — A fracture is a broken bone, or a sudden and forcible
solution of the continuity of bone.
Causes. — A. Predisposing.

1. Age. 3. Occupation.

2. Sex. 4. Certain diseased conditions.

INJURIES TO -BONES. 203

Age. — Fractures are more common after the age of forty-five, be-
cause of the fragile condition of the hones, and less common in small
children on account of the elasticity of the bones and because the sub-
ject is less liable to injury. Fractures increase in frequency from six
years upward, being more frequent in very old people.

Sex. — The male sex is more liable to fracture, because of greater ex-
posure to violence and injury.

Occupation. — Laborers, because of the greater risks they are com-
pelled to take in life, are more liable to fractures.

Certain diseased conditions, which render fractures more likely, may
be enumerated as follows: Atrophy, either senile or from pressure or
disuse; rickets; fatty degeneration; fragilitas ossium; osteomalacia;
nervous disorders; tuberculosis and syphilis; caries and necrosis; malig-
nant growths, and in fact, any condition which impairs the strength of
the bone renders it more liable to fracture.

B. Exciting causes.

1. External violence. 2. Internal violence.

a. Direct.

b. Indirect.

Direct Violence. — By direct violence we mean violence applied to the
spot where the fracture occurs. It is evident that in cases of this kind
there will be more or less contusion of the soft-parts at the site of
fracture. The fragments are more liable to be comminuted and the
injury to the soft-parts is likely to be greater in fractures from direct
than from indirect violence.

Indirect Violence. — Fractures from indirect violence take place
where the force is transmitted through the axis of the bone or through
other structures, as for instance, intra-capsular fracture of the femur
takes place in twisting the leg from catching the toe; fracture of the
clavicle may occur from falling on the hand ; fractures of certain verte-
brae or the base of the skull may be produced by falls upon the but-
tocks; fractures on the back part of the skull may take place because
of injury upon the front of the skull (fractures by centre coup).

Internal Violence. — Internal violence consists of muscular action.
Fractures from muscular action may take place in the long bones, in
diseased conditions, as in the case of spastic paralysis. Under ordinary
circumstances, they are more common in the patella.

Varieties of Fracture.

All fractures are divided into simple and compound, depending
upon whether there is an open wound leading to the site of fracture.

1. Simple Fracture is one in which air is not admitted to the site of
fracture.

2. Compound Fracture is one in which air is admitted to the site of
fracture or the wound leads to the surface. A flesh-wound attending a

204

INJURIES OF BONES.

fracture does not necessarily mean that the fracture is compound. The
wound may not lead to the site of fracture.

All fractures may also he divided into complete and incomplete.

3. Complete Fracture is one in which the hone is separated into two
or more fragments.

4. Incomplete Fracture is one in which the hone is not separated
into fragments, hut is only partially fractured. The most common form
of incomplete fracture is green-stick fracture, where the hone is par-
tially hent and partially hroken.

Other forms of fracture may he described as: —

5. Multiple Fracture, a condition where there
is a fracture at more than one point in the hone.

6. Comminuted Fracture, where the hone is
fractured at two points and these lines of frac-
ture unite.

7. Impacted Fracture, a condition where one

Fig. 35. Fig. 36.

Fig 3/

Comminuted fracture
of upper extremity of
tibia.

An impacted fracture of the up-
per extremity of the femur.

Transverse frac-
ture of the tibia.

fragment telescopes the other, or the ends of the hones are driven
into each other.

8. Fissured Fracture, a condition where the hone is simply fissured,
not entirely hroken off, and there is no displacement. This variety
occurs most frequently in flat hones.

9. Depressed Fracture occurs in bones of the skull most frequently.
One edge of the hroken bone is driven below its opposing edge.

10. Punctured Fracture is one which is produced by a pointed in-
strument without disjolacement of the fragments.

11. Splintered Fracture is a condition where the ends of the bones
ore splintered and separated into numerous fragments.

Other forms, described according to the line of fracture, may he:

INJURIES OF BONES.

205

. 12. Transverse, where the line of fracture is transverse to the long
axis of the hone.

13. Oblique, where the line of fracture extends obliquely to the shaft
of the bone.

14. Longitudinal, where the line of fracture extends lengthwise in
the bone.

In. Spiral, where the line of fracture extends spirally around the
bone.

16. Y or T Fractures are those occurring at the end of hones,
as in the lower end of the humerus or femur, the line of fracture
resembling the letter Y or T.

IT. Stellate Fracture is one occurring in the skull where several lines
of fracture radiate from a single point.

18. Epiphyseal Fracture is
one extending through the epi-
physeal cartilage which unites
the epiphysis and diaphysis. It
consists in the separation of the
epiphysis from the diaphysis.

19. Complicated Fracture is
one which is associated with
extensive injury to the soft-
parts, or is attended by rup-
ture of the main arterv of the
part, or by concomitant dislo-

Fig. 49.

Fig. 38.

Fig. 39.

Kxample of ob-
lique fracture of
the tibia.

Longitudinal fracture
of the tibia.

^*

Y fracture of the lower extrem-
ity of the humerus.

cation or other severe injury which interferes with treatment
and union of the fracture.

20. Ununited Fracture is one in which union has not taken place
within a reasonable length of time after the injury.

Signs of Fracture. — The signs of fracture are, in general, those of
local injury and may be enumerated as :

1. Pain.

2. Swelling.

3. Deformity.

4. Impaired function.

5. Preternatural mobility.

6. Crepitus.

7. Shortening.

8. Sensation of sudden snap.

9. History of the accident.

206 INJURIES OF BONES.

The pain of a fracture is not diagnostic. It may be severe, or slight.
Sometimes it is so severe as to cause great shock; especially is this
true where a large nerve, puch as the sciatic, is pressed upon by the
jagged end of the bone.

The swelling may be slight, or it may be severe, depending largely
upon the amount of injury to the soft-parts, and the amount of effusion
of blood amongst the tissues.

The deformity varies. It may be simply an enormous swell-
ing or it may be angular, such as to indicate at a glance that there is a
broken bone. Deformity, crepitus, shortening, and other signs will
depend largely upon the displacement of the fragments. The displace-
ment of the fragments depends upon three things, viz. :

1. Continuation of the fractur- 2. Muscular action.

ing force. 3. Weight of the limb.

Sometimes, because of these agencies acting, the deformity will
depend upon the amount of the swelling, the degree and nature of the
displacement of the fragments.

Impairment of the Function will depend largely upon the nature of
the fracture. Sometimes the function will be only slightly impaired, at
other times the function may be entirely lost.

Preternatural Mobility means mobility at a point where there should
be none. The mobility may som.etim.es be increased and at other times
diminished. In case of fracture of the shaft of a bone, there is mobility
at an abnormal location. In case of fracture at the end of a bone, the
mobility may be decreased. Preternatural mobility may be absent in
fissured fractures, in incomplete or green-stick fractures, or in impacted
fractures. When it can be obtained, preternatural mobility is proof
positive of fracture.

Crepitus is the sensation imparted to the surgeon's hands by the
scraping together of the roughened ends of the broken bone. This
scraping together of the ends of the bone may be sufficient that
a grating sound can be heard, but the crepitus refers to the sensation
which is obtained by touch. There are two kinds of crepitus, false and
true. False crepitus is obtained at joints Avhere there are roughened
tendon-sheaths or articular cartilages, or where fibrous adhesions have
been formed between the ends of the bones, so that motion of the joint
causes grating. In some cases this so closely resembles crepitus as to
make the sign of but little value. True crepitus is of great import-
ance. It is sufficient evidence upon which to base the diagnosis where
there is proof that it came from the bone, and not from other
structures.

Shortening" varies according to the fracture and according to the
condition of the member. It is produced by muscular contraction, the
muscles normally being slightly contracted, and when the bone is

INJURIES OF, BONES 207

broken the ends are pulled past each other. Sometimes the weight oi
the member, with no other agencies acting, may overcome this muscu-
lar contraction, when the shortening may not. be so great.

Sensation of Sudden Snap and .History of the Accident. — A history of
the accident, and the fact that the patient felt a cracking of the bone,
may be of some value. Subjective symptoms are often of not much
value.

Diagnosis of Fracture.— The diagnosis of fracture is made by weigh-
ing the symptoms and evidences obtained. Sometimes the fracture will
be extremely difficult to make out. The diagnosis may be clouded under
the following circumstances:

1. When the fracture occurs in the neighborhood of a joint.

2. When there is much fluid effusion and extravasation of blood and
serum about the site of fracture, so as to render it impossible to make
suitable examination.

3. In conditions where there is no displacement of the bones, or
where the fragments are held together by a companion bone.

4. Subperiosteal fractures or fissured fractures of the skull.

The sign? of fracture may be so meager and difficult to obtain that
a diagnosis is impossible. Where it is possible, in doubtful cases,
the injured member should be exposed to the x-rays. The diagnosis
can be made by successfully obtaining the various signs of fracture.
Crepitus can be obtained by making extension and counter-extension
where the fracture occurs in a long bone, thus bringing the
ends of the bone in apposition. Crepitus may be gotten
by grasping the limb above the site of fracture and rota-
ting the limb below. Sometimes effort at muscular action by
the patient will develop crepitus. Where crepitus can not be obtained
without the use of force, other signs must be looked for , Shortening is
an important sign in man}r fractures and is obtained by measuring,
a'fter placing the body in a normal position. Measurements should be
taken from fixed points. In case of fracture of the humerus, the short-
ening is determined by measuring from the acromion process to the
external condyle. Preternatural mobility is one of the most important
of the signs and is obtained, in some instances, by grasping the limb
above and below the fracture, and an effort at motion will determine
whether there is mobility at a point where there should be none.

How Fractures Heal.— As a rule, a broken bone heals, under favora-
ble circumstances, much better than any other tissue. The way in Avhich
union takes place is of the greatest importance, and should be thor-
oughly understood in order to appreciate the importance of the methods
of treatment. As soon as the fracture occurs, extravasation of blood
takes place in the soft parts and between the ends of the broken bones.
This extravasation may be great or it may be small. Sometimes it is
so great as to form a complication of the fracture, but under average
circumstances the hemorrhage into the site of fracture will cease when

208 INJURIES OF BONES.

the pressure becomes equal to that within the blood-vessels. The tissue
changes and inflammation which follow will be sufficient only to repair
the injury in case of simple fracture. In case of compound fracture,
the inflammation will likely be greater because of the introduction of
a certain amount of septic material. The periosteum, Haversian canals,
medulla of the bone, and soft tissues about, all become infiltrated with
leukocytes and round cells. These new cells are derived

from the endothelial cells in the Haversian canals, from the
endosteum (membrane lining the medullar cavity) and periosteum.
The blood which has extravasated between the ends of the bones,
becomes absorbed within four or five days in ordinary frac-
tures. In case of green-stick fracture, perhaps earlier, while if there is
extensive injury to the soft parts, the absorption might not be completed
before the sixth or eighth day. In young persons the reaction of the
tissues to injury is quicker and greater than in old people, so that the
absorption takes place more quickly. The formation of granula-
tion tissues at the site of fracture takes place just as soon as
the clot is sufficiently absorbed. When the diffused blood disappears,
its place is occupied by granulation-tissue cells which comprise the soft
callus. The formation of this soft callus begins, in children, as early
as the third or fourth clay; in very old people as late as the tenth or
twelfth day, but ordinarily it begins by the fifth or sixth day, so that
the fracture should be set before that time. This soft callus becomes
penetrated by delicate capillary loops which are derived from the vessels
in the Haversian canals and periosteum. The soft callus which fills
up the spaces between the ends of the bones is the permanent or defini-
tive callus. Within the medullary cavity the endosteal callus is
formed, whereas on the outside of the bone and derived from the per-
iosteum is formed the periosteal, or ensheathing callus. This new
tissue becomes firm and hard and highly organized until it is converted
into a fibrous or cartilagenous mass. Over the ensheathing callus new
periosteum forms because of a growing out of the periosteum from
either side of the fracture. All this has occurred, under average cir-
cumstances, by the fourteenth day after the fracture. At this time
ossification of the callus begins, usually at the point where the
ensheathing callus meets the periosteum. The ossifying process ex-
tends over either edge of the ensheathing callus until it meets in the
middle line and also extends down in through the definitive callus into
the endosteal callus. Ossification in the definitive callus begins at
the edges next to the healthy bone, Avhile ossification of the endosteal
callus starts where it is in contact with the endosteum and takes place
in the same manner as ossification from the periosteal callus. When
ossification is complete, the endosteal and periosteal callus become
absorbed and disappear, leaving the permanent callus sufficiently
strong to maintain the integrity of the bone. The new callus is vascu-
lar in the beginning, but becomes solid by the process of ossification.
The large vascular spaces are filled up by layers of bone successively

INJURIES OE BONES. 209

built in. In cases where the fragments overlap, the space is filled
up by the ensheathing callus, and under such circumstances the en-
sheathing callus will not be absorbed. When the fragments are in
good apposition and kept at rest, all the ensheathing and endosteal
callus will disappear. Where there is much motion, or not good appo-
sition, none of the ensheathing callus may be absorbed and a large
knot will always remain as an evidence of fracture. It is the rule in
children, for a considerable amount of ensheathing callus to be devel-
oped because of the energy of the tissues.

Treatment. — The indications in the treatment of fractures are:

1. Reduction. 3. Restoration of function.

2. Maintaining apposition. 4. Attention to the general health.

Reduction of fracture consists in bringing the ends of the bones in
apposition in as nearly normal position as possible.

Temporary Methods. — When a fracture is first seen, the member,
should be put in the best position possible to prevent injury. Effort
at reduction should not be made until the proper materials for splints
and bandages are at hand. In case of a fractured femur, the limb may
be tied to the opposite one, or it may be bound to an umbrella or stick,
so that further manipulation of the member will not injure the soft-
parts. Where the patient is already in bed, sand-bags or pillows may
be propped about the limb. Before efforts at reduction are made, the
clothing, shoes, etc., should be cut off and the limb exposed, so that a
careful examination can be made to determine the nature of the frac-
ture and amount of displacement. The conditions preventing reduc-
tion are:

1. Swelling. The swelling may be such as to interfere with the set-
ting of the fracture or the application of the proper dressings. Under
such circumstances anti-inflammatory measures, such as cold and rest,
should be employed for the first twenty-four or thirty-six hours, the
part having been kept immovable during this time. When tjhe swelling
has sufficiently subsided, efforts at reduction may be made.

2. Contraction of muscles may be such as to interfere with the re-
duction. When this occurs, a pulley and weight should be secured, so
when reduction is once made, the fragments may be kept in position by
means of extension and counter-extension.

3. Interposition of fascia, muscle, tendon, etc. The interposition of
some of the soft structures, as a piece of periosteum, tendon, muscle,
etc., may prevent the surgeon from securing apposition of the frag-
ments. It is necessary to get rid of this interposing tissue or union will
not take place.

4. Impaction of fragments will also prevent reduction; in fact, in
cases of impacted fracture, reduction should not be made. The frac-
tured bones should be allowed to heal in that position. Before efforts
fire made at reduction of a fracture, a suitable splint, such as the sur-
geon believes to be the best for the condition at hand, should be selected,

210 INJURIES OF BONES.

and all materials prepared before a reduction of the fracture is
attempted. The nature of the dressing will depend largely upon the
choice of the surgeon, inasmuch as there are many suitable dressings
that are known and tried, and if properly applied will bring about good
results.

Methods of Reduction of Fracture. — The reduction is usually
accomplished by extension and counter-extension. This overcomes mus-
cular contraction, when the pressure of the soft-parts will push the ends
of the bone in the proper position. This is not always true. In case of
fracture of the upper extremity of the femur, extension and counter-
extension will not bring about relaxation of the contractured muscles.
In this case the psoas and iliacus muscles tip the lower end of the upper
fragment forward and prevent the operator from securing the desired
apposition of the fragments. In such cases it is necessary to partially
flex the thigh upon the abdomen. In case of fracture of the lower
extremity of the femur, contraction of the muscles of the calf turns
the lower fragment backward, preventing apposition, and no amount
of extension and counter-extension will secure apposition. Here, by
flexing the leg at the knee, the limb may be properly manipulated and
apposition secured. In general, to secure reduction, extension and
counter-extension, rotation and flexion, and manipulation should be
made to mould the parts in position, and when once the bones ore got-
ten in good apposition, every effort should be made to maintain them in
such position.

Position of the Limb. — The limb must be put in such position as
to secure the greatest muscular relaxation and greatest ease to the
patient. Opposing muscles rarely act with equal force and it is neces-
sary to determine the muscles which are contracted. The limb must
be placed in such position as to secure relaxation of the contracted
muscles.

Position of the Fragments. — When the fragments are impacted, they
should be alloAved to remain in this condition. The reasons are,
that because of the injury to the ends of the fragments, one being
driven into the other, the effort at union will not be sufficient and
therefore a bad result may be obtained; whereas, if the impaction is
allowed to remain, good union may be obtained, but there may be some
deformity. It is better to have the slight deformity attending an
impacted fracture than lose the use of the member, which might occur
providing the impaction is broken up.

Maintaining Apposition. — In the treatment of fracture it is neces-
sary to maintain apposition in order that nature may, by the reparative
process, heal the injury. This apposition must be maintained at all
times until union is complete, when the apparatus used for the purpose
may be dispensed with. To maintain the fragments in apposition, it is
necessary to use splints, bandages, strappings, etc., such means as are
known to be reliable. These splints, bandages, and strappings vary ac-
cording to the location of the fracture and its nature.

INJURIES OF BONES.

211

Rules for Applying Splints. — Rules for applying splints may be best
considered under the following heads:

1. The splint must be well padded. The padding is best made by
means of aseptic lamb's- wool, borated lint, or surgeon's cotton. The
splint should be thoroughly padded to give the member a nice, soft,
easy bed in which to rest.

2. The splint should not press upon bony points. This should be
observed for fear a pressure-sore might result. Also unequal pressure
would result in displacing the fragments.

' 3. The bandage must not be applied too tightly, so that constriction
of the limb will take place. It may be possible, in the application of the
bandage, that it will so obstruct the return circulation that gangrene
will result, or it may so interfere with the nutrition of the limb as to
cause non-union.

4. Splints, in general, must render immovable the joints' above and
below the fracture. Inasmuch as the muscles which move the member

Fig. 41.

Extension apparatus applied, suitable for fractures of the femur. It consists of a long
strip of adhesive plaster extending up on either side of the leg. The adhesive plaster is
held in place by a roller bandage.

have their origins from above the joint, and their insertion is frequently
beyond the joint below, it is necessary to render both immovable in
order to secure immobility of the fragments.

5. The splint must not cover the wound, in case of compound frac-
ture. This is necessary, inasmuch as the wound must be treated. In
case of severe simple fracture, the site of fracture should be left exposed
in order to observe any changes which may take place.

6. The patient must be seen within twenty-four hours after apply-
ing the first dressing. This is necessary, inasmuch as the swelling
which follows fracture, may be such as to operate as an obstruction to
the return circulation. The bandage may become too tight.

7. Should the circulation not be disturbed and the fragments held
in apposition, the dressing should be left alone. This rule should be
followed conscientiously. It is not necessary to look at the site of frac-
ture every day, but it is necessary to see that the dressings accomplish
the desired purpose.

8. Where the splints will not maintain apposition, an extension

212

INJURIES OF BONES.

apparatus must be applied to overcome muscular contraction. This is
preferably done by a weight and pulley, the extension being made on the
lower fragment. On the lower extremity in strong men, the weight
should be five to ten pounds; in persons less strong the weight should
be less.

Fig. 42.

A plaster cast which encloses a rod by which the member
may he suspended.

Dressings. — There are many forms of dressings. Some surgeons
prefer one kind and some another. Some have secured better results
with one kind of dressing and, perhaps, are more adept at applying that
dressing. Dr. A. T. Still prefers a starch-paste dressing made with
starch-paste, pasteboard, and a many-tailed bandage.

Other forms of dressing consist of splints made of thin board, paste-
board, gutta percha, or a plaster-of-Paris dressing. At pres-

FiG. 43.

'VWW — ~^v^rf^=

A plaster trough applied to the lower leg It is an ex-
cellent dressing for fractures of the tibia or fifoula.

ent the plaster-of-Paris dressing is the most popular. It has
many advantages, viz., great strength and durability. A plas-
ter-of-Paris dressing is often applied at once, in case of frac-
ture, where there is not much injury to the soft parts, or
much swelling, or where the case is in a hospital and can be watched

INJURIES OF BONES.

213

Fig. 44.

by an intelligent attendant. In private practice this is not best, inas-
much as it may obstruct the return circulation. It is best to put on a
temporary dressing until the swelling reaches its maximum intensity,
when the gypsum splint may be applied.

Restoration of Function. — Eestoration of function is accomplished,
in the greater part, by manipulation. This manipulation assists the
return circulation, prevents adhesion among the soft-parts and main-
tains the integrity of the joint. This
manipulation should be begun at
the end of the second week in almost
all cases. Some fractures in old people
may form exceptions to the rule. The
former method of treating fracture
by not manipulating them until after
four or five weeks has been found to
be bad, inasmuch as by manipulation
you can assist the circulation and se-
cure union in many cases where other-
wise non-union would occur. Where
the fracture is in the neighborhood
of a joint, or involves the joint, just
as soon as the inflammation and swell-
ing disappear, which will be in four
or five days, manipulation to assist
the return circulation, to prevent the
formation of adhesions, will be found
of the greatest advantage. This ma-
nipulation should be gentle and not
vigorous and destructive, hut should
be regularly kept up. The manipula-
tion consists in pronating and supi-
nating, extending and counter-extend-
ing, rotating and circumducting the
member, and in loosening up the
soft-parts in the neighborhood of the
fracture in a mild way.

Attention to the General Health. — This can best be subserved by
placing the person upon a suitable bed. In general, the bed should be
smooth. "Where there is a tendency to bed-sores, a water-bed or air-
cushion should be provided, while the skin should be treated with
lotions of alcohol and an ointment of benzoated oxid of zinc. If availa-
ble, a fracture bed may be supplied. The patient should be placed upon
a suitable diet, consisting of substantial food which will sustain
the strength. The bowels should be kept acting daily. . Old
people should not be kept in bed too long, as edema of the lung is liable
to arise.

Time Within Which a Fracture Should Heal. — Complete union

The ambulatory method of treating
fractures of the leg.

214 INJURIES OF BONES.

takes place in fractures, in the average case, in from four to six
weeks. . In a child, good union may take place within three weeks,
whereas, in an old person, it may be considerably longer. If union has
not taken place in eight weeks, it may be considered a condition of
delayed union, but delayed union is liable to occur under many cir-
cumstances.

Ununited Fracture. — An ununited fracture is a condition in which,
within a reasonable time, the fractured ends of the bones are not united
with suificiently strong callus to enable the restoration of the function
of the member. There are various conditions of ununited fracture,
which may be classified as follows:

1. Delayed Union. This is a condition where, because of debility
or disease, or because of the treatment, the union is delayed beyond the
time when it should have taken place.

2. Fibrous Union. Fibrous union is a condition which may occur,
even under favorable circumstances, as in fractures of the patella, intra-
capsular fractures of the neck of the femur in old people, or fractures
of the anatomical neck of the humerus, where the parts of the bone at
the site of fracture are poorly supplied with blood. It occurs at other
locations, where the parts are not kept strictly immovable.

3. False Joint (Pseudo-arthrosis). A condition of false joint oc-
curs where the fracture has not been kept immovable, and the ends of
the bones become worn off; a thin covering of cartilage forms, and a
capsule is developed.

4. No Effort at Union Whatever. There are conditions of malnutri-
tion, where there is no effort at union whatever. The causes of non-
union or ununited fracture are local and general. The local causes
may be enumerated in this manner :

(a) Failure to maintain immobility, which may be because of im-
proper dressings, or because the patient did not properly follow the
instructions of the physician.

(b) Failure to secure apposition, not from the bungling work of the
operator, but from (1) muscular contractions which will cause overlap-
ping of the fragments; (2) interposition of muscle, tendon, fascia, per-
iosteum, etc. ; (3) the loss of a piece of bone. Where there is com-
minution, a piece of the bone may be destroyed. This loose piece of
bone may act as a foreign bod)'', preventing apposition.

(c) Defective nutrition to the injured bone may be brought about
by the following conditions: (1) injury to the nutrient artery of the
bone: (2) injury to the main artery of the limb; (3) defective nerve
influence, because of injury or rupture of the main nerve to the limb,
or because of injury to the spine, so that the trophic and vasomotor
impulses to the injured area are either interfered with or destroyed;
(4) poor blood supply to the site of fracture. This occurs in case of
fracture through the ends of the bone, as in the upper extremity of the
humerus or femur. (5) Necrosis of a fragment of bone may occur,

INJURIES OF BONES. 215

where it has been detached from the soft tissues and from the shaft
of the hone, its source of nutrition being thereby cut off.

The general causes of non-union are the following: Old age, gen-
eral debility, malnutrition, or sudden alteration of the patient's habits.
If the patient has been addicted to the use of stimulants, the sudden
withdrawal of them, may markedly interfere with the nutrition. Gen-
eral diseases, as Bright's disease, diabetes, syphilis, gout, tuberculosis,
rickets, and scurvy,' certain forms of paralysis, such as tabes dorsalis,
or paralysis agitans, will interfere with the general nutrition of the
body to that extent that there will be little or no effort at union.

Disunited Fracture. — A disunited fracture is a condition where the
fracture has once healed and, because of acute fevers or some general
disease, the callus is absorbed, and the fracture left ununited.

Treatment of Delayed Union. — The treatment of delayed union
°hould be taken up methodically. The first thing to determine is the
cause, and this should be corrected. In general, the following pro-
cedure should be strictly adhered to:

1. Keapply and fix a dressing, correct in every detail, which will
maintain the fragments in apposition and immovable. The general
health should then be corrected. If there are any local or spinal lesions,
or any condition wbich would interfere with the nutrition to a certain
area, these conditions must be relieved. At this same time, thorough
manipulation of the soft-parts, and of the member should be kept up,
to secure a good blood supply to the site of the fracture. If this fails,
the following should be tried:

2. Friction of the fragments should be made under anesthesia.
"When the muscles are thoroughly relaxed, the two fragments should be
grasped and raked together vigorously and thoroughly, in order to excite
the reparative process. Then a fixed dressing should be applied and
the parts kept in apposition, until the fracture has had an opportunity
to heal. In the meantime, any constitutional defect should be corrected.
Any lesion interfering with the circulation, general nutrition, or the
secretion of any organs, such as the kidneys, liver, etc., should be treated
and removed. If this method fails, the following should be tried:

3. Operative Procedure. The operative procedure, to unite an old
fracture, consists in drilling through the ends of the fragments with
a bone drill, and fastening the fragments together by means of aseptic
ivory pegs or steel nails, or the ends of the bones may be wired together.
Where the bones are subcutaneous, as in the case of the tibia, instead
of fraction, the bone drill may be introduced through the skin, and a
hole bored through the ends of the fractured bone to excite inflamma-
tion and union. Senn's bone-ferrules may be used. These are service-
able in the treatment of non-union, especially in case of the humerus
or femur.

Vicious Union. — Vicious union is a condition which sometimes
occurs in improperly adjusted fractures, or where the condition has

216 INJURIES OF BONES.

had bad treatment. An enormous amount of callus will be thrown out,
which will involve a nerve or a companion bone and interfere with the
use of the member.

Complications of Fractures. — Fractures may be complicated by the
following conditions, which must receive appropriate treatment:

1. General conditions, such as shock, delirium, retention of urine,
etc., brought about by the effects of the injury upon the general system.

2. Infection. Infections, such as erysipelas, tetanus, sepsis, etc., may
complicate fracture and interfere with union. Sepsis is rare, except in
compound fractures, but erysipelas and tetanus may occur in simple
fractures. These infections will likely bring about non-union and death,
unless they are successfully combated.

3. Dislocations. When a concomitant dislocation occurs, the heal-
ing of the fracture may be markedly interfered with, inasmuch as it
will be more difficult to secure apposition of the fragments and main-
tain immobility.

4. Injury to Other Structures. Injury to a joint, main artery to
the limb, or the nutrient artery to the bone, or to the nerve to the part,
may form a serious complication and prevent union, or, in some cases,
e\en demand amputation. Extensive extravasation of blood may form
a serious complication in the healing of a fracture.

5. Fat Embolism. Fat embolism may occur in case of fracture of
the long bones. This fat embolism is serious, but may be recov-
ered from. The fat gets into the deep veins, and, after passing through
the heart, will not circulate through the capillaries of the lung, causing
obstruction in the branches of the pulmonary artery.

6. Gangrene from tight bandage. Dr. A. T. Still advises the use of
his dressing, because the nutrition to the part below is not interfered
with, and the tightness of the bandage can be readily regulated. A
fixed dressing, as of plaster-of-Paris, may bring about gangrene of the
extremity, if it interferes with the return circulation.

7. Bed-sores and Pressure-sores. Unless guarded against, bed-sores
and pressure-sores may form such a serious complication of the fracture,
as to interfere with the general health of the patient and bring about
non-union. The attendant should be cautioned to watch for any indi-
cation of such sore.

8. Hypostatic pneumonia is a serious complication, in case of old
people, and should be avoided, if possible. If an old person is kept in
bed too long, the circulation being weak, the fluids settle in the lower
and back part of the lung, hypostatic pneumonia resulting. When once

.set up, it is fatal.

9. Paralysis may occur under at least two conditions. Crutch
: paralysis, because of the pressure of the crutch, or the nerve may become
involved in the callus, where the nerve is in relation with the bone, as
, the musculo-spiral in the upper arm.

10. Suppuration may occur, where the circulation is cut off, or
arrested to a certain portion of the tissues at the site of fracture, or

INJURIES OF BONES. 217

"it may- occur because of infection. This will interfere with the forma-
tion of the callus.

The combating of these conditions of fracture can best be
accomplished by a strict watch of the case and by relieving the condi-
tions, as they arise, by approved methods. An old person should
be propped up in bed, pressure should be kept from pressure-sores, and
the bandage must be properly applied. If an injury to the other
structures, such as the artery, nerve, or extravasation of blood,
it may demand amputation. Suppuration can be prevented by
aseptic treatment. Infections may be prevented, and if they arise,
should at once be combated by appropriate methods. Shock, delirium,

^and the retention of urine, should be relieved by proper manipulation.
If the shock is from loss of blood, the patient's health should be restored

-by appropriate treatment.

Epiphyseal Fracture. — Forcible removal of the epiphysis from the
diaphysis, consists of a fracture through the film of cartilage which
unites them. Obviously this fracture occurs before the age of twenty
or twenty-one. The signs of the fracture are not so pronounced as those
of ordinary fracture. Crepitus is moist, and being so near the joint,
it may be difficult to obtain. Inasmuch as the bone grows long from
the epiphyseal cartilage, permanent shortening will result, because of
this injury. It is easy enough to get union, but the patient should be
made to understand that deformity will result. The treatment is the
same as in other kinds of fractures. .:

Compound Fracture.

Compound fractures are those which are attended by a wound of
the soft parts which lead to the site of fracture.

How Produced. — 1. By the fracturing force. The fracturing force
may, in addition to breaking the bone, destroy the soft-parts down to
the site of the fracture. This wound, produced by the fracturing force,
may be incised, contused, lacerated, or punctured, as the case may be,
therefore a bullet might produce a compound fracture, being_made com-
pound by the fracturing agent.

2. Muscular action of the patient. Sometimes in the effort of the
patient to move about or perforin some physical act, the sharp end of
one of the fragments may be forced through the skin.

3. Later, fractures may become compound by sloughing of the soft-
parts down to the site of fracture. This is unusual.

Dangers in Compound Fractures. — (1) Hemorrhage, (2) shock, and
(3) sepsis.

Hemorrhage may be arrested by ligation of the ends of the artery
or by proper dressing. The shock may be relieved by appropriate
means. Sepsis may be guarded against by means of cleanliness.

Union in Compound Fracture. — Union in compound fracture, takes
place in the same manner as in simple fracture, but is longer delayed,

218 SPECIAL FRACTURES.

and accompanied by the formation of more callus. This callus some-
times involves the soft parts to a considerable extent.

The treatment of compound fracture consists in the following :

1. The wound should be rendered aseptic. All foreign bodies .should
be removed, loose fragments of bone, if detached, should be removed.

2. The fracture should be set and the wound dressed with suitable
antiseptic dressings. Splints should be applied which must maintain
immobility and at the same time allow the wound to be free from pres-
sure, and so it can be readily exposed.

3. The wound should be treated, from day to day, in an antiseptic
manner, to prevent sepsis and other complications.

Indications for Amputation. — One of the most troublesome questions
arising from compound fractures, or even from a bad simple
fracture, is whether or not the member can be saved. The older sur-
geons held that the following conditions demanded amputation:

1. Extensive injury to the soft-parts.

2. Where there is great comminution of bone.

3. Where there is involvement of a large joint.

4. Rupture of the main artery of the limb.

5. Old Age. In case the patient is very old, and his strength believed
not sufficient to heal the fracture, the member might be amputated with
advantage. The procedure adopted by the surgeon, in any case, will be
that which, in his judgment, is best. Where he is doubt about what
should be done, a consultation should be held. The patient should be
apprised of the condition, and under no circumstances should amputa-
tion be performed without the consent of the patient or his next friend.
If the patient is unconscious, it is the duty of the physician to do that
which he believes best. With modern aseptic and antiseptic methods,
wounds of the soft parts should be rendered aseptic and, if the circula-
tion to the part below is not too seriously interfered with, gangrene may
be avoided. Should the case be doubtful, it should be put in suitable
dressing and closely watched. Should evidence of gangrene appear,
amputation must be performed at once. Every attempt must be made
to save the member, but the patient's life must not be sacrificed in so
doing.

SPECIAL FRACTURES.

Fractures of the Nasal Bones.

Fracture of the nasal bone is produced by direct violence. The in-
jury is severe. The line of fracture is usually transverse, but may
be longitudinal and comminuted, also may be complicated by emphy-
sema of the tissues. The fracture may extend into the cribriform plate
of the ethmoid. The diagnosis is readily made by evidences of severe
injury and crepitus. There is often considerable deformity. Union
takes place quickly, and is, as a rule, good.

Treatment. — Tbe bones may be manipulated into position with the
fingers externally, or by covered probe or director internally. If the

SPECIAL FRACTURES. 219

bones will not remain in position of themselves, a tampon, made by
wrapping a section of a linen catheter with gauze, may be introduced.
This will assist in holding the fragments in position until the soft callus
is formed, which will be in five or six days. Should the treatment not be
successful in maintaining the bones in proper position, a Mason's pin
may be used. Should the fracture be compound, the wound must be
treated as an ordinary wound by antiseptic methods.

Fracture of the Lachrymal Bone.

Fractures of the lachrymal bones are produced by direct violence and
attended by severe injury of the soft-parts. The chief trouble is, that
the fracture may result in obstruction of the nasal duct, and in treat-
ment, this should be looked after.

Fracture of the Superior Maxillary Bone.

The superior maxilla is rarely fractured. The break is the result of
direct violence. The diagnosis is readily made by mobility and crepitus.
Deformity, the result of this fracture, is usually very great and is exag-
gerated upon the production of callus. The fracture through the
alveolar process will result in inability to chew. This fracture may be
produced in extracting teeth. Fracture of the nasal process may inter-
fere with the nasal dtict. If the antrum is fractured, emphysema
of the soft-parts may occur, or it may result in considerable depression
in the cheek. The infra-orbital nerve may be involved, frequently caus-
ing great pain. To manipulate the bone into position, put a finger of
one hand in the mouth and apply the other hand externally, when the
fragments may be approximated. Where the malar bone is driven into
the antrum, the antrum should be opened and the bone lifted out.
Loose teeth should be extracted. If the fracture is compound, the wound
should be kept aseptic. The mouth should be frequently washed to keep
it clean and the patient supported by liquid diet. Where the teeth are
irregular and out of line, they should be put in regular position and held
together by thongs.

Fracture of the Malar Bone.

The malar bone is rarely fractured. Where fracture occurs it is
the result of direct violence. If the bones are in abnormal position,
they should be put immediately in correct position. If chewing exag-
gerates the deformity the fragments should be wired. Fractures of the
zjrgomatic arch may be similarly treated.

Fractures of the Inferior Maxillary Bone.

Fracture of the lower jaw usually occurs at, or near, the symphysis,
but may occur anywhere on the body or ramus. The coronoid process
may be broken off or the line of fracture may extend through the neck.

220

S FECIAL FRACTURES.

Fig. 45.

Illustrating the locations of fractures of the inferior
maxilla.

The fracture is very liable to be compound in the mouth. The fracture

may be bilateral. The cause of the fracture is usually direct violence.
Diagnosis. — Laceration of the gums, blood-stained saliva, and the

irregular line of the teeth, together with pain and crepitus, will be suffi-
cient upon which to
base the diagnosis.
Where the fracture is
through the neck or
the coronoid process,
the signs are more ob-
scure. When the frac-
ture occurs far back,
the anterior frag-
ment is pulled down,
while the posterior
fragment is pulled
up and may override
the anterior. This is
caused by the oppos-
ing action of the
supra-hyoid muscles

and the muscles of mastication.

Treatment. — A splint of gutta-percha, leather or perforated tin is
made to fit over the chin. A Barton's bandage is then applied which
holds the jaws togetber. The patient should be instructed to avoid talk-
ing and chewing. The diet should be liquid and should be passed be-
tween the teeth or the gap beyond the last molar. Where the fracture is
compound within the mouth, suppuration
may occur. It is necessary to exercise the
strictest cleanliness; after taking food, the
mouth should be rinsed with an antiseptic
lotion — a saturated solution of boric acid or
Listerine. Union will take place in four or
five weeks. Where there is much displacement
and the patient is unruly, the fragments may
be held in apposition by means of thongs
passed between the teeth. Where this method
fails, wiring of the fragments may be advised.
Where the suppurative process is active, the
site of fracture should be cleansed and main-
tained aseptic until the inflammation sub-
sides, when apposition of the fragments can
be secured.

Fracture of the Hyoid Bone.

Fracture of the hyoid bone is rare and is produced by compression of
the throat. The fragments are pulled apart by the supra — and infra-

FlG. 46.

Barton's bandage applied
in fracture of the inferior
maxilla.

SPECIAL FRACTURES.

221

hyoid muscles. The bones may be manipulated into position, and the
neck strapped with adhesive plaster to keep the bones in apposition,
while the person should avoid talking or using the throat as much as
possible.

Fracture of the Ribs.

Fractures of the ribs are fairly common. They arise in two different
ways, by direct violence, as a blow upon them, or by compression of the
chest. The fifth to the eighth ribs are those usually injured. There,
may be contusion and laceration of the viscera, caused by driving the
sharp end of the fractured bone into the underlying structures.' The
fracture may be compound from within.

Signs. — The signs are evident. There is localized pain, which
is stabbing in character, and is increased on effort at breathing or
coughing. If there is much dis-
placement of the fragments, FlG- 47-
there will be considerable local
extravasation of blood and
swelling. Crepitus may be ob-
tained. Emphysema of the tis-
sues is an indication of perfora-
tion of the lung. If the patient
is fleshy, the diagnosis may be
difficult. Emphysema of the
tissues over the thorax without
external wound, is evidence of
fracture.

Treatment. — The treatment
of fractured ribs is to strap the
side with adhesive plaster. The
strips of plaster should be two
inches wide and extend from the
spine to the middle of the ster-
num, around the portion of the
rib broken. The ribs above and
below should be immobilized, so
that several strips, each overlap-
ping the other, are necessary. -

The strips must be applied at the end of a forced expiration. A figure-
of-8 bandage may then be applied over the plaster. When the lower ribs
are broken, tight bandages around the chest are, as a rule, contra-indi-
cated; troublesome hiccough may result. Union takes place within two
or three weeks. The mobility between the ends of the floating ribs is
so great that only fibrous union is obtained.

Fracture of the Costal Cartilages.

The costal cartilages are liable to fracture. The treatment is the
same as in fracture of the ribs.

Method strapping side with adhesive plaster
in fracture of the ribs.

222

SPECIAL FRACTURES.

Fig. 48.

Fracture of the Sternum.

Fracture of the sternum is produced by direct violence. The iine of
fracture is usually transverse. The fragments generally remain in situ.

Where there is displacement of the frag-
ments, great dyspnea may result.

Treatment. — The patient should be
kept in bed with a small pillow between
the shoulders and the chest strapped, as
in case of fracture of the ribs.

Fractures of the Clavicle.

The clavicle is one of the most fre-
quently fractured bones. The only other
bone so often fractured is the radius.
The clavicle is broken by direct and in-
direct violence, by blows directly upon
the clavicle, and by falls upon the shoul-
der or arm. The injury is common in
children and the fracture may be green-
stick. The bone may be broken in three
different locations, at the sternal ex-
tremity (least often), in the middle third
(most often) and in the outer third.
Sternal End. — This fracture is rare,
usually transverse, and the displacement slight.

Middle One-third.— This is the common site for fractures of this
bone. The line of fracture is
usually oblique. The deform-
ity is characteristic, the
shoulder falls downward and
inward, due to the weight of
the arm and the action of the
chest muscles. The outer ex-
tremity of the inner fragment
projects prominently against
the skin and appears to be
drawn up, but is not. It is
held in position by the sterno-
mastoid muscle, and by the
rhomboid ligament. The fall-
ing of the shoulder stretches
the skin over the sharp
outer end of the inner frag-
ment. The head is inclined
to the affected side and the
of a fall.

Fracture of the sternum.

Fig. 49.

Fracture of the clavicle, showing how deformity
takes place.

arm is useless. There is a history

SPECIAL FRACTURES.

223

Outer One-third. — This fracture is produced by direct violence, falls
upon the shoulder, or a blow upon the acromion. The deformity is not
great, the clavicle being held in relation with the scapula by means of
the coraco-clavicular ligament.

Signs of Fracture of the Clavicle. — The deformity is characteristic.
Pain, crepitus, deformity, evidences of injury, and history of accident.

Treatment. — Fracture of the clavicle is best treated by one of the
following methods :

1. A posterior figure-of-8 bandage serves the purpose of drawing the
shoulders backward, and a sling will sustain the weight of the arm. Suf-
ficient padding should be put in the axilla so as to prevent the arm from
falling against the chest. Velpeau's bandage, as far as appearance is
concerned, makes an excellent dressing, but it is believed that it exag-
gerates the deformit}r.

Fig. 51.
Fig. 50.

Sayre's Dressing. Method of ap-
plying the first strip of adhesive
plaster, which extends around the
body.

Sayre's Dressing. Method of ap-
plying the second strip of adhesive
plaster, which extends over the
shoulder and under the elbow.

2. Sayre's dressing is very successful, especially in children, as it
serves the purpose of holding the arm immovable. Two strips of ad-
hesive plaster, two to four inches wide, are necessary. A suitable pad
should be placed in the axilla. A strip of adhesive plaster of sufficient
length is fastened around the arm at the insertion of the deltoid. Tt is
then carried entirely around the body, and fastened on the back. An-
other strip is started on the scapula of the sound side, passed across the
back, doAvn the back of the arm, over the elbow, and up over the shoulder
of the sound side. Where the plaster passes over the elbow a slit should
be made to prevent pressure on the olecranon. This second plaster

224

SPECIAL FRACTURES.

should be drawn sufficiently tight to raise up the arm. The hand
should.be placed across the chest on the shoulder of the sound side, so.
that the plaster extends along up the forearm and over the hand. In
children this serves the purpose of maintaining immobility of the en-
tire arm.

3. Moore's dressing consists of a figure-of-8 bandage around the
_, _„ elbow, and over the arm and

r IG. 52.

shoulder, to the shoulder of
the opposite side.

4. Where even the slight-
est deformity is undesirable,
the patient should lie on a
smooth bed, with a small pad
between the scapulae, for at
least three weeks. A small
sand-bag can be placed over
the shoulder and the arm may
be strapped to the side, the
patient being cautioned to
avoid all unnecessary motion.
A considerable callus is the
rule in these fractures. When
the fracture is properly at-
tended to, a good result can
be obtained. In fractures
where there is violent injury,
the outer fragment may be
driven downward until it per-
forates the apex of tbe lung. Emphysema of the tissues will follow and
complicate the condition.

Fractures of the Scapula.

The scapula may be fractured in the following locations:

Moore'S dressing for fracture of the clavicle.
The arm is carried in a sling.

1. Acromion process.

2. Coracoid process.

3. Body.

Neck

Glenoid cavity.

The. acromion process may be broken by direct violence. The arm
and hand are helpless and there is evidence of local injury. The bone
is subcutaneous, and if seen early, there will be no difficulty in making
out the condition. Treatment. — If may be strapped in position and the
arm carried in a sling.

The coracoid process is rarely broken and then only from direct vio-
lence. There is little displacement. The arm should be raised and put
in a sling and the fragment of bone drawn up as far as possible.

:The body of the scapula is rarely broken and then only from direct
violence. The fracture may be longitudinal or transverse. It is a re-,
suit of injury to the spine of the scapula. The diagnosis can be made

SPECIAL FRACTURES.

125

by obtaining crepitus and preternatural mobility. The fragments may
be held together by strapping and by supporting the arm.

Fracture of the neck of the scapula is produced by great violence
to tiie shoulder. It may occur in two locations, through the neck, or
through the suprascapu-
lar notch back of the Fig. 53.
coracoid process. The
deformity resulting re-
sembles a dislocation of
the humerus downward.
These conditions are
readily differentiated,
since when the shoulder
is pushed up, as the arm
is lifted, crepitus is ob-
tained. On allowing the
arm to hang by the side,
the deformity returns.
The arm should be
bandaged to the side
and kept immovable.

Fracture of the glen-
oid cavity is extremely
rare. The prognosis of
the injury is good. It
should be treated as a
fracture of the neck of
the scapula.

Fractures of the Humerus.

These are divided into: —

1. Fractures of the upper extremity.

2. Fractures of the shaft.

3. Fractures of the lower extremity.

Fractures of the upper extremity are: —

A. Fractures of the anatomical neck (Intracapsular).

B. Fractures of the surgical neck (Extracapsular).

C. Fracture of the greater tuberosity.

D. Fracture of the epiphysis.

Fractures of the anatomical neck are : —

Fracture through the glenoid cavity of the scapula.

a.
b

Non-impacted.
Impacted.

A non-impacted fracture of the anatomical neck is extremely rare,
but is more frequent than the impacted form. The line of fracture is
partly within and partly without the capsule of tjtie joint. The signs
of the fracture are obscure, and consist of pain, swelling, loss of func-
tion, deformity (loss of rotundity of shoulder), crepitus, and absence

226

SPECIAL FRACTURES.

of the signs of dislocation and other injury. The fracture
occurs in old people. The prognosis is not very good, inasmuch as only
fibrous union may be obtained; furthermore, the upper fragment
may become turned in its position so that the fractured ends of the
bone can not be brought into position. Perhaps this can only be made
out by an x-ray examination. Should such a condition occur, an opera-
tion will be necessary to remove the upper fragment. Where there is
not much displacement of the fragments, and the patient has good gen-
eral health, the prognosis is fairly good.

In impacted fracture of the neck of the humerus, the head is driven
into the lower fragment. The
cause is from direct violence. The Fig. 55 .

signs are even more obscure than
in the non-impacted variety of frac-
ture. There is shortening, which is *P=^»««m
determined by measuring from the
acromion process to the external
condyle, and a slight prominence of
the acromion process. There is loss

Fig. 54.

Impacted fracture of the
anatomical neck of the
humerus.

Fracture of the surgical neck of the
humerus. S, scapula; D, deltoid; P.
M., pectoralis major; t,. D., latissimus
dorsi.

of rotundity of the shoulder, and later the head of the bone can not
be felt in an abnormal position, and there is no crepitus. There is
absence of the signs of dislocation. The signs of this fracture are
chiefly negative.

Treatment. — A shoulder-cap, extending down as far as the insertion
of the deltoid, should be made of a starch-paste dressing, leather, or
gutta-percha. The axilla should be well padded and the shoulder en-
veloped in cotton, and a figure-of-8 bandage applied from the fingers
up, to prevent edema. Obstruction to the circulation is produced by

SPECIA L FRA CTURES. 227

the callus compressing the deep ^eins in the axilla. Manipulation of
the soft-parts should be begun early, within ten days, and kept up reg-
ularly, in order to prevent a stiff joint.

Fracture of the Surgical Neck. — This fracture may be impacted or
non-impacted, but the impacted form is extremely rare, and when it
occurs, the lower fragment is driven into the upper one. The non-
impacted form, which is the most common, is caused by direct violence.

Displacement. — The upper fragment is rotated out by the muscles
which are attached to the greater tuberosity, while the deltoid, biceps,
and triceps, together with the pectoral muscles, draw the lower frag-
ment upward and forward, so that the roughened end of the lower
fragment makes a prominence against the anterior fold of the axilla.
The arm is helpless and is supported by the hand of the opposite side.

Signs. — There is marked pain, swelling, and some shortening. The
roughened upper end of the lower fragment makes a prominence against
the anterior fold of the axilla. Preternatural mobility is very evident
as the operator grasps the head of the humerus. The arm may be rotated
while the upper fragment remains stationary. There is increased
mobility upon manipulation by the surgeon, also loss of function.
Upon extension of the arm and approximation of the fragments, crepi-
tus is obtained.

Union. — In fracture of the surgical neck, union is bony, and the
result good. The only complication arising may be paralysis of the
deltoid, because of the involvement of the circumflex nerve in the cal-
lus. Where fracture is not attended by other injury, a good result
can be assured.

Treatment. — Tbe treatment consists in reducing the fracture by
extension and counter-extension. A firm pad should then be placed in the
axilla. A shoulder-cap, covering the outer, anterior, and posterior sur-
faces of the shoulder and upper arm, extending down below the inser-
tion of the deltoid, should be applied. Previous to the application of
the shoulder-cap, a moderate film of surgeon's cotton may be placed
over the shoulder. A figure-of-8 bandage should be applied from the
hand up and carried entirely over the shoulder. The arm is put in a
sling, and in a muscular person a one or two pound weight is hung on
the elbow to overcome muscular contraction. This is unnecessary in
weak people.

Fracture of the Greater Tuberosity is rare, and is the result of direct
violence. There is evidence of great local nn"ury; sometimes the bone
may be split.

Treatment. — The treatment must be modified according to the re-
quirements of the condition. If the tuberosity is drawn away from the
bone, it should be brought back and held there by adhesive strips. The
arm should be bandaged from the hand up and carried in a sling.

Epiphyseal Fracture of the upper extremity of the humerus is rare.
It happens before the age of twenty and resembles a fracture of the sur-

228

SPECIAL FRACTURES.

Fig. 56.

gical neck. The upper fragment carries with it the greater tuberosity.
The signs of the fracture are the same as the signs of fracture of the
surgical neck, with the exception that crepitus is moist, and the projec-
tion made against the anterior fold of the axilla is from a smooth, rather
than a roughened, end of the bone. The treatment is the same as treat-
ment of the surgical neck.

Fractures of the Shaft. — The shaft of the humerus is broken by di-
rect violence, while, in some rare cases, it may be by indirect violence.
In case of softening of the bone, muscular contraction has been said to
produce the fracture. The displacement of the fragments will depend
upon the location of the fracture. Where the line of fracture
is above the insertion of the deltoid, the upper fragment

is rotated outward by
means of the muscles
attached to the greater
tuberosity, while the
deltoid, biceps, and tri-
ceps, pull the lower
pragment upward and
lift it outward. The up-
per fragment is drawn
inward towards the
chest by the muscles at-
tached to the bicipital
ridges. Where the frac-
ture occurs below the
insertion of the deltoid,
the upper fragment is
drawn outward and for-
ward by the action of
the pectoralis major
and deltoid, and short-
ening is produced by the
biceps and triceps.

Signs. — The signs of
the fracture are very ev-
ident and may be enum-
erated as pain, swelling, preternatural mobility, crepitus, deformity,
and loss of function.

Union. — Good union may be obtained in treatment of fracture of
the shaft of the humerus, but it must be borne in mind that non-union
more often happens in this fracture than in any other. The chief
reason seems to be that the fragments are not maintained immovable
and in apposition. Complications may arise which consist of paralysis
of the extensor muscles because of the involvement of the musculo-
spiral nerve in the callus.

Oblique fracture of the lower extremity of the shaft of the
humerus, showing the displacement of the fragments.

SPECIAL FRACTURES.

229

Fig. 57.

Treatment. — The treatment of fracture of the shaft of the humerus
is simple, but whatever method is used, it should be attended to thor-
oughly. The splints used are the following:

1. A posterior trough, which is perhaps the best splint to use, is
made of perforated metal, or of pasteboard and starch-paste, and ex-
tends from the shoulder to the hand. It should be well padded, so as

to make a nice bed for the arm.

2. An internal angular splint,
which should extend from the shoul-
der to beyond the wrist, so as to im-
mobilize the hand. This may be re-
inforced by three simple splints, one
on the front of the arm, one on the
outer side, and one on the posterior
surface. These should extend from
the axilla to the elbow. The arm
should be well enveloped in cot-
ton and the splints, which are made
of heavy pasteboard or thin boards,
are then applied. A figure-of-8
bandage should be applied from the
hand entirely over the arm and en-
veloping the shoulder. The splint
should maintain extension and
counter-extension. The dressing
devised by Dr. A. T. Still is the
most suitable dressing after the
preparation has dried. Extension
and counter-extension may be made
after twenty-four hours and the
bandage readjusted.

3. A plaster-of-Paris dressing is
advocated by some physicians, but
it is not satisfactory.

Fractures of the Lower Extrem-
ity of the humerus consist of the
following :

Transverse fracture of tte humerus, show-
ing little displacement of the fragments.

A. Transverse.

B. T- or Y-shaped.

C. Internal condyle.

D. External condyle.

E. Epiphyseal.

A transverse fracture of the lower extremity of the humerus may
occur in two locations, one above the condyle, and the other below.
Transverse fracture below the condyles, taking off a portion of the lower
epiphysis, is an extremely rare condition. Transverse fracture above
the condyles is the common fracture.

230

SPECIAL FRACTURES.

Cause. — Direct violence, as falls on the elbow.

Displacement of Fragments. — The triceps, acting upon the olecranon,
draws the forearm backward; the biceps, brachialis anticus, triceps, and
other muscles, draw the forearm upward, while the lower end of the
upper fragment is carried forward and makes a prominence above the
crease at the bend of the elbow.

Signs. — Deformity in this fracture resembles the deformity in dis-
locations of both bones of the forearm backward. A diagnosis can be
made by careful examination. In fracture, the relation of the condyles
and the olecranon is unchanged, whereas in dislocations, the relation of
these bony points is changed. In case of fracture, upon reduction of the
deformity, crepitus is obtained, while in dislocations, no crepitus is ob-
tained. In case of fracture, the deformity will return after reduction;

Fig. 58.

Fig. 59.

Fracture of the outer con-
dyle of the humerus.

Fracture of the internal con-
dyle of the humerus.

in dislocations the deformity will not return. In fracture there is short-
ening, the distance from, the external condyle to the acromion process
is shorter on the injured side, while in dislocation, there is no shortening.
In fracture, the lower end of the upper fragment makes a prominence
above the crease at the bend of the elbow, while in dislocation, the
prominence is below the crease at the end of the elbow.

In T-shaped fracture there is not only a transverse fracture, but the
line of fracture extends into the joint. The signs are similar to those
of transverse fracture, with the exception that upon motion of the con-
dyles of the humerus, crepitus is obtained. Where the case is seen early,
crepitus may be obtained by compressing the condyles. Where great
fluid effusion has taken place in the joint, this sign may be absent.

Fracture of the condyles is the result of direct violence. The line
of fracture may, or may not, invade the joint. In case the internal

SPECIAL FRACTURES.

231

Fig. 60.

condyle is fractured, the fragment is drawn downward by the pronator
radii teres and the iiexor muscles of the arm, whereas in fracture of the
external condyle, it is drawn downward underneath the fibres of the
supinator longus. The loose fragment is readily manipulated, and when
drawn into position, crepitus can be obtained.

Epiphyseal fracture is the same as transverse fracture, with the ex-
ception that moist crepitus is obtained. The fracture occurs in young
persons.

Diagnosis. — The diagnosis in all these fractures is difficult; further-
more, great swelling is the rule. The best treatment, where the case
is not seen early, and before the
swelling is intense, is to place the
arm on a pillow, keep it in an im-
movable position, and apply cold to
combat the swelling, after which, a
correct diagnosis can be made. Fur-
thermore, the bones may be manip-
ulated in the proper position and a
permanent dressing better applied.
Where the diagnosis is uncertain,
an x-ray examination should be
made, if possible. It is of the great-
est importance to correctly deter-
mine the condition. The prognosis
should be guarded. Fractures ex-
tending into the elbow-joint are al-
ways serious, and it is difficult to
obtain good union without deform-
it}r, or without interference in some
of the functions.

Union. — Union takes place with
more or less deformity. In epi-
physeal fra tares, or fractures within the capsule of the joint, the union
is fibrous. In transverse fractures, and in fractures of the condyles,
the union is bony.

Treatment. — As before mentioned, where there is much swelling, the
arm should be placed upon a rubber cushion and cold applied.
When the swelling has been reduced sufficiently, the diagnosis may be
made, and a suitable dressing applied. A posterior trough, or
an external or internal angular splint, may be applied. The internal
angular splint is preferable in all cases, with the exception of fractures
of the internal condyle. Manipulation should be made early in all cases,
with the exception of transverse fracture, where the line of fracture does
not invade the joint. In all cases where the fracture invades the pint,
manipulation should be begun at the end of the first week. In case
it does not invade the joint, it may be delayed until the end of

Method of dressing the arm in acute
flexion for'T-fractures or for fracture of the
internal and external condyles of the hu-
merus.

232

SPECIAL- FRACTURES.

the second week. The success in the treatment of these fractures will
depend upon the proper management of the case.

Fractures of the Forearm — Both Bones.

Fracture of both bones of the forearm is the result of direct
violence, when both bones are broken at the same level. Where
the bones are not broken at the same level, it is the result of in-
direct violence, the bones breaking at the weakest point. In the latter
condition, the radius breaks in the upper one-third, while the ulna
breaks in the lower one-third.

Displacement. — The upper fragment of the radius is drawn toward

the upper fragment of the ulna by
the pronator radii teres, while the
lower fragment of the ulna is
drawn toward the lower fragment
of the radius by the pronator quad-
ratus, and in this manner the in-
terosseous space is more or Jess ob-
literated.

Signs. — Deformity, crepitus,
history of accident, pain, swelling,
preternatural mobility, etc. The
signs are \ery evident.

Treatment. — Flex the elbow to
a right angle and place the forearm
midway between pronation and
supination. In this position, the
thumb is directed upward. A
well-padded internal and exter-
nal splint should be applied.
The internal splint should ex-
tend from the axilla to the tips
of the fingers, while the external
splint need only extend from the
elbow to beyond the wrist. Both splints should be broader than the fore-
arm, so that the bandage may not compress the bones towards each
other, thus lessening the interosseous space. Manipulation of the hand,
fingers, and muscles of the forearm should be begun within two weeks.
If either the elbow-joint or wrist joint is involved, manipulation
should be begun earlier. Pronation and supination may be lost if this
manipulation is not begun early, and kept up regularly. The patient
should be seen within twenty-four hours after the accident, because of
the liability to constriction of the return circulation by the bandage.
Here, again, the dressing advised by Dr. Still will be found to be of the
greatest advantage. The fracture may be green-stick, in a child.

Fractures of the Radius. — Fractures of the radius are of the (1) neck,
(2) shaft, and (3) lower extremity.

Posterior trough, suitable for fractures of
the humerus and both bones of the forearm.

SPECIAL FRACTURES.

233

Fig

Fracture of the lower extremity of the shaft of the
radius showing deformity.

Fracture of the neck of the radius is the result of direct, or indirect,
violence. The diagnosis is sometimes difficult. The signs are crepitus,
obtained by extension and manipulation; preternatural mobility, ob-
tained by grasping the head of the bone and pronating and supinating
the arm. The head does not move. Occasionally, in young persons, the
upper epiphysis may be separated. This condition is difficult to diag-
nose. It gives moist crepitus, and evidence of a foreign body in the
joint.

Treatment. — The treatment of fracture of the neck of the radius
consists in flexing the arm at right angles, to relax the biceps, when a
posterior angular trough, or internal angular splint, may be used. Mild
manipulation should be begun at the end of the second week.

The shaft of the radius is broken by direct, or indirect, violence,
such as blows upon the arm, or
falls upon the paim. Displace-
ment of the fragments varies,
depending upon whether
the fracture is above or below
the insertion of the pronator
radii teres. Should it be above,
the upper fragment will be
flexed and supinated, while
the lower fragment will be
pronated and drawn towards

the ulna. When the fracture is below the insertion of the pronator
radii teres, the upper fragment is flexed and drawn inward, while the
lower fragment is approximated to the ulna,

Treatment. — The forearm should be placed midway between prona-
tion and supination, and flexed at right angles at the elbow. A posterior
or internal, angular splint may be used, with sufficient interosseous pad
to prevent the approximation of the bones. The splints should be car-
ried from below the wrist to above the middle of the arm. Manipulation
should be begun at the end of the second week.

Fracture of the
lower extremity of the
radius is called
Colles's fracture.
This injury occurs
most frequently in
elderly women, and
is produced by falls
upon the outstretch-
ed palm, while the
hand is completely
pronated and ex-
tended. The fracture may be an inch from the wrist-joint, but is
usually less. The deformity is characteristic, and is described as

Fig. 63.

Colles's fracture, showing displacement of the fragments.

234

SPECIAL FRACTURES.

"silver-fork," because of the position of the hand resembling a dinner
fork. .

Displacement. — The lower fragment of the bone is carried backward
and upward, because of the direction of the application of the violence.

_, „. Often there is some

Fig. b4. ;

impaction of the

fragments. This im-

paction, together

with the action of

the extensor carpi

radialis longior and

b r e v i o r muscles,

maintain the de-

Silver-fork deformity in Colles's fracture. „ • j -r>

iornii t y. Because
the main violence is directed on the ball of the thumb, the outer side
of the lower fragment is displaced more than the inner side. This
causes a prominence of the styloid process of the ulna, which will be
found in this injury on^a lower level than the styloid process of
the radios. The upper fragment is pronated and approximated to the
ulna. These forces acting, likely produce the characteristic deformity.

Signs. — The characteristic deformity is a prominence on the back
of the wrist, while there is a corresponding depression on the front of
the wrist. The styloid process of the radius is on a higher level than
that of the ulna. In case the fracture is not impacted, there is crepitus.
The history of the accident and the age of the patient may be consid-
ered. It may be confounded with dislocation of the wrist, but this dis-
location is rare, and the deformity different. The styloid process of
the radius is on a lower level than that of the ulna, while there is no
crepitus. If the deformity is reduced, it will not return.

Treatment. — The treatment of Colles's fracture is. first, to set the
fracture, providing it is not im-
pacted. Where there is impac-
tion, without much deformity,
the member should be treated in
that position. There are num-
erous splints which are of ex-
cellent service in the treatment
of this fracture. The chief ob-
jection to all of them seems to
be that a stiff joint is liable to
result. Levis's splint is, per-
haps, the most popular. A
splint similar to Levis's may
be made of Dr. Still's dressing.

Bond's splint is an excellent dressing. This splint has a pad which fits
over the lower end of the upper fragment, and a dorsal pad which fits

Deformity liable to result in the treatment of
Colles's fracture with a straight splint.

SPECIAL FRACTURES.

235

over the lower fragment. It tends to correct the deformity. The fingers
and thumb are allowed to he free. Passive motion should he begun in
four or five days, and kept up until cured.

Fracture of the Ulna.

Fractures of the ulna consist of fractures of the:

Olecranon.
Coronoid Process.

3. Shaft.

4. Styloid Process.

Fig. 66.

Fracture of the olecranon process, showing upper frag-
ment pulled up by the triceps muscle.

Fractures of the olecranon are produced by direct violence, as by

falls upon the elbow,
.,.,/„ ^ and bv muscular con-

WJtif* traction, in conditions
of disease of the bone.
Nature of the In-
jury.— Usually there
is considerable contu-
sion of the tissues
over the olecranon,
while the loosened,
fragment is drawn
upward by the tendon
of the triceps and can
be readily felt be-
neath the skin, an inch or more above the joint. The diagnosis is easy,
inasmuch as it cannot be mistaken for any other injury.

Union. — The union is sometimes fibrous, but in young and middle-
aged people, in good health, the union is good.

Treatment. — The arm is best treated in complete extension and by
strapping the olecranon in its normal position by means of adhesive
strips. Some surgeons advise the use of a right-angle splint and strap-
ping the bone in position. In case of non-union, the olecranon may be
wired in position. The arm should be kept in an extended position for
three weeks, when slight flexion should be made. Manipulation should
be instituted late.

Fractures of the coronoid process occur most frequently at the time
of dislocation of the ulna. It is said that contraction of the brachialis
anticus may produce this fracture. The fracture is attended by con-
siderable injury. Where it complicates a dislocation, a bad result is
liable to follow. It is best treated in flexion, with an internal angular
splint. Manipulation should be begun early, in order to prevent a
stiff joint.

Fractures of the shaft are caused by direct violence. The line of
fracture may be transverse, or oblique. The upper fragment is
held in position while the lower fragment is approximated to
the radius by the pronator radii teres. The diagnosis is easy, inas-

236 SPECIAL FRACTURES.

much as the posterior border of the ulna is subcutaneous. A finger run
along the posterior border would discover an offset in the bone. Union
is good.

Treatment. — It is best treated in a manner similar to fractures of
the shaft of the humerus. A splint, the length of the forearm and
hand, slightly wider than the forearm, applied to the inner side, will
be sufficient. The splint should be well padded, and held in position
by a figure-of-8 bandage. If extension and counter-extension are kept
up while the splint is applied, the bones will be held in apposition.

Fractures of the Carpus.

Fractures of the carpus are produced b}r severe, direct violence, and
very often the fracture is compound.

The diagnosis is readily made by crepitus. The injury is
more serious than is indicated at first glance. Because of the limited
blood supply to the carpal bones, one of the fragments may die, and
suppuration and abscess result. Should this occur, it will produce
ankylosis.

Treatment. — The bone should be manipulated into position, and
held by a well padded anterior splint, extending beyond the middle of
the forearm.

Fractures of the Metacarpus.

Fracture of the metacarpal hones is produced by direct violence.
The signs are evident, and consist of deformity and crepitus.

Treatment. — The bones may be readily manipulated into position,
while an anterior splint, extending beyond the wrist, should be applied.
In fractures of both the carpus and metacarpus, manipulation should
be begun early, in order to prevent fibrous adhesions of tendons and the
involvement of the joints.

Fractures of the Phalanges.

Fracture of one of the phalanges may take place because of direct
violence. The diagnosis is easy. It is best treated by a palmar splint
immobilizing the metacarpo-phalangeal, as well as the phalangeal
joints. The hand should be carried in a sling during the first two
weeks.

Fractures of the Pelvis.

Fractures of the pelvis are caused by heavy, direct violence, such as
the wheels of a loaded wagon passing over the body, or by falls from
a considerable distance. The nature of the injury depends upon the
line of fracture. If the line of fracture extends through the crest of
the ilium, it may not involve any of the pelvic viscera, but it may
extend through the ramus or body of the pubes and ischium, thus sep-
arating the two sides of the pelvis. Such fractures of the true

SPECIAL FRACTURES.

237

pelvis are usually attended by lacerations of the pelvic viscera, of the
rectum, vagina, urethra, and bladder.

Signs. — The signs will vary, depending upon the viscera injured.
There is severe contusion of the soft-parts. Crepitus is ob-
tained by pressing upon the ilia, or upon the pelvis ante'ro-posteriorly.
Bloody urine will indicate that the fracture extends into the bladder,
or blood may be voided from the bowel. A history of the accident may
lead to a suspicion of fracture. If any of the viscera are involved, the
prognosis of the fracture is grave. Infection, abscess formation, and
non-union, wall bring about exhaustion and death. Where there is
laceration of the viscera, the patient may be kept quiet with sand-bags
at the side, and with proper care and attention, may recover. The
acetabulum may be fractured because of blowrs upon the hip. This in-
jury is rare, and the diagnosis can be made by eliminating fractures
and dislocations of the hip, and by the presence of pain and crepitus.
In fractures of the pelvis, little dressing, beyond keeping the patient
quiet, will be required. A flannel roller may be applied around the
pelvis and the patient not allowed to move.

Fractures of the Femur.

Fractures of the femur are divided into: —

I. Fracture of the upper extremity. III. Fractures of the lower extremity.
II. Fracture of the shaft.

Fractures of the upper extremity are divided into: —

A. Intracapsular. C. Fractures of the greater tuberosity.

B. Extracapsular. D. Epiphyseal.

Intracapsular fractures are divided into:

1. Impacted. 2. Non-Impacted.

The non-impacted fracture is the most
common.

Cause. — The causes of non-impacted
fracture of the neck of the femur are :

1. The fragile condition of the bone.

2. Fatty degeneration of the neck.

3. Indirect violence.
The fracture happens in old people, and

is produced by slipping on cobble-stones,
etc., or catching the toe. The limb is
wrenched, and the neck of the bone easily
breaks off

Nature of the Injury.- — The fracture
may be transverse, or oblique, and the dis-
placement will depend somewhat upon the
line of fracture. In some cases, the fracture
is subperiosteal. In other cases, where the
periosteum is torn, or lacerated, greater dis-
placement of the fragments takes place.

Fig. 67.

Non-impacted intra-capsular
fracture of the neck of the fe-
mur.

238

SPECIAL FRACTURES.

Fig. 68.

Signs. — 1. Shortening — three-fourths of an inch, to one inch.

2. Eversion of the foot, which is produced by the weight of the
limb as it lies in a helpless condition.

3. Lessened arc of rotation of the great trochanter. This sign is
obtained by grasping the great trochanter and rotating the limb out-
ward and inward.

-1. Crepitus.

5. The great trochanter is nearer the anterior superior spine. This
may be determined by accurate measurements. These measurements
may be made in one of two ways. First, by Nelaton's line, which is a
line drawn from the anterior superior spine of the ilium to the most
prominent part of the tuberosity of the ischium. Under normal con-
ditions it crosses the upper edge ©f the great trochanter.

It may also be made by Bryant's line, which consists of a line drawn
around the body at the level of the anterior superior spines. A second
line is drawn upward from the great trochanter to this line. This sec-
ond line is shorter on the injured side than on the sound side, in case of

displacement of the great trochan-
ter upward.

6. A history of the accident.

7. Age of the patient. The
fracture happens in old people, and
from slight injury, by catching the
foot, or in slipping. It should be
noted that there is no injury to
the tissues over the trochanter.

Allis's Sign. — This is the relax-
ation of the fascia lata. The re-
laxation is caused by shortening,
lessening the tension on the ilio-
tibial band.

Impacted Intracapsular Frac-
ture of the neck of the femur is
rare.

Signs. —

1. No crepitus.

2. Very slight shortening.

3. Absence of the signs of other
injury or dislocation.

4. History of the accident and
age of the patient.

5. Eversion of the limb.
Occasionally in these fractures

the limb is not helpless, and the
patient may even attempt to walk.

!|Uc=€

Method of determining Allis's sign in frac-
ture of the neck of the femur.

SPECIAL FRACTURES. 230

The diagnosis is sometimes very difficult, inasmuch as the signs are
chiefly negative.

Extracapsular Fracture of the neck of the femur occurs in young,
or middle-aged people, and is either impacted, or non-impacted, but is
usually impacted. It is caused by direct violence, as heavy falls on,
or severe injury over, the trochanter. In the impacted variety, the upper
fragment is driven into the lower one.

Nature of the Injury. — The injury is brought about by severe direct
violence, therefore there is evidence of bruising of the skin and soft
tissues. The trochanter is considerably thickened. There is shorten-
ing of at least one inch, and is greater than in the intracapsular
fracture. There is a lessened arc of rotation of the trochanter, no
crepitus, eversion of the foot, while the trochanter is displaced above
Nelaton;s line.

In the non-impacted extracapsular fracture of the neck of the femur,
it is believed that the impaction is broken up by the extension of the
fracturing force, or by the efforts of the patient to move, or by subse-
quent manipulation. The cause of the injury is, great direct violence
over the trochanter.

Nature of the Injury. — The injury is very severe. There is intense
contusion of the skin and soft-parts. The line of fracture may even
extend through the base of the great trochanter, or may extend
through the line of union of the neck with the great trochanter.

Signs. — 1. Crepitus, which is pronounced, and is evidenced by
grasping the trochanter.

2. Shortening (one or two inches).

3. Evidence of great injury to the soft-parts over the trochanter.

4. History of the accident, and age of the patient.

5. Eversion of the limb.

Treatment. — ISTon-impacted Intracapsular Fracture. — As this frac-
ture occurs in old people, long confinement in the recumbent posture
is liable to result in hypostatic congestion of the lungs, and in bed-
sores, either of which may destroy life ; therefore, it is best to keep the
patient in bed the shortest time possible. The patient may be put to
bed, and an extension apparatus applied, with sand-bags along the side
of the femur, and the limb kept immovable until the preliminary sore-
ness disappears. At the end of the first week, and not later than the
second week, the patient should be allowed to sit up, or. if possible, to
get up and about on crutches. Where it is deemed advisable, and the
condition of the patient's health will permit it, a fixed-dressing should
be applied, which will immobilize the hip and knee. In the majority of
cases, this dressing can not be used. Fibrous union is the rule. Some-
times, because of the limited blood supply, and the enfeebled condition
of the patient, no union takes place, and the end of the bone may be-
come worn off. Sometimes the limb is left helpless. In order to secure
a good result, confinement in bed for six or eight weeks is usually neces-

240 SPECIAL FRACTURES.

sary, and where the patient is young, this may be permitted. A stiff
apparatus applied over the hip is necessanr, even after a considerable
length of time in bed. This stiff dressing over the hip may be in the
nature of a leather casing, or a pasteboard and starch-paste dressing,
and so constructed as to fit closely over the hip and thigh.

In the impacted form, a similar treatment should be followed, except
that the extension apparatus is unnecessary. No attempt should be
made to break up the impaction. Generally a good result can be ob-
tained, but the hip should be rendered immovable by some fixed dress-
ing. A plaster dressing in old people is bad.

Extracapsular Fracture. — In the impacted variety, it is only neces-
sary to keep the limb at rest. No extension apparatus is necessary.
Sand-bags should be placed along the side of the hip, and the limb
kept at rest until the soreness and swelling have disappeared, and then
the patient may get up and go about on crutches. Subsequent manipu-
lation may obtain a good result.

In the non-impacted variety, an extension apparatus will be neces-
sary. An eight or ten pound weight, sufficient to overcome the mus-
cular contractions, should be applied, and the patient kept quiet in
bed, and the limb kept immovable, by sand-bags, until the preliminary
swelling and inflammation have subsided, when a plaster dressing, encac-
ing the leg and pelvis, may be applied. This plaster dressing is kept on
for two weeks, when the patient is gotten up on crutches. The plaster
dressing should be removed at the end of four weeks. Some surgeons
advise, in the impacted variety, if the person is in good general health,
to pull the impaction apart and apply a plaster dressing, but this
method of procedure is questionable. Deformity, following this fracture,
is the rule. While the extension apparatus is used, the foot of the bed
should be raised from four to six inches, so that the weight of the
patient will operate as a counter-extending force.

Fractures of the greater tuberosity are very rare, and are accom-
panied by extensive local injury. The diagnosis is usually not difficult.
The broken fragments should be strapped into position, and the patient
kept at rest in bed until fibrous union, at least, has taken place.

Epiphyseal fracture is also rare, and occurs in young people.

Signs. — The signs are the same as non-impacted extracapsular
fracture, with the exception that there is moist crepitus. A history of
the case, and the age of the patient, indicate the nature of the
injury.

Fractures of the Shaft.

Fractures of the shaft of the femur are best considered in fractures
of the upper, middle, and lower one-third. The cause is usually direct
violence, but may be due to indirect violence, especially when occurring
in the upper one-third of the shaft. The line of fracture is usually
oblique. Muscular contracture may produce the fracture, in conditions

SPECIAL FRACTURES.

241

Fig. 70.

Fig. CD.

of softening of the bone, or in fragile conditions of the bone attending
paralysis agitans.

Upper One-third. — Displacement of the
Fragments. — In the upper one-third, the

upper fragment is tilted

forward by the action

of the iliacus and psoas

muscle s, while the

quadriceps extensors, bi-

c e p s, semitendenosus,

semimembranosus and

the adductors draw the

lower fragment upward,

so there is marked

shortening, the upper

end of the lower frag-
ment slipping past the

upper fragment. Ex-
tension made upon the

limb in an extended po-
sition, will not bring

about apposition of the

fragments. The limb

must be treated in a

semi-flexed position, in

order to relax the psoas

and iliacus muscles.
In fractures of the

middle one-third, a sim-
ilar displacement of the

fragments may occur,

but it is not so pro-
nounced. In fracture of the lower one-third of the femur,
the upper end of the lower fragment is usually turned back-
Fig. 71

Fracture of the up-
per extremity of the
shaft of the feinur,
showing- displacement
of the upper fragment
by the psoas and ili-
acus.

Union with angular deformity in
fracture of the upper one-third of
the shaft of the femur.

Deformity in fracture of the middle of the shaft of the femur.

242

SPECIAL FRACTURES.

Fig. 72.

ward, because of the action of the calf muscles on the upper
and back part of the condyles, whereas, the upper fragment is
usually tilted more or less forward, and there is marked shortening.
This deformity may not occur where the fracture is caused by direct
violence and the line of fracture is transverse. In fractures of the
middle one-third of the shaft, extension will bring about ap-
position of the fragments, and, the limb may be treated in a fixed dress-
ing in an extended position, but in fractures of the upper and lower
one-third, the thigh should be flexed on the abdomen, and the leg
partially flexed on the thigh. In fractures of the upper extremity,
union with angular deformity may occur, when good apposition has
not been obtained and the fragments are not kept immovable.

Signs. — The signs in fracture of the
shaft of the femur are so obvious that a
diagnosis is easy. The limb below the frac-
ture is helpless, and any effort at motion
causes great pain. There is shortening to
the extent of two or three inches. Preter-
natural mobility and crepitus, with deform-
ity, will be sufficient to enable the operator
to determine the injury. The foot is everted
and helpless. Sometimes this fracture is
attended by great shock and intense pain,
because of injury to the sciatic nerve. Fat
embolism forms a rare complication.

Dressing. — Numerous dressings, splints,
extension apparatus, and other forms of
dressings, have been devised for these frac-
tures. Whatever is used, the operator must
keep in mind the condition of the limb to
be treated. Dr. Still advises the use of a
dressing made of starch-paste, pasteboard,
and a many-tailed bandage, which is applied
to the thigh and leg. Each day the physi-
cian visits the case, to see that the bones
are kept in good apposition, and the dress-
ing does not interfere with the return cir-
culation. He has never had a failure with
this method of treatment. For fractures of
the upper and lower thirds of the femur,
Hodgeir's dressing is of great value. This
dressing consists of a cradle made of muslin, fastened to two iron bars,
which are bent at the knee. Two cross pieces, which can be readily de-
tached, hold the two bars a certain distance apart. Fastened to these
bars is a suspension apparatus, which is attached to a hook in the ceiling.
By this means the limb is swung in the cradle, which will accommodate
itself to the shape of the thigh, and by regulating the suspension appa-

Fracture of the lower extrem-
ity of the shaft of the femur,
showing the deformity produced
by the action of the calf mus-
cles.

SPECIAL FRACTURES.

243

ratus, any degree of extension can be obtained. For hospital use, this
dressing has no superior. The splint in most common use, both in the
hospital and private practice, is the double inclined plane. This,
in case of fracture of the upper one-third of the femur, re-
laxes the psoas and iliacus muscles; in case of the lower
one-third, it relaxes the calf muscles. Extension is made

Hodsren's dressing: for fractures of the shaft of the femur.

in the direction of the lower fragment. The difficulty in the
treatment of this fracture in small children is to maintain im-
mobility. Perhaps the dressing which yields the best result is a ver-
tical suspension of the limbs in a plaster dressing. This enables the
attendant to easily reach the excretories, so that cleanliness can be

Fig. 74

Double inclined plane and extension apparatus for fracture of the upper extremity of the
shaft of the femur.

maintained. Fracture of the middle third of the shaft can be treated
successfully with a plaster-of-Paris dressing, which is applied from the
foot up the thigh and around the pelvis, in the form of a spica bandage,
as high as the tenth rib. It does not matter how successfullv this dress-

244

SPECIAL FRACTURES.

ing is applied, it will soon become loose, so if a good cast is originally
put on, and along the site of fracture, the bandage, reinforced by two
or three narrow wooden strips, the plaster may be incised, and a roller
bandage applied over all, and the splint drawn snugly to the thigh. If
this splint is used, the patient should be gotten up at the end of two
weeks and made to go about on crutches. The reason for this is that
considerable atrophy of the muscles will take place, unless some such
method is used. In hospitals, a plaster-of- Paris bandage is applied
immediately. This is not wise in private practice. The best method
would be to put on an extension apparatus, keep the limb immovable
between sand-bags until the preliminary swelling has disappeared, and
then the plaster bandage can be put on, and in ten days, or two weeks,
the patient may get about on crutches. In fractures of any part of the
thigh, the hip-, knee-, and ankle-joints should be rendered immovable.
The knee and ankle may easily be rendered immovable, but the hip-
joint only with great difficulty. The reason is, that it is necessary for
the bowels to move daily, and the inserting of the bed-pan, and care of
the patient, will cause more or less motion at the hip-joint. Where it
can be obtained, a fracture-bed will be found of great service. If a

Fig. 75.

Long splint, fracture bed and extension apparatus used in fractures of the femur.

fracture-bed can be secured, only an extension apparatus will be re-
quired. The function of the fracture-bed is to raise the patient, by
means of canvas stretched on a frame. A hole through the sheet and
canvas, in the neighborhood of the buttocks, will allow the contents of
the bowel to be evacuated without motion of the body.

Fractures of the Lower Extremity.
Fractures of the lower extremity of the femur are: —

A. Transverse.

B. Y or T.

C. Internal or external condyle.

SPECIAL FRACTURES.

245

Transversa — The diagnosis of a transverse fracture is fairly easy,
when it is produced by direct violence. There may not be much dis-
placement. Where it is produced both by direct and indirect violence,
there may be considerable displacement. The upper end of the lower
fragment may be turned directly backward. When this occurs, some
difficulty may be experienced in setting the fracture. Cases are on
record where it was necessary to tenotomize the tendo Achilles in order
to effect relaxation of the calf muscles, so as to permit of manipulating
the lower fragment into position. When once in proper position, the
limb should be treated in a semi-flexed position by a double inclined
splint. The diagnosis is made by means of preternatural mobility, de-
formity, crepitus, history of the accident, and the nature of the injury.
Generally a good result is obtained in the treatment of the fracture.
The fracture may be kept immovable for three weeks in a young person,
and in older persons four weeks, when they may be gotten up on
crutches. Care should be taken in the preliminary use of the limb, that
the soft callus is not broken up. There is no danger of ankylosis at
the knee, inasmuch as the line of fracture does not invade the joint.

T or Y fracture is an extremely serious injury. It is produced by
direct and indirect violence, and the violence is usually of such
nature that it produces contusion and injury of the soft-parts, as well
as the fracture. This adds to the gravity of the case. Inasmuch as the
fracture invades the joint, effusion of blood will take place within the
joint cavity, and the swelling will be intense. Where the case is not
seen early, it had best be treated by antiphlogistic measures until the
swelling disappears, when an accurate diagnosis can be made. Where
it is possible, the limb should be exposed to the x-rays, in order to de-
termine the exact nature of the fracture, then a fairly accurate prog-
nosis may be made. Boivy union takes place between the
condyles and the shaft of the bone. Only fibrous union will take place
between the two condyles. The space between the condyles is widened,
and they will no longer fit the articular surfaces of the tibia, nor will
the patella fit in between the condyles, so that the joint will be per-
manently enlarged, and other deformity may result. The diagnosis
of the fracture is easily made. Crepitus is marked. There is
effusion in the joint. Motion of the patella will occasion crepitus.
More or less evidence of dislocation will be present. These, together
with the histor}r of the accident, and evidences of severe injury of the
knee, will be sufficient to make the diagnosis.

Treatment. — The limb should be kept immovable for a period of
ten days or two weeks. The parts adjacent to the injury may be manip-
ulated, to assist the return circulation. The patient should be kept
in the best possible condition and every effort made to get rid of the
inflammation. At the end of two weeks, slight manipulation of the
joint may be begun. This manipulation will prevent the formation
of adhesions. Where there is not much contusion of the parts, the

246

SPECIAL FRACTURES.

joint may be manipulated as early as the twelfth day. This manipu-
lation-is kept up lightly for two weeks, when the person may be gotten
about on crutches, and a leather knee-boot constructed, which can be
laced up closely to the limb, and which will hold the fragments in
position. This splint may be removed daily, to permit of manipulation
of the joint. If this treatment is followed out with care, the integrity
of the joint will be maintained and a fairly good result obtained.

Fracture of Either Condyle is produced by direct and indirect vio-
lence, either or both. The signs of fractures are the mobility of the
condyle and crepitus, together with evidence of injury. Usually a good
result will be obtained. Even if the union is but fibrous at first, it
will become bony, especially if the fracture occurs in a young person.
Such a fracture happening in an old person, is more grave, and the
integrity of the joint will be permanently lost. Deformity is the rule
in this kind of a fracture, inasmuch as more or less callus must form
between the condyle and the end of the bone. This slice of callus so
inserted, as it were, elongates the condyle, and in case of fracture of
the inner "condyle, the person will have knock-knee, whereas, if it hap-
pens in the external condyle, by lengthening it, a bowed condition of
the leg will result. This fracture should be treated with a double in-
clined plane and motion begun early (within two weeks) and kept up
until the freedom of the motion of the joint is not impaired.

Epiphyseal Fracture of the lower extremity of the femur is ex-
tremely rare. Moist crepitus, history of the accident, age of the
patient, evidence of a foreign body in the joint, and other signs of frac-
ture, will enable the physician to make the diagnosis.

Treatment. — The treatment is the same as in the other forms of

fracture. Tbe family should be notified that considerable deformity

results from this fracture. Destruction of the lower epiphysis will

result in marked shortening of the limb, since the limb will no longer

grow from this joint.

Fig. 77.
Fig 76

Transverse fracture of the
patella.

Fracture of the patella with
separation of the bone into
three fragments.

Fractures of the Patella.

The patella is fractured by direct violence. The line of fracture
may be vertical or transverse, but is usually transverse. The trans-

SPECIAL FRACTURES.

247

verse fracture is said to occur sometimes from muscular contraction,
by vigorous and forced action of the quadriceps extensors. The diag-
nosis of the transverse fracture is easy. The upper fragment is pulled.

Fig. 78.

Fig. 79.

Fracture of the patella, showing
displacement of the upper fragment.

Fracture of the patella, showing
the nature of the injury.

up above the knee, by the action of the quadriceps muscles, while the
lower fragment remains in situ. There is a gap between the fragments.
In the vertical fracture, the diagnosis is equally easy. It is so rare
that it scarcely merits description.

Treatment. — The treatment in case of a transverse fracture of the
patella is not followed by a very good result. Fibrous union is the rule,
although bony union may occur. The blood supply to the bone is in-
sufficient to secure strong union. In elderly people, it is perhaps best
to wire the bones together at the outset. Under aseptic conditions this
operation may be done without impairing the integrity of the joint.
In young or middle-aged healthy people, the limb may be dressed in
extension, while the upper fragment is drawn downward by means of ad-
hesive strips. The limb should be kept in an extended position for at
least six weeks, and then manipulation and passive motion should be be-
gun, but only mildly. The reason for not permitting motion of the
limb earlier is that the callus, which is yet only fibrous, will stretch
and allow the fragments to be pulled apart. This will lengthen the
distance between the origin and insertion of the quadriceps extensor
muscles and thereby impair their usefulness, and deformity will result.
Should fibrous union occur an operation may be advised. A slice of
callus may be sawed out and the ends of the bones united. It may
be treated by means of McBurnej^'s hooks, but this treatment is not
often used.

Compound Fracture of the Femur and Patella should be treated in the
same manner as a simple fracture, with the exception that the wound

248

SPECIAL FRACTURES.

Fig.

should be cleansed and asepticized at once and thereafter dressed anti-
septically. Should a plaster bandage be applied, a window may be cut
in the plaster over the site of the wound, so as to permit of daily treat-
ment and cleansing of the wound and provision for drainage.

Fracture of the Lower Leg.

Fractures of the lower leg may be divided into:

I. Fractures of the tibia and fibula.
II. Fractures of the tibia.
III. Fractures of the fibula.

Fracture of Both Bones is most common, with the exception, perhaps,
of fractures of the lower extremity of the fibula. The cause is direct
and indirect violence. If both bones ai*e fractured at the same level,
and the line of fracture is transverse, the cause is
direct violence. If the bones break at their weakest
point, because of falls on the foot, and more or less
force distributed to the leg at the same time, the
line of fracture will be oblique. In the latter case,
the tibia breaks in its lower third, while the fibula
breaks in its upper third. In the transverse frac-
ture, which is the result of direct violence, there is
not much deformity. The diagnosis is easy. The
tibia is subcutaneous and fracture can readily be de-
termined in it. It may not be so easy to determine
whether the fibula is broken, but in case only the
tibia is broken, preternatural mobility would not be
very marked, because, of the presence of the com-
panion bone, whereas if both bones were broken, the
preternatural mobility would be more marked. In
the oblique fracture, which is a much more serious
condition, there is great danger of the fracture be-
coming compound. The reason is, because the lower
end of the upper fragment projects forward against
the skin, while the action of the muscles pulls the
lower fragment past the upper. The lower end of
the upper fragment usually makes a sharp projection
against the skin, and unless great care is exercised
in handling the member, the skin may be broken.
Signs. — The signs of fracture are obvious. Evidences of
injury, preternatural mobility, crepitus, deformity, loss of motion, etc.,
are present.

Treatment. — In treating fractures of the tibia and fibula, it is impor-
tant to keep in mind that both the ankle- and knee-joints should be
rendered immovable. Furthermore, in setting the fracture, it is of the
greatest importance that the physician sees that he does not have union
with deformity. Eversion of the foot is the rule. The con-
traction of the tibial muscles will be greater than the peroneal,

Transverse fracture of
both bones of the leg as
results froni direct vio-
lence.

PLATE I.

Radiograph by George M. Laughlin, D. 0.

Radiograph of a compound fracture of both bones of the lower leg six weeks after the

iniury Note that the bones are fragmented and that there is non-union.

There is a multiple fracture of the fibula. The wound became

infected and inflammatory tissue shows on the

fibular side of the leg.

SPECIAL FRACTURES.

249

and a condition of varus, especially if the fracture is low down, may
occur. This can be prevented by making extension and having the
inner side of the great toe, the inner malleolus, and the inner border
of the patella in the same plane. As long as these points are kept in
the same plane and extension and counter-extension is maintained, a
good result will follow. The best dressing, and the one easiest
to apply, is the one advised by Dr. Still. The dressing used in hos-
pitals, where there is not too much injury to the soft-parts, or where
there is no comminution of the bones, is a plaster-of-Paris dressing.
It is carried to just beyond the middle of the thigh, sufficiently
high to render the knee immovable. Should the dressing become
loose, it can be cut in front and a roller bandage applied over the pla-
ter splint, so as to draw it tight to the leg. Extension is made on the
lower fragments by weight and pulley, in the same manner as for frac-
tures of the thigh. It is not necessary to keep this extension up if the
bandage is properly applied.

Fig. 81.

Fracture box for fractures of either or both bones of the leg.

Fractures of the Tibia. — Fractures of the tibia may occur in any part
of the bone, but fractures in the upper one-third are rare, except as
the result of great direct violence, when the fracture may be multiple
and comminuted. This is a very severe form of fracture, and may
demand amputation. Where the vitality of the patient is good, and
there is fairly good circulation, the limb may be put in a fracture-box
for a few days and watched. Where the fracture is not compound, this
procedure should always be followed. Amputation may be deferred
until there is evidence of deficient circulation, or gangrene appears.
Fracture of the middle or lower third of the shaft is caused by direct
and indirect violence — blows directly upon the bone or falls upon the
foot, either or both. Usually there is but little displacement, because
the companion bone, the fibula, is uninjured. The diagnosis of the in-
jury is easy, inasmuch as the bone is subcutaneous. As the finger is
passed along the anterior border of the tibia, at the site of the frac-
ture preternatural mobility and crepitus will be obtained, and there will
be evidences of local injury. Fractures of the upper and lower third of
the tibia may be treated similarly. It is necessary to carry the splint
only to the tuberosity of the tibia. Where there seems to be a consid-

250

SPECIAL ' FRA CTURES.

erable wrenching of the ligamentous attachments between the tibia and
fibula at the time of the injury, and where it appears to the physician
that there is mobility between the ends of the bones, it may be neces-
sary to carry the splint or dressing up to the middle of the thigh. In
all these fractures of the lower leg, the patient should be gotten up
within two weeks after the fracture. A plaster dressing may be ap-
plied over the foot and up to the tuberosity of the tibia. In this frac-
ture, Dr. Still's dressing is of the greatest service. It is easy to apply,
and is light, and if applied with care, will maintain the bones in appo-
sition, and will permit the patient to go about on crutches. The objec-
tion to the plaster-of-Paris dressing is, that it is weighty and cumber-
some and in numerous ways troublesome.

Fractures of the Fibula.

Fig. 82.

Fractures of the fibula are more common than fractures of the tibia.
The cause is direct violence, as blows directly upon the fibula, and indi-
rect violence, such as wrenches of the foot.
There is not much displacement of the bones
in fractures of the fibula. The diagnosis is
easy. The lower part of the bone is subcutan-
eous. There will not be much preternatural
mobility, but the normal springiness between
the tibia and fibula will be destroyed and there

Pott's fracture with the de
formity reduced.

lower extremity
the bone, the

will be crepitus. The
fracture most com-
mon in the fibula, and
the one which merits
the best description,
is that which occurs
in the lower one-fifth
of the bone, or two or
three inches above
the malleolus. This
fracture was first de-
scribed by Percival
Pott, and has since
borne his name. It is
usually caused by the
patient slipping on
the foot, as in step-
ping from a car or
cab upon a cobble-
stone. The astragalus
is driven against the
of the fibula, the force is
fracture occurring two o:

Fig. 83.

Pott's fracture, showing the
characteristic deformity.

transmitted up
three inches

along
above

SPECIAL FRACTURES.

231

the malleolus. The upper end of the lower fragment is directed
in towards the tibia, while the astragalus is dislocated outward. The
internal lateral ligament is ruptured, or the tip of the internal malleo-
lus is broken off. The deformity in this fracture is characteristic.
The inner side of the sole of the foot is directed downward, while the

The foot is displaced
Fig. 84.

sole itself is directed downward and outward,
outward, and at the same time everted. The
internal malleolus stretches the skin and is
markedly prominent. There is a depression on
the outer side of the leg above the external
malleolus. This is by far the most common
fracture. There are two or three similar frac-
tures described, one of which is Dupuytren's.
In this fracture, the fibula is broken, as before
mentioned, the tip of the internal malleolus is
broken off, while the tibio-fibular ligaments
are likewise torn, i. e., there is a separation of
the lower articulation of the tibia and fibula.
In the third variety of fracture, the fibula is
broken in the same situation, and the tibia
is broken transversely just above the articu-
lation. In these last two fractures, the deform-
ity is very similar to that of a Pott's fracture,
but the internal malleolus does not form such
a sharp prominence on the inner side of the
foot. Should the tip of the internal malleolus
be broken off in Pott's fracture, the fragment
of bone will be felt beneath the skin. Frac-
ture of the internal malleolus does not occur
in the majority of cases. In mild cases of
Pott's fracture, with but little injury to the
<?oft-parts, the patient may be able to walk
some distance, or may not discover that he has
a fracture, believing it is a sprain. There is a
rare form of this fracture described by some
authors, in which the foot is displaced inward, instead of outward. In
this case, the upper end of the lower fragment projects outward against
the skin, instead of inward. The diagnosis in Pott's fracture is fairly
easy. Where the characteristic deformity is present, it is only neces-
sary to determine the nature and amount of injury. If the surgeon
grasps the ankle, the natural springiness of the fibula is ab-
sent. Crepitus will be obtained upon extension. Eversion or in-
version of the foot will disclose preternatural mobility. In cases
where the physician is in doubt, it should be treated as a fracture. This
is equally true of all injuries to bones.

Treatment. — The treatment is to correct the deformity by traction
and manipulate the foot in proper position. When the inner side of

Dupuytren's fracture, which
closely simulates a Pott's frac-
ture.

252 DISEASES OF JOINTS.

the great toe, the inner malleolus, and the patella are in the same plane,
a suitable fixed dressing may be applied. Dr. Still's dressing is prefer-
able. An externa] splint, with a vertical foot-piece, or a plaster-of-Paris
dressing may be used. In any case, the patient should be gotten up,
so that he can get about on crutches, within two weeks after the injury.
The foot may be manipulated and the integrity of the joint restored.
It is necessary, in all cases, to maintain immobility of the frac-
ture. If this is not done, eversion of the foot may take place and a
condition of talipes valgus, or flat-foot, will result.

Fractures of the Tarsus.

Fracture of the tarsus is rare, except as a result of great direct vio-
lence. The diagnosis is usually easy. Preternatural mobility and
crepitus are easily obtained. In cases where there is great swelling, the
diagnosis cannot be readily made. The foot should be kept immovable
and at rest, and antiphlogistic measures applied until the swelling is so
reduced that a diagnosis may be readily made. An x-ray examina-
tion should be made when possible. The prognosis should be
guarded in these fractures, inasmuch as death of one of the fragments
may occur. Union is good. The fracture may result in the
letting down of the arch of the foot. The person should not be
allowed to walk until after good union has been obtained.

Fractures of the Metatarsus.

The metatarsal bones are fractured by direct violence, blows on top
of the foot, or by weighty objects falling upon the foot. The diagnosis
is easy. A stiff splint moulded to the sole of the foot and the member
snugly bandaged to assist the return circulation, will be all that is nec-
essary. The foot should be allowed rest for three or four weeks. In the
meantime, the parts may be manipulated.

Fractures of the Phalanges.

Fractures of the phalanges are common, and the diagnosis is made
without difficulty. The treatment is similar to treatment of the meta-
tarsal bones.

DISEASES OF JOINTS.

Synovitis.

Synovitis is an inflammation of the synovial membrane of a joint.
These inflammations may be divided into (1) acute, and (2) chronic.

Acute Synovitis is caused from injury, such as contusions, sprains,
wrenches, exposure to wet and cold, and to the deposit of certain in-
flammatory products, or micro-organisms, about the synovial membrane.
The abnormal relation of the articular surfaces of the joint, or partial
dislocations and contractions of fascia and muscles interfering with the

DISEA SES OF JOINTS. 253

return circulation, operate, as the most usual causes, in a large number
of cases.

Pathology. — The synovial membrane becomes congested and red;
following this there is an exudation of fluid into the synovial sac, which
prevents the inflamed surfaces of the membrane coming in contact.
This effusion ma}r be very great, or may be only slight. There is always
more or less inflammation about the joint, sometimes the congestion of
the periarticular structures is considerable. Where the activity of the
cause is not too great, and the case is properly treated, resolution may
take place without any organic changes occurring in any of the joint
structures. On the other hand, the inflammation may extend into the
cartilages, the connective tissues about the joint, or into the
bone. Suppuration and abscess may follow, and the cartilages and
bones become eroded and destroyed, resulting in osteo-arthritis and bony
ankylosis.

Symptoms. — The joint is swollen and painful; movements are im-
peded. Spasms of the muscles and a "fixed" condition of the ligaments
serve to hold the joint in a position (generally a flexed one) of the great-
est ease. In septic cases, congestion and inflammation are much greater
and the case is attended by considerable fever, while in the milder cases,
the fever may not rise to more than 100 degrees or 101 degrees F., or in
very mild cases there may be no febrile reaction whatever. In xhe se-
verer forms a chill may occur, together with a rise in temperature,
sordes, loss of appetite, coated tongue, confined bowels — indications of
the absorption of pus. If the joint is not covered with too many sur-
rounding tissues the swelling is quite manifest. The outline of the
distended synovial sac can be mapped out with ease. In the case of a
Tcnee-joint the greatest distension takes place on either side of the liga-
mentum patellae and just above the joint underneath the quadriceps
extensor muscles. In some cases, this distension may be enormous.
If pus forms within the joint, it burrows in the direction of
least resistance, which may be along the sheath of some muscle, a dis-
tance away from the joint. In case of the eTboiv, the distension of the
membrane takes place upward underneath the triceps. In the ankle,
there is puff mess behind the malleoli and underneath the extensor ten-
dons. Sometimes the fluid effusion is so small that it is difficult to
detect it. In conditions of the hip and shoulder, it may be overlooked.
In the knee-joint, the patella may even be lifted away from the con-
dyles (riding of the patella). In other cases, it may be necessary for the
person to bend at the hips in a standing position, with the legs extended,
and the hands resting on the front of the thighs (Fisk's method), when
fluctuation may be felt on the inner side of the patella. The severer
forms of septic synovitis will be indicated by the evidence of sepsis, the
increased pain, and redness about the joint, together with the general
systemic conditions already mentioned.

Treatment. — The treatment of acute synovitis is distinctly osteo-

254 DISEASES OF JOINTS.

pathic, until pus forms, when surgical interference may be necessary to
evacuate the pus, and prevent erosion of the articular cartilages, and
subsequent involvement of the ends of the bones. Destruction of the
joint tissues to any extent means ankylosis, which will more than likely
permanently interfere with the integrity of the joint. If the synovitis
arises from a penetrating wound, by which infectious materials have
been introduced, it is imperative to at once wash out the wound and
joint with an antiseptic solution, as a saturated solution of boric acid,
or 1:50 solution of carbolic acid in boiled water. Drainage must be
provided and the wound washed and dressed twice daily until all dan-
ger of infection of the synovial membrane has passed. When the inflam-
mation is set up by bruising the joint, and not by an open wound, cold
should be applied during the first twenty-four hours, then manipulative
measures, to secure normal circulation.

If the synovitis is the result of the deposit of germs in the joint,
and of obstructions to the circulation, or from subluxations or malposi-
tion of the bones, only manipulative measures will afford relief. Where
the joint is a point of least resistance, lesions will be found directly
affecting the blood supply, or spinal lesions ail' ecting the nerves to the
joint. The treatment consists of removing these lesions, releasing
the nerves, and in stimulating the circulation. Slight passive motion
must be kept up, to prevent ankylosis. Obstructions to the circulation,
and local congestion, may be relieved by appropriate methods. When
pus forms, which will be evidenced by chills and fever, loss of appetite,
confined, bowels, etc., a free incision should be made at| the most con-
venient point and the pus evacuated. The joint may then be washed out
daily with an antiseptic solution. Even though pus forms in the joint,
and the S3rnovial fluid drains out for weeks, there is no clanger
of ankylosis, unless the cartilages become eroded and destroyed. As
the inflammation subsides, more vigorous manipulation of the joint
should be made. Should any adhesions form, they may be readily
broken up and the inflammatory tissues absorbed.

Chronic Synovitis, or subacute synovitis, frequently follows an attack
of acute inflammation of the synovial membrane, or it may be subacute
from the beginning. It is stated by excellent authors that many of these
cases of chronic synovitis are tubercular inflammations. The opposite
of this might be stated with perhaps equal truth, that many cases diag-
nosed as tubercular synovitis are nothing more than simple cases of
subacute synovitis, the result of lesions, subluxations, and contractions
of fascia or muscles, which interfere with the circulation and bring about
the inflammatory conditions. The habit of calling these prolonged
cases of chronic synovitis which do not yield to the treatment admin-
istered, "tubercular," is nothing short of vicious. Without doubt, many
cases are due to the deposit of the tubercle bacillus outside of the mem-
brane, or within the membrane, and this low-grade inflammation results,
but there are other causes more important than these bacilli, and those

DISEASES OF JOIXTS. 255

causes might be summed up in the interference with the circulation to
the joint and bad general health.

Pathology. — The synovial membrane may be congested, but the
villus-like projections around the edges of the articular surfaces become
hypertrophied and edematous. A considerable amount of fluid may
exude into the joint. This may be so great as to give rise to a condi-
tion called ''hydrops articuli.*' The nature of the fluid effused into the
joint may be that of ordinary serum. The joint may remain in this
condition for years without change, while on the other hand, absorption
may take place and the disease disappear. The synovial membrane may
become thickened and liypertrophied. and as it becomes distended, it
may extend along sheaths of muscles in pouch-like dilations
(Baker's cvsts). The cartilages of the joints may become inflamed and
thickened. Sometimes degenerations of the thickened portions of the
synovial membrane may take place.

Symptoms. — Evidences of effusion in the joint, together with a his-
tory of acute synovitis or lesions, indicating interference with the return
circulation, or a history of injury, together with the presence of fluid in
the joint. Tn some cases there may be false crepitus in the joint, occa-
sioned by the formation of weak fibrous adhesions. On motion these
are broken up. If the joint is aspirated, a viscid, straw-colored fluid
will be obtained.

Treatment. — In the treatment of chronic, as in acute, synovitis,
osteopathic methods have accomplished wonderful results. If these
manipulative measures are persisted in, good results will be obtained,
and amputation rendered unnecessary. It does not matter whether the
case is tubercular or not, the same methods should be employed, while
uniformly good results may be expected. Even in cases of long
standing. where surgical authorities have advised amputation as the only
means of relief, good results have been obtained in many cases. It is
in this class of cases that osteopathic practitioners have achieved some
of their most brilliant results.

The treatment consists in securing the proper blood supply, remov-
ing obstructions to the circulation, and reducing subluxations. Certain
spinal lesions, affecting the nutrition to the joint, may be the cause of
the disease. These should be removed at once. Eesorption of the in-
flammatory thickenings and fibrous tissues about the joint may be
secured by obtaining the proper circulation.

Acute Arthritis.

Arthritis is an inflammation of all the tissues of a joint. In synovitis,
the inflammation is limited to the synovial membrane. In arthritis, the
synovial membrane also may be involved, but the inflammation ex-
tends into the connective tissues about the joint. The origin of the
disease mav be within the svnovial membrane, as svnovitis, or it may

256 DISEASES OF JOINTS.

be within the bone, as osteitis, but at all events, the inflammation in-
volves- -all of the articular structures.

Cause. — The causes are the same as in synovitis. In arthritis, there
is usually a history of greater injury, often penetrating wounds, or
a history of osteitis, periostitis, osteomyelitis, or abscess in the soft-
parts which may ha-ve involved the joint, or there may have been the
absorption of septic poisons from certain acute fevers, which have
lodged in and about the joint, setting up a general inflammation.

Pathology. — The changes occurring in the joint vary according
to the course of the disease, and according to its origin. It usually
begins as an acute inflammation of the synovial membrane, which
spreads into the surrounding tissues, the cartilages become eroded and
softened, and may be entirely destroyed. The ligaments become infil-
trated with inflammatory elements, softening may take place, with
marked increase in the connective tissue elements. Because of the mus-
cular spasm, and the weakened condition of the ligaments, luxation of
the articular ends of the bones follows, while because of the interference
in the circulation, and the partial arrest of the nutrition to the tissues
about the joint, disorganization is followed by the formation of pus and
further destruction of the articular structures. The pus will burrow in
the direction of least resistance, finally rupturing, perhaps, some,
distance from the joint. It will continue discharging pus for a consid-
erable length of time, afterward the abscess may heal and fibrous
tissues form between the articular ends of the bones, producing true
ankvlosis. This ankylosis may. in some cases, be bony, leaving a perma-
nently stiff joint. The cartilages are destroyed by the process of infil-
tration and degeneration. The ends of the bones may often be greatly
eroded or destroyed by a process of caries. Sometimes, before the
epiphysis has been united to the diaphysis, the entire epiphysis may be
destroyed, because of interference to the circulation. There is a certain
class of these cases in which the pus burrows in many directions
into the muscles and along the bones, giving rise to a general septic
condition. In such cases, the pus may even get into the medullary cav-
ity, setting up an osteomyelitis. Such cases end unfavorably.
In most cases, the pus will rupture in the neighborhood of the joint,
afterward healing by third intention. After prolonged suppura-
tion in the worst cases, lardaceous disease and affections of the viscera
may occur.

Symptoms. — The symptoms ma}' be those of an ordinary attack of
synovitis, but as soon as the structures about the synovial membrane
begin to be involved, the symptoms are more intense, greater swelling,
edema about the joint, and a bluish-reel color, will serve to distinguish
it from synovitis. The temperature is higher, and the pulse more
rapid. Where pus develops in the septic forms of the disease,
there will be chills, followed by rigors, a quiet condition of the bowels,
and a loss of appetite. The patient is often considerably debilitated.

DISEASES OF JOINTS. 257

The pain in the joint is xisually very severe, j,rid the reflex irritation of
the muscles gives rise to painful startings. After rupture of the abscess,
the condition heals slowly.

Treatment. — In general, the treatment is the same as in synovitis.
The pus must be evacuated early and good drainage obtained. The
patient must be given a nourishing diet, while the secretions should be
made as nearly normal as possible.- Where there is extensive destruction
of bone, and the case continues a considerable length of time, resection-
of the joint and scraping away of all the necrosed bone may be neces-
sary to save the limb. Even in bad cases, if good drainage is secured,
manipulative methods will obtain good results. Obstructions to the
return circulation must be removed, spinal lesions corrected, and the
general health built up. The prognosis should always be guarded,
although a fair result can usually be obtained.

Epiphysitis.

Epiphysitis is an inflammation of the epiphysis of the bone in young
persons. It may be acute, subacute, or chronic, and arises from injury
or lesions affecting the blood supply, or the abnormal relations of the
bones. It may, or may not, involve a joint.

Cause. — The causes are the same as those of synovitis and arthritis.
The changes taking place in the epiphysis arc such as to terminate
quickly in suppuration. Should the pus and inflammation extend into
the joint, arthritis may result. Sometimes the epiphysis may be sep-
arated from the dia.ph.ysis of the bone, forming a sequestrum, when by
a process of suppuration, ulceration, and a burrowing of the pus, the
sequestrum may be dislodged, or even exfoliated by nature. In most
cases, the injury and destruction of the epiphysis result in a shortened
limb. There are eases in which the limb even grows longer, because of
the formation of new tissues within the epiphysis. At all events, stiff-
ness and fixidity of the joint are the rule. Sometimes a large abscess
results.

Treatment. — The treatment is essentially the same as for arthritis
and synovitis. The prognosis should be guarded. Should the case be
seen before there is destruction of bone, relief may be given almost at
once. The reduction of the subluxation and the relaxation of the con-
tracted muscles, thus removing obstructions to the circulation, will
prevent destructive changes.

Gonorrheal Arthritis, or Gonorrheal Rheumatism.

Not infrequently during the course of gonorrhea, the patient may be
attacked with inflammation of the joints. Cases have been reported
where these inflammations attended gonorrheal opthalmia. These arth-
ritic inflammations vary in intensity; some are very mild, while others
are severe, furnishing a mental picture of the ordinary case
of acute rheumatism. Not all the rheumatic attacks taking place during
gonorrheal arthritis are the result of this disease, but many are.

258 DISEASES OF JOINTS.

Cause. — The cause of the joint-inflammation seems to be the ab-
sorption of the products of inflammation. It may be, in some cases, the
streptococci; in rare instances, the gonococci may be the exciting cause
of the inflammation. It is really not a form of rheumatism, but a form
of arthritis, due to the absorption of the inflammatory products from
the ulcer found in the urethra, or upon the mucous membrane of the
vagina. The inflammations are rather intractable, but yield to treat-
ment. The inflammations usually end in resolution, but may end in
ankylosis, fibrosis about the joint, and in suppuration. The disease
occurs during the later stages of gonorrhea, or after the discharge has
disappeared. It is usually confined to one joint, most often the knee;
the next most frequently affected are the tarsal-joints, which is often
followed by flat-foot. It may affect the hands or wrists. The disease
frequently recurs.

Symptoms. — The symptoms of the disease are those of acute and
chronic arthritis and synovitis. The presence of chronic gonorrhea,
together with evidences of rheumatism, will determine the diagnosis.

Treatment. — In the treatment of gonorrheal arthritis, the organs of
elimination, especially the kidneys, must be kept active, and the circula-
tion through the affected joint should be improved. Since the disease
is produced by the absorption of toxic products from the gonorrheal
ulcer, it is plain that these elements would lodge and excite an inflamma-
tion at a weak point. Stimulation of the spinal origin of the nerves to
the joint, together with local treatment about the joint, impro/ing the
circulation, and assisting resorption of the inflammatory elements, will
be necessary. Any subluxation existing must be reduced, as these are
regarded as responsible for the inflammation.

Tubercular Arthritis.

There is a large per cent of cases of chronic arthritis which are either
tubercular, almost from the incipiency, or become tubercular some time
within the history of the disease. The disease occurs more frequently
in' the spine than any other part of the body (See tuberculosis of the
spine). In order of frequency, the following joints and bones are
affected: Knee, hip, ankle, tarsus, elbow, wrist, hand, skull, face,
sternum, clavicle, ribs, pelvis, femur, tibia, fibula, shoulder, scapula,
ulna, radius, humerus, and patella. The disease is much more common
in young people. It is claimed that the imperfect structure and the
irregular contour of the vessels in the epiphyses of the bones entering
into the formation of the joints involved, constitute an important fac-
tor in the development of tubercular disease. This is hardly true. The
presence of spinal lesions, together with partial dislocations, muscular
contractions, contractions of fascia, etc., all assist in bringing about a
condition in which there is an abnormal blood supply and abnormal
nerve influence to the joint or bone, and under these circumstances, the
tubercle bacilli are deposited and the disease arises. The deposit of the

DISEA SES- OE JOIN TS. 25 '.)

germ takes place more frequently in the epiphysis in children, but in
adults the disease starts in the synovial membrane, or joint-capsule.

Changes Occurring In. — The pathological changes occurring in
tuberculosis of joints are, in general, as follows:

1. The formation of granulation tissue. This is characteristic of all
tubercular inflammations. Sometimes it is fungating in character. At
other times there will he but few tubercles and but little granulation
tissue, but the rule is that a considerable amount is formed.

2. Caseation and softening of the granulation tissue is sometimes
termed gelatiniform degeneration. This takes place according to
whether there is sufficient interference to the nutrition of certain area.-
of the affected tissues. In some cases, no caseation and softening follow,
while in other cases the degenerative changes are extensive.

3. Joint-effusion. Effusion into the joint is the rule. Sometimes
there is but little joint-effusion, while at other times it is extensive.
There is a certain class of cases in which there is a considerable y mount
of granulation tissue, with no effusion and no tendency to caseate. In
such cases there Avill be but few tubercles formed.

4. The contour of the joint is changed. The joint becomes spindle-
shaped, and the tissues are more or less glued together, and the motions
of the joint become limited. There may be considerable redness of the
joint, or there may be none. The veins about are often considerably
enlarged, due to the interference in the return circulation. Especially
is this true where the granulation tissue involves the deep veins, in case
of tuberculosis of the knee-joint.

5. Deformity is one of the most important changes occurring in
joint-tuberculosis. This deformity arises, many times, before the de-
posit of the tubercle. Primary injury is an important factor in the
cause of tubercular disease. This primary injury may be contusions of
the ends of bones, or it may be a subluxation. The injury of the joint
ma}* produce spasm of the muscles, holding the bones in an abnormal
position. This initial deformity is exaggerated in the later stages of
"tfie disease by muscular spasms, erosions of the bones, destruction of the
cartilages, and relaxation of certain of the ligaments, and contraction
of others, producing partial or complete dislocations. Furthermore,
the position of the limb assumed by the patient in obtaining relief from
pain, oftentimes results in deformity.

6. Abscess formation. In a certain proportion of cases, degeneration
and softening occur, resulting in the formation of a fluid similar to pus.
This fluid burrows along the sheaths of muscles, or fascia-planes, and
finally reaches the surface and ruptures, forming a sinus. Occasionally
infection will take place along back this sinus, which leads to pyogenic
infection of the joint. Fever and other evidences of the septic process
will be present. This acute suppuration is very often perilous to life,
so it should be avoided under all circumstances.

7. Ankylosis. By the old method of treatment, ankylosis was the

260 DISEASES OF JOINTS.

rule, and in only a very few cases was the disease recognized sufficiently
early, nor was the treatment sufficiently successful, to permit of a cure
without limited motion. Osteopathic treatment has improved upon the
older methods, from the fact that it not only secures an arrest of the
tuberculous process, but likewise prevents ankylosis in a large number of
cases. Sometimes ankylosis cannot be prevented. The disease may some-
times remain quiescent for several years, and again break out anew.

Treatment. — The treatment of tuberculosis of joints may be fol-
lowed out on the same principles as of tuberculosis of any other structure.
The deposit of the tubercle bacilli will not occur unless there is a dimin-
ished resistance of the tissues. This condition may be overcome by
building up the system and increasing the nutrition of the tissues at
the point of least resistance, or those affected. It is conceded
that our only protection against the onslaughts of the tubercle bacilli
is normal, healthy blood, and a free circulation. These may be best
obtained by osteopathic methods.

The manipulation employed should be at the spinal origin of the
nerves to the affected part or directly over the vessels carrying the blood
to and from the diseased area, always working in the direction of the
circulation ;also local manipulation, to prevent stasis and to increase the
local nutrition. Lesions directly, or reflexly, affecting the circulation,
or nerve supply, must be removed as soon as possible. Motion must be
kept up in the joint, to prevent ankylosis. There is no danger of dis-
seminating the tubercle bacilli. Very vigorous manipulation
will do mechanical injury. When abscesses occur, the necrosed
tissues should be washed away by antiseptic solutions, and rigid
cleanliness enforced. Antisepsis will not heal the sore — only good, fresh
blood can accomplish it.

Tuberculosis of Special Joints.

Hip Disease. — This affection has a variety of names, such as Morbus
Coxarius, Morbus Coxae, Coxitis, or Hip-joint disease.

Causes. — The causes of hip disease are (A) Contributory and (B) Ex-
citing.

The contributory causes consist of luxations and subluxations of the
hip, or conditions affecting the circulation and nerve supply to the joint
and surrounding tissues. The nerve supply of the hip-joint comes from
the anterior crural, obturator, great sciatic nerves, and filaments from
the sacral plexus. These nerves may be pressed upon by luxations,
curvatures in the lumbar spine, subluxations at the sacro-iliac joint,
usually a twisted condition, or at the hip itself, or by contractions of
the psoas magnus, pyriformis, and other muscles. The blood supply
comes from "the internal circumflex, sciatic, gluteal and obturator
arteries. These arteries and their accompanying veins may be ob-
structed by contractions of the internal femoral, gluteal, obturator,
psoas, and other muscles, also by certain bony lesions. By the operation

DISEASES OF JOINTS.

261

of these lesions, the joint becomes a weak point, when, because of a
slight injury, or the deposit of the bacilli, degenerative changes are
set up.

The exciting causes are injury and deposit of the tubercle bacilli.

Occurrence. — The disease occurs
more frequently in children. It is
claimed that between sixty and sixty-
five per cent of all cases occur in chil-
dren under ten years of age, while
eighty per cent, of the cases are found
in individuals under twenty.

Fig. 86.

Early hip disease, showing
obliquity of the pelvis.

Obliteration of the gluteal fold as
occurs in hip disease.

Point of Origin. — In the largest number of cases, the disease arises
from the deposit of the tubercle in the acetabulum. In a certain propor-
tion of cases, it first begins in the head of the femur, while other times
it may arise in the great trochanter. In cases developing in adults,
the deposit of the tubercle will be in the synovial membrane, or in the
connective tissues outside.

Symptoms. — The symptoms of hip-joint disease vary with the
nature of the changes taking place in the joint. They may, perhaps, be
best understood by classifying them in the following manner:

1. Sympathetic pain in the knee-joint, which is most likely due to
the involvement, either directly or reflexly, of the obturator nerve. It
may be due to pressure upon the obturator nerve, or to an irritation of
the filaments within the hip-joint itself. The pain is usually localized
on the inner side of the knee-joint. It may be on the front of the leg,
or extend along down the inner side of the thigh, leg, and foot.

2. Faulty position of the limb. The abnormal position of the leg

262

DISEASES OF JOINTS.

early in the disease consists of flexion, external rotation, and abduction.
The flexion may be slight and the abduction not great, depending upon
the severity of the symptoms. The cause of this position seems to be
the tension of the ilio-femoral, or Y-ligament. The fluid effusion in
the joint apparently lifts the head of the bone out of the socket. This
produces a greater tension upon the Y-ligament, causing the llexion.

Fig. 87.

Flexion of the thieh produced by tension of the Y-ligament as happens in coxitis.

This flexion gives rise to one of the earliest symptoms, viz., inability
of the patient to completely extend the limb, or should the limb be com-
pletely extended, it produces lordosis of the spine.

3. Later deformity. Later in the disease, because of the muscular
spasm and contracted fascia, and because of the changes taking place
in the head of the bone, or in the acetabulum, the limb becomes ad-

FiG. 88.

lordosis of the spine, produced by extension of the legs, as occurs in hip disease.

ducted, rotated inward, and flexed. Should the epiphysis become sep-
arated from the shaft of the bone, it may resemble a fracture of the
neck of the femur, while in other cases, the head of the femur is drawn
against the upper rim of the acetabulum. Here it presses against the
upper and back part of the capsule, which gives way, and the
muscular contraction produces a dorsal dislocation. This is the most
common and the characteristic position of old cases of hip-joint
disease. From early in the disease, extending through its clinical course,
there is a marked adductor spasm. Following fluid effusion in the joint,
there may be extensive erosion of the bones, ligaments, and cartilages.

DISEASES OF JOINTS. 263

The fluid effusions may be so great that fluctuation can be made out.
Where erosion of the bones and destruction of the cartilages, with
formation of pus, follow, this pus will burrow through the muscles of
the thigh, underneath the fascia lata, to the point where the tensor
fascia femoris muscle is inserted, where it ruptures. In other cases,
the pus may reach Scarpa's triangle, by passing through the cotyloid
notch, or by passing through the bursa underneath the psoas muscle.
In other cases, it may burrow upward underneath the glutei muscles.

4. Pain is produced in the hip-joint by pressure on the sole of the
foot and great trochanter. While pain is present in hip-joint disease,
it is markedly increased by pressure in these localities.

5. Marked atrophy of the muscles attends hip disease. There is
flattening of the buttock, and the gluteal crease, or fold, is lessened, or
absent, and is lower down on the affected side.

Early Signs. — The early symptoms of coxitis may be entirely over-
looked. Usually there is evidence of malnutrition, the child has night
terrors, and on arising in the morning, shows lameness, which wears off
during the day. The child easily tires at play, and should he lie down to
rest, the lameness is evident in the hip, which will, perhaps, wear off
again shortly. Pain may, or may not, occur in the hip, upon tapping
the sole of the foot, or upon pressure upon the trochanters. There is
slight adductor spasm, and as the disease grows worse, the little patient
complains of pain in the hip-joint and on the inside of the knee, while
there may be more or less tilting of the pelvis to allow the foot to touch
the ground in walking.

Diagnosis. — The diagnosis of early hip disease is very difficult;. In
making an examination, the pelvis should be placed in normal relation
with the spine, the anterior superior spines of the ilia should be on the
same level, when shortening of the limb can be detected. If the limb is
flexed, with the ilia in normal position, and then extended, lordosis of
the spine will be produced. There is usually limitation of motion in the
joint in some direction.

This disease may be confounded with lumbar or psoas abscess from
caries of the spine, sacro-iliac disease, congenital dislocations of the hip,
lordosis from rickets, infantile paralysis, gluteal bursitis, or gluteal ab-
scess. In psoas or lumbar abscess from caries of the spine, there will
be evidence of disease of the vertebrae, whereas, the abscess ap-
pears below Poupart's ligament, external to the femoral vessels, at a
point where hip abscess rarely, if ever, appears. In sacro-
iliac disease, pressure upon the iliac crests will produce pain, whereas
tapping of the sole of the foot will not produce pain. There will be no
limitation of motion in the hip-joint. In congenital dislocations, a his-
tory of the case, and absence of inflammatory signs, together with an
x-ray examination, will enable the physician to make a correct diagnosis.
In rickets, there will be evidence of the rachitic rosary, and the involve-
ment of other bones and joints than the hip. In infantile paralysis,

264 DISEASES OF JOINTS.

there are no inflammatory symptoms. There is progressive muscular
atrophy, which takes place rather rapidly. In gluteal bursitis, the symp-
toms are continuous and unremitting. Exercise aggravates the pain,
which is moderate. The location of the pain is behind the hip and be-
hind the knee.

Treatment. — The treatment of hip disease consists in removing the
lesions found. Twists in the pelvis and curvature of the spine call for
attention at once. It is not necessary, in many cases, to manipulate
the thigh at all. If the thigh is manipulated, it should be done gently,
and not so as to do injury. Treatment to correct the position of the
spine and the pelvic lesions will be followed by good results in from two
to six months. In bad cases, treatment may be required longer — a year
or more.

The methods employed in surgical practice are, fixation
and extension for a long period (six months to a year). By this treat-
ment, ankylosis is the rule. Ankylosis rarely, if ever, follows osteo-
pathic treatment. In fact, the ankylosis already present is often
cured by the treatment. When pus forms, it should be evacuated and
the cavity well drained and cleansed. No local application of medicine
is needed. If the strictly osteopathic methods are relied upon, good
results will follow. Where luxations, or subluxations, of the hip result
from the disease (which will nearly always occur in cases not treated),
they should be reduced at once, and the limb kept in an easy normal
position until the use is recovered and pain ceases.

Sacro-Iliae Disease.

Sacro-iliac disease is rare, and comes on after the age of fifteen. It
may arise from the tubercle bacilli being deposited within the joint, or
the adjacent bones, or through tuberculous pus burrowing into the joint
from caries of the spine. It may be associated with extensive disease
of the pelvic bones. The symptoms of the disease are obscure. It may
be confounded with vertebral caries, sciatica, or coxitis. There is con-
siderable limp on walking, stibluxation of the ilium, and pain
upon pressing the ilia together. The pain may be reflected down the
leg, because of the close proximity of the obturator nerve. If iliac ab-
scess results, there may be some fluctuation, otherwise there is none.

Diagnosis. — The tenderness and soreness over the iliac-joint, to-
gether with the absence of caries of the spine and hip-joint disease, and
evidence of inflammatory exudates about the joint, will determine the
•diagnosis.

*' !i Treatment. — In sacro-iliac disease, there is a condition of curvature
of the lumbar spine. This directly affects the nutrition to the joint.
There is a subluxation at the sacro-iliac joint. Treatment
.should be directed to these conditions only. When abscess occurs,
the pus" should be evacuated, and the treatment directed toward improv-
ing the circulation and nutrition to the affected area.

Radiograph by George M. Laughlin, D. O.
PLATE III.

Radiograph (posterior view) showing the condition of the hip in an old quiescent
case of morbus coxarius in a boy aged ten j^ears. There is entire destruc-
tion of the head and neck of the femur. There was no abscess
formation. There is good motion and about two inches of
shortening. Treatment is of no value.

DISbASES OF JOINTS. 2G5

Knee-joint. — (White Swelling). — The knee-joint is more frequently
involved than any other of the joints, except in the spine. It is said that
the disease begins, in case of the knee, in the femoral epiphysis most
often, but may begin in the synovial sac, or joint-capsule. It is most
common in young adults. It may follow an acute synovitis. In many
cases there is but little swelling, while at other times there may be
enormous swelling, with gelatiniform degeneration. There is great
muscular spasm. The tissues become glued together and the tibia is
dislocated backward. The disease may exist for years. Pain is rarely
severe, and the lameness is usually the result of deformity. The sud-
den spasmodic muscular contraction is one of the peculiarities of the
disease. In some cases, there may be rapid destruction of the joint,
whereas, jn others, it may become quiescent and thus continue for years.

Treatment. — The cause of the disease is a posterior condition of the
ilium at the sacro-iliac joint. In many cases, there will be lumbar lesions.
Muscular contractions, also, may directly affect the circulation. Sublux-
ations of the hip ma}^ be responsible for the ailment. In a case, in a
young lady, of one and one- half years standing, after treatment with
plaster cast and iodoform emulsion injections and various other
methods, amputation was advised by eminent surgeons. An osteopath
was consulted. He cut off the plaster cast, reduced the luxation at the
hip, corrected the lumbar spine, encouraged the circulation to the in-
flamed joint, and obtained a complete cure within a month. The lady
had been compelled to use crutches for nearly two years. It has been
four years since the case was discharged cured. There has been no
evidence of return of the trouble.

It is not necessary to manipulate the joint itself, but all attention
should be directed to correcting the lesions, and securing a good blood
supply. If. seen early, or there is not too much destruction of bone, a
cure may be expected in from one to six months. Ankylosis can usually
be prevented. ~By medical or surgical treatment, ankylosis is the rule;
in fact, what is looked for. Osteopathic treatment avoids anky-
losis, secures good use of the affected joint, and cures the disease.

Ankle-joint. — The evidences of disease in the ankle-joint are simply
the evidences of tuberculosis anywhere — more or less fluid effusion, pain
in the joint, lameness and limitation of motion. Caseation and sinus
may follow, with destruction of some of the bones of the tarsus. The
disease is caused by luxations of one or more of the tarsal bones, coupled
with injury and deposit of the germs. The treatment is directed to
replacing the bones and securing the proper nerve and blood supply.
If there is any abnormality at the hip, it should be corrected. Should
abscess occur, the treatment must still be directed to assisting and en-
couraging the circulation. Uniformly good results will follow the treat-
ment. Where the patient is in bad general health, and there is a con-
dition of malnutrition, attention must be directed to any spinal lesions
likely causing the mischief.

266 DISEASES OF JOINTS.

Elbow-joint. — The disease may arise in the humerus, ulna, or radius.
The pain is never great, hut is attended by great muscular wasting and
limitation of- motion. It is produced by subluxations at the elbow and
shoulder and by lesions in the cervical spine. The treatment in general
is that of synovitis. If a good circulation can be secured, the disease will
subside and the inflammatory exudates will be absorbed. The prognosis
is favorable.

Wrist-joint. — Tuberculosis of the wrist is rare, and may occur at any
age. The joint presents signs of chronic inflammation, and it is fusiform
in shape. All the motions of the wrist are impaired, as are also prona-
tion and supination. The tubercular inflammation may begin in the
joint-capsule or within the carpal bones. It is caused by luxations of
the carpal bones and by lesions in the cervical and upper dorsal spine.
The disease will extend over a considerable period. By judicious treat-
ment, attention to the general health, and with the proper diet and
hygienic surroundings, a good result may be obtained.

Shoulder -joint. — 'The disease usually begins at the head of the
humerus. There is more or less destruction of the bone
by process of dry caries (caries sicca). The disease is said to be more
common in adults. In some cases, there may be no swelling, simply a
shrinking and destruction of the joint, because of muscular spasm and
caries. Pus formation is rare. The disease is occasioned by cervical
lesions affecting the circumflex or suprascapular nerves. The blood
supply may be affected by muscular contractions and subluxations of the
humerus. The treatment is directed toward correcting these lesions.

Hysterical-joint. — Hysterical-joint, sometimes called Brodie's joint,
is an affection occurring chiefly in young women. The knee- and hip-
joints are the ones involved. There are always evidences of
latent hysteria. The disease may be brought on by an injury, while
sometimes it may arise almost from suggestion, without apparently any
cause. It may follow cases of synovitis, or inflammation of the joints.
The patient complains of pain, stiffness, and soreness. It
is easy to discover that the patient resists efforts at motion.
Muscular atrophy is not great, and is because of non-use. There is
hyperesthesia of the skin, so that a slight touch causes more pain than
deep pressure. The stiffness of the joint is produced by muscular rigid-
ity. This muscular rigidity is apparently involuntarily produced, and
the limb may be in any position of extension or flexion. The position of
the thigh is changed at different times. The skin is usually cool, but
may become hot at certain periods, when the pain is more excruciating.
The pain is more in the nature of a neuralgia. The phenomena attend-
ing this disease are not all confined to the affected joint. There are
other conditions which indicate that the subject is neurotic. There
is evidence of neurasthenia, convulsions, globus hystericus, or other
nervous disorders. On the whole, the general health of the patient is
good. The hysterical joint simulates, correctly or incorrectly, a certain

PLATE IV.

Radiograph by George M. Laughlin, D. O.

Radiograph showing white swelling of the knee joint. Infection followed vaccination. The case
is of one year's standing in a~boy fourteen years of age. Abscesses formed and the
tibia, patella and the femur are affected. The prognosis is good.

DISEASES OF JOINTS. 267

affection, only as the patient understands the symptoms of the disease
so simulated. The physician will likely observe that the symptoms dis-
appear when the attention of the attendant is attracted elsewhere. This
may not always be true.

Treatment. — The treatment consists in reducing whatever lesion may
be found along the spine. Where partial dislocations are present, the
reduction of these relieve the impinged nerves and will give instant re-
lief, and the patient may be permanently cured. The application of local
remedies and treatment will do no good.

Neuralgia of Joints. — The term "Neuralgia of a joint" applies to
those conditions described in texts as "obscure pains within the joint."
Pains do not arise de novo. The presence of neuralgia simply indicates
that there is a nerve impinged somewhere. The location of this pressure
upon the nerve can be accurately determined by proper physical exam-
ination. There is no excuse for labeling a case of sublux-
ation which may give rise to a terrific pain, idiopathic neuralgia of the
joint. Neuralgia of the joint is an impingement of the nerve of the
joint without inflammatory reaction. Eeduction of the subluxation re-
lieves the condition.

Acute Rheumatic Arthritis, or Acute Rheumatism.

This is an acute febrile reaction, characterized by an inflammation
and a fluid effusion in the joints, together with acid sweats and a general
interference in the metabolism of the body. The disease begins with
malaise and fever, when one or more joints may be affected. Where joints
are simultaneously affected, they are apt to be symmetrical, or after the
inflammation subsides in one joint, it is apt to reappear in another
(metastasis). When the inflammation begins it is evidenced by a burning
and pricking pain within the joint. The swelling is often considerable.
The joint is hot, red, and stiff, and there may be considerable effusion.
As soon as the fluid effusion is sufficient to separate the inflamed sur-
faces of the synovial membrane, the pain more or less disappears, when
in several days inflammation subsides, and finally disappears.
Suppuration rarely, if ever, takes place. The disease is at-
tended by pronounced anemia, and the exhaustion is very great. The
sweat is markedly acid, the urine scanty, highly colored, and highly
acid. Diseases of the heart, such as endocarditis, pericarditis, or myo-
carditis, frequently result from the circulation of this changed condi-
tion of the blood, apparently brought about by the presence of the
rheumatism. Occasionally cases are found in which there is a condition
of hyperpyrexia.

Treatment. — The treatment consists in removing lesions affecting the
kidneys and liver, or in stimulating the function of these organs, thus
eliminating the poisons retained in the system. Other bony lesions
directly affecting the joints inflamed must be removed. The contractions
of the- fascia, ligaments, and connective tissues about the joints, must

268 DISEASES OF JOINTS.

be relaxed. The lesions are not constant and should be searched for in
any given case. The most essential point is to keep the eliminative
organs active and the patient well nourished.

Chronic Rheumatic Arthritis.

Occasionally this disease is the result of an acute attack, but more
often it arises from other conditions. Associated with this disease are
exposure to cold and damp weather, poverty, and hardships. It seems
that the tendon-sheaths and the joint-capsules are more or less con-
gested and inflamed, and there may be effusions into the joint.
Conditions simulating chronic rheumatism, such as painful joints, are
frequently due to spinal lesions, subluxations, muscular con-
tractions, partial dislocations of the hip, involvement of the peripheral
nerves, etc. In pronounced cases of chronic rheumatism, affecting sev-
eral joints, there is a general tendency to the formation of fibrous tissue.
The joints become thickened and enlarged, and the muscles atrophy.
The contraction of these inflammatory tissues which form about the
joint, results in erosions of the articular ends of the bones and in great
deformity. Sometimes this deformity may be frightful.

Symptoms. — The joints are enlarged, painful, and stiff. Changes
of the weather, dampness, cold, etc., seem to aggravate the condition.
Only one joint may be involved, but usually several are implicated.
Effort at motion causes crackling In the joint and false crepitus. This
may be within the joint itself, or along the tendon-sheaths, and is pro-
duced by the roughened condition of the tendons gliding in the sheaths
or the roughened ends of the bones scraping over each other. Complete
ankylosis may take place in the joints. There is great wasting of the
muscles, with profound anemia. There is little tendency to pus forma-
tion, although suppuration and caseation sometimes. form a disagreeable
complication. There is little or no tendency towards recovery.

Treatment. — In this disease, bony lesions are the rule. The removal
of these lesions will be attended by a cessation of the pain. Where
fibrous tissues have formed extensively, and there is persistent contrac-
tion of muscles, not much can be done, especially if the case is of old
standing. Nature does not have suificient recuperative power. Eesorption
of the fibrous tissues will not take place, and degenerative changes are
apt to occur in the tendons, muscles, and ligaments.

Gouty Arthritis, Rheumatic Gout.

This disease arises in the tarsal and metatarso-phalangeal
articulations of the feet and hands. It is maintained that,
the disease is caused by the deposit of the urates of sodium
in the periarticular structures. This chemical irritant excites
the inflammation leading to the infiltration of the connective tissues
about the joint by granulation tissue. This afterward is converted

DISEASES OF JOINTS. 2&J

into fibrous tissues, when contraction, with consequent deformity, arises.
The mobility of the joint is lessened. Sometimes the deposit of the
urates may be sufficiently large as to cause chalk-stones. Premonitory
signs are not the rule, but in some cases they may be observed. The
seizure is acute and occurs in the morning when the patient
is asleep. He is aroused by excruciating pains in the metatarso-phalan-
geal articulations (usually the great toe), the joint becomes swollen,
painful, and hot to the touch. There may be considerable fever. The
intensity of the seizure usually abates within a short time, whereas
a recurrence, often with renewed violence, happens the following morn-
ing. These attacks recur with varied intensity for several days (six to
ten), when the disease subsides. Unless the person gets en-
tirely rid of the cause of the disease, and the system is more or less
regenerated, subsequent attacks will lead to a chronic condition, in
which there may be great deformity and stiffness of the joint. In some
cases, ulceration takes place, and these chalk-stone deposits may be ex-
foliated. The disease arises in people who eat highly concentrated and
highly seasoned foods, and who have been addicted to the use of stimu-
lants. It is attended by hypertrophy of the heart and increased arterial
tension.

Treatment. — The treatment is directed toward removing lesions,
causing a retention of these urates and to reducing subluxations of the
affected joints. Lesions affecting the kidneys are responsible for most
of the mischief. When these are removed, and the kidneys act nor-
mally, the irritating deposits are absorbed and eliminated. The sub-
luxations of the bones forming the affected joints, as the phalanges and
metatarsal, and tarsal, should be adjusted. The circulation to the
affected part must be improved and the inflammatory products absorbed.
Eelief may be given almost at once by this means. The prognosis is
favorable. The system must be renovated and the patient placed on a
plain, wholesome diet, and stimulants must be avoided.

Osteo-Arthritis, Rheumatoid Arthritis, or Arthritis Deformans
(Paget's Disease).

This is a progressive disease, which leads to great deformity, and,
oftentimes, to complete impairment of the function of the joint. One
of the marked peculiarities of the disease is that it is attended by a great
deal of destruction of the cartilages, enlargement and alteration in the
articular ends of the bones, and the formation of osteophytes in the
fibrous tissue about the joint. Because of the formation of the fibrous
tissue and the erosions of the ends of the bones, great shortening of
certain bones, such as the phalanges and metacarpal bones of the
thumb, may occur. The joints of the extremities are most frequently
involved, although it may affect the spine or lower jaw.

Causes. — Exposure to cold, lesions affecting the central nervous sys-
tem, or the roots of the spinal nerves, and a general depressed condition
of the nervous system, are believed to be the causes of the disease.

270 DISEASES OE JOINTS.

Pathology. — Inflammatory changes take place in and about, the
joints, - cartilages, ligaments, synovial membranes, etc., leading to
fibrosis. The cartilages become eroded and cracked, and by friction on
each other, gradually wear away. The pathological process is essen-
tially that of fibrosis, together with a softening of the matrix of the
cartilage and the absorption of its elements. It is claimed by some that
the process is one of ulceration, but this is hardly true. The changes
taking place in the synovial membrane are similar to those which occur
in chronic synovitis. Some fluid effusion takes place in the joint. This
comes from the congestion of the synovial membrane and the edematous
condition of the villus-like processes and fringes of the synovial sac.
Sometimes these processes become detached and form loose bodies with-
in the joint. Occasionally cartilages entirely disappear, and because of
the ends of the bones rubbing together, they become hard and polished
(eburnated) and look like porcelain. This solid condition of the bone
is likely due to the development of bony lesions within the Haversian
canals and the cavities within the bone. In some cases, erosions take
place before the development of such osseous tissues can take place,
when the end of the bone presents a honey-combed appearance. Ossi-
fication may take place in the tendons and the connective: tissues about
the joint.

Symptoms. — The following symptoms will be sufficient to determine
the disease early. First, a rapid action of the heart, together with vaso-
motor disturbances, resulting in an increased arterial tension. Second,
trophic conditions, clue to the affection of the central nervous system,
together with a clamminess of the skin and a bronzing of certain areas.
Pain is especially marked along the inside of the wrist and over the ball
of the thumb. There is characteristic creaking of the joints as in rheu-
matism, and the pain is increased upon motion of the affected parts.
Loose bodies are detected outside of the joints. The' margins of the
joints are not only thickened, but bulge out; the center of the bone
is absorbed, while the margins of the articular surfaces become thick-
ened, because of ossific deposit. Motion is limited and deformity is
usually great.

Treatment. — The treatment is directed first 'to removing the spinal
lesions affecting the nerve roots supptying the affected joint. Any
lesions affecting the central nervous system must be removed. The
treatment of the joint itself is directed toward encouraging the circu-
lation and nutrition. Eesorption of the fibrous tissue must- be secured
before a cure is obtained. The prognosis, especially in old cases, should
be guarded.

Charcot's Disease, or Neuropathic Arthritis.

This disease is a peculiar affection of the joints attending the course
of certain nervous diseases, especially locomotor ataxia. The exciting
cause of the disease may be injury, but the chief cause seems to be cer-

DISEASES IN JOINTS. 271

tain lesions of the spine or certain diseases of the nervous system, which
bring about the changes in the joint. The disease seems to be charac-
terized by lightning-like pains, and with more or less effusion into the
joint of light colored serum, which may diffuse into the surrounding
bursae, causing marked enlargements and deformity. It is said, in some
cases, that the distension of the joint may be so rapid as to cause dis-
location. The joints most frequently affected are the hip, shoulder, and
knee. In some cases, the fluid effusion is entirely absorbed, and the joint
returns to its normal size, although, apparently, it is considerably
weakened. Sometimes the attacks recur, and the patient becomes still
more crippled. In certain cases, it may so weaken the ligaments and
perivascular structures as to leave a condition of flail-joint. Osseous
outgrowths are not unusual, and, in continued cases, this will lead to
stillness of the joint. Where the disease runs a chronic course, hyper-
trophy of the periarticular structures, and erosion of the ends of the
bones, is the rule. Some cases resemble osteo-arthritis, but the rapidity
of the onset, together with but one joint being affected, the general ab-
sence of pain, subsequent atrophy of the ends of the bones, and the
presence of flail-joints, will serve to enable one to make the diagnosis.
Treatment. — The treatment is directed towards removing the spinal
lesions affecting the cord and nerve roots supplying the joint. Unless
further pathological change in the nervous system can be arrested, and
a better nerve supply to the joint can be secured, the prognosis will be
unfavorable. If seen early, the locomotor ataxia can be cured. In bad
cases, it may be arrested. Usually this will serve to arrest further
joint involvement.

Loose Bodies in Joints.

Loose bodies in joints consist of several varieties, which may be clas-
sified as f oIIoavs :

1. Masses of articular cartilages, which have been broken off by vio-
lence, and which, by friction, have been worn off into rounded, smooth
masses. There may be a nucleus of bone within the center.

2. "Melon seed-like" bodies, the result of fibrinous exudates.

3. Occasionally the villus-like fringes of the synovial membrane be-
come detached, or worn off, and form loose bodies, which have been
described by some as being fetal residue.

4. Certain portions of bone may become detached from the sur-
rounding bone, and become covered with cartilage, and exist as foreign
bodies. These foreign bodies are nourished by nutritious fluids, by which
they are surrounded. The diagnosis of these loose bodies may occasion-
ally be difficult. In the knee-joint, they must be differentiated from
displaced semilunar cartilages. The fact that the joint locks in certain
positions, would indicate a loose body.

Treatment. — If the foreign body is a serious obstacle to the mobility
of the joint, it should be removed by a surgical operation.

272 DISEASES OF JOINTS.

Ankylosis.

Ankylosis is a condition of immobility, partial or complete, of a
joint. It usually results from, inflammation.

Varieties. — (1) false, (2) true, (3) fibrous, and (4) bony.

False Ankylosis is a term applied to that form of stiff joint or anky-
losis which arises from changes without the capsule and among the
ligaments, tendons, etc., around the joint. Cicatricial contraction in
the skin, and formations of fibrous tissue between the tendons and their
sheaths, as occur in palmar abscess, are examples of false ankylosis.

True Ankylosis is caused by changes within the joint-capsule,
and is the result of inflammation or injury. It is the result of the
formation of fibrous tissue, or because of osseous deposits, which bind
together the articular ends of otherwise movable bones.

Fibrous Ankylosis (incomplete) may be either false or true, and is
the result of thickening cr contraction of the ligaments (as happens in
rheumatic conditions), or of the formation of fibrous bands, or adhe-
sions, between the ends of the bones (as occurs in synovitis), or in
erosion of the cartilages, the result of inflammation, and the subsequent
formation of fibrous bands between the cartilages. Some motion is
possible in the majority of the cases, although the joints may
be entirely fixed.

Bony Ankylosis (complete), sometimes called synostosis, is developed
from the union of the whole, or part of the opposing surfaces of two
bones, from which the cartilages have become eroded and destroyed.
The union is at first fibrous, but afterwards ossification takes place.

Causes. — The causes of ankylosis are various, but may be enumerated
as follows:

1. Injury involving the articular surfaces of a joint, the injury being
sufficient to destroy the cartilages.

2. Eheumatic or gouty inflammations, which result in the progres-
sive formation of fibrous tissue about the joints.

3. Erosions of the articular surfaces, the result of acute or chronic
suppurative conditions.

4. Certain nervous disorders, such as spina bifida, locomotor ataxia,
peripheral neuritis, Raynaud's disease, or operations on nerves.

5. Subluxations. The abnormal relations of the bones operate as a
source of irritation. Subsequent formation of fibrous tissues may occa-
sion more or less fibrous ankylosis.

Diagnosis. — It is of the utmost importance to determine whether the
case is one of true, or bony, ankylosis. The history of the case will deter-
mine whether the ankylosis is the result of extensive injury, such as
fracture in the joint, or if it is the result of suppuration within the
joint. In such cases, the ankylosis will be bony. It is of importance
to determine whether there was much abnormality of position or rela-
tion of the bones at the time ankylosis occurred. The more abnormal

DISL OCA TIONS. 273

the position, the greater will be the irritation, and the worse the anky-
losis. Dislocations, complicating fractures, will often lead to extensive
callus formation and the ankylosis will most likely be complete.

Treatment. — When the inflammatory reaction has not 'been severe,
or within the joint, the prognosis is favorable, even though there is no
motion whatever in the joint. All cases, except bony ankylosis, may be
benefited. If not entirely cured, very great improvement may be ob-
tained.

The treatment consists of persistent manipulative efforts to break
up the old adhesions, and secure resorption of the connective tissue ele-
ments forming the adhesions and thickening the joint structures. Vig-
orous efforts once or twice a week, kept up for a period of from one
month to two years, should cure all cases. Bony ankylosis is incurable. A
surgical operation will do no good. Anesthesia is not necessary to break
up the adhesions in false ankylosis, unless it is done at one treatment.
It is better to break up the adhesions gradually, as less pain results, and
there is no danger to the joint. The patient should be instructed to use
the joint as much as possible, consistent with comfort and good health.

DISLOCATIONS.

A dislocation is a partial or complete separation of the articular sur-
faces of two bones which normally should be in apposition. In fact, any
displacement, however slight, whether or not accompanied by injury to
the ligaments or other articular structures, constitutes a dislocation.
Without doubt, in many cases, such abnormality of relation exists.
This abnormality of relation comes under the head of partial disloca-
tions.

Varieties. — Dislocations are divided with reference to degree into
partial and complete.

1. Partial or Incomplete dislocation is a condition in which the artic-
ular surfaces of two bones, which should normally be in relation, are
partly separated, but not sufficiently, as a rule, to rupture the liga-
ments. This variety of dislocation is more common than any other.
They are caused by slight external violence and muscular action.
The effects of the dislocation are often overlooked, inasmuch
ns they may be slight at first. Where the bones continue in abnormal
rehtion, structural and functional changes are set up. Dr. A. T. Still
di-covered the relation between these subluxations and disease. He
proved beyond question that subluxations will affect nerve and blood
supply directly, or reflexly through the vasomotors. The nutrition of
some structure is interfered with, when inflammation, degeneration,
atrophy, tumefaction, etc., result. A reduction of these subluxations
is attended by a cessation of the diseased symptoms and a return to
health. This has formed the foundation of the science of osteopathy.
These subluxations are more common in the spine than in any other
•virt of the body. Subluxation of a vertebra may be anterior, posterior,

274 DISLOCA TIONS.

lateral, or it may consist of a twisting of the bone on the axis of its
body. Any of these lesions will cause pressure on the spinal nerve
roots, Or interfere with the blood supply to the cord itself. This con-
stitutes the most important causative agent in the production of disease.
Similar luxations of other bones, as the ribs, bones of the pelvis, thigh,
leg, ankle, foot, clavicle, humerus, forearm, wrist and hand, may occur.
In any case, disease production will depend upon whether a nerve,
artery, or vein is compressed, or if there is an obstruction to the flow of
the fluids in the tissues, thereby partially, or completely, arresting the
nutrition. Therefore, certain lesions will be found uniformly associated
with certain diseases. They constitute the underlying cause, rendering
bacterial action, fermentative, and other destructive processes possible.

2. Complete dislocation is one in which the articular surfaces of two
bones are entirely separated from each other.

3. Simple dislocation is one in which there is no wound leading to
the surface.

4. Compound dislocation is one in which there is a wound leading
into the joint, in addition to the articular surfaces of the bones being
separated.

5. Complicated dislocation is one which is attended by fracture or
laceration of the soft-parts, rupture of an artery, great injury to a
nerve, etc.

6. Recent dislocation is one which is not sufficiently old to permit
of the formation of fibrous adhesions which bind the ends of the bones
down in an abnormal position.

7. Old dislocation is one which has been standing for some months.
The inflammatory signs have disappeared, and fibrous adhesions have
formed about the head of the bone, binding it down in an abnormal
position.

8. Habitual dislocation is one occurring in a joint in which the con-
ditions are such as to predispose to a dislocation, as a rent in the cap-
sule not having healed, and the joint cavity being shallow, dislocation
takes place readily.

9. Congenital dislocation is one which happens because of a lack of
development of the joint cavity, or the articular end of the bone, or
because luxations have occurred in utero.

10. Spontaneous dislocation, or pathological dislocation, is one re-
sulting from slight injury or disease of the joint.

11. Traumatic dislocation is one which is caused by injury.

Congenital Dislocations.

Congenital dislocations should not be confounded with those occur-
ring at delivery, as they are not properly congenital.
The causes of congenital dislocations are : —
1. Malformation of the joint.

PIvATB V.

Radiograph by George M. Laughlin, D. O.

Radiograph (posterior view) of a congenital dislocation of the left hip in a girl aged
ten years. Note the malformation of the acetabulum and the smallness of
the femur. To effect reduction a radical operation is required.
The prognosis is doubtful. Several months' treat-
ment established good motion.

DISLOCATIONS. 275

2. "Violence in Utero. These dislocations nearly always take place at
the hip, but may occur in the shoulder. The causes are obscure. Without
doubt, they sometimes follow injury. Because of the fact that sometimes
the head of the bone is too large for the cavity, i. e., the head of the bone
develops and the cavity does not, or that the cavity is poorly developed,
or the head of the bone malformed, leads to the belief thal^ it is one of
the results of lesions of the nervous system. Quite likely lesions of the
spine bring about this condition, these lesions having been produced by
certain positions or injuries in utero.

Condition of the Joint. — The most universally present condition is
that the head, of the bone is malformed, or, if the head is of proper size
and shape, the joint cavity is too small. There is marked atrophy of the
muscles, and if the child has attained some age, a new cavity has formed
where the head of the bone rests, which, in case of the hip, is on the
dorsum of the ilium. The patient has a waddling gait, and if only one
hip is involved, there is marked shortening, and when both are affected,
there is marked lordosis of the spine. In a grown person, a new
capsule has been formed, a new articular surface, and the head of the
bone is rounded off so as to fit the abnormal conditions.

Treatment. — The treatment of congenital dislocation varies
according to the age of the patient and the conditions present. Usually
the case can be successfully treated before the age of ten years, but
after that, not much can be clone. In some cases, even afterward, the
condition of the limb may be greatly improved by treatment, but the
dislocation can not, as a rule, be reduced. The methods of reduction
are the same as used in recent dislocations. Where shortening of the
mnscles has occurred, they will require stretching, and perhaps ruptur-
ing, to permit of reduction. Some months of energetic treatment may
be required to prepare the muscles and other structures for the opera-
tion of reduction. The hip should be manipulated twice a week until
such time as it is believed reduction may be made. In some cases, the
dislocation may be reduced by the ordinary methods and a good result
obtained. In these cases, there is a good socket, and the head of the
femur is nearly normal. Where there is a malformed saucer-shaped
socket, even if reduction can be made, the dislocation will recur. It is
necessary to hold the femur in place by a stiff dressing, such as a plaster
cast. In many of these older cases, it will be necessary to rupture the
adductors before reduction can be made. As little injury to the soft
parts should be done as is compatible with reduction. In general, a
modification of the Lorenz method is best. An essential feature of the
treatment is to secure a good blood and nerve supply to the joint, so
that development of the muscles, ligaments, and joint structures, may
be encouraged.

Lorenz's Method. — Lorenz devised what he has styled a bloodless
method of reducing congenital dislocations of the hip, in contradis-
tinction to the open method of division of the muscles, tendons, liga-
ments, etc., with the knife, and subsequently replacing the bone. It is

276 DISL O CA TIONS.

far from a bloodless method, and is condemned by many surgeons as
brutal and in many cases harmful. The limb is forcibly abducted and
the shortened adductors are torn asunder. All ligaments, or other
structures, are torn or stretched by forcibly dragging down the limb. In
some cases, a block is used as a fulcrum above and the thigh forcibly ab-
ducted, thus compelling the head of the bone to enter the cotyloid cav-
ity. The limb is then fixed in extreme abduction by a plaster cast.
After several months a new cast is applied and the limb put in about
50 degrees of abduction and 45 degrees of flexion. The patient is then
encouraged to walk. After several months more, this cast is taken off
and the limb straightened. The treatment, when modified and supple-
mented by osteopathic methods, is less harmful and more successful.

Pathological or Spontaneous Dislocations

Are those which occur with slight force, insufficient in the average
case to bring about dislocation. The conditions which render these
dislocations possible are: — 1. A weak condition of the ligaments and a
relaxed capsule. 2. Nature of the joint, which may not be thoroughly
developed. 3. Chronic synovitis. 4. Tubercular disease. 5. Eheuma-
toid arthritis. 6. Typhoid fever. 7. Charcot's joint. 8. Locomotor
ataxia. 9. Any irregularity in the cavity or head of the bone.

Dislocations, especially in typhoid fever, may take place (usually on
the dorsum of the ilium) without the attending physician knowing any-
thing about it, unless examination especially for this condi-
tion be made. A careful examination should occasionally be
made during the course of this disease, to determine if a dis-
location has occurred. A reduction is usually easy, if at-
tempted early. Later, a reduction may be extremely diffi-
cult. Fluid effusions in the joint may lift the head of the bone
out, or so relax the capsule that dislocations follow. Tubercular
disease brings about fluid effusion in the joint, and by thickening of the
ends of the bones, muscular contractions in certain positions will draw
the head of the bone from its articular surface. In most cases of tuber-
cular disease, dislocation, either partial or complete, is the rule. In
rheumatoid arthritis, because of the formation of fibrous adhesions and
a consequent contraction, dislocations occur.

Traumatic Dislocations

Are those following injury. The causes are, predisposing,
and exciting.

The predisposing causes are: (1) Age. (2) Sex. (3) Muscular de-
velopment. (4) Occupation. (5) Kind of joint. (6) Location of the
joint. (7) Diseases of bone, joint, and ligaments. (8) Weakness of liga-
ments, etc.

Dislocations are most common in middle life, and more common in
men than women, because of their occupations. Persons of great liius-

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DISLOCATIONS. 277

cular development are more liable to dislocations, because of the vigor-
ous muscular action. People of certain occupations are more lia-
ble to dislocation than those of others, it being necessary for them to
take greater risks. Dislocations are more common in ball-and-socket
joints than in hinge -joints. Diseases, because they affect the integrity
of the ligaments, the amount of fluid within the joint, and sometimes
the contour of the articular ends, predispose to dislocations. Some
joints, because of their exposed position, are more liable to luxation.
In atonic conditions, and in certain spinal lesions, the integrity of the
ligaments may be affected to that extent that dislocation may occur.
The ligaments require a nerve supply as well as do muscles, skin, ar-
teries, and other structures, and any interference in the nerve or blood
supply of these ligaments will necessarily interfere with their integrity.
Weakness of the ligaments is a predisposing cause to traumatic dislo-
cations, but more especially to partial dislocations.

The exciting causes are external violence and muscular contraction.
External violence may be direct, or indirect. All of the causes may
operate at the same time to produce dislocation. Deformity is the
result of muscular contraction, tension upon the ligaments, and exten-
sion of the dislocating force.

State of the Parts in Dislocation. — Usually there is more or less
laceration of the ligaments and of the capsule of the joint. There may
be no laceration of the capsule, or the opening may be small, or large.
When the opening in the capsule is small, it may operate as an impedi-
ment to reduction. When there is no laceration of the capsule, re-
duction is easy. It is only in conditions of lax capsule that
will permit of complete dislocation without laceration of the capsule.
There may be extensive injury to the soft-parts, such as rupture of
muscles, tendons, nerves, or of large vessels. This injury sometimes
operates as a complication, and may be of such severity as to demand
operative interference.

Later Changes. — Should the dislocation not be reduced soon after
its occurrence, inflammation will arise because of the irritation. This
inflammation results in the formation of fibrous tissue. This fibrous
tissue will be in the nature of adhesions about the ends of the bones.
The inflammation may be sufficient to fill the socket which the bone
normally occupied. The joint cavity will not be obliterated
unless the inflammation is suppurative, when there may be
erosion and destruction of the cartilages. Sometimes this inflam-
mation and the pressure of the surrounding tissues cause the forma-
tion of a compact capsule, which will hold the bone in abnormal posi-
tion. In very old cases, a new socket may be formed, while the old
socket may still be good, but be filled with fibrous tissue, which of itself
will operate as an obstacle to reduction. The muscles about the joint
will atrophy "because of non-use, and will be bound down because of the
inflammation and the formation of the adhesions. Because of the

2 7S DISL O CA TIONS.

spasms which result from irritation, the muscles become perma-
nently contracted and shortened. The ligaments undergo changes and
become shortened, and in some cases weakened, and in other cases
thickened. It may be that a fairly good joint will be formed in the
new situation of the head of the bone. In old standing cases where
a fairly good new joint is formed, and the history of the case indi-
cates that there has been severe inflammation which would likely ob-
literate the joint structures, or at least interfere with their integrity,
it may be advisable to not attempt reduction. In the treatment of all
these old standing dislocations, even if the dislocation is not reduced,
treatment will always be followed by benefit.

Signs. — The signs of dislocation may be classified as follows: (1)
Pain of a nauseating or sickening nature. (2) Alteration in the general
outline of the joint. (3) Rigidity of the muscles about the joint, which
is increased on effort of the surgeon to manipulate the limb. (4)
Change in relation of the bony prominences about the joint, as in dis-
locations of the humerus, the greater tuberosity is not found a little
below and external to the acromion, as occurs normally. (5) Altera-
tion in the length of the limb. In some cases there may be shortening,
in other cases, lengthening of the limb. (6) Alteration in the axis of
the limb. (7) The head of the bone may be felt in an abnormal position.
(8) The head of the bone can not be felt in its normal cavity. (9) Loss
of function, which is more or less complete. Where the
diagnosis is impossible, or the signs are obscure, an x-ray examination
should be made to determine, if possible, the nature of the injury.

Methods of Examination. — To determine whether or not a disloca-
tion exists, or to definitely make out the pathological condition in the
joint, an accurate knowledge of the anatomy of i^he part and the rela-
tion of the structures is necessary. The relation of the bony promi-
nences and of the tendons, muscles, etc., must be observed. The
examination should be complete and methodical. All available signs
should be taken into consideration, and an effort should be made to
determine the relation of each structure in turn. An accurate history
of the injury should be obtained. The nature of the deformity should
be considered, and whether or not it has recurred. A dislocation may
be mistaken for a sprain, for effusions in the joint, or for fracture.
Where the condition can not be made out, and there is too much swell-
ing, antiphlogistic measures may be used to get rid of the inflamma-
tion and swelling, so an accurate diagnosis can be made. Where the
parts are painful, it is better to administer an anesthetic and make a
complete and careful examination. If a dislocation exists, it should be
reduced at once. When it is possible, an x-ray examination should be
made, which may lead to a diagnosis. Furthermore, when luxations
occur, if they are reduced, usually they will not recur. Deformity
from other injuries may recur.

Treatment. — (1) The luxation should be reduced. (2) The bones

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DISL O CA TIONS. 279

should be maintained in a normal position until the capsule of the joint
heals and the ligaments return to their normal condition.

Methods of Reduction.— A. Manipulation. — In general, this con-
sists of : —

1. Adduction. 4. Extension.

2. Abduction. 5. Rotation.

3. Flexion. 6. Circumduction.

Or any combination of these movements which have for their pur-
pose :

(a) To relax tense muscles, tendons, ligaments, etc.

(b) To disengage any bony prominence or the head of the bone.

(c) To direct the luxated bone so that it will return to its articula-
tion over the same route by which it got out. That this manipulation
may be properly executed, it is very necessary that the anatomical
relation of the structures be understood; furthermore, what muscles
or ligaments are put on a stretch, or what structures operate against
reduction. The reasons why manipulative methods are more successful
in the hands of some operators -than others, is because they more thor-
oughly understand the condition of the parts. This method is by all
means best, because it is attended by little or no injury. That it will
be successful in all cases, if attempted within a reasonable length of
time, is proven by osteopathic methods and results.

B. Extension and Counter-extension. Extension and counter-exten-
sion should be used only as a demur resort. This contemplates forcibly
dragging the bone into the normal position, regardless of the way in
which it got out. Great harm has been caused by this method of
reducing dislocations, and as we better understand the anatomy of the
joints, and the morbid conditions of dislocations, the more we will use
manipulative methods. The old method of reducing a dislocation of the
humerus under the coracoid process was to put the unbooted foot in
the axilla and make traction on the arm, forcibly dragging the bone
into the socket. Now we have better methods, although this method
may be used with great advantage sometimes. Ofttimes extension and
counter-extension can be used with great advantage with manipulation.
It is of service many times in breaking up adhesions in old standing
dislocations. Extension and counter-extension is made by the hands or
by a clove-hitch, by weight and pulley, or by hooks. The hooks are
fastened into one of the fragments, in case of fracture, and by this
means traction can be made.

After Treatment. — The limb should be kept quiet until the opening
in the capsule has had an opportunity to heal. A suitable bandage
should be applied and the parts allowed rest.

Compound Dislocations.

Compound dislocations are those in which not only the bone is dis-
located from its normal cavity, hut there is a penetrating wound into
the joint. The treatment depends largely upon the state of the

280 DISL OCA TIONS.

parts. Operative interference may be necessary. It may require ampu-
tation or excision, depending largely upon the amount of destruction of
the bone. Should there be extensive destruction of the bone, and a
stiff joint would render the limb useless, amputation may be advised.
The wound should be treated rss an ordinary wound, by the strictest
asepsis, and provision for drainage. Manipulation should be begun
early and kept up regularly in order to prevent fibrous adhesion. Some-
times fairly good results can be obtained in children after extensive
injury to a joint, especially if manipulation is begun early and kept
up. As* a rule, in elderly people, true ankylosis of a permanent nature
will develop if there is extensive injury.

Old Dislocations.

When a dislocation has existed for from four to eight weeks, fibrous
adhesions form around the ends of the bones, the opening in the
joint capsule close0, while other periarticular structures, such as ten-
dons, arteries, veins, nerves, etc., become bound down in abnormal
positions. By old methods, the reduction of these dislocations was often
attended by frightful injury, as evulsion of the limb, or fracture. An
open cutting method was advised, whereby all impediments to reduction
were cut and the bone put back in its proper position. This operation
is also unsuccessful. Hence the question, "How long after the dislocation
happens may reduction be safely attempted/' was a most important
one. Here, as in many other instances, the results obtained by
osteopathic methods are such as to revolutionize the science of surgery.
Dr. Still has reduced dislocations of the hip of seventeen years' stand-
ing. Because of his great skill in reducing old dislocations of years'
standing, when the most eminent practitioners of other schools had
failed, he has earned a wide and enviable reputation. The methods are
simple, but require a thorough knowledge of the anatomy of the joint
and periarticular structures. The adhesions should be gradually
broken up and the ligaments and muscles stretched to permit of
reduction without injury. In some cases it may require some time to
thoroughly prepare the joint. In other cases, reduction may be effected
at once. In general, the manipulative methods are similar to those
used in recent dislocations. It will be necessary in many cases to pro-
mote a healthv circulation and nerve supply to the joint to secure
resorption of the inflammatory tissues before reduction may be safely
attempted. No definite time may be set down as to when dislocations
become irreducible. It all depends upon the condition of the tissues
about the joint and the joint itself. Where too extensive injury has
taken place, and the tissues will not yield readily to treatment, the
prognosis is unfavorable.

Injuries Attending Reduction. — Sometimes, because of the vigorous
methods used, injury to the articular or periarticular structures will
occur. These may be classed as: —

DISLOCATIONS.

281

1. Fracture. This is sometimes the result of using the bones as
levers, or where too great force is used.

2. Extensive injury of the soft-parts, i. e., injury to nerve, vein,
artery, muscle, or tendon.

3. An adhesive or suppurative inflammation may he excited, which
may bring about ankylosis.

4. Eupture of the skin and soft-parts, producing a compound condi-
tion, will render sepsis possible.

5. Evulsion of the limb. Cases have occurred where such great
force has been used in traction that a limb has been torn from the body.
There is no need of any of the above injuries being produced. Dislo-
cations may be reduced without such barbarous methods.

Fig. 89.

Dislocation oi the lower jaw forward.

Special Dislocations.

Lower Jaw.— The lower jaw may be dislocated forward or backward
(very rare). The forward dislocations may be unilateral or bilateral.
They occur more frequently in women in middle life, and seem to be
brought on by vigorous efforts at yawning, laughing, and vomiting.
The condyle is drawn from its normal position, chiefly by the external
pterygoid muscle. The condyle is usually luxated into the zygomatic
fossa, while the temporal, masseter, and internal pterygoid muscles
hold the bone fixed in the abnormal position.

Signs. — There is a hollow behind the luxated condyle. The mouth
is permanently wide open, and the saliva dribbles away. The person
attempts to talk, or to explain the condition, and is unable to because
of inability to close the mouth. In the unilateral dislocation, there is
a hollow on but one side of the head and the teeth are out of line.

2S2 DISLOCATIONS.

Unilateral dislocations are rare. Backward dislocation is questionable,
and the .symptoms are not worth considering.

Treatment. — The reduction of dislocation of the jaw is best accom-
plished by wrapping the thumbs with a handkerchief, so as to protect
them, and inserting them in the mouth, one on either side. Strong
pressure is made downward upon the molar teeth, while at the same
time the operator should lift up on the symphysis by means of the
fingers. In this manner, the condyles are moved back into the glenoid
fossa. Should this fail, a cork may be placed between the molar teeth.
This acts as a fulcrum when pressure is made upward on the symphysis,
and as the bone is lifted from its position, it may be carried backward
into the articulation. As a rule, unless the thumbs are wrapped, be-
cause of the contraction of the muscles when the reduction is accom-
plished, the operator may have his thumbs wounded.

Subluxation of the Lower Jaw.

Subluxation or partial dislocation of the lower jaw may refer to
one of two conditions. There may be a partial dislocation of the con-
dyle from the interarticnlar fibro-cartilage, or there may be a subluxa-
tion of the fibro-cartilage from the eminentia articularis. In either
case, it may interfere markedly in chewing, so that the person may, on
effort to close the mouth, find motions of the jaw suddenly arrested.
In several months, perhaps, this will disappear of itself, or there may be
permanent difficulty in closing the mouth. The luxation can readily
be relieved by the proper manipulation.

Dislocation of the Clavicle.

The clavicle may be dislocated both at its sternal and acromial ex-
tremity.

Sternal Extremity. — Dislocations of the sternal extremity are: 1.
Forward. 2. Upward. 3. Backward.

Forward dislocations are produced by falls and blows upon the
shoulder. Usually the blows are directed backward and the falls for-
ward, so that the shoulder is driven backward. The sternal extremity
is tilted forward and is driven on the front of the sternum.

Signs. — The symptoms are plain. The clavicle makes a marked
prominence on the front of the sternum. Its relation Avith the sternum
is impaired. The head of the bone lies over towards the middle line of the
body. The distance to the acromion process is less than on the sound
side. The sterno-mastoid and other muscles of the neck are put
violently upon a stretch. The method of reduction is to place the knee
in the interscapular space over the spine, and to make traction outward
and backward on the two shoulders. In this manner, the head of the
bone is drawn into its normal position. Should this not be successful,
while an assistant makes traction outward and backward on the

DISLOCATIONS. 283

shoulders, the operator may manipulate the bone and push it into place.
This injury is best treated by means of a posterior figure-of-8 bandage.
While the bone is held in position, a gutta-percha splint may be moulded
to the surface of the body. This, when lightly padded with lint, may
be bandaged into position. This, in addition to the figure-of-8 bandage,
will be sufficient to maintain the bone in its normal position. A Vel-
peau's bandage may also be used. Where there is complete rupture of
the ligaments, it is difficult to maintain the bone in position, so that
more or less deformity will result. The original dressing to hold the
bone in position should be kept on for a period of three or four weeks.
After that, a dressing which will draw the shoulders backward will
assist in keeping the bone in position.

Upward dislocation of the clavicle is very rare. The cause is a fall
upon the shoulder, which drives the acromial end downward and inward,
tilting the clavicle upward and inward. The diagnosis is easily made.
The shoulder falls down and in, and the clavicle makes a marked prom-
inence in the suprasternal notch. It may be possible that the head of
the clavicle presses so much upon the trachea that dyspnea will resiilt.
The dislocation is easily reduced. Extension can be made upon the
arm outward from the body, and the counter-extending force may
be made by a sheet passed around the body beneath the arm. As the
bone is dragged into position, it may be held in situ by means of a
Velpeau's bandage. A firm pad, or gutta-percha splint, is placed over
the sterno-clavicular joint. In some cases it may be advisable to wire
the bone in position. Usually, if the case is seen sufficiently early, a
good result may be obtained by the application of proper dressings.

Backward dislocation of the clavicle is rare. The causes are severe
direct violence. The symptoms are pronounced and urgent.
There is marked pain, interference in breathing, and dysphagia. The
shoulder has fallen downward and inward, while there is a depression
oyer the point where the head of the clavicle should normally be felt.
Occasionally there may be obliteration of the pulse in the arm, because
of pressure on the subclavian artery, or there may be great venous
congestion of the head, because of pressure upon the external jugular,
and to some extent, upon the internal jugular. The dislocation may
be reduced by means of traction outward and backward upon the
shoulders, with pressure by the knee between the scapulae. In
some cases this method of reduction is said to have failed. Still more
vigorous traction may be made upward and backward upon the affected
side. In other rare instances it is said that an operation may be neces-
sary to remove the end of the clavicle. After reduction, the head of
the bone may be held in position by a posterior figure-of-8 bandage.

Acromial Extremity. — Dislocations of the acromial end of the clav-
icle may be upward or downward. If upward, the clavicle may lie on top
of the acromion, and if downward, it may lie beneath it. These dislo-
cations are produced by blows forcing the scapula forward, or by blows
on top of the clavicle, forcing it downward.

284 DISLOCA TIOXS.

Signs. — The signs in case of dislocation of the clavicle upward
are a prominence of the clavicle on top of the acromion; more or less
impaired function of the arm, as inability to raise the arm. The head
is usually inclined to the affected side, and there is more or less con-
traction of the trapezius muscle with an outlining of its clavicular
border. The arm is apparently lengthened. This dislocation upward
is reduced by pulling the scapula backward, which can be done by trac-
tion on the arm and by pressing downward upon the clavicle. By
former methods considerable- deformity often resulted from this dislo-
cation. A strip of adhesive plaster, carried around underneath the
elbow and over the top of the clavicle, may be sufficient to hold the bone
in proper position. Ehoads's dressing consists of a strap passing un-
derneath the elbow and over the top of the clavicle, with a second strap
extending around the chest underneath the axilla, and which is fastened
to the perpendicular strap, thus preventing it from slipping off. This
may be buckled sufficiently tight to hold the clavicle in position. In
reducing a dislocation downward, the clavicle is raised, while the
scapula is pushed outward and backward. Not much difficulty will be
experienced in effecting reduction. The same kind of dressing is used
as in dislocation upward.

Dislocation of both ends of the clavicle may occur in rare instances
simultaneously. The treatment would be a combination of the methods
used in reducing dislocations of the outer and inner extremity.

Dislocation of the Scapula.

A condition which was formerly called a dislocation of the scapula,
as when the lower angle was believed to slip out from under-
neath the latissimus dorsi muscle, is now considered to be a condition of
paralysis of the posterior thoracic nerve. Attending this condition will
be found a vertebral lesion, which if reduced, will result in restoring
the integrity of the serratus magnus muscle and the apparently luxated
condition of the scapula will disappear. There are some cases where
the latissimus dorsi muscle takes a portion of its attachment from the
scapula, and because of injury, this attachment may be torn loose. In
this condition, no vertebral lesion will be found.

Dislocations of the Shoulder-joint.

Dislocations of the Humerus, both partial and complete,
are common, because of the exposed condition of the joint, shallowness
of the glenoid cavity, and, in some cases, because of a relaxed or weak-
ened condition of the ligaments. These dislocations are most fre-
quently found in muscular adults.

Cause. — Falls on the extended arm or elbow, or directly upon the
shoulder. It may result from twists of the arm, or from muscular
action.

DISLOCATIONS.

285

Varieties. — 1. Subcoraeoid. 2. Subglenoid. 3. Subclavicular. 4.
Subspinous.

Symptoms. — In addition to the general symptoms of dislocation,
there are certain signs in connection with dislocations of the shoulder,
which are of great importance, and merit careful consideration.
(1) Perhaps the most prominent symptom is prominence of the acro-
mion process, together with (2) flattening of the shoulder. This will
contrast sharply, when compared with the sound side and the normal
rotundity of the shoulder. Sometimes this flattening of the shoulder
will even be exaggerated into a depression beneath the acromion pro-
cess. It is increased by raising the arm. (3) Change in the axis of the
bone. (4)Alteration in the length of the limb when compared with the
sound side. (5) Absence of the greater tuberosity from a little below and
Fig. 90. Fig. 91.

Subcoraeoid dislocation of the
humerus.

Subspinous dislocation of the
humerus.

external to the acromion process. In all cases, unless the condition is
obvious, the examination should be taken up methodically.

Tests. — The following tests will be of use in determining the nature
of the condition in question :

1. The circumference of the luxated shoulder is at least two inches
greater than on the sound side. This is determined by passing a tape-
line underneath the axilla and over the top of the acromion.

2. Straight edge test (Hamilton's). A straight edge, which touches
the external condyle and the acromion process, proves that there is a
dislocation. Normally, it will not touch these two points, because of
the presence of the greater tuberosity a little below and external to
the acromion.

3. Change in the axis of the bone. With the hand on the opposite
shoulder, the elbow can not be brought in relation with the chest.

I. In a thin subject, the greater tuberosity may be felt a little below
and external to the acromion process.

In doubtful cases, the shoulder should be exposed to the x-rays.

286

DISLOCATIONS.

Subcoracoid Dislocation is more frequent than all other disloca-
tions of the shoulder. In this injury the head of the bone is
displaced forward, downward, and inward under the coracoid
process. The head of the bone rests on the anterior surface
of the neck of the scapula, just beneath the coracoid process, while
the groove just back of the head of the humerus rests on the
anterior margin of the glenoid cavity. The capsular ligament is
torn at its lower and inner portion. It may be detached from the
glenoid cavity. The subscapulars muscle is often raised up, or
partially torn loose, from the anterior surface of the scapula,
while the muscles which are attached to the greater tuber-
osity (supraspinous, infraspinatus, and teres minor) are put tightly

FtCx. 92.

Fig. 93.

Subglenoid dislocation of the humerus.

Subclavicular dislocation of the
humerus.

on a stretch. The subscapularis may be torn at its insertion, as
may also happen with the muscles attached to the greater tuberosity.
In rare instances, it is said that the greater tuberosity may be detached.
This dislocation is described by the old writers as intracoracoicl, inas-
much as the head of the bone rolls underneath the coracoid process.
In this dislocation, the signs are distinctive ; the head of the bone
may be seen making a marked prominence on the front of the chest;
the elbow projects outward and backward; there is shortening of the
humerus, depending upon how far the head of the bone is displaced
inward. All the other signs of dislocation of the humerus are present.

Subglenoid Dislocation. — Next to the subcoracoid, the sub-
glenoid dislocation is the most common. In this disloca-
tion, the head of the bone rests upon the anterior border of
the scapula, below the glenoid cavity. The capsular ligament

DISL OCA TIONS. 287

is ruptured in its lower portion, while the muscles attached to the
greater tuberosity are put violently on a stretch. The deltoid muscle
may be paralyzed, because of pressure or injury to the circumflex nerve.
The symptoms of this dislocation are distinctive. In general, all the
evidences of dislocation of the shoulder are present. There is length-
ening of the arm, i. e., the distance betAveen the external condyle and
the acromion process is greater than on the sound side, and, in addition,
there is a marked depression beneath the acromion process. Tbe head
of the bone can be felt in the axilla. In a moderately thin subject, a
marked space of two inches can be felt between the head of the bone
and the acromion. The elbow is carried away from the side; in some
cases, it may be directed backward, and in others, forward, depending
upon the position of the bone. In exaggerated conditions, it is said
that the elbow will be raised on a level with the head, being neither
abducted nor adducted — this was formerly called luxatio erecta.

Subclavicular Dislocation. — Subclavicular dislocation is rather
rare, and it seems to be but an exaggerated form of the
subcoracoid dislocation. The head of the bone is carried in-
ward beyond the coracoid process, underneath the clavicle. The
capsule is ruptured in the lower and inner part. The head
of the bone plows up the pectoral muscles and rests on the ribs,
beneath the clavicle. The subscapularis muscle is torn from its attach-
ment to the anterior surface of the scapula; it is detached from the
humerus. The attachments of the muscles to the greater tuberosity are
more or less torn, but they retain their attachments, as a rule, to the
capsular ligament. The head of the bone may be seen, making a marked
prominence, beneath the clavicle. The shaft can be felt in the axilla,
ami there is marked shortening of the arm. It lies in close relation
with the chest. The elbow usually projects backward, and a little out-
ward.

Subspinous Dislocation. — Subspinous dislocation is very rare.
The head of the bone is forced out of the glenoid cav-
ity, between the infraspinatus and teres minor muscles, and
rests on the dorsum of the scapula, just beneath the spine,
in the infraspinous fossa. In some cases, the head of the
bone will be found just behind, or resting upon the edge of the glenoid
cavity. The elbow is directed forward and outward. The humerus is
rotated inward. The head of the bone makes a marked prominence
on the dorsum of the scapula, while the other signs of dislocation are
present. In addition to the signs already mentioned, there may be evi-
dences of injury to the soft tissues. These are evidences of injury
to the brachial plexus, intense pain or numbness, and even paralysis
in some cases, or the pressure upon the axillary vein causes intense
edema of the arm. The axillary arte^ may be compressed to such an
extent as to obliterate the pulse at the wrist. There may be great effu-
sion of blood, especially where there is considerable laceration of the
capsule and other soft tissues about the joint. These severe symptoms

288

DISLOCATIONS.

and the signs of dislocation before mentioned, are not present in condi-
tions of subluxation or partial dislocation at the shoulder-joint. These
conditions are common, and are produced by pushing the
head of the humerus underneath the coracoid process, without ruptur-
ing the capsule, but with injury to the long head of *the biceps, or the
long head of the biceps may be luxated from its tendinous groove.

Fig. 94.

First step in Kocher's method of reducing anterior dislocations of the
humerus.

Treatment. — 1. Kochers method, suitable for anterior dislocations,
consists of external rotation, adduction, and internal rotation. External
rotation should be complete, and is performed in order to relax the
muscles attached to the greater tuberosity. The elbow is then carried
to the middle line of the body in order to bring the head in relation
with the opening in the capsule, and, as internal rotation is accom-
plished, the head of the bone will slip through the rent in
the capsule without difficulty.

2. Other manipulative methods are as follows: If the dislocation
is in the right shoulder, the head of the bone is grasped by the left

DISLOCATIONS.

2S9

hand, while the elbow is seized with the right hand; the arm, in case
of an anterior dislocation, is rotated outward, with more or less exten-
sion from the body. The knee, against the chest wall, may be used as
a counter-extending force. The head of the bone may be dragged by
the left hand into the cavity. This manipulation may be modified to
suit all the dislocations.

3. Manipulative methods, with extension, may be made with the
patient sitting in a chair, when the operator's foot is placed on the edge

Fig. 95.

Second step in Kocher's method of reducing anterior dislocations of the
humerus.

of the chair, with the knee in the axilla. The knee is used as a ful-
crum, while the arm is seized above the elbow, the humerus being used
as a lever, when the head of the bone is lifted into the socket.

4. Extension may be made from the body with counter-extension "by
means of a towel or sheet passed underneath the axilla. This method,
may be successful when other methods have failed.

5. Forcible extension downward. The unbooted foot may be placed
in the axilla, so as to rest against the lower border of the glenoid cavity,
and strong traction is made on the arm. Where sufficient grasp can

290

DISLOCATIONS.

not be gotten on the arm, a clove-hiteh may be used around the arm.
By this means the head of the bone may be forcibly dragged into the
socket.

6. Air-cushion in the axilla. Where the dislocation can not be
reduced, an excellent treatment is to place an air-cushion in the axilla,
and bind the arm to the side. This air-cushion may lift the head of
the bone out of its position, when reduction can easily be effected. In

Fig. 96.

Completion of the manipulation in Kocher's method of reducing anterior dis-
locations of the humerus.

reducing a dislocation of the shoulder, care should be taken not to in-
jure the axillary vessels, the brachial plexus, or to fracture the bone.
The old method of placing the foot against the chest wall, and making
traction on the arm, has resulted in fracture of the upper ribs. These
methods are barbarous. Extension by means of pulley and tackle
should not be used, as it has resulted in severe and extensive injury.
Milder methods are more successful. All recent dislocations should be
reduced by manipulative methods. Anesthesia may be necessary, but,
in nearly all cases, the dislocation may be reduced without it. After
the dislocation is reduced, a Velpeau's bandage may be applied or the

DISL O CA TIONS. 291

arm may be bound to the chest, for a period of three weeks. After the
first week, manipulation will assist the return of the tissues to their
normal condition, and, after the third week, the bandage may be
removed.

Eeduction of old dislocations of the shoulder is best effected by
means of manipulation. Extension under ether is a bad procedure.
The great mortality of anesthesia, in the reduction of shoulder dislo-
cations, is brought about by the fact that the chest is compressed and
respiration interfered with, together with the fact that profound anes-
thesia is necessary to effect the entire relaxation of the muscles. Such
vigorous methods are unwarranted. Milder methods will be found
successful, if persisted in. Manipulation might not be successful at
first, but it may be successful later. Continued manipulation,
breaking up of adhesions, relaxing contracted muscles, releasing
bony prominences, and securing a better circulation to the injured tis-
sues, all tend to make reduction easier. If the dislocation is compli-
cated by fracture, an ef-
fort at reduction should FlG" 97'
be made by traction and
manipulation of the
head of the bone. This
should be done very
cautiously. If reduction
is impossible, McBurney
advises an open incision
and a hook attached to
the scapula, with an-
other hook fastened to Tlie clove-hitch applied as a means of making- extension.

the humerus; by these,

traction is made, and the dislocation reduced, when the frag-
ments are subsequently wired together. Usually, there is suf-
ficient periosteum, which unites the fragments, and the muscular
attachments are such that the dislocation can be reduced without oper-
ative procedure. In emergency cases, gimlets have been used to bore
into the bones and traction made from them. This is hardly warranted.
Subluxations are reduced by methods similar to those used in com-
plete dislocations. The condition may return, when subsequent reduc-
tion is necessary. If the nerve and blood supply to the joint and
other structures are properly improved, a cure will be effected.

,, . x. Dislocations of the Elbow,

v aneties :

1. Dislocation of both bones (ulna and radius).

a. Backward, b. Inward, c. Outward,
d Forward (with fracture of olecranon.)
e. Ulna backward and radius forward.

2. Dislocation of the ulna backward.

3. Dislocation of the radius.

a. Forward, b. Outward, c. Backward.

DISLOCATIONS.

Fig. 98.

Dislocation of Ulna and Radius Backward. — Causes. — The causes are
direct and indirect violence, operating together, as falls upon
the hand or wrenches of the arm. The injury is more frequent in young
people, and is often accompanied by laceration of the soft-parts. Tne
injury to the tissues depends somewhat upon the nature of the dis-
location.

Condition of the Parts. — In dislocation
backward, (which is the most common
dislocation at the elbow) there may be,
at the same time, more or less displace-
ment of the bones inward or outward.
As a rule, the coronoid process will be found
in the olecranon fossa. If the coronoid process
is not broken off, the attachment of the
brachialis anticus muscle is, more or less, torn
loose. The neck of the radius will be found in
relation with the articular surface of the hu-
merus. The anterior ligament is nearly always
torn, while sometimes the lateral ligaments are
ruptured. The olecranon and the head of the
radius form a marked prominence on the back
of the arm, while the lower end of the humerus
makes a marked prominence below the crease
at the bend of the elbow. The relation be-
tween the condyles and the olecranon will be
found changed. The forearm is fixed, flexed
and shortened.

Dislocation of Both Bones Inward is pro-
duced by falls upon the elbow and forearm. The internal and external
lateral ligaments are ruptured unless the dislocation is but slight. The
relation of the condyles and the olecranon will be found changed. The
outer condyle stands out prominently, while the inner condyle is ob-
scured by the upper extremity of the ulna lifting up the flexor muscles.
Tbe upper extremity of the ulna
will be found to stand out promi-
nently on the ' inner side of the
arm, while the head of the ra-
dius can not be felt. The de-
formity resulting may be twisted or
angular.

Dislocation of Both Bones Out-
ward will be evidenced by the mark-
ed prominence of the inner condyle
of the humerus, and the prominence
of theheadof the radius beneath the
supinator longus on the outside of
the arm. The relation between the

Dislocation of both bones of
the forearm backward.

Fig. 99.

Dislocation of the radius forward and
the ulna backward at the elbow.

DISL O CA TIONS. 293

condyles and the olecranon is altered. There is loss of function,
and the swelling and elevated muscles more or less obliterate the
external condyle.

Dislocation of Both Bones Forward. — In this dislocation, fracture of
the olecranon process usually takes place, although rare cases have oc-
curred where there is no fracture, the dislocation having been produced
by dragging down both bones, and, at the same time, forcing them for-
ward. In either case, a marked lengthening of the limb, the absence
of the olecranon process on the back of the humerus, and alteration in
the relation between the condyles and the olecranon, will serve to make
the diagnosis.

Treatment. — Reduction of the backward dislocation is best accom-
plished by the following methods:

1. Dr. Still makes traction on the forearm in exaggerated extension,
the object being to lift the coronoicl process out of the olecranon fossa.
This method will be found successful in all recent cases.

2. Some operators use the following method: The front of the
knee is placed against the front of the elbow-joint; this operates
as a fulcrum against the upper extremity of the forearm. Traction and
flexion are made simultaneously, the forearm being used purely as a
lever. In this way, the coronoicl process is lifted out of the olecranon
fossa and reduction is accomplished. In dislocations inward, outward,
or forward, extension and counter-extension are made to overcome the
rigidity of the muscles and the contracted ligaments, while the operator
molds the bones into position. The same course should be pursued in
dislocations of the ulna backward and the radius forward. Where the
diagnosis can not be made, an x-ray examination should be made,
if possible. Great swelling is the rule. This swelling ob-
literates the landmarks about the elbow-joint. Sometimes
the elbow is so painful that even a superficial examination
can hardly be made. Tinder no circumstances should the
patient be treated, except, perhaps, for a few days, to combat the swell-
ing, unless an accurate diagnosis has been made. The reasons for this
are that old dislocations of the elbow are difficult to reduce, and the
great liability of fibrous adhesions impairing the integrity of the joint.
Perhaps in no other location of the body are injuries attended by worse
results; still, there are many cases where the severest forms of injury
have been attended by the most remarkable results, but these cases are
unusual. In old cases, the family or friends of the patient should be
notified of its gravity. A too favorable prognosis should not be made.
The treatment will depend upon the nature of the injury. In eld dis-
locations of both bones backward, the prognosis is not favorable,
especially if there has been extensive inflammation following the in-
jury. The coronoid process will become, as it were, glued into the ole-
cranon fossa. Fibrous adhesions will prevent reduction. In disloca-
tions inward, or outward, and both bones forward, or the ulna back-
ward and the radius forward, reduction can be accomplished better, and

294

DISL OCsi TIONS.

more readily, and the results are better. In reducing these
old dislocations, it is necessary to prepare the joint for the operation
of reduction. . This means that the fibrous tissue must be gotten rid of.
While the bones may not be gotten into absolutely normal relation, the
treatment by manipulative methods will be attended by improvement
of the condition of the joint, x^ot only the range of motion will be
increased, but the pain will be lessened, and the deformity more or
less removed, so that the prognosis in old cases is much more favor-
able where osteopathic methods prevail.

Dislocation of the Ulna Backward. — This injury is rare and occurs
because of force directed upon the ulna itself. The most common dis-
location of the ulna is a condition of subluxation of the upper extremity
brought about by falls upon the hand, where more or less force is
directed against the inner side of the arm. The head of the radius is
used as a fulcrum, while the forearm is adducted. Partial dislocation
of the upper extremity of the ulna may take place without rupture of
any of the ligaments. This injury is often overlooked. Eeduction is
accomplished by exaggeration of the deformity, the thumb being placed
against the inner border of the coronoid process. While extension with
abduction and adduction is made, the ulna will be returned to its normal
position.

Dislocation of the Radius Forward is said to be the most common
dislocation at the elbow, and is caused by falls upon the hand with the

arm extended, and the
Fig. 100. forearm pronated. Some

writers have maintained
that forced pronation and
muscular contraction will
produce the dislocation.
The head of the radius
rests against the front of
the humerus, the arm is in
a semi-flexed position,
while the head of the bone
can no longer be felt be-
neath the external condyle.
The arm may be flexed
voluntarily, but will come
to a sudden stop, because
the head of the bone, being
drawn upward by the bi-
c e p s muscle, will be
brought forcibly against
the anterior surface of the
lower extremity of the humerus. At the point beneath the external
condyle, where the head of the radius should be, there is more or less of
a hollow. The arm can not be fully supinated, but can be pronated.

Dislocation of the radius forward at the elbow.

DISLOCATIONS. 295

The diagnosis of the dislocation is difficult, especially in muscular or
fleshy subjects. The injury may be confounded with fracture of the
neck of the radius or an epiphyseal separation.

Differential Diagnosis. — 1. Crepitus. In fracture, crepitus may be
obtained, while in dislocation, crepitus will be absent, except in case of
adhesions or roughened conditions of the ends of the bones, when false
crepitus only will be obtained.

2. Preternatural mobility. In fracture, preternatural mobility may
be obtained, by grasping the head of the bone and pronating and supi-
nating the arm; the head of the bone will be found not to move. In
dislocation, if the head of the bone can be grasped, it will be found to
rotate with the shaft of the bone, upon pronation and supination.

3. Keduction of the fracture will be followed by a return of the
deformity, whereas, in dislocation, if it is reduced, the deform-
ity will not return. In epiphyseal separation, where there is not
much swelling, a sensation as of a foreign body in the joint may be
obtained and moist crepitus is present. Where the diagnosis is
clouded, an x-ray examination should be made. Where this is not pos-
sible, the prognosis should be guarded. Where the diagnosis can not
be made, the deformity should be reduced and treated as a fracture.

Reduction of the dislocation is accomplished by extension applied
more particularly to the radius, while the bone is manipulated into posi-
tion, or the knee may be used as a fulcrum against the upper part of the
forearm, as the forearm itself is used as a lever , at the same time,
more or less extension is made.

Dislocation of the Radius Backward is produced by falls upon the
hand in supination. The head of the bone can be readily felt beside
the olecranon back of the external condyle. The forearm is flexed and
pronated. The diagnosis is usually easy. While extension is being
made, the bone is manipulated into position. The knee may be used
as a fulcrum, as the head of the bone is drawn into position.

Dislocation of the Radius Outward is rare. The head of the bone is
displaced to the outer side of the outer condyle, where it makes a
marked prominence. The head of the bone can be readily felt rotating
in this position, upon pronation and supination. Potation of the
radius, together with forced extension, will easily effect reduction.

Subluxation of the Radius. — Subluxation of the head of the radius
is a common injury, more frequent in children. It is the result of mus-
cular action, twisting or traction of the forearm. Various explana-
tions have been offered for the injury. Some operators say that extension
and adduction produce the injury, while others say that only extension
is necessary. In a child, the injury is called "pulled-elbow," and usually
occurs between two and four years of age. Complete supination or
falls produce subluxation. The symptoms are various, depending
upon the amount of displacement and the extent of injury to the liga-
ments. There is not much deformity at the elbow. Pressure over the
upner extremity of the radius will cause severe pain. The arm is usually

29G DISLOCATIONS.

flexed at an angle of about sixty degrees. Some movements of the arm
are painless, while complete extension of the arm causes great
pain. Complete pronation and supination also cause pain. Forced
supination will cause a distinct clicking sound. The subluxation can be
reduced by completely flexing the arm with supination and pronation,
together with abduction and extension. In some cases the edge of the
fibro-cartilage will be displaced or slip between the head of the bone
and the articular surface of the humerus. After reduction has been
accomplished, it is necessary to put a figure-of-8 bandage around the
elbow and carry the arm in a sling for a few days until the ligaments
return to a normal condition. In all dislocations at the elbow
starch-paste dressing may be put over the joint by means of paste-board
and a four-tailed bandage and the arm carried in a sling. After the
preliminary inflammation has disappeared, which will take place within
a week, the joint may be manipulated every few days, so as to prevent
ankylosis. Recovery is complete in uncomplicated cases.

Other peculiar conditions which may occur at the elbow, and which
may cause pronounced symptoms are:

1. Slight posterior displacement.

2. Slight anterior displacement of the head of the radius.

3. Luxations of the interartieular cartilages.

4. Locking of the tuberosity of the radius with the inner edge of
the ulna.

5. Intracapsular fracture of the head of the radius.

fi. Paralysis or neuritis of one of the large nerves of the arm brought
about by injury. «

The conditions may be made out only by careful physical examina-
tion by one who has an accurate knowledge of anatomical relations.
Dislocations of the Wrist are common and may be classified as :
1. Dislocations forward. 2. Dislocations backward.

3. Backward luxation of the ulna from the radius.

4. Forward luxations of the ulna from the radius.

5. Subluxations.

Dislocations Backward. — This dislocation is produced by falls upon
the hands. The carpus stands out prominently on the back of the wrist,
while the fingers are flexed and the lower extremity of the radius and
ulna project prominently in front of the forearm. It must be noted
that the styloid process of the radius is upon a lower level than that of
the ulna.

Fracture through the base of the styloid process of the radius
(Colles's fracture) simulates dislocation of the wrist, but the styloid
process of the radius is on the same level or higher than that of the
ulna. There is muscular rigidity and an absence of crepitus. Extension
and manipulation usually reduce the deformity.

Dislocations Forward. — In dislocations forward the carpus makes a
prominence on the front of the wrist, while the ulna stands out prom-

DISLOCATIONS.

297

inently on the back of the forearm. This injury is very rare. Reduction
is accomplished by extension and counter-extension.

Dislocation of the Ulna from the Radius, either forward or backward,
is accomplished by forced supination or pronation, as occurs in violent
twisting of the hand. In the backward dislocation, the forearm is pro-
nated and the space between the styloid processes of the ulna and radius
is diminished. The ulna stands out prominently on the back of the
wrist. In the forward dislocation, the ulna projects in front, while the
distance between the two styloid processes may be found lessened. The
arm is supinated. Reduction is accomplished by traction, exaggeration
of the deformity, and pressure upon the head of the bone with nexion
or extension, as the case may be, when it may be readily forced into
position.

Dislocation of the Carpus. — Dislocation of one of the carpal bones
may take place because of injur}- or forced movements of the wrist. The
deformity may not be great, but the involvement of the nerve filaments
causes great pain. The diagnosis can be made by a careful ex-
amination. The wenkest point in the wrist is between the scaphoid,
os magnum, and semilunar bones. Reduction is accomplished by exag-
geration of the deformity, and pressure upon the projecting bone, with
forced flexion or extension as the case ma}r require.

Dislocation of the Metacarpus. — Dislocation of the metacarpal bones
in their articulation with the carpus is rare. Subluxations are fairly
common, and when any nerve structures are involved, severe pain is
the chief symptom. The deformity is not great.
The first metacarpal bone is the one most frequently
dislocated. The diagnosis is usually readily made
upon careful examination. Flexion and extension
with adduction and abduction, while compres-
sion is made by the thumb upon the end of the dis-
located bone, will accomplish reduction.

Dislocations of the Metacarpophalangeal Articu-
lations are rare. The dislocation usually takes place
backward, and is caused by falls on the outstretched
hand. The diagnosis is made without difficulty.
Reduction is accomplished by manipulation as ex-
tension is being made. In only one of these disloca-
tions will any difficulty be found in making reduc-
tion, i. e., dislocation of the first phalanx of the
thumb. This dislocation takes place backward. The
obstacles to reduction are the margin of the capsu-
lar ligament, together with a stretched condition of
the flexor longus pollicis and the sesamoid bones
developed in the tendons of the flexor brevis pollicis.
Reduction is accomplished by forced extension and
lifting the head of the bone into place. Extension
should be made until the phalanx is at right angles

Fig. 101.

Dislocation of the
first phalanx of the
thumb.

298 DISLOCATIONS.

with the head of the metacarpal hone. This enlarges the opening
through which the dislocation took place. In some cases tenotomy may
he necessary.

Dislocations of the Phalanges are fairly common. The diagnosis is
easy and reduction is accomplished hy extension and counter-extension.
Where sufficient extension can not be made hy grasping the finger, a
Levis's splint may be used. This splint is made by means of a narrow
board, having two rows of holes the width of the finger. Tape is passed
through the holes so as to form loops upon one side of the splint. The
finger is inserted into these loops and the tape is drawn tightly to the
finger. Traction can be made by means of the splint.

Dislocations of the Ribs. — Clinical experience shows that traumatic
dislocations of the ribs often take place. These may accompany
fractures of the spine, or the luxation may take place without other
injury, being caused by direct or indirect violence. The displacement
of the head of the rib may be forward or backward, upward or down-
ward. The signs are:

1. Elevation or prominence of the luxated rib.

2. Depression or lessened prominence of the luxated rib.

3. Widening or narrowing of the intercostal space.

A history of the accident, together with the deformity present, will
easily enable the physician to make the diagnosis. Conditions of sub-
luxations are more thoroughly described in works on Osteopathic
Practice, to which the. reader is referred.

Reduction is accomplished by manipulation. These are elaborated
upon in works on osteopathic methods.

Dislocation of the rib from its costal cartilage may be produced by
direct or indirect violence. Inasmuch as the bone is subcutaneous, the
condition can readily be made out. Pain will be a prominent symptom,
together with an offset in the rib at that point. Eeduction is accom-
plished by manipulation. It may be held in position by strapping. In
severe conditions of luxation of the head of the rib from its articulation
with the spine, strapping of the rib, as in case of fracture, may be re-
quired.

Dislocation of the Costal Cartilages at their articulation with the
sternum may also take place and is the result of direct vio-
lence. The symptoms are pain and deformity. If the ribs are raised,
and that part of the chest kept immovable by strapping, complete re-
covery will take place without any troublesome symptoms.

Dislocation of the Sternum. — Inasmuch as bony union takes place
between the three portions of the sternum late in life, dislocations of
these parts of the bone may take place in children. Dislocation of the
gladiolus from the manubrium may take place because of great direct
violence. The symptoms are usually evidences of severe local injury,
together with a ridge at the point of union of the two bones. Where
the injury is very severe, there may be marked dyspnea, and
irregular heart action. Dorsal flexion, with pressure over the manu-

DISLOCATIONS.

299

brium and a raising of the ribs, will draw the bone into position. A
figure-of-8 bandage about the chest, to limit motion, will relieve the
pain and hasten recovery.

The Ensiform Cartilage may be dislocated by means of pressure, or
blows received. The displacement may be slight, or the deformity may
even be angular, and it may interfere with taking food. Cases are re-
ported where persistent vomiting followed such injury. The symptoms
are usually plain ; a history of the injury and pressure upon the carti-
lage are indicative; also there is a marked depression at the lower end
of the sternum. Eaising the ribs will lift out the cartilage. Operative
treatment is necessary.

Dislocation of the Sacro-iliac Joint. — Sacro-iliac dislocations partake
of the nature of subluxations. They are common and consist of dis-
placements backward, forward, upward, or downward, or of combina-
tions of these, as a luxation upward and backward. One or both sides
may be affected. It will produce inequality in the length of the limbs
and tilting or twisting of the pelvis. The posterior superior iliac
spines may be more prominent, or less so, and may be higher up, or
lower down, than normally. It may be evidenced by pain at the sym-
physis pubis, in the back, down the thigh, or within the joint. It may
cause hip-joint disease, white swelling, sciatica, pelvic disease, neural-
gic conditions, and various other diseases. A careful examination will
reveal the condition. The luxations are reduced by manipulation, or
well known osteopathic methods. Fig. 102.

Dislocations of the Hip. — Dislo-
cations of the hip are more common
than dislocations of many othei
joints, although the nature of the
anatomy of the joint is such as to
rather protect it from injury. The

and

.fits

lig-

to

cotyloid cavity is deep
the head of the femur
in with such nicety and the
aments are sufficiently strom

render dislocations unlikely. They
form, perhaps, ten per cent, of all
dislocations. They are more common
between the ages of twenty and
thirty, but may occur at any age. It
is important to thoroughly under-
stand the anatomy of the hip-joint
to understand the dislocations. The
most important of the ligaments is
the Y-ligament, which is the form
of an inverted Y, whose upper
attachment is the anterior inferior
spine of the ilium, and the lower

The Y-ligament intact.

300

DISLOCATIONS.

Fig. 103.

attachment, the outer limb, at the upper extremity of the anterior
intertrochanteric line, and the inner limb to the inner extremity of the
anterior intertrochanteric line. This Y-ligament is really a thickened
anterior portion of the capsular ligament. It is this ligament which
determines the position of the thigh in what are understood as the reg-
ular dislocations. Eegular dislocations are those in which the Y-liga-
ment is intact. The irregular dislocations are those in which the Y-
ligament, either the inner or outer limb, is ruptured.

The causes of the dislocations are those of dislocations of other
joints, but the luxations may happen in typhoid fever or they may be
produced by the assumption of habitual attitudes. The exciting cause
of the dislocation in certain abnormal conditions may be slight force,
as turning in bed. Muscular contractions play a great part in some of
the dislocations. In eighty per cent, the head of the bone gets out of

the capsule at its posterior portion. In other
cases, the head of the bone may rupture the
lower or the inner portion of the capsule. It
is believed that the dislocation takes place
largely by leverage. This may not always be
true. Many different classifications will be
found, but it is more important to understand
the nature of these dislocations than the par-
ticular classification. They may be best under-
stood as follows:

A. Regular. 1. Iliac, where the head of
the bone rests on the dorsum of the ilium. 2.
Sciatic, where the head of the bone is dislo-
cated beneath the obturator interims muscle.
3. Obturator or tlryroid, where the head of the
bone is displaced in the thyroid foramen. 4.
Pubic, where the head of the bone is displaced
inward on the front of the pubes.

B. Irregular. 1. Anterior oblique. 2.
Everted dorsal. 3. Perineal. 4. Supracoty-
loid. 5. Ischial.

Both iliac and sciatic dislocations are back-
ward displacements of the bone. The bone
gets out of the lower or upper part of the cap-
sule during flexion, adduction, and internal ro-
tation of the thigh. There are cases where
a drawing illustrating dorsal a thyroid dislocation may be transformed into
a dorsal, but this is unusual. The Y-ligament
is intact and stretched, producing flexion of the thigh. The ligamentum
teres is usually ruptured. The quadratus femoris, the gemelli, and per-
haps the obturatur internus and pyriformis muscles, are injured. The
head of the bone dissects up the glutei muscles, and in fairly thin sub-
jects; can often be felt imperfectly on the dorsum of the ilium.

as «j
•Hfl

DISLOCATIONS.

301

In the sciatic dislocation, the head of the hone gets out at the lower
and posterior part of the capsule. The head of the bone becomes en-
gaffed beneath the tendon of the obturator interims muscle and usually
Ties between it and the pyriformis. .Sometimes it may rest upon the
piriformis muscle. It seldom ever reaches the sciatic notch. As a rule,
if the head of the bone leaves the cavity at the lower and posterior part
of the capsule, a sciatic dislocation will result. If it leaves at a higher
point, the iliac dislocation results. The rim of the acetabulum may be
chipped off, or the head of the femur may be broken. Fifty per cent, of
all dislocations of the hip are dorsal; thirty per cent, are sciatic.

The symptoms of these dislocations are adduction, internal rotation,
and flexion. There may be considerable tilting of the pelvis, caus-
ing marked lordosis of the spine. The lower extremity of the femur
on the injured side, if projected, would cross the lower extremity of
the femur on the sound side, while in the erect position, the foot rests
on the top of the foot of the sound side. The hip is broadened, the
trochanter is elevated above Nekton's line, while Bryant's line is short-
ened, also indicating the ascent of the trochanter. The voluntary
movements are for the most part lost. Passive movements are possible
in flexion and adduction, but are impossible in
extension and external rotation or abduction.
Much shortening is the rule, but this comes
largely from the adduction and flexion of the
thigh. The adduction and flexion are pro-
duced by the tension on the Y-ligament and
the adductor muscles. The signs of a sciatic
dislocation are similar to those of an
iliac dislocation, but are not so pronounced.
The shortening is less upon extension of
the thigh and greater upon flexion of the
thigh.

Obturator or Thyroid Dislocations consti-
tute eleven per cent, of the hip dislocations,
and may be produced by blows on the back
part of the pelvis. The head of the bone is
displaced downward and inward. The Y-liga-
ment is intact and holds the limb in abduc-
tion and flexion. The limb can not be ex-
tended or adducted. Because of the tilting of
the pelvis forward, due to the tension upon
the Y-ligament, the limb is apparently length-
ened, but is shortened to some extent. While
the patient stands erect the limb is held for-
ward in abduction by the Y-ligarcent. In the
obturator dislocation the head of the bone gets

out of the cavity through the lower, or lower and inner part of the
cansule.

A drawing illustrating a thy-
roid dislocation of the hip.

302

DISLOCATIONS.

In Pubic dislocations, the head of the hone rests on the front of the
pubes. It may be a transformed obturator dislocation, or the bone ma}' get
out through the upper and inner part of the capsule. The injury is pro-
duced by hyper-extension, or by forced abduction and external rotation.
The head of the bone rests on the ilio-pectineal emi-
nence most often, but it may be displaced farther
inward. The limb is markedly abducted and evert-
ed. The hip is flattened, and there is considerable
shortening.

Irregular Dislocations constitute about two per
cent, of all the dislocations of the hip. One or both
limbs of the Y-ligament are ruptured.

The Everted Dorsal dislocation is the same as
the dorsal, with the exception that the head of the
bone is displaced forward and inward, while the
limb is abducted and extended. The outer limb of
the Y-ligament is broken.

In the Anterior Oblique dislocation there is out-
ward rotation and marked flexion and abduction.
The head of the bone rests just above the acetabu-
lum. The Y-ligament is broken.

Perineal dislocation is the same as the thyroid
dislocation, with the exception that the head of
the bone is displaced farther inward, while flexion
and abduction Fig. 106.

are more mark-
ed. Sometimes
the head of the
bone may be felt in the perineum.

In the Supracotyloid dislocation,
the head of the bone is just above
the acetabulum. There is eversion
and abduction.

A Suprapubic dislocation, which
is an anterior dislocation displaced
upward, may resemble the supra-
cotyloid, or an everted dorsal lux-
ation.

Ischial dislocations are rare.
The head of the bone is displaced
downward and backward, and rests
upon the tuberosity of the ischium.
The limb is everted, abducted, and
flexed.

Methods of Reduction.

. A drawing showing the method of reduc-

In the backward dislocations, tion in dorsal and sciatic dislocations. In

. _ , . . . pubic and thyroid luxations the limb is ad-

the dorsal and SCiatlC, the manip- ducted instead of abducted and also rotated

inward.

A drawing showing
the position of the limb
in public dislocations of
the hip.

DISLOCATIONS. 303

illation should be directed towards relaxing the Y-ligament and directing
the head of the bone toward the opening in the capsular ligament. The
patient should lie flat on his back, while the pelvis is held fixed by an
assistant. Flex the knee at right angles and rotate the thigh a little
further inward, then lift up or make traction upon the femur with con-
siderable force, at the same time rotating the limb outward. This is
followed by abduction and extension. T>r. Charles Still prefers to lift
the thigh in position by grasping the trochanter. He is very successful
with this method. Some operators have the patient lie upon the floor,
while the pelvis is held fixed, believing that more traction can be made
upon the thigh during the manipulation. Stimson places the patient
Avith the face down, with the hips projecting just beyond the end of the
table. An assistant holds the sound thigh, while the operator grasps
the foot on the injured, side and allows the weight of the limb to pull the
thigh in position. Ten or fifteen pounds of weight may be added to over-
come the tension of the muscles, when the hip may be dropped in posi-
tion. This manipulation is suitable for the reduction of backward dis-
locations. Leverage is, perhaps, one of the most important forces to be
utilized in the reduction of hip dislocations.

In Obturator dislocations, the thigh should be flexed at right angles,
while traction should be made upon the femur. The limb should then
be addncted and extended. It may be necessary to rotate the thigh
farther outward in order to secure relaxation of the Y-ligament.

In the Pubic dislocations, traction is made in flexion, while an
assistant makes pressure against the upper extremity of the thigh, on
the inner side, thus preventing the head of the bone returning on the
front of the pubes while internal rotation is performed by the operator.
In some cases, reduction may not be accomplished, but the skill of the
physician will depend upon his experience and his knowledge of the an-
atomical relations.

Compound Dislocations. — Compound dislocations are very rare, and
are usually fatal; but a few cases are on record. There is generally such
extensive injury to the soft-parts, and bone, that sepsis results.

Old Dislocations. — Unreduced dislocations are treated in the same
manner as recent dislocations. Should the operator fail to reduce the
dislocation at the first attempt, he should not be discouraged. Many
times, by breaking up the adhesions and relaxing the muscles, the head
of the bone may be made to retrace its steps. If there is no injury to
the cotyloid cavity, and the inflammatory reaction about has not been
too severe, reduction may be accomplished after a number of years. Dr.
A. T. Still has reduced a large number of these dislocations, even after
they had existed many years. Reduction, in many cases, may be accom-
plished only after months of treatment preparing the parts for reduc-
tion. After reduction has been accomplished, treatment may still be
required for some length of time to prevent the dislocation returning.

Pathological Dislocations. — Pathological dislocations are very com-

304 DISL O CA TIONS.

mon in inflammations of the joint, paralysis, in conditions of rickets,
and septic fevers, especially in conditions where the person assumes a
certain position for a considerable length of time. These pathological
dislocations are reduced by methods similar to those used in recent dis-
locations. The joint must first be prepared for reduction. The liga-
ments must be relaxed, the tonicity of the muscles improved, and the
adhesions broken up. After this has been done, the pelvis must be held
securely by an assistant while the operator makes traction on the thigh.
Too much force should not be applied to the limb. It is unnecessary
and may do harm. The old method of Sir Ashley Cooper of forcibly
dragging the head of the bone into the socket is bad, inasmuch as it may
do a vast deal of harm. Eeduction can be made by manipulative means
much more readily, even in old dislocations. If the femur is dislocated
inward or downward, the pelvis should be held securely to the table or
floor, while the physician makes traction on the thigh. Pressure may be
made on the inner side of the neck of the femur, while at the same time
the physician performs adduction, thus using the femur as a lever.
This may force the bone in the socket. Similar methods may be used
if the femur is dislocated backward. In this case, the assistant may
press upon the back part of the femur while abduction and extension
are made.

Dislocations of the Knee-Joint may be classified as:

1. Dislocations of the patella.

2. Dislocations of the tibia.

3. Dislocations of the semilunar cartilages.

Dislocations of the Patella. — The patella may be dislocated (a) out-
ward, (b) inward (very rare), and (c) edgewise (vertical rotation).

Dislocation Outward is the most common, on account of the
obliquity of the femur. It occurs in subjects suffering with genu
valgum, and is produced by direct violence. It occurs while the limb
is extended. If the luxation is complete, the patella will be felt hying
entirely on the outside of the external condyle. The knee will be flat-
tened, while the intracondylar space will be marked by a depression.
Where the luxation is incomplete, the inner half of the articular sur-
face of the patella lies in relation with the articular surface of the outer
condyle. Eeduction is accomplished by means of extension and manipu-
lation, the thigh at the same time being flexed upon the abdomen,
which thoroughly relaxes the quadriceps extensors, Avhen the bone may
readily be moved into position.

Inward Dislocation is extremely rare, and is due to direct violence.
The diagnosis is easy. The treatment is similar to that of dislocation
outward.

Dislocation edgewise, or vertical rotation, is a rare condition pro-
duced by twisting the patella on its own axis. Cases are on record
where the patella has been turned completely over. Partial rotation of
the bone is similar to an incomplete dislocation, either inward or out-

DISLOCATIONS. 305

ward, and reduction is accomplished in the same manner as reduction
of a dislocation either inward or outward. Complete rotation may be
reduced by relaxing the quadriceps extensors and. rotating the bone into
position.

Dislocations of the Tibia. — Dislocations of the tibia may occur (a)
inward, (b) outward, (c) backward, or (d) forward. When the disloca-
tion is caused by disease it is backward, but when caused by
traumatism, it is nearly always lateral. Dislocation either inward or
outward is rarely ever complete, and is accompanied by more or less
twisting of the leg. One or the other of the lateral ligaments will be
ruptured. The diagnosis of the dislocation can be readily made, as the
symptoms are prominent. E eduction of the dislocation is easy.
While extension is made, the limb is abducted or adducted as required,
and rotated- either inward or outward, or, while an assistant makes ex-
tension, the bone may be lifted into position by the operator.

Dislocation of the tibia forward is more common than dislocation
backward, when the result of trauma. The dislocation may be complete.
The lower extremity of the femur will project into the popliteal space
and obstruct the femoral vessels, while the tuberosity of the tibia will
stand out prominently on the front of the leg. There may be consider-
able shortening. Usually, the dislocation is incomplete and the symp-
toms are not so prominent. Seduction is accomplished by extension
and manipulation.

Dislocation of the tibia backward is usually not complete. The
cause of the injury is direct and indirect violence. The signs are so
constant and prominent as to be characteristic. The tibia is more or
less displaced into the popliteal space, and operates as an obstruction
to the return circulation through the femoral vessels. There will be
engorgement of the short saphenous vein. A depression beneath the
condyles of the femur in front will be prominent and the nature of the
dislocation is evident upon inspection. Like other dislocations of the
tibia, reduction can readily be accomplished in recent dislocations by
traction and manipulation. Under no circumstances should this dislo-
cation be allowed to continue for any length of time, not even a few
days, before reduction is made. The limb should be kept at rest for a
few days until the swelling and inflammation have subsided, when a
knee-boot can be applied, which is drawn tightly to the knee, and
which prevents a recurrence of the condition. Where there is rupture
of the ligaments of the knee, it is best to keep the knee at rest for a
period of two or three weeks, to permit union of the torn ends of the
ligaments.

Dislocation of the Semilunar Cartilages is sometimes called a sub-
luxation of the knee. The injury is freouent and happens during
flexion with rotary motion at the knee. Pressure of the condyles, under
certain circumstances, tends to displace the cartilages. In a condition
of flexion, these cartilages are more movable upon the surface of the

306 DISLOCA TIONS.

tibia than upon extension, so that in a flexed condition a sudden wrench-
ing or spraining of the joint may lead to a displacement of the carti-
lage. The internal cartilage is more frequently displaced than the ex-
ternal. The extent of the displacement varies, and the coronary lig-
ament may, or may not, be ruptured. Displacement of' the cartilage
usually takes place anteriorly, but may take place laterally. In certain
cases, it is said to have been displaced into the intra-condyloid notch,
or to have been doubled upon itself.

Signs. — The first sign of the injury is a cracking sound, as if some-
thing gives way in the joint, which is accompanied by an intense sick-
ening sensation. The joint remains fixed in a position of flexion. The
limb can not be forcibly extended, because of the obstruction afforded
by the cartilage. Efforts at manipulation cause a sickening pain.
It may be that, more or less twisting of the leg in a position of flexion
will result in spontaneous recovery. The disarticulated cartilage forms
a prominence on the front of the joint. A history of the accident, to-
gether with the absence of other injury, will serve to complete the diag-
nosis.

Methods of Reduction. — The flexion should be exaggerated. Should
it be the internal cartilage which is dislocated, the operator places his
two thumbs upon the dislocated cartilage, while his hands grasp the
hamstring tendons, and an assistant makes extension and abduction.
Tbe extension and abduction should be forcibly made, while at the same
time vigorous pressure is made upon the luxated cartilage. Where the
external cartilage is dislocated, the same procedure is adopted, with
the exception that at the time of extension the lower leg is aclducted.
This manipulation should be successful in all cases. Operative treat-
ment is recommended in various texts for the removal of the cartilage
where there has been a failure in the attempts at reduction. This opera-
tive treatment consists in removing the cartilage under the strictest
aseptic conditions, or by fixation of the cartilage by means of aseptic
chromicized catgut sutures. In case of such operation, it is necessary
to drain the joint for a day or two after the operation. Manipulative
methods, if kept up some length of time, and judiciously applied, will
be successful in restoring the integrity of the joint in all cases.

Dislocations of the Ankle-joint. — Dislocations of the ankle are (a)
outward, (b) inward, (c) backward, (d) forward, and (e) upward. Be-
cause of the peculiar relation of the astragalus with the tibia and
fibula, fractures not unusually complicate these dislocations. Disloca-
tions laterally rarel}' occur without fracture, therefore in reality they
are fracture-dislocations, as is the case in Pott's fracture of the lower
one-fifth of the fibula, or Dupuytren's fracture. The diagnosis may be
difficult, and will require a careful examination, perhaps with the assist-
ance of the x-rays, to make an accurate diagnosis. The luxation is
usually readily reduced.

Dislocation Backward is more common than dislocation forward, and
usually takes place in jumping. Both malleoli may be fractured, while

DISLOCATIONS. 307

the astragalus is driven behind the lower extremity of the tibia. The
heel protrudes prominently. The lower extremity of the tibia may
rest upon the scaphoid or cuneiform bones.

Dislocation Forward is very common, and is not associated
with fracture of the bones of the leg. Apparently the foot is lengthened.
The tibia stands out prominently on the upper surface of the os calcis.
The heel is not so prominent as normally, and a depression exists
over the top of the astragalus.

Dislocation Upward. — In this dislocation, the astragalus, with
perhaps other bones of the foot, is driven upward between the
tibia and fibula, after the ligamentous attachments of these bones have
been forcibly divided. At first glance it may be denied that this dislo-
cation is possible, but competent observers attest to the fact that the
dislocation does occur. Widening of the malleoli, together with a short-
ening of the foot and leg, make the diagnosis easy. There is a
history of violent injury.

Treatment. — Dislocation of the ankle may be reduced by means of
extension, together with rotation, abduction, adduction, and flexion.
By extension and counter-extension the tense muscles are relaxed, and
the bones may be manipulated into position. In some cases, it is said
that it is necessary to divide the tendo Achillis in muscular subjects.
In fracture-dislocations, the fracture requires special treatment. Where
there is dislocation pure and simple, it is necessary to keep the foot
immovable, and to apply antiphlogistic measures, such as assisting the
return circulation, relaxing the tissues, and keeping the foot immova-
ble for ten days. After that time, manipulation of the joint, to prevent
adhesions and to reduce inflammation, will be found necessary. The
person should go about on crutches within a week, but for a considera-
ble part of the day the foot should be elevated, to assist the return
circulation.

Dislocation of the Astragalus. — Dislocations of the astragalus alone
deserve special consideration. They consist of a partial or complete
detachment of the bone from its normal connection. It may be
luxated either. anteriorly or posteriorly.

Anterior Dislocation is usually associated with more or less rotation,
which may be outward or inward. If the dislocation should be com-
plete, the bone will be found lying in front, of the ankle loose and read-
ily movable upon the scaphoid. The skin over the dorsum of the foot
is tightly drawn over the bone. The limb is shortened, while the
malleoli approximate the bottom of the foot. The lower extremity of
the tibia usually rests upon the articular surface of the os calcis, in-
stead of the astragalus. In the incomplete variety, the head of the bone
simply presses upon the scaphoid or cuboid. Only about half of the
articular surface is displaced from the tibia. Prominence of the bone
mav be felt in front of the ankle.

308 DISL Oca tions.

Backward Dislocation may also be complete or incomplete. Rotation
of the - bone may attend the injury. The bone may be readily felt
making a marked prominence above the os calcis, the degree of promi-
nence depending upon the degree of luxation of the bone. The diag-
nosis in either dislocation, forward or backward, with or without rota-
tion, complete or incomplete, is usually easy, providing the swelling is
not too extensive. It may be confounded with a sprain, and until the
swelling is gotten rid of, the diagnosis may not be accurately made.

Treatment. — Reduction is accomplished in the incomplete form
of dislocation by exaggerating the deformity, while the operator
presses upon the bone with his thumbs, extension being made at the
same time. In this manner the bone is forced into its normal location.
More or less rotation may be necessary. Not a great deal of force will
be required, except in muscular subjects, or where the bone is tightly
wedged in. In complete dislocations an anesthetic may be required.
If the case is seen early, a reduction can be accomplished without great
difficulty. In all dislocations, after some hours, great swelling ob-
literates the characteristic evidences of the injur}7, while the pain,
because of the pressure of the effused fluids, is intense. The joint-
renexes are exaggerated and muscular spasms occur, so that reduc-
tion of the dislocation may be difficult. Where there is violent inflam-
mation, an anesthetic may be necessary for a thorough examination.
In cases where the diagnosis can not be made, an x-ray examination may
assist in clearing up the diagnosis.

Subastragaloid Dislocations. — These dislocations refer to the forci-
ble separation of the other bones of the tarsus from the astragalus.
Generally the astragalus maintains its normal relation with the malleoli,
while the ligaments which attach the astragalus to the other tarsal
bones have been either considerably stretched, or ruptured. The dislo-
cations are produced by violent wrenching of the foot. The displace-
ment of the bones may be inward, outward, or backward, but
is usually backward and outward, or backward and inward. The
luxation is incomplete, and while being classified under trau-
matic dislocations, it properly belongs to partial dislocations. The
dislocation may even be compound, and yet not be complete. The
scaphoid is sometimes completely separated from the head of the
astragalus. Great deformity is the rule. The heel projects
prominently, while the anterior part of the foot is apparent-
ly shortened. As a rule, "he toes point downward, the heel being
drawn upward by contraction of the calf muscles. The tendo Achillis
is put violently upon a stretch, while beneath the skin on the front of
the foo'* the astragalus projects prominently. The anterior tibial ves-
sels and nerves are usually severely injured. The extensor tendons
may be so engaged about the head 'of the astragalus as to operate
aerainst reduction. When the bones are dislocated inward, the foot is
everted so that the outer malleolus stands out prominently, and the

a o

DISEASES OF THE SPINE. 309

normal projection of the internal malleolus is lost. The position of the
foot resembles that of equino-varus. When the tarsus is displaced out-
ward, the foot is everted, while the inner malleolus is prominent and a
depression marks the position of the external malleolus. The position
of the foot is that of equino-valgus. In either variety, the tendo
Achillis is put violently upon a stretch and is somewhat curved, depend-
ing upon the degree and nature of the displacement. Tenotomy may
be necessary before reduction of the dislocation can be made. Exten-
sion and rotation and an exaggeration of the deformity, with pressure
upon the projecting bone, will enable the operator to force the luxated
bones into position.

Dislocations of Other Tarsal Bones, as the cuneiform, scaphoid, or
cuboid, occur but rarely, and are the result of severe direct violence
and twisting of the foot. The diagnosis is usually easy. The treatment
is to reduce the dislocation and to keep the foot qniet, to give it rest
until the ligaments may be restored, since there may be a sinking down
of the arch of the foot, because of a giving way of the ligaments. This
condition of subluxation in the tarsal bones will result in a deformity
which interferes greatly in walking.

Dislocations of the Metatarsophalangeal, or the Phalangeal Articu-
lations, occasionally occur, but are easily recognized and readily re-
duced by extension and counter-extension. They are not sufficiently
serious to merit description. Subluxations may cause bunions, Mor-
ton's disease, or other affections.

DISEASES AND INJURIES OF THE SPINE.

Spina Bifida.

Spina bifida is a congenital condition due to malclevelopment of the
dorsal plates in embryo. The dorsal plates not having properly closed,
(the lamina, pedicles, spinous processes, and sometimes part of the
membranes of the brain and cord, fail to develop. The tension of the
fluid within the neural canal is such as to form a tumor. The only
structures lying over the spinal cord are the skin, and perhaps a little
connective tissue, or the membranes may lie directly in connection with
the skin. The tumor presenting is produced by a collection of fluid in
the subdural spaces, or subarachnoidal spaces, or from within the spinal
canal. Three forms of tumor are usually described.

A. Meningocele, which consists of a protrusion of the dura mater
and arachnoid, but contains no part of the cord or spinal nerves. The
posterior portion of one, two, or more vertebrae mav be absent. The
tumor may be of considerable size.

B. Meningomyelocele is a condition where the fluid distension is
beneath the arachnoid and dura mater, the wall of the tumor containing
these two membranes, together with the cord and spinal nerves. The
cord may be spread out over the side of the tumor.

310 DISEASES OE THE SPINE.

C. Syringo-myelocele is a condition where the fluid distension is
within the central canal of the spinal cord, so that the spinal cord is
spread out around the tumor. Certain spinal nerves which run down
some distance within the spinal canal before making their exit may be
included in the tumor, providing it is located in the lumbar region.

Signs. — The location of the tumor is in the middle line of the back,
over the lower part of the spine. It may be covered with healthy skin,
but very often it is apparently scarred. The vessels often are obliter-
ated and the tumor is translucent. In infants, if the tumor is com-
pressed, it will be noticed that the fontanels raise up. On coughing, or
crying, there will be a distinct impulse over the tumor. The edges of
the bones, which are the imperfectly developed lamina or pedicles, may
be felt. There is more or less paralysis and imperfect development be-
low the tumor, because of the pressure upon the nervous tissues. There
may be talipes, perforating ulcers of the foot, or more or less complete
anesthesia. The child may be the subject of hydrocephalus. The
prognosis is not good.

Treatment. — When the tumor is small, an elastic band may be ap-
plied, which will, perhaps, prevent its development. Treatment of
the parts below will be found of service. The circulation to the
atrophied muscles and partially paralyzed nerves may be increased, but
by no known methods can the ill-developed vertebrae be restored. Tap-
ping has been advised. Where the wall of the tumor is not very
thick, as it enlarges, which may happen in some cases, spontaneous
rupture may take place. If this occurs, the contents will escape from
the tumor and the meningeal fluid will continue flowing for some days,
when the opening will heal up. The tumor will reappear in a short
time. Tapping has been advised, but it will do but, little good, as the
tumor will quickly return. Enucleation of the sac has been advised
by some surgeons, but it is not known whether the operation is attended
by good results or not. The best that osteopathic treatment can do for
the affection is to prevent the atrophy of the muscles, and to increase
the blood supply to the areas of paralysis, or paresis, and to increase
the nerve impulses to the Aveakened structures. Where perforating
ulcers are present, usually osteopathic treatment will cause these to
heal up, but the condition can not be cured.

Tumors of the Spine. — ISTew growths are of rare occurrence in the
spine. They may consist of gummata, because of tuberculosis, or syph-
ilis, or fibromata, lipomata, or gliomata, may develop. Earely secondary
cancers of the spinal cord occur. Spinal tumor will not
cause any difficulty until it attains the size of a medium
sized marble. The symptoms are pain, more or less localized, followed
by progressive anesthesia, usually ending in paraplegia, monoplegia, or
evidences of ataxia. The symptoms are those of compression and irri-
tation of the spinal cord. The reflexes are at first exaggerated, after-
wards paralyzed. Following exaggeration of the reflexes, there is paresis

SPINAL CURVATURE. 311

of the muscles, followed by paralysis. Sometimes spasms of the muscles
form a prominent symptom, because of irritation. Occasionally, instead
of paralysis, there is a condition of contracted muscles, due to irrita-
tion of the motor cells. .Different locations of the tumor will occasion
different symptoms. The diagnosis is usually made by eliminating other
conditions which might cause the same symptoms. These other condi-
tions are hemorrhage within the spinal canal, compression from inflam-
matory products, and luxations. Should the diagnosis be accurately
made, which in most cases can be clone, the tumor should be removed
by a surgical operation. The technic of the operation is that of
laminectomy.

Osteomyelitis of the Vertebrae. — Osteomyelitis is a rare, acute, sup-
purative disease of the vertebral bodies. It is caused by infection
from the pus cocci, and is often associated with osteomyelitis of other
bones, or by infection of the viscera. The symptoms, in general, are
those of osteonryelitis of other parts of the body, with the exception
that the disease involves the spine, causing, perhaps, paralysis, also
sequestration of the bodies of the vertebrae and abscess formation.

Treatment. — The treatment is similar to that for osteomyelitis.
This disease does not include the chronic suppuration of the bodies of
the vertebrae, a condition which arises from other causes. Acute
osteomyelitis of the vertebrae occurs in ill-fed and ill-nourished chil-
dren, and is a very difficult disease to treat. As soon as pus is evident,
a free incision and good drainage, with antisepsis, should be made.
Likely, in each of these individual cases, a certain spinal lesion will be
found, which will account for the origin of the disease. The general
condition of the patient will demand treatment, as well as the specific
inflammatory process.

Spinal Curvature.

The more common curvatures of the spine are scoliosis, kyphosis,
and lordosis. Scoliosis, or lateral curvature, is most common in the
upper dorsal region. The curvature usually extends to the right. A
compensatory curve occurs in the lumbar region, while a second com-
pensatory curve may occur in the neck. There are cases where even
more curves are found in the spine. The intervertebral discs are un-
equally compressed, while the ribs form a great convexity upon one side,
and as a rule, are widely separated. They are more horizontal, and the
scapula is crowded forward with them. As a general rule, with the
lateral curvature there exists considerable rotation. This rotation may
be so marked that the side of the body of the vertebra may look directly
backward, while the angles of the ribs upon one side may occupy the
position of the spinous processes. While the ribs are greatly projected
upon one side, they are markedly depressed upon the opposite side, and
in some cases the thorax may be so distorted that the lower ribs upon
one side may touch the iliac crest. One breast is usually much more
prominent than the other.

312 SPINAL CURVATURE.

Cause. — The causes of spinal curvature are: A. Lesions of the
spinal column (bones and cartilages). B. Lesions of the muscles. C.
Lesions of other tissues.

A. lesions of the Spinal Column are: 1. Subluxations of the verte-
brae and. ribs interfering with the nutrition to the intervertebral discs,
or parts of the body of the vertebrae, thus causing maklevelopment. 2.
Luxations of the vertebrae and ribs affecting directly the blood and
nerve supply to the bones. 3. Fractures of the vertebrae. 4. Destruc-
tive osteitis or Pott's disease of the spine. 5. Spina bifida, etc.

B. Lesions of the Muscles are: 1. Muscular spasm, producing sub-
luxations, or luxations, as happens in torticollis. 2. Muscular con-
tractions, as occur in muscular rheumatism. 3. Muscular atrophy,
whereby the muscles upon one side of the spine are rendered weak,
when those acting upon the opposite side produce curvature. 4.
Muscular hypertrophy, where the muscles upon one side of the spine
become hypertrophied and stronger than those upon the opposite side.
5. Contractions from burns.

C. Lesions of Other Tissues are: 1. Collapse of the lung. 2. Pleu-
ritic adhesions. 3. Habitual one-sided position of the body. 4. Strauma,
rickets, etc. 5. Weakness and ill health.

Kyphosis, or posterior curvature, is produced by: 1. Eelaxed con-
dition of the ligaments. 2. Failure of development of the anterior
parts of the bodies of the vertebrae. 3. Pickets and ill-nourished
conditions. 4. Certain occupations and bad hygienic surroundings. 5.
Caries of the anterior portions of the bodies of the vertebrae.

Lordosis, or anterior curvature, is often congenital. It may be sec-
ondary to Pott's disease, hip-joint disease, or sacro-iliac disease. This
curvature is usually found in the lumbo-dorsal region.

Pathology. — In general, pronounced cases of spinal curvature
are found in persons whose general health is more or Jess affected. There
may be lesions accounting for this condition. The curvature is the re-
sult of subluxations, or luxations of the vertebrae. These are really
pathological dislocations. Curvature of the spine will affect the integ-
rity of the spinal nerve roots. These nerve roots will be more or less
impinged upon and the blood supply to the spinal cord more or less
arrested. The trophic influence of these nerves to certain of the tissue^
will be withdrawn. . This results in paralysis, and in disease of organs.

Treatment. — The treatment of curvature of the spine has been rev-
olutionized in recent years, and especially by osteopathic methods.
Formerly braces, plaster casts, the jurymast and other apparatus were
used to' correct curvature, while no attempt was made to increase the
nutrition of the weak and diseased structures. The results from such
treatment were unfavorable. Some authors now advise against the use
of what Dr. Still condemned }rears ago. An instance is as follows:
"Perhaps the most important advice to be given to the general prac-
titioner in relation to the treatment of this condition is caution against

DISEASES OF THE SPINE.

312

Fig. 107.

the use of braces, corsets, jackets, and other mechanical appliances,
which by confining the movements of the chest and supplying all arti-
ficial support in place of the muscle which it is desired to develop,
actually do great harm to many patients instead of good" (American Text
Book of Surgery, page 622). The curvature may be cured by means of
manipulation. Whatever cause exists, this should be removed. Luxated
vertebrae should be reduced: tense ligaments should be stretched, while
spastic conditions of the muscles must be relieved by proper manipula-
tive measures, such as rotating the vertebra upon its axis and removing
pressure on certain nerves. By securing a better blood and nerve sup-
ply to the structures outside of the spine, the curvature may be cured.
Many times the spinal curvature is looked upon as secondary to other

ailments, when, on the other hand, it is
primary, or, if secondary, it serves to keep
up the disease process. If the spinal
curvature is relieved, the disease usually
abates. If manipulative means are kept
up, the most obstinate cases may be cured.
Cases of complete paraplegia and of the
worst forms of paralysis have been entire-
ly cured and the patient restored to health
by correcting the spinal curvature.

Caries of the Spine, or Pott's Disease
is sometimes called tuberculosis of the
spine. It is claimed by the majority of
authors that this disease is tubercular.
The ground for calling this affection a
tubercular process is its clinical course.
The pathological conditions do not war-
rant the statement that the disease is al-
ways tubercular. There are some cases
which undoubtedly are tubercular.

The exciting1 cause of the disease con-
sists of blows, wrenches, or strains which
excite inflammation.
The predisposing causes to this affection are spinal curvature, sub-
luxations of the vertebrae, such as spinal lesions, which may consist of
lateral, rotary, or antero-posterior displacement, subluxations of the
ribs, and muscular contractions. These interfere, more or less, with the
nutrition of the parts where the disease arises. This interference in
the nutrition may be in the shape of an obstruction to the return circu-
lation and an impingement of the arterial circulation, or a more or less
interference with the normal flow of nerve force.

Other Causes are tuberculosis, syphilis, acute infectious fevers, or
infection by the pus germs.

Situation of the Disease. — Any part of the spine may be affected,
but usually the dorsal and lumbar portions are the parts involved.

Pott's disease of the spine with
abscess formation.

314 DISEASES OF THE SPINE.

The disease nearly always starts in the anterior portion of the body of
the vertebra, and may result in the destruction of the vertebral body
and the intervertebral substance, but the vertebral body is destroyed
before the intervertebral substance. The reason why the anterior part
of the bodies of the vertebrae is affected is because of the anatomical
relations. The blood supply to this part of the vertebral body is more
liable to interference because of displacement of the body of the ver-
tebra,, or because of rib lesions.

Pathology. — The tissue changes occurring in this disease are the
same as those occurring in caries of bone elsewhere, or in formation of
chronic abscess. For the pathology of which see Caries of Bone and
Chronic Abscess. Because of the habits of the person, contractures of
the muscles, rib lesions, and a more or less debilitated state, the circu-
lation to the anterior portions of the bodies of the vertebrae become
so affected that sprains, wrenches, bruises, or other injuries, cause an
inflammation which results in some form of caries. This may be caries
sicca, caries necrotica, or caries suppurativa (usually caries sup-
purativa). In Pott's disease of the spine, pus is the rule. When the
disease occurs in the cervical region, a postpharyngeal abscess arises.
When in the lower cervical region, the abscess may burrow laterally be-
tween the scaleni muscles and open above the clavicle. If the disease
is in the dorsal region, a dorsal abscess may occur, when the
pus may burrow into the viscera. When the abscess occurs in the
lumbar region, in the neighborhood -of the attachments of the psoas
muscle, a psoas abscess arises. In some cases sequestration of the
bodies of the vertebrae may occur. In other cases, the pus may form a
distinct abscess, and caseation, and absorption of the pus taking place,
the active symptoms disappear. The lamina, pedicles, and posterior
portions of the bodies of the vertebrae are rarely affected. The cord
membranes are never affected. They may be compressed because of luxa-
tions of the vertebrae, or the developing of inflammatory products, or
pus formation, but the disease process does not invade the spinal cord. It
more often affects certain nerves as they come off from the spinal cord,
so that the symptoms are localized and refer to the compres-
sion or irritation of certain nerves. The cord may be compressed to
some extent, giving evidences of spinal irritation, shown by contracture
of the muscles, or exaggeration, or interferences with reflexes, but
paralysis is rare.

Signs. — The signs of the disease are: 1. Pain. 2. Rigidity of the
spine. 3. Deformity. 4. Abscess. 5. Muscular spasm. 6. Paralysis.
The pain manifests itself variously. There is always a localized spot
over the diseased bone which is painful. Other pains are neuralgic in
character, and may be in the nature of referred pains — those produced
by the pressure or irritation upon a nerve. The pain is referred to the
distribution of the nerve, as, for instance, the genito-crural nerve may

DISEASES OF THE SPINE.

315

Fig. 108.

be affected, or the anterior crural, or some other of the lumbar nerves.
If the second and third cervical vertebrae are affected, the auricularis
magnus, occipitalis major and minor nerves will be affected, causing
pain behind the ear on the back of the head. The pain may be in the
nature of bilateral cramps. In grown people, the pain is in the nature
of headache, backache, and girdle-pains.

Rigidity of the Spine is a constant accompaniment of Pott's disease,
and is one of the earliest symptoms. It is produced by contracture of
the muscles and ligaments, brought
about by irritation. This of itself
operates against recovery, inasmuch
as it interferes with a proper circu-
lation of the fluids. When the low-
er part of the spine is affected, the
back is held stiff and causes a pecu-
liar gait, while the movements of the
body in sitting or stooping are great-
ly modified. The patient often be-
comes weak and supports himself by
extended arms upon his legs. In a
little child, this rigidity of the spine
can be tested by having the patient
lie prone while the legs are lifted.
Under normal conditions the spine
is fairly flexible. It is hardly neces-
sary for the benefit of the osteopathic
practitioner to describe the methods
of determining the rigid condition
of certain portions of the spine, inasmuch as his teachings include all
such conditions. Stiffness in the neck, caused by caries, will be evident
upon forced movements.

The deformity depends upon the part of the spine involved and
the extent of such involvement. In the lumbar region, when but one
or two vertebrae are involved, there may be no deformity appreciable
upon inspection, but palpation will reveal a lesion. This lesion may be
of a single vertebra, or three or four, and may be displaced laterally,
antero-posteriorly, or twisted. When several of the vertebrae are af-
fected, and there is extensive destruction of the bodies, there may be
angular deformity, or a considerable area may be markedly curved. In
the cervical region, much curvature is not common, but the lesion is
apparent. The most profound curvature is found in caries of the dor-
sal region. In the cervical region, the deformity present may manifest
itself as a twisting of the vertebra and a partial dislocation of the
articular surfaces.

Abscess in Pott's disease occurs in the majority of cases. The abscess
may reach large proportions, or it may be small The direction which
the pus may take will depend largely upon the part of the spine affected.

Method of testing the rigidity of the spine.
as occurs in spinal caries.

318

DISEASES OF THE SPINE.

Fig. 109.

Retropharyngeal or Postpharyngeal Abscess arises in caries of the
cervical vertebrae. It forms a soft, iluctuating mass in the back part
of the pharynx, and may cause difficulty in swallowing and breathing.
The pus may rupture into the pharynx, or it may burrow down behind
the esophagus into the chest and posterior mediastinum. It may bur-
row laterally, opening above the clavicle, or passing beneath the clavi-
cle behind the axillary vessels. If it ruptures
within the pharynx, and the opening becomes
septic, the disease may terminate fatally.

Dorsal Abscess. — The pus which forms in
caries of the dorsal vertebrae passes back-
ward between the vertebral ends of the ribs
underneath the erector spinae mass, forming
an abscess four or five inches from the spi-
nous processes. This abscess yields an impulse
upon coughing. There are cases where the ab-
scess burrows along the vessels and nerves
and appears where the lateral cutaneous
branches are given off on the side. In some
cases, it may pass down the spine, going un-
derneath the ligamentum arcuatum internum
and into the sheath of the psoas muscle,
forming a psoas abscess.

Lumbar Abscess is due to the pus passing
backward along the posterior branches of the
lumbar vessels and nerves. It appears on the
surface of the outer border of the erector
spinae mass and usually points in Petit's tri-
angle. Psoas abscess forms in the sheath of
the psoas muscle, passes underneath Pou-
part's ligament, forming a tumefaction on
the front and inner side of the thigh. It may
then burrow underneath the fascia lata, but
usually ruptures in Scarpa's triangle. The
pus appears at a point at the junction of the
middle and inner one-third of Poupart's liga-
ment and to the outer side of the femoral
vessels. The constitutional symptoms at-
tending the formation of these abscesses are like those attending the
formation of any chronic abscess. The pain depends entirely upon
whether the trunk of a sensory nerve is affected.

Paralysis and Muscular Spasm do not, as a rule, occur in the course
of spinal caries. The cause is often due to the formation of a mass
of inflammatory tissue beneath the posterior common ligament. This,
if the irritation is slight, will cause muscular spasm and pain, or
if the pressure is considerable, cause areas of anesthesia, or localized

Psoas Abscess, pointing in
Scarpa's triangle.

DISEASES OF THE SEINE. 317

muscular paralysis. The effect will depend largely upon the rapidity
of the development of the pressure. Where the pressure comes on very
gradually, the symptoms are those of sclerosis. Where it comes on rap-
idly, the symptoms indicate inflammatory softening. Where the paraly-
sis is sudden, it is due to hemorrhage, or luxations. In conditions of
paralysis, the disease is usually located in the upper dorsal region. Par-
aplegia, or paralysis of the body below, happens only in about one case
in fifteen. Paraplegic symptoms must be differentiated from those of
pressure upon nerve roots. The pressure upon nerve roots causes
neuralgic pains, or paresis, or paralysis of a limited area. In compres-
sion of the cord, motor and sensory symptoms are combined, but the
motor symptoms usually predominate. At first there is a dragging of
the toes, a loss of power in the legs, weakness of the sphincters, and an
exaggeration of the reflexes. Later on paralysis becomes complete, be-
cause of degeneration of the cord. Afterward, rigidity of the muscles
and a loss of the reflexes occur. In sacral caries there may be no de-
formity and but. little pain. An abscess may form on the buttock, or
in the groin, and may be bilateral. Where the abscess ruptures
of itself, mixed infection usually occurs, which is followed by hectic
symptoms, and should the patient's resistance be low, the case will likely
terminate fatally. Long continued suppuration is of itself exhausting,
while at the same time lardaceous disease, together with degenerations
in the organs, may set up, which terminate the case fatally. The pus
may burrow into the viscera and cause death by rupture, or meningitis
may be set up, or a condition of pyemia or multiple abscess formation
may develop upon the absorption of pus germs. In paraplegic cases,
bed sores often operate as a complication, while septic cystitis may
bring about a fatal termination from exhaustion.

Diagnosis. — The diagnosis of the disease is easy. A psoas
abscess may be differentiated from an abscess of the hip by the fact
that if it ruptures in Scarpa's triangle the sinus extends back up the
psoas muscle, while in a hip abscess, should it rupture in the groin, the
sinus will extend backward and downward. It may be differentiated
from an iliac abscess by the presence of spinal disease. Occasionally
abscess of the appendix, in chronic appendicitis, ruptures in this same
neighborhood. A careful examination will enable the physi-
cian to distinguish between them. It may be confounded with femoral
hernia (see femoral hernia).

Treatment. — A. Osteopathic. — Like chronic abscess, or chronic bone
disease, this affection has its origin in the fact that the tissues of the
anterior parts of the bodies of the vertebrae have been partly deprived
of their nutrition because of luxated ribs, or, subluxated or twisted
vertebrae. These displacements cause direct pressure on the small
arteries, depriving the diseased, part of its proper blood supply. The
question as to whether the diseased process is tubercular or a degenera-
tive one does not in any way modify the treatment, since the deposit

313 DISEASES OF THE SPINE.

of the tubercle is dependent upon the lesions. It is not possible to in-
troduce into the diseased area any drug which will destroy the germ,
if present. The only treatment is to build up the tissues so that they
ma}r, after a time, resist the ravages of the germs, or destroy them.
Where the disease depends partly upon a general nutritive disorder,
the removal of the lesions directly responsible for the carious process
will not effect a cure. Other lesions in these cases will be found respon-
sible for the general depraved condition of the system. Where the cases
are seen early, no deformity apparatus will be found necessary, but the
lesions should be corrected and the blood supply encouraged through
the vasomotors. In cases seen late, after abscess forms, the same treat-
ment must be followed out. The abscess may be opened after it points
and rupture is imminent. Good drainage must be established and the
abscess cavity must be washed out daily with an antiseptic solution
1 :2000 bichloride of mercury, or 1 :40 carbolic acid solution. This will
not always be necessary. Only where streptococcic infection seems likely
will it be demanded. Where great deformity and paralysis have oc-
curred, the disease will require treatment for from six months to two
years. Many cases will get well in four or five months after abscess has
formed. The patient must have the benefit of a good substantial diet,
fresh air, and sunshine. As far as can be done, apparatus to limit the
use of the spine, as the jurymast, plaster casts, etc., should be avoided.
The results of the treatment are uniformly good. As a rule, the de-
formity and paralysis can be overcome in time. Hopeless cripples of
years' standing have been entirely cured by the above methods.

B. Surgical. — In view of the very favorable results obtained by
osteopathic treatment in spinal caries, operative measures such as ad-
vised by Treves and Halsted are not necessary. In the case of a psoas
or lumbar abscess, before much pus is formed, aspiration of the abscess
may be done under aseptic conditions, while osteopathic treatment
is regularly kept up. Usually this will be successful. Where it is not
successful, the abscess should be allowed to point. After pointing it
should be freely opened, the cavity thoroughly washed out, and good
drainage established. The abscess cavit}^ should be washed daily with
an antiseptic solution until the discharge has apparently ceased. Drain-
age should be provided for, while the osteopathic treatment is con-
tinued. Favorable results will be obtained. The application
of plaster jackets, or extension of the spine, are methods not advisable.
Formerly, many surgeons advised forcibly straightening the spine to
overcome the deformity, but this is not needed. Operations for the re-
moval of the carious bone and all of the diseased tissues have not been
attended by results sufficiently favorable to warrant such procedure.
More or less ankylosis of the spine will take place because of the forma-
tion of inflammatory tissues and a gluing together of the lamina and
articular processes, the ligaments of the spine remaining intact. The
deformity and ankylosis resulting may be more or less relieved by ap-
propriate treatment. The patient should have the benefit of out-door

INJURIES OF THE SPINE. 319

air and a nourishing diet. The secretions should he attended to, while
pressure symptoms may be relieved by a correction of the deformity
and relief of the inflammation. Septic cystitis developing demands irri-
gation of the bladder by an antiseptic solution.

Osteo-arthritis. — Arthritis deformans of the spine is a rare affection.
The margins of the bodies of the vertebrae become thickened and en-
larged, resulting in more or less ankylosis of the spine. This ankylosis
may extend even to the ribs, so as to render them almost entirely im-
movable. The cause of the disease is obscure. The symptoms will
depend upon the amount of involvement of the spinal nerves. Paralysis
and neuralgic pains are the rule.

Treatment. — Heretofore no favorable results have been reported in
the treatment. The osteopath should remove whatever lesions he finds.
Whether or not these wilt be attended by good results will depend upon
how early the case is seen.

Dislocations of the Spine may be complete, or incomplete. They are
more common in the cervical region, but may occur in the dorsal and
lumbar regions. It has been disputed by many that complete disloca-
tions of the lumbar spine may take place without fracture, but unques-
tioned cases have been found upon autopsy (See American Text Book
Surgery, p. 646). Dorsal dislocations occur in the lower part of the
dorsal region most frequently. Partial dislocations of the spine are the
rule, and are believed many times to play a great part in disease pro-
duction, sometimes operating as the direct cause of disease, at other
times as the indirect cause. The luxations may be bilateral, or unilat-
eral. Bilateral dislocations may be produced by forced flexion, or exten-
sion, and the dislocation may be forward, or backward. It is the rule
to speak of the upper vertebra as the one dislocated. In complete for-
ward dislocations, the inferior articular process will rest on the pedicle
of the vertebra below at a point between the articular process and the
body. In backward dislocations, the superior articular process will rest
between the inferior articular process and the body of the vertebra
above, In this condition there may be little or no pressure upon the
spinal cord, but there will be pressure upon the nerve roots as they
leave the spine, hence the paralysis may be only limited. In some cases,
the paralysis may be extensive, depending upon the amount of injury
to the spinal cord. Unilateral luxations are produced by extreme lateral
motions of the spine, with or without rotation. In such cases, it is much
less likely that there will be pressure upon the spinal cord. There may
he pressure only upon a single nerve as it passes out of the inter-
vertebral foramen. Tbis pressure may be evidenced by pain, or by
paralysis.

The causes of the dislocations are the same as dislocations in other
parts of the body, forced movements, muscular contractions, direct and
indirect violence, and wrenching or twisting of the spine. In incom-
plete dislocations, more or less pressure is made upon the roots of the

320 INJURIES fiF THE SPINE.

spinal nerves, cutting off the nerve supply to certain structures, making
a weak point, thus permitting the development of disease.

The diagnosis of these conditions may be made by palpating the
articular processes and by noticing the general alignment of the spine.
The transverse or articular process may be palpated and luxations can
be made out. The spinous processes will not always give an accurate
idea of the positions of the bodies of the vertebrae, inasmuch as they
may often be absent, twisted, or deformed, indicating that there might
be curvature, or luxation, when there is none. Usually the symptoms,
direct or reflex, are sufficiently pronounced to lead one to investigate a
certain part of the spine. Upon close examination, a subluxation, or
complete luxation, may be made out.

Reduction. — These luxations are reduced by manipulation. The
manipulation consists, in the main, of exaggerating the deformity, then
catching the luxated bone with the thumb, or finger, the body is rotated,
and the bone pushed into place by firm pressure. In general, this ap-
plies to all of the vertebrae. Reduction can easily be accomplished
without injury to the spinal cord. It was the former practice of physi-
cians of other schools to allow these luxations to remain, for fear death
would be produced by attempts to effect reduction. Complete disloca-
tions of the atlas and ads have occurred, reduction has been made, the
person afterward continuing in good health. Subluxations of these
vertebrae are much more common, and by the osteopathic practitioner
will bear an exhaustive study.

Fractures of the Spine are usually in the nature of a fracture-
dislocation; that is, a fracture accompanied by dislocation. The most
common site is in the dorsal and lumbar regions. Dislocations of the
spine are more common in the upper part of the column.

Cause. — The cause of the fracture is direct and indirect violence.
Direct violence, by blows, or heavy falls, where the force is transmitted
from behind directly upon the spinal column, or by falls upon the but-
tocks or extended legs. The nature of the fracture varies with the kind
of violence producing it.

Nature of the Injury. — When the fracture is produced by direct vio-
lence, the inferior articular processes may be broken off and the verte-
brae displaced forward. This results in rupturing of the anterior com-
mon ligament. The spinous processes, laminae, or pedicles, may be
broken without fracturing the bodies of the vertebrae. This is the rule
in fractures from direct violence. In fractures from indirect violence,
one or two vertebrae may be fissured, the bodies usually being
affected, inasmuch as the chief force is directed upon them. As a rule,
the transverse, articular, or spinous processes are not affected, nor are
the laminae or pedicles. The displacement of the vertebrae may be
much, or little.

Nature of the Injury to the Cord. — The importance of a condition of
fractured spine is not so much the injury to the vertebrae as it is the injury

INJURIES OF THE SPINE. ■ 321

to the cord. The cord may bo torn asunder, which will result in complete
and permanent paralysis of the structures below that point. It may
be compressed so that its conductivity is only temporarily suspended.
In other cases, fractures of the spine may occur without any paralytic
symptoms, nor is the primary injury to the spinal cord always of the
greatest importance. The nature of the inflammatory reaction which
follows is, perhaps, of greater importance. The functioning of the
spinal cord is usually destroyed by inflammatory softening. If the in-
jury is extensive, this inflammatory softening is more likely to occur.
Absolute paralysis of motion, sensation, and the reflexes below may be
followed by a complete recovery with proper treatment, providing the
inflammation is not too great.

Symptoms. — The symptoms of fracture of the spine vary, accord-
ing to the region injured, and according to the degree of compression
of the cord. The clearest mental picture may be obtained from con-
sidering a fracture at a single location. In fracture of the upper or
mid-dorsal region the symptoms are, in the main, as follows: There
is paralysis below, more or less complete — paraplegia. Immediately
above the site of injury, there quickly appears a zone of hyperesthesia.
The intercostal and abdominal muscles are more or less paralyzed,
so that respiration is carried on chiefly by the diaphragm and the elastic
and involuntary muscular tissues of the lung, the abdomen rising and
falling with the action of the diaphragm. There is paralysis of the
sphincters, the urine at first being retained, but after the bladder be-
comes distended, it dribbles away. There is incontinence of feces.
In the male, priapisms are liable to occur, especially upon using a
catheter. There may be a spastic condition of some certain groups of
muscles, while others raay be completely paralyzed. Some of the deep
reflexes may be present. Evidences of the reflexes returning, is a sign of
the conductivity of the cord returning. After a few days,
bronchial troubles will arise, or, if the fracture is high up, cardiac symp-
toms may appear, because of injury to the vasomotor fibres in the upper
dorsal region. The bronchitis will end fatally in a few days. If the
patient escapes these troubles, he may live two or three weeks, when
secondary complications, such as bed-sores, cystitis, etc., will cause the
case to terminate fatally. Bed-sores are the result of the dribbling away
of the urine, the bed-clothing being continually saturated with the
urine, which decomposes and brings about a foul condition. A little
scratch, or slight irritation of the skin, will result in bed-sores which
arc very difficult to heal. The bed-sores are partially the result of the
irritation of the urine, and partially the result of vasomotor distur-
bances and interference in the nerve influence to the tissues.

Cystitis. — Because the bladder is deprived of the proper nerve and
blood supply, and because micro-organisms are likely introduced into
the bladder with a catheter, decomposition of the urine may take place.
It becomes ammoniacal and will contain toj)j mucus and pus. The ab-
sorption of this pus brings about a septic condition. This in-

322 INJURIES. OF THE SPINE.

flammation may extend up the ureters and produce pyonephrosis
or a suppurative condition of the kidneys. This cystitis is usually
fatal. Sometimes bed-sores and cystitis will occur conjointly. The
bed-sores are best treated before the sore appears, by sponging the tis-
sues off with strong alcohol once or twice daily and dusting talcum over
the parts, so as to keep them dry, or, as each small pimple appears, apply
oxide of zinc ointment. After the sore appears, it should be dressed
once or twice daily with antiseptics. A solution of 1:20 carbolic acid
for a time, then 1:2000 corrosive sublimate. After the sores are thor-
oughly washed, boracic acid may be dusted in them, or aristol, or a little
balsam of Peru applied on cotton. Gauze and cotton may be applied to
the sore and held in place by adhesive strips. A water-bed is the most
useful appliance in the treatment of these cases. Cystitis is best treated
by washing out the bladder with a solution of boracic acid (ten grains
to the ounce) once or twice daily.

Terminations. — A. In the cervical region. If the fracture is of any
of the four upper cervical vertebrae, death is liable to occur, because of
paralysis of respiration.

B. Lower cervical and upper dorsal region. Hemorrhage into the
cord may extravasate upward, pressing upon the roots of the phrenic
nerve and producing death, or a low bronchitis may develop in a few
days. Bed-sores, cystitis, etc., usually cause the case to terminate fatally
within three or four weeks.

C. Middle and lower dorsal region. If the person survives the in-
flammatory reaction which follows the injuiy, he will partially recover,
and in some cases, almost complete recovery may occur, leaving only
some deformity of the spine as an evidence of the fracture.

D. Lumbar region. In the lumbar region, a fracture with disloca-
tion may occur without any paralytic symptoms. Below the second
lumbar there will be no injury to the cord, but the cauda equina will
suffer. There may be partial or complete paralysis of a group, or groups,
of muscles.

Prognosis. — The prognosis will entirely depend upon the nature of
the treatment. Osteopathic methods are superior to those of any sys-
tem of treatment.

Treatment. — A. First, rest until fibrous and bony union has oc-
curred.

B. Manipulative measures to increase the blood supply to the parts
affected.

C. Guard against cystitis and bed-sores, with attention to the secre-
tions. In the treatment of bed-sores above mentioned only surgical treat-
ment has been given. The osteopathic treatment is of greater import-
ance. Even with the strictest asepsis, a good recovery can not be ob-
tained unless nature herself can produce it. Osteopathic treatment means
to assist nature in that it increases the blood and nerve supply to the
affected areas. Conaestion of the inflamed area of the cord should be

INJURIES OF THE SPINE. 323

relieved, and the relieving of this congestion of the inflamed cord
brings about the recover}' of its conductivity. This is followed by a
better nerve and blood supply to the tissues generally, so that bed-sores
are avoided. Extensive bed-sores, attended by necrosis of large masses
of the tissues involving the erector spinae mass, denuding the iliac
bones and the lumbar spine, in fact, extending over the entire lower
back, have been successfully treated by osteopathic methods after all
hope had been given up by eminent surgeons. This but illustrates the
osteopathic principle. In almost all cases of bed-sores, unless there is
absolute paralysis of the tissues below, the sore may be readily healed,
if simple cleanliness is maintained and appropriate osteopathic treat-
ment is administered. This osteopathic treatment consists in increas-
ing the blood supply to the sore, and in gently manipulating the spine,
so as to increase its blood supply if required, or to relieve the conges-
tion, as the case may be, or to reduce any luxation present. Where the
case is seen early during inflammatory softening, appropriate osteo-
pathic treatment will prevent the appearance of the bed-sore.

Concussion of the Spine consists of a molecular displacement of the
anatomical elements of the spine. It is a disarrangement of the cells
because of severe jarring, as occurs in railway accidents. In some
cases, there may be punctuate hemorrhages, or even lacerations, at-
tended by paralysis, or the injury may be simply a partial dislocation,
more or less interfering with the blood supply to the spinal cord itself,
rendering it anemic, resulting in paresis. Where paralysis occurs, it
is likely due to hemorrhage, or laceration. The condition of railway
spine is the result of certain spinal lesions. The s}rmptoms vary
in the different cases, according to the lesions present and to their
length of standing.

Treatment. — In concussion of the spinal cord, or in conditions of
railway spine, the treatment is to remove the lesions present. If the
lesions are not of too long standing, the prognosis is favorable.

Compression of the Cord. — Compression of the cord is produced by
(1) dislocations, (2) hemorrhages, (3) inflammatory products, pus, etc.,
(4) tumors, (5) fractures. The differential diagnosis between these condi-
tions is usually easy. The evidences of inflammation and pus are
sufficiently plain and have been discussed elsewhere. The presence of
the fracture, or dislocation, may be determined by the deformity. In
the case of dislocation, the diagnosis is made by the alteration of the
alignment of the vertebrae and by crepitus, in case of fracture of the
spine. The symptoms of compression vary according to the degree
of compression and the part of the spine affected.

Traumatic Hysteria. — Traumatic hysteria, or a hysterical condition
the result of injury, always bears with it the element of suggestion;
furthermore, the stigmata of hysteria will be found present. There are
evidences of a neurosis. There are numbers of these cases where the
removal of a lesion will cure the case, but the prognosis should be

324 INJURIES' OF THE HEAD.

guarded. Many times the patient will be apparently helpless and the
removal of the lesion will produce remarkable recovery. As to whether
or not the lesion will produce the symptoms in question, will be evident
to the observer. Inasmuch as the patient has no knowledge of the anat-
omy, the symptoms which are simulated will not be in accordance with
the anatomy.

Operations on the Spine consist in operations for tumor, or lami-
nectomy, for the removal of pieces of bone or foreign bodies pressing
upon the spinal cord.

DISEASES AND INJURIES OF THE HEAD.

Contusions of the Scalp. — Contusions of the scalp, if sufficiently
severe, will cause extravasation of blood. This extravasation may take
place between the aponeurosis of the occipito-frontalis and the perios-
teum, or may take place beneath the periosteum. In any case, it forms
a puffy tumor. The blood may coagulate, afterward liquefaction may
follow, and a sort of cystic tumor result. The tumor will dis-
appear by absorption. A hematoma may be produced by the blade of
the forceps in instrumental delivery of a child. The diagnosis can be
made without difficulty by running the finger around along the edge
of the tumor, gradually encroaching upon it. The blood will be felt to
give way, and there will be no erosion of the bone. In the formation
of a cold abscess, there will be erosion of the bone and a ridge
of inflammatory tissue around the edge of the tumor. If suppuration
of the tumor occurs, it should be opened and freely drained. Where
the tumor persists, the contents may be aspirated. Manipulation, such
as loosening the tissues about the tumor, relieving contracted muscles
and fascia of the neck, to assist the return circulation, will secure ab-
sorption of the fluid.

Wounds of the Scalp. — Wounds of the scalp are of the varieties
of wounds in other soft tissues. Two dangers beset wounds of the scalp
Avhich may not be present in wounds of other parts of the body. These
dangers are:

1. Hemorrhage, because of the extensive blood supply.

2. Sepsis, inasmuch as the scalp is an unclean part of the body.
Sharp hemorrhage will occur from wounding the anterior or posterior
divisions of the temporal artery, or branches of the occipital artery.
This hemorrhage can be readily arrested by compression, but where it
is very severe, the artery should be caught up with hemostatic forceps
and the end of. the vessel tied. If the wound is extensive, it is neces-
sary to provide for drainage, which should be at the most dependent
portion of the wound. , Small scalp abrasions will require no suturing,
but extensive wounds will require a few* sutures. The number of
sutures should be f ew, and the distance between them greater than in
other parts of the body. A small cicatrix will do no harm, unless it is
on a part of the scalp where there is no hair. The wound should be

INJURIES OF THE HEAD. 325

rendered aseptic by thoroughly washing with antiseptic solutions, the
hair along the margins of the wound should he shaved off, and the skin
approximated. The wound may then he dressed with boracie acid,
borated gauze and cotton. A compress may be applied by means of
layers of gauze and a mass of cotton, the bandage being applied suf-
ficiently tight about the head to keep the dressing in position. These
wounds usually heal ver}- quickly, providing there is no sepsis, since
there is a luxuriant blood supply. Should the wound become unhealthy,
it must be freely opened by removing the sutures and every part
thoroughly washed with an antiseptic solution.

Contusions of the Bones of the Skull. — Contusions of the bones of
the skull are not serious in the ordinary healthy individual, but in per-
sons the subject of tuberculosis, or s}rphilis, necrosis of the bone may
occur. This may be serious. These contusions will require no special
treatment.

Fractures of the Skull. — Fractures of the skull may conveniently
be divided into :

x\. Fractures of the vault.

B. Fractures of the base.

Fractures of the Vault of the skull are nearly always produced by
direct violence. Fractures by indirect violence may occur, as by contre-
coup. The varieties of fractures are, in general, those of other bones.
Tbe most common are fissured, stellate, depressed, and punctured.
Elevated fractures may occur in military, but rarely in civil, practice.
The fracture may be simple, or compound, depending upon whether
there is a wound extending into the site of fracture.

Condition of the Parts. — This will vary according to the nature of
the fracture. A simple fissured fracture of the skull may be attended
by no signs whatever save that of a bruise of the soft tissues. In stel-
late fractures, several lines of fracture extend out in different direc-
tions from the same point. These irregularities may be felt. In de-
pressed fractures, the depression may be round, or oblong, the "pond
and gutter" fracture of the old writers. The fracture may be fissured,
with one fragment depressed, or both sides of the fissure may be de-
pressed. The fracture may be extensive, traversing the parietal, fron-
tal, and temporal bones. Where the fracture is compound, the diag-
nosis is easy, but where it is simple, unless the fracture is ele-
vated, depressed, or punctured, it is difficult to determine. The only
other symptoms indicating fracture may be evidences of compression.
Where the case is doubtful, it should be carefully watched, and if sec-
ondary symptoms, such as headache, epilepsy, evidences of neuritis, etc.,
develop, a flap should be raised and the skull trephined at the point of
injury. In general, where there are evidences of depressed bone, the
chisel, or trephine, should be brought into use. The case should not be
allowed to continue until traumatic epilepsy develops. After epilepti-
form seizures hav^ developed, the operation may not be attended by

326

INJURIES OF THE HEAD.

good results. In some cases of compound or depressed fracture, there
may be. extensive destruction of the brain substance, or a fragment of
the fractured bone may extend down through the dura mater, lacerating
or puncturing the brain. In these cases, a flap should be raised, the
loose pieces of bone removed, the lacerated tissues placed in normal
position, the dura mater sutured, and the periosteum having been sep-
arated from the loose fragments of bone, should be sutured over the
opening and drainage established. If the wound is extensive, the
strictest asepsis should be maintained, inasmuch as septic meningitis
may develop. If possible, drainage should be dispensed with, as it ren-
ders infection more liable. In any case, it should be removed early.
Every possible attempt should be made to have the wound heal by first
intention.

Fractures of the Base of the skull may result from direct, or indirect,
violence. Fractures from direct violence are caused by blows or falls

directly upon the skull.
Fig. 110. Fractures from indi-

r e c t violence occur
where a person falling
from a great height
alights on the feet or
buttocks; the force is
transmitted through the
spinal column to the
base of the skull, which
is fractured.

Site of Fracture. —
The fracture may ex-
tend in any direction,
through the (a) anter-
ior, (b) middle, or (c)
posterior fossa, or two
of the fossae may be
implicated in the same
line of fracture.

Anterior Fossa. — The
line of fracture may
extend through Vae or-
bital plates, or through
the cribriform plate of
the ethmoid, so that
hemorrhage may take place through the nose, or effusions of blood may
take place within the orbit and appear beneath the conjunctiva. Paraly-
sis of some of the nerves which enter the orbit may occur.

Middle Fossa. — Fracture of the middle fossa usually involves the
middle part of the petrous portion of the temporal bone, or may involve

Fracture at the base of the skull.

INJURIES OF THE HEAD. 327

all of the bones. The fracture may extend into the tympanum by
lacerating the membrana tympani, and may open into the meatus audi-
torius externus. The lateral sinus may be implicated, or branches of
the middle meningeal artery being ruptured, blood may effuse into the
middle ear and come out of the external ear. Blood extravasations
within the skull, or pressure of fragments of the bone may involve some
of the cranial nerves at their exit.

Posterior Fossa. — The fracture usually extends through the fora-
men magnum. It may extend into the petrous portion of the temporal
bone, or the fracture may take place through the basilar portion of the
occipital bone and by rupturing the mucous membrane beneath, hem-
orrhage will take place into the pharynx. Certain of the cranial nerves
will also be affected.

Symptoms. — The symptoms ma^ be divided into (A) General and
(B) Local.

The general symptoms of fracture at the base of the skull are those
of compression of the brain.

The local symptoms are:

1. The escape of cerebrospinal fluid. The most characteristic
feature of this symptom is the large quantity of the fluid escaping.
The quantity is variously estimated by different writers at from one
to three or four pints in twenty-four hours, so that numerous dressings
will be required to absorb the flow. The fluid is clear and somewhat
resembles serum. A chemical analysis is hardly necessary to determine
whether the fluid is cerebrospinal or not. The points from which the
escape of this fluid may be made, are wounds, the nose, mouth, and ear.
The escape of fluid may take place from wounds when the fracture at
the base of the skull is compound. It may take place through the nose,
when the fracture extends through the cribriform plate of the ethmoid.
It may take place through the mouth, when the fracture extends into
the vault of the pharynx. It may take place through the ear, when
the fracture extends entirely into the middle ear and the membrana
tympani is lacerated.

2. Blood Symptoms. These consist of hemorrhage and blood effu-
sions. Hemorrhage is of little value as an indication of fracture at the
base of the skull, inasmuch as the flow of blood is no more severe than
when there is but a Avound in the soft tissues, but blood effusion is of
more value. Blood effusions may be subconjunctival in fractures
through the orbital plates, and the effusion of blood takes place in the
orbit, or they may be about the mastoid process in fractures of the pos-
terior fossa, or the blood effusions may take place in the suboccipital
region. Blood effusions in these localities, without evidence of local
injury, are an indication of fracture of the base of the skull.

3. Paralysis of the Cranial Nerves. These may be manifest in
strabismus, ptosis, Bell's paralysis (where the facial nerve is implicated),
the pupils may be irregular and dilated, there may be diplopia, or there

328 CONCUSSION, OF THE BRAIN.

may be paralysis of accommodation. Where the patient is not uncon-
scious, the latter symptoms are of importance, but where the patient
is unconscious, they may not be of as much value.

Treatment. — The treatment of fracture at the base of the skull is
rest and attention to the secretions, together with local treatment of
the wound and manipulation, in general, to assist the return circulation.
ISTo drugs will be found of any advantage. There are cases where the
patient is delirious and more or less irritable, but under no circum-
stances should morphine, alcoholic stimulants or other drugs be allowed.
If the person survives the early compression, absorption of the fluids
may be secured, and the paralytic and other symptoms will gradually
disappear. The prognosis is unfavorable, but many cases recover.

Concussion of the Brain. — Injury to the brain itself is manifest by
certain symptoms which are classified, as a rule, under two conditions,
concussion and compression. The difference in the pathology of these
two affections is not always well defined, and the symptoms vary.

Concussion is a condition of extensive jarring of the brain. The
tissue elements of the brain are shaken up and the connections between
the cells and groups of cells are for a time suspended. It may be de-
scribed as a molecular displacement of the brain elements. In some
cases there may be punctuate hemorrhages; others describe the condi-
tions as a vasomotor disturbance. A person suffering from concussion
is popularly said to have been "knocked silly," or "stunned." The
severity of the symptoms varies with the severity of the injury to the
brain. There may be cases where the person is temporarily "queer,"
and may stagger about and be unable to speak for a little time, and
will appear as if drunk, but consciousness will quickly return and the
queer feeling disappear. Pronounced cases are attended with severe
symptoms, which may be classified as follows :

J. State of Mind. The person is more or less unconscious of his sur-
roundings. In mild cases, he may know something of what is going on
about him, but in severe cases, he knows nothing. Under all circum-
stances, he may be aroused to make an intelligent answer in monosylla-
bles, as "yes" or "no."

2. Skin. The skin is pale and cold, and the extremities are cold.
The body-temperature may be subnormal.

3. Muscular Symptoms. There may only be a giddiness, or a giving-
way of the muscles, or there may be complete muscular relaxation.

4. Respiration. Respirations are shallow, quiet, and a little more
rapid.

5. Pulse. The pulse is small, soft, irregular, and more rajaid. The
heart is fluttering.

6. Pupils. The pupils react to light. They may be dilated, or con-
tracted, but are unequal.

7. Paralysis. Paralysis of any part is rare, and if it occurs, is only
temporary. There may be muscular twitchings in certain muscles.

COMPRESSION OF THE BRAIN. 329

There are severe cases of profound concussion in which there is evidence
of great cortical irritation. This is manifest by the person shunning
light and curling up in bed, and by more or less rigidity and twitching
of the muscles. It may be almost impossible to open the person's eyes,
as it causes pain.

8. Urine and Feces. The urine and feces may both be voided in-
voluntarily.

9. ISiausea and Vomiting. Nausea and vomiting appear late,
and are favorable signs, as they are an evidence of reaction which they
precede.

Reactionary Signs. — Eeactionary signs are, as indicated, vomiting,
followed by headache, lassitude, insomnia, low spirits, perhaps hysteria,
and in severe cases, epilepsy and insanity. The longer the person re-
mams unconscious, the more likely is the mentality to be seriously
affected.

Treatment. — The treatment of concussion consists of equalizing the
circulation and the proper restoration of the vasomotor impulse. In
conditions of congestion of the brain, this congestion should be re-
lieved. Cases may be brought out of concussion by manipulation of the
bowels, which attracts the blood to the splanchnic area. Under no
circumstances should alcohol be given. The application of hot water
bottles to the abdomen and legs and restoring the circulation
by treatment in the neck and upper dorsal region, together with rest
and quiet, are all that is required. Enemata of hot water, or hot milk,
after the lower bowel has been evacuated, is advised. A few drops of
ammonia on a handkerchief may be of some service. Even if obstinate
wakefulness and cortical irritation are manifest, no opiates should be
allowed. Sleep can be produced by equalizing the circulation. It is
believed, in concussion, that the chief difficulty is the suspension of the
vasomotor function to the cerebral vessels. Undoubtedly in many of
these cases, cervical lesions will be found, and if these are reduced, the
concussion will disappear. It is believed that many of the cases which
are described as concussion are the result of displacement of the atlas
or some of the cervical vertebrae obstructing the return circulation.

Compression of the Brain. — Compression of the brain is produced
by the following conditions :

1. Fractures, as depressed fractures of the vault, or fractures at
the base of the skull. 2. Intracranial hemorrhage. 3. Tumor. 4. Pus,
as in abscess formation. 5. Inflammatory exudates. 6. Foreign bodies.

Symptoms. — 1. State of the Mind. The state of mind in compres-
sion of the brain is usually coma. The person may emit articulate
sounds, but they are not intelligent, in contradistinction to concussion
in which a reply can be obtained by speaking loudly in the ear.

2. Skin. The skin is hot and perspiring, while the face is flushed.
The temperature may be elevated, or may be subnormal.

330 COMPRESSION OF THE BRAIN.

3. Muscular System. In general, there is a loss of all voluntary
motion.

4. Kespiration. Inspirations are slow, deep, and noisy, because of
paralysis of the soft palate, which flaps back and forth during respira-
tion, and the buccinator muscles being paralyzed, the cheeks flap in and
out.

5. Pulse. The pulse is full and bounding. It may be slow, or rapid,
but is usually strong. It may be irregular.

6. Pupils. The pupils are iixed, and will not react to light. They
may be regular, or irregular, dilated, or contracted.

7. Paralysis. Paralysis exists and may be extensive, in-
volving one entire side — hemiplegia — or it may be limited to a member
— monoplegia. There may be paralysis of some one of the cranial
nerves, producing strabismus, ptosis, Bell's paralysis, etc.

8. Urine and Bowels. There is incontinence of feces and
urine.

9. Nausea and Vomiting. Nausea and vomiting are unfavorable
signs, indicating involvement of the base of the brain or medulla.

Differential Diagnosis. — Coma, present in compression of the brain,
may be simulated by comatose conditions arising in :

1. Apoplexy. 2. Uremia. 3. Diabetes. 4. Opium poisoning.

5. Alcoholic intoxication. 6 Epilepsy. 7. Hysteria.

Confusion in the diagnosis is not so liable in private practice as in
hospital practice.

Apoplexy. — Apoplexy may be ushered in by convulsive movements.
Hemiplegia is the rule. The temperature may be subnormal. It is
more liable in conditions of arterio-sclerosis during excitement, or in
a person the subject of syphilitic disease.

Uremia. — In uremia, albuminuria is one of the chief symptoms. In
a doubtful case, the urine should be withdrawn and tested. The pres-
ence of albumen and tube casts indicates Bright's disease. The skin is
sallow. Puffiness of the eyes and edema about the ankles are present.

Diabetes. — In diabetes, the quantity of urine is greatly increased
and has a sweetish odor. The patient also has a sweetish breath. There
is sugar in the urine. The pupils react to light.

Opium Poisoning. — In opium poisoning, there is a pin-point pupil,
and it will not react to light. The respirations are slow and shallow,
and there may be a history of the drug. In doubtful cases, the urine
may be withdrawn and tested for the drug.

Epilepsy. — In epilepsy, the person can be aroused The attitude of
the person simulates that of natural sleep. The presence of bloody and
frothy saliva is also indicative. There may be paralytic symptoms, but
these are usually temporary.

Hysteria. — In hysteria the coma apparently is the result of
choice. The patient can not be aroused, but can readily swal-

COMPRESSION OF THE BRAIN.

331

low articles put in the mouth. The pupils are normal. The disease
occurs in neurotic individuals.

Treatment. — The treatment of compression will depend upon the
cause. "Where there is a depressed fracture, it should be elevated.
Where it is the result of a tumor, and the case is operable, the tumor
should be removed. If caused by pus formation, a button of bone should
be removed over the site of the abscess and the pus evacuated. If from
foreign bodies, these should be removed, if possible. "Where the cerebral
compression is caused by hemorrhage, if the hemorrhage is extradural,
or subdural, operative treatment may give relief. Where operative
treatment is questionable, the patient should be kept quiet in bed and
all efforts made to assist the return circulation.

Extravasation of Blood Within the Cranium.

Extravasations of blood within the cranium may be classified as fol-
lows :

A. Extradural, where the effusion of blood is between the bone and
the dura mater.

B. Subdural, where the effusion of blood is below the dura mater
and. between it and the brain.

C. Subarachnoid, when the

effusion of blood takes place Fig. 111.

in the subarachnoid spaces.

D. Intracerebral, when
the hemorrhage talies place
within the brain substance.

Extradural. — Extradural
hemorrhage results from
rupture of the middle cere-
bral artery — usually the
anterior branch. It is fre-
quently associated with frac-
ture of the skull. It may al-
so be caused by wounds of
the lateral sinus, superior
longitudinal sinus, or small
vessels passing through the
inner table of the skull going
to the diploe.

Symptoms. — While there
may be symptoms of concus-
sion, still a distinct period of
consciousness, as a rule, in-
tervenes before evidences of
compression. As the extrav-
asated blood dissects up the
dura from the skull and presses upon the brain, the symptoms

Extradural hemorrhage from rupture of the
middle meningeal artery.

332 CONTUSIONS OF THE BRAIN.

will increase in severity, depending upon the amount of the effusion.
Usually there is paralysis of one side, which gradually increases, in
volving the face, arm and perhaps the leg. The temperature of the
affected side is elevated. The paralysis is on the opposite side to the
injury. At first it is limited. The coma gradually deepens, until death
may occur within a few days. In some cases the blood may force the
brain substance out of the site of fracture.

Subdural. — In subdural hemorrhage, there is no interval of con-
sciousness between the injury and the pressure symptoms, but paralysis
comes on at once and is soon complete. As a rule, it cannot be diag-
nosed from hemorrhage within the brain.

Subarachnoid. — Subarachnoid hemorrhage, when of any quantity,
attends lacerations of the brain, hence the symptoms of com-
pression are immediate.

Intracerebral. — Intracerebral hemorrhage in nearly all cases comes
from the rupture of the lenticulo-striate artery of Charcot. It is this
artery which is ruptured in cerebral apoplexy. For the symp-
toms and diagnosis, text-books on The Practice of Osteopathy should
be consulted.

Treatment of Cerebral Hemorrhage. — When the symptoms show that
the hemorrhage is extradural, operation should at once be performed
and the bleeding sinus or artery ligated. In subdural hemorrhage, if
operation is done early, it will be of use. Where the rupture of the
artery attends fracture, this is the only method of treatment which will
give relief. All other methods will result in permanent paralysis, or
death. Other forms of hemorrhage must be treated by other means.
No drugs administered will lessen the amount of effused blood. An
ice-cap may be applied, the person kept quiet in bed, and when the
hemorrhage is arrested, treatment to encourage the return circulation
from the brain and the absorption of the fluid may be administered.

Contusions and Lacerations of the Brain.

These injuries, like injuries of other soft-tissues, are attended by
extravasations of blood, subsequent congestion, and inflammation suf-
ficient to repair the injury. The symptoms, in general, are those of
compression and concussion. . They will vary from cerebral irritability,
restlessness, lassitude, headache, and spasms of muscles, to paralysis,
and perhaps coma. The symptoms vary according to the severity
of the injury, and also according to its location. If Broca's convolution
is affected, motor aphasia will result. If the lower part of the motor
area is affected, the lower part of the face will be paralyzed. Where
the tissues on either side of the upper part of the fissure of Rolando are
affected, the leg will be paralyzed. The paralysis may be incomplete,
localized, and delayed, and involve the entire limb, or but a group of
muscles. When the laceration is within the brain, the paralysis is im-
mediate, complete, and extensive.

DISEASES OF THE BRAIN. 333

Treatment of Cerebral Injuries. — If possible, foreign bodies within
the brain should be located by means of the x-rays, the aluminium probe,
or gravity probe, and an operation at once performed and the foreign
body removed. To determine the site of the injury, or the location of
a foreign body, tumor, or other object pressing upon the brain tissue,
it is necessary to understand cerebral localization. The most pro-
nounced symptoms attend pressure upon the motor area. To
locate this part of the brain is of the greatest importance. In gen-
eral, it is situated in the paracentral and postcentral lobules on either
side of the fissure of Rolando. Inasmuch as extradural hemorrhage
is from rupture of the branches of the meningeal artery, to locate
this artery is of importance. The anterior branch of the middle
meningeal artery may be uncovered by a button of bone removed at a
point one and one-half inches directly behind the external angular
process of the frontal bone. Providing the hemorrhage does not occur
from rupture of this artery, a button of bone may be taken out on the
same line, just below the parietal eminences. This will uncover the
posterior branch of the middle meningeal artery. To locate the
fissure of Rolando, first locate the bregma, which is found by drawing a
line from one external auditory meatus to the other. The upper end of
the fissure of Rolando is two inches behind the bregma. The fissure ex-
tends downward and forward from the bregma a distance of three and
three-eighths inches. It makes an angle of 67% degrees, with a line
drawn from the glabella to the external occipital protuberance. The
lower extremity of the fissure of Rolando will then be found two and
three-fourths inches behind the external angular process and one inch
above it. It will be found that pressure upon the tissues on either side
of the upper part of the fissure of Rolando results in paralysis of the
leg, while pressure behind the middle part, the arm, and pressure upon
the lower extremity produces paralysis of the face. For an exhaustive
discussion of this subject, larger texts should be consulted.

Intracranial Inflammation. — Intracranial inflammation consists of:

A. Meningitis, or inflammation of the coverings of the brain.

B. Encephalitis, or inflammation of the brain substance.

Cause. — The causes of these inflammations are acute, general dis-
eases of an infectious nature, middle ear disease, syphilis, tuberculosis,
injury, lacerations, bone disease, contusions, fracture, rheumatism, and
sunstroke.

Pachymeningitis is an inflammation of the dura mater, usually
circumscribed, and is caused by inflammation extending from without,
in.

leptomeningitis is an inflammation of the pia mater and arachnoid,
and may be localized because of infection from without. It is extensive,
when the inflammation spreads throughout the membranes of the brain
and cord.

Pathology. — The pathology of these inflammations is similar to the

'SU DISEASES, OF THE BRAIN.

pathology of inflammations of other like membranes. The extent
of the inflammation depends upon the nature of the cause and the
condition of the tissues.

Symptoms. — The symptoms are fever, pain in the head, which is
greatest over the site of the severest inflammation, intolerance to light
and sound. There is more or less nausea and retching, while the tongue
does not indicate any trouble with the intestinal tract. The pulse is
quick and full, the face is flushed, the pupils usually contract. There
is restlessness and insomnia, and perhaps delirium. Later, serous ef-
fusions, inflammatory exudates, or pus formation, etc., press on the
brain substance, and symptoms of compression supervene. These
will be recognized by a fixed and dilated pupil on the affected side, slow
pulse, stertorous breathing, paralysis, and coma. There may be rigors,
indicating pus formation. In chronic inflammations, the symptoms are
less severe and the onset sudden. There are localized evidences of sep-
sis. If the abscess is between the dura mater and the skull, puffiness
of the skin, and the presence of pus, or a foul wound, would indicate
abscess. Where there is no injury to the scalp, the symptoms arising
may be due to the vascularity of the membranes, produced by a concus-
sion or shaking up of the brain. After four or five da}rs, the pia mater
and the brain substance may be affected. In bruises and lacerations
of the pia mater and brain, inflammatory symptoms may supervene
several days after the injury.

Cerebral Abscess. — In the formation of a cerebral abscess, the symp-
toms are often delayed and are more or less obscure. There is evi-
dence of optic neuritis and paralytic disturbance in the motor area.
Rigors may, or may not, occur. The temperature may be primarily
elevated, but as the inflammatory reaction continues, it is usually
subnormal. Later along in the disease there may be an elevated tem-
perature of 101 or 102 degrees F. There is persistent headache, which
is more or less localized, and persists throughout the delirium, in contra-
distinction to headaches from any other cause. The pulse is
slow, respirations are shallow, or may be of the Cheyne-Stokes variety.
Vomiting of a retching character is a frequent symptom of cerebral
abscess. The symptoms are those of irritation; spasmodic action of the
muscles, followed by paralysis; the pupil on the affected side becomes
fixed; choke-disc may be present; later, one or more of the cranial
nerves may become involved. It is said that more than one-half of all
the cases of cerebral abscess come from middle ear disease. Cases are
caused b37 fractures of the skull, tubercular disease, and by infections
through the mouth and nose.

Intracranial Tumor.

New growths in the brain are tumors, such as gliomata, psammo-
mata, gummata (tubercular and syphilitic formations), cysts, and malig-
nant neoplasms.

Symptoms. — The symptoms of new growth of the brain are, vomit-

DISEASES OF THE BRAIN. 335

ing, headache, optic neuritis, spasms, and paralysis. Epileptiform seiz-
ures, in the nature of Jacksonian epilepsy, are a more or less constant
accompaniment of the development of intracranial tumor. Localization
is more or less indicated by these symptoms: (1) The beginning of the
epileptiform seizures may indicate the part of the brain affected. (2)
Pain. (3) The exaggerated contraction of the flexor or extensor mus-
cles proceeds from a certain area of the brain. (4) Paralysis of muscles,
as of the face, monoplegia, etc.; the affection of sensation or the
special senses, as of sight, hearing, etc. (5) The involve-
ment of certain cranial nerves. These symptoms may indicate the loca-
tion of the new growth.

Treatment. — The treatment of the new growth will somewhat de-
pend upon its nature and location. Some of these tumors are inopera-
ble and can best be treated by the ordinary methods in the treatment of
tumors. In tuberculosis and syphilis of the brain, the general treat-
ment for these affections will be required.

Hernia Cerebri. — Hernia cerebri is a condition where there is pout-
ing of the brain substance from a wound. It looks like a reddish-brown,
blood stained fungus mass. It pulsates with the brain. It usually over-
hangs an opening in the skull bone. It may slough off and the wound
cicatrize and heal, with more or less interference of function, or the
mass may recede and the patient recover. In other cases, paralysis,
coma, and death will occur.

Trephining". — For the treatment of extradural and subdural hem-
orrhage, cerebral abscess, intracranial tumor, depressed and punctured
fractures, bullet wounds, etc., and the removal of foreign bodies,
the operation of trephining is often required. It consists of the
following procedure : If the patient is in a state of unconsciousness, an
anesthetic may not be required, but where there is more or less con-
sciousness, an anesthetic should be given. Preparatory to the opera-
tion, the head should be shaved, the scalp thoroughly scrubbed, and ren-
dered as nearly aseptic as possible. A semi-circular flap, including all
the structures to the bone, should be raised. The flap should be so con-
structed as to receive the maximum blood supply and to give the best
opportunity for drainage. The instruments necessary for opening the
skull are the Gait's trephine, or a good bone chisel and mallet. It is
necessary to have a small brush for removing the saw-dust, or this may
be removed by means of irrigation. The trephine should be set upon
solid bone. A rongeur forceps should be at hand for the purpose of en-
larging the opening if necessary. Care should be taken not to puncture
the dura mater. In case of extradural hemorrhage, the dura will not
need to be opened. In depressed fracture, after the button is removed,
the chisel may be used as a lever and the depressed bone elevated. In
case of cerebral abscess, the dura mater may be opened, the abscess in-
cised, thoroughly drained, and washed out with a saturated solution of
horacic acid. The strictest asepsis is necessary throughout the operation

336 MASTOID DISEASE.

to prevent the development of meningitis. Before the operation, the
fissure of Rolando and the anterior and posterior branches of the mid-
dle meningeal artery, or the lateral sinus, or any part of the brain upon
which the operation is to be made, must be outlined with an anilin pen-
cil. This will serve as a guide to the operator. The pin of the trephine
should protrude perhaps one-tenth of an inch beyond the saw's edge,
and as soon as the diploe is reached, this pin should be withdrawn. If
it is necessary to open the dura mater, the greatest care should be taken
not to injure the cerebral vessels. After the removal of the foreign
body, the dura mater may again be closed by means of sterile catgut or
tendon sutures. Some surgeons make an osteoplastic flap by raising the
scalp and skull by means of an incision through the scalp and chisel-
ing through the bone. The operation, when the technic has been care-
fully observed in every detail, is eminently successful in the removal
of many brain tumors, in draining abscesses, and in the removal of for-
eign bodies and other conditions before mentioned.

Epilepsy.

By traumatic epilepsy is here meant that form of epilepsy which is
usually considered operable. This kind of epilepsy may be due to the
following conditions :

1. Fragments or outgrowth of bones. 4. Thickening of the meninges from ■

2. Tumors. ehronic'meningitis.

3. Scars or cicatrices of the men- 5. Hemorrhagic cysts or aneurysms.

inges.

The time to operate in cases of depressed bone, or injuries of the
brain, is at the time of the injury, and not after the development of
epilepsy. Too often the epilepsy becomes much worse after the opera-
tion. Some cases of cure by operation for epilepsy are reported in the
non-traumatic form, but almost all cases are not benefited, while some
may be made much worse. It is questionable whether operation in
either form of epilepsy is of any use. The removal of any object press-
ing upon the cortex of the brain would be attended by benefit, if not
by actual relief of the epileptiform seizures.

Treatment. — The treatment of epilepsy must be considered from
other standpoints. Osteopathic methods offer more hope than other
forms of treatment.

Mastoid Disease. — Mastoid disease is an inflammation of the mas-
toid cells caused by the extension of the inflammation from the tympa-
num (in cases of otitis media). The symptoms vary according to
the severity of the inflammation. The inflammation may be slight and
terminate in resolution, or it may become chronic and be followed by
fibroid changes, with subsequent ossification of the inflammatory
products, thus converting the antrum into bone. Often suppura-

DISEASES OF THE BRAIN. 337

tion results. Pus may open at the tip of the mastoid process, or
burrow down the neck. In other cases, the infection may extend into
the lateral sinus and an infected thrombus result, while in other cases
cerebral abscess may develop.

Symptoms. — Where the abscess makes its way into the cranial cavity,
there will be symptoms of cerebral abscess. Over the mastoid process
there is deep seated pain upon pressure. Where the periosteum over
the mastoid is involved, there will be great redness and swelling and in-
flammation of the tissues behind the ear. Sometimes the abscess is
but superficial and will point, and after rupturing, discharge its con-
tents spontaneously, but after pus forms, many cases will require some
operative interference.

Treatment. — The treatment of the disease is anti-inflammatory. Hot
fomentations should be applied, to attract the pus towards the surface.
As soon as fluctuation is felt, the abscess should be thoroughly opened
and cleansed. It should then be treated by hot borated poultices and
any cervical lesions removed, while the contracted fascia and muscles of
the neck should be relaxed. Suppuration is the rule. No measures are
entirely successful, inasmuch as the blood supply to the middle ear and
the mastoid cells must come through bony canals, which will not permit
of sufficient nutrition to enable the tissues to combat the infection.
Where the inflammation is deep seated, and the pus does not show a
tendency to burrow towards the surface, and there are evidences of
meningitis, the operation for trephining the mastoid should be done.
To open the mastoid antrum, the trephine should be set a half-inch
behind and one-fourth inch above the middle of the external auditory
meatus. In case the anterior surface of the petrous bone and the roof
of the tympanum are to be excised, the operation should be seven-
eighths of an inch above the middle of the auditory meatus, while if the
lateral sinus is to be operated upon, the point of operation is one and
one-eighth inches behind and one-fourth inch above the middle of the
auditory meatus. Abscess in the cerebellar region is opened at a point
one and one-fourth inches behind and a half inch below the middle of
the auditory meatus.

Abscess of the Scalp. — Abscess of the scalp, if it occurs beneath the
aponeurosis of the occipito-frontalis, may be spread over a large area. It
will require free incision and good drainage. It should be washed out
twice daily and thoroughly cleansed.

Microcephalus is a condition of abnormally small head, due to mal-
development. The skull frequently becomes ossified early. Operations
for the removal of sections of bone have been performed with the hope
of the brain developing, but this operation has not been attended with
any success. These patients should be sent to a home for the feeble-
minded. It is not known that any treatment will accomplish much
good.

Meningocele is a congenital tumor of the membranes of the brain

338 INJURIES OF MUSCLES.

which contains fluid. The tumor is translucent, and does not pulsate.
It is usually located in the occipital region. It is small and pedun-
culated. It may occur at the root of the nose. At this point, it is small
and sessile.

Encephalocele is a congenital tumor which is made up not only of
the membranes, bat of the brain tissues. These tumors are small,
opaque, and pulsatile. They have a broad base, and compression gives
pressure symptoms. Operative treatment is advised in some cases. In
meningocele, the tumor may be excised by plastic operation. In en-
cephalocele, no treatment is known to be of any use.

Hydrencephalus is a condition similar to encephalocele, but differs
from it in that the cavity of the tumor communicates with the ventricle
The tumor is larger than an encephalocele.

Hydrocephalus may be acute, or chronic, external, or internal.

Acute Hydrencephalus is caused by meningitis, and usually results
in tubercular meningitis. For the symptoms and treatment, texts on
osteopathic practice should be consulted.

Chronic Hydrencephalus is a congenital condition. The cranium en-
larges enormously, and the forehead is broad and overhangs the eyes.
Sometimes the skull bones are widely separated. The case is usually
apparent upon inspection. The child is often an idiot, and may not be
able to learn to walk, or talk. It usually dies young.

In External Hydrocephalus the fluid is between the membranes and
the brain, while in Internal Hydrocephalus the increase in the fluid
takes place within the ventricles.

Injuries and Diseases of Muscles, Tendons, Fascia, and Bursae.

Contusion of Muscles. — Contusion of muscles is a common and pain-
ful injury, and is usually associated with considerable extravasation of
blood within the tissues.

Treatment. — Apply cold water the first twenty-four hours; subse-
quent manipulation to diffuse the blood-clot will be of advantage. Some-
times intense discoloration of the subcutaneous tissues and skin will
take place. Unless abscess occurs, no other treatment will be neces-
sary, even though the condition is quite painful. If abscess occurs, ap-
plications of heat should be made. As soon as fluctuation is felt, the
abscess should be opened. However extensive the blood extravasation,
it should not be opened unless pus forms. Contusion of the muscles
may result in temporary paralysis, but manipulation and encouraging
the circulation and nerve force will result in recovery of function.

Strain and Rupture of Muscles. — Strain and rupture of muscles may
take place in violent exercise, or while performing athletic feats, or
from spasmodic action of muscles, such as happen in vomiting, delirium,
tetanus, and parturition. The muscles most often affected are the
biceps in raising weights, supinator longus, gastrocnemius, and rectus

INJURIES OF TENDONS. 339

f emoris in tennis, quadriceps extensor cruris in sprinters, and rectus ab-
dominus in parturition, etc.

Signs — Often there is a giving-way of the muscle, with a sud-
den snap and severe pain, while a gap forms between the ruptured ends.
The ruptured ends of the muscle form hard knots on either side of the
gap.

Treatment. — The ends of the muscle should be approximated as
nearly as possible by position and relaxation. Keep the limb at rest and
apply cold water for the first twenty-four hours, then daily manipula-
tion, together with rest, will bring about recovery. The integrity of
the muscle may be somewhat impaired.

Open Wounds of Muscles and Tendons. — The division of muscles and
tendons requires approximation of the structures by special suture, to
re-establish their function. This should be done in the manner de-
scribed in the treatment under "Closure of Wounds." It is best done
with aseptic catgut, or kangaroo tendon suture.

Dislocation of Museles and Tendons. — Displacement of muscles and
tendons takes place more frequently than is generally supposed. Sud-
den and violent contractions, spasmodic efforts, etc., are the cause.
Perhaps the long head of the biceps is more frequently dislocated than
any other individual muscle. The signs somewhat resemble dislocation
of the shoulder. Where the tendon is not returned to its normal posi-
tion, it may become absorbed. The peroneus longus and brevis may be
dislocated from behind the external malleolus. They will stand out
prominently beneath the skin over the lower extremity of the fibula.
The tibialis posticus may be dislocated from behind the internal mal-
leolus. Muscles of the calf, thigh, back, neck, arm, and forearm are
all liable to dislocation. The diagnosis can only be made by under-
standing the anatomical relations.

Treatment. — The treatment is to manipulate the parts into position
and enjoin rest and quiet until the ruptured sheaths heal. Operations
to place a halter about luxated tendons may sometimes be necessary,
where the dislocation becomes habitual. This operation is, if properly
done, successful.

Bupture of Tendons. — Tendon-rupture occurs because of violent
muscular contraction or violence to the tendon itself. The ends of the
ruptured tendon should be approximated and the limb flexed or ex-
tended, abducted or adducted, as the case may be, to thoroughly relax
the muscle. The member should be put in a splint until the tendon
heals, which will be within two or three weeks.

Myalgia. — Myalgia, or muscular rheumatism, so-called, is a painful
affection of voluntary muscles, or of the periosteum and fascia to which
these muscles are attached and by which they are surrounded. The
disease is properly not a rheumatism, but is more in the nature of a
neuralgia. The cause of the disease is a specific bony lesion pressing

340 DISEASES OF MUSCLES.

upon the vessels and nerves to the part affected, or congestion of the
muscles brought about by cold, damp, exposure, and climatic conditions.
These congestions bring about muscular contractions, producing bony
lesions, which of themselves serve to prolong the ailment. When it
affects the muscles of the back, it is termed lumbago; the intercostal
muscles, pleurodynia; the muscles of the scalp, cephalodynia. Myalgia
of the muscles of the neck is called rheumatic torticollis. A certain
class of these diseases is produced by mercury and lead poisoning,
syphilis, alcoholic excesses, gouty and rheumatic conditions.

Treatment. — The treatment is distinctly osteopathic. Certain
lesions are responsible for the affection. Sometimes these are bony,
and sometimes muscular. Occasionally, bony lesions will irritate certain
nerve filaments, when spasm of some muscle, or group of muscles, results.
This serves to perpetuate the lesion and to increase the pain and conges-
tion. Sometimes congestion of muscles and fascia will produce sufficient
irritation to bring about muscular contraction and thus cause lesions.
Wherever myalgia occurs, certain lesions may be found to which the
disease can be traced. The removal of these lesions will be attended
by a cessation of pain and recovery. Manipulation directed toward re-
lieving contracted and congested muscles, fascia, and ligaments, will be
necessary, as well as the removal of bony lesions. In the largest number
of cases, spinal lesions, causing pressure upon the roots of the nerves
as they leave the spinal canal through the intervertebral foramina, are
the direct cause of the ailment. These may be found upon careful ex-
amination. In any case, the appropriate treatment of the lesions pres-
ent will give relief.

Myositis. — Myositis is an inflammation of muscles produced by in-
jury and infection. The course it runs is not unlike that of inflamma-
tions of other structures, and the treatment is similar. Should an
abscess develop, it should be freely opened and drained.

Gummata. — Syphilitic gummata may occur as local swellings in
muscles in tertiary syphilis. History of the disease and the absence of
other causes will serve to make the diagnosis. The treatment is anti-
syphilitic.

Atrophy and Degeneration. — Atrophy of the muscles may be simple,
or numerical. Simple atrophy is usually due to non-use. This happens
in the case of fractures. The muscles do not lose their striations, and
appropriate treatment, or use, brings about the entire recovery and de-
velopment. Numerical atrophy often attends critical joint disease, with
long disuse of the limb. It may be impossible to secure complete re-
covery of the muscles affected.

Degeneration of Muscle takes place in acute fevers, progressive mus-
cular trophy, infantile palsy, and other paralysis. The prognosis is
only fair, if the case is of long standing. The degenerations are fatty,
waxy, and albuminoid in nature. The integrity of the muscle may be
more or less permanently impaired.

DISEASES OF TENDONS. 341

Treatment. — The condition of atrophied or degenerated muscles
may always he improved. The extent of improvement depends upon
the amount of pressure on, or injury to, the nerves, and as to whether
these nerves may he regenerated. Much depends on the condition of
the circulation, and to what extent the tissues respond to the treat-
ment. In many instances, withered limbs, or paratyzed members of
years' standing, have been relieved in a few months, the muscles being
restored to their normal strength and tonicity. In other instances, not
much relief can be given. Where there is disease of the nerve cells
governing the muscles, the prognosis is not favorable. In all other in-
stances manipulation directed toward assisting the circulation, nerve
supply, and to removing lesions affecting the nerve and blood supply
directly, will secure regeneration of the affected parts.

Ossification of Muscles. — Ossification of muscles may arise from cer-
tain diseased conditions, chronic irritation, or occupations. The most
frequent examples met with are the rider's bone in the adductor mus-
cles, or ossification of the deltoid in soldiers, the result of carrying
arms. Ossification of the quadriceps extensor is said to take place in
cases of Charcot's disease.

Tenosynovitis, or Thecitis. — This disease may occur in the form of
a simple inflammation of tendon-sheaths, as the result of injury or over-
exertion. It often affects the common extensor tendons of the thumb.
It is accompanied by a globular or elongated swelling- over the tendon.
It is painful until after the swelling takes place. The swelling is more
or less fluctuating and movable. After the swelling disappears, or in
chronic forms of the disease, movement will produce a characteristic
creaking sensation (false crepitus).

Treatment. — Strapping, as a strap buckled tightly around the wrist,
will give relief from pain. Local manipulation will assist the circulation
and may secure resorption of the inflammatory products. The treat-
ment must be persisted in, since the case yields but slowly. The
tendons should be given sufficient rest to permit the reparative process
to take place when there has been injury.

Thecal Abscess. — (Paronychia tendinosa). This is a suppurative
form of inflammation occurring in tendon-sheaths. The non-suppurative
form may occur in gonorrhea, rheumatism, and influenza. It is attended
by fluid effusions, crepitus, etc. Thecal abscess is one of the forms of
whitlow, or felon. It occurs in persons who are debilitated. Constipa-
tion exists, or the urinary secretions are abnormal. In addition, there
are bony or muscular lesions affecting the circulation or nerve supply
to the part This renders infection possible. Bacterial invasion
takes place in a finger or toe. The disease is more common in the
hand, where it is in the form of a palmar abscess. Thecal abscess of the
little finger and thumb is more serious than of the middle, index, and
ring fingers, inasmuch as the effusion of pus may take place along back
the tendon- sheath which communicates with the sheath of the common

342 DISEASES, OF FASCIA.

flexors in the hand. The pus may burrow underneath the annular lig-
ament and in some cases may extend up the arm. Such extension of
the pus is not, possible in abscess of the index, middle, and ring fingers,
inasmuch as the tendon-sheaths do not communicate directly with the
tendon -sheaths in the palm. The abscess may extend into the palm,
pass between the heads of the interossei muscles, and open on the back
of the hand, or may burrow underneath the annular ligament, produc-
ing a swelling above the wrist, or may even extend up the sheath of the
muscles into the forearm. Sepsis may result. Necrosis of
the bone may occur, or a considerable amount of fibrous tissue may
form and the sheaths of the tendons become glued to the tendon itself,
producing contractions and deformity, or it may involve the carpal,
phalangeal, metacarpophalangeal, or wrist-joints, producing ankylosis.

Symptoms. — Severe throbbing pain, extreme tenderness upon pres-
sure, swelling, and a dusky redness. Oftentimes there is swelling,
edema, and redness of the back of the hand. The lymphatics in the
axilla are enlarged and painful; constitutional symptoms, as rise of
temperature, are present; the appetite is lost; there is constipation; the
urine is less in amount and highly colored. Only one other affection
resembles this disease, and that is acute septic inflammation of the
connective tissues of the fingers and not involving the tendon-sheaths.
Care should be taken when the abscess is opened, which will nearly
always be necessary, not to make an incision into the tendon-sheath,
unless it is necessary.

Treatment. — Tbe treatment is manipulative and anti-inflammatory.
The manipulation consists of removing local lesions, increasing the cir-
culation and nerve supply to the part, together with correcting the con-
stipation and urinary secretions. Attention should be paid to any con-
stitutional defect found. Should suppuration be imminent, an early
incision is necessary. The incision should be made just a little to one
side of the middle line of the finger. The abscess should be thoroughly
washed out once or twice daily with antiseptic solutions (1:20 carbolic
acid, or 1 :2000 bichloride of mercury). In the meantime, hot borated
poultices should be applied. This facilitates the flow of pus, loosens
the tissues and maintains mild antisepsis. As the inflammation disap-
pears, a dry dressing may be substituted and manipulation of the hand
be made to prevent adhesions. If the treatment is instituted early,
before the pus has extended beyond the annular ligament, even though
a palmar abscess has formed, no deformity ox the hand will follow. In
opening a palmar abscess, an incision should not be made above the web
of the thumb, but beyond that point. If made beyond a line on the
level with the web of the thumb, there is no danger of wounding the
palmar arch, which would occasion severe hemorrhage. Efforts to ligate
the palmar arch may be futile, and it may be necessary to ligate the
brachial.

Whitlow, or Felon. — Whitlow is a pyogenic invasion of a finger or

DISEASES OF FASCIA. 343

toe. The cause is the same as that mentioned in thecitis. The location
of whitlow may be: 1. In the superficial connective tissues, which,,
when it occurs at the root of the nail, is popularly termed a "run-
around." 2. When within a tendon-sheath "thecitis." 3. Beneath the
periosteum it is called a bone felon.

The symptoms vary according to the location of the infection.
Manipulation to assist the circulation, the application of hot poultices
to secure the relaxation of the tissues, together with an early incision
to let out the stagnated blood and pus, and rigid antisepsis afterward,
form the best treatment.

Dup'iiytren's Contraction takes place in the palmar fascia. The
disease begins as a. small, round, fibrous nodule in the process of fascia
extending from the palm to the fingers. Generally two or three .lingers
are affected. The skin is drawn and puckered because of its attachment
to the fascia. In this manner it may be told from contractions of the
tendons. Local manipulation does but little good. The disease may be
attended by a cervical lesion, which is indirectly responsible for the
fascial contraction. Perhaps it is due to chronic inflammation of the
fascia, or to rheumatic conditions. Incisions between the puckered
portions and the use of splints to straighten the fingers will be found
to be successful. An open incision should be made under strictest
asepsis.

Ganglia. — Ganglia are of two varieties, simple and compound.
Simple ganglia are cysts in connection with the tendon-sheaths. They
develop from the synovial fringes in connection with the ex-
tensor tendons, but may occur on the front of the wrist, palm, or
about the ankle. They vary in size from a small pea to a guinea-egg,
and contain a viscid, semi-viscid, or jelly-like material. They impair the
action of the tendon and produce some deformity. The disease is quite
common in piano players.

Treatment. — Eupture by pressure of the thumbs. If this is not suc-
cessful, the tumor may be struck a smart blow with a piece of shingle.
Failing in this, the skin should be asepticized, a tenotome introduced,
the inside of the sac cut in several places, the contents expressed, and
the wound afterwards dressed antiseptically. The ganglion, will likely
not return, nor will it affect the use of the part, providing proper
manipulation is used to prevent adhesion. Compound ganglia usually
appear on the front of the wrist in connection with the flexor tendons.
They are oblong, or oval, sometimes containing a dark fluid, or they may
be filled with melon seed-like bodies, or the bits may resemble rice-
grains. Often there is some constitutional defect attending these condi-
tions, which should be treated. These ganglia can not be ruptured by the
methods mentioned before, but on the other hand, a valvular incision
should be made, the contents expressed and drained out, while anti-
septic dressings should be strapped on tightly.

Bursitis. — Bursitis is an inflammation of bursae, which may lie be-

344 TORTICOLLIS.

tween the skin and the tendons or bone, or between tendons and other
structures. There are two forms, acute and chronic. Acute inflamma-
tion is the result of injury, and anti-inflammatory treatment is neces-
sary. Kest and manipulation will usually relieve the fluid effusion.
The chronic form arises where the bursa is subject to chronic irritation.
Fluid effusions into the bursae seem to be more common in persons of
rheumatic tendency. The contents may be a clear fluid, or may be rice-
grain or melon seed-like bodies, or may be a fibrinous mass. The most
common site of this bursal inflammation is the bursa of the patella,
where it fonns a condition called "housemaid's knee;" or it may occur
in the bursa beneath the semimembranosus and form an enlargement in
the popliteal space, which more or less disappears upon flexion. (Baker's
cyst.) Enlargement of the bursa over the ischial tuberosity is called
"weaver's bottom."' Inflammation and enlargement of the bursa over
the olecranon is called "miner's elbow," while inflammation of the bursa
over the head of the first metatarsal bone occasions a condition called
"bunion." In other cases, adventitious bursae may form and produce
corns. These bursae may produce dislocations of bones. Absorption
of the fluid in these bursae will not, as a rule, take place of itself, un-
less the part is permitted rest and the irritation and cause removed.
Manipulative methods may be tried, and failing in this, antiseptic drain-
ing of the bursae will be found successful.

Torticollis. — Torticollis, or wry-neck, is a condition of contraction of
the sterno-mastoid and trapezius muscles. There are two forms, congenital
and acquired. The congenital form is produced by malposition in utero,
orinjuryat birth. These produce specific lesions in the cervical vertebrae
from the first to the fifth, inclusive. The acquired form is produced by
rheumatism, inflamed lymphatic glands, producing contractions of the
muscles, hysteria, and by traumatic lesions of the first to the fifth cervi-
cal vertebrae. These lesions affect the external division of the spinal
arcc-essory nerve, which is the motor supply to the trapezius and sterno-
mastoid, or it affects filaments of the cervical plexus, which sometimes
also supply these muscles. In cases where the lesion was the first cause,
reduction of the lesion will accomplish a cure. In old cases, congestion
and chronic inflammation take place within the muscles. This is ac-
companied by the formation of fibrous tissue, which displaces the
striated fibres and impairs the integrity of the muscles, and subsequent
contraction produces permanent shortening, so that a cure may not be
accomplished by the correction of the lesion. All cases may be
markedly benefited by treatment. Cases have been cured by os-
teopathic treatment after section of the muscle and resection of the
nerve had failed. The treatment consists of correcting the neck lesions
and improving the general health.

Tenotomy. — Tenotomy consists in the division of a tendon, or muscle,
the contraction of which produces deformity. Two methods are in use,
the open, and closed. The closed method is preferred, since it eliminates

TENOTOMY. 345

the danger of sepsis. The tendo Achillis is frequently tenotomized for
correcting conditions of club-foot, as equino-varus. This operation is
best performed by having the patient lie upon his back, inclined to-
wards the affected side. The part is rendered thoroughly aseptic. The
instruments used are a blunt and sharp-pointed tenotome. A knife is
inserted flatwise along the anterior border of the tendon until the point
of the knife may be felt on the opposite side of the leg just beneath
the skin. Care should be taken not to split the tendon. After this in-
cision is made, a blunt-pointed tenotome is introduced. After intro-
duction, the sharp edge of the tenotome is turned towards the tendon
and brought against it and held in that position firmly, while the tendon
is thoroughly stretched by flexing the foot. The tendon will snap in
two. The operation is done one and a half inches above the insertion
of the tendo Achillis into the tuberosity of the os calcis. The tibialis
anticus is tenotomized one and one-half inches above its insertion for
conditions of talipes varus. The peroneus longus and brevis may be
tenotomized one and one-half inches above the external malleolus. The
tibialis posticus is divided one and a half inches above the anterior an-
nular ligament. Fasciotomy of the plantar fascia is sometimes per-
formed by passing the knife flatwise between the skin and fascia and
cutting inward, dividing the fascia or the structures which are produc-
ing the abnormal arching of the foot. Sometimes instead of tenotomy,
tendon lengthening is performed. This is a plastic operation done by
splitting the tendon and sliding the two portions a distance apart. The
operation of tendon lengthening is also sometimes necessary where
sections of the tendons have been lost because of injury. In case of in-
jury, it may sometimes be necessary to attach the ruptured tendon to
adjacent muscles or tendons in order to not entirely lose the use of
the muscle. For more exhaustive descriptions of these operative pro-
cedures, an operative surgery should be consulted.

Syndactylism, or Web Pinger, is a congenital condition and is re-
lieved by operation. Some such operation as Diday's should be done in
dividing the fingers.

Polydactylism is a condition of supernumerary digits. The extra
finger should be amputated while the child is young, to prevent de-
formity.

Trigger-finger is a condition in which one or more of the fingers are
held in a flexed condition, but when forcibly extended they will open
with a snap, as in opening a knife. The hand may be readily closed. ■
It is said to be produced by contraction of the transverse ligament of
the palm. It may be produced by cartilagenous tumors, or ganglia. Some
maintain it is clue to enlargement or an inflamed condition of the flexor
tendons.

Mallet-finger is a condition due to the rupture of the extensor ten-
don, where it forms the posterior ligament of the phalangeal articula-
tion. A similar condition is found in base-ball players, and is due to a

346

CLUB-FOOT.

Fig. 112.

dislocation backward of the first phalanx. The condition may be cured
by reducing the dislocation which often exists and putting the finger
in a splint.

Club-hand is a deformity of the hand due to absence of one of the
carpal bones.

Genu Valgum, or Knock-knee, is an abnormal growth of the inner
condyle of the femur. This condition is brought about by an interfer-
ence in the nutrition to the outer condyle and outer part of the bone.
Spinal lesions interfere with the nerve supply to that part of the bone,
or interference with the blood supply may also cause the deformity, or
it may be brought about by a general co^ition of malnutrition. The
improvement of the general nutrition of the body and the correction
of local lesions will be attended by the correction of the deformity, pro-
viding this treatment is commenced reasonably early. Where this fails,
which may happen in long standing cases, an osteoplastic operation,
such as removing a wedge-shaped piece of bone from the internal con-
dyle, will be found to give relief.

Genu Varum, or Bow-legs, may be an inherited condition, or it may
be brought about by encouraging the child to stand before the bones of

the legs have properly ossified. It may
occur in rickety children, or conditions
of malnutrition. Bony lesions likely ac-
count for some cases. These bony
lesions either act directly upon the
nerve and blood supply, or bring about
a contraction of the muscles, which in-
terferes with the nutrition to the inner
side of the bones of the upper and lower
leg. The external condjde often grows
too long, or there may be bowing of
the femur and tibia. Improvement in
the general health often markedly bene-
fits the condition. The correction of
any bony lesions, reduction of disloca-
tions, or improvement of the general
health, will be attended by lessening of
the deformity.
Club-foot is a condition where the bones of the tarsus assume an
abnormal relation with the bones of the leg. It is accompanied by con-
tractions of the ligaments, fascia, and muscles of the foot and leg, to-
gether with distortion and twisting of the bones of the tarsus. It may
be congenital, or acquired.

A. Congenital Club-foot may be produced by one of the following
conditions: 1. Spastic contractions of the muscles, due to lesions af-
fecting the nerve centers governing the foot. 2. Malposition in utero.
3. Alteration of the tarsal bones, due to interference in the blood sup-
ply-

Genu Varum,

ClUB-FJOT.

347

B. The acquired form is produced by the following conditions : 1.
infantile paralysis — nearly all of the cases of acquired talipes, or cl uo-
foot, are produced by infantile paralysis. 2. Injury. 3. Spinal lesions
which bring about weak ligaments, disease, and fascial contraction.

Varieties, — The varieties of club-foot are:

1. Talipes varus.

2. Talipes equinus.

3. Talipes calcaneus.

4, Talipes valgus.

5, Talipes cavus.

Combinations of these mav occur in the form of:

1. Talipes equino-varus.

2. Talipes equino-valgus.

3. Talipes calcaneo-valfus.

Fig. 113.

Talipes Varus is the most common form

of club-foot. In this condition the tibialis

posticus and anticus muscles, together with

the tendo Achillis, are found contracted,

while the peronei muscles are correspond-
ingly relaxed. The foot is twisted so that

in walking the outer border of the foot first

comes in contact with the floor. The sole

of the foot looks, in mild cases, downward

and inward, but in pronounced cases the

foot may be turned so that the sole looks

directly upward, while the back of the foot

is directed downward. If the condition;

persists, the abnormal position of the foot

affects the blood supply to the bones, and

pressure upon the bones in an abnormal

position results in their irregular develop-
ment, so that they become deformed. The

tracted, and tbese often form the chief obstacle to reduction, even if

the muscles could be readily relaxed. In
the congenital variety, the deformity is
readily reduced. If allowed to persist, it
will result in extreme deformity. Talipes
varus per se is not common, but is very com-
mon when associated with equinus, so that
equino-varus is the common condition. The
acquired equino-varus is nearly always the
result of infantile paralysis, and that
amount of recovery can be expected com-
mensurate with the recovery of the part of
the spinal cord affected. The withdrawal of
the nerve supply and the interference in the
blood supply prevent the proper develop-
ment of the foot.

Acquired Talipes Varus.

ligaments become con-

Fig. 114.

Congenital Talipes Varus.

3-18

CLU3-FOOT.

Talipes Equinus is rare, and is either clue to paralysis of the extensor
tendons or to a spasm of the muscles forming the tendo Achillis. The
heel is drawn up, while the foot is extended.

Fig. 115.

Fig. 116.

Talipes Equinus.

Talipes Equino-calcaneus.

Fig. 117

Talipes Calcaneus may be congenital, or acquired. When congenital,
it is due to contraction of the extensor tendons, and when acquired it is
due to infantile paralysis of the calf muscles. In this condition the foot
is abnormally flexed upon the leg and the patient walks upon the heel.

Talipes Valgus, or flat-foot, may
be due to several conditions: 1.
Weakening and yielding of the lig-
aments of the bottom of the tarsus.
2. Supporting heavy weights for
some length of time. 3. Eheuma-
tism and gonorrheal affections of
the ligaments, together with
sprains and rachitic conditions. 4.
Paralysis of the tibialis anticus and
posticus muscles. 5. Badly set
Pott's fracture. The arch of the foot sinks down and is lost. In the
acquired form, the patient is badly crippled and the foot is longer and
broader than normally. The astragalus and scaphoid bones form pro-
jections on the inner side of the foot.

Talipes Cavus or Equino-calcaneus is a condition of abnormal in-
crease of the arch of the foot and is produced in some cases by contrac-
tions of the plantar fascia, while in other cases by spastic conditions of
the peroneal muscles.

Treatment. — Manipulation, begun early, will cure a large number
of the cases of club-foot. In congenital club-foot, the treatment should
be instituted immediately after birth. Whatever dislocation is found

Talipes Valgus.

\

CLUB FOOT.

349

should be reduced. This is important. The blood and nerve supply
to the weak muscles should be encouraged. If the condition is due to a
spasm of certain muscles, this spasm can be relieved by removing the
spinal lesions irritating certain nerve roots causing such spasm. If the
condition has persisted for a long time, and the spasm of the muscles
can not be relieved, tenotomy of these muscles may be done with ad-
vantage. Applying a plaster cast, with or without tenotomy, in all
cases, and holding the foot in normal position, is bad practice. Where the
deformity persists in spite of manipulation, a plaster cast may be applied,
or the foot may be held in normal position by means of some apparatus
which can be adjusted as required and can be removed for the purpose
of treatment. Strips of adhesive plaster, passed across the sole of the
foot and carried up along the side of the leg, will suffice to hold the
foot in normal position in some cases of talipes varus. These may be
removed at the time of treatment. Many cases may be cured without
application of any deformity appa- pIG ug# Fig. 119.

ratus. In old cases, where the pa-
tient has walked on the foot and
it is believed that the bones are
malformed, the prognosis should
be guarded. The case may be im-
proved, but may not be cured.
Operative treatment is likely nec-
essary. Where tenotomy will not
correct the deformity, the fascia
and ligaments should be divided so
as to permit the foot to be returned
to its normal position. Where the
foot can not be returned to its nor-
mal position after subcutaneous division of tendons and fas-
cia, tarsotomy may be performed with advantage. This oper-
ation, if properly done, offers hope of fair recovery of the
deformity. Even in old cases, after several unsuccessful opera-
tions, manipulative treatment will be found of great benefit. It
must not be expected that the deformed bones can be cured by manip-
ulative methods, but further deformity can be prevented by proper
treatment. In talipes cavus, the subcutaneous division of the plantar
fascia may give relief. In flat-foot, or pes planus, the fitting into the
sole of the shoe of a steel spring which will assist in raising the arch of
the foot, will be found of advantage. In equino-varus, tenotomy of the
ten do Achillis, together with both tibial muscles, should be done, while
in talipes equinus, tenotomy of the tendo Achillis will be sufficient.

Hallux Valgus, or Varus, is a partial dislocation of the great toe out-
ward, or inward. It most often occurs in old men. The cause is from
wearing narrow shoes, or wearing a shoe which presses against the
end of the toe and weakens the inner metatarsophalangeal ligament.
The bone is usually displaced inward, and because of pressure upon the

Imprint of a nor-
mal foot.

Imprint of the
foot in pes planus.

350

FLAIL-JOINTS.

head of the first metatarsal bone, bursitis follows. This bunion is fre-
quently an extremely painful condition. It may be successfully treated
by reduction of the dislocation. It may be necessary to hold the dislo-
cated toe in position hj means of an apparatus for straightening the
toe. Continued reduction and manipulation, to-
Fig. 120. gether with properly fitting shoes, will cure the ail-

ment, unless in very old people.

Hammer-toe is a condition of contraction of the
plantar fibres of the lateral ligaments. A bunion
forms on top of the toe. Probably amputation of
the toe is the best treatment.

Metatarsalgia (Morton's Disease). — This disease
is a partial dislocation of one or more of the meta-
tarsal bones, implicating certain nerve fibres, which
cause intense pain. The disease may be diagnosed
by grasping the foot and compressing it transverse-
ly. This occasions great pain. The disease may be'
associated with flat-foot, and is produced by wearing
a shoe that is too narrow. The pain is on the outer
and inner side of the little, or fourth toe, or about
the neck of the fourth metatarsal bone. Manipula-
tion for reduction of the subluxation and a properly
Hallux valgus, with fitting shoe will give relief.

the formation of a ° °

Coxa Vara is a disease in which there is abnormal
bending of the neck of the femur, usually laterally.
It is said to occur most frequently between twelve and
twenty years of age. Likely the disease is rachitic. The
disease is frequently diagnosed as dislocation. The neck of the
femur gives way and the trochanter ascends above JSTelaton's line.
The condition is frequently greatly improved by treatment, indicating
that it is due to an interference in the nutrition of the neck of the
femur. It may be brought about, more or less, by partial dislocation, or
the existence of certain spinal lesions. It may require the assistance
of the x-rays to determine the condition.

Flail-Joints. — Abnormal looseness of joints following infantile par-
alysis, or prolonged pressure upon a nerve to the joint, is called flail-
joint. The condition is most common in the hip, knee, and ankle.
When the condition is produced by dislocations, or spinal lesions, the
dislocation should be reduced and the spinal lesions corrected, together
with encouraging the blood supply and increasing the tonicity of the
ligaments and muscles. Where cases have persisted for years, there is
not much hope of recovery.

PART III.

DISEASES AND INJURIES OF REGIONS.
Face, Lips, Tongue, Mouth, and Throat.

Cracks and Fissures of the Lip. — Cause. — Exposure, cold, dyspepsia,
and neglect may lead to fissures of the lip, which obstinately refuse to
heal. These will require treatment. Compound tincture of benzoin
should be applied once daily or the fissure cauterized with a stick of
silver nitrate. If the sore is kept up by a foul condition of the mouth,
a boroglyceride solution should be used as a mouth wash after each
meal. If the sores are syphilitic, they should be at once cauterized, since
they may easily be a source of infection.

Papillomata or Warty Growths of the Lip should be removed with a
knife or curved scissors.

Ulcers of the Lip may be dyspeptic, syphilitic, or tubercular. In dys-
peptic ulcers, boroglyceride solution should be used as a wash several
times daily. These ulcers should not be cauterized. Syphilitic ulcers
occur in secondary syphilis. They should be cauterized with nitrate of
silver and afterwards treated as a simple sore.

Nevi or Angiomata may occur on the lips. They may be removed
by electrolysis or subcutaneous ligature.

Hypertrophy of the Lip may occur in strumous conditions, or in
syphilis. Constitutional treatment for these conditions may relieve the
thickness of the lip. Where the condition persists, a V-shaped mass
of tissues may be removed by operation.

Chancre of the Lip. — Chancre of the lips and tongue, and even of the
tonsil, has been reported in young persons in lower classes. Such sus-
picious sores should be immediately cauterized to prevent spreading of
the disease.

Tumors of the Lip are both benign and malignant. The malignant
tumors are of the nature of cancer and rodent ulcer, and may be diag-
nosed by the ordinary signs of malignant tumor, together with later en-
largement of the lymphatic glands. The enlargement of the lymphatic
glands does not appear before six months. After the cancer
ulcerates, the best treatment is a V-shaped incision, removing all ves-
tiges of the growth. This is more successful than cauterization. Cases
of persistent ulcer may be cauterized with chloride of zinc or arsenious
acid, or sulphuric acid paste. This causes extensive sloughing of the
tissues and may get rid of the malignant sore.

Harelip.— Harelip is a congenital malformation of the upper lip,
caused by failure of the fronto-nasal plates to close. It may be a mere
cleft in the lip, or it may extend into the nostril, or even to the inner

351

352 STOMATITIS.

canthus of the eye. Very rarely it may be bilateral. The most common
form is- a mere clefting of the lip. In some cases, the intermaxillary
bone and the septum of the nose are absent, or are partially developed.
Frequently, there coexists cleft palate, spina bifida, club-foot, etc.

Treatment. — The edges of the cleft should be pared, approximated
and held by harelip pins and appropriate sutures to secure union. The
operation should be done between the third and fifth months, since a
very small child withstands hemorrhage badly. The object of the op-
eration should be to secure primary union, without scar, and to prevent
a post-operative notch in the lip, and keep the margins of the lip in
lino. It is almost the universal practice to use pins and sutures.
The incision will depend upon the nature of the cleft. The
success of the operation frequently depends upon the ingenuity of
the operator. It requires more skill to secure an elegant result and
thorough correction of the deformity in many cases of harelip than it
does to perform many of the major operations. A nice approximation
of the wound must be secured. The pins should be removed within
thirty-six hours after the operation, otherwise scarring will result. The
sutures between the pins should ba allowed to remain until union has
taken place. After the removal of the pins, the lip should be thoroughly
strapped, in order to prevent the wound being torn asunder.

Stomatitis. — The more frequent and mild forms of stomatitis come
within the province of the physician, and not the surgeon. There are
two forms in which surgical measures are sometimes necessary. These
are the toxic stomatitis, mercurial stomatitis, or ptyalism, and the gan-
grenous stomatitis, or noma. In mercurial stomatitis, or ptyalism,
there is ulceration and edema of the gums, profuse secretion of
saliva, the breath is foul, arid the person is in great pain. The disease
is produced by the administration of some form of mercury, usually
calomel. The indications in the treatment are to at once remove the
drug and put the patient upon a nourishing liquid diet. See that the
other secretions, such as urine and stools, are free. Antiseptic
mouth washes should be used several times daily. Chlorate of potassium
in saturated solution, will be found of great service. Peroxid of hydro-
gen is also useful, diluted with equal parts of water. Boroglyceride
solution may be used with advantage. The mouth should be thoroughly
cleansed with an antiseptic solution each time after taking food.

Gangrenous Stomatitis. — See Gangrene.

Ranula. — Eanula is a bluish -white, semi-translucent, ovoid tumor
growing in the floor of the mouth. It is produced by closure of Whar-
ton's duct, or by distension of a mucous follicle. The operation is to
clip out a part of the tumor with curved scissors and cauterize the sac
with a stick of nitrate of silver.

Dermoid Cysts. — Dermoid cysts occur in the middle line of the neck,
and sometimes project into the mouth. They are the result of fetal
inclusions. They may extend up into the mouth, where they may be

CLEFT PALA TE. 353

shelled out, or they may develop in the neighborhood of the hyoid bone.
Where they develop lower down, they should be dissected out,
otherwise a fistula is liable to result.

Tongue-tie. — In the treatment of tongue-tie, a little notch should
be clipped in the margin of the frenum linguae soon after birth. Care
should be taken not to clip too much of the frenum, or to cut the ranine
artery.

Microglossia is a condition of obstruction of the lymphatics leading
from the tongue. The tongue develops in some cases to enormous size,
and may enlarge so as to fill the mouth and to distend it, keeping it per-
manently open. It is congenital, or acquired. It is sometimes asso-
ciated with a similar condition of elephantiasis of other parts of the
body. Where manipulative methods do not give relief, an operation
should be advised, and a wedge-shaped piece of the tongue removed.

Acute Glossitis. — Acute inflammations of the tongue result from
bee-stings and infections, from mercurial poisoning, as in mercurial
stomatitis, and injury, or acute fevers. Where manipulative methods
will not give relief by assisting the return circulation and relieving the
obstruction to the circulation, an incision should be made to provide for
drainage of the fluids, or pus.

TJlcers of the Tongue are simple, dyspeptic, syphilitic, tubercular,
and gangrenous. Simple ulcers may be cauterized with nitrate of sil-
ver, or the mouth may be rinsed with borax and honey, or boroglyceride
solution. Dyspeptic ulcers should not be cauterized, but should be
treated antiseptically. Syphilitic and tubercular ulcers should be cauter-
ized, but the conditions may return unless systemic treatment is ad-
ministered to get rid of the general poison. Cancer of the tongue may
be removed by excision of a considerable portion of the tongue, provid-
ing the diagnosis is made early.

Cleft Palate.' — Cleft palate is failure in the development of the hard
or soft palate, and is due to the arrest of development of the processes
which normally form the superior maxillary and palate bones, which
processes subsequently form the vomer. Various degrees of this condi-
tion may exist. Simply the uvula may be absent, or the cleft may be
in the soft palate only, or there may be entire absence of the inter-
maxillary processes, vomer and nasal septum. The cleft may be so ex-
tensive as to prevent the child nursing. The operation for relief of cleft
palate is staphylorrhaphy.

Staphylorrhaphy. — This operation is advised for the relief of cleft
palate. Uranoplasty may be necessary where the intermaxillary
processes are absent. These operations should, as a rule, be undertaken
after the end of the second year. The operation consists in paring the
margins of the cleft and uniting them by means of interrupted suture.
Relaxation sutures are often necessary. It may be necessary to make
a second incision, near the gums, through the soft tissues in order to
secure sufficient relaxation, that the pared edges may be united. For

354 TONSILITIS.

the technic of the operation of staphylorrhaphy and uranoplasty, larger
texts should he consulted.

Elongated Uvula is a condition in which the uvula becomes ab-
normally long, because of chronic inflammation, or because of certain
relaxed conditions. It may hang down on the back of the tongue and
act as a source of irritation. Where securing a better nerve supply to the
uvula does not give relief, and where it is a source of persistent trouble,
it may be amputated. This is readily done under cocaine, or local anes-
thesia. The end of the uvula may be grasped by forceps and clipped off
with curved or straight scissors. No hemorrhage is likely to result.

Tonsilitis. — Inflammation of the tonsils is considered by texts on
the Practice of Osteopathy, and the methods there advocated will be suf-
ficient to relieve almost all cases. Exceptionally abscesses of the tonsils
occur, or occasionally the tonsils, after several attacks of acute tonsi-
litis, may become hypertrophied. Abscess of the tonsil should be
treated in the following manner: Hot poultices should be applied to
the neck, until suppuration is evidenced by fluctuation, which may be
determined by bi-manua.l manipulation. The abscess should then be
opened. A small straight bistoury, or scalpel, should be wrapped
within half an inch of its point. This is inserted on the line of the
molar teeth. The knife is introduced, with the sharp edge towards the
median line of the throat, and pushed directly into the tonsil, and the
incision is made towards the median line. This is done to avoid the
carotid artery, which has been cut in lancing abscesses of the tonsil.
Such an accident would be immediately fatal.

Hypertrophy of the Tonsil may occasionally require operation. The
electro-cautery should be used by all means. Eemoving a small portion
of the upper part of the tonsil projecting will suffice to secure atrophy
of the organ.

Ulceration of the Tonsil may be simple, gangrenous, syphilitic, tuber-
cular, or malignant. It should be treated in the same manner as ulcer
of the mouth.

Tumors of the Tonsil are benign and malignant. The benign tumors
are papilloma and adenoma. These should be removed, but sarcoma
and carcinoma of the tonsil can not be successfully removed. Manip-
ulative treatment may give relief.

Alveolar Abscess results from caries, or periostitis of the teeth and
alveolar process. The superficial form is known as gum-boil. The
abscess may expand the alveolus burrowiing into the bone and appearing
on the face, cheek, angle of the jaw, or may lead to necrosis of the bone.
In some cases the pus may burrow into the pharynx. The symptoms
are pain, evidence of carious teeth, inflammation, and swelling.

The treatment is to remove the carious teeth. Sometimes this will
not arrest the disease. Application of poultice should be made to
hasten pointing of the abscess. When pointing occurs, it should be

INJURIES OF THE FACE. 355

opened and thoroughly washed with an antiseptic solution several times
daily. After the pus has been removed, the abscess will readily heal.
In old cases, it may be necessary to scrape out the sinus and remove
the carious bone before the condition will heal.

Epulis may exist in two forms; one a fibrous tumor which projects
from between the teeth, and the other a malignant growth developing
from a fibroma of the periosteum. Complete removal of the tumor will
give relief.

Abscess of the Antrum usually arises from carious teeth, or from
the extension of inflammations of the nose into the antrum. The tissues
of the cavity are rendered more liable to disease because of
the existence of certain lesions affecting the nerve and blood supply.
The chief symptoms of the disease are pain and an edematous swelling
of the face, which is brought about by the filling up of the antrum with
pus. Pressure over the front of the superior maxillary bone will elicit
crepitation. If the patient's head is held between his knees, the pus
flows into the nose. A small electric light held in the mouth shows
lessened transillumination of the affected side.

Treatment. — The treatment is at first manipulative, to encourage
the circulation, and to relieve any venous obstruction. Failing in this,
the carious teeth should be removed, and a trochar inserted through the
root of the tooth into the antrum, with the hope that drainage can be
secured in this way. Failing in this, a trocar should be introduced
through the nose, opening the antrum at the lower anterior part. The
normal opening of the antrum is the upper and back portion, hence the
pus which accumulates within the cavity can not be discharged. If
there is no abatement of the symptoms, a bone drill should be set just
above the second bicuspid tooth and the opening made directly into the
antrum. The antrum should then be thoroughly irrigated several times
daily with an antiseptic solution. Where this fails, the bone may be tre-
phined at this same point and a drainage tube inserted to secure free
drainage.

INJURIES OF THE FACE AND NECK.

The most frequent injury to the face is in the form of contusion,
and when about the eye, is accompanied by effusion of blood in the loose
connective tissue, which is popularly called a black-eye. This can be
prevented by pressure and the application of ice shortly after the in-
jury, and later manipulation to diffuse the effused blood.

Open Wounds of the Face occasion sharp hemorrhage, Avhich should
be attended to at once, Scarring and deformity will result unless the
wound is properly closed. Part of the sutures should be removed on the
second day; the remainder may be removed as soon as possible.

Wounds in the Neck may involve the superior thyroid, lingual, or
facial arteries, or the external jugular vein. In efforts at self-destruc-
tion, some one of these vessels is severed. The hemorrhage

356 INJURIES OF THE PHAR YNX.

will be severe, but may not occasion death. Where the internal jugular,
or the common or external carotid arteries are cut, death will be almost
immediate, or before help can be secured. The method of treatment
of wounds in general should be followed in the treatment of injuries of
this region. The special dangers in these wounds are the entrance of
air into the veins, edema of the glottis, dyspnea, loss of voice, fistula,
bronchitis, and scar formation. Where the wounds enter the trachea,
or larynx, bronchitis and broncho-pneumonia may develop because of
the septic condition.

Contusion of the Larynx sometimes occurs. It causes great pain,
edema glottidis, loss of voice, and hemoptysis. Ice should be applied
and the patient kept quiet and impediments to the return circulation
removed.

Rupture of the larynx and Trachea is the result of severe local in-
jury. It is usually fatal.

Fracture of the Laryngeal Cartilages occurs because of direct vio-
lence, compression, etc., and occasions great pain, spitting of blood,
swelling and ecchymosis in the connective tissues, dyspnea, crepitus,
and irregularity of the cartilages, which are evident upon examina-
tion. The treatment is to manipulate the cartilages into position,
where they may be held by strapping. The person should avoid talking,
and should be kept at rest until healing takes place.

Foreign Bodies in the Nose. — Foreign bodies, such as beans, beads,
buttons, or the seeds of fruit, may be pushed into the nose by small
children. Under certain conditions, foreign bodies may get into the
nose from behind during vomiting. Usually there are signs of catarrh.
Cases are on record where foreign bodies have remained in the nose for
a long time, occasioning an inflammation, and ofttimes a purulent dis-
charge, as in ozena. A careful examination will reveal the foreign body.
It may be engaged by mouse-toothed forceps and drawn out. Failing
in this, the nose may be anesthetized by a four per cent, solution of
cocaine and a scoop introduced, which may assist in pulling the body
out. If this fails, a nasal douche should be used. Where all these
efforts are unsuccessful, the patient should be anesthetized, when the
object may be readily grasped and removed.

Foreign Bodies in the Pharynx and Esophagus. — Foreign bodies, such
as portions of food, onions, beans, etc., may lodge in the pharynx, either
cross-wise, or become engaged underneath a fold of mucous membrane,
or they may lodge within the esophagus. In the pharynx, the foreign
body may be grasped by means of dressing forceps and removed. A
radioscopic mirror will assist in locating the foreign body. Where it is
near enough, it may be pulled out with the fingers. In case the pharyn-
geal reflexes are excited, the mucous membrane may be swabbed or
sprayed with a four per cent, solution of cocaine, then the finger may
be introduced sufficiently far into the pharynx to pull out the foreign
body. If these methods fail, a probang may be introduced, then ex-

INJURIES OF T.HE LARYNX. 357

paneled and withdrawn. The hairs usually engage the foreign body and
withdraw it. This same instrument may be used with advantage in the
esophagus. To introduce the instrument the patient should be seated
in a straight-backed chair, with the head well thrown back so as to bring
the mouth, pharynx, and esophagus on the same line. The instrument
is coated with glycerine, or white of egg, and then slowly introduced
over the back of the tongue. A long bullet forceps may be of advantage
to secure hard objects, such as coins. If these methods fail to secure the
foreign body, esophagotomy may ue performed. Before this is done, the
foreign body should be accurately located by means of the x-rays.

Foreign Bodies in the Larynx, Trachea, and Bronchi. — Foreign
bodies may lodge in the larynx above the vocal cords, in the chink be-
tween the vocal cords, or in the ventricle of the larynx. They may also
lodge at the entrance of the larynx, or they may pass farther on, falling
into the trachea, and perhaps, in some cases, entering the bronchi. The
s}rmptoms depend upon the extent of interference in the ingress and
egress of air. Sometimes the symptoms are rapidly urgent, but at other
times they cause but an irritation of the throat. If the foreign body
falls into the trachea, it excites violent spasms of coughing and dyspnea,
providing the body is of sufficient size to more or less obstruct the tube.
Where the foreign body is small, and falls down into the bronchus, it
may occasion great dyspnea, or the patient may be able to tell by sub-
jective sensation the location of the foreign body. The foreign body is
usually gotten in during forced inspiration, and while the head is
thrown back, rendering it easy for the object to enter.

Treatment. — -The patient should immediately be swung by his heels
to prevent the foreign body from falling into the lung. Snuff may
be administered, with the hope that the body may be expelled without
operative interference. This usually does no good. With the aid of a
laryngeal mirror, and a good light, the foreign body may
be reached with a forceps, if it is in the larynx. If
not, a probang introduced may engage the foreign body.
Where this fails, laryngotomy or tracheotomy may " be per-
formed. Laryngotomy should never be performed in a child under thir-
teen years of age. In older persons, laryngotomy is an excellent opera-
tion. In young children, tracheotomy is the rule. There are two oper-
ations for tracheotomy, the high and the low operation. The high oper-
ation is done above the isthmus of the thyroid cartilage. At this point
the trachea is more superficial and there is less danger of hemorrhage.
It should be performed at this point under all circumstances if possible.
The trachea should be carefully opened, and the foreign body having
been previously located, if it exists in the larynx, it may be pushed into
the pharynx by introducing the little finger into the trachea. The for-
eign body should be recovered. The lower operation should only be
done when the foreign body is low down in the trachea, and when the
high operation is not feasible. For the technic of the operation, the

358 DISEASES OF THE NOSE.

student is referred to an operative surgery. Quick laryngotomy is done
through the crico-thyroid membrane just above the cricoid cartilage,
avoiding the .. crico-thyroid artery, care being taken not to injure the
vocal cords.

Intubation. — Intubation may be performed with advantage in laryn-
geal croup, diphtheria, or in edema glottidis. For the technic of the
operation, the student is referred to more extensive texts.

Examination of the Nose. — In examination of the nose, the cavity
should be thorough!}7 illuminated by means of an electric light, or
rhinoscopic mirror, while the alae are distended by means of a suitable
speculum. This examination, if thoroughly made, will reveal the pres-
ence, or absence, of foreign bodies, polypi, inflammation, growths, or
ulcerations.

Polypi. — Xasal polypi are of three forms:

1. Myxomatous, or gelatiniform tumors. 3. Malignant, which may he either

2. Fibrous, or forms of soft fibromata. sarcomatous, or carcinomatous.

The tumors are of various shapes, oval, pedunculated, or sessile. The
most common forms are either pink, gra}rish-white, or semi-translucent.
There may be one, or a number. Polypi should be removed by electric
snare, or they may be pulled off by a polypus snare and the base cauter-
ized. This cauterization of the base is necessary, since tumors will re-
turn in two or three weeks if it is not done.

Catarrh. — There are various forms of inflammations of the mucous
membrane of the nose. These are attended by symptoms depending
upon the nature and severity of the disease. The disease may be suc-
cessfully combated in all ordinary forms by manipulative methods
described in texts on Osteopathic Practice. In bad cases, where there
is a foul discharge and an ulcerated condition of the mucous membrane,
an alkaline antiseptic may be of advantage. For this purpose, DobelPs
solution is perhaps best. Peroxid of hydrogen may do equally as well
when diluted one part of the peroxid and two parts of distilled or boiled
water. In tubercular and s}rphilitic diseases of the nose, local treatment
may do some good, but a cure can be effected only by constitutional
measures.

Ozena. — Ozena is a condition of purulent inflammation of the nose.
It is accompanied by a very foul discharge. The condition is produced
by atrophic nasal catarrh, caries, and necrosis of the bones, and by
syphilitic and lupoid ulcerations. Sometimes foreign bodies may occa-
sion a condition much like this in debilitated children. The treatment
is to cleanse the cavity.

Deflection of the Septum occurs as a congenital malformation, or is
the result of injury. Where the deformity is but slight, it may occasion
no symptoms, but where it forms a distinct projection into one nasal
cavity, with a corresponding depression in the other, it may affect the
voice, occasion headaches, partial deafness, and various nervous symp-

WOUNDS OF THE CHEST. 359

toms. The treatment is to forcibly straighten the septum by means of
appropriate forceps. It may be necessary in some cases to insert a hol-
low plug to maintain the septum in its normal position until reparative
tissues will develop to permanently anchor it.

Adenoid Vegetations. — Some subjects are apparently disposed to the
development of adenoid tissues. In these cases, the adenoid tissues
may enlarge and develop in the upper and back part of the nose and in
the upper part of the pharynx. These vegetations may often produce a
condition of mouth-breathing. The child is a dullard, the voice is
changed, and the nostrils widened and thickened. Soft tumefactions
may be felt behind the nose in the upper part of the pharynx, or they
may be readily seen by the aid of a laryngoscopic mirror. Where manip-
ulative treatment fails, they should be cut or burned out.

Tumors of the Phaiynx are extremely rare. Only the benign tumors
are operable. Malignant tumors should be treated by other methods.

Edema of the Glottis is produced by congestion and exudation of
serum beneath the mucous membrane of the epiglottis and the upper
part of the larynx. It is produced by inflammations, injuries, bee-
stings, erysipelas, fevers, small-pox, etc. The symptoms may come on
rapidly, attended by hoarseness, loss of voice, dyspnea, etc. Every
effort should be made to relax the tissues and relieve the return circu-
lation. Inhalations of steam may be of advantage, or just when it is
appearing, the application of ice to the throat. If this fails, the epi-
glottis may be punctured in several places with a small instrument to
permit the exudation of serum, thus relieving the urgent symptoms.
Intubation, or operative treatment, may be necessary.

Laryngeal Tuberculosis and Syphilis. — In these diseases, no local
treatment is effective. Only constitutional treatment gives relief.

Tumors of the Larynx. — The symptoms of tumor are hoarseness,
loss of voice, and d)7spnea, which may, or may not, be paroxysmal, de-
pending upon whether or not the tumor is pedunculated. The tumor
may be of various shapes. The diagnosis can be readily made by means
of the laryngoscope. The tumor may be removed from within while yet
small by an electro-cautery snare.

Tumors of the Parotid Gland. — Only benign tumors of the parotid
gland can be removed by operation. Sarcoma or carcinoma of this
organ cannot be successfully removed, and therefore should not be
operated upon.

Thyroid Gland, — Operations for ligations of the superior, or in-
ferior, thyroid artery, and extirpation of the gland for the relief of
goitre, are not warranted. The disease yields to appropriate osteo-
pathic treatment.

INJURIES AND DISEASES OF THE CHEST.

Wounds of the Chest Wall. — Non-penetrating wounds and con-
tusions of the chest wall may result in a localized pneumonia, or

360 EMPYEMA.

pleurisy, or they may cause pain, cough, and the expectoration of
bloody mucus, but are not serious. They should be treated as ordinary
wounds.

Punctured Wounds of the Pleura. — Punctured wounds of the pleura
may, or may not, involve the lung. Where the lung is not involved,
the wound is not so serious, and if hemorrhage is not severe, healing
may take place with but little difficulty, but if the lung js involved,
the wound is at once grave. It will be attended by great shock, pain,
and severe coughing, with more or less dyspnea, depending upon the
size of the wound. Air will escape from the wound into the pleural
sac, causing a condition of pneumothorax, while pulmonary collapse
may take place. The air in conditions of penetrating wounds of the
lung will be sucked into the wound during inspiration. If the wound
is of sufficient size, as occurs in stab-wounds of the chest, hernia of
the lung may follow. Where the hernia can not be restored within
the cavity, the part should be ligated and excised.

Incised wounds of the chest are usually fatal, because of rapid
hemorrhage and sudden collapse. Bullet wounds are not so serious.
This hemorrhage is treated in various ways. Where the intercostal
artery is wounded, two layers of antiseptic gauze may be placed over
the wound, and absorbent cotton pushed, with the gauze around it, into
the pleural sac. Enough cotton should be introduced to prevent its ex-
traction upon traction on the gauze. This will compress the intercostal
arteries so as to arrest the hemorrhage. It likewise will assist in ar-
resting the hemorrhage within the pleural cavity. Some surgeons
advise enlarging the wound and packing the lung with gauze. Em-
physema of the chest wall is not always an evidence of lung puncture.
Where the case is doubtful, the hemorrhage should be checked and the
part strapped and rendered more or less immovable, while the patient
is kept quiet in bed.

Pleuritic Effusions. — Serous effusions will take place within the
pleural cavity in debilitated conditions. These pleuritic effusions often
are allowed to remain for some length of time. The mouths of the
lymphatics becoming agglutinated, or pressed together, and efforts
toward absorption failing, aspiration of the effusion will be required.
The diagnosis of pleuritic effusion may be made by physical examina-
tion.

Empyema. — Empyema is a condition of pus within the pleural cav-
ity. This pus is the result of an infection of the effusion which follows
inflammations of the lung and pleura. The pus in the pleural cavity
may be the result of acute, or chronic, inflammation. In so-called
empyema, while the material looks like pus, it contains no micro-
organisms. Tn some cases, empyema is the result of the activity of the
tubercle bacillus. A bacteriological examination will determine whether
put cocci are present. The diagnosis is made by the signs of ab-
scess, the absorption of pus, hectic fever, and the evidence of pleuritic

STRICTURE OP THE ESOPHAGUS. ■ 361

effusion manifest upon physical examination. In pleuritic effusions,
and in empyema, where the symptoms are urgent, the lung should be
aspirated. Simple puncturing of the pleural cavity is no longer done.
There is too much danger of infection, in fact, many cases of pleuritic
effusion, at first sterile, have been rendered septic, and perhaps tuber-
cular, by the use of an unclean trocar. The side of the patient, the
hands of the operator, and the instruments, should be rendered thor-
oughly aseptic. h\ the axillary line, in the fifth intercostal space, the
aspirating needle should be introduced. The fore-finger of the operator
should be pressed against the upper border of the sixth rib so as to pre-
vent introducing the aseptic needle too close to the rib and thereby
puncturing the intercostal artery. A tiny incision may be made in the
skin, to make the puncture more easy. An instrument similar to
Potain's aspirator may be used and the fluid sucked out of the cavity,
no air being allowed to enter. This aspiration may be repeated if occa-
sion demands, but in most cases, if the proper treatment is instituted at
once, succeeding aspirations will not be required. In case of empyema,
where it is necessary to establish drainage, resection of the ribs will be
necessary. One or more ribs may be resected, likewise resection of a
rib may be done in cases of pneumonotomy, or pneumonectomy, for
abscess of the lung. For the teehnie of the operation of resection of a
rib, texts on operative surgery should be consulted.

Pneumothorax.— In case of puncture of the lung from fractured ribs,
effusions of air may take place within the tissues. If the pneumo-
thorax is pronounced, or the emphysema of the tissues is very great,
puncture by means of an aspirating needle may be performed, but strap-
ping of the emphysematous area will usually suffice. Occasional^, how-
ever, abscess is produced by such effusion of air, but this is rare.

DISEASES AND INJURIES OF THE DIGESTIVE TRACT, ABDOMEN

AND PELVIS.

Diverticula of the Esophagus. — Diverticula of the esophagus are of
infrequent occurrence, and may be congenital, or acquired. As a rule,
they occur on the posterior wall of the esophagus at its junction with
the pharynx. The causes are malformations and degenerations of the
muscular fibres of the esophageal wall and stricture. Each of these
conditions is responsible for pouch-like dilations, or diverticula. The
symptoms are dysphagia, more or less dyspnea, because of pressure on
the trachea, with the presence of tumor in the neck and regurgitation
of undigested food some hours after eating. The treatment is palliative.
Where the condition is congenital, it may be removed by operation.

Stricture of the Esophagus. — Stricture of the esophagus is either
spasmodic or organic, the spasmodic form being due to spasms of the
circular muscle fibres. Organic strictures are the result of the forma-
tion of fibrous tissue and cicatricial contraction, because of the erosion
of the esophagus by chemicals, or superheated fluids, or because of

362 INJURIES OF THE ABDOMEN.

injury. Malignant strictures form a certain class, and are due to the
development of cancer. Stricture of the esophagus may be simulated
by pressure iipon the esophagus from aneurysm, enlarged thyroid gland,
mediastinal tumor, and foreign bodies.

Spasmodic Stricture usually occurs in nervous women, and there are
evidences of hysteria. The patient can swallow at times, but if a bougie
is passed, the presence of the stricture is readily determined. If the
patient is given chloroform, the stricture disappears.

Organic Stricture occurs in two forms, fibrous and malignant.
Fibrous stricture may, in rare instances, be syphilitic; usually it affects
the upper half of the esophagus. Pouch-like dilatations will occur
above the stricture. The history of the case, together with the presence
of the stricture, will determine the diagnosis.

Malignant Stricture is often due to the development of an epithe-
lioma within the tube. The upper and lower ends are usually affected.
It may ulcerate into the trachea, or externally. The symptoms are very
often obscure; there is difficulty in swallowing, pain, exhaustion, hem-
orrhage, a foul discharge, and the patient is of advanced age. On
auscultation, a trickling sound may be heard over the esophagus. In
some cases, no symptoms may be evident until ulceration takes place
into the trachea, when the patient may die in an effort at drinking
liquids.

Treatment. — In hysterical stricture, whatever osteopathic lesion is
found must be removed. In the fibrous form, gradual dilatation with a
bougie is the proper treatment. In the malignant form, a soft tube
should be passed, either through the nose, or mouth, and left in situ.
Objectionable as this may seem, patients often apparently gradually
improve after passing the tube, by which they may be given a sufficient
amount of liquid nourishment. At best, it is a disagreeable method of
prolonging life. Gastrotomy may be performed in some cases, but this
hardly seems justifiable.

Contusions of the Abdominal Wall. — Contusions of the abdominal
wall are always grave, inasmuch as they may be attended by injury, or
rupture of the viscera. Very often there is great shock. The patient
should be put to bed, with the legs flexed on the abdomen, and care-
fully watched. If there is no evidence of internal injury, as soon as the
shock is relieved, an ice bag should be placed over the injury, to lessen
the amount of blood effusion. The shock should be treated by an equal-
ization of the circulation and the application of heat. Sometimes con-
siderable effusion of blood will take place in the muscle planes, or the
rectus muscle may be ruptured. Should the injury demand it, which
may be determined upon recovery, the integrity of the abdominal wall
may be restored by means of operation, but this is rarely necessary.
Under no circumstances should the blood, which has effused, be let out.
When there is evidence of abscess, it may be treated as such. Manipu-
lation will diffuse the effused blood and replace the viscera. The bowels

INJURIES OF THE ABDOMEN. 363

should be moved by appropriate treatment. A binder should be applied
until the integrity of the abdominal wall is established. Where ab-
scess develops from the extravasation of blood or urine, early incision
and drainage will be necessary.

Eupture of the Peritoneum. — The peritoneum may be lacerated by
injury. It is always attended by grave symptoms of shock and internal
hemorrhage. The patient rapidly sinks and faints away, while the surface
becomes cold and blanched. There is absence of vomiting, and in some
cases, pain may be absent, but usually there is marked rigidity of the
muscles. Unless the rupture is closed, peritonitis quickly supervenes.
If there is great shock, localized pain, evidences of internal hemorrhage,
shown by rapid, weak pulse, together with dullness over the injured
area, with great rigidity of the abdominal muscles, an operation should
be performed and the abdominal cavity explored, and if there is a rent,
it should be closed by suture. Where the operation is not performed,
the treatment should be rest, quiet, etc., practically the same as in acute
peritonitis.

Rupture of the Viscera. — Any of the abdominal viscera, with the ex-
ception, perhaps, of the pancreas, are liable to injury, and sometimes
the pancreas may be injured in stab or gun-shot wounds. Eupture of
the viscera is the result of great violence, such as a heavily loaded
wagon passing over the body, or severe blows. The liver, stomach, gall-
bladder, and intestines are more frequently injured.

Liver. — Injury to the liver is attended by severe hemorrhage, by
great pain, which is localized, an increasing area of dullness, due to the
effusion of blood, profound shock, and later, peritonitis. In some cases,
jaundice follows in a few days, or more rarely, diabetes. An examina-
tion should.be made for fractured rib over the liver. Eupture of the
liver is usually fatal, although some mild cases majr get well of them-
selves. Severe rupture of the organ is attended by fatal internal hem-
orrhage, inasmuch as the vessels remain open because of the structure
of the organ, and will not close, as occurs in other soft tissues.
Xature's method of controlling hemorrhage is of no avail.

Spleen. — Injury to the spleen is evident because of severe local
pain, increased area of splenic dullness, and, perhaps, fracture of the
ribs on the left side. Hemorrhage is very severe, and may be fatal.
Shock and collapse usually come on quickly. The injury will be fatal
unless there is operative intervention.

Stomach. — Extreme collapse attends rupture of the stomach.
Usually the injury is rapidly fatal. There is severe general pain,
which is more severe in the epigastric region, and extreme localized ten-
derness. There is free gas in the abdominal cavity, which brings about
a lessened area of liver dullness. Usually there is vomiting, the con-
tents having more or less blood intermingled. The stomach can not be
inflated with hydrogen. The contents of the stomach will effuse into
the peritoneal cavity, setting up a rapidly spreading, fatal inflammation.

364 INJURIES OF THE ABDOMEN.

Gall-bladder. — The gall-bladder is sometimes ruptured, which causes
groat pain and shock, together with a rapidly developing peritonitis.
There is great emaciation and distention of the cavity, with a bile
stained fluid.

Intestines. — Eupture of the intestines is attended by intense pain
and rigidity over the abdomen, but more severe at the point of the in-
jury. Vomiting is usually present, first of the contents of the stomach,
and second of bile, and perhaps blood. Very often there are bloody
stools. Tympanites is present, while there is dullness along the sides
of the abdomen. Fatal peritonitis usually follows. If rupture is small,
and the effusion of the contents of the abdomen but little, the rupture
may become glued to some part of the viscera and but a local inflamma-
tion result.

Kidney. — Injury of the kidney is attended by more or less injury to
the back. There is increased frequency of micturition and bloody
urine. TJrine extravasations may take place in the loin. There are
evidences of bruising and lumbar pains. There is more or
less retraction of the testicle. In case of extravasation of the urine
about the kiclne}'', a perinephritic abscess will likely follow. There may
be pus in the urine. A diagnosis of the perinephritic abscess can be
made without difficulty.

Ureter. — Eupture of the ureter gives rise to a fluctuating retro-
peritoneal swelling, together with bloody urine. This occurs
after a few days.

Injury to the abdominal viscera is attended by great shock and col-
lapse, but there are cases where marked rigidity of the abdominal
muscles, together with a rapid pulse, are about the only symptoms of
the injury. Evidences of internal hemorrhage which can be localized
by the symptoms should be treated by laparotomy and the bleeding
vessels secured. In case of the liver, where it is possible, the organ
should be sutured with sterilized gut sutures, but as a rule this can not
be clone, the best treatment being to pack the rupture liberally with
gauze, one end of which is brought out of the wound, and wdiich may be
removed when danger of hemorrhage has ceased. The same treatment
may be advised in case of the spleen, but usually splenectomy is per-
formed, inasmuch as this organ may be safely removed, and yet the
patient enjoy good health. Where the injury is of the gall-cyst, or in
any of the hollow viscera, where it is possible, the rent should be closed
by means of Lembert sutures placed one-eighth or one-sixteenth of an
inch apart. If the injury to the intestines is such that after closure,
more than one-half of the lumen of the intestines will be cut off, in-
testinal anastomosis is advisable, or where there is severe injury to the
duodenum, the gall-cyst may be united to the intestine at another point.
The abdominal wall should be closed by means' of a through-and-
through silkworm-gut suture — that is, the suture extends entirely
through all of the structures of the abdominal wall. It may be neces-

INTESTINAL ANASTOMOSIS.

:;•;.-,

sary in some cases to inflate the intestines, or stomach, with hydrogen
gas (Semi's method), in order to find the injury. Rectal or intra-venous
injections of hot normal salt solutions, may be necessary to save the
patient's life.

Intestinal Anastc- Fig. 121.

mosis. — Intestinal an-
astomosis is most
quickly performed by
means of Murphy's
button, and this is
often the safest
method. The button
is made of various
sizes, suitable to any
part of the intestinal |'
tract and the gall-
cyst. It consists of a
male and female por-
tion which fit snugly
together. By means of
this button the d i vided
and inverted ends of the gut are securely held together, the peritoneal
coats being held in contact. The operation consists of the following:
After removing the portion of the intestines, the portion of the button
is inserted into the lumen of each end of the intestine, while the edge
of the cut end of the gut is drawn around the button by means of a
purse-string suture, a double turn being necessary at the mesenteric
attachment. After both the male and female portions are inserted,
the parts are pushed together. The slit in the mesentery is closed by
moans of continuous sutures. Before the button is pushed together,
the peritoneal surfaces may be gently scratched with a needle. These
peritoneal surfaces unite, the edges of the bowel slough off, and the

Fig. 122.

Method of performing lateral anastomosis.

/ v I w \\\ ,

Method of performing intestinal anastomosis by means of Murphy's button.

3G6

WOUNDS OF THE VISCERA.

Fig. 123.

button will pass within ten days, or two weeks. Before the bowel is
returned to the abdominal cavity, it should be washed and cleansed and
any part of the contents of the gat removed from the abdominal cavity.
If the button does not pass within four weeks, a rectal examination
should be made. Liquid nourishment should be given as soon as the
patient recovers from the shock of the operation. The bowels should
be moved early (second day) and thereafter kept open. There are other
methods of perforating lateral anastomosis and circular enterorrhaphy,
but these operations are most successful in the hands of those who de-
vised them. The end-to-end anastomosis by means of Murphy's button
has the advantage that it is most rapid, and there is less shock.

Open Wounds of the Abdomen. — Open wounds of the abdomen
mav be divided into penetrating, and non-penetrating. In the
non-p enetrating

wounds, care should
be taken to secure ap-
position of the differ-
ent layers of fascia
and muscles after the
wound has been thor-
oughly cleansed. The
chief danger of non-
penetrating wounds
of the abdominal pa-
rietes is that the wall
may be so weakened
that hernia may re-
sult. Otherwise these
wounds will require

no special attention Halsted's method of performing enterorrhaphy.

different from other wounds. Penetrating wounds of the abdomen are
always grave. They vary in gravity, depending upon whether there
is any wound or injury to the viscera, or whether any of the
viscera protrude. Protrusion of the viscera renders sepsis more likely.
The peritoneal cavity must be regarded as a large lymph space which
communicates directly with the connective tissue spaces of all the sur-
rounding tissues and organs, so that septic material once gaining access
to this cavity, is quickly absorbed, producing a condition of general
poisoning. Punctured wounds may be divided into three classes :

1. Wounds with no injury to the viscera.

2. Wounds with protrusion of the viscera.

3. Wounds complicated hy injuries of the viscera.

Wounds With No Injury to the Viscera. — Penetrating wounds of the
abdomen should be explored, even when there is no injury or protrusion
of the viscera, and there is no evidence of septic material having en-
tered the cavity. The wound should be closed, with the layers of the

TRAUMA TIC PERITONITIS.

367

abdominal wall nicely approximated by means of a through-and-through
silkworm-gut suture.

Wounds With Protrusion of the Viscera. — The treatment of these
wounds will depend upon the condition of the viscus protruding. If
the viscus is healthy, all it will require is thorough cleansing, when it
may be returned. If the circulation has been cut off to the part and it
is gangrenous, intestinal anastomosis should be done, the gut thor-
oughly washed and cleansed and returned. The wound may then be
closed by means of a through-and-through abdominal suture.

Fig. 124.

Method of closing wounds of the stomajh or intestines by Lembert's suture.

Wounds Complicated by Injuries of the Viscera. — When the stomach
or intestines have been injured, as from a stab or gunshot wound, the
opening in the viscus should be closed by means of a Lembert or Hal-
sted suture. After the openings have been closed, the peritoneal cavity
must be thoroughly washed out in all its parts with several gallons of
sterile salt solution. Where it is imperative to operate immediately,
and the means are not at hand to accomplish intestinal anastomosis,
the gut may be fixed in the wound in the abdominal wall and an arti-
ficial anus made. Intestinal anastomosis should be performed when
there is gangrene or sloughing of the bowel, or when there is such in-
jury that the closing of the bowel would obstruct more than half its
lumen. Anastomosis may be done by the lateral or end-to-end method.

Traumatic Peritonitis. — This disease is considered here only in its
surgical aspect. A large per cent, of the cases of peritonitis may be
treated very successfully by osteopathic methods. For the treatment
of other forms of peritonitis, the student is referred to works on
Osteopathic Practice.

Traumatic peritonitis may be (A) Local and (B) General. The
causes of this form of peritonitis are injury and infection, associated

368 PERITONITIS.

with lesions of the lower ribs and any spinal lesions which may affect
the visceral rami of the sympathetic, bringing about vasomotor dis-
turbances, or. pelvic lesions affecting the nerve and blood supply of the
peritoneum, pelvis, and lower bowel, or any lesions affecting any of the
abdominal viscera. The exciting causes may be specified as penetrating
wounds, rupture, and disease of the hollow abdominal viscera, septic
diseases of the viscera, and rupture into the peritoneal cavity of an
abscess. The inflammation may be only local, or may involve the entire
membrane.

Local Peritonitis is caused by penetrating wounds, appendicitis,
salpingitis, cholecystitis, or small perforations of the stomach or intes-
tines. In other conditions, there is low virulence of the micro-organisms,
or a rapid formation of the inflammatory exudates, which glue the tis-
sues round about, and may localize the process.

Symptoms. — The symptoms are more or less pain, local tenderness,
nausea, slight fever, and a rapid pulse. The muscles are rigid over the
part inflamed. Later, the inflamed part will form a hard mass, within
which there may be an abscess cavity. Should the abscess form, it may
enlarge to considerable size. This abscess may rupture into the viscera,
onto the surface of the body, or it may rupture into the peritoneal
cavity, causing acute diffuse peritonitis and death. The general symp-
toms of such localized abscess formation are chills, fever, and sweats,
together with more or less emaciation and evidences of a fluctuating
tumor.

Treatment. — Under all circumstances, when the abscess has been
determined, an operation should be performed to evacuate its contents.

General Peritonitis. — Causes. — It may result from a local peritonitis,
or from a high grade of virulence of the infection, or of a large num-
ber of germs. It may come from perforation of the stomach, intestines,
or appendix. It may result from puerperal inflammations extending
through the uterus and its appendages. There are no adhesions in this
disease, or if any are formed, the inflammation quickly spreads beyond
them. The peritoneum is red, congested, and thickened. On autopsy,
it is found covered with a fibrinous exudate, or there may be masses of
coagulated fibrin scattered through the cavity and over the viscera.
Usually a foul odor emanates on opening the cavity. In some cases,
there may be general diffusion of pus.

Symptoms. — At first the symptoms are those of a local inflamma-
tion. There may be local or general pain over the abdomen, and a feel-
ing of weakness, exhaustion, and general malaise. Nausea and vomit-
ing appear early. There is an elevation of temperature and
acceleration of the pulse, while the patient appears anxious and is
flushed. Muscular rigidity is more or less general over the abdomen,
but greatest over the point of infection. As the disease progresses, the
abdomen becomes distended and tender, while rigidity of the muscles
becomes greater. The temperature rises, while the pulse becomes more

FOREIGN BODIES IN THE S TO MA CH . • 369

frequent; in short, the patient seems prostrated with sepsis. The bowel.*
are confined, and are more or less paralyzed, because of which there is
considerable distension from gas, although some gas may at first be ex-
pelled. Pain and tenderness apparently become lessened, because of
the action of the septic poisoning upon the brain and nerve centers. The
patient lies upon his back, with his legs drawn up, while the abdomen is
greatly distended and the respirations are shallow. The face is drawn, the
mouth and tongue dry, and the teeth are covered with sordes. Delirium,
as a rule, is present. Vomiting is the rule, although the patient may
be able to swallow and retain fluids. The vomited matter consists first
of the contents of the stomach, afterwards that of the intestines. The
temperature in some cases may be very high, while in others it may be
subnormal. The pulse becomes rapid, feeble, compressible, and inter-
mittent. Usually, efforts towards moving the bowels are futile when
the case becomes pronounced.

Prognosis and Treatment. — The prognosis of the disease depends
upon the cause and the severity of the infection. Where the disease
arises from rupture of the stomach, or gall-bladder, or a ruptured ab-
scess of the appendix, it is fatal. Cases arising from puerperal
infection extending through th-3 uterus and Fallopian tubes are
especially grave. Where the disease arises from perforation of the hol-
low viscera, or from rupture of an abscess within the peritoneal cavity,
only prompt surgical interference gives any hope of recovery. A mod-
erate opening should be made through the abdominal wall and all parts
of the peritoneal cavity washed out by means of irrigation with a large
quantity of sterile normal salt solution. After this is done, the wound
should be closed and drainage established by means of a cigarette drain.
The bowel should be moved by means" of enemata of glycerine, soap-
suds, turpentine or castor-oil. The patient should be given fluids in large
quantities, to encourage action of the kidneys in eliminating as much of
the poison as possible. Salines are said to have a beneficial effect.

Foreign Bodies in the Stomach and Intestines. — Foreign bodies which
can pass through the esophagus can pass through the intestinal canal,
but they may lodge in any part of the tract. The symptoms vary
according to the location and the inflammation arising. These foreign
bodie's are usually swallowed by children, drunkards, or the weak
minded. Foreign bodies, such as pieces of glass, needles, and fish bones,
may occasion serious trouble by being caught in the folds of the mucous
membrane. Museum freaks often eat glass, tacks, nails, etc., without
occasioning very serious trouble. A purgative should never be admin-
istered to hasten the passage of the foreign body, but a diet should be
given which leaves considerable residue and which may encase the for-
eign body and insure a safer passage. Many foreign bodies may be
skiagraphed and accurately located. It is sometimes possible to feel
the foreign body. If the foreign body lodges, the symptoms will be
largely those of intestinal obstruction. In such cases, an operation will
be required.

370 CANCER OF THE STOMACH.

Cancer of the Stomach. — Cancer of the stomach may occur in either
ourvature, the cardiac or pyloric end, or on the anterior or posterior
surface. Inthe majority of cases, the cancer is in the pyloric extremity.
When it occurs in the pyloric extremity, there is constriction of the
pyloric orifice, and the symptoms will be those of advanced age,
indigestion, progressive emaciation, weakness, and cachexia. A drag-
ging pain, which is increased upon eating, is present. Vomiting is fre-
quent, but is usually not very early. When the cardiac end is in-
volved, the vomiting is soon after eating, but when the pyloric extrem-
ity is affected, the vomiting is usually an hour or more after eating.
The vomitus is in the nature of coffee grounds, due to the action of the
fluids of the stomach. The presence of blood in the vomitus occurs
m only about 40 per cent, of the cases. As a general rule, there is no
free hydrochloric acid found in the gastric juice. Later in the disease,
there is formation of a tumor, which can frequently be felt by distending
the stomach with gas or fluid. To distend the stomach with gas, have
the patient take a Seidlitz powder in the following manner: The bicar-
bonate should be mixed in a half -cup of water, and may be all drunk at
once. The tartaric acid is dissolved in the same amount of water and
gradually sipped. The gas forms quickly and will distend the stomach,
when the tumor may be made out upon careful examination. To deter-
mine the presence or absence of free acid, a test meal may be given, and
later the stomach washed out and the vomitus examined. The diag-
nosis is difficult. The prognosis is unfavorable. Death usually occurs
in five or six months, but may be delayed two years.

Treatment. — The correction of rib or spinal lesions may relieve the
symptoms. Improvement of the circulation and blood supply to the
stomach should be kept up during the entire course of the disease. The
symptoms should be treated as they arise. The measures are palliative
and consist in limiting the diet to milk, gruels, and predigested foods.
Lavage of the stomach should be advised. After the tumor is made
out, in some cases, operation majr be advised. The operation consists in
removing the cancerous area, and it has been successfully done in a
number of cases. Almost the entire stomach has been successfully re-
moved by a number of operators in this country and abroad. The opera-
tion usually done is . gastroenterostomy, where the small intestine is
brought up and attached to a healthy part of the stomach.

Ulcer of the Stomach. — Causes. — Rib or spinal lesions affecting,
either directly or indirectly, the nerve and blood supply to the stomach.
"The condition of the 8th and 9th ribs anteriorly, and the 5th to 8th
ribs posteriorly, must be looked to" (Hazzard). It occurs in young
women. The ulcer is usually located in the pyloric region; only two
per cent, perforate. Only rarely may the ulcer be located on the an-
terior wall, when perforation may occur. The disease often attends
menstrual disorders or chlorosis, and seems to be influenced to some
extent by tight lacing, or by bending over, and thus compressing the

INTESTINAL OBSTRUCTION. 371

stomach. Alcoholism, anxiety, and dyspepsia are, if not exciting, con-
tributing causes.

Symptoms. — The symptoms of ulcer of the stomach are those
of acid dyspepsia and flatulency. Vomiting occurs two hours after
eating. The vomitus contains a considerable quantity of free hydro-
chloric acid. Blood is often vomited and the stools may be tarry, owing
to the presence of blood. There are violent paroxysmal pains, which
are aggravated by the taking of food. The pain is boring in
character and extends back to between the 8th and 9th dorsal vertebrae.
Usually there is considerable local tenderness upon pressure. Perfora-
tion of the ulcer is evidenced by rapid collapse, muscular rigidity, and
violent pains, which are increased upon the drinking of liquids. Where
the diagnosis can be made, a surgical operation should be performed,
and the edges of the ulcer united, and the effused contents of the stom-
ach washed out of the peritoneal cavity.

Treatment. — Osteopathic treatment should be relied upon in the
treatment of ulcer of the stomach. For a full description of the treat-
ment, texts on Osteopathic Practice should be consulted. Surgical
measures should be used only after perforation.

Stenosis of the Pyloric Orifice. — Stenosis of the pyloric orifice may
be made out by the following symptoms. The vomiting of food, which
has been taken several days previously; dyspepsia, and gradual disten-
sion of the stomach, with more or less pain. The dilated stomach
can be made out by a careful physical examination after distention with
gas. There is as. absence of cachexia, which attends cancer, and no free
hydrochloric acid. Where the stenosis is produced by a malignant
growth, the symptoms will be the same as those of cancer of the
stomach.

Intestinal Obstruction. — Intestinal obstruction is a condition where
there is partial or complete obstruction to the flow of the contents of
the bowel. Where there is obstruction to the circulation also, it consti-
tutes strangulation. It may arise from the following conditions :

1. Fecal Impactions, Foreign Bodies, Gall-Stones, Etc. — Fecal
impaction is the result of habitual or acute constipation, and
usually takes place in the large bowel, in the cecum, sigmoid flexure, or
rectum. Foreign bodies are raro, inasmuch as they can usually pass
through the canal of themselves. They may lodge in the ileum, cecum,
or rectum. Gall-stones and enteroliths sometimes produce obstruction
by fecal matter accumulating upon them. This may take place in the
small intestines. In some cases, there is a sort of paresis of the muscu-
lar wall of the bowel, which brings about the obstruction.

2. Volvulus. — Volvulus is a twisting of the bowel, either on its
own axis or upon the axis of the mesentery. It usually occurs in the
sigmoid flexure. It may occur in a hernia.

3. Intussusception is a telescoping or invaginating of the bowel.
The varieties are: (a) Ileocecal, where the ileum and ileocecal valve

372

INTESTINAL OBSTRUCTION,

Fig. 125.

Intussusception or telescoping of the bowel.

are prolapsed into the ascending colon, (b) Colic, where it occurs in the
colon. ' (c) Ileocolic, where the ileum is driven through the ileocecal
valve into the cecum and ascending colon. (d) Ileal, where only the
ileum is involved.

4. BANDS. — Obstruction by bands is brought about by peritoneal

adhesions, omentum and Meckel's
diverticulum (the persistence of the
vitellin duct, which comes off about
three feet above the ilocecal valve).
Obstruction by bands often takes
place in appendicular inflamma-
tions, or in disease of the Fallopian
tubes.

5. Tumors of the Bowel.— The
development of benign and malig-
nant tumors of the bowel may bring
about obstruction.

6. Tumors or Other Abnormalities Outside of the Bowel, such as mal-
position of the womb, retroflection or pregnancy, cysts and tumors of
the viscera, may cause obstruction.

7. Stricture of the Intestine, from injury or malignant growths, may
be the source of obstruction.

Symptoms. — The obstruction of the bowel may lie partial or com-
plete, acute or chronic, or there may be strangulation. When
strangulation exists, the blood supply has been cut off to a cer-
tain part of the bowel. The symptoms in acute obstruction are shock
and severe colicky pains, which are never absent, but there are frequent
exacerbations. The constipation soon becomes absolute, not even gas
passing. There is vomiting, first of the contents of the stomach,
then bile, and finally stercoraceous material. The abdomen is dis-
tended and tender. Usually there is some fever, although the temper-
ature may be subnormal. The face expresses pain, is anxious and shows
great shock. The pulse is rapid and feeble. When the obstruc-
tion is high, there will be neither vomiting nor tympanites. There may
be no great muscular cramping. The tongue is dry and the mind
clear. Peristalsis is very often vigorous and visible, and if not visible,
the case is likely to develop peritonitis. Digital explorations of the rec-
tum may reveal the condition. As a rule, early vomiting means a
tightly constricted condition of the .intestines. In chronic obstruction,
the attacks of pain are only at intervals, but they become more severe
with vomiting and constipation. Unless the obstruction is acute, there
is no stercoraceous vomiting. The constipation is not abso-
lute. ' There is a history of alternate diarrhea and constipation. Ab-
dominal distension is present. The patient gives a history of dyspepsia,
with loss of appetite, uneasiness, etc. Acute obstruction may follow
chronic obstruction.

APPENDICITIS. 373

Diagnosis. — The diagnosis may be made in the following manner:
Obstruction of the bowel by fecal accumulations gives a history of
chronic obstruction developing into acute. Constipation has preceded
the case. Very often a doughy-like mass may be made out in the sig-
moid flexure, cecum, or rectum. Pain and vomiting come on late. In
gall-stones, there is a history of the stone having passed. In case of a
foreign body, usually a history can be obtained. An x-ray examina-
tion may locate the foreign body. Volvulus is preceded by
constipation, and comes on with explosive suddenness; the constipation
is absolute, not even gas passing. It quickly attains great severity.
There is no tumor, and rectal examination is negative. The vomiting
comes on late, and is rarely stercoraceous. The abdominal distension and
tenderness are great, while peristalsis is very vigorous. The collapse is
not rapid. Intussusception occurs in children, usually in the iliac fossa.
A sausage-shaped tumor is present, tenesmus exists and bloody mucus
is passed from the bowel. The abdomen is not distended or tender.
The vomiting is not stercoraceous. The invaginated bowel
may be felt in the rectum. Bands are very often post-operative, or
there is a history of peritonitis. It usually comes on after violent exer-
tion and the attacks are like those of strangulated hernia — sudden and
the onset fierce. Vomiting is intractable and soonbecomes stercoraceous.
The pain is violent, while the peristalsis above the obstruction is very
vigorous. Collapse is early and muscular rigidity is pronounced. Obstruc-
tion is usually complete, and there is tympanites and distension because
of the accumulation of gas in the bowel above the obstruction; tender-
ness is very great. In tumor the examination or history of the case will
disclose the tumor. The symptoms are those of a chronic obstruction
engrafted upon acute.

Treatment. — The physician should first carefully examine all the
locations where hernia may occur. He should then determine whether
the case is one of appendicitis, peritonitis, or poisoning. The case
should be closely watched until the diagnosis is made. If it is one
of gall-stones or impacted feces, high enemata and manipulation will
give relief. Strangulation of the bowel, intussusception or volvulus
demand laparotomy. In no case should treatment be begun until an
accurate diagnosis is made.

Ulcer of the Bowel is said to sometimes follow burns. No surgical
treatment is required for these ulcers unless there is rupture, then oper-
ative interference is the only hope of saving life.

Malignant Tumors of the Bowel are sarcomata and carcinomata. Sar-
comata are very rare, while cancers are located at the ileocecal valve, in
the sigmoid flexure or rectum.

Appendicitis. — Appendicitis is an inflammation of the appendix ver-
miformis of the cecum. Other inflammations, such as typhilitis, peri-
typhilitis, etc., which occur in this region, are believed to
arise from inflammations of the appendix. The appendix is attached

374 APPENDICITIS.

to the lower, inner, and posterior part of the cecum, at which point the
pain and inflammation are greatest. It is indicated by McBurney's point,
which is located two and one-half inches up on a line from the anterior
superior spine of the ilium to the umbilicus. The position and relation
of the appendix has been the subject of great study. In two-thirds of all
cases, it has a well-developed mesentery, while in one-third of the cases,
it is more or less fixed in the iliac fossa, and there is no mesentery, or
one but partially developed. Its position in the abdominal cavity is
variable and will hardly be found in two cases exactly alike. Its length
may be from one to twelve inches, but is usually about four and one-
half. It has four coats similar to those of the large intestine. The
lumen is small and its opening into the intestine is guarded by the valve
of Gerlach.

Cause. — Appendicitis is a bacterial disease. In some cases, the
germs present are the pus cocci, while in others, the bacillus coli com-
munis. Infection is rendered possible by the diminished resistance of
the tissues of the appendix. This diminished resistance of the tissues
is brought about by interference in the blood supply, perhaps also inter-
ference in the nerve supply may be a contributing cause. This seems
to be supported by the fact that two-thirds of all cases are found in
yonng males, where the only blood supply to the appendix is from a
small branch of the ileocolic artery, while in the female an additional
blood supply is received by a small branch of the ovarian artery. Other
conditions contributing are the dependent position, the narrow mouth
and the short mesentery. Foreign bodies are not so frequently the
cause of this disease as was formerly believed. McBurney has stated
that he never saw but one grape-seed in the appendix, and that was by
accident, in performing an operation for another ailment. There were
no evidences of appendicitis. Four hundred and fifty-nine autopsies
show that in one hundred and seventy-nine cases, fecal concretions ex-
isted, while in sixteen, foreign bodies were found. In none of these were
there evidences of appendicitis. Interference in the blood supply is
brought about by twists, bruises, concretions, pressure, adhesions, and
perhaps, in some cases, the contraction of the psoas muscle may play an
important part. Da Costa says the disease is rare in women, because
the appendix has a larger blood supply. Without doubt, osteopathic
lesions, which affect the integrity of the lower bowel, will especially
affect the appendix, diminishing its resistance to the onslaughts of the
bacteria. Furthermore, that the disease is due to the interference in
the circulation, is proven by the fact that 70 per cent, of all cases will
recover without treatment. In a record of five hundred autopsies, 36
per cent, showed evidences of appendicitis. In none of these cases was
there any treatment administered for this ailment. This would indi-
cate that nature had overcome the pathological process by an increase in
the blood supply. In the combating of all inflammations, the freedom of
the blood supply is of the most vital importance. It is by means of a
good free blood supply that nature resists the onset of acute inflamma-

APPENDICITIS. 375

tions and acute infections. Kecognizing this fact, the osteopath may
relieve a large number of cases where operation would otherwise seem
imperative.

Varieties. — The disease may manifest itself in the following
varieties :

1. Catarrhal, where only the mucous and submucous tissues are
involved.

2. 0 bliterative, where the violence and extension of the inflammation
have resulted in the obliteration of the lumen of the appendix.

3. Suppurative, where the tissues of the appendix become infiltrated
with pus and an abscess forms.

4. Gangrenous, where the appendix dies because of the arrest of the
circulation.

5. Belapsing or recurrent, where the disease relapses or recurs at
various intervals.

Symptoms. — The symptoms of the disease are pain, more or less
general over the abdomen, or perhaps radiating about the umbilicus. It
finally becomes localized in the right iliac fossa, and at McBurney's
point the pain and tenderness are greatest. There is general malaise,
nausea, and \omiting, but in many cases this may not occur. At first,
there is little or no muscular rigidity over the area, but as the symp-
toms become more severe, the lower half of the rectus, the muscles over
the right iliac fossa, and other muscles, become rigid. The pulse is
rapid, while the temperature may not be elevated more than a degree.
In some cases, it soon runs to 102 or 103 degrees F., while in very bad
cases, the temperature may be higher. The disease may come on after
inflammations of some other part of the intestinal tract. It may come on
after injury, or in many cases, arise spontaneously. Perhaps, in some
cases, the presence of the fecal matter in the appendix is a contributing
cause of the disease, and may excite more or less of a catarrhal inflam-
mation. The effort of the appendix to rid itself of these materials may
occasion colicy pains — appendicular colic.

Treatment. — The treatment of appendicular inflammation is the
same as the treatment of other inflammations, and of abscess thereof,
the same as the treatment of other abscesses. As is indicated above,
this disease is usually the result of bacterial invasion. This bacterial
invasion is rendered possible by disturbances of the circulation, either
vasomotor or direct obstructions by pressure on the vessels. Where
the disease is produced by fecal concretions, atonic conditions of the
bowels are the cause. Spinal or rib lesions will be found in the splanch-
nic area, from the fifth dorsal to the second lumbar, to which the vaso-
motor disturbance and the atonic condition of the viscera are due.
With this in view, the treatment consists in correcting these lesions and
then stimulating the blood and nerve supply to the inflamed area.
Manipulation over the inflamed appendix should be avoided, since it
might cause rupture of the adhesions formed to limit the diffusion of

376 ENTEROPTOSIS.

the poison. Treatments should be given to evacuate the bowels. The
alimentary tract should be kept well cleaned out. When the tempera-
ture is elevated, treatment may be necessary to relieve it, but as a rule
not. During paroxysms of pain, when the appendix is endeavoring to
free itself of its contents, inhibitory treatment may be given in the
splanchnic region to cause the opening into the bowel to relax. Should
an abscess form, which is evidenced by a circumscribed tumefaction,
fever, and an accelerated pulse, or should the pulse suddenly become
rapid, and great depression follow, an operation should be advised. In
this operation the appendix is removed, if possible, without opening the
peritoneal cavity. During the course of the disease the patient should
be kept on a nutritious liquid diet. The urinary secretions should be
kept free. If these methods are followed out, surgical interference will
rarely be necessary.

Enteroptosis (Glenard's Disease). — This is a condition of displace-
ment downward of the abdominal viscera. All of the viscera, with the
exception of the pancreas, rarely the kidneys, may be involved.

Cause. — Various rib and spinal lesions affecting the nerve and blood
supply, and thus weakening the ligaments of the viscera, the mesentery,
and the muscle of Treitz. Contributing causes may be mentioned, such
as constipation, causing a dragging down of the transverse colon, stom-
ach, spleen, and perhaps the right kidney. The patient is usually
dyspeptic, anemic, and neurasthenic.

Treatment. — The treatment is entirely osteopathic. In some in-
stances, the kidney, liver, and spleen may be anchored by operation.

Abscess of the Liver. — Abscess of the liver is due to pyogenic in-
vasion in a condition of weakness brought about by lesions affecting
the circulation and nerve supply. The abscess may be pyemic, or may
be the result of other infection, as in case of abscess of the liver oc-
curring in inhabitants of hot countries.

Symptoms. — The symptoms are those of a septic fever. There is
enlargement and inflammation of the liver. The course of the disease,
in many instances, resembles enteric fever, while in others it resembles
malaria. The chills which occur in abscess of the liver are irregular.
The fever is remittent, and higher in the evening than in the morning.
Usually there is jaundice, cough, with diarrhea, and constipation alter-
nating. Fluctuation is rare, unless the pus burrows near the surface.

Treatment.— When it is perfectly clear that an abscess is located in
the liver, an exploratory incision should be made and the pus evacuated.

Osteopathic Measures. — In the treatment of abscess of the liver,
pother lesions than those directly affecting the organ itself will be
found. Lesions will be found causing weakened areas and permitting the
-absorption of pus cocci. These enter the circulation and lodge in
the liver, producing abscess formation. Any existing suppurating sur-
face or abscess cavity must be cleansed, while the lesions directly affect-

GALL-STONES. 377

ing the integrity of the liver must be treated. These lesions are found
in the splanchnic area and the lower ribs on the right side. By increas-
ing the circulation to the liver, abscess formation may be arrested, or
the inflammatory products absorbed. Should the abscess attain consid-
erable size, and give evidence of burrowing, an incision should be made,
the cavity opened, and the pus evacuated. The circulation should be
especially stimulated. This will prevent stasis and hasten absorption.

Hepatoptosis. — Displacement of the live* may occur in Glenard's
disease. A history of the case, together with a careful physical exami-
nation, will determine the condition. Osteopathic treatment may give
relief.

Gall-stones. — The condition of cholelithiasis is brought about by the
precipitation of certain materials from the bile. This precipitation, which
is usually around a nucleus of bacteria, shreds of epithelium, or blood-
clot, consists of crjrstals of cholesterin, or lime salts. The causes of
the disease are lesions of the left ribs, from the 8th to the 12th (Dr.
Still). Experience seems to show that lesions affecting the splanchnic
area, and in general, the lower ribs, deprive the chylopoetic viscera of
the proper nerve force and blood supply, and inflammations arising may
extend up the ducts into the gall-cyst, which will assist in bringing
about the condition of cholelithiasis. The quality of the bile becomes
changed and the salts are precipitated.

Symptoms. — The attack may come on gradually, being attended by
flatulency, but more often it makes its appearance suddenly, as a violent
colic. It usually occurs about three hours after a meal. The pains are
violent, spasmodic, and paroxysmal. They radiate over the epigastric
and hepatic regions, and finally extend up over the right half of the
thorax. The patient is nauseated and often vomits, while the abdomen
frequently becomes distended. Sometimes the condition of the patient
much resembles that of collapse. The attacks last a variable time. The
stone may pass on into the intestines, may regurgitate into the gall-
cyst, or may become encysted in the cystic or common duct. Where the
stone lodges in the common duct, jaundice will soon appear. It will
not be present if the cystic duct is obstructed. If the stone lodges, it
will cause repeated fierce attacks, the patient becomes more and more
exhausted, while jaundice is pronounced and continued. Occasionally
the stone may be large enough to be palpated. As the stone passes into
the intestine, there is complete relief from pain. Usually the stone will
pass from the bowel in several days, but this may not be true. It may
remain in the intestinal tract for some length of time, or it may have
been crushed within the duct, and afterwards dissolved by the intestinal
secretions.

Treatment. — Osteopathy has almost wrested this ailment from the
surgeon's hands. Stones of large size have been removed by manipu-
lative measures. It is only in cases where the gall-stone becomes en-
cysted in one of the ducts that an operation should be performed, and

378 GALL-STONES.

then only when it is determined that relief can not be given by other
means.. Cholecystotomy should be performed, the stone removed, and the
case treated as the condition requires. In some instances, it may be nec-
essary to make a new communication between the intestines and gall-
cyst, attaching the gall-cyst to the intestine — cholecystenterostomy.
Where the cystic duct is obstructed, the disease may gradually wear
off, and the contents of the gall-cyst become absorbed, or an abscess
may result.

The treatment consists in removing lesions affecting the integrity
of the gall-cyst and its ducts, and in stimulating the functions of the
liver, thus obtaining a normal biliary secretion. Even after calculi have
lodged in one of the ducts, they may be readily removed. The following
case well illustrates the treatment: Mrs. S., the wife of a Justice of a
United States Court, applied to the A. T. Still Infirmary for treatment.
She had been advised by eminent surgeons to submit to an operation
for the removal of the calculi, since all treatment had failed to remove
them. Upon examination, spinal lesions from the fourth to the eighth
dorsal were found. The corresponding ribs on either side were also
affected. Treatment was instituted. Within two weeks she began
passing the calculi per rectum. More than three hundred were gotten
rid of in this manner. Within three months .she was discharged, cured,
and has not since had a recurrence of the trouble. The treatment was
directed towards relieving the engorged duct, and to stimulating the
unstriped muscle in the duct wall. During the paroxysms of pain, in-
hibitive treatment was given in the dorsal region on the right side,
from the sixth to tenth dorsal. Manipulation was also made along
the course of the duct from the ninth costal cartilage downward, and
inward toward the umbilicus, to assist the progress of the stone. This
case can not be viewed as an accident, since many osteopathic physicians
have, by similar treatment, cured numerous cases suffering from gall-
stones, after all other treatment had failed, and surgical procedures
were considered the only means of relief. After the removal of the cal-
culi, the general system may be toned up, and the liver secretion re-
stored to its normal condition. This is most essential, since there may
be a recurrence of the trouble if the lesions are not corrected.

Pancreatitis. — A sudden, acute, hemorrhagic inflammation of the
pancreas may occur in drinkers. The pain is violent, and there is
nausea and vomiting. Constipation is always present, with more or less
fever and abdominal distension. Collapse usually comes on early. The
symptoms are obscure. The causes are the subject of dispute among
surgeons and authors. Undoubtedly certain lesions of the spine, affect-
ing the nerve supply to the organ, are chiefly responsible for the disease.
The treatment is osteopathic, and consists in removing any pressure on
the nerve roots (at their spinal origin), or in increasing the blood supply
through the vasomotors.

Tumors of the Pancreas. — Tumors of the pancreas are cysts and

HERNIA.

379

malignant disease. Where the diagnosis can be made, the cyst may he
attached to the abdominal wall, opened and drained, providing it does
not yield to osteopathic measures. In malignant disease, the treatment
is palliative. Surgery does no good.

Fig. 12G.

Drawing showing the spermatic cord, external abdominal ring and the
saphenous opening in the fascia lata.

Hernia.' — Hernia is a protrusion of a viscus from its normal cavity,
hence the term may he applied to the lung or brain, as well as to any of
the abdominal viscera. As the term is ordinarily used, it applies to the
escape of the contents of the abdomen. Abdominal hernias get out at
the umbilicus, along the spermatic cord, round ligament, along the
crural sheath of the femoral vessels, or through the diaphragm.

Causes. — The causes of hernia are congenital and acquired. The
congenital causes are: 1. The continuous persistence of the pouch of
peritoneum covering the testicle and cord. 2. The late descent of the
testicle seems to predispose to the development of hernia. 3. Congenital
phimosis, causing straining in the effort to void urine. 4. The abnormal
length of the mesentery will render hernia more likely. 5. Inherited
weakness of the parietes of the abdomen.

380 HERNIA.

Acquired Causes, — Any condition which increases the intra-abdom-
inal pressure, and weakens the abdominal walls, will bring on hernia.
These are violent exertion, pregnancy, coughing in prolonged cases of
bronchitis, straining in the erect position, constipation, urethral
stricture, etc.

Structure of Hernia. — The hernial contents are always enclosed
within a sac, called the hernial sac. This is made up of peritoneum,
which covers over and is about the opening through which the viscus
protrudes. This sac may be reduced when the viscus is restored to its
normal cavity, but usually when the hernia appears subsequently, the
sac becomes adherent to the surrounding tissues, and therefore is irre-
ducible, although the contents of the sac may be returned to the ab-
dominal cavity with ease. Sometimes this hernial sac may be the situa-
tion of a localized peritonitis, due to irritation, or injury. This inflam-
mation may result in the obliteration of the neck of the sac, resulting in
a spontaneous cure. Effusions of serum, or blood, may occur in the sac.
When the sac is made up of a neck and fundus, the fundus, or body, may
be of any size or shape. In some cases it is very large, while in other
cases quite small. The neck may be small, or quite large, easily permit-
ting the intestine or epiploon to insinuate itself. In general, there are
present the different structures forming the abdominal wall at the point
where the hernia escapes. In some cases, a portion of them may be
absent, while in other cases, the parietes may be represented by other
structures. These may be anatomically considered with benefit, but
are of no practical value, since they are never recognized during opera-
tion, with the exception of the cremaster muscle, which forms a useful
guide to the operator.

Contents of Hernia. — The contents of a hernia may be of any of the
viscera of the abdomen, but usually is made up of some portion of the
intestine or omentum.

Enterocele is a form of hernia which has for its contents intestine.

Epiplocele is a hernia which has for its contents omentum.

Entero-epiplocele is a form of hernia in which there is present both
omentum and intestine.

The cecum and appendix vermiformis may in rare instances form a
part of the hernial contents. In old cases, the bladder has been dragged
into the sac. Sometimes loose bodies are found in the hernial sac. They
are produced by cutting off of the appendices epiploicae.

Symptoms.- — The symptoms of hernia are: 1. A pear-shaped swelling.
2. The swelling is increased in size when the patient stands, or decreased
in size when he is in a recumbent posture. 3. There is an impulse on
coughing. 4. It reduces with a gurgle. 5. When the contents of the
hernial sac is omentum, it gives a doughy-like mass. 6. There is more
or less pain of a colicky nature. 7. Occasionally, when the bowel is dis-
tended with gas, there will be tympanites on percussion.

Condition of the Hernia. — The condition of the hernia may be: 1.

HERNIA. 381

Reducible. 2. Irreducible. 3. Incarcerated or obstructed.. 4. Inflamed.
5. Strangulated.

Reducible Hernia. — A reducible hernia is one which may be readily
returned to the abdominal cavity. The treatment of this hernia is either
by the application of a truss, or operation. (See treatment of hernia).

Irreducible Hernia. — In this variety there exists some impediment
to reduction. The causes are :

1. Structures outside of the sac. such as inflammatory thickening,
etc., which may so constrict the nee 3c as to render reduction impossible.

2. Thickening of the sac-wall. The sac-wall may become inflamed,
and this lessens the lumen of the neck, rendering reduction impossible.

3. Certain conditions within the sac. These conditions may be the
great amount of the contents of the sac, or it may be because of the
omentum or gut which forms a part of the hernial contents, or it may
be because of the adhesions between the parts of the hernial contents
and the sac, or there may be an effusion of fluid within the sac which
will prevent reduction.

Symptoms. — The symptoms of irreducible hernia consist of a
dragging down sensation, with colicky pains: there is impulse on
coughing, and the tumor is non-translucent. It may gurgle some on
handling. The symptoms are not alarming, but the hernia will be the
source of great annoyance, both to the patient and the physician. Like-
wise the patient is constantly in danger of strangulation occurring,
which might prove fatal.

Treatment. — The treatment of irreducible hernia is palliative and
operative. Palliative treatment consists in the application -of heat for
the relaxation of the tissues, or in other conditions, the application of
ice to lessen the congestion, or high enemata of castor oil or salines,
with manipulation along the spine to relax the contracted fascia and
muscles, and finally the application of gentle taxis. Should the hernia
become strangulated, an operation should be done immediately, to effect
reduction and radical cure. "Where the hernia has existed for some
length of time, and where the inflammatory symptoms have receded and
the hernia is still irreducible, it is fair to assume there are such ad-
hesions that reduction is impossible. A bag, or laced-up truss, may be
worn to prevent the hernia from becoming larger. They are often dif-
ficult to apply, and it may be better to take a plaster cast of the condi-
tion, so that the instrument maker may properly fit the truss. Where
the patient will submit, an operation should be performed for the rad-
ical cure of the hernia.

Incarcerated Hernia. — This is brought about by the accu-
mulation of hardened feces, fruit-stones, or other objects within the
bowel in the hernial sac, or it may occur in old people where the con-
tents become more or less inflamed. The inflammation may lead to
strangulation of the bowel. There is constipation, which is
not absolute, colicky pains, and more or less nausea. There may be vom

382 HERNIA.

iting. A hard fecal mass can be felt, and likewise a slight impulse on
coughing. In this form of hernia, high enemata of castor oil, or salines,
together with heat and manipulation judiciously applied, will relieve the
condition. If strangulation develops, an operation should be performed
at once.

Inflamed Hernia.— Inflamed hernia is a condition where the hernial
sac and its contents have become inflamed. It is most common in small
and irreducible hernias of the omentum (epiploceles). It may be be-
cause of excessive manipulation, or injury, or a badly fitting truss.
Many times, even though a truss is fairly well applied, the omentum may
insinuate itself through the neck underneath the truss into the sac.
The truss will more or less obstruct the return circulation and cause
the viscus to inflame and thicken.

Symptoms. — The hernia is hot, inflamed, and very often edematous.
There is vomiting, but it is not fecal. Usually there is constipation, but
it is not absolute. Gas seems to pass readily. There is an impulse on
coughing.

Treatment. — The treatment of inflamed hernia is the application of
heat, or in some cases, an ice-bag. The patient should be placed in the
recumbent posture and given high enemata. Heat will be found
of the greatest advantage. It may be applied by woolen cloths, wrung
from hot water every five minutes. Where gentle manipulation
of the hernia itself, together with appropriate spinal treatment, does
not give relief from the inflammation, and the symptoms become more
severe, herniotomy should be performed.

Strangulated Hernia. — Strangulated hernia is a condition in which
the circulation is more or less arrested to the hernial sac and its con-
tents.

Cause. — 1. There is contraction at the neck of the sac, because of
the small aperture.

2. It may be brought about by increase in the bulk of the
hernia by fresh portions of the abdominal contents being forced into
the sac, obstructing the return circulation.

3. Catarrhal inflammations of the mucous membrane, together with
fecal accumulations in the bowel, may arrest the circulation.

4. Congestion of the omentum, as may occur in inflamed or irre-
ducible hernia, may bring about strangulation.

Pathology. — There may be an obstruction to the return circulation,
or there may be a direct obstruction to the arterial blood flow, which is
sufficiently complete to result in death of the hernial contents within
a few hours. The changes taking place within the intestine largely
depend upon the amount of irritation and the extent to which the blood
supply is cut off. The intestine becomes dark and turgid, or
edematous. It loses its shiny appearance and becomes lusterless and
doughy. It may slough and a fecal fistula form and the patient sur-
vive, but usually intestinal obstruction supervenes and the patient dies
in collapse.

HERNIA. 383

Symptoms. — The symptoms are (A) Local and (B) General.

Local Symptoms. — 1. The hernia is irreducible. 2. It is tender, pain-
ful, and stony-hard. It may be tympanitic. 3. There is no impulse on
coughing. 4. Pain radiating about the umbilicus. As soon as strangu-
lation comes on, the pain radiates about the umbilicus. 5. The skin and
subcutaneous tissues over the hernia become a brick-dust red, and may
be emphysematous and have a fecal odor.

General Symptoms. — The general symptoms are those of intestinal
obstruction, as vomiting, first of the contents of the stomach, and then
afterwards fecal matter. The constipation is absolute. The face be-
comes pinched and drawn, the pulse small and wiry, and the tongue
furred and brown. Death ensues from collapse and general peritonitis.

Treatment. — In the treatment of strangulated hernia, the following
considerations should be kept in mind:

1. Purgatives are terribly injurious and should never be allowed.

2. Prolonged taxis is very harmful and must be condemned.

3. Not a moment's delay should be tolerated, as every hour adds
greatly to the danger. Necrosis of the bowel in some cases may occur
within a few hours.

4. Employ taxis gently for a few minutes, and if this is unsuccessful,

5. Put the patient in a hot bath for twenty minutes and for a few
minutes apply hot cloths over the hernia, and then try taxis again for
a short interval. Failing in this, if the symptoms are urgent, prepara-
tions should be made for an operation. The patient's consent to op-
erate should be obtained. The patient should then be given ether, and
after thoroughly anesthetized, the hernia should be gently manipulated
in an effort to effect reduction. If this fails, an operation should be
performed.

Taxis. — This is the manipulation which is employed for the purpose
of reducing a hernia, and it is made in the direction from which the
hernia came. In inguinal or femoral hernia, the hips should be elevated,
the legs flexed upon the abdomen, so as to relax the abdominal muscles,
while the tumor is grasped and gently manipulated, not with the inten-
tion of forcing the hernia back, but with the intention of assisting its
return.

How long should taxis be employed? This is a question of the
utmost importance. The application of taxis too long and too severely
may of itself bring about necrosis of the bowel. In the ordinary hernia,
taxis should not be applied longer than ten minutes, while in a tense
femoral or inguinal hernia, with symptoms of obstruction, taxis should
not be employed longer than five minutes. There are certain conditions
under which taxis should not be employed, and these are, first, when
there is evidence that vigorous and unsuccessful efforts have been made
by other physicians, and second, when the hernia is very tense and ten-
der, no manipulation should be made, biit means to counteract the
inflammation should be used. Manipulation is useless in a small, tender,

384

HERNIA.

and inflamed femoral hernia, where there is feeal vomiting. Little can
he expected from manipulation in femoral hernia. An operation is
usually necessary. A hot hath is most successful in young and mus-
cular subjects, but should not he given to old people.

Herniotomy. — Bassini's and Halsted's operations for inguinal hernia
are most successful, and if carefully performed will permanently cure the
rupture. Bassini's operation consists in making an incision from above
the internal abdominal ring to the spine of the pubes, uncovering the

Fig. 127.

Bassini's operation for the radical cure of inguinal hernia. This
drawing shows the internal oblique muscle drawn down and sutured to
Poupart's ligr ment to form the floor of the inguinal canal.

external abdominal ring. The external oblique aponeurosis is then
divided up to the internal ring and retracted. The various tunics cov-
ering the hernia are then separated and drawn aside, while the hernia
is separated from the spermatic cord. The cord is picked up and drawn
aside. The hernial contents are then restored to the abdominal cavity
and the sac ligated with catgut and removed, while the stump is allowed
to sink back into the cavity. While the cord is still retracted, the in-
ferior border of the internal oblique muscle is drawn down and sutured
to Poupart's ligament underneath the external oblique. In this man-
ner a good floor is made for the inguinal canal. The roof is made by
suturing the aponeurosis of the external oblique muscle over the cord.

HERNIA.

385

Chromicized catgut sutures are used. A continuous suture may be used
for the external oblique, and it should be carried down to the external
ring, not so close as to produce a constriction. The wound is then
closed by interrupted

silkworm-gut sutures. Fig. 128.

Halsted attaches all
the structures to Pou-
part's ligament and
leaves the cord be-
neath the skin. The
cord is brought out
through the aponeu-
rosis of the external
oblique above the in-
ternal ring. Other op-
erations have been
devised, but are not
so successful as the
above.

Varieties of Her-

nia.— The most eom-

Bassini's operation for radical cure of hernia. This shows

-mnn Inrmo n-p Viornin the external oblique muscle sutured over the spermatic cord
mull luiiiib Ui iiLiiuct to form the roof of the inguinal canal.

are inguinal and fe-
moral, but other forms, such as ventral, epigastric, diaphragmatic ob-
turator, lumbar, isehiatic, perineal, vaginal, and rectal, may occur.

Inguinal Hernia. — Inguinal hernia may be (A) Direct, and (E) Indi-
rect or oblique. It is a direct hernia Avhen it passes through the ex-
ternal abdominal ring only, and indirect when it comes through the
internal abdominal ring, traverses the inguinal canal, coming out the
external abdominal ring.

Direct Inguinal Hernia. — This variety of hernia escapes directly

through the external abdominal ring
without passing through the inguinal
canal. It is situated internal to the epi-
gastric artery. Inasmuch as the conjoined
tendon of the internal oblique and trans-
versalis muscles are attached immediately
behind the external abdominal ring, it
either pushes this conjoined tendon along
with it, or it passes around it. The cov-
erings of this hernia from without in, are
skin, superficial fascia, intercolumnar fas-
cia, conjoined tendon, transversal's fas-
cia, subserous areolar tissue, and perito-
neum which forms the sac. In some cases
where there are three fossae on the inside
of the front of the abdominal cavity instead of two, in which condition

Double incomplete inguinal hernia.

386

HERNIA.

Fig. 130.

the fibrous cord of the obliterated hypogastric artery does not accompany
the deep epigastric artery, the direct inguinal hernia may come out ex-
ternal to the conjoined tendon, appearing within the inguinal canal,
then passing out the external abdominal ring. Under such circum-
stances it would have as a covering, instead of the conjoined tendon,
fibres of the internal oblique and transversalis muscles. This hernia
always comes out through Hesselbacb/s triangle, which has as its base
Poupart's ligament, one leg being the outer border of the rectus muscle,
while the other is formed by the deep epigastric artery, so that the
artery is on the outer side of the neck of the sac. Strangulation in this
variety of hernia is situated in the external ring, or in the conjoined
tendon.

Oblique Inguinal Hernia. — -There are several varieties of oblique

inguinal hernia, the most common of
which are: 1. Acquired. 2. Congeni-
tal. 3. Infantile, or encysted.

ACxquired Indirect Inguinal Hernia
makes its appearance at the internal
abdominal ring. In some cases, the
hernia may remain in the inguinal
canal, never coming out the external
abdominal ring. This is called
incomplete hernia, or bubonocele.
When it passes through the external
abdominal ring, it will descend into
the scrotum (scrotal hernia), or when
along the round ligament into the
labia majora (labial hernia).

The covering's of the oblique in-
guinal hernia in the male are, from
without inward, skin, superficial
fascia, intercolumnar fascia, cremas-
ter muscle, infundibuliform fascia,
subserous areolar tissue, and peri-
toneum. In the female, the cremaster
muscle is wanting.
Congenital Hernia.-- In this variety, the pouch of peritoneum which
has been pushed down in front of the testicle remains patulous. The
abdominal contents readily descend into this sac. The testicle is more
or less surrounded by the hernia.

Infantile or Encysted Hernia. — This is a form of hernia arising
in a condition where the pouch of peritoneum pushed down by the testi-
cle is closed at the internal ring, but remains patent below so that the
cavity of the tunica vaginalis testis communicates with the pouch ex-
tending along up in front of the cord. The hernia then has a distinct
sac which passes down behind this pouch, so that in operating, the cav-
ity of the tunica vaginalis would be opened before the hernial sac could

Labial hernia or inguinal hernia in
the female.

HERNIA. 387

be reached. There are three coverings of peritoneum in front of
the hernia, two being connected with the tunica vaginalis, while one
forms the hernial sac. The sac of the hernia could not be reached with-
out pushing aside this process, hi some cases the fluid within this cav-
ity will entirely obliterate any evidence of hernia.

Diagnosis. — Inguinal hernia may be confounded with : 1. Enlarged
lymphatic glands in the groin. 2. Femoral hernia. 3. An encysted
hydrocele of the cord. 4. A retained testicle. 5. Hydrocele of the tunica
vaginalis. 6. Varicocele. 7. Psoas abscess.

A careful examination usually renders the diagnosis easy. In incom-
plete inguinal hernia, the swelling is a round, hard tumor, and is pain-
ful and not movable, while in enlarged lymphatic glands, more than one
gland will be enlarged, and they are more or less movable, also some
sore on the genitalia, or somevenereal dis-
ease, which is the cause of the lymphatic Fig. 131.
enlargement, will be present. In com-
plete inguinal hernia, the contents de-
scend into the scrotum. In femoral her-
nia, the enlargement is below Poupart's
ligament. In encysted hydrocele, there
is a translucent tumor, which is usually
tense, ovoid, and well defined, having no
connection above or below, while it gives
no impulse upon couahino-. In retained

, ,. . .., , ""p . , . ,. Femoral hernia showing the en-

teStlCle, the absence Of the Organ m the largement upward and outward be-

scrotum, together with the fact that °w oupart 3 1&amen •
it gives no impulse on coughing, will serve to distinguish
it. Usually it is quite movable within the inguinal canal.
If it has become inflamed, the nausea and vomiting are not
of the intense character that occurs in strangulated hernia. In
hydrocele of the tunica vaginalis, there is a translucent tumor, with a
history of its gradual appearance. It is irreducible, and the testicle may
be felt in the back part of the tumefaction. In children, sometimes
translucency can be obtained in the hernia, and, too, a hydrocele may be
more or less reducible, but the hydrocele is not reducible with a gurgle,
as is hernia. Varicocele will disappear when the patient assumes a re-
cumbent posture, and while standing it feels like a mass of earth worms,
or the intestines of a chicken. There is no impulse upon coughing. If
the external abdominal ring is compressed, the hydrocele will not dis-
appear upon lying down. It is nearly always on the left side.
Pott's Abscess appears below Poupart's ligament, and is more liable to
be mistaken for a femoral hernia. There is evidence of spinal trouble.
Pott's abscess is not reducible with a gurgle, and gives no impulse upon
coughing.

Femoral Hernia. — Femoral hernia is one which escapes through the
femoral canal internal to the femoral vessels, making its appearance
through the deep fascia at the saphenous opening. The neck of the sac

388

HERNIA.

FrG. 132.

is situated at the femoral ring. This ring is bounded above by Poupart's
ligament, internally by Gimbernat's ligament, below by the pubes, and
externally by the femoral vessels. The course of the hernia is through
the femoral ring, along clown the femoral canal, and out the saphenous
opening. It then turns upward and outward. In some cases, where it
is very large, it may ascend above Poupart's ligament on the abdomen.

The coverings of femoral hernia are, from without inward, skin
superficial fascia, cribriform fascia, femoral sheath, or fascia propria,
septum crurale, subserous areolar tissue, and peritoneum which forms
the sac. This form of hernia is rarely ever congenital. It is much more

common in women
than in men. When
strangulation of the
hernia takes place,
the stricture is at the
saphenous opening,
or in the femoral
opening.

Diagnosis. — It may
be mistaken for an
inguinal hernia, en-
larged lymphatic
glands, for a small
lipoma, or Psoas ab-
scess. Careful exam-
ination should render
the diagnosis not dif-
ficult.

Umbilical Hernia. —

Bassini's method of operation for radical cure of femoral
flemia.

There

forms

hernia

scribed,

infantile

quired.

is an

are three

of umbilical

usually cle-

congenital,

and ac-

Congenitai

exceedingly

rare form, due to imperfect closure of the abdominal walls.
The intestines escape into the sac which is beneath the umbilical cord.
The cord may be large and bulbous, so that the hernia may be included
in the ligature and fatal strangulation result, if care is not taken.
Infantile umbilical hernia is the result of weakness of the umbilical
scar which yields to intra-abdominal pressure. Chronic constipation,
phimosis, or pertussis, may bring it about. Kegulation of the bowels,
together with strapping on a properly fitting band, will be found
sufficient to effect a cure. The acquired form usually occurs in women
who have borne children, or from injury producing rupture of the linea

DISEASES OF THE RECTUM. 389

alba. Obstruction or strangulation of this hernia is rare. The
treatment is either by truss, or operation.

Ventral Hernia. — Ventral hernia is rare, except following operations
whereby the abdominal parietes are divided. These hernias may be very
large. In view of improved surgical methods, they are very rare. The
treatment should be to open the sac and freshen the edges of the mus-
cles and fascia and reunite them.

Lumbar Hernia. — Lumbar hernia is a rare condition where the ab-
dominal viscera protrude by the side of the erector spinae mass coming
to the surface between the latissimus dorsi and the external oblique,
in the space commonly known as Petit's triangle. The ordinary signs
of hernia are present. It can be readily distinguished from lumbar
abscess. The treatment is, as in other hernias, bandage, or operation.

Diaphragmatic Hernia. — This hernia is rarely recognized before
death. It is usually congenital, and arises from imperfect development
of one half of the diaphragm. The transverse colon, or stomach, is
forced into the thorax. There is no peritoneal sac.

Obturator Hernia. — This is a condition where there is protrusion of
the intestines through the obturator foramen. It usually occurs in
females. It is not often recognized in life, except in strangulation.
Fortunately it is rare.

Other forms or hernia, such as epigastric, ischiatic, perineal,
visceral, rectal, etc, are too rare to merit description here.

DISEASES OF THE RECTUM.

Malformations of the Rectum. — Imperforate Anus. — This is a con-
genital condition in which the process of development of the rectum
has been arrested. The rectum is formed by the invagination of the
epiblast and the absorption of the tissues between this invagination and
the intestinal canal. There may be no invagination, or there may be
but a thin membrane between the rectum and the bowel above.

Treatment. — The treatment is operative. A vertical incision is made
in the middle line and carefully extended to the gut. The wound should
be kept open with a bougie, *to prevent union of the sides.

Proctitis. — Proctitis, or inflammation of the rectum, is rare. The
cause is a prolapsed condition of the viscera, injury, gonorrhea, dysen-
tery, luxations of the coccyx, or at the sacro-iliac joint, or of the dorsal
and lumbar spine affecting the blood and nerve supply, either directly
or reflexly. The lesions are usually low down.

Treatment. — The bowels should be kept loose, and a liquid diet ad-
ministered. The bowels should be washed out, to relieve the mucous
membrane of any irritants. Lesions affecting the blood and nerve supply
to the rectum should be removed, also the secretions of the remainder
of the intestines should be looked after.

390 DISEASES OE THE RECTUM.

Pruritis Ani. — This is a condition of obstinate and terrible itching
of the skin and mucous membrane about the anus. In some conditions
there may be disease of the epithelium, or the superficial skin about the
anus. In most cases there seems to be a lesion affecting the nervous
system. The lesions will be for the most part found in the lumbar
region, also there may be deflections of the coccyx. If these lesions are
corrected and the coccyx straightened, the disease will disappear. Con-
tributing factors to the disease are constipation, vermes, pediculi,
eczema marginatum, piles, condylomata, digestive disorders, etc.

Treatment.- — The treatment is osteopathic. Being due to lesions
irritating nerve trunks, it can be cured by removing these lesions and by
taking proper care of the affected skin. The parts must be kept dry and
free from irritation. Where the itching is terrible, and immediate relief
can not be given by treatment, the following solution will be found
of advantage, simply as a palliative measure: Bathe the parts with
hot water and then apply a solution made of one dram of campho-
phenique, stirred into one ounce of water. Should this not give relief,
or should the itching persist, an application of the following ointment
will be found of advantage:

Oleate of cocain one part

Lanolin three parts

Vaselin two parts

Olive oil two parts

This should be made into an ointment and applied once or twice
daily as is needed.

Fissure of the Rectum is produced by the passage of hard fecal
masses, or irritating substances, or foreign bodies, within the stool. It
usually occurs in constipation when there is excessive straining at
stool. The symptoms are pain, which may radiate to other parts of the
body, and spasm of the sphincter muscle. The stool is streaked with
blood. Very often above the fissure there is a little pile, or it may be
the fissure consists of a small, inflamed, valve-like nodule of the mucous
membrane.

Treatment. — The treatment consists in relaxing the sphincter mus-
cle, correcting any bony lesions present, and touching the Assure with
equal parts of glycerine and carbolic acid. The use of carbolized vaselin
will frequently give relief. The sphincter muscle should be dilated and
the stool softened and kept free. Correcting the lesions of the lumbo-
sacral spine will relieve the spasm of the sphincter muscle.

Prolapsus of the Rectum and Anus. — This consists of a prolapsing
of the mucous membrane, occasionally the muscular coat, of the rectum
and anus. It usually happens in children, but may occur at any age.
The causes are certain spinal lesions affecting the rectum, together with
straining at stool, stricture of the urethra, phimosis, ascarides, stone in
the bladder, constipation, piles, polypi, etc. The diagnosis is evident.
The prolapsus can readily be reduced by gentle pressure. In some old
cases, the prolapsed bowel may be difficult to reduce. In these old cases,
the mucous membrane becomes gradually thickened and the prolapsed

HEMORRHOIDS. 391

mass may be of very large size. In children, the disease usually results
from constipation and relaxed and atonic conditions of the elastic tis-
sues which unite the mucous membrane to the muscular coat. Any pelvic
or spinal lesions should be removed. The stools should be kept loose,
the bowels moved in a reclining posture, or while the patient is lying
upon his side. It will require several months to effect a cure. In chil-
dren, cases yield readily to simple treatment. In grown people, the
disease may be difficult to cure without an operation. The habit of
voiding stool in a squatting posture is vicious. In severe cases, the
actual cautery may be necessary. Two or three sears are made with the
cautery through the mucous membrane. This causes adhesion to the
muscular coat and effects a cure. Astringents, or the local application
of any medicines, are worthless. Osteopathy will cure most of the cases,
providing the patient will follow the physician's instructions.

Hemorrhoids. — Hemorrhoids are varicosities of the veins of the rec-
tum and anus. The cause of hemorrhoids in the large majority of cases
is malposition of the coccyx. Deflection of the coccyx interferes directly
and reflexly with the blood supply to the bowel. Atonic conditions of
the bowels occur from dorsal, lumbar, or rib lesions affecting
the circulation and nerve supply, causing straining at stool, prolapsus
of the viscera, etc., which lead to constipation and the use of purgatives.
These purgatives are irritating to the mucous membrane of the bowel,
and cause congestion and inflammation and predispose to the formation
of hemorrhoids. The pressure of a tumor, gravid uterus, or obstruction
to the portal circulation, may be the active causes. In general, any
lesions affecting the circulation or nerve supply, either directly or re-
flexly, may be said to operate as causative agents. The piles may be
external, or internal. External piles are situated without the sphincter
muscle. They are soft, globular, pinkish-blue swellings. They may be
soft and fleshy or moderately firm. They may be due to the rupture of
a vein, or they may consist simply of hypertrophied tags of skin.
Internal piles are reddish-blue masses, situated within the sphincter
muscles. They may, or may not, prolapse at stool. If they prolapse at
stool, they may return voluntarily, or they may be so large as to require
assistance in returning them. They may become ulcerated and bleed
(bleeding piles), or they may become inflamed (inflamed piles). The
tumor may be pedunculated, may be large or small, or may be globular,
or sessile. There may be one, or many. They may be so plentiful and
large that prolapsus at stool resembles prolapsus of tv^ rectum. The
diagnosis can be readily made by having the patient lie prone across a
table or bed and require him to bear down as in defecation, at the same
time the buttocks should be retracted. The tumor will appear at the
anus, where it may be seen. Examination Avith the finger is deceptive,
as the pile can not be readily felt unless inflamed or ulcerated. Where
the spasm of the sphincter is very great and the piles come down and
can not be returned, a hot poultice of bread and milk may be ap-

392 FISTULA IN A NO.

plied, which will soften the tissues and usually brings about their return
without much difficulty. Where the parts are very sore, the application
of the benzoated oxide of zinc ointment as a protective, or of carbolated
vaselin, will be found excellent as palliative measures.

Treatment. — The treatment of hemorrhoids, as in other diseases,
consists in removing the cause. It is especially important, since piles
are nearly always the result of obstructions to the circulation. Lesions
responsible for them consist of deviations of the coccyx affecting the
circulation directly, or lower dorsal and lumbar lesions affecting the
circulation indirectly. Lesions affecting the heart, lungs, and liver may
interfere with the circulation to the lower bowel and cause the tume-
factions. Treatment directed toward repairing the diseased condition
of these viscera will in these cases cure piles. Piles may be caused by
pregnancy, a prolapsed condition of the bowels, tumors, or by a loss of
tonicity of the tissues comprising the submucous coat of the bowel.
Constipation and hard fecal masses, causing straining at stool, may
cause the obstruction producing the pile. In any case, the obstruction,
if possible, must be removed, the blood vessels toned up, and the fecal
mass softened by rendering the passing of the stool easy. Where the
piles are ulcerated, carbolized vaselin or benzoated oxide of zinc oint-
ment may be applied after voiding stool. Each time after defecation
the piles should be washed clean with warm water. Often the applica-
tion of cold cloths will markedly benefit inflamed piles. Operations will
sometimes be found necessary for the removal of the piles. These
operations consist of ligation of the piles, or removing them by the
clamp and cautery.

Ischiorectal Abscess is an abscess in the ischiorectal fossa. It must
not be confounded with perineal abscess. The causes are lesions affect-
ing the circulation in the ischiorectal fossa. Circulation through this
loose connective tissue is often not good. Pressure of a hard fecal mass,
and the wounding of the mucous membrane, permit the entrance of
bacteria. If then the tissues are deprived of their proper amount of
blood, an abscess results. The symptoms are pain, heat, redness, swell-
ing, and fluctuation.

Treatment. — An early incision should be made and the pus evacuated
and the abscess treated as an ordinary abscess until it heals.

Fistula in Ano is a communication between the bowel and the sur-
face tissues by means of a small tract, which is the result of the
burrowing of pus. The walls around the opening of the fistula
are hard and indurated, and there is a watery or puru-
lent secretion appearing. Fistulae are divided into complete and blind.
Blind fistulae are rare, and finally develop into complete fistulae. They
may be blind externally, or internally, that is, a sinus may extend from
the cavity in the tissues to the outside, or extend from the bowel a short
distance into the tissues. Complete fistula is where the tract extends
entirely through from the bowel to the surface of the tissues. The

FISTULA IN A NO.

393

opening may be at the margin of the anus, on the buttocks, or in the
perineum. The cause is burrowing of the pus of an ischiorectal abscess,
or the burrowing of pus from an ulcerated tract in the rectum. The
symptoms are pain, increased upon voiding stool, discharge of pus, and
the escape of feces. A correct diagnosis may be made with a probe,
which can be readily introduced into the fistula and its course and ex-
tent determined.

Fig. 133.

Fig. 134.

Fig. 135.

A complete fistula.

An incomplete internal
or "blind" fistula.

An incomplete external fistula.

Treatment. — The treatment is manipulative, and operative. By
keeping the fistulous tract clean, and increasing the blood supply to
the area and correcting the constipation, many of them may be cured.
Where this treatment fails, the patient may be anesthetized, the sphinc-
ter dilated, and a probe introduced at the external opening of the fistula
through to the internal opening and the end of the probe within the
bowel hooked up and brought out of the anus. Then the tissues over
the probe should be divided with a bistoury. The fistulous tract will be
found cartilagenous and hard. It should be scraped out with a
enrette, the wound packed with gauze, and made to heal from within
out. Where the fistulae are small, the sphincter may not require dila-
tation.

Tumors of the Rectum. — Polypi of the rectum are pedunculated
tumors, which may reach the size of a cherry. They are vascular, or
fibrous. They may be the cause of bleeding, especially in children. The
best treatment is to ligature the base of the polypus with a stout silk
ligature.

Papillomatous Tumors of the rectum are rare, and may easily be rec-
ognized upon examination.

Cancer of the Eectum occurs between thirty and thirty-five years of
life. It may occur later. It usually ulcerates and makes a hard ring
around the anus. It occasions severe burning pain, hemorrhage, and
stricture, and is attended by cachexia. Where the diagnosis can not be
made by inspection externally, a speculum, or the finger introduced, will
disclose a cauliflower excrescence.

Treatment. — Unless the tumor can be completely removed, no opera-
tion should be attempted, as it will excite the growth of the cancer,
causing it to bring about death much more quickly. Palliative measures

394 DISEASES OF THE URINARY ORGANS.

should be used. There is no specific treatment. Excision is practiced
in some cases.

Ulcers of the Rectum are simple, specific, tubercular, and malignant.
Simple ulcers are produced from passing hard fecal masses and are made
possible by the debilitated state of the general health, or lesions
affecting the nerve and blood supply. A diagnosis of the ulcer may be
made by means of a speculum. It is essential to determine the nature
of the ulcer. If it is simple, cauterizing the ulcer with a stick of nitrate
of silver and washing out the bowel will soon effect a cure. Some cases
ma}7 be treated successfully by correcting the coccyx, or any spinal or
other lesion present. If the ulcer is syphilitic, malignant, or tubercular,
the treatment must be modified accordingly. In case of syphilitic and
tubercular ulcer, cauterization will be of service.

Stricture of the Rectum may be caused by the growth of a tumor
from without the bowel, or by primary narrowing of the bowel from
growth of tumors within. It may be caused by malignant disease,
syphilis, or ulceration and sloughing, the result of injury and debilitated
states. It may be caused by tubercle and injury.

Treatment. — The treatment of stricture is many times questionable.
Where the tumor can be conveniently removed, it should be done. In
syphilitic stricture, the syphilis should be treated. In tubercular
stricture, the tubercle should be treated. In traumatic stricture, or
stricture the result of ulceration, not from tubercular or syphilitic
disease, gradual dilatation by means of a bougie, or speculum, is good
treatment. It may be possible, by increasing the circulation, to secure
absorption of a considerable part of the stricture.

DISEASES OF THE URINARY ORGANS.

Hematuria. — Hematuria may occur in hemorrhagic diathesis, scurvy,
or in fevers, or it may be due to injury or disease of the urinary organs.
The color of the urine may be bright red, dark, or smoky. The pres-
ence of blood may be determined by microscopical and chemical tests.

Cause. — The blood may come from the kidney, ureter, bladder, pros-
tate, or urethra. When the hemorrhage comes from the ureter or kid-
ney, it may be the result of the formation of calculus or injury, conges-
tion, inflammation, Bright's disease, ingestion of turpentine, or the
application of cantharides. The blood is intimately mixed with the
urine, which is of smoky color. When the blood is derived from the blad-
der or prostate gland, it may come from injury, or the formation of cal-
culus, cystitis, tubercle, or morbid growths. The urine contains more
blood towards the end of urination, and it is usually of a bright red
color. Whatever condition is the cause of the bloody urine, this should
be treated. In hemorrhage from the urethra, arising because of injury,
urethritis, chancre, rupture of the corpus spongiosum, or morbid
growths, the hemorrhage follows urination, or occurs during the interim.

DISEASES OF THE KIDNEY. 395

Micturition may be painful or frequent. It is painful in hyper-
acidity of the urine, or in irritated or diseased conditions of the genito-
urinary tract. The following points will be useful for the purpose of
diagnosis.

In stone in the bladder, the pain is in the head of the penis behind
the meatus, and is greatest at the end of urination. It is aggravated
by exercise.

In stone in the kidney, the pain is in the back, thigh, groin, and
testicle.

In orchitis, the pain is along the cord in the groin.

In cystitis, the pain is before micturition, and is often relieved by
the act.

In urethritis, the pain is intense during micturition.

In inflammation of the neck of the bladder, the pain is intense dur-
ing, and just after urination, and is associated with bloody urine and
tenesmus.

In inflammation of the prostate, there is intense pain during micturi-
tion and soreness in the gland. Defecation is painful.

Frequency of Micturition. — Micturition is increased in frequency
by spinal lesions, phimosis, a narrow meatus urinarius externus, inflam-
mation of the kidney, etc., very acid urine, calculi, sexual excess, mental
worry, fear, diabetes, Bright' s disease, tumors, and neuroses. It may be
increased by atony of the bladder with residual urine, stricture, or by
enlarged prostate. Urination may be increased in frequency without
an increase in the amount, so that it is necessary to determine the force
of the stream and the frequency of micturition. A small stream de-
notes stricture of the urethra. Slow urination denotes enlarged pros-
tate, stricture, or atony of the bladder. Frequent micturition, with
less force in the stream, denotes atony of the bladder, enlarged pros-
tate, or stricture. In making a diagnosis, it is essential to determine
the following points:

1. The frequency of urination, and the conditions affecting it.

2. Pain. Tts nature and location. Is it parox}rsmal, transitory, or
constant, and the conditions affecting the pain.

3. Character of the stream. The size and force.

4. Character of the urine. The amount, whether it contains sugar,
albumin, pus, blood, etc.

Tumors of the Kidney. — Tumors of the kidney are benign and malig-
nant. Benign tumors are fibroma, lipoma, and adenoma. Malignant
tumors are sarcoma (rare) and carcinoma. The signs of malignant
tumors are pain, tube casts, casts of the pelvis of the kidney and ureter,
cachexia, and the presence of the tumor, which can be made out on
palpation.

39G DISEASES OF THE KIDNEY.

The treatment is operative. When the non-malignant tumors can
be made out, they may be removed, providing they do not yield to appro-
priate osteopathic treatment over the kidney areas.

Movable Kidney (Nephroptosis). — This sometimes occurs in Glen-
ard's disease. The diagnosis can usually be made without difficulty.
A pad should be worn, to hold the organ in place, or the treatment for
enteroptosis given. The operations for anchoring the organ have not
been very successful.

Renal Calculus. — Renal calculus is brought about by lesions affect-
ing the suprarenal capsule of the kidney, or spinal lesions from the
tenth dorsal to the first lumbar, affecting the lower ribs.

Composition of the Stone. — It usually consists of the urates of
ammonia or uric acid. More rarely, it may be made up of lime salts —
the oxalate or acid phosphate. The stone excites pyelitis.. If it
is small and round, it may pass to the bladder without difficulty,
or it may ulcerate through the pelvis of the kidney, forming an abscess
and appear externally. It may form a complete obstruction to the flow
of urine to the bladder, causing a condition of hydronephrosis, or pus
may be formed in the pelvis of the kidney, causing pyonephrosis. The
symptoms are persistent pain in the loin, which is increased upon exer-
cise. The pain is usually along the genito-crural nerve. There is
retraction of the testicle in the male, labium majus in the female. Very
often the pain is down in the buttock, the thigh, or the heel. Hema-
turia and p}mria are present and are increased upon exercise. There is
frequent micturition, and the patient lies upon the affected side. The
kidney is enlarged, and the passage of the stone gives rise to renal colic.

Renal Colic comes on as a sudden excruciating, paroxysmal pain. It
is referred to the loin or along the genito-crural nerve. There is vom-
iting and shock. The patient writhes in agony, while he is covered
with cold perspiration. The temperature is often subnormal, the pulse
rapid and weak. The patient has strangury. The attack lasts a vari-
able time, when the stone may be regurgitated into the pelvis of the kid-
ney, or it ma}*- pass into the bladder.

Treatment. — The treatment is osteopathic and consists in relaxing
the ureter to permit the stone to pass. In severe cases nephrectomy
ma3r be performed.

Pyelitis. — Pyelitis is inflammation of the pelvis of the kidney. It
is caused by spinal or rib lesions, by injury, or the extension of inflam-
mations from the bladder up the ureter to the kidney, or the formation
of calculi, or by tubercle or cancer of the kidney, the ingestion of drugs
and by foreign bodies.

The treatment is to remove the cause. This can be successfully
done osteopathically. Providing the disease does not end in pyone-
phrosis or abscess of the kidney, operations will not be required.

Pyonephrosis.— Cause. — Pyonephrosis is the result of inflammations
of the pelvis of the kidney, or hydronephrosis.

DISEASES OF THE BLADDER. dJi

Symptoms. — The kidney is enlarged and tender, and there is more
or less sudden pain with an elevation of temperature. The urine is
scanty and contains pus. There is loss of appetite and emaciation.

Abscess of the Kidney. — Abscess of the kidney may follow infarcts,
pyogenic infection, pyelitis, and pyonephrosis. The abscess may be
single or multiple. It may be the result of interstitial nephritis from
injury. The symptoms are pyuria, enlarged kidney, fluctuation, pus,
and a nephritic abscess. In pyonephrosis or abscess of the kidney
nephrotomy may be necessary.

Perinephritic Abscess. — There are lesions affecting the connective
tissues surrounding the kidney, or it is because of rupture of the kidney
or ureter, or the extension of inflammation through the peritoneal cav-
ity or pleural cavities, or it may be produced by ulceration through the
pelvis of the kidney. In perinephritic abscess, there is evidence of deep
suppuration, chill with septic fever, swelling, and perhaps fluctuation.
If the abscess ruptures of itself, it may open alongside of the erector
spinae mass or through the side of the abdomen, or it may break into
the peritoneal cavity. The treatment is to open the abscess and drain it.

Tubercular Kidney. — The symptoms are obscure and the diagnosis
difficult.. Not too much stress should be placed upon the presence of
the tubercle bacillus in the urine. Eemoval of the lesions should effect
a cure. An exploratory operation is not advisable.

Rupture of the "Bladder. — The bladder may be ruptured by direct
violence to the lower part of the abdomen, when the viscus is distended,
or bjr penetrating wounds, or from fractures of the pelvis, or it may
be ruptured from over-distension. When rupture takes place, it occurs
either within or without the peritoneal cavity. Intraperitoneal rupture
produces severe shock and a burning pain in the hypogastrium. There is
a constant desire to micturate. Muscular rigidity is marked. Bloody
urine may be passed. If the bladder is catheterized, it will be found
empty. Attempts may be made to distend the bladder with sterile
water, which will prove the rupture. Immediate laparotomy is de-
manded, or fatal peritonitis will result. In extraperitoneal rupture, the
urine extravasates into the pelvic cellular tissues. It may extend
up over the front of the abdomen or around the perineum. If the
urine is not septic, urgent symptoms will not follow so quickly, but if
the urine is septic, abscesses will immediately follow. These abscesses
may be fatal. Incisions should be made early and the tissues drained.
Where the urine is not septic, the prognosis is fairly good.

Cystitis. — Cystitis is an inflammation of the bladder wall. It
usually involves the mucous coat, but may involve all the coats. It may
be acute, or chronic.

Acute Cystitis. — Cause. — Spinal and pelvic lesions and irritation to
the vesical plexus, thereby diminishing the integrity of the viscus.
Other causes are, injury from operation, or the passage of instruments,
irritation of calculi, or the extension of urethral and pelvic inflamma-

398 DISEASES OF THE BLADDER.

tions. Pressure of other organs and tumors may cause the disease, as
in case -of a gravid uterus. Exposure to cold and damp, especially in the
spring, will produce a mild cystitis.

Symptoms. — Pain and strangury (straining and passing urine drop
by drop), with a continuous desire to void urine. The onset of the
disease is often announced by a chill. The fever may be very high, or
it may assume a typhoid nature. There is increased pain with the accu-
mulation of urine, because of the stretching of the inflamed walls. The
urine is scanty and high colored, and may contain pus or blood. In mild
cases tbe fever may be high, but transitory, while in the severe forms,
destruction of the mucous, submucous, and even the muscular coats,
• may occur. The case may take on a typhoid nature, with delirium and
symptoms of general sepsis.

Pathology. — In mild cases the inflammation is limited to the neck
of the bladder and the mucosa, while in severe cases the whole bladder
may be affected, or all the coats. It may terminate in resolution, or in
a fibroid thickening of the coats, or in chronic cystitis. Ulcerations of
the mucous coat may occur, while. in other cases the inflammation may
extend on up the ureter to the pelvis of the kidneys, causing pyelitis,
or into the kidney itself, setting up nephritis or pyelonephritis. In other
cases the absorption of pus may lead to multiple abscess formation and
pyemia.

Treatment. — The treatment is osteopathic and surgical. The osteo-
pathic treatment consists in relieving the pain and improving the cir-
culation to the bladder wall, whereby it may be able to resist the in-
vasion of the germs. Surgical treatment calls for the removal of the
cause — if a retained catheter, it should be removed; if a stone, it should
be removed, either by crushing or cystotomy. The bladder may be
washed out with a boracic acid solution once or twice daily, in order to
get rid of the decomposing urine and pus. Cystitis is very often produced
by an unclean catheter. It is necessary to observe the strictest cleanli-
ness about the use of a catheter, and especially so when the bladder is
diseased. If this is done, many cases may be prevented.

In washing out the bladder, the following simple method will be
found highly satisfactory: A clean fountain syringe is filled with a
warm solution of boracic acid, ten grains to the ounce of boiled water.
The nozzle of the syringe should be replaced by the glass portion of a
medicine dropper. The air should now be exhausted from the syringe
by unfastening the catch and allowing the solution to flow out until it
flows a free stream, when the catch may then be snapped down and a
soft rubber catheter inserted in the bladder and the urine withdrawn.
When the urine is withdrawn, the medicine dropper may be inserted into
the end of the catheter and the bladder allowed to run full of the solu-
tion. When full, the syringe may be detached from the catheter and
the solution in the bladder allowed to flow into a vessel. The bladder
may again be filled and emptied in a similar manner. Several times

DISEASES OF THE BLADDER. 399

filling will soon be followed, by the solution coming clear from the blad-
der. The catheter should then be pinched together and withdrawn so
as to bring out that solution still remaining within the catheter. If the
strictest cleanliness is observed in this operation, it will have a very
beneficial effect upon the inflammation of the bladder. It may be done
once or twice daily, as the case may require.

Chronic Cystitis, — This is much more common. It may be the result
of acute cystitis, or it may be subacute from the beginning.

Cause. — The causes of chronic cystitis are acute cystitis, calculi,
foreign bodies, morbid growths, obstructions to the urine, as in
stricture, enlarged prostate, paralysis, gonorrhea, and bony lesions.

Symptoms. — Frequent micturition, the urine being passed every half-
hour to hour. The desire is urgent and spasmodic. The pain is usually
relieved on passing the urine. The urine contains ropy mucus, or muco-
pus. It is alkaline in reaction, often strongly ammoniacal, and may be
very offensive. Decomposition of the urea is brought about by the
action of the micrococcus . ureae.

Pathology. — The mucous membrane is dark and engorged. It is
much thickened and covered with muco-pus, and sometimes with a pre-
cipitation of phosphates. The mucosa may become sacculated, because
of the hypertrophy of the villus-like processes.

Treatment. — In this disease the osteopathic treatment may be relied
upon to effect a cure. Whatever lesions are found affecting the nerve
and blood supply to the bladder should be removed. The diet should
be non-stimulating, light, and of good quality. The other secretions
should be kept good, the bowels regular, the patient well clothed, and
he should pursue an even life. '.No alcoholics or coffee should be allowed.
The bladder may be washed out, where the urine is foul, with hoi water
or a boracic acid solution, in the manner above mentioned. The catheter
should be kept scrupulously clean. The lesions usually found are at
the lumbo-sacral articulation affecting the visceral rami of the sym-
pathetic, thus interfering with the nutrition of the viscus; and also, sub-
luxation of the lower dorsal and the lumbar vertebrae affecting the vas-
omotors to the bladder, thereby diminishing the blood supply. These
lesions must be corrected, the blood supply encouraged, and the viscus
toned up. Usually the disease yields readily to treatment.

Irritability of the Bladder is a condition described in texts as a
peculiar condition of the viscus in which it is affected by changes in the
water and by articles of food, etc. It is most likely that in all these
cases there are lesions which directly affect the nerve supply of the blad-
der. The removal of these lesion? will effect a cure.

Atony of the Bladder is a condition where the bladder wall is not
sufficiently strong to expel all of the urine.

Causes. — 1. Over-distension, because of holding the urine too long.

400

DISEASES OF THE BLADDER.

2. It may become gradually distended, since it is not able to entirely
empty itself, because of stricture or enlarged prostate.

3. Certain1 diseases of the bladder wall, as fibroid and other changes,
diminishing the integrity of the coats, as occurs in chronic cystitis.

Symptoms. — The symptoms are those of retention. There is fre-
quent urination, or the urine dribbles away, the patient being unable to
retain it. There may be involuntary flow during sleep, or upon exertion.
The disease is the result of certain lesions affecting the bladder, or ob-
struction to the flow of urine. These lesions should be treated, or the
obstruction to the flow of urine removed.

Fig. 136.

Drawing showing method of catheterization.

Retention of Urine. — This should not be confounded with suppres-
sion. It is symptomatic, being the result of obstruction, or a lack of
sufficient nerve and muscular power to empty the bladder. It occurs in :

1. The aged, because of enlarged prostate, or because of atony of
the bladder from over distension.

2. 'Middle-aged, because of organic, spasmodic, or congestive stric-
ture.

3. In women with hysteria, or enlarged uterus, or it may be because
of the pressure of the head in parturition.

DISEASES OF THE BLADDER. 401

4. In children, from calculus or phimosis.

5. It may, at all ages, be due to shock from injury or operation,
or from tumors of the neck of the bladder, or abscess of the urethra, or
paralysis from brain or cord injury.

Symptoms. — Eetention of urine can be distinguished by the fact that
the urine dribbles away, while a large amount of urine still remains
within the bladder (residual urine). In some cases, in old. men, the
patient may give a history of frequent micturition and may insist that
all the urine is passed. Palpation and percussion will reveal a full
bladder, when passing of the catheter will demonstrate to the patient
that he is deceived. In these cases it comes on slowly, and is manifest
by the residual urine. If the retention of urine is produced suddenly,
it may be followed by pain, constitutional symptoms, a small pulse, dry
tongue, and delirium. The bladder may rise out of the pelvis even as
far as the ensiform cartilage. Where the disease is the result of atony,
there will be a history of a slow stream, with less force, cystitis, and
painful micturition. It may come on in nephritis, or from rupiure of
the urethra behind a stricture.

Treatment. — 1. From stricture. — In spasmodic and congestive stric-
tures, appropriate treatment will relieve the spasm and congestion. In
organic stricture, treatment to relax the stricturej together with hot
sitz baths, may give relief. Where a small catheter can not be passed,
an anesthetic should be given. If this fails, the bladder should be
aspirated above the pubes: afterwards the organic stricture may be ap-
propriately treated by internal or external urethrotomy, or by cys-
totomy, draining the bladder through another channel.

2. Enlarged Prostate. — This usually occurs in alcoholism, and it
is necessary to have the patient correct his habits at once. A gum elas-
tic catheter, with stilet, should be secured. This may usually be passed
without difficulty. Sometimes tunnelling of the prostate may occur
from the passing of a hard catheter. Often the irritability of the pros-
tatic portion of the urethra causes a spasm of its muscular structure
which will form a barrier to the passing of the catheter. Aspiration of
the bladder may be demanded. As a rule, in these conditions, where
the patient may be controlled, proper osteopathic treatment will relieve
the spasm of the organ.

3. Hysteria. — Where retention of urine is from this cause, the
disease should be recognized and appropriate treatment administered.
The case should not be catheterized.

Tumors of the Bladder are benign and malignant. The benign are
fibromata, papillomata (villosities), myxomatous, or gelatiniform
tumors. The malignant growths are carcinomata and sarcomata (rare).
Fibromata and myxomata are rare tumors and are in the nature of
polypoid growths. Villosities are more common. They develop from the
mueous membrane, and may be extensive. Malignant tumors are chiefly
carcinomata.

402 DISEASES OF THE BLADDER.

Symptoms. — The symptoms are urinary obstruction, together with
pain and increased frequency of micturition. In malignant tumors,
there may be' hematuria, together with other signs of malignancy. It
may be possible to palpate the tumor. It may require a cystoscopic ex-
amination to make the diagnosis. In malignant tumors, as a rule, there
are symptoms of cystitis with foul urine containing muco-pus, pus, or
blood.

Treatment. — A suprapubic cystotomy should be done and the tumor
removed by the galvano-cautery, or cautery loop. If the malignant
tumor is extensive, no operation should be performed.

Urinary Fistula. — Urinary Fistula follows abscess in case of stric-
ture, wounds, or it may be produced by the ulcerations from calculi.
They may be perineal, scrotal, or penile. A perineal fistula should be
scraped out, while the bladder is drained with a catheter held in situ.
Should this fail, an operation may be required. A scrotal fistula will
usually require an operation. The bladder must be drained, while the
fistulous tract is laid open and scraped. In urinary fistula in the penile
portion of the urethra a plastic operation will usually suffice.

Tubercular Bladder. — This disease is rarely primary. The evidences
are those of chronic cystitis, and there are signs of tubercle elsewhere.
The treatment is the same as in tuberculosis of other regions.

Exstrophy of the Bladder (Ectopia Vesicae). — This is a congenital
malformation in which there is failure of the abdominal walls to close
and there is absence of the anterior part of the bladder wall, so that
the viscera push the posterior wall into the cleft and the mucous mem-
brane is exposed. A plastic operation may be necessary. Where the
symphysis is not united, a primary operation to separate the sacro-iliac
joints may be necessary before the symphysis may be united.

Enuresis or Incontinence of Urine is a condition which may arise
from paralysis of the bladder outlet (true enuresis), or there may be a
condition of nocturnal enuresis, or the condition may result from reten-
tion with incontinence.

Cause. — True enuresis is produced by paralysis of the sphincter ves-
icae. This may be brought about by lumbar lesions, or there may be con-
ditions of malformation of the prostate, permitting of enuresis. It may
be occasioned by over dilatation of the urethra in lithotrity, or it may be
produced by injury to the neck of the bladder during parturition. Noc-
turnal enuresis is brought about by lumbar lesions, thread worms, cal-
culi, or by a long prepuce or morbid growths. In this condition, oste-
opathic treatment will give relief, except when caused by a redundant
prepuce or tumor.

Stone in the Bladder occurs most commonly between the ages of
fifteen and twenty, or in old men. It may come on in children. It
appears in poor children, and in old men of gouty habits. The stone
may be made up of one or more salts. The uric acid calculus is the
most common. The next in frequency is the oxalate of calcium and the

PROSTA TITIS. 403

phospliatic calculi. The others consist of the ammonium magnesium
phosphate and phosphate of iron.

Cause. — Residence seems to have something to do with the produc-
tion of stone in the bladder. In certain parts of our country, as Ken-
tucky and Tennessee, the disease is quite common, while in other parts
of the country it is rarely, if ever, known. Certain conditions of the
system, such as gout and rheumatism, seem to predispose to the disease.
Without doubt, certain lesions predispose, if they are not the active fac-
tors, in producing the calculi.

Symptoms. — The symptoms of stone in the bladder are those of in-
flammation of the viscus. There is cystitis, with frequent micturition,
burning pain at the end of the penis, and the pain is increased upon ex-
ercise, or jolting. Tenesmus is marked at the end of urination, when the
stone is grasped by the muscular contraction of the bladder. Pus and
blood will be found in the urine. The person may be of gouty habit.
The symptoms will vary in different cases. Some cases give no symp-
toms, while in others the symptoms are exaggerated. There is but one
way of making sure of the diagnosis, and that is by passing a searcher.
An ordinary steel sound will be sufficient for the purpose. With this
the stone may be felt.

Treatment. — Osteopathic treatment will not always dissolve the
stone after it has once formed, but it will arrest the stone formation,
tone up the viscus, cure the attendant cystitis, correct the urine, and
prevent the subsequent formation of calculi after they have been re-
moved by lithotrity or cystotom}'. The treatment is directed toward
removing whatever lesions are found and to stimulating the blood sup-
ply by treatment in the lower dorsal and lumbar regions.

The operative treatment consists in cystotomy, either above the
pubes or a median or lateral lithotomy or lithotrity. By lithotrity is
meant crushing the stone Avithin the bladder, afterwards by suitable
evacuating apparatus the crushed stone may be washed out.

Prostatitis. — Prostatitis may be acute or chronic. Acute prostatitis
usually results from gonorrhea. It occasions painful and frequent mic-
turition and pain on defecation. There is a throbbing pain in the per-
ineum, together with slight fever, which may be ushered in by chilly
feelings, Sitz baths should be given and the bladder catheterized if
urine is retained. The bowels should be kept loose by appropriate treat-
ment, while the circulation to the prostate may be reached by treatment
over the lumbar spine. Any lesions present should be removed. The
circulation can be improved by stimulating the vasomotors to the in-
flamed organ. These come off from the spine in the lower dorsal or
upper lumbar region. When an abscess results it will be evidenced by a
chill and violent inflammation. As soon as pus is detected, a free incision
should be made in the median line of the perineum.

Chronic prostatitis may follow the acute, or ma3r be chronic from the
outset. The gland is painful and enlarged, and is attended by nocturnal

404 ENL ARGED PR OS TA TE.

emissions. There is more or less pus in the urine or there may be some
discharge of mucus and blood. Micturition is more or less painful and
interfered with.

Treatment. — The treatment consists in determining the cause, then
correcting it. If due to excessive venery, or to the use of
alcohol, the habits of the individual should be corrected. If due to
irritating conditions of the urine, lesions affecting the kidney may be
the cause. Where the organ becomes enlarged, and the disease persists,
lesions anywhere from the ninth dorsal doAvn to the lumbo-sacral articu-
lation may be found. Sacro-iliac subluxations are sometimes present.
Correcting these lesions, will prevent the further enlargement of the
organ, but it may not secure resoiption of the fibrous tissue formed in
the gland.

Vesiculitis. — Inflammation of the vesiculae seminales is the result
of the backward extension of gonorrheal inflammation. The symptoms
are pain in the back, hip-joint, anus, rectum, or perineum. Defecation
and urination are painful, while micturition is frequent. The disease is
often caused by injections. There may be painful and bloody emissions.
In the chronic form, there will be nocturnal emissions and seminal
weakness, together with a discharge of mucus. The treatment consists
in improving the circulation ana1 nerve supply to the seminal vesicles by
means of spinal treatment. Stripping of the seminal vesicles once in
seven days is practiced by many specialists. This operation is per-
formed by the person standing bent over a chair, the finger is introduced
into the rectum above the prostate gland, while, with strong and firm
pressure, the finger is drawn downward and the contents of the seminal
vesicles expressed. The posterior urethra may then be washed out and
irrigated, as in the treatment of chronic urethritis.

Hypertrophy of the Prostate. — Enlarged prostate is produced by
lesions of the sacral and innominate bones and of the tenth, elev-
enth, and twelfth dorsal and any of the lumbar vertebrae,
affecting the visceral rami to the organ. It occurs in old
men. There is hypertrophy of the muscular and glandular struc-
ture of the organ, so that it impedes the flow of urine. It comes on
slowly and causes increased frequency of micturition, at first at night.
The stream voided is smaller and discharged with less force. The
lumen of the urethra is more and more impinged upon until finally the
bladder is unable to entirely empty itself, when residual urine will be
present. This retained urine gives rise to cystitis and the formation of
calculi. A diagnosis of the disease is easy. There is obstruction to pass-
ing the catheter and the presence of residual urine, together with the
fact that upon palpation one or more lobes of the prostate gland are
found enlarged.

Treatment. — The lesions present must be corrected at once, and the
patient directed to pursue a quiet life. No stimulants should be allowed.
The general health should be built up. The circulation to the organ
should be stimulated. If constipation exists, this must be overcome,

INJURIES OF THE PERINEUM. 405

since the hard fecal mass in the rectum will produce irritation sufficient
to keep up the disease. In hypertrophy of the prostate or in cases of
chronic prostatitis, when there is obstruction to the flow of urine, after
other methods have failed Bottini's operation, burning out the prostate
with an electro-cautery, is often successful.

Fig. 137.

Enlargement of the Prostate Gland with a Catheter in situ.

Tubercle of the Prostate is a rare condition, and gives rise to the same
symptoms as chronic prostatitis, together with the evidence of tubercle
elsewhere. The treatment is the same as chronic prostatitis.

Malignant Disease of the Prostate Gland is rare. With the
enlargement of the gland, there are general evidences of malignancy.
The treatment, in general, is that of chronic inflammations of the gland.
Many cases may be benefited, but as a rule the disease runs an unfavor-
able course.

INJURIES TO THE PERINEUM, PENIS, URETHRA, ETC.

Injuries to the Perineum. — Open wounds leading to the urethra may
cause fistulae. Contusions causing effusions of blood beneath the skin
and mucous membrane, may cause interference in urination and require
catheterization. Open wounds leading into the urethra should be
closed as other wounds, and a catheter left in situ until the wound heals.
Injuries to the female perineum may lead to impairment and irregular-
ity and require immediate attention.

Fracture of the Penis.-— This injury occurs at the time of erection,
from blows or injury in coitus. The organ remains erect and is crooked.
A dorsal padded splint and bandage should be applied. Kecovery is
usually good.

406 URETHRAL STRICTURE.

Rupture of the Urethra. — This is attended by extravasation of the
urine. It may occur behind a stricture. Eupture of the urethra
with extravasation of urine demands cystotomy. A suprapubic opera-
tion should be done, while a catheter may be passed outward from the
posterior extremity of the urethra, and the mucous membrane of the
urethral tract united with gut suture.

Foreign Bodies in the Urethra. — Foreign bodies of all kinds may be
introduced into the urethra in both sexes. A history of the case,
with palpation, will determine the diagnosis. In case of small
foreign bodies, the penis may be distended while the patient strains
down, and the foreign body may be dislodged and expelled. It may
be recovered by means of forceps, or it may be expelled by rubber liga-
ture. In some cases, urethrotomy may be required; the urethra is
opened, the foreign body removed and the mucous membrane sutured
with a catheter in situ.

Chronic Urethritis. — The treatment of chronic urethritis consists in
overcoming the stricture often present and in removing the spinal
lesions. There may be some systemic defect responsible for the chronic
condition, but usually it is due to the presence of lumbar lesions. No
alcohol, tobacco, coffee, or any stimulants should be tolerated. Injec-
tions are contra-indicated. If constipation or urinary defects are pres-
ent, they must be attended to, or a cure may not be effected. Sexual
excitement must be avoided and the patient should be directed to pur-
sue an even life.

The prognosis is good if the patient can be controlled. The blood
supply to the inflamed area must be encouraged through the medium of
the vasomotors.

Urethral Stricture may be spasmodic, congestive, or organic.

Spasmodic Stricture is due to a spasm of the unstriped muscle
fibres situated within the muscular wall of the urethra. It is only tem-
porary, and is due to peripheral or spinal irritation

Congestive Stricture is due to congestion of the mucous membrane,
brought about by local injury or spinal lesion.

Organic Stricture is usually the result of a chronic or neglected
'Case of gonorrhea. In these cases, the inflammation and ulceration
extend through the mucous into the submucous coat and considerable
fibrous tissue is formed, which afterwards contracts and narrows the
lumen of the urethra. The anatomical appearance of the stricture may
be irregular, tortuous, or it may be linear or annular. Sometimes these
organic strictures become very sensitive, and in addition we have en-
grafted upon the organic stricture a spasmodic one. In old cases, the
stricture may be cartilagenous or hard. It may occur in any part of the
urethra, except in the prostatic portion. It is most common in the
bulbous portion. When a stricture occurs, the urethra behind
becomes distended and ulcerates. It may lead to perforation and

URETHRAL FEVER. ■ 407

urinary abscess, causing fistulae, this being the result of straining in
the effort at urination. The bladder becomes thickened and hyper-
trophied, and the mucous membrane inflamed. The ureters become
dilated and the kidneys may become more or less diseased, because of a
backward extension of the urine, which is more or less infected. The
symptoms are those of a chronic discharge, a stream smaller than nor-
mal and voided with less force. Passing of a bougie, or catheter, will
usually locate the stricture. There may be one or several.

Treatment. — The treatment of stricture may be considered as (A)
Osteopathic and (E) Operative.

Osteopathic Treatment. — The object of the treatment is to relax
the stricture and resorb the organized inflammatory products. If the
urine is irritating, it should be corrected by proper treatment over the
kidney areas. By promoting the blood supply, the chronic inflamma-
tion which is present may be overcome. In the majority of
these cases, the habits of the individual are harmful to his condition.
No alcohol, tobacco, or coffee should be allowed. The patient should
retire early at night and avoid sexual excitement. The treatment con-
sists in removing the spinal lesions which attend stricture and in pro-
moting resorption of the inflammatory products.

Operative Treatment consists in either slow dilatation, by means of
graduated sounds, or rapid dilatation, by means of an Otis's dilator, or
internal urethrotomy, by division within the urethra, or external
urethrotomy, a division of the stricture from without. Strictures of
large caliber, interfering but little with the stream, may be
successfully treated by means of electrolysis.

Urethral Fever follows operation, the introduction of sounds, cathe-
terization in case of stricture, or injury to the urethra or bladder. It is
attended by considerable nervous shock and followed by septic fever.
It is said that cleanliness will prevent the disease. It is especially fatal
in old people, as there is a marked tendency to the suppression of urine.
The disease is ushered in by a chill and high fever. Equalization of the
circulation by means of osteopathic treatment, together with irrigation
of the bladder, will give relief.

Urinary Fever is believed to be a sudden infection of the urine and
that it occurs after the withdrawal of residual urine. The patient has
chilly feelings, low fever, and a quick, feeble pulse, the tongue is dry,
and there is a loss of appetite. It occurs in old people. Delirium,
coma, and death may appear within a week. It will be found that
cystitis has developed, and this extending to the kidneys, causes a
Dvelonephritis.

Malformations of the Urethra. — Hypospadias. — It may be partial, or
complete. The partial form is a congenital absence of some part of the
floor of the urethra. The meatus usually opens in front of the scrotum.
Beyond the opening, the urethra is but a gutter on the under side of

408

PHIMOSIS.

the penis, instead of a tube as normally. In the complete form, the
urethra opens back of the perineum. The penis is frequently small,
distorted, and bound down, and much resembles the clitoris. The cases
are liable to urethral inflammations. Plastic operations may do some
good in some cases.

Epispadias. — This is a congenital absence of the roof of the urethra
in part or whole. There is clefting of the corpora cavernosa. If partial
a plastic operation will do good.

Chancroid or Venereal Sore is a local sore sharply defined, with un-
dermined edges. It looks
FlG- 138- "punched out." It is not

elevated, and has a gray
and sloughing base. There
is profuse ulceration and
the discharge of foul pus,
which will inoculate the
healthy tissues over which
it flows. Thirty per cent,
of the cases have buboes on
the same side upon which
the sore is situated. If the
sore is in the middle line,
buboes may be on both
sides. The sore is multi-
ple, painful, and appears
early. It may be situated
on any part of the glans
penis, prepuce, labia ma-
jora or minora, or ostium
vaginae.

Treatment. — Cauterize
the sore with carbolic acid,
or nitric acid. Afterwards,
wash twice daily with per-
oxid of hydrogen and car-
bolated water, while calo-
mel, aristol, or other drying powder, may be dusted on the sore, and
antiseptic gauze and cotton applied as in the treatment of other sores.

Cancer of the Penis demands amputation and removal of the en-
larged glands in the groin.

Phimosis is a condition where the prepuce can not be retracted he-
hind the glans. It gives rise to nervous symptoms, urinary inconti-
nence, and inflammation. The prepuce may be adhered to the glans. It
demands circumcision. Some cases may be cured by means of daily at-
tempts at pushing the prepuce over the glans, or small forceps may be
introduced into the lumen and the skin gradually stretched. In the
majority of cases this will not be successful.

Method of reducing paraphimosis.

CIRCUMCISION.

409

Paraphimosis is a more or less strangulation of the glans penis,
caused by the constriction of a too narrow prepuce. It occurs most
frequently in boys where the prepuce is pushed back and allowed to re-
main, forming an obstruction. In adults, it is the result of gonorrheal
inflammation.

The Treatment of the condition is to grasp the penis between the
thumb and first finger of one hand, behind the constriction, then with

Fig. 140.

Fig. 139.

Circumcision. Removing the
prepuce.

The skin and mucous
membrane sutured to-
gether in circumcision.

gentle and continuous pressure by the thumb and first finger of the
other hand upon the glans, the constricted portion may be pulled over,
when circumcision may be performed. Where this does not succeed,
anoint the glans penis, take strips of old washed linen and lay over the
glans, while with a small catheter the glans may be wrapped from the
tip backward, which drives the blood out of the glans back under the
constriction, when reduction is easy. If this operation is not successful,
an incision should be made on the dorsum of the penis, relieving the
constriction. Care should be observed to avoid the dorsal veins.

Circumcision. — -The opera-
tion of circumcision is neces-
sary in case of redundant or
inflamed prepuce or in case of
phimosis or paraphimosis. The
operation may be done under
local or general anesthesia.
The prepuce is grasped by for-
ceps close up to the glans and
the redundant portion beyond
the forceps is then cut off.
The mucous membrane is slit
up the back and trimmed off;
about one-eighth of an inch is
allowed to remain. This is then sutured to the skin, while the patient is
instructed to urinate through a bottle neck until the wound heals. The

Venereal warts on the female genitalia.

410

HYDROCELE.

sutures may be removed in five or six days. Slitting the prepuce on the
dorsum may be practiced on children. Suture will not be necessary if
the operation is done shortly after birth.

Venereal Warts.- — Many cases may be cured by washing daily with
peroxid of hydrogen and dusting the parts with boracic acid. In other
cases they may be clipped olf. Where this will not be allowed, paint
them with a solution of corrosive sublimate one dram, collodion fifteen
drams.

Amputation of the Penis is performed for malignant disease. TTeve's
or Eicord's operation should be performed.

Edema of the Scrotum occurs in conditions of ascites or general
dropsy. It may follow operations for hernia and varicocele. Supporting

Fig. 142.

Fig. 143.

An encysted hydrocele.

Encysted hydrocele of the cord.

the scrotum, and removing the cause, Mill be sufficient. Aspiration is
rarely called for.

Eczema and Prurigo of the Scrotum. — These diseases occasion an in-
tolerable itching of the scrotum, brought about by unclean con-
ditions and spinal lesions. It may be produced by the habit of scratch-
ing. Spinal treatment, together with the application of local sedatives,
will give relief. The local sedatives should be mentholated oil, solu-
tions of menthol, or carbolized vaselin.

Elephantiasis of the Scrotum and Penis consists of an obstruction to
the lymphatic circulation, and is similar to elephantiasis cruris and
pedis.

Hydrocele is an accumulation of fluid within the tunica vaginalis
testis. It may be congenital, infantile, encysted, or vaginal. In the con-
genital form, the tunica vaginalis communicates with the general
peritoneal cavity, whereas in the infantile and encysted forms, the part

HYDROCELE.

411

of the peritoneum covering the cord is open, but is cut off from the
general peritoneal cavity.

Cause. — There is usually an anterior condition of the fifth lumbar.
Other lumbar lesions may be present.

The Diagnosis can be made by the presence of a translucent tumor,
no impulse on coughing, and by the fact that it is not reducible. A his-
tory of the case will be a valuable aid in diagnosis. The testicle mav be
felt in the back part of the sac.

Treatment. — The fluid of a hydrocele may be evacuated by means of
a trocar and canula, or an aspirating needle. The trocar should be
directed upward and backward, to avoid the testicle which is at the
lower and back part of the tumor. FlG 144>

After the evacuation of the fluid,
the lesions in the lumbar region
may be corrected. A cure is readily
effected.

Varicocele is a condition of en-
largement of the veins of the testi-
cle. It usually is f oiind on the left
side, because of the relation of the
veins to other structures, and be-
cause of the circuitous route of the
return circulation.

Cause. — Lumbar lesions, ob-
struction to the return circulation,
and atony of the vessel walls.

Symptoms. — Usually the en-
larged veins may be seen within the
scrotum. While the patient is
standing the enlargement feels like Method of taPPins a hydrocele-

a maSS of earth Worms; Upon lying HY, Hydrocele; NH, Epididymis; HO.Testicle.

down the veins diminish in size. There is no impulse upon coughing,
and there is a history of a chronic condition.

Treatment. — The treatment is to remove the obstruction and im-
prove the circulation by improving the muscular tone of the vessel
walls. Proper spinal treatment, the application of cold and the correc-
tion of constipation, will usually effect a cure. Jn old cases, where the
veins are thickened and are like fibrous cords, they may be removed by
operation.

Hematocle of the Scrotum. — Effusions of blood within the scrotum
may be parenchymatous, vaginal, or encysted. In any case, the patient
should be put to bed in the recumbent posture and ice applied. Where
inflammation sets in, indicating the formation of pus, a free incision
should be made and the effusion evacuated.

412

ORCHITIS.

Fig. 145.

Orchitis, or inflammation of the testicle, may be acute or chronic.
Acute orchitis results from injury, exposure to cold and wet, from
epididymitis,- or mumps, rheumatism, acute and septic fevers, as
typhoid, etc. The testicle becomes enlarged, swollen, and extremely
painful and tender. The skin is red, while the tunica vaginalis and sub-
cutaneous tissues are infiltrated with fluid. There is a painful dragging
down sensation.

The chronic form may arise from the acute, from syphilis, or tuber-
culosis.

Treatment. — The treatment
is support of the testicle and im-
provement of the circulation.
Often lower dorsal, lumbar, or
, : ; ,; lumbo-sacral lesions will be

found. These may be corrected.
The most essential part of the
treatment is to encourage the
circulation through the medium

Fig. 146.

Varicocele, showing the dilated veins.

Method of operation for the
radical cure of varicocele.

of the vasomotors. The bowels and kidneys must be kept free
and active. The person should be kept in a recumbent posture, or after
the inflammation partially subsides, the testicle may be carried in a sus-
pensory bandage. Strapping of the testicle will frequently do good.

Tumors of the Testicle are sarcomata, carcinomata, cysts, and car-
tilagenous tumors. Of the malignant tumors, the sarcoma is the most
common. When it has not yet involved other tissues and the inguinal
glands, it should be removed. Some years ago the writer removed a
sarcoma of the left testicle of a physician from the Indian Territory.
The operation was successful, and the tumor did not recur.

VUL VITIS.

413

Epididymitis. — Inflammation of the epididymis is the result of the
extension of the urethral inflammations. It is very often the result of
the use of injections. The testicle should be supported by a suspensory
bandage. If constipation is present, it should be relieved. The circu-
lation must be promoted by treatment in the lower dorsal and up-
per lumbar regions. Whatever lesions exist — lumbo-sacral, ilio-sacral,
lumbar or dorsal — must be corrected before the inflammation will sub-
side. It usually extends over a period of two to four weeks.

Retained Testicle. — In 80 per cent of cases, the testicle descends
before birth. It may remain in the lumbar region, or may be arrested
in any part of its course of descent. Cases are reported where it has
descended into the scrotum as late as the thirteenth year. Eepeated
efforts at pulling it down into the scrotum will be attended by good
results. Where it gives trouble, it may be removed, providing the other
testicle is healthy.

Fig. 147.

DISEASES AND INJURIES OF THE FEMALE GENITALIA.

Vulvitis. — Inflammation of the vulva may arise in children where
they are ill-fed and unclean, or it may be caused by cold, exposure, in-
jury, parasites, irritating dis-
charges, etc.

Lesions. — Subluxations at
the sacro-iliac joint, or dis-
placed lumbar vertebrae af-
fecting the vasomotors and
viscero-motors, are often re-
sponsible for the disease. The
vulva is red, swollen, edema-
tous, and there is an offensive
discharge. In adults, the dis-
ease is usually the result of
gonorrhea.

Treatment. — The treat-
ment consists in removing
whatever lesions are regarded
as the cause, or are keeping
up the disease process. The
blood supply may be promot-
ed, and any obstruction to the
return circulation, such as a
displaced uterus, or prolapsed

bowel, must be corrected. The parts must be protected from irritating
discharges. In addition to this, a mild astringent, such as a teaspoon-
ful of the acetate of zinc to a quart of water, is often useful, or a 1 :5000
solution of bichloride of mercury where the conditions are foul.

Abscess of the Vulvo-vaginal Glands. — This abscess is due either to

Abscess of the vulvo-vaginal glands.

414

INJURIES OF THE PERINEUM.

Fig. 148.

an infection of the ducts of Bartholin, or to an irritation and inflamma-
tion being set up which cause closure of the ducts and retention of
secretions, resulting in abscess formation. The treatment is an early
incision, to evacuate the pus. The abscess should be washed out with
an antiseptic solution.

Cysts are produced by the closure of the ducts of Bartholin from
irritation. The proper treatment is to clip out a little piece of the wall
of the cyst and evacuate its contents, then scrape the wall within the
sac so as to set up an adhesive inflammation.

Tumors of the external genitalia are benign and malignant. The
benign tumors are fibromata, myxomata, and lipomata. The malig-
nant tumors are cancer and sarcoma. The tumors are rare and easily
distinguished. In malignant disease, a history of the case, lymphatic
enlargement, the age of the patient, and the signs of the tumor, will
suffice to make the diagnosis. The same treatment should be adminis-
tered here as in tumors of other locations.

Injuries of the Perineum. — Lacerations of the perineum frequently

occur during labor. The lacera-
tion may be of the fourchette
only, or it may be of any part
of the perineum, or it may ex-
tend through the sphincter mus-
cle into the bowel, or even de-
stroy the septum between the
vagina and rectum. The treat-
ment is the thorough approxi-
mation of the rupture by means
of suture. This should be done
immediately after labor. Should
the operation not be done, and
the case is seen several days
after the rupture, a secondary
operation will be necessary.
These operations are various, all
looking toward restoring the in-
tegrity of the perineal body.
Should this body not be re-
stored, there will probably be in-
continence of feces and flatus.
In the incomplete laceration of
the perineum, the operation is
simple and uniformly success-
ful, but the secondary opera-
tion for complete laceration of the perineum is difficult and
requires the utmost care and attention, likewise a thorough knowl-
edge of the technic of the operation. In general, the stumps of the
muscles of the perineum should be pared, all the scar tissue raised, the

Method of restoring the perineum in case
of laceration.

VAGINITIS. 415

two denuded surfaces nicely approximated and held together by silk-
worm-gut sutures. These sutures should he allowed to remain from
seven to fourteen days. The bowels should be kept confined for a week
after the operation. The stool should then be softened up with enemata
to prevent the hard fecal mass from separating the surfaces of the
wound. With the proper attention, considering that the operation has
been properly done, it should be successful in all cases.

Vaginitis (Gonorrheal). — This disease is the result of the infection
of the vagina with the diplococcus Neiseri. The inflammation of itself
is not serious, but the extension of the inflammation is frequently dan-
gerous to health, if not to life. It is apt to be followed by urethritis,
endometritis, and salpingitis. Salpingitis will frequently result in pyosal-
pinx, and a pelvic or general peritonitis. The treatment of gonorrhea
in the female is much easier than in the male. Frequent douching with
hot water, or a weak solution, one grain to four or six ounces of water,
of permanganate of potassium, to get rid of the foul discharge, together
with an antiseptic plug of gauze, to maintain thorough drainage, will
be found effective. A mercurial solution (1 :5000) may be used, but will
hardly be attended by better success than simply very hot water.
Osteopathic treatment, looking toward assisting the return circulation,
will be found sufficient in all cases, if supplemented by cleanliness and
antiseptics. Whatever lesions are present must be removed, since these
will affect the circulation and nerve supply to the mucous surface.

Fistula. — Vesicovaginal and rectovaginal fistulae are frequently
established, either by injury or by pressure of the head of the child dur-
ing parturition. This pressure of the head may cause rupture of the
membrane, or the continued pressure cause sloughing, which results in
the fistulous opening. The condition is ver}' troublesome, and can only
be relieved by plastic operation, which consists in denuding the margins
of the wound and nicely approximating them under aseptic conditions.

Rectocele is a protrusion downward through the vagina of the an-
terior wall of the rectum. It is the result of a giving way of the perineal
body, lacerations of the perineum, and a relaxation of the muscular
tissues of the bowel. Most of these cases will demand perineorrhaphy.

Cystocele is a prolapsus of the posterior wall of the bladder into the
vagina. It is usually the result of pressure of the head during parturi-
tion. A suitable plastic operation may be of benefit. Oftentimes this
condition is due to a lax condition of the muscles, which may be better
reached by appropriate spinal treatment, encouraging the nerve supply
to the part, and the removal of certain lesions, than by an operation.

Ovarian Tumor.— -Tumors of the ovary may be cystomata, carcino-
mata, sarcomata, and fibromata. Cysts are more common, and may
arise from the ovary or parovarium. The cysts may be unilocular, or
multilocular. Those appearing early in life are likely to be dermoid in
character. Those cysts arising from the ovary are probably the result
of changes taking plaee in the Graafian follicles, while the parovarian

416 OVARIAN TUMOR.

cysts are the result of the accumulation of fluid within Gartner's
ducts. The contents of the tumor may be of a high, or low, specific
gravity, and may consist of a thin clear fluid, or it may be thick like
tenacious mucus. A portion of the tumor may sometimes resemble
glandular tissue. The tumors may attain enormous size. Eecently
Dr. Charles Still delivered a woman of a normal child, who
had during pregnancy developed an ovarian cyst. The cyst contained
more than fifty pounds of liquid at the time of delivery. The author
successfully removed the tumor by laparotomy, although there were
very extensive adhesions. The patient was able to sit up on the four-
teenth day after the operation. Subsequently she made a com-
plete recovery. The diagnosis is not always easy. Sometimes
the case will require careful study before an accurate conclusion
may be reached. At first it may be mistaken for tubal pregnancy, or
inflammatory conditions; later, when the tumor distends the abdomen,
as it may, it may be mistaken for ascites. A patient was treated at the
A. T. Still Infirmary who had been tapped every two weeks for
two years. An average of nearly five gallons of fluid was removed at
each tapping. The case had been treated as one of ascites, whereas the
trouble was an ovarian cyst. If a careful history of the case is obtained
and a thorough physical examination made, a mistake need not be made.
Often the pedicle of the tumor may be made out. After the tumor be-
comes large, it will distend the abdomen most in the lower segment,
while fluctuation and dullness is evident over the central area of the
abdomen when the patient is in a recumbent posture, whereas in ascites,
the dullness and fluctuation are about the flanks. The presence of the
other tumors of the ovary may be made out b}r a careful examination.

Treatment. — The treatment of any of these tumors depends some-
what upon the conditions present. Luxation of the ilium, lesions at
the lumbo-sacral articulation, or in the lumbar region, must be cor-
rected. The general nutrition of the system must be improved. Tumors
are the result of an abnormal blood supply and defective nerve influ-
ence, or to some obstruction to the flow of the fluids from the parts.
When these conditions can be corrected, the tumors will be absorbed.
Osteopathic treatment will relieve many cases, unless of too long stand-
ing, or unless the tissues will not respond to treatment. Under such
circumstances, laparotomy should be advised. In simple cases the mor-
tality is ten per cent., while in complicated cases it may be twenty-five
per cent., or even higher.

Salpingitis (Pyosalpinx).— Inflammation of the Fallopian tube is
the result of the extension of inflammation from the endometrium or
ovary. Nearly all of the cases are the result of the extension of gonorrheal
inflammation. Even though an abscess results, its contents are often
discharged into the uterus, and a spontaneous cure effected. Adhesions
usually form about the inflamed organ, binding together the pelvic
viscera. Upon vaginal and rectal examination, the tubes are found in-

TUMORS OF THE BREAST. 417

flamed and thickened,, while the uterus is more or less fixed. Formerly
all these cases were operated upon at once and the diseased tube re-
moved. Only when an abscess of some size has formed is this necessary.
A large number of the cases may be relieved by correcting the lesions
present and by promoting the blood supply through the agency of the
vasomotors.

Paget's Disease of the Nipple. — This is an intractable form of ulcera-
tion of the nipple. It often appears eczematous. It is said that it may
often lead to cancer. Some observers have claimed that the disease is
parasitic, but it is more than likely due to a luxated rib, and should be
treated with that in view.

Acute Mastitis. — Inflammations of the breast arise from obstruc-
tion to the return circulation. This obstruction is usually in the axilla,
or between the ribs, and comes from subluxations of the clavicle, or of
the second, third, or fourth ribs, and muscular contractions, producing
impingement upon the internal mammary and axillary veins; The ab-
scess may occur in three locations, superficial to the gland, within the
gland, or beneath the gland. If proper osteopathic treatment is not in-
stituted sufficiently early, abscess will result. When this occurs, a free
incision should be made on a line radiating from the nipple. Eigid
cleanliness must be observed in the after-treatment. The breast and
the wound may be washed out with a saturated solution of boracic acid
several times daily. The obstructions to the circulation must be re-
moved and the blood flow promoted.

Tumors of the Breast are benign and malignant. The benign tumors
are usually fibromata. The malignant tumors are cancers and sarcomata.
The cause of these tumors comes primarily from a long established in-
terference in the circulation of the fluids from the breast. This is either
due to a rib lesion, or subluxation of the clavicle, and muscular con-
tractions. The benign tumors usually occur early in life. They are
round, hard, and sometimes globular, very freely movable, and not very
large. They never become adherent, and are not serious. They can
be relieved by the proper osteopathic treatment. Cancer of the
breast is usually scirrhus or hard, but may be encephaloid. It be-
gins as a small, hard lump within the gland and soon involves the skin
and pectoral muscles beneath. It ulcerates early and the lymphatic
glands in the axilla are enlarged. When near the center of the breast,
the nipple is retracted. As the case continues, it is attended by pro-
nounced cachexia and exhaustion. The skin over the tumor is drawn,
"bacon rind/" From the ulcer there is a foul discharge, while the
growth is often fungating and nodular.

Sarcoma arises from the connective tissues between the acini,
in contra-distinction to the cancer which arises from the epithelium of
the gland tubules. It is usually of the iarge spindle-celled or round-
celled variety. The veins over the tumor are enlarged and tortuous.
The tumor is smooth and elastic, may be lobulated, and grows rapidly.

418 TUMORS OF THE BREAST.

It occurs between twenty and forty years of age, and does not infiltrate
the skin, nor does it cause retraction of the nipple. It may perforate
the skin and protrude as a fungiform mass. It can not be successfully
removed by the knife. Cancers of the breast are operable early.

Osteopathic Treatment. — Appropriate osteopathic treatment in
tumors of the breast is attended by the most unusual and pronounced
beneficial results. A lady, aged forty-five, suffering from a scirrhus cancer
of the breast which involved both mammae, extending into the axilla
and down over the epigastrium, applied to Dr. Charles Still for treat-
ment. Upon examination, an ulcerating tumor the size of a child's head
was found in the left breast. The patient was cachectic and much de-
pressed. Because of the extensive involvement of other tissues, the case
was declared inoperable by several eminent surgeons. The patient' ap-
plied for osteopathic treatment as a drowning person grasps at a straw.
After a month's treatment the extensive ulcerated surface healed.
"Within four months the case was apparently cured. This case is most
remarkable. Not all cases can be so successfully handled. In the above
case the ribs were adjusted (third and fourth) and the circulation of the
fluids stimulated. Treatment should be advised in all cases of benign
or malignant tumors. Where the tnmor does not show signs of yielding
after three or four months' treatment, and it affects the general health,
or is malignant, the breast should be amputated.

INDEX.

INDEX

Abdomen, diseases and injuries of, 366
wounds of, 362

non-penetrating, 362
penetrating, 367
Abdominal hernia, 379
wall, contusion of, muscular rup-
ture from, 363
contusion of, without injury of
viscera, 362
Abernethy's extraperitoneal method
for ligation of external iliac,
169
Abscess, 23
acute, 23, 26
diagnosis, 28
in various regions, 27
symptoms, 28
treatment, 28
alveolar, 354
appendicular, 373
Brodie's 27, 195

cerebral, from ear disease, 334
chronic, 31, 26
cold, 31
deep, 27
dorsal, 316
iliac, 264

ischiorectal, 27, 392
lumbar, 316

of antrum of Highmore, 355
of appendix, 373
of bone, 195

of brain, 334. See also Brain, ab-
scess of.
treatment, 334
of breast, 28

treatment, 33
of hip, 260
of kidney, 397
of liver, 27
of \ung. 27, 360
of mammary gland, 417
of scalp, 337
of vulva, 413

Abscess, palmar, 341
perinephritic, 27, 397
pointing of, 28
postpharyngeal, 27, 316
prostatic, 27
psoas, 316
residual, 27

retropharyngeal, 27, 316
spinal, treatment, 316
subphrenic, 27
superficial, 27
tubercular, 33
treatment, 33
Acetabulum, fractures of, 236
Acromegaly, 201
Actinomycosis, 66
Acupressure

in hemorrhages, 127
Adenomata, 95
Aerobic bacteria, 11
Air-passages, foreign bodies in, 357
Alimentary canal, foreign bodies in,

356
Allis's sign, 238
Alopecia in syphilis, 81
Ambulatory dressing apparatus for
thigh, 213
of plaster-of-Paris for leg, 213
treatment of fractures, 213
Ameboid movements of leukocytes, 3
Anaerobic bacteria, 11
Anastomosis, aneurysms by, 158
intestinal, 365
lateral, 365
Ariel's operation for aneurysm, 155
Anesthesia, 110

complications in, treatment, 112
swallowing of tongue in, 112
Anesthetic state from ether or chloro-
form, 111
Aneurysm, 148
artero-venous, 158
circumscribed, 148
cirsoid, 148, 158

421

422

INDEX.

Aneurysm, consecutive, 148

cylindrical, 148

diagnosis, 151

dissecting, 148

false, 148

forms of, 148

fusiform, 148

operation for, Anel's, 155
Antyllus's, 155
Brasdor's, 156
Hunter's, 155
Wardrop's, 156

rupture of, 150

sacculated, 148

spontaneous, 148

traumatic, 148, 158

treatment, 157, 154

true, 148

varicose, 158
Aneurysmal varix, 158
Angina, Ludwig's, 47
Angiomata, 94, 174
Ankle-joint,

disease, 265

dislocations of, 306. See also Dislo-
cations of ankle-joint.
Ankylosis, 272
Anterior tibial artery, 170

ligation of, 170. See also Ligation.
Anthrax, 66
Antisepsis, 16

Antiseptic methods for surgical clean-
liness, 16
Antiseptics, chemical, 16
Antiseptic properties of the blood, 20
Antitoxins, 15
Antrum,

of Highmore, abscess of, 355
Antyllus's operation for aneurysm, 155
Anus, 389

diseases and injuries of, 389

fissure of, 390

imperforate, 389

prolapse of, 390

pruritus of, 390
Aorta, abdominal, ligation of, 168. See

also Ligation.
Appendicitis, 373

diagnosis, 375

etiology, 374

forms of, 375

symptoms, 375

Appendicitis, treatment, 375
Appendicular abscess, 373

colic, 373
Arterial

sclerosis, 147
Arteries, inflammation of, 147

ligation of, in continuity, 161. See
also Ligation of arteries.

wounds of, 159
Arteritis, 146
Artery, calcification of, 146

clots formed after division of, 160
Arthritis, 253

acute suppurative, 253

deformans, 269. See also Osteo-ar-
thritis.

gonorrheal, 257

gouty, 268

neuropathic, 270

rheumatic, 267

rheumatoid, 269. See also Osteo-ar-
thritis.

tubercular. 266
Arthropathy, tabetic, 270
Articular wounds and injuries, 260
Artificial respiration, 112
Asepsis, 20

methods for surgical cleanliness, 22
Astragalus, dislocations of, 307
Atheroma, 146
Atony of bladder, 398
Atrophy of bone, 200
Axillary artery, 167

ligation of, 365. See also Ligation.
Bacilli, 9
Bacillus anthracis, 16

coli communis, 16

mallei, 16

of malignant edema, 16

of typhoid fever, 16

pyocyaneus, 15

pyogenes foetidus, 15

tetani, 60

tuberculosis, 67
Bacteria, 8

aerobic, 11

amotile, 9

anaerobic, 11

distribution of, 10

conditions affecting growth, \\

facultative-aerobic, 11

forms of, 9, 15

INDEX.

m

Bacteria, life-conditions, of, 11

motile, 9

morphology of, 9

multiplication of, 9

non-pathogenic, 13

pathogenic, 13

reproduction, 9
Balanitis from gonorrhea, 86
Bandages, 103

Barton's, 220
of both eyes, 107

figure-of-8 of both eyes, 111

of jaw and occiput, 105

gauntlet, 103

plaster-of-Paris, 107

recurrent, of head, 107
of stump, 107

spica, of groin, 106
of shoulder, 105
of thumb, 104

T-, of perineum, 106

Velpeau's, 104
Barton's fracture, 232
Basedow's disease, 359
Bassinl's operation for femoral her-
nia, 388
for inguinal hernia, 384
Bed-sore, 44
Bees, stings of, 140
Bites of insects, 140

of reptiles, 139
Bladder, atony of, 398

diseases and injuries of, 397

exstrophy of, 402

injury of, in fracture, 236

operations on, 401

rupture of, 397

stone in, 402

tumors of, 401
Blood poisoning, 50
Blood-vessels, development of, 115

diseases and injuries of, 145
Boils, 183

Bond's splint in Colles's fracture, 232
Bone, abscess of, 195

atrophy of, 200

caries of, 197. See also Caries.

fractures of, 202. See also Fract-
ures.

hypertrophy of, 200

inflammation of, 190. See also Os-
teitis.

Bone, necrosis of, 198. See also Necro-
sis,
repair of, 113
tuberculosis of, 200
tumors of, 202
Bone-felon, 342
Bones, affections of, in syphilis, 82

diseases and injuries of, 190
Boracic acid, 18

Bbttini's galvanocaustic operation for
hypertrophy of prostate gland,
404
Bowel, obstruction of, 371. See also In-
testinal obstruction.
Bow-legs, 346
Brachial artery, 167

ligation of, 167
Brain, abscess of, 334
compression of, 329
differential diagnosis, 330
symptoms, 329
treatment, 331
concussion of, 328
symptoms, 328
treatment, 329
hernia of, 335
lacerations of, 332
operations on, 333, 335
traumatic inflammation of, 333

of membranes of, 333
water on, 338
wounds of, 332
Brain-disease from suppurative ear-
disease, 334
Brasdor's operation for aneurysm, 155
Breast, abscess of, 28, 417. See also
abscess of breast,
cancer of, 417. See also Mammary

gland, cancer of.
diseases of, 417
Brodie's abscess, 195

joint, 266
Bronchus, foreign bodies in, 357
Bruises, perineal, 414
Bubo from gonorrhea, treatment. 86

syphilitic, 79
Bunion, 349
Burns, 143
Bursae, diseases and injuries of, 338

inflammation of, 343
Bursitis, 343

424

INDEX.

Cachexia, cancerous, 97
Calcification of artery, 146
Calculus, renal, .396

vesical, 402. See also Vesical calcu-
lus.
Callus, 208
Cancer, 97. See also Carcinoma.

colloid, 98

of breast, 417. See also Mammary
gland, cancer of.

of esophagus, 362

of mammary gland, 417. See also
Mammary gland.

of penis, 408

of tongue, differentiation of, from
chancre, 353
Cancrum oris, 44
Carbolic acid, 16, 17
Carbuncle, 44, 184
Carcinoma, 97

classification of, 91

encephaloid, 98

glandular, 98

of mammary gland, 417

of stomach, 370

of tongue, 353

scirrhus, 98
Carcincmata, 86, 97
Caries, 197

necrotica, 197

of lumbar and dorsal vertebrae,
Treves's operation for, 318

sicca, 197

spinal, 313
treatment, 317
Carotid artery, common, 164

ligation of, 164

external, 165

internal, 164
Carpal bones, dislocation of, 297
Carpus, fractures of, 236
Cartilages, floating, 241
Catgut, 131

chromicized, 131

preparation of, 131
Cautery, actual, in hemorrhage, 127
Cell-proliferation in inflammation, 3
•Cellulitis, 25

Cellulocutaneous erysipelas, 57
Cephalodynia, 339
Cerebral abscess from ear-disease, 334

hemorrhage, 332

Chancre and chancroid, mixed infec-
tion, 79

from herpetic ulceration, 78

hard, 78

Hunterian, 78

redux, 79

soft, 78
Chancroid, 78, 408

Charcot's artery of cerebral hemor-
rhage, 332

disease, 270

joint, 270
Chemotaxis, 2
Chest, diseases and injuries of, 359

wounds of, 359
Chilblain, 185

Chloroform, administration of, 111
Chondroma t a, 93

Chordee from gonorrhea, treatment, 86
Cicatricial tissue, 3
Cicatrization, 3
Cigarette drains, 130
Circulation, retardation of, 2
Circumcision, 409
Cirsoid aneurysm, 148
Clavicle, dislocations of, 282. See also
Dislocations of clavicle.

fractures of, 222. See also Fractures,
of clavicle.
Clavus, 184
Cleft palate, 353
Clove-hitch knot applied above wrist,,

291
Club-foot, 346. See also Talipes.
Club-hand, 346
Cocci, 9

pyogenic, 23
Colles's fracture, 232. See also Fract-
ures, Colles's.

law in syphilis, 84
Compression, digital, 125

in hemorrhage, 125

of brain, 329
Concussion of brain, 328. See also
'Brain, concussion of.
of spinal cord, 323
Continuous suture, 133
Contused wounds, 127
Contusions, 143
of abdominal wall, 336. See also Ab-
dominal wall, contusion of.

INDEX.

425

Contusions of head, 324

of muscles, 338

of spinal cord, 318
Cooper's method for reducing shoul-
der-joint dislocations, 289
Corn, 184

Corrosive sublimate, 16
Costal cartilages, dislocation of, 298

fractures of, 221
Coxa vara, 350
Coxitis, 260
Creolin, 17

Cutaneous erysipelas, 56
Cystitis, 397

acute, 397

chronic, 398

rest in, 398

treatment, 398
Cystocele, 415
Cystotomy, 402

suprapubic, 403
Cysts, 100

dermoid, 100

extravasation, 100

exudation, 100
Cysts, hydatid, treatment, 102

of pancreas, 379

retention, 100

sebaceous, 101
Czerny-Lembert suture, 367
Decubital gangrene, 44
Deodorizers, 16
Dermatitis, 183
Dermoid cysts, 101, 352
Diabetic gangrene, 46
Diapedesis in inflammation, 2
Diaphragmatic hernia, 389
Diplococci, 9

Diplococcus pneumoniae, 16
Diseases and injuries of abdomen, 362

of antrum. 355

of bladder, 397

of blood-vessels, 145

of bones, 190

of bursae. 338

of chest, pleura and lungs, 359

of genito-urinary organs, 413

of head, 324, 355

of heart, 146

of kidney, 396

of larynx and trachea, 356

of lymphatics, 181

Diseases of muscles, 338
of nerves, 186
of nose, 358
of penis, 405
of prostate, 402
of rectum and anus, 389
of seminal vesicles, 404
of spine, 309
of tendons, 338
of testicles. 412
of tunica vaginalis, 412
of upper digestive tract, 361
of ureter, 364
of urethra, 406
and malformations of brain, 337

of bones of skull, 337
of bones, 190
of breast, 417
of head, 324
of joints, 252
of mouth, 352
of nails, 342, 185
of skin. 183
of tongue, 343
Disinfection of instruments, 21
Dislocations, 273
at inferior radio-ulnar articulation,

296
complete, 274
complicated, 274
compound, 274
congenital, 274
habitual, 274
incomplete, 273
occurring with fracture, reduction

of, 389
of ankle-joint, 306
of astragalus, 307
of carpal bones, 297
of clavicle. 282
acromial end of, 283

Rhoads's apparatus for, 284
sternal end of, 282
of costal cartilages, 298
of elbow-joint, 291

both bones, backward, 292
forward, 293
lateral, 292
reduction, 293
of femur, 299
downward, into obturator fora-
men, 301

426

INDEX.

Dislocations, into sciatic notch, 300
ischial, 302

on dorsum of ilium, 301
on pubis, 302
perineal, 302
suprapubic, 302
of fibula, 305
of hip, irregular, 299
of hip-joint, 299. See also Disloca-
tions of femur,
congenital, operations for, 274
of humerus, 284. See also Disloca-
tions of shoulder-joint,
of knee-joint, 304
of lower jaw, 281
of metacarpal bones, 297
of metatarsal bones, 309
of metacarpophalangeal joint of
\ thumb, 297

of muscles, 338
of patella, 304
of phalanges, 298
of radius, 294
of ribs, 298

of scapula, lower angle of, 284
of semilunar cartilages of knee, 305
of shoulder-joint, 284
partial, 291

reduction by extension, 289
subcoracoid, 286
subglenoid, 286
subspinous, 287
symptoms, 285
treatment, 288

Kocher's method, 288
of spine, 319
of sternum, 298
of tarsal bones, 308
of tendons, 338
of ulna, 294
of wrist, 296 '

deformity in, 297
old, 274
partial, 273
pathological, 276
recent, 274
simple, 274
spontaneous, 274
subastragaloid, 308
traumatic, 274, 276
causes, 276
compound, treatment, 279

Dislocations, diagnosis, 279
old, treatment, 280
pathological conditions in, 277
simple, treatment, 279
special, 281
symptoms, 278
treatment, 279
Dissection-wounds, 138
Diverticula of esophagus, 361
Dorsalis pedis artery, 171
Drainage, 129

cigarette, 130
Dressing, 19
Dupuytren's contraction, 343

fracture, 251
Ectopia vesicae, 402
Edema, of glottis, 359

of larynx, 359
Elbow, miners', 344
Elbow-joint, disease, 266
dislocations of, 292
fractures in, 230
Elephantiasis, 180

Arabum, 180
Embolism, 175
symptoms, 176
treatment, 178
Empyema, 360
Encephalitis, 333
Encephalocele, 338
Endospore, 9
Enterocele, 380
Entero-epiplocele, 380
Enteroptosis, 376
Enterorrhaphy, 366

circular, 366
Epididymitis, 412
in gonorrhea, 87
Epilepsy, 336

treatment, operative, 336
Epiphyseal separation, 217
Epiphysitis, acute, 257
Epiplocele, 380
Epispadias, 408

Epistaxis, plugging nares for, 125
Epithelioma, cylindrical-celled, 98

squamous-celled, 97
Epitheliomata, 97
Epulis, fibrous, 355
Ergotism, gangrene from, 46
Eruptions in syphilis, forms of, 80
Erysipelas, 56 .

INDEX.

427

Erysipelas, cellulocutaneous, 57

cutaneous, 57

forms of, 58

phlegmonous, 57

streptococcus of, 15

treatment of, 59
Esophagus, cancer of, 362

diseases of, 361

diverticula of, 361

foreign bodies in, 356

strictures of, 362
Ether, administration of, 111

anesthetic state from, 112
Exstrophy of bladder, 402
Extradural abscess, 334

hemorrhage, 331
Extravasation-cysts, 100
Exudation-cysts, 100
Eye, affections of, in syphilis, 81
Facial artery, 165
False joint, 214
Fasciotomy, subcutaneous, of plantar

fascia, 249
Fecal fistula, 23, 392
Felon, 342
Femoral artery, 169
ligation of, 169

hernia, 384
Femur, dislocations of, 299

fractures of, 238
Fever, suppurative, 25

surgical, 48

traumatic, 49

urethral, 407

urinary, 407
Fibromata, 91
Fibula, dislocations of, 305

fractures of, 250
Fistula, 23, 39

in ano. 392
Flail-joints, 350
Flat-foot, 349
Floating cartilages, 241

kidney, 396
Fracture-box in fractures of leg, 249
Fracture-dislocations of spine, 320
Fractures, 202

amputation for, 218

Barton's 232

bracketed plaster-of-Paris, dressing
in, 212

by contre coup, 202

Fractures, causes, 202
Colles's, 233
comminuted, 204
complete, 204
complicated, 205
complications in, 216

prevention of, 217

treatment, 217
compound, 202, 217

amputation for, 218

repair of, 217
treatment, 218
counter-extension in, 211
crepitus or crepitation in, 206
delayed union in, 214
depressed, 204
dislocation occurring with, reduction

of, 216
displacements in, 206
Dupuytren's, 251
extension in, 211
false joint in, 214
fenestrated plaster-of-Paris dressing

in, 212
fibrous union in. 214
fissured, 204
green-stick, 204
impacted, 204
incomplete, 204
injury of bladder in, 397

of urethra in, 397
longitudinal, 205
non-union of, 214
of bones of foot, 352
of carpus, 236
of clavicle, 222

at acromial end, 223

at sternal end, 222

in shaft, 222

Moore's dressing in, 224

Sayre's adhesive-plaster dressing
for, 223
of costal cartilages, 221
of false pelvis, 236
of femur, 238

above condyles, 246

at base of neck, 239

at lower epiphysis, 246

at upper epiphysis, 240

extracapsular, 239
diagnosis, differential, from in-
tracapsular, 239

428

INDEX.

Fractures, intracapsular, 238
treatment, 239

in upper third, dressing of, 261

separating either condyle, 244

shaft of, 240

upper extremity of, 240
of fibula. 250
of forearm, both bones of, splints

for, 232
of hip, intracapsular, 238
of humerus, 225

anatomical neck of, 225

at base of condyles of, 229

at lower epiphysis, 231

at upper epiphysis, 227

condyles of, apparatus for any
point above, 229

external condyle of, 230

head of, 227

internal condyle, 230

lower extremity of, 229

shaft of, 228

surgical neck of, 227

T-fractures, 230

upper extremity of, 227
of hyoid bone, 220
of inferior maxillary bone, 219
of lachrymal bone, 219
of laryngeal cartilages, 356
of leg, 248

both bones of, 248

fracture-box in, 249
of malar bone, 219
of metacarpus, 236
of metatarsal bones, 352
of nasal bones, 219

Mason's pin in, 219
of patella, 246

transverse, 246

treatment, operative, 247

ununited, 247
of pelvis, 236
of penis, 405
of phalanges, 236
of radius, 232
of ribs. 221
of scapula, 224
of skull, 325
of spine, 320
of sternum, 222

Of superior maxillary bone, 219
of tarsus, 252

Fracture of tibia, 249
of true pelvis, 236
of ulna, 235
of zygomatic arch, 219
Pott's, 250
repair of, 207
simple, 204
special, 218
spiral, 205
splintered, 204
stellate, 205
symptoms, 205
transverse, 205
treatment, 209

ambulatory, 213
T-shaped, 205
union of, delayed, treatment, 214

vicious, 215
ununited, 205, 214
treatment. 215

operative, 215
wiring of, 215
varieties of, 203
Frequency of micturition, 395
Frost-bite, gangrene from, 47
Fulminating gangrene, 43
Fungous ulcer, 35
Furuncle, 183

Gall-bladder, rupture of, 364
Gall-stones, 377
treatment, 378
Gait's conical trephine, 335
Ganglia, 343
Gangrene, 39
acute, 42
classification, 39
decubital, 44
diabetic, 46
dry, 39

from ergotism, 44
from frost-bite, 47
fulminating, 43
hospital, 43
microbic, 42
moist, 39
postfebrile, 47
Raynaud's, 48
senile, 41
special forms, 39
spreading traumatic, 42
symmetrical, 48
Gauze, dressings, 19

INDEX.

429

Genitourinary organs, disease and in-
juries of, 396
Genu valgum, 346
varum, 346
Germicides, 16
Glanders, 75
Gleet, 85

Glenard's disease, 376
Gliomata, 95
Glottis, edema of, 359
Gluteal artery, 168

ligation of, 168
Goiter, 359
Gonococcus, 85
Gonorrhea, 85

acute inflammatory symptoms, 86
treatment, 87

catarrhal, 85

complications of, 86

in female, 415
Gout, rheumatic, 268
Granny knot, method of tying, 126
Graves's disease, 359
Gummata in tertiary syphilis, 82
Gunshot wounds, 141

hemorrhage from, 141

prevention of infection of, 142

probing for bullet in, 142
Hagedorn's needles, 132
Hair, affections of, in syphilis, 87
Hallux valgus, 349
Halsted's suture, 133
Hammer-toe, 350
Hand and forearms, sterilization of,

21
Hare-lip, 351
Head, contusion of, 324

diseases and injuries of, 324
Healing of wounds, 113

by first intention, 113

by granulation, 115

by second intention, 115

by third intention, 116
Heart, diseases and injuries of, 146
Heat in inflammation, 5, 7
Hematocele, 411
Hematuria, 394
Hemorrhage, 121

actual cautery in, 127

acupressure in, 127

arrest of, 123

arterial, 121

Hemorrhage, capillary, 121

cerebral, 331

compression in, 125

extradural, 331

forced flexion in, 125

from nose, 125

intracranial, 331

ligation in, 126

method of controlling by ligature,
126

muscae volitantes in, 121

pressure in, 125

primary, 122

reactionary, 128

recurrent, 128

secondary, 128

styptics in, 128

torsion in, 127

tourniquet in, 126

venous, 121
Hemorrhoids, 391

application of ligature for, 391

causes, 392

treatment, 392
Hereditary syphilis, 83
Hernia, abdominal, 379

causes, 379

diaphragmatic, 389

femoral, 387

Bassini's operation for, 388

incarcerated, 381

infantile, 388

inflamed, 382

inguinal, 385
Bassini's operation for, 384

irreducible, 381

labial, 385

lumbar, 389

obstructed, 381

obturator, 389

of brain, 332

reducible, 381

scrotal, 379

strangulated, 382

umbilical, 388

varieties of, 380

ventral, 389
Herniotomy, 384

Highmore, antrum of, abscess of, 355
lip, abscess of, 261
lip-disease, 260
Hip-joint, disease of, 260

430

INDEX.

Hip-joint, dislocations of, 299
Hodgen's apparatus for fractures of

thigh, 243
Hospital gangrene, 43
Housemaid's knee, 338
Humerus, dislocations of, 284

fractures of, 225

subluxation of, 291
Hunterian chancre, 78
Hunter's operation for aneurysm, 155
Hutchinson's teeth, 83
Hydrencephalus, 338
Hydrocele, 410
Hydrocephalus, 338
Hydrogen peroxid, 17
Hydronephrosis, 396
Hydrophobia, 64

Pasteur treatment of, 66
Hydrops articuli, 352
Hyoid bone, fractures of, 220
Hypertrophy of bone, 200

of muscles, 340

of prostate gland, 404
Hyphomycetes, 9
Hypospadias, 407
Hysteria, traumatic, 323
Hysterical joint, 266
Iliac abscess, 264

arteries, 168
ligation of, 168
Imperforate anus, 389
Incarcerated hernia, 381
Incised wounds, 137
Infantile hernia, 388
Infarction, 176
Infection, 13
Infection, avenues of, 13

characteristics of, 14
Inferior thyroid artery, 166

ligation of, 166
Inflammation, 1

treatment of, 6
Inflammation, acute, symptoms, 5

treatment, 6

causes, 4

cell-proliferation in, 3

changes in perivascular tissue in, 3

chronic, 5

circulatory changes in, 2

cold in, 7

diapedesis in, 3

dilation of vessels in, 2

Inflammation, fomentation in, 7

heat in, 7

treatment, 6
Ingrown toe-nail, 184
Inguinal hernia, 379
Innominate artery, 163

ligation of, 163
Insects, bites of, 140

stings of, 140
Internal pudic artery, 168
Interrupted suture, 131
Intestinal approximation, considera-
tion of methods of, 365

obstruction, 371
acute, 371

chronic, symptoms, 372
diagnosis, 372
treatment, 373
Intestine, rupture of, without external
wound, 364

stricture of, 372

suture of, 365

tumors of, malignant, 373
Intracranial hemorrhage, 331

tumors, 334
Intussusception, 371
Involucrum, 198
Iodoform, 18
Iritis in syphilis, 81
Irreducible hernia, 381
Irrigation of wounds, 129
Ischiorectal abscess, 392
Jacob's ulcer, 38
Jaw, lower, dislocations of, 281
Jerk-finger, 345
Joint, Brodie's, 268
. Charcot's 270

dropsy of, 255

hysterical, 268

strumous, 258
Joints, disease of, 252

loose bodies in, 271

tuberculosis of, 72
Keloid, 92
Kidney, abscess of, 397

diseases and injuries of, 396

floating, 396

injuries of, 396

rupture of, 364

tuberculosis of, 397

tumors of, 395
Knee, housemaids', 343

INDEX

431

Knee-joint disease, 265

dislocations of, 304
Knee-joint, subluxation of, 304
Knock-knee, 346
Kocher's reduction of shoulder-joint

dislocation, 288
Kyphosis, 312
Labial hernia, 385
Lacerated wounds, 137
Lachrymal bone, fractures of, 219
Laryngeal cartilages, fractures of, 356
Laryngotomy, quick, 357
Larynx,

diseases and injuries of, 356

edema of, 359

intubation of, 358

operations on, 357

wounds of, 356
Leg, ulcers of, 37
Legs, bow-, 346
Lembert's suture. 367
Leontiasis ossium, 201
Leptothrix, 10
Leucomains, 15

Leukocyte; ameboid movements of, 3
Levis's splints for fracture of lower
end of radius, 234

for reduction of dislocation of pha-
langes, 398
Ligation in inferior carotid triangle,
164

in superior carotid triangle, 164

of abdominal aorta, 168

of anterior tibial artery, 170
in continuity, 162

of axillary artery, 167

of brachial artery, 167

of dorsalis pedis artery, 171

of external iliac by Abernethy's ex-
traperitoneal method, 169

of facial artery, 165

of femoral artery, 169

of gluteal artery, 168

of iliac arteries, 168

of inferior thyroid artery, 166

of innominate artery, 163

of internal mammary artery, 166

of lingual artery, 165

of occipital artery, 165

of popliteal artery, 170

of posterior tibial artery, 170

of radial artery, 168

Ligation of subclavian artery in third
part, 166

of superior thyroid artery, 165

of temporal artery, 165

of ulnar artery, 166

of vertebral artery, 166
Ligature, application of, for hemor-
rhoids, 391
Ligature-material, 131, 162
Lip, lower, carcinoma of, 351
Lipomata, 92
Lithotrity, 403
Liver, 363

abscess of, 376

movable, 377

rupture of, 363
Lockjaw, 60. See also Tetanus.
Lordosis, 312
Lorenz's operation, 275
Ludwig's angina, 47
Lumbago, 339
Lumbar abscess, 316
Lung, abscess of, 360

contusion of, 359

diseases and injuries of, 359

hernia, 360

operations on, 361
Lupus, 71

exedens, 71

hypertrophicus, 72

vulgaris, 71
Luxatio erecta, 286

Luxations, 273. See also Dislocations.
Lymphadenitis, acute, 181

chronic, 181

infective, 182
Lymphadenoma, 182
Lymphangiectasis, 180
Lymphangiomata, 180, 94
Lymphangitis, 179
Lymphatics, diseases and injuries of,

179
Lymphoma, 94
Lymphorrhea, 180
Lymphosarcoma, 183
Lyssa, 64
Microglossia, 353
Maculae of syphilis, 80
Maculopapular syphilides, 80
Malar bone, fractures of, 219
Malignant, pustule, 66

tumors, 91

432

INDEX.

Mallet-finger, 345

Mammary gland, abscess of, cold, 417

cancer of, 417

tumors of, 417
Mason's pin in fracture of nasal bones,

218
Mastitis, acute, 416

chronic, 417
Mastoid suppuration, operations for,

336
Maxillary bone, inferior, fractures of,
220

superior, fractures of, 219
McBurney's point, 375
Melanotic sarcoma, 96
Meningitis, tubercular, 333
Meningocele, 309, 337
Meningomyelocele, 309
Metacarpal bones, dislocation of, 297
Metacarpus, fractures of, 236
Metatarsal bones, dislocations of, 309

fracture of, 252
Metatarsalgia, 350
Mierobic gangrene, 43
Microcephalus, 337
Micrococci, 9
Micro-organisms, 8
Micturition, frequency of, 395
Miners' elbow, 344
Moist gangrene, 43
Mollities ossium, 201
Molluscum fibrosum, 92
Molluscum contagiosum, 186
Moore's dressing in fracture of clavi-
cle, 224
Morbus coxae, 260. See also Tuber-
culosis of hip-joint.

coxarius, 260
Morton's disease, 350
Mother's marks, 94, 174
Moulds, 18

Mouth, diseases of, 352
Muscae volitantes in hemorrhage, 121
Muscles and ligaments, atrophy of, 340

contusions of, 338

degeneration of, 340

diseases and injuries of, 338

dislocations of, 339

hypertrophy of, 340

rupture of, 338

strains of, 338

wounds of, 33,9

Myalgia, 339

Myomata, 93

Myositis, infective, 340

Myxomata, 92

Nails, diseases of, 185

Nares, plugging of, for epistaxis, 125

Nasal bones, fractures of, 218

Mason's pin in, 218
Necrosis, 198

acute, 198

causes of, 198

coagulation, 23

from osteitis. 197

from osteomyelitis, 193

liquefaction, 24

of bone, 198

symptoms, 199

treatment, 199
Needles, Hagedorn's, 132
Nephroptosis, 396
Nerve, inflammation of, 188

repair of, 117
Nerves, contusions of, 186

diseases and injuries of, 186

operations upon, 186

pressure upon, 187

ulnar, dislocation of, at elbow, 294

punctured, 187
Neuralgia, 190

of joints, 267
Neuritis, 189

in syphilis, 253
Neurofibromata, 95
Neuromata, 95
Neuroparalytic ulcer, 38
Nevi, 94, 174
Nipple, Paget's disease of, 417

tumors of, 417
Nitrate of silver, 18
Noma, 44
Nose, diseases and injuries of, 358

foreign bodies in, 356

hemorrhage from, 125
Obstructed hernia, 371
Obstruction, intestinal, 371
Obturator hernia, 389
Occipital artery, 165
Ointments, 19
Onychia, 185

Operations, Bassini's, for femoral her-
nia, 388
for inguinal hernia, 384

INDEX.

433

Operations, Bottini's, galvanoeaustic,
for hypertrophy of prostate
gland. 404

for fistula in ano, 392

for intussusception, 265

for ligation of arteries in continuity,
161

for stone in women, 303

for varicocele, 412

Lorenz's, 275

preparations for, 22
Opisthotonos in tetanus, 62
Orchitis, 412
Osteitis, 190, 194

necrosis due to, 198

suppurative, 195

treatment, 198

tubercular, 200
Osteo-arthritis, 269
Osteomalacia, 201
Osteomata, 92
Osteomyelitis, acute, 193

of vertebrae, 311

chronic, 193
Osteosarcoma, 202
Ovarian tumor, 417
Ozena, 358
Paget's disease, 269

of nipple, 417
Pain, 5

Palmar abscess, 341
Pancreas, 378

cysts of, 379
Pancreatitis, acute, 378
Papillomata, 93
Papular syphilides, 81
Paraphimosis from gonorrhea, 409
Paronychia, 185

Pasteur treatment of hydrophobia, 66
Patella, dislocations of, 304

fracture of, 246
Patient, preparation of, for operation,

22
Pelvic dislocations, 299
Pelvis, fractures of, 236
Penis, amputation of, 410

cancer of, 408

diseases and injuries of, 405

fracture of, 405
Perforating ulcer, 38
Pericardial effusion, 146

operation for, 146

Pericardial sac, tapping of, 146
Perineum, 414

injuries of, 414

operations on, 414
Perinephritic abscess, 297
Periostitis, 191
Peritoneum, 367

injuries with damage to, 363

rupture of, 367
Peritonitis, acute, 367

circumscribed suppurative, 368
Peritonitis, diffuse septic, 368
Perivascular tissue, changes in, in in-
flammation, 3
Permanganate of potash, 18
Peroxid of hydrogen, 17
Pes cavus, 348

planus, 349
Phagedena, 44, 36, 43
Phagedenic ulcer, 36
Phagocytes, 2
Phagocytosis, 2
Phalanges, dislocations of, 298

fractures of, 236
Pharynx, foreign bodies in, 356
Phimosis, 408
Phlebectasis, 172
Phlebitis, 171
Phlegmonous erysipelas, 57

suppuration, 25
Piles, 391. See also Hemorrhoids.
Plaster-of-Paris bandage, 212
Pleura, diseases and injuries of, 360
Pleural sac, exploratory puncture of,

360
Pleuritic effusion, 360
Pleurodynia, 339
Pleurothotonos in tetanus, 62
Pneumothorax, 361
Pointing of abscess, 28
Poisoned wounds, 138
Polydactylism, 345
Polypi, nasal, 357
Popliteal artery, 170

ligation of, 170
Port-wine stains, 94, 174
Posterior tibial artery, 170
Post-febrile gangrene, 47
Postpharyngeal abscess, 316
Pott's aneurysm, 311, 323

disease, 313

fracture, 250

434

IND.EX.

Poultice, 7

Preparations for operation, 21

Prolapse of anus, 390

of rectum. 390
Prostate, abscess of, 403

from gonorrhea, treatment, 87

diseases and injuries of, 402

gland, hypertrophy of, 404
Prostatitis, acute, from gonorrhea,

treatment, 403
Proud flesh, 35
Pruritis of anus, 390
Pseudo-arthrosis, 214
Psoas abscess, 316
Ptomains, 12, 14
Punctured wounds, 138
Pus, 24

blue, 24

caseous, 24

fibrinous, 24

foul, 24

ichorous, 24

laudable, 24

microbes, 15

sanious, 24

serous, 24

tubercular, 24
Pustular syphilides, 80
Pustule, malignant, 66
Pyelitis, 396
Pyemia, 53, 54
Pyogenic microbes, 15
Pyonephrosis, 397
Pyosalpinx, 416
Rabies, 64
Rachitis, 87
Radial artery, 168
- ligation of, 168
Radius, dislocations of, 295

fractures of, 232

subluxation of head of, 295
Ranula, 352

Raynaud's gangrene, 48
Rectoeele, 415
Rectum, cancer of, 393

diseases and injuries of, 389
Rectum, prolapse, of, 390

stricture of, non-cancerous, 390
ulcer of, 394
Recurrent bandage of head, 107
Reef-knot, 126
Renal calculus, 396

Renal colic, 396
Repair, 113-116
Reptiles, bites of, 126
Residual abscess, 27

urine, 401
Resolution of inflammation, 4
Retention of urine, 400
from enlarged prostate, treatment,
401
Retention-cysts, 100
Rhabdomyomata, 98
Rachitis, 87

Rheumatic torticollis, 344
Rheumatism, 267
gonorrheal, 257
muscular, 339
Rhoads's apparatus for dislocation of
acromial end of clavicle, 284
Ribs, dislocation of, 298

fractures of, 221
Rickets, 87

Risus sardonicus in tetanus, 60
Rodent ulcer, 38

Rolando's fissure, location of, 333
Rupture, muscular, from contusion of
abdominal wall, 363
of bladder, 397
of gall-bladder, 364
of intestine without external wound,

364. ,

of kidney, 364
of liver, 363
of peritoneum, 363
of spleen, 363
of stomach without external wound,

363
of urethra, 406
Saccharomyces, 8
Sacro-iliac disease, 264
Salicylic acid, 18
Salpingitis, 416
Sapremia, 49
Saprophytes, 10
Sarcina, 10
Sarcoma, 95
alveolar, 96
giant-celled, 96
melanotic, 96
Sayre's adhesive-plaster dressing for

fracture of clavicle, 223
Scalds, 143
of glottis, 144

INDEX.

435

Scalp, abscess of, 337

diseases of, 337
Scalp-wounds, 324

Scapula, dislocations of lower angle
of, 284

fractures of, 224
Schizomycetes, 9
Sciatic artery, 168
Scirrhus carcinoma, 97
Sclerosis, arterial, 147
Scoliosis, 311
Scorbutic ulcer, 38
Scrofula, 71
Scrotum, lymph-, 410
Scurvy, 88
Sebaceous cysts, 101
Seminal vesicles, diseases and injur-
ies of. 404
Senile gangrene, 41
Sepsis, 50
Septic infection, 48

intoxication, 49
Septicemia, 50
Sequestrum, 198
Shock, 119

cause, 119

treatment of, 120
Shoulder- joint, disease of, 266

dislocations of, 284
Silk suture, 131
Silkworm-gut, 131
Silver as an antiseptic, 18

wire sutures, preparation of, 131
"Silver-fork deformity," 232
Sinus, 23, 39
Skin, disease of, 183

syphilitic diseases of, 81
Skull, bones of, diseases and malfor-
mations of, 324

fractures of, 325

operations on, 335
Sloughing, 36

phagedena, 43
Snake-bites, 139
Sphacelus, 42
Spica of groin, 106

of shoulder, 105

of thumb, 104
Spina bifida, 309

operations for, 309
Spinal abscess, treatment, 315

caries, 313

Spinal concussion, 323

contusion, 323

curvatures, 311
Spine, congenital deformities of, 309

dislocations of, 319

fracture-dislocations of, 320

fractures of, 320

operations on, 324

tumors of, 310
Spirilla, 9

Spleen, rupture of, 363
Splint, internal angular, in fracture of
surgical neck of humerus, 227

in fracture of shaft of humerus, 228

Levis's, for fracture of lower end of
radius, 232
for reduction of dislocation of
phalanges, 298
Spores, 9
Staphylococci, 10
Staphylococcus, pyogenes albus, 15

aureus, 15
Staphylorrhaphy, 353
Sterilization, 20

of hands and forearms, 21
Sternum, fractures of, 222
Stings of bees and insects, 140
Stomach, 369

carcinoma of, 370

cicatricial stenosis of orifices of, 371

rupture of, without external wound,
363

ulcer of, peptic, 370
Stone in bladder, 402

in women, operation for, 403
Strangulated hernia, 382
Streptococcus of erysipelas, 15

pyogenes, 15
Stricture, hysterical,

of esophagus, 362

of urethra, 86, 406
Stumps, neuralgia of, 95
Subclavian artery, 166

ligation of, 166
Subdural hemorrhage, 331
Subluxation of head of radius, 295

of humerus, 291

of knee-joint, 305
Superior thyroid artery, 165
Supernumerary digits, 345
Suppuration, 23

phlegmonous, 25

436

INDEX

Surgeon's knot, method of tying, 132
Sutures, 131
continuous, 133
Czerny-Lembert, 367
Ford's, 134
Halsted's, 133
interrupted, 133
Lembert.s, 132
quilled, 132

subcuticular, Halsted's, 134
Sylvester's method of artificial respira-
tion, 113
Symmetrical gangrene, 48
Syndactylism, 345
Synovitis, 252
chronic, 252
simple acute, 252
Syphilides, 80
maculopapular, 80
papular, 80
pustular, 80
tubercular, 82
Syphilis, 76
acquired, 76
affections of bones in, 81

of ear in, 81

of eye in, 81

of hair in, 81

of joints in, 81

of mucous membranes in, 80

of nails in, 81
alopecia in, 81
arteritis in, 82
bacillus of, 76
brain, 82
choroiditis in, 81
Colles's law in, 84
eruptions in, forms of, 80
hereditary, 83

Hutchinson's teeth in, 83

symptoms, 83

treatment, 84
infection in utero, 83
initial lesions of, 79
mucous patches in, 80
neuritis in, 83
of skin, 80
primary, 80

rules of inheritance of, 84
secondary, 80
spinal, 82
tertiary, 81

Syphilis, transmission of, 83

reatment of complications in sec-
ondary stage, 84

in primary stage, 84

in secondary stage, 84

in tertiary stage, 85
Syphilitic affections of mucous mem-
branes, 80

arteritis, 82

bubo, 79

maculae, 80

roseola, 80

skin-diseases, 80

ulcer, 79
syringomyelocele, 310
Talipes, 347

calcaneovalgus, 348

calcaneus, 347

equinovalgus, 347

equinovarus, 348

equinus, 348

treatment, 349

valgus, 349

varus, 347
Tarsal bones, dislocations of, 308
Technic of brain-operations, 335
Telangiectasis, 94
Temporal artery, 165
Tendon-lengthening, 339
Tendons, diseases and injuries of, 338

dislocations of, 339

operations on, 339

repair of, 113

rupture of, 338

wounds of, 339
Tendon-suture, 339

Tenosynovitis, 341. See also Thecitis.
Tenotomy, 344
Testicles, diseases and injuries of, 412

encysted hydrocele, 410

retained, 413
Tetanus, 60

bacillus of, 60

of newborn, 60

treatment, 63
Tetracocci, 9
Thecitis, 341

suppurative, 341
Thrombosis, 176
Thrombus, ante-mortem, 178

infected, in vein, 178

white, 178

INDEX.

437

Thumb, dislocation, of metacarpopha-
langeal joint of, 297
Tibia, fractures of, 249
Tongue, carcinoma of, 353

diseases of, 353
Tongue-tie, 353
Tonsil, inflammation of, 354

hypertrophy of, 354
Torsion to control hemorrhage, 127
Torticollis, 344
Tourniquet, 127
Toxins, 14

Trachea, foreign bodies in, 357
Tracheotomy, 357
Traumatic fever, 49

gangrene, spreading, 40
Trephine, Gait's conical, 335
Trephining, in fracture of skull, 335
Trigger-finger, 345
Trophic ulcer, 37
Tubercle, 67

anatomical, 72
Tubercular abscess, 33, 70

gummata, 71
Tuberculin, Koch's, 75
Tuberculosis, 67

bacillus of, 68

of alimentary canal, 73

of bone, 73

of hip-joint, 260

of joints, 73

of lymphatic glands, 73

of sacro-iliac joint, 265

of skin, 71

of subcutaneous connective tissue,
72

peritoneal, 73

pulmonary, 72

treatment, 74
Tumors, 88

causes, 89

classification, 90

in corpus striatum, 334

innocent, 91

intracranial, 334

malignant, 91
Tumors of spine, 310
Tunica vaginalis, diseases and injuries

of, 410
Ulcer, 23, 34

edematous, 36

erethistic, 37

Tumors, fungous, 35

indolent, 36

irritable, 37

Jacob's, 38

neuroparalytic, 38

of leg, acute, 37

perforating, 38

phagedenic, 36

rodent, 38

scorbutic, 38

syphilitic, 38

trophic, 37

varicose, 37
Ulceration, 34
Ulna, dislocations of, 294

fractures of, 235
Ulnar artery, 167

ligation of, 167
Umbilical hernia, 388. See also Hernia.
Uranoplasty, 353
Ureter's, wounds of, 364
Urethra, diseases and injuries of, 406
Urethra, foreign bodies in, 406

inflammation of, 406. See also Ure-
thritis.

rupture of, 406

stricture of, 86, 406

wounds of, 406
Urethral, fever, 407
Urethritis, 85

specific, 85. See also Gonorrhea.
Urethrotomy, internal, 407
Urinary fever, 407
Urine, residual, 401

retention of. 401
Uvula, elongated, 354
Vagina, diseases of, 415
Varicocele, 412

operation for, 4i2
Varicose aneurysm, 158
Varicose veins, 172
Varix, 157, 172

aneurysmal, 157

treatment, 158, 173
Vascular system, operations on, 348
Vein, application of ligature to, 179

inflammation of, 171. See also Phle-
bitis.

varicose, 172. See also Varix.

wounds of, 179
Velpeau's bandage, 110
Venereal, sore, local, 78, 408

438

INDEX.

Venereal warts, 410

Ventral hernia, 379

Vermiform appendix, abscess of, 375

Vertebrae, acute osteomyelitis of, 311

Vertebral artery, 166

ligation of, 166
Vesical calculus, 402

crushing of, 402
Vesiculitis, 404
Vicious union, 214
Virchow's disease, 201
Viscera, injuries with damage to, 363
Volvulus, 371
Wardrop's operation for aneurysm,

155
Warts, 93

venereal, 409
Water on the brain, 338
Weavers' bottom, 344
Webbed fingers,. 345
White swelling, 265
Whitlow, 342. See also Felon.
Wound diphtheria, 55
Wounds, 118

and injuries of heart, 146

arrest of hemorrhage in, 123

cleansing of, 129

closure of, 130

contused, 127, 143
of arteries, 159

drainage of, 130

dressing of, 135

Wounds, gunshot, 141
of arteries, 160

hemorrhage in, 121

incised, 137

irrigation of, 121

lacerated, 137

non-penetrating, of abdominal wall,
363

abdominal wall, 363

of brain, 324

of chest, 359

of liver, 363

of rectum, 389

of spinal cord, 320

of veins, 179

pain in, 118

poisoned, 138

punctured, 138

removal of foreign bodies from, 129

rest in, 136

retraction of edges of, 118

scalp, 324

septic, 138
Wounds, shock from, 118

treatment, 129
Wrist, deformity at, due to fracture of
radius at lower extremity, 232

dislocations of, 296
Wrist-joint, disease of, 266
Wry-neck, 344. See also Torticollis.
Zygomatic arch, fractures of, 219

DATE DUE

1

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DEMCO NO. 36

-298

3 2243 00028 2556

10851

Young, Frank Philip

Surgery from an osteopathic standpoint,